1. M & M Conference October 15, 2008 Stephen F. Dierdorf, M.D.

2. You think your job is bad! 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 Orogastric tube placed: left open to atmosphere Surgeon: several comments about intermittent gastric distention Surgeon: several comments about intermittent gastric distention Is OTT too proximal with back leak into esophagus? 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 H type tracheoesophageal fistula Rarest of the TEFs Rarest of the TEFs 1:100,000 live births 1:100,000 live births Difficult to diagnose Difficult to diagnose Delayed diagnosis: adulthood Delayed diagnosis: adulthood High index of suspicion High index of suspicion Unexplained gastric distention Unexplained gastric distention Probable cause of aspiration 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 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 12 year 73 kg female for cranial MRI Inhalation induction, i.v. inserted Inhalation induction, i.v. inserted Size 3 LMA Size 3 LMA Anesthetic course uneventful Anesthetic course uneventful 4 mg ondansetron iv at end 4 mg ondansetron iv at end LMA removed LMA removed Sent to recovery room 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? Q: What can I give her? A: Decadron 4 mg A: Decadron 4 mg R: I don’t have any R: I don’t have any RR: Here, take some of mine RR: Here, take some of mine

19. Later MRI PACU nurse calls: The nausea is gone, but now she has a headache 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:

21. Look alike labels

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

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

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

25. Pediatric Microcuff tube

26. Distally displaced cuff Designed specifically for children

28. Better seal

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

31. 1.2 kg infant: expl lap CXR in NBICU Inability to ventilate

32. ETT repositioned Improved ventilation

33. 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