Case 34: The Butterfly Needle (Abbott)

Abstract

A 3-year-old boy (34 lb) is scheduled for an urgent manipulation of a fractured forearm. He has just come from a birthday party and has eaten cake and other sweets within the last hour. His medical history is unremarkable. The patient has no known drug allergies, and the family history is negative for anesthesia-related problems. An intravenous (IV) (25-gauge) Butterfly needle is established in the back of the hand with the help of lidocaine/prilocaine (EMLA cream). Monitoring equipment is placed on the child (electrocardiogram [ECG], pulse oximeter, a nerve stimulator, noninvasive blood pressure [BP], and precordial stethoscope). General anesthesia is induced with propofol (35 mg) followed by succinylcholine (20 mg) using the Butterfly needle to good effect. The patient’s trachea is easily intubated, and general anesthesia is initially maintained with isoflurane 1–3 % with 70 % nitrous oxide in oxygen. After 10 min, with the patient breathing spontaneously, meperidine, 10 mg, is injected again through the Butterfly needle. A few seconds later, the pulse oximeter alarms and the ECG shows a bradycardia of 40 beats per minute (bpm). You are puzzled because meperidine, being an atropine derivative, should produce a tachycardia, not a bradycardia.