emergencies in newborns for paediatric anesthesiologists · mindmap. ilcor. topics (n=26) dutch...
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Emergencies in newborns for
paediatric anesthesiologistsJos Bruinenberg, paediatrician-neonatologist
SKA and BAPA congress , March 11th 2017
• Patient docter
• Small people
• Milli- and microliters
• Islander
• Protocols
• Sometimes acute! Some newborns scare the
hell out of even experienced clinicians!
Neonatologist
• Important concepts of the guidelines 2015
• Selected subjects for anesthesiologists
Objectives
1. Quiz!
2. Guidelines 2015
3. Catch 22 in neonatal airwaymanagement in
general hospitals
4. ABCDEFGH
Content
• Go to https://kahoot.it
• Enter the pincode
• Choose your nickname
• Earn points for correct answers and reactiontime
QUIZ
Guidelines 2015
Ludwig swing, ca. 1920
Mindmap
ILCOR
Topics (n=26)
Dutch Resuscitation Council
• Self resuscitating baby
• Assisting in transition
• Suction is obsolete
• Avoid hypothermia
Important concepts
• Cessation of placental circulation; increase in
systemic vascular resistance and blood pressure
• Initiation of air breathing and marked relaxation
of pulmonary vascular resistance
• Adaptation of circulation
– decrease left-to-right shunt
– closure of the foramen ovale
• Thermoregulation increases oxygen consumption
Transition
Initiation of breathing air
Adaptations of circulation
Meconium stained amniotic fluid
• Routine endotracheal suctioning has been advocated for years!
– Always
– Only with meconium
– Perineal suctioning
– Depressed infant with meconium
• No evidence found in ILCOR 2015
• Emphasis on initiating ventilation
Maintenance of temperature
Between 36.5-37.5 degrees Celsius
• Association with morbidity and mortality
– 28% increase in mortality per degree!
– Association with IVH, respiratoiry problems, hypoglycemia, late sepsis
• Strong predictor
– Prognosis
– Quality of the clinical process
• 36 observationel studies!
Prevention of hypothermia
with a combination of measures
• Plastic bag <32 weeks
• Heated gas supply
• Heating mattress
• Environmental
teperature
• Cap
Intubation
• Minimum of 90 intubations for a
succespercentage >95%
• Minimum of 50 intubations per year for
maintenance
When are you skilled in intubation?
Number of intubations by paediatricians
10% 8%
9%
26%46%1 tot 5
6 tot 10
11 tot 15
16 tot 20
> 20
Perceptie vaardigheid
0% 0% 1% 1% 2%7%
21%
41%
20%
5%
1 2 3 4 5 6 7 8 9 10
1 slecht - 10 uitmuntend
• Position statement paediatric section of
anesthesiologists (children younger than 1
month or 60 weeks conceptional age
centralised)
• Emerging specialisation in paediatric
anesthesia
Developments in paediatric
anesthesia
Premedication
medicatie mg/kg percentage
Morfine 0,005 - 8,0 81,3%
Midazolam 0,01 - 1,0 41,2%
Etomidaat 0,01 - 0,5 13,2%
Fentanyl 0,002 - 0,3 6,7%
Pethidine 0,1 - 1,0 3,8%
Diazepam 0,2 0,2%
Phenobarbital 15 0,2%
Neonatal airway
• small
• larynx anterior
• large tongue
• big occiput
• soft epiglottis,
• Trachea not straight but diabolo
• Pediatricians know neonatal airway but lackongoing experience
• General anesthesiologist intubate a lot, but notso many infants and young children
• Which solutions are available?
– Education?
– Video-assisted intubation?
– LMA?
Catch 22
Laryngeal Mask Airway
Alternative for intubation
– >34 weeks, 2000 grams
– Failure of bag and mask ventilation
• Prolonged ventilation?
Laryngeal Mask Airway
A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation
Xiao-Yu Zhu, Bing-Chun Lin, Qian-Shen Zhang, Hong-Mao Ye and Ren-Jie Yu
Resuscitation
Volume 82, Issue 11, Pages 1405-1409 (November 2011)
DOI: 10.1016/j.resuscitation.2011.06.010
• Newborn, 2nd day of life
• Decreased consciousness, grayish colour
• Sepsis work up
• Gas, lactate, glucose normal, LP normal
• After 3 hours development of seizures
• Transfer to NICU; NH3 2000 mcmol/l>MCAD
The case of Mohammed
• Sepsis
• Seizures
• Hepatic failure
• Cardiomyopathy
Metabolic diseases are rare
• Uric acid cycle defects
– Arginin succinate lyase deficiency
• Organic acid syndroms
– Methylmalonic acidemie
• Aminoacidurias
– Maple syrup urine disease
– Non-ketotische hyperglycinemia
Catastrophal metabolic diseases
• Stop administration of substrate
• Investigate:
– Glucose/lactate/bloodgas/NH3
– Urine and heparinblood
• Consult your paediatrician or metabologist
Acute treatment
Questions?
• Congratulations, you are on your way!
• (Still, there is a lot to learn out there!)
Conclusions quiz
• Self resuscitating baby>airway!
• Take your time to allow recovery and assess
• Suctioning should not delay adequate and timely ventilation
• Prevent hypothermia
Conclusions concepts resucitation
• Concerning neonatal airwaymanagement:
“ Houston, we have a problem”
• Which solutions could we provide
Conclusies Catch 22
• Rare but many
• Expression in many vital organs
• “ Je ziet het pas als je het door hebt (Cruijff)”
• Don’t ever forget glucose and hyperammonia
(ABCDEFGH)
Conclusions metabolic diseases