Perioperative Care of the Child for High Risk Upper Airway Procedures

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Perioperative Care of the Child for High Risk
Upper Airway Procedures
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General Principles

• Diagnosing alterations in a patients airway
  infection, trauma, congenital defects.
• Establishing an airway distorted airway
• Devise an anesthetic plan that provides good
  surgical access, while maintaining safe
  ventilation and monitoring.
• Selecting appropriate anesthetic drugs
• Defining appropriate extubation criteria
• Define appropriate level of nursing care in PACU

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Preoperative Evaluation

• Previous anesthetic complications
• Respiratory pathology BPD, RSV/Asthma, URI,
  Obstructive sleep apnea, etc.
• Cardiac abnormalities (cleft palate, syndromic)
• Bleeding diathesis
• Obesity, neuromuscular disease
• Medications abx, antihistamines, aspirin
• Studies CBC, bleeding time, EKG/Echo,
  radiographic studies

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Admission Criteria for T A by American Academy
of Pediatric Otolaryngology Committee

• Age lt3 y
• Abnormal coagulation values
• Moderate to severe sleep apnea
• Systemic disorders that increase patient risk
• Craniofacial/airway abnormalities
  Treacher-Collins, Goldenhar, Downs, choanal
  atresia, laryngeal stenosis
• Acute peritonsillar abcess
• Extended travel time, weather conditions, and
  home social conditions not consistent with close
  observation, cooperation, or ability to return to
  hospital quickly

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Obstructive Sleep Apnea

• Most common indication for tonsillectomy
• Signs Symptoms obesity, daytime somnolence,
  behavior problems, snoring, sweating, mouth
  breathing
• Close monitoring pre- and post-op
• Avoid heavy narcotic sedation (local anesthetics,
  tylenol w/codeine)
• 90 improve after surgery

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Obstructive Sleep Apnea

• Sleep study criteria for severe sleep apnea and
  for admission
• Baseline PCO2 of 50mmHg or higher
• Baseline awake O2 saturation of 90 or less
• Episodes of desat of 80 or less
• gt10 episodes of obstructive apnea or hypopnea per
  hour of sleep

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Cardiorespiratory Syndrome

• History of obstructive symptoms x 1year
• Febrile, tachypneic, tachycardic, RVH on EKG
• More common in males/african american
• Stabilized with digitalis and diuretics pre-op

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Physical Exam

• Mouth opening (trismus common with peritonsillar
  abcess) 2 weeks
• Tonsillar size-effect on mask ventilation
  intubation
• Cleft palate-degree of friability
• Abcess size

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Radiographic studies
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Physical Exam

• Flaring, abdominal breathing, stridor, degree of
  phayngitis/ rhinorhea
• Ascultation for wheezes or rales
• Murmurs, gallops, heaves
• Signs of R heart failure JVD, RUQ fullness,
  abdominal striae, edema

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Induction

• Premed contraindicated in moderate OSA, 3
  tonsils, stridor, or resp difficulties
• Antisialagogue glycopyrolate
• Mask induction, Propofol, Short acting relaxant,
  barbituates not recommended
• Topical 2-4 lidocaine max 3mg/kg
• Oral rae, check for patency after mouth gag,
  bilateral breath sounds before/after positioning
• Modified Intavent LMA described by Alexander, CA
  -gtdecreased laryngospasm/stridor

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Maintenance

• O2, N2O, Sevoflurane/Isoflurane
• Plan for post-op analgesia codeine 1.5mg/kg IM,
  or fentanyl 2 mcg/kg (if not contraindicated)
• Bupivicaine w/ epinephrine (3mg/kg max) before
  surgery reduce narcotic needs post-op and
  decrease post-op bleeding
• Ondansetron and/or dexamethasone 1mg/kg

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Intraoperative management

• Standard ASA monitors
• IV fluid replacement of deficit and blood loss
  (much of which will be occult), hydration is a
  must for outpatient
• Transfuse for 10 blood volume
• Pass OG for decompression and gastric blood prior
  to emergence

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Emergence

• Carefully suction pharynx, no suction caths
  through nares
• Extubate when pt is fully awake and airway
  reflexes are fully restored
• Patel, et al. shown that deep extubations do not
  decrease airway complications
• Transfer to PACU in Tonsil position after
  satisfied with vitals and reflexes

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Complications

• Incidence of emesis (TA) as high as 65
• Aspiration
• Dehydration 20 to poor intake
• Laryngospasm
• Arrythmias
• Postop Hemmorhage causes the most morbidity and
  mortality

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Postoperative Hemorrhage

• Incidence 0.1-8.1
• 75 occur w/in first six hours
• Remaining 24 w/in first 24 hours
• Large amounts swallowed before recognized, may
  present as abdominal pain, pallor, restlessness,
  tachycardia, tachypnea, desaturation (aspiration)
  or laryngospasm

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Postoperative Hemorrhage

• Initial treatment suctioning, airway protection,
  orthostatic bps, pharyngeal packs, vessel
  ligation, cautery
• Reoperation should be treated as full
  stomach-gtpossibly NG suction-gtrestoration of
  blood volume-gtTC PRBCs-gtCoags-gtrapid sequence
  induction head down and assistance

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Postoperative Care-Phase I JCAHO-gtAS
Perianesthesia Nurses

• Class 12 one RN to Two patients
• One unconscious, stable s airway gt9 yo and one
  concsious, stable free of comps
• Two conscious, stable and free of comps
• Two conscious, stable, lt11yo
• Competent support staff must be present

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Postoperative Care-Phase I JCAHO-gtAS
Perianesthesia Nurses

• Class 11 one RN to one patient
• Mechanical life support and/or artificial airway
• Any unconscious lt9yo
• A second nurse must be available to assist
• Class 21
• One critically ill, unstable patient

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Postoperative Care

• Pain control-no salicylate, Acetaminophen c
  codeine often sufficient, careful with opiates
• Oral hydration,not forced, popsicles well
  tolerated
• Observation for at least 4 hours prior to dc,
  must be evaluated
• Telephone consult service must be available

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Recommendations for invasive airway procedures in
children

• lt5 yrs old
• Contraindicated blind nasal, combitube, surgical
  cricothyroidotomy
• Needle cricothyrotomy and Bag ventilation
• 14 G catheter
• 3.0 ET tube adapter
• 5cc syringe
• Bag

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Recommendations for invasive airway procedures in
children

• 5-10 yrs old
• Contraindicated blind nasal, surgical
  cricothyroidotomy, combitube (lt4 feet)
• Needle cricothyrotomy and Bag
• Transtracheal Jet vent low psi
• Melker cricothyrotome kit dilator to convert to
  tracheostomy tube

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Recommendations for invasive airway procedures

• gt10 yrs old
• Operator choice
• Cricothyrotome with Bag ventilation
• Surgical cricothyrotomy
• Needle cricothyrotomy with TTJV