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Oral case 77

Created: 11/10/2004

Pediatrics: cleft palate repair

An 18-month boy for cleft palate repair has a hemoglobin of 10 gm/dl.

1. Why do some anesthesiologists give routine anticholinergic premedication to pediatric patients?

Anticholinergic premedication may be given to blunt the paradoxical bradycardia response to laryngoscopy that pediatric patients often have.

1. What is your plan for fluid management?

2. At what point would you transfuse the patient?

3. Following extubation, in the recovery room, he has increasing respiratory distress. What is your differential diagnosis?

4. What is your management?

Effects of nitrous oxide

A colleague tells you that nitrous oxide should never be used.

1. What is your response?

2. What are the continuing concerns regarding effects of nitrous oxide?

3. Why use it?

Outpatient anesthesia

1. What are advantages and disadvantages of regional anesthesia for ambulatory surgery patients?

2. What discharge criteria should be used for outpatients who receive regional anesthesia?

3. What is a good intravenous agent for outpatient anesthesia?

Propofol is an excellent drug for this setting, because of rapid induction and recovery, antiemetic effects, and a shorter stay because of early cognitive function. Midazolam, along with fentanyl, sufentanil, or alfentanil, is used for brief periods. Alfentanil is particularly desirable, for it has a short period of action and can be used as a continuous infusion. Its tendency to cause nausea and emesis can be offset by using propofol and/or an antiemetic in conjunction with it.

Anticoagulation and regional anesthesia

A patient is on anticoagulant therapy for a prosthetic mitral valve, and is scheduled for surgery. Should she receive regional anesthesia?

Regional anesthesia is possible if it is clearly indicated. Since the risk of thrombosis or embolism is increased without anticoagulation, and if general anesthesia carries more risk in this setting, timing can be co-ordinated so that minimal risk of thrombosis and neuraxial bleeding occur.

2. How does one manage the dis-continuation of oral anticoagulant therapy?

Discontinue oral therapy three to five days prior to surgery, and begin intravenous heparin also. Stop heparin four to six hours prior to regional anesthesia, and restart after one hour if needed. If surgical bleeding is to be significant, restart after twelve or more hours.

3. Can regional anesthesia be performed on a patient taking aspirin for osteoarthritis?

Yes, if there is no history of bleeding or bruising, spinal or epidural anesthesia is appropriate.

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