Question of the Month – July 2018 VentricularTachycardia in a Ten-month-old?Jennifer Zieg MD, University of Colorado, Children’s Hospital Colorado A 9 kg 10-month-old is undergoing thoracotomy for unilateral congenital cystic adenomatoid malformation (CCAM) resection. He was born at full term, and has had no other health problems. The patient has a thoracic epidural in place that seems to have been working well. A new nurse enters her shift and accidentally gives a 10ml bolus through the epidural. The patient develops ventricular tachycardia and hypotension. What is the MOST appropriate next step? 1. Administer a dose of epinephrine 2. Start CPR and call for the defibrillator 3. Administer a dose of intralipid 4. Ask the surgeons to do internal cardiac massage Time's up
Question of the Month – May 2018 17 year old male with Ewing sarcoma of Left 7th rib with bilateral pulmonary metastases scheduled for chest wall resection (en bloc with 6th, 7th, and 8th ribs together with diaphragm and left lower pulmonary lobe), left upper lobe and left lower lobe pulmonary wedge resections. PMH: pneumonia 2 months ago -resolved. Otherwise unremarkable.Preop labs - Hemoglobin: 10.3 (L)Hematocrit: 30.9 (L)Platelet Count: 193Fibrinogen: 338INR: 1.0Part Thromboplastin: 59.8 (H)Prothrombin Time: 13.4The anesthesia team in the room has tried placing an awake thoracic epiduralwithout success. You are called to suggest options for pain management.What postoperative pain management options would you then choose? 1. PCA only 2. Thoracic epidural catheter under GA 3. Paravertebral catheter with PCA supplement 4. Erector spinae plane block with PCA supplement Time's up
Question of the Month – January 2018 A 2.5 month-old, ex- 31 week premature infant is scheduled for an exploratory laparotomy for adhesiolysis and possible small bowel resection. The infant has a history of necrotizing enterocolitis, and underwent a small bowel resection six weeks prior to the operation. Other history includes grade I IVH. The infant was intubated for 3 weeks after birth, and for one week following her initial operation. She required significant amounts of opioid for sedation during mechanical ventilation, and recently finished weaning opioids. The surgeon requests epidural placement to facilitate immediate postoperative extubation and minimize postoperative opioids. Preoperative lab results include an INR of 1.3 (normalized values 0.8-1.2), PTT of 45.4 (normal 28-37 seconds), fibrinogen 175 mg/dL (normal 200-400), platelets 375 K/uL. What strategy would you select for postoperative pain management? A. Epidural (thoracic or caudal-to-thoracic) placement with local anesthetic infusion B. Continuous Morphine infusion C. PRN intravenous morphine D. Single-shot Paravertebral Block Time's up
Question of the Month – November 2017 A 9 year old female had an epidural placement for postoperative analgesia after osteosarcoma resection and reconstruction of the left leg. The epidural placement required multiple attempts by resident and attending. Patient reported on POD 1 that she is not able to sit up without 8/10 pain described as in the occipital location, dull, and constant. Orthopedic surgery wants to mobilize her early. What are your treatment options? A) Caffeine, acetaminophen and wait before mobilizing B) Blood patch under general anesthesia C) Acupuncture D) Head Imaging Time's up
Question of the Month – September 2017 Welcome to your Question of the Month - September 2017 Spinal anesthesia in infants is a viable anesthesia technique for surgeries such as inguinal hernia. A 2 month-old former 30 week gestation female is scheduled for a unilateral inguinal hernia repair. The resident on the case has a strong desire to perform the spinal. How does practitioner level (Attending/CRNA/Resident) matter in terms of success/failure of placement of an infant spinal? A) Spinal success rate is similar regardless of practitioner type B) Anesthesia attendings have as much as 15 times lower failure rate than a resident C) In order of highest success rate- anesthesia attending>resident>CRNA D) Ability to obtain CSF flow is similar with all practitioners, but block effectiveness varies with practitioner type Time's up