Unusual Cases in Pediatrics

There are many ways of providing anesthesia, and yet, we often get locked into one particular type of anesthetic. It might make sense in pediatrics where children fear needles, deal with pain differently, and distrust physicians. Almost every anesthetic is a vanilla general anesthetic. We manage pain with IV acetaminophen, ketorolac, fentanyl, and occasionally, hydromorphone. But it doesn't always have to be this way. For some painful orthopedic procedures, I decided to put in a spinal for post-operative pain management. We decided to place the spinal awake, which can be harrowing experience for some teenagers. But when I think about it, we often put in epidurals for teenagers having a baby, and they do fine. So I began offering spinal anesthetics to any patient who I think might benefit. Although it is scary to have someone place a needle in the back where a patient can't see, a few older teeangers took us up on the offer, and their anesthetic was incredibly smooth with a great wake-up. It reminded me not to slip into the rut of doing everything by routine, because sometimes breaking out of the norm can really help a patient's experience.

The most interesting case I had during my month on pediatrics was a case booked simply as "extubation in the operating room." Although we had ENT surgeons present, they didn't do anything. A one-month old premature 2kg baby had a repair of a tracheo-esophagela fistula. This was complicated by severe tracheal swelling, and at the end of the procedure, the anesthesiologist felt unsafe extubating the patient. He stayed in the neonatal intensive care unit for several days awaiting the swelling to subside. We then took him back to the operating room. After examining the airway with a tiny fiberoptic bronchoscope and studying his airway mechanics, we decided he was ready and pulled the tube. He breathed independently just fine. It was a great case because it showcased the importance of our decision-making as anesthesiologists. We always think of surgeons as the center of attention, so it's fun when we can bring what we do into the spotlight.