A 3-year-old child with a history of mild reactive airway disease presents for evaluation of recurrent low-grade fevers, fatigue, anorexia, irritability, and lower extremity pain. Initial laboratory evaluation demonstrates leukocytosis (30,000 cells/μL), thrombocytopenia (50,000 cells/μL), and anemia (8 g/dL). Appropriate anesthetic management for a diagnostic bone marrow biopsy and LP in this child may include all of the following EXCEPT:

a) Consideration of premedication with midazolam in the preoperative area

b) Induction of general anesthesia with propofol

c) Administration of intravenous dexamethasone for nausea and bronchospasm prophylaxis

d) Utilization of fentanyl for intra- and post-procedural analgesia

e) Utilization of a supraglottic airway device (such as a laryngeal mask airway) throughout the operative procedure

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Answer

Answer c. The child in the vignette has signs and symptoms typical for a new diagnosis of leukemia. The provision of systemic glucocorticoids prior to the institution of chemotherapy may negatively impact the health of the child by altering the risk-category of the leukemia as well as the subsequent aggressiveness of the treatment regimen. While nausea and bronchospasm prophylaxis may be of value, numerous alternatives to systemic steroids are extant and should be considered (ondansetron, propofol, albuterol, avoidance of tracheal intubation, etc.).

Notes

This question originally printed in the Pediatric Anesthesiology Review Topics kindle book series, and appears courtesy of Naerthwyn Press, LLC.

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