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/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
/2008april/20080422.ppt" classPediatric laryngospasm
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/2008april/20080422.ppt" classPediatric laryngospasm

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Transcript

  • 1. Pediatric laryngospasm R4: 曾揚旗
  • 2. Pediatric laryngospasm
    • Laryngospasm: review of different prevention and treatment modalities
    • Pediatric Anesthesia 2008 18: 281–288
    • Pediatric laryngospasm
    • Pediatric Anesthesia 2008 18: 303–307
    • Risk factors for laryngospasm in children during general anesthesia
    • Pediatric Anesthesia 2008 18: 289-296
  • 3. Introduction
    • Laryngospasm is mainly seen in children.
    • A reflex closure of the upper airway as a result of the glottic musculature spasm  prevent foreign material entering the tracheobronchial tree.
    • This leads to hypoxia and hypercapnea.
  • 4. Introduction
    • Prolong hypoxia and hypercapnea  abolishes the spastic reflex and the problem is self-limited.
    • Cardiac arrest, arrhythmia, pulmonary edema, bronchospasm or gastric aspiration may occur.
  • 5. Definition
    • Laryngospasm can be defined as glottic closure due to reflex constriction of the laryngeal muscles.
    • Complete laryngospasm – chest movement but silent with no bag movement and no ventilation possible.
    • Partial laryngospasm – chest movement but stridulous noise with a mismatch between the patients’ respiratory effort and the small amount of bag movement.
  • 6. Epidemiology
    • The overall incidence of laryngospasm is 0.87%.
    • The incidence in children in the first 9 years of age is 1.74%.
    • A higher incidence of 2.82% in infants between 1 and 3 months
  • 7. Mechanism
    • Most laryngeal reflexes are elicited by stimulation of the afferent fibers contained in the internal branch of the superior laryngeal nerve.
    • These reflexes control the laryngeal muscle contractions which protect the airway during swallowing.
  • 8. Clinical manifestation
    • Signs in both partial and complete laryngospasm : airway obstruction (tracheal tug, paradoxical movement of the chest and abdomen).
    • Late signs: oxyhemoglobin desaturation, bradycardia and central cyanosis.
  • 9. Differential diagnosis
    • Complete laryngospasm
    • Partial laryngospasm
    • Supraglottic obstruction
    • Psychogenic laryngospasm
  • 10. Risk factors
    • Anesthesia-related factors
    • Patient-related factors
    • Surgery-related factors
  • 11. Anesthesia-related factors
    • During anesthesia and emergence:
    • (1) including tracheal intubation,
    • (2) laryngospasm tends to occur after extubation
    • (3) spontaneous breathing using a face or laryngeal mask.
  • 12. Anesthesia-related factors
    • Intravenous (i.v.) induction agents induce laryngospasm
    • Incidence : Barbiturates (thiopentone) > Ketamine > Propofol
  • 13. Anesthesia-related factors
    • Volatile anesthetics
    • Incidence : desflurane > Isoflurane > sevoflurane
    • Laryngospasm occur in children which are supervised by less experienced anesthesiologists
  • 14. Patient-related factors
    • Incidence of laryngospasm following GA is inversely correlated with age.
    • Upper respiratory tract infection and airway anomaly (10-fold more prone to develop laryngospasm).
    • ‘ passive smoking”, gastroesophageal reflux, patients with elongated uvula and those with history of choking during sleep
  • 15. Surgery-related factors
    • Tonsillectomy and adenoidectomy have the highest incidence of laryngospasm (21–26%).
    • Appendicectomy, cervical dilation, hypospadias surgery, skin transplant and esophageal procedures.
  • 16. Surgery-related factors
  • 17. Prevention Anesthesia induction Identify the risk factor Premedication with anticholinergics and benzodiazepine Insert IV line 2 min after sevoflurance induction ( loss of lid reflex) Tracheal intubation after ensuring adequate level of anesthesia
  • 18. Prevention
    • Premedication with anticholinergic agents to prevent larygospasm is controversial.
    • Anticholinergics:decrease secretions  play an indirect role in reducing the incidence of laryngospasm
    • Oral benzodiazepine : decreases upper airway reflexes  decrease laryngospasm during induction of anesthesia
  • 19. Prevention
    • Gentle suctioning of the blood and sections
    Prevention Emergence Put the patient on lateral position Discontinue inhalation anesthetics Give lidocaine 1mg/kg iv or propofol 0.25-0.5 mg/kg iv Wait for the patient to open the eyes and spontaneuosly wake up Extubate the trachea using the “artificial cough” technique
  • 20. Prevention
    • Both awake and anesthetized extubation have advantages and disadvantages.
    • Patel et al. undertook a study comparing awake vs anesthetized tracheal extubation of patients after tonsillectomy and adenoidectomy.
  • 21. Prevention Prevention Emergence Gentle suctioning of the blood and sections Premedication with anticholinergics and benzodiazepine Discontinue inhalation anesthetics Give lidocaine 1mg/kg iv or propofol 0.25-0.5 mg/kg iv Wait for the patient to open the eyes and spontaneuosly wake up Extubate the trachea using the “artificial cough” technique
  • 22. Prevention
    • The role of lidocaine in preventing laryngospasm is controversial.
    • May be attributed to a central increase in the depth of anesthesia.
    • Baraka et al : 40 children undergoing tonsillectomy and adenoidectomy (2mg/kg, 1min)
    • Leicht et al. studied 100 children after tonsillectomy in which i.v. (1.5 mg/kg)
  • 23. Treatment Identification and removal of the offending stimulus such as secretion, mucus or blood Inserting an oral or nasal airway if possible Apply jaw thrust maneuver while firmly pressing on the “ laryngospasm notch” Intermitent positive pressure ventilation with face mask If laryngospasm is not relieved, deepen the lavel of anesthesia by propofol iv 0.25-0.8 mg/kg If laryngospasm is not relieved, inject suxamethonium iv 0.1-3 mg/kg or im 3-4 mg/kg followed by mask ventilation and /or tracheal intubation
  • 24. Treatment
    • There is a technique which was first described 40 years ago by Guadagni and was later described by Larson.
    • This technique consists of firmly pressing inward toward the base of the skull with both fingers, while at the same time applying jaw thrust maneuver .
    • This opens the airway and induces periosteal pain by pressing on the styloid process which helps relaxing the vocal cords by the autonomic nervous system
  • 25. Treatment
  • 26. Treatment Identification and removal of the offending stimulus such as secretion, mucus or blood Inserting an oral or nasal airway if possible Apply jaw thrust maneuver while firmly pressing on the “laryngospasm notch” Intermitent positive pressure ventilation with face mask If laryngospasm is not relieved, deepen the lavel of anesthesia by propofol iv 0.25-0.8 mg/kg If laryngospasm is not relieved, inject suxamethonium iv 0.1-3 mg/kg or im 3-4 mg/kg followed by mask ventilation and /or tracheal intubation
  • 27. Treatment
    • The question of whether to use propofol or suxamethonium is a matter of timing.
    • Propofol should be used prior to suxamethonium.
    • It is successful in treating laryngospasm in 76.9% of cases and free of cardiovascular events.
  • 28. Treatment
    • First, is the lack of interaction of a depolarizing drug with a previously administered nondepolarizing muscle relaxant.
    • Second, avoiding suxamethonium will eliminate the possibility of prolonged paralysis in patients with pseudocholinesterase deficiency.
    • Finally, propofol can be used when suxamethonium is contraindicated
  • 29. Treatment
    • Suxamethonium still has a crucial role when propofol is unsuccessful.
    • Its administration should not be delayed until the patient becomes severely desaturated (SpO2 < 85%)  severe bradycardia and even cardiac arrest.
    • It is highly recommended to give atropine at 0.02 mg/kg) i.v. prior to administration of suxamethonium to treat laryngospasm
  • 30. Treatment
    • Chung and Rowbottom showed that the use of 0.1 mgAkg)1 i.v. of suxamethonium was successful in treating laryngospasm
    • Maintenance of spontaneous breathing thus avoiding further hypoxia and the avoidance of bradycardia.
  • 31. Treatment
    • When laryngospasm occurs during inhalational induction without previous i.v. access several options can be used.
    • Warner recommends that i.m. suxamethonium can be administered at 4 mg/kg) followed by tracheal intubation
  • 32. Treatment
    • Donati et al. Advise against the use of i.m. suxamethonium for intubation without i.v. access.
    • They suggest establishing an i.v. access for the administration of drugs to treat laryngospasm
    • Weiss et al. recommend using the I.O. route as an efficient and quick access to give neuromuscular blocking drugs with faster central circulation times.
  • 33. Conclusions

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