Paediatric Anaesthesia:

Eyes, ENT and Dental

Magen Schwarz

Summary of Talk
Ophthalmic Anaesthetics
Intra-ocular pressure/EUA
Eye trauma
Strabismus surgery

The Bleeding Tonsil

Pre-op
Peri-op
Post-op issues

GA in Dental Procedures

Paediatric Ophthalmic
Procedures
Usually under general anaethesia
Usually day procedures:
EUA
Lacimal duct probing
Strabismus correction

Beware the child with a cold

Some Congenital Issues

Craniosynostosis syndromes (glaucoma, squint, cataracts,
exophthalmos)
ie Crouzons, Aperts, Pfeiffer
Considerations mid-face hypoplasia

Craniofacial Syndromes (glaucoma, cataracts, squint)

ie Goldenhar, Treacher, Collins, Smith-Lemli-Opitz
Considerations Facial asymmetry, micrognathia

Downs Syndrome, Edwards Syndrome, Cri du Chat

Syndrome (cataracts, strabismus)
Considerations Difficult intubation, C-spine instability in Downs

Marfans Syndrome (lens dislocation)

Considerations Aortic root dilatation, aortic/mitral valve regurgitation

Ophthalmic Medications
-blockers (Timolol) glaucoma
Systemic Effect Bradycardia (refractory to Atropine); bronchospasm in asthmatics

Carbonic anhydrase inhibitors (Acetazolamide) Glaucoma

Systemic Effect Metabolic acidosis, electrolyte abnormalities, allergies including
SJS

Antimuscarinics (Atropine/Cyclopentolate) Pupil dilatation

Systemic Effects Dry mucous membranes, nausea, tachycardia

-adrenergic sympathomimetic agents (Pheynlephrine 2.5%) Pupil

dilatation
Systemic Effects Hypertension, tachycardia

Local Anaesthetics (Tetracaine, Oxybuprocaine, Proxymetacaine)

Analgesic
Systemic Effects LA toxiscity, especially in neonates

Anaesthesia and IOP

Normal IOP ranges from 10-20mmHg
Most induction agents will reduce IOP

Anaesthetic Techniques and

IOP
Factors affecting IOP
Laryngoscopy increases IOP
Lidocaine 1mg/kg can help
LMA is better
Hypoxia and hypercapnia increase IOP
Hypocapnia and hypothermia decrease
IOP

Oculocardic Reflex
Seen in up to 60% undergoing strabismus surgery
Afferent innervations
from the ophthalmic
portion of the trigeminal
nerve, relays via the sensory
nucleus in the 4th ventricle,
with the efferent impulse in
the Vagus nerve
Commonly due to traction on the medial rectus muscle
Atropine (20mcg/kg) or glycopyrrolate (10mcg/kg)
Sevo Vs Halothane
Atrac Vs Roc
High CO2 - consider controlled ventilation

Anaesthesia for Eye EUA

Most induction agents reduce IOP
Pathological increase in IOP may be masked

Ketamine:
IM (5-10mg/kg)
IV induction (1-2mg/kg)
May slightly increase IOP
Give with Atropine/Glycopyrrolate - ***contraversial

Sevofluorane:
Decreases IOP, restrict to 5% or less
Measure IOP quickly
Ideally no airway equipment is used:
Masks compress the eyes and the patient must be deep to
accept an LMA

Penetrating Eye Trauma

Patient will not be fasted:
Suxamethonium will rise IOP
Alternative:
Large dose NDMB,
Ventilate with cricoid pressure

Vitreous extrusion has not

been associated with Suxamethonium
RSI using Rocuronium is now more possible with the
use of Suggamadex

Minimise events that increase IOP

Consider pre-intubation Lidocaine

Nasolacrimal Ducts
Blocked nasolacrimal ducts require probing and irrigation
Usually present early with tearing

Blood or dye can encroach the posterior nasopharynx

Short procedure
Hypotensive anaesthetic
may be needed to reduce
bleeding.
LMA is sufficient
Ensure to suction

Strabismus Correction
Most common paediatric eye surgery
Seen in 3-5% of the population

Induction and maintenance as before

TIVA better for PONV
Anaesthetist preference

Have Atropine/Glycopyrrolate handy

OC reflex

Extubate deeply
A peribulbar block is good at reducing
PONV and pain
Risk of globe perforation
Sub-Tenon block is very effective

PONV is seen in 50-75% so dual therapy is indicated

Avoid intraop opiates where possible

Topical analgesics
Tetracaine

Blocks for Strabisumus

Surgery

GA Dental Procedures
Pre-assessment:
History and exam. Facial swelling?
Is mouth opening limited?

Induction:
IV or inhalational
Antisialogogue agents may help:
Atropine/Glycopyrrolate

Maintenance:
Nasal mask Vs ETT Vs Nasal ETT

GA Dental Procedures
Pharyngeal packs Ferguson pack with McKesson mouth
prop to maintain opening
LMA for longer procedures
ETT more extensive issues
ie Wisdom teeth removal

Nasal airways
Post-induction:
ETT with NMB and a short-acting opioid
Then controlled with volatile or target-controlled Propofol

Post-op compliations of GA
Minor cough, N&V, headache
Major complete respiratory obstruction, neck injury

Paediatric ENT Bleeding

Tonsil
Seen in 0.5 2% post-tonsil surgery
Hot Vs Cold techniques
A difficult scenario. Potential hazards
to consider:
Hypovolaemic shock
Pulmonary aspiration
Difficult intubation
Risks of a second GA

Paediatric ENT Bleeding

Tonsil
Pre-op assessment:
Resuscitate before induction
20ml/kg stat boluses in children

Note time since previous surgery

Fasted?
Any clots in the mouth
Signs of airway difficulty
Check the previous anaesthetic chart

Paediatric ENT Bleeding

Tonsil
General considerations:
Get senior help early
2 suction devices
Laryngoscopes of correct size
ET tube same size as last time and one
size smaller
Need two of each ET tube
Wide bore NG tubing
Get the surgeons scrubbed and ready

Bleeding Tonsil Anaesthetic

Technique
1. Inhalational induction, head down, lateral
Pros
- Familiar technique,
oxygenation well-maintained
- Gravity helps drain blood and clots
- Sux can be given prior to intubation
Cons
- Difficult in an anxious child
- Risk of deep anaesthesia
- Lateral laryngoscopy is not a
common practice

Bleeding Tonsil Anaesthetic

Technique
2. Intravenous RSI
Pros
- Less stressful for the child
if cannula in situ
- Induced supine with cricoid
pressure
- NMB create ideal environment
for intubation
Cons
- mRSI needed as impossible to pre-oxygenate an anxious child
who is bleeding
- Gentle bag-mask ventilation required
- Risk of hypoxia if intubation is difficult

Bleeding Tonsil
Perioperative considerations
Keep the child warm, hypothermia
promotes coagulopathy
NG tube after haemostasis
Extubate awake in left lateral, head
down
OR

Tonsil position
A bolster placed under the chest in the
lateral position
Head is below the level of the chest

Bleeding Tonsil
Post-operative Care:
Close monitoring in a well-lit area
Keep Hb over 8g/dl provided no more
bleeding
Should remain
in hospital for
at least 24 hours
post bleed

Thank-you

Any questions?