7.1 Child for Fundoplication

Question 1

A 4-year-old boy with a past medical history of birth asphyxia,
developmental delay, and poorly controlled epilepsy is scheduled for a Nissen’s
fundoplication due to chronic reflux.

He suffers from gastro-oesophageal reflux disease and gets recurrent chest
infections; roughly three admissions per year.

The child had to be admitted to the
paediatric intensive care unit 4 months ago with chest infection.

Medication
Lamotrigine and Sodium valproate

On examination

Weight: 12 kg

Afebrile
Heart rate: 140/min; regular
Heart sounds: normal
Respiratory rate: 32/min
Crackles right base

Blood investigations
Hb 10 g/dL (13–16)
Haematocrit 0.45 (0.38–0.56)
WCC 21.1 × 109/L (4–11)
Platelets 221 × 109/L (140–400)

MCV 70 femtolitres (80–100)
Na 128 mmol/L (137–145)
K 4.8 mmol/L (3.6–5.0)
Urea 6.1 mmol/L (1.7–8.3)
Creat 72 μmol/L (62–124)

summarise the case.

Answer 1

A 4-year-old child for elective major surgery, probably laparoscopic with
multiple comorbidities, exhibits:

• Poorly controlled epilepsy
• Significant chest infection
• Anaemia and hyponatremia
• Small stature for his age

These need to be optimised before going ahead with surgery.

Question 2

Why do you think he is small for his age? What would be his ideal weight

Answer 2

The commonly used formula to calculate weight from age is
Weight = 2(age + 4)

This means the ideal weight of this child should be 16 kg.

The Luscombe and owens formula [Weight = (3 × age) + 7] probably
reflects the actual weight in this country. It can be used over a larger age
range (from one year to puberty) and allows a safe and more accurate
estimate of the weight of children today and prevents underestimation and
hence under-resuscitation.

The main reason for poor weight gain in this child might be the
gastro-oesophageal reflux disease (GoRD) and chronic chest infection.

Question 3

Describe the blood and
CXR results.

Answer 3

Blood: Microcytic anaemia, raised WCC, and low sodium

CXR: Frontal chest radiograph shows right lower lobe consolidation and
the silhouette sign—the adjacent diaphragm is obscured, the right cardiac
silhouette, anterior to the consolidation, is preserved.
Diagnosis: Right lower lobe pneumonia.

Question 4

What are the causes of anaemia?

Answer 4

The causes of anaemia can be broadly grouped as:

1. Etiological classification
   a) Impaired RBC production
   b) Excessive destruction
   c) Blood loss
2. Morphological classification
   a) Macrocytic anaemia
   b) Microcytic hypochromic anaemia
   c) Normochromic normocytic anaemia

Question 5

etiological classification

Impaired Productio

Answer 5

Impaired RBC production

1. Abnormal bone marrow
   a) Aplastic anaemia
   b) Myelofibrosis
2. Essential factors deficiency
   a) Iron deficiency anaemia
   b) B12 deficiency
   c) Folate deficiency
   d) Erythropoietin deficiency, as in renal disease
3. Stimulation factor deficiency
   a) Anaemia in chronic disease
   b) Anaemia in hypothyroidism
   c) Anaemia in hypopituitarism

Question 6

Excessive destruction

Answer 6

1. Intracorpuscular defect
   a) Membrane: hereditary spherocytosis
   b) Enzyme: G-6 PD deficiency
   c) Haemoglobin: thalassemia, haemoglobinopathies
2. Extracorpuscular defect
   a) Mechanical: microangiopathic haemolytic anaemia
   b) Infective: Clostridium tetani
   c) Antibodies: SLE
   d) Hypersplenism

Question 7

Blood loss

Answer 7

1. Acute: trauma, acute GI bleed
2. Chronic: parasitic infestation, chronic NSAIDS

Question 8

Morphological classification

Macrocytic/megaloblastic anaemia

Answer 8

Macrocytic/megaloblastic anaemia
MCV > 94; MCHC > 31

• Vitamin B12 deficiency: Pernicious anaemia
• Folate deficiency: Nutritional megaloblastic anaemia
• Drug-induced abnormal DNA synthesis:
  anticonvulsant, chemotherapy agents, etc.

Question 9

Microcytic hypochromic anaemia

Answer 9

MCV < 80; MCHC < 31

• Iron deficiency anaemia:
  chronic blood loss, dietary inadequacy,
  malabsorption, increased demand, etc.
• Abnormal globin synthesis: thalassemia

Question 10

Normocytic normochromic anaemia

Answer 10

MCV 82–92; MCHC > 30

• Blood loss
• Increased plasma volume
• Hypoplastic marrow
• Endocrine: hypothyroidism, adrenal insufficiency
• Renal and liver disease

Question 11

Why do you think the patient’s
sodium is low?

Answer 11

Sodium valproate can cause this.

Hyponatremia is the most common electrolyte disturbance in hospitalised children.

This is usually due to hypotonic intravenous fluids.

It can be due to renal causes or rarely because of poor dietary intake.

Question 12

Would you anaesthetise him now?

Answer 12

No. He needs optimisation with paediatric and neurology reviews for

• Treatment of chest infection with antibiotics and physiotherapy
• Further investigation and correction of low sodium
• Further investigation and treatment of anaemia
• Optimisation of the epilepsy medications

Also one should bear in mind that these cannot be corrected to normal,

as his nutrition is not going to improve without surgery

due to his underlying problem resulting in recurrent chest infections.

Question 13

What do you know about this surgery?

Answer 13

Nissen’s fundoplication is the most common operation to stop reflux.

More than half the patients presenting for this procedure are neurologically
impaired, have cerebral palsy, epilepsy, or chronic pulmonary aspiration.

The operation is usually done by laparoscopic route and involves the
tightening of the lower oesophageal sphincter by wrapping the fundus of
stomach around it.

Complications include chest infection, port site hernia, and adhesions.

Failure rate for surgery is 5%–10%.

Question 14

The child now comes back after a month having been seen by the paediatric
team in view of treatment of chest infection and optimisation of epileptic
medication.

Discuss your anaesthetic management.

Preoperative assessment

Answer 14

• Careful airway evaluation as patient needs rapid sequence induction and
  there might be difficulties due to congenital deformities.
• History of previous anaesthetics, allergies,
  and fasting status should be established.
• Parental anxieties should be addressed carefully,
  and detailed discussion about the perioperative care
  should be discussed.
• Premedication in the form of antacids and
  topical local anaesthetic cream
  to aid cannulation should be prescribed.
• Preoperative pulmonary assessment to
  identify risk factors for postoperative respiratory compromise.

Question 15

Conduct of anaesthesia

Answer 15

• Mode of induction:

Intravenous mode is preferred due to need for rapid
sequence induction, but small child with recurrent hospital admissions
might be a challenge!

• Drugs:
  Thiopentone 5 mg/kg (60 mg) and Suxamethonium 2 mg/kg
  (25 mg). A nondepolarising muscle relaxant (Atracurium 0.5 mg/kg) is
  added once the effect of suxamethonium wears off.
• Tube:
  5 mm cuffed tube due to risk of reflux and laparoscopic surgery.
• Maintenance:
  Oxygen in air with inhalational agent is the routine.

Nitrous oxide is generally not used, as it can cause bowel distension
and increase nausea and vomiting.

Total intravenous anaesthesia using propofol and remifentanil infusion
can also be safely employed.

• Analgesia: See below.
• Antiemetics: Ondansetron 0.1 mg/kg (max 4 mg) is given routinely to
  prevent retching.
• Monitoring:
  Routine monitoring of ECG, pulse oximetry, noninvasive
  blood pressure and temperature along with capnography and gas
  measurement. An arterial line might be useful in this case due to poor
  premorbid condition.

Question 16

How will you manage intravenous cannulation?

Answer 16

At preassessment

• Building rapport with the child and the parents.
• Premedication and topical anaesthesia

a) Premedication:
oral midazolam (0.5 mg/kg) is widely used.
Ketamine and temazepam are alternatives.

b) Topical:
EMLA cream 5% emulsion—
eutectic mixture of 2.5% lidocaine and 2.5% prilocaine in 1:1 ratio.
Applied 45 min before and lasts for 60 min.

Ametop—4% gel formulation of amethocaine.
Onset in 30 min and lasts for 4 hours.
Usually causes vasodilation and
higher chance of allergy.

in anaesthetic room
* Distraction technique—distraction of child’s attention by the parent
and nurse/play specialist, hiding the needle, and asking to cough while
cannulating are some of the various techniques used.

Question 17

Causes of bradycardia

Answer 17

Heart rate < 60 per min is bradycardia in age group 2 to 10 years.

• Anaesthetic factors:
  hypoxia, deep plane of anaesthesia
• Surgical factors:
  surgical stimulation leading to parasympathetic activation
• Drugs:
  suxamethonium, remifentanil, clonidine, neostigmine, and β blockers
• Patient factors:
  congenital cardiac problems

Question 18

Bradycardia causes during this operation

Rx

Answer 18

Common causes during this operation are
hypoxia and reflux bradycardia
due to handling and traction of abdominal contents.

Management includes:
* Correction of hypoxia if present

• Lightening/deepening the level of anaesthesia as required
• Asking the surgeons to stop traction
• Treating with atropine (20 mcg/kg) if bradycardia
  is sustained and compromising the blood pressure.

Question 19

If patient is hypoxic, what is your management?

Answer 19

• Administer 100% oxygen.
• Call for help.
• Ask the surgeons to stop.
• Release pneumoperitoneum if possible.
• Check tube position—exclude accidental extubation or endobronchial intubation
• Check the circuit for disconnection, kink, or obstruction.
• Hand ventilation with 100% oxygen might be needed if ventilation is inadequate.
• Endotracheal suctioning of secretions obstructing the bronchi, trachea,
  and ET tube which may cause hypoxia.

Question 20

What is your plan for pain control?

Answer 20

Multimodal analgesia tailored to the needs of the patient and procedure.

Intraoperative

• IV paracetamol (15 mg/kg),
  diclofenac (1 mg/kg),
  and morphine (0.1–0.3 mg/kg).
  Remifentanil infusion is useful.
• Local infiltration with bupivacaine
  (maximum 2 mg/kg)
  will reduce the morphine requirement.

If it is an open procedure, thoracic epidural might
be useful in this patient, especially because of his respiratory comorbidity.

Question 21

Pain control post op

Answer 21

• Paracetamol 15 mg/kg 6 hourly and ibuprofen 5–10 mg/kg 8 hourly
• Morphine oral 0.3–0.5 mg/kg 4 hourly.

Morphine NCA (nurse-controlled analgesia) in open procedures.

There is marked difference in analgesic requirements between open and
laparoscopic Nissen’s fundoplication.

With the open procedure, the need for an intensive care unit bed on account of respiratory complications is significant, but is less so with epidural infusion compared to morphine
infusion.

Question 22

the procedure is now complete and was successful laparoscopically. Would you extubate this patient?

Answer 22

This decision depends on the condition of the patient.

If the child had pre-existing chronic lung disease and

had poor gas exchange during the operation,

he would benefit from postoperative ventilation in ITU.

If there were no significant issues and if the surgery was uneventful,
he can be extubated and warded.

Reasons for mechanical ventilation postoperatively:
* Need for airway control
* Abnormal lung function
* Assurance of stability during the immediate postoperative period
* Due to neurological concerns or residual anaesthesia

Question 23

How long would you continue Mechanical ventilation

Answer 23

Mechanical ventilation is continued until there is
adequate haemostasis,
the heart rate and rhythm are stable,
cardiac output is adequate with minimal inotropic support,
oxygen saturation is adequate,
lung function is close to normal,
and the patient is awake enough to have adequate respiratory drive
and airway protective reflexes.

In order to facilitate successful extubation, the patient must have the
following:
a patent airway,
return of muscle strength,
ability to cough
and protect the airway,
spontaneous respiratory drive,
adequate blood oxygenation,
cardiovascular stability with minimal support.

Question 24

Paediatric formulae

weight airway

Answer 24

General
* Estimated weight (kg) = 2 × (Age + 4)

Respiratory
* Endotracheal tube inner diameter (mm) = (> 1 year) = Age/4 + 4

• Oral Endotracheal tube length (cm): age/2 + 12
• Nasal Endotracheal tube length (cm): age/2 + 15
• LMA size
  Size 1 for < 5 kg;
  size 1.5 for 5–10 kg;
  size 2 for 10–20 kg;
  size 2.5 for 20–30 kg;
  size 3 for 30–50 kg

Question 25

Paediatric formulae

Answer 25

circulation
* Systolic BP = (Age × 2) + 80
* Adrenaline: 10 mcg/kg (0.1 ml/kg of 1:10,000 solution)
* Atropine: 20 mcg/kg
* Blood volume: 75 mL/kg
* Defibrillation: 4 J/kg

Fluids
* Crystalloid: 20 ml/kg for resuscitation (4:2:1 for maintenance)
* RBC units: 10 ml/kg
* Platelets: 10 ml/kg
* FFP: 15 ml/kg
* Cryoprecipitate: 5 ml/kg
* Glucose: 2 mls/kg of 10% dextrose

Question 26

Drugs

Answer 26

• Propofol: 4 mg/kg
• Thiopentone: 3–6 mg/kg
• Suxamethonium: 2 mg/kg
• Rocuronium: 0.5–1 mg/kg
• Atracurium: 0.5–1 mg/kg