10-HOUR OUTPATIENT PEDIATRIC ANESTHETICS FOR COMBINED ATRESIA-MICROTIA (CAM) EAR RECONSTRUCTION

 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

Introduction

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.

Case Report

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.

Discussion

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..

References:

(1)     Roberson JB Jr, Reinisch J, Colen TY, Lewin S. Atresia repair before microtia reconstruction: comparison of early with standard surgical timing.  Otol Neurotol. 2009 Sep;30(6):771-6.

(2)     Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of ambulatory anesthesia for children in the United States: 2006 and 1996.  Anesth Analg. 2010 Oct;111(4):1011-5. Epub 2010 Aug 27.

(3)     Erden IA, Pamuk AG, Ocal T, Aypar U. Parental satisfaction with pediatric day case surgery.Middle East J Anesthesiol. 2006 Oct;18(6):1113-21.

(4)     Mehler J.  Analgesia in pediatric outpatient surgery. Schmerz. 2006 Feb;20(1):10-6.

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Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:

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Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.

TwinCities.com PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press mgrossman@pioneerpress.com, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.

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The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:

BOOK REVIEW “THE DOCTOR AND MR. DYLAN”

This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

By

allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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3 thoughts on “10-HOUR OUTPATIENT PEDIATRIC ANESTHETICS FOR COMBINED ATRESIA-MICROTIA (CAM) EAR RECONSTRUCTION

  1. Hi. I am a relatively new attending anesthesiologist in Israel working in an academic hospital. I particularly like your blog because you’re teaching so much of the important stuff not in text books.

    What do you do in a 10hr outpatient op regarding Toilet breaks, lunch?

    Thanks for the great articles
    Joel

    Like

    1. We take quick bathroom breaks as needed, leaving the circulating RN to watch the monitors while we are absent. In a 10-hour case, it’s relatively easy to find a 2-minute window when the patient is very stable to do this. Likewise, we step outside for quick intervals to eat small amounts, again leaving the circulating RN to watch the monitors while we are absent. The RN can recall us to the OR within seconds if anything changes regarding the patient. With the judgment of experienced anesthesia attendings, such brief breaks are safe.

      Like

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