I hate f*ing peds

[ucsfgaspain]

---

Members don't see this ad.

Here's another case for everyone to take a crack at.

I'm chilling in our break room having a cup of coffee waiting in between cases and I get stat paged out to the PACU. My colleague is trying to break assumed laryngospasm on a healthy 4 year old male after T & A. She breaks it as I get there and the kids turns that wonderful shade of pink from that not so great purple color. I sit there with my colleague for about 3 minutes...shooting the ****...talking about the weekend. Kids breathing fine...satting fine. I head back to the break room to finish my coffee. I get paged back stat to the PACU. I run back and kid is obviously obstructed. We do a two person mask with myself managing the airway as she bags. I'm doing the two hand seal on this case with my fingers jammed into the laryngospasm notch and I am dislocating this kids mandible with so much force I literally feel like I'm going to to tear this kids jaw off.

The kid is not moving air at all. The kid is desatting fast. The kid is turning that god awful blue. The kid is beginiing to brady. The kid is dying on me.

I'm screaming to break out some succ and atropine. To get me a blade and a tube. Course there is none around. But I'm one of those so uncool dudes that wears a fanny pack Guess what I've got in the fanny nerd pack...succ. Nurse gets it out of my pack...draws it up...and as she's about to give it...the laryngospasm breaks.

I talk to my colleague about her kid. He is a healthy 4 y.o. with sleep apnea thus the T & A. She had extubated him deep. He had laryngospasm once in the OR at extubation...broken easily...spasms in the PACU now tX 2. It has been at least 30 minutes since the end of the case.

So my question is? Have you guys experienced laryngospasm this late afterwards and have you had woresening laryngospasm on subsequent bouts i.e. the 3rd episode being worse than the first two? I had never experienced the above so I was going down the whole differential of airway obstruction i.e. throat pack out..blah blah blah. We ended up doing a fiber to rule out upper airway edema which was normal, I gave the kid nebulized racemic epi empirically. Got a CXR which was neg.

I talked to one of our pedi guys and he had stated that he probably would have tubed the kid after the second laryngospasm and sorted **** out after the kid was totally wide awake. And NO the surgeon did not use local🙂

Thanks for your input.

Peace.

 

[deleted126335]

.

 

[pgg]

I don't do deep extubations after tonsils OR kids with OSA, even over at the childrens hospital where I can trust the PACU staff to (usually) do the right thing and keep their hands off the kid while he wakes up.

A kid who obstructs when he's asleep, who just had airway surgery where blood and snot are even more likely to drip down onto his cords, really ought to be wide awake when the tube comes out. I've worked with some attendings who directed me to extubate deep in these circumstances, and I've seen a couple laryngospasm in the PACU just like your case today, so when the choice is up to me, I wake them up.

On another note, I suspect that most kids with OSA are far more likely to benefit from calorie reduction than tonsillectomy. Point being, I don't think you can ever count on the surgery "fixing" the OSA, even though that's usually the stated point of the surgery in the first place.

 

[coprolalia]

I hate T&A's. This exact same scenario has happened to me. We have one Peds attending who's figured out some magic mojo anti-spasm juju potion that he always gives before waking them up, and he always pulls the tube deep. His T&A kids never spasm.

If you pay me $5 bucks, I'll tell you. I'll post my PayPal account.

-copro

 

[pgg]

If you pay me $5 bucks, I'll tell you. I'll post my PayPal account.

I guess my curiosity somewhat outweighs my dubiosity, but I'm not giving you $5. 🙂

 

[coprolalia]

I guess my curiosity somewhat outweighs my dubiosity, but I'm not giving you $5. 🙂

I'll give you a hint... among other things, it involves a LOT more fentanyl that most pediatric anesthesiologists are usually comfortably giving a toddler. 😉

-copro

 

[Monty Python]

Here's another case for everyone to take a crack at.

I'm chilling in our break room having a cup of coffee waiting in between cases and I get stat paged out to the PACU. My colleague is trying to break assumed laryngospasm on a healthy 4 year old male after T & A. She breaks it as I get there and the kids turns that wonderful shade of pink from that not so great purple color. I sit there with my colleague for about 3 minutes...shooting the ****...talking about the weekend. Kids breathing fine...satting fine. I head back to the break room to finish my coffee. I get paged back stat to the PACU. I run back and kid is obviously obstructed. We do a two person mask with myself managing the airway as she bags. I'm doing the two hand seal on this case with my fingers jammed into the laryngospasm notch and I am dislocating this kids mandible with so much force I literally feel like I'm going to to tear this kids jaw off.

The kid is not moving air at all. The kid is desatting fast. The kid is turning that god awful blue. The kid is beginiing to brady. The kid is dying on me.

I'm screaming to break out some succ and atropine. To get me a blade and a tube. Course there is none around. But I'm one of those so uncool dudes that wears a fanny pack Guess what I've got in the fanny nerd pack...succ. Nurse gets it out of my pack...draws it up...and as she's about to give it...the laryngospasm breaks.

I talk to my colleague about her kid. He is a healthy 4 y.o. with sleep apnea thus the T & A. She had extubated him deep. He had laryngospasm once in the OR at extubation...broken easily...spasms in the PACU now tX 2. It has been at least 30 minutes since the end of the case.

So my question is? Have you guys experienced laryngospasm this late afterwards and have you had woresening laryngospasm on subsequent bouts i.e. the 3rd episode being worse than the first two? I had never experienced the above so I was going down the whole differential of airway obstruction i.e. throat pack out..blah blah blah. We ended up doing a fiber to rule out upper airway edema which was normal, I gave the kid nebulized racemic epi empirically. Got a CXR which was neg.

I talked to one of our pedi guys and he had stated that he probably would have tubed the kid after the second laryngospasm and sorted **** out after the kid was totally wide awake. And NO the surgeon did not use local🙂

Thanks for your input.

Peace.

Were the tonsil beds still oozing ... was the kid coughing up enough blood to make you suspect this was the cause of the spasm?

 

[Pilot Doc]

I'll give you a hint... among other things, it involves a LOT more fentanyl that most pediatric anesthesiologists are usually comfortably giving a toddler. 😉

-copro

Guess you can't be stridorous if you're not trying to breathe

 

[ucsfgaspain]

It was my first thought too. But not much was coming up when we were suctioning. When we slipped the fiber down (I used my finger as the bite guard (ouch, the sacrifices we make for patient care), it was actually quite dry. Like I said, I hate f*ing peds...too much to lose, nothing to gain.

 

[huktonfonix]

shouldnt spasm if theyre awake, unless there is some other issue (hypocalcemic, etc..) . The next question is, did the kid receive some PACU meds to obtund him ? If not, maybe the kid was still obstructed and had enough CO2 on board to obtund him enough to go into laryngospasm (although thats kind of a stretch). Pulm edema after relieving the obstruction is another consideration although it doesnt really fit the picture here as this sounds like it was laryngospasm. Are you sure it wasnt bronchospasm?

 

[militarymd]

It was my first thought too. But not much was coming up when we were suctioning. When we slipped the fiber down (I used my finger as the bite guard (ouch, the sacrifices we make for patient care), it was actually quite dry. Like I said, I hate f*ing peds...too much to lose, nothing to gain.

amen brother

 

[usnavdoc]

shouldnt spasm if theyre awake, unless there is some other issue (hypocalcemic, etc..) . The next question is, did the kid receive some PACU meds to obtund him ? If not, maybe the kid was still obstructed and had enough CO2 on board to obtund him enough to go into laryngospasm (although thats kind of a stretch). Pulm edema after relieving the obstruction is another consideration although it doesnt really fit the picture here as this sounds like it was laryngospasm. Are you sure it wasnt bronchospasm?

My thought is that they were extubated deep and taken to PACU with alot of agent still onboard. When I extubate kids deep I wait in the OR till I get past stage 2. I also keep sux in my pocket when doing peds.

 

[huktonfonix]

My thought is that they were extubated deep and taken to PACU with alot of agent still onboard. When I extubate kids deep I wait in the OR till I get past stage 2. I also keep sux in my pocket when doing peds.

30 minutes later though? Thats a hell of a lot of agent on board. seems unlikely unless the kid was severely hypoventilating. I believe that the 1st spasm was stage 2 maybe the 2nd. I have a hard time believing that the last one is from residual agent. I agree with the awake extubation and sux (and atropine) though.

 

[SleepIsGood]

UCSF

I think from what you've posted...and great posts by the way.. I think I should always keep a stick of sux and atropine with me when taking these guys to the PACU.

Great stuff👍

 

[Pooh & Annie]

My thought is that they were extubated deep and taken to PACU with alot of agent still onboard. When I extubate kids deep I wait in the OR till I get past stage 2. I also keep sux in my pocket when doing peds.

This definitely seems like the safest route, but one of the benefits of extubating deep is the speed of room turnover, isn't it? I guess if I was at a hospital with PACU staff comfortable with kids I'd have no trouble bringing the kids in deep. Somewhere where they don't see a lot of deep extubations maybe I'd think twice.

 

[Noyac]

Like I said, I hate f*ing peds...too much to lose, nothing to gain.

Until you get your collections after doing 10-15 PE tubes all b/4 noon.

 

[militarymd]

My thought is that they were extubated deep and taken to PACU with alot of agent still onboard. When I extubate kids deep I wait in the OR till I get past stage 2. I also keep sux in my pocket when doing peds.

They let you do that at KD????

How's S. Defreitas doing?

 

[pgg]

When I extubate kids deep I wait in the OR till I get past stage 2.

They let you do that at KD????

How's S. Defreitas doing?

I think usnavdoc got out and is a civilian now.

Last year at KD the standard practice was almost every patient went to the PACU asleep to emerge there. I hear in recent months they got some new PACU staff and that fewer attendings were doing the deep extubation thing ... because of a few stat PACU calls for laryngospasm.

Haven't seen him since last December, but he was doing great then. Very nice, capable guy. Yet another great anesthesiologist the Navy couldn't hold onto.

 

[Fah-Q]

On another note, I suspect that most kids with OSA are far more likely to benefit from calorie reduction than tonsillectomy. Point being, I don't think you can ever count on the surgery "fixing" the OSA, even though that's usually the stated point of the surgery in the first place.

Great discussion. I just wanted to correct the above comment. T&A when done for adenotonsillar hypertrophy cures the OSA in kids about 95-99% of the time. The OSA will not be cured in PACU because of the acute swelling but I've never seen a kid at the one month post-op visit that was still snoring. T&A is a terrible operation for obese teens and adults when trying to cure OSA but kids are a completely different story.

 

[pgg]

Great discussion. I just wanted to correct the above comment. T&A when done for adenotonsillar hypertrophy cures the OSA in kids about 95-99% of the time. The OSA will not be cured in PACU because of the acute swelling but I've never seen a kid at the one month post-op visit that was still snoring. T&A is a terrible operation for obese teens and adults when trying to cure OSA but kids are a completely different story.

Interesting, thanks for posting. What about obese kids? Still high success rates?

 

[usnavdoc]

This definitely seems like the safest route, but one of the benefits of extubating deep is the speed of room turnover, isn't it? I guess if I was at a hospital with PACU staff comfortable with kids I'd have no trouble bringing the kids in deep. Somewhere where they don't see a lot of deep extubations maybe I'd think twice.

Having a good pacu with staff that knows how to deal with Peds is a benefit of training in a place with a dedicated Peds hospital.

 

[usnavdoc]

They let you do that at KD????

How's S. Defreitas doing?

Im at Emory. I got out of the Navy after my 4 yr GMO stint at Lejeune with PGG.

Incidentally, where are you off to next year PGG? Have the detailors started giving you ideas yet? The Job search has become an interesting little stressor on the civ side.

 

[pgg]

Incidentally, where are you off to next year PGG? Have the detailors started giving you ideas yet? The Job search has become an interesting little stressor on the civ side.

Not much information yet. If it's anything like last year, they'll be very secretive until December when the GME selection board results are out and they know which people are doing fellowships.

Several of us want to stay at Portsmouth, but the word is that it's likely that no residents can be retained this year. As they describe the scheme, there are 15 or 20 outservice people coming back in after civilian residencies, and they like to put all of them at one of the big 3 medcens, because if they suck they can be remediated. Apparently the Navy's been burned by putting some of these "unknowns" out at smaller commands, only to have to move people around midcycle if they turn out to be incompetent. Whereas inservice guys like me are "known commodities" and they're comfortable sending us out where there's less backup. Not sure I agree with that logic, but there it is.

Anyway, hoping to stay at Portsmouth, but I may well end up back at Lejeune. 🙂.

 

[militarymd]

Im at Emory. I got out of the Navy after my 4 yr GMO stint at Lejeune with PGG.

Incidentally, where are you off to next year PGG? Have the detailors started giving you ideas yet? The Job search has become an interesting little stressor on the civ side.

sorry, got you confused with PGG....pm me if you're interested in jobs.

 

[militarymd]

I think usnavdoc got out and is a civilian now.

Last year at KD the standard practice was almost every patient went to the PACU asleep to emerge there. I hear in recent months they got some new PACU staff and that fewer attendings were doing the deep extubation thing ... because of a few stat PACU calls for laryngospasm.

Haven't seen him since last December, but he was doing great then. Very nice, capable guy. Yet another great anesthesiologist the Navy couldn't hold onto.

Steve was one of my residents...than partner at NMCP....we tried to convince to move south with me, but my practice doesn't have enough peds for someone like him.

Although, from the housing market POV, he would have done a lot better with me.

 

[Mac Six]

We extubate about half of our peds T&A's deep and get them through stage 2 in the OR. Sometimes we work in a little precedex through the case and it smooths the wake up a bit (especially in cases like peds dental where the little tykes wake up a little fussy).

 

[Fastrach]

We extubate about half of our peds T&A's deep and get them through stage 2 in the OR. Sometimes we work in a little precedex through the case and it smooths the wake up a bit (especially in cases like peds dental where the little tykes wake up a little fussy).

I have a staff who insists on giving Dexmedetomidine as you describe for emergence delirium... yet I can't help but feel guilty opening such a pricey vial for such a tiny drug dosage, particularly when Propofol works just as nicely for this purpose with all my other Peds staff.

 

[maceo]

That's why I don't extubate kids deep. Doesn't look as slick 99% of the time and takes longer, but it avoids this ****.

i agree with you here. I NEver ever will extubate a kid deep after a tonsil. I had an ent doc request vehemently that i do one time. I felt so strongly about this that I said i wouldnt do the case. She said fine and got someone else to do the case to extubate a child who has friable tonsillar pillars... still oozing probably deep. This is asking for trouble. Trouble comes my way daily without me requesting trouble.

 

[Pooh & Annie]

I'm sure you already know this, but put them on their side so whatever oozing there is doesn't head toward the cords. Maybe you've had a couple bad experiences. Seems to work pretty well from what I've seen (which admittedly isn't a whole lot).