Women’s and Children’s Hospital
DEPARTMENT OF PAEDIATRIC ANAESTHESIA
GUIDELINES FOR ANAESTHESIA OF THE CHILD WITH A FRACTURED FOREARM
1. BACKGROUND:
Common anaesthetic case
“Emergency” case, often conducted after-hours
Deceptively straightforward
No high level evidence available to guide anaesthetic management
2. ANAESTHETIC ISSUES
Delayed gastric emptying secondary to:
Trauma
Concurrent opiate use
Uncertain fasting history
Associated other injuries
3. PATIENT ASSESSMENT:
Severity of injur(ies). Increased severity associated with increased gastric volume
Pre-injury fasting period. Decreased gastric volume with increased duration, but unpredictable
Post-injury fasting period
Opiate administration
Evidence of “empty stomach” i.e. hungry, bowel sounds. Case reports of massive aspiration despite patient stating they were hungry
Significant PMHx (eg. GORD, hiatus hernia)
4. STRATIFY ASPIRATION RISK:
Probable High Risk Factors:
Severe or multiple injuries
Pre-injury fasting period < 2 hours
Post-injury fasting period < 12 hours
Severe pain, opiate administration
Nausea ± vomiting
Significant GORD
5. PREMEDICATION:
Anxiolytics as needed
Analgesics as required
Topical LA if IV cannulation pre-induction
Questionable utility of pro-kinetic use in children
6. INDUCTION:
No “Gold Standard” technique that will prevent aspiration in all patients
Constant vigilance and preparation to manage intra-operative aspiration is vital, even in patients stratified as “low risk”
7. INDUCTION TECHNIQUES (HIGH RISK):
1. Rapid sequence induction with cricoid pressure
Frequently recommended in literature for patients at high risk of gastric aspiration
Conflicting evidence of benefit:
ETT (especially uncuffed) doesn’t reliably prevent aspiration
Cricoid pressure may decrease lower oesophageal sphincter tone
Cricoid pressure not routinely used in many countries with no evidence of increased aspiration
Cricoid pressure can hinder intubation
“Failure to intubate”
Suxamethonium exposure
2. Gas induction via mask with Sevoflurane ± N2O
Cricoid can also be used after loss of consciousness
Can be combined with patient positioning (lateral, trendelenburg, reverse trendelenburg)
Minimal evidence for positioning, use as per anesthetist preference with awareness of likely issues with position chosen
Instrumentation of the airway usually avoided, but if required, intubation can be performed with a suitable muscle relaxant or under deep volatile anaesthesia alone
INDUCTION TECHNIQUES (LOW RISK):
Either a gas or intravenous induction suitable
Airway management with minimal airway instrumentation still prudent due to risk of stimulating vomit reflex and evidence that airway devices (esp. LMA) may decrease lower oesophageal sphincter tone
If use Laryngeal Mask Airway (LMA), ProSeal™ possibly more suitable as:
Can pass nasogastric tube to decompress stomach
Minimises stomach insufflation
Passage for regurgitant fluid to exit pharynx
Increasing evidence for use in this setting
8. MAINTENANCE:
A modern volatile agent + O2/Air or O2/N2O mixture commonly used to maintain anaesthesia
Analgesia titrated to severity of injury and extent of surgery, good evidence for a multimodal approach. Suitable agents include:
Opiates (fentanyl / morphine)
Paracetamol (IV / PO / PR)
NSAID’s (after discussion with surgeon)
Ensure adequate anaesthetic depth during fracture manipulation to prevent stimulation of vomit reflex
Prophylactic anti-emetics appropriate for most patients due to high incidence of PONV in this age group
If surgery is prolonged, consider use of Intermittent Positive Pressure Ventilation (IPPV) or Pressure Support Ventilation (PSV) to minimise work of breathing
9. MANAGEMENT OF ASPIRATION:
If aspiration is suspected:
Inform surgeon, cease painful stimuli
Administer 100% O2
Place patient in steep Trendelenburg ± lateral decubitus
Suction down airway with wide bore catheter
Recommence IPPV
Aspiration with LMA should initially be managed with LMA in situ if in proper position, as it will minimse further aspiration, aid suctioning and ventilation
Prudent to perform Bronchoscopy to ensure airways clear of particulate matter
Most patients can be extubated if oxygenation is adequate with minimal supplementation
Post-operative management in high dependency setting appropriate
10. EMERGENCE:
Airway device if used should be removed either with the patient deeply anaesthetised or with full return of consciousness
Generally, patients stratified as high risk (if intubated) should be extubated awake in the lateral decubitus position
Routine recovery of patient in the lateral decubitus position is useful as it improves upper airway patency and allows clearing of secretions
Oxygen should be administered during emergence, and suction equipment readily available
11. POST OPERATIVE CARE:
Patient should be recovered as per hospital guidelines
Post-operative analgesia / fluids / anti-emetics should be titrated to surgery performed
Most patients can be managed with oral analgesia alone
Consider use of Patient Controlled Analgesia (PCA) or opioid infusion if pain likely to be severe (eg. open repairs)
12. REFERENCES:
Bricker SRW et al. McLuckie A, Nightingale DA. Gastric aspirates after trauma in children. Anaesthesia 1989; 44: 721–4
Marcus RJ et al. Anaesthesia for manipulation of forearm fractures in children: a survey of current practice. Paediatric Anaesthesia 2000; 10: 273–7
Brady M et al. Preoperative fasting for preventing perioperative complications in children. The Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005285. DOI: 10.1002/14651858.CD005285
William MS et al. Preoperative Fasting in Children: Review Article. Anesthesia & Analgesia 1999; 89: 80–9
Brimacombe JR et al. Cricoid pressure. Canadian Journal of Anaesthesia 1997; 44(4): 414-25
Tim MC et al. The ProSeal™ laryngeal mask airway: a review of the literature. Canadian Journal of Anesthesia 2005; 52(7): 739–760
Keller C et al. Aspiration and the laryngeal mask airway: three cases and a review of the literature. British Journal of Anaesthesia 1993 (4): 579–82 (2004)
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