Paediatric and neonatal anaesthesia

This chapter discusses the anaesthetic management of the neonate, infant and child. It begins with a description of neonatal physiology, then discusses fluid management, anaesthetic equipment and the conduct of anaesthesia in children, including postoperative analgesia. Regional anaesthetic techniques in children are discussed, including caudal, epidural, spinal and regional nerve blocks. Surgical procedures covered include repair of diaphragmatic hernia; gastroschisis/exomphalos; tracheo-oesophageal fistula (TOF); patent ductus arteriosus (PDA); pyloric stenosis; intussusception; herniotomy; circumcision; hypospadias repair; orchidopexy; cleft lip and palate; congenital talipes equinovarus (CTEV); femoral osteotomy, and inhaled foreign body. It includes a discussion of paediatric sedation, paediatric medical problems, paediatric advanced life support, resuscitation of the neonate, the collapsed septic child, stabilisation of the critically ill child, and paediatric drug doses and equipment.

Anaesthesia for radiology and cardiology

This chapter discusses the anaesthetic management of patients for CT or MRI scanning or interventional radiology procedures. It describes the particular hazards associated with the CT and MRI scanning rooms and recommends appropriate anaesthetic techniques. Interventional radiology procedures may include angioplasty; stenting; embolisation; chemotherapy; radiofrequency ablation; cryoablation; thrombolysis, transjugular intrahepatic portosystemic shunt (TIPSS), fluid aspiration, biopsies, percutaneous drain placement and vertebroplasty or cementoplasty. Anaesthesia for cardiology procedures is discussed, including cardioversion, angiography, cardiac device insertion and removal, electrophysiology procedures, and transcatheter aortic valve implantation (TAVI).

Rare Cases of Bilateral Lumbar Hernia: Anaesthesia Concerns and Lessons Learnt

Bilateral lumbar hernias are rare. There is a paucity of literature regarding the anaesthesia techniques used and challenges faced. In the present era of minimally invasive surgery, laparoscopy has gained name and fame and is the modality of choice for hernia repairs. Methods: We report a series of 4 cases of bilateral lumbar hernia operated in our institute, using 4 different anaesthesia techniques over a period of 2 years and 9 months with the aim to focus on the varied anaesthetic techniques and the advantages and disadvantages of each. Results: General anaesthesia supplemented with epidural anaesthesia is recommended for laparoscopic repair, while in very high risk cases, combined segmental spinal- epidural anaesthesia may be a better option. Low dose segmental spinal provides commendable cardiovascular stability. It is a useful alternative in patients with multiple comorbidities, cardiac and respiratory diseases and aids early recovery and ambulation. Conclusion: Irrespective of the type of anaesthesia technique administered, patients’ safety and comfort should be of prime importance, while maintaining optimum haemodynamics and physiology.

Attitudes and practices of veterinarians in Australia to acute pain management in cats

Objectives Up-to-date information on the current practices and attitudes of veterinarians in Australia to acute pain management in cats was sought in 2017–2018 in the first nationwide survey in over 20 years. Methods An online survey was created, consisting of 54 questions in four sections, with 18 feline-specific questions. Veterinarians throughout Australia were invited to participate in the survey through advertisements in the veterinary press, electronic and regular mail, and through in-clinic visits and promotional materials. Results A total of 614 veterinarians completed the survey, with 513 (83.6%) completing the feline-specific section. The demographics of the respondents of this survey were an accurate representation of the registered veterinarians in Australia at the time. Multiple different opioids and non-steroidal anti-inflammatory drugs (NSAIDs) were widely available in practices to manage pain, with analgesic efficacy reported as the primary factor influencing drug selection. Opioids were most commonly used in the preoperative period and NSAIDs were most commonly used postoperatively. Despite the wide availability in clinic (>99%), only 55% of respondents reported regularly using local anaesthetic techniques in cats. Pain assessment of hospitalised patients was primarily performed by veterinarians (91.1%); however, 84.7% of respondents did not routinely use a validated pain scale. Conclusions and relevance Veterinary practitioners in Australia are adequately equipped with analgesic medication to treat pain in their patients. In the management of acute pain in cats, they frequently use a multimodal approach and practice a variety of analgesic protocols. Based on the results of this survey, potential areas for improvement in feline pain management include an increase in duration of postoperative analgesia and more routine use of validated pain scales, performed by nurses and veterinarians alike, to assess individual analgesic needs.

Anaesthetic challenges and difficult airway in a child with Poland’s syndrome

: Poland’s syndrome is an uncommon clinical disorder with a typical musculoskeletal deformity of thorax and ipsilateral upper limb with a variable spectrum of associated anomalies. Although patients of this musculoskeletal disorder have several features with potential anaesthetic risks including malignant hyperthermia, previous reports about anaesthetic management of these patients are limited. : We report the successful anaesthetic management of a child of Poland’s syndrome posted for surgical correction of club foot who had an anticipated difficult airway alongwith unilateral chest wall defect with paradoxical breathing and ipsilateral syndactyly and hence, posing challenges in the insertion of endotracheal tube, ventilatory management, regional anaesthesia and prevention of any risk of development of malignant hyperthermia. Paramount in the anaesthetic care of such patients is a thorough preoperative evaluation and a cautious intraoperative anaesthetic management. Avoidance of halogenated inhalational agents and depolarising neuromuscular blocking drugs, and use of controlled ventilation and regional anaesthetic techniques are recommended. The possibility of a compromised airway should always be kept in mind while anaesthetising these patients.

Comparative analysis of caudal ropivacaine with clonidine vs ropivacaine alone with regards to hemodynamic changes, analgesic potency and side effects in children

Pain management is an essential component of care provided by pediatric anaesthesiologists. That specially holds true due to inability of this group of patients to report their overall experience of surgical procedures like adults. Caudal analgesia is one of the most popular regional anaesthetic techniques employed in children undergoing surgery for lower abdominal, urological, and lower limb operations. Of all the major advantages that this technique has, there is one major disadvantage of short duration of anesthesia. In children it is observed that combination of ropivacaine and clonidine administered caudally has shown to prolong the effects of analgesia. The present clinical study is therefore undertaken to compare caudal ropivacaine with clonidine and ropivacaine alone with regards to hemodynamic changes, analgesic potency and side effects in children. This study included 60 children of the age group 5-10 years ASA grade I and II, of either sex, coming for various elective infra-umbilical surgical procedures who were divided into two groups each comprising of 30 subjects. Group A received plain 0.20% Ropivacaine (1ml/kg) and Group B received 0.20%Ropivacaine (1ml/kg) with clonidine 1µg/kg and the effects were analysed on various parameters.In our study, we chose 0.20% ropivacaine which provides better quality of analgesia and clonidine 1.0μg/kg which prolongs the duration of analgesia significantly while avoiding the side effects like excessive sedation and bradycardia associated with higher doses. Other hemodynamic parameters did not differ significantly in both the groups.

1465 Anaesthetic Preferences in a Tertiary Hand Surgery Unit & Aetiology of Hand Trauma Presentations During the First UK lockdown: Lessons for the Future

Introduction Our tertiary plastics unit serves a 4.3 million population in the South East, providing a seven-day hand trauma service. Our aim was to assess differences in quantity and aetiology of hand trauma during the April 2020 lockdown compared with the equivalent period in 2019, and our ability to reduce risk by carrying out more procedures under local anaesthetic. Method Retrospective notes review for hand trauma surgery patients in April 2020 (3 weeks in first UK lockdown), with a comparative period in April 2019. Fisher’s Exact Test was applied to assess for difference in method of anaesthetia, injury location (workplace vs home) and DIY versus non-DIY aetiology. Results 2020 group: n = 165. 2019: n = 239. (31% reduction). Mean age 45 during lockdown vs 49 in 2019. There was significant reduction in the proportion of workplace injuries in 2020 (22% vs 29%), but the proportion of power tool injuries was similar (31.6% 2020 vs 26.6%). DIY injuries increased significantly (33.5% versus 9.2%). Use of local anaeshesia including increased significantly in our unit (84.2% vs 66.1% 2019) with reduction in use of regional and general anaesthesia. Conclusions Caseload somewhat reduced during lockdown. Fewer injuries occurred in the workplace. Our unit made good use of local anaesthetic techniques to avoid regional anaesthesia (and risk of need for GA conversion) wherever possible. Public safety warnings existed (BAPRAS and BSSH), but perhaps were less publicly available than desirable. Improving awareness further could reduce trauma surgery burden as we enter a third wave of the pandemic.

Efficacy of Anaesthesia Techniques in Periapical Diseased Tooth

Almost all minor oral surgical procedures can be performed effectively if patient is relaxed and comfortable. One of the contributing factor for patient comfort is effective pain control. This can be achieved pre and per-operatively by various local anaesthetic techniques. Infiltration techniques are commonly employed in all maxillary and mandibular teeth whereas mandibular posterior teeth requires a nerve block. In certain cases, these techniques fails or provide inadequate anaesthesia, for example, teeth associated with periapical pathology. Therefore, we conducted a study to determine effectiveness of infiltration and block techniques as well as when supplemented by intra-ligament injection for anaesthesia in periapical infected teeth. Keywords: anaesthesia, infiltration technique, block technique, intraligamental technique, periapical pathology.