Paediatric anaesthesia
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Although difficult airway management remains one of the leading factors in anaesthetic deaths, there have been tremendous advances in the field in the last few decades. The question is, are advanced airway management skills being taught and used? Of the numerous training tools available, simulators have the advantages of providing whole-task learning with the potential to change behaviour and, when applied to large groups of trainees, the possibility of achieving standardized application of the safest practices for a range of scenarios limited only by the creativity of the program designers. Partial-task trainers include computer-based software programs and simulators. ⋯ This can best be achieved through a dedicated airway management rotation. Monitored procedure logs may also be used. Whether using a simulator or in a clinical rotation, experiences should be graded, for example, gaining experience in an adult population before gaining experience in paediatrics and in each population mastering airway management skills for common scenarios before advancing to more complicated techniques such as fibreoptic bronchoscopy.
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Paediatric anaesthesia · Jan 2004
ReviewAnaesthetic management for the child with a mediastinal mass.
Administering anaesthesia to a child with an anterior mediastinal mass may lead to respiratory or circulatory collapse, even in those without symptoms. Institutions should have algorithms to manage children with mediastinal masses. ⋯ Alternatively, positive-pressure ventilation may be used, including tracheal intubation without muscle relaxants. Rigid bronchoscopy may be life-saving in the event of tracheal or bronchial collapse under anaesthesia.
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Although significant advances in respiratory care have reduced mortality of patients with respiratory failure, morbidity persists, often resulting from iatrogenic mechanisms. Mechanical ventilation with gas has been shown to initiate as well as exacerbate underlying lung injury, resulting in progressive structural damage and release of inflammatory mediators within the lung. ⋯ As a novel approach to replace gas as the respiratory medium, liquid assisted ventilation (LAV) with PFC liquids has been investigated as an alternative respiratory modality for over 30 years. Currently, there are several theoretical and practical applications of LAV in the immature or mature lung at risk for acute respiratory distress and injury associated with mechanical ventilation.
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Paediatric anaesthesia · Jan 2004
ReviewRigid bronchoscopy for foreign body removal: anaesthesia and ventilation.
Foreign body aspiration is a leading cause of death in children 1-3 years old, although mortality is low for children who reach the hospital. Presenting symptoms of an inhaled foreign body depends on time since aspiration. Immediately after inhalation the child starts to cough, wheeze, or have laboured breathing. ⋯ The procedure should be performed in a well-equipped room with at least two anaesthesiologists, one with paediatric experience, in attendance. Most experienced anaesthesiologists prefer inhalational rather than intravenous induction of anaesthesia and a ventilating bronchoscope rather than intubation. Equally good results have been reported with spontaneous ventilation or positive pressure ventilation; jet ventilation is not advocated for foreign body removal in children.
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Compression of the paediatric airway is a relatively common and often unrecognized complication of congenital cardiac and aortic arch anomalies. Airway obstruction may be the result of an anomalous relationship between the tracheobronchial tree and vascular structures (producing a vascular ring) or the result of extrinsic compression caused by dilated pulmonary arteries, left atrial enlargement, massive cardiomegaly, or intraluminal bronchial obstruction. A high index of suspicion of mechanical airway compression should be maintained in infants and children with recurrent respiratory difficulties, stridor, wheezing, dysphagia, or apnoea unexplained by other causes. ⋯ Vascular rings may be repaired through a conventional posterolateral thoracotomy, or utilizing video-assisted thoracoscopic surgery (VATS) or robotic endoscopic surgery. Persistent airway obstruction following surgical repair may be due to residual compression, secondary airway wall instability (malacia), or intrinsic lesions of the airway. Simultaneous repair of cardiac defects and vascular tracheobronchial compression carries a higher risk of morbidity and mortality.