Title : THRIVEing children A major advancement using tubeless anesthesia thrive for delivering pediatric endoscopy under general anesthesia
Abstract:
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is increasingly used in a range of settings in anaesthesia. It has been shown that THRIVE extends the safe apnoea time in children¹, and it is used well in paediatric resuscitation. At our quarternary referral centre we propose a further application of THRIVE to help provide anaesthesia without intubation, yet oxygenate paediatric patients undergoing upper gastrointestinal tract endoscopy. Established practice for paediatric oesophagogastroduodenoscopy (OGD) is tracheal intubation and ventilation under general anaesthetic or sedation. Our technique uses THRIVE combined with sedation without intubation. Patients are consented for anaesthetic. IV access, AAGBI monitoring is applied in the anaesthetic room and the child sedated with 1 mcg/kg fentanyl and 1-2 mg midazolam. The awake patient is taken into theatre where an OptiFlow™ nasal set (small) is applied. Initial flow rate is set at 20-30L/min humidified oxygen and the patient preoxygenated for at least 3 minutes in a 30 degree ramped position. Following WHO Time Out the patient is moved to the left lateral position, and given an induction dose of propofol which renders them apnoeic. The oxygen flow rate increases to 40-50L/min and a jaw thrust is maintained during the procedure. The child is closely monitored for respiratory effort and desaturation. They remain unresponsive to endoscopic oesophageal intubation. The OGD takes 5-10 minutes by which time, or soon after, spontaneous breathing returns. The patient remains in the left lateral position until recovery. Desaturation has never been observed with the use of this technique, and children have tolerated it well. We compared two groups of ASA 1-2 paediatric patients undergoing OGD: one using THRIVE (age 11-16 years); and one in which patients were intubated due to video capsule deployment (age 4-17 years). To account for the different procedures, the anaesthetic time before and after the procedure itself was calculated from the electronic theatre log. In both groups 6 patients also had a colonoscopy. Despite the small sample, both the pre and post-procedure anaesthetic time were significantly lower in the THRIVE group (p0.05) (see Table 1). Neither group exhibited desaturation during the procedure, however there was an episode of laryngospasm in one patient in the intubated group. THRIVE group (n=12)
In conclusion we propose ‘tubeless’ anaesthesia using THRIVE in combination with intravenous anaesthesia as a potentially safe, efficient and less invasive method of providing anaesthesia for paediatric endoscopy in low-risk children. Since this data was collected we have continued to use this technique with encouraging outcomes. In suitable candidates who are assessed to have low risk of airway compromise it provides a viable alternative to tracheal intubation, avoiding risks associated with instrumenting the airway and the use of muscle relaxant. There is also significantly less time taken to administer anaesthesia, increasing theatre utilization and the number of patients that can be treated.
