The first annual NEPAN educational meeting was held on the 14th November 2013. One of the most successful components of the meeting was the Clinical Conundrums discussion. In this two, expert paediatric anaesthetists discussed their suggested management of a series of paediatric anaesthetic scenarios.
The Panel:
Chairman. Dr David McColl, Consultant Anaesthetist, North Cumbria University Hospitals
Dr Sue Jackson, Consultant Anaesthetist / Intensivist, Great North Children’s Hospital, Newcastle
Dr Tim Murphy, Consultant Cardiothoracic Anaesthetist, Freeman Hospital Newcastle.
Scenario 1: Emergency surgery in patient with Tetralogy
12 year old boy with previous repair of tetralogy of Fallot (at 7months of age).
Under annual cardiology review, presents to his local DGH with symptoms and signs of appendicitis.
Should his operation be undertaken at his local hospital or should he be transferred?
Response / Discussion from floor
• Take full medical history
• Outcomes from fallot’s are good
• Pulmonary Regurgitation is common
• Criteria for valve replacement is not concrete
• Echo only if indicated and not to be routinely carried out
Summary / Conclusion
For acute appendicitis operate at the DGH.
If the fallot was outside of UK and/or cant access medical records, then it may be appropriate to transfer to tertiary centre so they can have a full review.
Scenario 2: Tonsillectomy for Sleep Apnoea
6 year old girl with history of multiple episodes of tonsillitis. Parents report loud snoring and apnoea.
Overnight oximetry shows oxygen saturation nadir of 79% for 30 seconds.
Parents report that oximetry was done “on a good day”
Should she be referred to a specialist centre?
Response / Discussion from floor
• Adequate monitoring throughout procedure
• Very standard case ‘bog’ standard
Summary / Conclusion
There is no indication to transfer and patient should be treated at DGH.
If there is CP this would need further evaluation by an anaesthetist and paediatrician with interest in sleep disorders.
Scenario 3: Airway Assessment in Uncooperative Patient
8 year old boy with severe learning disability.
Presents for dental extractions and conservative dentistry.
Refuses to co-operate with anaesthetic assessment
How would you assess his airway?
Response / Discussion from floor
• Pragmatic approach
• Be prepared
• Obtain detailed history
Summary / Conclusion
Sometimes it’s not always possible to carry out a thorough assessment, but fortunately airways that can’t be ventilated/intubated are rare so use own judgment and be prepared for the unexpected.
Scenario 4: Elective Surgery & Congenital Heart Disease
7 year old girl requires grommets. Previous coarctation repair and PDA ligation as neonate (very unwell at the time).
Cardiology follow up 6 monthly
“a bit of narrowing of a valve”
Who should anaesthetise her?
Response / Discussion from floor
• Arterial switch outcomes are good
• Being unwell at time of coarctation & PDA ligation is not an indication of how the child is fairing now
Summary / Conclusion
This patient could have surgery locally.
Obtain a thorough history and consider use of paediatric pre-assessment questionnaires same as being used in Carlisle by Dr McColl.
Sunderland have a nurse led pre assessment service.
Scenario 5: Emergency Surgery in an Adolescent Withholding Consent
12 year old child with an immediately limb threatening injury.
Refuses pre-med, IV access and inhalational induction
How would you proceed?
Response / Discussion from floor
• The patient legally can’t refuse treatment
• Speak with parents away from child, ask them how best to approach the situation with their child
• Ask the parents’ consent to physically restrain the child
• Ask the patient what is concerning them
• Be creative
• Consider intranasal diamorphine; ketamine in juice
Summary / Conclusion
There is no simple answer – use a mixture of different techniques.
Scenario 6: Airway Compromise in the DGH
2 year old child presents to A&E; with stridor and upper airway obstruction.
The hospital has no ENT services.
How would you manage this child?
Response / Discussion from floor
• Priority is to protect the airway
• Don’t transfer the child until stabile
• Are there any surgeons to draw on with skills in trachea?
• Call local colleagues for advice
Summary / Conclusion
Do the best that you can in that situation
Scenario 7: Difficult Airway Equipment in the DGH
What equipment for managing difficult paediatric airways is it appropriate for a DGH to provide?
Should all hospitals providing an elective ENT service have the facility to perform paediatric bronchoscopy in an emergency?
Response / Discussion from floor
Use the kit you are most familiar with
Summary / Conclusion
There is no need to have separate paediatric kit, make best use of what you have.
Scenario 8: Analgesia After Tonsillectomy
11 year old asthmatic known to be sensitive to NSAIDs.
Post-op tonsillectomy.
What analgesia is it appropriate to prescribe? What medications can she have to take home?
Response / Discussion from floor
• Confusion over what best to use since the withdrawal of codeine
• Diahydrocodeine can be used
• Tramadol can be used but there is no take home solution
• Use Oromorph
Summary / Conclusion
Consider using those listed in discussion
Scenario 9: CPR in a Neonate
2 day old infant found in cot with no respiratory effort and no cardiac output.
Intubated and transferred to A&E; CPR performed at 3:1 ratio.
Continuous chest compressions.
Was the 3:1 ratio appropriate?
Should compressions have been stopped to allow ventilations?
Summary / Conclusion
Do what you are familiar with.
Scenario 10: Use of Adult ITU for Paediatric Patients
Is it ever appropriate or desirable to manage a child in the adult ITU of a DGH?
Summary / Conclusion
A child who is nearly adult with adult problems could have one overnight stay.
Younger children should not be staying overnight
