Algorithm for Management of Paediatric Sepsis.
Once you feel any signs of shock are adequately reversed what other aspects of fluid therapy must be covered?
Further reading
Practical differences between adult and paediatric anaesthesia
You are asked to anaesthetize a 4-year-old child for an open reduction and internal fixation of her forearm. She is usually fit and well. She is fasted. She weighs 17 kg.
Consider the following true/false questions:
1. Premedication with 500 mg of oral paracetamol is suitable
2. Oral midazolam 0.5 mg/kg can be administered 60 minutes preoperatively
3. The starvation time for formula milk is 6 hours
4. A T-piece circuit should be used
5. A size 3 laryngeal mask airway (LMA) could be used
6. A size 5 uncuffed endotracheal tube could be used
7. The minimum alveolar concentration (MAC) of sevoflurane is lower in infants than in adults
8. Maintenance fluid requirements are 54 ml/h
9. The maintenance fluid of choice is sodium chloride 0.18% with glucose 4%
10. Codeine phosphate at 1 mg/kg is a suitable post-operative medication
Answers: FFTTFTFTFF
The practical differences between anaesthetizing adults and children include differences in preoperative management, equipment, drug dosing and fluids. During the preoperative assessment the child will be seen alongside his or her parents and, age permitting, have their questions and anxieties addressed. The planned approach to induction should be explained to the child and parent. Analgesic options should be discussed and consent for suppositories obtained if planned.
Starvation times are identical to adults except breast milk, which can be allowed up to 4 hours preoperatively. Starvation should be minimized for comfort and to reduce risk of nausea and vomiting.
The child should be weighed to allow drug dosing. Premedication may include sedative agents, analgesics and topical local anaesthetic cream.
Sedatives may often fail and timing of administration is important. Options include:
Midazolam 0.5 mg/kg given 15–30 minutes preoperatively.
Ketamine 3–8 mg/kg orally can be used 30–60 minutes before surgery.
Chloral hydrate 50 mg/kg orally.
Equipment should be prepared and a range of airways in different sizes should be available. A laryngoscope with a straight blade may be preferable in babies and infants, changing to a curved blade in the older age group. Endotracheal tube size can be calculated using the formula age/4 + 4. Generally uncuffed tubes are used until the age of 8 years. However, there has been a recent move to using cuffed tubes in a younger age group in emergencies, for those at risk of aspiration or those with low lung compliance.
Laryngeal masks are available in the sizes shown in Table 13.1.
LMA sizes by weight
| LMA size | 1 | 1.5 | 2 | 2.5 | 3 |
| Weight | Up to 5 kg | 5–10 kg | 10–20 kg | 20–30 kg | 30–50 kg |
A T-piece circuit can be used in children less than 20 kg as it has less dead space but a paediatric circle is also available.
Similar induction agents to adults may be used but a gas induction may be preferred by some children. For maintenance of anaesthesia MAC is higher in infants than adults. Propofol infusions should be avoided in children under 16 years of age as propofol infusion syndrome is more common in children.
During maintenance of anaesthesia attention to temperature management is important. Radiation is the main source of heat loss and babies and infants have a higher thermo-neutral environmental temperature than older children. Exposure should be minimized and babies’ heads covered. Overhead heaters, warming mattresses and forced air warming systems can be used.
Intravenous fluids are not usually required for short procedures.
The Holliday–Segar formula can be used for maintenance calculations, shown in Table 13.2.
Holliday–Segar formula for paediatric maintenance fluid calculation
| Body weight | Daily fluid requirement |
|---|---|
| 0–10 kg | 4 ml/kg/h |
| 10–20 kg | 40 ml/h + 2 ml/kg/h above 10 kg |
| >20 kg | 60 ml/h + 1 ml/kg/h above 20 kg |
Children above 1 month of age should receive isotonic fluid. Less than 1 month of age or at risk of hypoglycaemia should receive dextrose-containing solutions or have blood glucose checked regularly.
Shocked children should receive fluid boluses of 10–20 ml/kg titrated to response.
Intra and post-operative analgesia can include:
Paracetamol at 15 mg/kg maximum 4 hourly, 4 times a day. If being administered intravenously the dose should be reduced to 7.5 mg/kg for children under 10 kg.
Ibuprofen 5–10 mg/kg 3–4 times a day. (Maximum 30 mg/kg/day.)
Oral morphine 200–400 mcg/kg 4 hourly.
Codeine should now be avoided in children under 12 years and any child with a history of sleep apnoea. This is because of the unreliable metabolism and risk of apnoea.
Further reading
Intraosseous access
A 6-year-old child presents to the emergency department, moribund. Intravenous access is proving impossible and so intraosseous access (IO) is suggested to facilitate ongoing resuscitation.
Which sites would you choose for your first access attempt?
Intraosseous access is popular in paediatric resuscitation. It provides a non-collapsible compartment in which to infuse drugs and fluids in a population who not only require rapid intervention but also can have very difficult venous access. It should be attempted in a resuscitation setting if intravenous access is not achieved within 90 seconds. It is increasingly popular owing to its ease of insertion and low risk of complications.
A number of sites of insertion have been described, with the proximal tibia (2–3 cm below the anterior tuberosity) or distal femur (3 cm above the lateral condyle) being the preferred sites for resuscitation as they leave access to the airway and chest.
What other sites can be used?
Other sites you might consider are the proximal humerus (older children) or distal tibia.
What are the contraindications for insertion?
These include ipsilateral fracture, previous placement in the same limb, osteopetrosis and osteogenesis imperfecta (risk of fracture), coagulopathy and overlying skin infection (a relative contraindication).
What kit is available?
Paediatric patients have the benefit of thin, easily penetrable cortical bone which facilitates the use of hand-held needles. For the paediatric age group most people will be familiar with the Cook IO needle. This device consists of a needle and stylet with a shaped handle which is contoured for the palm of the hand. This allows firm pressure to be applied to pierce the bone cortex. In neonatal patients spinal needles may be used for IO access.
The extension of IO access into adult practice has necessitated the introduction of powered devices. These devices are increasingly popular in paediatrics. The EZ-IO has a battery-powered driver with several choices of needle size. The size of the needle is determined by the weight of the patient and the depth is set by the operator prior to insertion. A give is felt as the bone cortex is breached.
Complications of IO insertion include fracture, embolism, extravasation, compartment syndrome, haematoma formation and infection.
What blood tests can be done on samples taken?
Full blood count, biochemistry, cross-matching and cultures can be done on blood samples but you need to inform the laboratory of the sample site. In some hospitals, a bedside glucose test can also be done. It is reported that venous blood gas analysis can be performed on marrow samples but in practice you should check first: the sample will clog up some machines.
What drugs and fluids can be given via the intraosseous route?
All resuscitation drugs and fluids (including blood products) can be administered via the IO route.
IO access is usually removed when IV access is established, usually by 6–12 hours. It may be left in place for longer (up to 96 hours) but the risk of infection and dislodgement increases.
Further reading
Intravenous fluid replacement
You see a 17-month-old weighing 10 kg who is listed for orchidopexy. His mother tells you that he has not had anything to eat or drink since 20:00. It is now 11:00 and the patient is third on the list and expected to go to theatre at 15:00. You give the child a drink now (150 ml).
What will his fluid deficit be at induction?
a) 190 ml
b) 240 ml
c) 550 ml
d) 610 ml
e) 760 ml
Answer: d)
Maintenance fluid requirements, and therefore fluid deficit in starved patients, can be calculated using the formula of Holliday and Segar shown in Table 13.2.
This child’s maintenance fluid requirements are estimated at 40 ml/h. Without the drink, the deficit when he arrives in theatre will be 40 ml × 19 = 760 ml. The drink reduces this to 610 ml, which equates to 10% of total body water (TBW). The child described in this scenario should have been given his usual breakfast at 07:00 and ideally a clear fluid drink at 11:00. He would then have a fluid deficit of only (40 × 7) – 200 = 80 ml (approx. 1% TBW).
It is important to note that even the gross error of a 15-hour fast as opposed to a 2-hour fast for clear fluid is unlikely to make a physiologically significant impact on the cardiovascular status of the child, or necessitate a different anaesthetic technique for an otherwise fit child. However, it may give you a very unhappy and uncooperative child! General principles of paediatric fluid management require consideration of the following three issues:
1. Fluid deficit
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