Case Report:
A 13-month-old male, 10.8 kg, presented for anesthesia pre-procedure assessment before a scheduled laparoscopic left inguinal hernia repair under general anesthesia. The patient was born at 36 weeks via spontaneous vaginal delivery. Echocardiogram at 30 hours of life revealed a patent foramen ovale (PFO) and patent ductus arteriosus (PDA) with associated left to right shunting. Outpatient follow-up with pediatric cardiology showed likely spontaneous defect closure and continued follow-up was not recommended. Past medical history was otherwise significant for genetic testing-confirmed chromosome 4q deletion (q34.1-35.2), constipation, arachnoid cysts, and bilateral hearing loss. This patient had no history of previous general anesthesia but had an uneventful sedation with propofol for MRI at an outside institution. At that time, the patient had a size 4 nasopharyngeal airway successfully placed in one attempt with no complications.
On physical exam, the patient had a moderately dysmorphic appearance, with slightly slanted palpebral fissures, flattened nasal root, low-set ears, left eyelid ptosis, high-arched palate with a triangular mouth and micrognathia (see Figure 1A and B). The patient’s cardiovascular exam was unremarkable. The left inguinal hernia defect was easily reducible, and no signs of muscle weakness or lethargy were appreciated.
All other vital signs and electrocardiogram were unremarkable, and their airway was evaluated as not difficult. However, given the patient’s history of 4QDS and micrognathia on examination, consideration was given for the patient to potentially require a smaller-than-expected tracheal tube, and thus, video laryngoscopy via C-MAC® was chosen for intubation. The patient’s mother was informed of this plan and written consent was obtained. Shortly after the preoperative assessment, the patient was given 0.5 mg/kg of midazolam and 15 mg/kg of acetaminophen and then was brought to the operating room for general anesthesia induction, which was completed with propofol dosed at 3.2 mg/kg delivered in a 10 mg/mL bolus. Tracheal intubation was accomplished in one attempt via C-MAC® using a size 1 Miller blade and 3.5 ETT with microcuff. An intubating stylet and anterior, back, upward and right lateral pressure (BURP) were utilized to aid intubation. The laryngeal view was deemed Cormack-Lehane Grade I, with full visualization of the glottis. The view seen with the C-MAC® can be seen in Figure 2C and D, before and after intubation.
Laparoscopic repair of the patient’s hernia commenced and was completed uneventfully. Upon closing the patient’s surgical sites, two mL of 0.25% bupivacaine were injected into the umbilical incision. The anesthesia team then executed bilateral quadratus lumborum (QL) nerve blocks via ultrasound guidance. Needle placement was confirmed with saline injection and a total of 5 mg/kg of epinephrine and 0.8 mg/kg of ropivacaine were injected. After the QL nerve block, the patient was successfully extubated and transferred to the post-anesthesia care unit. Following surgery, the patient did not receive any additional medications for pain control and recovered uneventfully. The patient was discharged later the same day, and both three-day and one-month follow-up appointments were unremarkable; no complaints of pain were noted from the patient’s mother beyond mild soreness on Day 3.