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Problem Based Learning in Pediatric Anesthesia
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Problem Based Learning in Pediatric Anesthesia

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Presented at Egyptian Anesthesia 2011 @ MEDICONEX 2011

Presented at Egyptian Anesthesia 2011 @ MEDICONEX 2011

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  • 1. PROBLEM BASED LEARNING
    Dr Moataz Abdelrahman
    Consultant Paediatric Anaesthetist
    Central Manchester University Hospitals
    Royal Manchester Children’s Hospital
  • 2. CASE 3
    A 4 year old girl weighing 15.2 Kg is on your list for a lumbar puncture. She had a history of cough over the last 8 days which is non-productive, no history of asthma and her chest is clear to auscultation. With the start of the cough she was feverish 38.2 0C and suffered a brief seizure which resolved spontaneously. Temp is now 36.8 0C. CBC normal apart from mild leukocytosis.
    She had a GA last year for a cystoscopy which was uneventful.
    What is your approach?
  • 3. WHAT TO DO
    Do the case today
    Explain your anaesthetic
    Precautions
    Safety
    Postpone
    Reasons for delay
    Valid
    You are to convince clinicians and parents
    What will you achieve?
  • 4.
  • 5.
  • 6. MEDIASTINUM
  • 7. CAUSES
    Tumours of the lung, mediastinum and pleura.
    Primary (uncommon)
    Metastatic
    The commonest
    Lymphoblastic lymphoma (non-Hodgkin’s lymphoma)
    Hodgkin’s disease.
    Other lesions
    Vascular malformations
    Neurogenic tumours
    Germ cell tumours
    Cysts (bronchogenic or enteric)
  • 8. PRESENTATION
    No Cardio-respiratory symptoms
    Respiratory
    Cough, dyspnoea, stridor
    Cardiac
    Orthopnoea, syncope,
    Superior vena cava syndrome
    Swelling of the upper arms, face and neck
    General constitutional symptoms
  • 9. COMPRESSION
    Trachea
    Bronchi
    Lungs
    Heart (RVOT)
    Pulmonary artery
    Superior vena cava
  • 10. ALARMING S&S
  • 11. PROBLEMS
    Respiratory collapse
    Cardiovascular collapse
    During
    Induction (mainly)
    Maintenance
    Recovery
    Relation to preoperative manifestation???
  • 12. The incidence of cardio-respiratory complications is high (7-20% in adults) and higher in children
    Mortality in relation to general anaesthesia is high in children
    Asymptomatic children have suffered serious morbidity or even death whilst undergoing general anaesthesia
  • 13. EVALUATION
    Symptoms
    Signs
    Investigations
    CT
    ECHO
    PFT ? if feasible
    PREDICTABILITY OF AIRWAY COLLAPSE/OBSTRUCTION AND CVS COMPROMISE
  • 14. CARDIAC – echo, CT
    Pericardium
    Thickening
    Effusion
    RVOT
    LV function
  • 15. AIRWAY - CT
    CXR
    Level of compression
    Degree of compression
    Type of lesion and extent
    Other lesions
    30% occlusion  incidence of resp complications
    50% occlusion  incidence of complete obstruction
    Static pictures may not identify dynamic compression
  • 16. AIRWAY - PFT
    Difficult in children
    PEFR 50% of expected correlates with 50% central airway (trachea) obstruction
    50% of expected PEF incidence of complete obstruction
  • 17. ANAESTHETIC MANAGEMENT
    A clear strategy should be followed
    Multidisciplinary involvement
    Identify high risk patients
    The need for a general anaesthetic should be justified
    Local anaesthesia/sedation could be an alternative
  • 18.
  • 19. ANAESTHETIC MANAGEMENT
    The objective is to minimise airway and cardiovascular compression
    Reduce the size of the tumour
    Preoperative steroids for 1-5 days
    Preoperative chemotherapy
    Preoperative Radiotherapy
    Secure tracheal/bronchial patency
    Maintain spontaneous breathing
    Avoid muscle relaxants
    If IPPV high pressures may be needed + PEEP?
    Stinting the trachea and main bronchi
    Use of 2 micro-laryngosurgery tubes?
  • 20.
  • 21. ANAESTHETIC MANAGEMENT
    Inhalation technique recommended
    Rigid brochoscope should be available
    Bypass the obstruction
    Life saving
    Positioning
    Rt Lateral
    Prone
    Surgeon ready for sternotomy
    Immediate decompression
    Facilities should be available
    Cardiopulmonary bypass
    Sometimes not practical
  • 22. CONCLUSION
    Children presenting for malignancy investigation (LP - BMA - LN Biopsy) should have a chest X-ray and any mediastinal mass detected need to be dealt with according to a specific protocol