After Thanksgiving Day off, cousin Steve dropped me off at the Wallingford train station where I caught the SEPTA train in to Market East Station and crossed the street to the bus station to catch my Greyhound Coach d’Elegance back to Manhattan. As fellow passengers were boarding, the Indian woman behind me complained when I reclined my seat back a few inches. “Oh, oh, please raise your seat, my knees are hurting!” Irritated that a woman who couldn’t be taller than 5’4″ was complaining about her knees to someone a full foot taller than her, and resisting the urge to suggest she could pick out a different seat on the bus–preferably behind an unoccupied seat–I raised my seat a couple inches and rode the rest of the trip with this semi-comfortable compromise.
I took my first pediatric anesthesia long call on Friday. I went in expecting to anesthetize a three-day-old neonate for a Norwood procedure (palliative surgery for hypoplastic left heart syndrome), only to find out the case was cancelled. Instead I did a central line on a 1 year old and a pyloromyotomy on a 3 week-old, before helping with sedation for a 7 year-old in the MRI. This child had “single ventricle physiology” having a hypoplastic left heart as well, now having undergone the Norwood, bidirectional Glenn, and Fontan procedures.
I then did brief afternoon rounds with the pediatric pain attending, as I was covering the “OUCH” pager that night. Circling through the list before I left the hospital, everyone seemed comfortable enough, and I went home. This is one of the few rotations where we can take home call, or “pager call.”
I was awakened by my pager at 0100. There was a 7 year old with a ruptured eyeball, and the ophthalmologists wanted to take him to the operating room within the hour. I quickly paged my attending to notify her of the case, dressed, and caught a cab to the hospital. No telling how long I would have waited for the subway at that hour, and ten dollars seemed like a small price to pay to avoid the cold and get there quickly.
I was in scrubs and had the room set up by 0150. but the patient didn’t show up till nearly 0300 from the emergency room! Somebody felt the need to order a CT scan before sending him up to the operating room. Anesthetic concerns include the following:
- This is a trauma, and thus may put the child at risk for aspiration of stomach contents during induction of anesthesia. Pain and increased tone from the sympathetic nervous system delays gastric emptying, and aspiration can occur as a patient is anesthetized and loses protective airway reflexes. Aspiration, though rare, has a high fatality. In order to minimize the risk of aspiration, anesthesiologists frequently employ the “rapid sequence induction” technique. This involves ample preoxygenation of the patient to build up as large a reserve of oxygen as possible in the lungs, and a quick administration of a sedative and a paralytic–usually succinylcholine because of its rapid onset. As the medications are pushed, pressure is applied to the round cricoid cartilage in the neck to help close off the esophagus. This pressure is continued until the placement of the breathing tube is confirmed. The breathing tube with its inflatable cuff protects the lungs from aspiration. In this case, the child had not eaten for more than 12 hours, so this risk was probably lower.
- The eyeball (or “globe” in medical terms) is ruptured. Succinylcholine can increase intraocular pressure, which could lead to greater extrusion of contents from the eye. Most anesthesiologists get the willies when we think about jelly-like substances squirting out of an eye wound, so we prefer to avoid this. Additionally, succinylcholine is avoided in children because of the risk of malignant hyperthermia (serious adverse reaction) in a child with an undiagnosed myopathy (muscle disorder). Hence, we used rocuronium for our paralytic agent with an onset nearly as fast.
- General anesthesia, and eyeball surgery in particular, can cause nausea, and wretching can increase pressures in the eye. We would like to avoid this post-operatively as it could damage the surgical repair, so administering ondansetron (a powerful anti-emetic commonly used for severe gestational nausea or chemotherapy-related nausea) is a must.
- Coughing and bucking on the endotracheal tube as a patient emerges from anesthesia is also suboptimal for the same reason. We can treat patients with intravenous opioids and lidocaine to blunt airway reflexes, and we could topicalize the vocal cords with lidocaine, but in this case we opted for “deep extubation.” This is a technique in which the patient is allowed to resume spontaneous ventilation, and the endotracheal tube is removed while the the patient is still anesthetized. The airway is then supported and supplemental oxygen provided. This provides for smoother wake-ups.
It was around 0600 when I dropped off the patient in the recovery room, leaving me enought time to check e-mail and change into street clothes before heading uptown for my moonlighting shift which began at 0700. Thankfully, the day was as slow as it could be (not a single operating room case, epidural, cesarian section, or stat intubation) which meant I didn’t do much other than sleep, eat, and read.