Anaesthesia & Intensive Care Medicine

Self-assessment Publication date: Available online 10 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Viyayanand Nadella

Crystalloids, colloids, blood products and blood substitutes Publication date: Available online 9 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Christopher Naisbitt, K.F.A. Mos, Roop Kishen Abstract Understanding the physiology of fluid distribution in the human body is fundamental to good clinical practice in anaesthesia and intensive care. Intravenous fluid therapies have a range of clinical and metabolic consequences and they should be context and patient specific. Inadequate or excessive fluid treatment is harmful to patients. There are numerous trials, both historical and current, investigating best practice in fluid therapy. New paradigms and guidelines are being published, and it is important for clinicians to keep up to date with current practice. There is a continued drive to improve the safety of donor blood and prevent transfusion errors. Knowledge of how blood products are collected, separated and stored is essential to prevent harm to patients through transfusions. The development of blood substitutes is progressing, with NHS trials involving stem cell originated red cells having begun.

Peripheral and local anaesthetic techniques for paediatric surgery Publication date: Available online 9 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Steve Roberts, Katie Misselbrook, Ruth Cowen Abstract Peripheral nerve blocks provide intraoperative and postoperative analgesia and are usually used as adjuncts to general anaesthesia in paediatric patients. For children in the UK, most of these blocks are performed under general anaesthesia. In older cooperative children, some are performed awake, providing the correct environment and reassurances are available to minimize stress and anxiety. Peripheral nerve blocks provide good-quality analgesia without the adverse effects associated with systemic medications. Good pain management reduces morbidity and aids patient recovery, resulting in better patient and family satisfaction and earlier discharge. These factors are essential for successful and efficient paediatric surgery. Failure to achieve good pain control is obviously unpleasant, but has also been identified in the occurrence of sleep and behavioural disturbances in children following surgery. Delayed recovery and discharge can have significant disruptive and economic effects on the family and hospital. Despite these benefits, peripheral nerve blocks, like all invasive techniques, are associated with complications and adverse effects. They should only be performed after careful analysis of the risk:benefit ratio. This article discusses a general approach to peripheral nerve blocks in children, along with the benefits of a predominately ultrasound-based approach and the role of peripheral catheters.

Neuraxial anaesthesia in paediatrics Publication date: Available online 7 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Ryan Marcelino, Amod Sawardekar, Santhanam Suresh Abstract Neuraxial anaesthesia is a valuable aid in the practice of paediatric anaesthesia. Spinal and epidural blockade are used as either the sole anaesthetic or as an adjunct to general anaesthesia, and often confer significant postoperative analgesia. Caudal epidural anaesthesia is used extensively for lower abdominal, urological and orthopaedic procedures in the setting of outpatient surgery. Lumbar and thoracic epidural infusions via a catheter can provide analgesia for chest and upper abdominal procedures. Major complications related to neuraxial catheter placement are uncommon in paediatric anaesthesia, even though block placement is typically after the patient is anesthetized. The use of the ultrasound for real-time visualization during paediatric neuraxial blocks provides an opportunity for observing final catheter position or confirming successful injection into the epidural space.

Principles of paediatric anaesthesia Publication date: Available online 7 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Judith A. Nolan Abstract This article provides an overview of the practical aspects of paediatric anaesthesia, with particular emphasis on airway and fluid management. Common dilemmas that may be encountered during preoperative assessment are highlighted, including the child with asthma, obstructive sleep apnoea and the particularly anxious child. In light of the findings of the fourth National Audit Project (NAP4), strategies for managing the child with the difficult airway are discussed. The rationale for the use of isotonic perioperative fluids is outlined, along with the management of intraoperative blood loss. The increasingly recognized problem of emergence delirium is also discussed.

Paediatric day-case surgery Publication date: Available online 7 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Sarah Heikal, Lowri Bowen, Mark Thomas Abstract Paediatric day surgery is common and increasingly more complex surgeries are being carried out on more complex children. The benefits to the child and parent include less disruption to daily routines and fewer psychological and emotional effects than an overnight stay would incur. The use of day-case services improves efficiency and is more cost effective for organizations. To deliver high-quality paediatric day surgery services there are several key components to address. This article discusses the role of preoperative assessment and the need to consider each case individually despite robust inclusion/exclusion criteria. Optimization of preoperative hydration, pain management and prevention of postoperative nausea and vomiting are highlighted as important factors to successful day-case surgery.

Pain assessment in children Publication date: Available online 3 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Katherine Brand, Andrew Al-Rais Abstract Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be a challenge and is often inconsistent and suboptimal in many organizations. Pain and its perception are multi-factorial, hence an approach to pain assessment and treatment must also be multi-faceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variation; therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variation. This article outlines the different tools available for pain assessment in infants and children (excluding neonates).

Total intravenous anaesthesia in children: a practical guide Publication date: Available online 3 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Patrick Cowie, Alistair Baxter, Jon McCormack Abstract Total intravenous anaesthesia (TIVA) is increasingly used for maintenance of anaesthesia in both adults and children. This article will discuss topics relevant to administration of TIVA in children – the potential benefits of TIVA, challenges and some clinical examples of its use.

An update of systemic analgesics in children Publication date: Available online 3 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Jennifer A. Wright Abstract Effective and safe pain management in children can be complex and challenging. It remains an important goal in order to minimize acute distress, behavioural changes, central sensitization and hyperalgesia. Neonates are particularly susceptible to long-term neurodevelopmental changes due to the neuroplasticity of their immature brains, and adequate analgesia may help ameliorate these changes. The focus of this review is to look at systemic analgesic options available for children, infants and neonates. This review includes a brief description of important pharmacokinetic, pharmacodynamic and pharmacogenomic issues that can influence the effectiveness and safety of these medications, while highlighting the impact organ-immaturity in neonates can have on pain processing and analgesic pharmacology.

Safe sedation of children for diagnostic and therapeutic procedures Publication date: Available online 3 May 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Andrew M. Langdon, Rishi Diwan Abstract There is an increasing use of sedation in children requiring imaging and other minor procedures. This article will discuss how sedation can be safely performed. The depth of sedation has been classified into minimal, moderate and deep according to the National Institute for Health and Care Excellence. Amongst others, benefits of sedation include increased parental and child satisfaction, increased cost ben- efits for the hospital and reduced adverse effects of general anaes- thesia such as emergence delirium and postoperative nausea and vomiting. Safe sedation can be used for a wide range of procedures, most commonly for CT and MRI. Others include removing drains, changing burns dressings, simple plastic surgery procedures and endoscopy. Drugs can be used as sole agents or in combination to produce the desired level of sedation appropriate for the procedure. The children must be monitored according to the depth of sedation and personnel should be trained in the management of potential complications.