Help with peds extubation

[residency2010]

Hi all, I ve been in practice for 5 years in a trauma center. I do simple peds cases once a week. Usually they are ok, but for the past 3 months, almost all my peds cases give me hard time during extubation ( 1-2 yrs old) they start breathing but buck/ hypoventilate and spo2 drops to 60’s and I actively ventilate to bring it up and it delays my extubation. It never happened before 3 months. Not sure what I am doing different now. Any tips?

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[GaseousClay]

what kind of cases are these? I've been having great wake ups with 1mcg/kg intranasal of 0.5mcg/kg IV at beginning of the case. Usually for the tonsil cases but smooth wake ups for hernias as well with minimal to no narcotic. Good suctioning and having them breathe spontaneously early helps as well. I also deep extubate a lot of kids and have not had many problems. Doing kids like 1-10 years of age pretty regularly.

 

[DrAmir0078]

Hi all, I ve been in practice for 5 years in a trauma center. I do simple peds cases once a week. Usually they are ok, but for the past 3 months, almost all my peds cases give me hard time during extubation ( 1-2 yrs old) they start breathing but buck/ hypoventilate and spo2 drops to 60’s and I actively ventilate to bring it up and it delays my extubation. It never happened before 3 months. Not sure what I am doing different now. Any tips?

Peds have many tricks

One of our Attendings, used to do alveolar recruitment using medical air before extubation for 5 seconds, it helps a lot.

As other comment recommends good suctioning.

 

[kidthor]

for the past 3 months, almost all my peds cases give me hard time during extubation ( 1-2 yrs old) they start breathing but buck/ hypoventilate and spo2 drops to 60’s and I actively ventilate to bring it up and it delays my extubation.

What else is happening when they do this? Are they just sitting there and this is random - or is something else going on?

I find that adult-style harassment wakeups (aggressive suctioning, jaw thrusting, yelling "open your eyes!!!") will cause this kind of poor emergence in peds. Also when other members of the periop environment are harassing the kid with dressings, bovie pad removal, diaper changes, etc - similar suboptimal wakeup.

I personally have good success if some opioid (e.g. 1mcg/kg) and/or preccedex (0.5mcg/kg) is on board and then I try not to harass the kid during true emergence.

If this is trending over the last 3 months - do the kids maybe have secret URIs going around or seasonal/situational allergies?

 

[residency2010]

Thank you all. It happens only in general surgery cases like circ or hernia or lumps and bumps. Never in ent. I usually give fentanyl 1mcg/kg before intubation and that’s it. May be I lll try some propofol at the end of case.

 

[BobLoblaw78]

Work in more fentanyl. And I second what kidsore said, let sleeping dogs lie! I have seen 100's of kids breathing fine without obstruction, then someone puts in an oral airway and puts them in recovery position-----> Bronchospasm from harassment by staff/anesthesia. Why would you take anyone without obstruction and put in an oral airway. Or put them in recovery position? (I am sure I am in the minority)

 

[nimbus]

Thank you all. It happens only in general surgery cases like circ or hernia or lumps and bumps. Never in ent. I usually give fentanyl 1mcg/kg before intubation and that’s it. May be I lll try some propofol at the end of case.

Why not LMA+-caudal for these?

 

[daneeka]

Agree with propofol at the end. Say 1 mg/kg bolus, wait for breathing to start back up again (usually no apnoea with this dose) then pull the tube out lying lateral. Ensures they're deep enough, and reduces the incidence of emergence delirium.

 

[Impromptu]

I was often encouraged to use the "don't touch" method. Just let them wake up.

I have also tried the emergence fentanyl or [insert other drug here] adjunct methods. There are pros and cons to every one.

 

[Noyac]

I prefer LMA’s for the genera pedi cases. Caudals if necessary.
But when I do intubate I usually have them breathing nice and slow (for a kid) with good TV. Then I pull it deep with some propofol onboard for the emergence. Place them on their side either before or after extubating and roll off to PACU. Let them wake up on their own. I rarely use an oral airway as was mentioned earlier.

There are many ways to wake kids up.

 

[Hork Bajir]

Many good methods mentioned above. One thing I don’t think anyone has said yet: If you’re going to pull an ETT deep, first make sure you give a vigorous suction, then jiggle the tube. You’re looking to see if the stimulation makes the kid breath hold, or if they keep breathing regularly. Then take the cuff down, and look at the monitor again. If the kid breath holds, you’re at risk for spasm when you pull the tube; you either want to deepen them more, or let them wake up. If they continue to breathe regularly through all of this, then you’re good to go. Yank that sucker and do your thing.

Of course, this won’t prevent a laryngospasm 5 minutes later when they’re getting jostled around in the PACU... For successful deep pedi extubations, you really need peri-op/PACU staff who are familiar with the technique. But, doing the above will help avoid 99% of laryngospasms that happen immediately upon extubation due to patient not being deep enough. It takes more anesthesia than you might think- I’ve had kids laryngospasm after pulling the tube while breathing 3% sevo!

 

[dhb]

Caudals if necessary.

Haven't done one in 10 years, TAP blocks all the way!

 

[btbam]

Many good methods mentioned above. One thing I don’t think anyone has said yet: If you’re going to pull an ETT deep, first make sure you give a vigorous suction, then jiggle the tube. You’re looking to see if the stimulation makes the kid breath hold, or if they keep breathing regularly. Then take the cuff down, and look at the monitor again. If the kid breath holds, you’re at risk for spasm when you pull the tube; you either want to deepen them more, or let them wake up. If they continue to breathe regularly through all of this, then you’re good to go. Yank that sucker and do your thing.

Of course, this won’t prevent a laryngospasm 5 minutes later when they’re getting jostled around in the PACU... For successful deep pedi extubations, you really need peri-op/PACU staff who are familiar with the technique. But, doing the above will help avoid 99% of laryngospasms that happen immediately upon extubation due to patient not being deep enough. It takes more anesthesia than you might think- I’ve had kids laryngospasm after pulling the tube while breathing 3% sevo!

I extubate at 4%+ ET Sevo. You’ll suction them that deep and they still breath hold. Crazy.

 

[residency2010]

Thank you for all the responses. Will try some of these in my peds. I m not really comfortable with Lma for less than 2 yrs ago because of seating issues..

 

[Noyac]

Thank you for all the responses. Will try some of these in my peds. I m not really comfortable with Lma for less than 2 yrs ago because of seating issues..

Now is the time to practice and get good at it. It will save your arse one day.