Anaesthetic Management of

Paediatric Emergencies
Dr Oyeleye D.R
Dr Oria A.I
 Outline

• Introduction
• Neonatal/Infant physiology
• OAUTHC Review
• Paediatric emergencies and anaesthetic management
• Literature Review
• Conclusion
 Introduction

• Paediatric anaesthesia embraces patients from the premature

neonate to adolescent

• Paediatric patient should not be regarded as “little adult”

because the physiological, pharmacological, behavioural and
psychological responses are quite distinct from those of the
adult, particularly in the first few years of life.
 Introduction

• The delivery of safe paediatric anaesthesia requires a full

understanding of these responses at various stages of
development.

• Anaesthetic risk is inversely related to age and ASA status

with the highest risk in younger smaller patients.
 Paediatric Age Group

• Span from Newborn to adolescent

 Neonates – first 28 days of life.
May be preterm(<37wks)
term(37-42wks),post
term(>42wks)
 Infants – 1 month to 1 year
 Preschool -1-5 yrs
 Schoolage – 5-12 yrs
 Adolescent >12 yrs

5
 Neonatal/Infant Physiology

• Respiratory
• At birth, each terminal bronchiole opens into a single
alveolus, alveoli are thick-walled and growth continues by
multiplication until 6-8yrs
• Cartilaginous ribs are horizontally aligned
• Poorly developed intercostal muscles with a lower proportion
of type 1 muscle fibres
• Ventilation is essentially diaphragmatic and rate dependent
 Neonatal/Infant Physiology

• Respiratory
• High chest wall compliance due to the cartilaginous thorax
• Closing volume occurs within tidal breathing in neonate.
• Obligate nasal breathers
• Postoperative apnea in preterm neonate
• Increased basal oxygen consumption
• Higher metabolic rate & alveolar minute volume so volatile
agents achieve a more rapid induction and emergence than
adult
 Neonatal/Infant Physiology

• Cardiovascular
• High cardiac output(200ml/kg/min) than adult and rate
dependent
• Autonomic & baro-receptor control is fully functional at term
but vagally mediated parasympathetic tone predominates
 Neonatal/Infant Physiology

• GIT
• Immature liver
• Carbohydrates reserves are low in neonate
• Low vitamin K dependent factors at term. Routine
administration of Vitamin K may prevent haemorrhagic
disease of the newborn
 Neonatal/Infant Physiology

• Renal
• Nephron formation is complete at term but renal function is
immature
• Reduction in RBF due to high renal vascular resistance
• GFR achieves adult values by 2 yrs and renal tubular
function by 6-8 months
• Glucose and sodium reabsorption is less efficient in
premature infants
• Inability to excrete large solvent/sodium load
 Neonatal/Infant Physiology

• Haematology
• Post delivery Hb concentration ranges from 13-20g/dl
• Physiological anaemia of infancy (Hb conc. 10-12g/dl)
occurs due to
-fall in HbF concentration which is replaced with adult Hb
-increase circulating volume exceeding growth in bone
marrow activity
 Neonatal/Infant Physiology

• CNS
• At birth, the brain occupies a much larger proportion of the total
body weight than in the adult (10%-15% versus 2%)
• Higher cerebral metabolic requirement for oxygen (5ml/100g/min
versus 3.5ml/100g/min)
• Autoregulation of blood flow is present at term; however preterm
neonates are vulnerable to changes in blood pressure causing
intracranial haemorrhage, particularly affecting the periventricular
germinal matrix
• Dendritic proliferation, myelination and synaptic connections
develop in the 3rd trimester and 1st 2 yr of life
 Neonatal/Infant Physiology

• Spinal cord terminates at L3 at term, L1-L2 at early

adolescence
• Relatively large and non ossified sacral hiatus which allows
easy access to the epidural space via the caudal route
• Less densely packed epidural fat which facilitates spread of
local anaesthetic injected into the caudal space to the thoracic
region
 Neonatal/Infant Physiology

• Thermoregulation
• High surface area to volume ratio with minimal Sc fat and
poor insulation
• Non-shivering thermogenesis is achieved by metabolism in
brown fat at the base of the neck, scapulae, back
• Thermoneutral temperature
preterm neonates—34 degree centigrade
term neonates 32 degree centigrade
adult 28 degree centigrade
 Role of Anaesthetist In Paediatric Emergency

• Airway management
• Vascular access
• Fluid management
• Acute pain management
• Inotropic support
• Intensive care unit admission
• Pre-hospital services where available.
 OAUTHC Review from January 2022-September 2023

Diagnosis Frequency
Intestinal obstruction with no specific documented diagnosis 45
Tracheosesophageal fistula 8
Acute appendicitis 13
Typhoid perforation 3
Medical Surgical Anaesthesia related
Viral Croup Intussusception, Hirschsprung Laryngospasm
Stridor Acute appendicitis, Duodenal Bronchospasm
Paediatric Emergencies
atresia
Epiglottitis ARM, Foreign body aspiration Unanticipated difficult
airway
Status Ileal atresia, Jejunal atresia Suxamethonium apnoea
asthmaticus
Status epilepticus Pyloric stenosis, Typhoid Malignant hyperthermia
perforation
ARDS Tracheoesophageal fistula Aspiration pneumonitis
Severe anaemia Congenital diaphragmatic hernia

Cerebral malaria Gastroschisis, Omphalocele

Diabetic Incarcerated inguinal hernia,
ketoacidosis Acute abdomen, Bleeding
tonsils

Burns Intestinal obstruction, Head

injury
 Initial Resuscitative Measures for Paediatric Medical
Emergencies

• Call for help

• ABC of resuscitation
• Pass urethral catheter
• Monitor vital signs and arterial saturation
• Hematological investigations(FBC,SEUR,GXM)
• Random blood sugar
• Keep warm
• Acute pain management
• Make diagnosis and treat the underlying medical condition
 Initial Resuscitative Management for Paediatric Surgical
Emergency

• Call for help

• ABCDE of resuscitation
• Monitor vital signs
• Pass urethral catheter
• Pass nasogastric tube to decompress the abdomen
• Bed side ultrasound scan, Echocardiography, ABG
• Plain radiograph
• Hematological investigation
• Acute pain management
• Keep warm
 Intussusception

• Occurs when a portion of an alimentary tract is telescoped

into an adjacent segment.
• Most common cause of intestinal obstruction between 3mths-
6yrs of age
• Incidence is 4/1000 live births
• Male-Female ratio is 3:1
• Few reduces spontaneously but if left untreated can lead to
intestinal infarction, perforation, peritonitis and death
• 90% of cases are idiopathic
 Intussusception

• It is postulated that gastrointestinal infections &introduction of new

food proteins result in swollen peyer’s patches in the terminal ileum
• Lymphoid nodular hyperplasia leads to mucosal prolapse of the
ileum into the colon leading to intussusception
• Postoperative intussusception ileoileal can occur several days after
an abdominal operation
• Most often ileocolic, less commonly ceco-colic
• The upper portion of the bowel called intussusceptum invaginates
into the lower portion intussuscipiens. It pulls its mesentry along
with it thereby causing oedema and bleeding from the mucosa
leading to bloody stool.
Intussusception
 Clinical features

• Sudden onset severe paroxysmal colicky pain

• Fever
• Currant jelly stool
• Sausage shaped mass
• lethargy
 Anaesthetic concerns

• Full stomach
• Prevention of further distension of the stomach
• Electrolyte derangement
• Anaemia
 Previous hydrostatic reduction attempt could worsen all of
the above
 Management

• Preoperative
• Brief relevant history and examination
-Pass NG tube
-NPO
-Adequate hydration
-FBC
-E/U/Cr and correct derangement
-Radiological investigation (abdomen)
 Intraoperative Management

-Thermoneutral environment of the theatre is maintained

-Warming mattress
-Use of overhead radiant heater
-Avoid unnecessary exposure by covering unoperated parts and
extremities
-Fluid warmers
 Intraoperative Management

-Anaesthetic machine checked

-Airway equipment. Different sizes of facemask, oropharyngeal airway,
laryngoscopes with straight blades, appropriate size ETT,LMA
-Anticipate for difficult intubation due to airway peculiarities
-Appropriate monitoring device- BP cuff, ECG, Pulse oximeter
-Drugs are calculated according to their body weight, withdrawn, diluted and
labelled in syringes.
-It is mandatory to have IV Adrenaline drawn and labelled for emergency use
at 1:10,000
 Intraoperative Management

-Attach multiparameter monitoring device Pulse oximetery,

precordial stethoscope, ECG monitoring
-Ensure prophylactic antibiotics
-Premedicate with IV Atropine at 0.01mg/kg may be needed
-RSI with IV sodium thiopentone(4-6mg/kg) and IV
Suxamethonium 1.5-2mg/kg
-Use of low pressure, high volume tracheal tube
-Long acting neuromuscular drugs are to be used with caution in
neonates
 Intraoperative management

-Maintain on inhalational anaesthetic agents most likely Sevoflurane at a low

MAC
-Controlled ventilation with IPPV
--Multimodal approach to analgesics e.g IV PCM at 10-15mg/kg
-Be careful with the use of opioid, if necessary short acting opioid like
Fentanyl at 1-2 mcg/kg can be used.
-Multi-technique using a caudal block with LA
 Intraoperative management

-Warm IVF(Ringers lactate)

calculate deficit, maintenance and ongoing loss
- Blood transfusion trigger should be low
commence if patient is anaemic pre-op
if 10% calculated blood volume is lost
 Postoperative management

• At the end of surgery

-infiltrate the op site with 0.25% of plain Bupivacaine not
exceeding 2mg/kg as part of multimodal/technique approach to
pain management
- turn off inhalational agent
- watch for signs of return of neuromuscular function &
reverse residual neuromuscular blocking agents (if used)
-Check the vital signs after extubation and transfer patient to
PACU/ICU depending on clinical state of patient.
 Management of Anaesthetic related Paediatric Emergency

• Laryngospasm
• Give 100% oxygen
• Open airway with firm jaw-thrust
• Apply CPAP
• Gentle bag mask ventilation
• Eliminate the cause
• Give Suxamethonium 2mg/kg /Propofol 0.5mg/kg
• Intubate if necessary
 Management of Anaesthetic related Paediatric Emergency

• Bronchospasm
• Call for help
• Give 100% oxygen & ventilate
• Stop stimulation
• Nebulized Salbutamol
• IV Hydrocortisone 200mg 6hrly
• Adrenaline –Nebulized 5mls 1:1000
IV 0.1ml 1:10000 to 1ml 1:10000
 Management of Anaesthetic related Paediatric Emergency

• Malignant hyperthermia
• Remove triggers
• Turn off inhalational agent
• Give 100% oxygen
• Change breathing circuit
• Hyperventilate
• Use active body cooling e.g cold intravenous fluid, cold
peritoneal lavage, extracorporeal heat exchange
• IV Dantrolene 2-3mg/kg initially then 1mg/kg PRN
 Management of Anaesthetic related Paediatric Emergency

• Suxamethonium apnea
• ABC of resuscitation
• Maintain a patent airway & ensure adequate ventilation
• Maintain anaesthesia with volatile/IV agents once airway is
secured
• Monitor neuromuscular function with peripheral nerve stimulator
• Transfer to ICU
• Administer FFP to provide a source of plasma cholinesterase
• After recovery, refer for investigation
Unanticipated difficult airway
 Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for Neonatal Surgical
Emergencies in a Semi-Urban Hospital, Nigeria. East African Medical
Journal. 2004:81:11

• Introduction
• Providing safe anaesthesia for the neonate is a challenging
because of their peculiar anatomic, physiologic and
pharmacological features.
• Most surgical emergencies at this age group are due to life-
threatening conditions that increase the risk of anaesthesia
and surgery.
• Anaesthesia was still provided by mainly by nurses with
varying levels of experience.
• Objective of this paper was to establish the techniques of
anaesthesia for neonatal surgical emergencies in our hospital
and assess their adequacy and make recommendations to
improve our practice.
 Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for Neonatal Surgical Emergencies
in a Semi-Urban Hospital, Nigeria. East African Medical Journal. 2004:81:11

• This was a 10years retrospective study conducted in OAUTHC, Ile-ife.

• Case notes of all emergency neonatal surgeries done between Jan 1990 and
Dec 2000 were retrieved and reviewed.
• Age at admission, sex, weight, diagnosis, surgery performed, PCV, ASA
physical status, blood loss, status of the Anaesthetist, intra-Op blood
transfusion and outcome of surgery were reviewed.
• Data was analyzed using SPSS
• A total of 100 emergency surgeries out of 358 procedures were identified
and only 76 case notes could be retrieved.
 Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for Neonatal Surgical
Emergencies in a Semi-Urban Hospital, Nigeria. East African Medical Journal.
2004:81:11

• Results
Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for Neonatal Surgical Emergencies in a Semi-Urban Hospital, Nigeria. East
African Medical Journal. 2004:81:11
Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for Neonatal Surgical Emergencies in a Semi-Urban Hospital, Nigeria. East African Medical Journal. 2004:81:11
 Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for Neonatal
Surgical Emergencies in a Semi-Urban Hospital, Nigeria. East African
Medical Journal. 2004:81:11

• Conclusion
• General anaesthesia is still the main technique of anaesthesia and
mortality following surgery is still high.
• Effort needs to be intensified to train appropriate personnel to provide
improved care and thereby reduce morbibity and mortality .
 Talabi AO, Sowande OA, Adenekan AT, Adejuyigbe O, Adumah
CC, Igwe AO. A 10 year retrospective review of perioperative
mortality in paediatric general surgery at Ile-Ife Hospital, Nigeria.
J. Ped Surg. 2018: 53: 10.

• Background
• The analysis of perioperative mortality as well as surgery and
anaesthesia related death in paediatric patients may serve as a potential
tool to improve outcome.
• Aim: Report the 24-hr and 30-day overall surgery and anaesthesia
related mortality in a tertiary hospital.
 Talabi AO, Sowande OA, Adenekan AT, Adejuyigbe O,
Adumah CC, Igwe AO. A 10 year retrospective review of
perioperative mortality in paediatric general surgery at Ile-
Ife Hospital, Nigeria. J. Ped Surg. 2018: 53: 10.

• Methods
• This was a retrospective review of perioperative mortality in children
below 15 years at a general paediatric surgery unit.
• All paediatric general surgery cases operated under GA between 2007
and 2016 were included in the study.
 Talabi AO, Sowande OA, Adenekan AT, Adejuyigbe O,
Adumah CC, Igwe AO. A 10 year retrospective review of
perioperative mortality in paediatric general surgery at Ile-
Ife Hospital, Nigeria. J. Ped Surg. 2018: 53: 10.

• Results
• A total of 4108 surgical procedures were performed on 4040 patients
• Age was 1day -15years with median age of 2 years
• The all cause 24-h mortality was 34/10,000 procedures
• The all 30-day mortality was 156/10000 procedures
 Talabi AO, Sowande OA, Adenekan AT, Adejuyigbe O,
Adumah CC, Igwe AO. A 10 year retrospective review of
perioperative mortality in paediatric general surgery at Ile-
Ife Hospital, Nigeria. J. Ped Surg. 2018: 53: 10.

• Septicaemia was the most common cause of death.

• Determinants of mortality:
• Neonatal age group
• Emergency surgery
• Higher ASA status
• Multiple operative procedures
 Talabi AO, Sowande OA, Adenekan AT, Adejuyigbe O,
Adumah CC, Igwe AO. A 10 year retrospective review of
perioperative mortality in paediatric general surgery at Ile-
Ife Hospital, Nigeria. J. Ped Surg. 2018: 53: 10.

• Conclusion
• Neonatal age group, children with poorer ASA status, emergency and
multiple surgeries were predictors of perioperative mortality.
 Conclusion
• Anaesthesia for the management of paediatric emergencies
requires accuracy and precision from the Anaesthetist bearing
in mind the peculiarities associated with this class of patients.
• Regular review of management protocols, training and
retraining of personnel cannot be over-emphasized.
• A good understanding of the peculiar anatomy, physiology,
pharmacology of the paediatric patient and good
understanding of pathophysiology of the emergency
condition is vital in anaesthetic management and overall
reduction in morbidities and mortality.
Thank You for Your
Attention