Paeds Flashcards
Age based weight, HR, (RR), BP
Weight = (age+4)x2
Heart rate:
* < 28days 100-200
* 1-12months 100-190
* 1-2yrs 100-150
* 3-11yrs 80-120
* > 12yrs 60-100
Resp rate:
* < 1yr 30-53
* 1-2yrs 22-37
* 3-5yrs 20-28
* 6-11yrs 18-25
* 12-15yrs 12-20
MAP = 1.5 x age
Systolic
*Newborn < 1kg aim > 40
*Newborn 3kg aim >50
*1-12months aim>70
* 1-11 years aim > 70 + (agex2)
* >12years aim >90
Analgesic options for circumcision
- Caudal block
- Local anaesthetic infiltration
- Specific penile block
- Paracetamol
- Opiates (fent intraop, dihidrocodeine post-op)
- NSAIDs
Complete the labels
i. Sacral hiatus/sacrococcygeal membrane
ii. Epidural/caudal space
iii. Subarachnoid space
iv. Spinal cord
v. Dura mater
vi. Filum terminale
Where does the dural sac end?
S4 at birth
S2 at 1 yr
Spinal cord ends L3 in <1yr old
L1/2 in adults and children
List complications of caudal block
- Block failure
- Intrathecal injection
- Intravascular injection
- Hypotension
- Motor blockage
- Urinary retention
- Infection/epidural abscess
- Needle insertion into rectum/periosteum
State the name, concentration and volume of LA you would use in a caudal block by age
Bupivicaine/levobupivicaine 0.25%
Armitage formula:
* 0.5ml/kg lumbosacral (enough for circumcision)
* 1ml/kg thoracolumbar
* 1.25ml/kg mid thoracic
What could you add to LA mixture to prolong duration or quality of caudal block?
- Fentanyl 1-2mcg/kg
- Clonidine 1-2mcg/kg
- Preservative free ketamine 0.5mg/kg
List methods of assessing pain in paediatrics
- Physiological (HR, BP, RR)
- Behavioural
- Self reporting scales (piece of hurt scale, faces pain scale, visual analogue scale)
- Parent/carer reporting
What is the characteristic chromosomal abnormality that leads to Down’s syndrome
Trisomy 21
List airway issues associated with Down’s syndrome giving an implication for anaesthetic management
- Subglottic stenosis: consider need for smaller tube size
- Atlantoaxial instability: maintain neutral cervical spine positioning for intubation e.g. using hyperangulated blade videolaryngoscope
- Craniofacial changes predispose to OSA: avoid long acting opiayes, use multimodal analgesia
- Midfacial hypoplasia: difficult facemask ventilation, may require oropharyngeal airway
- Reflux disease: increased risk of aspiration, consider RSI
Other than Down’s syndrome, which genetic syndromes predispose to difficult paediatric airway
- Pierre Robin
- Treacher Collins
List congential cardiac conditions associated with Down’s syndrome
- ASD/VSD
- Patent ductus arteriosus
- Tetralogy of Fallot
List contributing causes for the development of pulmonary hypertension in a patient with Down’s syndrome
- Uncorrected left-to-right cardiac shunt from congenital cardiac defect
- Chronic hypoxaemia due to OSA
- Chronic hypoxaemia recurrent respiratory infections
Give characteristic ECG changes associated with pulmonary hypertension
- Right axis deviation
- RBBB
- Dominant R wave in V1
- P pulmonale lead II
List congenital neurological issues associated with Down’s syndrome
- Epilepsy
- Vaiable global developmental delay
- Autism
List the clinical features of meningococcal septicaemia
- Capillary refill time > 2s
- Skin colour change
- Cold hands or feet
- Moribund state
- Altered mental state
- Poor urine output
- Non-blanching rash
- Fever
List five anatomical features of young children < 3 years old which may adversely affect upper airway management
- Large head, prominent occiput: tendency to flex neck, use folded towel under shoulder for neutral positioning
- Large tongue: obstruction of airway possible with digital pressure, ensure fingers applied to bony surfaces
- No teeth: difficulty maintaining face mask ventilation, use appropriately sized ororpharyngeal airway
- Long U-shaped epiglottis: difficulty with laryngoscopic view, consider straight blade or VL
- Short trachea: risk of endobronchial intubation, auscultate chest
List patient factors that increase the risk of perioperative laryngospasm in children
- Younger age
- Recent upper respiratory tract infection
- Asthma
- Structural airway abnormality
List anaesthetic factors that increase risk of laryngospasm
- Inadequate depth of anaesthesia
- Airway instrumentation
- Intubation without neuromuscular blocker
- Anaesthetist with limited paediatric anaesthetic experience
Give four reasons it would be inappropriate to cancel a grommet surgery for a 5 year old with nasal discharge
- Nasal discharge may be associated with the reason for surgery and may not improve with more time
- Inefficient list usage
- Wasted time off school for child
- Wasted parental time off work with possible financial loss
- Loss of trust between child, parents and healthcare
List features in a paediatric history that might cause you to postpone an elective grommet surgery due to increased risk of airway complications in a 5-year old with nasal discharge
- Recent fever
- Unwell in self/too unwell for school
- Shortness of breath
- Sore throat
- Loss of appetite
- Significant cardiorespiratory comorbidities e.g. congential heart defect
List features on examination that might cause you to postpone an elective grommet surgery due to increased risk of airway complications in a 5-year old with nasal discharge
- Fever
- Listless
- Tachpnoea or respiratory distress
- Purulent nasal discharge
- Delayed capillary refill
Give social factors that may prevent paediatric treatment as a day case
- Poor housing conditions
- Distance > 1 hour from hospital that could appropriately manage complications
- Parents unable to care for child post-operatively
- No access to private transport
State organisational recommendations from the RCOA regarding provision of ay case surgery for children
- Aim to book cases with longer recovery times earlier in day
- Minimise starvation time
- Separation from adult patients by using facilities at a different time or use of a dedicated unit
- Provide preoperative information to caregiver and children including safetynetting advice
Define autistic spectrum disorder
- Life long condition affecting brain development
- Present from early childhood
- Significantly limits of impairs activities of daily living
Give clinical features of autistic spectrum disorder
- Communication problems e.g. language delay
- Social interaction difficulties e.g. poor eye contact
- Abstract thought difficulties e.g. reduced ability to understand metaphorical explanations
- Adherence to routines and stereotyped behaviours e.g. repetitive behavours
- Sensory issues e.g. over- reactivity to textures
- Associated learning difficulties and mental health disorders
Give organisational considerations when providing anaesthesia for dental extractions in children
- Availability of paediatric anaesthetic equipment
- Staff trained in care of paediatric patients including resuscitation
List perioperative considerations when providing anaesthesia for dental extractoins in children
- Shared small airway distant to anaesthetist and anaesthetic machine, risk of airway dislodgement and kinking
- Blood from extractions may result in blood inhalation or laryngospasm
- Throat pack may be used and need to be removed
- Analgesic requirements are low, paracetamol and NSAID may be sufficient
- Antiemetics given intraoperatively can facilitate day case
Describe problems providing anaesthesia for children with autism and give possible solutions for each
- Distress in unfamiliar setting may make preoperative assessment difficult: pre-operative assessment in community, quiet separate waiting area
- Language issues may mean child cannot understand what is happening: play specialists and visual information
- Preoperative starvation may be poorly tolerated as it breaks routine: first on list
- May dislike physical contact: warn prior to contact
- May have issues with consent
- May have difficulty co-operating with procedures e.g. blood tests
Define appropriate resuscitation goals for a 2 year old with meningcoccal sepsis
- Cap refill < 2s
- Normalisation of blood pressure
- Normalisation of heart rate
- Urine output greater than 1ml/kg/hour
- Normal lactate
- Normal mental status
List physical injuries that may prompt concerns of non accidental injury in a 5 year old with a forearm fracture
- Fractures of different ages
- Cigarette burns or thermal injuries
- Bite marks
- Injuries in inaccessible places e.g. neck, feet
- Ano-genital trauma
- Unusual bruise pattern e.g. strangulation bruises, hand shaped bruising
Give immediate actions to take if you suspect non-accidental injury
- Check hospital notes for known safeguarding issues
- Inform supervising anaesthetic consultant
- Inform wider theatre team including surgeon and ODP
- Inform child’s paediatrician or on-call paediatric consultant
- Paediatrician to make visual assessment
- Full documentation of findings and actions
Give parental factors that increase the risk of child abuse
- Substance misuse
- Single parent
- History of violent offending
- History of own domestic abuse/maltreatment as child
- Poor education
- Lack of support from family or friends
State features of a child’s past medical history that are associated with increased risk of abuse
- Chronic physical illness
- Mental disability
- Prematurity or low birth rate
Give respiratory issues associated with Down’s syndrome
- OSA
- Respiratory tract infections
- Subglottic stenosis
Define:
- Preterm
- Very preterm
- Extremely preterm
- Low birth weight
- Extremely low birth weight
- Neonate
- Infant
- Child
- Preterm 32-37 weeks gestational age at birth
- Very preterm 28- 32 weeks gestational age at birth
- Extremely preterm < 28 weeks gestational age at birth
- Low birth weight < 2.5kg
- Extremely low birth weight < 1.5kg
- Neonate 0-28 days
- Infant < 1yr
- Child 1yr +
What are the airway and respiratory concerns when anaesthetising an ex-preterm baby
- Complications of previous prolonged intubation e.g. tracheomalacia
- Poor muscle co-ordination in upper airways increases risk of airway obstruction on induction of GA
- Dirsupted vasculogenesis causes abnormal distribution of pulmonary capillaries causing V/Q mismatch
- Reduced type 1 muscle fibres in intercostal muscles and diaphragm, risk of respiratory fatigue
- Low lung elasticity leads to collapse of small airways and gas trapping
Aside from airway and respiratory issues, give other complications of prematurity which may need to be considered when planning a GA for an ex-preterm baby
Cardiac
* Increased risk of congential cardiac defects
* Difficult IV access due to multiple previous cannulations
* High ratio of fibrous to contractile tissue resulting in fixed stroke volume and HR dependent CO
Neurological
* Risk of intraventricular haemorrhage with consequences such as cerebral palsy or hydrocephalus
Endocrine/Metabolic
* Reduced glycogen stores, risk of hypoglycaemia with preoperative starvation
* Defective glucose regulation exacerbated by stress risks hyperglycaemia
* Increased risk of hypothermia due to paucity of adipose tissue
GI
* Reflux due to underdevelopment of gastro-oesophageal sphincter
* Necrotising enterocolitis in 10% of premature infants
Haem
* Anaemia from frequent blood sampling
* Coagulopathies
Give pharmacokinetic differences that may be observed in a preterm baby
- Reduced oral absorption due to reflux
- Relative increase in total body water, increased Vd of water soluble drugs
- Reduced plasma protein binding so increased availability of free drug
- Metabolism slow due to immature liver enzymes
- Excretion slower due to immature renal system
Give the advantages and disdvantages of GA for inguinal hernia repair for an ex-preterm baby
Advantages:
* Optimal operating conditions with still baby
* Avoids failed regional technique with need for on-table conversion to GA
Disadvantages:
* Risk of desaturation at induction with consequent risks of hypoxaemia
* Risk of apnoeas is increased following GA
Regional (spinal, caudal, epidural)
- analgesic effect
- but if sedation is used, risk of apnoeas
You are asked to assess a 15 kg 4-year-old child who is scheduled for a strabismus (squint) correction as a day case procedure.
List the anaesthetic considerations of this case with regards to the age of the patient.
- Limited understanding of surgery at 4 years old: use play therapist, parent and other techniques to maximise co-operation at induction
- Consider need for premedication
- Topical local anaesthetic for cannulation
- Ensure availability of paediatric equipment, drug doses and staffing
You are asked to assess a 15 kg 4-year-old child who is scheduled for a strabismus (squint) correction as a day case procedure.
List the anaesthetic considerations of this case with regards to day surgery
- Assurance of social factors e.g. within 1 hour from hospital in case of complications, parents happy to care for post-operative child at home
- Adequate management of pain and nausea to allow return to normal function and diet before discharge
- Use of short-acting agents
- Absence of major comorbidities that would contraindicate day surgery
Give specific anaesthetic considerations of strabismus surgery
- Increased incidence of PONV, use multi-agent approach
- Oculocardiac reflex risk intraoperatively, consider pretreatment with atropine or glycopyrrolate
- Airway under drapes and away from anaesthetist - ensure airway securely fastened e.g. with tapes
- Still eyes with neutral gaze required for surgery, anaesthetsia should be sufficiently deep
- Potential difficult airway if co-existing syndrome e.g. Trisomy 21
During strabismus surgery in a 5-year-old, the patient develops profound bradycardia. Give steps in your management
- Ask for a pause to surgical stimulation
- Give atropine 20mcg/kg
How can you reduce risk of PONV in paediatric strabismus surgery
- TIVA for maintenance
- Minimise preoperative fasting time
- Multimodal analgesia to minimise long acting opiates
- Multimodal antiemetic use including intraoperative dexamethasone and ondansetron
- Avoid nitrous oxide
Give three elements of post-operative analgesia in paediatric strabismus surgery
- Multimodeal analgesia including paracetamol and NSAIDs as premed and continued postoperatively
- Topical local anaesthetic drops by surgeon
- Sub-tenon’s block by surgery
- Intraoperative single dose long acting opioid
Give indications for adenotonsillectomy in children
- Frequent tonsillitis
- Obstructive sleep apnoea due to enlarged tonsils
- Peritonsillar abscess
How can anxiety in a child be managed preoperatively
- Give age-appropriate information
- Premedication e.g. oral midazolam/ketamine, intranasal dexmedetomidine
- Play therapist
- Active involvement of care-giver
- Psychological input prior to admission in severe cases
Give medical, surgical and social factors that determine suitability for day case surgery in paediatrics
- No major co-morbidities
- Over 60 weeks corrected age
- Minimal risk of serious complications
- Post-operative pain is expected to be manageable from procedure
- Caregiver happy to look after post-operative child
- Home is < 1 hour from hospital that can treat for potential complications
Give the analegesic strategy for adenotonsillectomy
- Paracetamol and ibuprofen (if no contraindication to NSAID)
- Dexamethasone single intraoperative dose
- Consider intraoperative ketamine or gabapentinoid in patients with contraindication to NSAID
- Short acting intraoperative opioid to minimise post-operative respiratory depression/complications in OSA
After extubation from adenotonsillectomy a 4-year-old develops airway obstruction. You suspect laryngospasm. Give gour sequential steps you would take after calling for help and alerting the theatre team.
- Direct visualisation and suction to remove contaminants e.g. blood
- Face mask CPAP with T-piece or circle system using 100% oxygen
- Give bolus of propofol intravenously to deepend anaesthesia
- Give neuromuscular relaxant e.g. suxamethonium intravenously 1mg/kg
What is the dose of suxamethonium IM?
4mg/kg
Give the contents of the anterior mediastinum
- Thymus
- Lymph nodes
- Connective tissue
Give the red flags for perioperative risk relating to mediastinal mass
- Orthopnoea
- Cough when supine
- Stridor
- Wheeze
- Syncopal symptoms
- Upper body oedema
List three findings on imaging that predict significant perioperative risk in a child with a mediastinal mass
- Reduction in tracheal cross-sectional area
- Carinal or bronchial compression
- Great vessel compression
- Pericardial effusion
List possible causes of anterior mediastinal mass in children
- Lymphoma
- Acute lymphoblastic leukaemia
- Vascular malformations
- Germ cell tumours
Give approaches to reducing the size of an anterior mediastinal mass to improve the safety of anaesthesia
- Chest radiotherapy
- Steroid treatment
8-yo with anterior mediastinal mass for diagnostic LN biopsy under GA
After induction of anaesthesia, and despite maintaining spontaneous ventilation, the patient shows signs of respiratory compromise. After calling for help and commencing 100% oxygen, list options to try to improve respiratory function
- CPAP
- Reposition patient to position they were most comfortable in preoperatively
- Positive pressure ventilation with PEEP
8-yo with anterior mediastinal mass for diagnostic LN biopsy under GA
Give options if cardiovascular compromise had occured after induction of anaesthesia
- IV fluid bolus of crystalloid
- Reposition patient
- Reduce anaesthetic depth
Give features in patient history that might suggest significant congenital heart disease
- Failure to thrive
- Difficulty feeding as neonate
- Recurrent chest infections
- Poor exercise tolerance
- Squatting
- Parental reports of cyanosis
List five findings on examination of the child that might suggest significant congenital heart disease
- Irregular pulse
- Harsh pansystolic murmur
- Cyanosis
- Respiratory distress e.g. basal crackles on auscultation of lungs
- Cool peripheries
Give ECG findings that would be expected in a child with atrial septal defect
- Prolonged PR interval
- RBBB
Give investigations other than ECG that would be useful in a child with suspected atrial septal defect and what information each would give about the defect
- ECHO: to assess direction of shunt and presence of pulmonary hypertension
- Cardiac MRI: to assess for valvular involvement and shunt volume
Describe the current guidelines regarding prophylactic antibiotics against endocarditis in patients with congenital heart disease undergoing dental extraction
- Amoxicillin or ampicilling in those at highest risk of infective endocarditis
- This includes prosthetic heart valves, previous infective endocarditis, cyanotic congenital heart disease, 6 months after prosthetic repair of congenital heart disease
- Surgical factors include whether there is perforation of the oral mucose, whether there is manipulation of the gingiva or periapical aspect of teeth
Give a possible long term consequence of unrepaired atrial septal defect
- SVT
- Heart failure
- Frequent chest infection
- Pulmonary hypertension
- Paraxodical embolism
Give advantages and disadvantages of supraglottic airway device compared to ETT when managing the airway for elective tonsillectomy
Advantages:
* May not require neuromuscular blocker - avoids risk of residual neuromuscular blockade
* Straightforward to site
* Avoids trauma of intubation
* Smooth emergence
Disadvantages:
* Greater risk of dislodgement
* Surgical access may be more limited
A 6-year-old suffers a post-tonsillectomy bleed on the ward, describe four signs or symptoms of blood loss
- Tachycardia
- Tachypnoea
- Pallor/mottled skin
- Prolonged capillary refill
- Reduced urine output
Give the blood volume of a 6 year old child and the equations used to determine this
Infants: 80ml/kg
Preterm infants: 90ml/kg
Child: 70ml/kg
Est weight = (6+4)x2=20kg
Est blood volume = 70 x 20= 1400ml
Give specific concerns regarding post-tonsillectomy bleed in a 6-year-old
- Ongoing blood loss causing hypovolaemic shock
- Swallowed blood causing full stomach
- Aspirated blood into lungs
- Possible difficult airway due to bleeding and oedema from previous intubation
Give two actions you would take on the ward to manage post-tonsillectomy bleed in a 6-year-old
- Urgent contact with ENT, theatres and senior anaesthetist
- Ensure IV access and commence IV resuscitation if haemodynamically compromised
- Send blood for POC Hb, lab FBC, coag, cross match
- Position child to allow blood to drain from mouth
What position to you choose for induction of a 6-year old with a post-tonsillectomy bleed
Give two additional precautions you would take at induction of GA
- Ramped position to facilitate blood to be swallowed rather than pooled in oropharynx, more comfortable than head down, risks of aspiration already present
- Two functioning suction devices available (suction device may become blocked with clots)
- Variety of endotracheal tubes including same size and smaller than previous intubation
- Second line airway equipment including VL
- Consider high flow nasal oxygen
- Ensure surgical team prepared and scrubbed
- Blood products and vasopressors available
Define cerebral palsy
A group of permanent, activity-limiting movement and posture disorders caused by acquired pathology the developming brain during peripartum or early infancy
Give the most common types of cerebral palsy
- Spastic
- Dyskinetic
- Ataxic
Give the respiratory effects of cerebral palsy and the anaesthetic implications
- Weak cough due to respiratory muscle hypotonia: increased propensity to perioperative lung infection
- Chronic lung disease secondary to premature birth, reflux, recurrent pneumonia: may require longer duration of O2 therapy or CPAP
- Restrictive lung disease secondary to scoliosis: ventilate according to restrictive defect, prepare for risk of pulmonary hypertension
Give the neurological effects of cerebral palsy and the anaesthetic implications
- Epilepsy: ensure medication not missed when NBM, ensure drug levels checked
- Cognitive problems: involve carers and play specialists
Give the airway effects of cerebral palsy and the anaesthetic implications
- Hypersalivation may impair laryngoscopy: consider antisialagogue
- Poor dentition may complicate airway management: decayed or loose teeth managed in advance
- Risk of TMJ dislocation if affected by spasticity: assess for possible difficult airway requiring asleep fibreoptic
Give the cardiac, GI and MSK effects of cerebral palsy and the anaesthetic implications
- Cardiac: right heart failure or pulmonary HTN, consider ECHO
- GI: swallowing difficulty, chronic constipation, nutritional optimization
- MSK: spasticity causes fixed flexion deformities and joint dislocations, difficult IV access and cannulation
State three difficulties that may be encountered during endotracheal intubation for a child with cerebral palsy
- Difficult positioning due to kyphoscoliosis and contractures
- Difficult preoxygenation due to patient compliance
- Excessive oral secretions may impair laryngoscopy view
- Spasticity of muscles at TMJ may reduce mouth opening
Give three classes of medication taken in cerebral palsy
- Chronic pain: analgesics including gabapentinoids
- Spasticity: antispasmodics e.g. baclofen, benzodiazepines
- Oral secretions: hyoscine patch or other antimuscarinics
- Seizures: anticonvulsants
List pharmacological considerations in cerebral palsy
- Delayed oral absorption due to GORD and chronic constipation
- Low body weight so reduced Vd of lipophilic drugs e.g. propofol
- Anticonvusants induce cytochrome P450 enzymes
- Avoid proconvulsant drugs e.g. alfentanil, pethidine
- Upregulation of acetylcholine receptors - non-depolarising NMBD are less potent, caution with use of suxamethonium
How would you manage post-operative pain in a patient with cerebral palsy undergoing femoral osteotomy
- Neuraxial technique including possible epidural infusion with LA +/- clonidine (avoid opiate respiratory depressant and constipation)
- Multimodal analgesia including paracetamol and NSAIDs if not contraindicated
- Continue chronic pain and antispasmodic medications
- Involve caregivers in pain assessment if communication difficulties
How would you resuscitate a 2 year old in septic shock secondary to meningococcal septicaemia
- IV or IO bolus of balanced crystalloid 10ml/kg
- Repeat to 60ml/kg titrating agent against markers of resoration of circulating volume e.g. cap refill, BP, HR, U/O, normal mental status, normal lactate
- Assess repeatedly for markers of fluid overload
Which antibiotic and dose should be given for meningococcal sepsis
Ceftriaxone 80-100mg/kg max 4g
Give four indications to intubate a 2 year old in septic shock from meningococcal sepsis
- Ongoing shock despite > 40ml/kg fluid resuscitation
- Post cardiorespiratory arrest
- Reduction in GCS, unable to protect airway reflexes
- For control of intractable seizures
- Evidence of raised intracranial pressure
- To facilitate safe transfer to tertiary centre
Which abnormalities would you see on bloods in a patient with meningococcal sepsis
- Raised WCC
- Raised CRP
- Acidosis
- Coagulopathy
Give the steps in management for a 2 year old with meningococcal septic shock despite fluid resuscitation
- Adrenaline or noradrenaline infusion. Vasopressin infusion if high dose catecholamine infusion required.
- Consider IV hydrocortisone
- Correct acidosis
- Correct hypocalcaemia
- Advice from PICU or retrieval service
You are asked to pre-assess a 10-month-old baby who has presented with a suspected inhaled foreign body.
Give five signs and symptoms that may indicate that this child needs immediate surgical management
- Change in voice
- Drooling
- Stridor
- Respiratory distress
- Low oxygen saturations
What is the most important thing to maintain during induction and why?
Spontaneous respiratory to maintain respiratory mechanics and muscle tone, avoiding PPV which risks the foreign body moving further down the airway (risks more difficult retreival or complete obstruction)
How can oxygenation be maintained during the procedure rigid bronchoscopy to retreive an inhaled foreign body in paediatrics
- High flow nasal oxygenation if procedure is brief
- Face mask oxygenation followed by brief intubation with rigid bronchoscope if straightforward obstruction
- Attach breathing circuit or oxygen tubing to 22mm side port of ventilating bronchoscope
Describe an analgesic strategy for rigid bronchoscopy
- Topicalise airway udner direct vision with 4mg/kg lidocaine via mucosal atomisation device
- Paracetamol and ibuprofen (if no contraindication to NSAID)
- Short acting opioids intraoperatively, titrated to effect and avoiding apnoea e.g. 0.5mcg/kg
Give four specific complications that may occur during provision of anaesthesia for inhaled foreign body removal
Anaesthetic:
* Hypoxaemia and hypercapnoea from pauses in ventilation
* Laryngospasm
* Bronchospasm
* Loss of airway
* Regurgitation/aspiration
Surgical:
* Foreign body dislodgement leading to complete airway obstruction
* Orodental damage from bronchoscope
* Trauma to airways from bronchoscope including haemorrhage
What drug and what dose to reduce risk of post-extubation airway swelling for a 10-month old undergoing rigid bronchoscopy for inhaled foreign body
I.V dexamethasone 0.25-0.5mg/kg
10-month-old baby has presented with a suspected inhaled foreign body and underwent rigid bronchoscopy.
You are called to recovery because the patient has developed stridor. State pharmacological therapy with dose that may be useful in reducing airway oedema
Nebulised adrenaline 0.5mg/kg of 1:1000 soln to max 5mg
Other than pyloric stenosis, give three differential diagnoses for regurgitation and vomiting in a 4-week old term baby
- Gastroenteritis
- Gastrooesophageal reflux
- Milk intolerance
Give the mechanisms of potassium loss in pyloric stenosis
- GI loss from vomiting (loss of water, hydrochloric acid, sodium and potassium, resulting in hypokalaemic, hypochloraemic metabolic alkalosis)
- Intracellular movement (buffering of aklalosis, H+ out of cells, K+ in)
- Renal loss (hypovolaemia triggers aldosterone release, sodium retained in exchange for potassium and hydrogen-> eventually worsens alkalosis)
State the initial approach to fluid resuscitation in a shocked baby with pyloric stenosis
10ml/kg isotonic crystalloid e.g. Hartmann’s and reassess volume status clinically
- give up to 40ml/kg before considering vasopressor and intubation
List three factors to consider regarding ongoing fluid requirements in a patient with pyloric stenosis following acute resuscitation
- Mainenance fluids corrected for body mass
- Compensation for ongoing losses
- Electrolyte needs, esp K+
- Glucose substrate whilst not being fed
- Clinical response in terms of dehydration vs fluid overload
Why does metabolic alkalosis need to be corrected prior to surgery
Alkalosis results in reduced respiratory drive, or apnoea due to reduced H+ conc in CSF
How may the risk of aspiration be reduced before induction of anaesthesia
- NG insertion and four quadrant aspiration prior to induction
- POCUS gastric antrum to assess contents
- Use of neuromuscular blockade on induction
List two possible techniques using local anaesthesia that may be used as part of the anaesthetic and analgesic approach for pyloromyotomy
- Local anaesthesia infiltation by the surgeon
- TAP blocks
- Rectus sheath blocks
Laprascopic pylorotomy benefits: shorter time to full feeds and improved post-op pain
List three post-operative complications following GA that neonates are at increased susceptibility to, stating the underlying physiological or anatomical reason for each
- Adverse airway events e.g. laryngospasm: airway is narrorwer so small reductions in diameter can lead to significant reductions in air flow
- Apnoeas: incompletely developed chemoreceptor and central respiratory responses to hypoxia and hypercapnia
- Hypothermia: thin skin, high surface area to volume ratio
- Hypoglycaemia: limited glycogen stores
Give 5 major co-morbidities associated with pre-term neonates
- Tracheomalacia
- Bronchopulmonary dysplasia
- Patent ductus arteriosus/ASD/VSD
- Intraventricular haemorrhage
- Retinopathy of prematurity
- Necrotising enterocolitis
- GORD
- Bilirubin encephalopathy
FLACC pain scale
- Face
- Legs
- Activity
- Cry
- Consolability
What is the most important risk factor for post-operative apnoea in an ex-prem baby?
Post-menstruational age (< 44wks)
Autism triad
- Difficulty with communication
- Difficulty with social interaction
- Difficulty with imagination
Examples of premeds and doses
- Ametop 4% 1.5g per dose
- EMLA 5% 5g per pack
- Midazolam 0.5mg/kg PO
- Ketamine 3-5mg/kg PO
- Ketamine 1-2mg/kg IM
- Clonidine 4mcg/kg PO
- Dexmetomidine 3mcg/kg intranasal
- Lorazepam 100mcg/kg PO
- Ondansetron 0.1mg/kg
- Cyclizine 1mg/kg
Resus medication doses:
* Atropine
* Adrenaline
* Suxamethonium
* Ketamine
* Cefuroxime
- Atropine 20mcg/kg
- Adrenaline 10mcg/kg
- Suxamethonium 2-3 mcg/kg IV, 4mg/kg IM
- Ketamine 2mg/kg
- Cefuroxime 25-50mg/kg
Paediatric fluid resuscitation
- 10ml/kg crystalloid
- After 40ml/kg has been given:
1. Vasopressors are required
2. Further 10ml/kg fluid boluses of packed red cells
3. Consider intubation
Where should defibrillator pads be placed on neonate?
Left of sternum and under left scapula
Assessment of dehydration
- < 5%: normal obs and clinical assessment
- 5-10%: some signs of dehydration e.g. slightly tachycardic, slightly sunken fontanelles, slightly delayed CRT, normotension
- 10-15%: unwell child e.g. lethargic, tachycardic, hypotensive, reduced urine output, significantly shrunken fontanelles, delayed CRT
Fluid maintenance
0.45% NaCl with 5% dextrose (consider + 20mmol/L potassium if needed e.g. pyloric stenosis)
Neonates:
1 day: 50ml/kg/day
2 day: 70ml/kg/day
3 day: 100ml/kg/day
4 day: 120ml/kg/day
5 day: 150ml/kg/day
Holliday Segar:
4ml/kg/hr or 100ml/kg/day first 10kg
2ml/kg/hr or 50ml/kg/day second 10kg
1ml/kg/hr or 20ml/kg/day rest of weight
Risk factors for post-op apnoea in infants
- Preterm delivery
- Low birth weight
- Neonate (< 28 days)
- History of apnoeic episodes
- Anaemia, cardiac, metabolic or hepatic comorbidities
- Use of GA
- Use of opiates
- Oxygen therapy
Risk factors pyloric stenosis
- Maternal FH pyloric stenosis
- Bottle feeding
- Male
- Post-natal erythromycin
- Autumn and spring births
Specific anaesthetic considerations neonate
- Ambient temperature 26 deg, temperature control
- Apnoeic episodes - requires monitoring post op if < 60 wks post conceptual age prem or < 44 weeks post conceptual age term
- RSI challenging in this age group, consider NG and four quadrant aspiration
- Glucose containing maintenance fluid
- Paracetamol 7.5mg/kg 36-44 weeks post conceptual age
- LA and regional techniques to optimise analgesia
Paediatric pain scores by age-group
Signs of propofol infusion syndrome
- Refractory bradycardia
- Arrythmias
- Metabolic acidosis
- Rhabdomyolysis
- Hyperkalaemia
- Enlarged fatty liver
- Lipaemic plasma
- Myocardial collapse
Risk factors for PRIS
- Paeds
- Inborn errors of fatty acid oxidation
- Low carbohydrate supply
- Sepsis
- Pancreatitis
Lab findings in PRIS
- Acidaemia
- Raised lactate
- Raised CK with no other cause
- Hyperkalaemia
- Hypertriglyceridaemia
Management of PRIS
- Stop propofol, provide alternate sedative
- Vasopressor
- Pacing for bradycardia
- Ensure adequate carbohydrate source
- RRT for acidaemia, AKI and hyperkalaemia
Mortality from PRIS
4%
Physical appearance Trisomy 21
- Brachycephaly
- Flat occiput
- Flat nasal bridge
- Epicanthic folds
- Upslanting palpebral fissures
- Small ears
- Small mouth
- Macroglossia
- Micrognathia
- Short neck
- Short stature
- Obesity
- Single palmar crease
- Sandal gap between first and second toe
Reasons for surgery in infancy for Trisomy 21
- Congenital cardiac defects e.g. ASD, VSD
- Duodenal atresia
- Hirschprung’s disease
- Pyloric stenosis
- Imperforate anus
Common spinal abnormalities in Trisomy 21
Cervical spondylosis
Atlantoaxial instability
Causes of cerebral palsy
Antenatal: fetal alcohol syndrome, maternal hyperthyroidism, TORCH infections
Post-natal: severe prematurity < 32 weeks gestation, events at birth e.g. placental abruption, events in first 2 years e.g. cerebral infection
