anesthesia for pediatric airway surgery
Post on 11-May-2015
2.837 Views
Preview:
TRANSCRIPT
DrMoatazAbdelrahmanConsultantPaediatricAnaesthetistCentralManchesterUniversityHospitalsRoyalManchesterChildren’sHospital,UK
AIRWAYSURGERY
EQUIPMENT TECHNIQUES TUBELESSAIRWAY ANAESTHESIA PROBLEMS ADVANTAGES DISADVANTAGES
Surgicalproceduresofthelarynxandtracheaininfantsandchildrenpresentspecialproblems Narrowanatomicalfield Aggravatedbypathologicalchanges
Sharedairway Adequateoxygenation Cooperation
REQUIREMENTSFORPAEDIATRICAIRWAYSURGERY
Specialequipment
Soundknowledgeoftheairway‐ Anatomy‐Physiology‐Pathology
Tertiaryreferralcentre(wheneverpossible)
Excellentcommunicationbetweenanaestheticandsurgicalteams
ACCESSTOTHEUPPERAIRWAY
Rigidbronchoscopes Storzventilatingscope±Hopkin’srod Venturiscope(microtubes,jetventilation)
Fibreopticscope
Hopkin’srodwithoutbronchoscope
Light source
Light source
Telescope Hopkin’s Rod
FGF Suction
Prism
2.7 mm
SuggestedETTandrigidbronchoscopesizes
Age Cricoiddiameter
Trachealtube Bronchoscopesize
SizeID ED Size ID ED
Premature 4.0 2.5‐3.0 3.5‐4.0 2.5 3.2 4.0
Term 4.5‐5.0 3.0‐3.5 4.0‐4.9 3.0 4.2 5.0
6months 5.0 3.5‐4.0 4.9‐5.4 3.0 4.2 5.0
1yr 5.5 4.0‐4.5 5.4‐6.2 3.5 4.9 5.7
2yr 6.0 4.5‐5.0 6.2‐6.9 3.5 4.9 5.7
3yr 7.0 5.0‐5.5 6.9‐7.4 4.0 5.9 6.7
5yr 8.0 5.5‐6.0 7.4‐7.9 5.0 7.0 7.8
10yr 9.0 6.5cuff
14yr 11.0 6.5cuff
METHODSFORAIRWAYANAESTHESIA
Storz Spontaneous/IPPV Apnoeicoxygenation
Jetventilation(supraglotticandsubglottic) Sanders Pneumothorax HFJV CO2accumulation LFJV
Tubelessfield
ANATOMICALDIFFERENCES
Largetongue Longnarrowepiglottisangledposteriorly Obligatorynasalbreathers Softhighanteriorlarynx,easilydisplaced Narrowestpartatthecricoidring Shortcricothyroidmembrane
Difficultcricothyroidotomy
ETT
Epig
Arytenoid
Aryepiglottic
Interarytenoid
VC
AIRWAYPHYSIOLOGY
Fixedtidalvolume Minuteventilationdependsonrate
Diaphragmaticbreathing FewertypeImusclefibres
Earlyfatigue
FRClessthanclosingcapacity Highermetabolicrequirement
HYPOXIA
Infantslessthan60weekspostconceptualageareathighriskofdevelopingapnoeaespeciallyif
ex‐premature
PROCEDURESONTHEAIRWAY
DIAGNOSTIC
THERAPEUTIC
DIAGNOSTICPROCEDURES
Laryngomalacia(floppyorflipperlarynx)
Laryngo‐tracheo‐bronchomalacia
Vocalcorddysfunction(palsies)
Narrowingandstenoticlesions Glottic Subglottic Tracheal
DIAGNOSTICPROCEDURES
Tracheo‐oesophagealfistula
Cysts(vocalcords)
Clefts(larynx)
Webs
Tumours(papilloma)
Inflammatorylesions
THERAPEURICPROCEDURES
Excisionoflesions
Laser
DividingWebs
Removalofforeignbodies
Stentsforstenoticlesions(trachea)
Correctionofclefts(larynx)
ANAESTHESIA
Pre‐anaestheticassessment
Anaestheticroompreparation
Monitoring
Induction
Maintenance
Analgesia
Post‐anaesthesiacare
PREANAESTHETICASSESSMENT
Ageatbirth Post‐conceptualage Ventilatoryproblemsatbirth–IPPV Chroniclungdiseaseandbroncho‐pulmonarydysplasia
Airwaymanifestations
Previousanaestheticcharts Investigations Clearcervicalspine(rigidbronchoscopes) Premedication
Airwaymanifestations
Upperairway Obstruction Partial(monophasicorbiphasicstridor) Complete(intubated–ICU)
Oxygensaturation:low Lowerairway:coughandwheeze Feeding:historyofsevereregurgitation
ANAESTHETICROOM Experiencedassistant Localanaesthetic
Spray Atomiser
Airwayequipment
Laryngoscopes Straightblades Curvedblades
Face masks LMAs Tubes, stylets, bouggies Laryngoscopes Suction Cricothyroidotomy - tracheotomy
MONITORING
ECG BP SpO2
ETCO2 GAS
TUBELESSFIELDWITHHOPKIN’SROD
Unobstructedairway Noendotrachealtube Nasopharyngealairwayformaintenance TelescopeorHopkin’srodonly
INDUCTION
SecuringIVaccessispreferablebeforeinduction
Inhalationinduction SevofluraneinO2 HaluthaneinO2 Isoflurane? Desflurane?
Maintainspontaneousbreathing+CPAP Deepinhalation
Confirmdeepanaesthesia Centeraleyeballs‐smallpupils‐regularbreathing
Insertnasopharyngealairway ETTofappropriatesizestoppingshortoftheairway
Localanaesthesiatotheairway Laryngoscopy
Lignocaine3mg/kg Spray LAD
Assessthepositionofthetube Maintainspontaneousbreathingthroughthe
nasopharyngealairway
Finalpicture:spontaneouslybreathingchildwithanaesthetisedairwayandnotubeinthelarynx
TubelessAirway
Readyforprocedure
ETT
Nasopharynx
MAINTENANCE Gas/O2
Spontaneousbreathing+CPAP(hand) Equipment
Drugs Adrenaline▪Topical ▪Nebulizer
Dexamethasone Propofol
Tubes, stylets, bouggies LMAs Laryngoscopes Ventilating bronchoscope Suction Cricothyroidotomy - tracheotomy
PROBLEMS
Rememberyouareworkingonadegreeofobstructiontostartwith
Toodeep apnoea,lossofairway,desaturation
Lightcoughing,airwayobstruction,desaturation
InadequateCO2monitoring
PROBLEMS
Difficultyinmaintainingspontaneousbreathing
Airwaybleeding‐ Obstruction ‐Bronchospasm‐Desaturation
(Topicaladrenalineandsuction)
Airwayobstruction‐Bleeding ‐Oedema‐Dislodgementofmasses ‐Traumatotheairway(rare)
ANALGESIA
Localanaesthesia Paracetamol Ibuprofen
POSTANAESTHESIA
AIRWAYOEDEMA
AIRWAYBLEEDING
POSTANAESTHESIA
Recoveryposition AdequatetimeinPACU Anaestheticandsurgicalteamsavailable
POSTANAESTHESIA
Desaturation Stridor Obstruction Apnoea
Adrenalinenebulizer 1:1000@0.5ml/kg RepeatPRN
Dexamethasone 0.6mg/kg
O2 CEPAP Reintubate
ADVANTAGES
Tubelessunobstructedfield Lessmanipulationoftheairway
‐Intubation‐Extubation
Facilitationofusinglargerinstruments Nomusclerelaxants LittleCO2accumulation Minimalriskofpneumothorax
DISADVANTAGES
Nodefinitiveairway
Difficultyinmonitoringbreathing ETCO2
SomeCO2accumulation
CONCLUSION
Tubelessairwayfieldofferssomeadvantagesforsurgicalproceduresinasafemannerwithlesscomplications
REFERENCES
1.AlbertSN.TheAlbert‐Sandersadaptorforventilatinganaesthetizedpatientsformicro‐laryngealsurgery.BrJAnaesth1971;43:1098
2.BaerG,PaloheimoM,RahnastoJ,etal.End‐tidaloxygenconcentrationandpulseoximetryformonitoringoxygenationduringintratrachealventilation.JClinMonit1995;11:37
3.CowlCT,PrakashUB,KrugerBR.Theroleofanticholinergicsinbronchoscopy:arandomised,clinicaltrial.Chest2000;118:188
4.McRaeK.Anesthesiaforairwaysurgery.AnesthesiolClinNorthAmerica2001;19:497–541,vi
5.KainZN,O’ConnorEZ,BerdeCB.Managementoftracheobronchoscopyandesophagoscopyforforeignbodiesinchildren:Asurveystudy.JClinAnesth1994;6:28
6.OssoffRH.Lasersafetyinotolaryngology—headandnecksurgery:anestheticandeducationalconsiderationsforlaryngealsurgery.Laryngoscope1989;99:1–26
7.EnglishJ,NorrisA,BedforthN.ContinuingEducationinAnaesthesia,CriticalCare&PainVolume6Number12006
top related