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  • Impending airway obstruction:

    • Difficult bag mask ventilation & intubation

    • Do not upset child or manipulate airway 

  • Emergency: risk of aspiration, ↓ time to optimize

  • Sepsis & need for early goal-directed therapy  

  • Pediatric patient considerations 

  • Post-op disposition: PICU & plan for extubation once process resolved





  • Call for ENT ("double set up") & maintain spontaneous ventilation 

  • Use smaller endotracheal tubes (1-3mm smaller) 

  • OR set up with second anesthetist or anesthesia assiant & difficult airway cart, rigid bronchoscopy & tracheostomy set

  • Skin topicalization for IV start 

  • Obtain CBC & blood cultures 

  • Fluid bolus 20 ml/kg, repeat prn

  • Aspiration prophylaxis ranitidine 0.5 mg/kg & maxeran 0.1 mg/kg

  • Glycopyrrolate 10 mcg/kg to dry secretions 

  • Small styletted ETT (cuffed preferable)

  • Spontaneouly-breathing induction with sevoflurane or propofol/remifentanil if IV, then intubate 

  • IV antibiotics, fluids, PICU​ post-op:

    • Antibiotics: cloxacillin, cetriaxone, ampicillin, clindamycin +/- vancomycin

  • Extubation plan: ensure there is a leak & swelling has resolved.  Then extubate in the OR & be prepared for re-intubation 

  • Don't use steroids empirically but consider if extubation has proven difficult after several days of antibiotic therapy 

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