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Definition |
· Brain injury before, during or shortly after birth · Upper motor neuron effects are static · Muscle and bone effects evolve |
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Classification |
Gross Motor Function Classification System (GMFCS) · From minimal impairment to wheelchair-bound |
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Assumptions |
· Variable intellectual disability · Variable sensory deficit – vision, hearing · Good but not perfect correlation with physical abilities ->Always address both child and parent |
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Fear |
· Variable utility of pre-medication o May facilitate pre-induction vascular access o May delay emergence -> Ask what works |
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Pain |
· Difficult to assess -> Have plan (e.g. regional + nurse-controlled PCA) -> Make sure devices work (e.g. epidurogram, long PIVCs) -> Monitor by appearance / vital signs / help from parents |
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Airway |
· Contractures · Small dimensions · ±Bulbar palsy · ±GORD -> Difficult intubation -> Aspiration risk: suction PEG pre-op |
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Access |
· Atrophied limbs · Contractures · Small calibre vessels -> Consider pre-induction vs post-induction: safety, ease, pain -> Consider topicalization -> Consider ultrasound |
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Hypnotic |
· ↓MAC -> slow wake-up -> Fast-offset hypnotic: ***flurane -> Fast-offset reflex suppressant: N2O, remifentanil -> Avoid relaxant to allow titration to effect |
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Muscle relaxant |
· Sensitive to non-depolarising NMBD · Dangerous if depolarizing NMBD -> Use rocuronium and sugammadex -> Don’t use sux |
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Opioid |
· Sensitive -> sedation, respiratory depression -> Titration to effect -> Short-acting agent if appropriate -> Opioid-sparing analgesia |
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Pressure care |
· Atrophied muscles · Spasticity and contractures · Osteopaenia -> Need meticulous limb pressure care |
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Temperature care |
· Low metabolic rate · Low heat capacity · Cold extremities · Propensity for intra-op hypothermia -> Need peri-op forced air warmer |
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Bowel care |
· At risk of constipation -> Opioid-sparing analgesics -> Pair opioids with aperients |
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Medication |
· Multiple comorbidities · Multiple medications -> Continue all peri-op incl psychoactives and anticonvulsants -> Avoid proconvulsants – e.g. tramadol |
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