Mr. Julian Roberts, Consultant Paediatric Surgeon, Sheffield & Chair of the National Clinical Reference Group for Paediatric Surgery
Dr. Sarah Bell, Consultant Paediatric Anaesthetist, Great North Children’s Hospital
Dr. Reema Nandi, Consultant Paediatric Anaesthetist, Great Ormond Street Hospital
Mr. Steven Powell, Consultant Paediatric ENT Surgeon, GNCH
Dr. David McColl, Consultant Anaesthetist and Lead for Paediatric Anaesthesia, Cumberland Infirmary
My hospital has a large, rural catchment area. Should we be imposing maximum travel times or distances when agreeing to day-case surgery for children? Should we consider this for certain age-groups, perhaps under-1s or under-5s?
There are no national guidelines on this issue; even the AAGBI adult guidelines are not specific on maximum travel distances (Verma R, Alladi R, Jackson I, et al. Day case and short stay surgery: 2, Anaesthesia 2011; 66: pages 417-434). From the panel and delegate discussions, it was clear that this is an issue that raises questions frequently with hospitals around our region, especially as the time it takes to travel from areas of the Pennines, Northumberland and Cumbria to any hospital could be large.
There was a feeling from the audience that a pragmatic suggestion of a one-hour travel time would be sensible when considering day-case surgery, but this needs to be tempered with consideration of other factors including the age and comorbidities of the child, the type of surgery, and the likelihood of significant complication. However, more than one experienced clinician pointed out that they had never had a problem with allowing children to travel home further than this.
A 6 year old boy presents on a Saturday afternoon to A&E at a remote DGH (which has A&E facilities and inpatient Paediatrics, but no out-of-hours / emergency operating). He has a painful, swollen hemi-scrotum and a presumed diagnosis of testicular torsion is made. The local surgeon and anaesthetist are willing to undertake the procedure. The nearest hospital with emergency surgical provision is 40 minutes away, and their CEPOD list is busy. What should happen to this child? Should he be transferred or treated locally?
All agreed that this child should be an obvious priority for scrotal exploration, and all efforts should be made to expedite this. A 40 minute transfer time in reality takes far longer than this to organise, and there would be further delays for assessment at the receiving hospital, even if the theatre happened to be waiting. The procedure requires no special equipment above that which could be found in a district general hospital, so the key decision has to be whether the teams available have the required skills to provide safe care. If a theatre team can be made available, consideration must also be given to the care of the child in the post-op period, both in recovery, and the ward. It could be argued that the greatest chance of saving a torted testis would be from immediate operation in the original hospital, and if overnight post-op care is not available, the child may have to be transferred to the second centre once out of the immediate post-op recovery phase. However, in the absence of a complete team able to look after the child safely, the panel felt it would have to remain a defensible option to transfer the child to the second hospital for surgery.
A 3kg 23 day old baby presents to A&E in a DGH with a history and examination findings suggestive of bronchiolitis. She is having hypoxic episodes with frequent apnoeas and bradycardic episodes. Following review by the Consultants in Paediatrics, Anaesthesia and Intensive Care, a decision is made that she requires intubation and respiratory support. She is transferred to theatres where she is anaesthetised. The three Consultants present are unable to intubate her but are, with difficulty, able to oxygenate her with a Mapleson F system and facemask with an oropharyngeal airway. What should be the next steps in her management plan?
The contents of a paediatric difficult airway trolley were the subject of an APA ‘Hot Topics’ review (http://www.apagbi.org.uk/professionals/education-and-training/apa-hot-topics). Bronchiolitis and difficult intubation are subjects in the AAGBI’s ‘Tutorial of the Week’ (http://www.aagbi.org/education/educational-resources/tutorial-week/my-events/tutorial/Paediatric%20Anaesthesia). A similar question posed at the previous NEPAN meeting raised the point that whilst a non-specialist hospital needs to stock a full range of emergency paediatric airway equipment (similar to that in the ‘hot topic’ review), it cannot be expected to have paediatric bronchoscopes available. The DAS / APAGBI unanticipated difficult intubation guideline is more applicable to the context of surgery, but can be found at http://www.apagbi.org.uk/sites/default/files/images/APA2-UnantDiffTracInt-FINAL.pdf.
In the situation above, there isn’t realistically a ‘wake-up’ option, so the options would be the unpalatable decision to transfer without intubation, or to find a way of performing intubation. Once direct laryngoscopy had been attempted with a range of blades, the next option would be indirect laryngoscopy with whichever of the indirect laryngoscopes that the physician was most familiar with. Airtraqs and Glidescopes in particular are available in paediatric sizes, though the smaller blades of some other scopes may offer a view. Should these methods fail, in the absence of a 2.2mm paediatric bronchoscope it is not possible to use a standard fibreoptic bronchoscope for endotracheal tubes of less than 4.5mm diameter. However, it is possible to visualise the cords and pass a guidewire into the trachea through the suction port of a standard fibreoptic scope. The scope can then be withdrawn, leaving the wire in situ, which would then be used to guide an endotracheal tube into position. This technique can also be used with an LMA as a conduit, with the added advantage that ventilation can be continued during intubation.
The new BTS guidelines mandate two group & save samples taken at separate times before crossmatched blood can be issued. How would the panel suggest this should be tackled for paediatric practice?
Three options were discussed, with enthusiasts and detractors of each: two separate samples to be taken in the anaesthetic room after induction, one sample from the ward and one from the anaesthetic room after induction, and two samples pre-op on the ward. It was recommended that there should be a discussion and local policy in each hospital / trust, as time mode of issuing and crossmatching of blood may mean more or less delay after receipt of the second sample.
The following section contains the discussions from the 2013 NEPAN meeting.
The first annual NEPAN educational meeting was held on the 14th November 2013. One of the most successful components of the meeting was the Clinical Conundrums discussion. In this two, expert paediatric anaesthetists discussed their suggested management of a series of paediatric anaesthetic scenarios. The discussions are summarised below.
- Chairman. Dr David McColl, Consultant Anaesthetist, North Cumbria University Hospitals
- Dr Sue Jackson, Consultant Anaesthetist / Intensivist, Great North Children's Hospital, Newcastle
- Dr Tim Murphy, Consultant Cardiothoracic Anaesthetist, Freeman Hospital Newcastle.
Scenario 1 Emergency surgery in patient with Tetralogy12 year old boy with previous repair of tetralogy of Fallot (at 7months of age)
Under annual cardiology review
Presents to his local DGH with symptoms and signs of appendicitis
Should his operation be undertaken at his local hospital or should he be transferred?
Response / Discussion from floor• Take full medical history
• Outcomes from fallot’s are good
• Pulmonary Regurgitation is common
• Criteria for valve replacement is not concrete
• Echo only if indicated and not to be routinely carried out
Summary / ConclusionFor acute appendicitis operate at the DGH
If the fallot was outside of UK and/or cant access medical records then it may be appropriate to transfer to tertiary centre so they can have a full review.
Scenario 2 Tonsillectomy for sleep apnoea6 year old girl with history of multiple episodes of tonsillitis
Parents report loud snoring and apnoea
Overnight oximetry shows oxygen saturation nadir of 79% for 30 seconds
Parents report that oximetry was done “on a good day”
Should she be referred to a specialist centre?
Response / Discussion from floor• Adequate monitoring throughout procedure
• Very standard case ‘bog’ standard
Summary / ConclusionThere is no indication to transfer and patient should be treated at DGH
If there is CP this would need further evaluation by an anaesthetist and paediatrician with interest in sleep disorders.
Scenario 3 Airway assessment in uncooperative patient8 year old boy with severe learning disability
Presents for dental extractions and conservative dentistry
Refuses to co-operate with anaesthetic assessment
How would you assess his airway?
Response / Discussion from floor• Pragmatic approach
• Be prepared
• Obtain detailed history
Summary / ConclusionSometimes it’s not always possible to carry out a thorough assessment but fortunately airways that can’t be ventilated/intubated is rare so use own judgment and be prepared for the unexpected.
Scenario 4 Elective surgery & congenital heart disease7 year old girl requires grommets
Previous coarctation repair and PDA ligation as neonate (very unwell at the time)
Cardiology follow up 6 monthly
“a bit of narrowing of a valve”
Who should anaesthetise her?
Response / Discussion from floor• Arterial switch outcomes are good
• Being unwell at time of coarctation & PDA ligation is not an indication of how the child is fairing now
Summary / ConclusionThis patient could have surgery locally
Obtain a thorough history and consider use of paediatric pre-assessment questionnaires same as being used in Carlisle by Dr McColl. Sunderland have a nurse led pre assessment service.
Scenario 5 Emergency surgery in an adolescent withholding consent12 year old child with an immediately limb threatening injury
Refuses pre-med, iv access and inhalational induction
How would you proceed?
Response / Discussion from floor• The patient legally can’t refuse treatment
• Speak with parents away from child, ask them how best to approach the situation with their child
• Ask the parents’ consent to physically restrain the child
• Ask the patient what is concerning them
• Be creative
• Consider intranasal diamorphine; ketamine in juice
Summary / ConclusionThere is no simple answer – use a mixture of different techniques
Scenario 6 Airway compromise in the DGH2 year old child presents to A&E with stridor and upper airway obstruction
The hospital has no ENT services
How would you manage this child?
Response / Discussion from floor• Priority is to protect the airway
• Don’t transfer the child until stabile
• Are there any surgeons to draw on with skills in trachea?
• Call local colleagues for advice
Summary / ConclusionDo the best that you can in that situation
Scenario 7 Difficult airway equipment in the DGHWhat equipment for managing difficult paediatric airways is it appropriate for a DGH to provide?
Should all hospitals providing an elective ENT service have the facility to perform paediatric bronchoscopy in an emergency?
Response / Discussion from floorUse the kit you are most familiar with
Summary / ConclusionThere is no need to have separate paediatric kit, make best use of what you have.
Scenario 8 Analgesia after tonsillectomy11 year old asthmatic known to be sensitive to NSAIDs
What analgesia is it appropriate to prescribe?
What medications can she have to take home?
Response / Discussion from floor• Confusion over what best to use since the withdrawal of codeine
• Diahydrocodeine can be used
• Tramadol can be used but there is no take home solution
• Use Oromorph
Summary / ConclusionConsider using those listed in discussion
Scenario 9 CPR in a neonate2 day old infant found in cot with no respiratory effort and no cardiac output
Intubated and transferred to A&E
CPR performed at 3:1 ratio
Continuous chest compressions
Was the 3:1 ratio appropriate?
Should compressions have been stopped to allow ventilations?
Summary / ConclusionDo what you are familiar with
Scenario 10 Use of adult ITU for paediatric patientsIs it ever appropriate or desirable to manage a child in the adult ITU of a DGH?
Response / Discussion from floor
Summary / ConclusionA child who is nearly adult with adult problems could have one overnight stay
Younger children should not be staying overnight