RJPO Paediatric

8/13/2019 RJPO Paediatric

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Herlien H. Megawe Dept. of Anesthesiology & Reanimation

Airlangga University School of MedicineSurabaya

No matter what time it is, wake me up, even if its in the middle of a cabinet meeting

Ronald Reagan


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I. BASIC PRINCIPLES :

a. Urgency of childs problem

b. Ordering of priorities (e.g. epidural hematoma, closed femoral fracture)

c. Critically ill and profound hypotensive condition, an immediate operationneeded resuscitation & anesthesia are provided simultaneously

d. Establish : - clear airway : A- provide ventilation : B- support hemodynamics : C

e. Hypnosis & analgesia, as condition will allow

f. Titrated doses of : - Hypnotics (Benzodiazepine, for amnesia Ketamine)

- Opioids for pain- Neuromuscular blocking agent for immobility

g. As patient stabilizes, inhalation agent are added as tolerated


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II. RAPID CLINICAL ASSESSMENT OF THE SERIOUSLY ILL INFANT/CHILD

A = AIRWAY : - Obstruction

- Partial- Total

B = BREATHING : - Respiratory rate

- Flare- Recession : - sternal- intercostal- subcostal

- Silent chest C = CIRCULATION : - Pulse : volume

- Blood pressure- Capillary refill time- EKG- Skin colour : - dry, red, warm

- greyish, cold, wet, clammy

D = DISABILITY : - Unresponsive to voice/pain- Posture- Pupils : size/reaction- Conscious level- Convulsions

E = EXPOSSURE : - Rash - Purpura- Swelling - Urticaria

- Fever - Angio-edema


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ASSESSMENT OF PROGRESS AND DETECTION OF

DETERIORATION :Re-assessment of ABCDE at frequent intervals

LEVEL OF CONSCIOUSNESS SHOULD BE RECORDED USING

THE AVPU SCALE : A : Alert V : Responds to voice

* P : Responds to pain (GCS < 8)U : Unresponsive

* Pinching a digit, pulling frontal hair


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III. PATHWAYS LEADING TO CARDIO. RESPIRATORYARREST :

FLUIDLOSS

BLOOD LOSS

GASTROENTERITIS

BURN

LOSSMALDISTRIBUTION

SEPTIC SHOCK

CARDIAC DISEASE

ANAPHYLAXIS

RESPIRATORYDISTRESS

FOREIGN BODY

CROUP

ASTHMA

RESPIRATORYDEPRESSION

CONVULSIONS

RAISED ICP

POISONING

CIRCULATORY

FAILURE

RESPIRATORY

FAILURE

CARDIAC ARREST


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Indication for intubation and ventilation :

Inadequate oxygenation via bag-and-mask technique

Prolonged ventilation required

Flail chest

Inhalational burn injury

Shock


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VASCULAR ACCESSPreferred options :

A. Intra venousB. Intra osseous

A. Preferable via the superior v. cava Via the inferior v. cava takes longer to reach the heart Via the periph. route fluid flush

First priority : accurate safety rapidlyB. Intra osseous :

- Easy & safe- Reach the heart = periph. ven. access- Also in older age & adults

C. Tracheal :Third placeFor first drug adrenaline

D. Intracardiac : not recommended


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IV. RESUSCITATION BEFORE ANESTHESIA

Weight in kg = 2 (age in years + 4)

Estimated blood volume = 80 ml/kg body weight

Assess

response

Assessresponse

F lu id vo lum e and typ e An initial fluid bolus of 20 ml/kg is given as fast

as possible

This should be repeated after assessment if thereis no improvement in vital signs

The most common mistake in the treatment ofhypovolaemic shocked children is failure to giveenough fluid

Crystalloid20 ml/kg

Colloid20 ml/kg

Blood

UrgentSurgical opinion


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V. OTHER VITAL PROCEDURES CARRIED OUT BEFORE

RESUSCITATION AND ANESTHESIA : HISTORY :

Vomit (quantity & quality) Last urination/defaecation) Bloody stool/profuse

BLOOD TESTS (taken immediately after venous access)

NASOGASTRIC TUBE PLACEMENT

RADIOGRAPHS


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VI. PLAN1. Weight (kg) = 2 (year + 4) kg2. Estimated Blood Volume : 80 ml/kg

3. Internal diameter endotracheal tube : Year + 4 = one size smaller, actual size , one size bigger, e.g. :

4 4 - 4,5 - 54. Fluid bolus : 20mg/kg

- Crystalloid

(Colloid)- Blood5. Defibrill. Dose I : 2 Joule/kg

2 Joule/kg in 90 seconds4 Joule/kg

Defibrill. Dose II : 4 Joule/kg4 Joule/kg in 90 seconds4 Joule/kg

6. Between defibrill. dose I and II : Adrenalin dose I : 1 ml/10.000 sol. (10 Ug/kg) Adrenalin dose II : 1 ml/1000 sol. (100 Ug/kg)


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VII. PREMEDICATION, ANXIETY & FEAR

I.V. anticholinergics benefits :1. Maintenance of cardiac output by increasing heart rate2. Prevention of reflex bradycardia :

Airway manipulation Scoline/halothane

ANXIETY & FEAR

Calm appearance Reassuring Of the anesthesiologist is of greatbenefit for patients & parents


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VIII. URGENT SITUATION WITH COMPROMISED AIRWAY

Foreign body aspiration Epiglottitis Croup Bleeding tonsil Facial/laryngeal trauma

Compromised airway & struggle during intubation attempt,choices are : Awake intubation Volatile agent (Sevoflurane/Halothane) in oxygen with gentle

cricoid pressureThis approach is favoured = The patient continues

breathing ! Slight head down position : pulmonary aspiration is less likely

when patient regurgigates


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FULL STOMACH

Postpone surgery for > 4 hours

Reduce the mean gastric residual volume by 50% (does notguarantee empty)

If there is no specific airway for difficult intubation Anesthesia of choice : rapid sequence of induction

Pre-oxygenation + sulfas atropine Rapid induction agent : - Ketamine

- Propofol- Thiopenthal

Muscle relaxant = Recuronium 1,2 mg/kg The smaller the child, the more rapid he will desaturate (< FRC) Newborns can become hypoxic in less than 1 minute

Difficult to pre-oxygenate & denitrogenate a struggling toddler


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HYPOVOLEMIA

Ongoing bloodloss

Pending blood availability

Type specific un-crossmatched low incidence oftransfusion reaction

Ketamine : induction agent of choice in small

dosis 1 2 mg/kg I.V. (within one minute) Atropine 0,02 mg/kg or scopolamine 0,01 mg/kg

administered before

5% Albumine


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IX. PAIN MANAGEMENT

Injured children are in pain on arrival Potentially hypovolemic : Fentanyl preferable

Must be titrated in small increments (0,5 1,0 Ug/kg) to avoid

chestwall or glottic rigidity

Unstable & neurologic dysfunction : opioids with caution

Regional nerve blocks = - femoral nerve

- axillary

Providing analgesia

As a primary anesthetic

(avoid risks of general anesth. = aspiration)

Supplement for postop analgesia


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CAUTIONS

Titrate sedative in small increments to avoid lossof airway reflexes

Appear alert & Sedation sleepy After the block : painfull stimuli is removed

Close communication with surgeons = ability toperform sensory and motor examinations


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X. SPECIAL PROBLEMS & MANAGEMENT A. AIRWAY

Acute airway obstruction : Inspiratory stridor Tachypnoea Sternal & intercostal retractions Agitation (due to hypoxia) Cyanosis Tachycardia

Few of these symptoms & signs are manifested, yet their

condition may rapidly become life-threateningInitial respons :O2 & calm, to prevent dynamic collapse of the airway associated with agitation

- Not cyanotic- Sable vital signs

- Upright position- Supine position further airway obstruction

Blood gas analysis is not vitalPaO2 = 80 torr ; orPaO2 = 60 torr

In Contrast : pulse oxymetry Non-invasive Immediate & continuous means for assessing oxygenation

Recommended as a modality in all airway emergencies

X-ray is helpful clarifying the cause of obstruction

does not alter the response of the anesthesiologist


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B. UPPER AIRWAY OBSTRUCTION1. Epiglotitis Skill

Knowledge Urgent diagnosis & treatment Additional signs : - drooling

- difficulty in swallowing Favoured approach worldwide : Endotracheal intubation

Avoid = inspection increase obstruction (dynamic airway collapse) Radiographic = - Only when stable- Skilled personnel- Adequate resuscitation equipment

In the operationg room : Calm, sitting on the lap o/t mother Induction overface : - Halothane

- Sevoflurane Looses consciousness supine Head up slightly

Essential for the anesthesiologist


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Intubation tehnique

Lifting the base of the tongue

Without touching the epiglottis

Exposure of the rimaglottidis

Partially obstructed orifice

0,5 mm ID smaller choosen sprayed beforehand

A stylet within the endotracheal tube Failure : - tracheostomy

- cricothyorotomy

Adequate sedation to prevent extubation

* Titrated opioids

- Breathe spontanneously

- ETT remains in place for 24 48 hours, until swelling decreased

- Extubation


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2. Foreign body aspiration History of choking

Cyanosis

A wheezing child : Not always asthmatic May be foreign body aspiration

Agitation : due to seriously underlying hypoxemia Radiographic examination

If the child is stable Helpful to localize & identify Mostly are not radiopaque

Hyperinflation Atelectasis Principle of anesthetic management = epiglottitis

While eating suspicious

(peanut, popcorn)

Clues of presence of foreign body


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C. LOWER AIRWAY OBSTRUCTION1. Bronchiolitis

Tachypnea Retractions Wheezing Hyperinflated chest & diffuse crepitations Progressive exhaustion hypercarbia respiratory failure (silent chest)

Focus of treatment = correct hypoxemia Pulse oxymetry : - degree of hypoxemia

- respons to therapy Nebulized mist Bronchodilators

Titrated I.V, fluids not able to drink Ribavirin : antiviral agentCaution : Particles tend to disk, obstructing the ventilator

No absolute P aCO2 value that dictates the course of action

Not proven beneficial


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2. Asthma, status asthmaticus

A cardinal feature : reversibility spontaneuous or with therapy Wheezing sinonymous with bronchospasm Predominant expir. wheezing With increasing fatique slight air movement wheezing no

longer audible

Management :a. Support oxygenationb. Reduce airway obstruction

c. Support ventilationd. Prevent complication (e.g. pneumothorax)e. Inhaled & I.V. drugs


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Anesthesia : Optimize oxygenation, control brochospasm Standard agents Ketamine : - Bronchodilating

- Hypersecretion Avoid histamine release agents : - Morphine

- Curare- Thiopental

Drying of secretions intra-operatively : - Atropine- Glycopyrrolate

May exacerbate mucous plugging post-operatively Wheezing during anesthesia mechanical problem :

- endobronchial intubation- plugging, kinking- cuff herniation

Mechanical ventilation is difficultHigh Airway Pressure: - air trapping

- pneumomediastinum- pneumothorax

Controlled mechanical ventilation: - Degree of hypercarbia is pernitted/accepted- Adequate oxygenation- Adequate cardiac output

No sciencetific data yet


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CIRCULATION :

1. Hypovolemia : Most common cause of shock Crystalloid solutions are effective

No scientific studies of superiority of colloid solutions Blood as soon as crossmatching is carried out, or

O neg.Type spec. uncrossmatched

Urgent


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XI. OPERATING ROOM MANAGEMENT

1. Acute blood loss Secure large bore venous access is of higher priority than arterial access Arterial catheters in :

Arterial blood gas for adequate ventilationFrequent blood sampling : metabolic derangements

Hemodynamic instabilityNeed to alter blood pressure rapidly

Central venous access, only when hemodynamic stability returns Body temperature, hypothermia :

Potentiates neuromuscular blockade

Exacerbates coagulopathy

2. Anesthesiologists vigilance continued : until care is transferred to the appropriate physicians and nurses


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RJPO Paediatric

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