Paediatric!&!Obstetric! Anaesthesia!

66 Pages·2015·2.6 MB·English

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Report to SAFE Project Operational Grou! p
Title: Membership and terms of reference
Paediatric!&!Obstetric!
Author: Karin Pappenheim

Anaesthesia!
Below is the list of proposed members of the SAFE Project Board and the draft terms of
reference, for discussion.
Pocket'Handbook'

SAFE project board: Terms of reference !
Introduction
'
SAFE is an initiative of the AAGBI and WFSA which aims to provide education and training in
anaesthesia to lower resource countries. The AAGBI’s primary focus is on delivery o'f the programme
in Africa; WFSA’s focus is on expanding the programme to other regions.
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This is a multi year project (see concept note). The role of the project board will be to formulate
strategy and to oversee the operational delivery of th!e programme.
Membership !
Chairman of IRC and one other IRC member: Rachel Collis, Paul Clyburn '
Vice President (international focus): Isabeau Walker
Maytinee'Lilaonitkul!'!
Project leads for SAFE topics and in country: James Leedham, David Snell, Maytinee Lilaonitkul,
Nick'Boyd''
Michelle White. Mike Dobson? Iain Wilson?
WFSA and AAGBI senior staff: Julian Gore-Booth an!d Karin Pappenheim
AAGBI secretariat staff in attendance (minutes and admin support)
Frequency of meetings
2-4 meetings per year
Teleconference or video conference preferred
Remit
Formulating future development strategy including target countries and regions
Planning and overseeing programme delivery
Development of learning resources
Securing resources
QA, evaluation and improvement
Communications: internal and external
Reporting to:
Boards of AAGBI and WFSA as necessary.

KP, 9 October 2014
Paediatric!Quick!Reference!
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Normal!Physiology!ranges:!
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Age! Respiratory! Heart!! Normal! Lowest!
rate!! rate! Systolic! Systolic!!
(per'min)' (per'min)'' BP! BP!
(mmHg)! (mmHg)!!
<!1!yr! 30=40' 110=160' 80=90' 65=75'
1–2!yr! 25=35' 100=150' 85=95' 70=75'
2–5!yr! 25=30' 95=140' 85=100' 70=80'
5–12!yr! 20=25' 80=120' 90=100' 80=90'
>12!yr! 15=20' 60=100' 100=120' 90=105'
!
Weight!estimation:!
(only!to!be!used!if!weighing!the!child!is!not!possible)!
! !
Birth' 3'–'3.5'kg'
6'months' 7.5'kg'
1'year' 10'kg'
Over!1!year' (Age!in!years!+!4)!x!2'
Above&10&years&this&formula&may&underestimate&weight&
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Emergency!drugs!and!equipment:!
! !
ETT!size!(mm)' (Age!÷!4)!+!4.5!
ETT!length!(cm)' ETT!size!x!3!
Fluid!bolus! 10!–!20!ml/kg!
Adrenaline!! 10!mcg/kg!IV!
(in'cardiac'arrest)! 0.1'ml/kg'of'1:10,000'
10%!glucose!bolus! 2!ml/kg!
Atropine! 20!mcg/kg!IV!
Suxamethonium! 2!mg/kg!IV!
4!mg/kg'IM!
Defibrillation! 4!J/kg!
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1'
Foreword!
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Safer'Anaesthesia'From'Education'(SAFE)'obstetric'and'paediatric'
courses'have'been'developed'for'anaesthesia'providers'in'low'
resource'settings.'This'pocket'handbook'is'designed'to'accompany'
the'SAFE'courses'and'to'be'used'in'clinical'practice.'The'aim'is'to'
provide'a'quick'reference'guide'for'essential'information'and'
includes' drug' doses,' important' calculations' and' management'
protocols.'The'SAFE'courses'are'supported'by'the'Association'of'
Anaesthetists'of'Great'Britain'and'Ireland'(AAGBI)'and'the'World'
Federation'of'Societies'of'Anaesthesiologists'(WFSA).'We'would'
like'to'thank'the'WFSA'for'funding'this'handbook.''
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Disclaimer!
We'have'worked'hard'to'ensure'that'all'of'the'information'
provided'in'this'handbook'is'accurate'and'up'to'date.'Whilst'every'
care'has'been'taken'to'ensure'that'doses'and'recommendations'
are'correct,'the'responsibility'for'final'checking'must'rest'with'the'
prescriber.'The'authors'cannot'accept'any'responsibility'for'errors'
in'this'publication.'
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Maytinee'Lilaonitkul'
Nick'Boyd'
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Published!January!2015!
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This'work'is'licensed'under'a'Creative'Commons'Attribution'–'Non=
Commercial'4.0'International'License.'To'view'a'copy'of'this'license,'
visit'http://creativecommons.org/licenses/by=nc/4.0/'
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Back!cover:'WHO'Surgical'Safety'Checklist'2009.'http://whqlibdoc.who.int/&
publications/2009/9789241598590_eng_Checklist.pdf&©World&Health&Organization.&All&
rights&reserved.&Reproduced'with'permission'from'the'World'Health'Organization'
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2'
Contents!
Page!
Paediatric!Anaesthesia! ! !
• Pre=operative'considerations' 4' '
• Airway'equipment' 6'
• Circulation' 7'
• Neonatal'anaesthesia' 9'
• Pain'assessment'and'management' 10'
• Caudal'and'ilioinguinal'block' 14'
• Burns'fluid'resuscitation' 16''
• Paediatric'anaesthetic'emergencies' 19'
• Paediatric'life'support' 20'
• Newborn'life'support' 22'
• Sick'laparotomy' 24'
• Anaphylaxis' 25'
• Status'epilepticus' 26'
• Local'anaesthetic'toxicity' 27'
• Pre=calculated'equipment'and'drugs'tables' 29'
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Obstetric!Anaesthesia! !
• Physiological'changes'in'pregnancy' 37'
• Urgency'of'caesarean'section' 38'
• Spinal'anaesthesia' 39'
• General'anaesthesia' 42'
• Post=operative'pain'management' 43'
• Obstetric'anaesthetic'emergencies' 45'
• Maternal'basic'life'support'' 46'
• Failed'intubation' 48'
• High'spinal'and'total'spinal' 49'
• Major'obstetric'haemorrhage' 50'
• Pre=eclampsia'and'eclampsia' 53'
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Drug!formulary! 56!
Lifebox!information! 62!
SBAR!handover! 63!
Anaesthetic!preparation!checklist! 64!
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Paediatric!Anaesthesia!
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Pre_operative!considerations!
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Fasting!guidelines!
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Minimum!fasting!time!
Oral!intake!
(before'induction)!
Clear!fluids! 2!hours!
Breast!milk! 4!hours!
Solids!!
6!hours!
(including'formula'milk)!
!
• Problems'associated'with'prolonged!fasting:''
! Dehydration'
! Difficult'venous'access'
! Hypoglycaemia'
! Irritable'and'miserable'at'induction'
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• Babies'and'small'children'should'be'scheduled'first!on'
an'elective'list'to'avoid'prolonged'dehydration'
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• If'the'operation'will'be'delayed,'allow'the'child'to'have'
clear'fluids'until'2!hours!before!induction!of!
anaesthesia'
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• Sickle!cell!patients'in'particular'should'avoid'
dehydration'due'to'the'risk'of'sickle'cell'crises'
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Upper!Respiratory!Tract!Infection!(URTI)!guidance!
An'active'URTI'can'increase'the'risk'of'complications,'including:'
• Laryngospasm'and'bronchospasm'
• Airway'obstruction'
• More'rapid'desaturation'
Therefore,'elective!surgery'should'be'cancelled'and'postponed'for'
four!weeks'if'the'following'symptoms'are'present:'
• Systemic'illness'(malaise,'reduced'appetite)'with'a'
fever'above'38°c'
• Productive'cough'
• Purulent'nasal'discharge'
• Chest'signs'on'auscultation'(wheeze,'crackles,'
reduced'air'entry)'
! !
High!risk!children!
Children'who'need'paediatric'review,'further'pre=operative'
investigations'and'possible'transfer'to'a'specialist'centre'include:'
• Premature'babies'and'neonates!
• Oxygen'saturations'in'air'of'less'than'94%!
• Heart'disease!
• Sickle'cell'disease''
• Severely'malnourished'children'
• Significant'systemic'diseases'
• Congenital'abnormalities'or'diseases'
Heart!murmurs!are'common'and'it'can'be'difficult'to'decide'if'a'
child'has'a'‘flow’'murmur'or'a'more'concerning'abnormality.'
Pathological!heart!murmurs'are'generally'loud'and'may'be'
associated'with'a'thrill.'Signs'that'may'indicate'significant'heart'
disease'include:'
• Babies:'cyanosis,'sweating'on'feeding,'
hepatomegaly,'failure'to'thrive'
• Younger!children:'cyanosis,'tachypnoea,'failure'to'
thrive'
• Older!children:'cyanosis,'history'of'reduced'exercise'
tolerance,'fainting'episodes'
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5'
Airway!Equipment!
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Facemask!'
Fits'comfortably'from'bridge'
of'nose'to'below'the'mouth,'
without'pressing'on'the'eyes'
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Oral!(Guedel)!airway!
Estimated'as'the'distance'
from'the'incisors'to'the'angle'
of'the'jaw'
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Endotracheal!tube!(ETT)''
Internal'Diameter'(ID)'for'uncuffed'tube'(in'mm):'
• Neonate'ETT'size'='' 3.0!–!3.5'
• 1'yr'old'ETT'size'='' 4.0!–!4.5'
• 2yrs'and'older'ETT'size'='' (Age!÷!4)!+!4.5'
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ETT'length'at'teeth'(in'cm)'='ETT!size!(ID)!x!3'
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Laryngeal!Mask!Airway!(LMA)!
LMA!size! Weight!of!child!
1' <'7.5'kg'
1½' 7.5'–'12.5'kg'
2' 12.5'–'20'kg'
2½' 20'–'30'kg'
3' >'30'kg'
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6'
Circulation!
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Normal!physiological!values!according!to!age:'
Age!! Heart!Rate!! Systolic!BP!
(years)! (per!min)! (mmHg)!
<'1' 110'–'160' 80'–'90'
1'='2' 100'–'150' 85'–'95'
2'='5' 95'–'140' 85'–'100'
5'='12' 80'–'120' 90'–'110'
>'12' 60'–'100' 100'–'120'
!
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Estimated!Blood!Volume!=!80!mls/kg!
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Resuscitation!Fluids:!
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Fluid!bolus!for!resuscitation!=!10!–!20!mls/kg!
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Blood!bolus!=!8!mls/kg!of!whole!blood!!!!!!!
''''''''''''''''''''''''''(or'5mls/kg'of'packed'cells)!! !
! ''increases!Hb!by!approximately!1g/dL!
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Glucose!bolus!=!2!mls/kg!of!10%!dextrose!
10%'dextrose'can'be'made'by'diluting'50%'dextrose'
(e.g.'4mls'of'50%'dextrose'diluted'with'16mls'of'water)'
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Choice!of!fluid:!!!
• Use'0.9%'saline'or'Ringer’s'Lactate'
• NEVER'use'5%'dextrose'for'resuscitation'fluids'
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Maintenance!Fluids!
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• Always!give'oral!fluids!where!possible'
• If'unable'to'tolerate'oral'fluids,'use'IV'regime'
below:'
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HOURLY!intravenous!fluid!requirement!(4_2_1!rule)1'
! !
Weight!of!child! mls/kg/hr!
First'10kg' 4!
Second'10kg' 2!
Every'additional'kg' 1!
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&&&&&&&&&&&&
Example:'''Maintenance'fluids'for'a'25kg'child'
' ' ' 'first'10kg'='(4x10)'=' ' 40mls/hr'
' ' ' 'second'10kg'='(2x10)'='' 20mls/hr'
' ' ' 'additional'5kg'='(1x5)'=' '5mls/hr'
! ! !!!!!!!!Total!maintenance!fluid'requirement'='!65mls/hr'
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Choice!of!fluid:!
• 5%'dextrose'0.9%'saline'or'
• 5%'dextrose'0.45%'saline'or'
• 5%'dextrose'Ringer’s'Lactate'
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• NEVER!use!5%!dextrose!for!maintenance!fluids!!
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1Holliday'M,'Segar'W.'The'maintenance'need'for'water'in'parenteral'fluid'therapy.'Pediatr&1957;19:823O32&
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8'
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! Neonatal!Anaesthesia!
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Special'Considerations'
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Pre_operative!assessment!
• Actual'weight'and'post=conceptual'age''
• Assess'for'congenital'abnormalities'
• Ensure'Vitamin'K'has'been'given''
• Check'baseline'Hb'(normally'16=18'g/dL'at'birth)'
!
Preparation!
• Drug'doses'calculated'and'drawn'up'before'induction'
• At'least'1'unit'of'blood'cross=matched'
• Warm'theatre'and'keep'baby'covered'at'all'times'
!
Intra_operatively!
• Use'NG'tube'to'decompress'abdominal'distension'
• Keep'baby'warm'(cover'head,'warm'fluid,'warming'devices)'
• Check'blood'glucose'level'and'treat'if'<3mmol/L'
!
Analgesia!
• Consider'local'anaesthetic'blocks'and'wound'infiltration'
• Regular'paracetamol,'avoid'NSAIDs'
• Cautious'use'of'opioids'(risk'of'post=operative'apnoea)'
!
Postoperative!management!
• Extubate'when'fully'awake'
• Close'postoperative'monitoring'in'first'24'hours'
• If'oxygen'is'required'post=operatively,'saturations'should'be'
monitored'and'maintained'at'95=98%'
• Premature'neonates'are'most'at'risk'of'postoperative'apnoea'
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