Pediatric anesthesiologist Philip Yun, DO, participated in a surgery to treat an abdominal aortic aneurysm during his residency, but never in his work as attending physician in the NICU at Oregon Health & Science University (OHSU) Doernbecher Children’s Hospital. Often referred to as “AAA,” an abdominal aortic aneurysm creates a bulge or swelling on the lower part of the aorta that runs through the belly area.

That all changed within a matter of hours last spring when a PANDA Team, a group of clinicians specially trained in critical care transport, arrived via Life Flight helicopter with 8-month-old Blakely Busk.

An ultrasound and CT scan confirmed Blakely was facing an AAA. Usually seen in men 65 and older, it is exceptionally rare in children. An AAA that ruptures can cause life-threatening bleeding and has an extremely high mortality rate – about 85% – without surgical intervention. The condition is especially dire in an infant who, unlike adults, is unable to tolerate much blood loss.

This extremely risky surgery has only been performed by a small handful of surgeons across the country. Anesthesia risks with this procedure were significant. The aorta is the largest artery in the body and carries blood from the heart to the rest of the organs. Work on the aorta is associated with the most dramatic changes in vital signs and bleeding when manipulated. These changes have physiologic effects on the entire body’s homeostasis.

The complex procedure itself involved other risks. To manage an AAA in an adult patient, surgeons often insert a stent in the aorta, which allows the area to expand and blood to flow through. However, these devices are much too large to use in an infant like Blakely. The 11-person team, which included two pediatric surgeons, three vascular surgeons, a pediatric cardiac surgeon, Dr. Yun and an anesthesiology fellow, and three nurses, planned precise surgical methods and medical materials to create a solution for immediate, effective stabilization and resumption of blood flow.

Despite the high stakes, Dr. Yun was confident that he and the team were up to the task. “Admittedly, there was some apprehension given that this was completely new,” he shared. “We’ve all seen AAAs in adults, and we’ve all had pediatric patients that required significant resuscitation with blood products. We knew the cadence of what needed to be done and had good communication with the surgeons and the nurses in the room.”

Fortunately, Dr. Yun was working with a pediatric anesthesiology fellow already scheduled to work that day. Being less than a year out from residency, she had performed the surgery recently and quickly stepped in to administer medications and blood products with the necessary speed on certain parts of the case.

When the Busks arrived at OHSU, Blakely’s right leg was blue and swollen because her aorta had ruptured into her iliac veins. The team needed to act quickly yet with meticulous preparation and collaboration.

From an anesthesiology standpoint, the greatest surgical risk was associated with managing the hemodynamic consequences of aortic cross-clamping. Given the patient’s size, hemorrhage was a significant concern. This patient had a fistula between the left common iliac vein and the aneurysm, so that presented further apprehension for hemorrhage even with aortic cross-clamping.

“What we did have going for us is that most adult patients with AAA have comorbidities,” Dr. Yun remarked. “Blakely was otherwise a very healthy 8-month-old. Given how rare this is in pediatric patients, literature is limited to case reports for anesthetic care for any pediatric AAAs, let alone one in a 7-month-old with a fistula.”

Dr. Yun’s optimism and honesty didn’t go unnoticed by the parents, who had requested that the team not sugarcoat their daughter’s case. While acknowledging that staff had not seen this condition in the hospital before, Dr. Yun emphasized they had time to prepare, and that Blakely’s youth was on their side.

Despite the chaos of the day, Blakely’s parents reported being encouraged by the hourly text updates from the surgical team during the seven-hour procedure.

While communication with the parents was important, communication with the staff was literally a matter of life or death. Dr. Yun described the pediatric OR at Doernbecher as a tight-knit group, but it was the first time working with many of the vascular surgeons, all of whom primarily had experience working with adult patients.

“Communication is arguably the most important piece, and I felt like there was good communication with everybody treating Blakely that day,” he recalled. “That being said, there were individuals that I was working with for the first time. This required everybody to have to be very intentional with verbal communication.”

Blakely was discharged home a week after the dramatic surgery. Within weeks, she was eating, sleeping, and smiling again. Depending on the outcomes and development of her condition, she may require additional vascular surgeries down the road.

As for Dr. Yun, he encourages other anesthesiologists to be confident in their skillset, should the need to work on such a complex surgery arise. “With understanding of the hemodynamic changes during adult AAA repair and experience with massive transfusion in an infant, any experienced pediatric anesthesiologist should feel confident in taking care of these patients,” he said.