Time for another podcast and a chance to introduce a new guest. Dr David Kinchington has things to share about bread and butter paeds anaesthesia – Ts and As. Dr Andrew Weatherall took the chance to pick his brains.
Ts and As represent the sort of work that can challenge paediatric anaesthetists working in a variety of settings. David Kinchington has spent more than a bit of time thinking about this stuff and this conversation is a quick run through things that should be useful to any anaesthetist. I think in the actual thing this gets called the 6th podcast on here. Whoops.
Behind the scenes exclusive…
Anyway, here it is…
Right click and choose save as to download the podcast. (That’s control-click if you’re on a trusty Mac.)
Of course you could just find the podcast over at iTunes here.
It’s not even pretending to be the end of the story. Did you notice this whole site is set up so you can provide comments and clever thoughts? We’d love it if people took the chance to share their clever thoughts with the rest of us. Go hit that comment thing.
Of course any quick chat is the very start of wrestling with this topic. Following is a bunch of links for further reading for the anaesthetist finding the way to deliver periop care for these patients that works best in their hands.
Right. Well there’s a little light reading. Did you get this far? Maybe you should take a moment to listen to 2000 marbles playing music (with some guy I guess).
And if you like the stuff here there are at least two things you can consider doing. You could consider signing up to follow. Go with the email version and you’ll get a notification every time something drops.
Oh, and the image of the mic check dog was used unchanged under Creative Commons via flickr and posted by HaeckDesign.
You could also choose to give us hints on topics that should get covered. We are keen for guidance.
7 responses to “The ABCs of Ts and As – Podcast #5”
A great summary of T&As. Thanks Andrew & Kinch! I definitely recommend all anaesthetist doing t&a’s to tune in. I also sunscribe to patients waking up comfortable, rather than leaving recovery comfortable!
Fascinating and thought provoking podcast. I was hoping to have no questions after this but sadly…..
So a couple of things.
1. I am a user of morphine for intraop analgesia. I agree wholeheartedly with the small dose initially. I am less enthused about the titration. Our tonsillectomies take 20-25min. For me, this allows no time for titration and almost uniformly, when I have the patient breathing at 30/min after the small dose and I give another small dose, I have issues with profound sedation in recovery. I’d be interested to hear David’s thoughts on this given the delay to onset of peak respiratory depression with morphine cf other synthetic opiates. (Or maybe their tonsils take an hour?)
2. No mention was made of premedication. We have no access to clonidine in our setting, midazolam for me makes them very sedated and I’ve seen kids quite obtunded with it AND also profoundly dysphoric kids so I don’t use it. What I am using is a codeine/promethazine combo 60min pre induction which leaves me with an awake but pretty cooperative child. (And it may be a completely science free test of opiate sensitivity) What are you guys using a premedication in the “putative OSA” group?
3. We have no oxycodone syrup(in South Africa) – which leaves us in a bind for breakthrough pain post tonsillectomy.. I’m really reluctant to use codeine postop and haven’t prescribed it for at least 18months now (it helps me sleep at night to not use it on postop kids). So do we cast our patients on the rough seas of occasional unmanageable breakthrough pain? It’s a real issue here. Folks have suggested morphine syrup but that has a risk profile connotation that I can’t quite stomach (although i think that’s probably all in my head…). It would be more socially acceptable to have prescribed codeine and have an adverse event than to have prescribed (the arguably safer) morphine.
So yes.
Lots of questions. I somehow have to make peace that T/A’s will be giving me grey hair long after my hear has all gone grey of its own volition
Hi Mike, Thanks for the comments.
Regarding morphine, I think it is a great drug and I have used it for the overwhelming majority of TsAs cases I have done. I like it because it is a good analgesic and makes the kids a little more sedated when they wake up. I have moved to IV oxycodone only because it has recently become available, appears very similar to morphine in its action but seems to have less PONV. I agree that the titratability of morphine/oxycodone is harder but believe that oxycodone has a slightly faster onset but nonetheless neither is in the league of fentanyl. I have surgeons of varying times and believe that for both morph and oxycodone I can “get a second dose in” if I need to. I start with 0.05mg/kg pre-intubation for both morph or oxycodone and “titrate” with 0.025mg/kg dose. I have not and I do not know of anyone who has had apnoeas related to this schedule of opioids. but remember we are effectively using a half dose of morphine/oxycodone mixed with clonidine and parecoxib.
Just thinking about your statement of sedation after the case. We use no premeds and the same amounts of morphine and these kids are not very sedated post op. I wonder if the problem is the codeine/Phenergan premed. Paracetamol is about the limit for most kids as premed not withstanding the behaviourally challenging autistic kids who might get midazolam and/or ketamine (another topic).
Lastly in the context of no oxycodone, the variably large group of fast metabolisers and the absent metabolisers have removed codeine from our use. The mainstay of my post op time remains paracetamol and ibuprofen ( one regularly and other for breakthrough pain) with oxycodone for the rescue. 4 -6 doses of oxycodone cover most kids use in the entire postop course with some using nothing. I know there are some (not me) who have changed to tramadol from codeine but now US FDA and SPANZA have put out warnings and position statements respectively. my own sense is that morphine syrup has broadly the same issues with potential inadvertent and advertent misuse. Limiting the doses going home and matching medications to home capabilities would seem to be key.
Hope this helps
Thanks Andrew, this has been helpful
The ENT surgeon I have worked with is incredibly fast and so my anaesthetic often takes twice as long as the surgery. After gas induction I have used a propofol remifentanil TIVA in the interests of non muscle relaxant intubation, predictable extubation and intense analgaesia during the actual surgery.
I presume from the podcast that the technique described was gas induction, with propofol (any short acting opioid?) to facilitate intubation then maintenance with sevo and permissive hypercarbia to encourage spontaneous ventilation?
As a rural generalist anaesthetist I really appreciate the logistical discussion points particularly down to the minutiae of drug dosing. I’d really appreciate an even more blow by blow account of the topics you cover that appeal to a generalist audience.
What is the parecoxib /kg dose?
The great advice regarding opioid sparing agents which are also useful in preventing emergence delirium will get a trial on my next ENT list.
H, Thanks for the discussion.
Yes, it is a gas induction, canulation, iv oxycodone 0.05mg/kg, Clonidine 1mcg/kg, Dexamethasone 0.2 – 0.3mg/kg, propofol 2mg/kg followed by intubation. Sevo for the whole case. Short term ventilation until patient starts breathing then pressure support Sevo insp 1.5-2.5%.
I don’t use remi in this circumstance. It adds nothing that is not dealt with by other parts of technique. I use parecoxib 0.66mg/kg iv. I know others use 0.5 – 1 mg/kg.
Thanks and hope this helps
ps I don’t spray the cords (though I know many do) and don’t find any particular issues by not
Songs or Stories 
A great summary of T&As. Thanks Andrew & Kinch! I definitely recommend all anaesthetist doing t&a’s to tune in. I also sunscribe to patients waking up comfortable, rather than leaving recovery comfortable!
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[Waves] Hi Kim. So glad to have you drop in plus a vote for the super comfy.
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Fascinating and thought provoking podcast. I was hoping to have no questions after this but sadly…..
So a couple of things.
1. I am a user of morphine for intraop analgesia. I agree wholeheartedly with the small dose initially. I am less enthused about the titration. Our tonsillectomies take 20-25min. For me, this allows no time for titration and almost uniformly, when I have the patient breathing at 30/min after the small dose and I give another small dose, I have issues with profound sedation in recovery. I’d be interested to hear David’s thoughts on this given the delay to onset of peak respiratory depression with morphine cf other synthetic opiates. (Or maybe their tonsils take an hour?)
2. No mention was made of premedication. We have no access to clonidine in our setting, midazolam for me makes them very sedated and I’ve seen kids quite obtunded with it AND also profoundly dysphoric kids so I don’t use it. What I am using is a codeine/promethazine combo 60min pre induction which leaves me with an awake but pretty cooperative child. (And it may be a completely science free test of opiate sensitivity) What are you guys using a premedication in the “putative OSA” group?
3. We have no oxycodone syrup(in South Africa) – which leaves us in a bind for breakthrough pain post tonsillectomy.. I’m really reluctant to use codeine postop and haven’t prescribed it for at least 18months now (it helps me sleep at night to not use it on postop kids). So do we cast our patients on the rough seas of occasional unmanageable breakthrough pain? It’s a real issue here. Folks have suggested morphine syrup but that has a risk profile connotation that I can’t quite stomach (although i think that’s probably all in my head…). It would be more socially acceptable to have prescribed codeine and have an adverse event than to have prescribed (the arguably safer) morphine.
So yes.
Lots of questions. I somehow have to make peace that T/A’s will be giving me grey hair long after my hear has all gone grey of its own volition
LikeLike
Hi Mike, Thanks for the comments.
Regarding morphine, I think it is a great drug and I have used it for the overwhelming majority of TsAs cases I have done. I like it because it is a good analgesic and makes the kids a little more sedated when they wake up. I have moved to IV oxycodone only because it has recently become available, appears very similar to morphine in its action but seems to have less PONV. I agree that the titratability of morphine/oxycodone is harder but believe that oxycodone has a slightly faster onset but nonetheless neither is in the league of fentanyl. I have surgeons of varying times and believe that for both morph and oxycodone I can “get a second dose in” if I need to. I start with 0.05mg/kg pre-intubation for both morph or oxycodone and “titrate” with 0.025mg/kg dose. I have not and I do not know of anyone who has had apnoeas related to this schedule of opioids. but remember we are effectively using a half dose of morphine/oxycodone mixed with clonidine and parecoxib.
Just thinking about your statement of sedation after the case. We use no premeds and the same amounts of morphine and these kids are not very sedated post op. I wonder if the problem is the codeine/Phenergan premed. Paracetamol is about the limit for most kids as premed not withstanding the behaviourally challenging autistic kids who might get midazolam and/or ketamine (another topic).
Lastly in the context of no oxycodone, the variably large group of fast metabolisers and the absent metabolisers have removed codeine from our use. The mainstay of my post op time remains paracetamol and ibuprofen ( one regularly and other for breakthrough pain) with oxycodone for the rescue. 4 -6 doses of oxycodone cover most kids use in the entire postop course with some using nothing. I know there are some (not me) who have changed to tramadol from codeine but now US FDA and SPANZA have put out warnings and position statements respectively. my own sense is that morphine syrup has broadly the same issues with potential inadvertent and advertent misuse. Limiting the doses going home and matching medications to home capabilities would seem to be key.
Hope this helps
LikeLike
Thanks Andrew, this has been helpful
The ENT surgeon I have worked with is incredibly fast and so my anaesthetic often takes twice as long as the surgery. After gas induction I have used a propofol remifentanil TIVA in the interests of non muscle relaxant intubation, predictable extubation and intense analgaesia during the actual surgery.
I presume from the podcast that the technique described was gas induction, with propofol (any short acting opioid?) to facilitate intubation then maintenance with sevo and permissive hypercarbia to encourage spontaneous ventilation?
As a rural generalist anaesthetist I really appreciate the logistical discussion points particularly down to the minutiae of drug dosing. I’d really appreciate an even more blow by blow account of the topics you cover that appeal to a generalist audience.
What is the parecoxib /kg dose?
The great advice regarding opioid sparing agents which are also useful in preventing emergence delirium will get a trial on my next ENT list.
LikeLike
H, Thanks for the discussion.
Yes, it is a gas induction, canulation, iv oxycodone 0.05mg/kg, Clonidine 1mcg/kg, Dexamethasone 0.2 – 0.3mg/kg, propofol 2mg/kg followed by intubation. Sevo for the whole case. Short term ventilation until patient starts breathing then pressure support Sevo insp 1.5-2.5%.
I don’t use remi in this circumstance. It adds nothing that is not dealt with by other parts of technique. I use parecoxib 0.66mg/kg iv. I know others use 0.5 – 1 mg/kg.
Thanks and hope this helps
ps I don’t spray the cords (though I know many do) and don’t find any particular issues by not
LikeLike
@thomas5757 FWIW I don’t use opiates to facilitate intubation for my tonsillectomies. I simply spray the cords with 1ml of lignocaine 2%..
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