9mo old with upper esophageal FB

[PpfSuxTube]

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Bull**** this was bronchospasm. You don't die of bronchospasm with a secure airway and the ability to deliver albuterol, epinephrine and volatile anesthetics.

Something else happened.

100%. Surely if there was a death like this, all lines tubes etc have to be left in situ untouched?
So the obvious solution of a dislodged tube should have been confirmed on autopsy?
Also part of the resus algorithm here is to debug high APs all along the circuit including machine, tubing, ETT and also patient. In this scenario, did they verify that there wasn't like a mucus plug? Or kinked ETT? Reintubate?

Meds for asthma in a 9 month old is honestly just not likely...

This was a tube problem


I couldn't see further detail but what was the capnogram trace? Cuffed ett or uncuffed? Paralysed or no? What were the Airway pressures? What were the auscultation sounds? Did they overbag the patient and causes a pneumo?

So many qs. This crna should not have been doing the case. Sorry but the presence of an adequately trained anesthesiologist absolutely would have made a difference here.

Unless I'm missing things here there was no diagnostic algorithm followed here

 

[cchoukal]

this is not uncommon.
lot’s of “expert” witnesses trying to make a buck.

In my experience, there is a qualifying process where the fact that an oncologist has no experience with these cases would be exposed and their testimony, even at deposition, would not be allowed, especially if testifying to standard of care (as opposed to causation). This is a very strange situation.

 

[cchoukal]

We only have the choice to do the case.

I have a colleague who has refused young peds cases on call and forced a transfer. Takes balls, but he’s done it.

 

[PpfSuxTube]

I have a colleague who has refused young peds cases on call and forced a transfer. Takes balls, but he’s done it.

We can t refuse any case, never heard of it but definitely calling a second person in

 

[crna2006]

We can t refuse any case, never heard of it but definitely calling a second person in

I have refused a case or 2 but it was very unpleasant

 

[Southpaw]

We can t refuse any case, never heard of it but definitely calling a second person in

If my small little hospital did very few peds cases, didn’t have adequate peds equipment, and I were concerned about how this pediatric patient would recover and be cared for post operatively, better believe I’d push the surgeon to transfer to a children’s center if time allowed. I find it tough to believe that anyone here would see that as far fetched.

 

[deleted87051]

Our city is set up with a large specialty pediatric hospital. Most of the private hospitals don’t take care of kids under 14. Those patients are triaged to the children’s hospital where they only take care of children.

 

[coffeebythelake]

If my small little hospital did very few peds cases, didn’t have adequate peds equipment, and I were concerned about how this pediatric patient would recover and be cared for post operatively, better believe I’d push the surgeon to transfer to a children’s center if time allowed. I find it tough to believe that anyone here would see that as far fetched.

Sure u can push but you don't have the final say.

 

[Southpaw]

Sure u can push but you don't have the final say.

I’d have to be convinced by the surgeon that this case was life or death and there wasn’t time for transfer. I’ve pushed for transfers before with a tertiary care center being within an hour away. Most surgeons I’ve worked with don’t want intra op or post op disasters, especially for cases they don’t routinely do.

Sure, if I’m convinced that I have to do the case to save the kids life then I do the case. But it’s not like a surgeon tells me ‘hey I’ve got an appy it’s emergent’ conversation. There’s going to be a real convo about this one.

 

[gasmd98]

Sure u can push but you don't have the final say.

Reminds me the story of the death of the sick young girl undergoing a major liver resection at a hospital that did very few, if any, such cases. Anesthesiologist pushed back hard but was overruled and then lost her job. Can’t win if a surgeon is hell bent on doing a case.

 

[crna2006]

Reminds me the story of the death of the sick young girl undergoing a major liver resection at a hospital that did very few, if any, such cases. Anesthesiologist pushed back hard but was overruled and then lost her job. Can’t win if a surgeon is hell bent on doing a case.

That is the price for strong convictions. In the end if they did the case and patient died or had a bad outcome that anesthesiologist would carry that forever.
I did a case that should have been done and it still bothers me 17 years later.

 

[ProRealDoc]

I didn’t peruse the file but a coin cannot be removed through an ET tube, certainly not in a 9 month old. The procedure is to remove the foreign body and remove the ET tube simultaneously. Sounds like the airway was lost afterwards.

Coin was in the esophagus

 

[ProRealDoc]

But the surgeon was supervising the CRNA.

The blind leading the blind

 

[DocMcCoy]

That is the price for strong convictions. In the end if they did the case and patient died or had a bad outcome that anesthesiologist would carry that forever.
I did a case that should have been done and it still bothers me 17 years later.

Been there too

 

[UscGhost]

I would say what I usually do, little kids or babies ( less then 3) should ALWAYS go to facilities that are designed to take care of them.
They have staff that are used to them and understand their particular needs for drug dosage, complications etc. Etc.
If you need a bypass or transplant do you go to your local community hospital? If you are a trauma patient do they field you to the closest hospital or closest trauma center?.
I know that some here are going to come up with the what if?
This was a planned procedure. There was time to set up everything.
I know that many people here say an anesthesiologist would make a difference, i doubt it unless they were peds fellowships or did sick peds all the time.
If the medical center specializes in peds I am wrong. All i know is that in every interview I always ask how much peds and how sick.
Transplants do best with a facility for transplants, same for cardiac and same for peds.
The first question i will ever ask if my grandchild (kids are grown) need a procedure is ....how much do they do kids.

I would agree.

A crna with tons of peds experience will generally be more comfortable than an anesthesiologist who hasn't done peds in years

Peds anesthesia would be the best option as you said (in a peds heavy hospital)

Removal of a FB from a peds patient should be done by a peds comfortable surgeon as well.


But if t

Surely if there was a death like this, all lines tubes etc have to be left in situ untouched?
So the obvious solution of a dislodged tube should have been confirmed on autopsy?
Also part of the resus algorithm here is to debug high APs all along the circuit including machine, tubing, ETT and also patient. In this scenario, did they verify that there wasn't like a mucus plug? Or kinked ETT? Reintubate?

Meds for asthma in a 9 month old is honestly just not likely...

This was a tube problem


I couldn't see further detail but what was the capnogram trace? Cuffed ett or uncuffed? Paralysed or no? What were the Airway pressures? What were the auscultation sounds? Did they overbag the patient and causes a pneumo?

So many qs. This crna should not have been doing the case. Sorry but the presence of an adequately trained anesthesiologist absolutely would have made a difference here.

Unless I'm missing things here there was no diagnostic algorithm followed here

I would agree.

The average anesthesiologist in a peds hospital or non peds hospital is just going to be more qualified on average.

Now if it was a crna who has been heavy peds for years vs a anesthesiologist who never does peds, that can be different

I would also wonder whether cuffed or uncuffed. Every easy for that uncuffed tube to get dislodged during extraction

 

[HalO'Thane]

This case to me has lost airway written all over it. If you have ever seen a rigid esophagoscopy in a baby, you know that they can be dicey even in the most experienced surgeon's hands. You have a giant metal scope going down the baby's throat along with the forceps. You have to try to pull out the foreign body, scope, and forceps all at once. It can be very easy to extubate a baby in this scenario when the ETT is only taped at 10-11 cm. My guess is that this event, combined with the pre-existing lung infection and likely copious secretions and aspirants from not being able to swallow, lead to an arrest.

I agree with others that it is insane that a CRNA did this case solo and it should have been done at a children's hospital. There are just too many intraop and post op complications that can occur. The kid would benefit from having a whole team of pediatric experts, not just the surgeon and anesthesia provider.

 

[IlDestriero]

I did this same case the last time I was on call. Same age, probably the same size, active URI, etc. This kid with a solo CRNA and a General Surgeon at some Podunk hospital is a recipe for disaster. I wasn’t too excited about it at 10pm at the mother ship with a resident as a second set of hands and an extremely experienced pediatric ENT at the wheel.
It’s definitely an emergency. They are under a year and already symptomatic. It’s not a “we will meet you in the OR” kind of emergency, but it’s on the way. Wait a few more hours and they’ll be worse with more stridor and then respiratory failure.
I’d also never induce this kid with a mask. He was under a year, had just been discharged from a respiratory related admission, had stridor, probably should get RSI, no back up, etc., etc. If I was feeling the airway was stable they might get 50% nitrous, otherwise Brutane and an US guided IV in the OR. That alone was a near miss and tells you all you need to know about the CRNAs experience with these kinds of cases.
I’m not sure how an oncologist is an expert in pediatric airways. They probably can’t even identify the anatomy. Isn’t that something that the defense attorney can challenge at trial? How many rigid scopes have you done in your career? Zero…
Who knows what happened. Kids can definitely have a “terminal bronchospasm”. I had one of those recently as well. Emergency surgery, maybe 2yo, sick lungs, full stomach precautions, some chromosomes that ain’t all there, the wake up was rough. They’re bearing down fighting you and the lungs feel like you’re trying to ventilate a brick wall. Pips in the 40’s and minimal exchange. Good times. Epi FTW, and rolling the dice on a deep extubation.

 

[arkgal]

This case to me has lost airway written all over it. If you have ever seen a rigid esophagoscopy in a baby, you know that they can be dicey even in the most experienced surgeon's hands. You have a giant metal scope going down the baby's throat along with the forceps. You have to try to pull out the foreign body, scope, and forceps all at once. It can be very easy to extubate a baby in this scenario when the ETT is only taped at 10-11 cm. My guess is that this event, combined with the pre-existing lung infection and likely copious secretions and aspirants from not being able to swallow, lead to an arrest.

I agree with others that it is insane that a CRNA did this case solo and it should have been done at a children's hospital. There are just too many intraop and post op complications that can occur. The kid would benefit from having a whole team of pediatric experts, not just the surgeon and anesthesia provider.

What if you're in BFE Montana or Wyoming?

 

[ucsfgaspain]

Kids don't follow "rules". I've had complete lock up with the tube in correct position from massive bronchospasm, I've had complete lock up from massive mucus plugging, I've had complete lock up from a crimp in the tube, I've had the mother of all laryngospasm. In the heat of battle, it is often hard to roll down the diagnostic algorithm when you are sh*tting in your pants cuz the sat is playing the bass tones. I've been humbled in high stress situations. As a boxer says, every plan goes out the window, when u get punched in the face. I aboslutely hate doing the little f*ckers. For most non peds anesthesiologist with longer experience (>10 years), they hate doing a healthy kid. Why? Everything to lose and nothing to gain.
I'll take a ruptured AAA any day of the week over a 2 year old for tonsils who had a "recent" URI (BTW they will always be recovering from a URI until the tonsils come out). I think I've lost a decade of my life from all the **** that has happened on these cases! I don't second guess on these cases since I wasn't there. Yeah, we can all agree that this is a case that we would all like to go to a pedi center. I honestly don't know any reasonable person that would be excited to do this case. In my experience, I don't know many CRNA's that would jump on this case. Hell , I don't know many anesthesiologists that would either. I'm old school. If push came to shove, I would do this case. But man, my stress level would be sky high. In comparison, a ruptured AAA induces maybe a 5 to 6 beat baseline heart rate increase in me.
I'm proud of u young guys that have the chutzpah to refuse to do the case or to call in a colleague. I'm too old school. Too brainwashed from my training in the old days. I'd reluctantly do the case all the while muttering under my breath "F*ck my life, F*ck the surgeon, F*ck this job, F*ck it, This **** ain't worth it!

 

[pgg]

I did this same case the last time I was on call. Same age, probably the same size, active URI, etc. This kid with a solo CRNA and a General Surgeon at some Podunk hospital is a recipe for disaster. I wasn’t too excited about it at 10pm at the mother ship with a resident as a second set of hands and an extremely experienced pediatric ENT at the wheel.
It’s definitely an emergency. They are under a year and already symptomatic. It’s not a “we will meet you in the OR” kind of emergency, but it’s on the way. Wait a few more hours and they’ll be worse with more stridor and then respiratory failure.
I’d also never induce this kid with a mask. He was under a year, had just been discharged from a respiratory related admission, had stridor, probably should get RSI, no back up, etc., etc. If I was feeling the airway was stable they might get 50% nitrous, otherwise Brutane and an US guided IV in the OR. That alone was a near miss and tells you all you need to know about the CRNAs experience with these kinds of cases.
I’m not sure how an oncologist is an expert in pediatric airways. They probably can’t even identify the anatomy. Isn’t that something that the defense attorney can challenge at trial? How many rigid scopes have you done in your career? Zero…
Who knows what happened. Kids can definitely have a “terminal bronchospasm”. I had one of those recently as well. Emergency surgery, maybe 2yo, sick lungs, full stomach precautions, some chromosomes that ain’t all there, the wake up was rough. They’re bearing down fighting you and the lungs feel like you’re trying to ventilate a brick wall. Pips in the 40’s and minimal exchange. Good times. Epi FTW, and rolling the dice on a deep extubation.

God that sucks.

Yesterday I had a crusty fragile octogenarian with critical AS getting a balloon valvuloplasty via axillary cutdown because her femoral vessels were so bad, so she can be (maybe) marginally lower risk for an urgent fem tib to revasuclarize her dying feet today.

(It knocked her mean gradient down 5 whole mmHg at the expense of slightly worsening her AI. Yay!)

Still better than doing peds. 🙂

And outcome expectations are somewhat different for my case vs the 2yo FB patient.

So glad we don't do kids here.

 

[Katheudontas parateroumen]

I had a 2yo otherwise healthy who swallowed a coin (also a couple cheetoes at 6am) come in with coin ingestion about 8 hours later. The coin was imaged in the proximal esophagus on admission but kid had basically no symptoms. No IV. I went with mask induction and everything went fine with ETT but I kept thinking to myself afterward “maybe that was a bit too cavalier”. Reading this case has made me second guess things for sure although this kid sounded much sicker and was under one year old. For this presentation, I would have called in the peds person (I almost always call in peds person under one years old anyways). If no one was available, definitely would find an IV and go RSI. This case is urgent and unless you have a children’s hospital that can take the kid in a couple hours (doubt it), you almost have to do the case. This case definitely sounds like loss airway. Not because of the small esophageal laceration.

Also agree with everyone that peds takes years off of my life. I did a fellowship in ADULT Crit care so I am so far removed from taking care of peds. But I did do a lot of peds in residency which was recent. So it’s funny I get pegged into doing most of the peds cases (albeit generally healthy peds) over my seasoned generalists colleagues who have been attending for years.

 

[sevoflurane]

In my experience, there is a qualifying process where the fact that an oncologist has no experience with these cases would be exposed and their testimony, even at deposition, would not be allowed, especially if testifying to standard of care (as opposed to causation). This is a very strange situation.

My wife was wrapped into a lawsuit she was dropped from last year. Big fusion case with neuromonitoring. Expert witness was a family practicinoner who probably has never seen an O arm or the inside of an OR since medical school. Some of the stuff she was saying was just dumb. Probably just slipped through the cracks somehow.