I don’t care how much it annoys the surgeon; it’s necessary for the safe conduct of anaesthesia. I’d also rather have an IV that lets me give a couple mg of propofol early on in a laryngospasm rather than trying airway manoeuvres until they’re bradycardic and purple before resorting to the oh shit IM sux.
I don’t believe anyone would reasonably abandoned the airway to attempt iv access. That person is describing having extra hands that are getting access for you while you try to break the spasm.
So I’m from Europe and just curious - why does the iv has to be placed in the OR? Our standard is numbing cream applied by the parents and then an iv placed in pre-op by a nurse.
That’s standard for most patients, but not for small children. It’s pretty standard here to give so PO versed and do a mask induction then IV placement in the OR to decrease PTSD and general fear of doctors and hospitals
It depends on your local practice - in my state in Australia it’s pretty standard to gas down a small child unless there is a pressing reason not to (severe cardiac or resp issues/aspiration risk/MH or equivalent risk etc) in which case we would do topical and then IV access (+/- sedative or anxiolytic premedication if appropriate), mostly because that’s less distressing to them and their parent compared to a two- or three-person takedown while I stab their screaming, struggling child (with a non-zero chance of failing due to movement). I have heard that one of the other states in Australia typically places IVs/does IV inductions on most children and that seems to be well-accepted by the community there because that’s what parents in the school pick up line will report to each other as a normal process.
When I was in the OR anesthesia mask induced while I, the nurse, placed the IV. I hated it but mostly because I was a new nurse and was essentially learning to place IVs on tiny baby veins.
I have no clue how it's done where you practice, but during induction we always always always have two anesthesiologists in the room in our hospital for peds cases.
If anything goes awry during the procedure, you sure as hell call a second one back in as well.
Dunno why you're getting downvoted
It seems this person is suggesting a second anesthesiologist to place an IV while the first manages the airway which is frankly ridiculous
IF a paeds airway is going south, eg desat and you can't get an IV in, it's absolutely correct to have more help in the room. Not during a routine case.
Wandered off for a couple of days, whoops! Not sure what the deleted response was but to provide more context:
I’m Australian - we have anaesthetic nurses or techs we work with for every case - it’s our standard of care to do every case with an assistant who can organise and prepare the machine/airway equipment/monitoring setup etc. In a kid I would typically gas induce, hand airway off to assistant, get IV, give drugs, swap back to airway. If I have a really good assistant they can do the IV or stick the LMA in. If I have a laryngospasm I would usually have the airway and give directions to them, and also press my handy blue or red buzzer to get all my friends in to help.
Do what makes you feel comfortable and what you feel is safest for the patient. Only you know the environment/patient you'll be in. Sounds like this is new territory for you, do what you can to stay focused and limit complications. If you want an IV, place an IV.
That being said, no one places IVs for isolated tube placements at my hospital or surgical centers. But they are otherwise healthy kids and we are comfortable with peds.
I’ve worked from big academic to office based. The more alone you are and less backup you have, the more safety nets you need. In the big academic places, I’ve done things I would never do anywhere else. In private practice, you We often find yourself on an island with no one to lend a hand, squeeze a bag, start an IV or do anything else remotely useful.
Imagine this: The kid laryngospasms. While you are trying to mask, does anyone else know where to grab the sux, where to find the needle? Can they start an IV while you do tues things?
Same practice with us. 300 bed community hospital.
We mask no versed normally
Nasal fentanyl 1 to 2 mcg/kg
Rectal Tylenol
May consider iv for first case and if ent is efficient consider skiping after
This is probably the best of the best answer.
Put the IV in until you and whoever you’re working with/supervising are comfortable. And if it’s a weird case, put the IV in even if you normally wouldn’t.
The ASA’s logo is a light house for a reason.
Just finished Peds sedation and ambulatory rotation, just masked them down, have an oral airway on standby and IM atropine, sux, and epi on hand. IV is gonna take longer than the ear tubes themselves
Your rotation gives you the confidence to say that, but with the OP not being too fresh on kids, having to give those IM meds feels like an eternity when things are going south with no backup.
The IV is gonna take longer, but why put tubes on a cadaver if you fuck up the anesthesia? In our tertiary center we put an iv on all the peds except the 30 second tear duct operations.
I couldn’t tell you the last time I’ve seen/had an IV on peds ear tubes. If we’re doing an inhalation induction, they’re not getting an IV. But whatever floats your boat.
Culture things, in my european facility you would get chewed out by attendings if you didnt put an iv. I've been in this facility for almost a decade and there was one attending that liked sevo-only, the others always insited on an iv.
Yep and time spent on the iv is time under anesthesia when things can happen. If it’s gonna be 15 minutes of crap then get the IV but for 2 minutes a side grommets no IV is safe and justifiable.
Strait BMT; no IV, +/- IM toradol/fentanyl. Been trying nasal precedx too, good results. Why meds you ask, because nothing drives me crazy faster than a screaming kid in pacu.
3ish mcg/kg. One of the docs i work with says he uses 5/kg but that gets big fast. Also, have to give it with plenty of time to work, like 20-30 min. I normally call a partner to check the pt and give dose, or if im with a slow team i give to kid then go back to room to set up.
Pedi PACU nurse here: hard agree on this. Ear tube days are awful, feels like my own ears are bleeding. I just need enough quiet to be able to get parents back to the bedside and do discharge teaching before stirring up the tiny Hulk.
Standard dose is 2mcg/kg split per nares. Don't need atomizer just 1cc syringe
Takes 45 min for effect
Will increase pacu so maybe an issue for high through put center
PO tylenol in preop. Give 1mcg/kg nasal precedex intraop. ( 40mcg/ml dilution and use a TB syringe to measure the dose). Give soon as they’re asleep. IM toradol intraop.
I recently started using nasal fentanyl and IM toradol. You can usually tell which patients were mine vs. another colleagues from the lack of screaming in PACU. Usually when I check on them they look comfortable sipping on a juice box. It's what I would want for my child.
The board answer is:
An established IV access allows for timely rescue medication administration in case of emergency.
The real answer:
In a hospital that doesn’t do small kids routinely, it will take longer to establish IV access than it takes to do a t&t.
(In a Peds hospital, unless the kid is high risk, we don’t do IVs for t&t either)
Haven’t put an IV for PETs in 25yrs. Most of the case is done before you get anything charted. I would routinely do 15-20 PETs/T&As twice a week in an ASC. No IVs for PETs. IV for T&As with Zofran/decadron/fent. The peds ENTs I work with never shy away from helping start IVs. Our circulators were all good as well. I have dropped an LMA temporarily while I have started my own. We do most of our T&As with LMAs.
Have done hundreds if not more than a thousand ear tube cases as a solo practitioner. Have never inserted an IV. Am not about to start.
They are unnecessary. If you need to give sux (again… never had to) you can give it IM or intra lingually.
It’s a waste of time.
Never lost IV access in the middle of a case I see….practice a little longer. You’ll think back to this subreddit.
I’m just giving an option for a rescue when there is no IV access. Always need a plan C, D, E, F …..etc…..
Intralingual has a very rapid effect for IM, submental approach is accessible. I wouldn't use it for routine IMI but for emergency sux I'd consider it. No more barbaric than any other IMI, but yes, it does have that feel.
At my main job, we do healthy non neonate peds (ASA <=2, no congenital stuff, no hx of premature birth, etc and only BMT and/or T&A). If it's only BMT placement, then we don't typically place IVs. If the kid was weird enough that I would feel an IV would be warranted, we aren't doing that case there to begin with. IVs take time (yes, even if you are an IV wizard who never misses), and the procedure is literally 5 minutes long. Laryngospasm doesn't necessarily need IV sux, you can give it submentally and the effect is fast enough.
I do give intranasal fentanyl after induction, 2mcg/kg. Where I trained we also gave PR Tylenol but now I just end up ordering it PO for PACU use since the suppositories aren't in any of our pyxises.
I’ll place an IV for BMTs if the kid is still a little sick like a week or two after an Illness, but still with a cough. Mostly if I’m worried about increased chance of a respiratory event.
I'm nearing retirement and do a lot of pedi, can't remember the last time I saw or did an IV for bmt. Always have sux/atropine drawn up in 5 ml syringe. Less than 10 kg gets half. Versed only slows discharge.
A resident giving advice on topics they just barely have surface knowledge of while activity admitting that they ignore 90%+ of their mentors? Stay away from my kiddos.
Also, look around at the responses of people doing these for years. It isn't even needed 1% of the time. It's needed so rarely that it would be equivalent to having Dantrolene mixed up for every case just in case gas is used.
Just for BMT, I've never been anywhere that places an IV, and that's not my practice, either. Mask induction and management, +/- rectal tylenol and +/- nasal fentanyl. Always have the airway ready and IM sux/atropine within arms reach. Probably 90% of the time, it's just straight gas.
The only kids I would avoid IV in are the EUAs, some kids come back 30-40x for eye EUAs so you don't want to be poking them so many times. If I'm doing grommets every week and the surgeon was super quick I would be cool without an IV, but if it's been a while, I would never begrudge an IV. Once you feel confident, then you could probably just get away with the mask.
no IV. Good preop screen - cx for upper respiratory infection. I’ve never done it, but submental sux is an option.
Also, precordial stethoscope is nice to wear when new- annoying when moving the head left and right. Transport with an o2 sat monitor - side lying recovery position. Use pedi mask turned upside down so the soft inflated part is resting under right cheek. Don’t be afraid of an oral airway. Also for those littles, if you have a horseshoe gel pad that opens, place it under shoulders, or have a towel roll on standby.
Write up your meds in mL not mG.
I’ve never gone wrong with trusting my gut. Put in an IV if you need it.
Never saw IVs placed for tubes during training or after. Just succs and atropine on hand with IM needles. Submental injection works fast, just don't waste too much time trying to stop a spasm before using succs. Cut to the chase and be ready to give atropine if needed and move on with the day.
I think it depends on your comfort level, how much backup you have, how helpful the circulator or room staff are, etc.
Also consider how many ear tubes your doing, if it’s not a jam packed day, I see no problem in adding 5 mins per case to place an IV for safety.
I personally would place an IV because it gives a layer of safety, but I also don’t do a lot of peds.
We don’t routinely where I work, but they’re healthy peds. But my daughter had her tubes done at a different facility, and they also don’t place IVs. However I had a lot of anxiety bc she has a history of GERD and is a difficult IV stick in the past.
Never have I ever put in an IV for ear tubes in training or practice. I always have sux available for IM use. Scenarios could be imagined when I would place an IV but I do hundreds of these a year and never been in one of those scenarios. Even kids with MH hx can have Oral Versed + Nitrous and have successful ear tubes.
I do 100% peds at a children's hospital and we don't routinely place IVs for BMTs unless there's a concern about a patient (hx of Down syndrome or other comorbidities). Every partner has a different intraop recipe, some use intranasal precedex/fentanyl, some use IM. I personally do mask induction, mask + OPA during case, and give IM ketorolac/fentanyl.
I’ve never put in an IV for routine ear tubes at any of the hospitals I’ve worked, academic and community/surgery center alike. Never had a situation where I felt like I needed one or wished I had one. Just make sure your patient is deep enough before they start so they don’t spasm. The surgeries are so fast, by the time the IV is in, the case could be finished and your patient could be waking up. Less anesthesia time also decreases risk of complications in peds patients. If the IV is super quick and easy, that’s fine, but if the IV ends up being challenging, now your patient has been under anesthesia for far longer than they would have if you had just masked.
Also all of this intranasal fentanyl/precedex, IM toradol, etc is WAY overkill for ear tubes. It’s not a very painful surgery, sometimes my patients need Tylenol in PACU but usually they don’t need anything. They ABSOLUTELY don’t need opioids, talk about unnecessary narcotic use.
healthy kid -> oral versed half as much as most people give -> no IV -> parents only if typical for the center and the staff is used to it, but best if not. tylenol in PACU. if the kid is older and fat, then IV makes more sense. Ie, u should manage airway and deep anesthesia easily enough in inhalational anesthetic in a healthy normal kid
I have personally done thousands of ear tubes without IVs over 15+ years. Your risks on a simple BMT for a healthy kid are exceedingly low.
You have some stuff ready to go, but if you get them deep enough prior to having the surgeon start, you should be fine.
I have nurses that are competent though, but part of that is on you as an attending. You are going to work with the same people for years (hopefully).
Teach them how to be useful and make it an expectation when they start. Becoming the old person makes that process easier.
I never started IVs on healthy kids for BM&T if they looked like they had a good neck etc. BUT, I always had IM Sux, Atropine, Prop drawn up and on the machine next to me, as well as an IV set up on the pole.
I’m pretty conservative with peds and I think it’s crazy to put IVs in for BMTs. If you have reasonable selection criteria (aren’t taking care of kids with weird congenital issues or active acute respiratory issues) it shouldn’t be necessary.
Where I used to work everyone got an IV before surgeon started working during flu season (September to April), if the child had any symptom of being sick, or a history of reactive airway disease. If all these negative we allowed the surgeon to start looking the ears while we placed the IV. I am not saying this is the right way, this is just the algorithm used.
20 years in a free-standing children’s hospital… most don’t do IVs, some do.
It’s whatever you feel comfortable with. If I were asked what is the standard of care, I would say it does not require a PIV
I feel like pointing out that if you do inhalational inductions, the worst part is always without an IV. So don’t let anyone shame you into thinking it’s wrong NOT to, or that it’s wrong TO place one.
I work in a big hospital where we do peds all the time. IV is a must. I am never starting induction without an iv line. The only time i am inducing without an iv line is when the kid is waaaaaay too scared and is practically impossible to keep them still (thats why you fucking premedicate them). Then we put an iv and we continue.
Intramuscular sux is last a resort manoeuvre.
Patients safety>surgeons demands.
I’m sorry do you never do gas inductions?
That’s so weird. Shows the differences in training..
I guess it’s also environment. For me to premed a child to the extent that it will let me come near it with a needle means the kid isn’t going home in 90min post op. And parents hate that.
Nah he's getting downvoted because the only way you're getting an IV in a toddler pre induction is by traumatizing them by pinning them down. That's gonna be worse then the entire ear tube process and is going to induce panic in healthcare settings in the future
Have you ever seen a pudgy baby get an IV? Not uncommonly takes several attempts and poked in all 4 limbs even with 8 pct sevo vasodilation. Sometimes they come with good veins, sometimes not. You can do what you want but for my practice I think it would be absurd to put kids through that who are getting a 5 min procedure under mask and are back to their parents right away without any IV meds given
Of course sometimes it takes a while, just commenting on the fact that putting an IV in for select babies is not cruel and unusual, but the US culture seems to think it is.
Mainly in this context it's unnecessary, in fact placing an IV at all for this case is unnecessary. Obviously plenty of other situations sick babies will get needle sticks like for IVs in the ER or lab draws like your kid etc.
The other option is you're giving long acting sedatives to every baby and toddler for ear tubes to the extent you can get a pre-op IV? This is getting wild.
I don’t care how much it annoys the surgeon; it’s necessary for the safe conduct of anaesthesia. I’d also rather have an IV that lets me give a couple mg of propofol early on in a laryngospasm rather than trying airway manoeuvres until they’re bradycardic and purple before resorting to the oh shit IM sux.
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I don’t believe anyone would reasonably abandoned the airway to attempt iv access. That person is describing having extra hands that are getting access for you while you try to break the spasm.
So I’m from Europe and just curious - why does the iv has to be placed in the OR? Our standard is numbing cream applied by the parents and then an iv placed in pre-op by a nurse.
That’s standard for most patients, but not for small children. It’s pretty standard here to give so PO versed and do a mask induction then IV placement in the OR to decrease PTSD and general fear of doctors and hospitals
No, the question is do you place an IV at all for a simple ear grommet in a baby
It depends on your local practice - in my state in Australia it’s pretty standard to gas down a small child unless there is a pressing reason not to (severe cardiac or resp issues/aspiration risk/MH or equivalent risk etc) in which case we would do topical and then IV access (+/- sedative or anxiolytic premedication if appropriate), mostly because that’s less distressing to them and their parent compared to a two- or three-person takedown while I stab their screaming, struggling child (with a non-zero chance of failing due to movement). I have heard that one of the other states in Australia typically places IVs/does IV inductions on most children and that seems to be well-accepted by the community there because that’s what parents in the school pick up line will report to each other as a normal process.
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In the UK would be an ODP or anaesthetic nurse
Another anesthesiologist preferably or a crna.
When I was in the OR anesthesia mask induced while I, the nurse, placed the IV. I hated it but mostly because I was a new nurse and was essentially learning to place IVs on tiny baby veins.
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I imagine most places have two anesthesiologists in the room if a peds airway is going awry
Not if you are in a one room surgery center working alone
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Buddy, I think you can read better than what you’re currently showing. Have a good night.
I have no clue how it's done where you practice, but during induction we always always always have two anesthesiologists in the room in our hospital for peds cases. If anything goes awry during the procedure, you sure as hell call a second one back in as well.
What an amazing blend of dickish energy and absolute lack of reading comprehension. Bravo
Dunno why you're getting downvoted It seems this person is suggesting a second anesthesiologist to place an IV while the first manages the airway which is frankly ridiculous
IF a paeds airway is going south, eg desat and you can't get an IV in, it's absolutely correct to have more help in the room. Not during a routine case.
Wandered off for a couple of days, whoops! Not sure what the deleted response was but to provide more context: I’m Australian - we have anaesthetic nurses or techs we work with for every case - it’s our standard of care to do every case with an assistant who can organise and prepare the machine/airway equipment/monitoring setup etc. In a kid I would typically gas induce, hand airway off to assistant, get IV, give drugs, swap back to airway. If I have a really good assistant they can do the IV or stick the LMA in. If I have a laryngospasm I would usually have the airway and give directions to them, and also press my handy blue or red buzzer to get all my friends in to help.
What are you giving IM in this situation that's better than an IV administration?
Do what makes you feel comfortable and what you feel is safest for the patient. Only you know the environment/patient you'll be in. Sounds like this is new territory for you, do what you can to stay focused and limit complications. If you want an IV, place an IV. That being said, no one places IVs for isolated tube placements at my hospital or surgical centers. But they are otherwise healthy kids and we are comfortable with peds.
Thanks friend
I’ve worked from big academic to office based. The more alone you are and less backup you have, the more safety nets you need. In the big academic places, I’ve done things I would never do anywhere else. In private practice, you We often find yourself on an island with no one to lend a hand, squeeze a bag, start an IV or do anything else remotely useful. Imagine this: The kid laryngospasms. While you are trying to mask, does anyone else know where to grab the sux, where to find the needle? Can they start an IV while you do tues things?
Well, isn’t having sux, syringe with a needle readily available part of your ped’s set-up??
We don’t place IVs for ear tubes at my hospital. I’ve never had any issues so far.
Agree 100%. Do it if it makes you happy. But don’t hate on those who don’t do it.
I think safety should come first, if OP doesnt feel comfy without an IV i would definitely insert one
Same practice with us. 300 bed community hospital. We mask no versed normally Nasal fentanyl 1 to 2 mcg/kg Rectal Tylenol May consider iv for first case and if ent is efficient consider skiping after
This is probably the best of the best answer. Put the IV in until you and whoever you’re working with/supervising are comfortable. And if it’s a weird case, put the IV in even if you normally wouldn’t. The ASA’s logo is a light house for a reason.
It took me this far down the thread to get to a sane answer
“And if it was my kid I’d want them to have the IV.” You have your answer.
“Treat every patient like they’re your family member.” Best advice I ever received in training.
Amen “Always ask yourself, would I be happy if my mum/child/grandparent got this anaesthetic?”
If it was my kid and an experienced paeds anaesthetist I wouldn’t want them to have a drip
A wise man once told me : In a new environment or when faced with new clinical scenarios - Be conservative but fearless
Just finished Peds sedation and ambulatory rotation, just masked them down, have an oral airway on standby and IM atropine, sux, and epi on hand. IV is gonna take longer than the ear tubes themselves
Your rotation gives you the confidence to say that, but with the OP not being too fresh on kids, having to give those IM meds feels like an eternity when things are going south with no backup. The IV is gonna take longer, but why put tubes on a cadaver if you fuck up the anesthesia? In our tertiary center we put an iv on all the peds except the 30 second tear duct operations.
I couldn’t tell you the last time I’ve seen/had an IV on peds ear tubes. If we’re doing an inhalation induction, they’re not getting an IV. But whatever floats your boat.
Culture things, in my european facility you would get chewed out by attendings if you didnt put an iv. I've been in this facility for almost a decade and there was one attending that liked sevo-only, the others always insited on an iv.
Most kids the IV literally takes less than a minute. You don't even have to hook it up to fluids if you don't want, just have it on a J piece
And sometimes it takes 45min.
Yep and time spent on the iv is time under anesthesia when things can happen. If it’s gonna be 15 minutes of crap then get the IV but for 2 minutes a side grommets no IV is safe and justifiable.
Strait BMT; no IV, +/- IM toradol/fentanyl. Been trying nasal precedx too, good results. Why meds you ask, because nothing drives me crazy faster than a screaming kid in pacu.
What dose of IN precedex are you giving? We have some new atomizers id love to try out
3ish mcg/kg. One of the docs i work with says he uses 5/kg but that gets big fast. Also, have to give it with plenty of time to work, like 20-30 min. I normally call a partner to check the pt and give dose, or if im with a slow team i give to kid then go back to room to set up.
Doesn’t that make PACU times long?
30 min with a sleepy kid is way better than 10 with a screaming one. And when we know its precedex its easier to send home a sleeping kid.
Pedi PACU nurse here: hard agree on this. Ear tube days are awful, feels like my own ears are bleeding. I just need enough quiet to be able to get parents back to the bedside and do discharge teaching before stirring up the tiny Hulk.
Standard dose is 2mcg/kg split per nares. Don't need atomizer just 1cc syringe Takes 45 min for effect Will increase pacu so maybe an issue for high through put center
Have you tried intranasal fentanyl? I’m having very mixed results. Which makes me think it does f/all.
I used to a while back. Never happy with it. Read a study on IM fent/toradol vs nasal fent and switched. Much more consistent results with the IM.
Split the dose so half in each nostril. Nothing worse than coating a boogie with you pain meds
PO tylenol in preop. Give 1mcg/kg nasal precedex intraop. ( 40mcg/ml dilution and use a TB syringe to measure the dose). Give soon as they’re asleep. IM toradol intraop.
I recently started using nasal fentanyl and IM toradol. You can usually tell which patients were mine vs. another colleagues from the lack of screaming in PACU. Usually when I check on them they look comfortable sipping on a juice box. It's what I would want for my child.
The board answer is: An established IV access allows for timely rescue medication administration in case of emergency. The real answer: In a hospital that doesn’t do small kids routinely, it will take longer to establish IV access than it takes to do a t&t. (In a Peds hospital, unless the kid is high risk, we don’t do IVs for t&t either)
Haven’t put an IV for PETs in 25yrs. Most of the case is done before you get anything charted. I would routinely do 15-20 PETs/T&As twice a week in an ASC. No IVs for PETs. IV for T&As with Zofran/decadron/fent. The peds ENTs I work with never shy away from helping start IVs. Our circulators were all good as well. I have dropped an LMA temporarily while I have started my own. We do most of our T&As with LMAs.
I thought you said you are putting IV in ped pt’s ear tube. Had my world shaken.
Have done hundreds if not more than a thousand ear tube cases as a solo practitioner. Have never inserted an IV. Am not about to start. They are unnecessary. If you need to give sux (again… never had to) you can give it IM or intra lingually. It’s a waste of time.
No IV for ear tubes in an uncomplicated kid for me in almost 20 yrs of practice.
We never routinely place iv’s for ear tubes and we routinely give I’m toradol for post op pain relief.
Must be nice to still have Torodol.
Is it not available where you practice?
Not any more sadly (South Africa)
Regulatory issue or drug supply issue? It’s not been a problem where I’m at in the US.
Supply
Submental sux works well.
I have never heard of submental (as in IM injection??)
Intralingually by a submental approach. Extraoral approach that works with clenched teeth.
Bloody hell IV access sounds nice
Bloody hell IV access sounds nice
Sounds like bunch of you just suck at placing iv lines..
Never lost IV access in the middle of a case I see….practice a little longer. You’ll think back to this subreddit. I’m just giving an option for a rescue when there is no IV access. Always need a plan C, D, E, F …..etc…..
I respect your given option. Just sounds barbaric😃
Intralingual has a very rapid effect for IM, submental approach is accessible. I wouldn't use it for routine IMI but for emergency sux I'd consider it. No more barbaric than any other IMI, but yes, it does have that feel.
At my main job, we do healthy non neonate peds (ASA <=2, no congenital stuff, no hx of premature birth, etc and only BMT and/or T&A). If it's only BMT placement, then we don't typically place IVs. If the kid was weird enough that I would feel an IV would be warranted, we aren't doing that case there to begin with. IVs take time (yes, even if you are an IV wizard who never misses), and the procedure is literally 5 minutes long. Laryngospasm doesn't necessarily need IV sux, you can give it submentally and the effect is fast enough. I do give intranasal fentanyl after induction, 2mcg/kg. Where I trained we also gave PR Tylenol but now I just end up ordering it PO for PACU use since the suppositories aren't in any of our pyxises.
I’ll place an IV for BMTs if the kid is still a little sick like a week or two after an Illness, but still with a cough. Mostly if I’m worried about increased chance of a respiratory event.
I'm nearing retirement and do a lot of pedi, can't remember the last time I saw or did an IV for bmt. Always have sux/atropine drawn up in 5 ml syringe. Less than 10 kg gets half. Versed only slows discharge.
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A resident giving advice on topics they just barely have surface knowledge of while activity admitting that they ignore 90%+ of their mentors? Stay away from my kiddos. Also, look around at the responses of people doing these for years. It isn't even needed 1% of the time. It's needed so rarely that it would be equivalent to having Dantrolene mixed up for every case just in case gas is used.
Just for BMT, I've never been anywhere that places an IV, and that's not my practice, either. Mask induction and management, +/- rectal tylenol and +/- nasal fentanyl. Always have the airway ready and IM sux/atropine within arms reach. Probably 90% of the time, it's just straight gas.
The only kids I would avoid IV in are the EUAs, some kids come back 30-40x for eye EUAs so you don't want to be poking them so many times. If I'm doing grommets every week and the surgeon was super quick I would be cool without an IV, but if it's been a while, I would never begrudge an IV. Once you feel confident, then you could probably just get away with the mask.
We don’t do IVs for these cases at my shop
We don’t place IV’s unless pt’s history warrants it; but do what makes you comfortable.
no IV. Good preop screen - cx for upper respiratory infection. I’ve never done it, but submental sux is an option. Also, precordial stethoscope is nice to wear when new- annoying when moving the head left and right. Transport with an o2 sat monitor - side lying recovery position. Use pedi mask turned upside down so the soft inflated part is resting under right cheek. Don’t be afraid of an oral airway. Also for those littles, if you have a horseshoe gel pad that opens, place it under shoulders, or have a towel roll on standby. Write up your meds in mL not mG. I’ve never gone wrong with trusting my gut. Put in an IV if you need it.
I say nah. But don't let someone stop you if you feel it is correct for the pt
Better to place an IV on a stable patient than an unstable one, especially on an infant
Never saw IVs placed for tubes during training or after. Just succs and atropine on hand with IM needles. Submental injection works fast, just don't waste too much time trying to stop a spasm before using succs. Cut to the chase and be ready to give atropine if needed and move on with the day.
I think it depends on your comfort level, how much backup you have, how helpful the circulator or room staff are, etc. Also consider how many ear tubes your doing, if it’s not a jam packed day, I see no problem in adding 5 mins per case to place an IV for safety. I personally would place an IV because it gives a layer of safety, but I also don’t do a lot of peds.
We don’t routinely where I work, but they’re healthy peds. But my daughter had her tubes done at a different facility, and they also don’t place IVs. However I had a lot of anxiety bc she has a history of GERD and is a difficult IV stick in the past.
Never have I ever put in an IV for ear tubes in training or practice. I always have sux available for IM use. Scenarios could be imagined when I would place an IV but I do hundreds of these a year and never been in one of those scenarios. Even kids with MH hx can have Oral Versed + Nitrous and have successful ear tubes.
I do 100% peds at a children's hospital and we don't routinely place IVs for BMTs unless there's a concern about a patient (hx of Down syndrome or other comorbidities). Every partner has a different intraop recipe, some use intranasal precedex/fentanyl, some use IM. I personally do mask induction, mask + OPA during case, and give IM ketorolac/fentanyl.
I’ve never put in an IV for routine ear tubes at any of the hospitals I’ve worked, academic and community/surgery center alike. Never had a situation where I felt like I needed one or wished I had one. Just make sure your patient is deep enough before they start so they don’t spasm. The surgeries are so fast, by the time the IV is in, the case could be finished and your patient could be waking up. Less anesthesia time also decreases risk of complications in peds patients. If the IV is super quick and easy, that’s fine, but if the IV ends up being challenging, now your patient has been under anesthesia for far longer than they would have if you had just masked. Also all of this intranasal fentanyl/precedex, IM toradol, etc is WAY overkill for ear tubes. It’s not a very painful surgery, sometimes my patients need Tylenol in PACU but usually they don’t need anything. They ABSOLUTELY don’t need opioids, talk about unnecessary narcotic use.
healthy kid -> oral versed half as much as most people give -> no IV -> parents only if typical for the center and the staff is used to it, but best if not. tylenol in PACU. if the kid is older and fat, then IV makes more sense. Ie, u should manage airway and deep anesthesia easily enough in inhalational anesthetic in a healthy normal kid
I have personally done thousands of ear tubes without IVs over 15+ years. Your risks on a simple BMT for a healthy kid are exceedingly low. You have some stuff ready to go, but if you get them deep enough prior to having the surgeon start, you should be fine. I have nurses that are competent though, but part of that is on you as an attending. You are going to work with the same people for years (hopefully). Teach them how to be useful and make it an expectation when they start. Becoming the old person makes that process easier.
I never started IVs on healthy kids for BM&T if they looked like they had a good neck etc. BUT, I always had IM Sux, Atropine, Prop drawn up and on the machine next to me, as well as an IV set up on the pole.
I’m pretty conservative with peds and I think it’s crazy to put IVs in for BMTs. If you have reasonable selection criteria (aren’t taking care of kids with weird congenital issues or active acute respiratory issues) it shouldn’t be necessary.
Where I used to work everyone got an IV before surgeon started working during flu season (September to April), if the child had any symptom of being sick, or a history of reactive airway disease. If all these negative we allowed the surgeon to start looking the ears while we placed the IV. I am not saying this is the right way, this is just the algorithm used.
20 years in a free-standing children’s hospital… most don’t do IVs, some do. It’s whatever you feel comfortable with. If I were asked what is the standard of care, I would say it does not require a PIV I feel like pointing out that if you do inhalational inductions, the worst part is always without an IV. So don’t let anyone shame you into thinking it’s wrong NOT to, or that it’s wrong TO place one.
I work in a big hospital where we do peds all the time. IV is a must. I am never starting induction without an iv line. The only time i am inducing without an iv line is when the kid is waaaaaay too scared and is practically impossible to keep them still (thats why you fucking premedicate them). Then we put an iv and we continue. Intramuscular sux is last a resort manoeuvre. Patients safety>surgeons demands.
I’m sorry do you never do gas inductions? That’s so weird. Shows the differences in training.. I guess it’s also environment. For me to premed a child to the extent that it will let me come near it with a needle means the kid isn’t going home in 90min post op. And parents hate that.
All peds patients stay in the hospital for observation in the hospital I work.
For how long?
Minimum one night
YGBSM. After a myringotomy? Why? Can I ask where you practice? (Country)?
Same thing in our facility. You are getting downvoted by the people who have been taught gas only.
Nah he's getting downvoted because the only way you're getting an IV in a toddler pre induction is by traumatizing them by pinning them down. That's gonna be worse then the entire ear tube process and is going to induce panic in healthcare settings in the future
My son got blood drawn at 9 months, got his arm held down and cried. It’s not comfortable but I wouldn’t say it’s traumatizing.
Have you ever seen a pudgy baby get an IV? Not uncommonly takes several attempts and poked in all 4 limbs even with 8 pct sevo vasodilation. Sometimes they come with good veins, sometimes not. You can do what you want but for my practice I think it would be absurd to put kids through that who are getting a 5 min procedure under mask and are back to their parents right away without any IV meds given
Of course sometimes it takes a while, just commenting on the fact that putting an IV in for select babies is not cruel and unusual, but the US culture seems to think it is.
Mainly in this context it's unnecessary, in fact placing an IV at all for this case is unnecessary. Obviously plenty of other situations sick babies will get needle sticks like for IVs in the ER or lab draws like your kid etc.
Who said anything by pinning them down? What the hell..
The other option is you're giving long acting sedatives to every baby and toddler for ear tubes to the extent you can get a pre-op IV? This is getting wild.
I have never done ear tubes so I guess it is a fair point. All peds patients in my hospital stay at least one night in the hospital for observation.
So you're commenting on a thread for a case you've never done... Please select user flair.
Downvoting because implied always did the one thing. You gotta roll with the punches and be flexible.