#2 – Myth’s Mistakes and Misconceptions in the Pediatric Population – Steven Auden, M.D.

Steven Auden, M.D., attending anesthesiologist at Kosair Children’s Hospital, discusses myths, mistakes and misconceptions in pediatric anesthesia.  Dr Auden is the Medical Director of Kosair Children’s Hospital Department of Anesthesiology and a Clinical Professor of Anesthesiology for the University of Louisville School of Medicine.  He is a board certified pediatric anesthesiologist and a Diplomate of the American Board of Anesthesiology and the American Board of Pediatrics.

Myths, Mistakes & Misconceptions In Pediatric Anesthesia by Dr. Steve Auden

Two Topics of Discussion:
1.  The Cricoid Ring.
2.  Cricoid Puncture.

Questions.
What is the narrowest point of the pediatric airway?
Is Cricoid Pressure (Sellick Maneuver) needed in pediatrics?
Should Atropine be given as a premedication in the pediatric population?
What is the minimal dose of Atropine?
Which is more potent Atropine or Glycopyrrolate?

So To Recap:
What’s the narrowest point in the pediatric airway?

  • The glottic opening just as in adults
  • Proven by Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg, 2009;108:1475-9
  • Supported again in the May 2009 issue of Anesthesia and Analgesia by Motoyama – The Shape of the Pediatric Larynx: Cylindrical or funnel shaped.

What’s to remember about Cricoid Pressure?

  • It is very difficult to do properly.
  • More Importantly. DO NOT inflate the stomach.
  • Pre-oxygenate very well
  • Do NOT attempt intubation until the pt is very deep.
  • Use a serial twitch monitor
  • It is NOT effective against forceful vomiting

Should Atropine be used routinely as a premedication?

  • No!
  • Unless there is a known history of bradycardia or disease process that is prone to bradycardia.
  • Supported by Johr in the 1999 issue of Pediatric Anaesthesia – Is it time to question the routine use of anticholinergic agents in pediatric

Glycopyrrolate versus Atropine which is more potent?

  • Given IV there is basically No Difference in Potency.
  • IM there is a difference. Why?
  • Glycopyrrolate is a quaternary ammonium – Big and does NOT cross the BBB. So no CNS Symptoms. (Lethargy, somnolence, Seizures)
  • Atropine is a Tertiary Amine – Smaller – DOES cross BBB.
  • In a Code situation maybe give 1 dose to follow protocol otherwise just go straight to Epi.

Cricoid puncture can be done in pediatrics, but it should be done by trained and qualified personnel.

 

Disclaimer
The information provided can NOT necessarily be applied to CRNA board questions as the content of boards may have not been updated to reflect the results of the studies and information discussed.  However, hopefully this will help to improve your knowledge base and personal practice.

 

References:

Cricoid Ring

Dalal, P. G., Murray, D., Messner, A. H., Feng, A., McAllister, J., & Molter, D. (2009). Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg, 108(5), 1475-1479. doi: 10.1213/ane.0b013e31819d1d99

Lerman, J. (2009). On cricoid pressure: “may the force be with you”. Anesth Analg, 109(5), 1363-1366. doi: 10.1213/ANE.0b013e3181bbc6cf

Motoyama, E. K. (2009). The shape of the pediatric larynx: cylindrical or funnel shaped? Anesth Analg, 108(5), 1379-1381. doi: 10.1213/ane.0b013e31819ed494

Ovassapian, A., & Salem, M. R. (2009). Sellick’s maneuver: to do or not do. Anesth Analg, 109(5), 1360-1362. doi: 10.1213/ANE.0b013e3181b763c0

Rice, M. J., Mancuso, A. A., Gibbs, C., Morey, T. E., Gravenstein, N., & Deitte, L. A. (2009). Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg, 109(5), 1546-1552. doi: 10.1213/ane.0b013e3181b05404

Weiss, M., & Gerber, A. C. (2008). Rapid sequence induction in children — it’s not a matter of time! Paediatr Anaesth, 18(2), 97-99. doi: 10.1111/j.1460-9592.2007.02324.x

 

Glycopyrrolate

Barrington, K. J. (2011). The myth of a minimum dose for atropine. Pediatrics, 127(4), 783-784. doi: 10.1542/peds.2010-1475

Haas, R. E., Johnson, T. W., Werlinger, D. J. (1987). Cardiovascular effect of atropine and glycopyrrolate on anesthetized children. Journal of the American Association of Nurse Anesthetist, 55(6), 559-538.

Johr, M. (1999). Is it time to question the routine use of anticholinergic agents in paediatric anaesthesia. Paediatric Anaesthesia(9), 99-101.

Lavis, D. M., Lunn, J. N., Rosen, M. . (1980). Glycopyrrolate in Children. Anaesthesia,  35, 1068-1071.

Zimmerman, M. D., Steward, D. J. . (1986). Bradycardia Delays the Onset of Action of Intravenous Atropine in Infants. Anesthesiology, 65, 320-322.

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