A new Case

[epidural man]

Can I post a case being a resident and all?

Anyway, what would you do.......I saw this kid yesterday.

Called to do an emergent MRI on a 2 year old.

HPI: 2 y/o with a history of febrile seizures - last year and was on phenobarbital until late last year then it was stopped. Pt had another sz early this year with a fever. In the last two weeks, pt got sick with URI symptoms with green sputum production, high fever, and then started having seizures and vomiting. They were admitted a few days ago for the seizures and worked up. LP negative. Pt was given chloral hydrate for EEG about a day ago and was abnormal. Pt was sent home on the day before and brought back later the afternoon after the mom found the child unresponsive covered in vomit. When you see the child "today", he is alert and grumpy complaining of "tummy hurts." Last big meal was "yesterday" and he had some cheerios and apple juice this am at 730. It is now 1400.

According to the mom (who has witnessed ~6 seizures in the last week or so), and the pediatric resident - the child is usually post-ictal for 1 to 1.5 hrs. Mom also says he is still coughing with green sputum.-

The pt is currently ataxic, and the pediatric neurologist thinks that it is a prolonged recovery from the chloral hydrate. According to the pediatric attending who took care of him a year ago - the pt also had this funny prolonged recovery from chloral hydrate then (for an MRI - which was midly abnormal). Neurologist thinks the kid has epilepsy but really wants the MRI to rule out anatomical causes currently.

PMHx - neg other than above. Otherwise is a normal kid with normal development.

PSurgHx: Pyloromyotemy
Meds: phenobarbital

PE: Grumpy child, but acts appropriate for a 2 year old. Alert.
Normal childhood facies
CV: RRR, no murmurs
Lungs: difficult to tell because the kid is crying, but maybe some coarse breath sounds bilat.

Labs: I don't recall, but essentially all normal. No phenobarb level.
No head CT

A/P ??

In our institution, most our MRI's are done with nasal cannula and propofol. How would you do this one? Tube? LMA? Delay? This case caused a big discussion here - so I was just curious how others would approached. I'm not quizing.....

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[intubator]

Interesting dilemma.

I think I would stay away from intubating. I have seen to many cases of laryngospasm and severe bronchospasm in active lower URI cases. This kid is at serious risk for both. The MRI scanner is not a great place to be for severe bronchospasm.

I understand the risks for aspiration also, but I would take that risk. Given the huge amount of recent case reports and studies using dexmedetomidine in pediatrics, I might use this as the child might still be able to protect his own airway. There was a recent report comparing precedex to propofol in the MRI scanner which showed a decrease in laryngospasm and hypoxic events with precedex.

 

[pd4emergence]

I would talk to the peds resident. Ask them if waiting an hour and a half will make a difference in this patients outcome. If you can wait for the patient to be NPO (some people would say the 6 hrs is enough with just cheerios and apple juice) then put in an LMA. If they don't want to wait and say that this has to be done now then put in a tube. I do a good number of peds MRI's and usually put in an LMA. It seems to work pretty well. I feel you have more control ie patient movement and airway management if you place an LMA. With just a nasal canula even with CO2 monitoring, if the kid gets too much and stops breathing and desats you have to stop the exam and start all over. I know this kid has had a recent URI but it sounds like this MRI needs to be done soon.

 

[Masseter Spasm]

I agree with these plans. I would delay 2 hours. Nothing in this case suggests that an earlier anatomic diagnosis will change therapy significantly. (If a neurosurgeon has been consulted and wants an emergent MRI to determine whether the kid needs an emergent craniotomy that would be different.) Most likely even if the kid has a lesion this would not warrant an emergent surgical intervention.

An LMA sounds like a good idea given the URI Sx this kid is exhibiting. You could use a maintenance anesthetic with either volatile agent or propofol. Dexmed is another consideration if you have experience with its dosing. I look at an LMA as a fancy oral airway in this situation. While I have done many MRI with nasal cannula and never had a problem, nothing stinks more than having to repeat a procedure because the patient became apneic and you needed to pull him or her out of the MRI tube. The LMA allows you to support ventilation should the patient become apneic or hypoxic.

 

[CremeSickle]

Now thats quite a rough situation.

I have to be honest and say that at our institution we would have done exactly how it happened based on the information given.

I like the other plans and the idea of delay/LMA is nice, but it simply wouldnt happen where i am at. Not b/c they arent safe but b/c there would be confusion as to why an LMA was needed in a A&O x 4 pt for a simple scanning procedure. It would be especially hard to justify a 4-6 hour delay for an MRI so the pt is NPO. How many pts do we put through MRI that "may vomit" daily and arent emergent?

His hx dosent tell me i really have to have him under GA to do an MRI, it says i need to be in the room in case he needs to be rescued..

Am i crazy here?

 

[pd4emergence]

Now thats quite a rough situation.

I have to be honest and say that at our institution we would have done exactly how it happened based on the information given.

I like the other plans and the idea of delay/LMA is nice, but it simply wouldnt happen where i am at. Not b/c they arent safe but b/c there would be confusion as to why an LMA was needed in a A&O x 4 pt for a simple scanning procedure. It would be especially hard to justify a 4-6 hour delay for an MRI so the pt is NPO. How many pts do we put through MRI that "may vomit" daily and arent emergent?

His hx dosent tell me i really have to have him under GA to do an MRI, it says i need to be in the room in case he needs to be rescued..

Am i crazy here?

No question that we need to be there. The problem is keeping a 2 year old still for 30-45 minutes (depending on the MRI machine). I have a 2 year old, I have never seen him still for more than 30 seconds. I have also had to have a few MRI's. It doesn't sound difficult to stay perfectly still for 30 minutes but it is. It is impossibe for a two year old. Now the question is do you try to just sedate him. I think with just sedation you end up with a room air general anesthetic and risk having to interupt the exam for patient movement or for apnea. Once the kid gets to be older (maybe 4 or 5) sometimes (depending on the kid) you can get them to stay still. But with this two year old, they need good pictures and they need them soon.

 

[CremeSickle]

Sorry pd4, now im getting the picture better. (im childless)

Well... damn. I just dont know what the right answer is.

part of me feels like you could ketamine dart him and go to it. another part of me feels like im not close enough to KNOW whats really happening in the MRI if he was vomiting etc.

I can certainly see the case for GA. But i have to be honest, i just dont know what the right answer is...

Anyone have better experience with this?

No question that we need to be there. The problem is keeping a 2 year old still for 30-45 minutes (depending on the MRI machine). I have a 2 year old, I have never seen him still for more than 30 seconds. I have also had to have a few MRI's. It doesn't sound difficult to stay perfectly still for 30 minutes but it is. It is impossibe for a two year old. Now the question is do you try to just sedate him. I think with just sedation you end up with a room air general anesthetic and risk having to interupt the exam for patient movement or for apnea. Once the kid gets to be older (maybe 4 or 5) sometimes (depending on the kid) you can get them to stay still. But with this two year old, they need good pictures and they need them soon.

 

[BLADEMDA]

Sorry pd4, now im getting the picture better. (im childless)

Well... damn. I just dont know what the right answer is.

part of me feels like you could ketamine dart him and go to it. another part of me feels like im not close enough to KNOW whats really happening in the MRI if he was vomiting etc.

I can certainly see the case for GA. But i have to be honest, i just dont know what the right answer is...

Anyone have better experience with this?

Yes. I would LMA the kid provided he was NPO for at least 4-6 hours ( 6 for solid foods). My agent would be sevoflurane and an MRI compatible anesthesia machine.

If EMERGENT then intubate and keep the little guy deep. You could extubate in the PACU if concerned about laryngospasm in the MRI suite ( a diff. place to be when stuff goes wrong). Use propofol for the transport to the PACU if intubated. Once in PACU D/C Propofol and/or extubate
with lots of help around.

For a good study comparing laryngospasm with the use of LMA vs. ET tube see Blade's ENT case.

Blade

 

[epidural man]

Yes. I would LMA the kid provided he was NPO for at least 4-6 hours ( 6 for solid foods). My agent would be sevoflurane and an MRI compatible anesthesia machine.

If EMERGENT then intubate and keep the little guy deep. You could extubate in the PACU if concerned about laryngospasm in the MRI suite ( a diff. place to be when stuff goes wrong). Use propofol for the transport to the PACU if intubated. Once in PACU D/C Propofol and/or extubate
with lots of help around.

For a good study comparing laryngospasm with the use of LMA vs. ET tube see Blade's ENT case.

Blade

This is how it was done here. I did the preop, but wasn't involved with the actually anesthesia. The staff heard the kid tell the mom he "felt sick" and "wanted to thow up" - That changed his planned and they came to the MOR to intubate him. Plan was to take him intubated to the MRI scanner, do the scan, and bring him to PACU for extubation.

The kid went into laryngospams during the mask induction. After airway secured, they placed an OG, and apparently got a lot of fluid out - I don't know exactly how much but apparently it was impresive.

The staff decided that it was okay to extubate down by the scanner (our MRI is MILES away from the OR) and the child had some severe laryngospam down there also.

Overall, the child did well and outcome was great - but it gave a lot of sphincter tone-increasing excersize to the anesthesiologist.

 

[pd4emergence]

This is how it was done here. I did the preop, but wasn't involved with the actually anesthesia. The staff heard the kid tell the mom he "felt sick" and "wanted to thow up" - That changed his planned and they came to the MOR to intubate him. Plan was to take him intubated to the MRI scanner, do the scan, and bring him to PACU for extubation.

The kid went into laryngospams during the mask induction. After airway secured, they placed an OG, and apparently got a lot of fluid out - I don't know exactly how much but apparently it was impresive.

The staff decided that it was okay to extubate down by the scanner (our MRI is MILES away from the OR) and the child had some severe laryngospam down there also.

Overall, the child did well and outcome was great - but it gave a lot of sphincter tone-increasing excersize to the anesthesiologist.

It's nice to have a MRI compatable anes machine. That way you don't end up having to move patients to and from the scanner while they are intubated/LMA'ed. Our MRI suite is pretty much set up like an OR with most everything we need for a general anesthetic. It is still not a whole lot of fun to have a problem down there. We also had a compatable machine where I did my residency and I never dealt with having to move patients to and from the OR. I am glad to hear it came out ok.