Breathing them down

[susruta]

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I am almost into my final year of residency and might be going to do peds fellowship after.
One thing that still freaks me is breathing kids down during induction. I had a few laryngospasms earlier on.

I understand that holding the mask and letting them breath themselves down is the way to go.

Any tips or suggestions.

 

[BobBarker]

Sure, preop IV.

 

[susruta]

Sure, preop IV.

Very unfriendly atmosphere for that

 

[Sublimazing]

IM sux

 

[deleted9493]

Hypoxia breaks all laryngospasm eventually. 😛

Concomitant IM atropine and succinylcholine to reduce the bradycardia associated with either the oxygen deficit or the succinylcholine itself. An appropriately sized oral airway and well-applied CPAP will break the majority of episodes. I find that having someone else depress the abdomen over the stomach helps minimize stomach insufflation.

 

[Idiopathic]

Hypoxia breaks all laryngospasm eventually. 😛

Concomitant IM atropine and succinylcholine to reduce the bradycardia associated with either the oxygen deficit or the succinylcholine itself. An appropriately sized oral airway and well-applied CPAP will break the majority of episodes. I find that having someone else depress the abdomen over the stomach helps minimize stomach insufflation.

yeah i dont think hes asking how to break spasm so much as how to prevent it.

my thoughts are that you arent letting them get deep enough quickly enough if you are having spasm on induction. high dose volatile and nitrous then taper it back when you have taken over masking, that was always my plan. shouldnt take long, dont try for the IV before the kid is induced, if you are having early spasm then you are stimulating a kid who isnt asleep. but remember you are inducing anesthesia, rather than "breathing down", it needs to be quick.

other thought is that your mask technique is lacking,

 

[deleted9493]

In that case, the importance of priming your circuit before applying the mask to the child's face cannot be overstated. If you crank your flows and vaporizer at the time of application, the circuit (absorbent, reservoir bag, tubing) dilutes the concentration and so slows the transition through stage 2.

For kids that you suspect won't tolerate having a mask on their face (eg nitrous and then titrating the volatile on), crank your agents immediately upon arriving to the room or even before going to get them in preop. This dramatically speeds the transition through excitement phase because their first inspirations contain more potent concentrations.

Some children, like those with Down's Syndrome, for example, have a proclivity to become bradycardic with high concentration mask inductions. Giving them a stout oral premedication can be helpful. In the same way, post-medication with alpha-2 agonist or emerging the child on propofol can significantly attenuate the spasm reflex in kids who are very reactive on induction.

 

[jetproppilot]

My previous ROKKSTARR gig (1997-2004)

FIVE OF US PARTNERS which meant ONE WEEK OUT OF FIVE

I was at the Surgery Center, a surgery center that started at 0630 and sometimes ended

after the sun went down.

WE HAD PROLIFIC ENT SURGEONS THAT WOULD DO

TEN KIDS

on their OR day... (per surgeon)

In other words, during that week of mine at the surgery center, I would induce

TONS OF KIDS.

It's not Rocket Science man. That being said,

WE DID IT SO OFTEN WE MADE IT A SCIENCE. (alotta the above posts like Priming The Circuit, etc, DOGMA not needed)

HOW TO VERY SAFELY AND VERY EFFICIENTLY DO A PEDIATRIC T&A AND DELIVER AN ANESTHESIA PRODUCT WHERE KIDS WERE

IN AND OUT SAFELY AND EFFICIENTLY.

We did it

TO THE POINT WHERE I COULD DO IT ASLEEP

DAY AFTER DAY. After day. After day, AFTER DAY, AFTER DAY, AFTER...

 

[jetproppilot]

In that case, the importance of priming your circuit before applying the mask to the child's face cannot be overstated..

HUH?

It can't be

OVERSTATED?

Why yes.

YES IT CAN.



Where do you work, dude?

Dude, lemme ask you a question:

DID YOU EVER QUESTION AND SUBSEQUENTLY REALIZE THE RELEVANCE AND EFFICACY OF

ORAL MIDAZOLAM

WHICH SMOKES THE KIDS PREOPERATIVELY SO

THEY DON'T CARE

DON'T REMEMBER?

Makes your concern about the kid in the O.R. archaic.

Don't know what rock you've been laying under for the last many years but dude we've got these

SHORT ACTING BENZODIAZEPINES

that we can

GIVE TO KIDS ORALLY

that

1) Eases the transition from parent to physician and nursing staff

2) COMPLETELY messes up their memory so they don't remember

hudsontc's reference of having a circuit

PRIMED WITH VOLATILE ANESTHETIC

is also heard, but if you're receiving a well sedated child the concept and significance of a primed circuit is IRRELEVANT.

I think preoperative oral midazolam used effectively removes concerns.

 

[pgg]

ORAL MIDAZOLAM

I'm curious how many people here routinely use PO midazolam, especially the peds guys who not only do a lot of kids, but see the same kids return to the OR repeatedly.

The best argument I've heard for using it is that it makes the kid's NEXT visit to the OR less traumatic and scary because they don't remember the first procedure.

But as far as a one-off case I'm not convinced that it's really worth it. Pre-op PO midaz takes time (not much, but not zero) and the scared kids who arguably benefit most usually end up wearing 90% of it. Post-op, it definitely makes them sleepier longer and delays emergence, especially for short cases. The peds hospital where I did my residency rotations virtually never used it, so I was forced to learn to be nice and reassuring and gentle when I overpowered and gassed the little monsters down.

I'm firmly anti-midazolam in adults and almost never use it pre-GA, but I'm more ambivalent about it in kids. Again, just curious what the peds experts think of it.

 

[Precedex]

Rarely use oral versed. Always prime the circuit if I think they're gonna put up a fight. Start taking over the ventilation within about thirty seconds. Iv usually goes in before they are that deep. I dont believe you have to wait and there is some data to support that. Nitrous only gets turned off once IV is in. I think I've had one or two spasms on induction in four years doing 90%pedi cases in high volume center. A lot of kids will obstruct on induction which may mimic laryngospasm but resolves with good mask technique.

 

[Dejavu]

As a guy who has been masking pts down for 37 yrs with Halothane and now Sevo (adults and kids), I agree with the above statement that time is important.

Boring war story alert....
When we used to masked kids down with Halothane, we used to start at 0.25% and increase by 0.25% every 3-4 breaths. They went to sleep, went apneic often, but not always, always hyponeic though, took a few minutes. Rarely spasmed, cause they were deep by then.

Nowadays, people jack the Sevo to 8, put the mask on, the pt takes 5 breaths in 30 secs, they go apneic and lose their lid reflex, but believe me, they are not asleep enough to instrument the airway beyond a smallish oral airway. They just look like they are.

Start bagging them deeper, cause they are often going to wiggle and object to even an IV start, much less an LMA or tube. Once they are deeper, get the IV, give 4-5cc of Propofol or more agent and the relaxant. Turn down your agent and you have reached your cruising altitude.

Oh, sorry, forgot to warn about the repetitive boring airplane analogy at the end there.

 

[gasattack3]

I'm curious how many people here routinely use PO midazolam, especially the peds guys who not only do a lot of kids, but see the same kids return to the OR repeatedly.

The best argument I've heard for using it is that it makes the kid's NEXT visit to the OR less traumatic and scary because they don't remember the first procedure.

But as far as a one-off case I'm not convinced that it's really worth it. Pre-op PO midaz takes time (not much, but not zero) and the scared kids who arguably benefit most usually end up wearing 90% of it. Post-op, it definitely makes them sleepier longer and delays emergence, especially for short cases. The peds hospital where I did my residency rotations virtually never used it, so I was forced to learn to be nice and reassuring and gentle when I overpowered and gassed the little monsters down.

I'm firmly anti-midazolam in adults and almost never use it pre-GA, but I'm more ambivalent about it in kids. Again, just curious what the peds experts think of it.

I hate when I go easy (rarely none at all) on the versed and patients say "oh, I didn't remember any of this the last time". It's their way of saying "dude, gimme some drugs".

I do think we tend to overdo the versed on adults.

 

[gasattack3]

As a guy who has been masking pts down for 37 yrs with Halothane and now Sevo (adults and kids), I agree with the above statement that time is important.

Boring war story alert....
When we used to masked kids down with Halothane, we used to start at 0.25% and increase by 0.25% every 3-4 breaths. They went to sleep, went apneic often, but not always, always hyponeic though, took a few minutes. Rarely spasmed, cause they were deep by then.

Nowadays, people jack the Sevo to 8, put the mask on, the pt takes 5 breaths in 30 secs, they go apneic and lose their lid reflex, but believe me, they are not asleep enough to instrument the airway beyond a smallish oral airway. They just look like they are.

Start bagging them deeper, cause they are often going to wiggle and object to even an IV start, much less an LMA or tube. Once they are deeper, get the IV, give 4-5cc of Propofol or more agent and the relaxant. Turn down your agent and you have reached your cruising altitude.

Oh, sorry, forgot to warn about the repetitive boring airplane analogy at the end there.

No apologies necessary. A guy with 37 years experience is welcomed. Don't think we residents and even attendings aren't reading and learning from this. We are. It's appreciated too.

 

[periopdoc]

But as far as a one-off case I'm not convinced that it's really worth it. Pre-op PO midaz takes time (not much, but not zero) and the scared kids who arguably benefit most usually end up wearing 90% of it. Post-op, it definitely makes them sleepier longer and delays emergence, especially for short cases. The peds hospital where I did my residency rotations virtually never used it, so I was forced to learn to be nice and reassuring and gentle when I overpowered and gassed the little monsters down.

It also makes them significantly more irritable and difficult to control in PACU and after discharge. It is rare that I will go through a day of peds and use it even once.

I am not in a Rokkstar place, but on a Peds ENT day we can do half a dozen kids between 7:30 start and 12:30ish when we switch over to adult ENT patients. I prefer handing them my iPhone with Nemo/ Cars/ Blues Clues... playing on it. They get glued to that and don't pay attention to me, and all my kids movies are tax deductible. For young kids, I prime the circuit with Sevo/ Nitrous for a 3-4 breath induction. For older kids I prime it with Nitrous, flow rate of 5LPM, give them 4-5 breaths then crank the Sevo to 8. It comes up at a reasonable rate since I don't have the flows cranked to 11.

Nitrous only gets turned off once IV is in. I think I've had one or two spasms on induction in four years doing 90%pedi cases in high volume center. A lot of kids will obstruct on induction which may mimic laryngospasm but resolves with good mask technique.

QFT A couple of real keys in there. Keeping the nitrous on until the IV is in makes a huge difference. "Laryngospasm" on induction is usually obstruction.



For true laryngospasm (before or after airway manipulation), the worst thing you can do is stimulate them, so I follow the old adage "Don't just do something, sit there." No "breaking the laryngospasm with positive pressure. What a dumb idea. Any air that goes in against a closed glottis is going straight into the stomach. No oral airway. Do we really need more stimulation of spasmed cords? No jaw thrust etc. etc. etc. Just wait a few seconds and it will usually break. If not, then consider pharmacologic assistance.

I'm firmly anti-midazolam in adults and almost never use it pre-GA, but I'm more ambivalent about it in kids.

I was beginning to think that I was the only one who feels this way.

- pod

 

[Mman]

po Midaz is effective, but is a terrible drug to use routinely in a fast outpatient surgicenter because for quick cases like ear tubes you end up adding 30-60 minutes to their PACU stay. Our ENTs bang out BMTs in slightly under 15 minutes of case time (including room turnover) so they get through at least 4 per hour. When 2 or 3 of them are operating on a day, that means as many as 12 kids an hour are coming through the PACU in addition to all the other rooms. If you start doubling the PACU stay for all of them, you end up backing up the whole day.

I use it when necessary, but definitely not routine.

 

[pgg]

I hate when I go easy (rarely none at all) on the versed and patients say "oh, I didn't remember any of this the last time". It's their way of saying "dude, gimme some drugs".

I don't let that bother me. 🙂

I do tell all my adult patients that they will very likely remember going into the OR, me and the nurse putting monitors on, and breathing some oxygen before going to sleep ... and that this is OK and expected. I find this is usually sufficient to reassure the ones who are expecting to be induced in the holding area.

 

[Idiopathic]

.

 

[Arch Guillotti]

It also makes them significantly more irritable and difficult to control in PACU and after discharge. It is rare that I will go through a day of peds and use it even once.

I am not in a Rokkstar place, but on a Peds ENT day we can do half a dozen kids between 7:30 start and 12:30ish when we switch over to adult ENT patients. I prefer handing them my iPhone with Nemo/ Cars/ Blues Clues... playing on it. They get glued to that and don't pay attention to me, and all my kids movies are tax deductible. For young kids, I prime the circuit with Sevo/ Nitrous for a 3-4 breath induction. For older kids I prime it with Nitrous, flow rate of 5LPM, give them 4-5 breaths then crank the Sevo to 8. It comes up at a reasonable rate since I don't have the flows cranked to 11.




QFT A couple of real keys in there. Keeping the nitrous on until the IV is in makes a huge difference. "Laryngospasm" on induction is usually obstruction.



For true laryngospasm (before or after airway manipulation), the worst thing you can do is stimulate them, so I follow the old adage "Don't just do something, sit there." No "breaking the laryngospasm with positive pressure. What a dumb idea. Any air that goes in against a closed glottis is going straight into the stomach. No oral airway. Do we really need more stimulation of spasmed cords? No jaw thrust etc. etc. etc. Just wait a few seconds and it will usually break. If not, then consider pharmacologic assistance.




I was beginning to think that I was the only one who feels this way.

- pod

I disagree with almost all of this. I never use nitrous for inductions in kids. I think laryngospasm should be treated with jaw thrust, oral airway, gentle clap, then gentle positive pressure and then sux/propofol (unless they decompensate quickly).

 

[IlDestriero]

The Il D special.
My routine technique is to give them 0.5mg/kg midaz P.O., up to 10 mg, 15-30 min before induction time. Sometimes that means medicating when you are picking up the patient ahead of them (for BMT). If they're a teen, I don't care if they get it or not.
When they hit the bed they are usually pretty stoned, or old enough to have the midaz take the edge off and talk them down. Distracting questions, singing, story time starts.
While monitors are going on, they get 6l/m nitrous with 3l/m O2 in a mask flavored with flavored lip balm. We used to use awesome artificial flavoring liquid, but it burned a couple kids nose tips! so no more.🙁 If they're not stoned yet, this gets them giggling.
Start BP as a distraction and put Sevo up to about 3%. 30 to 60 seconds later 8%.
Kid goes to sleep, jaw lift, good mask position, +/- OPA, manual vent support.
IV placement. When it's in, nitrous off, 100% O2.
If I'm placing an LMA, I usually don't give any prop at all. Just LMA and done, then dial back Sevo and you're off to the races. They've usually been on 8% Sevo for several minutes now. If they're still moving a bit with the iv, or I think they're not deep because the Iv was placed by a ninja in 10 seconds, I'll give 1/kg of prop.
For a tube, I'll give 1-2 mg/kg, 3 for the babies, prior to ETT placement.
If the line takes a while, they may not tolerate 8% Sevo and 60% nitrous, so I'll kill the nitrous and dial back the Sevo to 4 or 5%.
If the pre med didn't work well for whatever reason, parent inductions can be useful. Kids that are crying added carrying on on induction have increased sections and can take a long time to settle down into a good anesthesia plane, sometimes longer than the BMT. That's why we pre med everyone.
If they're crying on the bed on arrival, I just go straight to 8% Sevo with 60% nitrous and ride it out.
For the downs kids, I usually use 60% nitrous and gentle Sevo induction like the halothane one described above. By doing that, you usually don't get a profound Brady. I trained on halothane as well BTW! 🙂 Now you only find it in the third world. BTW, if you find yourself abroad and are inducing with halothane for the first time, you can't treat it like a straight to 8 Sevo induction or you'll be in a world of Shiite.

 

[Arch Guillotti]

I give premeds about half the time. Just depends on the kid mostly.

 

[periopdoc]

I think laryngospasm should be treated with jaw thrust, oral airway, gentle clap, then gentle positive pressure and then sux/propofol (unless they decompensate quickly).

So you think that a problem, caused by stimulating underanesthetized cords, should be treated with more stimulation? Or do you think that laryngospasm is caused by something else?

How does jaw thrust and oral airway treat laryngospasm? I would agree with both if what you are treating is in fact upper airway obstruction (90% of what is called laryngospasm is probably only upper airway obstruction anyway IMHO), but how will either help with true laryngospasm?

If their glottis is closed, where is your "gentle positive pressure" going to go, and how does this stimulation of the cords break the laryngospasm if it is indeed a stimulation induced phenomenon?

If you aren't convinced that this is the root cause, then you can make a logical argument for your interventions... except "gentle positive pressure." Filling the stomach with air is never a positive thing.

- pod

 

[mehc012]

I don't let that bother me. 🙂

I do tell all my adult patients that they will very likely remember going into the OR, me and the nurse putting monitors on, and breathing some oxygen before going to sleep ... and that this is OK and expected. I find this is usually sufficient to reassure the ones who are expecting to be induced in the holding area.

I don't even remember meeting the anesthesiologist when I had surgery. Personally, I find that creepy as hell...one moment you're sitting there waiting to be put to sleep, expecting to get wheeled into surgery, etc, and the next you're coming out of it in post-op. Less drugs, please! I wanna at least remember meeting the guy who gave them to me!

 

[dhb]

"laryngospasm" on induction is usually obstruction.

+1

 

[deleted9493]

HUH?

It can't be

OVERSTATED?

Why yes.

YES IT CAN.



Where do you work, dude?

Dude, lemme ask you a question:

DID YOU EVER QUESTION AND SUBSEQUENTLY REALIZE THE RELEVANCE AND EFFICACY OF

ORAL MIDAZOLAM

WHICH SMOKES THE KIDS PREOPERATIVELY SO

THEY DON'T CARE

DON'T REMEMBER?

Makes your concern about the kid in the O.R. archaic.

Don't know what rock you've been laying under for the last many years but dude we've got these

SHORT ACTING BENZODIAZEPINES

that we can

GIVE TO KIDS ORALLY

that

1) Eases the transition from parent to physician and nursing staff

2) COMPLETELY messes up their memory so they don't remember

hudsontc's reference of having a circuit

PRIMED WITH VOLATILE ANESTHETIC

is also heard, but if you're receiving a well sedated child the concept and significance of a primed circuit is IRRELEVANT.

I think preoperative oral midazolam used effectively removes concerns.

I guess a singular post doesn't well-describe one's own practice. I orally premedicate the majority of my patients. I was only speaking to the matter of a quicker transition through stage II using volatile anesthetics. Using a higher concentration of inhaled agent, as with single breath induction, speeds that transition.

 

[jwk]

I don't even remember meeting the anesthesiologist when I had surgery. Personally, I find that creepy as hell...one moment you're sitting there waiting to be put to sleep, expecting to get wheeled into surgery, etc, and the next you're coming out of it in post-op. Less drugs, please! I wanna at least remember meeting the guy who gave them to me!

You really think a baby/child/teen wants to remember meeting the guy who puts them to sleep? Remember the patient population we're talking about here.

BTW - lots of adult patients get midaz, and a lot of them remember very little. Fine by me.

 

[jwk]

The Il D special.
My routine technique is to give them 0.5mg/kg midaz P.O., up to 10 mg, 15-30 min before induction time. Sometimes that means medicating when you are picking up the patient ahead of them (for BMT). If they're a teen, I don't care if they get it or not.
When they hit the bed they are usually pretty stoned, or old enough to have the midaz take the edge off and talk them down. Distracting questions, singing, story time starts.
While monitors are going on, they get 6l/m nitrous with 3l/m O2 in a mask flavored with flavored lip balm. We used to use awesome artificial flavoring liquid, but it burned a couple kids nose tips! so no more.🙁 If they're not stoned yet, this gets them giggling.
Start BP as a distraction and put Sevo up to about 3%. 30 to 60 seconds later 8%.
Kid goes to sleep, jaw lift, good mask position, +/- OPA, manual vent support.
IV placement. When it's in, nitrous off, 100% O2.
If I'm placing an LMA, I usually don't give any prop at all. Just LMA and done, then dial back Sevo and you're off to the races. They've usually been on 8% Sevo for several minutes now. If they're still moving a bit with the iv, or I think they're not deep because the Iv was placed by a ninja in 10 seconds, I'll give 1/kg of prop.
For a tube, I'll give 1-2 mg/kg, 3 for the babies, prior to ETT placement.
If the line takes a while, they may not tolerate 8% Sevo and 60% nitrous, so I'll kill the nitrous and dial back the Sevo to 4 or 5%.
If the pre med didn't work well for whatever reason, parent inductions can be useful. Kids that are crying added carrying on on induction have increased sections and can take a long time to settle down into a good anesthesia plane, sometimes longer than the BMT. That's why we pre med everyone.
If they're crying on the bed on arrival, I just go straight to 8% Sevo with 60% nitrous and ride it out.
For the downs kids, I usually use 60% nitrous and gentle Sevo induction like the halothane one described above. By doing that, you usually don't get a profound Brady. I trained on halothane as well BTW! 🙂 Now you only find it in the third world. BTW, if you find yourself abroad and are inducing with halothane for the first time, you can't treat it like a straight to 8 Sevo induction or you'll be in a world of Shiite.

Ah, memories of doing a dozen kids in a day...

Change sevo to halothane and (except for the %age) it's the same way I did it more than 30 years ago. N2O for all - no parents (hate it now) and if they cry, big cry = big breath in, so it didn't matter..

 

[mehc012]

You really think a baby/child/teen wants to remember meeting the guy who puts them to sleep? Remember the patient population we're talking about here.

BTW - lots of adult patients get midaz, and a lot of them remember very little. Fine by me.

Sorry, I was responding to a quote which specifically referenced adult patients.

Personally, I think memory loss is an awful, disorienting side effect, but I suppose it could be a good thing for kids.



Sent via phone, please excuse typos and formatting errors!

 

[pgg]

How does jaw thrust and oral airway treat laryngospasm?

Larson's maneuver (jaw thrust & anterior mastoid pressure) will break laryngospasm, sometimes.

I favor gentle CPAP and patience, though not much, followed by drugs. Succ for laryngospasm is like an endotracheal tube ... can't say I've ever regreted grabbing succ or a tube early, but I've occasionally regretted waiting.

Re: PPV, laryngospasm comes in shades of gray, and I don't agree that it's contraindicated or pointless in all cases, though of course you have to be mindful of stomach insufflation.

BTW - lots of adult patients get midaz, and a lot of them remember very little. Fine by me.

It's fine with me also. What's also fine with me are short PACU stays, and anecdotally I find that no midaz (and desflurane, not that I really want to derail this thread into a blue gas vs inferior gases debate 🙂) make a difference there. Maybe it's just my hospitals that are cheap and understaff the PACU but sitting in the OR an extra 10 or 15 min because the place is gridlocked sucks.

 

[IlDestriero]

I'm not convinced midazolam causes big delays in kids, I guess it would depend on your number of pacu beds. We can do 25-30 ent cases (mostly tubes) at the ASC with one surgeon in 2 ORs and be done before 3. We rarely have delays, and when we do, it's usually only 5 min.

 

[stonemd]

I give versed po prep routinely to kids 1-7 years old. Patients better tolerate separation from parents and mask induction. Some of the reasons given to avoid midaz I disagree with
Amnesia only important if patient having Anes/surg in the future -
I can mask down quickly if they are crying -
Patients need longer pacu stay and this will fill my pacu -
Traumatic inductions can cause behavior issues weeks after surgery. One never knows when a child will return to the OR. 'bruticaine' inductions would never be considered on adults and are wrong. Versed will not routinely lengthen paci stays and Patients who have unusual sensitivity to versed can get romazicon.

Other advantages to po versed not mentioned include
One can start an IV earlier in the mask induction process, while a patient still 'light' without the increase in laryngospasm risk that occurs with no versed premed and mask induction.
Po versed prep in the majority of studies will decrease the incidence of postoperative delerium.

Parental presence is an alternative but I believe more difficult and less reliable than po versed. In the past when we did not use versed routinely there were some kids who we thought would be cooperative in the OR, but with the best efforts of Anes and child life went ballistic in the OR during induction.

I am not a peds fellow but 10 year medical director of 11 room asc with ent, dental, and peds opth.

 

[stonemd]

Quote from and article

Laryngospasm Management
Laryngospasm may present as complete or incomplete airway obstruction. If incomplete airway obstruction is present sounds should be present - eg. grunts, expiratory squeaks. Complete or incomplete airway obstruction should have initial treatment with jaw thrust and chin lift. The middle finger of each hand should be placed in the "laryngospasm" notch. It is behind the lobule of the pinna of each ear and is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone and cephalad by the base of the skull. Press firmly inward toward the base of the skull with both fingers at the same time lifting the mandible at the right angle to the plane of the body (jaw thrust or forward displacement of the mandible). This will convert laryngospasm within one or two breaths to laryngeal stridor and then to unobstructed respirations.56 This should include administration of 100% O2 with gentle positive pressure. It must be remembered that incomplete airway obstruction may rapidly become complete.
Complete airway obstruction shares many of the signs of incomplete airway obstruction - tracheal tug, retractions of the chest wall and marked abdominal respiration, but there is no sound present. Positive pressure will not "break" laryngospasm in the presence of complete airway obstruction.57 It may worsen it by forcing supraglottic tissues downward into the glottic opening. High pressure generated by the flush valve may dilute anesthetic gases, and lead to a lighter level of anesthesia. It may also force gas down the esophagus into the stomach making ventilation more difficult. Treat with IM or preferably IV sux.

 

[cchoukal]

It's not Rocket Science man. That being said,

WE DID IT SO OFTEN WE MADE IT A SCIENCE. (alotta the above posts like Priming The Circuit, etc, DOGMA not needed)


DAY AFTER DAY. After day. After day, AFTER DAY, AFTER DAY, AFTER...

I got to the end of your post hoping you'd share HOW you actually conducted it day after day, so to speak. Other than routine oral midazolam, were there some techniques you wanted to share?

 

[cchoukal]

Two questions:

1) For kids, has anyone tried intranasal dex for pre-op sedation? There are a couple case reports out there, and I've done it in adults with behavioral problems and no IV. It takes superhuman doses (200 mcg per naris for adults, at least), and I'd wonder if it wouldn't also cause delay in PACU (I find that my heavily dex'd adult patients stay in PACU longer 2/2 hypotension and somnolence).

2) For adult pre-med, is anyone (other than me) using just a touch of propofol (10-20 mg) in pre-op holding? It's a great anxiolytic and in our elderly (read: delirium-prone) population, we can avoid benzos altogether.

I'll take my answer off the air.

 

[somedumbDO]

I'm curious how many people here routinely use PO midazolam, especially the peds guys who not only do a lot of kids, but see the same kids return to the OR repeatedly.

The best argument I've heard for using it is that it makes the kid's NEXT visit to the OR less traumatic and scary because they don't remember the first procedure.

But as far as a one-off case I'm not convinced that it's really worth it. Pre-op PO midaz takes time (not much, but not zero) and the scared kids who arguably benefit most usually end up wearing 90% of it. Post-op, it definitely makes them sleepier longer and delays emergence, especially for short cases. The peds hospital where I did my residency rotations virtually never used it, so I was forced to learn to be nice and reassuring and gentle when I overpowered and gassed the little monsters down.

I'm firmly anti-midazolam in adults and almost never use it pre-GA, but I'm more ambivalent about it in kids. Again, just curious what the peds experts think of it.

10 months and up I routinely use it. Works great, crying kid are much more docile. There are some studies that it decreases associated pathology in kids post op (bed wetting, sleep disturbance ect). Most importantly, I do it so mom and dad dont see an unruely crying kid with seperation. Thats the image they remember the most and utimalely determines if you are a "good" or "bad" anesthesiologist in there eyes. As far as priming the circuit I only do it for the 2-4 yr old that can be hooligans with going to sleep. Priming the circuit on a pre 60 weeker get the atropine ready cuz you are gonna need it. Priming the circuit maybe knocks off 15-30 sec of induction time.

This is my exprience I am a PP peds guy that does a billion peds cases a yr. hahah almost....

 

[somedumbDO]

Two questions:

1) For kids, has anyone tried intranasal dex for pre-op sedation? There are a couple case reports out there, and I've done it in adults with behavioral problems and no IV. It takes superhuman doses (200 mcg per naris for adults, at least), and I'd wonder if it wouldn't also cause delay in PACU (I find that my heavily dex'd adult patients stay in PACU longer 2/2 hypotension and somnolence).

2) For adult pre-med, is anyone (other than me) using just a touch of propofol (10-20 mg) in pre-op holding? It's a great anxiolytic and in our elderly (read: delirium-prone) population, we can avoid benzos altogether.

I'll take my answer off the air.

I actually preformed some of the studies on IN dex in kids, there is published literature as well. I use it for less than 60 wk PCA kids for MRI that dont need contrast or similar cases. You need to give it a good 30 min to start working so timing is difficult. Also, kids have snotty noses and absorb can be unpredictable. It can last for up to two hours so be careful. doses are generally 2-4 mcg/kg. If it is a long case remember PO/IN clonidine is amazing decreases mac, sedative, ect ect. Most recent studies (this is IV dex) has shown either no or up to 15 min delay in PACU. So the answer is maybe...

Yes a touch of da prop for the elderly is magic....

Finally, In response the the above, kids larnygospasm/obstruct/bronchospasm ect we are all trained what to do. It happens just be prepared for it. I have only seen a handfull of kids that were so reactive that needed to be left intubated and managed for reactive airway dz. N=2

 

[jwk]

hooligans with going to sleep. Priming the circuit on a pre 60 weeker get the atropine ready cuz you are gonna need it. Priming the circuit maybe knocks off 15-30 sec of induction time.

I'm not clear what priming the circuit, or not, has to do with potential bradycardia.

I'm also not clear why it's necessary at all to prime the circuit. What kinds of flows are y'all using that this would make any appreciable difference?

 

[imfrankie]

I rarely use premed for kids anymore (possibly influenced by neuroapoptosis uncertainty), I don't put monitors on them pre induction except maybe a pulse ox. We go to sleep in the chair on my lap usually.
Distraction, humor and concern for kid over surgeon. All parties happy so far.

 

[stonemd]

This is anoyher topic but ...

Using no premed means you use more intraop anesthetic - presume inhalational - is there really any evidence that one 'anesthetic' (midaz vs propofol vs volatile) is riskier than another? Is there any age when a patient would be safe from neurologic injury from standard anesthetic delivery? I don't think the answers are there yet - though in the youngest patients I tell parents there is some low risk of neurologic injury from a standard anesthetic

Distraction and humor often work well, but not in all situations. What do you do when a patient screams leaving the parents or fights to keep the mask off their face?

 

[jetproppilot]

po Midaz is effective, but is a terrible drug to use routinely in a fast outpatient surgicenter because for quick cases like ear tubes you end up adding 30-60 minutes to their PACU stay. Our ENTs bang out BMTs in slightly under 15 minutes of case time (including room turnover) so they get through at least 4 per hour. When 2 or 3 of them are operating on a day, that means as many as 12 kids an hour are coming through the PACU in addition to all the other rooms. If you start doubling the PACU stay for all of them, you end up backing up the whole day.

I use it when necessary, but definitely not routine.

Goes to show how

DIFFERENT ANESTHESIA PRACTICES ARE

I previously worked at a gig where

EVERY KID

got oral midazolam

working with

ROKKSTARR ENT SURGEONS

T&A on a four year old takes

TEN MINUTES

Yes.

ROKKSTARR SURGEONS.

HOW DOES AN ANESTHESIOLOIGIST DO A CASE LIKE THIS?

1) Buzzed out kid on oral midazolam; easy transition from parents
2) HIGHEST SEVO concentration via mask
3) MD or Someone starts IV
4) Intubation
5) Bed turned
6) Tonsils removed
7) Bed turned back
8) Kid already breathing
9) ETT removed; breathing supported
10) To PACU...READY FOR NEXT CASE

 

[Mman]

Goes to show how

DIFFERENT ANESTHESIA PRACTICES ARE

I previously worked at a gig where

EVERY KID

got oral midazolam

working with

ROKKSTARR ENT SURGEONS

T&A on a four year old takes

TEN MINUTES

Yes.

ROKKSTARR SURGEONS.

HOW DOES AN ANESTHESIOLOIGIST DO A CASE LIKE THIS?

1) Buzzed out kid on oral midazolam; easy transition from parents
2) HIGHEST SEVO concentration via mask
3) MD or Someone starts IV
4) Intubation
5) Bed turned
6) Tonsils removed
7) Bed turned back
8) Kid already breathing
9) ETT removed; breathing supported
10) To PACU...READY FOR NEXT CASE

there are definitely different ways to skin a cat, I've just seen significantly longer PACU stays for kids having 5 minute procedures (when I said 15 minute procedure time I was including getting in room, inducing, waking up, and turning room over - actual procedure is about 2-4 minutes at most. tonsils are about a 5-10 minute case). I mean the median LOS in PACU for our BMTs is around 32 minutes and that's because we force them to stay for at least 30 minutes. I've seen some need near 2 hours to get d/c'd home with the same anesthetic except po versed first. They are just much sleepier afterwards.

Now that's not to say I don't use it on occasion. But most of the time some distractions and toys (including movies, ipads, whatever) can get them away from their parents without difficulty.

And turning the bed for tonsils? Really?

 

[pgg]

And turning the bed for tonsils? Really?

One of our surgeons insists on it too. It's almost as annoying as the OMFS'ers who insist on nasal intubations to pull wisdom teeth.

 

[periopdoc]

Unless they are going 180 (which is BS), why turn the bed at all? It wastes five min per case (ok, maybe two min if your nurses are good about getting all the suction/ cautery/ etc **** off of the patient at the end so you can turn the bed back). I just modify my technique to suit whatever position the bed is going to be in while we are operating. Induction, operative phase, and extubation happen with the bed in the same 90 degree to usual position.

- pod

 

[jetproppilot]

I got to the end of your post hoping you'd share HOW you actually conducted it day after day, so to speak. Other than routine oral midazolam, were there some techniques you wanted to share?

Why yes,

SLIM.

Post #40 elucidates the process fairly well.

What I FORGOT TO INCLUDE is a

Tylenol suppository was inserted by a nurse

during our induction/IV start.

Hope that helps you 🙄

 

[fakin' the funk]

1) For kids, has anyone tried intranasal dex for pre-op sedation?

2) For adult pre-med, is anyone (other than me) using just a touch of propofol (10-20 mg) in pre-op holding?

1. Not preop, but intraop to smooth out wakeup, definitely.
2. Nice idea. I like the pharmacokinetics. Though I feel like I've heard a fair number of horror stories starting with "So I pushed 1 cc of propofol and..."

 

[Oggg]

Squirting 1-2cc of Dex up a kid's nostrils? I would expect the kid to be protective of his/her nose. I'd expect even adults would be leery of a nasal squirt. Most of it probably goes on the floor or into the stomach, right? I'd love to try it though. I remember we gave IN fentanyl to BMTs after induction, in residency.

 

[EdPierce]

prime circuit 8% sevo 50/50 nitrous and oxygen. no premedication necessary: if the kid is a cool customer he wont need it, hell go right out with the gas playing a ipad, in the arms of his parents. then no concerns about increased emergence delirium, apnea, etc. if the kid is a spaz, good luck shooting that oral midaz into his mouth and getting him to actually swallow it. i think the better approach to the difficult kid is keep him in the arms of parents, prime circuit and hold the mask in the palm of you hand. suddenly put the mask on the kids face and hold the back of his head and the mask tightly to his face. follow his head around as he squirms, slowly lowering him to the bed. thanks mom you can go. start giving gentle chin lift, let him breath himself down, dont give PPV, dont mask them deeper, let them spontaneously get deeper and deeper. this way they wont suddenly get deeper than they need to be. at around 2.5-3 mac they will either be hypotensive or significantly obstruct requiring an OA and lots of jaw thrust. turn the gas down if this happens. once they are deep, like 1.5-2 MAC at least, pick up their arm and let it fall. if there is no tone and the arm flops down on the bed, they are ready for the iv. if the kid holds the arm up or the arm is not floppy in any way, wait a little longer. once they do lose tone, get an iv, maybe a little prob, intubate (+/- relaxant/remi depending on the case)

 

[btbam]

Our standard is PO versed for everyone over the age of ~18 months. If child is combative/autistic, you can try a little Sprite mixed with Ketamine PO or go for the K dart with a little glyco mixed in.

Once in room 70/30 N20/O2, 8% sevo for infants.

Depending on how much toddlers/kids/teenagers are freaking out we usually start with the 70/30 mix and slowly dial up the sevo. Parents never come back to the room. Don't F with the kid til they are through stage 2 and gently give CPAP when they start to obstruct, put IV in, go to 100% O2, give prop + fent --> tube.

 

[cchoukal]

Squirting 1-2cc of Dex up a kid's nostrils? I would expect the kid to be protective of his/her nose. I'd expect even adults would be leery of a nasal squirt. Most of it probably goes on the floor or into the stomach, right? I'd love to try it though. I remember we gave IN fentanyl to BMTs after induction, in residency.

That was my experience the couple times I tried it in uncooperative adults. IM Ketamine works better.

 

[Jay K]

Large proportion of my practice is outpatient ENT and peds dental with a scattering of <6 mo's peds and/or neonates.

1) Last 4 yrs probably one instance of oral versed and one instance of IM ketamine for older adult-sized developmental delay patients

2) No dexmed avail for outpt, much less up the nose

3) All kids breathe themselves down on N20 and Sevo FiO2 30-100%

4) When the kids can tolerate eventual jaw thrust and exhibit regular spontaneous ventilation without squirming or tension, then they're deep enough (past stage II) for an IV

5) IV in, additional fentanyl and touch o' prop, intubate

6) kids remain spontaneously ventilating or resume prior to desat

7) our surgeons all turn bed 90 degrees for tonsils

To OP - you're not waiting till they're deep enough and out of stage II if they're laryngospasming on the regular. Note this also applies on emergence - just cause they're squirming doesn't mean they're out of stage II and ready for extubation.