PS29 2019: Paediatric anaesthesia

 

List:

·         Definitions

·         Can I anaesthetise this child?

·         Should I anaesthetise this child?

·         Disaster plans

·         Environment

·         Staff

·         Equipment

·         Drug safety

·         Suitability for day procedures

 

tl;dr

Q: “Do I have the necessary knowledge, skills and assistance to care for this child and manage any complications that might arise in the context of this health facility?”

A: I’m uneasy, and it’s not that urgent -> transfer

A: I’m uneasy, but it’s desperately urgent -> have a crack, son! (T&C apply)

 

Premise:

·         Most paed anaesthesia is conducted outside tertiary centres

 

Definitions:

Age brackets

·      Premature: born <37/40

·      Neonate: <4/52

·      Infant: 1-12/12

Age before birth

·      Gestational age = time since first day of last period

Age after birth

·      Chronological age = time since birth

·      Corrected age = time since birth minus number of weeks premature (until 2y)

·      Post-menstrual age (PMA) = time since first day of last period (use this one)

·      Post-conceptual age = time since sperm met egg. Rarely used.

 

https://pediatrics.aappublications.org/content/114/5/1362

 

Can I anaesthetise this child?

Age “cut-off”

(not really)

·      If >2y, fairly healthy, moderate complexity operation: all FANZCAs

·      Otherwise: need “additional education and training”

Obligations

·      Must have adequate training, knowledge, skills and currency of practice

·      Must understand intra-op and post-op requirements

·      Must understand intra-op and post-op risks

·      Must be trained in paed ALS

·      Must attend to CPD

·      Must know legal rules for consent, rights, child protection

·      Must have Police Check and Working With Children Check

Maintenance of competence

·      Regular paed caseload

·      Visits to paed centres

·      Simulation

·      Courses

·      Conferences

·      *Regional centres should support the above*

 

Should I anaesthetise this child?

Factors

·      Patient: age, comorbidity

·      Surgery: type, urgency

·      Surgeon: training, knowledge, skill, currency of practice

·      Anaesthetist: as above (N.B. hospital is responsible for credentialing us)

·      Anaesthesia assistant: capable and willing

·      Hospital: staffing, equipment, peri-op services

Consider sending to RCH if

·      Age group: <1

·      Operations: cardiac, thoracic, neuro

·      Post-op requirements: ICU stay, complex pain management

·      Patient: ASA3+, ex-prem, congenital heart disease, significant congenital abnormalities, significant cardiorespiratory disease

Wiggle room

·      Age cut-off may be different for emergency cf. elective surgery

·      Age is not the only factor (e.g. neonatal hernias done at La Trobe, Bendigo)

Children needing urgent surgery must not be neglected

·      Seek expert advice

·      Use local protocols

·      Use available resources

 

Disaster plans

Systems for seeking advice

·      Paediatric anaesthetist

·      Paediatrician

·      Paed allied health

Systems for transfer

·      Clinical triggers

·      Referral

·      Transport

Systems for emergency care

·      Paed MET call

·      Paed trauma

·      Neonatal code blue (if obstetric hospital)

 

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 trained in paed ALS in the theatre complex)

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 to oversee all this stuff

 

Equipment

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

Ultrasound

·       

Emergency

·      Drugs

·      Equipment

·      Defibrillator + pads

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

 

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

 

Suitability for day procedure:

Age limit determinants

·      Patient: ASA 1-2, ASA3 if stable and minor surgery

·      Operation

·      Facilities

Post-op apnoea cut-off

·      Ex-preterm infants: ok if PMA >54/40 and healthy

·      Term infants: ok if PMA >46/40 and healthy

Discuss with parents! (GAS study?)

Post-op apnoea considerations

·      Watch out with opioids

·      Give limited prescription

·      Educate parents

·      Follow up with GP

Logistics

·      Must have clear discharge criteria

·      Must provide clear discharge advice including when to return

·      Must go home in a car with two adults

·      Must have a pathway for failed discharge, including transfer

 

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