From Chuck Pribble MD Primary Children's Hospital, Heart Center, Salt Lake City, UT.
I read Ruchika Smarma’s post on pre oxygenation in kids for nasal intubations and specifically those with CHD (Nov 10, 2023 PAAD reader response. I read Susan’s response also and it points toward success with videolaryngoscopy. We began nasal intubation for all neonates having cardiac surgery in January 2019 in a QI project looking at feeding outcomes. While we were all used to doing nasal intubation in older kids for dental surgeries, intubating neonates proved a bit more difficult and the issue of keeping the sats in a livable range in kids with CHD proved troublesome at first. I had never done one until this study, yet as the PI, I thought I better get good at it quickly. To solve the issue of preoxygenation and keeping sats up, I would intubate orally after induction. This had three advantages. First, it took away the stress of getting the nasal tube in atraumatically in a short time. As you can imagine, if any bleeding was encountered in ramming the tube in, it doesn’t get better with 400 units/kg of heparin. If this occurred, it would have been the death of the QI project. One case cancelled because of nasal hemorrhage and that would have done it. Second, it allowed me to size the airway for the ultimate (nasal) ETT I would place. While we tend to use 3.0 ETT for neonates, there are some bigger neonates that would do well with a 3.5 and this allowed us to put a 3.5 in and test a leak. If no acceptable leak, then we would use a 3.0 for the nasal tube. Third, by having a secure airway in place, I would then put in all PIVs, arterial line, and central line. While I was doing this, I was preparing the nose with vasoconstrictor spray and dilating with progressively larger nasal trumpets. Then when all the lines were in, I would pass the ETT through the nose and was able to take my time getting the best possible visualization of both the oral ETT and the end of the nasal ETT before the RN would pull the oral out and I would use Magills to inch the nasal tube through the cords. This takes practice but really decreased the stress of getting the nasal tube in quickly and atraumatically.
To make a long story short, the QI project was published in July 2022 in PCCM and nasal ETTs are now the standard of care at our hospital. In summary, feeding outcomes have been improved with the early introduction of speech therpay on POD#1 where with an oral ETT, they did not begin until after extubation. We are now over 300 kids into this and it has become my passion.
So again, sorry for the late entry and I know this is way too long to be a decent response but wanted to just communicate with you on a small niche of the ped anesthesia world.
Reference
Marietta J, Glotzbach KL, Jones CE, Ou Z, Profsky TK, Clegg D, Winder MM, Pribble CG. Assessing the Impact of Nasotracheal Intubation on Postoperative Neonates With Congenital Heart Disease: A Quality Improvement Project at a Single Heart Center. Pediatr Crit Care Med. 2022 Jul 1;23(7):e338-e346. doi: 10.1097/PCC.0000000000002958. Epub 2022 Apr 19. PMID: 35439234.
I received multiple reader responses to the December 8th PAAD: Respiratory adverse events after LMA removal: Does the anesthetic make a difference? YES!! Here is a sample:
From Dr. Peter Howe, Clin Assoc Professor, Dept of Paediatrics, University of Melbourne, Staff anaesthetist, Supervisor of Training, Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville Victoria 3052
My TIVA journey began when my 17yo son had two anaesthetics for hernia repair, 3 months apart. The first was sevo based, two antiemetics, no problems perceived. The second was TIVA. My son is a quiet lad and I was surprised when he volunteered aspects of his experience: 'I feel more alert, even thought I know I keep falling back to sleep.' 'Last time they brought me Vegemite toast post op and I didn't want it (a big shock in our family). This time I'm quite hungry! (a phrase that made his nurse laugh at his understatement as he tackled his 5th successive packet of sandwiches').The 3rd memorable comment: "I JUST FEEL BETTER !!)
From Rita Agarwal Stanford University
I stopped using sevo as my primary anesthetic many, many years ago. It is better for the environment (maybe) when used judiciously, less PONV, less delirium and repeatedly studies demonstrate less airway reactivity and laryngospasm.
I will often supplement propofol with low dose sevo to prevent movement when neuromuscular blockade is not needed or is contraindicated. I still prefer my patients with supraglottic airway in place to breathe spontaneously or with pressure support so will not paralyze them.
From Bevan Londergan Vanderbilt University
In reading this interesting article it occurred to me that 8 laryngospasms in 134 anesthetics with an LMA is a lot – and in fact it’s worse than that, it was 7 laryngospasms in 69 patients for the sevoflurane arm. As most anesthesiologists have observed in their own practice, the rate of complications observed with LMA airway management is influenced by technique and anesthetic strategy. This study specifically considered awake removal of the LMA and therefore excluded from its possible scope of conclusion the rate of airway complication with deep LMA removal for either maintenance strategy. This study suggests that sevoflurane maintenance and awake LMA removal may be a suboptimal combination of strategy and technique that increases the risk of laryngospasm, and that propofol TIVA may be a preferred maintenance strategy IF an awake removal of the LMA is desired. I didn’t find that this study swayed me in the overall sevo vs. propofol maintenance debate, rather it isolated and highlighted a technique/strategy combination that can be problematic.
From Anonymous
Great PAAD! I am a former PICU fellow at a major Eastern Children’s Hospital program and current CA1 anesthesiology resident (I am pursuing dual training pathway; 7 yrs down, 3 to go!). Please forgive any naivete on the topic as just random musings from an enthusiastic forever-trainee.
I have found that attendings have often intensely different preferences from each other when it comes to the topic of TIVA vs gas. I wonder how Dr. Fiadjoe handles the concept of "pure TIVA" vs the so-called "dirty TIVA" (TIVA plus some background gas) in children).
This is fresh in my mind. Last week I started a Functional Endoscopic Sinus Ssurgery (FESS) case in an ENT room and worked with 3 separate anesthesia attendings over the course of the 2-hour case (owing to that delightful 5P-7P window when attendings have their own different levels of relief i.e. "late call" vs "call call"). This therefore allowed a single patient to be his own case-control for 3 different anesthesia strategies - somewhat annoying at the time, but educationally interesting.
Attending #1 was in favor of pure TIVA (propofol/remifentanyl with a dose of rocuronium given the delicate anatomy of a FESS and desire to avoid stroke or hemorrhage with unintended patient movement). Attending #1 did not want any "background" gas (ie a "dirty TIVA") due to the perception that any gas might lead to a less smooth wakeup, cause retching, and, in turn, a CSF leak. Reasonable. I hear this argument from attendings about TIVA all the time and it usually bears out.
Attending #1 was sent home, making way for Attending #2 to come in and independently turn on 0.2 or 0.4% sevo in the background. Attending #2's belief was that TIVA is an inherently dangerous mode of anesthesia (e.g. IV might slowly fail under the drapes/tucked arms unbeknownst to you; if a bite block is not in place, one may find oneself unable to ventilate the patient and potentially arrest on the OR table) - so better safe than sorry with some background sevo as insurance. Furthermore, 0.2-0.4% likely won't cause too much nausea. Also reasonable.
Attending #2 was sent home. Attending #3 came in and asked, "What the hell do you think you're doing with your anesthesia plan?" Oh, the joys of being an eternal trainee! He felt it was nonsensical to mix general anesthetic strategies. You either 1) believe in your TIVA (and believe in your ability to monitor its efficacy/titration with questionable neuromonitoring) and increase your propofol dosing (while hoping that the reason you are increasing the dose isn't because the propofol is leaking out onto the table), or 2) you believe in your volatile gas and the more reliable end-tidal gas displayed on the monitor. While this attending does routinely use TIVA for select neurosurgical cases, he largely avoids TIVA in almost all other cases. He also largely rejects the notion that TIVA is associated with a smoother emergence. I'm not saying that I agree (TIVA clearly seems like a smoother wake up to me), but of course as a trainee you toggle back and forth between attendings who praise TIVAs smooth emergence, and others who categorically deny a difference. As a learner, you just have to gather data, bask in the privilege of hearing these different schools of thought, and figure out how you want to practice in the future. Needless to say, he turned off the TIVA and switched to sevoflurane.
I appreciate all three approaches. However, in my early juvenile CA1 months, I have come to believe that, if one chooses a TIVA-based strategy, there can be no compromises to safety. This sounds obvious, but often these compromises are often made. Ostensibly, our approach to TIVA is to place 2x peripheral IVs to have immediate backup access in case one IV fails. However, I admit that many attendings are often perfectly satisfied with 1 well-functioning PIV, thereby introducing some clinical risk if that 1 IV fails. Ostensibly, a bite block is placed during TIVA cases in the event of IV failure (or insufficient anesthesia) to prevent a "can't ventilate" situation. However, a bite block is often not placed until the end of the case ("high doses of remifentanyl provide sufficient akinesis"), introducing yet additional clinical risk. Finally, it is additionally difficult to marry oneself to neuromonitoring (e.g. a BIS monitor) that is not always accurate and fraught with its own limitations. For those reasons, I personally feel that a small amount of background volatile anesthetic to TIVA is a reasonable approach. That might change as I grow up and develop a more fully formed anesthesia frontal lobe.
On the one hand, children's smaller blood vessels and smaller PIV gauges introduce even more risk for IV/TIVA failure compared to the gigantic IVs used in adults. So maybe gas is inherently less risky in that regard. Conversely, as children have an increased propensity to laryngospasm compared to adults, the smoother awakening observed with TIVA compared to gas may be more desirable - aka the entire point of the PAAD article reviewed here. Dr. Fiadjoe comments that the increased respiratory events associated with sevoflurane are more a nuisance than harmful. However, complications associated with TIVA failure (e.g. PIV loss, underappreciation of underdosed anesthesia due to neuromonitoring limitations) likely represent more harm than nuisance. The risk-benefit of the two anesthetic strategies is pretty fascinating.
Again, please forgive any and all naivete on the part of this new anesthesia learner. However, I have been struck by the wide variety of opinions surrounding this topic, albeit in an adult hospital.