Anaesthetic and post anaesthetic care of children

• Local and regional anaesthesia
• General anaesthesia
• Post operative care
• Management of anaesthetic and postanaesthetic complications

LOCAL AND REGIONAL ANAESTHESIA

DESCRIPTION

Local anaesthesia is accomplished by either local infiltration of soft tissue or the instillation of local anaesthetic into potential or existing body spaces such as the epidural space, sub-arachnoid spinal spaces or around major nerves or plexuses.
Appropriate care is always used to limit the volumes. Use appropriate agents, avoid adrenaline (epinephrine) where end-artery blood supply exists and ensure the agents are in the correct sites. This should be learnt under appropriate learning situations.

MEDICINE TREATMENT

Dental local anaesthesia

• Lignocaine (lidocaine) 2% with adrenaline (epinephrine) (1:80 000).
  • Maximum dose: 7 mg/kg Lignocaine (lidocaine) with adrenaline (epinephrine) (i.e. 0.35 mL/kg) per use.

Diffuse local soft tissue infiltration

Do not use adrenaline containing lignocaine in sites where vascular (end- artery) compromise may result from vasoconstrictor use, i.e. fingers, toes, penis and eyes.

For sites where vascular (end-artery) compromise is a risk:

• Lignocaine (lidocaine) 2% [without adrenaline (epinephrine)].
  • Maximum dose: 3 mg/kg of Lignocaine (lidocaine) (i.e. 0.15 mL/kg) per use.

For sites where vascular (end artery) compromise is not a risk:

• Lignocaine (lidocaine) 2% with adrenaline (epinephrine) (1:80 000).
  • Maximum dose: 7 mg/kg Lignocaine (lidocaine) with adrenaline (epinephrine) (i.e. 0.35 mL/kg) per use.

Intercostal nerve block/penile block/digital ring block/brachial (axillary approach) block, preferably with an ultrasound or nerve stimulation.

• Lignocaine (lidocaine) 2% [without epinephrine (adrenaline)].
  • Maximum dose: 3 mg/kg of Lignocaine (lidocaine) (i.e. 0.15 mL/kg of 2%).

OR

• Bupivacaine 5 mg/mL (0.5%) [without epinephrine (adrenaline) and without dextrose]. Can be diluted to 0.25% with normal saline where larger areas need anaesthetising.
  • Maximum dose: 2 mg/kg of bupivacaine (i.e. 0.4 mL/kg of 5mg/mL).

GENERAL ANAESTHESIA

PREPARATION

DESCRIPTION

Premedication of children for anaesthesia is largely a sedative/anxiolytic intervention.
Recognition of the child’s condition should guide in the choice of agent.

Avoid sedative premedication in children less than 6 months, with evidence of airway compromise, obstructive sleep apnoea or hypotonia.

Other special medical interventions such as prevention of hyper-secretion are ordered according to specific-or anticipated need.

Premedication care should be learnt in an appropriate learning situation.

Pre-operative starvation period:

• clear fluid: 2 hours,
• breast milk: 4 hours,
• solids, breast milk substitutes, non-human milk: 6 hours.

MEDICINE TREATMENT

Premedication:

• Midazolam, oral, 0.5 mg/kg, 10–30 minutes pre-operative.

LoEIII [7]

• Maximum dose: 15 mg.

LoEIII [6]

OR

For children over 2 years of age:

• Promethazine, oral, 0.5 mg/kg, 30-60 minutes pre-operative.
  • Maximum dose: 25 mg (2-5 years) – 50 mg (over 5 years).
  • Decrease dose of any narcotics given.

LoEIII [8]
OR

• Ketamine, oral, 3-5 mg/kg. (Acts within 30 minutes. Effect lasts 60 minutes).

INDUCTION

Induction should be learnt in an appropriate learning situation.

DESCRIPTION

Induction of anaesthesia is the critical part of the transition from consciousness to general anaesthesia.

All patients undergoing anaesthesia should be monitored with a minimum of:

• clinical observation,
• ECG,
• blood pressure monitor,
• pulse oximeter, and
• temperature monitoring, especially in neonates and infants.

It is desirable to do capnography for ventilated patients.

This is a period which requires highly attentive and skilled care.

MEDICINE TREATMENT

Endotracheal intubation

Caution
This procedure should be learnt under supervision.

The condition of the patient and the surgical requirements dictate airway management by way of face mask, supraglottic device or endotracheal tube.

Inhalational agents:

• Nitrous oxide.
• Oxygen.
• Sevoflurane.
• Halothane.
• Medical air.

LoEIII [9]

Intravenous agents: (Use reduced doses if inhalational agents also used).

• Propofol, IV, titrate up to 2.5 mg/kg. Titrate as necessary to achieve required sedation. (Acts within 30 seconds. Effect lasts 3-10 minutes).

LoEIII [1]
OR

• Ketamine, IV, 1–2 mg/kg. (Acts within 60 seconds. Effect lasts 5-10 minutes).

OR

• Thiopental sodium, IV, 2–5 mg/kg. Titrate as necessary to achieve required sedation. (Acts within 30-60 seconds. General effect lasts 5-30 minutes, sedation may last for up to 24 hours.) Use smaller doses in neonates and child, higher dose in infants.

Muscle relaxant during induction for intubation:

Note: A nerve stimulator should always be used when non-depolarising muscle relaxants are used.

Ventilate all patients receiving muscle relaxants.

• Suxamethonium, IV, 1-2 mg/kg. (Produces 5–10 minutes of neuromuscular blockade within 30-60 seconds). Causes paralysis and apnoea.
• Note: Avoid Suxamethonium in patients with or at risk of hyperkalaemia, neuromuscular disease and a family history of malignant hyperthermia.

OR

• Rocuronium bromide, IV, 0.3-0.6 mg/kg. (Acts within 1-2 minutes. Effect lasts 20-30 minutes). Causes paralysis and apnoea.

LoEIII [10]

Endotracheal tube sizes in anaesthesia (Children)

*If using a cuffed endotracheal tube, use a half size smaller.

MAINTENANCE

Caution
This procedure should be learnt under supervision.

DESCRIPTION

After induction, transition occurs to maintenance of adequate level of pain prevention, amnesia and immobility to allow pain-free and safe surgical care, i.e. adequate narcosis, analgesia and muscle relaxation.

Appropriate care is always required to monitor the patient, detect complications of, and depth of anaesthesia.

MEDICINE TREATMENT

Inhalation anaesthesia

• Oxygen.
• Nitrous oxide.
• Isoflurane.
• Halothane.
• Medical air.

Intravenous medicine used during anaesthesia in children (not neonates):

• Fentanyl, IV, 1–2 mcg/kg bolus as required (under anaesthetist supervision up to 2–5 mcg/kg).
  • Maximum dose: 50–100 mcg if unventilated.

OR

• Morphine, IV, 0.05-0.1 mg/kg bolus as required.

LoEIII [11]

Muscle relaxant during maintenance:

• Rocuronium bromide, IV.
  • Maintenance doses: IV, 0.15 mg/kg, as needed, and guided by use of nerve stimulator.

Reversal of muscle relaxant:

• Neostigmine, IV, 50 mcg/kg plus atropine 10 mcg/kg solution:
  • Neostigmine/atropine solution, IV: 0.5 mL of neostigmine 2.5 mg/mL plus 0.6 mL atropine 0.5 mg/mL plus 0.4 mL sodium chloride 0.9%.

OR

• Neostigmine plus glycopyrrolate, IV, 1 mL/5 kg of neostigmine/glycopyrrolate solution below:
  • Neostigmine/glycopyrrolate solution: 1 mL of neostigmine 2.5 mg/mL plus 2 mL glycopyrrolate 0.2 mg/mL plus 7 mL sodium chloride 0.9%.

LoEII [12]

To reduce secretions, only if required (especially if ketamine is given):

• Atropine, IV, 0.02 mg/kg.

POST OPERATIVE CARE

DESCRIPTION

After surgery, adequate control of pain is required for comfort and also for the optimisation of outcome and minimisation of adverse effects of pain on recovery. Pain relief should be adapted to the specific needs of each patient – according to the severity of pain, site of pain and type of pain.

GENERAL AND SUPPORTIVE MEASURES

Appropriate control of the environment, provision of sedation (as above), normal physiological requirements, monitoring of vital signs and provision of comforting care should be incorporated into the care of infants and children during and after surgery.

MEDICINE TREATMENT

Less than 3 months of age: Refer to a tertiary centre.

For pain (post operation): older child (more than 3 months of age).

• Ventilated: Morphine, IV, 20–40 mcg/kg/hour infusion.
  • i.e. Morphine (15 mg/mL) 1 mg/kg mixed with 50 mL dextrose 5% or sodium chloride 0.9% at 1– 2 mL/hour.
• Unventilated: Morphine 5-20 mcg/kg/hour infusion.
  • i.e. Morphine (15 mg/mL) 1 mg/kg mixed with 50 mL dextrose 5% or sodium chloride 0.9% at 0.25 – 1 mL/hour.
    LoEII [13]

OR

• Tilidine, oral, 1 mg/kg/dose (i.e. 1 drop per 2.5 kg) 6 hourly.

OR

• Morphine, IM/SC, 0.1 mg/kg/dose 4–6 hourly as necessary.

Note:
Use all the above medications for pain control with cardio-respiratory monitoring, especially in infants.

PLUS

• Paracetamol, oral, 20 mg/kg as a single dose immediately.
  • Follow with 15 mg/kg/dose 6 hourly oral.

If oral cannot be used:

• Paracetamol suppositories, rectal, 6 hourly.
  • If 3–12 months of age: 62.5-125 mg.
  • If 1–5 years of age: 125–250 mg.
  • If 6–12 years of age: 250–500 mg.

OR

• Ibuprofen, oral, 4–10 mg/kg/dose 6–8 hourly.

Regional anaesthesia

See Local and regional anaesthesia.

REFERRAL

• Inability to provide appropriate care.

MANAGEMENT OF ANAESTHETIC AND POSTANAESTHETIC COMPLICATIONS

DESCRIPTION

Various events may occur during and after anaesthesia, which require management.

MEDICINE TREATMENT

Laryngospasm

Bag-mask ventilation, maintaining continuous positive pressure and reintroduction of a volatile general anaesthetic agent (but not isoflurane) may overcome laryngospasm without the need for Suxamethonium.

• Suxamethonium, IV, 1-2 mg/kg. (Produces 5–10 minutes of neuromuscular blockade within 30-60 seconds). Causes paralysis and apnoea.
  • Note: Avoid Suxamethonium in patients with or at risk of hyperkalaemia, neuromuscular disease and a family history of malignant hyperthermia.

LoEIII [3]

Bronchospasm

Intraoperatively, the first step is to deepen anaesthesia with sevoflurane or halothane and check patient for precipitating factors, e.g. ET tube at carina, light anaesthesia, secretions, aspiration, allergic reactions.

• Salbutamol nebulisation – administered in line (i.e. in circuit) or by mask.

OR

• Salbutamol, IV 5–10 mcg/kg/minute for 1 hour.
  • Follow with 1–2 mcg//kg/minute.

See Asthma attack, acute .

Hypersecretion

• Atropine, IV, 0.02 mg/kg.
  • Maximum dose: 0.6 mg.

Respiratory depression/apnoea from opiates:

• Naloxone, IV, 0.01 mg/kg, repeated every 2 minutes, if required, up to 4 times.
  • Maximum dose: 0.4 mg.

Note: All patients need to be kept under direct observation until the effect of the opiates has completely worn off. Further doses of naloxone may be needed as naloxone has a shorter duration of action than most opiates.

Post operative nausea and vomiting

Children > 2 years of age:

• Ondansetron, slow IV, 0.1 mg/kg.
  • Maximum dose: 4 mg.

LoEIII [14]

Malignant hyperthermia

• Dantrolene, IV, 1 mg/kg/minute until improvement.
  • Do not exceed a cumulative dose of 10 mg/kg.
  • Follow with 1–2 mg/kg IV 6 hourly for 1–3 days.

Shock

See Shock .

Dysrhythmias

See Cardiac dysrhythmias .

Prevention of hypocalcaemia during rapid large blood transfusion in children with acid citrate anticoagulated blood:

• Calcium gluconate 10%, IV infusion.
  • 5–10 mL of calcium gluconate 10% added to 200 mL bag of compatible IV infusion fluid.
  • Infuse at maintenance IV fluid rate if blood transfusion volumes approach circulating volume of child (~80 mL/kg).