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Anästhesieeinleitung und Intubation beim Kind mit vollem Magen

Zeit zum Umdenken!

Induction of anaesthesia and intubation in children with a full stomach

Time to rethink!

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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.

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  1. Anästhesieabteilung, Universitäts-Kinderkliniken, Steinwiesstrasse 75, 8032, Zürich, Schweiz

    M. Weiss & A.C. Gerber

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  1. M. Weiss
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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

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