Pediatric laryngospasm

[2Fast2Des]

So in peds, we've been taught the mantra about cranking up agent to 2 -3 mac to deepen prior to deep extubation to decrease risk of spasm. Then I've had an attending who breathes the kiddo down and then extubates on 0.2 Mac. Is there a mandated rule or do we go overboard with over anesthetizing? If the kid or patient is breathing with minimal pressure support or with no support, at .7 or 1 mac, can airway be pulled safely?

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[T-burglar]

I say wake em up so laryngospasm happens in the OR and not in the hallway or pacu

 

[dhb]

So in peds, we've been taught the mantra about cranking up agent to 2 -3 mac to deepen prior to deep extubation to decrease risk of spasm. Then I've had an attending who breathes the kiddo down and then extubates on 0.2 Mac. Is there a mandated rule or do we go overboard with over anesthetizing? If the kid or patient is breathing with minimal pressure support or with no support, at .7 or 1 mac, can airway be pulled safely?

You can extubate any patient at any time but 2-3 mac is foolish. Now if you extubate in stage 2 the risk of laryngospasm is increased but if you extubate in stage 3 the patient will be going through stage 2 later on.
0.6% sevo is a nice place to extubate kids.

 

[deleted59964]

i deepen with propofol at the end of the case this generally makes them apneic briefly. i then turn the gas off, and bag to maintain oxygenation till they start breathing again.

when they recover from apnea i extubate.

propofol at the end gives good extubation conditions and reduces emergence delirium.

 

[sigrhoillusion]

You extubate deep or you extubate awake... 2-3 MAC seems unnecessary (or did you mean 2-3%?)

Key is to have them emerge either in OR or in the PACU (preferably in a peds hospital that knows how to manage laryngospasm). Worst case is laryngospasm while you're on transport. Also, I'm not afraid to keep a kid a few minutes in the OR after extubation to emerge than risk laryngospasm in the hallway...

My CRNA had a laryngospasm on a toddler the other day while moving the kid from the OR table to the stretcher. Luckily all the equpment/drugs were present to manage it.

 

[Arch Guillotti]

Worst case is laryngospasm while you're on transport.

Also unpleasant is when it is in the PACU and a frantic call is heard overhead and you arrive only to scramble to find the right stuff.

 

[Arch Guillotti]

Then I've had an attending who breathes the kiddo down and then extubates on 0.2 Mac. Is there a mandated rule or do we go overboard with over anesthetizing? If the kid or patient is breathing with minimal pressure support or with no support, at .7 or 1 mac, can airway be pulled safely?

This is idiotic, pediatric extubation should be performed when criteria are met, not when some arbitrary MAC number is met. I have pulled a tube on a kid at 1.2 mac only to have them cough and sputter as a laryngospasm precursor.

 

[drmwvr]

I love the fractions of MAC being thrown around here as though they were pitons being driven into granite to be depended on to arrest some free fall to catastrophe...spare me...

 

[Crabbygas]

Hahaha. When I was a resident many years ago I worked with a VERY well known pediatric anesthesiologist. He would ask the residents why do you turn the Isoflurane dial to 5 percent for a deep extubation? Answer: Because it won't go to 6. Lots of ways to skin the cat. Just have to be ready in case there's a problem.

 

[2Fast2Des]

You extubate deep or you extubate awake... 2-3 MAC seems unnecessary (or did you mean 2-3%?)

Key is to have them emerge either in OR or in the PACU (preferably in a peds hospital that knows how to manage laryngospasm). Worst case is laryngospasm while you're on transport. Also, I'm not afraid to keep a kid a few minutes in the OR after extubation to emerge than risk laryngospasm in the hallway...

My CRNA had a laryngospasm on a toddler the other day while moving the kid from the OR table to the stretcher. Luckily all the equpment/drugs were present to manage it.

No 2-3 MAC, not percent...

 

[propadope]

Clinical picture is more important than an arbitrary MAC. Respiratory rate, tidal volume, heart rate, blood pressure etc... are more important. A good test would be to do a deep suction or to wiggle the tube; if no change in vital signs and no coughing, breath holding etc... then probably safe to extubate.

Also depends if other agents are on board. Propofol, narcs precedex will decrease airway reflexes and attenuate stage 2 due to vapour

Depends on the patient as well. Secretions and blood can trigger laryngospasm despite an apparent adequate depth. Glyco for me is a must for deep extubation. Also depends on individual airway reactivity. Watch out for asthma, RAD, recent URTI, household with smokers. I find black/African/African American patients tend to salivate more and have more reactive airways.

As has been pointed out, you are only delaying stage 2 until after a deep extubation. You still have to be careful with transfering and transporting the patient.

 

[Psai]

Something is deeply wrong with your program op

 

[Noyac]

Just had this discussion yesterday with one of my partners. We had a possible bronchospasm vs laryngospasm in a 2yo at the end of a case. It was the real deal with unreadable sats and HR in the 50’s for a minute. Resolved by reintubating and recruiting alveoli. The kid did fine and was d/c’d home. We have a wild fire raging in town and everyone is feeling the effects, wheezing etc. I have put a hold on doing elective kids with reactive airway disease that are under 3yo (arbitrary number I admit) until the smoke clears.

But the vast majority of my group extubates their pedi pts awake. I usually extubate deep, especially the kids with reactive airways and living with smokers. Reasons in my head are that I don’t want them to potentially cough or buck on a Tube, stirring up a reaction. Plus on a busy dental or ENT day it is much faster. And it is safe when done properly and when your staff understands what the plan is.

My process is this, I spray the trachea with an LTA of 4% lido then come out and bag for a little bit. Maybe 5 breaths. Then I pass the tube and I make sure the kid is deep when I do all of this. Maintenance is irrelevant other than I do give narcs to an appropriate RR for age. When the case is finished I give 2-4 cc propofol depending on weight and age and turn off the gas. Suction well to assure myself that there is no bleeding or secretions to induce laryngospasm and then pull the tube with a small amount of positive pressure. Place the mask and apply PP again to assure patent airway. Roll the kid on its right side with a face mask applied and reassure that I see fogging ( too high of fresh gas flow can make this hard to see) of the mask with consecutive breaths and no need for assistance (jaw lift). Roll out to PACU were my staff knows not to disturb the kid until they see purposeful movements which take around 5minutes. No BP, just a pulse ox. I go to see my next pt and then return to be sure the kid is coming around and doing well. I don’t like to go back to the OR with the next case until the kid is moving purposefully and out of the woods. This is where I think the OP’s comment of pulling it at 2-3MAC would burn me. I’d be waiting fo that kid arouse for way too long.

If during induction, I found the mask ventilation to be suspect at all then I extubation that kid awake.

 

[Arch Guillotti]

Just had this discussion yesterday with one of my partners. We had a possible bronchospasm vs laryngospasm in a 2yo at the end of a case. It was the real deal with unreadable sats and HR in the 50’s for a minute. Resolved by reintubating and recruiting alveoli. The kid did fine and was d/c’d home. We have a wild fire raging in town and everyone is feeling the effects, wheezing etc. I have put a hold on doing elective kids with reactive airway disease that are under 3yo (arbitrary number I admit) until the smoke clears.

But the vast majority of my group extubates their pedi pts awake. I usually extubate deep, especially the kids with reactive airways and living with smokers. Reasons in my head are that I don’t want them to potentially cough or buck on a Tube, stirring up a reaction. Plus on a busy dental or ENT day it is much faster. And it is safe when done properly and when your staff understands what the plan is.

My process is this, I spray the trachea with an LTA of 4% lido then come out and bag for a little bit. Maybe 5 breaths. Then I pass the tube and I make sure the kid is deep when I do all of this. Maintenance is irrelevant other than I do give narcs to an appropriate RR for age. When the case is finished I give 2-4 cc propofol depending on weight and age and turn off the gas. Suction well to assure myself that there is no bleeding or secretions to induce laryngospasm and then pull the tube with a small amount of positive pressure. Place the mask and apply PP again to assure patent airway. Roll the kid on its right side with a face mask applied and reassure that I see fogging ( too high of fresh gas flow can make this hard to see) of the mask with consecutive breaths and no need for assistance (jaw lift). Roll out to PACU were my staff knows not to disturb the kid until they see purposeful movements which take around 5minutes. No BP, just a pulse ox. I go to see my next pt and then return to be sure the kid is coming around and doing well. I don’t like to go back to the OR with the next case until the kid is moving purposefully and out of the woods. This is where I think the OP’s comment of pulling it at 2-3MAC would burn me. I’d be waiting fo that kid arouse for way too long.

If during induction, I found the mask ventilation to be suspect at all then I extubation that kid awake.

This is precisely how a deep extubation should be done. None of the CRNA's I work with can give a kid this level of attention and precision so I insist that they extubatne the kid awake rather than at some arbitrary mac number.

 

[Noyac]

This is precisely how a deep extubation should be done. None of the CRNA's I work with can give a kid this level of attention and precision so I insist that they extubatne the kid awake rather than at some arbitrary mac number.

Funny because it was a crna that taught me this 17 yrs ago but I have adjusted or perfected my technique a bit since then.

 

[Arch Guillotti]

Funny because it was a crna that taught me this 17 yrs ago but I have adjusted or perfected my technique a bit since then.

Too bad the ones I work with are not this skilled.

 

[Noyac]

Too bad the ones I work with are not this skilled.

This guy was seasoned. A pleasure to work with. And no chip on his shoulder. He taught me a lot, as I was fresh out of residency and didn’t know **** from shine. I did get the chance to bail him out a few times as well. Which he was always grateful for. Not like the others that act like they did nothing wrong.

 

[WholeLottaGame7]

As others have said, it doesn't really matter what the numbers are, it depends on the clinical state. Though I assume most people are using numbers just for ballpark.

I agree with those that say to deepen the anesthetic if you're going to extubate deep. Kids will definitely laryngospasm at times if you pull it at 0.7-1 MAC (depending on opioids, precedex, etc). I prefer to bolus propofol and then suction/wiggle tube to make sure, though you can also crank the gas and get the same effect. I'm not a huge fan of volatiles in general though so not my first choice.

 

[acidbase1]

Do you guys have any issues with your Peds patients waking up striderous after T&As? I check the cuff pressure after induction after every case. They tend to do fine but it seems as if they struggle a bit for 5-10 min in PACU (no desaturations)

 

[deleted171991]

So in peds, we've been taught the mantra about cranking up agent to 2 -3 mac to deepen prior to deep extubation to decrease risk of spasm. Then I've had an attending who breathes the kiddo down and then extubates on 0.2 Mac. Is there a mandated rule or do we go overboard with over anesthetizing? If the kid or patient is breathing with minimal pressure support or with no support, at .7 or 1 mac, can airway be pulled safely?

For the best answer, you need to go back and read about the stages of anesthesia, and deep extubation. Then figure it out. Hint: there is more than one correct way.