Common Postoperative Problems In Pediatric Anesthesia

Linda J. Mason, M.D.

Professor of Anesthesiology and Pediatrics Loma Linda University

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 strategy?

Emergence Delirium

• • • Dissociated state of consciousness, child is inconsolable, irritable, uncooperative or uncompromising - characterized by thrashing, crying, moaning or incoherent Paranoid ideation Usually self limiting (5-15 min) but can result in physical harm to child or caretaker

Anesthetic Agents Associated with Emergence Delirium

• • • • • • Inhalational agents Atropine or scopolamine Ketamine Droperidol Barbiturates Benzodiazepines

Emergence Delirium Incidence

• All patients - 5.3% • Children 12-13% • With inhalational agents 2-55%

Emergence Delirium Etiology

• Agents with rapid emergence profile - sevoflurane, desflurane?

• Lack of pain control?

Decreased Incidence of Emergence Delirium with Pain Control

• • Ketorolac decreased ED 3-4 fold after myringotomy with halothane or sevoflurane.

Davis PJ, et al. Anesth Analg 1999;88:34-38.

Fentanyl 2.5 µg/kg IV or 2 m g/kg intranasal decreased ED. Cohen IT, et al. Anesth Analg 2001;93:88-91.

Finkel JC, et al. Anesth Analg 2001;92:1164-1168

Emergence Delirium and Regional Anesthesia

• • • Effective regional analgesia Most frequently seen in preschool children 1-5 years Lasts 5-15 minutes, often resolved spontaneously.

Aono, et al. Anesthesiology 1997;87:1298-1300

Emergence Delirium and No Surgery

• General anesthesia for MRI. ED - 33% sevoflurane, 0% halothane. •

Cravero JP, et al. Paediatric Anaesthesia 2000;10:419-424

MRI with sevoflurane and fentanyl 1 m g/kg - ED 12%, placebo - 56%.

Cravero JP, et al. Anesth Analg 2003;97:364-367

Emergence Delirium and Adequate Pain Control

• • • It is difficult to differentiate pain related agitation to other sources Pain may be a contributing factor but there are other causes Pain management is important in short surgical cases where peak onset of analgesics may be after patient is awake.

Anesthetic Technique and Emergence Delirium

• • Propofol vs sevoflurane - ED - 0% vs 38%. Sevoflurane shorter PACU stay.

Uezono S, et al. Anesth Analg 2000;91:563-566

Sevoflurane vs propofol - 23.1% vs 3.7%.

Cohen IT, et al. Anesth Analg 2000;90:S354

Agents to Decrease Emergence Delirium

• • Clonidine 2 mcg/kg IV – 40 male children age 2-7 years, circumcision – Penile nerve block – Placebo - 16 with ED, severe in 6 – Clonidine - 2 with ED.

Kulka PJ, et al. Anesth Analg 2001;93:335-338

Oral clonidine or midazolam - decreased incidence ED slower awakening?

Lapin SL, et al. Paediatr Anaesth 1999;9:299-304.

Fazi L, et al. Anesth Analg 2001;92:56-61

Emergence Agitation

• • Single dose of IV dexmedetomidine, 0.3 µg/kg after induction and maintenance of anesthesia with sevoflurane plus caudal blockade Decreased emergence agitation with no adverse effects Ibacache ME et al. Anesth Analg 2004;98:60-3

Dexmedetomidine Decreases Emergence Agitation in Pediatric Patients After Sevoflurane Anesthesia Without Surgery

Berrin Isik, M.D.

Mustafa Arslan, M.D.

Alper Dogan Tunga, M.D.

Omer Kurtipek, M.D.

Pediatric Anesthesia 2006;16:748-53.

Data

• • • • 42 children (ASA I-II, 18 months to 10 yrs) undergoing MRI 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 Incidence of emergence agitation was 47.6% in Group P and 4.8% in Group D

Isik B, et al. Pediatric Anesthesia 2006;16:748-53.

Does Dexmedetomidine Prevent Emergence Delirium in Children After Sevoflurane-based General Anesthesia?

Mohanad Shukry, M.D.

Mathison C. Clyde, B.S.

Philip L. Kalarickal, M.D.

Usha Ramadhyani, MBBS

Pediatric Anesthesia 2005;15:1098-1104.

Data

• • • • • 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 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.

QuickT ime™ and a TI FF (Uncompressed) decompressor are needed to see this picture.

QuickT ime™ and a TI FF ( Uncompr essed) decom pres sor are needed to see this pic ture.

Emergence Agitation

• Dexmedetomidine 0.5 tonsillectomy patients m g/kg decreased agitatation due to sedation and analgesia in

Guler G et al. Pediatric Anesthesia 2005;15:762-6

Premedication and Emergence Delirium

• Oral midazolam 0.2 mg/kg and sevoflurane anesthesia – ED-47% – Placebo - 81%.

Ko Y, et al. Acta Anaesthesiol Scand 2001;39:169-177

Theories About Emergence Delirium

• • • Sevoflurane has a biphasic effect on GABA A receptor mediated inhibitory postsynaptic currents (IPSC s ) – Low concentrations - inhibit, high concentrations - potentiate Propofol induction potentiates GABA calmer patients A - IPSC s and results in Benzodiazepines may also potentiate inhibitory effects of GABA A receptors.

Hapfelmeier G, et al.

Eur J Anaesthesiol 2001;18:377-383 Olsen RW, et al. Life Sci 1986;39:1969-1976

Age Differences with Emergence Delirium

• • Most likely in children less than 5 years of age with sevoflurane anesthesia As child ages GABA A receptor becomes inhibitory rather than excitatory as it is in the postnatal period. •

Ben-Ari Y, et al. Prog Brain Res 1994;102:261-273

Developmental differences in neurotransmitters and neuromodulators may account for age-related differences.

• •

Premedication and Emergence Delirium

No difference in premedication with midazolam in ED incidence.

Kain ZN, et al. Anesthesiology 1998;89:1147-1156

Benzodiazepines have been associated with agitation reversed with flumazenil.

Thurston TA, et al. Anesth Analg 1996;83:192

A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit.

Voepel-Lewis T, Malviya S, Tait AR. Anesth Analg 2003;96:1625-1630.

Data

• • • • • 521 children, age 3-7, outpatient procedures 18% had emergence agitation Mean duration - 14 minutes (up to 45 minutes) 52% with agitation required pharmacologic intervention prolonging PAR stay 5 adverse events

Ten Factors Associated With Emergence Agitation

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

Independent Risk Factors for Emergence Agitation

1) Otorhinolaryngology procedures 2) Time to awakening 3) Isoflurane

Other Factors

• • Premedication with midazolam or no premedication had the same incidence of EA in both groups Temperament and emergence outcomes need to be studied

Pediatric Anesthesia Emergence Delirium Scale

1. The child makes eye contact with the caregiver 2. The child’s actions are purposeful 3. The child is aware of his/her surroundings 4. The child is restless 5. The child is inconsolable Items 1,2,3 reversed scored : not at all(4), just a little(3), 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 Emergence Agitation in Children after Sevoflurane Versus Halothane Anesthesia B. Craig Weldon et al. Anesth Analg 2004;98:321-6

DATA

• • • • • 80 children 12 mo-6 yr undergoing inguinal hernia repair Oral midazolam, mask induction, caudal analgesia halothane or sevoflurane EA greater after 5 min in PACU with sevoflurane (26% vs 6%) but no time later in PACU stay Brief, more agitation with higher preop anxiety, difficult mask induction Combination of premedication and effective postop analgesia minimizes EA.

Treatment of Emergence Delirium

• • • Wait Propofol (0.5 mg/kgIV) or midazolam (0.02 mg/kgIV) Paradoxical reaction to midazolam – Flumazenil 0.01 mg/kg IV (max 0.2 mg dose at 1-2 min intervals to a maximum of 1 mg) – Flumazenil 0.2 mg/dose at 1-2 min intervals to a total dose of 1 mg in children greater than 12 years

Differential Diagnosis of Emergence Delirium

• • • • • • Hypoxia Hypercarbia Hypotension Hypoglycemia Increased ICP Bladder Distention

You are called back to the recovery room for a 4 year old male post orchidopexy who is experiencing oxygen desaturation and noisy breathing. What is your differential diagnosis and plan of action?

Airway/Respiratory Complications

• • • • • Upper Airway Obstruction Laryngospasm Post Intubation Croup Bronchospasm Aspiration

“Never Confuse Movement with Action”

Ernest Hemingway

Upper Airway Obstruction

• • Common in children - larger amount of airway soft tissue (tonsils, adenoids) Residual inhalational anesthetics cause persistent pharyngeal muscle hypotonia and posterior displacement of the tongue

Which Airway Maneuvers Work Best?

• • Adding CPAP of 10 cm of H stridor-score. 2 O to chin lift or jaw thrust improved upper airway patency and decreased

Meier S, et al. Anesth Analg 2002;94:494-499.

Jaw thrust was more effective in children with adenoidal hyperplasia with or without CPAP 5 cm of H 2 O.

Bruppacher H, et al. Anesth Analg 2003;97:29-34.

Where Does Airway Obstruction Occur?

• • Propofol- airway narrowing occurs throughout the upper airway but is most pronounced in the hypopharnyx at the level of the epiglottis May depend on depth of anesthesia -Light anesthesia - obstruction at the soft palate -Deep anesthesia-soft palate and epiglottis collapse -Obstruction occurs at more than one anatomic site

Evans et al. Anesthesiology 2003;99:596-602

Laryngospasm

• Incidence – 8.7/1000 - total population – 17.4/1000 - age 0 - 9 years – 3x rate of any age group - 1 - 3 months

Complications of Laryngospasm

• • • • • • Hypoxia Bronchospasm Gastric aspiration Arrhythmias Pulmonary edema 5/1000 have cardiac arrest

Laryngospasm

• • • • • • • Most common is children less than 2 years of age Equal in ASA PS 1-2 and 3-5 One third had URI or copious secretions 20% had negative pressure pulmonary edema One third occurred during induction, majority no IV present requiring IM succinylcholine Two thirds occurred during emergence or transport An IV can be helpful, intubate as soon as possible Bhananker SM et al. Anesth Analg 2007;105:344-50

Laryngospasm - Etiology

• • Glottic or subglottic mucosal stimulation Risk factors – Age – NG tube or oral airway placement – URI – Endoscopy or esophagoscopy – Volatile anesthetics (induction with desflurane or isoflurane)

Fink BR, Anesthesiology 1956;17:569-77

Laryngospasm

• • • • 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

Do Children Who Experience Laryngospasm Have and Increased Risk of Upper Respiratory Tract Infection?

Mark S. Schreiner, M.D., Irene O’Hara, M.D., Dorothea A.Markakis, M.D., George D. Politis, M.D., M.P.H.

Anesthesiology, 1996;85:475-80

Data

• • 15,183 day surgery patients Development of laryngospasm – 2.05 x more likely to have URI – Younger – Undergoing airway surgery

Use of the Laryngeal Mask Airway in Children With Upper Respiratory Tract Infections: a Comparison With Endotracheal Intubation Alan R Tait, PhD, Uma A Pandit, M.D., Terri Voepel-Lewis, BSN, MS et al Anesth Analg 1998;86:706-11

Data

• • • 82 patients - elective surgery with URI Risk of laryngospasm equal with LMA use or intubation Bronchospasm higher in the intubated group

Environmental Tobacco Smoke: A Risk Factor for Pediatric Laryngospasm Naren Lakshmipathy, M.D., Paula M Bokesch, M.D., Douglas E Cowan, M.D.

Anesth Anal 1996;82:724-7

Data

• • • • 310 children ASA I outpatients Risk of laryngospasm – Exposed to environmental tobacco smoke 9.4% – No exposure - 0.9% All occurred on emergence Higher if source of passive smoke was maternal

Awake vs Deep Extubation ?

• • 70 children 2 - 8 years – No difference in laryngospasm

Patel RI, et al Anesth Analg 1991;73:266-270

Children 1- 4 years – No difference in laryngospasm – Awake extubation more oxygen hemoglobin desaturation < 90%

Pounder DR, et al Anesthesiologt 1991;74:653-5

The Incidence of Laryngospasm with a “No Touch” Extubation Technique After Tonsillectomy and Adenoidectomy

Ban C. H. Tsui, MD, MSc, FRCP(C), Alese Wagner, BSc, Dominic Cave, MB, FRCP(C) et al.

Anesth Analg 2004;98:327-9

Data

• • • • • • • Incidence of laryngospasm is 21-26% after T&A 20 children age 5-15 years Propofol induction (3-5 mg/kg), mivacurium (.3mg/kg), morphine (0.15 mg/kg), ondansetron (0.15 mg/kg) and dexamethasone (.2mg/kg) Desflurane and nitrous oxide discontinued after patient turned 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 - 1

• • • Complete or incomplete obstruction Initial jaw thrust and chin lift 100% O 2 with gentle positive pressure

Laryngospasm Management - 2

• Complete airway obstruction – Positive pressure will make it worse • Dilutes anesthetic gases • Forces air into stomach with decreased ventilation or regurgitation

Laryngospasm Management - 3

• IV access present – Succinylcholine 0.5 - 1 mg/kg with atropine .02 mg/kg – No IV access • Succinylcholine 4 mg/kg IM in deltoid muscle

Treatment of Laryngospasm

• • • • • Apply CPAP Specialized airway maneuvers Pressure in layngospasm notch Pull mandible forward IV access-succinylcholine 1-2 mg/kg(?0.1-0.5 mg/kg) and atropine 0.02 mg/kg or consider propofol 0.5-0.8 mg/kg( incomplete airway obstruction) No IV access- succinylcholine 3-4 mg/kg IM with atropine 0.02 mg/kg IM Intubate as necessary

Laryngospasm - Prevention

• • Suction only when deeply anesthetized IV lidocaine 2 mg/kg - one minute before extubation - to be effective must be given before swallowing begins

Leicht P, et al Anesth Analg 1985;64:1193-96

Post Intubation Croup

• •

Incidence 1-6% of pediatric cases Contributing factors

– – – – – – –

Traumatic repeated intubations Coughing or “bucking” on ET tube Changing position after intubation Trisomy 21 Surgery greater than 1 hour Surgery of the head and neck Tight fitting ET tube (air leak >25 cm H 2 O)

Post Intubation Croup - Course and Treatment

• • • • • Symptomatic in first hour, maximum of 4 hours, resolves in 24 hours.

Humidified oxygen Nebulized racemic epinephrine (0.25-0.5 ml of a 2.25% solution) Steroids - dexamethasone 0.3-0.4 mg/kg Helium/oxygen (70%/30%) in patients with subglottic stenosis

Post Intubation Croup - Discharge to Home?

• • • Watch for rebound edema after racemic epinephrine use-keep 2 hours after last treatment Physicians and parents agree on ability of parents to care for and observe patient at home.

Where to return if respiratory distress worsens at home.

Bronchospasm

• Increased risk in asthmatics, URI’s, especially with intubation, ex-premature with BPD • Seen in anaphylaxis, histamine release, mucous plugging, aspiration.

Bronchodilator Premedication Does Not Decrease Respiratory Adverse Events in Pediatric General Anesthesia. Elwood T, Morris W, et al.

Can J Anesth 2003;50:277-284

Data

• • • ASA I-II age 2 m -18 yr 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 airway problems (desaturation, laryngospasm and bronchospasm)

Treatment of Bronchospasm

• • • • • Oxygen Nebulized ß agonists (albuterol or metoproterenol) Terbutaline (MDI or SC) Epinephrine 0.01 ml/kg (IV or SC) Steroids

History of this presentation

• • • • • • • Initial form completed 9/10/2003 Updated 9/29/2003 Corrected 10/21/03 New slides added and corrected 12/28/2003 Animation 2/1/2004 Editing and additions on 7/22/08 Revised 10/07/08