Anesthesia STAT! Acute Pediatric Emergencies in PACU: A Clinical Casebook

Preface
Contents
Contributors
Passing the Baton: Check List/PACU Handoff: What Is Best?
1 A Safe and Complete PACU Handoff: Why?
1.1 Introduction
1.2 Importance of Checklists: Historical Evidence
1.2.1 Anesthesia Stat (AS) Calls
1.2.2 What Are the Steps Involved in Passing the Baton Safely?
1.2.3 Walk; Don’t Run: Vigilant Patient Monitoring During Transport Is Vital!
1.3 Why Use Recovery or Lateral Position During Patient Transport?
1.4 Are There Studies to Prove This?
2 Receiving Team: PACU Nursing Team
2.1 PACU Setup/Highlights
2.1.1 Introduction
Who We Are
2.1.2 PACU: Physical Setup
2.1.3 When a Patient Arrives at the PACU Bay After Surgery
2.1.4 Surgical Handoff
2.1.5 Anesthesia Handoff
2.1.6 PACU Patient and Pain Treatment
2.1.7 Kids Are Not Small Adults
Respiratory Obstruction in PACU
Croup
Emergence Delirium
Development of Shock
2.1.8 Drug Administration in PACU
Hypoglycemia
2.1.9 Autism and Autism Spectrum Disorders
3 Conclusion
References
Anaphylaxis After Antibiotics in PACU
1 Case Presentation
2 Discussion
2.1 What Is Anaphylaxis and How Common Is It?
2.2 Why Is the Incidence of Anaphylaxis Less Common in Children Compared to Adults?
2.3 What Is the Pathophysiology of Anaphylaxis?
2.4 What Are the Clinical Manifestations of Anaphylaxis?
2.5 Clinical Manifestations of Anaphylaxis by Organ System [6]
2.6 Anaphylaxis Grading Adapted from Ring and Messmer Grading Scale [5, 8]
2.7 Does the Patient’s Asthma History Place Her at Risk for Anaphylaxis? What Are the Associated Risk Factors?
2.8 Identify the Most Common Causes of Anaphylaxis in the Perioperative Period
2.9 What Is the Differential Diagnosis?
2.10 How Do You Diagnose Anaphylaxis?
2.11 How Do You Treat Anaphylaxis?
2.12 Management of Anaphylaxis
2.13 What Interventions Are Applied if the Patient Remains Hypotensive?
2.14 How Will You Monitor This Patient in PACU?
2.15 How Do You Manage the Airway During Anaphylaxis?
2.16 How Long Should the Patient Be Observed?
2.17 What Is the Mortality Rate of Anaphylaxis?
2.18 What Can Be Done to Prevent Anaphylaxis?
3 Summary
References
Somnolence After V-P Shunt Revision in an Infant
1 Stem Case
2 Discussion
2.1 What Is an IVH and How Is It Graded?
2.2 What Causes Hydrocephalus Following an IVH?
2.3 What Is the Treatment of Hydrocephalus?
2.4 What Are the Anesthetic Concerns of an Infant with a History of Prematurity?
2.5 What Is the Anesthetic Management of an Infant Undergoing VP Shunt Revision?
2.6 What Are the Signs and Symptoms of VP Shunt Malfunction? How Likely Is It with Her Current Presentation?
2.7 Apart from Issues with the VP Shunt, What Are Other Potential Causes of Her Somnolence?
2.8 What Would Be the Most Common Presentation in the PACU if an Excessive Amount of Opioid Was Administered to the Infant? How Would You Treat This?
2.9 How Would Her Presentation Differ if Inadequate Reversal of the Neuromuscular Blocking Agent Was Suspected? How Would This Scenario Be Treated?
2.10 What Are Other Important Diagnoses for Somnolence to Rule Out Immediately?
2.11 What Tests or Studies Can Help in the Differential Diagnosis?
2.12 What Findings on an Arterial Blood Gas Could Result in the Patient’s Somnolence?
2.13 What Electrolyte Abnormalities Could Be the Cause of Her Current Condition?
2.14 If the Patient’s Electrolyte Panel Demonstrated Hyponatremia, What Would Be the Treatment? How Should the Treatment Be Carried Out?
2.15 What Are the Concerns with Treatment of Hyponatremia?
2.16 What Are the Implications of Her Hemoglobin and Hematocrit Values?
2.17 Which Finding on the Above Labs Is MOST Likely the Cause of the Somnolence?
2.18 What Is the Treatment of This?
2.19 What Treatment During the Case Could Have Helped to Avoid This?
2.20 What Maintenance Fluids Should She Be Given Now?
2.21 If the Laboratory Values Were All Within Normal Limits (i.e., No Electrolyte Abnormalities), What Would Be the Appropriate Next Step in the Diagnosis and Treatment of Her Somnolence?
2.22 At What Point Should Neurosurgery Be Notified of the Patient’s Condition?
2.23 Where Should This Patient Be Monitored? And for How Long a Period?
2.24 What Would You Discuss with the Parents and the New Surgeons Who Are Going to Be Managing Her Overnight Stay and Discharge?
3 Summary
References
Emergence Delirium in a Toddler
1 What Is the Differential Diagnosis for This Behavior?
2 What Is Emergence Delirium and What Are Its Risk Factors?
3 Are There Specific Factors That Can Predict ED in Children?
3.1 Risk Factors for Emergence Delirium
4 What Clinical Measurement Tools Are Used to Assess Emergence Delirium?
5 Which Types of Anesthesia Increase the Risk of Emergence Delirium?
5.1 Volatile Anesthetics
5.2 General Anesthesia Vs. Total Intravenous Anesthesia (TIVA)
6 What Treatments and Preventative Measures Are Available for Emergence Delirium?
6.1 Fentanyl/Ketamine and Regional Anesthesia
7 What Are Some of the Non-pharmacological Techniques to Reduce ED?
7.1 Non-pharmacological Techniques
7.2 Hypoactive Delirium
8 Summary
References
Cardiac Arrest After Central Line Placement in a Child
1 Case
2 Discussion
2.1 What Is a Broviac CVC?
2.2 What Are the Broad Indications for a CVC?
2.3 How Does a Broviac Catheter Differ from the Other Types of CVCs?
2.4 In This Patient Who Is S/P Tunneled Line Insertion, What Is Your Differential Diagnosis for Hypoxia?
2.5 Why Is Aspiration on Your Differential Diagnosis for Hypoxia in This Patient?
2.6 Why Are Airway Obstruction and Pulmonary Edema on Your Differential Diagnosis?
2.7 Any Procedure Specific Concerns That May Be Contributing to the Clinical Picture?
2.8 Why Are You Concerned About a Congenital Heart Defect?
2.9 If You Suspected a Venous Air Embolism, What Would You Do?
2.10 How Could You Prevent a Venous Air Embolism?
2.11 How Could an Inadvertent Arterial Puncture Lead to This Clinical Presentation?
2.12 If an Arterial Puncture Was Suspected Intraoperatively, What Should Have Been Done?
2.13 Which CVC Insertion Site Is More Prone to Hematoma Formation with Accidental Arterial Puncture? Which Site Is More Prone to Cause Airway Compromise?
2.14 Any Late Complications That You Are Concerned About with Accidental Arterial Puncture?
2.15 Could a Dysrhythmia Account for This Clinical Picture? Any Preventative Steps?
2.16 Would You Order Any Diagnostic Studies in This Patient?
2.17 What Are the Expected Chest X-ray Findings for Aspiration, Pulmonary Edema, and Pneumothorax?
2.18 What Are the Expected Echocardiographic Findings for Tamponade?
2.19 What Is a Tension Pneumothorax?
2.20 How Would You Diagnose a Tension Pneumothorax?
2.21 What Are the Chest X-ray Findings of a Tension Pneumothorax?
2.22 Which PALS Algorithm Will You Use?
2.23 If the Child Is in PEA Arrest, What Is Your Next Step?
2.24 What Is Considered Good Quality CPR?
2.25 What Are the Reversible Causes You Consider with PEA Arrest?
2.26 What Are the Interventions for These Reversible Causes of PEA Arrest?
2.27 If You Are Suspecting a Tension Pneumothorax, How Would You Perform a Needle Decompression?
2.28 How Does the Needle Decompression in a Pediatric Patient Differ from an Adult Patient?
2.29 Should the Patient Be Intubated Prior to Needle Decompression?
2.30 Should a Chest Tube Be Inserted Following Needle Decompression?
2.31 Any Concerns with Rapid Lung Re-expansion?
2.32 What Are the Possible Procedural Factors Which May Have Contributed to the Development of a Pneumothorax?
2.33 How Would You Differentiate Pneumothorax from Cardiac Tamponade?
2.34 Any Preventative Measures to Reduce the Likelihood of Causing a Pneumothorax?
2.35 What Are the Pros and Cons of the Various CVC Access Sites?
3 Summary
References
Lost Tooth After EGD in a 6-Year-Old Child
1 Case Discussion
2 What Are Some of the Questions You May Have to Answer to Explain This Unexpected Tooth Loss?
3 What Is the Appropriate Response You Should Give the Parent?
4 At the Meeting the Chief Safety Officer Asks: How Common Are Perianesthetic Dental Injuries and Which Patients Are at Highest Risk for Dental Injuries?
5 What Should Be Done to Prevent Perioperative Dental Injury?
6 Summary
References
Intractable Cardiac Arrhythmias After Bone Marrow Biopsy in a Child with Leukemia
1 Stem Case
2 What Is This Rhythm and What Is the Management?
3 What Is the Treatment for Hyperkalemia in This Child?
4 Discussion
5 Immediate Postanesthetic Events in PACU
6 What Are the Changes Seen in Electrocardiogram in Children with Hyperkalemia?
References
Shoulder Pain/Tachycardia After Liver Biopsy in a Teenager
1 Stem Case
2 What Are Indications for Liver Biopsy in Pediatric Patients?
3 What Preprocedural Workup Should Be Done Prior to Liver Biopsy for NAFLD?
4 What Are Postanesthetic Concerns in Obese Children?
5 What Are Known Complications of Liver Biopsy in Pediatric Patients?
6 What Is Kehr’s Sign?
7 What Are Risk Factors for Complications After Percutaneous Liver Biopsy?
8 What Are Next Management Steps?
9 What Is the Recommended Post-biopsy Observation Period?
References
Teenager with Acute NPPE in PACU After Hardware Removal
1 Stem Case
2 What Is Negative Pressure Pulmonary Edema?
3 How Common Is NPPE?
4 What Are the Etiology, Pathophysiology, and Risk Factors of NPPE?
5 How Does NPPE Present?
6 What Is the Differential Diagnosis?
7 Which Tests Will Be Helpful in Making the Diagnosis?
8 How Should NPPE Be Treated?
9 What Is the Typical Course of NPPE?
10 Conclusion
References
Latex Allergy Developing in PACU in a Child with Spina Bifida After Suprapubic Catheter Placement
1 Case Presentation
2 Discussion
2.1 Spina Bifida
2.2 Latex
2.3 Anaphylaxis
2.4 Assessment and Management of Anaphylaxis
2.5 Prevention of Latex Allergy
3 Conclusion
References
O2 Desaturation in a Teenager After Esophagoscopy, Dilatation and Biopsy
1 Stem
2 What Is the Differential Diagnosis for the Abrupt Desaturation?
3 What Would You Do in This Clinical Scenario?
4 Which Pediatric Patients Are at Higher Risk of Cardiopulmonary Arrest? What Is the Commonest Cause of Cardiopulmonary Arrest in Kids?
5 What Are Well-Known Risk Factors for PRAE in Pediatric Patients?
6 What Are Some Prevention Strategies for Respiratory Complications in the PACU?
7 What Is the Incidence of Esophageal Perforation?
8 What Is the Etiology of Esophageal Perforation?
9 What Is the Most Common Etiology of Esophageal Perforation?
10 What Is the Most Common Cause of Esophageal Stenosis in Children and Infants?
11 Why Is Esophageal Perforation Life-Threatening?
12 What Are the Most Common Anatomical Areas Affected by Esophageal Perforation?
13 What Area of the Esophagus Is Affected in Neonates?
14 What Is the Clinical Presentation of Esophageal Perforation?
15 What Are the Main Symptoms of Esophageal Perforation in Neonates and Infants?
16 What Is the Mackler Triad?
17 Patient Starts Complaining of Left Shoulder Pain and Is Tachypneic and Febrile. What Is the Possible Pathophysiology?
18 Complete Blood Count Was Ordered, and Hematocrit Is 33%, and White Blood Count Is 22,000 and Platelet Count 440,000. What Other Labs Would You Order?
19 A Portable Posterior-Anterior Chest Radiograph Was Ordered at Bedside and Showed Subcutaneous Emphysema with No Other Findings. Is This Radiographic Change Expected in an Esophageal Perforation? What Are the Main Radiographic Changes Expected on a
20 Would You Order Any Other Imaging Study if the Chest Radiograph Is Normal? What Is the Gold Standard for Diagnosing Esophageal Rupture?
21 What Are Important Factors to Consider When Deciding How to Treat an Esophageal Perforation?
22 What Patients Might Benefit from a Surgical Approach?
23 What Is the Pittsburg Perforation Severity Score?
24 What Is the Nonsurgical or Nonoperative Treatment of Esophageal Perforations?
25 What Is the Surgical Treatment of Esophageal Perforations?
26 What Is the Rule of 3?
27 When Would You Start Diet After Repair and How Long Would You Expect to Be the Length of Stay at the Hospital?
28 What Surveillance Should Be Done After Stent Placement?
29 Summary
29.1 Rapid Diagnosis
References
Respiratory Arrest in an Obese Teenager in PACU After Cardiac Catheterization
1 Case Presentation
2 Discussion
2.1 What Is Obstructive Sleep Apnea (OSA)?
2.2 How Is OSA Diagnosed?
2.3 What Are Risk Factors for OSA?
2.4 What Determines the Severity of Obstructive Sleep Apnea?
2.5 Does Obstructive Sleep Apnea Affect Anesthetic Management?
2.6 Does the Presence of 22q11 Deletion Syndrome Affect the Probability of OSA?
2.7 Does Hypothyroidism Contribute to Worsening of OSA?
2.8 What Is the Postoperative Management?
2.9 What Could Have Been Done Differently if the Diagnosis of OSA Was Made Beforehand?
2.10 What Is the Effect of Using Dexmedetomidine in Cardiac Patients Undergoing Catheterization?
2.11 How Does Oral Premedication with Midazolam Affect Respiration in Healthy Children?
2.12 What Else Can You Use if You Do Not Have Access to a CPAP?
2.13 Are There Any Serum Biomarkers Available to Evaluate the Degree of OSA in Our Patient if He Did Not Have Any Polysomnography Studies in the Past?
2.14 What Is the Etiology for Impaired Respiratory Function in Obese Patients Under Anesthesia?
3 Summary
References
Inability to Walk After Caudal Anesthesia in a Toddler
1 Case and Questions
2 What Are the Complications Following a Caudal Block? What Additional Information Would Be Helpful?
3 What Is the Whoosh Test? What Are Other Ways to Confirm Epidural Placement Via Caudal Approach?
4 What Is Next in the Diagnostic Work Up for This Motor Block?
5 Should This Patient Be Discharged with Close Follow-Up or Admitted?
6 Discussion
6.1 Concentration Vs Volume of the Local Anesthetic Drug Dose
6.2 Test Dose for Confirmation of Correct Needle Placement in Caudal Space
6.3 Auditory Tests for Correct Needle Placement Confirmation
6.3.1 Whoosh (Air) Vs Swoosh (Saline)
6.4 Ultrasound Use for Caudal Block in Children (Fig. 2)
6.5 Efficacy of Caudal Block Evaluation
7 Conclusion
References
Croupy Cough and O2 Desaturation in Ex-Premature Toddler
1 Case Presentation
2 Discussion
2.1 What Is the Differential Diagnosis for this Child?
2.2 The Patient Received No Muscle Relaxant and Only 0.5 mcg/kg of Fentanyl Intraoperatively. Upon Evaluation, He Is Awake, Responsive, and Tachypneic with Stridor, Chest Retractions on Inspiration, and a Seal-like Barking Cough. There Is No Wheezing
2.3 What Is Post-extubation Croup?
2.4 What Are the Risk Factors for Developing Post-extubation Croup?
2.5 What Are the Key Features of a Pediatric Airway?
2.6 What Are the Factors Affecting Work of Breathing?
2.7 Does Endotracheal Tube Sizing and the Presence or Absence of a Cuff Matter?
2.8 What Are Microcuff Tubes and Their Advantages?
2.9 Are There Any Strategies That Can Be Employed to Prevent Post-extubation Croup?
2.10 Could This Case Have Been Done Without Endotracheal Intubation?
2.11 How Do You Manage Post-extubation Croup?
3 Summary
References
Postop Apnea in An Infant After Spinal Anesthesia for Hernia Repair
1 Case Presentation
2 Discussion
2.1 What Are the Risk Factors for Postop Apnea in Ex-premature Infants Undergoing Anesthesia?
2.2 What Is Spinal Anesthesia?
2.3 What Are the Complications of Spinal Anesthesia (SA)?
2.4 Is There a Difference in Risk of Postoperative Apnea Between General Anesthesia and Regional Anesthesia?
2.5 If Postoperative Apnea Is Identified, What Is the Expected Course?
2.6 What Are the Risks in This Particular Ex-premature Patient?
2.6.1 What Is His Age?
2.6.2 Does His Natal Age Add to His Risk of Post-operative Apnea?
2.6.3 What Is Physiologic Anemia of the Newborn?
2.6.4 How Does Caffeine Prevent Apnea of Prematurity?
3 Summary
References
Persistent Vomiting After Eye Muscle Surgery
1 Stem Case
References
Blindness After Bone Marrow Harvest in a Healthy Patient
1 Stem Case
1.1 How Common Is Post-operative Visual Loss (POVL)?
1.2 Are There Specific Risk Factors That Make POVL More Likely?
1.3 Which Risk Factors Exist in Our Patient Who Presents for Bone Marrow Harvest?
1.4 What Is the Differential Diagnosis for Postoperative Visual Loss?
2 Corneal Abrasions Describe the Presentation, Natural Course and Treatment of Corneal Abrasions
3 Ischemic Optic Neuropathy: Symptoms, Pathophysiology, and Prevention
4 Retinal Vascular Occlusion: Etiology and Natural Course
5 Cortical Blindness: Etiology and Course
6 Could This Be Related to the Failed Caudal Attempts in Our Patient?
6.1 What Is the Goal in Assessing This Patient?
References
Further Reading
Tachycardia and Hypertension in a Teen After Goiter Surgery
1 Stem Case
2 Discussion
2.1 Different Steps Involved in Thyroid Hormone Synthesis
2.2 Different Types of Thyrotoxicosis
2.3 Complications of Thyroid Surgery/Resection
3 Summary
References
Prolonged Apnea After Treatment of Laryngospasm in a Child After Botox Injection
1 Stem Case
2 Cause of Laryngospasm
2.1 What Is the Ideal Safe Way for Their Daughter to Undergo Future Anesthesia for Botox Injection?
3 Discussion
4 Management
5 Summary
References
Seizures in a Child After Caudal Block for Circumcision
1 Case History
2 What Are Typical Symptoms and Signs of Seizures?
3 What Initial Steps Should You Perform to Manage Patients Experiencing Convulsive Movements?
4 What Significant Patient Medical History Findings Predispose the Patient to Unprovoked Seizures?
5 What Intraoperative Events Predispose Pediatric Patients to Seizures in the Postoperative Period?
6 What Laboratory Measurements Will Help Determine the Cause of Seizures?
7 What Predisposing Perioperative Factors Could Lead to Hypoglycemia in the Postoperative Period?
8 What Intraoperative Medications Predispose Patients to Seizures in the Postoperative Period?
9 What Risks Are Associated with Developing LAST?
10 What Cerebral Nervous and Cardiovascular Signs Are Characteristic in LAST?
11 What Are the Phases of LAST?
12 How Do You Reduce the Risk of LAST?
13 What Is the Treatment for Patients with Suspected LAST?
14 What Is Lipid Emulsion Therapy for the Treatment of LAST?
15 Summary
References
Hyperthermia in a Child After Dental Rehabilitation: Is This M.H
1 What Is the Differential Diagnosis and Workup for Fever for this Postoperative Patient?
2 Could This Immediate Postoperative Fever Be Due to Inflammatory Changes?
3 Could This Fever Be Related to Malignant Hyperthermia?
4 Did This Child Have Risk Factors for Malignant Hyperthermia?
5 Pathophysiology of MH
6 How Does MH Cause Fever and Lead to Death?
7 How Do You Treat MH?
8 Is There a Definitive Test to Confirm Diagnosis for MH?
9 If This Was Not MH, Could This Be Aspiration of Secretion/Blood During Intubation/Extubation?
10 Could This Be Starting a Viral Illness in the Family? Should the Case Have Been Started Given the Child Had a Resolved Upper Respiratory Illness (URI) and a Sick Contact at Home?
11 Is MH the Diagnosis for Rising Temperature in PACU?
12 Summary
References
Vomiting Blood After Routine T&A
1 Stem Case
1.1 How will you prepare this child for surgery? Do you keep the patient on his mothers lap?
1.2 How will you manage loss of peripheral IV access?
2 What Are Some Special Considerations for Intraoperative Management?
3 What is the plan for emergence and recovery?
4 Summary
References
O2 Desaturation After Bariatric Surgery in a Teenager
1 What Are the Differential Diagnoses for Postoperative Desaturation After Bariatric Surgery?
2 How Does Respiratory Mechanics Differ in an Obese Patient?
3 What Is the Prevalence of OSA in the Bariatric Population and What Role Did This Patient’s OSA Play in Her Postoperative Desaturation?
4 What Is Obesity Hypoventilation Syndrome and How Prevalent Is It in the Bariatric Population?
5 What Role Does Opioid Administration Play in Postoperative Desaturation in Bariatric Patients and What Alternative Pain Management Strategy Could Have Been Employed in This Patient?
6 Could the Obstruction Have Been Secondary to Position?
7 Is It Possible for the Desaturation to Be Secondary to Atelectasis?
8 Is Pulmonary Embolism a Potential Cause of the Postoperative Desaturation?
9 What Were the Risk Factors for Postoperative Desaturation in This Bariatric Surgery Patient and How Could the Postoperative Outcome Have Been Optimized?
10 Could Residual Neuromuscular Blockade Be a Potential Cause of This Patient’s Postoperative Desaturation?
11 Could Bronchospasm or Laryngospasm Be Contributors to This Postoperative Desaturation? What Is the Treatment?
12 What Was Determined to Be the Cause of the Desaturation in This Patient?
13 Discussion
13.1 General Anesthesia for Morbidly Obese Teenagers for Gastric Sleeve Operation
13.2 Types of Bariatric Surgery
13.3 Preoperative Evaluation and Planning
13.4 Drug Dosing
13.5 DVT Prophylaxis
13.6 Antibiotic Prophylaxis
13.7 Postoperative Analgesia
14 Anesthetic Safety Checklist for Bariatric Surgery
15 Summary
References
Confusion and Sudden Onset of Left Sided Weakness in a Patient with Sickle Cell Disease (SCD) After Gall Bladder Surgery
1 Case Study Part I
1.1 What Is Sickle Cell Disease (SCD)?
1.2 What Are the Most Common Clinical Presentations of SCD?
1.3 What Are the Most Common Elective Surgeries in Children with SCD?
1.4 What Other Disease States Are Associated With Sickle Cell Disease and May Affect Perioperative Outcomes?
1.5 Why Is This Patient Having an Elective Laparoscopic Cholecystectomy?
1.6 How Will You Preoperatively Assess Sickle Cell Patients and Plan for Surgery?
1.7 Will You Transfuse a Sickle Cell Patient Prior to Surgery?
2 Case Study Part II
2.1 How Will You Induce and Maintain Anesthesia, and What Intraoperative Management Strategies Benefit Patients with SCD?
3 Case Study Part III
3.1 What Are the Most Common Complications After Elective Surgery in Children with SCD?
3.2 What Is Your Differential Diagnosis in the Patient With a New-Onset Neurologic Deficit?
3.3 What Therapeutic Interventions Should Be Initiated for Neurologic Complications After Surgery?
3.4 What Other Interventions Should Be Considered Postoperatively for All Patients With SCD to Prevent Complications?
4 Case Study Part IV
5 Summary and Conclusion
References
Profound Bradycardia in a Child After Dexmedetomidine Treatment for Agitation on Induction and After Extubation: To Treat or Not to Treat?
1 Stem Case
2 Discussion
2.1 Autism and ASD
2.2 Brain Evoked Auditory Response (BAER) Test
3 Premedication or Preinduction Drugs
4 Conclusion
References
Index