After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy!
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes
BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved
Anaesthesia. 2007 Jun;62(6):637
Category Archives: Kids
Acute Paediatrics
Decision instrument for head CT in children
A derivation then validation study was done on over 40000 children with head injuries to identify factors associated with clinically important brain injury. Prediction rules based on history and examination findings were developed for children younger than two years and for children two years and older. Both rules had high negative predictive values and may be useful tools in supporting the decision not perform a head CT.
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Lancet. 2009 Oct 3;374(9696):1160-70
Hypothermia reduced cerebral palsy in asphyxiated newborns
An RCT of induced hypothermia to 33.5 degrees for 72 hours was undertaken in 625 newborns at least 36 weeks gestation who had evidence of asphyxial encephalopathy.
The intervention (hypothermia) group had improved scores in mental, psychomotor, and gross motor function and a reduced risk of cerebral palsy. There was an increased rate of survival without neurological abnormality. Overall survival was not different between groups.
Moderate hypothermia to treat perinatal asphyxial encephalopathy
N Engl J Med. 2009 Oct 1;361(14):1349-58
New Paediatric DKA guidelines
The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.
Their summary:
• DKA is caused by either relative or absolute insulin deficiency.
• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently
• Begin with fluid replacement before starting insulin therapy.
• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.
• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.
• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy
• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion
• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.
• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.
• There is no evidence that bicarbonate is either necessary or safe in DKA.
• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.
• In case of profound neurological symptoms, mannitol should be given immediately.
• All cases of recurrent DKA are preventable.
Full guidelines available here
Other ISPAD guidelines available here
Small infant IJV cannulation tip
Simple taping using Transpore tape of the skin over the internal jugular vein insertion point increased IJV cross sectional area and AP diameter, and shortened to time to successful cannulation in this RCT on 28 infants and neonates undergoing cardiac surgery. Also, the degree of IJV collapse during advancement of the needle was less in the taped group.
The skin over the right IJV (RIJV) was lifted up with several pieces of tape in the cephalad and caudad directions. The skin cephalic to the RIJV was stretched cephalad, whereas the skin caudal to the RIJV was stretched caudad. The other ends of the tape were attached to the metal edge of the operating table.
A Novel Skin-Traction Method Is Effective for Real-Time Ultrasound-Guided Internal Jugular Vein Catheterization in Infants and Neonates Weighing Less Than 5 Kilograms
Anesth Analg. 2009 Sep;109(3):754-9
emergence with ketamine overstated
A prospective study of 746 children sedated in the emergency department with iv or im ketamine revealed 2.1% may have experienced ’emergence delirium’ although the authors concede this was difficult to define. In contrast, 291 (38%) reported pleasant altered perceptions. Follow up revealed at least one nightmare in the following weeks in 3.4% of patients, which may be well under the rate reported in the normal unsedated paediatric population.
What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?
Emerg Med Australas. 2009 Aug;21(4):315-22
Vasopressin in Pediatric Vasodilatory Shock
This Canadian multi-centre study on 65 children compared vasopressin infusions with placebo in children with vasodilatory shock who had already received fluid resuscitation and catecholamine infusions. No significant difference was observed in the primary endpoint of time to haemodynamic stability or the secondary endpoints of mortality, organ-failure–free days, length of critical care unit stay, and adverse events, although there was a trend toward increased mortality in the vasopressin group.
Vasopressin in Pediatric Vasodilatory Shock
Am J Respir Crit Care Med. 2009 Oct 1;180(7):632-9
Tracheal deviation in infants
It is common for the infant trachea to deviate to the right, with a frequency of 50% at one year, 25% at two years, 15% at three years and 6% at four years (tending not to occur in the over fives), but it may be missed on inspiratory chest films with the head in extension. In a case report from India, authors point out that anaesthetists are often unaware of this normal variant. Since many tracheal tubes are designed with the bevel facing left, the angled tracheal wall may occlude the distal outlet of the tube, necessitating repositioning of the tube higher in the trachea above the bend.
Anaesth Intensive Care. 2009 Jan;37(1):144-5
The relationship between body temperature, heart rate and respiratory rate in children
Vital signs from children seen at two emergency departments (but not admitted, so as to exclude those with serious illness) were examined to quantify the effect of temperature on heart rate (over 21000 cases) and respiratory rate (over 14000 cases).
A rule of thumb was derived showing an increase in heart rate of about 10 beats per minute for every 1 degree celcius above normal.
The relationship between temperature and respiratory rate was less easy to demonstrate because of the widening of the normal spread of respiratory rates as temperature increases. However, previous reports of an increase of 5-11 breaths per minute per degree are likely to be an over estimate; this study would suggest it is closer to 0.5-2 breaths per minute.
The authors plan further study to validate these findings.
The relationship between body temperature, heart rate and respiratory rate in children
Emerg Med J. 2009 Sep;26(9):641-3
Frog leg position for femoral vein cannulation
An ultrasound study of 80 children from 5 pre-determined age groups showed that the femoral veins increased their diameter in the frog-leg compared with straight-leg positions. Left and right femoral veins were the same size. There was significant overlap of the femoral arteries and veins which increased with distance distal to the inguinal ligament.
The Anatomic Relationship between the Common Femoral Artery and Common Femoral Vein in Frog Leg Position Versus Straight Leg Position in Pediatric Patients.
Acad Emerg Med. 2009 Jul;16(7):579-84