PS29 2019: Paediatric anaesthesia

 

List:

·        Intro

·        Decision making

·        Requirements

 

INTRO

 

Premise:

·        Most paediatric anaesthesia is done outside tertiary centres

·        It is often unclear whether risk of proceeding outweighs the risk of delay

 

Definitions:

Age brackets

·      Premature: born <37/40

·      Neonate: <4/52

·      Infant: 1-12/12

Age measurement

·      Gestational age: time since first day of last period (in utero)

·      Post-menstrual age: time since first day of last period (after birth)

·      Post-conceptual age: time since fertilisation (rarely used)

·      Chronological age: time since actual birth

·      Corrected age: time since hypothetical birth at 40 weeks

(applies to premature children until 2 years old)

 

 

DECISION MAKING

 

Can I anaesthetise this child?

Age cut-off

General rules:

·      >2yo and healthy: all FANZCAs

·      1-2yo: paed fellowship

·      <1yo: paed full time

Considerations:

·      General health

·      Complexity of surgery

Knowledge

·      Trained in paed anaesthesia, paed ALS

·      Understand peri-op needs

·      Understand peri-op risks

·      Understand legal rules for consent, rights, child protection

·      Valid Police Check and Working With Children Check

Skills

·      Regular paediatric caseload

·      Visits to paediatric centres

·      Simulation

·      Courses

·      Conferences

·      *Regional centres should support the above*

 

Should I anaesthetise this child?

Patient

·      Age (N.B. neonates undergo herniorraphy in Bendigo, La Trobe)

·      Comorbidity

Surgery

·      Organ system (i.e. not cardiac, thoracic, neuro)

·      Urgency

·      Post-op requirements (i.e. not severe pain, not ICU)

Hospital

·      Paed specialist

·      Paed ward

·      Paed equipment

Assistant

·      Capable

·      Willing

Surgeon

·      Training / knowledge / skills

·      Currency of practice

 

Post-op apnoea (major consideration for day surgery)

Risk factors

Youth and prematurity:

·      Term: <46 weeks

·      Prem: <54-60 weeks (∝ degree of prematurity)

Other stressors:

·      Opioid

·      Anaemia

·      Hypothermia

·      Stress response

·      Pain

·      Lung disease

Apnoea monitoring

·      Continuous SpO2

·      Continuous ECG 3-lead

·      Alarms set properly

·      For 12 apnoea-free hours (N.B. most are in the first 2 hours)

Discharge plan

·      Clear discharge criteria

·      Two adults in the car

·      Return advice

·      Pathway for failed discharge

 

 

REQUIREMENTS

 

Environment:

Pre-op area

·      Caters for children (e.g. toys)

Induction room

·      Non-threatening

·      Space for a parent

Recovery

·      Separate from adult patients

·      Enough room for parent in each bay

·      Easy access for parents in and out

Ward

·      Space for a parent to sleep overnight

 

Staff:

Operating room

·      Paed anasthetist present throughout (and two if it’s tricky)

·      Paed anaesthetic assistant available throughout

·      Nurses in the theatre complex are trained in paed ALS

Recovery

·      Nurses trained in paed ALS and with experience

·      1:1 ratio until awake + airway safe + normal vital signs

·      2:1 ratio if complex or unstable

Anaesthesia department

·      Paed anaesthesia clinical lead

 

Equipment: appropriately sized…

Airway

·      Bag+mask

·      OPA and NPA

·      LMA

·      ETT

·      Laryngoscope

·      Suckers

Breathing systems

·      T piece

·      Bain

·      Ventilator with age-appropriate settings

Monitoring

·      Sat probes

·      BP cuffs

·      Invasive BP monitoring

Temperature

·      Thermometers

·      Forced air warmer

·      Fluid warmer

IV equipment

·      IVC

·      IO

·      Giving sets with graduated burettes

Drugs

·      Paed TCI pump

·      Paed concentrations of oral meds

Emergency

·      Drugs

·      Equipment

·      Defibrillator + pads

(I don’t think this is an exhaustive list)

 

Disaster plans:

Seeking advice

·      Paediatric anaesthetist

·      Paediatrician

Transfer

·      Clinical triggers

·      Referral

·      Transport

Emergency care

·      Paed MET call

·      Paed trauma

·      Neonatal code blue (if obstetric hospital)

 

Drug safety:

·        Record and display weight

·        Guidelines for IV fluids

·        Guidelines for post-op analgesic assessment

·        Guidelines for post-op analgesic drugs

·        Systems to minimize drug errors

·        Systems to report drug errors

·        Pharmacist with paed knowledge

 

 

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