Paediatrics – post-tonsillectomy haemorrhage

 

Issues:

Airway difficulty

Problems:

·     Bloody

·     Swollen

·     Shared

·     Stomach full of blood

Assessment:

·     Hx: difficult intubation last time?

·     Ex: work of breathing, stridor, drooling?

Plan:

·     Two suckers

·     Two assistants

·     Direct laryngoscopy

·     South RAE ETT

·     Secure +++

·     Decompress stomach with orogastric tube prior to emergence

Hypovolaemia

Problems:

·     Bleeding

·     Dehydration

Assessment:

·     Hx: volume of blood, oral intake, wet nappies

·     Ex: behaviour, vital signs, CRT

·     Ix: FBE, VBG, coags, G&H vs XM

Plan:

·     2 x IVC + pump set

·     Forced air warmer

·     20mL/kg crystalloid pre-induction

·     Metaraminol 10mcg/kg PRN

·     Tranexamic acid 15mg/kg

·     NIBP q2mins

Bleeding

Timing of surgery:

·     If active and fast bleeding: surgery then resuscitation

·     If inactive or slow bleeding: resuscitation then surgery

Plan:

·     Substrate: rarely needed

·     Adjuncts: TXA 15mg/kg

·     Warming

Induction conflict

Problems:

·     Risk of aspiration -> want big dose

·     Risk of cardiovascular toxicity -> want little dose

Plan:

·     Crystalloid 20mL/kg pre-induction if time

·     Propofol 3mg/kg

·     Rocuronium 1.2mg/kg

·     Metaraminol 10mcg/kg q1min PRN

 

 

 

ALTERNATIVE PRESENTATION:

 

Paediatrics – post-tonsillectomy haemorrhage

 

Issues:

Airway

·     Bloody

·     Swollen

·     Shared

·     Stomach full of blood

Bleeding

·     Bleeding

·     Dehydration

·     Difficult IV access

 

Assessment:

Airway

·     Hx: difficulty last time?

·     Ex: distress? Stridor? Drooling?

Bleeding

·     Hx: volume of bleeding? Oral intake? Wet nappies?

·     Ex: behaviour, colour, warmth, vital signs, CRT

·     Ix: VBG, FBE

 

“how would you manage?”

 

Pre-op:

Usual things

·     Investigations: VBG, FBE, BGHO

·     Treatment: CSL 20mL/kg

·     Phone calls: second anaesthetist, ±blood bank

Paed things

·     Rapport/discussion/planning

·     ±Pre-medication: 0.25mg/kg midazolam close to theatre

·     Topicalisation

 

Intra-op:

Anaesthetic

·     Relaxant GA – prefer IV induction

o  Induction: mRSI, with cricoid, fent 2mcg/kg, prop 3mg/kg, sux 2mg/kg, metaraminol 10mcg/kg, fluid

o  Maintenance: sevo/nitrous 1 MAC

o  Emergence: suction stomach with orogastric, awake extubation

Airway

·     Two of everything: laryngoscopes (steel and video), RAE ETTs, suckers

Access

·     2 x PIVC, giving set with burette, fluid warmer

Probes

·     Standard (with NIBP q2mins) + temp

People

·     Second anaesthetist for drugs and fluids

·     Assistant for airway

·     Parent for child until just before induction

·     Tech to take parent out

·     Surgeon in room ready to operate

Pain

·     Multi-modal

 

 

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