Anesthesia STAT!
Acute Pediatric Emergencies in PACU A
Clinical Casebook
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Susan T. Verghese
Editor
Anesthesia STAT! Acute
Pediatric Emergencies
in PACU
A Clinical Casebook
Editor
Susan T. Verghese
Department of Anesthesiology, Pain and Perioperative Medicine
Children’s National Hospital
Washington, DC, USA
ISBN 978-3-031-24395-0 ISBN 978-3-031-24396-7 (eBook)
https://doi.org/10.1007/978-3-031-24396-7
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This book is dedicated to all the pediatric
perioperative caregivers worldwide,
who run the race each day for the safety
and well-being of the patients entrusted
to them!
Preface
The art and science of pediatric anesthesia has evolved over the years to enable the
pediatric surgical team to perform complex surgeries in children of all ages and sizes.
The improvement in continuous intra-operative hemodynamic monitoring,
minimally invasive approach to surgical sites, use of short-acting muscle relax-
ants, hypnotics, narcotics, and of regional blocks have enabled the anesthesiolo-
gist to awaken the patient breathing spontaneously with minimal pain after
complex surgeries.
The continuation of optimal postoperative clinical safety and care in the immedi-
ate postoperative period of these surgical patients is a topic that should interest
every pediatric anesthesiologist.
Hitherto, there has not been a single textbook published that has described urgent
postoperative complications that occur in a pediatric PACU.
A year ago, two of our PACU nurses, Ms. Kathleen Curtis and Ms. Susan
Joslyn asked me this question: “Why is it that no one has written a book about
anesthesia stat calls and emergency situations in a pediatric PACU and how to
minimize these?”
Since we have collectively managed multiple emergency clinical situations post-
operatively in children, I realized that it was time to put down on paper, different
urgent clinical scenarios we have managed successfully.
As a pediatric anesthesiologist, blessed with the privilege to work at Children’s
hospital for more than 4 decades, I thank God for this opportunity to raise awareness
among the readers to anticipate these complications in children and perhaps learn to
decrease potential anesthesia stat calls.
The goal of this endeavor would be to teach members of the perioperative teams
around the globe, how we do things at Children’s hospital to keep anesthesia stat
calls to a minimum. The authors will first focus on how clinical monitoring and
safety of our post-op patients can and must continue after we hand off their care to
the PACU team and then describe 24 interesting clinical scenarios that needed
urgent intervention in PACU.
The task is undertaken by authors who are friends and colleagues, who describe
these clinical scenarios from their experience of caring for children who developed
these complications.
Chapter 1 is an introduction to this book—about nuts and bolts of post-op hand-
off and why the transfer of information of surgical patient is important for post-op
vii
viii Preface
care in pediatric anesthesia. It is titled “Passing the Baton” as in a relay race sce-
nario and is about the transfer of patient’s medical and surgical information or the
“Baton” between members of the relay team.
The focus of the first half is on how checklists became an important part of
handoffs historically and why an ideal complete handoff is necessary for continu-
ation of the patient’s safety. The specific focus on lateral or recovery positioning
of patients postoperatively and the scientific reason why an emerging patient
should be in lateral position is described with studies to support the importance of
this positioning. This is one simple effective technique used by the author Dr.
Susan T. Verghese to maintain airway patency of all patients during transport
from OR to PACU. The second half is authored by two experienced nurses at
Children’s PACU team: Ms. Kathleen Curtis BSN, RN, and Ms. Susan P. Joslyn
BSN, RN. They highlight the physical PACU setup, the flow of cases from Phase
1 to Phase 2 and the clinical problems seen in pediatric patients from the PACU
nursing perspective.
The first clinical scenario by Giuliana Geng-Ramos, is about a young child
developing anaphylaxis after administration of antibiotic in PACU.
The next clinical scenario titled somnolence in an infant after VP shunt revision
is by Dr. Nina Deutsch who discusses the etiology of lethargy in a child after place-
ment of a ventriculo-peritoneal shunt.
Dr. Chaitanya Challa takes on the task of detailing an undesirable post-op prob-
lem in PACU by describing the scenario of emergence delirium in a toddler after
surgery.
An unusual complication of cardiac arrest after central line placement in a child
in PACU is described by Dr. Chinwe Unegbu.
A 7-year-old young child who has a loose tooth pre-operatively seems to have
lost it on arrival to PACU! Dr. Jonathan Maxwell Teets takes the reader through a
hide and seek game where the tooth was there before but not now! Where is it? Who
saw it last?
It is unusual to anticipate problems after a bone marrow biopsy in a child with
leukemia. Dr. Andrew Matisoff describes a sudden clinical deterioration in a young
child who develops intractable cardiac arrythmias after anesthesia for a brief surgi-
cal procedure.
Dr. Cassie Rim describes another rare but clinically fascinating scenario where
an obese teenager develops shoulder pain and tachycardia after a liver biopsy per-
formed by the interventional radiologist under fluoroscopic guidance.
In a scenario of acute oxygen desaturation in a healthy teen on arrival to PACU
after hardware removal, Dr. Dan Vuong Thoai describes a classic clinical picture of
negative pressure pulmonary edema developing from airway obstruction.
Establishing Latex-free OR environment has made allergic reactions to latex, a
rare occurrence. Dr. Mingfei Wang takes the reader through an unanticipated case
scenario of a child with Spina Bifida developing latex allergy in PACU.
In another interesting clinical scenario, Dr. David Rico Mora, describes acute
O2 desaturation developing in a teenager in PACU after esophagoscopy and esopha-
geal dilatation.
Preface ix
Although the lateral positioning of patient is the most beneficial position in
patients with OSA, this position may not be possible for the patient to assume in
some cases. Dr. Daniela Perez Velasco describes the problem of respiratory arrest
occurring in a teen with obesity and OSA after a cardiac catheterization procedure.
Caudal anesthesia is an easily performed regional technique used in children to
provide intra-operative and postoperative analgesia for urological surgery. Dr.
Elisha Peterson describes the complication of weakness and the inability to walk
in a toddler in PACU after a caudal block.
Dr. Pooja Gupta draws an informative clinical picture of the acute complication
of post-extubation croupy cough and desaturation in ex-premature toddler. She
highlights important techniques to minimize the development of croup and the ways
to treat it in PACU.
Dr. Philip Dela Merced describes the genesis of apnea in an ex-premature infant
undergoing hernia repair under spinal anesthesia and describes the current treatment
available for this complication.
Dr. Nina Rawtani gives the reader a comprehensive clinical picture of a child
with persistent vomiting after eye muscle surgery. She describes the pathophysiol-
ogy and effective preventable methods to lessen this retching problem in the PACU.
Dr. Gregory Lessans describes an unusual scenario of a healthy young boy
developing blindness after undergoing bone marrow harvest in the prone position.
In another dynamic case scenario, Dr. Claude Abdallah invites the readers to
watch in awe as a clinical storm unfolds in PACU in a teenager who develops tachy-
cardia and hypertension after thyroidectomy.
Dr. Marjorie Brennan describes a clinical scenario of prolonged apnea after
laryngospasm treatment in a child with hiccups and coughing in PACU after Botox
injection for limb spasticity. Etiology?
What could cause seizures in a child after a caudal block performed after anes-
thetic induction for circumcision? Dr. Andrew Waberski invites the reader to take
a comprehensive look at this critical problem which can occur after a seemingly
successful caudal block.
Dr. Jerry D. Santos takes the readers through a maze of causes for sudden fever
after dental rehabilitation in a child. Wait, but could this be malignant hyperthermia?
Dr. Angela Lee details an urgent scenario of a young child vomiting blood in
PACU after T&A and enumerates steps to treat this perilous complication promptly
to decrease morbidity.
Dr. Phayon Lee describes the scenario of a morbidly obese teenager developing
acute oxygen desaturation shortly after arrival to PACU. What went wrong?
Children with sickle cell disease (SCD) require general anesthesia for cholecys-
tectomy for gall stones. Robert Scott Dingeman describes an uncommon but
alarming vascular complication in an SCD patient who develops sudden onset of
confusion and left-sided weakness in PACU.
Managing children with autism can be challenging to the entire perioperative
team. Dr. Alberto Rivera Cintron and Dr. Susan T. Verghese tackle the problem
of profound bradycardia when dexmedetomidine was used for treating agitation on
induction and emergence. To Treat or not to Treat this problem—is a dilemma!
x Preface
Finally, the authors of this book sincerely hope that reading these case series will
succeed in helping the reader to anticipate postoperative problems that can poten-
tially occur in children after surgery and attempt to minimize them by early preven-
tive interventions.
For this allegorical relay race from OR to PACU to succeed, the following steps
are vital:
First, know your patient well by detailed history and thorough physical examina-
tion, to plan and provide the safest and best anesthetic for the scheduled surgery.
Anticipate and prevent possible complications from occurring during transport
and in PACU by careful patient positioning and focus on continuous monitoring of
vital signs.
Next, communicate effectively to the PACU team EVERYTHING necessary
regarding the post-op patient, to spur them to continue the same vigilance in moni-
toring, to provide care and comfort in a seamless fashion.
It is important to remember that the prize is only won if the race is run for the
ultimate safety and comfort of our pediatric patients!
Washington, DC Susan T. Verghese
Contents
Passing the Baton: Check List/PACU Handoff: What Is Best? �������������������� 1
Susan T. Verghese, Kathleen Curtis, and Susan P. Joslyn
Anaphylaxis After Antibiotics in PACU ���������������������������������������������������������� 23
Giuliana Geng-Ramos
Somnolence After V-P Shunt Revision in an Infant���������������������������������������� 33
Nina Deutsch
Emergence Delirium in a Toddler�������������������������������������������������������������������� 45
Chaitanya Challa
Cardiac Arrest After Central Line Placement in a Child������������������������������ 55
Chinwe Unegbu
Lost Tooth After EGD in a 6-Year-Old Child�������������������������������������������������� 71
Jonathan Maxwell Teets
Intractable Cardiac Arrhythmias After Bone Marrow
Biopsy in a Child with Leukemia �������������������������������������������������������������������� 81
Andrew Matisoff
Shoulder Pain/Tachycardia After Liver Biopsy in a Teenager���������������������� 89
Catherine Rim
Teenager with Acute NPPE in PACU After Hardware Removal������������������ 99
Thoai An Vuong
Latex Allergy Developing in PACU in a Child
with Spina Bifida After Suprapubic Catheter Placement������������������������������ 111
Mingfei Wang
O2 Desaturation in a Teenager After Esophagoscopy,
Dilatation and Biopsy���������������������������������������������������������������������������������������� 123
David A. Rico Mora
Respiratory Arrest in an Obese Teenager in PACU
After Cardiac Catheterization�������������������������������������������������������������������������� 141
Daniela Perez-Velasco
xi
xii Contents
Inability to Walk After Caudal Anesthesia in a Toddler�������������������������������� 153
Elisha Peterson
Croupy Cough and O2 Desaturation in Ex-Premature Toddler�������������������� 163
Pooja Gupta
Postop Apnea in An Infant After Spinal Anesthesia
for Hernia Repair���������������������������������������������������������������������������������������������� 177
Philip dela Merced
Persistent Vomiting After Eye Muscle Surgery ���������������������������������������������� 187
Nina Rawtani
Blindness After Bone Marrow Harvest in a Healthy Patient ������������������������ 197
Gregory Lessans
Tachycardia and Hypertension in a Teen After Goiter Surgery�������������������� 205
Claude Abdallah
Prolonged Apnea After Treatment of Laryngospasm
in a Child After Botox Injection ���������������������������������������������������������������������� 219
Marjorie P. Brennan
Seizures in a Child After Caudal Block for Circumcision������������������������������ 229
Andrew T. Waberski
Hyperthermia in a Child After Dental
Rehabilitation: Is This M.H������������������������������������������������������������������������������ 241
Domiciano Jerry Santos
Vomiting Blood After Routine T&A���������������������������������������������������������������� 257
Angela C. Lee
O2 Desaturation After Bariatric Surgery in a Teenager �������������������������������� 267
Phayon U. Lee
Confusion and Sudden Onset of Left Sided Weakness
in a Patient with Sickle Cell Disease (SCD) After Gall
Bladder Surgery ������������������������������������������������������������������������������������������������ 287
Robert Scott Dingeman
Profound Bradycardia in a Child After Dexmedetomidine
Treatment for Agitation on Induction and After Extubation:
To Treat or Not to Treat?���������������������������������������������������������������������������������� 301
Alberto A. Rivera Cintron and Susan T. Verghese
Index�������������������������������������������������������������������������������������������������������������������� 313
Contributors
Claude Abdallah Division of Anesthesiology, Children’s National Hospital,
Washington, DC, USA
Marjorie P. Brennan Children’s National Hospital, Washington, DC, USA
Chaitanya Challa Children’s National Medical Center, Washington, DC, USA
Kathleen Curtis Children’s National Medical Center, Washington, DC, USA
Nina Deutsch Children’s National Hospital, Washington, DC, USA
Robert Scott Dingeman The George Washington University School of Medicine
and Health Sciences, Washington, DC, USA
Department of Anesthesiology, Pain and Perioperative Medicine, Children’s
National Hospital, Washington, DC, USA
Giuliana Geng-Ramos Children’s National Hospital, The George Washington
University School of Medicine, Washington, DC, USA
Pooja Gupta Children’s National Hospital, George Washington University,
Washington, DC, USA
Susan P. Joslyn Children’s National Medical Center, Washington, DC, USA
Angela C. Lee Division of Anesthesiology, Pain and Perioperative Medicine,
Children’s National Hospital, Washington, DC, USA
Phayon U. Lee Children’s National Hospital, The George Washington University
School of Medicine, Washington, DC, USA
Gregory Lessans Department of Anesthesiology, Pain and Perioperative Medicine,
Children’s National Hospital, Washington, DC, USA
Andrew Matisoff Division of Cardiac Anesthesia, Children’s National Hospital,
Washington, DC, USA
Philip dela Merced Department of Anesthesia, Pain, and Perioperative Medicine,
Children’s National Hospital, Washington, DC, USA
xiii
xiv Contributors
Daniela Perez-Velasco Division of Pediatric Cardiac Anesthesiology, George
Washington University, Washington, DC, USA
Division Anesthesiology, Pain and Perioperative Medicine, Children’s National
Hospital, Washington, DC, USA
Elisha Peterson Children’s National Medical Center, Washington, DC, USA
Nina Rawtani Division of Anesthesiology, Sedation and Perioperative Medicine,
Children’s National Hospital—George Washington University, Washington, DC, USA
David A. Rico Mora Department of Anesthesiology, Pain, and Perioperative
Medicine, Children’s National Medical Center, Washington, DC, USA
Catherine Rim Division of Anesthesiology, Pain and Pediatric Medicine,
Children’s National Hospital and George Washington University Hospital,
Washington, DC, USA
Alberto A. Rivera Cintron Children’s National Medical Center, Washington,
DC, USA
Domiciano Jerry Santos Children’s National Medical Center,Washington, DC, USA
Jonathan Maxwell Teets Department of Anesthesiology, Pain and Perioperative
Medicine, Children’s National Hospital, Washington, DC, USA
Chinwe Unegbu Division of Cardiac Anesthesiology, Children’s National
Hospital, Washington, DC, USA
Susan T. Verghese Children’s National Medical Center, Washington, DC, USA
Thoai An Vuong Division of Anesthesiology, Pain and Perioperative Medicine,
Children’s National Hospital, George Washington University SMHS,
Washington, DC, USA
Andrew T. Waberski George Washington University School of Medicine,
Washington, DC, USA
Mingfei Wang Children’s National Medical Center, Washington, DC, USA
Passing the Baton: Check List/PACU
Handoff: What Is Best?
Susan T. Verghese, Kathleen Curtis, and Susan P. Joslyn
Handing Patient Information as a Baton in a Relay Race. Illustration of a baton handoff in a relay
race. Need for a structured Handoff—History and Evidence -OR team Handoff to PACU—as seen
from the anesthesiologist view point. Author: Susan Verghese MD. PACU setup and PACU Nursing
Concerns in PACU: OR team to PACU as Seen from the PACU Nurses’ View point. Authors:
Kathleen Curtis BSN, RN; Susan P. Joslyn BSN, RN
S. T. Verghese (*) ⋅ K. Curtis ⋅ S. P. Joslyn
Children’s National Medical Center,
Washington, DC, USA
e-mail:
[email protected];
[email protected];
[email protected]© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 1
S. T. Verghese (ed.), Anesthesia STAT! Acute Pediatric Emergencies in PACU,
https://doi.org/10.1007/978-3-031-24396-7_1
2 S. T. Verghese et al.
1 A Safe and Complete PACU Handoff: Why?
1.1 Introduction
The operating room (OR) environment is one of the constant bustling areas with
patients’ arrival at the pre-op holding area and departure to the assigned OR for
anesthesia and surgery. The preoperative nurse welcomes patients after they are
registered, directing them and their families to assigned holding bays and evaluat-
ing, recording, and transferring information about the patient to surgeon, anesthesi-
ologist, and the OR nurse.
The anesthesiologist is ultimately responsible for assessing each patient for
appropriateness for surgery after the pre-op nurse’s initial assessment and for
administering premedication whenever indicated. The anesthesiologist relies on the
preoperative evaluation of each patient, derived from patient’s electronic medical
records, preoperative interview, and physical examination of the patient, to plan and
execute the optimal anesthetic technique for each case. Preoperative planning for
induction, monitoring, and pain management with narcotics and/or regional blocks
are all discussed with parents, before proceeding with anesthetic induction. When
the anesthesiologist, surgeon, OR nurse, technician, and the pre-op nurse are all
satisfied with necessary paperwork regarding consent, updated history, and physical
and specific tests for the patient, then the induction of anesthesia is signaled to pro-
ceed. Anesthetic management, type of airway used, intraoperative use of drugs and
intravenous fluids administered, blood loss, and urine output are recorded in the
electronic chart during anesthesia in the OR and available for the PACU nurse even
before patient reaches the PACU bay.
Patient’s vital signs (continuously monitored) and hemodynamic responses dur-
ing induction, surgery, emergence, and extubation are data that are also recorded in
the electronic chart. Even if the information about the anesthesiologist’s preopera-
tive assessment, need for premedication, and anesthetic management of each patient
is in the electronic record, this is again verbally repeated during handoff to the
PACU nurse.
A very busy OR schedule may not allow sufficient time for the anesthesia pro-
vider to transfer all the vital information regarding the patient to the receiving PACU
nurse. Incomplete and erroneous handoffs are well known to affect patient care and
safety adversely. Information without a structured approach can result in the omis-
sion of vital patient medical information if the handoff time is brief and rushed. A
well-structured method of handoff can assist each member in the perioperative team
to focus on vital information related to each patient necessary for continuing care
and safety.
1.2 Importance of Checklists: Historical Evidence
Checklists were first developed in aviation industry—a high-risk field that is often
compared to the specialty of anesthesia as modalities to help structure complex
processes involved in flying. Use of a checklist allows transfer of patient
Passing the Baton: Check List/PACU Handoff: What Is Best? 3
information to be complete, efficient, and safe for continuation of optimal patient
care in PACU. Its use during PACU handoff process has become very useful since
its benefits became evident following many studies in children and adults.
In a multicenter study by World Health Organization’s Safe Surgery Saves Lives
program involving 3733 enrolled diverse patients, 16 years and above in 8 hospitals
in 8 different cities undergoing noncardiac surgery, implementation of the checklist
was shown to reduce the morbidity and mortality [1].
In another study, the researchers’ review of literature on transfer of patient care
from OR to PACU showed that out of more than 500 papers, there were 31 papers
directly assessing postoperative handoffs, and 24 of them had recommendations for
a structured processing of information during handoffs, by using protocols and
checklists.
Several other broad recommendations included the following:
1. The need to have all relevant team members to be present for handoffs
2. The transfer of information to happen only after completing urgent clinical tasks
for the patient safety
3. To focus only on the patient-specific discussion, avoiding spurious discussions
not pertaining to patient
4. Emphasis on the need to provide training in improving team skills and
communication
An association between poor-quality handovers and adverse events was also
demonstrated in this review. [2]
An easy to remember technique named SBAR (Situation, Background,
Assessment, Recommendation) was suggested to frame important details about the
patient in a concise form by focusing on a stepwise fashion: the situation, followed
by a brief background of the present situation and the assessment you were able to
make about this problem and your recommendation.
SBAR continues to provide an ease of communication between healthcare team
members to focus on precise essential factors to improve patient safety [3].
Ineffective handoffs can occur when multiple handoffs occur in a speedy fashion
in PACU increasing the chance to omit transfer of vital information, for example,
about patient’s allergy or bleeding tendency. Anesthesiologists in Cincinnati
Children’s Hospital used quality improvement structured processes to facilitate
handoff in OR and PACU. Initiating a standardized PACU checklist improved the
reliability of their handoffs from 59 to 90% [4].
A pilot study examined the relationship between quality of handoff and PACU
length of stay. The authors of this study recommended that more efforts are needed
to train anesthesia providers to improve the quality of PACU handoffs [5]. Another
study recorded videos of handoffs between anesthesiologist and PACU nurse before
and after initiating checklists and recommended that the use of a checklist for post-
anesthesia handoff might improve its quality by increasing the quantity of informa-
tion handed over [6].
In conclusion, there is a need for continuation of increased vigilance in the care
of every patient after surgery.
4 S. T. Verghese et al.
1.2.1 Anesthesia Stat (AS) Calls
Despite the presence of advanced communication capabilities that currently exist,
emergency calls or Anesthesia Stat (AS) calls are still common in many medical
centers.
An interesting study from a tertiary university medical center showed the reason
for stat calls in children in the OR and in the PACU after emergence. The research-
ers of this study collected data prospectively for more than 3 years on the incidence
of Anesthesia Stat (AS) calls from pediatric operating rooms and in PACU. Of the
82 Anesthesia Stat calls in children whose ages ranged from 11 days old to 17 years,
60% AS occurred during emergence in OR, and 71% occurred in PACU.
Respiratory events were the cause of 97% of PACU calls and 86% of these calls
required the intervention of an anesthesia staff member. Eighty-nine percent
occurred within 30 min of patient arrival.
The researchers recommended the presence of an anesthesiologist or a member
of the anesthesia staff team with advanced airway management skills to be present
and available in PACU.
In our PACU at Children’s National Medical Center, the credit goes to our cur-
rent chairman, Dr. Eugenie Heitmiller who insisted on a daily assignment for a
PACU staff for exactly this reason for improved safety of PACU patients.
Another interesting finding was that 21% of the patients in the PACU AS call had
URI symptoms and 43% of patients in the PACU AS call group were patients who
were slowly emerging because of deep LMA removal in OR [7].
The above study reveals what most experienced pediatric anesthesiologists have
always known. PACU emergency or AS calls occur commonly from respiratory
events in children and in those who are emerging from a deeper plane of anesthesia.
Positioning of these patients in the recovery position or the lateral side when
possible is a simple efficient way to prevent airway obstruction and aspiration. The
presence of preoperative URI symptoms and a history of reactive airway disease in
the child can further worsen perioperative respiratory events.
A recent pediatric study evaluated the prevalence and risk factors associated with
perioperative respiratory adverse events (PRAE) in 210 pediatric postsurgical
patients in university hospitals in Ethiopia. Definition of PRAE included episodes of
coughing, breath holding, hypoxemia, laryngospasm, and bronchospasm. Incidence
of PRAE was reported as 26.2%, and 89% occurred in the postoperative period with
desaturation being the commonest, in age <1 year, presence of recent URI, increased
upper airway secretions, ASA status ≥3, and airway-related surgery [8].
The role of the PACU anesthesiologist is a very important role in evaluating
children after surgery for airway safety and pain control and in assessing their
readiness for discharge. In addition, there is active involvement in helping the
PACU nurses to provide optimal care, administer intravenous medications to
decrease emergence agitation in certain children, and discuss any concerns par-
ents may have regarding their children’s need for pain and comfort prior to
discharge.
Focus on complete and thorough patient information during handoffs cannot be
overemphasized because the lack of it can have deleterious effect on patient care
and safety. The relay of patient information starts from the preoperative team to the
