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ADVERSE EVENT
(Significant Bradycardia and Tachydysrhythmia)
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HISTORY OF PRESENT ILLNESS
patient noted bilateral lower Patient had difficulty patient discharged and scheduled for change of
PICU admission
discharged
on day of procedure
2 years prior to consult
extremity weakness, breathing and was instructions given for home tracheostomy and
abdominal pain and subsequently intubated and care and follow up visits. gastrostomy tube.
vomiting. Admitted for tracheostomy and Advised tracheostomy
progressive ascending gastrostomy tube inserted change to be done 3-6moths,
weakness. Imaging, blood after prolonged intubation however, due to the current
chem and studies were taken. and hospital stay. pandemic, change of
Managed as a case of GBS. while admitted, patient had tracheostomy done yearly.
episodes of tonic-clonic
seizure thus maintained on
Valproic Acid 11mkd 2x a
day.
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PAST MEDICAL HISTORY
DELIVERED TERM VIA NSD AT A LOCAL INSTITUTION
COMPLETE IMMUNIZATION
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DIAGNOSIS
GUILLAINE BARRÉ SYNDROME
SEIZURE DISORDER
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Mallampati – not
assessed
Limited mouth
opening and neck
mobility
Pre anesthetic NPO for 8 hours
evaluation Risk discussed to
parents
Patient examined and
history were reviewed
Anesthetic consent
secured.
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ASA: 3
WEIGHT: 37KG
NO ALLERGIES
Intraoperative GCS:12 (E4 V3 M5)
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• Midazolam 1mg IV given
• Vital
10:32AM
AM
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• O2 increased to 6LPM
• midazolam 1mg IV given
• Vital signs: 100/60, HR 100, O2 sat 99%
10:32AM
• procedure ended
• oral and tracheal secretions suctioned
• vital signs: BP- weak pulses, HR 70s-48bpm, O2 Sat 99%
• Atropine 0.5 mg IV given
10:50 AM • noted loss of consciousness
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• paracetamol 600mg IV given
• patient started regaining consciousness
11:15AM • Pupils equally reactive to light
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◦ Procedure
◦ Change of gastrostomy tube abd tracheostomy
Anesthetic technique
MAC-sedation
Total operative time
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◦ Patient admitted
◦ On gastrostomy feeding
◦ Labs
◦ 12 Leads ECG
◦ CBC
◦ Na, K, Ca
◦ Hgb 134/ Hgb 0.42/WBC
POST Therapeutics:
12.4/Plt 282
PROCEDURE 5ml Q12H
Valproic Acid 250mg/5ml,
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Signs and
Procedure Drug administered
symptoms
What is the • Atropine 1mg IV • Significant
most likely • Change of • Amiodarone bradycardia
• tachydysrhythmia
gastrostomy tube 150mg slow IV
diagnosis and
tracheostomy
What could have happened
• Autonomic • Significant
dysfunction bradycardia
• Vasovagal • Hypotension
syncope • Tachydysrhthmia
STATEMENT
Adverse
OF THE
outcome
PROBLEM
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DISCUSSION
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o an acute inflammatory polyneuritis that is triggered by humoral and cell-
mediated autoimmune response to a sensitizing event.
o etiology is unknown
Guillain-Barré o (in many cases a timely association with a viral (influenza-
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Epidemiology
GBS worldwide is 1.1–1.8 cases per
100,000 per year, with higher rates in
males than females.
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Signs and
symptoms
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W
ea
k ne
Th s sa
em nd
os
tc se
om ns
m or
on y
pr di
es st
en
t in
ur
b
g an
sy
m ce
pt
2
om
s
di
ff ic
ul
w ty
ca eak w
us ne al
e r ss ki
es m ng
pi ay
ra a to
t o sc
ry en pa
fa d ra
il u t o
re in ly
vo
lv
sis
er
es
3
pi
ra
to
ry
A m
us
Co
bl m
u t cl
es
an ood mo
o n an
d n o d
hy pre an m
p e ss d m
rh ure a
i c
yd , u y dy
ria ri cau sf
s i s n a se un
. ry ar
re rh ct
te y io
nt t h
io m n
n, i a
pa s, s
ra w
ly in
ti c g s
il e in
us
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GBS SUBTYPES
ACUTE INFLAMMATORY ACUTE MOTOR AND SENSORY
DEMYELINATING AXONAL NEUROPATHY
POLYRADICULOPATHY
• both motor and sensory fibres are
• most common form involved
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Creatine kinase may be raised
Serum biochemistry
ESR is usually raised and CRP is sometimes
elevated.
Anti-GM1 associated with worse outcome. Anti
Inflammatory markers GD1 associated with AMAN, Anti GQ1b with
MFS.
Nerve
majority show demyelinating
conduction pattern
study
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Differential diagnoses
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MANAGEMENT AND
ANESTHETIC
CONSIDERATION
Succinylcholine- contraindicated
non-depolarizing drugs- avoided
◦ Around 30% of patients with GBS require ventilatory
support.
◦
◦ Close monitoring of respiratory function tests is
SUPPORTIVE imperative.
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◦ Neuropathic pain
◦ Venous thromboembolism
◦ Non-opioid analgesics
prophylaxis
(paracetamol, NSAIDs) in
combination with opioid ◦ Low molecular weight
analgesia Adjunctive heparin in combination with
neurologic treatments such as either pneumatic
anticonvulsants (e.g. compression devices or
gabapentin or anti-embolism stockings.
carbemazepine), and
tricyclic antidepressants
may be effective.
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◦ There is a high incidence of
depression among patients
with GBS. –
◦ Careful attention should be
◦ it is important for the paid to limb positioning and
patient and their family to posture.
Psychological and have access to support
◦ Patients may also suffer from
rehabilitation groups.
persistent fatigue, which may
◦ counselling and respond to an exercise
psychiatric help be program.
available if needed.
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◦ Plasma exchange
◦ IV immunoglobulin
medications ◦ cortocosteroid
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◦ Most patients with GBS recover fully
◦ 15% of patients suffer persistent disability.
◦ 10% are unable to walk unaided at one year.
◦ The mortality from GBS ranges from 2–12%.
prognosis ◦ venous thromboembolism,
◦ pneumonias, arrhythmias and
◦ complications related to dysautonomia.
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“
◦ Pediatric Advanced
Life Support
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Age Awake rate (/min) Sleeping rate
(/min)
Neonate 100-205 90-160
Heart rate and
Infant 100-180 90-160
rhythm Pre-school 80-120 80-120
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quickly determine if the arrhythmia is causing hemodynamic
instability or other signs of deterioration.
Priorities in initially managing arrhythmias are the same as they are for all critically ill children:
• support the ABCs- airway,
• breathing, and
• circulation- and
• treat the underlying cause.
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Atropine
Epinephrine
◦ a parasympatholytic (or anticholinergic) drug
◦ for symptomatic bradycardia that that accelerates sinus or atrial pacemakers and
persists despite effective enhances atrioventricular (AV) conduction.
oxygenation and ventilation.
◦ for bradycardia caused by increased vagal
increases heart rate and cardiac
tone.
contractility, and alpha adrenergic
activity causes vasoconstriction. ◦ For IV/IO route, give 0.02 mg/kg; minimum
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◦ assess and look for signs of hypotension, altered mental status, shock
(ie, poor perfusion), or life-threatening hemodynamic instability.
◦ Maintain a patent airway; assist breathing as necessary.
◦ Use a cardiac monitor to identify the rhythm, and monitor pulse, blood
pressure, and oximetry.
Managing ◦ Establish IV/IO access.
Tachyarrythmias ◦ Obtain a 12-lead ECG if available (but do not delay urgent
intervention).
◦ Obtain laboratory studies
◦ Assess neurologic status.
◦ Anticipate the need for medications Simultaneously try to identify and
treat
◦ reversible causes.
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ADENOSINE AMIODARONE
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• Synchronized shocks • Use synchronized • Start with an energy
are used for cardioversion for dose of 0.5 to 1 J/kg
cardioversion from Hemodynamically for cardioversion of
SVT and VT with a unstable patients (poor SVT or VT with a
SYNCHRONOUSED pulse. perfusion, hypotension, pulse.
or heart failure) with • If the initial dose is
CARDIOVERSION tachyarrhythmias (SVT, neffective, increase the
atrial flutter, VT), but dose to 2 J/kg.
with palpable pulses
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THANK YOU
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