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“Anaesthesia for paediatricians” A very practical approach!. Jenny Thomas Paediatric Anaesthesia, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa. Objectives. Recognise who not to tackle How to prepare What to do When to ask for help
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“Anaesthesia for paediatricians” A very practical approach! Jenny Thomas Paediatric Anaesthesia, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa
Objectives • Recognise who not to tackle • How to prepare • What to do • When to ask for help • Document everything
It’s all in the preparation • Environment: what do you need? where are you? what do you have • Patient: good, bad, indifferent. Beware syndromes, other abnormalities • Self: skills, knowledge, confidence, humility
Paediatric sizes: laryngoscopes, masks, LMA, airways, ETTs, cannulae, volume controllers Suction: functioning Oxygen source: humidified: pre-oxygenate! Bag, mask / ventilator (may be you) Monitoring Drugs Telephone: in case help /advice is required Equipment: functioning (check)
Patient factors • Airway: profile, ears, adenoids/ tonsils, mouth-opening, teeth • Breathing • Circulation • Drugs / disability • Environment • Fluids / blood • Glucose
Intubation • “Awake” intubation • Oral or nasal • Hypnotic / analgesia agent vs not • Muscle relaxant vs not • Rapid sequence vs not • Size of ETT: Age/4 + 4 • Cuffed or not • How far to place the ETT • Local anaesthetic to vocal cords • Secure strapping • Confirm placement: Capnography? • LMA Airway Mask ETT LMA
How to make life easier • Nose drops: oxymetazoline • Lubrication tip of ETT • Warm tip of ETT (nasal) • Bougie / introducer (very gentle in neonate or septic child) • Position of patient: NB anterior larynx • Support behind body (not only shoulders); neonates, hydrocephalus • Do not hyperextend the head • Roll ETT through 180º as through cords
Anaesthetic department rules • Call consultant always: • Airway problem: regardless of age of patient • Any child under one year of age • Any cardiac, severely systemically ill child, critically ICP • When > 2 hands are necessary
Circulation • Haemodynamics: normal vs compromised • Heart rate: myocarditis vs trauma • Vascular access: peripheral vs central vs none • Time available? • Resuscitation: easy choices
Drugs • Route: Sublingual, oral, nasal, intravenous • NPO? • Induction agents: sedation vs anaesthesia • Propofol: 1-3 mg/kg/dose • Etomidate: 0.3-0.5 mg/kg/dose • Ketamine: 0.5 – 2 mg/kg/dose • Inhalational agents: only DA or FCA • Ketofol: 0.75 mg/kg/ketamine + 1 mg/kg/dose propofol • Muscle relaxants: do not paralyse if airway control is not guaranteed
My preferences: • Patient condition, line, and time-dependant • Oxygenate well, plan, have help • Local anaesthetic: EMLA, infiltration: drip, Macintosh spray (mouth, pharynx) • Perfalgan • Induction agent: ketamine, etomidate propofol ± ketamine / fentanyl • (Muscle relaxant: cisatracurium / sux) • Intubate, ventilate, check ABC
Other options • Midazolam • Fentanyl: 10mcg/kg for stress-free intubation • Entonox • Clonidine, Dexmedetomidine • Beware: fentanyl + etomidate+ sux
Conclusion • Know yourself (your limitations) • Know your patient (A,B,C) • Know your drugs ( know and use a few drugs well) • Where to after your hard work?
