Anesthesia for Pediatric Airway Surgery
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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    History
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
    Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube. www.youtube.com/watch?v=jFQr2eqm3Cg.
    Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.
    Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.
    Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.
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Anesthesia for Pediatric Airway Surgery Presentation Transcript

  • 1. Dr
Moataz
Abdelrahman
 Consultant
Paediatric
Anaesthetist
 Central
Manchester
University
Hospitals
 Royal
Manchester
Children’s
Hospital,
UK


  • 2. AIRWAY
SURGERY
   EQUIPMENT
   TECHNIQUES
   TUBELESS
AIRWAY
   ANAESTHESIA
   PROBLEMS
   ADVANTAGES
   DISADVANTAGES

  • 3. 
Surgical
procedures
of
the
larynx
and
trachea
in
 infants
and
children
present
special
problems
   Narrow
anatomical
field

   Aggravated
by
pathological
changes
 Shared
airway
   Adequate
oxygenation
   Cooperation

  • 4. REQUIREMENTS
FOR
PAEDIATRIC
AIRWAY
 SURGERY
   Special
equipment
   Sound
knowledge
of
the
airway
 ‐  Anatomy


‐
Physiology

‐
Pathology
   Tertiary
referral
centre
(whenever
possible)
   Excellent
communication
between
anaesthetic
 and
surgical
teams

  • 5. ACCESS
TO
THE
UPPER
AIRWAY
   Rigid
bronchoscopes
   Storz
ventilating
scope
±
Hopkin’s
rod
   Venturi
scope
(microtubes,
jet
ventilation)
   Fibreoptic
scope
   Hopkin’s
rod
without
bronchoscope

  • 6. Suction FGF Prism Light source 2.7 mm Telescope Hopkin’s Rod Light source
  • 7. Suggested
ETT
and
rigid
bronchoscope
 sizes
 Age
 Cricoid
 Tracheal
tube
 Bronchoscope
size
 diameter
 Size
ID
 ED
 Size
 ID
 ED
 Premature
 4.0
 2.5‐3.0
 3.5‐4.0
 2.5
 3.2
 4.0
 Term
 4.5‐5.0
 3.0‐3.5
 4.0‐4.9
 3.0
 4.2
 5.0
 6
months
 5.0
 3.5‐4.0
 4.9‐5.4
 3.0
 4.2
 5.0
 1
yr
 5.5
 4.0‐4.5
 5.4‐6.2
 3.5
 4.9
 5.7
 2
yr
 6.0
 4.5‐5.0
 6.2‐6.9
 3.5
 4.9
 5.7
 3
yr
 7.0
 5.0‐5.5
 6.9‐7.4
 4.0
 5.9
 6.7
 5
yr
 8.0
 5.5‐6.0
 7.4‐7.9
 5.0
 7.0
 7.8
 10
yr
 9.0
 6.5
cuff
 14
yr
 11.0
 6.5
cuff

  • 8. METHODS
FOR
AIRWAY
ANAESTHESIA
   Storz
   Spontaneous/IPPV
   Apnoeic
oxygenation
   Jet
ventilation
(supraglottic
and
subglottic)
   Sanders
 
 

Pneumothorax
   HFJV 
 
 

CO2
accumulation
   LFJV
   Tubeless
field 
 
 


  • 9. ANATOMICAL
DIFFERENCES
   Large
tongue
   Long
narrow
epiglottis
angled
posteriorly
   Obligatory
nasal
breathers
   Soft
high
anterior
larynx,
easily
displaced
   Narrowest
part
at
the
cricoid
ring
   Short
cricothyroid
membrane
   Difficult
cricothyroidotomy 


  • 10. Epig Aryepiglottic VC Arytenoid ETT Interarytenoid
  • 11. AIRWAY
PHYSIOLOGY
   Fixed
tidal
volume
   Minute
ventilation
depends
on
rate
   Diaphragmatic
breathing
   Fewer
type
I
muscle
fibres
   Early
fatigue
   FRC
less
than
closing
capacity
   Higher
metabolic
requirement
 
 
 
 

 HYPOXIA

  • 12. Infants
less
than
60
weeks
postconceptual
age
are
 at
high
risk
of
developing
apnoea
especially
if
 ex‐premature

  • 13. PROCEDURES
ON
THE
AIRWAY
   DIAGNOSTIC
   THERAPEUTIC

  • 14. DIAGNOSTIC
PROCEDURES
   Laryngomalacia
(floppy
or
flipper
larynx)
   Laryngo‐tracheo‐bronchomalacia
   Vocal
cord
dysfunction
(palsies)
   Narrowing
and
stenotic
lesions
   Glottic

   Subglottic
   Tracheal

  • 15. DIAGNOSTIC
PROCEDURES
   Tracheo‐oesophageal
fistula
   Cysts
(vocal
cords)
   Clefts
(larynx)
   Webs
   Tumours
(papilloma)
   Inflammatory
lesions

  • 16. THERAPEURIC
PROCEDURES
   Excision
of
lesions
   Laser
   Dividing
Webs
   Removal
of
foreign
bodies
   Stents
for
stenotic
lesions
(trachea)
   Correction
of
clefts
(larynx)

  • 17. ANAESTHESIA
   Pre‐anaesthetic
assessment
   Anaesthetic
room
preparation
   Monitoring
   Induction
   Maintenance
   Analgesia

   Post‐anaesthesia
care

  • 18. PREANAESTHETIC
ASSESSMENT
   Age
at
birth
   Post‐conceptual
age
   Ventilatory
problems
at
birth
–
IPPV
   Chronic
lung
disease
and
broncho‐pulmonary
dysplasia
   Airway
manifestations
   Previous
anaesthetic
charts
   Investigations
   Clear
cervical
spine
(rigid
bronchoscopes)
   Premedication

  • 19. Airway
manifestations

   Upper
airway
   Obstruction

   Partial
(monophasic
or
biphasic
stridor)


   Complete
(intubated
–
ICU)

   Oxygen
saturation:
low
   Lower
airway:
cough
and
wheeze
   Feeding:
history
of
severe
regurgitation


  • 20. ANAESTHETIC
ROOM
   Experienced
assistant
   Local
anaesthetic
   Spray
   Atomiser
   Airway
equipment
 Face masks LMAs Tubes, stylets, bouggies Laryngoscopes Suction Cricothyroidotomy - tracheotomy   Laryngoscopes
   Straight
blades
   Curved
blades

  • 21. MONITORING
   ECG
   BP
   SpO2
   ET
CO2
   GAS

  • 22. TUBELESS
FIELD
WITH
HOPKIN’S
ROD
   Unobstructed
airway
   No
endotracheal
tube
   Nasopharyngeal
airway
for
maintenance
   Telescope
or
Hopkin’s
rod
only

  • 23. INDUCTION
   Securing
IV
access
is
preferable
before
 induction
   Inhalation
induction
   Sevoflurane
in
O2
   Haluthane
in
O2
   Isoflurane?
   Desflurane?
   Maintain
spontaneous
breathing
+
CPAP
   Deep
inhalation

  • 24.   Confirm
deep
anaesthesia
   Centeral
eye
balls
‐
small
pupils
‐
regular
breathing
   Insert
nasopharyngeal
airway
   ETT
of
appropriate
size
stopping
short
of
the
airway
   Local
anaesthesia
to
the
airway
   Laryngoscopy
   Lignocaine
3mg/kg

   Spray
   LAD
   Assess
the
position
of
the
tube

   Maintain
spontaneous
breathing
through
the
 nasopharyngeal
airway

  • 25. 
Final
picture:
spontaneously
breathing
child
with
 anaesthetised
airway
and

 no
tube
in
the
larynx
 Tubeless
Airway

 Ready
for
procedure

















































  • 26. ETT Nasopharynx
  • 27. MAINTENANCE
   Gas/O2
   Spontaneous
breathing
+
CPAP
(hand)
   Equipment
 Tubes, stylets, bouggies LMAs Laryngoscopes Ventilating bronchoscope Suction Cricothyroidotomy - tracheotomy   Drugs
   Adrenaline
 ▪Topical 
 
▪
Nebulizer 

   Dexamethasone
   Propofol

  • 28. PROBLEMS
   Remember
you
are
working
on
a
degree
of
 obstruction
to
start
with
   Too
deep
 




apnoea,
loss
of
airway,
 desaturation
   Light






coughing,
airway
obstruction,
 desaturation
   Inadequate
CO2
monitoring

  • 29. PROBLEMS
   Difficulty
in
maintaining
spontaneous
breathing
   Airway
bleeding
 ‐  Obstruction

 
‐
Bronchospasm


‐
Desaturation
 
(Topical
adrenaline
and
suction)
   Airway
obstruction
 ‐
Bleeding 
 
 
 
‐
Oedema
 ‐
Dislodgement
of
masses 
 
‐
Trauma
to
the
airway
(rare)

  • 30. ANALGESIA
   Local
anaesthesia
   Paracetamol
   Ibuprofen

  • 31. POSTANAESTHESIA
 AIRWAY
OEDEMA
 AIRWAY
BLEEDING

  • 32. POSTANAESTHESIA
   Recovery
position
   Adequate
time
in
PACU
   Anaesthetic
and
surgical
teams
available

  • 33. POSTANAESTHESIA
   Desaturation

   Adrenaline
nebulizer
   Stridor
   1:1000
@
0.5ml/kg
   Repeat
PRN
   Obstruction

   Apnoea
   Dexamethasone
   0.6mg/kg
   O2
   CEPAP
   Reintubate

  • 34. ADVANTAGES
   Tubeless
unobstructed
field
   Less
manipulation
of
the
airway
 ‐
Intubation
‐
Extubation
   Facilitation
of
using
larger
instruments
   No
muscle
relaxants
   Little
CO2
accumulation
   Minimal
risk
of
pneumothorax

  • 35. DISADVANTAGES
   No
definitive
airway
   Difficulty
in
monitoring
breathing
   ET
CO2
   Some
CO2
accumulation

  • 36. CONCLUSION
 
Tubeless
airway
field
offers
some
advantages
 for

surgical
procedures
in
a
safe
manner
with
 less
complications

  • 37. REFERENCES
   1.
Albert
SN.
The
Albert‐Sanders
adaptor
for
ventilating
anaesthetized
patients
for
micro‐ laryngeal
surgery.
Br
J
Anaesth
1971;
43:
1098
   2.
Baer
G,
Paloheimo
M,
Rahnasto
J,
et
al.
End‐tidal
oxygen
concentration
and
pulse
oximetry
for
 monitoring
oxygenation
during
intratracheal
ventilation.
J
Clin
Monit
1995;
11:
37
   3.
Cowl
CT,
Prakash
UB,
Kruger
BR.
The
role
of
anticholinergics
in
bronchoscopy:
a
randomised,
 clinical
trial.
Chest
2000;
118:
188
   4.
McRae
K.
Anesthesia
for
airway
surgery.
Anesthesiol
Clin
North
America
2001;19:
497–541,
vi
   5.
Kain
ZN,
O’Connor
EZ,
Berde
CB.
Management
of
tracheobronchoscopy
and
esophagoscopy
for
 foreign
bodies
in
children:
A
survey
study.
J
Clin
Anesth1994;
6:
28
   6.
Ossoff
RH.
Laser
safety
in
otolaryngology—head
and
neck
surgery:
anesthetic
and
educational
 considerations
for
laryngeal
surgery.
Laryngoscope
1989;
99:
1–26
   7.
English
J,

Norris
A,

Bedforth
N.
Continuing
Education
in
Anaesthesia,
Critical
Care
&
Pain
 Volume
6
Number
1
2006