Anesthesia for Pediatric ENT surgery Flashcards
Indications for Myringotomy & Pre-Op Eval
Chronic serous otitis media
Preoperative Evaluation
Check for recent/ current URI
History and Physical Exam
+/- premedication: disadvantage of premed is prolonged sedation postoperative
Intraoperative Management for Myringotomy
GA with inhalational induction and mask ventilation
Brevity of surgery usually precludes IV placement
Rectal acetaminophen
Ensure good mask ventilation with patient’s head tilted to either side
Pre-operative evaluation/workup for tonsillectomy/adenoidectomy
Thorough H & P
? presence of URI
Increased incidence of peri-operative complications in patients with:
Hematologic abnormalities
Immunosuppression
Obstructive sleep apnea
Children under 3 with adeno tonsillar hypertrophy
Frequently have sleep apnea
Evaluate coagulation status
+/- pt/ptt, hct & plt count
NO ASA for at least one week pre-op
? Use of NSAIDs 48 hours prior to surgery
Pre-op management for tonsils and adenoids
Evaluation of Airway
Adequate premedication
Midazolam: 0.25-0.5 mg/kg po @ least 30 min before procedure
If IV in situ: Midazolam 0.1-0.2 mg/kg IV
Induction for Tonsils and Adenoids
Inhalational Induction
Start IV once patient adequately deep
Intubate after IV in and running
ETT: Oral or Oral Rae ETT
Tape ETT to lower lip - midline position
Check with surgeon re: abx and dexamethasone
Maintenance for Tonsillectomy & Adenoidectomy
Inhalational agents – Narcotic - Antiemetic
Adequate IV hydration
Monitor EBL (5-10% of blood volume may be lost)
Surgeon will empty stomach with OGT
Surgeon will release mouth gag and evaluate hemostasis before removing mouth gag and throat packs placed at start of surgery
Extubation for Tonsillectomy & Adenoidectomy
Extubate awake/deep post patient breathing regularly with good VT
Adequate pain relief on board
Muscle relaxants reversed
Oropharynx thoroughly suctioned
(be careful to suction midline and avoid trauma to site of surgery
Throat packs removed
Positioning
Tonsillar position to facilitate drainage of secretions into mouth and away from larynx
Ensure patent airway with VSS before transfer to PACU
Transfer patient on side
Postoperative Management Tonsils and Adenoids
Postoperative Management
Adequate pain relief
Treatment of nausea
Adequate hydration post-op
Management of Post-tonsillectomy Hemorrhage
- Can occur early (first 8 hours) or late (1 week after surgery)
- Usually requires GA for surgical management
PREOP: Prompt volume resuscitation necessary - Do not induce anesthesia until patient has received fluid resuscitation
Labs – H/H & Coagulation Profile
Patient at risk of aspiration due to large amount of blood swallowed
Increases PONV
If possible, suction stomach before induction
OGT intraoperative
Adjuvant drugs:
Ephedrine – Epinephrine – Phenylephrine – Atropine - Sux
Pre oxygenation crucial
Have multiple laryngoscope blades and ETT available
Have two separate suction catheters immediately available
Assess patency of airway - ? Tracheal deviation
RSI with cricoid pressure
Ketamine - Succhinylcholine (if no contraindication from pt’s Hx)
Inhalational Induction with cricoid pressure
Extubate patient fully awake with adequate Vt regular respirations & adequate pain relief
Peritonsillar Abscess
Inhalation induction vs RSI
Depends on severity of upper airway obstruction
PPV established before administration of muscle relaxant
Induce head-down tilt position with head turned toward abscess if possible
Avoid rupturing abscess
Cuffed tube may prevent aspiration
Epiglottitis/Supraglottitis
Life-threatening supraglottic infection that produces SEVERE edema of the supraglottic structures
Caused by Hemophilus influenza
Sx:
Sudden onset of sore throat
Fever
Inspiratory stridor
Respiratory distress
Age: 2-6 years old
Supraglottitis
(Epiglottitis)
characteristics
Age: 2-6 years
Onset: fulminant
Etiology: bacterial
Voice: muffled
Secretions: drooling
Fever: >38.5
Distress: Anxious, sitting
Laryngeal Tracheal Bronchitis (LTB)
Croup
characteristics
Age: 2mos-3yr
Onset: gradual
Etiology: viral
Voice: bark
Secretions: drooling
Fever: 37-38
Distress: normal
Clinical PEARLS for Epiglottitis
Intubation and administration of abx
Sitting position
Keep child calm to avoid further obstruction of airway
Inhalational induction – Surgeon available
Adequate depth of anesthesia - IV in place
Administer atropine
Lidocaine may be given
Use ETT one size smaller than normal with stylet in place
Maintain spontaneous ventilation
Secure ETT
May require laryngoscopy to evaluate readiness for extubation
ETT should be approx. 0.5 to 1.0 mm smaller in diameter than is appropriate for the age and size of the patient
PEARLS for Endoscopy
Sharing the airway
Bronchoscopy used either to extract foreign bodies or to selectively aspirate thick plugs from bronchi
Pre-op sedatives and opiates judiciously
Antisialogue
