Ts & As and Dental Anaesthesia in Children

A personal and evidence based approach

Rural SIG June 2018

Dr Patrick T. FarrellJohn Hunter Hospital Newcastle NSW@PTFazza

ENT morbidity versus other surgery

Pediatric Anesthesia 2004 14: 158–166

Pre-operative Assessment

• Past GA

• Family History … bleeding disorders• Pathology only if indication

• URTI

• Smoking in the home

• OSA ( vs recurrent tonsillitis) “snoring”• Sleep study if suspected high risk but usuallly not available

• Other illnesses

• Medications and Allergies

• Airway assessment … including teeth

• CVS / RS exam

Anaesthesia Plan

• Post op care• HDU required• Long PACU stay• Overnight stay• Monitoring

• Fasting encourage clear fluids up to 2 hours ( soon to be one hour)• Premedication

• Default = NIL

• Induction• Airway• Maintenance• Analgesia

The Journal of Laryngology & Otology (2013), 127 (Suppl. S1), S26–S29

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Sleep Studies … Variables

Premedication

• Parental presence and distraction

• Default = NIL

• Oral Midazolam at 0.5 mg /kg peak effect 50 minutes (oral30%)• Better mask acceptance• Dysphoria on emergence• Increased PRAE?

• Clonidine 4mcg/ kg peak effect 60 minutes (oral 50% )• Needs time • Sedation post op

• Dexmetedomidine?

INDUCTION IV versus inhalation … Choice

IV access after induction is my normal practice BUT requires competent assistanceIV induction less PRAE

“T” Piece v Circle

“T” for induction and emergence

Circle for maintenance

Avoid “Brutane”

Guedel and CPAP

Airway Selection

• “South” RAE cuffed ETT • (Anaesthesia 2018, 73, 160–168)

• Smaller children• More complex• Surgeons preference• Insert after 3mg/kg propofol no NMB

• 4.7% Sevoflurane =MACED95Intubation

• Age/4 plus 3.5 for cuffed ETT

• LMA• Larger child• Surgeons preference• Flexible LMA

Maintenance

• Circle system - 15mm low dead space• Low flow cuffed ETT

• Ventilation • Trigger mode e.g. CPAP/PSV

• Sevoflurane with Nitrous Oxide ( TIVA when indicated )• N20 = Intraoperative analgesia• Remifentanil

• Analgesia• Morphine, Paracetamol, LA not effective• Parecoxib has been used ? Bleeding risk

• Antibiotics NOT routinely required

• Fluids = Hartmann's solution 20ml/kg bolus• NOT low salt solutions

Opioids … which and why

• OSA increased sensitivity to opioids OIRD ( up to 50%)

• Morphine• Peak effect at 30 minutes• Single dose 60-70mcg/kg dose

• Fentanyl• Rapid offset propensity for apnoea

• Remifentanil• With TIVA … “OIH”

• Tramadol ... FDA warning 2015

• Codeine ... FDA warning 2013• ultra-rapid or extended metabolisers with CYP2D6 gene duplications.

• Pethidine

Dexamethasone

• Dexamethasone (Cochrane Database Syst. Rev. 2011)• 0.2mg/kg (studies from 0.1 up to 1mg/kg!)

• Decreased nausea and vomiting during the first 24 hours following tonsillectomy (summary odds ratio [OR] 0.23; 95% CI 0.16-0.33)

• Decreased time to first oral intake

• Decreased postoperative pain

Emergence when to extubate

• On the table “is it safe”

• Deep versus awake with ETT• Deep more airway support required

• Awake more coughing breath holding

• “At just the right time”• Beware the single cough

• LMA “deep” and watch

Post-op Analgesia, Fluids and PONV

• Paracetamol• 15mg/kg “around the clock” ATC

• Ibuprofen 10/kg q6h PRN• J Laryngol Otol. 2001 Mar;115(3):205-8.• Post discharge Adenotonsillectomy patients continued to have moderate pain

for several days with pain lasting on average 9 days

• Opioids … avoid→OIRD• {Oxycodone 0.1mg/kg oral 6 hourly}

• CSL or Saline overnight

• Ondansetron 0.1mg/kg IV

Post op observation

• Recovery stay .. How long?• Often reveal trouble at this time

• Longer stay and sign out

• ICU /HDU

• Same day• Not with the case mix we see

• One night stay with IV oximetry if indicated

Dental Anaesthesia … 3 kinds

• “Mask and grab”

• LMA flexible

• ETT• Oral• Nasal

Dental… Nasal ETT

• ETT Plain “north” RAE

• Inhalation plus propofol 3Mg/Kg

• Oxymetazoline

• Lubricant in nostril

• Soften the tip (2-3 cm) with very hot water

• Magill forceps

• 2-3 sprays or drops = 60-90 µL• Both nostrils = 180 µL

• Inverted 473 – 2196 µL

• Pledget= 1500 µL

BP =170/110

Analgesia

• Paracetamol

• Ibuprofen

• Parecoxib

• Dexamethasone

• Local infiltration of tooth

• Avoid big blocks

GENERAL INFORMATION 28 – 29 September 2018 Newcastle NSW Australia CONTACT Conference Secretariat PO Box 180 Morisset NSW 2264 Tel: (02) 4973 6573 Fax: (02) 4973 6609 Email: info@thenac.com.au Web: www.thenac.com.au

VENUE The Conference will be held at Quality Hotel NOAH’S On the Beach Newcastle which is located opposite the spectacular Newcastle Beach, Newcastle’s most renowned surf and swim beach, and in the heart of the Newcastle East heritage precinct.

Newcastle’s Central Business District, Entertainment venues, Newcastle Harbour and the revitalised Honeysuckle foreshore are all only a short walk or ride on the free inner city bus network from Quality Hotel NOAH’S On the Beach Newcastle.

DESTINATION Newcastle is Australia’s 7th largest city and one of its oldest. It has a fast growing reputation as a conference destination as it offers a unique blend of big city facilities and country town friendliness. It is the capital of the Hunter Region and the most popular tourist destination outside of Sydney in NSW.

Newcastle is the gateway to the attractions of the region including Hunter Valley Wine Country, Lake Macquarie, the wilderness of the Upper Hunter or the Shores of Port Stephens, renowned for its dolphin population and whale watching opportunities.

GETTING THERE Newcastle is an easy 2 hour drive from Sydney or 2.5 hours by rail or there is a regional airport (Newcastle Airport) located just 20 minutes’ drive from the CBD. Direct flights are available from Sydney, Brisbane, Melbourne, Gold Coast and Canberra.

INVITATION TO ATTEND Following on from the success of the first three Newcastle Anaesthesia Conferences, we are inviting you to join us again in beautiful Newcastle for the 4th Newcastle Anaesthesia Conference. The theme of the conference is Perioperative Anaesthesia.

INVITED SPEAKERS

• Dr Sean McManus joined the ANZCA Council in 2014. Sean is a senior specialist in the Department of Anaesthesia, Perioperative Medicine and Intensive Care at the Cairns Hospital, QLD.

• Dr Tracey Tay is a Senior Staff Specialist Anaesthetist & Director of Perioperative Medicine at John Hunter Hospital in Newcastle, NSW.

• Prof David A Scott is the current president of ANZCA ( to May 2018) and a Clinical Professor with the University of Melbourne. He is the Director of the Department of Anaesthesia and Acute Pain Medicine at St Vincent’s Hospital in Melbourne.

• Dr David Rowe Clinical Director of Anaesthesia at Armidale District Hospital, Dr Rowe is Australia’s leading expert in carbohydrate preoperative clear fluids & has been challenging the traditional preoperative fasting dogma since 2015.

• Dr Costa Karihaloo is a Consultant Gastrointestinal Surgeon specialising in endoscopic, laparoscopic & minimally invasive techniques, as well as Bariatric Surgery. He is the current Director of the Department of General Surgery at John Hunter Hospital, Newcastle, NSW.

• Dr Pragya Ajitsaria is a staff Specialist Anaesthetist at John Hunter Hospital, Conjoint Lecturer at the University of Newcastle and emerging Researcher.

www.thenac.com.au

FEATURED WORKSHOPS

• Echocardiography Workshop

• Thromboelastography PBL

• Regional Block Workshop

•

TOPICS TO BE COVERED Through a variety of formats including plenary sessions, posters and interactive workshops we will cover the following topics;

• Point of Care Ultrasound

• Utility of Scoring Systems

• Obesity Pathophysiology

• Regional Anaesthesia

• Feeding and Fasting

CPD EMERGENCY RESPONSE SESSIONS As part of the conference we will be offering CICO and ALS CPD emergency response sessions as recognised by ANZCA CPD.

THE NEWCASTLE ANAESTHESIA CONFERENCE 2018 PROGRAM

FRIDAY 28 SEPTEMBER

ANZCA CPD EMERGENCY RESPONSE SERIES - Hunter New England Simulation Centre, John Hunter Hospital Additional payment is required for these sessions. Please either click here or refer to the workshop tab for exact pricing details.

CICO ALS

0830 – 1100 0830 – 1100

1130 – 1400 1130 – 1400

1430 Registrations open

1500 AFTERNOON TEA

OPENING SESSION CHAIRPERSON: PATRICK FARRELL

1530 Welcome and Opening Patrick Farrell

1540 The future of education and training in Perioperative Medicine Sean McManus

1605 Future directions in clinical care in perioperative medicine Tracey Tay

1630 Fasting not starving David Rowe

1655 Panel discussion

1705 DAY CLOSE

1830 CONFERENCE DINNER AT LONGWORTH HOUSE

SATURDAY 29 SEPTEMBER

SESSION ONE CHAIRPERSON: CANDICE PETERS

0915 Opening Patrick Farrell

0930 The utility of scoring systems in patient selection for anaesthesia and surgery Pragya Ajitsaria

1000 Diabetes new treatments, new complications Paul Healey

1030 Obesity pathophysiology and the role of surgery Costa Karihaloo

1100 MORNING TEA & POSTER VIEWING

SESION TWO CHAIRPERSON: CATE McINTOSH

1130 Cognitive function outcome and consent David A Scott

1200 Deal makers and breakers patients with coexisting cardiovascular disease Nick Collins

1230 Scholar Role session

1300 LUNCH & POSTER VIEWING

AFTERNOON SESSIONS

NOAH’S ON THE BEACH JOHN HUNTER HOSPITAL Additional charge of $140 per person is required for either of these workshops

1400

Thromboelastography PBL

Julian Baldwin & Haemonetics

Paediatric PBL Michael Dobbie

Acute pain PBL Richard Burstal &

Rob Thomas Regional Anaesthesia Ultrasound Workshop

Facilitator: Mark Davies

With Steve Bruce & Berni Frost

ECHO Workshop

Facilitator: Rob McMonnies

With Sabry Eissa & Paul Healey

1500

Thromboelastography PBL (repeated)

Julian Baldwin & Haemonetics

Anaesthesia for cataract surgery

PBL Tom Martin

Acute pain PBL (repeated)

Richard Burstal & Rob Thomas

1600 AFTERNOON TEA

1630 Obstetrics PBL

Ajit Sivasankaran

Anaesthesia for cataract surgery PBL (repeated)

Tom Martin

Paediatric PBL (repeated)

Michael Dobbie

1730 DAY CLOSE & HAPPY HOUR AT NOAH’S ON THE BEACH