Book 6, Case 3-Pedi strabismus

Question 1

Succinylcholine in pedi pt if you couldn’t get LMA (pt still stable) This is a strabismus case

Answer 1

I would prefer not to use succinylcholine for this case because it may interfere
with the forced duction test often used during strabismus surgery (it may interfere with the
test for up to 20 minutes), and due to the risk of undiagnosed muscular dystrophy in this
patient < 8 years of age

Question 2

You give sux and then stiff jaws-what’s your DDx?

Answer 2

• masseter muscle rigidity
• undiagnosed muscular dystrophy
• MH

Question 3

Why is MMR concerning? and does it typically inhibit ventilation?

Answer 3

b/c it can suggest a susceptibility to MH. It doesn’t usually inhibit ventilation. Due to this risk of developing MH or rhabdo. Rhabdo can sometimes happen independent of MH in MMR

Question 4

What should yuou do with MMR (assuming the pt is okay and it resolves)

Answer 4

Elective case cancelled and pt admitted to hopsital for 12-24 hours for monitoring of possible moglobinuria, myalgias, or rigidity. Thye should also have a neurology evaluation fro presence of occult myopathy and close monitoring of electrolytes.

Question 5

You gonna suggest that pt with MMR get Caffeine Halothane Contacture test?

Answer 5

I would recommend it to evaluate susceptibility to MH, but I would relay that I understand that the test would require expenses and that they could also always alert the anesthesiologist

Question 6

You administering prophylactic dantrolene? Why or why not?

Answer 6

Nah. Dantrolene has side effects of nausea and vomiting-but threshold for tx is low in pts

Question 7

How do you prepare for MH cases?

Answer 7

In addition to all the vaporizer stuff you know, also ensure that MH cart nearby, Ice nearby

Question 8

HR falls to 62 during strabismus surgery-what are you thinking? Wyd?

Answer 8

Thining: oculocardiac reflex.
Ask surgeon to stop
Thenensure oxygenation and ventilation, evaluate rhythm and bp, assess volume and anesthetic depth-insufficient depth could lead to cardiac depression
Consider administration of IV atropine if that doesn’t work. Dose: 0.02 mg/kg

Question 9

What is the oculocardiac reflex?

Answer 9

The afferent limb of the reflex
involves the ciliary nerves and ophthalmic division of the trigeminal nerve, while the efferent
limb is the vagal nerve. Stimulation of this reflex, which may occur under local or general
anesthesia, most commonly results in bradycardia, but can lead to a wide variety of cardiac
dysrhythmias.

Question 10

PACU calls you because your strabismus kid with MMR now has HR of 118-wyd?

Answer 10

First I would evaluate the patient’s volume status and ensure adequate pain
control, oxygenation, and ventilation, and ensure that pressure is okay.

Next, given the fact that there is an increased
incidence of MH in patients who experience an episode of significant MMR, I would
evaluate the patient for other signs of MH such as generalized rigidity, tachypnea, changes in
blood pressure, arrhythmias, increased temperature, peripheral mottling, rhabdomyolysis (tea
colored urine), sweating, and cyanosis.

If optimization of the patient’s ventilation, volume
status, and pain control did not resolve the tachycardia, I would obtain an arterial blood gas
(decreased P02, metabolic and respiratory acidosis) and check for hyperkalemia,
hypercalcemia, myoglobinemia, and elevated serum creatine kinase.

Question 11

initial stages of MH reaction may show a blood gas with what? What are you going to do if that blood gas is accompanied by an unlabored pt?

Answer 11

during the initial stages of a MH reaction an arterial blood gas
may show a nearly pure respiratory acidosis. So if this happens in pts who seem like theyre brathing okay:if the patient’s ventilation appeared
adequate, I would order a mixed or peripheral venous blood gas and, if the results indicated a
hypermetabolic state (Pv02 < 40 mmHg despite supplemental oxygen due to increased
oxygen consumption), initiate aggressive treatment.

Question 12

How will you manage a pt with suspected MH who is extubated and in PACU?

Answer 12

I would: (1) call for assistance; (2) hyperventilate the patient with 100%
oxygen by face mask;(3) administer dantrolene (2.5 mg/kg ofDantrolene every 5-10 minutes
as necessary to control symptomatology); ( 4) maintain urine output with intravenous fluids,
mannitol, and lasix; (5) monitor urinary output, potassium, calcium, and arterial blood
gasses; (6) order serum creatine kinase, liver function tests, and a coagulation profile; and (7)
treat hyperkalemia (dextrose and regular insulin), acidosis (bicarbonate-only if you know what!), hyperthermia (cold
intravenous fluids; ice packs over major arteries of the groin and axilla; gastric, bladder,
rectal, and wound lavage; cold peritoneal dialysis; and even cardiopulmonary bypass),
rhabdomyolysis (mannitol), and dysrhythmias as necessary. Finally, after resolution of the
crisis, I would (8) continue intravenous dantrolene, 1 mg/kg every 6 hours, for 24-48 hours to
prevent relapse; and (9) monitor the patient for up to 72 hours in the ICU for signs of
disseminated intravascular coagulation, myoglobinuric renal failure, and recrudescence
(relapse).

Question 13

When should active cooling be stopped in MH?

Answer 13

Active cooling should be discontinued when the temperature drops
to 38-38.5 °C to prevent hypothermia.

Question 14

How long would you continue dantrolene after the patient’s ABGs returned to normal?

Answer 14

I would continue dantrolene, 1 mg/kg every 6 hours,
for 24-48 hours, because up to 25% of patients may experience relapse within the first 24
hours.

Question 15

After MH episode, pt has urine output of 0.5 mL/kg/hr-you concerned?

Answer 15

Although this is normal, it is on the edge of being abnormal. I wouldattempt to improve urine output
by administering intravenous fluids and mannitol or lasix. In addition, if the patient’s urine
was acidic, I would give bicarbonate to help prevent renal tubule injury (helps prevent cast
formation).

Question 16

What’s a reasonable strategy for managing a child with respiratory infection?

Answer 16

(1) delay
surgery for 4-6 weeks whenever severe symptoms such as fever> 38.5 °C, (101.3) productive cough,
mucopurulent secretions, malaise, and pulmonary involvement are present (an example of the
latter would be wheezing that does not clear with coughing); (2) delay surgery for 2-4 weeks
when patients with mild symptoms (i.e. sneezing, mild nasal congestion, and nonproductive
cough) require ETT placement and have additional risk factors, such as second-hand smoke
exposure and/or underlying pulmonary disease (i.e. asthma); and (3) proceed with surgery
when patients with mild symptoms do not require ETT placement (i.e. regional anesthesia,
general anesthesia with mask or LMA).

Question 17

Fever:

Answer 17

100.4 or 38 or greater

Question 18

Would CXR be helpful prior to making a decison about cancellectomy?

Answer 18

No, since radiographic changes often lag behind clinical symptoms

Question 19

Don’t forget to ask parents about secondhand smoke when deciding whether or not to delay

Answer 19

Okay!

Question 20

What are the risks of proceeding with the case when the child has an upper respiratory
tract infection (URI)?

Answer 20

increased
risk of experiencing perioperative respiratory complications such as laryngospasm,
bronchospasm, and oxygen desaturation. The risk is even greater in patients who have severe
symptoms (fever> 38.5 °C, productive cough, mucopurulent secretions, malaise, and
pulmonary involvement), have high risk factors (i.e. reactive airway disease), require general
anesthesia, and/or require endotracheal intubation.

Question 21

LMA is associated with less what compared to ETT? And what else can you consider to reduce the risk of resp complications?

Answer 21

Using a LMA in patients
with an acute or recent respiratory tract infection is associated with fewer perioperative
respiratory complications when compared to endotracheal intubation (i.e. reduced risk of
bronchospasm and desaturation events). Other measures I would consider to reduce the risk
of respiratory complications include administering a preoperative anticholinergic (decreases
airway hyperresponsiveness ), ensuring an adequate depth of anesthesia during LMA
placement, and carefully suctioning the oropharynx under deep anesthesia prior to removal of
the LMA.

Question 22

Any pre op meds for kids with strabismus surgery and asthma?

Answer 22

High potential for PONV: I would administer oral
midazolam, ondansetron, dexamethasone, and
provide a fluid bolus and
bronchodilator

Question 23

anticholinergics prior to a strabismus surgery in kid with asthma-you giving it or no? why and for which conditions?

Answer 23

Anticholinergic medications may be beneficial for asthmatic patients
secondary to reduced mucous gland secretions
and
airway hyperreactivity
However, their preoperative administration is controversial, since
they could result in increased inspissation (increased viscosity and thickening of airway
secretions), potentially leading to airway plugging and the initiation of an asthmatic attack.However, in this case, I would administer atropine, preoperatively, in order
to reduce the magnitude and duration of the bradycardic events associated with strabismus
surgery.