Morning ReportAalap Shah, MDJue Wang, MD

6.28.2016

11(61%)4(22%)

3(17%)

# Procedures

IIIIII

ASA

Cases by ASA Classification

Cases by Surgical Service

10(56%)5(28%)

1 (5%)1(5%)1(6%)

# Procedures

GSOrthoOMFSORLOnc

GS Ortho OMFS ORL Onc0

2

4

6

8

10

12

IIIIII

ASA

Cases by Surgical Service and ASA

Cases by Patient Age

0-1 mon 1-12 mon 1-2 year 3-11 year 12-17 yr 18+ yr0

1

2

3

4

5

6

7

8

9

Weekend Cases 6/10-6/13ASA 1 ASA 2 ASA 3

13 y/o M w/ LLE laceration after ATV

accident I&D

9 y/o M w/ appendicitis lap appy

1 d/o FT M w/ imperforate anus colostomy

4 y/o M w/ metastatic Burkitt’s lymphoma and lumbosacral involvement LP

3 y/o M w/ R. supracondylar fx CRPP

6 y/o M swallowed wedding ring EGD

removal FB

12 y/o M s/p IR drainage of pleural effusion R. VATS biopsy, pleurodesis

6 m/o F w/ recurrent retinoblastoma, chemoRx CVL revision

2 y/o F with LLE FB removal FB

3 y/o F with spiral femur fracture after child fell on her

2 y/o M h/o MRSA abscesses, buttock abscess I & D

7 y/o F with B-ALL s/p induction chemoRx port revision

11 y/o F w/ open BBFx I&D + fixation

6 y/o M elbow fx after monkey bars

PP/repair

22 y/o F Pfeiffer’s sx, POD11 s/p LeFort III w/ jaw wound I & D

12 y/o F with pelvic rami and iliac fx after horse fell on her ORIF b/l

pelvis

17 y/o M punched window, R. wrist lac

exploration/repair

20 y/o w/ tonsil bleed POD4 s/p T&A

cauterization

20 y/o for T&A

HPI

• 20 y/o F with recurrent sore throat, R. ear otalgia, fever, trismus

• PE: 3+ tonsils, reactive cervical lymphadenopathy

• Scheduled for tonsillectomyPMHx: - Chronic nasal congestion

- s/p septoplasty (6/2015)- s/p wisdom teeth extraction- L. ACL partial tear (2008)- Concussion/post-concussive syndrome x 2

(9/2010, 5/2011)

Labs (4/2016)CBC: WBC 9.8, Hct 37.0, Plt 260, PBS wnlBMP: Na 139, K 3.7, Cl 103, CO2 27, BUN 15, Cr 0.7Blood Type: O+

20 y/o for T&A• Indications for tonsillectomy?

– Sleep-disordered breathing and sleep apnea • Tonsillar hypertrophy (age 3-6); involution after age 8 • Children with sleep apnea benefit from tonsillectomy, although decreased efficacy with

obesity– Severe recurrent sore throats

• Cochrane Review 11/2014: 3 vs 3.6 episodes/year (decrease in 0.6/year)• Recurrent strep infection despite abx

– Various other relative indications (ex, Peritonsillar cellulitis/abscess, dental malocclusion, hemorrhagic tonsillitis, prevention of secondary rheumatic fever)

• Comorbid conditions with long-standing disease?– Pulmonary Hypertension, cor pulmonale– OSA and “adult” comorbidities : DM, HTN, stroke

• How would you induce this patient?

20 y/o - Anesthetic Plan?

• Pre-med: Midazolam• Airway: 7.0 cETT, Mac 3, Gr 1 view• Monitors: ASA Standard• Induction: Propofol/Lidocaine/Fentanyl• Analgesia: Acetaminophen• Anti-emetics: Dexamethasone / Ondansetron

NSAIDs also work

• IV Fluids: LR 900cc• Discharge Rx: Acetaminophen, Oxycodone

20 y/o - Anesthetic Plan?

T&A POD 5…

• BCH ED after spitting up ~1.5 tbsp. of BRB while taking PO

• To OR for Tonsillar cauterization– Labs? Hydration? IV?• WBC 9.8, Hct 37.0, Plt 260, PBS wnl

– Findings: bleeding from R. tonsillar fossa; b/l inferior poles, EBL “minimal”

T&A POD 5…

• What are some common complications?

• Does age or time course of bleeding matter?

• How will you induce her now?– RSI, Propofol/Succinylcholine

Cauterization POD 5…

Tonsillectomy: Management Pearls

• Children who undergo the procedure for OSA are at particularly high risk of significant respiratory complications in the postoperative period

• Complications:– Pre-: Turbulent flow with anxiety/rapid breathing– Induction: Laryngospasm (↑ incidence vs. general population)– Intra: secretions, laryngospasm with extubation– Post: PONV, hypopnea, bleeding*

• Who should be observed overnight?– Pts. With OSA or evidence of RH dysfunction

The airway is shared between the anesthesiologist and the surgeon and must be protected from blood and secretions.

Tonsillectomy: Bleeding Management

• Post-Tonsillectomy hemorrhage rates = 1.9 –7%– Undiagnosed bleeding disorders!

• Does timing of bleeding make a difference? – First 24 hrs: More severe bleeding (usually in first 6 hours)

associated with “cold steel”– Secondary 5-10 days, after eschar falls off associated with cautery

• Mucosa involution• Does age make a difference?

– ↑ Incidence with ↑ Age (age 21-30: ~3.7%)– Prior hemorrhage ~12% risk for repeat hemorrhage

• If bleeding significant, may not be able to obtain Hgb in time– ↓ baseline SpO2: ominous for ↓ dO2 (d/t anemia)

ASA 1 ASA 2 ASA 313 y/o M w/ LLE

laceration after ATV accident I&D

9 y/o M w/ appendicitis lap appy

1 d/o FT M w/ imperforate anus colostomy

4 y/o M w/ metastatic Burkitt’s lymphoma and lumbosacral involvement LP

3 y/o M w/ R. supracondylar fx CRPP

6 y/o M swallowed wedding ring EGD

removal FB

12 y/o M s/p IR drainage of pleural effusion R. VATS biopsy, pleurodesis

6 m/o F w/ recurrent retinoblastoma, chemoRx CVL revision

2 y/o F with LLE FB removal FB

3 y/o F with spiral femur fracture after child fell on her

2 y/o M h/o MRSA abscesses, buttock abscess I & D

7 y/o F with B-ALL s/p induction chemoRx port revision

11 y/o F w/ open BBFx I&D + fixation

6 y/o M elbow fx after monkey bars

PP/repair

22 y/o F Pfeiffer’s sx, POD11 s/p LeFort III w/ jaw wound I & D

12 y/o F with pelvic rami and iliac fx after horse fell on her ORIF b/l

pelvis

17 y/o M punched window, R. wrist lac

exploration/repair

20 y/o w/ tonsil bleed POD4 s/p T&A

cauterization

Weekend Cases 6/10-6/13

12 y/o M for VATS biopsy

HPI

• P/w fever, cough, myalgias, congestion, nausea, vomiting, sore throat, intermittent H/A

• Dx PNA 3 months ago with mild R. pleural effusion• Treated with CTX complete resolution (per CXR)

PMHx: Born at at 31wks, 2-wks in NICU intubated; Otherwise HealthySocHx: From Sudan, travelling through Istanbul to US PE: Lethargic

- CBC: [6/2]: WBC 5.5, Hct 36, PLT 455; ESR 62, CRP 10, LDH 176 264- CXR [6/2]: RML/RLL consolidation + R. effusion: c/fPNA + parapneumonic effusion - CT [6/2]: R. pleural effusion with pleural thickening,

mediastinal + hilar LN: c/f empyema- Nl ECHO, respiratory cultures, ANA, pleural fluid flow cytometry and various bacterial/fungal cx Received CG in Sudan, started on Vancomycin/ceftriaxone at BCH

- To IR 6/3: PICC, 10Fr pigtail CT 825 ml serous straw-colored fluid (+400cc up to 6/10)- Negative induced sputum AFB x 3, but persistent fevers…

- 6/8: Positive Tspot and slightly elevated ADA (suggestive of isolated TB effusion) VATS

12 y/o M for VATS biopsy• How will you induce this patient and secure airway?• What are the absolute indications for single/one-lung

ventilation? How can you achieve it?– Protection (Blood/Pus/need for lavage)– Vt mismatch (BP/BPCF, ominous bullae, bronchial disruption)– VATS

• In addition to ASA standard monitors, what else would you like to look at?– Spirometry– Reliable Pulse oximeter!!!– ART (Measure PO2(A-a) gradient)

OLV - Approach• Age < 8 yrs

– Mainstem intubation +/- FOB, active/passive ipsilateral decompression• PRO: Single airway maneuver• CON: Cannot apply CPAP to nondependent lung; must withdraw tube for TLV

– Bronchial Blocker (individual, coaxial)• PRO: ETT in situ• CON: No passive oxygenation to dependent lung, inexperience

• Age > 8 (26+ F)• Robertshaw tubes (DL ETT)

– PRO: Seals/protects lung (suppurative pus), passive oxygenation and application of PEEP to dependent lung

– CON: Decreased airway diameter SLETT exchange for ICU, balloon herniation, inexperience, size

DLETT Placement: OpenAnesthesia.org

12 y/o - Anesthetic Plan?

Pre-med: IV MidazolamAirway: 6.5 cETT, Mac 3, Gr 1 view

EZ Blocker (41 min)Monitors: ASA StandardInduction: IV Propofol/FentanylAnalgesia: IV Morphine/KetorolacAnti-emetics: IV Dexamethasone/OndansetronIV Fluids: LR 300cc

12 y/o - Anesthetic Plan

OLV - Hypoxemia

• What are your SpO2 goals for this patient?– What happens to PaO2 with OLV? For how long does this

last?• What are some predictors of hypoxemia?• What do you do?– FOB– CPAP 10mmHg (at what lung volume? Contraindications?)– PEEP (dependent lung)– Pause surgery/OLV– Compress/clamp ipsilateral PA

OLV Hypoxemia - Pearls• Incidence of hypoxemia (with FiO2 1.0):

– 1950s 20%, 1980s 10%, Today 1%• V/Q mismatch + shunt (↑ with open chest)• Prediction of Hypoxemia:

– Hypoxemia (increased A-a pO2 gradient) during TLV– R > L (higher paO2 in PV return from L side)– GOOD spirometric PFTs

• Don’t have auto-PEEP – Baseline restrictive lung disease or severe COPD

• Avoid aggressive hyperventilation– ↓CO2 Inhibits beneficial hypoxic pulmonary vasoconstriction in ipsi lung– Increased alveolar pressures ↓ PBF in dependent lung

OLV Hypoxemia – Infants1. Easily compressible rib cage promotes atelectasis of the dependent (ventilated) lung2. ↓ hydrostatic pressure gradient between the dependent and nondependent lungs expected increase in dependent PBF is diminished3. ↓ abdominal hydrostatic pressure gradient ↓ functional advantage of dependent diaphragm4. ↑ VO2

OLV Hypoxemia - Algorithm

Thank You!

• Jue Wang, MD• Thomas Mancuso, MD [Course Director]• Carlos Munoz-San Julian, MD; Izabela Leahy,

RN BSN MS [Course Planners]