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Paediatrics - Coggle Diagram
Paediatrics
Congenital Heard Disease
History
FHx of congenital HD
Syndrome with known association (Downs, VATER, Turners)
Squatting, parental report of cyanosis
Hx of cardiac failure - failure to thrive, difficulty feeding, chest infections, cough, poor ET
Examination
Cyanosis
Features of associated syndrome
Murmur
Innocent
Venous hum or early systolic, no precordial thrill, variation with posture
Pathological
Harsh, variable sound, precordial thrill, diastolic, pansystolic, rarely varies with posture
Signs of failure
Tachypnoea, accessory muscles, crackles on chest, cool peripheries, sweating, tachycardia, hepatomegaly
Irregular pulse
Abdominal distension - hepatic/splenic distention or ascities -> CCF
ASD
ECG findings
Prolongued PR
RBBB
L axis deviation if primum defect, R axis deviation if secundum defect
Increased P wave in II
Ix
CXR
Assess if pulmonary oedema
Cardiac MRI
3D structure of heart, valvular involvement, shunt volume
ECHO
Determines primum or secundum defect
Assess pulmonary HTN
Assess direction of shunt
Cardiac CT
3D structure of heart, chamber size
IE prophylaxis dental procedures
Do not give ABx
Do not give chlorhexidine mouthwash
Explain to patient/parents risk of prophylaxis outweighs potential benefits
Prompt treatment if infection does occur
Aware of increased risk of infection
Classification
Decreased pulmonary blood flow
Complex shunts
Increased pulmonary blood flow
LVOTO
Complications
Cardiac failure
Cyanosis
Arrhythmia
Pul HTN
PDA
Normally functionally closed by 12-24h, fully by 2-3w
Constant, machinery murmur
Associated with low birth weight, wide pulse pressure (>30mmHg)
Prostaglandins will keep duct open, COX inhibitors will close it
Fallot's
RV obstruction, RVH and VSD with overiding aorta
Commonly pul stenosis too
R-L shunt
Physiology
Oxygen requirements
Sustained high CO
High O2 requirement
Infant BMR 2x adult
Hb
Shift from HbF to HbA from birth to 6months
CVS
Neonatal heart has high collagen content and is more compliant
Heart starts as globular with even ventricle size, remodelling to adult ventricular ratios by 2y/o
CO changes by HR rather than SV
Thermoregulation
Limited ability to alter body temp/generate heat
Consider ways of minimising loss and maximising gain when required (theatre temp 25, monitor, transport appropriately)
Deleterious metabolic and physiological effects
Lose and gain heat easily (esp prems)
Hypoglycaemia (<2.5 mmol/l)
High glucose requiremetns due to BMR and increased non shivering thermogenesis
Consider IVF with 10% dextrose perioperatively and monitor glucose if surgery >1h
Limited by glycogen stores
Damaging to developing CNS
Pharmacokinetics
Distribution - high CO, reduced protein binding, high TBW, less developed BBB
Elimination - reduced metabolism due to less P450, reduced GFR and tubular function
Variable absorption
Pharmacodynamics
Opioids Rs - more sedated
NMDA Rs
nACh R is 3x more sensitive to depolarising agents
Implications
Always pharmacologically reverse
Care with opiate dosing
APGAR
Grimace
0 - absent, 1 - gimace/body movement, 2 - cough/sneeze/pull away
Activity
0 - absent, 1 - some flexion of edges, 2 - active movement
Pulse
0 - absent, 1 - <100, 2 - >100
Respiration
0 - absent, 1 - slow & irregular, 2 - good breathing + crying
Appearence
0 - pale/blue, 1 - pink body, blue edges, 2 - pink
Caudal Blocks
General
Injection of LA into caudal canal
Blocks L and S roots
Useful to supplement in GA and provide post op analgesia
Catheter technique can be used for continuous
Spread is beeter in children vs adults as epidural fat has a loose wide meshed structure
Anataomy
Sacrum is triangular bone that articulates with L5, coccyx and ilia
Dorsal roof is fused laminae of 5 sacral vertebrae andis convex
Hiatus covered by sacro-coccygeal membrane
Midline is median crest (sacral spinous processes)
S5 articular processes are remenants and form the cornua - landmark for sacral hiatus
Canal contains areolar connective tissue, fat, sacral nerves, lmyphatics, filum terminale and a venous plexus
Dura normally ends @ S2
Technique
Cornua are palpable either side of hiatus
Aseptic needle (22/20G) inserted slightly cranially through hiatus
Sacral hiatus is the point of triangle between it and two posteior sup iliac spines (dimples in skin)
Click felt on piercing the sacrococcygeal membrane
L lateral position with knees drawn to chest
Direct needle cranially, aspirate for -ve blood & -ve CSF
There should be little resistance to injection
LA choice
1ml/kg 0.25% L-bupiv -> upper abdo block
1.5ml/kg 0.25% L-bupiv -> mid thoracic block
0.5ml/kg 0.25% L-bupiv -> sacro-lumbar block
Contraindicaitons
Coagulation disorders
Progressive neurological disorders
Local infection
Pt/parent refusal
Autistic Spectrum Disorder
Definition
Condition affecting brain development. Impacting communication, social interaction and abstract thought, it's associated with reduced IQ in about half of cases
Clinical features
Communication
Language delay, avoidance of conversation, literal interpretation
Abstract thought
Inability to generalise information, unable to appreciate other's thoughts/knowledge/beliefs
Interaction
Lack of eye contact, reduced interaction, low understanding of social rules, intolerant of people entering their personal space
Behaviour
Routine, repetitive, rigid food preferences, specific interest for particular subjects or activities
Anaesthesia (dental)
Preoperatively
Play specialist/psychologists especially if special needs or specific fears
Maximise patient cooperation for induction
Premedication (incl topical LA for cannulation), consider antisialagogue
Plan strategies if uncooperative child, parental presence
Done on day of admission so careful questioning and explaination
Postoperatively
Manage nausea + swelling (Dex + Ondans)
Daycase - antiemesis and analgesia must be managed to facilitate early post op E&D and then discharge
May resist oral medication
Laryngospasm risk
Manage pain (NSAIDs + PCM)
Organisational
Available paeds equipment
Staff trained in paeds and resuscitation
Proper hospital setting & care as for other GAs
Facility for preop assessment in certain cases
Intraoperatively
Throat pack
Airway dislodgement risk
Blood in airway can cause laryngospasm
Head up causes reduced CO and cerebral perfusion
Small/shared airway
Anaesthetic challenges
Dislikes physical contact
Keep to a minimum
Topical LA may not be tolerated
Consider INH induction
Preop starvation affecting routine
1st on list, clear fluids 1h before operation
Dysphoric response to midazolam
?need for premed ?ketamine + midazolam
Language issues -> difficult comprehension
Use visual info, play specialist/psychologist to improve understanding
Inability to communicate likes/dislikes
Utilise parent's knowledge to anticipate problems, communication passport
Distress due to unfamiliar setting
Consider community pre-assessment, or in quiet area
Maximise familiarity and minimise disruption to routine (own clothes, toys, food etc)
Fluids
Intraop
Calculate and correct deficit
Fasting period, insensible losses
10ml/kg/h per body cavity, 5ml/kg/h for brain
Maintanence fluid - consider glucose for neonates and longer ops
Preop
Assess dehydration
Bolus 20ml/kg of NaCL/CSL
Postop
U&Es every 24h, glucose too
Daily weight, fluid input/output chart
Post op ileus
Assess status and ongoing losses
Maintanence - consider 2/3rd spost op
Maintanence
4-2-1 rule (4ml/kg for 10kg, then 2ml/kg next 10kg, then 1ml/kg for further kgs) gives hourly rate
Pain
Operations & Analgesia
Circumcisions
LA
Caudal epidural, penile, LA gel or ointment post op
Systemic
PO/IV PCM, PR/IV diclofenac, IV opiate
Hernia repair
LA
Ilioinguinal, regional block (TAP or caudal), laparoscopic - LA for ports
Systemic
PO/IV PCM, PR/IV diclofenac, IV opiate
Orchidopexy
LA
Caudal epidural, paravertebral, ilioinguinal and/or scrotal
Systemic
PO/IV PCM, PR/IV diclofenac, PO/OV opiate
Tonsillectomy
Postop can be severe and last 5-10 days
Systemic
PO/IV PCM, PR/IV diclofenac, dexamethasone, IV & PO opiate
Surgical technique ?co-ablation
Ortho lower limb
LA
Peripheral nerve blocks, continuous nerve block, epidural blocks
Systemic
PCM and NSAID to reduce opioid
Appendicectomy
LA
LA to port sites, TAP block
Systemic
PO/IV PCM, PR/IV diclofenac, IV and oral opiate, ?PCA
Assessment
QUESTT
Evaluate behaviour and physiological changes
Secure parents involvement
Use pain scale
Take casue of pain into account
Question child
Take action and evaluate results
Rating Scales
Numeric
Behavioural
Faces
Behavioural/physiological
Treatment
Simple measures
NSAIDs
Ibuprofen max dose 30mg/kg/d, diclofenac max 3mg/kg/d
Consider even in atopic child
Only after 3months
Synergy of above for need vs dosing
PCM
Loading 20mg/kg orally, rectal varies
Under 10kg - max dose 30mg/d, over 10kg max dose 60mg/d
IV Neonate 32w corrected and above 7.5mg/kg every 8h, Neonate 10mg/kg 4-6hly (max 30mg/kg), Child up to 10kg 10mg/kg 4-6h (max 30mg/kg)
Peripheral LA blocks
Sucrose 20% (babies) for short procedures
Moderate/severe
Avoid codeine - some extensive metabolisers
Oramorph 0.2-0.4mg/kg 2-4hly, reduced dose in OSA
IV opiates
Fentanyl 0.5-1mcg/kg
Morphine 0.1mg/kg and titrate
PCA - dependent on child and parents
1mg/kg in 50ml 1ml is 20mcg/kg
RA
SEs
Motor block, retention, catheter issues
Ilioinguinal Block
Iliohgypogastric and ilioinguinal nerve from L1/2
US from ASIS to umbilicus slide up & down
Nerves lie between internal oblique and transverses abdominus
Meningococcal Sepitcaemia
Features
Non specific
Fever, nausea, vomiting, lethargy, irritable, muscle ache, respiratory Sx, DiB, shivering, rapidly worsening
More specific
Non blanching rash, CR >2s, shock, hypotension, cold hands & feet, toxic state, unconsciousness
Initial Mx
Senior help + ceftriaxone 80mg/kg IV
A - consider need for immediate intubation of resp issue or moribund
B - RR, sats, give 100% O2
C - IV access (IO if needed) - assess for shock (CR > 2s, tachy +/- hypotension, toxic state, low u/o, cold hands & feet, reduced GCS)
Treat shock with 20ml/kg of 4.5% HAS or 0.9% NaCl over 5-10min x 3
After 3rd bolus intubate & ventilate (cardiostable induction - ketamine 2mg/kg + rocuronium 1mg/kg)
Consider blood for further boli, vasoactives as per retrival team advice
Contact paeds retrival service
D - Monitor GCS + need for intubation. Glucose
Ix
Electrolytes
CRP - can be raised or normal
Glucose - hypoglycaemia due to infection + resuscitation
ABG - need for intubation or adequacy of ventilation
Coag screen - Mx DIC
Neisseria meningitidis - whole blood PCR, if -ve CSF test for N.meningitidis and strep pnumoniae PCR
FBC - check platelets (may stop LP)
Blood culture
CSF - PCR or culture
CT head - may give DDx or contraindicate LP if signs of raised ICP
Paeds Daycase
Cancellation consequence
Issues with non resolution of Sx
Wasted parental time & financial los
Waste of school time
Loss of trust between child/parent and hospital
Inefficient list use
Social factors needed
Private transport
Distance <1h to hospital
Good housing conditions
Telephone communications
No one able/willing to care for child post op
Cancellation (day case)
History
Loss of appetite
SoB, sore throat, cough, sputum
Unwell in self (too unwell for school etc)
Significant comorbidities (OSA/cardiac/severe asthma)
Fever >38
Examination
Purulent nasal discharge
Creps on chest
Tachypnoea
Tachycardia
Listless, unwell
Delayed CR
Fever
Normal parameters
Weight
(3 x age) + 7
MAP
(1.5 x age) + 55
SBP
80+agex2
NAI
Types of suspicious injury
Bite marks
Injury to inaccessible place (neck, ears, feet, buttocks)
Cigarette/thermal injuries
Ano-gential trauma
Unusual/excessive bruising
Trauma without adequate history
Actions
Inform
Anaesthetic consultant on call/Paeds team/Safeguarding team/Theatre team
Paeds teview of injuries
Check notes for safeguarding issues
Fully document finidings and actions
Respect right to confidentiality if applicable
Consultant discussion with family after procedure
Act in child's best interests
Risk of abuse
Parent related factors
Parent previously abused
Disabled parent
Substance abuse
MH issues
Teenage parents
DV
Step-parents
Single parent
Poverty
Child related factors
Prematurity or low birth weight
Unplanned/unwanted child
Chronic disability
Major Haemorrhage
80ml/kg/24h
Trauma 1:1, non trauma 2:1 (blood to FFP)
3ml/kg/min
Prems
Apnoea
Hypopnoea also common (assoc with brady and desat)
Risk factors with anaesthesia
Gestational age (esp <34w)
PGA (esp if <56w)
Anaemia
Central/obstructive or both
Resp pause >20s or pause with brady/desat
Anaesthetic Mx
Nasal CPAP
Intubation
Stimulate/open airway/mask ventilate
Caffeine prophylaxis
Avoid GA
Monitor
Low glucose, hyper/hypothermia and low ionised Ca all associated
Day surgeries
44-60w PGA - term babies only may be suitable
<44w PGA - all babies unsuitable for daycare
Over 60w PGA - all suitable for daycare
Note: if prem and <60w PGA assume overnight monitoring required
Perioperative checklist
D
Avoid big swings in CO2, low BP
E
Eyes - ROP (avoid high O2)
C
?PDA & R-L shunt, measure and maintain BP
F
Fluid - Na losers, post op feeding
B
RDS - consider O2 requirements, restrict pressures, look @ CXR
G
Glucose
A
Airway is small and very short
H
Hypothermia and haematocrit
Difficult Intubation
Hypoplastic mandible
Treacher Collins
Hemifacial microsomia
Pierre-Robin
Mid-face hypoplasia
Apert's
Hemifacial microsomia
Macroglossia
Down's
Glycogen storage dissorders (Hurler's, Hunter's)
Down's Syndrome
Features
C
Pulmonary HTN
Risk of conduction defects following congenital lesion repairs
Congential HD - atrioventricular canal defects, ASDs, VSDs, PDAs, tetralogy of Fallot
Valvular issues in adulthood - mitral valve prolarpse, AR
A & B
Subglottic/tracheal stenosis - consider smaller tube
Cervical ankylosis (Kippel-Feil) - limited neck movement
Atlanto-axial instability - care with neck manipulation (extension)
OSA due to (macroglossia, narrow midface, oropharyngeal hypotonia, micrognathia, small mouth) - difficult FMV
Predisposition to LRTIs due to hypotonia, GORD and reduced immunity
D
Hypotonia - careful positioning
Epilepsy
Intillectual impairment
Postop agitation
Reduced MAC requirement
Increased sensitivity to sedatives and anaesthetics
Anaesthetic Mx
Intraoperative
C - Difficult access, prone to bradys after induction, avoid hypotension
D - careful positioning (especially hyperextension of neck). Avoid longacting opioids & consider lower MAC
A - intubate, ?RSI. Range of tube sizes. Difficult intubation trolley. Guedel may be needed for FMV
Infection - ensure full asepsis + prophylactic ABx cover
Ensure carer comes to theatre +/- play specialist
Postoperative
Pain - avoid long acting opiates - carer need to be aware of childs needs etc
Monitor for post op infection (esp LRTI)
Risk of postoperative agitation - prolonged recovery stay and higher level of postop care may be required
Monitor for signs of SC compromise (due to positioning or hypotension)
Risk of OSA - may need CPAP, overnight sats and close nurse monitoring
Preoperative
C - assess exercise capacity and r/v Hx of defects +/- repairs. Right heart strain on ECG - ?pul HTN (ST depression & TWI in right leads - V1-3 [+ II, III, aVF inferior leads]
Endo - TFTs and glucose
B - assess for OSA (especially if ENT), assess for LRTI. Consider antisialagogue (atropine)
GI - ?GORD - premed with PPI and plan for RSI
Airway - assess for difficulties associated with Downs - ?radiological cspine assessment if A-A instability is likely
Full patient assessment with carers - appropriate consent to patients understanding. Visit to ward to meet staff & familiarise with environment
Potential communication difficulties - play specialist etc
Cerebral Palsy
Definition
Permanent damage to brain in utero, at birth or very early infancy
Primarily affecting motor function but can impact cognition, sensation or communication
Increased risk of epilepsy
Very variable presentation
Clinical Effects
CNS
Epilepsy
Ensure medications continues and levels correct. Caution with enzyme inducers and inhibitors
Cognition/communication issues
Increased anxiety, involve carers and play specialists, consider anxiolytic
GI
TMJ dislocation
Possible difficult intubation. Asleep FOI or videolaryngoscope
Poor dentition
Can complicate airway Mx
Swallowing difficulties
Reflux risk - ?RSI
Poor nutrition, low weight, dehydration, difficulty with oral medications
Resp
Weak cough & resp muscle
Increased risk of post op infection
Long term truncal spasticity -> scoliosis
Restrictive defect, pul HTN, cardiac failure
Chronic lung disease (prem and GORD)
Assess for LRTI, may need LTOT or CPAP
MSK
Spasticity causes fixed flexion deformities
Cannulation, monitoring, positioning issues
Thin skin & low SC fat
Pressure sores, poor wound healing, need careful padding and active warming
Immobility
Difficult to assess exercise tolerence
Non WB bones - osteopenia
Fracture risk
Prematurity (30/40 @ 12w for hernia repair)
Perioperative concerns
Metabolic
Risk of hypothermia due to high SA/volume ratio and low brown fat stores
C
Increased risk of congential defects, incl PDA
Difficult access (numerous prev cannulations)
GI
Reflux is common due to under developed G-O sphincter
D
Risk of intraventricular haemorrhage
Can lead to CP or hydrocephalus
B
Bronchopul dysplasia - reduced lung compliance and greater O2 requirement
Apnoeas (obstructive, central or mixed)
Anaesthetic agents increase this
Respiratory failure - can only increase RR to increase MV
Endo
Reduced glycogen stores + starvation
Hypoglycaemia
A
Complications of previous prolonged intubation (tracheomalacia or subglottic stenosis)
Pharm
Altered renal an hepatic function -> drug elimination changes
Anaesthetic options
Spinal
Caudal analgesia in addition
Caudal
Rarely used alone due to short duration
GA
RSI or standard intubation
Gas induction can reduce desaturation risk vs IV induction
PPV can help reduce fatigue
Caudal analgesia or local infil by surgeons can reduce opioid requirements
Advantages
Better operating conditions than suboptimal RA
Avoids sedatives without airway secured
Disadvantages
Should be avoided if baby is O2 dependent due to lung disease
No post op analgesia
Increased desaturation period risk
?Increase inb post op apnoeas
Possible airway difficulties
Excessive PPV can caused R-L shunt worsen or barotrauma
Pyloric Stenosis
Most common congenital obstruction
Features
Vomit is not bile stained
Causes hypertrophy and hyperplasia of antrum of stomach
M:F ratio - 5:1
Hyponatraemia, hypokalaemia, hypochloraemic metabolic alkalosis
Projectile vomiting 3-6w
Westley Croup score
Over 6 is severe croup
Scores
Cyanosis 0-5
GCS 0-5
Stridor 0-2
Auscultation 0-2
Chest wall retractions 0-3
Airways
Upper
Neonates and small infants
Nose breathers until about 6 months
Long floppy epiglottis
Small midface
Anterior 'high' larynx (C2/3 vs C4/5 in adults)
Large occiput
Airway narrowest @ cricoid cartilage
Friable mucosal tissues - easy oedema generation
Lower
Infants
Short trachea
Diaphragm is main resp muscle
Small airways
Very compliant rib cage
Airway anatomy
<3 yrs
Pliant sub-mental tissue + large tongue
Easy obstruction by digital pressure (ensure fingers on bony surfaces)
Short trachea
High incidence of endobronchial intubation
Check with auscultation
Long floppy epiglottis, anterior larynx
Difficult laryngoscopy - consider straight blade or McCoy blade
Absence of teeth
Difficult FMV
Guedel or other adjunct
Narrow trachea
Recued flow (r^4) from any trauma or oedema - careful handling & tube size choice
Large head with prominent occiput
Tendency to flex head
Ensure neutral head position
Airway narrowest @ cricoid, not VCs
Cricoid is a non compliant ring so tube can cause pressure damage
Uncuffed tube (and ascertain leak) or high volume, low pressure cuffs