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M & M Conference October 15, 2008

M & M Conference October 15, 2008. Stephen F. Dierdorf, M.D. You think your job is bad!. Three Presentations. 1. Why can’t I decompress the stomach? 2. The patient is nauseated. Thanks for the treatment. Now she has a headache. 3. It is time for new pediatric tracheal tubes!. Case #1.

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M & M Conference October 15, 2008

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  1. M & M ConferenceOctober 15, 2008 Stephen F. Dierdorf, M.D.

  2. You think your job is bad!

  3. Three Presentations • 1. Why can’t I decompress the stomach? • 2. The patient is nauseated. Thanks for the treatment. Now she has a headache. • 3. It is time for new pediatric tracheal tubes!

  4. Case #1 • 5 month old, 5.2 kg infant girl with trisomy 18 • Feeding intolerance: PEG tube • Recurrent aspiration pneumonitis • Clinical evidence of GER • Radiographic studies: no evidence of GER

  5. Case #1 • Continued clinical evidence of GER and aspiration pneumonitis • Scheduled for open Nissen • Induction: thiopental, cis-atrac • Intubation: 3.0 mm COTT • Slight leak, = breath sounds

  6. Case #1 • Orogastric tube placed: left open to atmosphere • Surgeon: several comments about intermittent gastric distention • Is OTT too proximal with back leak into esophagus?

  7. Case #1 • Nissen completed • Flexible FOB via ETT: tube in good position in mid-trachea, no tracheal anomalies • Rigid bronchoscopy with ETT removed

  8. Case #1 Rigid bronchoscopy #1

  9. Case #1 Rigid bronchscopy #2

  10. Case #1 Rigid bronchoscopy #3

  11. Case #1 Rigid bronchoscopy #4

  12. Case #1: Conclusions • H type tracheoesophageal fistula • Rarest of the TEFs • 1:100,000 live births • Difficult to diagnose • Delayed diagnosis: adulthood • High index of suspicion • Unexplained gastric distention • Probable cause of aspiration

  13. MRI Day Do I remember how to get there!

  14. Walking to MRI

  15. The door to MRI

  16. Case #2 MRI Day 6 scheduled, 1 cancelled 3 or 4 added, unscheduled ABR “Can we run two scanners” Moyamoya patient added Neurologist: “use Moyamoya protocol”

  17. Case #2 • 12 year 73 kg female for cranial MRI • Inhalation induction, i.v. inserted • Size 3 LMA • Anesthetic course uneventful • 4 mg ondansetron iv at end • LMA removed • Sent to recovery room

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

  19. Later MRI PACU nurse calls: The nausea is gone, but now she has a headache I go see the patient HR: 46 BP: 148/90 I look at the end of the bed and see:

  20. Look alike labels

  21. Anesthesia cart in MRI Away from the main OR Cart needs to be well stocked for any event

  22. Case #2 Conclusions Be careful of look-alikes Always read the labels Encourage others to read the label

  23. The ideal pediatric ETT Minimize reactivity to ETT Reduce tissue trauma Good seal to prevent gas leak reduced ventilation aspiration

  24. Pediatric Microcuff tube

  25. Distally displaced cuff Designed specifically for children

  26. Better seal

  27. Infant vs adult larynx Small tube through glottis and cricoid Seal in trachea

  28. 1.2 kg infant: expl lap CXR in NBICU Inability to ventilate

  29. ETT repositioned Improved ventilation

  30. ETT Conclusions Microcuff tube: several advantages Smaller tube Low pressure tracheal seal More options May not be suitable for less than 3 kg Recommend large trial stock more MC tubes

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