Morbidly Obese 5 year old with sleep apnea

[militarymd]

This was a case that I was consulted on today.

5 year old with OSA....body weight 42 kg scheduled for T&A. No sleep studies were available, but by history, this kid has a very high apnea/hyponea index.

Case done in standard fashion...receives only 25 mcg of fentanyl. Patient emerges and extubates in the OR and transported to PACU.

Patient now develops the typical severe sleep apnea post anesthesia clinical course. If you arouse the patient, he screams in pain and is combative, but once he calms down, he obstructs and becomes apneic leading to hypoxia.

This goes on for 3 and a half hours before they ask me for help.

What does everyone think and would like to do?

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[Noyac]

This was a case that I was consulted on today.

5 year old with OSA....body weight 42 kg scheduled for T&A. No sleep studies were available, but by history, this kid has a very high apnea/hyponea index.

Case done in standard fashion...receives only 25 mcg of fentanyl. Patient emerges and extubates in the OR and transported to PACU.

Patient now develops the typical severe sleep apnea post anesthesia clinical course. If you arouse the patient, he screams in pain and is combative, but once he calms down, he obstructs and becomes apneic leading to hypoxia.

This goes on for 3 and a half hours before they ask me for help.

What does everyone think and would like to do?

Trach him and bring him back for Lipo and gastric banding

More to come when I have time.

 

[jetproppilot]

This was a case that I was consulted on today.

5 year old with OSA....body weight 42 kg scheduled for T&A. No sleep studies were available, but by history, this kid has a very high apnea/hyponea index.

Case done in standard fashion...receives only 25 mcg of fentanyl. Patient emerges and extubates in the OR and transported to PACU.

Patient now develops the typical severe sleep apnea post anesthesia clinical course. If you arouse the patient, he screams in pain and is combative, but once he calms down, he obstructs and becomes apneic leading to hypoxia.

This goes on for 3 and a half hours before they ask me for help.

What does everyone think and would like to do?

Really the only way to prevent the downward spiral in a sleepy. post-op OSA patient is CPAP/ nasal BiPAP pretty quick after extubation to keep a patent airway until they're awake enough to maintain it themselves.

OR.....if you plan the anesthetic right, you may not need post-op CPAP/BiPAP.

I'd do the case thinking about minimizing post op sleepiness...no midaz, no opiods...bring him into the OR, Sevo/N20/O2 induction, start the IV after hes asleep, make sure hes deep on the gas, put the tube in. Gas-only aneshetic with intraop toradol/decadron.

I love pre-op oral midaz in kids, but in this case where it may make the difference between going home and getting admitted, I'd avoid it. Do a DVM-animal induction if you have to (hold him down, put the mask on).

You can titrate in some fentanyl in the PACU if hes really hurting AFTER you wake him up.

And have the CPAP available if the kid wakes up too sleepy to support his airway, which shouldnt happen with the above, minimal-residual-effect anesthetic.

 

[jetproppilot]

Trach him and bring him back for Lipo and gastric banding

More to come when I have time.

BUT, at this point, if hes still really sleepy, his pCO2 is probably approaching 70 and he may have to be reintubated. You're behind the 8 ball at this point.

Put the CPAP/BiPAP on, wait 30 minutes. Draw an ABG. If its good, you're golden, but kid has to spend the night on a telemmetry unit.

If ABG is bad, he has to be reintubated, let him wake up, then use some positive airway pressure device right after extubation until he looks good enough clinically to DC it.

 

[zippy2u]

It was ok to pull the tube and see if the kid would fly. He didn't fly so reintubate and turf to the icu. Explain to parents why you did what you did. Extubate next day and kid should be able to go home. --Zip

 

[Noyac]

I agree with old Zip "again".

But I tend to give these kids morphine, however. I give .1mg/kg IBW. I Get them breathing and extubate deep. I know that these kids have resp depression issues but I don't plan on sending a kid this obese home after a T&A. They are watched closely for the majority of the day at least. So, with the MS they are calm and comfy. If they choose not to breath well enough to go home they get to stay over night. THESE KIDS DIE!

I ain't killin no kid!

 

[Idiopathic]

My first thought was a trial of BIPAP with reintubation if no good. given the scenario now.


Does ketamine have any place for intraoperative anesthesia in this patient? That would have been my (inexperienced) choice for IV agent.

 

[HeyDoc]

Are you not worried about the increase in bleeding with Toradol?? I like using it as well but surgeons seem to frown on the idea of using it.

thanks

Really the only way to prevent the downward spiral in a sleepy. post-op OSA patient is CPAP/ nasal BiPAP pretty quick after extubation to keep a patent airway until they're awake enough to maintain it themselves.

OR.....if you plan the anesthetic right, you may not need post-op CPAP/BiPAP.

I'd do the case thinking about minimizing post op sleepiness...no midaz, no opiods...bring him into the OR, Sevo/N20/O2 induction, start the IV after hes asleep, make sure hes deep on the gas, put the tube in. Gas-only aneshetic with intraop toradol/decadron.

I love pre-op oral midaz in kids, but in this case where it may make the difference between going home and getting admitted, I'd avoid it. Do a DVM-animal induction if you have to (hold him down, put the mask on).

You can titrate in some fentanyl in the PACU if hes really hurting AFTER you wake him up.

And have the CPAP available if the kid wakes up too sleepy to support his airway, which shouldnt happen with the above, minimal-residual-effect anesthetic.

 

[militarymd]

There is published data that suggests that toradol IS safe in ENT surgery despite initial case reports that link it to post-operative bleeding.


After 3 and 1/2 hours of intermittent obstruction and hypoxia, I was finally consulted. I considered all of the options that was mentioned already.

I even considered giving narcan for the 25 mcg of fentanyl given 3 hours ago.

I ultimately gave 5 mg/kg of caffeine citrate.....kid woke his fat ass up in 10 minutes and maintained his airway.

He was going to be admitted overnight anyways....I'm going to check today to see how he did.

 

[militarymd]

I know the data for caffeine is for premature infants, but the drug is a respiratory stimulant.

I had considred dopram and progesterone to increase his drive, but I settled on caffeine.

I decided to attempt medical therapy prior to intervening with Non-invasive or Invasive mechanical ventilatory support.

Caffeine worked like a charm.

 

[Gimlet]

.....kid woke his fat ass up in 10 minutes

 

[jetproppilot]

I know the data for caffeine is for premature infants, but the drug is a respiratory stimulant.

I had considred dopram and progesterone to increase his drive, but I settled on caffeine.

I decided to attempt medical therapy prior to intervening with Non-invasive or Invasive mechanical ventilatory support.

Caffeine worked like a charm.

Cool idea!

 

[IN2B8R]

"I ultimately gave 5 mg/kg of caffeine citrate.....kid woke his fat ass up in 10 minutes and maintained his airway."

Doubtful that the caffeine did anything to his pain issues Toradol is O.K, but I have personally seen enough bleeding with it--mainly due to lack of adequate surgical hemostasis.

 

[militarymd]

Patients with sleep apnea have no way around it....they're either going to have pain or die...unless you do regional.

 

[Stillinscrubs]

Does ketamine have any place for intraoperative anesthesia in this patient? That would have been my (inexperienced) choice for IV agent.

I would appreciate feedback on this one also. I have seen it used in gastric bypass pts with quick recoveries and apparently good results, no peds exposure yet....

 

[Noyac]

I would appreciate feedback on this one also. I have seen it used in gastric bypass pts with quick recoveries and apparently good results, no peds exposure yet....

In training I experimented with all types of ways of doing these cases. I went as far as using a Remi drip and low dose ketamine in these OSA obese kids. It works very well and they got a Tylenol suppository for post op pain. The ketamine seemed to cover a lot of the post-op pain but did cause some post-op confusion in these kids. Recovery Rn's didn't like it all that much b/c the kids wouldn't wake up as calm as when I used 0.1mg/kg MS. I guess the RN's got spoiled with the MS as I have done since leaving residency. 0.1mg/kg has not caused any airway problems for me in this population and I have done a bunch of really obese asthmatic FLK's.

 

[Stillinscrubs]

Thanks. We use remi drips quite a bit here where I train. I think it has some real advantages, I will remember the MS and give it a try when the opportunity presents itself.

Scrubs

 

[militarymd]

"I ultimately gave 5 mg/kg of caffeine citrate.....kid woke his fat ass up in 10 minutes and maintained his airway."

Doubtful that the caffeine did anything to his pain issues Toradol is O.K, but I have personally seen enough bleeding with it--mainly due to lack of adequate surgical hemostasis.

The caffeine was not meant to relieve pain. It was meant to be a respiratory and otherwise non-specific stimulant to arouse the patient and relieve episodes of apnea/hypopnea.....allowing the care staff to stop holding chin lift/jaw thrust, and perhaps giving pain medication.

The patient ultimately did not require any more pain meds.

 

[Noyac]

The caffeine was not meant to relieve pain. It was meant to be a respiratory and otherwise non-specific stimulant to arouse the patient and relieve episodes of apnea/hypopnea.....allowing the care staff to stop holding chin lift/jaw thrust, and perhaps giving pain medication.

The patient ultimately did not require any more pain meds.

What do you mean the caffeine was not for pain? Without it every morning I get a raging headache that is only relieved with caffeine.

Personally, I think the caffeine was a great idea. It obviously woke the fat ass up and got him breathing so that everyone else could stop holding their breath. I will remember it for the future. Thanks Mil.