Clinical Procedure
 
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Short but highly stimulating procedure with a shared airway.
Four strategies for ventilation.
1. Spontaneous ventilation with TIVA and/or volatile anesthetic via nasal catheter.
2. IPPV using ventilating bronchoscope (eg Storz bronchoscope) or intermittent mask ventilation.
3. Jet ventilation (not commonly used in paediatrics).
4. Apnoeic insufflation (oxygenation via O2 cannula in oropharynx) which is limited by its inability to eliminate CO2.

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Assess neck extension. Consider lateral neck xray in severe rheumatoid arthritis

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Antisialogogue 10min prior to procedure to reduce secretions

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At risk of post operative subglottic oedema (rigid bronch trauma). Consider steroids if not contraindicated (eg malignant tumor)

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Minimise risk of laryngospasm by spraying cords with local anaesthetic

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Place an oxygen catheter down the nose to sit in the oropharynx to effuse either oxygen or volatile anesthetic. Make sure its not passed into the oesophagus and inflating the stomach.

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Monitor for safe neck extension

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For small children: Draw up two syringes of fentanyl for titration throughout the case. Each syringe add 2.5mcg/kg and dilute up to 10ml normal saline. Don't usually need more than 2 syringes.

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Highly stimulating. Blunt sympathetic response with short acting opiod +- betablocker

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If using a volatile only technique, watch the volatile levels during the case to make sure it doesn't run out.
An open t-piece circuit is often used with high flows.

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Propofol TIVA 12-16mg/kg/hr

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Recover the patient in the lateral position with the disease lung down.

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