Category Archives: speciality

Anticipated Difficult Airway

Remember to consider – to get an idea of what you are dealing with.

Thoughts. Which of the following are anticipated to be difficult and what is the plan for each:

  • Mask ventilation
  • LMA insertion/use
  • Endotracheal intubation
  • Front of neck access


Options to consider:

  • AFOI
  • Inhalational induction vs IV induction
  • Spontaneous vs controlled ventilation (+/- muscle relaxant)
  • Mask ventilation with guedel + two person technique
  • Direct laryngoscopy
  • Video laryngoscopy
  • Asleep FOI
  • Front of neck: surgical cricothyroidotomy by us vs ENT trache (awake?)

Paediatric foreign body aspiration – recipe for EUA

Gas induction. Maintain spontaneous ventilation. Adequate depth of anaesthesia

(+/- check ventilation – risk of pushing FB distally. Avoid insufflation of stomach)

Direct laryngoscopy

Spray cords with lignocaine

Insert uncuffed nasal (standard) ETT to level just above cords

+/- close mouth as required

Spontaneous ventilation of O2+anaesthetic vapour. PEEP on T-peice

Also see:


Remember basic manoeuvres e.g. Abdominal thrusts, Heimlick Manoeuvre, back blows.
In the event of cardiac arrest CPR/chest compressions may dislodge the foreign body.

Caudal tips


Identify surface landmark

enter approx 45 degrees

upon entry anlge needle more parallel

advance needle slightly

then keeping needle stable, advance the cannula. Does not need to be to hilt.

Watch/aspirate for CSF or blood

inject LA (+1-2mcg/kg clonidine) as per Armitage regime, visualising the skin/subcut tissue


The feel of entering cuadal space is similar to the gentle LOR when piercing rubber bung on antibiotic bottle.

If after inserting needle through sacrococcygeal membrane and resistance is encountered on advancing cannula or needle or injection of LA (likely the dorsal aspect of the ventral plate of the sacrum) then withdraw cannula/needle and redirect cranially, walking off the bone if necessary. Better to enter at caudal aspect of sacral hiatus.

More reliable and consistent than nerve blocks.

Use up to approx 20kg weight/7yr

Blocking the penis

e.g. for circumcision

weight / 3 = mls of 0.75% levy-bupivicane

Sterile precautions. Counter-traction as necessary.

1. Ring block at base of shaft

27 1/2 gauge needle

start at dorsum, just lateral to dorsal vein either side, aiming laterally. watching for circumferential spread.

inject at approx 3 o’clock and 9 o’clock for remaining ventral half.

inject into ‘watershed’ areas as needed to complete the ring

2. Dorsal n. of penis

blue needle

identify pubic symphysis

two entry points, just lateral to midline on each side, just below PS

advance needle perpendicularly until bone is hit

Inject – resistance will be felt

Continuous pressure trying to inject while withdrawing – there will be sudden LOR as LA spreads within the correct plane/under Buck’s fascia. 0.5-2ml per side.

– EdM @ LRI

Paediatric airway surgery recipe

e.g. laryngo-tracheo-bronchoscopy

Standard induction (IV or gas)

Maintenance using TIVA:

  • propofol 400 -> 300 -> 100 mcg/kg/min
  • remi 0.2 – 0.1 mcg/kg/min


  • Use to judge adequate depth of anaesthesia
  • insert nasal uncuffed (standard) ETT to level just proximal to cords
  • Spray larynx/cords/distally – take max allowed dose of lignocaine 10%, dilute to make up to desired volume, spray using MAD/atomiser


  • Aim for spontaneous ventilation of oxygen enriched air while applying PEEP with bag
  • Can hand ventilate if mouth is closed (but risks insufflation of stomach)

Emergence of spontaneously breathing patient with NPA

– KP @ LRI