Medical emergencies

This chapter is meant as a brief guide to the immediate management of medical emergencies that an anaesthetist may be called to assist with. It is not intended as an in-depth text on the conditions covered. The severity and immediate management of acute asthma are detailed, including tips on induction and ventilation strategies. An overview of bronchiolitis includes presentation, risk factors, medical management, and tips on intubation and ventilation. Convulsive status epilepticus is a common referral, and its causes, treatment and indications for intubation and early extubation are discussed. Diabetic ketoacidosis management is described, specifically including the treatment of cerebral oedema. A common cause of mortality and morbidity in children is sepsis, and in this final section of the chapter the ‘Sepsis 6’ approach is taken.

Dental and oral surgery

Dental and oral surgery is one of the commonest reasons for providing anaesthesia to children in the UK. Other than simple extractions for caries, patients may present for restorative work and to facilitate orthodontic treatment. A familiarity with the techniques involved is essential, including that of airway maintenance with a nasal mask, which is still used in some centres.

Cardiothoracic surgery

Congenital heart disease occurs in around 1% of live births and will be more common in children presenting for surgical correction of other congenital anomalies. Whilst the anaesthetic care of children undergoing cardiac surgery is a highly specialized area of practice, any anaesthetist looking after children and young adults will encounter patients with congenital heart disease and therefore requires an understanding of optimal anaesthetic management of these children. The objects of this chapter are first to describe different congenital heart lesions and their implications with respect to anaesthesia and to provide advice for anaesthetic care of these patients. More specialist areas of anaesthetic care are also discussed, including anaesthesia for cardiac surgery in children, anaesthesia in the cardiac catheter laboratory, and use of mechanical support of the circulation. The second part of the chapter concerns surgery on thoracic structures other than the heart. Indications for thoracic surgery, general conduct of anaesthesia, analgesic techniques, and techniques for one-lung ventilation in children are described. Mediastinal surgery and surgery on the chest wall are also discussed.

Neonatal anaesthesia

Paediatric anaesthetists often place emphasis on the differences between children and adults. These differences will be greatest when considering neonates, whose physiology will also differ substantially from that of older children. This chapter focuses on general issues around anaesthesia in neonates, including airway management, fluids, and vascular access. Specific sections discuss the cardiovascular changes around birth and anaesthesia for premature infants. The effect of anaesthetic agents, and anaesthesia, on bran development is controversial, and key aspects of this debate are summarized.

Advanced vascular access

In this chapter, the use of ultrasound to facilitate cannulation of a vessel is described in detail, including commentaries on equipment, preparation, scanning, and needling technique. Equipment and techniques for the insertion of short-term non-tunnelled central lines, long-term central venous access devices, arterial lines, and intraosseous needles are presented.

Anaesthetic equipment

This chapter presents anaesthetic equipment used in paediatric anaesthesia. Airway equipment is described in detail with specific examples. This includes a description of the variety of supraglottic airway devices, endotracheal tubes, laryngoscopes for direct and indirect visualization of the larynx, breathing systems, ventilators, and modes of ventilation. Equipment for perioperative monitoring of the paediatric patient is reviewed. Practical advice regarding monitoring neonates and small babies is given particular attention. The use of the bispectral index (BIS) monitor and near-infrared spectroscopy (NIRS) are discussed. New advances in pulse oximetry that enable better monitoring with low perfusion states and motion are included.

Comorbidities and syndromes

It is not uncommon for a child or infant to present with a congenital syndrome or condition that may have specific implications for the conduct of their anaesthesia. There are many thousands of such syndromes in existence. This chapter focuses on a few of the more commonly known syndromes and conditions, with emphasis on their clinical features, anaesthetic management, and potential problems that may arise during the perioperative period.

Plastic surgery

Elective and emergency plastic surgical patients make up a significant proportion of cases in paediatric anaesthesia. Frequently, patients are fit and well, the surgical site is peripheral, and the surgery is done in normal working hours as a day case. Certain presentations such as syndactyly or congenital microtia may be part of a syndrome, and anaesthesia for surgery in these patients may present specific difficulties for the paediatric anaesthetist. Laser treatment for pigmented lesions or scars may present a challenging working environment, and anaesthesia for free flap reconstructive surgery challenges the anaesthetist to provide optimum conditions for graft success. Acute trauma, including small burns and scalds, is common in children and is usually minor. Major burns require a structured approach in resuscitation, surgical and anaesthetic management, and aftercare, including pain management.

Radiology

This chapter covers both diagnostic and interventional radiology. Unlike adults, many children require general anaesthesia or sedation to be able to cooperate with diagnostic radiology, e.g. a breath hold during CT chest, or keeping still for a long MRI scan. Commonly, general anaesthesia is delivered in the radiology department. This can mean the anaesthetist is working remotely from colleagues and therefore must be experienced and aware of the potential hazards in this environment (e.g. radiation). Increasingly, interventional procedures are being performed in children (e.g. venous access), with large numbers of personnel and equipment often involved; therefore, organisation and planning are imperative. This chapter helps highlight the issues involved.

Advanced airway management

Management of the difficult paediatric airway is described in this chapter. Airway assessment and a structured approach to planning for the anticipated difficult airway are the essence of the chapter. This includes a plan for induction of anaesthesia, a plan for laryngoscopy and intubation, and a plan for safe extubation. Detailed, step-by-step guides describing the techniques for intubation using a flexible bronchoscope, Macintosh-style video laryngoscope, and rigid optical stylet are provided. The conditions commonly associated with the difficult paediatric airway are classified according to the mechanism by which they cause difficulty.