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2013 Pediatric Fellows Boot Camp_ETI
 

2013 Pediatric Fellows Boot Camp_ETI

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    2013 Pediatric Fellows Boot Camp_ETI 2013 Pediatric Fellows Boot Camp_ETI Presentation Transcript

    • Pediatrics Fong Lam, MD Baylor College of Medicine Critical Care Medicine Boot Camp Endotracheal Intubation
    • Page 2 Pediatrics Endotracheal Intubation Objectives •By the end of this workshop, the learner will be able to: •Recite at least 3 indications and 5 complications associated with orotracheal intubation •Derive the appropriate ETT size for orotracheal intubation using a formula and/or the patient’s age/weight/size •Determine the appropriate sized laryngoscopy blade according to the patient’s age/weight/size •Name at least 3 anatomic differences between the pediatric and adult airway
    • Page 3 Pediatrics 8 MONTH OLD WITH RESPIRATORY DISTRESS
    • Page 4 Pediatrics 8 Month Old With Respiratory Distress •Previously healthy male •Fever (41C) x 2 days with cough •P 155 R 50 BP 75/40 SpO2 85% on ambient air •Tired-appearing, grunting, decreased aeration on left
    • Page 5 Pediatrics Assessment and Plan •Assessment? •Pneumonia •Plan? •Supplemental oxygen •Peripheral IV •IV antibiotics •IV fluids •+/- CXR
    • Page 6 Pediatrics Moments Later… •After being placed on 15 LPM non-rebreather mask •How much FiO2 does this provide? •SpO2 now 92% •Still tired-appearing, grunting, subcostal retractions •P 170 R 20 BP 70/40 •Now what? •Intubate!
    • Page 7 Pediatrics THE PEDIATRIC AIRWAY From: respiratory-care-sleep-medicine.advanceweb.com/Article/Building-intubation-skills-and-confidence.aspx
    • Page 8 Pediatrics Differences in Pediatric Airway From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
    • Page 9 Pediatrics Differences in Pediatric Airway From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
    • Page 10 Pediatrics Children Have Larger Tongues •Children’s tongues are proportionally larger •May make it difficult to maneuver the laryngoscope for an optimal view •Remember to place the blade on the right side of the mouth and move toward the left to move the tongue
    • Page 11 Pediatrics Differences in Pediatric Airway From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
    • Page 12 Pediatrics Large, Floppy Epiglottis •May be difficult to maneuver with the laryngoscope blade •The Miller (straight) blade is designed to LIFT the epiglottis (more finesse) •The Macintosh (curved) blade is designed to be placed in the vallecula and encourage the epiglottis to move From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012
    • Page 13 Pediatrics Differences in Pediatric Airway From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
    • Page 14 Pediatrics The Funneled Larynx Adult Infant Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt •Narrowest point is in the subglottic (below vocal cords) region •Too tight of an ETT may cause airway edema and stridor post- extubation
    • Page 15 Pediatrics Differences in Pediatric Airway From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
    • Page 16 Pediatrics Pediatric Airways Are More Anterior and Superior Than Adult Airways Image from: http://depts.washington.edu/pccm/Pediatric%20Airway%20management.ppt Adult Infant •This makes proper position vital to the success of intubation •Common mistakes are: • Placing the laryngoscope blade too far • Hyperextension of the neck •Sometimes, you may need to gently manipulate the thyroid cartilage to move the larynx into view (BURP)
    • Page 17 Pediatrics Difficulty Viewing the Cords? BURP Image from: Carrillo-Esper et al. Rev Mex Anes. 2008
    • Page 18 Pediatrics PREPARING FOR INTUBATION
    • Page 19 Pediatrics Indications for Intubation •Primary respiratory disorder • Severe hypoxemia (pneumonia, ARDS) • Severe hypoventilation (bronchiolitis, emphysema, CLD) •Primary neuromuscular disorder • Myopathy (DMD, SMA) • Altered mental status with hypoventilation (TBI, intoxication) • Lack of airway protection (TBI, severe HIE, intoxication) • Need for sedation with risk of airway protection or ventilation •Tight control of paCO2 or pH • Severe increased ICP (paCO2) • Severe pulmonary hypertension (pH) •To reduce metabolic demands in severe shock
    • Page 20 Pediatrics Use SOAP to Prepare for Intubation •Suction •Rigid catheter with constant suction (Yankauer) •Oxygen •10-15 LPM 100% (make sure it is not on a blender) •Airway •Appropriate sized tubes (estimated size and ½ size smaller) •Appropriate sized laryngoscope blades •Oral airways •Pharmacology •Based on disease www.mountainside-medical.com/products/Yankauer-Suction-Tip-Handle.html
    • Page 21 Pediatrics Medications for Intubation •Premedication for laryngoscopy •Sedation +/- analgesia •Neuromuscular blockade •Make sure you can ventilate prior to neuromuscular blockade •Make sure you can ventilate prior to neuromuscular blockade •Make sure you can ventilate prior to neuromuscular blockade
    • Page 22 Pediatrics Premedication •Atropine (neonates, infants) •0.02 mg/kg IV (0.1 – 1 mg total dose) •Blunts the vagal response from laryngoscopy •Use if bradycardic/risk of bradycardia •Lidocaine (TBI, elevated ICP) •1 mg/kg IV •Anesthetizes airway to blunt the ICP spike from laryngoscopy
    • Page 23 Pediatrics Sedation •Midazolam (85% of routine patients) • 0.1 – 0.2 mg/kg IV •Fentanyl (85% of routine patients) • 2 – 6 mcg/kg IV (slow infusion, may cause rigid chest) • Give sedative with fentanyl (no sedative effect) •Propofol • 1 mg/kg IV (may cause hypotension) •Ketamine (shock states, asthma) • 1 – 3 mg/kg IV (may cause increased bronchorrhea) • 2 mg/kg IV for RSI •Thiopental vs. Etomidate (elevated ICP) • Thiopental 3 – 5 mg/kg IV (high risk of hypotension) • Etomidate 0.2 – 0.6 mg/kg IV (may cause adrenal suppression)
    • Page 24 Pediatrics Neuromuscular Blockade •Rocuronium vs. Vecuronium (85% of patients) • Rocuronium 0.6 – 1.2 mg/kg IV (1.5 – 2 mg/kg IV for RSI) • Vecuronium 0.1 – 0.4 mg/kg IV • Effect may be prolonged in renal/hepatic failure •Cisatracurium • 0.2 mg/kg IV • Cleared by Hoffman degradation (good for renal/hepatic failure) •Succinylcholine • 1 – 2 mg/kg IV; 4 mg/kg IM • Patient will fasciculate, consider a defasciculating dose of rocuronium/vecuronium (1/10 dose) • Beware of hyperkalemia in patients with neuromuscular disorders, burns, crush injuries, renal failure
    • Page 25 Pediatrics ENDOTRACHEAL INTUBATION
    • Page 26 Pediatrics Laryngoscope and ETT Selection •Match the patient! If the patient is smaller than stated age (or unknown age), ETT can be estimated by the patient’s 5th finger size Age Blade Size & Type ETT Size (mm; Uncuffed & Cuffed) NB < 2 kg 0 Miller 2.5 NB > 2 kg ~ 6 mo 1 Miller 3.5 or 3.0 C 6 mo ~ 1 yr 1 ~ 1.5 Miller 4.0 or 3.5 C 1 yr ~ 2 yr 1.5 Miller 4.5 or 4.0 C 2 yr ~ 8 yr 2 Miller For UNcuffed tubes: 8 yr ~ 12 yr 2 Miller or 2 Macintosh > 12 yr 3 Miller or 3 Macintosh Age(yrs) 4 + 4 Subtract 0.5 mm for Cuffed tubes
    • Page 27 Pediatrics Choose Your Blades Miller Blades Macintosh Blades
    • Page 28 Pediatrics http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259 Head Tilt-Chin Lift Maneuver
    • Page 29 Pediatrics Alignment of The Airway: Children <3 years McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84 O: Oral axis P: Pharyngeal axis L: Laryngeal axis Large occiput flexes head and neck Shoulder roll will help line up the pharyngeal and laryngeal axes Extension of atlantooccipital joint will line up oral axis with the other two
    • Page 30 Pediatrics Placement of the Laryngoscope Blade (< 3 years) From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001 Shoulder Roll for Infants
    • Page 31 Pediatrics Alignment of The Airway: Children >3 years McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84 O: Oral axis P: Pharyngeal axis L: Laryngeal axis Cushion under head will flex neck to line up pharyngeal and laryngeal axes Extension of atlantooccipital joint will line up oral axis with the other two
    • Page 32 Pediatrics Placement of the Laryngoscope Blade (> 3 years) From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
    • Page 33 Pediatrics Laryngoscopic View From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 1918 (Right)
    • Page 34 Pediatrics ETT Insertion Depth – How Far? •3 x ETT size •Black marking or cuff past vocal cords
    • Page 35 Pediatrics POST-INTUBATION CARE
    • Page 36 Pediatrics How Do You Confirm Intubation? •Bilateral & equal breath sounds •If decreased on one side? •If absent on one side and hypertympanic •Improvement of oxygenation •If saturations rapidly decrease? •EtCO2 confirmation •Colorimetric: Yellow = Yes •Waveform analysis/quantitative: > 15 mm Hg •CXR confirmation •Absent sounds over stomach •Mist in ETT during bag-ventilation
    • Page 37 Pediatrics Potential Complications of Oral Intubation •Inability to ventilate (difficulty intubating and cannot BMV) • This can lead to death • Make sure you can ventilate prior to neuromuscular blockade •Tube malposition (esophageal intubation) • What will you notice/see? •Airway trauma • Teeth (check for loose or missing teeth before and after) • Vocal cord injury (ineffective paralytic/VC closed during insertion) • Subglottic edema/stenosis (incorrect tube size) •Pulmonary disease • Mainstem (left or right) intubation • Pneumothorax (usually from over-exuberant bagging)
    • Page 38 Pediatrics Pneumothorax From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)
    • Page 39 Pediatrics Dental Trauma (DON’T DO THIS) From: Windsor and Lockie. Anaesth and Int Care Med. 2008
    • Page 40 Pediatrics Endotracheal Intubation Objectives •By the end of this workshop, the learner will be able to: •Recite at least 3 indications and 5 complications associated with orotracheal intubation •Derive the appropriate ETT size for orotracheal intubation using a formula and/or the patient’s age/weight/size •Determine the appropriate sized laryngoscopy blade according to the patient’s age/weight/size •Name at least 3 anatomic differences between the pediatric and adult airway
    • Page 41 Pediatrics QUESTIONS?