Principles of paediatric anaesthesia

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Principles of paediatric anaesthesiaJulian Berry

Paul Waterhouse

Abstractthis article describes the principles and practice underlying the safe de-

livery of paediatric anaesthesia in the UK. it outlines the rationale behind

the organization of paediatric anaesthetic services. the article describes

the practicalities of creating an appropriate environment, and the equip-

ment and techniques for general anaesthesia. Presenting an overview of

the principles of paediatric anaesthesia, this article is complimented by

specific articles in the series, which include principles of neonatal and

day-case anaesthesia as well as dental and sedation procedures.

Keywords induction; maintenance; paediatrics; standards of care

National standards of careDespite increasing specialization within anaesthesia and medi-cine, there is a large volume of paediatric work undertaken in general hospitals throughout the UK. The organization of paediatric anaesthesia services in the UK was prompted almost 20 years ago by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which reported that the out-come of surgery and anaesthesia in children was related to the experience of the clinicians involved.1,2 As a result many hospitals not sustaining an adequate paediatric case-load lim-ited or ceased undertaking paediatric anaesthesia. More recent reports from both the anaesthetic3 and surgical4 royal colleges state clearly the role of a consultant-led service, with designated paediatric clinical areas for induction and recovery. Appropriate equipment and training in paediatric skills for all staff involved with caring for children are mandatory. By endorsing these recommendations, the National Service Framework for Children

Julian Berry, FRCA, is final year Specialist Registrar in Anaesthesia and

Intensive Care at the Royal Cornwall Hospital Trust, Truro. He qualified

in 1994 at the University of Glasgow, and has trained in anaesthesia

in London, Perth (Australia) and the South West of England. He

undertook a fellowship in paediatric anaesthesia and intensive care in

Bristol and Glasgow. He is currently undertaking a Masters degree

in Healthcare Leadership and Management.

Paul Waterhouse, FRCA, is Consultant Anaesthetist at The Royal

Cornwall Hospital Trust, Truro. He qualified at the Charing Cross

and Westminster Medical School, London. His anaesthetic training

was based in Bristol, but included a fellowship year at the Alder

Hey Hospital for Sick Children, Liverpool. His specialist interests are

paediatric and ophthalmic anaesthesia.

ANAestHesiA ANd iNteNsiVe cAre MediciNe 8:5 1

from the Department of Health5 ensures the central support of those involved in implementing these guidelines (Table 1).

Practical standards for delivery of paediatric anaesthesiaThe Royal College of Anaesthetists provides guidance on the stan-dards required for the practical conduct of all sedation and anaes-thesia3 and for the role of trainees in paediatric anaesthesia. An appropriately trained and experience anaesthetist must be present throughout the conduct of all general and regional anaesthetics. A trainee at the level of Senior House Officer should not be expected to be the solo practitioner in any paediatric case. A Specialist Reg-istrar in year 1 or 2 should be able to organize and safely manage a list of straightforward paediatric patients aged more than 3 years, with available consultant cover. A Specialist Registrar in year 3, 4 or 5, aspiring to be a generalist, should be skilled to indepen-dently anaesthetize children aged more than 1 year. Consultant supervision is required for neonates and infants.

PreparationSafety of the child is the priority at all times in paediatric anaes-thesia. This cannot be ensured without adequate preoperative preparation. This begins at the initial outpatient visit by a clear verbal explanation supported by written information outlining what to expect during a particular surgical procedure. In addi-tion, information regarding where to go, dates, times and fasting guidelines should be included. For complex medical or surgical cases, parental anxiety or request, a pre-assessment clinic can be very useful. At this clinic a rapport can be established with the family as the anaesthetic components of the procedure are explained. Options for pain relief can be discussed and arrange-ments for visiting the theatre suite can be made.6 Every child (and whenever possible his/her parents/guardian) must be seen preoperatively.6,7 For a detailed discussion of preoperative assessment see Anaesthesia and intensive care medicine 7:10: 375. This assessment should always follow the structure shown in Table 2.

Emergency preoperative assessmentEmergency preoperative assessment will follow the same struc-ture and attention to detail as for the elective patient (Table 2). Difficulties may be encountered because of the lack of informa-tion relating to case notes, medical and surgical history and the urgency of the clinical condition requiring treatment. Clear communication between the anaesthetic and surgical team and parents is essential. Resuscitation and stabilization are required before undertaking investigations, diagnostic imaging or surgery.

FastingGuidelines for fasting times in elective surgery are summarized in Table 3. Preoperative fasting does not guarantee an empty stomach, and prolonged starvation can be harmful (dehydra-tion and hypoglycaemia) and increase postoperative nausea and vomiting. In the emergency or trauma situation, the gastric vol-ume at induction has been shown to be more clearly related to the interval between food and injury, than to the total fasting period. This is reinforced by pain and analgesic use. Hunger is not predictive of an empty stomach. Therefore, a rapid-sequence induction is indicated in all cases of emergency surgery, and should even be considered in urgent surgery where a period of

69 © 2007 elsevier Ltd. All rights reserved.

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greater than 6 hours fasting has occurred (especially if a signifi-cant injury occurred immediately after a meal).

Resuscitation before anaesthesiaTrauma, burns and other emergency cases require resuscitation and stabilization before definitive surgery. This should follow the

Standards for the delivery of a surgical service for children in the UK

General guidance

every hospital that receives children must have a policy for

securing both emergency and non-emergency surgical services

for children. All areas of the hospital (e.g. day surgery, icUs, pain

services, outpatient, pharmacy and radiology) must be aware

of child- and family-centred care, equipment and environment.

this includes the geographical separation of child patients from

adult patients in combined clinical care areas, such as theatre

reception, recovery, and outpatient clinics.

Personnel and training

Pre-, intra- and postoperative care should be provided by

appropriately trained staff, including reception, theatre, recovery

and registered children’s ward nurses. For anaesthesia, the royal

college has made the following recommendations:

• A minimum of 6 months’ training in paediatric anaesthesia

• to obtain adequate experience the anaesthetist must

undertake the care of:

12 children < 6 months (i.e. one per month)

50 children < 3 years (i.e. one per week)

300 children < 10 years (i.e. approx one per day or one

regular full paediatric list per week)

For surgery, the recommendations are:

• A minimum of 6 months’ training in paediatric surgery

• care of a sufficient number of children per year to maintain a

high level of competence

• Operate on children at least one operating list per fortnight

Equipment

As part of each Primary care trust’s clinical governance

framework, equipment must be available and tailored for

different needs, ages and stages of development.

Critical care

24-hour availability of staff trained in paediatric life-support,

with access to facilities, equipment and medications as required.

All hospitals admitting children should be able to carry out

emergency treatment, stabilization (to level 2 intensive care)

and preparation for transfer of critically ill children. A network of

children’s critical care services should be established in the local

area, and should combine accident and emergency, ambulance

services, district General children’s wards and intensive care

areas, and a tertiary centre for paediatrics with a 24-hour

retrieval service.

department of Health. Paediatric intensive care: a framework for the future. National coordinating Network on Paediatric intensive care report to the chief executive of the NHs executive, 1997

Table 1


principles and protocols described in the Advanced Paediatric Life Support manual.8 Senior involvement should be obtained in every case, and liaison with the tertiary regional paediatric centre should also be sought at an early stage. The ‘ABCDE’ assessment structure of airway (and cervical spine immobilization if traumatic presentation), breathing, circulation, disability and exposure ensures a complete initial resuscitation phase before undertaking a comprehensive secondary survey. It is essential to correct any life-threatening abnormalities as soon as they are found. Reassess-ment is a key part of the process. Always reassess when there is a change in the clinical condition, following an intervention and regularly whilst progressing through the protocol.

Parental presenceParental presence at induction in the anaesthetic room is normal practice in the UK. However, there are some exceptions, including infants aged up to 6 months (minimally upset by parental separa-tion), a child who refuses parental presence, parental request not to be present, anaesthetic discretion, and compromised clinical safety, for example, extremely sick children. Adequate prepara-tion of the parent is vital to ensure their presence is advant-ageous, particularly in the preschool age group.9 Table 4 outlines the advantages and disadvantages of parental presence.

Structured preoperative assessment

• read notes

• establish a rapport

• History

Perinatal

Anaesthetic

Medical (exclude recent Urti)

drug

Previous pain experience

starvation times

Allergies (exclude latex allergy)

• examination

Weight

Baseline observations

Airway

respiratory

cardiovascular

Abdominal

Neurological

• resuscitation as indicated

• review investigations

• request and review other relevant investigations

• Age-appropriate information

• risks

• consent

• continue usual medications, especially anti-epileptics

• Optimize medical condition

• reassurance and psychological preparation

• Premedication as indicated

Urti, upper respiratory tract infection

Table 2

© 2007 elsevier Ltd. All rights reserved.

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Induction of anaesthesiaThe decision to use intravenous or inhalational induction depends primarily on the urgency of securing the airway and the medical needs of the patient. A full stomach, trauma, air-way bleeding or gastro-oesophageal reflux disease mandates a rapid-sequence intravenous induction technique. Any patients presenting with stridor or airway obstruction require a careful inhalational induction. Thereafter, the wishes of the child, parent and/or anaesthetist can be considered. The rapport established at the preoperative assessment should be continued throughout the chosen type of induction.

Intravenous induction: Ametop or Emla cream should be pre-scribed and applied at least 1 hour preoperatively to suitable sites for venous access. Good sites to consider are the back of the hands, ventral surface of wrist and saphenous veins. If difficulty in cannulation is predicted, experienced assistance should be called early to avoid unnecessary discomfort and upset to the child. A 22 G (blue) cannula is most commonly used. However, for neonates and children with predicted difficult veins, a 24 G (yellow) Neoflon is suitable. Flush cannulae with saline before use to facilitate the ‘flash-back’ of blood, indicating correct placement.

Pain on injection of propofol should be avoided at all times, especially where repeated procedures requiring anaesthesia are

Advantages and disadvantages of parental presence at induction

Advantages Disadvantages

• A parent or carer may relieve

anxiety and provide support

and affection

• reduction in requirements of

sedative premedication

• Facilitation of the processes of

inhaled induction

• distraction during intravenous

cannula placement

• Holding of face-mask during

pre-oxygenation/inhalation

induction

• transmission of

anxiety or fear to child

• refusing to leave child

after induction

• Undue stress for

parent or carer

• increased stress to

the (inexperienced)

anaesthetist

Table 4

Minimum elective fasting times before anaesthesia

Intake Minimum fasting time (hours)

Food/solids (including cows’ milk) 6

Formula milk (< 3 months) 4

Breast milk 4

clear fluids 2

Table 3


likely (e.g. lumbar puncture for cancer patients). Pain can be reduced with slow administration and the addition of 1 ml of 1% lignocaine per 100 mg propofol.

Rapid-sequence induction: the technique of rapid-sequence induction (RSI) should be carefully explained to both child and parent. The need for the accompanying adult to leave the anaes-thetic room when instructed should be emphasized. Preoxygena-tion is always preferred in RSI anaesthesia; however, this must be balanced against causing stress in young children. In infants, crying and restless movement may increase oxygen consumption and reduce the effectiveness of preoxygenation. Cricoid should not be placed until drooping of the eyelids occurs. Thiopentone should be manually flushed with a small volume of saline to avoid precipitation with suxamethonium. Oxygenation should be maintained throughout the induction sequence. Laryngo-scopy should be attempted once fasciculation has ceased (fas-ciculation may not be present in younger children). Intubation should be abandoned after two failed attempts and the patient should be woken up to avoid arterial desaturation. Thereafter, experienced assistance should be obtained and alternative strategies sought.

Inhalational induction: young children and those attending for repeated procedures (e.g. changing burns dressings) may occasionally request inhalational induction. Inhalation may be preferred after failed venous cannulation and is preferred in the UK for an obstructed or difficult airway. An adequate and reassuring explanation of the technique should be made to both child and parents, in particular the excitation phenom-ena associated with deepening levels of anaesthesia that may cause undue parental distress. In their eagerness to provide reassurance, the encouragement given by the anaesthetic team can be confusing and distressing for the child during inhala-tional induction. To avoid this, only the inducing anaesthe-tist plus the accompanying parent should comfort the child. Inhalational induction is safe and rapid with 50:50 oxygen and nitrous oxide.10

Sevoflurane has all but replaced halothane as the agent of choice because of its non-pungent, non-irritant, rapid induction and recovery characteristics. Agent-monitoring in the anaesthetic room may offset its main disadvantage of cost. The anaesthetic vapour is gradually introduced with increments of 2%. The child is constantly informed and reassured, until the maximum strength is achieved, which for sevoflurane at 8% equals approximately 3 MAC (minimum alveolar concentration). Increasing the vola-tile too rapidly or inserting the venous cannula before the patient is deeply anaesthetized may induce coughing, breath-holding or laryngospasm.

Choice of induction agentAdvantages and disadvantages of induction agents used in paedi-atric practice are summarized in Table 5.

MaintenanceA comparison of volatiles and total intravenous anaesthesia (TIVA) is shown in Table 6. In most cases a volatile agent is satisfactory, using sevo-, iso- or desflurane. Desflurane has the advantage of rapid emergence because of its very low blood:gas


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Common induction agents used in paediatric anaesthesia

Drug Dose Advantages Disadvantages

Propofol i.v. 3–5 mg/kg • rapid, smooth induction

• rapid, predictable recovery following

induction

• reduction in PONV a

• Pain on injection

• dystonic movements

• dose-dependent decrease in MAP

thiopentone i.v. 3–5 mg/kg • rapid and identifiable onset of anaesthesia

• No pain on injection

• Less reduction in MAP than propofol

• inexpensive

• Anti-epileptic

• Prolonged recovery

Ketamine i.v. 1 mg/kg

i.m. 10 mg/kgb

• intense analgesia, dissociative anaesthesia

• Maintains cardiovascular stability

• Bronchodilator

• Maintains respiratory reflexes

• i.m. administrationb

• Unpleasant excitatory emergence

phenomena

• raised intracranial and intraocular pressure

• Nausea and vomiting

• salivation

i.v., intravenous; i.m., intramuscular; MAP, mean arterial pressure; PONV, postoperative nausea and vomitingatramer M, Moore A, McQuay H. Propofol anaesthesia and post-operative nausea and vomiting: quantitative systematic review of randomized controlled studies. BJA 1997;78:247–55bOnly with parental consent, in an uncooperative child where establishing a rapport and oral sedation have failed

Table 5

solubility, whilst isoflurane offers the advantages of cost. TIVA with target-controlled infusion of propofol and short-acting opioids, such as remi- or alfentanil infusions, is especially use-ful in procedures or patients associated with postoperative nausea and vomiting (e.g. strabismus surgery or malignant- hyperthermia susceptible individuals). The dose of propofol for TIVA is twice that in adults (ED50 of 10.5 mg/kg/hour, compared with 5 mg/kg/hour when combined with alfentanil 50 μg/kg/hour).11

AirwayIn very short procedures, a correctly sized oropharyngeal airway with an anaesthetic circuit (e.g. T-piece) is effective, simple and safe. The laryngeal mask airway (LMA) has become the cornerstone of paediatric airway management for many elective procedures. Major elective cases and some medical conditions (e.g. gastro-oesophageal reflux, abnormal oropha-ryngeal anatomy) will still require endotracheal intubation. It is common practice in the UK to use appropriately sized uncuffed endotracheal tubes for children who weigh 20 kg or less. How-ever, there is an increasing body of evidence that shows the safe use of cuffed endotracheal tubes in all children, exclud-ing small infants. The benefits include constant minute venti-lation, precise respiratory and capnography monitoring. In an emergency situation and in patients with severe lung disease, a good seal with a cuffed endotracheal tube becomes even more important.12 Although unpredicted difficult intubation is very rare in children, knowledge of paediatric ‘can’t intubate–can’t ventilate’ algorithms is essential. During elective intubation, confirmation of a patent airway by manual ventilation is funda-mental before administration of a non-depolarizing muscle relaxant.


FluidsKnowledge of the physiology of fluid compartments and fluid shifts in children, combined with an understanding of the properties of intravenous fluids, underpins the safe practice of fluid management in infants and children (Anaesthesia and intensive care medicine 3:12: 459; Anaesthesia and intensive care medicine 7:12: 462).13,14

Administration of a hypotonic fluid in the perioperative period (when the stress response results in water retention and the release of vasopressin) can result in fatal hyponatraemia in children. Thus, the Association of Paediatric Anaesthetists recommends an isotonic fluid, such as 0.9% NaCl (or Ringer’s lactate) plus 2% dextrose for intraoperative maintenance, and a solution of 0.45% NaCl plus 5% dextrose plus 20 mmol potas-sium for postoperative maintenance. In preterm babies and neo-nates, a solution of 10% dextrose (with added electrolytes) is required to prevent hypoglycaemia because of their low glycogen stores. In all situations, electrolytes and blood glucose should be monitored.

Volumes: perioperative fluid management consists of account-ing for pre-, inter- and postoperative losses, and providing main-tenance fluids throughout these periods.

Preoperative losses: replacing the starvation deficit – elective surgical cases will have a deficit of their hourly maintenance requirements multiplied by the starvation period (normally 2 hours). Maintenance fluid calculation was developed by Hol-liday and Segar in 1957 on the basis of caloric requirements. It is simply translated into fluid administration as shown in Table 7.

Intraoperative losses consist of immeasurable but estimated ‘third-space’ isotonic losses, such as evaporation from exposed


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Comparison of volatile and total intravenous anaesthesia for maintenance of paediatric anaesthesia

Advantages Disadvantages

Volatile • Familiarity and established use

• Ability to monitor gas concentrations

• easy to administer

• Predictable

• Possible when no intravenous access

available (failure, refusal, etc)

• Low cost in low-flow circle system

• increased PONV

• irritant (to airway)

• emergence delirium

• environmental concerns

• cost of scavenging

• requires ventilation (spontaneous or manual)

• trigger for MH

tiVA • reduction in PONV

• rapid, clear recovery following emergence

• No scavenging required

• rapid control of depth of anaesthesia

• some cases can be managed with simple oxygen delivery

devices (mask/nasal prongs) without anaesthetic circuits

• Mode of choice for MH susceptible patients

• reduced atelectasis

• Algorithm accuracy

• Validity of Bis monitoring endpoint in paediatrics

• cost

• risk of awareness

• risk of intravenous dislodgement

• Pain on injection (propofol)

• Long, context-sensitive half-life

• requires antisyphon valve

• Lipid load

• Bradycardia (remifentanil)

• tachyphylaxis

Bis, bispectral index; MH, malignant hyperthermia; PONV, postoperative nausea and vomiting; tiVA, total intravenous anaesthesia

Table 6

surgical sites, and actual blood loss. The concept of ‘allowable-blood loss’ (ABL) is useful, as it allows planning for the allow-able haemorrhage, calculation of the replacement fluid, and ordering of the cross-matched blood in advance. ABL is calcu-lated as shown below:

ABL = weight (kg) EBV (Hb Hb )/Hb0 1 a× × −

where EBV is the estimated blood volume (neonates: 90 ml/kg; infants: 80 ml/kg; > 1 year: 70 ml/kg); Hb0 is the patients origi-nal haemoglobin; Hb1, is the lowest acceptable haemoglobin; and Hba is the average haemoglobin (Hb0 + Hb1)/2. Haemtocrit val-ues may be used in place of haemoglobin. The lowest acceptable value is controversial, and must be judged on previous medical history, rate of current and ongoing losses, and risks of allogenic transfusion. For example, an 11-month previously well 10 kg infant is being assessed for elective bilateral pelvic and femoral

Maintenance fluid requirements

Body weight Fluid requirement (ml/kg/hour)

0–10 kg 4

11–20 kg 2

≥ 21 kg 1 for every kg over 21 kg

For example, a 12-year-old child with estimated body weight of 32 kg will require (40 + 20 + 12) 72 ml/hour of maintenance fluids

Table 7


osteotomies. The ABL would be calculated as: 10 kg × 80 ml/kg × (12−7)/((12+7)/2) = 421 ml ABL.

Up to this allowable volume, losses should be replaced with crystalloid in a volume ratio of 3:1, and with colloids in a ratio of 1:1. In infants and neonates, human albumin solution 10% is the preferred solution. Thereafter, cross-matched blood may be required. In all procedures pre-, peri-, and postoperative strat-egies should be adopted to minimize the transfusion of allogenic blood to children, in particular fluid overload, hypothermia, impaired clotting and metabolic disturbances.

Postoperative losses include ongoing maintenance require-ments, recommended as 0.45% NaCl, 5% dextrose and 20 mmol KCl. Losses from drains, fistulas or nasogastric tubes should be replaced in a 1:1 ratio with colloid or crystalloid. Appropriate checking of serum electrolytes, glucose, haemoglobin and clot-ting status is essential, with correction as required.

EmergenceThe most common problem encountered during emergence from anaesthesia is laryngospasm. Safe removal of the airway device is achieved in most cases when the patient is almost or fully awake, thus reducing the incidence of laryngospasm. This is mandatory in emergency cases. However, some clinical situations lend themselves to deep extubation with spontaneous ventilation, avoiding coughing or straining. Following tonsil-ectomy, gently inspecting the oropharynx, transferring the patient to the recovery trolley in the lateral ‘tonsillar’ position and removing the endotracheal tube or LMA can all be under-taken whilst maintaining deep anaesthesia to avoid provoking bleeding from the tonsillar bed.


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Common complications in paediatric anaesthesia and reduction strategies

Complication Preoperative strategies Interoperative strategies Postoperative strategies

Nausea and

vomiting

identification of:

• risk factors: previous incidence,

motion sickness, early postop

mobilization, sex, age

• surgical procedure: orchidopexy,

otoplasty, strabismus correction

• Prophylaxis for at risk cases:

ondansetron, dexamethsaone

(sole agents or in combination)

• Propofol, tiVA10

• Avoidance of precipitants:

opioids

• Prescribing multimodal anti-emetic

agents:

• i.v. fluid administration

• Avoidance of early mobilization

• Avoidance of early oral fluids

Pain • identification of high-risk

procedures: opening of body cavity

• Preventative analgesics:

paracetamol, NsAids, clonidine,

gabapentin

• Obtunding stress response

• Multi-modal analgesia

• regional anaesthetic techniques

• Adjuncts to neuroaxial local

anaesthetics: ketamine, clonidine

• Pain team involvement

• regional catheter techniques

• regular administration of adjuvant

analgesic agents

• Benzodiazepines for muscle spasm

Hypothermia theatre preparation:

• Ambient temperature and humidity

• Availability of warming equipment

(e.g. forced air warmer, overhead

heater etc)

• core and peripheral temperature

measurement

• Forced air warmer

• Microenvironment for neonates

• Warmed i.v. fluids

• covering of exposed skin

(e.g. head, limbs)

• Warmed recovery area

• continuation of intraop warming

techniques

• Warming of recovery or ward bed

Laryngospasm • identification of those at risk

(younger > > older children)

• Urti

• exposure to cigarette smoke

• Positive airway pressure

• increase depth of anaesthesia

• Administer muscle relaxants

• Administer propofol bolus

• Adequate oropharyngeal

suctioning pre-extubation

• ‘deep’ or fully awake extubation

• Positive airway pressure

Postoperative

psychological or

sleep disturbance

• identification of those at risk

• Behavioural and cognitive therapy

• Plan for day surgery

• Premedication

• Avoidance of opioids where

possible

• Minimally invasive surgery

• Adequate analgesia

• rapid return to home environment

HMe, heat and moisture exchanger; i.v., intravenous; NsAids, non-steriodal anti-inflammatory drugs; Urti, upper-respiratory tract infection

Table 8

RecoveryThe facilities in the recovery room should follow the guidelines stated by the Association of Anaesthetists of Great Britain and Ireland.15 In particular, the need for a designated paediatric area, with one-to-one staffing trained in the recovery of paediatric patients is essential. Clear postoperative instructions regarding analgesics and fluids should be prescribed, with the anaesthetist contact details in the event of any complications.

ComplicationsCommon complications in paediatric anaesthesia and reduction strategies are shown in Table 8. ◆

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