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Improve outcomes in pediatric anesthesia

Improve outcomes in pediatric anesthesia. Presented by : Muhammad Hamdy Lecturer of anesthesia - Ain Shams University. Our GOAL. Are we practicing safe pediatric anesthesia?. Outcome. Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007.

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Improve outcomes in pediatric anesthesia

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  1. Improve outcomes in pediatric anesthesia Presented by :Muhammad Hamdy Lecturer of anesthesia -Ain Shams University

  2. Our GOAL

  3. Are we practicing safe pediatric anesthesia?

  4. Outcome

  5. Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007 Cardiovascular41% • Hypovolemia with blood loss 12% • Air embolism 2% • Other CV 6% • Unclear CV mechanism 13%

  6. AlarmSigns of Hypovolemia under Anesthesia • Hypotension (low for age, narrow pulse pressure, vary with respiration) • Persistent tachycardia • Capillary filling not brisk • Skin mottling, cold extremities • Reduced urine output Jenkins&Mathur,2011

  7. Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007 Respiratory 27% • Airway obstruction-laryngospasm6% • Difficult intubation 1% • Bronchospasm 2% • Pneumothorax1% • Aspiration 1%

  8. Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007 Medication 18%(more in ASA I,II) • Halothane induced CV depression 5% • Sevoflurane CV depression 3% • Allergic reaction 1% • Intravascular injection of local anesthetics 1%

  9. Five Golden Rules of Safe Injection of Local Anesthetics • 1- Aspirate before injection. • 2- Give test dose 1-2 ml with epinephrine 1µ/ml→tachycardia) • 3- Slow injection rate < 10 ml/min → high plasma level • 4-Verify usual resistance throughout injection • 5- Repeat aspiration every 5 ml at least Aboulghare.a. Hum. Reprod 2011

  10. Anesthesia-Related Cardiac Arrest in ChildrenBananker et al, Anesthesia & Analgesia, August 2007 Anesthesia-Related. • kinked or plugged ET tube 1% • Inadequate peripheral venous access 22% • Central catheter (pneumoth., hemoth.) 3% • Breathing circuit 1%

  11. Prediction or anticipation of potential complications is crucial to improve outcomes in pediatric anesthesia.

  12. Neonatal Anesthesia • Children < 1 year old have more complications: I. Oxygenation II. Ventilation III. Airway management IV. Response to volatile agents and medications • Stress response is poorly tolerated • Consider: 1. Organ system immaturity 2. High metabolic rate. 3. Ease of miscalculating a drug dose Schenker and Weinstein, 2011

  13. Neonatal Anesthesia • Be aware of: • Sudden changes in hemodynamics • Unexpected responses • Unknown congenital problem

  14. Hypovolemia with blood loss accounts for 12% of causes of cardiac arrest in OR with almost half of it due to under estimation of blood loss Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007

  15. Immature hepatic function (drug dosing intervals &maintenance) • Immature renal function (poor toleration of fluid restriction/overload) Golan et al, 2010

  16. Age-specific considerationsFast desaturation • Low FRC, high closing volume, highly compliant airways►atelectasis • High oxygen consumption + can’t do forced inspiration ► increase R.R. ►high work of breathing • Diaphragmatic breathing►easily fatigue (less type I muscle fibers)►fast desaturation Schenker and Weinstein, 2011

  17. How Long Pre-oxygenation?

  18. 60 seconds 6L/min (gives 80-90 seconds before desaturation) (Morrison JE et al: Pediatric Anaesthesia2008:8;293)

  19. Spontaneous Vs controlled? -Spontaneous: more than 6 mos, less than 30 min Pressure Vs volume control? • Pressure control: First few days, premature • Volume control: surgical manipulations interfere with ventilation • Peep 3-5 is routine “ Whatever the technique, an expired tidal volume & PIP should be tailored to the desired levels” Schenker and Weinstein, 2011

  20. Competentnociceptivesystem AVOID (nonanalgesicpractice) AVOID

  21. Bosenberg AT et al, PediatrSurg Int2010:7, 289

  22. Monitoring equipment

  23. Monitoring equipment • ECG • NIBP • ETCO2 • Pulse oximetry • Temperature

  24. Monitoring equipment • precordial stethoscope • esophageal stethoscope • CVP (vasoactive drugs) • Direct BP (accurate, intravascular volume status)

  25. Monitors Predicting Complications. Webb et al,2011: The Australian Incident Monitoring Study

  26. Outcome

  27. THANKS

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