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Protective Ventilation for Paediatric Anaesthesia - Paediatric anaesthesia induction in the OR

Protective Ventilation for Paediatric Anaesthesia

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Summary

Paediatric patients present a special challenge to anaesthetists. The anaesthesia-related mortality of children is currently estimated at 1:30,000, vs. 1:250,000 in adults – so it becomes clear that there is still room for improvement when it comes to standards around ventilating a child under general anaesthesia. At the moment, there is very little evidence regarding paediatric ventilation practices during surgery, which could lead to paediatric anaesthetists determining ventilator settings mainly based on personal experience1. Here, we discuss the main considerations when ventilating children and newborns and offer further insight into this topic to help you best protect your patient.

Lung protective ventilation of paediatric patients during general anaesthesia

The particular challenges of anaesthetising newborns, infants and young children is reflected in the higher perioperative mortality of paediatric patients as compared to adults. The incidence of intraoperative cardiac arrests is 1:10,000 and respiratory causes are responsible for about a third of these paediatric mortalities. The pitfalls and risks for small children and especially newborns were recently confirmed in the APRICOT study, which analysed a total of 31,000 anaesthetic procedures in around 30,000 children treated in 261 centres across 33 European countries.

Protective Ventilation for Paediatric Anaesthesia - Insight into lung protective ventilation of paediatric patients during general anaesthesia

Ventilating paediatric patients: what we should keep in mind?

A large RCT (APRICOT study) recently found that 5.2% of all paediatric surgery patients suffer from severe anaesthesia-related complications – and respiratory complications account for a substantial percentage. It’s therefore important to factor in various conditions such as short oxygen desaturation times (apnoea tolerance), high airway resistance, pre-existing (congenital) diseases and more, and to remember that ventilation parameters including tidal volumes, inspiratory pressure and PEEP may also need to be adapted.

Avoiding pitfalls during ventilation

Tube displacement

Sometimes, the tube is placed too low in the airways. Airways of small children are only approximately 2 cm long before bifurcation, hence the high risk of ventilating only the right or only the left lung. On rare occasions, a tube is placed too high and can easily slip out. The correct tube placement should be validated (through x-ray), especially in long-term intubations.

Oxygen saturation

Oxygen saturation should be measured pre- and postductal due to the risk of right to left shunting in newborns with persistent Ductus arteriosus.

Dead space

You should reduce the dead space distal to the Y-piece as much as possible. In small children, place the HME filter close to the anaesthesia device, not close to the patient, and critically question the need for additional devices, such as extension tubes etc.

Patient weight

Above 25 kg BW, dead space becomes less relevant. Below 25 kg it is deemed highly relevant. Every person has an anatomic dead space of 2 -3 ml per kg BW. Therefore, a 30 kg child has a dead space of 60 ml. With a system setup distal to the Y-piece, the same amount of dead space may be added, with the risk of hypercapnia or inadequate Vt/airway pressure to achieve adequate minute ventilation.

Paediatric ventilation in need of improvement whitepaper

Paediatric ventilation in the OR

With the goal of helping your hospital give the best possible care in paediatric ventilation, we have put together an overview that provides you with important knowledge based on literature as well as on clinical experience.

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Sources

1 Kneyber MC, Intraoperative mechanical ventilation for the paediatric patient, Best Pract Res Clin Anaesthesiol. 2015 Sep;29(3):371-9