The child with a cold

 

List:

·        Summary

·        Disease

·        Considerations

·        Anaesthesia

 

Summary:

Problems with proceeding

·          High risk of airway 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

Upshot

·          Two bad options are available

·          Considerations are multi-factorial

·          Discuss with both surgeon and parents

 

Disease process:

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

 

Assessment

Child

Questions:

·          Need hospital admission?

·          Risk of airway complications?

·          Consequences of upper airway complications?

Past history:

·          Prematurity

·          General health

·          Respiratory disease (esp. asthma)

·          Passive smoking

Presenting illness:

·          General:

o    Activity level

o    Oral intake

o    Wet nappies

·          URTI:

o    Cough

o    Snoring

o    Secretions

Examination:

·          General appearance: WOB, lethargy

·          Vital signs: high fever*, SpO2

·          Airway: difficult-looking?

·          Breathing: wheeze*? Crackles*?

   *red flags

Family

·          Previous did-not-attends

·          Previous cancellations

·          Travel time

Surgery

·          Airway surgery

·          Urgency

Hospital

·          Paediatric caseload

·          Inpatient beds

·          Other anaesthetists present

·          Assistant’s training

·          PACU nurses’ training

 

Anaesthesia:

Main things

·          Experienced anaesthetist

·          Intravenous induction

·          Avoid ETT

Induction

·          Discussion + rapport

·          Pre-medicate

·          Topicalise skin

·          Cannulate

·          Propofol + opioid + relaxant

·          Topicalise vocal cords

·          Intubate (careful)

Maintenance

·          Sevoflurane -> propofol

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

 

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