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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 a penetrating open eye injury, and is taken to the nearest hospital. You are on call for the repair. You’re are an experienced practitioner, but not a pediatric anesthesia specialist. What do you do?
Discussion: There are two issues. One is how to safely perform the open-eye, full stomach anesthetic, and the other is the performance of 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). Sudden increases in IOP in patients with an open globe injury can lead to vitreous loss and blindness. The list of things that increase IOP and risk further eye damage includes crying, coughing, the Valsalva maneuver, vomiting, firm pressure with an anesthesia face mask, laryngoscopy, and endotracheal intubation. Ketamine and succinylcholine also increase IOP. Trying to start an IV without causing crying and the attendant increase in IOP in a 3-year-old can be difficult.
True ophthalmic emergencies (e.g. central retinal artery occlusions or chemical burns) must be treated within minutes to avoid blindness or permanent vision loss. A penetrating open globe injury is usually urgent, rather than emergent. At times urgent procedures are delayed until the patient has been fasting for 6 hours, and has an appropriate NPO status.
Let’s assume your surgeon is determined to operate urgently, and doesn’t want to wait 6 hours after the patient’s meal. In his judgment delaying the surgery would increase the patient’s risk of loss of vision.
No single approach to this patient is ideal, but a proposed approach is:
- Apply EMLA cream with an occlusive dressing over several potential IV sites 45-60 minutes before the IV attempt. Next give the boy an oral midazolam premedication (0.67 mg/kg), and wait until he becomes sedated enough to start an intravenous line.
- Once the IV is in place, a modified rapid sequence induction is done with cricoid pressure, using rocuronium as the muscle relaxant. A dose of 1-1.5 mg/kg is used to speed the pace of neuromuscular blockade. With the availability of sugammadex to reverse deep rocuronium motor block, the risks of a high dose of rocuronium in this setting are minimal. A nerve stimulator is used to confirm that depth of muscled blockade is adequate, to avoid any 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 tonic increase (4-20 minutes) in extraocular muscle tone, which causes an increase in IOP of 10 to 20 mm Hg.
- If the child has chubby arms, hands, ankles and feet, and you are not able to place the IV despite adequate oral sedation, you may proceed with an inhalation induction. Utilize sevoflurane with cricoid pressure maintained throughout. Once the child is asleep, the IV can be placed, relaxant given, and the endotracheal tube inserted.
- An oral gastric tube is used to suction out the stomach.
- Controlled ventilation is recommended, to insure the field is quiet for the surgeon.
- At the conclusion of surgery, because of the full stomach, the patient is extubated awake. For tips on a smooth emergence, see my column on Smooth Emergence from Anesthesia.
- Postoperative nausea and vomiting can increase IOP. Prophylactic IV ondansetron is recommended.
- Postoperatively, a pain-free child will cry less and have fewer increases in IOP. The surgeon should consider a regional block of the eye to decrease the need for postoperative narcotics.
The second issue in this case is that you’re not a pediatric anesthesiologist. A children’s hospital or a university hospital will have a team of pediatric anesthesiologists with specialized training on call for emergencies. Call schedules and staffing are different in community hospitals, where a smaller team of anesthesiologists shares night call. Unless the hospital is very large, it’s uncommon to have anesthesiologists of multiple specialties on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and one for the general operating rooms. It’s common for general anesthesia practitioners to cover many or all specialties when they’re on call. If the on-call anesthesiologist is not comfortable with an individual case, he or she can seek out and call in a better-trained anesthesiologist, if one is available. The goal of producing 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 this patient at a community hospital at all is a judgment as to whether standards of care can be met with the physicians who are available. I’m double-boarded in internal medicine and anesthesiology, and have no extra post-graduate training in pediatric anesthesia, yet I have cared for children age 10 months and over for over 30 years. I consider myself expert and confident in the anesthesia care of children of these ages in a community setting.
In my opinion, neonates and younger infants need anesthesiologists with specialized pediatric training. Whether specialized training should be mandated when anesthesiologists care for older children is debatable. Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic in the future.
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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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