Case 6: Tonsillectomy: Hurray, a Child!

Fatty foods

Light non-fatty meal, nonhuman milk, infant formula

Breast milk

Clear liquids

8 h

6 h

4 h

2 h

The general stress reaction to accidents, injuries, intra-abdominal pain, or severe illness significantly slows stomach emptying, so that it is not useful to wait out the fasting period in such cases. Pediatric patients would not have an empty stomach by waiting under such circumstances; on the contrary, increasing stress and pain would increase gastric acid production. However, the time period between the last oral intake and the trauma gives a false impression of a fasting state (see Sect. 20.1.2).

>> The next morning, Dr. Maverick came in super motivated and ready to work. The past evening he had spent reading a pediatric anesthesia chapter with all the doses because his attending had promised to let him do the pediatric anesthesia case.

He was in a good mood walking into the OR where the anesthesia technician Robert had already set up everything. Tech Robert was experienced in pediatric anesthesia, and Dr. Maverick was thankful to have him at his side today. Kevin was brought from the preanesthesia area; he and his mom said goodbye, with tears pouring down each of their cheeks. Premedication with a 10 mg midazolam rectal suppository didn’t seem to be working. Tech Robert didn’t let this get to him; he carried Kevin and his stuffed animal into the OR, as the surgical nurses looked on with condescending looks.

6.1.5 How Should Pediatric Patients of This Age Be Premedicated?

Preoperative sedation is often desired in children 6 months of age and older, because separation from the parents leads to separation anxiety and therefore very uncooperative patients. Alternately, anesthesia may be induced with the parents present in order to avoid separation anxiety. It is common in many pediatric hospitals to have the parents accompany the child who is having elective surgery to the OR. Sedative premedication should be avoided in children with obstructive sleep apnea, intermittent obstruction, or very large tonsils.

Midazolam is the preferred benzodiazepine in pediatric anesthesia because it has a rapid onset of action and a short half-life.

6.1.5.1 Rectal Premedication

For rectal administration: 0.5–1 mg/kg (maximum 15 mg) begins to induce sedation after just 5 min. After 15 min, children should be sufficiently sedated. Sometimes, however, inadequate sedation is observed (see Sect. 28.1.3).

6.1.5.2 Oral Premedication

For oral premedication, a dose of 0.3–1 mg/kg (maximal 15 mg) is recommended, given either in tablet form (school-aged children may begin to swallow tablets) or as syrup.

6.1.5.3 Nasal Premedication

Nasal premedication with midazolam (0.2–0.4 mg/kg) works just as quickly as rectal administration. The fluid irritates the children’s airways, making for very unhappy patients. If used, consider anesthetizing their nasal mucosa with a local anesthetic – for example, nasal spray or nose drops made with lidocaine 1 %.

Paradoxical excitation after midazolam is uncommon. It may occur due to a low dose or too early administration; the rapid onset of action and short duration demands careful timing between the preoperative area and the OR. Hence, midazolam is generally not given until the OR is ready to receive the patient.

Anticholinergics are no longer used as premedicants, now that succinylcholine and halothane are rarely used. In special circumstances, such as during strabismus surgery, anticholinergics can be given IV during or after induction of anesthesia (see Sects. 28.1.4 and 28.1.5). Barbiturates and neuroleptics are only given if there is a special indication. In general, one must use caution in pediatric premedication when increased intracranial pressure, cyanotic heart disorders, or obstructive sleep apnea is present.

>> Robert, the anesthesia tech, hooked Kevin up to the usual monitoring, and Dr. Maverick started working on an IV. “Skin looks mottled,” he thought to himself as he removed the EMLA patch from the back of the hand. It made no difference; they had to get a line in. Tech Robert held Kevin’s arm still; the dorsal hand showed only a hint of a tiny recognizable vein. Dr. Maverick declined to listen to tech Robert’s suggestion to look for a vein on the patient’s feet. “There wasn’t an EMLA patch there,” he thought, making up his mind to stick the back of the hand. His disappointment was enormous, as not one drop of blood was to be found, and Kevin began to cry. “I’ll try just once more,” thought Dr. Maverick. “Who knows when I’ll have another chance?”

Sadly, his second attempt on the other hand was no more successful. Kevin now began to scream as if he was being burned alive. Dr. Maverick gave up. “You try,” he said to tech Robert. Robert touched a nice vein in the elbow, but because Dr. Maverick didn’t hold the arm tight enough, the child yanked away at just the critical moment, and the vein was shot. Dr. Maverick had underestimated the little guy’s strength.

6.1.6 What Are the Possible Causes of the Difficult Venous Access?

Placement of an IV in conscious children should only be done after the skin has been anesthetized, such as with EMLA cream (“eutectic mixture of local anesthetics”). One gram EMLA cream contains 25 mg of prilocaine and 25 mg of lidocaine. In order to achieve the full effect, the cream must be on for at least 60 min. If the EMLA patch is removed just before attempting IV placement, the vasoconstrictive effect of the prilocaine causes the IV insertion to be very difficult. Therefore, the patch should be removed at least 20 min before attempting an IV. EMLA is not approved for newborns <3 months of age due to the possible methemoglobin formation.

Fear and stress also lead to vasoconstriction. Waiting for a good pharmacological premedication can lead to success faster than repeatedly attempting IV placement, which increases stress (and not just the child’s stress). The obesity epidemic has reached the pediatric population as well. Therefore, it is recommended to search for and mark the best vein while first seeing the patient; ordering an EMLA patch to be placed by the admitting nurse alone is inadequate.

>> The attending anesthesiologist, Dr. Eldridge, heard the screaming coming from the OR and looked in. “What are you doing? There isn’t any need for an IV before induction! Begin the induction with the mask!” he ordered. Dr. Maverick was glad he had reviewed the pediatric chapter the night before. He opened the sevoflurane vaporizer and pressed a face mask over Kevin’s mouth and nose. Kevin subsequently squirmed and screamed even more, before finally slowly falling asleep. Even so, Dr. Maverick was actually very dissatisfied with himself and the events thus far. At least he could hold the child’s mask well, and the child could ventilate well. As Kevin fell into a deep sleep, Dr. Maverick wanted to try once more to get an IV. Dr. Eldridge took over the mask, and Dr. Maverick chose a vein on the foot. With such deep anesthesia, he would have never expected the patient to react, but Kevin did and another vein was shot. Now Dr. Eldridge lost his patience. He handed over the mask to Dr. Maverick and felt the last visible foot vein on the other foot, and IV access was finally secured.

“Just got lucky!” thought Dr. Maverick. Dr. Eldridge gave Kevin 4 mg/kg body weight propofol and 2 μg/kg of fentanyl, and he began to talk to the surgeon, who had just walked into the OR. Tech Robert gave Dr. Maverick a 2.5 laryngeal mask airway. Dr. Maverick was actually expecting an endotracheal tube. Much to his surprise, Dr. Maverick placed the laryngeal mask airway without incident, and it even seemed tightly sealed. He began to mechanically ventilate Kevin and declared the patient was ready for surgery. As the ENT surgeons started surgery, Dr. Maverick filled out his anesthesia record. Tech Robert went off to “prepare the next patient.” Attending anesthesiologist Dr. Eldridge was paged to another OR and with a “See, it works!” comment, he was gone.

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