A CRITICALLY ILL CHILD

PRESENTING AT AN ACUTE

TRUST- A CLINICAL AND

ETHICAL CHALLENGE

DR SRIKANTH UPPUGONDURI

CONSULTANT ANAESTHESTIST

NEW CROSS HOSPITAL

CALL FROM PAEDIATRIC TEAM

• CALL FROM PAEDIATRIC REGISTRAR TO ANAESTHETIC REGISTRAR TO ASSIST WITH

THE MANAGEMENT OF A CRITICALLY ILL CHILD ON THE PAEDIATRIC WARD

• ITU CONSULTANT ON-CALL AND ANAESTHETIC REGISTRAR RESPONDED

IMMEDIATELY

ON ARRIVAL ON PAEDIATRIC WARD

• PAEDIATRIC TEAM IN ATTENDANCE

• CONSULTANT PAEDIATRICIAN, PAEDIATRIC REGISTRAR AND SHO TOGETHER WITH

NURSING STAFF

• PATIENT IN PEDIATRIC “TREATMENT ROOM”

• MUM AT THE BEDSIDE

• PATIENT BEING MONITORED

• IN OBVIOUS DISTRESS

• A : PATENT

• B: NASAL CPAP IN-SITU FIO2 80% PEEP 10CMH2O

• SPO2 92-93%

• TACHYPNOEIC 40-50B/MIN

• C: CAP REFILL <2SECS

• TACHYCARDIC 130B/MIN

• BP 100/60

• D: DROWSY BM 7.6MMOL.L

CAP GAS

• PH 7.17

• PAO2 9.7KPA

• PACO2 8.6KPA

• BE -5.8

• BICAB 19.6MMOL.L

• LACTATE 2.2MMOL.L

SIGNS OF POTENTIAL DIFFICULT AIRWAY

• ABNORMALLY LARGE HEAD (EVEN FOR A CHILD)

• LIMITED PASSIVE NECK EXTENSION

• SMALL MOUTH

• MUM SAID “THEY HAD DIFFICULTY GETTING A TUBE DOWN WHEN HE WAS A

BABY”

DISCUSSION WITH PAEDIATRIC TEAM

• PATIENT DM 3 YEAR OLD CHILD

• ADMITTED UNDER THE CARE OF THE PAEDIATRICIANS’ 07/06/2015 GENERALLY

UNWELL AND AGITATED

• SIGNIFICANT BACKGROUND HISTORY:

• SEVERE DEVELOPMENTAL DELAY – DEVELOPMENTAL AGE OF <6MONTHS

• CRYPTOGENIC EPILEPTIC ENCEPHALOPATHY

• PEG FED

• VASCUPORT IN SITU- TUNNELLED IJ LINE

DISCUSSION WITH PAEDIATRIC TEAM

• DIAGNOSED AS LRTI

• COMMENCED ON ANTIBIOTICS FOR COMMUNITY ACQUIRED PNEUMONIA

(CEFUROXIME AND CLARITHROMYCIN)

• HOWEVER DESPITE ANTIBIOTICS, DEVELOPED INCREASING OXYGEN REQUIREMENT

• OVERNIGHT HAD BEEN COMMENCED ON CPAP, BUT INCREASING OXYGEN

REQUIREMENTS

• CXR THAT MORNING

MANAGEMENT PLAN

• DISCUSSION WITH CONSULTANT PAEDIATRICIAN REGARDING THE

APPROPRIATENESS OF ESCALATION OF TREATMENT IN THIS CHILD

• OPINION OF THE ADULT ITU CONSULTANT:

• YOUNG CHILD WITH VERY SEVERE DEVELOPMENTAL DELAY, DIFFICULT TO

CONTROL EPILEPSY, PEG FED, ESCALATION OF TREATMENT TO INVASIVE

VENTILATION WAS INAPPROPRIATE IN THIS CIRCUMSTANCE…

• CONSULTANT PAEDIATRICIAN ON-CALL AGREED THAT IT WOULD BE

INAPPROPRIATE TO ESCALATE TREAMTENT…..

• HOWEVER PATIENT HAD AN ADVANCED DIRECTIVE IN PLACE STATING THAT THE

MUM WANTED ALL TREATMENT OPTIONS TO BE ACTIVELY EXPLORED AND THE

PATIENT WAS FOR FULL RESUSCITATION IN THE EVENT OF A CARDIO-RESPIRATORY

ARREST.

• CONSULTANT PAEDIATRICIAN ATTEMPTED A BRIEF CONVERSATION WITH MUM

REGARDING THE APPROPRIATENESS OF ESCALATION OF TREATMENT, HOWEVER

MUM WAS ADAMANT THAT SHE WANTED EVERYTHING DOING FOR THE CHILD.

MANAGEMENT PLAN

• DECISION TAKEN TO TRANSFER THE PATIENT TO THEATRE TO ATTEMPT A GASEOUS

INDUCTION

• CONSULTANT PAEDIATRICIAN TO CONTACT KIDS TEAM AND REQUEST DIFFICULT

AIRWAY SUPPORT

• TRANSFERRED TO THEATRE SUITE

• TRAUMA THEATRE AND TEAM AVAILABLE AS NO TRAUMA CASES THAT MORNING

GAS INDUCTION

• TRANSFERRED TO ANAESTHETIC ROOM

• FULLY MONITORED (AAGBI GUIDELINES)

• PAEDIATRIC AIRWAY TROLLEY PRESENT

• GAS INDUCTION WITH 8% SEVOFLURANE IN 100% OXYGEN

• ABLE TO MANUALLY VENTILATE WITH MAPLESON F CIRCUIT AND GUEDEL AIRWAY IN-

SITU

• GRADE IV VIEW!......

• BOTH WITH CURVED BLADE AND MILLER BLADE

DISCUSSION WITH PAEDIATRICIAN

• INFORMED PAEDIATRIC CONSULTANT THAT PATIENT WAS A GRADE IV VIEW AT

LARYNGOSCOPY

• UNABLE TO INTUBATE

• COULD KIDS TEAM SEND AN ANAESTHETIST SKILLED AT DIFFICULT PAEDIATRIC

INTUBATION

• THE PATIENT WOULD BE MANUALLY BAGGED WITH THE MAPLESON F CIRCUIT

UNTIL THE ARRIVAL OF THE KIDS TEAM…..

• AFTER SOME TIME…

• CONSULTANT PAEDIATRICIAN RETURNED WITH THE FOLLOWING ADVICE.....

• KIDS RETRIEVAL CONSULTANT AGREED THAT THE PATIENT WAS PROBABLY NOT A

CANDIDATE FOR ESCALATION OF TREATMENT TO INVASIVE VENTILATION IN THEIR

VIEW.

• HOWEVER KIDS DO NOT PROVIDE DIFFICULT AIRWAY SUPPORT.

• UNLESS THE AIRWAY WAS SECURED THEY WOULD NOT DISPATCH A RETRIEVAL

TEAM TO RETRIEVE THE PATIENT…........

• FURTHER DISCUSSION BETWEEN ADULT ITU CONSULTANT AND PAEDIATRIC

CONSULTANT

• ITU CONSULTANT REQUESTED PAEDIATRICIAN TO CONTACT KIDS TEAM AGAIN

AND STRESS THAT THE PATIENT WAS A GRADE IV VIEW AND SKILLED PAEDIATRIC

AIRWAY ASSISTANCE WAS NEEDED.

• THE REPLY WAS THE SAME…..

• KIDS DO NOT PROVIDE DIFFICULT AIRWAY SUPPORT. UNLESS THE PATIENT WAS

INTUBATED THEY WOULD SEND OUT A RETRIEVAL TEAM.

MY ARRIVAL

• TRAUMA ANAESTHETIST ON-CALL

• ATTENDED THEATRE

• PATIENT BEING MANUALLY VENTILATED

• APPRAISED OF THE CLINICAL PICTURE

• ADVISED TO CONSIDER VENTILATION VIA A LARYNEAL MASK AIRWAY

• SIZE 2.5 ILMA INSERTED

• ABLE TO MANUALLY VENTILATE VIA THE ILMA

• SIZE 5.0MM CUFFED ETT INSERTED THROUGH ILMA.

• CAPNOGRAPH TRACE OBTAINED….

• HOWEVER UNCERTAIN AS TO WHETHER THE TIP OF THE ETT WAS POSITIONED IN

THE TRACHEA OR JUST ABOVE THE LARYNGEAL INLET...

• TO CONFIRM THE POSTION OF THE ETT VISUALLY, FIBRESCOPE REQUESTED.

• ADULT DIFFICULT AIRWAY TROLLEY BROUGHT TO THE ANAESTHETIC ROOM.

• AMBU A3 DISPOABLE SCOPES PRESENT ON THE ADULT DIFFICULT AIRWAY TROLLEY

IN OUR TRUST

• SIZE 5.0MM CUFED ETT RAILROADED OVER AMBU A3 SCOPE.

• SIZE 5.0MM ETT IN-SITU OVER ILMA REMOVED AND FIBRESCOPE PASSED

THROUGH THE ILMA

• CORDS SEEN VIA AMBU A3 SCOPE

• FIBRESCOPE PASSED THROUGH THE CORDS

• SIZE 5.0MM CUFFED ETT RAILROADED OVER SCOPE

• WITH SCOPE AND ETT IN POSITION, ATTEMPTED TO REMOVE THE ILMA

• HOWEVER…

• UNABLE TO REMOVE ILMA AS THE PILOT BALLOON COULD NOT FIT IN THE SPACE

BETWEEN THE ETT AND THE ILMA......

• DECISION TAKEN TO SACRIFICE THE PILOT BALLOON...

• PILOT BALLOON CUT

• ILMA REMOVED

• AMBU A3 SCOPE REMOVED

• CONNECTED TO MAPLESON CIRCUIT WITH CAPNOGRAPH..

• CAPNOGRAPHY AND AUSCULTATION CONFIRMED THAT AIRWAY WAS SECURED!!

• HOWEVER WITH NO PILOT BALLOON, UNABLE TO INFLATE ETT CUFF WITH LARGE

LEAK +++

• CUFF INFLATED USING A NEEDLE ATTACHED TO A SYRINGE AND INFLATING THE

CUFF

• ARTERY FORCEPS USED TO CLAMP CUFF TUBING AND ETT CUFF SEAL

MAINTAINED…

• WITH 100% O2 AND 10CMH20 PEEP , SPO2 MAINTAINED AT 90-92%

• INFORMATION CONVEYED TO KIDS TEAM

• RETRIEVAL TEAM DISPATCHED

• ON ARRIVAL OF RETRIEVAL TEAM, A NEW SIZE 5.0MM CUFFED ETT RAILROADED

OVER BOUGIE

• A-LINE INSERTED

• PATIENT TRANSFERRED TO UHNS PICU

QUESTIONS

THANK YOU!