Morbidly obese kids...

[deleted9493]

Today I had a pre-pubescent 110kg (5'3") kid coming for a cath in the setting of JET-induced DCM for attempted ablation. LV/RV function is moderately depressed on echo. He had no visible or palpable veins--skin looks dry and well, thick. Airway looks "ok-ish". Good mouth opening and TM distance with maskable features. Dad is the domineering type, probably twice his son's size and is insisting that this should be painless.

How do you proceed?

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[sevoflurane]

Today I had a pre-pubescent 110kg (5'3") kid coming for a cath in the setting of JET-induced DCM for attempted ablation.

Sorry, what does JET mean? I don't know that abbreviation.
How bad is his DCM. Mitral valve annular dilatation with big regurg, b/l atrial enlargement, big RV and plum htn.? EF? I'd like to hear more about the echo and also know what the kid can actually do on a day to day basis.
So long as his conditions are optimized, I'd proceed with IV placement (PIV or central), controlled induction and maintenance of anesthesia in the usual fashion.

 

[sevoflurane]

Or… mask ind. and IV.

Depends on the kid.

 

[deleted9493]

That's all I've got on the echo report--the report doesn't give numerical values to fractional shortening or ejection fraction or regurgitant severity, for whatever reason. JET stands for Junctional Ectopic Tachycardia. Functionally, he's limited by his weight and his initial presentation was with atypical, non-activity related chest pain. Monitor in the holding area shows largely junctional rhythm in the 100-110 range with an occasionally conducted beat of sinus origin.

 

[sevoflurane]

...he's limited by his weight and his initial presentation was with atypical, non-activity related chest pain. Monitor in the holding area shows largely junctional rhythm in the 100-110 range with an occasionally conducted beat of sinus origin.

So, he has chest pain at rest. Has this been investigated besides the echo? Holter monitor? What does it show? He jump to 300?
Is he optimized from a non-operative point of view? Amio,etc.

He gets zoll pads for the procedure.

 

[sevoflurane]

Nice case.

 

[deleted9493]

Sorry, I forgot to mention that he had undergone holter monitoring which identified the JET at rates of upwards of 160's. He was being managed with Diltiazem, Digoxin and Sotalol...all of which had been held 24hrs prior in hopes of allowing the EP team to localize the aberrant focus. His EKG was highly disorganized and in the 110's when I saw him in preop holding. This is a case of non-operative JET.

 

[urge]

How old is the child? I would try to put an IV with ultrasound. Maybe some po versed. Tell dad that more importantly than being painless, it has to be safe.

 

[fabfive5]

Sorry, what does JET mean? I don't know that abbreviation.
How bad is his DCM. Mitral valve annular dilatation with big regurg, b/l atrial enlargement, big RV and plum htn.? EF? I'd like to hear more about the echo and also know what the kid can actually do on a day to day basis.
So long as his conditions are optimized, I'd proceed with IV placement (PIV or central), controlled induction and maintenance of anesthesia in the usual fashion.

JET = Junctional Ectopic Tachycardia....a form of SVT sort of. It is junctional in nauture so can theoretically go into SVT/VF/VT. JET is NOT good for cardaic output.

I would explain to the dad that a pre-surgical PIV is a must, since the kid is morbidly obese and probably has the FRC of a neonate. I would do a mod-RSI with propofol and Succh.

At my institution, we do CVLs for the EP guy for his/her coronary sinus catheter. Run them on Iso or Sevo, VEC, Fentanyl, and precedex after ablation is over.

 

[deleted9493]

For oral preoperative anxiolytic, what would you all prescribe in a big 12 year old like this...bearing in mind goal of extubating him quickly at case's end and the volume that would be required for midazolam syrup? Thankfully, I got lucky with topicalization and blindly placing a 22g in the 4th knuckle region. He was so skiddish that I didn't know that an ultrasound was going to help me...it just had to go in fast, if it was going to work.

For my plan B, I was thinking a vehicle of 20mg midazolam syrup with 500mg of ketamine, knowing that he would probably need an oral or nasal airway for recovery. Would anyone consider giving an IM midazolam/ketamine here? Anyone have experience with other benzos in tablet form?

 

[somedumbDO]

Ultrasound in the ac w a jtip lido "popper" and a 20g angio then the usual stuff. If super nervous 20mg po midaz. You don't need ket/midaz in this situation why make it complicated?

 

[nap$ter]

Ultrasound in the ac w a jtip lido "popper" and a 20g angio then the usual stuff. If super nervous 20mg po midaz. You don't need ket/midaz in this situation why make it complicated?

plus the ketamine might jack the jet

 

[HollywdAnesth]

I would put a tourniquet on and see if anything pops up. If that didn't work, I would bust out the ultrasound.
If that didn't work, I would use an EZ IO.