Solo peds case

[deleted875186]

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Just curious logistically how a solo peds case would go. Mask induction without IV, we typically always immediately place an IV after induction. How do you do this if solo? Who manages the airway? Or so you ask the nurse to place an IV?

 

[drmwvr]

Can be done either way...nurse place the IV or nurse place the tqt, prep the skin. Briefly set down the mask , and place the IV then have the nurse dress it and attach fluid. Less than 10 seconds to do from the head of the bed with the arm/hand angled "chicken wing" toward you. If a more difficult stick, deep intubation, secure tube, tape eyes etc. and them come around and place it.

 

[deleted162650]

Just curious logistically how a solo peds case would go. Mask induction without IV, we typically always immediately place an IV after induction. How do you do this if solo? Who manages the airway? Or so you ask the nurse to place an IV?

A few options:

1) Nurse places IV (depends on who the nurse is)
2) Nurse holds mask while you place IV
3) Surgeon places IV (yes, to my surprise we actually have a couple peds ENT's that get off on starting the IV - good at it too)
4) My favorite (Thanks @Noyac for the idea): place kid's hand over the mask sorta like he's holding it - this allows you to hold the mask down with your middle finger while while your index finger holds the wrist and your thumb holds the fingers down over the mask keeping the skin taut. Now pop in the IV while masking the whole time. Straight status.

 

[deleted875186]

A few options:

4) My favorite (Thanks @Noyac for the idea): place kid's hand over the mask sorta like he's holding it - this allows you to hold the mask down with your middle finger while while your index finger holds the wrist and your thumb holds the fingers down over the mask keeping the skin taut. Now pop in the IV while masking the whole time. Straight status.

Amazing. Have to see it to believe it .

 

[deleted162650]

Amazing. Have to see it to believe it .

I’ll try to put up a tutorial on YouTube. 😉

 

[deleted592694]

You can also place an LMA (assuming inhalational induction) after breathing down, free yourself to place an IV then keep the LMA or remove and intubate if that is your airway plan. I saw a senior faculty member do this at Boston Children’s.

 

[Psai]

A few options:

1) Nurse places IV (depends on who the nurse is)
2) Nurse holds mask while you place IV
3) Surgeon places IV (yes, to my surprise we actually have a couple peds ENT's that get off on starting the IV - good at it too)
4) My favorite (Thanks @Noyac for the idea): place kid's hand over the mask sorta like he's holding it - this allows you to hold the mask down with your middle finger while while your index finger holds the wrist and your thumb holds the fingers down over the mask keeping the skin taut. Now pop in the IV while masking the whole time. Straight status.

God one time I placed an iv on a "difficult stick" patient in 2 seconds and felt like a god then the next patient is a totally normal kid, miss the IV multiple times and the peds ENT gets it in one shot. Ego deflated.

 

[deleted87051]

God one time I placed an iv on a "difficult stick" patient in 2 seconds and felt like a god then the next patient is a totally normal kid, miss the IV multiple times and the peds ENT gets it in one shot. Ego deflated.

We have a urologist who is good at Aline’s and likes to do them. Reportedly she will ask for an Arrow catheter and will start working on the opposite wrist if the anesthesiologist is having problems. Thankfully she hasn’t had the opportunity with me.....yet.

 

[Ezekiel2517]

We have a urologist who is good at Aline’s and likes to do them. Reportedly she will ask for an Arrow catheter and will start working on the opposite wrist if the anesthesiologist is having problems. Thankfully she hasn’t had the opportunity with me.....yet.

Maybe if she got better at her own specialty, she wouldn't need arterial lines for her cases. Can't recall the last time I had to place one for a urology case

 

[deleted162650]

We have a urologist who is good at Aline’s and likes to do them

The weird part is that she puts 'em in the dorsal artery.

 

[deleted87051]

Maybe if she got better at her own specialty, she wouldn't need arterial lines for her cases. Can't recall the last time I had to place one for a urology case

She’s a uro-oncologist, does lots of big whacks and she’s very very good.

 

[Psai]

The weird part is that she puts 'em in the dorsal artery.

Usually that costs extra!

But yeah we've had some uro cases go really bad that could have used an a line a little earlier.

 

[HalO'Thane]

Another option is to stay at the head of the bed managing the airway, have the nurse place the tourniquet and prep the hand, have her flip the hand up to you, and you place the IV with your right hand while holding the mask with the left, then having the nurse tape it down, etc. If I think the IV may be difficult I would rather intubate/place an LMA first under deep inhalation and then come down to the other side of the bed.

 

[propadope]

I just ask a nurse or assistant to hold the mask. Its usually not hard for them to learn and you can always throw in an OPA if they suck at it. That way I am free to look around for the best vein which is often the saphenous.

Also intubating without an IV makes me nervous although I know it can be done in a pinch

 

[norski]

Brilliant thread! Don't think I'll ever have to do this myself, as generally a peds induction solo is a no-go over here, but definitely interesting to read about the varying degrees of pragmatism on display here. Love it!

When you say intubation under deep inhalation, is your patient at MAC 1.3 or 1.5? Higher?

( Re: uro patients needing a-lines: Most of our uros are ASA3-4, so many of ours get them in conjunction with norepi or phenylephrine drips. Not routinely,though,and I can't for the life of me recall ever having witnessed anyone but an anesthesia doc or nurse place one. )

 

[narcusprince]

I would like to know more about tge deep intubation technique. I do not do a lot of peds I was always trained to mask induce then place IV then instrument the airway.

 

[BeatriZZ]

All of our peds circulators place IVs after mask induction. Really surprised how many of you have to pull your attention away from an unsecured airway to place a dumb IV, something pre-an nurses routinely do.
If the nurse can flip the kids hand up and hold it for you why can't they put the damn IV in? Your nursing staff must suck

 

[deleted87051]

I would like to know more about tge deep intubation technique. I do not do a lot of peds I was always trained to mask induce then place IV then instrument the airway.

Mask induction—>assisted ventilation—>controlled ventilation for about a minute all with 8% sevo—>check to see they are completely apneic/zero spontaneous ventilatory effort—>tube.

Obviously you only do this in healthy kids.

 

[narcusprince]

Mask induction—>assisted ventilation—>controlled ventilation for about a minute all with 8% sevo—>check to see they are completely apneic/zero spontaneous ventilatory effort—>tube.

Obviously you only do this in healthy kids.

How often do they laryngospam? Ever have to give im sux in this scenario?

 

[deleted87051]

How often do they laryngospam? Ever have to give im sux in this scenario?

They never spasm if they are deep enough. Only if they are too light. If there’s any sign of excitation or ventilatory effort, keep mask ventilating until there isn’t.

 

[deleted162650]

All of our peds circulators place IVs after mask induction. Really surprised how many of you have to pull your attention away from an unsecured airway to place a dumb IV, something pre-an nurses routinely do.
If the nurse can flip the kids hand up and hold it for you why can't they put the damn IV in? Your nursing staff must suck

Pre-op nurses = good at IVs

Circulators = not so much

It was a different story at the children’s hospital. Circulators there had solid IV skills.

 

[deleted162650]

Here’s another peds induction pro-tip. Don’t tape the eyes right away. Once the kid’s asleep, take a quick peek at the eyes. It they’re midline (stage 3) go for the IV. If they still have chameleon eyes give it a minute before you poke them into laryngospasm.

 

[Psai]

Our ob nurses can't even hit an iv on a healthy well hydrated athlete with garden hoses so I can't imagine our circulators doing a peds iv

 

[d9sccr]

Our ob nurses can't even hit an iv on a healthy well hydrated athlete with garden hoses so I can't imagine our circulators doing a peds iv

It's quite astonishing how bad the OB nurses are everywhere. I don't get how this is a universal rule. You'd assume some units would luck out eventually and get some good nurses. One of our partners swears that if you have them gather all the IV supplies, including the ultrasound, they just stop calling and somehow are able to place them independently.

Side note, anyone billing for the OB IVs when asked to start them? If you use the ultrasound and obtain a picture, can you bill for the ultrasound as well?

 

[Arch Guillotti]

Here’s another peds induction pro-tip. Don’t tape the eyes right away. Once the kid’s asleep, take a quick peek at the eyes. It they’re midline (stage 3) go for the IV. If they still have chameleon eyes give it a minute before you poke them into laryngospasm.

 

[narcusprince]

Our ob nurses can't even hit an iv on a healthy well hydrated athlete with garden hoses so I can't imagine our circulators doing a peds iv

Ob nurses are not good at sticking but quite apt at getting stuck the 9 month kind......

 

[deleted162650]

Ok, what part of that was dumb?

 

[T-burglar]

This stage 1 2 3 **** is nonsense. Just pin the arm down and put the IV in as soon as you’re sure the kid won’t remember.

 

[deleted875186]

This stage 1 2 3 **** is nonsense. Just pin the arm down and put the IV in as soon as you’re sure the kid won’t remember.

I too have never seen a kid laryngospasm from an IV stick, and we typically place an IV as soon as the kid is out, but the rational seems correct, anyone else have this happen to them??

 

[drmwvr]

All of our peds circulators place IVs after mask induction. Really surprised how many of you have to pull your attention away from an unsecured airway to place a dumb IV, something pre-an nurses routinely do.
If the nurse can flip the kids hand up and hold it for you why can't they put the damn IV in? Your nursing staff must suck

A deep, stable breathing child with and opa (or without, for that matter) right in front of you hardly constitutes an unsecured airway. Applying a mask to that makes the airway secure? And if placing an IV in the time the patient takes 3 breaths with the airway between you and the IV is taking attention away from the airway, solo peds isn't the place for you.

 

[drmwvr]

I too have never seen a kid laryngospasm from an IV stick, and we typically place an IV as soon as the kid is out, but the rational seems correct, anyone else have this happen to them??

It is absolutely "a thing". Sticking a light child risks spasm...of course it does. It is rarely a big deal, but why have to deal with it? This is a question?

 

[deleted162650]

I too have never seen a kid laryngospasm from an IV stick, and we typically place an IV as soon as the kid is out, but the rational seems correct, anyone else have this happen to them??

We just had a thread about this: multiple IV sticks, spasm, IM roc.

 

[ethilo]

Our OR RN's will place the IV after mask induction. I don't let them touch the patient until the HR has peaked and has started drifting downward with induction. If they can't get the IV after a couple tries I'll intubate quickly with no IV and start looking myself

 

[Arch Guillotti]

Here’s another peds induction pro-tip. Don’t tape the eyes right away. Once the kid’s asleep, take a quick peek at the eyes. It they’re midline (stage 3) go for the IV. If they still have chameleon eyes give it a minute before you poke them into laryngospasm.

Ok, what part of that was dumb?

Our OR RN's will place the IV after mask induction. I don't let them touch the patient until the HR has peaked and has started drifting downward with induction. If they can't get the IV after a couple tries I'll intubate quickly with no IV and start looking myself

This. Forget looking at the eyes.

 

[deleted162650]

This. Forget looking at the eyes.

Agree 100% with following the HR. The trainees amongst us may appreciate having a 2nd way to evaluate depth however.

 

[propadope]

This stage 1 2 3 **** is nonsense. Just pin the arm down and put the IV in as soon as you’re sure the kid won’t remember.

If the kid is not deep enough they WILL react to the IV placement. Flinching, withdrawing, tachycardia, etc... and yes potential laryngospasm. Why not wait an extra minute? The whole point of the mask induction is to avoid a moving target

 

[propadope]

They never spasm if they are deep enough. Only if they are too light. If there’s any sign of excitation or ventilatory effort, keep mask ventilating until there isn’t.

Another concern for me is possible bradycardia from the laryngoscopy. Ever seen it with deep inhalational intubation?

 

[deleted87051]

Another concern for me is possible bradycardia from the laryngoscopy. Ever seen it with deep inhalational intubation?

I’ve seen it on rare occasion but I attribute it to anesthetic overdose. I decrease the inhaled sevo after intubation and they recover.

 

[propadope]

Agree 100% with following the HR. The trainees amongst us may appreciate having a 2nd way to evaluate depth however.

Another good sign is when the muscles relax.

 

[Laryngophed]

4) My favorite (Thanks @Noyac for the idea): place kid's hand over the mask sorta like he's holding it - this allows you to hold the mask down with your middle finger while while your index finger holds the wrist and your thumb holds the fingers down over the mask keeping the skin taut. Now pop in the IV while masking the whole time. Straight status.

Why does it not surprise me that Noy would have a ballin' ninja move like this?

 

[T-burglar]

I did a lot of peds cardiac as a fellow and resident and we would start stabbing the saphenous as soon as the mask was on.

Larygnospasm happens maybe. But I’ve never seen it. And our peds cardiac team certainly didnt care about anesthetic depth prior to IV attempts. Can’t remmebwr a single problem.

I think laryngospasm can happen I guess but I don’t think it’s predictable or associated with stimulation. Just my opinion.

 

[btbam]

Another trick to assess depth is hold up whatever limb you're sticking for an IV and let it drop. If the kid resists or twitches at all, they aren't ready. Once it flops back to the bed, then you stick.

 

[deleted643396]

Once it flops back to the bed, then you stick.

Is that called the Cosby maneuver?

 

[michigangirl]

I'm surprised noone has mentioned a mask strap? Especially when noone else in the room can help with IV/masking? Works beautifully when kid is an easy mask and spontaneously breathing.

 

[deleted643396]

I'm surprised noone has mentioned a mask strap? Especially when noone else in the room can help with IV/masking? Works beautifully when kid is an easy mask and spontaneously breathing.

Yup. I use mask straps a lot...even for non-peds. It’s also good for good pre-O2 (denitrogenation, or whatever you want to call it) in adults when you are putting on monitors and drawing up drugs (we’ve gotten yelled at so many times by the clipboard army that I don’t draw meds until patient is in room and on OR table).

 

[narcusprince]

Yup. I use mask straps a lot...even for non-peds. It’s also good for good pre-O2 (denitrogenation, or whatever you want to call it) in adults when you are putting on monitors and drawing up drugs (we’ve gotten yelled at so many times by the clipboard army that I don’t draw meds until patient is in room and on OR table).

That is malignant. Drawing up drugs only when the patient is in the room. Could you imagine doing cardiac anesthesia or vasc or neuro? This is the definition of insanity.

 

[Psai]

That is malignant. Drawing up drugs only when the patient is in the room. Could you imagine doing cardiac anesthesia or vasc or neuro? This is the definition of insanity.

Trying to start a STAT ob case with nothing premade or drawn up is just stupid. We've probably had so many near misses, but because no one has actually died yet nothing has changed. They also want us to have nothing made up until the patient is in the room but they also want us to be able to drop off a patient, see the next patient and have the room ready in an absurdly short period of time without any of the resources necessary to make it possible. It's just not feasible. *****s who have never set up an OR for a patient make up stupid rules that aren't based in reality and don't have any discernable effect on patient safety whatsoever.

They sit around tables with their clipboards all day while brainstorming for the next idiotic mandate, thinking they're the second coming of Semmelweis. smh

 

[narcusprince]

This is a reflection of poor leadership. Your group president and vp need to speak with the leadership in regards to this. Or pharnacy needs to have premixed meds. Cannot turn chicken $h!t into chicken salad!

 

[deleted875186]

I'm surprised noone has mentioned a mask strap? Especially when noone else in the room can help with IV/masking? Works beautifully when kid is an easy mask and spontaneously breathing.

I admit I’ve never tried the strap in a peds case, but love using it in adults. This sounds like the easiest solution to doin a peds case. Pop in an oral airway and strap them in.

As a side question, anyone know what that nose mask contraption the dentists use in kids is called.

 

[drmwvr]

I think laryngospasm can happen I guess but I don’t think it’s predictable or associated with stimulation. Just my opinion.

Extubate a 3 year old in a light plane of anesthesia...larygospasm is as predictable as the sun rising in the east.