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Challenging Cases in Pediatric Anesthesia

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Challenging Cases in Pediatric Anesthesia

  1. 1. Bad cases, Strange cases & Legal cases Jerrold Lerman BASc, MD, FRCPC, FANZCA Clinical Professor of Anesthesiology Women’s & Children’s Hospital of Buffalo, SUNY and Strong Memorial Hospital, University of Rochester, New York
  2. 2. Ambulatory surgery <ul><li>History: </li></ul><ul><ul><li>8 year old T&A outpatient </li></ul></ul><ul><ul><li>Late am arrival in community hospital </li></ul></ul><ul><ul><li>Prean nurse notified MD in the OR </li></ul></ul><ul><ul><li>Weight: 85 kg </li></ul></ul><ul><ul><li>Nursing h x : Ebstein's anomaly…&quot;not sure what it is, will search it on the internet&quot; </li></ul></ul><ul><ul><li>In the meantime, 15 mg PO midazolam </li></ul></ul>
  3. 3. Ambulatory Surgery <ul><li>Course: </li></ul><ul><ul><li>Within 5 min of PO midazolam, nurse started IV </li></ul></ul><ul><ul><li>Child sitting on the guerney </li></ul></ul><ul><ul><li>Rolled his eyes and lost consciousness </li></ul></ul><ul><ul><li>What do you do? </li></ul></ul><ul><ul><li>Face mask, 100% oxygen, Observed ECG </li></ul></ul><ul><ul><li>15 minutes before tracheal intubation </li></ul></ul><ul><ul><li>No definitive diagnosis… </li></ul></ul>
  4. 4. Ambulatory Surgery <ul><li>Considerations: </li></ul><ul><ul><li>Morbid Obesity </li></ul></ul><ul><ul><ul><li>Chronic hypoxemia </li></ul></ul></ul><ul><ul><ul><li>↓ cardiac function </li></ul></ul></ul><ul><ul><li>OSA: nocturnal hypoxemia </li></ul></ul><ul><ul><ul><li>Sensitivity to opioids ± benzos </li></ul></ul></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>OSA </li></ul></ul></ul><ul><ul><li>Ebstein's anomaly </li></ul></ul><ul><ul><ul><li>Tricuspid regurgitation </li></ul></ul></ul><ul><ul><ul><li>?ASD </li></ul></ul></ul><ul><ul><ul><li>WPW </li></ul></ul></ul>Right ventricular failure !
  5. 5. Cardiac Arrest in the OR <ul><li>Surgeon: </li></ul><ul><ul><li>Healthy 10 y.o. child, outpatient surgery </li></ul></ul><ul><ul><li>Just a little (hard) cervical node biopsy…. </li></ul></ul><ul><ul><li>Proceed? </li></ul></ul><ul><ul><li>Any tests? </li></ul></ul>
  6. 7. Case Presentations <ul><li>Just a little node biopsy: </li></ul><ul><ul><li>Induction of anesthesia </li></ul></ul><ul><ul><li>Tracheal intubation with a non-depolarizing relaxant </li></ul></ul><ul><ul><li>Cardiac arrest! </li></ul></ul><ul><ul><li>Management? </li></ul></ul><ul><ul><ul><li>Position </li></ul></ul></ul><ul><ul><ul><li>Position </li></ul></ul></ul><ul><ul><ul><li>Position </li></ul></ul></ul>
  7. 8. Simple hernia or not! <ul><li>Anesthetic: </li></ul><ul><ul><li>13 kg 2 year old male for hernia repair </li></ul></ul><ul><ul><li>Intravenous induction with thiopental, atropine and succ. and tracheal intubation; </li></ul></ul><ul><ul><li>Maintenance: 1% halothane in N 2 O </li></ul></ul><ul><ul><li>IPPV </li></ul></ul><ul><ul><li>Within 5 min, after the first automatic BP, bradycardia and cardiac arrest occurred. </li></ul></ul><ul><ul><li>Child died on the table!!! </li></ul></ul><ul><li>Why? </li></ul>
  8. 9. Vaporizer design

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