What's Going on Here?

 

Kalocsa, Hungary - photo by JoAnn Sturman

Scott Sturman, M.D.

Every once in a while the unexpected occurs. 

The patient, a healthy 18 kilogram six year old, presented for dental restoration and received midazolam 10mg orally by protocol.  The sedative left her calm but awake and provided near perfect conditions for masked induction.  She was intubated without muscle relaxants, received no narcotics, and placed on the ventilator with ETCO2 = 40.  MAC levels = 2.0.

When the surgeon advised it was about 20 minutes from completion, transition to spontaneous ventilation began.  Normally, under these conditions children begin to breath within a minute or two.  Thirty minutes later the surgeon finished, and the patient was not breathing despite high CO2 levels and MAC = 1.  15 minutes later with MAC = 0, the patient began to respond and was extubated.  Spontaneous ventilation abruptly ceased which required mask ventilation.  10 minutes later I asked the nurse to given the patient 1mg of flumazenil.  Within a minute the patient was breathing unassisted at a minute ventilation of 6 liters.

Nearly two hours elapsed between the administration of midazolam in preop and receiving the reversal agent in OR.  Of all the children I have anesthetized, this the first time I have seen a vigorous, non ill one respond to this particular preop with such significant respiratory depression...but there is always a first time. 

 Iron Gates on the Danube - photo by JoAnn Sturman