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YOUR PATIENT

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A 14-year-old male patient with developmental delay presents for a Nissen fundoplication and gastrostomy tube. He takes esomeprazole and ranitidine. He has a history of having been born at 27 weeks’ gestation, with cerebral palsy, developmental delay, seizure disorder treated by levetiracetam, chronic lung disease, and severe gastroesophageal reflux disease (GERD) with multiple episodes of aspiration pneumonias. He takes fluticasone and albuterol daily. He also takes glycopyrrolate to help with management of copious oral secretions. During your rapid-sequence induction, a large volume of clear liquid is noted in the oropharynx, which you suction before passing your endotracheal tube.

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PREOPERATIVE CONSIDERATIONS

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Patients with chronic GERD and a history of aspiration pneumonia will come to you with chronic lung disease secondary to multiple episodes of aspiration. Even if they have no documented episodes of aspiration pneumonia, they may have microaspiration and will not have a great pulmonary reserve. We consider them at risk for aspiration during the induction of anesthesia, and should plan to do a rapid-sequence induction (or alternatively, an awake fiberoptic intubation). Patients with severe developmental delay and cerebral palsy will have varying degrees of cognitive dysfunction, and we should be careful when approaching these patients to be sensitive to the fact that they may have a perfect understanding of what is happening around them but be unable to communicate effectively.

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ANESTHETIC MANAGEMENT

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  • Rapid-sequence induction should be favored. Premedication with benzodiazepines is controversial; sometimes, it seems that they are necessary to preoxygenate a patient adequately, and giving patients a small dose of midazolam should not be detrimental to the patient’s ability to protect the airway. The risks and benefits of doing this should be weighed.

  • Always have suction available when you induce, as a rapid-sequence induction does not guarantee the absence of regurgitation.

  • Be ready to treat aspiration with suction and bronchoalveolar lavage if it is noted; bronchoscopy is indicated in the case of particulate aspiration.

  • The cricoid maneuver is classic, but the evidence to support its effectiveness is lacking. It may make visualization of the vocal cords harder.

  • Succinylcholine is not necessarily contraindicated in patients with cerebral palsy. Their cerebral injury is remote and stable. However, some of them are quite immobile, depending on the severity of their spasticity.

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POSTOPERATIVE CONSIDERATIONS

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The decision on whether or not to extubate a patient who has suffered aspiration depends on how the patient is doing during the case. If the patient has significant desaturation and is difficult to ventilate, the case should be rescheduled and the patient should be taken to the pediatric intensive care unit for further management of aspiration pneumonia or pneumonitis. More commonly, patients will be asymptomatic, and following bronchoalveolar lavage, the patient will be stable for surgery to continue. If the patient remains stable from a respiratory standpoint, then extubation should be attempted, but the patient should definitely ...

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