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Clinical Case for Discussion: A 3-year-old boy is eating a McDonalds Happy Meal on the lawn of the restaurant. A lawn mower approaches, and a rock is ejected from the mower, hitting the child in the eye. The boy suffers an open eye injury, and is taken to the nearest hospital. You are on call for the repair. You are an experienced practitioner, but not a pediatric anesthesia specialist. What do you do?
Discussion: There are two issues. One is how to do the open-eye, full stomach anesthetic, and the other is pediatric anesthesia by non-pediatric anesthesia specialists.
Your goals for this anesthetic are to protect the airway, and to avoid increases in intraocular pressure (IOP). The list of things which increase IOP, and risk further eye damage, includes crying, coughing, the Valsalva manuver, laryngoscopy, and endotracheal intubation. Ketamine and succinylcholine may also increase IOP. Trying to start an IV without causing crying in a 3 year old can be difficult.
No single approach to this patient is ideal, but a proposed approach to this patient is: (1) Apply EMLA cream, with occlusive dressing, over several potential IV sites 45 – 60 minutes before the IV attempt. Next, give the child an oral midazolam premedication (.75 mg/kg), and wait until he becomes sedated enough to start the IV.
(2) Once the IV is in place, a modified rapid sequence induction is done with cricoid pressure, using rocuronium as the muscle relaxant. Either a priming dose of the relaxant, or a dosage of 2 X the normal intubating dose is used to speed the pace of neuromuscular blockade. A nerve stimulator is used to confirm that depth of muscle blockade is adequate, to avoid coughing during laryngoscopy. The FDA black box warning regarding pediatric use of succinylcholine allows for its use for emergency intubation or for patients with a full stomach, but this author prefers to avoid it if alternatives exist. Succinylcholine causes a transient (4 – 6 minute) increase in IOP of 10 to 20 mm Hg, although there have been no clinical case reports of further eye damage or other complications in open eye surgery following succinylcholine. (Miller, Anesthesia, 2000, 2176-79).
(3) If the child is chubby, and you are not able to place the IV despite adequate oral sedation, you may proceed with an inhalation induction with cricoid pressure maintained throughout. Once the child is asleep, the IV can be placed, relaxant given, and the endotracheal tube inserted.
(4) An oral gastric tube is used to suction out the stomach.
(5) At the conclusion of surgery, the patient is extubated awake. The approach to this type of patient is well summarized in Gregory, Pediatric Anesthesia, 1994, p 683.
The second issue in this case is that you are not a pediatric anesthesiologist. Los Angeles Times articles on February 24, and March 6, 2003, described an infant death and a near-death at a Southern California Kaiser hospital, when pediatric anesthesia care was given by a general anesthesiologist. This Kaiser hospital has adopted an interim policy to limit anesthesia care for patients under the age of 2 years to anesthesiologists with specialized pediatric training.
At Stanford University Medical Center and Packard Children’s Hospital, the University service has a team of pediatric anesthesiologists with specialized training who attend to each pediatric anesthetic. When private or University attendings reapply for medical staff privileges at Stanford every 2 years, we are required to tally the number of children we have anesthetized in the following age groups: (a) newborn to 6 months, and (b) 6 months to 6 years. A minimum number of cases is needed to maintain privileges.
Things are different at a community hospital, where a smaller team of anesthesiologists shares night call. Unless the hospital is very large, it is uncommon to have multiple specialist anesthesiologists on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and one for the general OR. It is common for general anesthesia practitioners to cover many or all specialties when they are on call. If they are not comfortable with an individual case, they can seek out a better trained anesthesiologist, if one is available. The trend for having a specialist anesthesiologist for every type of case, at all hours of the night and weekend, is a difficult one to staff. The decision to care for a patient at a community hospital is a judgment as to whether standards of care can be met with the physicians who are available.
In my opinion, neonates and young infants should be cared for by anesthesiologists with specialized pediatric training. Whether specialized training should be mandated for older children is debatable. Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic for the future.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: