Paediatric Anaesthetics - Emergency Management

Paediatric Anaesthetics

Pre-operative assessment of child with a URTI

·        Peri-operative risk variably increased

·        Postpone high risk:

o  Neonates and infants 

o  Existing upper airway/respiratory pathology (eg CF) - ¯ reserve – easy to tip over the edge

o  Systemic symptoms

o  Lower respiratory tract involvement

o  Surgical impact on respiratory function (eg upper abdo surgery)

·        Complications usually manageable

Pre-operative assessment of child with a murmur

·        Innocent murmurs often detected by anaesthetists

·        Murmurs in up to 95%, but pathology in only 0.5%.  May need referral for investigation

·        3 Common innocent murmurs:

o  Early systolic from ventricular outflow tracts (either pulmonary or aortic)

o  Continuous murmur from SVC

o  Grade 1 – 2

·        Bad murmurs mimicking benign ones:

o  Severe hypertrophic obstructive cardiomyopathy

o  Critical aortic stenosis

o  These develop after birth – so may not have been picked up in post natal checks

·        Postpone and refer if suspicious, esp if < 1 year

·        ECG recommended if echo unavailable (can fax to a paediatric cardiologist for interpretation)

·        SBE prophylaxis may be indicated

Risk Factors for Aspiration

·        High risk for aspiration: Treat as full stomach

o  Full stomach

o  Regurgitation

o  Impaired protective reflexes 

o  Airway obstruction (big negative pressure in thorax in order to suck air in past obstruction – but this also sucks contents out of stomach)

·        Hazards of fasting:

o  Discomfort

o  Hypovolaemia.  Guidelines are:

§  Clear fluids till 2 hours before

§  Breast milk till 4 hours before

§  Food till 6 hours before (no chewing gum)

o  Hypoglycaemia: only an issue for neonates

Assessment for Sedation

·        Need to risk assess any child before any sort of sedation – its all too easy for something to go wrong (or more usually, for lots of little things to mount up)

·        Always need to be confident you could ventilate, intubate and get IV access quickly if necessary

Pain Management in Children

·        Myths:

o  Neonates don‟t experience pain

o  Neonates have no memory of pain (they retract from a needle the 2^nd time)

o  Pain is not harmful (it leads to stress response ® ¯healing, etc. ? Impact on the development of pain pathways) 

o  It is dangerous to treat pain

·        Management principles:

o  Mild to moderate pain relief is achieved through oral or rectal doses

o  Children hate needles, especially repeated IM injections

o  Using loading doses and regular maintenance doses to achieve therapeutic effect 

o  Don‟t overdose with paracetamol (may ® hepatotoxicity).  Limit duration

o   Child-friendly environment and parental involvement important

·        Available drugs: 

o   Paracetamol (oral better than rectal). Only use aspiring where specially indicated (eg Rheumatic fever)

o   NSAIDs: Diclofenac, Ibuprofen, Naproxen 

o   Codeine Phosphate (metabolised to morphine): constipation, plus dose related opiod side-effects – sedation, respiratory depression, nausea and vomiting

o   Morphine for serious pain (eg burns and fractures) 

o   Pethidine less used in kids - ­toxicity (including seizures)

o   Tramadol – not often used but less respiratory depression 

o   Nitrous Oxide (always administered with O2). OK for brief analgesia (eg fracture immobilisation). Ensure resuscitation equipment available. Month pieces preferred to masks