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YOUR PATIENT

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A 9-year-old boy with a history of developmental delay presents for bilateral hip osteotomies; he is bedridden and nonverbal.

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Physical examination shows an undernourished male with bilateral hip dislocation.

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PREOPERATIVE CONSIDERATIONS

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There are many underlying conditions that cause developmental delay, the most frequent of which condition is premature birth. Prematurity may also be associated with other conditions, including chronic lung disease, hydrocephalus, intracranial hemorrhage, seizure disorder, feeding problems and malnutrition, history of necrotizing enterocolitis, gastroesophageal reflux, chronic or recurrent aspiration, and retinopathy of prematurity.

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If the patient is taking seizure medication, it is important to maintain the medication schedule as much as possible, and to minimize any disruption of it. We need to evaluate the severity of gastroesophageal reflux. A history of central nervous system conditions, including the presence of a ventriculoperitoneal shunt, may be important if you are planning to use epidural anesthesia.

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Evaluate the extent of respiratory reserve. Assess the extent of aspiration pneumonia or bronchodilator use.

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ANESTHETIC MANAGEMENT

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  • Consider mask induction vs rapid-sequence induction.

  • Malnourished patients are prone to be hypotensive right after induction. They may require fluid resuscitation or vasoactive agents.

  • In patients with developmental delay, it may be harder to find a good endpoint for the extubation.

  • Load epidural catheter with 0.5-1 ml/kg bupivacaine 0.25%.

  • Maximal dose of bupivacaine (continous infusion + bolus) should be 0.4 mg/kg/h. You may add 1-2 mcg fentanyl to each ml of bupivacaine.

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POSTOPERATIVE CONSIDERATIONS

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Depending on the underlying conditions, the patient may need postoperative ventilator support and an intensive care unit bed. Use of epidural anesthesia with good analgesia may facilitate extubation after the surgery. The patient will usually get a spica cast. Create an opening in the cast so that the epidural insertion site can be examined if you plan to use epidural anesthesia postoperatively.

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DOs and DON’Ts

  • ✓ Do obtain a detailed history to evaluate the underlying conditions.

  • ⊗ Do not interrupt seizure medication if the patient is on it.

  • ✓ Do evaluate the risk and benefit of postoperative ventilation support.

  • ⊗ Do not forget that most patients will get a spica cast after surgery.

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CONTROVERSIES

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  • Placement of an epidural catheter can be confirmed using electrical stimulation, a radiopaque catheter, or water-soluble dye (Omnipaque 180, 3-5 ml).

  • Postoperative ventilator use vs extubation at the end of surgery.

  • Epidural use vs narcotics infusion postoperatively.

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SURGICAL CONCERNS

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A smaller femur head is at a higher risk for postoperative dislocation. Avascular necrosis of the femur head can occur.

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FACTOID

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Children in cultures where mothers swaddle children have a higher incidence of hip dysplasia. Swaddling brings the hip into forced adduction and promotes hip dislocation.

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