Awake peds crani

[WholeLottaGame7]

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Just wondering if any of the peds guys/gals out there had any pointers for a peds crani.

Had a 9yo scheduled to undergo grid removal/seizure focus excision the other day. Initially posted as supine, no special monitoring, 4 hours. Case before that was a laminectomy/tethered cord release.

Had an ortho/regional attending in the room that day (fortunately one of the good ones). She came up to me in-between cases and said change of plan, they want to do the 2nd case as an awake crani.

To this point, I'd only done a few peds cranis, no neuro rotation yet (our residents do usually get several awake cranis on neuro).

Anyway, popped in an LMA, turned on some sevo while we got a couple PIVs, a-line. Turned sevo off, turned on some remi/prop/dex, got positioned. When the neurosurgeon got where he wanted, we turned the infusions off, took the LMA out, and a couple minutes later she woke up....and flipped the F out.

Yelling, trying to get out of the mayfield, crying, etc. We could get her to squeeze our hand, but that was about it as far as following commands went. Def could not look at a laptop and identify pictures.

Eventually tried working in a little bit of fentanyl, but then she was either "sleeping" or yelling.

All told, the surgeons/neurologists got enough of what they wanted, but I couldn't help but wonder if there was anything we could have done to make the whole process a little easier. Keep the dex running at a low dose to try to smooth things out? Haha, prepared the girl sooner than the morning of that she was going to be awake during part of it?

Still, it was a very cool case, glad to have been a part of it and glad she did well.

 

[michigangirl]

Just wondering if any of the peds guys/gals out there had any pointers for a peds crani.

Had a 9yo scheduled to undergo grid removal/seizure focus excision the other day. Initially posted as supine, no special monitoring, 4 hours. Case before that was a laminectomy/tethered cord release.

Had an ortho/regional attending in the room that day (fortunately one of the good ones). She came up to me in-between cases and said change of plan, they want to do the 2nd case as an awake crani.

To this point, I'd only done a few peds cranis, no neuro rotation yet (our residents do usually get several awake cranis on neuro).

Anyway, popped in an LMA, turned on some sevo while we got a couple PIVs, a-line. Turned sevo off, turned on some remi/prop/dex, got positioned. When the neurosurgeon got where he wanted, we turned the infusions off, took the LMA out, and a couple minutes later she woke up....and flipped the F out.

Yelling, trying to get out of the mayfield, crying, etc. We could get her to squeeze our hand, but that was about it as far as following commands went. Def could not look at a laptop and identify pictures.

Eventually tried working in a little bit of fentanyl, but then she was either "sleeping" or yelling.

All told, the surgeons/neurologists got enough of what they wanted, but I couldn't help but wonder if there was anything we could have done to make the whole process a little easier. Keep the dex running at a low dose to try to smooth things out? Haha, prepared the girl sooner than the morning of that she was going to be awake during part of it?

Still, it was a very cool case, glad to have been a part of it and glad she did well.

As you know, awake peds cranis are rare. And 9 is young. May have helped to start discussion about the procedure long before the day, as most case reports have reported was done. I would have continued the dexmedetomidine and titrated to effect, it seems turning everything off at once might have worsened things. I think dexmed would have been your friend here. Even so, every kid is different, and getting a 9 year old to look at pictures and talk through it when they know their brain is being manipulated is pretty difficult no matter how you cut it-- no pun intended.

 

[somedumbDO]

Yeah you wont get a nine year old to do that. I would of told the surgeon NO.

 

[IlDestriero]

As you know, awake peds cranis are rare. And 9 is young. May have helped to start discussion about the procedure long before the day, as most case reports have reported was done. I would have continued the dexmedetomidine and titrated to effect, it seems turning everything off at once might have worsened things. I think dexmed would have been your friend here. Even so, every kid is different, and getting a 9 year old to look at pictures and talk through it when they know their brain is being manipulated is pretty difficult no matter how you cut it-- no pun intended.

What she said.
We do it occasionally on teens. Dex.👍 I would have said it was not possible, unless it was the most mature 9 yr old in history and he was fully prepared including a psych eval. Our surgeons would never have considered it on someone that young. They're lucky they didn't cause harm. I hope the kid has amnesia. He's got enough problems without PTSD.

 

[Bertelman]

.....she woke up....and flipped the F out.

That's exactly what I expected to read when I saw the thread title.

 

[WholeLottaGame7]

What she said.
We do it occasionally on teens. Dex.👍 I would have said it was not possible, unless it was the most mature 9 yr old in history and he was fully prepared including a psych eval. Our surgeons would never have considered it on someone that young. They're lucky they didn't cause harm. I hope the kid has amnesia. He's got enough problems without PTSD.

The night before she came across as pretty calm and mature, but the morning of you could tell the storm clouds were on the horizon.

I went and talked with her and her mom the next day. Didn't report any recall from the surgery, thankfully. Hopefully it doesn't come up with her shrink in 20 years.

After the awake portion we got a gas and it looked great. So we ultimately ended up finishing the case up without replacing the LMA and risking laryngospasm. No different than all the propofol "MACs" we run on a daily basis, but it still felt odd.

 

[jwk]

Back before the days of intraop SSEP, EMG, etc., we used to do wake-up tests during scoliosis surgery. Crazy. Laminectomy, all the hooks and rods went in, then NMB's reversed, agents off, and gave doxapram. After a minute or two, we'd start shouting "move your legs". As soon as they moved their legs, a slug of pentothal and back to sleep they went and the surgeons closed.

These kids, usually 12-16 y/o, were told before surgery that we would do this, that they wouldn't feel it or remember it, and that they would only be awake for a few seconds until they moved their feet and that was it.

 

[Bertelman]

Back before the days of intraop SSEP, EMG, etc., we used to do wake-up tests during scoliosis surgery. Crazy. Laminectomy, all the hooks and rods went in, then NMB's reversed, agents off, and gave doxapram. After a minute or two, we'd start shouting "move your legs". As soon as they moved their legs, a slug of pentothal and back to sleep they went and the surgeons closed.

These kids, usually 12-16 y/o, were told before surgery that we would do this, that they wouldn't feel it or remember it, and that they would only be awake for a few seconds until they moved their feet and that was it.

We still did that in residency

 

[michigangirl]

I'm sure you all would agree its one thing to do a quick wake up test to make sure a kid can move all four extremities and slamming in an induction agent vs. asking a 9 year old kid to look at pictures and help surgeons identify regions of their cerebral cortex when they're in a halo.

I was a bit floored that this was attempted. But I realize that my experience isn't the end all be all. So I'm willing to have an open mind-- but a 9 year old is just too young, IMHO.

 

[WholeLottaGame7]

I'm sure you all would agree its one thing to do a quick wake up test to make sure a kid can move all four extremities and slamming in an induction agent vs. asking a 9 year old kid to look at pictures and help surgeons identify regions of their cerebral cortex when they're in a halo.

I was a bit floored that this was attempted. But I realize that my experience isn't the end all be all. So I'm willing to have an open mind-- but a 9 year old is just too young, IMHO.

My n=1 leaves me with the same opinion. Was just wondering what others' experiences with it were like. We have some great peds attendings who trained at CHOP, etc, but not being at an actual renowned peds hospital I wasn't sure if it was rare here or rare everywhere.

 

[Stitch]

I'm sure you all would agree its one thing to do a quick wake up test to make sure a kid can move all four extremities and slamming in an induction agent vs. asking a 9 year old kid to look at pictures and help surgeons identify regions of their cerebral cortex when they're in a halo.

I was a bit floored that this was attempted. But I realize that my experience isn't the end all be all. So I'm willing to have an open mind-- but a 9 year old is just too young, IMHO.

I don't do much time in the OR, but this was my feeling exactly.

 

[Arch Guillotti]

I think it sounds dumb too.

I'm sure you all would agree its one thing to do a quick wake up test to make sure a kid can move all four extremities and slamming in an induction agent vs. asking a 9 year old kid to look at pictures and help surgeons identify regions of their cerebral cortex when they're in a halo.

I was a bit floored that this was attempted. But I realize that my experience isn't the end all be all. So I'm willing to have an open mind-- but a 9 year old is just too young, IMHO.

 

[Mman]

Patient selection is very important for awake cranis and they require a good deal of preop patient education to make them go successfully. The best I've seen are by a surgeon who has his PA meet with the patient for several hours in clinic preoperatively and go over what they can expect and what kinds of things they will be asking them to do in the OR (squeeze my hand, wiggle your toes, count backwards, etc).

Doing it in a 9 year old kid is asking for failure IMHO

 

[neusu]

We'll ask for clonidine and a short acting benzo in preference of narcotics. The skin is suitably anesthetized for the duration of the case with local + epi so pain isn't the main issue once the dura is open. Kids tend to flip out more in general after neurosurgery, we had a kid sit bolt upright and take himself out of pins once.

 

[Poetic Silence]

As someone who has had brain surgery while conscious and aware of my surroundings, I tell you this: if that poor child remembers anything, it will stay with her for life.

I know, you're residents and you are doing what you feel is best, but I'm a 21 year old male who will break into tears recalling that horror. Yes, I have symptoms of PTSD, not all of it because of that one procedure, but it is a part of it.

That indifference you guys seem to have towards that child, that's what is really eating me up as I read this thread. Was she given amnesia inducing medication as she was waking up from the procedure?

 

[lushmd]

That indifference you guys seem to have towards that child, that's what is really eating me up as I read this thread. Was she given amnesia inducing medication as she was waking up from the procedure?

It's unfortunate that you had that experience. Having said that, I don't think that anyone has expressed indifference to the child in this thread. Also, there's no medication that causes retrograde amnesia.

 

[WholeLottaGame7]

As someone who has had brain surgery while conscious and aware of my surroundings, I tell you this: if that poor child remembers anything, it will stay with her for life.

I know, you're residents and you are doing what you feel is best, but I'm a 21 year old male who will break into tears recalling that horror. Yes, I have symptoms of PTSD, not all of it because of that one procedure, but it is a part of it.

That indifference you guys seem to have towards that child, that's what is really eating me up as I read this thread. Was she given amnesia inducing medication as she was waking up from the procedure?

What indifference? The attending surgeon in consultation with the neurologists felt that this was the safest approach for the surgery. Then my attending anesthesiologist and myself came up with a plan to help them accomplish that plan.

As could be anticipated, it didn't go exactly as planned, but all things considered it probably went as well as possible. My point in the thread was to see if there was anything we could improve upon (besides patient selection).

Personally, I thought it was pretty brave of her to even try it, considering she didn't know what she was getting herself into. I was glad to see she didn't remember any of it (at least not yet), and hopefully it stays that way.

 

[Mman]

I know, you're residents and you are doing what you feel is best, but I'm a 21 year old male who will break into tears recalling that horror.

You can rest assured that a resident was not making the decision on how and when to proceed with this procedure.


Also, sorry you had to go through something so painful to recall.

 

[michigangirl]

As someone who has had brain surgery while conscious and aware of my surroundings, I tell you this: if that poor child remembers anything, it will stay with her for life.

I know, you're residents and you are doing what you feel is best, but I'm a 21 year old male who will break into tears recalling that horror. Yes, I have symptoms of PTSD, not all of it because of that one procedure, but it is a part of it.

That indifference you guys seem to have towards that child, that's what is really eating me up as I read this thread. Was she given amnesia inducing medication as she was waking up from the procedure?

I am sorry about your experience. I assure you noone in this thread has shown any indifference to the plight of this girl, including the original poster, who as a resident is asking for guidance on how something like this would have been approached by colleagues. Those of us who are pediatric anesthesiologists on this thread do think patient selection was a major issue here, based on our experience, but this is a multidisciplinary decision between surgeons, neurologists and the anesthesiologists.