1. i don't know any kids under 5 that would even think about letting you place an IV.
Were we talking about children under 5? I mask induce almost all children under five, unless they
already have an IV (or port, etc.). I'm suggesting what's safest and able to be done most predictably. No one would argue that mask induction doesn't work. What the OP wants to know is if this is a good technique for an
uncooperative adult. The answer to that is a resounding "
no".
I get in "discussions" with attendings all the time about mask inducing a 15-year-old because they're afraid of needles. Often, if you have a nice discussion with a fifteen-year-old, calm their fears, use some lidocaine 1%, and start a painless IV, you've done your job as being a true
doctor and you've helped them grow up. If you choose to mask them down, you risk laryngospasm, emetogenesis, and a whole host of other bad things that can happen in a rammy teenager. And, now you don't have IV access to save your ***.
2. read your own articles copro...
The association of anesthetic agents with both seizure activity and with epileptiform EEG patterns is longstanding, with information on enflurane induced electrocortographic seizure activity dating back at least 27 years (6). After a decade of clinical use of sevoflurane, and a considerably longer duration using isoflurane and enflurane, there is no evidence that potent agent induced epileptiform EEG patterns have caused cerebral injury in any patients, even those that had actual clinical seizures. Considering the information we have cited, our reply to Wappler and Bishoffs questions is that the rapid, smooth, and predictable sevoflurane induction technique that we recently advocated (7) is safe, and that the sevoflurane concentration required to elicit non-ictal epileptiform activity is not particularly relevant because such EEG activity is not associated with the risk of epilepsy, provoked seizures, nor their sequelae.
First, we pre-med a lot of kids with oral midazolam. So, I wonder how much epileptiform activity we're actually missing/suppressing...
Second, a seizure is a seizure. I appreciate this
opinion here, but the fact is that we don't really know what a single seizure will do longterm. If you tell a neurologist that you're doing an anesthetic technique that elicits seizures, they're going to fry you in court if something bad happens and you get sued. Are you uncovering an epileptiform focus, or are you actually damaging the brain? You don't know. These authors don't know. I think it's incredibly arrogant for the authors above to summarily dismiss that point.
I'm not suggesting not doing mask inductions or that they're inherently unsafe. I will tell you that I don't blast them with 70/30 N20 and 8% sevo off the starting blocks. I do pre-med them. I do slowly turn up the agent until they fall asleep. I was taught that technique by a world renowned pediatric anesthesiologist. I've never seen rigidity. I've never seen a seizure. And, I've never seen a squirmy, fighting kid. Smooth as butter.
Certainly not a "single breath" induction, which is more a carny act than it is a safe anesthetic.
3. DARTING a human is NOT a vet procedure!?!?
So what? If you have a
truly uncooperative patient who won't even tolerate a mask induction, what else are you going to do? A ketamine dart works.
-copro
