Private Practice T&A, what's your recipe

[snowman8]

What's your recipe for the quick T&A and fast wake up? What if your pt has OSA?

Also, anyone uses narcs for their PE tubes? I usually don't and just mask my pt's, but had an attending who uses 1mcg/kg of intranasal fentanyl.

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[jwk]

What's your recipe for the quick T&A and fast wake up? What if your pt has OSA?

Also, anyone uses narcs for their PE tubes? I usually don't and just mask my pt's, but had an attending who uses 1mcg/kg of intranasal fentanyl.

For PE tubes - nada. MAYBE a tylenol suppository.

I assume you mean kiddie T&A's. PO versed in pre-op. IV induction in older kids, inhalation induction in younger kids. Get 'em deep on agent, lidocaine 2-4mg/kg IV, tube, back off the agent a little, do the case, do NOT lighten agent until tube is out, extubate by surgeon along with the mouth gag, a minute of 100% O2, and off to the PACU. Tylenol suppository somewhere between induction and wakeup in PACU. Most of the time they never stop breathing, and they're all breathing well before extubation. With the tonsils out, most of them don't have sleep apnea either.

Lots of ways to do them - mine is PP and assumes 10-15 minutes tops for the actual procedure.

 

[snowman8]

For PE tubes - nada. MAYBE a tylenol suppository.

I assume you mean kiddie T&A's. PO versed in pre-op. IV induction in older kids, inhalation induction in younger kids. Get 'em deep on agent, lidocaine 2-4mg/kg IV, tube, back off the agent a little, do the case, do NOT lighten agent until tube is out, extubate by surgeon along with the mouth gag, a minute of 100% O2, and off to the PACU. Tylenol suppository somewhere between induction and wakeup in PACU. Most of the time they never stop breathing, and they're all breathing well before extubation. With the tonsils out, most of them don't have sleep apnea either.

Lots of ways to do them - mine is PP and assumes 10-15 minutes tops for the actual procedure.

You don't use introp narcs for your pedi T&A's? Do you wait until they are more awake and screaming in PACU?

 

[jwk]

You don't use introp narcs for your pedi T&A's? Do you wait until they are more awake and screaming in PACU?

Nope - ENT uses a coblator technique and maybe some intra-op local. PO liquid pain meds at home and +/- in PACU if needed. Regardless of technique however, I've never given narcotics for a pedi T&A in all the years I've done them.

 

[huktonfonix]

Keep in mind the deep extubation technique relies heavily on your level of comfort in your PACU staff. This thread has also been covered nicely in the past I think the name was also private practice T and A 's. its under one of the stickies.

 

[Arch Guillotti]

Try this thread, found using the search function.

http://forums.studentdoctor.net/showthread.php?t=323621&highlight=tonsils

 

[SleepIsGood]

What's your recipe for the quick T&A and fast wake up? What if your pt has OSA?

Also, anyone uses narcs for their PE tubes? I usually don't and just mask my pt's, but had an attending who uses 1mcg/kg of intranasal fentanyl.

At my residency program we have one of the region's "Top ENT" surgeons

Anyways, this dude cranks through these TnAs in about 10 min, no joke.

All I do is mask inhalation, start IV, Deepen more, give 25mcg of fent or so (no NMB agent). Intubate, mark tube.

Turn off gas maybe 1 min after they coblate the second tonsil and it's out. O2 cranked all teh way up, tape tube.

Pt grimaces and is moving some extremities. Tube is out. I dont see the reason to extubate these guys deep.

Just turn off the gas early for fast result. Recall peds population has a high MV/FRC ratio so they emerge quicker. no magic here.

 

[Fastrach]

Premed midaz + tylenol PO, mask em deep, in goes IV, and our peds ENT's like us to use a flex LMA. Shoot in some morphine 0.1mg/kg iv + zofran, pull LMA out deep at the end, stick in oral airway, turn em on their side and slide on into pacu.

 

[SleepIsGood]

Premed midaz + tylenol PO, mask em deep, in goes IV, and our peds ENT's like us to use a flex LMA. Shoot in some morphine 0.1mg/kg iv + zofran, pull LMA out deep at the end, stick in oral airway, turn em on their side and slide on into pacu.

an LMA for a Tonsils?

That seems sort of dangerous? You have to keep them VERY deep or else, possibility of laryngospasm, not to mention aspiration of blood.....

 

[ncdoc1974]

an LMA for a Tonsils?

That seems sort of dangerous? You have to keep them VERY deep or else, possibility of laryngospasm, not to mention aspiration of blood.....

I work with some ENTs who are comfortable with this technique in pp...Overall, I think I have tried every anesthetic techinque mentioned here and many that have not been mentioned here...I seem to one of 2 problems with every technique: Either it is too slow or too potentially dangerous...I was hoping sugammadex would change my life, (will we ever get it?)but for now I guess I will continue to hate tonsil days (i.e. 16 tonsils in a row)...

 

[Noyac]

I would love it if my ENT's were comfortable with the LMA for T&A's.

 

[ncdoc1974]

I would love it if my ENT's were comfortable with the LMA for T&A's.

Just hope it is the "dry" ENTs that are comfortable and not the bloody ones...nothing worse than when a bloody ENT says "uh, everyone's using LMAs now of tonsils...let try that today!"

 

[candycane]

at our childrens hospital we adverage 15 min for our tonsils. for our kiddies, PO versed, mask induction. 2mg/kg propofol, PR tylenol, 0.05 mg/kg morphine, zofran, decadron- intubation. 2% sevo with 2:1 N20/O2. One tonsil out 1% sevo, both tonsils out sevo off. N2O/O2 for adenoids. Surg done off N20- head back to me extubate to PACU- morphine up to 0.1mg/kg

have also done it with clonidine- pretty sweet 2mcg/kg up front if pressures tolerate it. Can use about 1/3 to 1/2 less narcotics. pts wake up comfortable