What are the appropriate anesthesia, medication, and pain management strategies for a 7-year-old patient (20kg) undergoing orthopedic casting of both lower limbs, who experiences bronchospasm (co thắt phế quản), tachycardia (mạch nhanh), and stable blood pressure during the procedure?

From the Guidelines

For a 7-year-old, 20kg patient undergoing orthopedic casting of both lower limbs, intravenous anesthesia with Ketamine is recommended, as it provides both anesthesia and analgesia while maintaining airway reflexes, which is beneficial in pediatric patients, especially those with bronchospasm and tachycardia 1. The typical dose of Ketamine is 1-2 mg/kg IV. If bronchospasm occurs during the procedure, use inhaled Ventolin (salbutamol) as the first-line treatment, administering 2.5 mg via nebulization, as recommended for children weighing less than 20 kg 1. For post-procedure pain management, use Paracetamol orally or rectally, with a recommended dose of 15 mg/kg every 4-6 hours, not exceeding 60 mg/kg/day, as it provides effective pain relief with a good safety profile in children 1. Throughout the procedure, maintain close monitoring of vital signs, especially respiratory rate and oxygen saturation, and ensure the availability of emergency airway equipment and resuscitation drugs as a precaution. Some key considerations for anesthesia and pain management in this patient include:

• The patient's age and weight, which influence the choice of anesthesia and medication dosing
• The presence of bronchospasm and tachycardia, which require careful monitoring and management during the procedure
• The need for effective pain management, while minimizing the risk of adverse events and ensuring the patient's safety and comfort. In terms of specific medications, Ketamine is a suitable choice for anesthesia, given its ability to maintain airway reflexes and provide analgesia, while minimizing the risk of respiratory complications 1. Additionally, the use of inhaled salbutamol as a premedication may be beneficial in reducing the incidence of perioperative respiratory adverse events, such as bronchospasm, in children with an upper respiratory tract infection 1.

From the FDA Drug Label

Pediatric Patients Most patients aged 3 years through 16 years and classified ASA-PS I or II require 2.5 mg/kg to 3. 5 mg/kg of propofol injectable emulsion for induction when unpremedicated or when lightly premedicated with oral benzodiazepines or intramuscular opioids. A lower dosage is recommended for pediatric patients classified as ASA-PS III or IV Changes in vital signs indicating a stress response to surgical stimulation or the emergence from anesthesia may be controlled by the administration of 25 mg (2. 5 mL) to 50 mg (5 mL) incremental boluses and/or by increasing the infusion rate of propofol injectable emulsion.

For a 7-year-old patient (20kg) undergoing orthopedic casting of both lower limbs, who experiences bronchospasm, tachycardia, and stable blood pressure during the procedure, the appropriate anesthesia and medication strategy would be to:

• Use a lower dosage of propofol injectable emulsion for induction, considering the patient's age and potential ASA-PS classification.
• Administer incremental boluses of 25 mg (2.5 mL) to 50 mg (5 mL) and/or increase the infusion rate of propofol injectable emulsion to control changes in vital signs indicating a stress response to surgical stimulation.
• Consider using other medications, such as anticholinergic agents, to manage potential increases in vagal tone.
• Monitor closely for cardiorespiratory depression, apnea, and airway obstruction, especially following rapid bolus administration.
• Use slow infusion or slow injection techniques for MAC sedation to minimize undesirable cardiorespiratory effects.
• Consider premedication with opioids, such as morphine, to decrease the necessary propofol injectable emulsion maintenance infusion rates and therapeutic blood concentrations 2.
• Titrate downward the infusion rate of propofol injectable emulsion in the absence of clinical signs of light anesthesia to avoid administration at rates higher than clinically necessary 2.

From the Research

Anesthesia Strategies

• For a 7-year-old patient undergoing orthopedic casting of both lower limbs, propofol/fentanyl (P/F) and ketamine/midazolam (K/M) are two medication regimens that can be considered for brief orthopedic procedural sedation 3.
• Propofol has a quicker offset and smoother recovery profile compared to ketamine, but it also has a greater potential for respiratory depression and airway obstruction 3, 4.
• The use of regional anesthesia, such as peripheral nerve blocks, has increased over time for children undergoing ambulatory orthopedic procedures, and is often performed in conjunction with general anesthesia 5.

Medication Management

• Propofol is extensively metabolized and has a favorable operating condition, but it can cause apnea and blood pressure reductions 4.
• Ketamine has antiepileptic and anxiolytic properties, and can be used as an alternative to propofol 4.
• The choice of medication should be based on the patient's individual needs and medical history, including the presence of bronchospasm and tachycardia.

Pain Management

• Effective pain management is crucial for patients undergoing orthopedic casting, and can be achieved through the use of medication and other strategies such as cast valving and patient education 6.
• The use of cotton padding and fiberglass or plaster casts can help to prevent further fracture displacement and promote healing 6.
• Patient education is an important aspect of pain management, and can help to prevent complications such as thermal injuries and skin complications 6, 7.

Considerations for Patients with Bronchospasm and Tachycardia

• Patients with bronchospasm and tachycardia require careful consideration and monitoring during anesthesia and medication management 3, 4.
• The use of medications that can exacerbate these conditions should be avoided, and alternative strategies should be considered 4, 7.
• Close monitoring of the patient's vital signs and medical history is crucial to ensure safe and effective anesthesia and pain management 7.