Paediatric anaesthesia

Paediatric remote-site anaesthesia

Introduction

In recent years, there have been an increasing number of paediatric procedures performed outside of the theatre environment by medical specialists and radiologists. This poses challenges when working in the less familiar environment for the theatre team, often with additional members of the multi-disciplinary team. In addition, staff procedure risks such as radiation exposure and infection control need to be considered. The overall aim is to provide the same high standard of care that patients receive in theatre areas.

This guide is written to support the multidisciplinary team in providing safe anaesthetic care for paediatric patients.

Locations

The locations that this guideline will cover include:

Staffing

It is recommended that anaesthesia should be provided by a consultant or occasionally a senior trainee with consultant support, ideally on-site. It is important that all members of the anaesthetic team are familiar with working in these remote locations.

Endoscopy: There will be a consultant anaesthetist assigned to each daily elective list.

IR: cases are performed on a weekly theatre list in IR or ACAD theatres. Emergency or out of hours cases are covered by the on-call paediatric anaesthetic team.

MRI: There are elective paediatric MRI lists twice a week, but for non-elective MRIs, this is usually facilitated with the on-call anaesthetic team.

In addition to the paediatric ODPs, there are two additional ODPs in the IR suite covering adults patients, who if paediatrically trained could also be of assistance.

Out of Hours: All OOH cases should be discussed with the consultant paediatric anaesthetist

Equipment

Level of monitoring for anaesthesia should be the same as that provided in theatre. This should include:

Routine Equipment for anaesthesia should include:

Anaesthetic machines and other equipment must be checked before use in accordance with AAGBI guidelines. Anaesthetic machine checks should be recorded in a log by the anaesthetic practitioner and on the anaesthetic chart by the anaesthetist. It is important that all monitoring equipment is on the same service schedule as theatre equipment.

The monitoring at Royal London Hospital is the Philips Expression MR4000 and all members of the team should familiarise themselves with the equipment prior to any case.

MRI specific ECG electrodes are needed to monitor patients during anaesthesia.

The anaesthetic team must ensure an adequate supply of oxygen is available before starting any procedure. Back up cylinders should always be available in addition to piped gas supply.

Medication

A standard list of anaesthetic medication, including reversal agents, should be available and prepared for areas where anaesthesia or sedation is performed.

Anaesthetists should prepare their own medications when working in the endoscopy and MRI suite. Medication, including controlled drugs, is provided in all IR suites.

Emergency Equipment/Drugs

Please also refer to the Box app for guidelines related to the management of the associated emergencies.

Cardiac Arrest

In the event of a cardiac arrest, the scan/procedure should be stopped immediately. If arrest occurs in the MRI suite, members of the team should evacuate the patient as swiftly and safely as possible to the anaesthetic preparation area for resuscitation.

Trolley Locations

Difficult Airway Trolley

Anaesthetic Emergency Drugs

Massive Haemorrhage

Pre-operative Assessment

For the majority of cases performed in the these remote areas, the pre-operative assessment for these patients will still initially performed on the paediatric day-case unit on 6B. Inpatients will be seen on the ward and emergency cases occasionally in ED.

Consent

It is the responsibility of the procedura list to consent the parent and/or patient for the specific procedure.

Patients with complex needs may need more thorough preoperative assessment and multidisciplinary discussion regard the best-interest decisions.

Learning disability team should be involved at earliest convenience for those patients. The LD CNS can be contacted on 07713099156

Some children with learning disabilities may have hospital passports that give caregivers some information to help provide more personalised care.

As per theatre cases, appropriate strategies for managing anxious children can be arranged for remote areas, e.g. play specialists

Pre-procedural Checks

When faced with an unfamiliar procedure, it is important that the team discuss important aspects of the procedure at the team brief that may include:

With the advancement of interventional techniques, the potential for error increases and so surgical checklists have become standard. The WHO's 'Safe Surgery Saves Lives' checklist has been adapted for non-theatre environments. The purpose of these checks is to identify possible causes of error before they cause harm to the patient.

The NHS Commissioning Board Special Health Authority requires the WHO checklist to be completed for every patient undergoing a surgical procedure; this includes Sign In, Time Out and Sign Out.

All procedures should be compliant with National Safety Standards for Invasive Procedures (NatSSIPs) and the Safe Surgery Checklist.

MRI

Providing anaesthetic management in the MRI scanner is complex due to the limited patient access and remote environment. These challenges can be amplified in the context of a paediatric patient.

All patients and staff should be screened for implanted devices and the relevant safety of these devices prior to arrival into the MRI suite. It is the responsibility of the imaging department to ensure that patients are screened for these devices.

Devices can be largely divided into:

If there is any doubt about a device/implant, please liaise with the MR Responsible Person.

Patients should have earplugs or ear defenders provided.

In the event of an emergency magnetic field shutdown or quench, it is important that all staff are aware of the departmental emergency quench procedure.

Recovery

A plan for the recovery of patients with learning disabilities should be discussed in advance. It is of benefit if the patient can be recovered in a quieter room with earlier presence of a parent/guardian or learning disability nurse.

All patients should have met the following criteria before discharge from recovery:

Escalation Policy

During the team brief, the team should discuss how and who to escalate to in the event of an emergency. All members of the team should familiarise themselves with the location of their nearest emergency buzzer.

In the first instance, the on-call paediatric anaesthetic team can be contacted via Dect phone 45661 or bleep 1061.

In the event of a cardiac arrest/medical emergency, it is appropriate for the team to call 2222 and put out a 'Paediatric Cardiac Arrest' or 'Neonatal Cardiac Arrest' call, dependent on the child's age.

In case of a surgical emergency, the team should contact the on-call paediatric surgical registrar on 45668.

If the patient needs to be transferred urgently to theatre, the team should also contact the paediatric theatre coordinator on 45663

If the patient requires critical care admission following the procedure, the PICU registrar can be contacted on 45667 or NICU registrar on 45853.