Fasting Breach, Recent URI and a Loose Tooth in a 4-Year-Old
An 18 kg, 4-year-old boy is booked for adenotonsillectomy at 10:30. At 09:45 the parent says he drank 120 mL of apple juice at 09:30 because he was crying, and he has had a clear runny nose and a dry cough for 3 days but no fever today. His last solid food was 19:00 the previous night. The anesthesiologist is in another theatre. You are asked to prepare the airway trolley and to 'sort out the fasting issue' so the list does not slip. The child is anxious, will not sit still, and has a loose deciduous incisor. The theatre has a full set of paediatric equipment but no video laryngoscope smaller than a Macintosh 2 blade.
1. What fasting interval applies, and what will you recommend about the 09:30 apple juice? Show your reasoning.
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Fasting rule. For elective anaesthesia, clear fluids are normally permitted up to 2 hours before induction; breast milk 4 hours; formula/light meal 6 hours; fatty meal 8 hours. Apple juice is a clear fluid, but 09:30 to a 10:30 start is only 1 hour - and induction would be later still. The 19:00 solid meal is more than 8 hours ago and is not the problem.
Recommendation. Do not proceed at 10:30. The earliest safe start would be about 11:30, assuming the child takes nothing else by mouth. Inform the anaesthesiologist and the theatre coordinator, document the exact volume and time, and do not let list pressure change the facts. A mild clear coryza with dry cough is a separate risk: it increases laryngospasm and bronchospasm, and the anaesthesiologist may decide to postpone. The technician's job is to give accurate information, prepare the trolley, and not to make the final fasting/anaesthesia decision.
2. Calculate and list the airway equipment you would prepare, including ETT size, depth, blade and suction, and justify your choices.
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Airway trolley for an 18 kg, 4-year-old.
- ETT: uncuffed 5.0 mm ID (age/4 + 4 = 5.0); cuffed 4.5 mm ID (age/4 + 3.5 = 4.5). Have 4.0, 4.5 and 5.0 in both types, plus half-size smaller/larger.
- Depth: cuffed about 3 × ID = 13.5 cm at the lip; uncuffed about age/2 + 12 = 14 cm. Confirm with auscultation and capnography.
- Blades: Macintosh 1 and 2, Miller 1; check light.
- Suction: 8–10 Fr catheter and Yankauer, tested.
- Circuit: paediatric circle or Mapleson with 1.5–2 L bag; masks size 2 and 3; oral airways 1 and 2; supraglottic airway size 2.
- Adjuncts: stylet, bougie, Magill forceps, tape, 5–10 mL syringe for cuff, lubricant, precordial or oesophageal stethoscope.
- Drugs/emergency: atropine and suxamethonium as ordered, salbutamol, adrenaline, and a working self-inflating bag.
Test the cuff and check the ETT connector. Because the tooth is loose, avoid using it as a fulcrum; have Magill forceps ready.
3. What non-technical and safety issues would you flag to the anesthesiologist before induction?
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Safety and non-technical issues to flag.
- The fasting breach: state the time and volume clearly; ask the anaesthesiologist to decide and document.
- Recent URI: higher risk of laryngospasm, bronchospasm and desaturation; ensure suction, emergency drugs and a clear plan are ready.
- Loose deciduous incisor: aspiration risk; document it, tell the anaesthesiologist, consider a dental guard or removal by a dentist before induction, and plan laryngoscopy that avoids the tooth.
- No small video laryngoscope: have a direct laryngoscopy plan with Macintosh 1/2, bougie and stylet, and call for a second experienced airway operator if intubation is difficult.
- Anxious child: parental presence at induction if local policy allows, or premedication only as ordered by the anaesthesiologist; do not sedate a child on your own.
- Confirm identity, weight, allergies, consent and NPO status; keep the parents informed about the delay.