45.4.1 How Is the Airway Usually Managed in Post-tonsillectomy Bleeding?
Large volumes of blood may be swallowed, and blood or blood clots are often present in the oral cavity of these children. Despite the fact that the aspiration of blood is not similar in severity to aspiration of gastric acid, it remains an undesirable occurrence.
In addition to hypovolemia, patients with post-tonsillectomy bleeding present two major problems:
- Aspiration: These patients must be considered to have a full stomach and are at an increased risk of aspiration.
- Difficult airway: Blood and blood clots may impair visualization to the vocal cords. In addition swelling of the oropharynx may have occurred because of surgery or infection. This may lead to a changed laryngeal anatomy.
Because of the risk of aspiration, a mask induction maintaining spontaneous breathing is not desirable and a rapid-sequence induction should be considered. The efficacy and use of cricoid pressure, especially in children, is currently controversial. It is noteworthy that cricoid pressure can distort the laryngeal anatomy and worsen the view of the larynx. In addition, it can induce vomiting in the partially anesthetized patient.
The blood and blood clots in the oropharynx can impair vision during laryngoscopy or cause plugging of the endotracheal tube. A working suction apparatus is lifesaving and must be prepared in duplicate. One should be a large-bore, rigid surgical suction and the other mounted with a flexible endotracheal suction catheter. If one becomes blocked with a blood clot, another is readily available. If large amounts of clot are present, it may be necessary during the initial laryngoscopy to manually remove them with a finger or gauze. Magill forceps should be available to grab clots deeper in the pharynx, recognizing that these clots may be too fragile to be grasped and removed from the oral cavity using the forceps.
Awareness of a past history of difficult laryngoscopy is helpful, although this never precludes preparations for a difficult and failed airway. Different-sized curved and straight blades as well as a flex tip blade (McCoy laryngoscope) should be readily available. Different-sized cuffed endotracheal tubes, with one size up and down of the calculated size must be prepared. They should be preloaded with a well-lubricated intubating stylet, as is standard for a rapid-sequence induction.
An Eschmann Tracheal Introducer may be helpful in the presence of a Grade 3 view. If the epiglottis is visible, but no laryngeal entrance can be appreciated, a stroke of chest compression may help find the glottic opening by creating air bubbles.
The pediatric lightwand represents an elegant technique for intubation in the case of a glottic view obscured by secretions or blood. The extremely bright light can shine easily through blood and blood clots. However, experience is necessary when using this device.
Indirect laryngoscopy using the video laryngoscope (GlideScope® or the Airtraq®) can be difficult. Blood and secretions may block the optical lenses and impair the view to the vocal cords. The lens in the Airtraq® with its position between the lightsource on one side and the guide channel for the endotracheal tube on the other side might be more protected than the lens of the GlideScope®. Case reports or studies, however, have not been published in this regard.
The laryngeal mask plays an accepted role as an alternative airway device in managing the difficult pediatric airway (see Chapter 42). It is used frequently in primary adenotonsillectomies. It can be placed quickly and can be used as a conduit for a flexible bronchoscope to guide intubation if required. On the positive side, a laryngeal mask may briefly tamponade the bleeding site, and therefore protect the airway and the optical lens of the bronchoscope. Though, on the other hand, it may not provide sufficient airway protection in situations with increased risk of aspiration like post-tonsillectomy bleeding. A case report recently described the successful use of a laryngeal mask for a failed intubation in a post-tonsillectomy bleed.8
The use of a flexible bronchoscope alone is not recommended in cases of oropharyngeal bleeding. Experts recommend that the practitioner should rely on the alternative techniques with which they have the most experience and skill.
Preparation for the unexpected is essential. An experienced otolaryngologist or other qualified rigid laryngoscopist/bronchoscopist should be in the OR for all of these cases. If direct laryngoscopy fails, a rigid device wielded by the otolaryngologist may just be successful. An appropriately sized, lubricated, and tested rigid laryngoscope/bronchoscope connected to a light source and suction must be readily available at the head of the child. Preparation for a surgical airway is also essential (eg, tracheotomy tray opened and ready).
To reduce the risk of postoperative nausea and vomiting the stomach content of the child should be suctioned using an orogastric tube at the end of the procedure, recognizing that this does not guarantee an empty stomach as much of the blood may be clotted.
45.4.2 What Are the Airway Management Options for This Patient?
This patient presents several issues regarding anesthesia induction and airway management:
- High risk of aspiration
- Difficult intravenous access
- Suspected atlanto-occipital instability
- Known difficult direct laryngoscopy with easy face mask ventilation
- Expected difficult view of the larynx due to blood and secretions
Several options for the anesthetic and airway management of this child need to be weighed and considered in light of their risks and benefits.
22.214.171.124 Intravenous Induction versus Inhalation Induction without IV Access
This child is undergoing a second surgical procedure within 24 hours. Due to the frightening emergency situation, pain, bleeding, and his mental impairment, he is distressed and uncooperative. While a smooth inhalation induction with a face mask was preferred for his first surgery, a stomach potentially full of blood mitigates against this approach and for a rapid-sequence induction to minimize the duration of an unprotected airway. One might even hope for a rapid venous access following a mask induction to permit medication administration but we know in this case that is not likely.
126.96.36.199 Anesthesia Induction with C-Spine Precautions versus No C-Spine Precautions
Down syndrome is associated with atlanto-occipital instability in up to 20% of cases. It can occur in children as young as 4 years of age. The atlanto-occipital instability of this child with Down syndrome places him at increased risk for C-spine injury during anesthetic induction. Radiographic findings of C-spine instability in Down syndrome remain controversial. Lateral radiographs of the neck in flexion and extension do not reliably detect atlanto-occipital instability. Due to impaired cognition and anxiety, positioning of the patient can be difficult. Old lateral neck radiographs are not available for this child. Due to the emergency situation, a current neck radiograph is not possible. Therefore C-spine precautions should be performed. Extreme neck extension should be avoided in this child.
188.8.131.52 Awake Tracheotomy versus Anesthesia Induction with Attempted Laryngoscopy
The fact that this child has a known difficult direct laryngoscopy together with a documented Grade 3 view favors an awake tracheotomy under local anesthesia. This approach would maintain a protected airway at all times. Awake tracheotomy in adults and children are challenging. Optimal surgical positioning with neck extension is crucial for successful procedure. It is not expected that this child will tolerate this procedure. This fact, together with the required C-spine precautions would exclude an awake tracheotomy as an option for this child.
The plan is to perform an intravenous rapid-sequence induction employing indirect laryngoscopy to place an endotracheal tube. Preparations for rigid laryngoscopy are in place and the surgeon is prepared to embark immediately with a surgical airway (in this case a triple setup).
45.4.3 How Should You Prepare for This Case?
Following the failed attempt to start an intravenous line in the emergency department, the child was brought to the operating room. As previously outlined, venous access is crucial for induction and fluid resuscitation. Placement of a central line in the awake child is a possible option. For internal jugular vein access, the head may need to be rotated with increased risk associated with the presumed atlanto-occipital instability. The subclavian approach has the risk of a pneumothorax. An ultrasound-guided femoral vein approach is an alternative.
On the other hand, several studies have shown that an intraosseous cannula can be placed within 60 seconds and that this line provides an excellent access for the administration of medications and fluids. Because of the risks associated with central line placement, the child was prepared for an intraosseous cannula. The right leg was prepped with antiseptic solution, and local anesthetic injected at the tibial plateau. An intraosseous cannula was placed without incident. A normal saline solution flowed freely, permitting the administration of 20 mL·kg−1 body weight.
Atropine 0.1 mg IV was administered to reduce additional secretions and mitigate vagal responses secondary to laryngoscopy. The usual monitors were applied (pulse oximetry, noninvasive blood pressure, and ECG).
The surgeon was prepared as was his equipment; the rescue airway cart was in the room.
45.4.4 Management of This Child
Concurrent with the placement of the intraosseous cannula, the child was prepared for a rapid-sequence induction. The lungs of the child were denitrogenated with 100% Fio2 for 3 minutes employing a facemask that was reasonably tolerated with much cajoling. Considering the possibility of significant hypovolemia a 50-50 mix of ketamine and propofol (ketofol) was selected for induction and succinylcholine for neuromuscular blockade. Cricoid pressure during induction was not applied to avoid stimulating vomiting in the already agitated child. It was applied after the child was deeply anesthetized. As soon as the child was deeply asleep and paralyzed, the mouth was suctioned easily and several clots were removed with the Magill forceps. The brisk bleeding from the right tonsillar bed was noted.
Since the previous direct laryngoscopy showed a Grade 3 view, a repeated direct laryngoscopy was not attempted. Because the oral cavity seemed to be free of clot, it was decided to proceed with indirect laryngoscopy with the GlideScope®. Unfortunately, blood obscured the lens and following a prolonged laryngoscopy the attempt to intubate was abandoned. Oxygen saturations fell from 100% to 94% and despite the risk of aspiration, bag-mask-ventilation was begun and cricoid pressure was maintained. Oxygen saturations recovered nicely.
At this point, faced with a failed intubation, rather than a failed airway it was decided to insert an LMA-Proseal™. The oral cavity was once again suctioned with a rigid catheter under direct laryngoscopy and a number 3.0 LMA-Proseal™ was easily placed. No air leak was noted and pressure-controlled ventilation with a pressure limit of 15 cm H2O was started. A 5.5-mm ID uncuffed endotracheal tube was loaded on a pediatric flexible bronchoscope. Using the LMA-Proseal™ as a conduit, the bronchoscope was advanced into the trachea. Blood and secretions were present in the LMA and in the trachea but did not obscure the view through the bronchoscope. The ETT was advanced easily over the bronchoscope into the trachea. With a small air leak at 20 cm H2O airway pressure, it was decided not to change the ETT over a pediatric Cook airway exchanger to a cuffed ETT. Since the LMA-Proseal™ did not obscure the surgeons view, it was decided to leave the LMA-Proseal™ in place and remove it together with the ETT at the conclusion of the procedure and anesthesia.
With a secured airway, the ENT surgeon cauterized the tonsillar bed, and the bleeding artery could be ligated.
At the end of the procedure, a nasogastric tube was placed through the suction port of the LMA-Proseal™ and the stomach suctioned. The child was taken to the pediatric ICU where the ETT and LMA-Proseal™ were removed together an hour later.