anesthesia for common pediatric emergencies

Report
ANESTHESIA FOR COMMON PEDIATRIC
EMERGENCIES
(BEYOND NEWBORN)
DANIEL E. LEE, MD PhD
Associate Clinical Professor of Anesthesiology and Pediatrics
University of California, San Diego
PEDIATRIC PERIOPERATIVE RISK
 Pediatric Perioperative Cardiac Arrest registry (POCA)
– 1.4 cardiac arrests per 10,000 instances of anesthesia
– Cardiac arrest mortality of 26%
– Age < 1 year and emergency status are independent predictors of mortality
 Unique Anesthetic Management Concerns
– Smaller FRC, increased metabolic rate, more rapid desaturation with
apnea
– Often uncooperative, impacting upon ease of IV placement,
preoxygenation, awake intubation, etc.
– Infants and young children in particular may have unrecognized
underlying disease that can affect response to anesthesia, e.g. cardiac or
airway anomalies
COMMON PEDIATRIC EMERGENCIES
 FOREIGN BODY ASPIRATION
 EPIGLOTTITIS
 PERITONSILLAR ABSCESS
 RETROPHARYNGEAL ABSCESS
 POST TONSILLECTOMY HEMORRHAGE
 HYPERTROPHIC PYLORIC STENOSIS
FOREIGN BODY ASPIRATION
 Most common in toddler age group
 Presentation
– Coughing or choking while eating
– Persistent cough or difficulty swallowing
– Wheezing or stridor
 Examination: locate level of obstruction
– Stridor: esophageal FB at cricoid level
– Severe obstruction/cyanosis: large FB trapped in glottis or trachea
– Unilateral wheezing/air trapping: distal airway aspiration
Foreign Body Aspiration

Figure 1. A chest radiograph may appear normal during inspiration (A) following foreign body
aspiration. A hyperinflated right lung and a leftward mediastinal shift during expiration (B) suggest a
foreign body in the right mainstem bronchus.
PEDIATRIC OTOLARYNGOLOGIC EMERGENCIES. Susan T. Verghese and Raafat S. Hannallah . Anesthesiology
Clinics of North America 19 (2) : 237-256
FOREIGN BODY RETRIEVAL
FOREIGN BODY ASPIRATION - II
 Preoperative Preparation
– Timing
• Emergency? (e.g. cyanosis, noxious substance)
• Discuss with surgical specialist re: urgency and special needs
– Premedication
• Atropine 20 mcg/kg IV/IM: dries secretions, facilitates topical
anesthesia, maintains heart rate.
 Anesthetic Induction
• Sevoflurane or Halothane inhalation induction
• Maintain spontaneous ventilation initially
– Avoids need for positive pressure ventilation
– May decrease risk of dislodging FB
FOREIGN BODY ASPIRATION - III
 Anesthetic Maintenance
– Deep Sevoflurane/Halothane, spontaneous ventilation,
supplementation with propofol IV
– Under deep anesthesia > direct laryngoscopy > supraglottic FB
may be removed if visualized
– Topical lidocaine spray (2-4%) to airway, max 3-5 mg/kg
– Intermittent airway obstruction?
• Supplemental IV propofol 50-200 mcg/kg/min
– Excessive coughing with airway manipulation?
• Supplemental topical tracheal lidocaine by surgeon
• Short acting narcotic or paralytic. Then controlled ventilation
via sideport of rigid bronchoscope or intermittently by mask.
– Esophagoscopy needed?
• First secure airway with endotracheal tube
EPIGLOTTITIS
 Life-threatening airway
emergency
 Less common since advent of
Haemophilus Influenza type B
vaccine
 Symptomatology occasionally
mistaken for croup, a more
common childhood airway
problem. Misdiagnosis can be
disastrous.
EPIGLOTTITIS vs CROUP
CROUP
EPIGLOTTITIS
6mo-6yr
1-7yr
Viral
Bacterial
Gradual
Rapid
Low fever
Stridor
Tachypnea
Barking cough
High fever
Stridor
Tachypnea
No Cough
Drooling
 Physical Exam
+/- Cyanosis
Retractions
Sitting up – ‘tripod’
Retractions
 Neck X-rays
Anterior view
Steeple sign
Subglottic edema
Lateral view
Swollen epiglottis
Loss of valecula




Age
Organism
Onset
Symptoms
EPIGLOTTITIS - II
 Preoperative airway management:
– Airway EMERGENCY
– Do not agitate patient
– Proceed immediately to OR if stable, parental accompaniment may
help to keep child calm
– ENT standby for emergency tracheostomy
 Anesthetic induction & intubation:
–
–
–
–
Inhalation (Sevo/Halo) induction with patient sitting
Establish IV as soon as child is anesthetized
Atropine 20 mcg/kg and fluid bolus while anesthesia is deepened
Intubate under deep anesthesia with child spontaneously
ventilating
– Use styletted ETT at least 0.5mm smaller than normal
– If laryngeal structures cannot be identified, external compression
of thorax may allow air bubbles to be seen at the tracheal inlet
EPIGLOTTITIS - III
 Post-intubation management
– IV antibiotics
– 24-48 hours intubation as swelling subsides
– Trial of extubation should be attempted only after airway swelling
has significantly diminished (check with bronch and/or glidescope)
– All preparations should be made for emergent reintubation or
tracheostomy should trial of extubation fail (e.g. use tube
exchanger, bronch available, LMA available, ENT surgeon/trach
kit).
PERITONSILLAR ABSCESS
 Most common in children &
young adults
 Presentation:
– Fever, pain, difficulty swallowing,
trismus
– Uvula deviation, pharyngeal
swelling at tonsillar bed
 Treatment:
– IV Antibiotics
– Surgical incision & drainage
PERITONSILLAR ABSCESS - II
 Anesthetic management:
– If minimal airway distortion and no difficulty with intubation
anticipated
• IV induction with short acting paralytic
• Gentle laryngoscopy, avoid premature rupture of abscess
• Cuffed ETT and head down position may limit soiling of the airway
when abscess is lanced
– If trismus is severe or any difficulty with airway anticipated
•
•
•
•
Inhalational (Sevo/Halo) induction
Maintain spontaneous ventilation
Trismus generally resolves as anesthesia deepens
Gentle laryngoscopy and intubation, advanced airway techniques if
necessary, surgeon should be present for possible surgical airway
 Postoperative emergence:
– Airway is cleared of all inflammatory material
– Child is extubated fully awake
RETROPHARYNGEAL ABSCESS
 Retropharyngeal inflammation pushes
posterior pharynx forward obstructing
airway
 More likely to cause airway
obstruction than peritonsillar abscess
 Presentation:
– Fever, pain, difficulty swallowing, trismus
– Posterior pharyngeal mass (exam, lateral Xray,
CT)
RETROPHARYNGEAL ABSCESS - II
 Anesthetic management:
– If mild airway distortion and no difficulty with airway anticipated,
may proceed with IV induction, gentle laryngoscopy and
intubation
– If any concern of difficult airway or if trismus is severe
•
•
•
•
Inhalational (Sevo/Halo) induction
Maintain spontaneous ventilation
Trismus generally resolves as anesthesia deepens
Gentle laryngoscopy and intubation, advanced airway techniques if
necessary, surgeon should be present for possible surgical airway
 Post-operative emergence
– Airway is cleared of all inflammatory material
– Child is extubated fully awake
POST TONSILLECTOMY
HEMORRHAGE
 Surgical emergency
 May occur early (24 hrs) or late (5-10 days)
 Presentation:
– Anemia
– Hypovolemia
– Stomach often full of blood
 Pre-operative preparation:
– Hematocrit, type & crossmatch
– Aggressive fluid resuscitation should begin prior to induction
POST TONSILLECTOMY
HEMORRHAGE - II
 Anesthetic induction
– Airway may be obscured by blood – 2 x large bore suction,
multiple laryngoscope blades and styletted endotracheal tubes
should be prepared
– Hypovolemia may persist despite aggressive pre-operative
resuscitation
– Rapid sequence IV induction with ketamine 2 mg/kg or etomidate
0.2 mg/kg with succinylcholine 2 mg/kg minimizes risk of
hemodynamic embarrassment with induction
POST TONSILLECTOMY
HEMORRHAGE - III
 Intraoperative management
– Airway can be protected with a cuffed ETT or snug fitting
uncuffed ETT in smaller children
– If specific source of bleeding is not identified, child may have
underlying bleeding disorder
– Clotting studies should be sent
– Clotting factors replaced as necessary if ongoing bleeding – FFP,
Cryo, Platelets, DDAVP (if type of von Willebrand’s deficiency is
known)
 Post-operative emergence
–
–
–
–
Stomach contents are suctioned
Endotracheal extubation fully awake
Repeat hematocrit postoperatively
Monitor for airway obstruction or recurrent hemorrhage
HYPERTROPHIC PYLORIC STENOSIS
 1:500 live births
 Presents ~ 6weeks of age
 Pyloric muscle hypertrophy
(gastric outlet obstruction)
– Non-bilious, projectile emesis
– Lose H+/Cl• Hypochloremic metabolic
alkalosis - promotes
hypoventilation
• Hypokalemia - kidneys
exchange K+ for H+
• Hyponatremia/hypocalcemia
• Dehydration may be severe
PYLORIC STENOSIS - II
 Preoperative preparation:
– NOT true surgical emergency – should ‘tune up’ first
– Rehydrate, nasogastric suction, correct electrolytes
– Ready for surgery when:
• HCO3 < 30
K+ > 3.2
• Cl- > 90
UOP > 1-2 cc/k/hr
• Urine spec. grav. <1.02
 Anesthetic induction:
– Premedicate with atropine 20 mcg/kg
– Rapid sequence or modified rapid sequence
induction/intubation if normal airway - propofol 2-3
mg/kg IV, succinylcholine 2 mg/kg IV
– Awake intubation if difficult airway is anticipated?
PYLORIC STENOSIS - III
 Emergence:
– Stomach contents suctioned
– Child fully awake prior to extubation
 Post-operative considerations:
– Significant apnea risk due to residual CSF alkalosis
– Intra-operative local anesthesia (bupivacaine 2.5 mg/kg max) and
rectal acetaminophen (30-40 mg/kg loading dose) may minimize
apnea risk by avoiding narcotics
– Apnea monitoring should be maintained 12-24 hours post
operatively
Most Important Part of a Pediatric Anesthetic?
AIRWAY, AIRWAY, AIRWAY
SUMMARY
Anesthesia for emergency surgery in pediatric patients carries increased risks.
These risks can be minimized with careful pre-operative evaluation and preparation.
Cooperation between the anesthesiologist and surgeon is especially important in the
management ENT emergencies.
Pre-operative resuscitation and post-operative apnea monitoring in pyloric stenosis
also require close coordination with surgical colleagues.

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