Postoperative problems - Emergence Delirium Emergence Delirium by dfsdf224s

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									   Common Postoperative
Problems In Pediatric Anesthesia
                                                        A 5 year old girl wakes up post T&A very
                                                        agitated and pulls out her IV on the way to
                                                        the recovery room. She is thrashing and
                                                        very disoriented. What is your management
            Linda J. Mason, M.D.                        strategy?
  Professor of Anesthesiology and Pediatrics
            Loma Linda University

  Emergence Delirium                                       Anesthetic Agents Associated with
                                                           Emergence Delirium
 • Dissociated state of consciousness, child is            •   Inhalational agents
   inconsolable, irritable, uncooperative or
   uncompromising - characterized by thrashing,            •   Atropine or scopolamine
   crying, moaning or incoherent                           •   Ketamine
 • Paranoid ideation                                       •   Droperidol
 • Usually self limiting (5-15 min) but can result in      •   Barbiturates
   physical harm to child or caretaker
                                                           •   Benzodiazepines

  Emergence Delirium                                       Emergence Delirium
  Incidence                                                Etiology
                                                           • Agents with rapid emergence profile
• All patients - 5.3%                                        - sevoflurane, desflurane?
• Children 12-13%                                          • Lack of pain control?
• With inhalational agents 2-55%

  Decreased Incidence of Emergence                                    Emergence Delirium and Regional
  Delirium with Pain Control
• Ketorolac decreased ED 3-4 fold after myringotomy
  with halothane or sevoflurane.                                      • Effective regional analgesia
    Davis PJ, et al. Anesth Analg 1999;88:34-38.                      • Most frequently seen in preschool
• Fentanyl 2.5 µg/kg IV or 2 µg/kg intranasal decreased                 children 1-5 years
    Cohen IT, et al. Anesth Analg 2001;93:88-91.
                                                                      • Lasts 5-15 minutes, often resolved
    Finkel JC, et al. Anesth Analg 2001;92:1164-1168                    spontaneously.
                                                                               Aono, et al. Anesthesiology 1997;87:1298-1300

  Emergence Delirium and No                                           Emergence Delirium and
  Surgery                                                             Adequate Pain Control
 • General anesthesia for MRI. ED - 33% sevoflurane,               • It is difficult to differentiate pain related agitation to
   0% halothane.                                                     other sources
       Cravero JP, et al. Paediatric Anaesthesia 2000;10:419-424
                                                                   • Pain may be a contributing factor but there are other
 • MRI with sevoflurane and fentanyl 1 µg/kg - ED-                   causes
   12%, placebo - 56%.
                                                                   • Pain management is important in short surgical cases
       Cravero JP, et al. Anesth Analg 2003;97:364-367
                                                                     where peak onset of analgesics may be after patient is

   Anesthetic Technique and                                           Agents to Decrease Emergence
   Emergence Delirium                                                 Delirium
                                                                     • Clonidine 2 mcg/kg IV
                                                                        –   40 male children age 2-7 years, circumcision
• Propofol vs sevoflurane - ED - 0% vs 38%.                             –   Penile nerve block
                                                                        –   Placebo - 16 with ED, severe in 6
  Sevoflurane shorter PACU stay.
                                                                        –   Clonidine - 2 with ED.
      Uezono S, et al. Anesth Analg 2000;91:563-566                           Kulka PJ, et al. Anesth Analg 2001;93:335-338
• Sevoflurane vs propofol - 23.1% vs 3.7%.                           • Oral clonidine or midazolam - decreased incidence ED -
                                                                       slower awakening?
     Cohen IT, et al. Anesth Analg 2000;90:S354
                                                                             Lapin SL, et al. Paediatr Anaesth 1999;9:299-304.
                                                                             Fazi L, et al. Anesth Analg 2001;92:56-61

  Emergence Agitation                                                                    Dexmedetomidine Decreases Emergence
                                                                                         Agitation in Pediatric Patients After
• Single dose of IV dexmedetomidine, 0.3 µg/kg after                                     Sevoflurane Anesthesia Without Surgery
  induction and maintenance of anesthesia with
  sevoflurane plus caudal blockade
• Decreased emergence agitation with no adverse                                                      Berrin Isik, M.D.
  effects                                                                                          Mustafa Arslan, M.D.
       Ibacache ME et al. Anesth Analg 2004;98:60-3                                              Alper Dogan Tunga, M.D.
                                                                                                   Omer Kurtipek, M.D.

                                                                                                                     Pediatric Anesthesia 2006;16:748-53.

                                                                                         Does Dexmedetomidine Prevent
           Data                                                                          Emergence Delirium in Children After
  • 42 children (ASA I-II, 18 months to 10 yrs) undergoing MRI                           Sevoflurane-based General Anesthesia?
  • After induction with sevoflurane patients received
    dexmedetomidine 1 ug/kg (D) or placebo (P)
  • Time to removal of LMA and eye opening was longer in
    dexmedetomidine group                                                                         Mohanad Shukry, M.D.
  • Incidence of emergence agitation was 47.6% in Group P and                                     Mathison C. Clyde, B.S.
    4.8% in Group D
                                   Isik B, et al. Pediatric Anesthesia 2006;16:748-53.
                                   Isik B, et al. Pediatric Anesthesia 2006;16:748-53.
                                                                                                 Philip L. Kalarickal, M.D.
                                                                                                 Usha Ramadhyani, MBBS

                                                                                                             Pediatric Anesthesia 2005;15:1098-1104.

  • Inhalation induction sevoflurane, airway secured
  • 5 min after securing airway - 0.2 ug/kg/hr infusion of
    dexmedetomidine (Group D) or saline ( Group S) infused
  • BIS 40 to 60                                                                                             QuickTime™ and a
                                                                                                   TIFF (Uncompressed) decompressor
                                                                                                      are needed to see this picture.

  • Infusion maintained 15 min into recovery
  • ED was 26% in Group D vs 60.8% in Group S

               Shukry M, et al. Pediatric Anesthesia 2005;15:1098-1104.

                                                                               Emergence Agitation

                                                                     • Dexmedetomidine 0.5 µg/kg decreased
                                                                       agitatation due to sedation and analgesia in
                                QuickTime™ and a
                    TIFF (Uncompressed) decompressor
                        are needed to see this picture.
                                                                       tonsillectomy patients
                                                                         Guler G et al. Pediatric Anesthesia 2005;15:762-6

  Premedication and Emergence                                         Theories About Emergence
  Delirium                                                            Delirium
                                                                  • Sevoflurane has a biphasic effect on GABAA receptor mediated
                                                                    inhibitory postsynaptic currents (IPSCss)
                                                                     – Low concentrations - inhibit, high concentrations - potentiate
• Oral midazolam 0.2 mg/kg and sevoflurane                        • Propofol induction potentiates GABAA - IPSCss and results in
  anesthesia                                                        calmer patients
  – ED-47%                                                        • Benzodiazepines may also potentiate inhibitory effects of
                                                                    GABAA receptors.
  – Placebo - 81%.                                                      Hapfelmeier G, et al. Eur J Anaesthesiol 2001;18:377-383
                                                                        Olsen RW, et al. Life Sci 1986;39:1969-1976
           Ko Y, et al. Acta Anaesthesiol Scand 2001;39:169-177

  Age Differences with Emergence                                       Premedication and Emergence
  Delirium                                                             Delirium
                                                                  • No difference in premedication with midazolam in ED
• Most likely in children less than 5 years of age with             incidence.
  sevoflurane anesthesia
• As child ages GABAA receptor becomes inhibitory rather
                                                                        Kain ZN, et al. Anesthesiology 1998;89:1147-1156
  than excitatory as it is in the postnatal period.               • Benzodiazepines have been associated with agitation
                                                                    reversed with flumazenil.
      Ben-Ari Y, et al. Prog Brain Res 1994;102:261-273
• Developmental differences in neurotransmitters and                           Thurston TA, et al. Anesth Analg 1996;83:192
  neuromodulators may account for age-related differences.

A Prospective Cohort Study of Emergence
Agitation in the Pediatric Postanesthesia
Care Unit.                                             • 521 children, age 3-7, outpatient procedures
                                                       • 18% had emergence agitation
                                                       • Mean duration - 14 minutes (up to 45 minutes)
 Voepel-Lewis T, Malviya S, Tait AR.
                                                       • 52% with agitation required pharmacologic
    Anesth Analg 2003;96:1625-1630.                      intervention prolonging PAR stay
                                                       • 5 adverse events

 Ten Factors Associated With Emergence                       Independent Risk Factors for
 Agitation                                                   Emergence Agitation
1) Younger age (4.8 vs 5.9 years)
2) No previous surgery
3) Poor adaptability
4) Ophthalmology procedures                                1)   Otorhinolaryngology procedures
5) Otorhinolaryngology procedures
6) Sevoflurane                                             2)   Time to awakening
7) Isoflurane
8) Sevoflurane/Isoflurane (2 x as likely to have EA)
                                                           3)   Isoflurane
9) Analgesics (98% vs 86%)
10) Short time to awakening

                                                           Pediatric Anesthesia Emergence
 Other Factors                                                Delirium Scale
                                                           1. The child makes eye contact with the caregiver
• Premedication with midazolam or no                       2. The child’s actions are purposeful
  premedication had the same incidence of EA               3. The child is aware of his/her surroundings
                                                           4. The child is restless
  in both groups
                                                           5. The child is inconsolable
• Temperament and emergence outcomes need                  Items 1,2,3 reversed scored : not at all(4), just a little(3),
  to be studied                                               quite a bit(2) very much(1), extremely(0)
                                                           Items 4,5 scored: not at all(0), just a little(1), quite a bit(2),
                                                              very much(3) extremely (4)
                                                                                                   Sikich,N, Lerman J
                                                                                                   Anesthesiology in press

The Effect of Caudal Analgesia on                            • 80 children 12 mo-6 yr undergoing inguinal hernia repair
Emergence Agitation in Children                              • Oral midazolam, mask induction, caudal analgesia halothane or
after Sevoflurane Versus Halothane                           • EA greater after 5 min in PACU with sevoflurane (26% vs 6%) but
                                                               no time later in PACU stay
Anesthesia                                                   • Brief, more agitation with higher preop anxiety, difficult mask
                                                             • Combination of premedication and effective postop analgesia
    B. Craig Weldon et al. Anesth Analg                        minimizes EA.

                                                              Differential Diagnosis of
 Treatment of Emergence Delirium
                                                              Emergence Delirium
• Wait                                                          •   Hypoxia
• Propofol (0.5 mg/kgIV) or midazolam (0.02                     •   Hypercarbia
  mg/kgIV)                                                      •   Hypotension
• Paradoxical reaction to midazolam                             •   Hypoglycemia
  – Flumazenil 0.01 mg/kg IV (max 0.2 mg dose at 1-2 min
    intervals to a maximum of 1 mg)
                                                                •   Increased ICP
  – Flumazenil 0.2 mg/dose at 1-2 min intervals to a total      •   Bladder Distention
    dose of 1 mg in children greater than 12 years

You are called back to the                                    Complications
recovery room for a 4 year old
male post orchidopexy who is                                        •   Upper Airway Obstruction
experiencing oxygen desaturation                                    •   Laryngospasm
                                                                    •   Post Intubation Croup
and noisy breathing. What is your
                                                                    •   Bronchospasm
differential diagnosis and plan of
                                                                    •   Aspiration

“Never Confuse Movement                                        Upper Airway Obstruction
with Action”
                                                             • Common in children - larger amount of
                                                               airway soft tissue (tonsils, adenoids)
                         Ernest Hemingway                    • Residual inhalational anesthetics cause
                                                               persistent pharyngeal muscle hypotonia and
                                                               posterior displacement of the tongue

  Which Airway Maneuvers Work Best?                          Where Does Airway Obstruction Occur?
                                                             • Propofol- airway narrowing occurs throughout the
• Adding CPAP of 10 cm of H2O to chin lift or jaw              upper airway but is most pronounced in the
  thrust improved upper airway patency and decreased           hypopharnyx at the level of the epiglottis
  stridor-score.                                             • May depend on depth of anesthesia
          Meier S, et al. Anesth Analg 2002;94:494-499.
                                                               -Light anesthesia - obstruction at the soft palate
• Jaw thrust was more effective in children with
  adenoidal hyperplasia with or without CPAP 5 cm of           -Deep anesthesia-soft palate and epiglottis collapse
  H2O.                                                         -Obstruction occurs at more than one anatomic site
          Bruppacher H, et al. Anesth Analg 2003;97:29-34.                  Evans et al. Anesthesiology 2003;99:596-602

Laryngospasm                                                 Complications of Laryngospasm

                                                                •   Hypoxia
                                                                •   Bronchospasm
• Incidence
                                                                •   Gastric aspiration
   – 8.7/1000 - total population
                                                                •   Arrhythmias
   – 17.4/1000 - age 0 - 9 years
                                                                •   Pulmonary edema
   – 3x rate of any age group - 1 - 3 months
                                                                •   5/1000 have cardiac arrest

           Laryngospasm                                                                   Laryngospasm - Etiology
• Most common is children less than 2 years of age                             • Glottic or subglottic mucosal stimulation
• Equal in ASA PS 1-2 and 3-5
                                                                               • Risk factors
• One third had URI or copious secretions                                        – Age
• 20% had negative pressure pulmonary edema                                      – NG tube or oral airway placement
• One third occurred during induction, majority no IV present                    – URI
  requiring IM succinylcholine                                                   – Endoscopy or esophagoscopy
• Two thirds occurred during emergence or transport                              – Volatile anesthetics (induction with desflurane or
• An IV can be helpful, intubate as soon as possible                               isoflurane)
           Bhananker SM et al. Anesth Analg 2007;105:344-50
           Bhananker SM et al. Anesth Analg 2007;105:344-50

                                                                               • Can occur in PAR if patient has undergone
                                                                                 “deep extubation”
                                                                               • Increased in children with URI
                                                                               • Increased in children with exposure to
                                                                                 environmental tobacco smoke
                                                                               • Not decreased with URI and LMA use

                                      Fink BR, Anesthesiology 1956;17:569-77

Do Children Who Experience                                                                  Data
Laryngospasm Have and Increased Risk
of Upper Respiratory Tract Infection?
                                                                                   • 15,183 day surgery patients
              Mark S. Schreiner, M.D.,                                             • Development of laryngospasm
                Irene O’Hara, M.D.,                                                   – 2.05 x more likely to have URI
            Dorothea A.Markakis, M.D.,                                                – Younger
           George D. Politis, M.D., M.P.H.                                            – Undergoing airway surgery
                                   Anesthesiology, 1996;85:475-80

Use of the Laryngeal Mask Airway in
Children With Upper Respiratory Tract                                   Data
Infections: a Comparison With Endotracheal
Intubation                                                      • 82 patients - elective surgery with URI
                                                                • Risk of laryngospasm equal with LMA
  Alan R Tait, PhD, Uma A Pandit, M.D., Terri                     use or intubation
          Voepel-Lewis, BSN, MS et al                           • Bronchospasm higher in the intubated
                                Anesth Analg 1998;86:706-11

Environmental Tobacco Smoke: A                                         Data
Risk Factor for Pediatric
Laryngospasm                                                   • 310 children ASA I outpatients
                                                               • Risk of laryngospasm
          Naren Lakshmipathy, M.D.,                               – Exposed to environmental tobacco smoke 9.4%
                                                                  – No exposure - 0.9%
           Paula M Bokesch, M.D.,
                                                               • All occurred on emergence
           Douglas E Cowan, M.D.
                                                               • Higher if source of passive smoke was maternal
                                  Anesth Anal 1996;82:724-7

Awake vs Deep Extubation ?
                                                              The Incidence of Laryngospasm with a
                                                              “No Touch” Extubation Technique
• 70 children 2 - 8 years
  – No difference in laryngospasm
                                                              After Tonsillectomy and Adenoidectomy
           Patel RI, et al Anesth Analg 1991;73:266-270

• Children 1- 4 years                                               Ban C. H. Tsui, MD, MSc, FRCP(C),
  – No difference in laryngospasm
                                                                            Alese Wagner, BSc,
  – Awake extubation more oxygen hemoglobin
    desaturation < 90%                                               Dominic Cave, MB, FRCP(C) et al.
           Pounder DR, et al Anesthesiologt 1991;74:653-5
                                                                                        Anesth Analg 2004;98:327-9

            Data                                                    Laryngospasm Management - 1
• Incidence of laryngospasm is 21-26% after T&A
• 20 children age 5-15 years
• Propofol induction (3-5 mg/kg), mivacurium (.3mg/kg),             •   Complete or incomplete obstruction
  morphine (0.15 mg/kg), ondansetron (0.15 mg/kg) and               •   Initial jaw thrust and chin lift
  dexamethasone (.2mg/kg)
• Desflurane and nitrous oxide discontinued after patient turned    •   100% O2 with gentle positive pressure
  in lateral position, spontaneous ventilation resumed
• No stimulation until patients woke up
• Extubated when patients opened their eyes (7.7 min)
• No laryngospasm, coughing or oxygen saturation < 92%

  Laryngospasm Management - 2                                      Laryngospasm Management - 3

 • Complete airway obstruction                                     • IV access present
                                                                     – Succinylcholine 0.5 - 1 mg/kg with
    – Positive pressure will make it worse
                                                                       atropine .02 mg/kg
       • Dilutes anesthetic gases
       • Forces air into stomach with decreased                      – No IV access
         ventilation or regurgitation                                    • Succinylcholine 4 mg/kg IM in deltoid

               Treatment of Laryngospasm                      Laryngospasm - Prevention
• Apply CPAP
• Specialized airway maneuvers
  Pressure in layngospasm notch
                                                                • Suction only when deeply anesthetized
  Pull mandible forward                                         • IV lidocaine 2 mg/kg - one minute before
• IV access-succinylcholine 1-2 mg/kg(?0.1-0.5 mg/kg) and         extubation - to be effective must be given
  atropine 0.02 mg/kg or consider propofol 0.5-0.8 mg/kg(         before swallowing begins
  incomplete airway obstruction)
• No IV access- succinylcholine 3-4 mg/kg IM with atropine
                                                                                         Leicht P, et al
  0.02 mg/kg IM                                                                          Anesth Analg 1985;64:1193-96
• Intubate as necessary

    Post Intubation Croup                                       Post Intubation Croup - Course and
     • Incidence 1-6% of pediatric cases                     • Symptomatic in first hour, maximum of 4 hours,
     • Contributing factors                                    resolves in 24 hours.
        –   Traumatic repeated intubations
                                                             • Humidified oxygen
        –   Coughing or “bucking” on ET tube
        –   Changing position after intubation
                                                             • Nebulized racemic epinephrine (0.25-0.5 ml of a
        –   Trisomy 21
                                                               2.25% solution)
        –   Surgery greater than 1 hour                      • Steroids - dexamethasone 0.3-0.4 mg/kg
        –   Surgery of the head and neck                     • Helium/oxygen (70%/30%) in patients with subglottic
        –   Tight fitting ET tube (air leak >25 cm H2O)
                                                    2          stenosis

   Post Intubation Croup - Discharge                           Bronchospasm
   to Home?
                                                               • Increased risk in asthmatics, URI’s,
• Watch for rebound edema after racemic epinephrine
  use-keep 2 hours after last treatment
                                                                 especially with intubation, ex-premature
• Physicians and parents agree on ability of parents to
                                                                 with BPD
  care for and observe patient at home.                        • Seen in anaphylaxis, histamine release,
• Where to return if respiratory distress worsens at             mucous plugging, aspiration.

  Bronchodilator Premedication Does                            Data
  Not Decrease Respiratory Adverse
  Events in Pediatric General                             • ASA I-II age 2 m -18 yr
  Anesthesia.                                             • URI in preceding 6 weeks (76) active URI in the
                                                            preceding 7 days (21)
                                                          • Pretreatment with inhaled ipratroprium or albuterol
                                                            prior to anesthesia did not demonstrate a decrease in
                  Elwood T, Morris W, et al.                airway problems (desaturation, laryngospasm and
                  Can J Anesth 2003;50:277-284              bronchospasm)

  Treatment of Bronchospasm                                History of this presentation
                                                           •   Initial form completed 9/10/2003
    • Oxygen                                               •   Updated 9/29/2003
    • Nebulized ß agonists (albuterol or                   •   Corrected 10/21/03
      metoproterenol)                                      •   New slides added and corrected 12/28/2003
    • Terbutaline (MDI or SC)                              •   Animation 2/1/2004
    • Epinephrine 0.01 ml/kg (IV or SC)                    •   Editing and additions on 7/22/08
    • Steroids                                             •    Revised 10/07/08


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