Emergency agitation during extubation in pediatric patient

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Emergency agitation during extubation in
pediatric patient

• R1???/VS???

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Schedule of adenoidectomy

• Premedication
• Induction Sevoflurane, Ketamine, Fentanyl.
• Maintenances Sevoflurane, Desflurane
• Emergence Stimulation, Agitation, Crying,
• Laryngospasm
• Post OP care Nalbuphine.

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Outline

• Definition Emergence agitation
• Risk factor
• Anesthesia
• Emergence, extubation and laryngospasm

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Emergence agitation (EA)

• Do not recognize or identify familiar objects or
  people and hypersensitivity to stimuli and
  hyperactive motor behavior in the immediate
  postanesthesia period (lt30 min).
• Self-limited (515 min), and often resolves
  spontaneously

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Risk factor-Patient

• 2-5 yrs in 30-50.
• Brain maturation period decline in
  norepinephrine, acetylcholine, dopamine, and
  GABA.
• 
  Martini DR. J Am Acad Child Adolesc Psychiatry
  2005
• Preoperative anxiety
• ?Midazolam(PO)0.5mg/kg (SEVO67?39)
• Lapin SL. Paediatr
  Anaesth 1999

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Risk factor- Surgery

• Surgery type Head and neck.
• Inadequate pain relief
• ?Ketorolac(IV)1mg/kgSEVO38 ?14. Anesth
  Analg 1999
• ?Clonidine(IV)3µg/kg5
• Clonidine(caudally)3µg/kg0 Br J Anaesth
  2002
• ?Dexmedetomidine(IV)0.3µg/kg37 ?17. Anesth
  Analg 2004
• ?Fantanyl(IV)1µg/kg56 ?12. Anesth Analg 2003
• Fantanyl(Intranasal)2µg/kg46 ?15. Anesth
  Analg 2001

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Premedication

• Midazolam(PO)0.5mg/kg
• Clonidine (PO)4µg/kg
• Dexmedetomidine(Intranasal)1µg/kg
• ?a2-agonist less perioperative sympathetic
  stimulation and postoperative pain
• 
  Paediatr Anaesth 1999
• Fentanyl(oral transmucosal)1520 µg/kg
  Midazolam(PO)0.5 mg/kg
• ? Fentanyl gt Midazolam
• 
  Anaesthesia 2002

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Anesthesia

• Less soluble, inhaled anesthetics Sevoflurane
  and desflurane.
• CNS irritation by volatile anesthesia
  electroencephalogram change.
• ? SEVO, DES, ISO
• 
  Eur J Anaesthesiol 2004 / Br J Anaesth
  1996.
• ?Sevoflurane Propofol Paediatr Anaesth 1999
• ?Isoflurane Propofol Br J Anaesth 1996

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Post operative care

• Reuniting with a parent
• Analgesics Fentanyl(IV)1-2µg/kg
• BZDs Midazolam(IV)0.02-0.1mg/kg
• Hypnotics Propofol(IV)0.5-1.0mg/kg

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• If laryngospasm

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Laryngospasm

• Internal branch of the superior laryngeal.
• ?Protect the airway during swallowing.
• Laryngospasm abnormal excitation.
• Sign Inspiratory stridor (partial), absence of
  breath sounds(complete), tracheal tug,
  paradoxical movement of the chest and abdomen are
  noticed, desaturation, bradycardia and central
  cyanosis.

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Risk factor-Patient

• Agelt5yrs 68
• Upper respiratory tract infection or active
  asthma10X
• ?Airway hyperactivity lasts for up to 6 weeks.
• Chronic smokers
• ?Abstinence period least 48 h possibly up to 10
  days.

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Risk factor- Surgery

• Tonsillectomy and adenoidectomy have the highest
  incidence of laryngospasm (2126)

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Anesthesia-Induction

• Insufficient depth of anesthesia during both
  inductionlaryngoscope blade.
• Drug Thiopentone gtKetamine, Propofol.
• _at_ Ketamine hypersalivation
• Less experienced anesthesiologists.

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Anesthesia

• Volatile anesthetics
• Sevoflurane gt Isoflurane gt Desflurane.
• Emergence Mucus or blood and airway manipulation
  with suction catheter.

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Prevention
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(No Transcript)
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Treatment
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Laryngospasm notch
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Summary

• Identify risk factors
• Premedication
• Treatment
• ?EA Fentanyl(IV)1-2µg/kg
• BZDs Midazolam(IV)0.02-0.1mg/kg
• Propofol(IV)0.5-1.0mg/kg.
• ?Laryngospasm
• Intermittern positive ventilation, deepen the
  level of anesthesia, re-intubation.

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References

• Laryngospasm review of different prevention and
  treatment modalities
• Pediatric Anesthesia 2008 18 281288
• Emergence Delirium in Children Many Questions,
  Few Answers
• Anesth Analg 200710484 91