Ambulatory Surgery case

[Noyac]

10 yo male with Rubinstein-Taybi Syndrome for Bil PE tubes and frenulectomy at the ambulatory center attached to the hospital.

Moderately obese, Lg VSD, Multiple Resp Infections with last being 1 yr ago. He does not communicate. Has frequent emesis.

Do you do the case?

Rubinstein-Taybi source ( I had no idea what it was):
http://www.emedicine.com/PED/topic2026.htm

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[jetproppilot]

10 yo male with Rubinstein-Taybi Syndrome for Bil PE tubes and frenulectomy at the ambulatory center attached to the hospital.

Moderately obese, Lg VSD, Multiple Resp Infections with last being 1 yr ago. He does not communicate. Has frequent emesis.

Do you do the case?

Rubinstein-Taybi source ( I had no idea what it was):
http://www.emedicine.com/PED/topic2026.htm

Yes.

Ketamine/glycopyrrolate dart to the thigh 10 min before going back..... bring'em back, reverse trendelenberg the bed, turn on 70% nitrous in 30% oxygen and let the kid breathe it for a cuppla minutes. Dont bag him as to not insufflate the belly. That should be enough. If not, crank a whiff of sevo.....I know......vasodilatation which may exacerbate a right to left shunt but not if you use justa whiff and the surgeon is fast.

The whole procedure should take less than 5 minutes. Tube, tube, clip.

 

[Planktonmd]

In my opinion kids with weird syndromes don't belong at the ambulatory surgery center.

 

[BISof60]

Especially at 10y/o, I wouldn't expect problems with ventilation so I'd feel confident doing the case. However, if a site like emedicine lists

• • Cardiac arrhythmia with use of succinylcholine

• • Laryngeal wall collapsibility

• • Sleep and anesthesia problems

it does make you pause.

that said, at my academic and generally conservative center we do outpatient ent stuff on pierre-robin kids so unless the airway looks critical, i'm confident doing this case. he's probably going to need some extra time in the pacu, though.



why does he have emesis?

 

[Noyac]

Especially at 10y/o, I wouldn't expect problems with ventilation so I'd feel confident doing the case. However, if a site like emedicine lists

• • Cardiac arrhythmia with use of succinylcholine

• • Laryngeal wall collapsibility

• • Sleep and anesthesia problems

it does make you pause.

that said, at my academic and generally conservative center we do outpatient ent stuff on pierre-robin kids so unless the airway looks critical, i'm confident doing this case. he's probably going to need some extra time in the pacu, though.



why does he have emesis?

I'm not sure why he has emesis. Apparently, he throws up when he gets nervous. He threw up 3 times in teh OR b/4 induction. Green bile.

 

[Noyac]

In my opinion kids with weird syndromes don't belong at the ambulatory surgery center.

I understand but does the fact that the ASC is directly attached to the hospital by a doorway which makes it easy to transfer make any difference?

 

[militarymd]

mask em

or you could tube them....but the risks are no different...just my opinion.

 

[Noyac]

mask em

or you could tube them....but the risks are no different...just my opinion.

You gonna place an IV?

 

[militarymd]

You gonna place an IV?

I doubt it...it would take longer to put the iv in than to do the case....and having the IV means another thing to worry about....the VSD...

don't get me wrong...I would have stuff ready for vascular access for emergencies....but just doesn't seem worth the hassle to put it in for the case .

 

[Noyac]

So what would be your plan in the case of an airway issue?

No IV (this guys hands looked like he had boxing gloves on with very short stubby fingers. there is no way you are going to pop an IV in quickly)
Bad juju with sux
very short case
Collapsible airway


Should he get abx due to VSD and frenulectomy? I didn't give any. We give it for dental procedures though.

I'm not saying that I know the right answer here.

 

[militarymd]

So what would be your plan in the case of an airway issue?

No IV (this guys hands looked like he had boxing gloves on with very short stubby fingers. there is no way you are going to pop an IV in quickly)
Bad juju with sux
very short case
Collapsible airway


Should he get abx due to VSD and frenulectomy? I didn't give any. We give it for dental procedures though.

I'm not saying that I know the right answer here.

Backup airway plan.....same as all other backup airway plans where you can't use sux and have no IV.

The latest revision of the AHA guidelines has pretty much removed everything off the list ...so no ABX....if peds really worried...PO abx like we're supposed to do anyways.

 

[Noyac]

I'm with you on this one, Mil. I didn't give abx but questioned the need for po abx. I didn't place an IV and looking at him I knew that my usual plan was not going to work, which is quickly place IV or give sux in the tongue. LMA was my backup and teh emesis just b/4 induction had me concerned. i did the case b/c I am comfortable with the nursing staff at the ASC and the hospital OR was thru the door just 30 sec away.

I did a sevo mask induction. I assisted his breathing throughout, without taking over. His sats were tenuous at best. His ECG looked like V tach from the start but never really changed. I did have a large EJ to access if needed. Everytime I turned his head to start the PE tube placement I nearly lost his airway. We got around that. His airway was very collapsible just like the emedicine blurb stated. But the guy was KOOL. He didn't have any problem with the mask. He walked back on his own. His mom was totally kool with the whole thing (unlike the parents of the "healthy" kid b/4 him who had to come to the OR for induction, they won't ask to do that again).
So I went ahead with it. I'll tell you, I think everyone of my partners would have cancelled the case. The surgeon didn't even know he had a VSD
Maybe, I should have cancelled it and rescheduled him at the hospital but what good would that have done? Once it was over, I said "well, we got away with one today". All in all, it was a good case and the kid did great. He went home within the hour. Things worked out fine but I still don't know if I did the right thing here.

 

[militarymd]

tell me this....what could the guys over at the "hospital" done that you couldn't have?

Some risks are modifiable....

Most are not....

This kid had nothing that I can see that is modifiable.

Then you have to ask yourself....are your skills as good as the next guy...if the answer is yes...then TALLY HO.

If not, then punt.

This is only a problem for those of us who are legends in our own minds.

The hard part is figuring out who are legends in their own minds.

 

[jetproppilot]

I'm with you on this one, Mil. I didn't give abx but questioned the need for po abx. I didn't place an IV and looking at him I knew that my usual plan was not going to work, which is quickly place IV or give sux in the tongue. LMA was my backup and teh emesis just b/4 induction had me concerned. i did the case b/c I am comfortable with the nursing staff at the ASC and the hospital OR was thru the door just 30 sec away.

I did a sevo mask induction. I assisted his breathing throughout, without taking over. His sats were tenuous at best. His ECG looked like V tach from the start but never really changed. I did have a large EJ to access if needed. Everytime I turned his head to start the PE tube placement I nearly lost his airway. We got around that. His airway was very collapsible just like the emedicine blurb stated. But the guy was KOOL. He didn't have any problem with the mask. He walked back on his own. His mom was totally kool with the whole thing (unlike the parents of the "healthy" kid b/4 him who had to come to the OR for induction, they won't ask to do that again).
So I went ahead with it. I'll tell you, I think everyone of my partners would have cancelled the case. The surgeon didn't even know he had a VSD
Maybe, I should have cancelled it and rescheduled him at the hospital but what good would that have done? Once it was over, I said "well, we got away with one today". All in all, it was a good case and the kid did great. He went home within the hour. Things worked out fine but I still don't know if I did the right thing here.

nice, Mikey.

I said ketamine cuz it sounded like he was gonna give you alotta trouble. If the mentally challenged kids start raising alotta rukkus I dart'em in the thigh like that old guy used to do to elephants on The Wild Kingdom.

He didnt, and your plan was easier.

Plus it worked.

 

[Planktonmd]

I understand but does the fact that the ASC is directly attached to the hospital by a doorway which makes it easy to transfer make any difference?

Yes it does.

 

[Noyac]

tell me this....what could the guys over at the "hospital" done that you couldn't have.

Nothing since I am the guy that would be doing it at the hospital as well. Some of my thinking goes like this, tell me if I am wrong. You do a case like this at the ASC and something goes wrong. People will then start to ask questions.
Why was this case done at an ASC?
Why didn't you secure the airway?
Why didn't you place an IV in this type of pt?
etc, etc.

So just as we don't practice defensively, we don't do cases worrying what others may say if things don't go so smoothly. There are always going to be Monday morning quarterbacks.

But this is definitely not your run of the mill ASC case and I know that just about every other partner of mine would have likely cancelled this case. And they probably would have been right to do so. But I thought, what is going to be different? And just as Plank said, having your ASC attached to the hosp directly does make a difference. Thanks for helping me work this out.

 

[Noyac]

nice, Mikey.

I said ketamine cuz it sounded like he was gonna give you alotta trouble. If the mentally challenged kids start raising alotta rukkus I dart'em in the thigh like that old guy used to do to elephants on The Wild Kingdom.

He didnt, and your plan was easier.

Plus it worked.

Your are absolutely right. These kids usually don't do well in this situation and the vitamin K is a great technique. This kid was just too Kool. He literally strutted down the hall to the OR like Tony Montana. He had no verbal communication skills but was very clear in what he wanted. As he was vomiting up small amount of bile just b/4 surgery, he pushed away the kidney basin and reached around the nurse to grab the suction. It was awesome. We laughed so hard that you just sort of felt like everything was going to be just fine.

 

[militarymd]

Nothing since I am the guy that would be doing it at the hospital as well. Some of my thinking goes like this, tell me if I am wrong. You do a case like this at the ASC and something goes wrong. People will then start to ask questions.
Why was this case done at an ASC?
Why didn't you secure the airway?
Why didn't you place an IV in this type of pt?
etc, etc.

So just as we don't practice defensively, we don't do cases worrying what others may say if things don't go so smoothly. There are always going to be Monday morning quarterbacks.

But this is definitely not your run of the mill ASC case and I know that just about every other partner of mine would have likely cancelled this case. And they probably would have been right to do so. But I thought, what is going to be different? And just as Plank said, having your ASC attached to the hosp directly does make a difference. Thanks for helping me work this out.

Like you said...Monday morning quarterbacks.

If you are at the top, there's only one way to go......and there's always many who would like to help you down.

You (and I) just got to do what you know is right...for the patient and for you.

I believe that you did the right thing...with or without complications...which WILL happen at the hospital or at the ASC...