The morning report summarizes 18 surgical cases from June 10-13. The majority of cases were ASA class I or II. The largest proportion of cases were from general surgery. A post-tonsillectomy bleeding case on postoperative day 5 required cauterization. Key considerations for one-lung ventilation were discussed for a 12-year-old undergoing VATS biopsy for possible tuberculosis including goals for oxygen saturation and approaches for addressing hypoxemia.

1. Morning Report
Aalap Shah, MD
Jue Wang, MD
6.28.2016

2. 11
(61%)
4
(22%)
3
(17%)
# Procedures
I
II
III
ASA
Cases by ASA Classification

3. Cases by Surgical Service
10
(56%)5
(28%)
1 (5%)
1
(5%)
1
(6%)
# Procedures
GS
Ortho
OMFS
ORL
Onc

4. 0
2
4
6
8
10
12
GS Ortho OMFS ORL Onc
III
II
I
ASA
Cases by Surgical Service and ASA

5. Cases by Patient Age
0
1
2
3
4
5
6
7
8
9
0-1 mon 1-12 mon 1-2 year 3-11 year 12-17 yr 18+ yr

6. Weekend Cases 6/10-6/13
ASA 1 ASA 2 ASA 3
13 y/o M w/ LLE
laceration after ATV
accident  I&D
9 y/o M w/ appendicitis
 lap appy
1 d/o FT M w/
imperforate anus 
colostomy
4 y/o M w/ metastatic
Burkitt’s lymphoma and
lumbosacral involvement 
LP
3 y/o M w/ R.
supracondylar fx  CRPP
6 y/o M swallowed
wedding ring  EGD
removal FB
12 y/o M s/p IR
drainage of pleural
effusion  R. VATS
biopsy, pleurodesis
6 m/o F w/ recurrent
retinoblastoma, chemoRx 
CVL revision
2 y/o F with LLE FB 
removal FB
3 y/o F with spiral
femur fracture after
child fell on her
2 y/o M h/o MRSA
abscesses, buttock
abscess  I & D
7 y/o F with B-ALL s/p
induction chemoRx  port
revision
11 y/o F w/ open BBFx 
I&D + fixation
6 y/o M elbow fx after
monkey bars 
PP/repair
22 y/o F Pfeiffer’s sx,
POD11 s/p LeFort III w/
jaw wound  I & D
12 y/o F with pelvic rami
and iliac fx after horse
fell on her  ORIF b/l
pelvis
17 y/o M punched
window, R. wrist lac 
exploration/repair
20 y/o w/ tonsil bleed
POD4 s/p T&A 
cauterization

7. 20 y/o for T&A
HPI
• 20 y/o F with recurrent sore throat, R. ear
otalgia, fever, trismus
• PE: 3+ tonsils, reactive cervical
lymphadenopathy
• Scheduled for tonsillectomyPMHx:
- Chronic nasal congestion
- s/p septoplasty (6/2015)
- s/p wisdom teeth extraction
- L. ACL partial tear (2008)
- Concussion/post-concussive syndrome x 2
(9/2010, 5/2011)
Labs (4/2016)
CBC: WBC 9.8, Hct 37.0, Plt 260, PBS wnl
BMP: Na 139, K 3.7, Cl 103, CO2 27, BUN 15,
Cr 0.7
Blood Type: O+

8. 20 y/o for T&A
• Indications for tonsillectomy?
– Sleep-disordered breathing and sleep apnea
• Tonsillar hypertrophy (age 3-6); involution after age 8
• Children with sleep apnea benefit from tonsillectomy, although decreased
efficacy with obesity
– Severe recurrent sore throats
• Cochrane Review 11/2014: 3 vs 3.6 episodes/year (decrease in 0.6/year)
• Recurrent strep infection despite abx
– Various other relative indications (ex, Peritonsillar cellulitis/abscess, dental
malocclusion, hemorrhagic tonsillitis, prevention of secondary rheumatic fever)
• Comorbid conditions with long-standing disease?
– Pulmonary Hypertension, cor pulmonale
– OSA and “adult” comorbidities : DM, HTN, stroke
• How would you induce this patient?

9. 20 y/o - Anesthetic Plan?
• Pre-med: Midazolam
• Airway: 7.0 cETT, Mac 3, Gr 1 view
• Monitors: ASA Standard
• Induction: Propofol/Lidocaine/Fentanyl
• Analgesia: Acetaminophen
• Anti-emetics: Dexamethasone / Ondansetron
NSAIDs also work
• IV Fluids: LR 900cc
• Discharge Rx: Acetaminophen, Oxycodone

10. 20 y/o - Anesthetic Plan?

11. T&A POD 5…
•  BCH ED after spitting up ~1.5 tbsp. of BRB
while taking PO
• To OR for Tonsillar cauterization
– Labs? Hydration? IV?
• WBC 9.8, Hct 37.0, Plt 260, PBS wnl
– Findings: bleeding from R. tonsillar fossa; b/l inferior
poles, EBL “minimal”

12. T&A POD 5…
• What are some common complications?
• Does age or time course of bleeding matter?
• How will you induce her now?
– RSI, Propofol/Succinylcholine

13. Cauterization POD 5…

14. Tonsillectomy: Management Pearls
• Children who undergo the procedure for OSA are at particularly high risk
of significant respiratory complications in the postoperative period
• Complications:
– Pre-: Turbulent flow with anxiety/rapid breathing
– Induction: Laryngospasm (↑ incidence vs. general population)
– Intra: secretions, laryngospasm with extubation
– Post: PONV, hypopnea, bleeding*
• Who should be observed overnight?
– Pts. With OSA or evidence of RH dysfunction
The airway is shared between the anesthesiologist and the surgeon and
must be protected from blood and secretions.

15. Tonsillectomy: Bleeding Management
• Post-Tonsillectomy hemorrhage rates = 1.9 –7%
– Undiagnosed bleeding disorders!
• Does timing of bleeding make a difference?
– First 24 hrs: More severe bleeding (usually in first 6 hours) 
associated with “cold steel”
– Secondary 5-10 days, after eschar falls off  associated with cautery
• Mucosa involution
• Does age make a difference?
– ↑ Incidence with ↑ Age (age 21-30: ~3.7%)
– Prior hemorrhage  ~12% risk for repeat hemorrhage
• If bleeding significant, may not be able to obtain Hgb in time
– ↓ baseline SpO2: ominous for ↓ dO2 (d/t anemia)

16. ASA 1 ASA 2 ASA 3
13 y/o M w/ LLE
laceration after ATV
accident  I&D
9 y/o M w/ appendicitis
 lap appy
1 d/o FT M w/
imperforate anus 
colostomy
4 y/o M w/ metastatic
Burkitt’s lymphoma and
lumbosacral involvement 
LP
3 y/o M w/ R.
supracondylar fx  CRPP
6 y/o M swallowed
wedding ring  EGD
removal FB
12 y/o M s/p IR
drainage of pleural
effusion  R. VATS
biopsy, pleurodesis
6 m/o F w/ recurrent
retinoblastoma, chemoRx 
CVL revision
2 y/o F with LLE FB 
removal FB
3 y/o F with spiral
femur fracture after
child fell on her
2 y/o M h/o MRSA
abscesses, buttock
abscess  I & D
7 y/o F with B-ALL s/p
induction chemoRx  port
revision
11 y/o F w/ open BBFx 
I&D + fixation
6 y/o M elbow fx after
monkey bars 
PP/repair
22 y/o F Pfeiffer’s sx,
POD11 s/p LeFort III w/
jaw wound  I & D
12 y/o F with pelvic rami
and iliac fx after horse
fell on her  ORIF b/l
pelvis
17 y/o M punched
window, R. wrist lac 
exploration/repair
20 y/o w/ tonsil bleed
POD4 s/p T&A 
cauterization
Weekend Cases 6/10-6/13

17. 12 y/o M for VATS biopsy
HPI
• P/w fever, cough, myalgias, congestion, nausea,
vomiting, sore throat, intermittent H/A
• Dx PNA 3 months ago with mild R. pleural effusion
• Treated with CTX  complete resolution (per CXR)
PMHx: Born at at 31wks, 2-wks in NICU intubated; Otherwise Healthy
SocHx: From Sudan, travelling through Istanbul to US
PE: Lethargic
- CBC: [6/2]: WBC 5.5, Hct 36, PLT 455; ESR 62, CRP 10, LDH 176  264
- CXR [6/2]: RML/RLL consolidation + R. effusion: c/fPNA + parapneumonic effusion
- CT [6/2]: R. pleural effusion with pleural thickening,
mediastinal + hilar LN: c/f empyema
- Nl ECHO, respiratory cultures, ANA, pleural fluid flow cytometry and various bacterial/fungal cx
 Received CG in Sudan, started on Vancomycin/ceftriaxone at BCH
- To IR 6/3: PICC, 10Fr pigtail CT  825 ml serous straw-colored fluid (+400cc up to 6/10)
- Negative induced sputum AFB x 3, but persistent fevers…
- 6/8: Positive Tspot and slightly elevated ADA (suggestive of isolated TB effusion)  VATS

18. 12 y/o M for VATS biopsy
• How will you induce this patient and secure airway?
• What are the absolute indications for single/one-lung
ventilation? How can you achieve it?
– Protection (Blood/Pus/need for lavage)
– Vt mismatch (BP/BPCF, ominous bullae, bronchial
disruption)
– VATS
• In addition to ASA standard monitors, what else would
you like to look at?
– Spirometry
– Reliable Pulse oximeter!!!
– ART (Measure PO2(A-a) gradient)

19. OLV - Approach
• Age < 8 yrs
– Mainstem intubation +/- FOB, active/passive ipsilateral decompression
• PRO: Single airway maneuver
• CON: Cannot apply CPAP to nondependent lung; must withdraw tube for TLV
– Bronchial Blocker (individual, coaxial)
• PRO: ETT in situ
• CON: No passive oxygenation to dependent lung, inexperience
• Age > 8 (26+ F)
• Robertshaw tubes (DL ETT)
– PRO: Seals/protects lung (suppurative pus), passive oxygenation and application of PEEP
to dependent lung
– CON: Decreased airway diameter  SLETT exchange for ICU, balloon herniation,
inexperience, size
DLETT Placement: OpenAnesthesia.org

20. 12 y/o - Anesthetic Plan?
Pre-med: IV Midazolam
Airway: 6.5 cETT, Mac 3, Gr 1 view 
EZ Blocker (41 min)
Monitors: ASA Standard
Induction: IV Propofol/Fentanyl
Analgesia: IV Morphine/Ketorolac
Anti-emetics: IV Dexamethasone/Ondansetron
IV Fluids: LR 300cc

21. 12 y/o - Anesthetic Plan

22. OLV - Hypoxemia
• What are your SpO2 goals for this patient?
– What happens to PaO2 with OLV? For how long does
this last?
• What are some predictors of hypoxemia?
• What do you do?
– FOB
– CPAP 10mmHg (at what lung volume? Contraindications?)
– PEEP (dependent lung)
– Pause surgery/OLV
– Compress/clamp ipsilateral PA

23. OLV Hypoxemia - Pearls
• Incidence of hypoxemia (with FiO2 1.0):
– 1950s 20%, 1980s 10%, Today 1%
• V/Q mismatch + shunt (↑ with open chest)
• Prediction of Hypoxemia:
– Hypoxemia (increased A-a pO2 gradient) during TLV
– R > L (higher paO2 in PV return from L side)
– GOOD spirometric PFTs
• Don’t have auto-PEEP
– Baseline restrictive lung disease or severe COPD
• Avoid aggressive hyperventilation
– ↓CO2 Inhibits beneficial hypoxic pulmonary vasoconstriction
in ipsi lung
– Increased alveolar pressures ↓ PBF in dependent lung

24. OLV Hypoxemia – Infants
1. Easily compressible rib cage  promotes atelectasis of the
dependent (ventilated) lung
2. ↓ hydrostatic pressure gradient between the dependent and
nondependent lungs  expected increase in dependent PBF is
diminished
3. ↓ abdominal hydrostatic pressure gradient  ↓ functional
advantage of dependent diaphragm
4. ↑ VO2

25. OLV Hypoxemia - Algorithm

26. Thank You!
• Jue Wang, MD
• Thomas Mancuso, MD [Course Director]
• Carlos Munoz-San Julian, MD; Izabela Leahy,
RN BSN MS [Course Planners]