Rigidity/laryngospasm case report

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Precedex

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Can you help me with this case report from the 90s. I mean, please tell me honestly what you think happened here. I have my own ideas but I am very skeptical of this case report. Has anyone out there used narcan to treat laryngospasm after extubation? Who does that?


The child was a 4-year-old boy, who was scheduled for adenotonsillectomy. Premedication consisted of atropine 0.4 mg and pentobarbitone 40 mg intramuscularly. Anaesthesia was induced with propofol40 mg which was followed by vecuronium 2 mg. The trachea was intubated with a 5.5 mm tube, and anaesthesia maintained with nitrous oxide: oxygen (2: 1) supplemented with fentanyl 25 pg. Automatic controlled ventilation was maintained throughout surgery using the double T-piece system [2]. At the end of surgery, which lasted 30 min, the patient’s lungs were ventilated with 100% oxygen. The neuromuscular block was reversed with a mixture of atropine 0.3 mg and neostigmine 0.6 mg, and the trachea extubated while applying a positive pressure to the lungs. This was followed by severe laryngospasm associated with masseter muscle spasm. Manual controlled ventilation with a tightly fitting face mask and 100% oxygen did not result in any chest movement and the oxygen saturation decreased rapidly to 68%. Naloxone 0.1 mg was injected intravenously and was followed within 60 s by sustained and complete relief of both the laryngospasm and the masseter muscle spasm. The child resumed spontaneous breathing and the oxygen saturation increased to 97%.

Extubation laryngospasm is frequent in children after upper airway surgery such as adenotonsillectomy [ 11. Laryngospasm is essentially a protective reflex, mediated by
the vagus nerves, which acts to prevent foreign material entering the tracheobronchial tree [3]. Extubation laryngospasm has been reported in children who had been
anaesthetised with nitrous oxide supplemented with halothane or isoflurane [4,5]. The present report demonstrates the occurrence of severe extubation laryngospasm in
a child who had been ,anaesthetised with nitrous oxide supplemented with fentanyl. The laryngospasm was associated with masseter muscle spasm and was completely
relieved by naloxone, suggesting that fentanyl might have predisposed to this complication.
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Who reverses with atropine and neo?
 
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Tough case. I have never heard of laryngospasm being treated with Naloxone. I wonder if SPO2 of 68 percent had anything to do with breaking the laryngospasm not the Naloxone. This is one reason I prefer not to do a lot of peds. Nobody cares about sick grandma but junior is another thing. And kids Laryngospasm.
 
narcusprince said:
I wonder if SPO2 of 68 percent had anything to do with breaking the laryngospasm not the Naloxone.
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this is my belief, i mean reversal of laryngospasm in 60 seconds is nothing to write home about, and definitely the hypoxemia would have been a factor in breaking the spasm. they may be confusing apnea/difficult mask ventilation following tonsillectomy with laryngospasm
 
What was the reasoning? Edrophonium was around then right?
 
I'm just coming off my first peds rotation, and we still used atropine with neo but only for the little babies. All others got glyco 10 mcg/kg and neo 70 mcg/kg for reversal. But even so, those kids chewed through those NMBs!
 
Maybe it's the whole pain theory in breaking the laryngospasm? i.e. pain will get the pt to come out of phase 2 quicker. I am forgetting the name of that pressure point but it's one reason we do jaw thrusts to provide the stimulus for the pt to breath.

Just a thought.
 
laryngospasm is involuntary, pain shouldnt break it. the patients are usually trying to breathe, and this part of the problem.
 
yeah i use that for apnea, and i would imagine it might help you get some air through but i dont think that taking a deep breath is the cure for laryngospasm, at least as it is classically described. am i wrong?
 
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But don't they occur because the pt is in stage 2, wouldn't increasing pain get you out of stage 2 quicker? I always thought you could do two things with a laryngospasm either deepen them i.e. propofol, or try to wake them up i.e. painful stimulation.

I might totally be wrong here so please correct me so that I can learn.

Succinylcholine also works but I haven't seen that drug at my childrens hospital.
 
From the mouth of a professor of mine in those situations, he would calmly say, " Do not worry, when the heart stops, the jaw will relax." > tube in 100% 02 and the heart will start. This guy had larger gonads than I will ever grow. But he was right in every crisis he managed, that I heard of.
 
RussianJoo said:
But don't they occur because the pt is in stage 2, wouldn't increasing pain get you out of stage 2 quicker? I always thought you could do two things with a laryngospasm either deepen them i.e. propofol, or try to wake them up i.e. painful stimulation.

I might totally be wrong here so please correct me so that I can learn.

Succinylcholine also works but I haven't seen that drug at my childrens hospital.
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plain and simple, laryngospasm is due to airway manipulation in the not fully anesthetized/not fully awake patient, although you could see it in any of the stages (although we typically have an endotracheal tube in during stage 3). you can treat it by deepening the anesthetic or paralyzing, although your first line therapy should be positive pressure ventilation.

pain could worsen your spasm, especially if you arent that close to stage 1
 
RussianJoo said:
Yep, seriously. They say they have it in the pixys somewhere but no one has used it in a very very long time.
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Not having immediate access to sux in a patient population at known high risk of laryngospasm, with mask inductions, etc. sounds a lot like practicing (far) below the standard of care. (assuming sux was available of course) If my kid got the old hypoxia and asystole (with chest compressions I'm guessing?) breaks laryngospasm every time treatment instead of a timely dose of sux, that attending himself might find himself getting a dose of sux when I take him out for trip on the boat to introduce him to Osama.
I certainly don't give sux for every case of laryngospasm, but when you need it you need it, and waiting for hypoxia to do the job is ******ed. It's also useful for the frequent RSI cases that only take 15 min, like a pyloromyotomy.
WTF kind of Children's Hospital is this?
 
I'll mail you a bottle of Succ. I don't start a case without it in the room. After 30,000 cases I can tell you it is a useful drug at times. I do avoid the routine use of Succ. for intubation. ........ It isn't just useful in the OR. I used it numerous times for dislocated joints in the ER.
 
I have a bottle of Sux sitting on top of my cart for every single anesthetic I perform. Rarely crack it, but it's there and part of every MSMAID preinduction. ...I'm not a concealed carry guy.
 
IlDestriero said:
Not having immediate access to sux in a patient population at known high risk of laryngospasm, with mask inductions, etc. sounds a lot like practicing (far) below the standard of care. (assuming sux was available of course) If my kid got the old hypoxia and asystole (with chest compressions I'm guessing?) breaks laryngospasm every time treatment instead of a timely dose of sux, that attending himself might find himself getting a dose of sux when I take him out for trip on the boat to introduce him to Osama.
I certainly don't give sux for every case of laryngospasm, but when you need it you need it, and waiting for hypoxia to do the job is ******ed. It's also useful for the frequent RSI cases that only take 15 min, like a pyloromyotomy.
WTF kind of Children's Hospital is this?
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This. One of my pedi anesthesia mentors, now dearly departed, always carried a syringe of succ and syringe of atropine in his pocket. We teach our residents rotating through peds that the only two drugs they MUST have in the top drawer at the beginning of the day is a syringe of succ and a syringe of atropine with a 22 gauge needle attached (for quick IM admin if no IV). Not having succ available is straight up malpractice. I know you're not making the rules, but someone needs to get on this at your institution- STAT.
 
Unless you work at the Hospital for Myopathic Children, this is a battle worth fighting and one that you and your kiddies will win.
 
pgg said:
Heh

I got written up once during an ICU month for keeping vasopressors, paralytics, and propofol within easy reach. Had to modify my carry method to avoid being spotted after that.
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Sheeeeiitt. PAs in the unit used to seek us out for a quick hit of Neo. If we didn't have any, they'd look all disappointed.
 
Yes I knew it was strange when I first started. For rapid sequence we use Roc. It seems like the roc we have is super weak because with in 20min it seams to wear off, and no matter how fast the surgery is it will still be longer than 20min with the prep and everything. Another thing you guys will find crazy is that we reverse without checking twitches. They only dose the paralytic once and assume that after 1hr the kids are reversible. I called the anesthesia tech for a twitch monitor once and it took them 30min to find one, my attending came into the room and raised a stink that I wanted to check twitches before reversing.


I've tried to fight battles before and got punished, after talking to a few senior residents I realized that the only thing that will happen is that I'll get fired if I try to fight more battles. So I am keeping my head low and getting the hell out once I graduate. I've probably already said too much and will get in trouble if any of my attendings see this. So I am done discussing this issue.

Bottom line is that I know what's right and what's wrong and know how I'll be practicing when I am an attending, but I need to get to that level first.

Also yesterday while on call I had a parent tell me that her daughter had a T+A at another hospital and they told her that she'll only get a mask and that's it. I flat out told her that they lied to you and that it's impossible to do a T+A without a breathing tube.

There are a ton of incompetent anesthesiologists out there. My theory is that this all came from the fact that anesthesia had a 50% match rate in the late 90's and people who really wanted to go into psych or IM or FM just couldn't get in and chose Anesthesia and simply don't give a crap and because of the lack of interest never bothered to learn correct ways of doing things or explaining things to patients. The only thing that saves these people is the fact that emergencies are pretty rare.
 
RussianJoo said:
Yes I knew it was strange when I first started. For rapid sequence we use Roc. It seems like the roc we have is super weak because with in 20min it seams to wear off, and no matter how fast the surgery is it will still be longer than 20min with the prep and everything. Another thing you guys will find crazy is that we reverse without checking twitches. They only dose the paralytic once and assume that after 1hr the kids are reversible. I called the anesthesia tech for a twitch monitor once and it took them 30min to find one, my attending came into the room and raised a stink that I wanted to check twitches before reversing.
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This is pretty much par for the course, actually. Most of us rarely ever use Sux, the point is that you have to have it available for emergencies. Most kids can tolerate an apneic RSI with rocuronium doses appropriately, their lungs are healthy, and you can afford to wait the requisite time to create intubating conditions. Roc is the go to paralytic in almost all our peds cases when u need paralytic, and yes, it wears off quickly. 20 minutes is about right. But usually you are able to keep the patient deep enough with anesthetic/opioid to maintain surgical conditions for however long the case takes. The majority of the time I don't use paralytic for intubation, except when it is specifically indicated. Of course paralytic is necessary when in pins, most neurosurgical cases and other specific circumstances.

It's true that in 99.9% of cases the kid will be reversible after one dose of roc and 30 minutes. I rarely insist on twitches, i do want the residents to learn how to get the kid breathing spontaneously while maintaining surgical conditions and titrating opioid. breathing=reversible, no need to futz round for a twitch monitor.
 
RussianJoo said:
There are a ton of incompetent anesthesiologists out there. My theory is that this all came from the fact that anesthesia had a 50% match rate in the late 90's and people who really wanted to go into psych or IM or FM just couldn't get in and chose Anesthesia and simply don't give a crap and because of the lack of interest never bothered to learn correct ways of doing things or explaining things to patients. The only thing that saves these people is the fact that emergencies are pretty rare.
Click to expand...

Don't kid yourself. Ignoring the match cycle in the 90's, there are just lazy, incompetent worthless doctors in all specialties.
 
RussianJoo said:
Also yesterday while on call I had a parent tell me that her daughter had a T+A at another hospital and they told her that she'll only get a mask and that's it. I flat out told her that they lied to you and that it's impossible to do a T+A without a breathing tube.
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Laryngeal mask airway? Maybe they were fudging a little to not scare the parents?

Like michigan, the majority of attendings prefer not using muscle relaxant to intubate (where's that crazy New Zealander?). Get 'em deep on sevo, a little prop after the IV goes in, tube. Always had sux/atropine/triple dilute epi drawn up and on the cart, never used it in 2 months.
 
I don't always tell my adult pt's about the tube, but I feel like the parents should know everything that will happen with their kids. I explain to them that all of this is done for their child's safety and I feel they're more grateful when I am honest and detailed with them, they also come to understand the importance of my job as an anesthesiologist. To the really nervous parents I explain the different monitors and safety precautions that we take to ensure their child's safety. This puts a lot of parents at ease.

As for paralyzing, I feel like a lot of my attendings like to paralyze because it just makes things easier. I know how to keep a pt relaxed and not moving without paralysis and don't like to paralyze kids if it's not needed i.e. not an abdominal procedure. Even my propofol dose will be drastically lower for intubations just because they're deep on sevo.

I've been on peds for over 2 months now and can think of only maybe 2 incidents where a little succs could have been useful. But none of the attendings ask me about having emergency drugs ready, these guys are more hands on than my attendings at the adult hospital and I don't know anyone who draws up emergency drugs on a regular basis, maybe if the kid is really sick then we'll have double diluted epi ready, and i've only given epi pre-emptively once before laryngoscopy.

Over all I think I am getting great training because I am used to being on my own and have a lot of exposure to a lot of pathology and really sick patients. Yes more supervision in my CA1 year would have been nice but now I am used to being on my own and have learned how to get myself out of tough situations. This will definitely make me a better and more confident attending once I get out. Even the OR nurses who would call for an attending at the drop of a hat are more at ease when I am in the room and know that they can count on me to tell them when I am over my head and need help. (I know this because many have told this to me, and a few attendings have confused me for a CA-3 after working with me for the day.)
 
Fell for the old I though you were a CA-3 trick? I feel like most attendings know exactly what year you are. This is just a way of saying good job without saying good job. Do not get confused.
 
Don't lose sight of the big picture here: you need to have sux in the rooms where patients are anesthetized. This is important.
 
Amen.
Anyway, one of the things you learn from some attendings during training, and your colleagues later at M&M, is how not to best do things.
It sounds like your peds hospital is a real mess. At least you recognize that.:thumbup: If you want to do peds instead of CV, come on over and we'll show you how to do it safely.
 
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