A dwarf in my holding area!

[Planktonmd]

Today, I came to work at noon since I am on call tonight, passed by the holding area and there she was: an adorable 65 Y/O, almost 3 foot tall achondroplastic dwarf waiting to have a 4 level laminectomy.
She said that she had GA once 25 years ago and that she had sore throat for 3 months after that.
She is healthy otherwise.
Propofol sux tube?

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[DO4lifer]

i'm curious about dosing. body proportions aren't like an adult's. although they aren't like ped's either.... hmmmm

 

[aphistis]

Airway exam?

 

[urge]

pent, sux, tube.

 

[OB1🤙]

Airway exam?

Yeah, without knowing more about the airway it's hard to say much. The sore throat gives you some nonspecific information suggesting it might be hard to intubate, but you knew that the second you saw the pt.

For the boards I think I'd say awake FOI is the way to go.

If you think you'll be able to mask this patient, then have a fiberoptic setup lit up and ready to go, topicalize a nare, then gently induce (i.e. stun dose propofol, not 200 fent and the whole stick of diprivan), prove you can in fact mask, more prop + sux, and take a look with your blade du jour or a Glidescope depending on how you think the cosmos will line up. Glide right off the bat may optimize the likelihood of success of your first look. At the first sign of difficulty ditch and go to FOI with the already prepared nare. LMA/bougie at the ready obviously.

 

[OB1🤙]

On second thought, nasal FOI probably isn't necessary and oral would do just fine in either scenario.

 

[aredoubleyou]

no experience in the matter, but it is an instance where I would for sure ventilate before muscle relaxants are pushed if the airway looked good. If I cant push air, then wake her up. I wouldnt try to read into the sore throat thing, no way to know what happenend (i.e. wouldnt go straight to FOB based soley on a sore throat).

 

[aredoubleyou]

Yeah, without knowing more about the airway it's hard to say much. The sore throat gives you some nonspecific information suggesting it might be hard to intubate, but you knew that the second you saw the pt.

For the boards I think I'd say awake FOI is the way to go.

If you think you'll be able to mask this patient, then have a fiberoptic setup lit up and ready to go, topicalize a nare, then gently induce (i.e. stun dose propofol, not 200 fent and the whole stick of diprivan), prove you can in fact mask, more prop + sux, and take a look with your blade du jour or a Glidescope depending on how you think the cosmos will line up. Glide right off the bat may optimize the likelihood of success of your first look. At the first sign of difficulty ditch and go to FOI with the already prepared nare. LMA/bougie at the ready obviously.

My concern about the stunning propofol dose is that you are going to almost certainly have a difficult mask - if you think she can handle a couple minutes of apnea I'd push an appropriate dose. Just my take on it.

 

[Trisomy13]

2 mg Versed.

Demand to know where pot of gold is.

I'm rich, bitch!!

 

[Planktonmd]

On further questioning she said that an ENT saw her for that sore throat 25 years ago and told her that "she has some scar tissue in the throat"!

She is MP III but opens her mouth reasonably well.
The neck does not extend much and she has a full set of teath.
The thyromental distnce is about 3 cm.

So, what's the plan?
Any concerns other than the airway?

 

[DET0897]

Today, I came to work at noon since I am on call tonight, passed by the holding area and there she was: an adorable 65 Y/O, almost 3 foot tall achondroplastic dwarf waiting to have a 4 level laminectomy.
She said that she had GA once 25 years ago and that she had sore throat for 3 months after that.
She is healthy otherwise.
Propofol sux tube?

Interestingly, I had a similar experience last week: 51 y/o achondroplastic, multilevel spine assault. 120 cm tall but she weighed 70kg. Prop/sux/tube (could of used roc but for the monitoring) easy mask and intubation, but had to get A-line in the foot. Typically, no special airway complications are associated with achondroplasia.

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

The day prior, did a TSR in a woman with acromegaly. go figure

 

[Planktonmd]

Achondroplastic dwarfs can be a challenge in many aspects when it comes to anesthesia management (despite what that study on achndroplastic babies say):
1- They frequently have limited mouth opening, limited neck movement, macroglossia, and small trachea.
2- They have body weight equivalent to children but they also have old livers and old kidneys which makes dosing medications interesting to say the least.
3- They frequently have cardiac abnormalities.
4- They Frequently have severe arthritis of the cervical spine which further complicates the airway management.
5- They are particularly challenging when it comes to volume replacement in a surgery that involves major bleeding.
From the answers we got so far it seems to me that no one really understood these concerns which is pretty scary.
If you don't believe me look for the tragic story of the Rice brother in Florida not too long ago.
http://www.upi.com/Entertainment_Ne...hospital-over-twins-death/UPI-63781150243697/
So, let's ask again, do you have any concerns? or just Propfol, Sux tube???

 

[2win]

Achondroplastic dwarfs can be a challenge in many aspects when it comes to anesthesia management (despite what that study on achndroplastic babies say):
1- They frequently have limited mouth opening, limited neck movement, macroglossia, and small trachea.
2- They have body weight equivalent to children but they also have old livers and old kidneys which makes dosing medications interesting to say the least.
3- They frequently have cardiac abnormalities.
4- They Frequently have severe arthritis of the cervical spine which further complicates the airway management.
5- They are particularly challenging when it comes to volume replacement in a surgery that involves major bleeding.
From the answers we got so far it seems to me that no one really understood these concerns which is pretty scary.
If you don't believe me look for the tragic story of the Rice brother in Florida not too long ago.
http://www.upi.com/Entertainment_Ne...hospital-over-twins-death/UPI-63781150243697/
So, let's ask again, do you have any concerns? or just Propfol, Sux tube???

Sedation, awake FOB, good IV acces. I understand that this is an achondroplastic dwarf - is it?
page 4 - Roizen "Essence of anesthesia practice"
If she's 65 most likely you have some info about cardiac and respiratory status. I would include here (if any) the degree of restrictive disease (and I would explain to the patient potential complications). Really careful wit positioning. SSEP before and after positioning, intraop (for the board...)
Regarding the mtbolism of drugs - I believe that they are the "normal". The muscular mass (if the patient is not obese) is increased compared with "normal". I don't have other info and please let us know if is something different.
I remember that I had 5 years ago a dwarf in ER - called for emergency intubation. Suicidal, non cooperative, under who knows what influence with a maxilo - facial trauma. The bullet penetreted the mandibulla, tongue, and maxila. Blood all over - no view, no cooperation. Intubated FOB - a pain....

 

[LongSnow]

One "jedi" anesthesiologist taught me how to manually intubate - on a dwarf. Real character. I was a resident, all worried about how to intubate a dwarf who was coming for basically a whole body lami. He pushed STP, vec, masked (thankfully), and I took a look - nothing. Taught me how to put the tube between my middle and index finger, and advance the tube in this way. put fingers down mouth until feel epiglottis, and advance tube with other hand into trachea. Particularly good for adult dwarfs, as the problem is often with the "angles". Ie - such and acute angle from pharynx to glottis - even a nasal endoscopic aproach the scope may not flex quite enough.

Certainly not board answer number one, but not a bad thing to try and learn how to do. I've resorted to this technique at a few codes - you know - the ones where you get no help, no equipment whatsoever? When you pull this off, it looks pretty damn slick!

 

[pjl]

An old but good article on dwarfs of various types, no direct link, but there is one off that page: There are some good overall discussions of issues, then later on a chart with particular concerns in various specific disorders.

http://journals.lww.com/anesthesiol...warfs__Pathophysiology_and_Anesthetic.21.aspx

Typically (in my limited experience, and per literature) dwarfs are easy to mask, hard to intubate. In the MPS disorders there is likely to be deposition of glucosaminoglycans throughout the airway, limited neck ROM, and atlantoaxial instability making intubation more worrisome. It is recommended to do flex-ex neck films preop.

 

[ssmallz]

I don't get this whole "stun dose of propofol" thing to figure out if we can mask. If we anticipate a difficult mask then lets just do an awake FOI, if we believe we can mask just give the intubating dose and be done with it. There's just no point in making a patient apneic even for a few seconds if we don't think we can ventilate. Too many bad things can happen. IMO, if you're thinkin of stunning her w/propofol you should just awake FOI b/c you already have your answer. If topicalized correctly FOI is not THAT uncomforable for the patient.

To me this sounds like a pt who we should be able to ventilate but based on here airway anatomy might be tough to intubate. Propofol, Roc, Miller blade or glidescope would be my first choice. I would give it 1 attempt and switch over to the FOB very quickly if I didn't feel like got a great view.

 

[OB1🤙]

What I meant by "stun dose" propofol really was an induction dose closer to 1mg/kg rather than 1.5 or 2 (which I realize is not what we usually mean when we say "stun dose" propofol, my bad). My point was that I'd want to use the lowest dose that will allow you to legitimately mask. What that dose will be in this particular little person will be determined by two parts experience (which I still lack), one part luck, and one part voodoo IMO.

Anyway, the points about the likelihood of a more difficult mask with lower induction doses are well-taken.

 

[ssmallz]

What I meant by "stun dose" propofol really was an induction dose closer to 1mg/kg rather than 1.5 or 2 (which I realize is not what we usually mean when we say "stun dose" propofol, my bad). My point was that I'd want to use the lowest dose that will allow you to legitimately mask. What that dose will be in this particular little person will be determined by two parts experience (which I still lack), one part luck, and one part voodoo IMO.

Anyway, the points about the likelihood of a more difficult mask with lower induction doses are well-taken.

Why do you want to use the lowest dose you can to mask? If you don't think you can mask, don't even push any propofol, just do an awake technique. I want to use the lowest dose or propofol I can to optimize my intubating conditoins, thats why I'm inducing in the first place. I wouldn't induce this patient, or any other for that matter, if I didn't think I could mask them.

 

[Prodigal OU Son]

Does your institution have a McGrath or Glidescope?

 

[Prodigal OU Son]

Double post.

 

[radslooking]

i would intubate through the rectum

 

[Arch Guillotti]

Today, I came to work at noon since I am on call tonight, passed by the holding area and there she was: an adorable 65 Y/O, almost 3 foot tall achondroplastic dwarf waiting to have a 4 level laminectomy.
She said that she had GA once 25 years ago and that she had sore throat for 3 months after that.
She is healthy otherwise.
Propofol sux tube?

Bump because I was reminded of this thread by the other one about a dwarf.

What happened?

 

[OB1🤙]

I would just like to say that 2014 me totally agrees with the people questioning 2009 me's judgment on induction doses.

2014 me thinks you should give a full induction dose with paralytics if you are going to give anything involving the possibility or likelihood of apnea. Otherwise do it awake.

2009 me had much to learn (though, to be honest, so does 2014 me).

 

[Arch Guillotti]

I would just like to say that 2014 me totally agrees with the people questioning 2009 me's judgment on induction doses.

2014 me thinks you should give a full induction dose with paralytics if you are going to give anything involving the possibility or likelihood of apnea. Otherwise do it awake.

2009 me had much to learn (though, to be honest, so does 2014 me).

Almost all the attendings I trained under believed in "test" ventilation. Now I think it's bunk 99+% of the time.

 

[deleted171991]

Now we have much better tools than back in the day.

 

[Mman]

Almost all the attendings I trained under believed in "test" ventilation. Now I think it's bunk 99+% of the time.

I agree that if I've given an IV induction, I'd rather not waste 30-60 seconds seeing if I can ventilate. Because if I can't it's going to be a struggle anyway and I'd rather give myself the best shot at intubation possible.

 

[Planktonmd]

I did good topical airway anesthesia + Transtracheal block, gave 1 mg of Midazolam and did a smooth awake fiberoptic intubation.
Then for anesthesia we did TIVA with Propofol + Remi since they were doing Motor EPs.
We placed an Aline and watched the blood loss closely.
She required 2 units of PRBCs intra-op.
Was able to extubate post-op.
Since then I have taken care of this patient twice and she now asks for me when she is having surgery