Hypothetical ASC case

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Noyac

Noyac

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5 yo with H/O OSA and recurrent tonsillitis undergoes an uneventful T&A under GA. Adequate leak around the ETT, no muscle relaxants, 0.1 mg/kg MS for pain, decadron and zofran given. ENT injects local at the end and pt is awakened and extubated without difficulty. Transported to the pacu in lateral position with spontaneous respirations. 15 minutes after arrival to PACU pt is very agitated, gasping for air, with obvious retractions around the clavicle and neck. Nurses are unable to calm the child and sats are not reading since the child is moving so much. Child does not appear hypoxic around the lips but something is obviously wrong. What?
Plan?
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Was the pt run on sevo? Could be related to the volatile. I'd try a little bolus of propofol, which works wonders. If the pt got some midaz pre-op, my next step would be flumazenil.
 
I would do that of course after evaluating the airway & lungs for some other source (ie broncho/laryngospasm; aspiration...)
 
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Propofol is most definitely NOT the answer here. I know what it is, but I'll let others work through it......
 
It could be many things. If her lungs or airway sound bad, I'd be thinking aspiration, spasm or post-obstructive edema. I'd check a CXR if I hear rales. I'd check an ABG if I was thinking CO2 retention. Otherwise, I'd start thinking about emergence delerium.
 
take a listen to the lungs (i agree r/o bronchospams etc). Consider bleeding around where the surgery was and subsequent aspiration/ingestion of the blood.

Bring the parents in to see if they can help calm the kid down. Retractions,etc...I dont know how significant that is since in this age group things like that can be seen when they're crying/agitated.

Is the kid crying (ie maintaining a patent airway)? IF kid is crying and arousable. Then do nothing. Ok let the flaming begin :0
 
first thing i thought of was perhaps vascular injection of local.
but the throat pack thing is a good possibility as well.
i've had to, in the past, ask surgeons if it was alright to pull the packing out 😀
 
Bleeding, throat pack, swelling.

Might consider some vaponephrine.
 
urge said:
Bleeding, throat pack, swelling.

Might consider some vaponephrine.
Click to expand...

howya gonna give this if nurses can't even settle agitated kid down?
 
All very good responses.
No midaz given
Sevo was used
No throat pack
No bleeding, dry as a bone.
There is a very apparent inspiratory stridor.
Pt remains combative, stridorous and severely dyspneic. Sats 88-92% when able to get the pulse ox on. Ascultation reveals bil BS.
 
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Noyac said:
All very good responses.
No midaz given
Sevo was used
No throat pack
No bleeding, dry as a bone.
There is a very apparent inspiratory stridor.
Pt remains combative, stridorous and severely dyspneic. Sats 88-92% when able to get the pulse ox on. Ascultation reveals bil BS.
Click to expand...

Sedate the kid with Propofol while you assist ventilation with mask and ambu, then allow the kid to wake up slowly and see if the stridor is improving, if not re intubate.
 
Planktonmd said:
Sedate the kid with Propofol while you assist ventilation with mask and ambu, then allow the kid to wake up slowly and see if the stridor is improving, if not re intubate.
Click to expand...

May be worth a try. I don't think you lose anything here. But tell me, do you think it will work?

Consig seems to think it won't help. 👍
 
Noyac said:
May be worth a try. I don't think you lose anything here. But tell me, do you think it will work?

Consig seems to think it won't help. 👍
Click to expand...

🙂
So, I guess you are hinting to vocal cord paralysis caused by the local anesthetic injection?
No, Propofol and PPV are not going to help but I would still R/O the common causes (bleeding, laryngospasm) as we already did and then just intubate the kid and wait for the local anesthetic to resolve.
 
has happened a few times to me --

1) immediately bring child back to OR
2) have ENT paged to OR
3) get set-up for intubation
4) put mask on face w/ O2 and try to aid w/ some positive pressure
5) if kid TOO combative and you still have IV access then a touch of versed can help

in all 4 experiences (i remember them well), I ended up re-intubating or masking after propofol bolus (with ENT next to me) with no blood in the airway... just weird laryngospasm...

then in all 4 cases, we woke them up very, very slowly in the OR, and didn't transport back to PACU until we felt comfortable w/ their respiratory efforts

you ain't gonna take short cuts when it is a kid...
 
Planktonmd said:
This is a diagnosis of elimination and when faced with stridor after tonsillectomy you have first to rule out the common causes:
Laryngospasm and Bleeding.
Click to expand...

In my opinion the most common cause of upper airway obstruction post T&A with local injection is spread of the local to the recurrent laryngeal nerve. If tachycardia and hypertension is present then the spread is to the vagus nerve.

The study Gern posted is a good read. 9 of 16 pts experienced some form of UAO after local injection. Thats a high percentage. Most commonly onset of symptoms is about 15 minutes post injection. In this day, you are in the pacu by this time and on to the next pt. Narcotics seem to worsen the situation if spread does occur due to decreased resp drive. Clearing of secretions is also quite difficult in these pts.

How many of you work with ENT's that inject after a T&A? How much (cc's) do they inject? Do you see UAO like this study describes?
 
Noyac said:
In my opinion the most common cause of upper airway obstruction post T&A with local injection is spread of the local to the recurrent laryngeal nerve. If tachycardia and hypertension is present then the spread is to the vagus nerve.

The study Gern posted is a good read. 9 of 16 pts experienced some form of UAO after local injection. Thats a high percentage. Most commonly onset of symptoms is about 15 minutes post injection. In this day, you are in the pacu by this time and on to the next pt. Narcotics seem to worsen the situation if spread does occur due to decreased resp drive. Clearing of secretions is also quite difficult in these pts.

How many of you work with ENT's that inject after a T&A? How much (cc's) do they inject? Do you see UAO like this study describes?
Click to expand...

I work with several ENT's, one of them injects every patient with Marcaine and over the past 7-8 years I have not seen any post op complications with his patients, they are all pain free and wake up nicely, while the other ENT's who don't inject have patients who wake up agitated and develop laryngospasm in the OR or in PACU.
My guy injects 2cc of 0.25% with epi on each side.
So, I guess it is operator dependant.
 
Tenesma said:
has happened a few times to me --

1) immediately bring child back to OR
2) have ENT paged to OR
3) get set-up for intubation
4) put mask on face w/ O2 and try to aid w/ some positive pressure
5) if kid TOO combative and you still have IV access then a touch of versed can help

in all 4 experiences (i remember them well), I ended up re-intubating or masking after propofol bolus (with ENT next to me) with no blood in the airway... just weird laryngospasm...

then in all 4 cases, we woke them up very, very slowly in the OR, and didn't transport back to PACU until we felt comfortable w/ their respiratory efforts

you ain't gonna take short cuts when it is a kid...
Click to expand...
Agree.
 
Planktonmd said:
This is a diagnosis of elimination and when faced with stridor after tonsillectomy you have first to rule out the common causes:
Laryngospasm and Bleeding.
Click to expand...

I know that. No one was criticizing you.
 
Good post.

I still have a question. What do you do with a pt like that? Tube them and wait an hour or two for the local to wear off? I would imagine if both rec laryn nerves are blocked there is nothing else you can do.

Is that the way to go?
 
Planktonmd said:
🙂
So, I guess you are hinting to vocal cord paralysis caused by the local anesthetic injection?
No, Propofol and PPV are not going to help but I would still R/O the common causes (bleeding, laryngospasm) as we already did and then just intubate the kid and wait for the local anesthetic to resolve.
Click to expand...

so, depending on the time from injection to PACU,
is re-intubation the recommended consensus here?
 
I've had one case and I just supported the kid while he sat upright allowing me to suction his oropharynx deep. He was more cooperative than the others my partners have had. I believe one or two kids have been re-intubated. Then extubated at some time afterwards and d/c'd home that day.
So re-intubation is not always necessary. But read the article posted above. It can help you in your decision making. Some of these kids went to the ICU.
 
By the way, if I give sux and resolve the problem I may not elect to re-intubate but you gotta understand what got you in this situation in the first place. If you wake the kid up after breaking the pattern it may just occur again. So if the obstruction is bad enough for re-intubation then I'd probably keep him intubated for some time. And if I got pink frothy sputum then he goes to the unit more than likely for about 24 hrs.
 
Thanks, great case. Pulled the article.
 
Noyac said:
I've had one case and I just supported the kid while he sat upright allowing me to suction his oropharynx deep. He was more cooperative than the others my partners have had. I believe one or two kids have been re-intubated. Then extubated at some time afterwards and d/c'd home that day.
So re-intubation is not always necessary. But read the article posted above. It can help you in your decision making. Some of these kids went to the ICU.
Click to expand...

in case 1, of the article above,
does anybody know why hypokinesis/mitral regurg developed?
anything to do with stunning the heart due to partial block of any of the branches of the vagus n.?
 
dfk said:
in case 1, of the article above,
does anybody know why hypokinesis/mitral regurg developed?
anything to do with stunning the heart due to partial block of any of the branches of the vagus n.?
Click to expand...

I was thinking it was due to hypoxia. True, once they got an ABG, oxygenation was adequate, but during the incident there must have been some hypoxia. There was definitely pulmonary edema. Perhaps there was also some pulmonary hypertension which would hamper the right ventricle. I don't know how blocking the vagus would cause stunning of the heart, as noyac points out, blocking the vagus will cause tachycardia as the sympathetics take over.
 
dfk said:
in case 1, of the article above,
does anybody know why hypokinesis/mitral regurg developed?
anything to do with stunning the heart due to partial block of any of the branches of the vagus n.?
Click to expand...

Like milrisome said. But also had to do with the work load placed on the heart during the UAO. The increased left ventricular after load and wall tension put undo stress on the heart while also decreasing subendocardial blood flow. Basically, a stunned heart.
 
Good case, I didn't know why the local caused the rxn it did, but I knew what you were hinting at when you presented the case. I think what tipped me off is when you said "ENT injects local AT THE END" and THEN S**T hit the fan.
 
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