Herlien H.

Megawe
Dept. of Anesthesiology & Reanimation
Airlangga University School of Medicine
Surabaya

o matter what time it is, wake me up,

in the middle of a cabinet meeting
Ronald Reagan

I.

BASIC PRINCIPLES :
a.

Urgency of childs problem

b.

Ordering of priorities (e.g. epidural hematoma, closed femoral fractu

c.

Critically ill and profound hypotensive condition, an immediate opera

needed resuscitation & anesthesia are provided simultaneously

d.

Establish : - clear airway

- provide ventilation
- support hemodynamics : C

e.

Hypnosis & analgesia, as condition will allow

f.

Titrated doses of : - Hypnotics (Benzodiazepine, for amnesia Ketamin

- Opioids for pain
- Neuromuscular blocking agent for immobility

g.

As patient stabilizes, inhalation agent are added as tolerated

:A
:B

II. RAPID CLINICAL ASSESSMENT OF THE SERIOUSLY ILL INFANT/CHILD

A = AIRWAY : - Obstruction
- Partial
- Total

B = BREATHING : - Respiratory rate

- Flare
- Recession : - sternal
- intercostal
- subcostal
C = CIRCULATION : - Pulse : volume
- Silent chest
- Blood pressure
- Capillary refill time
- EKG
- Skin colour :
- dry, red, warm
- greyish, cold, wet, clammy
D = DISABILITY :
-

- Unresponsive to voice/pain
Posture
Pupils : size/reaction
Conscious level
Convulsions

E = EXPOSSURE :
- Rash
- Purpura
- Swelling
- Urticaria
- Fever
- Angio-edema

 ASSESSMENT OF PROGRESS AND DETECTION OF

DETERIORATION :
Re-assessment of ABCDE at frequent intervals
LEVEL OF CONSCIOUSNESS SHOULD BE RECORDED
USING
THE AVPU SCALE :
A : Alert
V : Responds to voice
* P : Responds to pain (GCS < 8)
U : Unresponsive
* Pinching a digit, pulling frontal hair

III. PATHWAYS LEADING TO CARDIO. RESPIRATORY

ARREST :
FLUID
LOSS

LOSS
MALDISTRIBUTION

RESPIRATORY
DISTRESS

RESPIRATORY
DEPRESSION

BLOOD LOSS

SEPTIC SHOCK

FOREIGN BODY

CONVULSIONS

GASTROENTERITIS

CARDIAC DISEASE

CROUP

RAISED ICP

BURN

ANAPHYLAXIS

ASTHMA

POISONING

CIRCULATORY
FAILURE

CARDIAC ARREST

RESPIRATORY
FAILURE

Indication for intubation and ventilation :

Inadequate oxygenation via bag-and-mask technique
Prolonged ventilation required
Flail chest
Inhalational burn injury
Shock

VASCULAR ACCESS
Preferred options :
A. Intra venous
B. Intra osseous
A. Preferable via the superior v. cava
Via the inferior v. cava takes longer to reach the heart
Via the periph. route fluid flush
First priority : accurate
safety
rapidly
B. Intra osseous :
- Easy & safe
- Reach the heart = periph. ven. access
- Also in older age & adults
C. Tracheal :
Third place
For first drug adrenaline
D. Intracardiac : not recommended

IV. RESUSCITATION BEFORE ANESTHESIA

Weight in kg = 2 (age in years + 4)
Estimated blood volume = 80 ml/kg body weight
Crystalloid
20 ml/kg
Assess
response

Colloid
20 ml/kg
Assess
response

Fluid volume and type

An initial fluid bolus of 20 ml/kg is given as fast
as possible
This should be repeated after assessment if there
is no improvement in vital signs

Blood
Urgent
Surgical opinion

The most common mistake in the treatment of

hypovolaemic shocked children is failure to give
enough fluid

V.

OTHER VITAL PROCEDURES CARRIED OUT BEFORE

RESUSCITATION AND ANESTHESIA :
HISTORY :
Vomit (quantity & quality)
Last urination/defaecation)
Bloody stool/profuse
BLOOD TESTS (taken immediately after venous access)
NASOGASTRIC TUBE PLACEMENT
RADIOGRAPHS

VI. PLAN

1. Weight (kg) = 2 (year + 4) kg

2. Estimated Blood Volume : 80 ml/kg
3. Internal diameter endotracheal tube :
Year + 4 = one size smaller, actual size, one size bigger, e.g.
4
4
4,5
5
4. Fluid bolus : 20mg/kg
- Crystalloid
(Colloid)
- Blood
5. Defibrill. Dose I : 2 Joule/kg
2 Joule/kg
in 90 seconds
4 Joule/kg
Defibrill. Dose II : 4 Joule/kg
4 Joule/kg
in 90 seconds
4 Joule/kg
6. Between defibrill. dose I and II :
Adrenalin dose I : 1 ml/10.000 sol. (10 Ug/kg)
Adrenalin dose II : 1 ml/1000 sol. (100 Ug/kg)

VII. PREMEDICATION, ANXIETY & FEAR

I.V. anticholinergics benefits :

1. Maintenance of cardiac output by increasing heart r
2. Prevention of reflex bradycardia :
Airway manipulation
Scoline/halothane
ANXIETY & FEAR
Calm appearance
Reassuring

Of the anesthesiologist is of great

benefit for patients & parents

VIII. URGENT SITUATION WITH COMPROMISED AIRWAY

Foreign body aspiration

Epiglottitis
Croup
Bleeding tonsil
Facial/laryngeal trauma
Compromised airway & struggle during intubation attempt,
choices are :
Awake intubation
Volatile agent (Sevoflurane/Halothane) in oxygen with gent
cricoid pressure
This approach is favoured = The patient continues
breathing !
Slight head down position : pulmonary aspiration is less like
when patient regurgigates

FULL STOMACH

Postpone surgery for > 4 hours

Reduce the mean gastric residual volume by 50% (does not
guarantee empty)
If there is no specific airway for difficult intubation
Anesthesia of choice : rapid sequence of induction
Pre-oxygenation + sulfas atropine
Rapid induction agent :
- Ketamine
- Propofol
- Thiopenthal
Muscle relaxant = Recuronium 1,2 mg/kg
The smaller the child, the more rapid he will desaturate (< F
Newborns can become hypoxic in less than 1 minute
Difficult to pre-oxygenate & denitrogenate a struggling toddler

HYPOVOLEMIA
Ongoing bloodloss
Pending blood availability

5% Albumine

Type specific un-crossmatched low incidence of

transfusion reaction
Ketamine : induction agent of choice in small
dosis 1 2 mg/kg I.V. (within one minute)
Atropine 0,02 mg/kg or scopolamine 0,01 mg/kg
administered before

IX. PAIN MANAGEMENT

Injured children are in pain on arrival
Potentially hypovolemic : Fentanyl preferable
Must be titrated in small increments (0,5 1,0 Ug/kg) to avoid
chestwall or glottic rigidity
Unstable & neurologic dysfunction : opioids with caution
Regional nerve blocks =

- femoral nerve

- axillary
Providing analgesia
As a primary anesthetic
(avoid risks of general anesth. = aspiration)
Supplement for postop analgesia

CAUTIONS
Titrate sedative in small increments to avoid loss
of airway reflexes
Appear alert & Sedation sleepy
After the block : painfull stimuli is removed
Close communication with surgeons = ability to
perform sensory and motor examinations

X. SPECIAL PROBLEMS & MANAGEMENT

A. AIRWAY

Acute airway obstruction :

Inspiratory stridor
Tachypnoea
Sternal & intercostal retractions
Agitation (due to hypoxia)
Cyanosis
Tachycardia
Few of these symptoms & signs are manifested, yet their
condition may rapidly become life-threatening
Initial respons :
O2 & calm, to prevent dynamic collapse of the airway associated with agitat
- Not cyanotic
X-ray is helpful clarifying the cause of obstruction
- Sable vital signs
- Upright position
- Supine position further airway obstruction
Blood gas analysis is not vital
PaO2 = 80 torr ; or
does not alter the response of the anesthesiologist
PaO2 = 60 torr
In Contrast : pulse oxymetry
Non-invasive
Immediate & continuous means for assessing oxygenation
Recommended as a modality in all airway emergencies

B. UPPER AIRWAY OBSTRUCTION

1. Epiglotitis

Skill
Essential for the anesthesiologist
Knowledge
Urgent diagnosis & treatment
Additional signs :
- drooling
- difficulty in swallowing
Favoured approach worldwide : Endotracheal intubation
Avoid = inspection increase obstruction (dynamic airway collapse
Radiographic = - Only when stable
- Skilled personnel
- Adequate resuscitation equipment
In the operationg room :
Calm, sitting on the lap o/t mother
Induction overface :
- Halothane
- Sevoflurane
Looses consciousness supine
Head up slightly

 Intubation tehnique
Lifting the base of the tongue
Without touching the epiglottis
Exposure of the rimaglottidis
Partially obstructed orifice
0,5 mm ID smaller choosen sprayed beforehand
A stylet within the endotracheal tube
Failure : - tracheostomy
- cricothyorotomy
Adequate sedation to prevent extubation
* Titrated opioids
- Breathe spontanneously
- ETT remains in place for 24 48 hours, until swelling decreased
- Extubation

2. Foreign body aspiration

History of choking
While eating suspicious
Cyanosis

(peanut, popcorn)
A wheezing child :
Not always asthmatic
May be foreign body aspiration
Agitation : due to seriously underlying hypoxemia
Radiographic examination
If the child is stable
Helpful to localize & identify
Mostly are not radiopaque
Hyperinflation
Clues of presence of foreign body
Atelectasis
Principle of anesthetic management = epiglottitis

C. LOWER AIRWAY OBSTRUCTION

1. Bronchiolitis

Tachypnea
Retractions
Wheezing
Hyperinflated chest & diffuse crepitations
Progressive exhaustion hypercarbia respiratory failure (silent ches
Focus of treatment = correct hypoxemia
Pulse oxymetry :
- degree of hypoxemia
- respons to therapy
Nebulized mist
Not proven beneficial
Bronchodilators
Titrated I.V, fluids not able to drink
Ribavirin : antiviral agent
Caution : Particles tend to disk, obstructing the ventilator
No absolute PaCO2 value that dictates the course of action

2. Asthma, status asthmaticus

A cardinal feature : reversibility spontaneuous or with therapy

Wheezing sinonymous with bronchospasm
Predominant expir. wheezing
With increasing fatique slight air movement wheezing no
longer audible

Management :
a. Support oxygenation
b. Reduce airway obstruction
c. Support ventilation
d. Prevent complication (e.g. pneumothorax)
e. Inhaled & I.V. drugs

Anesthesia :
Optimize oxygenation, control brochospasm
Standard agents
Ketamine : - Bronchodilating
- Hypersecretion
Avoid histamine release agents :
- Morphine
No sciencetific data yet
- Curare
- Thiopental
Drying of secretions intra-operatively :
- Atropine
- Glycopyrrolate
May exacerbate mucous plugging post-operatively
Wheezing during anesthesia mechanical problem :
- endobronchial intubation
- plugging, kinking
- cuff herniation
Mechanical ventilation is difficult
High Airway Pressure:
- air trapping
- pneumomediastinum
- pneumothorax
Controlled mechanical ventilation:
- Degree of hypercarbia is pernitted/acc
- Adequate oxygenation
- Adequate cardiac output

CIRCULATION :
1. Hypovolemia : Most common cause of shock

Crystalloid solutions are effective

No scientific studies of superiority of colloid solutions

Blood as soon as crossmatching is carried out, or

O neg.
Urgent
Type spec. uncrossmatched

XI. OPERATING ROOM MANAGEMENT

1. Acute blood loss

Secure large bore venous access is of higher priority than arterial a
Arterial catheters in :
Arterial blood gas for adequate ventilation
Frequent blood sampling : metabolic derangements
Hemodynamic instability
Need to alter blood pressure rapidly
Central venous access, only when hemodynamic stability returns
Body temperature, hypothermia :
Potentiates neuromuscular blockade
Exacerbates coagulopathy

2. Anesthesiologists vigilance continued : until care is transferre

to the appropriate physicians and nurses