4 year old asthmatic

[deleted9493]

I'm not on anesthesia this month but did a peds consult for ENT today in the PACU and was just curious as to everyone's opinions.


Four year old girl apparently presents for preop today with a resolving URI that she's had going for 1.5 weeks on top of underlying asthma. She's got albuterol PRN (mother says she's not needed it) and also singulair, daily. Parents are smokers but both "make sure that she's not around when they do." She's to have bilateral tubes and T&A but the anesthesiologist isn't satisfied with her respiratory status, as she is actively wheezing. Mother flips out when she hears that he wants to cancel the case and basically ends up (somehow) getting him to go ahead with the case anyway. Myringotomies go fine but when the ETT is placed for the T&A, they get about two breaths in and the girl goes into bronchospasm. From what I could tell, they dosed her up with rocuronium, propofol, and albuterol to try to turn things around. I think they were giving sevo throughout, as well?

She was about 2.5 hours in the OR before they sent her to the PACU where I saw her. She was pretty well obtunded, wheezing throughout and was saturating in low 90's on 5L. Only one dose of albuterol had been given in the OR, almost 3 hours prior to my arriving.

From what I could piece together, everything about this case just seemed jacked up to me. I know that the information is limited here but I'm wondering how some of you guys would have managed this girl, assuming you did choose to clear her for surgery.

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[TIVA]

This is like the classic oral board question.

You know, there are pro's and con's to proceeding with surgery.

Those who would postpone the case would point to the 4-year old's hx of asthma, current URTI, and active wheezing and say "sorry, but not today." Children with active or recent URTI's do have a ten-fold increase in respiratory complications during and after anesthesia, usually in the form of bronchospasm, laryngospasm, and delayed emergence, not to mention that anesthetic gases paralyze the cilia, thereby impairing the muco-ciliary elevator and potentially causing an aggravation of their URTI, if not super-imposed bacterial infection upon viral infection.

But before the parents call Brown and Crouppen, they should hear the other side of the story, which is, children presenting for myringotomies and T/A's often suffer from recurrent URTI's and surgery is often the definitive cure. Not only that, but these children have so many recurrent infections that there never really is a window when they can proceed to the OR 100% optimized. And canceling cases especially in pediatrics should not be taken lightly. Often parents have taken the day off of work and or traveled 100's of miles to have their children taken care of. Now I know some will say this last point is weak and should not play a role in the anesthesiologist's medical decision-making process, but it does play a role in the real world. And finally, the same textbook (Smith's Anesthesia for Infants and Children) points out that while there is a ten-fold increase in post-operative respiratory complications in children with active/recent URTI's, these complications can often be handled effectively by the anesthesiologist.

So, in conclusion, the decision to proceed or not rests on taking into account multiple factors including how sick the kid is, how urgently do they need the surgery, what sort of complications can you expect and can the PACU nurses handle them, and whether the parents are agreeable to proceeding after having been made aware of the anesthetic risks.

 

[Noyac]

This is like the classic oral board question.

You know, there are pro's and con's to proceeding with surgery.

Those who would postpone the case would point to the 4-year old's hx of asthma, current URTI, and active wheezing and say "sorry, but not today." Children with active or recent URTI's do have a ten-fold increase in respiratory complications during and after anesthesia, usually in the form of bronchospasm, laryngospasm, and delayed emergence, not to mention that anesthetic gases paralyze the cilia, thereby impairing the muco-ciliary elevator and potentially causing an aggravation of their URTI, if not super-imposed bacterial infection upon viral infection.

But before the parents call Brown and Crouppen, they should hear the other side of the story, which is, children presenting for myringotomies and T/A's often suffer from recurrent URTI's and surgery is often the definitive cure. Not only that, but these children have so many recurrent infections that there never really is a window when they can proceed to the OR 100% optimized. And canceling cases especially in pediatrics should not be taken lightly. Often parents have taken the day off of work and or traveled 100's of miles to have their children taken care of. Now I know some will say this last point is weak and should not play a role in the anesthesiologist's medical decision-making process, but it does play a role in the real world. And finally, the same textbook (Smith's Anesthesia for Infants and Children) points out that while there is a ten-fold increase in post-operative respiratory complications in children with active/recent URTI's, these complications can often be handled effectively by the anesthesiologist.

So, in conclusion, the decision to proceed or not rests on taking into account multiple factors including how sick the kid is, how urgently do they need the surgery, what sort of complications can you expect and can the PACU nurses handle them, and whether the parents are agreeable to proceeding after having been made aware of the anesthetic risks.

Well said TIVA. I agree with it all. I don't make it a habit of canceling peds cases b/c of URI's unless they are febrile, look sick, or are actively wheezing. Some of these kids wheeze all the time and then you have to make a decision. Just on a side note there are someother things that the anesthesiologist could have done and may have done but we don't know. They are deepen the pt with sevo, and SQ epi for starters. I also probably would have given more albuterol since it is pretty benign.

 

[Planktonmd]

You know, although the anesthesiologist did not want to proceed and although the mother "made him" do it, that same mother would still sue him in a heart beat if anything went wrong.
So, if they have asthma and recovering from URI and actively wheezing in holding , I would probably see how they respond to Albuterol, if they don't respond well then no surgery that day.

 

[ketafol]

Waiting to hear the wise words of Zippy on this one. That guy cracks me up.

 

[Noyac]

Waiting to hear the wise words of Zippy on this one. That guy cracks me up.

Zippy?

Who's Zippy, never heard of him!

 

[jetproppilot]

This is like the classic oral board question.

You know, there are pro's and con's to proceeding with surgery.

Those who would postpone the case would point to the 4-year old's hx of asthma, current URTI, and active wheezing and say "sorry, but not today." Children with active or recent URTI's do have a ten-fold increase in respiratory complications during and after anesthesia, usually in the form of bronchospasm, laryngospasm, and delayed emergence, not to mention that anesthetic gases paralyze the cilia, thereby impairing the muco-ciliary elevator and potentially causing an aggravation of their URTI, if not super-imposed bacterial infection upon viral infection.

But before the parents call Brown and Crouppen, they should hear the other side of the story, which is, children presenting for myringotomies and T/A's often suffer from recurrent URTI's and surgery is often the definitive cure. Not only that, but these children have so many recurrent infections that there never really is a window when they can proceed to the OR 100% optimized. And canceling cases especially in pediatrics should not be taken lightly. Often parents have taken the day off of work and or traveled 100's of miles to have their children taken care of. Now I know some will say this last point is weak and should not play a role in the anesthesiologist's medical decision-making process, but it does play a role in the real world. And finally, the same textbook (Smith's Anesthesia for Infants and Children) points out that while there is a ten-fold increase in post-operative respiratory complications in children with active/recent URTI's, these complications can often be handled effectively by the anesthesiologist.

So, in conclusion, the decision to proceed or not rests on taking into account multiple factors including how sick the kid is, how urgently do they need the surgery, what sort of complications can you expect and can the PACU nurses handle them, and whether the parents are agreeable to proceeding after having been made aware of the anesthetic risks.

Very nice post.

Shows how this case could go either way, depending on the anesthesiologist.

I'm very aggressive.

Not a cowboy, but aggressive. Heres an example for ya:

I'm on call yesterday. Charge OR RN calls. Urology dude has a ureteral stent add on for a stone....its now 5 pm. Pt ate at 1 pm. Wondering when we can do the case.

Jet: "Go ahead and send for the patient."

OR Nurse: "Uhhhhhhhhh....huh? You heard the patient ate at one-o'clock, right?"

Jet: "Uh huh. Please send for the patient. We can do him now"

Some will question this call.

I see it as a rapid sequence intubation on a dude who is nauseated and in pain from a ureteral stone. Waiting another few hours isn't gonna change whats in his stomach now.

That being said,

URIs in kids with chronic OM, eustachian tubes clogged up all the time, big-ass adenoids.....

Yep. Lets put her to sleep.

But if she's got all that crap going on AND is actively wheezing,

Sorry. Case over-before-it-starts.

Cuz I ain't puttin' her to sleep.

Many of you have done a ton of kids.

Many of you havent.

Heres the bottom line with kids:

There is no safety line.

Know how, in a preoxygenated adult, if you induce and the SRNA or intern intubates the esophagus, you say:

"Uhhh.....NOPE. No end tidal. Pull it out and try again."

SRNA or intern frantically pulls the tube out while you're talking to the surgeon about how the trout are hitting around the Causeway Bridge in Lake Pontchartrain.

SRNA/Intern reaches for an oral airway so they can mask ventilate for a while.

Jet: "No, Dude. Grab the laryngyscope and try again. It's all good."

SRNA (deleting intern now for realism...I work with SRNAs. No interns) looks at me like I'm crazy.

Jet "Trust me, Dude. I stayed at a Holiday Inn Express last night." ......(true story by the way)

Pulse-ox still 100%. About two minutes have passed.

SRNA frantically grabs the Mac 3, hurriedly inserts it, now shaking, but gets the tube in.

Nice job.

Truth is, I couldda left the room, ran to the doctor's lounge-men's room, took a (quick) whiz, ran back to the room, and the pulse-ox would probably still be 100%, in a healthy young adult.

Plenty of room for error.

There is very little room for error in a healthy toddler.

Let alone one with a URI who is in active bronchospasm.

Healthy kid to the back and induced...

on the rare occasion that the ETT isnt in the first time, you don't see people standing around talking about their BMW crotch rocket. Yeah, not an urgent situation yet.

But the kid's gonna desaturate CDAZY FAST if a professional doesnt slip it in likkity split.

No second looks for amateurs here. Either bag for a while before the second look, or let somebody who knows what they're doing put it in right now.

And this is a healthy kid.

Not one thats in active bronchospasm like the kid described in the initial post, with histamine and MAST cells roving her bloodstream like Lucifer looking for lost souls at The Hustler Club on Bourbon Street.

This kid is gettin' cancelled on my watch.

Sorry, Mom.

 

[rmh149]

Not one thats in active bronchospasm like the kid described in the initial post, with histamine and MAST cells roving her bloodstream like Lucifer looking for lost souls at The Hustler Club on Bourbon Street.

This kid is gettin' cancelled on my watch.

Sorry, Mom.

Love it! I'm going to have to use that phrase....dont worry, I will give you credit.