Pediatric Anesthsia.pdf

1680 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations
Figure 98-17. Airway foreign bodies.
A-B: Tracheal foreign body. A: Sunflower
seed straddling the carina causing
near complete obstruction. B: View of
the carina subsequent to foreign body
removal. C-D: Bronchial foreign body.
C: Plastic flower lodged in distal
bronchus. D: Bronchial foreign body following
removal. Courtesy V. Forte.
lidocaine should be applied to the vocal folds and then the child
intubated with an appropriate sized tracheal tube. If this is not
possible then a bronchoscope should be used to secure the airway;
if this fails, a tracheotomy should be performed. Once the airway
is secured, careful evaluation of the airway is performed to
determine the diagnosis and commence treatment. If the child is
not in imminent danger requiring immediate airway manage -
ment, then nebulized racemic epinephrine (1 to 2.5 mL of 1 in
1000) and steroids (dexamethasone: 1 to 2 mg/kg) may be given.
Investigations to determine the cause of the obstruction (softtissue
neck x-rays and CT scanning) should only be performed if
the child is stable. Inhaled budesonide has shown benefit in the
management of croup and should be commenced if croup is
suspected. 93
Figure 98-18. Rigid bronchoscopes and instruments used for foreign
body removal. A: Nonfenestrated bronchoscope. B: Fenestrated
bronchoscope. C: Telescope for rigid bronchoscope. D:
Light carrier cable for rigid bronchoscope. E: Light carrier cable
for telescope. F: Prism. G: Window. H: Optical forceps for foreign
body removal. I: Telescope for optical forceps. Courtesy V. Forte.
TRACHEOTOMY
Indications for pediatric tracheotomy include upper airway
obstruction, pulmonary toilet, and maintenance of long-term
mechanical ventilation. Infant and pediatric tracheotomies require
planning and close cooperation between the surgeon and the anes -
thesiologist, as the responsibility for maintenance of the airway
shifts during the procedure. If the child cannot be intubated, the
airway is first established by introduction of a fenestrated bron -
choscope. If the child is intubated before tracheotomy, some sur -
geons prefer to replace the endotracheal tube with a bronchoscope
in the infant and small child because it offers a firmer anatomic
reference for tracheal location. The disadvantage of ventilating
through a bronchoscope is that it must be held in place. The
patient is positioned with the neck fully extended and a shoulder
roll placed to hold the position. This brings the trachea anteriorly
and improves operative exposure. The appropriate sized tracheo -
tomy tube is one half-size larger than the endotracheal tube it