Down Syndrome
Considerations
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Potential for atlanto-axial (AAI) or atlanto-occipital instability & neurologic injury with neck manipulation
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Potential for difficult bag mask ventilation (but not usually intubation):
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Large tongue,↑ oropharyngeal soft tissue, small mouth, subglottic stenosis, high arched palate
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Tonsillar & adenoid hypertrophy
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Possible obstructive sleep apnea:
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Pulmonary hypertension/RV dysfunction
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Sensitive to sedatives/hypnotics
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Developmental delay/cooperation problems
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Associated congenital heart disease (up to ½):
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Cushion defect (AVSD) = #1
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VSD, ASD, TOF
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Pulmonary hypertension
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Other medical issues:
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Obesity
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Accelerated coronary disease & valvulopathy (MVP, AI)
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Hypothyroidism
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GI: duodenal atresia or stenosis, TEF, Hirschsprungs, celiac disease
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Heme: polycythemia, leukemia, immune deficiency
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Joint laxity (careful with positioning)
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Early Alzheimer’s dementia
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Goals
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Rule out & manage AAI: neurologic exam/history & flexion-extension views of c-spine
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Airway adjuncts such as a video laryngoscope
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Skin topicalization for IV start
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Sedation (midazolam may be paradoxical)
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Arrange post-op monitoring
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Overnight oximetry useful
Conflicts
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Unstable C-spine vs uncooperative patient with developmental delay:
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Consider IM/PO sedation to facilitate IV placement
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Ketamine 5 mg/kg IM, 7 mg/kg PO
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Midazolam 0.5 mg/kg PO (max dose 20 mg)
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Inhalational induction may be problematic in an adult with DS due to obesity, OSA, uncooperative nature
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