Gas induction. Maintain spontaneous ventilation. Adequate depth of anaesthesia
(+/- check ventilation – risk of pushing FB distally. Avoid insufflation of stomach)
Spray cords with lignocaine
Insert uncuffed nasal (standard) ETT to level just above cords
+/- close mouth as required
Spontaneous ventilation of O2+anaesthetic vapour. PEEP on T-peice
Also see: https://anaesthesiaonreflection.wordpress.com/2014/12/05/paediatric-airway-surgery-recipe/
Remember basic manoeuvres e.g. Abdominal thrusts, Heimlick Manoeuvre, back blows.
In the event of cardiac arrest CPR/chest compressions may dislodge the foreign body.
0.5mg/kg (preservative free) ketamine.
Prolongs action of caudal. Up to 12-16 hours.
Good for paediatric orthopaedics
Identify surface landmark
enter approx 45 degrees
upon entry anlge needle more parallel
advance needle slightly
then keeping needle stable, advance the cannula. Does not need to be to hilt.
Watch/aspirate for CSF or blood
inject LA (+1-2mcg/kg clonidine) as per Armitage regime, visualising the skin/subcut tissue
The feel of entering cuadal space is similar to the gentle LOR when piercing rubber bung on antibiotic bottle.
If after inserting needle through sacrococcygeal membrane and resistance is encountered on advancing cannula or needle or injection of LA (likely the dorsal aspect of the ventral plate of the sacrum) then withdraw cannula/needle and redirect cranially, walking off the bone if necessary. Better to enter at caudal aspect of sacral hiatus.
More reliable and consistent than nerve blocks.
Use up to approx 20kg weight/7yr
e.g. for circumcision
weight / 3 = mls of 0.75% levy-bupivicane
Sterile precautions. Counter-traction as necessary.
1. Ring block at base of shaft
27 1/2 gauge needle
start at dorsum, just lateral to dorsal vein either side, aiming laterally. watching for circumferential spread.
inject at approx 3 o’clock and 9 o’clock for remaining ventral half.
inject into ‘watershed’ areas as needed to complete the ring
2. Dorsal n. of penis
identify pubic symphysis
two entry points, just lateral to midline on each side, just below PS
advance needle perpendicularly until bone is hit
Inject – resistance will be felt
Continuous pressure trying to inject while withdrawing – there will be sudden LOR as LA spreads within the correct plane/under Buck’s fascia. 0.5-2ml per side.
– EdM @ LRI
Standard induction (IV or gas)
Maintenance using TIVA:
- propofol 400 -> 300 -> 100 mcg/kg/min
- remi 0.2 – 0.1 mcg/kg/min
- Use to judge adequate depth of anaesthesia
- insert nasal uncuffed (standard) ETT to level just proximal to cords
- Spray larynx/cords/distally – take max allowed dose of lignocaine 10%, dilute to make up to desired volume, spray using MAD/atomiser
- Aim for spontaneous ventilation of oxygen enriched air while applying PEEP with bag
- Can hand ventilate if mouth is closed (but risks insufflation of stomach)
Emergence of spontaneously breathing patient with NPA
– KP @ LRI
Vecuronium or Pancuronium 0.1mg/kg
Vec 0.05 mg/kg
Panc 0.02 mg/kg
Bolus: 0.1mg/kg = 100mcg/kg
Infusion: 1-4 mcg/kg/min
Syringe: 3 x BW (in mg) in 50ml
1ml/hr = 1mcg/kg/min
1ml = 0.06mg/kg = 60mcg/kg
Run at 1-4ml/hr
Bolus: 0.1mg/kg = 100mcg/kg
Syringe: BW (in mg) in 50ml
1ml/hr = 20mcg/kg/hr
1ml = 20mcg/kg
Run at 0.5-2ml/hr
Bolus: 1-2 mcg/kg
Infusion: 2-8 mcg/kg/hr
A random post I came across…
We once saved a child admitted with severe scalds after trying to drink from a teapot spout using ketamine iv and some topical lidocaine.On laryngoscopy just saw a bubble of air escaping the swollen tissues and managed to push through a 2.5mm shouldered ET tube-The child was 5!
If child ‘understands’:
Explain they need to have an anaesthetic to have op
Give them a CHOICE of either IV or gas
More likely to co-operate if they are going along with what they chose
Avoid giving ‘yes vs no’ choices/options
Works for even young children
Up to 1ml/kg of 0.25% bupivicaine
in TAP blocks use 0.2ml/kg to each side