Mod V: Peds Emergence

Question 1

_{Peds Emergence - Extubation}

What are your two extubation options?

Answer 1

Extubate the trachea while patient is fully awake or

While pt is deeply anesthetized

In between is always a mistake!!!

Question 2

_{Peds Emergence - Extubation}

How does Fully awake presents?

Answer 2

Recovery of airway reflexes

Children

^{Follow commands, purposeful movement, eye opening}

Infants

^{Hip flexion and strong grimaces}

Question 3

_{Peds Emergence - Extubation}

T/F: Coughing is a sign child is ready for extubation

Answer 3

False

Coughing is not a sign child is ready for extubation

Question 4

_{Peds Emergence - Extubation}

Signs that a child is fully awake

Answer 4

Recovery of airway reflexes

Follow commands, purposeful movement, eye opening

Question 5

_{Peds Emergence - Extubation}

Signs that an infant is fully awake:

Answer 5

Recovery of airway reflexes

Hip flexion and strong grimaces

Question 6

_{Peds Emergence - Extubation}

Signs that pt is Deeply anesthetized (for deep extubation):

Answer 6

Breathing at regular rate

Eyes are not disconjugate

Requires 1.5 MAC or deeper!!!

Question 7

_{Peds Emergence - Extubation}

What are indications for doing a deep extubation?

Answer 7

When coughing undesirable

^{(s/p hernia repair)}

Patients with reactive airway diseases

^{(which increases the risk of bronchospasm)}

Question 8

_{Peds Emergence}

The occlusion of the glottis and the laryngeal inlet by action of laryngeal muscles contraction is also known as:

Answer 8

Laryngospasm

This is what we are the most afraid of on induction and on emergence from an airway perspective

Question 9

_{Peds Emergence - Laryngospasm}

Typical situations of occurrence of Laryngospasm:

Answer 9

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

Question 10

_{Peds Emergence - Laryngospasm}

How do we prevent a Laryngospasm?

Answer 10

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

Question 11

_{Peds Emergence - Laryngospasm}

What are S/s of Laryngospasms?

Answer 11

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

Question 12

_{Peds Emergence - Laryngospasm}

How are Laryngospasms managed in peds?

Answer 12

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

Question 13

_{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?

Answer 13

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

Question 14

_{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?

Answer 14

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

Question 15

_{Peds Emergence - Laryngospasm}

What’s the next invasive maneuver if oxygenation cannot be maintained after administration of Sux?

Answer 15

Reintubate

Cricothyrotomy with transtracheal jet ventilation

Tracheostomy

Question 16

_{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

Answer 16

Postextubation Croup/Stridor

Question 17

_{Peds Emergence - Postextubation Croup/Stridor}

Postextubation Croup/Stridor is inflammation/edema of the subglottic region due to mechanical irritation caused by:

Answer 17

Inappropriate sized ETT

Multiple attempts at intubation or bronchoscopy

Manipulation of ETT during surgery

Question 18

_{Peds Emergence - Postextubation Croup/Stridor}

How can Postextubation Croup/Stridor be prevented?

Answer 18

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

Question 19

_{Peds Emergence - Post-Extubation Croup/Stridor}

T/F: Post-Extubation Croup/Stridor typically occurs immediately after extubation

Answer 19

False

Post-Extubation Croup/Stridor typically occur within 1-2 hrs, not immediately after extubation

Question 20

_{Peds Emergence - Post-Extubation Croup/Stridor}

How does Post-Extubation Croup/Stridor look like when it manifests?

Answer 20

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

Question 21

_{Peds Emergence - Post-Extubation Croup/Stridor}

When Post-Extubation Croup/Stridor manifests as inspiratory stridor, what does this indicate?

Answer 21

Extrathoracic airway obstruction

Extrathoracic = Subglottic region

^{(this is where Postextubation croup occurs)}

Question 22

_{Peds Emergence - Post-Extubation Croup/Stridor}

When Post-Extubation Croup/Stridor manifests as Expiratory stridor, what does this indicate?

Answer 22

Intrathoracic airway obstruction

Foreign Body aspiration

Bronchospasm

Question 23

_{Peds Emergence - Post-Extubation Croup/Stridor}

How is Post-Extubation _Croup/Strido_r managed?

Answer 23

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}

Question 24

_{Peds Emergence - Post-Extubation Croup/Stridor}

Watch the following Youtube video at your leisure!!!

Answer 24

https://www.youtube.com/watch?v=4oqVkfkUXaw

Video not available

Account terminated!

What was the video about?