Herlien H. Megawe Dept.

of Anesthesiology & Reanimation Airlangga University School of Medicine Surabaya

No matter what time it is, wake me up, even if its in the middle of a cabinet meeting Ronald Reagan

I. BASIC PRINCIPLES :
a. b. c. d. Urgency of childs problem Ordering of priorities (e.g. epidural hematoma, closed femoral fracture) Critically ill and profound hypotensive condition, an immediate operation needed resuscitation & anesthesia are provided simultaneously Establish : - clear airway :A - provide ventilation :B - support hemodynamics : C Hypnosis & analgesia, as condition will allow Titrated doses of : - Hypnotics (Benzodiazepine, for amnesia Ketamine) - Opioids for pain - Neuromuscular blocking agent for immobility As patient stabilizes, inhalation agent are added as tolerated

e. f.

g.

II. RAPID CLINICAL ASSESSMENT OF THE SERIOUSLY ILL INFANT/CHILD

A = AIRWAY : - Obstruction - Partial - Total B = BREATHING : - Respiratory rate - Flare - Recession : - sternal - intercostal - subcostal C = CIRCULATION : - Pulse : volume - Silent chest - Blood pressure - Capillary refill time - EKG - Skin colour : - dry, red, warm - greyish, cold, wet, clammy D = DISABILITY : Unresponsive to voice/pain Posture Pupils : size/reaction Conscious level Convulsions - Purpura - Urticaria - Angio-edema

E = EXPOSSURE : - Rash - Swelling - Fever

 ASSESSMENT OF PROGRESS AND DETECTION OF DETERIORATION : Re-assessment of ABCDE at frequent intervals LEVEL OF CONSCIOUSNESS SHOULD BE RECORDED USING THE AVPU SCALE : A : Alert V : Responds to voice * P : Responds to pain (GCS < 8) U : Unresponsive

* Pinching a digit, pulling frontal hair

III. PATHWAYS LEADING TO CARDIO. RESPIRATORY ARREST :

FLUID LOSS
BLOOD LOSS GASTROENTERITIS BURN

LOSS MALDISTRIBUTION
SEPTIC SHOCK CARDIAC DISEASE

RESPIRATORY DISTRESS
FOREIGN BODY CROUP

RESPIRATORY DEPRESSION
CONVULSIONS RAISED ICP POISONING

ANAPHYLAXIS

ASTHMA

CIRCULATORY FAILURE

RESPIRATORY FAILURE

CARDIAC ARREST

Indication for intubation and ventilation : Inadequate oxygenation via bag-and-mask technique Prolonged ventilation required Flail chest Inhalational burn injury Shock

VASCULAR ACCESS
Preferred options : A. Intra venous B. Intra osseous

A. Preferable via the superior v. cava Via the inferior v. cava takes longer to reach the heart Via the periph. route fluid flush First priority : accurate safety rapidly B. Intra osseous : - Easy & safe - Reach the heart = periph. ven. access - Also in older age & adults
C. Tracheal : Third place For first drug adrenaline D. Intracardiac : not recommended

IV. RESUSCITATION BEFORE ANESTHESIA

Weight in kg = 2 (age in years + 4) Estimated blood volume = 80 ml/kg body weight
Crystalloid 20 ml/kg
Assess response

Colloid 20 ml/kg
Assess response

Fluid volume and type An initial fluid bolus of 20 ml/kg is given as fast as possible This should be repeated after assessment if there is no improvement in vital signs

Blood

Urgent Surgical opinion

The most common mistake in the treatment of hypovolaemic shocked children is failure to give enough fluid

V. OTHER VITAL PROCEDURES CARRIED OUT BEFORE RESUSCITATION AND ANESTHESIA : HISTORY : Vomit (quantity & quality) Last urination/defaecation) Bloody stool/profuse

BLOOD TESTS (taken immediately after venous access)

NASOGASTRIC TUBE PLACEMENT RADIOGRAPHS

VI. PLAN
1. Weight (kg) = 2 (year + 4) kg 2. Estimated Blood Volume : 80 ml/kg 3. Internal diameter endotracheal tube : Year + 4 = one size smaller, actual size, one size bigger, e.g. : 4 4 4,5 5 4. Fluid bolus : 20mg/kg - Crystalloid (Colloid) - Blood 5. Defibrill. Dose I : 2 Joule/kg 2 Joule/kg in 90 seconds 4 Joule/kg Defibrill. Dose II : 4 Joule/kg 4 Joule/kg in 90 seconds 4 Joule/kg 6. Between defibrill. dose I and II : Adrenalin dose I : 1 ml/10.000 sol. (10 Ug/kg) Adrenalin dose II : 1 ml/1000 sol. (100 Ug/kg)

VII. PREMEDICATION, ANXIETY & FEAR I.V. anticholinergics benefits : 1. Maintenance of cardiac output by increasing heart rate 2. Prevention of reflex bradycardia : Airway manipulation Scoline/halothane ANXIETY & FEAR Calm appearance Reassuring

Of the anesthesiologist is of great benefit for patients & parents

VIII. URGENT SITUATION WITH COMPROMISED AIRWAY Foreign body aspiration Epiglottitis Croup Bleeding tonsil Facial/laryngeal trauma Compromised airway & struggle during intubation attempt, choices are : Awake intubation Volatile agent (Sevoflurane/Halothane) in oxygen with gentle cricoid pressure This approach is favoured = The patient continues breathing ! Slight head down position : pulmonary aspiration is less likely when patient regurgigates

FULL STOMACH
Postpone surgery for > 4 hours Reduce the mean gastric residual volume by 50% (does not guarantee empty) If there is no specific airway for difficult intubation Anesthesia of choice : rapid sequence of induction Pre-oxygenation + sulfas atropine Rapid induction agent : - Ketamine - Propofol - Thiopenthal Muscle relaxant = Recuronium 1,2 mg/kg The smaller the child, the more rapid he will desaturate (< FRC) Newborns can become hypoxic in less than 1 minute Difficult to pre-oxygenate & denitrogenate a struggling toddler

HYPOVOLEMIA Ongoing bloodloss Pending blood availability

5% Albumine

Type specific un-crossmatched low incidence of transfusion reaction Ketamine : induction agent of choice in small dosis 1 2 mg/kg I.V. (within one minute) Atropine 0,02 mg/kg or scopolamine 0,01 mg/kg administered before

IX. PAIN MANAGEMENT

Injured children are in pain on arrival Potentially hypovolemic : Fentanyl preferable Must be titrated in small increments (0,5 1,0 Ug/kg) to avoid chestwall or glottic rigidity Unstable & neurologic dysfunction : opioids with caution Regional nerve blocks = - femoral nerve - axillary Providing analgesia As a primary anesthetic (avoid risks of general anesth. = aspiration) Supplement for postop analgesia

CAUTIONS
Titrate sedative in small increments to avoid loss of airway reflexes Appear alert & Sedation sleepy After the block : painfull stimuli is removed

Close communication with surgeons = ability to perform sensory and motor examinations

X. SPECIAL PROBLEMS & MANAGEMENT A. AIRWAY

Acute airway obstruction : Inspiratory stridor Tachypnoea Sternal & intercostal retractions Agitation (due to hypoxia) Cyanosis Tachycardia Few of these symptoms & signs are manifested, yet their condition may rapidly become life-threatening Initial respons : O2 & calm, to prevent dynamic collapse of the airway associated with agitation - Not cyanotic X-ray is helpful clarifying the cause of obstruction - Sable vital signs - Upright position - Supine position further airway obstruction Blood gas analysis is not vital PaO2 = 80 torr ; or does not alter the response of the anesthesiologist PaO2 = 60 torr In Contrast : pulse oxymetry Non-invasive Immediate & continuous means for assessing oxygenation Recommended as a modality in all airway emergencies

B. UPPER AIRWAY OBSTRUCTION 1. Epiglotitis

Skill Essential for the anesthesiologist Knowledge Urgent diagnosis & treatment Additional signs : - drooling - difficulty in swallowing Favoured approach worldwide : Endotracheal intubation Avoid = inspection increase obstruction (dynamic airway collapse) Radiographic = - Only when stable - Skilled personnel - Adequate resuscitation equipment In the operationg room : Calm, sitting on the lap o/t mother Induction overface : - Halothane - Sevoflurane Looses consciousness supine Head up slightly

 Intubation tehnique

Lifting the base of the tongue

Without touching the epiglottis Exposure of the rimaglottidis

Partially obstructed orifice

0,5 mm ID smaller choosen sprayed beforehand A stylet within the endotracheal tube Failure : - tracheostomy - cricothyorotomy Adequate sedation to prevent extubation * Titrated opioids - Breathe spontanneously - ETT remains in place for 24 48 hours, until swelling decreased - Extubation

2. Foreign body aspiration

History of choking Cyanosis

While eating suspicious (peanut, popcorn)

A wheezing child : Not always asthmatic May be foreign body aspiration Agitation : due to seriously underlying hypoxemia Radiographic examination If the child is stable Helpful to localize & identify Mostly are not radiopaque Hyperinflation Clues of presence of foreign body Atelectasis

Principle of anesthetic management = epiglottitis

C. LOWER AIRWAY OBSTRUCTION 1. Bronchiolitis

Tachypnea Retractions Wheezing Hyperinflated chest & diffuse crepitations Progressive exhaustion hypercarbia respiratory failure (silent chest) Focus of treatment = correct hypoxemia Pulse oxymetry : - degree of hypoxemia - respons to therapy Nebulized mist Not proven beneficial Bronchodilators Titrated I.V, fluids not able to drink Ribavirin : antiviral agent Caution : Particles tend to disk, obstructing the ventilator No absolute PaCO2 value that dictates the course of action

2. Asthma, status asthmaticus

A cardinal feature : reversibility spontaneuous or with therapy Wheezing sinonymous with bronchospasm

Predominant expir. wheezing With increasing fatique slight air movement wheezing no longer audible

Management : a. Support oxygenation b. Reduce airway obstruction c. Support ventilation d. Prevent complication (e.g. pneumothorax) e. Inhaled & I.V. drugs

Anesthesia : Optimize oxygenation, control brochospasm Standard agents Ketamine : - Bronchodilating - Hypersecretion Avoid histamine release agents : - Morphine No sciencetific data yet - Curare - Thiopental Drying of secretions intra-operatively : - Atropine - Glycopyrrolate May exacerbate mucous plugging post-operatively Wheezing during anesthesia mechanical problem : - endobronchial intubation - plugging, kinking - cuff herniation Mechanical ventilation is difficult High Airway Pressure: - air trapping - pneumomediastinum - pneumothorax Controlled mechanical ventilation: - Degree of hypercarbia is pernitted/accepted - Adequate oxygenation - Adequate cardiac output

CIRCULATION :
1. Hypovolemia : Most common cause of shock Crystalloid solutions are effective No scientific studies of superiority of colloid solutions Blood as soon as crossmatching is carried out, or O neg.

Type spec. uncrossmatched

Urgent

XI. OPERATING ROOM MANAGEMENT

1. Acute blood loss Secure large bore venous access is of higher priority than arterial access Arterial catheters in : Arterial blood gas for adequate ventilation Frequent blood sampling : metabolic derangements Hemodynamic instability Need to alter blood pressure rapidly Central venous access, only when hemodynamic stability returns Body temperature, hypothermia : Potentiates neuromuscular blockade Exacerbates coagulopathy Anesthesiologists vigilance continued : until care is transferred to the appropriate physicians and nurses

2.