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Gas induction for pyloromyotomy
Gemma E Scrimgeour1, Nicholas W F Leather1, Rachel S Perry1
1Shackleton Department of Anaesthesia, University Hospital Southampton, Southampton, UK.
Insights
Gas induction is a safe anesthesia technique for infants undergoing pyloromyotomy, avoiding risks associated with traditional rapid sequence induction. This method prioritizes maintaining ventilation until optimal intubation conditions are met, preventing hypoxemia.
Area of Science:
- Anesthesiology
- Pediatric Surgery
Background:
- Infants with pyloric stenosis face high aspiration risk during anesthesia induction.
- Traditional methods like rapid sequence induction (RSI) and awake intubation (AI) have drawbacks, with RSI components being controversial and AI falling out of favor.
- Concerns exist regarding hypoxemia risk if ventilation is interrupted during RSI and the unproven efficacy of cricoid pressure (CP).
Purpose of the Study:
- To evaluate the safety and efficacy of a specific gaseous induction technique for pediatric pyloromyotomy.
- To assess the incidence of aspiration events using this alternative anesthesia approach.
- To compare gas induction with traditional methods in the context of pyloric stenosis surgery.
Main Methods:
- Retrospective review of medical records for patients undergoing pyloromyotomy between 2005 and 2012.
- Analysis of anesthesia induction techniques employed, including gas induction, intravenous (IV) induction, and rapid sequence induction (RSI).
- Data collection on patient demographics, weight, and aspiration events.
Main Results:
- 269 patients were included; 93.7% received gas inductions, while 6.3% received IV inductions. Only two patients underwent RSI.
- No aspiration events were recorded in any of the patients across all induction techniques.
- No identifiable patient factors correlated with the choice of IV induction over gas induction.
Conclusions:
- Gas induction is a viable and safe anesthetic option for children undergoing pyloromyotomy.
- This technique, involving nasogastric tube de-compression, sevoflurane induction, and maintained ventilation, appears to prevent aspiration.
- The findings support considering gas induction as an alternative to more controversial RSI techniques in this patient population.
Background:
Infants with pyloric stenosis are considered to be at high risk of aspiration on induction of anesthesia. Traditionally, texts have recommended classic rapid sequence induction (RSI) or awake intubation (AI). AI has generally fallen out of favor, while the components of RSI have become increasingly controversial. Infants are at high risk of hypoxemia if ventilation is not maintained while waiting for neuromuscular blockade to establish. The efficacy of cricoid pressure (CP) to prevent aspiration has not been proven. It can impair visualization of the glottis and make intubation difficult. It is debatable whether any RSI technique is needed for pyloromyotomy. A recent review of 235 infants reported no aspiration events. These children were anesthetized with a variety of techniques, including RSI, gas induction, and AI. In our institution, we teach a gaseous induction. The nasogastric tube is used to empty the stomach and anesthesia is induced with sevoflurane. A nondepolarizing muscle relaxant is administered and ventilation maintained until neuromuscular blockade is established and intubating conditions are optimal. We report our experience of this technique.
Method:
A retrospective medical notes review of all patients undergoing pyloromyotomy between 2005 and 2012.
Results:
There were 269 patients (84.4% male, mean weight 3.74 kg ± 0.74). Two hundred and fifty-two (93.7%) received gas inductions and 17 (6.3%) intravenous (IV) inductions. Two children received an RSI. No patient-specific factors were identified to explain operator choice in those receiving IV inductions. There were no recorded aspiration events.
Conclusion:
Gas induction can be considered for children undergoing pyloromyotomy.
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