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ANESTESIKURSET  TROMSØ  January  30th  2016  

Rolf  Holm-­‐Knudsen  Ass.  professor  Dep.  of  Anaesthesia,  HOC  Copenhagen  University  Hospital,  Rigshospitalet  DK-­‐2100  Copenhagen,  Denmark  rolf.holm-­‐knudsen@regionh.dk  

 

  Dimensions  are  smaller    Head  is  large    Tongue  is  large    Palate  extends  to  the  epiglottis    Larynx  is  located  ”higher”    Narrowest  part  at  the  cricoid  cartilage    Airway  is  softer  and  more  collapsible    Airway  is  more  reactive    Residual  lung  volume  is  small   Metabolism  is  high  

Trachea  in  a  3  month  old  child  Diameter  5  mm  

cross section area

Normal

20 mm2

Flow  resistance  is  inversely  proportionel  with  r4    (r5)  

0,6 mm oedema

11 mm2

  Atraumatic  technique  

  Appropriate  tube  size    Appropriate  cuff  pressure    Avoid  movement  of  the  head    Avoid  movement  of  the  endotracheal  tube  

and  coughing    

  Avoid  intubation  in  children  with  upper  respiratory  tract  infection  ?  

  <  6  –  12  mo  3.0  

  6  -­‐  (12  mo-­‐2  yr)  3.5    

  2  -­‐  4  yr  4.0  

  4  -­‐  6  yr    4.5  

     >  6  yr  3.0  +  age/4  

Preformed ET tubes: The lenght of the distal part of the tube is related to the the size of the tube - and it may be too short or too long

  Positioning  -­‐  elevated  head    Dexamethasone  0,6  mg/kg    

(max  12  mg)  

  Adrenaline-­‐inhalation  1  mg/ml  (volume  sufficient  to  vaporize)  

  Helium-­‐O2  inhalation  

  Reintubation  

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18 mo

E = Epiglottis

P = Palate

Neonate

At 4 years of age larynx is at the C5-6 level as in adults

  Show the mask to the child   Avoid covering the eyes   Avoid pressure

under the chin   Neck slightly

extended   Keep the mouth

open   If obstruction:

Check head position and mouth opening

In the case of upper airway obstruction because of tonsillar hypertrophia or airway malacia:

  Continuous positive airway pressure 10-15 cmH2O to ”expand” the airway Palate

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  Show the mask to the child   Avoid covering the eyes   Avoid pressure

under the chin   Neck slightly

extended   Keep the mouth

open   If obstruction:

Check head position and mouth opening

In the case of upper airway obstruction because of tonsillar hypertrophia or airway malacia:

  Continuous positive airway pressure 10-15 cmH2O to ”expand” the airway

  Always  on  the  table  or  in  the  bed!  

  NOT  on  the  lap  of  mum  or  dad  

  In  anxious  children-­‐  ,  sitting  on  the  table  facing  one  of  the  parents  is  a  useful  alternative  

 More  difficult  to  maintain  a  patent  airway    Slower  induction    Risk  of  excitation    Risk  of  desaturation  

  The  child  is  moved  during  light  anaesthesia            risk  of  laryngeal  spasm  

  Pollution  with  anaesthetic  vapours  

  Bad  working  position    

Why not on the lap ????!!!!!!

  7  month  old  child  for  myringotomy  and  grommets  insertion.....    

  Induction  with  sevoflurane  and  nitrous  oxide  sitting  on  lap  of  mum.    

  Clear  crying  during  induction.   Moved  to  the  table.  Impossible  to  

ventilate  despite  the  use  of  an  oral  airway.    

  Happy  ending  anyway  

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  Upper  airway  infection    Thick  nasal  secretions    Nasal  obstruction    Reduced  general  condition  

  Younger  children    Airway  surgery    Inexperienced    

anaesthetist    Passive  smoking    Ex-­‐premature    Asthma      

  Intubation  uden  anvendelse  af  muskelrelaxantia  

  Thiomebumal  >  Sevofluran  >  Propofol  

  Endotracheal  tube  >  LMA  >  Maske  

• Laryngeal  spasm  

  Breath  holding  

  Cuffing  

  Bronchospasm  

  Desaturation  

  Provoked  by  stimulation  during  light  anaesthesia    Light    stimulation  in  the  airway    Painful  stimulation  ”systemically”  

  Occurs  most  frequently..    During  induction  and  intubation      When  extubating  

Is  there  any  reason  to  worry    about  a  laryngeal  spasm?  

They  disappear  always  eventually  

?  

Acta Anaesthesiol Scand 1984;28:567-75.

Laryngospasm During Anaesthesia. A Computer- Aided Incidence Study in 136 929 Patients.  G. L. Olsson and B. Hallen.

Complication  of  laryngeal  spasm:    0,5%  cardiac  arrest!  

Acta Anaesthesiol Scand 1984;28:567-75.

Laryngospasm During Anaesthesia. A Computer- Aided Incidence Study in 136 929 Patients.  G. L. Olsson and B. Hallen.

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Can’t  you  just  intubate  the  child?  

In  stead  of  waiting  for    the  spasm  to  disappear?  

?   Vocal cords

 False vocal cords

 Arytenoid Cartilage

 Vocal cords

 False vocal cords

 Arytenoid Cartilage

 Mask-­‐CPAP  or  ventilation  with  moderate  pressure  and  100%  O2  

  Jaw  trust  and  digi†al  pressure  just  in  front  of  the  Mastoid  Process  

  Propofol  1-­‐(2)  mg/kg  iv,  if  readily  available  

  Suxamethonium  0,25-­‐0,30  mg/kg  iv    (the  child  will  still  be  able  to  breathe)  

  If  no  IV:  Suxamethonium  4-­‐5  mg/kg  intramusc.  

Strategy  

  Don’t touch the shaft of the laryngoscope with 1st finger

  Apply extern pressure on larynx with the 5th finger

  Laryngoscope blade in mid-line, deep in vallecula

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  Support arms on the table

  Use both hands to optimize the view of glottis

  Let the assistant insert the endo- tracheal tube

  Remember to empty the stomach after intubation

  Air in the intestine often cause more pain postop than the surgery!

 Malformation  of  the  face  

  Large  tongue    Upper  airway  neoplasm  

  Limited  movement  of  neck  /  jaws  

                   .....or  combinations  

All  of  which  are  relieved  by  a    nasopharyngeal  airway  

Most frequently upper airway patology:  Positioning   Pull  tongue/  jaw  

 Nasopharyngeal  airway  

 Nasopharyngeal  airway  

 Nasopharyngeal  airway  

 Laryngeal  airway  mask  

  Endotracheal  tube  introduced  nasally  until  breathing  is  heard  in  the  tube    (use  a  suction  catheter  as  a  guide  in  children  older  than  two  years)  

  The  jaw  is  pulled  forward  

  Distance  from  the  nostril:    0-­‐1  yr:    8  ±  0,5  cm    1-­‐2  yrs:  8,5  ±  0,5  cm  

Type  1:  Hurler   Type  2:  Hunter  

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 Malformation  of  the  face   Large  tongue   Upper  airway  neoplasm   Limited  movement  of  neck  /  jaws                     .....or  combinations   Mucopolysaccharidoses  

A  LMA  is  useful  and  a    nasopharyngeal  airway  may  be  helpful    

Most frequently upper airway patology:

Intubation  ease  Difficult  Failed    

Overall  25%  8%  

Hurler  54%  25%  

Pediatric Anesthesia 2000; 10: 53-8

The laryngeal mask airway in the difficult paediatric airway: an assessment of positioning and use in fibreoptic intubation Walker RW.

Anesthesia 1994; 49: 1078-84

Anaesthesia and mucopolysaccharidoses. A review of airway problems in children. Walker RW, Darowski M, Morris P, Wraith JE.

  Increased  secretions   Faster  desaturations   Bleeding   Laryngeal  oedema?  

  Atropine  40  microgram  per  kg  orally  or  p.r.    30  minutes  before  induction  of  anaesthesia      Better  view  by  drying  secretions    Better  effect  of  local  anaesthetics      Protect  against  vagal  reflexes  

 Midazolam  (0,3-­‐0,5  mg*kg-­‐1)  if  appropriate  

Premedication

  Sevoflurane  in  100%  oxygen  via  face  mask  

  A  small  endotracheal  tube  is  placed  as  a  nasopharyngeal  airway  as  soon  as  the  child  relaxes  -­‐  before  obstruction  occurs  

  Important!    The  size  must  be  small  in  order  not  to  deviate  the  nasal  septum  or  traumatize  the  mucosa    

Induction of anaesthesia  Induction of anaesthesia   The  anaesthetic  circuit  is  connected  to  the  

nasopharyngeal  airway  

  The  free  nostril  and  mouth  is  closed  and  anaesthesia  is  continued  via  the  nasopharyngeal  airway...  

  ...  which  is  dedicated  to  anaesthesia,  oxygenation  and  monitoring  during  the  intubation  

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 When  anaesthesia  is  deep..  

  Lidocaine  3-­‐4  mg  per  kg  is  flushed  through  the  nasopharyngeal  airway  

Topical analgesia   Cautiously  suctioning  of  the  airway  

  The  fiberscope  is  introduced  via  the  second  nostril  

  The  glottis  is  identified  and  the  fiberscope  is  introduced  into  trachea  

  The  endotracheal  tube  is  railroaded  over  the  fiberscope  

  Optimal  positioning  of  head  

  Keep  the  mouth  open  during  mask  ventila-­‐tion  without  applying  pressure  under  the  chin  

  Apply  CPAP  in  soft  airways  

  Special  hand  position  on  the  laryngoscope  making  it  possible  to  apply  pressure  on  larynx  with  the  5th  finger  during  intubation  

  “Two-­‐anaesthetist-­‐intubation”  

  Nasopharyngeal  airway