THE CHILD WITH AN OPEN EYE INJURY AND A FULL STOMACH

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

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?

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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:

  1. 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.
  2. 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.
  3. 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.
  4. An oral gastric tube is used to suction out the stomach.
  5. Controlled ventilation is recommended, to insure the field is quiet for the surgeon.
  6. 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.
  7. Postoperative nausea and vomiting can increase IOP. Prophylactic IV ondansetron is recommended.
  8. 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.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

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Will I Have a Breathing Tube During Anesthesia?

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How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

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Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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.

KIRKUS REVIEW

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:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: WHY DO I HAVE TO STOP EATING AND DRINKING AT MIDNIGHT BEFORE SURGERY?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

“Why do I have to stop eating and drinking prior to surgery?” This is a common question I hear from my patients—they’re puzzled by the connection between going to sleep and stopping eating prior to surgery.

 

It’s vital that your stomach is empty prior to elective surgery and anesthesia. Once you’re anesthetized, your cough reflex and gag reflex are abolished. These reflexes prevent food or liquids from entering your windpipe or your lungs, and are life-protecting reflexes in awake, healthy humans.

Under anesthesia these reflexes are absent. If you vomit or regurgitate stomach contents into your mouth, the material can descend into your windpipe or lungs. The complication of stomach contents entering your lungs is a dire event. The medical term for this occurrence is aspiration pneumonia. Aspiration refers to inhaling, and pneumonia refers to an inflammation of the lung tissue. In severe aspiration pneumonia, the lungs fail to exchange oxygen from the airways into the bloodstream, and brain and heart oxygen levels can drop to life-threatening lows.

The American Society of Anesthesiologists guidelines for fasting prior to elective surgery requiring general anesthesia, regional anesthesia, or conscious sedation/analgesia are as follows:

Fried or fatty foods                                                8 hours

A light meal (toast and clear liquids)                     6 hours

Non-human milk                                                    6 hours

Breast milk                                                             4 hours

Infant formula                                                         4 hours

Clear liquids                                                            2 hours

Clear liquids may be consumed up to 2 hours prior to anesthesia. Clear liquids include water, fruit juices without pulp, soda beverages, Gatorade, black coffee or clear tea. Milk and thick juices with pulp are not clear liquids.

These fasting guidelines do not apply to surgical procedures under local anesthesia, or to those with no anesthesia. You don’t have to fast for a dentist office visit, for example. The guidelines do apply for colonoscopies or upper gastrointestinal endoscopy procedures. The intravenous sedation drugs used for endoscopy procedures may sedate you to a deep enough level such that your gag and cough reflexes are absent.

In certain conditions, the stomach will be considered to be full even if the patient has not eaten or consumed fluids for eight hours. Acute pain syndromes such as appendicitis, a gall bladder attack, a broken bone, or a febrile illness are known to diminish the stomach’s emptying, and anesthesiologists treat these patients as if they had a full stomach whether they’ve fasted or not. Pregnant women and morbidly obese patients are also treated as having full stomachs for any surgery, because of delayed stomach emptying due to increased intra-abdominal pressure.

If a patient presents for emergency surgery, the anesthesiologist must proceed without waiting for the recommended fasting times. On induction of general anesthesia, the physician anesthesiologist will have a second individual (a nurse or a physician) apply downward pressure on the cricoid cartilage of the patient’s neck immediately upon loss of consciousness. The science of this is as follows: the circumferential ring of the cricoid cartilage encircles the windpipe.

Pushing downward on this ring compresses the esophagus below, to prevent passive regurgitation or vomiting of stomach contents. This pressing-down maneuver is called “giving cricoid pressure” or “the Sellick Maneuver,” named after Dr. Brian Arthur Sellick, the anesthesiologist who first described the maneuver in 1961. Inducing anesthesia using the Sellick maneuver is referred to as a Rapid Sequence Induction (RSI) of general anesthesia. In a RSI the anesthesiologist administers into the patient’s intravenous line: 1) a hypnotic drug such as propofol, followed by 2) a rapid paralyzing drug such as succinylcholine. The endotracheal breathing tube can then be placed in the windpipe within about 30 seconds after the loss of consciousness. The Sellick maneuver is held throughout those 30 seconds until medical confirmation that the tube is in the windpipe.

If stomach contents enter the upper airway at any time during an induction of anesthesia, the anesthesiologist will see vomitus in the patient’s mouth or inside the clear plastic facemask. The anesthesiologist may also detect evidence of inadequate oxygen exchange—i.e. the patient’s pulse oximeter readings will decline to less than the safe level of 90%. The anesthesiologist will then suction the upper airway and place a breathing tube into the windpipe as soon as possible. This tube is called an endotracheal tube, and it has a balloon near its tip. When inflated, the balloon protects stomach contents from descending into the lungs.

The anesthesiologist will then suction out the lungs through the inside the breathing tube. Suction catheters of varying length and diameters exist for this purpose. The surgery will likely be cancelled if it has not yet started. If the aspiration of stomach contents occurs in the middle of surgery, it’s likely the surgery will be aborted or shortened.

As I have written in multiple posts on this website, all critical care medicine resuscitation follows the A-B-C mantra of Airway—Breathing—Circulation. The regurgitation of stomach contents interferes with both A and B by blocking the airway and interfering with breathing.

The medical term for fasting prior to surgery is NPO, which stands for “nil per os,” a Latin phrase for nothing per mouth. If you hear your doctor or nurse say, “Is she NPO?” they’re asking the important question of whether you have fasted as required. Being NPO may seem inconvenient and unnecessary, but it’s critical to assure your health and well being during anesthesia.

Reference: Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters, 2011; Anesthesiology, Vol 14(3), 495-511.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

*
*
*
*

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.

KIRKUS REVIEW

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:

41wlRoWITkL

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

DSC04882_edited