Zusammenfassung
Die klassische in der Erwachsenenanästhesie übliche Vorgehensweise bei der Ileusintubation ist für die Anwendung bei Kindern nicht in allen Punkten zweckmäßig. Erschwerte Präoxygenation, verminderte Sauerstoffreserven, erhöhter Sauerstoffverbrauch sowie Atelektasenneigung führen beim Neugeborenen, Säugling und Kleinkind zu einer verkürzten Apnoetoleranz mit sehr schnell eintretender Hypoxämie nach der Anästhesieeinleitung. Eine sanfte Maskenbeatmung mit Drucklimitierung bei 10–12 cm H2O führt nicht zur Mageninflation mit Aspiration. Hauptfaktoren für eine Aspiration bei Kindern sind Sperren, Pressen, Husten des Patienten während der Anästhesieeinleitung und Intubationsversuchen bei inadäquater Muskelrelaxation. Die sanfte Maskenbeatmung erlaubt eine ruhige, kontrollierte endotracheale Intubation bei optimierter Oxygenation, hämodynamischer Stabilität, genügender Anästhesietiefe und vollständiger Muskelrelaxation. Die Anwendung des Krikoiddrucks hat sich in der Praxis zur Verhinderung einer Aspiration nicht immer als effektiv erwiesen. Unmittelbar nach der Einleitung durchgeführt, kann er zu Husten und Pressen sowie zu erschwerter Beatmung und Intubation führen; er ist damit kontraproduktiv und provoziert geradezu eine Aspiration. Deshalb soll der Krikoiddruck bei der „Rapid-sequence-induction“- (RSI-)Intubation beim Kind in der Regel nicht angewendet werden. Wichtige Elemente einer an die Kinderanästhesie adaptierten RSI-Intubation sind die suffiziente schnelle i.v.-Anästhesieeinleitung mit profunder Muskelrelaxation, die sanfte Maskenbeatmung mit Druckbegrenzung bei 10–12 cm H2O und die atraumatische Intubation unter kontrollierten Bedingungen.
Abstract
Classical adult type rapid sequence induction (RSI) intubation is not always appropriate in children. In newborns, infants and small children, limited cooperation during pre-oxygenation, reduced respiratory oxygen reserves, increased oxygen demand and a tendency for airway collapse, easily lead to hypoxaemia after induction of anaesthesia. Gentle mask ventilation with pressures not exceeding 10–12°cm H2O allows oxygenation without the risk of gastric inflation and aspiration. Risk factors leading to pulmonary aspiration are bucking, coughing and straining during induction or tracheal intubation and active regurgitation and vomiting during laryngoscopy under light anaesthesia and incomplete muscle paralysis. Gentle mask ventilation allows tracheal intubation under optimised oxygenation, haemodynamics, depth of anaesthesia and complete muscle relaxation. Application of cricoid pressure does not reliably prevent pulmonary aspiration. In children cricoid pressure clearly interferes with smooth induction of anaesthesia, results in difficult mask ventilation and intubation as well as provokes bucking and straining and, therefore, should not be routinely used. Key features of RSI intubation for children are effective induction of deep anaesthesia followed by profound muscle paralysis, careful mask ventilation and gentle tracheal intubation under optimised conditions.
Literatur
Adams HA, Panning B (2003) Zur Sprache in unserem Fachgebiet. Anasthesiol Intensivmed Notfallmed Schmerzther 38: 745–746
Aitkenhead AR, Smith G (1996) Techniques of anaesthesia. In: Aitkenhead AR, Smith G (eds) Textbook of anaesthesia. Churchill Livingstone, Edinburgh, pp 523–525
Bock M, Haselmann L, Bottiger BW, Motsch J (2007) Priming with rocuronium accelerates neuromuscular block in children: a prospective randomized study. Can J Anaesth 54: 538–543
Borland LM, Sereika SM, Woefel SK et al. (1998) Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. J Clin Anesth 10: 95–102
Brimacombe JR, Berry AM (1997) Cricoid pressure. Can J Anaesth 44: 414–425
Brock-Utne JG (2002) Is cricoid pressure necessary? Paediatr Anaesth 12: 1–4
Byers GF, Muir JG (1997) Detecting wakefulness in anaesthetised children. Can J Anaesth 44: 486–488
Combes X, Andriamifidy L, Dufresne E et al. (2007) Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth 99: 276–281
Cook TM, Wolf AR, Henderson AJ (1998) Changes in blood-gas tensions during apnoeic oxygenation in paediatric patients. Br J Anaesth 81: 338–342
Donati F (2003) The right dose of succinylcholine. Anesthesiology 99: 1037–1038
Engelhardt T, Strachan L, Johnston G (2001) Aspiration and regurgitation prophylaxis in paediatric anaesthesia. Paediatr Anaesth 11: 147–150
Fahnenstich H, Steffan J, Kau N, Bartmann P (2000) Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants. Crit Care Med 28: 836–839
Flick RP, Schears GJ, Warner MA (2002) Aspiration in pediatric anesthesia: is there a higher incidence compared with adults? Curr Opin Anaesthesiol 15: 323–327
Frei F, Erb T, Jonmaker C et al. (2004) Akute Notfälle. In: Frei F, Erb T, Jonmaker C et al. (Hrsg) Kinderanästhesie. Springer, Berlin Heidelberg New York Tokio, S 295−310
Freid EB (2005) The rapid sequence induction revisited: obesity and sleep apnea syndrome. Anesthesiol Clin North America 23: 551–564
Fuchs-Buder T, Tassonyi E (1996) Intubating conditions and time course of rocuronium-induced neuromuscular block in children. Br J Anaesth 77: 335–338
Hardman JG, Wills JS (2006) The development of hypoxemia during apnoea in children: a computational modelling investigation. Br J Anaesth 97: 564–570
Hartsilver EL, Vanner RG (2000) Airway obstruction with cricoid pressure. Anaesthesia 55: 208–211
Heier T, Caldwell JE (2000) Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg 90: 175–179
Heier T, Feiner JR, Lin J et al. (2001) Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesthesiology 94: 754–759
Jöhr M, Berger TM (2004) Fiberoptic intubation through the laryngeal mask airway (LMA) as a standardized procedure. Paediatr Anaesth 14: 614
Jöhr M (2007) Anaesthesia for the child with a full stomach. Curr Opin Anesthesiol 20: 201–203
Kim JY, Kim JY, Kim YB, Kwak HJ (2007) Pretreatment with remifentanil to prevent withdrawal after rocuronium in children. Br J Anaesth 98: 120–123
Kluger MT, Short TG (1999) Aspiration during anaesthesia: a review of 133 cases from the Australian Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 54: 19–26
Kretz FJ, Krier C (2002). Ein nichtnüchternes Kind kommt zur Narkose. Anasthesiol Intensivmed Notfallmed Schmerzther 37: 514–519
Landsmann I (2004) Cricoid pressure: indications and complications. Pediatr Anesth 14: 43–47
Lawes EG, Campbell I, Mercer D (1987) Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth 59: 315–318
Lin JA, Yeh CC, Lee MS et al. (2005) Prolonged injection time and light smoking decrease the incidence of fentanyl-induced cough. Anesth Analg 101: 670–674
Lui JT, Huang SJ, Yang CY et al. (2002) Rocuronium-induced generalized spontaneous movements cause pulmonary aspiration. Chang Gung Med J 25: 617–620
Lussmann RF, Gerber HR (1997) Schwere Aspirationspneumonie mit der Larynxmaske. Anasthesiol Intensivmed Notfallmed Schmerzther 32: 194–196
McAllister JD, Gnauck KA (1999) Rapid sequence intubation of the pediatric patient. Fundamentals of practice. Pediatr Clin North Am 46: 1249–1284
Meek T, Gittins N, Duggan JE (1999) Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia 54: 59–62
Morgan JM, Barker I, Peacock JE, Eissa A (2007) A comparison of intubating conditions in children following induction of anaesthesia with propofol and suxamethonium or propofol and remifentanil. Anaesthesia 62: 135–139
Moynihan RJ, Brock-Utne JG, Archer JH et al. (1993) The effect of cricoid pressure on preventing gastric insufflation in infants and children. Anesthesiology 78: 652–656
Murat I (2003) Airway protection in children with a full stomach. Ann Fr Anesth Reanim 22: 659–662
Naguib M, Samarkandi AH, Abdullah K et al. (2005) Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients. Anesthesiology 102: 35–40
Patel R, Lenczyk M, Hannallah RS, McGill WA (1994) Age and the onset of desaturation in apnoeic children. Can J Anaesth 41: 771–774
Perry J, Lee J, Wells G (2003). Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 1: CD002788
Picard P, Tramèr MR (2000) Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 90: 963–969
Politis GD, Tobias JD (2007) Rapid sequence intubation without a neuromuscular blocking agent in a 14-year-old female patient with myasthenia gravis. Pediatr Anesth 17: 285–288
Reid C, Chan L, Tweeddale M (2004) The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Emerg Med J 21: 296–301
Salem MR, Wong AY, Fizzotti GF (1972) Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients. Br J Anaesth 44: 401–404
Schreiber MN (2007) Rapid-Sequence-Induction des nicht nüchtern Kindes – Warum brauchen wir eine neue Handlungsempfehlung? Anaesthesiol Intensivmed 46: S86–S87
Sellick BA (1961) Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 2: 404–406
Sparr HJ, Vermeyen KM, Beaufort AM et al (2007) Early reversal of profound rocuronium-induced neuromuscular blockade by sugammadex in a randomized multicenter study: efficacy, safety, and pharmacokinetics. Anesthesiology 106: 935–943
Sparr HJ, Jöhr M (2002) Succinylcholine – Update. Anaesthesist 51: 565–575
Spears RS Jr, Yeh A, Fisher DM, Zwass MS (1991) The „educated hand”. Can anesthesiologists assess changes in neonatal pulmonary compliance manually? Anesthesiology 75: 693–696
Stedeford J, Stoddart P (2007) RSI in pediatric anesthesia – is it used by nonpediatric anesthetists? A survey from south-west England. Pediatr Anesth 17: 235–242
Stoddart PA, Mather SJ (1998). Onset of neuromuscular blockade and intubating conditions one minute after the administration of rocuronium in children. Paediatr Anaesth 8: 37–40
Thwaites AJ, Rice CP, Smith I (1999). Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia 54: 376–381
Tournadre JP, Chassard D, Berrada KR, Bouletreau P (1997) Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology 86: 7–9
Vanner RG (1992) Tolerance of cricoid pressure by conscious volunteers. Int J Obstet Anesth 1: 195–198
Videira RL, Neto PP, Amaral RV do, Freemann JA (1992) Preoxygenation in children: for how long? Acta Anaesthesiol Scand 36: 109–111
Goedecke A von, Voelckel WG, Wenzel V et al. (2004) Mechanical versus manual ventilation via a face mask during the induction of anesthesia: a prospective randomized, crossover study. Anesth Analg 98: 260–263
Warner MA, Warner ME, Warner DO et al. (1999) Perioperative pulmonary aspiration in infants and children. Anesthesiology 90: 66–71
Warner MA, Warner ME, Weber JG (1993) Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 78: 56–62
Weiler N, Heinrichs W, Dick W (1995) Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. Prehosp Disaster Med 10: 101–105
Wells S, Williamson M, Hooker D (1994) Fentanyl-induced chest wall rigidity in a neonate: a case report. Heart Lung 23: 196–198
Weiss M, Gerber AC (2006) Cuffed tubes in children – things have changed. Pediatr Anesth 16: 1005–1007
Weiss M, Gerber AC (2007) Rapid sequence induction in children – it’s not a matter of time. Pediatr Anesth (in press)
Xue FS, Tong SY, Wang XL et al. (1995) Study of the optimal duration of preoxygenation in children. J Clin Anesth 7: 93–96
Zelicof-Paul A, Smith-Lockridge A, Schnadower D et al. (2005) Controversies in rapid sequence intubation in children. Curr Opin Pediatr 17: 355–362
Zimmerman AA, Funk KJ, Tidwell JL (1996) Propofol and alfentanil prevent the increase in intraocular pressure caused by succinylcholine and endotracheal intubation during a rapid sequence induction of anesthesia. Anesth Analg 83: 814–817
Interessenkonflikt
Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Weiss, M., Gerber, A. Anästhesieeinleitung und Intubation beim Kind mit vollem Magen. Anaesthesist 56, 1210–1216 (2007). https://doi.org/10.1007/s00101-007-1281-y
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00101-007-1281-y