This episode of Cautionary Tales will focus on a couple of lessons I’ve learned from experience when providing sedation for children undergoing multiple procedures during the same sedation event. To many of you, this information may seem like common sense, but some, like me, may have learned the hard way. Let’s hope that these tips prevent at least one of you from experiencing the same problems.
The first case (that occurred many years ago) is that of E.B., a three year-old girl with neuroblastoma who was scheduled for a CT of the chest, abdomen and pelvis in addition to an MIBG scan. Both studies were planned to occur in the morning with deep (propofol) sedation, with a natural airway. The MIBG was scheduled for 9:00 am table time, with the CT to follow at 10:30 am. The patient was screened the day before and deemed healthy enough for isotope injection. (Another caution with this particular scan is to screen early and well, as the isotope is injected the day before the actual sedation, and it is quite expensive. To cancel the sedated procedure the following day due to illness is a costly inconvenience).
The sedation event went well and both scans were obtained uneventfully. Unfortunately, the chest portion of the CT scan was deemed difficult to interpret due to significant dependent atelectasis. Atelectasis can occur in a fairly short period of time in sedated or anesthetized children, even in relatively healthy children breathing spontaneously. A recent article (Newman B, et al. “Chest CT in Children: Anesthesia and atelectasis,” Pediatr Radiol 2014;44(2):164-72) describes successful prevention of atelectasis with a controlled-ventilation anesthetic technique. In our institution, we’ve avoided problems with atelectasis by changing our scheduling practices, always performing the chest CT before the linked longer imaging study, be it MIBG, MRI or bone scan. We generally induce sedation for CT “on the table” to minimize the opportunity for atelectasis to occur.
Another commonly occurring issue around linked events in our facility is that of the young patient with newly-diagnosed leukemia. These kids usually require several sedated procedures in a short period of time, and they warrant an effort to streamline the process. Our oncologists and interventional radiologists work with us to accomplish long-term vascular access (PICC or port), bone marrow studies, and the first dose of intrathecal chemotherapy all in the same sedation event. I had a case last week of a very shy school-aged boy with new ALL where we also included a sedated testicular exam in the list of procedures. Our oncologists are sticklers for their patients remaining flat for a full hour after the IT chemo, which can be a challenge in toddlers and pre-schoolers. Whenever possible, when a lumbar puncture with IT chemo is part of a “batch” of procedures in a young patient, we try to do the LP first. That way the patient is supine (or lateral decubitus position) for the remaining procedures, minimizing the “flat” time in recovery.
I’m sure many of you have tips of your own to share, around multiple procedures, or sedation in general. Feel free to share them in this Cautionary Tales forum. We at SPS News hope that this column serves all of us as a non-judgmental, educational forum. Speak up and share!
Finally, in follow-up to last edition’s “look alike” medication cautionary tale, here is a picture of another set of VERY similar appearing medications that could have potentially catastrophic if confused – ketamine and heparin!
