Matthias Hübler, Thea Koch and Karen B. Domino (eds.)Complications and Mishaps in Anesthesia2014Cases – Analysis – Preventive Strategies10.1007/978-3-642-45407-3_14
© Springer-Verlag Berlin Heidelberg 2014
14. Case 14: Septoplasty
(1)
Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
(2)
Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
Abstract
Dr. Pia was annoyed. It was Friday afternoon, shortly before quitting time, and she was sent to do a preoperative evaluation. Actually, she had planned to leave the hospital at 4 p.m. on the dot and set off on a weekend trip to the beach with a friend. “I bet my attending won’t be working late,” she mumbled to herself.
14.1 Case Introduction
>> Dr. Pia was annoyed. It was Friday afternoon, shortly before quitting time, and she was sent to do a preoperative evaluation. Actually, she had planned to leave the hospital at 4 p.m. on the dot and set off on a weekend trip to the beach with a friend. “I bet my attending won’t be working late,” she mumbled to herself.
There was a 12–year–old waiting with her mother. At the last minute, the ENT surgeon had scheduled the girl’s surgery for the first case on Monday morning. The preanesthesia clinic staff had just left for the weekend. “What crappy organization,” thought the annoyed Dr. Pia. “I’ll have to work this all out by myself. I hope it doesn’t take too long.”
She disappeared into an exam room to review the medical record. The patient’s name was Olivia. On Monday she was scheduled for a septoplasty due to trouble breathing through her nose. In an outpatient surgery 1 year ago, she had some complications. The report didn’t have any other details. “I’d better ask the mother; she’d know what happened,” thought Dr. Pia as she walked to the waiting room. “Olivia, please!” she called out, before leading patient and mom into the exam room.
Olivia – a pale petite girl – and her mother entered the exam room. Dr. Pia introduced herself and clarified the purpose of their preanesthetic visit. “During the last anesthesia, there seems to have been a problem. Do you know what that was?” she asked.
“No, I don’t exactly know,” said the mom. “However, I brought this.” She pulled out a worn yellow patient information ID card and an even more worn patient report. Dr. Pia read each carefully. On the yellow patient information ID, a propofol and midazolam allergy was noted. The ID card was signed by a pediatric allergist. It seems that during her previous surgery, Olivia had serious cardiovascular difficulties, aspirated gastric contents, and developed pulmonary edema, which required that Olivia be admitted to the hospital. Therefore, the ENT surgeons had decided to schedule the septoplasty as an AM admit procedure.
Olivia could not remember much from the last hospital stay. “Do I have to go to the ICU again? Will I have to stay for such a long time in the hospital?” Dr. Pia tried to calm her “No, there’s nothing to worry about. We now know what medications were problematic for you, and we can avoid those medications. Are you otherwise healthy? What do you do for exercise? Do you take any medication on a daily basis?”
“Olivia is on the regional table tennis team. That’s the reason it was so shocking for us last time. She is so healthy – hardly ever sick. She does not take any medication,” said her mother.
Dr. Pia was not sure if she should order premedication. Midazolam was standard; however, since an allergy was reported, it was better to be safe and not order anything.
14.1.1 What Do You Think of the Decision Not to Order Premedication?
This decision is wrong. The child is traumatized by her experiences during her last surgery and ICU stay and is therefore very anxious.
14.1.2 What Is the Point of Premedication?
The main goals are:
Sedation and reduction of fear – Fear activates the sympathetic nervous system, which can cause hypertension and tachycardia. In addition, sympathetic nervous system activation delays gastric emptying and increases gastric acid secretion.
Amnesia.
Prevention/minimization of postoperative vomiting and its associated risks.
Analgesia – Analgesia is usually indicated when painful positioning is required, for example, in unstable fractures or when patients have extreme pain due to their condition and therefore have an increased sympathetic activation.
Vagolysis (inhibition of parasympathetic nervous system) – In special circumstances, inhibition of salivary and bronchial secretions and prevention of vagal bradycardia can be beneficial.
Possible histamine blockade when allergic reaction is likely.
Possible aspiration prophylaxis/alteration of the composition of stomach acid.
>> In an attempt to discuss premedication, Dr. Pia phoned her attending. “Probably already gone for the weekend,” she thought. Sure enough, no one answered the phone. “Olivia is almost an adult; she can handle the situation without premedication,” thought Dr. Pia, who then informed Olivia and her mother about the anesthesia and possible complications. They felt well enough informed, and her mother signed the consent form. They said goodbye and headed for home. Dr. Pia was excited that her beach weekend was finally beginning!
14.1.3 What Medications Are Indicated as Premedication, and Which Ones Would You Have Ordered?
14.1.3.1 Benzodiazepines
Benzodiazepines are the most common group of medications to be used for premedication.
Effect: Anxiety reducing, calming, sedating, hypnotic, amnestic, muscle relaxing, and anticonvulsive.
Benefits: Minimal toxicity within a broad therapeutic range, minimal hemodynamic or respiratory side effects, and safe in malignant hyperthermia.
Disadvantages: Lack of analgesic effect, relatively long acting, duration of effect extended in liver disease and older patients, and occasional paradoxical excitation reactions.
Interactions: In chronic alcohol abuse, tolerance is expected; however, in acute alcohol intoxication, the central sedative effect is increased. Benzodiazepines decrease the MAC value of volatile anesthetics and decrease the requirement of intravenous anesthetics for induction of anesthesia.
Contraindications: Acute alcohol, opioid, or sedative intoxication, myasthenia gravis, ataxia, and known allergy.
The choice of benzodiazepines is based on the desired onset and duration of action. The substance most commonly used is midazolam, with a rapid onset of action and elimination. The substance can be given oral, IM, IV, and, in pediatrics, rectal or nasal (see Sects. 6.1.5 and 28.1.3). Midazolam is water soluble, whereas diazepam is not; therefore, injection of midazolam is not painful. Given orally, 50 % of the dose undergoes a first-pass effect. Midazolam is metabolized to 1-α-hydroxymidazolam and to 4-hydroxymidazolam, which contribute to about 10 % of the pharmacological activity of midazolam. Both metabolites have short half-life (~1 h), and although they are pharmacologically active, they do not prolong the duration of action of midazolam.
14.1.3.2 Barbiturates
The advantages of midazolam have drastically reduced the use of barbiturates. Only phenobarbital is rarely used.
Effect: Sedating, hypnotic, and anticonvulsive.
Benefits: Respiratory and cardiovascular effects minimal when given orally.
Disadvantages: Nonspecific central nervous system effects, a more restricted therapeutic range than benzodiazepines. When given in the presence of pain: excitation and confusion.
Contraindications: Acute hepatic porphyria.
14.1.3.3 Neuroleptics
Neuroleptics cause psychomotor retardation, emotional liability, and effective indifference.
The butyrophenone droperidol might be used for adult premedication and is usually combined with an opioid. There was a time when it was used for neuroleptic analgesia, but it has been abandoned today. FDA issued a black box warning for patients with QT prolongation, as some patients developed torsades de pointes following administration of droperidol. An ECG, to rule out preexisting long QT syndrome, is required prior to administration of droperidol.
The phenothiazine promethazine is extremely sedative, hypnotic, anticholinergic, antiemetic, and histamine antagonistic. There is no effect on anxiety, a major disadvantage that has limited its use.
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