“Anaesthesia for paediatricians” A very practical approach!

Jenny ThomasPaediatric 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

Equipment: functioning (check)

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

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

AirwayMaskETTLMA

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?

This should not be a hair-raising experience!

The end