Case 36: Delayed Postoperative Respiratory Obstruction

Abstract

A 2-year-old boy (12 kg) is admitted as an outpatient for electroretinography under general anesthesia. His medical history is unremarkable. He underwent, uneventfully, a similar procedure under general anesthesia at the age of 6 months. He has no known allergies and is on no drug therapy. He has had a recent upper respiratory tract infection, but his preoperative physical examination is normal. He is premedicated with oral midazolam (0.07 mg/kg) with an antacid for faster onset of sedation [1]. The child is anesthetized with sevoflurane in oxygen, and an intravenous (IV) infusion is established. Atropine and vecuronium are given in usual doses, and the trachea is intubated atraumatically with a 4.5-mm internal diameter (i.d.) tracheal tube. Anesthesia is maintained with sevoflurane and nitrous oxide in 30 % oxygen. One hour later, the procedure is completed and the child is awakened from the anesthetic. The pharynx is suctioned with a soft, rubber catheter without vision and the tracheal tube is removed. The postoperative course is uneventful. Suddenly after 20 min in the recovery room, the child stands up in bed. He has an episode of choking and coughing that leads to cyanosis. He is quickly placed in the right lateral position and given oxygen 100 % via mask. The child resumes normal breathing and the oxygen saturation is now 100 %. You carefully listen to the child’s chest and find no abnormality. You lift him up to show the anxious parents that there is nothing to worry about but as you do that he coughs and retches and the oxygen saturation falls to 88 %. You put the child down and he recovers again.