Dear Son's VNS Surgery-Meeting with Anesthesia

The meeting with Anesthesia went well on Friday.  We discussed Dear Son’s past surgical history and mapped out a plan for tomorrow.  Prior to meeting with the Attending Physician (Clinical Associate), I met with the “senior” resident. That drives me crazy quite frankly however because we go to a Big Academic Medical Center, they make you meet with the resident first.  I guess it’s not stressful for me enough to have to go through this surgery and to go back through my notes and rehash all of it to prepare for the meeting. Then I have to go through it with the resident AND again with the Attending Physician.

As I mentioned before, Dear Son is a high risk for respiratory depression and aspiration, meaning he has trouble breathing over the anesthesia and the airway can collapse. This is why the physicians ruled out any further surgeries after 2009. In addition, Dear Son has trouble normally managing his saliva. For that reason, he can never sleep on his back and must be side lying at all times. He only lasts two hours on his left side before he starts choking so I make sure to turn him at the two hour mark or as soon as I hear him gurgling. I typically prop him on his side at night and since Dear Son can’t roll over on his own, I turn him. If he were to be on his back and choking, he couldn’t turn himself over to help himself.

Anyway, it went well until he states that due to Dear Son’s extremely high surgical risk, that they may have to do the intubation (insertion of the breathing tube) while Dear Son is awake! He states that the administration of anesthesia prior to getting the tube in place can cause the airway to collapse hence doing it when he was awake. This is the point in the exam where the residents fail me. They come up with these ideas that they wouldn’t want done to them and that they have no problem recommending for someone else.  I told him it wouldn’t be done. I wouldn’t do it for myself and it won’t be done for Dear Son. Can you imagine someone placing a breathing tube in your mouth while you are awake? Now can you imagine someone inserting a breathing tube while you are on your back, choking AND you can’t roll over to help yourself or speak or push them away with your hands to stop?  I can’t either, that’s why it won’t be done. Anyway, I explained that Dear Son has an easy gag reflex and that if they tried to do it while he was awake, he would definitely aspirate so that the risk of aspiration was 100%.  I said previously people tried deep suctioning (where they insert a tube down to your lungs to suck out the fluid) and that in every case, Dear Son gagged, choked an aspirated. After I explained this to him and he kept trying to build his case, I simply stated that he needed to get the attending because I wasn’t going to agree. He did. We didn’t argue or anything and overall he was fine, it was just a case where the residents think more in terms of solving a problem than they do with the practical applications of things.

The Attending Physician came in and she was very nice. She agreed it wasn’t the right solution and said it wouldn’t be done. She said it’s not very successful in disabled patients anyway. We went on to have a nice discussion of the entire procedure. Granted, it’s really high risk.  As in enormously high risk.  She had read through the Anesthesia notes from August of this year when I had met with Anesthesia to discuss the possibility of throat surgery. The surgery was nixed due to the high risk. We talked about the previous surgery for the replacement of Dear Son’s Vagus Nerve Stimulator and the drugs used and what happened. I  had reviewed my notes previously from this surgery and gave her the highlights. Like I mentioned, there were problems however when I went through the issues with the surgery, I am careful not to use any names. My goal is for a great outcome tomorrow; I am not trying to ruffle any feathers. Since they won’t be using Propofol, they’ll use a technique called, “Rapid Sequence Intubation” to insert the breathing tube. Essentially, they administer anesthesia and a paralyzing medicine quickly, then insert the breathing tube quickly. Once it’s in, Dear Son should be o.k. The risk to the procedure is if his airway collapses from the anesthesia PRIOR to the insertion of the breathing tube. She asked me if any of the doctors had difficulty in inserting the breathing tube in past surgeries. I said I wasn’t sure however he had been intubated previously (on a ventilator) and that I didn’t recall that. She said if those insertions were successful previously, then the odds were things would be o.k. A lot depends on how Dear Son can manage this.  We also discussed using a Scopolamine patch to dry up Dear Son’s secretions. We had previously used this patch however it caused seizures for him. I did notice it doesn’t cause seizures until the 12-20 hour mark but is really effective in drying up secretions. We agreed to put the patch on 6 hours prior to surgery ; this should help prevent some aspiration since there would be less secretions to swallow or aspirate. Other drying agents weren’t effective for Dear Son.

We discussed the surgery and mapped out a plan for tomorrow:

·        Dear Son will get an IV in the pre-surgery room. We haven’t had issues with an IV previously so that is good.

·        They’ll keep him on his side so he doesn’t choke. They’ll keep him like this up until they intubate him.

·        Due to his high surgical risk, they’ll most likely use an Anesthesiologist that is double board certified in Anesthesia and Critical Care (ICU) versus one that is certified in just Anesthesia. (The good news here is that most of the ICU staff is familiar with Dear Son and also we see the Section Chief of Pediatric Pulmonary in clinic so she is very familiar with him should there be any issues tomorrow.)

·        They’ll give him IV meds to put him to sleep.

·        Next, they’ll do the Rapid Sequence Intubation. He’ll probably need to be on his back by that time for that but the surgery can be done on Dear Son's side. It’s actually on a good side for Dear Son and he doesn’t choke as much on this side. Once the breathing tube is inserted, they’ll put him on a ventilator for the surgery. The ventilator breathes for him in case he can’t breathe on his own (respiratory depression is averted since the ventilator breathes for him).

·        The surgery is performed.

·        Once the surgery is done, they’ll shut off the anesthesia gasses. They’ll measure the gasses on his exhalations which will tell them how much of the anesthesia is left. They are using a short acting anesthesia for him. Once they no longer have any anesthesia present in the exhalted breaths, they’ll remove hm from the ventilator.

·        The breathing tube may or may not be removed right after the surgery. It depends on how he does. I expected this. They think they can remove it right away but we’ll see.

·        He’ll stay in the hospital overnight to make sure everything is fine.

Overall, the meeting with anesthesia went well. So the nerve racking portion will be getting the tube in.  After I came home from the meeting, I recalled an episode at the local hospital many years ago where they administered seizure medicine (Dear Son was taken to the ER for seizures.) without protecting the airway and his airway collapsed and they had a code blue. This was while we were waiting for the helicopter to arrive to take him to Big Academic Medical Center.

Anyway, last night I thought I’d send an email to two of the ICU docs that have treated Dear Son previously. If I recall, one of them was present when he had respiratory failure in 2009 when he had the swine flu the day before his Make a Wish Trip. The other doctor was there to remove the tube and I couldn’t recall if she had but a breathing tube in his for a different time when he was on a ventilator. I sent an email to them both with a quick question to see if they recalled having any difficulty inserting the breathing tube in Dear Son. I wasn’t sure if I’d hear back. With all of the time we had spent in the ICU over the past years, I have come to know most of them pretty well and they certainly know Dear Son.

Luckily, one of them responded this morning and even took the time to look up the medical records from 2009 (I sent her his medical record number in the email, lol.). She provided me with the drugs they used to intubate him and also told me she didn’t have any issues getting the breathing tube in. I think that is good news. I’ll be able to provide the Anesthesiologist with this information tomorrow. And because it was all done at Big Academic Medical Center, they’ll know the docs involved.

Thank you for all of your prayers for tomorrow. I am still nervous but I think I’ve done everything I can to help it be successful tomorrow. I just heard back from the other ICU doc and she mentioned that she didn’t recall any issues with intubation so that certainly helps. I am also glad we are able to get this done right away-Dear Son is having more seizures now that the battery is low. He's crying out in his sleep and during the day; when I look at him, his hands are shaking.