Paediatric tonsillectomy

 

Airway disasters:

Difficult intubation

Problems:

·      Obesity

·      Abnormal upper airway anatomy

·      Large tonsils

->> Difficult BMV

->> Difficult ETT

Solution:

·      Planning!

C-spine injury

Problem:

·      Extreme neck extension

Beware if:

·      Down syndrome: need C-spine X ray with flex/ex views

Laryngospasm

Causes:

·      Inadequate anaesthesia

·      Airway manipulation

·      Painful stimulation

Prevention:

·      Induction: CPAP + avoid manipulation during excitement

·      Incision: 1 MAC sevoflurane + fentanyl 1mcg/kg 5 mins prior

·      Extubation: ppF 3mg/kg + suction + deflate + extubate + CPAP

Aspiration

Problem:

·      Soiled, bloody airway

·      Deep extubation

Prevention:

·      Suction pharynx and nasopharynx (‘coroner’s clot’)

·      Ensure haemostasis before extubation

·      Lateral decubitus at extubation

Obstruction

Problem:

·      Swollen airway

·      Opioid analgesia

·      ±OSA

->> Risk of death

Risk factors:

·      Severe OSA
Or mild-mod plus:

·      Morbidly obese

·      Very young (<2)

·      Major comorbidity

·      Abnormal upper airway anatomy

Prevention:

·      HDU if any risk factors (see above)

·      Minimise opioid (see below)

 

Unpleasant experiences:

Induction distress

Conflict:

·      IV: don’t like needles

·      Inhalation: don’t like mask, risk of airway complications

Compromise:

·      Midazolam pre-med

·      Inhalational induction

·      IM sux drawn up

Emergence delirium

Problems:

·      Pre-school age

·      Anxiety

·      Volatile anaesthetic

·      Surgery

·      Pain

Prevention:

·      Midazolam pre-med

·      Switch to propofol TIVA mid-procedure

·      Clonidine 1mcg/kg

·      Generous pain relief intra-op

Pain

Conflict:

·      Very painful

·      At risk of obtundation

Compromise:

·      Local anaesthetic by surgeon

·      Maximise non-opioids: paracetamol, COX2i, clonidine, (tramadol)

·      Evaluate opioid sensitivity intra-op: fentanyl 1mcg/kg q5 min

·      Low dose opioid for ward: oxycodone 0.1mg/kg Q3H PRN

·      Trial oral opioid in PACU

Nausea

Problems:

·      Volatile anaesthetic

·      Opioid

·      Blood in stomach

Prevention:

·      Switch to propofol TIVA mid-procedure

·      Multiple anti-emetics intra-op

·      Ensure haemostasis before extubation

·      Decompress stomach if bleeding +++

 

 

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