Reader response

Myron Yaster MD

From Casey Lenox MD, semi retired

Today’s PAAD here has me wondering…should we be using rocuronium instead of succinylcholine for laryngospasm?

In response from Jamie Peyton, MD, Boston Children’s Hospital

It depends! Lots of variables to consider, for example:

Do you have IV access? - IM rocuronium will take too long to work so sux would be a better choice if you have no IV access

When did it happen? - Management at induction may be different from during emergence in terms of what you want to happen after you have solved the problem.

What drugs have already been given? - If sux has already been used as part of your management you run the risk of significant bradycardia on top of an already hypoxic insult, so roc may be a better choice, Conversely if roc has already been used and then reversed with sugammadex, sux may be preferable.

What are the patient’s comorbidities? - There are a host of conditions where we think carefully about avoiding sux, so if the patient has one them moving to high dose roc may be sensible given we can rapidly reverse even high doses.

Personally I think because one of the highest risk periods for us is at induction when we may well not have IV access, that sux is here to stay as when given IM it has a more reliable and faster onset time than roc.

Interested to know what others think. Send your thoughts to Myron (myasterster@gmail.com) and he will post next week.

From Jordan Ruby, MD, Alex Sideris, PhD, Michelle Carley, MD, Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College, Hospital for Special Surgery

Thank you for the recent PAAD on pediatric regional anesthesia here. The controversy over performing peripheral nerve blocks awake or under general anesthesia has long been of interest to us. There is another option that is infrequently discussed- we place the majority of our peripheral nerve blocks after neuraxial anesthesia.

This allows the patient to be lightly sedated, amnestic, and breathing spontaneously, but the limb to be blocked is immobilized. We do over 1000 spinals a year in children and adolescents, and many of these children receive peripheral nerve blocks after the spinal anesthetic. We find low complication rates and high success rates with this approach.

With regards to LAST, our most recent look at our data shows that over a 10-year period with 11,000 blocks in patients <18 years old, we had no instances of LAST requiring intralipid in our institution. We had one instance of a seizure in a child who has a pre-existing diagnosis of a seizure disorder which was presumably not related to the PNB. Our population tends to skew towards older children and adolescents, but we find it reassuring that LAST remains a rare event in the current era of heavy reliance of PNB for postoperative pain relief.

From Dr Daniel Braunold, Lead for pediatic cardiac anesthesia, Rambam Medical Centre, Israel on button battery ingestion management

I thought I would send my two cents about my experience from button batteries and a warning about a possible rapid sequence induction for these children. What’s critically important to understand is that there’s a significant difference between initial problems with the battery adhering to the side of the oesophagus and later complications, which happen to be about a week later, where you get oesophageal stricture, perforations, and other complications.

In the initial presentation, where the button has been swallowed within the past 24 hours, these children need an urgent esophagoscopy and bronchoscopy to make sure there is no damage. Simply performing a rapid sequence induction is not necessarily what these children need, even with the possibility of having it in the stomach. It becomes even more complicated one week later down the line, where there is a suspicion of a button battery. I remember a case where a child presented one week after ingestion of a button battery that had caused tracheal oesophageal fistulas and three perforations inside the trachea, one in the main trachea, one in the left bronchus, and one in the right bronchus. This child had an oesophagoscopy and MLB under spontaneous breathing, and we needed to generate a plan in which we could get this child on to bypass after a sternotomy while spontaneously breathing on an LMA. Placing an endotracheal tube in a child with massive perforations in their trachea and bronchi would only cause pneumediastinum and an inability to ventilate the child.

From Audra M. Webber, MD FASA, Department of Anesthesiology and Critical Care Medicine, CHOP, Associate Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Chair, ASA Committee on Ambulatory Surgical Care, Co-Chair SAMBA Pediatric Committee

Thank you so much for discussing our review of anesthesia for ambulatory pediatric orthopedic surgery in today’s PAAD here, and many thanks to Suresh’s expertise and for the highlighted review and discussion of compartment syndrome. We would like to respectfully point out that we discussed the risk of compartment syndrome within the orthopedic trauma section with regard to utilization of regional methods. Additionally, because the paper focused on ambulatory surgery, we mentioned compartment syndrome and neurovascular compromise with regard to discharge instructions. In answer to the question posed--- “Do you perform nerve blocks in patients at high risk for compartment syndrome?”– and particularly because we are discussing ambulatory surgery where the patient is going home and will not have an on-site ortho resident to assess them– I would NOT block a patient in whom there is a significant risk for compartment syndrome. It is questionable whether a patient with a high risk for compartment syndrome would be undergoing ambulatory surgery at an ASC in the first place.

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