Paediatrics Flashcards
What is sleep-disordered breathing?
Spectrum of upper airway dysfunction during sleep characterised by SNORING and INCREASED RESPIRATORY EFFORT causes by upper airway collapse
Most severe form is obstructive sleep apnoea
Paediatric diagnosis of sleep disordered breathing
Habitual loud breathing/snoring
Audible or witnessed pauses
Bizarre positioning
Daytime symptoms - hyperactivity, inattatention
Paediatric diagnosis of OSA
Loud snoring i.e heard through door
Daytime somnolence
Poor school performance
Medical hx of GORD, prematurity
IF diagnostic uncertainty options include overnight pulse oximetry at hospital/home
Overnight polysomnography
What is the main indication for tonsillectomy in UK
Obstructive sleep-disordered breathing
Paediatric adenotonsillar hypertrophy can contribute to anatomical pharyngeal obstruction and increased upper airway resistance
Peak age is 3-10
Overnight bed required for paediatric patients?
Varies between hospitals but generally overnight bed required
Children <3
Comorbidities e.g. obesity, failure to thrive
Severe obstructive sleep apnoea
Post-op analgesia for severe OSA
Multimodal analgesia
- Non-opioid analgesics: paracetamol and NSAIDs
- Dexamethasone
- Opioids for rescue (be aware children with OSA have increased sensitivity to opioids)
Pre-med doses in paediatrics
- Midazolam
- Ketamine
- Clonidine
Midazolam
ORAL/buccal = 0.5mg/kg (max 20mg) (20-30mins onset)
Intranasal = 0.2mg/kg
Ketamine (avoid in under 2s)
ORAL = 5-10mg/kg (careful salivation)
IM = 5mg/kg
Clonidine
ORAL 4mcg/kg
INTRANASAL 2mcg/kg
General “HOW TO” paediatrics for pre-op management
Perform through history, examination, review old hospital charts and relevant ix.
Establish rapport with child and parents
Prescribe 20mg/kg oral paracetamol and 5mg/kg oral ibuprofen
Midazolam pre-medication 0.5mg/kg ORAL/BUCCAL up to 20mg
If concern re: airway or OSA then pulse oximetry in period between midazolam administration and anaesthetic room arrival
Request AMETOP applied to both hands
In preparation for child arriving in anaesthetic room
Prepare and check anaesthetic machines, monitoring, suction
Prepare induction and emergency drugs
Prepare airway equipment
Anaesthetic HOW TO - intraoperative, tonsillectomy
Allow for premedication to take effect
Gain IV access using distraction techniques
Ask ODP to apply full AAGBI monitoring and pre-oxygenate patient
Induce anaesthesia with 1mcg/kg fentanyl and 2-3mg/kg propofol with maintanence using sevoflurane with target age adjusted MAC 1
D/w surgeon regarding airway - either flexible LMA or RAE ETT
Administed 0.15mg/kg dexamethasone and 0.1mg/kg ondansetron
Infiltration of tonsilar fossae with local anaesthetic
Key intraoperative moments during tonsilectomy
Boyle-Davis gag application - may cause obstruction/dislodgement of LMA.
Ensure inspection of nasopharynx for blood clots by surgeon or under direct vision
Risk factors for post-op respiratory complications post tonsillectomy
Children <3
Severe OSA
Failure to thrive
Obesity
RV hypertrophy
Down’s
Craniofacial abnormalities
Chronic lung disease
Sickle cell disease
WETFLAG RECITE
Name 5 considerations in the post-tonsillectomy bleed case
- Paediatric patient with heightened anxiety amongst patient and paretns
- Full stomach with high risk of aspiration
- Hypovolaemia and anaemia due to blood loss
- Difficult airway - oedematous, obstructed by blood, recent instrumentation and surgery
- Recent anaesthesia - residual effects
Pre-op key points for post-tonsillectomy bleed
Review key history/examination/investigations
Previous anaesthetic chart
Post-op drugs, what given when
Targeted clinical examination
- HR/CRT/BP/skin colour
- Conscious level
- If time send bloods for Hb, haematocrit, cross-match, VBG
Resucitation with 20ml/kg crystalloid, further boluses to effect, blood x-match and available
Assistance from consultant anaesthetist and senior ODP
TXA 15mg/kg bolus over 10mins
Talk through the RSI technique for post tonsillectomy bleed
Supine position
IV access with fluids running, trained assistant, suction x2
Pre-oxygenation and cricoid pressure
Propofol and suxamethonium
Consider ketamine
Intubation with calculated device + one smaller
Orogastric tube to empty stomach removed prior to extubation
Extubate head down, left lateral
Talk through Gas induction for post tonsillectomy bleed
Head down, left lateral
Sevoflurane in 100% O2
Intubate when deep during spontaneous ventilation either in left lateral or turn supine
ONLY advantage is maintanence of spontaneous ventilation if intubation is difficult
How can you classify paediatric hypovolaemia
Mild <5% volume loss
Moderate 5-10% volume loss
Severe >10% volume loss
Fluid deficit = % volume loss, x weight (in kg) x 10 = fluid in mls
What is blood volume in neonate/child/adult
Neonate 85-90ml/kg
Infant 75-80mls/kg
Child 70-75mls/kg
Adult 65-70mls/kg
Paediatric weight formulae
1-12 months = 0.5 x age in months x 4
1-5 years = (2x age) + 8
6-12 years = (3x age) + 7
Uncuffed ETT calculation
Age/4 + 4 = uncuffed
What is the maintanence fluid calculation in kids
4-2-1 rule
4ml/hr x 1st 10kg + 2ml/hr x 2nd 10kg + 1ml/hr every kg over 20
E.g. 18kg = 56mls/hr
How can you classify post-tonsillectomy haemorrhage
Primary
= Occurs within 24hrs of surgery
- Affects 2% adenotonsillectomies
- Caused by inadequate haemostasis during surgery
Secondary
= Occurs more than 24hrs
- Commonly day 5-10
- Detachment of crust from removed tonsil.
- 2% of tonsillectomies
- Risk factors = adults> children, chronic tonsilitis
