Let's talk technique

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Noyac

Noyac

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Lets see how people approach this case.
3-5 yo pt with history of asthma. Had an episode of RSV one month ago with residual cough up until 2 weeks ago. Currently doing well, afebrile and mild cough but not much different from his usual status. Hasn't used albuterol in over a week. Posted for BMT & adenoids at out-pt surgery center. Parents are well educated non smokers. Pt is not obese and has mild snoring habits but no real OSA. Enlarged tonsils but no symptoms of tonsillitis in the past so they are staying.
Questions are:
- would you do the case?
- what's your induction plan?
-what's your intraop plan?
- what's your emergence plan?
- what's your discharge plan?
 
1. If patient is at his baseline, lungs are clear, afebrile I would do the case. I usually wait about 4 weeks for RSV. He might be chronically congested just from his large adenoids and may never get better until he has his surgery

2. Preop: midazolam po 0.5 mg/kg. Albuterol nebulizer in preop holding

3. Intraop: Gas induction, PIV, +/- propofol depending on how deep he is, tube. Maintenence: Sevo, Fentanyl 1 mcg/kg increments titrated to RR. Decadron 0.5 mg/kg.

4. Emergence: Deep extubation, laying on his side

5. Discharge: If patient has no documented OSA either from a sleep study or from a thorough history from parents and he is doing well in PACU with no desat episodes or apnea spells I would send him home after watching him for an hour. I would warn the parents about the possibility of being admitted post op given his recent URI and a patient undergoing airway surgery.
 
Noyac said:
Questions are:
- would you do the case? Yes
- what's your induction plan? Mask induction with sevo; place IV, intubate
-what's your intraop plan? Maintain pt on sevo, fentanyl 2 mcg/kg, decadron 0.5 mg/kg IV
- what's your emergence plan? Extubate when awake
- what's your discharge plan? Discharge when drinking liquids and pain adequately controlled
Click to expand...
 
HalO'Thane said:
5. Discharge: If patient has no documented OSA either from a sleep study or from a thorough history from parents and he is doing well in PACU with no desat episodes or apnea spells I would send him home after watching him for an hour. I would warn the parents about the possibility of being admitted post op given his recent URI and a patient undergoing airway surgery.
Click to expand...

Pretty ballsy. I've done hundreds and probably thousands of these cases at a surgery center and they mandate that the pt. stays 4 hours post-op.
 
HalO'Thane said:
1. If patient is at his baseline, lungs are clear, afebrile I would do the case. I usually wait about 4 weeks for RSV. He might be chronically congested just from his large adenoids and may never get better until he has his surgery

2. Preop: midazolam po 0.5 mg/kg. Albuterol nebulizer in preop holding

3. Intraop: Gas induction, PIV, +/- propofol depending on how deep he is, tube. Maintenence: Sevo, Fentanyl 1 mcg/kg increments titrated to RR. Decadron 0.5 mg/kg.

4. Emergence: Deep extubation, laying on his side

5. Discharge: If patient has no documented OSA either from a sleep study or from a thorough history from parents and he is doing well in PACU with no desat episodes or apnea spells I would send him home after watching him for an hour. I would warn the parents about the possibility of being admitted post op given his recent URI and a patient undergoing airway surgery.
Click to expand...
Pretty good plan.
But why would a 3-5 yo have apnea spells?
 
Consigliere said:
Pretty ballsy. I've done hundreds and probably thousands of these cases at a surgery center and they mandate that the pt. stays 4 hours post-op.
Click to expand...
Noyac said:
Pretty good plan.
But why would a 3-5 yo have apnea spells?
Click to expand...

@Consigliere: I believe at our institution if the patient is > 3 y.o., has no documented OSA, and is undergoing an adenoidectomy only (e.g. no tonsillectomy) we treat them like a regular ambulatory case, which is usually 30 min in PACU and another 30 min - 1 hour in phase 2, but I can look into this because now I am curious

@Noyac: While the majority of these kids have an obstructive component to their sleep disordered breathing as a result of their adenotonsillar hypertrophy, there may be a component of central sleep apnea as well as hypopnea (cessation of airflow), thereby making them at further risk of post op respiratory complications that will not be fixed right away from their procedure. I suppose I should have clarified my statement by saying that I would make sure that the kid did not have any apnea OR hypopnea episodes.
 
Yeah the "apnea spells" wording is something I associate with premature infants.
 
Consigliere said:
Pretty ballsy. I've done hundreds and probably thousands of these cases at a surgery center and they mandate that the pt. stays 4 hours post-op.
Click to expand...
When you say "these pts" do you mean all adenoidectomies? Or are you talking about pts like this one in particular? If you are talking about this pt, then what are the triggers you are talking about?
 
Tell me more about the "apnea spells". I'd probably have ENT admit for overnight obs if there isn't more to say about it. Also would do racemic epi in pacu if any hint of wheezing and give Decadron and zofran during case. Maybe avoid benzos and narcs and give ofirmev intraop if apnea is a real thing for him.
 
Noyac said:
Lets see how people approach this case.
3-5 yo pt with history of asthma. Had an episode of RSV one month ago with residual cough up until 2 weeks ago. Currently doing well, afebrile and mild cough but not much different from his usual status. Hasn't used albuterol in over a week. Posted for BMT & adenoids at out-pt surgery center. Parents are well educated non smokers. Pt is not obese and has mild snoring habits but no real OSA. Enlarged tonsils but no symptoms of tonsillitis in the past so they are staying.
Questions are:
- would you do the case?
- what's your induction plan?
-what's your intraop plan?
- what's your emergence plan?
- what's your discharge plan?
Click to expand...

Yes.
Inhalation.
GETA.
Consider deep extubation.
Per pedi pacu protocol.

*Can adjust as patient course develops.
 
Ok so it appears that everyone so far would proceed.
Some of the discrepancies between posters are:
1) albuterol pre op- is this a good idea or not? This pt is 3-5yrs old.
2) deep vs awake extubation
3) keep the kid for extended period post op or not.
 
So I believe the academic answer is to wait 6 weeks post-URI in these types of patients. Studies have shown in healthy children increased risk of respiratory complications in those with recent URIs and have also shown increased airway reactivity for up to 6 weeks post-URI.

Cough up until 2 weeks ago means he was still symptomatic until recently. I personally had one very bad bronchospasm in a kid with recent URI and I never want to relive that again (parents were *****s by the way and failed to tell me despite my asking if the patient had asthma/RAD).

I would cancel, wait and additional 4 weeks. Bring back, inhalation induction with Sevo/nitrous and propofol prior to intubation. Can also get away with an LMA for adenoids only if the surgeon doesn't mind. Deep extubation and to PACU.
 
Anesthesia Intern, but just finished my peds month. The peds attendings have told us repeatedly albuterol treatments during RSV or post RSV does absolutely nothing. I have not checked lit, but one attending said literature also "proved" really did not make a significant difference, but we do it "because it makes us feel better."

Would this also be the case in this situation? I've also noticed we do nebulizer treatments in anesthesia. When I asked the pediatric attendings, they again state literature shows MDI superior to nebulizer treatment, or at best equal, therefore no use in doing nebulizer when you can just do 4-6puffs of the MDI attached to a chamber.

What am I missing?
 
I do quite a few of these at the ambulatory center.

If pt is baseline , non febrile not wheezing, pt may not have another URI free period to do the case.

Preop: 0.25 mg/kg versed

Induction : Mask with sevo, Iv placed , GETA. Zofran , decadron , ofirmev , Fentanyl 1mcg/kg.

Emergence : awake . don't like to mess around with airway cases and awake

Discharge : If pt has no sleep apnea diagnosis , and questioning parents on signs of osa ... discharge in hour ... IF suspicious of Osa d/ c in 3 hours .


Sent from my iPhone using Tapatalk
 
Noyac said:
Ok so it appears that everyone so far would proceed.
Some of the discrepancies between posters are:
1) albuterol pre op- is this a good idea or not? This pt is 3-5yrs old.
2) deep vs awake extubation
3) keep the kid for extended period post op or not.
Click to expand...

1.) No difference.
2.) Deep unless difficult airway or copious bleeding/secretions
3.) Per PACU protocol unless problem arises.
 
PainDrain said:
So I believe the academic answer is to wait 6 weeks post-URI in these types of patients. Studies have shown in healthy children increased risk of respiratory complications in those with recent URIs and have also shown increased airway reactivity for up to 6 weeks post-URI.

Cough up until 2 weeks ago means he was still symptomatic until recently. I personally had one very bad bronchospasm in a kid with recent URI and I never want to relive that again (parents were *****s by the way and failed to tell me despite my asking if the patient had asthma/RAD).

I would cancel, wait and additional 4 weeks. Bring back, inhalation induction with Sevo/nitrous and propofol prior to intubation. Can also get away with an LMA for adenoids only if the surgeon doesn't mind. Deep extubation and to PACU.
Click to expand...

The academic answer is to RSI everyone with GERD, but I'm guessing you don't do that? You'd never get away with waiting 6 weeks for every kid who had a URI at a busy children's hospital; you'd never get any surgery done between October and May.

Even at my academic hospital, nobody would wait 6 weeks. Most wouldn't even wait a month, and I have some conservative co-workers. I would say most people range from 1-2 weeks symptom free prior to doing an elective case. Maybe more, maybe less depending on the actual procedure and the indication for the procedure and how scary the story sounds.

Assuming this kid is afebrile, has a normal lung exam and is acting normally per the parents, I would proceed with the case. I do alter my pre-op consent to address the issue of pulmonary complications and give the parents the option to go super conservative if they want (most don't).

Pre-op: +/- midaz 0.5mg/kg PO (depending on the kid), no albuterol unless wheezing (in which case I'm probably cancelling the case)
Intra-op: inhalational induction, PIV, ETT (usually prop/fent, no muscle relaxation), 1-2mcg/kg fentanyl, 15mg/kg IV tylenol, 0.5mg/kg decadron, 0.1mg/kg ondansetron, as much LR as you can get in in 15 min
Extubation: Awake
Post-op: In this kid, regular discharge. Mod-severe OSA, young age, other comorbidities = overnight stay.
 
Last edited:
Albuterol for RSV only if wheezing. If no active wheeze, no albuterol - there's no benefit to give. If kiddo is wheezing and requiring albuterol (and wheeze improves with it), delay case.

I'd avoid LMA. I recall similar case. Kiddo was 2 or 3 y/o and was sick 2-3 weeks ago and at his baseline. We did LMA, kid had significant oral and nasal secretions and began to laryngospasm. We had to remove, suction, provide PPV which broke the spasm, and wake the kid up and post-pone the case. I'd make a decision on delaying until 4-6 weeks of sick free days, unless there is a pattern of repetitive illnesses, then I'd proceed assuming this is the best kid will be and just intubate to protect airway. I'd extubate awake as well in this case. Discharge if pt tolerating po liquid.

Induce with mask ventilation, sevo/nitrous. PIV, intubate. I would provide zofran/decadron. Decadron for PONV, but also for possible edema following removal of adenoids. Provide IV Tylenol intraop and po liquid Motrin in PACU.
 
No albuterol if not wheezing
No VSD, haven't used this on a kid in almost a year.
Mask, PIV, prop to blunt laryngoscopy. No paralytic
Fent 0.5-1mcg/kg
Dexmedetomidine 0.5-1 mcg/kg over 5 min or so.
Dexamethasone 0.2mg/kg for pain, PONV, and swelling
Zofran
Suction good
Extubate at 1% EtSevo.
Oral airway
On side to pacu w the circuit mask over ear supporting the head and a simple mask O2.

Never really used precedex much for these in residency but the pacu nurses like it and it does seem to smooth things out and help with emergence delerium. Just push it in increments to avoid for bradycardia.

Edit: this is a 10-15 min case at our place. You could do 12 of these before noon. Tubes alone are more like 5-8 min total OR time.
 
I have never done T n A with a LMA. Do the surgeons go for that? I believe on the orals we should extubate awake :0
 
Noyac said:
Not sure but it makes me feel better so I give it. (Don't believe everything I say).
Click to expand...

There actually is data out there to support the use of decadron for both PONV relief and pain control (likely by relieving post op swelling)

Can J Anaesth. 2003 Apr;50(4):392-7.
Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy.
[Article in English, French]
Elhakim M1, Ali NM, Rashed I, Riad MK, Refat M.
Author information
  • 1Department of Anesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt. [email protected]
Abstract
PURPOSE:
Previous studies on dexamethasone's antiemetic and analgesic potential in children undergoing tonsillectomy have produced conflicting results. The aim of this study was to evaluate the effects of a single dose of dexamethasone on the incidence and severity of postoperative vomiting and pain in children undergoing electrocautery tonsillectomy under standardized general anesthesia.

METHODS:
In a double-blinded study, 120 patients were randomly allocated to receive either dexamethasone 0.5 mg.kg(-1) (maximum dose 8 mg) iv or an equivalent volume of saline preoperatively. The incidence of early and late vomiting, need for rescue antiemetics, time to first oral intake, time to first demand of analgesia and analgesic consumption were compared in both groups. Pain scores used included Children's Hospital Eastern Ontario Pain Scale, "faces", and a 0-10 visual analogue pain scale.

RESULTS:
Compared with placebo, dexamethasone significantly decreased the incidence of early and late vomiting (P < 0.05, P < 0.001 respectively). Fewer patients in the dexamethasone group needed antiemetic rescue (P < 0.01). The time to first oral intake was shorter, and the time to first dose of analgesic was longer in the dexamethasone group (P < 0.01). Pain scores 30 min after extubation were lower (P < 0.05) in the dexamethasone group. At 12 and 24 hr postoperative swallowing was still significantly less painful in the dexamethasone group than in the control group (P < 0.01).

CONCLUSION:
Preoperative dexamethasone 0.5 mg.kg(-1) iv reduced both postoperative vomiting and pain in children after electrocautery tonsillectomy.

PMID:
12670818
[PubMed - indexed for MEDLINE
 
HalO'Thane said:
Yes if the following criteria were met: easy intubation, no respiratory issues intraop, dry surgical field (i.e. oropharynx)
Click to expand...

That seems reasonable. I nearly always extubate deep. Both kids and adults.

I used to bang out days of quick ent cases at my old shop and always extubated deep. For some reason, some people insist on awake extubations--> if you don't you're breaking some golden rule.

It works but not my style. I'm smoother and faster at deep extubations. Laryngospasm is a myth if you do it right.
 
Last edited:
Noyac said:
You definitely simplifying everything, which I am a big fan of.
Click to expand...

Thanks. I like keeping it simple. I think it adds flexibility in thinking and adjustments.

That's just me though. Maybe I'm a simpleton.
 
Arch Guillotti said:
This case is seems pretty routine. What's the catch?
Click to expand...
Doctor4Life1769 said:
Albuterol for RSV only if wheezing. If no active wheeze, no albuterol - there's no benefit to give. If kiddo is wheezing and requiring albuterol (and wheeze improves with it), delay case.
Click to expand...
No catch. I think I let things get away from what I wanted to discuss. I was interested in everyone's technique with regards to a case like this. So I will get back on track.

I think most people agree that they would do this case. Good, so do I because it is too difficult to catch these kids when they are completely URI free and we are two weeks out from any symptoms.
Albuterol- correct, it isn't used for RSV if wheezes are absent. This kid also has asthma but not wheezing. I think there is something to be said for that. I personally believe you must stimulate the airway a little as possible in a kid like this. I have my technique that has served me well for years and I believe has allowed me to "get away" with passing and removing an ETT without much stimulation.
sevoflurane said:
would anyone extubate deep?
Click to expand...
This is one of my questions to be discussed here. Seems like some would and some wouldn't. I definitely do. Curious as to why others wouldn't assuming an easy airway.

So how would you go about doing this case without stimulating the airway? That's what we are concerned about here, right?
 
Flexible LMA is the bomb for adenoidectomy...limitation is typically surgeon's willingness.
 
I think one good question, and I don't know the evidence on this, is "What is the complication rate of using an LMA versus extubating deep"?

Or really, we know theoretically that an LMA would result in less airway complications than an ETT, but is their literature to support this? I'm interested to know.
 
dhb said:
I practice the same way but i wouldn't go as far as saying laryngospasm is a non issue.
Click to expand...

You misunderstand my comment.

I don't believe for one second that a deep extubation carries higher risk for laryngospasm than an awake extubation.

I personally believe this to be a myth.
 
sevoflurane said:
You misunderstand my comment.

I don't believe for one second that a deep extubation carries higher risk for laryngospasm than an awake extubation.

I personally believe this to be a myth.
Click to expand...
I almost agree (still see slightly more laryngospasm with LMAs), provided that one knows how to recognize the stages of anesthesia (as in no extubation while in stage II).
 
Noyac said:
No catch. I think I let things get away from what I wanted to discuss. I was interested in everyone's technique with regards to a case like this. So I will get back on track.

I think most people agree that they would do this case. Good, so do I because it is too difficult to catch these kids when they are completely URI free and we are two weeks out from any symptoms.
Albuterol- correct, it isn't used for RSV if wheezes are absent. This kid also has asthma but not wheezing. I think there is something to be said for that. I personally believe you must stimulate the airway a little as possible in a kid like this. I have my technique that has served me well for years and I believe has allowed me to "get away" with passing and removing an ETT without much stimulation.

This is one of my questions to be discussed here. Seems like some would and some wouldn't. I definitely do. Curious as to why others wouldn't assuming an easy airway.

So how would you go about doing this case without stimulating the airway? That's what we are concerned about here, right?
Click to expand...

We usually spray the cords with 2% lidocaine if not using muscle relaxation.

Extubate awake because I have yet to be at a place where you are not moving the patient to the stretcher or the PACU RNs are stimulating the child by checking vitals, poking, prodding, etc as the child is going through stage 2. I'd rather they go through stage 2 with a tube in than in PACU when I'm starting another case.
 
WholeLottaGame7 said:
We usually spray the cords with 2% lidocaine if not using muscle relaxation.

Extubate awake because I have yet to be at a place where you are not moving the patient to the stretcher or the PACU RNs are stimulating the child by checking vitals, poking, prodding, etc as the child is going through stage 2. I'd rather they go through stage 2 with a tube in than in PACU when I'm starting another case.
Click to expand...
On the other hand, there is extubating at the beginning of stage I (just a bit after the end of stage II - parallel gaze), and there is extubating when almost fully awake. I personally prefer the former (the kind academics teach us not do), but it needs experience. I have had exactly one laryngospasm with this technique in residency.
 
So part of my "don't stimulate the airway" technique is the well performed deep extubation. I do this nearly every pedi case that has a good airway or at least that I could mask easily enough.

Other things I do in kids with reactive airways is good topicalization. I like 4% lido via the MADgic atomizer.
I give decadron and some fentanyl as well.
I'm not a fan of preop versed but I will use it if necessary.
When I do a deep extubation I give a small dose of propofol and pull the tube. I put them on their side and if breathing well, off we go to PACU. I instruct the nurses not to disturb the kiddo until they open their eyes. This is usually less than 10 min. The nurses like it because they get to chart at the beginning and then they are say to attend to the kid.

So what happened in this kid. I did everything I mentioned above and extubated deep. There were no signs of restrictive expiration during the case and the kid was breathing spontaneously throughout. I didn't give any muscle relaxants. Once extubated and on his side he was breathing just fine. No retractions, clear lungs sounds and good sats. Since there wasn't a case to follow I just watched him in the OR for a couple minutes and let him come around on his own. Once he started to wake up he started to have some difficulty. Remember,he had large tonsils to begin with. He was now wheezing and retracting. Sats remained good throughout. I gave him a bunch of albuterol puffs through the mask but things were very slow to improve. He actually completely obstructed for a second which I was able to break with pressure at the angle of the jaw bilaterally.

I want to stop there to see what any of you would have done differently. And what you would do in this situation. Sats are still good.
 
FFP said:
On the other hand, there is the beginning of stage I (just after stage II), and fully awake. I personally prefer the former (the kind academics teach us not do), but it needs experience. I have had exactly one laryngospasm with this technique in residency.
Click to expand...

Oh no I'm not talking about "ready-to-walk-to-the-recovery room" awake. I only use that in the obese difficult airway cases.

For kids, as soon as they do something halfway purposeful (grimace, reach for tube, etc), that's when I pull it. A lot of times it is subtle and it is hard to explain to junior residents exactly how I know it's OK to pull. A lot of it is just experience.

And there sure are a lot of people who zero or very very few laryngospasms for all the kids they do. I wonder if we're all using the same definitions. I'm not talking about the "need to push prop or sux to break it" kind of laryngospasm. I agree that is very rare. There are lesser degrees of what I still consider laryngospasm where you just need some jaw thrust/stimulation or a little PEEP to get through some obstruction.
 
WholeLottaGame7 said:
We usually spray the cords with 2% lidocaine if not using muscle relaxation.

Extubate awake because I have yet to be at a place where you are not moving the patient to the stretcher or the PACU RNs are stimulating the child by checking vitals, poking, prodding, etc as the child is going through stage 2. I'd rather they go through stage 2 with a tube in than in PACU when I'm starting another case.
Click to expand...
I like your approach and it is a safe plan. I didn't read this before my post above. I'm glad I explained that I instruct the nurses to not stimulate the child. All we do is place a pulse Ox monitor on them. The kids are usually awake before we are back in the OR. I'd say the vast majority are moving around a bit and opening their eyes within 5 minutes. 10 minutes at the longest. But some kids just continue to snooze and you just have to stir them a bit. They are well past stage II by this time however.
 
Noyac said:
I like your approach and it is a safe plan. I didn't read this before my post above. I'm glad I explained that I instruct the nurses to not stimulate the child. All we do is place a pulse Ox monitor on them. The kids are usually awake before we are back in the OR. I'd say the vast majority are moving around a bit and opening their eyes within 5 minutes. 10 minutes at the longest. But some kids just continue to snooze and you just have to stir them a bit. They are well past stage II by this time however.
Click to expand...
I used to do the same as a resident. But the nurses did only pedi cases, so they knew even without me saying. In a surgicenter, it can be much more complicated, and I would probably wait longer before extubating in a place where pedi cases are rare.
 
Actually FFP, it's pretty easy to get the nurses to understand. Maybe yours are just being resistant.
 
sevoflurane said:
You misunderstand my comment.

I don't believe for one second that a deep extubation carries higher risk for laryngospasm than an awake extubation.

I personally believe this to be a myth.
Click to expand...
Depends how "awake" 😉
Back to the case at this point there's not much to do i wouldn't even have bothered with the albuterol initially just wait for further wake up.
 
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