Moderator : Dr(Prof.) Maya Presenter: Priyanka jain

Moderator : Dr(Prof.) Maya Presenter: Priyanka jain

www.anaesthesia.co.in anaesthesia.co.in@gmail.com

ANKUR16 years old male Student of class 10 th Noida ( U.P.)

Chief complaints:

Difficulty in breathing through nose × 13 yrs Associated with recurrent episodes of URI

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 .

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

No H/O excessive bleeding from any site blood transfusion seizures, cyanosis , drug allergy .

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

GPE:

Alert awake and cooperative Well oriented to time space and person

Average build Speech quality : normalFacies : prominent nose, maxillary hypoplasia,

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

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

Inspection : trachea central,Chest was symmetrical in shape , both sides

moving equally with respiration. Palpation : findings on inspection confirmed.

Auscultation: B/L NVBS

Apex beat in 5th intercostal space midclavicular line

No visible swelling ,abnormal pulsations S1S2 heard , no murmur

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)

…

Barash,5th edition

Age URTI OSA Difficult airway Airway surgery Ponv Pain management Bleeding Post op complications

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

Issues: Bleeding and Hypovolemia Difficult airway Aspiration Emergency surgery full stomach with blood

Assessment Volume repletion OT preparation : suction , iv lines large bore

, Difficult airway Positioning RSI Tracheostomy

Large bore i.v. access Correction: crystalloids ,colloids , blood Difficult to estimate blood loss: adrenergic drive,

swallowing of blood HCT measurement

Emergent tracheostomy Experienced anesthesiologist 2 large bore suction catheters Extra laryngoscope handles and blades Cuffed ETT and stylets

Sedation:?? Preoxygenation Rapid sequence induction Induction: thiopentone/ propofol/ etomidate/

ketamine MR: succinylcholine/ rocuronium Gastric tube Extubation: fully awake, normal gag & cough

reflexes

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

Patient related Age URI Smoking GERD H/o choking during sleep

Surgery related

T&A (21-26%)Appendicectomy, cervical dilation, hypospadias, thyroid

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

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

1. Chronic/ recurrent tonsillitis2. Adenotonsillar hyperplasia with OSA3. Tonsillar hyperplasia4. Peritonsillar abscess5. Adenoiditis6. Recurrent/ chronic rhino sinusitis/Otitis media

1. Suspicion of malignancy2. Hemorrhagic tonsillitis3. Abnormal maxillofacial growth4. Failure to thrive5. Speech impairment6. Dysphagia

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 …

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

Treacher Collins syndrome Crouzon's syndrome Goldenhar syndrome Pierre Robin C.H.A.R.G.E. association Achondroplasia Down syndrome Mucopolysccharidoses: Hunter 1& 2…

HB, Hct, Platelet count Bleeding time Clotting time X-ray: neck lateral view: adenoids PT/ aPTT vWD, factor VIII deficiency XRAY chest: LRI

Sedation: oral midazolam 0.5mg/kg

Antisialagouge: dry secretions better operating field NPO Consent Blood arranged

SPO2 ETCO2 Precordial stetho ECG Temp BP PAP Blood loss

Intravenous/ inhalational Preformed RAE ETT cuffed/ uncuffed Oral packing Armoured LMA Midline fixation Brown- Davis mouth gag

Maint: propofol infusion/ inhalational/ muscle relaxant

Spontaneous/ controlled ventilation

Pain management PONV prophylaxis

Advantages: Patent with Boyle-

Davis gag Avoid intubation& its

complications

Disadvantages: Risk of aspirationInadequate positioningPilot balloon snaredTonsillar enlargement: difficult placement

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..

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

Prevention:1. Deep extubation/ fully awake (OSA)2. I.V. lidocaine3. Topical anesthesia4. Magnesium5. CPAP at extubation

NSAIDS

Opioids

Local infiltration

TENS

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.

Francis et al. Analgesics for postoperative pain after tonsillectomy and adenoidectomy in children.

(Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3.

Decreased doses in OSA

Opioid sparing effect of NSAIDS

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.

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…

Incidence: 40-70%1. Irritant blood in stomach2. Inflammation/ edema3. Dehydration: poor oral intake

Prophylaxis:1. Maintain adequate hydration2. Gastric decompression3. Antiemetic drugs4. Acupuncture

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

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

1. Bleeding: 2. Pain: 3. Obstruction: 4. PONV: severe C/I5. Oral intake not required for discharge6. Adenoidectomy: safely discharged

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

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

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

Def: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns.

Anatomical: upper airway narrowing: adenotonsillar hypertrophy, craniofacial anomalies

Obesity: strongest predictor

Neuromotor factors: reduced central mediated activation of upper airway muscles, neuromuscular diseases

Daytime: Mouth breathing Poor school

performance Daytime somnolence Morning headaches Fatigue Hyperactivity Aggression Social withdrawal

Nocturnal:SnoringLabored breathingParadoxical respiratory effortApneaSweatingUnusual sleep positionsEnuresis

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

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

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)

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

Surgery: Adenotonsillectomy Uvulopharyngoplasty Tongue reduction

CPAP/ BIPAP

SUPPLEMENTAL OXYGEN

TRACHEOSTOMY

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

Polysomnography

ECG: PHT,RVH, cor- pulmonale

ABG: hypercarbia, hypoxia

Antireflux medications

Sedation: monitoring, titrated

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

Apnea Pulmonary edema PHT crisis Pneumonia

ICU care

Prognosis: 13% recurrence

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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