Home > Anaesthesia, Paediatrics, Uncategorized > Term 8 Week 6 (w/c June 23, 2014)

Term 8 Week 6 (w/c June 23, 2014)

June 21, 2014

We’d like to give a big thank you to the fantastic @mjslabbert for facilitating last week’s trauma case.  We had a lot of involvement and discussion from some new and old followers.

This week, we will be featuring another guest facilitator.  Dr. Clyde Matava is a pediatric anesthesiologist from Sick Kids Hospital in Toronto, Canada, with special interests in medical e-learning, innovation, and technology in practice and learning.  He also runs the Pediatric Anesthesia twitter account.

It is Saturday late morning and you are on call. You receive a page from the neuroradiologist who is requesting an emergency (priority 1) MRI for a 7 month old (6.5kg).  The child was previously healthy, had good milestones and presented to ER this morning.   The parents report that the child stopped moving her left hand yesterday. While concerned, the parents were not particular anxious about this.  However, this morning, a few hours after breakfast, the patient had a left sided seizure and what appeared to be weakness of the whole left side.  Neurology and neuroradiology are requesting a stat MRI.  The patient is awake and responsive with some flaccidity of the left side.  There have been no further seizures.

What are the differential diagnoses?

What other information do you require?

What are your anesthetic considerations?  What would you do differently for an elective versus emergency MRI for a child?

Day 2
Hi everyone
Thank you for your comments on twitter.  So the case started yesterday with a child who had normal milestones but presented with a brief history of a single seizure and what appears to be left sided weakness.  The patient requires an MRI.

What are the differential diagnoses?
As @Neil_brain1 alludes to, the differentials list is pretty wide.   Unfortunately, this is common in infants particularly with a sudden onset on clinical symptoms devoid of a prodromal phase.
The common issues in pediatric neurology are
Seizures
Intracranial tumours (supratentorial and subtentorial)
Strokes
Vascular
Intracranial bleeds

The primary issues for the anesthesiologist are
the presence or risk for raised ICP
progression of pathology such as bleeding, stroke etc

What other information do you require?
Milestones, family history and other symptoms are important, family history of MH.

Elective Cases
With a good NPO status, often enough a gas induction, followed by nasal prongs and a propofol infusion will suffice for a routine MRI brain scan. These scans are typically 30-40 mins long.

However this case is an emergency.  You are concerned about the possibility of a bleed or a tumour and so ask that neurosurgery be consulted.  Neurosurgery confirms that a tumour is possible and they need to take the patient to the OR if this is a tumour.  Furthermore, neurosurgery does not rule out the possibility of the patient needing to go to interventional suite if warranted.

A systemic review shows a previously health child with no known allergies, all immunizations are up to date.

The child last are some cereal 4 hours ago.

You examine the patient and note the following:
GCS 12/15 but patient is responsive
Weakness of the left side
HR – 110
BP – 100/50
RR – 30

No IV access

You prepare for the anesthetic.

Question
What is your plan? What are your local practices?

Going forward we will move quickly through the rest of the case.

You decide to do an IV start and modified rapid sequence IV induction in view of food intake 4 hours ago.  You have considered also considered starting an IV under oxygen and nitrous oxide or even inhalation induction if the IV start is difficult.  A distressed and screaming child during multiple IV attempts may worsen the underlying pathology particularly if it is a bleed.

You get the IV on the first go and proceed to intubate the patient. The MRI proceeds uneventfully, however the scan reveals a right sided grapefruit sized supratentorial tumour arising from the ventricle with midline shift and flattening of the gyrii.  The neurosurgeon believe this to be a choroid plexus tumour and needs to removed immediately.   They will need the patient positioned supine with head turned laterally.  As a passing comment, the neurosurgeon, remarks ‘these really pour’.

You move the patient to the OR.  Currently your patient is stable, with one 24 gauge IV line and a size 4.0 microcuffed ETT.

What are your concerns regarding the patient and procedure? 

What monitoring will you need?

What potential issues might you face and how are you planning on mitigating them?

Welcome back after the weekend.

At the end of last week, we were faced with a conundrum of consenting proportions. Consenting around MRIs is a key element of providing pediatric anesthesia.  Discussions at recent pediatric anesthesia meetings do suggest that consent for GA is obtained for MRI, even-more-so when patients are critical with a worsening condition.  True informed consent has a few key components and always involves a patient.  In pediatrics, the concepts of parental permission and patient assent (age appropriate) come in to play.  A few great articles on this can be found here.

http://jme.bmj.com/content/early/2014/06/10/medethics-2013-101395.abstract

http://jmp.oxfordjournals.org/content/39/1/8.abstract

http://pediatrics.aappublications.org/content/132/5/962.abstract

http://pediatrics.aappublications.org/content/95/2/314.abstract?fulltext=informed+consent

Going back to the case.

Following a lengthy discussion with the ICU, Surgical and anesthesia, Chaplaincy department, the parents provide consent for surgery.  The surgeons estimate 4 hours of surgical time.

The patient is lined up with

  •  2x 20ga IVs (saph & arm),
  • art line
  • urinary catheter
  • blood/fluid warmer
  • underbody body warmer
  • maintained on sevo/remi, oxygen and air.
  • Frequent Bedside blood sampling for Hb, lytes and gases.
  • Mannitol
  • Low EtCO2

Within an hour of surgery, it is clear there is continuos bleeding from the tumour.  The suction has been running continuously and you have been working hard to keep up.  The patient has already lost ⅔ of their estimated blood volume.  You continue your work for 4 hours and the final tally estimates blood loss at two blood volumes.

Questions

How did you manage the patient?

What was your strategy for blood products in pediatrics with large ongoing blood loss?

What is your local institutional practice for massive transfusion cases?

What complications have you seen?

Remember there are no right or wrong answers.  Please tag your replies with #gasclass!

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