Mod V: Peds Emergence Flashcards
Peds Emergence - Extubation
What are your two extubation options?
Extubate the trachea while patient is fully awake or
While pt is deeply anesthetized
In between is always a mistake!!!
Peds Emergence - Extubation
How does Fully awake presents?
Recovery of airway reflexes
Children
Follow commands, purposeful movement, eye opening
Infants
Hip flexion and strong grimaces
Peds Emergence - Extubation
T/F: Coughing is a sign child is ready for extubation
False
Coughing is not a sign child is ready for extubation
Peds Emergence - Extubation
Signs that a child is fully awake
Recovery of airway reflexes
Follow commands, purposeful movement, eye opening
Peds Emergence - Extubation
Signs that an infant is fully awake:
Recovery of airway reflexes
Hip flexion and strong grimaces
Peds Emergence - Extubation
Signs that pt is Deeply anesthetized (for deep extubation):
Breathing at regular rate
Eyes are not disconjugate
Requires 1.5 MAC or deeper!!!
Peds Emergence - Extubation
What are indications for doing a deep extubation?
When coughing undesirable
(s/p hernia repair)
Patients with reactive airway diseases
(which increases the risk of bronchospasm)
Peds Emergence
The occlusion of the glottis and the laryngeal inlet by action of laryngeal muscles contraction is also known as:
Laryngospasm
This is what we are the most afraid of on induction and on emergence from an airway perspective
Peds Emergence - Laryngospasm
Typical situations of occurrence of Laryngospasm:
Excitement phases of anesthetic induction or emergence
During light anesthesia relative to surgical stimulus
You will never know if you have a Laryngospasm while the pt is still intubated - the cord cannot snap shut d/t presence of the ET tube
Pts can have a Laryngospasm during the procedure if they are under light anesthesia and they are getting a stronger surgical stimulus, but you will never know
Presence of mechanical irritants in the airway
Blood, secretions, gastric contents - Airway instrumentation
Patients with GERD
Patients with active URI
Peds Emergence - Laryngospasm
How do we prevent a 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” the larynx or reduce the sensory pathways
Peds Emergence - Laryngospasm
What are S/s of Laryngospasms?
Stridor - Hypoxemia
Tachycardia
(initially, leading to bradycardia if the pt becomes too hypoximic)
Tachypnea
Increased secretions
Sternal/intercostal retractions
No air flow despite ventilatory effort
Unable to phonate
Peds Emergence - Laryngospasm
How are Laryngospasms managed in peds?
Similar as in adults
Institute CPAP with 100% O2 via bag/mask
Use maximum efforts to open airway (jaw thrust, head tilt)
Monitor oxygenation carefully
Suction secretions or gastric containt
Ventilate with helium/O2 mixture (Heliox) if available
Peds Emergence - Laryngospasm
Most rooms are not set up to have helium delivery. What’s the benefit of ventilating with helium/O2 mixture (Heliox) if available, rather than O2 alone?
During turbulent flow, gas density determines flow characteristics
Heliox has a lower density thant O2 alone
It should be easier for the helium/O2 mixture to navigate through tight spaces and get into the lungs
Peds Emergence - Laryngospasm
If you are still facing a laryngospasm and PPV isn’t working (if it does not break and pt becomes hypoxic), what are the next steps in the Tx management?
Administer succinylcholine (0.25 – 1mg/kg IV or 4-6 mg/kg IM)
Must establish patent airway, and sometimes Sux is the only way to get there
Add atropine (0.02 mg/kg) if bradycardic/hypoxic
Establish PPV
Maintain patent airway, either via intubation or just by continuing mask ventilation
Allow return of spontaneous ventilation
Peds Emergence - Laryngospasm
What’s the next invasive maneuver if oxygenation cannot be maintained after administration of Sux?
Reintubate
Cricothyrotomy with transtracheal jet ventilation
Tracheostomy
Peds Emergence
Poextubation phenomenom which is the result of Poiseuille’s law, where small amount of edema in the trachea can result in a severe decrease in the cross sectional area of laminar flow
Postextubation Croup/Stridor
Peds Emergence - Postextubation Croup/Stridor
Postextubation Croup/Stridor is inflammation/edema of the subglottic region due to mechanical irritation caused by:
Inappropriate sized ETT
Multiple attempts at intubation or bronchoscopy
Manipulation of ETT during surgery
Peds Emergence - Postextubation Croup/Stridor
How can Postextubation Croup/Stridor be prevented?
Use uncuffed ETT of appropriate size in children
Confirm leak around ETT at 15-25 cmH20
Minimize manipulation ETT/pt’s head
Avoid anesthesia in children with URI
Peds Emergence - Post-Extubation Croup/Stridor
T/F: Post-Extubation Croup/Stridor typically occurs immediately after extubation
False
Post-Extubation Croup/Stridor typically occur within 1-2 hrs, not immediately after extubation
Peds Emergence - Post-Extubation Croup/Stridor
How does Post-Extubation Croup/Stridor look like when it manifests?
High-pitched, noisy respiration at level of trachea/larynx
Inspiratory stridor:
Associated with extrathoracic airway obstruction
Postextubation croup occurs in subglottic region = extrathoracic
Expiratory stridor:
Intrathoracic airway obstruction
Foreign Body aspiration, bronchospasm
Respiratory distress
Hypoxemia
Increased pulmonary secretions
Tachycardia
Peds Emergence - Post-Extubation Croup/Stridor
When Post-Extubation Croup/Stridor manifests as inspiratory stridor, what does this indicate?
Extrathoracic airway obstruction
Extrathoracic = Subglottic region
(this is where Postextubation croup occurs)
Peds Emergence - Post-Extubation Croup/Stridor
When Post-Extubation Croup/Stridor manifests as Expiratory stridor, what does this indicate?
Intrathoracic airway obstruction
Foreign Body aspiration
Bronchospasm
Peds Emergence - Post-Extubation Croup/Stridor
How is Post-Extubation _Croup/Strido_r managed?
Ensure adequate oxygenation/ventilation
Administer O2 as cool mist - Maintain patent airway
Institute CPAP with bag/mask if needed
Continue spontaneous ventilation (decreases turbulent flow)
Prepare for reintubation!!!
Administer nebulized racemic epinephrine
(2.25 %, 0.5ml in 204 ml NS)
Helpful in reducing edema
Administer dexamethasone IV, 0.5-1mg/kg (controversial)
Administer heliox if available
Intubate if respiratory failure occurs despite above
ETT 0.5mm size smaller calculated
<strong>Leak at 20-25 cm H20,</strong> which is a<strong> larger leak,</strong> and you want that because you don’t want anything touching an edemateous trachea; this could make the situation worse
Peds Emergence - Post-Extubation Croup/Stridor
Watch the following Youtube video at your leisure!!!
https://www.youtube.com/watch?v=4oqVkfkUXaw
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