ANAESTHETICS AND AIRWAY
CICO
Know how to do a cricothyroidotomy - Knife-finger-bougie-6.0ETT-check ventilating, secure tube.
PromptCICO - PAEDS
Response
PromptCannula cricothyrodotomy vs surgical cricothyroidotomy: Pros/cons
ResponseControversial
Success rates higher with surgical approach (~60% of cannula techniques fail - NAP4 Study)
Cannula approach may not be feasible in obese patients - unable to locate membrane and higher failure rate (kinking, displacement)
Cannula technique possibly easier to perform - less confronting for operator
Cannula technique permits oxygenation but not ventilation.
Success rates higher with surgical approach (~60% of cannula techniques fail - NAP4 Study)
Cannula approach may not be feasible in obese patients - unable to locate membrane and higher failure rate (kinking, displacement)
Cannula technique possibly easier to perform - less confronting for operator
Cannula technique permits oxygenation but not ventilation.
PromptDescribe the use of percutaneous transtracheal ventilation (PTV) in upper airway obstruction
ResponseUpper airway obstruction = Relative contraindication to PTV
In routine use of PTV, much of the expired air exits through mouth and nose - upper airway obstruction = Difficult egress of expired air
PVT often successful in partial upper airway as “ball valve” effect as it adequately permits expiration and constraining natural inspiration.
Reasonable in upper airway obstruction if other methods have failed
Use modified techniques with longer expiratory times (I:E 1:8-1:10), largest possible catheter, and lower oxygen delivery pressure and flowrate
Monitor for chest rise and fall with inspiration and expiration. Diminished chest fall with expiration = gas trapping = prolonged expiratory time. Look for barotrauma with CXR
In routine use of PTV, much of the expired air exits through mouth and nose - upper airway obstruction = Difficult egress of expired air
PVT often successful in partial upper airway as “ball valve” effect as it adequately permits expiration and constraining natural inspiration.
Reasonable in upper airway obstruction if other methods have failed
Use modified techniques with longer expiratory times (I:E 1:8-1:10), largest possible catheter, and lower oxygen delivery pressure and flowrate
Monitor for chest rise and fall with inspiration and expiration. Diminished chest fall with expiration = gas trapping = prolonged expiratory time. Look for barotrauma with CXR
PromptDescribe a method for connecting a BVM to a 16 ga catheter inserted through the crycothyroid membrane
Response10 mL syringe with the plunger removed - insert small ETT and inflate cuff
3 mL Leur lock syringe with plunger removed with 7.5 mm ETT connector (BVM connector)
3.0mm ID ETT attached directly to BVM connector
2.5 ETT connector attached to cut off IV tubing with luer lock end connected to the catheter.
3 mL Leur lock syringe with plunger removed with 7.5 mm ETT connector (BVM connector)
3.0mm ID ETT attached directly to BVM connector
2.5 ETT connector attached to cut off IV tubing with luer lock end connected to the catheter.
PromptAirway burn in 5yo, unable to find the cords. Management:
ResponseDeclaire critical situatoin - Cant’ intubate, can’t ventilate. Child <8 so need jet insufflation
Perform cannula cricothyroidotomy
Perform cannula cricothyroidotomy
- Extend neck (shoulder roll) + stabilise larynx with non dominant hand. Access cricothyroid membrane with a dedicated 14/16ga cannula. Aim in caudal direction
- Confirm position by air aspiration using a syringe filled with saline
- Connect to either an adjustable pressure limiting device, set to lowest delivery pressure. OR, a 4 bar O2 source with flowmeter to mach childs age in L/min and Y connector
- Cautiously increase inflation pressure/flowrate to achieve adequate chest expansion
- Wait for full expiration before next inflation. Maintain upper airway patency to aid in expiration.
PromptKey steps in performing a cricothyrotomy using seldinger technique
ResponseLocate cricothyroid membrane
Insert needle through membrane until air aspirated
Pass guidewire through needle
Remove needle
Incise skin
Dilate tract
Insert tube
Insert needle through membrane until air aspirated
Pass guidewire through needle
Remove needle
Incise skin
Dilate tract
Insert tube
PromptVentilation techniques for percutaneous transtracheal ventilation
Note: Every resource was different. Every answer was different. Probably obstructive ventilation (long expiratory time), and realise this is oxygenation not ventilation. Need to keep working on airway plan
Note: Every resource was different. Every answer was different. Probably obstructive ventilation (long expiratory time), and realise this is oxygenation not ventilation. Need to keep working on airway plan
ResponseFor most children - Use I:E ratio of 1:4-1:5, RR 10-12.
Head injury/raised ICP - I:E 1:2-1:3, RR 15 to improve CO2 elimination
Upper airway obstruction (partial/complete) I:E 1:8-1:10, Rr 5-6 to minimise risk of pulmonary barotrauma
Adjust ratios based on clinical monitoring, blood gas measurements and chest radiography
Other answers quite different:
Turn O2 to 15L/min
Jet insufflate by occluding open port of device for 2-4 seconds (500-1000 mL). Observe chest movement rise and monitor sats.
Allow expiration
Next insufflation delivered with
Head injury/raised ICP - I:E 1:2-1:3, RR 15 to improve CO2 elimination
Upper airway obstruction (partial/complete) I:E 1:8-1:10, Rr 5-6 to minimise risk of pulmonary barotrauma
Adjust ratios based on clinical monitoring, blood gas measurements and chest radiography
Other answers quite different:
Turn O2 to 15L/min
Jet insufflate by occluding open port of device for 2-4 seconds (500-1000 mL). Observe chest movement rise and monitor sats.
Allow expiration
Next insufflation delivered with
- Sats drop 5%
- Ever 10-30 seconds
PromptComplications of Percutaneous transtracheal ventilation
ResponseUnsuccessful catheter placement or successful catheter placement with subsequent obstruction, kinking or dislodgement.
Infection
- Inability to ventilate
- S/C Emphysema
- S/C emphysema, Pneumomediastinum, pneumothorax, pneumatocoele of larynx
- Posterior tracheal laceration or perforation, oesophageal perforation, mediastinitis, vocal cord injury, laryngeal injury/laryngospasm
Infection
- Cellulitis, abscess (Cutaneous, prevertebral), tracheeitis, osteomyelitis of C spine