SPS Plenary Session | May 22, 2019, 9:45 am
Moderator: Lorie Reilly
Panel: Laura Mitchell, Amber Rogers, Carmen Sulton
Our closing plenary session for the 2019 conference was the ever-popular “stump the experts” panel. The panel discussed a total of six challenging cases this year.
The first patient was a seven year-old presenting with a chin and upper gingival laceration requiring repair by oral/maxillofacial surgery. Related to the injury, her upper incisors are also now loose. She ate at McDonald’s approximately four hours ago. She is otherwise healthy.
Our panelists reviewed the significant potential aspiration risks associated with intraoral blood and loose teeth. Dr. Sulton discussed that, assuming that this is not an emergently required repair, she would recommend for the patient to be more fasted to minimize aspiration risk from her recent full meal. She also suggested potential referral to the OR if the teeth are quite loose and could pose a problematic airway. She’d think about utilizing nitrous oxide, intranasal midazolam, and/or distraction if the repair needed to be completed in the ED. Ms. Mitchell identified that this is a more challenging procedure to provide distraction for since the proceduralist, procedure, equipment, etc., will all be in the child’s face. Dr. Rogers discussed the potential use of ketamine as well as removal of the loose baby teeth to minimize aspiration risk during the procedure.
The next patient was a 10 year-old child with an underlying history of autism, ODD, and ADHD, who presented for a lab draw, immunizations, as well as a potential ECG. He weighs 62 kg and has a BMI of 24. His clinic was unable to draw his labs awake. He’s had a previous sedation with oral midazolam (with moderate effect) and had no problems with propofol or general anesthesia. He does still have an occasional loud snore despite having a T&A at age four.
The team discussed a number of questions, strategies to provide the best possible environment, and potential interventions. Does the patient take oral medications? If so, he might be a candidate for an oral benzodiazepine at home, though this practice is controversial and not allowed at some institutions due to the associated risk. The willingness to take oral medications does increase potential anxiolysis/minimal and moderate sedation options once he has been evaluated further. Does the patient utilize a mask for breathing treatments or not mind a mask on his face? If so, then inhaled nitrous oxide might be a reasonable option. The panelists all agreed that having all members of the care team on the same page up front and engaging parents as partners in collaboration on a customized care plan are keys to success. They also recommended having child life specialists work with satellite sites to ensure a safe and positive experience there as well.
This six year-old presented for a MRI of the brain for headaches. She’s developmentally appropriate and the scan will only take ~10-15 minutes at most, but mom is insistent that she cannot hold still and will require sedation. Mom herself is claustrophobic and feels her daughter will be as well.
The panel discussion focused on communicating and collaborating with the parent and child. Many families don’t completely understand what is involved in “trying without” sedation, including child life involvement, movie goggles/systems, faster turn-around, and the ability to convert to procedural sedation quickly if the child is unable to remain still (rather than being sent home to return at another time). Keeping expectations reasonable is important. Panelists agreed that one way to approach and present this is, what would I do if this was my child?
In the next case, a 28 year-old presented for an MRI of the brain with and without contrast for NF1 and monitoring of stable CNS lesions. This young man has severe cognitive delay and anxiety, and his parents have ongoing custody of him. His BMI is 23. He’s had GA for all of his previous MRIs, and his parents insist that an oral benzodiazepine will not provide adequate sedation to obtain the images.
For this situation, panel members focused their discussion on the need to develop transition plans earlier for young adults so that they can be adequately triaged and managed by providers who are trained and credentialed to provide care to adult patients. None of the panelists felt that sedation provided by a pediatric team was the best/safest plan for this young man.
The following case involved an 11 year-old who is scheduled for moderate sedation for a video urodynamic study followed by a non-sedated DMSA scan for recurrent UTIs. She is developmentally appropriate but does have a history of anxiety. Upon hearing more about what will be involved for these tests, she is refusing to allow the team to proceed, stating that her parents lied to her about what would be happening and, “you can’t make me do this.”
Ms. Mitchell provided a significant amount of insight for cases involving children who are old enough to participate in the assent/consent process. In many cases, patients’ concerns involve the preparation for the exam, such as the IV placement, rather than the exam itself – such concerns can largely be alleviated with conversation, reassurance, comfort techniques, and oral anxiolytics. Parents need to be active participants in age appropriate sharing of information and in developing an understanding regarding the need for the test or procedure in question with their child. All panelists agreed that, given the age of the patient in the case, it would not be appropriate to force the child to proceed if she remains adamantly opposed after further discussion with the family. In that case, the test should be rescheduled, the child and parents should take additional time to talk so that the parents can regain her trust, and the ordering team should perhaps be involved in reviewing the need for the exam and regrouping with the child and family.
The final patient case was a 14 year-old young woman who presented with bilateral foot tingling and lower extremity weakness following a gastroenteritis illness 2-3 weeks ago and who now requires an LP. She and her mother speak Farsi and an interpreter is required for all communication. The patient is quite anxious at baseline. On further discussion about the history and plan with mom, she does not want her daughter to be told that a lumbar puncture is being performed, just that she will be sleepy to have another test. Neurology had previously obtained informed consent for the procedure from mom, and because the team is quite busy they are interested in getting started with the procedure ASAP.
Our panel members were all uncomfortable with proceeding without the patient having some understanding of what will be happening to her while she is sedated. Ms. Mitchell again provided lots of insight on communicating with families in these types of challenging situations. All panel members felt that an interpreter should be engaged to help the sedation team members to explore with mom why she does not want her daughter to know what’s being done and to discuss more with the patient about what she understands is happening so far. Ms. Mitchell emphasized that the patient’s autonomy must be considered and that proceeding without informing her could contribute to lack of trust between the patient and her mother as well as the health care team. Dr. Rogers made the point that we did need to make sure we weren’t projecting our values onto the family or situation, but both she and Dr. Sulton agreed that the patient needed to be told something, and that if she then refused to have the sedated procedure performed, the neurology team would need to be more involved in the discussion.