anbuitachi

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i have done zero of these in residency (i know, embarrassing)

ive done plenty of awakes in adults. can anyone explain to me the difference in steps theyve experienced?

how do you topicalize when they are like 1kg? and wont they try to punch your face off during it?

the recommendation for a lot of procedures are still awake fiberoptics (like in TEF repair) so i figure i should figure out how to do it before i need to do it!
 
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SaltyDog

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i have done zero of these in residency (i know, embarrassing)

ive done plenty of awakes in adults. can anyone explain to me the difference in steps theyve experienced?

how do you topicalize when they are like 1kg? and wont they try to punch your face off during it?

the recommendation for a lot of procedures are still awake fiberoptics (like in TEF repair) so i figure i should figure out how to do it before i need to do it!
You’re worried about getting punched in the face by a 1kg neonate??

Wow, @FFP was right. Residents really are snowflakes these days.
 
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Generally speaking there are no awake fiber optics performed in pediatrics because children and babies do not cooperate with having things stuck into their mouths and noses regardless of topicalization. Instead of guaranteeing airway patency like in adults it can give you the opposite. So the technique you are probably looking for instead is a sedated but spontaneously ventilating fiberoptic intubation.

I do them like a laryngoscopy/bronchoscopy case. Gas induction to maintain respiratory drive. Get them as deep as they’ll go while still breathing. 1 mcg/kg precedex and 1mg/kg IV lidocaine will let almost any baby tolerate airway instrumentation without reaction. You can topicalize with another 2-3mg/kg lido but your scope won’t have a working channel at that size. Often the best airway approach will be using the fiberoptic around a glidescope.
 

somedumbDO

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i have done zero of these in residency (i know, embarrassing)

ive done plenty of awakes in adults. can anyone explain to me the difference in steps theyve experienced?

how do you topicalize when they are like 1kg? and wont they try to punch your face off during it?

the recommendation for a lot of procedures are still awake fiberoptics (like in TEF repair) so i figure i should figure out how to do it before i need to do it!
Can’t tell if you are serious....
 
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Mman

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7.5 years of peds, have never done an awake fiber optic on a neonate. Is OP trolling?
I've witnessed hundreds of awake DLs on neonates (aka baby born looking crappy and gets intubated by NICU team immediately) but never seen an awake FOI on one for a surgery
 
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IlDestriero

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You can just manhandle the neonate and put the tube in, but that causes, as you can imagine, a rather large stress reaction, hypertension, etc. That stress reaction may have long term consequences and that technique has largely gone away. The literature continues to support that paralysis improves intubation conditions.
If you need to fiber an infant the usual method is sedation with spontaneous ventilation +/- some support and then fiber through an LMA. The LMA will seat better than you think in many of these syndromic kids. Alternatively you can freehand fiber through the nare or mouth +/- a videoscope. Some kids have a combination of a small mandible and/or a large tongue, but distal to the tongue their airway is normal. A CMAC or Glide O can help displace the tongue and make the fiber 100 times easier.
I’ve done a mostly awake fiber on someone down to about 9 years or so, but that was a special case and a special patient that was unfortunately very mature for her years.
 
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dchz

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I’ve done a mostly awake fiber on someone down to about 9 years or so, but that was a special case and a special patient that was unfortunately very mature for her years.
What was the situation? in adults we mostly do it for supraglottic mass or radiation from cancer. which mostly don't appear in peds. Also in the case of TEF like in OP, you don't actually need the awake fiber, just use the fiber after the tube is in. I'm struggling to see why someone would awake fiber a child.
 

sigrhoillusion

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Peds guy here... did a handful of asleep fiberoptics, but I don't even think there's such a thing as an "awake" fiberoptic. Closest I've come is an extubated post-op Pierre Robin patient who needed a fiberoptic to get the tube in with a lot of tongue retraction with forceps... but that kid required extensive bagging and wasn't really awake, more like moving...
 

urge

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i have done zero of these in residency (i know, embarrassing)

ive done plenty of awakes in adults. can anyone explain to me the difference in steps theyve experienced?

how do you topicalize when they are like 1kg? and wont they try to punch your face off during it?

the recommendation for a lot of procedures are still awake fiberoptics (like in TEF repair) so i figure i should figure out how to do it before i need to do it!
I would use a neonatal Ovasapian airway and a micro MAD
 
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anbuitachi

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What was the situation? in adults we mostly do it for supraglottic mass or radiation from cancer. which mostly don't appear in peds. Also in the case of TEF like in OP, you don't actually need the awake fiber, just use the fiber after the tube is in. I'm struggling to see why someone would awake fiber a child.
TEF, bad syndromic kids, was taught to awake fiber them. but then again like i said, i never done one..
 
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anbuitachi

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Peds guy here... did a handful of asleep fiberoptics, but I don't even think there's such a thing as an "awake" fiberoptic. Closest I've come is an extubated post-op Pierre Robin patient who needed a fiberoptic to get the tube in with a lot of tongue retraction with forceps... but that kid required extensive bagging and wasn't really awake, more like moving...
so you mean the kid was too hypoxic or hypercarbic to be fully awake?
 

sigrhoillusion

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TEF, bad syndromic kids, was taught to awake fiber them. but then again like i said, i never done one..
TEF you're more concerned about PPV. As long as you keep them breathing spontaneously and don't insufflate the stomach you should be fine. Fiberoptic for tube positioning.

Syndromic children can be a pain, but most of them can be put asleep with gas and maintain SV. Even if paralyzed, they tend to be harder to intubate, rather than ventilate. Unless you have a very mature child, the chance of doing an "awake" fiberoptic is pretty low. The best you could do is maybe light sedation with PRecedex or remi infusion.
 
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sigrhoillusion

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so you mean the kid was too hypoxic or hypercarbic to be fully awake?
LOL... pretty much. They were "awake" in that they were crying, and choking and desatting and flailing their arms. But recently post-op we weren't giving any sedatives, and ENT was at bedside with a trach in hand just in case.
 
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sigrhoillusion

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LOL... pretty much. They were "awake" in that they were crying, and choking and desatting and flailing their arms. But recently post-op we weren't giving any sedatives, and ENT was at bedside with a trach in hand just in case.
It was tough enough to get the tube in pre-op...
 
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anbuitachi

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TEF you're more concerned about PPV. As long as you keep them breathing spontaneously and don't insufflate the stomach you should be fine. Fiberoptic for tube positioning.

Syndromic children can be a pain, but most of them can be put asleep with gas and maintain SV. Even if paralyzed, they tend to be harder to intubate, rather than ventilate. Unless you have a very mature child, the chance of doing an "awake" fiberoptic is pretty low. The best you could do is maybe light sedation with PRecedex or remi infusion.
how are you extubating the TEFs or are you keeping them intubated and extubating later?
 

sigrhoillusion

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Surgical preference and site healing. Not gonna lie, haven't done one in probably a year, since I do everything, not just peds. Could ask some of my colleagues who have done one more recently. We only do a few a year though.
 
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