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:
Airway |
· Bloody · Swollen · Shared · Stomach full of blood |
Bleeding |
· Bleeding · Dehydration · Difficult IV access |
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?”
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 |
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 |
Feedback welcome at ketaminenightmares@gmail.com