Pediatric Patient with Foreign Body Aspiration
A 3-year-old boy (weight 15 kg) presents with sudden onset of choking and coughing while eating peanuts. He has stridor, suprasternal retractions, and decreased breath sounds on the right. He is agitated and his SpO2 is 90% on room air. You are in the emergency department and the ENT surgeon is ready for rigid bronchoscopy. The child has a full stomach and is crying.
1. What is your anesthetic plan for rigid bronchoscopy?
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The key is to maintain spontaneous ventilation to avoid further obstruction and to prevent positive pressure ventilation from pushing the foreign body deeper. I would induce anesthesia with an inhalational agent (sevoflurane) in 100% oxygen, keeping the child sitting up if possible. I would avoid muscle relaxants until the airway is secured. I would place an IV after induction. I would maintain spontaneous ventilation with sevoflurane and possibly add propofol for amnesia. The ENT surgeon would perform rigid bronchoscopy under spontaneous ventilation. If the child desaturates, I would assist ventilation gently. The rationale is to avoid converting a partial obstruction into a complete one. I would also have a range of endotracheal tubes and a tracheostomy kit ready.
2. How would you manage the induction if the child becomes uncooperative and desaturates?
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If the child desaturates and is uncooperative, I would immediately administer 100% oxygen via a tight-fitting mask and consider gentle positive pressure ventilation if necessary, but with caution to avoid dislodging the foreign body. If severe hypoxia persists, I would proceed to emergency rigid bronchoscopy with the child in the sitting position, using inhalational induction. If the child is combative, I might need to use intramuscular ketamine (4-5 mg/kg) to provide sedation and maintain airway tone. The rationale is to secure the airway and remove the obstruction as quickly as possible. I would avoid succinylcholine because of the risk of negative pressure pulmonary edema and because it may cause the foreign body to move. I would also ensure suction is available.