moderator : dr(prof.) maya presenter: priyanka jain moderator : dr(prof.) maya presenter: priyanka...
TRANSCRIPT
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Moderator : Dr(Prof.) Maya Presenter: Priyanka jain
Moderator : Dr(Prof.) Maya Presenter: Priyanka jain
www.anaesthesia.co.in [email protected]
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ANKUR16 years old male Student of class 10 th Noida ( U.P.)
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Chief complaints:
Difficulty in breathing through nose × 13 yrs Associated with recurrent episodes of URI
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HOPI :The parents noticed difficulty in breathing
through nose since 2-3 years of age sleeping with open mouth occasional episodes of difficulty in breathing
and restlessness during sleep .no h/o morning headache , nocturnal
awakening , feeling sleepy during daytime .
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h/o regular use of nasal decongestant drops to relieve obstruction
recurrent episodes of URI once every month No current h/o fever , cough , cold, earacheNo h/o orthopnea, syncope, cyanosis
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No H/O excessive bleeding from any site blood transfusion seizures, cyanosis , drug allergy .
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Past history : no h/o any other medical and surgical illness .
Family history : no h/o bleeding disorder Personal history : school performance good vegetarian bowel bladder habits N
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GPE:
Alert awake and cooperative Well oriented to time space and person
Average build Speech quality : normalFacies : prominent nose, maxillary hypoplasia,
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Wt : 45 kg Ht : 160 cm VITALS :PR : 80/min rt. radial , regular , normal
volume and character, no radioradial and radiofemoral delay
BP: 106/ 74 mm Hg , RUAS. Afebrile
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No pallor, icterus , cyanosis , clubbing , edemaOral and airway examination :MMP I, NM and MO wnl TMD 6 cm B/L tonsils enlarged ( grade II)No deviated nasal septum B/L nostrils patent .No loose teeth
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Inspection : trachea central,Chest was symmetrical in shape , both sides
moving equally with respiration. Palpation : findings on inspection confirmed.
Auscultation: B/L NVBS
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Apex beat in 5th intercostal space midclavicular line
No visible swelling ,abnormal pulsations S1S2 heard , no murmur
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Hb : 13.9gm/dl TLC : 11,200/ cu mm DLC : N 70, L 20, M 2 Platelet : 3,04,000/ cu mm Bleeding time : 3.15 min ( upto 7 min) Clotting time : 6.40 min( upto 11 min)
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…
Barash,5th edition
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Age URTI OSA Difficult airway Airway surgery Ponv Pain management Bleeding Post op complications
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Primary : < 24hrs, generally < 6 hrs More brisk, fatal, profuse, slipping of ligatures
Secondary: 24hrs – 5/6 days post op Eschar on tonsillar bed sloughs
Measures:Post nasal packRe-exploration
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Issues: Bleeding and Hypovolemia Difficult airway Aspiration Emergency surgery full stomach with blood
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Assessment Volume repletion OT preparation : suction , iv lines large bore
, Difficult airway Positioning RSI Tracheostomy
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Large bore i.v. access Correction: crystalloids ,colloids , blood Difficult to estimate blood loss: adrenergic drive,
swallowing of blood HCT measurement
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Emergent tracheostomy Experienced anesthesiologist 2 large bore suction catheters Extra laryngoscope handles and blades Cuffed ETT and stylets
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Sedation:?? Preoxygenation Rapid sequence induction Induction: thiopentone/ propofol/ etomidate/
ketamine MR: succinylcholine/ rocuronium Gastric tube Extubation: fully awake, normal gag & cough
reflexes
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Risk factors :
Anesthesia related Inadequate depth Airway irritation with volatiles( D> I>
E>H=S), mucus or blood and suction catheter or laryngoscope.
Thiopentone increase incidence Propofol< Sevo Less experience
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Patient related Age URI Smoking GERD H/o choking during sleep
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Surgery related
T&A (21-26%)Appendicectomy, cervical dilation, hypospadias, thyroid
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Prevention adequate depth Awake vs deep extubation Positive pressure before extubation
( artificial cough) Drugs : anticholinergics , BZD, lidocaine ,
magnesium ( 15mg/kg in 30 ml 0.9% NS over 20 min after intubation)
Acupunture
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Remove the stimulusJaw thrust Laryngospasm notch Oral or nasal airwayPPV with 100% oxygen Deepen anesthesia Drugs propofol 0.25-0.8 mg/kgSch 0.1-3 mg/kgiv , 4 mg/kg im Doxapram 1.5 mg/kg NTG 4 g/kgivSLN block
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1. Chronic/ recurrent tonsillitis2. Adenotonsillar hyperplasia with OSA3. Tonsillar hyperplasia4. Peritonsillar abscess5. Adenoiditis6. Recurrent/ chronic rhino sinusitis/Otitis media
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1. Suspicion of malignancy2. Hemorrhagic tonsillitis3. Abnormal maxillofacial growth4. Failure to thrive5. Speech impairment6. Dysphagia
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Higher incidence of respiratory complications but little residual morbidity
Risk factors:1. ETT in child <5yrs2. Prematurity3. Reactive airway disease4. Parental smoking5. Airway surgery6. Copious secretions7. Nasal congestion
Tait AR et al. Risk factors for perioperative adverse events in children with respiratory tract infections. Anesthesiology 2001;95:299-306 …
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Oral & nasal airway patency : mouth breathing, nasal quality of speech, chest retractions, wheeze, stridor, rales
Adenoid facies: elongated face, high arched palate, retrognathic mandible
Tonsil size: Loose teeth: age, laryngoscopy, mouth gag Syndromes
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Treacher Collins syndrome Crouzon's syndrome Goldenhar syndrome Pierre Robin C.H.A.R.G.E. association Achondroplasia Down syndrome Mucopolysccharidoses: Hunter 1& 2…
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HB, Hct, Platelet count Bleeding time Clotting time X-ray: neck lateral view: adenoids PT/ aPTT vWD, factor VIII deficiency XRAY chest: LRI
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Sedation: oral midazolam 0.5mg/kg
Antisialagouge: dry secretions better operating field NPO Consent Blood arranged
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SPO2 ETCO2 Precordial stetho ECG Temp BP PAP Blood loss
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Intravenous/ inhalational Preformed RAE ETT cuffed/ uncuffed Oral packing Armoured LMA Midline fixation Brown- Davis mouth gag
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Maint: propofol infusion/ inhalational/ muscle relaxant
Spontaneous/ controlled ventilation
Pain management PONV prophylaxis
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Advantages: Patent with Boyle-
Davis gag Avoid intubation& its
complications
Disadvantages: Risk of aspirationInadequate positioningPilot balloon snaredTonsillar enlargement: difficult placement
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In the presence of a URI : evidence that a LMA may be superior to an ETT.
Some evidence that the incidence of airway complications is lower than with an ETT. Most anesthesiologists, however, prefer the intraoperative security of an ETT.
Robin G. Anesthetic management of pediatric adenotonsillectomy.CAN J ANESTH 2007 / 54: 12 / pp 1021–1025..
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Laryngoscopy & thorough suction
Positive airway pressure: 1. Attenuates excitation of superior laryngeal nerve
& diminish laryngospasm2. Expel secretions3. Maintain oxygenation
Awake/ deep Lateral position, head down
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Prevention:1. Deep extubation/ fully awake (OSA)2. I.V. lidocaine3. Topical anesthesia4. Magnesium5. CPAP at extubation
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NSAIDS
Opioids
Local infiltration
TENS
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NSAIDs did not cause any increase in bleeding requiring return to theatre. There was significantly less nausea & vomiting when NSAIDs were used compared to alternative analgesics.
Cardwell et.al. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database of Systematic Reviews 2005, Issue 2.
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Francis et al. Analgesics for postoperative pain after tonsillectomy and adenoidectomy in children.
(Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3.
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Decreased doses in OSA
Opioid sparing effect of NSAIDS
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Bupivaciane infiltration pre and post surgery, with & without adr, spray
Reduces bleeding No evidence that the use of perioperative LA in
Pts undergoing tonsillectomy improves post-operative pain
Hollis LJ et al. Perioperative local anesthesia for reducing pain following tonsillectomy. Cochrane Database of Systematic Reviews 1999, Issue 4.
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TENS for post tonsillectomy pain relief is a safe, easy and promising method over alternative analgesic regimes which can be safely employed by the recovery staff.
A.K.Gupta et al. POST - TONSILLECTOMY PAIN : DIFFERENT MODES OF PAIN RELIEF. Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 2, April - June 2002…
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Incidence: 40-70%1. Irritant blood in stomach2. Inflammation/ edema3. Dehydration: poor oral intake
Prophylaxis:1. Maintain adequate hydration2. Gastric decompression3. Antiemetic drugs4. Acupuncture
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Good evidence: prophylactic anti-emetic effect of dexamethasone, ondansetron, granisetron, tropisetron & dolasetron, metoclopramide are efficacious.
Not sufficient evidence: dimenhydrinate/ perphenazine/ droperidol/ gastric aspiration/ acupuncture are efficacious
C. M. Bolton et al. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: A systematic review and meta-analysis. Br J Anaesth 2006; 97: 593–6041
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Concealed hemorrhage: with tropisetron, ondansetron
P G Herreen et al. Concealed post-tonsillectomy hemorrhage associated with the use of the antiemetic; Anesthesia and Intensive Care; Aug 2001; 29, 4
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1. Bleeding: 2. Pain: 3. Obstruction: 4. PONV: severe C/I5. Oral intake not required for discharge6. Adenoidectomy: safely discharged
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Age ≤3 yr
Abnormal coagulation with/without identified bleeding disorder in patient/family
Evidence of OSA/apnea
Craniofacial/ other airway abnormalities, syndrome disorders: choanal atresia & laryngotracheal stenosis
Barash 5th edition
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Systemic disorders: preop cardiopulmonary, metabolic/ general medical risk
Procedure done: acute peritonsillar abscess
Extended travel time, weather conditions & home social conditions not consistent with close observation, cooperation & ability to return to the hospital quickly
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1ºh’gge: < 24hrs, generally < 6 hrs More brisk, fatal, profuse, slipping of ligatures
2ºh’gge: 24hrs – 5/6 days post op Eschar on tonsillar bed sloughs
Measures:Post nasal packRe-exploration
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Def: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns.
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Anatomical: upper airway narrowing: adenotonsillar hypertrophy, craniofacial anomalies
Obesity: strongest predictor
Neuromotor factors: reduced central mediated activation of upper airway muscles, neuromuscular diseases
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Daytime: Mouth breathing Poor school
performance Daytime somnolence Morning headaches Fatigue Hyperactivity Aggression Social withdrawal
Nocturnal:SnoringLabored breathingParadoxical respiratory effortApneaSweatingUnusual sleep positionsEnuresis
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Growth impairment: failure to thrive PHT, cor-pulmonale, heart failure BP dysregulation Each apneic episode-increased PAP-significant
PAH & systemic HT- ventricular dysfunction- dysrrhythmias
CNS dysfunction: persistent hypercarbia
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Features Children Adults
Peak age Preschool Middle age
Gender ratio M=F M>F, postmenopausal
Causes Adenotonsillar hypertrophy, obesity, craniofacial abnormalities
Obesity
Body habitus Failure to thrive, normal, obese
Obesity
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Features Children Adult
Daytime somnolence Uncommon Very common
Neurobehavioral Hyperactivity, developmental delay, cognitive impairment
Cognitive impairment, impaired vigilance
Treatment 1º: surgical (adenotonsillectomy)2º: CPAP
1º: CPAP2º: surgical (uvulopharyngoplasty)
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Gold standard: polysomnography Any age Diff 1ºsnoring & OSAS May predict success of treatment/ postop.
complications
Desaturate with relatively short apneas: <10sec maybe significant
Normal children: usually not > 1 apnea/hr
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Surgery: Adenotonsillectomy Uvulopharyngoplasty Tongue reduction
CPAP/ BIPAP
SUPPLEMENTAL OXYGEN
TRACHEOSTOMY
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Treating OSA by tonsillectomy &/or adenoidectomy is associated with increased gain in ht, wt & BMI in most children, including the obese &morbidly obese
Neurobehavioral, cor-pulmonale improvement
Zafer Soultan et al. Effect of Treating Obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children. Pediatr Adolesc Med. 1999;153:33-37
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Polysomnography
ECG: PHT,RVH, cor- pulmonale
ABG: hypercarbia, hypoxia
Antireflux medications
Sedation: monitoring, titrated
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Inhaled/ intravenous: titrated CPAP 10-15 cm Oral airway/ jaw thrust/ other Difficult airway management: FOB/ LMA
Pain: opioid sparing adjuncts, non-opioid analgesics, nonpharmacological preferred
Extubation: awake in OT/ ICU
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Apnea Pulmonary edema PHT crisis Pneumonia
ICU care
Prognosis: 13% recurrence
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Older children Severe sore throat, odynophagia, high fever,
trismus Limited mouth opening-difficult airway Head down position, turned to side of abscess I &D: sedation/ topical/ LA/ GA Spontaneous breathing maintained Gentle laryngoscopy, suction Cuffed ETT
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