1. Pediatric Airway Compromise: OSA and Obesity Amanda Derby RN, BSN, SRNA York College of Pennsylvania/WellSpan Health Nurse Anesthetist Program

2. Objectives  Review Pediatric vs. Adult airway anatomy  OSA and Obesity  Common Procedures Seen and Complications  Anesthesia Implications and Management  Summary and Questions

5. Respiratory Center

6. Pediatric OSA…Not Just An Adult Issue

8. Obesity

11. Possible Facial Features Difficult Airway

12. Common Procedures for Airway Compromise  Tonsillectomy and Adenoidectomy (T & A)  Repeat Adenoidectomy  Bilateral Myringotomy Tubes (BMT)  Magnetic Resonance Imaging (MRI) Sedation

15. Anesthesia Implications and Management  Duty to Pre-op Assessment  Studies, labs, chart review, and most importantly discussion with the parents or if old enough the child – if it’s not in the chart then ask! Remember STBUR  Communication from the surgeon of what is needed from an anesthesia stand point and pre-op H&P for children not undergoing ENT or sedation  Pre-op sedation – Think alternative to Benzodiazapines  Ketamine or Dexmedetomidine  Pre-oxygenation and standard monitors while planning postop oxygenation – plan emergence on induction  Plan for management PONV  Multi-modal pain therapy – alternatives to opiods  Ketamine, toradol, acetaminophen, COX-2 inhibitors, dexmedetomidine, tramadol, dexamethasone, and regional when possible

16. Multi-Modal Pain Management and Sedation  Rectal or PO acetaminophen pre-op  10-15mg/kg po Q4-6hrs. and doses as high as 25-40mg/kg have been recommended for pre-op  Ketamine  0.5-1mg/kg IV  1-5mg/kg PO  5mg/kg IM  Toradol  0.25mg/kg – 0.5mg/kg Q6h for up to 48hrs.  Tramadol – mu1 agonist  30mg is equivalent to 10-12mg of Morphine  0.5mg/kg Tramadol = 0.1 mg/kg Morphine intra-op doses as high as 2mg/kg have been given  Dexmedetomidine  2mcg/kg intranasal = 0.5mg/kg po midazolam  0.5-1mcg/kg loading dose IV over 10 mins. and then titration 0.5-3mcg/kg/hr  Dexamethasone  0.15-0.2mg/kg PONV  0.5-0.625mg/kg Airway edema  COX-2 Inhibitors – Celebrex  Age 10kg and 25kg 100mg, capsules can be opened and mixed in food

17. Induction and Intraoperative Management  3 Words…..  Propofol  Sevoflurane  Dexmedetomidine

18. 13-18% (-31.3)28-34% (-55.4) Overall mean difference from low to high dose was 24.5 at the epiglottis

19. Dexmedetomidine

20. Emergence and PACU  Plan emergence on induction  Observation of airway on DL or LMA placement for postop management  CPAP and/or NC  Suction  Deep or awake  Emergence delirium  Patient positioning on bed  Lateral or supine with sniffing position…  Preparedness for airway emergency  Mask, emergency drugs, laryngoscope and tube or LMA  Multi-modal pain management  Discuss out patient meds w/surgeon if concern of airway compromise or possible admission if planned out patient  PACU RN education and parent education starts at pre-op