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[jafo1964]

In private practice I end up tackling all aspects of anaesthetic care with little untrained help if any. I guess a lot of you are also doing much the same
I find extubation of children who have had tonsillectomies far from perfect and intimidating, requiring a lot of physical restraint of the kid. I have tried various strategies. But the results have been largely inconsistent and far from utopia.
So I am hoping to be educated by people who may have mastered the technique
Adults are easy to handle. But kids between ages 3 to 15 pose whole lot of emergence problems. Paediatric practice constitutes less than 15% of my total anaesthetic practice

MY ANAESTHETIC IS USUALLY AS FOLLOWS
Fasting for 6 hours
Premedication – Inj. Tramadol 0.5 mg/kg + Inj. Glycopyrollate 0.1 mg/kg IM 1 hour before surgery
In OT-  20 or 22G IV cannula. No fluids hooked on.
Monitors – 3 lead ECG, ANIBP, SpO2, ETCO2 and precordial stethescope
Preoxygenation – 100% O2 X 3 mins
Induction – Fentanyl 2 mcg/kg + Xylocard 1 mg/Kg + Propofol 3mg/kg + Rocuronium 0.6 mg/kg
Ventilate with 100% O2 and 2% Sevoflurane
Intubate at 90 secs – appropriate size RAE preformed oral ETT, confirm BAE,  fix
Maintenance – 70% N2O + 30% O2 + 2% Sevo - IPPV with Mapleson F or Circle system with anaesthesia ventilator
Titrate ventilation to ETCO2 around 30 – 35 mm Hg
Intra-op drugs include Ondansetron 4 mg, Antibiotic IV and Sometimes Decadron if airway edema suspected.
Relaxant and Narcotic top up usually not given, used only if needed.
Procedure( Laser assisted adenotonsillectomies) usually lasts 60 to 90 mins.

End of procedure – Cut sevo to 0.5%. Hand ventilate with high flows. Suction and final inspection of airway done by surgeon
Demonstrate physical recovery of diaphraghmatic function.
Reverse with Neostigmine 50mcg/kg + Glycopyrollate 10mcg/kg. Switch to 100% O2 and don’t stimulate patient again until he is ready to extubate.

EXTUBATION GOALS
Awake comfortable patient
Opens eyes to commands
Airway reflexes are fully recovered
Hopefully TOF > 0.9
Adequate respiratory function and haemodynamics

MY SUCCESS RATE IN ACHIEVING THIS ENDPOINTS
Adults  > 90%
Children < 20%

WHAT HAPPENS
Kids wake up struggling, require severe restraint. Extubation is not smooth. They are crying and agitated and don’t make a pretty picture. Since it is an airway surgery prone to airway problems, I prefer to do an awake intubation

STRATEGIES I HAVE ADOPTED AND NOT BEEN TOO SUCCESSFUL
Extubate child while still breathing 0.5% Sevo in 100% O2 – deep extubation – Increased my incidences of post-extubation breath holding and laryngospasm

Deep extubation with N2O on flow – still post- extubation airway Problems

IV Xylocard – works brilliantly in adults but not so in children

Dribble in 2% Lignocaine into ETT or spray 10% lingocaine down the ETT about 3 - 5 mins before extubation, hoping they will tolerate ETT better. Not good enough


LET ME HEAR ABOUT WHAT WORKS BEST FOR YOU

[yogenbhatt1]

Hi, I thought you all must never be doing this surgery, which is counted as a minor surgery in India. The risk involved is high and it takes time too. Still it is counted as a minor surgery.
The method is almost same as what you have described, except that by rule, we give one Hydrocort 100 mg stat, as Dexamethasone takes time to act. We use Granisetron, and IV Diclophenac at induction. We prefer Atracurium as the reversal is much easier and complete. Instead of Sevo, we are still mainly at Fluothane or Iso, or We use Propofol continuous. I personally like to use a nasal Portex tube( Softened by hot water, just before intubation)  ,as the surgeon keeps moving the tube for a better vesion.
Hypothetically, I feel that intra tracheal Xylocain can supress the cough reflex, so I avoid it.
But if analgesia is good enough, I think the child should come out smoother.
Rest is all agreeble to what you think,
Regards.

[gasman]

I get very smooth extubation conditions with my technique. Not 100% smooth, but either no coughing or attenuated coughing.

I do 2 things differently to you.

1. Do not paralyse. I use 1mg/kg lignocaine spray directly onto cords and below just after induction (sevo or propofol), then wait 30 seconds and intubate. Almost all children can be intubated easily without relaxant as long as you give the lignocaine enough time to work, and you have used an adequate induction. I use much higher doses of propofol 5-7mg/kg to acheive this. Hypotension in children is rarely an issue.

2. Get child to breath spontaneously during case (no relaxant used) and give enough narcotic (I use morphine upto 0.2mg/kg for simple tonsils and 0.1mg/kg for sleep apnea children) to get respiration rate down to the low teens before emergence.

The combination of lignocaine on cords and generous narcotic doses means a later waking time (my registrar often takes the patient out to recovery still intubated while I get started on the next case) but a much smoother waking.

[Pascal]

I do some things differently.  I give no premedication.  Use same induction with nitous oxide and sevoflurane.  Place cannula after induction with a nurse holding the mask.  I use pethidine for analgesia 1 - 2 mg /Kg and atracurium 0.3 - 0.5mg /Kg, turn off the nitrous oxide and ventilate with oxygen and sevo just before intubation.

I extubate immediately the operation is finished thus avoiding emergence laryngeal spasm.  The surgeon always applies suction and haemostasis so I don't suck out any more unless necessary thus avoiding overstimulation.  I give reversal drugs just before extubation then sit at the top of the table ventilating the lungs with oxygen thus maintaining good oxygenation and getting rid of sevoflurane.

I transfer to the trolley after patient is breathing well.

Usually not too many problems.  One case only of clot in the trachea - quite worrying at the time as it caused complete obstruction.  Reintubated and it came out when I re-extubated.

[ladyapol03]

I think, based on their child's experience, only one third of the parents approved of day-case tonsillectomy in principle, a finding which has implications for the instigation of day-case tonsillectomy procedures.




_________________
International medical insurance

[dhanvantri]

all the drugs you are using are short acting ones ,emergence reactions are definitely going to be high as there is no residual effect of either fentanyl ,propofol or sevoflurane.
midazolam premedication - 1 mg in children will give adequate amnesia,and help prevent emergencce reactions from sevoflurane
fentanyl can be topped up after 45 minutes.this will help you to cut sevo well in time and prevent hemodyanamic response to our suctioning under vision.it also supresses upper airway reflex-so no need of xylocard before extubation and the child also tolerates tube better once he comes out of relaxant
we use atracurium....as recovery is complete and safe of recurarization for short procedures.
and we do give fliuds for tonsillectomies...........adequate hydration is necessary to prevent ponv.

[Dr. Mian]

Some good techniques, mine is most similar to gasman's:

- rarely premedicate (midaz only if pt bouncing off the walls and then only 0.25   Mg/kg)

- inhalation induction followed by PIV and IV propofol (high dose ~ 5 mg/kg), no NMBD, oral RAETT

- maintenance with o2+n2o+sevo (titrated to hemodynamic parameters)+morphine (~0.5 mg/kg) on vent

- extubation after suctioning stomach, when pt SV (RR in teens), and ET sevo at 0.3

Usually gives good results: postop pain well managed with IV meperidine 5 mg boluses or Tylenol with codeine syrup

[Dr. Mian]

Correction I usually give morphine 0.05-0.1 mg/kg

[ha7271]

My recipe works very well:

- inhalational induction sevo/nitrous, no premedication
- insert IV cannula
- 5mg/kg propofol, 0.1mg/kg morphine
- intubate (RAE) with no relaxant
- get the child to breath as soon as possible
- surgery is usually 15 minutes
- once done switch to 100% oxygen and sevo, put patient on the side, make sure patient is breathing well, remove the tube without suctioning (since the surgeon has done all that) quickly while the patient is pausing his breath at the end of expiration
- once patient is awake in recovery, can get another 0.1mg/kg of morphine
- decadron intraoperatively