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Clinical Case: In your first week in community practice post-residency and fellowship, you’re scheduled to anesthetize a 4-year-old for a tonsillectomy. You’ll start the anesthetic without an attending or a second anesthesiologist. How do you start a pediatric anesthetic alone?
Discussion: During residency it’s standard to initiate pediatric cases with an attending at your right hand to mentor and assist you through the induction of anesthesia. The second pair of hands is critical—one of you manages the airway for the inhalation induction, and the second anesthesiologist starts the IV. In community practice you’ll have to manage all this yourself.
A significant percentage of pediatric anesthetics are performed in regional hospitals and surgery centers rather than in pediatric tertiary hospitals. How does the community practice of pediatric anesthesia differ from pediatric anesthesia in residency?
In community practice you’ll likely telephone the parents the night prior to surgery to discuss the anesthetic. It’s uncommon for a 4-year-old and his family to visit any pre-anesthesia clinic. You’ll take a history over the phone from the parents, explain the basics of anesthetic care, and answer any questions they have.
On the morning of surgery you’ll meet the parents and the child. It’s likely you’ll prescribe an oral midazolam premedication. You’ll set up your operating room with appropriate sized pediatric equipment, heeding the M-A-I-D-S mnemonic for Machine and Monitors-Airway-IV-Drugs-Suction.
What about a request from the mother and/or father to accompany the child into the operating room? This author advises against bringing parents into the O.R. Instead premedicate the child to minimize the emotional trauma of separation from the parent(s), and explain that the duration of time from when they hand you their child to when the gas mask is applied will only be a few minutes.
It’s common to induce anesthesia with the child in a sitting position. The one most important monitor you can place prior to induction is the pulse oximeter. Once unconsciousness is attained, the child is laid supine and a pretracheal stethoscope, the ECG leads, and the blood pressure cuff are applied. If you’re not using a pretracheal stethoscope during mask inductions, let me recommend it to you. No other monitor gives you immediate information on the patency of the airway like the stethoscope does. You can remedy partial or total airway obstruction more promptly than if you wait for oxygen desaturation or end-tidal CO2 changes.
Most children have an easy airway and require no more than occasional positive airway pressure via the mask to keep spontaneous ventilation open. Young children scheduled for tonsillectomy sometimes carry the diagnosis of obstructive sleep apnea (OSA) based on a clinical history of snoring, noisy breathing, or daytime somnolence. It’s uncommon for these patients to have a formal sleep study to document OSA. OSA children may have more challenging airways and have an increased incidence of partial airway obstruction during inhalation induction.
In residency I was taught to supplement the potent volatile anesthetic (halothane in decades past) with 50-70% nitrous oxide. Because the blood:gas partition coefficient of sevoflurane is 0.65, comparable to nitrous oxide’s 0.45, anesthetic induction with sevoflurane alone is nearly as fast as sevoflurane-nitrous oxide. The addition of nitrous oxide to the induction mix is unnecessary, and using an FIO2 of 1.0 affords an extra cushion of oxygen reservoir if the airway is difficult or if the airway is lost.
How will you start the IV after induction? There are several options: 1) You can ask the surgeon or a nurse to start the IV. In my experience, neither surgeons nor O.R. nurses are as skilled in starting pediatric IV’s as an anesthesiologist is, so I don’t recommend this plan; 2) You can ask the surgeon or the O.R. nurse to hold the mask and manage the airway while you start the IV. This option is safe if the airway is easy and you trust the airway skills of the other individual; 3) You can stand at your normal anesthesia position, hold the mask over the patient’s airway with your left hand, and ask the nurse to bend the patient’s left arm back toward you. The nurse tourniquets the patient’s arm at the wrist, and with your right hand you perform a one-handed IV start in the back of the patient’s left hand; 4) The option I feel most comfortable with is to fit mask straps behind the patient’s head, and secure the mask in place with the four straps after the patient is fully anesthetized (when their eyes have returned to a conjugate gaze). While the straps hold the mask in place, you listen to the patient’s breathing via the pretracheal stethoscope to assure yourself that the airway is patent. Then move to the left-hand side of the table and start the IV in the child’s left arm. The typical length of time away from the airway should be less than one minute. If the child has no obvious veins, fit the automated blood pressure cuff (in stat mode) on top of the tourniquet on the upper arm. The BP cuff is a superior tourniquet and the inflated cuff makes it easier to find a suitable vein.
Once the IV is in place, proceed with intubating the patient. In community practice the surgical duration of tonsillectomies can be very short, so the choice of muscle relaxant is important. Succinylcholine carries a black box warning for non-emergent use in children, and should not be used for elective intubation. You can: 1) administer rocuronium and later reverse the paralysis with neostigmine plus atropine; 2) administer a dose of propofol, e.g. 2 mg/kg, which blunts airway reflexes enough to allow excellent intubating conditions in most patients; or 3) you can do perform two laryngoscopies, the first to inject 1 ml of 4% lidocaine from a laryngotracheal anesthesia (LTA) kit, and another 30 seconds later to place the endotracheal tube in the now-anesthetized trachea. Some anesthesiologist/surgeon teams prefer an LMA rather than an endotracheal tube. LMA use for tonsillectomy is not routine in our practice, but one advantage is that an LMA does not require paralysis for insertion.
What if you’re working alone and your patient develops acute oxygen desaturation with airway obstruction and/or laryngospasm during inhalation induction before any IV has been placed? What do you do?
If you anesthetize enough children you will have this experience, and it can be frightening. The immediate management is to inject succinylcholine 4 mg/kg plus atropine 0.02 mg/kg intramuscularly, usually into the deltoid. Then you do your best to improve mask ventilation using an oral airway or LMA if necessary. The oxygen saturation may dip below 90% for a short period of time while you wait for the onset of the intramuscular paralysis. Once muscle relaxation is achieved, ventilation should be successful and the oxygen saturation will climb to a safe level. The trachea can then be intubated, and an IV can be started following the intubation.
If such a desaturation occurs, should you cancel the case? It depends. I’d recommend cancelling the case if: 1) the duration of the oxygen saturation was so prolonged that you are worried about hypoxic brain damage; or 2) gastric contents are present in the airway and you are concerned with possible pulmonary aspiration.
Working pediatric cases alone is rewarding as well as stressful. Nothing in my practice brings me as much joy as walking into the waiting room following a pediatric case to inform parents their child is awake and safe. The parents are relieved, and watching the mother-child reunion minutes later in the Post Anesthesia Care Unit is a heart-warming experience.
Not all anesthesiologists will choose to do pediatric cases during their post-residency career. If you will be anesthetizing children alone in community practice, it’s a good idea toward the end of your anesthesia residency or fellowship to ask your pediatric anesthesia attending keep their hands off during induction, so you can hone your skills managing both the airway and IV. That way you’ll be ready and capable of inducing a child alone after you leave training.
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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.
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: