Pediatric induction and emergence

intramuscular induction is used for

extremely uncooperative or mentally challenged children

prevention of postextubation croup

use uncured ETT of appropriate size in children confirmed leak around ETT at 15 - 25 cm H2O minimize manipulation eTT/pts head avoid anesthesia in child with URI

Stage 3 of anesthesia

"surgical anesthesia" unconscious and lies quietly, pupils are small but contract, respirations are regular, pulse rate normal, skin is pink

ETT for intubation for postextuabtion croup

0.5 mm size smaller calculated leak at 20 - 25 cm H2O

manifestations of postextubation croup

1 - 2 hours after extubation high pitched ,noisy respiration at level of trachea/larynx inspiratory and expiratory stridor respiratory distress hypoxemia increased pulmonary secretions tachycardia

MMR vs MH

50% - susceptible to MH more likely MH if MMR accompanied by chest/limb rigidity peripheral nerve stimulator shows flaccid paralysis with MMR

children with full stomachs induction is

RSI with CCP

older children and IV induction

>8 years of age may be preferred over mask local anesthetic before IV placement EMLA (2.5% lidocaine and 2.5% prilocaine) - 45 mins to work LMX (4% lidocaine)

management of laryngospasm

CPAP with 100% O2 via bag/mask max efforts to open airway (jaw thrust/head lift) monitor oxygenation carefully suction ventilation with helix if available admin suc if does not break and becomes hypoxic establish PPV maintain patent airway allow return of spontaneous ventilation

what are signs of stage 2 of anesthesia

aka excitement stage laryngospasm risk increased irregular breathing disconjugate gaze tachycardia

inspiratory stridor post extubation croup

associated with extra thoracic airway obstruciton post extraction croup occur in subglottic region = extra thoracic

children who need RSI

atropine may be given IV to prevent brady especially if succinylcholine will be given

backup plan to inhalation induction

can try IM induction but this is often reserved for mental defects

steal technique used on

children 8 months to 5 y/o who are premeditated

"slow" inhalation induction

cooperative toddlers and older children child shown how to breathe through face mask N2O/O2 given followed by gradual addition of volatile anesthetic (sveo/halothane) engage child in a store like "blow up balloon"

if MH is developing or strongly suspected

declare MH emergency often do NOT continue surgery

before induction if gastric distention is present (RSI in peds)

decompress stomach ranitidine 2 - 4 mg/kg can be given consider use of cuffed tube

manifestations of masseter muscle rigidity

difficulty in opening mouth (apparent active tetany) adminsitrion of additional sux does not result in relaxation of masseter muscles - other skeletal muscles are relaxed MMR persists until neuromuscular function begins to return in peripheral muscles (may be up to 30 mins)

prevention of laryngospasm

ensure adequate depth prior to laryngeal manipulation extubate fully awake or deeply anesthetized clear all secretions prior to and after extubation use muscle relaxants to facilitate intubation consider topical local anesthetics to "de-afferent" larynx

management of post extubation croup

ensure adequate oxygneation/ventilation - O2 as cool mist, maintain patent airway, CPAP if needed, continue spontaneous ventilation (Decreases turbulence) prepare for reintubation admin racemic epi neb 2.25% 0.5 ml in 204 ml NS admin dexamethasone IV 0.5 - 1 mg/kg (controversial) admin helix if available intubate if respiratory failure occurs

typical situations of occurrence of layrngospasm

excitement phases of anesthetic induciton or emergence during light anesthesia relative to surgical stimulus (may not be noted bc ETT in place) presence of mechanical irritants in the airway - blood, secretions, gastric contents, airway instrumentation patients with GERD patients with active URI

extubate the pediatric patient when

fully awake or deeply anesthetized - in-betweens always a mistake

avoid metoclopramide

gastric outlet or bowel obstruction present

IV induction challenge

hard to get IV started on child

why does heliox work

helium/o2 mixture has lower density - during turbulent flow gas density determines flow characteristics

apnea infant during induction

hypoxemia occurs within 30 - 45 seconds even after preoxygenation

other events that mimimix masseter spasm

inadequate sux dose inadequate onset of Suction TMJ issues myotonic syndrome

deeply anesthetized extubation of peds patient

indications - when coughing undesirable (hernia repair),patients with reactive airway diseases requires 1.5 MAC or deeper regular rate of breathing etc

postextubation croup stridor

inflammation/edema of subglottic region due to mechanical irritation inappropriate sized eTT multiple attempts at intubation or bronchoscopy manipulation of ETT during surgery

most common induction technique in pediatrics

inhalation - really only time you won't be doing inhalation induction is an RSI

expiratory stridor post extubation croup

intrathoracic airway obstruciton FB aspiration bronchospasm

parental presence during induction

is questionable - can worsen if patient is decompensating then they could been the way

ketamine art

ketamine 4 - 8 mg/kg im which takes effect in 3 - 5 mins atropine 0.02 mg/kg) or glyco (0.01 mg/kg IM) should be mixed to prevent excessive salivation) midazolam (0.2 - 0.5 mg IM) also decrease incidence of emergence delirium

induction agent doses for RSI in peds

larger doses required STP 5 - 6 mg/kg Propofol 3 to 4 mg/kg Succinylcholine 1 to 2 mg/kg IV children and 2 mg/kg neonates and infants and 4 - 6 mg/kg IM

management of MMR

maintain positive pressure ventilation with bag/mask until muscles relax intubate trachea when feasible observe for signs of mH

why is steal technique dangerous

mask away from patients face so OR staff will be breathing in some anesthetic as well

steal technique

mask held near face but not touching low flow rates of O2/N2O begun (1 - 3L) add sevo or halothane gradually increase concentration in 0.5% increments mask applied when lid reflex disappears

why use flavor on mask for inhalation induction

may increase acceptance of having mask on the face

post masseter muscle rigidity s/e

myalgia/weakness 36 horus following increase of CK and myoglobinuria can follow within 24 hours

laryngospasm

occlusion of the glottis and laryngeal inlet by action of laryngeal muscles

cease intubation of pediatric patient if

onset of bradycardia cyanosis desaturation admin 100% O2 until oxygen saturation improves

how to set up for single breath induction

pre fill circuit with 70% N2O/30% O2 and 7 - 8% sevoflurane occlude end of circuit with plug or another reservoir bag leave pop off valve open to minimize nonscavenged spillage child takes deep breath (vital capacity) of room air, blows all out (forced expiration) holds breath - place mask on child and allow to take deep inspiration of anesthetic mixture and hold breath

fully awake extubation of pediatric patient

recovery of airway reflexes - coughing is not a sign child is ready for extubation children - follow commands, purposeful movement, eye opening infant - hip flexion, and strong grimaces

if unable to maintain oxygenation with laryngospasm

reintubate cricothyrotomy with transtracheal jet ventilation tacheosotmy

masseter muscle rigidity

rigidity of jaw muscles developed after administration of succinylcholine - incidence increased with halothane and six together

single breath induction LOC can be achieved with

single VC breath, however most will be anesthetized in 60 seconds good if frightened/crying - as deep breathing/crying will anesthetize quickly

MH s/s

skeletal muscle rigidity increased CO2 production/O2 consumption metabolic acidosis tachycardia/arrhtyhmia increased body temperature myoglobinuria

Laryngospasm manifestations

stridor hypoxemia tachycardia tachypnea increased secretions sternal/intercostal retractions no air flow despite ventilatory effort unable to phonate

succinylcholine and atropine dose for layrngosapsm

succinylcholine 0.25 - 1 mg/kg IV 4 - 6 mg/kg IM atropine 0.02 mg/kg