Paediatrics

Question 1

Discuss Anaesthetic care for surgical management of adolescent idiopathic scoliosis (BJA Jul 19)

Answer 1

Idiopathic scoliosis - usually otherwise well

Long case anaesthesia -
maintain normothermia, warmed fluids, repeated antibiotic dosing

Positioning - Prone - pressure points, nerve compression etc

Pain - post operative pain plan - epidural (dep on
surgeon), otherwise PCA +/- Ketamine, Paracetamol

Neurophysiological monioring / SSEP and MEP ie. no volatile for sensory potentials, no muscle relaxants for motor potentials - TIVA w remifentanil

PONV ( according to BJA) - consider aprepitant

Blood Loss (from posterior spinal fusion) - varies significantly , usually does not require cell saver

Post operatively - depending on case may need PICU

Question 2

SSU Review - How do you anaesthetise a 2 year old child for an inhaled foreign body?

Answer 2

1) Communication with Surgeon to formalise plan
2) Spont breathing technique with sevo then switching to TIVA
3) Assess depth , Topicalise vocal cords
4) Suspension
5) Oxygen cannula via nose with 100% oxygen
6) Rigid Bronchoscopy
7) Assess airway at end of case suitiable to remain extubated + Dexamethasone airway dose
8) Post operative monitoring in appropriate environment

Question 3

SSU Review - What particular issues does anaesthesia for MRI pose?

Answer 3

1) Access
2) Off floor anaesthesia
3) Less ability to control anaesthetic - need to go in between sequences
4) Emergency equipment cannot come into room

Question 4

How would you manage a child with an anterior mediastinal mass?

Answer 4

Preop.
MDT - does this procedure need to be done ? risks/benefits
Imaging - CT - evidence of airway compression >70% reduction in tracheal CSA, carinal/bronchial compression
evidence of SVC/great vessel obstruction or peri cardial effusion?

History - signs - orthopnoea, cough when supine, stridor,wheeze, syncopal symptoms, upper body oedema

Intra op
Find out with position is best ie. lateral
Aim to keep spont breathing
Aim to place ETT - incase need to OLV
Have ENT on standby if need rigid bronch

Respiratory collapse:
FiO2, CPAP. Reposition, IPPV with PEEP, OLV, rigid bronch, consider CVS component

CVS collapse
Fluid Bolus, reduce depth anaesthesia, reposition, sternotomy and elevate mass, ECMO unlikely to be helpful (time)