Inhalation induction actually more safe in kids

[Sonny Crocket]

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Anyone think that an inhalation induction in pediatrics is more safe? Particularly in the age group less than 5 years. I feel that I can get the kids deep with sevo and N2O or sevo alone, keep them spontaneously ventilating, and go from there. All the while gaining lots of information about the kid's airway with regard to masking.

In contrast to an IV induction followed by apnea. Then struggling sometimes to get good mask ventilation before intubating or mask/LMA anesthesia.

Had a 2 year old last night for a wound wash out after a burn in the left hand. Had an IV. My resident wanted to mask the kid for the case which I thought was fine as the kid was NPO and not in any pain. We induced with prop and fent. Resident took the airway, struggled with mask ventilation. And before we know it the kid is in laryngospasm.

 

[Idiopathic]

i think you need to fix your avatar

 

[Depakote]

Do you routinely induce kids with an IV in place?

Your scenario is not exactly optimal, but I feel like you have several options to treat (positive pressure mask/ IV sux). If you're inducing with a mask and no IV and the kid laryngospasms or bradys your options are much more limited. I'll take an IV at induction whenever I can.

 

[Idiopathic]

thats not what i meant

 

[deleted126335]

Anyone think that an inhalation induction in pediatrics is more safe? Particularly in the age group less than 5 years. I feel that I can get the kids deep with sevo and N2O or sevo alone, keep them spontaneously ventilating, and go from there. All the while gaining lots of information about the kid's airway with regard to masking.

In contrast to an IV induction followed by apnea. Then struggling sometimes to get good mask ventilation before intubating or mask/LMA anesthesia.

Had a 2 year old last night for a wound wash out after a burn in the left hand. Had an IV. My resident wanted to mask the kid for the case which I thought was fine as the kid was NPO and not in any pain. We induced with prop and fent. Resident took the airway, struggled with mask ventilation. And before we know it the kid is in laryngospasm.

Kids (and adults) that I want to do a mask case get little to no fentanyl. I like spontaneous ventilation.
If doing a mask case I give a large dose of propofol. Less likely to spasm if deep,
Nothing wrong with gas inductions with an IV in place
With experienced hands it doesn't matter, of course cases like this is how residents get experience.

 

[IlDestriero]

If you're going into laryngospasm immediately after an IV induction, you probably need significantly more induction agent(s). The burn patients laugh at standard induction doses.

There are cases where maintaining spontaneous ventilation is essential. Those cases get mask inductions with gentle iv supplementation. Otherwise it's lido, fent, prop, +/- paralytic and the tube.

 

[KLPM]

i think you need to fix your avatar

I normally have two half windows open. I couldn't even see the question.

 

[KLPM]

[double post]

 

[somedumbDO]

Anyone think that an inhalation induction in pediatrics is more safe? Particularly in the age group less than 5 years. I feel that I can get the kids deep with sevo and N2O or sevo alone, keep them spontaneously ventilating, and go from there. All the while gaining lots of information about the kid's airway with regard to masking.

In contrast to an IV induction followed by apnea. Then struggling sometimes to get good mask ventilation before intubating or mask/LMA anesthesia.

Had a 2 year old last night for a wound wash out after a burn in the left hand. Had an IV. My resident wanted to mask the kid for the case which I thought was fine as the kid was NPO and not in any pain. We induced with prop and fent. Resident took the airway, struggled with mask ventilation. And before we know it the kid is in laryngospasm.

For an expirenced pedi doc it really is the same. There are no studies I know of that compare the two. In europeiv induction is much more common and the risks are the same as in the states.Why didn't u just do a Mac case w prop and sv?? Either way it dosent matter except u had the resident factor. Larygospasm just means u didn't give enough agent or there was something tickling the airway.

 

[Sonny Crocket]

For an expirenced pedi doc it really is the same. There are no studies I know of that compare the two. In europeiv induction is much more common and the risks are the same as in the states.Why didn't u just do a Mac case w prop and sv?? Either way it dosent matter except u had the resident factor. Larygospasm just means u didn't give enough agent or there was something tickling the airway.

Agree. My point is that when you start off mask ventilating, you can probably recognize quicker the fact that you are not ventilating and laryngospasm may be happening, should that happen. Start IV induction on the other hand, patient goes apneic. You MIGHT struggle getting your mask ventilation, before you know it, hypoxia.

Could not agree more with the resident factor.

 

[supahfresh]

I do exclusive pedi cardiac and do most of my inductions as inhalation with sevo so I feel that it can be a very safe induction method in this age group. But having an IV is having control. When your inhalation induction goes bad, you regain control by getting an IV. Ironically you lost control because of your IV.

The fact of the matter is that not every healthy kid needs an iv before induction and even the sicker ones may be difficult access that you risk more problems whereas aspiration during inhalation induction is usually pretty low.

I agree that there is an advantage in keeping the patient spontaneously breathing because it clues you in to titrating their depth which is important when drops in SVR and cardiac depression are important. It also has the advantage of not insufflating the stomach with air especially if your technique is poor or uses greater than 15 cm h20 pressure breaths. Spontaneous breathing is also important for airway cases like a TEF and a foreign body.

Although you could be right that you may notice earlier when you cease to ventilate, quite frankly you should always be able to rapidly make that assesment regardless of technique. When the chest isn't moving and you don't have CO2, you're not ventilating. Pretty simple. So if you say you were struggling to mask ventilate after induction, that sounds like operator error. The induction dose and or mask technique is poor. Have your resident use an oral airway, deepen the anesthetic, seal the mask, and make the chest rise.

You are not protecting yourself better from laryngospasm with the inhalation induction. That sounds like a false sense of security and i have been burned many times doing an inhalational induction on a child with a mild cough who went into laryngospasm as soon as they hit stage 2 anesthesia. The iv induction is superior for suppressing laryngeal reflexes and laryngospasm assuming you give an appropriate dose and it sounds like you might have given too little. My first and second responses to laryngospasm are CPAP and deepen the anesthetic, ie more propofol in your case. I rarely use sux because deepening the anesthesia usually does the trick.

I would always rather have the IV in place prior to induction. When an inhalation induction goes wrong, think about your backup plan.

 

[pgg]

As others have noted, I don't think you can make the claim that one method is safer than the other.

All else being equal, I'd rather have an IV. IV inductions spend a lot less time going through stage 2 than inhalation inductions. Why spend more time in stage 2 than you need to? It typically isn't a problem, unless helpfully impatient helpers in the OR want to get started on an IV, positioning, or prep. Maybe I just work with really helpful people, but when I do peds cases I have to constantly remind them to not bother the patient the instant he quits crying and looks limp.