1. The Deteriorating Child – what is our vector, Victor? Adam Skinner Staff Anaesthetist Royal Children’s Hospital 30 th July 2015

4. Aims Review anatomical and physiological differences between adults and children and link with clinical features seen in children in recovery. Discuss the (my) thought process when managing acute hypoxia and bradycardia in a child. Discuss ViCTOR and its current practical role in recovery.

5. Children vs Adults Airway differences Oxygen balance differences Cardiac differences

6. Children vs Adults Airway differences Oxygen balance differences Cardiac differences

7. The ‘Normal’ Airway AdultInfant

8. Holding an Airway

9. Airway Oedema

10. Laryngospasm

11. Children vs Adults Airway differences Oxygen balance differences Cardiac differences

12. Demand vs Supply

13. Oxygen Consumption

14. Demand vs Supply

15. Oxygen Uptake Respiratory Drive Rib Cage and diaphragm mechanics Volumes and Elastic forces

16. Oxygen Uptake Respiratory Drive Rib Cage and diaphragm Mechanics Volumes and Elastic forces

17. Oxygen uptake – Respiratory drive Immature Respiratory Centre (Neonates) Opioid Sensitivity Neonates Genetics Co-morbidity (eg CP, OSA)

18. Opioid sensitivity - codeine

19. Codeine Variability

20. Oxygen Uptake Respiratory Drive Rib Cage and diaphragm Mechanics Volumes and Elastic forces

21. Chest Mechanics

22. Chest wall differences InfantAdult

23. Oxygen Uptake Respiratory Drive Rib Cage and diaphragm Mechanics Volumes and Elastic forces

24. Elastic Forces

25. Cardiac Differences

26. Bradycardia– GIVE OXYGEN!!

27. Scenario 1: 5 year old 23 kg in recovery for tonsillectomy for obstructive sleep apnoea. Rapid desaturation to 60%, cyanosed

28. Initial Action Buzzer Mask, T-Piece 100% OXYGEN Position Patient and airway Inflate lungs

29. Scenario 1 Can’t inflate lungs Why? What do we need? Who do we need?

30. Laryngospasm

32. Scenario 2: 5 year old 23 kg in recovery for tonsillectomy for obstructive sleep apnoea. Saturation 78%, shallow breathing.

33. Initial Action Buzzer Mask, T-Piece 100% OXYGEN Position Patient and airway Inflate lungs

34. Scenario 2 Able to inflate with temporary improvement in saturations What is going on?

35. Maybe difficult to diagnose in children

36. Scenario 3 5 year old 23 kg in recovery for tonsillectomy for obstructive sleep apnoea. Noted on monitor to be bradycardic at 60 beats per minute. How do we assess and manage?

37. Initial Action Buzzer Mask, T-Piece 100% OXYGEN Position Patient and airway Inflate lungs

38. Are we starting CPR?

39. What is normal?

40. Arch Dis Child. August 2015

41. Normal Values

42. What is ViCTOR?

43. National Standard 9: Recognition and response of the deteriorating patient Key element - recording of patient observations - greater emphasis on ‘Human Factor’ principles in the design of charts

45. Paediatric Clinical Network Initiative Examples of Track and Trigger Charts

46. 1 – 4 year old Observation and Response Chart : RESPIRATORY RATE ServiceNormal Range (white area) Clinical review trigger point (high) MET or CODE trigger point RCH * trial chart 20 – 4041High 56 / Low 16 Eastern Health 21 – 3031High 36 / Low 11 Barwon Health 20 – 4041Highest 60 / Lowest 15 * 3 tier escalation Bendigo Health 21 - 3536Highest 41 / Low 14 The Alfred 21 – 4950High 60 / Low 15 Austin Health 20 – 4041Highest 60 / Lowest 20 * 3 tier escalation NSW 20 – 4041Highest 60 / Lowest 15 * 3 tier escalation SA 20 – 3435Highest 40 / Lowest 12 * 3 tier escalation

47. 5 age groups 0 - 3 months 3 - 12 months 1 - 4 years 5 - 11 years 12 - 18 years Paediatric Clinical Network Initiative

48. Percentile curves for HR and RR in hospitalized children Bonafide C P et al. Pediatrics 2013;131:e1150-e1157 ©2013 by American Academy of Pediatrics

49. What is the point of ViCTOR for recovery?

50. “Tool for communication and justification” Sharon Kinney PhD, RCH. Forces the team to consider the patient with objective measurements (IN CONTEXT) outside ‘normal’ EARLY. Provides communication framework between specialities, wards and hospitals. Mandates response in a timeframe with suggested roles. At the moment we use it in PACU just before transfer.

52. Summary Physiology link with Clinical Interpretation By recognising human factors we can better recognise and managing critical incidents in recovery as a team. PRACTICE with multi-disciplinary scenarios if possible!