SUCCESSFUL TEN-HOUR OUTPATIENT PEDIATRIC GENERAL ANESTHETICS FOR EAR COMBINED ATRESIA-MICROTIA RECONSTRUCTION
Richard J. Novak, M.D.
Adjunct Clinical Associate Professor of Anesthesia, Stanford University School of Medicine
Joseph Roberson, M.D.
California Ear Institute, Palo Alto, California
John Reinisch, M.D.
Cedar Sinai Hospital, Los Angeles, California and Children’s Hospital Los Angeles
The surgical team of Joseph Roberson, M.D. and John Reinisch, M.D. regularly performs Combined Atresia-Microtia (CAM) ear reconstruction surgery on children born without normal ear anatomy. The total anesthetic time for these surgeries regularly totals 9- 10 hours. These children, who are generally in good health other than their undeveloped ear, are observed in the recovery room for 1 – 1 ½ hours, and are then discharged home with their parents. As of 2016, the total number of CAM reconstructions have totaled over 250 cases. Surgeries are performed at California Ear Institute in East Palo Alto, CA, and Waverley Surgery Center in Palo Alto, CA. The text below describes a the anesthetic care for a typical CAM reconstruction.
A 5-year-old male was with congenital atresia and microtia of the left ear was scheduled for combined atresia repair and microtia reconstruction under general anesthesia. The estimated duration of the surgery was 9 hours, and the case was scheduled as outpatient surgery with no overnight stay planned. The child was healthy. A previous general anesthetic for adenoidectomy at the age of 2 was unremarkable. The child weighed 17 kg, and the physical exam was normal except for the deformed ear. One anesthesiologist administered the anesthetic care.
Premedication was oral midazolam 0.75 mg/kg. The well-sedated child was brought into the operating room 20 minutes later. Standard non-invasive monitors were applied, and a mask induction with 8% inspired sevoflurane was carried out. A 20-gauge IV was inserted into the left arm, and the trachea was intubated. Maintenance anesthesia was sevoflurane 1 – 1.5% end-tidal, nitrous oxide 50%, propofol infusion at 25 – 50 mcg/kg/min, and incremental doses of fentanyl as needed. Prophylactic antiemetics included ondansetron 2 mg, dexamethasone 4 mg, and metoclopramide 4 mg.
The operating room table was turned 180 degrees, the circulating nurse inserted a Foley catheter, and a Bair Hugger warming blanket was applied to the patient’s torso.
The surgical procedure was carried out by the otologist and plastic surgeon as previously described (1). Local anesthesia of bupivicaine 0.5% with 1/200,000 epinephrine was injected into the scalp and ear by the surgeons as indicated. The surgical procedure was combined atresia repair of the middle ear, reconstruction of the external auditory canal, and Medpor microtia reconstruction of an external ear. Total surgical time was 8 ½ hours.
A total of 160 mcg of fentanyl was administered. Total fluids for the case were 1000 ml of Lactated Ringers intravenously, and the estimated blood loss was 20 ml. Vital signs were stable throughout, and there was minimal physiologic perturbation. Esophageal temperature was maintained as normal.
In addition to two surgical attendings and one anesthesiologist, staffing included two R.N.’s and one scrub tech. The surgery concluded and the surgical dressing was applied 8 ½ hours after the induction of general anesthesia. The Foley catheter was removed. The anesthetics were discontinued, and the trachea was extubated when the patient opened his eyes. Post-operative pain was treated by incremental 5 mcg doses of intravenous fentanyl until the patient was comfortable and calm, and the patient was transferred to the recovery room. The parents were allowed into the recovery room 15 minutes after extubation. The patient was discharged from the facility 70 minutes after extubation. At the time of discharge, the patient was alert, pain-free, nausea-free, and tolerating oral fluids, and his Aldrete Score was 9.
This combined atresia and microtia repair, requiring a total anesthetic time approaching ten hours, is a new procedure being carried out by our surgical team. The atresia surgery involves a post-auricular incision, drilling through the mastoid to access the middle ear, and ossiculoplasty, tympanoplasty, creation and skin grafting of an external auditory canal as necessary to reconstruct the atresia. The microtia repair involves the implantation of the Medpor synthetic auricular prosthesis, and covering the prosthesis with skin grafts obtained from the patient’s abdomen. The surgical-anesthetic team to date has successfully performed the combined procedure on 55 patients, 90% of who were of the ages between 2 and 5 years old. All patients are ASA I – II, without significant medical comorbidity. Every procedure to date has been performed as an outpatient. Patients are discharged when their post-anesthesia care unit Aldrete Score reaches 8/10, and the family and physicians agree that the patient was stable to leave the facility. The discharge times vary between 70 – 100 minutes post-extubation for the 55 patients in our series, with a mean time of 91 minutes. Post-operative pain is well-controlled by the bupivicaine injected into the operative sites, and because of the minimal post-operative pain, it has been possible to discharge the patients home despite the very long duration of their endotracheal anesthetic.
None of the combined surgeries were performed in a hospital. The first 20 patients were operated on at a freestanding surgery center, 2 miles distant from the nearest hospital. Ten of the following 35 patients had their surgery in an operating room in the surgeon’s office. To date there have been no complications from the anesthetic management, and no admissions to a hospital or an emergency room following the combined procedures.
This case, one of 120+ in a series of similar cases, is noteworthy in that it markedly expands the boundaries of what is possible to safely accomplish with pediatric outpatient general anesthesia performed in a freestanding surgery center or in a surgeon’s office.
Outpatient pediatric surgery is increasingly common. In 2006, an estimated 2.3 million ambulatory anesthetics were provided in the United States to children younger than 15 years. Only 14,200 of these 2.3 million pediatric ambulatory anesthetics patients were admitted to the hospital postoperatively, a rate of 6 per 1000 ambulatory anesthesia episodes. In 1996, 26 per 1000 children under the age of 15 experienced ambulatory pediatric surgery, while in 2006 that statistic increased to 38 per 1000 children.
Parents are often more satisfied with outpatient surgery over post-operative hospitalization. (3) The advantages of outpatient surgery are significant: reduced costs, lower rate of infection, avoidance of hospitalization with the inherent psychological stress, and timely return of the patients to their familiar home environment. (4)
This case report is evidence that pediatric patients can be discharged safely following a prolonged outpatient anesthetic. Our current experience with such CAM reconstructions, exceeding 120 such cases without serious complication or adverse outcome, demonstrates that this combined procedure can be successfully carried out as an outpatient. The duration of an anesthetic is not in itself an indication for overnight hospitalization post-operatively. As well, selected pediatric ambulatory anesthetics of long duration can be safely performed in well-staffed operating rooms in a surgeon’s office, in addition to using a freestanding surgery center..
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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.
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