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?
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
Intracranial tumours (supratentorial and subtentorial)
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.
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.
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.
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.
- 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.
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!
Welcome to a new week of Gasclass! This week we’ll talk about a short series of pediatric anesthesia cases.
Case 1: You are on-call and paged by ENT because they want to book a 2 yo child for extraction of foreign body.
How will you manage this situation?
As mentioned on twitter, there are two options for induction: inhalational or IV.
You induce the child with an inhalational induction because they do not have an IV. After placing an IV asleep, you continue to deepen the anesthetic under spontaneous ventilation and test the depth with laryngoscopy. While going in with the laryngoscope and about to spray the cords, you notice a piece of white-yellow food (possibly nut?) just at the laryngeal inlet below the epiglottis.
What would you like to do at this point?
Case 2: General surgery has booked a 2 mo boy for pyloromyotomy. They have asked for a preop consult because of a diagnosis of sickle cell disease.
What are your considerations for this surgery? What are your goals for preoptimization?
Thanks for all the responses! Common themes seemed to be:
– this is non urgent surgery and patient’s fluid status and electrolytes should be preoptimized
– concerns for sickle cell disease: warm, hydrated, good analgesia (? Regional techniques), crossmatch may be difficult if previous transfusions and alloantibodies
– consultation with hematology for optimization preop (physiologic anemia of infancy, preop transfusion)
– might benefit from postop ICU monitoring?
Case 3: you are doing a tonsils and adenoids list.
What are your criteria for suitability for outpatient T&A vs inpatient admission? How do you assess for pediatric OSA?
The next child, a 4yo boy, has been snoring so loudly his parents say “the walls shake” as well as having overall daytime somnolence, decrease in activities and witnessed “breath holding” spells when asleep. He has not had any investigations (sleep study, overnight oximetry) or treatments. He is average weight but parents feel he would not be cooperative with a preinduction IV. He has grade IV kissing tonsils on exam, with audible noisey breathing at rest.
What investigations (if any) would you like? What is your anesthetic plan?
Remember to tag your tweets with #gasclass! There are no right or wrong answers.
Good morning and welcome to the start of a new term for Gasclass.
For novices and veterans to Twitter and Gasclass, remember there are no right or wrong answers here. Over the course of the day and week, additional information and feedback to your inqueries will be provided here. Please tag your Twitter responses with #gasclass so we can find it and include in our Storify summary.
This week we will be working on call in the OR/OT…
You are paged by interventional radiology around 4pm because they want to book an add-on image guided biopsy of a mediastinal mass in a 10 yo child. What are your initial thoughts?
A good start to the new term! A number of common concerns came up:
– What is the urgency of this case? Does it need to be done as an add-on after hours, or can it wait until the morning?
– Is there a role for preop steroids to shrink the mass, and how will that affect diagnosis and treatment?
– How symptomatic is the child? Is there stridor or SVC obstruction?
When you go to assess the child, you find out that he has been previously healthy, but over a course of weeks has become increasingly short of breath on exertion. He was getting breathless with sports and was initially prescribed a puffer that didn’t help, and now he gets winded walking up stairs. When questioned about sleeping positions, he has been sleeping on his side and now on his belly. He immediately gets short of breath on lying flat and has had an episode where he felt like he was going to pass out. There is no hoarseness, ptosis, or meiosis.
On physical examination, there are no signs of plethora or swelling of the face, but his neck and arm veins are visibly distended. He is not struggling to breath sitting up, but appears anxious.
The CXR shows a large central mass. The CT scan was done in the prone position, and it shows a large mass causing complete compression of the SVC with extensive chest wall collateralization. The trachea is compressed to >50% just above the carina, but the mainstem bronchi are unobstructed.
Are there any additional investigations that you would like?
Several people suggested getting an echo, which is important to look for compression of vessels and chambers as well as pericardial fluid. The echo showed no compression of the RA/RV, and unobstructed flow from the IVC. The SVC was complete obstructed. There was no pericardial effusion. Biventricular function visually appeared normal.
Some people suggested looking for a more superficial node to biopsy. Many would delay the case until the daytime, as well as having cardiothoracics available.
What are your anesthetic concerns and plan for this child’s needle biopsy? Does your centre have the resources or staffing to handle this case?
You decide to delay the case to daytime hours with full staffing and backup available. The procedure is planned to be done in IR under ultrasound guidance. The patient is positioned with a ramp and blankets to maintain more backup position, and light sedation with a benzodiazepine is given. He is quite cooperative during the initial local infiltration and scanning.
During the biopsy portion, the patient starts complaining of chest discomfort. He starts to cough and desaturate.
What is your differential and management plan?
Lung U/S and fluro in the IR suite rule out a significant pneumothorax. However, he is coughing more and continues to desaturate. He is beginning to become agitated, and is coughing up some frank blood.
How would you manage this emergency situation?
Thank you to everyone who read our blog and contributed to the discussion on Twitter! The summary of this week’s case can be found here.
Some of the salient points brought up with this case include:
– ECMO/CPB might be unfeasible and take too long to prevent neurological injury
– Ideally, an awake biopsy should be performed under local anesthetic and judicious sedation
– Pre-operative echo is important to determine any structural compression or effusion that may need to be drained
– May be safer to delay surgery until daytime hours
– Prudent to anticipate and plan for emergencies, and have rigid bronch, ENT/cardiothoracics/ECMO on standby for the highest risk patients
– RSI and paralysis in anterior mediastinal mass with airway compression may cause complete collapse and inability to ventilate. May be difficult to pass ETT past obstruction. Safer to maintain spontaneous ventilation during intubation.
– Preoperative steroids and radiation therapy (sparing part of tumour) may help in high risk cases, but need to discuss timing of biopsy with oncology to maximize diagnostic potential
Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol. 2007 Feb;20(1):1-3. PubMed PMID: 17211158
Blank RS, de Souza DG. Anesthetic management of patients with an anterior mediastinal mass: continuing professional development. Can J Anaesth. 2011 Sep;58(9):853-9, 860-7. doi: 10.1007/s12630-011-9539-x. Epub 2011 Jul 21. Review. English, French. PubMed PMID: 21779948.
We’ve escaped the community and are back in theatre this week. You are the cardiac anaesthesia registrar, slated to cover Paeds Cardiac Surgery this week. Your first case tomorrow is an 8month old girl who is booked for a Blalock-Taussig Shunt.
Her diagnosis is listed as Tetralogy of Fallot.
What information would you like to elicit in order to help you manage this child peri-operatively?
Some interesting questions asked yesterday, thanks for the input. Most have concentrated on the degree and nature of the cyanosis, which is entirely appropriate.
You see the child. She is 8 months old, weighs 5.2kg and at rest, she is not cyanotic. The mother reports that she was born at term, was discharged routinely from hospital but soon after birth mom noticed that the child became discoloured during feeding and when she cries. She was seen and assessed at age 2 months as a tetralogy of Fallot, shunting was recommended but the pair were lost to followup until recently.
The cyanotic episodes are becoming more frequent and they are limiting the ability of the child to feed. The mother also reports that the child has “fainted” on one or two occasions. In terms of medical therapy, the baby is on a beta blocker (inderal). Mom reports that this has helped somewhat.
The child has had an evaluation by the paeds cardiology team who have demonstrated the typical findings of tetralogy of Fallot – RV hypertrophy, over-riding aorta (50%), VSD and infundibular narrowing (RVOT obstruction). During spelling the gradient across the infundibular obstruction was noted to be 50mmHg.
What are some of the relevant sequelae of ongoing cyanosis, wherever it’s clinical context? (child, adult)?
How should we manage these in this scenario?
Remember all input is welcome. yesterday was decidedly top heavy on the consultant side. In many countries, a thorough working knowledge of the management of this disease is expected of candidates for the specialist exit exam!
After assessing the child, you decide that you are happy to proceed. The Hb is 18g/DL and renal function is normal. The child is first on the theatre list for tomorrow. It is booked for left thoracotomy and modified BT shunt with a goretex graft from left subclavian to left pulmonary artery. What is the anaesthetic plan?
You have the child in theatre, induction has gone smoothly and the tube is in. As you are preparing for arterial line insertion, you notice a fall in ETCO2 and the saturation begins to drop.
What is your immediate plan of action?
A brief summary of the issues will follow tomorrow.
Thank you for the input this week. What follows is a brief summary of how I approach the child with a tetralogy of fallot. It represents nothing more than a personal approach, a rubric that works for me. Comments welcome.
Tetralogy of Fallot is a congenitally acquired cardiac condition characterised by right ventricular hypertrophy, a sub membranous VSD, overriding aorta and infundibular spasm. It can be categorised as a cyanotic defect, with low pulmonary blood flow.
Children usually present early with a history of cyanosis and hyper cyanotic spells, exacerbated with feeding and crying. Those who do not present early develop and are often seen to adopt the classical squatting pose to break the cyanotic spell.
Surgical management is usually directed at increasing pulmonary blood flow, initially with a palliative procedure, some variation of a Blalock Taussig shunt whereby pulmonary blood flow is augmented by draining the left subclavian artery into the left pulmonary artery. This is done to provide relief from the hyper cyanotic spells, and to “mature the pulmonary circulation” to a level where complete correction can be undertaken, usually at age 3-4y.
From an anaesthesiology point of view, these children provide a challenging opportunity. They are often underweight, with tenuous right ventricular function. The ongoing cyanosis is exacerbated by polycythaemia and many of the comments this week alluded to this. polycythaemia leads to increased viscosity of the blood with sluggish cerebral blood flow, worsened in states of dehydration. If the child is symptomatic or has had some sort of cerebral event preoperative venesection can be considered to reduce Hb to more manageable levels, although this is (in our setting) rarely done. The polycythaemia also has functional effects on coagulation, the hyper coagulability mentioned above is one issue. The other is that platelet function is suppressed and these children may exhibit increased surgical bleeding. The effects of the polycythaemia are exacerbated in the presence of dehydration so limit starvation time to 6hours for solids and 2 hours for liquids. The parents should be encouraged to give the child fluid right up to the 2h mark.
For those preparing for examinations, the controversial aspects in the management of Tetralogy patients coming for surgery are (a) whether or not to premeditate and (b) IV or gas induction.
Premedication presents a double edged sword. On one hand, the premeditated child is less likely to cry and struggle on induction which is advantageous as these may increase the likelihood of a hyper cyanotic spell. However, the heavy premedication required to prevent this may present the risk of respiratory depression, hypercarbia and hypoxemia. Premedication in the ward is not recommended. If your pre op holding area is monitored and access to pulseoximetry is easy, then premedication is reasonable. In my practice I typically do not premedicate. I have spoken to anaesthesiologists at major children’s hospitals and some recipes for premedication include Midazolam 0.5mg/kg PLUS Ketamine 7.5-10mg/kg po. I’m told the children are very compliant at this dose and tolerate IV insertion. Your mileage may vary but you’d need very well monitored holding areas for this technique, remembering that his cocktail can take up to 45minutes to work.
On choice of induction technique, the recommended approach is to establish IV access and do an IV induction. Again agents of choice are controversial. Ketamine probably represents the best option as these children generally are not in extremis and a conventional dose will maintain systemic vascular resistance, and augment contractility, which should limit right to left shunting. Induction with propofol is not recommended. A high dose opiate induction is also a reasonable approach. If IV access is available then a preload with 20ml/kg prior to induction will be helpful.
Typically, our practice is to perform a gas induction with Sevoflurane. The problem with this approach is that on gassing is dependant on adequate pulmonary blood flow which is obviously not present in this scenario. We take over ventilation early in order to prevent the breath holding that occurs during second stage (which feels like a very long time in these children) and the resultant hypercarbia.
Monitoring is with arterial and central access in the contralateral side. Surgery is done via a high left sided thoracotomy. The vessels are side clamped so there is no interruption in the limited pulmonary blood flow. On opening of the shunt there may be an element of reactive pulmonary hypertension due to the acute increase in flow. Analgesia is via opiates and intercostal nerve blocks. There is always potential for disaster (rupture/tearing of the vessels) and the bypass machine should be ready to run if not primed.
In terms of a broad approach to cardiac defects in children, a wise man once taught me this approach, a rubric, if you will.
Draw the anatomy – not in Frank Netter detail, but what we call a “box diagram”
Trace the path of the red blood cells, it sounds trivial, but draw it on your box diagram. It will give you a good working idea of the functional physiology of the defect.
Think. What is the effect of changes in downstream resistances? What will increasing SVR or PVR have? Decreasing?
What could go wrong? I.e what are the potential disasters
How will you manage these if they occur?
Now we know the anatomy, and the red cell path, we can look at 3, the effect of changes in downstream resistances.
SVR up leads to decreased R to L Shunt, the converse happens when SVR drops, like during an IV induction with Propofol or a careless gas induction
PVR increases worsen hypoxaemia. Decreases in PVR have little clinical effect because the RVOT obstruction usually limits flow.
Next, what can go wrong? In this case, a hyper cyanotic spell. How do we manage this? Physical maneuvers like flexing the hips or compressing the femorals increase SVR and limit right to left shunting. The same effect can be achieved with phenylephrine/neosynephrine. I usually draw up before hand, a few syringes with phenyl diluted to 1mg/kg/ml. I chase these with boluses of fluid (used to use colloids but now not so much) of 10-15ml/kg which seems to stent open the RVOT.
So this is a quick and dirty approach to TOF. The same rubric could be applied to any congenital cardiac condition.
Good morning (although it is not morning for your international editor). Thank you to Team Gasclass for the invitation & the opportunity.
On your walk/ride/drive to work today, one of your tasks is to mentally prepare for your first case of the day: a 5 year old needs a brain MRI. What are your initial thoughts. One tweet at a time, please.
You have arrived in the MRI suite. The patient is not here yet & neither is the chart. The MRI requisition is from neurosurgery. In the clinical information it says, “Increasing clumsiness and falls”. A radiologist reviewed the req last week & approved it. There are no previous imaging studies. Accepting that you have not yet interviewed the child & family, how would you routinely set up for this case?
Thanks for all the input yesterday. The child & his mother have now arrived & you have learnt the following. The child was completely healthy until 18 months ago, when he fell and sustained a head injury that, Mum says, ‘needed him to have a blood clot taken out of his brain’. He was in hospital about a week. Mum says he made a good recovery. The family moved & now live in a remote rural community. Over the last 3 months, he has had several episodes of stumbling or falling to the ground. He has been referred to the nearest neurosurgical centre because of his previous surgery. They flew in yesterday. The neurosurgeon has arranged to see them after the MR, to review the findings. This is their first time in this hospital.
What are your thoughts? What else would you like to know?
Some more details from the history. His original head injury resulted from a tumble down some concrete steps. The more recent episodes have all been playground incidents. Mum is worried he may be having seizures. There is no family history of problems with anaesthesia and she says he was OK during his last surgery. He was unwell with a cold & cough all last week, but is better now – just a bit of a runny nose still & the occasional cough. On exam., he weighs 20 kg. He does have a runny nose, but his chest is clear. His airway looks normal, & his cardiovascular & neuro exams are unremarkable. He is cooperative.
Are you ready to anaesthetise him? If so, what’s your plan? If not, why not?
Thanks for today’s input. You have put him to sleep & he’s in the magnet, breathing spontaneously (O2/air/sevo) on an LMA. You’re in the control room. About 10 mins in, his end-tidal CO2 disappears & the SaO2 starts to fall.
How do you manage this scenario?
Scanning paused. You, MR tech & ODP check the child. He is apnoeic & pulseless. Now that the scanning sequence is paused, his monitored ECG is legible:
Diagnosis? Actions & priorities?
Final question for the week: if/when this child returns for a procedure requiring general anaesthesia, what additional precautions/preparations would you take/make?
Ask The Expert
Thanks to our expert Simon this week.
Children under 7 are rarely able to tolerate the immobility &/or noise required for successful MRI, so providing general anaesthesia for them is a routine & common pastime for the paediatric anaesthetist. As the availability of, and indications for MRI widen, so does the likelihood of the occasional paediatric anaesthetist needing to be prepared for such an event.
This child requires an MR head. A ‘straight-shot head’ – no contrast, no spectroscopy – takes about 15 mins & doesn’t require breath holding. It does need an unobstructed airway, or else the head moves too much. I routinely do these cases on TIVA (to avoid emergence delirium; good for kids with recent upper respiratory tract infection [URTI]), with the child breathing spontaneously on nasal prongs that have an integral CO2 sampling port. This minimises the depth of anaesthesia required to tolerate the ‘airway’, avoids airway instrumentation (good for URTI again) & makes for efficient wake up & turn around. Many people would prefer the relative security of a laryngeal mask and volatile; a bit of thought is needed about MR compatible pumps if TIVA is the plan.
Two issues complicate this case – the child’s underlying medical problem, & the co-existence of a resolving URTI.
The history of falls, and concerns about seizures, & the fact that the child has previous neurosurgical intervention made it feel like a neuro problem, but as some tweeters mused, all that falls is not neurological, & cardiovascular problems, particularly dysrhythmias – which would be on everyone’s radar, had this been an older adult – also occur in children, albeit less commonly. A pre-induction ECG could be easily justified. In the luxury of a tertiary centre, one can always call a friendly paediatric cardiologist too, if really worried. If the rhythm underlying the arrest is torsades de pointes, the unifying diagnosis of long QT syndrome becomes obvious. LQTS is a complex family of cardiac ion channelopathies that is more common than generally realised, but the condition is highly heterogeneous & so often not recognised or known about, even by the patient. Symptoms, when they occur, are due to torsades, & range from pre-syncope, through syncope & self-aborting arrest, to sudden cardiac death. In children, the syncopal episodes are often misdiagnosed as seizures. The perioperative period is extremely high-risk in untreated LQTS, as sympathetic stimulation, electrolyte disturbances, hypothermia, & some anaesthetic drugs all increase the risk of torsades. Intraoperative arrest should be treated in accordance with APLS guidelines for CPR in children; basic life support should commence immediately on recognition of no pulse. Once the non-perfusing rhythm is identified as torsades, it should be treated as for pulseless VT. MgSO4 can stabilise the myocardium once a perfusing rhythm is restored. The mainstay of long-term LQTS management is beta-blockade, which will control symptoms in the majority – but not all – cases. Additional treatments include mexilitene, cervical sympathectomy & ICD; increasingly treatment is being individualised according to genotype. Preparations for anaesthesia in the child with known LQTS include ensuring maintenance of beta-blockade, normalising & monitoring modifiable risk factors (electrolytes, temperature), avoiding QT-prolonging drugs (see http://www.azcert.org) and being set up to manage an arrest (MgSO4 drawn up; defib pads in situ, low threshold for invasive monitoring). Relevant articles for the interested reader include bja.oxfordjournals.org/content/90/3/349.full; ceaccp.oxfordjournals.org/content/8/2/67.full; www.anesthesia-analgesia.org/content/112/5/1163
The child with a recent/resolving URTI is a classic paediatric anaesthesia chestnut. The weight of published literature on the topic is considerably greater than the amount of clarity about when/when not to proceed. Everyone agrees that the risk of PRAE (periop respiratory adverse events, usually defined as any of laryngospasm, bronchospasm, desaturation or coughing) is increased up to 10-fold in the wake of a recent URTI. Classical dogma defines ‘recent’ as 6 weeks; given that the average number of colds/yr is 7, this has never been of practical help. The salient points, from more recent publications, that have helped me to make day-to-day decisions are the following: if the URTI resolved >; 2 wks ago, no problem; if the child is sytemically unwell, has thick yellow/green snot, or if there is a COUGH, these are all red flags & I would have a low threshhold for postponing; for the 80% who fall between these extremes, it’s as much art as science. There’s no convincing evidence of worse hard outcomes (death, unplanned PICU admission, unplanned overnight stay, for example), & a stormy induction or emergence is typically undetectable a few hours later; I often feel it’s worse for my coronaries than the child’s. I base my decision on a combination of personal comfort level, type of surgery planned & the parents’ attitude to risk. For children who are symptom-free on the day, but had symptoms within the last 2 weeks, there is evidence that a salbutamol nebuliser reduces PRAE. In this week’s gasclass case, I would have proceeded simply because the planned ‘surgery’ was an MRI and I am comfortable with TIVA (which there is some evidence to suggest reduces PRAE risk compared to volatile) – I would have postponed the same child having dental surgery or a tonsillectomy, both of which require airway instrumentation & surgical mucking around in a primed airway.
There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.
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.
There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client. We are really keen on some new contributors and especially welcome Core Trainees and Pre Fellowship STRs. Feel free to pose questions to some of the more senior tweeters!
You are the resident on-call. It’s about 10pm at night and you get a call from the ENT team. They have seen a 4 year old child in the emergency department who has presented with a left submandibular swelling and they would like to take the child to theatre. What are your initial thoughts?
The child has had increased pain and swelling for 2 days. He was started on antibiotics and analgaesics. Clinically it is hot, red, swollen and painful.
He is saturating fine on air and not in respiratory distress. There is however some mild stridor on flexion of his neck. Examination of his chest is otherwise unremarkable.
Mouth opening and teeth are satisfactory. There is nothing discharging into the mouth. He doesn’t have IV access at them moment. Reasonably co-operative yet in a lot of pain. He last ate at 4pm.
What is your plan?
Lots of discussion on method of induction. You are now underway. Regardless of gas versus IV induction you are now in a position to take over ventilation. You can ventilate, with a bit of difficulty, but larynx displaced & view not good? Assuming the tube won’t just slip into the trachea what are you going to do? Will you use a neuromuscular blocker and which one? What other measures might be helpful?
Regardless of your choices so far you have induced anaesthesia and with the help of the surgeon secured an airway with a size 4 tube. The surgeons are now undertaking exploration.
They only manage to drain a little amount of pus like material from the superficial tissue plane but at the base it is indurated. This doesn’t turn out to be a short quick case of drainage of an abscess as was supposed earlier. It takes 2.5h for the surgeons to dissect and explore the area and it’s 3 O’clock in the morning now.
What are you thinking now?
This will be the final post for this case.
Any hospital could conceivably receive a child with this kind of problem. The urgency to deal with it will be entirely dependent on the airway assessment and the perception of obstruction risk.
Assuming that there is time to plan management, it is advisable to transfer to a hospital with an experienced anaesthetic and ENT / OMFS team. It goes without saying that a detailed history and examination as able is needed followed by IV access and movement to an operating theatre.
Abscesses in this region of the body may affect the movement and appearance of soft tissue thus making airway management especially including gas induction difficult. Direct laryngoscopy may also be diificult in terms of access as well as what you end up looking at. The view down a fibre optic scope may be particularly difficult to discriminate with everything swollen and red! The difficult airway trolley must be available.
The discussion of IV versus gas induction is dependent on experiences and often seems counter to textbook teaching. I would love to see the randomised trial of 1000 children with airway obstruction comparing technique A and B. But it’s not going to happen and therefore one needs the right person as well as the right technique.
There are three controllers of the airway. The patient, the anaesthetist, the surgeon. Once anaesthesia is induced the latter two need to have communicated in detail about Plan A then B then C and informed the team about the sequence.
The end result was a child with a secure airway at 0300. It would take a brave person to want to return airway care to the patient at this time.
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