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Postextubation Complication of Pediatrics

Postextubation Complication of Pediatrics. Ri 吳凱筠 Ri 何文藻. General Data. Name: 施揚文 Age: 2y6m/o Sex: male Chart No: 4016982 Bed No: 7C06-1 Admission Date: 92/12/15 Information source: patient’s mother.

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Postextubation Complication of Pediatrics

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  1. Postextubation Complication of Pediatrics Ri 吳凱筠 Ri 何文藻

  2. General Data • Name: 施揚文 • Age: 2y6m/o • Sex: male • Chart No: 4016982 • Bed No: 7C06-1 • Admission Date: 92/12/15 • Information source: patient’s mother

  3. Chief Complaint • Productive cough and yellowish rhinorrhea for one month • Preparation for L’t inguinal hernia repair and R’t orchipexy

  4. Present Illness • G2P2, GA: 38wks, 3000g, NSD, Apgar score: 9→9 • Growth and development: WNL

  5. Present Illness • Enlarged L’t scrotum → urology OPD in this Nov. • Dx: L’t inguinal hernia and R’t undescended testis • Admission for L’t inguinal hernia repair and R’t orchipexy • Hold due to URI • Medical control at Dr. 黃立民‘s OPD

  6. Past History • 90. 07 - breast feeding induced hyperbilirubinemia s/p pototherapy • 91.02 - acute bronchiolitis • 92.04 - bronchiopneumonia, AOM • 92.11 – preparation for operation, URI

  7. Process of anesthesia • 2y6m/o, 15kg, ASAIII • Before ETGA: Aminophylline 1.5cc drip • Induction: 1. Atropine 0.15mg (0.01-0.02mg/kg) 2. Thiopental 75mg (5-6mg/kg) 3. Succinylcholine 30mg (2-3mg/kg) 4. Fentanyl 25mcg 5. Solumedrol(prednisolone) 20mg (dexamethasone 0.25-0.5mg/kg ) 6. Aminophylline 0.5cc

  8. Process of anesthesia • Intubation: 5.0, smoothly • Maintain: N2O and Isoflurane • Operation time: 30mins • Extubation: desaturation → SCC 20mg and bagging →SaO2:94﹪in room air → PICU

  9. What happened to this child? • Laryngeal edema ? • Laryngospasm ? • Postextubation croup ?

  10. Laryngeal edema • A potential complication of intubation in all children • Highest incidence: 1~4 y/o

  11. Laryngeal edema • Etiology: controversial 1. Material of ETT (red rubber→polyvinychloride) 2. Size of ETT: major factor - 4+age/4 - air leak test to confirm 3. Cuffed ETT 4. Mutiple intubation attempts 5. Patient: age, hypersensitivity airway 6. Procedure: head and neck 7. Prolonged surgery 8. Excessive movement of the tube: cough, move head

  12. Laryngeal edema • Predisposing factor: co-existing URI, especially neonate or infant • Treatment: 1. Cool mist inhalation 2. Dexamethasone IV 0.5-1mg/kg 3. Racemic Epi. IH 0.5-1cc of 2 ﹪RE diluted 1:4 in saline

  13. Air leak test • How to perform ? 1. Partially close breathing circuit 2. Squeeze the bag to increase airway pressure until audible leak around the ETT 3. Airway pressure at leak≒pressure exerted by ETT on the tracheal mucosa

  14. Air leak test • Application: 1. Not exceed 20-40cmH2O (30cmH2O→prevent mucosal capillary perfusion→ischemia, edema) 2. A predictor

  15. Laryngospasm • Definition: A forceful involuntary spasm of the laryngeal musculature by sensory stimulation of the superior laryngeal nerve

  16. Laryngospasm • Trigger: 1. Pharyngeal secretion 2. Passing an ETT through the larynx during extubation

  17. Laryngospasm • Predisposing factor: 1. Recent URI 2. Smoker

  18. Laryngospasm • Symptoms/signs: 1. Stridor on inspiration 2. Increased ventilatory effort 3. Total closure of the vocal cords 4. Cyanosis

  19. Laryngospasm • Prevention: 1. Extubate either deeply asleep(spontaneous breathing but no reaction to suction) or fully awake(eye open, purposeful movement) 2. Thoroughly suctioned before extubation 3. Pure O2 4. Gentle positive airway pressure

  20. Laryngospasm • Treatment: 1. Pure O2 2. Gentle positive airway pressure 3. Digital pressure at the laryngospasm notch and open airway 4. Lidocaine 1-1.5mg/kg 5. Succinylcholine 0.25-1mg/kg

  21. Laryngospasm • Treatment: 6. Small dose(0.8mg/kg) of propofol Background: propofol depress laryngeal reflex Method: 3-10y/o, ASA I and II, under GA with LMA, receive minor surgical procedure Result: laryngospasm→20 O2 and gentle positive airway pressure→7 success in small dose of propofol→10 (76.9﹪) Conclusion: propofol as a suitable alternative for relieving laryngeal spasm in situation where SCC is contraindicated ~Pediatric Anaesthesia Vol 12 Sep 2002

  22. Laryngospasm • Treatment: 7. Acupuncture at Shao Shang or Shang Yang acupoints Method: 76, randomly divided into two group (1) acupuncture at the end of operation→38 (skin grafting, fasciotomy, debridement, scar revision, hernia repair, insertion and removal of tissure expander, hydrocoeleexcision, orchiopexy, fracture fixation, tumor excision) (2) control→38 Result: (1) acupuncture→laryngospasm 5.3％(2/38) (2) control→laryngospasm 23.7％(9/38) (3) If laryngospasm, acupuncture immediately →all relieved with 1min Conclusion: acupuncture can prevent and treat laryngospasm occurring after extubation in children ~Anaethesia Vol 53 Sep 1998

  23. Laryngospasm • Treatment: 8. Intravenous Nitroglycerin Case 1- 26y/o, male, 75kg, healthy, varicocelectomy laryngospasm relieved within 1min by nitroglycerin IV 4mcg/kg BP dropped from 142/73mmHg to 125/62mmHg SaO2: 92 ％ →99 ％ Case 2- 27y/o, male, 70kg, healthy, I/D for perianal abscess laryngospasm relieved within 1min by nitroglycerin IV 4mcg/kg BP dropped from 130/80mmHg to 110/68mmHg SaO2: 94 ％ →99 ％

  24. What is croup? • Laryngotracheobronchitis • Viral infection of the upper respiratory tract • Tyically afflict children yonger than 2 year of age • Crop and epiglotitis share certain clinical features and at times confused with each other • Laryngotracheobronchitis has a peak incidence of 5 cases per 100 children per year during the second year of life.

  25. What kinds of virus can cause croup? • Paramyxovirus • Influenza virus type A • Respiratory syncytial virus (RSV) • Adenovirus • Rhinovirus • Enterovirus • Coxsackievirus • Enteric cytopathogenic human orphan virus (ECHO virus) • Measles virus

  26. Differential croup from epiglottitis?

  27. What should be alert ? • The cricoid ring of the trachea (in the immediate subglottic area) is the narrowest portion of the airway in a child. A small amount of edema in this region can cause significant airway obstruction. (Remember that the resistance to flow through a tube is inversely proportional to the fourth power of the radius.)

  28. Imaging Studies • Imaging tests are not required in mild cases with typical history that respond appropriately to treatment. • An anteroposterior (AP) soft tissue neck x-ray may show subglottic narrowing. • The usual squared-shoulder appearance of the subglottic area is replaced by cone shaped narrowing just distal to the vocal cords. This is called the steeple or pencil-point sign. • Monitor patients during imaging because progression of airway obstruction may be rapid.

  29. epiglottitis

  30. Treatment • racemic epinephrine is the cornerstone of symptomatic relief during exacerbations of croup • Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. • Budesonide (Pulmicort Turbuhaler) -- Has been shown in several studies to be equivalent to oral dexamethasone.

  31. Use of the Laryngeal Mask Airway in Children with Upper Respiratory Tract Infections: A Comparison with Endotracheal Intubation Pediatric Anesthesia Volume 86(4) April 1998 pp 706-711 Tait, Alan R. PhD; Pandit, Uma A. MD; Voepel-Lewis, Terri BSN, MS; Munro, Hamish M. MD, FRCA; Malviya, Shobha MD Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan.

  32. Abstract • Several studies suggest that placement of an endotracheal tube (ETT) in a child with an upper respiratory infection (URI) increases the risk of complications.However, the development of the laryngeal mask airway (LMA) has provided anesthesiologists with an alternative means of airway management. This study was therefore designed to evaluate the use of the LMA in children with URIs and to compare it with the ETT

  33. Method • The study sample consisted of 82 pediatric patients (3 mo to 16 yr of age) who presented for elective surgery with an URI. Patients with URIs were randomly allocated to receive either an ETT (n = 41) or a LMA (n = 41) and were followed for the appearance and severity of any perioperative complications. The two groups were similar with respect to age, gender, anesthesia and surgery times, number of attempts at tube placement, and presenting URI symptoms. There were no differences between groups in the incidence of cough, breath-holding, excessive secretions, or arrhythmias.

  34. ASA physical status I or II pediatric patients between the ages of 3 mo and 16 yr of age who presented for elective outpatient surgery with an URI

  35. Conclusion • Anesthesia for patients with uncomplicated URIs, then the LMA provides an acceptable alternative to the ETT • This does not imply that the ETT is necessarily unacceptable for children with an URI, but given its ease of use and its apparent reduced propensity for coughing, bronchospasm, and oxygen desaturation • LMA seems to offer several advantages over the ETT for airway management in this group of patients

  36. Surgery for undescended testis • Surgery to move an undescended testicle into the scrotum is called orchiopexy or orchidopexy • Early surgery preserves potential for spermatogenesis and androgen synthesis between 12 and 18 months of age to prevent the degenerative change • Boys with one undescended testicle more likely to be fertile than boys with two undescended testicles

  37. Should the mother take the risks of operation while croup had not been well-controlled? • The risk of developing testicular cancer is 20 to 40 times greater in males who have an undescended testicle • Treatment does not appear to reduce the general risk of developing testicular cancer!!! Most doctors recommend treatment to place undescended testicles in the scrotum because this makes it much easier to detect and treat testicular cancer if it does develop) • The 2.5y/o boy had been beyond the Golden time for surgery to keep his fertility rate!!!

  38. About this patient • Prevention: 1. History taking 2. Well explain 3. Medication (Solumedrol, aminophylline) 4. Smooth intubation 5. Thoroughly suction ?

  39. About this patient • Treatment: 1. Pure O2 2. Open airway 3. Medication: SCC

  40. Thank you for your attention !

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