Private Practice Tonsillectemies -

[johankriek]

I think you have answered that one.

i think my reason trumps his reason

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[Laurel123]

To Deep extubaters:

1) How 'deep' are the patients? i.e. end-tidal sevo? At Shriner's we used to do very, very deep - as in end-tidals of about 2.5. Just wanted to know if you guys do the same.

2) How about older tonsil patients, like 17 or 18 year olds and above. Do you also do deep extubations. I do, but someone said that they prefer it in young kids only.

 

[Noyac]

I like it in all tonsil pts.

If my Sevo is less than 1.5% I will give a small dose of propofol just b/4 pulling the tube. They don't stop breathing. They may may receive some anti emetic benefits and they go to the pacu very comfortable. After around 5 minutes in pacu they start to arouse and everyone is happy.

Let me make a few things very clear. If the pt is at all difficult to mask or intubate I don't extubate deep. If there is the possiblity of something in their stomach I don't extubate deep. If their respiratory pattern isn't regular with good TV's I won't do it. If it was a bloody T&A, I will be very sure the stomach is emptied and that the pillars are DRY or I won't do it. I am not just willy nilly pulling the tube on everyone.

 

[epidural man]

if the kid bleeds when he gags and coughs you wanna know in the OR

This is why we wake the kid up in the OR - we call it the RED test. If he is going to bleed, let's find out now. I know this doesn't exclude the 5-7 day bleed when the scar falls off, but as you all know, tonsills rebleed after the case, and in a week. At least this eliminates one of those.

 

[epidural man]

Hey Private practice guys,

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

I have a wonderful secret. Get your PACU trained in extubation and take all your kiddos intubated to the PACU. Turnover is very fast, and that means more start up units for you!

 

[Intubate]

Anyone care for some data? This is from Anesthesiology or A&A in 1991. The citation fell off somehow. Awake extubation did not have fewer airway related complications in this study of 70 kids. There are many papers that support this and none (that I found) that refute it. Sorry Johan.

Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients.Patel RI, Hannallah RS, Norden J, Casey WF, Verghese ST.
Department of Anesthesiology, Children's National Medical Center, Washington, DC 20010.

We compared the differences in oxygen saturation and airway-related complications after tracheal extubation in pediatric patients undergoing elective strabismus surgery or adenoidectomy and/or tonsillectomy who were awake versus anesthetized. Seventy otherwise healthy patients between 2 and 8 yr of age were studied. Anesthesia was induced with halothane or thiamylal and maintained with nitrous oxide and halothane. After induction of anesthesia, the patients were randomly assigned to group 1 (awake extubation) or group 2 (anesthetized extubation). Oxygen saturation was measured continuously and recorded 10 min before extubation and at 1, 2, 3, 5, 7, 10, 15, 20, 25, and 30 min after tracheal extubation. Supplemental oxygen was administered when oxygen saturation values were less than 90% while breathing room air. Oxygen saturation levels were higher in group 2 than in group 1 at 1, 2, 3, and 5 min after extubation. There were no differences between the two groups in the number of patients requiring supplemental oxygen. The incidence of airway-related complications such as laryngospasm, croup, sore throat, excessive coughing, and arrhythmias was not different between the two groups. We conclude that the anesthesiologist's preference or surgical requirements may dictate the choice of extubation technique in otherwise healthy children undergoing elective surgery.

 

[jwk]

I have a wonderful secret. Get your PACU trained in extubation and take all your kiddos intubated to the PACU. Turnover is very fast, and that means more start up units for you!

We used to let our PACU nurses extubate adults, but NEVER kids.

 

[Noyac]

This is why we wake the kid up in the OR - we call it the RED test. If he is going to bleed, let's find out now. I know this doesn't exclude the 5-7 day bleed when the scar falls off, but as you all know, tonsills rebleed after the case, and in a week. At least this eliminates one of those.

Just curious, how many of these red tests came back positive at your institution?

I have not had one since residency. I have seen 1 at 8hrs post op and another at 2 days postop. The rest have been in the 5-7 days window.

By the way both of those early bleeds were red headed females.

 

[BLADEMDA]

Anyone care for some data? This is from Anesthesiology or A&A in 1991. The citation fell off somehow. Awake extubation did not have fewer airway related complications in this study of 70 kids. There are many papers that support this and none (that I found) that refute it. Sorry Johan.

Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients.Patel RI, Hannallah RS, Norden J, Casey WF, Verghese ST.
Department of Anesthesiology, Children's National Medical Center, Washington, DC 20010.

We compared the differences in oxygen saturation and airway-related complications after tracheal extubation in pediatric patients undergoing elective strabismus surgery or adenoidectomy and/or tonsillectomy who were awake versus anesthetized. Seventy otherwise healthy patients between 2 and 8 yr of age were studied. Anesthesia was induced with halothane or thiamylal and maintained with nitrous oxide and halothane. After induction of anesthesia, the patients were randomly assigned to group 1 (awake extubation) or group 2 (anesthetized extubation). Oxygen saturation was measured continuously and recorded 10 min before extubation and at 1, 2, 3, 5, 7, 10, 15, 20, 25, and 30 min after tracheal extubation. Supplemental oxygen was administered when oxygen saturation values were less than 90% while breathing room air. Oxygen saturation levels were higher in group 2 than in group 1 at 1, 2, 3, and 5 min after extubation. There were no differences between the two groups in the number of patients requiring supplemental oxygen. The incidence of airway-related complications such as laryngospasm, croup, sore throat, excessive coughing, and arrhythmias was not different between the two groups. We conclude that the anesthesiologist's preference or surgical requirements may dictate the choice of extubation technique in otherwise healthy children undergoing elective surgery.

Your preference as I have said all along. As for speed/wake-up once you get to know the surgeon then either technique will work well. For those who don't do much Peds I recommend the wake-up on the tube model.

Blade

 

[nimbus]

Almost every T&A at Children's Hosp in San diego is extubated awake in PACU by nurses. Makes for very fast turnover.

 

[epidural man]

Almost every T&A at Children's Hosp in San diego is extubated awake in PACU by nurses. Makes for very fast turnover.

Almost every kid on EVERY case is extubated in the PACU at Children's in San Diego.

The problem with this approach as a resident rotating there is you get NO experience at extubating kids, which is certainly an art.

 

[epidural man]

Just curious, how many of these red tests came back positive at your institution?

I have not had one since residency. I have seen 1 at 8hrs post op and another at 2 days postop. The rest have been in the 5-7 days window.

By the way both of those early bleeds were red headed females.

Good question. I don't really know, but I am pretty sure that not many have a postitive test. I have seen one. To tell you the truth, I doubt it does much to really prevent seeing a re-bleed in the PACU or a few hours later, as you mention.