Problem Based Learning in Pediatric Anesthesia


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Presented at Egyptian Anesthesia 2011 @ MEDICONEX 2011

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Problem Based Learning in Pediatric Anesthesia

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