The child with a cold

 

List:

·         Summary

·         Disease

·         Considerations

·         Anaesthesia

 

Summary:

How to decide

·           Two bad options are available

·           Considerations are multi-factorial

·           Discuss with both surgeon and parents

Problems with proceeding

·           High risk of many complications

Problems with cancellation

·           Most complications are benign

·           Most complications are easily treatable

·           Hyperreactivity lasts 6 weeks

·           Children have colds all the time

·           Cancellation is hard on the child and family

 

Disease:

Pathophysiology

·           Hyperreactive airways

·           Impaired mechanics

·           Impaired gas exchange

Complications

Intra-op: (mainly induction and emergence)

·           Breath holding

·           Desaturation

·           Coughing

·           Larnyogspasm

·           Bronchospasm

·           Airway obstruction

Post-op:

·           Prolonged intubation

·           Re-intubation

·           Oxygen requirement

·           Post-extubation stridor

·           Hospital admission

·           Pneumonia

Risk factors

Current illness:

·           Snoring

·           Secretions ++

·           Blocked nose

Comorbidities:

·           Prematurity

·           Asthma

·           Passive smoking

Red flags

·           High fever

·           Wheeze

·           Crackles

 

Considerations:

Surgery

·           Airway surgery

·           Urgency

Hospital

·           Paediatric caseload

·           Inpatient beds

·           Other anaesthetists present

·           Assistant’s training

·           PACU nurses’ training

Child

·           General health

·           Risk factors

·           Red flags

Family

·           Previous did-not-attends

·           Previous cancellations

·           Travel time

 

Anaesthesia: if proceeding

Induction

·           Discussion + rapport

·           Pre-medicate

·           Topicalise skin

·           Cannulate

·           Propofol + fentanyl + atracurium +++

·           Topicalise vocal cords

·           Intubate (careful)

Maintenance

·           Sevoflurane +++

Extubation

If difficult intubation: extubate awake and prepare for failure

If easy intubation: extubate deep and prepare for failure

Deep extubation:

·           Prepare drugs and equipment for re-intubation

·           Transfer onto bed

·           Spontaneous ventilation

·           Propofol 3mL/kg q30sec

·           Await three breaths after apnoeic period

·           Deflate cuff

·           Swift extubation at end-inspiration

·           Face mask + PEEP

Post-op

·           Low threshold for admission

 

 

Feedback welcome at ketaminenightmares@gmail.com