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

Chief Complaint

Productive cough and yellowish

rhinorrhea for one month Preparation for L’t inguinal hernia repair

and R’t orchipexy

Present Illness

G2P2, GA: 38wks, 3000g, NSD,

Apgar score: 9→9 Growth and development: WNL

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

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

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

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﹪

What happened to this child?

Laryngeal edema ? Laryngospasm ? Postextubation croup ?

Laryngeal edema

A potential complication of intubation in

all children Highest incidence: 1~4 y/o

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

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

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

Air leak test

Application:

1. Not exceed 20-40cmH2O

(30cmH2O→prevent mucosal capillary

perfusion→ischemia, edema)

2. A predictor

Laryngospasm

Definition:

A forceful involuntary spasm of the

laryngeal musculature by sensory

stimulation of the superior laryngeal nerve

Laryngospasm

Trigger:

1. Pharyngeal secretion

2. Passing an ETT through the larynx

during extubation

Laryngospasm

Predisposing factor:

1. Recent URI

2. Smoker

Laryngospasm

Symptoms/signs:

1. Stridor on inspiration

2. Increased ventilatory effort

3. Total closure of the vocal cords

4. Cyanosis

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

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

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

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

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 ％

What is croup?

LaryngotracheobronchitisViral infection of the upper respiratory tract Tyically afflict children yonger than 2 year of

ageCrop 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.

What kinds of virus can cause croup?

Paramyxovirus Influenza virus type ARespiratory syncytial virus (RSV)AdenovirusRhinovirusEnterovirusCoxsackievirusEnteric cytopathogenic human orphan virus

(ECHO virus)Measles virus

Differential croup from epiglottitis? croup epiglotittis

age <2yrs 2-6yrs

onset 24-72hrs Over 24hrs

etiology Virus Bacteria(Hib)

inccidence 80%with stridor 5%with stridor

Signs and symptoms

Inspiratory stridor

Barking cough

rhinorrhea

Fever drooling inspiratory stridor

cyanosis

Subglotic narrowing Swollen epiglottis

X-ray steeple sign Thumb sign

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.)

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.

epiglottitis

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.

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.

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

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.

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

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

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

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!!!

About this patient

Prevention:

1. History taking

2. Well explain

3. Medication

(Solumedrol, aminophylline)

4. Smooth intubation

5. Thoroughly suction ?

About this patient

Treatment: 1. Pure O2

2. Open airway

3. Medication: SCC

Thank you for your attention !