Term 2 Week 4 (w/c 6/02/12)
This week we start with something pretty straightforward. It’s Monday morning and you see that there is a 10 year old boy listed for bilateral Tendo Achilles lengthening. As you head off to the changing room to get changed what anaesthetic plans will be going through your mind?
With the limited information so far what will you be planning?
You run into your orthopaedic colleague in the changing room (must be same sex) and ask some of the questions that have been raised so far.
They tell you that the operation will be performed supine and that it will be percutaneous approach i.e. not a fully open procedure. It wont take more than 15 minutes to do both sides and they should be able to finish that and the other case on the list which is a pelvic osteotomy before lunch. The patient is a lively character by their estimation. It could be a challenge.
What are your thoughts about premedication?
Now we know what everyone thinks about premedication. You are now actually with the child. He is 10 years old with a diagnosis of Autistic Spectrum Condition. He has challenging behaviours and is not able to attend mainstream schooling. His mother is with him and says that he can get very upset with new people that he doesn’t know. He last had an anaesthetic at 2 years old for a diagnostic MRI when his behaviours were first noted to be causing concern.
He walks a bit on tip toes and has had falls. The orthopaedic team are fairly convinced that they can improve his mobility and this is a reasonable indication for surgery.
Does any of this change your thought process so far? What are your main concerns?
Further update. He refuses oral premedication on the ward but happily comes with his Mother to the OR. He comes into the Anaesthetic Room and hesitantly sits on the trolley. There is absolutely no way he is agreeing to a cannulation and tucks his arms up tight.
Plan A has now gone, plan B seems obvious but we want to explore how far to push it and if you have a plan C. How far can you force a gas induction? What else will you do and why?
Thanks for all the input this week. It has been a great multidisciplinary effort and revealed a somewhat different approach from paediatrics and anaesthetics. It is a fairly common event for a paediatric anaesthetist to deal with the combative child. Advice from the print media is available http://t.co/M8EoEnSD and reinforces the tweet stream from the discussion.
Induction of anesthesia in a combative child; management and issues
Article first published online: 11 APR 2005
Volume 15, Issue 5, pages 421–425, May 2005
A developmentally delayed, 13-year old autistic boy required management of multifocal cerebral and pulmonary tumors, involving several anesthetics over a 4-month period. At each anesthetic he refused premedication, displayed increasing anxiety and became more combative. With parental guidance and involvement, a variety of anesthetists tried a range of techniques to achieve induction, each ultimately resorting to the use of physical restraint. Principles essential to the care of such a child include early recognition, parental support, multi-disciplinary planning of procedures requiring general anesthesia, continuity of anesthesia care, and clear guidelines about the perioperative management of uncooperative children, including the ethical use of restraint.
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