Inhalational induction and intubation BEFORE IV

[John Farnsworth]

I trained in the UK and then worked for 1 year in Boston, USA. I was surprised at how different some things were. The most striking difference in clinical practice which I must admit I have not imported back to the UK is the American practice of doing an inhalational induction in a child, then proceding to secure the airway (either with an LMA or ETT) BEFORE obtaining IV access.

Where I trained, this would be grounds for failing the Finals. What would happen (I can hear the examiner ask) if after induction an one attempt at intubation, the child laryngospams before IV access is obtained?

I know the stock answers: children are almost always easy to intubate, IM sux, CPAP.

Is this common practice in the USA? Or was it just a regional variant?

[Igor Bulatov]

I don't think intubation before IV is a standard of practice in pediatric anesthesiology in the US,but its totally acceptable especially when circulating RN is not very comfortable with IV placement and no other help (nurse anesthetist as in most European countries) is available.

[Emma Davey M.D.]

Where I work, once the child is induced, I get my assistant (resident or nurse) to hold the mask while I place an IV. Once that's done, then I or my assistant secrues the airway. Thisworks well only if the child has a fairly easy airway to maintain with bag and mask, and if my assistant is fairly experienced at holding a mask on a child.

[Bucky]

Not common practice in the USA.  I was trained as were you.  In a pinch, I'll go ahead and intubate then look for an IV when others have failed.

[Hossam]

I think it is common trend  where it is bit difficult to cannulate a young child either due to inaccessible veins or fearing of painful prick in case of lacking of EMLA cream. But I think we can do cannulation just after inhalation induction and before intubation to guard against unexpected events.

[jetproppilot]

I would say it is uncommon to secure the airway before an IV is secured in the US. I spent six months at a children's hospital during residency and on chubby babies it might take five minutes to get an IV, maybe more, with more than one person working on IV access while still mask ventilating. If IV access is unsuccessful and the case warrants, the surgeon may modify the procedure, I.E. scheduled tubes and adenoids, he/she may just to tubes and cancel the adenoids.

[chait]

i would suggest that in case where you expect a really difficult iv then sedate the patient with im ketamine 5mg/kg 10 min before taking him to OR and then seach for the iv .

[frontier]

hi,
  what we do in our setup in ranchi,india if a child is not allowing an iv line assess ,we just give IM KETAMINE to sedate patient according to bodyweight then place iv line then ,we go for securing airway.

[petolana]

i am working in anaesthesia for the last 15 years and i am used to give a sedative dose of ketamine preoperative at the OR then i start iv line followed by inhalation induction .
i suggest this way and i think its a safe practice

[Jabawho]

Been doing paed anaesthesia for About 15 years. In elective simple surgerys haven't put an IV in first for at least 10 years.
My practice - sevoflurane induction, insert LMA  or intubate when deep ( for lma  if age < about 2 spray cords with lignocaine. If intubating then all get spray of lignocaine) . Then go and  insert IV. Gas has had time to cause vasodilation so IV insertion much easier. This way you don't have to rely on unskilled people either holding a mask ( which most can't do and you have to keep watching to see they are doing ok) or inserting an IV and pranging the decent veins in the best spot.
15 years - complications rate zero. Need for suxamthonium during induction - zero.  (So far)

Same question discussed on other forums - highly varied responses. Seems to be a very geographically varied practice. Some USA ones do same as me some the opposite.

[kidder]

I work in a pediatric same day surgery center in OH. We do inhalation induction N2O/ O2 70%/ 30% and after a minute start Sevo 2% and double % every 4-5 breaths. When heart rate starts to slow cut off N2O back off sevo and start IV.Then depending on airway of choice for surgery IV meds administered and LMA or ETT secured.About only time we dont start IV are mask ventilation cases such as BMT's and frenulectomies. Has anyone ever experiencedpatient ceasing spontaneous respirations when eyeball is prepped with betadine? We've been doing rectus recessions and other eye muscle cases with LMA's, regaining spontaneous rspirations quickly after insertion, and when eye prep is done spontaneous respers stop for a brief period requiring assits. Any clues why this should occur?

[sandiphari]

IN INDIA USUALLY WE SECURE IV LINE BEFORE INHALATION.THAT IS THE STD PRACTICE