1. “Anaesthesia for paediatricians” A very practical approach! Jenny Thomas Paediatric Anaesthesia, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa

2. Objectives  Recognise who not to tackle  How to prepare  What to do  When to ask for help  Document everything

3. It’s all in the preparation  Environment: what do you need? where are you? what do you have  Patient: good, bad, indifferent. Beware syndromes, other abnormalities  Self: skills, knowledge, confidence, humility

4. Equipment: functioning (check)  Paediatric sizes: laryngoscopes, masks, LMA, airways, ETTs, cannulae, volume controllers  Suction: functioning  Oxygen source: humidified: pre-oxygenate!  Bag, mask / ventilator (may be you)  Monitoring  Drugs  Telephone: in case help /advice is required

5. Patient factors  Airway: profile, ears, adenoids/ tonsils, mouth-opening, teeth  Breathing  Circulation  Drugs / disability  Environment  Fluids / blood  Glucose

7. Intubation  “Awake” intubation  Oral or nasal  Hypnotic / analgesia agent vs not  Muscle relaxant vs not  Rapid sequence vs not  Size of ETT: Age/4 + 4  Cuffed or not  How far to place the ETT  Local anaesthetic to vocal cords  Secure strapping  Confirm placement: Capnography?  LMA Airway Mask ETT LMA

8. How to make life easier  Nose drops: oxymetazoline  Lubrication tip of ETT  Warm tip of ETT (nasal)  Bougie / introducer (very gentle in neonate or septic child)  Position of patient: NB anterior larynx  Support behind body (not only shoulders); neonates, hydrocephalus  Do not hyperextend the head  Roll ETT through 180º as through cords

9. Anaesthetic department rules  Call consultant always: Airway problem: regardless of age of patient Any child under one year of age Any cardiac, severely systemically ill child, critically  ICP When > 2 hands are necessary

10. Circulation  Haemodynamics: normal vs compromised  Heart rate: myocarditis vs trauma  Vascular access: peripheral vs central vs none  Time available?  Resuscitation: easy choices

11. Drugs  Route: Sublingual, oral, nasal, intravenous  NPO?  Induction agents: sedation vs anaesthesia Propofol: 1-3 mg/kg/dose Etomidate: 0.3-0.5 mg/kg/dose Ketamine: 0.5 – 2 mg/kg/dose Inhalational agents: only DA or FCA Ketofol: 0.75 mg/kg/ketamine + 1 mg/kg/dose propofol  Muscle relaxants: do not paralyse if airway control is not guaranteed

12. My preferences:  Patient condition, line, and time-dependant  Oxygenate well, plan, have help  Local anaesthetic: EMLA, infiltration: drip, Macintosh spray (mouth, pharynx)  Perfalgan  Induction agent: ketamine, etomidate propofol ± ketamine / fentanyl  (Muscle relaxant: cisatracurium / sux)  Intubate, ventilate, check ABC

13. Other options  Midazolam  Fentanyl: 10mcg/kg for stress-free intubation  Entonox  Clonidine, Dexmedetomidine  Beware: fentanyl + etomidate+ sux

14. Conclusion  Know yourself (your limitations)  Know your patient (A,B,C)  Know your drugs ( know and use a few drugs well)  Where to after your hard work?

15. This should not be a hair-raising experience! The end