T&A tricks

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acidbase1

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What are your tonsillectomy tricks?

Sometimes I use ketamine, others precedex

My surgeon is horrible so we tend to have a lot of laryngospasms, have been spraying the cords with LTA as of late

Also worried to pull deep due to inexperienced PACU nurses. Would it be better to extubate deep then wake up in OR?
 
acidbase1 said:
What are your tonsillectomy tricks?

Sometimes I use ketamine, others precedex

My surgeon is horrible so we tend to have a lot of laryngospasms, have been spraying the cords with LTA as of late

Also worried to pull deep due to inexperienced PACU nurses. Would it be better to extubate deep then wake up in OR?
Click to expand...
What does the surgeon have to do with laryngospasm?
 
acidbase1 said:
What are your tonsillectomy tricks?

Sometimes I use ketamine, others precedex

My surgeon is horrible so we tend to have a lot of laryngospasms, have been spraying the cords with LTA as of late

Also worried to pull deep due to inexperienced PACU nurses. Would it be better to extubate deep then wake up in OR?
Click to expand...
Don’t take them to the pacu deep unless you have good nurses and the ability to respond immediately in the case of emergency.
 
Use LTA. They're laryngospasming bc you're extubating too early. Turn off the gas early. Gotta learn how to time it. Deep extubation and inexperienced pacu nurses is a recipe for the worst outcomes. Extubating deep in OR and waiting for the patient to wake up in the OR doesn't save time or prevent laryngospasm so why would you do this?
 
Ezekiel2517 said:
Use LTA. They're laryngospasming bc you're extubating too early. Turn off the gas early. Gotta learn how to time it. Deep extubation and inexperienced pacu nurses is a recipe for the worst outcomes. Extubating deep in OR and waiting for the patient to wake up in the OR doesn't save time or prevent laryngospasm so why would you do this?
Click to expand...

Making way too many assumptions here chief. Certainly not extubating too early. Extubating in OR monitoring patient until they’re through stage two and awake instead of trusting inexperienced PACU nurses will definitely prevent laryngospasm.
 
acidbase1 said:
Making way too many assumptions here chief. Certainly not extubating too early. Extubating in OR monitoring patient until they’re through stage two and awake instead of trusting inexperienced PACU nurses will definitely prevent laryngospasm.
Click to expand...
Not if there is bleeding in the airway. Deep extubation sounds like a bad idea
 
I would not pull deep with a bad surgeon. Way too likely some blood drips back on the cords and you spasm. When I extubate them (awake) and they start spazzing out I do 0.5 mcg/kg precedex bolus with 0.1-0.2 mg glyco. Do another 0.5 if they are still crazy after 3 minutes.
 
Oh and reasoning for deep extubating and waking up in OR.

In residency most were extubated deep, never had any pulm issues. Now it seems I’m having to give more albuterol in PACU bc pt in waking up in the tube. Not sure if increased incidence of bronchospasm or what. But it’s definitely a noticeable difference
 
Wouldnt extubate deep for tonsillectomy, definitely too much risk than I'm willing to accept. Question is why laryngospasm is occurring for what seems like "awake patients" outside of stage 2. Still feel like OP is extubating too early, maybe because pt bucking too much?
 
You have to do T&As frequently with the same surgeon to be slick. Otherwise, don’t worry about being slick and worry about being safe instead. If you only occasionally do tonsils, wait the extra 2 minutes (it feels like 30 minutes, but I assure you it’s only 2 minutes) and extubate awake. Smooth out emergence with whatever you like...propofol, precedex, narcs, etc...but focus on being safe, not slick. If you are getting a ton of larygospasms then YOU are doing something wrong (not the surgeon).
 
I am 10000% not extubating too early. Other providers are having the same issues so it’s not just me. Guys that are in their 60s and have been doing this forever. We have chalked it up to the surgeon. I’d say 1/10 have laryngospasms and they’re broken w PPV. I did TONs of these cases and never had any issues in residency.
 
acidbase1 said:
What are your tonsillectomy tricks?

Sometimes I use ketamine, others precedex

My surgeon is horrible so we tend to have a lot of laryngospasms, have been spraying the cords with LTA as of late

Also worried to pull deep due to inexperienced PACU nurses. Would it be better to extubate deep then wake up in OR?
Click to expand...

not to much pre-med, usually truly 0.5mg/kg of midaz if anything

i personally dont do lta

i get them breathing early ( never turn on the vent)

titrate in narcotic to usually 2mcg/kg of fent once breathing

lower level of sevo like 1.5% during maint phase

glyco to everyone

try to anticipate the timing of surgeon taking patient out of suspension and kill the gas (this is the part where you must know the surgeon)

iv tylenol and possibly more narcotic to get resp rate down to 12-18

wake up with lots of suctioning, put on side with FM in front of them.

low threshold to give a neb through the facemask prophylactially to those with asthma or any wheezing after extubation

if wild after wakeup fentanyl

i wouldnt ever deep extubate a tonsil
 
Sevo induction.
3-5mcqs per kg fentantyl
Propofol bolus 2 mg per kg
LTA
Intubate
Turn off sevo
Run propofol at 15mg/kg/hr

1mcq per kg clonidine IV
Dexamethasone IV
Paracetamol IV
Selective cox 2 inhibitor IV

Get them breathing when first tonsil out while continuing propofol. Suction out airway if needed. Insert oral airway. Extubate deep while running propofol.

Thank me later.
 
Sonny Crocket said:
Sevo induction.
3-5mcqs per kg fentantyl
Propofol bolus 2 mg per kg
LTA
Intubate
Turn off sevo
Run propofol at 15mg/kg/hr

1mcq per kg clonidine IV
Dexamethasone IV
Paracetamol IV
Selective cox 2 inhibitor IV

Get them breathing when first tonsil out while continuing propofol. Suction out airway if needed. Insert oral airway. Extubate deep while running propofol.

Thank me later.
Click to expand...
Elegant......
Mask induction sevo
Iv
Glyco 3mcg/kg
Morphine .1mg/kg
Propofol 2-3mg/kg
Decadron .5mg/kg
Get spontaneous breathing early.
Propofol bolus 1mg/kg for any excessive movement.
.75- .5 mac sevo.
As soon as they do adenoids or stop boving start turning off the gas. By the time the bed is turned that tube is ready to come out.
 
Sonny Crocket said:
Sevo induction.
3-5mcqs per kg fentantyl
Propofol bolus 2 mg per kg
LTA
Intubate
Turn off sevo
Run propofol at 15mg/kg/hr

1mcq per kg clonidine IV
Dexamethasone IV
Paracetamol IV
Selective cox 2 inhibitor IV

Get them breathing when first tonsil out while continuing propofol. Suction out airway if needed. Insert oral airway. Extubate deep while running propofol.

Thank me later.
Click to expand...

15mg/kg/h?
 
Psai said:
Oh i missed a zero somehow. Why so high?
Click to expand...
For a young kid seems pretty appropriate. I’ve had to so as high as 400 mcg/kg/min in a very young kid for TIVA with fentanyl.
 
Last edited by a moderator:
Psai said:
Oh i missed a zero somehow. Why so high?
Click to expand...

At the end of the day, it isn't the rate, it's the total dose. Reasonably fast (or even just OK fast) surgeons mean more or less a very slow bolus of not much propofol.
 
once the patient is turned back over to me, i suction them aggressively with the yankauer. if there is any hint of oozing or bleeding, i tell the surgeon to fix it before the tube comes out. i've also had to wake up a kid or two in the lateral position which seemed to help.
 
Sonny Crocket said:
Run propofol at 15mg/kg/hr.
Click to expand...

TIVA is a life changing technique for tonsils, and kids in general.

For foolproof TIVA in small kids add remifentanil 100microg to a 20mL propofol syringe, and run the mix at 1.5mL/kg/hr (titrate down for longer cases or they'll never wake up). Spont vent the whole time, extubate deep on the side after checking for bleeding, then turn the propofol off. Very easy recipe and they wake up great.
 
Last edited:
Unless the kid weighs more than me, I spray the cords with lta or poor man's version (angiocath) making sure to watch total volume of local, no paralytic, start working in my narcotic, turn the bed, fast good surgeon, OGT, deep extubation, pacu lateral position with good nurses.

For a known post op delrium patient or someone with DD, precedex bolus.
 
ranvier said:
You are probably right as it rarely brings up blood but sometimes I'm surprised as to the gastric volume and it's quick and part of my routine.
Click to expand...

Is it clinically significant though? Is what youre doing actually helping
 
Sorry but this is a random journal no one heard of with a bunch of nobodies from turkey. In any case, they are careful to mention their induction doses but I don't see where they administered antiemetics.
 
I left the authors off due to the turkish factor and you got me. The real papers show no difference. An homage to blade.

Arch Otolaryngol Head Neck Surg. 2001 Aug;127(8):980-4.
Efficacy of gastric aspiration in reducing posttonsillectomy vomiting.
Jones JE1, Tabaee A, Glasgold R, Gomillion MC.
Author information

Abstract
OBJECTIVE:
To determine the effectiveness of postoperative gastric decompression in reducing the incidence and complications associated with vomiting following tonsillectomy.

DESIGN:
A prospective, randomized controlled study.

SETTING:
Private office and clinic of a university teaching hospital and research center.

PATIENTS:
Eighty pediatric patients ranging in age from 22 months to 11 years, American Society of Anesthesiologists class I or II, undergoing tonsillectomy with or without adenoidectomy were enrolled in the study. Six were excluded from the final analysis, 5 because of failure of the parents to complete and return the data forms and 1 because of postoperative bleeding. Of the 74 patients included in the study, 35 were in the control group and 39 were in the study group.

INTERVENTIONS:
The 39 patients in the study group underwent postoperative aspiration of gastric contents with an orogastric tube placed under direct visualization while the patient was still under general anesthesia. The 35 patients in the control group did not undergo gastric aspiration following surgery.

MAIN OUTCOME MEASURES:
The incidence of vomiting, the number of episodes of vomiting before and after hospital discharge, the total volume of emesis, the postoperative length of stay, the need for rescue antiemetic prophylaxis, and the number of readmissions to the hospital for persistent vomiting were noted.

RESULTS:
No statistically significant difference (P<.05) was noted between the control group and the study group for the percentage of patients experiencing vomiting (74% vs 85%), the mean number of episodes of vomiting before (2.6 vs 2.8) and after (0.8 vs 0.7) hospital discharge, the mean volume of emesis (157 mL vs 222 mL), the postoperative length of stay (394 minutes vs 334 minutes), the percentage of patients requiring rescue antiemetics (34% [12 patients] vs 33% [13 patients]), and the percentage of unplanned admissions because of vomiting (9% [3 patients] vs 15% [6 patients]).

CONCLUSION:
Our results indicate that gastric aspiration does not decrease the incidence of vomiting following tonsillectomy
 
ranvier said:
I left the authors off due to the turkish factor and you got me. The real papers show no difference. An homage to blade.

Arch Otolaryngol Head Neck Surg. 2001 Aug;127(8):980-4.
Efficacy of gastric aspiration in reducing posttonsillectomy vomiting.
Jones JE1, Tabaee A, Glasgold R, Gomillion MC.
Author information

Abstract
OBJECTIVE:
To determine the effectiveness of postoperative gastric decompression in reducing the incidence and complications associated with vomiting following tonsillectomy.

DESIGN:
A prospective, randomized controlled study.

SETTING:
Private office and clinic of a university teaching hospital and research center.

PATIENTS:
Eighty pediatric patients ranging in age from 22 months to 11 years, American Society of Anesthesiologists class I or II, undergoing tonsillectomy with or without adenoidectomy were enrolled in the study. Six were excluded from the final analysis, 5 because of failure of the parents to complete and return the data forms and 1 because of postoperative bleeding. Of the 74 patients included in the study, 35 were in the control group and 39 were in the study group.

INTERVENTIONS:
The 39 patients in the study group underwent postoperative aspiration of gastric contents with an orogastric tube placed under direct visualization while the patient was still under general anesthesia. The 35 patients in the control group did not undergo gastric aspiration following surgery.

MAIN OUTCOME MEASURES:
The incidence of vomiting, the number of episodes of vomiting before and after hospital discharge, the total volume of emesis, the postoperative length of stay, the need for rescue antiemetic prophylaxis, and the number of readmissions to the hospital for persistent vomiting were noted.

RESULTS:
No statistically significant difference (P<.05) was noted between the control group and the study group for the percentage of patients experiencing vomiting (74% vs 85%), the mean number of episodes of vomiting before (2.6 vs 2.8) and after (0.8 vs 0.7) hospital discharge, the mean volume of emesis (157 mL vs 222 mL), the postoperative length of stay (394 minutes vs 334 minutes), the percentage of patients requiring rescue antiemetics (34% [12 patients] vs 33% [13 patients]), and the percentage of unplanned admissions because of vomiting (9% [3 patients] vs 15% [6 patients]).

CONCLUSION:
Our results indicate that gastric aspiration does not decrease the incidence of vomiting following tonsillectomy
Click to expand...

Am i reading this result wrong? 74% of the control group vomitted vs 85% of the study group? so 3/4th of their patients vomitted?? the other results are weird too?
 
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