Paediatric Anaesthetic Paediatric Anaesthetic Emergency Drug - PowerPoint PPT Presentation

Paediatric Anaesthetic Paediatric Anaesthetic Emergency Drug Solution ‘PAEDS’ Donovan Dwyer Emergency Staff Specialist St George and Sydney Children’s Hospitals ECI Emergency Care Symposium g y y p Friday 9 November 2012

6 6 year old boy, ped vs car ld b d • Obvious facial injuries Obvious facial injuries • GCS 9, BP 100/70, PR 126 • Sats 90% NRB • Sats 90% NRB • Blood and vomitus in airway • Recognition of urgent need for RSI Recognition of urgent need for RSI

O Overview i • Drug calculations, preparation and delivery add a layer g , p p y y of stress, complexity and potential morbidity • A simple and safe system for rapid draw up and delivery A simple and safe system for rapid draw up and delivery of emergency intubation drugs is presented • All patients receive 0 1mL/kg of any/all of the drugs All patients receive 0.1mL/kg of any/all of the drugs drawn up according to specified formulations e.g 35kg child receives 3.5mLs • The Medical Team Leader decides on the appropriate drugs for the situation

O Overview i • Emergency Paediatric intubation is uncommon • Emergency Paediatric intubation is uncommon • There are few ‘experts’ • There are many challenges • There are many challenges − Condition of child − Resuscitation fluid choices and volumes Resuscitation fluid choices and volumes − Age, weight, development factors − Drugs D

O Overview i • What drugs? g − What are their formulations • What dosages? − What weight is this based on? − How do you want them diluted? • How drawn up? − What size syringe − Only want dose needed or total vial drawn up and O l t d d d t t l i l d d administering Dr gives dose? • How labelled? How labelled?

6 6 year old boy, ped vs car ld b d • Obvious facial injuries Obvious facial injuries • GCS 9, BP 100/70, PR 126 • Sats 90% NRB • Sats 90% NRB • Blood and vomitus in airway • Recognition of urgent need for RSI Recognition of urgent need for RSI

P Premise for new approach i f h • Accept that our dosing is based on estimated weight p g g • Agreed on a group of drugs that would suite almost all intubation scenarios − Atropine − Thiopentone/ketamine − Suxamethonium Suxamethonium − Midazolam − Fentanyl/Morphine Fentanyl/Morphine − Vecuronium/Rocuronium • Accept that the ‘Therapeutic Index’ for drugs in this p p g setting is wide (some exceptions)

H How has this progressed h hi d • Drug dose calculator that lists RSI drugs Drug dose calculator that lists RSI drugs separately

P Premise for new approach i f h • A new draw up method − Allows all RSI drugs to be drawn up rapidly − With specific formulations all drugs drawn up to 10 mL − Drugs labelled and stored in sequence of delivery f − Allows dosing of all drugs to be 0.1mL/kg

Atropine Thiopentone Ketamine Suxamethoniu Midazolam Morphine Fentanyl Dose Vecuronium Dose Dose Dose Required m Dose Dose Dose Required Required Dose Required Required Required 2mg/kg Required Required 0.1mg/kg 1 μ g/kg 0.1mg/kg 5mg/kg 5mg/kg 1mg/kg 1mg/kg 0.15mg/kg 0 15mg/kg 20 µgm/kg Atropine Thiopentone Ketamine Suxamethoniu Midazolam Morphine Morphine Vecuronium Formulation Formulation Formulation Formulation Formulation Formulation m Formulation m Formulation Formulation Formulation Formulation Formulation Formulation Formulation Formulation Formulation 600µgm/mL 500mg dry 200mg/2mL 100mg/2mL 15mg/3mL 10mg/mL 100 μ g/2mL 10mg dry formulation formulation Atropine Thiopentone Ketamine Suxamethoniu Midazolam Morphine Morphine Vecuronium Dilution Dilution Dilution m Dilution Dilution Dilution Dilution Dilution Draw up to Draw up to Draw up to Draw up to Draw up to Draw up to Draw up to Draw up to 3mL in 3mL 10mL in 10mL in 10mL 10mL in 10mL 10mL in 10mL in 10mL 10mL in 10mL 10mL in 10mL syringe with 10mL syringe syringe with syringe with 10mL syringe syringe with syringe with syringe with water t with water ith t water t water t with water ith t water t water t water t Labelling Labelling Labelling Labelling Labelling Labelling Labelling Labelling Add Atropine Add Add Ketamine Add Add Add Morphine Add Morphine Add Label and Thiopentone Label and Suxamethoniu Midazolam Label and Label and Vecuronium write Label and write m Label and Label and write 1mg/mL write 10 μ g/mL Label and 200 μ gm/mL write 20mg/mL write 10mg/mL write write 1mg/mL 50mg/mL 1.5mg/mL

E Emergency Intubation Drugs I t b ti D • The drugs are labelled according to the Australia/New Zealand standard AS 4375 and stored in order of likely usage. • For infants estimated to have F i f t ti t d t h weights < 10 kg − drugs are diluted as above g − attached by way of a 3 way tap to a 1mL syringe − appropriate dose drawn into the pp p 1mL syringe. − Example 5kg infant receives 0.5 mL.

Medical Team Leader Responsibility M di l T L d R ibilit • Ensure estimated weight recorded on drug box e.g 22kg • Ensure volume to be given is recorded on box e g 2 2mL Ensure volume to be given is recorded on box e.g. 2.2mL • Select medications to be delivered • Ensure child receives 0.1mL/kg of selected drugs in the correct order at appropriate time appropriate time • The only exceptions are − Infants under 5 kg should receive a minimum dose of 0.5mL of atropine (100micrograms). − Where adult doses are reached computer will default to that as a maximum e.g Midazolam stops at 5mg (3.3mL) − Ketamine at 0.1mL/kg should be considered the drug of choice for the septic, hypotensive asthmatic child and the potentially haemodynamically hypotensive, asthmatic child and the potentially haemodynamically compromised child with a head injury. − Thiopentone at 0.1mL/kg is a maximum dose and lower doses will usually be more appropriate. Avoid maximum dose in septic, hypotensive, hypovolaemic children • These exceptions are the responsibility of the Medical Team Leader.

Summary • Emergency Paediatric intubations are g y uncommon but stressful • A simple method of safe, rapid draw up, and easy to remember dosing may improve process at your institution • Recommend • Engaging clinicians involved in RSI • Simulation training

A k Acknowledgements l d t • Dr Lee Fineberg and Glenn Arendts g • Dr Adrian Bonsall • Senior Medical Staff at SCH • Nursing staff at SCH and SGH for input and audit Thank You Thank You

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