Severe maladaptive behaviour in a child after GA?

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propadope

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Had a consult for peds dental on a 6 year old. Apparently had his adenoids removed at age 2. Mother said that she was not able to be present during induction and recovery. The child apparently freaked out acccording to the mon had to be held by 4 nurses in recovery. Only then was she allowed to see him. The child consequently has severe separation anxiety. The mother was not able to bring the child to the grocery store etc... and required several years of psychiatric care. The child is in senior kindagarten now. The mother has serious reservations with putting the child through GA again; wanted to be present before the child wakes up.

I know maladaptive behaviour has been described but I have never heard to this extent. I have not seen the child and only spoken to the mom over the phone. I would send the child to his pediatrician for preop evaluation only if the mom wants to go ahead.

Thoughts?
 
It took 4 nurses to hold down a 2 year old? WTF?!?!

Otherwise, Precedex would work very well along with Parental presence during Induction
 
sethco said:
It took 4 nurses to hold down a 2 year old? WTF?!?!

Otherwise, Precedex would work very well along with Parental presence during Induction
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2 year olds can be insanely strong when they are full on berserker.

I have parents in 99% of the time. I personally am not a fan of precedex as a premed. I would give midazolam +/- ketamine. And precedex intraop/on emergence. Just to be clear I wasn’t asking how to do the case. Although I agree that premed is a must. Just never heard of such an extreme situation. Ive reassured mom that I would do everything to manage the separation anxiety but she is not confident. Is going to talk it over with dad before deciding to proceed.
 
propadope said:
Had a consult for peds dental on a 6 year old. Apparently had his adenoids removed at age 2. Mother said that she was not able to be present during induction and recovery. The child apparently freaked out acccording to the mon had to be held by 4 nurses in recovery. Only then was she allowed to see him. The child consequently has severe separation anxiety. The mother was not able to bring the child to the grocery store etc... and required several years of psychiatric care. The child is in senior kindagarten now. The mother has serious reservations with putting the child through GA again; wanted to be present before the child wakes up.

I know maladaptive behaviour has been described but I have never heard to this extent. I have not seen the child and only spoken to the mom over the phone. I would send the child to his pediatrician for preop evaluation only if the mom wants to go ahead.

Thoughts?
Click to expand...
Don’t think there is a winning strategy out of this one.

The kid will have a fit regardless of what you do and will end up in therapy again.

The parents need to weigh dental care vs. psych care. If they are ok with it go ahead.
 
propadope said:
2 year olds can be insanely strong when they are full on berserker.

I have parents in 99% of the time. I personally am not a fan of precedex as a premed. I would give midazolam +/- ketamine. And precedex intraop/on emergence. Just to be clear I wasn’t asking how to do the case. Although I agree that premed is a must. Just never heard of such an extreme situation. Ive reassured mom that I would do everything to manage the separation anxiety but she is not confident. Is going to talk it over with dad before deciding to proceed.
Click to expand...

If i find myself unable to handle a two year old, that's the day I'll pack it all up
 
urge said:
Don’t think there is a winning strategy out of this one.

The kid will have a fit regardless of what you do and will end up in therapy again.

The parents need to weigh dental care vs. psych care. If they are ok with it go ahead.
Click to expand...
I basically told mom I would do everything possible to avoid traumatizing her child but there are no guarantees. I would do the case if she agrees but I would also be fine if she declines. I don’t want to be held responsible for negative behaviour and chances are there will be.
 
Pediatrician and now anesthesia resident, have never heard of anything like this before in my former life after a single GA. Are there case reports in the anesthesia literature that I have just not been exposed to? 99% of the time in clinic when we'd encounter something like those severe behavioral reports in a toddler/early elementary school kid, the parents gave you an amazing demo in real time while you were trying to take a history of all of their maladaptive parenting and discipline behaviors. So glad I don't have to deal with that world anymore.
 
shepardsun said:
Pediatrician and now anesthesia resident, have never heard of anything like this before in my former life after a single GA. Are there case reports in the anesthesia literature that I have just not been exposed to? 99% of the time in clinic when we'd encounter something like those severe behavioral reports in a toddler/early elementary school kid, the parents gave you an amazing demo in real time while you were trying to take a history of all of their maladaptive parenting and discipline behaviors. So glad I don't have to deal with that world anymore.
Click to expand...
I have never heard of anything this severe as well. I suspect there is more to this than just the GA. Most maladaptive behaviour is very short term but there is a small incidence of it lasting beyond 6 months

Postoperative maladaptive behavioral changes in children. - PubMed - NCBI

Postoperative Behavioral Outcomes in Children :Effects of Sedative Premedication | Anesthesiology | ASA Publications

https://journals.lww.com/anesthesia...ct_PR279___Incidence_and_Duration_of.270.aspx

https://www.google.ca/amp/s/www.res...m_and_Postoperative_Maladaptive_Behaviors/amp
 
propadope said:
Had a consult for peds dental on a 6 year old. Apparently had his adenoids removed at age 2. Mother said that she was not able to be present during induction and recovery. The child apparently freaked out acccording to the mon had to be held by 4 nurses in recovery. Only then was she allowed to see him. The child consequently has severe separation anxiety. The mother was not able to bring the child to the grocery store etc... and required several years of psychiatric care. The child is in senior kindagarten now. The mother has serious reservations with putting the child through GA again; wanted to be present before the child wakes up.

I know maladaptive behaviour has been described but I have never heard to this extent. I have not seen the child and only spoken to the mom over the phone. I would send the child to his pediatrician for preop evaluation only if the mom wants to go ahead.

Thoughts?
Click to expand...
Textbook PTSD. What maladaptive behavior? Keep mother with child as late and as early as possible. Use preop midazolam. Induce in mother's arms. Try to spend as little time as possible with the kid preop. You are his Vietnam.

Four nurses holding down a toddler? They should have been fired. They have no business in pediatrics. Heartless people. Just imagine what must have happened there for a child to need years of psych care.

What do you need a pediatric eval for?
 
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FFP said:
Textbook PTSD. What maladaptive behavior? Keep mother with child as late and as early as possible.

Four nurses holding down a toddler? They should have been fired. They have no business in pediatrics. Heartless people. Just imagine what must have happened there for a child to need years of psych care.
Click to expand...
Severe separation anxiety. Mom couldn’t take the kid anywhere. I don’t know all the details but it was bad enough to require psychiatric care and to delay the child going to school.
 
propadope said:
Severe separation anxiety. Mom couldn’t take the kid anywhere. I don’t know all the details but it was bad enough to require psychiatric care and to delay the child going to school.
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I understand that. But I am sure it was not that bad before. They traumatized that child, I'm convinced. There is literally no excuse for 4 adults to hold down a toddler, except for administering lifesaving therapy. And it must have gone on for a while to leave such a memory in the kid. Haven't they heard of precedex or midazolam?

Bad parenting? Maybe. Still...

I had similar stuff happen to me as a toddler, except that it was brief and I got over it. But I still remember it well, decades later. I don't know why some adults think that kids get easily over being restrained and hurt, when their pain threshold is waaaaay lower.
 
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propadope said:
I have never heard of anything this severe as well. I suspect there is more to this than just the GA. Most maladaptive behaviour is very short term but there is a small incidence of it lasting beyond 6 months

Postoperative maladaptive behavioral changes in children. - PubMed - NCBI

Postoperative Behavioral Outcomes in Children :Effects of Sedative Premedication | Anesthesiology | ASA Publications

Abstract PR279: Incidence and Duration of Post-Operative... : Anesthesia & Analgesia

https://www.google.ca/amp/s/www.res...m_and_Postoperative_Maladaptive_Behaviors/amp
Click to expand...
Spoiled little kid wakes up. Mom is not there, serious postop pain, feels like crap. Temper tantrum, pulls on stuff, IV. Inexperienced/impatient nurses immobilize him physically, instead of chemically, or just simply trying to hold and reassure him, or how about this - just leaving him alone until mom arrives? But, hey, nurses always need to feel in control; they are like policemen in scrubs. Can you imagine 4 adults restraining a toddler? More temper tantrum, plus lifetime memories. More torture, still no results. Etc.

Maladaptive is what I call the "science" of pediatric psychiatry, the geniuses who brought us autism spectrum and ADHD, and oppositional-defiant disorder, and every possible invented pretext to drug children and motivate their own existence.
 
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FFP said:
I understand that. But I am sure it was not that bad before. They traumatized that child, I'm convinced. There is literally no excuse for 4 adults to hold down a toddler, except for administering lifesaving therapy. And it must have gone on for a while to leave such a memory in the kid. Haven't they heard of precedex or midazolam?

Bad parenting? Maybe. Still...

I had similar stuff happen to me as a toddler, except that it was brief and I got over it. But I still remember it well, decades later. I don't know why some adults think that kids get easily over being restrained and hurt, when their pain threshold is waaaaay lower.
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Got it. You were being facetious about maladaptive behaviour. I don’t disagree that something most likely went awry in recovery. I also have no idea how the induction was as mom was not present and I don’t know if the kid got a premed
 
If this were the US I would be highly suspicious of any story like this because in our litigious culture it signals that someone is fishing for a lawsuit. I have heard of lawsuits for the most ridiculous things and it kinda sounds ridiculous that a kid at 2yo is psychologically devastated and requires psych care after a GA. Not saying it is impossible just highly highly improbable.
 
I dunno, I think FFP could be correct. A two year old wakes up lost, alone, confused, in pain... then is held down by four adults for who knows how long. This isn't an infant. Two year olds remember things, they have personalities. It's not inconceivable a child would develop serious issues, it sounds traumatic. I wouldn't blow off the mother or child.
 
FFP said:
Textbook PTSD. What maladaptive behavior? Keep mother with child as late and as early as possible. Use preop midazolam. Induce in mother's arms. Try to spend as little time as possible with the kid preop. You are his Vietnam.

Four nurses holding down a toddler? They should have been fired. They have no business in pediatrics. Heartless people. Just imagine what must have happened there for a child to need years of psych care.

What do you need a pediatric eval for?
Click to expand...
Ped eval to cover my ass. For what its worth.
 
MoMoGesiologist said:
I dunno, I think FFP could be correct. A two year old wakes up lost, alone, confused, in pain... then is held down by four adults for who knows how long..... I wouldn't blow off the mother or child.
Click to expand...

I wouldn't blow off anybody, but if you've met some of the "special" parents I have through the years, you could also see how what in reality may very well have been a sweet 22 year old new grad recovery room nurse trying to gently comfort a child going through emergence delirium becomes four burly men putting the leather jackets on ****oo's Nest style upon retelling from a histrionic parent with a slightly bratty kid.
 
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Such a dramatic description on the part of the mother makes me wonder how much of the child's behavior is rooted in her parenting. Not that that helps OP at all.
 
You could ask for a copy of the psych notes to maybe help figure out whether this is really a parenting issue or whether the child is suffering a psych issue from his last experience with surgery/anesthesia.
 
MoMoGesiologist said:
You could ask for a copy of the psych notes to maybe help figure out whether this is really a parenting issue or whether the child is suffering a psych issue from his last experience with surgery/anesthesia.
Click to expand...
Yes. This is part of the reason for me getting a peds eval. I want another perspective other than mom’s. I would also potentially send the kid back to psych to prepare for the appointment if mom decides to go ahead.
 
"Peds dental on a 6 year old". That in itself is frequently a clue about the parents as well as the child.

I'm not a fan of a parent at induction but it's our routine. We would NEVER allow a parent in the OR for emergence. We do allow them in PACU once the child has awakened.
 
I was surprised to see this patient yesteday. Didn’t think she was going to go ahead and did not get a heads up. Was caught off guard when I was pre op-ing the kid. The mother mentioned we had spoken on the phone and it clicked who it was. Child was suprisingly cooperative. Mom declined IM premed. Had her come in to the op Kid played a Nintendo and was a relatively smooth induction. Ran 0.7 MAC sevo/N2O and a propofol/precedex infusion. Uneventful anesthetic and had mom come in to recovery. No delirium. Just did a post op call and no maladaptive behaviour other than the kid being groggy yesterday and a little frustrated because of that.
 
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