Private Practice Tonsillectemies -

[Laurel123]

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Hey Private practice guys,

So I seem to have adjusted pretty well to private practice knee scopes (LMA's!), but I will soon be going to a hospital that does a lot of T & A's and they expect a very fast turn-over. In an academic setting, tonsils can take half an hour and then with all the other stuff, if I take 15 minutes to wake the patient up, no big deal. Deep extubation (and deep de-LMA'ing) with some jaw lift have really sped up my turnover times, but I am not at all confortable with deep extubation of an airway case.

So do any of you guys have any secrets to rapid turn-over of T & A's?

 

[militarymd]

1) practice
2) semi-deep extubations
3) no versed
4) no narcotics
5) bust your ass
6) have a good relationship with your ent.

 

[Laurel123]

1) practice
2) semi-deep extubations
3) no versed
4) no narcotics
5) bust your ass
6) have a good relationship with your ent.

Interesting...

So no narc's - how do the kiddos wake-up?

 

[militarymd]

Interesting...

So no narc's - how do the kiddos wake-up?

Ask the PACU nursings.

They can handle it.

 

[jetproppilot]

Hey Private practice guys,

So I seem to have adjusted pretty well to private practice knee scopes (LMA's!), but I will soon be going to a hospital that does a lot of T & A's and they expect a very fast turn-over. In an academic setting, tonsils can take half an hour and then with all the other stuff, if I take 15 minutes to wake the patient up, no big deal. Deep extubation (and deep de-LMA'ing) with some jaw lift have really sped up my turnover times, but I am not at all confortable with deep extubation of an airway case.

So do any of you guys have any secrets to rapid turn-over of T & A's?

The fastest way for kids 3-4 years old and less is....give .5mg/kg oral midaz in pre-op....makes 'em nice and calm when separating from mom....than a sevo-only anesthetic...bring the kiddy back to the OR, crank N2O to 7 liters and O2 to 3 liters (Or just turn the O2 up to 10 liters), crank the sevo to 3-4, put the mask on, let the kid take breaths for 10-15 seconds, then crank the sevo all the way up,,,,when the kid loses his airway take over, hyperventilate for thirty seconds or so then turn sevo down to 4-5%....concominantly if youre lucky the nurses in the ENT room will start your IV likkity split...if not, an RN can put a tourniquet on for you while you are bagging and flip a good looking dorsal hand vein up your way, put the mask down, stick the 22" or 24" angio in, continue bagging....RN can hook up the IV line.

Intubate, cuppla breaths to verify placement, turn the table, rehook up the circuit, click on the vent. Keep sevo in the 3-5% range.

Tylenol suppository while they are asleep.

Decadron 4 mg IV.

Sometimes but not always, mostly in the 5-10 year old age group, deep sevo still has them wiggling before intubation so a small dose of mivacurium (4-6 mg) will keep the kid still, yet won't hamper you when you're ready to wake him up 15 minutes later.

remember with these cases, the less stuff you give the better. No opiods required. And usually no muscle relaxants required.

Once you've worked enough with a busy pedi-ENT dude he'll start to say "I'll be done in less than five minutes", cueing you that its time to get the kid ready to breathe again. Aim to have him breathing before the metal-mouthpiece-thinghy comes out.

Good respiratory effort? Suck him out, yank the tube, give a healthy jaw lift.

ready to go to PACU.

Always have sux ready just in case.

On to the next one....

 

[jetproppilot]

3) no versed
.

At my previous gig's surgery center, Mil, where we had a factory line of these cases, every kid got oral versed....usually thirty minutes before being taken back...able to extubate after a 15 minute T&A routinely.

I agree one would think it would be a problem but it wasnt...but we did an only-sevo GA 90% of the time.

 

[Laurel123]

At my previous gig's surgery center, Mil, where we had a factory line of these cases, every kid got oral versed....usually thirty minutes before being taken back...able to extubate after a 15 minute T&A routinely.

I agree one would think it would be a problem but it wasnt...but we did an only-sevo GA 90% of the time.

So you would extubate them deep, if they had a good respiratory pattern?

 

[jetproppilot]

So you would extubate them deep, if they had a good respiratory pattern?

absolutely.

 

[jetproppilot]

absolutely.

another good trick to hasten a kids wake up- say you pull the tube and they are really sleepy...is to apply some sort of stimulation....a healthy jaw lift, or my faxorite: pinch their earlobe between your thumb and middle-finger's fingernails....try it on youself....hurts like s h it....works on adults too.

they dont remember it and alotta times it provides the needed stimulation to wake them up a bit.

 

[Noyac]

My technique:
No pre-op meds (vesed) to the OR calm or crying doesn't matter to me. Crying and they go down faster. Sevo mask induction. Nurse puts the IV in or the tourniquet on like Jet says. I bend the hand over the mask while the pt is breathing spont holding the mask on the face and the hand all with one hand. I place the IV and then hand it to the nurse to hook up. Then I intubate deep. If they are not deep enough I give some propofol, no muscle relaxants. Next I give 4mg decadron 0.1 mg/kg morphine (my favorite for kids) and I want them breathing spont near the end of the case. ENT done and I make sure the surgical site is dry. If dry, I pull the tube after passing a quick OG tube to suction. Oral airway goes in and I put the kids in the lateral position with blowby O2. Off to the PACU. The MS really smoothes out the wakeup and the kids are calm. Parents are happy and the kids drinks soon after.

 

[jetproppilot]

My technique:
No pre-op meds (vesed) to the OR calm or crying doesn't matter to me. Crying and they go down faster. Sevo mask induction. Nurse puts the IV in or the tourniquet on like Jet says. I bend the hand over the mask while the pt is breathing spont holding the mask on the face and the hand all with one hand. I place the IV and then hand it to the nurse to hook up. Then I intubate deep. If they are not deep enough I give some propofol, no muscle relaxants. Next I give 4mg decadron 0.1 mg/kg morphine (my favorite for kids) and I want them breathing spont near the end of the case. ENT done and I make sure the surgical site is dry. If dry, I pull the tube after passing a quick OG tube to suction. Oral airway goes in and I put the kids in the lateral position with blowby O2. Off to the PACU. The MS really smoothes out the wakeup and the kids are calm. Parents are happy and the kids drinks soon after.

👍

 

[jwk]

No muscle relaxants, no narcs, +/- lidocaine IV prior to intubation, tylenol suppository for post op pain. Always breathing at the end of the case. Our ENT's leave them nice and dry and suction well, so they pull the tube along with the mouth gag. On their side and off to recovery.

 

[Laryngospasm]

My technique:
No pre-op meds (vesed) to the OR calm or crying doesn't matter to me. Crying and they go down faster. Sevo mask induction. Nurse puts the IV in or the tourniquet on like Jet says. I bend the hand over the mask while the pt is breathing spont holding the mask on the face and the hand all with one hand. I place the IV and then hand it to the nurse to hook up. Then I intubate deep. If they are not deep enough I give some propofol, no muscle relaxants. Next I give 4mg decadron 0.1 mg/kg morphine (my favorite for kids) and I want them breathing spont near the end of the case. ENT done and I make sure the surgical site is dry. If dry, I pull the tube after passing a quick OG tube to suction. Oral airway goes in and I put the kids in the lateral position with blowby O2. Off to the PACU. The MS really smoothes out the wakeup and the kids are calm. Parents are happy and the kids drinks soon after.

You just quoted the exact way I was taught during my childrens hospital time. The PACU nurses will love you.🙂

 

[Noyac]

You just quoted the exact way I was taught during my childrens hospital time. The PACU nurses will love you.🙂

I wasn't taught any specific way but I have tried many different ways and this is by far the best in my hands. I am really not a fan of the no narc's technique but I understand it and don't fault it at all.

 

[IN2B8R]

Hey Private practice guys,

So I seem to have adjusted pretty well to private practice knee scopes (LMA's!), but I will soon be going to a hospital that does a lot of T & A's and they expect a very fast turn-over. In an academic setting, tonsils can take half an hour and then with all the other stuff, if I take 15 minutes to wake the patient up, no big deal. Deep extubation (and deep de-LMA'ing) with some jaw lift have really sped up my turnover times, but I am not at all confortable with deep extubation of an airway case.

So do any of you guys have any secrets to rapid turn-over of T & A's?

Try using some ketamine. Works well in this setting. Also minimizes post-op MSO4 needs.

 

[timtye78]

Rectal acetominophen

In my one of my textbooks:"A Practice of Anesthesia for Infants and Children" by Cote, Todres, et al, 3rd Ed. p 678 It says:

"....It should be noted that the absorption of rectal acetominophen is quite irregular and delayed, with peak blood levels occuring at 60 to 180 minutes following administration."

So you slip this bad-boy in at the end or beginning of your 30-45 minute Outpatient peds cases...are you personally convinced the patient derives benefit in the pacu or is this for home pain control, and do you use iv fent/morphine for pacu pain control??

At OU Childrens Hospital, my pacu nurses snicker when we report rectal tylenol as our post op pain med for T&As, BMTs, etc. What gives?

 

[jetproppilot]

.

 

[Intubate]

any of you guys use clonidine? 0.5- 1 mcg/kg. Analgesia, sedation, no respiratory depression. Its beautiful. I use it for all kinds of peds cases.

 

[cchoukal]

We have a couple people at the U of Chicago that use flex LMAs for tonsils. The Crow-Davis holds it in place (if you steady it while they're placing the gag). The thought process is that for deep removal, an LMA is less likely than an ETT to tickle the cords on the way out and cause laryngospasm. In addtion, routinely use PO midaz (usually only for the first case, as the timing during turnover doesn't allow absorption), rectal APAP, IV morphine (0.1 mg/kg for infections, 0.05 mg/kg for OSA), dexamethasone, ondansetron.

I've done maybe 50 T/A's in residency and never once used relaxant. They all ventilated spontaneously for the duration of the case. I frequently used Des if my attending preferred an awake extubation.

Incidentally, did anyone read the Cote study in A/A last month regarding dexamethasone dosing in pedi T/A's? The premise was previous studies looked at a range of doses that varied more than 20-fold, so they randomized kids to anywhere from 0.0625 mg/kg to 1 mg/kg and found no difference in PONV, time to drinking, time to discharge, or post-op narc use. Apparently, you can just walk into the room with the vial and that's enough...

 

[BISof60]

What percent of folks in private practice use Des for kids T&A, BMT, etc. We are taught Des in kids = laryngospasm.

 

[Noyac]

What percent of folks in private practice use Des for kids T&A, BMT, etc. We are taught Des in kids = laryngospasm.

I'm on to you! You only need one forum profile. Drop one.

 

[nimbus]

any of you guys use clonidine? 0.5- 1 mcg/kg. Analgesia, sedation, no respiratory depression. Its beautiful. I use it for all kinds of peds cases.

Yes!! Learned this while doing pedi plastics cases in Mexico. Also use it for adult inpatients.

 

[cchoukal]

Don't want to hijack the thread, but I wanted to ask/follow up about the clonidine issue. I'd read in a book on TIVA about the use of clonidine and potential MAC reductions of 30-40%. How much clonidine? PO in pre-op? IV at induction? Does it affect wake-up for shorter cases? Thanks.

 

[Laurel123]

Bumping...

So do you use nitrous for management?

And those that use narcotics? Do you have problems with nausea?

 

[johankriek]

im responding to an old thread..

i agree with military on the no narcs but i truly disagree with him with the semi deep extubation this goes against my tenet in anesthesia.. the kid doesnt get extubated until he is choking on that tube.. period.. that goes for any kid..I may be conservative but thats the best way to stay out of the laryngospasm in kids.. and thats one thing ou do not wanna be treating..


DONT worry about fast turnover... worry about your safe anesthetic. how much time can you possible be saving.. 6 minutes.. NO VERSED also..

 

[BLADEMDA]

im responding to an old thread..

i agree with military on the no narcs but i truly disagree with him with the semi deep extubation this goes against my tenet in anesthesia.. the kid doesnt get extubated until he is choking on that tube.. period.. that goes for any kid..I may be conservative but thats the best way to stay out of the laryngospasm in kids.. and thats one thing ou do not wanna be treating..


DONT worry about fast turnover... worry about your safe anesthetic. how much time can you possible be saving.. 6 minutes.. NO VERSED also..

Johan,

Your way is safe. I agree with you. But, I have also extubated deep and that works well. AS far as Versed you can always reverse it with Romazicon 0.1mg IV if needed. One of my senior partners (old guy) has extubated a few thousand T and A's deep with excellent results. He doesn't use any relaxant.

I usually wake my kid up on the tube then extubate. If you know your surgeon then "speed" is almost identical to the deep extubation.

Both are safe and both can be "perfected" over time. Your choice.

Blade

 

[johankriek]

Both are safe and both can be "perfected" over time. Your choice.

Blade

awake extubations are safer.. otherwise we would be extubating adults deep.. and i dont think touting deep extubations in children is very wise on this site... that should be left to experts who do exclusively peds or have a fellowship and thats not me...

 

[Gator05]

Coupla comments...

Dosing for rectal and PO tylenol is NOT the same! 40mg/kg rectal (and wait 6h until the next dose) per Cote et al, and we have a new attending who was taught up to 60mg/kg rectal is ok (don't have a reference). Kills me when we slip a 120mg supp in a 10kg kid "just to be safe".
Anesthesiology. 2001 Mar;94(3):385-9.
Anesthesiology. 1999 Aug;91(2):442-7.


Do you all use motrin? We don't for bleeding concerns. But...
Arch Otolaryngol Head Neck Surg. 2003 Oct;129(10):1086-9
Otolaryngol Head Neck Surg. 1998 Nov;119(5):492-6.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591.


Clonidine is wonderful stuff; articles from CHOP, italy, Sweden. According to my informal metanalysis: takes longer to setup (45min-1h orally, and LONGER intranasal!), takes longer to wear off, and most (2/3's) parents surveyed preferred to have a sleepy child post-op anyhow. Dose 1-4 mcg/kg depending on route/study used. Sampling:
Anesth Analg. 2001 Jan;92(1):56-61.
Anesth Analg. 2001 Aug;93(2):335-8, 2nd contents page.

I'm much more comfortable with deep extubations depending on the anesthetic itself. I'm leary with Des, perhaps even Iso if you read Cote's pediatric chapter in Miller. Sevo, or better still propofol, I'm happier. Why? Sevo is less pungent than the other gases, and propofol suppresses the laryngeal reflexes anyway. Topical lidocaine apparently doesn't hurt. Interestingly, neither does Mg!
Paediatr Anaesth. 2003 Jan;13(1):43-7
Paediatr Anaesth. 2005 Dec;15(12):1094-7.
Otolaryngol Head Neck Surg. 1998 Jun;118(6):880-2.
Arch Otolaryngol Head Neck Surg. 1991 Oct;117(10):1123-8


I also figure that if they don't spasm (or, even better, buck) with deep suction, then a clean ETT removal should go smoothly as well. I REALLY hate to see them bucking. If you're willing to do the case with an LMA, I don't understand the logic in not wanting to extubate deep.

Tonsils HURT! Morphine is good. Fentanly--> more PONV. If they've been diagnosed with severe OSA, then maybe not.

I hear folks talk about "taking over ventilation" while masking children. I'm curious as to why? If you're on Sevo, then the kiddo has a LOT of Sevo in the brain when their rate slows down, and maybe time to turn in down a little. Sevo will cause kids to decrease their rate and tidal volume significantly in Stage 3-4, thus self-limiting their exposure somewhat. Forcefully bagging them past this point pushes them towards CV collapse, and yes this can happen even with Sevo!

PO versed depends on the age/child, and again on the OSA. Dosing depends on the formulation. I kid you not, we cover kids at 2 different hospitals; one places IV versed in juice du jour, the other uses the official formulation. Juice du jour takes ~30min to effect, while official formulation with a lower dose takes 10-15 minutes.

Sometimes, PPoI works wonders. While rapid turnover keeps the ENT/hosp/SurgCenter happy, nobody's gonna be happy if momma bear is in tears while you tear her cub from her arms. When momma bear has to put up with the nightmares for the next month, you might find your face on her new favorite voodoo doll.

When momma bear raves to her play group pals about how peacefully Johnny went to sleep and woke up, and comrade ENT gets 12 new referrals, that's a good day. (All is moot if not done safely.)

Next question: How do you all handle your tonsil rebleeds?

 

[sdn1977]

Wow! Old thread!

A few additional APAP thoughts in kids - yeah, po/rectal dosing is different - use the appropriate rectal dose. But, the time of onset doesn't really make a difference and PACU nursing won't see the effect. The big effect is duration.

You've "loaded" them for mom & dad for discharge. They go home with an rx for Tyl/Cod elixir. Mom gives the first dose at home & boom - they vomit that blood/saliva & their pain med they've swallowed...but your rectal APAP is still working. Thats why moms are told not to start the pain meds until kiddie is not nauseated (hard to tell in a 3yo) - but they start it anyway. They need the T/C elixir MUCH more a week later!!!

Post op bleeding - anyone still use IV Premarin??? I still have one or two a year who use this.

 

[Noyac]

Post op bleeding - anyone still use IV Premarin??? I still have one or two a year who use this.

Nope.

Why?

 

[Intubate]

awake extubations are safer.. otherwise we would be extubating adults deep..

I extubate adults deep all the time. What are you talking about??

 

[Noyac]

I extubate adults deep all the time. What are you talking about??

He must be talking about his practice. The awake extubation is safer in his practice. And then he is trying to tell everyone else how to practice.

Johan, I have been extubating everyone that meets my criteria deep for over 6 yrs and I have never had a problem. Deep extubation is very safe and many will argue that it is even safer for some pts.

 

[sdn1977]

Nope.

Why?

I've got this ENT who gives IV Premarin for post-op tonsillectomy bleeding about 1-2x/year. There is no good literature supporting it & truly, he is the ONLY guy who uses it (he's close to 70yo). He says its supposed to increase vonWillibrand factor & factors VII, XII & possibley antithrombin, but I've never found that in the literature.

But - it works! One dose & bleeding slows to nothing. But - the kid has swallowed plently of blood before it stops - hence the bloody vomit & nausea @ home.

I was hoping someone here could give some current insight into why such an old tx works.😉

 

[BLADEMDA]

I've got this ENT who gives IV Premarin for post-op tonsillectomy bleeding about 1-2x/year. There is no good literature supporting it & truly, he is the ONLY guy who uses it (he's close to 70yo). He says its supposed to increase vonWillibrand factor & factors VII, XII & possibley antithrombin, but I've never found that in the literature.

But - it works! One dose & bleeding slows to nothing. But - the kid has swallowed plently of blood before it stops - hence the bloody vomit & nausea @ home.

I was hoping someone here could give some current insight into why such an old tx works.😉

Holy Toledo Batman! I looked up I.V. Premrin and it was in "vogue" during the early 1960's as a PROCOAGULANT for ENT and Pulmonary hemorrhage. There is no mechanism of action described for this use and it fell out of favor in the late 1960's.

I wouldn't use it because the only surgeon old enough to want it retired last year. The new ENT's with only 20 years of clinical experience convinced the senior ENT about a decade ago to stop usng I.V. Premarin. Where is your modern, clinical evidence for giving a yound child this drug? If it was my kid who developed a serious side-effect from such a medication (that I see no evidence for giving) I would be quite angry at your use of 1960's medicine.

Blade

 

[Fah-Q]

A few questions from an ENT for you guys to ponder:

1) How many ENT's out there are injecting local into the tonsillar fossa at the end of the case? Does it make much difference with post-op pain? Ever seen it injected into the carotid?

2) Do you adjust your extubation strategy when the case was done "hot" vs "cold" (i.e., knife/scissors/snare vs bovie/coblation/laser). Cold methods tend to bleed more.

3) Do you have strong feelings on the surgeon placing a throat pack or passing an OG tube to suck the stomach at the end of the case?

4) What is the rate of laryngospasm with deep vs awake extubation in peds T&A? Is there any good evidence for one way over the other in this population or is it just personal preferences?

5) Any of you ever seen a "coroner's clot"? This is a a large blood clot from the adenoids that falls into and occludes the airway in the PACU. I've had some attendings scare the #$%^ out of me by telling me it has happened before. Sometimes I stare at the adenoids longer than the tonsils to make sure nothing is bleeding before taking out the mouth gag.

Thanks

 

[johankriek]

Johan, Deep extubation is very safe and many will argue that it is even safer for some pts.

ill change my statement.. there is more of a risk of aspiration and laryngospasm when extubating someone deep...

if its so safe why didnt anyone ever say.. hey let me show you how you extubate this child deep after his/her tonsil during residency? it was always that kid better be awake before you take that tube out..

 

[Noyac]

if its so safe why didnt anyone ever say.. hey let me show you how you extubate this child deep after his/her tonsil during residency? it was always that kid better be awake before you take that tube out..

I don't know why YOUR attendings never allowed you to extubate deep. Mine did. I was at a childrens hospital with well trained pediatric anesthesiologist. I don't know where you where but maybe that is the difference.

Can you provide support for your statement that aspiration is a higher risk? how about laryngospasm? I'm sure there are case reports of these things but there are also cases of aspiration and laryngospasm with awake extubations as well.

 

[johankriek]

I don't know why YOUR attendings never allowed you to extubate deep. Mine did. I was at a childrens hospital with well trained pediatric anesthesiologist. I don't know where you where but maybe that is the difference.

Can you provide support for your statement that aspiration is a higher risk? how about laryngospasm? I'm sure there are case reports of these things but there are also cases of aspiration and laryngospasm with awake extubations as well.

it is awell known fact that there is an increased risk for laryngospasm upon emergence especially at stage 2.. Prolly difficult to find int he literature nowadays because the stages are blurred becuase things go so fast with the medications.. but i believe arthur geudel wrote about these things...

if you pull a tube prior to stage 2 then they will be in stage 2 without a definite airway and all sorts of stuff can happen

 

[sdn1977]

Holy Toledo Batman! I looked up I.V. Premrin and it was in "vogue" during the early 1960's as a PROCOAGULANT for ENT and Pulmonary hemorrhage. There is no mechanism of action described for this use and it fell out of favor in the late 1960's.

I wouldn't use it because the only surgeon old enough to want it retired last year. The new ENT's with only 20 years of clinical experience convinced the senior ENT about a decade ago to stop usng I.V. Premarin. Where is your modern, clinical evidence for giving a yound child this drug? If it was my kid who developed a serious side-effect from such a medication (that I see no evidence for giving) I would be quite angry at your use of 1960's medicine.

Blade

Yeah - I'm old (old enough to remember how often this was used) & as I said, I've only got 1 guy who continues to use it & just a few times a year.

As I said, I've never found a mechanism so I have no modern (or even old fashioned) clinical evidence of any value - just observation, which is why I asked the question. Fortunately, there are no immediate or short-term side effects over all the years I've seen it used. But, I've always wondered about long term possible effects....decades later. But nothing has ever been tracked back to this, as far as I'm aware. And - surprisingly...it does work - crazy!

I only dispense - not prescribe.....so if Premarin is called to OR 4 - it goes to OR 4. Thats not the place for me to bring up a discussion about its use & it occurs so rarely it never gets brought up in surgical committee. We are all waiting for this guy to retire!

 

[Noyac]

Yes we all know about stage 2 extubation. It is taught very early on in everyones training. Deep extubation is not in stage 2.

So you and i will not agree on this so I propose youb do it your way and I will do it my way.

 

[johankriek]

Just because you you extubate deep doesnt mean they dont go through all the things that guedel decribes for stage 2...
when they get there

 

[jwk]

Just because you you extubate deep doesnt mean they dont go through all the things that guedel decribes for stage 2...
when they get there

So what? At that point, IF you extubate truly deep, we're back to a simple mask airway, which is the way some of us still do cases anyway. Extubate deep, assist as needed, turn off vapors, allow to wake up. Maybe your center didn't do this, but my colleagues and I have done many thousands of T&A's this way.

Anesthesia was done for many moons before LMA's ever came along.

 

[johankriek]

So what? At that point, IF you extubate truly deep, we're back to a simple mask airway, which is the way some of us still do cases anyway. Extubate deep, assist as needed, turn off vapors, allow to wake up. Maybe your center didn't do this, but my colleagues and I have done many thousands of T&A's this way.

Anesthesia was done for many moons before LMA's ever came along.

umm anesthesia is much safer now.. that we have endotracheal tubes.. would you agree? because we understand things differently..we understand who needs an et tube and who can be done under mask.. in the olden days.. things were not as clear as they are now..

Hey if you wanna extubate a tonsil deep thats your business I dont care..

I take out LMAs deep.. and I still get laryngospasm about 20 percent of the time.. almost all of it can be reversed with postive pressure.. but it still happens...

 

[pd4emergence]

A few questions from an ENT for you guys to ponder:

1) How many ENT's out there are injecting local into the tonsillar fossa at the end of the case? Does it make much difference with post-op pain? Ever seen it injected into the carotid?

ENT's where I practice and where I trained do not and did not inject. To be honest I am glad they didn't. I have not seen local injected into the carotid but apparently if it happens it takes very little to cause CNS local anesthetic toxicity.

2) Do you adjust your extubation strategy when the case was done "hot" vs "cold" (i.e., knife/scissors/snare vs bovie/coblation/laser). Cold methods tend to bleed more.

I haven't seen a cold T and A since residency. I feel if it was a routine case in a healthy child with good hemostasis either way would be acceptable for me to extubate deep. If there was any question I would wait for them to wake up. See below.

3) Do you have strong feelings on the surgeon placing a throat pack or passing an OG tube to suck the stomach at the end of the case?

I always get our ENT's (they pretty much do it automatically) to run an OG down. It is good for you guys to do it while the gag is on because you can direct the OG where it should go. If we do it, it goes in blindly and I always worry about stirring up bleeding. Emptying the stomach before emergence is helpful for post op nausea esp if there is alot of blood in the stomach. We never use throat packs. The surgeons I work with just don't use them.

4) What is the rate of laryngospasm with deep vs awake extubation in peds T&A? Is there any good evidence for one way over the other in this population or is it just personal preferences?

If you asked two anesthesiologists this question you will get two different answers, see the above debate. My personal feeling is that in a normal healthy child, with good hemostasis, routine case with not alot of bleeding, and who an OG was passed, I would extubate them deep. My feeling on the whole deep extubation debate with T and A's is that in young kids most are still using uncuffed tubes, as far as aspiration goes, uncuffed tubes provide about as much protection as them not being intubated at all. As far as laryngospasm goes, I don't feel it is any more frequent than in awake extubations. I think the advantage of deep extubation is they don't cough and gag on the tube thus they don't stir up as much bleeding from their nice newly formed clot in their tonsillar bed. For adults having T and A's I don't extubate them deep.

5) Any of you ever seen a "coroner's clot"? This is a a large blood clot from the adenoids that falls into and occludes the airway in the PACU. I've had some attendings scare the #$%^ out of me by telling me it has happened before. Sometimes I stare at the adenoids longer than the tonsils to make sure nothing is bleeding before taking out the mouth gag.

I haven't heard of this and would be happy to end my career not seeing it.

 

[Noyac]

My answers to Pd4:
1) My current ENT injects and I am not a fan. Not b/c of the carotid risk (he has not hit it in any of my cases) but b/c the kids can't feel their throats enough to swallow and then they start coughing and choking on secretions in PACU when they are awake b/c they can't swallow effectively. THis happens maybe 1 in 20 cases.
2) I have not seen a cold case in many years. so no.

3)No strong feelings. I can pass the OG at the end if I need to. I haven't stirred up any bleeding yet that I know of.

4) You know my preference. And everything you said is correct on this topic. And those that do may of these also do the deep extubations. Plus if you extubate deep you can manage to do about 20-40% more cases in the same amount of time. This means you finish the day sooner. Not a reason to do something you are not comfortable with but possibly a reason to get comfortable with it.

%) Never seen it. fingers crossed

 

[johankriek]

A
4) What is the rate of laryngospasm with deep vs awake extubation in peds T&A? Is there any good evidence for one way over the other in this population or is it just personal preferences?

theoretically there should be NO laryngospasm in an awake patient and certainly theoretically in an awake patient.. there should be aspiration since they have their airway reflex intact and able to protect airway.. i was at a place once where the ENTs wanted me to extubate deep.. and i said.. NO thanks.. I dont understand.. if the kid bleeds when he gags and coughs you wanna know in the OR you dont wanna know when you are home... And if there is bleeding upon coughing.. hemostasis wasnt achieved adequately..

thats like surgeons who are upset when patients strain on emergence with hernia repairs. My response.. if the repair is done adequately there should be no problem..

 

[Noyac]

theoretically there should be NO laryngospasm in an awake patient and certainly theoretically in an awake patient.. there should be aspiration since they have their airway reflex intact and able to protect airway.. i was at a place once where the ENTs wanted me to extubate deep.. and i said.. NO thanks.. I dont understand.. if the kid bleeds when he gags and coughs you wanna know in the OR you dont wanna know when you are home... And if there is bleeding upon coughing.. hemostasis wasnt achieved adequately..

thats like surgeons who are upset when patients strain on emergence with hernia repairs. My response.. if the repair is done adequately there should be no problem..

Sorry but you are comparing apples and oranges. Tonsils will only get better as the clot stablilizes until day 5-7 of course when it will slough. Hernias are repaired from the get go. There is some healing and scarring that occurs but testing a hernia post op is not like testing the tonsilar pillars postop.

Have you ever asked yourself why the surgeon even wanted deep extubation. They have seen more tonsils that you have.

And not to be nit picky but I know you meant to say "there should NOT be aspiration since they have their airway reflex intact and able to protect airway". I'm just correcting your type-o for those that may be confused.

 

[johankriek]

Sorry but you are comparing aples and oranges. Tonsils will only get better as the clot stablilizes until day 5-7 of course when it will slough. Hernias are repaired from the get go. There is some healing and scarring that occurs but testing a hernia post op is not like testing the tonsilar pillars postop.

Have you ever asked yourself why the surgeon even wanted deep extubation. They have seen more tonsils that you have.

have you ever asked yourself why I DONT want deep extubation

 

[Noyac]

have you ever asked yourself why I DONT want deep extubation

I think you have answered that one.

 

[johankriek]

I think you have answered that one.

i think my reason trumps his reason