My case today Cerebral palsy, impossible spinal, bad pulmonary function

[Sleeplessbordernights]

22 year old 66 lbs 3’2 ft, with bad cerebral palsy, non verbal, badly contracted limbs, spine literally on the side with the worst kyphosis and scoliosis I have ever seen. Had a femur fracture a month ago, had a bout with multi resistant pneumonia which lef him with a bad Pulmonar function (which was bad to begin with due to his condition). Last week was scheduled for a femoral nail. I was not present but the attending then said meddling with the airway was out of the way, and just could not get a spinal. Today was scheduled again, trauma wanted to do an external fixator this time so they can send the pt home. Again the attending in the room Told them that a spinal was impossible and due to his pulmonary function we Might not be able to extubate if we opt to give general. Trauma Then said wanted to do the external fixator with local only, again my attending told them that was a stupid idea. What would you do in this case?

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[GassYous]

ketamine fascia iliaca peng pray

 

[Sleeplessbordernights]

ketamine fascia iliaca peng pray

I asked about that option to my attending but she said we would go over the safe dose of local

 

[GassYous]

Ask your attending what the safe dose of local actually is and how it was determined.

Why not try the spinal with a c arm or ultrasound?

 

[2010houston]

Agree with regional options.
66lb = 29kg.
29kg = Max dose of ropi of nearly 90mg. So that would give you 18cc of 0.5%, or 24cc of 0.35%. Plenty of room for a block. Could also do an LMA and pressure support and a whiff of sevo / iso and if the PNA was a month ago he would probably tolerate that.

 

[DrOwnage]

Since its ex-fix or nail, its a supine case. Prop, lido, LMA 3 or 2.5.

Edit: Might walk back the LMA if you have PFTs with how bad his restrictive disease is.

 

[Lidolover]

Since its ex-fix or nail, its a supine case. Prop, lido, LMA 3 or 2.5.

Edit: Might walk back the LMA if you have PFTs with how bad his restrictive disease is.

Bad idea. These peeps have terrible GERD and GI issues and are considered by default high aspiration risk

 

[2010houston]

Bad idea. These peeps have terrible GERD and GI issues and are considered by default high aspiration risk

If you keep them true spontaneous / pressure support it’s relatively rare to have issues with this. Ask. Parents usually know. He’s undoubtedly got a g-tube, and you can suction / vent it.
For me , risk / benefit in the setting of a recent PNA and questionable pulm status would make me more interested in an LMA unless really really contraindicated.

 

[Morzh]

This kind of case is relatively common in children's hospitals. There's no perfect answer here - you have a bunch of competing goals but the case is not elective and has to get done.

My approach:

1 - GA, LMA if otherwise appropriate (ETT if you have to), either way, keep spontaneous as much as possible with pressure support
2 - Pick your favorite US-guided regional technique for maximum intra-op and post-op analgesia. Depends where the fracture is and where ex-fix will be applied. Suprainguinal fascia iliaca +/- sciatic, vs lumbar plexus would be my choice. Put 0.5%, and I would add Precedex to make the block last even longer (sometimes will get to >24h).
3 - Minimize opioids (make the block count), use adjuncts like ketamine / precedex / APAP / NSAID
4 - Extubate, sit in the OR for a few extra minutes holding CPAP to make sure he flies. Use BiPAP in PACU if necessary. Tell everyone before you start that he may very well need an ICU stay for 1 night to make sure he's doing OK. Don't discharge for at least 24 hours.

 

[Justice4all]

Regional fem/sci and lotta of ketamine + precedex

 

[Arch Guillotti]

I was not present but the attending then said meddling with the airway was out of the way

Because of the bad pulmonary function or a crappy airway?

 

[Katheudontas parateroumen]

Tough case but we do these kind of cases pretty often in the peds hospital. Assuming he isn’t requiring much supplemental O2 and that his airway is otherwise reassuring, I think GETA is fine. I would still try to extubate if he meets parameters but if he needs to stay intubated for the ICU then that’s what it is. This is non elective so has to be done. Neuraxial would be very difficult even under fluoro I would think especially for a neuromuscular spine. I imagine it’d be tough to do a block on someone so contracted. I’d also avoid LMA as they are high aspiration risk but those things can me mitigated as stated above.

 

[deleted697535]

Why are ppl so afraid to give patients a general anesthetic?

Just fvcking do the case

 

[Arch Guillotti]

Why not try the spinal with a c arm

This is funny!

 

[Hoya11]

22 year old 66 lbs 3’2 ft, with bad cerebral palsy, non verbal, badly contracted limbs, spine literally on the side with the worst kyphosis and scoliosis I have ever seen. Had a femur fracture a month ago, had a bout with multi resistant pneumonia which lef him with a bad Pulmonar function (which was bad to begin with due to his condition). Last week was scheduled for a femoral nail. I was not present but the attending then said meddling with the airway was out of the way, and just could not get a spinal. Today was scheduled again, trauma wanted to do an external fixator this time so they can send the pt home. Again the attending in the room Told them that a spinal was impossible and due to his pulmonary function we Might not be able to extubate if we opt to give general. Trauma Then said wanted to do the external fixator with local only, again my attending told them that was a stupid idea. What would you do in this case?

lma no regional necessary

 

[coffeebythelake]

How bad is the pulmonary function? Quantifiable?

 

[ethilo]

US-assisted epidural or spinal, I'd probably choose epidural and do it paramedian, lateral decubitus. If they are small and thin, structures should be shallow and easily seen.

 

[deleted875186]

Fluoro guided spinal would be a slam dunk, can always get in somewhere, the pain people could do it.

If you really want to do neuraxial, why not a caudal catheter and dose it up to an appropriate level?

honestly though, it’s not elective so I would just do GETA, minimum opioids, leave intubated overnight if needed but try to extubate on the table.

 

[Arch Guillotti]

honestly though, it’s not elective so I would just do GETA, minimum opioids, leave intubated overnight if needed but try to extubate on the table.

Neuraxial and blocks and whatnot are great until they don't work like you want them to. And if they do work well you are stuck sedating someone who may not be able to tolerate much sedation at all.

 

[fakin' the funk]

Bad idea. These peeps have terrible GERD and GI issues and are considered by default high aspiration risk

Please. "These peeps?" It's something to consider but you need a careful and individualized history to define high aspiration risk.

 

[coffeebythelake]

Please. "These peeps?" It's something to consider but you need a careful and individualized history to define high aspiration risk.

Not sure how much history you are going to get from a nonverbal, presumably quite mentally ****** patient like this

(Apparently re-tarded is a bad word)

 

[DirtDocMD]

Why are ppl so afraid to give patients a general anesthetic?

Just fvcking do the case

Yeah. Sometimes you just gotta be honest with folks about the risk of prolonged post-op ventilation (with family and surgeons), suck it up, and do it.

If just an ex-fix, might be worth trying a hefty dose of ketamine, and see if you can avoid GETA. If it doesn’t work, it’s not that hard to stop an ex-fix for a bit (no huge bleeding open incision), while you get an airway. (Supine, or is this case lateral??)

I wouldn’t keep chasing your tail with neuraxial/regional. Tell the surgeons you’re going to try some ketamine, and if it’s not working, you’re going to stop them for 5-10 minutes, intubate, and move on...

 

[dhb]

I'm a regional guy, been doing some almost every working day in the past 10+years. In no way shape or form is this a case for regional anesthesia.

This is GETA all the way, no paralysis just a lido cord spray and no narcs (2.5-5mcg of sufenta if there really is no other way to control sympatheyic output).

Extubate at the end as usual. I've never had an pure OR extubation failure.

 

[deleted875186]

I'm a regional guy, been doing some almost every working day in the past 10+years. In no way shape or form is this a case for regional anesthesia.

This is GETA all the way, no paralysis just a lido cord spray and no narcs (2.5-5mcg of sufenta if there really is no other way to control sympatheyic output).

Extubate at the end as usual. I've never had an pure OR extubation failure.

Agree GETA is the ideal choice.

I will disagree with no paralysis, in fact I prefer paralysis so I can avoid deep GA, minimal opioids. Reversal with suga makes avoiding paralysis outdated.

 

[coffeebythelake]

Agree GETA is the ideal choice.

I will disagree with no paralysis, in fact I prefer paralysis so I can avoid deep GA, minimal opioids. Reversal with suga makes avoiding paralysis outdated.

Agree. Unless there is some hemodynamic
or cardiopul reason you want to keep pt breathing spontaneously I would paralyze w roc to use less sevo

 

[deleted697535]

22 year old 66 lbs 3’2 ft, with bad cerebral palsy, non verbal,

Had a femur fracture a month ago, had a bout with multi resistant pneumonia which lef him with a bad Pulmonar function (which was bad to begin with due to his condition).

Last week was scheduled for a femoral nail.

Today was scheduled again, trauma wanted to do an external fixator this time so they can send the pt home. Again the attending in the room Told them that a spinal was impossible and due to his pulmonary function we Might not be able to extubate if we opt to give general. Trauma Then said wanted to do the external fixator with local only, again

my attending told them that was a stupid idea.

Am i reading this right?
This poor defenseless child has been lying in agony with a broken hip for a month because your anesthesia department are too afraid to do their job...

This is a new low.

 

[repititionition]

Am i reading this right?
This poor defenseless child has been lying in agony with a broken hip for a month because your anesthesia department are too afraid to do their job...

This is a new low.

it also seems par for the course there from what I’ve read

 

[GassYous]

I'm a regional guy, been doing some almost every working day in the past 10+years. In no way shape or form is this a case for regional anesthesia.

This is GETA all the way, no paralysis just a lido cord spray and no narcs (2.5-5mcg of sufenta if there really is no other way to control sympatheyic output).

Extubate at the end as usual. I've never had an pure OR extubation failure.

What is the point of the tube if you're not giving narcs or paralysis?

 

[dhb]

LMAs aren't made for cripples

 

[Sleeplessbordernights]

it also seems par for the course there from what I’ve read

To be fair, most of my cases feature the same attending, we rotate peer week with a different one, the rest of the team of the hospital is amazing most of the time

 

[Sleeplessbordernights]

Because of the bad pulmonary function or a crappy airway?

Both, the kid was in a bad spot

 

[narcotics999]

Not sure how much history you are going to get from a nonverbal, presumably quite mentally ****** patient like this

(Apparently re-tarded is a bad word)

Mentally challenged!

This is ridiculous. One month! Prop, Roc, tube.

I assume he is breathing by himself and maintains decent sats. What prevents one from ETT him for 1-2 hours?

 

[dhb]

Mentally challenged!

Camp 2