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Complications in Pediatric Anesthesia

Feb 03 | 3:30 PM

Anesthetic complications are more common and consequential in children than in adults. Respiratory problems, medication errors, intravenous puncture difficulties, and pulmonary aspiration are common complications in pediatric anesthesia. Newborn babies and children undergoing emergency interventions or having significant co-morbidities are more vulnerable to these problems. Let's hear from Dr. Sangharsh More on how to manage the problems of pediatric anesthesia.

[Music] so good evening everyone i'm dr rishali from netflix and i would like to welcome you for this session on complications in pediatric anesthesia today we have with us uh dr sangershmored after completing his mbbs from grant medical college and jj hospital mumbai he did a diploma in anesthesiology followed by a dnb in anesthesiology from bridge candy hospital mumbai after that he did a fellowship in pediatric anesthesiology from bjvaria hospital for children from mumbai then he started working as a freelance anaesthetist with nasik anesthesia and pain services he is currently assistant professor in anesthesiology at dr vassendrapur medical college nashik his topics of interest are pediatric anesthesiology and labor analgesia so before starting the actual discussion about complications first let's see how to avoid the complications is it possible to avoid the complications we know prevention is better than cure right so what can we do to avoid the complications better preparation of the ot preparing the ot properly keeping all your drugs from his emergency troll is ready choosing the right drug choosing the right drug formulation giving the right dose of the drug being meticulous about the procedures being gentle about the procedures when it comes to pediatric anesthesiology yes it all helps to decrease to decrease the incidence of complications but can we totally avoid the complications no we can't right i think the only way of totally completely avoiding the complications is to stop practicing the medicine that is the only thing complications are part and parcel of our medical practice and we have to live with them so what matters more rather than avoiding the complications is sometimes to diagnose to identify the complication in time and to treat it to treat the complication by a right way so this doesn't come as a surprise incidence of anesthesia related complications is higher in pediatric populations especially in children less than 3 years old you must have heard that dictum that child is not a small adult and infant is not a small child so everything the anatomy the physiology it changes according to the age all the fundus and methods that are applicable in adult physiology in adult anesthesia practice might not be applicable to pediatric anesthesia practice or they might have their own variations for example when we talk about complications the respect prevents the cardiac events the respiratory events are more common in pediatric rather than cardiac events whereas in adults the cardiovascular complications are more common than respiratory complications so what are all display treatments what respiratory complications do we see in pediatrics all of these airway obstruction bronchospasm hypoxemia aspiration speaking of all four of these area obstruction is actually the commonest and the causes of area obstruction is a tongue fall laryngospasm laryngeal edema we are going to discuss all these in detail airway surgeries if the surgery involves the upper area there are more chances of airway obstruction if you are given if you are not given the complete dose of reversal then the geometrical blockade will still be there and can cause very obstruction and yes we have had a few incidences when after clearly pellet surgeries repair surgeries units or infants were choking in the river room and we realized later on that actually the throat of throat was left inside so make sure uh during the upper airway surgery is like transvectomy or cleft lip and pellet repair make sure you remove the throat type before removing the tube so what are the signs of airway obstruction first of all the splitter starts dropping there is a paradoxical movement of the chest and abdomen we call it a seesaw breathing there might be intercostal in drawing and subcostal or external recession now if it is a tongue fall an age-old method of head tilt chain lift jaw thrust will always work but if i want to keep my hands free then i can simply make use of an oropharyngeal airway or a nasopharyngeal airway they are easily available everywhere but make sure you choose the right size of an airway if it is a smaller size it might not completely relieve the obstruction and if it's a larger size it can actually irritate the pharyngeal mucosa and it will serve as an invitation to the laryngospasm so make sure you are choosing the right size how to choose the size we all know this nasopharyngeal airway measure the distance between the tip of nose and mattress of the year or triggers of the earth and for our pharyngeal we measure the distance between the central incisor teeth and the angle of mandible the angle object many times there is a scarcity of small size mesopharyngeal airway in that case you can use a uncuffed or cuffless indo tracheal tube also choose the right size whatever size you're going to intubate once mice smaller than that you can choose for the nasopharyngeal airway make sure there is no cough and measure the distance between the tip of the nose and triggers of the air cut the tube according to that length and reconnect that uh 15 mm connector or 15 mm universal connector to the cutting of the tube that becomes even as a pharyngeal airway make sure you have you have to lubricate before inserting the nasopharyngeal airway laryngospasm the most commonly discussed and the most treated complication of pediatric anesthesia is it really that scary let's see what is a laryngospasm laryngospasm is basically the closure of vocal folds closure of vocal cords is because of the adduction of laryngeal muscles so that causes a complete or a partial loss of airway along with the other signs of aerial obstruction that we have just seen there might be a cascading fall in oxygen saturation speed rapidly drops as the children as the child is trying to breathe against the closed lot is a strata is produced there is an inspiratory spreader and to make the scenario further complicated to make it sometimes more scary it is also associated with bradycardia this bradycard is because of the hypoxia so laryngospasm what are the risk factors and triggers for laryngospasm preoperative recent upper respiratory tract infection now the months of december and january you will see many spasms that is because these months are of winters in indian subcontinent and many children they might harbor the subclinical uiti that causes and that causes a laryngospasm second smoke exposure yes passive smoking sometimes the parents are the culprit intraoperative the most common cause is inadequate depth the like plane of anesthesia and if you are doing any airway manipulation or instrumentation in a light plane of anesthesia that might cause spasm if there are noxious stimuli in the pharynx blood secretion sometimes really vomiters if there are mucous plus in the pharynx intelligent the pharyngeal mineral can cross spasm now these noxious stimulable situations are likely to be there more for surgical procedure involving the upper airway so tonsillectomy cleft lip left palate surgeries all these procedures last but not the least training anesthesiologist months of december and january are the months of spasm because these are the moments of winter but my teachers from the pediatric hospital where i was trained as a pediatric anaesthesiologist they used to say that the months of july and august are the months of spasm because that is when a batch of new fellows join so trainee anesthesiologist one who hasn't seen many spasms sometimes difficult it is difficult for them to identify when the spasm is occurring one who has seen and handled many spasms they are definitely better at handling the spasms and they also are better at avoiding the spasm they know what are the risk factors what are the street because when the child is going to when the child is going to go under spasm so initially the training should be under supervision so prevention make sure you prevent the spasm by avoiding any airway manipulation or instrumentation avoids copy avoid even suction during the light plane of anesthesia make sure deepen the plane of anesthesia i will add okay now you must have seen that mini anaesthesiologist for a foreign body removal case so before the ent surgeon or a pediatric surgeon inserts a rigid bronchoscope in the trachea any sociologists will perform a gentle laryngoscopy they will spray the vocal parts with lidocaine so that decreases the chances of spasm suck out if there's any secretions or blood or mucous plugs in the pharynx before actually removing the tube make sure the plane is not that the plane is not light and what do we mean by extubate patient in proper anaesthetic plane so proper definitely means definitely not a light plane of anesthesia either the child should be deep it should be a deep extunation or make sure the child is completely awake so again we are referring to the light plane of anastasia that has to be avoided at any cost and extubation under positive pressure and this is a very nice technique i am sure most of you must be following this what do we mean by extubation under positive pressure please squeeze the reservoir back before removing the tube we press the reservoir back we keep it press and then we remove the tube now how does this help how does this maneuver helps to decrease the spasm when you are pressing the reservoir back that will create the positive pressure in upper airway that will attenuate the response of superior laryngeal now that will attenuate the excitation of superior laryngeal law superior laryngeal is one of the motor supply for the laryngeal muscles and thus the laryngeal much muscle action is also prevented the adductor response of laryngeal muscles it is decreased so it decreases the laryngospasm subsequently you can also look at it in another way ah when you are giving the inspiration when you spracing the reservoir back you are actually giving an inspiration to the patient so that is an inspiration for the patient what will follow the inspiration will be a passive and forceful exploration so if there is any blood or secretion in the firings or if there is any if there are necessary secretions patient will exhale them out patient will cuff them out so in a way you are producing an artificial cough that will expel all the secretions or if there are any stimuli in the fairings so that also helps so distribution under positive pressure if you're not doing that in pediatric definitely try to do that always helps the chances of parents are more during incubation and even more during extubation so this manual decreases the chances of spasm there are many algorithms given for the treatment of the spasm more or less the points are the same the strips are the same so whenever there is spasm whenever the oxygen saturation goes down definitely automatically we increase the oxygen uh percentage we make it hundred percent deepen the pain of anesthesia so light pain of nssa has to be avoided how do we deepen we have two options either we can use an inhalational agent or we can use an iv induction agent any national will be slow iv will act faster so a language spasm is a scary situation is better to act fast give iv propofol propofol is your friend remove it and stimulus suck out if there is any secretions of blood in the upper airway in the pharynx but make sure you deepen the plane yet you have deepened the plane before doing the actual suction cpav with the jaw thrust is a time tested old method the conventional treatment what is a cpap with the jaw thrust again we press the reservoir back we keep it pressed and we make sure that there is a good seal between the mask between the face mask and the face of the child so it is a cpap with the jaw thrust keep it pressed until the spin breaks the spasm it hardly takes five to ten seconds not even ten seconds hardly four five seconds to break the spiral it almost always works and then larson's maneuver has also been described what is the license manual you can give a firm digital pressure pressure of your fingers on the styloid processes of the mandible styloid process is somewhere anterior to the mastoid behind the rams of the mandible so you keep it pressed and that will break the spasm this method has not been subjected to studies but i think if you are giving cpf with a jaw thrust you are also giving license maneuver somehow license manual is definitely is basically a altered version of a job thrust it is a very variable version of a jaw thrust you already giving job we are doing many things simultaneously whenever the spasm occurs we immediately increase the oxygen we deepen the plane of anesthesia will hold the john will give the cpap so larson's manure actually we are doing that when we are doing the when we are following the conventional method one of the pediatric and sociologists i know she was so good at licensed malware that she always used to tell that if larson's manual doesn't break his spasm then it was not a laryngospasm she was that good at it but everyone is that good at lazarus mother not everyone is that good at everything if it doesn't work for you definitely you can go to a cpap with the job first and if that even doesn't doesn't work for you you can resort to the conventional method if that doesn't work for you you can resort to the pharmacological method so could you please explain cpap with the jar thrust and license manual i think i have answered already the cpap with the jaw thrust press the reservoir back you keep it pressed you close the wall if it is a closed circuit close the apl wall if it is a chassis clamp the outlet wall create a positive pressure and hold it tightly around the face of the patient so there should be a good cell between the face mask and the face of the patient they should air should not escape that positive pressure will break the spasm process maneuver firm digital pressure over the mandibles so if it doesn't work for you go for pharmacological method if language spasm is basically adduction of laryngeal muscles decrease the muscle action decrease give the muscle direction that will how long to maintain the sleep till the spasm breaks and if that that doesn't work for you for five to ten seconds then you can go ahead with the scoline so how why why should we go with schooling because laryngospasm is spasm of the laryngeal muscles you can give muscle relaxant to break the spasm now for breaking the spasm such symmetrium or schooling you do not need to give intubating those two mg package you do not need to use 0.521 mg per kg is sufficient to break the spasm do not forget to couple it with atropine to counter the parity card because of the spasm giving scrolling does make sense because you do not need to know usually scrolling for intubation if you are used it takes 30 60 to 90 seconds for the complete body relaxation sometimes we do not need a complete body to relax studies have proven that if you give scolie the laryngeal muscles the relaxation and laryngeal muscle muscles occur earlier than the full body relaxation that's what we want we want to break this pattern we want the action on laryngeal muscle it happens earlier than other muscles so it does make sense if iv root is not there you can use intramuscular root or submental or interlingual root has also been suggested and then lastly but schooling i know it sounds very attractive it sounds very lucrative option give the scrolling and break the spasm but actually i had asked one of the very senior pediatric anesthesiologist with decades of experience i asked her when was the last time she had actually used the schooling to break the spiral she answered definitely not in last 20 to 25 years so if you go with the conventional method you do not need to resort to you not need to resort to a pharmacological method lastly attempt intubation always lead to rome all algorithms lead to the intubation and cpr in the end laryngospasm bronchospasm expiratory vis is one of the clinical signs but if it is a very severe bronchoconstriction exploratories might not be there in a very severe bronco constriction the airway sounds are almost absent or questioned in that case what we'll get on the monitor is a increased peak airway pressure and whatever tidal volume that you set on the monitor it will it will not decrease it will not completely uh able it will not be able to completely deliver the exact title volume title volume delivered will be less but your set will be higher and there is a characteristic sharp pin appearance on the etc so what are the precipitants lrtis passive smoking inhalational agents dysfluorine and isopurine both are punching so definitely avoid any pungent gas during especially during the induction uh of anesthesia you can use halothane and you can use ceo fluorine hello thing right now nowadays is not easily available now many people have stopped using halogen zeofluorin is widely available attraction causes histamine release can cause the arrangement spasm better prefer a seaside aquarium it will cause less system and release make sure that your anesthetic gases are humidified avoid repeated manipulation stimulation of flarings and laggings treatment uh treatment line is same as that of an adult ladok and one in chipotle defend the plane of anesthesia gives alberta inhalation give nebulization with turbutalin and steroids and hydrocarbons uh honorable mention post extubation group or laryngeal edema so this needs a special mention because look at this diagram carefully those circles they are actually the cross section of airway of an adult compared to an infant so if you can see what does a edema of one millimeter passes to the cross section of an airway if you can see in adult item of one millimeter the resistance increases by three times in an infant airway adam of same magnitude one millimeter will increase the resistance by whopping sixteen percent one six sixteen percent and the cross sectional area of an infant area will drop by 75 only 25 percent will be there too for the passage of an air in adults is still here decreases by 44 so the airway of an infant or an unit will be severely compromised because of even a one millimeter of laryngeal edema and that is why this needs to be avoided at any cost and if it occurs and we need to treat it asap as soon as possible so what are the risk factors repeated attempts at intubation if you're using a larger size of endotracheal tube that will cause pressure over there in general mucous and make i might call it to swell up material up into tracheal tubes unfortunately most of the smaller size of into turkey tubes they are softer but if it is a hard to better to avoid it or keep it in the warm water to make the material softer make sure to avoid the make sure to avoid the cold and dry gases uh treatment humidified oxygen hundred percent oxygen nebulization with neoprene always helps yeah for the students and residents epinephrine almost every textbook mentions resembling an impression with the racemic epinephrine but in if the examiner asked in the why not the recent phenomenon is commercially not available in india so make sure you utter either epinephrine or if your examiner asks why not recently tell them that the rasmus mixture is commercially not available in india steroids are query the role of steroids is not completely proven but i think we can use steroids the basic principle of medicine is primal non-necessary do no harm that is important steroids cause no harm there is no harm in giving steroids hypoxemia i have just put this slide to brush up that to refresh that old mnemonic dop dope so make sure that your tube is not this large you should be in the truck yeah this particularly holds an importance in case of in case of a new metal airway the turkey is hardly four centimeters we have we have a small safety margin with the head manipulation of head during the surgery the tube can easily come out or it can migrate in the bronchial it can go into bronchial so make sure the tube is in the trachea make sure the tube is not obstructed because of the blood secretion vomiters mucousness make sure that it is not king somewhere make sure the circuit is not obstructed there should not be any clamp applied to the circuit exclude the pneumothorax and do the thorough equipment check right from the cylinders oxygen cylinders right from the pipelines to the machine check if the walls are properly working check everything card equipments are actually rare than pediatric respiratory events but when they occur uh they definitely cause tachycardia in anesthesiologist the heart rate becomes equal to that of a neonate 140 160 isn't it so what are the cardiac events that we experience frequently that we come across frequently bradycardia hypotension cardiac arrest and cardiac arrhythmias bradycardia again is very important if you want to discuss one of all these cardiac events it has to be platycardia vibrating cardio is important why is this so disastrous that is because when we talk about cardiac output cardiac output indian adults the formula of cardiac output is sv into hr strict voice stroke volume into heart rate now in numeration infants the myocardium is not fully mature so according to demand according to need the stroke volume cannot increase stroke volume is fixed so co is equal to stroke volume into heart rate stroke volume is fixed so cardiac output is directly proportional to the heart rate if the heart rate goes down if there is bradycardia cardiac output will also decrease and if you do not treat the bradycardia in time cardiac output will decrease to a further level and that might ultimately deteriorate into cardiac arrest so what are the causes during general anaesthesia aero instrumentation laryngoscopy and intuition and intubation can cause decrease in heart rate inhibition regions hello thing was very notorious now nowadays hello thing is not being used frequently but halo thin knowledge in your probably your senior anesthetist must be knowing if you use it for a longer duration at a higher concentration it can cause bradycardia hiv drugs choline causes bradycardia most of the opioids quentin is buprenors in the cosmetic cardiac now we are rampantly using alpha and agonist to supplement the anesthesia chronic index metatominating all these can cause bradycardia other causes hypoxia out of all these causes hypoxia is one of the most important cause make sure that you extruded hypo hypoxia when you're dealing with the bradycardia you can use the algorithm given by the you can use the algorithm given by the aha to treat the pediatric bradycardia dose of atropine is 20 mics per kg and the dose of epinephrine they are 1.1 ml per kg of bonus to 10 000 how to load this truck suppose you have a 4 kg uh child weighing 4 kg and you need to give 10 mics per kg or 0.1 ml per kg of 1s to 10 000 concentration of an epinephrine so a commercial commercially available ampule is one is to 1000 one cc is one ml is one is to one thousand take that one cc in a 10 cc range dilute it up to ten now that one is to one thousand has been diluted to ten times so that makes up one is to ten thousand solution one is to ten thousand concentration now take a one cc syringe the new metal one cc range this one cc series is usually divided in ten marks so one cc divided by 10 each mark is 0.1 ml if the child is going 4 kg drop 4 c's draw 4 marks of that diluted adrenaline solution and that becomes your epinephrine dose for that kg if child is in 7 pg draw 7 marks of 1 cc syringe so that is how you should lower the epinephrine it's very helpful even in cases of anaphylaxis whenever you want to give epinephrine according to the weight is not always less than 90 by 60 millimeters of mercury it depends on the age of the patient so causes hypovolemia the child might be exsanguinated or there might be a plasma loss from the bones or if the child is having vomiting and diarrhea there is a water loss synthesis or sorry sepsis is a veterinary state nfl alexis causes drop in blood pressures most of the anesthesia agents that we use they cause hypotension except for fuel like ketamine and query spinal anaesthesia i have written query because spinal anesthesia does not cause a drop in heart does not cause a drop in blood pressure in children especially less than five to six years old what causes hypertension in spinal anaesthesia is because of the sympathetic blockage it causes the peripheral hydrodylation in adults and the vascular reservoir is larger and there is a pooling of blood in the peripheries that causes hypotension in pediatrics usually the peripheral visualization doesn't occur after central university and even the reservoirs are small so that's why we do not pre-load or co-load the pediatric patients before or during the central universal blockade treatment treat the cause give iv fuels give crystalloids colloids replace the blood and blood products cardiac arrhythmias this will be the use topic for discretion but only one cardiac arrhythmia particularly i have particularly i would like to focus upon and that is svt so preventable tachycardia that is because 90 of pediatric arrhythmias are svds now how to differentiate between an svt and sinus tachycardia so sinus tachycardia if it is less than 200 then it is a sinus tachycardia if heart rate goes beyond 200 you can suspect supraventricular tachycardia and when it is an emergency when it is a when it is not an emergency you can call it as an emergency when the hemodynamic fluctuations are there when the hemodynamic instability are there along with the heart rate in this heart rate if blood pressure drops significantly then it is an emergency and then you need to cardiovert the child with point five to one joules per kg and if it is not emergency if the blood pressures are holding on you can use corrupted sinus massage as a regular manure or you can use adenosine as we use in headaches in adults dosa pattern notion is phosphorous is 6 mg second loss is 12 mg similar are the doses in periodic divided by 60 60 kg usually and the retinal symbols will be 0.1 mg per kg first dose second dose will be to mg per kg variable dose will be point three in g so you can remember adenosine point one point two miracle point three cardiac arrest definitely will follow the age algorithm again that will be the huge topic that should be actually conducted as a separate topic for discussion but few selling points i would like to focus upon most of them most of the cpr scenarios are of respiratory origin again most of the beneficiaries are from respiratory origin because of hypoxia in the context of cpr it is not important to identify the exact rhythm start treating it as soon as you identify it as a slow rhythm and white complex traffic cardia in pediatric must be considered as ventricular tachycardia until proved otherwise start treating it as a personalized beauty because if you do not treat it in time it will the ventricular tachycardia will eventually deteriorate into either a pus less ventricular typically or ventricular fibrillation so lastly if you honorable mentions again hypothermia obviously will warm the child will cover the child will start a warm reveals you will give warm iv fluids but remember a single thin plastic sheet a single thin sheet of polythene it acts as an excellent insulation it acts as an excellent heat barrier and make sure you have covered the head of a unit or anything for a species specifically for units and influence their heads are larger the surface area is large it's not covered with hair the skin is thin so they tend to lose the heat from their head area it's a larger surface here cover that you can use the iv bottle wrapper to cover the hair cover the head of new knit or in front of the iv fluid bottles they come in a plastic wrapper cut the one end and you can make a nice cap of it to cover the head of neonate or any one hypoglycemia sugar levels anything below 45 mg per dl or hypoglycemia give 2 to 4 meals per kg of dextrose solution preferably index was 25 that will act faster ponv postoperative nausea and vomiting obviously along with the pharmacological treatment make sure you are not fasting the child you know starving the child necessarily your prolonged nbm period before the surgery before the schedule time of the surgery can contribute to the pon can contribute to the nausea and vomiting after the surgery so many hospitals have now resorted to the technique of giving a small amount of happy or fruity to the patient before actually starting the two hours before actually starting the surgery two hours before actually administering the anastasia so we are shortening the uh indian period before the surgery now post-operative sort of throat is definitely because of repeated laryngoscopies and dramatic integration but recently in the last five to ten years the more common reason is improper fit of a supraglottic airway device we are now started using psychiatric devices almost for everything now we're using them very equipment make sure the right size is there lubricating anaphylaxis treatment again is the same as that in adults take care of a b c airway breathing and circulation if it is a moderate hypotension and bronchospasm you can give you can get away with one to five mics per kg of an epinephrine if it is a very severe hypotension or severe bronchospasm give 10 mics per kg full dose 10 mice per kg of if anything and if the hypotension doesn't respond to the epinephrine do not hesitate to start nor eternal injury and lastly complications of original anesthesia we all know they are same as that in adults thank you thank you so much dr pawan kumar is asking can you please explain larson's maneuver a little bit so lasso's menu is basically in front of the mastoid and behind the ramus of mandible in between there somewhere you have to give a firm pressure with your fingers and keep it pressed keep it pressed till the spasm breaks that is a licensed maneuver as i told you when you actually you are giving c pattern using the conventional method when you are giving a cpap with the jaw thrust actually in a way you are doing license manual also you are doing many things simultaneously so there are few anesthesiologists who use license manual as a sole method to treat the varying spasm but if it doesn't work for you go for a conventional method it will always and always work okay uh next question we have in cardioversion how to calculate the energy um for children the cardioversion the first dose is really 0.5 to 1 joules per kg the subsequent cardioversion doses are two joules per kgs okay rasheed is saying he he has witnessed bradycardia with sibo fluorine on higher concentrations higher concentration can occur can occur more common with hello things co and other inhibition relations are not very luxurious when it comes to bradycardia but yes if you're ventilating for a round uh for a long time and the child is not getting ventracted properly hypoxia might be one of the reasons but yes can occur with a higher concentration for a prolonged duration dr rasheed only has another question how long to maintain cpap till this father breaks and if it doesn't break within 5-10 seconds and if the saturation is dropping further it touches zero giveaways of proper fall and gives choline resort to the pharmacological method but within five seconds usually the cpap will break the right uh dr spasm is asking what is p peak p peak is peak airway pressures so it is a pressure of an air that is passing through the endotracheal tube and going into the airways your machine will show the peak airway pressure the workstation will show the peak repression if you're using a boys machine then the during ventilation uh back resistance will let you know that if there is a higher peak if you need to place the bag with a more resistance with a more force that might be the reason for the hierarchy is asking what is the minimum age to give spinal anesthesia you can give right to the units there are many case studies many people are giving a spinal anesthesia to a neonate also but it has a very uh limited uh i would say use most of the neonates that are being given spinal anesthesia are usually for congenital hernia repairs and the key selection should be proper especially for preterm children who have repeated episodes of acne or prematurity they might go into prematurely very frequently so in such patients we would like to prefer the general anesthesia or a higher sedation in that case we can use spinal anaesthesia but make sure that your surgeon is faster the duration of spinal anesthesia is very short short it might last mix to max 40 to 45 minutes so that i may in that time your surgeon should be able to finish the procedure if your surgeon is low do not give spinal anesthesia and even other indications i think most of the neonatal surgeries and infantile surgeries can be carried out under ga or under portal block if you have such excellent technique as a caudal block the learning techniques are easy the prolonged duration is there can last for about 12 and a half hour there is no need of spinal analysis unless the only indication is a premature infant or premature newness that is the only indication currently no need to be heroic otherwise uh so uh with the same question it's which side spinal needles to use in children particularly infants and neonates 27 small linked little iron available i think with the icon company smaller length uh two and a half centimeters and uh four centimeter needles are now available 27 gauges are usually available okay all right uh i think we can go back just a small i would like to add on uh the csf circulation in units and infants it is at high speed so what happens if you're inserting the spinal needle for uh spinal analysis in a neonate and you given that drug amount is very small usually use a one cc syringe for giving the truck so after you are given the spinal anesthesia make sure that your entire assembly the spinal needle and the syringe should be there for the next five seconds and then remove the entire system otherwise what will happen you are given the dose the dose is very small sometimes only 0.4 or 0.5 mils and you remove the needle and the track that has been created because of the needle that oozes out of the track and the drug is not in the csf now so the spinal won't act or it will act inadequately so make sure the assembly is there for next four to five seconds and then slowly remove the needle all right uh well dr manish says he is proud to see a gmc right here thank you your fellow alumni i think we have to use a pediatric dose what doctor projector is asking what would be the pediatric dose for spinal nerves um can we share there is a chart actually so in the presentation no it's not in the presentation okay yeah yeah so it's basically for dp working heavy and bp and rupiah the chart has been given depends on less than 5 kg they have categorized into less than 5 kgs 5 to 15 kgs and more than 15 kgs okay okay great so i think we can go to the polls now let's see what is the change in the answers let's start with the first one which of the following anatomical difference in a pediatric patient makes airway obstruction more likely event in them so i think the large tongue wins yes so floppy pictures will cause a problem for intubation not for a nearby obstruction for a spontaneously breathing child or a mildly sedated child it is a large tongue that falls on the there is a tongue fallen that causes obstruction a floppy epilogue will not cause airway obstruction unless you are trying to individually are not able to integrate so last time is the answer yes so before i think we had floppy epic lotus winning and this time clearly it was large tongue so yeah so for the second one which of the following maneuvers helps with management of laryngospasm yes lassen wins by a big margin and i was expecting this to be the answer i think it was only when that was disgusting so which is the best way to major ideal size of oropharyngeal airway yeah so it's a distance between angle of mandible to angle of lip actually the for our pharyngeal airway yes right angle of tip next will be which of the following agent has highest incidence of laryngospasm and or bronchospasm associated with its use [Music] is not actually the answer halothane and cebu fluorine are sweet smelling so they will not actually irritate the upper pharyngeal mucosa it's isoflurane and destroying these two are pungent and they are more likely to cause laryngospasm out of those two if you want to prefer one the answer should be this fluorine it is even more pungent than isofluorine also causes bradycardia not laryngospasm so in an event of unwitnessed collapse in a child what is the first step that one should do yeah start the cpr immediately and then you can call for help or alert the emergency response system right next is what is the ideal dose of adrenaline in pediatric cpr so the b option is i am happy this was difficult so yes obviously our audience is paying attention even though like you said even in cases of hypoglycemic audience they are paying attention the most common cause of cardiac arrest in pediatric patients is yes so respiratory is the clear yeah yes so we have had an uh amazing session thank you so much the polls answers are also giving proof that yes everyone has attended and has enjoyed the session and i would also like to thank the audience for being with us you

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