Let's talk technique

[Noyac]

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How do you dose it?

I just keep it under the the 5mg/kg range.
Is that what you mean?
But I definitely am close to this.

 

[WholeLottaGame7]

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.

That's a solid plan. I like that you deepen the anesthetic before pulling the tube; I totally agree. 1 MAC isn't enough; a tube on the cords might not be the same as a surgical stimulus but it's pretty close. Kids will move at that level. I will crank the sevo or give some prop before pulling a tube deep. I also jostle the tube or use the Yankauer to test the anesthetic depth before actually pulling it.

I don't think I would have done anything differently. I'll take your word for it that it was actually wheezing, but the fact that it didn't get better with albuterol and that it progressed to obstruction makes me think it might have just been high-pitched stridor. It could have been his tonsils obstructing but that usually sounds more like snoring. I usually associate that kind of squeaky noise with some degree of obstruction at the level of the cords.

I usually just watch and wait to see which way the situation goes. I don't tend to leave the kid (in the OR or in PACU) until they prove they're moving good air without a lot of stimulation on my part. If it's getting worse you can always just bump them with a little propofol and get them deeper and let them circle the runway another time before trying to land.

 

[Noyac]

I don't think I would have done anything differently. I'll take your word for it that it was actually wheezing, but the fact that it didn't get better with albuterol and that it progressed to obstruction makes me think it might have just been high-pitched stridor. It could have been his tonsils obstructing but that usually sounds more like snoring. I usually associate that kind of squeaky noise with some degree of obstruction at the level of the cords.

bingo. It was both, wheezing and obstruction.
By letting him wake up more the obstruction began to improve.
After about 30 minutes in PACU his lungs still sounded crappy so I gave him an albuterol news as well. He got racemic epi earlier. After another hour he looked real good, was eating crackers and wanted to go home. Sats would drop to 88% without O2. Believe it or not he lived a few houses down from me and his parents are our friends. So I sent him home and told them I would come by when I got off of work to check on things. He was all better by then.

 

[Noyac]

What would I do different?
I don't really know. Maybe an albuterol neb preop but he wasn't wheezing then.
I wouldn't have cancelled because I don't think I had any good reason to.
I still think the deep extubation is key in these cases.
So I guess the point is sometimes we do cases and we get away with things and sometimes things are just bound to happen and you have to deal with them.

 

[dhb]

Sats would drop to 88% without O2.

A touch of negative pressure PE maybe?
And you absolutely don't need 1+mac to do a deep extubation. Actually if you do you just set yourself up for the event to happen in the pacu when the patient goes through stage 2

 

[deleted59964]

...
you absolutely don't need 1+mac to do a deep extubation. Actually if you do you just set yourself up for the event to happen in the pacu when the patient goes through stage 2

agree - I like less volatile, and a dose of propofol at the end prior to deep extubation.
maybe less emergence delirium that way too

 

[Ignatius J]

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.

I think you did it well. Nothing to add from my standpoint.

I'm in the minority, but I'm not a "put them on their side" guy. Just don't like doing it that way and having to flip them back over if something happens. Just a personal preference though.

 

[WholeLottaGame7]

A touch of negative pressure PE maybe?
And you absolutely don't need 1+mac to do a deep extubation. Actually if you do you just set yourself up for the event to happen in the pacu when the patient goes through stage 2

The negative pressure pulm edema crossed my mind, also.

Unless you sit in the room with the patient while they go through stage 2, most patients are going to go through stage 2 in the PACU. That's what a lot of this discussion is about. If you're already lightening them up and then extubate them "deep," you're asking for laryngospasm. Giving prop to deepen them is perfectly fine, but I'm including that in the MAC calculation.

I assume that most people extubate deep for efficiency's sake, and not actually to minimize airway irritation. Because I take care of a lot of kids with asthma and extubate them awake (or in stage I, if you want to call it that) and they don't go into bronchoospasm. Extubating every kid deep because of a history of asthma is like RSIing everyone with a history of GERD.

 

[Noyac]

A touch of negative pressure PE maybe?
And you absolutely don't need 1+mac to do a deep extubation. Actually if you do you just set yourself up for the event to happen in the pacu when the patient goes through stage 2

I thought negative pressure edema was possible as well. I am not sure it occurred because he never fully obstructed but for an instant (which yes can cause it but more commonly in older stronger kids and adults) and his symptoms more resembled bronchospasm. The albuterol also was moderately helpful once I decided to give it. But it could have been time that actually resolved everything. I wouldn't be surprised if he had a touch of pulm edema though.

 

[BigRedBeta]

Interesting discussion. As a PICU attending we of course get the ones with significant OSA with varying degrees of ridiculousness seen on their polysomnograms. My favorites are the ones who come in a night early and are snoring while awake playing with toys. Had one who you could sit there and watch him obstruct while wide awake and mouth breathing, with the mother saying "no that's just how he breathes"

A touch of negative pressure PE maybe?

That was my first thought.

As for the albuterol question and wheezing a few things. 1) wheezing is the result of complete obstruction of the airway, which with airflow causes them to vibrate at their resonant frequency. So anything that causes that degree of obstruction will result in wheezes. Most people are never taught that at any point in their training in any field. 2) RSV and associated viruses generally don't cause bronchospasm and the wheezing is due to inflammation and associated schmutz in the airways that leads to obstruction. As y'all know, no bronchospasm leaves little for albuterol to affect, so it really is useless...unless there is a history of asthma/reactive airways. The kid shouldn't have been sent home on the albuterol to begin with unless there was documented effect. A rac epi to vasoconstrict and cut down on some of the edema has a better chance of helping you, and given the situation, y'all are only looking for a short term bridge. Don't know if there is any anesthesia specific literature about this, but one thing to keep in mind is that all the pediatrics studies discounting any intervention on bronchiolitis are all powered to look at hospital stays/avoiding admission, so you're practice environment is very different, so it matters more to think about the physiology.

My question is why do all these (and I mean every single one of them in now 3 different institutions I've been at) come back to my PICU screaming bloody murder? Is there some sort of dogma that these kids don't hurt after this procedure? Invariably my nurses are scrambling to get doses of fentanyl to calm them down. Doesn't happen with any other surgical procedure in this age group that makes it my way extubated, only T&A's.

 

[Chloroform4Life]

Interesting discussion. As a PICU attending we of course get the ones with significant OSA with varying degrees of ridiculousness seen on their polysomnograms. My favorites are the ones who come in a night early and are snoring while awake playing with toys. Had one who you could sit there and watch him obstruct while wide awake and mouth breathing, with the mother saying "no that's just how he breathes"


That was my first thought.

As for the albuterol question and wheezing a few things. 1) wheezing is the result of complete obstruction of the airway, which with airflow causes them to vibrate at their resonant frequency. So anything that causes that degree of obstruction will result in wheezes. Most people are never taught that at any point in their training in any field. 2) RSV and associated viruses generally don't cause bronchospasm and the wheezing is due to inflammation and associated schmutz in the airways that leads to obstruction. As y'all know, no bronchospasm leaves little for albuterol to affect, so it really is useless...unless there is a history of asthma/reactive airways. The kid shouldn't have been sent home on the albuterol to begin with unless there was documented effect. A rac epi to vasoconstrict and cut down on some of the edema has a better chance of helping you, and given the situation, y'all are only looking for a short term bridge. Don't know if there is any anesthesia specific literature about this, but one thing to keep in mind is that all the pediatrics studies discounting any intervention on bronchiolitis are all powered to look at hospital stays/avoiding admission, so you're practice environment is very different, so it matters more to think about the physiology.

My question is why do all these (and I mean every single one of them in now 3 different institutions I've been at) come back to my PICU screaming bloody murder? Is there some sort of dogma that these kids don't hurt after this procedure? Invariably my nurses are scrambling to get doses of fentanyl to calm them down. Doesn't happen with any other surgical procedure in this age group that makes it my way extubated, only T&A's.

You say these kiddos are being admitted to your PICU because they are obstructing and you are asking why they don't get more fentanyl? Kids cry for many reasons and not always from pain. I guess we like to err on the side of not wanting them to obstruct more. Typically for a T&A we are sending home, we give them Tylenol and some fentanyl intraop and they do fine post-op without needing much more opioid. They stop crying when their parents calm them down so I think in your case, they are crying because they are scared (being in an ICU) more so than from pain.

 

[BigRedBeta]

You say these kiddos are being admitted to your PICU because they are obstructing and you are asking why they don't get more fentanyl? Kids cry for many reasons and not always from pain. I guess we like to err on the side of not wanting them to obstruct more. Typically for a T&A we are sending home, we give them Tylenol and some fentanyl intraop and they do fine post-op without needing much more opioid. They stop crying when their parents calm them down so I think in your case, they are crying because they are scared (being in an ICU) more so than from pain.

Yeah, that's the answer I got from staff when I was a fellow. Except it is pain. Believe me, I run through the paces of trying all non-pharmacological methods of getting them to calm down including parents (who love seeing their kid after an operation freaking out let me tell you...🙄). A quarter to half mcg/kg of fentanyl is often all that's needed to take the edge off. And if they're going to a monitored environment where their nurse only has them and one other patient - better than PACU staffing, no? - the risk of obstruction is mitigated right?

Edited to correct my dosing of fentanyl

 

[Ignatius J]

The negative pressure pulm edema crossed my mind, also.

Unless you sit in the room with the patient while they go through stage 2, most patients are going to go through stage 2 in the PACU. That's what a lot of this discussion is about. If you're already lightening them up and then extubate them "deep," you're asking for laryngospasm. Giving prop to deepen them is perfectly fine, but I'm including that in the MAC calculation.

I assume that most people extubate deep for efficiency's sake, and not actually to minimize airway irritation. Because I take care of a lot of kids with asthma and extubate them awake (or in stage I, if you want to call it that) and they don't go into bronchoospasm. Extubating every kid deep because of a history of asthma is like RSIing everyone with a history of GERD.

Honest question, how often do you see laryngospasm in ear tubes?

 

[deleted171991]

Yeah, that's the answer I got from staff when I was a fellow. Except it is pain. Believe me, I run through the paces of trying all non-pharmacological methods of getting them to calm down including parents (who love seeing their kid after an operation freaking out let me tell you...🙄). A quarter to half mcg/kg of fentanyl is often all that's needed to take the edge off. And if they're going to a monitored environment where their nurse only has them and one other patient - better than PACU staffing, no? - the risk of obstruction is mitigated right?

Edited to correct my dosing of fentanyl

Fentanyl can make a lot of people "happy", pain or no pain. 😉

 

[WholeLottaGame7]

Honest question, how often do you see laryngospasm in ear tubes?

Similar rates (so, rarely) to other cases. Why?

 

[WholeLottaGame7]

Interesting discussion. As a PICU attending we of course get the ones with significant OSA with varying degrees of ridiculousness seen on their polysomnograms. My favorites are the ones who come in a night early and are snoring while awake playing with toys. Had one who you could sit there and watch him obstruct while wide awake and mouth breathing, with the mother saying "no that's just how he breathes"


That was my first thought.

As for the albuterol question and wheezing a few things. 1) wheezing is the result of complete obstruction of the airway, which with airflow causes them to vibrate at their resonant frequency. So anything that causes that degree of obstruction will result in wheezes. Most people are never taught that at any point in their training in any field. 2) RSV and associated viruses generally don't cause bronchospasm and the wheezing is due to inflammation and associated schmutz in the airways that leads to obstruction. As y'all know, no bronchospasm leaves little for albuterol to affect, so it really is useless...unless there is a history of asthma/reactive airways. The kid shouldn't have been sent home on the albuterol to begin with unless there was documented effect. A rac epi to vasoconstrict and cut down on some of the edema has a better chance of helping you, and given the situation, y'all are only looking for a short term bridge. Don't know if there is any anesthesia specific literature about this, but one thing to keep in mind is that all the pediatrics studies discounting any intervention on bronchiolitis are all powered to look at hospital stays/avoiding admission, so you're practice environment is very different, so it matters more to think about the physiology.

My question is why do all these (and I mean every single one of them in now 3 different institutions I've been at) come back to my PICU screaming bloody murder? Is there some sort of dogma that these kids don't hurt after this procedure? Invariably my nurses are scrambling to get doses of fentanyl to calm them down. Doesn't happen with any other surgical procedure in this age group that makes it my way extubated, only T&A's.

Go to any children's PACU and you see screaming kids. A) Screaming means awake and breathing, and B) most of it is emergence delirium and will resolve on it's own in 15-20 minutes. The rest of it is being hungry and scared which are relieved with something in the stomach and a parent, respectively.

I think most posters on here state that they give somewhere between 1-2mcg/kg of fentanyl, which is a lot for a 15 min procedure, plus tylenol and dexamethasone. We typically shoot for 1-3mcg/kg/hr for longer cases.

That said, it is prudent to be more cautious with T&As, particularly because a lot of times the indication is OSA, and multiple studies note that these kids are more sensitive to narcotics than their non-OSA controls. It was a bigger deal when most of these kids went home with codeine, given the variability in metabolism of that drug.

 

[Ignatius J]

Similar rates (so, rarely) to other cases. Why?

I don't know how many I have done, but I have done a fair amount I would say, and I have never seen a laryngospasm. I know it happens and I've been lucky. I was just curious. It just happens at a rate far, far lower than with my GETA cases. That is just based anecdotally on my experience.

It has shaped my thinking that I think having airway stimulation during Stage 2 is a high risk factor for laryngospasm. I still see it when I pull it deep, but not very often. And the children wake-up much nicer.

 

[IlDestriero]

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.

We send ours home whenever they meet criteria, which usually is about 1 hour.
I don't think 1-2 mcg/kg fentanyl, or 0.1-0.13mg/kg morphine is too much for a T&A and give it all the time. They have just had a significant amount of their sensitive airway tissue cut into and burned with the cautery. It hurts like hell.

--
Il Destriero

 

[deleted171991]

We send ours home whenever they meet criteria, which usually is about 1 hour.
I don't think 1-2 mcg/kg fentanyl, or 0.1-0.13mg/kg morphine is too much for a T&A and give it all the time. They have just had a significant amount of their sensitive airway tissue cut into and burned with the cautery. It hurts like hell.

--
Il Destriero

It does. Ice cream is a safer option.

 

[nap$ter]

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.

this was a routine case until your emergence. i would have proceeded as you did with a routine anesthetic. for me (hi volume asc) for 3-5yo bmt/adenoids this is:

preop: mask flavor selection/knockknockjokes. iPhone video prn. no premed (99.9% of the time). no neb.
intraop: mask induction nitrous/sevo/monitors. piv. propofol 1-2mg/kg if nurse is fast with piv and/or kid is >10kg. dl, ett. morphine 0.1ug/kg. spont vent. decadron 0.5mg/kg. zofran 0.1mg/kg. ofirmev 15mg/kg. chart. nurse/surgeon chitchat. awakish extubation. there is some subjectivity to this. in general kids wake up like they go to sleep. i used to do deep extubations but now think that is a stupid plan in my setting because it slows the flow - i am intubating the next kid when the previous kid is hitting stage 2. we have 6-10min turnovers. if you turn off the gas early enough every kid can have an awake extubation. small bumps of propofol if the surgeon is buzzing bleeders. i turn bmt's on their side i.e. 9mos-2yo. i do not see the wisdom in turning a 3-5 yo on his side after an adenoidectomy. imho that just makes ventilation/airway assessment more difficult. shoulder bump is great for that age group supine after extubation.
postop: routine discharge, 30 min.

monday morning quarterbacking but for what it's worth - i would have extubated this kid awake. i would not turn him on his side. i would have used a shoulder roll. i suspect he developed nppe from obstruction. (not bronchospasm). i would have used the time when he was retracting and "wheezing" to place my fingers in the laryngospasm notches and give some jaw lift instead of giving albuterol. all of your descriptions sound like stage 2 upper airway obstruction and not bronchospasm to me, and in my humble experience this is what usually occurs on emergence. all that being said - i wasn't there.

if you do enough peds, sooner or later you will encounter a kid who is off the bell curve and misbehaves even when you do everything right.

 

[Noyac]

monday morning quarterbacking but for what it's worth - i would have extubated this kid awake. i would not turn him on his side. i would have used a shoulder roll. i suspect he developed nppe from obstruction. (not bronchospasm). i would have used the time when he was retracting and "wheezing" to place my fingers in the laryngospasm notches and give some jaw lift instead of giving albuterol. all of your descriptions sound like stage 2 upper airway obstruction and not bronchospasm to me, and in my humble experience this is what usually occurs on emergence. all that being said - i wasn't there.

if you do enough peds, sooner or later you will encounter a kid who is off the bell curve and misbehaves even when you do everything right.

I am positive that it wasn't stage 2. Symptoms were still present while he was in moms arms. No different just less dramatic. He was looking at us and making purposeful movements from the start. When he was sleeping everything was fine.

The more I think about it the more I think it was reactive airway disease in a child that had an URI in the not too distant past. He still met all criteria to proceed but as we all know, you proceed with caution. Caution to me means as little stimulation as possible.

 

[deleted162650]

1) wheezing is the result of complete obstruction of the airway, which with airflow causes them to vibrate at their resonant frequency.

This makes absolutely no sense. If there's complete obstruction of the airway, then there's no airflow. how can you have airflow with "complete obstruction." I'm sure many of us here have seen severe bronchospasm in the OR where you're not moving any air. Bag feels like pushing against a brick wall. Those pts don't wheeze.

 

[nap$ter]

I am positive that it wasn't stage 2. Symptoms were still present while he was in moms arms. No different just less dramatic. He was looking at us and making purposeful movements from the start. When he was sleeping everything was fine.

The more I think about it the more I think it was reactive airway disease in a child that had an URI in the not too distant past. He still met all criteria to proceed but as we all know, you proceed with caution. Caution to me means as little stimulation as possible.

i meant stage 2 in the OR when you had him on his side and he obstructed.

by the time he was in mom's arms maybe a little RAD and NPPE explaining the hypoxia.

 

[BigRedBeta]

This makes absolutely no sense. If there's complete obstruction of the airway, then there's no airflow. how can you have airflow with "complete obstruction." I'm sure many of us here have seen severe bronchospasm in the OR where you're not moving any air. Bag feels like pushing against a brick wall. Those pts don't wheeze.

I'm talking obstruction of the distal airways - well down the tracheobronchial tree - not the conducting airways. Proximal obstruction will make it impossible to bag, but that's not the issue at hand in bronchiolitis. And while asthmatics may have severe bronchoconstriction of the more proximal airways in the OR, that's rarely how their pathophysiology plays out when at home, in the ED, on the floor, or even in the ICU...otherwise you'd see a lot more people dropping dead of asthma attacks.

 

[Noyac]

i meant stage 2 in the OR when you had him on his side and he obstructed.

by the time he was in mom's arms maybe a little RAD and NPPE explaining the hypoxia.

That's what I'm saying. He didn't obstruct until he was awake. I no what stage 2 is.

 

[Noyac]

I'm talking obstruction of the distal airways - well down the tracheobronchial tree - not the conducting airways. Proximal obstruction will make it impossible to bag, but that's not the issue at hand in bronchiolitis. And while asthmatics may have severe bronchoconstriction of the more proximal airways in the OR, that's rarely how their pathophysiology plays out when at home, in the ED, on the floor, or even in the ICU...otherwise you'd see a lot more people dropping dead of asthma attacks.

I don't think this is entirely true.
Reactive airways is reactive airways no matter where they are in the hospital. We just have an easier time usually of dealing with it because we either turn on the gas or give albuterol through the ETT and things usually improve. The tube itself is well known to initiate it so we see it fairly often. We may see proximal obstruction more often because we induce GA and or paralyze but we still see distal airways obstruction as well. I think proximal, we call it upper airway, obstruction is easier to deal with.
And for what it's worth, you have seen status asthmaticus, right? They are pretty impossible to bag as well.

 

[nap$ter]

That's what I'm saying. He didn't obstruct until he was awake. I no what stage 2 is.

ok cool, but regardless of awake or stage 2, laryngospasm or other anatomic upper airway obstruction is more easily recognized and managed in a supine position - no benefit to turning this age group on their side after a deep extubation imho. just my $0.02.

 

[Noyac]

ok cool, but regardless of awake or stage 2, laryngospasm or other anatomic upper airway obstruction is more easily recognized and managed in a supine position - no benefit to turning this age group on their side after a deep extubation imho. just my $0.02.

I don't completely agree with this either. I wouldn't fault anyone based on if the kid was lateral or supine. I have masked many many pts, adults, children, infants and neonates in the lateral position. It isn't any more or less difficult. It's the technique that makes the greatest difference. The main reason I place many in the lateral position is that the blow by O2 is easier to keep infront of the kid.