Paediatric Anaesthesia

July 2018

Written Final FRCA Teaching

Aims

´ Hot/Recent topics

´ Past FRCA paper questions

´ Paediatric DAS guidelines

´ Resuscitation guidelines

Recent Topic ExamplesRCOA CPD Study Day 2018

´ The paediatric pre-operative assessment clinic´ Challenges of anaesthetic management of uncooperative and

difficult children´ Management of severe burns in paediatrics´ Intra and post-operative pain management´ The paediatric airway´ TIVA for tots´ Managing trauma in the young´ Corrective spinal surgery – New frontiers´ Paediatric anaesthesia for the non-paediatric anaesthetist´ Stabilisation and retrieval of the acutely ill child´ Paediatric intensive care management of the Manchester

bombing victims

APAGBI Guidelines

´ APA Consensus Statement on updated fluid fasting guidelines for children prior to elective general anaesthesia, 2018

´ Prevention of Peri-operative Venous Thromboembolism in Paediatric Patients, 2017

´ Guidelines on the Prevention of Postoperative Vomiting in Children, 2016 (2009)

´ Paediatric Difficult Airway Guidelines, 2015´ Good Practice in Postoperative and Procedural Pain

Management, 2nd edition, 2012´ APA Consensus Guideline on Perioperative Fluid

Management in Children, 2007

Past Final FRCA Questions

SBA: 15kg 2 yr old boy under GA for small umbilical hernia. LMA spont breathing. Othewise F+W. 30 min into procedure sudden brady to 30bpm and ETCo2 -0.

´ ◦Which is the correct answer

´ ◦A) 4.0 ETT, 300 mcg adrenaline, defib 30 J

´ ◦B) 4.5 ETT, 150mcg adrenaline, defib set to 60 J

´ ◦C) 4.0 ETT, 150mcg adrenaline, defib 60J

´ ◦D) 4.5 ETT 150mcg adrenaline, defib set to 30 J

´ ◦E) 4.0 ETT 300mcg adrenaline, defib set to 60J

September 2013 – Airway & Anatomy

a) List the normal anatomical features of young children (<3 years old) which may adversely affect upper airway management? (35%)

b) Which airway problems may occur due to these anatomical features? (30%)

c) Outline how these problems are overcome in clinical practice? (35%)

And …….. May 2007

a) List the normal anatomical features of a young child (<3 years old) which may adversely affect airway management? (25%)

b) What airway problems may occur due to these anatomical features? (30%)

c) Describe how these problems are overcome in clinical practice? (35%)

Airway Anatomical Features

´ Large head with prominent occiput´ Short neck´ Small mandible´ Pliant submental soft tissue´ Enlarged tonsils +/- adenoids´ Large tongue´ Funnel shaped larynx´ Epiglottis long and stiff´ Anterior and cephalad larynx´ Cricoid ring is the narrowest point of the upper airway´ Trachea is short (5cm in newborn vs 15cm in adults)´ Smaller airway diameter

Anatomical Feature Problem

Large head/prominent occiput/short neck

Airway obstruction due to tendency to neck flexion when anaesthetised

Pliant submental tissue Easily obstructed airway due to digital pressure during airway management

Enlarged tonsils/adenoids and large tongue

Tendency to airway obstruction when anaesthetised

Epiglottis/larynx Difficulty visualising laryngeal inlet at laryngoscopy

Cricoid ring Subglottic trauma if ETT too large resulting in oedema and stridor on extubation

Short trachea High incidence of endobronchialintubation

Problem Solution

Large head/prominent occiput/short neck Avoid natural tendency to neck flexion by use of roll placed behind shoulders

Submental obstruction of airway Ensure fingers confined to bony surfaces only during airway management

Enlarged tonsils/adenoids Use of oro/nasopharyngeal airways, LMA, intubation

Large tongue Use of airway adjunctsDisplacement of tongue to left at laryngoscopy

Long stiff epiglottis Small, straight bladed laryngoscope to obtain view for intubation (Miller blade)

Short trachea Awareness that distance from glottis to carina is shortConfirm bilateral lung expansion by auscultation

Anterior cephalad larynx Use straight bladed laryngoscope to obtain optimal view of laryngeal inlet

Narrow cricoid ring Cuffed vs uncuffedEnsure no subglottic obstruction to passage of un-cuffed ET tubeSmall audible leak with IPPV at 20 cmH2O

Different shaped mask

Sept 2017/March 2014 – Child with a URTI

´ A 5 year old patient presents for a myringotomy and grommet insertion as a day case. During your pre-operative assessment you notice that the child has a nasal discharge.

a) Why would it be inappropriate to cancel the operation on the basis of this information alone? (25%)

b) List the features in the history (35%)& examination (25%) that might cause you to postpone the operation due to an increased risk of airway complication in this patient.

c) What social factors would preclude this child’s treatment as a day case? (15%)

´ Children have an average of 7 episodes of URTI per year

´ Most viral aetiology, but the prodromal phase of severe systemic illness can have similar symptoms

´ ¼ of children have a runny rose for a large proportion of the year due to other causes e.g. hypertrophic adenoids or allergic rhinitis

Potential Anaesthetic Problems´ Airway reactivity takes 6-8 weeks to resolve

´ Coughing

´ Breath holding

´ Laryngospasm and bronchospasm

´ Desaturation

Schedule/Cancel surgery???

´ Cancellation imposes significant emotional and economic burden for the parents

´ Schreiner et al estimated that 2000 surgical procedures in children with mild URTI would need to be cancelled to prevent 15 episodes of laryngospasm

´ Defer surgery for 4-6 weeks for cases with severe URTI as airway hyper-activity may persist for up to 4 weeks, increasing the risk of airway complications

History

´ Onset and duration´ Prolonged/unusual illness´ Purulent nasal discharge´ Productive cough´ Pyrexia >38°C´ Dyspnoea´ Malaise´ Receiving antibiotic therapy´ If asthmatic - é use of inhalers, steroids, antibiotic therapy´ Decreased appetite´ Irritable behaviour´ Absence from school

Examination

´ Inspection of nostrils for purulent discharge

´ Exclude crackles, wheeze and bronchial breathing

´ Visualise oropharynx – enlarged tonsils

´ Temperature > 38 degrees is significant

Suggested algorithm for assessment and anaesthetic management of a child with URTI

March 2018/March 2013 –Cerebral Palsy

´ An 8 year old child with severe cerebral palsy is scheduled for an elective femoral osteotomy.

a) Define cerebral palsy? (15%)

b) List the clinical effects of cerebral palsy on the central nervous system, gastrointestinal, respiratory and musculoskeletal systems with their associated anaesthetic implications? (50%)

c) What are the specific issues in managing post operative pain in this patient? (35%)

Cerebral Palsy

´ Collective term used to describe a diverse group of neurological disorders characterised by varying degrees of motor, sensory and intellectual impairment

´ incidence ∼1 in 500 live births

Causes/Risk Factors

Congenital (80%) Fetal pathogenic factors

§ Preterm <32 weeks§ Low birth weight <2.5kg§ Multiple pregnancy§ Low APGAR score§ Prenatal TORCH infections§ Vascular mal-development§ Neonatal asphyxia

Maternal pathogenic factors

§ Pre-eclampsia§ Breech presentation§ Fetal alcohol syndrome§ PPH§ Maternal hyperthyroidism

Acquired (20%) in the first2 years of life

§ Intracerebral haemorrhage§ Head injury§ Viral encephalitis§ Bacterial meningitis§ Neonatal seizure

Systemic Effects

Neurological

´ Motor impairment

´ Impaired intellectual and cognitive function

´ Visual and auditory impairment

´ Expressive language disorder problems affecting speech –can exacerbate anxiety due to communication difficulties

´ Abnormal perception of pain and touch

´ Epilepsy

Respiratory

´ If premature, will have underlying chronic lung disease secondary to respiratory distress syndrome

´ Increased risk of aspiration pneumonitis

´ Weak cough /respiratory muscle hypotonia /recurrent chest infections

´ Scoliosis/restrictive lung defects, pulmonary hypertension, cor pulmonale and respiratory failure

Musculoskeletal

´ Fixed flexion deformity of limbs and trunk secondary to contractors – difficulty in position patient and vascular access

´ Increased risk of joint dislocation and fractures – care on transferring patient

´ Bleeding

´ Heat loss

Gastro-intestinal

´ Swallowing difficulty secondary to pseudo-bulbar palsy

´ Oesophageal dismotility and GORD

´ Malnutrition and dehydration

´ Anaemia and electrolyte imbalance

´ Likely to have NG or gastrostomy feed

Other

´ Significant side effects and drug poly-pharmacy can have implications for anaesthesia

Post-operative Pain Management´ Communication difficulties

´ Analgesia -“continuous” rather than “on demand” regimens

´ Regular paracetamol and NSAIDs

´ IV morphine infusions /LA based epidural infusions/regional blocks as appropriate

´ Systemically and extradurally administered opioids should be used with caution

´ Risk of accumulation and over sedation

´ Suppresses cough reflex

´ Further respiratory depression in vulnerable patient

´ Pain post-operatively can trigger acute muscle spasm

Sept 2016/September 2011 –Down’s Syndrome

A 9-year-old child with Down’s syndrome is scheduled for an adeno-tonsillectomy.

a) List airway/respiratory (30%), cardiovascular (10%) and neurological (10%) features of the syndrome relevant to the anaesthetist

b) What are the general principles involved in the preoperative (15%), intraoperative (25%) and postoperative (10%) management of this patient with Down's syndrome?

Downs Syndrome

´ Extra chromosome 21

´ Results from:´ Commonly - Non-disjunction at the time of gamete

formation

´ Less commonly - translocation (4%) or mosaic trisomy 21 (1%)

Airway/Respiratory´ Macroglossia and microganthia

´ Possible subglottic stenosis – smaller ETT tube

´ Atlanto-axial instability (20%) - avoid excess neck movements esp at laryngoscopy

´ OSA is common due to adenotonsillar hypertrophy

´ Chronic lower respiratory tract infections are common often secondary to reduced immunity and gastro oesophageal reflux

Cardiovascular´ CHD occurs in 40-60%

´ Most common left to right shunt leading to pulmonary hypertension

´ Endocardial cushion defect: AVSD (40%), VSD (27%), ASD (10%)

´ Other defects´ PDA (12%) and TOF (8%)

´ Pulmonary hypertension is more severe and earlier in onset with defects resulting in left to right shunt

´ Without corrective surgery may progress to Eisenmenger’s Syndrome

Neurological´ Developmental delay (95-99%)

´ Epilepsy (10%)

´ Early onset Alzheimer's

´ Microcephaly

Perioperative ManagementPre-operative

´ Often difficult to obtain history from patient

´ History ?cyanotic episodes

´ OSA – ?HDU admission

´ ?History of surgical corrections or invasive procedures should be noted

´ Previous anaesthetic charts

´ Examination: careful assessment of airway, signs of heart failure

´ Investigations: C-spine X-ray

´ Premedication: EMLA cream, analgesia, sedative, antacid

Perioperative ManagementIntra-operative´ Parent/carer should be present´ Prepare for:

´ Difficulties with cooperation at induction – calm environment, ? Restraint

´ IV access may be difficult´ Airway difficulties ´ Careful airway manipulation

´ Second pair of hands

´ Strict asepsis for all procedures – decreased immunity and increased risk of infection

´ Increased vigilance for aspiration risk´ Multi-modal analgesia – minimal/avoid opioids

Perioperative ManagementPost-operative

´ May require overnight stay esp if history of OSA

´ High incidence of laryngospasm and airway obstruction

´ Increased risk of post-operative chest infection and pulmonary oedema (prone to airway hypotonia)

´ Supplemental humidified oxygen and physiotherapy should be started early if needed

´ Multi-modal analgesia – avoid opioids

March 2016 - Child Abuse

You have anaesthetised a 5-year-old boy for manipulation of a forearm fracture. During the operation you notice that he has multiple bruises on his upper arms and body that you think may indicate child abuse.

a) Which other types of physical injury should raise concerns of abuse in a child of this age? (6 marks)

b) What timely actions must be taken as a result of your concerns? (7 marks)

c) List parental factors (5 marks) and features of a child’s past medical history (2 marks) that are known to increase the risk of child abuse.

And ….. October 2008

All healthcare professionals have responsibility to act if they suspect a child has been subjected to physical abuse

a) In what situations may the anaesthetist encounter possible child abuse? (20%)

b) List the clinical features that would arouse suspicion that physical child abuse has occurred? (40%)

c) What should the anaesthetist do if they suspect child abuse has taken place? (30%)

Child Abuse

A child is defined as anyone who has not yet reached their 18th birthday. The Children Acts 1989 and 2004 ´ safeguarding is everyone’s responsibility, and the welfare of children is paramount.

Four Categories

´ Physical abuse´ Emotional abuse´ Sexual abuse´ Neglect

Risk Factors for child abuse

Child  Related Factors• Chronic  disability/illness• Prematurity/low  birth  weight• Unplanned/unwanted   children• Children  with  physical  or  learning  

disability/behavioural problems

Family  Factors• Single-­‐parent families• Domestic  violence

Parental  Factors• Step-­‐parents• Teenage  parents• Substance abuse• Parents  abused  as  a  child• Disabled  parents• Mental  health  problems

Social  Factors• Unemployment• Poverty• Social isolation

Situations Encountered by Anaesthetist for an at Risk Child

´ Resuscitation of a critically ill child who has sustained injuries under circumstances that can not ne explained

´ During routine pre-operative assessment/examination or surgical procedure where unusual or unexplained signs are noted that may explain physical or sexual abuse

´ When asked to anaesthetise a child for formal forensic examination

´ If informed by the child directly´ In the paediatric intensive care unit where injuries can

not be explained by normal circumstances

Clinical Features of Abuse

´ Unusual bruising – both the pattern and the extent of the bruising is important, particularly in the non-ambulant baby/child

´ Unexplained thermal injury, for example, cigarette burns

´ Bite marks

´ Unexplained fractures

´ Unusual injuries in inaccessible places, e.g. neck, ears, hands, feet and buttocks

´ Unexplained intra-oral injury in a non-ambulant child

´ Unexplained anogenital injury

´ Poisoning

Clinical Features of Abuse

´ Unusual ano-genital signs/appearance

´ Other trauma without an adequate history, e.g. intra-abdominal injury

´ Very poor quality parent/child relationship, e.g. the parent seems oblivious to the emotional needs of the child, or is verbally abusive to the child

´ Parental risk factors such as parents with mental health or substance misuse issues, and living in a home where domestic violence takes place

J l 2006

Anaesthetist has concerns about child’s welfare (inform surgical

team)

Discuss with consultant paediatrician, Named or Designated Doctor/Nurse for CP as appropriate

Still has concerns No longer has concerns

Consultant paediatrician and anaesthetist have

discussion with parents and child when surgery

completed

No further CP action

Ensure documentation is complete.

Assessment made. CP procedures follow

Ensure documentation is complete

LOCAL TELEPHONE CONTACTS Named Doctor….. Named Nurse…. Designated Nurse… Designated Doctor… Local Social Services…..

Concerns remain

Published by the Royal College of Paediatrics and Child Health.

(c) 2006 Royal College of Paediatrics and Child Health, Royal College of Anaesthetists and the Association of Paediatric Anaesthetists.

While the RCPCH are the publishers all other organisations must be cited as joint authors and copyright holders.

Child Protection and the Anaesthetist:Safeguarding Children in the Operating Theatre

Remember

Child Welfare is of Paramount

Sept 2016/Sept 2012 –Meningoccocal Septicaemia

A 4 year old child is admitted to the emergency department with suspected meningococcal septicaemia. You are asked to help resuscitate the patient prior to transfer to a tertiary centre.

a) List the clinical features of meningococcal septicaemia? (35%)

b) Outline the initial management of this patient? (45%)

c) Which investigations will guide care? (20%)

Sept 2016

´ You are called to the Emergency Department to see a 2 year-old child who presents with a 4-hour history of high temperature and drowsiness. On examination there is prolonged capillary refill time and a non-blanching rash. A presumptive diagnosis of meningococcal septicaemia is made.

´ a) What are the normal weight, pulse rate, mean arterial blood pressure and capillary refill time for a child of this age? (4 marks)

´ b) Define appropriate resuscitation goals for this child (2 marks) and outline the management in the first 15 minutes after presentation. (7 marks)

´ c) After 15 minutes, the child remains shocked and is unresponsive to fluid. What is the most likely pathophysiological derangement in this child’s circulation (2 marks) and what are the important further treatment options? (5 marks)

NICE Guidelines

´ Meningitis and Meningococcal Septicaemia –recognition, diagnosis and management (CG102) guidelines (updated February 2015)

´ https://pathways.nice.org.uk/pathways/bacterial-meningitis-and-meningococcal-septicaemia-in-under-16s

´ Infection is defined as a pathological process caused by invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic micro-organisms. It is important to point out that, frequently, infection is strongly suspected without being microbiologically confirmed.

´ Sepsis is the clinical syndrome defined by the presence of both infection and the systemic inflammatory response syndrome (SIRS). (9) However, since infection cannot be always microbiologically confirmed, the diagnositic criteria are infection, suspected or confirmed and the presence of some of the SIRS criteria. (9)

´ Severe sepsis refers to sepsis complicated by organ dysfunction.

´ Septic shock is defined as severe sepsis with circulatory shock with signs of organ dysfunction or hypoperfusion

Commonest Causative Organisms´ In neonates (children younger than 28 days):

´ Streptococcus agalactiae (Group B streptococcus)

´ Escherichia coli, S pneumoniae

´ Listeria monocytogenes

´ In children and young people aged 3 months or older:´ Neisseria meningitidis (meningococcus)

´ Streptococcus pneumoniae (pneumococcus)

´ Haemophilus influenzae type b (Hib)

´ Organisms occur normally in the upper respiratory tract

Common signs and symptoms of meningitis and meningococcal septicaemia

MAP = (1/3)Psys + (2/3)Pdia

MAP (50th percentile at 50th height percentile) = 1.5 x age in years + 55

Initial Management

´ ABC

´ If spontaneously ventilating – 15L oxygen via a reservoir rebreathing mask

´ Airway maneuvers

´ Intubation may be required – Call for help from senior anaesthetist

´ A critically ill child may suddenly deteriorate following intubation. Must ensure following are present:´ Experienced help

´ Facilities to administer fluids

´ Vasoactive drugs

´ Antibiotics, IV fluids and steroids

´ Transfer to tertiary centre - EMBRACE

´ Communication with parents is of paramount

When to give intravenous ceftriaxone

´ Give intravenous ceftriaxone immediately to children and young people with a petechial rash if any of the following occur at any point during the assessment (these children are at high risk of having meningococcal disease):

´ • petechiae start to spread

´ • the rash becomes purpuric

´ • there are signs of bacterial meningitis

´ • there are signs of meningococcal septicaemia

´ • the child or young person appears ill to a healthcare professional.

Investigations

´ Bedside tests´ Bloods (FBC, CRP, Coagulation, Glucose)

´ Look for metabolic disturbances

´ Venous blood gas

´ Whole blood PRC for N. meningitidis

´ Lumbar puncture´ CSF examination: white blood cell count, total protein and

glucose concentrations

´ Gram stain and microbiological culture

´ When do you not perform a lumbar puncture???

Paediatric Sepsis 6GET 31. IV or IO assess and take bloods• Blood culture• FBC• Glucose & treat if low• Blood gas2. Urine output measurement3. Early senior input

GIVE 31. High flow Oxygen2. IV fluids• Aim to restore circulating volume• Titrate 20mls/kg isotonic fluid over 5-10mins• Repeat if necessary• Caution for fluid overload• Monitor for crepitations or hepatomegaly3. Broad spectrum antimicrobialsWithin 1 hour

September 2011 – Squint SurgeryYou are asked to assess 4 year old child who is scheduled for strabismus (squint) surgery as a day case procedure.

a) List the anaesthetic related issues this case presents (60%)

b) During surgical traction, the patient suddenly develops profound sinus bradycardia. How would you manage this situation? (20%)

c) Describe the key post-operative problems and relevant management strategies. (30%)

Paediatric Day Case Exclusion Criteria

Patient Factors

• If not ASA 1 or 2 with controlled systemic disease e.g. asthma, epilepsy

• Full term infant <50 weeks corrected gestation

• Pre-term infant <50-60 weeks post conceptual age• Preterm infants are at increased

risk of apnoea in post operative period

• Innocent heart murmur or complex cardiac disease

• Sickle cell disease (NOT trait)• Known diabetes mellitus• Active infection• Presence of viral/bacterial infection

• Take 2-4 weeks to completely resolve

Anaesthetic Factors

• Inexperienced anaesthetist• Family history of MH• Sibling to a victim of sudden infant

death syndrome• Potential/known difficult airway• OSA

Anaesthetic Issues

Paediatric Patient• Altered physiology• Altered psychology• Paediatric trained staff/unit• Consent

Fulfil appropriate day case criteria• Anaesthetic/surgical factors –

relatively short surgery, no significant haemorrhage, not difficult airway

• Medical factors – ASA ½• Social factors – parent willing, not

single carer with multiple other siblings, phone access, transport

Problems of all ophthalmic surgery• Limited access to airway during

surgery

Problems specific to squint surgery• High incidence of PONV• Oculo-cardiac reflex during surgery• Significant post-operative pain

Miscellaneous• Increased incidence of squint in

children with underlying primary or secondary myopathy

• Risk of malignant hyperthermia

Anaesthetic Factors Affecting IOP

Bradycardia & Eye Surgery

´ Why does bradycardia occur??

´ Management´ Ask surgeon to stop

´ Administer IV atropine (20mcg/kg) o glycopyrrolate10mcg/kg

´ Exclude other causes e.g. hypoxia, acidosis, hypothermia

Post-operative Problems

PONV • Avoid prolonged fasting times• Intra-operative fluid administration• TIVA technique• Avoid opioids if possible• Combination anti-emetics – ondansetron,

dexamethasonePain • Multi-modal approach and post-operative

instructions• Regular oral paracetamol and NSAIDS• Amethocaine eye drops• Diclofenac eye drops + sub-Tenon’s • Other LA blocks

September 2010 – Stridor

A 2 year old presents to the emergency department with sudden onset of fever (38 degrees aural), sore throat, drooling and stridor.

a) What conditions should be considered in the differential diagnosis? (20%)

b) What would be your initial management of this child in ED? (25%)

c) How would you subsequently manage a deteriorating child? (45%)

And …… October 2007

You are asked to see a 2-year old boy in the Emergency Department who has stridor and a barking cough. He is febrile and is sitting up with suprasternal and subcostal recessions.

a) What is stridor and what does it indicate? (15%)

b) List the possible causes of stridor in a child of this age, indicating which is the most likely in this case? (35%)

c) Outline your initial management of this child in the emergency department? (40%)

Stridor

Definition´ A harsh vibrating sound produced when the airway

becomes partially obstructed resulting in turbulent flow of air in the respiratory passages

Phases of Stridor

Inspiratory Above the cords (Extra-thoracic)e.g. croup and epiglottitis

Expiratory Below the cords (Intra-thoracic) e.g. foreign body

Biphasic At or blow the cords (intra- or extra-thoracic)e.g. foreign body, bacterial tracheitis

Differential Diagnosis

Congenital

• Laryngomalacia (or pharyngo/trachea/bronchomalacia)

• Vocal cord dysfunction• Laryngeal stenosis (subglottic

stenosis)• Laryngeal papillomatosis• Vascular ring• Tumour

Acquired

• Croup (laryngotracheobronchitis)• Inhaled FB• Tracheitis• Abscess• Anaphylaxis• Epiglottis (rare since Hib)

Management

´ Disturb the child as little as possible and parents should be present

´ Crying and agitation increase respiratory effort and may precipitate complete airway obstruction

´ Adopt posture which is most comfortable for the child

´ Examination may be limited to inspection – look for signs of increased work of breathing

´ Pulse ox well tolerated

´ Do NOT attempt examination of the throat or IV cannulation

´ Children with symptoms and signs of severe airway obstruction require urgent examination of the airway under anaesthesia

Management

´ Experienced anaesthetist and surgeon need to be present

´ Induction in theatre´ Inhalation induction with sevoflurane in oxygen 100% in

the position the child feels most comfortable

´ A low level of CPAP via the T-piece may improve airway obstruction

´ Establish full monitoring and IV access as soon as the child has lost consciousness

´ Use a smaller ET tube than normal (0.5-1.0mm smaller) – why?

Further Management

´ Once stable, paralyse and sedate for transfer to PCIU for further care to include:´ CXR

´ Bloods (FBC, electrolytes, glucose)

´ Laryngeal and blood cultures

´ IV fluids and NG tube

´ IV antibiotics (usually cefotaxime/ceftriaxone) or according to local guidelines

´ Extubation may be possible after 2-3 days with full recovery by 5-7 days

Indications for Extubation

´ Normal body temperature

´ Leak around ET tube

´ Direct examination under anaesthesia with propofolconfirming the presence of a normal epiglottis

SBA – regarding acute stridor in children which one is correct?

´ ◦A)RSV most commonly causes laryngotracheobronchitis

´ ◦B) Because of the potential for complete airway obstruction, a IV cannula should be inserted as a priority

´ ◦C) Steroids no longer have a place in the treatment of croup

´ ◦D) Once intubated – patients with croup tend to have a longer time to extubation than those with epiglottitis

´ ◦E) A 2 day history of high fever and barking cough in a 4 yr old is a typical history of croup.

Answer ◦D

´ ◦The commonest cause of croup is parainfluenza virus

´ ◦RSV can cause croup but more likely to cause bronchiolitis

´ ◦Rx of croup O2, steroids and nebulised adrealine

´ ◦If croup is severe enough to need intubation extubation may take up to 10 days.

´ ◦4 yrs a little old for croup, rapid onset and high grade fever more likely epiglottitis.

Paediatic Difficult Airway Guidelines - 2015

Paediatic Resuscitation Guidelines

WET FLAG calculations

W Weight

1-12months (0.5 x age in months) + 4

1-5yrs (2 x age in yrs) + 8

6-12yrs (3 x age in yrs) + 7

E Electricity

4 Joules / Kg/ biphasic

T Tube ETT

Internal Diameter (age/4 + 4) = --- mm

Length (age /2 +12) = -- cm

Nasopharyngeal tube (age /2+ 15) = --- cm

WET FLAG calculations

F Fluids

Medical / cardiac arrest – 20 ml/ kg

Trauma cases initial Bolus 10 ml/ kg, then 2nd 10 ml /kg

L Lorazepam

0.1 mg / Kg IV/ IO

A Adrenaline

0.1 ml/kg of 1:10, 000 = 10mcg/kg

G Glucose

2ml / kg of 10% dextrose

April 2009 – IV fluids ´ ◦A 4 year-old (20kg) girl is admitted with acute appendicitis and is scheduled

for urgent surgery. She has been vomiting for two days and is pyrexial 38.7 oC. Her pulse rate is 170 beats per minute with a capillary refill time of 4 seconds.

´ ◦a) Describe the perioperative intravenous fluid management of this case. (60%) b) Outline the metabolic and clinical complications that can occur with inappropriate intravenous crystalloid therapy. (30%)

´ Again in April 2008….. ´ ◦A 4 year old (20kg) is admitted with acute appendicitis and is scheduled for

urgent surgery. She has been vomiting for 2 days, is pyrexial, has a tachycardia of 170 bpm and prolonged capillary refill.

´ ◦a) Describe the perioperative fluid management of this case using intravenous crystalloids. (60%)

´ ◦b) Outline the complications that can occur with inappropriate intravenous crystalloid therapy. (30%)

´ And Oct 05… ´ ◦Describe the perioperative fluid and electrolyte management of a 6 month

old child presenting in casualty with abdominal distention requiring urgent laparotomy.

Fluids- Nice Guidelines 2015

´ https://www.nice.org.uk/guidance/ng29/resources/algorithms-for-iv-fluid-therapy-in-children-and-young-people-in-hospital-set-of-6-pdf-2190274957