A scary experience I had this week

[Jalopycat]

I had an weird experience I'd like to share.

I had a port placement on an 18 kg, 5 year old girl. We did an inhalational induction, then after IV started, gave 50mg propofol and 20mcg fentanyl and I placed an LMA. She never went apneic and maintained spontanous breathing with no problems. I had her on 66% nitrous and had Sevo on between 2-3%. She had an ET sevo of 1.7. The case started and about 5 minutes later, the surgery resident tells me that the kid is talking. I thought he was just messing with me but then I saw her move a little and then heard a very muffled "help!" and she began desaturating. I immediately cranked up the sevo, pushed some fentanyl, and then began assisting ventilations. I heard her yell out about 5 or 6 more times before I got her deeper. Her sats came back up, and the rest of the case went smoothly. Post op, the child did not appear to have an recall and a call to her home the next day revealed nothing unusual (no nightmares or anything).

So I've just been thinking about it all week and don't know what really happened or how I could have prevented it. I wasn't out of sevo, the machine did not malfunction. I felt I had her on plenty of anesthesia (obviously not). I've run cases on much less than that and never had anything like this happen. The only thing I can think of is the sevo wasn't calibrated right. The dial was set between 2-3% but my ET sevo didn't really reflect this. I pray this kid never has any recall of it. I could never forgive myself if a 5 year old girl developed PTSD from this. So far, it's not really an M&M case because the child remembers nothing.

Anything like this ever happen to you guys?

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[Noyac]

That sucks, but maybe you got away with one though.

I read a blurb claiming a genetic link to anesthesia awareness pts. Although she apparently didn't have awareness.

I luckily can say I have never had this happen or even heard of it. But it obviously isn't out of the realm of possibility.

 

[TIVA]

Is there any chance the IV wasn't working?

I would think 50 mg propofol and 20 mcg fentanyl should be enough to cause apnea in 5 year old.

 

[zippy2u]

Skippy, what ya got on your hands is a certifiable case of exorcism done under anesthesia. Yeah buddy, you took the "evils" right out of her. Here's how ya play it to get your 15 minutes of fame and perhaps some monetary benefit. Get on the phone pronto to the National Enquirer and pitch it as a modern day exorcism. Create a photo in one of those photoshop programs with "apparitional vapors" eminating from a child's head and maybe attach Hendrix's "Voodoo Child" playing eerily in the background. Send it to them and tell them you'll accept $3000 for the story. Nowadays, ya gotta blow it up bigtime to getcha self off the porch. Run with it dog, and make us proud... Regards,----Zippy

 

[jwk]

I had an weird experience I'd like to share.

I had a port placement on an 18 kg, 5 year old girl. We did an inhalational induction, then after IV started, gave 50mg propofol and 20mcg fentanyl and I placed an LMA. She never went apneic and maintained spontanous breathing with no problems. I had her on 66% nitrous and had Sevo on between 2-3%. She had an ET sevo of 1.7. The case started and about 5 minutes later, the surgery resident tells me that the kid is talking. I thought he was just messing with me but then I saw her move a little and then heard a very muffled "help!" and she began desaturating. I immediately cranked up the sevo, pushed some fentanyl, and then began assisting ventilations. I heard her yell out about 5 or 6 more times before I got her deeper. Her sats came back up, and the rest of the case went smoothly. Post op, the child did not appear to have an recall and a call to her home the next day revealed nothing unusual (no nightmares or anything).

So I've just been thinking about it all week and don't know what really happened or how I could have prevented it. I wasn't out of sevo, the machine did not malfunction. I felt I had her on plenty of anesthesia (obviously not). I've run cases on much less than that and never had anything like this happen. The only thing I can think of is the sevo wasn't calibrated right. The dial was set between 2-3% but my ET sevo didn't really reflect this. I pray this kid never has any recall of it. I could never forgive myself if a 5 year old girl developed PTSD from this. So far, it's not really an M&M case because the child remembers nothing.

Anything like this ever happen to you guys?

A couple thoughts...

It's kinda hard to say the word "help" with a giant hunk of plastic in your mouth and throat. Making some sort of sound - sure. And "yell out" ? If the patient was that light, I assume they'd be coming up off the table, , not just moving "a little".

I think they were definitely light, although I actually found it interesting that you gave propofol IV after the child was already induced. I've had patients "vocalize" (for lack of a better term) but it wasn't anything purposeful. Deepen the gas or narcs, and/or maybe a little positive pressure, and it goes away.

 

[militarymd]

many cases of recall is not reported until a couple of weeks later....I wouldn't say you are out of the woods yet....but I doubt it will cause any problems for the kid.

 

[Jalopycat]

A couple thoughts...

It's kinda hard to say the word "help" with a giant hunk of plastic in your mouth and throat. Making some sort of sound - sure. And "yell out" ? If the patient was that light, I assume they'd be coming up off the table, , not just moving "a little".

I'm just telling you what happened. I didn't believe it either when the surgeon first told me. Her yelling was really muffled, but it sure sounded like "help". She was really yelling, not just making some sounds. As for why she didn't "come of the table" I can't explain other than than it was just a port placement and the resident stopped what he was doing until I got her deeper.

 

[BISof60]

Although nothing will likely come of it, a one week follow-up phone call is probably in order. Just tell parents it is routine follow-up. Ask age appropriate variations of last thing you remember before going to sleep, first thing remembered waking up, anything unpleasant about surgical experience, etc.

You said the ET Sevo didn't match the vaporizer. Out of curiosity, what was it? Regardless, with that quantity of fentanyl and nitrous on board this child's response is very atypical.

 

[Fastrach]

And you're sure it wasn't just a noisy/imperfectly seated LMA?

 

[coprolalia]

I don't think that plastic IV cannula was in the vein.

And, she was possessed.

-copro

 

[Planktonmd]

No one knows what really happened but we don't always have all the answers.
I wouldn't be concerned about PTSD in a 5 Y/O child who obviously has been through allot already to reach the point to need a port placement.
This is such a simple procedure and having an LMA in the mouth is not such a traumatic event, in addition to that, PTSD is extremely rare in people who are genuine patients with genuine diseases, it is more likely to be seen in people who would enjoy the perks that come with that diagnosis.