Jurnal Anastesi PDF

Education for anaesthetists worldwide
Volume 30 Number 1 June 2015
Edition Editors: Rachel Homer, Isabeau Walker, Graham Bell ISSN 1353-4882
Special Edition
Paediatric Anaesthesia and
Critical Care
The Journal of the World Federation of Societies of Anaesthesiologists

Guest Editorial
In my opinion, paediatric anaesthesia is one of the Modern anaesthetic teaching often emphasises the latest
most interesting, rewarding and fulfilling specialities developments, but we should not forget the importance
but Im aware this may not be an opinion shared of the vigilant anaesthetist and the use of equipment
by all! There can be nothing more frightening than to such as the pre-cordial stethoscope, now seldom used
Editorial
be faced with an acutely ill or injured child when you in high resource countries.
dont have any colleagues to help you or to discuss the
case with, and there is no time to transfer to a specialist Effective pain management in children undergoing
centre, or there is no specialist centre. I imagine this surgery should always be a high priority, and the
must be the case particularly for those who only authors of the excellent section on regional anaesthesia
anaesthetise children occasionally. This edition of highlight the importance of local blocks in children.
Update in Anaesthesia includes a wealth of information Much is possible with simple equipment using
on different areas of paediatric anaesthetic practice, landmark techniques, and local blocks such as the
and will be enormously useful to all those who care caudal provide excellent analgesia for common surgical
for children. interventions. The newer ultrasound-guided techniques
described help us to perform a wider range of blocks
Core lifesaving skills relating to airway management with great accuracy and safety, and using smaller doses
and fluid resuscitation are fundamental our practice, no of drug.
matter what the age of the patient, and maintaining these
basic skills, and basic anaesthesia skills, should form the The sections on resuscitation and critical care highlight
basis of our on-going professional development. For some important differences between adults and
some, this may involve spending time with a colleague children. For example, in adults, cardiac arrest is usually
during an elective operating list, so that when you need due to a primary cardiac cause, whilst in children,
to look after a child in an emergency you feel more cardiac disease is rare, and the most common cause of
confident. For others, it may mean updating local cardiac arrest is hypoxia or hypovolaemia, or in parts
guidance, for instance relating to pain management of the world where halothane is still used routinely,
and fluid management, and making sure that the due to deep halothane anaesthesia. This is reflected in
appropriate equipment is available when you need it. the resuscitation guidelines for children that emphasise
Even the normal infant airway can be difficult for those identification and prevention of cardiac arrest as much
who are inexperienced, and it helps to have thought as treatment itself. Early recognition of a seriously ill or
about your plan in advance. Neonatal anaesthesia injured child, whether due to a common or rare disease
presents very particular challenges of its own. condition, is essential to achieve a good outcome.
Preparation of a child for surgery is vital to ensure Paediatric anaesthesia is an important sub-speciality
smooth and safe anaesthesia, especially in the of anaesthesia, but sadly the facilities to deliver safe
presence of comorbidities. Asthma is increasingly anaesthesia care are not always available everywhere.
common. Environmental pollution particularly The mission of the WFSA is to improve patient
affects our younger patients, and makes them more care and access to safe anaesthesia by uniting
prone to respiratory infections. Whether to proceed anaesthesiologists around the world. I believe that this
or to cancel the child with a common cold is often a edition of Update in Anaesthesia, written by experts in
difficult dilemma, even for the experienced paediatric paediatric anaesthesia from around the globe, offers an
anaesthetist. In any setting, even those with the best of important contribution to this mission.
resources, anaesthetists have had to learn to trust their
instincts and their senses (their eyes, ears and touch).
Dusica Simic MD, PhD

Professor of Anesthesiology, Reanimation and Intensive care,
Head Department of Pediatric Anesthesia and Intensive Care,
School of Medicine, University of Belgrade, Serbia
Serbian Association of Anesthesiologist and Intensivists (SAAI) Board member;
Board member of the Section for Anesthesiology, Critical Care and Pain Therapy of Serbian Medical Society
Pediatric anesthesia subsection president;
ESPA ACORNS member
Chair of WFSA Committee for Paediatric Anaesthesia
Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia page1

Editors notes
Dear readers
Welcome to this special edition of Update in Anaesthesia, contribution from Dr Sam Richmond, who sadly died
which focuses on paediatric anaesthesia and critical in April 2013 Sam was a consultant neonatologist at
Editorial
care. Anaesthetists play an important role in the care of the City Hospitals Sunderland, UK, and was dedicated
children in hospital, providing anaesthesia, pain relief, to furthering education in newborn resuscitation in
resuscitation and critical care services for some of our low- and middle-income countries.
most vulnerable patients.
Providing high quality anaesthesia and critical care
The speciality of paediatric anaesthesia has developed requires a trained workforce, but it can be difficult to
over the last 30-40 years as the particular requirements access refresher training in some parts of the world.
for safe care of the newborn, infant, young child and The WFSA and AAGBI have pioneered the Safer
adolescent have been recognised. In many countries, Anaesthesia From Education (SAFE) short courses
there are now sub-speciality paediatric anaesthesia for physician and non-physician anaesthetists to
societies, and anaesthetists can specialise in paediatrics address these training needs. This edition of Update
as a sole area of practice. Whilst the approach the child in Anaesthesia has been designed to support the SAFE
is not a miniature adult is important, it is also essential Paediatric Anaesthesia course, and we hope that the
to recognise that the fundamental principles of safe SAFE course participants find it useful. We also hope
anaesthetic practice can be applied to all our patients, that the regular readers of Update find it a useful
and that there is a need for the generalist anaesthetist addition to their anaesthesia libraries; this edition will
to maintain their skills in caring for children. In many be available along with all the other WFSA education
parts of the world, more than 50% of the population resources at www.wfsahq.org.
is under 14 years, and it has been estimated that more
All previous Update in Anaesthesia articles and Tutorials
than 85% of children will require some form of surgery
of the Week are available to download for free from
before their 15th birthday whether this is for minor
http://www.wfsahq.org/resources/virtual-library
trauma, hernia repair or tonsillectomy, to treat common
congenital abnormalities such as cleft lip and palate, or Finally, I would like to offer particular thanks to my
as the result of trauma from a road traffic accident. In fellow editors, especially to Rachel Homer for all her
all these areas, essential anaesthetic skills play a key role. hard work and dedication that has seen this project
through to completion.
This edition of Update represents the contributions
of paediatric anaesthetists from around the globe;
we are grateful to them for their hard work and for
sharing their wisdom. We have aimed to provide Isabeau Walker
both theoretical background and practical advice that Consultant Paediatric Anaesthetist
will be useful in every day practice. The section on Great Ormond Street Hospital, London, UK
basic science includes a description of physiological
and pharmacological differences between young Update Team
children and adults, and advice about the selection of
Editor-in-chief
equipment for children. There is a section to describe
Bruce McCormick
the anaesthetic implications of both common and
rarer co-morbidities in children. The section on Edition Editors
principles of basic clinical anaesthesia describes the Rachel Homer
essentials of preoperative preparation, intravenous fluid Isabeau Walker
management, analgesia and sedation, that are applicable Graham Bell
in any setting. The articles describing speciality areas Illustrators
of practice are written by experts in the field, and we Dave Wilkinson, Bruce McCormick
are grateful to them for making their contributions
so relevant to the practice of anaesthetists worldwide. Typesetting
Some of the articles have been published previously in Angie Jones, sumographics (UK)
Update in Anaesthesia and Anaesthesia Tutorial of the Printing
Week, and we have indicated this in the article where COS Printers Pte Ltd (Singapore)
relevant. We are particularly pleased to include the
page 2 Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia

Contents
1 Editorial 154 Anaesthesia for cleft and lip palate surgery
BASIC SCIENCE Ellen Rawlinson
4 Basic science relevant to practical paediatric anaesthesia 159 Anaesthesia for paediatric orthopaedic surgery
Anthony Short and Kate Stevens Tsitsi Madamombe, Jim Turner and Ollie Ross
13 Equipment in paediatric anaesthesia COMMON EMERGENCIES
Graham Bell and Rachel Homer 168 Large airway obstruction in children
23 Paediatric drawover anaesthesia N S Morton
Sarah Hodges 174 Bronchoscopy for a foreign body in a child
Anaesthesia and co-morbid disease P Dix and V Pribul
27 Anaesthesia and congenital abnormalities 178 Anaesthesia for emergency paediatric
K Ganeshalingam and T Liversedge general surgery
35 The anaesthetic management of children with Mark Newton
sickle cell disease TRAUMA IN CHILDREN
Tanya Smith and Christie Locke 187 Head injury in paediatrics
40 HIV in children and anaesthesia Delia Chimwemwe Mabedi, Paul Downie and Gregor Pollach
S Wilson and S Patel 196 Major haemorrhage in paediatric surgery
46 Anaesthesia for non-cardiac surgery in Stephen Bree and Isabeau Walker
children with congenital heart disease 199 Paediatric burns and associated injuries
Isabeau Walker A J Pittaway and N Hardcastle
58 Anaesthesia in patients with asthma, bronchiolitis 204 Stabilisation and preparation for transfer in
and other respiratory diseases paediatric trauma patients
David Liston and See Wan Tham D Easby and K L Woods
PRINCIPLES OF CLINICAL ANAESTHESIA CRITICAL CARE
65 The preparation of children for surgery 210 Paediatric intensive care in resource-limited
Nicholas Clark and Roger Langford countries
72 Perioperative analgesic pharmacology in children Rola Hallam, Mohammod Jobayer Chisti,
Glynn Williams Saraswati Kache and Jonathan Smith
77 Paediatric procedural sedation 224 Recognising the seriously ill child
D S Sethi and J Smith Laura Molyneux, Rebecca Paris and Oliver Ross
81 Perioperative fluids in children 236 Meningococcal disease in children
Catharine M Wilson and Isabeau A Walker Rob Law and Carey Francombe
88 Paediatric caudal anaesthesia 242 Intraosseous Infusion
O Raux, C Dadure, J Carr, A Rochette, X Capdevila Eric Vreede, Anamaria Bulatovic, Peter Rosseel
and Xavier Lassalle
93 Abdominal wall blocks
Nuria Masip and Steve Roberts 244 The child with malaria
Rachel A. Stoeter and Joseph Kyobe Kiwanuka
99 Upper and lower limb blocks in children
251 Acute lower respiratory disease in children
Adrian Bosenberg
Rebecca Paris, Oliver Ross, and Laura Molyneux
112 Paediatric spinal anaesthesia
RESUSCITATION
Rachel Tronci and Christophe Dadure
265 Paediatric life support
116 Paediatric difficult airway management
Bob Bingham
Michelle C White and Jonathan M Linton
270 Resuscitation at birth
ELECTIVE PROCEDURES
Sam Richmond
123 Neonatal anaesthesia
Heidi Meyer and Karmen Kemp 273 Anaphylaxis; recognition and management
Crawley S M and Rodney G R
133 Major elective surgery in children, and surgery in
remote and rural locations 279 Accidental poisoning in children
Mark Newton Susara Ribbens
141 Anaesthesia for paediatric ear, nose, MISCELLANEOUS
and throat surgery 285 Further resources available online or to
Radha Ravi and Tanya Howell download
147 Anaesthesia for paediatric eye surgery Rachel Homer
Grant Stuart
Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia page 3

Basic science relevant to practical
paediatric anaesthesia
Basic Science
Anthony Short* and Kate Stevens

*Correspondence Email: tone_short@hotmail.com
It is often said that paediatric patients are not The major anatomical differences affecting
simply small adults. The truth is that from the airway management in neonates and infants are
premature neonate to the near-adult adolescent, as follows:
children are very diverse (see Table 1 for age
definitions used in this article). This article Relatively large head and prominent occiput
will consider the basic science and calculations Small mandible
SUMMARY
commonly used in paediatric anaesthesia;
This article considers our challenge is to consider the anatomical, Relatively large tongue
the basic science and physiological and other differences that impact
calculations commonly used Short neck
on anaesthetic practice.
in paediatric anaesthesia,
including the anatomical,
Estimation of weight Soft tracheal cartilages, easily compressed.
physiological and other
differences relative to adults It is essential that every child is weighed prior
that impact on anaesthetic to anaesthesia. This allows correct calculation These differences predispose to airway
practice. of drug doses and selection of anaesthetic obstruction, particularly if the childs head is
equipment. In emergencies, weight can also placed on a pillow, or the soft tissues on the
be estimated from the age of the child from floor of the mouth are compressed, or the head
standard growth charts (use the weight at the is hyperextended. Ideally, maintain the childs
50th centile), from the length of the child using head in a neutral position, or slightly extended,
a Broselow tape, or using the formulae shown in possibly with a small pad under the shoulders,
Table 2. and open the airway using a chin lift or jaw
thrust, avoiding compression of the soft tissues
Airway and respiratory tract of the floor of the mouth (see Figure 1).
Anatomical differences of the paediatric airway
influence airway management and the selection Anatomical differences affecting the larynx
of appropriate equipment. include:
Table 1. Age definitions

Neonate Up to 44 weeks post conception (includes premature neonates)
Infant From 44 weeks post conception 1 year
Anthony Short
Child 1 12 years of age
ST7 Anaesthetics,
Morriston Hospital, Adolescent 13 16 years of age
Swansea, Adult Greater than 16 years of age
South Wales
Table 2. Formulae to estimate the weight of children at different ages
Kate Stevens
Consultant Anaesthetist Age of child Formula to estimate weight in kg
and Intensivist 0-12 months (0.5 x age in months) +4
Morriston Hospital,
1-5 years (2x age in years) +8
Swansea,
South Wales 6-12 years (3x age in years) +7

Chin lift
Jaw thrust
Figure 2. The paediatric airway compared to the adult airway

(illustration by Mrs P. Klebe, used with permission)
The intubation technique in infants needs to take account of

these anatomical differences:
Prepare all your equipment, find an assistant, monitor the
Figure 1. Chin lift and jaw thrust in a child, avoiding compression child and preoxygenate; give yourself enough time
of the soft tissues
Handle the tissues gently and choose the appropriate sized
tube. Multiple attempts at intubation may result in post-
A high, anterior position of the larynx (level of C3-4 in extubation stridor
infants compared to C5-6 in adults)
Place the head in a neutral position or slightly extended,
A long, U-shaped epiglottis projecting at 45 degrees and stabilise the head with your right hand; use your right
posteriorly index finder to open the mouth
A funnel shaped larynx. The narrowest part of the airway Hold the laryngoscope close to the hinge of the blade,
is at the cricoid cartilage (below the vocal cords). The using the thumb and index finger of your left han.
narrowest part of the airway in adults is at the vocal cords.
If necessary, use the little finger of your left hand to press
A thin loose lining to the airway which is easily damaged on the larynx to bring the laryngeal structures into view.

Place the tip of the larygngoscope blade into the vallecula, pressures and high-inspired oxygen concentration predisposes
the space above the epiglottis (curved blade), or beneath to bronchopulmonary dysplasia and chronic lung disease.
the epiglottis (straight blade) to lift the epiglottis to expose
the larynx and vocal cord. The airways are very small in neonates, and easily obstructed.
The flow in the airway can be described by the Hagen Pouiselle
Pass the tube carefully between the vocal cords, under formula, assuming laminar flow:
direct vision. Do not insert the tube too far; the tracheal
length is approximately 4.5cm in most infants. Q =(P r4) / (8 L)
Adenotonsillar hypertrophy is common in children 3 8 years where
of age. Airway obstruction may develop when pharyngeal
tone is lost after induction of anaesthesia; an oropharyngeal Q = volumetric flow rate
may help to maintain a patent airway. Take care when passing P = pressure drop
nasopharyngeal, nasotracheal and nasogastric tubes in these
= a constant
children.
r = radius
Children aged 5-13 years may have loose teeth; take note of
loose teeth at your preassessment visit. - dynamic viscosity
L airway length
Respiratory considerations
Up to 6 months of age, infants are almost exclusively breast The flow is therefore proportional to the radius4; halving the
fed, and need to breathe through their nose rather than their radius of the airway decreases the flow rate by a factor of 16.
mouth (obligate nasal breathers). Respiratory difficulties may A small amount of airway oedema from a difficult intubation,
result if the nose is blocked, for instance due to secretions from or infection, or respiratory secretions, will significantly reduce
upper respiratory tract infections, or if a nasogastric tube is airflow and increase the work of breathing for a neonate.
present.
Respiratory mechanics in the neonates are not very efficient.
Neonates have very limited respiratory reserve, and become The rib cage is soft and compliant, and the ribs move in
hypoxic very easily. They have a high metabolic rate and the horizontal plane only (rather than in the horizontal and
twice the oxygen consumption compared to older children anterior-posterior direction in adults, like a bucket handle).
and adults (6-7ml.kg-1.min-1 in neonates compared to This means the tidal volume is relatively fixed (5-7 ml.kg-1), and
3-4 ml.kg-1.min-1 in adults). the infant can only increase minute ventilation by increasing
respiratory rate (see Table 3 for normal values). Deadspace
The respiratory exchange surface is immature, with only volumes should be kept to a minimum for neonates and infants
1/10 the number of alveoli compared to adults; in premature to reduce the work of breathing and to reduce re-breathing.
neonates this is compounded by a lack of respiratory surfactant
that helps to reduce surface tension and to stabilise the The diaphragm is the main muscle of respiration in neonates
alveolar air spaces. The lack of surfactant in premature infants and infants, but is prone to fatigue due to a lack of type 1
predisposes them to airway collapse, poor gas exchange and (oxidative, fatigue resistant) muscle fibres. The diaphragm
increased work of breathing. Ventilation with high airway may be splinted by gastric distension due to swallowed air
Table 3. Cardiorespiratory physiology normal values
Age (years) Respiratory rate Heart rate Blood pressure (mmHg)

(breaths per minute) (beats per minute)
Pressure increases with
Rate reduces with increasing age Rate reduces with increasing age increasing age
<1 40-30 160-110 80-90
>1-2 35-25 150-100 85-95
>2-5 30-25 140-95 85-100
>5-12 25-20 120-80 90-110
>12 20-15 100-60 100-120

(very common with crying or facemask ventilation), or due (apnoea). Apnoeas are particularly common in premature and
to bowel obstruction. It is important to consider placement of ex-premature infants, and are significant if they last longer than
a nasogastric tube to decompress the stomach in infants with 15 seconds or are associated with desaturation or bradycardia.
abdominal distension or respiratory distress. Volatile anaesthetics and opioids reduce the respiratory drive
further, and should be used cautiously in neonates, especially
The soft rib cage means that the chest wall in babies is highly premature neonates. Consider opioid sparing techniques
compliant, and there is less outward spring exerted by the (paracetamol, local anaesthetic blocks) whenever possible.
rib cage, and less negative intrapleural pressure to keep the Caffeine given orally prior to surgery has been used to reduce
lungs expanded. This results in a relatively low functional the risk of apnoea. All ex-premature neonates <60 weeks post
residual capacity (FRC), and airway closure may occur during conception should be monitored carefully after an anaesthetic,
normal breathing. Intercostal and sternal recession is common ideally with an apnoea monitor if available. Term neonates are
in babies if there is any airway obstruction, or reduction in also susceptible to apnoeas after routine anaesthesia for minor
lung compliance (for example due to infection) (see figure 3). procedures, likely until they are at least a month old.
Tracheal tug also occurs. An infant with respiratory distress
may grunt to maintain airway volumes there is partial Premature infants (before 35 weeks gestational age) are at
closure (adduction) of the vocal cords during expiration, risk of retinopathy of prematurity due to abnormal vessel
which effectively provides physiological continuous positive proliferation in the vitreous of the eye, which may result
airway pressure (CPAP), and helps to keep the airways open. in haemorrhage, scarring and retinal detachment, and is a
Conversely, the presence of recession, tracheal tug and grunting common cause of blindness in this population. High PaO2
in an older child with a more rigid rib cage is an ominous may worsen retinopathy, which is also seen in term infants
sign, and suggests very severe respiratory distress. Increased given unmonitored oxygen therapy. If oxygen therapy is
respiratory rate is an important sign of respiratory distress at required on the ward, saturations of 87-94% are acceptable in
any age. neonates, particularly premature neonates. Preoxygenation is
still indicated prior to intubation, but if possible, avoid 100%
The control of respiration is immature in neonates. Responses
FiO2 during the maintenance phase of anaesthesia.
to hypercarbia and hypoxia are blunted and poorly sustained,
and neonates often respond to hypoxia by stopping breathing Summary - practical implications for the anaesthetist:
Consider the normal values for respiratory rate by age
If a mechanical ventilator is available, select the appropriate
tidal volume and respiratory rate for age pressure control
ventilation is preferred
Recognise the signs of respiratory distress; increased
respiratory rate, grunting and recessions in an older child
are extremely ominous
Neonates and infants have a high oxygen requirement
and limited reserve; they become hypoxic rapidly if they
are apnoeic or if the airway is obstructed. This is particularly
important during induction of anaesthesia
Small children may not tolerate preoxygenation well, but
you should always try
Gastric distension splints the diaphragm, the main muscle
of respiration in neonates and infants; consider a nasogastric
tube (NGT) in cases of gastric distension
CPAP/PEEP (positive end-expiratory pressure) are useful
and may help avoid airway collapse and maintain oxygen
saturations in neonates and infants
Figure 3. Tracheal tug, subcostal and intercostal recession is
common in babies with respiratory distress (illustration by Mrs P. Select anaesthetic equipment with low deadspace volume
Klebe, used with permission) to reduce the work of breathing

Monitor all babies for apnoeas after surgery; ex-premature Venous return from the lungs to the left atrium increases and
babies are at increased risk until they are 60 weeks post the pressure gradient reverses across the foramen ovale, which
conception begins to close. The pressure in the pulmonary artery falls,
and blood flow through the ductus arteriosus is reversed so
If oxygen therapy is required, SpO2 87-94% is that blood flows from the aorta to the pulmonary artery. The
recommended in premature neonates. ductus arteriosus begins to constrict due to increasing PaO2
and decreasing levels of prostaglandin E2 (PGE2). This is a
Cardiovascular considerations transitional period. The ductus does not undergo full fibrosis
Transitional circulation for one month, and the foramen ovale may reopen in the first
With a newborns first breath, there is a transition from the 5 years of life. Large decreases in systemic vascular resistance
fetal circulation (gas transfer at the placenta) to the newborn or increases in pulmonary vascular resistance due to hypoxia,
circulation (gas transfer at the lungs). Pulmonary vascular hypercarbia, sepsis or acidosis in the first few weeks after birth
resistance decreases with the first breath by up to 80% (mainly may cause the pulmonary vascular resistance to rise, and the
due to the rise in PaO2 and in part due to the rise in pH and the fetal shunts to reopen with right to left shunting; the baby will
fall in PaCO2 at birth). Systemic vascular resistance increases become very cyanosed as deoxygenated blood flows from the
with clamping of the umbilical cord hence exclusion of the low pulmonary artery to the aorta and pulmonary blood flow falls.
resistance placental bed (see Figure 4). Worsening hypoxia leads to increased pulmonary vascular
resistance, which further amplifies the right to left shunt. This
is called persistent pulmonary hypertension of the newborn
(PPHN).
Neonatal considerations
At birth the right ventricle is a similar size to the left ventricle,
due to the high PVR in fetal life. There is therefore right-sided
dominance on the newborn ECG. By two months of age the
left ventricle is twice the size of the right, and a left dominant
ECG is seen from 4 6 months of age. As the heart grows,
the PR interval, QRS duration and the QRS size all increase.
The newborn period is a time of rapid growth and development.

High tissue oxygen delivery is required for the developing brain
and other organs. The cardiac output is therefore relatively
high compared to adults (see Table 4).
The ventricles are immature, and less compliant, with a

relatively fixed stroke volume (1.5mls.kg-1 at birth), so increase
in cardiac output is achieved through an increase in heart rate,
rather than an increase in stroke volume as in adults (see table
3). This limits the ability to increase the cardiac output with a
fluid challenge in a neonate, and it is easy to push the neonate
into pulmonary oedema if too much fluid is given. Bradycardia
(most commonly due to hypoxia) will reduce both cardiac
output and blood pressure significantly.
In the newborn, vagal tone predominates. Hypoxia, airway
manipulation, surgical stimuli and deep halothane anaesthesia
are all likely to provoke bradycardia. Hypoxia should always
be corrected and a dose of atropine (20mcg.kg-1) should always
be drawn up when anaesthetising children. Start CPR if the
HR drops below 60 bpm; small doses of adrenaline up to 10
Figure 4. Fetal and neonatal circulation (illustration by Mrs P. mcg.kg-1 may be required if the heart rate is unresponsive to
Klebe, used with permission) atropine.

Table 4. Changes in cardiac output with age
Age of child Cardiac output (ml.kg-1.min-1)

Neonate 300
Adolescent 100
Adult 70-80
Normal blood pressure varies with age, and can be estimated It is important to monitor and replace intraoperative losses
using the formula below (see table 3 for normal values): meticulously. It is estimated that 10mls.kg.-1hr.-1 evaporative
losses occur during paediatric laparotomy. Swabs should be
Systolic BP (50th centile) = 85 + (age in years x 2) weighed and suction fluid losses measured carefully.
Systolic BP (5th centile) = 65 + (age in years x 2)
Summary practical implications for the anaesthetist:
As the child grows, the stroke volume rises, the heart rate falls Children are prone to dehydration, and should not be
and the systemic vascular resistance rises. The response to fasted excessively. Allow free clear fluids (water) up to 2
volume loading is more predictable from 2 years of age. hours before surgery
Summary practical implications for the anaesthetist Fluid balance should be monitored carefully during surgery
Normal values for HR and BP vary with age
Children are prone to hyponatraemia in the perioperative
The response to a fluid challenge may be blunted in the period; use only isotonic fluids.
neonate or small infant
Haematology
It is important to avoid bradycardia. This should be treated At birth 70% of haemoglobin is HbF; this has alpha and
rapidly should it occur; the most common cause is hypoxia gamma haemoglobin chains, and is ideally suited to efficient
delivery of oxygen to the tissues in the hypoxic environment
There is a transitional circulation at birth, and fetal shunts
in the fetus. However, tissue oxygen delivery by HbF at the
may reopen in the critically ill neonate
higher values of PaO2 found in the newborn is less efficient.
Fluid balance Haemoglobin concentrations, blood volume and cardiac
At birth total body water may be as high as 80%, which output are relatively high in the newborn to facilitate oxygen
gradually decreases to 65% in the adult. Extracellular fluid delivery to the tissues, and to meet the high metabolic demand
accounts for 40% of this volume (higher in prematurity), for oxygen. Premature neonates may have a low haemoglobin
more than in adult patients. Children are particularly prone as iron stores are laid down in the final three months of
to dehydration as they have a higher metabolic rate and gestation. HbF declines to negligible levels by 6 months of age.
extracellular fluid turnover, they do not concentrate the urine Production of haemoglobin HbA2 increases from birth, and
well to conserve water, and infants also have a higher surface reaches adult levels by 6 months of age; physiological anaemia
area to weight ratio with relatively higher insensible losses. of infancy is seen at 3-6 months as HbF levels decline and
There is poor compensation for extracellular fluid dehydration HbA2 levels increase (see Table 5 for normal values).
as the intracellular compartment is relatively small.
The relative blood volume in neonates is high, but the absolute
The stress response to surgery may result in hyponatraemia volumes are very small. If the absolute volume is 300mls, blood
due to the release of antidiuretic hormone (ADH) from the loss of just 60ml is 20% of the circulating volume. Transfuse
pituitary, over-riding the effect of plasma osmolarity (see blood (packed red blood cells) if 20% of blood volume is
chapter on fluids, page 81). The use of hypotonic fluids (such lost or if the haematocrit falls to less than 25%. Consider
as 0.18% saline with 4% glucose) may exacerbate this and clotting factors, platelets and fibrinogen (or use whole blood)
should be avoided. Normal saline or Ringers lactate would if blood losses are more significant. (See the article on major
normally be chosen for fluid maintenance. Due to the risk of haemorrhage for more information, page 195).
hypoglycaemia, glucose containing solutions should be given
to neonates or children below the 3rd centile of weight (for Thermoregulation
example 0.9% saline with 5% dextrose). Use close monitoring Heat stores in children are small due to their low body mass.
of sodium and glucose levels when giving IV fluids in these Heat is lost rapidly due to high evaporative losses, and poor
patients. insulation:

Table 5. Haemoglobin levels and blood volume normal values
Age group Blood volume (mls.kg-1) Haemoglobin concentration (g.l-1)

Neonate 90 180-200
Infant 85 90-120
Child 80 110
Adult 70 110
Large surface area to body weight ratio the renal cortical tubules are immature; babies therefore
produce large volumes of dilute urine and do not tolerate
High minute ventilation dehydration well. Sodium is required for normal growth, and
Thin skin sodium is actively conserved. Dietary sodium requirements
may be higher in premature neonates due to increased renal
Poor subcutaneous fat stores. sodium losses. Expansion of the plasma fluid volume should
be avoided in the first few days of life before the post-natal
Neonates are unable to maintain body heat as the
diuresis has occurred; babies do not require added sodium
thermoregulatory centres are immature, and they cannot
if they receive IV maintenance fluids in the first few days of
shiver or sweat efficiently. They can generate heat through
life; add sodium should be added to maintenance fluids after
the metabolism of brown fat (non-shivering thermogensis).
the first few days of life. Isotonic fluid should always be used
Brown fat accounts for about 5% of a neonates body weight
during surgery. Urine output in the newborn is approximately
and is distributed around the scapulae, kidneys, adrenals
1-2mls.kg-1.hr-1.
and mediastinum. Metabolism is neurally mediated (3
adrenoreceptors) and generates heat. This is inefficient and Hepatobiliary considerations
increases oxygen consumption. Older children (>3 months) Neonates have poor liver glycogen stores and are at risk of
have ineffective shivering due to limited muscle mass. hypoglycaemia. A 10% dextrose infusion may be required
Vasconstriction in children is inefficient. to prevent this. There is an increase in red cell breakdown
Children are therefore prone to hypothermia. The consequences and a limited ability to handle unconjugated bilirubin, so
of hypothermia include: physiological jaundice is common in the first two weeks of
life. Vitamin K dependent clotting factors (II, VII, IX and X)
Increased oxygen consumption are deficient in the newborn and ideally, vitamin K should be
given at birth to prevent haemorrhagic disease of the newborn,
Respiratory depression particularly in a neonate who requires surgery. Platelet function
is reduced and there is a risk of bleeding, particularly in the
Cardiac arrythymias septic neonate (the platelet count falls in sepsis).
Coagulopathy Hepatic metabolism of drugs is reduced in the neonatal
period, and may take 3 months to reach full activity. This is
Acidosis particularly relevant to opioids - the half-life of morphine is
6-8 hours in the term neonate compared to 2 hours in infants
Hyperglycaemia and older children, so increased dosing intervals should be
used and opioids strictly titrated to effect in neonates.
Immunosupression
Immune system
Prolonged drug metabolism.
The neonate is relatively immunosuppressed. Maternal IgG
Keeping children warm improves outcomes. (See Equipment antibodies, which can cross the placenta, fall during the first 6
article for strategies, page 13). months. Breast-feeding helps protect against gastrointestinal
and respiratory tract infections.
Renal considerations
Renal vascular resistance is higher in the newborn and there Nervous system
is a relatively low renal blood flow and glomerular filtration The central nervous system is immature at birth and cerebral
rate. The ability to concentrate urine is poorly developed as myelination continues for up to 3 years. The process of

Table 6. Central nervous system normal values
Patient group Cerebral blood flow Cerebral metabolic rate for CSF volume CSF volume
(ml.100g-1.min-1) oxygen (CMRO2) (ml.kg-1) (ml.kg-1)
(ml.100g-1.min-1)
Newborn 50 4 <2
Child 100 5.8
Adult 50 3.5 2 7-15
Table 7. Comparison of volatile agents in children

Halothane Sevoflurane Isoflurane
MAC (%) MAC (%) MAC (%)
Infant: 0.9 Infant: 3.3 Infant: 1.6
Child: 1.2 Child: 2.5 Child: 1.9
Adult: 0.75 Adult: 1.7 Adult: 1.2

Sweet smelling, well-tolerated Non-irritant Pungent, irritant, difficult to use for
inhalational induction
High lipid solubility, slow onset/offset Low lipid solubility, rapid onset/offset of Low lipid solubility, rapid onset/offset of
anaesthesia; induction rate increased if anaesthesia anaesthesia
used with nitrous oxide.
Arrhythmias common, myocardial Good haemodynamic stability; blood Good haemodynamic stability; blood
depression common pressure may fall due to fall in systemic pressure may fall due to fall in systemic
vascular resistance vascular resistance
Respiratory depression seen Respiratory despression common Respiratory depression seen
Inexpensive Expensive, although costs coming down Expensive, although costs coming down
Hepatic metabolism; halothane hepatitis Not highly metabolised Low hepatic metabolism
seen rarely (repeat anaesthetics)
Compatible with draw-over systems; not Compatible with modern anaesthesia Compatible with modern anaesthesia
all modern anaesthesia systems include a systems; not all draw-over systems include systems; can be used in a halothane
halothane vaporiser a sevoflurane vaporiser vaporiser
central nervous system maturation continues during fetal Pharmacological considerations

and neonatal development, but the ability to feel pain is well
developed even before birth. Pain in neonates is associated Volatile anaesthetics
with behavioural changes such as tachycardia, hypertension, Neonates are more sensitive to volatile agents than older
grimacing, crying and restlessness; pain scores in children children, and the minimum alveolar concentration (MAC)
take these behavioural features into account. There is concern values are decreased in neonates but increased by up to 30%
about the effect of anaesthetics on the developing brain, and in infants and children compared to adults. Halothane and
unnecessary anaesthetics should be avoided in infancy. sevoflurane remain the agents most popular for inhalational
induction of anaesthesia (see table 7 for comparison between
Cerebral blood flow is high in childhood, and intracranial volatile agents).
pressure (ICP) is lower in the newborn (see table 6 for normal
values). Rises in intracranial pressure are well-compensated Sedatives and hypnotics
in infancy, in part by expansion of sutures and bulging of Children are particularly sensitive to sedative and hypnotic
fontanelles, and intracranial pressure can be estimated by drugs such as barbiturates and benzodiazepines due to the
palpation of the fontanelles. Ossification of the fontanelles is immature blood brain barrier and reduced drug metabolism/
complete by about 18 months. excretion; these drugs should be used with caution, in weight

appropriate doses, titrated according to effect. Propofol opioids or local anaesthetics. (This topic is considered in more
infusions may be used in children older than 3 years. See detail on page 72).
article Paediatric procedural sedation on page 77).
Acknowledgements
Muscle relaxants
I would like to thank Dr Steven Froom, Consultant Paediatric
The volume of distribution of water soluble drugs is higher
Anaesthetist for a review of the final draft and my sister, Mrs
at birth due to the increased extracellular fluid volume. (This
Penelope Klebe, for her excellent illustrations.
is true for all water soluble drugs, not only muscle relaxants).
This explains the need for a higher dose of suxamethonium Further reading
in infants relative to adults (2mg.kg-1 vs 1mg.kg-1). A second
1. Berg S. Chapter 33: Neonatal/infant physiology. In: Allman KG, Wilson
dose of suxamethonium may provoke bradycardia due to the IH, eds. Oxford handbook of Anaesthesia (3rd edition) Oxford: Oxford
high parasympathetic tone in infants; atropine should always University Press, 2011: 800-809.
be available. 2. Jewitt H. Chapter 2.8: Principles of Neonatal Physiology. In: Allman
KG, Wilson IH, eds. Dr Podcast Scripts for the final FRCA (1st edition)
Neonates and infants are more sensitive to non-depolarizing Cambridge: Cambridge University Press, 2011: 325-331.
neuromuscular blocking drugs. A normal loading dose is
3. Macfarlane F. Paediatric anatomy and physiology and the basics of
given but subsequent doses should be reduced.
paediatric anaesthesia. World Federation of Societies of
Anaesthesiologists 2005; Tutorial of the week number 7.
Analgesics and local anaesthetics
Drug doses need to be reduced due to immature metabolism, 4. Brown K. The application of basic science to practical paediatric
and in the case of local anaesthetics, lower levels of plasma anaesthesia. Update in Anaesthesia 2000; 11: 73-77.
Available from: http://www.wfsahq.org/components/
binding proteins (serum albumin and alpha-1 acid com_virtual_library/media/f28df37342cf2cb1f6390ccf0e49453d-
glycoprotein). Take extra care not to exceed maximum doses 7a87e9e9c2b627962e0aebe1ae752e45-The-Application-of-Basic-
or dose intervals of analgesics such as paracetamol, ibuprofen, Science-to-Practical-Paediatric-Ana.pdf

Equipment in paediatric anaesthesia
Basic Science
Graham Bell* and Rachel Homer
*Correspondence Email: gebell@btinternet.com
AIRWAY ADJUNCTS Lubricate with gel to minimise trauma to the

turbinates
Oropharyngeal (Guedel) airways
These are universally popular in children as they Avoid local anaesthetic preparations because
are easy to use and fast to insert. They can be these can alter pharyngeal muscle tone and
used to supplement airway manoeuvres such impair airway patency
SUMMARY
as jaw-thrust and chin lift during resuscitation, Insert gently along the floor of the nose
induction, and emergence from anaesthesia. The Differences in anatomy and
airway should only be inserted when the child is Take care not to exert too much pressure at physiology between children
deeply anaesthetised. If the child is too light the the post nasal space where the adenoids may and adults mean that much
of the equipment needed to
airway will not be tolerated, potentially leading be damaged. anaesthetise children needs to
to coughing, gagging, expulsion of the airway, or be specially adapted.
laryngospasm. Nasopharyngeal airways are usually used during
recovery rather than during anaesthesia. A
Oropharyngeal airways in children are best common indication is for the child at risk of
inserted correctly oriented. You should take care upper airway obstruction after cleft palate repair.
to avoid damage to the delicate soft palate in To prevent damage to the suture line during
young children, and to the posterior pharyngeal insertion, railroad the airway over a smaller
wall if a relatively large airway is used. They are nasogastric tube (confirm that this is in the
less likely to cause trauma on insertion than a stomach first), or allow the surgeon to insert the
nasopharyngeal airway. nasopharyngeal airway under direct vision.
Nasopharyngeal airways Facemasks

These are particularly useful in children with a A plastic facemask with an inflatable cuff/
tendency towards upper airway obstruction or a rim gives a better seal on the face, and is less
reduced level of consciousness. They are better frightening to the child than the traditional black
tolerated than an oropharyngeal airway. To rubber facemask. The correct size of facemask
insert: is one that reaches from the cleft of the chin
Graham Bell
Consultant in Paediatric
Anaesthesia
Rachel Homer
Fellow in Paediatric
Anaesthesia
Figure 1. Oropharyngeal airways come in a range of sizes suitable for premature neonates up to adults. To Royal Hospital for
find the correct size, hold with the flange in line with the middle of the incisors. The tip should just reach the Sick Children,
angle of the childs jaw Glasgow

Figure 2. The correct diameter of the nasopharyngeal airway is the same as the size of the endotracheal tube for that child (see Table 2).
Estimate the length by the distance from the nostril to the tragus of the ear as show. An uncuffed endotracheal tube makes a satisfactory
nasopharyngeal airway. Either attach a standard connector (to stop the tube from advancing and becoming lost in the nose); or split
the tube to facilitate secure taping as shown. Sutures may be tied around the tube to secure the airway as shown.
Figure 3. Clear plastic facemasks
to the bridge of the nose, but does not cover the eyes. For Laryngeal mask airways (LMAs)
small babies, round masks are available, or turn a shaped mask The LMA is the most widely available example of a supraglottic
upside down for an acceptable seal. airway device. They are suitable to use during maintenance

Figure 4. LMAs are available in a range of sizes appropriate for babies up to adults. They may be either single-use or designed for repeat
resterilisation. Rigid versus flexible stems can be easier to insert but more frequently displaced by heavy drapes or when close to the
surgical field
of anaesthesia in cases which you would otherwise manage In adults it is common to mechanically ventilate the lungs
by holding a facemask (low aspiration risk), to free the through the LMA. In children there is a higher risk of gastric
anaesthetists hands for other tasks. insufflation, so this is not widely practiced.
The size 1 LMA is less useful for routine anaesthesia because: Serious airway damage from the LMA cuff has not been
reported, but be aware that the cuff pressure exceeds that of
It is designed for children <5kg in whom a tracheal tube. Capillary perfusion pressure in children is
intubation and ventilation are generally preferred lower than in adults, thus the potential for injury is probably
It tends to dislodge, in which case it occludes rather than greater, even if the cuff is not inflated above the recommended
maintains the airway maximum volume (see Table 1). Be even more cautious in
longer procedures, as lingual oedema has been reported after
Coughing and laryngospasm on insertion are more LMAs have been in for a long time.
common with smaller LMAs.
Avoid overinflation of the LMA cuff:
It may still be useful to rescue a difficult airway, even in a small
baby (see Difficult airway article, page 116). Lower cuff pressures tend to give a better seal
There is less risk of pressure injury to tissues.
Table 1. Manufacturers guide to LMA sizes Opinions vary as to when to remove the LMA in children. The
choice is either deeply anaesthetized (asleep) or fully awake;
Weight (kg) LMA size Maximum cuff volume
between these extremes, you risk precipitating laryngospasm.
(mls)
Some suggest that the best time to remove the LMA is when
<5 1 4
the pharyngeal reflexes return and the child spits the airway
5-10 1 7 out.
10-20 2 10
Use in difficult intubation see article page 116
20-30 2 14
The intubating LMA is not made below a size 3, therefore is
30-50 3 20 not suitable for young children.

Laryngoscopes broken during clinically realistic force tests. Manufacturers
The epiglottis is long and U-shaped in infants and small label these blades Miller, Robertshaw etc., but they are often
children. This is advantageous when breast-feeding but not exact copies of the blades whose name they bear. Both
requires a different approach for intubation. A curved blade laryngoscopic view and illumination may vary.
placed in the vallecula will not provide a reliable view of the Endotracheal Tubes (ETT)
glottis. Straight blades designed to lift the epiglottis along with
the soft tissues at the base of the tongue give an easier view. The black marks used for guidance during laryngoscopy
vary widely between manufacturers and between tube types.
Some are meant to indicate the appropriate position at the
cords. Others simply make the tip easier to see. The only
reliable advice that can be given on ETT markings is to ignore
everything except the actual distance markings in centimetres.
A 3.5mm uncuffed ETT is suitable for the normal term
neonate. Use the formulae below to guide ETT selection in
older patients (Table 2). There should be a small leak around
the ETT to avoid excessive pressure on delicate mucosa. If
ventilation is compromised, the leak is too large. The nose
will accommodate the same size ETT as the larynx prior to
puberty.
A neonates trachea may be less than 4cm in length. The ETT
should sit at least 1cm above the carina, which is anteriorly
inclined and more symmetrical than in adults. Small flexion/
extension movements may cause accidental endobronchial
intubation or extubation respectively. You must be meticulous
in placing and securing the ETT.
Some children receiving intensive care benefit from a cuffed
tracheal tube. Most paediatric anaesthetists prefer uncuffed
tubes for routine anaesthesia in children up to 8 10 years old.
Reasons to choose an uncuffed tube:
Larger internal diameter tube can be used
Figure 5. The most popular straight blades are [left to right]
the Miller, the Robertshaw and the Oxford [top in (a)]. Many Confusing tube markings and long cuff shoulders have led
paediatric anaesthetists use a MacIntosh (size3) curved blade in to frequent endobronchial intubation with traditional
all children over 1 year old. Others prefer a straight blade until 5 cuffed tubes. The microcuff tube avoids these problems
years old. No one design has been shown to be truly superior.
Overinflation of endotracheal tube cuffs risks the potential
The international standards organization has a size mark for but rare complication of tracheal stenosis
laryngoscopes from 5 (largest) to 000 (smallest too small even Reasons to choose a cuffed tube:
for tiny premature babies). A size 1 blade is the correct size for Fewer intubation attempts with different sized tubes
a normal term baby, and a size 0 for premature neonates who
weigh less than 3kg. Reduced leak more important in ICU, also in anaesthesia
as better paediatric circle systems are developed and use of
It is possible to intubate with a laryngoscope that is slightly low flow anaesthesia in children increases
too big, and rarely possible with one too small. MacIntosh
considered smaller sizes of his original (size 3) blade unnecessary, There is no good evidence that either cuffed or non-cuffed
as the distal portion of the size 3 blade is straight and therefore tracheal tubes are better.
suitable for smaller children. He was correct!
BREATHING SYSTEMS
Many disposable laryngoscope blades exist. Some are of high
quality but this cannot be assumed, for example some have Semi-open (see article on drawover anaesthesia, p23)

Semi-closed However, in less skilled hands, the T-piece may result in
The T-piece is the most popular system for anaesthetising small
children in UK with many advantages: Inadequate ventilation (requires practice to use)
Lightweight Gastric insufflation
Compact High peak inflation pressures
The bag is easily visible whilst observing the patient Inadvertent barotrauma.
Simple to use for spontaneous or controlled ventilation It is customary to use adult breathing systems in children > 20
30kg. To prevent hypercarbia during controlled ventilation,
No valves the fresh gas flow in ml can be predicted by the formula (1000
+ (200 x kg)) (minimum of at least 3 l/minute), which is
Low internal resistance approximately 1.5x the minute volume. During spontaneous
Low compression volume (i.e. the operator has a good feel breathing in young children, there is no end expiratory pause
for the lung compliance). and the system becomes less efficient; twice the fresh gas flow
required for controlled ventilation should be used (i.e. about 3
Jackson-Reece modified the system by adding an open-ended x the minute volume).
bag. This bag has several advantages:
Respiratory monitor during spontaneous ventilation
Easy to convert to manual controlled ventilation
Easy to apply PEEP.
In skilled hands the T-piece is the best system for resuscitation.
The application of CPAP / PEEP splints the upper airway
open and so improves the efficacy and ease of ventilation.
Figure 7. Humphrey ADE. Newer versions are, in fact, AE systems;

there is no option for a Mapleson D. The E system (lever down) is
a T-piece; it has no bag and no valve and is used for controlled
ventilation (fresh-gas flow as for the T-piece, above). The A system
Figure 6. T piece attached to oxygen cylinder. The same (lever up) has the configuration of a parallel Lack circuit. This is
connection will fit the outlet of an oxygen concentrator. ideal for children breathing spontaneously because of the low
Alternatively, the T pieces green tubing connects directly to an resistance of both the smooth inner bore of the tubing and the
anaesthetic machines common gas outlet. A T piece requires gas expiratory valve. A flow rate of 3 l/minute is sufficient for most
flow. children before adolescence.

Closed particularly if an IV extension has been used. Avoid flushing
Early circle systems imposed a high work of breathing due to with heparinised saline in neonates. Heparinised saline
the resistance of one-way valves. This is much less of a problem contains 10 iu.ml-1 of heparin; 10ml given to a 3kg neonate is
with modern circles but other issues remain: 33 iu.kg-1 and this could easily affect clotting.
A leak around the tracheal tube means that low flows Central venous catheters
cannot be used efficiently (solve by using cuffed tracheal These are smaller versions of adult catheters, with up to 4
tubes) lumens.
The volume of the breathing system is large compared Sites for central venous access
with minute volume, giving longer equilibration times Femoral venous access is more popular in children than adults.
than in adults The tip of the catheter is the most likely place for thrombus
formation, so choose the length of the catheter so that the tip
The tubing has a significant compression volume, which does not lie at the junction of the renal veins with the inferior
may alter the characteristics of ventilation during positive vena cava (IVC). Either short lines (catheter tip in the iliac
pressure ventilation. Avoid by using stiffer tubes and vein or lower IVC) or long lines (tip just below the diaphragm)
smaller bellows are appropriate. Central venous pressure monitored from the
Paediatric circle systems do not maintain the temperature latter position is as accurate as from the superior vena cava
or humidity of inspired gases adequately. (SVC). Confirm the position of longer femoral lines on X-ray
if available, because the line may pass into the contra-lateral
femoral vein, the renal vein or the epidural venous plexus.
IV ACCESS
In children <2 years old, the J-portion of J wires may exceed
Administering fluids the dimensions of the central vein which will make the wire
Standard blood and fluid administration sets are suitable for difficult to thread.
children. A burette should be used for small children (<10kg)
The umbilical vessels are easily accessible during the first 24
so that the volume of fluid can be measured accurately and to
hours of life (and less easily so for a further 3 days). Placing
avoid giving excessive volumes of fluid.
the tip of an umbilical venous catheter in the correct position
In-line fluid warmers are of great benefit, but they add is easier if you adapt the catheter tip to be a unipolar electrode
considerable deadspace into the system, and require electricity, and monitor the ECG signal until you obtain a characteristic
and costly single-use disposables. Water baths are not atrial ECG. Umbilical arterial lines have been linked with the
commonly used to warm IV fluids because contamination development of necrotising enterocolitis, although this is not
with Pseudomonas species can cause serious infection. Fluids proven. Umbilical venous catheters are particularly prone to
may be stored in a warming cabinet or other warm place prior thrombosis, which may lead to portal hypertension. They
to administration. Some anaesthetists place the sealed bag of should be replaced as soon as alternative access is practical.
IV fluid on top of the monitor as this becomes warm during
Peripherally inserted central catheters (PICC lines)
use. This is only partially effective, but makes use of a readily
These are available as small as 27g and provide access for drugs
available source of heat!
or parenteral nutrition. Smaller lines cannot be used for pressure
Peripheral cannulae and flushing monitoring or sampling. Hypertonic drugs (e.g. thiopentone)
Young children more commonly have a patent foramen ovale. or drug precipitates (e.g. thiopentone/ suxamethonium) are
This means that bubbles administered IV may embolise to likely to block these lines. Flush all medicines in immediately
the systemic circulation rather than the lung. Remove all air after administration.
bubbles from the fluid administration system. It is difficult to
Intra-osseous needles
give guidelines about the amount of air that poses a danger
There are discussed in a separate article (see page 242)
because speed of injection is as important as volume. Deaths
have occurred after as little as 0.5ml.kg-1 injected rapidly. DEFIBRILLATORS
The dead-space of injection ports and cannulae can be There are no specific defibrillators designed for children. Many
significant. For example, neonates have been paralysed by standard defibrillators have paediatric paddles similar to those
the quantity of suxamethonium present when the hub of shown in Figure 8: the adult paddle slides off the smaller
the cannula was flushed post-operatively. Anaesthetists must paediatric paddle. Paddles must be positioned as far apart as
flush the cannula carefully with saline after injecting drugs, possible to reduce the chances of arcing. Use gel pads (not

shown) to reduce impedance between paddle and patient as pads on an AED will deliver up to 360J.
for adults. Self-adhesive pads may be available (see Figure 8).
There is evidence that biphasic waveforms are more effective
The appropriate size of paddle is the largest pad that will for the treatment of ventricular fibrillation. Advantages seen in
fit the childs chest, as this will reduce both transthoracic adult practice include
impedence and the potential for chest burns. These pads are
often labelled with a recommended weight range for standard Less time needed to charge
hospital controlled dose defibrillators, or with an age range for Improved first shock success rate (90% compared
automatic external defibrillators (AEDs). with 60%)
The appropriate energy levels for children are different from Less myocardial injury
those for adults (see Paediatric Resuscitation p264). Advisory
defibrillators and AEDs prompt the user down adult Advanced Decreased incidence of skin burns
Life Support (ALS) algorithms and so are not recommended in
Increased battery life of the defibrillator.
infants < 1 year old, although they have been used successfully
in young children when there has been no alternative. Current paediatric recommendations are to select the same
Paediatric pads, if used on an AED, will automatically deliver a energy (4J.kg-1 in cardiac arrest) for a monophasic or biphasic
lower energy, which varies between defibrillator models. Adult defibrillator (see resuscitation articles p267 and 270.)
Figure 8. Paediatric defibrillator pads and paddle positions.

TEMPERATURE CONTROL Oesophageal or precordial stethoscope
This low-technology device offers continuous, immediate
Good temperature control is vital in paediatric anaesthesia information on breath and heart sounds without the lag times
(see basic sciences article p4). You must monitor temperature associated with oximetry and capnography.
during active warming.
Pulse oximeter
Warming methods include: Oximetry probes need to be matched to the size of the patient.
Too large a probe will give a poor reading due to light scatter
Forced air heating blankets e.g. the Bair Hugger. These
and easily falls off. When you choose the site carefully, you
devices deliver warm air up to 43C for active warming.
can use adult sized probes for younger children e.g. an adult
They can also blow room temperature air to cool patients
ear probe can be attached to a digit. These ear probes have
who are pyrexial
spring closures, which may produce sufficient pressure to cause
Simple warming blankets reduce conductive losses to the ischaemia in a childs finger. Wrap-around probes are available
table and are cheap and effective although not as efficient and may be used on digits, or in small babies wrapped around
Overhead radiant heaters are also cheap and effective. Pay a foot or hand. They have no risk of pressure necrosis but
strict attention to the safe minimum height of radiant do produce heat. Burns have occurred in children with low
heater above the patient. Patient signs of systemic peripheral perfusion e.g. during cardiopulmonary bypass.
overheating will be late. Local overheating presents as burns. The absorption spectra of foetal and adult haemoglobin are
Radiant heaters increase insensible water loss in neonates similar, and at 660nm and 910nm in a basic pulse oximeter
Prevent heat loss by insulation when active heating is the device is accurate in detecting desaturation of foetal
impractical or unavailable. Almost any insulating material haemoglobin.
may be used e.g. clean blanket or clothing, cotton wool,
Problems and pitfalls
tinfoil or bubble wrap
Pulse oximeters are poor indicators of hyperoxia due to the
Raised operating theatre temperature for babies or small
shape of the oxyhaemoglobin dissociation curve. Whilst the
children. You will need to compromise between the thermo
pathogenesis of retinopathy of prematurity is multifactorial,
neutral temperature for the anaesthetised patient (34C for
it is important to avoid hyperoxia in at risk babies
premature neonates, 33C for term neonates reducing
(particularly premature neonates)
through childhood to 30C at adolescence) and a
comfortable working temperature for staff (up to 25C). Pulse oximeters may be inaccurate in the presence of certain
One solution is to have the temperature relatively high pigments: methylene blue gives a falsely low reading.
during induction of anaesthesia, and then reduce it once Bilirubin does not affect pulse oximetry
the patient is draped and use a forced air warmer if available
to maintain a microclimate during surgery Potential inaccuracies in children with congenital heart
disease: the oximeter derives arterial saturation by
In theory circle systems warm and humidify inspired gases. subtracting the fixed absorbance part of the signal. In
In practice these effects are small. Some circle systems have tricuspid regurgitation, the monitor may detect a pulsatile
additional heaters to aid gas warming. HME (heat moisture venous component of the signal, and display the venous
exchange) filters help saturation
Heated humidifiers may be added to any breathing circuit, In infants with a physiological shunt through a patent
and will help warm the patient by warming airway gases. ductus arteriosus, the pulse saturation will vary between
Monitor gas temperature at the patient end to avoid airway the right arm (pre-ductal) and other limbs (post-ductal).
burns The pre-ductal blood supplies the cerebral circulation, so
measure saturation on the right arm as a minimum.
Warm fluids as above.
Phone app based pulse oximeters are appearing on the market.
MONITORING All necessary hardware is incorporated into the finger probe
Standard monitors for a child are the same as for an adult. It with a connection to a mobile phone where the phone app
is acceptable to complete the attachment of patient monitors provides the software and display. Some of the probes now
after induction of anaesthesia to prevent a child becoming have FDA approval, but experience of their use is limited at
distressed as long as there is no compromise to safety. present.

Apnoea monitors 2-5 years, the axis is within the adult range. T wave inversion
These are frequently requested by paediatric anaesthetists to reverses by 10 years old when the ECG becomes similar to that
monitor babies <6 months old after anaesthesia. They are of an adult.
designed to alarm after 15 or 20 seconds of apnoea. They
detect breathing in one of two ways: Lead II is usually the best choice in all ages as the prominent P
wave aids rhythm recognition. A common error is that large T
By changes in impedance measured through ECG waves may be read as QRS complexes by the monitor causing
electrodes on the chest double counting of the rate.
By a change in pressure detected by a sealed mattress or a Blood pressure measurement
small sensor on the abdomen as shown in Figure 8
(abdominal excursions move a fine foil strip in the monitor) Non-invasive blood pressure measurement
(More common). All non-invasive blood pressure machines that measure from
a cuff are automated oscillotonometers. The most important
Apnoea monitors are cheap and non-invasive but have some considerations are the width and length of the bladder used in
disadvantages: the cuff (see Table 3).
Prone to false positive alarms, and to interference from Table 3. Determining the appropriate size of a blood pressure
mobile phones cuff. If the cuff is too small, the reading will be artificially high;
the reverse is true if the cuff is too big. Common Error: generally,
Will not detect airway obstruction, because movement of oscillotonometers over-read lower pressures, i.e. they over-read
the chest and abdomen still occurs values within the normal neonatal range.
Cardiac pulsation may trigger the monitor, even if the BP cuff bladder Should cover Neonate 3cm
child is apnoeic. width approximately 2/3
of the upper arm Baby 5cm
These monitors should be used as an adjunct to high
dependency nursing care, not a substitute for it. Small child 6cm
Electrocardiography (ECG) Large child 9cm

As children do not usually have ischaemic heart disease, the BP cuff bladder Minimum 40% of
ECG is used mainly as a heart rate and rhythm monitor and length the circumference
rarely to detect ischaemia. At birth, the right ventricle is as of the upper limb;
80% is ideal
thick as the left. This manifests as right axis deviation and
right ventricular hypertrophy on the ECG (dominant R wave The machine settings for adult, paediatric or neonatal modes
in V1, deep S wave V5 & V6, inverted T wave V1-4). With usually control only the maximum inflation pressure. This is
growth, the left ventricle becomes larger than the right. By age to avoid excessive pressure and the risk of bruising or trauma
in babies or small children if exposed to the values in a
hypertensive adult.
Direct arterial blood pressure measurement has the same
principles as in adults. If using an umbilical arterial catheter
in neonates, which is relatively long and thin, inspect the trace
for signs of overdamping.
Safety point: take care with manual flushing. Meticulously
avoid bubbles, and note that a brisk 1ml flush in a neonate is
sufficient to push bubbles or thrombus from the radial artery
back as far as the vertebral artery.
Peripheral nerve stimulators
Peripheral nerve stimulators may be used in children for
monitoring neuromuscular blockade, or localization of
peripheral nerve. The response of the paediatric neuromuscular
Figure 10. An apnoea monitor for a baby junction to neuromuscular blockade is similar to that of

adults. In neonates, the immature junction is sensitive to non- You should still obtain some CO2 tracing if you are careful to
depolarising muscle relaxants, with reduced prejunctional minimise equipment deadspace, but with a large and variable
reserves of acetylcholine. A-a gradient.
CO2 monitoring/end-tidal agent monitoring/oxygen
monitor CONCLUSION
End-tidal gas measurements are unreliable in babies. The tidal Consideration of the anatomical and physiological differences
volume is small compared with equipment dead space volume, between paediatric and adult patients makes it easier to select
fresh gas flow, and leak around the endotracheal tube. Small the correct equipment to anaesthetise all patients safely.
tidal volume and rapid respiratory rate confound the monitors Availability of the appropriate equipment may be the more
real-time analysis. difficult problem.

Paediatric drawover anaesthesia
Basic Science
Sarah Hodges
Correspondence Email: sarahhodges1911@gmail.com
INTRODUCTION designed specifically for ether,

The drawover system provides anaesthesia Oxford inflating bellows with two one way
without requiring compressed gases and is the valves
most commonly used method for delivering
Heidbrink valve at the patient end.
anaesthesia wherever there is not a reliable supply
of compressed gases. Over the years the Ambu E valve was introduced
to replace the Heidbrink valve. This enables both Summary
The essential components of the drawover system
spontaneous and assisted ventilation but makes The drawover system
are
the second valve on the Oxford inflating bellows provides anaesthesia without
A vaporiser (OIB) redundant. There is a magnet which sits requiring compressed gas.
A self-inflating bag or Oxford inflating over the second valve to disable it when an Ambu It is very robust, portable,
bellows E valve is being used. compact and easy to
maintain.
Two valves. The drawover system is very robust, portable,
compact and easy to maintain and as it does not Even though it is challenging
BASIC PRINCIPLES OF USE anaesthetising small babies
rely on a supply of compressed gases it is not only with minimal equipment, the
Air is the carrier gas, which can be enriched with
popular in developing countries but also with the drawover system can provide
oxygen if available. This is drawn by the patients
military for battlefield anaesthesia. a safe, robust, portable and
inspiratory effort through the vaporiser into cost effective system for
the patients lungs via a non-rebreathing valve. The vaporisers used in drawover anaesthesia have anaesthetising babies and
Drawover is a low pressure system and without a very low resistance. During anaesthesia the children.
the one way valves gas flow could occur in any gas flow is intermittent (during inspiration with
direction. The valves ensure flow of air and spontaneous ventilation and during expiration
oxygen through the vaporiser to the patient. with assisted ventilation). The volume of air
passing through the vaporiser is determined by
One of the earliest systems consisted of:
the patients tidal volume and respiratory rate.
EMO (Epstein-Mackintosh-Oxford vaporiser There may be huge variations depending on
the respiratory effort and size of the patient.
Oxford inflating bellows
The dialled concentrations remain very accurate
despite these massive variations.
EMO
The first drawover vaporisers were designed for
ether. Characteristics of ether include:
Magnet Low boiling point - 34oC
High saturated vapour pressure - 56.6kPa
Blood gas solubility coefficient (12) which is
much greater than most commonly used
Embu E valve volatiles like sevoflurane (0.9) and isoflurane Sarah Hodges
(1.2) Mengo Hospital
PO Box 20146
Both induction and wake up are slow
Nakawa
Figure 1. A basic drawover system incorporating an EMO Atropine is required in all patients due to the Kampala
vaporiser excessive salivation produced Uganda

Respiratory stimulant a TEC 3 or TEC 4 vaporiser which has a resistance of 21-
29cm of water (= 2.02.84kPa). It has cloth wicks which still
Sympathomimetic
contain 200mls of ether when the level indicator is empty. If
Causes bronchodilatation the EMO is overfilled the wicks will be submerged and the
Some analgesic effect at low doses output will decrease. It has a temperature indicator which is
red when above 30oC, aluminium at less than 10oC and black
Potentiates the effect of muscle relaxants at the optimal working temperature 10oC to 30oC. It produces
Tends to increase blood glucose concentration, and to relax very accurate concentrations with variable flow rates but loses
uterine muscle precision with continuous flow and with extremely low flow
rates.
Gas induction is very slow as it is also a respiratory
irritant. Increase the concentration by 1% every 6-8 breaths OMV
up to 10% and then increase it by 2.5% every 6-8 breaths
Detachable
up to 20% calibration
scale
Maintenance concentration is 6-8% with spontaneous
breathing and 2-4% if the patient is being ventilated.
Although ether was removed from the WHO essential drugs
list in 2012, it is a useful and safe volatile anaesthetic especially
in areas where oxygen is scarce or where there is no trained
anaesthetic provider. There is a risk of explosion which is No
minimised when using only air as the carrier gas and in remote keyed
locations diathermy is rarely available. If diathermy is being filling
used a safe distance of 20cm between the expired port and
the diathermy should be maintained. Ether is heavier than air Figure 3. The OMV
and a scavenging tube can be fixed to the expiratory port and
dropped to the ground to minimize the amount ether around
the surgical site. A version of the Oxford miniature vaporiser (OMV) is used
as part of the Triservice apparatus. Although the carrier gas
THE EMO flows from right to left in most drawover apparatus, in the
triservice version of the OMV carrier gas flows from left to
right. It is very compact with a capacity for 50ml of anaesthetic
agent. It has a metal wick and is not thermally compensated
but only thermally buffered with an ethylene glycol jacket.
In the original design the downstream vaporiser was filled
Temperature
indicator
with trichloroethylene. The calibration scale can be detached
allowing use of different inhalational agents, most commonly
Level
indicator halothane. It is accurate with variable flow rates but this
Port for filling
the vaporiser
accuracy drops off in the continuous flow mode. As it is only
thermally buffered, with prolonged and high gas flows the
concentration decreases as the temperature decreases and you
will see condensation appear on the outer surface.
The PAC vaporiser is another drawover vaporiser originally
made with different models for ether, methoxyflurane,
Figure 2. The EMO vaporiser trichloroethylene and halothane. It is now only used for
halothane. Some models have keyed filling. It is thermally
As such high concentrations are required to maintain
compensated with a bimetallic strip. Its accuracy decreases
anaesthesia, the EMO and Afya - the two drawover vaporisers
rapidly when used with continuous flow and very low flows.
designed for ether - are very bulky. The EMO is thermally
buffered with a 1500ml water jacket and compensated with a TECHNIQUE
small ether bellows and requires no keyed filling. The resistance In the standard drawover system the inspired oxygen concentration
through the EMO is only 0.5cm of water (= 0.049kPa) unlike is determined by:

Diamedica drawover apparatus A pedivalve (no longer manufactured)
PEEP
valve
Vaporiser
Self-inflating bag
Reservoir bag for oxygen
Figure 2. The Diamedica drawover apparatus. In recent years this system

has been incorporated into a more typical anaesthesia machine, the
Glostavent
Total ventilation
Oxygen flow rate
Size of the reservoir tubing upstream of the vaporiser.
The respiratory rate and inspiration/expiration ratio have
much less influence on the inspired oxygen concentration. If
the reservoir tubing is short, with a volume of 104ml, then
a high inspired oxygen concentration is impossible whatever
flow rate is used. With a reservoir tubing of at least one metre
in length and 415ml volume an inspired oxygen concentration
(FiO2) of 30% can be achieved with a flow rate 1L.min-1 and
60% with a flow rate of 4L.min-1 As air is the main carrier
gas for the drawover system it is impossible to achieve 100% Figure 5. Paediatric Drawover using a paedivalve, a small self- inflating bag
inspired oxygen concentration for pre-oxygenation unless you and two OMV vaporisers as in the Triservice apparatus.
fill a large bag with 100% oxygen and attach it tightly to the
In the earliest system everything was downsized except the
reservoir tubing.
EMO. There was a paediatric Oxford inflating bellows and
The portable Diamedica drawover system has overcome the a pedivalve instead of the standard Ambu E valve. A small
limitation on inspired oxygen fraction by adding a reservoir self-inflating bag (SIB) can also be used to replace the Oxford
bag which is constantly being filled with oxygen throughout inflating bellows.
the respiratory cycle. Another way to use drawover in children is to convert it to
Standard drawover systems have to be adapted for use in small a manual continuous flow. Attach an Ayres T-piece to the
children to overcome the deadspace and turbulence in the outlet of the Oxford inflating bellows (OIB) or self-inflating
apparatus and the resistance in the valve. These all increase bag (SIB) which is attached to the outlet of the vaporiser (EMO,
the work of breathing for small children and potentially cause OMV, PAC). With the Oxford inflating bellows both valves are
alveolar collapse. in use to ensure unidirectional flow as this is still a low pressure
system. Compress the bellows about 6-8 times per minute
Mask induction, providing CPAP and pre-oxygenation are all with a rapid upward jerk and a slow downward movement.
more problematic with drawover anaesthesia in small children. This sucks a flow of air and oxygen across the vaporiser and
The other issue in paediatrics is the performance of the fills the bag on the T-piece which is used to ventilate the
vaporiser. Generally the drawover vaporisers continue to baby. The compression of the bellows has to be constant and
be efficient at small tidal volumes as their output is affected continue in both spontaneous and assisted ventilation. A
more by a drop in temperature than tidal volume. With all similar effect can be achieved with a self-inflating bag but as
the vaporisers except the recently designed ones, there is a by its nature a self-inflating bag reinflates automatically with
noticeable loss of output with continuous flow. air 60 small squeezes per minute will achieve a tidal volume of

approximately 100ml. It is important not to over compress the
self-inflating bag as this will be transmitted to the babys lungs Merucry
and may cause overinflation. This manual continuous flow sphygmomanometer
mimics adult drawover but the output of the vaporisers is not
as expected. You will usually need to dial up a higher inspired
concentration and is therefore less economical. It can be used
when there is no oxygen or electricity but it is very labour
intensive as one hand is pumping the bellows and the other Farmans
entrainer
ventilating with the Ayres T-piece. This can make it difficult at
induction especially if there is no assistance to the anaesthetic
provider.
Another way of using the drawover apparatus in small infants
Oxygen supply
is to convert it to simple continuous flow. This can be done
using a Farmans entrainer:
Fits into the distal end of any drawover vaporiser.
Farmans entrainer in use with the EMO
Acts as a venturi entraining air as oxygen flows through at
Figure 5. Farmans entrainer in use with the EMO.
2L.min-1. This produces total flow approximately 10L.min-1
and FiO2 35%.
Oxford inflating bellows have to be closed but remain in circuit that its total volume is 2 litres: only slight movement is needed
for their valves: this is still a low pressure system and flow could to ventilate babies. You may prefer to insert a paediatric self-
become bidirectional without the valves. inflating bag instead. As ether has now been removed from the
WHO essential drugs list halothane will be the main volatile
Produces a continuous flow of air and oxygen so that the in use in remote locations. With halothane it is much safer if
vaporisers markedly lose their accuracy: drawover vaporisers oxygen can be added to air using reservoir tubing at least 1
were designed for intermittent gas flow. metre in length.
Attach the side arm of the vaporiser to a mercury Even though it is challenging anaesthetising small babies with
sphygmomanometer. Adjust the flow of oxygen until the minimal equipment, the drawover system can provide a safe,
manometer reads 100mmHg which is supposed to ensure robust, portable and cost effective system for anaesthetising
a total flow of 10-12L.min-1. babies and children.
You can also produce continuous flow by simply attaching Key points:
the oxygen supply directly onto the vaporiser and putting an
Ayres T-piece on the outlet of the vaporiser. This needs a high <5kg assist ventilation for all cases
flow of oxygen and a one way valve between the vaporiser and 5-10kg spontaneous ventilation for short cases, assisted
the T-piece to prevent backflow and ensure filling of the bag ventilation if longer than 20 minutes
on the T-piece. As with the Farmans entrainer the vaporiser
>10kg spontaneous ventilation unless muscle relaxation
will deliver significantly lower concentrations than expected.
required.
In the newer designed systems with a reservoir bag attached
to the inlet of the vaporiser, you can connect a T-piece with References
a one way valve directly to the vaporiser outlet or substitute a 1. Primary Anaesthesia Edited by Maurice King.
paediatric self-inflating bag for the adult one. 2. Anaesthetic vapour concentrations in the EMO system. H.G.
In situations where there is a lack of paediatric equipment it is Schaefer & J.V. Farman. Anaesthesia 1984; 39: 171-80.
safe to use the adult drawover equipment. You must ventilate 3. Minimum oxygen requirements during anaesthesia with the Triservice
all babies under 5kg body weight however short the procedure. apparatus. A study of drawover anaesthesia a in the young adult.
S.Q.M. Tighe, et al. Anaesthesia 1991; 46: 52-6.
You may allow 5-10kg infants to breathe spontaneously for
short cases but use assisted ventilation for the longer cases. 4. The Oxford miniature vaporizer in paediatric anaesthesia. An
experimental study. I.H. Wilson et al. Anaesthesia 1988; 43: 700-2.
Allow spontaneous respiration for children over 10kg. If only
the Oxford inflating bellows is in use then you must remember Figure 1 and 6 courtesy of Dr Iain Wilson.

Co-morbid disease
Anaesthesia and congenital abnormalities
K Ganeshalingam and T Liversedge*

*Correspondence Email: Tim.Liversedge@gosh.nhs.uk
There are many congenital abnormalities that affect a flat nasal bridge, midface hypoplasia and a
children and where children may require surgery protruding tongue.
in childhood. Many conditions affect multiple Prominent epicanthic folds, upwardly
systems, so it is important for the anaesthetist to slanting palpebral fissures.
have a thorough understanding of the problems
Generalised hypotonia and joint laxity.
that may be encountered. This article will consider Summary
Down syndrome and other congenital syndromes of Single transverse palmar crease and wide 1st
and 2nd toe gap. This article reviews some of
relevance to the paediatric anaesthetist.
the congenital conditions
Brushfield spots (light coloured spots near a paediatric anaesthetist
DOWN SYNDROME (TRISOMY 21) the periphery of the iris). can expect to encounter,
Down syndrome (DS) is associated with major Children are often low birthweight and small in with an emphasis on Down
congenital abnormalities including cardiac lesions, infancy; however there is a tendency to be overweight syndrome.
craniofacial abnormalities and intellectual impairment. by 3-4 years and to obesity in adolescence. This may Many conditions affect
It is the commonest chromosomal abnormality with in part be due to their reduced resting metabolic multiple systems, so it
an incidence of 1 in 740 live births in the UK.1 First is important to have a
rate.3 Venous access may therefore be difficult.
thorough understanding
described by John Langdon Down in 1866,2 the Small stature, hypotonia and increased ligament of the potential problems.
association between DS and trisomy of chromosome laxity require vigilance during positioning under Children presenting
21 was identified in 1959.3 95% of people with anaesthesia. Hearing impairment, ophthalmological for surgery should be
DS have trisomy 21, 3-4% have an unbalanced and dermatological problems, dental disease and assessed carefully, with
translocation for all or part of chromosome 21 or orthodontic problems contribute to the many surgical particular attention to the
mosaic trisomy 21.4 There is higher incidence with interventions required, and also carry implications for cardiorespiratory system
increasing maternal age (1 in 1600 at 25 years old, 1 development of children with DS. and the airway.
in 40 at 43 years old).5 The diagnosis of DS is made It is not possible to cover all
by chromosome analysis, either antenatally when risk Cardiovascular syndromes in one article,
factors are identified or postnatally in infants with the Up to half of children with DS have congenital but a Google search on
characteristic features of the condition. cardiac lesions.3 DS is the condition most frequently the internet provides an
associated with congenital heart disease, therefore all invaluable resource when
Fifty years ago, 30% children with DS died in their children with DS who require anaesthesia should be faced with a child with a
first month, 53% in their first year, and 70% in assessed for signs and symptoms of cardiac disease. rare congenital syndrome.
their first 10 years.6 Today, 1-year survival is 90% or The commonest lesions are:
more, with 45% surviving to 60 years old in some
Atrioventricular septal defect (AVSD) (45%)
countries.5 This increase in 1-year survival is partly due
to improving surgical techniques and more aggressive Ventricular septal defect (VSD) (35%) K Ganeshalingam
treatment of life-threatening abnormalities.5 However, SpR Anaesthesia
outcomes differ throughout the world. Children Atrial septal defect (ASD) (8%) Barts and the London
with DS present for surgery and general anaesthesia School of Anaesthesia
Patent ductus arteriosus (PDA) (7%)
throughout childhood and many of the features of DS London
have significance for the conduct of anaesthesia. Tetralogy of Fallot (TOF) (4%)
T Liversedge
Pulmonary vascular disease (PVD). Consultant Paediatric
Clinical features and anaesthetic
Children with DS develop pulmonary vascular Anaesthetist
implications of DS
disease and pulmonary hypertension in the presence Great Ormond Street
The characteristic phenotypic features of patients with of cardiac defects with a left to right shunt at an earlier Hospital NHS
DS include: stage than children without DS and the same defects.7 Foundation Trust
Flat occiput, short neck, small low set ears, Pulmonary vascular disease (PVD) may also occur in London

the absence of cardiac lesions as a result of hypoxaemia due to chronic border of the odontoid peg). Where history or examination reveals
pulmonary infections, hypoventilation due to muscle hypotonia, and any signs or symptoms suspicious of cervical cord compression,
obstructive sleep apnoea. It is recommended that all newborns with elective surgery should be postponed and specialist referral made.8
DS be assessed with an echocardiogram by a paediatric cardiologist For urgent surgery in this setting, standard precautions should be
by 6 weeks old, and a plan of action be put in place early for those taken to immobilise the cervical spine.8 There have been a number
with a cardiac defect.5 This is not always practical in low and middle of case reports of cervical spinal cord injury related to anaesthesia
income (LMIC) settings; careful auscultation and pulse oximetry, and surgery.8 If the patient has no clinical evidence of cervical cord
especially if both of these are repeated, will inform a discussion with a compression, but requires prolonged positioning in a non-neutral
specialist centre about which patients should be seen early. Morbidity position or difficult laryngoscopy is anticipated, it is recommended
and mortality for uncorrected lesions is high. Surgical correction of that radiological evidence of cervical spine stability be obtained.8
AVSD should take place by 6 months of age, before the development Some centres conduct routine screening with upright lateral cervical
of PVD, with some authorities recommending correction by 4 spine Xrays, but this is not universally recommended.7 In the absence
months for optimum outcome.5 46% of adolescents and young of abnormal neurological signs and symptoms on history and
adults with DS develop mitral valve prolapse with or without examination, avoidance of forced neck flexion, extension or rotation
tricuspid valve prolapse and 17% will develop aortic regurgitation;2,3 under anaesthesia should be adequate.7
repeat echocardiographic screening should be undertaken for those
requiring anaesthesia as adolescents, young adults and in later life. Central Nervous System
Conduction defects can occur following surgical repair of defects.4 Developmental delay and moderate to severe learning
disability,
Respiratory/airway
Microcephaly,
Airway management during anaesthesia can be challenging and there
is a higher incidence of perioperative respiratory complications in Epilepsy (10%).
patients with DS:
A degree of intellectual impairment and developmental delay is
The incidence of obstructive sleep apnoea (OSA) is 50- universal. There is a higher incidence of behavioural disorders and
75%.5 This is related to the craniofacial abnormalities autism.
and pharyngeal hypotonia seen in DS and will be worsened
Gastrointestinal
in the presence of hypertrophy, inflammation and infection
Gastrointestinal abnormalities are a frequent association with DS
of the tonsils and adenoids (children with DS will
and a common reason for surgery in early life.7
frequently present for adenotonsillectomy). Patients with
DS require close observation for obstruction post Duodenal atresia is the most common association,
anaesthesia,
Gastro-oesophageal reflux,
Recurrent respiratory tract infections,
Hirschsprungs disease.
Macroglossia, small mouth, midface hypoplasia, mild
Tracheoesophageal fistula, pyloric stenosis and imperforate anus may
mandibular hypoplasia, oropharyngeal hypotonia,
also occur.
Adenotonsillar hypertrophy,
Subglottic or tracheal stenosis is seen in 2-6% of patients.
Endocrine
Hypothyroidism occurs in up to half of affected individuals.5
Musculoskeletal Screening for thyroid disease should be undertaken at birth, 6
Craniocervical instability, months and yearly thereafter. 1% children and adolescents with DS
Generalised poor muscle tone. develop diabetes mellitus.3 Relatively low catecholamine levels and
diminished sympathetic nervous system activity have been reported.7
Craniocervical instability is a feature of DS and may be due to
laxity of the transverse ligament and abnormalities of C1 (atlas) Haematological/immunological
or C2 (axis) vertebrae. Asymptomatic atlantoaxial dislocation Acute lymphoblastic leukaemia, acute myeloid leukaemia,
occurs in 12 to 20%, however spinal cord compression is rare.2 Any
history of neck pain, limited neck mobility or head tilt, change in Polycythaemia in neonates,
gait pattern, clumsiness, abnormal neurological reflexes, abnormal Impaired cellular immunity with increased susceptibility to
sensation or the presence of bladder and bowel dysfunction suggest infections.
the possibility of cervical spine pathology. Diagnosis of cervical
spine instability is difficult. Lateral flexion, extension and odontoid Preoperative evaluation of a child with Down
cervical spine radiographs are poorly predictive of cord compression. syndrome
Atlantoaxial instability (AAI) is defined by an anterior atlantodental Thorough pre-operative evaluation includes a detailed history taken
interval (AADI) greater than 4-5mm (the distance between the from the parent or carer and examination of the child, performed
posterior border of the anterior arch of the atlas and the anterior with particular emphasis on the cardiovascular and respiratory

systems, airway and cervical spine. The degree of cooperation from In a retrospective review of anaesthesia for patients with DS for
the child will vary with age and severity of learning disability. noncardiac surgery, severe bradycardia occurred in 3.66% cases
during induction of anaesthesia.4 This may be associated with
Cardiovascular evaluation includes assessment for symptoms and
significant haemodynamic instability in children, who are more
signs of congenital heart disease, an ECG, and an echocardiogram
reliant on heart rate to preserve cardiac output. Intravenous atropine
and cardiology opinion where appropriate. Symptoms suggestive
should be readily available on induction, and pre-treatment may be
of congenital heart disease (CHD) include failure to thrive,
indicated, for instance if halothane is used.
dyspnoea, poor exercise tolerance, recurrent respiratory infections,
cyanotic spells, syncope and chest pain. Signs include tachycardia, The same study found a 1.83% incidence of airway obstruction
tachypnoea, cyanosis, finger clubbing, heart murmurs, precordial on induction of anaesthesia and 0.54% incidence of difficult
thrills, cardiomegaly, hepatomegaly, and decreased or absent femoral intubation.4 Be prepared for potentially difficult bag-mask
pulses. ventilation, laryngoscopy and/or intubation. Appropriately-sized
oro/naso-pharyngeal airways and laryngeal mask airway must be
You must assess the airway and evaluate for features of craniocervical immediately available to rescue a potentially difficult airway. A
instability. History and examination of the respiratory system should smaller endotracheal tube (ETT) than predicted by age/weight is
search for features of OSA, subglottic or tracheal stenosis and frequently required in the presence of subglottic or tracheal stenosis.
respiratory tract infection. There is also a higher incidence of airway obstruction on emergence
and an increased incidence of post-extubation stridor (1.83%).4
Children with DS are generally gentle, cheerful and outgoing,
Intubation should be carried out with minimal manipulation of
but may have a tendency to hyperactivity and will have limited
the craniocervical spine by an experienced anaesthetist if there is a
understanding compared to a normal child of the same age. A clear
suspicion of atlantoaxial instability.
explanation of the anaesthetic plan should be given to the parent
or carer, and explain to the child in appropriate language. As with During positioning avoid excessive neck movement. During
other children with developmental delay and associated behavioural procedures such as laryngoscopy, rigid bronchoscopy and
disorders, careful preoperative preparation is essential, enlisting oesophagoscopy, attempt to maintain the neck in a neutral position
the help of parents, in order to try to gain the childs trust and avoiding excessive extension or flexion. Table tilt may be preferable
cooperation. Premedication may be necessary more frequently due to to neck rotation, although a study investigating the safety of neck
limited understanding, developmental delay and a higher incidence rotation for ear surgery concluded that patients with DS who have
of behavioural disorders. Premedicate with caution in the presence of no neurological symptoms and normal cervical spine radiographs do
severe OSA. Preoperatively the child and parent should be given the not appear to be at high risk with neck rotation up to 60 degrees.11
choice of either inhalational or intravenous induction as appropriate
Routine antibiotic prophylaxis against infective endocarditis is no
and prepared accordingly. A supportive parent or carer can often
longer recommended.12
be of great benefit to the child at induction. Intravenous access
can be more challenging in children with DS, so inspect potential Adequate analgesia is important as postoperative pain assessment
cannulation sites carefully and apply topical local anaesthetic cream and management can be challenging due to intellectual impairment.
at an appropriate preoperative interval. Antacid premedication The use of regional anaesthetic techniques may be challenging in
may be beneficial in those with gastro-oesophageal reflux disease. obese patients with behavioural difficulties but the benefits include
Antimuscarinics (atropine or glycopyrrolate) may be indicated for avoiding the respiratory depressant effects of opioids and improved
their antisialogue effect and to attenuate a bradycardic response on compliance with chest physiotherapy.
induction of anaesthesia.
Postoperative considerations in Down syndrome
No abnormal responses to anaesthetics or other agents have
Patients should be observed closely in the recovery room until full
been documented;6 nor has a reported excessive heart rate
recovery from anaesthesia, as there is a higher incidence of airway
response to atropine,7,9 Vagal block with atropine may in
obstruction. Hypotonia may affect the ability to maintain the airway,
fact be beneficial for several reasons including the higher
which may require simple airway manoeuvres (head tilt, chin lift or
reported incidence of bradycardia on induction of anaesthesia,4
jaw thrust) or positioning the child in the lateral position to maintain
the chronotropic effects in the presence of low plasma
airway patency. Where craniocervical instability is suspected or
catecholamine concentrations and for its antisialogogue effects.7
present, only the jaw thrust manoeuvre should be used. Use of
Intraoperative considerations in Down syndrome airway adjuncts (oropharyngeal or nasopharyngeal airway) may be
Routine monitoring should be used as for any other case. If helpful depending on the childs level of consciousness. There is
inhalational anaesthesia is chosen skilled assistance should be present a higher incidence of post-extubation stridor in children with DS.
at induction to maintain the airway while intravenous access is This is managed with humidified oxygen, nebulised epinephrine
obtained - this allows for the challenging nature of the airway, higher (adrenaline) and intravenous dexamethasone. Postoperative agitation
incidence of airway obstruction on induction and the occurrence can be problematic, occasionally requiring sedation to prevent
of severe bradycardia on induction. Children with DS are prone to harm. This may be limited by the presence of parents or carers in
infection and all invasive lines should be inserted under full aseptic combination with effective analgesia. Postoperative chest infections
precautions. are more frequent in patients with DS.

Summary Down syndrome repair, the tongue may cause airway obstruction, so these children
DS is the commonest congenital abnormality and is associated should be extubated when they are fully awake and observed closely
with defects concerning for safe anaesthetic management including for impending airway obstruction.
congenital cardiac disease, craniofacial abnormalities, cranio-cervical
instability and intellectual impairment. There is a higher incidence of Pierre Robin sequence
perioperative respiratory complications including airway obstruction Features of this syndrome are micrognathia, posterior displacement
and postextubation stridor. Rarely neurological problems may occur of the tongue, cleft palate and an association with congenital heart
due to atlantoaxial subluxation. Children with DS presenting for disease (commonly VSD, PDA, ASD). With severe micrognathia
surgery require careful preoperative evaluation and perioperative care there can be life threatening airway obstruction soon after birth
to minimise these risks requiring prone positioning, a nasopharyngeal airway and in very
severe cases, intubation or tracheostomy. Upper airway obstruction
CONGENITAL CONDITIONS AFFECTING THE AIRWAY often occurs after induction of anaesthesia, necessitating the
Many congenital syndromes present challenges with airway use of airway adjuncts or a LMA to maintain the airway. Direct
management due to difficulty with one or more of maintaining a laryngoscopy can be very difficult. With age and growth of the
mask airway, mask ventilation and intubation. mandible these children usually become easier to manage. It often
There are distinct anatomical features associated with difficult airway occurs in otherwise normal children but can occur as a feature of a
management in children, each producing its own challenges:10 multiple malformation syndrome.
Macroglossia (large tongue) Goldenhar syndrome

Micro/retrognathia (small or receding mandible) Features of this syndrome are asymmetrical hypoplasia of malar,
maxillary and mandible (hemifacial microsomia), associated with
Limited mouth opening epibulbar dermoids, congenital heart disease (VSD, TOF) and
Midface hypoplasia cervical vertebral defects. Face mask ventilation is challenging due
to poor mask seal and intubation may be difficult due to mandibular
Cervical spine instability/limited motion hypoplasia and limited mouth opening especially in the setting of
Abnormal soft tissue airway structures and other facial right sided hemifacial microsomia and a short immobile neck. The
abnormalities impairing mask fit. facial asymmetry may worsen as the child grows, increasing the
difficulties associated with airway management.
It is important to perform comprehensive preoperative evaluation
of the childs airway in order to plan management. Features Treacher Collins syndrome
possibly indicating airway compromise are poor feeding, apnoea, This condition is characterised by bilateral malar, maxillary and
airway obstruction (OSA, stridor), respiratory failure, subcostal or mandibular hypoplasia, small mouth, temporo-mandibular joint
intercostal muscle recession, tracheal tug, use of accessory muscles abnormalities, downslanting palpebral fissures, defect of the lower
and pulmonary hypertension. eyelid and malformation of the external ear.2 Direct laryngoscopy
Examination should seek the features above and make an assessment and intubation may be very difficult and become more so with
of jaw protrusion, Mallampati score, mouth opening, dentition, increasing age. There is an association with cleft palate and cardiac
nasal patency, neck abnormalities and restriction of movement. anomalies.
Formal airway assessment is often difficult in uncooperative children.
Review previous anaesthetic records for details of mask ventilation, Syndromic craniosynostosis
Cormack and Lehane laryngoscopy grade, special techniques used Apert, Crouzon, Pfeiffer and Saethre-Chotzen are the commonest
during airway management and any difficulties experienced. All syndromes. They are characterized by prematurely fused skull-bone
of the conditions described here may be associated with awkward sutures and involvement of the facial skeleton, which can result in
direct laryngoscopy, and alternate means of glottic visualization (e.g. upper airway obstruction and raised intracranial pressure. Almost
fibre-optic or video-laryngoscopy) plus airway rescue devices (e.g. 50% have OSA and there is risk of airway obstruction on induction
supraglottic airway) should be immediately available. It is essential of anaesthesia, difficult mask ventilation and perioperative respiratory
that the anaesthetist has an assistant when managing a child with a complications. Difficult laryngoscopy is unusual.
difficult airway; it is particularly important to address this in settings
where the anaesthetist usually operates alone without a specifically Mucopolysaccharidoses
trained anaesthetic assistant. These are classified into the following sub-types:
I H: Hurler syndrome
Cleft lip and/or palate
This is a relatively common abnormality and may be an isolated I S: Scheie syndrome; previously classified Type V
finding or associated with a number of different syndromes. It may I HS: Hurler-Scheie compound
contribute to difficult laryngoscopy particularly if associated with
micrognathia or other craniofacial abnormalities. A more lateral II: Hunter syndrome
approach for direct laryngoscopy may be helpful. Following palate III: Sanfilippo syndrome

IV: Morquio syndrome Cardiac disease is a frequent association of a number of congenital
abnormalities. Careful evaluation of the cardiovascular system should
V: Formerly Scheie syndrome
be undertaken when other major abnormalities are present. Aside
VI: Maroteaux-Lamy syndrome from DS, other conditions of note include:
VII: -Glucuronidase deficiency Turner syndrome
Females with short stature, short webbed neck, ovarian dysgenesis2,
Type I H, I HS, II, VII Affects bones and intellect 10
and XO karyotype. 30% have a bicuspid aortic valve and 10%
Type III Affects intellect only coarctation. Micrognathia may predispose to airway difficulty. 50%
have renal abnormalities; therefore take caution with renally excreted
Type I S, IV, VI Affects bones only drugs.
The mucopolysaccharidoses (MPS) are lysosomal storage
Noonan syndrome
disorders caused by enzyme defects that result in accumulation of
These individuals have phenotypic similarities to Turner syndrome;
glycosaminoglycans in cellular lysosomes throughout the body. This
short stature and short or webbed neck. Cardiac defects associated
results in coarse facial features, airway abnormalities, organomegaly,
with this condition are pulmonary valve stenosis (62%), hypertrophic
cardiac dysfunction, joint and bone deformities, visual, auditory
cardiomyopathy (20%), ASD, TOF, aortic coarctation, mitral valve
and intellectual impairment. The consequences of deposition
anomalies and atrioventricular canal defects.2,10 Other associations are
in the soft tissues of the mouth and pharynx are macroglossia,
micrognathia, hydronephrosis and platelet dysfunction. Preoperative
thickened oropharyngeal and nasal mucosae, adenoidal and tonsillar
assessment should focus on possible difficulty with intubation,
hypertrophy, copious secretions and a narrow trachea. Deposition
cardiac anomalies and renal function.
in joints and bones can result in a short, immobile and potentially
unstable neck and reduced temporo-mandibular joint movement.
All of the above can combine to make airway management and
CHARGE association
This is an association of the following abnormalities:2
intubation extremely difficult. The most challenging are those with
Hurler (MPS I) and Hunter (MPS II) syndromes. These conditions C: ocular Coloboma (80-90%)
are progressive and lethal, but the natural history of airway
H: Heart defect (TOF, PDA, double outlet right ventricle,
disease may be altered by successful bone marrow transplantation.
VSD, ASD, right-sided aortic arch-75-80%)
Spontaneous ventilation should be maintained until the airway has
been secured; however airway obstruction can occur early during A: choanal Atresia (58%), growth (70%)
inhalational induction. Placement of LMA airway in these patients
R: developmental Retardation (100%)
may be difficult, require several attempts, and be only partially
effective or ineffective. While managing the airway, it is important G: Genital anomalies (75%)
to maintain the neck in a neutral position as there may be cervical E: Ear anomalies or deafness (90%)
spine involvement, as in Morquio syndrome (MPS IV). Spinal
cord compression may occur due to thickening of the dura and to Tailor the anaesthetic according to the individual lesions present.
odontoid hypoplasia. Preoperative MRI scans (without anaesthesia)
of the spinal cord may be appropriate in affected individuals. VACTERR (or VACTERL) association
This is an association of the following abnormalities:2
Beckwith-Wiedemann syndrome
This is a syndrome of macrosomia, visceromegaly, macroglossia, V: Vertebral anomalies (70%)
omphalocoele and hypoglycaemia. Cor pulmonale may result A: anal Atresia (80%)
from chronic airway obstruction. Cardiomegaly may be part of the
visceromegaly which may also involve other organs. Macroglossia C: VSD and other Cardiac defects (53%)
can cause upper airway obstruction and may complicate direct
T-E: Trachea-oEsophageal fistula (70%)
laryngoscopy; partial glossectomy is occasionally required. Serum
glucose should be monitored perioperatively. Renal anomalies (53%)
Klippel-Feil syndrome Radial dysplasia (or L for limb) (65%)

This condition is due to a failure of cervical vertebrae segmentation Again, anaesthetic management is dictated by the specific
during foetal development. These children have a short neck with low lesions present.
hairline and neck rigidity due to fusion of 2 or more of the cervical
vertebrae, most commonly C2 and C3.2 Direct laryngoscopy/ Di George syndrome (22q11.2 deletion syndrome)
intubation may be very difficult. Chromosome 22 microdeletions result in the failure of the 3rd and
4th embryological pharyngeal pouches to differentiate into thymus
CONDITIONS ASSOCIATED WITH CONGENITAL HEART and parathyroid glands. Hypoplasia/aplasia of the thymus results in
DISEASE deficiency in T-cell-mediated immunity leading to a susceptibility to

fungal and viral infections and hypoplasia/absence of parathyroids incidence of 1 in 4000.13 Clinical features are a consequence of
results in severe hypocalcaemia with tetany and seizures in early defects in electron transport or oxidative phosphorylation and tissues
infancy. Cardiac defects are present in 85% and DiGeorge syndrome that are most metabolically active such as the nervous system and
is the second most common cause of congenital heart disease, most muscles are most affected.10 The three basic categories are:
commonly VSD (62%), right aortic arch (52%), TOF (21%),
Respiratory chain deficiencies,
aberrant left subclavian artery, truncus arteriosus, double aortic
arch and interrupted aortic arch.2,10 Affected individuals commonly Mitochondrial DNA mutations including mitochondrial
have micrognathia, cleft palate and choanal atresia. Micrognathia encephalopathy, lactic acidosis and stroke-like
may make intubation difficult and a short trachea predisposes to episodes (MELAS), mitochondrial neuro-gastrointestinal
inadvertent endobronchial intubation. Serum calcium should encephalopathy (MNGIE), myoclonic epilepsy with
be checked preoperatively, blood products should be irradiated to ragged red fibres (MERRF),
prevent a graft versus host reaction and meticulous sterile technique Mitochondrial deletions such as Kearns-Sayre syndrome.
is important when caring for these children.
The severest forms present in the neonatal period with profound
OTHER CONGENITAL CONDITIONS OF IMPORTANCE weakness, acidosis, liver/renal failure and substantial neurological
TO THE PAEDIATRIC ANAESTHETIST impairment. Optimal anaesthetic technique for this group of
conditions remains controversial although propofol may best be
Neuromuscular disease avoided, particularly by infusion.
These conditions can be divided into the following categories:13
Pre-operative work-up will depend on the clinical condition of
Myasthenic syndromes (abnormalities in the release or the patient but should include a full cardiorespiratory evaluation
action of acetylcholine), including (in severe cases) arterial blood gases, pulmonary function
Channelopathies (abnormalities in the post-synaptic tests and where appropriate assessment of other organ function with
membrane or the sarcoplasmic reticulum), measurement of electrolytes, glucose, lactate, pyruvate, creatinine
kinase, liver function and renal function.10
Dystrophies / myotonias (abnormalities in the myofibrils),
Malignant hyperthermia
Mitochondrial myopathies (abnormalities in
Three conditions with a definite link with malignant hyperthermia
mitochondria).
are central core disease, King-Denborough syndrome and Evans
Important congenital conditions in this group of disorders include: Myopathy.13
Duchenne muscular dystrophy Inherited metabolic disorders

Duchenne muscular dystrophy (DMD) is seen in 1 in 3500 live male These are caused by genetic defects resulting in the absence/
births in the UK. It is an X-linked recessive disorder. This condition dysfunction of structural proteins or enzymes. Some conditions
is associated with rapidly progressive weakness presenting between 2 present significant challenges to anaesthesia. Symptoms and
and 5 years of age with sufferers usually wheelchair bound by the age signs may be related to accumulation of intermediate metabolites
of 12. Myocardial degeneration leads to cardiac failure and respiratory proximal to the blocked enzyme that may be toxic or inappropriately
muscle weakness results in ventilatory failure. Death usually occurs stored within cells and/or deficiency of a metabolite downstream of
by third or fourth decade. There is a weak recommendation that the blocked enzyme. They are broadly classified into the following
volatile agents be avoided due to the risk of anaesthesia-induced categories:14
rhabdomyolysis. Succinylcholine (suxamethonium) must NOT be
used due to risk of hyperkalaemia. Disorders of amino acid (and branched-chain amino acid)
metabolism
Myotonic dystrophies Urea cycle disorders
These are a group of hereditary diseases of skeletal muscle associated
with sustained contraction after stimulation. Dystrophia myotonica Organic acidaemias
is the commonest form and typically presents in late adolescence;
50% develop cardiac conduction defects. Other diseases in this group Disorders of carbohydrate metabolism e.g. glycogen storage
are myotonia congenita, which presents at birth or early childhood diseases
and paramyotonia congenita, which also presents in early childhood
Lysosomal storage disorders
and is induced by exposure to cold. Succinylcholine can induce
generalised myotonia and is contraindicated in these conditions. Disorders of fatty acid oxidation.
If muscle spasm occurs (e.g. masseter spasm), lignocaine directly
injected into the muscle may prove useful. Conditions of particular concern to the anaesthetist are the
mucopolysaccharidoses (described above); glycogen storage disorders,
Mitochondrial myopathies which prevent the production of glucose from glycogen and cause
These are a heterogeneous group of conditions with a collective the accumulation of glycogen within tissues such as liver and muscle;

and organic acidaemias (propionic and methylmalonic acidaemia). Osteogenesis imperfecta
As a general principle, keep children with inherited metabolic This is an inherited disorder of connective tissue principally involving
disorders well hydrated, and take care to avoid hypoglycaemia bones, making them fragile. There are several forms of osteogenesis
during starvation. Children with organic acidaemias are treated with imperfecta (OI). The two main forms are OI tarda (type I) and
a protein-restricted diet, and children with glycogen storage diseases congenita (type II).
are particularly prone to hypoglycaemia.
OI Tarda presents with pathological fractures, blue sclera
and deafness. Osteoporosis can result in kyphoscoliosis and
Epidermolysis bullosa
restrictive lung disease. Fragility of vessels leads to
This is an inherited group of skin disorders characterised by cleavage
subcutaneous haemorrhage. Dentine deficiency results
at the dermal-epidermal junction resulting in erosions and blisters
in carious, fragile teeth. Extreme care must be taken with
from seemingly minor trauma to skin or mucous membranes.
positioning and moving patients; fractures have been
There are three main forms of epidermolysis bullosa (EB), each with reported from minimal manipulation, including
several subtypes: application of a blood pressure cuff.16 Careful
laryngoscopy should avoid neck hyperextension and dental
Simplex: This is usually a relatively mild form with rapid damage. Intravenous access can be difficult to maintain
healing and little scarring, due to fragile vessels. OI is associated with abnormal
Lethalis: This is a junctional epidermolysis bullosa. This is platelet function which may exacerbate perioperative
a severe form of the condition that presents at birth, leading bleeding.
to extensive scarring and death usually before the age of 2, OI Congenita is the more severe form and usually presents
as a stillbirth or proves rapidly fatal.
Dystrophic: This is a rare but severe form of the disease.
Lesions are slow to heal with extensive scarring resulting
CONCLUSION
in strictures of the mouth, pharynx, larynx and oesophagus,
In this article we have reviewed some of the congenital
limb contractures and fusion of the digits. Blistering /
conditions a paediatric anaesthetist can expect to encounter
strictures of oesophagus and oropharynx can lead to
occasionally. Children presenting for surgery should be
decreased oral intake and nutrition leading to growth
assessed carefully, with particular attention to the cardiorespiratory
retardation and anaemia. Infections are common and
system and the airway. It is not possible to cover all syndromes in one
antibiotic prophylaxis may be necessary. Adrenal
article, but a Google search on the Internet provides an invaluable
suppression can occur due to use of powerful topical steroids
resource for the paediatric anaesthetist faced with a child with a rare
or oral steroids necessitating perioperative steroid
congenital syndrome.
replacement. There is an association with dilated
cardiomyopathy.
REFERENCES
Children with EB must be assessed carefully preoperatively, with 1. Morris JK, Alberman E. Trends in Downs syndrome live births and
particular reference to the airway. Airway management may be antenatal diagnoses in England and Wales from 1989 to 2008: analysis
difficult as a result of oral lesions, limited mouth opening, adhesion of data from the National Down Syndrome Cytogenetic Register. Br
of the tongue and pharyngeal strictures. Care must be taken to avoid Med J 2009; 339: b 3794.
trauma to skin or mucous membranes. Frictional shearing forces 2. Jones K. Smiths recognizable patterns of human malformation. 6th
must be avoided. Allow the patient to position himself or herself ed. Philadelphia: WB Saunders, 2006.
if possible. Avoid intubation and instrumentation of the airway
3. Roizen NJ, Patterson D. Downs syndrome. Lancet 2003; 361: 1281-89.
or lubricate the ETT and laryngoscope generously and select an
endotracheal tube at least 0.5mm smaller than predicted by age/ 4. Borland LM, Colligan J and Brandom BW. Frequency of anaesthesia-
size. If a LMA is used ensure that it is lubricated and it may be related complications in children with Downs syndrome under
appropriate to select a smaller size. Use a lubricated face-mask for general anaesthesia for non-cardiac procedures. Pediatric Anaesthesia
2004: 14: 733-8.
inhalational induction and lubricate gloves or apply paraffin gauze
to the mask as well as the face. Do not use adhesive tape on the 5. The Downs Syndrome Medical Interest Group. http://dsmig.org.uk
skin. Secure intravenous access and ECG dots with low- adherence 6. Kobel M, Creighton RE ad Steward DJ. Anaesthetic considerations
dressings such Mepiform or Mepitel, which are silicone based. If in Downs syndrome: Experience with 100 patients and a review of the
these are unavailable, an unfolded gauze swab smeared with paraffin literature. Canadian Anaesthesiology Society Journal 1982; 29: 593-9.
gel makes a sticky dressing that doesnt shear the skin. This may be
7. Mitchell V, Howard R, Facer E. Clinical review: Downs syndrome.
kept in place with a crepe bandage. Padding should be applied under Paediatric Anaesthesia 1995; 5: 379.
the non-invasive blood pressure cuff. Oropharyngeal secretions can
be cleared with lubricated soft suction catheters under low pressure, 8. Hata T, Todd M. Cervical spine considerations when anesthetizing
avoiding contact with the mucosa.15 Anaesthesia for this group of patients with Down syndrome. Anesthesiology 2005; 102: 680-5.
patients can be extremely challenging but with meticulous attention 9. Roizen MF. Anesthetic Implications of Concurrent Diseases. p 1116 In:
to detail good outcomes are possible. Anesthesia Ed: Miller RD. Churchill Livingstone 2000. 5th edition.

10. Rampersad SE, Lynn AM. Congenital and inherited disease. p 425-444. 14. Stuart G, Ahmad N. Perioperative care of children with inherited
In Hatch & Sumners Textbook of Paediatric Anaesthesia. Ed Bingham metabolic disorder. CEACCP 2011; 11 (2): 62.
R, Lloyd-Thomas A, Sury M. Hodder Arnold 2008. 3rd edition.
15. Herod J, Denyer J, Goldman A, Howard R. Epidermolysis bullosa in
11. Todd NW, Holt PJ, Allen AT. Safety of neck rotation for ear surgery in children: pathophysiology, anaesthesia and pain management.
children with Down syndrome. Laryngoscope 2000; 110: 1442-5. Paediatric Anaesthesia 2002; 12: 388-97.
12. Prophylaxis against infective endocarditis. NICE guidelines, March 16. Lauder GR. Orthopaedic surgery. p 547-548. In Hatch & Sumners
2008. http://www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf Textbook of Paediatric Anaesthesia. Ed Bingham R, Lloyd-Thomas A,
Sury M. Hodder Arnold 2008. 3rd edition.
13.
Ragoonannan V, Russell W. Anaesthesia for children with
neuromuscular disease. CEACCP 2010; 10 (5): 143-7.

Co-morbid disease
The anaesthetic management of children with sickle
cell disease
Based in part upon Locke, C. Anaesthetic management of sickle cell disease in children. Anaesthesia Tutorial
of the Week 153 (2009).
Tanya Smith and Christie Locke*

*Correspondence email: christielocke@me.com
INTRODUCTION
Si c k l e c e l l d i s e a s e ( S C D ) i s a c o n g e n i t a l
haemoglobinopathy inherited in an autosomal recessive
manner. It is a multisystem disease which affects
approximately 4 million people worldwide. Surgery
and anaesthesia carry a high risk for these patients, and
meticulous perioperative care is essential to prevent Summary
complications of SCD.1
Sickle cell disease may
PATHOPHYSIOLOGY cause serious perioperative
Adult red blood cells normally contain three different complications.
types of haemoglobin; Haemoglobin A (HbA) which Management of these
makes up 96-98% of total haemoglobin, haemoglobin patients requires careful
preparation, and close
A2 (HbA2) which accounts for 1.5-3% of the total,
attention to those factors
and foetal haemoglobin (HbF) which accounts for that could precipitate
Figure 1. Normal and sickle red cell morphology
0.5-0.8% of the total. a sickle crisis. The basic
Haemoglobin S (HbS) occurs as a result of a single principles of oxygenation,
nature, rather than its insolubility. Biochemical markers hydration, analgesia,
DNA base change (adenine to thymidine) that results of endothelial damage are present and suggest that avoidance of hypothermia
in the substitution of valine for glutamic acid in the perhaps the disease should be considered as a chronic and acidosis, and blood
-globin chain. inflammatory disorder. transfusion where
Sickle cell diseases are inherited in an autosomal indicated, are essential.
The spectrum of sickling disorders is widened by the
recessive fashion, with homozygous expression of the combination of HbS with other haemoglobinopathies
abnormal gene (HbSS) producing SCD. These patients such as thalaessaemia and haemoglobin C and
have no normal adult haemoglobin (HbA) and only haemoglobin D. This is because polymerisation of
have HbS, HbA2 and HbF, with approximately 95% HbS is affected by the presence of other haemoglobins,
haemoglobin as HbS. Patients who are heterozygous but in varying degrees. For example, patients with
for HbS (HbSA) are carriers but are asymptomatic and HbSD are severely affected, while patients with
have a normal life expectancy. HbSC are less affected by sickling, and suffer more
Sickle haemoglobin (HbS) polymerises into insoluble thrombotic complications. The combination of and
microfibrils in the deoxygenated state. It is thought thalassaemia with HbS result in disease ranging in
that these parallel microfibrils cause red cell membrane severity depending on the nature of the thalassaemia
damage and result in the classical sickle cell deformity mutation.
(Figure 1). The deformed red cells are more rigid and
EPIDEMIOLOGY
less capable of passing through the microcirculation,
SCD affects approximately 4 million people worldwide
causing increased blood viscosity and impaired blood
and it is most common in West African and Caribbean Tanya Smith
flow. The cells also have a shortened survival time (5-
populations. In Equatorial Africa the sickle cell trait Specialist Registrar
15 days in homozygous sickle cell disease) with the
occurs in up to 30% of the population. This is due in Anaesthesia,
resulting haemolytic anaemia that is characteristic of
to a phenomenon called balanced polymorphism, Northwick Park Hospital,
SCD.
which is when the heterozygote for two alleles of a UK
There is increasing evidence that the primary event in gene has an advantage over either of the homozygous
SCD is oxidative damage to the arterial endothelium states. Heterozygotes for sickle cell anaemia show a Christie Locke
(the lining of the vessel wall) due to the effects of marked resistance to malaria. The mechanism for this Consultant Anaesthetist,
sickle haemoglobin breakdown. The vascular damage is unknown but could be explained by the fact that East Surrey Hospital,
caused by HbS, may be due to its extremely unstable sickle cell trait red cells deform when infected by the UK

parasite, and are then targeted for destruction by phagocytes. The CLINICAL MANIFESTATIONS OF SCD IN CHILDREN
destruction of these cells decreases the parasite burden Because of this SCD has a variety of clinical presentations.
relative resistance, people with sickle cell trait in high malaria areas
are more likely to reach reproductive age and pass on their genes to Anaemia
the next generation. This is universal in patients with HbSS. Patients usually have a
haemoglobin level of 6-9g.dL-1. The anaemia is usually well tolerated,
In North America approximately 8% of the black population has sickle and adequate tissue oxygenation is maintained due to a compensatory
cell trait, and up to 1.3% has SCD. The majority of SCD in the UK increase in cardiac output and increased effective release of oxygen
is found in African-Caribbean populations in large cities where up to to the tissues due to the low affinity of HbS for oxygen. A systolic
10% individuals carry the gene. flow murmur (non-pathological murmur as a result of increased
The HbS gene also occurs in some areas in Mediterranean regions such cardiac output) is a frequent finding, and congestive heart failure
as Greece, southern Italy, Turkey, and in Saudi Arabia and central India. with cardiomegaly on clinical examination/chest radiograph can
occur in adults. Children with SCD should receive iron and folic
DIAGNOSIS acid supplementation.
The gold standard for the diagnosis of SCD is haemoglobin
electrophoresis. Painful crises
This is associated with the sudden onset of severe pain, most commonly
The simpler Sickledex test confirms the presence of HbS, however arising in bone and joints due to ischaemia and infarction in the
electrophoresis is required to distinguish between HbSA (sickle cell marrow or cortical bone. Dactylitis (painful swelling of small bones
trait) and HbSS (sickle cell disease). of hands and feet) occurs in up to half of children by the age of two
The Sickledex test uses sodium metabisulphite as a reducing agent years and is a sign of severe disease. Abdominal pain occurs in older
that causes HbS to precipitate in a hyperosmolar phosphate buffer children and can be caused by bowel dysfunction, organ infarction
solution to produce a cloudy suspension. or referred pain from the ribs. These abdominal crises can be difficult
to distinguish from other common acute surgical disorders. 1% of
The Sickledex test is not reliable in the neonatal period where low patients have more than six episodes of pain per year. Precipitants
levels of HbS and high levels of HbF (with normal solubility) may for acute painful crises include infection, dehydration, cold, hypoxia
result in false negative results. It becomes reliable after 6 months of
and stress.
age when the HbF levels have dropped.
Acute chest syndrome
Haemoglobin electrophoresis separates molecules on the basis of their
This is defined as a fever of more than 38.5C, respiratory distress or
charge at a given pH (Figure 2). Electrophoresis of umbilical cord
chest pain and the appearance of new lung lobar infiltration on chest
blood can be used for diagnosis in the newborn.
X-ray. Hypoxia is common and ventilatory support is occasionally
needed in severe sickle chest crisis. The majority of patients are
managed with oxygen therapy, hydration and blood transfusion. The
incidence of acute chest syndrome in the postoperative child may be
as high as 10% in those with severe disease undergoing major surgery.
Risk factors for sickle chest crisis are age between 2-4 years and a
persistently raised white cell count. Multiple episodes of acute chest
syndrome in children are likely to result in pulmonary fibrosis and
chronic lung disease as the child gets older.
Cerebrovascular accidents (CVA)
The majority of CVAs in patients with SCD occur during childhood
(5% of children with sickle cell disease have overt CVAs due to
ischaemia). These are typically caused by vascular lesions in the cerebral
vessels and may present as watershed infarctions during a sickle crisis
(infarction occurring at the more vulnerable regions between major
cerebral arterial zones). Transcranial Doppler ultrasonography can
identify children at risk of cerebral infarction, by detecting reduced
blood flow in cerebral vessels. It has been shown that treating patients
at risk with regular transfusion programmes significantly reduces
the incidence of stroke. Children are also at risk of intracerebral and
subarachnoid haemorrhage.
Aplastic crisis
This is usually precipitated by infection, parvovirus being an important
Figure 2. Haemoglobin electrophoresis results for different haemoglobin
types. Antenatal diagnosis of sickle cell disease is possible by analysis of the
pathogen. There is suppression of erythropoiesis (red blood cell
DNA of foetal tissue from chorionic villous sampling or amniocentesis. formation) in the bone marrow and a dramatic fall in haemoglobin

levels. Early diagnosis and treatment with blood transfusion is essential. Although more commonly seen in adults, cardiomegaly may be
seen on chest X-ray, and echocardiography may be indicated to
Acute splenic sequestration assess cardiac function.
This is a rare complication that is most common in children under the Careful neurological examination is essential and any pre-
age of five. Large numbers of red cells are sequestered in the spleen existing neurological deficit from previous CVAs should be
and the haemoglobin level drops precipitously. This may present documented.
with acute collapse and shock, and may require resuscitation and
blood transfusion. Children who suffer repeat episodes of splenic Renal and hepatic function should also be assessed for signs of end-
sequestration may require splenectomy. organ damage. Even children with HbAS have a renal
concentrating defect and may not tolerate dehydration.
More commonly, splenic infarction occurs as a result of repeated
sickling episodes, which results in functional hyposplenism. Patients If there is any evidence of active infection, elective surgery should
are at increased risk of infections, particularly with encapsulated be postponed.
bacteria such as Streptococcus pneumoniae, Neisseria meningitides, and Where possible, children with SCD should be scheduled first on the
Haemophilus influenza B. All children with homozygous SCD should operating theatre list to avoid prolonged starvation and dehydration.
receive prophylactic penicillin V from birth. Patients should be encouraged to drink free clear fluids until two
hours before surgery.
Osteomyelitis
Patients are at higher risk of osteomyelitis than the rest of the Blood transfusion and SCD
population, with the most common pathogens being salmonella and Preoperative blood transfusion is a controversial area,5 particularly
staphylococci. now that standards of anaesthetic care have improved for patients with
SCD. The pathophysiology of the disease is better understood and
Priapism many of the precipitating factors for sickle crisis in the perioperative
Attacks start as young as the age of eight and are reported by up to period can be avoided (see below). The NHS Blood and Transplant
30% of male sufferers of SCD. It can occur in the postoperative service in the UK recently undertook a randomized controlled trial to
period. Treatment includes hydration, exchange transfusion and intra- evaluate whether blood transfusion should be given to patients with
cavernous injections of an alpha-adrenergic agent. SCD pre-operatively (so-called TAPS trial). Although the recruitment
target was 400 patients, the trial was ended early (after 70 patients)
Avascular necrosis
as a review of patient safety identified that there were more serious
Intravascular sickling of the red blood cells in the microcirculation of
complications in patients who did not receive pre-operative blood
the bone results in intramedullary sludging, stasis, thrombosis, and
transfusion6 (unpublished data).
progressive ischaemia, most often of the femoral head. These patients
present with pain in the affected joint. Orthopaedic management may Theoretically, reducing the percentage of HbSS by prophylactic
be conservative or surgical. transfusion should prevent complications. However, aggressive
transfusion regimens are associated with a high incidence of
Long-term complications of SCD in adults
transfusion-associated complications.
Recurrent sickle cell crises may cause many complications including
gall stones, sickle retinopathy, leg ulcers, chronic renal failure due to In resource poor areas where screening for infection and highly specific
renal parenchymal scarring, pulmonary hypertension, chronic lung blood cross matching is limited, the balance of the risks versus the
disease, and neurological impairment. Chronic bone damage may benefits of blood transfusion needs to be carefully considered.
occur, leading to avascular necrosis, impaired growth and joint damage. Management plans for transfusion therefore need to be individualised
for each patient, taking into account the patients medical history
ANAESTHETIC MANAGEMENT OF CHILDREN WITH SCD and type of surgery, in consultation with the anaesthetist, surgeon,
Pre-operative screening paediatrician and haematologist, as well as the patients family.
All children in a high-risk population or those with a positive family Guidelines may vary between hospitals and between regions.
history should be screened for SCD. Transfusion may be used to increase the haemoglobin level; repeated
Pre-operative assessment and preparation top-up transfusion will also reduce the percentage of HbS in the
Patients with a history of chest crisis, stroke, frequent painful crises, blood. Below are current transfusion guidelines at Great Ormond
or those with severe obstructive sleep apnoea have a higher risk of Street Childrens Hospital in London.
perioperative complications. All patients with SCD require meticulous Children with no special risk factors having short procedures
perioperative care.3 4 such as insertion of myringotomy tubes or minor dental work: no
Pre-operative assessment should involve a careful review of all systems. transfusion, provided the haemoglobin is at the normal baseline
level (Hb >6g.dL-1)
Multiple episodes of acute chest syndrome may result in reduced
lung volumes, pulmonary infarction and pulmonary Children with no special risk factors having intermediate risk
hypertension with low oxygen saturation. It is important to surgery such as tonsillectomy or laparotomy: top-up transfusion
check the baseline oxygen saturation before surgery. to Hb 9-11g.dL-1

Children who have had a chest crisis, CVA or suffer frequent in patients with SCD should therefore be considered on an individual
painful crises, or children undergoing major surgery such as basis weighing up the risks and benefits.
thoracic or neurosurgery: sequential top-ups or exchange
Tourniquet after exsanguination of the limb may be used safely in
transfusion to achieve a Hb of 9-11g.dL-1 and a HbS level
patients with sickle cell trait.
of <30%
Cell saver devices
As it is essential to avoid increased tissue viscosity, the Hb should
The high incidence of sickling in cell savers prevents their use in SCD.
not exceed 12g.dL-1
For emergency surgery, patients should ideally be treated POSTOPERATIVE MANAGEMENT
the same, but if time does not allow, then blood should be Oxygen therapy
crossmatched and ready for surgery. All cases should be Oxygen saturation should be monitored continuously and
discussed with a haematologist if possible supplemental oxygen should be given to maintain saturations >92%.
Fluid management
INTRAOPERATIVE MANAGEMENT
Continue intravenous maintenance fluids until the child is tolerating
Oxygenation oral fluids.
The primary goal is to maintain good oxygenation during the
perioperative period. Perioperative pulse oximetry monitoring is Postoperative analgesia
essential as patients may have impaired oxygen delivery resulting from Management of post-operative pain is challenging. Patients may
chronic anaemia or chronic lung damage, and may have a limited have very high perioperative analgesic requirements, and may have
ability to maintain tissue perfusion and oxygenation during hypoxic developed tolerance to opioids. A multimodal approach should be
episodes. Even short periods of hypoxia must be avoided. Postoperative used with a combination of opioids where indicated, paracetamol and
continuous positive airway pressure (CPAP) or a nasopharyngeal NSAIDs, and regional anaesthesia when possible.
airway may be indicated in those with obstructive sleep apnoea (see Physiotherapy
below). Physiotherapy and early ambulation are important to avoid vascular
Dehydration stasis.
Dehydration is poorly tolerated. Dehydration may lead to increased Nasopharyngeal airway
tissue viscosity, poor perfusion, acidosis and increased sickling. Obstructive sleep apnoea secondary to adenotonsillar hypertrophy
Adequate hydration is essential and must be maintained before, during is common in children with SCD. Careful attention should be
and after surgery. The patient should be encouraged to drink clear paid to these patients postoperatively to avoid airway obstruction,
fluids up until 2 hours before surgery, or if this is not possible, to have hypoventilation or hypoxia. A nasopharyngeal airway may be used
intravenous fluids during the preoperative fasting period. Intravenous after tonsillectomy or in those with severe obstructive sleep apnoea to
fluids should be used during surgery, and postoperative intravenous prevent post-operative airway obstruction and hypoxia.
fluids should be prescribed until oral intake is re-established.
Postoperative complications
Acidosis
Patients should be monitored carefully for early signs of complications
Avoid acidosis. Acidosis causes increased sickling, with subsequent
as serious post-operative complications usually occur within 48hrs of
increased blood viscosity and impaired tissue perfusion. This will cause
surgery. These include:
the tissues to become more acidotic, causing further sickling, which
may result in a sickle crisis. Painful crisis
Temperature management Cerebrovascular accident
Avoid hypothermia. Hypothermia causes vasoconstriction, Acute chest syndrome.
hypoperfusion, increased blood viscosity, and decreased venous oxygen
tension which all lead to increased sickling. Management of sickle complications
The anaesthetic team may be involved in managing the acute
Vascular stasis complications of sickle cell disease, both when they present post-
Avoid vascular stasis by maintaining a good circulating volume, operatively, and when the patient presents to the hospital with an
careful positioning, and the use of thromboembolic deterrent (TED) acute crisis.
stockings. Pneumatic calf compression devices can be used during
prolonged surgery. These should be avoided if there is evidence of The management of all sickle crises includes the same principles
peripheral vascular occlusive disease. of establishing intravenous fluids, oxygen therapy, analgesia, and
antibiotics.
Tourniquets
Studies reporting outcomes after tourniquet use are scarce in patients Analgesia may require high doses of opiates, as well as the use of
with sickle cell disease. A recent systematic review concluded that regular paracetamol and NSAIDs such as ibuprofen or
tourniquets may be used with relative safety in most patients, as long diclofenac.
as other peri-operative precautions are taken. The use of tourniquets Transfusion to an Hb>10g.dL-1 is important, but over transfusion

(>12g.dL-1) must be avoided. Exchange transfusion to reduce REFERENCES
HbS <20-30% may be indicated in certain situations such as acute Locke C. Anaesthetic management of sickle cell disease in children.
chest syndrome or CVA. As a guide, transfusion of 4ml.kg-1 of ATOTW (2009) 153. Available at: http://www.wfsahq.org/components/
packed cells or of 8 ml.kg-1 of whole blood raises the haemoglobin com_virtual_library/media/e0645e0e5cce77faef81cd00f0a0efa4-
concentration by 1g.dL-1. 134dcf42c0b8f21e61db61b943aa0c8b-153-Sickle-cell-disease-in-
children.pdf
Ventilatory support (continuous positive airway pressure
(CPAP), or intubation and ventilation) may be required for acute 1. Marchant WA, Walker I. Anaesthetic management of the child with
chest syndrome. Patients should be carefully monitored for signs sickle cell disease. Paediatr Anaesth 2003;13:473-89.
of respiratory decompensation. 2. Nandi R, Martin R. Haematology. In: Bingham R L-TA, Sury M, editor.
Hatch and Sumners Textbook of Paediatric Anaesthesia. 3rd ed,
Acute sequestration crisis is an important cause of death in
2008.
children with sickle cell disease. Acute hypovolaemia can
occur due to pooling of blood in the spleen. Treatment is 3. Firth PG, Head CA. Sickle cell disease and anesthesia. Anesthesiology
transfusion of blood and intravenous 0.9% saline for volume 2004;101:766-85.
replacement. 4. Frietsch T, Ewen I, Waschke KF. Anaesthetic care for sickle cell disease.
Eur J Anaesthesiol 2001;18:137-50.
CONCLUSIONS
Anaesthetists need to be aware of the possible serious complications 5. Hirst C, Williamson L. Preoperative blood transfusions for sickle cell
disease. Cochrane Database Syst Rev 2012;1:CD003149.
of SCD in the perioperative period. Management of these patients
requires careful preparation, and close attention to those factors that 6. http://www.sicklecellsociety.org/websites/123reg/LinuxPackage22/
could precipitate a sickle crisis.7 The basic principles of oxygenation, si/ck/le/sicklecellsociety.org/public_html/news/view/22
hydration, analgesia, avoidance of hypothermia and acidosis, and 7. Davies SC, Oni L. Management of patients with sickle cell disease.
blood transfusion where indicated, are essential. BrMed J 1997;315:656-60.

Co-morbid disease
HIV in children and anaesthesia

Based in part upon: Wilson S. HIV and Anaesthesia. Update in Anaesthesia 2010; 25,1: 25-29.
S Wilson* and S Patel

*Correspondence Email: wdrsam@googlemail.com
It is estimated that 3.3 million children under 15 years period, or during breastfeeding. The risk of perinatal
of age are living with HIV, the vast majority of which acquisition without intervention (such as maternal
are in sub-Saharan Africa. Due to improved HIV ART, caesarean delivery, avoidance of breast milk) is
prevention a 35% reduction in numbers from 2009 25-40%. Other routes of transmission, as for adults,
means that in 2012 approximately 260,000 children are sexual or via contaminated blood through the
Summary under 15 were diagnosed with HIV and 647,000 administration of blood products, organ donations or
It is estimated that 3.3 million children were receiving antiretroviral therapy (ART). by sharing contaminated needles during intravenous
children under 15 years of drug use.
A significant number of these children will require
age are living with HIV, the
vast majority of them in sub- surgery for elective or emergency procedures, either The Centers for Disease Control and Prevention
Saharan Africa. A significant directly related or unrelated to HIV. For this reason, it (CDC) classification system (Table 1) clearly shows
number of these children will is essential for us to fully understand the implications the increasing severity of symptoms as HIV infection
require surgery. It is essential for anaesthesia. In order to safely anaesthetise an HIV- progresses.
to understand the implications infected child, we require a reasonable understanding
for anaesthesia in order to of HIV infection: its pathophysiology, multisystem MULTISYSTEM INVOLVEMENT
formulate an appropriate complications and the pharmacology of ART. An In order to perform a thorough preoperative
anaesthetic management plan. accurate assessment of the child with HIV can assessment of the child with HIV, it is important that
In order to safely anaesthetise potentially impact upon your choice of anaesthesic you appreciate which organ systems may be affected,
an HIV-infected child, agents, whether to use regional anaesthesia, how to either as a direct consequence of HIV infection
we require a reasonable
manage pain, approaches to infection control and (opportunistic infection / malignancy), or indirectly
understanding of HIV infection:
its pathophysiology, potential
general issues surrounding peri-operative care. such as from side effects of ART, chemotherapy or
multisystem complications anti-infective agents. Awareness of these effects allows
and the pharmacology of ART. PATHOGENESIS, AETIOLOGY AND us to appropriately adapt our anaesthetic.
An accurate assessment of the CLASSIFICATION
child with HIV may affect your HIV is a single-stranded RNA virus with HIV-1 and Haematological system
choice of anaesthesic agents, HIV-2 types and multiple subtypes recognised. These The haematological system can be greatly affected
how to manage pain including subtypes express differences in geographical prevalence during HIV infection; anaemia, neutropaenia
whether to use regional
as well as disease progression and transmission and thrombocytopaenia are common. Persistent
anaesthesia, approaches to
infection control, and general rates. Like other retroviruses, HIV contains the generalised lymphadenopathy may be a feature and
issues surrounding peri- enzyme reverse transcriptase that enables viral RNA may also be the target of surgery for the affected child
operative care. to be transcribed to DNA, which then becomes in the early stages of disease for diagnostic purposes.
incorporated into the host cell genome and is able Haematological malignancies are often seen as are
to replicate freely. Inhibition of this viral replication coagulation abnormalities, with obvious implications
process is the target of ART. HIV preferentially for surgical and anaesthetic interventions.
Wilson S infects T helper lymphocytes (CD4+ T cells) and
Consultant in Anaesthesia, leads to their progressive quantitative and qualitative Cardiovascular system
Hampshire Hospitals destruction. This makes the host increasingly The cardiovascular system may be affected in a number
Foundation Trust immunocompromised, and thus more susceptible to of ways in an HIV-infected child. The pericardium,
opportunistic infections and malignancies. myocardium or endocardium may be involved or
S Patel there may be vascular lesions or neoplasms. Important
Consultant in Paediatric More than 80% of HIV infections in children and common cardiovascular complications that have
Infectious Diseases and are due to vertical transmission (ie.trans-placental major implications for patient management are:
Immunology exposure to maternal HIV during the perinatal
Pulmonary hypertension
Southampton Childrens period). Perinatal transmission can occur during any
Hospital one of three phases: in utero, during the peripartum Pericardial effusions

Table 1. CDC classification of paediatric HIV infection
Category Associated symptoms
N - Asymptomatic No symptoms
1 category A symptom only.
A - Mild symptoms 2 or more of the following symptoms:

Lymphadenopathy
Hepatomegaly
Splenomegaly
Dermatitis
Parotitis
Recurrent or persistent upper respiratory infection, sinusitis, or otitis media.
B - Moderate symptoms Anaemia, neutropenia, or thrombocytopenia

Bacterial meningitis, pneumonia, or sepsis
Candidiasis, oropharyngeal (thrush),
Cardiomyopathy
Cytomegalovirus infection, with onset before 1 month
Diarrhoea, recurrent or chronic
Hepatitis
Herpes simplex virus (HSV) stomatitis, recurrent
HSV bronchitis, pneumonitis, or oesophagitis
Herpes zoster (shingles)
Leiomyosarcoma
Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia complex
Nephropathy
Nocardiosis
Persistent fever
Toxoplasmosis
Varicella, disseminated (complicated chickenpox).
C - Severe symptoms: Serious bacterial infections, multiple or recurrent

Candidiasis, oesophageal or pulmonary
Coccidioidomycosis, disseminated
Cryptococcosis, extrapulmonary
Cryptosporidiosis or isosporiasis
Cytomegalovirus disease
Encephalopathy
Herpes simplex virus infection
Histoplasmosis, disseminated
Kaposis sarcoma
Lymphoma
Mycobacterium tuberculosis, disseminated or extrapulmonary
Mycobacterium, other species disseminated
Mycobacterium avium complex or Mycobacterium kansasii
Pneumocystis carinii pneumonia
Progressive multifocal leukoencephalopathy
Salmonella (nontyphoid) septicemia, recurrent
Toxoplasmosis of the brain.

Endocarditis and valvular lesions neuropathy and seizures are all recognised complications of HIV
which have important implications in our clinical management.
Vasculitis
Cardiomyopathies. Full neurological examination pre-operatively with appropriate
documentation is essential especially if you plan to use regional
Respiratory system anaesthesia.
Both the upper and lower airway can be involved in HIV infection
Endocrine and metabolic system
in children, and respiratory symptoms are a common presenting
ART has common endocrine side effects including lipodystrophy,
complaint. These include:
insulin resistance (metabolic syndrome), hypothalamic-pituitary-
Upper respiratory tract infections (chronic otitis media) adrenal axis dysfunction, hypo- or hyperthyroidism and lactic
acidosis.
Bacterial pneumonia
Atypical infections (commonly tuberculosis, non- ANTIRETROVIRAL THERAPY
tuberculous mycobacteria, and fungal infections) The use of a combination ART or highly active antiretroviral therapy
(HAART) has been a major advance in the treatment of HIV
Lymphocytic interstitial pneumonia (LIP) infection. These drugs are classified into the following five classes
Bronchitis according to the mechanisms of inhibition of viral replication (Table
2):
Sinusitis
Airway obstruction. Reverse transcriptase enzyme inhibitors
Protease enzyme inhibitors
Gastrointestinal system
Commonly encountered complications of the gastrointestinal tract Integrase inhibitors
associated with HIV infection and its treatment can have major Entry inhibitors
effects on the metabolism of our anaesthetic agents and any other
Fusion inhibitors.
drugs used. These effects include:
Adherence to antiretroviral therapy is of paramount importance;
Poor nutritional status with resultant delayed healing times
adherence levels below 95% are associated with increases in viral load
Difficulty or pain on swallowing and drug resistance. This naturally has implications for interruption
Increased gastric emptying times. of ART due to perioperative fasting. Fasting times should be kept to
an absolute minimum.
Acute or chronic diarrhoea is common, with associated dehydration
and electrolyte dysfunction and in addition, there can be hepato- Many adverse side effects are associated with ART and you should
biliary and pancreatic impairment. look for these during preoperative assessment. They can be divided
broadly into four groups:
Renal system Allergic reactions: skin rashes and hypersensitivity

Acute and chronic renal disease can be associated with HIV. Potential responses
causes of renal impairment include:
Bone marrow suppression: anaemia, neutropaenia and
Drug induced nephrotoxicity thrombocytopaenia.
Hypertension Metabolic abnormalities: fat maldistribution and change
in body habitus, dyslipidaemia, hyperglycaemia and insulin
Diabetes
resistance, bone disorders e.g. osteopaenia, osteoporosis
HIV-associated nephropathy. and osteonecrosis
It is important to avoid nephrotoxic drugs where possible in these Mitochondrial dysfunction: lactic acidosis, hepatic toxicity,
children and to dose adjust renally excreted drugs and adequately pancreatitis, peripheral neuropathy.
hydrate the child in order to prevent further renal damage.
Anaesthetic drugs may interact with ART. Anaesthetic agents may
induce pharmacodynamic changes to affect their efficacy and toxicity
Neurological system via cytochome p450 induction/inhibition, and the pharmacokinetic
HIV can affect the neurological system directly (HIV encephalopathy) effects of ART can affect the absorption, distribution, metabolism
or indirectly via opportunistic infections, neoplasms or immune and elimination of anaesthetic and analgesic drugs.
deficiency. These can involve all structures including the meninges,
brain, spinal cord, peripheral nerve or muscle. Neurocognitive Pharmacodynamic interactions can be managed by avoiding
impairment, developmental delay, encephalopathy, autonomic anaesthetic agents such as halothane or methoxyflurane that cause

hepatic or renal dysfunction. Propofol and NRTIs may both Benzodiazepines Saquinavir may inhibit midazolam
potentially promote mitochondrial toxicity and lactic acidosis,so it metabolism.
may be wise to avoid propofol infusions in patients receiving ART
Local anaesthetics such as lignocaine may have increased
due to the already potentially compromised mitochondrial function.
plasma levels due to enzyme inhibition with direct
Pharmacokinetic interactions are more complex and are primarily implications for toxic doses.
due to liver enzyme induction or inhibition, particularly of the
Neuromuscular blocker effects may be prolonged, even
CYP450 3A4 enzyme. Protease inhibitors (PIs) and NNRTIs are the
after a single dose.
most commonly implicated groups of drugs. Enzyme induction or
inhibition can affect the action of several classes of anaesthetic drugs: Calcium channel blockers may have enhanced hypotensive
effects due to enzyme inhibition.
Opioids. The effects of fentanyl may be enhanced by
ritonavir due to both liver enzyme inhibition and These interactions are complicated and multiple and databases
induction. Enzyme inhibition reduces fentanyl clearance exist that describe these interactions in detail (such as www.hiv-
and enzyme induction increases metabolism to active druginteractions.org).Evidence for interactions specifically with
metabolites such as normepiridine. anaesthetic drugs is relatively sparse.
Table 2. ART
Drug class Available drugs
1. Reverse transcriptase inhibitors

Nucleoside/nucleotide analogues (NRTIs) Abacavir (ABC)
Didanosine (ddI)
Emtricitabine (FTC)
Lamivudine (3TC)
Stavudine (d4T)
Zidovudine (AZT, ZDV)
Non-nucleotide reverse transcriptase
Inhibitors (NNRTIs) Delavirdine (DLV)
Efavirenz (EFV)
Etravirine (ETR)
Nevirapine (NVP)
2. Protease inhibitors (PIs) Atazanavir (ATV)

Darunavir (DRV)
Fosamprenavir (FPV)
Indinavir (IDV)
Lopinavir (LPV)
Nelfinavir (NFV)
Ritonavir (RTV)
Lopinavir/ritonavir (LPV/r)
Saquinavir (SQV)
Tipranavir (TPV)
Amprenavir (APV)
3. Integrase inhibitors Raltegavir (RAL)

Dolutegravir
4. Entry inhibitors
CCR 5 antagonists Maraviroc (MVC)
5. Fusion inhibitors Enfuviritide (ENF, T-20)

Due to the risk of developing resistance if doses are missed, it is Dispose of sharps safely (into a rigid locking container
recommended that ART be continued throughout the perioperative prior to incineration)
period if at all possible. Naturally this needs to be compatible with
the proposed surgery and with the patients gastrointestinal function. Do not re-sheath needles
Some drugs are available in liquid form enabling administration via Wear gloves
nasogastric feeding tube or gastrostomy. Parenteral preparations are
limited to zidovudine and enfuvirtide only. Cover any cuts or broken skin with an impermeable
dressing
REGIONAL ANAESTHESIA
The presence of HIV infection is not an absolute contraindication to Strongly consider eyeshields and facemasks
regional anaesthesia and there is no evidence that HIV progression
Use disposable equipment where possible; clean reusable
is increased by central neuraxial blockade. Regional anaesthesia may
equipment properly.
be relatively contraindicated with several pathologies associated with
HIV infections such as myelopathy, vertebral or spinal neoplasms, Post-exposure prophylaxis for healthcare workers should be available
CNS infections and coagulopathies, as well as in the severely and should commence as soon as possible after potential high risk
immunocompromised patient. You must conduct a full preoperative exposure (ideally within the first 1-2hrs).
neurological assessment and document any pre-existing neurological
deficit if you plan a regional anaesthetic technique. If tuberculosis is suspected or likely in a patient known to have HIV,
all healthcare workers should wear a tight fitting facemask to reduce
BLOOD TRANSFUSION the risk of transmission (ideally a high quality particulate mask if
There is evidence that allogeneic blood transfusion in the HIV available e.g. N95 or HEPA).
infected patient can lead to transfusion-related immunomodulation
(TRIM) and can result in an increase in HIV viral load. Blood APPROACH TO FORMULATING AN ANAESTHETIC
should therefore only be transfused where unavoidable to maintain MANAGEMENT PLAN FOR THE HIV-INFECTED CHILD
patient safety.
A multisystem and multidisciplinary approach is recommended.
PAIN Thorough preoperative assessment for status of HIV infection:

Pain is common in advanced HIV disease and can be very difficult
History, including risk factors (for child & parents)
to treat. The aetiology of this pain can be multifactorial, including:
Physical examination
Opportunistic infections such as herpes simplex
Laboratory tests
HIV-related arthralgia
Assess organ involvement
Peripheral neuropathy
Drug history and side effects.
Drug-related pain.
Investigations ideally include:
Pre-existing pain and its treatment can affectthe treatment of
postoperative pain and will necessitate a multimodal approach. Full blood count
Clotting function to exclude coagulation abnormalities
INFECTION CONTROL (consider use of TEG/platelet mapping if available)
Infection control is an important issue both for the protection of the Biochemical tests including glucose, electrolytes, renal
immunocompromised child from opportunistic infections, as well as & liver function to exclude possible metabolic, liver or
for the professionals caring for the child during any procedures. Use renal disturbances
a strict aseptic technique for all procedures.
Viral load and CD4 count
The cumulative risk of contracting HIV over an anaesthetic
career can be as high as 4.5%. This can occur due to a needlestick Chest radiography to screen for opportunistic infections
injury (transmission risk of 0.3%); the risk is increased if there is and tuberculosis
a higher volume of blood injected, such as with hollow needles or Cardiac evaluation with electrocardiography and
deep punctures. Risk of transmission via the mucocutaneous route echocardiography (if possible) to screen for cardiomyopathy.
(splashing of a mucosal surface or broken skin by body fluid) is
extremely low (0.03%). Preparation of operating theatre and personnel:
There are universal precautions that should be taken to reduce the Infection control preparation including universal
risk of HIV transmission to healthcare workers: precautions with gloves, aprons, visors available

Sharp object collection devices with appropriate sharps REFERENCES AND FURTHER READING
handling (no re-sheathing of needles) Bayer R: Discrimination, informed consent, and the HIV infected clinician.
British Medical Journal 1997; 314: 915-6.
Staff fully aware of protocols in the event of occupational
exposure Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report
2004. Vol. 16. Atlanta, Ga: US Department of Health and Human Services,
- Rinse and wash affected area with soap & water Centers for Disease Control and Prevention; 2005. 1-46.
- Recipient lab tests: HIV, acute hepatitis panel Diprose P, Deakin CD and Smedley J. Ignorance of post-exposure
- Determine infectious status of source prophylaxis guidelines following HIV needlestick injury may increase the
risk of seroconversion. British Journal of Anaesthesia 2000; 84: 767-70.
Availability of post exposure prophylaxis to be started Horlocker TT and Wedel DJ. Regional Anaesthesia in the
as soon as possible following accidental high risk exposure Immunocompromised Patient. Regional Anaesthesia and Pain Medicine
(ideally within 1 hour of exposure) 2006; 31: 334-45.
- HIV PEP protocol with 3 or more antiretroviral drugs Joint WHO/United Nations programme on HIV/AIDS; 2008 report on
if known HIV positive donor or high-risk patient or global AIDS epidemic. www.unaids.org
with 2 or more if low risk. ART is given for 4 weeks or
Kharasch ED, Mitchell D, Coles R and Blanco R. Rapid clinical induction of
until source is found to be negative for HIV
hepatic cytochrome P4502B6 activity by ritonavir; . Antimicrobial Agents
- Follow up with counselling and HIV testing for at and Chemotherapy 2008; 52:1663-9.
least 6 months post exposure (tests done at baseline, 6 Kuczkowski KM. Anaesthetic considerations for the HIV-infected pregnant
weeks, 12 weeks and 6 months) patient. Yonsei Medical Journal 2004; 45:1-6.
- Hepatitis B immune globulin +/or hepatitis B vaccine Leelanukrom R: Anaesthetic considerations of the HIV-infected patients.
- Achieve early identification of chronic hepatitis C Current Opinion in Anaesthesiology 2009, 22: 412-418.
disease. Leelanukrom R and Pancharoen C. Anaesthesia in HIV-infected children.
Perioperative considerations for the child with HIV: Pediatric Anaesthesia 2007; 17: 509-19.
Minimise interruptions in ART as far as possible to Parthasarathy S and Ravishankar M: HIV and anaesthesia; Indian Journal of
Anaesthesia 2007; 51: 91-99.
diminish the risk of developing drug resistance
Prout J and Agarwal B: Anaesthesia and critical care for patients with HIV
Consider drug interactions between ART and drugs
infection. Continuing Education in Anaesthesia Critical Care and Pain 2005;
affected by hepatic enzyme inhibition and/or induction 15: 153-6.
Exercise strict aseptic technique as HIV infected children Schwartz D, Schwartz R, Cooper E and Pullerits J: Anaesthesia and the child
are immunocompromised and are susceptible to with HIV infection. Canadian Journal of Anaesthesia 1991; 38: 626-33.
opportunistic infections
Wilson S: HIV and Anaesthesia. Update in Anaesthesia 2010; 25: 25-9.
Additional emotional and psychological support may be Available at: http://www.wfsahq.org/components/com_virtual_library/
necessary as primary caregivers may have been affected by media/25b2de5bdb19692a50cc78dbbbab9a9c-HIV-and-Anaesthesia--
HIV/AIDS Update-25-1-2009-.pdf
The anaesthetic plan should of course be tailored to the World Health Organization. Global summary of the AIDS epidemic: 2009.
individual child and the type of surgery to be undertaken. Available at http://www.who.int/hiv/data/2009_global_summary.png.

Co-morbid disease
Anaesthesia for non-cardiac surgery in children with

congenital heart disease
Based in part upon: Story E. Recognising cardiac disease in children Anaesthesia Tutorial
of the Week 93 (2008)1
Isabeau Walker
Correspondence Email: isabeauwalker@mac.com
INTRODUCTION
The risk of perioperative complications is higher in disease are likely to die due to lack of access to
children with congenital heart disease (CHD) for both corrective or palliative surgery, in particular those
minor and major surgery, particularly in neonates with duct dependent lesions. A child with untreated
SUMMARY and those with complex lesions.2 Although CHD is heart failure due to high pulmonary blood flow is
uncommon, it is important for the anaesthetist to more likely to die from pneumonia, which is the most
Children with congenital understand how to recognise a child with CHD, and common cause of mortality in the under 5 age group.
heart disease provide a
the principles of anaesthetic management for children If a child with high pulmonary blood flow remains
challenge to the anaesthetist,
but with careful planning, with both unrepaired and repaired lesions. untreated they may develop Eisenmengers syndrome,
most can be anaesthetised which is associated with high mortality in childhood
safely. This article covers INCIDENCE OF CONGENITAL HEART or early adult life.
pathophysiology, DISEASE
recognition, and principles of The incidence of CHD is approximately 8:1000 However, as surgical systems improve, there are an
anaesthesia for children with live births. The frequency of different lesions varies increasing number of programmes to treat children
congenital heart disease, between populations, with ventricular septal defect with CHD in LMIC, many developed in partnership
including anaesthesia for with international outreach teams, so that the outlook
(VSD) being the most common in all populations
specific cardiac lesions. for children born with simple conditions such as VSD,
(see Table 1).
atrial septal defect (ASD), patent ductus arteriosus
Most CHD is untreated in low- or middle-income (PDA), coarctation of the aorta or Tetralogy of Fallot
countries (LMIC). Babies with complex cardiac is much more optimistic.
Table 1. The incidence of different types of congenital heart disease in children in the UK
Condition Incidence
Ventricular septal defect (VSD) 32%
Patent arterial duct (PDA) 12%
Pulmonary stenosis (PS) 8%
Coarctation of the aorta (CoA) 6%
Atrial septal defect (ASD) 6%
Tetralogy of Fallot (TOF) 6%
Aortic stenosis (AS) 5%
Isabeau Walker Transposition of the great arteries (TGA) 5%

Consultant Paediatric
Hypoplastic left heart syndrome (HLHS) 3%
Anaesthetist
Great Ormond Street Hypoplastic right heart syndromes 2%
Hospital NHS Foundation
Trust Atrioventricular septal defects (AVSD) 2%
London
WC1N 3JH Truncus arteriosus (common arterial trunk) 1%

CAUSE OF CONGENITAL HEART DISEASE AND Left to right shunting lesions: ASD, VSD, AVSD, PDA
ASSOCIATED ABNORMALITIES The child with acyanotic heart disease presents with signs and
The cause of most CHD is unknown, but may be related to symptoms of cardiac failure. The severity of the symptoms depends
chromosomal abnormalities, exposure of the mother to teratogens on the volume of the shunt:
(e.g. alcohol, or drugs such as anti-epileptics or warfarin), or maternal Atrial septal defect, ASD. (See Figure 1). A secundum ASD
disease (rubella, diabetes). is associated with a low volume left to right shunt with
Recognisable chromosomal abnormalities are present in 25% of right heart overload. The child may present with recurrent
children with CHD. The diagnosis of a chromosomal abnormality chest infections, failure to thrive, or may be asymptomatic.
should lead to assessment of the child for CHD. The most common Ventricular septal defect, VSD. A restrictive VSD is
chromosomal abnormality is Down syndrome (trisomy 21) 40% small, and causes a low volume shunt with few symptoms.
of children with Down syndrome have CHD, most commonly An unrestrictive VSD is large, associated with a high volume left
atrioventricular septal defect (AVSD) or VSD. Chromosomal to right shunt and symptoms of severe cardiac failure in infancy
abnormalities associated with cardiac lesions are shown in Table 2.
Atrioventricular septal defect, AVSD. (See Figure 2). There
is an abnormal atrioventricular valve, an atrial septal defect
PATHOPHYSIOLOGY OF CONGENITAL HEART DISEASE (primum ASD), +/- a ventricular septal defect. This results
It is useful to classify CHD according to the pathophysiology of the in a high volume shunt and signs of severe cardiac failure in
major heart lesion, in particular, whether the child is acyanotic (i.e. infancy leading to early pulmonary hypertension.
the child is pink), or the lesion is associated with cyanosis (i.e. the Untreated, children with AVSD develop Eisenmengers
child is blue). Most CHD is acyanotic. Measuring oxygen saturation syndrome (see later) by the age of 1-2 years, with 4%
by pulse oximetry shortly after birth is a useful screening test to survival beyond 5 years.
identify cyanotic lesions such as tetralogy of Fallot, transposition
of the great arteries (TGA), total anomalous pulmonary venous Patient ductus arteriosus, PDA. (See Figure 3). If the duct is
drainage (TAPVD) or duct dependent lesions such as hypoplastic restrictive the child may present with relatively few
left heart syndrome. However, the most common cause of cyanosis symptoms initially, or signs and symptoms of cardiac
in the neonatal period is due to a respiratory problem. A description failure. Premature neonates with a large unrestrictive PDA
of common lesions is shown in Table 3. may have severe cardiac failure and be ventilator dependent.
Table 2. Chromosomal abnormalities associated with cardiac lesions
Abnormality Clinical features and associated conditions Typical cardiac lesion

Down syndrome Typical facial appearance, single palmar AVSD, VSD
crease, short stature, learning difficulties, lax
Trisomy 21 joints (including cervical spine instability),
hypothyroidism, obstructive sleep apnoea,
leukaemia, duodenal atresia.
DiGeorge syndrome (Catch 22) Learning difficulties, cleft palate, hypocalcaemia, Aortic arch abnormalities, VSD
absent thymus (frequent respiratory infections),
22q11 deletion typical facial appearance
Marfans syndrome Abnormally tall stature, long fingers, scoliosis, Aortic root dilatation and dissection
abnormal shaped chest, high arched palate,
retinal detachment, inguinal hernia, spontaneous
pneumothorax
Apert syndrome Craniosynostosis (premature fusion of cranial PS, VSD
sutures), syndactyly (fused fingers), deafness
Charge association Abnormal iris (coloboma), choanal atresia Variety, including VSD, AVSD
(abnormal nasal passageway), developmental
delay, abnormal genitalia, ear deformity
VATER Vertebral abnormalities, anal atresia, VSD, TOF
tracheo-oesophageal fistula, renal abnormalities
Goldenhar syndrome Hemifacial microsomia (poorly developed maxilla/ VSD, TOF
mandible), difficult intubation, ear abnormalities,
cleft palate

Table 3. Classification of common congenital heart lesions
Acyanotic congenital heart disease pink babies

Common examples Comment
Left-to-right shunt Small ASD, VSD, PDA Large (non-restrictive) lesions are associated with
Restrictive lesions severe congestive cardiac failure in infancy.
Large VSD, PDA, AVSD, common arterial
Non-restrictive lesions trunk If unrepaired, may lead to pulmonary
hypertension and reversal of shunt (Eisenmengers
syndrome).
Obstructive lesions Aortic stenosis, coarctation of the aorta, Severity of lesion determines age at presentation
pulmonary stenosis neonates with severe obstruction may be
critically ill with a duct dependent circulation
Cyanotic lesions blue babies
Right-to-left shunt Tetralogy of Fallot: May present with severe cyanosis and
VSD with aortic override hypercyanotic spells, or if unrepaired in an older
Right ventricular outflow tract child, with cyanosis, fatigue and a history of
obstruction squatting.
Right ventricular hypertrophy,
Transposition of the Great TGA may be associated with ASD, VSD, Long term survival requires intervention in early
Arteries (TGA) PDA infancy (arterial switch operation)
Single ventricle physiology Hypoplastic left heart syndrome (HLHS), Duct dependent circulation; survival requires
hypoplastic right heart syndrome, tricuspid intervention in the neonatal period
atresia.
Common mixing Total anomalous pulmonary venous Present with heart failure and/or cyanosis
drainage (TAPVD). survival requires intervention in the neonatal
period
Figure 1. Echocardiographic appearance of secundum ASD with left-to-right flow

Figure 2. CXR and echocardiographic appearance in a child with heart failure secondary to AVSD
Figure 3. Echocardiographic appearance and CXR in a child with a PDA, showing left heart volume overload and
prominent pulmonary vasculature
Tetralogy of Fallot The child presents with cyanosis from birth and may develop cyanotic
Tetraolgy of Fallot (TOF) is associated with a right to left shunt. The spells in infancy, due to spasm of muscle bundles in the right ventricular
abnormality in TOF is due to: outflow tract in response to adrenergic stimulation, for instance when
the child is upset or cries. An older child who has not had corrective
VSD with aortic override. surgery may squat when tired to increase pulmonary blood flow (by
Right ventricular outflow tract obstruction (RVOTO) increasing systemic vascular resistance), and will having clubbing.
(muscle bundles below the pulmonary valve; valvar or (See Figure 4).
supravalvar obstruction). A modified Blalock-Taussig (mBT) shunt may be placed as a
Right ventricular hypertrophy due to the RVOTO. palliative procedure in the first few weeks of life to provide a secure

the pulmonary artery to the descending aorta via the duct.
The blood in the pulmonary artery is deoxygenated, so the
oxygen saturation in the feet (post-ductal) will be lower
than the oxygen saturation in the right hand (pre-ductal)
Pulmonary atresia (duct dependent pulmonary circulation).

In pulmonary atresia, the only blood supply to the lungs is
that which passes from the aorta to the pulmonary artery
via the duct.
Continued survival of these babies requires infusion of prostaglandin

E1 to keep the duct open until urgent cardiac surgery can be
performed.
Eisenmengers syndrome
A large (unrestricted) VSD allows blood to pass from the left
ventricle to the right ventricle (left-to-right shunt), which results
in high pulmonary blood flow and congestive cardiac failure. The
Figure 4. Finger clubbing in a child with Tetralogy of Fallot normal physiological response to high pulmonary blood flow is for the
resistance in the pulmonary vessels (pulmonary vascular resistance,
blood supply to the lungs before corrective surgery is performed. PVR) to increase. With time, the PVR rises until eventually it
This is an arterial shunt between the innominate artery and the right exceeds the systemic vascular resistance, and the flow across the VSD
pulmonary artery. The shunt is restrictive so that the pulmonary reverses - this is known as Eisenmengers syndrome. Clinically, this is
blood supply is adequate, but not too high; the ideal SpO2 is around associated with an initial improvement in symptoms of cardiac failure
85%. If the shunt is too large (unrestrictive), the child will have too as pulmonary blood flow reduces, followed by increasing cyanosis
high a pulmonary blood flow, causing signs of cardiac failure, with as the shunt reverses to become right-to-left. Surgical closure of the
low systemic pressure due to excessive runoff from the innominate shunt is not possible at this stage as the resistance to flow through the
artery to the lungs. pulmonary circulation is too high and right ventricular failure will
Surgery for TOF should ideally be at a few months of age. Complete occur. Individuals with Eisenmengers syndrome are deeply cyanosed
correction involves closure of the VSD and relief of the obstruction with clubbing of fingers; they may develop haemoptysis, endocarditis
at the right ventricular outflow tract. The surgical course may be or cerebral abscess, and will eventually die from cardiac failure.
complicated, but the saturation will be normal after surgery and
the long-term outlook is usually good. Some patients may develop
pulmonary regurgitation, right heart dilation and arrhythmias if a
patch has to be placed across the pulmonary annulus.
Duct dependent circulation

In utero, the placenta is the main site for gas exchange for the
developing foetus and the blood flow to the foetal lung is minimal.
Blood from the right ventricle bypasses the lungs and passes directly
to the aorta via a foetal vessel called the arterial duct. After birth,
a number of changes occur in transition from the foetal to the
newborn circulation, one of which is closure of the arterial duct so
that blood now perfuses the lungs. (See Basic Science article, this
edition of Update, page 4)
There are certain severe congenital cardiac lesions that are only
compatible with life if the arterial duct remains open the circulation
is said to be duct dependent. If undiagnosed at birth, these babies
typically present with acute collapse as the duct closes within the first
5 days of life (the differential diagnosis is septic shock).
Examples of duct dependent circulations:

Critical coarctation of the aorta (duct dependent systemic
circulation). There is extreme narrowing of the aorta where
the arterial duct joins the aorta, and blood supply to the Figure 5. Cardiac MRI of patient with AVSD and right-to-left
lower half of the body is only possible if blood passes from shunt in Eisenmengers syndrome

Corrective cardiac surgery must be undertaken before the onset of in the newborn. Older babies may be placed in the knee to
pulmonary vascular disease to avoid Eisenmengers syndrome. The chest position in response to a cyanotic spell. The
ideal age for surgery is critically dependent on the underlying lesion. differential diagnosis for episodic cyanosis is fits or
Eisenmengers syndrome occurs before the age of 1 year in children respiratory problems such as croup or asthma.
with very high pulmonary blood flow, such as unrepaired AVSD, but
may occur at 40-50 years in adults with unrepaired ASD who have Respiratory symptoms. Breathlessness due to increased pulmonary
had moderately increased pulmonary blood flow over many years. blood flow is a common respiratory symptom in children with
(See Figure 5). cardiac failure, for instance due to a large VSD or AVSD. In babies,
this presents as slow feeding, breathlessness, cold clammy sweatiness
RECOGNISING CONGENITAL HEART DISEASE IN and poor weight gain. An older child may have limited exercise
CHILDREN tolerance and not keep up with their peers. Frequent respiratory tract
It is important to recognise the child with CHD so that they can be infections and poor weight gain are common in older children with
prepared for surgery: an ASD, although there may not be overt breathlessness.
Treat cardiac failure (e.g. VSD, AVSD).
Funny turns and chest pain funny turns are an unusual presentation
Recognise a condition that may be associated with acute for cardiac disease in children, more commonly associated with
decompensation during surgery (hypercyanotic spell in simple faints, or neurological disease such as epilepsy. Sudden collapse
Tetralogy of Fallot; loss of cardiac output in aortic stenosis, may be due to arrhythmias, and collapse with exercise is a very
coarctation; cardiomyopathy; pulmonary hypertensive worrying sign in a child with significant left ventricular outflow tract
crisis in Eisenmengers syndrome). obstruction such as aortic stenosis. Most chest pain in children is due
to musculoskeletal problems, especially in older children. Coronary
Ensure antibiotic prophylaxis is given to children at risk of
artery abnormalities, and hence chest pain due to angina, is rare. A
endocarditis.
young infant with angina due to Kawasaki disease or Anomalous
Children rarely present with the symptoms classically associated origin of the Left Coronary Artery from the Pulmonary Artery
with heart disease in adults (i.e. chest pain, shortness of breath, (ALCAPA) may present with quiet episodes associated with reduced
swollen ankles); they usually present with symptoms such as failure activity and sweatiness more commonly with breathlessness and
to thrive, frequent chest infections, or unexplained funny turns. A listlessness due to left ventricular failure.
careful history and examination is key, as are special investigations
Poor weight gain this is common in conditions causing heart
such as CXR, ECG, SpO2, echocardiogram, or occasionally cardiac
failure or associated with increased pulmonary blood flow such as
catheterisation. Cardiac MRI is increasingly used.
VSD. Older children with acquired heart disease such as endocarditis
or cardiomyopathy may have anorexia and weight loss. Conditions
History associated with cyanosis and reduced pulmonary blood flow such as
Ask about the following: TOF are not usually associated with poor weight gain.
Pregnancy: Maternal disease, drug and alcohol intake
General enquiry this may reveal other symptoms suggestive of
Birth history: A history of prematurity is associated with PDA. Birth a complex congenital disorder such as Downs syndrome, a family
asphyxia is associated with persistent foetal circulation (persistent history of cardiac disease, or symptoms suggestive of acquired heart
pulmonary hypertension of the newborn, PPHN) disease such as rheumatic fever or endocarditis.
Cardiac symptoms
Examination
Cyanosis - central cyanosis is an important cardiac Examine the child using the standard routine of inspection,
symptom that is difficult to detect and may often be missed palpation, percussion and auscultation:
by parents. Central cyanosis is seen as blue discoloration
Look for dysmorphic features, for instance suggestive of
of the tongue and lips and may be confirmed using pulse
Downs syndrome, or the presence of an associated
oximetry.
congenial abnormality such as cleft palate or spinal
Hypercyanotic spell. This is a classic symptom of Tetralogy deformity.
of Fallot (see Table 3). The child may become deeply
Signs of poor weight gain and failure to thrive should
cyanosed when upset or crying, and may become limp and
be sought (weigh the child and compare to standard growth
unresponsive; this is a sign of acute reduction in
charts).
pulmonary blood flow associated with sudden increase in
the dynamic obstruction to the right ventricular outflow Signs of breathlessness will be apparent as increased
tract. Older children with uncorrected TOF may squat respiratory rate, and in the infant, intercostal and sub-costal
to increase pulmonary blood flow this position increases recession, nasal flaring and grunting. In an older child, chest
the systemic vascular resistance and reduces the right-to- deformity may be associated with longstanding ventricular
left shunt across the VSD. Cyanotic spells are uncommon enlargement.

Peripheral cyanosis is common in children at any age and - Best heard at the left sternal edge, no radiation
is not important. Central cyanosis is always important - Changes with posture softer when standing.
but may be missed in a child with severe anaemia or
children with pigmented skin. Look at the colour of the Pathological cardiac murmurs
tongue if blue, it suggests the SpO2 is <85%. Saturation Cardiac murmurs associated with a left to right shunt such as
must be confirmed using a pulse oximeter. Long standing a VSD may not be very obvious in the newborn period when
cyanosis may be associated with clubbing of the nails the pulmonary vascular resistance is high. The pulmonary
of the hands and feet. Children who have long standing vascular resistance falls in the first few days of life - the loud
cyanosis develop compensatory polycythaemia and possibly systolic murmur due to a VSD will become apparent and the
complications such as cerebral thromboembolism. child may develop signs of heart failure as the flow increases
The jugular venous pulse is very difficult to see in children across the shunt. A murmur is the result of turbulent
<5 years who have chubby necks and who move around flow and is graded as soft, moderate, or loud; a very loud
a great deal the liver size gives a much better estimate of murmur may also be felt (thrill). See Table 4 and Figure 6
venous pressure. for description and location of pathological cardiac
Palpate the pulses to assess rate, rhythm, volume and murmurs.
character. Radio-femoral delay or absent femoral pulse is Investigations
seen in coarctation; differential right and left radial
pressures are seen in aortic arch interruption. Special investigations include the Chest Xray, ECG, echocardiography
and cardiac catheterisation.
A suprasternal thrill may be felt in aortic stenosis,
occasionally in pulmonary stenosis or other causes of aortic Chest Xray. Consider the age of the patient and if the film was taken
arch anomaly leading to a palpable murmur. A palpable in the sitting or lying position. Evaluate the chest Xray systematically:
heave indicates ventricular hypertrophy.
A - Adequacy and alignment. The film should be sufficiently
The normal position of the cardiac apex is the 4th penetrated to just visualise the disc spaces of the lower
intercostal space inside the nipple line in a child <5 years, thoracic vertebrae through the heart shadow. At least 5
the 5th intercostal space at the nipple line in a child >5 anterior rib ends should be seen above the diaphragm on
years. the right hand side. Alignment can be assessed by ensuring
Estimate the liver size by palpation. The normal neonate that the medial ends of both clavicles are equally spaced
may have 1cm of liver palpable, an older child may have about the spinous processes of the upper thoracic vertebrae.
a liver edge palpable anything more may indicate B Bones. Check the ribs, clavicles and vertebrae. (Rib
increased right atrial pressure, usually due to heart failure, notching is sometimes seen in severe coarctation of the
or a non-cardiac cause of hepatomegaly. aorta).
Dependent peripheral oedema is a late sign of cardiac failure C - Cartilage and soft tissues.
in children, and may be felt by palpation over the sacrum.
Lungs - Compare side-to-side and upper, middle and lower
Percussion may be useful to estimate liver size and the thirds of the chest. Look for pleural effusions, pneumothorax,
presence of ascites (rarely due to cardiac failure in children). vascular markings that are increased or decreased (plethoric
or oligaemic), fluid in the fissures, white lung areas which
Heart murmurs could be consolidation or haemorrhage.
Innocent cardiac murmurs
The most common murmur in children is a
functional, innocent or physiological heart
murmur, which is heard in 10% of normal children. The
classical innocent murmur in children is known as the
Stills murmur. Innocent murmurs may also be due to
flow murmurs associated with increased cardiac output,
heard in children with a fever or anaemia. The heart is
structurally normal in all children with an innocent
murmur. A murmur in a child may be classified as innocent
if the child has no other signs or symptoms of cardiac disease, and the
murmur has certain characteristic features:
- Soft (no thrill)
- Systolic and short (never pansystolic)
- Asymptomatic Figure 6. Best location to hear cardiac murmurs

Table 4. Pathological murmurs in children
Murmur Location murmur heard best
Systolic murmurs
Soft = grade 2/6; Moderate = grade 3/6; Loud with thrill = grade 4/6
Ejection systolic Aortic stenosis: Upper right sternal edge +/- carotid thrill
Pulmonary stenosis or ASD: Upper left sternal edge, no thrill
TOF: Long harsh murmur (in a child with cyanosis)

Pansystolic VSD: Lower left sternal edge +/- thrill
Mitral regurgitation (NB. rheumatic fever): Apex

Diastolic murmurs (unusual in children)
Soft = grade 2/4; Moderate = grade 3/4; Loud = grade 4/4

Aortic regurgitation (NB. endocarditis): Lower left sternal edge,
sitting forward, collapsing pulses
Continuous murmurs
Patent ductus arteriosus (PDA): Left infraclavicular region
Arteriovenous malformation: Any site (head, shoulder, lungs).
Heart: Look at the size of the heart; is it enlarged? Is the Situs. In the normal situation (situs solitus) the heart is on
shape unusual? (See below). In normal infants the heart the left with the gastric bubble on the left and the liver on
is up to 60% of the thoracic diameter, 50% thereafter. (See the right. In situs inversus these relations are reversed
Figure 7). Remember that a normal cardiac shadow does
not rule out cardiac disease. Oligaemic lung fields are seen in conditions associated with
reduced pulmonary blood flow such as TOF and pulmonary
The upper mediastinum: In children under the age of 18 atresia
months, the normal thymus may simulate superior
mediastinal widening (above the level of the carina) (See Plethoric lung fields are seen in children with left to right
Figure 7). shunts, especially VSD and AVSD.
D Diaphragms. The border between the heart and The electrocardiogram (ECG)
the diaphragm and between the diaphragm and the ribs The ECG may be useful to investigate rhythm and conduction
(cardiophrenic and costophrenic angles) should be clear abnormalities, as well as assessing chamber hypertrophy and strain.
on both sides. Loss of definition of the left diaphragm Interpretation of the paediatric ECG is complex and must take the
behind the heart suggests left lower lobe collapse, an childs age into account, with comparison to tables of normal values.
abnormal hump suggests diaphragmatic rupture, a hazy
diaphragm suggests effusion or collapse in the bordering Echocardiography
lung segment, and an elevated diaphragm suggests phrenic Echocardiography is a form of cardiac imaging that uses reflection
nerve palsy of ultrasound pulses from interfaces between tissue planes. It can be
used to generate detailed real time images of the cardiac anatomy. It
There are some classical appearances of the chest Xray in children: has become the standard investigation for all patients with valvular
heart disease, congenital heart disease, myocardial and pericardial
Egg-on-side = Transposition of great arteries in a neonate
disease, and to assess myocardial function.
Boot shaped heart = Tetralogy of Fallot (right ventricular
The heart is examined in a systematic way, deciding first the
hypertrophy and reduced pulmonary markings (See Figure
orientation of the heart within the body (normal = solitus);
8))
the connections between the atria and the ventricles (normal =
Snowman in a snow storm = Obstructed total anomalous concordant), ventricles and major vessels (normal = concordant);
pulmonary venous connection in a neonate and the side of the aortic arch (normal = left). The normal position
and connections is often described in short hand as SCCL. The
Globular heart. Usually associated with pericardial effusions, echocardiologist then describes the ventricular function, the valves,
may be secondary to pericarditis or dilated cardiomyopathy the shunts, and the size of the major vessels.

Figure 7. Normal chest Xrays in children
Doppler ultrasound may be used to estimate pressure gradients across Avoid air emboli, particularly for cyanotic children with
valves and shunts using the following formula: right-to-left shunts; make sure there are no air bubbles in
the drugs or fluids given
Pressure = 4 v2, where v is the velocity measured by
Doppler m.sec-1 Consider endocarditis prophylaxis
Consider the effect of anaesthesia on the pulmonary blood
The z score is used to describe the heart compared to normal values flow, and the balance between systemic and pulmonary
for the age of the child; if the aortic valve has a z score of -2, this blood flow.
suggests the valve is 2 standard deviations smaller than the normal
average size. Pulmonary blood flow
Pulmonary blood flow may be low due to increased pulmonary
Cardiac catheterisation vascular resistance (PVR), which may be due to excessive
Cardiac catheterisation is used to answer specific diagnostic questions muscularisation of the pulmonary arterioles secondary to long-
in children with congenital heart disease. A catheter can be passed standing high pulmonary blood flow. Pulmonary vascular resistance
into the heart chambers under Xray control to measure intracardiac may be increased acutely, particularly in neonates, due to:
pressures and oxygen saturations, or for radiological imaging by
injection of contrast media. Interventional cardiology is increasingly
providing definitive treatment for a number of conditions, for
instance closure of ASD or PDA by insertion of an occlusion device,
balloon dilatation of pulmonary stenosis, or diathermy ablation of
abnormal conduction pathways.
PRINCIPLES OF ANAESTHESIA IN CHILDREN WITH

CONGENITAL CARDIAC DISEASE
Unnecessary surgery should be avoided due to the increased risk
associated with anaesthesia, particularly in neonates, and children
with complex (cyanotic) disease. It is important to optimise the
condition of the child preoperatively, to understand the physiology
of the lesion, and know how to avoid acute decompensation during
surgery.
The general principles of anaesthesia are as follows:

Avoid deep (halothane) anaesthesia Figure 8. Chest Xray of a child with tetralogy of Fallot and right-
Support ventilation where possible sided aortic arch showing a boot shaped heart

Hypoxia patient is cyanosed. The mortality from Eisenmengers syndrome is
Acidosis 75% at 30 years of age. (See figure 5).
Over/under inflation of the lungs. Problems
Shunt reversal
The most powerful pulmonary vasodilator available therapeutically is
oxygen. The effect of oxygen is particularly evident in the first weeks Cyanosis
of life when the pulmonary vasculature remains very reactive. It is
Anaesthesia for Eisenmengers syndrome
sometimes important to avoid giving too much oxygen. For instance,
The patient is severely unwell, and may present with the following
if a patient with high pulmonary blood flow is given 100% oxygen
signs and symptoms:
to breathe (e.g. a baby with a large unrepaired AVSD), this will cause
the pulmonary vascular resistance to fall, pulmonary blood flow will Limited exercise tolerance
increase and the symptoms of cardiac failure, such as breathlessness, Polycythaemia, hyperviscosity syndrome (fatigue,
will get worse. A saturation of 94% is adequate in children with headache, blurred vision, cerebral thrombosis, cerebral
unrepaired AVSD, and excessive oxygen should be avoided. abscess)
Other pulmonary vasodilators include: Coagulopathy
Nitric oxide, an inhaled pulmonary vasodilator, used for Thromboembolic events
the treatment of pulmonary hypertension in neonates
Sildenafil, a cGMP-specific phosphodiesterase type 5 Endocarditis.
inhibitor This is very high-risk surgery, with an estimated perioperative
Bosentan, an endothelin receptor antagonist. mortality of 10-14% even for minor surgery. The risks and benefits
of proceeding with surgery have to be considered carefully. The
If a patient has impaired pulmonary blood flow due to pulmonary
following is recommended:
hypertension, for instance, a child with sepsis and persistent
pulmonary hypertension of the newborn, they should be treated Polycythaemia is associated with hyperviscosity. Consider
with oxygen, nitric oxide +/- sildenafil if available. venesection if the haemaotcrit is >60. Do not let the patient
become dehydrated; start IV fluids preoperatively.
ANAESTHESIA FOR SPECIFIC CARDIAC LESIONS
Children who have had corrective surgery e.g. for ASD, VSD or Give high inspired oxygen at all times.
PDA, may be treated the same as any other child. Children with Use a careful balanced general anaesthetic and close
uncorrected cardiac lesions may be more challenging. monitoring. Induce anaesthesia with small incremental
doses of midazolam and fentanyl IV, and a small dose of
Uncorrected left-to-right shunt; ASD, VSD, AVSD, PDA induction agent (ketamine, etomidate).
Problems Support ventilation to reduce the work of breathing, but
Increased pulmonary blood flow do not over/under inflate the lungs (increases PVR).
Cardiac failure. Avoid increases in pulmonary vascular resistance, as this
will make the cyanosis worse.
Anaesthesia for uncorrected left-to-right shunt
Do NOT use a spinal, as this will cause a fall in systemic
Careful preoperative assessment; if possible, treat cardiac vascular resistance, and will encourage the right to left
failure with diuretics (furosemide, spironolactone PO). In shunt.
older children, exclude signs of Eisenmengers syndrome
Maintain oxygen carrying capacity; do not allow the
and shunt reversal
patient to become anaemic, and maintain haemoglobin
Avoid deep halothane anaesthesia 12-14g.dl-1 (Hct 36-42).
Avoid excessive oxygen; keep FiO2 at a minimum, Consider a pulmonary vasodilator if possible sildenafil or
accept SpO2 approx. 94% (but see below for Eisenmengers inhaled NO
syndrome)
Management of a pulmonary hypertensive crisis
Support the ventilation to reduce the work of breathing In the event of a pulmonary hypertensive crisis with falling SpO2 and
(increased pulmonary blood flow causes lung compliance blood pressure, you must intervene to reduce the PVR and increase
to fall). cardiac output:
Eisenmengers syndrome Give 100% oxygen and hyperventilate the patient
Irreversible pulmonary hypertension has developed as a consequence
Give analgesia
of long-standing or significantly raised pulmonary blood flow. There
is now right-to-left shunting or bidirectional shunting and the Treat metabolic acidosis

Support the circulation adrenaline infusion to effect. Do NOT use adrenaline as this will worsen the
right ventricular outflow tract obstruction (1-receptor
Start a pulmonary vasodilator if available (inhaled NO,
agonist effect).
sildenafil via a nasogastric tube).
Consider a -blocker esmolol or propranolol IV.
The patient must be monitored in a high dependency area or ICU
after surgery. Anaesthesia for children with a modified BT shunt (mBT shunt)
Tetralogy of Fallot Check the shunt is patent before the start of surgery
SpO2 should be around 85%, and a shunt murmur should
Problems be audible (continuous murmur in the second intercostal
Reduced pulmonary blood flow due to obstruction at the space, mid-clavicular region on the right).
right ventricular outflow tract (NB PVR is LOW) Avoid dehydration as this may result in the shunt becoming
Hyperviscosity syndrome and polycythaemia due to long- blocked.
standing cyanosis. Keep the blood pressure up; if the blood pressure falls,
pulmonary blood flow will also fall and the oxygen
Anaesthesia for children with unrepaired TOF saturation will drop.
Sedative premedication; keep the child calm
High-risk lesions
Balanced anaesthesia with good analgesia; avoid
There are a number of high-risk lesions that should ring alarm
dehydration, keep well-filled, avoid sympathetic
bells; these red flag patients must be assessed and optimised before
stimulation to avoid hypercyanotic spells.
surgery, and the risk/benefits of non-cardiac surgery considered very
Management of a hypercyanotic spell during surgery in carefully.
unrepaired TOF
The following are high-risk lesions:
Increase the FiO2.
Eisenmengers syndrome. (See above)
Deepen anaesthesia.
Aortic stenosis. Avoid a fall in SVR do not use spinal
Give a bolus of Ringers 20ml.kg-1 to increase cardiac anaesthesia
output and blood flow to the lungs.
Cardiomyopathy. May be dilated or restrictive, and the
Increase the systemic vascular resistance to reduce the right- child will have limited reserve. Ketamine is useful for
to-left shunt; phenylephrine bolus 1mcg.kg-1 IV, titrated induction, and the child should be monitored carefully
postoperatively
Pericardial effusion. Must be drained by the cardiologist
before surgery (See Figure 9)
Endomyocardial fibrosis. Manage as for restrictive
cardiomyopathy.
ENDOCARDITIS PROPHYLAXIS
Children who have had bacterial endocarditis, who have a prosthetic
valve, and who have congenital heart disease are at high risk of
bacterial endocarditis. The current advice from the American Heart
Association is to give prophylactic antibiotics in the following
situations:
High risk dental surgery e.g. involving suturing or dental

infection
Give antibiotics as indicated for the surgical procedure.
ANAESTHESIA FOR A CHILD WITH AN UNDIAGNOSED

CARDIAC LESION
There may be situations in LMIC where the anaesthetist is presented
with a child with a murmur and an undiagnosed cardiac condition.
Figure 9. Large pericardial effusion in a child The following approach is advised:

Elective surgery CONCLUSION
Children with CHD may provide a challenge to the anaesthetist,
Refer for investigation if possible.
but with careful planning, most can be anaesthetised safely. It is
Emergency surgery: important to understand the physiology of the particular cardiac
lesion, to prepare in advance, and to do the simple things well.
Well child, pink, breathless with cardiomegaly. Likely to
be a condition associated with left to right shunt such ACKNOWLEDGEMENT
as an ASD, VSD or PDA. The child may have heart failure I would like to thank Dr Jan Marek who provided the
with increased work of breathing. Support ventilation echocardiographic images for this article.
during surgery to reduce the work of breathing.
REFERENCES
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Ketamine is a good agent to use in these high-risk cases.
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All children with undiagnosed cardiac disease should be referred to a 3. Paediatric cardiology: an introduction. Archer N, Burch
cardiologist as soon as possible for investigation. M. Chapman Hall Medical. Philadelphia 1998.

Co-morbid disease
Anaesthesia in patients with asthma,

bronchiolitis and other respiratory diseases
Based in part upon: Liston DE. Childhood asthma and anaesthesia. Anaesthesia Tutorial
of the Week 187 (2010)
David Liston* and See Wan Tham
*Correspondence email: david.liston@seattlechildrens.org
ASTHMA
more than 20% of children developing symptoms
Introduction
within the first year of life.1 However, the diagnosis
Asthma is a leading cause of morbidity in children
of asthma in an infant is unusual and other causes for
throughout the world.1 In urban hospitals, it is the
wheezing should be investigated. Asthma most likely
most common reason for hospital admission. The
results from an interaction between both an inherited
prevalence among children in Western countries
Summary modifier of inflammation and environmental
is between 2 and 10%.1 Asthma is a lung disease
influences. A number of risk factors have been
Respiratory illnesses are
characterized by three distinct features: airway
identified but the best researched include gender,
common in the paediatric obstruction, airway inflammation and airway hyper-
atopy, allergens, infections, obesity, tobacco smoke,
population. As a result, responsiveness. Symptoms manifest as episodes of
and perinatal factors.
children often present for recurrent wheezing, chest tightness, dyspnoea and dry
surgery and anaesthesia with cough. Typically episodes result in variable obstruction Childhood asthma tends to occur predominantly in
respiratory symptoms. The of airflow that resolves either spontaneously or with males until puberty. After age 20 the prevalence is equal
child with well controlled treatment. Asthma has no radiologic, histologic between the sexes. The association between asthma
asthma or minimal or confirmatory blood test. It is characterized by and other atopic diseases has been well researched.
symptoms of respiratory
reversible symptoms, findings on examination and An atopic march has been identified which starts as
infection may proceed with
anaesthesia. The dilemma
pulmonary function tests. While the characteristic atopic dermatitis in the infant, followed by allergic
lies in the decision to cancel symptom of asthma is wheezing (usually expiratory), rhinitis and asthma in the older child or adolescent.
or proceed when symptoms it is important to realize that wheezing is produced Indoor allergens have been shown to play a significant
are more than minimal. This simply by airflow passing through a sufficiently role in the development of asthma. The dust mite,
article describes respiratory narrowed airway. Wheezing can occur during different Alternaria mould, cockroach allergens, as well as cat
conditions in children as phases of the respiratory cycle depending on the site of and dog allergens have all been implicated.
they relate to anaesthetic the airway obstruction and its cause. The differential
perioperative management. Smoke exposure from cooking on open wood fires
diagnosis of wheezing in children is extensive
Our goal is to inform is an important risk factor in many developing
and includes: asthma, foreign body, bronchiolitis,
anaesthesia providers of safe countries. Viral and bacterial infections are well
practices, and the risks and
inhalational injury, pneumothorax, endobronchial
known triggers of asthma exacerbations but their
benefits of administering intubation, herniated endotracheal tube cuff, cardiac
causal relationship remains unproven. Several large
anaesthetics to these failure, cystic fibrosis, sickle cell disease, recurrent
studies have suggested that patients with an elevated
patients. aspiration, mediastinal mass, tracheomalacia, vascular
body mass index (BMI) or that are actively smoking
ring, tracheal web/stenosis, bronchial stenosis and
are at increased risk of developing asthma. Lastly,
roundworm infestation.2
perinatal risk factors have been studied extensively but
An acute exacerbation of asthma can quickly progress have so far found few strong correlations. This is most
to severe respiratory distress and may ultimately likely due to the inherent difficulty in controlling for
lead to respiratory failure defined by hypoxaemia/ confounders between study groups.1
David Liston hypercarbia. It is important to note that as an
acute asthma attack worsens and the child fatigues, Pathophysiology
David Liston
wheezing may become diminished or be completely The chronic airway obstruction seen in asthmatic
Attending Anesthesiologist
absent. Many children with chronic asthma also have patients is caused by inflammation and hypertrophied
chronic inflammatory changes that may be associated bronchial smooth muscle leading to hyperinflation
See Wan Tham
with permanent alterations in their airway structure. and air trapping. This results in decreased lung
Pediatric Anesthesiology
These patients may not be responsive to commonly compliance and increased work of breathing. Chronic
Fellow
used treatments. airway obstruction leads to a ventilation/perfusion
Seattle Childrens Hospital
mismatch and dead space ventilation which are
Seattle
Epidemiology clinically evident as hypoxaemia and further increased
USA
The median age of onset for asthma is 4 years old with work of breathing.

Preoperative assessment Preoperative treatment for mild intermittent or mild persistent
asthma involves administering a nebulized 2-adrenergic agonist,
Assessment of acute asthma
such as salbutamol, 1 to 2 hours prior to surgery.
Important questions when evaluating a child with asthma include
the following: Preoperative treatment for moderate persistent asthma involves
frequency of symptoms, additional optimization with any inhaled anti-inflammatory agent
(i.e. cromolyn, theophylline, montelukast - all act by suppressing the
amount and purulence of sputum, inflammatory mediators that cause airway hyperreactivity) and by
use and effectiveness of medications, consistent use of nebulized 2 agonists in the week prior to surgery.
Preoperative treatment for severe persistent asthma involves a visit
asthma triggers, to their primary care physician or pulmonologist prior to surgery
activity level, previous history of surgery and anaesthesia, recent in order to optimize treatment. Some children benefit from short-
upper respiratory infections, term oral corticosteroid therapy, such as prednisone (2mg.kg-1 PO
once daily for 3-5 days, max of 60 mg.dose-1) or oral dexamethasone
hospitalizations and emergency department attendance.2 (0.6mg.kg-1 PO once daily for 2 days, max of 16mg.dose-1) prior to
Investigate hospitalizations to determine if ICU admission or surgery.
intubation were required. Use the physical examination to assess for
wheezing, a prolonged expiratory phase, use of accessory muscles of These preoperative treatments have all been shown to be both
breathing (e.g. intercostal and subcostal retractions), respiratory rate,effective and safe with a low incidence of side effects.1 However,
cyanosis, and drowsiness. Oxygen saturation (SpO2) is useful to have determining the severity of the patients asthma is not sufficient. It
preoperatively. is also important to determine the patients control of their disease.
A patient with severe asthma may nevertheless be well controlled,
Preparation for surgery whereas a patient with mild asthma may be very poorly controlled.
Instruct parents to administer all asthma medications, including on It is also important to note the difference between poorly controlled
the morning of surgery to ensure optimal treatment. Children with asthma and severe persistent asthma. Poorly controlled asthma (i.e.
well controlled asthma who are scheduled for elective surgery should non-compliant with preventative or therapeutic medications) can
not have wheezing on the morning of surgery. Preoperative wheezing occur within all severity classifications of chronic asthma. However,
is predictive of perioperative complications. Stabilize patients in to be categorized as having severe persistent asthma the patient must
conjunction with the paediatric medical team and anaesthetise only meet the specific qualifications of symptom frequency and measured
when determined to be stable by a senior anaesthetist. PEFR and FEV1 values. The potential for perioperative complications
(e.g., bronchoconstriction, bronchospasm, laryngospasm and
Treatment reduced FEV1) is present with either of these scenarios. Most
Understanding the patients asthma severity is critical to administering patients with asthma should be seen by the physician who manages
the appropriate preoperative treatment. Table 1 defines each severity their disease one week prior to surgery for appropriate and timely
classification based on frequency of daytime symptoms, frequency preoperative management.
of night time symptoms, ratio of Peak Expiratory Flow Rate (PEFR)
to Forced Expiratory Volume over 1 second (FEV1) and the PEFR For the child with asthma, base your decision whether to proceed
variability. In medical settings where these pulmonary function tests with surgery on the stability of asthma symptoms and whether
are unavailable, spirometry is a useful alternative for preoperative symptoms are optimally managed. The possible intraoperative
assessment. Spirometry offers an easy method of determining the complications include bronchospasm and laryngospasm. Warner and
presence and severity of airway obstruction. The patient is asked to colleagues3 identified three factors that correlate with perioperative
place on a nose clip and then take a deep breath, exhaling into the bronchospasm:
spirometer as hard and for as long as possible. This is immediately
1. Use of bronchodilators
followed by a rapid inhalation and results in a diagnostic flow-
volume loop. 2. Recent asthma exacerbation
Table 1. Severity classification of chronic asthma
Days with symptoms Nights with symptoms PEFR/FEV1 % PEFR variability

predicted
Mild intermittent 2 / week 2 / month 80% 20%
Mild persistent 3-6 / week 3-4 / month 80% 20-30%
Moderate persistent Daily 5 / month 60-80 % > 30%
Severe persistent Continuous Frequent 60% >30%

3. Recent visit to a medical facility to treat asthma. and others show no change. Desflurane is a very pungent agent that
This makes an accurate asthma history crucial. The intraoperative is irritant to the airway and has been shown to increase secretions,
goal is to depress airway reflexes with appropriate anaesthetic drugs. coughing, and laryngospasm. Halothane and sevoflurane remain
This will prevent bronchoconstriction of the patients hyperreactive good choices for inhalational induction.
airway that can occur with airway manipulation. Stimuli that would Muscle relaxants
not usually cause an airway response in a patient without asthma Gallamine, pipecuronium and rapacuronium are all neuromuscular
may initiate a serious episode of bronchoconstriction in a patient blockers that bind and stimulate M2 muscarinic receptors more
with asthma. than M3 muscarinic receptors, causing bronchoconstriction. The
neuromuscular blockers that stimulate the M2 and M3 muscarinic
Intraoperative management receptors evenly, such as vecuronium, rocuronium, cisatracurium
Anaesthetic technique and pancuronium, do not cause bronchoconstriction. Atracurium,
Consider regional anaesthesia as the sole technique since this may mivacurium and suxamethonium dose-dependently release histamine
prevent the need for airway instrumentation. This is particularly and thus trigger bronchoconstriction. The rapid onset and short
important in patients undergoing emergency surgery when there duration of action of suxamethonium continue to make it a useful
is insufficient time to optimize their pulmonary status. When agent for a rapid sequence induction.
choosing to do a general anaesthetic, a thorough understanding of Intubation technique
the physiological effects of each anaesthetic drug and its interaction Airway manipulation, particularly in a light plane of anaesthesia, is
with an asthmatic patient is crucial. These are described below. a potent stimulus of bronchospasm, laryngospasm, coughing and
breath-holding. Use of an inhaled 2-agonist before intubation may
Intravenous drugs reduce bronchospasm. In general, avoidance of airway stimulation
Midazolam does not alter bronchial tone and is therefore a safe seems sensible. For short cases a face mask may be sufficient.
choice for preoperative anxiolysis. Whenever possible, avoidance of tracheal intubation is preferred
Propofol inhibits bronchoconstriction and increases airway dilation and a laryngeal mask airway (LMA) should be used since it may be
by directly relaxing the airway smooth muscle. These actions less stimulating than an endotracheal tube.2 However, in cases that
decrease the risk of bronchospasm during induction and propofol require airway protection (for instance patients with severe gastro-
is considered safe for patients with asthma. This agent may not be oesophageal reflux disease), and endotracheal intubation is necessary,
suitable for haemodynamically unstable patients. ensuring a deep level of anaesthesia prior to airway instrumentation
reduces the risk of bronchoconstriction.2 An endotracheal tube that
Ketamine has sympathomimetic bronchodilatory properties, with is too long and touches the carina is a potent cause of bronchospasm;
a direct relaxing action on bronchial smooth muscle. These actions the length of the endotracheal tube should therefore be assessed
decrease the possibility of bronchospasm with induction so that carefully after intubation. The Morgan formula, (endotracheal
ketamine has been proposed as a good choice for patients with severe tube length measured at the front upper teeth [cm] = 0.10 x height
persistent asthma. Ketamine also increases bronchial secretions and [cm] +5), is a useful gauge of appropriate endotracheal tube depth
should be given simultaneously with an anticholinergic drug such as in children. Another alternative which is simple to calculate for
glycopyrolate or atropine. If possible, ketamine sedation may also be oral endotracheal tube depth (in cm) is endotracheal tube (internal
considered as an alternative to general anaesthesia. diameter) size x 3. Neither formula uses age in its calculations, since
Thiopental use has been associated with bronchospasm, making it a this can be misleading in poorly-nourished populations.
poor first choice for induction of anaesthesia.
Maintenance
Lidocaine, when given intravenously, significantly increases the Maintenance of anaesthesia with inhalational agents such as
histamine threshold and blocks the cough reflex. It may be given halothane helps to dilate bronchioles and prevent bronchospasm.
to decrease the airway responses associated with endotracheal It is important to have a method to deliver a bronchodilator (e.g.
intubation. salbutamol) intraoperatively after the airway is secured. A simple
technique is to remove the plunger from a 60ml syringe and place
Morphine causes histamine release which may result in bronchospasm.
a bronchodilator metered dose inhaler (MDI) into the barrel. The
Fentanyl, if rapidly administered in large doses, can result in chest
plunger is then replaced and when depressed will trigger the MDI to
rigidity which could be mistaken for bronchospasm. However,
spray through the Luer Lock connector of the syringe. This can easily
fentanyl administered more judiciously is preferable to morphine.
be incorporated into the anaesthesia circuit at the elbow connecting
the endotracheal tube. Synchronize the MDI with inspiration to
Inhalational anaesthetics
increase its administration. Commercially available adaptors also
Halothane, enflurane and isoflurane are potent bronchodilators that
exist which optimize timing of drug administration with inspiration
act via -adrenergic receptor stimulation. They have been shown
and further improve efficiency.4
to decrease airway responsiveness and help ease histamine-induced
bronchospasm. Many studies have shown their effectiveness in the You must be vigilant for the signs of intraoperative bronchospasm in
treatment of status asthmaticus. Sevoflurane has controversial effects order to be able to treat it. Intraoperative bronchospasm presents as
in asthmatics: some studies show an increase in airway resistance a prolonged expiratory phase/wheeze with increased airway pressure,

bronchospasm when the endotracheal tube is removed. For patients
undergoing emergency surgery, with a potentially full stomach,
awake extubation is a more sensible option. An awake extubation
occurs after upper airway reflexes have returned and the patient can
therefore protect their airway. Sufficient amounts of opioid and re-
dosing of inhaled 2-agonists may also be useful prior to extubation
to decrease the reflex bronchoconstriction that may occur. It is
important to remember when reversing muscle relaxants that both
neostigmine and physostigmine cause increased secretions and
bronchial hyperreactivity.
Postoperative management
Figure 1. Typical up-sloping capnograph trace seen with bronchospasm
Analgesia
upsloping in the end-tidal CO2 waveform and hypoxia, and may When possible and where indicated, postoperative regional analgesia
result in difficulty with ventilation. You must rule out other causes is preferable. A functioning epidural will block afferent pathways
of airway obstruction (e.g. equipment malfunction) and wheeze (e.g. mediating pain from the abdominal viscera/incision and therefore
pulmonary aspiration) before starting treatment: help to maintain the patients respiratory muscle function. This
leads to more adequate tidal volume and vital capacity and helps to
Treatment of bronchospasm under general anesthesia preserve diaphragm function. A regional-only anaesthetic technique
also eliminates the need for airway manipulation, thus preventing
1. Remove causative stimulus, while increasing the FiO2
potential airway irritation. Avoidance of both meperidine (pethidine)
2. Deepen the volatile anaesthetic and morphine is preferable, given their ability to release histamines
which can result in bronchospasm. As mentioned above, fentanyl is
3. Inhaled salbutamol the best opioid alternative. An infusion of ketamine has also been
4. SC or IV adrenaline (10mcg.kg-1 SC or 1mcg.kg-1 IV, caution used in the postoperative period since it is capable of providing
with IV adrenaline) analgesia with the direct advantage of preventing bronchospam.4 Use
nonsteroidal anti-inflammatory drugs (e.g. ibuprofen and ketorolac)
5. IV steroids with caution in patients with asthma given that a small proportion of
children (1 in 50) may have a bronchospastic response.
6. Paralysis (if not already)
7. IV ketamine (consider). Monitoring
Standard postoperative monitors are indicated while waiting for the
The end-tidal CO2 waveform is an early indicator of the effectiveness patient to regain normal airway/breathing function. The head up
of these interventions. Do not be overly concerned with treating position is preferred to help clear secretions and prevent atelectasis.
a high CO2 which may lead to excessive ventilation, elevated peak The early control of sputum and respiratory symptoms helps to
inspiratory pressures and possible pneumothorax. prevent postoperative complications.
Extubation BRONCHIOLITIS
For patients undergoing elective surgery and where no other Introduction
contraindications exist, deep extubation is the best option. The Bronchiolitis is a lower respiratory tract infection with a spectrum
depth of anaesthesia should be sufficient to prevent laryngo-/ of clinical presentations ranging from minimal symptoms to
fulminant respiratory failure requiring mechanical ventilation. It is
usually a clinical diagnosis; routine laboratory or radiologic studies
are not recommended. A child usually presents with symptoms of
a respiratory infection (e.g. cough, nasal congestion). This may be
followed by fever, poor appetite and lethargy. Clinical symptoms
peak around day 3 to 4 of illness and bronchiolitis is usually a self-
limiting disease.6 Those at higher risk of clinical deterioration include
infants with chronic lung disease, congenital heart disease, and/or
prior prematurity.
Epidemiology
Viral bronchiolitis is the most common cause of respiratory disease
in children under two years of age requiring hospitalization. The
most common cause (80%) is respiratory syncytial virus (RSV).
Less common causes include rhinovirus, parainfluenza, influenza,
Figure 1: MDI incorporated into anaesthesia circuit using a 60ml syringe human metapneumovirus and adenovirus. Annual epidemics of RSV

bronchiolitis occur during the winter and spring months. Risk factors anaesthesia have a higher risk of requiring mechanical ventilation in
include prematurity (gestation < 37 weeks), low birth weight, age the postoperative period.
< 612 weeks, chronic lung disease, haemodynamically significant
Preoperative treatment
congenital heart disease, immune deficiency, neurologic disease and
Preoperative treatment goals for the child with active symptoms of
anatomical airway abnormalities.7 Outcome is generally favourable,
bronchiolitis, who requires urgent surgery include optimizing the
although a significant number will develop reactive airway disease.
respiratory status and rehydration. The key therapeutic intervention
Pathophysiology is oxygen administration to maintain SpO2 > 92%. Oxygen
The virus penetrates the terminal bronchioles lining of epithelial cells, can be administered via nasal cannula, head box or facemask.
causing necrosis, ciliary disruption and peri-bronchiolar lymphocyte Nasopharyngeal suctioning is often effective and can relieve upper
infiltration. Pathological changes are detectable 18 to 24 hours airway obstruction, increase comfort and decrease work of breathing.
after infection. Subsequently oedema, excess mucus and sloughed Intravenous fluids are often administered starting with a crystalloid
epithelial cells lead to obstruction of small airways and atelectasis. bolus of 10ml.kg-1 until deficits are replaced. Fluid requirements
Ventilation-perfusion mismatch leads to hypoxaemia. Infants are are increased due to fever, tachypnoea and decreased oral intake.
more susceptible than adults due to proportionally smaller diameter Consider nasogastric feeding for nutritional support until feeding
airways. improves prior to surgery, provided that it meets fasting time
requirements prior to surgery.
Preoperative management
Therapeutic interventions that have been used include
Assessment bronchodilators, corticosteroids, antiviral agents, antibacterial
When you assess a child with bronchiolitis prior to surgery, it is agents, chest physiotherapy and decongestant drops. None of these
important to assess the severity of illness to determine the course of have demonstrated significant impact on illness duration, severity or
action. Postponing surgery may well be safest. Usually the child with clinical outcomes.
mild bronchiolitis presents with nasal congestion. With increasing
severity, hallmark findings include rhonchi and crepitations, with The use of bronchodilators in the routine treatment of bronchiolitis
occasional expiratory wheezes.8 More severe disease is associated with is not recommended by the American Academy of Pediatrics. Their
respiratory distress (increased work of breathing and tachypnea), efficacy is uncertain and published results have been variable.10 Given
cyanosis, hypoxaemia (SpO2 < 95% on room air), dehydration and the excellent safety profile of this medication, you may consider a trial
restlessness or lethargy. Severe cases often involve infants younger of bronchodilators, but continue only if a response is documented.
than 3 months old, who appear ill or toxic, and likely will have Adrenaline and salbutamol are used most commonly (refer to Table
atelectasis on chest X-ray.9 The most significant clinical parameters in 2), although adrenaline should be reserved for hospitalized patients
determining severity of illness are respiratory rate, work of breathing, only.
and hypoxia. Possible indications for medical management in the
intensive care unit include recurrent apnoea, slow irregular breathing, Table 2. Recommended doses of medications
reduced level of consciousness, shock, exhaustion, hypoxia despite
high levels of inspired oxygen, and respiratory acidosis (pH < 7.20).4 Salbutamol:
Continuous positive airway pressure can be effective; however, the 0.15 mg.kg-1 (minimum 2.5mg, maximum 5mg) diluted in 2.5 to
majority of deteriorating infants require mechanical ventilation. 3ml saline and administered over 5 to 15 minutes via nebuliser
(requires oxygen/driving gas); or 4 to 6 puffs via MDI with spacer
In the setting where the child with bronchiolitis presents for surgery, and facemask dependent upon size/age of child.
you must evaluate the urgency of the surgical procedure. If it is
an elective case, postpone it and reschedule after 4 to 6 weeks. If Adrenaline:
the procedure is an emergency or urgent, the risks associated with 0.05ml.kg-1 of 2.25% adrenaline diluted in 3ml normal saline and
anaesthesia may be outweighed by the benefits of surgery. These risks administered via nebuliser.
include:
Corticosteroids should not be used as they have not been shown to
Airway hyperreactivity - this may result in bronchospasm,
reduce the length of stay or disease severity. In addition, they have a
laryngospasm and wheezing
well-established undesirable side effect profile. Chest physiotherapy
Supplemental oxygen should also be avoided as it will not improve the diffuse regions
Excessive secretions - may cause airway obstruction, necessitating of inflammation involved in bronchiolitis. Likewise, ribavirin and
frequent suctioning antibacterial agents are not recommended for routine use.
Apnoea and respiratory failure - RSV causes significant apnoea Intraoperative management
in infants by an unknown mechanism. In one retrospective Choice of anaesthetic technique
review, 21% of infants who were hospitalized with RSV presented Preoxygenation is essential prior to induction of anaesthesia.
with apnoea. This may be worsened by the use of inhalation Where IV access is available it might be the preferable route for
anaesthetics, sedatives and opioids. induction. It may be better to use agents that are associated with less
As a result, children with bronchiolitis undergoing general bronchoconstriction and suppress airway reflexes (e.g. propofol), as

for the asthmatic child. Wherever possible, avoidance of opioids will apnoea, hypoxaemia, hypercapnia (PaCO2 > 55mmHg/7kPa) prior
decrease the risk of postoperative apnoeic episodes. When IV access to surgery, haemodynamically significant heart disease and chronic
is unavailable, proceed with cautious inhalation induction (using lung disease.
halothane or sevoflurane) recognizing that there is an increased risk
of bronchospasm and laryngospasm. Avoid nitrous oxide as it may Postoperative management
worsen hypoxaemia. Analgesia
Intubation technique Avoid opioids or titrate them carefully. Multi-modal analgesia, using
It is essential to ensure a deep plane of anaesthesia before attempting acetaminophen (paracetamol), non-steroidal anti-inflammatory
intubation. IV lidocaine can reduce airway reflex responses. drugs and regional anaesthesia techniques are useful to supplement
Endotracheal tube placement provides advantages of a definitive postoperative analgesia.
airway and allows for frequent suctioning. Once the airway is
secured, the goals of ventilation are to minimize air-trapping and Monitoring
lung distention, and prevent barotrauma. If available, employ a Postoperative monitoring with continuous pulse oximetry and
pressure-controlled mode of mechanical ventilation (or manual apnoea monitoring for 24 hours minimum is recommended. If
ventilation) to minimize the risk of dangerously high inspiratory frequent monitoring with pulse oximetry is impractical, the child
pressure. A preset long respiratory phase will allow full expiration. should be located such that there is direct visual monitoring of the
patient (e.g., close to the nursing station).
Intraoperative management
Maintenance of anaesthesia using volatile agents which bronchodilate OTHER RESPIRATORY DISEASES
may be preferable (e.g. halothane). Drying of secretions with atropine
or glycopyrrolate may be useful intra-operatively but can exacerbate Overview
mucus plugging postoperatively. Avoid histamine-releasing agents The spectrum of respiratory tract infections ranges from the
which may contribute to bronchospasm. Consider regional and uncomplicated upper respiratory infection (URI) to pneumonia and
neuraxial anaesthesia for analgesia. These techniques should reduce pneumonitis. The most frequently encountered by the anaesthesia
opioid use and decrease the risk of postoperative apnoea and provider is the child with an uncomplicated URI, who presents
hypoventilation. with nasal secretions and cough. Provided that there is no fever,
no lethargy or decreased appetite, and no findings of respiratory
Intraoperatively, monitor airway pressure closely for subtle changes disease on physical examination (e.g. lack of wheeze or crepitus
in lung compliance. A sudden elevation of airway pressure may be on auscultation), consider the child as having an uncomplicated
due to mechanical problems such as kinking or mucus plugging of URI. If the child presents with the above symptoms, a complicated
the endotracheal tube, pneumothorax, or endobronchial intubation. URI (e.g. pneumonia) must be considered. The more common
If obstruction of the endotracheal tube from mucus plugging etiologies include viral (influenza, parainfluenza, adenovirus,
is thought to be the cause, suctioning using soft catheters may human metapneumovirus, rhinovirus) and bacterial (Streptococcus
reduce obstruction, or replacement may be required. The use of pneumoniae, Mycoplasma pneumoniae, Chlamydophilia pneumoniae)
humidifiers may reduce the risks of inspissated mucus plugs. If the causes. In immunocompromised children, additional etiologies
cause is thought to be bronchospasm, inhaled salbutamol (4-8 puffs include tuberculosis, fungal and less common bacterial and viral
every 20 minutes x 3 doses) can be introduced into the anaesthesia causes.
circuit. Further interventions may include subcutaneous adrenaline
(10mcg.kg-1 SC every 20 minutes x 3 doses, up to 500mcg.dose-1) Management of respiratory diseases will depend on the severity of
or intravenous adrenaline (1mcg.kg-1 IV every 20 minutes). Given infection and the etiology. In uncomplicated viral URIs, no additional
its cardiovascular side effects, use intravenous adrenaline cautiously measures are usually required. However, in the case of more severe
and reserve it for cases when other treatments fail to alleviate disease, antibiotics targeting the organisms involved, oxygen, nasal
symptoms. Capnography is a useful monitor as the changing shape pharyngeal suction, rehydration, and respiratory support may be
of the capnograph trace (slower upstroke) is an early indicator of necessary.
bronchospasm and the effectiveness of treatment.
Upper respiratory infections
Extubation A longstanding controversial issue is whether to proceed with
For some elective surgery patients, the trachea may be extubated under anaesthesia in a child who presents with an uncomplicated URI. As
deep inhalational anaesthesia to avoid triggering bronchospasm. a general rule, elective surgery should be postponed 4 to 6 weeks
Close monitoring into the postoperative recovery phase is mandatory. from the end of symptoms to allow acute airway reactivity to
For emergency surgery with a potentially full stomach, extubate the resolve. The risks of anaesthesia in the setting of increased airway
trachea once the child is awake and the upper airway reflexes have reactivity include severe coughing, breath holding, bronchospasm,
returned. The use of anticholinesterases for neuromuscular blockade laryngospasm, apnoea with more rapid oxygen desaturation and post
reversal is recommended if muscle relaxants were used to optimize operative oxygen desaturation.11 In a study by Cohen and Cameron,
respiratory function postoperatively. In some circumstances, you patients with URI symptoms preoperatively were 2 to 7 times more
may prefer to leave the child electively intubated at the conclusion likely to experience respiratory related intraoperative complications
of surgery. This is particularly true in patients with a history of and 11 times more likely if intubated.12

However, a child may experience 6 to 8 URIs per year and to postpone REFERENCES and FURTHER READING
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SUMMARY
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and Diagnosis. Up To Date, September 3, 2009.
Bronchiolitis
Wide spectrum of severity 8. Mcnamara D, Nixon G, Anderson B. Methylxanthines for the treatment
of apnea associated with bronchiolitis and anesthesia. Pediatr Anesth
Most common cause is RSV 2004; 14: 541-50.
Usually self limiting course
9. American Academy of Pediatrics Clinical Practice Guideline. Diagnosis
Treatment is generally supportive with oxygen, nasopharyngeal and Management of Bronchiolitis. Pediatrics 2006; 118:1774-93.
suctioning and rehydration
10. Piedra P, Stark A. Bronchiolitis in Infants and Children: Treatment;
Recommend postoperative monitoring with pulse oximeter and outcome; and prevention. Up To Date, June 5, 2009.
apnoea monitor.
11. Tait AR, Malviya S, Voepel-Lewis T, et al. Risk factors for perioperative
Upper respiratory tract infections adverse respiratory events in children with upper respiratory tract
Common presentation in children infections. Anesthesiology 2001; 95:299-306.
General management depends on severity of infection and 12. Cohen MM, Cameron CB. Should you cancel the operation when
etiology the child has an upper respiratory traction infection? Anesth Analg
1991; 72:282-8.
Postpone elective surgery 4 to 6 weeks to allow acute airway
hyperreactivity to resolve 13. Tait AR, Malviya S. Anesthesthesia for the child with an upper
respiratory tract infection: still a dilemma? Anesth Analg 2005; 100:59-
In otherwise healthy children with uncomplicated URI, 65.
intraoperative complications can generally be managed without
serious complications 14. Ungern-Sternberg BS, Boda K, Chambers N, Rebmann C, Johnson C,
Sly PD, Habre W. Risk assessment for respiratory complications in
Proceeding with anaesthesia in a child with an uncomplicated paediatric anaesthesia: a prospective cohort study. Lancet 2010;
URI is a case by case decision. 376:773-83.

Principles of clinical ananesthesia
The preparation of children for surgery
Based in part upon: Langford R. The preparation of children for surgery. Anaesthesia Tutorial of The Week 132
(2009)
Nicholas Clark and Roger Langford*

*Correspondence email: rogerlangford@doctors.org.uk
INTRODUCTION anaesthesia. Psychological development is related to

Good preoperative assessment and preparation of the age of the child (Table 1).
children for surgery is essential. This article reviews
Behavioural issues can result in a stormy anaesthetic
the preparation of children for elective and emergency
induction and post-operative psychological difficulties
surgery, including psychological preparation.
such as nightmares, phobias, fears and negativism.
Post-operative psychological problems are more likely
WHY DO CHILDREN REQUIRE A DIFFERENT Summary
to occur in:
APPROACH?
The physiological, psychological and social differences Children aged between two and three years old Preparation of children for
between children and adults necessitate a tailored Children displaying a withdrawn affect pre- surgery is essential.
approach to preoperative preparation. operatively All children should be
A difficult, stressful induction weighed and examined
Physiological carefully prior to surgery.
Most children presenting for elective surgery are A child with a history of multiple procedures.
systemically well and require little in the way of For elective procedures, a
It is important to be aware of these factors and to pre-assessment visit may be
physiological assessment and investigation. Some manage them effectively. This will improve the peri- helpful.
children can present with complex congenital disease operative experience for the child, and help shape long
or unusual syndromes that may require specific Children presenting for
term attitudes to healthcare.
preoperative investigation and preparation. Previously emergency surgery may
fit children presenting for emergency surgery may Safeguarding children be critically ill and require
All staff working with children should be trained in basic thorough assessment
become very unwell, very quickly this group of
child protection. Children are inherently vulnerable and resuscitation prior to
children must be recognised so that their condition is induction of anaesthesia.
optimised prior to surgery. by virtue of their dependant status. Evidence of abuse
or neglect may be encountered by the anaesthetist in
Psychological a variety of ways, including direct disclosure. It is
In comparison to adults, children are more likely important to remember that the childs safety should
to demonstrate behavioural issues at induction of have primacy over all other considerations. Act upon
Table 1. Psychological developmental milestones
Age Psychological developmental stage

<9 months Babies are able to accept surrogates to parent and respond well to physical contact,
talking and rocking.
1-3 years Children are bonded to parents, and more likely to display separation anxiety. Stormy
inductions are most frequent and post-operative behavioural problems are more likely.
3-6 years Children are more likely to display literal thinking: use euphemisms and metaphors with
care. A clear explanation of events and description of procedures will reduce post- Nicholas Clark
operative anxiety. Specialist Registrar
Anaesthesia
7-12 years Children can think logically about real objects, but have trouble understanding
hypothetical concepts. They are more independent and should be given simple honest
Roger Langford
explanations and the opportunity to participate (e.g. hold their own mask for induction)
Consultant Anaesthetist,
Adolescents Reasoning and mature adult-like defence mechanisms have developed. Clear Royal Cornwall Hospital
explanation and the opportunity to make decisions are essential to minimise anxiety. UK

any suspicions by discussing concerns with colleagues and if possible, Preoperative instructions
involving professionals specifically trained in child protection. Written instructions used in addition to verbal information reduce
confusion and increase compliance. Give particular emphasis to
ELECTIVE SURGERY peri-operative fasting and instructions regarding regular medication.
Children are frequently admitted on the day of surgery. Day case
There is controversy as to suitable fasting limits for breast and formula
surgery has been shown to reduce post-operative behavioural problems
milk, resulting in a lack of uniformity between institutions. Even
and should be encouraged where possible. Over 60% of paediatric
the concept of solids and liquids is difficult to fully appreciate. For
surgery in the USA is now completed as a day case procedure.
example gelatine (jelly) is ingested as a solid, but turns to liquid in
Day surgery minimises disruption to families but leaves little time the stomach; cows milk is ingested as a liquid, but turns to solid
for preparation or for the child to adjust to their surroundings. Pre- (curds) in the stomach. There is some evidence that human milk and
admission programmes are now used in the majority of UK childrens whey-based formula empties from the stomach faster than cows-milk
hospitals to help prepare for surgery. (casein) based formula. This may be due to the higher protein content
Common approaches to pre-assessment include: of casein formulas. There is great variability in gastric emptying. Table
3 shows some standard fasting guidelines for elective surgery.
Telephone screening - this is particularly useful if the child lives
far away from the hospital. Table 3. Preoperative fasting times
Nurse-led pre-assessment clinics - for children who live close to Time before surgery
the hospital.
Solids 6 hours
Many institutions have produced a standard proforma for pre- Milk (formula) 6 hours
assessment as part of the pre-operative pathway, which allows a
Milk (breast) 4 hours
thorough history to be taken. Hospital patient records, including
clinic letters should be retrieved for review. The child can be screened Clear fluids 2 hours
for suitability for day surgery, the requirement for further investigation,
In recent years, there has been a greater emphasis on preventing
and the precautions required for anaesthesia in order to reduce day-
unnecessary pre-operative fasting in children. There are many reasons
of-surgery cancellations, also whether an anaesthetist needs to see the
to encourage clear fluids up to 2 hours before surgery.
child for further assessment prior to surgery.
Infants and small children are less able to tolerate dehydration,
Table 2 (following page) lists a selection of common issues encountered
especially in hot environments.
in pre-operative screening and their implications. It is helpful to use
this table during pre-assessment to identify high-risk patients. Nausea and vomiting is more frequent in children starved for a
long period of time.
The childs social situation is important when assessing suitability for
day surgery. The family should have access to suitable transport from Hypoglycaemia can be avoided.
the hospital with one carer free, (i.e. not driving), should ideally live less Paradoxically, there may be an increase in gastric contents through
than one hour from the hospital, and must have access to a telephone. increased secretion if starvation is prolonged.
An adult should be present at home for 24 hours after surgery. It is
advisable for the family to purchase suitable analgesics in advance. Pre- and postoperative behaviour is improved by minimising
fasting times.
Pre-assessment visit
Some units require the parent to sign a form at pre-assessment to ensure
Explanation of procedures that they have understood pre-operative instructions.
Allow time to explain the peri-operative sequence of events to the
parent and child. Preparation of the parent is crucial in reducing Consent
parental and therefore the childs anxiety. Parents should be The pre-operative visit is the ideal opportunity to gain surgical consent
encouraged to ask questions about any concerns they may have. If for the procedure if this has not been obtained already. Consent should
the parents are anxious, the child is more likely to display signs of be obtained from the parent with parental rights, and child if they are
anxiety themselves. old enough to understand. Anaesthetists should understand the local
rules about who may give and obtain consent.
Explain using:
In some countries, an older childs consent can be accepted provided
Videos they can fully understand
Play
The procedure
Booklets and written instructions
Face-to-face discussions. Potential complications
If using interpreters, check for understanding and supplement by The implications of not having the procedure.
written explanation and instructions in the patients own language Often a child younger than sixteen years is assumed to lack such
whenever possible. understanding, but the child may want to countersign the consent

Table 2. Common issues encountered in pre-operative screening and their implications
Problem Implication for anaesthesia and surgery
Potential airway problems Airway management in most children is not usually problematic. Abnormal airway anatomy
associated with difficult ventilation or intubation may be found in syndromes such as Pierre
Robin (airway improves with age), Treacher Collins and the mucopolysaccharidoses (airway
worsens with age). Intubation can be extremely challenging in these patients.
Asthma [see article Anaesthesia in Markers for poorly controlled and brittle asthma:
patients with asthma, bronchiolitis Recurrent admission to hospital (including HDU or PICU)
and other respiratory disease, page
Regular oral steroids and nebulised bronchodilators.
58]
Previous use of NSAIDs should be established: while some childrens asthma control is
worsened by NSAIDs, the majority are not.
Behavioural issues/ additional needs Attention deficit hyperactivity disorder (ADHD) does not usually present peri-operative
problems.
Autism: Pre-operative visits may be difficult due to the childs requirement for familiarity and
routine.
A quiet room with toys helps keep the child calm pre-operatively
Parents will often have successful coping methods
Discuss with the parents:
- Sedative premedication
- Alternative approaches e.g. successful distraction techniques for the child
- When to abort anaesthesia
- Possible use of therapeutic restraint this should be avoided if possible.
Patients with additional needs/ learning disabilities may need reasonable adjustments to
the perioperative routine to allow them to tolerate the hospital experience. These should be
discussed case by case with the parents/ carers.
Congenital heart disease [see This may be cyanotic, acyanotic, corrected or palliated.
article page 46]
Further investigation and optimisation will depend on functional reserve and previous history
and liaison with the cardiologist or paediatrician is essential.
Medications should be carefully documented and, in general, continued. Anticoagulants

require careful consideration. Consider endocarditis prophylaxis.
Heart murmur Innocent murmurs tend to be quiet, early in systole, unaccompanied by abnormal signs or
symptoms.
Pathological murmurs are diastolic, pansystolic or late systolic, loud or continuous, often
associated with suggestive signs or symptoms:
Failure to thrive
Recurrent chest infections
Reduced exercise tolerance compared to their peers
Hypertension
Radio-femoral pulse delay
Syncope
Cyanotic episodes.
If there is any doubt as to the nature of a murmur, it must be further assessed before surgery
goes ahead. Give antibiotic prophylaxis as dictated by the surgery being undertaken and
current guidelines.

Diabetes Ask about normal blood sugar and current insulin regimen. Involve the diabetic nurse if
possible.
Agree careful instructions with respect to peri-operative insulin doses and fasting times.
Book first on the list if possible. Regular testing of blood sugar is required peri-operatively.
Downs syndrome [see article , page Pay particular attention to co-existing cardiac conditions.
27]
Seek history suggestive of atlanto-axial subluxation or tracheal stenosis (neck pain, noisy
breathing). These may be difficult to detect pre-operatively - maintain a high index of
suspicion.
Increased incidence of: behavioural problems, obstructive sleep apnoea, leukaemia, thyroid
abnormalities, duodenal atresia, Hirschsprungs disease, epilepsy.
Ex-premature babies Chronic lung disease (including requirement for postoperative oxygen), developmental delay,
seizure disorders, gastro-oesophageal reflux and failure to thrive are common. Venous access
may be difficult.
Peri-operative apnoea and bradycardia are more frequent.
Ex-premature babies less than 60 weeks post conceptual age (PCA) should not be discharged
home on the day of surgery, and should ideally be monitored with a pulse oximeter for 12
hours postoperatively.
Immunisations It is essential that the immunisation schedule is not interrupted by surgery. Occasionally, the
child may be pyrexial after vaccination, in which case elective surgery may be postponed if the
child is unwell.
Obstructive sleep apnoea (OSA) Signs of OSA include snoring, nocturnal apnoea, daytime somnolence, behaviour disturbances,
failure to thrive or obesity.
OSA may be due to adenotonsillar hypertrophy or congenital abnormalities such as Aperts
syndrome or Pierre Robin sequence, or follow interventions such as pharyngoplasty. Use
opioids cautiously and monitor post-operative respiratory function, ideally with a pulse
oximeter for 12 hours postoperatively.
Previous bad experiences Peri-operative behavioural problems especially at induction are more frequent.
Plan for alternative approaches: involve parents, play therapy if available, consider sedative
premedication.
Repeat procedures and anaesthetics These patients often have an established peri-operative routine.
Anxiety may be minimised by keeping to this routine.
Sickle cell disease [see article, page This may be evident from the family history or a Sickledex test.
35]
Patients with severe disease (frequent painful crises, chest crises, or stroke) or major surgery
may require a pre-operative top-up transfusion.
The child should be first on the list to avoid excessive dehydration. Give intravenous peri-
operative fluids and avoid hypothermia during surgery. Adequate analgesia and early
mobilization are essential.
Thalassaemia Suspect if there is a family history of anaemia in patients from endemic areas.
FBC and cardiac investigation may be required.
Pre-operative blood transfusion is sometimes necessary.

form to demonstrate assent, when their parents have signed consent. Re-affirm or obtain consent.
This can give them some positive feelings of control of their situation.
Parents may be keen to hear about all the treatment alternatives and
The process becomes complicated in the infrequent event of the child risks, while young children are often disinterested in these discussions.
consenting whilst the parent refuses. In many countries, a child under They tend to focus much more on the practicalities, for example, how
the age of 16 may not refuse consent against their parents wishes. The long the operation takes, how they are going to feel afterwards, and
legal implications are complex, depending on the country. what activities they may be temporarily excused from.
Play therapy Clinical assessment of the child
Young children learn and process experiences through playing. Some Review the pre-assessment record and note any new history such as
hospitals employ play specialists to assist in preparing children for a recent upper respiratory tract infection (URTI), gastroenteritis or
surgery. The aims are to: change in medications. The anaesthetist should examine all children
Establish a rapport through normal play. pre-operatively, in the presence of the parents, with particular attention
to the cardiorespiratory system. This examination also helps with
Explore the childs interpretation of their operation. establishing rapport with the child and can help determine whether
Prepare the child for their peri-operative experience, for example, the child trusts you and will let you near them!
by use of a doll to simulate anaesthetic induction.
Upper respiratory tract infection (URTI)
Identify children that fail to engage or those with particular anxiety Colds are very common in children, but they may be associated with
issues that might be improved with targeted sessions prior to the a 2-10 fold increase in peri-operative respiratory complications such
date for surgery. as infection, laryngospasm and wheeze.
Investigations Elective surgery should be postponed 2-4 weeks if the child is unwell,
Most children do not require routine pre-operative screening or if there is any suggestion that the child has a lower respiratory tract
investigations unless there is a specific clinical indication such as infection:
anaemia or sickle cell disease.
Fever > 38C
Day of surgery
Conduct on the day of surgery will be dictated by whether there has General malaise
been the opportunity for a pre-assessment visit. It is essential that
Chest signs on auscultation
all children are identified by name-band, consent is signed, and the
operation site marked by the surgical team, as recommended by the Productive cough
WHO Safe Surgery Saves Lives team.
The child is under one year old
All patients should be assessed by the anaesthetist immediately prior
to surgery. Wheezy child
The value of the pre-operative visit cannot be overstated: it is a final Major surgery
opportunity to consider the childs fitness for anaesthesia and surgery,
and to prepare for the peri-operative period. Surgery involving the airway.
The main points to address include: Investigations
It is essential that all children are weighed on the day of surgery.
Fasting
Establish the fasting status. Children who are not adequately fasted Special investigations are not usually required on the day of surgery.
should not undergo elective procedures. See above for fasting Exceptions include:
recommendations. Malaria parasites/full blood count in malaria endemic areas
Preparation of child and parent Peak expiratory flow rate (for brittle asthmatic children or those
Before surgery, the anaesthetist should see the child and parent and with an exacerbation of asthma)
conduct a pre-operative assessment.
Blood sugar level (for diabetic children only).
Wear appropriate dress. An anaesthetist who looks unprofessional will
not inspire confidence. Prescription of premedication if required (see below)
Speak directly to the child using simple and age-appropriate Other Issues
language in the presence of the parents to help ensure a fuller
understanding of proceedings. Preparation of environment
Consider a child friendly environment with brightly coloured pictures
Aim to put yourself at the childs eye level, adapted as best as on the walls and toys (be wary of soft toys for infection control
possible to the childs developmental stage and personality. reasons). Devices such as mobile phones with music may provide
Give an opportunity for the child and parents to ask questions useful distraction. If possible, allow children to enter the theatres in
and discuss options. their own clothes to help maintain normality and dignity.

Premedication EMERGENCY SURGERY
Consider premedication for: There are additional psychological and physiological issues to consider
Anxiolysis when preparing children for emergency surgery.
Analgesia Psychological issues

By their nature, these admissions are unplanned. The child may be
Antiemesis quiet and withdrawn due to pain, fear, hypotension or sepsis, with
Antisialogogues little interest in interacting with their environment (state of passivity).
Be alert to a child presenting in this manner - never assume that the
Antacids child is simply frightened. Immediately examine the child to exclude
Topical anaesthesia of suitable veins (using local anaesthetic cream) septic or hypovolaemic shock.
to reduce the pain associated with cannula placement and to help It is important to consider the parent. Parental anxiety can present in a
facilitate an intravenous induction. spectrum of behaviour from silence and crying to open aggression. This
There has been a reduction in routine anxiolytic pre-medication over can often be attenuated by a full explanation of the peri-operative plan.
the last decade. Appropriate preparation of the child combined with Physiological issues
parental presence at induction is sufficient in the majority of cases. All of the conditions outlined in table 2 above can also be present in
There are still situations where anxiolytics are appropriate: the acutely ill child and the principles of management are the same.
Multiple/repeated procedures Often patient notes are not immediately available. Balance the need
for further investigation of pre-existing disease against the urgency
Learning difficulties for surgery.
Extreme anxiety Children presenting for emergency surgery may be critically ill and
Uncooperative children. will require thorough assessment and, if necessary, resuscitation prior
to induction. Key aspects of the assessment of the critically ill child
Anxiolytics should be used with caution if there is a history suggestive are outlined in Table 4.
of obstructive sleep apnoea due to the increased risk of post-operative
apnoea. Inadequate resuscitation of a critically ill child prior to induction can
result in severe peri-operative haemodynamic instability. Pre-operative
Midazolam (0.5mg.kg-1 PO (maximum 20mg), or 0.3mg.kg-1 buccally) shock may be due to hypovolaemia (e.g. trauma, dehydration, acute
is the most commonly used pre-operative anxiolytic. The child is sleepy abdomen) or sepsis (e.g. abscess, appendicitis). The principles of
and cooperative after 15-30 minutes and it has minimal effect on wake- management of the shocked child should follow the ABC framework,
up times. Midazolam tastes bitter, which can be disguised by mixing and are discussed further on page 223.
with a small amount of paracetamol elixir or fruit flavoured drink.
Surgery should only proceed if resuscitation is incomplete for
Paracetamol is commonly used PO preoperatively and is preferable
haemostasis in trauma or other resuscitation situations.
to perioperative suppositories as rectal absorbtion of paracetamol is
unpredictable. A small amount of water with tablets or a minimal Anaesthetic induction and maintenance in emergency situations is
volume of analgesic elixir does not significantly increase the risk of difficult use extreme caution. A rapid sequence induction using
pulmonary aspiration. NSAIDs such as ibuprofen or diclofenac may judicious (lower than normal) drug doses is usually most appropriate.
also be given.
More thorough reviews of the management and assessment of the
Induction critically ill child, including cardiopulmonary resuscitation, are
The presence of parents at induction has become more common in elsewhere in this Update (pages 209, 223, 264).
recent years and reduces peri-operative anxiety in both the parent and Fasting
child. You will need to prepare the parent with a description of what Patients awaiting emergency surgery should be nil by mouth for solids
to expect, their role, and when to leave. for 6 hours pre-op and clear fluids 2 hours, as for elective surgery.
There are certain situations when it may not be appropriate to allow However, a risk-benefit decision may be required depending on surgical
parents to be present at induction: urgency (e.g. trauma). Beware the use of pre-operative opioids, which
can lead to a significant delay in gastric emptying. Intubation is often
Neonates and babies - there is little benefit to children under 6 prudent in this situation. If in doubt, you should choose intubation
months in having a parent present. over an LMA or facemask to protect the airway. If the child is unable
Many parents may prefer not to be there for the acute management to take oral fluids, consider starting pre-operative IV fluids.
of a critically ill child. Consent
The anaesthetist or other staff may find that working under the This should be obtained where possible. Proceed in the childs best
scrutiny of the parent impairs their ability to treat the child in interests if emergency life-saving surgery is required and there is no
stressful situations. parent or guardian available.

Table 4. Recognition of the critically ill child
Clinical signs of concern

Airway and breathing: A very sensitive sign. Normal rate varies with age. Tachypnoea may indicate pain, respiratory or
circulatory compromise.
Respiratory rate
Recession, grunting, accessory muscle use and gasping are especially concerning.
Respiratory effort
Look for poor expansion or reduced breath sounds on auscultation.
Efficacy
Heart rate, skin colour, conscious level will alter if the child is hypoxic.
Effects on other organs
Circulation: May be raised due to shock (septic or hypovolaemic), pain, or anxiety. Bradycardia is a worrying
sign and may be pre-terminal.
Heart rate
Hypotension is a late sign of shock. Age-normal blood pressure is NOT a good measure of volume
Blood pressure status.
Pulse volume May be bounding in early septic shock or reduced in severe shock.
Capillary refill Five seconds of pressure on the sternum should result in capillary refill in 2-3 seconds. Prolonged
refill is a sensitive measure of hypoperfusion.
Peripheral temperature
The peripheries may be warm in early septic shock, cold in established shock, or simply cold due
to a cool ambient temperature.
Neurological status: Reduced consciousness or lethargy is concerning and may be due to hypovolaemia, sepsis or
have a primary neurological cause (e.g. head injury, meningitis).
Conscious level
Investigations REFERENCES and FURTHER READING

Depending on the pathology, pre-operative blood tests are much more Langford R. The preparation of children for surgery. ATOTW (2009) 132. Available
from: http://www.wfsahq.org/components/com_virtual_library/media/64cd
important for emergency surgery. Significant electrolyte imbalance 6bb5b4307b722eedf89c4b4bd7d0-db600de236b211016cf0b4647da75d42-
(e.g. pyloric stenosis, bowel obstruction) or anaemia (trauma) may 132-preparation-of-children-for-surgery.pdf
be present. Blood group typing or cross match may also be necessary. Advanced Life Support Group. Advanced paediatric life support. The
Always measure blood sugar concentration in a shocked child. practical approach (APLS) 5th Edition..John Wiley & Sons ( Wiley-
Blackwell), 2011.
CONCLUSION Association of Paediatric Anaesthetists of Great Britain and Ireland. APA
Preparation of children for surgery is essential to ensure a safe Consensus guideline on perioperative fluid management in children.
v 1 . 1 S e p t e m b e r 2 0 0 7 . w w w. a p a g b i . o rg. u k / s i t e s / d e f a u l t / f i l e s /
perioperative course and pleasant experience for the child. All children Perioperative_Fluid_Management_2007.pdf
should be weighed and examined carefully prior to surgery. Brennan LJ, Prabhu AJ. Paediatric day-case anaesthesia. BJA CEPD Review
2003; 8: 134-8.
For elective procedures, a pre-assessment visit may be helpful to
Ferrari LR, Rooney FM, Rockoff MA. Preoperative fasting practices in
smooth the preoperative process and avoid cancellations on the day. pediatrics. Anesthesiology 1999; 90: 978-80.
McGraw T. Preparing children for the operating room: psychological
Children presenting for emergency surgery may be critically ill and
issues. Can J Anaesth 1994; 41: 1094-103.
require a thorough physiological assessment to ensure that resuscitation
Tait, AR, Malviya, S. Anesthesia for the Child with an Upper Respiratory
measures are taken prior to induction of anaesthesia. Tract Infection: Still a Dilemma? Anesth Analg 2005: 100: 59-65.

Principles of clinical ananesthesia
Perioperative analgesic pharmacology in children

Reprinted with revisions from: Williams G. Perioperative analgesic pharmacology in children. Anaesthesia
Tutorial of the Week 23 (2006)
Glynn Williams
Correspondence email: willig3@gosh.nhs.uk
introduction pain in children, to minimise moderate and severe

The inadequate treatment of pain in children following pain safely in all children, to prevent pain where it is
surgery was first highlighted over 20 years ago. A survey predictable, to bring pain rapidly under control, and
at the time found that 40% of paediatric surgical to continue pain control after discharge from hospital.
patients experienced moderate or severe postoperative
Once a pain management plan is implemented it
pain and that 75% had insufficient analgesia. Since
should be regularly reassessed and changes made as
then increased interest in this area has led to a better
Summary required. Appropriate pain assessment is vital to aid
understanding of the developmental neurobiology of
this. This should involve clinical assessment of the
It is both desirable and pain and analgesic pharmacology and, consequently,
child and the use of an appropriate pain scoring tool
possible to achieve allowed for the development of safer and more effective
to identify discomfort and monitor the efficacy of any
safe, effective analgesia analgesic techniques for children of all ages.
for children of all ages
analgesic intervention. Due to the subjective nature of
using individualised pain pain and the lack of a reliable measure many different
PAIN PERCEPTION
management planning tools are available. If the child is able to communicate
During foetal, neonatal and infant life the nervous
and combined multimodal their pain then a self reporting score, such as the pain
system is continually evolving. This allows structural
analgesic techniques. faces (see figure 1) should be used. If the child cannot
and functional changes to occur continuously in
communicate then other tools using behavioural and
response to the child`s needs as it grows and develops.
physiological signs should are appropriate, the one
The pain pathways mirror these changes with different
chosen from the many available will depend on the
components developing along differing time frames.
age of the child, their neurological and cognitive state,
For instance the structural components required to
and local preference.
perceive pain are present from early foetal life whereas
pathways involved in modifying pain perception are The plan should also include provision for the rapid
still developing during infancy. Also opioid and other control of pain that is not alleviated by the original
receptors vary in their number, type and distribution treatment (breakthrough pain) and the identification
between early life and adulthood. and treatment of side-effects. In established paediatric
centres with high level of resources a dedicated
The challenge of treating pain in these young age
paediatric pain service is the standard of care. Where
groups is to understand how this changing nervous
this is not available significant improvements in pain
system affects the childs perception of pain and the
management can be made by the establishment of
efficacy and safety of analgesic treatments. The field
clinical routines and protocols for the treatment and
is the subject of much research but there are many
assessment of postoperative pain and a network of
gaps in our knowledge that need to be filled. Pain is a
interested medical and nursing staff to provide ongoing
subjective experience and is thus difficult to assess if
education.
communication is not possible. Assessment relies on
using non-specific behavioural and hormonal signs MULTIMODAL ANALGESIA
of distress/stress. It has been shown in neonates and Multimodal, or balanced, analgesia, involves the
infants that the use of adequate perioperative analgesia simultaneous use of a number of analgesic interventions
will modify behavioural and hormonal stress responses to achieve optimal pain management. Our increased
and reduce morbidity. understanding of pain biology has allowed us to
use analgesic techniques that modify nociceptive
Glynn Williams PERIOPERATIVE PAIN MANAGEMENT transmission at different points along the pain pathway.
Consultant Anaesthetist Successful pain management is based on the formulation This produces analgesia using minimal doses of drugs,
Great Ormond Street of a sensible analgesic plan for each individual patient. thereby reducing side-effects.
Hospital for Children It is best to take a practical and pragmatic approach
NHS Trust dependent on the patient, the type of surgery and Using a multimodal approach effective pain management
UK the resources available. Realistic aims are to recognise is achievable for most cases and the technique can be

prostaglandin synthesis in the hypothalamus, reduce hyperalgesia
mediated by substance P and reduce nitric oxide generation involved
in spinal hyperalgesia induced by substance P or NMDA.
It is the most widely prescribed drug in paediatric hospitals and has
become the mainstay base analgesic for almost all procedures. The
analgesic potency is relatively low and on its own it is only really
effective against mild pain. In combination, however, with NSAIDs
and weak opioids it has been shown to be effective for moderate pain
and it has also been shown to have an opioid sparing effect when used
in tandem with the more potent opioids.
The oral bioavailablity of paracetamol is very good as it is rapidly
absorbed from the small bowel. Rectal absorption is slow and
incomplete, except in neonates. Though the formulations of different
brands of suppository vary and the more lipophillic the better the
bioavailability. Even so, if paracetamol is given rectally at the start of
a short procedure (<1hour) it is unlikely to reach therapeutic plasma
levels by the time the child wakes in the recovery room. Thus, if
possible, paracetamol should be given orally and pre-operatively.
Figure 1. Wong-Baker Faces Pain Rating Scale. Reproduced from Intravenous paracetamol preparations are becoming widely available
Hockenberry MJ, Wilson D, Winkelstein ML: Wongs Essentials of Pediatric in many countries. Studies suggest that it may have a higher analgesic
Nursing, ed. 7, St. Louis, 2005, p. 1259. potency than either the oral or rectal preparations though the time
to peak analgesia is still 12 hours. Irrespective of the route of
adapted for day cases, major cases, the critically ill child, or the very
administration a regular rather than an as required post-operative
young. In current practice most analgesic techniques are based on
prescription has been shown to provide better analgesia.
differing combinations of four main classes of analgesics: paracetamol,
non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and local In recent years the accumulation of a large body of evidence concerning
anaesthetics. Though it is not uncommon for other agents, e.g. NMDA the use of paracetamol in children has led to the revision of dosing
antagonists and alpha-2 agonists, and non pharmacological analgesic schedules to ensure a balance between efficacy and safety. Smaller doses
methods to be used in addition. Unless there is a contraindication to and longer dosage intervals are required in the neonate or sick child.
do so, a local/regional analgesic technique should be used in all cases.
For many minor and day case procedures this, in combination with Non-steroidal anti-inflammatory drugs (NSAIDs)
paracetamol and NSAIDs, may allow opioids to be omitted. NSAIDs act mainly peripherally by inhibiting prostaglandin synthesis
and thus reducing inflammation, although central effects have also
Paracetamol (Acetaminophen) been postulated involving the opioid, serotonin and nitric oxide
Paracetamol has a mainly central mode of action producing both pathways. They are highly efficacious in their own right in the
antipyretic and analgesic effects. It has been shown to inhibit treatment of mild to moderate pain in children. They have a reported
Table 1. Dosing guide for oral and rectal paracetamol
Age Oral: Maintenance Rectal: Maintenance Maximum daily Duration at

Loading dose dose Loading dose dose dose maximum dose
Pre term <32 20mg.kg-1 15mg.kg-1 up to 20mg.kg-1 15mg.kg-1 up to 45mg.kg-1.day-1 48h
weeks 12 hourly 12 hourly
32 weeks 1 20mg.kg-1 15mg.kg-1 up to 30mg.kg-1 15mg.kg-1 up to 60mg.kg-1.day-1 48h
month 6 hourly 6 hourly
>1month 20mg.kg-1 15mg.kg-1 up to 30-40mg.kg-1 20mg.kg-1up to 6 90mg.kg-1.day-1 72h
4 hourly hourly
Table 2. Dosing guide for intravenous paracetamol
Age/Weight Dose Maximum daily dose

1month 50kg 15 mg.kg up to 6 hourly
-1
60 mg.kg-1/day
>50kg 1g up to 6 hourly 4 mg.kg-1

Table 3. Dosing guide for NSAIDs
Drug Route Dose

Ibuprofen Oral <20kg: 5-10mg.kg-1 up to 6 hourly
>20kg: 200mg 6 hourly
Diclofenac Oral/Rectal 1-3mg.kg-1 up to 3mg.kg-1 in divided doses
opioid-sparing effect of 30 40 % when used in combination with of morphine seen clinically in neonates. Codeine however, another
opioids and also reduce opioid-related adverse affects as well as popular opioid in neonates and infants, works via metabolism
facilitating more rapid weaning of opioid infusions. They have also to morphine. The cytochrome P450 enzyme responsible for this
been shown to be highly effective in combination with local or regional conversion shows markedly reduced activity at these ages compared
nerve block. Combination with paracetamol produces better analgesia with that seen in older children and adults. Thus it may be that
than either drug alone. little or no morphine is produced from a dose of codeine. This may
explain codeine`s good safety profile in young children but may also
There are limitations to their use in paediatric populations. At present, suggest that the analgesic efficacy is questionable. Recently there has
in general, their use is not recommended for children less than 6 been increased awareness of children suffering respiratory depression
months of age, although in the UK Ibuprofen is now available over following codeine, this is thought to be due to ultra-fast metabolism
the counter in formulations for ages 3 months and above. Care should converting codeine into its active metabolite, morphine. In UK it is
also be taken in those patients who are asthmatic, have a known aspirin no longer recommended to use codeine in any child under 12 years
or NSAID allergy, are hypovolaemic or dehydrated, renally-impaired, old for this reasons. It is not possible to predict who will metabolise
coagulopathic or where there is a significant risk of haemorrhage. A codeine quickly or poorly.
careful history of previous use of NSAIDs should be taken in every
case. Different NSAIDs have different side-effect profiles and the Many routes for the administration of opioids are available in children.
relative risks associated with each of the contraindications given will During surgery, with an IV cannula in situ, the intravenous route
differ between drugs. In the UK the Committee on the Safety of is the easiest. In terms of bioavailability and consistency of effect it
Medicines has classified Ibuprofen and Diclofenac as having the best is also the most reliable. For these reasons it is usually the route of
side-effects profile. choice postoperatively, especially after major surgery. Safety, however,
must always be a priority. Potentially serious complications such as
Pharmacokinetic studies have indicated a higher than expected
over-sedation and respiratory depression can occur even when using
dose requirement in children if scaled by body weight from adult
well constructed protocols for opioid use. With infusion or bolus
doses. Rectal and oral bioavailability are both good though again for
techniques safe practice must include the presence of appropriately
short cases they are best give orally preoperatively. Other routes of
educated staff and regular observation of sedation and respiratory rate.
administration are available, such as intravenous and topical, though
Oxygen and opioid antagonists should be easily accessible in case of
their use in children has been limited so far.
emergency. If these are not available then other routes of administration
Opioids or analgesic strategies are indicated. It is sensible for each institution to
As with adults, opioids, and morphine in particular, remain the devise protocols for opioid use dependent on their own local resources.
mainstay of analgesic treatment for the majority of all but minor
Oral and rectal formulations of many opioids are available and have
surgical procedures. The choice of which opioid to use will depend on
a place for some patients in the perioperative period, especially if
the patient`s medical history, the type of surgery, drug availability, any
safety is a prohibitive local issue for other methods of delivery. If
locally devised protocols and, often, individual anaesthetic preference.
the IV route is available postoperatively, continuous IV infusions
The pharmacology of these agents changes during early life and these
and intermittent intravenous boluses have been shown to be safe
changes are not consistent between different drugs. When using a
and effective. Where local resources allow, IV opioids are usually
particular opioid in neonates and infants it is important to understand
administered via patient (PCA) or nurse (NCA) controlled delivery
the pharmacology of that particular drug in those age groups to ensure
systems which demonstrate good efficacy and safety in all age groups,
both efficacy and safety.
even neonates. The subcutaneous route remains an alternative to IV
Morphine remains the most commonly used opioid and, consequently, administration but absorption is not as reliable and it should not be
is the most studied. Morphine clearance is decreased and the used in hypovolaemic patients. Intramuscular injection demonstrates
elimination half-life is increased in neonates compared with infants slow absorption and unreliable effect and is considered undesirable in
and older children. Also in neonates the glucuronidation pathways, the the awake child due to the pain and distress of the injection. Other
main metabolic pathway for morphine, are still developing, slowing routes of administration are available, e.g. sublingual, transdermal
morphine metabolism and giving a relatively increased production and intranasal and may be appropriate in specific cases or where local
of morphine-6-glucuronide, an active metabolite of morphine. These resources dictate their use. Opioids are also commonly used as adjuncts
differences may to some extent account for the increased efficacy to local anaesthetics.

The extensive study and use of morphine in all age groups has lead Regional analgesia produces excellent perioperative analgesia for
to the formulation of safe and effective dosing strategies in children, major surgery at all age groups, even preterm neonates, and has
provided appropriate monitoring is used: been shown to decrease postoperative complications. The evidence
for this, however, is limited as is the evidence for the risks associated
Titrated loading dose of IV morphine with paediatric epidural analgesia. In general these techniques should
50mcg.kg-1 increments, repeated up to x4 only be performed by experienced practioners with appropriately
trained staff and protocols and monitoring guidelines available for
Ongoing bolus dose of IV morphine the postoperative period. Plexus or peripheral nerve blocks have been
20mcg.kg-1 per bolus, repeated to effect shown to have good efficacy and safety for limb and head and neck
surgery. In some procedures involving the lower limbs the analgesia
Oral morphine* obtained from a peripheral nerve block has a much longer duration
80mcg.kg-1 4hrly (1month 1yr) of action than that obtained from a single shot central block.
200 400mcg.kg-1 4 hourly (>1yr)
For many years bupivacaine has been the local anaesthetic of choice
IV or s.c. morphine infusion in paediatric practice. It has been extensively studied and safe-dosing
10 40mcg.kg-1.hr-1 guidelines have been established which have greatly reduced the
incidence of systemic toxicity. Neonates demonstrate decreased
PCA with morphine
clearance and decreased protein binding of local anaesthetic agents.
Bolus dose 10 20mcg.kg-1
Therefore, at this age, there is a risk of systemic toxicity and dosing
Lockout interval 5min
schedules have to be adjusted. Although thankfully rare, bupivacaine
Background infusion 0 4mcg.kg-1.hr-1
still carries the risk of significant cardiotoxicity and this has lead to
NCA with morphine the increasing introduction of the newer agents, ropivacaine and
Bolus dose 10 20mcg.kg-1 levo-bupivacaine (chirocaine), into current practice. There are now
Lockout interval 20 - 30min sufficient paediatric data to recommend either of these agents. Adjuncts
Background infusion 4 20mcg.kg-1.hr-1** such as opioids, adrenaline, ketamine and clonidine are commonly
added to local anaesthetic agents. This is mainly seen with regional/
* Can be used in neonates at 80mcg/kg but may need to increase dosage central blockade. They allow for increased duration and spread of the
interval to 6 hourly and child must be closely monitored. block with minimal increase in side-effects, due to the low doses used.
**For neonates a background dose is omitted to reduce the possibility of DISCHARGE FROM HOSPITAL
a prolonged effect of the morphine. This allows the carer to use the bolus
A sensible analgesic plan should include provision for analgesia to
function to titrate the analgesia and anticipate painful episodes.
continue once the child has been discharged from hospital. Clear and
easy to follow instructions should be given to aid compliance and thus
efficacy. Inadequate pain relief at home, as in hospital, will lead to
Local Anaesthetics (see chapters on specific local anaesthetic
unacceptable distress for both child and carer and the potential for
blocks)
complications. In general an assessment is needed of the likely severity
Local anaesthetic agents work by blocking the conduction of
and duration of the pain. Again a multi-modal approach should be
nociceptive stimuli along the pain pathway. This can be achieved by
adopted and regular dosing schedules are superior to as required
many different routes, the commonest being central/regional blocks,
prescriptions when the pain is likely to be significant.
plexus blocks, peripheral nerve blocks, infiltration at the site of injury,
and topical application. Some method of nerve blockade is appropriate If a single bolus local anaesthetic technique has been used then the
for nearly all surgical procedures and forms an important part of a time that this will wear off must be anticipated and analgesic provision
balanced analgesic technique. Though, once again, the technique used made. Often analgesia is required for a significant period of time after
will depend on the patients medical history, the type of surgery, any discharge. For instance it is well described that children still experience
locally devised protocols and, often, individual anaesthetic preference. significant pain 7-10 days following adenotonsillectomy.
Table 4. Dosing guide for bupivacaine, levobupivacaine and ropivacaine:
Single bolus injection Maximum dosage

Neonates 2mg.kg-1
Children 2.5mg.kg-1
Continuous Infusion Maximum infusion rate

Neonates 0.25mg.kg-1.hr-1
Children 0.5mg.kg-1.hr-1

SUGGESTED READING 3. Howard RF, Lloyd-Thomas A. Pain management in children. In:
Williams G. Perioperative analgesic pharmacology in children. Sumner E and Hatch DJ eds. Paediatric Anaesthesia. London, U.K.
ATOTW (2006) 23. Available from: http://www.wfsahq.org/components/ Arnold. 1999.
com_virtual_library/media/e558e631b7d38a387f407ae65805690c- 4. http://onlinelibrary.wiley.com/doi/10.1111/pan.2012.22.issue-s1/
490d426becffb3927dcc16bd60ef9805-23-perioperative-analgesic- issuetoc#group1. Good Practice in Postoperative and Procedural Pain
pharmacology-for-children.pdf Management, 2nd Edition, 2012 (79 page special issue, free to
1. Lonnqvist P-A, Morton NS. Postoperative analgesia in infants and download).
children. Br J Anaesth 2005; 95: 59 68. 5. Association of Paediatric Anaesthetists & Royal College of Paediatrics
2. Berde CB, Sethna NF. Analgesics for the Treatment of Pain in Children. and Child Health. Guidance for the administration of codeine and
N Engl J Med 2002; 347: 1094 103. alternative opioid analgesics in children. 2013. http://www.apagbi.org.
uk/sites/default/files/images/Codeine_Nov2013.pdf.

Principles of clinical anaesthesia
Paediatric procedural sedation
Reprinted from: Sethi DS, Smith J. Paediatric Sedation. Anaesthesia Tutorial of the Week 105 (2008)
Dr D S Sethi* and Dr J Smith

*Correspondence Email: darshansethi@rediffmail.com
INTRODUCTION Control anxiety, minimize psychological trauma

Sedation is the use of drugs for reduction of fear and and maximize the potential for amnesia
anxiety, induction of drowsiness or sleep and comfort.
Control behaviour and/or movement to allow the
All sedation techniques carry risk and many safe completion of the procedure
procedures done under sedation are performed outside
Return the patient to a state in which safe discharge
operating theatres. Sedation in children needs special
from medical supervision is possible.
considerations, and some drugs used for sedation are Summary
not as reliable as those for anaesthesia. Its safety and PATIENT SELECTION
success depends upon skill and judgement. You must carefully assess the patient with detailed Sedation in children needs
special considerations,
history and clinical examination; this is important
DEFINITIONS OF SEDATION and some drugs used for
to identify potential risk factors. [See also article on sedation are not as reliable
Sedation is a continuum from the awake state. The
Preparation of children for surgery in this edition of as those for anaesthesia. Its
American Society of Anaesthesiologists uses the
Update, page 65] Previous sedation history is important safety and success depends
following definitions for levels of sedation:
as previously failed sedation may indicate a need for upon skill and judgement.
Minimal sedation (formerly known as anxiolysis) is general anaesthesia. Although the ASA classifications If you act as a sedation
a drug-induced state during which patients respond are not totally appropriate for paediatrics, the Scottish practitioner, you should
normally to verbal commands. Although cognitive Intercollegiate Guidelines Network advises that only be trained in sedation
function and coordination may be impaired, respiratory patients in ASA classes I and II should be considered techniques.
and cardiovascular stability is unimpaired. suitable for sedation as outpatients. Patients in classes
III to V should be regarded as high risk patients who
Moderate sedation (formerly known as conscious
should only be managed in a hospital setting with the
sedation) is a drug-induced depression of consciousness
involvement of an anaesthetist trained in paediatric
during which patients respond purposefully to verbal
sedation, anaesthesia and resuscitation.
commands, either alone or accompanied by light
tactile stimulation. It is important to remember that
INDICATIONS FOR SEDATION
reflex response to a painful stimulus is not a purposeful
response. No interventions are required to maintain a Painless procedures:
patent airway, and spontaneous ventilation is adequate. Transthoracic echocardiography
Cardiovascular stability is usually maintained.
Radiotherapy
Deep sedation/analgesia is a drug-induced depression
of consciousness during which patients cannot be easily Computed tomography
roused but respond purposefully following repeated
or painful stimulus. Patients may require assistance MRI
in maintaining a patent airway, and spontaneous Electroencephalography.
ventilation may be inadequate. Cardiovascular stability D S Sethi
is usually maintained. Painful procedures: Specialist Registrar
Minor, painful oncology procedures in Anaesthesia
In the UK deep sedation is considered to be a part of
Great Ormond
the spectrum of general anaesthesia. Interventional radiology Street Hospital
GOALS OF SEDATION Dental procedures
J Smith
The goals of sedation in the paediatric patient for Wound care, including burns dressings Consultant Anaesthetist
diagnostic and therapeutic procedures are to:
Cardiac angiography Great Ormond Street
Guard the patients safety and welfare Hospital
Minimize physical discomfort and pain Fracture manipulation. London

CONTRAINDICATIONS TO SEDATION Emergency cases who are not adequately starved
Children with any of the following should not normally be
Anticonvulsant therapy
sedated
Children receiving opioids and other sedatives
Abnormal airway. This includes adenotonsillar hypertrophy
causing obstruction to breathing when asleep (Obstructive Sleep Children receiving drugs that potentiate the action of sedatives (e.g.
Apnoea, or OSA), or any other anatomical abnormality of upper macrolide antibiotics such as erythromycin potentiate and prolong
and lower airway the sedative effects of midazolam).
Raised intracranial pressure PATIENT PREPARATION AND MONITORING
Depressed conscious level During procedural sedation when protective airway reflexes are lost,
gastric contents may be regurgitated into the airway. Therefore, patients
History of sleep apnoea (OSA)
with a history of recent oral intake or with other known risk factors
Respiratory failure for aspiration should not be sedated.
Cardiac failure
Neuromuscular disease Appropriate intake of food and liquids before elective sedation
Bowel obstruction Ingested Material Minimum Fasting Period (Hours)

Active respiratory tract infection Clear liquids: water, fruit juices
without pulp, carbonated beverages,
Known allergy to sedative drug / previous adverse reaction
clear tea, black coffee 2
Child too distressed despite adequate preparation Breast milk 4
Older child with severe behavioural problems Infant formula / non human milk 6
Refusal by the parent / guardian / child. Solids 6
The following subgroup of patients should not be sedated
with nitrous oxide
There are specific contraindications to the use of nitrous oxide due to Systematic approach to sedation
its ability to diffuse into enclosed air spaces causing them to expand It is important to use a systematic approach to sedation techniques so
or increase in pressure, or in the case of pulmonary hypertension, as as to not overlook an important drug, piece of equipment, or monitor
it increases pulmonary vascular resistance. that may be required at the time of a developing emergency. To avoid
Intracranial air (e.g. after skull fracture) this problem, it is helpful to use an acronym that allows the same
setup and checklist for every procedure (see Figure 1).
Pneumothorax, pneumopericardium
Bowel obstruction WHO SHOULD ADMINISTER SEDATION?
If you act as a sedation practitioner, you should be trained in sedation
Pneumoperitoneum techniques. You should be competent to obtain consent, prescribe and
Pulmonary cysts or bullae administer sedative drugs, understand the pharmacology of the agents
used and be capable of providing Paediatric Basic Life Support and
Lobar emphysema preferably Paediatric Advanced Life Support. For deep sedation this
Severe pulmonary hypertension. should be an anaesthetist or a practitioner with training in anaesthesia.
Extra caution should be exercised when sedating children DRUGS USED FOR SEDATION
who have any of the following conditions A drug can only be considered safe after experience in hundreds and
Neonates, especially if premature or ex-premature thousands of cases; however, few drugs have been studied to this extent.
Good protocols are important for the safety and success of sedation.
Children with cardiovascular instability or impaired cardiac
function Choral hydrate and Triclofos
Renal impairment Choral hydrate and triclofos are effective oral sedatives and are
metabolised to trichlorethanol. Chloral hydrate has an unpleasant taste
Hepatic impairment and causes gastric irritation; triclofos is more palatable but is slower
Severe respiratory disease and less potent (1g triclofos = 600mg chloral hydrate). Respiratory
complications, vomiting and paradoxical reactions can occur. Deaths
Gastro-oesophageal reflux
have occurred in unattended children. Small children are calmed by
Impaired bulbar reflexes sub-sedation doses.

Figure 1: A system for planning sedation
A commonly used acronym that is useful in planning and preparation for a procedure is SOAPME:
S Suction Size-appropriate suction catheters and a functioning suction apparatus (e.g. Yankauer-type suction)
O Oxygen Adequate oxygen supply and functioning flow meters/other devices to allow its delivery
A Airway Size-appropriate airway equipment (nasopharyngeal and oropharyngeal airways, laryngoscope blades and handles
[checked and functioning], tracheal tubes, stylets/bougies, face mask, bag-valve-mask or equivalent device
[functioning])
P Pharmacy All the basic drugs needed to support life during an emergency, including antagonists as indicated
M Monitors Functioning pulse oximeter with size appropriate oximeter probes. Other monitors as appropriate for the procedure
(e.g., non-invasive blood pressure, end-tidal carbon dioxide, ECG, stethoscope)
E Equipment Special equipment or drugs for a particular case (e.g. defibrillator)
This table summarizes the expected clinical responses and the ideal monitoring requirements for different levels of sedation:
Minimal sedation Moderate sedation Deep sedation
Responsiveness Normal Purposeful to light stimulation Purposeful to painful stimulation
Airway Unaffected No intervention () Intervention
Ventilation Unaffected Adequate () Inadequate
Cardiac stability Unaffected Maintained () Maintained
Monitoring Observation & Pulse oximetry Pulse oximetry
intermittent assessment
Heart rate ECG continuous
Intermittent recording of RR and BP every 3-5 minutes
BP
() EtCO2, precordial stethoscope
Benzodiazepines
Midazolam Diazepam
Midazolam induces anxiolysis, sedation and amnesia; it is absorbed Intravenous diazepam (Diazemuls) is 4-5 times less potent than
enterally and via oral and nasal mucosa. By mouth, 0.5mg.kg -1 midazolam. Despite a longer elimination half-life, recovery profiles
(maximum 20mg, 30 min beforehand) reduces crying during are similar (usually by 2h). Dose- 200-300microgram.kg-1 orally and
induction of anaesthesia, but occasionally dizziness, dysphoria and 100-200microgram.kg-1 IV.
paradoxical reactions occur. Its bitter taste needs masking with a
sweetening agent. In the emergency department, 0.5-1mg.kg-1 orally Temazepam
is useful to calm children for suture of lacerations. Intranasal drops 0.2 Temazepam tablets are preferred to the taste of the elixir and oral doses
mg.kg-1 effectively calms irritable infants but this method is unpleasant of 0.5-1mg.kg-1 cause minimal sedation and sleep.
and causes crying - an atomizer may be better. Absorption is so rapid Reversal of benzodiazepine sedation
that apnoea and desaturation occur occasionally. Flumazenil 20-30microgram.kg -1 IV can be used to reverse
Sublingual administration is more pleasant, equally rapid and effective, benzodiazepine sedation. There may be a risk of fitting from sudden
but requires co-operation. Rectally, 0.3-1mg.kg-1 may cause moderate benzodiazepine withdrawal. As the half-life of flumazenil is less than
sedation. that of some benzodiazepines, there is a risk of re-sedation.
IV titration is best but effects are variable, unpredictable and depend Barbiturates
upon the discomfort of the procedure (0.05-0.2mg.kg-1 for moderate
Thiopental
sedation). Co-administration of opioids increases the risk of apnoea
while co-administration of macrolide antibiotics may result in Intravenous thiopental is too potent for non-anaesthetists to use safely.
prolonged unconsciousness due to inhibition of hepatic metabolism. When given rectally in children, thiopental 25-50mg.kg-1 produces
Occasionally children may develop paradoxical excitation and anxiety sedation after 30 min. Airway obstruction can occur and recovery
(confusion/disinhibition). takes between 30 and 90 min.

Pentobarbital and quinalbarbital Chlorpromazine and promethazine
Quinalbarbital (7.5-10mg.kg-1 orally) makes 90% of children (<5 yr) Chlorpromazine and promethazine have been combined together with
sleep but older children may have paradoxical excitement. meperidine (pethidine) to form pethidine compound (1ml contains 25
mg meperidine, 6.25mg chlorpromazine and 6.25mg promethazine).
For painless imaging, pentobarbital 2-6mg.kg-1 IV is very successful
It is for IM administration only and combines analgesia, anxiolysis and
but 1-3% of children have airway obstruction or paradoxical reactions.
sedation; effective doses are between 0.06 and 1ml.kg-1. This powerful
Pentobarbital is not available in the UK.
combination can cause apnoea.
Propofol
Nitrous oxide
The short action and lack of side effects make propofol the best of
Nitrous oxide provides valuable analgesia and sedation in cooperative
all the IV agents but, because apnoea and desaturation are common,
children for a wide variety of painful procedures. Loss of consciousness
it is not recommended for non-anaesthetists. Sedation is induced by
can occur when combined with other sedatives or when used alone in
2-4mg.kg-1 and usually maintained by an infusion of 6-8mg.kg-1.h-1;
concentrations over 50%.
recovery is pleasant and occurs within a few minutes. Tolerance and
behavioural disturbances are reported. Ketamine
This anaesthetic drug causes a dissociative sedation or anaesthesia
Melatonin with analgesia. In maintaining cardio-respiratory function, ketamine
Natural sleep may be induced successfully in 55% for MRI and 80% (IV or IM) is extremely useful when other methods of anaesthesia
for EEG. Doses range from 2-10mg orally. are unavailable or impractical. If non-anaesthetists use ketamine they
must be prepared for laryngospasm and apnoea. Apnoea has occurred
Opioids following 4mg.kg-1 IM and is more likely if ketamine is combined with
opioids. Nausea and vomiting can occur in 15-33% and distressing
Morphine
hallucinations in 3% even when combined with midazolam. For
Morphine is useful for painful procedures such as wound care. A dose
needle-phobic children, 5mg.kg-1 orally causes variable sedation
of 60microgram.kg-1 IV has been used in combination with midazolam
after 10-20min, and 10mg.kg-1 makes 50% of children unconscious;
0.05mg.kg-1 IV without major respiratory effects.
recovery can take up to 2 hours.
Meperidine
KEY REFERENCES
Meperidine 0.5-1mg.kg -1 IV combined with midazolam Sethi DS, Smith J. Paediatric Sedation. ATOTW (2008) 105. Available at:
0.05-0.1mg.kg-1 IV provides effective sedation for endoscopy. http://www.wfsahq.org/components/com_virtual_library/media/477f2ba
However, oxygen desaturation has been reported in cases. f45cc2bb9a4494be0d922870a-788e4c95dcdadbf9e5a5af36b465ebff-105-
Paediatric-sedation-v2.pdf
Fentanyl
SIGN. Safe sedation of children undergoing diagnostic and therapeutic
The potency of fentanyl increases the risk of apnoea. For example,
procedures. A national clinical guideline. Scottish Intercollegiate Guidelines
5% of children given IV midazolam and fentanyl (1-6mcg.kg-1) for Network, 2004 http://www.sign.ac.uk/guidelines/fulltext/58/index.html
gastroscopy required reversal with naloxone. Fentanyl is absorbed from
the mucosa of the mouth and oral transmucosal fentanyl citrate is Editorial note - guideline has been withdrawn by SIGN since original
publication of this article.
available both as a lozenge and a palatable lollypop; side effects include
vomiting (30%) and desaturation. Charles J. Cote, Stephen Wilson and the Work Group on Sedation,
Guidelines for Monitoring and Management of Pediatric Patients During
Reversal of opioid-induced respiratory depression and After Sedation for Diagnostic and Therapeutic Procedures: An Update.
Opioid-induced respiratory depression can be reversed with naloxone. Pediatrics 2006;118;2587-2602 http://pediatrics.aappublications.org/
The usual dose is 10microgram.kg-1 IV, repeated as necessary. content/118/6/2587.full.pdf+html
Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse
Major tranquillizers sedation events in pediatrics: a critical incident analysis of contributing
factors. Pediatrics 2000; 805-814
Trimeprazine
Trimeprazine 3-4 mg.kg-1 orally causes sleep in 50% of children before M R J Sury Paediatric Sedation, British Journal of Anaesthesia CEPD, Number
anaesthesia. However, because of reports of hypotension, the maximum 4, Volume 4 August 2004.
recommended dose is 2mg.kg-1. At this dose, it can be combined with M R J Sury, Anaesthesia and sedation outside operating theatres, Chapter 44
morphine 0.2mg.kg-1 IM for sedation of children >15kg for MRI. in: Hatch and Sumners Textbook of Paediatric Anaesthesia (2007 Edition).
Publisher Hodder Arnold.

Perioperative fluids in children
Reprinted with revisions from: Wilson CM. Perioperative fluids in children. Update in Anaesthesia 2005;
19: 36-8.
Catharine M Wilson* and Isabeau A Walker

*Correspondence Email: catharinewilson@yahoo.co.uk
INTRODUCTION
Starvation, surgery and anaesthesia cause Maintenance: to provide water, electrolytes
stress and alter physiology. Intravenous fluids and glucose during starvation.
are administered perioperatively to maintain
homeostasis during this period. Water and Replacement: of ongoing losses due to
Summary
electrolytes are required to correct deficits and evaporation from an open wound or via the
ensure adequate intravascular volume, cardiac humidification of dry inspired gases, bleeding, This article is a revision of
pyrexia, gastrointestinal and third space losses one written for Update 10
output and ultimately tissue oxygen delivery. years ago. Changes in the
Calories in the form of dextrose may be needed (fluid leak into tissues) during surgery and
intervening years include
to prevent hypoglycaemia. into the post-operative period. greater awareness and more
defined acknowledgement
The majority of healthy children undergoing of the dangers of using
RESUSCITATION
minor surgery (e.g. circumcision, hernia repair) hypotonic fluids, and
Any child who is dehydrated or hypovolaemic increasing evidence that
will be able to drink in the early postoperative
should be resuscitated prior to surgery unless the isotonic crystalloids (0.9%
phase and will not need intravenous fluids before,
nature of the illness and operation precludes this. saline, Hartmanns, Ringers
during or after surgery. Fasting times should be lactate, Plasma-Lyte) are the
In this case rapid correction of hypovolaemia
observed so that children are not left without fluid of choice for resuscitation
should commence at, or as soon as possible after
fluid intake for longer than necessary. The fasting and maintenance during
induction to maintain circulating volume and surgery. New on the horizon
guidelines for elective surgery are shown in Table
cerebral perfusion. is the Fluid Expansion as
1. Supportive Therapy (FEAST)
Patients undergoing longer or more major Hypovolaemia (losses from the intravascular study for African children with
space) should be corrected rapidly, initially with severe infection; this will be
procedures, or anyone compromised by considered at the end of this
underlying problems, will need intravenous boluses of 10-20ml.kg-1 isotonic crystalloid
article.1
fluids during surgery. (0.9% saline, Hartmanns, Ringers lactate,
Plasma-Lyte). Blood should be considered if the
Fluids are given for three reasons: haemoglobin or haematocrit are low (Hct less
Resuscitation: to correct pre-existing than 25%) or more than 40ml.kg-1 of fluid is
hypovolaemia or dehydration. required.2
Catharine M Wilson,
Table 1. Fasting guidelines for elective surgery Anaesthetist
Sheffield Childrens NHS
Type of food/fluid Minimum fasting time (hours)
Foundation Trust
Clear liquids 2 Sheffield UK
Breast milk 4
Isabeau A Walker
Infant formula 4 (<3 months old)
6 (> 3 months old) Anaesthetist
Great Ormond Street NHS
Non-human milk 6
Foundation Trust
Light meal 6 London UK

Dehydration (total body water loss) should be corrected more the weight of the child in kg (see Table 2 below).
slowly, preferably by the oral route if tolerated and time allows,
Electrolyte and glucose requirements were also estimated
but otherwise intravenously. The rapid rehydration technique
depending on the weight of the child (dietary sodium and
advocated by Assadi and Copelovitch describes an initial rapid
potassium = 1.2mmol.kg-1.day-1). An ideal maintenance
(1-2 hours) infusion of isotonic saline up to 60-100ml.kg-1 as
solution was proposed that contained the maintenance
required to correct hypovolaemia.3 This is followed by a slower
requirements for water and sodium in one bag, with dextrose
correction of dehydration over 24-72 hours with 0.9%, 0.45%
added to make the fluid isotonic with the vessels (0.2% saline in
or 0.2% saline depending on measured plasma sodium. The
5% dextrose in the US, 0.18% saline in 4% dextrose in the UK,
plasma sodium should be measured at regular intervals (at least
with added potassium chloride (KCl) 20mmol.l-1 if required).
6 hourly if outside the normal range). Too rapid correction
This solution became the mainstay of IV maintenance fluid for
of dehydration with hypotonic fluid will result in cerebral
many years, however its validity has recently been questioned
oedema secondary to hyponatraemia.
and the use of isotonic fluid advocated instead, particularly in
An otherwise healthy child starved pre-operatively will have the perioperative period.7,8,9,10
a fluid deficit. The size of the deficit may be calculated by Neonates (up to 44 weeks post-conceptual age) have a slightly
multiplying the hourly maintenance requirement (see table different fluid requirement. They are born physiologically
2) by the number of hours starved. The majority of children waterlogged but then lose up to 10% of their body weight in
do not require replacement of this deficit if the period of the first week of life.
starvation for fluid is short. If the child has been starved for They must not be given too much water or sodium on the
a longer period, for instance overnight, and has not had any first few days of life, so much smaller maintenance volumes
fluid orally preoperatively, the deficit can be replaced during are prescribed initially, which then increase over the next few
surgery using a bolus of 10-20ml.kg-1 isotonic crystalloid. For days. Premature or low birth weight babies have a greater
children undergoing minor day case surgery this ensures the surface area to weight ratio, lose more water by evaporation
child is well hydrated and may possibly reduce postoperative and consequently require more replacement fluid (Table 3).
nausea and vomiting. The fluid is usually given as 10% dextrose with saline added
only after the postnatal diuresis has occurred (i.e around day
MAINTENANCE FLUIDS THE 4,2,1 RULE 3 of life).11
Maintenance fluid requirements have been calculated a number
of ways including by estimation of expenditure of calories and REPLACEMENT
body surface area. The simplest and most commonly used Measured losses should be replaced with a similar fluid to that
formula was devised by Holliday and Segar and modified by lost. This will usually be isotonic crystalloid or blood to replace
Oh, and is known as the 4,2,1 rule.4,5 The formula relates haemorrhage and to avoid unacceptably low haemoglobin
energy (calorie) expenditure, and volume of fluid required to levels.
Table 1. Holliday and Segar formula and Oh modification
Holliday and Segar Oh

Body weight
1-10kg 4ml.kg-1.hour-1 4ml.kg-1.hour-1
10-20kg 40ml.hour-1 + 2 ml.kg-1.hour-1 for each kg above 10kg 20 + (2 x weight in kg) in ml.hour-1
>20kg 60ml.hour-1 + 1ml.kg-1.hour-1 for each kg above 20kg 40 + (weight in kg) in ml.hour-1
For example a child of:

9kg requires 4 x 9 = 36 ml.hour-1
18kg requires 40 + (2 x 8) = 56ml.hour-1
or, using the Oh version of the formula:
20 + (2 x 18) = 56 ml.hour-1
36kg requires 60 + 16 = 76ml. hour-1
or, using the Oh formula:
40 + 36 = 76ml. hour-1

Table 3. Paediatric surgical unit fluid guidelines for neonates at Sheffield Childrens Hospital, taking postnatal weight and age into
account
Age Fluid requirement (ml.kg-1.day-1)

<1.0kg 1.0-1.5kg 1.5-2.0kg >2.0kg
Day 1 100-200 80-100 60-80 40-60
Day 2 120-150 110-130 90-110 60-90
Day 3 150-170 140-160 120-140 80-100
Day 4 180-200 160-180 140-160 100-120
Day 5 180-200 170-200 150-180 120-150
Fluid evaporation from an open wound or 3rd space losses the body is subjected to stress such as surgery, pain, nausea
varies depending on the operation and may be up to 20 or hypovolaemia, antidiuretic hormone (ADH) levels rise.
ml.kg-1.hour-1. Loss of fluid via the respiratory tract due to ADH blocks the renal excretion of water; water is conserved,
humidification of inspired gas may be reduced by using a circle and plasma sodium levels fall. Even the relatively mild
system or HME (heat and moisture exchange filter) in the hypovolaemia of pre-operative starvation causes a rise in ADH
breathing circuit. levels.12 If the plasma sodium falls rapidly to a low level (acute
hyponatraemia), water moves into the cells in compensation
Neonates have a large ECF volume relative to adults so greater
and causes swelling of the cells. The brain is particularly
3rd space losses. Replacement with colloids (specifically 4.5%
vulnerable to acute hyponatraemia; this can manifest as
albumin) is more common in neonatal practice than in older
cerebral oedema, raised intracranial pressure, and can cause
children.
brain stem herniation, coning and death. Prepubertal children
Blood or other fluid loss is often difficult to measure especially are particularly susceptible to brain damage associated with
when irrigation fluids are used. For this reason the childs postoperative hyponatraemic encephalopathy. Retrospective
clinical state should be monitored continuously looking at analyses of patients with acute hyponatraemia have shown
heart rate, capillary refill time and blood pressure. In longer or that more than 50% of children develop symptoms when the
more complicated cases core-peripheral temperature gradient, plasma sodium is less than 125mmol.l-1, and that there is a
urine output (volume and osmolarity), invasive blood pressure mortality of 8.4% for severe acute hyponatraemia.7,8
and central venous pressure should be measured. In a warm Acute hyponatraemic encephalopathy typically presents with
and otherwise stable child with good analgesia, a rise in heart non-specific features such as nausea, vomiting and headache; if
rate and prolonged capillary refill time are reliable indicators of untreated, this will progress to reduced level of consciousness,
fluid loss; hypotension due to hypovolaemia occurs relatively seizures, respiratory depression and death. Nausea, vomiting
late. and drowsiness may be attributed to the side effects of
anaesthesia, but unfortunately by the onset of seizures
WHICH FLUIDS AND WHY? and respiratory depression it may be too late to salvage the
Isotonic fluids situation. A high index of suspicion should be maintained in all
An isotonic fluid contains the same concentration of solutes as children receiving IV fluids; hypotonic fluids should NEVER
plasma, and therefore exerts an equal osmotic force. Dextrose be given in the perioperative period (see below). If there are
is metabolised in blood, so although 5% dextrose solution any concerns about hyponatraemia, plasma electrolytes should
is isosmolar to plasma, and isotonic in vitro, once given, be measured urgently.
the dextrose is metabolised and it effectively becomes water. Acute symptomatic hyponatramia presenting with seizures is a
Dextrose solutions, unless they contain electrolytes of an medical emergency. A typical case is as follows:
equivalent amount to plasma are therefore termed hypotonic
fluids. Table 4 shows the electrolyte content of different IV A healthy 9-year-old presented for routine elective surgery. He
fluids. was given 4% dextrose 0.18% saline at maintenance rate during
the operation, and the fluid was continued postoperatively. He
Hyponatraemic encephalopathy in children was slow to get going after surgery, complaining of headache
Children given hypotonic fluid may become and nausea. IV fluids were continued. At 4.00am he suddenly
hyponatraemic.7,8,9,10 Ordinarily the kidneys will excrete a free developed a seizure. Electrolytes taken at this time showed a
water load rapidly, and homeostasis is maintained. When plasma sodium of 123mmol.l-1.

Table 4. Electrolyte content of different IV fluids
Fluid Na+ K+ Cl- HC03- Osmolality Tonicity* Other pH
mmol.l-1 mmol.l-1 mmol.l-1 mmol.l-1 mOsm.l-1
5% dextrose 0 0 0 0 252 Hypotonic Dextrose 50g 4.0
4% dextrose
30 0 30 0 284 Hypotonic Dextrose 40g 4.0
0.18% saline
5% dextrose
0.45% saline
5% dextrose
0.9% saline
0.9% saline 150 0 150 0 308 Isotonic - 5.0
28 (as Ca2+
Ringers lactate 130 4 109 273 Isotonic 6.5
lactate) 2 mmol.l-1
29 (as Ca2+
Hartmanns 131 5 111 255 Isotonic 6.5
lactate) 2 mmol.l-1
Mg2+
Plasma-Lyte 27 (as 1.5 mmol.l-1
140 5 98 294 Isotonic 4-6.5
148 acetate) Gluconate
23mmol.l-1
4.5% albumin in
100-160 <2 150 0 275 Isotonic 7.4
saline
Gelofusine 154 <0.4 120 0 274 Isotonic Gelatin 40g 7.4
Haemaccel 145 5 145 0 293 Isotonic Gelatin 35g 7.4
* with respect to plasma.
This child must be treated immediately with hypertonic saline than was previously thought.
(3% saline) to correct the plasma sodium, not an isotonic fluid
The diurnal variation in cortisol levels effects blood glucose
(and definitely not a hypotonic fluid). Ideally, the child should
levels. Cortisol levels are higher in the morning than the
be cared for in a PICU and 3% saline administered as follows:6
afternoon, so children starved overnight have a higher blood
Give 3% NaCl 2ml.kg-1 over 10 minutes. glucose than those starved during the day.13 The stress response
to surgery may result in hyperglycaemia in children as young
Repeat as necessary 1-2 times.
as two weeks of age, even if no dextrose-containing fluids are
Recheck plasma Na+ after second bolus or 2 hours. given.14 Although less catastrophic than severe hypoglycaemia,
Stop therapy when the patient is symptom free (awake, hyperglycaemia also has detrimental effects, and should be
alert, responding to commands, resolution of nausea and avoided. In the ischaemic or hypoxic brain hyperglycaemia
headache); a rise of Na+ 5-6mmol is achieved; or there is may result in accumulation of lactate, cellular acidosis and
an acute rise in Na+ of 10mmol.l-1 in the first 5 hours. compromised cellular function. Hyperglycaemia also causes
an osmotic diuresis, which may lead to dehydration and
Do not exceed a correction of Na+ more than15-20mmol.l-1 electrolyte disturbance. Routine administration of dextrose-
in 48 hours. containing fluids during surgery should be reserved for those
at risk of hypoglycaemia.
What about dextrose?
Dextrose may be required to prevent hypoglycaemia while the Recent studies have shown that hypoglycaemia during surgery
child is starved, although this appears to be less of a problem is rare in most children. Exceptions to this are premature

infants, neonates less than 48 hours old, neonates in whom Lyte during surgery. Always check electrolytes with prolonged
a preoperative glucose infusion is interrupted and children use of any IV fluids.
below the 3rd centile in weight.16 Children with an extensive
regional block or surgery of greater than 3 hours duration Crystalloid or colloid?
may also be at risk of intraoperative hypoglycaemia and these The use of crystalloids or colloids has been controversial for
groups of children should be maintained on dextrose infusions many years. Recently, concerns have been raised about the use
without prolonged interruption.16 of intravenous starch solutions in patients with sepsis and/or
at risk for renal failure. There is little evidence in children (and
However, if children are given dextrose free solutions even less evidence to support the use of intravenous gelatins in
postoperatively, they may become hypoglycaemic, or they may children). Colloid solutions also cause a greater fall in plasma
metabolise lipids and develop ketosis, particularly if they are haemoglobin than an equivalent volume of crystalloid solution,
less than 6 years of age.10 and may increase the requirement for blood transfusion.
The majority of children can therefore be given dextrose free Colloids are more expensive than crystalloids, gelatins may
isotonic crystalloid solutions such as Hartmanns/Ringers be associated with increased risk of anaphylaxis, and the long
Lactate during surgery. After surgery, all children should receive term side-effects of starch solutions in children are not known.
maintenance fluids containing dextrose. Any child perceived A pragmatic approach suggests that a balanced salt solution
to be at risk of hypoglycaemia should have their blood glucose should be used in preference to colloids during surgery, with
monitored at regular intervals. blood transfused when required.
A low concentration of dextrose should be used (1%-2.5%) if Trigger for transfusion?
dextrose is required for a child at risk of hypoglycaemia during Most children undergoing surgery are healthy with normal
surgery; 0.9% saline with 5% dextrose may result in moderate cardiorespiratory function, and excellent tissue oxygen
to marked hyperglycaemia. Isotonic crystalloid solutions delivery, particularly during infancy when their cardiac output
containing 1% or 2.5% dextrose are commercially available is relatively high, and they tolerate anaemia well. However,
in some countries. As an alternative, solutions can be made up newborns have high levels of HbF and require a higher
as follows: haemoglobin level, as HbF is less efficient at off-loading
Hartmanns 1% dextrose add 10ml 50% dextrose to oxygen to the tissues; similarly, children with cyanotic heart
500ml Hartmanns disease have less effective tissue oxygen delivery. It is difficult to
be prescriptive about the haemoglobin level that should be the
Hartmanns 2.5% dextrose add 25ml 50% dextrose to
trigger for transfusion, but suggested levels are shown in Table
500ml Hartmanns
5. Ideally, the haemoglobin level should be measured regularly
Choice of isotonic cystalloid during surgery; saline or during surgery; blood should be transfused to minimise donor
balanced salt solution? exposure, usually in a dose of 10-20 ml.kg-1. A useful formula
Saline has a greater chloride content than plasma, also to predict the haemoglobin rise is as follows:
than Hartmanns, Ringers or Plasma-Lyte, and may cause Transfusion 8ml.kg-1 whole blood raises the haemoglobin
hyperchloraemic acidosis (see Table 4). by 1g.dl-1
Balanced salt solutions such as Hartmanns or Ringers are Transfusion 4ml.kg-1 packed cells raises the haemoglobin
slightly hypotonic and may result in a fall in serum sodium if by 1g.dl-1
given in large quantities. The clinical impact of hyperchloraemic
acidosis is uncertain, but it is common practice to use a Postoperative maintenance fluids
balanced salt solution such as Hartmanns, Ringers or Plasma- The choice of maintenance fluids in the postoperative period
Table 5. Suggested trigger haemoglobin for blood transfusion in children

Haemoglobin level that should trigger blood transfusion g.l-1
Healthy child 70
Newborn (untransfused) - high HbF 120
Cyanotic heart disease 100-120
Early severe sepsis 100
Chronic anaemia To maintain normal baseline haemoglobin

remains controversial; the choice of both sodium content and perfusion) were randomised to receive a fluid bolus of
dextrose needs to be considered. Hypotonic fluids containing 20ml.kg-1 0.9% saline or 20ml.kg-1 5% albumin when they
0.18% saline in 4% dextrose must NOT be used at any time were admitted to hospital, or they were included in a control
in the perioperative period.1 group and treated with routine maintenance fluids using
the4,2,1 rule. More than 3000 children were included in the
Children younger than 6 years require a source of dextrose
trial, which is the largest study of its kind in fluid resuscitation
postoperatively to avoid hypoglycaemia and to avoid lipolysis.10
in children. Children with gastroenteritis, burns or requiring
Hypotonic fluids should not be administered if the plasma
surgery were NOT included in the study.
sodium is less than 140 mmol.l-1, although measurement of
electrolytes may not always be possible. If a hypotonic fluid The results were surprising, and lead to the trial being stopped
containing 0.45% saline is given in the immediate postoperative early on safety grounds. Children who received a fluid bolus
period, the plasma sodium tends to fall due to the effect of were 3.3% more likely to die in the first 48 hours after
raised ADH. If the plasma sodium is already low, it will remain admission than the control group children who received
low if 0.45% saline is used. When the plasma electrolytes are routine maintenance fluids. The children in the study were
not known it is safer to give 0.9% saline to a patient with all severely unwell (76% had impaired consciousness, 83%
an elevated plasma sodium, than it is to give hypotonic fluids had respiratory distress); 57% had malaria and 32% had a
to a hyponatraemic patient. A pragmatic approach therefore haemoglobin <5g.dl-1, but the adverse effect of a fluid bolus
suggests that isotonic solutions containing dextrose, such as was still seen in those without malaria and those who did not
0.9% saline 5% dextrose, or Hartmanns/Ringers/Plasma- have severe anaemia. The reason for the excess mortality in
Lyte 5% dextrose should be used for maintenance fluids in the those receiving a fluid bolus is not clear; the children appeared
immediate postoperative period. to do well initially, but the clinical benefit was not maintained.
It is essential that fluid balance and vital signs continue to There were no intensive care facilities in the study hospitals
be monitored in the post-operative period, ideally including and the terminal event in most cases was cardiogenic shock.
urine output, and daily plasma electrolytes and the weight of It may be that shock is an important adaptive response in this
the child. Abnormal losses such as naso-gastric tube or wound setting, and that administration of a fluid bolus overrides this
drain losses should be measured and replaced ml for ml with adaptation; or perhaps there are subtle effects of a fluid bolus
0.9% saline + 10mmol KCl. KCl should not be added to related to hyperchloraemic acidosis. More research is required.
maintenance fluids until urine output is established (usually The important conclusion from this study is that critically ill
day 2 postoperatively). Intravenous fluids should be stopped as children with sepsis in Africa should NOT receive rapid fluid
soon as possible in the postoperative period; it is much better resuscitation with saline or albumin, but should receive IV
for the child to control their own fluid balance. fluids at normal maintenance rates whilst definitive treatment
Suggested perioperative fluid regimen: for sepsis is started (e.g. antibiotics or antimalarials). The
authors state that children with acute gastroenteritis or burns
During surgery; use Hartmanns/Ringers/Plasma-Lyte
or surgical conditions may still require resuscitation fluids,
and/or blood as clinically indicated. Give fluid boluses of
and the recommendations do not apply to these patients. The
10-20ml.kg-1 and assess clinical signs.
relevance of the FEAST study to children in high-income
Low dose dextrose may be required for neonates and those countries is still uncertain, but current treatment protocols
at risk of hypoglycaemia; check the blood sugar regularly. must re-evaluated in the light of this important study.
Postoperative maintenance fluids; give an isotonic fluid CONCLUSIONS
with 5% dextrose and calculate the fluid requirement using Children should not be starved for prolonged periods before
the Holliday and Segar 4:2:1 rule. surgery, and oral fluids should be given wherever possible.
Give additional fluids to correct deficits, measured or Intravenous fluids should be prescribed carefully, as for any
suspected ongoing losses using 0.9% saline, Hartmanns/ drug:
Ringers/Plasma-Lyte, colloid or blood as indicated.
The majority of healthy children undergoing minor surgery
THE FEAST STUDY will re-establish oral intake in the early postoperative phase
The FEAST study was a large randomised controlled study and will not need routine intravenous fluids.
carried out in six hospitals in Africa (Kenya, Uganda and Hypovolaemia should be corrected by rapid infusion of
Tanzania), published in 2011.1 Children aged 2 months to isotonic fluid while dehydration is corrected more slowly
12 years with a diagnosis of a severe febrile illness (impaired over 14-72 hours as appropriate. Ongoing losses should be
consciousness and/or respiratory distress with impaired measured and replaced.

During surgery the majority of children over 1 month of 6. Moritz et al. New aspects in the pathogenesis, prevention and
age will maintain a normal blood glucose if isotonic, non- treatment of hyponatraemic encephalopathy in children.
dextrose containing fluids are given. Pediatr Nephrology 2010; 25: 1225-38.
Hypotonic fluids should be used with care in the 7. Arieff AI, Ayus JC, Fraser CL. Hyponatraemia and death or
permanent brain damage in healthy children. British Medical
perioperative period, and must not be infused in large
Journal 1992; 304: 1218-22.
volumes or at greater than maintenance rates. 0.18% saline
4% dextrose must NOT be used. 8. Halberthal M, Halperin ML, Bohn D. Acute hyponatraemia in
children admitted to hospital: retrospective analysis of factors
Ideally, plasma electrolytes, glucose and haemoglobin contributing to its development and resolution. British Medical
(or haematocrit) should be measured regularly in any child Journal 2001; 322: 780-82.
receiving large volumes of IV fluid, or who remains on IV
9. Bailey et al. Perioperative crystalloid and colloid fluid
fluids for more than 24 hours. management in children: where are we now and how did we
Critically ill children with sepsis should receive IV fluids at get here? Anesth Analg 2010; 110: 375-90.
normal maintenance rates whilst definitive treatment is 10. Neville et al. Prevention of hyponatraemia during maintenance
started. They must not receive IV fluid boluses for intravenous administration; a prospective randomised study of
resuscitation. fluid type versus fluid rate. J Pediatr 2010; 156: 313-9.
REFERENCES 11. OBrian F, Walker IA. Fluid homeostasis in the neonate. Paediatric
Wilson CM. Perioperative fluids in children. Update in Anaesthesia 2014; 24: 49-59.
Anaesthesia 2005; 19: 36-8. Available from: http://www.wfsahq. 12. Judd BA, Haycock GB, Dalton RN, Chantler C. Antidiuretic
org/components/com_virtual_library/media/07417f70e0b2 hormone following surgery in children. Acta Paediatrica
4 3 f c 7 9 5 d 7 3 7 b b b 8 e b d 1 8 - Scandinavia 1990; 79: 461-6.
57883b2855874aa26a469a64e36d77af-Perioperative-Fluids-
in-Children--Update-19-2005-.pdf 13. Redfern N, Addison GM, Meakin G. Blood glucose in
anaesthetised children. Comparison of blood glucose
1. Maitland K, Kiguli S, Opoka RO et al. Mortality after fluid bolus concentrations in children fasted for morning and afternoon
in African Children with severe infection. NEJM 2011; 364: surgery. Anaesthesia 1986; 41: 272-5.
2483-95. 14. Nilsson K, Larsson LE, Andreasson S, Ekstrom-Jodal B. Blood-
2. NPSA (2007) Reducing the risk of hypontraemia when glucose concentrations during anaesthesia in children. Effects
administering intravenous infusions to children. Alert no 22. of starvation and perioperative fluid therapy. British Journal of
National Patient safety Agency London http://www.nhs.npsa. Anaesthesia 1984; 56: 375-9.
nhs.uk/resources/type/alerts 15. Larsson LE, Nilsson K, Niklasson A, Andreasson B, Ekstrom-Jodal
3. Assadi F, Copelovitch L. Simplified treatment strategies to fluid B. Influence of fluid regimens on perioperative blood glucose
therapy in diarrhea. Pediatric Nephrology 2003; 18: 1152-6. concentrations in neonates. British Journal of Anaesthesia
1990; 64: 419-24.
4. Holliday MA, Segar WE. The maintenance need for water in
parenteral fluid therapy. Paediatrics 1957; 19: 823-832. 16. Leelanukorum R, Cunliffe M. Intraoperative fluid and glucose
management in children. Paediatric Anaesthesia 2000; 10:
5. Oh TH. Formulas for calculating fluid maintenance 353-9.
requirements. Anesthesiology 1980; 53: 351.

Principles of clincial anaesthesia
Paediatric caudal anaesthesia

Reprinted with minor changes from O Raux, C Dadure, J Carr, A Rochette, X Capdevila. Paediatric caudal
anaesthesia. Update in Anaesthesia (2010); 26: 32-6.
O Raux*, C Dadure, J Carr, A Rochette and X Capdevila

*Correspondence email: o-raux@chu-montpellier.fr
INDICATIONS FOR CAUDAL ANAESTHESIA S5 articular processes and which face the coccygeal
The indications for single shot CA are abdominal, cornua. Palpation of the sacral cornua is fundamental to
urologic or orthopaedic surgical procedures located locating the sacral hiatus and to successful caudal block.
in the sub-umbilical abdominal, pelvic and genital
areas, or the lower limbs, where postoperative pain
does not require prolonged strong analgesia. Examples
of appropriate surgery include inguinal or umbilical
Summary
herniorrhaphy, orchidopexy, hypospadias and club foot
Caudal anaesthesia (CA) surgery. CA is useful for day case surgery, but opioid
is epidural anaesthesia of
additives to the local anesthetic agent should be avoided
the cauda equina roots in
the sacral canal, accessed in this setting. When CA is used, requirement for mild
through the sacral hiatus. or intermediate systemic analgesia must be anticipated
CA is a common paediatric to prevent pain resurgence at the end of caudal block.
regional technique that is Catheter insertion can extend the indications to include
quick to learn and easy to surgical procedures located in the high abdominal
perform, with high success or thoracic areas, and to those requiring prolonged
and low complication rates. effective analgesia.
CA provides high quality
intraoperative and early CONTRAINDICATIONS
postoperative analgesia The usual contraindications to regional anaesthesia
for sub-umbilical surgery. such as coagulation disorders, local or general infection,
In children, CA is most
progressive neurological disorders and patient or
effectively used as adjunct
to general anaesthesia parental refusal apply to CA. Furthermore, cutaneous
Figure 1. The posterior aspect of the sacrum and sacral
and has an opioid-sparing anomalies (angioma, hair tuft, naevus or a dimple) near
hiatus
effect, permitting faster and the puncture point require radiological examination
smoother emergence from (ultrasound, CT or MRI), in order to rule out The sacral hiatus is the shape of an inverted U, and
anaesthesia. underlying spinal cord malformation such as a tethered is covered by the sacro-coccygeal ligament, which
cord.23 A Mongolian spot is not a contraindication to is in continuity with the ligamentum flavum. It is
CA. large and easy to locate until 7-8 years of age. Later,
progressive ossification of the sacrum (until 30 years
ANATOMY old) and closing of the sacro-coccygeal angle make its
identification more difficult. Note that anatomical
Anatomical landmarks (Figure 1)
anomalies of the sacral canal roof are observed in 5%
The sacrum is roughly the shape of an equilateral
of patients and this can lead to unplanned cranial or
triangle, with its base identified by feeling the two
O Raux lateral puncture.
posterosuperior iliac processes and a caudal summit
C Dadure
corresponding to the sacral hiatus. The sacrum is
J Carr The sacral canal
concave anteriorly. The dorsal aspect of the sacrum
A Rochette The sacral canal is in continuity with the lumbar
consists of a median crest, corresponding to the
X Capdevila epidural space. It contains the nerve roots of the
fusion of sacral spinous processes. Moving laterally,
Dpartement dAnesthsie cauda equina, which leave it through anterior sacral
intermediate and lateral crests correspond respectively
Ranimation foraminae. During CA, leakage of local anaesthetic
to the fusion of articular and transverse processes.
Centre Hospitalo- agent (LA) through these foraminae explains the
Universitaire Lapeyronie The sacral hiatus is located at the caudal end of the high quality of analgesia, attributable to diffusion of
Montpellier median crest and is created by failure of the S5 laminae LA along the nerve roots. Spread of analgesia cannot
France to fuse (Figure 1). The hiatus is surrounded by the be enhanced above T8-T9 by increasing injected LA
CHU Montpellier sacral cornua, which represent remnants of the inferior volume.

The dural sac (i.e. the subarachnoid space) ends at the level of S3 in
infants and at S2 in adults and children. It is possible to puncture
the dural sac accidentally during CA, leading to extensive spinal
anaesthesia. Therefore the needle or cannula must be cautiously
advanced into the sacral canal, after crossing the sacro-coccygeal
ligament. The distance between the sacral hiatus and the dural sac
is approximately 10mm in neonates. It increases progressively with
age (>30mm at 18 years), but there is significant inter-individual
variability in children.1 The contents of sacral canal are similar to those
of lumbar epidural space, predominantly fat and epidural veins. In
children, epidural fatty tissue is looser and more fluid than in adults,
favoring LA diffusion.
TECHNIQUE
Preparation
Obtain consent for the procedure either from the patient or, if
appropriate, from the parents. After induction of general anaesthesia Figure 3. Bony landmarks
and airway control, the patient is positioned laterally (or ventrally), is between 5 and 15mm, depending on the childs size. The sacro-
with their hips flexed to 90 (Figure 2). Skin disinfection should be coccygeal ligament gives a perceptible pop when crossed, analogous
performed carefully, because of the proximity to the anus. Aseptic to the ligamentum flavum during lumbar epidural anaesthesia. After
technique should be maintained. crossing the sacro-coccygeal ligament, the needle is redirected 30 to
the skin surface, and then advanced a few millimeters into sacral canal.
If in contact with the bony ventral wall of sacral canal, the needle must
be moved back slightly.
Figure 2. Preparation of patient - lateral position with the surgical site down
According to the childs size, needle diameter and length are

respectively between 21G and 25G, and 25mm and 40mm. A short
bevel improves the feeling of sacrococcygeal ligament penetration Figure 4. Puncture - orientation of the needle and reorientation after
and decreases risk of vascular puncture or sacral perforation.2 Use of crossing the sacro-coccygeal ligament
a needle with a stylet avoids risk of cutaneous tissue coring, and the
(theoretical) risk of epidural cutaneous cell graft. If a styletted needle
is not available, a cutaneous pre-hole can be made with a different
needle prior to puncture with the caudal needle. Another solution is to
puncture with an IV catheter, the hollow needle of which is removed
before injection through the sheath.
Puncture (Figures 3, 4 and 5)
After defining the bony landmarks of the sacral triangle, the two sacral
cornuae are identified by moving your fingertips from side to side.
Figure 5. Orientation of the needle during puncture
The gluteal cleft is not a reliable mark of the midline. The puncture
is performed between the two sacral cornuae. The needle is oriented After verifying absence of spontaneous reflux of blood or cerebrospinal
60 in relation to back plane, 90 to skin surface. The needle bevel fluid (more sensitive than an aspiration test), injection of LA should
is oriented ventrally, or parallel to the fibers of the sacro-coccygeal be possible be without resistance. Inject slowly (over about one
ligament. The distance between the skin and sacro-coccygeal ligament minute). Where available this may be preceded with an epinephrine

test dose under ECG and blood pressure monitoring, in order to Catheter insertion
detect intravascular placement. Subcutaneous bulging at the injection Although CA was initially described as a single shot technique, some
site suggests needle misplacement. Blood reflux necessitates repeating authors have described use of a caudal catheter to prolong analgesic
the puncture, however in case of cerebrospinal fluid reflux caudal administration in postoperative period. In addition advancement
anaesthesia should be abandoned, in order to avoid the risk of extensive of the catheter in the epidural space up to lumbar or even thoracic
spinal anaesthesia. Aspiration tests should be repeated several times levels can achieve analgesia of high abdominal or thoracic areas.8
during injection. However, two pitfalls restrict extension of this technique; a high
risk of catheter bacterial colonization, particularly in infants and a
In skilled hands, the success rate of CA is about 95%, however a variety
high risk of catheter misplacement.9,10 Subcutaneous tunnelling at a
of misplacements of the needle are possible (Figure 6). The moment of
distance from the anal orifice, or occlusive dressings decrease bacterial
surgical incision is the true test of block success, but various techniques
colonization.11 Electrical nerve stimulation or ECG recording on the
have been suggested to authenticate the puncture success, such as
catheter, or its echographic visualization have been suggested to guide
injection site auscultation (the swoosh test), or searching for anal
its advancement in epidural space.12,13 However, most anaesthetists
sphincter contraction in response to electrical nerve stimulation on the
presently prefer a direct epidural approach at the desired level that is
puncture needle. No clear benefit of these techniques against simple
appropriate to the surgical intervention.14,15
clinical assessment have been shown.3,4 More recently, ultrasound has
been suggested to help sacro-coccygeal hiatus location and to visualize
isotonic serum or LA injection into sacral epidural space (Figures 7
and 8).5,6 These authors have also outlined the interest in ultrasound
control within the context of learning the technique, rather than for
use in standard practice.5,7
Figure 7.
Figures 8a and 8b.
LOCAL ANAESTHETIC AGENTS
Test dose
Early neurosensory warning symptoms of LA systemic toxicity are
concealed by general anaesthesia. Halogenated anaesthetic agents
worsen LA systemic toxicity and can also blunt the cardiovascular signs
Figure 6A and B. Needle misplacement of an intravenous epinephrine test dose injection. Aspiration tests to
A marrow (resistance +++. Equivalent to IV injection) elicit blood reflux are not very sensitive, particularly in infants. A test
B posterior sacral ligament (subcutaneous bulge) dose of epinephrine 0.5mcg.kg-1 (administered as 0.1ml.kg-1 lidocaine
with epinephrine 1 in 200 000) allows detection of intravenous
C subperiostal
injection with sensitivity and specificity close to 100%, under
D decoy hiatus
halogenated anaesthesia. Warning symptoms are cardiac frequency
E intrapelvic (risk of damaging intrapelvic structures: rectum) modification (an increase or decrease by 10 beats per minute), increased
F 4th sacral foramen (unilateral block). in blood pressure (up to 15mmHg), or T-wave amplitude change in

Figure 9. T-wave amplitude change after intravascular injection of a local anaesthetic agent
the 60 to 90 second period after injection (Figure 9).16,17 Slow injection Additives
of the whole LA dose under haemodynamic and ECG monitoring Several drugs have been demonstrated to prolong duration of analgesia
remains essential for patient safety. by a few hours after single shot caudal injection of LA. Among them,
most popular are opioids (fentanyl 1 g.kg-1), clonidine (1-2 g.kg-1)
Full dose and preservative free ketamine (not the IV form) (0.5 mg.kg-1).21
The volume of caudally injected LA determines the spread of the block Recent reports of spinal cord toxicity of intrathecal ketamine in
and this must be adapted to surgical procedure (Table 1). Analgesic neonatal rats leads us to discourage its use by caudal route in neonates
spread will be two dermatomes higher on the down positioned side at and infants.22 Morphine and clonidine do not provoke such spinal cord
the time of puncture. Injected volume must not exceed 1.25 ml.kg-1 toxicity in neonatal rats, but their dose requirements are decreased in
or 20 to 25ml, in order to avoid excessive cerebrospinal fluid pressure. younger pups.23 Principal adverse effects are: pruritus and nausea and
Table 1. Spread of block as a function of caudally injected local vomiting for opioids, light sedation for clonidine, and hallucinations
anaesthetic volume18 for ketamine. Theoretical risk of respiratory depression with opioids
mandates adequate postoperative monitoring. Some cases of respiratory
Volume (ml.kg-1) Dermatomal level Indication depression have been reported with caudal clonidine in neonates.24
0.5 Sacral Circumcision
COMPLICATIONS
0.75 Inguinal Inguinal Complications of CA are uncommon (0.7 per 1000 cases), are
herniotomy
more likely if inadequate equipment is used and are more frequent
1 Lower thoracic (T10) Umbilical in infants.16 If the technique fails it should be abandoned to avoid
herniorraphy,
occurrence of potentially serious complications.
orchidopexy
1.25 Mid thoracic Significant complications, in order of decreasing frequency, are:
LA choice prioritizes long lasting effects with the weakest motor block Dural tap. This is more likely if the needle is advanced excessively in the
possible, since motor block is poorly tolerated in awake children. sacral canal when subarachnoid injection of local anaesthetic agent may
Bupivacaine meets these criteria. More recently available, ropivacaine cause extensive spinal anaesthesia. Under general anaesthesia this
and L-bupivacaine have less cardiac toxicity than bupivacane at should be suspected if non-reactive mydriasis (pupillary dilation)
equivalent analgesic effectiveness. They may also confer a more is observed.
favorable differential block (less motor block for the same analgesic
Vascular or bone puncture can lead to intravascular injection and
power) and the 2.5mg.ml-1 (0.25%) concentration is optimal for these
consequently LA systemic toxicity. Preventative measures are use of
agents. Four to six hours analgesia is usually achieved with minimal
a test dose, cessation of injection if resistance is felt and slow
motor block.19,20
injection under hemodynamic and ECG monitoring. Sacral
Maximal doses must not be exceeded (Table 2) but use of a more perforation can lead to pelvic organ damage (e.g. rectal
dilute mixture may allow the desired volume to be achieved within puncture).
the recommended maximum dose. Hemodynamic effects of CA
are weak or absent in children, so intravenous fluid preloading or Exceeding the maximal allowed LA dose risks overdose and related
vasoconstrictive drugs are unnecessary. cardiovascular or neurological complications.
Table 2. Maximal allowable doses of local anaesthestic agents Delayed respiratory depression secondary to caudally injected
opioid.
Plain local With epinephrine
anaesthetic (mg.kg-1) (mg.kg-1) Neonates Urinary retention - spontaneous micturition must be observed
before hospital discharge.
Bupivacaine 2 2
Lidocaine 3 7 20% Sacral osteomyelitis is rare (one case report).25
Ropivacaine 3 3

CONCLUSION guidance in pediatric patients: a review of 289 patients. Anesthesiology
This technique has an established role in paediatric regional anaesthesia 2004; 100: 683-9.
practice since it is easy to learn and has a favorable risk/benefit ratio. 13. Chawathe MS, Jones RM, Gildersleve CD, Harrison SK, Morris SJ,
Despite being more complex to learn, alternative peripheral regional Eickmann C. Detection of epidural catheters with ultrasound in
anaesthesia techniques are gaining popularity and may begin to replace children. Paediatr Anaesth 2003; 13: 681-4.
caudal anaesthesia as a popular choice.
14. Bsenberg AT. Epidural analgesia for major neonatal surgery. Paediatr
Anaesth 1998; 8: 479-83.
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regional anesthesia in children: a one-year prospective survey of the
anaesthesia. Update in Anaesthesia (2010) 26:32-36. Available from:
French-language society of pediatric anesthesiologists. Anesth Analg
http://www.wfsahq.org/documents/Update%20in%20Anaesthesia/
1996; 83: 904-12.
update%20026%202010.pdf
1. Adewale L, Dearlove O, Wilson B, Hindle K, Robinson DN. The caudal 16. Kozek-Langenecker SA, Marhofer P, Jonas K, Macik T, Urak G, Semsroth
canal in children: a study using magnetic resonance imaging. Paediatr M. Cardiovascular criteria for epidural test dosing in sevoflurane- and
Anaesth 2000; 10: 137-41. halothane-anesthetized children. Anesth Analg 2000; 90: 579-83.
2. Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: success 17. Tobias JD. Caudal epidural block: a review of test dosing and
rate and adverse effects in 750 consecutive patients. Anesth analg recognition injection in children. Anesth Analg 2001; 93: 1156-61.
1989; 68: 83-9.
18. Armitage EN. Local anaesthetic techniques for prevention of
3. Orme RM, Berg SJ. The swoosh test - an evaluation of a modified postoperative pain. Br J Anaesth 1986; 58: 790-800.
whoosh test in children. Br J Anaesth 2003; 90: 62-5.
19. Bsenberg AT, Thomas J, Lopez T, Huledal G, Jeppsson L, Larsson LE.
4. Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal needle
Plasma concentrations of ropivacaine following a single-shot caudal
placement using nerve stimulation. Anesthesiology 1999; 91: 374-8.
block of 1, 2 or 3 mg/kg in children. Acta Anaesthesiol Scand 2001; 10:
5. Raghunathan K, Schwartz D, Conelly NR. Determining the accuracy 1276-80.
of caudal needle placement in children: a comparison of the swoosh
test and ultrasonography. Paediatr Anaesth 2008; 18: 606-12. 20. Breschan C, Jost R, Krumpholz R, Schaumberger F, Stettner H,
Marhofer P, Likar R. A prospective study comparing the analgesic
6. Roberts SA, Guruswamy V, Galvez I. Caudal injectate can be reliably efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric
imaged using portable ultrasound - a preliminary result. Paediatr patients undergoing caudal blockade. Paediatr Anaesth 2005; 15:
anaesth 2005; 15: 948-52. 301-6.
7. Schwartz DA, Dunn SM, Conelly NR. Ultrasound and caudal blocks in
21. Menzies R, Congreve K, Herodes V, Berg S, Mason DG. A survey of
children. Paediatr Anaesth 2006; 16: 892-902 (correspondence).
pediatric caudal extradural anesthesia practice. Paediatr Anaesth 2009;
8. Tsui BC, Berde CB. Caudal analgesia and anesthesia techniques in 19: 829-36.
children. Curr Op Anesthesiol 2005; 18: 283-8.
22. Walker SM, Westin BD, Deumens R, Grafe M, Yaksh TL. Effects of
9. Kost-Byerly S, Tobin JR, Greenberg RS, Billett C, Zahurak M, Yaster M. intrathecal ketamine in the neonatal rat. Evaluation of apoptosis and
Bacterial colonisation and infectious rate of continuous epidural long-term functional outcome. Anesthesiology 2010; 113: 147-59.
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23. Walker SM, Yaksh TL. Neuraxial analgesia in neonates and infants: a
10. Valairucha S, Seefelder D, Houck CS. Thoracic epidural catheters
review of clinical and preclinical strategies for the development of
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safety and efficacy data. Anesth Analg 2012; 115: 638-62.
confirmation. Paediatr Anaesth 2002; 12: 424-8.
11. Bubeck J, Boss K, Krause H, Thies KC. Subcutaneous tunneling of 24. Fellmann C, Gerber AC, Weiss M. Apnoea in a former preterm infant
caudal catheters reduces the rate of bacterial colonization to that of after caudal bupivacaine with clonidine for inguinal herniorrhaphy.
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12. Tsui BC, Wagner A, Cave D, Kearny R. Thoracic and lumbar epidural 25. Cohen IT. Caudal block complication in a patient with trisomy 13.
analgesia via the caudal approach using electrical stimulation Paediatr Anaesth 2006; 16: 213-5.

Abdominal wall blocks
Nuria Masip and Steve Roberts*

*Correspondence Email: Steve.Roberts@alderhey.nhs.uk
INTRODUCTION
Regional anaesthesia is an essential component Bilateral blocks can be used, but it is important
of paediatric anaesthetic practice. Regional to keep the dose of local anaesthetic within safe
blocks allow for a lighter plane of anaesthesia limits.
during surgery, and provide excellent pain Perform ILNBs after induction of anaesthesia, SUMMARY
control after surgery.1 The aim of this review is to before the start of surgery; it is important to make Regional anaesthesia is
describe how to perform the three most common sure that the child is adequately anaesthetised an essential component
abdominal wall blocks in children: ilioinguinal/ when the cord structures are mobilised, and that of paediatric anaesthetic
iliohypogastric, rectus sheath and transversus additional local infiltration/analgesia is used if a
practice. This review
abdominis plane. describes how to perform
scrotal incision is made. the three most common
We will describe landmark techniques as well There is much anatomical variation of nerve
abdominal wall blocks
as ultrasound-guided techniques. Ultrasound in children: ilioinguinal/
position between the abdominal wall muscles. iliohypogastric, rectus sheath
guided blocks are increasingly considered the The effectiveness of this block can be improved and transversus abdominis
gold standard as it is possible to identify the greatly when performed with ultrasound, and plane, using either landmark
anatomy more accurately, which increases the lower amounts of local anaesthetic can be used.2 or [if available] ultrasound-
reliability of the block and allows a smaller dose guided techniques.
of local anaesthetic to be used. Anatomy (see Figure 1):
Regional anaesthetic blocks are simple to do, The iliohypogastric (T12, L1) and ilioinguinal
but should be taught by an appropriately skilled (L1) nerves are terminal branches of the
mentor. All local anaesthetic blocks should be lumbar plexus. They lie deep to the internal
performed using an aseptic technique; clean the oblique.
skin with an alcohol-based cleaning solution
The iliohypogastric nerve supplies the gluteal
and wear gloves. Ideally use a short-bevelled
region and the skin over the pubic symphysis.
block needle for abdominal wall blocks, but
a 23G or 21G hypodermic needle may also be The ilioinguinal nerve supplies the area of the
used; many advocate blunting the tip of the skin beneath that supplied by the
needle on the inside of the cap of the needle to iliohypogastric nerve and the anterior
better appreciate the facial planes. All the blocks scrotum.
described should be performed after induction of Nuria Masip
The nerves emerge at the lateral border of
general anaesthesia. Specialist Registrar in
psoas major and pass anterior to quadratus Anaesthesia
ILIOINGUINAL/ILIOHYPOGASTRIC NERVE lumborum. They pierce the lumbar fascia at
BLOCK (ILNB) the lateral border of quadratus lumborum Steve Roberts
and run in the plane between the internal Consultant Paediatric
The ilioinguinal/iliohypogastric nerve block
oblique muscle and transversus abdominis Anaesthetist
(ILNB) provides excellent analgesia after inguinal
muscles. Alder Hey Childrens NHS
hernia repair, hydrocele repair and orchidopexy. Foundation Trust
It does not abolish visceral pain due to peritoneal The iliohypogastric nerve pierces (again) the West Derby
traction or manipulation of the spermatic cord internal oblique and runs under the external Liverpool
during inguinal hernia repair or orchidopexy. oblique superior to the inguinal canal L12 2AP

The ilioinguinal nerve continues in the inguinal canal.
In infants the average nerve-peritoneum distance is only
3.3mm3.
The fascial plane between the transversus abdominis
muscle and the transversalis fascia is in continuity with the
space around the femoral nerve.
Anterior superior iliac
spine (ASIS) Ilioinguinal nerve
Iliohypogastric
nerve
Figure 2. The injection point for the ILNB should be equal to the childs
finger breadth medial to the ASIS, not the operators finger..
Figure 1. Anatomy of the ilioinguinal/iliohypogastric nerve block
Insert the needle just through the skin into the subcutaneous
Dose tissues; advance the needle slowly until a fascial click or
Use a volume of up to 0.5ml.kg-1 0.25% bupivacaine for loss of resistance is felt. The click is felt as the aponeurosis of
the landmark technique. In expert hands as little as 0.075 the external oblique is pierced. Aspirate and then inject the
ml.kg-1 0.25% bupivacaine can be effective using ultrasound- local anaesthetic in this position; there is no need to fan the
guidance; 4 we recommend 0.1-0.2ml.kg-1. injection, and this may increase the incidence of complications.
Complications Ultrasound guided technique
The most common complication is block failure (more Position the patient supine and clean the skin. Place a high
common using the landmark technique). Transient femoral frequency linear probe on the anterior abdominal wall along
nerve palsy with transient quadriceps paresis may be seen if the line joining the anterior superior iliac spine (ASIS) and the
the injection is too deep. Visceral perforation (colon puncture, umbilicus (a small footprint probe is useful for infants). (See
small bowel puncture, pelvic retroperitoneal haematoma, bowel Figure 3).
haematoma) is associated with poor technique, particularly an
injection that is too medial.
Techniques
Landmark technique
Place the patient supine. Clean the skin over the lower quadrant
of the abdominal wall, including the skin over the anterior
superior iliac spine (ASIS). Draw up the appropriate dose of
local anaesthetic.
The needle insertion point is close to the ASIS, approximately
2 - 5mm medial to the ASIS on a line drawn between the ASIS
and the umbilicus.5 Some suggest using the childs finger as
an appropriate guide for the distance from the ASIS to the
injection point (NOT the operators finger! - see Figure 2). It is
important to keep the injection point high, away from the skin
crease in the groin where the surgeon will make the incision; Figure 3. Ultrasound probe position for iliinguinal/iliohypogastric nerve
otherwise the operating field will be obscured. block

The ASIS is the most easily recognizable landmark for this postoperative analgesia for mid-line abdominal incisions,
block, it appears as a dark echo-lucent shadow beneath a for instance, periumbilical surgery (e.g. umbilical hernia
hyperechoic peak and should be kept at the lateral part of the repair,6 paraumbilical hernia repair, epigastric hernia repair),
screen for orientation. Identify (always from the inside out) pyloromyotomy, laparoscopic surgery and excision of urachal
the peritoneum (hyperechoic line, underneath it you may see remnants.
peristalsis), transversus abdominis muscle, and internal oblique
muscle. The external oblique muscle may not be visible as a Anatomy
distinct muscle layer at this level as it may have become an The rectus sheath encloses the rectus abdominis muscle
aponeurosis. and is formed by the aponeuroses of the three flat abdominal
Slide the probe up over the iliac crest, whilst maintaining the muscles. These aponeuroses join in the lateral border of the
same orientation of the probe, to bring all three muscles into rectus muscle in the point called linea semilunaris.
view as three distinct layers. This may be useful if there is any Medial to the semilunaris, the aponeuroses split with some
doubt about the anatomy and the relevant planes. fibres passing anterior to the rectus muscle and some
The ilioinguinal and iliohypogastric nerves are seen in close posterior:
proximity to each another as two small round hypoechoic - The external oblique aponeurosis and the anterior
structures with a hyperechoic border. They lie in the plane layer of the internal oblique aponeurosis form the
between the internal oblique muscle and the transversus anterior wall of the rectus sheath.
abdominis muscle close to the ASIS. In children the average
- The transversus abdominis aponeurosis and the
distance from the ilioinguinal nerve to the ASIS is 7mm.4
posterior layer of the internal oblique aponeurosis
form the posterior wall of the sheath.
- In the midline the aponeuroses from both sides join
to form the linea alba.
The anterior cutaneous branch of the ventral rami of the
inferior six thoracic nerves (T7-T12) run anteriorly
through the posterior of the rectus muscle to give off
sensory branches to the paraumbilical skin.
The anterior layer of the rectus sheath is firmly attached to
the rectus abdominis muscle at three tendinous intersections
(at the level of the xiphoid process, the umbilicus and
half-way in between). These tendinous intersections are
what separate the muscle into the well-known 6-pack, but
it is actually an 8-pack.
Figure 4. Ultrasound landmarks for iliinguinal/iliohypogastric nerve The rectus sheath is loosely attached posteriorly, forming
block. ASIS=anterior superior iliac spine; EO=external oblique muscle; a potential space. Local anaesthetic can spread caudad
IO=internal oblique muscle; TA=transversus abdominus muscle; I=ilium.
and cephalad in the plane between the rectus muscle and
Arrow shows location of the nerves.
the posterior rectus sheath.
Insert the block needle in plane from medial to lateral and
There is little correlation between the depth of the posterior
ensure that the needle tip is visible at all times as it is advanced.
rectus sheath with age, weight, height or surface area.
Deposit local anaesthetic around the nerves in the transversus
abdominis plane. Note that it may not always be easy to This block is not advisable in neonates without ultrasound
visualise the nerves, in this cause you could place the local guidance as the muscle is so thin and the viscera (especially
anaesthetic in the transversus abdominis plane. If you have liver and spleen) are in close proximity.
any concerns regarding the proximity of your injection to the
Dose
nerve use a higher volume of local anaesthetic (e.g. 0.2ml.kg-1
0.25% bupivacaine). Using a landmark technique, use a volume of 0.4ml.kg-1 of
0.25% bupivacaine per side. Using an ultrasound-guided
RECTUS SHEATH NERVE BLOCK technique a dose of 0.1-0.2ml.kg-1 of 0.25% bupivacaine per
A rectus sheath block provides intraoperative and side is sufficient.

Complications posterior sheath). If there is resistance to injection, it is not
Intraperitoneal injection, visceral damage, vascular puncture sited correctly. Repeat the technique for the opposite side.
(it is possible to identify the inferior epigastric vessel in larger In children under 10 years of age the rectus muscle is rarely
children with Doppler). greater than 1cm in thick, therefore when performing this
technique the needle should not be inserted any further than
Techniques
this. The depth of the posterior rectus sheath in children is
Landmark technique unpredictable, and many advocate using ultrasound for this
Use an aseptic technique and draw up the appropriate doses reason.7
of local anaesthetic. The injection point is just above the
Ultrasound technique
umbilicus at the apex of the bulge of the rectus muscle, at
Position the patient supine. Select the screen depth (in neonates
11 oclock and 1 oclock to the umbilicus (thinking of the
this will usually be 2cm, infants 3cm, thereafter 4cm). A high
umbilicus as the centre of a clock) (See Figure 5).
frequency linear probe is placed transverse on the abdomen,
midline above the umbilicus (see Figure 6).
The initial image will have the linea alba in the midline, with
a rectus abdominis muscle either side. Posterior to the rectus
muscle there are two hyperechoic lines (train track): the
more superficial one is the posterior part of the rectus sheath
and the deeper one is the peritoneum. Use the Doppler to
identify the epigastric vessels, although this is not easy in small
children (See Figure 7).
Figure 5. Injection point for rectus sheath block for repair of umbilical
hernia
Figure 7. Ultrasound landmarks for rectus sheath block: L=linea alba;

R=rectus abdominis muscle; LA=local anaesthetic; AS=anterior rectus
sheath; PS=posterior rectus sheath; A=epigastric artery (blood flow seen
with colour Doppler function). Note needle visible over its whole length
Figure 6. Ultrasound probe position for rectus sheath block

Insert the block needle in-plane from lateral to medial. Note
it can be difficult to puncture the skin with a block needle
Introduce a short-bevelled needle perpendicularly through the (either lift the skin and push the needle through or make a
skin Advance the needle medially at an angle of 60 towards knick in the skin using a sharp bevelled needle). The needle is
the umbilicus. Identify the anterior sheath by moving the advanced from lateral to medial, in a shallow trajectory; aim to
needle back and forth until a scratching sensation is felt; a pop position the tip of the needle between the rectus muscle and
is felt as the needle passes through the anterior sheath. Advance the posterior rectus sheath.
the needle through the muscle with continued movement of Stop the needle tip just superficial to the first white line (the
the needle until a scratching is again felt (this indicates the posterior sheath); often a small give is felt as you come out

of the muscle into the potential posterior space. The needle Anatomy
is positioned correctly if the rectus sheath peels away from The skin of the anterior abdominal wall is supplied by the
the muscle during injection of the local anaesthetic. Deposit ventral rami of the inferior six thoracic spinal nerves (T7 to
local anaesthetic in this potential space between the rectus T12).
abdominis muscle and the posterior rectus sheath.
In the lateral part of the anterior abdominal wall there are 3
In neonates you could use saline to identify the correct plane, muscle layers, from deep to superficial they are: the
avoiding the waste of the limited local anaesthetic. Note that transversus abdominis muscle (TA, it is the most internal
in small children it is possible to use a large footprint probe in of the 3 muscle layers), the internal oblique muscle (IO, it
the midline and block both sides without adjusting the probe. is positioned in-between TA and EO) and the external
Spread of the local anaesthetic after injection can be assessed oblique muscle (EO, it is the largest and most superficial of
by turning the probe into a paramedian longitudinal plane. the 3 muscles).
The ventral rami of T 7 to T12 run in the plane between
TRANSVERSUS ABDOMINIS PLANE BLOCK (TAP) the transversus abdominis muscle and the internal oblique
BLOCK muscle: the transversus abdominis plane (TAP).
The standard transversus abdominis plane (TAP) block Dose
provides intraoperative and postoperative analgesia for lower
abdominal incisions. A subcostal TAP block can be provide Use a volume of 0.3 0.5ml.kg-1 of 0.25% bupivacaine per
analgesia for abdominal surgery above the umbilicus. TAP side.
block can be performed unilaterally (e.g. inguinal hernia Techniques
repair), or bilaterally (e.g. for laparoscopic surgery). It may be The landmark technique is not recommended in children
used as an alternative to an epidural, but it does not provide due to the danger of visceral damage and is therefore not
visceral analgesia; it should be performed after induction of described here. If ultrasound is not available, in terms of risk-
anaesthesia, and adequate anaesthesia should be provided benefit, other techniques such as simple infiltration with local
during visceral manipulation. A comprehensive review of the anaesthetic are preferable.
transversus abdominis plane (TAP) block can be found in
WFSA ATOTW 239.8 Ultrasound-guided mid-axillary TAP block
Position the patient supine. Place a high frequency linear
ultrasound probe in a transverse plane between the iliac crest
and the costal margin. Start scanning from the linea alba in
the midline, then move laterally until the probe is between the
iliac crest and the costal margin (See Figure 8).
Identify the peritoneum and then the abdominal muscles:
transversus abdominis, internal oblique, and external oblique.
In obese children fascial planes may be present within the
adipose tissue, this can lead to misidentification of the muscle
layers; therefore always identify the muscle layers from deep to
superficial.
The target is the fascial plane between the transversus abdominis
and the internal oblique muscles. Advance the needle in an
antero-posterior direction (See Figure 8). Aim to puncture the
fascia on the deep aspect of the internal oblique muscle layer
Figure 8. Ultrasound probe position for the transversus abdominis plane (a slight give or pop is often felt) (See Figure 9).
(TAP) block
In neonates the muscles are less developed and therefore
differentiation between the layers can be difficult to the
A TAP block is ideally used for inguinal hernia repair, inexperienced practitioner. The injection is seen as a neat
colostomy formation, appendectomy (laparoscopic and open lens-shaped deposit of local anaesthetic forming between the
techniques), iliac crest bone graft harvesting, laparoscopic transversus abdominis muscle and the fascia separating the
cholecystectomy, and laparoscopic nephrectomy or to provide internal oblique muscle and transversus abdominis. If you are
analgesia after renal transplant. concerned that the local anaesthetic dose may be wasted whilst

identifying the correct plane, use saline to identify the correct and spleen are particularly prominent). The TAP block has a
plane before injecting the local anaesthetic dose. higher rate of complications than other blocks in children.9
In older children it may prove difficult to enter the TAP.
FURTHER READING
Guide the needle very carefully into the transversus abdominis
http://www.euroespa.com/science-education/specialized-
muscle, then slowly withdraw the needle as an assistant injects;
sections/us-regional-anaesthesia/
as the needle enters the correct position, local can be seen
spreading through the plane. REFERENCES
1. Boretsky KR. Regional anesthesia in pediatrics: marching forward.
Curr Opin Anaesthesiol. 2014; 27: 556-560.
2. van Schoor AN, Boon JM, Bosenberg AT, Abrahams PH, Meiring
JH. Anatomical considerations of the pediatric ilioinguinal/
iliohypogastric nerve block. Paediatr Anaesth. 2005; 15: 371-
377.
3. Willschke H, Marhofer P, Bosenberg A et al. Ultrasonography for
ilioinguinal/iliohypogastric nerve blocks in children. Br J
Anaesth. 2005; 95: 226-230.
4. Willschke H, Bosenberg A, Marhofer P et al. Ultrasonographic-
guided ilioinguinal/iliohypogastric nerve block in pediatric
anesthesia: what is the optimal volume? Anesth Analg. 2006;
102: 1680-1684.
5. Weintraud M, Marhofer P, Bosenberg A et al. Ilioinguinal/
iliohypogastric blocks in children: where do we administer the
local anesthetic without direct visualization? Anesth Analg.
Figure 9. Ultrasound landmarks for TAP block: EO=external oblique 2008; 106: 89-93.
muscle; IO=internal oblique muscle; TA=transversus abdominus muscle;
LA=local anaesthetic; needle seen slanting from anterior. 6. Flack SH, Martin LD, Walker BJ et al. Ultrasound-guided rectus
sheath block or wound infiltration in children: a randomized
blinded study of analgesia and bupivacaine absorption.
Ultrasound guided subcostal approach Paediatr Anaesth. 2014; 24: 968-973.
Position the patient supine. Place high frequency linear
7. Willschke H, Bosenberg A, Marhofer P et al. Ultrasonography-
ultrasound probe in an oblique transverse plane, parallel to
guided rectus sheath block in paediatric anaesthesia--a new
the subcostal margin (lateral to the rectus sheath). Identify the approach to an old technique. Br J Anaesth. 2006; 97: 244-249.
medial border of the external oblique, internal oblique and
transversus abdominis muscles. Subsequently identify the TAP 8. Russon K et al. Transversus abdominus plane block. WFSA
in between these inner two muscles. Insert the needle at the Anaesthesia Tutorial of the Week 2011 No. 239.
http://w w w.wfsahq.org/components/com_vir tual_
lateral edge of rectus abdominis muscle. Advance the needle
librar y/media/ea51ff0934644a9e41bcf82f65a96a58-
in-plane away from the midline and parallel to the costal 474f4fcc0e20052dd9ed683ca9995db2-239-Transversus-
margin; use the local anaesthetic to hydrodissect the plane, Abdominus-Plane-Block.pdf
carefully advancing the needle into the space created. Repeat
this process until the anterior 2/3 of the subcostal margin has 9. Long JB, Birmingham PK, De Oliveira GSJ, Schaldenbrand
KM, Suresh S. Transversus abdominis plane block in children: a
been covered.
multicenter safety analysis of 1994 cases from the PRAN
Complications (Pediatric Regional Anesthesia Network) database. Anesth
Peritoneal perforation, organ perforation (in neonates the liver Analg. 2014; 119: 395-99.

Upper and lower limb blocks in children
Adrian Bosenberg
Correspondence Email: adrian.bosenberg@seattlechildrens.org
INTRODUCTION insulated needles are the next best option

Regional anaesthesia is commonly used as an although successful blocks can be achieved with
adjunct to general anaesthesia and plays a key non-insulated needles.6
role in the multimodal approach to perioperative Nerve stimulator
pain management in children.1,2 Peripheral nerve Many peripheral nerve stimulators are available. SUMMARY
blockade has increased with the development of Familiarise yourself with a particular device and
age-appropriate equipment, safer, long-acting This article outlines regional
stick with it. Read the manufacturers instructions anaesthetic techniques and
local anaesthetic agents, increasing experience and understand how the nerve stimulator works methods used to identify and
and low complication rates. before you use it.7 block individual nerves to
provide analgesia for surgical
The safety of peripheral nerve blocks in children The following basic principles should be followed procedures of the upper
has been established in large-scale prospective to locate a peripheral nerve or plexus accurately: and lower limbs. Expertly
studies, although caudal epidural remains the performed, peripheral nerve
most popular and frequently used block in Muscle relaxants must be withheld until after blocks can provide long lasting
completion of the block. anaesthesia and analgesia
infants and small children.3-5 The experience of
for surgery or after injury to
the operator, pathology, the site and extent of Attach the Negative electrode to the Needle the upper or lower limbs in
surgery, the childs body habitus and the presence and the Positive electrode to the Patient using children.
of contractures will dictate the final choice of a standard ECG electrode. Specific knowledge is required
technique. for the indication, technique
Set the initial peripheral nerve stimulator and dose of local anaesthetic
This article outlines regional anaesthetic output to 1-1.5 mA at 1-2 Hz for 0.1msec. for each block. A safe dose
techniques and methods used to identify and Advance the needle through the skin and of local anaesthetic must be
used at all times, and care
block individual nerves to provide analgesia for underlying tissue planes until you elicit taken to avoid inadvertent
surgical procedures of the upper and lower limbs. nerve-specific muscle contractions distally. intravascular injection of local
The differences between adults and children are anaesthetic. The differences
Decrease the current output and adjust the between adults and children
highlighted together with techniques to improve
needle location until you see maximum motor are highlighted together with
the success of blocks.
response with least current i.e. at techniques to improve the
approximately 0.3-0.5mA. success of blocks.
METHODS TO IMPROVE ACCURACY OF
PERIPHERAL NERVE BLOCKS Aspirate and inject local anaesthetic
Adrian Bosenberg
Peripheral nerve blocks, particularly in young (provided no blood returns when you aspirate Professor, Department
children, can be challenging because anatomical as this implies the needle tip is within a blood Anesthesiology and Pain
landmarks are poorly defined and vary with vessel) - muscle twitches will stop immediately Management,
age. Successful peripheral nerve blocks require indicating a successful block is likely. If this Faculty Health Sciences,
an awareness of these differences, knowledge of does not happen you must reposition the University Washington,
developmental anatomy and an understanding needle and repeat the process. Seattle, USA
of the equipment used. Director Regional
Do NOT inject local anaesthetic if you find Anesthesia
Most children are sedated or under general vigorous muscle contraction at <0.2mA or Seattle Childrens Hospital
anaesthesia when nerve blocks are performed. resistance to injection. Both suggest 4800 Sandpoint Way NE
Ultrasound guidance is preferable when intraneural injection, and nerve damage Seattle, WA 98105
available. A peripheral nerve stimulator and could result. USA

Surface nerve mapping local anaesthetic within this sheath produces complete plexus
This is a modification of the standard nerve stimulator blockade by blocking the trunks (supraclavicular approaches)
technique.8 The path of a superficial motor nerve (or plexus) or the cords (infraclavicular approaches). As the spinal roots
can be traced by stimulating the motor component of the nerve pass between the scalenus muscles they unite to form three
transcutaneously. The nerve stimulator output is set at 2-5mA trunks - upper C5-C6; middle C7; lower C8-T1. Emerging
at 1-2Hz and the negative electrode used as the mapping from the interscalene groove, the three trunks pass downward
electrode. The current required varies and is dependent on and laterally to lie postero-lateral to the subclavian artery as
the depth of the nerve and the skin moistness. Mark the point it crosses the upper surface of the first rib. The subclavian
at which maximal motor response is elicited. This serves as the artery is not easily palpable above the clavicle in children.
surface landmark for that block. Excess pressure applied over At the lateral border of the first rib, each trunk divides into
the nerve may inhibit the response. Direct muscle stimulation anterior and posterior divisions, which then join to form the
is finer and more localized. lateral, medial and posterior cords, named according to their
relationship to the axillary artery. These cords then divide into
The nerve mapping technique may be used for:
the nerves of the brachial plexus musculocutaneous, ulnar,
The brachial plexus (supraclavicular, axillary) median and radial.
Musculocutaneous, ulnar, median and radial nerve blocks
of the upper limb
Femoral, sciatic and popliteal nerve blocks in the lower
limb.
Surface nerve mapping is particularly useful where anatomical
landmarks are difficult e.g. children with arthrogryposis or
congenital limb defects.
Ultrasound guidance
This has become an important adjunct in regional anaesthesia;
although anaesthesia departments in low- and middle-income
countries (LMIC) may not be able to make this expensive
item a priority.9-13 Using real time ultrasound imaging, correct
needle and local anaesthetic placement around the nerve can
be verified and thus the risk of intraneural or intravascular
injection reduced. Detailed descriptions of ultrasound-guided Figure 1. Diagrammatic representation of brachial plexus
blocks can be obtained from recent review articles.10-13 anatomy (reproduced with permission from: Harclerode Z,
Michael S. Axillary brachial plexus block landmark techniques.
UPPER LIMB BLOCKS Tutorial of the Week 165 (January 2010))
The motor and sensory innervation of the whole upper
Many anatomical landmarks used in adults maybe difficult to
extremity is supplied by the brachial plexus, with the exception
feel in anaesthetised children, particularly infants8. The scalenus
of part of the shoulder (innervated by the cervical plexus), and
muscles are poorly developed making the interscalene groove
the sensory innervation to the medial aspect of the upper arm
difficult to delineate. The subclavian artery is seldom palpable
(supplied by intercostobrachial nerve, a branch of the 2nd
above the clavicle in infants and preadolescent children.
intercostal nerve).
The brachial plexus can be blocked at various levels, the choice
Anatomy of the brachial plexus (see Figure 1) depending on the planned surgical procedure, the experience
The anterior primary rami of C5-8 and the bulk of T1 form the of the provider and anatomical variants (See Table 1).12,13
brachial plexus. These five roots emerge from the intervertebral
Interscalene approach
foramina to lie between the scalenus anterior and scalenus
Although the interscalene approach has been used for shoulder
medius muscles (which attach to the anterior and posterior
and elbow surgery in children, this approach must be used
tubercles of the transverse process of the cervical vertebrae
with caution.14 Potential complications include intravascular
respectively).
injection, intrathecal injection, pneumothorax (reported
The fascia of these muscles encloses the plexus in a sheath incidence in children is low), Horners syndrome and
that extends laterally into the axilla. A single injection of temporary phrenic nerve palsy.

Table 1. Approaches to the brachial plexus low. The main limitation is incomplete block of the shoulder
and lateral aspect of the forearm onto the thenar eminence
Neck (musculocutaneous nerve sensory distribution). Axillary
block may be used for a variety of procedures on the hand
Interscalene
and forearm (particularly on the medial aspect), such as open
Parascalene reduction with internal fixation of a forearm fracture, closed
reduction of forearm fractures, congenital hand anomalies
Supraclavicular (syndactyly repair), treatment of vascular insufficiency or
Infraclavicular finger re-implantation.16,17
Axillary Perivascular approach

Position: Supine, arm abducted 90, elbow flexed, hand
Perivascular approach behind head.
Transarterial approach Landmarks: Pectoralis major, the coracobrachialis muscle,
axillary artery.
Supraclavicular approach Dose: 0.2-0.5ml.kg-1 0.25-0.5% bupivacaine or 1-2%

This is indicated for all upper extremity surgery, particularly lignocaine. Lower concentrations reduce the degree of motor
if the shoulder is involved. Position: Supine, pillow under block.
shoulders, arm extended along side the body, head turned to Technique: Palpate the axillary artery as high as possible in
opposite side. the axilla in the tissues overlying the humerus at the junction
Landmarks: Clavicle-mid point, transverse process of C6 of the lower border of pectoralis major and coracobrachialis
(Chassaignacs tubercle), posterior border sternocleidomastoid, muscles (see Figure 2). If using a nerve stimulator technique,
cricoid cartilage, brachial plexus. introduce an insulated needle immediately superior to the
pulsation at a 45-60 angle to the skin and direct parallel
Dose: 0.2-0.3ml.kg-1 0.25-0.5% bupivacaine or 1-2% to the artery towards the midpoint of the clavicle with the
lignocaine. Lower concentrations reduce the degree of motor nerve stimulator set at 1mA.18 Distal muscle twitches are
block. elicited, usually in the median or radial nerve distributions,
Technique: With the patient correctly positioned, the as the sheath is penetrated. Gradually reduce the output of
components of the brachial plexus become more superficial the nerve stimulator to approximately 0.3-0.4mA while the
and are easily palpable in most children. The site of puncture is muscle twitch is maintained, adjust the position of the needle
at the junction of the middle and lower third of a line joining as needed. Local anaesthetic solution can then be injected.
Chassaignacs tubercle to the midpoint of the clavicle (if
Chassaignacs tubercle cannot be palpated extending a line from
the cricoid cartilage to posterior border of sternocleidomastoid
should suffice).
Alternatively, insert an insulated needle perpendicular to the
skin at the site where maximal distal muscle twitches (usually
flexion or extension at the elbow) is mapped or simply over
the point where the brachial plexus can be palpated.
Complications: Success rate is high. Complications caused by
faulty technique include pneumothorax, vascular puncture,
Horners syndrome and phrenic nerve palsy.14 Nerve damage
is possible with injudicious injection against resistance but the
possibility of surgical damage should always be excluded. Figure 2. Axillary approach to brachial plexus. Palpate the
axillary artery as high as possible in the axilla at the junction of
Axillary approach the lower border of pectoralis major and coracobrachialis muscle
The axillary block is the most popular brachial plexus block in (reproduced with permission from: Harclerode Z, Michael S.
children.14-17 It is relatively safe and provides good analgesia for Axillary brachial plexus block landmark techniques. Tutorial of the
surgery of the forearm and hand. The risk of complications is Week 165 (January 2010))

Alternatively, use a nerve stimulator set at 3-5mA to map the until forearm flexion is elicited using a nerve stimulator. Inject
median nerve, radial and ulnar or musculocutaneous nerves 0.5-1ml local anaesthetic just deep to the fascia.
transcutaneously in the axilla on either side of the arterial
pulsation. Insert an insulated needle at the point of maximum Complications are rare but include hematoma from accidental
muscle twitch. vascular puncture; in this event apply pressure for at least 5
minutes.
A cannula-over-needle technique can be used to cannulate
the brachial plexus sheath in the axilla using a landmark Infraclavicular approach
technique. The axillary artery is located as described above, Position: Supine, pillow under shoulders, head turned to
and a 22G cannula is inserted at 30 to the skin, anterior to opposite side, upper arm adducted alongside body, elbow
the artery and in a line parallel to the pulsation of the axillary flexed to 90 with forearm placed on abdomen.
artery.17 The cannula is passed over the needle after feeling a
click when the cannula pierces the axillary sheath. Check for Landmarks: Clavicle-lower border, coracoid process of scapula,
negative aspiration of blood and inject 0.5ml.kg-1 0.25% plain axillary artery as it emerges beneath clavicle.
bupicavaine. Dose: 0.2-0.3ml.kg-1 0.25-0.5% bupivacaine, 1-2% lignocaine.
Whichever technique is used, distal pressure applied during Lower concentrations reduce the degree of motor block.
and immediately following injection will facilitate proximal Technique: A number of approaches have been described.18-20
spread and blockade of the musculocutaneous nerve. With the child positioned correctly, divide the clavicle into
The musculocutaneous nerve may be blocked separately to three parts. Make a mark at the point where the pulse is felt
provide analgesia for procedures involving the lateral forearm. as it emerges below the clavicle, or where any distal flexion
Advance a needle, introduced perpendicularly to the skin just or pronation is mapped. Insert a needle infra-clavicularly at
above the axillary pulsation, into the coracobrachialis muscle the junction of the middle and lateral third of the clavicle and
Figure 3. Cutaneous
nerve supply of the
upper limb. (reproduced
with permission from:
Harclerode Z, Michael S.
Axillary brachial plexus
block landmark techniques.
Tutorial of the Week 165
(January 2010)

directed towards this mark. The needle passes lateral to the and the medial epicondyle.
cupola of the lung and is unlikely to encounter the lung along Technique: The ulnar nerve can be blocked at the olecranon
its course. Seek pronation or flexion at the elbow. Once the groove. A small volume of 0.25% bupivacaine is injected into
nerve is located, reduce the voltage on the nerve stimulator to the area.
0.2 to 0.3mA.
Complications: Nerve injury, compression of the nerve.
Alternatively, insert the needle at the midpoint of the lower
border of the clavicle at 45-60 angle and direct towards the Radial nerve
axilla in the same manner until distal muscle twitches are Position: Supine, elbow slightly flexed.
elicited.
Landmarks: Biceps tendon, lateral condyle of humerus.
A vertical infra-clavicular approach using the coracoid process
as a landmark has also been described in children.18-20 The Dose: 1-2ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
site of puncture is 1-2cm caudad and 0.5-1cm lateral to the Technique: Identify lateral condyle of humerus and tendon of
coracoid process in the lower part of the delto-pectoral groove. the biceps muscle. The radial nerve lies adjacent to the condyle,
Insert the needle perpendicular to the skin until distal muscle lateral to the biceps tendon. With the arm slightly flexed at
twitches are elicited. the elbow, the radial nerve can be stimulated with a mapping
Location of the brachial plexus may be difficult in some patients probe in this position. Movement of the thumb confirms the
and ultrasound guided approach has been recommended.12,21 location and small volume of local anaesthetic can be injected
Proponents of this technique claim more effective sensory and at that point.
motor block than with the axillary approach.20,21
Musculocutaneous nerve in the forearm
Elbow blocks Position: Arm extended or arm on abdomen.
Median nerve Landmarks: Lateral condyle of humerus.
Indication: Surgery on volar aspect of the forearm and the Dose: 1-2ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
palmar portion of the hand.
The musculocutaneous nerve courses superficially along the
Position: Supine, arm extended, elbow slightly flexed to lateral aspect of the forearm where it can be mapped along most
accentuate the tendons of the biceps and the brachioradialis. of its course. A superficial ring of local anaesthetic solution
Landmarks: Cubital fossa, brachial artery, biceps tendon. (0.1ml.kg-1) injected at the distal end of the lateral condyle of
the humerus along the pronator teres muscle should block the
Dose: 0.1-0.2ml.kg-1 0.25-0.5% bupivacaine or 1-2% musculocutaneous nerve.
lignocaine.
Wrist blocks
Anatomy: The median nerve in the cubital fossa is located
An appropriate nerve block at the wrist may be used to provide
medial to the brachial artery and the biceps tendon beneath
analgesia for children undergoing minor surgical procedures
the deep fascia.
on the hand or fingers. The nerves that can be blocked at this
Technique: After surface mapping the median nerve, insert level are the median, ulnar and radial nerves. Small volumes
an insulated needle medial to the pulsation of the brachial of local anaesthetic (1-2ml) can provide good analgesia for a
artery. Pronation of the arm with opposition of the fingers is number of hours.
noted when the median nerve is stimulated.
Median nerve
Ulnar nerve The median nerve is the major nerve supplying the hand and
Indication: For surgery in the ulnar distribution of the hand therefore most surgical procedures of the hand will require a
including the medial aspect of the hand and fingers median nerve block at least.
Position: Supine, elbow flexed 90, arm on chest with hand on Position: Hand pronated.
opposite shoulder.
Landmarks: Palmaris longus tendon. Volar aspect wrist
Landmarks: Olecranon groove.
Dose: 0.5-1ml 0.25-0.5% bupivacaine or 1-2%lignocaine.
Dose: 1-2ml 0.25-0.5% bupivacaine, or 1-2% lignocaine.
Anatomy: The median nerve lies within a fascial sheath between
Anatomy: The ulnar nerve lies in the groove posterior to the palmaris longus tendon and flexor carpi radialis. Surface nerve
medial condyle of the humerus midway between the olecranon mapping at this point will elicit opposition of the thumb. A

sheath that communicates with the neurovascular bundle is Insert a second cannula into the opposite arm for IV access
located at the ulnar aspect of the palmaris longus tendon. in case of emergency. Elevate the limb for several minutes
to exsanguinate. Inflate the tourniquet 50-100mmHg above
Complications: Rare - carpal tunnel syndrome or injury to the
systolic BP and ensure the cuff does not leak. Inject the local
median nerve can be avoided by restricting the volume of local
anaesthetic slowly via the IV cannula. Surgery may proceed
anaesthetic used.
after about 5 minutes. The tourniquet must remain inflated for
Radial nerve a minimum of 20 minutes from the time of local anaesthetic
Position: Hand supinated. injection. At the end of the procedure the cuff can be deflated
- closely observe the patient for at least 10min for signs of
Landmarks: Anatomical snuff box, styloid process-radius, toxicity. IVRA is generally safe provided the tourniquet cuff
radial artery. does not leak or accidentally deflate. A purpose made double
Doses: 1-2ml 0.25-0.5% bupivacaine or 1-2% lignocaine. cuff may be used to increase the safety of this technique and
to manage pain from the tourniquet (see http://www.nysora.
Anatomy: The radial nerve at the wrist is purely sensory and com/techniques/3071-bier-block.html).
thus nerve mapping is not possible. Just above the styloid
process, the radial nerve divides into two branches, one LOWER LIMB BLOCKS
supplying dorsum of the hand and another supplying the Most lower extremity procedures can be performed under a
thenar eminence and 1.5 fingers. caudal block (see article p88). Peripheral nerve blocks are more
Technique: The nerve lies superficial proximal to the specific and confined to the site of surgery, the duration of
anatomical snuff box. Inject a wheal subcutaneously starting analgesia is longer and the potential side effects of neuraxial
lateral to the radial artery on the lateral aspect of the wrist blockade can be avoided (bilateral motor weakness, urinary
using a fine needle. retention).23-25
Anatomy of the lumbar and sacral plexus
Ulnar nerve Motor and sensory innervation of the lower extremity is
Position: Hand supinated. supplied by the lumbar and sacral plexus. The lumbar plexus is
Landmarks: Flexor carpi ulnaris tendon, ulnar artery.
From 12th thoracic
Dose: 1-2ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
1st lumbar
Anatomy: The ulnar nerve is located in the palmar sheath
immediately lateral to the flexor carpii ulnaris tendon but Iliohypogastric
medial to the ulnar artery. Mapping at this point will elicit Ilioinguinal
2nd lumbar
flexion of the little finger. Inject into this area to provide
Genitofemoral
analgesia for surgery on the ulnar aspect of the hand and the
medial 1.5 fingers.
3rd lumbar
Biers block or intravenous regional anaesthesia Lat. femoral cutaneous
Biers block or intravenous regional anaesthesia (IVRA) is

performed by introducing local anaesthetic into a limb isolated 4th lumbar
by means of tourniquet. IVRA is suitable for short (<30min)
surgical procedures on the distal arm or leg or reduction of To Psoas and
fractures in older children. Operating time is limited by Iliocus
5th lumbar
tourniquet pain (30-40 min).
Femoral
Equipment: Single or double cuff tourniquet cuff, IV cannula, Accessory obturator
monitors. Obturator
Drugs: 10-40ml 0.5% lignocaine or prilocaine depending

Lumbosacral trunk
on limb and size of patient. Maximum safe dose: lignocaine
3mg.kg-1; prilocaine 6mg.kg-1
Figure 4. Anatomy of the lumbar and sacral plexus reproduced
Technique: Set up monitors (ECG, BP, SpO2) and insert an IV with permission from McEwen A. Femoral nerve block: landmark
cannula as distal as possible in the limb to be operated upon. approach. TOTW 249 (February 2012)

Table 2. Lower extremity nerve blocks
Lumbar plexus block
Femoral nerve
Lateral cutaneous nerve of thigh
Sciatic nerve
Posterior approach
Infragluteal approach
Popliteal fossa approach
Ankle block
derived from the anterior primary rami of lumbar nerves L1-

L4 and a variable contribution from T12 and L5. The lumbar
plexus is located anterior to the transverse processes of the
lumbar vertebrae within the psoas major muscle. The psoas
Figure 5. Psoas compartment block. The needle is inserted at
compartment is bordered posteriorly by quadratus lumborum the intersection of a perpendicular line drawn from the posterior
and anteriorly by psoas major. The femoral nerve, lateral superior iliac spine to the intercristal line.
cutaneous nerve of thigh, and obturator nerve are branches
of the lumbar plexus and supply the majority of the upper leg Dose: 0.5ml.kg-1 0.25-0.5% bupivacaine or 1-2% lignocaine.
including the thigh and its lateral aspect. The saphenous nerve Technique: With the child in position, insert an insulated
provides sensory innervation below the knee to the medial needle perpendicular to the skin where a line drawn from the
aspect of the lower leg and foot. (See Table 2 and Figure 4) posterior superior iliac spine (PSIS) parallel to the spinous
The sacral plexus is derived from the anterior primary rami processes of the vertebrae intersects the intercristal (Touffiers)
of L5, S1-S3 with contributions from L4 and S4. The plexus line (see Figure 5). Advance the needle slowly through the
lies anterior to the piriformis muscle behind the pelvic fascia posterior lumbar fascia, paraspinous muscles, anterior lumbar
on the posterior wall of the pelvic cavity. The sciatic nerve is fascia, quadratus lumborum and into the psoas muscle.
derived from the sacral plexus to supply the knee, the leg and Passage through these fascial layers may be detected by distinct
most of the foot except for the medial aspect supplied by the pops when using a short bevelled needle. Using a nerve
saphenous nerve. A proximal branch of the sciatic nerve, the stimulator quadriceps muscle twitches in the ipsilateral thigh
posterior cutaneous nerve of the thigh, supplies the posterior are sought. If hamstring contractions are observed, direct the
aspect of the thigh and the hamstring muscles. needle laterally. If hamstring and quadriceps contractions are
observed simultaneously, direct the needle more cephalad to
Lumbar plexus block isolate the lumbar plexus rather than sacral plexus.27
The lumbar plexus can be blocked within the psoas muscle at the
The depth from the skin to the lumbar plexus is approximately
level of the transverse process of L4. In children the transverse
the same distance as the posterior superior iliac spine is to the
process is not fully developed and using the transverse process
intercristal line.27 The depth of the needle is emphasized because
as a guide usually places the needle too medial and increases
complications include renal haematoma, vascular puncture
the risk of complications, i.e. spinal anaesthesia secondary to
(retroperitoneal haematoma) or even bowel puncture.
puncture of the dural cuff on the spinal roots, or retrograde
epidural spread to opposite side. Femoral nerve block
Position: Supine, foot rotated outward.
Indications: Unilateral block of the hip (congenital dislocation
of hip), thigh (open reduction and internal fixation of femoral Landmarks: Femoral pulse, inguinal ligament.
fractures) or knee surgery. Dose: 0.2-0.3ml.kg-1 0.25-0.5% bupivacaine or 1-2%
Position: Lateral position, hips and knees flexed. lignocaine.
Landmarks: Posterior superior iliac spine, intercristal line, Femoral nerve blocks are most useful in cases of fractured
spinous process L4. femur, and allow painless transport, radiographic examination

and application of splints.23,28,29 Most lower limb surgery can posterior branches.
be performed when femoral nerve block is used in combination Technique: Insert a needle 1-2 cm below and medial to the
with sciatic nerve or lateral cutaneous nerve of thigh block. origin of the inguinal ligament at the anterior superior iliac
For surgery on the knee it is best used in combination with a spine until a pop is felt as the fascia lata is penetrated and a
sciatic nerve block.23,30 second pop when the fascia iliaca is entered. If bone contact is
Technique: The femoral nerve may be blocked as it emerges made, the needle should be withdrawn and redirected. Correct
from below the inguinal ligament in the femoral canal lateral to placement of the needle can also be determined with a loss of
the femoral artery in the femoral triangle. Although a femoral resistance technique noted as the fascia iliaca compartment is
nerve block can be performed without a nerve stimulator (e.g. entered.
for unsedated children with femoral fractures to avoid pain
caused by muscle contractions) greater success can be achieved Fascia iliaca compartment block
using one. Indications: This block is particularly useful for any surgery
performed on the lower extremity above the knee and for
Insert the needle approximately 0.5-1cm lateral to the femoral femoral shaft fractures. The fascia iliaca compartment block
pulsation and approximately 0.5-1cm below the inguinal was originally described in children by Dalens and is more
ligament. It is useful to map the course of the femoral nerve effective in blocking the femoral, lateral cutaneous nerve of
prior to inserting the needle.8 thigh and obturator nerves than the 3-in-1block.31
The nerve lies beneath the fascia lata and fascia iliaca and Position: Supine.
often two distinct pops are felt as needle traverses these layers.
Quadriceps contraction confirms femoral nerve stimulation Landmarks: ASIS, inguinal ligament, pubic tubercle.
but should not be confused with direct stimulation of the Dose: 0.5-1ml.kg-1 0.25-0.5% bupivacaine, or 1-2%
sartorius muscle. Local anaesthetic should be easy to inject into lignocaine.
the femoral canal. Resistance to injection suggests intraneural
injection. Technique: With the child in the supine position and the thigh
slightly abducted and externally rotated, draw a line from the
3 in 1 block pubic tubercle to the ASIS along the inguinal ligament. Insert
A 3 in 1 block is essentially a femoral nerve block that a needle perpendicular to the skin 0.5-1cm below the junction
attempts to anaesthetize the femoral, lateral cutaneous nerve of lateral and middle third of this line. Two pops are felt
of thigh and obturator nerves with one injection by causing as the needle pierces the fascia lata and then the fascia iliaca.
retrograde spread of local within the femoral sheath up to Larger volumes are required because the aim is to block all three
the lumbar plexus by applying digital pressure distal to the nerves with one injection. Massaging the area in an upward
injection site. It is only 20% effective in blocking all three direction may facilitate the upward spread of local anaesthetic.
nerves.31 All three nerves are more reliably blocked with a No significant complications are seen provided that the needle
fascia iliaca or a lumbar plexus block. remains (below) inferior to the inguinal ligament and away
from the femoral vessels.
Lateral femoral cutaneous nerve of thigh
Indications: To provide analgesia for plating of the femur, plate Sciatic nerve block
removal, drainage of femoral osteitis, harvesting skin grafts or The sciatic nerve leaves the posterior pelvis via the greater
muscle biopsies. sciatic foramen through the piriformis muscle into the buttock
Position: Supine. and descends in the midline of the leg posteriorly to the apex
of the popliteal fossa. The sciatic nerve lies midway between
Landmarks: Anterior superior iliac spine, inguinal ligament. the greater trochanter and the ischial tuberosity at the gluteal
Dose: 1-3ml 0.25-0.5% bupivacaine or 1-2% lignocaine. cleft where it is palpable in most young children.6 The sciatic
nerve divides into the common peroneal and the tibial nerve
Anatomy: The lateral cutaneous nerve of thigh is derived from
within the popliteal fossa in the majority of children.32
the lumbar plexus (L2-L3) and is purely sensory supplying
the anterolateral aspect of the thigh. The nerve descends over The sciatic nerve can be blocked using several different
the iliacus muscle just below the pelvic rim in an aponeurotic approaches at the hip or in the popliteal fossa.32-35 The
canal formed in the fascia lata and enters the thigh close to approach chosen ultimately determines the distribution of
the anterior superior iliac spine (ASIS) behind the inguinal motor and sensory blockade. Sciatic nerve block at the gluteal
ligament. In the thigh it crosses or passes through the tendinous level provides anaesthesia for the posterior aspect of the thigh
origin of the sartorius muscle. It divides into anterior and and leg below the knee but excludes the medial aspect of the

lower half of the leg, the medial malleolus and the medial Infragluteal approach to the sciatic nerve
aspect of the foot. Position: Supine or lateral decubitus, hip flexed, knee extended.
Indications: All surgical procedures involving the posterior Landmarks: Greater trochanter, ischial tuberosity, gluteal
aspect of the leg especially below the knee, for example crease, biceps femoris muscle.
lengthening of the Achilles tendon, uni- or bilateral club foot Dose: 0.2-0.3ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
repair as well as for major foot arthrodesis.6 It may need to
be supplemented with other blocks depending on the type of Technique: A useful technique in children has been described
surgery, for example knee surgery or tibial osteotomies. by Raj.6,35 Insert a needle posteriorly perpendicular to the skin
at a point midway between the ischial tuberosity and greater
The different approaches to the sciatic nerve in children are trochanter on the gluteal crease. With exaggerated hip flexion
described below. the glutei may be flattened and the sciatic nerve becomes
relatively superficial even in some obese children. The nerve
Posterior approach to the sciatic nerve
is often palpable in the groove lateral to biceps femoris in
Position: Lateral recumbent, hip flexed, knee flexed, the side to
young children. Plantar flexion, inversion or dorsi-flexion at
be blocked uppermost.
0.3-0.4 mA confirms sciatic nerve stimulation. The posterior
Landmarks: Coccyx, greater trochanter, ischial tuberosity. cutaneous nerve of the thigh may be missed since the nerve
may separate more proximally in the thigh.
Dose: 0.2-0.3ml.kg-1 0.25-0.5% bupivacaine or 1-2%
lignocaine. Anterior approach to the sciatic nerve
Technique: With the child in position, draw a line from the tip Position: Supine, hip and knee extended
of the coccyx to the greater trochanter. Insert a needle at the Landmarks: pubic tubercle, anterior superior iliac spine,
midpoint of this line and direct towards the ischial tuberosity. greater trochanter
Dose: 0.2-0.3ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
L4
Technique: (see Figure 6). A line drawn from the pubic tubercle
to the anterior superior iliac spine (inguinal ligament) is divided
L5 into thirds. A perpendicular is then dropped from the junction
of the inner and middle thirds onto a line drawn parallel to the
inguinal ligament through the greater trochanter. This point
S1 corresponds approximately with the lesser trochanter below.
1
S2 Posterior mid-thigh approach to the sciatic nerve
1/3 S3
Position: Supine, hip flexed, knee flexed or extended.
SN
Landmarks: Ischial tuberosity, head of fibula.
1/3 Dose: 0.2-0.3ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
Technique: Insert a needle perpendicular to the midpoint of a
2 line drawn from the head of fibula to the ischial tuberosity in
the posterior thigh. The nerve is surrounded by the hamstring
SN 4
muscles at this point and this compartment can be located
using a loss of resistance technique or by nerve stimulation
3
that produces a motor response in the ankle, foot or big toe.36
The posterior cutaneous nerve of thigh is missed at this level.
Figure 6. Anterior approach to the sciatic nerve: anatomy. Sciatic nerve in the popliteal fossa
Morphett S. Nerve blocks for anaesthesia and analgesia of the
Position: Prone, lateral or supine.
lower limb A practical guide: Femoral, Lumbar plexus, Sciatic.
Update in Anaesthesia 11(2000):56-66 Landmarks: Apex-popliteal fossa.
A nerve stimulator, set at 0.3 to 0.4mA, will elicit distal motor Dose: 1-2ml 0.25-0.5% bupivacaine or 1-2% lignocaine.
responses in the leg or foot confirming stimulation of the The sciatic nerve may be blocked as it courses through the
sciatic nerve (which supplies all the muscles below the knee). popliteal fossa behind the knee for procedures of the distal

lower extremity.36-38 The popliteal fossa is formed by the compliment a sciatic nerve block for surgery on the medial
semimembranosus and semitendinosus tendons medially, aspect of the lower limb or foot.
the biceps femoris tendon laterally, and the popliteal crease Position: Supine.
between the femoral condyles inferiorly.
Landmarks: Femoral artery, sartorius, inguinal ligament.
The sciatic nerve divides in the vicinity of popliteal fossa into
Dose: 0.1-0.2ml.kg-1 0.25-0.5% bupivacaine or1-2%
two branches - the common peroneal and the posterior tibial
lignocaine.
nerves. The exact location of this division is variable but in
the majority of children it is within the popliteal fossa.32,39 The saphenous nerve runs along the medial aspect of the thigh
The common peroneal nerve courses laterally medial to the just lateral to and within the same fascial sheath as the motor
biceps femoris tendon before passing over the lateral head nerve supplying the vastus medialis.
of gastrocnemius and around the head of the fibula. The
The nerve to vastus medialis can be located using a nerve
posterior tibial nerve courses down the midline of the lower leg
stimulator. Insert an insulated needle perpendicular to the skin
posteriorly in close proximity, but superficial to the popliteal
0.5cm lateral to the point where the femoral artery crosses the
artery within the popliteal fossa.
medial border of the sartorius muscle in the anterior thigh.
Although the nerves branch, there is a common epineural Muscle twitches in the sartorius muscle confirm the close
sheath that envelops both the posterior tibial and the common proximity to the saphenous nerve at this level. The distance
peroneal nerve.38 For this reason a high rate of success can be from the inguinal ligament (3-5cm) varies with age, as does the
achieved even when the motor response of only one branch depth of the nerve (0.5-3cm).
is elicited. Stimulation of the common peroneal will cause An advantage of this block over a femoral block is that motor
dorsiflexion and eversion of the foot while stimulation of the activity in the remainder of the quadriceps is spared.
posterior tibial nerve will elicit inversion and plantar flexion.
(Internal nerve, i.e. posterior tibial nerve - Inversion; External The saphenous nerve is a purely sensory nerve at the knee. At
nerve i.e. common peroneal nerve - Eversion). The nerves can the level of the tibial plateau the saphenous nerve perforates
be mapped individually particularly in young infants. the fascia lata between the sartorius and gracilis where it lies
subcutaneously in close proximity to the long saphenous vein.
Various landmarks have been described for the insertion of
the needle. For each 10kg body weight the needle insertion Make a deep linear subcutaneous infiltration below and
moves 1cm further above the popliteal crease just lateral to behind the insertion of the sartorius tendon (medial surface of
the midline.32 Alternatively, insert a needle at the apex of the tibia) where the nerve lies in a shallow gutter immediately in
popliteal fossa to block both the posterior tibial and common front of the upper part of the medial head of gastrocnemius.
peroneal nerve. Intermittent aspiration will reduce the risk of injection into
the long saphenous vein.
Complications are rare but take care to avoid intravascular
injection. Ankle block
Position: Supine or prone.
Lateral approach to the sciatic nerve at the knee
Position: Supine. Landmarks: Medial and lateral malleolus, extensor hallucis
longus tendon, Achilles tendon, dorsalis pedis pulse.
Landmarks: Biceps femoris tendon.
Dose: 0.1ml.kg-1 0.25-0.5% bupivacaine or 1-2% lignocaine.
Dose: 0.1ml.kg-1 0.25-0.5% bupivacaine or 1-2% lignocaine.
Ankle blocks are used for procedures confined to the foot
A lateral approach to the popliteal fossa has recently been
including distal phalangeal amputations, foreign body removal
described in children.40 Identify the biceps femoris tendon on
and simple reconstructive surgery. The five peripheral nerves
the postero-lateral aspect of the knee approximately 4-6 cm
blocked at this level are the terminal branches of the sciatic
above the popliteal crease. Insert a needle anterior to the biceps
(posterior tibial, superficial peroneal, deep peroneal and sural
femoris tendon until the needle contacts the shaft of the femur.
nerves) and femoral (saphenous) nerves.
At this point gently walk the needle off the femur posteriorly
and advance until foot dorsiflexion or plantar flexion along An ankle block is relatively easy to perform by injecting
with eversion is elicited. a subcutaneous ring at the ankle. Avoid local anaesthetics
containing adrenaline since it may compromise end-arteries
Saphenous nerve block in the foot. Block each nerve separately for best results (see
Indication: The main indication for blocking this nerve is to Figure 7).

vein. It is located on the medial side of the dorsum of
the foot anterior to the medial malleolus. A subcutaneous
injection from the medial malleolus along the anterior
i aspect of the ankle towards the saphenous vein will block
the nerve.
h h SAFE CONDUCT OF PERIPHERAL NERVE BLOCKS
Patients should be carefully monitored whilst nerve blocks are
performed. This should include ECG, BP and pulse oximetry.
Resuscitation equipment (oxygen, anticonvulsants, Ambu
bag and Intralipid) should be available in the event of local
anaesthetic toxicity or anaphylaxis. (See Table 3)
e e
g Table 3. Management of local anaesthetic toxicity
f
Management of systemic toxicity42
d b Airway - Maintain the patients airway, administer 100% oxygen
ba f
c Breathing - Start ventilation: if breathing inadequate intubate
Circulation - Pulse check: if cardiac arrest, start CPR.

Figure 7. Cutaneous nerve supply of the leg and foot,
demonstrating the nerves involved in an ankle block: a) medial Convulsions - IV diazepam, 1-3mg.kg-1 thiopentone, muscle
and lateral plantar nerves; b) superficial peroneal nerve; c) deep relaxation prn
peroneal nerve; d) medial calcaneal nerve (branch of the tibial
Hypotension - Ephedrine 3-6mg increments, elevate legs, IV
nerve); e) saphenous nerve ; f) sural nerve; g) lateral cutaneous
fluid bolus
nerve; h) femoral nerve; i) lateral femoral cutaneous nerve
Intralipid 20% - 1-1.5ml.kg-1 followed by infusion
(a) The tibial nerve innervates the sole of the foot and medial 0.25ml.kg-1.min-1
aspect of the heel and lies between the medial malleolus
and the calcaneum deep to the flexor retinaculum CONCLUSION
immediately posterior to the posterior tibial artery. Local Expertly performed, peripheral nerve blocks can provide long
anaesthetic injected through a needle inserted postero- lasting anaesthesia and analgesia for surgery or after injury
medially to the Achilles tendon and directed towards the to the upper or lower limbs in children. Specific knowledge
arterial pulsation should block the tibial nerve. is required for the indication, technique and dose of local
anaesthetic for each block. Accuracy is improved if a nerve
(b) The superficial peroneal nerve supplies the dorsum of the
stimulator or ultrasound guidance is used. A safe dose of
foot and is blocked by a subcutaneous injection across the
local anaesthetic must be used at all times, and care taken to
dorsum of the foot between the lateral malleolus and the
avoid inadvertent intravascular injection of local anaesthetic.
extensor hallucis longus tendon.
Additional information and video descriptions of peripheral
(c) The deep peroneal nerve innervates the first web space nerve blocks can be obtained from the Internet, for instance
between the 1st and 2nd toe. Insert a needle medial to extensor from the New York School of Anaesthesia website: http://
hallucis longus tendon along anterior tibial arterial www.nysora.com/
pulsation until it contacts the tibia. Withdraw the needle a
few millimetres and inject the local anaesthetic solution. REFERENCES
1. Suresh S, Wheeler M. Practical pediatric regional anesthesia.
(d) The sural nerve innervates the lateral aspect of the foot. Anesthesiol. Clin.North America 2002; 20: 83-113.
Introduce a needle posterio-lateral to the Achilles tendon
2. Ross AK, Eck JB, Tobias JD. Pediatric regional anesthesia:
between the lateral malleolus and the calcaneum until beyond the caudal. Anesth Analg 2000; 91: 16.
bony contact is made. Withdraw the needle a few
millimetres and inject the local anaesthetic solution. 3. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity
of regional anesthesia in children: A one-year prospective survey
(e) The saphenous nerve innervates the medial aspect of the of the French-language society of pediatric anesthesiologists.
ankle and foot and lies in close proximity to the saphenous Anesth Analg 1996; 83: 904-12.

4. Polaner DM, Taenzer AH, Walker BJ et al. Pediatric Regional 20. Fleischman E, Marhofer P, Greher M et al. Brachial plexus
Anaesthesia Network (PRAN): A Multi-Institutional Study of anaesthesia in children: lateral infraclavicular vs axillary
the Use and Incidence of Complications of Pediatric Regional approach. Paediatr Anaesth 2003; 13:103-8.
Anaesthesia. Anesth Analg 2012; 22: 115-9.
21. Marhofer P, Sitzwohl C, Greher M et al. Ultrasound guidance for
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2010; 20: 1061-9. approach to the brachial plexus in children: comparison with
the supraclavicular approach. Anesth Analg 1987; 66: 1264-71
6. Bosenberg AT. Lower limb blocks in children using unsheathed
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7. Hadzic A. Peripheral nerve stimulators: cracking the code
one at a time. Reg Anesth Pain Med 2004; 29: 185-8. 24. McLeod DH, Wong DH, Claridge RJ, Merrick PM: Lateral popliteal
sciatic nerve block compared with subcutaneous infiltration
8. Bosenberg AT, Raw R, Boezaart AP: Surface mapping of
for analgesia following foot surgery. Can.J.Anaesth. 1994; 41:
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9. Chan V: Advances in regional anaesthesia and pain 25. Tobias JD, Mencio GA. Popliteal fossa block for postoperative
management. Can.J Anaesth. 1998; 45: R49-63 analgesia after foot surgery in infants and children. J Pediatr
Ortho 1999; 19: 511-4.
10. Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional
anaesthesia. Br J Anaesth 2005; 94: 7-17. 26. Dalens B, Tanguy A, Vanneuville G. Lumbar plexus block in
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11. Tsui B, Suresh S. Ultrasound imaging for regional anaesthesia Anesth Analg 1988; 67: 750-8.
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literature and its application in the practice of extremity and 27. Walker BJ, Flack SH, Bosenberg AT. Predicting lumbar plexus
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112: 661-5.
12. Marhofer P, Willschke H, Kettner S. Ultrasound-guided upper
extremity blocks-tips and tricks to improve the clinical practice. 28. Ronchi L, Rosenbaum D, Athouel A, et al. Femoral nerve
Pediatr Anesth 2012; 22: 65-71. blockade in children using bupivacaine. Anesthesiology 1989;
70: 622-4.
13. Sites BD, Chan VW, Neal JM et al. The American Society of
Regional Anaesthesia and Pain Medicine and the European 29. Tobias JD: Continuous femoral nerve block to provide analgesia
Society of Regional Anaesthesia and Pain Therapy joint following femur fracture in a paediatric ICU population.
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31. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia
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16. Cramer KE, Glasson S, Mencio G, Green NE: Reduction of 32. Konrad C, Johr M. Blockade of the sciatic nerve in the popliteal
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J.Orthop. Trauma 1995; 9: 407-10. 1998; 87: 1256-8.
17. Fisher WJ, Bingham RM, Hall R. Axillary brachial plexus blocks 33. Dalens B, Tanguy A, Vanneuville G. Sciatic nerve blocks
for perioperative analgesia in 250 children. Paediatr Anaesth in children: comparison of the posterior, anterior, and lateral
1999; 9: 435-8. approaches in 180 pediatric patients. Anesth Analg 1990; 70:
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18. Kilka HG, Geiger P, Mehrkens HH: Infraclavicular vertical brachial
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19. Dadure C, Raux O, Troncin R, Rochette A, Capdevila X: 35. Raj PP, Parks RI, Watson TD, et al. A new single-position supine
Continuous infraclavicular brachial plexus block for acute pain approach to sciatic-femoral nerve block. Anesth Analg 1975;
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36. Kempthorne PM, Brown TCK. Nerve blocks around the knee in 40. terRahe CT, Suresh S: Popliteal fossa block: Lateral approach
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2002; 6:141-3.
37. Tobias JD, Mencio GA. Popliteal fossa block for postoperative
analgesia after foot surgery in infants and children. J Pediatr 41. Neal JM, Bernards CM, Butterworth JF et al ASRA Practice
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38. Vloka JD, Hadzik A, Lesser JB, et al. A common epineural sheath Pain Med 2010; 35: 152-61.
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42. Harclerode Z, Michael S. Axillary brachial plexus block landmark
for sciatic nerve block. Anesth Analg 1997; 84: 387-90.
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39. Schwemmer U, Markus CK, Greim CA, Brederlau J, Trautner H,
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14:1005-8.

Principles of clinical amaesthesia
Paediatric spinal anaesthesia

Reprinted from: Rachel Troncin and Christophe Dadure. Paediatric spinal anaesthesia. Update in Anaesthesia
(2009); 25,1: 22-4.
Rachel Troncin* and Christophe Dadure

*Correspondence Email: racheltroncin@hotmail.fr
EDITORIAL COMMENT a history of apnoeas. General anaesthesia increases

This article correctly suggests that the resurgence the risk of apnoea and bradycardia, and ex-premature
of interest in spinal anaesthetic techniques in infants remain at risk until after 60 weeks post-
neonates and young infants was driven by the conception.3,4
reduced risk of postoperative apnoea. More
Outside the neonatal period, SA has been used
recently, concerns have arisen about the long
for general surgery (rectal biopsy, incision of
Summary term effects on neurodevelopment after exposure
rectal abscess), urological surgery (orchidopexy,
to general anaesthesia due to evidence from a
Spinal anaesthesia circumcision), lower limb orthopaedic surgery,5 and
broad base of literature in animals. Although
provides a good may be of particular use in developing countries as an
alternative to general
the current human evidence is not conclusive, a
alternative to general anaesthesia.
anaesthesia in newborns large paediatric trial is underway and will begin
with increased to report in 2014 as this issue goes to press. The SA has also been suggested for patients in whom
anaesthesia-related GAS (General Anaesthesia vs Spinal 2015) study GA may pose a significant risk such as those with
risk, and for infants will look at the differential rates of postoperative facial dysmorphia and difficult intubation, muscular
undergoing lower apnoea and examine neurodevelopment up to age dystrophy, family history of malignant hyperthermia
abdominal or lower 5 years, the final reports are due in 2018. Spinal or a full stomach with aspiration risk.5
extremity surgery during anaesthesia is currently the mainstay of practice for
the first 6 months of life. SA has also been described in combination with GA
young infants in many low resource environments. in children undergoing complex surgery. For instance,
It is most successful as
a single shot technique,
It could be that this pattern of practice may be preoperative morphine SA combined with GA for
limited to surgery lasting adopted throughout many more healthcare systems scoliosis surgery is associated with reduced blood
less than ninety minutes. in years to come. loss and better pain control.6,7 SA has been used with
Spinal anaesthesia GA during cardiopulmonary bypass in neonates to
in children requires INTRODUCTION
blunt the stress response, protect hemodynamic status
the technical skills of Spinal anaesthesia consists of inserting a spinal needle
experienced anaesthesia
and reduce perioperative morbidity and mortality,4,9
into the subarachnoid space and, when a free flow of
providers. although its use in this situation is not common.
cerebrospinal fluid (CSF) is obtained, injection of a
SA has also been described for use in chronic pain
solution of local anaesthetic directly into the CSF.
management.4,8
Spinal anaesthesia (SA) was first described in children
in 19091 but did not become part of routine practice CONTRAINDICATIONS TO SA
until the 1980s when regional anaesthesia increased in There are a number of specific contraindications to SA
popularity. The particular advantage suggested for SA in children that are listed below:
in children was the avoidance of general anaesthesia Coagulation abnormalities
(GA) in those at risk of postoperative apnoea. Several
studies demonstrated that SA had a particular role Systemic sepsis or local infection at the puncture
Rachel Troncin in high-risk former preterm neonates undergoing point
Consultant Anaesthetist inguinal herniorraphy.2
Uncorrected hypovolaemia
Christophe Dadure APPLICATIONS OF SPINAL ANAESTHESIA Parental refusal or an uncooperative child
Consultant Anaesthetist SA remains popular for ex-premature infants,
Neurological abnormalities such as spina bifida,
Dpartement dAnesthsie specifically those undergoing inguinal herniorraphy.
increased intracranial pressure
Ranimation These patients often have a history of apnoea of
Centre Hospitalo- prematurity, bronchopulmonary dysplasia and Procedures lasting more than 90 minutes.
Universitaire Lapeyronie chronic lung disease. The incidence of postoperative
Montpellier apnoeas correlates with gestational age at birth, the ANATOMICAL CONSIDERATIONS
France post-conceptional age at surgery, weight, anaemia and A line connecting the top of the iliac crests crosses the

spinal axis at the L5-S1 level in neonates and infants up to one year TECHNIQUE OF SA IN CHILDREN
of age and at the L4-L5 level in older children.5 The spinal cord ends
approximately at L3 level at birth and at L1-L2 level in children over Preoperative preparation
one year old. The technique should be explained fully to the parents (and child
if appropriate), with a description of risks and benefits. Informed
The distance between the skin and the subarachnoid space is consent should be obtained.
influenced by age from 10 to 15mm in newborns.10 The distance
between skin and subarachnoid space can be related to height or A full blood count including platelet count and coagulation screen
weight using the formulae: (prothrombin time, PT; activated partial thromboplastin time,
APTT) may be performed preoperatively where clinically indicated.
Distance from skin to subarachnoid space (cm) = 0. 03 x height (cm)
Blood tests are not usually required for a routine herniotomy, the
most common indication for infant spinal anaesthesia.
Distance from skin to subarachnoid space (mm) = [2 x weight (kg)] + 7(mm)11
The child should be fasted as for GA (4 to 6 hours for milk
The subarachnoid space in newborns is very narrow (6 to 8mm) and 2 hours for clear liquid). If possible, topical anaesthesia
and successful lumbar puncture in this population requires great is used by application of EMLA (Eutectic Mixture of Local
precision and avoidance of lateral deviation. Anaesthetics) or Ametop on the lumbar area, 60 to 90 minutes
prior to SA. Premedication with oral or rectal atropine
Cerebrospinal fluid is a clear body fluid that occupies the
(20mcg.kg-1) will vary with institutional preferences, but you should
subarachnoid space and the ventricular system of the brain and
consider using it in all ex-premature neonates.
spinal cord. Cerebrospinal fluid volume at different periods of life is
shown in Table 1. Operative management
In the operating room, routine monitoring and standard intravenous
Table 1. CSF volume in children infusion are started. Some anaesthesiologists have suggested placing
Cerebrospinal fluid the intravenous cannula in an anaesthetized lower extremity after
volume (ml.kg-1) performing the subarachnoid block. We advise placing it prior to
SA puncture. Although cardiopulmonary complications are unlikely
Neonates 10 following SA, they are possible and the presence of a cannula will
Infants less than 15kg 4 allow more rapid intervention, particularly in environments where
trained anaesthetic assistants are not universally available
Young children 3
There should be an assistant for the anaesthetist to help with
Adolescent /Adult 1.5 - 2 preparation of the equipment, positioning and holding the child
during insertion of the SA. All drugs and equipment should be
The volume of distribution of drugs injected into the subarachnoid
prepared and checked prior to starting. Full barrier aseptic technique
space is higher in infants and neonates than in adults and consequently
the injected dose is relatively greater in infants and neonates. Table 2. Dose of local anaesthetic for SA in children
Weight < 5kg 5 to 15kg > 15kg
PHYSIOLOGICAL EFFECTS OF SPINAL ANESTHESIA
Isobaric or 1mg.kg -1
0.4mg.kg 0.3mg.kg-1
-1
Hemodynamic consequences of SA hyperbaric (0.2ml.kg ) (0.08ml.kg ) (0.06ml.kg-1)

-1 -1
Cardiovascular changes related to the SA are less common in bupivacaine

children than in adults. In children under 5 years of age, minimal 0.5%
changes in heart rate and blood pressure have been reported.5,12,13 Isobaric or 0.4mg.kg-1 0.3mg.kg-1
In older patients (>8 years old), the sympathetic block can induce hyperbaric (0.08ml.kg ) (0.06ml.kg-1)
-1
bradycardia or hypotension. A few studies of SA in newborns tetracaine 0.5 %

have noted hypotension ten minutes after injection of the local
anaesthetic. Cardiovascular changes due to spinal block are
generally short lasting and respond to a bolus of intravenous fluid
(10ml.kg-1).14 Cardiovascular stability in infants undergoing SA
is probably related to smaller venous capacitance in the lower
limbs leading to less blood pooling, and to relative immaturity of
the sympathetic nervous system resulting in less dependence on
vasomotor tone to maintain blood pressure.
Respiratory effects of SA
Respiratory effects of SA are generally seen in association with high
motor block above T6.5 Children with severe chronic lung disease
should receive supplemental oxygen or Continuous Positive Airway
Pressure (CPAP) during SA. Figure 1. Lateral position to perform SA in 4kg newborn

should be used, with a sterile work surface for equipment. The COMPLICATIONS OF SA
operator should use sterile gloves, gown and mask and the patients There are a number of potential complications of SA that are listed
skin should be cleaned with an alcoholic solution such as 0.5% or below:
2% chlorhexidine (+/- iodine). The skin should be allowed to dry and Potential traumatic puncture with spinal damage.
a sterile sheet should be placed over the child with a hole to reveal the Careful technique with the appropriate equipment and a trained
field. The dose of local anaesthetic solution is calculated according to assistant is essential
the weight of the child and is shown in Table 2;5 the drugs should be
drawn into a 1-2ml syringe as appropriate and placed on the sterile Respiratory (+/-cardiovascular) insufficiency due to high SA or
work surface in preparation for use. secondary to intravenous sedation. Resuscitation measures must
be taken (ABC) - tracheal intubation and volume resuscitation
Both the sitting or lateral decubitus position have been described for may be required.
lumbar puncture.4,5 We have great experience of the lateral position
Convulsions due to overdose of local anaesthetic. All doses
for awake neonates or infants but careful attention must be directed at
should be calculated carefully and checked with another
maintaining patency of the airway which may be compromised with
practitioner.
overzealous positioning (Figure 1). The lateral position may be easier
than the sitting position for older patients for whom intravenous Post dural puncture headache. This has been reported in children >8
sedation with a benzodiazepine such as midazolam may be indicated. years old, but the incidence in younger children is unknown,
in part since headaches in infants and young children are difficult
Lumbar puncture is performed at L3-L4 or L4-L5 level. Various sizes to assess.5,16
and lengths of needles are available depending on the childs age.
We use a 25G or 26G needle with stylet for neonates and infants Infectious complications such as meningitis. The incidence of
(Figure 2). Using a needle without a stylet is not recommended since meningitis is very low careful aseptic technique must be used at all
epithelial tissue can be deposited in the intrathecal space and may times and multidose ampuoles of local anaesthetic must never
cause dermoid tumours of the neural axis. be used. We suggest repeating lumbar puncture in patients who
develop fever after SA.4,5
Figure 2. Different types of SA needles
Neurological injury due to injection of incorrect solutions.
A free flow of cerebrospinal fluid should Great care must be taken at all times in preparation and checking
be obtained when the spinal needle is of drugs.
advanced into the intrathecal space. The
local anaesthetic syringe is attached and CONCLUSION
the anaesthetic solution is injected over In our experience, the incidence of serious complications associated
30 seconds (Figure 3). The legs should not with SA is very low, even in small premature infants. We think that
be lifted after the spinal injection has been this technique provides a good alternative to general anaesthesia
administered, otherwise an excessively in newborns with increased anaesthesia-related risk and for infants
high block will develop. undergoing lower abdominal or lower extremity surgery during the
first 6 months of life. SA may be used to avoid GA in patients outside
the neonatal period, if needed combined with intravenous sedation.
SA is most successful as a single shot technique, limited to surgery
lasting less than 90 minutes. SA in children requires the technical
skills of experienced anaesthesia providers. Neonates and infants are
at high risk of complications during surgery, irrespective of the type
of anaesthesia, and the presence of clinician trained in paediatric
anaesthesiology is mandated.
Figure 3. Lumbar puncture and LA injection with 1ml syringe REFERENCES

Troncin R, Dadure C. Paediatric spinal anaesthesia. Update in Anaesthesia
SA may produce a degree of sedation in newborns and infants so (2009);25(1):22-24 Available from: http://www.wfsahq.org/components/
com_vir tual_librar y/media/b11bcbd8ca5b2fcdd6762e26503838b0-
additional intravenous sedation is not required.15 Intravenous bd58f3feb0a0db474a5ea3c41f4f0431-Paediatric-Spinal-Anaesthesia.pdf
sedation should be avoided if at all possible in infants at risk of
1. Tyrell-Gray H. A study of spinal anaesthesia in children and infants.
apnoea. We find that a dummy dipped in sucrose or honey will help Lancet 1909; 2: 913-7.
to settle these infants.
2. Abajian JC, Mellish RW, Browne AF, Perkins FM, Lambert DH, Mazuzan
JE. Spinal anesthesia for surgery in the high risk infant. Anesth Analg
Postoperative care 1984; 63: 359-62.
In our hospital, children are discharged from the post anaesthesia 3. Welborn LG, Rice LJ, Hannalah RS, Broadman LM, Ruttimann VE, Fink R.
care unit when the block disappears, i.e. free lower limb movement Post-operative apnea in former infants: prospective comparison of
returns. Children are allowed to feed on demand, provided there spinal and general anesthesia. Anesthesiology 1990; 72: 838-42.
are no surgical restrictions. All infants younger than 60 weeks post 4. Tobias JD. Spinal anaesthesia in infants and children. Paediatric
conception are monitored on the ward for 24 hours after SA. Anaesth 2000; 10: 5-16.

5. Dalens B, Veyckemans F. Trait dAnesthsie Loco-Rgionale, de la 11. Arthurs, Murray M, Zubier M, Tooley J, Kelsall W. Ultrasonographic
naissance lge adulte. Montpellier: Sauramps Mdical 2008, determination of neonatal spinal canal depth. Archives of Disease in
463-512. Childhood - Fetal and Neonatal Edition 2008; 93: 451-4.
6. Dalens B, Tanguy A. Intrathecal morphine for spinal fusion in children. 12. Dohi S, Naito H, Takahashi T. Age-related changes in blood pressure
Spine 1988: 13: 494-7. and duration of motor blockade in spinal anesthesia. Anesthesiology
1979; 50: 319-23.
7. Gall O, Aubineau JV, Bernire J, Desjeux L, Murat I. Analgesic effect
of low dose intrathecal morphine after spinal infusion in children. 13. Oberlander TF, Berde CB, Lam KH, Rappaport LA, Saul JP. Infants tolerate
Anesthesiology 2001; 94: 447-52. spinal anesthesia with minimal overall autonomic changes: analysis of
heart rate variability in former preterm infants undergoing hernia
8. Berde C, Sethna N, Conrad LS, Hershenson MB. Subarachnoid repair. Anesth Analg 1995; 80: 20-7.
bupivacaine analgesia for seven months for a patient with a spinal
cord tumour. Anesthesiology 1990; 72: 1094-6. 14. Mahe V, Ecoffey C. Spinal anesthesia with isobaric bupivacaine in
9. Kowalewski R, MacAdams C, Froelich J, Neil S, Maitland A. Anesthesia infants. Anesthesiology 1988; 68: 601-3.
supplemented with subarachnoid bupivacaine and morphine 15. Disma N, Tuo P, Astuto M, Davidson AJ. Depth of sedation using cerebral
for coronary artery bypass surgery in a child with Kawasaki disease. J index in infants undergoing spinal anaesthesia. Pediatric Anesthesia
cardiothor Vasc Anesth 1996; 10: 243-6. 2009; 19: 133-7.
10. Blaise GA, Roy WL. Spinal anaesthesia for minor paediatric surgery. 16. Wee LH, Lam F, Cranston AJ. The incidence of post dural puncture
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Principles of clincial anaesthesia
Paediatric difficult airway management
Michelle C White* and Jonathan M Linton

*Correspondence email: mcwdoc@doctors.org.uk
INTRODUCTION intubation is more common in children with cleft lip

Airway management in children is generally and palate (4.7%) and cardiac abnormalities (1.25%),
straightforward in experienced hands. Problems are most likely related to associated syndromes or limited
more common for the non-paediatric anaesthetist, cardiac reserve.
and are a major cause of anaesthesia-related morbidity
An audit of difficult airway management in the UK
and mortality. Genuine difficult airways are rare in
Summary in 2001 (the 4th National Audit Project, NAP 4),
children compared to adults and many are predictable.
prospectively measured major airway complications
However, differences in adult and paediatric physiology
Unexpected difficult airways in almost 115,000 patients undergoing anaesthesia.2
mean irreversible hypoxic damage occurs more quickly
in paediatric practice are Children comprised a small proportion of the total
rare. Many problems can be
in children if there is an airway problem. Simple step-
population, and complications were rare (only 7-8%
prevented by routine pre- wise strategies are essential. Many guidelines exist for
of total complications).
operative airway assessment, the management of difficult airways in adults, but there
pre-oxygenation, and are few specifically designed for use in children. Common contributing factors to bad outcomes were:
preparation of equipment. A
simple step-wise approach
The aim of this article is to outline the basic principles Poor airway assessment
to management improves of paediatric airway assessment and to discuss the
management of unexpected and expected difficult Poor planning
outcome. Anaesthetists have
a responsibility to be familiar paediatric airways. Failure to plan for failure
with airway algorithms
Evidence to support best practice is difficult to obtain Repeated attempts at intubations
and make pragmatic
modifications to account for for unpredictable events such as management of the
paediatric difficult airway, and there is a lack of high Lack of monitoring (oxygen saturation and
available resources.
quality data. Many new devices and techniques are capnography)
available, but most are evaluated in healthy children Slow response to hypoxia resulting in bradycardia
or simulated difficult situations. Due to this lack of leading to cardiac arrest
evidence, guidelines are often based on a consensus of
expert opinion, which may have a bias against newer Failure to use devices such as the laryngeal mask
devices and techniques, or indeed bias towards the airway (LMA) when faced with a difficult
latest technique that has gained popularity. This review intubation.
takes a pragmatic and cautious approach in applying One of the key findings in NAP4 was the failure to
existing guidelines to settings where experts and a range plan for failure. Airway management plans should
of technology are not always available. always include a back-up plan to use if the first plan
fails. Whenever unexpected difficulties occur, seek
BACKGROUND experienced help immediately. Another key finding
Management of the difficult airway can be divided into of NAP4 was that repeated attempts at intubation can
three critical areas: cause severe airway oedema in children and worsen the
Dr Michelle White,
1. Difficult mask ventilation situation, hence their recommendation, a change of
Consultant Anaesthetist,
approach is required, not repeated use of a technique
Mercy Ships 2. Difficult tracheal intubation
that has already failed.
Guinea
3. Cant intubate and cant ventilate (CICV).
Many countries have adult guidelines for management
Dr Jonathan Linton, The incidence of difficult airways in children each of difficult airways, but few have child specific
Specialist Trainee is unknown. The incidence of impossible mask guidelines. The Association of Paediatric Anaesthetists
Anaesthesia, ventilation is reported as 0.15%, and is more frequently of Great Britain and Ireland (APA) published paediatric
University Hospital encountered by inexperienced paediatric anaesthetists. guidelines in 2012, which are shown in Figures 1-3
Southampton, Difficult intubation ranges from 0.05%, rising to and form the basis for management of the unexpected
UK 0.57% in children less than one year of age.1 Difficult difficult airway discussed here.3

AIRWAY ASSESSMENT Due to a lower functional residual capacity (FRC) and higher
Proper airway assessment, proper planning for airway management, metabolic rate, oxygen saturation falls much faster in infants and
and the use of monitoring are essential basic principles for safe young children than adults. Preoxygenation before induction of
anaesthesia in children. anaesthesia establishes a reservoir of oxygen in the lungs by displacing
nitrogen. This means a patient can remain oxygenated for longer than
Airway assessment may be considered in two parts:
otherwise expected, which gives more time to address unexpected
Will facemask ventilation be difficult? airway problems. Therefore preoxygenation is an important part of the
A tumour or abnormal face shape may prevent the facemask from airway management plan and should form part of normal anaesthetic
sealing easily over the face. practice wherever possible, even in children.
Syndromes associated with midface hypoplasia THE UNEXPECTED DIFFICULT AIRWAY
Children with severe obstructive sleep apnoea (e.g. tonsillar Problems with airway management may be due:
hypertrophy). 1. Difficult mask ventilation
Will intubation be difficult? 2. Difficult tracheal intubation
Factors that may predict difficult intubation in children include:
3. Cant intubate and cant ventilate (CICV).
Mandibular hypoplasia e.g. syndromes such as Pierre Robin
The first step is to administer 100% oxygen and call for help. Another
Poor mouth opening pair of hands is always useful.
Obstructive sleep apnoea The next step is to consider is this a problem with the equipment or
Stridor the patient? All equipment should be checked prior to induction of
anaesthesia to minimise the chance of equipment failure.
Syndromes associated with facial asymmetry. Note ear
abnormalities are often associated (e.g. Goldenhar syndrome). 1. Difficult mask ventilation
A simple algorithm for the management of difficult mask ventilation
Various tests and scoring systems have been suggested for use in is given in Figure 1: Difficult mask ventilation algorithm. http://
adults. Many have a very poor sensitivity and/or specificity and are www.apagbi.org.uk/sites/default/files/images/APA1-DiffMaskVent-
not validated in children. However, assessment of the following is FINAL.pdf
essential. The anaesthetist may need some ingenuity to achieve these
assessments in a small uncooperative child! Difficult mask ventilation equipment problems
Equipment failure should be excluded quickly check the mask,
Mouth opening
circuit, and oxygen supply. Always have a self-inflating bag available
Range of neck movement in case of equipment problems.
Mandibular hypoplasia - micrognathia makes intubation difficult. Difficult mask ventilation patient factors
Assess the airway by observing the child in side view rather than These can be divided into anatomical or functional problems.
from the front.
Anatomical problems associated with difficult mask ventilation may
Mandibular hyperplasia - ameloblastoma may cause jaw be due to poor head positioning, large adenoids/tonsils, or due to
protrusion and can make laryngoscopy and intubation difficult airway obstruction from cricoid pressure (if used).
Inspection of the oral cavity (e.g. for intraoral masses). Functional problems may arise in the upper or lower airways. Upper
The Mallampati score can be used for older children who are airway obstruction may be due to inadequate depth of anaesthesia and
cooperative. Even though there is no validated scoring system in infants laryngospasm; lower airway problems include inflation of the stomach
and young children, the anaesthetist must still make a risk assessment, (very common in infants), bronchospasm or chest wall rigidity (rare).
and decide on the anticipated difficulty of intubation. This airway Management of difficult mask ventilation:
assessment must be documented in the anaesthetic record.4
Adjust the head position does the child need a head roll (or
PLAN FOR AIRWAY MANAGEMENT should the head roll be removed)
After airway assessment, a structured plan for airway management Use simple airway opening manoeuvres (chin lift, jaw thrust)
is required before induction of anaesthesia. The plan must consider:
Apply positive end expiratory pressure (PEEP)
Choice of airway e.g. facemask, supraglottic airway device or
tracheal tube Adjust cricoid pressure if it has been used
Mode of ventilation e.g. spontaneous ventilation or positive Insert an oropharyngeal airway (if the patient is deep enough)
pressure Increase depth of anaesthesia
Monitoring e.g. pulse oximeter (minimum); end tidal carbon Ventilate using a two-person technique (one holding the mask
dioxide. with two hands, the other ventilating by squeezing the bag)

Figure 1: Difficult mask ventilation algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists from: http://
www.apagbi.org.uk/sites/default/files/images/APA1-DiffMaskVent-FINAL.pdf
Pass a nasogastric tube to deflate the stomach. Change of personnel (a more senior anaesthetist);
If mask ventilation is impossible despite all the above measures or the Change of position
childs oxygen saturation begins to fall: Change of equipment.
EITHER insert an LMA (if available), Visualisation of the larynx and successful tracheal intubation are
improved by:
OR deepen anaesthesia, attempt to visualise the vocal cords and
intubate the trachea. Proper positioning of the child,
External laryngeal manipulation
There is no randomised controlled trial to assess which is the best
Adequate depth of anaesthesia and adequate muscle paralysis (if
response, but insertion of an LMA is recommended first, and then
this has been used).
intubation (Figure 1).
Simple aids such as a bougie or stylet may make intubation
If oxygenation and ventilation is satisfactory through the LMA or straightforward even when the view of the larynx is poor. An alternate
tracheal tube then it is safe to proceed with surgery. laryngoscope may also be used if available and if the operator is familiar
If in doubt, wake the child up. with its use.
Straight bladed laryngoscopes are traditionally used in children under
2. Unexpected difficult tracheal intubation
one year old, but may be useful in older children, or in patients
A simple algorithm for the management of unexpected difficult
with relative macroglossia. They can be used with a paraglossal or
tracheal intubation is given in Figure 2: Difficult tracheal intubation
retromolar technique. McCoy levering laryngoscopes are also available
algorithm. http://www.apagbi.org.uk/sites/default/files/images/APA2-
for paediatric use, based on a Seward blade (sizes 1 and 2) and may
UnantDiffTracInt-FINAL.pdf
improve the view of the larynx, particularly if the view is obstructed
The key point is, if tracheal intubation fails, DO NOT simply repeat by a large epiglottis.
what has just failed. Multiple attempts at intubation may traumatise In addition to straight bladed and McCoy laryngoscopes, new alternate
the airway and will cause airway oedema, which may make the child laryngoscopes have been developed recently (see table 1). High quality
impossible to intubate. Intubation attempts must be limited to a evidence supporting efficacy is largely absent in the life-threatening
maximum of three or four (Figure 2). scenario of unexpected failed intubation. Firm recommendations
If the first intubation attempt fails, it is essential to make changes cannot be made so many algorithms suggest alternate laryngoscopes/
that improve the chance of successful intubation. These may include: techniques should be considered.

Figure 2: Difficult tracheal intubation algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists from:
http://www.apagbi.org.uk/sites/default/files/images/APA2-UnantDiffTracInt-FINAL.pdf
Table 1. Classification of rigid indirect laryngoscopes
Classification Description of technique Examples
Non-guided devices Provide an indirect view of larynx but require direction Bullard laryngoscope
of tracheal tube towards larynx. Glidescope
Storz DCI Videolaryngoscope
Storz C-MAC laryngoscope
Guided devices Provide indirect view and act as a conduit for passage Airtraq
of tracheal tube.
Optical stylets Provide indirect view via rigid or semi-rigid stylet, with Bonfils and Brambrink
a loaded tracheal tube for railroading. Shikani
Lightwand
Alternate techniques conduit for fibreoptic intubation (FOI) where necessary, or in older
Traditional laryngoscopes (curved, straight or McCoy levering blades) children, the specifically designed intubating LMA, may be used.
give a direct view of the larynx. Alternate techniques use an indirect
approach with flexible or rigid equipment. If LMA insertion fails, then oxygenation and ventilation must be
provided by mask ventilation.
Flexible indirect laryngoscopy, in the form of fibreoptic intubation,
is the established gold standard for the management of the 3. Cannot intubate, cannot ventilate (CICV) - rescue
predicted difficult airway in adults (see below). techniques
A simple algorithm for the management of cannot intubate, cannot
New rigid indirect laryngoscopes are available, including in ventilate is given in Figure 3 : Cant intubate cant ventilate algorithm.
paediatric sizes. Rigid indirect laryngoscopy has a place in the http://www.apagbi.org.uk/sites/default/files/images/APA3-CICV-
unexpected difficult tracheal intubation algorithm. The choice of FINAL.pdf
device depends on local availability and expertise.
Rescue techniques for the CICV situation have been extensively
If visualising the larynx is impossible, then an LMA should be inserted. researched in the adult literature, but their use in paediatric emergencies
LMAs provide a clear airway in the vast majority of children. This is more anecdotal than evidence-based. The choice is between a surgical
allows delivery of ventilation, oxygenation and anaesthetic gases with or needle (cannula) technique for cricothyroidotomy. The technique
a lower risk of gastric insufflation. The LMA may also be used as a for cannula cricothroidotomy is shown in Figure 3, and for surgical

Figure 3: Cant intubate cant ventilate algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists from:
http://www.apagbi.org.uk/sites/default/files/images/APA3-CICV-FINAL.pdf
Table 2. Technique for surgical cricothyroidotomy
1. Position the patient so that the neck is fully extended so that the trachea and larynx are pushed forward
2. Locate the cricothyroid membrane and stabilise the trachea
3. With a scalpel blade make a stab incision through the skin and cricothyroid membrane*
4. Insert a tracheal hook or retractor at the lower edge of the incision
5. Pass an appropriately sized tracheal or tracheostomy tube
6. Ventilate patient and assess effectiveness
7. Secure the tube
Arterial forceps, the scalpel blade and tracheal dilators may be used to dilate the orifice.
cricothyroidotomy, in Table 2. The cricothyroid membrane is much smaller, with an average size
Since there is no randomised controlled trial of one technique versus of only 2.6 x 3mm, smaller than the smallest tracheal tubes.
another, the choice should be determined by local experience and It is more difficult to locate the cricothyroid membrane than in
availability of equipment. This includes utilising the surgeon who may adults due to a differing orientation of the hyoid bone and the
be more experienced than the anaesthetist. Adult evidence suggests cricoid and thyroid cartilage. This orientation also increases the
surgical cricothyroidotomy is preferable, so this is recommended in chance of laryngeal trauma during cricothyroidotomy.
older children.
It is easier to locate the space between the tracheal rings rather
The important factor is that at least one technique is actually attempted than the cricothyroid membrane.
by someone in the CICV situation when the oxygen saturations are
Together these factors mean it may be more appropriate in infants
less than 80% and falling and/or the heart rate is decreasing.
and small children to perform a surgical tracheostomy.
The CICV situation is a particular challenge in infants and small
All rescue techniques have significant potential for complications so
children, due to important anatomical differences:
should only be performed in life threatening situations. Clearly, all the
The trachea is small, elastic, flaccid and mobile, and so prone to steps for difficult facemask ventilation should be tried first. If muscle
collapse during insertion of a transtracheal device. relaxants have been used and can be reversed, wake the child up.

THE EXPECTED DIFFICULT AIRWAY atropine is 90 minutes if given PO, 25 minutes if given IM.
If the preoperative airway assessment alerts the anaesthetist to expected
Anaesthetic technique
difficulties in airway management then there are three key questions:
The most important principle in managing the difficult airway in
1. Does the anaesthetist have the necessary paediatric airway children is to maintain spontaneous ventilation until the airway is
experience? secure.
2. Does the hospital have the necessary paediatric equipment?
Awake techniques require good patient co-operation, which is rarely
3. Does the relative benefit of the planned surgery outweigh the possible in children. Therefore, the child must be anaesthetised so the
possible risks of anaesthesia? choice is between an inhalational or intravenous technique. The variety
If there is any doubt, full discussion should take place with the parents of airway problems encountered in children means the anaesthetic
(or carers), child, surgeons and anaesthetists. It may be appropriate must be tailored to the individual situation:
for the child to be referred to specialist hospital or wait for a more Large extraoral tumours may mean a face mask will not fit
experienced paediatric anaesthetist to attend. the childs face, so an inhalational induction is impossible and IV
The anaesthesia plan must be carefully considered, including what to induction/sedation must be used instead.
do if tracheal intubation is unsuccessful; will the child be woken up, Large intraoral tumours prevent laryngoscopy and the use of an
or will a tracheostomy be necessary. The anaesthesia plan should be LMA - nasal fibreoptic intubation (FOI) should be used.
communicated clearly to the whole theatre team including surgeons
and nursing staff. Difficult airway equipment must be checked and Conditions such a noma (cancrum oris) often cause severe
prepared. limitation of mouth opening - nasal FOI is likely to be required.
The primary plan for management of the expected difficult paediatric Other problems such as partial mouth opening, severe retrongathia
airway will likely be one of the following: or bony abnormalities (ameloblastoma) often make laryngoscopy
difficult but do permit the insertion of an LMA if laryngoscopy
1. Laryngoscopy anticipated to be difficult but may be possible: proves impossible.
Attempt laryngoscopy and intubation. If fails, consider
repositioning and try alternate laryngoscopes if available, or insert Burns contractures causing fixed flexion of the neck may be
LMA and perform fibreoptic intubation (FOI) via LMA. released prior to intubation using ketamine anaesthesia and with
local infiltration.
2. Laryngoscopy predicted to be impossible: Perform nasal FOI or
insert LMA and perform FOI via LMA. The variety of clinical conditions mean a one-size-fits all approach is
impossible. The best technique will depend on the equipment and
3. Laryngoscopy and LMA insertion known to be impossible: expertise available, as well as the nature of the difficult airway.
perform nasal FOI.
Inhalational induction, using halothane or sevoflurane in 100%
4. Laryngoscopy, LMA insertion and nasal FOI not available
oxygen, is generally recommended Intravenous access may be
or known to be impossible: perform tracheostomy either using
established either before or after induction but must occur before
inhalational anaesthesia via face mask or intravenous ketamine
airway instrumentation. The general technique is to deepen anaesthesia
especially if face mask anaesthesia impossible.
until laryngoscopy is tolerated or LMA inserted or FOI performed
Blind intubation through an LMA is NOT recommended in children depending on the airway management plan.
due to risk of airway trauma. Attempts at FOI should be limited to two
and if unsuccessful, consider waking child, or continue with surgical If inhalational induction is impossible, small doses of IV induction
procedure on an LMA. In situations where LMAs are unavailable, agent should be given to induce loss of consciousness but still
ventilation by face mask is the alternative. If neither LMAs nor FOI preserving spontaneous ventilation. Propofol 0.5-1mg.kg-1 or ketamine
are available, the surgeon and anaesthetist need to discuss whether 0.5-1mg.kg-1 should be given and titrated to effect.
the benefits of surgery outweigh the risk of attempting anaesthesia
If inhalational induction is not possible due to pain, for instance, from
in a child with a known difficult airway with insufficient equipment
an infected facial mass/tumour (rather than because of a large extraoral
to provide safe management. This is a very difficult decision and will
tumour meaning a face mask will not fit), give a small dose of ketamine,
depend on the individual merits of each case.
then apply the face mask and deepen anaesthesia by spontaneous
Premedication inhalation with sevoflurane or halothane. In our experience, this
The use of sedative premedication in a child with a potential airway combination provides better conditions for laryngoscopy than when
problem is controversial. A frightened, screaming child producing using intravenous ketamine alone.
lots of secretions and in whom it is difficult to place monitoring,
Nasal fibreoptic intubation general
intravenous cannula, and even approach to do an inhalational
Maintain anaesthesia either with incremental doses of ketamine
induction, is also a risk.
or inhalational anaesthesia either via a nasal airway in the other
Therefore, a small dose of sedative premedication, such as midazolam nostril connected to the breathing circuit or using a specially
0.3-0.5mg.kg-1 is often appropriate. Atropine is useful as an antisialogue designed facemask with a port for insertion of the fibreoptic
(30-40 micrograms.kg-1 PO or 20 micrograms.kg-1 IM). Peak effect of bronchoscope.

Table 3. Size compatibility of tracheal tubes, bronchoscopes and LMAs
Tracheal tube size 2.5 3.0 3.5 4 4.5 5 6

Will fit through classic LMA size: 1 1 1.5 2 2 2.5 3
Will fit over bronchoscope Outer Diameter: 2.0mm 2.5mm 2.8mm 3.5mm 3.5mm 4.1mm 5mm
Will fit over AEC size: 7F 8F 8F 11F 11F 11F 14F

[Note: different brands of LMA vary in their internal diameter. It is important to determine the compatibility of equipment within your own department.]
Use a topical vasoconstrictor to prevent bleeding from the nose it is readily accessible in an emergency. Many hospitals use a difficult
during FOI, as otherwise this may make intubation impossible. airway cart to do this. This is simply a trolley or cart where all the
Pseudoephedrine, ephedrine, phenylephrine, oxymetazoline, or useful equipment for managing difficult airways is stored according
nasal packs soaked in 1:10,000 adrenaline may be used, depending to the step-wise approach to managing a difficult airway.
on local availability.
For example, using the algorithms presented in this review, the difficult
Apply topical lidocaine to the nose and oropharynx. Larger airway cart could consist of a series of drawers or boxes containing:
fibreoptic laryngoscopes often have a channel through which local
anaesthesia can be injected. Alternatively an epidural catheter can Drawer 1: simple laryngoscopes and airway adjuncts.
be passed through the suction port (if present) and local anaesthetic Drawer 2: alternative laryngoscopes and LMAs.
injected through this. Be careful not to exceed the maximum dose Drawer 3: equipment for fibreoptic intubation
of lidocaine (3mg.kg-1 i.e. 0.3ml.kg-1 of a 1% solution). Drawer 4: equipment for CICV situations.
The correct size of tracheal tube is critical to success. Too large a Whatever the availability and variety of equipment, the difficult airway
tube will fail and require the bronchoscope to be withdrawn and the cart (or boxes) should always be stored in the same place, close to the
procedure repeated. Too small may make subsequent positive pressure operating rooms, and the contents regularly checked. The cart should
ventilation difficult. It is sensible to use a small cuffed tube if available, be physically present in the operating room for any child with an
rather than repeated bronchoscopy. anticipated difficult airway; and can be quickly fetched when faced
Fibreoptic intubation through an LMA with an unexpected problem.
There are three main techniques available: CONCLUSION
1. Railroad the tracheal tube over the fibreoptic bronchoscope into Unexpected difficult airways in paediatric practice are rare. Many
the trachea problems can be prevented by routine pre-operative airway assessment,
2. Railroad an airway exchange catheter (AEC) over the bronchoscope pre-oxygenation, and preparation of equipment. A simple step-wise
into the trachea. approach to management improves outcome. Anaesthetists have
a responsibility to be familiar with airway algorithms and make
3. Pass a soft tip wire through the suction channel of the bronchoscope
pragmatic modifications to account for available resources.
into the trachea, then pass an AEC or similar over the wire as a
guide for the tracheal tube. REFERENCES
The choice of technique depends upon size of the child, the size of the 1. Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult
pediatric airway. Pediatr Anesth 2010; 20: 454-64. http://onlinelibrary.wiley.com/
LMA, and the diameter of available bronchoscope (Table 3). Removal doi/10.1111/j.1460-9592.2010.03284.x/pdf
of the LMA once the tracheal tube is in situ may be challenging. 2. The 4th National Audit Project of the Royal College of Anaesthetists and the
Options include: Difficult Airway Society: Major Complications of Airway Management in the
United Kingdom. March 2011. http://www.rcoa.ac.uk/nap4/
Leave the LMA in situ
3. The Association of Paediatric Anaesthetists (APA) Guidelines for difficult airway
Use a long tracheal tube (croup tube) management in children. 2012. http://www.apagbi.org.uk/publications/apa-
Fix two tracheal tubes together over the FOB; the LMA may be guidelines
withdrawn over the tracheal tubes. 4. World Health Organisation. Guidelines for Safe Surgery 2009. http://whqlibdoc.
who.int/publications/2009/9789241598552_eng.pdf and http://www.who.int/
Use an AEC. patientsafety/safesurgery/en/
5. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of
Tracheostomy impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiol 2009;
A tracheostomy should be performed by an experienced practitioner, 110 : 891-7.
normally an ENT surgeon. Inhalational anaesthesia or small 6. Holm-Knudsen R. The difficult pediatric airway - a review of new devices for
incremental doses of ketamine (as above) may be given to supplement indirect laryngoscopy in children younger than two years of age. Pediatr Anesth
local infiltration anaesthesia. The child should breathe 100% oxygen 2011; 21: 98-103
by facemask. 7. Doherty JS, Froom SR, Gildersleeve CD. Pediatric laryngoscopes and intubation
aids old and new. Pediatr Anesth 2009; 19 (Suppl. 1): 30-37 http://onlinelibrary.
wiley.com/doi/10.1111/j.1460-9592.2009.03001.x/pdf
DIFFICULT AIRWAY CART
8. Walker RWM and Ellwood J. The management of difficult intubation in children.
The equipment available in different institutions will vary considerably. Pediatr Anesth 2009; 19 (Suppl. 1): 7787 http://onlinelibrary.wiley.com/
It is good practice to organise airway equipment in such a way that doi/10.1111/j.1460-9592.2009.03014.x/pdf

Elective Procedures
Neonatal anaesthesia
Heidi Meyer and Karmen Kemp*

*Correspondence Email: karmen.kemp@uct.ac.za
INTRODUCTION Examination
Neonates present a challenge to the anaesthetist. Examine the child carefully. In particular, it is
They have unique physiology as they transition important to look for signs of respiratory distress
from intrauterine to extrauterine life, limited (respiratory rate, nasal flare, subcostal recession),
physiological reserve and immature drug and cardiovascular compromise (check heart DEFINITIONS
handling. The goals of anaesthesia are to rate, blood pressure, peripheral perfusion and
provide stable conditions for surgery, minimise capillary refill). Check the oxygen saturation Neonate is aged up to
physiological disturbance, reduce pain, and low oxygen saturation may be associated with 28 days
support the neonate during the postoperative respiratory disease, or in some cases with cyanotic Term neonate is born
period. This article will describe general congenital heart disease. between 37 to 40
considerations for anaesthesia in term and weeks post
Investigations conception
preterm neonates, and anaesthesia for some
specific neonatal conditions. Relevant investigations will be guided by the Preterm neonate is
clinical findings and the underlying condition, born at <37 weeks
PREOPERATIVE ASSESSMENT OF THE although resources may limit investigations post conception
NEONATE that can be performed. They may include the Extreme preterm
As for any child undergoing anaesthesia, following: neonate is born <28
weeks post
it is important to take a detailed history
Laboratory investigations: conception
and examination, together with relevant
Full blood count and haemtocrit Low birthweight
investigations to assess the current physiological
<2.5kg
status and the impact of any associated congenital Blood glucose
abnormalities, which may or may not be related Very low birthweight
to the surgical condition. This helps to plan when Urea and electrolytes <1.5kg
best to proceed with the surgery, and the level of
Coagulation studies
postoperative support required.
Liver function tests and bilirubin
History
The history should include the gestational Capillary blood gas.
age, birth history, current age and weight, and
Radiological investigations:
significant peri-natal events such as low APGAR
scores, respiratory distress requiring respiratory CXR, AXR
support, hypoglycaemic episodes, NICU Heidi Meyer
admissions, evidence of sepsis or any antenatal Echocardiogram
Karmen Kemp
concerns such as maternal illness. The anaesthetist Cranial/spinal/renal ultrasound. Red Cross War Memorial
should check whether intramuscular vitamin K Childrens Hospital
has been given to prevent haemorrhagic disease Finally, the anaesthetic plan, including risks, Rondebosch
of the newborn. The fasting status should be should be discussed with the parent(s) or Cape Town 7700
established if the child is receiving feeds - ideally guardian(s), and consent taken for anaesthesia Western Cape
2 hours for clear fluids, 4 hours for breast milk, 6 including regional anaesthesia and blood Cape Town
hours for formula feed. transfusion if indicated. South Africa

GENERAL PRINCIPLES OF ANAESTHESIA IN NEONATES a size 3.5 tracheal tube (see Table 1). Make sure that strapping
It is important to prepare and check all equipment that may be is available. Precut the tape to fix the tracheal tube firmly in
required, prior to the start of anaesthesia (see Figure 1). place immediately after intubation. An appropriately sized oral
airway (preterm 000 00 and term neonate 0) and face mask
should be available. Dead space within the apparatus is kept
to a minimum with the appropriate sized breathing circuit and
filter.
Warming
Neonates are extremely vulnerable to heat loss and
hypothermia. Hypothermia (core temperature <36C) is
associated with postoperative apnoeas, coagulopathy and
poor wound healing, and worsens outcomes. The theatre
environment should be warmed (or air conditioning turned
down) to at least 20-23C and the baby kept covered as much
as possible. A forced air warmer and a radiant heater should
be used if available. Warmed packs should be considered if
other sources of warming are not available; take care not to
place warmed packs directly in contact with the skin. Fluids
Figure 1. Airway and monitoring equipment and blood products should be warmed. The temperature of the
baby should be measured unless the procedure is very quick.
Monitoring
Standard monitoring must be applied prior to induction of Preparation of drugs
anaesthesia. This includes oxygen saturation, ideally pre-ductal The first thing to be drawn up is a saline flush so that the IV
(right hand) and post-ductal (other limbs). A low post-ductal line can be flushed immediately after a drug is given. Calculate
oxygen saturation may be a sign of low pulmonary blood flow, the correct dose of analgesics, muscle relaxants and antibiotics
for instance due to significant pulmonary hypertension in a and draw these up. Double check dose calculations it is easy
septic neonate (see transitional circulation below). to make 10-fold errors in neonatal practice.
ECG and non-invasive blood pressure measurement should Emergency drugs should be drawn up in the appropriate
be used. The lower limit of mean arterial blood pressure can doses. These include atropine (20mcg.kg-1), suxamethonium
be estimated to be equivalent to the gestational age in weeks; (1-2mg.kg-1) and adrenaline (10mcg.kg-1, i.e. 0.1ml.kg-1
by about 6 weeks of age, the normal mean arterial pressure is 1:10,000 adrenaline).
50-60 mmHg. Basic intra-operative monitoring should ideally
also include a precordial or oesophageal stethoscope and, if Induction of anaesthesia
available, capnography must be used. Inhalational induction is ideally with sevoflurane although
halothane can also be used. The MAC of volatile agents is
Airway equipment lower in neonates than in older children, and the onset of
Intubation and ventilation will be required unless it is an anaesthesia is relatively fast due to the rapid respiratory rate
extremely short procedure. The size of the tracheal tube will and high cardiac output. However, the neonatal myocardium
depend on the weight of the neonate; most term babies require is extremely sensitive to the negative inotropic effects of volatile
Table 1. Uncuffed tracheal tube sizes and lengths in neonates
Weight Tube Size (ID) (MM) Oral Length (cm) Nasal Length (cm)
<0.7 2.0 5 5
<1.0 2.5 5.5 7
1.0 3.0 6 7.5
2.0 3.0 7 9
3.0 3.0 8.5 10.5
3.5 3.5 9 11

agents, so deep volatile anaesthesia must be avoided. used where possible. Non-steroidal anti-inflammatory drugs
(NSAIDs) should be avoided because of the immature renal
Sevoflurane can cause apnoea at high concentrations and the
system. Non nutritive sucking, sucrose and breast milk have
induction concentration should not exceed 6%. The neonate
also been shown to be safe and effective for reducing pain
might require assisted mask ventilation until an airway is
associated with procedures such as cannulation.4,5
secured as they may hypoventilate during induction; take care
to turn the inspired concentration of volatile agent down if Invasive monitoring
assisted ventilation is used, otherwise the child will become Invasive monitoring (intra-arterial and central venous pressure)
very deep, very quickly. Halothane is more likely to cause may be indicated depending on the type of surgery and the
myocardial depression and the induction concentration should physiological status of the patient. Invasive monitoring is
be kept less than 2%. Halothane can cause arrhythmias in high mandatory in circumstances such as cardiac surgery where
concentrations, especially if the CO2 is also high. Atropine there is the potential for rapid changes in blood pressure, use
(20mcg.kg-1 IM or IV) should be considered prior to induction of inotropes or potential for large volume blood loss. In other
to reduce bradycardia, particularly if halothane is used. circumstances, for instance neonatal laparotomy, the risks/
Alternatively, intravenous induction with ketamine benefits should be considered. Invasive monitoring is time
(2mg.kg-1) or thiopentone (2-4mg.kg-1) can be performed; consuming to insert, associated with complications and may
induction of anaesthesia will be rapid (the anaesthetist must delay the start of surgery. If the surgery is sufficiently urgent it
be confident they can manage the airway), and recovery may may be necessary to proceed without. 24G or 22G catheters
be delayed. Ketamine is particularly useful for the critically may be inserted into radial or femoral arteries for arterial
unwell neonate as cardiovascular depression is minimised. Use monitoring, but distal limb perfusion must be checked. 4Fr or
glycopyrrolate (10mcg.kg-1 IV) or atropine (20mcg.kg-1 IV or 5Fr central lines may be inserted into the femoral or internal
IM) to minimise the secretions caused by ketamine. jugular vein, ideally with ultrasound guidance. Near infrared
spectroscopy (NIRS) can be used, if available, as a non-invasive
Maintenance of anaesthesia monitor of tissue perfusion.6
Anaesthesia is maintained with volatile, oxygen and air or
nitrous oxide. A ketamine infusion run at 2-4mg.kg.hr-1 is a Oxygen
useful alternative in unstable neonates. Unmonitored oxygen therapy leading to hyperoxia in
neonates is associated with retinopathy of prematurity,
Attention must be paid when positioning the patient and bronchopulmonary dysplasia and damage to the developing
pressure points must be protected. Whenever the child is brain. Neonatal exposure to 100% oxygen is rarely necessary,
moved, check the position of the tracheal tube as it is very easy and should be avoided except prior to interventions such
to displace the tracheal tube in neonates, which could have as intubation. Hypoxia is also harmful, so targeting oxygen
potentially catastrophic consequences. saturation levels between 91% and 95% is probably the safest
practice.7-9 In low income countries where it may not be
Pain management possible to deliver a variety of inspired oxygen mixtures, an air/
It is important to consider pain management in all neonates. oxygen mix should be used if possible and oxygen saturations
Pain pathways are fully developed before birth, and neonates should be monitored before, during and after anaesthesia.
display the physiologic, hormonal, and metabolic markers of
the stress response.1 Preterm infants have been shown to have Postoperative apnoea
an increased sensitivity to pain and even non-painful stimuli Apnoea can be defined as a pause in breathing of more than 20
may be perceived as painful.2 Long-term effects on pain seconds or cessation of respiration of any duration accompanied
responses have been documented in neonatal boys who were by bradycardia or oxygen desaturation. Preterm infants are
circumcised without analgesia.3 However, immature metabolic particularly at risk apnoeas due to an immature respiratory
pathways for drugs and immature respiratory control mean control centre. This effect is potentiated by general anaesthetic
that neonates are more sensitive to the side effects of analgesics agents, and all term neonates <44 weeks post-conceptual age
commonly used during surgery. (PCA) and pre-term neonates (<60 weeks PCA) are at risk
Multimodal analgesia should be used for all neonates. Options of postoperative apnoea. Infants with multiple congenital
include paracetamol (7.5mg.kg-1 IV, or 20mg.kg-1 PR), opioids abnormalities, a history of apnoea and bradycardia, chronic
such as fentanyl or morphine titrated to effect (fentanyl lung disease and anaemia (Hb <10g.dl-1) are at particular risk
1mcg.kg-1 IV, morphine 10-20mcg.kg-1 IV). Regional for postoperative apnoeas.10
anaesthesia or infiltration of local anaesthetics should be Prophylactic caffeine (10mg.kg-1 orally) can be given to prevent

post-operative apnoea in premature neonates.11 Intravenous Intraoperative fluids
aminophylline (5mg.kg-1) is an alternative although it has During surgery, isotonic fluids such as Hartmanns or Ringers
more side effects including tachycardia, jitteriness, irritability, lactate must be used for resuscitation, replacement and
feed intolerance, vomiting and hyperglycaemia. maintenance to maintain intravascular fluid volume, replace
fluid deficits and avoid hyponatraemia. Blood glucose should
It is important to allow sufficient time for neonates to wake be monitored.
up at the end of the operation, and they should be closely
The decision whether to order or administer blood or blood
monitored in recovery until the anaesthetist is happy that they
products will depend on the cardiovascular status of the
have returned to their normal awake state. All neonates <44
neonate, presence of haemorrhage, type of surgery, the most
weeks post-conceptual age (PCA), ex-preterm infants up to 60
recent blood results and the normal expected values (Table
weeks PCA and any patients with whom there is any concern
3). Once the decision to transfuse has been taken it may
regarding the possibility of post-operative apnoeas should have
be worth transfusing to higher haemoglobin levels to avoid
post-operative apnoea and oxygen saturation monitoring for
exposure to further donors. Ideally, the haematocrit should
24 hours.
be measured during surgery using near-patient testing device
Hypoglycaemia and hyperglycaemia such as a HemoCue or a blood gas machine. The British
Persistent, recurrent or severe hypoglycaemia (blood glucose Committee for Standards in Haematology (BCSH) has a
<2.5mmol.l-1) may lead to irreversible neurological injury in suggested transfusion trigger for neonatal top-up transfusion
neonates. Preterm infants and those with intrauterine growth (Transfusion Guidelines for Neonates and Older Children
retardation (IUGR) are at particular risk of hypoglycaemia. (http://www.bcshguidelines.com) (see Table 4). Suggested
Fasting times should be minimized, blood glucose should be transfusion doses for blood and blood products are described
monitored and glucose containing maintenance fluids should in Table 5.
be continued if they have been required prior to surgery. Transitional circulation
In utero, the pulmonary vascular resistance is high and there
Treat hypoglycaemia with a bolus of 2ml.kg-1 of 10% is very little blood flow to the lungs as the placenta is the
dextrose. Hyperglycaemia (blood glucose >10mmol.l-1) is also source of gas exchange. After birth as the neonate takes the
detrimental and is associated with increased mortality and first few breaths, a chain of events is set in place that results
sepsis in extremely low birth weight infants, so do not use in the transition from the foetal circulation to the neonatal
boluses of 50% glucose.12 circulation with closure of the foetal shunts (foramen ovale,
ductus venosus and ductus arteriosus). During the first few
Perioperative fluids weeks of life the pulmonary vasculature is highly reactive; an
Assessment of the fluid status of the neonate will help to guide increase in pulmonary vascular resistance can lead to reopening
peri-operative fluid replacement. It is helpful to consider of the foetal shunts, in particular the arterial duct between the
preoperative maintenance fluids, intraoperative fluids and pulmonary artery and the aorta. As a result there is right-to-
postoperative maintenance. left shunting from the pulmonary artery (deoxygenated blood)
to the aorta, causing profound hypoxia. The oxygen saturation
Preoperative maintenance fluids measured in the right hand may be normal (pre-ductal); the
A neonate may require preoperative maintenance fluids if oxygen saturation in the other limbs (post-ductal) will be low.
they are unable to take fluids by mouth before surgery. In During the perioperative period it is important to prevent
the first few days of life, the sodium requirement is not high, factors that increase pulmonary vascular resistance such as
and typically 10% dextrose is recommended. After the post- sepsis, hypoxia, acidosis, hypercapnoea, pain and hypothermia.
natal diuresis has occurred at around day 3 of life, an isotonic When post-ductal oxygen saturations drop in relation to
fluid containing 5% dextrose and sodium should be used, and preductal oxygen saturations it may indicate a return to a
electrolytes and plasma glucose monitored (Table 2). foetal circulation.
Table 2. Routine maintenance fluids in neonates
Day 1 of life 2ml.kg.hr-1 (50ml.kg.day-1)

Day 2 of life 3ml.kg.hr-1 (75ml.kg.day-1)
Day 3 of life and thereafter 4ml.kg.hr-1 (100ml.kg.day-1)

Table 3. Normal haematological ranges for term and preterm babies (adapted from United Kingdom Blood Services Handbook of
Transfusion Medicine, p54 4th Edition 2007 TSO)
Term Preterm Adult

Haemoglobin g.l -1
140 - 240 140 -240 115 - 180
Platelets x 10 .l
9 -1
150 - 450 150 -450 150 - 400
PT (sec) 10 -16 11 - 22 11 - 14
APTT (sec) 31 - 55 28 - 101 27 - 40
Table 4. The British Committee for Standards in Haematology (BCSH) transfusion trigger for neonatal top-up transfusion
- reproduced from British Committee for Standards in Haematology (BCSH) Transfusion Guidelines for Neonates and Older Children -
http://www.bcshguidelines.com with permission
Postnatal age Suggested transfusion threshold (g.l-1)

Ventilated On oxygen/CPAP Off oxygen
First 24 hours <120 <120 <100
week 1 (days 1-7) <120 <100 <100
week 2 (days 8-14) <100 <95 <75-85
week 3 (days 15 onwards) <85 Depending on clincial situation
Table 5. Suggested transfusion doses for blood and blood products

(Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee http://www.
transfusionguidelines.org/transfusion-handbook/10-effective-transfusion-in-paediatric-practice/10-2-neonatal-transfusion)
Product Suggested transfusion dose

Packed cells 10-20ml.kg-1
Platelets 10-20ml.kg-1
FFP 12-15ml.kg-1
Neurodevelopmental effects of anaesthetics in option and treatment may not always be possible.
neonates
Inadequate anaesthesia and analgesia have been shown to Prior to transfer the appropriate personnel, equipment, drugs
be detrimental to neonates, and associated with increased and fluids should be prepared and checked using a transfer
mortality. However, many animal model studies have been checklist (Table 6). The neonate should be carefully assessed
published recently that have demonstrated accelerated for stability for transfer or if necessary transfer may need to be
neuronal cell death (apoptosis) and long-term behavioural delayed for further resuscitation and optimisation. Check that
changes after animals are exposed to anaesthetic agents in the the monitoring is functional and the patient is adequately fluid
neonatal period. The situation in humans remains unclear.13 resuscitated. Take time to ensure that the neonate is stable
The risks and benefits of surgery in neonates should be prior to transfer on the current drug infusions and mode of
considered carefully, and non-essential elective surgery should ventilation.
be avoided in the neonatal period where possible. Careful monitoring during transfer is extremely important and
will highlight clinical trends. A detailed handover is essential
Transfer of neonates for good continuity of care.
Neonatal surgery should ideally be undertaken in an
environment where the facilities and expertise are available for SPECIFIC NEONATAL PATHOLOGIES
definitive treatment and on-going care. In certain situations,
if the baby is unstable and not suitable for transfer to theatre, Inguinal hernia repair
it may be necessary to undertake surgery on the NICU itself. Inguinal hernia is common in premature neonates. The
In certain situations the baby may need to be transferred to a timing of surgery depends on the risk of incarceration,
specialist centre. In low-income countries this may not be an bowel strangulation or testicular atrophy versus the risk of

postoperative apnoea and the potential harm to intravenous paracetamol is a useful adjunct if available.
neurodevelopment. The major anaesthetic risk is post- Standard monitoring is usually all that is required. Opioids
operative apnoea, which has been shown to vary from 4.7% to should be carefully titrated as the usual aim is to extubate at
49% of patients.10,14 the end of surgery.
Some units prefer spinal anaesthesia for inguinal hernia The patient may be positioned supine or prone depending
repair, others use a balanced anaesthetic technique using on the surgical technique. Prone positioning is associated
general anaesthesia with intubation, supplemented with a with increased risk to pressure areas, abdominal compression
regional technique. There is currently not enough evidence to resulting in difficulty with ventilation, endobronchial
show whether the incidence of apnoea is lower using spinal intubation or tracheal tube displacement. Long-term outcome
anaesthesia, and the choice is usually determined by local is variable depending on the complexity of the anorectal
preference of the surgeon and anaesthetist.15 malformation. These patients usually require serial anal
Editors note: As this edition of Update goes to press, the editors are
dilatations following repair.
aware that the GAS study is reporting its preliminary findings on
apnoea comparing GA and spinal in >700 neonates, publication of Intestinal malrotation
full results is expected late 2018. Malrotation occurs in approximately 1:500 live births. Normal
intestinal rotation around the superior mesenteric artery
Caudal anaesthesia using 0.25% bupivacaine 0.75ml.kg-1 (SMA) and fixation during foetal development is interrupted.
provides excellent supplementary analgesia for inguinal hernia It may also be associated with congenital diaphragmatic hernia,
repair under general anaesthesia. Alternatively, an ilioinguinal exomphalos and gastroschisis.
block can be performed with 0.5-1.0ml.kg-1 0.25%
bupivacaine. These patients may require post-operative apnoea Nearly 50% of cases will present in the first week of life most
monitoring dependent on their PCA, as discussed earlier, and commonly with bilious vomiting secondary to duodenal
some premature infants will require post-operative ventilation obstruction.18 This may be due to a midgut volvulus, or
or CPAP for treatment of apnoea. Paracetamol (7.5mg.kg-1 physical compression secondary to peritoneal tissue bands
IV or 20mg.kg-1 rectal suppository) provides adequate post- or abnormal locations of the duodenum and its surrounding
operative analgesia. structures. If the condition is diagnosed early the neonate
may be relatively well with only subtle abdominal signs. The
Anorectal malformations neonate may present late with frank sepsis and peritonitis
Anorectal malformations (ARM) occur in approximately secondary to perforated or necrotic bowel. The gold standard
1:5000 live births. They represent a wide spectrum of disease, radiological investigation is an upper GI contrast series. Plain
from a simple membrane involving the distal rectum and anus X-rays are useful if there is concern of another diagnosis or to
to more complex anomalies involving the genital and urinary exclude visceral perforation.
tract. Spinal anomalies are frequently found in these patients.
These include spinal dysraphism, low lying cord (LLC) and These patients require adequate volume resuscitation and
tethered cord.16 Plain spinal Xrays and spinal ultrasound are electrolyte replacement for ongoing fluid losses and should be
used to screen for these abnormalities although they may taken to theatre as soon as is feasible. A nasogastric tube is
be normal in occult dysraphism. Caudal anaesthesia may be inserted to suction the stomach. Prophylactic antibiotics such as
beneficial and can be used in ARM if there is certainty that co-amoxiclav or benzylpenicllin, gentamicin and metronidazole
anomalies of the spine and spinal cord have been excluded.17 are required. Ideally invasive monitoring is inserted although it
ARM may be associated with other anomalies including should not delay surgery in the sick neonate. If the gut has been
Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal and compromised, inotropes may be needed and any coagulopathy
Limb abnormalities, collectively known as the VACTERL will require correction. A central venous line may be required
association. for ongoing total parenteral nutrition in the septic neonate.
An opioid based technique can be used although a caudal may
Primary surgical repair can be undertaken in the neonatal
be considered if the patient is haemodynamically stable, there
period although more commonly a colostomy is performed
are no other contra-indications and extubation is anticipated.
and a definitive repair is carried out at a later date.
Post-operative NICU care and ventilation is often necessary.
If caudal anaesthesia is contraindicated an opioid-based
technique is used (fentanyl 1-2mcg.kg-1 or morphine Long-term outcomes depend on the extent of the necrotic
20-50mcg.kg-1 [0.02-0.05mg.kg-1], with infiltration with bowel. Some patients will develop short bowel syndrome and
local anaesthetic. Rectal suppositories cannot be used but if there is extensive bowel necrosis the mortality is 100%.

Necrotising enterocolitis (NEC) or a central line should not delay the start of surgery in the sick
Necrotising enterocolitis occurs in approximately 0.5 5:1000 infant. There is a significant risk of coagulopathy and significant
live births. More than 90% of infants diagnosed with NEC are blood loss, and inotropes are often required. Packed red cells
preterm.19 Morbidity and mortality are inversely proportional should be available and fresh frozen plasma and platelets are
to the infants post-conceptual age (PCA) and birth weight. often indicated based on laboratory results or clinical evidence
of bleeding. Hypothermia and glucose instability are common
The aetiology of NEC is multifactorial. Risk factors and should be managed appropriately.
include vascular compromise of the gastrointestinal tract,
commencement of enteral feeding, immature gastrointestinal Mortality remains significant and long term complications
immunity and sepsis. Hypoxia or ischaemia combined with include short bowel syndrome and neurodevelopmental delay.
reduced splanchnic blood flow can occur with patent ductus
arteriosus (PDA), cyanotic heart disease, respiratory distress Oesophageal atresia and tracheoesophageal fistula
syndrome, shock, asphyxia and with the use of umbilical Congenital tracheoesophageal fistula (TOF) occurs in
catheters. approximately 1:3,000 live births. It arises during foetal
development as a result of incomplete separation of the
NEC may present with subtle gastrointestinal signs including oesophagus from the laryngotracheal tube. It is classified based
abdominal distension, intolerance of feeds, abdominal on the site and presence of the fistula and whether there is
tenderness, blood in the stool and bilious vomiting or may oesophageal atresia (Figure 2). There may be other associated
present with perforation and peritonitis with systemic VACTERL anomalies.
signs including shock, temperature instability, acidosis and
disseminated intravascular coagulopathy. Supine and decubitus
plain Xrays may show the presence of hepatic venous gas, free
intraperitoneal air, dilated bowel loops, ascites and asymmetric
bowel gas patterns along with pneumatosis intestinalis.
Initial management includes discontinuation of enteral feeds,
insertion of a nasogastric tube and commencement of broad-
spectrum antibiotics such as benzylpenicillin, gentamicin and
metronidazole. Ongoing fluid and electrolyte management
with parenteral nutrition will be required. Frequent clinical
monitoring of systemic and abdominal signs together with
radiographic examination, monitoring of laboratory values
and acid-base status guides further management. The only
absolute indication for surgery is bowel perforation although
the decision to proceed to surgery may be made if there is a
clinical deterioration.
The preoperative assessment should evaluate and optimise any
cardiovascular instability, metabolic acidosis, coagulopathy
and respiratory compromise. If the patient is too unstable it
may be necessary to carry out surgery on the NICU. Figure 2. Incidence and types of oesophageal atresia/tracheo-
oesophageal fistula
These patients are often already intubated and ventilated. A
high dose fentanyl technique (10-20mcg.kg-1) may be used Neonates with TOF classically present within a few hours of
to promote cardiovascular stability and reduce the systemic birth with frothy sputum as they are unable to swallow oral
stress response.20 Nitrous oxide should be avoided because secretions; delayed diagnosis is associated with episodes of
of the risk of bowel distension. Low cardiac output state, coughing and choking associated with cyanosis, particularly if
organ hypoperfusion and acidosis secondary to large fluid feeding is attempted. There may be copious oral secretions and
shifts is common, and large volumes of intravenous fluids are abdominal distension due to gastric insufflation via the fistula.
frequently required. Invasive monitoring is useful to guide Left untreated the neonate will develop aspiration pneumonia.
fluid management and allow frequent arterial blood gas The diagnosis of oesophageal atresia is confirmed if it is not
sampling although this must be balanced against the risk of possible to pass a nasogastric tube and the chest Xray will
limb ischaemia in the preterm neonate. Insertion of an arterial show the nasogastric tube coiled in the proximal blind-ending

oesophagus (Figure 3). There may be an absent gastric bubble of manual ventilation may be required. If gastric distension
in isolated oesophageal atresia without a tracheoesophageal occurs prior to ligation of the fistula, the tracheal tube should
fistula. be disconnected intermittently to decompress the stomach via
the airway. An arterial line is useful to facilitate arterial blood
gas measurement as end tidal CO2 measurement is unreliable.
Alternatively, transcutaneous CO2 monitoring can be used.
Hypercapnoea and acidosis is of particular importance in
the presence of certain cardiac anomalies as the increased
pulmonary vascular resistance can lead to right-to-left shunting
and severe hypoxia. Other pitfalls include ligation of the
wrong structure, intubation of the fistula and endobronchial
intubation.
A balanced anaesthetic should be given, with bolus fentanyl

analgesia as required (1-2mcg.kg-1). Blood loss should be
minimal and Ringers lactate 10-20ml.kg-1 is usually all
that is required. The wound should be infiltrated with local
anaesthetic at the end of surgery. Some term infants born in
good condition and with normal preoperative pulmonary
function may be extubated at the end of surgery; most are
likely to require post-operative ventilation and they should be
Figure 3. Chest Xray showing nasogastric tube curled in the transferred to a facility able to provide this level of care for
upper oesophageal pouch in a child with oesophageal atresia their surgery. Many patients will require serial dilatation of the
oesophagus during infancy.
The goals of pre-operative management are to stabilise the
child, minimise respiratory embarrassment and assess for Congenital diaphragmatic hernia
timing of surgery. A nasogastric tube is inserted into the Congenital diaphragmatic hernia (CDH) occurs in
upper oesophageal pouch to drain secretions. The patient approximately 1:3000 live births. In most cases the aetiology
must be nursed head up or on the side to minimise the risk remains unknown. A defect in the diaphragm, usually on the
of aspiration. Intravenous fluids and prophylactic antibiotics left side, results in herniation of midgut structures into the
should be commenced. This allows time for investigations such thoracic cavity. Pulmonary vascular structure and reactivity
as an echocardiogram to exclude other associated congenital are abnormal and there is a varying degree of lung hypoplasia.
abnormalities. Diagnosis is made on antenatal ultrasound or on plain Xray
postnatally when the abnormal bowel loops can be seen within
Our preferred technique is to induce anaesthesia after pre- the thoracic cavity.
oxygenation and to maintain spontaneous ventilation initially
with volatile or intravenous anaesthesia. Prior to repair the Morbidity and mortality is related to the degree of pulmonary
surgeons may perform flexible or rigid bronchoscopy to assess hypertension, right ventricular dysfunction and lung
the level of the fistula and to see if there is a second or proximal hypoplasia.21 A pre-operative echo is performed as a significant
fistula. Take note of the distance measured from the cords proportion of CDH have associated cardiac anomalies.
to the fistula to guide tracheal tube placement; the fistula is Mortality still remains high in patients with significant co-
mid-tracheal in two thirds of cases, and located at level of the existing congenital cardiac disease.22 It is generally accepted
carina in one third of cases. Muscle relaxants and gentle mask that delaying surgery, usually for 24-48 hours, allows a period
ventilation may be given prior to intubation. If possible the of stabilisation. The reduction in pulmonary artery pressures
tracheal tube is placed distal to the fistula, with the bevel of the and improvement in right ventricular dysfunction may
tracheal tube facing anteriorly. improve outcome.
A right thoracotomy is performed with the patient on the There has been a significant improvement in survival over the
side with a roll under the chest. The tube position must be past 20 years due to the introduction of gentle ventilation
checked and effective ventilation confirmed after the change strategies.23 These include permissive hypercapnoea (PaCO2
of position. The lung is then retracted which often results in <70mmHg), limiting inflation pressures (avoid PIP>25cm
difficulty with ventilation, hypercapnoea and acidosis. Periods H2O and PEEP > 5 cm H2O) and accepting relative hypoxaemia

(aim for pre-ductal SpO2 90-95%). Surgery may need to be dried, any exposed bowel covered with plastic and a nasogastric
performed whilst the neonate is on high-frequency oscillation tube is inserted to decompress the stomach. Fluid resuscitation
ventilation or extra-corporeal membrane oxygenation.24 is commenced, a urinary catheter inserted and broad spectrum
antibiotics started. Co-existing congenital abnormalities,
Preoperative assessment must pay particular attention to the
especially cardiac, should be assessed. A renal or cranial
presence of significant pulmonary hypertension, ventilation
ultrasound may also be indicated.
requirements, and associated cardiac anomalies. If the infant
is not already intubated, anaesthesia is induced with care to Surgery is more urgent in gastroschisis due to the ongoing fluid
avoid gastric insufflation with bag valve mask ventilation and losses and electrolyte and metabolic derangement. If primary
further lung compression. A nasogastric tube is inserted to closure is not possible then a silo is placed over the exposed
decompress the stomach. Invasive monitoring is required to bowel, which may require a general anaesthetic if the defect
allow serial blood gas measurement. There is a risk of blood loss needs extending to fit the device. The silo is suspended above
and a unit of packed red cells should be available. In patients the patient postoperatively, and the bowel is gradually reduced
with significant pulmonary hypertension, having nitric oxide into the abdominal cavity under gravity over the ensuing few
available in theatre may be critical for treatment of pulmonary days in the NICU. When the patient is stable and spontaneous
hypertensive crises. reduction of the bowel has reached a plateau, then surgery
A subcostal or transverse abdominal incision is made and for reduction and closure of hernia is performed. Surgery for
the herniated viscera are reduced into the abdomen. The exomphalos is less urgent, unless the sac has ruptured. If the
diaphragmatic defect is then either closed primarily or with patient is stable and the defect is small a primary repair can
a prosthetic patch if the defect is large. Thoracoscopic repair usually be done. In large defects, if the sac has not ruptured,
is being undertaken in some centres. Following abdominal it may be treated with topical silver sulfadizine to allow
closure, raised intra-abdominal pressures may lead to epithelisation with definitive surgery at a later stage.
difficulty with ventilation and a risk of developing abdominal
The neonate will require intubation and ventilation for surgery.
compartment syndrome, and delayed closure may be necessary.
Expect significant ongoing fluid and heat losses due to the
Lung compliance decreases post-operatively and post-operative
exposed viscera. Peripheral intravenous access may be all that
ventilation is usually necessary. These patients often suffer from
is required, but central venous pressure monitoring and an
chronic respiratory disease, gastro-oesophageal reflux disease
arterial line are useful to help guide fluid administration. Avoid
and neurodevelopmental delay.
the femoral vessels as there is a risk of decreased perfusion with
the increased abdominal pressures. Placing the post-ductal
Gastroschisis and exomphalos (omphalocele)
oxygen saturation probe on either lower limb helps to give an
Gastroschisis and exomphalos are both ventral wall defects
indication if there is poor perfusion. Muscle relaxants will assist
resulting in herniation of abdominal viscera. Diagnosis is
the surgeons in reducing the abdominal contents. Reduction
ideally made on antenatal ultrasound scan.
of the bowel may cause abdominal compartment syndrome,
Gastroschisis occurs in approximately 1:3000 live births. The diaphragmatic splinting and high ventilation pressures. If the
herniated viscera are not covered by a sac. It is thought to intra gastric pressures are >20mmHg or the peak inspiratory
occur secondary to an ischaemic insult during abdominal pressures exceed 30cm H2O then a staged repair is indicated.26
wall development or due to early rupture of the hernia of
the umbilical cord. A relatively small percentage (10-20%) Unless there is a very small defect the infant will require post-
are associated with other congenital abnormalities and these operative ventilation and a generous opioid-based anaesthetic
predominantly involve the gastrointestinal tract.25 technique can be used (fentanyl 10-20mcg.kg-1). These patients
often require parenteral nutrition and a significant proportion
Exomphalos occurs in approximately 1:5000 live births. Failure
present for further abdominal surgery.
of normal embryological development results in the bowel
remaining within the umbilical cord and not returning to the
abdomen. The herniated viscera is covered by a sac. There is a CONCLUSION
high incidence of associated congenital abnormalities including Improving outcomes in neonatal anaesthesia is dependent
cardiac anomalies. Specific chromosomal associations include on a thorough understanding of the unique anaesthetic
trisomies 13, 15, 18 and 21 and it can be associated with requirements of the neonate and a detailed knowledge of
Beckwith-Wiedemann syndrome. the different pathologies that present during this period.
Unnecessary surgery should be avoided during the neonatal
To avoid bowel injury the baby is delivered by caesarean period as anaesthesia and surgical stress may have detrimental
section. The operating theatre should be warmed, the baby effects on the very immature child.

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Elective Procedures
Major elective surgery in children, and surgery in
remote and rural locations
Mark Newton
Correspondence Email: mark.w.newton@Vanderbilt.Edu
INTRODUCTION
Safe, effective care of children presenting for and describe some clinical cases with practical
surgery is challenging, even more so when the solutions to equipment requirements and clinical
child presents with advanced pathology, the goals, which we hope will be useful to anaesthesia
systems to support safe anaesthesia care are not providers working in any setting. Summary
well-developed, and the need for surgery is large.
In many low-income countries, more than 50% GENERAL PRINCIPLES Children presenting for
elective paediatric surgery in
of the population is less than 15 years old, and Cardiac sub-Saharan Africa may have a
more than 85% of children are predicted to need Infants and young children have a relatively high morbidity and mortality.
some form of surgical intervention by the age fixed cardiac output compared to adults due to Understanding the basic
of 15. The overall morbidity and mortality in immature myocardial function. The resting heart anatomy, physiology and
this group of patients is alarmingly high when rate is high and there is limited ability to increase pharmacology together with
appropriate equipment for the
compared to similar patients in high-income the stroke volume in response to a fluid challenge. paediatric patient will improve
countries, and the mortality would be expected Babies become bradycardic (heart rate slows) in the anaesthesia mortality
to be even higher in the emergency cases. response to hypoxia, but children older than 6 statistics. The development
months of age have developed a balance between of paediatric surgical centres
Elective paediatric cases in children older than 6
the sympathetic and parasympathetic nervous in both the rural and urban
months old are performed at many hospital levels settings will allow for greater
systems, and have the more usual tachycardia experience to be obtained
in the rural and the urban setting. Common
in response to hypoxia. The fall in the heart rate in paediatric anaesthesia,
elective procedures in rural hospitals include:
due to hypoxia in babies causes a fall in blood which will improve care.
Inguinal and umbilical hernia pressure; your immediate response should be The most valuable asset for
these paediatric centres is to
to control the ventilation with 100% oxygen, have well-trained physicians
Circumcision or whatever level of oxygen is available in your and nurses who can provide
setting, rather than attend to the blood pressure high quality care for children
Incision and drainage of soft tissue and
i.e. you should not grab for the atropine but with the advanced surgical
orthopaedic infections.
rather open the airway and/or assist ventilation, pathology encountered,
taking account of the lack of
Larger more challenging cases often undertaken as hypoxia will be the source of the bradycardia in infrastructure and the limited
in urban centres include: the vast majority of the situations. Your response supplies that are a common
to hypoxia must be rapid as babies have twice problem. A successful
Hypospadias repair the oxygen consumption of adults, and quickly perioperative course can be
expected even for children
become desaturated. Always prepare your age requiring surgical intervention
Excision of abdominal mass (e.g. mesenteric
appropriate airway equipment and full range of in austere environments .
cyst, Wilms Tumor, ovarian mass)
drugs prior to the start of a case, and make sure
Head and neck surgery. you have an assistant. Mark Newton
Vanderbilt University,
These patients are likely to be challenging even Children presenting for elective surgery,
Department of
in a large national referral centre and good particularly those with congenital conditions Anesthesiology and
understanding and preparation is required. associated with midline defects such as Pediatrics (USA)
hypospadias, cleft lip and cleft palate, may also AIC Kijabe Hospital,
This article will give a brief overview of the have associated congenital heart disease (CHD). Department of
general principles of anaesthesia in children, If a murmur is present, or the child has a history Anesthesiology (Kenya)

suggestive of cardiac disease (failure to thrive, frequent chest The following airway equipment must always be prepared
infections and/or cyanosis), then a further work-up may be and checked prior to surgery. This preparation is a necessary,
indicated prior to surgical intervention. Most children will essential and professional aspect of the anaesthetic plan:
present to a general hospital without an adult cardiologist,
let alone a paediatric cardiologist. Work-up for such a child Stethoscope
should include a good history, including questions about Pulse oximeter
feeding, weight gain, chest infections, funny turns and
exercise tolerance; examination to listen for murmurs or Functioning laryngoscope with blades
cyanosis and clubbing; chest Xray (to exclude cardiomegaly or Endotracheal tube and stylet
pulmonary edema); and room air oxygen saturation measured
with a pulse oximeter to exclude cyanotic heart disease or a Oropharyngeal airways
chest infection in a child with cardiac failure. If the child is Mask.
well and asymptomatic, not cyanosed, the murmur is not loud,
not diastolic, there is no thrill and the chest Xray is normal, it It is essential to have the appropriate sized paediatric airway
should be safe to proceed as the murmur is likely to be benign. equipment available, including laryngoscope blades (Miller 0,
These cases will not require antibiotic prophylaxis unless the 1, 2 blades), endotracheal tubes, facemasks and oral airways.
surgeons request an antibiotic for their surgical procedure. A stylet can be helpful but, if not available, can be made with
a flexible metal tube that has been blunted on both ends to
Acquired rheumatic valvular heart disease is always a possible prevent tracheal damage or endotracheal tube perforation.
finding in a low resource setting, as the prevalence of this disease A precordial stethoscope and a pulse oximeter are essential
is higher and is increasing. If the patient is asymptomatic with monitoring equipment for all cases.
good exercise tolerance and oxygen saturation, an elective
surgical case can be performed safely. The technical skill of intubation should be practised in adults
or older children before attempting to perform even an elective
Respiratory intubation in a small child; many paediatric airway disasters
Anaesthetic induction and intubation in babies requires special could have been avoided with better training, also with
care because the oxygen saturation will decrease much faster assistance on induction. The anaesthetist should always ask
than in an adult due to the higher oxygen consumption, high the surgeon or a nursing colleague to help with induction and
minute ventilation and reduced functional residual capacity intubation as respiratory disasters can happen very quickly in
(FRC) per kg body weight compared to adults. children.
The narrowest part of the airway in the child is the cricoid Renal
cartilage, not the vocal cords as in the adult. The glottis is Glomerular filtration rate (GFR) reaches adult levels by one
more anterior and the epiglottis is less rigid and tends to fall year of age, and most children presenting for elective surgery
back to occlude the glottic opening during intubation. The have normal renal function. Routine questions such as Any wet
large occiput in infants tends to cause neck flexion, the tongue diapers/nappies, and when? will be useful to assess hydration
is relatively large, and it is easy to press on the floor of the and renal function healthy children. Routine electrolytes and
mouth to push the tongue up, which means the airway is easily creatinine are not necessary except for in renal surgery where it
obstructed during facemask anaesthesia. The airway cartilages is useful to record baseline values. A urinary catheter is rarely
are soft and easily compressed; if cricoid pressure is used, the required, except for hypospadias repair or Wilms tumours. The
pressure should be gentle otherwise the trachea can collapse smaller sizes of urinary catheter are often not available, and
and you may not be able to ventilate due to obstruction of it is much better to avoid damage to the urethra rather than
the trachea itself. Lateral displacement is also a frequent factor to insert an inappropriately large catheter. The bladder can be
when an assistant is applying cricoid pressure with too much emptied by the surgeon pressing gently on the lower abdomen
enthusiasm. If this is the case, ask your assistant to release the during the case (if the area is surgically prepped), and urine
pressure to improve your view of the larynx. The combination collected in a diaper. Urine output can be estimated from the
of these anatomical differences and the limited oxygen reserve, difference in weight of the diaper pre-surgery and post-surgery;
relatively high oxygen requirement, and poor tolerance of one mg increase in weight in the diaper is equivalent to one ml
hypoxia means that intubation can be more difficult in a of urine. A scale capable of measuring small weights must be
neonate compared to an adult, but with skill and experience, used. All doses of drugs should be calculated and drawn up
safe intubation becomes routine. accurately, especially renal toxic drugs such as gentamicin.

Fluid balance should be assessed carefully before surgery, Do not let the room get too cold. An open window
particularly if the child has been starved for a long period of producing a breeze for the surgical team may cool the
time; many children are starved for far too long preoperatively. patient down too much. If air conditioning is available,
Patients in an arid climate often have a chronically low make sure the temperature is not turned down too low.
intravascular volume; the additive effect of the pre-existing
deficit and the fasting deficit may be revealed on induction of Keep the patient covered with warm sheets whenever
anaesthesia with inhalational agents such as halothane, which possible, including at the start of the case when IV lines
results in a dramatic fall in blood pressure. A bolus dose of 10- are being inserted, and/or prior to cleaning and draping by
20ml.kg-1 0.9% saline or Ringers provides adequate hydration the surgical team. It is very helpful if the early heat loss
(and rehydration) for most minor elective cases. Weigh swabs caused by vasodilation at the start of anaesthesia can be
and assess fluid balance carefully for children undergoing major reduced.
surgery with on-going fluid and blood losses. Most children
Haematology
presenting for elective general surgery do not require dextrose
Anaemia with haemoglobin level (Hb) less than 8g.dl-1 is
containing fluids as the stress response to surgery causes the
common in children presenting for elective surgery. Most will
blood sugar to increase; neonates or malnourished children
be nutritional, but you should consider other causes such as:
should have their blood sugar checked to make sure they are
not hypoglycaemic before surgery starts. Malaria
Make sure the child is well hydrated at the end of surgery; Sickle cell disease
and, if possible, avoid IV fluids on the ward unless the child
has undergone major surgery and is not able to drink. This Intestinal worms
is important even in the elective patient as it is difficult to
monitor IV fluids on the wards as the patient:nurse ratio is Drug-induced anaemia (rare).
often very high. Patients frequently do not get an intravenous
It is feasible for children to have elective surgery when their
line in good time, the IV fluids may not be available or may
haemoglobin is less than 8 g.dl-1, but they have reduced tissue
not be infused accurately.
oxygen delivery, and may need supplemental oxygen to maintain
Temperature regulation oxygen saturations, especially if they have upper abdominal
Temperature monitoring is not available in many countries, surgery and impaired respiratory function due to pain. Minor
but low technology devices to detect hypothermia are procedures such as hernia repair can be undertaken safely with
available, and valuable, particularly in younger children. A Hb as low as 6-7g.dl-1, but any major surgery needs a starting
simple thermometer can be used for axillary skin temperature Hb above 8g.dl-1. If the child is anaemic and is presenting for
measurement to help monitor trends. Children have a relatively elective surgery, and they live relatively close to the hospital,
large surface area and little fat for insulation, especially if they should be treated with a course of iron supplements for 3
malnourished. This can lead to dangerous hypothermia (low months before re-booking.
temperature) during surgery, which may result in clotting
problems, hypoventilation and even cardiac arrhythmias. Basic Acute malaria can produce unexpected complications and
heating pads and fluid warmers are helpful but need very close increased morbidity. All children presenting for elective surgery
monitoring as they may also cause burns if not used properly. who have malaria should be treated and surgery postponed.
In particular, the heating pad should never be applied directly Sickle disease is associated with increased perioperative
to the skin, and rarely placed on high. complications, usually due to sickle chest or painful crisis.
Intraoperative hypothermia can be avoided in the following Children with sickle disease presenting for elective surgery
ways: should not be allowed to become dehydrated, and should be
transfused using fresh whole blood if the Hb is below 8g.dl-1.
Avoid excessive betadine to prep the surgical field. If you Ideally, freshly donated blood should be used for sickle cell
are not watching the surgical technicians use of betadine, disease patients, particularly if it is not possible to measure
the patient will be floating in cold fluid for the entire case. the sickle status of the donated blood. Typically a top up
Pooling of betadine (or alcohol) against the childs skin transfusion of 20ml.kg-1 will be sufficient, along with the
may also cause a chemical burn. normal sickle cell precautions, page 35. If the temperature is
If possible, warm the theatre (22-25C, depending on the high after blood transfusion in a malaria endemic area, the
age of the child). An ambient heating unit is useful to child should have blood taken to test for malaria parasites and
warm the room and reduce early heat loss. treatment for malaria considered.

CLINICAL CASES Each child needs an accurate weight documented in the
chart for drug dosing, fluid requirements, and overall health
Case 1 assessment. Essential laboratory measurements include:
A three-year-old male child was referred to a tertiary referral haemoglobin, platelet count, creatinine (allows comparison
hospital in East Africa with an 8 month history of enlarging of pre and postoperative renal function) and blood type and
abdominal mass. The child was previously healthy, travelled cross match, anticipating the potential for significant blood
from a neighbouring country, had been examined by multiple loss. A minimum of two adult units of type specific blood
medical care providers, and was very malnourished. His must be ready prior to skin incision. In addition, two family
mother came with a CT scan of the mass and an exploratory members with a matching blood type, or other appropriate
laparotomy was scheduled by the surgical team. See Figure 1. donors, must be available in the theatre waiting area, with
direct communication from the surgical team. You will need
to have a minimum of two blood transfusion sets in theatre, in
case one becomes obstructed with blood clots during the case.
Additional labs are unnecessary and costly.
Postoperative care must be planned before surgery, including
where the child will be cared for after surgery. The postop ward
must allow for close observation with access to:
Oxygen
Suction
Bed which has the capability to elevate the head (improving
respiratory efforts)
Focused nursing care and monitoring of vital signs.
Figure 1. CT scan: large renal mass on the patients right side (the
left side of the scan) - indicated within broken line This is often the key component to a successful hospital
discharge from the surgical procedure and should never be
Preoperative evaluation and plan overlooked in the preparatory phase of an anaesthesia plan.
Nephroblastoma (Wilms Tumor) is the most common Many hospitals do not have an ICU, but good care is possible
abdominal tumour in children, with a reported incidence of as a substitute for a formal ICU if the patient is positioned
1:20,000 to 1:100,000. Typically tumours in sub-Saharan in the area closest to the nursing station with access to close
Africa are more advanced and in Nigeria, nephroblastoma is monitoring. The vital signs and fluid input and output must
reported to be Stage III and IV in 72% of the children with be monitored (bladder catheter required), and a key person
an undocumented overall survival.1 Advanced disease suggests identified who will show an active response to the postoperative
suggests delayed presentation, poor surgical infrastructure or, observations.
possibly, more aggressive tumours compared to children in
western research studies. Anaesthesia and surgery for advanced Induction and maintenance of anaesthesia
tumour cases can be very challenging. A large intra-abdominal tumour may predispose the patient to
regurgitation of gastric contents on induction of anaesthesia.
A CT scan and a chest Xray are essential to plan surgery, to
The diaphragm will be pushed up which will limit the lungs
determine the mass effect of the tumour, location within the
from fully expanding thus causing a faster oxygen desaturation.
vascular system (e.g. identify involvement of the inferior vena
Both of these factors should prompt the anaesthesia care
cava or renal vein), presence of bilateral renal involvement (8-
provider to ask for assistance during the induction phase of
12% of cases), and spread to the pulmonary parenchyma. Each
anaesthesia. (See Figure 2)
of these would help determine if surgery should be altered
or even cancelled due to extensive spread and unnecessary This patient should have an IV induction with careful
risks, although a surgical palliative mass debulking could still application of cricoid pressure (NOT an inhalation induction).
be considered. Many of these patients present in a state of Remember, if you are having difficulty viewing the glottis, ask
malnutrition and their response to inhalation agents such as your assistant to reduce the cricoid pressure and/or change
halothane may be more dramatic with more cardiovascular their compression direction to a more midline position. This
depression and drop in blood pressure than anticipated. patient could have any induction agent (thiopentone, propofol,

cava (IVC), which will then need to be clamped for surgery. If
the IV access is in the legs in this situation you would not be
able to transfuse fluid to reach the central circulation and your
lines would be useless.
Figure 2. Induction of a child with a large Wilms tumor: note multiple

assistants, head of bed elevated, cricoid pressure, stethoscope ready,
senior anaesthesia care provider ready to assist in intubation in teaching
scenario
or ketamine); and muscle relaxation (succinylcholine or Figure 3. Anaesthetic set up for Wilms Tumour. Note peripheral IV lines
rocuronium) to provide good conditions for rapid intubation. x2 in the arms, arm at 90 degrees to keep an infusion port next to the
I would not use any narcotics at this stage, but would wait anaesthesia provider (no extension tube available); bladder catheter to
monitor urine output, eyes taped. Note, a sterile small (6-8 Fr) nasogastric
until the airway has been secured. Children can have a more
tube can be used if there is no urinary catheter available
dramatic drop in oxygen saturation when they are apnoeic
compared to adults, due to higher oxygen consumption, and in
this case, the child will also have a reduced functional oxygen During the surgical exposure of the tumour, the surgical team
reserve, so will require efficient intubation. If the mass is very could decrease venous return to the heart by compression
large, the head of the bed can be elevated slightly to reduce of the IVC or by torsion on the liver, which would result
the effect of the mass compressing on the diaphragm, which in a sudden drop in the blood pressure without any signs of
may assist during the induction period. The lung volumes blood loss. You must watch the surgery closely so that you
will be reduced due to elevation of the diaphragm, so check can anticipate blood loss and be aware of the manipulation
more than once that the endotracheal tube is not down too of the tumour; you should alert the surgeons when the blood
far and is in the proper position in the trachea. This patient pressure drops. There will be times when you need to have
will do best with a cuffed endotracheal tube, if available, due the blood in the room and be ready to transfuse. If you are
to increased intra-abdominal pressure during surgical tumour warming the blood in a bath of warm water, make sure that it
manipulation. If an uncuffed endotracheal tube is all that is is not too hot; if you cannot keep your hand in the water for
available, place the appropriate size tube that only has a leak more than 5 seconds then it is too hot and must not be used as
around the tube at higher pressures (between 20-30cmH20). you can cause haemolysis and massive infusion of potassium.
Remember that 98% of the potassium in blood is intracellular;
Higher inspiratory pressures than normal may be required due if the blood becomes haemolysed, the potassium will flood out
the mass effect of the tumour on the lungs, as would apply of the cells and cause arrhythmias and even cardiac arrest when
to any intra-abdominal pathology such as bowel obstruction you transfuse the blood. With this child, the blood will need
that pushes up on the diaphragm. If the chest is not moving to be given in a 30-60 ml syringe, so that you can keep an
well, recheck the position of the endotracheal tube and adjust accurate measurement of blood transfusion volume. Ideally,
the inspiratory pressure; this should be undertaken as a place a three-way stop cock in the infusion line, which will
priority rather than waiting for desaturation or carbon dioxide allow you to keep the syringe attached and to aspirate from the
retention to occur. bag and infuse into the patient without a break in the blood
line.
Two large bore intravenous catheters should be inserted into the
upper limbs for surgery. The cannulas are placed in the hands Children having major tumour excision need to have a urinary
or arms because the tumour could involve the inferior vena catheter inserted. An arterial line is not possible in many

to opioids given during the procedure, the surgeon infiltrates
the wound edges with a safe dose of local anaesthetic at the
end of surgery (lignocaine 2% 3mg.kg-1 or bupivacaine 0.25%
2mg.kg-1). The surgery will be associated with significant
postoperative pain, which should be managed by small doses of
morphine or pethidine titrated to effect in the recovery room.
If morphine is the drug available, a dose of 0.05mg.kg-1 should
be given then an observation period before adding to reach
a maximum does of 0.1mg.kg-1 every 4-6 hours depending
upon the patients condition. Postoperatively, these patients
need to be observed in a setting with a higher nurse to patient
ratio, with a bed that can have the head elevated, oxygen in
the room, and careful monitoring of fluid intake and output
by the nursing team. If close observation is not possible,
intramuscular opioids, at the appropriate dose, may be safer
Figure 4. Wilms Tumor intraoperative manipulation: liver compression than intravenous narcotics in these settings. The appropriate
(left side of photo - arrowed) can decrease venous return to the heart and dosing based upon accurate weight is critical when dealing
the blood pressure will decrease, which should prompt communication with the paediatric surgical patient. The surgeons will usually
with the surgical team request a nasogastric tube to be inserted as the child is likely
to have a postoperative ileus after this large intra-abdominal
tumour is removed.
Figure 5. Wilms tumour, pathological specimen: note the tumour

located in the upper regions of the kidney and the abnormal tissue in the
upper aspect
settings, so accurate non-invasive blood pressure monitoring Figure 6. Wilms tumour incision. Postoperative pain management after
upper abdominal surgery will require careful treatment, with small doses
needs to be done every two minutes, ideally using an of opioids titrated to effect, and close monitoring of respiratory rate by
automated cuff. As one can see in the pathological specimen, the ward nurses
these tumours will involve a large section of the kidney and
one can see haematuria at times. In cases of bilateral tumour
Case 2
involvement, the surgeons may need to do renal sparing
procedures (hemi-nephrectomy), which can be associated A 6-year-old female living in a very rural and resource poor
with very large blood loss and high risk for renal dysfunction area of Africa has had a one year history of abdominal swelling
postoperatively. which has not responded to medical treatment. She is afebrile,
with normal vital signs, no past medical or surgical history, and
If the surgery is successful and the blood loss is minimal, the neither the family nor the medical facility has access to CT or
child can be extubated at the end of the procedure but needs MRI. She has travelled for two days to for a surgical consult
to have good pain management. It is helpful if, in addition by your outreach team as the area she lives in has minimal

access to paediatric surgery. A portable ultrasound machine
revealed a large intra-abdominal cystic mass and the surgeon
would like to proceed to surgery. The hospital is without piped
gases or oxygen tanks, no anaesthesia machines, and has one
electrically powered oxygen concentrator that produces flow
up to 6 litres.minute-1. The lighting is poor, but there is a diesel
generator available. The child weighs 17kg.
Preoperative evaluation and plan

The surgical skill level available in the rural hospital is critical
when considering this type of surgery. Is this an experienced
surgeon who can adjust to the environment and will be able
to retreat and stop surgery if direct visualization of the mass
demonstrates a very difficult excision? Can the surgeon operate
safely and efficiently (i.e. fast)? You need to consider these
types of questions when working in extremely remote regions
Figure 7. Abdominal mass and remote anaesthesia and surgery. There
with challenging surgical and anaesthesia cases. is no anaesthesia machine, and anaesthesia for exploratory laparotomy
is delivered using an oxygen concentrator and propofol/ketamine TIVA
The only laboratory test needed in this scenario would be a mixture.
haemoglobin level and a type and crossmatch for one unit of
blood. If payment for treatment is required, do not spend the
familys limited funds on laboratory tests that will not change The propofol and ketamine mixture for this rural anaesthesia
your anaesthetic management. In even the very remotest of TIVA technique (Ketofol) can be made by adding 20ml
locations, there should be a blood bank for family donors and propofol 10mg.ml-1 (200mg) and 2ml ketamine 100mg.ml-1
a pharmacy near the hospital that sells the blood and IV giving (200mg) to the burette of a paediatric buretrol (microdrop)
sets for the family to purchase and bring to the operating intravenous giving set. The concentration of propofol
theatre. A laboratory that is able to check for HIV, hepatitis, (10 mg.ml-1) and the ketamine (100 mg.ml-1) allows one
malaria and blood typing would be beneficial. Always to combine 20mls of propofol and 2mls of ketamine in an
remember in an emergency situation a full cross match does approximate 1:1 mg:mg combination for infusion, which
not need to be done; give type-specific blood if the patients simplifies the dosing. Each ml will have 10mg of propofol and
vital signs cannot wait for the full cross match. This specific 10 mg of ketamine. Most paediatric buretrols have 60 drops of
case would prompt the purchase of two blood giving sets so fluid being equivalent to 1ml of fluid which translates to the
that if bleeding occurs and one filter blocks, you would have a infusion rates in the table. Confirm the dropper calibration
secondary giving set ready. with your specific buretrol being used.
At times, you may need a small dose of muscle relaxant
Induction and maintenance of anaesthesia (succinylcholine) but most surgeons can operate with a
A suitable anaesthesia plan in this situation would be total spontaneously ventilating patient. The goal in the remote
intravenous anaesthesia (TIVA) (combination of ketamine environment is to maintain spontaneous breathing, which will
and propofol), and endotracheal intubation. A peripheral IV add a level of safety. The TIVA technique could be combined
catheter is placed, 18 or 20 gauge, and intravenous induction with a spinal anaesthetic if the anticipated blood loss is
performed with succinylcholine and thiopental, propofol or minimal. This would allow for a lower dose of the ketofol,
ketamine. Succinylcholine has a short duration of action, which which would be less expensive.
will allow for spontaneous respiration to return quickly and
avoid the need for positive pressure ventilation. This allows for Decrease the infusion rate 15-20 minutes before the projected
a greater margin of safety in case the generator powered oxygen completion of surgery and stop completely 5 minutes before
concentrator malfunctions and you are forced to use a self- the end. The patient should be extubated awake, and should
inflating Ambu bag with room air only. Any size Ambu bag be monitored closely postoperatively in the bed closest to the
will be suitable, but take care to avoid excessive tidal volumes nursing station for 48 hour postoperatively, ideally in a bed
if you use an adult Ambu bag for a small child. Monitor the that can elevate the head to 30 degrees. Intestinal perforation
chest expansion carefully and do not squeeze the bag totally: is a potential risk for this procedure and should be considered
note that some Ambu bags can give up to 2 litres of volume. if there is any concern about sepsis postoperatively.

Table 1: Ketofol doses2
Phase of anaesthesia Dose in ml Dose in buretrol drops assuming 60

drops = 1ml
Mean induction dose 0.2 ml.kg-1 12 buretrol drops.kg-1
Maintenance infusion: deep sedation (e.g. 0.2 ml.kg-1.hour-1 12 buretrol drops.kg.hour-1
orthopaedic procedures)
Maintenance infusion: anaesthesia for 0.3-0.4 ml.kg-1.hour-1 18-24 buretrol drops.kg.hour-1
laparotomy
Incremental increases in infusion rate if 0.1 ml.kg.hour-1 extra 6 buretrol drops.kg.hour-1 extra
the patient demonstrates signs of pain
[respiratory rate, heart rate, movement]
paediatric patient will improve the anaesthesia mortality

statistics. The development of paediatric surgical centres in both
the rural and urban settings will allow for greater experience
to be obtained in paediatric anaesthesia, which will improve
care. The most valuable asset for these paediatric centres is to
have well-trained physicians and nurses who can provide high
quality care for children with the advanced surgical pathology
encountered, taking account of the lack of infrastructure and
the limited supplies that are a common problem. A successful
perioperative course can be expected even for children
requiring surgical intervention in austere environments if the
basic foundations of anaesthesia are adhered to and if there is a
high level of surgical skill available.
REFERENCES:
Figure 8. Mesenteric cysts. Intestinal damage, intraoperative
blood loss and postoperative ileus need to be considered in the 1. Hadley LG, Rouma BS, Saad-Eldin, Y: Challenge of
perioperative plan pediatric oncology in Africa. Seminars in Pediatric Surgery
2012; 21: 136-141.
SUMMARY 2. Weatherall A, Venclovas R: Experience with a propofol-
Children presenting for elective paediatric surgery in sub- ketamine mixture for sedation during pediatric
Saharan Africa may have a high morbidity and mortality.3 orthopedic surgery. Pediatric Anesthesia 2010; 20: 1009-16.
Understanding the basic anatomy, physiology and 3. Walker IA, Wilson IH: Anaesthesia in developing countries
pharmacology together with appropriate equipment for the - a risk for patients. Lancet 2008; 371: 968-9.

Elective Procedures
Anaesthesia for paediatric ear, nose,
and throat surgery
Reprinted with minor revisions from Continuing Education in Anaesthesia, Critical Care and Pain by kind
permission of the Board of Management and Trustees of the British Journal of Anaesthesia . Originally
reprinted as Update in Anaesthesia 2008, 24(1):18-23
Radha Ravi and Tanya Howell*

*Correspondence Email: tanya.howell@cmmc.nhs.uk
Adenotonsillectomy apnoeas, restless sleep, extended neck position
Tonsillectomy is one of the most frequently during sleep, and daytime hypersomnolence.
performed surgical operations in children. Over time, this can lead to neurocognitive
According to the Department of Health Hospital impairment, behaviour problems, failure to
Episode Statistics (http://www.hesonline. thrive, and rarely cor pulmonale. Summary
nhs.uk), 25 000 tonsillectomies and 6500
Children with severe OSA have a higher incidence Children account for
adenoidectomies were performed in children
of perioperative complications and may need approximately one-third
under 15 years of age in England in 2003.4 of all patients undergoing
postoperative HDU/ICU care. Specifically,
The tonsils and adenoids are lymphoid tissues ear, nose, and throat
they are at an increased risk of desaturation,
forming part of the Waldeyers ring encircling the (ENT) surgery. Procedures
laryngospasm, and developing airway obstruction range from simple day-
pharynx. They appear in the second year of life,
during induction of anaesthesia.2 They have case operations, such as
are largest between 4 and 7 years of age and then
increased sensitivity to the respiratory depressant myringotomy, to complex
regress. Children with adenotonsillar hypertrophy airway reconstruction
effects of sedatives and opioids and a diminished
can present with nasal obstruction, recurrent surgery undertaken in
ventilatory response to CO2 compared with
infections, secretory otitis media and deafness specialist centres. This
normal.2,3 The overall incidence of postoperative article describes the
(secondary to Eustachian tube dysfunction), and
respiratory complications in children with severe anaesthetic management
obstructive sleep apnoea (OSA). Tonsillectomy is of some of the commonly
OSA is 16 27% compared with an incidence of
indicated in children with recurrent tonsillitis if performed paediatric ENT
1% in children without OSA. Other risk factors
they have had five or more episodes of sore throat procedures, including
for respiratory complications include age >3 adenotonsillectomy,
per year because of tonsillitis, or if symptoms have
years, craniofacial abnormalities, neuromuscular oesophagoscopy, and
persisted for at least 1 year and are disabling, that
disorders, failure to thrive, and obesity.3 middle ear surgery. Paediatric
is, interfering with normal functioning (SIGN bronchoscopy is discussed
publication no. 34, available from http://www. Preoperative investigations are not in detail in a separate article,
sign.ac.uk). Other indications for tonsillectomy routinely indicated for patients undergoing page 173.
include chronic tonsillitis, peritonsillar abscess, adenotonsillectomy (NICE Guideline
and OSA. Adenoidectomy is indicated when on Preoperative Tests, available from
there is evidence of enlarged adenoids causing http://www.nice.org.uk). It is difficult to confirm Radha Ravi
nasal obstruction, OSA, or hearing loss. In the the diagnosis and quantify the severity of OSA. Consultant Anaesthetist,
presence of OSA, adenotonsillectomy eliminates The gold standard for diagnosis is nocturnal Alder Hey Childrens
obstruction in 85 95% of children, yielding Hospital
polysomnography, but there is a great deal of
improvement of symptoms and quality of life. Eaton Rd
variability in scoring methods between different
Liverpool
sleep laboratories, and the test is expensive to Merseyside
Preoperative assessment perform. L12 2AP
In your preoperative assessment you need to
elicit features of OSA, especially in the younger Recent studies suggest that overnight oximetry
to score the frequency and depth of desaturation Tanya Howell
child, in whom obstructive symptoms rather Consultant Anaesthetist
than recurrent infections are commonly the events may be useful in identifying patients with
Royal Manchester
indication for surgery (prevalence of OSA severe OSA.4 In children with long-standing Childrens Hospital
1 3%). OSA, a full blood count will reveal polycythaemia Pendlebury
and an ECG may show a right ventricular strain Manchester
Symptoms of OSA include heavy snoring, pattern. M27 4HA

Anaesthetic considerations The main disadvantages of the LMA are that it does not offer
The main areas of anaesthetic concern are airway management, the definitive airway provided by a tracheal tube and it may
provision of analgesia, and prevention of postoperative nausea restrict surgical access in younger patients. However, with both
and vomiting (PONV). the tracheal tube and the LMA, dislodgement or compression
can occur during positioning of the mouth gag, and airway
Airway management patency must be re-confirmed before surgery proceeds.
Sharing the airway with the surgeon, remote access, and the
need to prevent soiling of the respiratory tract are factors that A postal survey of anaesthetic techniques used in paediatric
need to be taken into consideration in airway management. tonsillectomy in the UK in 1996 7 suggested that only
Two techniques are commonly used: the tracheal tube and the 16% of anaesthetists used the reinforced LMA routinely.7
reinforced laryngeal mask airway (LMA).5,6 The advantages I.V. induction with propofol, tracheal intubation with
and disadvantages of these techniques are compared in Table1. succinylcholine, and spontaneous ventilation with isoflurane
were the commonest anaesthetic techniques.7 Concern about
The tracheal tube provides a definitive airway, and a south- the danger of succinylcholine-induced hyperkalaemic cardiac
facing RAE tube positioned in the midline provides good arrest in children with undiagnosed muscle disease has led to a
surgical access. The disadvantages of intubation are that decline in the use of this drug for elective intubation. Alternative
muscle paralysis or a deep plane of anaesthesia are required, techniques for intubation include deep inhalation anaesthesia,
bronchial intubation or accidental extubation can occur with combinations of propofol with a short-acting opioid, or the
surgical movement of the neck, and there is variable protection use of a short-acting non-depolarizing neuromuscular blocking
against airway soiling. The dilemma of whether to extubate agent during light anaesthesia.
the patient when fully awake and able to protect their airway
or still deeply anaesthetized to avoid a stormy emergence and Analgesia
bleeding always exists. The reinforced LMA offers a good Adequate postoperative analgesia is best provided with a
airway with no soiling of the respiratory tract, avoidance of the combination of simple analgesics and small doses of opioids.
use of neuromuscular blocking agents, smooth emergence, and Paracetamol8 and NSAIDs have a morphine-sparing effect.
airway protection until awake. To avoid soiling the laryngeal The concerns around the potential for increased perioperative
inlet, the LMA should be removed with the cuff still inflated. bleeding with NSAIDs have largely been discounted. The
To ensure best surgical access, the smallest LMA for size should exception is ketorolac, which you should avoid. Administering
be used, and when positioned correctly, the cuff should not be the simple oral analgesics before operation is safe and ensures
visible once the Boyle-Davis gag has been opened to its fullest effectiveness by the end of surgery. Alternatively, the rectal
extent. An incorrectly sized LMA, or too large a blade on the route can be used after induction of anaesthesia. However, this
mouth gag, can cause obstruction. route is less acceptable to many patients and will not achieve
Table 1. Comparison of the LMA and the tracheal tube for tonsillectomy
LMA Tracheal tube

Advantages Straightforward airway More secure airway
No soiling of airway with blood Good surgical access
Smooth emergence
Paralysis not required
Airway protection until awake
Minimizes trauma to the airway
Disadvantages Less secure airway Risk of airway trauma

May impair surgical access Oesophageal/bronchial intubation
Requires paralysis
Soiling of airway with blood
Problems associated with extubation

therapeutic levels by the end of surgery in most cases. haemorrhage and the management of postoperative pain and
PONV.
A single dose of dexamethasone 0.1 0.5mg.kg-1 has also
been shown to reduce postoperative analgesic requirements, The incidence of early postoperative bleeding is <1% and the
whereas local anaesthetic infiltration of the tonsillar bed has majority of these occur within the first 4h after surgery. An
not been found to be superior to placebo. Regular doses of extended observation period of 4 6h before discharge is
paracetamol and an NSAID after operation provide good therefore recommended; this limits surgery to morning lists.
analgesia. Recently, concerns have been raised about respiratory A multimodal analgesic and antiemetic regimen as previously
depression and even death following use of codeine for discussed is very important, as the main reasons for overnight
postoperative analgesia. The current UK recommendation is admission are PONV, pain, and poor oral intake.
to avoid codeine in any child with history of OSA undergoing Bleeding tonsil
(adeno)tonsillectomy, and in any child under 12 years old.9 Haemorrhage is the most serious complication after
tonsillectomy and can occur within the first 24h (primary
Prevention of postoperative nausea and vomiting (PONV)
haemorrhage) or up to 28 days after surgery (secondary
The incidence of PONV can be as high as 70% after
haemorrhage). In the National Prospective Tonsillectomy
adenotonsillectomy and a multimodal approach is indicated
Audit (July 2003 September 2004), the incidence of post-
to combat this.
tonsillectomy haemorrhage patients was 3.5% and the overall
Minimizing starvation, avoiding the use of rate of return to theatre was 0.9%. The incidence of primary
nitrous oxide (N2O), and balanced analgesia with haemorrhage was 0.6% and the majority of these occurred
prophylactic administration of antiemetics reduce the within the first 6h after operation. Factors influencing
incidence of PONV. A combination of ondansetron haemorrhage rates were age (lower rates in children than
0.1 - 0.2mg.kg-1 and dexamethasone 0.1 - 0.5mg.kg-1 adults), indication for surgery (highest rates with quinsy and
(maximum 8mg) intraoperatively has been shown to recurrent tonsillitis, lowest with obstructive symptoms), and
greatly reduce the incidence of PONV.9 Intraoperative fluid surgical technique (higher rates with use of diathermy and
administration has also been shown to decrease the incidence disposable equipment, lowest with blunt dissection).
of postoperative nausea. Rescue antiemesis can be provided by The anaesthetic considerations in bleeding tonsil include
further doses of ondansetron with or without cyclizine 0.5 hypovolaemia, the risk of pulmonary aspiration (swallowed
1mg.kg-1 (up to 50mg). blood with or without oral intake), potential for a difficult
intubation because of excessive bleeding obscuring the view
Special considerations with or without oedema after earlier airway instrumentation,
Severe OSA a second general anaesthetic, and the stress to both child and
In general, sedative premedication and long-acting opioids are parents. Blood loss is because of venous or capillary ooze from
best avoided in patients with severe OSA. Inhalation induction the tonsillar bed and is difficult to measure, as it occurs over
is preferred, as airway obstruction commonly occurs during several hours and is partly swallowed.
induction, and children with associated craniofacial anomalies Excessive blood loss may lead to the child spitting blood. In
may prove to be difficult to intubate.2 Consideration should these cases, the child is likely to be seriously hypovolaemic,
be given to the use of a small dose of fentanyl to supplement anaemic, and potentially difficult to intubate because of
simple analgesia, as this is associated with less postoperative poor visualization of the larynx. Tachycardia, tachypnoea,
respiratory depression. delayed capillary refill, and decreased urine output are early
The incidence of complications varies with the time of day that indicators of hypovolaemia, whereas hypotension and altered
the procedure is performed. Children undergoing surgery in sensorium are indicators of advanced volume depletion.
the morning have fewer desaturations than those undergoing Preoperative resuscitation ( guided by trends in monitoring) is
the same procedure in the afternoon. Close postoperative essential, even if this requires the insertion of an interosseous
monitoring and the availability of an ICU bed is required. needle. Induction of anaesthesia in a hypovolaemic child
can precipitate cardiovascular collapse. Haemoglobin and
Day-case tonsillectomy coagulation variables should be checked. Blood and blood
Successful and safe implementation of day-case tonsillectomy products should be immediately available and transfused
requires careful patient selection. Exclusion criteria include as necessary. Before induction, in addition to the standard
age >3 years, significant co-morbidity, OSA, and living further equipment, a selection of laryngoscope blades, smaller than
than a one hour drive from the hospital or having no private expected tracheal tubes, and two suction catheters should
transport. Thought also needs to be given to the risk of early be immediately available. Anaesthesia is induced once the

child is haemodynamically stable. Preoxygenation and rapid secondary to recurrent URTI, and mechanical obstruction of
sequence induction with slight head-down positioning of the the Eustachian tube orifice by enlarged adenoids, lead to a
patient ensures rapid control of the airway and protection negative pressure in the middle ear and a transudative effusion
from pulmonary aspiration. Consider adopting the left (secretory otitis media). Children with otitis media present
lateral position if bleeding is excessive. Controlled ventilation with deafness and complications such as perforation, ossicular
provides good conditions for haemostasis. chain damage, and cholesteatoma. Surgery is performed to
improve hearing and to eradicate middle-ear disease.
Fluid resuscitation and transfusion of blood and blood
products should continue intraoperatively as necessary. Once Myringotomy
haemostasis is achieved, a large-bore stomach tube is passed Myringotomy and insertion of pressure-equalizing tubes are
under direct vision and the stomach emptied. Neuromuscular used to improve middle-ear aeration and hearing in chronic
block is antagonized and the trachea is extubated, with the otitis media. It is a short procedure performed as a day-case.
child fully awake in the recovery position. After operation, The preoperative assessment should elicit features of URTI,
the child should be monitored closely for any recurrence of as otitis media is associated with recurrent URTI and these
bleeding. children can consequently have increased airway irritability. A
Oesophagoscopy small percentage of this population may also display symptoms
Rigid oesophagoscopy is performed for the removal of an of OSA secondary to adenoidal hypertrophy. The anaesthetic
ingested foreign body. History of ingestion, dysphagia, and technique usually involves the patient breathing spontaneously
odynophagia are the usual presenting symptoms, whereas a via a facemask or LMA, with the head positioned to one side.
previous stricture is a predisposing factor for obstruction. The Mild postoperative pain can occur in up to 75% of patients,
commonest site of impaction of the foreign body is at the level but this can be avoided with the preoperative administration
of the cricopharyngeus muscle. Oesophagoscopy should be of paracetamol, NSAIDs, or both.11
performed in all cases of suspected impacted foreign body to
prevent complications of perforation, mediastinitis, and fistula Myringoplasty, tympanoplasty, and
formation. mastoidectomy
Children with complications of chronic otitis media need
Anaesthetic considerations include management of the shared more complex ear surgery. Myringoplasty involves repair of a
airway and the risk of pulmonary aspiration or oesophageal tympanic membrane perforation in a dry ear. Tympanoplasty
perforation during the procedure. A rapid sequence induction is performed when there is extensive middle-ear damage and
protects against pulmonary aspiration and ensures rapid involves reconstruction of the tympanic membrane and the
control of the airway. The tracheal tube should be secured ossicular chain. The approach to the ear can be permeatal
on the left side to allow easier access for the endoscopy. or postaural, the latter providing better surgical access. Two
Adequate depth of anaesthesia and muscle relaxation during surgical techniques of tympanic membrane grafting are used,
the procedure are essential to reduce the risk of oesophageal the underlay and the overlay. The underlay technique involves
perforation. Analgesia is provided by a combination of elevation of a tympanomeatal flap and placing the graft
intravenously or rectally administered simple analgesics and material underneath (or medial to) the eardrum.
a small dose of opioid. The patient is extubated when fully
awake. If oesophageal perforation is suspected, withold oral The overlay technique involves stripping the lateral epithelium
intake, commence IV antibiotics, and observe the patient off the eardrum and placing the graft material on the outer
closely for features of mediastinitis, such as severe chest pain, side of (or distal to) the eardrum. Various graft materials may
pyrexia, and subcutaneous emphysema. be used, the most common being temporalis fascia, tragal
perichondrium, and fat.
Ear surgery Mastoidectomy is performed to eradicate chronic suppurative
The most common surgical procedures on the ear are those middle-ear disease. The anaesthetic considerations associated
performed to treat otitis media and its complications. Otitis with these three procedures are similar; therefore, we shall
media is the second most prevalent illness of childhood. This described their anaesthetic management collectively.
is because of a combination of factors including Eustachian
tube dysfunction and an increased susceptibility to upper Anaesthetic considerations
respiratory tract infection (URTI) in early childhood. The Typically, these procedures are performed in the older child or
short Eustachian tube in young children predisposes to reflux teenager and can be of prolonged duration. The main factors
of nasopharyngeal secretions into the middle ear space and thus that have a bearing on anaesthetic management are the effect
to recurrent infections. Oedema of the Eustachian tube mucosa of N2O on the middle ear, the need for a bloodless operative

field, the use of facial nerve monitoring by the surgeon, and reinforced LMA. The advantages of a tracheal tube over an
the high associated incidence of PONV. LMA are a secure airway and ease of controlled ventilation,
though a stormy emergence contributing to graft displacement
As the relative solubility of N2O in blood is 34 times that of is a potential problem. Smoother emergence can be ensured by
nitrogen, it diffuses across into the non-compliant middle-ear tracheal extubation in a deep plane of anaesthesia. A reinforced
cavity much more rapidly than nitrogen can leave. This can LMA has the potential advantages of less airway stimulation
lead to pressures as high as 350 mm H2O within 30 min of and smooth emergence, but care must be taken to limit airway
commencing N2O, especially in the presence of Eustachian inflation pressures in order to prevent gastric distension during
tube dysfunction.12 controlled ventilation.
Displacement of tympanoplasty grafts, worsening of deafness, For either technique and where available, maintenance of
rupture of the tympanic membrane, and increased PONV anaesthesia with propofol and remifentanil, or sevoflurane and
have all been associated with elevated middle-ear pressures. In remifentanil, offers many advantages. They allow controlled
addition, after discontinuation of N2O, rapid re-absorption of ventilation without neuromuscular blocking agents, thus
the gas leads to negative pressures in the middle ear and this permitting unimpeded facial nerve monitoring. Remifentanil
can lead to lifting off of the underlay tympanic membrane provides a titratable degree of hypotension while maintaining
graft. As the middle ear remains open until the surgeon places a stable heart rate and provides excellent operating conditions.
the graft over the tympanic membrane, N2O can be used up The use of TIVA is also associated with a lower incidence of
to 10 15min before graft placement and then discontinued. PONV.13
However, it may be best to avoid its use in middle-ear surgery
completely.
Analgesia and antiemesis
Any bleeding during middle-ear surgery distorts the view A multimodal approach provides good analgesia and minimizes
through the operating microscope and can make the procedure opioid-induced PONV. Oral paracetamol and NSAIDs
difficult. Venous ooze can be minimized by a head-up tilt of 10o given before operation are better accepted by the older child;
15o and ensuring unimpeded venous drainage. Epinephrine alternatively, these can be given rectally or intravenously
infiltration by the surgeon, relative hypotension (mean arterial during surgery. As remifentanil has no residual analgesic effect
pressure 10 20%, normal), and avoidance of tachycardia after termination of the infusion, a small dose of morphine
minimize arterial bleeding. should be given 30 40 min before the end of the procedure
to ensure adequate analgesia on awakening. A greater auricular
In its course through the temporal bone, the facial nerve runs nerve block has been shown to reduce postoperative opioid
through the middle ear in close relation to the ossicles and requirement. Postoperative analgesia is provided by regular,
through the mastoid before emerging from the stylomastoid simple analgesics and small doses of opioids if necessary.
foramen. Therefore, it is vulnerable to damage during middle-
ear surgery, especially as the disease process can distort the Routine prophylactic ondansetron and dexamethasone are
anatomical relationship of the nerve to the ear structures indicated because of the emetogenic potential of middle-ear
and make identification difficult. Intraoperative facial nerve surgery. Avoiding prolonged starvation, adequate hydration,
monitoring is useful for identification and preservation of the avoiding N2O, use of TIVA, and balanced analgesia also help
nerve during ear surgery. A single dose of a short-intermediate decrease PONV.
acting relaxant can be used to aid tracheal intubation, its
effects should have worn off sufficiently before the stage in the Bone-anchored hearing aid
operation when facial nerve monitoring is required. However, it The bone-anchored hearing aid (BAHA) is a surgically
may be prudent to avoid the use of relaxants altogether by using implantable system for the treatment of conductive deafness
other agents to facilitate intubation or by avoiding intubation. in children with chronic ear infections or congenital external
Whether using a tracheal tube or an LMA, the patient requires auditory canal atresia who cannot benefit from conventional
controlled ventilation for this procedure. Much of the surgery hearing aids. It allows sound to be conducted through the bone
is performed using an operating microscope; therefore, if rather than via the middle ear, a process known as direct bone
paralysis is to be avoided, a deep plane of anaesthesia is conduction. The procedure involves two short operations.
required to guarantee immobility. Controlled ventilation also Firstly, a titanium fixture is implanted into the mastoid bone
allows control of the end-tidal CO2, which helps to minimize and this over time integrates with the bone of the skull. Around
bleeding. 6 months later, at a second operation, an external abutment is
placed over the fixture and this allows a sound processor to be
The options for airway management are a tracheal tube or a connected.

The majority of children presenting for BAHA implant 5. Williams PJ, Bailey PM. Comparison of the reinforced laryngeal
have associated congenital anomalies, the commonest being mask airway and tracheal intubation for adenotonsillectomy.
Br J Anaesth 1993; 70: 30 3.
Goldenhars syndrome (26%) and Treacher Collins syndrome
6. Webster AC, Morley-Forster PK, Dain S, Ganapathy S, Ruby R,
(21%).13 There is also a high incidence of congenital heart
Au A, Cook MJ. Anaesthesia for adenotonsillectomy: a
disease (19%) and craniofacial anomalies. The main anaesthetic comparison between tracheal intubation and the armoured
concern is an increased incidence of difficult intubation. In laryngeal mask airway. Can J Anaesth 1993; 40: 1171 7.
most instances, after inhalation induction, the airway can be 7. Hatcher IS, Stack CG. Postal survey of the anaesthetic techniques
safely and easily maintained using a reinforced LMA. However, used for paediatric tonsillectomy surgery. Paediatr Anaesth 1999;
equipment for fibreoptic intubation and appropriately trained 9: 311 5.
staff should be available in the event of a need for intubation. 8. Korpela R, Korvenoja P, Meretoja OA. Morphine-sparing
Analgesia is provided with a combination of paracetamol, effectof acetaminophen in pediatric day case surgery.
NSAID, and a small dose of opioid. Routine antiemetics are Anesthesiology 1999; 91: 442 7.
indicated, as PONV is common. 9. Guidance for the administration of codeine and alternative opioid
analgesics in children: Joint guidance from the RCoA, APA and
RCPCH. Published November 26th 2013 Available from: http://www.
References apagbi.org.uk/sites/default/files/images/Codeine_Nov2013.pdf
Ravi R, Howell T. Anaesthesia for paediatric ear, nose and
throat surgery. Update in Anaesthesia (2008), 24(1):18-23. 10.
Steward DL, Welge JA, Myer CM. Steroids for improving
Available from: http://www.wfsahq.org/components/com_ recovery following tonsillectomy in children. Cochrane Database
virtual_library/media/cf2070c8974e043763936f7aeeffad69- Syst Rev 2003; 1: CD003977.
6922932df850570c39edd579d02ab2bf-Anaesthesia-for-Paediatric-ENT-
11. Watcha MF, Ramirez-Ruiz M, White PF, Jones MB, Lagueruela
Surgery--Update-24-1-2008-.pdf
RG, Terkonda RP. Perioperative effects of oral ketorolac and
acetaminophen in children undergoing bilateral myringotomy.
1. Dix P. Bronchoscopy for a foreign body in a child.
Can J Anaesth 1992; 39: 649 54.
See article in this editon, page 173.
12.
Chinn K, Brown OE, Manning SC, Crandell CC. Middle ear
2. Warwick JP, Mason DG. Obstructive sleep apnoea syndrome in
pressure variation: effect of nitrous oxide. Laryngoscope 1997;
children. Anaesthesia 1998; 53: 571 9.
107: 357 63.
3. Rosen GM, Muckle RP, Mahowald MW, Goding GS,
Ullewig C. Postoperative respiratory compromise in children 13. Mukherjee K, Seavell C, Rawlings E, Weiss A. A comparison of
with obstructive sleep apnoea syndrome: can it be anticipated? total intravenous with balanced anaesthesia for middle ear
Pediatrics 1994; 93: 784 8. surgery: effects on postoperative nausea and vomiting, pain and
conditions for surgery. Anaesthesia 2003; 58: 176 80.
4. Nixon GM, Kermack AS, Davis GM, Manoukian JJ, Brown
KA, Brouillette RT. Planning adenotonsillectomy in children 14. Jones SEF, Dickson U, Moriarty A. Anaesthesia for insertion of
with obstructive sleep apnoea: the role of overnight oximetry. bone- anchored hearing aids in children: a 7 year audit.
Pediatrics 2004; 113: 19 25. Anaesthesia 2001; 56: 777 98.

Elective Procedures
Anaesthesia for paediatric eye surgery
Reprinted with revisions from: Stuart G. Anaesthesia for paediatric eye surgery. Anaesthesia Tutorial of the
Week 144 (2009)
Grant Stuart
Correspondence email: grant.stuart@gosh.nhs.uk
INTRODUCTION Anaesthetic considerations
Unlike adults, children requiring eye surgery do not Premedication and induction of anaesthesia
tolerate sedation or local anaesthetic techniques and The decision to premedicate the child and the
therefore almost always require general anaesthesia. choice of induction technique, intravenous (IV)
This update will present a general review of the or inhalational, should be tailored to the needs of
principles of anaesthesia for children undergoing the child and to the preferences of the anaesthetist.
eye surgery and a description of anaesthesia for some Children with visual impairment should be handled Summary
specific procedures. in a careful and sensitive manner.
Children require general
Airway management anaesthesia for
GENERAL PRINCIPLES OF ANAESTHESIA FOR
Airway management should be tailored to the ophthalmic procedures/
PAEDIATRIC EYE SURGERY
procedure. For measurement of intraocular pressure surgery, but can
Preoperative considerations (IOP), spontaneous respiration via a facemask should generally be managed as
Most children presenting for eye surgery are healthy, be used, as intubation will raise the intraocular day cases.
ASA I or II and may be managed as day cases. A pressure. For simple procedures such as examination The oculocardiac
small number have underlying conditions, often of a under anaesthesia (EUA) it may be more convenient reflex may be induced
chromosomal or metabolic nature, which pose more to maintain spontaneous respiration through a during eye surgery and
specific anaesthetic challenges.1,2 Examples of these reinforced laryngeal mask airway (LMA), particularly risks provoking
are described in appendix 1. where a sterile field is required. dangerous bradycardias.
Prevent these by
The reinforced LMA may be used in older children for premedicating with
Ophthalmic medications
most eye procedures. It is possible to use controlled anticholinergic agents.
Many children requiring eye surgery receive eye drops.
ventilation with muscle relaxants, and coughing is
Knowledge of commonly used drugs and potential Postoperative nausea
reduced at the end of the surgery.
side effects is useful (See table 1). Medications may and vomiting is
be absorbed through the pharyngeal mucosa via the Intraocular surgery requires a still eye with low common after eye
nasolacrimal ducts to cause systemic effects, although intraocular pressure. The airway is best managed by surgery in children.
this is rarely a significant problem.2,3,4 intubation with paralysis and controlled ventilation.
Table 1. Common ophthalmologic preparations and their side effects.
Eye preparations Indication Systemic side effect

Beta-blockers: Timolol maleate or Glaucoma Bradycardia refractory to atropine;
Betaxolol hydrochloride bronchospasm in asthmatics
Carbonic anhydrase inhibitors: Glaucoma Metabolic acidosis, electrolyte
Acetazolamide (diamox) abnormalities, allergies, including
Stevens-Johnson syndrome
Antimuscarinic agents: Cyclopentolate Pupil dilatation Dry mucous membranes, nausea and
or Atropine vomiting, tachycardia
Alpha-adrenergic sympathomimetic Pupil dilatation Hypertension, tachycardia
agents: Phenylephrine 2.5%
NSAIDS: Diclofenac sodium, Ketorolac Pain relief Potential to worsen or precipitate acute Grant Stuart
trometamol 0.5% asthma Consultant Anaesthetist,
Local anaesthetic agents: Amethocaine Pain relief or prevention Local anaesthetic toxicity, particularly Great Ormond
(Tetracaine), Oxybuprocaine, preterm neonates Street Hospital,
Proxymetacaine London

Similarly, eye surgery in very young children is best managed with Laryngoscopy, coughing, straining, crying, bucking and the process
intubation and controlled ventilation to ensure a secure airway. Access of tracheal extubation may all cause a rise in IOP. This effect may be
to the airway will be restricted during the surgery so it is important to attenuated by lidocaine 1mg.kg-1 IV 3 minutes prior to intubation
secure the tracheal tube firmly. A preformed south facing RAE tube or extubation. Use of the LMA allows smoother induction and
is ideal, but this may be too long in neonates; a reinforced flexible emergence from anaesthesia and has much less effect on IOP.13,14,15
tracheal tube (ETT) may be preferable in this situation. Hypoxia and hypercapnia both increase IOP.
Maintenance of anaesthesia Hypocapnia and hypothermia decrease IOP.
As with induction, the choice of maintenance technique rests largely
The oculocardiac reflex
on the preferences of the anaesthetist and the availability of different
The oculocardiac reflex is common during eye surgery in children,
agents.
and is seen in up to 60% of children undergoing strabismus surgery.
The incidence of dysrhythmias is increased with halothane, It is essential to use continuous heart rate monitoring with an
particularly if there is hypercapnia and eye preparations containing ECG during eye surgery in children. The reflex takes its afferent
atropine or adrenaline are used. Isoflurane or sevoflurane may be innervations from the ophthalmic division of the trigeminal nerve,
preferable. relays via the sensory nucleus in the 4th ventricle, with the efferent
impulse passing through the vagus nerve.1,2
Propofol has anti-emetic effects. Total intravenous anaesthesia
(TIVA) with propofol reduces the risk of postoperative nausea and Surgical traction on the extra-ocular eye muscles or pressure on the
vomiting (PONV). Remifentanil can reduce volatile requirements.5,6 globe causes a sinus bradycardia, and occasionally junctional rhythms,
atrioventricular block, atrial ectopics or ventricular ectopics. The
Nitrous oxide is of limited value in eye surgery as it increases reflex is most commonly induced by traction on the medial rectus
PONV and diffuses into gas filled spaces. It should be avoided in muscle, rather than the smaller lateral rectus muscle. The bradycardia
vitreoretinal detachment surgery where intraocular gas bubbles of resolves almost immediately after the stimulus has been removed and
sulphur hexachloride or perfluropropane are introduced into the eye weakens with repetition of the stimulus.
to tamponade detached surfaces as it will cause significant rise in
intraocular pressure. It should also be avoided for any patient who Atropine 20mcg.kg-1 IV or glycopyrrolate 10mcg.kg-1 IV at induction
has undergone recent vitreoretinal detachment surgery as the bubble will block the oculocardiac reflex. If not given at induction, it is
may last several weeks. Alternatively, if nitrous oxide was used from important to have the drugs drawn up and ready to administer if
the start of the anaesthetic, prior to placement of the gas bubble, it bradycardia should occur.
will diffuse out of the bubble on completion of the anaesthetic and The reflex may be attenuated by application of topical local
increase risk of re-detachment. anaesthetic agents to the eye (such as tetracaine eye drops), or by
blocking the afferent limb of the reflex with a peribulbar block,
Anaesthetic agents and intraocular pressure although this block is not usually used in children due to the risk of
Normal intraocular pressure (IOP) ranges from 10 to 20mmHg. globe perforation.16,17
Most anaesthetic agents will decrease this. Table 3 describes the
effects of commonly used anaesthetic agents on IOP.7,8,9,10,11,12 If The oculocardiac reflex is less common with sevoflurane compared
serial measurements of IOP are being made, it is important to be to halothane, and less common with deep anaesthesia compared
consistent with the type of anaesthetic used on different occasions. to light anaesthesia.18 The likelihood of significant bradycardia is
doubled if hypercarbia is present, so controlled ventilation should
Anaesthetic techniques and intraocular pressure be considered. The oculocardiac reflex is more likely to occur with
Physical and physiological variables have an important effect on IOP. rocuronium compared to atracurium.1
Table 2. Anaesthetic agents and their effects on intraocular pressure.
Anaesthetic agent Effect on intraocular pressure

Propofol, thiopentone IOP reduced by 20-30% (3-7mmHg)
Halothane, sevoflurane, isoflurane, desflurane IOP reduced by 20-30% (3-7mmHg)
Opioids Minimal to no effect on IOP
Ketamine Dose dependent increase in IOP (minor); marked when dose exceeds
5mg.kg-1
Atropine No effect on IOP
Non-depolarising muscle relaxants Minimal to no effect on IOP
Suxamethonium Significant increase in IOP within 30 sec of administration (approx 8mmHg),
effect lasts for 5-7 minutes, less if given with agents that reduce IOP
Acetazolamide, mannitol, dextrans Used for acute reduction of IOP perioperatively

Children who exhibit the oculocardiac reflex are more likely to develop Alternatively, inhalational induction may be used. The
PONV19 and should receive an antiemetic during anaesthesia. ophthalmologist should be present in the room so that the IOP can
be measured as soon as the child is still. The child should not be too
Extubation and emergence from anaesthesia
deeply anaesthetised, the eyes should be central and the facemask
It is important to avoid coughing and bucking on the tracheal tube
must not press on the eyes.
at the end of surgery, particularly for children who have undergone
intraocular surgery. For this reason, many anaesthetists use a laryngeal Regardless of the technique used, the IOP should always be measured
mask airway for eye surgery. If a tracheal tube has been used, the before laryngoscopy or LMA insertion, although there is little
child should be extubated deep, if possible. If deep extubation is evidence to prove that the latter significantly raises IOP. A consistent
contraindicated, for instance if the child has a full stomach, lidocaine technique should be ensured if serial measurements of IOP are to be
1mg.kg-1 IV can be given to reduce rises in IOP. made.
Principles of pain relief and postoperative care Syringing and probing of nasolacrimal ducts
Pain after eye surgery is usually mild to moderate and can be Children with blocked nasolacrimal ducts will usually present early
managed with simple analgesics such as paracetamol, NSAIDS and in life with increased tearing. Most respond to probing of their
topical local anaesthetic agents. These may be given pre-emptively as nasolacrimal ducts, which is a short procedure for which an LMA
oral preparations preoperatively or rectally/IV at induction. will suffice.
Squint surgery, evisceration and vitreoretinal surgery is associated Should simple probing fail, the surgeon might place a silicone catheter
with more severe pain. Analgesia should include an opioid such as through the duct where it is secured for a few weeks. Alternatively the
fentanyl IV, paracetamol, NSAIDs, and topical local anaesthetic inferior turbinate bone may be fractured to relieve the obstruction.
if possible. Multimodal analgesia should be continued into the Dacrocystorhinostomy is a more extensive procedure that involves
postoperative period, with the addition of codeine phosphate or exposure of the duct and creation of a new opening into the nasal
tramadol, escalating to morphine if required. The use of opioids cavity.1
increases the risk of PONV and antiemetics are essential.
Anaesthetic considerations
PONV is extremely common after paediatric eye surgery, and The main problem is bleeding from the nasal mucosa:
for strabismus surgery can be as high as 60% if no prophylaxis is
Topical vasoconstrictors reduce bleeding from the nasal mucosa.
given. The combination of ondansetron 0.15mg.kg-1 IV , and
dexamethasone 0.1-0.2mg.kg-1 IV reduces PONV to 10% in Hypotensive anaesthesia may be required to reduce bleeding, for
strabismus surgery.20,21,22 It is wise to leave the IV cannula in place instance, relatively deep anaesthesia with moderate head up tilt.
postoperatively where PONV may be a problem so that further anti-
The airway should be protected from blood, ideally with a throat
emetics and IV fluids can be given.
pack, and the nasopharynx should be suctioned before
Ketamine is associated with emergence phenomena and the child extubation.
should be recovered in a quiet area with minimal stimulation.12 Opioids may be required for analgesia for this procedure.
Most paediatric eye procedures are treated as day cases and children Strabismus surgery
may resume oral intake as soon as they are able. Occasionally PONV Squint is a common problem that affects 3 5% of the population,
results in an unplanned overnight admission. making strabismus surgery the most commonly performed eye
operation in children. It affects males and females equally.
ANAESTHESIA FOR SPECIFIC OPHTHALMIC CONDITIONS
AND PROCEDURES Squints are usually idiopathic, but may also be secondary to
intracerebral space occupying lesions, trauma, infection or
EUA and measurement of IOP inflammation causing muscle palsies. Most patients are healthy,
For an examination of the eyes under anaesthesia, either an but occasionally squints may be associated with a family history,
inhalational or intravenous induction technique and airway prematurity, and disorders of the central nervous system such as
maintenance with a facemask will suffice. It may be technically easier cerebral palsy, hydrocephalus and myelomeningocoele. Patients
to place an LMA for a longer EUA. may have occult myopathies and there is a threefold increase in the
incidence of masseter spasm. Anecdotal evidence of an increased
Most anaesthetic agents decrease IOP, which may potentially mask
association with malignant hyperpyrexia remains unproven.2
a high IOP.
Squint correction is achieved by lengthening (recession), shortening
Some anaesthetists advocate the use of ketamine 12mg.kg-1 IV or
or tightening (resection) or transposition of any of the four rectus
510mg.kg-1 IM for IOP measurements, as it does not drop IOP.
and two oblique extra-ocular muscles, or combinations of any of the
Although it may slightly raise IOP, this may be safer than having a
above.
falsely low reading. Ketamine increases secretions so should be given
with either atropine 20mcg.kg-1 IV or glycopyrolate 10mcg.kg-1 IV. Surgeons may use forced duction testing to distinguish a paretic
Airway reflexes are maintained and instrumentation of the airway is muscle from one that has restricted motion. Botulinum toxin may
rarely required.1,11,12 be injected into the extra-ocular muscle for minor abnormalities.

This requires electromyelogram (EMG) control and muscle relaxants 3 4 divided doses suppresses aqueous production, but its usefulness
should be avoided.1 is limited since the causes of glaucoma are usually structural and
related to drainage.
In older children an adjustable suture may be used that allows fine
adjustments to be made 24 to 48 hours postoperatively under topical Surgical treatments may vary:
local anaesthetic once the patient is awake. Goniotomy involves visualising the anterior chamber with a
Anaesthetic considerations gonioscope and making an incision into the trabecular meshwork
Induction technique, the method of airway control and choice of to allow drainage.
ventilation may be guided by the preference of the anaesthetist. Trabeculotomy involves the insertion of a fine probe into
TIVA with propofol reduces PONV. Alternatively, anaesthesia Schlems canal to create a new drainage channel.
may be maintained with a volatile agent and air/oxygen. Trabeculectomy involves the creation of a new drainage channel
Consider atropine 20mcg.kg IV or glycopyrolate 10mcg.kg
-1 -1 from the anterior chamber into sub-Tenons space where the
IV to block the oculocardiac reflex. aqueous is absorbed.
PONV is common postoperatively, up to 5075%. Give Cyclocryotherapy is the ablation of part of the ciliary body by a
two anti-emetic agents such as ondansetron 0.1mg.kg-1 IV and cryoprobe at - 60 to - 80 degrees Celsius to reduce the production
dexamethasone 0.1-0.2 mg.kg-1 IV.20,21,22 of aqueous humour.2
Extubate the child deep if possible. Anaesthetic considerations

Avoid raising the IOP by ensuring a smooth induction and deep
Analgesia should include topical tetracaine or oxybuprocaine, emergence without coughing.
NSAIDS such as ibuprofen or diclofenac and paracetamol,
unless contraindicated. Maintain a motionless eye; consider muscle relaxants and
controlled ventilation to avoid hypercapnia.
Intraoperative opioids should be avoided if possible.
Analgesia with paracetamol and NSAIDS is usually adequate,
A peribulbar block is effective for analgesic requirements and however when cyclocryotherapy is used opioids may be necessary.
reduces PONV, possibly by blocking the ophthalmic division of
the trigeminal nerve that passes to the vomiting centre in the High incidence of PONV, give routine anti-emetics.
medulla. The risk of globe perforation in children makes most Cataract extraction
practitioners cautious of this.17 Cataracts are a major cause of childhood morbidity worldwide,
A sub-Tenon block performed intraoperatively by the surgeon predominantly in the developing countries of Africa and Asia (85%
provides effective analgesia. of cases).
Glaucoma Aetiology may be varied:2

The pressure within the eye is maintained through a balance between Hereditary cataracts are autosomal dominant and present in
the production of aqueous humor, primarily by the ciliary body in otherwise healthy children.
the posterior chamber, and drainage via the trabecular network to the Syndromes may be associated with cataracts. Some include Lowes
canal of Schlem in the anterior chamber. oculo-cerebro-renal syndrome (X-linked recessive), Down
syndrome (trisomy 21), Edward syndrome and Cri-du-chat
In glaucoma the normal IOP of 1020mmHg is elevated so that
syndrome.
capillary blood flow to the optic nerve is reduced, which compromises
the function of the optic nerve. Metabolic causes of cataract may include glucose-6-phosphate
dehydrogenase deficiency, hypoglycaemia, hypocalcaemia and
The causes of glaucoma are varied: galactosaemia.
Primary congenital glaucoma is caused by a failure of the
development of the trabecular network, reducing the drainage of Blunt or penetrating trauma over time may cause unilateral
aqueous humour. It is bilateral in 75% of cases and has a cataracts.
prevalence of 1:10000 births. There is a male to female ratio of Inflamation such as the uveitis associated with juvenile chronic
35%: 65% and it is more common in children below the age of arthritis may cause cataracts.
3 years.
Tumours, such as retinoblastoma can cause cataracts.
Secondary glaucoma is usually caused by blockage of existing Intrauterine infections, including rubella, cytomegalovirus
drainage channels by infection, inflammation or trauma. It is (CMV), toxoplasma and toxocariasis.
also seen in some rare syndromes such as Sturge-Weber
Syndrome, Axenfeld Syndrome and in association with aniridia Radiation for leukaemia might cause cataracts.
in 20% of patients with Wilms tumour.2 Chronic steroid use can result in cataracts.
Treatment may be medical or surgical. Medical treatment consists of Treatment involves surgical implantation of an intraocular lens. This
drugs used to reduce IOP. Acetazolamide 1530mg.kg-1.day-1 PO in needs to be done very early (as early as 4 weeks old) in order to allow

stimulation of the retina and visual development. The procedure Consider blunting the intubation response prior to laryngoscopy.
takes about 30 - 60 minutes, but complications can be more frequent Administer lidocaine 1-2 mg.kg-1 IV given 3 minutes prior to
than in adults and include uveitis, glaucoma, endophthalmitis, rapid sequence intubation during preoxygenation.
iris damage or prolapse, retinal detachment and thickening of the
Vitreoretinal surgery
posterior lens capsule.2
Vitreoretinal surgery is performed for the repair of a detached retina,
Anaesthetic considerations and although uncommon, may be necessary in children. Detachment
Aim for a motionless eye either with deep anaesthesia or muscle may be primary where it is related to a defect in the retina, or secondary
relaxants. to an underlying illness. The surgery involves creating a choreoretinal
scar with cryotherapy and placing a scleral buckle towards the back of
Avoid high IOP with a smooth induction and emergence.
the eye, which serves to oppose the neuroretina and retinal pigment
Consider controlled ventilation to avoid hypercapnia. epithelium. The surgeon may place an intraocular bubble of either
sulphur hexafluoride or perfluropropane to tamponade the detached
Give anti-emetics.
surfaces together.1,2
Enucleation and evisceration
Anaesthetic considerations
Enucleation is the removal of the whole eye. This may be done for
Avoid nitrous oxide if an intraocular gas bubble is used, both
surgical treatment of a retinoblastoma, significant eye trauma or for
during surgery and for several weeks after. Parents should be
cosmetic reasons where an eye is blind. It involves the dissection of
given clear instructions in this regard for future anaesthetics.
the extra-ocular muscles off the globe. There is a similar risk here
for the oculocardiac reflex as in squint surgery, although less risk of Controlled ventilation and muscle relaxants should be used
PONV. IV atropine/glycopyrrolate should be available. This procedure is painful and analgesia including opioids should
be considered.
Evisceration involves the removal of the contents of the globe, but
retention of the sclera. This procedure is often painful and opioid Anti-emetics should be used routinely
analgesia will be required.1 Avoid raised IOP during extubation - usually achieved by deep
extubation.
Penetrating eye injury
A penetrating eye injury is a relatively common injury in children, CONCLUSION
primarily boys between 3 and 9 years. Surgery is required to close This update has reviewed the general principles of anaesthesia for
the defect or remove a foreign body. Up to 30% of these injuries paediatric eye surgery, as well as considerations for some common
may be associated with trauma to the head, orbit or adnexa, and the procedures. Key learning points include:
risks of anaesthesia under these circumstances need to be weighed
against the benefits of early closure.23 Surgery is urgent, as anything Children require general anaesthesia for ophthalmic procedures
that raises IOP (coughing, straining) may cause the globe to extrude and surgery, but most are healthy and can be managed as day
its contents.2,3 cases.
This presents two conflicting anaesthetic problems. First, the The oculocardiac reflex may be induced during eye surgery and
child may have a full stomach so a rapid sequence intubation with risks provoking dangerous bradycardias, which can be prevented
suxamethonium is indicated in order to prevent aspiration. Second, by premedicating with anticholinergic agents.
there is a need to protect the globe from a rise in IOP that could Postoperative nausea and vomiting is common after eye surgery
result in extrusion of the structures of the anterior chamber or the in children and might delay discharge if suitable prophylaxis is
vitreous humor. The transient rise in intraocular pressure produced not given.
by the use of suxamethonium could theoretically cause this.24
One approach recommends the use of a large dose of non- REFERENCES
Anaesthesia for paediatric eye surgery. Anaesthesia Tutorial of the Week
depolarising muscle relaxant (NDMR) and ventilation with
144 (2009). Available from: http://update.anaesthesiologists.org/wfsa-
cricoid pressure until intubating conditions are achieved, education-resources/tutorial-of-the-week/atotw-archive/Archive%20
providing the child has a normal airway.10 To t W / ATo T W % 2 0 A r t i c l e s % 2 0 2 0 0 9 / P a e d i a t r i c s / 1 4 4 % 2 0
Another view is that there have been no documented reports of Anaesthesia%20for%20paediatric%20eye%20surgery/detail
vitreous extrusion after the use of suxamethonium, and protection 1. James I. Anaesthesia for paediatric eye surgery. Continuing Education
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Appendix 1. Conditions associated with eye abnormalities requiring special precautions.
Underlying condition Eye condition Special precautions

Neonates and premature babies Congenital cataracts As for neonatal surgery warming,
glucose management, monitoring for
postoperative apnoea
Craniosynostosis syndromes Glaucoma, cataracts, squint, exopthalmos Difficult to maintain airway with facemask
(Crouzon, Apert and Pfeiffer (mid-face hypoplasia); improved by oral
syndromes) airway; intubation usually easy
Craniofacial syndromes (Goldenhar, Glaucoma, cataracts, squint Micrognathia/facial asymmetry difficult
Treacher Collins, Smith-Lemli-Opitz) intubation
Mucopolysaccharidoses (Hunter and Corneal opacities, retinitis pigmentosa Difficult airway and intubation,
Hurler syndromes) cardiomyopathy, cervical spine instability
Down syndrome, Edward syndrome, Cataracts, strabismus Difficult intubation, cervical spine
Cri-du-Chat syndrome instability in Down syndrome
Hallerman-Strieff syndrome Congenital cataract Difficult intubation
Stickler syndrome Glaucoma, chorioretinoid degeneration, Cleft palate and associated airway
lens dislocation problems
Homocystinuria Lens dislocation Hypoglycaemia
Marfan syndrome Lens dislocation Aortic root dilatation, aortic/mitral valve
regurgitation
Neuro-oculo-cutaneous disorders Retinal vascular disorders Seizures, intracranial lesions, cardiac
(Neurofibromatosis Sturge-Weber lesions and phaeochromocytoma
syndrome, tuberous sclerosis, Von-
Hippel-Lindau syndrome)

Elective Procedures
Anaesthesia for cleft and lip palate surgery

Reprinted with minor revisions from Rawlinson E. Anaesthesia for cleft lip and palate surgery. Anaesthesia
Tutorial of the Week 72 (2007).
Ellen Rawlinson
Correspondence Email: Ellen.Rawlinson@gosh.nhs.uk
INTRODUCTION each year. Two-thirds involve the lip with or without

Cleft lip and palate (CLP) is one of the commonest the palate and the remainder the palate alone. CL is
congenital deformities. The associated facial unilateral in 80% of cases and occurs on the left in
disfigurement causes feeding, speech and dental over 70% of cases. Approximately 85% of infants with
development problems and has significant psychosocial a bilateral CL and 70% with a unilateral CL will have
consequences. Surgery aims to restore form and an associated cleft palate.
function, and modern techniques can leave many
Summary The incidence of CL with or without CP is strongly
defects undetectable. Airway management problems,
dealing with associated abnormalities and young influenced by race. At 3.6 per 1000 live births it is most
Cleft lip and palate (CLP)
is one of the commonest patients all present anaesthetic challenges. common in Native Americans compared with 1.0 per
congenital deformities. 1000 Caucasians and 0.3 per 1000 Afro-Caribbean
Surgery aims to restore form CLASSIFICATION AND ANATOMY births. CP alone occurs more evenly across races at
and function, and modern Cleft lip (CL) is a unilateral or around 0.4 per 1000 live births. CLP is more common
techniques can leave many bilateral fissure in the upper in males and the more severe the cleft the wider the sex
defects undetectable. discrepancy becomes. In contrast isolated palatal clefts
lip. Complete CL extends
Airway management are more common in females.
problems, dealing with across the whole lip and into
associated abnormalities the nostrils. Incomplete CL
ranges from small indentations Embryology
and young patients all
present anaesthetic to large defects with little Lip and palate development occurs in the first
challenges. connecting tissue between the trimester, the critical period being between 6 and 9
two clefts. weeks gestation. The upper lip and primary palate are
formed from the fusion of the frontonasal and bilateral
Cleft palate (CP) is a unilateral maxillary prominences - CL occurs when this fusion
Figure 1. Incomplete
unilateral cleft lip
or bilateral fissure in the soft fails on either or both sides.
palate that may extend into
the hard palate. CP may occur with CL when the The secondary palate is formed from lateral palatal
lip fissure extends beyond the incisive foramen and processes arising from the deep portions of the
includes the sutura palatina. CP without CL is an maxillary prominences. Initially these lie vertically
aetiologically and embryologically distinct entity. alongside the tongue, but as mandibular development
proceeds the tongue moves inferiorly allowing the
The hard palate is formed by the palatine processes of
palatal shelves to assume a horizontal alignment. Fusion
the maxillae and the horizontal plates of the palatine
of the two shelves occurs in an anterior to posterior
bones. It is continuous with the soft palate, a movable
direction incomplete fusion produces CP.
fibromuscular fold from which the uvula hangs. The
incisive foramen lies immediately behind the central
CL may be reliably diagnosed at the 18-20 week
maxillary incisors - the primary palate is anterior to
scan. CP is harder to see and can only be excluded
the incisive foramen and secondary palate posterior.
onexamination after delivery.
Complete CP involves both primary and secondary
palates whereas incomplete CP affects the secondary Aetiology
Ellen Rawlinson palate alone. A mucosal covering may obscure palatal The cause of CLP is unknown but appears to be
Consultant defects often delaying diagnosis until the child develops multifactorial with genetic and environmental
Paediatric Anaesthetist subsequent speech problems. influences. It is familial; affected parents have a 3-5%
Great Ormond Street chance of an affected child, and with one affected child
Hospital Incidence the sibling risk is 20-40%. Monozygotic twins show
London The overall worldwide incidence is 1 in 7-800 live the same defect in 40-50% of cases, but only 5% in
UK births and in the UK affects approximately 1000 babies dizygotic twins.

Some cases may result from mechanical obstruction. Impaired surgical repair
mandible development can prevent the tongue descending, which then CL is classically repaired between 6 and 12
obstructs fusion of the palatal shelves. Teratogen exposure associated weeks but there is an increasing trend to
with CLP includes maternal alcohol use and smoking, anticonvulsants operate in neonatal period. More popular
(phenytoin, benzodiazepines), salicylates and cortisone. The with parents, this has a positive influence
risk increases with rising maternal and paternal age. Folic acid on the associated sleep disordered breathing
400mcg.day-1 has a role in preventing CLP. problems, and also produces better aesthetic
results and may promote bonding. CP is
Associated Conditions usually repaired later, between 3 and 9 months,
CLP is associated with over 200 syndromes or sequences and several in a one or two stage operation to promote
have significant anaesthetic implications (Table 1). Children with normal speech development and reduce nasal Figure 1. Large adult
CLP may have multiple abnormalities without a recognised syndrome. regurgitation. Surgery may be delayed due to cleft palate
Additional abnormalities are most likely to be found with isolated associated abnormalities, or more commonly
CP (particularly submucous CP) and least likely with isolated CL. lack of access to appropriate services CLP patients are likely to require
Craniofacial abnormalities are most common, followed by CNS further surgery either related to the primary problem e.g. plastic
abnormalities e.g. mental retardation and seizures, congenital cardiac improvements to a CL repair, or for associated abnormalities. Around
disease, renal and abdominal defects. 20% will require pharyngoplasty for velopharyngeal dysfunction at
around 4-6 years.
Estimates of CLP patients with associated abnormalities range from
10-60%. Studies of birth records produce lower values compared with Primary palatoplasty disrupts normal palate growth and despite
those subjecting patients to detailed clinical and genetic examination. orthodontic treatment, some will require significant maxillofacial
Table 1: Syndromes and sequences associated with cleft lip and palate
Syndrome or sequence Clinical details

Velocardiofacial syndrome, , also Most common syndrome associated with CLP
known as Sprinzens syndrome; Cleft palate in ~30%, velopharyngeal incompetence
includes DiGeorge syndrome
Congenital cardiac disease, immune deficiency
(22q11 deletion)
Pierre Robin syndrome Cleft palate in 80% of cases
Micrognathia
Glossoptosis
Intubation becomes easier with age due to mandible growth
Stickler syndrome Progressive connective tissue disorder (autosomal dominant)
Midface hypoplasia, micrognathia, Pierre Robin sequence
Retinal detachment and early cataracts, deafness
Hypermobility of joints
Treacher Collins Cleft palate in ~30% of cases
Hypoplasia of zygomatic bones and mandible
Eye and ear abnormalities, deafness
Choanal stenosis or atresia
Significant risk of airway obstruction in neonatal period
Intubation may become more difficult with increasing age
Down syndrome Macroglossia, microstomia
Atlantoaxial subluxation and instability
Small stature, mental retardation
Congenital cardiac disease
Goldenhar syndrome Incomplete development of palate, lip, nose, ear and mandible on one side of the face
(Hemifacial microsomia) Scoliosis, renal and lung abnormalities
Intubation may become more difficult with increasing age
Foetal alcohol syndrome Small palpebral fissures, smooth philtrum, thin upper lip
Growth deficiency, CNS abnormalities, microcephaly

surgery in their teens to correct midface hypoplasia and maxillary increased risk of airway obstruction at induction and post-operatively.
retrusion If cardiac involvement is suspected an ECG and ECHO should be
considered and a higher-level post-operative monitoring is advised.
Anaesthesia for CLP
Nutrition and hydration
Anaesthesia for primary CLP surgery may be successfully provided
CLP defects make it difficult for an infant to create a seal sufficient
in a wide range of environments from the well-equipped dedicated
to suckle. Feeding difficulties are common and surgery should
paediatric hospital, to isolated resource poor clinics. In the UK CLP
be deferred in malnourished or dehydrated children. Nutritional
surgery is limited to 10 specialist centres; anaesthetising CLP patients
or physiological anaemia may occur (a nadir at around 9 weeks);
without oxygen would be an anathema here, yet it is a reality borne
measuring haemoglobin may be appropriate but CLP repairs are
of necessity for many. There are a variety of acceptable anaesthetic
successful in resource-poor environments without laboratory facilities.
techniques and practice should be modified by experience and available
facilities.
Premedication
Sedatives may precipitate airway obstruction and should be avoided.
Pre-operative sssessment
Atropine (20mcg.kg-1 intramuscularly 30 minutes pre-operatively or
History and examination should assess general fitness for anaesthesia
10-20mcg.kg-1 intravenously at induction) is an effective drying agent
and surgery. Particular attention should be paid to associated
and is advisable when difficult intubation is anticipated or anaesthesia
abnormalities. Some issues specific to CLP patients are explored below.
planned with ether or ketamine.
Airway management Intraoperative management
Over 70 years ago Magill recognised problems with airway Cleft lip repair in adults and older children can be performed with
management in children with CLP, but predicting which children local anaesthetic infiltration and conscious sedation e.g. diazepam
may have difficult airways is problematic. CLP does not make upper 0.05-0.1mg.kg-1 All other patients will require general anaesthesia.
airway obstruction inevitable and when obstruction occurs it is more
often due to associated structural or neuromuscular problems Induction
In general, choose a technique that maintains spontaneous
Some syndromes are well associated with difficult intubation (see Table ventilation. Gas induction with a volatile agent (e.g. sevoflurane,
1). In non-syndromic patients difficult laryngoscopy and intubation halothane) in oxygen is common; ketamine given intramuscularly
were strongly associated with retrognathia and bilateral cleft lip (due (10-12.5mg.kg-1) or intravenously (1-2mg.kg-1) is an alternative.
to the protruding maxilla). Fewer problems occur with increasing age Intravenous access, if not already established, should be obtained as
and are very uncommon over the age of 5. soon as the child is asleep and facemask ventilation confirmed before
Patients with previous CLP repairs more commonly have difficult the use of any neuromuscular blocking drugs. A standard intravenous
airways. Nasal intubation is acceptable except with history of induction may be appropriate for older children or adults without
pharyngoplasty when it should be avoided. The nostril of choice is anticipated airway difficulty e.g. propofol 4-6mg.kg-1, thiopentone
the side of the original cleft as this will be wider. Laryngeal mask 3-5mg.kg-1.
airways (LMAs) have been widely used in children with previous Difficult mask ventilation is unusual but should it occur options
repairs without reported adverse effects although rotation on insertion include nasal or oropharyngeal airways, a laryngeal mask airway or
is not advised. turning the patient lateral. These manoeuvres may achieve sufficient
anaesthetic depth to allow intubation. However, CLP repair is not
Upper respiratory tract infection (URTI) life-saving surgery if the airway cannot be managed safely surgery
Chronic rhinorrhoea is common in children with CLP due to food should be deferred until they are older when maturation often makes
reflux into the nasal passages and they may present with overt, often airway management easier.
recurrent, URTI. Even if clinically well, pre-operative antibiotics for
Endotracheal intubation may be performed under deep inhalational
children with low grade infection (positive nasal swabs) reduces the
anaesthesia or using muscle relaxants e.g. suxamethonium 2mg.kg-1
incidence of post-operative respiratory complications (PRC). Surgical
or a non-depolarising agent. Difficult laryngoscopy (Cormack and
repair reduces rhinorrhoea and URTI so risks of anaesthesia and PRC
Lehane views grade III or IV) occurs in up to 10% of ASA I patients
should be individually balanced against the benefits of surgery.
for CLP repair and the incidence rises in those with an associated
The risk of PRC increases with the severity of the defect. Infants with syndrome. Large alveolar defects may hamper laryngoscopy, as there
bilateral CLP have a significantly higher risk of PRC (9%) than infants is a tendency for the laryngoscope to fall into the cleft; packing with
with isolated CL or unilateral CLP (2 and 3% respectively), even gauze may help prevent this, as may the use of a straight blade.
when clinical scoring pre-operatively gives no indication of infection.
A variety of techniques are available for difficult intubations; anterior
Chronic airway obstruction laryngeal pressure, alternative laryngoscopes and the gum elastic
Snoring, apnoea during feeds or protracted feeding time may indicate bougie are simple, readily available and effective. The LMA has been
chronic airway obstruction. Older children and adults may have successfully used to allow CLP repair in a child in whom intubation
chronic hypoxia, right ventricular hypertrophy and cor pulmonale. had proved impossible. It is more bulky and less secure than an
These patients are more sensitive to sedative drugs and have an endotracheal tube and its routine use is not advised.

Fibreoptic techniques often use an LMA as a conduit. A guide-wire the positive-pressure ventilation required
may be threaded down the suction port of an adult endoscope, the for neonates and infants is possible with
LMA and endoscope are then removed and the wire used to railroad the bag of the T-piece whilst the OIB can
a tube. be used to generate a fresh gas flow.
Alternatively a paediatric endoscope may be used to introduce a pre- Surgery usually lasts 1-2hours. Although
loaded tube directly through the LMA. blood transfusion is uncommon, CP
repairs have the potential for significant
Rarely an emergency surgical airway may be required. A preformed oral
blood loss so facilities for cross matching
south facing RAE tube is ideal for this surgery as it can be taped on the
should be available. Existing fluid deficits
chin and improves surgical access although standard and reinforced
and intraoperative losses are replaced
tubes are both acceptable.
with crystalloid and a single dose of
Intubation is not always necessary. In children older than one year, intravenous antibiotic e.g. augmentin
routine CL repair has been described using only ketamine, atropine given. Figure 3. Cleft palate repair
and local anaesthetic infiltration. This requires considerable experience
Infiltration of local anaesthetic by the surgeon is recommended e.g.
and co-operation between anaesthetist and surgeon but may be useful
1% lidocaine with 1:200,000 adrenaline. This provides intraoperative
when resources are limited.
analgesia, reduces blood loss and improves the surgical field. The dose
of adrenaline should be limited to 5 micrograms.kg-1 if halothane is
Maintenance
being used.
A head ring and roll under the patients shoulders extend the neck
and tip the head down, and throat packs are used to absorb blood and Paracetamol (acetaminophen) can be given orally as a pre-medication
secretions. During palate surgery a gag inserted over the endotracheal (20mg.kg-1) or rectally after induction (30-40mg.kg-1). Non-steroidal
tube keeps the mouth open and tongue clear. Tube problems are anti-inflammatory drugs (NSAIDS) are effective analgesics and most
common during surgery with a shared airway and may occur at any paediatric anaesthetists prescribe them to infants over 6 months old.
time. Vigilance is needed to prevent inadvertent extubation, intubation They may increase the risk of post-operative bleeding thus some
of the right main bronchus and tube kinking or occlusion. advocate delaying administration until 12 hours postoperatively.
Maintenance is most often with an inhalational agent choice. Despite local anaesthetic infiltration, endotracheal tube movement can
Halothane should only be used if oxygen is available due to the risk of produce marked intraoperative stimulation, which can be obtunded
arrhythmias. Ether precludes the use of diathermy due to the explosion with intraoperative opioids. For CL repairs short acting agents e.g.
risk. There is growing interest in desflurane as it produces rapid fentanyl 1-2micrograms.kg-1 are sufficient whereas for more painful
recovery with early return of airway reflexes. However it is expensive, CP repairs a longer acting agent is more appropriate e.g. morphine
requires special vaporisers and is not suitable for gas inductions. 0.05-0.1mg.kg-1. Opioids have the advantage of promoting a smoother
emergence with less crying, which may reduce swelling and bleeding
Intravenous bolus doses of ketamine may be given for maintenance from the surgical site.
(0.25mg.kg-1). It produces dissociative anaesthesia and has the
advantage of maintaining respiration and cough reflex. However, The use of opioids in neonates and infants raises justifiable concerns
experience is required to titrate the dose of ketamine correctly, regarding post-operative sedation, respiratory depression and
particularly in infants or small children, and there are disadvantages consequent airway compromise. Where postoperative supervision is
of hypersalivation and emergence phenomena. inadequate it is vital that the child leaves theatre fully awake and in
control of their airway. If trained staff, pulse oximetry and apnoea
Spontaneous ventilation techniques are safer if there is a disconnection monitors are not available then opioids should be avoided and
or inadvertent extubation but are not suitable for infants and small alternative analgesia provided.
children.
Infraorbital nerve blocks can provide effective post-operative analgesia
Controlled ventilation with muscle relaxation reduces anaesthetic
for cleft lip repair. The infraorbital foramen may be palpated in
requirements promoting a more rapid wake up and recovery of reflexes,
children and adults; in neonates it may be found at the mid-point of
as well as allowing lower PaCO2, which may reduce blood loss.
a line drawn from the midpoint of the palpebral fissure to the angle
If available, modern anaesthetic machines with integral ventilators of the mouth (approximately 7.5mm from the alar base). The nerve
allow the anaesthetist to select his or her preferred technique. Drawover may be approached percutaneously or via the mucobuccal fold; only
systems are more commonworldwide and are sufficient for CLP small volumes of local anaesthetic are required e.g. 0.5-2mls 0.5%
surgery. A standard system may include a vaporiser such as the Epstein bupivacaine depending upon weight (maximum bupivacaine dose
Macintosh Oxford (EMO) for ether or Oxford Miniature Vaporiser 2mg.kg-1 which is 0.4ml.kg-1 0.5% solution).
(OMV) for halothane connected in series to an Oxford Inflating
Bellows (OIB; Penlon, Abingdon, UK, See Drawover Anaesthesia Extubation and postoperative care
article, page XXXXX). Drawover systems are not suitable for children The very real risk of postoperative airway obstruction is most likely to
who weigh less than 20kg due to high respiratory resistance. Attaching a occur in children with pre-operative airway problems. Throat packs
Jackson Rees circuit to an OIB is an example of a suitable modification; should be removed at the end of the operation and the oropharynx

inspected for blood clots and to check haemostasis. Thereafter keep associated with this. If pulse oximetry is available it is highly advised
suction to a minimum. If nondepolarising relaxants have been used while the child is asleep, to continue until you observe them to sleep
they should be antagonised. Extubate the child once fully awake and without significant oxygen desaturation occurring.
protective reflexes have returned.
Children can be reluctant to feed and intravenous fluids should be
Airway obstruction may be due to swelling of the tongue from gag continued until adequate oral intake is established.
pressure, inadequate mouth breathing, laryngospasm, retained throat
Post-operative analgesia includes opioids administered as intravenous
pack, blood clot or a combination of factors. A short period of CPAP
boluses, continuous infusions or nurse controlled analgesia according
may suffice as may turning the child lateral or prone. Nasopharyngeal
to locally developed protocols, as well as regular paracetamol and
airways (NPA) are effective and well tolerated; in patients at high
NSAIDS (for those over 6 months).
risk of postoperative airway complications - in particular those who
have a pharyngoplasty (Furlow procedure) as part of their surgery -
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Elective Procedures
Anaesthesia for paediatric orthopaedic surgery
Tsitsi Madamombe, Jim Turner and Ollie Ross*

*Correspondence Email: oliver.ross@uhs.nhs.uk
INTRODUCTION
Paediatric orthopaedics in low or middle income Neurological conditions: Cerebral palsy,
countries (LMIC) ranges from simple fractures spina bifida
(but often complicated by delayed presentation,
anaemia or nutritional deficiency), to chronic Auto-immune conditions: Juvenile
osteomyelitis and fracture non-union, to idiopathic arthritis (JIA)
SUMMARY
complex elective procedures in children with Tumours: Sarcomas, osteochondromas
cerebral palsy. This article will consider the Paediatric orthopaedic
Rare congenital conditions: procedures range from fixing
spectrum of disorders encountered in paediatric
Osteogenesis imperfecta, neurofibromatosis, simple fractures in otherwise
orthopaedic surgery in LMICs, the orthopaedic healthy children to more
mucopolysaccharidosis (Hunters, Hurlers),
manifestations of specific conditions in complex procedures in
arthrogryposis multiplex.
childhood, specific orthopaedic procedures and patients with major
anaesthetic management of these conditions. co-morbidities. Anaesthetic
COMMON ORTHOPAEDIC CONDITIONS IN management is generally
Practical aspects of regional anaesthesia are
dependent on the complexity
covered elsewhere in this issue of Update (page LMIC of the procedure as well as
99). Trauma the childs general health. Pain
relief is a particular challenge.
THE SPECTRUM OF DISORDERS SEEN IN Acute fractures and burns are common in
Regional anaesthesia
PAEDIATRIC ORTHOPAEDIC SURGERY children in LMIC and can be associated with plays a very important role
high morbidity. A high proportion of fractures in managing intra- and
Conditions can be considered under the
are treated non-surgically with traction or simple postoperative pain. Availability
following broad headings: of resources, training and
casting, with fracture manipulation under
safety are a major determinant
Trauma: Simple and complex fractures anaesthesia one of the most common paediatric of anaesthesia technique in
(acute or delayed), burns, polytrauma, orthopaedic procedures undertaken. Paediatric LMICs.
traumatic paraplegia, conflict related musculoskeletal impairment (MSI) has a
prevalence of 2.6-4.8% in children under 12 Tsitsi Madamombe
Common congenital conditions: Talipes years; angular limb deformity and fracture non/ Consultant paediatric
equinovarus (club foot), scoliosis and other mal-union are seen in a significant proportion anaesthetist,
congenital limb deformities, achondroplasia, of children presenting for elective surgery.1,2 University Hospital,
bone cysts Polytrauma and burns (acute and reconstructive Southampton
procedures) are challenging problems associated
Infections: Osteomyelitis (acute, untreated, Ollie Ross
with high mortality, which are considered
chronic), TB, poliomyelitis Consultant paediatric
elsewhere in this edition of Update [page 199
anaesthetist,
Developmental abnormalities: and 204]. University Hospital,
Developmental dysplasias of the hip
Congenital talipes equinovarus (clubfoot) Southampton
(congenital dislocation of the hip (CDH)),
Congenital talipes equinovarus (clubfoot)
Perthes disease, slipped upper femoral Jim Turner
seems to have a higher prevalence in developing Orthopaedic surgeon,
epiphysis (SUFE), idiopathic scoliosis
countries compared to elsewhere - for example, Beit Cure International
Neuromuscular conditions: Muscular the incidence of clubfoot in Malawi is 2 per Hospital,
dystrophies, progressive muscular atrophy, 1000 children, twice that of North America Blantyre
poliomyelitis, scoliosis and Europe.3,4 Although clubfoot programmes Malawi

with Ponseti serial casting are widespread in LMIC, disability
associated with untreated or partially treated clubfoot remains
high.5,6
CASE SELECTION
The success of orthopaedic programmes in LMICs depends
on case selection and choice of surgical procedure. In general,
interventions that have a good outcome are those that require
little or no follow up, are cheap to perform with minimal
instrumentation and implanted material, and do not require
specialised surgical skills. The majority of children with cerebral
palsy are best treated with prolonged physiotherapy; operative
intervention and prolonged multidisciplinary follow-up are
time consuming and expensive.
Five common orthopaedic conditions that benefit from
operative intervention and where operative treatment is
financially and practically feasible are:
Figure 1. Recurrent club foot
Neglected or recurrent talipes (club foot): postero-medial

release, posterior release, wedge tarsectomy or triple
arthrodesis (see Figure 1)
Chronic osteomyelitis: sequestrectomy and debridement.
Figure 2. Blounts Disease (Bow legs) showing angular deformities
Some cases occur secondary to overlying soft tissue injury
around the knee, more severe on the right leg
but many cases are caused by blood borne infection. If the
osteomyelitis is adjacent to a joint there should be a as Blounts disease cause angular limb deformities, especially
high index of suspicion for intra-articular spread with around the knee (see Figure 2). An open osteotomy is
septic arthritis. Systemic infections prevalent in required to re-align the limb and the reduction is usually
the developing world include tuberculosis and Human maintained by casting rather than metalwork.
Immunodeficiency Virus (HIV). Thanks to a successful
global polio vaccination programme, the prevalence of this Burns contractures. Releases and skin grafting are common
disease is now very low but it has yet to be eradicated. procedures undertaken by orthopaedic surgeons,
particularly when involving the hands
Angular limb deformities: Malnutrition with vitamin
D deficiency and rickets, and developmental disorders such Open fracture requiring wash out and debridement

ANAESTHETIC MANAGEMENT OF CHILDREN The anaesthetic plan should be explained to the parents and
PRESENTING FOR ORTHOPAEDIC SURGERY the child if possible, and consent obtained.
Pre-operative assessment and preparation Anaesthetic technique
All children should be seen pre-operatively, preferably with a The surgery and available resources will determine the choice
parent present, and a full history and appropriate examination of technique. Some procedures such as tendon release in
taken as routine (see p XX this Update). Pay particular the Ponseti procedure are routinely performed under local
attention to co-existing conditions, particularly for children anaesthesia. Many cases are safely anaesthetised with either IM
with cerebral palsy or cardiorespiratory disease. Previous or IV ketamine; regional anaesthesia may be used for older
experience of anaesthesia can be a useful pointer as many of children. For peripheral surgery, a standard GA technique is
these children may have had other procedures, with positive appropriate for most cases, with spontaneous breathing with
or negative experiences. Review of previous anaesthetic charts inhalational anaesthesia, ideally supplemented by regional
is useful when available. A particular challenge is the small block or local infiltration. Consider tracheal intubation if there
malnourished child presenting for the first time with a long is delayed gastric emptying, expected poor respiratory effort
history of an untreated fracture or osteomyelitis to a facility under anaesthesia (e.g. neurologically impaired), or a very long
with minimal facilities for pre-operative investigation, but procedure.
much can be gained from the patient history and examination.
Intravenous access is best practice for all cases. Short simple
Pain management is often a special concern for children and cases such as application of hip spicas and other plaster
parents, and pain management plans should be discussed applications may be safely anaesthetised without IV access;
before surgery. For fractures, this is usually best provided by infants, however, should have secure IV access even for these
a cast, sling or traction, supplemented with oral analgesia. IV cases. Though simple and often quick, fracture manipulation
morphine may be required if pain is severe, or a regional block can be very stimulating and an IV is useful for quickly
may be of benefit (e.g. femoral nerve block). Consent should deepening anaesthesia. Ketamine anaesthesia or regional
be obtained if rectal analgesics are to be used. blocks awake are safest with IV access in place.
Starvation: This should be as standard, but children with acute
Analgesia is best provided with a multi-modal technique
fractures or complex co-morbidities may well have delayed
(ketamine, oral analgesics, a regional block or local anaesthetic
gastric emptying. Extra caution is required.
infiltration, +/- opioids if required). Postoperatively, use
Pre-medication: This is not usually required, but those with regular simple analgesics supplemented by stronger opioid
learning difficulties or previous difficult experiences may drugs if required (given by agreed protocol), guided by age-
benefit from sedative pre-medication. For a child undergoing appropriate pain assessment tools (e.g. FACES, FLACC) (see
multiple procedures, a calm, smooth induction of anaesthesia pain management page 72 this Update)
can help enormously with subsequent anaesthesia.
It is good practice to give intravenous fluids to rehydrate
Simple oral analgesics such as paracetamol 20mg.kg-1 PO or following a period of fasting and to replace intra-operative
ibuprofen 5-10mg.kg-1 PO can be given as a premed. This is losses. Postoperative nausea and vomiting can be reduced with
easy to do, welltolerated, inexpensive, may reduce opioid good hydration, and this is less expensive and more readily
requirements, and improves postoperative pain management. available than anti-emetic drugs.
Examination: This should be a focused physical examination
Open procedures will require prophylactic antibiotics, which
relevant to the history and practical aspects of anaesthesia,
should be given before knife to skin.
for instance, intravenous access, airway management and
positioning.
Regional anaesthesia in paediatric orthopaedic
Investigations: Children who are fit, healthy and having minor surgery
procedures do not require laboratory investigations. Those Regional anaesthesia can provide excellent perioperative
undergoing major surgery will need a haematocrit or full blood analgesia and anaesthesia, but requires special training and
count with group and screen as a minimum. Investigation of equipment; regional anaesthesia is discussed elsewhere in this
cardio-respiratory disease is best done in consultation with Update. (See article page 99).
a paediatrician. Screening with pulse oximetry, particularly
an overnight assessment of SpO2 may be useful if there is a Specific considerations for orthopaedic surgery are as below:
concern about cardiorespiratory disease. Choice of block: Discuss with surgeons and ward nurses

when deciding which block will be the most useful (location BLOOD LOSS AND BLOOD CONSERVATION
and longevity required). The child and parents previous It is important to develop good blood conservation practices
experience of regional anaesthesia may guide decisions. during orthopaedic surgery in LMIC as chronic anaemia is
Catheters can also be used in regional techniques to prolong common in children, access to safe blood transfusion is limited
analgesia. and costly, and this type of surgery has the potential for large
blood loss.
Lower extremity surgery: The simplest block to perform is
caudal block, as this covers many lower limb procedures, Blood conservation is greatly aided by the use of tourniquets
and is safe and efficacious in all paediatric age groups.7,8,9 where possible, but much can be achieved by simple changes in
Unilateral limb blocks provide good quality analgesia; anaesthetic technique, without the use of induced hypotension
the most common and easy to perform being femoral/3:1 or expensive drugs.
or popliteal sciatic blocks. Any procedure below the knee
The following techniques help to reduce the requirement for
can be covered with popliteal blocks, supplemented locally
blood transfusion:
or by infiltration of the saphenous nerve for lateral surgery
at the ankle or foot. Ankle blocks are straightforward and In elective surgery, optimise preoperative haemoglobin:
can provide good pain relief for foot procedures. consider de-worming and iron supplements in at-risk
populations
Surgery at the hip: This requires a higher block usually an
epidural, as a one shot or catheter technique. This provides A stable anaesthetic with good analgesia, with control of
excellent prolonged analgesia for most lower limb surgery. heart rate and blood pressure in the low normal range.
Lumbar epidurals can only be safely performed in children Use sedative premedication if the child is anxious. If
under general anaesthesia. available, TIVA with propofol and remifentanil is useful as
anaesthetic depth can be varied easily according to the level
Spinal anaesthesia: This can be used in older children as an of surgical stimulation
alternative to a GA. It is safe and cost effective in
experienced hands and if the appropriate equipment is Maintain normothermia to prevent cooling and hence
available, particularly when working with a fast surgeon. coagulation problems; limit patient exposure from
Consent is clearly an important issue. induction of anaesthesia onwards
Position the child carefully to reduce venous congestion,
Upper extremity surgery: Brachial plexus block at the
avoid hypercarbia and avoid the child coughing. This will
axilla provides excellent analgesia for wrist and hand surgery
help to reduce bleeding from the surgical site
in children, and may be supplemented by local infiltration
or ketamine IV or IM if required to provide anaesthesia for Tranexamic acid 10-20mg.kg-1 bolus IV at induction,
surgery. In expert hands, supraclavicular block or repeat dose 10mg.kg-1 IV at 4 hours. This is a safe drug
interscalene block may be used to provide anaesthesia or and has been shown to reduce blood loss in trauma patients
analgesia.10 and should be increasingly available
Table 1. Different types of cerebral palsy
Description: Spastic CP Ataxic CP Athetoid/dyskinetic Mixed type

CP
Incidence (% cases) 70% 10% 10% 10%
Clinical features: Hemiplegic CP - one Intention tremor Dystonic - maintained Spastic athetoid
side of the body is twisting position of torso
affected. Head tremor and extremities
Diplegic CP - both Poor sense of balance Athetosis - slow,

legs are usually more with falls and stumbles purposeless, distal
affected than both arms movements
Tetraplegic CP - all four Chorea - quick, jerky,

limbs are involved proximal

Use clearly defined transfusion protocols, in particular the Temporomandibular joint dysfunction, increased incidence
trigger for transfusion. Healthy children can tolerate an of malocclusion; possible difficult intubation
acute drop in haemoglobin to 7g.dl-1 with no adverse
effects. A low haemoglobin threshold for transfusion is a Autonomic neuropathy; poor control of temperature
cost free way of avoiding transfusion and blood pressure. Intraoperative hypothermia is common,
compounded by lack of fat and muscle in the malnourished
If available, intra- and post-operative cell salvage is very child
useful
Difficult venous access due to spasticity or dystonia
If major blood loss occurs (i.e. more than half circulating
blood volume), use whole blood to correct coagulopathy, or Ideally, children with CP undergoing major surgery should
reconstituted whole blood, using FFP and platelets with be assessed by a paediatrician prior to surgery, to make
each red cell transfusion. sure that they are as fit as possible for the proposed surgery.
Anticonvulsant therapy should be continued perioperatively
SPECIFIC CONDITIONS REQUIRING ORTHOPAEDIC
and restarted as soon as possible postoperatively. These
SURGERY
patients may also require physiotherapy, bronchodilators
Cerebral palsy and antibiotics preoperatively. Several readings of the blood
Most children with cerebral palsy (CP) presenting for surgery pressure should be taken to check the baseline. Keep the child
in LMIC will have mild deficits affecting one or two limbs, warm and avoid exposure whenever possible.
but without the major complications associated with CP. Orthopaedic procedures in children with CP
These children will often be otherwise well, but with decreased Soft tissue releases to relieve contractures are commonly
mobility or limb deformity requiring correction. Rarely, performed in these children. Repeat procedures are common.
children with severe comorbidity may also present (see Table Recent trends are for single event multilevel surgery involving
1). tenotomies and/or osteotomies at different levels on one or
Intellectual disability and epilepsy are common in children both limbs.
with spastic quadriplegic CP. Bulbar muscles are involved Conduct of anaesthesia
to a varying degree, resulting in poor control of the mouth, It is important to have a good rapport with these children
tongue and pharynx. Aspiration pneumonia is most likely in and engage them in the discussions. Communication may be
this group. Dyskinetic CP may be associated with deafness, difficult and the child may be anxious, so it is useful to have
dysarthria and drooling.11 their carer available at induction and in the recovery room.
Anaesthetic implications of CP:11, 12 Sedative premedication can be considered but these patients
can have an unpredictable response to them. Antacids,
Cognitive, communication and behavioural disorders prokinetics and drugs to reduce secretions may be useful.
Epilepsy (30% of children) Thiopentone is a useful IV induction agent in children with
epilepsy. Intubation should be considered in children with
Gastro-oesophageal reflux is common; may cause recurrent reflux. The child should be positioned carefully to prevent
respiratory problems pressure sores, nerve or muscle damage. Children with severe
Drooling of saliva may be related to pseudobulbar palsy CP may have reduced volatile anaesthetic requirements and
with impaired swallowing or tongue thrusting may take a long time to wake after surgery.
Poor nutritional status, with potential for electrolyte Muscle spasms are a particular problem in children with
imbalance or anaemia spastic CP, and for this reason, regional techniques are strongly
recommended for intra-operative and postoperative analgesia,
Respiratory problems; poor respiratory reserve, sub-clinical
also to reduce opioid requirements. In children having
pulmonary aspiration from reflux, recurrent respiratory
extensive lower limb surgery, epidural analgesia is beneficial.11
tract infections, and chronic lung disease
Pain assessment can be challenging, but should not prevent the
Poor dentition; dental caries and loose teeth are common. anaesthetist seeking to provide good analgesia.
The potential for bacteraemia during airway
instrumentation has important implications for children Postoperatively, drooling can present problems, and frequent
receiving metal implants suctioning may be necessary. Aspiration of gastric contents

Table 2. Classification of neuromuscular disorders
Inherited Acquired
Prejunctional Peripheral neuropathies Motor neurone disease
Charcot-Marie Tooth Multiple sclerosis
Friedreichs ataxia Guillain-Barr syndrome
Peripheral neuropathies
Junctional Myasthenia Gravis
Eaton-Lambert Syndrome
Post-junctional Dystrophies Inflammatory myopathies
Duchenne (DMD) Critical illness polyneuropathy and

myopathy
Beckers
Myotonias
Myotonic dystrophy
Myotonia congenital
Other myopathies
Hyper/hypokalaemic periodic paralysis
Metabolic/mitochondrial disorders
may occur in children with pseudobulbar palsy. Children condition, also that they are realistic as to their expectations
with CP are commonly irritable on emergence, but it may be about surgery.
difficult to elicit the cause.
Assessing functional capacity during exercise is very useful,
Neuromuscular disorders as it will help identify to significant cardiorespiratory or
airway compromise. However, if the child is inactive this
Pre-operative assessment
may mask the severity of both respiratory and cardiac disease.
Children with significant neuromuscular conditions presenting
Formal sleep studies are often used to indicate the need for
for orthopaedic surgery usually have a clear diagnosis (see
non-invasive respiratory support postoperatively; overnight
table 2). If there is limited information, it is important to ask
oxygen saturation monitoring can also reveal useful clinical
how long the child has been weak, whether the weakness is
information. Children already established on non-invasive
stable or progressive, if the muscle weakness is associated with
ventilatory support can be safely anaesthetised; familiarity
fatigability and what limits activity. All major cases should be
with the particular device and current settings is essential
discussed with a neurologist or paediatrician before surgery. All
preoperatively (the parents are often expert). The device must
medication should be continued preoperatively, and restarted
be available for immediate use as the child wakes after surgery.
as soon as possible after surgery.
Progressive degeneration of cardiac muscle fibres, resulting in
Anaesthetic assessment should include current status, airway,
conduction defects and cardiomyopathy occurs in DMD; this
cardio-respiratory and any other system disorders. The
occurs in later adolescence and is managed in the early phase
principal anaesthetic risks relate to the airway, respiratory
with ACE inhibitors. Friedrichs ataxia is also associated with
impairment, poor myocardial function, gastro-oesophageal
cardiomyopathy.
reflux, abnormal drug reactions (principally MH), and excess
bleeding in certain myopathies (e.g. Duchenne muscular
Dysphagia and decreased gastric motility are common.
dystrophy, DMD). Investigations are best undertaken in
consultation with respiratory paediatricians and/or paediatric Review of previous anaesthetics is useful but does not mean
cardiologists if available. The family should be counselled to subsequent anaesthetics will be problem-free, for instance,
make sure that they are aware of the prognosis of the specific relating to airway or respiratory events. Previous uneventful

use of suxamethonium or volatile agent does not guarantee SPECIFIC ORTHOPAEDIC PROCEDURES
that they can subsequently be used safely.13
Surgery for osteomyelitis and septic arthritis
Perioperative management Antibiotics have a limited role in the treatment of septic
There should be full discussion with the family before surgery arthritis and established osteomyelitis. Infection within a joint
to discuss potential risks and benefits of surgery. Sedative pre- is an orthopaedic emergency and requires urgent open or
medication should be used with caution if at all, as it may arthroscopic wash out.
cause respiratory depression or reduced respiratory muscle
tone. However, anxiety can be high in these patients. Infected bone needs thorough debridement of the connecting
sinus tracts and ample curettage of the bone segment to
Spontaneous ventilation techniques are often not well tolerated remove dead bone (sequestrum), one of the major causes of
in children with neuromuscular disease. TIVA with propofol recurrence of osteomyelitis. Extensive infection may require
and remifentanil is effective and safe for these patients, one side of the bone to be removed to allow adequate drainage,
provided cardiac function is not severely impaired. a process known as decortication. Soft tissues are allowed to
Choice of anaesthetic technique can be very difficult in some heal by secondary intention and regular dressing changes
children, but must be made on an individual basis. For instance, are essential for healing. These children may be chronically
a child may have a history of difficult intubation, or severe unwell, anaemic, with poor nutrition, and they may also have
respiratory impairment, but refuses surgery under regional impaired clotting.
anaesthesia. The child may be willing to undergo a regional Ponseti procedure
anaesthetic block, but these techniques are often technically This technique involves manipulation and casting to correct
more challenging in children with neuromuscular disease. congenital clubfoot without surgery (see Figure 3). The
It is sensible to avoid large doses of opioids perioperatively, ligaments, joint capsules and tendons are stretched under
particularly where ventilatory support postoperatively is gentle manipulations and a plaster cast is applied after each
limited or unavailable. manipulation. The displaced bones are gradually brought
All cases should be closely monitored, including core body into correct alignment and remodel. The initial phases of
temperature, as these children are prone to both hypo- and this procedure do not require anaesthesia. One stage requires
hyperthermia. Hyperthermia may occur due to increased a percutaneous tenotomy, which can be done under local
muscle activity seen in myotonias, iatrogenic causes or infiltration with lignocaine and/or topical anaesthesia. In 10-
malignant hyperthermia. Monitoring must be continued 30% of cases, a tibialis anterior tendon transfer to the lateral
postoperatively, ideally in a high dependency area. Intensive cuneiform may be required when the child is about 3 years
care, ideally with ventilatory support, should be available for old and this will require general anaesthesia with or without
high-risk cases and/or those undergoing major surgery. regional analgesia.
Children with neuromuscular diseases have increased Application of hip spica casts
sensitivity to non-depolarizing neuromuscular blocking drugs. Spica casts create stability and immobilise femoral fractures
The use of a nerve stimulator and short acting neuromuscular and hip abnormalities. Anaesthesia is usually required to apply
blocking agents is recommended. Suxamethonium must NOT
be used. In the channelopathies, there may be a dramatic rise in
serum potassium in response to suxamethonium.14 Malignant
hyperpyrexia (MH) and anaesthesia-induced rhabdomyolysis
(AIR) may also be precipitated. The only conditions shown to
have a definite link to MH are King-Denborough syndrome,
central core disease and Evans myopathy. Patients with other
neuromuscular conditions have shown MH-like symptoms
under general anaesthesia but the link with true MH remains
unclear.15
Children presenting for muscle biopsy have a 10-20% chance
of a positive finding and around half of these have a diagnosis
of muscular dystrophy. In these circumstances, avoid volatile
agents and use total intravenous anaesthesia (TIVA) or spinal
anaesthesia with sedation in preference. Figure 3. Ponseti casts in a hospital in Nepal

a hip spica. In small children, hip spicas are applied with the Figure 4. Slipped Upper Femoral Epiphysis (SUFE)
child on an elevated narrow table that provides very little head
support.
During cast placement, the goals of anaesthesia include
haemodynamic stability, appropriate anaesthesia and safe
patient positioning. The patients health status and any pre-
existing disease dictate the choice of anaesthetic technique. It
is important to remain vigilant when the child is placed on the
spica table to ensure that the airway is secure and to prevent
nerve damage. Consider intubation in children who weigh
<10kg, particularly as the abdomen may be compressed during
the application.
Pelvic osteotomies for congenital dislocation of the
hip (CDH)
These are used to correct developmental dysplasia of the hip
joint to stabilise the hip, allow corrective remodelling and
prevent early osteoarthritis. The choice of osteotomy will
depend on the severity of the acetabular dysplasia, the presence
or absence of congruent hip reduction and the age of the child.
Figure 5. Insertion of femoral screw for slipped upper femoral
Both general and regional anaesthesia can be used if no
epiphysis
contraindications exist. These procedures can be long and can
be associated with considerable blood loss. General anaesthesia
combined with spinal or epidural analgesia can provide good
surgical conditions as well as effective postoperative pain
control. Postoperatively, oral pain medication can be given,
including paracetamol PO, opioids PO and non-steroidal
anti-inflammatory drugs (give NSAIDs short-term to reduce
any interference with bone healing).
Slipped upper femoral epiphysis
Slipped upper femoral epiphysis (SUFE) is a condition seen in
children who are growing rapidly, and usually presents between
the ages of 8 and 15. It is due to weakness in the growth plate
that results in slippage of the femoral head from the rest of the
femur. The child will often complain of knee or hip pain and
may present with a limp.
SUFE is an orthopaedic emergency if the child presents acutely,
as further slippage may result in occlusion of blood supply
to the femoral head resulting in avascular necrosis. Surgery
involves the placement of one or two percutaneous cannulated
screws into the femoral head to prevent further slippage. In Intraoperatively, the patient may be positioned supine or
20-40% of cases the opposite hip may become affected and lateral. Take care to avoid nerve compression or injuries.
therefore the other side is also fixed. (See Figures 4 and 5) General anaesthesia, in conjunction with regional anaesthesia,
can be used if there are no contraindications to regional
There is a high association of obesity with SUFE. Other anaesthesia. A single shot caudal or epidural can be helpful.
associations include endocrine abnormalities especially
hypothyroidism and treatment with growth hormone. A high Treatment of limb deformity and leg length inequality
incidence of renal osteodystrophy is also found in this group of There are many different conditions in childhood that can lead
patients. Preoperative investigations should therefore include to deformity of a limb of differences in leg length. Treatment
full blood count, urea and electrolytes, thyroid screen and a depends on the age of patient (how much growth is to be
group and screen for blood. expected) and the pathology causing the limb length inequality.

Epiphysiodesis Acknowledgements
This is surgery that slows down the growth of the longer leg Thanks to Tim Nunn, CURE Hospital, Addis Ababa, Ethiopia,
over a period of time or corrects angular knee deformities and for providing Figure 2.
is only performed in growing children. Small incisions are
made around the knee near the femoral and/or tibial growth REFERENCES
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1999.
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2. Atijosan O et al. The orthopaedic needs of children in
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Common emergencies
Large airway obstruction in children

Reprinted with revisions from Update in Anaesthesia, (2004)18:44-49. Originally Royal College of
Anaesthetists Newsletter 1999; Issue 47: 159-162, reused with permission.
N S Morton
Correspondence Email: neilmorton@mac.com
PART 1: CAUSES AND ASSESSMENT The larynx is funnel shaped and is narrowest at the
Opening and maintaining the airway is fundamental level of the cricoid ring compared with the cylindrical
to the treatment of all emergency situations in adult conformation, which is narrowest at the level of
paediatrics, as in adults. All resuscitation algorithms the vocal cords. The airway is more compressible as
start with ABC (Airway, Breathing, Circulation) and cartilage support components are less well developed.
must be qualified in trauma to include cervical spine Thus, extrinsic pressure from haematomas, neoplasms,
Summary control. The commonest cause of paediatric airway vessels or enlarged heart chambers may more readily
obstruction is still the child with depressed conscious compress the airway. The collapse of the laryngeal
There are anatomical, level who is not positioned properly or whose airway inlet during inspiration is a feature of laryngomalacia
physiological and is not opened adequately by Basic Life Support and the collapse of the trachea and/or bronchi during
developmental reasons for manoeuvres. Airway foreign bodies are also common expiration occurs in tracheo-bronchomalacia. If the
children to be particularly
and may need rapid intervention. The pattern of intrathoracic airways are narrowed from whatever
susceptible to airway
infective causes of airway obstruction has changed cause, the extra work of inspiration and of expiration
obstruction.
since the introduction of vaccination programmes leads to large swings in intrathoracic pressure and the
Rapid clinical assessment, against Haemophilus influenzae type B. There has been a potential for gas trapping and hyperinflation behind
minimal disturbance, marked reduction in the incidence of epiglottitis, with a the obstructed airway causing further compression of
and rapid intervention
relative predominance now of viral croup and bacterial small airways. During forced expiration efforts, the
are important. Summon
senior experienced help if
tracheitis, usually caused by Staphylococcus aureus. intrathoracic airways may collapse down exacerbating
available. the gas trapping effect.
Why are children at increased risk from airway
Hyperinflation and gas trapping also impair the
obstruction?
function of the diaphragm which is unable to contract
There are anatomical, physiological and developmental
so efficiently from its optimal length. In infants the
reasons for children to be particularly susceptible to
diaphragm has a smaller proportion of contractile
airway obstruction.
elements and fewer fatigue resistant muscle fibres. The
The nares, upper and lower airways are smaller in rib cage is cartilaginous and more compliant, so the
absolute terms in children. Resistance to air-flow (and diaphragm anchor points are more mobile, leading
thus the work of breathing) increases during quiet, to wasted inspiratory work and the clinical sign of
laminar flow breathing in inverse proportion to the recession of the chest wall. The chest wall shape in
fourth power of the radius. A small decrease in radius cross-section is circular in the infant compared with the
of the airway increases markedly the resistance to eliptical shape in the older child and the ribs are attached
breathing. This is even more noticeable during crying perpendicular to the vertebral column compared with
when air-flow is turbulent as resistance is then related the acute angle of attachment in the older child. This
to the fifth power of the radius. An example of this means that the contribution of the bucket-handle
amplification effect in the upset child is to compare the movement of the rib cage to inspiration is minimal
increase in airway resistance when the airway narrows in small infants and also the elastic recoil effect is
from 4mm to 2mm: in the quiet child the airway much less during expiration. The intercostal muscles
resistance increases 16-fold but when the child cries and accessory muscles of inspiration are also less well
the increase is 32-fold. developed. Thus, the small infant is very reliant on the
diaphragms contribution to inspiration and thus has
The infant has a relatively large tongue and the
Neil S Morton few reserves when work of breathing has to increase.
larynx is situated relatively high in the neck, with the
Reader in Anaesthesia, This is on top of the already high basal demands placed
epiglottis at the level of C1 at birth, C3 in the infant
Royal Hospital for on the infant respiratory system by the higher rate of
and C6 from puberty. The laryngeal inlet appears to
Sick Children metabolism in early life.
lie more anteriorly because of its high position. In
Glasgow the infant, the epiglottis is long and omega shaped The small absolute size of airways in children means
UK and angled away from the long axis of the trachea. that secretions, small airway constriction, oedema or

compression more readily lead to airway closure and either atelectasis A see-saw pattern of chest and abdominal breathing movements is
or gas trapping. The interalveolar pores and bronchoalveolar channels seen in airway obstruction. This sign occurs earlier in younger infants.
do not develop until the ages of 1 year and 8 years respectively so Recession of the intercostal spaces, subcostal region and sternum
collateral ventilation is not an option around an area of obstruction are also seen early in young infants and reflect the forces generated
by these mechanisms. by vigorous contractions of the diaphragm and the compliant chest
wall. If recessions are seen in older children they indicate severe
Thus anatomical, physiological and developmental factors conspire to
airway obstruction. Use of the accessory muscles of inspiration
make the child susceptible to airway obstruction and is exacerbated
(sternomastoids, scalene muscles and intercostals) is associated with
in disease states (Table 1).
tracheal tug, suprasternal and supraclavicular recessions and nasal
flaring. Often the child sits upright and may adopt the tripod
What are the symptoms and signs of airway obstruction? position to improve the mechanical advantage of these muscles in
Signs of foreign body aspiration moving the chest wall and that of the diaphragm. In the small infant,
Sudden onset of respiratory compromise associated with coughing, an opisthotonic posture may be seen in airway obstruction and head
gagging, choking, aphonia or stridor suggests foreign body aspiration bobbing is a sign of accessory muscle contraction in the infant. Lack
and this may necessitate emergency basic life support measures for of effort associated with deteriorating conscious level may indicate
the choking child. Signs of gas trapping behind a foreign body (ball- exhaustion and decompensation.
valve effect) may be seen with hyper-resonance of the hemithorax, Expiratory grunting is often noted in infants with respiratory distress
loss of percussion dullness over the liver, surgical emphysema, tracheal who are trying to generate auto-CPAP or expiratory braking at
deviation and unequal breath sounds. It is particularly important to laryngeal level to maintain a residual lung volume at end expiration.
think of the possibility of pneumothorax and actively exclude it and
treat it promptly. Pneumomediastinum, pneumopericardium and Stridor during inspiration is usually a sign of airway obstruction at
pneumoperitoneum may be seen. Collapse or consolidation of lobes supraglottic or laryngeal level but can occur in tracheal obstruction
or lungs with bronchial breathing, widespread crackles and expiratory also. Stridor during expiration is usually a sign of intrathoracic airway
wheeze may all be elicited depending on the cause, site and duration obstruction. Prolonged expiration with wheeze is usually a sign of small
of the airway obstruction. airways obstruction as in bronchiolitis or asthma but can occur in
large airway obstruction especially due to foreign body or if there is an
Signs of increased work of breathing underlying anatomical abnormality. The volume of stridor or wheeze
The increased effort of breathing caused by airway obstruction may does not correlate with the degree of airway obstruction. Indeed, the
produce an increase in respiratory rate for age. A rate >50bpm in an most ominous sign is the silent chest where obstruction is so severe
infant and >30bpm in a child may be considered abnormal. However, that no gas flow is occurring.
of even more concern would be respiratory distress associated with a
normal respiratory rate, bradypnoea or apnoeic spells which indicate Signs of ineffective breathing
decompensation and exhaustion. Cyanosis, depression of conscious level, slow respiratory rate, the
Table 1. Some causes of large airway obstruction in children
Depressed conscious level

Foreign body
Infection
Viral: croup, papillomatosis
Bacterial: epiglottitis, tracheitis, tonsillitis, abscess
Adjacent to airway
Trauma
Thermal injury
Congenital abnormalities: choanal atresia, choanal stenosis, micrognathia, macroglossia, laryngomalacia, laryngeal web
Neoplasm: haemangioma, lymphoma, mediastinal mass
Peripheral neurological disease
Neuromuscular disease
Iatrogenic: subglottic stenosis, post-intubation stridor, neck haematoma
Anaphylactoid reactions
Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia page169

silent chest despite vigorous respiratory efforts or lack of adequate Lateral soft tissue neck films are seldom indicated but may
respiratory effort, apnoeic spells and bradycardia are most worrying show a foreign body, thumb sign of epiglottitis, prevertebral or
signs of ineffective breathing. a retropharyngeal abscess. CT and MRI scanning have no place
in emergency management but are very helpful in cases such as
Secondary effects of airway obstruction
haemangioma, mediastinal mass, or abscess adjacent to the airway.
Airway obstruction may produce hypoxaemia and hypercarbia.
Tachycardia, sweating, confusion, restlessness, agitation, anxiety, The process of obtaining arterial, capillary or venous blood gases is
dyspnoea, inability to speak, peripheral vasoconstriction with pallor likely to cause undue distress which will worsen airway obstruction. In
or mottling, cyanosis, decreased conscious level, apnoeic spells and the obtunded child intervention should be immediate and should not
bradycardia may occur. Generalised convulsions may occur secondary await blood gas results. For less severe cases, trends in carbon dioxide
to hypoxaemia. Hypertension and bounding pulses may be felt levels, pH and oxygen values may be helpful in guiding treatment
and pulsus paradoxus of greater than 20 mmHg may be elicited in and in reinforcing the need to intervene. Chronic airway obstruction
older children. Chronic airway obstruction may cause chest wall leads to a respiratory acidosis which induces renal compensatory
abnormalities, pulmonary hypertension, right heart failure and mechanisms with retention of bicarbonate and a metabolic alkalosis
obstructive sleep apnoea syndrome. reflected in a high serum bicarbonate level and often a near normal
arterial pH.
What investigations are helpful?
The assessment of the child in order to identify and manage airway Making the diagnosis
obstruction is a clinical one. Do not try to examine the childs throat. Some features of the history and examination may be particularly
The pulse oximeter is a very helpful, non-invasive and atraumatic helpful in pointing to a specific diagnosis and they are summarised in
monitor of arterial oxyhaemoglobin saturation and heart rate. Table 2. These clinical signs are suggestive only as each disease process
However, the readings need interpretation in context with the clinical has a spectrum of severity. In individual cases it can be difficult to
picture as they are affected by poor perfusion, movement, ambient differentiate between the infective causes and foreign body aspiration.
light and carboxyhaemoglobinaemia (as may occur in smoke inhalation Severe tonsillitis or abscesses near the airway can produce similar
injury) and are less accurate at values below 70%. symptoms and signs. Oedema of the face, periorbital tissues, tongue
and peripheries is suggestive of angioneurotic oedema or anaphylactoid
Radiology should not be used in the child in extremis before
reactions.
intervening but in the less acute situation may help elucidate chest
signs, such as pneumothorax, consolidation, collapse, foreign body, Severity scoring system
steeple sign in croup, mediastinal mass, etc. It should be carried out A scoring system for croup (Table 3) is helpful in assessing severity,
at the bedside. response to therapy and of the need for intervention
Table 2. Differentiation between croup, tracheitis and epiglottitis

Croup Tracheitis Epiglottitis
Cause Viral Staphylococcus aureus Streptococcus Haemophilus influenzae B
Age 6m 3y Any age 2 6y
Onset Gradual Gradual Sudden
Pyrexia Mild >38 C
o
>38oC
Abnormal sounds Barky cough, stridor Barky cough, stridor Muffled, guttural cough
Swallowing Normal Difficult Very difficult with drooling
Posture Recumbent Sitting Tripod position
Facies Normal Anxious Anxious, distressed, toxaemic
Table 3. Croup score

0 1 2
Breath sounds Normal Harsh, rhonchi Delayed
Stridor None Inspiratory Insp. + Exp.
Cough None Hoarse cry Bark
Retractions/ flaring None Flaring + suprasternal retractions Flaring + suprasternal + intercostal
retractions
Cyanosis None In air In 40% oxygen

Paediatric Large Airways Obstruction
Call for senior experienced help
as per local protocol
Clinical
Assessment
CHRONIC
Immediate
NO AIRWAY
Measures
Intervention OBSTRUCTION
to Buy
Required? ANATOMICAL
Time
ABNORMALITY
Oxygen
YES humidity
nebulised
adrenaline
steroids
cpap
Foreign Basic
helium
Body Life
Aspirations Support
OPEN AIRWAY
OXYGENATE
SUPPORT INADEQUATE
VENTILATORY EFFORTS
Choking Advanced Drain

Bronchoscopy Child Life Tension
Protocol Support Pneumothorax
BACK BLOWS
INHALATIONAL TECHNIQUE
CHEST COMPRESSIONS
IV ACCESS
ABDOMINAL THRUSTS
Failed
Intubation Endotracheal
CrichOthyrotomy
Protocol Intubation
(DIFFICULT INTUBATION PROTOCOL)

Tracheotomy
Post-Intubation
Intensive care

PART 2: MANAGEMENT cannulae, nasal prongs or a nasopharyngeal airway. It is a very useful
measure particularly during the preparation phase prior to intubation
Importance of rapid clinical assessment, minimal and during inhalational induction of anaesthesia. It can be very useful
disturbance and rapid intervention in the management of chronic airway obstruction. A development of
An assessment from the end of the bed with minimal disturbance CPAP is bi-level CPAP or BIPAP; it is becoming increasingly popular
should be possible in most cases with the child sitting in the parents in the management of children.
arms and the child should be allowed to adopt the posture in which
Prone position +/- nasopharyngeal airway can be useful in babies with
they are most comfortable. Clinical assessment and a concise history
congenital upper airway abnormalities where the tongue is relatively
as described in part 1 should allow identification of the need for
large eg hemifacial microsomia, Pierre-Robin syndrome, or Treacher-
intervention. A pulse oximeter probe is relatively atraumatic to
Collins syndrome. The tongue falls forward from the posterior
apply. Gentle physical examination of the chest seeking actively
pharyngeal wall and often improves the airway. In conjunction with
for the important signs described in part 1 should be possible. In
nasal CPAP and /or a nasopharyngeal airway, the child may improve
some cases, the need for immediate intervention will be obvious. In
markedly with this simple manoeuvre.
others, measures to buy time to enable experienced help to arrive
may be appropriate. It is often stated that attempts at venous access Helium is less dense than air or oxygen and gas flow tends to be more
should not be made as they will upset the child - this is a reasonable laminar which reduces the work of breathing. However, it is not readily
view. However, some argue that, in the less ill child and with topical available, is expensive and dilutes the inspired oxygen concentration.
local anaesthesia or ice analgesia of the skin and a skilled paediatric Breathing a helium-oxygen mixture may be helpful in buying time.
venepuncturist, this is not an issue. Some experienced paediatric
How should I intervene to open and secure the airway?
anaesthetists are of the view that, in the hypercarbic, obtunded child
The algorithm in Figure 1 is a useful guide. If possible, call for expert
with a hyperdynamic circulation, establishing venous access is relatively
help.
simple and appropriate. Despite this debate, the classical approach of
not attempting venepuncture is recommended for the non-specialist Basic life support manoeuvres and the choking child
anaesthetist. Head tilt, chin lift and jaw thrust are the first basic steps. Physical
methods of clearing the airway should only be used if the diagnosis
When is immediate intervention required to open the of foreign body aspiration is clear and dyspnoea is increasing rapidly
airway? or apnoea has occurred. Do not use finger sweeps as this may push
Immediate intervention is needed in the choking child or if the child the foreign body further down the airway and may impact it in
is apnoeic or exhausted and making ineffective respiratory efforts. A the laryngeal inlet. Do not try to examine the throat. In infants,
silent chest or no stridor (either in the child making maximum effort immediately carry out five back blows with the heel of the hand
to breath or in the exhausted child) are very sinister indications of with the infant lying prone and head down along your arm which
complete airway obstruction. The simultaneous treatment priorities should be resting along your thigh. If the obstruction remains, turn
are oxygenation, opening the airway, improving failing respiratory the baby supine and give five chest thrusts as for cardiac compression
efforts and relieving tension pneumothorax. but more slowly and repeat airway opening manoeuvres, expired air
Can I buy time prior to intervening to secure the airway? ventilation and cardiac compressions as appropriate. In older infants
Steroids improve airway patency in croup, haemangioma, lymphoma and children, five back blows with the child prone across the lap and
and some mediastinal masses. They can be given orally, parenterally up to five abdominal thrusts exactly in the midline with the child
or by nebuliser. Prednisolone 4mg.kg-1 orally, or dexamethasone standing, kneeling, sitting or supine should be used.
0.6mgkg-1 intravenously or intramuscularly, or budesonide 1-2mg by
Advanced life support manoeuvres
nebuliser are favoured as initial therapy with maintenance by repeated
Oxygen 100% should be administered by self-inflating bag and mask
nebuliser therapy or oral prednisolone or parenteral dexamethasone
or anaesthetic T-piece circuit, depending on familiarity. The latter has
at one quarter of the initial dose every 8-12h for up to 48h. Prompt
the advantage that CPAP can easily be applied and the transition from
administration of steroids often pre-empts the need for intubation in
spontaneous to controlled ventilation is simple. It is very important
most cases of moderate or severe croup.
to actively exclude tension pneumothorax and, if present, to intervene
Nebulised adrenaline 1:1000 standard solution at a dose of 0.5ml.kg-1 with a needle, cannula or drain. This can be inserted under local
(maximum 5ml) diluted if necessary with 0.9% saline to a total volume anaesthesia in the conscious child giving careful attention to technique.
of 5ml will give a dose of 2-5mg in most cases. It reduces mucosal Some distress may be caused to the child but this is transient and
oedema and acts very rapidly but when stopped may give rise to a justifiable in the emergency situation. In the context of a tension
rebound worsening of airway obstruction. It is a useful temporising pneumothorax secondary to acute airway obstruction, it is very wise
measure. ECG monitoring is recommended although dysrhythmias to drain the pneumothorax prior to inducing anaesthesia. However,
are seldom a problem. circumstances may dictate simultaneous intervention to drain the
pneumothorax and induce anaesthesia to secure the airway if rapid
CPAP - Continuous positive airway pressure acts as an effective splint
decompensation is occurring.
for the collapsible, compressible paediatric upper airway and can be
delivered to infants and children by a well fitting facemask (especially Endotracheal intubation technique
using the Jackson-Rees T-piece circuit) and, in babies, by nasal It is better to have the child in an intensive care or operating theatre

environment. Senior experienced staff only should attempt intubation Small diameter endotracheal tube
unless circumstances mandate a life-saving attempt. Some recommend Child with signs of septicaemia
calling for assistance from the ENT team in case a bronchoscopy
Lower respiratory or lung disease
or tracheostomy is needed. A wide range of paediatric airway and
intubation equipment should be to hand and checked. Child who has sustained a hypoxic insult
Very abnormal, inflamed or oedematous airway
Inhalational induction of anaesthesia with halothane (increasing
gradually to 5%) in oxygen, starting with the child in the position Traumatic intubation
in which they are most comfortable is recommended. Some experts Need to transport the child to another hospital
now prefer sevoflurane (starting with 8%) in oxygen but experience Sedation, analgesia and muscle relaxation should be given as
in children with critical airway obstruction is limited and sevoflurane appropriate. Some children develop post-intubation pulmonary
is intrinsically less potent making it difficult to gain a sufficient depth oedema which requires ventilatory support with PEEP and diuretic
of anaesthesia to allow intubation. Remember, alveolar ventilation therapy.
may be severely compromised and uptake of volatile agents may be
very slow. It may take up to 10 minutes to reach a sufficient depth Antibiotic therapy is indicated for likely organisms - the third or
of anaesthesia. As the depth of anaesthesia increases and the patient fourth generation cephalosporins are favoured with some preferring
is moved to the supine position, airway obstruction may occur and flucloxacillin for staphylococcal tracheitis. Duration of intubation
it is wise to change position gradually and to add CPAP to splint the varies widely from 18-24 hours for acute epiglottitis to days or weeks
airway open. Once the pupils become constricted and central, wait for for those with lung involvement, severe disease and pre-existing
a further 30 breaths and then perform laryngoscopy and orotracheal congenital anomalies. Some children may require formal investigation
intubation. Change to a nasotracheal tube once the child is stabilised of their airway eg endoscopy, foreign body removal or reconstructive
and fix securely with tape or a tube holder and fixation system (eg surgery.
Tunstall, Burtles, Secure-ET).
CONCLUSION
If intubation is difficult or impossible, a number of techniques Large airway obstruction in children is a common emergency. If
using the flexible fibreoptic or rigid bronchoscope are possible and available, senior experienced help should be summoned immediately.
very occasionally blind or retrograde intubation techniques may be Therapy is guided by clinical assessments. All consultants should be
employed. The use of a nasopharyngeal airway or the laryngeal mask competent in the performance of basic life support measures for the
airway may be helpful in certain cases. All these techniques are for choking child and for opening the airway, oxygenating the child and
the expert only. supporting inadequate ventilation. Measures to buy time can be very
In certain cases of impossible intubation where the child is rapidly helpful in croup and where the airway anatomy is abnormal. Advanced
deteriorating, the safest option may be to consider an emergency life support measures are for experienced staff but you may have to
cricothyrotomy using a cannula, 3mm endotracheal tube connector, intervene immediately to save a childs life. The results of correct
a T-piece or self inflating bag and oxygen source. Remember that there management are excellent.
must also be a patent expiratory pathway to avoid barotrauma. Carbon FURTHER READING
dioxide levels will tend to rise with this technique. Jet ventilation Morton NS. Large airway obstruction in children. Update in Anaesthesia (2004)18:44-
is not recommended in children due to the risks of overpressure 49. Available from: http://www.wfsahq.org/components/com_virtual_library/me
and barotrauma. In other cases, particularly of severe anatomical dia/92df8f6507212855c41926db87562732-
9872ec3f9b81c17cad5c78fcbaa5d71c-Large-Airway-Obstruction-in-Children--
abnormalities, the safest option may be an emergency tracheostomy Update-18-2004-.pdf
under mask anaesthesia and or local infiltration analgesia. 1. Kissoon N. Acute respiratory emergencies. In: Duncan A, ed. Paediatric Intensive
Care. London: BMJ Books, 1998:9-40.
When should I not intervene? 2. Robinson D. Airway management. In: Morton N, ed. Paediatric Intensive Care.
If you are inexperienced with advanced life support measures in Oxford: Oxford University Press, 1997:81-108.
children, you should try to maintain oxygenation, airway patency 3. Advanced Life Support Group. Basic Life Support. Advanced Paediatric Life
and ventilatory support with basic measures until experienced staff Support. 5th ed. London: BMJ Publishing Group [Wiley-Blackwell], 2005:19-33.
arrive. Advanced life support interventions should be carried out by the 4. Morton NS, Doyle EI. Case Presentations in Paediatric Anaesthesia and Intensive
most experienced staff present. However, you may have to intervene Care. Oxford: Butterworth-Heinemann, 1994.
in the extreme situation to save the childs life. If it is available, it is 5. Morton NS. Large airway obstruction in children. Part 1: Causes and Assessment.
Royal College of Anaesthetists Newsletter 1999; Issue 47: 159-162.
vital that expert help is called as early as possible to manage children
6. Kissoon N. Acute respiratory emergencies. In: Duncan A, ed. Paediatric Intensive
with airway obstruction. Care. London: BMJ Books, 1998:9-40.
How should I manage the child after the airway is secured? 7. Robinson D. Airway management. In: Morton N, ed. Paediatric Intensive Care.
Oxford: Oxford University Press, 1997:81-108.
It is important to ensure that the artificial airway is fixed securely
8. Morton NS, Doyle EI. Case Presentations in Paediatric Anaesthesia and Intensive
and is correctly positioned. A post-intubation chest X-ray is useful Care. Oxford: Butterworth-Heinemann, 1994.
for checking tube position and identifying lower respiratory tract 9. Special Issue: The Pediatric Airway. Pediatric Anesthesia, July 2009;19s1:III-IV,
or pulmonary parenchymal changes. Indications for controlling 1-197 Available at: http://onlinelibrary.wiley.com/doi/10.1111/pan.2009.19.
ventilation rather than allowing spontaneous ventilation are: issue-s1/issuetoc

Common emergencies
Bronchoscopy for a foreign body in a child

Based in part on: Dix P. Bronchoscopy for a foreign body in a child. Update in Anaesthesia (2003): 17: 20-21.
P Dix and V Pribul

Correspondence Email: pippadix@doctors.org.uk
INTRODUCTION
Inhalation of a foreign body (FB) is a potentially life
threatening event, with boys in the age range 1 to 3
years most at risk. Clinical features of FB inhalation
vary from acute upper airway obstruction to pneumonia
due to distal airway collapse, depending on where the
Summary FB becomes impacted in the airway and when the child
presents. This article will discuss common presentations
1. The clinical effect of of FB inhalation, and a suggested technique to remove
an inhaled foreign body the FB safely.
depends where the foreign
body becomes impacted
PATHOPHYSIOLOGY
most small foreign bodies Figure 1. Back blows in a choking infant with a FB above
pass into the distal airway,
The clinical features of inhaled FB depend on the size
and nature of the FB, and where it becomes impacted the vocal cords
but larger objects may
become impacted in the in the airway. Resistance to gas flow in the airway is The vocal cords are the narrowest part of the airway in
supraglottic area to cause related to the fourth power of the radius, so a small the child - in the majority of children who inhale a FB
choking, or in the trachea to reduction in airway radius in a child will result in a and reach hospital, the FB has passed between the vocal
cause severe airway distress. large increase in resistance to airflow. Inhalation of cords to a distal main bronchus (usually right main
2. Children often inhale an organic FB may result in airway hyperreactivity bronchus). Occasionally, the FB becomes impacted in
foodstuff such as peanuts and mucosal oedema. The occurrence of oedema in the larynx or in the trachea:
organic foreign bodies can addition to the physical presence of the FB results in
cause airway oedema and a rapid increase in airway resistance. Coupled with Signs and symptoms of laryngeal or tracheal obstruction:
hyperreactivity, which may the high oxygen consumption of infants and small Cough
be worsened by anaesthetic children, hypoxia may occur rapidly if the FB is
gases. Topical lignocaine to lodged in a major airway. Choking
the airway assists smooth
anaesthesia. Respiratory distress
PRESENTATION
3. A foreign body may Presentation may be acute in the case of a supraglottic Cyanosis, desaturation
become impacted distally FB or FB in a major airway, or more insidious if the Stridor
or exert a ball valve effect FB is distal and presentation is delayed. The signs and
to allow inflation but not Tachypnoea.
symptoms depend on the position of the FB in the
deflation. For this reason, you
must maintain spontaneous
airway. Sign and symptoms due to obstruction of a main
ventilation, and allow rigid The history may help in the diagnosis, for example bronchus:
bronchoscopy prior to sudden onset of respiratory distress while playing Respiratory distress
intubation. with small objects. A child who is actively coughing
after a witnessed choking event has a supraglottic Tachypnoea
FB and should be managed according to choking Wheeze
P Dix
algorithms - encourage the child to cough to clear
Consultant Anaesthetist Absent breath sounds on the affected side.
the obstruction, use alternating back blows and
V Pribul, chest thrusts (abdominal thrusts in the older child), If the FB is small and has lodged in a distal airway, there
Anaesthetic Registrar or standard CPR if the child becomes unconscious may be no clinical findings during the acute phase, even
Royal Devon and Exeter (see Figure 1 and Paediatric Resuscitation article p following a clear history of FB inhalation. Air trapping
NHS Foundation Trust 265). It is essential to intervene early children with might be seen on a chest X-ray on expiratory films, due
Exeter untreated airway obstruction due to a supraglottic FB to a ball valve effect. Initially an air bronchogram
UK do not often survive to reach hospital. may be seen, with later evidence of atelectasis distal

to the obstruction. The child may present a few weeks later with Expiratory wheeze - infraglottic FB.
chronic cough, chest infection, and signs of consolidation affecting
Measure the oxygen saturation with a pulse oximeter and give high
one or more lobes.
flow oxygen if required.
If the child is stable a chest Xray may be helpful in localising the FB,
although the majority of FBs will not be radio-opaque. In the acute
situation few other investigations are indicated.
The child should be starved according to the recommended guidelines,
but careful judgement of clinical priorities is required in a child with
acute respiratory distress. Consider anticholinergic premedication
to decrease airway secretions (atropine 20mcg.kg-1 PO). This will
also reduce the vagal tone and avoid bradycardia during airway
instrumentation. Sedative premedication should not be used.
TYPES OF BRONCHOSCOPE
A rigid bronchoscope should be prepared, and the anaesthetist should
be familiar with the equipment available locally.
Rigid bronchoscopy has several clear advantages:
Complete airway control
Better view of the bronchial tree
Larger channels through which to pass instruments and withdraw
FBs.
Figure 2. Hyperlucent appearance of the right lung on this expiratory chest In older children, the rigid bronchoscope only allows limited access
Xray demonstrates air trapping from a foreign body lodged in the right main to the upper lobes and more distal airways.
bronchus. Image reproduced with kind permission of the Department of
Radiology, Virginia Commonwealth University Medical Center, from www. Two types of rigid bronchoscope are available. The older Negus
pedsradiology.com bronchoscope is the original rigid bronchoscope, and has a tapered
shape.
You should consider FB aspiration in every child presenting with cough
or stridor. The differential diagnosis includes infective causes such as: The Stortz ventilating bronchoscope is the most commonly used rigid
bronchoscope. It is available in a variety of sizes and lengths from
Croup (viral infection typical barking cough with stridor and 2.5mm internal diameter. It has a side port to which the anaesthetic
respiratory distress as a late complication), breathing circuit can be attached to provide anaesthesia during airway
Acute epiglottitis (Haemophilus influenza type B infection causes examination (see Figure 2). This allows safe examination of all children,
supraglottic cellulitis with severe sore throat, fever, toxic, muffled including neonates.
voice and drooling),
Acute tracheitis (Staphylococcal infection child toxic, unwell).
Peanut oil is particularly irritant to the airways and can cause local
mucosal oedema as well as a chemical pneumonitis picture, which may
be the only presenting factor. A FB in the upper part of the oesophagus
(hypopharynx) may present with respiratory distress due to external
compression of the trachea.
PREPARATION, INVESTIGATION AND EXAMINATION

OF THE CHILD
To a large extent this will be dictated by the clinical condition of the
child, and intervention should be planned carefully with the ENT
surgeon (if available).
You should make a rapid assessment of the child. Pay particular Figure 3. Storz ventilating bronchoscope with anaesthetic T-piece attached
attention to examination of the airway and chest. If the FB has The Hopkins rod lens telescope is inserted through the lumen of the
impacted in the airway but is not causing complete obstruction, the bronchoscope, allowing a clear view of the endobronchial tree. A wide
clinical signs may help to localize the site of obstruction: range of instruments including long grasping forceps are available to
Inspiratory stridor - glottic or supraglottic FB enable the FB to be retrieved (see Figure 3).

problem with halothane, and are worsened by of hypoxia,
hypercapnia and high circulating levels of catecholamines
More rapid onset.
Advantages of halothane:
Longer lasting anaesthetic effect. This allows more time for airway
manipulation without the child becoming too lightly anaesthetised
and developing laryngospasm
Often more readily available
Lower cost.
Figure 4. Storz ventilating bronchoscope with long grasping forceps The choice will be dictated by personal experience and preference, and
The anaesthetic T-piece circuit is attached to the sidearm of the also local availability. Ether is very slow in onset and difficult to use
bronchoscope to allow delivery of oxygen and anaesthetic gases during for inhalational induction, and is not recommended in this context.
the procedure. The presence of the telescope, with the viewing end The key to successful bronchoscopy is adminstration of topical local
occluded, results in a closed system, through which either spontaneous anaesthetic to the airway this allows the surgeon to insert the
or controlled ventilation may occur. When the telescope is removed bronchoscope and remove the FB without the child coughing. A safe
the system is open, allowing only spontaneous ventilation, unless the dose of local anaesthetic must be used (4mg.kg-1 topical). Draw up the
operator occludes the port with their thumb. The telescope occupies a required dose into a syringe prior to the start of anaesthesia; attach a
significant proportion of the bronchoscope through which expiration long cannula with the needle removed. This is used to apply the correct
must occur. It may be necessary to remove the telescope periodically dose of local anaesthetic to the cords (see Figure 5)
to allow adequate breathing through the lumen of the bronchoscope,
especially when using smaller diameter bronchoscopes. Remember - 1% lignocaine contains 10mg.ml-1 lignocaine. The safe
dose for a 8kg child is 3.2ml.
A Sanders injector can be attached to the sidearm to enable controlled
ventilation, when the telescope is not being used. It uses the Venturi
effect to entrain oxygen-enriched air. The entrainment of air means
that it is not possible to deliver high oxygen concentrations, which
may not maintain adequate patient oxygenation. Maintain anaesthesia
with IV anaesthetic agents. In smaller children barotrauma can easily
occur, so this is not the best technique for them.
ANAESTHESIA
Bronchoscopy is performed under general anaesthesia. The anaesthetic
machine and other equipment should be checked, especially suction
equipment. A range of sizes of tracheal tubes should be available,
in case intubation is required urgently. Airway oedema reduces the
tracheal diameter and a smaller tube than usual may be required
prepare a range of sizes.
Monitoring including pulse oximetry, ECG, non-invasive blood
pressure, and capnography should be applied. Intravenous access Figure 5. Use of a cannula to administer topical lignocaine
should be secured prior to induction. If the child is distressed this can Spontaneous ventilation should be maintained if possible, although
be performed immediately after induction. occasionally you might need to use gentle mask ventilation.
A senior anaesthetist and ENT surgeon should be present at induction, Aggressive positive ventilation increases the risk of hyperinflation
along with the most skilled anaesthetic assistant available. Good and pneumothorax if the FB is exerting a ball valve effect, allowing
communication between all members of staff is vital with an agreed inflation but not expiration. Positive pressure ventilation is also likely
plan for how the case will proceed. We recommend inhalational to dislodge the FB distally. For this reason muscle relaxants are avoided.
induction using either sevoflurane or halothane in 100% oxygen. After induction, site a cannula if it is not already in place, and
There is much debate about the relative advantages of halothane and discontinue nitrous oxide if used. Wait until the child is deeply
sevoflurane: anaesthetized before laryngoscopy. This can take a long time due to
Advantages of sevoflurane: the reduced airflow. Apply topical lignocaine to the larynx and trachea
as described above (maximum dose 4mg.kg-1) if possible apply the
Less airway irritation
lignocaine to the cords and also between the cords. Rigid bronchoscopy
Greater cardiovascular stability. Arrhythmias are a potential can be performed after a few minutes.

During bronchoscopy, maintain anaesthesia by connecting a T-piece 3. A foreign body may become impacted distally or exert a ball valve
to the sidearm of the Stortz rigid bronchoscope. Do not intubate prior effect to allow inflation but not deflation. For this reason, you
to rigid bronchoscopy, due to the risk of dislodging or fragmenting must maintain spontaneous ventilation, and allow rigid
the FB possibly leading to complete airway obstruction. If the child bronchoscopy prior to intubation.
desaturates during bronchoscopy of one lung, the bronchoscope can
be withdrawn into the trachea to allow re-ventilation of both lungs,
CASE HISTORY
before a further attempt at bronchoscopy is made. The telescope might
A 4 year-old boy presented to the emergency department with a
also need to be removed from the bronchoscope to allow adequate gas
history of coughing and choking while he was lying on his back
flow. Observe chest movements during bronchoscopy and monitor
playing with some coins. His mother reported that he went blue
carefully at all times; the child may have little respiratory reserve and
for a few seconds, and the child said that he had swallowed a
will desaturate very quickly. The bronchoscopist and anaesthetist must
coin.
work closely together.
On examination he was upset, but well. He was apyrexial, and had
After removal of the FB the airway can be maintained using a face
a respiratory rate of 20min-1 with no recessions. Chest auscultation
mask, tracheal tube or laryngeal mask, depending on the condition
revealed reduced breath sounds in the right lower lobe. A chest
of the child. If the child has copious distal airway secretions, intubate
Xray showed a radio-opaque sphere in the area of the right main
and suction the airway, with gentle on-table physiotherapy if required.
stem bronchus. Ametop local anaesthetic cream was applied to
Discontinue the anaesthetic, administer 100% oxygen, and observe both hands.
the child carefully until awake and extubated. Address other symptoms
The child was transferred to the operating theatre. The anaesthetic
at the same time, for example give IV fluids to counter dehydration.
machine, suction equipment, and laryngoscopes were checked.
Postoperatively, you must monitor the child for stridor and airway The consultant ENT surgeon was present. A pulse oximeter and
obstruction due to oedema. The child may have a sore throat, which ECG leads were applied, and a 22G cannula was sited. Atropine
can be managed with simple analgesia such as paracetamol and 10mcg.kg-1 and dexamethasone 250mcg.kg-1 were given IV.
NSAIDs rather than opioids. Anaesthesia was induced using 3% halothane in oxygen breathed
spontaneously via a face mask and Ayres T-piece circuit. After
The child may need HDU care depending on their condition,
several minutes, when deep anaesthesia had been achieved,
particularly if presentation has been delayed. If the child has a
laryngoscopy was performed and the cords sprayed with 2mls
secondary chest infection regular physiotherapy and antibiotics should
of 4% lignocaine. A 3.5mm rigid bronchoscope was introduced
be given (e.g. co-amoxiclav).
into the trachea. The coin was retrieved uneventfully from the
Humidified oxygen should be given for 24 hours if required, right main bronchus, and the bronchoscope was withdrawn
particularly if the child has low oxygen saturations and/or stridor. If from the airway. The halothane was discontinued, and the airway
worsening stridor occurs, nebulised adrenaline 1:1000 may be useful maintained with a face-mask until the child was fully awake.
(0.5ml.kg-1, maximum 5ml). Dexamethasone 250mcg.kg-1 IV at
Humidified oxygen was given overnight on the ward, and the child
induction, followed by 100mcg.kg-1 6 hourly for 24 hours has also
was monitored with pulse oximetry. The child was discharged
been recommended.
home the next day.
LEARNING POINTS
1. The clinical effect of an inhaled foreign body depends where the
foreign body becomes impacted most small foreign bodies pass REFERENCE
into the distal airway, but larger objects may become impacted Dix P. Bronchoscopy for a foreign body in a child. Update in Anaesthesia
in the supraglottic area to cause choking, or in the trachea to cause (2003): 17: 20-21. Available from: http://www.wfsahq.org/components/
severe airway distress. com_virtual_library/media/b27816bcf8b61cce6fa0cc6a30571d56-
424afcbfe58e46b3dc60622590113cad-Bronchoscopy-for-a-Foreign-Body-
2. Children often inhale foodstuff such as peanuts organic foreign in-a-Child--Update-17-2003-.pdf
bodies can cause airway oedema and hyperreactivity, which may
be worsened by anaesthetic gases. Topical lignocaine to the airway
assists smooth anaesthesia.

Common emergencies
Anaesthesia for emergency paediatric

general surgery
Mark Newton
Correspondence Email: mark.w.newton@Vanderbilt.Edu
INTRODUCTION
Paediatric emergency general surgery in Sub- signs of severe illness, and careful preoperative
Sahara Africa has a high morbidity and mortality assessment and resuscitation is essential. Severe
with multiple contributing factors. Delayed pre-existing metabolic abnormalities, including
Summary presentation and diagnosis, hospital stays acidosis and dehydration, will be a challenge
elongated by postoperative complications, and for any anaesthesia care provider, but in an
Emergency surgery for bowel the lack of appropriate paediatric intensive care environment with limited anaesthesia, surgery
obstruction in children
facilities all contribute to the overall mortality and intensive care resources, the challenges are
presents many challenges
for the anaesthesia of this surgical population. The mortality in the even greater.
care provider. Delayed neonates (less than 6 months) is even higher.
This article will review the pathophysiology of
presentation and sepsis have The following paediatric abdominal surgical intra-abdominal emergencies in children; how to
a profound physiological emergencies were documented in a case series
impact on many organ construct an anaesthesia plan for such patients;
from a teaching hospital in southeastern Nigeria, intraoperative and postoperative problems; and
systems. Hospital stays
elongated by postoperative and provide a description of the typical paediatric typical case presentations. We hope to provide
complications, and the lack surgical practice in sub-Saharan Africa:1 a greater understanding of general surgical
of appropriate paediatric emergencies in children, and to assist with the
intensive care facilities %workload management of these challenging patients.
also contribute to the high
Typhoid intestinal
morbidity and mortality
of this surgical population. perforation (TIP) 19 PATHOPHYSIOLOGY OF BOWEL
Mortality in neonates is even OBSTRUCTION
Intussusception 17
higher. The normal bowel contains gas and the sum of
Children have a great reserve Obstructed hernia 15 food and salivary, gastric, biliary, pancreatic,
and ability to heal but also and intestinal secretions. Intrinsic or extrinsic
the potential for sudden Neonatal intestinal obstruction 10 blockage of the small bowel leads to accumulation
decompensation. Good of secretions that dilate the intestine proximal
Appendicitis 10
outcomes rely on meticulous
to the obstruction. Patients with delayed
perioperative planning, Trauma 7
proper training, equipment, presentation may have a diminished oral intake
and basic supplies. A Ruptured omphalocele/ for many hours, and perhaps even days or
team approach involving gastroschisis 7 weeks, but intestinal secretions continue so that
the nurses, laboratory the bowel remains full of fluid. Vomiting is an
technicians, paediatricians Hirschsprungs disease 6 important sign of obstructed bowel in children;
and surgeons is essential. the nature of the fluid vomited will suggest
Adhesive bowel obstruction 6
the level of the obstruction. Green coloured
Mark Newton Malrotation 4 bilious vomiting is characteristic of small bowel
Vanderbilt University, obstruction.
Department of
The incidence of typhoid perforation varies If the intraluminal pressure of the obstructed
Anesthesiology and
between regions; it follows infection with bowel exceeds the capillary and venous pressure
Pediatrics (USA)
AIC Kijabe Hospital, Salmonella typhi, the usual source of infection in the bowel wall, intestinal absorption and
Department of being contaminated water supplies. lymphatic drainage decreases and the bowel
Anesthesiology (Kenya) Patients frequently present late, often with may become ischaemic; this is a dangerous

development that may lead to perforation, but it is difficult to <1 year, bradycardia in absence of drugs, vagal stimulation or
predict when this will occur. congenital heart disease, or otherwise unexplained
bradycardia, for over a 30 minute time period (see Table 1).
Bacterial translocation High respiratory rate or mechanical ventilation for an acute
Once the bowel becomes ischaemic, bacteria will pass into problem not related to a neuromuscular disease or for just
the peritoneum by a process known as bacterial translocation, receiving general anaesthesia (see Table 1).
even if the perforation cannot be visualized. The colonized
Leukocyte count elevated or depressed for age, not related
fluid is then transported via the lymphatic channels into the
to chemotherapy.
thoracic duct, which drains into the central venous system.
This allows bacteria to enter the circulation, which in turn The criteria for definition of severe sepsis in children is sepsis
causes septicaemia. Studies have shown that bacteria injected PLUS one of the following:2
into the peritoneum can be cultivated from peripheral blood Cardiovascular dysfunction,
only six minutes after the injection into the peritoneum, Acute respiratory distress syndrome (proven need for >50%
confirming the extremely rapid flow from the peritoneum into inspired oxygen (FiO2 >0.5), to maintain arterial saturation
the systemic circulation. Bacterial translocation will produce >91%),
a cascade of events, which will impact multiple systems.
Two or more organ dysfunction (respiratory, renal,
Septicaemia is common in children with delayed presentation
neurologic, hematologic, or hepatic),
due to an abdominal emergency, and a child presenting for
emergency paediatric surgery in this condition will provide The presence of organ dysfunction can be determined clinically
many challenges to the anaesthetist. or with basic lab tests such as platelet count, creatinine level,
or bilirubin level. This allows the clinician at the bedside to
DEFINITION OF PAEDIATRIC SEPSIS diagnose sepsis without sophisticated tests, and prompts the
appropriate interventions. It is important to understand that
The International Paediatric Sepsis Consensus Conference
the paediatric surgical patients who require emergency surgery
(2005) attempted to develop specific criteria for an
could have an assortment of organs that are functioning
international definition of sepsis. These experts determined
abnormally; this information will help you to plan the
that the presence of two of the following four criteria, one
perioperative care for these very ill patients.
of which must be abnormal temperature or leukocyte (white
blood cell) count, along with a suspected or proven infection, Cardiovascular dysfunction
would constitute the definition of sepsis. The infection could Children compensate for a decrease in circulating volume and
be bacterial, viral, fungal or rickettsial in origin.2 In most may not become hypotensive until long after septic shock
patients with a surgical abdomen, the infection would be a develops, unlike in adult shock patients where hypotension is
suspected bacterial infection. commonly seen.
The criteria for the definition of sepsis in children are as follows: Some investigators have defined the cardiovascular symptoms
Core (rectal, oral) temperature of >38.5C or <36C. of septic shock as tachycardia with signs of decreased perfusion
Tachycardia in the absence of external stimulus, chronic including:2
drugs or painful stimuli, or otherwise unexplained elevation, Decreased peripheral pulses compared to central pulses
for over a 30 minute to 4 hour period, OR, for children Altered alertness
Table 1. Criteria for definition of sepsis in children of different ages
Age Group Heart Rate, Heart Rate, Respiratory Rate, Leukocyte Count, Systolic Blood
Beats/Min Beats/Min Breaths/Min Leukocytes x Pressure, mmHg
103.mm-3
Tachycardia Bradycardia
0 days to 1 wk >180 <100 >50 >34 <65
1 wk to 1 mo >180 <100 >40 >19.5 or < 5 <75
1 mo to 1 yr >180 <90 >34 >17.5 or < 5 <100
2-5 yrs >140 N/A >22 >15.5 or < 6 <94
6-12 yrs >130 N/A >18 >13.5 or < 4.5 <105
13 to <18 yrs >130 N/A >14 >11 or < 4.5 <117

Capillary refill >2 seconds A detailed history will help determine the period of decreased
Cool extremities fluid intake and also the type of fluid used for resuscitation by
the caregivers or the medical care provider prior to arriving
Decreased urine output.
at your institution. A question to the patients mother (or
If a child presents with signs above and with hypotension caregiver) regarding frequency of a wet diaper/nappy in the
and tachycardia, this indicates that they have lost a significant last 24 hours will help one assess intravascular status and renal
amount of blood (e.g. from trauma), or they are severely function.
volume depleted (e.g. due to intra-abdominal pathology).
A child presenting for surgery with this picture requires Inappropriate ADH (vasopressin) secretion is common in the
significant fluid resuscitation prior to induction of anaesthesia. sick child, and children presenting with abdominal pathology
are at particular risk of perioperative hyponatraemia. It is
Blood volumes in children are small in absolute terms (75- important to avoid intravenous fluids with a low sodium
80 ml.kg-1). Every paediatric patient will need to be weighed content at all times in these patients, especially if they are
accurately prior to starting fluid resuscitation. There are many requiring fluid at more than normal maintenance rate.
references that discuss assessment of percentage of deficit, but
in general, if a patient is dehydrated, a fluid bolus of 10ml.kg-1 Unfortunately, iatrogenic harm is common in paediatric fluid
normal saline (0.9% saline) or a balanced salt solution such management, particularly if low sodium containing fluids
as lactated Ringers, should be given and repeated as required. such as 4% dextrose 0.18% saline are used for resuscitation.
A child with a surgical abdomen may typically require This may lead to symptomatic hyponatraemia (low plasma
repeated IV boluses up to 30-50ml.kg-1 preoperatively to sodium), which may complicate diagnosis and delay surgical
restore adequate intravascular volume. If repeated crystalloid intervention. For example, if hypotonic fluids are used for fluid
boluses are required, greater than 30ml.kg-1, consider blood resuscitation in a child with an acute abdomen, the plasma
transfusion. sodium may fall to extremely low levels (<125mmol.l-1), and
the child may have seizures. This causes diagnostic confusion
Renal system and fluid and electrolyte management if the child is investigated for a seizure disorder when in fact
Decreased circulating volume and hypotension also trigger the child has dehydration secondary to bowel obstruction.
sodium and water conservation by the kidneys through Severe hyponatraemia may lead to irreversible brain damage
decreased urinary output. Remember that the developing child in children, but can be avoided by using isotonic fluids for
does not have the same anatomical and functional renal capacity resuscitation.
as the adult patient, thus maximum concentrating capacity may
not be demonstrated. Increase in sympathetic tone in shock Early symptoms of hyponatraemia include nausea and
causes constriction of the renal arteries, which reduces blood headache. Later symptoms can include confusion, seizures and
flow to the kidneys and decreases filtration and urine output. even respiratory arrest. A seizure caused by hyponatraemia is
This low flow state causes the kidney to release vasopressin very difficult to control with benzodiazepines and barbiturates
(antidiuretic hormone, ADH), a potent vasoconstrictor, and until the sodium level reaches 120mmol.l-1. This scenario may
activates the renin-angiotensin-aldosterone hormone pathway be extremely dangerous without adequate critical care facilities
which results in further decrease of blood flow to the kidneys, to manage ventilation and cardiac monitoring since the
as well as generalized vasoconstriction. All of these actions are tendency is overaggressive treatment of the seizures with long-
focused on improving systemic blood pressure, blood flow, acting benzodiazepines causing respiratory depression. A bolus
and maintaining tissue perfusion. Note the above mechanism of hypertonic saline (3% sodium chloride) 1ml.kg-1 should
describes the normal mechanisms that will occur in all patients be given, and may be repeated if the seizures continue. Over
with fluid loss into the gut; some may have the abnormal correction must be avoided; the rate of correction of plasma
syndrome of inappropriate anti-diuteric hormone secretion; sodium should not exceed 8mmol.kg.d-1.
SIADH - see below.
Patients with septic shock typically present with acute changes The renal system in children is immature, which affects the
in their fluid status including: ability to compensate during periods of decreased oral intake,
emesis, and bowel obstruction. For example, in the first year
Decreased oral intake
of life, the renal plasma flow and the GFR are approximately
Fever one half that of the adult patient. Additionally, the fractional
Fluid shift into the gastrointestinal system excretion of sodium does not reach adult levels until 6 months
Electrolyte disturbances of age. Hyponatraemia is common at presentation in children
Pronounced reduction in intravascular volume. with an acute abdomen, again reinforcing the importance of

only using isotonic fluids (0.9% saline, Ringers) to expand the should not be warmed by placing into a bath of warm water;
circulating blood volume in the dehydrated patient. water that is too hot may cause haemolysis of the red blood
cells, which would produce a massive release of potassium.
Large extracellular fluid deficits due to poor intake, excessive The hyperkalaemia could result in sudden cardiac arrest
losses and poor renal capability to compensate may require immediately after the blood is transfused. Water that is too hot
aggressive fluid resuscitation with close monitoring of fluid to submerge your hand in for over 5 seconds will be too hot to
input, urine output and pulmonary status. An indwelling warm IV fluids and should not be used.
bladder catheter may be necessary, and the respiratory rate and
oxygen saturation (if available) should be monitored closely. CLINICAL APPLICATION - CASE EXAMPLE
Even if a patient receives 50-70ml.kg-1 of intravenous fluids, A previously healthy 10-month-old male infant presents to the
pulmonary oedema is rare in this patient population with clinic with a five day history of sudden crying, irritability, and
previously normal cardiovascular function. sweating but with periods where the child seems to be acting
normally. The child has been able to take fluids during the
Haematologic system times where he appears normal but the frequency of pain and
Altered production and function of white blood cells sweatiness has increased in the last two days and the intake
(WBC), red blood cells (RBC), and platelets is common has significantly decreased. The mother denies any fever until
in children with bowel obstruction and sepsis. Sepsis may yesterday but over the last 4 days the child has had loose stools
be associated with anaemia, or the haemoglobin level may described as some blood and mucus with a frequency of 4-6
be artificially high due to severe dehydration. Anaemia in stools per day.
sepsis may develop from haemodilution due to early fluid
resuscitation and also anaemia of inflammation (decreased The mother took the child to a local dispensary where he was
erythropoietin production, decreased bone marrow response given IM antibiotics and some intravenous fluids while being
to the erythropoietin, and decreased RBC survival).3 Chronic monitored. After 12 hours of fluids and no improvement, the
anaemia is also common in this patient population. The child was transported to the referral hospital (6 hours by taxi)
platelet count may be reduced in sepsis, or the function may be where he presented with abdominal tenderness and distention,
abnormal, which may lead to excessive bleeding. Coagulation decreased peripheral perfusion, and breathing difficulties.
abnormalities frequently occur in sepsis. The more delayed Vital signs: HR= 200bpm; RR= 40min-1; BP 50/30 (very
the presentation of bowel obstruction, the greater the chance weak pulses); oxygen saturation (no monitor available) but
of disseminated intravascular coagulation (DIC). DIC is patient appears pale. Initial labs: Na+= 126mmol.l-1; creatinine
characterized by intravascular thrombosis and secondary tissue
ischaemia, which leads to abnormal bleeding.4 Figure 1. Intussusception. Upright abdominal Xray: note loops
of bowel, flattened diaphragm, and rounded abdomen. The child
In many hospital settings, the ability to perform a bleeding
will be at risk of aspiration on induction of anaesthesia
study in a patient with suspected DIC is impossible, and a
clinical diagnosis must be attempted. The clinician should
have a low index of suspicion for coagulopathy in a patient
with sepsis, particularly if there is prolonged bleeding with
simple interventions such as insertion of IV lines. Whole fresh
blood, less than 48 hours old, is available in the blood bank
in most rural hospitals, which is a good option for children
who undergo emergency abdominal surgery as it will improve
haemoglobin, platelet count and coagulation factors. A dose
of 20ml.kg-1 blood in divided doses is a good starting point
for children requiring blood transfusion. The heart rate,
blood pressure and respiratory status should be monitored.
Blood that is needed for surgery should be given immediately
(less than one hour) before the surgery starts, to maximize
the function of coagulation factors and platelets. If blood is
donated immediately prior to surgery, it can be given without
refrigeration, as the warmth of the recently donated blood will
assist in keeping the temperature normal during surgery, for
instance during an exploratory laparotomy. If possible, blood

impact of the pathological state on the loss of intravascular
volume. This child is demonstrating clinical signs of over 15%
deficit which will require a significant amount of fluid in the
form of normal saline. Bloody diarrhoea in this patient may
cause anaemia, protein loss, and electrolyte disturbances; a
normal haemoglobin in a patient with this clinical picture may
be misleading as it may be due to haemoconcentration and
severe dehydration with a RBC mass which is actually low. Be
aware that significant volume resuscitation may then reveal the
true anaemia and low haemoglobin.
This child needs urgent intravenous or intra-osseous access
and resuscitation with a normal saline (isotonic) fluid bolus.
IV access should not be delayed; the patient is near complete
cardiac collapse, and his sympathetic nervous system is working
at maximum capacity to maintain mean arterial blood pressure
with vasoconstriction and tachycardia. Children at this age
can have a significant reduction in the intravascular volume
without demonstrating a large drop in blood pressure, but
then suddenly have a cardiac arrest due to low intravascular
Figure 2. Intussusception. Lateral abdominal Xray: air-fluid volume as their compensatory mechanisms are overwhelmed.
levels (intravascular volume status impacted) and no obvious The mother may be able to inform you of the last time the
perforation (non-specific) child had any urine output which will help estimate deficit.
The normal urine output is 0.5 to 1ml.kg-1.hr-1 but many
patients with this clinical picture may be severely dehydrated
= 1.1mg.dl-1 (97mcmol.l-1); K+= 3.0mmol.l-1; haemoglobin = with present with no urine output and no wet diapers for 24
8g.dl-1. Weight = 6kg. The surgery team has decided that this hours.
patient needs an exploratory laparotomy for bowel obstruction.
This patient should have 20ml.kg-1 IV (IO) 0.9% saline
In most centres, intussussception is the most common cause bolus push, repeated until there are clinical signs of improved
of intestinal obstruction in the age group 3 months to 3 perfusion and the HR falls; the mental status will also
years. Delayed presentation is common due to the nature of improve as perfusion improves. Dont forget blood should
the disease, partly as the obstruction is intermittent initially, be considered if 30-50ml.kg-1 volume resuscitation is required,
partly due to the lack of appropriate centres for paediatric particularly if there is a history of bleeding. The patient may
surgery and anaesthesia. Typically, upper intestinal obstruction require up to 100ml.kg-1 IV volume resuscitation, ideally a
causes emesis as the primary symptom and lower intestinal combination of isotonic saline and blood prior to surgery.
obstruction results in diarrhoea, unless the obstruction is The fluids need to be warmed to avoid causing hypothermia.
prolonged in which case you will see emesis with diarrhoea. Do not give potassium to any volume depleted patient until
Once the obstruction has become fixed, the pain will get urine output is established and renal function can be assessed.
progressively worse and will become constant, which typically Place a bladder catheter to help determine fluid status in this
causes the care givers to seek urgent surgical care. situation. The specific gravity (SG) of the urine has been
shown to be a rough indicator of intravascular dehydration
Preoperative considerations and sensitivity to the negative inotropic effects of anaesthetic
Haemodynamic assessment and initial management agents. If the SG is less than 1009, i.e. the urine is not very
This child has low blood pressure, tachycardia, and poor concentrated, then the risk of hypotension with halothane is
peripheral perfusion and demonstrates the most common form lower compared to when the SG is greater than 1009. A urine
of cardiovascular instability, namely hypovolaemia. The history specific gravity can be obtained in most basic laboratories.
describes a period of low intake, diarrhoea, bowel obstruction, Note that the patient with decreased level of consciousness
fever, and possibly sepsis. Each of these factors contributes to an will improve after volume resuscitation. The serum glucose
overall picture, that results in low circulating blood volume in level must be measured in any patient with reduced level of
a child where the total body water represents 60-70% of body consciousness to rule out hypoglycaemia. At times, when the
weight. Delayed presentation further amplifies the negative intravascular volume is replaced but due to hypoglycaemia, the

child remains in a less responsive state. When in this clinical Electrolytes
situation an intravascular glucose bolus may be required while A child presenting late with bowel obstruction may have
still attempting to maintain normal serum glucose levels. significant electrolyte abnormalities. In patients with altered
mental status, the sodium and glucose levels must be measured
Respiratory assessment and initial management and corrected. Hypoglycemia can be a result of decreased
A patient who presents with tachypnoea and/or hypoxia (or intake over many days, especially in paediatric patients who
low oxygen saturation documented with pulse oximetry) must are at baseline malnourished and then get sepsis. If the blood
be assessed carefully prior to the induction of anaesthesia. glucose level is low, give a bolus of 50% dextrose 2ml.kg-1
High respiratory rate may be a secondary compensation and recheck with a glucometer before starting surgery. If the
to metabolic acidosis due to decreased perfusion. Oxygen surgery lasts longer than 1 hour, recheck the blood sugar again
delivery to the cells may be inadequate in conditions of poor as undetected hypoglycaemia under anaesthesia can have
perfusion for instance due to septic shock, which results in serious neurological implications.
acidosis and excess hydrogen ion production. The body is
attempting to remove carbon dioxide to correct the acidosis. Hyponatremia (low sodium) is common in the surgical
Subtle changes in the respiratory system may precede frank paediatric patient and could be caused by diarrhoea, vomiting,
respiratory failure if the child becomes exhausted and low salt oral fluids, and use of incorrect fluids such as 4%
compensation is overwhelmed. The lungs are not the primary dextrose 0.18% saline for resuscitation at a medical care
organ of failure but merely required to overwork to balance the facility. Paediatric patients who have been resuscitated using
metabolic derangement. As with the cardiovascular system, the 5% dextrose (without added sodium) due to concerns about
respiratory reserve is immense but can suddenly fail, resulting blood glucose levels can present with an altered mental status
in respiratory arrest. Any sudden slowing of the respiratory and even seizure activity due to iatrogenic hyponatremia.
rate should prompt immediate airway assistance such as Hyponatraemic seizures are very difficult to manage with anti-
tracheal intubation. The treatment of this metabolic process seizure medications such as diazepam, and even phenobarbital,
is not bicarbonate but resuscitation fluids (normal saline), if the sodium level is below 120mmol.l-1. These patients
titrated as described. When the patients fluid status improves, should be resuscitated with 0.9% saline; their seizure activity
the patient will become more alert, the perfusion will improve and alertness will improve as the plasma sodium rises. The
and the respiratory rate will become more normal. Note that anaesthesia care provider should not delay emergency surgery
fever will also elevate the respiratory rate and could confuse the until the plasma sodium level is normal if the intravascular
clinical picture. Metabolic acidosis should be primarily treated fluid status has been corrected. A documented rise in
in this scenario with isotonic fluids. plasma sodium towards normal is reassuring, and shows that
resuscitation measures are having a positive impact.
An alternative cause of tachypnoea in this patient may be When can you start the surgery?
primary respiratory pathology, such as pneumonia caused by The case described is a surgical emergency, particularly if there
the aspiration of gastric contents. Gastro-oesophageal reflux is is vascular compromise to the intestines. Bowel ischaemia,
common in the child less than 1 year and when a child has a necrosis then perforation (with ensuing sepsis) increases
distended abdomen, reflux of gastric contents occurs readily. the morbidity and mortality of surgery dramatically. If the
Gentle insertion of a nasogastric tube should be considered patient continues to demonstrate metabolic acidosis after
to drain some gastric fluid, although this procedure can resuscitation with isotonic fluids, removal of a necrotic section
prompt emesis and aspiration in the child with a decreased of intestine may be the only intervention that improves the
mental status. The nasogastric tube (size 10-12 French) clinical condition of this child. With the history of delayed
should be softened in warm water prior to placement to help presentation, the child does not need to go to theatre in a few
avoid trauma and the patient should be placed in the lateral minutes, rather in a period of less than 2 hours after IV fluid
position to avoid aspiration in case they vomit. Auscultation resuscitation has commenced. The heart rate, respiratory rate
of chest sounds will help to differentiate between metabolic and peripheral perfusion should begin to normalize prior to
acidosis (non-pulmonary) and aspiration pneumonia. If the the induction of anaesthesia. Establishing some urine output
chest sounds are clear the chance of aspiration pneumonia is is a useful sign and indicates improved renal preload following
lowered but if you hear crackles or wheezing particularly on the resuscitation efforts.
right side of the chest, this could help diagnose pneumonia.
Pneumonia in this setting should not delay surgery in a child The following laboratory measurements need to be obtained if
with compromised gut perfusion, but will indicate that the possible, but do not delay surgery for the results to normalize:
child is at greater risk postoperatively. Full blood count

Type and cross match for one unit of blood (typically will need full precautions to prevent aspiration on induction,
400ml of whole blood in a rural hospital). irrespective of the length of time they have been starved, or
Plasma sodium the fact they have a nasogastric tube (NGT). Cricoid pressure
needs to be applied so that it does not distort the airway, as this
Glucose
will make the intubation more difficult. Ask the assistant to
If you are working in a hospital that cannot measure direct the trachea backwards, upwards and gently to the right.
electrolytes, do not attempt to get a plasma sodium level at Preoxygenation prior to intubation is extremely important in
another hospital, but rather give volume resuscitation with children with intestinal obstruction as the functional residual
0.9% saline as indicated, and proceed with the surgery. capacity (FRC) is reduced and the child will desaturate rapidly
when apnoeic. However, preoxygenation may be difficult
Prepare the theatre with a warmer if the environment is cool, if the child is crying, but you can achieve some form of
as the child will have extensive exposure and opportunity for preoxygenation if you waft high flow oxygen through a mask
heat loss. Prepare all the equipment required to anaesthetise a directed towards the childs face. If the patient is obtunded and
child. Do not attempt to give the anaesthetic alone but find less responsive, a good mask fit may be achieved, which will
an assistant. Explain about airway management, the aspiration allow preoxygenation with 100% oxygen, thus reducing the
risk, and the need for cricoid pressure. risk of desaturation during intubation. As you can see from
Consider the plans for postoperative care well in advance: figure 3, if the abdomen is very distended it has the potential
to restrict diaphragmatic movement and lung volumes,
Staffing level on the ward particularly in the supine position. Both of these factors will
cause a rapid drop in the oxygen saturation once the patient
Oxygen
stops breathing spontaneously.
Suction
Monitoring
Location on the ward relative to the nursing station
Light.
Intraoperative considerations
Induction concerns
This patient has a distended abdomen due to obstruction and
is considered to have a full-stomach so must have a rapid
sequence induction with cricoid pressure. The anaesthetist
must have an able assistant. A child with intestinal obstruction
Figure 4. Intubation hand positioning: notice that the trachea is

being displaced posterior and midline
If the patient has an NGT to help drain the stomach, it should

be suctioned prior to the induction of anaesthesia. Some
suggest it should be removed immediately prior to induction
to ensure a good seal with the facemask if you need to ventilate
the patient with cricoid pressure, should more than one
attempt at intubation be required. Check the position of the
endotracheal tube by auscultation prior to removal of cricoid
pressure. Early removal of the cricoid pressure can result in
aspiration if the endotracheal tube is placed in the oesophagus.
A cuffed tube of an appropriate size can be considered in
Figure 3. Child with bowel obstruction. The high intraperitoneal children of all ages, but the cuff pressure should be measured
pressure will decrease the lung capacity, FRC and oxygen reserve and the cuff should not be overinflated. Uncuffed tubes are still
prompting a rapid drop in oxygen saturation during intubation routinely used in many institutions. Clinical evaluation of the

position of the tube in the trachea is essential after intubation, To prepare a solution of dopamine for use without a syringe
ideally confirmed by capnography, if available. infusion pump, place 200mg dopamine into 100ml of
normal saline in a paediatric microdrop giving set. Titrate this
The choice of induction agent includes thiopentone (2-4mg. infusion to maintain the blood pressure in the normal range.
kg-1), propofol (1-2mg.kg-1), or ketamine (1-2mg.kg-1) IV. The infusion may be required for a few days in severe cases.
Ketamine is an ideal agent if the child is critically unwell. Monitor urine output as an indirect measurements to assess
An even lower dose of induction agent should be used if adequate organ perfusion and keep the patient warm in the
the patient is in shock not responding to fluid. If the child perioperative period with the means which you have available
has been sick for some time, the blood pressure may drop to you in your hospital setting.
even with ketamine as the sympathetic nervous system is
overwhelmed. Never perform an inhalation induction in these The use of inhalation agents, ketamine, opioids or any
patients. Succinylcholine (2mg.kg-1 IV) should be used as combination will be determined by the patients response to
the muscle relaxant. Rocuronium could be considered as an induction and surgery. Inhalation agents will all cause some
alternative, if available. Once the endotracheal tube position degree of vasodilation and cardiac depression, which may not
is confirmed, the NGT should be replaced if it has been be tolerated in the seriously ill patient, thus prompting the use
removed to decompress the stomach during the remainder of of a ketamine infusion. You will need to control the ventilation,
the intraoperative and postoperative course. either by manual ventilation or using a ventilator with settings
for a paediatric patient. If the patient is acidotic (determined
Maintenance concerns clinically or by measurement of the venous or arterial blood
After induction of anaesthesia and intubation with gas), they will not tolerate spontaneous ventilation with low
succinylcholine, monitor the haemodynamic status closely. tidal volumes, particularly if the abdomen is compressed by
Induction may reveal hypovolaemia and cause the blood the surgical team during laparotomy. Consider using a non-
pressure to fall. If this happens, give a fluid bolus of normal depolarising muscle relaxant to assist the surgeon and expedite
saline or blood in 10ml.kg-1 increments. Two peripheral IV lines the procedure, but the child must be fully reversed at the
should be inserted (ideally 22G), with access to an injection end of the operation. Beware sudden cardiac arrest in theatre
port during surgery. Place a three-way stop-cock in line so that due to hypovolaemia, myocardial depression, or associated
blood or normal saline can be pushed with a 20-60ml syringe. with CO2 in the absence of end-tidal CO2 monitoring. If
This helps to deliver fluids accurately, also rapidly if required. the monitors stop recording, do not automatically consider
It is important that fluid balance is documented as accurately monitor malfunction but immediately evaluate the patient for
as possible; pulmonary oedema can be a complication of cardiovascular collapse.
excessive fluid administration in the operative setting. Blood
should be given based upon blood loss, with the goal of At the end of surgery, consider the options for extubation
improving oxygen delivery dictated by cardiac output, oxygen carefully. If a stoma is placed, the surgeon may manually
saturation, and haemoglobin level. Studies have shown that in decompress the bowel and the abdominal compartment may
stable sepsis in the paediatric population that a haemoglobin not be too tight. Alternatively, if there is a primary anastomosis,
level above 7g.dl-1 should be safe.5 In a rural hospital setting, abdominal distension may persist postoperatively. In severe
this figure may need to be higher due to the weak medical cases of obstruction and sepsis, primary anastomosis would
infrastructure and support systems. not be the primary option due to potential failure and leakage.
In either case, the child needs to be fully awake, breathing well
Inotropes will need to be started if blood pressure remains low and adequately reversed, indicated clinically by flexion of the
despite fluid administration. Opening the abdominal fascia legs.
may reduce venous return if the abdomen is tense, for instance
where there is bowel ischaemia and necrosis, which will cause Postoperative considerations
a fall in the cardiac output (BP). In addition, movement of The two most important factors for safe postoperative care are
bacteria from the obstructed, and possibly necrotic intestines the location in the hospital and the nurse: patient ratio. The
to the blood stream may release mediators and hydrogen ideal location should have oxygen, suction, good lighting, be
ions (producing acidosis), resulting in more cardiovascular close to the nursing station; the room should be warm, the
instability during surgical manipulation and repair of the head of the bed elevated, and there should be, one paediatric
damaged intestines. A bolus of adrenaline 1 mcg.kg-1 IV nurse assigned to 1-2 children. In many hospitals the nurse:
may be useful whilst an infusion of adrenaline is prepared patient ratio is 1:15 , with very ill children, and this will not
(dilute 1 mg adrenaline in 1000ml saline to give a solution of be safe for this child for the 72 hour period when the risk
1mcg.ml-1 adrenaline). of morbidity and mortality will be greatest. The location of

postoperative care must be considered early so that the child involving the nurses, laboratory technicians, paediatricians
has the best chance of survival. and surgeons is essential. The anaesthesia care provider faced
Regular paracetamol 20-30mg.kg-1 PR should be given every with this challenge needs to be cautious, ask for assistance, and
6-8 hours around the clock for 3 days, with very small doses be extremely diligent in monitoring the patient during the
of opioids titrated as required. Good nursing care is essential. entire perioperative course.
Many of these patients will have an oxygen requirement
for a few days while the sepsis and any pneumonia resolves. REFERENCES
1. Ekenze SO, Anyanwu PA, Ezomike UO. Profile of pediatric
The respiratory status, respiratory rate, should be monitored
abdominal surgical emergencies in a developing
carefully, particularly if opioids are given to a child receiving countries. Int Surg. 2010; Oct-Dec; 95(4): 319-24.
oxygen. A fall in saturation is a late finding and narcotics
should only be used in the setting of a 1:2 nurse:patient ratio. 2. Goldstein B, Giroir B, Randolph A. International pediatric
Diligent monitoring of the vital signs is essential, and the sepsis consensus conference: Definition for sepsis and
surgical or ICU team must respond rapidly to concerns raised organ dysfunction in pediatrics. PediatrCrit Care Med
by the nursing team. 2005; 6 No. :pp 2-8.
3. Aird, WC. The hematologic system as a marker of organ

CONCLUSION dysfunction in sepsis. Mayo Clin Proc 2003; 29: 605-606,
Emergency surgery for bowel obstruction in children presents vii.
many challenges for the anaesthesia care provider. Delayed
presentation and sepsis have a profound physiological impact 4. Levi, M. The coagulant response in sepsis. Clin Chest Med
on many organ systems. Children have a great reserve and 2008; 29: 627-642, viii.
ability to heal but may also hide the seriousness of their illness, 5. Karam, O, et al. Red blood cell transfusion thresholds in
and have the potential for sudden decompensation. Good pediatric patients with sepsis. PediatrCrit Care Med 2011;
outcomes rely on meticulous perioperative planning, proper 12, No. 5. (free online link via http://www.researchgate.
training, equipment, and basic supplies. A team approach net/)

Trauma in children
Head injury in paediatrics
Delia Chimwemwe Mabedi, Paul Downie* and Gregor Pollach

*Correspondence Email: p.downie@nhs.net
INTRODUCTION
Trauma is one of the leading causes of death and muscles, this makes them vulnerable to head
disability in children. The aetiology of injury injury following trauma. The open fontanelles
varies with age and children with serious head and sutures also predispose infants to a higher
trauma often have multiple injuries. The most incidence of subdural haematoma. Primarily
common mechanism for head injuries globally for social reasons the causation varies with age;
is from motor vehicle collisions, and in the toddlers frequently suffer head injuries from SUMMARY
developing world the incidence is increasing falls, while older children suffer head injuries Trauma is one of the leading
dramatically. The presentation of head injury from road traffic collisions and sports related causes of death and disability
varies with the severity of the insult ranging from injuries. Non-accidental injury must always be in children. Children with
considered, particularly in infants. serious head trauma often
an altered level of consciousness to deep coma.
have multiple injuries. Early
Early identification and proper management identification and proper
of these patients greatly affects the outcome. Cerebral blood flow
management of these
Survivors of severe traumatic brain injury in Normally, cerebral blood flow is maintained at a patients greatly affects the
childhood unfortunately are frequently left with constant level to meet the metabolic demands of outcome.
significant behavioural, cognitive, emotional and the brain over a wide range of blood pressure by This article covers
physical challenges. the process of autoregulation. The autoregulation pathophysiology of head
range is not known in infants and children, but is injury in children; assessment
and immediate management;
PATHOPHYSIOLOGY likely to be around 40-90mmHg. anaesthesia for neurosurgical
Anatomy Cerebral autoregulation is impaired by acute management; and principles
of postoperative care in PICU.
Children have a disproportionately larger brain injury; in this situation, cerebral blood
and heavier head and relatively weak neck flow follows cerebral perfusion pressure passively.
Figure 1. Cerebral blood flow
Delia Chimwemwe Mabedi

Department of Anaesthetics,
College of Medicine,
University of Malawi
Paul Downie
Gloucester Royal Hospital,
UK
Gregor Pollach
College of Medicine,
University of Malawi

As cerebral perfusion pressure is an easier figure to derive The MAP and therefore CPP vary with age, as does the ICP.
clinically, it is this parameter that is usually used as a treatment There is a wide discrepancy between different organisations as
target. to the acceptable blood pressures in paediatric traumatic head
injury. In one of the few evidence based papers Haque and
Cerebral perfusion pressure Zaritsky suggested in children aged one to eighteen years the
Cerebral perfusion pressure (CPP) is the blood pressure that MAP target should be calculated as follows:
perfuses the brain and is defined as the difference between the
mean arterial pressure (MAP) and the intra-cranial pressure MAP target = 1.5 x (age in years) + 55
(ICP). The central venous pressure (CVP) also contributes
negatively to the perfusion pressure: Cautious fluid resuscitation and infusion of vasoconstrictors
such as noradrenaline may be required to maintain achieve the
CPP = MAP (ICP + CVP) target MAP in a child with head injury.
Intracranial pressure
In head injury patients the intracranial pressure, in the absence The intracranial pressure (ICP) is determined by the volume
of invasive monitoring, is often assumed to be 20mmHg, of the brain tissue, the cerebrospinal fluid (CSF) volume, and
therefore a MAP 70-90mmHg is targeted to achieve a cerebral the cerebral blood volume. An increase in any of these volumes
perfusion pressure of 50-70mmHg. increases the ICP. For example an increase in brain tissue may
Mean arterial pressure (MAP) result from swelling of the brain parenchyma, which is referred
The MAP may be calculated from systolic (SBP) and diastolic to as brain oedema.
(DBP) pressures: Small increases in ICP can be compensated by an increase in
CSF absorption and reduction in intracranial blood volume.
MAP = DBP + (SBP-DBP/3) Infants can further compensate due to their open fontanelles
and suture lines. Sudden acute changes in intracranial pressure
Cerebral perfusion pressure less than 50mmHg has been are not well tolerated at any age. If compensatory mechanisms
demonstrated to be a predictor of poor outcome in severe are overwhelmed, intracranial pressure will increase rapidly
traumatic brain injury in children and adults. Extreme and the brain will herniate through the structures within the
hypertension should also be avoided, as it will result in skull or the foramen magnum (coning) to cause coma and
increased cerebral blood flow and cerebral oedema. death.
Figure 2. Intracranial pressure vs volume

Typical intracranial pressures are lower in children compared ASSESSMENT AND IMMEDIATE MANAGEMENT OF
to adults (210mmHg vs. 818mmHg respectively). In CHILDREN WITH HEAD INJURY
health the central venous pressure does not impact upon the Assess the conscious level and pupil responses at the same time
CPP, however in polytrauma, thoracic injuries (e.g. tension as attending to ABCDE as follows:
pneumothorax or cardiac tamponade) may increase the CVP
to such an extent that ICP is impaired. Airway with cervical spine immobilisation
Breathing and ventilatory control
An increase in the cerebral blood volume could result from the
following causes of intracranial bleeding: Circulation and control of obvious external bleeding
Epidural haemorrhage usually results from rupture of the Disability and neurological status, including pupil
meningeal arteries between the dura mater and the skull. responses
It occurs quickly and may lead to death if not identified Exposure - secondary survey with top to toe examination
and quickly treated. Treatment is usually surgical drainage to detect associate injuries (consider non-accidental injury).
through a burr hole or craniotomy.
Subdural haemorrhage usually results from rupture of the Airway and cervical spine control and immobilisation
bridging veins between the dura and the arachnoid mater. Establish a patent airway with jaw thrust, making sure to
It can be self limiting but if large can raise the intracranial keep the cervical spine immobilised. Suspect cervical spine
pressure and will need to be evacuated. injuries whenever there is high-energy mechanism of injury,
reduced level of consciousness, and tenderness or bruising of
Intracerebral haematoma arise when there is bleeding from
the cervical spine. Foreign objects in the mouth and pharynx
the blood vessels within the brain tissue. The figure below
should be scooped out with a finger and secretions gently
shows the three types of intracranial haemorrhage as would
suctioned. Immediately provide oxygen by mask as soon as the
be seen on CT scans (note CT scans are usually shown as if
airway is patent.
looking up from the feet). (See Figure 3).
Traumatic subarachnoid haemorrhage occurs when blood Breathing and ventilatory control
accumulates below the arachnoid mater where cerebral Assess the respiratory rate. Look for chest expansion while
spinal fluid normally resides. This type of bleed is more assessing symmetry and adequacy. Listen for presence/absence
classically associated with spontaneous rupture of cerebral of breath sounds. Palpate for emphysema and broken ribs.
aneurysms but is also common in head injury where it Assess the percussion note. Pathologies to look out for include
frequently communicates with intraventricular blood. pneumo-haemothoraces, flail chest, surgical emphysema. If
Figure 3. CT scans of different types of intracranial haemorrhage
Left extradural haematoma Right subdural haematoma Right intracerebral haematoma

any of these are present they should be managed immediately: The normal pupil reaction to light is brisk. After removal of
Give rescue breaths if the child is not breathing the light source, the pupil should return to its original size.
There should also be a consensual reaction to the light-source -
Decompress a tension pneumothorax by a large bore that is the opposite pupil also constricts when the light source
cannula in the second intercostal space midclavicular line is applied to one eye. Unreactive pupils can be caused by an
on the affected side expanding mass compressing the third cranial nerve. A fixed
Chest drain insertion for a haemothorax and also as dilated pupil may be due to herniation of the medial temporal
definitive management for the tension pneumothorax. lobe.
Consider advanced airway management in unconscious It is important to consider factors that may affect the assessment
patients who cannot protect their airway and also in children of pupils:
with hypo- or hyperventilation and significant injuries to the Any pre-existing irregularity with the pupils, for example
head, neck and thorax. cataracts, false eye or previous eye injury
Use arterial blood gas analysis to assess the oxygenation, Any other factors that can cause pupillary dilation, for
ventilation and acid base, and electrolyte status. example medications including atropine and
sympathomimetic drugs (adrenaline) and direct trauma
Circulation and control of obvious external bleeding
(traumatic mydriasis)
Assess the haemodynamic status of the child first by feeling
for arterial pulsation. Use the brachial artery in small children Any pre-existing factors that can cause pupillary
and the carotid in older children. Avoid palpating both carotid constriction, for example medications including narcotics
arteries at once as this may cause cerebral hypoperfusion. and topical beta-blockers.
Treat hypotension actively, obtain venous access as an early
The best guide to the severity of head injury is the conscious
priority and collect blood samples for full blood count,
state and the Glasgow Coma Scale (GCS), which allows the
electrolytes and group and save. Rule out any potential sources
conscious state to be quantified. The score is decided on the
of external bleeding - an isolated head injury will not cause
patients best responses. Note that:
hypotension.
The GCS may be falsely low if one of the following is
As discussed above, a higher than normal blood pressure present: shock, hypoxia, hypothermia, intoxication, post-
should be maintained to ensure adequate cerebral perfusion. ictal state or sedative drug administration
Use normal saline or Ringers for initial resuscitation. Give an
initial bolus of 10ml.kg-1, repeat if hypotension persists. Avoid The GCS may be impossible to evaluate accurately if the
over hydration and anaemia. Ensure a haemoglobin >7g.dl-1 patient is agitated, uncooperative, dysphasic, intubated or
for adequate oxygen delivery. Look out for active bleeding and has significant facial or spinal cord injuries
prevent any further blood losses. It should be repeated regularly every 15 minutes, as rapid
deterioration may occur
Disability
Assess the neurological status of the patient quickly using the The GCS is an important tool, but should be used in
AVPU scale. conjunction with a full neurological assessment to assess
the childs neurological state.
Alert
The modified paediatric GCS is the standard tool for the
Responds to Verbal stimuli
assessment of a childs neurological status over time. The
Responds to Painful stimuli trend in the level of the consciousness is more important than
Unresponsive a single value. (See Table 1 below). A GCS of 15 indicates
no neurological disability and GCS of 3 means a deeply
Assess pupil size, equality and responses to light alongside the unconscious patient. All children with GCS less than 8 should
AVPU as this can give clues that an intracranial haemorrhage be intubated and ventilated (see below).
is present, and can help guide surgical management. Exposure
The pupils should be equal in size and round. Abnormal Expose the child to allow head to toe and back examination.
shapes may indicate cerebral damage; oval shape could indicate Do this cautiously to avoid hypothermia, i.e. in a cool
intracranial hypertension. environment, keep the child covered when possible. Treat

Table 1: Modified Glasgow Coma Scale for children
Score Score Infants Older children

4 Eye opening Spontaneously Spontaneously
3 To verbal To verbal
2 To pain To pain
1 No response No response
5 Speech Babbles and coos normally Oriented

4 Spontaneous irritable cries Confused
3 Cries to pain Inappropriate words
2 Moans to pain Incomprehensible sounds
6 Best motor response Normal spontaneous movement Follows commands

5 Withdraws to touch Localises pain
4 Withdraws to pain Withdraws from pain
3 Abnormal flexion to pain Abnormal flexion to
2 Extension to pain Extension to pain
any injuries immediately they are discovered. Note that Nausea and vomiting (children may vomit 2 or 3 times,
scalp lacerations may result in significant blood loss. If the even after a minor head injury)
child remains cardiovascularly unstable and requires volume
Clinical course prior to consultation - stable, deteriorating,
resuscitation, consider other sites of blood loss, for instance,
improving
chest, abdomen, pelvis or major limb fracture. Specifically
look for: Other injuries sustained.
Lacerations, bruising and deformity of the face and scalp. Even in the heat of a major trauma, always seek a history.
Be aware that scalp lacerations may result in significant Especially in children, it could be that the injury might be not
blood loss the reason for the coma, but vice versa. A child with cerebral
Signs of base of skull fractures which include: malaria or meningitis may become unconscious and then
subsequently fall.
- Bleeding or leakage of cerebrospinal fluid from ear or
haemotympanum Radiological investigations
- Periorbital bruising (racoon eyes) and bruising Consider the following investigations in patients presenting
around the mastoid (Battles sign) with traumatic head injury (see Table 2):
- Rhinorrhea (CSF leak from the nose). Skull Xray

This is useful in areas where CT or MRI scans are not available.
History Lateral and antero-posterior (AP) views of the skull should be
It is important to gain as much information as possible taken. Look for depressed fracture, diastasis and other bony
regarding the incident and specifically to determine: abnormalities. Skull Xray is no better than clinical examination
Time, mechanism and circumstances of the injury; speed at identifying intracerebral pathology.
of the vehicle; any restraints? (seat belt, car seat)
Computed Tomography (CT) scan
Loss or impairment of consciousness with duration (may This is the imaging of choice. It reveals bony pathologies,
be inconsistent or unreliable) haematoma (appears hyperdense when compared to brain
Seizures or fits parenchyma), evidence of cerebral oedema (hypodense

compared to normal brain parenchyma and isodense compared When there is intractable raised ICP, a decompressive
to CSF) and also mass effect (midline shift). craniectomy to remove part of the frontal lobes may be
indicated.
Magnetic resonance imaging (MRI)
MRI can be used in the acute setting to determine the Anaesthesia for evacuation of intracranial haematoma
presence and extent of injury and to guide surgical planning A small percentage of children with head injury may require
and minimally invasive interventions. It is also important surgery to evacuate intracranial haematoma. Bear in mind that:
in the long-term management of traumatic brain injury to Volatile anaesthetic agents reduce cerebral metabolic rate
identify chronic sequelae, determine prognosis, and guide but increase cerebral blood flow and ICP. Halothane
rehabilitation. It is however expensive and time consuming. increases ICP more than isoflurane and should be avoided
if possible.
Cervical spine Xray
Intravenous anaesthetic agents reduce the cerebral
A lateral view of the cervical spine is indicated to rule out
metabolic rate, and also reduce cerebral blood flow and
cervical bony injury or dislocation. However, if CT or MRI is
ICP.
available, do a CT/MRI of the cervical spine at the same time
as the head scan as these are more precise and save time. Use adequate doses of opioids to obtund the reflex
cardiovascular responses to intubation.
NEUROSURGICAL MANAGEMENT
Suxamethonium is indicated for rapid sequence induction
Neurosurgical management includes operative removal
in head injured patients even though it causes transient
of epidural or subdural haematomas, or insertion of an
increase in ICP.
extraventricular drain (EVD) as soon as possible after the
diagnosis is made. An intra-cranial pressure monitor can be Although ketamine has beneficial effects on blood pressure
placed for ICP and CPP monitoring and further management and is an analgesic, it raises ICP when used as a single agent
in the paediatric intensive care unit. in induction doses so is usually avoided.
Table 2. Indications for CT or MRI scanning in children
Age over 1 year: Glasgow coma score <14 on assessment on initial assessment
Age under 1 year: Glasgow coma score paediatric <15 on assessment on initial management
Age under 1 year and presence of bruise, swelling, or laceration (>5 cm) on the head
Dangerous mechanism of injury
Clinical suspicion of non-accidental injury
Loss of consciousness lasting more than five minutes (witnessed)
Post-traumatic seizure but no history of epilepsy
Abnormal drowsiness
Confusion or aggression
Signs of a basal or depressed skull fracture
Worsening level of consciousness
Failure of the mental status to improve over time
Focal neurological findings
Penetrating skull injuries
Amnesia

MANAGEMENT IN THE PAEDIATRIC INTENSIVE CARE Sedation and muscle relaxation
UNIT (PICU) Sedation and initially muscle relaxation are recommended
The management is mainly supportive, to contain the primary for adequate control of ICP. An opioid such as morphine,
injury and prevent secondary insult to the brain. It is important midazolam and a non-depolarising neuromuscular blocker are
to maintain cerebral perfusion pressure by control of ICP and good in combination as long as hypotension can be avoided.
haemodynamic status. Ketamine was previously avoided but new data suggest that it
General principles of PICU management produces minimal effects on ICP when used in combination
with midazolam, and it may help to maintain the blood
Management of intracranial hypertension and pressure. Pentobarbitone, phenobarbitone, or propofol may
cerebral perfusion pressure (CPP). be used, subject to availability. In severely raised ICP multiple
Intracranial hypertension is defined as ICP >20mmHg for agents may be required, but it is essential to avoid hypotension.
>5 min. Recommendations for adults include maintaining Pain and anxiety increase cerebral metabolic demands and
an ICP of less than 20mmHg and perfusion pressure (CPP) should be treated promptly. Intermittent thiopentone and IV
of >60mmHg. These may be applicable for older children. lidocaine are recommended to blunt raised ICP response while
Although no normal data is available through clinical evidence, suctioning the endotracheal tube. Alternatively instillation of
in infants with severe traumatic brain injury it would be lidocaine into the endotracheal tube may be as effective.
logical to suggest targeting for an ICP of <15mmHg and a
CPP of >45 to 50mmHg. Careful use of inotropic agents such Seizure control
as dopamine or noradrenaline may be necessary to maintain Seizures, both convulsive and non-convulsive, are extremely
these parameters. Induced hypertension with phenylephrine common after head injury. They increase both cerebral
is not recommended since cerebral autoregulation is lost metabolic rate and ICP and must be avoided or treated
and further increases in cerebral blood flow may exacerbate promptly. Deep sedation should reduce the rate of seizure
oedema formation by hydrostatic effect. Some units advocate activity but may not abolish it totally.
the insertion of a jugular venous bulb catheter, to allow
Midazolam boluses may be used to control seizures. Propofol
measurement of the SjO2. This allows identification of global
or thiopentone may also be used. Treat hypotension
mismatch between oxygen delivery to the brain and cerebral
associated with the use of these agents with fluid therapy.
metabolic rate.
Start Phenytoinin patients with posttraumatic seizures. Use
CSF drainage by venticulostomy has been shown to be as of prophylactic phenytoin in head injured children without
effective as mannitol therapy in reducing ICP. seizures is not supported by clinical evidence.
Ventilation If available, EEG monitoring is extremely useful in identifying
As both low oxygen (hypoxia) and carbon dioxide retention non-convulsive seizures, which should be controlled to reduce
(hypercarbia) cause cerebral vasodilatation and increase the cerebral oxygen consumption.
cerebral blood flow, it is key to maintain these in the normal Fluid therapy
range (PaO2 8-12kPa and PaCO2 4-5kPa). Over-ventilation Initial resuscitation should be with normal saline. Hypotonic
to hypocarbia causes damaging cerebral vasoconstriction. fluids must be avoided in children with head injury as a fall in
Hyperventilation is occasionally employed as part of salvage plasma sodium will exacerbate cerebral oedema. Ringers lactate
therapy if the ICP is very high. This may be as a bridge to is slightly hypotonic and many authors suggest it should not be
neurosurgical intervention, or more long term if jugular used. Maintain plasma sodium and plasma osmolality within
venous oxygenation is monitored. the high normal range (aim for plasma sodium 150mmol.l-1 in
It is assumed that all children with GCS less than 8 will not be severe head injury). Place a central line to guide fluid therapy
able to protect their airway or maintain ventilation adequately; by central venous pressure monitoring.
intubation and mechanical ventilation is required. Keep the Maintain glucose within normal levels. Due to stress of the
head in the midline and at 30 degrees elevated position. head injury, serum glucose is commonly high, so avoid glucose
Positive end expiratory pressure (PEEP) in the range of 4 to 5 containing fluids initially.
cm of H2O has minimal impact on ICP, and should be used to
prevent atelectasis. Children with traumatic brain injury are susceptible to a
variety of abnormalities of plasma sodium for example:
Patients with severe head injuries often develop neurogenic
pulmonary oedema. This may require further elevation of the Syndrome of inappropriate antidiuretic hormone
PEEP if adequate oxygenation cannot be achieved. (SIADH). This is characterised by hyponatraemia,

low plasma osmolality, high urinary osmolality, Steroids
normo- or hypervolaemia. Patients are at risk of developing There is no clinical evidence supporting the use of steroids
cerebral oedema. Manage promptly with fluid restriction in cerebral oedema due to head injury. Reserve steroids for
if asymptomatic or hypertonic saline if symptomatic (1-2 patients with brain tumours.
ml.kg-1 3% saline iv bolus).
Nutrition
Cerebral salt wasting. This typically presents with Early institution of enteral feeds is recommended if there is
hyponatraemia, high urinary osmolality, hypovolaemia no associated intra-abdominal injury to major organs such as
and hypotension. Manage with an IV bolus of normal liver, spleen, or duodenal hematoma.
saline.
Positioning
Diabetes insipidus. This presents with hypernatraemia, Nurse intubated children at 30 degrees head up to reduce ICP
high plasma osmolality, low urinary osmolality, and reduce the risk of ventilator-associated pneumonia (VAP).
hypovolaemia and hypotension. Diabetes insipidus occurs Regular turning and the use of splints will reduce bedsores and
as a result of failure of blood supply to the posterior pituitary contractures.
with loss of ADH production in the posterior pituitary.
Treat it by administration of DDAVP (Desmopressin). Rehabilitation
Note that diabetes insipidus is often a late sign in head Tracheostomy may be indicated in patients in prolonged
injury and often heralds brain stem death. comatose state who cannot protect their airway or who require
long-term ventilation.
Mannitol
Mannitol reduces ICP by two mechanisms, osmotic and Once the patient has recovered from acute injury in the PICU,
reduction in viscosity. Its osmotic effect is the more effective early physiotherapy for prevention of deep vein thrombosis
mechanism. Reduction of viscosity is transient, and depends and prevention of contractures may be necessary. Arm, leg,
upon autoregulation being intact. hand and feet splints should be used as indicated.
Mannitol in doses of 0.5 to 1g.kg-1 may be used intravenously Table 3. Outcomes after paediatric head injury
at 6 hourly intervals with monitoring of serum osmolality (aim
to keep serum osmolality under 320mOsmol.kg-1). Mannitol is Early complications
contraindicated if any of the following is present: Transient cortical blindness
Serum osmolality is >330mOsmol.kg -1
Seizures
The patient is hypotensive
Cranial Nerve palsy
The patient is known to be in renal failure.
Diabetes insipidus
Rapid boluses of mannitol can transiently increase ICP by
causing transient systemic hypertension and should be avoided. Syndrome of inappropriate secretion of ADH
Mannitol also has a theoretical risk of enlarging a haematoma Cortical venous occlusion
by rapid shrinkage of brain and tearing of bridging veins.
Hemiparesis
Temperature control Late complications
Body temperature has an important effect on cerebral
blood flow. For every 1C increase in body temperature, Post traumatic epilepsy
there is a 5% increase in cerebral metabolic rate leading to Post traumatic aneurysm
an increase in cerebral blood flow and intracranial pressure. Meningitis
In children with head injury, avoid pyrexia (>37.6C), and
aim for normothermia or moderate hypothermia. Excessive Hydrocephalus
hypothermia (< 33C) has been shown to increase mortality. Memory loss
In patients with refractory ICP induced hypothermia may be
Disability
used as a last resort, however clinical studies have shown this
to be of no benefit. Muscle contractures

OUTCOMES OF HEAD INJURY IN CHILDREN REFERENCES
Complications of traumatic head injury can be grouped into 1. Raghavan K, Waddington R. Management of Paediatric
early and late categories (see Table 3). traumatic brain injury. Anaesthesia Tutorial of the Week 127
(2009). Available at: http://www.wfsahq.org/components/
Several outcome scores have been described. The Kings c o m _ v i r t u a l _ l i b r a r y / m e d i a /
Outcome Score for Childhood Head Injury, which was derived f1fa2673a7be4eb43f4f85980290b135-
from the adult Glasgow Outcome Score is described in Table 4fa20962568cbe51f494b34724e63b32-127---management-
4. of-paediatric-traumatic-brain-injury.pdf
ICU mortality in paediatric severe traumatic brain injury is 2. Khilnani P. Management of paediatric head injury. India J Crit
slightly lower than in adult practice. Children younger than Care Med 2004; 8: 85-92.
4 years of age have been reported to have poor prognosis
3. Dykes E. Paediatric trauma. Br J Anaesth 1999; 83: 130-8.
similar to adults while better outcomes have been reported
in 5 to 15 year age group. Unfortunately in many survivors 4. Haque I, Zaritsky A. Pediatr Crit Care Med 2007; 8:138 144.
there are significant neurocognitive, educational and social
consequences. The GCS at 24hrs remains the strongest 5. Verive M et al. Paediatric head trauma. Medscape 2012 http://
predictor of outcome. emedicine.medscape.com/article/907273-overview (accessed
4th October 2014.
CONCLUSION
The improvement in outcomes from traumatic head injury 6. Alterman D et al. Considerations in paediatric trauma.
over the past decade has been achieved by strict attention Medscape 2011. http://emedicine.medscape.com/
article/435031-overview (accessed 4th October 2014).
to physiology, a protocolised approach to treatment and
underlying improvements in critical care. In well-resourced 7. Clayton TJ et al. Reduction in mortality from severe head injury
countries the focus is on centralised care allowing more following introduction of a protocol for intensive care
invasive monitoring particularly of ICP. Unfortunately in less management Br. J. Anaesth. 2004; 93: 761-67.
well-resourced countries the burden of road traffic collisions is
increasing, but with the application of applied physiology one 8. Crouchman M et al. A practical outcome scale for paediatric
would still expect to make an impact on outcomes. head injury. Arch Dis Child 2001; 84: 1204.
Table 4. The Kings Outcome Score for Childhood Head Injury
1 Death
2 Vegetative
The child is breathing spontaneously and may have sleep/wake cycles. He may have non-purposeful or reflex movements
of limbs or eyes. There is no evidence of ability to communicate verbally or non-verbally or to respond to commands.
3 Severe disability
(a) The child is at least intermittently able to move part of the body/eyes to command or make purposeful spontaneous
(b) Implies a continuing high level of dependency.

4 Moderate disability
(a) The child is mostly independent but needs a degree of supervision/actual help for physical or behavioural problems
(b) The child is age-appropriately independent but has residual problems with learning/behaviour or neurological sequelae
affecting function.
5 Good recovery
(a) This should only be assigned if the head injury has resulted in a new condition that does not interfere with the childs
well being and/or functioning.

Trauma in children
Major haemorrhage in paediatric surgery
Stephen Bree* and Isabeau Walker

*Correspondence Email: stevebree@gmail.com
INTRODUCTION
Major haemorrhage is the single most common The blood volume of a child can be estimated
cause of cardiac arrest during surgery in using the following formulae:
children.1 Problems arise as blood loss is often
Neonate 90 ml.kg-1
SUMMARY underestimated, venous access is inadequate,
there is not enough help, or the child develops Child 80 ml.kg-1
Major haemorrhage is the
commonest cause of cardiac electrolyte imbalance (hyperkalaemia, Adult 70 ml.kg-1
arrest during surgery in hypocalcaemia) or coagulopathy.1 Hypothermia
children. Problems include: is a particular challenge in major haemorrhage The weight of the child will be known already in
- underestimate of blood in children. a child undergoing elective surgery; in the case of
loss trauma the weight of the child can be estimated
- inadequate venous access
This article will consider a practical approach to using a Broselow tape, paediatric growth chart
- insufficient help
management of major haemorrhage in a child (use the 50th centile for age); or using the
from both a clinical and logistical point of view. following formula:
- electrolyte imbalance
(hyperkalaemia, Effective teamwork and communication is an
hypocalcaemia) essential part of this process.2 Weight = (age +4) x 2
- coagulopathy It is recommended that each hospital develop
- hypothermia CLINICAL ASPECTS a major haemorrhage protocol for adults and
We consider a practical Major haemorrhage may be seen in children in for children; as soon as a diagnosis of major
approach to management the following situations:1,2,3,4 haemorrhage has been made, the child should
of major haemorrhage in
be treated according to the major haemorrhage
a child from both a clinical Road traffic accidents
and logistical point of view. protocol as outlined below:2,4
Effective teamwork and Civil conflict or war (penetrating injuries,
Immediate actions for a child presenting
communication is essential. typically gunshot wounds)
to the hospital with a diagnosis of major
Major surgery (neurosurgery, spinal, cardiac haemorrhage after trauma:
or tumour surgery)
Stop the bleeding by applying direct pressure,
Stephen Bree Associated with an underlying disorder of a tourniquet or by packing the wound.
Consultant coagulation.
Give oxygen.
Paediatric Anaesthetist,
The magnitude of blood loss is typically
Military of Defence Obtain IV access; ideally two large bore IV
Hospital Unit,
underestimated in smaller children. All sources
cannulae, the size depending on the age
Derriford, of blood loss must be estimated by direct
of the child, or central access (femoral vein or
UK observation, also from the clinical signs and
internal jugular). Intra-osseous access is
symptoms displayed by the child.
effective and can be used to help establish
Isabeau Walker
There are a number of definitions of major perfusion but the IO needle is likely to
Consultant
haemorrhage; a pragmatic definition is when become dislodged, so should only be used as
Paediatric Anaesthetist
Great Ormond Street 1-1.5 times the blood volume needs to be a temporary measure. Do not repeat IO access
Hospital NHS infused acutely, or within a 24-hour period.1 The at the same site, as there is a risk of
Foundation Trust, estimated blood volume of the child must be extravasation. Do not attempt sternal IO
UK calculated. access in children.

Take blood for cross match. Call for group compatible, Volumes of blood products may seem high to those
non-cross matched blood if required. not experienced in major haemorrhage in children, but be
reassured that cardiovascular parameters provide an
Avoid crystalloid infusions if the need for early blood
excellent guide to effectiveness of ongoing resuscitation.
transfusion is obvious.
Once the bleeding has been controlled, it is important to
Order 1 unit of packed red cells and 1 unit of fresh frozen
aim for a normal blood pressure, treat acidosis and to keep
plasma (FFP) per 20kg weight of the child. A 25kg child
the patient warm. Avoid vasopressors if possible. Be aware
will need 2 units of blood and 2 units of FFP.
of over transfusion once stability has been achieved.
4ml.kg-1 of packed cells in a child is equivalent to one
unit of blood in an adult, and will raise the haemoglobin Coagulation problems
by approximately 1g.dl-1 Dilutional coagulopathy is likely if packed cells are used
without FFP; whole blood contains platelets and
Assess the child coagulation factors, so coagulopathy is not so much of a
Baseline observations heart rate, blood pressure, capillary problem if whole blood is used.
refill, CVP.
If blood loss of one blood volume is expected, give FFP
Blood tests haemoglobin, platelet count; blood gases, early to prevent dilutional coagulopathy, rather than
coagulation profile (PT, APTT, fibrinogen), lactate if waiting for coagulopathy to occur.
available. Continue transfusion as required, alternating 5ml.kg-1
Near patient coagulation testing if available (TEG/ packed red cells with 5ml.kg-1 FFP, to a total of 15ml.kg-1
ROTEM). of each if required. Keep an accurate record of blood
products and volume given.
On-going management
Consider platelets 5ml.kg-1 and cryoprecipitate 5 ml.kg-1
Transfuse blood use blood Group O negative if if there is on-going bleeding or signs of coagulopathy.
immediate transfusion is required; or group specific blood
if there is time. Full cross match may take up to 45 minutes. Recheck blood tests haemoglobin, platelet count; blood
O Positive blood may be given to males if there are gases, coagulation profile (PT, APTT, fibrinogen), lactate if
insufficient stocks of O Negative blood. possible.
Near patient coagulation testing if possible (TEG/
Transfuse 5ml.kg-1 packed red cells alternating with ROTEM).
5ml.kg-1 FFP, to a total of 15ml.kg-1 of each if required.
Ongoing transfusion will be required if there is continued Coagulation factor concentrates may be required for
bleeding and/or the cardiovascular targets are not achieved. patients with inherited abnormalities of clotting
(haemophilia, von Willibrands disease).
Monitor the temperature. The blood and fluids MUST be
warmed. The patient must be covered, and actively warmed Targets
if possible. Aim to maintain fibrinogen >1.5 g.l-1 and platelet count >
Monitor the ECG. Watch for hypothermia, hyperkalaemia, 75 x109.l-1
hypocalcaemia, hypomagnesaemia. Aim for ionised calcium greater than 1mmol.l-1. If
measurement of calcium is difficult, consider giving 10%
Give tranexamic acid as early as possible (but do not give CaCl 0.2ml.kg-1 slow IV bolus for every 20ml.kg-1 of
more than 3 hours after the acute injury). blood given.
Consider imaging/definitive management of the bleeding Monitor potassium levels. If there are tented T waves on
(surgery). Alert the theatre teams. the ECG, or K+ is greater than 5.5mmol.l-1, consider 10%
CaCl 0.2ml.kg-1 or insulin/dextrose infusion.
On-going assessment
Continuous assessment and reassessment of the clinical Aim for haematocrit greater than 0.3 (Hb >10 g.dl-1) once
signs (HR, BP, capillary refill; blood gasses if possible). Is a steady state is achieved.
the blood pressure adequate? If the child is in the emergency PT and APTT are not very sensitive in the context of
department and is talking and you can feel a peripheral bleeding (the values may be relatively normal, but the
pulse, the blood pressure is adequate. It is not necessary to patient is still bleeding). Aim to maintain PT and APTT
achieve a normal blood pressure at this stage. <1.5x normal value.

Repeat coagulations tests, if possible, every hour. CONCLUSION
Repeat this cycle if necessary. The management of major blood loss in children can be a
daunting prospect in any facility due to the limited physiological
Tranexamic acid reserve of the patients and the technical difficulties of dealing
There is good evidence to support the use of tranexamic with a small child in shock. The emotional component can
acid in trauma. It is also frequently used in major also add to the stresses involved but it is essential that simple
haemorrhage after elective surgery. It should be given basic resuscitation principles are applied, as they would be for
within 3 hours of the haemorrhagic insult. an adult. Calm strong leadership adds to positive outcomes in
these circumstances.
Give a loading dose of 15mg.kg-1 slow IV bolus (consider
an additional infusion of 15 mg.kg-1 over 8 hours). Recent experiences in conflict zones have emphasised the
importance of applying the above principles to the most
Tranexamic acid is excreted in the kidney; it should be used
severely injured and shocked children.4 Early blood gas results
with caution in patients with renal failure.
can demonstrate extremely deranged physiology, which
corrects rapidly when resuscitation is adequate. Volumes of
ORGANISATIONAL ASPECTS
products used may often seem excessive for those new to these
Organisational aspects of management of major haemorrhage circumstances but careful monitoring of clinical parameters,
are important to consider. Good leadership is essential, with bedside clotting, Hb, electrolytes and blood gases will support
clear allocation of tasks. Make sure the phone numbers of and aid in decision making with respect to ongoing blood
key personnel are readily available in the event of a major product requirements. Acute transfusion of many multiples of
haemorrhage being called. the patients blood volume is not unusual.
Identify a team leader to be in charge and to coordinate The switch from the unstable to stable patient will be achieved
care. This is usually the senior surgeon or anaesthetist, and once surgeons have gained control of the bleeding and
ideally someone who can stand back and direct as a non- coagulopathy is managed. Until this is achieved, the outcome
hands on leader. will be determined by the ability to follow and apply the above
Communicate early with the laboratory so that they guidelines in a methodical way, as well as clear leadership and
understand the gravity of the situation. teamwork.
Identify someone to take blood samples to the lab or to REFERENCES
collect the blood.
1. Bhananker SM, Ramamoorthy C, Geiduschek JM et al. Anesth
Make sure all blood is checked properly before it is given; Analg 2007; 105: 344-50.
put two name bands on the patient (in case one is taken
2. Association of Anaesthetists of Great Britain and Ireland,
off); use this to check the blood. It is the responsibility of
Thomas D, Wee M, Clyburn P et al. Blood transfusion and the
the person administering the blood to check that the anaesthetist: management of massive haemorrhage.
correct blood is being given to the correct patient. Anaesthesia. 2010; 65: 1153-61.
All blood should be given through a blood giving set with 3. Gonzalez LP, Braz JRC, Modolo MP et al. Pediatric Perioperative
filter; a special filter is not required for platelets, but they Cardiac Arrest and Mortality: A Study From a Tertiary Teaching
should be given through a clean giving set to avoid the Hospital. Pediatr Crit Care Med 2014; 15: (e-publish before
platelets sticking to the blood in the giving set. print).
A scribe should be designated early on to record all 4. Bree S, Wood K, Nordmann GR, McNichols J. The Paediatric
interventions and products / drugs given until the tempo Transfusion Challenge on Deployed Operations. J R Army Med
has settled down. Corps 2010; 156 4: S361364.

Trauma in children
Paediatric burns and associated injuries
Reprinted with revisions from Pittaway AJ. Managing Paediatric Burns. Anaesthesia Tutorial of the Week 78
(2007)
A J Pittaway* and N Hardcastle

*Correspondence Email: Andrew.pittaway@seattlechildrens.org
paediatric deaths due to burns. The same is not true

CASE SCENARIO
for LMIC children, where prevention and treatment
A 5-year-old boy is brought to your hospital at
advances have been incompletely applied, and where
midnight from a housefire. He had been rescued
mortality from burns remains more than 7 times higher.
from his upstairs bedroom by a neighbour who
had subsequently jumped to the ground with Mortality following a burn occurs as a bimodal
him. His rescuer, who suffered a fractured ankle, distribution. Early deaths occur due to airway
tells you that when he found him in his smoke- obstruction (eg smoke inhalation and associated Summary
filled room, he was deeply asleep and his sheets oedema), carbon monoxide poisoning, refractory
were smouldering. shock or co-existing trauma. With good resuscitation Despite the temptation to
techniques, this early mortality can be reduced immediately attend to the
On examination he is sleepy but rouseable, and burn, it is vital to remember
to 5%. Late mortality often occurs as a result of
cries when disturbed. His pyjamas are charred the ABCDE approach to a
wound sepsis and multi-organ failure. A coordinated
across the chest and left arm. His respiratory rate victim of trauma. Severely
multidisciplinary approach to patient care can also
is 25 breaths per minute, pulse is 130 beats per burnt children may well
reduce this late mortality. have other major injuries
minute, blood pressure is 75/40, and capillary refill
time is 4 seconds. A pulse oximeter reads 99%. You not obviously apparent.
PATHOPYSIOLOGY
notice soot around his nostrils.
Two factors determine the severity of a burn its
temperature and the duration of contact with it. Cell
EPIDEMIOLOGY
death occurs exponentially quickly as temperature
Cutaneous burns, or thermal injury, can be conveniently
rises. Temperatures as low as 40 degrees centigrade
divided into scalds and flame burns. Flame burns are
can rapidly inflict significant injury in young children.
frequently associated with flammable liquids spilt
onto clothing. Scalds are burns specifically caused Scalds caused by water below its boiling point in
by contact with hot liquids. They also often involve brief contact (the majority of such injuries) are not
clothing, which prolongs the duration of harmful surprisingly less severe than scalds caused by liquids
contact between hot liquid and skin. The World Health e.g. cooking oil at higher temperature, or liquids which
Organization (WHO) estimates there are 265,000 are in skin contact for a longer time. Infants or those
deaths per year worldwide attributed to burns, with children physically unable to move themselves away
greater than 95% occurring in low and middle-income from the burning agent are susceptible to this latter
countries (LMIC). Most fatalities occur in house fires, mechanism.
where death by smoke inhalation is the usual cause. Flame burns have a higher temperature and cause
Burns are the 5th most common cause of non- the most severe injuries. Histologically, the burnt
fatal childhood injury, and the 11th leading cause skin consists of a central coagulated, necrotic area A J Pittaway
of death in children aged 1-9, with comparable surrounded by zones of venous stasis and hyperaemia. Anesthesiologist
incidence between males and females. Children are The capillary leakage that occurs in these outer Seattle Childrens Hospital
particularly prone to burns due to the inability to two areas is the result of both direct heating and Seattle
recognise danger in the younger age groups and the secondary inflammation. Burnt epidermis permits USA
risk taking behaviours of the older child. As well, large evaporative fluid losses of up to 200ml.m-2.h-1.
children have thinner skin, lose proportionately more These and other fluid losses cause hypoalbuminaemia N Hardcastle
fluid, are more prone to hypothermia and mount and the clinical picture of shock. Nevertheless, in the Paediatric
a greater Systemic Inflammatory Response than first hour after a burn, the commonest cause of death Anesthesia Fellow
adults. Through prevention mechanisms and better is smoke inhalation. The burning contents of enclosed Seattle Childrens Hospital,
treatment modalities, high-income countries have rooms contain a lethal mixture of hot, noxious gases, Seattle
made significant advancements in lowering the rate of soot particles and depleted oxygen level. USA

EARLY MANAGEMENT OF SIGNIFICANT BURNS ventilatory support. Invasive arterial monitoring, if available, prevents
Despite the temptation to immediately attend to the burn, it is vital to the need for repeated blood sampling and provides important
remember the ABCDE approach to a victim of trauma. Severely burnt metabolic, respiratory and haemodynamic information. An Acute
children may well have other major injuries not obviously apparent, Respiratory Distress Syndrome frequently supervenes which requires
either as a result of an associated blast injury or in their efforts to specialist critical care, including protective ventilation strategies,
escape the fire e.g. by jumping from a window. regular bronchoalveolar lavage, and timely tracheostomy insertion
if required. Circumferential burns to the chest (or abdomen in
Airway and inhalational injury infants) can restrict chest wall excursion and require urgent excision
The airway, as well as breathing and circulatory systems should escharotomy. This procedure is not without difficulties; the potential
be rapidly assessed whilst you administer high-flow oxygen and for severe blood loss, hypothermia, and difficult positioning are all
establishing monitoring. You may need to immobilise the cervical spine significant considerations.
with collar, sandbags and tape or manual inline stabilisation (with an
assistant). Obtain further history. The patients airway may be affected Carbon monoxide poisoning
either by inhalational injury (which if present increases mortality by up Fire produces carbon monoxide (CO) when organic chemicals burn in
to 50%) or by thermal injury to the face. Whilst the latter is usually low oxygen environments. Inhaled CO combines with haemoglobin
obvious, indicators of the former may be more subtle. Environmental with 200 times the affinity of oxygen
factors that can contribute to inhalational injury include fire in an to form carboxyhaemoglobin. Thus, less oxygen is delivered to the
enclosed space or fire associated with explosion. Loss of consciousness tissues. Pulse oximeters cannot distinguish oxyhaemoglobin from
is also associated with inhalational injury. The following features on carboxyhaemoglobin, giving erroneously high (or falsely normal)
examination also point to an inhalational injury: readings. If possible, carboxyhaemoglobin level should be measured
Soot around the nose/mouth/in sputum, burning of eyelash/brow (some blood gas analysers do this) and if between 5-20%, the child
& nasal hairs should remain on high-flow oxygen, which speeds the dissociation of
carboxyhaemoglobin.
Drooling, dysphonia or dysphagia, stridor.
Metabolic acidosis and coma are associated with levels >20%.
Approximately 60% of flame facial burns will have an associated Whilst hyperbaric oxygen therapy is the treatment of choice where
smoke inhalational injury. Inhalation of hot dry gases tends to cause available, use intubation and 100% oxygen where it is not to treat
supraglottic injury to the lungs, whereas steam inhalation also results carboxyhaemoglobin levels over 20%.
in deeper, parenchymal injury. The shockwave from a blast can cause
a mixture of chest injuries: barotrauma and contusion to the lung and Other poisons e.g. cyanide can sometimes accompany the incomplete
blunt trauma. Any suspicion that an inhalational injury has occurred combustion of common household plastics. Cyanide poisoning
should make you consider immediate, elective intubation. Airway presents as metabolic acidosis, coma and unusually high venous oxygen
oedema can develop very quickly and make later attempts at securing saturation (cyanide prevents cells from using oxygen).
the airway extremely difficult. Circulation
There are several considerations about endotracheal intubation that Hypovolaemic shock occurring in the first few hours after a significant
are particular to burns patients: burn must be assumed to be due to another injury, which must be
sought. Obtain the largest venous access possible, preferably in two
Expect to use a smaller endotracheal tube than calculated due to unaffected sites. Burnt skin can be cannulated if necessary, although
airway oedema the skin creases over the femoral vessels are often spared. Finding
Do not cut the endotracheal tube, as facial swelling can be dramatic unaffected sites for non-invasive monitoring can be problematic; non-
and bury the end of an inappropriately short tube somewhere invasive blood pressure measurement may be difficult with extensive
within the mouth limb burns and non-adhesive ECG electrodes can be stapled directly
The tube should also be inserted sufficiently far that the distal end to burnt skin. Urine output measurement, ideally via urinary catheter
is not drawn out of the trachea by the effects of proximal mucosal is essential to monitor haemodynamic status and guide ongoing fluid
oedema resuscitation in the shocked burnt victim. Send initial blood samples
should be sent for complete blood count, electrolytes, glucose and
A tracheostomy might not be feasible for a prolonged period if
cross-match. Haematocrit rises initially as a result of plasma loss but
the tissues of the neck are injured, but may help prevent long-term
anaemia may then follow due to haemolysis, recurring surgical blood
complications such as tracheomalacia and subglottic stenosis if
loss and sepsis-induced marrow suppression. A significant catabolism
done earlier during hospital stay
develops; early excision and skin cover of the burn can reduce this
It is useful to site a nasogastric tube at the same time to allow hypermetabolic state, although protracted protein loss can occur up
gastric decompression and early feeding, which is important in to a year after burn injury.
any burn affecting >10% body surface area.
Fluid calculation
Breathing Shocked children should initially be managed as would any shocked
Tachypnoea, hypoxaemia, and eventual cyanosis suggest a lung child: warmed IV saline 0.9% boluses of 20ml.kg-1. Non-shocked
parenchymal thermal injury, which will almost certainly require children with burns of greater than 10% will require IV fluid

resuscitation, which can be calculated according to total body surface of urine output, which should be maintained at >2ml.kg-1.hour-1 in
area (TBSA) burnt, with the following (Parkland) formula: children. Of note, significant over-resuscitation with fluids can result in
abdominal or extremity compartment syndrome or severe pulmonary
% TBSA x weight in kg x 4 ml insult causing worsening gas exchange.
TBSA involvement can be calculated in adolescents using the rule There has been renewed interest in resuscitation using oral rehydration,
of nines (Figure 1A), and can be calculated with Lund-Browder and while this may be appropriate for minor burns <10-15%, you
modification in infants and children (Figure 1B). Give half of this must be cautious in the patient with more extensive burns due to the
volume over the first 8 hours since the burn occurred and the rest high incidence of ileus.
over the next 16 hours; this is in addition to the normal daily fluid
requirements of the child. The type of fluid used is generally a (A) Rule of nines
crystalloid such as compound sodium lactate (Hartmanns) or 0.9% (B) Lund-Browder diagram for estimating extent of burns
saline. Colloid has not been shown to confer any additional benefit
in the early stages of burn management. Adapted from U.S. Department of Health and Human Services [Public
domain] (http://www.remm.nlm.gov/burns.htm)
There are criticisms of the Parkland formula, especially with
the extremes of injury, in which the Parkland formula tends to Neurological Assessment
underestimate fluid resuscitative needs with large A rapid assessment of conscious state is part of the trauma primary
survey. Reduced conscious state could have many causes such as head
TBSA burns, and overestimate resuscitative needs with small TBSA injury, hypoxaemia, inhalation of toxins, shock or pre-existing disease
involvement. Other formulae exist that can assist in guiding fluid states (e.g. diabetes).
resuscitation, which can alternatively be used, especially in these
extremes of injury. These formulae are guides only, for you to use
Exposure and secondary survey
in conjunction with regular clinical assessment and measurement
It is important to fully undress the child to estimate the full extent
of the burn, but once done ensure the child is covered again as rapid
heat loss occurs. Warm the room if necessary. If taking the child to
the operating room, the temperature should be raised, aiming for a
warm thermoneutral environment. This reduces the patients energy
expenditure as well as helping to prevent hypothermia.
Although beyond the remit of this article, it is important to think
of significantly burnt children as trauma victims and conduct a
thorough head to toe examination once the initial stabilisation has
been completed.
Figure 1: Estimating Percentage Total Body Surface Area in Children Affected by Burns

FURTHER SUPPORTIVE MEASURES observed predisposition to gastric stress-ulceration.
Optimal dietary support is extremely important in view of the
hypermetabolic state; a patient with a burn of 40% Body Surface Wound care
Area can lose up to 25% of body weight in 3 weeks if not optimally Leave blisters intact. Cold irrigation and compresses can be soothing
supported. Starting enteral feeds as soon as practically possible can but run the risk of excessive heat loss and should only be used for
help to prevent gastroparesis and meet the high metabolic demand. <10 minutes in situations with superficial/partial thickness burns of
<10-15%. Cling film if available may be applied loosely to protect
Some centres are using partial beta blockade (e.g. propranolol to and prevent fluid loss. Cover burns with sterile towels and avoid
decrease heart rate by 20%) in children who remain tachycardic after repeated exposure.
the initial resuscitation phase despite appropriate fluid replacement
and adequate analgesia. This further reduces the hypermetabolic state. Wound infection is a major cause of late fatality following a burn;
This has been associated with an increased net protein balance and gram-negative bacterial colonisation occurs early, despite aseptic
reduced energy expenditure. techniques in cleaning the wound. Suitable dressings should be applied
early both to reduce this colonisation and to provide some analgesia. A
Burn assessment variety of silver (Ag) based dressings are commonly used due to their
Severity is related to surface area affected and depth. Also, burns to antimicrobial gram-negative, gram-positive and anti-fungal activity.
certain areas of the body warrant specialist attention e.g. hands, feet
and perineum in order to achieve a good functional outcome. Antibiotics should not be used prophylactically. Take care to diagnose
sepsis and wound infection; this can be difficult as frequently the
Area patients temperature increases due to the raised metabolism. If a
Burn area is often assessed with the aid of charts (Figure 1). The familiar patient is unwell, particularly with fever, rash, drowsiness, low serum
rule of 9 and adult burn charts are not suitable for use in children sodium concentration and lymphopaenia, you must exclude other
younger than 14 years because of the variation in the relative size of causes of sepsis (eg line-related infection) and consider the diagnosis
their heads and limbs with age. A useful rule states that the area of the of toxic shock syndrome. This is potentially fatal and should be treated
childs hand (palm and adducted fingers) is approximately equal to with antibiotics and fluids. Consider further dressing change and
1% of their total body surface area, whatever their age. Alternatively, possibly fresh frozen plasma.
a Lund-Browder diagram can be used.
Other Anaesthetic Considerations
Depth
Suxamethonium is safe to use, if indicated, in the first 24 hours after a
Burns are classified into groups dependent upon depth:
burn. Following this, concerns about causing acute severe hyperkalemia
- Superficial - epidermis only; skin appears red, no blisters precludes its use for up to a year. To complicate matters, resistance to
non-depolarising muscle relaxants is often seen for up to 3 months.
- Partial thickness - epidermis/dermis; skin appears pink/
mottled, some blisters In the acute situation, ketamine is the intravenous induction agent
of choice (2mg.kg-1), particularly in cases of hypovolemia. Clearly, it
- Full thickness - dermis/deeper layers, appears white/charred,
is very important to try to fluid resuscitate any hypovolemic patient
painless (although marginal areas may still be painful).
prior to anaesthetizing them, just as in any other emergency situation.
Superficial burns are painful but heal rapidly. Partial thickness burns If you suspect a significant inhalational injury with impending upper
come in 2 varieties those in which epidermal islands persist around airway obstruction, treat the patient as you would any such case: either
sweat glands and hair follicles and those more severe burns in which a gaseous induction, maintaining spontaneous breathing, or if you
these islands are destroyed. The former are painful and take up to 2 have one and are confident of your skills (and the child!), an awake
weeks to spontaneously heal. The latter may be less painful (due to fibreoptic technique (impossible in non-cooperative children). In
destruction of nerves) but take longer to heal and may require surgical the extreme and catastrophic case of complete, sudden upper airway
excision and grafting in order to do so. Full thickness burns require obstruction you should be prepared to perform an emergency surgical
early excision and grafting to reduce infection and improve morbidity airway. Having an appropriately skilled (i.e. ENT) surgical colleague
and mortality. In practice, the exact depth of many partial thickness scrubbed and standing by with the necessary instruments to hand can
burns are difficult to determine with accuracy on initial presentation, be immensely reassuring in such cases.
however surgical management often comprises early cleaning and
Final Points
covering in theatre under anaesthesia.
The most effective strategy for burns management involves prevention.
Further management Widespread education, safety procedures and devices such as smoke
alarms can help to prevent many thousands of deaths per year.
Analgesia
Burnt children are likely to experience significant pain titrate boluses Finally, it is important to remember that occasionally burns are
of IV morphine 0.1mg.kg-1 until comfortable, carefully observing their caused by non-accidental injury. If you suspect this due to pattern
level of sedation. Ketamine, if used for anaesthesia/dressing changes, of injury, delay in presentation or inconsistencies in the history then
provides excellent analgesia. Later, oral analgesics are preferred you must investigate with experienced colleagues to prevent further
though beware non-steroidal anti-inflammatory drugs because of the future injury to the child.

CASE SCENARIO DISCUSSION References
Pittaway AJ. Managing Paediatric Burns. ATOTW (2007) 78.
The history has several clues as to the likely type and extent of the Available from: http://www.wfsahq.org/components/com_
injuries. He was found deeply asleep, probably unconscious, in an virtual_library/media/833fed4a0395f87316973c2fc9fdf31c-
enclosed burning room (his sheets were smouldering). The fact that the f7f1848f0519358f530a9b575414659b-78-Managing-paediatric-
rescuer sustained a broken ankle suggests he may also have traumatic burns.pdf
injury. The pattern of charring to his pyjamas raises the possibility
of circumferential chest burn. His initial vital signs indicate that he Barret JP, Desai MH, Herndon DN. Effects of tracheostomies on
is shocked. The reduced level of consciousness in the context of soot infection and airway complications in pediatric burn patients. Burns
around the nostrils strongly suggests an inhalational injury, despite 2000; 26: 190-2.
the normal pulse oximeter reading. He will require early definitive
Black RG, Kinsella J. Anaesthetic management for burns patients.
airway management.
BJA CEACCP 2001; 26: 177-80.
After giving high inspired oxygen and applying an immobilising Cockcroft S, Way C. Burns and smoke inhalation. Anaesth Int Care
hard cervical collar resuscitation proceeds according to the familiar Med 2002; 38: 279-82.
ABCDE approach. Upon removing his pyjamas, he is seen to have
an extensive area of pink-blistered skin across his chest and left arm. Fuzaylov, G. and Fidkowski, CW. Anesthetic considerations for major
Unfortunately, no burns chart is available so the extent of the burnt burn injury in pediatric patients. Paediatric Anaesthesia 2009; 19:
area is estimated using the childs palm + adducted fingers = 1% rule. 202-11.
Using this method the burn, which has partial thickness characteristics, Hilton PJ, Hepp M. Immediate care of the burned patient. BJA CEACCP
is estimated at 20%. 2001; 1: 113-6.
Using the Parkland formula (and assuming a weight of [age+4] x2 i.e. Fraser JF, Venkatesh BS. Recent Advances in the Management of
[5+4] x2=18kg), the fluid bolus required over the ensuing 24 hours is: Burns. In: Australasian Anaesthesia 2005; 23-32. Australia and New
20x18x4=1440ml. 720ml should be given over the first 8 hours since Zealand College of Anaesthetists.
the burn and the rest over the next 16 hours. This is in addition to
Fenlon S, Nene S. Burns in Children. BJA CEACCP, May 2007; 7: 76-80
the normal daily maintenance requirements. Estimated weight enables
Instructor Manual: Advanced Paediatric Life Support, 4th Ed. 2004
calculation of drug doses e.g. morphine bolus 0.1mg.kg-1 = 1.8mg.
White MC, Thornton K, Young AER. Early Diagnosis and Treatment of
Endotracheal tube size is estimated in the usual way: age/4+4 i.e. Toxic Shock Syndrome in Paediatric Burns. Burns 2005; 31: 193-197.
5/4+4=5. It is prudent to have smaller tube sizes available than the
estimated size in case of airway oedema.

Trauma in Children
Stabilisation and preparation for transfer in

paediatric trauma patients
D Easby and K L Woods
Correspondence Email: woodskate@hotmail.com
Introduction
The principles of trauma management in paediatric
patients are the same as those that apply to adults COAGULOPATHY
who have been involved in trauma. These principles
are those taught in courses such as Advanced Trauma
Life Support (ATLS), European Trauma Course and
Summary Primary Trauma Care.
Stabilisation of paediatric This article will focus on recent developments in trauma

trauma patients and management and in the stabilisation of the traumatised
preparation for transfer patient. Many of these come from experience gained
METABOLIC
of these patients, should from the military. It is important to note that many HYPOTHERMIA
follow the same principles ACIDOSIS
of these developments have occurred in relation to
as when dealing with patients with penetrating trauma and the lessons may
adult patients in similar
not apply in the same way to blunt trauma. Figure 1. The lethal triad of trauma
circumstances. Attempting
to return physiology Stabilisation
to normal as soon as
Patients who have suffered significant trauma are likely Management of coagulopathy, as part of management
possible and transferring
in a safe and timely fashion
to require stabilisation as part of their treatment. This of massive transfusion, will be discussed in a separate
to a hospital with the may either be as part of their definitive treatment or, in article in this journal.
appropriate facilities to smaller units, prior to their transfer to a larger trauma
provide the best possible centre or hospital with specialist facilities. Patients Acidosis
care, will allow for the best should be as stable as possible prior to transfer in Acidosis is associated with poor tissue perfusion and
outcomes after paediatric order to reduce the risks of a complication occurring will be associated with a low pH, high base deficit
trauma. during transit. (negative base excess) and raised lactate on blood
In order to stabilise the patient it is important to gases. If blood gases are not easily available, then other
consider what is happening at a physiological level. factors associated with poor tissue perfusion should
be considered. These clinical markers of poor tissue
Massive haemorrhage caused by trauma is associated perfusion include factors such as prolonged central
with poor tissue perfusion, which leads to multi-organ capillary refill time, tachycardia and reduced urine
dysfunction and death. Stabilisation of a trauma output. Treatment of acidosis in these circumstances
patient will involve restoration of normal physiology involves adequate fluid resuscitation. Where injuries
D Easby as soon as possible in order to maintain adequate are life-threatening or where fluid requirements are
Anaesthetic organ perfusion and so minimize damage and improve expected to be more than 20ml.kg-1 it is best to start
Specialist Registrar outcome. fluid replacement using blood products wherever
Norfolk and Norwich Coagulopathy, acidosis and hypothermia are termed available. Restoration of circulating volume to provide
University Hospital, the lethal triad of trauma (Figure 1). This term is used adequate tissue perfusion and thus allow resolution of
Norwich to describe factors in major trauma that, if present, are the acidosis is the aim here, so if blood is not available,
UK associated with increased risk of death. use crystalloids instead. Where hypotension is present
due to loss of blood volume from haemorrhage, it
K L Woods Coagulopathy should be treated by replacing circulating volume in the
Consultant Anaesthetist, Approximately one third of trauma patients have a first instance, not with inotropes or vasoconstrictors,
James Cook coagulopathy on admission to hospital, and these which will only serve to worsen tissue acidosis. Once
University Hospital, patients have a worse outcome than patients without the patient has adequate tissue perfusion and has
Middlesbrough a coagulopathy.1 Therefore treatment of major trauma become haemodynamically stable the acidosis should
UK should involve identification of any coagulopathy. begin to resolve.

Hypothermia any clot that may be forming. This approach should be used both in
Hypothermia is likely to be seen in trauma patients, even in warm the pre-hospital setting and also within the Emergency Department
environments, and has negative effects on many bodily functions (ED). Controlling catastrophic haemorrhage has resulted in improved
including, for example, causing coagulopathy. It should be actively numbers of patients surviving who previously may have exsanguinated
avoided in major trauma patients and simple treatment solutions in the pre-hospital setting.3
adopted. Minimise the exposure of the patient where possible using
When using tourniquets, try to apply the tourniquet as close as is
blankets and covers in the pre-hospital environment and continue this
feasible to the proximal edge of the wound in order to preserve as
in the emergency department. Use of active warmers, such as forced
much tissue as possible, in particular saving joints where practicable.
warm air devices will reduce hypothermia further and can be used to
Ideally tourniquets should be applied directly onto exposed skin to
actively warm children if they have become cold despite best efforts.
avoid slipping. If one tourniquet adequately tightened does not control
If the operating theatre has temperature control, this should be raised
the haemorrhage then a second tourniquet can be applied proximal to
to ensure a warm environment for surgery and if fluid warmers are
the first. It is important to remember that a tourniquet which is tight
available these should be used as well. Monitoring of the patients
enough to control haemorrhage is going to be painful and that the
temperature is important because once children start to warm up it
patient may try to remove it. Reassuring the patient is very important
can be easy to overshoot and for the patient to become hyperthermic.
and in paediatric patients parental presence in this situation may be
This is particularly important in head trauma where hyperthermia
vital. Always bear in mind that that permanent lethal damage can be
worsens secondary brain injury, so every attempt should be made to
caused to the tissues distal to the tourniquet, so tourniquets should
maintain normothermia. Regular temperature checks should form
only be used where the distal limb is not viable or the haemorrhage
part of the standard management of these patients.
is life threatening.
All parts of the lethal triad should be considered and appropriately In paediatric patients, control of blood loss is vitally important due
managed when treating trauma patients in order to reduce trauma to the reduced total blood volume in comparison to that of an adult.
related deaths. Whilst commercially available tourniquets may be too large for the
paediatric patient, tourniquets can be improvised or adapted to ensure
Recent developments in trauma management have considered how to haemorrhage control. Improvised tourniquets may be created by the
correct the physiological disturbance associated with trauma as quickly use of belts or similar devices with cloth used under the tourniquet to
as possible, in order to try to reduce multi-organ dysfunction. Whilst act as padding. The same principles apply when using an improvised
many of these involve use of new and technical solutions, which may tourniquet as when using a commercial device. Experience shows that
not be easily available worldwide, the principles behind them can be hospital surgical tourniquets are more effective than field tourniquets,
applied in many situations. even those that are purpose designed. It is therefore appropriate to
change to surgical tourniquets as soon after arrival as is felt safe to do so,
Catastrophic haemorrhage control which will usually be once large bore venous access or an intra-osseous
Any patient who presents with major trauma has the potential to be needle is sited and fluids/blood products are available for resuscitation.
unstable, particularly from a haemodynamic perspective. In recent
years, it has been recognised that in situations of overwhelming Damage control resuscitation (DCR)
haemorrhage, in order to save life, quick interventions to stop further This is a term that has been used to describe a systematic approach to
blood loss need to be undertaken before airway measures. This has led trauma management, combining <C>ABC with attempts to minimise
to the development of a new paradigm, changing Airway, Breathing, blood loss, maximise tissue oxygenation and optimise outcome.4
Circulation (ABC) to <C>ABC with <C> being catastrophic
haemorrhage control.2 DCR begins with haemorrhage control at point of wounding and
continues with use of advanced resuscitation techniques during
Catastrophic haemorrhage control involves the use of tourniquets casualty evacuation. On arrival in hospital this involves the use of a
to control massive haemorrhage (applied ideally at the point of consultant led trauma team and aggressive management of the lethal
wounding). Tourniquets are used for any traumatic limb amputation triad of trauma.
or limb injuries where there is blood loss which would be significant
Early use of diagnostic imaging including chest Xray, pelvic Xray,
enough to threaten life and which is not controlled by direct pressure.
Focused Abdominal Sonography for Trauma (FAST) and CT allows
Tourniquets cannot be used in head and neck trauma or to control
decisions to be made in a timely manner. DCR may involve an
chest or abdominal bleeding. Other methods of haemorrhage control
early decision to transfer to theatre for damage control surgery if
include direct pressure and the use of novel haemostatic agents such as
haemorrhage control is difficult, and surgical haemorrhage control
Quiclot, Haemcon and Celox. Quiclot is a kaolin based product
is required.
which initiates the intrinsic coagulation pathway, whilst Haemcon
and Celox are both polysaccharide based haemostatic agents, which Diagnostic peritoneal lavage (DPL) could be considered if diagnostic
are non-exothermic. If none of these novel agents is available, then imaging is not available, although this is no longer used in areas where
direct pressure should be used and can be applied in areas where a the technique of DCR has been developed. DPL has a significant false
tourniquet would not work. If possible use a sterile dressing and if positive rate and so will result in some unnecessary laparotomies being
bleeding occurs through the dressing then apply a second dressing performed. It is also invasive and there are risks of organ perforation
over the top of the first, rather than removing the first and disrupting associated with it. However, a positive DPL in a haemodynamically

unstable child with abdominal trauma would be an indication for Decision to transfer
laparotomy. If there is life-threatening haemorrhage and clinical When considering the need for transfer a number of questions need
examination identifies the abdomen as the obvious source, it is to be considered in order to ensure that the right patient is moved at
appropriate to proceed straight to laparotomy as part of the damage the right time to the right place and with the right team to carry out
control resuscitation strategy and not waste time preceding this with that transfer safely.
DPL.
These questions can be considered as a list:
Fluid resuscitation is carried out using blood and blood products
instead of crystalloid or colloid. This, as well as correction of Why?
coagulopathy as part of management of paediatric massive transfusion, Where?
will be discussed in another article within this journal and so will not When?
be covered here. Early use of intra-osseous access, if venous access is
not available, should also be considered. How?
Who?
Right turn resuscitation (RTR)
This phrase refers to the movement of the trauma team from the ED Is it safe?
into the operating theatre in order to carry out DCR at the same time
as surgical haemorrhage control.5 The intent is to reduce the time Why?
needed to restore normal physiology by carrying out resuscitation in This question should focus on Why are we transferring this child?
the operating theatre at the same time as surgical damage control. Is this move for urgent care for example a child with an extra-dural
This approach to the most critically injured relies upon having a full haematoma being transferred for urgent neurosurgery, or could this
trauma team on standby and also an immediately available operating urgent care be provided in the current location? This can also be
theatre. It may not be possible to replicate this in all hospitals, but the thought of as a risk/benefit balance: What are the benefits to the
principles can still be used. If a patient is determined to be critically child of being moved at this time and what are the risks associated
injured, and in need of immediate surgery to control the haemorrhage with the transfer.
at the same time as resuscitation, then the decision is made to run It may be that the risks for transferring an unstable child are greater
the resuscitation in the operating theatre. The entire team from the than the benefits of movement to a specialist centre and so the child
ED move into the theatre, provide immediate airway control and may need to undergo damage control surgery in order to be made
anaesthesia and continue trauma resuscitation as they would have done stable enough for the transfer.
in the ED at the same time as the surgeon is obtaining haemorrhage
control as quickly as possible. This may include clamping large Where?
vessels or performing a thoracotomy. Whilst this is ongoing, the ED This question should focus on Where are we moving this child to?
consultant and ED team will be present and continuing to run the
Is the closest specialist centre the most appropriate to look after this
trauma until stability is achieved.
child or may it be more appropriate to move the child to a more
The decision to begin RTR may be made before the patient arrives in distant hospital, but one that has the facilities to provide better care?
the hospital if reports from any pre-hospital team suggest it is necessary. For example, not all neurosurgical facilities can provide paediatric
Alternatively an early decision made by the trauma team leader very care and so the local neurosurgical unit may not be the best place to
shortly after the arrival of the patient ED will optimise the usefulness transfer the child to, it may be better to move further to definitive
of this strategy for the most seriously injured trauma casualties. care, if the child is stable enough, rather than transfer to the closest
unit and then have a second transfer within a short period of time.
A team working together to reduce blood loss, particularly of non-
compressible haemorrhage, use of blood products to resuscitate the Answering this question requires local knowledge and understanding of
patient and early airway control and ventilation will give the patient the facilities and capabilities of the local units and good communication
the best chance of survival. These new developments when used in between departments will allow a critically injured child to be moved
combination with the standard principles of trauma management to the appropriate location for treatment.
will allow the best possible care to be delivered to the severely injured
patient. When?
This question should focus on When is the appropriate time to
PREPARATION FOR TRANSFER
transfer this child?
Introduction
The need to transfer children who have been involved in trauma Answering this question will depend on the injuries the child
between hospitals is well recognised. Children may need to be moved has sustained. A child with a traumatic amputation or significant
urgently to specialist centres for treatment, to be moved to larger penetrating abdominal injury is likely to require damage control
hospitals for definitive treatment or may need to be repatriated for surgery before they are stable enough to transfer to a specialist centre.
care closer to home once the need for specialist care is finished. This This is likely to involve haemorrhage control, airway management,
part of the article will look at the safe management of the transfer of ventilation, massive blood transfusion and warming, as they are
children for emergency or urgent care. being stabilised. Alternatively, a child with a head injury who requires

neurosurgery that cannot be carried out in the local hospital, may requires communication, preparation of equipment and preparation
have to be transferred before they are stable because the only way of documentation.
to stabilise them is at the specialist centre.
Communication
How? Communication is one of the most important parts of carrying out a
This question should focus on How are we going to carry out the transfer. Communication allows all those involved in the childs care
transfer? to work together to ensure the best outcome for the child. This will
The answer to this question will depend on the methods of transport involve communication by a lot of people, both external and internal
available. The main alternatives are road ambulance, rotary aircraft to the team carrying out the transfer.
(helicopter) or fixed wing aircraft (aeroplane). Access to aircraft may
be limited both by availability and also by weather conditions. If all Communication with the receiving hospital
the alternatives are available, then timelines for transfer need to be Before a transfer can be made, the receiving hospital needs to have
considered. It may actually take longer to task an aircraft, move the accepted the patient. Often the team taking over the care will have
patient to the airport/helipad, load the patient, fly between points, been contacted, but this may not mean that a bed has been arranged
move the patient out of the aircraft and transfer to the destination or that there is space in the intensive care unit. All of this should be
hospital, than it would to carry out a road transfer between the two verified before starting the transfer and the patients destination within
points. Again, knowledge of the local area and what alternatives are the hospital should be confirmed. Communication with the receiving
available will dictate the method of transfer between locations. Any unit should also include patient information such as whether they are
vehicles used should be well maintained and appropriately equipped. intubated and ventilated, what lines are in situ and what drugs are
Ability of transferring staff to access the patient and ability to control running. This allows the receiving unit to prepare in advance of the
temperature and light should be considered. patients arrival.
Who? Communication within the hospital transfer team

This question should focus on Who is going to carry out this transfer? Once the decision has been made about who is going on the transfer
Again the answer to this question will vary depending on the situation then the members of the transfer team need to discuss the plans for
and the type of transport to be used. Staff who transfer children should the transfer. This will include discussion about what equipment
ideally have completed a training course on transfer. Those staff and drugs need to be prepared and drawn up and what else may be
carrying out the transfer should be competent in the management of required. Actions on plans may also need to be discussed. This
the paediatric airway, including intubation, and in the management means planning in advance what roles people will carry out in an
of the acutely unwell child. Ideally a doctor and nurse should carry emergency scenario. This may include planning who will take what
out a transfer, in addition to the usual crew of the vehicle. Which role in the event of a cardiac arrest, an accidental extubation or need
staff go will depend on individuals levels of experience, the need to for intubation. Discussion about what to do in the event of oxygen
provide appropriate cover at the hospital and the injuries sustained by failure or power failure should also be considered.
the child. Parental presence also needs to be considered at this point.
Communication with the vehicle team
Is it safe? Whatever type of transport is used, the team on the vehicle will all need
This question covers two areas: Is it safe for the child and is it safe to know the destination of the patient, any concerns about what may
for the team? occur during the transport and how urgent the transfer is. Further
details required will depend on the type of transport being used. Good
Is it safe for the child? This means, is the child in a safe condition to communication will enable the transfer to go as smoothly as possible
transfer? Are they stable enough, or do they require further treatment and will help to minimise the risk to the patient.
prior to the journey? Is the airway and are all lines secured, or should
further access be obtained first? Is there anything that can be done Communication with the patient and their relatives
to make this child safer for transfer? Intubation during transfer can
The patient and their relatives will also need to know about the
be difficult and even dangerous. Consider if it is safer to secure the
transfer. This will include the reasons for transfer, the destination and
airway with an endotracheal tube prior to transfer than to attempt
arrangements for transfer. If a parent is to travel with the child this
this during the transfer.
will need to be arranged, or if the parents are to travel independently,
Is it safe for the team? This means, are there external factors, such as then they will require information about how to get to the receiving
poor weather, that make carrying out the transfer a risk to the medical hospital. Contact details for the parents should also be obtained and
staff, and therefore the patient? If this is the case, the risk of carrying given to the receiving hospital and contact details of the receiving
out the transfer and the potential loss of medical staff, needs to be hospital should be given to the parents.
balanced with the need to carry out the transfer.
Equipment
Preparation for transfer The exact equipment needed on a transfer will vary from location to
Once the decision to carry out the transfer has been made, then location. Many units have transfer bags pre-prepared and stocked
preparation for transfer needs to begin. Preparing to transfer a child with a full range of equipment to carry out a transfer. Often there

will be different bags for neonatal or infant transfer and transfer of ventilation, whether the ventilator is driven by compressed oxygen
an older child. and the availability of oxygen supplies in the vehicle. It is always
worth taking double the calculated requirement to allow for delays
This reduces the need to carry all the possible sizes of equipment
and equipment problems. A suitable calculation is:
on every transfer and may also mean taking a different ventilator
dependent on the childs age. If these bags are used it is important to Minute volume x estimated journey time (in minutes) x 2
ensure those carrying out the transfer are familiar with the equipment
Round this up to the nearest cylinder size. The contents of various
and where it is stored in the bag. Table 1 (following page) lists some
cylinders are as follows: D cylinder 340L, E cylinder 680L, F
essential requirements: please note this is not an exhaustive list and
cylinder 1360L.
other equipment may be needed depending on the individual situation.
Documentation
Equipment used for transfer should be durable, lightweight and be Ensuring the correct documentation is taken on the transfer is
able to work on battery supply for prolonged periods of time, and important. Copies of all notes and all imaging such as Xrays and
replacement batteries should be available. For this reason gas driven CTs should be sent with the patient. Blood test results should also
ventilators are often used for transport, provided there is an adequate be included. If there is specific documentation for the transfer then
supply of compressed gases. A self-inflating bag may be preferable, and this should be taken and completed during the transfer. If there is
is essential as back-up. The equipment must be able to be adequately no specific paperwork then a chart such as an anaesthetic chart where
secured within the chosen transport, either using brackets or onto a observations, drugs and any interventions required can be completed
special transport bridge. This could be manufacture locally to suit should be used and filled in for the transfer.
specific needs. Equipment alarms need to be pre-set appropriately
to each child and should be visible as well as audible as conditions Packaging for transfer
during transfer are often noisy. Sufficient equipment should be left at Once the decision has been made to transfer the patient will need
the departing hospital to allow treatment of any further emergencies to be prepared. This will include transferring onto the appropriate
that occur whilst the transfer team are away. transfer trolley, and ensuring all IV access lines, the endotracheal
Equipment should be checked prior to transfer to ensure it is fully tube and any other lines such as chest drains, urinary catheter and
working and there is nothing missing. Drugs should be checked to Nasogastic tubes are inserted if required and are secured appropriately.
ensure they are in date. If there is any question about cervical spine injury then the cervical
spine will need to be appropriately protected. When packaging the
If the patient is receiving drug infusions, then these should be made up patient for transfer consideration needs to be given to protecting the
in advance of the transfer and spare syringes prepared. The time taken patients pressure areas. Once packaged the childs clinical condition
for the transfer should always be considered, allowing for significant should be re-assessed to ensure they remain appropriately stable at
delays, and consideration should also be given to the possibility of point of departure.
needing to increase the dose during the transfer. It is better to make
up too many spare syringes than to try and draw up further spares in Once the team are ready to depart, the receiving hospital should
the back of a moving vehicle. Emergency drugs should also be drawn be contacted again to let them know that the patient is on the way.
up, labelled and capped off so they are easily accessible during the During transfer vital signs should be observed and documented and
transfer. Drugs that may need to be bolused during transfer should any interventions carried out recorded, so that the receiving team have
also be prepared, labelled and capped off for easy use. Consider having a complete picture on handover.
two syringes of any emergency or bolus drugs in case one is dropped
in the vehicle. References
1 Brohi, K., Singh, J., Heron, M. & Coats, T. (2003) Acute traumatic
Enough fluid should be taken to provide maintenance fluid as well as coagulopathy. The Journal of Trauma Injury, Infection and Critical Care;
boluses during the transfer. In the traumatised child this may include 54: 1127-30.
taking blood or blood products and this will need to be arranged prior
2 Hodgetts T, Mahoney PF, Byers M, Russell MQ. ABC to <C>ABC:
to transfer and suitable storage organised to keep the products at the Redefining the military trauma paradigm. Emerg Med J 2006; 23: 745-
correct temperature during the transfer. 46.
Any electrical equipment must be fully charged prior to transfer. If
3 Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.
the equipment can be plugged in during the transfer then power cables Survival with Emergency Tourniquet Use to Stop Bleeding in Major
should be taken. If this is not possible then enough spare batteries Limb Trauma. Annals of Surgery 2009; 249: 1-7.
should be taken for the equipment to last for the longest possible
duration of the transfer. 4 Hodgetts TJ, Mahoney PF, Kirkman E. Damage Control Resuscitation. J
R Army Med Corps; 153(4): 299-300.
The amount of oxygen required for the transfer should be calculated.
This applies to both ventilated and non-ventilated patients. How 5 Tai NRM, Russell R. Right Turn Resuscitation: Frequently Asked Questions.
much is needed will depend on the FiO2 of the patient, their minute J R Army Med Corps; 157 (3 Suppl 1): S310-S314.

Table 1. Suggested equipment for transfer of a critically injured child
Airway equipment Oro-pharyngeal airway
Naso-pharyngeal airway
Facemask
Ambu-bag (self-inflating bag) and Ayres T-piece
Endotracheal tubes
Bougie
Laryngoscope + blades + batteries
Ties / tape to secure endotracheal tube
Suction device
Yankauer suction catheter
Endotracheal suction catheter
End tidal CO2 monitoring
Breathing equipment Ventilator appropriate to childs weight

Oxygen
Spare batteries / power adaptors for ventilator
Circulation equipment IV fluids
Pressure bags
Syringe drivers + spare batteries
Cannulae
Intra-osseous device
Invasive monitoring equipment
Defibrillator
Drugs Sedatives
Muscle relaxants
Epinephrine
Atropine
Inotropes
Anti-emetics
Mannitol / hypertonic saline
Other Portable monitor giving SpO2, ECG, Non-invasive blood pressure. Ideally
with facility to monitor CVP and arterial BP.
Blankets
Thermometer
Urinary catheter + bag
Pen torch
Blood glucose monitor
Medical + nursing notes
Radiology images
Transfer documentation
Personal Equipment Money
Mobile phone + contact numbers
Protective clothing and footwear
Personal protective equipment - gloves

Paediatric intensive care in resource-limited
countries
Critical Care
Rola Hallam, Mohammod Jobayer Chisti, Saraswati Kache and

Jonathan Smith*
*Correspondence Email: drjonathansmith@me.com
The leading causes of death in the under-five (LIC) as those having a per capita gross national
age group are pneumonia, diarrhoea, malaria, income of US $1,025 or less. This describes the
complications of prematurity and birth asphyxia. situation in 36 countries, mainly in sub-Saharan
Acute febrile illness is the most common cause Africa.
of hospital admission, and the largest proportion
of admissions are due to malaria and/or invasive The WHO recommends that every hospital
SUMMARY performing surgery and anaesthesia should have
bacterial disease. Malnutrition contributes to
This article provides guidance approximately one third of all childhood deaths. an ICU, but a survey from Zambia showed that
on setting up a PICU in a The demand for intensive care services for only 7% of hospitals do.1 Where an ICU does
low-income country, based
children and the global burden of critical illness exist, many admissions are for children under five
on the personal experience of years old (nearly 30% of admissions to an urban
the authors. We also describe is hard to estimate, but 10 to 20% of children
who present to primary care are severely ill and ICU in Uganda (RH personal experience)).
clinical management of
specific conditions. need referral for hospital care. Mortality rates The challenges to provision of intensive care
of severely ill children admitted to hospital vary for children are similar in many LIC. There are
between 10% and 30%. few trained staff, and few trained in care of the
Critical care is defined as care given in hospital critically ill child; in one study, 73% of doctors
Rola Hallam and 91% of nursing staff displayed insufficient
Research Fellow, Great to patients with sudden and reversible critical knowledge in at least one of the medical
Ormond Street Hospital, illness. Paediatric critical care is often thought
conditions assessed.1 Nurses provide most of
London of as a luxury, but the underlying principles of
rapid recognition and targeted interventions the care, but there are often few nurses on duty
Mohammod using a simple ABC approach, appropriate fluid overnight. Basic resources to support intensive
Jobayer Chisti resuscitation, oxygen and antibiotic therapy are care may not always be available; the majority
Scientist and Clinical Lead, not expensive and do not depend on complex of hospitals have access to supplies of water and
Paediatric Intensive Care equipment. Younger patients with reversible electricity, but power surges and intermittent
Unit,
processes represent the majority of critical illness water shortages are common. In a study of 21
Dhaka Hospital, hospitals in Bangladesh, Dominican Republic,
in low income countries; therefore, simple timely
International Centre Ethiopia, Indonesia, Philippines, Tanzania and
for Diarrhoeal Disease intervention can save lives.
Uganda, supplementary oxygen was present in
Research, Bangladesh
This article provides guidance on setting up 87% of city teaching hospitals but only in 47%
(ICDDR,B)
a PICU in a low-income country, based on of district hospitals.1 Compressed air, pressurized
Saraswati Kache the personal experience of the authors from oxygen or basic monitors such as pulse oximeters
Clinical Associate working in Bangladesh, Nepal and Uganda. may not be available, and there are few biomedical
Professor, Lucile Packard We will also consider clinical management of engineers to maintain sophisticated equipment.
Childrens Hospital, children presenting with shock, convulsions, Mechanical ventilation is not a viable option
Stanford University School fever, gastroenteritis and malnutrition; the for children in these situations, and alternative
of Medicine, USA management of children with pneumonia is approaches to respiratory support must be used.
considered in detail on page 251.
Jonathan Smith SETTING UP A PICU
Consultant Paediatric PAEDIATRIC CRITICAL CARE IN LOW-
Anaesthetist, Great INCOME COUNTRIES Children requiring intensive monitoring and
Ormond Street Hospital, support include those with a medical diagnosis,
London The World Bank defines low-income countries such as severe pneumonia, acute dehydration or

sepsis, or after traumatic injury or burns, or after major surgery A reliable oxygen source. Oxygen concentrators cost up to
such as laparotomy. $1200, but are reliable, cheap to maintain, and can
provide oxygen up to four patients simultaneously using a
Much can be achieved through structured education and flow splitter. Oxygen cylinders are cheap to buy but expensive
training of existing staff and reorganization of available and cumbersome to maintain. A supply of compressed air
resources. Substantial financial input is not required and and oxygen will be needed for invasive ventilation, but this
setting up a PICU is thus a realistic goal. Establishing an is by no means an essential part of setting up a PICU
intensive care unit may also motivate professional development
more widely, and help to foster a culture of education, training Further equipment is needed for an advanced PICU such
and clinical improvement in a hospital. as patient ventilators, a blood gas machine, and IV infusion
pumps
An initial needs assessment is essential to identify and prioritize
key issues; these depend on the institution, the patient volume, Is this equipment available from a local vendor or agent?
rates and causes of mortality, and available resources. The
WHO has developed a useful tool for assessing the quality of Are essential and emergency drugs available?
hospital care for children that scores various aspects of hospital Antibiotics, fluids, resuscitation drugs, inotropic agents,
care against a standard applicable to LIC.1 anti-epileptic agents, bronchodilators, anaesthetic agents,
analgesics and sedatives should be available in the PICU
The following are useful questions to consider:
Drugs should be stored in a locked drug cupboard, but
Why do you want to establish a PICU?
must be easily accessible when needed
What are your rates of admission of children?
Access to blood and blood products
What are the leading causes of mortality and morbidity
amongst children in your hospital? Is there access to basic laboratory studies and diagnostics?
A laboratory that can run a basic chemistry panel, a
What physical space do you have available?
complete blood count, cultures, and check for malaria
How many bed spaces?
should be available
Do you have the actual beds?
Are isolation rooms available? Diagnostics capabilities such as X-ray should also be
available within the institution. Although a CT-scan is
Is the infrastructure reliable? not essential, it will be of benefit in a location with multiple
Is the water supply reliable? Do you need a water trauma patients
purification system?
Personnel
Is the electricity supply reliable? Do you need an upstream Who will be responsible for the management of children in
voltage stabiliser to protect your equipment? the PICU?
Is there a temporary automatic emergency power supply in How many nurses do you have available to work on the
case of power failure? PICU?
What equipment is available? Are they local staff? Are they trained? Do you have links
There are many pieces of equipment to consider, but we think with any other institutions to assist with training?
these are the most important:
Are the staff dedicated to the PICU, or are they required to
Patient cardio-respiratory monitors, including pulse cross cover for another area? A nurse is required to look
oximeters, one per patient bed space after the child at the bedside, and another is required as a
Patient charts to record observations runner
An Ambu bag (self-inflating bag), adult, child and infant Management

sizes Does your hospital management support this initiative?
Airway equipment, including facemasks, oral airways, Who will be the key people in the hospital/community/
tracheal tubes country that are going to move this project forward?

Finances Children who are marginal may decompensate while waiting
How much money is available for this PICU to be to be seen. In one study, triage in 14 of 21 hospitals was judged
established? to be poor due to avoidable delays, poor organization of the
facilities or inadequate assessment of patients.1
Will this be adequate to make changes to the physical space
and buy the equipment that is required? An estimated 50 to 87% of children who die in hospital do
so in the first 24 hours.1 Effective triage and emergency care
Is someone assigned to take care of the finances? can lead to impressive reductions in in-patient mortality,
and should be an early focus of training when setting up a
Is there a plan to maintain the PICU once opened, for paediatric critical care unit.
instance to support on-going costs of staff, maintenance of
Diagnostic considerations
equipment, drugs and supplies of disposable equipment?
Precise diagnosis of the cause of severe illness, in particular,
Time-line differentiation between severe malaria, sepsis, pneumonia, and
When do you expect to open the PICU? meningitis, is often not possible at the time of admission as
most sick children present with signs and symptoms related to
Is this realistic? more than one of these conditions. Striving to make a single
diagnosis may not be possible or appropriate, and may lead to
Hurdles incorrect or delayed management.
What are the main hurdles you and other key personnel
see? The initial management of critically ill children should
therefore be largely independent of the underlying diagnosis,
This process is useful to identify other issues that may not and should focus on addressing life threatening conditions such
have been considered previously as hypoxia, hypovolaemia, hypoglycaemia, and convulsions.
The WHO advocates the use of integrated management of
It is possible to start small, with a few high dependency beds childhood illnesses (IMCI) approach whereby children are
identified on the childrens ward or in the adult intensive care treated according to clinical symptoms rather than focusing
unit. The ideal is to have specific areas identified for childrens on a specific diagnosis. This approach is illustrated in the
critical care, both for neonates and for infants and older following case study and has been described in detail on page
children. 224.
GENERAL PRINCIPLES OF PICU MANAGEMENT Case study

Adebola is a 16-month-old girl in Nigeria. She weighs 10
The WHO Pocket book for hospital care of children1 is a kg. Her temperature is 38C. Her mother says Adebola
valuable resource, which should be available to all clinicians has been coughing for 6 days, and she is having trouble
caring for children in these settings. The WHO Emergency breathing. The health worker checks Adebola for general
Triage Assessment and Treatment (ETAT) course has been danger signs. The mother says that Adebola is able to drink.
developed by the WHO and is planned for widespread She has not been vomiting. She has not had convulsions
implementation in LIC. Staff retention and training and a during this illness. The health worker asks, Does Adebola
change in culture are often the key to sustain improvements. seem unusually sleepy? The mother says, Yes. The health
worker claps his hands. He asks the mother to shake the
Triage child. Adebola opens her eyes, but does not look around.
Triage is the process of rapid screening of children on arrival The health worker talks to Adebola, but she does not watch
to hospital in order to identify those with emergency signs his face. She stares blankly and appears not to notice what is
who require immediate life-saving treatment to avert death, going on around her.
and those with priority signs who need to be treated before
those deemed non-urgent. It is an essential part of care for the The health worker asks the mother to lift Adebolas shirt.
critically ill child, and is described in detail on page 223. Initial He then counts the number of breaths the child takes in
management of the critically ill child is also described there. a minute. He counts 60 breaths per minute. The health
worker sees lower chest wall in-drawing, but does not hear
In practice, we have found that triage is frequently not present, stridor.
or is of variable quality. Parents queue with their children at
the hospital or clinic, and do not undergo medical evaluation The health worker asks, Does the child have diarrhoea?
until they reach the front of the line, which may be hours later. The mother says, No.

Due to presence of danger signs, the child is admitted. Helps stent airways open and decreases the work of
Oxygen and anti-pyretics are given. IV antibiotics are given breathing, often with minimal oxygen requirement;
due to presence of a clinical condition requiring antibiotics particularly effective as children are prone to small airway
(pneumonia). It is high season for malaria so IV anti- disease.
malarials are also given. Bubble-CPAP is a low cost, but effective method of providing
Adebola makes good progress and is discharged 5 days later. continuous positive airway pressure (CPAP) oxygenation in
neonates, infants and children and is widely used in LIC for
Treatment of hypoxaemia conditions such as pneumonia and respiratory distress of the
newborn. The following are required (see figure 1 and 2):
Hypoxaemia is common in children with pneumonia, and is
associated with high mortality. Source of gas flow (typically 510L.minute-1; start at low
flow rates in neonates)
Hypoxaemia is defined as peripheral arterial oxygen
saturation <90% in room air at sea level as recorded by An air-oxygen blender
pulse oximetry
A humidifier
The treatment target SpO2 is >92%
T-piece connector, for instance nasal prongs with
Severity of hypoxaemia is defined as follows inspiratory and expiratory limbs (see Figure 1).
Mild: SpO2 85-90% The long expiratory limb of the T-piece breathing tube is
Moderate: SpO2 80-85% inserted into a bottle of water: the level of CPAP delivered is
equivalent to the length of the expiratory tubing that remains
Severe: SpO2<80% under water. Modern equipment is now available at a fraction
Indications for oxygen therapy: of the cost of mechanical ventilators.
SpO2 <90% Bubble CPAP has been proposed as an inexpensive method of

delivering CPAP in developing countries. Bubble CPAP is used
In the absence of pulse oximetry: as a step up treatment from facemask or nasal prong oxygen.
Central cyanosis
Severe lower chest-wall in-drawing
Grunting respiration
Restlessness (due to hypoxaemia)
Inability to drink or feed
Respiratory rate >70 breaths.min-1
Head nodding.
Bubble CPAP
Continuous Positive Airway Pressure (CPAP) is commonly
used to provide non-invasive mechanical support for children
in ICU, either using conventional mechanical ventilators or
increasingly using specifically designed CPAP devices.2,3
CPAP may be given by facemask or nasal cannulae. Advantages
of nasal CPAP (nCPAP) are as follows:
Effective treatment for hypoxaemia
Figure 1. Figure of bubble CPAP. Reproduced, with permission
Reduces the number of children requiring endo-tracheal of the publisher, from The clinical use of oxygen. Geneva, World
intubation and mechanical ventilation Health Organisation, 2011 (Fig 6.1, page 38)2

Obtain cultures first wherever possible.
Then Focus is:
Review the clinical diagnosis and the continuing need for
antibiotics by 48 hours and make a clear plan of action -
the Antimicrobial Prescribing Decision
The four Antimicrobial Prescribing Decision options are:
1. Stop
2. Switch IV to Oral
3. Change
4. Continue and Outpatient Parenteral Antibiotic
Therapy (OPAT)
Figure 2. Bubble CPAP in the ICU of the Dhaka Hospital of It is essential that the review and subsequent decision is
ICDDR,B clearly documented in the medical notes.
The advantages of Bubble-CPAP over invasive mechanical MANAGEMENT OF SPECIFIC CONDITIONS

ventilation are as follows: Management of children presenting with shock, convulsions,
fever, gastroenteritis and malnutrition will be considered below.
Low cost Detailed management of children presenting with respiratory
Easy to use, minimal training required infections is considered on page 251.
Sedation not required to tolerate treatment Child presenting with shock
No need for a physician to intubate the patient The WHO definition of shock is as follows1:
No need for respiratory therapist to operate/maintain a Cold peripheries

ventilator Capillary refill time greater than 3 seconds
Lower risk of complications e.g. pneumothorax Weak pulse with tachycardia.
Greater hemodynamic stability. Narrow pulse pressure.
Use of antibiotics in PICU Blood pressure is not commonly recorded in low resource
There is an emerging problem with antibiotic resistance, and settings and a fall in blood pressure is a very late sign.
antimicrobial stewardship is being encouraged to assure that Hypotension is associated with poor outcomes (See Table 1).
antibiotics are used appropriately, and for the correct length Types of shock:
of time. The basic tenet of antimicrobial stewardship is Start
smart, then focus: Haemorrhagic shock
Start smart is: Cardiac shock
Do not start antibiotics in the absence of clinical evidence Septic shock
of bacterial infection
Hypovolemic shock
If there is evidence/suspicion of bacterial infection, use local
Specific infectious outbreak: e.g. Dengue shock syndrome
guidelines to initiate prompt effective antibiotic treatment
A combination of several of the above.
Document on a drug chart and in the medical notes:
clinical indication, duration or review date, route and dose A careful history, examination and investigations should be
of antibiotics performed (see Table 2).

Table 1. Cardiorespiratory parameters of shock in children
<2 months 2- 12 months 1-5 years >5 years

Blood pressure (mmHg) <50 <50 <60 <70
Heart rate
>180 >180 >160 >140
(beats.min-1)
Respiratory rate
60 50 40 30
(breaths.min-1)
Septic shock in children in LIC Hypothermia, particularly neonates and malnourished

patients
Septic shock is common in LIC, and treatment guidelines
formulated for high-income countries should be adopted with Hypotension (late finding)
care. Prolonged capillary refill time of >3 seconds (cold shock)
Pathophysiology Flash capillary refill (warm shock)
Septic shock occurs when a severe infection in any anatomic Altered mental status
location within the body leads to Systemic Inflammatory
Response Syndrome (SIRS). When uncontrolled, this leads Decreased urine output.
to hypotension, multi-system organ dysfunction, failure, and
Children with concerning findings on physical examination
eventual death. SIRS triggers both pro- and anti-inflammatory
should receive an IM dose of antibiotics immediately,
mediators; the vascular endothelium is the primary culprit in
and should be referred to the hospital if in a clinic setting.
being both a source and a target of injury to multiple organs.
Concerning signs include convulsions, lethargy or unconscious,
The three basic changes that occur are vasodilation, third
tachypnea, severe chest indrawing, nasal flaring or grunting,
spacing due to capillary leak, and myocardial dysfunction.
bulging fontanelle, umbilical redness, fever or hypothermia,
Diagnosis severe skin pustules.
The following may be present:
2007 American College of Critical Care Medicine algorithm
High fever for management of septic shock in children is as follows4:
Table 2. Shock in children
History Examination Investigation

Nature of onset? As per rapid initial assessment plus: Haemoglobin
Any trauma? Fever?
Bleeding? Any bruises or bleeding? Malaria blood smear
History of congenital or rheumatic heart Heart murmur?

disease?
Distended neck veins? Blood cultures if fever
History of diarrhoea?
Enlarged liver?
Any febrile illness?
Petechiae? Microscopy of CSF and urine
Any known regional outbreaks of
infectious diseases eg: meningitis/dengue Purpura?
fever? Level of consciousness? HIV testing
Are they able to feed?

Prompt recognition If the patient shows signs of respiratory distress and non-
invasive or invasive mechanical support is available, use it.
Initial resuscitation
Otherwise, give facemask oxygen
Diagnosis
If an infusion pump is not available to administer
Appropriate antibiotics inotropes, a solution of dopamine can be made by placing
200mg dopamine into 100ml normal saline in the burette
Source identification and control
of a paediatric microdrop IV set. Titrate this infusion to
Early access to critical care if available, but delays in access maintain the blood pressure in the normal range. Similarly,
to a critical care bed should not delay these interventions adrenaline or noradrenaline 1mg can be added to 100ml
saline and titrated to effect in a microdrop burette
Institution of inotropic support
Inotropes are always best administered through an infusion
Management of metabolic derangements pump when available.
Frequent, repeated assessment of the response to therapy
Child presenting with convulsions
Early aggressive fluid therapy should be used with caution
The differential diagnosis for a child presenting with
in LIC
convulsions is as follows:
The recent FEAST trial results5 suggest the traditional Age less than 2 months
recommendations of aggressive fluid resuscitation for
patients with septic shock may not be applicable in the Birth asphyxia/birth trauma
LIC environment (see page 81). Use IV fluids with
Hypoxic ischaemic encephalopathy
caution when resuscitating patients in septic shock in LIC,
particularly if there is concern that the patient has a Intracranial haemorrhage
malarial infection. Start with isotonic fluids (Ringers) at
normal maintenance rate initially. 5% dextrose must NOT Haemolytic disease of the newborn
be used in this setting
Neonatal tetanus
Malnourished children require slower rehydration and
Meningitis
careful observation (every 5-10 minutes) as they are at greater
risk of congestive heart failure from over-hydration Sepsis.
Anaemia is common in LIC; consider blood transfusion Age more than 2 months
early
Meningitis
Other interventions in septic shock are as follows
Encephalitis
Within the first hour (ideally within the first 15 minutes),
give the first dose of antibiotics Cerebral or severe malaria
Correct any abnormalities in calcium and glucose Febrile convulsion

If venous access is difficult, place an intraosseous line to Hypoglycaemia
administer fluids, antibiotics, blood products and inotropes
if required Head injury (including Non Accidental Injury)
If available, place a central venous catheter with central Poisoning

venous pressure (CVP) monitoring if more than 60ml.kg-1
Shock (not likely to cause convulsions)
fluid boluses are required
Consider starting inotropes if a patient continues in shock Diabetic ketoacidosis
despite fluid resuscitation: use dopamine (5-9mcg.kg-1. Acute glomerulonephritis with encephalopathy.
min-1) or adrenaline (0.05-0.3mcg.kg-1.min-1) for cold
shock and norepinephrine (0.05-0.3mcg.kg-1.min-1) for A careful history, examination and special investigations is
warm shock required (see Table 3).

Table 3. Convulsions in children
History Examination Investigations
Fever General: (as per rapid initial assessment +) Malaria blood smear
Fever
Head injury
Jaundice
Drug overdose or toxins Glucose
Palmar pallor
History of convulsions: how many, how
long did they last? Peripheral oedema
Lumbar puncture and CSF microscopy
Known epilepsy? Level of consciousness (AVPU) if no signs of raised intracranial pressure
(unequal pupils, paralysis, irregular
If < 1 week: birth asphyxia or trauma Petechial rash breathing, rigid posturing)
Deep breathing (sign of acidosis)
Head/neck:
Stiff neck
Signs of trauma
Pupil size and reaction to light
Tense or bulging fontanelle
Abnormal posture
Child presenting with fever - Skin/soft tissue infection

A febrile illness is the commonest cause of children presenting - Viral URTI
to hospital in LICs. Some causes are only found in particular
regions (e.g. dengue fever); some are seasonal or occur in - Throat abscess
epidemics. - Dengue fever.
There are three main diagnostic categories: Fever with a rash
Fever without localizing signs - Measles
- Malaria - Viral infection
- Septicaemia - Meningococcal infection
- Typhoid - Relapsing fever
- Urine tract infection - Typhus
- HIV related. - Dengue haemorrhagic fever.
Fever with localizing signs A careful history, examination and special investigations are
- Meningitis required (see Table 4).
- Pneumonia Child with gastroenteritis
- Otitis/mastoiditis/sinusitis Gastroenteritis is a common problem in developing

countries, presenting with diarrhoea and vomiting. Pre-
- Septic arthritis existing malnutrition can cause the diarrhoea to be more

Table 4. A child with a fever
History Examination Investigation

Duration of fever As for rapid initial assessment + Malaria blood smear
Are they in a malarious region? Stiff neck? LP if suggestion of meningitis
Skin rash? Headache? Bulging fontanelle
Pain on passing urine Mastoid region tenderness Urine microscopy
Cough or difficulty breathing? Rash? Blood culture
Ear ache Skin sepsis: pustules, purpura, petaechiae
Discharge/redness in ear
Refusal to move joint or limb
Tachypnoea
severe, prolonged and frequent compared to diarrhoea in A child who presents with dehydration is likely to be acidotic,
the non-malnourished child. Close monitoring in PICU which can cause tachypnoea. Under these circumstances, it
may be necessary to treat life-threatening consequences of can be difficult to differentiate increased respiratory rate due
gastroenteritis such as severe dehydration and electrolyte to pneumonia, or acidosis, or both. The following approach is
abnormalities, especially in children with severe acute suggested:
malnutrition (SAM).
Rehydrate the child in the first 4-6 hours using IV/oral
Differential diagnosis of children who present severely unwell fluids according to the type of dehydration present
with diarrhoea:
Then continue respiratory rate monitoring according to
Acute watery diarrhoea: the standard WHO pneumonia guidelines1
Cholera
Perform a chest radiograph after full hydration to confirm/
Dysentery e.g. shigella. exclude the diagnosis of pneumonia
Persistent diarrhoea >14 days. Note: Do not delay antibiotics during the rehydration
process in a child with suspected sepsis.
Diarrhoea with severe malnutrition
Pneumonia in children with severe acute malnutrition
Diarrhoea secondary to recent antibiotic use (SAM)
Intussusception. Severe malnutrition significantly increases the risk of death
from pneumonia. Clinical signs are relatively poor predictors
Take a careful history, including the frequency and number
of pneumonia in malnourished children, so you may fail to
of days of diarrhoea, the presence of blood, and any relevant
diagnose pneumonia if using standard WHO criteria.
infectious history. Assessment and management of dehydration
is described in Table 5. Common bacterial pathogens: S. aureus, enteric Gram
Pneumonia in children with dehydrating diarrhoea negative bacilli, particularly K. pneumoniae and E. coli;
Gram positive bacteria such as S. pneumoniae and H.
The clinical classification of pneumonia based on the diagnostic influenza
criteria according to WHO1 should be carefully evaluated in
children presenting with dehydrating diarrhoea caused by Give routine broad-spectrum antibiotics in children with
Vibrio cholerae, Enterotoxigenic E Coli (ETEC) or rotavirus. severe malnutrition.

Table 5. Recognition and management of dehydration in children
Level of dehydration Examination Management
Severe dehydration 2 of the following: WHO treatment plan C
> 10% lethargy/unconscious, Admit to hospital
sunken eyes, Rapid IV hydration* (100ml.kg-1 Ringers

lactate**)
unable to drink,
Frequent reassessment (every 15-30
skin pinch returns very slowly (2 minutes)
seconds).
Switch to ORS when able to drink
Give antibiotics if appropriate
Note: 5% dextrose is NOT effective and

must never be used for IV rehydration.
Some dehydration 2 of the following: WHO treatment plan B
5-10% restless/irritable, Give food and fluid
sunken eyes, Then as for no dehydration
thirsty,
skin pinch returns slowly.
No dehydration Not enough of the above signs WHO treatment plan A
0-4% Treat at home
Oral rehydration solution (ORS)
Advice mother when to return
Follow up in 5 days if not improved

*<12 month old: 30ml.kg-1 in first 1 hour, then 70 ml.kg-1 over next 5 hours
*>12 months old: 30ml.kg-1 in first 30mins, then 70 ml.kg-1 over next 2.5 hours
**If Ringers lactate/Hartmanns is not available, normal saline (0.9% NaCl) can be used.
Electrolyte abnormalities in children with 2.5 times greater in children with hyponatraemia compared to
gastroenteritis those with normal plasma sodium.
Sodium Hyponatraemic dehydration

Children with gastroenteritis may present with dehydration
associated with hyponatraemia (Na<135mmol.l-1) or The following signs and symptoms are suggestive of acute
hypernatraemia (Na > 150mmol.l-1); it is important to measure hyponatraemic dehydration in a child with diarrhoea:
plasma electrolytes so that these children can be managed Reduced activity
appropriately. This is a particular challenge in situations where
measurement of electrolytes is not routine. Hyponatraemia Lethargy
is more common in older children, and in patients with Hypotonia
malnutrition, whereas hypernatraemia is more common in
younger children. The case fatality rate from gastroenteritis is Convulsion and coma

History of invasive diarrhoea Give fluids IV in the following circumstances only:
Diminished deep tendon reflexes. - Circulatory collapse (hypovolaemic or septic shock)
Treatment of hyponatraemic dehydration - Persistent vomiting (3 or more episodes per hour)
Correct hyponatremia slowly to prevent osmotic demyelination
syndrome: - High purging (stool output > 15ml.kg-1.hour-1)
If serum sodium <120mmol.l-1, child asymptomatic: - Paralytic ileus
Add sodium to the diet If IV fluids are required for above conditions, give 0.9%
saline 20ml.kg-1 IV over 2 hours, then continue with ORS.
If the child needs IV fluid for other indications (such as
paralytic ileus, dehydration with persistent vomiting), give Potassium
0.9% NaCl The normal plasma potassium is 3.5-5.3mmol.l-1. The
symptoms of hypokalaemia and hyperkalemia are similar:
If serum sodium <120mmol.l-1, child symptomatic (i.e.
convulsions): Lethargy
Give 3% NaCl (12ml.kg-1 over 4 hours IV, maximum Abdominal distension with ileus
500ml)
Bradycardia.
If serum sodium < 110mmol.L , irrespective of presence or
-1
absence of symptoms: They may be distinguished by ECG morphology:

Give 3% NaCl (12ml.kg-1 over 4 hours IV, maximum Hypokalaemia
500ml)
- Narrowing QRS complex
Hypernatraemic dehydration
The following signs and symptoms are suggestive of acute - Flat T waves
hypernatraemia in children with diarrhoea:
- Prolonged ST segment
Irritability
- U waves
Excess thirst
Presentation during winter months (association with Hyperkalaemia
rotavirus diarrhoea) - Tall, peaked T wave (mild hyperkalaemia)
History of intake of several packets of ORS or of
- Prolonged PR interval
inappropriately concentrated ORS
Exaggerated deep tendon reflexes - ST segment depression
Fever. - Loss of P wave
Treatment of hypernatraemic dehydration - Widening QRS complex, gradually leading to `sine

The serum sodium concentration should be reduced slowly wave in severe hyperkalaemia, then asystole
at a rate of 0.5mmol.l-1 per hour to prevent cerebral oedema Treatment of hypokalemia
and convulsions. Estimate the fluid deficit and correct the Hypokalemia is common in children with SAM, and fluid
deficit using reduced osmolarity Oral Rehydration Solution overload a great concern if hypokalemia is treated with IV
(i.e. WHO recommended ORS, Na+ 75mmol.l-1): fluids. Oral potassium supplementation is usually adequate:
Give ORS PO to replace the fluid deficit over 24-48 Give potassium 4mmol.kg-1 per day in divided doses 8
hours hourly PO for 5 days.
If the child cannot take ORS by mouth, then rehydrate via If a child requires IV fluids for severe dehydration, or has
the nasogastric route a large stool output that cannot be managed with ORS,

- Increases potassium wasting in urine
then add potassium to IV fluids as follows:
Dialysis: If available, when other measures fail.
- If serum potassium is <2mmol.l-1, increase
potassium in IV fluids to 40 mmol.l-1
Typhoid fever
- If serum potassium is between 2 and 2.5 mmol.l , -1 Typhoid fever affects more than 21 million people globally
increase potassium in IV fluids to 30 mmol.l-1 each year. It is due to ingestion of food or water contaminated
with Salmonella typhi, and is most common in school-aged
children or young adults in areas of over-crowding with poor
Treatment of hyperkalemia
sanitation. Transmission is usually from a chronic carrier and
Check potassium not being given in IV fluids it is endemic in many low-income countries, most commonly
in Central and South-East Asia.
Rehydrate; may be sufficient to treat mild hyperkalemia
(K+<6 mmol.l-1) The WHO recommendation is to consider typhoid if a child
presents with fever lasting 7 or more days with the following
If serum K+ is >6.0mmol.l-1:
signs (and malaria has been excluded):
10% Calcium gluconate: 0.5ml to 1.0ml.kg-1 over 2 to 5
Constipation followed by diarrhoea (pea soup)
minutes IV
- Reduces cardiac toxicity Vomiting
- Protective effect within minutes, but effective only for
Abdominal pain
an hour
Salbutamol (nebulised or inhaler): 2.5 to 5mg inhaled: Headache
- Increases potassium movement into the cells by Cough.
increasing the activity of Na-K-ATPase
- Very effective, for up to 2 to 4 hours The main diagnostic features of typhoid are:
8.4% Sodium bicarbonate: 1 to 2mmol.kg-1 over 3 - 5 Fever with no obvious focus of infection
minutes IV: No features of meningitis
- Increases pH and shifts potassium into the cells
Inability to feed
- Effect begins in 5 - 15 minutes, lasts for 1 to 2 hours
- Bicarbonate causes precipitation of calcium; flush the Convulsions
IV line between drugs
Lethargy and disorientation
Insulin and glucose: dextrose 0.5 g.kg-1 IV + insulin 0.3
unit per gram of dextrose over 30 minutes. Be sure to check Persistent vomiting
a blood sugar in 30 minutes to assure the patient does not
develop hypoglycemia. Rose spots on the abdominal wall
- Use if other measures fail Hepatosplenomegaly and a distended and tender abdomen.
- E.g. for a 5.0kg child: 2.5g of glucose (25ml 10% or
10ml 25% dextrose) + 1.5 unit (5 x 0.3) insulin Complications
Mild hyponatremia and hypokalaemia are common
Calcium resonium: 1g.kg-1 PO or PR
- Binds potassium in the gut and permanently removes Enteric encephalopathy is seen in 10-30% of cases of
- Contraindicated in patients with diarrhoea, severe enteric fever, and presents with altered consciousness,
hypovolaemia or uraemia since it may precipitate disorientation, confusion and delirium, mainly in children
colonic necrosis and young adults. The case fatality from enteric
encephalopathy is high. A positive Widal test for typhoid
Furosemide: 1-2mg.kg-1 effective in only those patients fever, leucopenia, and severe dehydration are predictors of
that have renal function and native urine output encephalopathy

Perforation of an ulcer in the small bowel. The child Acute phase
presents critically unwell in the second to third week of Identify and treat problems that endanger life e.g.
untreated illness. hypoglycaemia and infection
Treatment of Salmonella typhi Initiate feeding according to standard feeding schedule

IV fluids (blood transfusion) Correct micronutrient deficiencies
Antibiotics (antibiotic resistance is common) Give broad-spectrum antibiotics
- Ciprofloxacin IV (Africa)
Vitamin and mineral supplementation
- Ceftriaxone or cefotaxime IV (Asia)
Slow rehydration using oral rehydration therapy
- Add metronidazole and gentamicin in cases of bowel
perforation Early recognition of complications
Surgery for bowel perforation; high mortality. If there Mortality is highest during this phase of management, the
is general peritonitis the child will require a laparotomy for principal causes being hypoglycaemia, hypothermia, infection,
peritoneal washout and oversewing of the typhoid and water-electrolyte imbalance.
perforation. Bowel resection may be required for multiple
perforations. A localised mass may be treated conservatively Nutritional rehabilitation phase
(as for an appendix mass)
Recover lost weight - intensive feeding.
Dexamethasone 3 mg.kg-1 loading dose then 1 mg.kg-1
per dose IV 6 hourly for 48 hours this is recommended Stimulate the child emotionally and physically
mainly for enteric encephalopathy with or without multi
drug resistant (MDR) enteric fever, and improves outcomes Train the mother to continue care at home
Exclude hypoglycaemia Follow up

Treat electrolyte abnormalities. Follow up prevents relapse of severe malnutrition, and ensures
proper physical growth and development of the child
The child with malnutrition
A number of critical problems may be seen during the acute
Malnutrition is a major independent risk factor for death in stage of treatment of malnutrition:
children in developing countries, and increases the risk of
mortality from other conditions such as septic shock, acute Hypoglycaemia
respiratory infection, diarrhoea, malaria, or measles. Children with severe malnutrition and hypoglycaemia may die
Severe Acute malnutrition (SAM) is defined by the WHO as within minutes. Test the child for hypoglycaemia on admission
a weight-for length/height < 3SD below normal, a mid-upper or whenever you find lethargy, convulsions or hypothermia.
arm circumference < 115mm, or oedema of both feet (sign of If blood glucose cannot be measured, suspect all children
kwashiorkor). with SAM to have hypoglycaemia and treat accordingly.
Hypoglycaemia can also be a sign of infection.
The cause of the high mortality among malnourished children
is unclear, but may relate to both changes in physiology and If the child is conscious and blood glucose is <3mmol.l-1
poor case management. All aspects of physiology are affected (54mg.dl-1): give 50ml of 10% glucose or 10% sucrose
including cardiovascular, GI, renal, endocrine and immune solution PO or NG (1 rounded teaspoon of sugar in 3.5
function. tablespoons water). The starter diet (F-75) is given every
30 minutes for two hours (giving one quarter of the
A standardised management protocol for severely two-hourly feed each time). Thereafter, two-hourly feeds
malnourished children has been developed in the Dhaka are continued for first 24-48 hours
hospital at the International Centre for Diarrhoeal Disease
Research, Bangladesh (ICDDR,B), which has resulted in a If the child is unconscious, lethargic or convulsing, give
47% reduction in death rates among severely malnourished 10% glucose 5ml.kg-1 IV, followed by 50ml of 10%
children. The management of diarrhoeal disease in children glucose or sucrose by NG tube. Then give the starter diet
with malnutrition is divided into three phases: F-75 as above.

Septic shock SUMMARY
Defined as weak or absent radial pulse, delayed CRT (> In summary, a basic PICU is an opportunity to focus and
3sec), cold peripheries, or hypoglycaemia concentrate resources in terms of personnel, drugs and
equipment such that the most critically unwell children have
Give fluid bolus 15ml.kg-1 IV over one hour using 5%
a better standard of medical and nursing care, are observed 24
dextrose 0.9% saline
hours a day and can have vital services available such as oxygen
Cholera saline with 5% dextrose is preferred if there to maximize their chance of survival.
is a history of watery diarrhoea (Na+133 mmol.l-1, K+
13mmol.l-1, Cl- 98mmol.l-1, acetate 48mmol.l-1) References
Repeat rescue therapy once if signs of shock remain 1. WHO pocket book of hospital care for children, 2nd edition.
Geneva, World Health Organisation, 2013. Available from
Provide broad-spectrum antibiotics: IV ceftriaxone http://www.who.int/maternal_child_adolescent/documents/
100mg.kg-1 once daily and gentamicin 5mg.kg-1.day-1 child_hospital_care/en/ (accessed 22/10/14).
in divided doses 12 hourly
2. The clinical use of oxygen. Geneva, World Health Organisation,
Supportive measures include oxygen therapy, correction of 2011 (Fig 6.1, page 38, available from http://video.rch.org.au/
hypoglycaemia, hypothermia or acidosis. cich/The_Clinical_Use_of_Oxygen_November_2011.pdf
accessed 20/01/15).
Hypothermia
3. Duke T. CPAP: a guide for clinicians in developing countries.
Wrap the child in blankets if axillary temperature is <35C Paediatr Int Child Health 34(2014): 3-11.
Place an electric lamp close to the body but sufficiently 4. Brierley J et al. Clinical practice parameters for hemodynamic
away to avoid burns support of pediatric and neonatal septic shock: 2007 update
Measure temperature every 30 minutes during re-warming from the American College of Critical Care Medicine. Crit Care
with a lamp, as the child may become hyperthermic Med. 2009 Feb;37(2):666-88. doi: 10.1097/
CCM.0b013e31819323c6.
Measure rectal temperature with a rectal thermometer;
never use an oral thermometer for this purpose 5. http://www.feast-trial.org/ (accessed 20/01/15). Now available
as: Maitland K, Kiguli S, Opoka RO et al. Mortality after fluid
Start feeding (hypothermia can co-exist with bolus in African Children with severe infection. NEJM 2011;
hypoglycaemia). 364: 2483-95

Recognising the seriously ill child
Critical Care
Laura Molyneux, Rebecca Paris and Oliver Ross*

*Correspondence Email: oliver.ross1@btinternet.com
INTRODUCTION
Each year approximately 11 million children are also included in this edition of Update in
die before reaching the age of five, 99% from Anaesthesia (pages 264 and 269).
low- and middle-income countries (LMIC).1-3
Three-quarters of deaths are from preventable or PRINCIPLES OF MANAGEMENT OF THE
treatable causes such as pneumonia, diarrhoea, SERIOUSLY ILL CHILD
SUMMARY In order to recognise the child who is unwell it
malaria, and measles. Children can become
Use the ABC approach unwell very quickly, and the outcome from cardiac is important to know the normal physiological
to assess and treat the arrest in a child is poor, so early recognition and values for different age groups, signs of critical
seriously ill child illness, and how children compensate for serious
treatment of the seriously ill child is vital. In the
Normal physiological developed world the recognition, assessment illness. It is important to be prepared to receive a
values vary by age critically ill child to your facility, to understand
and management of the seriously ill child has
If the physiological improved following the introduction of courses the principles of triage and the ABC approach
values are normal, this such as Advanced Paediatric Life Support4 to assessment and treatment.
does not always mean
the child is well
(APLS) in the UK and Paediatric Advanced Life The normal values of heart rate, respiratory rate
Support5 (PALS) in the US, and these courses and systolic blood pressure are shown in Table
Children can
compensate for serious
are now often mandatory for clinicians working 1.12
illness effectively, which with children.
may mask how unwell Physiological compensation
they are Studies have shown that that many health workers
Children can compensate effectively during the
in emergency facilities in resource-poor countries
When treating an early stages of serious illness, which may mask
unwell child, it is have no standardised assessment or treatment
how unwell they really are. Compensation refers
important to protocols for severely ill children, but that
to the ability to maintain perfusion of vital
reassess them after improved training, assessment and emergency
every intervention organs such as the brain and heart at the expense
care could improve outcomes.6,7 In response,
of non-vital organs such as skeletal muscle
the WHO has developed the Emergency Triage
and gut. When compensatory mechanisms fail,
Assessment and Treatment (ETAT) system to
decompensation occurs, which if unaddressed,
reduce childhood mortality, particularly within
rapidly leads to organ failure and death. Signs
Laura Molyneux, the first 24 hours of admission.8 This course
of compensation include increased respiratory
Specialist Registrar in has been shown to significantly improve care
rate, increased heart rate and peripheral
Anaesthesia, for children presenting with common serious
vasoconstriction causing cold extremities. Health
Leeds General Infirmary illnesses (e.g. dehydration, pneumonia and severe
workers must be vigilant to signs of compensation
malnutrition).9 Approximately 50% of children
Rebecca Paris, so that intervention and treatment can be started
who die after admission to hospital do so in the
Specialist Registrar in promptly. Signs of decompensation include
Anaesthesia, first 24 hours. ETAT+ has been developed to
10
hypotension and bradycardia, and babies may
Worcester Royal Hospital include admission care for the first 24 hours.
11
develop apnoeic episodes.
Oliver Ross
This article will focus on the assessment, Assessment of end-organ function is important
Consultant Paediatric recognition and initial management of the and can also indicate decompensation. For
Anaesthetist seriously ill child and is based on ETAT and instance, children may appear outwardly well,
Southampton University APLS principles; the topics of paediatric life but they are listless, not interested in their
Hospital support, trauma and neonatal resuscitation surroundings and tolerate examination and

Table 1. Normal heart rate, respiratory rate and blood pressure values for children
Neonate Infant Small child Adolescent
< 1 month < 2 years 2 - 5 years 5 - 12 years
Heart rate (min )-1
110-160 100-150 80-120 60-100
Resp rate (min-1) 30-40 25-35 25-30 15-20
Systolic BP (lower limit of 5-70 70-80 65 + age x2 90-120
normal, mmHg)
interventions without complaint; this can be an early sign of Box 2. Example of WETFLAG calculations for a 5-year-old child
neurological decline or fatigue. Confusion in a child is a very
worrying sign and indicates inadequate cerebral perfusion. 5-year-old child
Conscious level can be assessed quickly using the AVPU score
(Alert, responds to Voice, responds to Pain, Unconscious). Weight = (2 x 5) +8 = 18kg
Unlike adults, reduced urine output due to inadequate renal
perfusion is often a late sign in children, and therefore not Energy = 4 x 18 = 72J
useful in initial emergency care. However, if a mother reports
that the child has not passed urine, this is a serious sign. Tube = 5/4 + 4 = 5 - 5.5 - 6
PREPARATION Fluids = 20ml x 18 = 360ml of 0.9% saline

Health facilities caring for sick children must provide not only
essential drugs and equipment but also ensure competence and
ongoing training of all staff to foster excellent resuscitation Adrenaline 0.1ml.kg-1 = 1.8ml 1:10,000
team performance.
Glucose = 2ml x18 = 36ml 10% glucose
When preparing to receive a sick child to your facility, individual
roles and responsibilities of the resuscitation team members
should be clearly understood. The WETFLAG mnemonic TRIAGE AND THE ABCDE + DEFG APPROACH
(Weight, Energy, Tube, Fluids, Adrenaline, Glucose) is helpful Triage is a system to prioritise who needs to be treated first.
to prepare to receive a sick child to the hospital facility8 (see Initial triage involves categorizing children who present to
Box 1). A worked example of the WETFLAG calculations for the emergency department into three groups of urgency:
a 5-year-old child is given in Box 2, and a table of calculations emergency cases, priority cases and non-urgent cases (see Box
for children <1 year in Table 2. 3).
Box 1. WETFLAG mnemonic Emergency cases
Signs of a potential emergency case are identified from
Weight*
0-12 months = (0.5 x age (months)) + 4 conducting a rapid primary survey of any child presenting
1-5 years = (2 x age) + 8 for treatment. The child is assessed using the ABC approach
6-12 years = (3 x age) + 7 in order to identify those abnormalities that are most rapidly
(* Estimation of weight is a guide only) lethal:
Energy = 4 x weight (J) Airway. Are there signs of airway obstruction?
(Energy required for defibrillation) Breathing. Is the child having difficulty breathing? (e.g.
Tube = age/4 + 4 increased work of breathing, using accessory muscle,
(Approx. size of uncuffed tracheal tube) cyanosis, abnormal noise such as stridor, wheeze, or silent
chest.)
Fluids = 20ml.kg-1 of 0.9% saline
(Fluid bolus for shocked child) Circulation. Does the child have signs of circulatory failuree.g.
cold peripheries, a rapid, weak pulse or capillary refill time >
Adrenaline = 10mcg.kg-1 = 0.1ml.kg-1 of 1:10,000 2 seconds?
(Dose in cardiac arrest)
Disability or Dehyration. Is the child Awake, or do they
Glucose = 2ml.kg-1 10% glucose have a decreased level of consciousness (assessed quickly using
(Treatment of hypoglycaemia) the AVPU score)

Table 2. WETFLAG calculations for a child less than 1 year. Reproduced with permission. Lorazepam is included as first line treatment for
seizures.
Box 3. Triage categories
5-year-old child
Emergency cases Immediate emergency treatment

Priority cases Assessment and rapid attention
Non-urgent cases Can wait their turn in the queue
Priority cases
Exposure. Are there visible signs of trauma (e.g. fracture) or Once emergency signs are excluded, look for the conditions
disease (e.g. rash)? Is the temperature normal? (very hot or very that need to be treated as a priority. Deciding which children
cold) fit in the priority category can be difficult; in the ETAT course
this has been developed as the 3TPR-MOB mnemonic.8 The
+ Dont Ever Forget the Glucose. Does the child have
mnemonic stands for 3xT (tiny, temperature, trauma), 3xP
hypoglycaemia?
(pallor, poisoning, pain), 3xR (respiratory, restless, referral),
These emergency signs must be treated IMMEDIATELY they and malnutrition, oedema, burns (see box 4 for an explanation
are discovered, before moving on to the next step. of the 3TPR-MOB priority clinical signs).

If any of the priority signs are identified, the child must be seen Airway
quickly, blood taken for emergency investigations including There are some important features to be aware of when
glucose, malaria smear and haemoglobin (Hb), and senior assessing and managing the airway in a child (see also page 4)
help should be sought.
Nasal breathing. Infants less than 6 months old breathe
There are a few conditions such as severe malnutrition, predominantly through their nose; nasal obstruction can
anaemia or cardiac disease that must be identified as part of the result in severe respiratory distress, which may be relieved
initial triage process, as modifications in management will be by simple suction to clear the airway.
needed. For example, children with malnutrition who develop Tongue. The tongue in an infant is relatively large and may
diarrhoea are at a higher risk of death than those who are well obstruct the airway when the conscious level is impaired.
nourished, and management of children with malnutrition
must be modified.13 These special circumstances are discussed Teeth. These may be loose in children between around
below. 6-13 years of age.
Adenotonsillar hypertrophy. This is common in 3-8 year
The ABCDE + DEFG approach
olds and may cause upper airway obstruction.
The core cycle of assessment, treatment and reassessment using
Airway, Breathing, Circulation, Disability, Exposure (ABCDE) Soft palate and tonsils. These may be damaged when an
is fundamental to the safe and effective care of sick children, oropharyngeal airway is inserted; airways must be inserted
and facilitates communication between healthcare workers. with care.
For this approach to be successful, the child must be reassessed Trachea. Soft and short, and prone to external compression,
regularly, and accurate timed records kept, with results including from cricoid pressure. It is very easy to put a
communicated to all team members. tracheal tube down too far.
Large occiput with short neck in infants tends to force
the head into flexion, potentially making airway obstruction
Box 4. 3TPR-MOB priority signs when assessing the ill child worse.
(ETAT) The airway is narrow in absolute terms. A small amount
3 Ts: of airway swelling or obstruction by secretions may result
Tiny baby less than 2 months (because difficult to assess, in severe airway obstruction.
deteriorate quickly) Cricoid ring. This sub-glottic region is the narrowest part
Temperature: child very hot (high fever) of the airway in a small child (compared with the vocal cords
Trauma (including hidden head and abdominal injuries) in an adult) and is susceptible to oedema. In general,
uncuffed tracheal tubes are preferred for children < 8
3Ps:
years old; modern microcuff tracheal tubes with cuff
Pain (may indicate a severe condition)
pressure monitoring are a new alternative.
Pallor (severe anaemia)
The first question to consider when evaluating the airway is is
Poisoning (if history, may need specific urgent
treatment) the airway obstructed?
3 Rs: Observe for:

Respiratory Distress (if severe, this is an emergency) Talking or crying the airway is open
Restless: continuously irritable or lethargic (may indicate a Noisy breathing. Is this due to stertor or stridor i.e.
severe condition) partial obstruction above or below the larynx respectively
Referral: urgent referral to your facility
See-saw chest and abdominal movements respiratory
MOB: effort is present, but potentially with complete airway
Malnutrition: visible severe wasting (specific treatment obstruction.
protocols are used)
Common causes of airway obstruction are shown in Box 5.
Oedema: both feet (may indicate severe malnutrition)
If there is total airway obstruction, the airway must be opened
Burns (may cause urgent airway problem, severe respiratory immediately with simple manoeuvres: head-tilt, chin lift or jaw
distress, severe pain, be associated with large fluid losses or thrust. Airway adjuncts e.g. oropharyngeal (Guedel) or naso-
other injuries) pharyngeal airway may be required. If total airway obstruction

persists despite these simple measures, any subsequent the oropharynx as this can rapidly worsen partial airway
intervention will be determined by the specific history and obstruction. Do not attempt intravenous cannulation before
condition of the child. For example, a child with suspected the airway can be improved; causing the child added distress
inhaled foreign body might require specific interventions to may worsen the situation. Strategies to manage a child with
clear the airway. stridor are shown in Box 6.
Attempt to provide breaths whilst an assistant maintains airway- Breathing
opening manoeuvres. If unable, consider direct laryngoscopy
Look, listen and feel for effort and efficacy of breathing. There
and intubation. If unable to intubate or ventilate, proceed
are a number of signs to look for in the rapid assessment of
urgently to a surgical airway down the cant ventilate, cant
breathing, but increased respiratory rate is one of the key
intubate emergency airway algorithm (see page 116).
indicators of severe illness. Increased respiratory rate may be
Box 5. Common causes of airway obstruction in children due to a variety of causes, such as respiratory disease, sepsis
or hypovolaemia. The respiratory rate should be assessed and
Reduced level of consciousness compared to normal values for age, and the trend followed by
repeated assessment. Increasing respiratory rate is a worrying
Inhaled foreign body sudden onset, often sign and usually indicates a child that is tiring and at risk of
witnessed imminent collapse; a sudden fall in respiratory rate is a sign of
Dental abscess this collapse (it is a pre-terminal sign).
A child with respiratory disease will have to work hard to breath
Croup gradual onset, viral illness usually due to
and will tire easily. The airways are relatively narrow and are
parainfluenza virus, with characteristic barking
cough
Box 6. Initial management of stridor in a child with partial airway
Epiglottitis rapid onset, severe, bacterial illness obstruction.
usually due to Haemophilus influenzae. The child is
toxic, with sore throat, drooling, muffled voice Reassure the child; keep them close to their
and a high temperature, and often adopts a tripod parents or carer
position to maintain the airway Give high flow humidified oxygen via a mask
Tracheitis systemically unwell, bacterial illness Consider adrenaline nebuliser: 5ml of 1:1000
usually due to Staphylococcus aureus. Bacterial adrenaline with oxygen
tracheitis usually occurs as a complication of a viral
infection. Consider antibiotics (epiglottitis) or steroids
(croup)
Retropharyngeal abscess usually due to
lymphatic spread of infection from sinuses, teeth or
middle ear. The child presents with fever, sore easily obstructed by oedema or secretions. A small reduction
throat and neck pain and swelling. Stridor is not in airway diameter leads to a large increase in resistance, and
often a major feature. hence the work of breathing. In infants, respiratory mechanics
are not very efficient; the ribs are soft and horizontal and
the diaphragm is a major muscle of respiration. Abdominal
If the child has a traumatic injury, the cervical spine must be
distension is poorly tolerated. The soft ribs mean that subcostal
immobilised and the airway must be opened using a jaw thrust
and intercostal recession is relatively common in infants with
to keep the head in a neutral position.
respiratory infection, but is an ominous sign in an older child
Partial airway obstruction in whom the chest wall is relatively more rigid.
If there is partial airway obstruction, and the child is The signs to look for in assessment of breathing are shown in
unconscious, open the airway using the manoeuvres described Table 3.
above (chin lift, jaw thrust).
Increased work of breathing is a compensatory mechanism and
If there is partial obstruction and the child is conscious, may be effective in keeping oxygen delivery normal. The child
allow the child to adopt a comfortable position this will will still require support and close watching. Carbon dioxide
often be sitting up or leaning forwards. Leave the child with retention is unusual unless there is a reduced conscious level or
their parent or carer as this reduces distress; avoid inspecting lower airway obstruction.

Detecting hypoxaemia with pulse oximetry is an important Feel the pulse rate (compare to normal values for age).
measurement, especially for children with suspected
Feel pulse strength (compare the strength of central and
pneumonia. Regular monitoring of oxygen saturation can be
peripheral pulses).
used to guide effective use of oxygen, and is associated with
improved outcomes. Untreated hypoxaemia in children with Capillary refill. Ideally the child should be normothermic
pneumonia is associated with increased mortality.14,15 Note and should be viewed in good light. Press on a central area
that inability to obtain a pulse oximetry reading may be due to such as the chest for 5 seconds; the skin will blanch but
reduced perfusion of the extremities due to shock. normal colour should return within 2 seconds when the
It is important to review other systems to look for signs pressure is released. Note that vasodilatation in warm
of respiratory distress, such as an increased heart rate shock may mean that capillary refill appears to be normal,
(compensation), bradycardia (a pre-terminal sign), skin even if the child has severe sepsis. On its own, capillary
colour for cyanosis, and level of consciousness for evidence refill time is not a reliable sign of cardiovascular compromise.
of cerebral hypoxia. Exhaustion, reduced conscious level and Feel the extremities. Are the hands and feet cold compared
slow breathing or apnoea (stopping breathing) are signs of with central parts of the body? Where does the zone of
decompensation and are pre-terminal signs. warmth extend to?
If the child has compensated respiratory distress, the Blood pressure. Choose the correct size of cuff (as large
management must include the following: as fits comfortably on the arm); a normal BP does not
Sit the child up always mean all is well. Remember that hypotension is a
late sign that decompensation is occurring. As a guide, the
Give oxygen high flow via mask, humidified if possible. lowest level of normal systolic pressure is 65 + (2 x age in
The oxygen mask can be held near to the childs face if they years).
are distressed by it
Look for associated respiratory compensation (tachypnoea).
If the child has decompensated respiratory distress (reduced
breathing or apnoeic episodes, cyanosis or desaturation, Assess end-organ function: level of consciousness (AVPU
bradycardia, reduced level of consciousness), intervention to see Disability below). Confusion in a child is a worrying
support breathing should be immediate, using 100% oxygen sign.
and bag and mask ventilation in the first instance.
Signs to look out for when assessing the cardiovascular system
Circulation are shown in Table 4.
The next step is to assess circulation, assessing key elements at The management of cardiovascular insufficiency in children
the same time (this is important to correctly diagnose shock): must include:
Table 3. Assessment of breathing

Signs of increased effort i.e. increased work of breathing Signs of efficacy of breathing i.e. is the respiratory
effort effective?
Respiratory rate (compare to normal values) Colour - look for central cyanosis
Body position - sitting forward or adopting tripod position Oxygen saturation
Recession - intercostal, subcostal and or sternal Breath sounds (a silent chest is a pre-terminal sign)
Tracheal tug Chest expansion
Grunting Conscious level. Reduction on conscious level is a late

sign.
Wheeze
Use of accessory muscles (e.g. sternocleidomastoid in the neck)
Nostril flaring
Head bobbing

Table 4. Indicators of cardiovascular insufficiency or shock
Severe but compensated shock Decompensated shock pre-terminal
Mottled, cold skin Hypotension
Tachycardia Bradycardia
Weak peripheral pulses Unconscious
Cold peripheries to knees or elbows
Prolonged capillary refill (>2 seconds)
Increased respiratory rate
Oxygen high flow via face mask excluded. The main finding was that children given a fluid
bolus of 20-40 ml.kg-1 0.9% saline or 5% albumin did worse,
Stop any bleeding
with an increased risk of mortality compared to the control
IV access intravenous or intraosseous group who received maintenance fluids only.16
Fluids - oral, nasogastric or intravenous. This was a well-conducted study and has provoked much
Intravenous access can be difficult in children with shock. An debate.17-21 The children were severely unwell by any measure,
intraosseous needle is an effective method of fluid and drug but there were no intensive care facilities in the study
administration and should be considered early if intravenous hospitals. Many children had malaria and were anaemic, but
access is difficult. (See article, page 240) the detrimental effects of fluid bolus were still seen in those
without malaria and those without severe anaemia. The
Traditional fluid management for a child in shock has been to children appeared to die from cardiovascular collapse (rather
give a fluid bolus of 10-20ml.kg-1 0.9% saline or Ringers lactate, than fluid overload), within 24-48 hours of treatment.20 Excess
followed by reassessment. However, intravenous fluid therapy mortality associated with fluid bolus was still seen in a smaller
for children in resource-poor settings has been addressed in group of children who met the more strict WHO criteria for
an important new study, the Fluid Expansion as Supportive sepsis (i.e. capillary refill time > 3 secs, cold peripheries, a weak
Treatment (FEAST) study, published in the New England pulse, and a fast pulse).21 The implications of the FEAST study
Journal of Medicine in 2011. This is a randomised controlled are that children with febrile illness and shock in Africa should
study of over 3000 children in six hospitals in Uganda, Kenya receive maintenance fluids only (Ringers lactate 5% dextrose
and Tanzania, comparing fluid resuscitation starting with a or 0.9% saline 5% dextrose), and aggressive resuscitation with
bolus of fluid to just starting maintenance fluids without a boluses of 0.9% saline or albumin should be avoided. From a
bolus, in children with fever and shock. Shock was defined pragmatic point of view, this would appear to be a safer course
as signs of impaired perfusion plus impaired consciousness of action in hospitals with low numbers of nursing staff and
or respiratory distress, or both. Children with gastroenteritis, without burettes to accurately measure fluid volumes, and no
severe malnutrition, burns or surgical conditions were backup intensive care facilities.
Figure 1. Intraosseous needle Disability: neurological assessment
Make a quick assessment of neurological function. This is
essential to assess end-organ function. If the child is alert,
this indicates that there is adequate cardio-respiratory
compensation; a child with decompensated cardiorespiratory
failure will have a depressed conscious level. Depressed
conscious level or confusion may also be due to a primary
cerebral cause (trauma or cerebral infection).
The three quick assessments are:
Pupils (size and reactivity to light) always compare left
and right
Posture

Conscious level assessed using the AVPU system: Breathing. Increased intracranial pressure may present as
hyperventilation, Cheynes Stokes respiration or apnoea
A Alert
Circulation. Bradycardia + hypertension = Cushings
V responds to Voice
response, a pre-terminal sign of elevated intracranial
P only responds to Painful stimuli pressure
U Unresponsive to painful stimuli.
Dehydration
AVPU is a quick reliable method of assessing conscious level Once shock has been treated (if present), make an assessment
without using an age-specific Glasgow or Blantyre coma scale.15 of fluid deficit in order to calculate the fluid requirements of
In general, a child responding to pain (P) or unresponsive (U) the child over the next 24 hours:
corresponds to a GCS of 8 or below and will likely need airway
support. Total fluid requirement = degree of dehydration +
maintenance fluid + ongoing loss
Exposure
Check for rashes, burns and bruises or other injuries
A guide to assessing dehydration in children is provided in
Check temperature. Table 5, and a case example putting everything together is
shown in Box 7.
Glucose
Dont Ever Forget Glucose (DEFG) is the final part of the Special circumstances
disability assessment, especially in children with a reduced Cardiac disease
conscious level. Aim for a blood glucose of >2.5mmol in a well
nourished child, >3mmol in a malnourished child. It is important, particularly in newborns, to consider cardiac
disease as a cause for cardiovascular insufficiency and shock.
Treat hypoglycaemia with 10% dextrose Signs to look for include:
2 ml.kg-1 IV, or with oral glucose Cyanosis not correcting with oxygen. Ideally all newborn
infants should be screened for cyanotic heart disease using
pulse oximetry
Review other systems for signs of neurological failure:
Tachycardia
Airway. Reduced conscious level will eventually lead to
airway obstruction Raised jugular venous pressure
Table 5. Clinical assessment of dehydration in children
Clinical sign Mild Moderate Severe

Weight loss Less than 5% 5-10% Greater than 10%
Total fluid deficit Less than 50 ml.kg-1
50-100 ml.kg -1
>100 ml.kg-1
General appearance Alert Irritable, thirsty Lethargic, drinks poorly
Mucous membranes Normal Dry Dry
Eyes Normal Normal Sunken
Respiration Normal Fast Fast
Pulse Normal Fast Fast, weak
Blood pressure Normal Normal Low
Pinched skin* Springs back Slow skin fold present less Very slow skin fold greater
than 2 seconds than 2 seconds
(Pinch skin between thumb
and forefinger on abdomen or
thigh)

Box 7. Putting it all together - case example
A 5-year-old girl is brought to the emergency department with

Triage look for emergency signs
diarrhoea and a poor appetite. She is lethargic and refusing
water. She has a respiratory rate of 40 and a weak femoral She has a clear airway but has rapid breathing, fast
pulse with a rate of 140bpm. Her blood pressure is 100mmHg pulse and has dehydration with lethargy. This child
systolic. How would you assess and manage this child? must be treated immediately with:
Preparation. Ensure the team and equipment are prepared to Breathing high flow oxygen via face mask and sit
receive the child remember WETFLAG: upright
Circulation and Dehydration If possible give

5 year-old child... oral fluids, however with a lethargic child it may
Weight = (2x5) + 8 =18 be necessary to consider an intravenous fluid bolus
Energy = 4x18 = 72J 20 ml.kg-1 0.9% saline if there are signs of shock
in association with a surgical diagnosis or acute
Tube = 5/4 + 4.5 = 5.5-6.0 dehydration from gastroenteritis.
Fluids = 20 ml.kg-1 = 360ml 0.9% saline*
Adrenaline = 0.1ml.kg-11:10,000 = 1.8ml Check blood for glucose, malaria and Hb
Glucose = 2x18 = 18ml 10% dextrose
Assess and treat ABCD + DEFG
Move on to a full ABC assessment. Her airway is clear and maintained unaided. For assessment of breathing look at effort
and efficacy (see Table 2). She has a respiratory rate of 40 breaths per minute, indicating an increased effort of breathing.
She is not using accessory muscles. She has good air entry on auscultation with SpO2 99% in room air, demonstrating good
efficacy despite increased effort. We have already started oxygen via facemask and sat her upright as part of our emergency
management. This is sufficient treatment for breathing.
As A+B are now stable, move on to circulation. Her pulse rate is fast and thready. She is in the compensated phase of shock
- her blood pressure is normal for her age and she remains conscious. She has acute dehydration and is refusing oral fluids.
There are no signs of cardiac disease, such as cyanosis or liver enlargement or malnutrition. She should receive an IV fluid
bolus 20ml.kg-1. After IV fluids her heart rate reduces to 110bpm.
To calculate her ongoing fluid requirement, first calculate her level of dehydration (Table 4). She is lethargic with a raised
respiratory rate and tachycardia. She has at least a 10% deficit with clinical signs of hypovolaemia. She is too unwell for
oral rehydration. Her fluid requirements for the next 24 hours are: (Total fluid requirement = degree of dehydration +
maintenance fluid + ongoing loss)
10% deficit (100ml.kg-1) in an 18kg child = 1800ml

Replace 50% over 8 hours = 900ml
Replace the remaining volume over the next 16 hours = 900ml
Maintenance = 100ml.kg-1 for first 10kg (100x10) + 50ml.kg-1 for next 10kg (50x8) = 1400ml
i.e. IV fluids for first 8 hours = 900ml replacement + 466ml maintenance.
For next 8-24 hours = 900ml replacement + 933ml maintenance.
Give as Ringers lactate 5% dextrose
We can move on to assess Disability. Using the AVPU assessment tool she is responding to voice and is only lethargic. This
is still an important sign and must be reassessed during and after treatment. A blood glucose is taken and is within normal
limits.
After so many interventions it is important to reassess her and treat any abnormal signs before she is transferred to a
paediatric ward for ongoing fluid resuscitation and investigation.

Gallop rhythm/murmur Box 8. Fluid resuscitation for a child with malnutrition and shock
due to acute dehydration from gastroenteritis
Enlarged liver
Absent femoral pulses. Slow IV fluid bolus = 15ml.kg-1 Ringers lactate with
Fluids must be given cautiously. This topic is covered in more 5% dextrose over 1 hour
detail on page 81. Reassess
Malnutrition Oral rehydration with low sodium (ReSoMAL) oral
Malnutrition is a contributing factor in approximately one rehydration solution
third of child deaths, making children more susceptible to
severe disease.15 It is vital that malnutrition is identified in
seriously ill children as specific management strategies must Measles
be adopted. Despite an effective vaccine against the virus, more than 20
million people are affected by measles every year, predominantly
The child with serious malnutrition undergoes metabolic and
in parts of Africa and Asia. The majority of deaths occur in
physiological changes to conserve energy and preserve essential
low-income countries and in children who are malnourished,
processes.22 If these changes are not acknowledged when
particularly with vitamin A deficiency.25
initiating treatment, the child will be at increased risk of death
from heart failure, electrolyte imbalance, hypoglycaemia, Children with measles present with symptoms which usually
hypothermia and they may have untreated infection. Mortality appear 1012 days after infection, including a fever, runny
rates of up to 60% are seen in the most severe group.23 nose and white spots on the inside of the mouth. Several days
later a rash appears, starting on the face and neck, gradually
Signs of malnutrition include:
spreading downwards.
Severe wasting
The most serious complications of measles include blindness,
Oedema in feet encephalitis (an infection that causes brain swelling), severe
Underweight for age. diarrhoea with dehydration, and severe respiratory infections
such as pneumonia.
The WHO has produced guidelines for the management
of severe malnutrition, which outlines key steps for initial Measles is caused by a virus for which there is no specific
management24: treatment. Children should be assessed using the ETAT triage
tool followed by a thorough ABC assessment, with particular
The child should be fed every 23 hours, day and night, to attention to assessment of nutritional status and dehydration,
prevent hypoglycaemia and hypothermia and treated symptomatically with supportive therapy.
Keep the child warm
Malaria
Rehydrate with low sodium fluids; monitor closely for signs Malaria is one of the five main causes of death in children
of fluid overload; avoid intravenous fluids, except in shock under 5 years, with symptoms appearing 7-15 days after
Give 100kcal.kg-1.day-1 and 1g protein.kg-1.day-1 the infective mosquito bite. It typically presents with non-
specific symptoms such as fever, headache and vomiting.26
Give potassium and magnesium to correct electrolyte It is frequently over-diagnosed and over-treated, yet it is
imbalance; restrict sodium also often treated sub-optimally with incorrect doses of anti-
Give micronutrient supplements; do not give iron malarial medication prescribed.27-32 Over-diagnosis of malaria
may result in failure to treat other potential causes of febrile
Give broad spectrum antibiotics even when clinical signs illness.33 Bedside testing is now available in many countries for
are absent as infections can be silent. malaria parasites.
Critically, children with severe malnutrition must not be Children with malaria commonly present with:
aggressively resuscitated with IV fluids as this may lead to
heart failure. Intravenous fluids should not be given unless the High temperature
child is lethargic or unconscious and shocked. When restarting Shock
feeding malnutrition protocols should be used. A suggested
regimen for fluid resuscitation for a child with malnutrition Severe anaemia
and acute dehydration is shown in box 8. Hypoglycaemia

Jaundice. 6. World Health Organization, Division of Child Health and
Development. Hospital study of the referral care project. Final
In severe cases of cerebral malaria they may also present with: Report, February 1998.
Convulsions 7. Nolan T, Angos P, Cunha A et al. Quality of hospital care for
Coma. seriously ill children in less-developed countries. Lancet 2001;
357: 106-10.
The assessment and management of malaria should follow
8. World Health Organization. Emergency Triage and Assessment
ETAT guidelines, with identification and treatment of
(ETAT) Course. http://www.who.int/maternal_child_
emergency signs followed by a thorough ABC assessment. adolescent/documents/9241546875/en/ (accessed 4th
Important additional points to remember for suspected October 2014).
malaria are:
9. Irimu G et al. Performance of Health Workers in the Management
Treat hypoglycaemia of Seriously Sick Children at a Kenyan Tertiary Hospital: Before
and after a Training Intervention. PLoS One 2012; 7: e39964.
Assess conscious level and consider lumbar puncture to
rule out meningitis 10. Molyneux E. Paediatric emergency care in developing
countries. Lancet 2001; 357: 867.
Do an early blood film to establish diagnosis
11. English M, Wamae A, Nyamai R, Bevins B, Irimu G. Implementing
Treat using local anti-malarial guidelines ensuring accurate locally appropriate guidelines and training to improve care of
dosing serious illness in Kenyan hospitals: a story of scaling-up (and
down and left and right). Arch Dis Child 2011; 96: 28590.
Consider broad spectrum antibiotics if there is some doubt
as to the diagnosis 12. Fleming S et al. Normal ranges of heart rate and respiratory rate
in children from birth to 18 years of age: a systematic review of
Give cautious fluids if there is impaired perfusion or shock, observational studies. Lancet 2011; 377: 1011-18.
especially if there is anaemia or cerebral impairment.
13.
World Health Organisation. Management of severe
CONCLUSION malnutrition: a manual for physicians and other senior health
workers. Geneva: WHO, 1999.
In this article we have looked at the initial assessment and
14. Molyneux ME, Taylor TE, Wirima JJ, Borgstein A. Clinical features
management of the seriously ill child. Key points to consider
and prognostic indicators in paediatric cerebral malaria: a study
are rapid initial assessment and triage using the ETAT criteria of 131 comatose Malawian children. Q J Med 1989; 71: 441-59.
followed by treatment of emergency signs. This must then be
followed by a thorough review using the ABCDE + DEFG 15. World Health Organization. Children: reducing mortality.
http://www.who.int/mediacentre/factsheets/fs178/en/index.
approach, commencement of appropriate treatment with
html (accessed 4th Oct 2014).
frequent reassessment of ABCDE +DEFG. This system
will ensure effective and accurate initial management for all 16. Maitland K, Kiguli S, Opopka RO et al. Mortality after fluid bolus
seriously ill children. in African children with severe infection. NEJM 2011; 364:
2483-95.
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1. Murray C, Lopez A. The global burden of disease: comprehensive will cause harm: response to mortality after fluid bolus in
assessment of mortality and disability from diseases, injuries African children with severe infection. Arch Dis Child 2011; 96:
and risk factors in 1990 and projected to 2020. Geneva: WHO, 9056.
1996.
18. Duke T. What the African fluid-bolus trial means. Lancet 2011;
2. UNICEF. The state of the worlds children 1998. New York:
387: 1685-87.
Oxford University Press, 1998.
3. World Health Organisation. Global Health Observatory http:// 19. Myburgh J1, Finfer S. Causes of death after fluid bolus
www.who.int/maternal_child_adolescent/epidemiology/ resuscitation: new insights from FEAST. BMC Med. 2013 Mar 14;
child/en/index.html (accessed 3rd October 2014). 11: 67
4. Advanced Life Support Group. Advanced paediatric life 20. Maitland K, George EC, Evans JA et al. Exploring mechanisms
supportthe practical approach, 2nd ed. London: BMJ of excess mortality with early fluid resuscitation: insights from
Publishing Group, 1997. the FEAST trial. BMC Med. 2013; 11: v68.
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Association. Textbook of pediatric advanced life support. resuscitation in children: missing the FEAST data. BMJ 2014;
AHA1994 revision. 348: f7003 doi: 10.1136/bmj.f7003 (Published 14 January 2014)

22. Jackson AA. Severe malnutrition. In: Warrell DA, Cox TM, Firth 28. Rowe AK, Hamel MJ, Flanders WD, Doutizanga R, Ndoyo MS.
JD, Benz EJ, eds. Oxford textbook of medicine, 4th edn, vol 1. Predictors of correct treatment of children with fever seen at
Oxford: Oxford University Press, 2003. 10541061. outpatient health facilities in the Central African Republic. Am
J Epidemiol 2000; 151: 1029-35.
23. Schofield C, Ashworth A. Why have mortality rates for severe 29. Rowe AK, Onikpo F, Lama M, Deming MS. Risk and protective
malnutrition remained so high? Bull World Health Organ 1996. factors for two types of error in the treatment of children with
74: 223229.229 fever at outpatient health facilities in Benin. Int J Epidemiol
2003; 32: 296-303.
24. World Health Organization. Management of the child with a
30. Zurovac D, Rowe AK, Ochola SA et al. Predictors of the quality
serious infection or malnutrition. Guidelines for care at the
of health worker treatment practices for uncomplicated
first-referral level in developing countries. Geneva: WHO, 2000
malaria at government health facilities in Kenya. Int J Epidemiol
http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.1.pdf
2004; 33: 1080-1091.
(accessed 4th October 2014).
31. Osterholt DM, Rowe AK, Hamel MJ et al. Predictors of treatment
25. World Health Organization. Measles. http://www.who.int/ error for children with uncomplicated malaria seen as
immunization/topics/measles/en/index.html (accessed 3rd outpatients in Blantyre district, Malawi. Trop Med Int Health
October 2014). 2006; 11: 1147-56.
26. World Health Organization. Malaria http://www.who.int/ 32. Nshakira N, Kristensen M, Ssali F et al. Appropriate treatment
immunization/topics/malaria/en/ (accessed 3rd October of malaria? Use of antimalarial drugs for childrens fevers in
2014). district medical units, drug shops and homes in eastern
Uganda. Trop Med Int Health 2002; 7: 309-316.
27. Amexo M, Tolhurst R, Barnish G, Bates I. Malaria misdiagnosis: 33. Reyburn H, Mbatia R, Drakeley C et al. Overdiagnosis of malaria
effects on the poor and vulnerable. Lancet; 2004; b364: in patients with severe febrile illness in Tanzania: a prospective
1896-98. study. BMJ. 2004; 329: 1212.

Meningococcal disease in children
Reprinted with revisions from Law R. Meningococcal disease in children. Update in Anaesthesia (2007) 22:
26-30.
Critical Care
Rob Law* and Carey Francombe

*Correspondence email: Robert.Law@rsh.nhs.uk
Case history 1
A three-year-old girl presents to her doctor with fever, lethargy and a rash. The rash is initially
petechial but spreads rapidly. The doctor makes a presumptive diagnosis of meningococcal
disease and gives her intramuscular penicillin and refers her to hospital by ambulance. On arrival
she is confused, shocked and has widespread purpura. She receives appropriate resuscitation and
Summary emergency treatment in the emergency department and is transferred to the Intensive Care Unit.
Meningococci are seen on microscopy of a skin scraping of a purpuric area. She develops multiple
Both meningitis and organ failure and requires inotropes and ventilation. Three fingers on her left hand become necrotic
meningococcal septicaemia and require amputation. After 5 days she has recovered sufficiently to leave ICU.
can present with non-
specific initial signs and Case history 2
symptoms but progress
rapidly. Prompt diagnosis A fifteen-year-old boy presents to hospital with fever, vomiting and lethargy. He has no neck-stiffness,
and treatment are vital. photophobia or rash and is admitted with a diagnosis of a viral infection. Over the next few hours
Mortality of those reaching he becomes irritable and drowsy. After a blood culture is taken, he is started on ceftriaxone and
hospital remains 5-10% with intravenous fluids. His level of consciousness continues to decline and he has a seizure on the ward.
a further 10% long term He is admitted to Intensive Care where he is ventilated but he later dies from raised intracranial
morbidity.
pressure.
These two cases represent the opposite ends of the cases/100 000 population/year. In sub-Saharan Africa
spectrum of meningococcal disease. The first case (the meningitis belt) epidemics occur every 5-10
is an example of meningococcal septicaemia whilst years with rates of 500 cases/100 000 population/
case 2 is an example of meningococcal meningitis. A year. In the UK serogroups B and C, and worldwide
mixed picture is also very common. It is vital that serogroups A, B and C, are responsible for the majority
all doctors that may treat sick children have a good of cases. Serogroup W-135 has been particularly
understanding of how to diagnose and treat this associated with pilgrims attending the Haj religious
condition, as it occurs worldwide and is currently festival in Saudia Arabia. The disease is characterised
the leading infective cause of death in children in the by local clusters or outbreaks and there is a winter
developed world. predominance in the UK. Nasopharyngeal carriage of
the organism occurs in about 10% of the population.
MICROBIOLOGY Most of these strains are non-pathogenic. The factors
Neisseria meningitidis (meningococcus) is a capsulated associated with pathogenicity are not well understood
gram-negative diplococcus. There are more than ten at present. Risk factors include:
serogroups based on the polysaccharide that makes up
their capsule. The commonest serogroups are A, B, Age (<1 year of age)
C, Y and W-135. They can be further serotyped and Overcrowding
subtyped based on proteins in the outer membrane of
the bacterium. More complex techniques of enzyme Poverty
electrophoresis and DNA typing allow the accurate Smoking
Robert Law identification of individual strains of individual
Shrewsbury meningococci to be determined. This is important Complement deficiency.
UK public health information.
Although the relative risk of developing meningococcal
Carey Francombe EPIDEMIOLOGY disease following exposure to a case is high (500-1000
Shrewsbury The disease occurs worldwide but the incidence times the background rate in the population), only
UK varies greatly. In the UK the incidence is about 5 about 1 in 200 contacts will develop the disease.

The epidemiology of this disease may change due to vaccines being Endothelial changes cause capillary leak (leakage of fluid into the
developed. Purified polysaccharide vaccines have been developed interstitial space and hypovolaemia) and pathological vasospasm
against serogroups A, C, Y and W-135, but they are poorly and vasodilatation.
immunogenic in young children and the immunity is short lived.
Intravascular thrombosis causes organ ischaemia and
This is because the immunological response is T-cell independent.
consumptive coagulopathy.
These vaccines may be useful for controlling outbreaks and
epidemics, but are not suitable for use as part of a primary vaccination Generalised endothelial injury activates procoagulant pathways.
program. A conjugated group C vaccine has been developed where
Anticoagulant pathways (protein-C and fibrinolytic) are down-
the polysaccharide antigen is conjugated to a carrier protein. The
regulated.
immunological response to this is T-cell dependent, which overcomes
the problems associated with the purified vaccines and makes it Multiple organ failure is caused by cytokine production and by
suitable for primary immunisation. In the UK all children receive ischaemia due to intravascular thrombosis and shock.
conjugated meningococcal C vaccine at 3, 4 and 12 months of age. Cardiac dysfunction is often an important feature of septic shock
A conjugated group A vaccine has recently been developed and was due to meningococci.
introduced into African countries in December 2010, with the aim
of introducing it into all 25 countries in the African belt by 2016. It CLINICAL FEATURES
as already led to a decrease in the number of confirmed cases in these Patients who present early may have very non-specific symptoms
countries. Group B polysaccharide appears not to be immunogenic. and signs. The disease may progress very rapidly, so a high index
of suspicion needs to be maintained if the diagnosis is to be made
PATHOPHYSIOLOGY
early enough for treatment to be effective. The classical feature of the
Development of the disease involves:
disease is a petechial or purpuric rash (purple rash, which does not
Colonisation of the nasopharynx fade on pressure), but up to 20% of cases may have no rash or an
atypical maculopapular rash. Other infections rarely can produce a
Invasion
similar rash and septicaemia.
Multiplication.
Symptoms of meningitis include:
Both innate and acquired immune mechanisms are responsible for
Headache
host protection. The resultant disease process may be focal infection
(normally meningitis), septicaemia or both. About 60% of cases in Fever
Europe have evidence of meningitis and septicaemia, while about Vomiting
20% have meningitis only and 20% septicaemia only. Endotoxin
and other bacterial factors cause a host response that results in Photophobia
much of the damage. This pattern of events is shown in Figure 1. In Lethargy or confusion
meningococcal septicaemic shock,
Figure 1. Pathophysiology of meningococcal disease
ENDOTOXIN Endotoxin + EBP Compliment activation
Neutrophil activation
Monocytes/macrophages
Proteases
Cytotokines Tissue factor

ENDOTHELIAL CHANGES
ORGAN DYSFUNCTION INTRAVENOUS THROMBOSIS
EBP = Endotoxin binding protein

Some patients present with seizures. GCS <13
Neck stiffness, neurological signs and signs of raised intracranial Focal neurological signs
pressure should be sought on examination. In infants, particularly,
the features can be very non-specific; they frequently present with Raised intracranial pressure
only: Recent or prolonged seizures
Irritability
Cardiorespiratory compromise
Refusal to eat
Coagulopathy
Drowsiness
Infection at the site.
Fever.
If a positive microbiological diagnosis can be made from a skin
Death is usually caused by refractory raised intracranial pressure. scraping, LP is unnecessary. However LP may be useful for the
Septicaemia is characterised by: following reasons:
Fever Gram stain is frequently diagnostic and thus allows a definite

diagnosis to be made early.
Rash
It will detect resistance - in some areas pneumococci are resistant
Vomiting to penicillin and cephalosporins.
Headache
Will identify unusual pathogens and allow a positive diagnosis of
Myalgia (muscle pains) viral meningitis to be made (enteroviral meningitis can be
diagnosed on PCR allowing hospital discharge on no antibiotics).
Abdominal pain
Allows public health monitoring of the aetiology of meningitis.
Tachycardia
Allows appropriate prophylaxis to be given to contacts.
Cool peripheries
Hypotension. Makes it possible to investigate vaccine failures.
Typically the rash spreads rapidly and can lead to widespread necrosis Unless contra-indication exists, patients with suspected meningitis
and gangrene of skin and underlying tissues. The rash is a visible should have a lumbar puncture, but it should be done promptly and
sign of the endothelial changes and coagulopathy, which is occurring should not delay giving the antibiotics by more than thirty minutes.
throughout the body. Death due to septic shock will ensue rapidly if CT scanning is of no benefit in making the diagnosis of meningitis or
these patients are not resuscitated promptly. in determining whether the intracranial pressure is raised in patients
with known meningitis. It should only be used to exclude other
DIAGNOSIS causes for focal neurological signs or to investigate complications of
Because of the need for immediate treatment once the disease meningitis.
is suspected, laboratory tests are not of use in making the initial
diagnosis. They may also offer false reassurance since in fulminant TREATMENT
infections the white cell count, C-reactive protein and lumbar
puncture may all be normal early in the disease. The initial Initial assessment and resuscitation
diagnosis is based on clinical history and examination. Following Early recognition and prompt treatment is vital. If the diagnosis
the institution of treatment, the diagnosis can be confirmed later is suspected in the primary care setting the patient should receive
by microbiological culture (blood, CSF or skin), antigen detection intramuscular penicillin or a cephalosporin, if available, and be
(PCR, latex agglutination test) or serology. Blood cultures and CSF referred immediately to hospital. In hospital, assessment and
cultures are more likely to be positive if taken before antibiotics are resuscitation of vital functions should occur together, with
given. problems treated as they are found. Priorities are:
There have been a number of reports suggesting that major morbidity 1. Maintaining a patent airway. Patients with a decreased level of
(particularly death following cerebral herniation) was caused by consciousness due to meningitis or shock may need assistance in
performing lumbar punctures (LP) in patients with meningitis. maintaining their airway.
Cephalosporins are effective in treating all the common causes of
2. Supporting ventilation as necessary.
bacterial meningitis. There has thus been a trend not to perform LP
in these patients. Some experts believe that too few lumbar punctures All patients should receive a high concentration of inspired
are done and this remains a controversial area.1 Contra-indications to oxygen Ventilatory drive may be impaired due to raised
lumbar puncture are: intracranial pressure.

Hypoxia is common due to the capillary leak associated with It may be difficult to distinguish the central nervous system effects of
shock (acute lung injury). shock (caused by decreased cerebral perfusion) from those of raised
intracranial pressure, especially since raised intracranial pressure can
Intubation and ventilation may be required soon after the sometimes be associated with abnormal vasoconstriction. Patients
patient reaches hospital. with raised intracranial pressure require treatment to optimise
3. Circulation cerebral perfusion. Protect their airway by intubation and control
their breathing by mechanical ventilation to a normal PaCO2. Treat
Shock is recognised by the presence of an increased heart rate and shock aggressively if present.
respiratory rate for age, a prolonged capillary refill time and cool
skin and peripheries Patients with isolated meningitis (i.e. no shock) should receive
dexamethasone (0.4mg.kg-1 BD for 2 days) either with or before
Reduced end organ perfusion will cause a metabolic acidosis the first dose of antibiotic (see later).2 Mannitol and frusemide may
(Kussmaul breathing), oliguria (not a sign that can be elicited be used if the intracranial pressure is raised. The patient should be
immediately) and a decreased level of consciousness examined for the typical rash but this may not always be present.
Hypotension is often a very late clinical sign Antibiotic therapy
Treatment of shock requires: A third generation cephalosporin is the drug of choice for suspected
meningococcal disease and should be given intravenously for 7 days.
Stabilisation of the airway and breathing. Cefotaxime 50mg.kg-1 4 times a day or ceftriaxone 80mg.kg-1 as a
single daily dose are appropriate. Advantages of these agents over
Intravenous or intraosseous access.
penicillin are:
Replacement of circulating blood volume. Give 20ml.kg-1
Broader spectrum (covering the other common causes of bacterial
boluses of resuscitation fluid (crystalloid or colloid) and
meningitis)
assess the response. As soon as intravenous access is
obtained, take blood for culture, biochemical (including Activity against meningococci that are less sensitive to penicillin
glucose) and haematological tests, and give antibiotics (see (due to a different penicillin binding protein) or resistant to
later). penicillin (rarely meningococci can produce B-lactamases)
Large volumes of fluid may be required, frequently 60ml.kg-1 in Better CSF penetration
the first hour. The increased vascular permeability that is
associated with septic shock means that fluid will continue Less CNS toxicity (especially important if renal failure is present)
to extravasate and these patients may become very They eliminate carriage of the organism, which penicillin does
oedematous. If more than 40ml.kg-1 of resuscitation not do.3
fluid is required initially, consider intubation and ventilation
since pulmonary oedema is likely to develop. Use a tidal Ongoing treatment and Intensive Care
volume of 6-7ml.kg-1 and add positive end-expiratory The initial priority of management is the identification and treatment
pressure (PEEP). of immediately life threatening problems. These problems (e.g.
airway obstruction or shock) should be treated as they are detected,
4. Determine whether major neurological compromise exists: even if the cause for them is not immediately obvious. After the
Rapid assessment of level of consciousness (AVPU - alert, resuscitation has commenced, a focussed medical history, fuller
responds to voice, responds only to pain or unresponsive). examination and the results of special investigations will either
confirm the initial diagnosis of meningococcal disease, or allow a
Examination of the pupils. differential diagnosis to be made which will determine what further
treatment is required.
Observation for seizures or abnormal posturing.
Other complications that may need treatment include:
Patients with meningitis rather than septicaemia may develop raised
intracranial pressure. Look for: Hypoglycaemia. This is particularly common, causes major
morbidity if unrecognised, and is easy to treat. Determine the
Fluctuating or decreasing level of consciousness
blood glucose when intravenous access is first obtained
Unequal, dilated or poorly reacting pupils
Hypokalaemia
Focal neurological signs
Hypomagnesaemia
Abnormal posturing
Seizures Hypocalcaema
Hypertension accompanied by tachycardia or bradycardia Anaemia
Papilloedema is sometimes seen. Coagulopathy.

Many of these patients will require ongoing intensive care. Patients treatment (1mg.kg-1 6 hourly IV) decreases 28 day mortality.6 In
who remain hypotensive following intravenous fluid resuscitation paediatric septic shock adrenal insufficiency has been shown to be
need vasoactive drug administration to counter ventricular associated with an increased vasopressor requirement and duration
dysfunction and vasodilation. A central venous line should be of shock. Also, in paediatric meningococcal septicaemia a low serum
inserted as a route for inotropic/vasopressor agents, although their cortisol and a high ACTH has been shown to be associated with
use as a guide for fluid therapy is limited. In very young children severe disease or death. As a result, many paediatric intensivists give
a femoral line may be inserted as it is associated with less morbidity hydrocortisone in a replacement dose (1mg.kg-1 6 hourly) to patients
than jugular or subclavian lines. Where available an arterial line will with meningococcal septicaemia either on the basis of an ACTH
be required for cardiovascular monitoring and to facilitate blood stimulation test or to all those that have shock requiring high dose
sampling. Ventilated patients should have a nasogastric tube and inotropic support. If the patient is already receiving dexamethasone,
urinary catheter inserted. further steroid supplementation is not required.
The use of inotropes/vasopressors should be guided by clinical Coagulopathy
assessment and markers of global metabolic status: Deranged clotting is commonly seen as part of the septic process and
blood products are often required to correct this.
Clinical signs
Arterial blood pH OUTCOME

The mortality of all patients admitted to hospital is about 5-10%, but
Blood lactate the mortality of those admitted to intensive care varies from 5-35%.
The mortality is greater in those patients who have septicaemia.
Base deficit
Approximately 10% of patients will have long term morbidity due
Mixed venous oxygen saturation.4 to neurological complications (especially deafness) or amputations.
Long-term problems related to renal or myocardial function are less
Choice of vasoactive drug should be guided by the clinical picture common.
(warm shock and low BP, cold shock with low BP, or cold shock
with normal BP) and titrated to achieve an acceptable cardiac SECONDARY PREVENTION
output and systemic vascular resistance. The haemodynamic picture Patients remain infectious for 24 hours after receiving a cephalosporin
can change frequently during the first 48 hours and high doses and should be isolated during this period. Household contacts
of drugs may need to be given due to receptor down-regulation. and carers exposed to oropharyngeal secretions should receive
Dopamine, epinephrine, norepinephrine, vasopressin and various chemoprophylaxis:
vasodilators may all have a place in managing the haemodynamic
Ciprofloxacin as a single oral dose (>12 years 500mg, 5-12 years
changes associated with this condition. Children with septic shock,
250mg, <5 years 30mg.kg-1 up to 125mg); or
particularly those with meningococcal disease, often die with a high
systemic vascular resistance and low cardiac output (compared to Rifampicin twice daily for 2 days (> 12 years 600mg, 1-12 years
adults that tend to have a low systemic vascular resistance that is 10mg.kg-1, < 12 months 5mg.kg-1); or
refractory to therapy). This makes dopamine an appropriate first line
agent. High dose epinephrine or norepinephrine are usually required A single IM injection of ceftriaxone (<12 years 125mg and >12
in severe cases. years 250mg)
The skin and limb involvement in meningococcal septicaemia If the infection is due to serogroup C, contacts should also receive
distinguishes it from most other causes of sepsis and can be the conjugated group C vaccine
responsible for major morbidity. Widespread thrombosis and
haemorrhagic necrosis of the skin and underlying tissues is called If infection is due to serogroup A, W-135 or Y, contacts should
purpura fulminans. When the thrombosis involves large vessels, also receive the quadrivalent conjugate vaccine.
infarction and gangrene of the limbs occurs. The combination of Further information on meningitis and meningococcal disease is
ischaemia, necrosis and oedema can cause compartment syndrome. available at www.meningitis.org
The management of these problems is difficult. It has been suggested
that fasciotomies are only indicated in the first 24 hours after References
onset of purpura fulminans and only for compartment syndrome Law R. Meningococcal disease in children. Update in Anaesthesia
of the lower limb and where there is no major bleeding diathesis. (2007)22:26-30. Available from: http://www.wfsahq.org/images/wfsa-
A combination of clinical assessment, doppler flow studies and documents/updates_in_english/Update_22_2007.pdf
compartment pressures should be used as a guide to the decision
1. Kneen R et al. The role of lumbar puncture in suspected CNS infection
to perform a fasciotomy. Leave gangrenous limbs to demarcate if - a disappearing skill? Arch Dis Child 2002; 87: 181-3
possible; amputation should be an elective procedure.5
2. McIntyre PB et al. Deaxamethasone as adjunctive therapy in bacterial
There is now evidence from randomised controlled trials of adults meningtis: A meta-analysis of randomised clinical trials since 1998.
and children with septic shock that low dose hydrocortisone JAMA 1997; 278: 925-31.

3. Wall RA. Meningococcal disease: treatment and prevention. Annals ischaemia in meningococcal septicaemia in children. Journal of Bone
of Medicine 2002; 34: 624 - 34. and Joint Surgery 2000; 82B No.3: 383 - 86
4. Rivers E et al. Early goal directed therapy in the treatment of severe 6. Annane D et al. Corticosteroids for treating severe sepsis and septic
sepsis and septic shock. NEJM 2001; 345: 1368 - 77. shock. Cochrane Database of Systemic Reviews 2004, Issue 1. Art. No:
5. Davies MS et al. The orthopaedic management of peripheral CD002243. DOI: 10.1002/14651858.CD002243.pub2.

Intraosseous infusion
Reprinted from Update in Anaesthesia 2000; 12: 38-40.
Critical Care
Eric Vreede, Anamaria Bulatovic, Peter Rosseel and Xavier Lassalle

Correspondence Email: rachelhomer@doctors.org.uk
INTRODUCTION
The technique of intraosseous infusion was first Contra-indications
described in humans in 1934 and it became increasingly Femoral fracture on the ipsilateral side
popular in the 1940s. In recent years it has regained
popularity in both adult and paediatric resuscitation. Do not use fractured bones
Unfortunately many doctors do not know this
Do not use bones with osteomyelitis.
Summary technique or do not employ it.
Equipment
Intraosseous infusion is a However, intraosseous infusion is one of the quickest
temporary emergency 1. Skin disinfectant
ways to establish access for the rapid infusion of fluids,
measure
drugs and blood products in emergency situations as
Indicated in life- 2. Local anaesthetic
well as for resuscitation. In many countries, where
threatening situations
children are the victims of war trauma, road traffic 3. 5ml syringe
when intravenous access
fails (3 attempts or >90 accidents or severe dehydration and need good
seconds) circulatory access, this technique can be life-saving. In 4. 50ml syringe
Use the anteromedial
these situations peripheral venous access can be difficult
to obtain and alternatives such as central venous access 5. Intraosseous infusion needle or Jamshidi bone
aspect of the tibia marrow needle. There are different needle sizes;
can be difficult and/or dangerous.
Insert pointing caudal to 14, 16 and 18G. The 14 and 16G are usually used
avoid the epiphyseal for children older than 18 months. However any
growth plate Introduction to the technique
The marrow cavity is in continuity with the venous size can be used for all ages.
Use an aseptic technique
circulation and can therefore be used to infuse fluids It is possible but not ideal to use a 16 20G butterfly
Crystalloids, colloids,
and drugs, and to take blood samples for crossmatch, needle, spinal needle or even hypodermic needle. The
blood products and
drugs can be infused for example. The procedure must be performed under chance that the needle gets blocked with bone marrow
sterile conditions to avoid causing osteomyelitis. It is however, is much increased when not using a needle
Remove as soon as the
child has been resuscitated
also recommended to limit the duration of the use of with a trochar.
and intravenous access has intraosseous infusion to a few hours until intravenous
been established. access is achieved. It is thus a temporary emergency Site
measure. In experienced hands intraosseous access can The best site to use is the flat anteromedial aspect of the
be established within 1 minute. tibia. The anterior aspect of the femur and the superior
The authors are members of
the international medical aid iliac crest can also be used. The tibia is preferred since
It has been shown that the onset of action and drug the anteromedial aspect of the bone lies just under the
organisation Mdecins Sans
Frontires (MSF). levels during cardiopulmonary resuscitation using skin and can easily be identified. Avoid bones with
the intraosseous route are similar to those given osteomyelitis or fractures and do not use the tibia if
Eric Vreede, Consultant
Anaesthetist in London, intravenously. the femur is fractured on the same side.
anaesthetic advisor MSF
Holland. Indications Technique
Anamaria Bulatovic, attending Placement of an intraosseous needle is indicated when 1. Palpate the tibial tuberosity. The site for cannulation
Pediatrician in Baltimore, vascular access is needed in life-threatening situations lies 1 - 3cm below this tuberosity on the anteromedial
President of MSF USA. in babies, infants and children under the age of six surface of the tibia.
Peter Rosseel, years. It is indicated when attempts at venous access
2. Use sterile gloves and an aseptic technique and a
Anaesthesiologist in Breda fail (three attempts or 90 seconds) or in cases where it
sterile needle.
(Holland), Consultant is likely to fail and speed is of the essence. Although
Anaesthesiologist MSF Belgium. principally advocated for use in young children, it has 3. Clean the skin. Placing a bone marrow needle
Xavier Lassalle, CRNA in Paris, been successfully used in older children where the iliac without using a sterile technique obviously
anaesthetic advisor MSF France. crest may also be used. increases the chance of osteomyelitis and cellulitis.

4. Inject a small amount of local anaesthetic in the skin and continue Complications
to infiltrate down to the periostium. When the child is unconscious Important complications are tibial fracture especially in neonates,
it is not necessary to use local infiltration. compartment syndrome, osteomyelitis and skin necrosis. When an
aseptic technique is used, the incidence of osteomyelitis is less than
5. Flex the knee and put a sandbag as support behind the knee.
1%. Microscopic pulmonary fat and marrow emboli do not seem to
6. Hold the limb firmly above the site of insertion, usually at the level be a clinical problem.
of the knee. Avoid putting your hand behind the site of insertion
Provided the correct technique is employed there does not seem to be
to avoid accidentally injuring your own hand.
any long-term effects on bone growth.
7. Insert the intraosseous needle at 90 degrees to the skin
(perpendicular) and slightly caudal (towards the foot) to avoid the Infusion
epyphysial growth plate. Fluid can be infused under gentle pressure, manually by using a 50ml
syringe or by inflating a blood-pressure cuff around the infusion bag.
Crystalloids, blood products and drugs can be infused using this
technique.
The intraosseous route should be replaced as soon as a normal vein
can be cannulated and certainly within a few hours. The longer the
period of use the greater the risk of complications.
Conclusion
In emergencies rapid intravenous access in children may be difficult to
achieve. Intraosseous access is an easy, safe and life-saving alternative.
Editors note
Since this article was first published, battery-powered insertion
devices for intraosseous needles became available. Insertion
technique is as described above for the hand-held intraosseous
needles. These new devices are more expensive; some find them
easier to insert and hence more reliable.
Figure 1. Insertion of intraosseous needle in the right tibia References

Vreede E, Bulatovic A, Rosseel P, Lassalle X. Intraosseous infusion.
8. Advance the needle using a drilling motion until a give is felt Update in Anaesthesia (2000)12:38-40. Available from:
this occurs when the needle penetrates the cortex of the bone. http://www.wfsahq.org/components/com_virtual_library/me
Stop inserting further. dia/88e559324c3f259ce183b8f9fbf6047c-Intraosseous-Infusion-
-Update-12-2000-.pdf
9. Remove the trochar. Confirm correct position by aspirating blood
using the 5ml syringe. If no blood can be aspirated the needle 1. Chameides L, Hazinski MF, Eds. Textbook of Pediatric Advanced
may be blocked with marrow. To unblock the needle, slowly Life Support. 1994; 5-5 to 5-7
syringe in 10ml of saline. Check that the limb does not swell up
and that there is no increase in resistance. 2. Brickman KR, Krupp K, Rega P, Alexander J, Guinness M. Typing
and screening of blood from intraosseous access. Annals of
10. If the tests are unsuccessful remove the needle and try the other leg. Emergency Medicine 1992; 21: 414-7.
11. Secure the needle in place with sterile gauze and strapping.
3. Sawyer RW, Bodai BI, Blaisdell FW, McCourt MM. The current
Correct placement is further confirmed by the following: status of intraosseous infusion. Journal of American College of
Surgeons 1994; 179: 353-60.
A sudden loss of resistance on entering the marrow cavity (less
obvious in infants who have soft bones). 4. Claudet I, Fries F, Bloom MC, Lelong-Tissier MC. Etude
The needle remains upright without support (because infants have retrospective de 32 cas de perfusion intraosseus. Archives of
softer bones, the needle will not stand as firmly upright as in older Paediatrics 1999; 6: 566-9.
children).
5. Nafiu OO, Olumese PE, Gbadegesin RA, Osinusi K. Intraosseous
Fluid flows freely through the needle without swelling of the infusion in an emergency situation: a case report. Annals of
subcutaneous tissue. Tropical Paediatrics 1997; 17: 175-7.

The child with malaria
Critical Care
Rachel A. Stoeter and Joseph Kyobe Kiwanuka

Correspondence email: kijoek@yahoo.com
MALARIA: CAUSE, TRANSMISSION & occur in children. The risk is greater across all ages
EPIDEMIOLOGY when natural immunity is reduced:
Malaria is a life-threatening disease caused by four Limited previous exposure
protozoan parasite species of the genus Plasmodium
Pregnancy
infecting humans: P. falciparum, P. vivax, P. ovale, and
P. malariae. Co-infection with more than one species Severe concomitant illness
Summary is possible. A 5th species P. knowlesi, which primarily Surgery.
Malaria is a multi-system
affects primates, has also recently been found to infect
humans. P. falciparum is the most deadly species, Malaria in pregnancy affects both the mother and the
disease that can coexist
and P. falciparum and P. vivax the most common. P. foetus, which can lead to loss of the pregnancy or low
with other infections and
conditions, including those vivax and P. ovale both lead to a dormant liver form birth weight.
that may require surgery. (hypnozoites) that may cause relapses months or years Infants can be protected by maternal antibodies and
Intensive care may be later. by foetal haemoglobin, up to around 6 months of age.
necessary.
The parasites are transmitted through the bite of A behavioural tendency to cover infants may also be
Malaria can vary from an a vector, the infected female Anopheles mosquito. protective. Some inherited abnormalities of red cells
insidious febrile illness to can be protective against malaria, for instance, the
There are around 20 Anopheles species across the
an acute life-threatening sickle cell trait and Melanesian ovalocytosis, a genetic
disease. Rapid deterioration
world. The intensity of malaria transmission depends
on factors relating to the parasite, vector, host and polymorphism associated with mild haemolytic
is much more likely in
environment. Mosquitoes exhibit different breeding anaemia, common in South East Asia.
children. If malaria is
suspected, it should be and biting preferences, with the important vectors Malaria is both preventable and curable. Where
investigated rapidly and tending to bite at night. High humidity and warmer prevention and control measures have been applied
treated appropriately. WHO temperatures (between 20oC and 30oC) favour aggressively, the malaria burden has been effectively
and national diagnostic transmission of malaria due to increase in mosquito reduced.
and treatment guidelines numbers. Consequently, the disease is often seasonal,
should be followed. Children
relating to rainfall patterns. Some areas, with constant PREVENTION
should be observed closely
for the development of
temperatures and humidity, have steady parasite rates. Methods used to avoid disease transmission include
complications. Anaesthesia Climate changes may lead to alterations in the pattern prevention of mosquito bites using the following:
and surgery should be of disease.
avoided in the child with
Insecticide treated nets (ITNs)
40% of the global population reside in malaria
malaria if at all possible, but,
endemic areas. Most cases of malaria are found in Use of mosquito repellents
if it is necessary, the multi-
system nature of the disease sub-Saharan Africa, Asia and Latin America; a few
cases occur in the Middle East and in some areas of Indoor residual spraying with insecticides
should be considered.
Europe. Increased international air travel has also Maximum coverage clothing
introduced malaria into malaria free zones, resulting
in disease misdiagnosis. The World Malaria Report Reduction of mosquito breeding grounds by
Rachel A Stoeter 2011 estimated 216 (uncertainty range of 149- drainage of stagnant water and clearing of bushes.
274) million cases of malaria with 655,000 deaths Chemoprophylaxis is required for
Joseph (uncertainty range 537-907,000). 80% of the deaths
Kyobe Kiwanuka occur in African children, most of them being in the High-risk populations, such as travellers to malaria
Department of under five age range. Since 2000, deaths from malaria endemic regions
Anaesthesia and have been reduced by >25 % globally, and by 33% Intermittent preventive treatment in pregnancy
Critical Care, in Africa.
Mbarara University of Infants in high transmission areas (infants receive 3
Science and Technology, Partial immunity to the disease can develop over years doses of sulfadoxine pyrimethamine alongside
Uganda of exposure; consequently the majority of deaths routine vaccines).

Seasonal malaria chemoprevention was recommended in 2012 by indolent and asymptomatic picture. Malaria can be classified as
the World Health Organisation (WHO) in areas of the Sahel sub- simple/uncomplicated or severe/complicated.
region of Africa.
Uncomplicated malaria is defined by the WHO as symptomatic
Vaccinations against malaria are currently being evaluated in clinical infection with malaria parasitaemia without signs of severity and/
trials, but there is, as yet, no licensed vaccine. One such study, for a or evidence of vital organ dysfunction. Typical presentation of
vaccine against P. falciparum, is expected to finalise results towards uncomplicated malaria includes a febrile illness with headache, night
the end of 2014, which will subsequently lead to a review by the sweats, weakness, myalgia, arthralgia, diarrhoea, abdominal cramps
WHO. and vomiting. Gastrointestinal symptoms are more common in
children.
Anti-malarial drug treatment and drug resistance
Chloroquine: forms complexes with haem molecules in haemoglobin, The acute febrile illness is sometimes associated with classic cyclical
interfering with haem polymerisation. This is effective at preventing paroxysms, each lasting several hours. Paroxysms consist of chills
formation of intraerythrocytic trophozoites. Resistance has occurred and rigors, followed by fever spikes, then profuse sweating and,
relating to genetic mutations in the transporter molecule, the P. finally, extreme exhaustion. They occur in regular cycles every 48 or
falciparum chloroquine resistance transporter (PfCRT). 72 hours, depending on the P. lasmodium species, and correspond
with schizont rupture. However, these patterns may vary, and fever
Doxycycline: binds to ribosomes to inhibit parasite protein synthesis.
may be absent. Lack of such features, particularly with P. falciparum,
Sulfadoxine-Pyrimethamine combination: interferes with the should not delay diagnosis or treatment.
folate pathway and therefore parasitic nucleic acid synthesis through
Complicated malaria occurs with falciparum malaria and is due
inhibition of dihydrofolate reductase (DHFR). Sulfadoxine inhibits
to significant multisystem involvement. Presentation may include
parasite dihydropteroate synthase (DHPS). Pyrimethamine inhibits
extreme weakness, confusion or drowsiness. WHO diagnostic
parasite (DHFR). Resistance due to point mutations in the DHPS
features and manifestations of complicated malaria include:
has been found.
Cerebral malaria
Atovaquone-Proguanil combination: affects the function of the
parasite mitochondria via inhibition of the electron transport Generalised convulsions
chain. Resistance to Atovaquone and combination therapy has been Hyperparasitaemia
described due to substitution mutations. DHFR point mutation has
been found in Proguanil resistance. Hyperpyrexia
Artemisinin derivatives: the mechanism of action is not clear, but Prostration
may relate to peroxide bond and production of oxide radicals, Severe anaemia
which destroy the parasite, or to inhibition of cellular redox cycling.
Monotherapy is discouraged for fear of resistance. Consequently, Hypoglycaemia
they are usually used with other classes of anti-malarials, referred to Acute renal failure
as Artemisinin based Combination Therapy (ACT).
Acute pulmonary oedema
Mefloquine, quinine, quinidine: bind with haem molecules, leading
to the creation of parasite-toxic complexes. Mutations in the Fluid and electrolyte abnormalities
P-glycoprotein homolog-1 gene pfmdr-1 and PfCRT have been Metabolic acidosis with respiratory distress
identified.
Shock
Resistance to antimalarials remains a concern. Combination therapy
is preferred in order to prevent the development of resistant parasites. Haemoglobinuria
Routine monitoring of antimalarial resistance is essential. Resistance Abnormal bleeding
of mosquitoes to insecticides has also emerged in come countries,
although in most areas they remain an effective prevention tool. Jaundice.
Widespread resistance to chloroquine and the sulfadoxine- Falciparum malaria can be much more acute and severe compared to
pyrimethamine (SP) combination was identified in the 1970-1980s. malaria caused by the other species and carries the greatest mortality.
Resistance to artemisinin derivatives was reported around the P. vivax may also be fatal.
Cambodia/Thailand border in 2009. There has also been documented The severity of falciparum malaria relates to the ability of the parasite
resistance to quinine in Africa and concerns over reduced efficacy of to sequester in the microvasculature. Severe illness may be due
quinine in Southeast Asia. to delayed or inadequate treatment and can occur very rapidly in
children and in visitors from non-endemic areas. Rapid recognition
History, Clinical Features and Parasitological
and treatment is crucial and influences outcome. There should be a
Diagnosis
high index of suspicion of malaria in both endemic and non-endemic
History and clinical presentation areas. It is important to elicit a travel history to at risk areas, as well as
Children with malaria may present acutely unwell, or with a more a history of exposure to infected blood through transfusion.

Table 1. Differences between severe malaria in adults and in children. These features will vary depending on the region and levels of immunity in the
population
Signs or symptoms Adults Children

Duration of illness before severe features Long (5-7 days) Short (1-2 days)
Anaemia Common Very common
Convulsions Common Very Common
Pre-treatment hypoglycemia Less common Common
Metabolic acidosis Less common Common
History of cough Uncommon Common
Cerebral malaria Common Very common
Jaundice Very common Uncommon
Renal failure Common Uncommon
Pulmonary oedema, Acute Respiratory Distress Syndrome (ARDS) More common Rare
CSF pressures Usually normal Usually raised
Resolution of coma Longer (2-4 days) Shorter (1-2 days)
Bleeding/clotting disturbances Up to 10% Rare
Abnormality of brainstem reflexes (e.g. oculovestibular, oculocervical) Rare More common
Signs and symptoms can be non-specific and so other diagnoses must Microscopy identifies the species, parasite density and parasite stage.
also be considered. Differential diagnoses include: Giemsa stained thick and thin films are the accepted standard for
Meningitis diagnosis, but require experienced personnel.
Malarial parasitaemia may be reported as:
Influenza
- the percentage of parasite infected red blood cells, or
Typhoid and paratyphoid enteric fever
- the number of parasites per microlitre of blood.
Dengue fever
The higher the parasite density, the greater the risk of developing
Hepatitis severe malaria. The stage of the parasite in peripheral blood also
influences prognosis.
Acute schistosomiasis
RDTs detect parasite specific antigen. They may not identify low
Leptospirosis
level infections and accuracy will depend on the manufacturer. They
African tick fever are useful if microscopy skills are not available or well developed.
East African trypanosomiasis Antimalarial treatment should be reserved for test positive
cases. Occasionally the film can be negative when intense tissue
Yellow fever sequestration has occurred. False negative cases are also more likely in
recent artemisinin-derivative use. Rarely, treatment may therefore be
Viral encephalitis.
considered in test negative cases where severity of suspected disease is
For primary attacks, the incubation period may last 8-25 days, significant. Differential diagnoses must be remembered.
but can be longer. This relates to the patients immune status, the
Blood smears should be repeated 24-48 hours after initiation
Plasmodium strain, the sporozoite load, and chemoprophylaxis use.
of treatment to monitor efficacy of the drugs used. A change in
Relapses can cause delayed presentation months to years later and are
medication may be required if parasites have not been cleared.
due to dormant hypnozoites.
Where clinically indicated, other laboratory tests include full blood
The features found in children may differ to those found in adults
count, clotting studies, renal function test, liver function test,
(see Table 1).
blood glucose measurement, chest X-ray and lumbar puncture.
Parasitology Children with complicated malaria may be profoundly anaemic and
Diagnosis is based on clinical suspicion and on parasite detection in hypoglycaemic. Hyponatraemia is common.
blood (parasitological diagnosis). Current WHO advice recommends
rapid parasite diagnostic testing before treatment in suspected cases. Treatment
Where such testing is not possible, or delayed, treatment can still be Delayed diagnosis and treatment leads to increased morbidity and
considered. Parasitological testing includes either light microscopy or mortality. This may be due to
rapid diagnostic tests (RDT). Low index of suspicion

Unclear history associated with increased morbidity and mortality, both intra- and
Failure to request blood films post-operatively. Where possible, delay surgery to allow for time
to respond to anti-malarial treatment. The following precautions
False negative results. should be taken if surgery cannot be delayed:
Treatment includes targeted antimalarial therapy as well as supportive Preoperative assessment should include routine history and
therapy. examination, specific to the child, and with an emphasis on
Drug therapy the multi-system effects associated with malaria. The anaesthetic
WHO recommends use of ACTs for uncomplicated P. falciparum. plan will depend on which systems are affected. Determine
Initial treatment of P. falciparum malaria should be started according features and severity of the malaria should be determined, assisted
to national and/or local guidelines. National malaria treatment by a full examination. A complete set of observations is required,
policies should be in place, and should be assessed by in vivo including temperature and blood sugar measurement.
monitoring for therapeutic efficacy to ensure the correct antimalarial
Preoperative assessment should include the level of consciousness,
regimen is in use. Treatment depends on local resistance patterns and
with documentation of the GCS/Blantyre Coma Scale and
species of plasmodium. Uncomplicated malaria can be treated with
identification of any features of cerebral malaria (see below).
oral medication and on an outpatient basis.
There is an increased risk of deterioration post operatively
ACTs are commonly used in Africa and South East Asia for if the child has signs of CNS involvement preoperatively. Place a
uncomplicated malaria due to multidrug resistant P. falciparum. nasogastric tube if there is a reduced level of consciousness.
Combination with another drug is necessary to reduce the risk of
recrudescence and resistance. Combinations will depend on patterns Avoid premedication with sedative drugs in complicated malaria,
of resistance to the partner drug. to prevent confusion between the drugs sedative effects and clinical
deterioration, as well as to avoid the risk of airway compromise.
In severe malaria, treatment should commence with one of the
following parenteral drugs: artesunate IV or IM/ quinine IV or Aim for low normal PaCO2 and good oxygenation. Reduced
IM / artemether IM. If definitive treatment is delayed, pre-referral respiratory effort may lead to raised PaCO2 and falling PaO2,
treatment may include rectal artesunate. Parenteral antimalarials risking cerebral vasodilatation and a raised ICP. The airway
should be given for 24 hours. Once this is complete, and oral therapy should be secured and controlled ventilation used to prevent a rise
can be tolerated, antimalarial cover should be continued with in intracranial pressure (ICP). Avoid drugs that lead to an increase
either 1) an ACT, or 2) artesunate with clindamycin or 3)quinine in ICP such as halothane and ketamine and prevent hypertension
with clindamycin. Refer to the latest online WHO guidelines on at intubation and extubation. Vigilance is required to identify
treatment of malaria. convulsions under anaesthesia: use signs such as hypertension,
tachycardia and pupil changes.
Adult studies comparing quinine to artemesinin derivatives
(artesunate, artemether and artemortil) show superiority of the Consider atracurim or cis-atracurim due to its reliance on Hoffman
artemesinins. This relates to the artemesinins wider range of action degradation, although renal failure is less common in children
in the lifecycle of the parasite and faster clearance of the parasite, compared to adults. Avoid halothane if hepatic dysfunction is
alongside a reduced incidence of hypoglycaemia. Neurological present. If hyperkalaemia is present, avoid suxamethonium.
outcomes are not felt to differ between artesunante and quinine use. Avoid vecuronium and pancuronium due to delayed clearance.
Quinine will enhance the effect of neuromuscular blockade.
Supportive therapy
Monitoring and supportive therapy are key to the management of Transfusion requirements and the use of invasive monitoring will
the child with malaria. This includes regular measurement of vital depend on factors such as proposed surgery and expected blood
signs, level of consciousness, urine output, blood sugars and oxygen loss. Beware of the possibility of a low platelet count and the
saturation, alongside intensive nursing care. presence of coagulopathy when considering regional techniques
such as a caudal block or spinal anaesthesia.
Fluid resuscitation is often needed. There is a risk of pulmonary
overload, although it is rare in children. The requirement for Intraoperative vigilance with blood glucose monitoring and
respiratory support ranges from oxygen supplementation to full treatment is vital.
ventilatory support. Renal failure may require haemodialysis. The
Post-operative assessment of consciousness is important - patients
nature of multi organ involvement will determine the support
should not be returned to the ward if they are not awake and alert. If
required.
there is deterioration in the GCS/BCS, hypoglycaemia, seizures or
Pharmacological adjuncts may include anitpyretics, antibiotics, the child is post-ictal, consider worsening cerebral malaria
anticonvulsants and antiemetics. in addition to anaesthetic causes. The child should be monitored
carefully postoperatively, ideally in a high dependency area. Anti-
Anaesthetic Considerations The Child with malarial treatment must be continued postoperatively.
Malaria Presenting for Surgery
If a child with malaria presents for surgery, you must assess the Multi-Organ Involvement, ICU Management
urgency of the surgery. Surgery in the presence of acute malaria is Malaria is a multi-system disease that can coexist with other infections

Table 2. The Blantyre Coma Scale Pathogenesis is thought to include sequestration of parasitised
Blantyre Coma Scale
erythrocytes in cerebral microvasculature with associated
inflammatory responses. Inducible nitric oxide production is also
Score
thought to play a role through inhibition of neurotransmission.
Best MOTOR response There is reduced oxygen and glucose delivery with raised temperature,
Localises to painful stimulus 2 hypoglycaemia and metabolic acidosis exacerbating the effects.
Withdraws limb from painful stimulus 1 In children, febrile convulsions may occur, with a post-ictal state
No response or inappropriate response 0 lasting several hours. Hyperpyrexia and hypoglycaemia should be
Best VERBAL response excluded as causes of both coma and convulsions.
Cries appropriately with painful stimulus, or, if verbal, 2 The optic fundi should be examined. Meningitis should be
speaks considered in the differential diagnosis. In cerebral malaria, Kernigs
Moan or abnormal cry with painful stimulus 1 sign is negative (if positive, the child is unable to straighten the leg
No vocal response to painful stimulus 0
whilst lying down with the hip flexed a sign of meningism e.g.
due to meningitis). Neck stiffness, photophobia and focal neurology
EYE Movements are rare in cerebral malaria. However, cerebral malaria may present
Watches or follows (e.g. mothers face) 1 with coma, convulsions or posturing. Retinal haemorrhages may be
Fails to watch or follow 0 present in 15%. CSF pressure at lumbar puncture may be elevated
in children, but is often normal in adults. Cerebrospinal fluid (CSF)
and conditions, including those that may require surgery. Intensive is clear with < 10 white blood cells per microlitre but protein is often
care may be necessary. slightly raised. Computed tomography scans are usually normal.
Remember, a child may deteriorate rapidly, particularly if In older children and adults the Glasgow Coma Scale (GCS) is used
hyperparasitaemia is present. Severe anaemia (Hb <5g.dl-1), to measure the level of consciousness. In younger children either a
respiratory distress due to metabolic acidosis and cerebral malaria are modified GCS or the Blantyre Coma Scale (BCS) can be used (see
seen more frequently in children. Table 2).
Laboratory and diagnostic tests should include: full blood count, Convulsions should be treated with intravenous or rectal diazepam,
liver function tests, urea, creatinine and electrolytes, clotting profile, or intramuscular or rectal paraldehyde.
blood type and crossmatch where appropriate (depending on FBC
Patients require meticulous nursing care. The level of consciousness
and coagulation findings). Pulse oximetry is helpful. Arterial blood
must be regularly monitored alongside temperature, blood pressure,
gas, ECG and chest Xray may also be indicated.
heart rate, and respiratory rate. A urinary catheter is required, with
Criteria for intensive care admission include: strict input/output recordings. There is currently no role for drugs
Presence of immediate life threatening complications such as to reduce cerebral oedema.Respiratory and ventilatory support may
coagulopathy or end organ failure be required.
Presence of signs or symptoms of cerebral malaria Respiratory distress
Non-immune patients with P. Falciparum parasitemia >2% or semi- There may be several processes present leading to respiratory distress
immune patients with P. Falciparum parasiteamia >5% including:
Presence of any other severe complications of malaria. Pulmonary oedema

Respiratory compensation for metabolic disturbance, particularly
Cerebral malaria
acidosis
Cerebral malaria has been defined by the WHO as: Superadded chest infections
Severe P. falciparum malaria with cerebral manifestations, usually Severe anaemia.
including coma (Glasgow Coma Scale < 11, Blantyre Coma Scale < 3)
(see below) Non-cardiogenic pulmonary oedema involves sequestration of
erythrocytes in the lungs and associated inflammatory responses in
Malaria with coma persisting for more than 30 minutes after a
the pulmonary vasculature, alongside increased capillary permeability.
seizure.
Mild ARDS may develop and can progress to be severe. Patients can
Other causes for reduced cerebral function should be sought and appear to otherwise be improving clinically at the time it develops.
excluded. Excessive fluid administration, renal failure and hypoalbuminaemia
can contribute. Pulmonary oedema can occur in both falciparum and
Cerebral malaria is more common in children and non-immune
vivax malaria.
adults. Mortality can be as high as 40% in children, who are also
at a greater risk of developing neurological sequelae (10%). Such Abnormal breathing patterns can be due to effects on the respiratory
sequelae include hemiparesis, cerebellar ataxia, cortical blindness, centre. Patients may have a superadded chest infection due to
hypotonia, mental retardation and cerebral palsy. immune suppression.

Metabolic acidosis is more common in children than in adults. Determine the degree of anaemia alongside the clinical picture
Confirm with arterial blood gas results where possible. Consider and consider transfusion if the haematocrit is <25%, or when
and treat bacterial infection and the impact of a reduced level of hypovolaemic shock is present. Transfuse whole blood (20ml.kg-1)
consciousness. or packed cells (10ml.kg-1) as per hospital guidelines. Transfusion
should be carried out cautiously due to the risk of pulmonary
Although there is a risk of pulmonary oedema and ARDS in children,
oedema. Children with a hyperdynamic circulation may need
this is much less common than in adults. Care is needed with fluid
intravenous furosemide for transfusions. Platelet and fresh frozen
therapy. In anaemic children, dyspnoea is more commonly related to
plasma transfusions may be required in the presence of coagulopathy.
acidosis and hypovolaemia, which therefore needs urgent correction.
Ventilatory support may become necessary. Increased FiO2 and Hypoglycaemia
positive end expiratory pressure may be required. In the event of Hypoglycaemia is common in severe malaria. Pregnant women
fluid overload, intravenous furosemide can be used. and children are at a greater risk, especially neonates and infants.
It should be suspected in all those with a reduced conscious level,
Circulatory collapse and may present with coma or convulsions. Regular blood sugar
Cardiovascular collapse in malaria may be due to: monitoring is essential and hypoglycaemia must be appropriately
Secondary bacterial infection treated and observed. Hypoglycaemia can be due to:
Metabolic acidosis Increased demand (anaerobic glycolysis, febrile illness and
Dehydration demand from parasites)
Bleeding, including a ruptured spleen Failed hepatic glycogenolysis and gluconeogenesis

Pulmonary oedema. Quinine-stimulated pancreatic beta-cell insulin secretion.
Often the bacterial infection is Gram-negative sepsis. Seek possible Hypoglycemia contributes to central nervous system dysfunction
infection sites, including respiratory tract, urinary tract, meningitis and associated neurological deficits in survivors of cerebral malaria.
and intravenous lines. Correct hypovolaemia and commence broad-
spectrum antibiotics, ideally after blood cultures are sent. Myocardial Fluid and electrolyte disturbance, metabolic acidosis
function is often well preserved, however there is potential for There is often evidence of hypovolaemia and dehydration.
impaired myocardial function and a preoperative echocardiogram Metabolic acidosis can occur with severe illness, hypoglycaemia,
may be advised. hyperparasiteamia, or renal failure. Lactic acidosis is mainly due
to reduced oxygen delivery to tissues caused by hypovolaemia,
Preoperative assessment of hydration is important, with identification
sequestration, and anaemia. Contributing factors include parasite
and treatment of hypovolaemia, as well as sepsis and shock. Consider
anaerobic glycolysis, impaired hepatic and renal function with
fluid therapy, possible blood transfusion and potential inotropes.
reduced lactate clearance and cytokine release. In children with
Children with severe anaemia may present with tachycardia and
severe malaria, lactate level >5mmol.L-1 is a major predictor of death.
dyspnoea.
Hyponatraemia is a common finding. Children with acute renal
Haematological disturbances tubular dysfunction may have raised potassium levels.
All patients with malaria are prone to anaemia. Children and non-
Hyperpyrexia
immune patients with high parasite loads are at the greatest risk.
High fevers are more common in children and may contribute to
The anaemia can be severe, with a haemoglobin <5g.dL-1. Causes are
convulsions (febrile convulsions) and coma, with increased mortality.
multifactorial and relate to:
Persistently high temperatures (42oC.) may cause permanent
Haemolysis neurological sequelae.
Removal of both parasitized and non-parasitized erythrocytes in the Monitor temperature carefully. Children are also prone to
spleen hypothermia and so hyperthermia must be aggressively treated,
Impaired bone marrow function whilst avoiding hypothermia. Treatment of a raised temperature
includes the use of antipyretics and cooling methods such as tepid
Reduced erythropoietin production and response to erythopoeitin
sponges and fans, aiming to keep the temperature <39oC.
Nutrition
Gastrointestinal (GI) system
Infective causes (e.g. hookworm).
GI symptoms of malaria are frequently found in children, presenting
Thrombocytopenia is very common in falciparum malaria, often with nausea and vomiting, abdominal pain and diarrhoea. There
occurring in the absence of other clotting dysfunction. It relates to an may be gastric/duodenal ulceration, malabsorption and an increase
increase in splenic clearance of platelets. Disseminated intravascular in gastrointestinal infections such as salmonella. Jaundice may be
coagulation (DIC) can occur and may present as bleeding gums, present due to haemolysis, hepatocellular dysfunction, cholestasis,
epistaxis, petechiae, haematemesis, and malaena. DIC and significant or a combination of each. Serum bilirubin and liver enzymes may
bleeding occurs in < 10%, with the greatest risk among non-immune be elevated, although less than with viral hepatitis. Splenomegaly is
patients. also common and most likely related to the clearance of erythrocytes.

Spontaneous splenic rupture can occur with P.vivax infection. SUMMARY
Malaria can vary from an insidious febrile illness to an acute life-
Renal dysfunction threatening disease. Rapid deterioration is much more likely in
Acute renal failure usually occurs in adults. It can be due to prerenal or children. If malaria is suspected, it should be investigated rapidly and
renal causes and is often secondary to acute tubular necrosis (ATN). treated appropriately. WHO and national diagnostic and treatment
Microvascular obstruction and cellular damage due to filtration of guidelines should be followed. Children should be observed closely
free haemoglobin, myoglobin and cellular material can lead to ATN. for the development of complications. ICU admission may be
Usually there is a protracted period of oliguria, followed by anuria; required. Anaesthesia and surgery should be avoided in the child
occasionally a polyuria may be found. IV fluids and antimalarial with malaria if at all possible, but, if it is necessary, the multi-system
treatment will aid pre-renal factors. nature of the disease should be considered.
Monitor blood urea, creatinine and electrolytes and hydration status.
A urinary catheter is required, with close monitoring of input and REFERENCES AND FURTHER READING
output balance. In severe cases, dialysis may be required. 1. Espina-Bertoso S. Malaria for the anaesthetist. Update in Anaesthesia
(2010)26:24-27. Available from: http://www.wfsahq.org/components/
Blackwater fever, although uncommon, can occur in severe malaria com_virtual_library/media/3e15badd08cee5e7f909ba92d916a0b1-
and is due to massive haemoglobinuria. It is more likely found in Malaria-for-the-anaesthestist--Update-26-2010-.pdf
adults with renal failure. The urine is tea/coca-cola coloured. Those 2. Fairhurst RM, Wellems TE. Chapter 275: Plasmodium Species (Malaria). In;
with glucose-6-phosphate dehydrogenase (G6PD) deficiency are Mandell, G.L., Bennett, JE and Dolin,R. eds. Principles and Practice of
at a greater risk of developing the condition, especially if receiving Infectious Diseases (7th Edition) New York: Churchhill Livingstone
oxidant drugs such as primaquine and sulphonamides. Elsevier, 2009 pp. 3437-3462.
3. Gupta D, Chugh K, Sachdev A, Soni A. ICU management of severe malaria.
Hyperparasitaemia Indian J Pediatr 2001; 68: 1057-1061.
High parasite densities (>5%) and peripheral schizontaemia tend 4. Pavsol, G. Chapter 2A: Malaria. In; Eddlestone M, Davidson R, Wiklinson R,
to be associated with severe disease, particularly in children and Perini S. eds. Oxford Handbook of Tropical Medicine (2nd Edition) New
those who are non-immune. In endemic areas, and in the partially York: Oxford University Press, 2005: pp 9-37.
immune, higher mean densities (20-30%) may be found without 5. World Health Organization. Guidelines for the treatment of malaria. (2nd
clinical symptoms. edition). Geneva: World Health Organization; 2010. Available at: http://
whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf
Exchange transfusions can be considered in high parasitaemia, but
must be weighed against the risk of the transfusion itself. 6. World Health Organization. Management of severe malaria: a practical
handbook.(2nd edition). Geneva: World Health Organization; 2000.
Miscellaneous 7. http://www.who.int/malaria/world_malaria_repor t_2011/
Malaria can be transmitted via a needle stick injury. Observe universal WMR2011_factsheet.pdf (Accessed 16 June 2012).
precautions. 8. http://www.who.int/mediacentre/factsheets/fs094/en

Acute lower respiratory disease in children
Critical Care
Rebecca Paris, Oliver Ross*, and Laura Molyneux
*Correspondence Email: oliver.ross1@btinternet.com
INTRODUCTION Starting as an upper respiratory tract infection, it is

Pneumonia is the leading cause of death in children caused by viral infections, which then trigger lower
worldwide. Vulnerability is highest in the first 28 days respiratory symptoms of bronchospasm, wheeze,
of life, remaining a huge burden in the subsequent cough and respiratory distress.8
five years. In 2010 it was estimated that throughout
the world 21,000 children under the age of five died PNEUMONIA
every day, with a total of 7.6 million deaths each year.1 Pneumonia is most commonly caused by the bacteria SUMMARY
Of these 1.4 million deaths (18%) were attributable Streptococcus pneumoniae (Spn) or Haemophilus
influenzae (HiB). Other significant bacteria include Pneumonia continues to be
to pneumonia, which is more than those caused by the leading cause of death in
AIDS, malaria and tuberculosis combined.1,2 Staphylococcus aureus and Klebsiella pneumoniae.
children under 5, worldwide
Viral causes of pneumonia include Respiratory
The vast majority of these childhood deaths occur in Synctial Virus (RSV), parainfluenza virus and Poverty contributes notably -
the developing world, particularly in Africa and South adenovirus. Fungal infections such as pneumocystis the risk of a child dying under
jiroveci are important to consider in the child with the age of five is 18 times
East Asia. The risk of a child dying under the age
AIDS.2,5 Increasing immunisation coverage against greater in a low income
of five in a low-income country is 18 times greater country
than in a high-income country.1 The highest under-5 Spn and HiB is expected to change the aetiology of
mortality rates are seen in the poor rural communities pneumonia. The Pneumonia Etiology Research for Assessment and initial
Child Health (PERCH) study is a large multinational management follows the ABC
with low levels of education.1,3-5 Poverty contributes
study investigating the aetiology of pneumonia in approach, as for any acutely ill
to increasing susceptibility through risk factors such child
as malnutrition, inadequate sanitation, and reduced children.9
access to health care services.1,3,6 Inhalation of Standardised and prompt
Transmission of pathogens between individuals
particulate matter from indoor air pollution caused treatment improves outcomes
usually occurs via droplets, which are aerosolised
by the use of biomass fuels for heating or cooking through coughing and sneezing. Neonates are also Supplementary oxygen saves
is responsible for almost half of deaths due to acute at risk of blood borne infection at or shortly after extra lives.
lower respiratory tract infections.2,7 birth.2,5
DEFINITIONS Risk factors for childhood ALRI are shown in Box

Acute lower respiratory disease in children consists of 1. It is estimated that more than 20 million children
asthma (acute severe or life-threatening asthma) and suffer severe malnutrition, which compromises their
Acute Lower Respiratory Infections (ALRI), which defence against infection and increases their risk
includes pneumonia and bronchiolitis. All are acute, of dying from pneumonia. Immunity can also be
serious and potentially life threatening. weakened by concurrent illnesses such as HIV or Rebecca Paris
measles. Non-exclusively breast fed infants are 15 Specialist Registrar
Pneumonia is an acute lower respiratory tract infection times more likely to die from pneumonia, and suffer in Anaesthesia
that presents with symptoms of cough, fever, and more frequent and severe infections than exclusively Worcester Royal Hospital
difficulty breathing. breastfed children.2-4
Asthma is a condition of hyper-reactive, inflamed and Laura Molyneux
Approximately one million children could be saved
narrowed airways resulting in difficulty breathing, Specialist Registrar
through effective prevention and treatment of
wheeze, cough and chest tightness. Although a in Anaesthesia
pneumonia every year.2 The Global Action Plan for
chronic condition, patients often present with acute Leeds General Infirmary
the Prevention and Control of Pneumonia presents
exacerbations related to infective or non-infective a framework to reduce pneumonia morbidity and
triggers (physical exertion, allergens, irritants or cold Oliver Ross
mortality through three facets:7
weather). Consultant Paediatric
1. Protection - strategies include the provision of Anaesthetist
Bronchiolitis is an acute, communicable condition a healthy living environment to enhance natural Southampton
mainly affecting infants between 3-6 months of age. defences. University Hospital

2. Prevention - includes using immunisation against high-income countries, reflecting increasing atopic sensitization.
Haemophilus influenzae B, Streptococcus pneumoniae, Prevalence is increasing in developing countries, possibly as a result
measles and pertussis. Children with HIV or diarrhoea of urbanization.13
are at even greater risk of pneumonia, and infected
or exposed children should receive daily cotrimoxazole Prevention of acute life threatening exacerbations depends on
prophylaxis.2,7 effective management of chronic disease. As with many diseases,
this is hampered by poverty, poor education and limited access to
3. Treatment - for children with pneumonia, the mainstay health care.
of reducing mortality is appropriate treatment, either in
the community, health centre or hospital. Evidence shows BRONCHIOLITIS
mortality can be reduced through: Bronchiolitis predominantly affects infants under six months old.
It is a leading cause of ALRI and a major contributor to acute
Standardised guidelines for diagnosis and treatment respiratory distress, hospitalisation and PICU admission14,15 The
most common pathogen is RSV and it is estimated that almost
Early recognition and treatment with antibiotics. 199,900 children under the age of 5 died in 2005 as a result of RSV-
The majority of cases of pneumonia in developing countries are associated ALRI. As with pneumonia, 99% of these deaths occurred
bacterial in origin, but it is not possible to differentiate pathogens in developing countries.14 Other infective agents include human
by clinical assessment.5 Less than 30% of children with pneumonia meta-pneumovirus (HMPV), influenza, para-influenza, adenovirus,
rhinovirus, and less commonly Mycoplasma pneumoniae.
receive the appropriate antibiotics.2
Risk factors for bronchiolitis are shown in Box 2.
ASTHMA
Over the past four decades the global prevalence, morbidity and Morbidity and mortality may be reduced by ensuring a healthy living
mortality of asthma has risen sharply, particularly in children. While environment and addressing risk factors in a similar manner to those
most of the 180,000 annual deaths from asthma are in patients over for pneumonia. Vaccination for RSV is only recommended in high-
the age of 45 years, there has been a marked increase in hospitalisation risk groups (e.g. children with significant cardiac disease), and has
in very young children. Prevalence of asthma is already high in been shown to reduce the length of illness, reduce hospital stay and
intensive care admissions.15,16
Box 1. Risk factors for Childhood Acute Lower Respiratory
Infection (ALRI)3,10-12 PRESENTATION AND DIFFERENTIAL DIAGNOSIS
The common presenting symptoms and signs of acute lower
respiratory tract disease are cough, difficulty breathing and wheeze.
Definite Risk Factors for ALRI
The differential diagnoses are summarised in Table 1. Children
Malnutrition normally have a higher respiratory rate than adults; normal cardio-
Low birth weight respiratory ranges are shown in Table 2. As a rule of thumb, a
Non-exclusive breast feeding for first 6 months respiratory rate of more than 50 breaths per minute in a child aged
Lack of measles immunisations (within first 12 months) between 2 and 12 months, or more than 40 breaths per minute in
Indoor air pollution a child aged 1-5 years is considered rapid (Table 3). Upper airway
Crowded living conditions are described in detail in another article of this Update
(page 168).
Likely Risk Factors for ALRI
DIAGNOSIS, TRIAGE, AND MANAGEMENT
Parental smoking Assessment and triage of the seriously ill child are described in detail
Zinc deficiency in Recognising the seriously ill child in this edition of Update
Maternal experience (page 224). Undertake an ABC assessment and categorise children
Concomitant diseases (diarrhoea, cardiac disease, asthma) according to the Emergency Triage Assessment and Treatment
(ETAT) need for treatment28: Emergency, Priority or Non-urgent.
Possible Risk Factors for ALRI
Emergency cases require immediate attention; priority cases require
assessment and rapid attention; non-urgent cases can wait their turn
Mothers education
in a queue.
Day-care attendance
Rainfall (humidity) Use a step-wise ABC approach for all critically ill children. You
High altitude (cold air) must monitor and record vital signs regularly (oxygen saturation,
Vitamin A deficiency respiratory rate, heart rate, conscious level and temperature). Any
deterioration should prompt full reassessment of the child:
Birth order
Outdoor air pollution Re-evaluate the diagnosis
Look for complications of the disease

Box 2. Risk factors for developing bronchiolitis14,15 Pulse oximetry correlates well with arterial PaO2 in adults and is
recommended by WHO for detecting hypoxia in children with
Prematurity acute respiratory disease and for guiding oxygen therapy.19 Target
Male gender oxygen saturations are shown in Table 2. Where a pulse oximeter is
not available, clinical signs can give useful clues to the presence of
Age <3 months hypoxia:
Indoor air pollution (smoking/ biomass fuels) Central cyanosis
Non-breast feeding Nasal flaring
Poverty Grunting
Respiratory disease (chronic lung disease of prematurity, Altered mental state (drowsiness or lethargy)
cystic fibrosis) Inability to feed due to respiratory distress.
Congenital heart disease with pulmonary hypertension
Be aware that no single sign can accurately identify hypoxia, so you
Immunodeficiency should take signs together in context of the overall clinical condition
of the child.31-33 For example, the blue discolouration of lips or nail
Neurodevelopmental delay beds in central cyanosis can be difficult to identify. There is inter-
observer disagreement and assessment is further complicated by the
Upper airway obstruction
presence of severe anaemia (Hb<7g.dl-1) or in dark skinned children.
Central cyanosis is a highly specific sign but with low sensitivity.32 In
Ask for senior support a critically ill child, severe lower chest wall in-drawing, breathing rate
of more than 70min-1 or head bobbing may be more sensitive signs
Consider the need to transfer the child to intensive care
signaling the need for supplementary oxygen.19
facilities.
Immediate treatment is outlined in Table 4. Many investigations
Pneumonia to direct management (chest X-rays, blood tests, sputum tests)
The WHO recommends using clinical features of a recent onset may be unavailable in the low-resource setting thus diagnosis and
cough and rapid breathing to diagnose pneumonia.5,28 Normal management is based on clinical symptoms and signs.4 All children
and abnormal cardiorespiratory values are shown in Tables 2 and 3. with severe or very severe pneumonia and infants aged two months
Consider other respiratory illnesses than pneumonia if the child has or younger require admission to hospital.2
a cough without rapid breathing. Remember, it is not possible to
differentiate between viral or bacterial pneumonia clinically as the The current recommendation is to administer IV antibiotics for
symptoms are so similar. Some symptoms, such as wheezing do tend at least three days. As the child recovers, switch to oral antibiotics
to occur more commonly in viral pneumonia, but do not rely on this (amoxicillin or ampicillin), and ensure that the child completes
to direct treatment. a total of at least five days. Reassess on a regular basis. Clinical
deterioration or failure to improve by 48 hours should prompt a
When a child presents with symptoms of pneumonia, triage by change in antibiotics (to chloramphenicol).18 Parenteral ampicillin
the severity of their disease (See Table 4). Seek specific signs and plus gentamicin is preferable to chloramphenicol in treating severe
symptoms, in particular pneumonia in children between one month and five years of age in
a low-resource setting.34
The danger signs (cyanosis, stridor, somnolence, lethargy
or difficulty feeding) Complications of pneumonia
Lower chest wall in-drawing Hypoxaemia is the most serious complication of pneumonia.35
It indicates severe disease and has been associated with four times
Rapid respiratory rate. increase in mortality.31,36 Most children who require oxygen will have
very severe pneumonia, but hypoxia may also be present in children
In normal respiration the whole chest expands with inspiration. In with less severe disease.
severe disease the lower chest wall may be sucked in during inspiration
(lower chest in-drawing). In combination with rapid breathing and Oxygen is an expensive resource. Oxygen concentrators require a
cough this represents severe clinical pneumonia. Other signs of severe reliable supply of electricity and many rural health facilities may
difficulty in breathing are grunting with each breath, nasal flaring need to use cylinder supply. Cylinders are logistically challenging
and tracheal tug. Children with very severe pneumonia will have to transport to remote areas so that shortages occur frequently.
additional symptoms and signs such as cyanosis, stridor, the inability Monitoring oxygen saturation and providing oxygen to children with
to feed or drink, loss of consciousness, hypothermia or convulsions. severe pneumonia reduces the risk of death by 35%. This is in part
They need urgent transfer to hospital. due to improved detection of hypoxia and regular reassessment of
treatment.35 Neonates are vulnerable to the toxic effects of hyperoxia,

Table 1. Differential diagnosis for children presenting with acute respiratory symptoms2,5,15,17-25
Presenting Feature
Pneumonia Most common in 0-5-year-olds
Cough for less than 2 weeks
Rapid breathing rate or difficulty breathing
Fever or chills
Wheeze
Hypoxia (low SpO2 or clinical signs - see text)
Loss of appetite or unable to feed due to respiratory distress
Bronchiolitis Age 3-6 months (less than 2 years)
2-3 day coryzal phase with nasal discharge
Fast or difficult breathing
Harsh cough
Irritability or poor feeding
Wheeze
Fever <39oC
Apnoeas (especially in preterm infants)
Bilateral crepitations
Clinical signs of air trapping
Acute severe asthma Most common above 5 years of age
Known diagnosis of asthma and exposure to trigger factor
Difficulty in breathing/ respiratory exhaustion
Wheezing or chest tightness
Cough
Fast heart rate
Hypoxia
Hyperinflation of the chest
Confusion or drowsiness
Pleural effusion Cough
Rapid breathing
Wheeze
Chest pains
Vomiting
Fever (if empyema/ parapneumonic effusion)
Unilateral abnormal air entry
Unilateral dull percussion
Tuberculosis History of exposure (usually in a confined space)
Stridor
Wheeze
Hypoxia
Difficulty breathing or rapid breathing

Pneumothorax Sudden onset of difficulty in breathing
Wheeze
Hypoxia
Unilateral abnormal air entry
Unilateral hyper-resonant percussion
Tracheal deviation (indicates tension pneumothorax requiring immediate decompression)
Anaphylaxis Sudden onset
Airway compromise (swelling, stridor, hoarse voice)
Rapid breathing
Wheeze
Cyanosis/ hypoxia
Cardiovascular collapse (pale, clammy, low blood pressure)
Skin changes/ rashes
Upper airway conditions: e.g. Foreign body: sudden episode of coughing or choking, stridor, voice changes
airway foreign body, croup, Croup: stridor, barking cough
epiglottitis, tracheitis
Epiglottitis/ tracheitis: toxic looking child, drooling
Other medical conditions presenting with respiratory symptoms:
Gastro-oesophageal reflux Cough worse with feeds or lying flat
disease Intermittent wheeze
Vagally-mediated reactions (apnoea, bradycardia, laryngospasm)
Severe chronic anaemia Shortness of breath with exertion
Fatigue, weakness or irritability
Dizziness or syncope
Pallor
Severe sepsis Rapid breathing
Fast heart rate (or slow heart rate for age)
Fever, or low temperature
Presence of infection
Cardiovascular dysfunction (low blood pressure, prolonged capillary refill time, cold
peripheries)
Hypoxia
Altered consciousness
Malaria Fever
Rapid breathing
Fast heart rate (may have circulatory collapse)
Altered consciousness, convulsions
Jaundice and abnormal bleeding
Children with malaria may also have severe anaemia or concomitant pneumonia
Heart failure and congenital Fast breathing rate
cardiac conditions Fast heart rate
Clammy, pale, cold peripheries
Weak pulses
Irritability
Limited exertion tolerance
Hypoxia
Enlarged liver

Table 2. Normal values in children14,19,26
Neonate Infant Small child Adolescent

Heart rate 110-150 100-150 80-120 60-100
Respiratory rate 30-40 25-35 25-30 15-20
Oxygen Saturation 88% at sea level Altitude greater than 2500m: SpO2 > 87%
Altitude less than 2500m: SpO2 > 90%

Systolic Blood
Pressure (lower limit, 65-75 70-80 (65+2 x age) 90
mmHg)
Table 3. Definition of rapid breathing and increased heart rate in children26-28
<2 months 2-12 months 1 -5 years >5 years

Breathing Rate >60 >50 >40 >30
Heart Rate
(Beats per minute) >150 >150 >140 >125
Table 4. Assessing the seveity of pneumonia5,18,19,29
Signs Classification Immediate treatment

Danger signs present: Very severe pneumonia If in hospital:
Cyanosis Seek urgent senior help
Stridor (in calm child) Give oxygen
Somnolence Give appropriate antibiotics IV
Lethargy Consider admission to Intensive Care
Difficulty drinking liquids If not in hospital:
Seek senior help urgently
Give first dose of appropriate antibiotic IV.
Refer urgently to hospital for IV antibiotics and oxygen.
Fast breathing Severe pneumonia If in hospital:
Give first dose of appropriate antibiotic promptly and
Lower chest wall in-drawing
continue
Assess need for oxygen
If not in hospital:
- Give first dose of appropriate antibiotic promptly
- Refer urgently to hospital for antibiotics and oxygen
therapy as required
Fast breathing: Pneumonia (non-severe) If no lower chest wall in-drawing or danger signs:
>50 bpm in 2-12months Prescribe appropriate antibiotics
>40 bpm in 1-5 years Does not require hospitalisation
Advise mother on supportive measures and when to return
for follow-up
No fast breathing Other respiratory illness No need for antibiotics
Does not require hospitalisation
Advise mother on supportive measures and to return if
symptoms worsen

so should only receive monitored oxygen therapy to maintain SpO2 ketamine if initial treatments fail and appropriate HDU/ICU level
around 87%-94%.19 care and monitoring is available. The indications for admitting a
child to PICU are shown in Box 4.
Severe pneumonia may be complicated by a collection of either fluid
(parapneumonic effusion) or pus (empyema) in the pleural space, Chest Xrays are not routinely necessary. Use them for signs of surgical
adding significantly to morbidity.37,22 Exclude these complications in emphysema, persistent signs of pneumothorax, consolidation or if
any child who is not responding to treatment after 48 hours. They life-threatening asthma is not responding to treatment.27
also necessitate admission to hospital with intravenous antibiotic
therapy. Chest imaging with anteroposterior or posteroanterior For children under two years, response to treatment can be
X-rays and ultrasound can aid diagnosis and guide thoracocentesis. unpredictable. First line treatment of salbutamol given via an
Chest drains should be sited for large collections and will prompt inhaler and spacer with a close fitting mask is better than nebulizer.27
referral to a tertiary centre. Blood, sputum and pleural fluid may be Ipratropium may be beneficial to infants with severe symptoms.
sent for microbiological evaluation if available. Remember that 6% Steroids should be given (10mg soluble prednisolone for up to
of empyemas globally are due to tuberculosis.37 three days). After discharge it is not usually necessary to continue
bronchodilator therapies in this age group.
Asthma
Acute severe asthma and life-threatening asthma are conditions of Bronchiolitis
severe bronchospasm. Inflammation and mucus secretions worsen Bronchiolitis is diagnosed on the basis of clinical features. The child
airway narrowing. It is important to realise that acute exacerbations is usually between 3-6 months old and certainly under the age of
may be life threatening do not underestimate their severity.20,21 two years old. High fever is uncommon and temperatures > 39oC
Asthma is uncommon in children under the age of 5 years old. should prompt evaluation for other causes. Danger signs are shown
in Table 6.
A child with asthma should be assessed with an ABC approach.
Clinical symptoms and signs do not always correlate well with the The principle of managing bronchiolitis is providing supportive care
degree of airway obstruction. Severity classification is shown in Table since there are no effective therapies (Box 5). Admission to hospital is
5. Pay particular attention to respiratory rate, degree of breathlessness, often necessary because the baby is unable to feed due to respiratory
use of accessory muscles, amount of wheeze, heart rate and degree of distress, and for administration of oxygen. As far as possible, give
agitation or drowsiness. Danger signs include a silent chest, cyanosis enteral (oral or nasogastric) fluids and feed. If the child is too sick to
or low SpO2, poor breathing effort or exhaustion, low blood pressure tolerate enteral feed, give intravenous fluids at 2/3 maintenance rate.
and confusion. As asthma worsens so does the heart rate. A falling For calculation of fluid requirements see Recognising the Critically
heart rate in a child with life-threatening asthma is a pre-terminal Ill Child article in this edition of Update, page 224.
sign.21,27
Approximately 2% of infants will require ventilatory support. CPAP
Oxygen saturation monitoring is essential in all wheezy children. Peak may reduce the need for intubation and ventilation. Look out for any
Expiratory Flow (PEF) rate is commonly used for disease monitoring infant who is tiring or has other danger signs indicating the need for
in developed countries. If the child is familiar with its use it can also intubation or PICU admission. (See Box 6).
provide additional information in the acute exacerbation, but is not
essential. Routine antibiotics are not recommended.17,38 Children requiring
ventilatory support or with more serious illness may have co-existing
For children under the age of 2 years the primary cause of intermittent bacterial infections, so empirical antibiotic cover is reasonable in
wheeze is usually viral infections. Very few will have wheeze due to these children.
asthma.27
One or two doses of 3% saline administered through a nebuliser
The child with an acute severe exacerbation of asthma needs may increase the clearance of mucus in children with non-severe
immediate medical attention, assessment and treatment. It can be a bronchiolitis presenting to hospital. Evidence suggests a shorter
frightening situation, not only for the child and their carers, but also hospital stay with no significant adverse effects. Further research
for hospital staff, so call for senior help immediately. Keep calm so is required to determine the safety profile of nebulised hypertonic
as not to distress the child further. Allow the child to position itself saline.39
in the most comfortable posture, which is often sitting upright, to
reduce respiratory distress and improve chest wall movement. The wheeze in bronchiolitis is mainly caused by debris in the airway,
unlike the bronchospasm seen with asthma. Bronchodilators are
Management of asthma is shown in Box 3. Treatment aims to reverse not recommended due to their lack of efficacy, cost and side-effects
bronchospasm so that normal respiratory gas exchange is restored. (rapid heart rate and shakiness).8,17
Use bronchodilators to relieve bronchospasm, steroids to reduce
bronchial oedema, and treat any infection if present. The majority Current evidence implies possible positive short-term benefit of
of acute asthma attacks are triggered by viral infection so antibiotics steroids for inpatients with bronchiolitis, but long-term outcomes
should not be given routinely.27 Avoid any drugs that are known are unchanged.40 Although some research indicates that the
to release histamine, as they will worsen bronchospasm. Consider combination of steroids used with epinephrine nebulisers may
medications such as magnesium, salbutamol, aminophylline and reduce outpatient admissions, long term effectiveness and safety still

Table 5. Assessng the severity of asthma in children > 2 years old21,27
Symptoms and Signs Classification Immediate treatment

Danger signs: Life threatening Seek urgent senior help
Silent Chest Continue management as for severe asthma
Cyanosis or low saturation Consider adjuncts, intubation and ventilation.
(SpO2 <92%) Needs ICU admission
Poor respiratory effort
Low blood pressure
Exhaustion
Confusion
PEF <33% predicted/best
Cant complete sentences or unable Severe Seek urgent senior help
to feed Check ABC
PEF 33-50% of predicted/best Administer oxygen
Fast breathing: Nebulised salbutamol 2.5-5mg (or 2 puffs of inhaler
- >50 bpm 2-12month old via spacer every 2 mins up to 10 puffs)
- >40 bpm 1-5 year old Nebulised ipratropium bromide
- >30 bpm >5 year old
Fast heart rate
- >140 2-5 year old
- >125 >5 years year old
Able to talk in sentences or feed well Moderate Administer Oxygen
SpO2 >92% Nebulised Salbutamol 2.5-5mg (or 2 puffs of inhaler
PEF >50% predicted/ best via spacer every 2 mins up to 10 puffs)
Fast breathing but: Nebulised Ipratropium
- <50 bpm 2-12month old
- <40 bpm 1-5 year old
- <30 bpm >5 year old
Fast heart rate, but:
- <140 in 2-5 year old
- <125 in >5 year old
requires further research and adrenaline nebulisers are not routinely continuous positive pressure of between 5-10 cmH20 to keep alveoli
recommended.17,40,41 There is insufficient evidence to support the use open, reduce sheering injury and allow improved oxygenation. CPAP
of adrenaline in inpatients, but it may be of value in the outpatient can be administered via nasal prongs in infants or through a tight
setting.41 fitting facemask in older children. Low cost systems are available.
Non-invasive positive pressure ventilation (NIPPV) administers
ADVANCED VENTILATORY SUPPORT IN CHILDREN an alternating inspiratory and expiratory pressure triggered by the
WITH ALRI patients own breathing efforts. It is particularly useful for aiding
carbon dioxide clearance. Non-invasive techniques may reduce the
Advanced ventilatory support necessitates high-dependency or
need for intubation and ventilation.
paediatric intensive care admission. The main options are either non-
invasive or invasive ventilation. Invasive ventilation
Invasive ventilation requires intubation with an endotracheal tube.
Non-invasive ventilation There are numerous ventilation modes and equipment available. The
Non-invasive ventilation relies on augmenting the childs own choice of technique will depend on clinician experience, equipment
respiratory effort to reduce the work of breathing. Continuous Positive availability and the childs clinical condition. Lung-protective
Airway Pressure (CPAP) acts as its name suggests by administering a strategies should be used (Box 7). The process of intubating a

Box 3. Management of acute severe asthma15,21,27
Initial management of acute severe asthma:

Asses ABC and administer high flow oxygen
Nebulised salbutamol (2.5-5mg) or 10 puffs administered via an inhaler and spacer
Nebulised ipratropium bromide (250 micrograms)
Oral prednisolone 20mg (2-5years), 30-40mg (>5year). Use hydrocortisone 4mg.kg-1 IV if unable to take orally
Review response to treatment. Repeat ABC assessment
If there is no improvement:
Adrenaline IM 10 micrograms.kg-1 (consider IV adrenaline infusion only if specialized syringe pumps and continuous
electrocardiography monitoring are available)
IV salbutamol bolus dose (15mcg.kg-1 over 10 min)
IV aminophylline
IV magnesium sulphate 40mg.kg-1 (max 2g)
Ketamine or volatile agents may assist in relieving intractable bronchospasm
Subsequent management:
Rehydrate with 10-20ml.kg-1 crystalloid
Oral prednisolone 20mg (2-5years), 30-40mg (>5year) for three days
Repeat nebulisers every 20-30 minutes if required, or 3-4 hourly
Perform a chest X-ray and arterial blood gases if life-threatening asthma is not responding to treatment
Consider admission to PICU for non-invasive ventilation or intubation and ventilation
Box 4. Indications for admission to ICU for children with asthma15
The child has severe acute- or life-threatening asthma

The child is not responding to treatment
Persistent or worsening hypoxia
Hypercarbia
Falling pH on arterial blood gases
Exhaustion, feeble respiration, drowsiness or confusion
critically ill child can provoke cardiorespiratory instability and an medical treatment, the decision to intubate and ventilate should be
initial deterioration. Be prepared for potential complications as well based on the following criteria:
as competent in the management of the paediatric airway. Positive
Availability of Paediatric Intensive Care facilities
pressure ventilation may also reduce venous return to the heart thus
causing low blood pressure. Respiratory arrest
In cases of severe refractory hypoxia, consider high frequency Hypoxia and rising hypercarbia
oscillation (HFO) if available. This acts on the open lung strategy Exhaustion
by providing a continuous distending pressure around which
oscillations of a frequency of >150 per minute allow gas exchange.15 Altered mental state.
Invasive ventilation - special considerations Intubation risks significant complications, which you should
anticipate and plan for. These include worsening of bronchospasm,
Asthma laryngospasm, worsening hypoxia, pneumothorax and barotrauma,
If a child with life-threatening asthma fails to respond to maximal and hypotension due to reduced venous return.

Table 6. Assessing the severity of bronchiolitis15,17
Symptoms and Signs Classification Immediate treatment

Danger signs: Severe Seek urgent senior help
Breathing Rate >70bpm Administer oxygen
Periods of apnoea Assess need for ventilatory support or admission to
Infant looks ill and exhausted PICU
Sweaty and irritable
Atelectasis, marked overinflation or
evidence of ARDS on CXR
Fast breathing rate Moderate Consider admission to hospital
Increased effort of breathing Administer oxygen if required
Cough Maintain hydration
Wheeze
Hyperinflation of the chest
Fast heart rate
Box 5. Management of bronchiolitis
Assess ABC
Administer oxygen to maintain appropriate saturations
Maintain hydration:
- Attempt to hydrate with oral or NG fluids
- IV fluids may be required if the child is too sick to take oral or NG feed
- Restrict IV fluids to 2/3 maintenance
Review indications for ventilation and PICU admission
Consider nebulised adrenaline
Box 6. Indications for PICU admission in children with bronchiolitis15
Increasing oxygen requirement or inability to maintain adequate oxygen saturation in high flow oxygen
Signs of becoming exhausted
Progressive rise in PaCO2
Apnoeas
Process of intubation: Avoid rapid ventilation of the child once intubated as this
will lead to air trapping, increase the risk of pneumothorax
Ensure good intravenous access
and worsen gas exchange. Use a slow rate with a long
Give IV fluid bolus 10ml.kg-1 of crystalloid expiratory time
Pre-oxygenate for 3 minutes with tight fitting mask If severe air trapping does occur, disconnect the child from
the ventilator and physically squeeze on the chest to assist
Use ketamine for induction as it has bronchodilator effects expiration
(2mg.kg-1)
Always perform a chest X-ray after intubation to confirm
Use a cuffed endotracheal tube as high inflation pressures the correct position of the endotracheal tube and to
may be required carefully check for pneumothorax which will worsen with
positive pressure ventilation

Table 7. Ventilation in acute severe asthma42
Rationale
Mode of ventilation Pressure Controlled (PC) The decelerating waveform results in lower
inspiratory pressures for a given mean
airway pressure
Volume Controlled (VC) PC is preferable but VC may be used.
Aim for tidal volume 4-8ml.kg-1

Rate Slow for age A slow rate reduces air-trapping
5-15 breaths per minute

Inspiratory time Suggested 1.0-1.5 seconds
I:E Ratio 1:3 - 1:5 Long expiratory time helps avoid dynamic
hyperinflation
Positive Inspiratory Pressures (PIP) Limit PIP < 35cmH2O High inspiratory pressures are likely to be
required
Limit inspiratory plateau pressure
<30 cmH2O
PEEP Avoid high PEEP High PEEP will worsen hyperinflation and
air trapping
Box 7. Principles of lung protective ventilation15,42
The main aim is to optimise lung mechanics to reduce parenchymal damage, accepting altered physiological goals.
Avoid the following:
Barotrauma
High pressures over-stretch healthy lung:
Maintain plateau airway pressures <30cmH2O
Maintain peak airway pressures <35cmH2O
Volutrauma
High tidal volumes cause sheering injury to the alveoli:
Maintain tidal volumes 4-8ml.kg-1
Hyperoxia
Hyperoxia worsens atelectasis and inflammatory changes. Use the minimum oxygen required to maintain oxygen
saturations:
If possible keep FiO2 0.4
Consider the following:

PEEP to recruit alveoli
Avoid in conditions which have high intrinsic PEEP such as acute severe asthma
Permissive hypercapnoea
Accept high PaCO2 if pH normal or near normal (>7.2)
Relative hypoxia (accept SpO2 85-90%)

Optimise oxygen delivery (Cardiac output, Haemoglobin) and if possible, use lactate level to assess organ perfusion.

Ventilation of a child with asthma can be difficult. Due to the tight 6. United Nation Childrens Fund (UNICEF). Child info: monitoring
bronchoconstriction, high pressures may be required. Be careful the situation of children and women - Pneumonia. http://
to use techniques to limit barotrauma and air trapping which are www.childinfo.org/pneumonia.html (accessed 28th August
common in asthma. Hypercarbia can be tolerated so long as the pH 2012).
remains >7.2. Table 7 shows suggestions for ventilating such a child.
7. World Health Organisation (WHO)/The United Nations
Continue bronchodilators during ventilation. Administer by Childrens Fund (UNICEF). Global action Plan for Prevention
nebulised form via the breathing system or as intravenous infusions. and control of Pneumonia (GAPP). France: WHO, 2009.
8. Gadomski AM and Brower M. Broncholdilators for bronchiolitis
Ketamine (0.5-2mg.kg-1.hour-1) may be used as a sedative, either
(a review). Cochrane Database of Systematic Reviews 2010;
alone or with morphine/midazolam.
Issue 12.
If the patient remains hypoxic, investigate for pneumothorax and 9. Gilani Z, Kwong YD, Levine OS, Deloria-Knoll M, Scott JAG, OBrien
signs of infection. Evaluate the use of beta2-agonists, which may KL et al. Literature Review and Survey of Childhood Pneumonia
worsen VQ mismatch in the presence of hypovolaemia. Studies: 2000-2010. Clin Infect Dis 2012; 54(Supplement 2):
S102-108.
Bronchiolitis
In bronchiolitis, the primary difficulty is achieving adequate 10. Rudan I, Boschi-Pinto C, Biloglac Z, Mulholland K, Campbell H.
oxygenation. High inspiratory pressures may be required. Low Epidemiology and etiology of childhood pneumonia. Bull
respiratory rates with long inspiratory times will help to allow World Health Organ 2008; 86(5):321-416. http://www.who.int/
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11. World Health Organisation (WHO). Fact sheet N292: Indoor
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mediacentre/factsheets/fs292/en/ (accessed 22rd July 2012).
CONCLUSIONS
Poverty is a substantial risk factor for many diseases, both infectious 12. World Health Organisation (WHO). What are the key health
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acute lower respiratory tract disorders should be managed with the (Supplement 1): 4S-12S.
same systematic (ABC) approach. Following diagnosis, the key is to
deliver prompt treatment, regularly reassess the childs response to 14. Nair H, Nokes JD, Gessner B, Dherani M, Madhi S, Singleton, RJ
treatment and watch for signs of deterioration, which may necessitate et al. Global burden of acute lower respiratory infections due
admission to intensive care facilities. Development of guidelines to respiratory syncytial virus in young children: a systematic
will improve the quality of treatment delivered, thereby reducing review and meta-analysis. Lancet 2010; 375: 154555.
morbidity and mortality. 15. Chapter 21: Respiratory Disease. In: Barry P, Morris K and Ali
T (eds). Oxford Specialist Handbook in Paediatrics: Paediatric
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Resuscitation Council (UK)
Paediatric
Basic Life UNRESPONSIVE?
Support
(Healthcare professionals
with a duty to respond) Shout for help
Open airway
NOT BREATHING NORMALLY?
5 rescue breaths
NO SIGNS OF LIFE?
15 chest compressions
2 rescue breaths
15 chest compressions
Call resuscitation team

OCTOBER 2013
5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR
Telephone (020) 7388 4678 Fax (020) 7383 0773 Email enquiries@resus.org.uk
www.resus.org.uk Registered Charity No. 286360
Figure 1. Reproduced by kind permission of the European Resuscitation Council and available at: www.resus.org.uk/pages/pblspost.pdf
Paediatric life support
Reprinted with updates for 2013 algorithms from: Bingham B. Paediatric life support. Update in Anaesthesia
Resuscitation
2009 25(2):31-37.
Bob Bingham
Correspondence email: bingham@doctors.org.uk
There are some differences between resuscitation
techniques for children and adults but there are also Signs of decompensation
many similarities. There is no doubt that a child in
Diminishing level of consciousness is an important sign of
cardiorespiratory arrest will be harmed more by doing decompensation and imminent arrest
nothing than by using adult resuscitation guidelines.
In addition, for decompensating respiratory failure
Children usually suffer from secondary cardiac arrest
Sudden fall in respiratory rate Summary
the heart stops secondary to hypoxia or ischaemia
caused by respiratory or circulatory failure. The main Exhaustion Children usually suffer
implication of this is that there is potential to recognise cardiac arrest secondary to
Very quiet or silent chest.
the primary cause early on and prevent its progression hypoxia or ischaemia due
to full blown arrest. Respiratory or circulatory failure Decompensating circulatory failure to respiratory or circulatory
is initially compensated by the bodys physiological failure.
Hypotension
mechanisms and the signs are fairly subtle. Cardiac arrest is commonly
Sudden fall in heart rate.
reversed by simple
interventions.
Signs of compensated respiratory failure
Fortunately, the actions required to reverse this process Early recognition of a child
Tachypnoea or bradypnoea (e.g. in narcotic at risk of deterioration is
overdose)
are usually simple and follow the familiar ABC format.
essential.
Increased work of breathing: COMMENTARY - BASIC LIFE SUPPORT Avoid interruptions in chest
- Anxious appearance (Figure 1) compressions.
- Use of accessory muscles of respiration A Airway

- Noises stridor, grunting or wheeze Opening a childs airway is similar to opening that
of an adult a head tilt and chin lift. The most
- Nasal flaring.
important difference is to avoid pressing on the soft
tissues underneath the jaw as this pushes the tongue
backwards into the oropharynx and can worsen
Signs of compensated circulatory failure airway obstruction. Infants have a prominent occiput
Tachycardia and simply require the head to be placed in a neutral
position overextension is not helpful. If this simple
Slow capillary refill
manoeuvre is ineffective a jaw thrust (performed in the
Cool peripheries same way to that in adults) usually works.
Thirst Sometimes an airway adjunct is required and the most
useful is an oropharyngeal airway. The size is selected
Lethargy. so that tip of the airway is level with the angle of the
jaw when the flange is lined up with the lips. It can
be inserted in the same way as for an adult airway (i.e. Bob Bingham
In the compensated phase there are good opportunities Consultant Paediatric
introduced upside down and then rotated 180 degrees
to prevent deterioration by the administration of Anaesthetist
into its final position) but care should be taken not to
general treatment such as oxygen and fluid (in The Hospital for Sick
damage the hard palate.
circulatory failure) and specific treatments such as Children
salbutamol in asthma and antibiotics in pneumonia Successful opening of the airway should be assessed by Great Ormond Street
or sepsis. This compensated phase may progress to looking (for chest movement), listening (for air flow London
decompensation, however and, if immediate action is at the nose and mouth) and feeling (for expired air on WC1N 3JH
not then taken, to cardiorespiratory arrest. your cheek held close to the childs nose and mouth). UK

If there is chest movement and you can hear and feel expired air If a shockable rhythm is present defibrillation with 4J.kg-1 should
then the airway is clear and oxygen (if available) should be be performed immediately. Chest compression should be restarted
given. immediately even if a rhythm change is seen on the monitor. This
is important, as the heart will not be able to support the circulation
If there is chest movement but no expired air then the airway is
for a minute or so, even if sinus rhythm resumes. If defibrillation
still obstructed and it should be repositioned.
is unsuccessful, CPR should be continued for a further 2 minutes
If there is no chest movement, positive pressure ventilation is and the defibrillation cycle repeated. If a third shock is necessary,
required. epinephrine (adrenaline) should be given immediately before and an
anti-arrhythmic should be used before a fourth shock. Amiodarone
B Breathing (5mg.kg-1), where available, is preferred but lidocaine (1mg.kg-1) is
Positive pressure ventilation (IPPV) may be given with expired air an acceptable alternative.
(mouth to mouth) or bag mask ventilation (BMV) with a self-inflating
2. Non-shockable rhythm - asystole or pulseless electrical
bag/mask system.
activity (PEA)
Mouth to mouth ventilation requires no equipment but is inefficient If the rhythm is not shockable, the emphasis is on good quality
as it only delivers expired oxygen concentrations (about 17%). CPR with minimum interruption in ECC together with adrenaline
Nevertheless it can be lifesaving. administration every 3-5 minutes.
The most important points are to open the airway effectively (as above) 3. Reversible causes
and to achieve a good seal with your lips over the childs mouth (or In both shockable and non-shockable rhythms treatable causes should
nose and mouth in a small infant). You should deliver enough breath be sought and dealt with. Children rarely suffer from primary heart
to make the childs chest rise as if they had taken a normal breath. disease, so there is often a precipitating cause and resuscitation will not
The same principles apply to BMV the airway should be open and be successful if this is not removed. Treatable causes can be remembered
there should be a good seal, this time between the mask rim and the by the 4Hs and the 4Ts mnemonic.
childs face. If this is difficult it may help to have 2 people one to
do a jaw thrust and to achieve a seal with the mask using both hands 4Hs 4Ts
and the other to squeeze the reservoir bag. Again, the aim is to make
the chest rise as if the child has taken a normal breath. Five rescue Hypoxia Tension pneumothorax
breaths should be delivered in this fashion and then an assessment of
Hypovolaemia Cardiac Tamponade
the circulation should be made.
Hypo/hyperkalaemia Toxicity
C Circulation
In diminished level of consciousness due to decompensated respiratory Hypothermia Thromboembolism
or circulatory failure, failure to respond to positive pressure ventilation
by moving, coughing or resuming breathing is a sure sign of absence of
4. Other points
an effective circulation and external chest compression (ECC) should
be immediately commenced. Prolonged searching for a pulse (>10 Drugs
seconds) is unnecessary may result in error or delay. By far the most important treatment in resuscitation is good quality
basic life support with continuous chest compression and effective, but
ECC is performed by compression of the chest to a depth of 1/3 to
not excessive, lung inflation. The next important action is to remove
1/2 of the A-P diameter, at a point just (1 fingers breadth) above the
any reversible precipitating causes. Although drugs are commonly
xiphisternum. Dont be afraid of pushing too hard. Compressions
administered, there is little evidence to support routine administration
should be at a rate of 100 per minute and 2 breaths should be given
of many of them. As the tracheal route of administration is largely
after every 15 compressions. Compressions should be interrupted
ineffective, circulatory access had to be achieved rapidly; this is most
as little as possible so, if the trachea is intubated, they should be
effectively performed by intraosseous cannulation unless a peripheral
continuous with about 10 breaths delivered every minute. Generally,
vein can be accessed immediately.
people ventilate too vigorously during resuscitation and this has been
shown to impede venous return and reduce blood flow. Oxygen
This is the most important drug in paediatric resuscitation as many
If a monitor or defibrillator is available it should be applied to check
arrests in children are due to hypoxia. Although high concentrations
whether there is a shockable cardiac rhythm (ventricular fibrillation
are often used, effective airway opening and lung inflation are by far
or ventricular tachycardia) or not. Adrenaline (10mcg.kg-1) should
the most important steps in achieving adequate oxygenation.
be given every 3-5 minutes during ECC as it increases cerebral and
myocardial perfusion. Epinephrine (adrenaline)
Epinephrine been shown to increase the chances of restoring
COMMENTARY - ADVANCED LIFE SUPPORT (Figure 2) spontaneous circulation and should be administered in a dose of
1. Shockable rhythms - ventricular fibrillation (VF) or 10mcg.kg-1 every 3-5 minutes during resuscitation. Larger doses have
pulseless ventricular tachycardia (pVT) not been shown to be effective and should not be used.

Paediatric Unresponsive?
Not breathing or only occasional gasps
Advanced Call
Resuscitation
Life Support CPR Team
(1 min CPR first,
(5 initial breaths then 15:2) if alone)
Attach defibrillator / monitor
Minimise interruptions
Assess
rhythm
Shockable Non-shockable
(VF / pulseless VT) (PEA / Asystole)
Return of
1 Shock spontaneous circulation
4 J.kg
Immediate post cardiac

arrest treatment
Immediately resume Use ABCDE approach Immediately resume
CPR for 2 min Controlled oxygenation CPR for 2 min
and ventilation
Minimise interruptions Minimise interruptions
Investigations
Treat precipitating cause
Temperature control
During CPR: Reversible Causes
Ensure high-quality CPR: rate, depth, recoil Therapeutic hypothermia?
Hypoxia
Plan actions before interrupting CPR Hypovolaemia
Give oxygen Hypo/hyperkalaemia/
Vascular access (intravenous, intraosseous) metabolic
Give adrenaline every 3-5 min Hypothermia
Consider advanced airway and Tension pneumothorax
capnography
Tamponade, cardiac
Continuous chest compressions when Toxins
advanced airway in place Thromboembolism
Correct reversible causes
5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR
Telephone (020) 7388 4678 Fax (020) 7383 0773 Email enquiries@resus.org.uk
www.resus.org.uk Registered Charity No. 286360
October 2010
Figure 2. Reproduced by kind permission of the European Resuscitation Council and available at: www.resus.org.uk/pages/palspost.pdf
Sodium bicarbonate (NaHCO3) biased by infants with sudden infant death syndrome (SIDS). Older
Bicarbonate neutralises acidosis by releasing carbon dioxide. During children and adolescents have survival rates of about 9%.
resuscitation, this cannot be cleared as there is insufficient pulmonary
Children with respiratory arrest only who havent progressed to full
gas exchange, consequently, it has not been shown to be effective and
cardiac arrest have an excellent chance of survival with about 70%
should not be used routinely. NaHCO3 may be indicated in specific
alive after 1 year.
circumstances such as hyperkalaemia or in drug toxicity (e.g. tricyclic
antidepressants).
SUMMARY
The most important intervention in paediatric resuscitation is early
Calcium has not been shown to be effective in resuscitation and it may
recognition of the child at risk of deterioration and the instigation of
even be harmful, consequently it should not be used routinely. It may
treatment intended to prevent progression to cardio-respiratory arrest.
however, be effective in hyperkalaemia, hypocalcaemia and calcium
receptor blocker overdose. Once cardio-respiratory arrest has occurred, early and good quality
CPR is the most important step for a favourable outcome. Interruptions
Amiodarone (5mg.kg-1) has been shown to be the most effective in chest compression should be avoided and compressions can be
anti-arrhythmic in resistant VF or pVT but lidocaine is an acceptable continuous once the trachea is intubated. Reversible causes should be
alternative. Amiodarone is incompatible with saline and should be actively sought and treated as many paediatric arrests are secondary
diluted in 5% glucose. to another event.
Outcomes REFERENCES
Although it is often thought that children have extremely poor Bingham B. Paediatric life support. Update in Anaesthesia 2009 25(2):31-37.
Available from: http://www.wfsahq.org/components/com_virtual_library/
outcome after cardiac arrest, this is not entirely true. Large North
media/4ffc7f76113dd649ce4ff5a2b1dd607c-Paediatric-Life-Support--
American databases have shown that children that have a full cardiac Update-25-2-2009-.pdf
arrest in a hospital have a 27% chance of survival to discharge and that
75% of these will have a good neurological outcome. Out of hospital Resuscitation Council UK. https://www.resus.org.uk/resuscitation-
resuscitation has poorer survival rates, but these figures are significantly guidelines/

Resuscitation at birth
Reprinted with updates for 2013 algorithms from: Richmond S. Resuscitation at birth. Update in Anaesthesia
Resuscitation
2009; 25(2): 65-8.
Sam Richmond
Correspondence Email: rachelhomer@doctors.org.uk
INTRODUCTION
Resuscitation of a newborn infant at birth is 1. Heat loss
straightforward, and much more likely to be successful The first item addresses the issue of minimising heat
than resuscitation of a collapsed adult. The principles loss. The baby should be received into warm towels
underlying the approach are simple. The issue is not and rapidly dried. Remove the now-wet towels, cover
complicated by a need to interpret ECGs or to manage the baby in warm dry towels and, ideally, place the
arrhythmias. Babies are well adapted to withstand the baby on a flat surface under a radiant heater. This will Summary
periods of intermittent hypoxia which are a feature of take 20 to 30 seconds during which time you can also
normal labour and delivery. At term, their hearts are begin to assess the condition of the baby. A floppy baby is unconscious
packed with glycogen and, by switching to anaerobic - a baby with good tone is
not.
respiration if necessary, can maintain some circulation 2. Assessment
for up to about 20 minutes in the face of anoxia. The baby then needs to be rapidly assessed. A healthy Good airway management
baby will: and effective rescue
Of those few neonates who get into difficulties, the breaths are key to achieving
vast majority will recover rapidly once their lungs have Adopt a flexed posture with good tone oxygenation of fluid-filled
been successfully inflated. However, it is necessary to be Have a normal heart rate which rapidly rises to lungs.
aware of some important differences between babies at above 100 beats per minute (bpm) Chest compressions and
birth and adults. It is equally necessary to maintain a drug administration are
logical approach, evaluating and completing each step Cry and breathe normally within about 30 seconds
rarely needed.
before proceeding to the next. of delivery
Though born blue, will rapidly become pink even
Neonates compared to older children
though the extremities will remain somewhat
One obvious difference between babies and older
cyanosed.
children or adults is that babies are small and have a
large surface area to weight ratio. They are also always An asphyxiated baby will:
born wet which means they are particularly prone
Be very floppy
to rapid evaporative heat loss. The initiating insult
will virtually always be an interference with placental Have a slow or even absent heart rate
respiration but the condition that a baby is born in Make no attempt to breathe or may give only a
can vary from healthy to extremely sick and all shades shuddering gasp
between., Perhaps the most important difference to
Remain blue, or maybe appear very pale due to
remember is that a baby at birth is in transition from
restriction of blood flow to the skin in an attempt
placental to pulmonary respiration. It will therefore
to maintain central circulation
have fluid-filled lungs that have never yet been inflated
with gas. You will certainly need help if the baby is like this.
COMMENTARY ON ALGORITHM Of these four attributes the most indicative of a serious

Let us now approach the algorithm.1 This algorithm problem is tone. Sam Richmond
deals primarily with term infants. To some extent Consultant
this approach can be extended to preterm infants in A floppy baby is in serious difficulty, a baby Neonatologist
similar difficulty. The management of transition in with good tone is not. Sunderland Royal
significantly preterm infants is also often referred to, Hospital
confusingly, as resuscitation; it is beyond the scope A floppy baby with a low heart rate is in serious Sunderland
of this article but is covered in detail in the Newborn difficulty whereas a baby with a slow heart rate but SR4 TTP
Life Support manual.1 good tone is probably OK. UK

Newborn Life Support
Dry the baby

Birth
Remove any wet towels and cover
Start the clock or note the time
AT
30s
Assess (tone), breathing and heart rate
ALL
If gasping or not breathing:
Open the airway
Give 5 inflation breaths
Consider SpO2 monitoring
60s STAGES
Re-assess
If no increase in heart rate
ASK:
look for chest movement
Acceptable
If chest not moving: pre-ductal SpO2
Recheck head position 2min 60%
Consider 2-person airway control
3min 70%
and other airway manoeuvres
Repeat inflation breaths 4min 80%
Consider SpO2 monitoring 5min 85%
Look for a response 10min 90%
If no increase in heart rate

look for chest movement DO
When the chest is moving:
If heart rate is not detectable YOU
or slow (< 60 min-1)
Start chest compressions
3 compressions to each breath
NEED
Reassess heart rate every 30s
If heart rate is not detectable
or slow (<60 min-1)
consider venous access and drugs
HELP?
October 2010
Figure 1. Reproduced by kind permission of the European Resuscitation Council and available at: http://www.resus.org.uk/pages/nlsalgo.pdf
The next most important attribute is heart rate. In a baby in difficulty 5. Circulation - re-evaluate heart rate
the heart rate will almost instantly respond as soon as oxygenated Having given five inflation breaths you should then assess whether
blood reaches the heart. This will give you the first sign that your the heart rate has increased. If it has then this is a firm indication
resuscitative efforts are having a positive effect. You therefore need that you have aerated the lung. This also tells you that all that is
to know what the heart rate is at the start so as to be able to judge necessary is for you to gently ventilate the baby until it starts to breathe
whether it has later improved. normally. A rate of 30 or so ventilation breaths per minute, each with
an inspiratory time of around one second, will usually be sufficient
ABCD to maintain the babys heart rate above 100bpm during this period.
From here on the algorithm follows a familiar pattern Airway,
Breathing, Circulation and Drugs. It is vital that you deal with these If the heart rate has not improved, you need to know whether this is
items in sequence. In adult collapse compression only CPR may be because your attempts at lung aeration have not been successful the
effective because the primary problem is commonly cardiac. In babies most likely reason or have you actually succeeded in aerating the
the problem is a respiratory one. Applying chest compressions before lungs but the circulation has deteriorated to such an extent that this
inflating the lungs merely attempts to circulate blood through fluid alone is not going to be sufficient. The only way to judge this is to see
filled lungs where it has no hope of acquiring oxygen and is a time- if you can detect passive chest movement in response to attempts at
consuming distraction. lung inflation. Is the chest moving when you try to inflate it?
3. Airway Initial chest movement is likely to be subtle and you may have to
An unconscious baby placed on its back will tend to obstruct its airway stoop down and look carefully from the side during further attempts
due to loss of tone in the oropharynx and jaw. This allows the tongue at inflation to be sure on this point. The commonest error is to assume
to fall back to obstruct the oropharynx. This tendency is exacerbated successful chest inflation when it is not present. It is absolutely crucial
by the relatively large occiput of the newborn baby which will tend that this question is answered correctly. If you assume that you have
to flex the neck. In order to open the airway of a baby the head is best inflated the lungs when you have not, then proceeding to chest
held in the neutral position with the face supported parallel to surface compressions will not have any hope of success and you are merely
on which the baby is lying. Over-extension of the neck is likely to wasting time. Equally, if you assume you havent inflated the chest
obstruct the airway, as is flexion. when you have then you will fail to initiate chest compressions when
they are necessary and will also waste precious time. The one saving
Supporting the jaw and, in very floppy babies, providing formal grace is that if you actually have inflated the chest then the rapidly
jaw thrust is sometimes necessary. Given the relatively large size of improving chest compliance will make chest movement easier to
the newborn babys tongue compared to size of the mouth an oro- see with subsequent imposed inflations so chest movement should
pharyngeal airway may also be helpful. eventually become obvious.
Special case meconium aspiration If chest movement is not seen then the airway is the problem and this
Some babies who get into difficulties before delivery may pass must be addressed before going any further. Unless and until the lung
meconium in utero. If insulted further, they may inhale this meconium is successfully inflated nothing else will have any chance of success.
into the oropharynx or airways during episodes of anoxic gasping Apart from checking for obvious problems such as failure to switch on
before birth. In a baby who is born through heavily meconium the air supply or a big leak from the mask, check the following issues:
stained liquor and who is unresponsive at delivery and only if
Consider:
unresponsive2,3 - it is worth inspecting the oropharynx and removing
any thick particulate meconium by means of a large bore suction Is the baby truly being supported in the neutral position?
device. If the infant is unresponsive and you have the appropriate
skill then intubating the larynx and then hoovering out the upper Is jaw thrust necessary?
trachea by applying suction to the tracheal tube during withdrawal
may remove a potential blockage. Attempting to remove meconium Would an oro-pharyngeal airway be helpful?
or other endotracheal blockages by passing a suction catheter down Might you achieve better airway control with two people
through the endotracheal tube itself is unlikely to be successful as the controlling the airway?
bore of the catheter will be too small for the purpose.
Are you actually delivering an appropriately long inspiratory time?
4. Breathing
If the baby has not yet responded then the next step is to ventilate the Might there be a blockage in the oro-pharynx or trachea?
lungs. Remember the lungs will be fluid filled if the baby has made no The presence of meconium on a collapsed baby may give a clue to
attempts to breathe. Apply a well fitting mask to the mouth and nose a blocked airway. It is well known that other less obviously visible
and then attempt to inflate the lungs with air at a pressure of around substances such as blood clots, lumps of vernix or thick mucus plugs
30 cm of water aiming for an inspiratory time of 2 to 3 seconds. Five can equally be inhaled and block the airway in exactly the same way.6
such inflation breaths will usually be successful in aerating the lung
to an extent that will allow any circulation to bring some oxygenated Once chest movement has been achieved and only then consider
blood back to the heart producing a rapid increase in heart rate. chest compressions if the heart rate remains slow or absent.

6. Chest compressions who have undergone a severe but sudden and recent insult rather than
If the heart rate has not responded to lung inflation alone then a brief those whose insult has been intermittent and chronic.
period of chest compressions may be all that is necessary to bring a
little oxygenated blood from the lungs back to the coronary arteries 8. Post-resuscitation care
which will then produce a rapid cardiac response. The most effective Watch babies who have been successfully resuscitated for signs of
way to perform chest compressions is with both hands encircling the hypoxic-ischaemic encephalopathy. Those showing such signs should
chest. Place the thumbs together centrally over the lower sternum with be offered therapeutic hypothermia.8
the fingers overlying the spine at the back, briskly compress the chest
between fingers and thumbs at a rate of about 120 beats per minute. SUMMARY
Current advice is that you should intersperse breaths at a rate of one Resuscitation of babies at birth relies upon good airway management
breath for every three beats during this manoeuvre though there is no and effective lung inflation with the need to add chest compressions
clear evidence as to the most appropriate compression:inflation ratio. on very rare occasions. Air is all that is necessary for lung inflation
and drugs have a very limited place.
The need to proceed as far as this is relatively rare probably around
1 in 1000 births and the length of time compressions are needed is
REFERENCES
also relatively short a few minutes at most.7
Richmond S. Resuscitation at birth. Update in Anaesthesia (2009) 25(2):65-
Having given 30 to 60 seconds of chest compressions you should 68. Available from: http://www.wfsahq.org/components/com_virtual_
look for a response. Once again look for an increase in heart rate library/media/b4866481ef4d3dec79740f12a3a50482-Newborn-Life-
which indicates successful delivery of oxygenated blood to the heart. Support--Update-25-2-2009-.pdf
Virtually all babies will have responded by this stage. Because this is 1. Richmond S, ed. Newborn Life Support. Resuscitation at Birth. 3rd ed
the expectation it is important to check once again that lung inflation Resuscitation Council (UK), London, 2011.
has definitely been successful and that chest compressions are being 2. Wiswell TE, Gannon CM, Jacob J et al. Delivery room management
delivered as expected before deciding that further intervention is of the apparently vigorous meconium stained neonate: results of a
needed. However, if the heart rate remains slow less than about 60 multicenter international collaborative trial. Pediatr 2000 ; 105: 1-7.
beats per minute - or is absent then consider further intervention. 3. Vain NE, Szyld EG, Prudent LM et al. Oropharyngeal and nasopharyngeal
suctioning of meconium-stained neonates before delivery of their
7. Drugs shoulders: multicentre, randomised controlled trial. Lancet 2004; 364:
What else is available? There is very little published evidence to 597-602.
support any of the drugs which have been suggested for use at this 4. Wyllie J, Perlman J, Kattwinkel J et al. 2010 International consensus on
stage. Epinephrine (adrenaline) is traditional in these situations and, cardiopulmonary resuscitation and emergency cardiovascular
if given centrally - ideally via an umbilical venous cannula does care science with treatment recommendations: Neonatal
improve coronary artery perfusion pressure in animal experiments. resuscitation. Resuscitation 2010; 81S: e260-87.
Early animal studies by Geoffrey Dawes and others appear to show a 5. Dawson JA, Kamlin COF, Vento M, et al. Defining the reference range
possible place for the use of alkalinising agents such as bicarbonate and for oxygen saturation for infants after birth. Pediatrics. 2010; 125:e1340-
dextrose - again given centrally - in boosting a failing circulation at 7.
this point. Intuitively one might expect that babies who are seriously 6. Maskrey S. Neonatal resuscitation. Clinical Risk 2008; 14: 46-8.
hypovolaemic, perhaps from blood loss, would respond to appropriate
fluid expansion. If any of these manoeuvres are to be employed then 7. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery
room. Arch PediatrAdolesc Med 1995; 149: 20-5.
it is necessary to rapidly establish central venous access. This is easily
done by inserting a catheter into the umbilical vein. 8. Perlman JM, Davies P, Wyllie J et al. Therapeutic hypothermia following
intrapartum hypoxia- ischemia. An advisory statement from
It must be said that babies who appear to require this degree of help the Neonatal Task Force of the International Liaison Committee on
to survive are at very high risk of permanent and severe neurological Resuscitation. Resuscitation 2010; 81:145961.
damage, if they survive at all. Those with the least risk will be those 9. https://www.resus.org.uk/resuscitation-guidelines/

Anaphylaxis; recognition and management
Resuscitation
Crawley S M* and Rodney G R
*Correspondence Email: simoncrawley@nhs.net
INTRODUCTION
Anaphylaxis has been defined as a serious allergic and comes from the cascading release of many
reaction that is rapid in onset and may cause death.1 vasoactive substances including histamine, tryptase,
Rates of allergy and anaphylaxis in low-income leukotrienes, cytokines, platelet activating factor and
countries appear to be low compared to high-income prostaglandins.
settings, although the incidence appears to be
increasing worldwide, and anaphylaxis is becoming Initial antigen exposure results in the formation of SUMMARY
more common in children. A survey by the World specific IgE antibodies on mast cells. Second exposure
Allergy Organisation (WAO) found that essential allows binding of an antigen with IgE antibodies on Anaphylaxis is a life
drugs used in the assessment and management of the presensitised mast cells. The resulting antigen- threatening condition
anaphylaxis, with the exception of adrenaline, are antibody complex leads to the degranulation of mast Prompt recognition and
not universally available to healthcare providers, and cells and massive chemical mediator release, which optimal management
clinical guidelines were in use in only 70% of surveyed results in the classical features of: reduces adverse outcomes
nations.2 This article will describe recognition and Airway oedema Follow basic life support
management of anaphylaxis in children, with reference and anaphylaxis guidelines
Bronchoconstriction
to the UK Resuscitation Council Guidelines. Avoid further allergen
Increased vascular permeability
exposure, administer
EPIDEMIOLOGY Vasodilatation/hypotension oxygen and intravenous
Accurate information on the prevalence of fluid and raise the
perioperative anaphylaxis in children is difficult Other mechanisms are described, with non-
patients legs. These
to find. The condition is likely to be both under- IgE mediated responses often being labelled as simple measures are
diagnosed and under-reported. The incidence of all anaphylactoid reactions. These reactions do not useful in the management of
anaphylactic reactions in children and adolescents require antigen pre-sensitization, and can involve anaphylaxis
has been estimated as 10.5 in 100,000 or higher.3 direct mast cell/basophil interactions or complement
Prompt administration of
Perioperative anaphylaxis is thought to occur in activation, but still result in massive chemical
adrenaline is the most
around 1 in 10,000 anaesthetics in children. Asthma, mediator release. IgE and non-IgE reactions are effective treatment in
family history, multiple surgeries, latex exposure and clinically indistinguishable in their presenting features anaphylaxis
food allergy are all risk factors.4 Mortality rates can be and do not differ in their management. The term
significant, with up to 10% of all reported anaesthesia- anaphylactoid has now largely been abandoned.
related reactions having fatal outcomes, although it is
likely that less severe reactions go unreported.5 Asthma COMMON ALLERGENS IN CHILDREN S M Crawley
is an important risk factor for both the occurrence and Food Speciality Registrar
severity of reaction. Most fatal cases of anaphylaxis are Food allergy is the commonest cause of anaphylaxis Dept of Anaesthesia,
seen in patients with asthma. Variations in diagnostic in children.8 A 5-year retrospective study in Australia Ninewells Hospital and
criteria and reporting rates raise doubts over the true found 85% of paediatric admissions to the emergency Medical School,
incidence and outcomes in anaphylaxis treatment. department for an allergic reaction were following Dundee,
Certainly, the incidence of allergy and the number exposure to a food related allergen.9 Peanuts, fish, Scotland DD1 9SY
of prescriptions for self-administered adrenaline (e.g. milk, eggs and shellfish are most commonly identified
EpiPen) is increasing.6,7 triggers, although any food can be implicated. G R Rodney
Worldwide variation in common food allergens is Consultant
PATHOPHYSIOLOGY seen. Of particular interest to the anaesthetist is Dept of Anaesthesia,
Anaphylaxis is an IgE mediated type I hypersensitivity the association between egg allergy and propofol Ninewells Hospital and
reaction, which occurs after exposure to a (discussed below). Some children outgrow their food Medical School,
foreign molecule/antigen, and results in mast cell allergy; hypersensitivity to allergens such as nuts and Dundee,
degranulation and histamine release. The clinical shellfish remain throughout life and are commonly Scotland
syndrome of anaphylaxis is much more complex associated with more severe reactions.10 DD1 9SY

Common perioperative allergens likely with repeated usage. Etomidate hypersensitivity is exceedingly
Common allergens encountered in the perioperative period include rare. Ketamine use is increasing in hospital and pre-hospital settings
neuromuscular blocking agents, antibiotics and latex. These account and has been a common sole anaesthetic agent in the developing
for the majority of perioperative reactions. Radiological contrast, world for many years. Allergic reaction to ketamine is also rare. Thus
colloid based intravenous fluids, dye and chlorhexidine anti-septic both ketamine and etomidate provide a good anaesthetic option for
solutions are all potential causative agents. patients with previous anaphylaxis from an unidentified agent.
Neuromuscular blocking agents Other anaesthetic agents
Neuromuscular blocking agent (NMBA)-related reactions account Local anaesthetic allergy is rare. Reported reactions are more likely
for more than 60% of anaphylactic reactions in the perioperative to be caused by accidental intravascular injection or reaction to
period. All NMBAs are potentially allergenic, and cross-reactivity preservative. Inhalational anaesthetic agents are the only agents in
amongst them is common.11 Suxamethonium is more likely to perioperative practice not to have associated immune-mediated
cause anaphylaxis than any of the non-depolarising agents. The risk allergic reactions.
of anaphylaxis with different NMBA has been suggested to be as
follows12: Latex
Latex hypersensitivity is increasingly reported, and as a result,
High risk: suxamethonium, rocuronium many healthcare institutions have moved to a latex free clinical
environment. Perioperative reaction rates are now falling in areas
Intermediate risk: vecuronium, pancuronium where this has been achieved. The following groups of children are at
Low risk: atracurium and its isomer, cisatracurium high risk for latex allergy:17
Controversy surrounds the risk of anaphylactic reaction to Multiple operations

rocuronium. Some studies claim it to be a high-risk allergen Surgery in the neonatal period
while others suggest that it is an intermediate risk agent and that
Atopic children
increased reaction rates merely reflect increased frequency of use.13
Non-immune histamine release is seen with atracurium and other Spina bifida
benzylquinolonium compounds. Anaphylaxis during first time
Cerebral palsy.
exposure to NMBAs is also common. Sensitisation is thought to be
due to exposure to other compounds with a quaternary ammonium There is also recognised cross reactivity between latex and food such
ion, found in common household products such as cosmetics, as kiwi, banana and avocado.18 Hospitals should have clear policies
toothpaste, cough syrup and detergent. for latex allergic patients. Staff should have good knowledge of latex
products and the latex-free alternatives. Medical staff should use latex
Antibiotics free products where possible to avoid sensitisation of themselves and
Antibiotics account for up to 15% of all reactions occurring under their patients.
anaesthesia and up to a third of all adverse drug reactions in the
paediatric population. Rates seem to be increasing.12, 14 Penicillins Chlorhexidine
and cephalosporins are commonly used in perioperative care and are Chlorhexidine is a chemical antiseptic used for skin preparation
the most frequent cause of drug-related hypersensitivity reactions in surgery, and is also present in a number of different household
in children. The two agents have a shared -lactam ring, and cross- products such mouth washes, antiseptic wipes, eye drops, and as a
reactivity rate of 10% between the two classes of drug is often quoted, coating for medical devices such as urinary catheters, central lines
but is now discounted by many experts.15 It is prudent to avoid cross- and antiseptic dressings. Anaphylaxis to chlorhexidine has been
exposure in those with previously documented anaphylaxis to either reported in those with a known allergy to chlorhexidine, but where
agent. Fortunately, anaphylactic reactions to other broad-spectrum the presence of chlorhexidine was not recognised, for instance in a
antibiotics such as clindamycin and gentamicin are rare. medical device.
Induction agents RECOGNITION OF ANAPHYLAXIS
Propofol is formulated in a lipid emulsion of soya oil, glycerol and egg
Anaphylaxis is an acute, severe multisystem disorder. It varies in
phosphatide and is a commonly used induction agent. The egg-based
its presentation and severity and so a high index of suspicion is
constituent of propofol is a highly purified phosphatide, lecithin,
required. Clinical diagnosis is aided by history and clinical context.
whilst the allergens responsible for hypersensitivity reactions are the
It is important to recognise that anaphylaxis can occur on the first
egg white proteins: ovoalbumin, ovotransferrin and ovomucoid.
exposure to a drug and within seconds of administration, particularly
Propofol allergy is well documented, but a direct causal relationship
if given by the intravenous route. The vast majority of anaphylactic
between propofol and egg allergy has not been demonstrated.
reactions occur around induction of anaesthesia. Symptoms and
Manufacturers suggest a cautious approach is best in those with egg-
signs evolve within seconds or minutes of allergen exposure. The
related anaphylaxis, but propofol has been widely administered to
chief difficulty in managing perioperative anaphylaxis has often
egg allergic patients without incident.16
been to distinguish it from other serious adverse reactions during
Thiopentone related anaphylaxis is recognised and becomes more surgery and anaesthesia, shown in Table 1. Anaphylaxis must always

be considered in the event of perioperative airway obstruction, Table 2. Clinical criteria for diagnosing anaphylaxis (adapted
bronchospasm and hypotension. with permission from Sampson HA,1 included with permission of
Sampson HA & Elsevier)
Dermatological signs may be the first to appear and can include
pruritis, urticaria, erythema, flushing or angioedema. Over 80%
of paediatric reactions have skin manifestations. In the absence of Anaphylaxis is highly likely when any ONE of the following three
skin manifestations the diagnosis can be overlooked in favour of criteria is met:
an alternative event. Even when present, these classical signs may
1. Acute onset of illness (minutes to several hours) with involvement
be missed as access for examination is limited by surgical drapes or
of the skin, mucosal tissue, or both (e.g. generalised urticaria,
impeded by poor theatre lighting. Signs may also be less obvious in itching or flushing, swollen lips-tongue-uvula) and at lease ONE of
pigmented skin. the following:
Respiratory manifestations occur in over 90% of children and are the Respiratory compromise (e.g. dyspnoea, wheeze,
most worrying. Laryngeal swelling and bronchospasm may rapidly bronchospasm, stridor, reduced PEF, hypoxaemia)
cause hypoxia. If the child is conscious, they may initially develop Reduced blood pressure or associated symptoms of end
hoarseness or complain of a tingling throat. They can rapidly develop organ dysfunction (e.g. hypotonia [collapse], syncope,
stridor and upper airway obstruction. incontinence)
Cardiovascular effects such as hypotension are less common signs 2. Two or more of the following that occur rapidly after exposure to
in children, only found in between a quarter and a third of cases. a likely allergen for that patient (minutes to several hours):
Tachycardia and hypotension indicate more severe reactions. Involvement of skin-mucosal tissue (e.g. generalised
Cardiovascular collapse is a late sign, which occurs peri-arrest. It is urticaria, itch-flush, swollen lips-tongue-uvula)
usually due to hypovolaemia due to both profound vasodilatation Respiratory compromise (e.g. dyspnoea, wheeze,
and increased capillary permeability leading to fluid leakage. bronchospasm, stridor, reduced PEF, hypoxaemia)
Reduced blood pressure or associated symptoms (e.g.
Gastrointestinal symptoms such as abdominal pain, nausea, vomiting
hypotonia [collapse] syncope, incontinence)
and diarrhoea may also be seen in non-anaesthetised children.
Persistent gastrointestinal symptoms (e.g. abdominal pain,
A diagnostic tool has been proposed to improve identification of vomiting)
patients with anaphylaxis.1 This is outlined in Table 2. It is proposed
3. Reduced blood pressure after exposure to a known allergen for
that following these criteria will identify over 90% of reactions,
that patient (minutes to several hours)
leading to early treatment and thus improved outcome.
Infants/ children: low age - specific systolic blood pressure
ALGORITHMS AND GUIDELINES or greater than 30% decrease in systolic pressure
There are many published guidelines and management algorithms
in the literature. Many nations adopt those produced by their own
national societies and expert panels. In 2011, the World Allergy
and is an excellent resource.19 The algorithm produced by the UK
Organisation (WAO) Anaphylaxis guideline was created following
Resuscitation Council is well presented and concise, making it ideal
a lack of a single global template for anaphylaxis management
for display in clinical areas.20 This is shown in Figure 1. The choice
of guideline in itself is not important. Of greater importance is that
Table 1. Differential diagnosis of anaphylaxis clinical staff are aware and have access to the guideline. They must
also have opportunity to rehearse critical incident scenarios in the
Depth of anaesthesia (too deep i.e. hypotension) management of anaphylaxis.
Depth of anaesthesia (too light i.e. bronchospasm) Immediate management

Use an ABCDE approach for assessment. This approach, combined
Inhaled foreign body with knowledge of presenting symptoms/signs and implementation
of diagnostic criteria, aids a prompt diagnosis. Once anaphylaxis
Acute asthma
has been recognised, you should also follow an ABCDE approach
Drug induced histamine release (opioids, atracurium etc) in management, combined with the rapid implementation of basic
measures of care as outlined below (see Figure1). For life threatening
Flushing syndrome (red man syndrome with vancomycin) or severe reactions, you must do this together with the prompt
Pulmonary /air embolism administration of intramuscular adrenaline. A rapid decision is
needed as to whether the surgical procedure is able to continue.
Vagal syncope It is recognised that many healthcare providers may have limited
resources and limited access to drugs and monitoring equipment.
Hypovolaemic shock
It is important to recognise that many reactions can be treated
Septic shock successfully with implementation of simple measures and the early
administration of adrenaline alone.

FIGURE 1. Treatment algorithm for anaphylaxis (with permission from Resuscitation Council UK20)

Basic measures adrenaline. Titrate IV adrenaline to effect, starting from 0.1mcg.
Stop further administration of potential causative agents, administer kg-1.min-1 (range 0.1-1.0mcg.kg-1.min-1) to achieve a normal blood
supplementary oxygen and place the patient supine with legs raised. pressure. Although adrenaline can be infused peripherally initially, it
These are simple measures to implement. These can be instituted should be administered via a central venous catheter if possible. An
whilst extra help, equipment and adrenaline is obtained. If not adrenaline infusion can be made by adding 0.3mg.kg-1 adrenaline
already in place, obtain appropriate airway management and vascular to 50ml of 0.9% saline or 5% dextrose; an infusion of 1ml.hr-1 =
access. Treat cardiac arrest using the standard resuscitation protocols. 0.1mcg.kg-1.min-1.
Early adrenaline Dopamine, noradrenaline and phenlyephrine are acceptable
The early use of adrenaline is the most important factor in achieving alternatives; noradrenaline has a powerful alpha-receptor agonist
a good outcome. Adrenaline acts on alpha and beta adrenoreceptors effect and should be considered if hypotension is unresponsive to
and increases systemic vascular resistance, coronary perfusion adrenaline. Specialised equipment, monitoring and appropriately
pressure, cardiac contractility whilst causing bronchodilatation and trained staff are required if a vasopressor infusion is used: the child
inhibiting inflammatory mediator release. should be looked after in an intensive care unit or high dependency
unit if possible. Mortality can be high in this patient group, even in
Adrenaline 1:1000, at a dose of 0.01ml.kg-1 intramuscularly (IM), well-resourced clinical settings.
is the drug of choice and should be injected into the antero-lateral
thigh. Some algorithms have simplified adrenaline dosing to include Secondary management
EpiPen use, with a range of 150micrograms (0.15ml 1:1000 Adrenaline is the drug treatment of choice for severe anaphylaxis.
adrenaline) to 500micrograms (0.5ml 1:1000 adrenaline) depending Antihistamines and steroids are useful adjuncts for the management
on age (see Figure 1). The IM route is preferred as it confers a better of anaphylaxis, but their administration should not delay the use
safety profile in the hands of most health professionals. of adrenaline. There is concern that inclusion of agents other than
adrenaline in guidelines risks their use as inappropriate first line
The intravenous (IV) route should be used with caution. Arrhythmias
agents.23
can be induced if adrenaline is given IV (VF/VT), so ECG monitoring
is essential. The intraosseous (IO) route can also be used, using the Histamine (H1) antagonists such as chlorpheniramine (2.5-10mg
same dose as the IV route. IO adrenaline should be followed by a IM or slow IV, see Figure 1) are useful in minor allergic reactions
saline flush. Ongoing clinical assessment is essential. If ineffective, but their speed of action means they are not appropriate as first line
the IM adrenaline can be repeated at 5-minute intervals with further agents. Some guidelines omit them entirely as there is a lack of strong
doses indicated until clinical improvement is achieved. evidence for their use, their effect on outcomes, or in prevention of
biphasic reactions.
Airway
It is essential to maintain a clear airway and give oxygen. Early Steroids, such as hydrocortisone (25-200mg IV depending on age,
endotracheal intubation is advised if there is any suggestion of upper see figure 1), are often given IV in the treatment of anaphylaxis, but
airway obstruction developing. A range of endotracheal tube sizes offer little benefit in the acute phase. Intravenous methylprednisolone
should be available to allow for any developing laryngeal oedema and (1mg.kg-1) has been used in less severe reactions, or where the oral
intubation difficulty. Surgical cricothyroidotomy may be required if route is still available, prednisolone 1mg.kg-1 PO. Steroids are
there is severe oedema or if mask ventilation is not possible. thought to reduce the risk of biphasic reactions. Biphasic reactions
can occur in up to 20% of cases, with most occurring in the first
Breathing
6 hours. A period of close observation is recommended in a well-
Bronchospasm may be alleviated by IM adrenaline through its action
staffed and monitored environment. They are more often seen in
on beta-2 adrenoreceptors. Treatment with a nebulised beta-2 agonist,
those patients who have delayed administration of adrenaline, or
such as salbutamol 2.5-5mg is useful, although this should not delay
in those who require repeated doses, so a period of observation is
administration of adrenaline if it is required. Administration to an
required after stability is achieved.20 A recently published systematic
anaesthetised patient is described elsewhere (page 61 and reference
review showed that there is no good quality evidence to support the
21).
use of glucocorticoids in this setting, although use in patients with
Circulation coincidental asthma is still advisable.23
Obtain vascular access, if not already secured, and begin fluid
Investigations and follow-up
resuscitation. Change to the IO route if IV access is difficult. Give
Correct identification of triggers for anaphylactic reaction in the
20 ml.kg-1 IV bolus of crystalloid (0.9% saline or balanced salt
perioperative period can be difficult as patients are exposed to
solutions) if the child is hypotensive. Give further fluids titrated to
multiple drugs and potential causative allergens in a brief period.
blood pressure, urine output and heart rate. Position the child head
down if hypotension persists. This increases venous return, and is Specialist laboratory assays are required to confirm the diagnosis.
useful if IV access has yet to be achieved or if access to IV fluids At present serum tryptase is the only useful blood test commonly
is limited. If more than 40ml.kg-1 IV fluid is required, consider available in most modern laboratories.
inotropic support and invasive ventilation.
The half-life of tryptase is approximately 2 hours; levels increase after
Manage fluid resistant hypotension with an adrenaline infusion mast cell activation, peaking rapidly and falling again. It is important
rather than continuing IM injections or intermittent IV boluses of that a sample of clotted blood is taken as soon as possible during

the reaction and a second sample 1 to 2 hours later to show the 6. Leiberman P, Camargo CA, Bohkle K, Jick H, Miller RL, Sheikh
rise and fall in serum tryptase. A third sample is taken at 24 hours A, et al. Epidemiology of anaphylaxis: findings of the American
to determine baseline tryptase levels and allow interpretation of the College of Allergy, Asthma and Immunology Epidemiology of
earlier results. It is essential to record the times that samples are taken Anaphylaxis Working Group. Ann Allergy Asthma Immunology.
2006; 97: 596-602.
for analysis purposes. Samples that require transfer to another centre
for analysis should be refrigerated at +4C. 7. Sheikh A, Hippisley-Cox J, Newton J, Fenty J. Trends in national
incidence, lifetime prevalence and adrenaline prescribing for
Patients who have experienced anaphylaxis under anaesthesia should anaphylaxis in England. J R Soc Med. 2008; 101:139-143.
undergo investigation prior to repeated exposure to anaesthesia. 8. Bock SA Munoz-Furlong A, Sampson HA. Fatalities due to
Make detailed records of all drugs, timings and events surrounding anaphylactic reactions to food. J Allergy Clin Immunol 2001;
the reaction. Ideally, the child should undergo further investigation 107:191-193.
and immunological testing to identify the causative agent under 9. de Silva IL, Mehr SS, Tey D, Tang MLK. Paediatric anaphylaxis; a
the guidance of a specialist allergist. This may include skin testing 5-year retrospective review. Allergy 2008; 63:1071-1076.
utilising dilute concentrations of drugs. Skin pricks or intradermal
10. Sampson HA. Anaphylaxis in children. Paediatrics 2003; 111(6
injections can be used to look for signs of sensitisation. Specific
Pt3): 1601-1608.
immunological assays, looking for antigen-specific IgE, are available
for a number of drugs. Tests are available for suxamethonium, latex 11. Krila C, Brunet-Langot C, Labbez F et al. Anaphylaxis during
and many commonly used antibiotics, but this is often only available anaesthesia: results of a 12 year survey at a French paediatric
in specialist laboratories. For many this is not achievable due to center. Allergy 2005; 60: 828-834.
lack of resource and access to a certified allergist. The Association of 12. Mertes PM, Laxenaire MC, Alla F and GERAP. Anaphylactic and
Anaesthetists of Great Britain and Ireland (AAGBI) have produced anaphylactoid reactions occurring during anaesthesia in
guidelines for anaesthetists detailing the immediate investigation and France 1999-2000. Anaesthesiology 2003; 99: 536-545.
more specialist tests that may be warranted.5 13. Rose M, Fisher M. Rocuronium; high risk for anaphylaxis? Br J
Anaesth 2001; 86: 678-82.
A strategy for any future anaesthesia is very important as patients are
14. Le J, Nguyen T, Law AV, Hodding J. Adverse drug reactions
at increased risk of another reaction. Future operations should occur
among children over a 10-year period. Paediatrics. 2006; 118
in a latex free environment where possible. Regional anaesthesia is (2): 555-562.
ideal and avoidance of NMBAs and any drug previously used or
those with recognised cross-reactivity is strongly recommended. 15.
Anne S, Reisman RE. Risk of administering cephalosporin
antibiotics to patients with histories of penicillin allergy. Ann
Allergy Asthma Immunol 1995; 74: 167-70.
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symposium on the definition and management of anaphylaxis;
140-4.
summary report: Second National Institute of Allergy and
Infectious Disease/Food Allergy and Anaphylaxis Network 17. Kagy L, Blaiss MS. Anaphylaxis in children. Paediatric Ann, 1998;
Symposium. J Allergy Clin Immunol. 2006; 117:391-397. 27 (11): 727-734.
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Immunol. 2011; 127(3): 58793.
3. Bohlke K, Davis, RL, DeStefano F et al. Epidemiology of
anaphylaxis among children and adolescents enrolled in a 20. Resuscitation Council UK. Emergency treatment of anaphylactic
health maintenance organisation. J Allergy Clin Immunol. reactions. www.resus.org.uk/pages/reaction.pdf.
2004; 113: 536-542.
21. Wilson I. Asthma and anaesthesia. Tutorial of the Week 2005;1
4. Tam JS, Kelly K, Pongracic JA. A seventeen-year review of available from http://www.anaesthesiauk.com/documents/
peri-operative anaphylaxis in a paediatric hospital. J Allergy Asthma%20and%20anaesthesia%20iii.pdf (accessed 17/10/14)
Clin Immunol 2011; 127: AB247. 22. Ellis AK. Biphasic anaphylaxis: a review of the incidence,
characteristics and predictors. The Open Allergy Journal. 2010;
5. Association of Anaesthetists of Great Britain and Ireland Safety
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Guideline. Suspected anaphylactic reactions associated with
anaesthesia. Anaesthesia 2009; 64: 199-211 available from 23.
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Accidental poisoning in children
Reprinted with revisions from: Ribbens S. Accidental poisoning in children. Anaesthesia Tutorial of the
Resuscitation
Week 95(2008)
Susara Ribbens
Correspondence email: susara@btinternet.com
INTRODUCTION if life-threatening poisoning has occurred within

Poisoning is a significant global public health problem. the previous hour, but contra-indicated if the
According to World Health Organisation data, an airway cannot be protected. Gastric lavage is also
estimated 350 000 people died from unintentional contra-indicated in the ingestion of hydrocarbons
poisoning in 2002. Accidental poisoning occurs (risk of aspiration and chemical pneumonitis) and
most often in the age group 1-5 years, although less corrosives. Multiple-dose activated charcoal
than one per cent of poisoning in children is serious. (1g.kg-1 every four hours) is used for substances Summary
More than 94% of fatal poisonings occur in low-and with a long half life (anticonvulsants, digoxin,
middle-income countries. It remains a challenge to and theophylline). The complications of gastric Prevention of childhood
identify those at risk at an early stage. lavage include aspiration pneumonia, hypoxia, poisoning is vital. prevention
requires adequate
mechanical injury to the gut and the induction of
Education of the general public and also the provision supervision, safe placement
hypo-or hypernatraemia. It may also induce of medications, child safe
of child-proof containers for household chemicals and charcoal bezoars that may cause intestinal cabinets and containers,
medicines play a key role in prevention. obstruction. Activated charcoal can cause serious blister packaging and
complications if aspirated. education. Most paediatric
(Toxic plants, insect and snake bites are not discussed
cases are not severe.
in this article, but see www.rch.org.au/poisons for 6. Remove contaminated clothing and wash patient
Recognition of potentially
more information) with soap and water. life-threatening ingestions
is important so that
ACCIDENTAL POISONING IN CHILDREN: 7. Send samples for lab investigation (urea,
appropriate early treatment
GENERAL PRINCIPLES electrolytes, blood glucose.) Urine and gastric can be instituted. Aggressive
A history of poisoning usually makes the diagnosis aspirates should be saved for later toxicology supportive care is essential.
obvious but poisoning should be considered in analysis (where available).
any child presenting with altered consciousness,
cardiorespiratory depression, hypothermia, seizures 8. Measure relevant drug levels (paracetamol and
or gastrointestinal symptoms. The possibility of more salicylate and others if available).
than one poison should always be considered. 9. ECG important in cases of tricyclic
1. Ascertain the nature and time of poisoning. antidepressants and unknown poisons. QRS
prolongation is an early sign of cardiovascular
2. Contact the local Poison Centre for advice (if involvement
available). Sources on information are common
and include internet-based information databases 10. Specific antidotes should be given as per
such as the International Programme on Chemical instruction by Poison Centre.
Safety (www.inchem.org), the UK-based
TOXBASE (www.spib.axl.co.uk ), or in the USA, SPECIFIC POISONS
TOXNET (toxnet.nlm.nih.gov). Household chemicals
3. Assess the patient following the principles of Children frequently ingest household substances and
ABC (Airway, Breathing, and Circulation). If most of these are nontoxic. However, some products
airway protection is impaired, the patient requires contain alcohol which may cause seizures and hypoxia.
intubation. Household solutions of bleach contain approximately
4. Induced emesis is no longer recommended and is 10% hypochlorite. They are rarely ingested as they are
contraindicated with volatile substances. extremely unpalatable. Commonly, they cause nausea, Susara Ribbens De Vos
vomiting and diarrhoea. Less than 100ml of household Consultant Anaesthetist
5. Consider gastric emptying and administration of bleach is unlikely to cause serious problems. Fluids University College Hospital
activated charcoal. Gastric lavage is recommended should be encouraged, particularly milk. Oesophageal London

damage occurs rarely and is associated with concentrated solutions. Nausea and vomiting are common. Aspiration pneumonitis occurs
There is a worrying recent increase in oesophageal injury associated in 12-40% of patients. Signs and symptoms appear 30 minutes after
with dishwasher tablets. Removal of these under anaesthesia is a ingestion but may be delayed for 8 hours. A non-productive cough,
medical emergency. tachypnoea and tachycardia are signs of a developing chemical
pneumonitis. There may be wheeze, coarse crackles as well as signs of
Ingestion of small quantities of strong alkalis such as drain cleaner respiratory distress (intercostals and subcostal retraction). Hypoxia
containing sodium hydroxide may cause devastating injuries. and cyanosis may be present in severe cases. Patients may be lethargic
Oesophageal injury is most common and evolves over the course or irritable. A fever may also be present. The clinical picture generally
of a few days. Ingestion causes immediate burning pain, swelling deteriorates over the first 24 hours. A temperature that persists or
of the lips, and depending on the quantity ingested, salivation, only develops after 24 hours usually suggests a secondary infection.
haematemesis, dyspnoea, stridor or shock.
Abnormalities on the chest film may be seen within 30 minutes
The burn injury is classified by endoscopy: after aspiration even in the absence of clinical signs or symptoms.
Common radiological findings of chemical pneumonitis include
mucosal (first degree burn)
bilateral perihilar infiltrates which progress to form patchy infiltrates
- usually resolves after 2-3 days and later become large areas of consolidation.
submucosal (second degree burn) Management of hydrocarbon poisoning
- requires total parenteral nutrition
ABC principles.
full thickness (third degree burn)
Observe all asymptomatic patients for at least 8 hours. Carefully
- shocked, will require intensive care.
examine patients for the development of respiratory signs. A
Third degree burns may lead to gastrointestinal perforation or airway chest film at 6 hours is recommended.
complications or long term, severe oesophageal stricture causing
absolute dysphagia which evolves over a period of several months. If asymptomatic after 8 hours and the chest film is normal, the
patient may be discharged.
Treatment is supportive; emesis is contraindicated and nasogastric
aspiration unhelpful as the injury is oesophageal. Patients with first Symptomatic patients should be Xrayed on admission.
degree burns may be discharged after 2-3 days once tolerating oral
fluids. Patients with third degree burns will be in shock and will Emesis and gastric lavage is contra-indicated as it increases the
require intensive care: tracheostomy is indicated for patients with risk of aspiration. The use of milk is not recommended, but clear
evidence of supraglottic/epiglottic burns. Steroids may reduce the fluids are not contra-indicated.
risk of stricture formation if given within 12-24 hours but their use
Oxygen should be administered to all patients with respiratory
is controversial. Antibiotics are indicated for perforation. Long term
signs or symptoms. Other respiratory support modalities should
gastrostomy or oesophageal replacement surgery (gastric pull-up)
be instigated as required, according to standard indications.
may be required for oesophageal stricture.
Hydrocarbons (paraffin, white spirit) Corticosteroid therapy may increase the risk of secondary
Most of the hydrocarbons are petroleum distillates, containing a bacterial infection and has not been shown to be of any benefit.
variable amount of saturated and unsaturated aliphatic (open-chain) Antibiotics should be given if there are suggestions of a secondary
and aromatic (cyclic) hydrocarbons. The aliphatics are not readily infection (persistent fever or a fever that develops after 24 hours.)
absorbed from the gastrointestinal tract and therefore cause minimal
systemic toxicity. Paraffin, petrol, thinners, diesel and benzene are Prophylactic antibiotics have not been shown to prevent
low viscosity aliphatic-based petroleum distillates. The aromatic secondary infection and are not advocated.
hydrocarbons are well absorbed, and therefore may cause systemic
toxic effects but are less inclined to aspiration-related complications. PESTICIDES
The main hazard of accidental ingestion of the aliphatic hydrocarbons
(paraffin) is that of chemical pneumonitis characterised by ventilation/ Paraquat
perfusion imbalance and hypoxia. The aspirated hydrocarbons Paraquat ingestion remains a problem in a large number of countries.
inhibit surfactant and also cause direct broncho-alveolar injury. This Most of these cases are intentional suicide attempts (73% in a
can occur even in the absence of vomiting or impaired consciousness Malaysian study) or occupational exposure and therefore not that
and as little as 1ml aspirated hydrocarbon can result in a chemical frequently seen in the paediatric population. It is the most toxic
pneumonitis. herbicide known, producing multi-organ failure. After oral ingestion,
patients develop a severe gastroenteritis with oral, oesophageal and
Paraffin is often sold or stored in unlabeled containers which may be gastric ulceration. Depending on the dose ingested, multi-organ
within childrens reach. Volumes ingested tend to be small because failure may develop within 48-72 hours. As little as 10ml may be
of a burning sensation in the mouth and the bad taste of the liquid. fatal. Those who survive the initial phase develop pulmonary fibrosis

as a response to the acute alveolitis in the first phase. This leads to Gastric lavage, activated charcoal
respiratory failure and patients die of anoxia.
Remove all contaminated clothes (take care not to get exposed
Management of paraquat poisoning yourself )
Any history of oral exposure should be considered potentially Wash patient with soap and water (mild alkaline soap helps
fatal. Treatment strategies are aimed at prevention of absorption, deactivate organophosphates)
enhancement of elimination and prevention of pulmonary
damage. Start intravenous atropine administration as soon as possible.
Initial test dose of 0.01mg.kg-1. Then 0.05mg.kg-1 every 15 minutes
Treat immediately with Fullers earth (Fullers earth 300g and
until full atropinisation is reached. Maintenance therapy is usually
magnesium sulphate 50g in a litre of water). Give 5-10ml.kg-1
around 0.05mg.kg-1.h-1. Adequate therapy is achieved when there
orally every 2-3 hours for 2-3 days.
is control of excessive bronchial and oral secretions. Dont worry
Activated charcoal may be used if Fullers earth is not available. about the tachycardia it is well tolerated. Eye signs arent a good
Mix with saline and a laxative such as lactulose to prevent marked of progress. When the patient improves, the dose should
constipation. Repeat every 4 hours until paraquat is no longer be tapered slowly over 24 hours. Atropine should never be stopped
detected in the urine. abruptly. Close observation is required as rebound
organophosphate toxicity may occur due to their lipid solubility.
If neither is available, careful gastric emptying may be done but
be aware of possible pharyngeal and oesophageal ulceration and Watch out for chemical aspiration pneumonia as a lot of the
perforation. organophosphate pesticides have a petroleum base.
Haemoperfusion or dialysis may be used (if available).
INHALED POISONS
Appropriate management of respiratory complications includes
PEEP/CPAP. Low FiO2 should be used as high concentrations Carbon monoxide
of oxygen lead to worse pulmonary toxicity. Paraquat accumulates Carbon monoxide is produced through incomplete combustion
in the lung where it generates superoxide anions through the processes. It is colourless, tasteless and non-irritant. The commonest
reaction with oxygen. sources of carbon monoxide poisoning are smoke inhalation, poorly
maintained domestic gas appliances, and deliberate inhalation of
Organophosphate poisoning
car exhaust fumes (the latter less common in children). Carbon
Organophosphate poisoning (OP) remains an issue in developing
monoxide causes tissue hypoxia by the interruption of electron
countries. In one study, 35% of OP poisoned victims were children.
transport in the mitochondria. It also reduces oxygen delivery by
The organophosphates and carbamates are cholinesterase inhibitors, competing with O2 for binding to Hb and altering the shape of the
thereby eliciting cholinergic signs and symptoms. They can be absorbed HbO2 dissociation curve (making the curve less sigmoidal, a shift to
by ingestion, inhalation or via the skin. The organophosphates form the left). Its affinity for Hb is >200-fold that of O2.
an irreversible complex with cholinesterase but the carbamyl-enzyme
complex is reversible. Thus a less severe clinical picture of shorter Carbon monoxide causes injury by hypoxia, with symptoms referable
duration is presented. It also causes fewer CNS effects because of less to tissues with greatest oxygen consumption, notably the heart and
penetration of the blood brain barrier. brain. Patients present with hypoxia without cyanosis. Skin and
mucosal surfaces may appear cherry red. Symptoms correlate roughly
OP poisoning causes: SLUDGE; Salivation,Urination, Lacrimation, with the COHb level:
Defication, Gastric, Emesis and may progress quickly to CNS
symptoms with seizures, especially in children.
Carboxyhaemoglobin Symptoms
Muscarinic effects hypersecretion, vomiting, diarrhoea, (COHb) level
constricted pupils, bronchoconstriction and urinary incontinence
<30% dizziness and headache
Nicotinic effects muscular weakness, fasciculations (rarer in
children) and respiratory muscle weakness (may override
muscarinic effect and cause tachycardia, hypertension and 50-60% syncope, tachypnoea, tachycardia
mydriasis) and fits
CNS effects irritability, seizures, coma (and accompanying
respiratory depression). >60% increased risk of cardiorespiratory
failure and death
Management of organophosphate poisoning
ABC
Anaemia, increased metabolic rate (e.g. children) and underlying
Patient may require intubation (avoid suxamethonium because ischaemic heart disease all increase susceptibility to CO. Neurological
of prolonged effect) recovery depends on the duration of hypoxic coma.

Management of carbon monoxide poisoning Apply 100% O2 with a tight fitting mask. Treatment is supportive.
Pulse saturation monitoring does not distinguish between HbO2 Decontaminate the skin with soap and water.
and COHb and will read falsely high.
Gastric lavage could be attempted where there are no signs of
Arterial blood gases should be done if available. PaO2 may be cyanide poisoning.
normal but any evidence of metabolic acidosis indicates serious
poisoning (useful even in the absence of COHb measuring Dicobalt ededate, sodium thiosulphate and sodium nitrate are
facilities.) COHb measurements are diagnostic but not always used as antidotes.
available.
Medicines
Treat according to ABC principles. Children frequently ingest medicines. Dangerous substances for
children include salicylates, paracetamol, iron, theophylline and
Apply tight-fitting mask with 100% oxygen. This reduces the
tricyclic antidepressants.
half life of COHb from 320 mins (in room air) to 80 minutes.
Intubation and ventilation may be necessary in severe cases.
Aspirin / salicylate poisoning
Hyperbaric oxygen is useful to further reduce the COHb half Commonly ingested by children. Also probably the commonest
life, but access and transfer times to a hyperbaric chamber make drug to be ingested deliberately in overdose. Oil of wintergreen is
it an impractical option. 98% methyl salicylate. Its primary toxic effect is by uncoupling of
oxidative phosphorylation.
Check 12 lead ECG if there are signs of myocardial ischaemia,
the patient needs intubation/ventilation. Patients present with restlessness, hyperventilation, tinnitus,
deafness, tachycardia, nausea, vomiting, sweating, hyperthermia and
Supportive care should include continuous cardiac monitoring, dehydration. Pulmonary oedema, acute renal failure, hypokalaemia,
treatment of arrhythmias and correction of acid/base and hypoglycaemia and hypothrombinaemia may also develop. In adults
electrolyte abnormalities. there is an early increase in respiration rate causing a respiratory
Lab bloods should be done for creatinine and electrolytes, FBC, alkalosis that precedes the later development of metabolic acidosis.
creatine kinase and cardiac enzymes. However this is not seen in children.
Brain hypoxia leads to cerebral oedema and fits. Diazepam Management of aspirin / salicylate poisoning
5-10mg iv is used to control the fits. Gastric lavage should be attempted, even up to 12 hours or
Initial chest Xray may be normal even in severe smoke inhalation. longer post ingestion. In overdose, salicylates may form
concretions in the stomach and delay absorption.
Patients need to be followed up as some of the neuropsychiatric
complications may take weeks to develop. Activated charcoal orally every four hours.
Combustion of household materials can also generate a number of Severity of the poisoning can be determined by measuring
other toxic substances such as sulphur dioxide, nitrogen dioxide, blood salicylate levels 6 or more hours after ingestion but may be
acrolein, cyanide and various acids from PVC and polyurethane. misleading in severe acidosis. Ideally should be done on admission
This may cause direct lung, skin and conjunctival injury. and 4 hours later to assess continued absorption. Therapeutic
levels of salicylate are generally less than 300mg.l-1. Levels more
Cyanide poisoning than 750mg.l-1 represents severe poisoning.
Most commonly seen in victims of smoke inhalation as a combustion
product of polyurethane foams. Cyanide derivates are also used in Check electrolytes. Blood glucose monitoring should be done
industrial processes and fertilizers. Children may ingest amygdalin, a every 2 hours.
cyanogenic glycoside contained in kernels of almonds and cherries.
Cyanide acts by irreversibly blocking mitochondrial electron Dehydration, acidosis, hypoglycaemia and electrolyte
transport. disturbances should be corrected. Pay particular attention to
potassium. Care should be taken to avoid fluid overload, and
HCN gas can lead to cardiorespiratory collapse and arrest within renal function should be closely monitored.
a few minutes. Patients surviving to reach hospital are unlikely to
have suffered significant poisoning. Early signs include dizziness, Alkalinisation of the urine (pH 7.5-8.5) by administering sodium
chest tightness, dyspnoea, confusion and paralysis, followed by bicarbonate (either orally or by infusion) is recommended to
cardiovascular collapse, apnoea and seizures. increase excretion of salicylates.
Management of cyanide poisoning Haemodialysis or charcoal haemoperfusion may be required in

severe poisoning (levels > 1000mg.l-1 or 7.25mmol.l-1) or in
Do not attempt mouth to mouth resuscitation as the skin will be patients with decreased urine output, pulmonary oedema or
contaminated. progressive deterioration.

Paracetamol overdose three phases (not always very clear). Patients present with vomiting,
Paracetamol ingestion is common but seldom leads to severe toxicity diarrhoea, abdominal pain, haematemesis and rectal bleeding in the
in children due to the diluted concentration of the paediatric early phase (0-2 hours). This is followed by a period of stabilisation
syrup formulation. The children at risk are those with glutathione (up to 12 hours) during which a deceptive recovery occurs. This
depletion, such as children with cystic fibrosis, adolescents with is followed by a life-threatening period during which coma, fits,
eating disorders and those also on enzyme inducing agents such as jaundice, hepatic failure renal failure, clotting abnormalities,
anticonvulsants. The liver is the main target organ in paracetamol hypoglycaemia and cardiovascular collapse may occur.
poisoning. Patients are generally asymptomatic up to 24 hours post
ingestion. Mild nausea, vomiting and anorexia may occur. Hepatic Patients alive 72 hours after ingestion usually make a full recovery.
necrosis becomes apparent in 24-36 hours with right subchondral Late complications of gut stricture, gastric fibrosis and pyloric
pain and tenderness, jaundice, vomiting and acute liver failure. obstruction have been reported.
Confusion and encephalopathy develop over 36-72 hours. Oliguria Management of iron overdose
and renal failure may occur from acute tubular necrosis in the absence The stomach should be emptied with gastric lavage.
of liver failure. Lactic acidosis may be seen early or late.
Blood samples for FBC, glucose, UE, iron levels and ABG where
Management of paracetamol poisoning available.
Patients presenting within 4 hours of ingestion should undergo
gastric lavage. Serum iron only peaks four hours after ingestion.
Activated charcoal should not be given orally if the specific An abdominal X-ray helps to determine the number of tablets
antidote is also given orally. ingested and also the success or failure of gastrointestinal
evacuation.
Measure paracetamol levels at least 4 hours post ingestion
and plot on plasma paracetamol concentration time graph to A patient with serum iron >90mmol.l-1 may be treated with a
determine treatment line. chelating agent.
- If the initial levels indicate no treatment, repeat after 4 If <20mg.kg-1 are ingested, treatment is supportive. Patients with
hours to check for delayed absorption. iron level below 54mmol.l-1 and who remains asymptomatic 6
- All patients on or above the Normal treatment line should hours post ingestion would not be expected to develop significant
be given N-acetylcysteine. toxicity and require no active treatment.
- Patients on enzyme-inducing drugs should be treated if For ingestion of between 20-60mg.kg-1 elemental iron, gastric
above the Enhanced risk treatment line. emptying may be considered if within one hour of ingestion.
Where levels are not available, assume liver damage after ingestion Whole bowel irrigation may be used in patients with ingestion
of a single dose of more than 150mg.kg-1 paracetamol, or a of more than 60mg.kg-1 and more than one hour post ingestion.
staggered overdose (spread over several hours) of the same It is especially useful if a slow release preparation has been
amount. ingested. Charcoal is of no benefit as iron does not bind to it.
Acetylcysteine is the antidote of choice and is usually given iv. Desferrioxamine chelates iron and is the recommended
Oral methionine may be used if the patient is allergic to treatment.
acetylcysteine and is also a suitable alternative in remote areas - Give 1 gram im every 6-12 hours for children (2g for
if vomiting is not a problem. Oral acetylcysteine and carbocysteine adolescents). (100mg of desferrioxamine binds 8.5mg of
have also been used. elemental iron)
- If the patient is hypotensive, give desferrioxamine iv at a
Monitor urea and electrolytes, PT and LFT. rate of 15mg.kg-1.hr-1, until the serum iron falls (maximum
Give vitamin K but avoid giving fresh frozen plasma unless there daily dose 80mg.kg-1)
is active bleeding. The PT is the best indicator of the severity of Haemodialysis is indicated in very high serum iron levels that
liver failure. respond poorly to chelation therapy or if the urine output is not
maintained. (the iron-chelate is excreted entirely in the urine)
All patients with encephalopathy or a rapidly rising PT should be
referred to a liver unit (where available). Theophylline poisoning
Supportive treatment and treatment of liver and renal failure as This type of poisoning is rare but serious. Most preparations are
indicated. slow release so that problems develop 12-24 hours after ingestion.
Features of acute ingestion reflect the local irritant GI effects nausea,
Iron poisoning vomiting, haematemesis and diarrhoea. The child may be hyperactive
Ingestion of more than 20mg.kg-1 of elemental iron is considered with dilated pupils, hypereflexia, hypotonia and myoclonus. There
potentially toxic, and the lethal dose is estimated at about 180mg. may also be severe hypokalaemia, arrhythmias, metabolic acidosis,
kg-1 Iron is extremely irritant. The clinical features can be divided into hyperglycaemia, hypotension and seizures.

Management of theophylline poisoning Continue cardiac monitoring for up to 48 hours.
Gastric lavage should be considered if ingestion occurred within
1-2 hours. Inotropic support should be given as necessary.
Repeated administration of activated charcoal to prevent further Correct metabolic acidosis to enhance protein binding of the
absorption and enhance systemic clearance. (May be difficult in drug.
the presence of nausea and vomiting).
Control seizures with diazepam.
Whole bowel irrigation is considered if a slow-release preparation
is ingested. SUMMARY
Prevention of childhood poisoning is vital. There must be adequate
Haemoperfusion should also be considered. supervision, safe placement of medications, child safe cabinets and
Seizures are treated with diazepam. containers, blister packaging and education. Most paediatric cases
are not severe. Recognition of potentially life-threatening ingestions
Assess hydration and correct hypokalaemia and electrolyte is important so that appropriate early treatment can be instituted.
disturbances. Aggressive supportive care is vital.
Cardiac monitoring to detect arrhythmias.
Ribbens S. Accidental poisoning in children. Anaesthesia Tutorial
Verapamil and propanolol may be required to treat
of the Week 95(2008) available from: http://www.wfsahq.org/
supraventricular and ventricular tachyarrhythmias. Lignocaine
components/com_virtual_library/media/0bcfbeac632c1b044303ba
appears to have little effect on ventricular ectopy.
371f9491c6-a96849513ae3b1ef36a9fb85127f0b50-95-Accidental-
Tricyclic antidepressants poisoning-in-children.pdf
Cardiovascular toxicity is the main cause of death in tricyclic
antidepressant overdose. It is caused by the blockade of noradrenaline Useful websites
uptake as well as the anticholinergic, membrane-stabilising and World Health Organisation The International Programme on
alpha-blocking effects. Nervous system toxicity includes drowsiness, Chemical Safety : Poisoning Prevention and Management (www.
agitation, hallucinations, hyperreflexia, myoclonus, rigidity, inchem.org)
convulsions, respiratory depression and coma. Anticholinergic TOXBASE.org www.spib.axl.co.uk (NHS only, requires
effects include flushing, dry mouth, dilated pupils, hyperpyrexia registration)
and bladder/bowel paralysis. Cardiovascular toxicity includes sinus
tachycardia, hypotension, conduction abnormalities and arrhythmias. Agency for toxic substances & disease registry: (no password
Respiratory complications include respiratory depression, aspiration or registration required) http://www.atsdr.cdc.gov/substances/
pneumonia, ARDS and pulmonary oedema. toxsubstance.asp?toxid=19
Management of tricyclic overdose TOXNET (toxnet.nlm.nih.gov)
Gastric emptying is delayed by tricyclic antidepressants, and
therefore gastric lavage should be attempt as late as 12 hours post Royal Childrens Hospital Melbourne: Victorian Poisons
ingestion Information Centre (www.rch.org.au/poisons)
Due to CNS depression and inadequate ventilation, intubation

may be required.

Further resources available online or to download
Miscellaneous
Rachel Homer, Edition Editor
This is not intended to be an exhaustive list, but the emergency department. May also aid preparations
Ive tried to bring together cheap or (majority) free in theatre for urgent cases requiring intubation.
resources which Ive found useful or interesting, or
http://www.wakeupsafe.org/index.iphtml
which have been recommended to me.
This is an incident reporting system run by the
US Society for Pediatric Anesthesia. Participating
Websites
institutions [who have to pay a fee to join] share
Safety critical incidents so that lessons on safer practice can
http://www.who.int/patientsafety//safesurgery/en/ result. Findings are free to download, and although
index.html not designed for a resource-poor setting it may still
be helpful to read about common problems and how
The 2009 edition of WHO surgical safety checklist
they have been solved or avoided.
available to download free in English, French, Arabic,
Chinese, Russian or Spanish. Also links to http://www.aagbi.org/safety/salg/salg-incident-
summaries
The checklists implementation manual in the
The Safe Anaesthesia Liaison Group [SALG] is jointly
same languages
hosted by the UKs Royal College of Anaesthetists
WHO guidelines for safe surgery (English) and Association of Anaesthetists of Great Britain
Pilot study showing mortality benefit and Ireland. Safety incidents across the breadth of
[Haynes et al] anaesthesia [not just paediatrics as for Wake Up Safe]
are shared from across England and Wales. SALG
Examples of locally adapted checklists
produce a quarterly report of recurring themes, as
Draft translations into further languages well as safety briefings on specific topics, which again
Other resources (also free). assume a high-income environment but still contain
useful learning points. All are free to download.
http://www.lifebox.org/education/
Training materials, user manual and trouble-shooting Education
guide developed to support the Lifebox foundations Not specific to paediatric anaesthesia, but have
distribution of free (donated) rugged pulse oximeters paediatric content:
to widen access to this critical patient safety monitor. http://www.anaesthesiologists.org/
Free to download in English, Arabic, Chinese, World Federation of Societies of Anaesthesiologists
Portuguese, French, Spanish, and Russian. Also links homepage. Links from here to Update in Anaesthesia,
to application/needs assessment for a Lifebox pulse Tutorial of the Week, and many other resources.
oximeter if your hospital does not yet have one.
http://www.rcoa.ac.uk/e-learning-anaesthesia/
http://www.phoneoximeter.org/the-phone-
sample-sessions
oximeter/
E-Learning for Anaesthesia (e-LA) is an extensive
[Hudson et al] Prototype of software activated by
online resource designed for anaesthetists who work
connecting hardware (pulse oximeter probe, cable) to
for the UKs National Health Service. It follows the
a mobile phone. First use of mobile phone technology
UK Royal College curriculum in anaesthesia. Free
for continuous pulse oximetry monitoring. Cost:
registration is only available if you have an NHS email
perhaps $20 USD; not yet available as at June 2015.
address. Otherwise the programme is available to
http://www.saferintubation.com/ purchase annual access at high cost [full programme
Intubation Checklist pdf is designed to help the whole 600/year]. These sample sessions can be completed
team, who may be unfamiliar, share a mental model free, and some other sessions are available on the
for emergency intubation under stress and in less e-SAFE DVD.
familiar conditions, such as a major trauma patient in

http://www.rcoa.ac.uk/e-SAFE Fluid management
The Royal College of Anaesthetists, Association of Anaesthetists
Nausea and vomiting prevention
of Great Britain and Ireland and e-LfH [e-learning for healthcare]
have developed e-SAFE, an e-learning DVD to support education Immunisations.
in anaesthesia throughout the developing world. This DVD contains
http://www.euroespa.com/science-education/specialized-
over 100 interactive e-learning sessions and an e-Library with over
sections/espa-guidelines/ English-language guidelines set compiled
500 articles covering basic science and clinical anaesthesia, including
by the European Society for Paediatric Anaesthesiology. Divided into
many e-Learning for Anaesthesia sessions [see above]. Online form
Emergency Care, Treatment, and Safety sections. Some are online,
to request a copy.
others free to download.
http://www.anaesthesiacases.org/ http://www.sickkids.ca/Anesthesia/Pediatric-anesthesia-forum/
Library of online case reports. Requires free registration [link on index.html
home page] to read or submit cases. Pediatric anesthesia forum is a discussion board run by Torontos Sick
Kids Hospital and open to anyone worldwide who registers [email
http://www.logbook.org.uk/
address required].
Keeping a logbook of your cases can help you reflect on and improve
your practice, as well as being a requirement in some countries. This http://medstation.yale.edu/pedres/files/Resident%20Education/
free software works on a variety of systems [take care to download PED/ShockAfricaNEJM.pdf
the correct version]. There is also a troubleshooting [help] guide. The FEAST (Fluid Expansion as Supportive Therapy) trial, a large
multicentre randomised trial, examined the effectiveness of fluid
http://www.nysora.com resuscitation of children with severe infections in Africa. The results
Illustrated online tutorials on a range of regional anaesthesia - that children given fluid at maintainance rate did better than
techniques. Tutorials include nerve stimulator and landmark those given boluses surprised both the investigators and the wider
techniques as well as ultrasound-guided for those possessing this paediatric medicine community.
technology. Most of these nerve blocks are useful in paediatric
patients. http://www.virtualpediatrichospital.org/
http://www.biodigitalhuman.com/ APPS
Interactive human anatomy. Requires free registration [email address iPhone and iPad users have a wide choice of medical apps. Android
or facebook account]. Works with Google Chrome and Firefox phone apps are more limited, but Android versions of some of these
browsers but not Internet Explorer. are in development. iTunes versions can be downloaded to both Mac
and PC computers.
Specifically paediatric anaesthesia
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1460-9592/ Free copies of latest guidelines available from the iTunes
issues website include:
The journal Paediatric Anaesthesia offers many articles and entire iRESUS: Latest Resuscitation Council (UK) guidelines and
issues free; the remainder require a subscription. algorithms for adult and paediatric resuscitation, currently 2010.
Automatic updates when new guidelines released. Review and
Examples of free issues [accessed 08/08/2013] include: screenshots at http://www.imedicalapps.com/2011/04/title-enjoy-
free-quick-access-resuscitation-guidelines-iresus-app/
Anything published in or before 2008
Volume 19, Issue Supplement s1 (July 2009) Special Issue: iDAS: Adult algorithms produced by the UK Difficult Airway
The Pediatric Airway Society; assume ready availability of a wide variety of airway adjuncts.
Volume 19, Issue 10 (October 2009): range of articles The following listings contain further ideas, all free to
Volume 22, Issue Supplement s1 (July 2012) Special download:
Issue: Good Practice in Postoperative and Procedural Pain http://www.imedicalapps.com/2013/06/free-iphone-medical-
Management, 2nd Edition apps-physicians/
Volume 23, Issue 1 (January 2013): range of articles. http://www.imedicalapps.com/2011/01/top-free-android-
medical-apps-healthcare-professionals/
http://apagbi.org.uk/publications/apa-guidelines
lists guidelines and advice from the Association of Paediatric Calculate by QxMD
Anaesthetists of Great Britain and Ireland. Accessed on 08/08/2013, https://itunes.apple.com/us/app/calculate-medical-calculator/
contains free-to-download guidelines on: id361811483?mt=8 is useful for paediatric drug dose calculations.
Pain management MediBabble
Difficult airway http://www.medibabble.com/features.html

This is a medical translator app which does not require an internet The Open Anaesthesia Self-Study app
connection once downloaded. Language choice is currently limited https://itunes.apple.com/us/app/openanesthesia-self-study/
but more languages are being added. id657712202?ls=1&mt=8
is a question/model answer bank aimed at resident physicians and
Bhansali and Armstrong recently reviewed paediatric anaesthesia nurse anaesthetists preparing for US credentialing examinations. It
apps. They found the following worth considering: covers the whole of anaesthesia, not just paediatric patients, and has
a strong first-world emphasis. Basic concepts are well covered. Basic
Peds ED
app free to download, updates/additional questions rather costly.
https://itunes.apple.com/us/app/peds-ed/id326615524?mt=8 and
References
Paeds ED Lite
https://itunes.apple.com/us/app/paeds-ed-lite/ Sheraton TE, Wilkes AR, Hall JE. Mobile phones and the developing world.
Anaesthesia 2012; 67(9) : 945-50.
id331122046?mt=8
are quick reference guides to resuscitation and simple PICU Hudson J, Nguku SM, Sleiman J, et al. Usability testing of a prototype
calculations, and both are currently [31/08/13] free to download. Phone Oximeter with healthcare providers in high- and low-medical
resource environments. Anaesthesia 2012; 67(9) : 957-67.
AnaPaed Haynes AB, Weiser TG, Berry WR, et al, for the Safe Surgery Saves Lives
https://itunes.apple.com/us/app/anapaed-peds-anesthesia/ study group. A Surgical Safety Checklist to Reduce Morbidity and
id393135847?mt=8 Mortality in a Global Population N Engl J Med 2009; 360 : 491-499.
contains a wealth of useful information on airway device sizing and This article is free to download; http://www.nejm.org/doi/full/10.1056/
regional anaesthesia techniques as well as routine and emergency NEJMsa0810119#t=articleTop.
drug dose calculations. Bhansali R, Armstrong J. Smartphone applications for pediatric anesthesia.
Paed Anaesth 2012;22: 400-4 this article is free to download; http://
This app has relatively low cost at the time of writing. onlinelibrary.wiley.com/doi/10.1111/j.1460-9592.2012.03805.x/full.

Guide for Contributors
Update in Anaesthesia is primarily an educational journal, which aims Authors details
to provide ongoing learning and support for anaesthetists working in Please supply the full forename and surname of all authors, stating
situations with limited resources. their title (Anaesthetic Clinical Officer, Dr, Professor etc) and
Update is sent to over 3000 English-speaking anaesthetists, and the name and address of their institution. One author should be
read by many others including surgeons, nurses and medical identified for correspondence, with an email address provided.
students. Update is also translated into different languages
Drug doses
including Spanish, Russian, French and Mandarin. After being
Please use the international units, e.g. mg.kg-1 rather than mg/kg. Use
produced in the paper format, Update is published on the internet
SI notation for g, mg, mcg etc. Please use internationally accepted
(www.worldanaesthesia.org) and read by 90 people a day from more
non-proprietary drug names, e.g. furosemide, epinephrine and avoid
than 130 countries. Update is also distributed in the form of a CD-
trade names.
ROM, produced by the Association of Anaesthetists of Great Britain
and Ireland.
Headings
Three levels of heading may be used CAPITALS, bold and italic.
Articles for consideration by the Editorial Board should Please do not employ different fonts within the text. Bullet points
be submitted as Word documents (Rich Text Format is can be helpful.
preferred) to the Editor-in-chief, Bruce McCormick, by
email at Bruce.McCormick@rdeft.nhs.uk or post on CD-
Illustrations / figures
These may be sent to us as drawings (black on white), which we will
ROM or paper copy to Dr Bruce McCormick, Department
scan into the text, or as picture files in jpg (JPEG) format. Black and
of Anaesthesia, Royal Devon and Exeter Hospital, Barrack
white photos are also suitable. If you do not have facilities to produce
Road, Exeter, EX2 5DW, UK.
drawings, contact the editor for help. If you copy illustrations from
another publication please obtain copyright permission from the
Clinical Overview Articles publishers or author. If patients appear in a photo please ensure that
they have consented to this. Text accompanying illustrations should
General considerations
be supplied on a separate piece of paper.
l Papers must not have been published in whole or any part
in another journal. Tables or figures reproduced from other published texts should be
accompanied by a statement that permission for reproduction has
l Papers are subject to editorial revision.
been obtained from the author or publisher. An acknowledgment
l On acceptance for publication copyright becomes vested should be included in the caption and the full reference included in
in the journal. the reference list.
l Original textual matter quoted from other authors must
Tables
have formal citation and be appropriately referenced.
These should be prepared using the Microsoft Word table facility
l Some readers first language may not be English. Please whenever possible.
keep your text straightforward and avoid long sentences
and complex terminology. Explain words and abbreviations Graphs
that may not be universally standardised. Aim to include Graphs should be supplied using the Microsoft graph-compiling
the full range of therapies available worldwide, but provide feature within Microsoft Word, or as a figure on paper.
most detailed descriptions of those therapies available in
References
resource-poor settings (see Management of sepsis with
A minority of Update readers have access to journals and therefore
limited resources in Update 23 www.worldanaesthesia
references should in general be limited to those that would be
org/component/option,com_docmantask,cat_view
considered as further reading. Please format your references as
gid,67 Itemid,49/). Discuss older drugs as well as newer
shown. Number the references in the order they appear, using the
ones; halothane, thiopentone, ketamine and ether are
reference number as a superscript at the relevant point in the text.
widely used around the world.
References should include: names and initials of all authors (unless
l The article should be long enough to cover the topic in
more than 6, when only the first 6 are given followed by et al.), title
reasonable detail. Many readers will not have access to
of the paper; Medline abbreviation of the journal title (in italic); year
texts or journals to supplement their reading. Include text
of publication; volume number; first and last page numbers.
boxes and teaching points to make the layout interesting.
Avoid long numbered lists with complex subdivisions. Papers accepted but not yet published should be included in the
Check that your text is correct, particularly drug doses, as many references, with the abbreviated journal name, followed by (in
readers will not be able to verify them. press).

Those in preparation (including any submitted for publication), Brief Communications
personal communications and unpublished observations should be l Original investigative articles or audits of patient outcome
referred to as such in the text. or clinical techniques.
1. Reynolds F, OSullivan G. Lumbar puncture and headache. l Up to 1500 words (approximately 2 pages of Update in
Atraumatic needle is a better term than blunt needle. Anaesthesia).

Br Med J 1998; 316: 1018. l Subdivided into:
- Summary (maximum five sentences) and key words
2. Costigan SN, Sprigge JS. Dural puncture: the patients
perspective. A patient survey of cases at a DGH maternity - Introduction
unit 19831993. Acta Anaesthesiol Scand 1996; 40: 71014. - Patients and methods
- Results
3. Spriggs DA, Burn DJ, French J, Cartlidge NE, Bates D. Is - Discussion
bedrest useful after diagnostic lumbar puncture? Postgrad Med - Acknowledgements
J 1992; 68: 5813. - References maximum 15
References to books should give book title, place of publication, - Tables and/or figures - limited to two per article.
publisher and year; those of multiple authorship should also
include chapter title, first and last page numbers, and names and Case Reports
initials of editors. For example: l Suitable for presenting descriptive studies (a series of
cases), personal experience or individual case reports of
1. Roberts F. Chapter 22: Ear, nose and throat surgery. In: particular interest.
Allman KG, Wilson IH, eds. Oxford handbook of l Up to 800 words. Three tables or figures is allowed in addition
Anaesthesia (1st edition) Oxford: Oxford University Press, to text.
2001: 506-39.
l A summary may be included (up to five sentences). Division
into sections is optional.
Update Short Reports
The scope for publication of articles describing original research l Up to seven references may be given.
and audit conducted in, and specifically relevant to, poorly-
resourced settings is limited. Successful publication in major Correspondence
journals is rare and the distribution and accessibility of the national l Welcomed on any subject, including editorials or articles
and regional journals that currently publish these articles is often that have appeared in Update in Anaesthesia.
poor. As the official journal of the World Federation of Societies l Letters may also be a suitable vehicle for presenting
of Anaesthesiologists, Update in Anaesthesia is the appropriate items of experience or observation that are too brief for
forum for publication of these manuscripts and offers a wide Brief Communications.
distribution.
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The guidance above for clinical overview articles applies, with the adapted by readers to their own conditions of work are
following additional considerations. welcomed.
Legal considerations Proofs

l Papers based on clinical investigation on humans should l Proofs are sent to the author designated to receive them.
include the consent of patients and a statement of Corrections should be kept to a minimum and the proofs
approval from an appropriate Ethics Committee. In those returned within 7 days of receipt.
institutions where Institutional Review Board consent is
required for the performance of audits, this should be The editorial team will be delighted to help with the
obtained and referred to in the text. preparation of articles. The best way of doing this is via email -
Bruce.McCormick@rdeft.nhs.uk
l Avoid use of identifiable names, initials and hospital
numbers of patients. Dr Bruce McCormick
Editor-in-chief
l Human subjects of case reports, research or audits should Update in Anaesthesia, July 2008
not be identifiable. Manuscripts should not disclose
patients names, initials, hospital numbers (or other data Department of Anaesthetics
that might identify the patient(s)). Royal Devon and Exeter Hospital
Barrack Road
l Guides for use of tables, figures and illustrations are as described Exeter EX2 5DW
above for Clinical Overview articles. United Kingdom

Education for anaesthetists worldwide
Volume 30 Number 1 June 2015
1 Guest Editorial 147 Anaesthesia for paediatric eye surgery
BASIC SCIENCE 154 Anaesthesia for cleft and lip palate surgery
4 Basic science relevant to practical paediatric anaesthesia
159 Anaesthesia for paediatric orthopaedic surgery
13 Equipment in paediatric anaesthesia
COMMON EMERGENCIES
23 Paediatric drawover anaesthesia 168 Large airway obstruction in children
ANAESTHESIA AND COMORBID DISEASE 174 Bronchoscopy for a foreign body in a child
27 Anaesthesia and congenital abnormalities
178 Anaesthesia for emergency paediatric
35 The anaesthetic management of children with general surgery
sickle cell disease
TRAUMA IN CHILDREN
40 HIV in children and anaesthesia 187 Head injury in paediatrics
46 Anaesthesia for non-cardiac surgery in 196 Major haemorrhage in paediatric surgery

children with congenital heart disease
199 Paediatric burns and associated injuries
58 Anaesthesia in patients with asthma, bronchiolitis
and other respiratory diseases 204 Stabilisation and preparation for transfer in
paediatric trauma patients
PRINCIPLES OF CLINICAL ANAESTHESIA
65 The preparation of children for surgery CRITICAL CARE
210 Paediatric intensive care in resource-limited
72 Perioperative analgesic pharmacology in children countries
77 Paediatric procedural sedation 224 Recognising the seriously ill child
81 Perioperative fluids in children 236 Meningococcal disease in children
88 Paediatric caudal anaesthesia 242 Intraosseous Infusion
93 Abdominal wall blocks 244 The child with malaria
99 Upper and lower limb blocks in children 251 Acute lower respiratory disease in children
112 Paediatric spinal anaesthesia RESUSCITATION

265 Paediatric life support
116 Paediatric difficult airway management
270 Resuscitation at birth
ELECTIVE PROCEDURES
123 Neonatal anaesthesia 273 Anaphylaxis; recognition and management
133 Major elective surgery in children, and surgery in 279 Accidental poisoning in children
remote and rural locations
MISCELLANEOUS
141 Anaesthesia for paediatric ear, nose, 285 Further resources available online or to
and throat surgery download
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Education for anaesthetists worldwide

Volume 30 Number 1 June 2015

The Journal of the World Federation of Societies of Anaesthesiologists

Dusica Simic MD, PhD

Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia page1

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Anthony Short* and Kate Stevens

Table 1. Age definitions

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Figure 2. The paediatric airway compared to the adult airway

The intubation technique in infants needs to take account of

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Table 3. Cardiorespiratory physiology normal values

Age (years) Respiratory rate Heart rate Blood pressure (mmHg)

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The newborn period is a time of rapid growth and development.

The ventricles are immature, and less compliant, with a

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Age of child Cardiac output (ml.kg-1.min-1)

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Age group Blood volume (mls.kg-1) Haemoglobin concentration (g.l-1)

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Table 7. Comparison of volatile agents in children

Infant: 0.9 Infant: 3.3 Infant: 1.6

Child: 1.2 Child: 2.5 Child: 1.9

Adult: 0.75 Adult: 1.7 Adult: 1.2

central nervous system maturation continues during fetal Pharmacological considerations

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AIRWAY ADJUNCTS Lubricate with gel to minimise trauma to the

Nasopharyngeal airways Facemasks

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Figure 3. Clear plastic facemasks

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Lightweight Gastric insufflation

Compact High peak inflation pressures

Figure 7. Humphrey ADE. Newer versions are, in fact, AE systems;

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Figure 8. Paediatric defibrillator pads and paddle positions.

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Electrocardiography (ECG) Large child 9cm

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INTRODUCTION designed specifically for ether,

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Reservoir bag for oxygen

Figure 2. The Diamedica drawover apparatus. In recent years this system

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K Ganeshalingam and T Liversedge*

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