ANESTHESIA FOR COMMON PEDIATRIC
EMERGENCIES
(BEYOND NEWBORN)
DANIEL E. LEE, MD PhD
Associate Clinical Professor of Anesthesiology and Pediatrics
University of California, San Diego
PEDIATRIC PERIOPERATIVE RISK
 Pediatric Perioperative Cardiac Arrest registry (POCA)
– 1.4 cardiac arrests per 10,000 instances of anesthesia
– Cardiac arrest mortality of 26%
– Age < 1 year and emergency status are independent predictors of mortality
 Unique Anesthetic Management Concerns
– Smaller FRC, increased metabolic rate, more rapid desaturation with
apnea
– Often uncooperative, impacting upon ease of IV placement,
preoxygenation, awake intubation, etc.
– Infants and young children in particular may have unrecognized
underlying disease that can affect response to anesthesia, e.g. cardiac or
airway anomalies
COMMON PEDIATRIC EMERGENCIES
 FOREIGN BODY ASPIRATION
 EPIGLOTTITIS
 PERITONSILLAR ABSCESS
 RETROPHARYNGEAL ABSCESS
 POST TONSILLECTOMY HEMORRHAGE
 HYPERTROPHIC PYLORIC STENOSIS
FOREIGN BODY ASPIRATION
 Most common in toddler age group
 Presentation
– Coughing or choking while eating
– Persistent cough or difficulty swallowing
– Wheezing or stridor
 Examination: locate level of obstruction
– Stridor: esophageal FB at cricoid level
– Severe obstruction/cyanosis: large FB trapped in glottis or trachea
– Unilateral wheezing/air trapping: distal airway aspiration
Foreign Body Aspiration

Figure 1. A chest radiograph may appear normal during inspiration (A) following foreign body
aspiration. A hyperinflated right lung and a leftward mediastinal shift during expiration (B) suggest a
foreign body in the right mainstem bronchus.
PEDIATRIC OTOLARYNGOLOGIC EMERGENCIES. Susan T. Verghese and Raafat S. Hannallah . Anesthesiology
Clinics of North America 19 (2) : 237-256
FOREIGN BODY RETRIEVAL
FOREIGN BODY ASPIRATION - II
 Preoperative Preparation
– Timing
• Emergency? (e.g. cyanosis, noxious substance)
• Discuss with surgical specialist re: urgency and special needs
– Premedication
• Atropine 20 mcg/kg IV/IM: dries secretions, facilitates topical
anesthesia, maintains heart rate.
 Anesthetic Induction
• Sevoflurane or Halothane inhalation induction
• Maintain spontaneous ventilation initially
– Avoids need for positive pressure ventilation
– May decrease risk of dislodging FB
FOREIGN BODY ASPIRATION - III
 Anesthetic Maintenance
– Deep Sevoflurane/Halothane, spontaneous ventilation,
supplementation with propofol IV
– Under deep anesthesia > direct laryngoscopy > supraglottic FB
may be removed if visualized
– Topical lidocaine spray (2-4%) to airway, max 3-5 mg/kg
– Intermittent airway obstruction?
• Supplemental IV propofol 50-200 mcg/kg/min
– Excessive coughing with airway manipulation?
• Supplemental topical tracheal lidocaine by surgeon
• Short acting narcotic or paralytic. Then controlled ventilation
via sideport of rigid bronchoscope or intermittently by mask.
– Esophagoscopy needed?
• First secure airway with endotracheal tube
EPIGLOTTITIS
 Life-threatening airway
emergency
 Less common since advent of
Haemophilus Influenza type B
vaccine
 Symptomatology occasionally
mistaken for croup, a more
common childhood airway
problem. Misdiagnosis can be
disastrous.
EPIGLOTTITIS vs CROUP
CROUP
EPIGLOTTITIS
6mo-6yr
1-7yr
Viral
Bacterial
Gradual
Rapid
Low fever
Stridor
Tachypnea
Barking cough
High fever
Stridor
Tachypnea
No Cough
Drooling
 Physical Exam
+/- Cyanosis
Retractions
Sitting up – ‘tripod’
Retractions
 Neck X-rays
Anterior view
Steeple sign
Subglottic edema
Lateral view
Swollen epiglottis
Loss of valecula




Age
Organism
Onset
Symptoms
EPIGLOTTITIS - II
 Preoperative airway management:
– Airway EMERGENCY
– Do not agitate patient
– Proceed immediately to OR if stable, parental accompaniment may
help to keep child calm
– ENT standby for emergency tracheostomy
 Anesthetic induction & intubation:
–
–
–
–
Inhalation (Sevo/Halo) induction with patient sitting
Establish IV as soon as child is anesthetized
Atropine 20 mcg/kg and fluid bolus while anesthesia is deepened
Intubate under deep anesthesia with child spontaneously
ventilating
– Use styletted ETT at least 0.5mm smaller than normal
– If laryngeal structures cannot be identified, external compression
of thorax may allow air bubbles to be seen at the tracheal inlet
EPIGLOTTITIS - III
 Post-intubation management
– IV antibiotics
– 24-48 hours intubation as swelling subsides
– Trial of extubation should be attempted only after airway swelling
has significantly diminished (check with bronch and/or glidescope)
– All preparations should be made for emergent reintubation or
tracheostomy should trial of extubation fail (e.g. use tube
exchanger, bronch available, LMA available, ENT surgeon/trach
kit).
PERITONSILLAR ABSCESS
 Most common in children &
young adults
 Presentation:
– Fever, pain, difficulty swallowing,
trismus
– Uvula deviation, pharyngeal
swelling at tonsillar bed
 Treatment:
– IV Antibiotics
– Surgical incision & drainage
PERITONSILLAR ABSCESS - II
 Anesthetic management:
– If minimal airway distortion and no difficulty with intubation
anticipated
• IV induction with short acting paralytic
• Gentle laryngoscopy, avoid premature rupture of abscess
• Cuffed ETT and head down position may limit soiling of the airway
when abscess is lanced
– If trismus is severe or any difficulty with airway anticipated
•
•
•
•
Inhalational (Sevo/Halo) induction
Maintain spontaneous ventilation
Trismus generally resolves as anesthesia deepens
Gentle laryngoscopy and intubation, advanced airway techniques if
necessary, surgeon should be present for possible surgical airway
 Postoperative emergence:
– Airway is cleared of all inflammatory material
– Child is extubated fully awake
RETROPHARYNGEAL ABSCESS
 Retropharyngeal inflammation pushes
posterior pharynx forward obstructing
airway
 More likely to cause airway
obstruction than peritonsillar abscess
 Presentation:
– Fever, pain, difficulty swallowing, trismus
– Posterior pharyngeal mass (exam, lateral Xray,
CT)
RETROPHARYNGEAL ABSCESS - II
 Anesthetic management:
– If mild airway distortion and no difficulty with airway anticipated,
may proceed with IV induction, gentle laryngoscopy and
intubation
– If any concern of difficult airway or if trismus is severe
•
•
•
•
Inhalational (Sevo/Halo) induction
Maintain spontaneous ventilation
Trismus generally resolves as anesthesia deepens
Gentle laryngoscopy and intubation, advanced airway techniques if
necessary, surgeon should be present for possible surgical airway
 Post-operative emergence
– Airway is cleared of all inflammatory material
– Child is extubated fully awake
POST TONSILLECTOMY
HEMORRHAGE
 Surgical emergency
 May occur early (24 hrs) or late (5-10 days)
 Presentation:
– Anemia
– Hypovolemia
– Stomach often full of blood
 Pre-operative preparation:
– Hematocrit, type & crossmatch
– Aggressive fluid resuscitation should begin prior to induction
POST TONSILLECTOMY
HEMORRHAGE - II
 Anesthetic induction
– Airway may be obscured by blood – 2 x large bore suction,
multiple laryngoscope blades and styletted endotracheal tubes
should be prepared
– Hypovolemia may persist despite aggressive pre-operative
resuscitation
– Rapid sequence IV induction with ketamine 2 mg/kg or etomidate
0.2 mg/kg with succinylcholine 2 mg/kg minimizes risk of
hemodynamic embarrassment with induction
POST TONSILLECTOMY
HEMORRHAGE - III
 Intraoperative management
– Airway can be protected with a cuffed ETT or snug fitting
uncuffed ETT in smaller children
– If specific source of bleeding is not identified, child may have
underlying bleeding disorder
– Clotting studies should be sent
– Clotting factors replaced as necessary if ongoing bleeding – FFP,
Cryo, Platelets, DDAVP (if type of von Willebrand’s deficiency is
known)
 Post-operative emergence
–
–
–
–
Stomach contents are suctioned
Endotracheal extubation fully awake
Repeat hematocrit postoperatively
Monitor for airway obstruction or recurrent hemorrhage
HYPERTROPHIC PYLORIC STENOSIS
 1:500 live births
 Presents ~ 6weeks of age
 Pyloric muscle hypertrophy
(gastric outlet obstruction)
– Non-bilious, projectile emesis
– Lose H+/Cl• Hypochloremic metabolic
alkalosis - promotes
hypoventilation
• Hypokalemia - kidneys
exchange K+ for H+
• Hyponatremia/hypocalcemia
• Dehydration may be severe
PYLORIC STENOSIS - II
 Preoperative preparation:
– NOT true surgical emergency – should ‘tune up’ first
– Rehydrate, nasogastric suction, correct electrolytes
– Ready for surgery when:
• HCO3 < 30
K+ > 3.2
• Cl- > 90
UOP > 1-2 cc/k/hr
• Urine spec. grav. <1.02
 Anesthetic induction:
– Premedicate with atropine 20 mcg/kg
– Rapid sequence or modified rapid sequence
induction/intubation if normal airway - propofol 2-3
mg/kg IV, succinylcholine 2 mg/kg IV
– Awake intubation if difficult airway is anticipated?
PYLORIC STENOSIS - III
 Emergence:
– Stomach contents suctioned
– Child fully awake prior to extubation
 Post-operative considerations:
– Significant apnea risk due to residual CSF alkalosis
– Intra-operative local anesthesia (bupivacaine 2.5 mg/kg max) and
rectal acetaminophen (30-40 mg/kg loading dose) may minimize
apnea risk by avoiding narcotics
– Apnea monitoring should be maintained 12-24 hours post
operatively
Most Important Part of a Pediatric Anesthetic?
AIRWAY, AIRWAY, AIRWAY
SUMMARY
Anesthesia for emergency surgery in pediatric patients carries increased risks.
These risks can be minimized with careful pre-operative evaluation and preparation.
Cooperation between the anesthesiologist and surgeon is especially important in the
management ENT emergencies.
Pre-operative resuscitation and post-operative apnea monitoring in pyloric stenosis
also require close coordination with surgical colleagues.