M & M ConferenceM & M Conference

October 15, 2008October 15, 2008

Stephen F. Dierdorf, M.D.Stephen F. Dierdorf, M.D.

You think your job is You think your job is bad!bad!

Three PresentationsThree Presentations

1. Why can’t I decompress 1. Why can’t I decompress the stomach?the stomach?

2. The patient is nauseated. 2. The patient is nauseated. Thanks for the treatment. Thanks for the treatment. Now she has a headache.Now she has a headache.

3. It is time for new 3. It is time for new pediatric tracheal tubes!pediatric tracheal tubes!

Case #1Case #1

5 month old, 5.2 kg infant girl 5 month old, 5.2 kg infant girl with trisomy 18with trisomy 18

Feeding intolerance: PEG tubeFeeding intolerance: PEG tube

Recurrent aspiration pneumonitisRecurrent aspiration pneumonitis

Clinical evidence of GERClinical evidence of GER

Radiographic studies: no Radiographic studies: no evidence of GERevidence of GER

Case #1Case #1

Continued clinical evidence of Continued clinical evidence of GER and aspiration pneumonitisGER and aspiration pneumonitis

Scheduled for open NissenScheduled for open Nissen

Induction: thiopental, cis-atracInduction: thiopental, cis-atrac

Intubation: 3.0 mm COTTIntubation: 3.0 mm COTT

Slight leak, = breath soundsSlight leak, = breath sounds

Case #1Case #1

Orogastric tube placed: left Orogastric tube placed: left open to atmosphereopen to atmosphere

Surgeon: several comments Surgeon: several comments about intermittent gastric about intermittent gastric distentiondistention

Is OTT too proximal with back Is OTT too proximal with back leak into esophagus?leak into esophagus?

Case #1Case #1

Nissen completedNissen completed

Flexible FOB via ETT: tube in Flexible FOB via ETT: tube in good position in mid-trachea, no good position in mid-trachea, no tracheal anomaliestracheal anomalies

Rigid bronchoscopy with ETT Rigid bronchoscopy with ETT removedremoved

Case #1Case #1

Rigid bronchoscopy #1Rigid bronchoscopy #1

Case #1Case #1

Rigid bronchscopy #2Rigid bronchscopy #2

Case #1Case #1

Rigid bronchoscopy #3Rigid bronchoscopy #3

Case #1Case #1

Rigid bronchoscopy #4Rigid bronchoscopy #4

Case #1: ConclusionsCase #1: Conclusions

H type tracheoesophageal fistulaH type tracheoesophageal fistulaRarest of the TEFsRarest of the TEFs1:100,000 live births1:100,000 live birthsDifficult to diagnoseDifficult to diagnoseDelayed diagnosis: adulthoodDelayed diagnosis: adulthoodHigh index of suspicionHigh index of suspicionUnexplained gastric distentionUnexplained gastric distentionProbable cause of aspirationProbable cause of aspiration

MRI DayMRI DayDo I remember how to get there!Do I remember how to get there!

Walking to MRIWalking to MRI

The door to MRIThe door to MRI

Case #2Case #2

MRI DayMRI Day6 scheduled, 1 cancelled6 scheduled, 1 cancelled3 or 4 added, unscheduled ABR3 or 4 added, unscheduled ABR““Can we run two scanners”Can we run two scanners”Moyamoya patient addedMoyamoya patient addedNeurologist: “use Moyamoya protocol”Neurologist: “use Moyamoya protocol”

Case #2Case #2

12 year 73 kg female for cranial MRI12 year 73 kg female for cranial MRIInhalation induction, i.v. insertedInhalation induction, i.v. insertedSize 3 LMASize 3 LMAAnesthetic course uneventfulAnesthetic course uneventful4 mg ondansetron iv at end4 mg ondansetron iv at endLMA removedLMA removedSent to recovery roomSent to recovery room

Case #2Case #212 year old in recovery (MRI)12 year old in recovery (MRI)Induction underway next caseInduction underway next caseMRI tech: “Can we do another room?”MRI tech: “Can we do another room?”Neurologist: “Use the Moyamoya protocol”Neurologist: “Use the Moyamoya protocol”Recovery nurse: 12 year old is nauseatedRecovery nurse: 12 year old is nauseated Q: What can I give her?Q: What can I give her? A: Decadron 4 mgA: Decadron 4 mg R: I don’t have anyR: I don’t have any RR: Here, take some of mine RR: Here, take some of mine

LaterLater

MRI PACU nurse calls:MRI PACU nurse calls:The nausea is gone, The nausea is gone, but now she has a headachebut now she has a headacheI go see the patientI go see the patientHR: 46 BP: 148/90HR: 46 BP: 148/90I look at the end of the bed and I look at the end of the bed and see:see:

Look alike labelsLook alike labels

Anesthesia cart in MRIAnesthesia cart in MRIAway from the main ORAway from the main OR

Cart needs to be well stocked for any eventCart needs to be well stocked for any event

Case #2 ConclusionsCase #2 Conclusions

Be careful of look-alikesBe careful of look-alikesAlways read the labelsAlways read the labelsEncourage others to read the labelEncourage others to read the label

The ideal pediatric ETTThe ideal pediatric ETTMinimize reactivity to ETTMinimize reactivity to ETTReduce tissue traumaReduce tissue traumaGood seal to preventGood seal to prevent

gas leakgas leakreduced ventilationreduced ventilationaspirationaspiration

Pediatric Microcuff tubePediatric Microcuff tube

Distally displaced cuffDistally displaced cuffDesigned specifically for children

Better sealBetter seal

Infant vs adult larynxInfant vs adult larynxSmall tube through glottis and cricoidSmall tube through glottis and cricoid

Seal in tracheaSeal in trachea

1.2 kg infant: expl lap1.2 kg infant: expl lapCXR in NBICUCXR in NBICU

Inability to ventilateInability to ventilate

ETT repositionedETT repositionedImproved ventilationImproved ventilation

ETT ConclusionsETT Conclusions

Microcuff tube: Microcuff tube: several advantagesseveral advantagesSmaller tube Smaller tube Low pressure tracheal sealLow pressure tracheal sealMore optionsMore optionsMay not be suitable for less than 3 kgMay not be suitable for less than 3 kgRecommendRecommend

large triallarge trialstock more MC tubesstock more MC tubes