Real World Bread and Butter Case

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

BLADEMDA

Full Member
Lifetime Donor
15+ Year Member
Joined
Apr 22, 2007
Messages
22,257
Reaction score
8,902
Case Number 6 reflects basic Peds ENT Case. For the Residents especially Venty how would you handle the case?

4 year white male Normal Vital Signs. Afebrile.

PMH
Asthma

Meds
Albuterol Nebulizer

FH
Nothing significant

Scenario A) Current cold, upper Resp only, slight wheezing and rhonchi on exam. For PE tubes ONLY. Mom tells you little Jimmy always seems sick.

Scenario B) Current cold, slight wheezing and rhonchi on exam for TONSILLECTOMY AND ADENOIDECTOMY

Scenario C) Your Partner CANCELLED little Jimmy 3 weeks ago because of scenario B. He returns today still wheezing plus rhonchi. What do you do?
What do you tell Mom?

Blade

Members don't see this ad.
 
Not a big pedi expert but here we go:

A: no biggie case goes through i'd give him albuterol + ipratropium + steroids (inhaled) pre-op, intra-op: hit him with some decadron, ketamine and he should be fine.

Cases B + C i'd cancel on the basis that he is not medically optimised:eg no inhaled steroids or anti-cholinergic, give him full regimen + physiotherapy and keep him away from sick kids eg day-care for a week and reprogram if still the same then i'd go through on the basis that it's the best he can get... and manage as above have some epi ready for sub-cu or intra-tracheal
 
Members don't see this ad :)
Case Number 6 reflects basic Peds ENT Case. For the Residents especially Venty how would you handle the case?

4 year white male Normal Vital Signs. Afebrile.

PMH
Asthma

Meds
Albuterol Nebulizer

FH
Nothing significant

Scenario A) Current cold, upper Resp only, slight wheezing and rhonchi on exam. For PE tubes ONLY. Mom tells you little Jimmy always seems sick.

Scenario B) Current cold, slight wheezing and rhonchi on exam for TONSILLECTOMY AND ADENOIDECTOMY

Scenario C) Your Partner CANCELLED little Jimmy 3 weeks ago because of scenario B. He returns today still wheezing plus rhonchi. What do you do?
What do you tell Mom?

Blade

Scenario A - 45 second case. To OR - mask induction; once induced turn Sevo. off, keep at 60/40 nitrous/oxygen until last PE tube in. O2 up all the way when tube in - to PACU quick

Scenario B - Ask when pt. had last neb. treatment. In AM? To OR. Not in AM? Give one pre-op then to OR. Mask induction, IV, NO muscle relaxant and 2 mcg/kg of fentanyl. Our ENTs all want Decadron and Zofran so I give it - have to be accomodating. And yeah.....I know about pre-op nebulizers not being effective, but guess what? The pre-op nurses look at you like you're a sadistic swine if you don't do it, so I do.

Scenario C - Tell parents about the SLIGHTLY INCREASED risk of post-op pulmonary complications. Emphasize that this is probably as good as their kid is going to get, though and he needs the surgery. Apologize for the inconvenience of them having to come in a 2nd time.

Peace out
 
Scenario A) Current cold, upper Resp only, slight wheezing and rhonchi on exam. For PE tubes ONLY. Mom tells you little Jimmy always seems sick.

Scenario B) Current cold, slight wheezing and rhonchi on exam for TONSILLECTOMY AND ADENOIDECTOMY

Scenario C) Your Partner CANCELLED little Jimmy 3 weeks ago because of scenario B. He returns today still wheezing plus rhonchi. What do you do?
What do you tell Mom?

Blade

Not to split hairs, but I'm not sure the terminology is right here. He has an "upper" respiratory tract infection with abnormal lung sounds (rhonchi)? Isn't that a lower respiratory infection?

An afebrile kid that is non-toxic appearing without an abnormal chest exam can have GA. The surgery is probably the cure for Jimmy's problem, and he's unlikely to ever be "optimized" without it. If he really has a lower tract infection, or if he was febrile/toxic he should be postponed, otherwise, to the OR.

Oh yeah, I'd give the wheezer a neb... I'm a sucker.
 
Scenario A - 45 second case. To OR - mask induction; once induced turn Sevo. off, keep at 60/40 nitrous/oxygen until last PE tube in. O2 up all the way when tube in - to PACU quick

Scenario B - Ask when pt. had last neb. treatment. In AM? To OR. Not in AM? Give one pre-op then to OR. Mask induction, IV, NO muscle relaxant and 2 mcg/kg of fentanyl. Our ENTs all want Decadron and Zofran so I give it - have to be accomodating. And yeah.....I know about pre-op nebulizers not being effective, but guess what? The pre-op nurses look at you like you're a sadistic swine if you don't do it, so I do.

Scenario C - Tell parents about the SLIGHTLY INCREASED risk of post-op pulmonary complications. Emphasize that this is probably as good as their kid is going to get, though and he needs the surgery. Apologize for the inconvenience of them having to come in a 2nd time.

Peace out


Agree. You can't keep cancelling this kid forever. Counsel the parents. Preop albuterol. Have albuterol in OR and some dilute epiniphrine in case th shi t hits the fan. Both mask inductions as per sensei.
 
Agree. You can't keep cancelling this kid forever. Counsel the parents. Preop albuterol. Have albuterol in OR and some dilute epiniphrine in case th shi t hits the fan. Both mask inductions as per sensei.


Do you agree with your partner cancelling the case in Scenario B and rescheduling? Would you have done the case in scenario B if it was under LMA? Do you mention to MOM increased risk of respiratory complications in scenario B and C if you do the case? Any mention of possible admission overnight? What about preoperative inhaled steroid therapy? Any role here?
 
Scenario A - 45 second case. To OR - mask induction; once induced turn Sevo. off, keep at 60/40 nitrous/oxygen until last PE tube in. O2 up all the way when tube in - to PACU quick

Scenario B - Ask when pt. had last neb. treatment. In AM? To OR. Not in AM? Give one pre-op then to OR. Mask induction, IV, NO muscle relaxant and 2 mcg/kg of fentanyl. Our ENTs all want Decadron and Zofran so I give it - have to be accomodating. And yeah.....I know about pre-op nebulizers not being effective, but guess what? The pre-op nurses look at you like you're a sadistic swine if you don't do it, so I do.

Scenario C - Tell parents about the SLIGHTLY INCREASED risk of post-op pulmonary complications. Emphasize that this is probably as good as their kid is going to get, though and he needs the surgery. Apologize for the inconvenience of them having to come in a 2nd time.

Peace out

Nice Answer. But, half on my partners would cancel the case in scenario B because the case is ELECTIVE. Most would do the case in scenario C as you describe. So, do you do little kids with active URI's for routine elective surgery that require intubation?

My personal opinion (and it is just that) is that cases that are short and can be performed under MASK or LMA are "doable" with these kids. Those that require intubation I am more hesitant to give the go ahead. Comments?

Blade
 
Case Number 6 reflects basic Peds ENT Case. For the Residents especially Venty how would you handle the case?

4 year white male Normal Vital Signs. Afebrile.

PMH
Asthma

Meds
Albuterol Nebulizer

FH
Nothing significant

Scenario A) Current cold, upper Resp only, slight wheezing and rhonchi on exam. For PE tubes ONLY. Mom tells you little Jimmy always seems sick.

Scenario B) Current cold, slight wheezing and rhonchi on exam for TONSILLECTOMY AND ADENOIDECTOMY

Scenario C) Your Partner CANCELLED little Jimmy 3 weeks ago because of scenario B. He returns today still wheezing plus rhonchi. What do you do?
What do you tell Mom?

Blade

I've done a whopping ONE MONTH of peds. I'll be better equipped to answer this after my 3month stint at Childrens Memorial this upcomming year. But here goes:

A) I'd do it. Give the kid a puff of albuterol beforehand. Maybe some decadron intraop. Sevo Nitrous O2 Mask.

B) I wouldn't do the case. Although the kid is older than 1yr, if he is having active asthma WITH a current NEW cold AND I gotta tube him then why the hell bother? Have em come back in a month.

C) Well its been 3 weeks...no purulent garbage, no temperature, no acute asthmatic attacks requiring trips to the hospital since the cold, and the kid doesn't look like ass...then I'd tell the parents that the child may have to be observed until late tonight or even until the morining. There is a definite increased risk of some sort of intraop/post op respiratory issue. If they are ok then lets go for it.

Roids for post op crap, albuterol puff upfront for the wheeze. Maybe bring a neb into the OR to run if need be. Pull tube deep. Thats it I guess. I'd certainly be prepared to encounter some desaturation from bronchospasm.
 
You know I'd probably do all three kids.

case A, for sure. Mask him, thats all.

case B, if not febrile with normal appetite and activity level per parents.

case C, well 3 weeks hasn't benefitted him why wait another 3 weeks. Assuming he isn't worse now, like in case B.


I'd extubate the T&A's deep as I do all my kids. I'd really watch them post-op though. And I would have informed parents of possiblity of little Johnny spending the night but not likely.
 
Most of the debate centers around scenario B. I have to say I am suprised at the agressiveness of the posts. I think with an active URI in a 4 year old plus wheezing I would cancel the case. The literature reports an increased probability of respiratory events in this type of patient. That said, a 15 minutes case could easily be pulled off in this patient by an experienced provider.

Scenario C in my world is a go ahead because the MOM would want to get the surgery over with even if little Jimmy had to spend the night. I would give a treatment to Jimmy pre-op and be careful not to intubate him "light."
I have done this case under LMA with the right surgeon.

Blade
 
Most of the debate centers around scenario B. I have to say I am suprised at the agressiveness of the posts. I think with an active URI in a 4 year old plus wheezing I would cancel the case. The literature reports an increased probability of respiratory events in this type of patient. That said, a 15 minutes case could easily be pulled off in this patient by an experienced provider.

Scenario C in my world is a go ahead because the MOM would want to get the surgery over with even if little Jimmy had to spend the night. I would give a treatment to Jimmy pre-op and be careful not to intubate him "light."
I have done this case under LMA with the right surgeon.

Blade

How the hell do they get back there with a lma lounging in the pharynx?
 
Members don't see this ad :)
BTW I think lidocaine down the tube or IV doesn't do JACK FRIGGEN SQUAT for decreasing coughing during extubation.

I bring this up because in the books I read they suggest LIDOCAINE IV or via the TUBE to decrease cough---->bronchospasm.

I call BS. I've been squirt'n and spraying that S$^T like no tomorrow and it DOESN'T WORK for extubation. That F^*King LTA is a JOKE too.
 
How the hell do they get back there with a lma lounging in the pharynx?


There was a peer reviewed study a few year back describing the use of LMA for this procedure. They did a series with one or two ENT surgeons and it worked well.

At my instituton I have ONE surgeon who is EXTREMELY fast and skilled. He worked around the LMA for me when I had scenario B and he asked "if there was any way we could do the case today."

Blade
 
I prefer the E.T. tube over LMA for Tonsillectomy and so do my surgeons.
But, for those of you who want a study backing up the use of LMA for this procedure here it is:

Anesthesia and Analgesia 1998 Apr;86 (4) 706-711

There are others from the Canadian Journal of Anesthesia and the ENT journals. Those two report the LMA has limitations for Tonsillectomy and were more "guarded" in their endorsement.

Blade
 
I usually try to define what a cold is to the parents. If there is a definite change from the kid's usual state of health, ie cough, wheezing, fever that has gotten worse over the past few days I would not do A,B, or C. If there has been no change in the kid, I would do A, send him to the peds for better control of his asthma for B. If our group cancels a case in the above scenario, we tell the parents that if the kid is not better in a week to go see his/her pediatrician. That way if scenario C happens then the ball was in their court and they dropped it if they did not follow those instructions. If they did go see the peds and were adequately treated, then I would do it in scenario C. If they just did not go to see their doctor and show up with the kid not better they are not too suprised when they get cancelled. We have a good preop clinic and are usually able to avoid B and C by bringing the kid in a few days before and if anything is not right we get called andare able to head it off.
 
I usually try to define what a cold is to the parents. If there is a definite change from the kid's usual state of health, ie cough, wheezing, fever that has gotten worse over the past few days I would not do A,B, or C. If there has been no change in the kid, I would do A, send him to the peds for better control of his asthma for B. If our group cancels a case in the above scenario, we tell the parents that if the kid is not better in a week to go see his/her pediatrician. That way if scenario C happens then the ball was in their court and they dropped it if they did not follow those instructions. If they did go see the peds and were adequately treated, then I would do it in scenario C. If they just did not go to see their doctor and show up with the kid not better they are not too suprised when they get cancelled. We have a good preop clinic and are usually able to avoid B and C by bringing the kid in a few days before and if anything is not right we get called andare able to head it off.

Many private practices don't have pre-op clinics. The case I gave you was real world. The kid had a URI (runny nose, mild cough but no fever) but MOM wanted the surgery so she brough little Jimmy in anyway (scenario B).

We all agree on scenario A. The discussion is scenario B. Does this mean you cancel the case and wait a few weeks? Or, in scenario B, do you do the case? THere is NO WE in this case just YOU so make a decision. In the real world the buck stops with you so start thinking like it.

Blade
 
"We all agree on scenario A. The discussion is scenario B. Does this mean you cancel the case and wait a few weeks? Or, in scenario B, do you do the case? THere is NO WE in this case just YOU so make a decision. In the real world the buck stops with you so start thinking like it."

Blade, I said what I would do in the previous post. I don't know how to make it any more clear. I guess I was trying to delineate between a true URI ie symptoms that are truly worse than the norm for this kid. If they are then no elective surgery. If they have been evaluated by their pediatrician, treated, with no change in symptoms, then I would do the case but only with no worsening in symptoms. How long would I wait? If the kid showed up 3 weeks later, adequately treated, I would go ahead and do it. That time period is not ideal but I would not make the parents come back. I don't know what else I can say. By the way, Do we really make the final decision about who and what cases get done? Is this really the real world? I just did not know that. Anyway, these are good cases for this forum as are most of the ones that get presented. I guess it is your case and your thread and I will not try to knock you off your soapbox.
 
The discussion is scenario B. Does this mean you cancel the case and wait a few weeks?



I don't know why we are discussing this. There is no right or wrong answer. You can do whatever the hell you want.

Of course, if you decide to do the case and have a bad outcome, you will end up with a double outlet GI system (after they tore you a new hole, that is). So, do it at your own risk.

Next case.
 
"We all agree on scenario A. The discussion is scenario B. Does this mean you cancel the case and wait a few weeks? Or, in scenario B, do you do the case? THere is NO WE in this case just YOU so make a decision. In the real world the buck stops with you so start thinking like it."

Blade, I said what I would do in the previous post. I don't know how to make it any more clear. I guess I was trying to delineate between a true URI ie symptoms that are truly worse than the norm for this kid. If they are then no elective surgery. If they have been evaluated by their pediatrician, treated, with no change in symptoms, then I would do the case but only with no worsening in symptoms. How long would I wait? If the kid showed up 3 weeks later, adequately treated, I would go ahead and do it. That time period is not ideal but I would not make the parents come back. I don't know what else I can say. By the way, Do we really make the final decision about who and what cases get done? Is this really the real world? I just did not know that. Anyway, these are good cases for this forum as are most of the ones that get presented. I guess it is your case and your thread and I will not try to knock you off your soapbox.


Actually it isn't my soapbox here. Urge is correct that 'you can do whatever you want' but must bear the consequences of that decision. That is the real world. YOU decide along with the surgeon what case gets done. Sure, a few surgeons will try to "bully" you especially if you have a history of cancelling cases. But, those of us like JPP who do more than 99% of posted cases without delay have good 'street credibilty' in the O.R. When we cancel a case the surgeon rarely challenges the decision.

The fact is YOU are responsible for the MEDICAL DECISION to proceed with a case. THe surgeon is relying on your judgement regarding MEDICAL MANAGEMENT AND ANESTHESIA. This is one of big differences between a CRNA and a Board Certified Anesthesiologist. CRNA's follow orders/protocols but Physician Anesthesiologists make the orders/protocols regarding care in the O.R. This is how a lawyer and Jury would view it. My bet is that under oath the surgeon would view it that way as well. (Please NO CRNA Response here-this is a clinical thread).

Blade
 
There was a peer reviewed study a few year back describing the use of LMA for this procedure. They did a series with one or two ENT surgeons and it worked well.

At my instituton I have ONE surgeon who is EXTREMELY fast and skilled. He worked around the LMA for me when I had scenario B and he asked "if there was any way we could do the case today."

Blade

There is a guy at Children's in San Diego that uses a proseal for all his T and A's. He has an english accent so I suppose he is from england. Those english guys love the LMA. I did an appendectomy with a proseal with him (and it wasn't an interval appy, mind you.)
 
Actually it isn't my soapbox here. Urge is correct that 'you can do whatever you want' but must bear the consequences of that decision. That is the real world. YOU decide along with the surgeon what case gets done. Sure, a few surgeons will try to "bully" you especially if you have a history of cancelling cases. But, those of us like JPP who do more than 99% of posted cases without delay have good 'street credibilty' in the O.R. When we cancel a case the surgeon rarely challenges the decision.

The fact is YOU are responsible for the MEDICAL DECISION to proceed with a case. THe surgeon is relying on your judgement regarding MEDICAL MANAGEMENT AND ANESTHESIA. This is one of big differences between a CRNA and a Board Certified Anesthesiologist. CRNA's follow orders/protocols but Physician Anesthesiologists make the orders/protocols regarding care in the O.R. This is how a lawyer and Jury would view it. My bet is that under oath the surgeon would view it that way as well. (Please NO CRNA Response here-this is a clinical thread).

Blade

The problem with many of these children presenting for T&A/PETS with a history of hyper reactive airway dz/frequent colds is it is hard to get them well.....thats why they are coming for the procedure.

The above cases are seen every day. And most of them are done on schedule.

My regimen for a wheezing kid involves how bad he looks. Is he tachypneic? Suprasternal/intercostal retractions? Is he just sitting in mommies lap breathing faster than Paris Hilton's last drunken-driving escapade? Or is he playing with a toy, acting normal, but wheezing?

If they look bad, they get cancelled. Period. And like Blade said, we dont cancel many cases....because there arent alotta times you need to cancel a case. But this is one of them. And the surgeons dont argue.

A tachypneic and/or retracting toddler needs to be optimized and return another day.

If they look OK but are wheezing, even with a URI, they get an albuterol neb pre-op and methylprednisilone 2mg/kg IV intraop.

The problem with LMAs in kids like this is the increased risk of laryngospasm...so I wouldnt risk it in a hyperreactive airway kid with a cold.

The above goes for PETs AND T&As.

Any stridor in the PACU gets a racemic epi neb.
 
For what it is worth (not an invitation to bash), during my pediatric rotation, which was only three months so I'm not the pediatric expert, we rarely cancelled a kid that had a crappy upper airway. Like jet said, the reason why they were there was to fix the problem that is causing them to constantly get (or stay) sick.

Again, if they looked like they were in true distress, they may have been cancelled or at least postponed. But if they were trucking along regardless of the wheezes and goo dripping to the floor....we did the case. Of course we expected hyper-reactive airway, but nothing we couldnt handle. Pre-op albuterol and prednisone and away they go. The pre-op sometimes looked like a crack house with all the kids smoking the pipes. Peds was a great rotation to gain experience in handling reactive airways. I have never seen so many da mn laryngospasms.
 
The problem with LMAs in kids like this is the increased risk of laryngospasm...so I wouldnt risk it in a hyperreactive airway kid with a cold.


I don't know if it is supported by data, but I thought the general understanding was exactly the opposite-- the good thing about LMAs in these kids is the decreased risk of laryngospasm. Avoiding manipulation/stimulation of the cords is good. I don't use LMAs with T&As because its a pain for the surgeons. I'm sure they could learn to do fine with it, but they fear change.
 
I prefer the E.T. tube over LMA for Tonsillectomy and so do my surgeons.
But, for those of you who want a study backing up the use of LMA for this procedure here it is:

Anesthesia and Analgesia 1998 Apr;86 (4) 706-711

There are others from the Canadian Journal of Anesthesia and the ENT journals. Those two report the LMA has limitations for Tonsillectomy and were more "guarded" in their endorsement.

Blade

That is what this study showed-less laryngospasm with LMA.

Blade
 
Top