Down syndrome for strabismus surgery7-year-old girl with Down syndrome, 22 kg, for day-case bilateral strabismus correction

The patient

The examiner asks

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1. Consider

   What are your considerations?

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   • A 7-year-old with Down syndrome, a closed VSD and probable sleep apnoea, for day-case squint surgery. Patient
   • As a child with learning disability, she needs her mother with her and an unhurried induction.
   • Her big tongue and low tone obstruct quickly at induction, and her subglottis is narrow. Airway
   • Atlantoaxial instability is silent in 10–30%; she has no symptoms, but her neck stays neutral.
   • Squint surgery triggers the oculocardiac reflex and frequent vomiting. Surgery

2. Prepare

   How will you assess her?

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   • Any neck pain, head tilt or change in walking? She has none. Airway
   • No routine neck films without symptoms; minimal neck movement regardless.
   • Echo before surgery: any residual shunt, valve leak or pulmonary hypertension after her VSD closure. Disease
   • Thyroid tests checked, as Down syndrome brings thyroid disease and she's on replacement.
   • Witnessed pauses mean OSA: sparing opioids and an overnight monitored stay, not a day case. After surgery

3. Plan

   What is your anaesthetic plan?

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   • Gas induction with her mother present, atropine ready, as sevoflurane can slow her heart. Airway
   • A tube smaller than her age predicts, with a leak confirmed below 25 cmH2O.
   • Her neck stays neutral through laryngoscopy and positioning.
   • Vomiting prophylaxis: dexamethasone 0.15 mg/kg plus ondansetron 50–100 mcg/kg. After surgery
   • Paracetamol 15 mg/kg IV, keeping opioids to a minimum.

4. Crisis

   As the surgeon pulls on the medial rectus, HR falls from 95 to 40, BP 70/40. What now?

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   • PALS bradycardia, vagal cause: the oculocardiac reflex; the surgeon lets go of the muscle now. (Crisis)
   • Check her depth and ventilation; hypoxia, high CO2 and light anaesthesia make it worse.
   • Her rate usually recovers within about 20 seconds of release.
   • Severe or recurring: atropine 10–20 mcg/kg IV, or glycopyrrolate 10 mcg/kg.
   • Still under 60 and poorly perfused after release and atropine: CPR, adrenaline 0.01 mg/kg.
   • Surgery resumes once she recovers; the reflex usually weakens with repeated pulls.

5. Crisis

   In recovery she has inspiratory stridor and a barking cough; SpO2 92% on air. What do you do?

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   • Post-intubation croup is likely; Down syndrome is a known risk factor. Crisis
   • Calm her on her mother's lap, sitting up, with humidified oxygen; crying makes it worse.
   • Nebulised racemic adrenaline, 0.5 mL of 2.25% in 3–5 mL saline.
   • Dexamethasone 0.4–1 mg/kg (maximum 20 mg) IV, though it takes 4–6 hours to peak.
   • Rebound is possible, so she's watched 4 hours past the final nebuliser, and stays overnight. After surgery