Emergence & Recovery
Pediatric patients are particularly vulnerable to two postanesthetic
complications: laryngospasm and postintubation croup. As with adult patients,
postoperative pain requires close, careful attention. Pediatric anesthesia
practice varies widely, particu-larly in regard to extubation following a
general anesthetic. In some pediatric hospitals, all children who will be
extubated after a general anesthetic arrive in the postanesthesia care unit
(PACU) with the tube still in place. They are subsequently extu-bated by the
PACU nurse when defined criteria are reached. In other centers, nearly all children
are extubated in the operating room before arriving in the PACU. High quality
and safety are reported at centers following either protocol.
Laryngospasm is a forceful, involuntary spasm
of the laryngeal musculature caused by stimulation of the superior laryngeal
nerve . It may occur at induction, emergence, or any time in between without an
endotracheal tube. Presumably it can also occur when a tube is in place, but
its occurrence will not be recognized. Laryngospasm is more common in young
pediatric patients (almost 1 in 50 anesthetics) than in adults, and is most
common in infants 1–3 months old. Laryngospasm at the end of a procedure can
usually beavoided by extubating the patient either while awake (opening the
eyes) or while deeply anesthetized (spontaneously breathing but not swallowing
or coughing); both techniques have advocates and despite strong opinions,
evidence is lacking as to which is the better approach. Extubation during the
interval between these extremes, however, is gener-ally recognized as more
hazardous. Recent URI or exposure to secondhand tobacco smoke predisposes
children to laryngospasm on emergence. Treatment of laryngospasm includes
gentle positive-pressure ventilation, forward jaw thrust, intravenous lido-caine
(1–1.5 mg/kg), or paralysis with intravenous succinylcholine (0.5–1 mg/kg), or
rocuronium (0.4 mg/kg) and controlled ventilation. Intra-muscular
succinylcholine (4–6 mg/kg) remains an acceptable alternative in patients
without intrave-nous access and in whom conservative measures have failed.
Laryngospasm is usually an immediate postoperative event but may occur in the
recovery room as the patient wakes up and chokes on pharyn-geal secretions. For
this reason, recovering pediatric patients should be positioned in the lateral
position so that oral secretions pool and drain away from the vocal cords. When
the child begins to regain con-sciousness, having the parents at the bedside
may reduce his or her anxiety.
Croup is due to glottic or tracheal edema.
Because the narrowest part of the pediatric airway is the cricoid cartilage,
this is the most susceptible area. Croup is less common with endotracheal tubes
that are small enough to allow a slight gas leak at 10–25 cm H 2O. Postintubation croup is associated with
early child-hood (age 1–4 years), repeated intubation attempts, overly large
endotracheal tubes, prolonged surgery, head and neck procedures, and excessive
movement of the tube (eg, coughing with the tube in place, mov-ing the
patient’s head). Intravenous dexamethasone (0.25–0.5 mg/kg) may prevent
formation of edema, and inhalation of nebulized racemic epinephrine (0.25–0.5
mL of a 2.25% solution in 2.5 mL nor-mal saline) is an often effective
treatment. Although postintubation croup is a complication that occurs later
than laryngospasm, it will almost always appear within 3 h after extubation.
Pain in pediatric patients has received considerable attention in recent
years, and over that time the use of regional anesthetic and analgesic
techniques (as described above) has greatly increased. Commonly used parenteral
opioids include fentanyl (1–2 mcg/ kg), morphine (0.05–0.1 mg/kg),
hydromorphone (15 mcg/kg), and meperidine (0.5 mg/kg). A multi-modal technique
incorporating ketorolac (0.5–0.75 mg/kg) will reduce opioid requirements. Oral,
rec-tal, or intravenous acetaminophen may also be a helpful substitute for
ketorolac.
Patient-controlled analgesia can
also be successfully used in patients as young as 6–7 years old, depending on
their maturity and on preoperative preparation. Commonly used opi-oids include
morphine and hydromorphone. With a 10-min lockout interval, the recommended
interval dose is either morphine, 20 mcg/kg, or hydromor-phone, 5 mcg/kg. As
with adults, continuous infu-sions increase the risk of respiratory depression;
typical continuous infusion doses are morphine, 0–12 mcg/kg/h, or
hydromorphone, 0–3 mcg/kg/h. The subcutaneous route may be used with morphine.
Nurse-controlled and parent-controlled analgesia remain controversial but
widely used techniques for pain control in children.
As with adults, epidural infusions for
postopera-tive analgesia often consist of a local anesthetic com-bined with an
opioid. Bupivacaine, 0.1–0.125%, or ropivacaine, 0.1–0.2%, are often combined
with fen-tanyl, 2–2.5 mcg/mL (or equivalent concentrations of morphine or
hydromorphone). Recommended infusion rates depend on the size of the patient,
the final drug concentration, and the location of the epi-dural catheter, and
range from 0.1 to 0.4 mL/kg/h. Local anesthetic infusions can also be used with
continuous nerve block techniques, but this is less common than in adults.
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