Interesting Case

[Noyac]

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4 yo male otherwise healthy for removal of wires to mandible. His mouth is wired shut. Its gonna take about 30 minutes to remove the wires. How you gonna do the case?

 

[coprolalia]

IM ketamine and a nasal cannula. Actually, that's what I need. (I'm stuck on call right now.)

-copro

 

[IceDoc]

So the problem with just ketamine (I'm assuming you'd add glyco/atropine and midaz) is that it's still possible to have laryngospasm. And if that happens, it's messy (broken surgical field, an attempt to remove wires quickly, etc).

Plan: With ENT in the room (as they're probably the ones removing the wires too), mask induction, iv as soon as practical, nasal intubation.

You might get away with not controlling the airway for this short procedure, but I think you'd have a very hard time justifying that to anyone if something untoward happened.

 

[VentdependenT]

Nasal fiberoptic if general needed.

If surgeon doesn't need it then whatever. Titrate to comfort but cooperativity...sheeaut. Put some nitrous in his nasal canula if you want. can you tell I'm post call and friggen exhausted.

Nothing beats having to converting your 1.3cc .75bup spinal with 25ucg fent and 200duramorph to general on a 5'3 200lber for c-section. All at 5am after no sleep.

 

[VentdependenT]

Just noticed it was for a 4yr old.


ket/scope/vers dart up front.

See how the kid is in the room. If glazed over then slap in nasal canula with some sevo running through it.

If kid still too squirmy then FOI with 5.0ETT on peds fiberoptic. Deep mask induction. Keep spont vent. Stick tube in.

 

[dhb]

If kid still too squirmy then FOI with 5.0ETT on peds fiberoptic. Deep mask induction. Keep spont vent. Stick tube in.

Can you get a 5.0 through a 4 y/o nostril?

 

[epidural man]

mask induction, iv placement, propamine (1-2) mg/kg, nasal cannula for co2 monitoring, precordial stethescope. Probably some reglan and gylco. Maybe some fentanyl. Toradol for sure.

Fiber optic nasal intubation in a 4 yr old?
can it be done? What is the diameter of a pedi scope?

 

[Noyac]

Fiber optic nasal intubation in a 4 yr old?
can it be done? What is the diameter of a pedi scope?

THis is what I was looking for. Are any of you really going to do a FOB on a 4 yo? What is the smallest tube that the pedi scope will fit into? Do you really need to intubate this kid? He had the jaw wired with a 4.5 ETT in place so we know that will fit but can you get a pedi scope through a 4.5 or a 5.0?

 

[cchoukal]

Maybe if you'd used a real dose of bupivicaine... Just a little ribbing from your cross-town colleague. I just came off a month of OB and I don't think I saw anyone over 5'3" who wasn't over 100kg. It's ridiculous.

Nasal fiberoptic if general needed.

If surgeon doesn't need it then whatever. Titrate to comfort but cooperativity...sheeaut. Put some nitrous in his nasal canula if you want. can you tell I'm post call and friggen exhausted.

Nothing beats having to converting your 1.3cc .75bup spinal with 25ucg fent and 200duramorph to general on a 5'3 200lber for c-section. All at 5am after no sleep.

 

[Fah-Q]

THis is what I was looking for. Are any of you really going to do a FOB on a 4 yo? What is the smallest tube that the pedi scope will fit into? Do you really need to intubate this kid? He had the jaw wired with a 4.5 ETT in place so we know that will fit but can you get a pedi scope through a 4.5 or a 5.0?

We have a 2.7mm scope but you shouldn't need it. A standard scope is 4.0mm and the ETT's are named for the inner diameter. So a 4.5 or 5.0 ETT would be fine over a scope for nasal fiberoptic.

What's good to know about the procedure is that there are usually only 2-4 wires that actually have the mandible and maxilla together and these are easily cut (we always have wire cutters at the bedside). If I were doing the case I would ask for a little ketamine to cut the wires (~30 seconds), then you guys can induce and intubate because the mouth will be able to be opened. I would need another ~20 minutes to take the arch bars off.

 

[IceDoc]

The youngest patient I have nasally intubated via FOB was 6mos old, so a 4yo shouldn't be a problem.

Now, like Fah-Q said, if the adept surgeon (who hasn't burned you in the past) assures that the wire part can be done in under 30sec, then I say do it just like he said; though I might still choose a sevo mask induction for style preference.

 

[Noyac]

My partner did Sevo Mask.

 

[coprolalia]

My partner did Sevo Mask.

Yeah, that's a good technique too. You could also mask him down with sevo/nitrous, place the IV, and then start a propofol infusion at 200-250 mcg/kg/min until the case is done. The kid will spontaneously breath until the wires are cut. You can even drop in a nasal trumpet for good measure, if you want. But, you gotta be careful not to tear up Kiesselbach's plexus and start a bleeder. That could be potentially disastrous.

-copro

 

[VentdependenT]

Can you get a 5.0 through a 4 y/o nostril?

Never done it. Dunno.

 

[VentdependenT]

My partner did Sevo Mask.

He had to go and get all fancy on us eh?

 

[huktonfonix]

I think as long as you have some sort of backup plan in place for whatever type of emergency (cant vent, laryngospasm, etc) you should be ok. I would also do what FahQ suggested, mask then tube once wires are off. If Im not sure about the surgeon (i.e. if its plastics) or if the airway looks hard I might just nasal FBO and save myself any potential trouble. Of course I havent had to nasal FBO too many kids yet so Im not sure what size tube will fit in what size nostril.

 

[Fah-Q]

I think as long as you have some sort of backup plan in place for whatever type of emergency (cant vent, laryngospasm, etc) you should be ok. I would also do what FahQ suggested, mask then tube once wires are off. If Im not sure about the surgeon (i.e. if its plastics) or if the airway looks hard I might just nasal FBO and save myself any potential trouble. Of course I havent had to nasal FBO too many kids yet so Im not sure what size tube will fit in what size nostril.

A 14 Fr catheter (5.7mm outer diameter) should be able to be passed with some resistance in a newborn. This corresponds to a 4.0 ETT. I think a 5.0 tube should go just fine in a 4 year-old nose. Just don't leave it in for longer than a day or you'll start to necrose the nasal cavity. The subglottis is the narrowest portion of a pedi airway...this includes the nose.

 

[milrisome]

Unless the kid's got some full stomach issue, no reason to mandate intubation. Shouldn't be any bleeding from the "surgery". I like the idea of pre-op versed, mask induction, IV access, then continuing with propofol/narcotic of choice/Nasal cannula with spontaneous respiration. Shouldn't be too stimulating a procedure either.

If full stomach, pre-op versed, emla, to OR for inhaled nitrous and IV, then induce and place nasal ETT.

 

[milrisome]

Can you get a 5.0 through a 4 y/o nostril?

I do a fair amount of pedi dentals. I start with the same size ETT as I would try orally, and with lube and vasoconstrictor it usually passes. The issues are length of ETT and leak. Smaller ones are shorter and sometimes don't reach as far as you would like. And there is often a large leak with smaller ETTs, though if you keep spontaneous ventilation it's not such a big issue.
It also depends on the size of the kid...If they're smaller than usual for their age, might have to go down a size.
Don't force it, it's a pain to have nasal bleeding. If it won't pass, go down a half size.

 

[dhb]

I do a fair amount of pedi dentals. I start with the same size ETT as I would try orally, and with lube and vasoconstrictor it usually passes. The issues are length of ETT and leak. Smaller ones are shorter and sometimes don't reach as far as you would like. And there is often a large leak with smaller ETTs, though if you keep spontaneous ventilation it's not such a big issue.
It also depends on the size of the kid...If they're smaller than usual for their age, might have to go down a size.
Don't force it, it's a pain to have nasal bleeding. If it won't pass, go down a half size.

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