Paediatrics
PA_1.1 Describe the anatomy of the neonatal and paediatric airway, how this changes with age and the implications for airway management
Anatomy of the Neonatal and Paediatric Airway and Its Changes with Age
Neonatal and Paediatric Airway Anatomy
Head and Neck
Relatively large occiput: Tends to flex the neck when supine, requiring careful positioning for airway alignment.
Short neck: Leads to reduced anatomical distance for airway instrumentation.
Tongue
Proportionally larger in relation to the oral cavity: Increases the risk of airway obstruction.
Nasal Airway
Neonates are obligate nasal breathers: Nasal obstruction (e.g., secretions, edema) can lead to significant respiratory distress.
Epiglottis
Larger, floppy, and omega-shaped: Positioned more anteriorly and angled, making visualization during laryngoscopy more challenging.
Larynx
Higher and more anterior (C2–C3 in neonates vs. C4–C5 in adults): This makes a straight laryngoscope blade more effective.
Narrowest part is the cricoid cartilage (in neonates and infants) compared to the vocal cords in older children and adults.
Trachea
Shorter and more compliant: Increases the risk of endotracheal tube (ETT) displacement and dynamic airway collapse.
Cartilaginous Support
Airway structures are more compliant and prone to collapse under negative pressure or with external compression.
Changes with Age
Laryngeal Position
Larynx descends with age (C4–C5 by adolescence).
Changes in laryngeal anatomy lead to the vocal cords becoming the narrowest part of the airway.
Airway Size and Shape
Airway diameter increases with growth, reducing resistance to airflow.
The cricoid ring becomes less prominent as the airway transitions to an adult-like configuration.
Neck and Head Proportions
Relative size of the occiput decreases, reducing the need for a towel roll or positioning aids for airway alignment.
Tongue and Epiglottis
Tongue size relative to the oral cavity decreases.
The epiglottis becomes less floppy and more linear, facilitating improved visualization during laryngoscopy.
Trachea
Length and rigidity increase, reducing the risk of tube displacement and collapse.
Implications for Airway Management
Positioning
Neonates and infants require a shoulder roll or head tilt to achieve the ""sniffing position"" due to the large occiput.
Airway Instrumentation
Use a straight blade (e.g., Miller) for neonates and infants to lift the floppy epiglottis.
Ensure appropriate ETT size (smaller, uncuffed tubes often preferred in neonates to avoid cricoid injury).
Monitoring and Ventilation
Higher risk of airway obstruction due to tongue size and compliance of airway structures.
Avoid excessive pressure during bag-mask ventilation to prevent airway collapse or gastric insufflation.
Tube Placement
Carefully secure the ETT due to the short trachea and risk of displacement.
Confirm placement with capnography and auscultation, as malposition can occur easily.
Anatomical Challenges
Be prepared for difficulty visualizing the larynx during intubation in neonates and infants.
Anticipate rapid desaturation due to higher metabolic demand and limited oxygen reserves.
Equipment
Use age-appropriate airway adjuncts (e.g., oral airways, laryngoscope blades, and supraglottic devices).
Ensure availability of smaller-sized endotracheal and nasopharyngeal tubes.
Understanding these anatomical differences and their progression with age ensures effective and safe airway management for neonates and pediatric patients.
PA_1.2 Describe airway and ventilatory equipment specific for paediatric patients, including: • Estimation of ETT size • Estimation of LMA of appropriate size • Accurate placement of ETT including fixation techniques • Use of cuffed and uncuffed tubes • Breathing circuits
Airway and Ventilatory Equipment for Paediatric Patients
Managing paediatric airways requires appropriately sized equipment and careful attention to anatomical and physiological differences. Below is a detailed discussion of essential equipment and techniques for paediatric airway management.
1. Estimation of Endotracheal Tube (ETT) Size
A. Formula for Uncuffed ETT Size
Age-Based Formula: ( \text{ETT size (internal diameter, mm)} = \frac{\text{Age in years}}{4} + 4 )
Example: A 4-year-old child: ( \frac{4}{4} + 4 = 5.0 , \text{mm} ).
B. Formula for Cuffed ETT Size
Use one size smaller than for uncuffed tubes: ( \text{ETT size for cuffed tube} = \frac{\text{Age in years}}{4} + 3.5 ).
C. Alternative Methods
Compare to the child’s little finger diameter.
Use a Broselow tape for weight-based sizing.
2. Estimation of Laryngeal Mask Airway (LMA) Size
A. Size Selection
Weight-Based Guidelines:
Size 1: < 5 kg.
Size 1.5: 5–10 kg.
Size 2: 10–20 kg.
Size 2.5: 20–30 kg.
Size 3: 30–50 kg.
B. Insertion Technique
Ensure correct positioning with the tip of the cuff in the hypopharynx.
Confirm placement with capnography and chest movement.
3. Accurate Placement of Endotracheal Tube
A. Depth of Insertion
Formula for ETT depth (at lips): ( \text{Depth (cm)} = \text{ETT size} \times 3 ).
Example: For a 4.0 mm ETT, depth = ( 4.0 \times 3 = 12 , \text{cm} ).
B. Confirmation of Placement
Use multiple modalities:
Capnography: Continuous waveform confirms tracheal placement.
Auscultation: Equal breath sounds bilaterally and absence over the stomach.
Chest Rise: Symmetrical movement with ventilation.
C. Fixation Techniques
Use adhesive tape or commercial tube holders.
Anchor the tube securely but avoid excessive pressure on the lips or skin.
4. Use of Cuffed and Uncuffed Tubes
A. Cuffed Tubes
Advantages:
Better airway seal and lower gas leak.
Reduced need for frequent tube changes during surgery.
Disadvantages:
Risk of tracheal injury if overinflated.
Pressure Monitoring: Ensure cuff pressure ≤ 20 cmH(_2)O to prevent mucosal damage.
B. Uncuffed Tubes
Advantages:
Lower resistance to airflow in smaller airways.
Safer in neonates and infants with narrow airways.
Disadvantages:
Potential for leaks requiring higher ventilation pressures.
5. Breathing Circuits
A. Types of Circuits
T-Piece Circuit:
Common in neonates and infants (<10 kg).
Minimal dead space and low resistance.
Bain Circuit:
Suitable for children up to 20–30 kg.
Lightweight and efficient for spontaneous or controlled ventilation.
Circle Circuit:
Used in older children and adolescents (>20 kg).
Suitable for extended surgical procedures with efficient gas delivery and heat/humidity conservation.
B. Adjustments for Paediatric Patients
Use of smaller reservoir bags and low compliance tubing to match tidal volume needs.
Adjust fresh gas flows to prevent rebreathing in non-rebreathing circuits.
6. Safety Considerations
Always have multiple sizes of ETTs and LMAs available.
Monitor ventilation closely with capnography, pulse oximetry, and airway pressure measurements.
Avoid overinflation of cuffs to prevent airway trauma.
Maintain proper humidification during prolonged ventilation.
Conclusion
Effective management of the paediatric airway requires correctly sized equipment and adherence to age-appropriate techniques. Accurate placement, secure fixation, and proper circuit selection are vital to ensure safety and optimal ventilation. Regular training and preparedness for airway challenges enhance outcomes in paediatric anaesthesia.
PA_1.3 Describe how preoxygenation and rapid sequence induction may be modified in paediatric patients
Preoxygenation and Rapid Sequence Induction (RSI) in Paediatric Patients
Preoxygenation and RSI in paediatric patients require specific modifications to account for their physiological differences, smaller anatomical structures, and heightened susceptibility to hypoxia.
1. Preoxygenation in Paediatrics
Challenges in Paediatrics:
Higher Oxygen Consumption: Infants and children consume oxygen at 6–8 mL/kg/min, compared to 3–4 mL/kg/min in adults.
Lower Functional Residual Capacity (FRC): Paediatrics have a lower FRC, providing less oxygen reserve.
Higher Alveolar Ventilation Rate: This promotes faster oxygenation but also faster desaturation during apnoea.
Modifications:
Optimal Mask Fit: Use age-appropriate masks to ensure a good seal and minimize leaks.
High-Flow Oxygen: Administer oxygen at high flow rates (≥10 L/min) to maximize alveolar oxygenation.
Calming Measures: Allow parental presence, play videos, or use distraction techniques to reduce anxiety and improve compliance.
Tidal Volume Breathing vs. Vital Capacity Manoeuvres: While vital capacity breathing can achieve quicker preoxygenation, tidal volume breathing over 2–3 minutes is often more practical for uncooperative children.
Nasal Oxygenation: Use nasal cannula during preoxygenation and apnoeic oxygenation to prolong the safe apnoea time.
2. Rapid Sequence Induction in Paediatrics
Challenges in Paediatrics:
Risk of Hypoxia: The combination of lower FRC and higher oxygen consumption means paediatrics desaturate rapidly.
Small Airway Anatomy: Increases the risk of airway obstruction and difficult intubation.
Physiological Response to Drugs: Haemodynamic responses to induction agents are more pronounced, especially in neonates and infants.
Modifications:
Preparation:
Have all equipment, including appropriately sized airway devices (ET tubes, LMAs), readily available.
Prepare suction and drugs for emergency management.
Induction Agents:
Use age-appropriate doses of induction agents (e.g., propofol, thiopental).
Consider ketamine for haemodynamic stability in critically ill or hypovolaemic children.
Neuromuscular Blockade:
Succinylcholine (1–2 mg/kg IV) is often used for rapid paralysis.
If contraindicated (e.g., hyperkalaemia, neuromuscular disorders), use rocuronium (1.2 mg/kg IV) as an alternative.
Cricoid Pressure:
Apply cricoid pressure cautiously, balancing the risk of regurgitation with the potential for airway obstruction.
Ventilation Prior to Intubation:
Gentle mask ventilation may be required to prevent hypoxia, especially in younger children. Use low-pressure ventilation to avoid gastric insufflation.
Apnoeic Oxygenation:
Continue nasal oxygenation during apnoea to extend safe apnoea time.
3. Special Considerations
Uncooperative Patients: In younger or anxious children, premedication with oral midazolam or inhalational induction with sevoflurane may be needed before RSI.
Neonates and Infants: Their immature physiological systems make them more prone to bradycardia and hypotension; atropine (10–20 µg/kg IV) is often given prophylactically.
Emergency Scenarios: Always have a difficult airway algorithm and rescue devices ready (e.g., LMAs, surgical airway).
By tailoring preoxygenation and RSI to paediatric-specific needs, anaesthetists can optimize oxygenation, ensure rapid and safe induction, and minimize complications.
PA_1.4 Describe positioning for direct laryngoscopy in paediatric patients
Positioning for Direct Laryngoscopy in Paediatric Patients
Positioning for direct laryngoscopy in paediatric patients differs from adults due to anatomical and physiological differences. The goal is to align the oral, pharyngeal, and laryngeal axes to optimize visualization of the glottis and facilitate intubation.
Key Anatomical Considerations in Paediatrics
Larger Occiput: Infants and young children naturally have a more flexed neck position due to the prominent occiput.
Anteriorly Positioned Larynx: The larynx is higher and more anterior (C3–C4 in infants vs. C5–C6 in adults).
Floppy Epiglottis: This requires lifting with the tip of the laryngoscope blade for optimal glottic view.
Optimal Positioning for Laryngoscopy
Sniffing Position:
The classic sniffing position aligns the oral, pharyngeal, and laryngeal axes.
Achieved by:
Infants and Young Children: Use a shoulder roll or towel under the shoulders to counteract the naturally flexed neck. Avoid excessive neck flexion.
Older Children: A small head elevation may suffice, similar to adults.
Neutral Head Position (for Neonates and Infants):
In neonates, a neutral head position is often adequate due to the natural alignment caused by the larger occiput.
Flexion-Extension Balance:
Ensure slight neck flexion with head extension at the atlanto-occipital joint. This prevents airway obstruction and enhances glottic view.
Steps for Positioning
Preparation:
Place the child supine on the operating table.
Assess the occiput prominence and airway alignment before adjusting.
Shoulder Roll (if needed):
Use a rolled towel or soft pad under the shoulders to elevate the chest and extend the neck.
Head Elevation (if required):
Place a small pad under the head in older children to achieve optimal neck flexion and head extension.
Midline Positioning:
Ensure the head and neck are straight and midline to avoid misalignment.
Confirm Axial Alignment:
Visualize alignment of the external auditory meatus with the sternal notch as a quick guide.
Additional Tips
Avoid Overextension: Excessive extension can obstruct the airway and hinder visualization.
Assistant Support: An assistant can stabilize the head if needed, especially in younger or less cooperative patients.
Check Glottic View: Adjust positioning dynamically if the glottis is not visible during laryngoscopy.
PA_1.5 Describe techniques for endotracheal intubation in paediatric patients
Techniques for Endotracheal Intubation in Paediatric Patients
Endotracheal intubation in paediatric patients requires a tailored approach due to their anatomical and physiological differences. These techniques ensure safe and effective airway management across various age groups and clinical scenarios.
Preparation
Equipment Selection:
ET Tube:
Cuffed or uncuffed based on patient size and clinical need.
Use the formula:
Uncuffed: (Age/4) + 4
Cuffed: (Age/4) + 3.5
Laryngoscope Blade:
Straight blade (e.g., Miller) preferred in infants and young children to lift the epiglottis directly.
Curved blade (e.g., Macintosh) can be used in older children.
Size selection:
Preterm: Size 0
Term neonates: Size 1
Older infants and toddlers: Size 1–2
Children >8 years: Size 2–3
Stylet: Soft, malleable stylet to pre-shape the tube as needed.
Suction: Yankauer or flexible catheter ready for secretion clearance.
Capnography: Ensure continuous ETCO₂ monitoring.
Patient Positioning:
Sniffing position or neutral position (depending on age).
Use a shoulder roll in neonates and infants to optimize head alignment.
Premedication and Anaesthesia:
Preoxygenate with 100% oxygen.
Use age-appropriate induction agents (e.g., sevoflurane, propofol) and neuromuscular blockers (e.g., succinylcholine, rocuronium) as indicated.
Techniques for Intubation
Direct Laryngoscopy:
Insert the laryngoscope blade from the right side of the mouth, sweeping the tongue to the left.
Advance the blade until the epiglottis is visualized.
Straight blade: Lift the epiglottis directly.
Curved blade: Place the tip in the vallecula to indirectly lift the epiglottis.
Visualize the vocal cords and pass the ET tube gently through the cords under direct vision.
Video Laryngoscopy:
Use when direct laryngoscopy is challenging or for teaching purposes.
Provides improved glottic visualization, especially in difficult airways.
Bougie-Assisted Intubation:
Insert the bougie through the vocal cords under direct vision, then advance the ET tube over the bougie.
Awake Intubation (Rare in Paediatrics):
May be needed in patients with difficult airways.
Use topical anaesthesia and gentle sedation.
Nasotracheal Intubation:
Preferred in certain surgical procedures (e.g., dental or maxillofacial surgery).
Ensure proper lubrication and select a tube 0.5 mm smaller than the calculated size for oral intubation.
Fiberoptic Intubation:
Used in difficult airway scenarios or in neonates and infants with congenital anomalies.
Advance the fiberoptic scope into the trachea, then slide the ET tube over it.
Confirmation of Placement
Observe bilateral chest rise.
Auscultate over both lungs and the epigastrium.
Confirm with continuous capnography (persistent ETCO₂ waveform).
Secure the tube with appropriate tape or ties.
Special Considerations
Smaller Margins for Error: Ensure accurate depth (ETT depth = 3 × tube size at the lips).
Avoid Trauma: Use gentle techniques to minimize airway injury or bleeding.
Difficult Airway Preparedness: Always have rescue devices (e.g., LMA) and a difficult airway algorithm ready.
By adhering to these principles and adapting techniques to the paediatric population, anaesthetists can perform safe and effective endotracheal intubation.
PA_1.6 Discuss indications for paediatric nasal intubation
Indications for Paediatric Nasal Intubation
Nasal intubation is a specialized technique used in paediatric airway management when oral intubation is impractical or contraindicated. It involves the insertion of an endotracheal tube (ETT) through the nostril into the trachea.
Indications for Paediatric Nasal Intubation
Surgical Access Requirements:
Procedures involving the oral cavity, mandible, or maxillofacial structures where oral intubation would obstruct the surgical field:
Cleft palate repair.
Dental or orthodontic surgeries.
Mandibular or maxillary reconstruction.
Tonsillectomy or adenoidectomy (occasionally used for airway management).
Difficult Airway Management:
In cases where oral access is limited due to anatomical anomalies or pathology:
Temporomandibular joint disorders or ankylosis.
Severe micrognathia (e.g., Pierre Robin sequence).
Congenital anomalies (e.g., Treacher Collins syndrome).
Medical Conditions Requiring Prolonged Intubation:
Chronic mechanical ventilation in cases where nasal intubation offers better stability and patient comfort.
Patients requiring concurrent feeding access via the oral route (e.g., severe prematurity, critical illnesses).
Trauma Cases:
Maxillofacial trauma where oral intubation is challenging or contraindicated.
Cervical spine immobilization requiring less manipulation of the oral cavity.
Airway Patency Concerns:
Severe airway swelling or obstruction (e.g., epiglottitis, abscesses) where nasal intubation provides a bypass route.
Advantages of Nasal Intubation in Paediatrics
Better Tube Stability: Reduced risk of accidental extubation in active children.
Improved Surgical Access: Frees the oral cavity for surgical or procedural needs.
Comfort: May be better tolerated in conscious or lightly sedated patients.
Contraindications to Nasal Intubation
Basal Skull Fractures: Risk of intracranial tube placement.
Coagulopathy: Increased risk of epistaxis.
Severe Nasal Obstruction: Polyps, deviated septum, or congenital anomalies.
Recent Nasal Surgery or Trauma: Risk of mucosal damage or complications.
Special Considerations
Age-Appropriate Equipment: Use smaller-sized, cuffed or uncuffed tubes and ensure adequate lubrication.
Anatomical Differences: Paediatric nasal passages are narrower, requiring gentle and precise insertion.
Airway Assessment: Pre-procedure assessment of nasal patency with inspection or nasal speculum is essential.
Post-Intubation Monitoring: Vigilance for nasal trauma, obstruction, or mucosal damage is critical.
By carefully selecting candidates for nasal intubation and tailoring the technique to paediatric anatomy and physiology, anaesthetists can safely and effectively manage the airway in these unique scenarios.
PA_1.7 Describe the clinical features and management of a paediatric difficult airway
Clinical Features and Management of a Paediatric Difficult Airway
A paediatric difficult airway presents unique challenges due to the anatomical and physiological differences in children compared to adults. Early recognition and appropriate management are critical to ensure safety and effective oxygenation.
Clinical Features of a Paediatric Difficult Airway
History
Congenital Syndromes: Conditions associated with craniofacial abnormalities, such as:
Pierre Robin Sequence (micrognathia, glossoptosis).
Treacher Collins Syndrome (mandibular hypoplasia).
Goldenhar Syndrome (hemifacial microsomia).
Down Syndrome (macroglossia, atlantoaxial instability).
Previous Difficult Intubation: History of challenging airway management in prior procedures.
Medical Conditions: Airway trauma, tumors, or infections (e.g., epiglottitis, retropharyngeal abscess).
Physical Examination
Facial Features: Micrognathia, retrognathia, midface hypoplasia, large tongue, or facial asymmetry.
Airway Anatomy: Narrow nasal passages, high and anterior larynx, floppy epiglottis.
Neck Mobility: Limited due to congenital or acquired conditions (e.g., torticollis, cervical spine anomalies).
Signs of Obstruction: Stridor, retractions, difficulty speaking or crying, cyanosis.
Investigations (as needed)
Imaging: X-rays, CT scans, or MRIs to assess airway anatomy in complex cases.
Management of a Paediatric Difficult Airway
Preoperative Preparation
Assessment and Planning:
Conduct a thorough airway examination.
Prepare an individualized plan based on anticipated difficulty (e.g., difficult ventilation, intubation).
Include a backup plan, such as supraglottic airway (SGA) or surgical airway options.
Equipment:
Age- and size-appropriate airway devices, including:
Endotracheal tubes (ETTs) (cuffed and uncuffed).
Laryngoscope blades (straight and curved).
Video laryngoscope.
Fiberoptic bronchoscope.
Bougies or stylets.
SGAs (e.g., laryngeal mask airways).
Emergency equipment for cricothyrotomy or tracheostomy.
Team Communication:
Involve experienced anaesthetists, surgeons, and nursing staff.
Ensure all team members understand the plan and backup options.
Intraoperative Management
Induction of Anaesthesia:
Consider inhalational induction (e.g., sevoflurane) to maintain spontaneous ventilation in uncertain airways.
Use intravenous induction (e.g., propofol) with muscle relaxants in controlled situations.
Airway Techniques:
Direct Laryngoscopy: First-line if anatomy permits.
Video Laryngoscopy: Useful for visualizing anteriorly positioned larynx.
Fiberoptic Intubation: Ideal for anticipated difficult intubation or awake intubation in older children.
Supraglottic Airway Devices: Use as a rescue option if intubation or ventilation fails.
Surgical Airway Access:
Cricothyrotomy or tracheostomy as a last resort in life-threatening situations.
Postoperative Management
Extubation:
Perform only when the child is fully awake and airway patency is ensured.
Use a leak test to confirm absence of significant airway edema.
Monitoring:
Observe for signs of airway obstruction or complications (e.g., laryngospasm, stridor).
Provide humidified oxygen, nebulized adrenaline, or corticosteroids for airway edema.
Special Considerations
Minimize Trauma: Use gentle techniques to prevent airway injury.
Avoid Desaturation: Ensure continuous oxygenation, even during attempts at airway management.
Rapid Decision-Making: Escalate to advanced or surgical techniques promptly in case of failure.
By combining thorough preparation, tailored airway techniques, and vigilant postoperative care, paediatric difficult airways can be managed effectively while minimizing complications.
PA_1.8 Discuss the clinical features, possible causes, and management of perioperative paediatric upper and lower airway obstruction, especially laryngospasm and bronchospasm
Perioperative Paediatric Upper and Lower Airway Obstruction
Airway obstruction in paediatric patients during the perioperative period can occur at various levels, with significant risks to oxygenation and ventilation. Recognizing clinical features, identifying underlying causes, and initiating prompt management are critical.
Clinical Features
Upper Airway Obstruction
Inspiratory Stridor: High-pitched sound during inspiration.
Suprasternal and Intercostal Retractions: Visible effort in upper chest and neck.
Agitation or Cyanosis: Indicators of hypoxia.
Increased Work of Breathing: Tachypnoea, nasal flaring, and use of accessory muscles.
Lower Airway Obstruction
Expiratory Wheeze: Characteristic of bronchospasm.
Prolonged Expiratory Phase: Increased respiratory effort during expiration.
Hypoxaemia: SpO₂ drop despite oxygen supplementation.
Silent Chest: Ominous sign of severe obstruction.
Common Causes
Upper Airway Obstruction
Laryngospasm: Reflexive glottic closure triggered by:
Airway irritation (e.g., secretions, blood, or gastric contents).
Light anaesthesia during stimulation (e.g., intubation, extubation).
Anatomical Factors:
Enlarged tonsils or adenoids.
Congenital anomalies (e.g., micrognathia, macroglossia).
Edema or Inflammation:
Croup, epiglottitis, or allergic reactions.
Lower Airway Obstruction
Bronchospasm: Hyperreactive airway response triggered by:
Asthma, recent respiratory tract infection, or allergic reactions.
Airway irritation (e.g., inhalation of cold gases, aspiration).
Infections:
Bronchiolitis or pneumonia.
Airway Foreign Body:
Obstruction from aspirated material or secretions.
Management
Laryngospasm (Upper Airway Obstruction)
Immediate Actions:
Call for help.
Remove the triggering stimulus (e.g., secretions, blood).
Provide 100% oxygen via a tight-fitting mask.
Airway Maneuvers:
Apply continuous positive airway pressure (CPAP).
Perform a jaw thrust and ensure the head is in the sniffing position.
Pharmacological Management:
Administer deepening anaesthesia with propofol or thiopentone.
Succinylcholine (0.5–1 mg/kg IV or 4 mg/kg IM) for refractory cases.
Post-Resolution:
Monitor for pulmonary edema secondary to the obstruction.
Bronchospasm (Lower Airway Obstruction)
Immediate Actions:
Call for help.
Deepen anaesthesia with volatile agents or intravenous agents (e.g., propofol).
Administer 100% oxygen.
Bronchodilators:
Inhaled β2-agonists (e.g., salbutamol via nebulizer or metered-dose inhaler).
Intravenous β2-agonists or aminophylline in severe cases.
Corticosteroids (e.g., dexamethasone) for inflammation.
Ventilation Adjustments:
Allow prolonged expiratory time.
Use low tidal volumes and higher inspiratory flow rates.
Treat Underlying Cause:
Suction secretions or clear airway obstruction.
General Supportive Measures
Optimize Positioning: Ensure airway patency with the appropriate head and neck alignment.
Fluid Management: Address hypovolemia, if present, to improve oxygen delivery.
Post-Event Monitoring: Observe for recurrence of obstruction or complications such as pulmonary edema or aspiration.
Prevention
Adequate Depth of Anaesthesia: Avoid light planes during airway manipulation.
Minimize Irritants: Suction secretions and ensure a clean airway before extubation.
Optimize Patient Condition: Delay elective procedures in the presence of active respiratory infections.
Pre-emptive Bronchodilation: For patients with asthma or reactive airway disease
PA_1.9 Discuss the principles of mechanical ventilation in paediatric patients, including appropriate ventilation, normal volumes and pressures, and the role of PEEP
Principles of Mechanical Ventilation in Paediatric Patients
Paediatric patients require tailored mechanical ventilation strategies due to their unique anatomical and physiological differences. The goal is to ensure effective gas exchange while minimizing ventilator-induced lung injury (VILI).
Key Principles
Individualized Approach
Adapt ventilation settings to the child's age, weight, and underlying condition.
Monitor closely to ensure effective oxygenation and ventilation without causing harm.
Low Tidal Volume Ventilation
Prevents overdistension of alveoli and reduces the risk of VILI.
Tidal Volume (Vₜ):
Neonates: 4–6 mL/kg ideal body weight.
Infants and older children: 5–8 mL/kg ideal body weight.
Respiratory Rate (RR)
Set based on age to maintain normocapnia:
Neonates: 30–50 breaths/min.
Infants: 25–40 breaths/min.
Children: 20–30 breaths/min.
Inspiratory Pressure and Plateau Pressure
Avoid excessive airway pressures to minimize barotrauma.
Inspiratory Pressure: ≤20 cmH₂O (adjust for disease severity).
Plateau Pressure: <30 cmH₂O.
Positive End-Expiratory Pressure (PEEP)
Maintains alveolar recruitment, improves oxygenation, and prevents atelectasis.
Typical PEEP settings: 4–6 cmH₂O.
Use higher PEEP cautiously in conditions like ARDS to optimize oxygenation.
Fraction of Inspired Oxygen (FiO₂)
Start with 100% FiO₂ in emergencies, then titrate to maintain SpO₂ at:
Neonates: 90–94%.
Infants and older children: 92–97%.
Inspiratory Time (I-time)
Adjust to match age and lung mechanics:
Neonates: 0.3–0.5 seconds.
Infants and older children: 0.5–1 second.
Ventilation Modes
Pressure-Controlled Ventilation (PCV): Preferred in paediatrics due to reduced risk of barotrauma.
Volume-Controlled Ventilation (VCV): Ensures consistent tidal volume delivery but requires careful pressure monitoring.
High-Frequency Oscillatory Ventilation (HFOV): Used in severe lung disease or ARDS.
Monitoring and Adjustments
Clinical Monitoring
Assess chest rise, oxygen saturation (SpO₂), and capnography.
Monitor for signs of distress (e.g., tachypnoea, retractions).
Ventilator Monitoring
End-Tidal CO₂ (ETCO₂): Aim for 35–45 mmHg.
Arterial Blood Gas (ABG): Regularly assess PaO₂ and PaCO₂.
Weaning Considerations
Reduce support gradually as lung function improves.
Perform a trial of spontaneous breathing to assess readiness for extubation.
Role of PEEP in Paediatric Ventilation
Alveolar Recruitment: Prevents alveolar collapse, particularly in conditions like surfactant deficiency or ARDS.
Improved Oxygenation: Increases functional residual capacity (FRC) and reduces ventilation-perfusion (V/Q) mismatch.
Reduction of Atelectotrauma: Stabilizes alveoli during exhalation.
Caution with PEEP: Excessive levels may compromise venous return, reducing cardiac output and causing overdistension.
Common Challenges and Solutions
Small Airway Size
Higher airway resistance; use appropriate-sized endotracheal tubes and ensure patency.
Higher Oxygen Consumption
Ensure adequate minute ventilation to meet metabolic demands.
Susceptibility to Barotrauma
Carefully monitor and limit inspiratory and plateau pressures.
By applying these principles, paediatric ventilation strategies can balance effective gas exchange with the minimization of lung injury, ensuring optimal patient outcomes.
PA_1.10 Describe the practical pharmacology of drugs commonly used in paediatric anaesthesia.
Practical Pharmacology of Drugs Commonly Used in Paediatric Anaesthesia
Paediatric patients differ significantly from adults in drug metabolism, distribution, and elimination, requiring precise dosing and consideration of developmental physiology. The following summarizes the practical pharmacology of commonly used drugs in paediatric anaesthesia.
Induction Agents
Propofol
Mechanism of Action: GABA-A receptor agonist causing sedation and hypnosis.
Dosing: 2–4 mg/kg IV for induction.
Onset/Duration: Rapid onset (30–60 seconds); short duration (5–10 minutes).
Special Considerations:
Reduced clearance in neonates; prolonged recovery in younger patients.
Causes hypotension and respiratory depression; use cautiously in hypovolaemic or haemodynamically unstable children.
Ketamine
Mechanism of Action: NMDA receptor antagonist; produces dissociative anaesthesia.
Dosing: 1–2 mg/kg IV or 5–6 mg/kg IM.
Onset/Duration: IV onset ~1 min; IM onset 3–5 min; duration 10–20 min.
Special Considerations:
Preserves airway reflexes and stimulates cardiovascular system.
Commonly used in haemodynamically unstable children or those with difficult IV access (IM route).
Can cause hypersalivation and emergence delirium (reduce with co-administration of anticholinergics or benzodiazepines).
Sevoflurane
Mechanism of Action: Inhalational agent that enhances GABA-A receptor activity.
Dosing: Induction via inhalation at 6–8% concentration in oxygen or air.
Onset/Duration: Rapid onset due to low blood-gas partition coefficient.
Special Considerations:
Minimal airway irritation; ideal for inhalational induction.
May cause hypotension and myocardial depression at higher concentrations.
Maintenance Agents
Isoflurane, Desflurane, and Sevoflurane
Commonly used inhalational agents for maintenance.
Adjust concentration based on age-dependent MAC (e.g., higher MAC in neonates).
Considerations:
Desflurane is less commonly used due to airway irritation in paediatrics.
Sevoflurane preferred for its favourable haemodynamic profile and minimal airway reactivity.
Propofol
Used as a continuous infusion for total intravenous anaesthesia (TIVA).
Dosing: 100–200 mcg/kg/min.
Consider reduced clearance in neonates and infants.
Analgesics
Paracetamol
Mechanism of Action: Inhibition of central prostaglandin synthesis.
Dosing:
IV: 15 mg/kg every 6 hours (max 60 mg/kg/day).
Oral/Rectal: 20 mg/kg loading, then 15 mg/kg every 6 hours.
Considerations: Monitor for hepatotoxicity, particularly in neonates with reduced glucuronidation capacity.
Fentanyl
Mechanism of Action: Mu-opioid receptor agonist providing potent analgesia.
Dosing: 1–2 mcg/kg IV bolus; infusion 1–2 mcg/kg/hr.
Special Considerations:
Short duration of action; useful in short procedures.
Monitor for respiratory depression, particularly in neonates.
Morphine
Mechanism of Action: Mu-opioid receptor agonist.
Dosing: 0.05–0.1 mg/kg IV bolus; infusion 10–40 mcg/kg/hr.
Considerations:
Neonates have reduced clearance due to immature hepatic metabolism.
Risk of respiratory depression and prolonged sedation in neonates.
Regional Anaesthesia Adjuvants
Ropivacaine/Bupivacaine: For caudal, epidural, or nerve blocks.
Dose: 0.2–0.3 mL/kg of 0.25% solution.
Monitor for systemic toxicity (CNS and cardiovascular effects).
Muscle Relaxants
Succinylcholine
Mechanism of Action: Depolarizing neuromuscular blocker.
Dosing: 1–2 mg/kg IV; 2–4 mg/kg IM.
Special Considerations:
Used for rapid sequence induction.
Risk of hyperkalaemia in muscular dystrophies and burns.
Avoid in neonates without co-administration of atropine to prevent bradycardia.
Rocuronium
Mechanism of Action: Non-depolarizing neuromuscular blocker.
Dosing: 0.6–1.2 mg/kg IV for induction.
Special Considerations: Rapid onset and suitable for RSI when succinylcholine is contraindicated.
Antiemetics
Ondansetron
Mechanism of Action: 5-HT3 receptor antagonist.
Dosing: 0.1–0.15 mg/kg IV (maximum 4 mg).
Special Considerations: Prolonged QT interval risk at high doses.
Reversal Agents
Neostigmine and Glycopyrrolate
Neostigmine: Acetylcholinesterase inhibitor (0.04–0.07 mg/kg).
Glycopyrrolate: Anticholinergic to counteract bradycardia (0.01–0.02 mg/kg).
Sugammadex
Mechanism of Action: Encapsulates rocuronium or vecuronium, reversing their effects.
Dosing: 2–4 mg/kg IV (depends on depth of blockade).
Special Considerations: Effective but expensive; use cautiously in renal impairment.
Adjunctive Medications
Atropine: Reduces bradycardia during induction or succinylcholine administration.
Dose: 10–20 mcg/kg IV.
Dexamethasone: Reduces airway oedema and PONV.
Dose: 0.15 mg/kg IV.
By understanding the pharmacological profiles and practical applications of these agents, paediatric anaesthesia can be tailored to achieve safe and effective perioperative care.
PA_1.11 Describe the use of weight-based calculations to guide administration of drugs in paediatric anaesthesia and resuscitation
Weight-Based Calculations in Paediatric Anaesthesia and Resuscitation
Accurate weight-based drug dosing is critical in paediatric anaesthesia and resuscitation to ensure efficacy and avoid toxicity due to the physiological differences between children and adults.
Principles of Weight-Based Dosing
Accuracy: Paediatric doses are calculated per kilogram (mg/kg or mcg/kg).
Methods for Estimation:
Use actual body weight from a recent measurement if available.
For emergencies, estimate using age-based formulas (e.g., Weight (kg) = (Age in years × 2) + 8) or length-based resuscitation tapes like Broselow tape.
Drug Categories and Weight-Based Dosing
Induction Agents
Propofol: 2–4 mg/kg IV for induction.
Ketamine: 1–2 mg/kg IV or 5–6 mg/kg IM for dissociative anaesthesia.
Sevoflurane: Delivered via inhalation; not weight-dependent but MAC varies with age.
Analgesics
Paracetamol: 15 mg/kg IV or oral every 6 hours (maximum daily dose: 60 mg/kg).
Morphine: 0.05–0.1 mg/kg IV bolus or 10–40 mcg/kg/hr infusion.
Fentanyl: 1–2 mcg/kg IV bolus or infusion 1–2 mcg/kg/hr.
Muscle Relaxants
Succinylcholine: 1–2 mg/kg IV or 2–4 mg/kg IM.
Rocuronium: 0.6–1.2 mg/kg IV for intubation or maintenance.
Resuscitation Drugs
Adrenaline (Epinephrine):
Cardiac arrest: 10 mcg/kg IV bolus every 3–5 minutes.
Anaphylaxis: 10 mcg/kg IV or 0.01 mg/kg IM (max 0.5 mg).
Atropine: 10–20 mcg/kg IV for bradycardia (minimum dose 0.1 mg).
Fluids
Resuscitation Fluid (Crystalloid): 10–20 mL/kg bolus for hypovolaemia.
Maintenance Fluid:
4 mL/kg/hr for first 10 kg.
2 mL/kg/hr for next 10 kg.
1 mL/kg/hr for every kg above 20 kg.
Antibiotics
Cefazolin: 30 mg/kg IV for surgical prophylaxis.
Vancomycin: 15 mg/kg IV over 60 minutes.
Key Considerations
Developmental Pharmacokinetics:
Neonates and Infants: Reduced drug clearance due to immature liver enzymes and renal function.
Older Children: Often require higher doses (per kg) due to faster metabolism.
Dosing Safety:
Verify doses using reliable paediatric reference guidelines.
Double-check calculations, especially in emergencies.
Administration:
Use syringes and infusion pumps with accurate graduations to deliver small, precise doses.
Monitoring:
Closely monitor for efficacy and adverse effects due to variability in pharmacodynamic responses.
Resuscitation Context
In emergencies, weight-based dosing ensures accurate drug delivery for life-saving interventions:
Use Broselow tape for rapid weight estimation when exact weight is unknown.
Prepare common drug doses and fluid boluses in advance for emergency trolleys to reduce errors.
By adhering to weight-based dosing principles and tailoring treatment to paediatric physiology, safe and effective anaesthesia and resuscitation can be delivered.
PA_1.12 Describe and justify fasting guidelines used in paediatric anaesthesia
Fasting Guidelines in Paediatric Anaesthesia
Fasting guidelines for paediatric patients are designed to minimize the risk of aspiration during anaesthesia while avoiding unnecessary discomfort and hypoglycemia due to prolonged fasting. The following guidelines are widely adopted and evidence-based:
1. Fasting Times by Type of Intake (see table 1)
2. Justifications for Fasting Guidelines
A. Reduction of Aspiration Risk
Aspiration of gastric contents during anaesthesia induction can cause severe complications, including pneumonitis and hypoxia.
Fasting ensures that the stomach is empty, minimizing the risk of regurgitation and pulmonary aspiration.
B. Physiological Considerations in Paediatric Patients
Children are more prone to dehydration and hypoglycemia due to smaller glycogen stores and higher metabolic rates. Shorter fasting durations for clear fluids mitigate these risks.
Prolonged fasting can increase irritability, anxiety, and difficulty cooperating during induction.
C. Evidence-Based Approach
Studies show that a 2-hour fasting period for clear fluids does not increase aspiration risk compared to longer fasting periods, even in high-risk populations.
Guidelines are consistent with those from professional bodies such as the American Society of Anesthesiologists (ASA) and the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI).
3. Practical Considerations
A. Clear Fluids
Allowing clear fluids up to 2 hours preoperatively ensures hydration and reduces preoperative discomfort.
Examples include water, apple juice, or electrolyte solutions. Avoid opaque or thick fluids (e.g., milk).
B. Communication with Parents
Provide clear instructions to caregivers about the importance of adhering to fasting guidelines.
Emphasize the risks of non-compliance, including cancellation of the procedure or increased perioperative complications.
C. Individualized Adjustments
Modify fasting times for children with delayed gastric emptying, such as those with diabetes, obesity, or gastrointestinal conditions.
In emergencies, assess aspiration risk versus the urgency of surgery, and consider rapid sequence induction if fasting criteria are not met.
4. Challenges and Controversies
Non-Adherence: Parents may misinterpret or fail to follow fasting instructions. Reiterate guidelines during preoperative counseling.
Prolonged Fasting: Overly conservative fasting times can lead to unnecessary distress. Efforts should be made to minimize non-medical delays.
Emergent Cases: Employ strategies like rapid sequence induction or gastric emptying with a nasogastric tube when fasting guidelines cannot be followed.
Conclusion
Paediatric fasting guidelines balance the need to prevent aspiration with minimizing the risks of dehydration, hypoglycemia, and discomfort. Shorter fasting times for clear fluids are supported by evidence and improve the patient experience without compromising safety. Standardized yet flexible approaches ensure optimal care tailored to individual needs."
PA_1.12 Table A: Fasting Times by Type of Intake
Type of Intake
Fasting Time
Justification
Clear Fluids
2 hours
Clear fluids empty rapidly from the stomach, reducing the risk of aspiration while preventing dehydration.
Breast Milk
4 hours
Breast milk has a higher fat content than clear fluids, requiring more time for gastric emptying.
Formula Milk
6 hours
Formula milk empties more slowly than breast milk due to higher protein and fat content.
Light Solids (e.g., toast)
6 hours
Light solids take longer to digest, increasing the risk of residual gastric contents if not sufficiently fasted.
Heavy Solids/Fatty Foods
8 hours
High-fat or complex meals prolong gastric emptying, necessitating longer fasting periods.
PA_1.13 Describe the pharmacology and appropriate use of paediatric premedication agents
Pharmacology and Appropriate Use of Paediatric Premedication Agents
Paediatric premedication aims to alleviate anxiety, facilitate smooth induction, and reduce perioperative complications. Selection of agents depends on patient factors (age, comorbidities), the surgical procedure, and the anaesthetic plan.
Goals of Premedication
Anxiolysis: Reduce anxiety and stress.
Amnesia: Prevent traumatic memory formation.
Sedation: Ensure calm and cooperative behaviour during induction.
Physiological Stability: Maintain haemodynamic and respiratory stability.
Adjunctive Effects: Reduce secretions, prevent nausea, and decrease autonomic responses.
Commonly Used Premedication Agents
Midazolam (Benzodiazepine)
Mechanism of Action: Enhances GABA-A receptor activity, causing sedation, anxiolysis, and amnesia.
Onset/Duration:
Oral: Onset 15–30 min, duration 1–2 hrs.
Intranasal: Onset 10–15 min, duration similar to oral.
Dosing:
Oral: 0.3–0.5 mg/kg (maximum 20 mg).
Intranasal: 0.2–0.3 mg/kg.
Benefits: Reliable anxiolysis and amnesia.
Side Effects: Respiratory depression, paradoxical reactions (rare).
Clonidine (Alpha-2 Agonist)
Mechanism of Action: Centrally acts on alpha-2 adrenergic receptors to provide sedation and anxiolysis.
Onset/Duration:
Oral: Onset 30–60 min, duration 4–8 hrs.
Dosing:
Oral: 2–4 mcg/kg.
Benefits: Sedation without significant respiratory depression; analgesic properties.
Side Effects: Bradycardia, hypotension.
Dexmedetomidine (Alpha-2 Agonist)
Mechanism of Action: Similar to clonidine but with greater selectivity for alpha-2 receptors.
Onset/Duration:
Intranasal: Onset 30–45 min, duration 6–8 hrs.
Dosing:
Intranasal: 1–2 mcg/kg.
Benefits: Sedation, anxiolysis, and analgesia; minimal respiratory depression.
Side Effects: Bradycardia, hypotension.
Ketamine (NMDA Receptor Antagonist)
Mechanism of Action: Blocks NMDA receptors, producing sedation, amnesia, and analgesia.
Onset/Duration:
Oral: Onset 20–30 min, duration 1–2 hrs.
Intranasal: Onset 5–10 min.
Dosing:
Oral: 5–6 mg/kg.
Intranasal: 3–5 mg/kg.
Benefits: Excellent sedation and analgesia; preserves airway reflexes.
Side Effects: Nausea, vomiting, increased salivation, emergence delirium (mitigated by co-administration with midazolam).
Atropine or Glycopyrrolate (Anticholinergics)
Mechanism of Action: Reduce secretions and vagal tone by blocking muscarinic receptors.
Dosing:
Atropine: 10–20 mcg/kg IV/IM.
Glycopyrrolate: 4–6 mcg/kg IV/IM.
Use: Common adjunct to other agents to minimize secretions or prevent bradycardia.
Fentanyl (Opioid)
Mechanism of Action: Mu-opioid receptor agonist providing analgesia and mild sedation.
Dosing:
Intranasal: 1–2 mcg/kg.
Use: For patients requiring analgesia pre-induction.
Side Effects: Respiratory depression, nausea, pruritus.
Considerations for Use
Patient Factors:
Age, weight, comorbidities (e.g., respiratory or cardiac conditions).
Route of Administration:
Oral and intranasal routes are preferred for ease of administration and patient comfort.
Timing:
Administer premedication 30–60 minutes before induction for optimal effect.
Surgical and Anaesthetic Factors:
Longer surgeries may benefit from agents with extended duration (e.g., clonidine).
Special Precautions
Monitor for respiratory depression, especially with midazolam and opioids.
Use anticholinergic agents for ketamine-induced hypersalivation.
Ensure adequate recovery time for patients with sedative premedication to avoid delayed awakening.
Premedication in paediatric anaesthesia should be tailored to the individual patient to maximize benefit and minimize risk, ensuring a smooth perioperative course.
PA_1.14 Outline measures to optimise patient experience with intravenous cannulation in paediatric patients
Measures to Optimise Patient Experience with Intravenous Cannulation in Paediatric Patients
Intravenous (IV) cannulation can be a source of significant anxiety and discomfort for paediatric patients. Implementing child-friendly, evidence-based strategies helps reduce fear, improve cooperation, and enhance the overall experience.
1. Preparation Before Cannulation
A. Pre-procedure Education
Explain the process to the child and parent using age-appropriate language.
Use toys, books, or videos to demonstrate the procedure in a non-threatening way.
B. Distraction Tools
Provide visual or auditory distractions, such as:
Tablets or smartphones with videos, games, or music.
Toys, books, or a favorite comfort item (e.g., stuffed animal).
C. Pharmacological Measures
Apply topical anesthetics (e.g., EMLA cream or Lidocaine-Prilocaine patches) 30–60 minutes before the procedure to numb the skin.
Consider intranasal midazolam or oral anxiolytics for highly anxious patients if appropriate.
D. Parent Involvement
Encourage parental presence and involvement in comforting or distracting the child during the procedure.
Guide parents to remain calm and supportive, as their anxiety can affect the child.
2. Optimizing the Environment
A. Child-Friendly Setting
Use a dedicated, colorful paediatric procedure room with non-threatening visuals and equipment hidden from sight until needed.
B. Staff Attitude
Maintain a calm, cheerful, and reassuring demeanor.
Build rapport by engaging the child with conversation or play before starting the procedure.
3. Procedural Techniques
A. Skillful Cannulation
Ensure staff are experienced and proficient in paediatric IV cannulation.
Use the smallest appropriate cannula size to minimize discomfort.
Choose veins that are easily accessible and visible without excessive manipulation.
B. Distraction During Procedure
Engage the child in play, counting games, or storytelling.
Use virtual reality (VR) headsets or augmented reality (AR) tools if available.
Involve child life specialists to assist with distraction techniques.
C. Pain Management
Consider the use of jet injectors or needle-free devices for local anesthetic delivery.
Employ techniques such as warm compresses to dilate veins and reduce pain.
D. Swift and Confident Technique
Minimize attempts by ensuring proper preparation and a single skilled operator.
Avoid extended explanations or delays that might heighten anxiety.
4. Positive Reinforcement
Offer praise and encouragement throughout the procedure.
Reward the child afterward with stickers, small toys, or verbal acknowledgment of their bravery.
5. Post-Procedural Care
Reassure the child and parent, acknowledging their cooperation.
Address any lingering discomfort or concerns immediately.
Conclusion
Optimizing the IV cannulation experience for paediatric patients involves a combination of preparation, distraction, skilled technique, and environmental modifications. A child-centered approach not only reduces distress but also builds trust, improving future interactions with healthcare providers.
PA_1.15 Describe methods to optimise patient experience and minimise the anxiety of paediatric patients and their parents during the induction of anaesthesia
Methods to Optimise Patient Experience and Minimise Anxiety During Paediatric Anaesthesia Induction
Induction of anaesthesia in paediatric patients can be stressful for both the child and their parents. A compassionate, structured approach helps reduce anxiety and improves cooperation, ultimately enhancing the safety and experience of care.
1. Preparation Before Induction
A. Preoperative Education
For Parents:
Provide clear, age-appropriate explanations about the anaesthetic process and address concerns.
Discuss the parent's role during induction (e.g., comforting the child).
For the Child:
Use simple language, avoiding technical terms.
Introduce play-based teaching tools, such as dolls or visual aids, to explain procedures.
B. Preoperative Visit
Allow children to meet the anaesthetist and explore non-threatening parts of the environment, such as monitors or masks.
C. Premedication
Consider pharmacological anxiolysis if appropriate:
Midazolam: Oral or intranasal (commonly used, fast-acting).
Alternatives: Dexmedetomidine or clonidine for specific indications.
Avoid sedatives if the child’s cooperation can be gained non-pharmacologically.
2. Parent Participation
Allow parents to be present during induction, depending on hospital policy and their comfort level.
Guide the parent to stay calm and focus on comforting the child, avoiding any display of anxiety.
3. Child-Centered Techniques
A. Distraction Methods
Visual and Auditory:
Use videos, cartoons, or interactive screens.
Play soothing music or encourage singing.
Tactile: Allow the child to hold a favorite toy, blanket, or comfort item.
B. Play Therapy
Engage with toys, bubbles, or role-playing activities.
Use “practice” sessions where the child pretends to give anaesthesia to a doll or toy.
C. Positive Reinforcement
Provide verbal encouragement and praise for cooperation.
Offer small rewards, such as stickers or toys, post-procedure.
4. Induction Techniques
A. Choice of Induction Method
Tailor induction to the child’s preference and clinical condition:
Inhalational Induction: Gradual introduction of sevoflurane via a flavored mask can be more acceptable to children.
Intravenous Induction: Avoid unless medically necessary; use topical anesthetics (e.g., EMLA cream) to reduce pain from cannulation.
B. Desensitization
Allow the child to handle the mask or blow into it (“blow up the balloon”) before applying it to their face.
C. Parental Coaching
Teach parents to provide comforting words or distractions during mask application.
5. Environmental Modifications
Child-Friendly Environment: Decorate the induction room with colorful, non-threatening visuals.
Anaesthetic Staff Attitude: Use a calm, cheerful, and reassuring demeanor to foster trust and cooperation.
6. Post-Induction Follow-Up
Reassure parents immediately after induction that their child is comfortable and stable.
Keep parents informed about the progress of the procedure to reduce their anxiety.
Conclusion
Optimizing the patient and parent experience during paediatric anaesthetic induction requires a blend of communication, child-centered techniques, and environmental adjustments. By prioritizing comfort and minimizing anxiety, the process becomes smoother and more positive for all involved.
PA_1.16 Calculate paediatric intravenous fluid requirements
Paediatric Intravenous Fluid Requirements
Fluid requirements in children vary based on the clinical context, such as maintenance, replacement of deficits, or resuscitation. The following outlines calculations for each scenario.
1. Maintenance Fluid Requirements
The Holliday-Segar Formula is commonly used to calculate maintenance fluids:
0–10 kg: 4 mL/kg/hr
11–20 kg: 2 mL/kg/hr (for each kg above 10 kg)
>20 kg: 1 mL/kg/hr (for each kg above 20 kg)
Example Calculation:
Child weight = 25 kg
First 10 kg: ( 10 \times 4 = 40 ) mL/hr
Next 10 kg: ( 10 \times 2 = 20 ) mL/hr
Remaining 5 kg: ( 5 \times 1 = 5 ) mL/hr Total = ( 40 + 20 + 5 = 65 ) mL/hr
2. Fluid Deficit Replacement
For dehydration or preoperative fasting deficits:
Estimate deficit as: [ \text{Deficit (mL)} = \text{Maintenance rate (mL/hr)} \times \text{Duration of fasting (hours)} ]
Replace the deficit:
50% in the first hour.
50% over the next 2–4 hours.
3. Resuscitation Fluids
For hypovolaemia or shock:
Crystalloid (e.g., Normal Saline, Hartmann's): 10–20 mL/kg bolus over 5–20 minutes.
Assess response and repeat as needed (up to 3 boluses).
Colloids: 5–10 mL/kg bolus if crystalloid fails.
4. Replacement for Ongoing Losses
Ongoing fluid losses (e.g., vomiting, diarrhoea, drains) should be replaced:
Use the type of fluid similar to the loss (e.g., isotonic saline for gastric losses).
Measure and replace volume loss 1:1.
5. Electrolyte Considerations
Sodium: Maintenance fluids typically contain 0.45–0.9% sodium chloride.
Potassium: Add potassium (20 mmol/L) if urine output is adequate.
Practical Example
For a 15 kg child who has been fasting for 6 hours:
Maintenance Rate:
First 10 kg: ( 10 \times 4 = 40 ) mL/hr
Next 5 kg: ( 5 \times 2 = 10 ) mL/hr
Total = ( 40 + 10 = 50 ) mL/hr
Deficit:
( 50 \times 6 = 300 ) mL
Replace ( 150 ) mL in the first hour, then ( 150 ) mL over the next 2–4 hours.
Resuscitation (if required):
( 15 \times 10 = 150 ) mL bolus of crystalloid.
Key Points
Fluid Type: Use isotonic fluids (e.g., Hartmann's, 0.9% saline) initially. Avoid hypotonic solutions in acutely unwell children.
Monitor: Reassess hydration status, urine output, and serum electrolytes regularly.
Adjust: Modify calculations for ongoing losses, fever, or sepsis.
This systematic approach ensures accurate and safe fluid management in paediatric patients.
PA_1.17 Discuss the physiological differences in paediatric anaesthesia, especially the importance of temperature maintenance
Physiological Differences in Paediatric Anaesthesia and the Importance of Temperature Maintenance
Paediatric patients have unique physiological characteristics that influence anaesthetic management, requiring careful attention to specific challenges such as thermoregulation.
Key Physiological Differences
1. Thermoregulation
Higher Surface Area-to-Volume Ratio:
Infants and young children lose heat more rapidly due to proportionally larger surface area.
Immature Thermoregulatory Mechanisms:
Neonates and infants rely on non-shivering thermogenesis (via brown fat metabolism) rather than shivering.
Limited vasoconstriction and inability to conserve heat effectively.
Higher Basal Metabolic Rate:
Increased energy expenditure but limited reserves for prolonged thermogenesis.
2. Cardiovascular System
Immature Myocardium:
Limited ability to increase stroke volume; cardiac output is heart rate dependent.
Increased Circulating Blood Volume (per kg):
Neonates: ~80–100 mL/kg compared to ~70 mL/kg in adults.
3. Respiratory System
High Oxygen Demand:
Neonates have higher metabolic rates, increasing susceptibility to hypoxia.
Compliant Chest Wall and Reduced FRC:
Increased risk of atelectasis and desaturation during apnoea.
4. Central Nervous System
Immature Blood-Brain Barrier:
Enhanced sensitivity to anaesthetic agents.
Rapid Brain Growth:
Vulnerability to hypoxia and hypoperfusion.
5. Renal and Hepatic Systems
Immature Renal Function:
Reduced ability to concentrate urine and excrete drugs/metabolites.
Immature Liver Enzymes:
Delayed metabolism of anaesthetic drugs.
Importance of Temperature Maintenance in Paediatric Anaesthesia
1. Consequences of Hypothermia
Metabolic Effects:
Increased oxygen consumption from non-shivering thermogenesis.
Risk of metabolic acidosis and hypoglycaemia.
Cardiovascular Effects:
Bradycardia and decreased cardiac output.
Coagulation Impairment:
Increased bleeding risk due to enzymatic dysfunction.
Delayed Drug Metabolism:
Prolonged recovery from anaesthesia.
2. Prevention of Hypothermia
Pre-warming:
Warm the operating room and use heated blankets.
Active Warming Devices:
Forced-air warming systems (e.g., Bair Hugger).
Heated Fluids:
Administer intravenous and irrigation fluids at body temperature.
Minimise Heat Loss:
Reduce exposure by covering the patient and insulating the head.
Key Considerations in Clinical Practice
Monitoring:
Continuous temperature monitoring (e.g., oesophageal or axillary probes).
Tailored Anaesthetic Doses:
Adjust for immature pharmacokinetics and altered drug responses.
Team Preparedness:
Ensure all equipment and techniques to maintain normothermia are ready before induction.
By addressing these physiological differences and actively preventing temperature dysregulation, paediatric anaesthesia can be conducted safely and effectively.
PA_1.18 Discuss the prevention and management of postoperative paediatric emergence phenomena
Prevention and Management of Postoperative Paediatric Emergence Phenomena
Emergence phenomena in children include a range of behavioural and physiological disturbances occurring during recovery from anaesthesia, most commonly emergence delirium (ED). It is essential to prevent and manage these phenomena effectively to ensure patient safety and comfort.
1. Understanding Emergence Phenomena
Emergence Delirium (ED)
Clinical Features:
Restlessness, inconsolability, crying, agitation, or confusion.
Occurs within 10–30 minutes after anaesthesia emergence.
Resolves spontaneously in most cases.
Incidence:
Common in children aged 2–6 years.
Higher with sevoflurane and desflurane use.
Causes:
Rapid emergence from anaesthesia (especially volatile agents).
Immature central nervous system and coping mechanisms.
Pain, fear, or unfamiliar surroundings.
Hypoxia, hypercapnia, or hypoglycaemia.
2. Prevention Strategies
Anaesthetic Techniques
Use of Total Intravenous Anaesthesia (TIVA):
Propofol has a lower incidence of ED compared to volatile agents.
Adjust Anaesthetic Depth:
Avoid overly deep or excessively light planes of anaesthesia.
Adjunct Medications
Analgesia:
Multimodal pain relief (e.g., regional blocks, non-opioid analgesics) to prevent pain-triggered ED.
Premedication:
Midazolam reduces anxiety and ED incidence.
Adjuncts for Prevention:
Dexmedetomidine or clonidine for sedation and smoother emergence.
Ketamine in low doses for dissociative sedation.
Non-Pharmacological Measures
Parental Presence:
Reduces anxiety during induction and recovery.
Child-Centric Approaches:
Familiar toys, comforting staff, and distraction techniques.
3. Management of Emergence Phenomena
Initial Assessment
Exclude serious causes such as hypoxia, hypercapnia, or hypotension.
Check for pain or other physiological disturbances (e.g., bladder distension).
Treatment
Comfort and Reassurance:
Calm environment, soothing speech, and parental presence.
Pharmacological Interventions:
Small doses of propofol (0.5–1 mg/kg) for agitation.
Dexmedetomidine bolus or infusion for sedation.
Fentanyl (0.5–1 mcg/kg) for unresolved pain-related agitation.
Oxygen Therapy:
Administer supplemental oxygen to prevent hypoxia.
4. Long-Term Considerations
Document the event for future anaesthetic planning.
Counsel parents on the benign and self-limiting nature of ED.
Plan for modified anaesthetic techniques in future surgeries if ED recurs.
Key Points
Emergence phenomena are distressing but generally self-limiting.
Prevention is achieved through appropriate anaesthetic choices, adjunct medications, and a child-friendly environment.
Management focuses on addressing physiological causes, reassurance, and pharmacological support when necessary.
By proactively addressing these factors, the incidence and impact of postoperative paediatric emergence phenomena can be minimised.
PA_1.19 Describe the management of day case analgesia for paediatric patients
Management of Day Case Analgesia for Paediatric Patients
Effective analgesia in paediatric day case surgery ensures adequate pain relief while minimizing adverse effects, enabling rapid recovery and safe discharge. A multimodal approach tailored to the patient's age, type of surgery, and individual needs is key.
1. Principles of Day Case Analgesia
Minimize Pain: Provide sufficient pain relief for immediate postoperative and at-home recovery.
Rapid Recovery: Use short-acting agents with minimal side effects to promote early mobilization and discharge.
Parental Involvement: Educate parents on administering pain relief and recognizing complications.
Multimodal Analgesia: Combine non-opioid and opioid options to enhance efficacy while reducing opioid doses.
2. Preoperative Planning
A. Preoperative Assessment
Identify risk factors for severe pain (e.g., surgical complexity, anxiety).
Consider patient comorbidities and previous responses to analgesics.
B. Preemptive Analgesia
Administer analgesics before surgery to reduce postoperative pain intensity:
Paracetamol: Oral or rectal (15 mg/kg).
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Ibuprofen (5–10 mg/kg) or diclofenac.
3. Intraoperative Analgesia
A. Local and Regional Anaesthesia
Techniques reduce systemic drug requirements and provide prolonged pain relief:
Local Infiltration: At the surgical site with lidocaine or bupivacaine.
Regional Blocks:
Caudal block (common for lower abdominal or urological procedures).
Nerve-specific blocks (e.g., ilioinguinal block for hernia repair).
B. Intravenous Analgesia
Use titrated doses of short-acting opioids (e.g., fentanyl or morphine) for intraoperative pain control.
Avoid long-acting opioids to reduce side effects like respiratory depression and nausea.
4. Postoperative Analgesia
A. Multimodal Pain Control
Paracetamol
First-line agent for mild to moderate pain.
Dose: 15 mg/kg every 4–6 hours (maximum 4 doses/day).
NSAIDs
Add for moderate pain or if inflammation is a component.
Example: Ibuprofen 5–10 mg/kg every 6–8 hours.
Opioids (if required)
For severe pain unresponsive to non-opioid therapy.
Example: Oral oxycodone 0.05–0.1 mg/kg every 4–6 hours, limited to short-term use.
5. Non-Pharmacological Strategies
Distraction techniques: Use toys, videos, or books to reduce anxiety and perceived pain.
Parental presence: Reassure and comfort the child during recovery.
6. Discharge Criteria
Pain adequately controlled with oral medications.
Minimal nausea, vomiting, or other side effects.
Parental understanding of pain management instructions.
7. Discharge Medications and Instructions
Prescription: Provide clear dosing instructions for paracetamol and ibuprofen, with or without mild opioids.
Warning Signs: Educate parents on when to seek medical attention (e.g., uncontrolled pain, fever, or side effects).
Follow-Up: Ensure access to a healthcare provider for questions or concerns post-discharge.
8. Special Considerations
Age: Adjust doses and routes of administration for neonates and infants.
Surgical Type: Anticipate pain severity based on the procedure (e.g., minor surgery vs. orthopaedic interventions).
Chronic Pain or Anxiety: Preoperative interventions and close monitoring may be required.
Conclusion
Day case analgesia in paediatric patients requires a well-structured, multimodal approach to ensure effective pain management while promoting rapid recovery and discharge. Collaboration with parents and careful follow-up enhances safety and satisfaction.
PA_1.20 Describe the principles of the assessment and management of acute pain in paediatric patients including the developmental impacts, the importance of psychosocial factors, relevance of functional assessment, and the use of paediatric pain scales
Principles of Assessment and Management of Acute Pain in Paediatric Patients
Effective management of acute pain in paediatric patients is essential to prevent immediate distress and long-term developmental and psychological consequences. It requires a multidisciplinary approach tailored to the child's age, developmental stage, and psychosocial factors.
1. Pain Assessment in Paediatric Patients
Developmental Considerations
Infants and Young Children:
Limited ability to verbally express pain; rely on behavioural and physiological cues.
School-Aged Children:
Better communication but may struggle to describe intensity or location.
Adolescents:
Closer to adult understanding; emotional and social factors may influence pain perception.
Psychosocial Factors
Anxiety, fear, or separation from caregivers can amplify pain perception.
Social support and parental involvement reduce pain-related distress.
Functional Assessment
Pain’s impact on activities, feeding, sleep, and play helps guide management strategies.
Paediatric Pain Scales
Neonates and Infants:
CRIES: Crying, oxygen requirement, vital signs, facial expression, and sleep.
FLACC: Face, Legs, Activity, Cry, Consolability (observational scale).
Children Aged 3–7 Years:
Faces Pain Scale–Revised (FPS-R): Self-reported pain using facial expressions.
Older Children and Adolescents:
Numerical Rating Scale (NRS): 0–10 scale for pain intensity.
Visual Analogue Scale (VAS): Mark pain on a line.
2. Principles of Pain Management
Multimodal Analgesia
Combines pharmacological and non-pharmacological methods to maximise efficacy and minimise side effects.
Pharmacological Management
Mild Pain:
Paracetamol: First-line for mild to moderate pain.
NSAIDs: (e.g., ibuprofen) for inflammatory pain.
Moderate to Severe Pain:
Opioids: Morphine, fentanyl, or oxycodone for severe pain, with careful dosing and monitoring.
Adjuvants: Ketamine for procedural pain or neuropathic components.
Local and Regional Anaesthesia:
Peripheral nerve blocks or caudal epidurals.
Non-Pharmacological Management
Cognitive and Behavioural Interventions:
Distraction (e.g., toys, music, videos), relaxation techniques, and guided imagery.
Parental Involvement:
Presence during procedures and reassurance.
Environmental Modifications:
Create a calm, child-friendly atmosphere.
3. Developmental Impacts of Poor Pain Management
Short-Term Consequences:
Increased fear, anxiety, and procedural pain in future.
Long-Term Effects:
Changes in pain perception, hypersensitivity, and altered neurodevelopmental pathways.
4. Individualised Care
Tailor pain management plans to age, developmental stage, and clinical context.
Regular reassessment to adjust therapy based on pain severity and functional recovery.
Key Takeaways
Pain assessment must account for developmental stages and psychosocial factors.
Use validated paediatric pain scales to guide management.
Multimodal analgesia combining pharmacological and non-pharmacological methods is ideal.
Adequate pain management is crucial to prevent immediate distress and long-term developmental impacts.
PA_1.21 Discuss safe acute pain management in paediatric day-case anaesthesia
Safe Acute Pain Management in Paediatric Day-Case Anaesthesia
Effective and safe management of acute pain in paediatric day-case anaesthesia is critical to ensure rapid recovery, minimise complications, and facilitate discharge. Strategies should address the unique requirements of paediatric patients and the outpatient setting.
1. Principles of Acute Pain Management in Day-Case Anaesthesia
Key Goals
Provide adequate pain relief while minimising side effects.
Facilitate rapid recovery and discharge.
Enable effective pain management at home.
Challenges
Limited observation time postoperatively.
Dependence on caregiver-administered analgesia after discharge.
Wide inter-individual variability in pain perception and drug metabolism.
2. Pain Assessment
Use age-appropriate tools to evaluate pain (e.g., FLACC scale for younger children, FPS-R for older children).
Observe for behavioural and physiological signs of pain, especially in non-verbal children.
3. Multimodal Analgesia Approach
Combining pharmacological and non-pharmacological strategies ensures balanced pain relief with minimal side effects.
Pharmacological Management
Preoperative:
Oral paracetamol (15 mg/kg) given preoperatively for baseline analgesia.
Consider preoperative NSAIDs (e.g., ibuprofen 10 mg/kg) if no contraindications.
Intraoperative:
Local and Regional Anaesthesia:
Peripheral nerve blocks (e.g., ilioinguinal block for hernia repair).
Caudal blocks for lower abdominal or perineal surgery.
Opioids:
Judicious use of short-acting opioids (e.g., fentanyl 1–2 mcg/kg) for moderate-to-severe pain, avoiding residual sedation.
Adjuvants:
Low-dose ketamine for enhanced analgesia and reduced opioid requirements.
Postoperative:
Regular paracetamol and/or ibuprofen at home as first-line agents.
Avoid routine opioid prescriptions; consider oral opioids (e.g., oxycodone 0.1 mg/kg) only for severe pain, with clear instructions.
Non-Pharmacological Management
Distraction techniques (e.g., toys, videos, music).
Parental presence and reassurance pre- and post-operatively.
4. Safety Considerations
Minimise Sedation and Respiratory Depression:
Limit intraoperative and postoperative opioid use.
Monitor patients for adequate recovery before discharge.
Prevent Nausea and Vomiting:
Administer antiemetics (e.g., ondansetron 0.1 mg/kg) if high-risk procedures or opioids are used.
Hydration and Feeding:
Ensure adequate oral intake before discharge to avoid dehydration.
5. Discharge Planning
Caregiver Education:
Provide clear instructions on home analgesia dosing, timing, and administration.
Educate about recognising pain, side effects, and when to seek help.
Written Instructions:
Include guidance on analgesic schedules and any red flags.
Follow-Up:
Arrange a mechanism for follow-up to address unresolved pain or complications.
6. Common Procedures and Pain Management Strategies
Tonsillectomy: Regular paracetamol and ibuprofen; avoid NSAIDs if bleeding risk is high.
Hernia Repair: Ilioinguinal block with regular paracetamol and ibuprofen.
ENT Procedures: Consider dexamethasone for pain and swelling relief.
Key Points
Multimodal analgesia combining paracetamol, NSAIDs, and regional techniques is the cornerstone of paediatric day-case pain management.
Minimise opioid use and ensure safe recovery before discharge.
Provide comprehensive caregiver education for effective at-home pain management.
Tailor strategies to the surgical procedure, patient needs, and outpatient setting.
PA_1.22 Discuss the common conditions identified in a preoperative assessment that may require further investigation, optimisation and/or referral to a tertiary hospital for specialist anaesthetic care, for example: • Prematurity and ex-prematurity • Asthma • Sleep apnoea • Cystic fibrosis • Down syndrome • Cerebral palsy • Autism • Obesity • Diabetes
Common Conditions Identified in a Preoperative Assessment Requiring Further Investigation, Optimisation, or Specialist Referral
The preoperative assessment identifies conditions that increase anaesthetic or surgical risk. Some conditions require further investigation, optimisation, or referral to a tertiary hospital to ensure safe management. Below is an overview of common conditions and their considerations.
1. Prematurity and Ex-Prematurity
Concerns
Immature respiratory control: Risk of apnea and bradycardia, particularly in those <60 weeks corrected gestational age.
Chronic lung disease and increased airway reactivity.
Vulnerability to hypothermia.
Management
Investigate recent apnea or oxygen requirements.
Plan postoperative monitoring for apnea (up to 24 hours postoperatively in high-risk infants).
Referral for specialist care if significant comorbidities exist.
2. Asthma
Concerns
Risk of perioperative bronchospasm.
Sensitivity to airway irritants (e.g., anaesthetic gases).
Management
Optimise control preoperatively with bronchodilators and corticosteroids.
Consider premedication with bronchodilators.
Avoid airway triggers during anaesthesia.
3. Sleep Apnoea
Concerns
Difficult airway management due to anatomical changes.
Risk of hypoxia and respiratory depression postoperatively, particularly with opioids.
Management
Screen for OSA using tools like STOP-BANG or confirm diagnosis with a sleep study.
Plan for CPAP therapy perioperatively.
Consider overnight monitoring in a high-dependency unit for severe cases.
4. Cystic Fibrosis (CF)
Concerns
Risk of respiratory infection, thick airway secretions, and bronchospasm.
Potential malnutrition or electrolyte imbalances.
Management
Perform preoperative respiratory optimisation (e.g., physiotherapy, bronchodilators).
Ensure hydration and electrolyte balance.
Refer to a tertiary hospital if advanced respiratory or nutritional support is needed.
5. Down Syndrome
Concerns
Difficult airway due to macroglossia, atlantoaxial instability, and subglottic stenosis.
Cardiac anomalies such as AV septal defects.
Increased sensitivity to sedatives and opioids.
Management
Obtain neck X-rays if atlantoaxial instability is suspected.
Perform cardiac evaluation if undiagnosed anomalies are suspected.
Tailor anaesthetic plan to airway and cardiac considerations.
6. Cerebral Palsy (CP)
Concerns
Risk of aspiration due to poor control of oral secretions and gastroesophageal reflux.
Challenges with positioning due to contractures or spasticity.
Potential difficulty with IV access and drug metabolism changes.
Management
Consider preoperative gastroparesis management.
Optimize positioning and padding intraoperatively.
Plan postoperative pain management tailored to spasticity and baseline function.
7. Autism
Concerns
Heightened anxiety and potential for behavioral issues during induction.
Sensory sensitivities complicating preoperative preparation.
Management
Use preoperative sedation if appropriate (e.g., oral midazolam).
Involve caregivers to help manage behavior and reduce stress.
Plan a calm, sensory-friendly environment during induction.
8. Obesity
Concerns
Difficult airway management and increased risk of OSA.
Higher incidence of cardiovascular and metabolic comorbidities.
Postoperative respiratory compromise due to reduced functional residual capacity.
Management
Assess for OSA or other comorbidities preoperatively.
Prepare for difficult airway scenarios, including positioning and equipment.
Use multimodal analgesia to minimize opioid use.
9. Diabetes
Concerns
Risk of hyperglycemia, hypoglycemia, and ketoacidosis.
Potential for delayed wound healing and infection.
Management
Optimize blood glucose control preoperatively (HbA1c <8%).
Develop an individualized perioperative insulin and glucose protocol.
Monitor blood glucose levels intraoperatively and postoperatively.
Referral to a Tertiary Centre
Referral is necessary when:
The condition requires advanced monitoring or specialist expertise.
The patient’s condition poses significant anaesthetic or surgical risk.
Facilities are inadequate for postoperative care or unexpected complications.
Conclusion
Preoperative identification and optimisation of conditions like prematurity, asthma, and obesity are critical to ensuring perioperative safety. Collaboration with specialists and referral to tertiary hospitals when necessary enhances outcomes for high-risk paediatric patients.
PA_1.23 Describe the preanaesthetic consultation and the preoperative preparation of paediatrics patients and their parents
Preanaesthetic Consultation and Preoperative Preparation for Paediatric Patients
1. Preanaesthetic Consultation:
Patient Medical History:
Detailed review of past medical history (e.g., previous surgeries, allergies, chronic conditions like asthma, diabetes).
Inquire about any previous anesthetic experiences (complications such as nausea, delayed recovery).
Review of current medications, including prescribed, over-the-counter drugs, and any herbal supplements.
Physical Examination:
Assess vital signs (height, weight, blood pressure, heart rate) for drug dosing and overall health.
Detailed airway assessment: mouth opening, Mallampati score, tonsil size, neck mobility, and jaw structure.
System review: respiratory, cardiovascular, and neurological evaluations, noting any abnormalities affecting anesthesia management.
Laboratory Tests:
Based on age and comorbidities, consider blood tests (e.g., complete blood count, renal function), ECG, and imaging (e.g., chest X-ray) if necessary.
Risk Assessment:
Assess ASA classification and anesthesia risks based on health status, comorbidities, and planned surgery.
Tailor anesthesia plan (e.g., choice of anesthetic agents, technique – general vs. regional) based on clinical findings.
2. Preoperative Education and Parental Involvement:
Explanation of Anesthesia:
Discuss the planned anesthetic technique (general, regional), risks, and benefits with parents in an understandable manner.
Use child-appropriate language, potentially using visuals or storyboards to help explain the procedure to the child.
Fasting Guidelines:
Provide specific fasting instructions (e.g., solids 6 hours, clear fluids 2 hours before surgery) based on surgery and age.
Emphasize the importance of adhering to these guidelines to reduce the risk of aspiration.
Anxiety Management:
Address parental and child anxiety: explain what will happen before, during, and after surgery.
Offer preoperative sedation or anxiolytics (e.g., midazolam) if needed to reduce stress and anxiety, especially for younger children.
Preoperative Medications:
Administer any prescribed premedication (e.g., sedatives, antiemetics) to reduce anxiety and prevent postoperative nausea.
Parent/Carer Support:
Encourage parents to be involved in the process, especially in the preparation and comforting their child.
For younger children, suggest bringing comfort items (e.g., a favorite toy or blanket) to the hospital.
3. Preoperative Preparation:
IV Access:
Insert intravenous (IV) access if indicated, ensuring appropriate vein selection and minimizing discomfort.
Ensure the line is patent and functional for medication administration and fluid management.
Monitoring:
Ensure appropriate monitoring equipment is set up (e.g., pulse oximeter, blood pressure cuff, ECG, temperature).
Assess baseline parameters to monitor during the procedure.
Parental Presence:
Allow parents to accompany the child to the operating room if appropriate and hospital policy allows.
If necessary, ensure a brief preoperative period in the holding area with the child, offering comfort and reassurance.
Final Review:
Final assessment of fasting compliance, health status, and any changes in the child’s condition since the initial consultation.
Confirm anesthesia plan and prepare any equipment or medications based on patient-specific needs.
Communication with the Surgical Team:
Ensure clear communication with the surgical team regarding any special anesthetic considerations, especially if the child has complex medical issues (e.g., difficult airway, cardiac conditions).
4. Postoperative Expectations:
Recovery Process:
Prepare parents for what to expect in the recovery room: child waking from anesthesia, potential for disorientation, and pain management.
Provide instructions on monitoring the child postoperatively, including signs of complications like excessive pain, bleeding, or respiratory difficulties.
By following these steps, the anesthesia team can ensure a smooth, safe, and anxiety-reducing experience for the pediatric patient and their parents, optimizing both the medical and emotional aspects of the surgical journey.
PA_1.24 Describe the implications of preoperative URTI or other intercurrent medical illness in paediatric patients.
Implications of Preoperative Upper Respiratory Tract Infection (URTI) or Other Intercurrent Illness in Paediatric Patients
The presence of a preoperative upper respiratory tract infection (URTI) or other intercurrent illness in paediatric patients poses significant anaesthetic challenges. It requires careful evaluation, decision-making, and risk mitigation strategies to ensure patient safety.
1. Clinical Features of URTI in Paediatrics
Symptoms: Nasal congestion, rhinorrhoea, cough, sore throat, fever, irritability.
Signs: Wheezing, stridor, increased work of breathing, pharyngeal erythema.
2. Risks Associated with URTI
Anaesthetic Risks
Airway Reactivity:
Increased risk of laryngospasm, bronchospasm, and desaturation.
Secretion Management:
Excessive airway secretions may impair ventilation and increase aspiration risk.
Respiratory Complications:
Higher rates of perioperative hypoxaemia, atelectasis, and prolonged recovery.
Surgical Risks
Delayed wound healing and higher postoperative infection rates in some systemic illnesses.
3. Decision to Proceed with Surgery
Considerations
Severity of Symptoms:
Mild symptoms (e.g., clear nasal discharge) may be acceptable with careful planning.
Severe symptoms (e.g., wheezing, fever >38°C, productive cough) often necessitate deferral.
Nature of Surgery:
Elective cases can be postponed; urgent or emergency cases often proceed with modifications.
Age and Comorbidities:
Younger children and those with chronic conditions (e.g., asthma, prematurity) are at higher risk.
4. Preoperative Assessment
Thorough History:
Duration, severity, and progression of symptoms.
Recent treatments (e.g., antibiotics, bronchodilators).
Physical Examination:
Assess airway patency, respiratory rate, oxygen saturation, and auscultation findings.
Investigations (if needed):
Chest X-ray or blood tests for significant respiratory compromise or systemic illness.
5. Intraoperative Implications
Airway Management
Avoid manipulation unless absolutely necessary; consider mask ventilation or LMA over endotracheal intubation.
Use smaller endotracheal tubes to reduce trauma and airway reactivity.
Anaesthetic Techniques
Opt for regional anaesthesia or sedation if feasible.
Use humidified oxygen and ensure adequate hydration to manage secretions.
Minimise airway irritants (e.g., desflurane) and use bronchodilators pre-emptively if indicated.
6. Postoperative Management
Close Monitoring:
Observe for respiratory complications, particularly laryngospasm or bronchospasm.
Pain and Secretions:
Ensure adequate analgesia and consider nebulised saline or suctioning for secretion clearance.
Parental Education:
Highlight red flags (e.g., increased work of breathing) for early intervention.
Implications of Other Intercurrent Illnesses
Fever: Assess for underlying infections; defer elective cases if systemic symptoms.
Gastroenteritis: Risk of dehydration and electrolyte imbalance; ensure adequate resuscitation.
Asthma or Bronchiolitis: Optimise treatment preoperatively, including bronchodilators or corticosteroids.
Key Points
URTI and intercurrent illnesses increase perioperative risk, especially respiratory complications.
Proceed cautiously with minor symptoms in elective cases, but optimise or postpone if severe symptoms are present.
Tailor anaesthetic management to minimise airway manipulation and prevent complications.
Effective communication with parents is crucial to ensure understanding and readiness for surgery.
PA_1.25 Describe the implications of a preoperative undiagnosed murmur detected in paediatric patients
Implications of a Preoperative Undiagnosed Murmur in Paediatric Patients
The detection of an undiagnosed heart murmur in a pediatric patient during a preoperative assessment has significant implications for anesthesia management, patient safety, and surgical planning. It requires a systematic approach to evaluate the potential causes of the murmur and assess the risks associated with anesthesia. Below are key considerations and implications:
1. Differentiating Pathological from Innocent Murmurs:
Innocent Murmurs:
Common in children and typically benign (e.g., flow murmurs associated with increased cardiac output, such as in febrile illness or anemia).
Generally, these murmurs are systolic, low-grade, and do not indicate structural heart disease.
Often diminish or disappear with age, and there is no need for special management unless symptoms or signs of cardiovascular compromise are present.
Pathological Murmurs:
Caused by structural heart disease (e.g., congenital heart defects like ventricular septal defect, patent ductus arteriosus, aortic stenosis).
These murmurs may be more prominent, louder, or associated with additional clinical signs (e.g., cyanosis, poor feeding, failure to thrive, or abnormal pulse).
Require further investigation and potentially a change in anesthetic and surgical approach.
2. Further Investigation and Diagnosis:
Echocardiography:
To confirm whether the murmur is due to congenital or acquired heart disease. This is essential for assessing the severity of the underlying condition.
Referral to a Pediatric Cardiologist:
If the murmur is suspected to be pathological, a pediatric cardiology consult may be warranted to evaluate the presence of any structural heart abnormalities.
Electrocardiogram (ECG) and Chest X-ray:
These tests may be used to evaluate for arrhythmias or signs of heart failure, particularly if there are concerning clinical signs or symptoms.
3. Anesthesia Considerations:
Risk Stratification:
Children with innocent murmurs generally do not require significant changes to the anesthesia plan. However, those with pathological murmurs or diagnosed heart disease may be at increased risk for intraoperative hemodynamic instability or complications.
Preoperative Optimization:
If the murmur is associated with significant heart disease, preoperative optimization (e.g., correction of electrolyte imbalances, treatment of heart failure symptoms) may be necessary before proceeding with surgery and anesthesia.
Monitoring:
For children with known cardiac conditions, more intensive intraoperative monitoring may be needed (e.g., invasive blood pressure monitoring, central venous pressure monitoring) to ensure adequate cardiac output and oxygenation.
Anesthetic Agents:
Choice of anesthetic agents may need to be adjusted based on the type of cardiac pathology (e.g., avoiding certain agents that may cause a drop in blood pressure if there is aortic stenosis or managing airway pressures carefully in cases of pulmonary hypertension).
Risk of Hypotension:
Certain congenital heart defects may increase the risk of hypotension under anesthesia (e.g., tetralogy of Fallot), and anesthesia must be managed to avoid worsening these issues.
4. Surgical Planning:
Cardiac Involvement:
In cases where the murmur is associated with significant heart disease, the surgical team may need to adjust the surgical approach, considering the cardiovascular status of the child. For example, certain procedures may be delayed or modified to manage the cardiac risks.
Timing of Surgery:
If a pathological murmur is identified, surgery may need to be postponed until a full cardiology workup is completed and any cardiac condition is appropriately managed.
Collaboration Between Teams:
Close coordination between the anesthesia, surgical, and cardiology teams is critical to manage the child’s care. In some cases, the cardiology team may be involved in the intraoperative period if there is concern about cardiac instability.
5. Postoperative Management:
Recovery Considerations:
Postoperative monitoring should include close attention to the child’s hemodynamics, especially if they have underlying cardiac disease. Blood pressure, oxygenation, and fluid balance must be carefully managed.
Signs of Cardiac Decompensation:
Postoperative complications such as heart failure, arrhythmias, or hypoxia may arise, particularly in children with significant cardiac pathology. Early recognition and intervention are vital.
6. Communication with Parents:
Education and Reassurance:
It is important to educate parents on the potential implications of the murmur, the need for further investigation, and the possible outcomes. This helps manage parental anxiety and prepares them for potential delays in surgery or additional evaluations.
Referral and Follow-up:
Parents should be informed if a referral to a pediatric cardiologist is necessary, and any follow-up tests or management plans should be discussed before proceeding with surgery.
Conclusion:
An undiagnosed murmur in a pediatric patient requires a thorough evaluation to determine whether it is an innocent or pathological murmur. If pathological, it can significantly alter anesthesia management, surgical planning, and postoperative care. Early identification, investigation, and collaboration between the healthcare team are essential to ensure the child’s safety and optimize outcomes. The management approach should be individualized based on the severity and nature of the underlying cardiac condition.
PA_1.26 Describe the maximum local anaesthetic agent doses in different paediatric patients
Maximum Local Anaesthetic Doses in Paediatric Patients
Paediatric patients are particularly vulnerable to local anaesthetic (LA) toxicity due to their smaller body mass, reduced protein binding, and immature liver metabolism. Understanding the safe maximum doses of commonly used agents is crucial to prevent toxicity.
General Principles
Weight-Based Dosing:
LA doses are calculated in mg/kg of actual body weight.
In obese children, ideal body weight or lean body mass may be used to avoid overdosing.
Dilution and Concentration:
Use the lowest effective concentration to reduce the total LA dose while achieving adequate analgesia.
Additives:
Adrenaline (epinephrine) can extend the duration of action and reduce systemic absorption, increasing the maximum safe dose.
Cumulative Dose:
Consider cumulative doses from multiple injections or infusions.
Maximum Safe Doses of Common Local Anaesthetics in Paediatric Patients (See table A below)
Important Considerations
Patient Factors:
Neonates and Infants: Reduced metabolism and protein binding; lower maximum doses recommended.
Premature Infants: Increased susceptibility to toxicity; conservative dosing is essential.
Toxicity Symptoms:
Central Nervous System: Agitation, seizures, drowsiness, or coma.
Cardiovascular: Bradycardia, arrhythmias, hypotension, cardiac arrest.
Prevention of Toxicity:
Use incremental dosing with frequent aspiration to avoid intravascular injection.
Monitor the patient closely during and after LA administration.
Examples of Safe Dosing by Age Group
Neonates (<1 Month)
Use 75% of the standard paediatric maximum dose due to immature metabolism.
Infants and Young Children (1 Month–2 Years)
Full weight-based maximum dose, but avoid cumulative toxicity.
Older Children (>2 Years)
Generally tolerate maximum recommended doses, but individual variability applies.
Clinical Scenarios
Infiltration:
Lidocaine 0.5% for localised surgical procedures.
Caudal/Epidural Blocks:
Bupivacaine 0.25% or ropivacaine 0.2%.
Peripheral Nerve Blocks:
Bupivacaine 0.25% or ropivacaine 0.2% with adrenaline for prolonged analgesia.
Key Points
Always calculate doses accurately using body weight and dilute the LA appropriately.
Add adrenaline to extend the safety margin when clinically suitable.
Monitor for signs of LA toxicity and have resuscitation equipment readily available.
Avoid exceeding the cumulative maximum dose across all administered LA agents.
PA_1.26 Table A: Maximum Safe Doses of Common Local Anaesthetics in Paediatric Patients
Agent
Without Adrenaline (mg/kg)
With Adrenaline (mg/kg)
Notes
Lidocaine (Lignocaine)
3–5
7
Commonly used for infiltration, nerve blocks; rapid onset.
Bupivacaine
2.5
3
Long-acting; preferred for regional blocks but avoid IV injection due to toxicity risk.
Ropivacaine
3
3.5
Similar to bupivacaine but with a better safety profile.
Levobupivacaine
2.5
3
S-enantiomer of bupivacaine; lower cardiotoxicity risk.
Prilocaine
6
N/A
Rarely used; risk of methemoglobinemia at high doses.
Chloroprocaine
10
N/A
Rapid onset, short duration; often used in spinal anaesthesia.
PA_1.27 Describe the aetiology, assessment and management of perioperative cardiac arrest in paediatric patients
Cardiac arrest in paediatric patients during the perioperative period is a rare but critical event. Effective management requires understanding its aetiology, prompt recognition, and timely intervention to improve outcomes.
1. Aetiology of Perioperative Cardiac Arrest in Paediatrics
Anaesthetic-Related Causes
Medication Errors: Incorrect dosing of anaesthetic agents, opioids, or muscle relaxants.
Local Anaesthetic Systemic Toxicity (LAST): Overdose or intravascular injection.
Airway Management Issues: Hypoxia, hypercapnia, laryngospasm, or aspiration.
Malignant Hyperthermia: Triggered by volatile agents or succinylcholine.
Surgical Causes
Blood Loss and Hypovolemia: Uncontrolled haemorrhage.
Vagal Stimulation: E.g., during eye or upper airway surgery.
Pneumothorax or Tamponade: Especially in thoracic procedures.
Patient-Specific Causes
Congenital Heart Disease: Underlying structural or functional abnormalities.
Electrolyte Imbalances: Hypokalaemia, hyperkalaemia, or hypocalcaemia.
Sepsis or Septic Shock: Systemic inflammatory response.
Metabolic Disorders: Hypoglycaemia, acidosis, or inherited metabolic conditions.
2. Assessment of Cardiac Arrest
Clinical Features
Sudden loss of pulse, consciousness, or respiratory effort.
Bradycardia or severe hypotension as warning signs.
Cyanosis, poor perfusion, or absent capillary refill.
Immediate Evaluation
Assess airway, breathing, and circulation (ABC).
Confirm cardiac arrest with palpation of central pulse or ECG.
3. Management of Perioperative Cardiac Arrest
Immediate Actions
Call for help and activate the paediatric cardiac arrest team.
Start high-quality cardiopulmonary resuscitation (CPR):
Compressions: 100–120/min at a depth of one-third the chest diameter.
Ventilations: 2 breaths every 15 compressions if intubated.
Administer 100% oxygen and secure the airway.
Advanced Life Support (ALS)
Drug Therapy:
Epinephrine 10 mcg/kg IV/IO every 3–5 minutes.
Atropine for severe bradycardia associated with vagal stimulation.
Defibrillation:
For shockable rhythms (VF/VT): 4 J/kg biphasic.
Address Underlying Causes (4 Hs and 4 Ts)
Hypoxia: Ensure adequate oxygenation and ventilation.
Hypovolemia: Rapid IV fluid boluses (20 mL/kg crystalloid).
Hypothermia/Hyperthermia: Rewarm or cool as needed.
Hyperkalaemia/Hypokalaemia/Acidosis: Correct electrolytes and pH.
Tension Pneumothorax: Immediate needle decompression.
Tamponade: Pericardiocentesis if clinically indicated.
4. Post-Resuscitation Care
Transfer to a paediatric intensive care unit (PICU) for monitoring.
Address organ dysfunction and ensure haemodynamic stability.
Conduct thorough root cause analysis to prevent recurrence.
Key Points
Paediatric perioperative cardiac arrest is often related to hypoxia, medication errors, or underlying medical conditions.
Rapid CPR, airway management, and correction of reversible causes are critical.
Structured team communication and adherence to paediatric ALS protocols improve survival.
Ongoing education and simulation training in paediatric resuscitation are essential for anaesthetic teams.
PA_1.28 Outline approaches for vascular access in shocked paediatric patients
Establishing vascular access in a shocked paediatric patient can be challenging due to peripheral vasoconstriction, small veins, and the urgency of resuscitation. A systematic approach and familiarity with alternative techniques are essential.
1. General Principles
Prioritization: If immediate vascular access is not achievable, initiate resuscitation measures like oxygen and manual ventilation.
Preparation: Use appropriate-sized equipment for the child's weight and age.
Time Management: Limit attempts at peripheral venous access to 90 seconds or 2 failed attempts before escalating to alternative methods.
2. Methods of Vascular Access
Peripheral Venous Access
Preferred First-Line Approach:
Use a small-gauge cannula (22G or 24G for infants).
Common sites: dorsum of the hand, antecubital fossa, and saphenous vein.
Techniques to Aid Success:
Use a tourniquet or vein-visualization devices.
Employ warming of extremities to dilate veins.
Intraosseous (IO) Access
Indications:
First-line alternative in emergencies when peripheral venous access fails.
Suitable for rapid volume resuscitation, drug administration, and blood sampling.
Common Sites:
Proximal tibia, distal femur, proximal humerus.
Procedure:
Insert an IO needle perpendicular to the bone surface.
Confirm placement by aspiration of marrow or free flow of fluid.
Central Venous Access
Indications:
If IO access is unavailable or long-term access is needed.
Sites:
Internal jugular, subclavian, or femoral veins.
Techniques:
Use ultrasound guidance to improve success rates and reduce complications.
Umbilical Venous Catheterization (Neonates)
Indications:
Available for neonates up to 1 week of age.
Used in critical scenarios where other access is impractical.
Procedure:
Insert the catheter through the umbilical vein under sterile conditions.
Scalp Veins (Infants)
Indications:
Alternative for neonates and small infants.
Can be used in less emergent situations.
Sites:
Frontal, temporal, or parietal veins.
3. Adjunct Techniques for Difficult Access
Ultrasound-Guided Access:
Useful for peripheral and central venous access in shocked patients.
Transillumination:
For visualizing veins in infants and small children.
4. Considerations and Precautions
Fluid Administration:
Use weight-based boluses (e.g., 20 mL/kg crystalloid).
Infection Prevention:
Maintain strict aseptic technique during insertion.
Monitoring for Complications:
IO: Extravasation, compartment syndrome.
Central lines: Pneumothorax, arterial puncture.
5. Escalation and Alternatives
If all conventional methods fail:
Consider surgical venous cutdown (e.g., saphenous vein).
Discuss with paediatric or vascular specialists for further options.
Key Points
IO access is the fastest and most reliable alternative when peripheral venous access fails.
Use ultrasound guidance where available to improve success rates.
Time-critical scenarios demand a low threshold for escalation to IO or central access.
PA 1.29 Discuss the diagnostic approach and resuscitative management of a paediatric patient with a life-threatening condition/illness, such as: • Respiratory arrest • Sepsis, including meningococcal sepsis • Severe bronchospasm • Post-tonsillectomy haemorrhage • Quinsy • Croup • Epiglottitis
1. Respiratory Arrest
Diagnostic Approach
History: Rapid onset suggests foreign body or anaphylaxis; progressive onset may indicate respiratory fatigue, infection, or worsening airway obstruction.
Examination: Assess for absent breath sounds, cyanosis, and chest movement.
Investigations:
Blood gas: Assess hypoxia, hypercapnia, or acidosis.
Imaging (e.g., chest X-ray): Identify pneumothorax, infection, or foreign body.
Management
Immediate ABCs:
Open the airway; suction if obstructed by secretions.
Provide 100% oxygen via bag-mask ventilation.
Intubate if necessary using age-appropriate equipment.
Resuscitation:
Address the cause (e.g., nebulized epinephrine for anaphylaxis).
Initiate CPR if required.
2. Sepsis, Including Meningococcal Sepsis
Diagnostic Approach
History: Fever, lethargy, poor feeding, and rash (petechiae or purpura).
Examination: Tachycardia, hypotension, cold extremities, prolonged capillary refill, or altered mental state.
Investigations:
Blood cultures, complete blood count, and CRP.
Lumbar puncture (if stable and no contraindications).
Management
Immediate Resuscitation:
IV access: Administer 20 mL/kg crystalloid boluses.
Broad-spectrum antibiotics: Ceftriaxone ± vancomycin.
Correct hypoglycaemia and acidosis.
Monitoring:
Consider inotropes (e.g., dopamine, epinephrine) for persistent shock.
3. Severe Bronchospasm
Diagnostic Approach
History: Wheezing, previous asthma, exposure to triggers.
Examination: Use of accessory muscles, inability to speak, or silent chest.
Investigations:
Blood gas: Look for hypercapnia and acidosis.
Chest X-ray: Rule out pneumothorax.
Management
Airway Support: High-flow oxygen.
Bronchodilators:
Nebulized salbutamol ± ipratropium bromide.
Intravenous magnesium sulfate for refractory cases.
Steroids: IV hydrocortisone or oral prednisolone.
Escalation: Consider non-invasive ventilation or intubation in severe cases.
4. Post-Tonsillectomy Haemorrhage
Diagnostic Approach
History: Assess for recent tonsillectomy and bleeding onset.
Examination: Look for active oral bleeding, hypovolemia (tachycardia, hypotension).
Investigations:
Crossmatch for blood.
Coagulation studies.
Management
Immediate Resuscitation:
Suction blood from the airway and provide 100% oxygen.
Insert large-bore IV lines; give crystalloid boluses.
Definitive Care:
Transfer to ENT for surgical hemostasis.
5. Quinsy (Peritonsillar Abscess)
Diagnostic Approach
History: Fever, muffled voice, drooling, difficulty opening the mouth.
Examination: Swollen tonsil with uvular deviation.
Investigations: Clinical diagnosis; imaging (CT neck) if uncertain.
Management
Airway Protection: Be prepared for rapid deterioration.
Antibiotics: Broad-spectrum IV antibiotics (e.g., ceftriaxone + metronidazole).
Definitive Treatment: Needle aspiration or incision and drainage by ENT.
6. Croup
Diagnostic Approach
History: Barking cough, stridor, recent viral illness.
Examination: Inspiratory stridor, hoarseness, and chest retractions.
Investigations: Clinical diagnosis; imaging (AP neck X-ray) shows subglottic narrowing (steeple sign).
Management
Mild: Oral dexamethasone.
Moderate/Severe:
Nebulized epinephrine for significant stridor.
Oxygen for hypoxia.
7. Epiglottitis
Diagnostic Approach
History: Sudden onset of high fever, drooling, and tripod positioning.
Examination: Avoid agitation; look for muffled voice and stridor.
Investigations: Avoid imaging in unstable patients.
Management
Airway Management:
Avoid upsetting the child; prepare for emergent intubation.
Intubate in the operating theatre with skilled personnel.
Antibiotics: IV ceftriaxone or cefotaxime.
Key Points
Recognize life-threatening conditions promptly using history and physical examination.
Stabilize ABCs and address the underlying cause immediately.
Escalate care as needed, ensuring specialized teams are involved early.
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