the deteriorating child – what is our vector, victor? adam skinner staff anaesthetist royal...

The Deteriorating Child – what is our

vector, Victor?Adam Skinner

Staff AnaesthetistRoyal Children’s Hospital

30th July 2015

AimsReview anatomical and physiological differences

between adults and children and link with clinical features seen in children in recovery.

Discuss the (my) thought process when managing acute hypoxia and bradycardia in a child.

Discuss ViCTOR and its current practical role in recovery.

Children vs AdultsAirway differences

Oxygen balance differences

Cardiac differences

Children vs AdultsAirway differences

Oxygen balance differences

Cardiac differences

The ‘Normal’ AirwayAdult Infant

Holding an Airway

Airway Oedema

Laryngospasm

Children vs AdultsAirway differences

Oxygen balance differences

Cardiac differences

Demand vs Supply

Oxygen Consumption

Demand vs Supply

Oxygen UptakeRespiratory Drive

Rib Cage and diaphragm mechanics

Volumes and Elastic forces

Oxygen UptakeRespiratory Drive

Rib Cage and diaphragm Mechanics

Volumes and Elastic forces

Oxygen uptake – Respiratory drive

Immature Respiratory Centre (Neonates)

Opioid SensitivityNeonatesGeneticsCo-morbidity (eg CP, OSA)

Opioid sensitivity - codeine

Codeine Variability

Oxygen UptakeRespiratory Drive

Rib Cage and diaphragm Mechanics

Volumes and Elastic forces

Chest Mechanics

Chest wall differencesInfant Adult

Oxygen UptakeRespiratory Drive

Rib Cage and diaphragm Mechanics

Volumes and Elastic forces

Elastic Forces

Cardiac Differences

Bradycardia– GIVE OXYGEN!!

Scenario 1:5 year old 23 kg in recovery for tonsillectomy for

obstructive sleep apnoea.

Rapid desaturation to 60%, cyanosed

Initial Action Buzzer

Mask, T-Piece

100% OXYGEN

Position Patient and airway

Inflate lungs

Scenario 1Can’t inflate lungs

Why?

What do we need?

Who do we need?

Laryngospasm

Scenario 2:5 year old 23 kg in recovery for tonsillectomy for

obstructive sleep apnoea.

Saturation 78%, shallow breathing.

Initial Action Buzzer

Mask, T-Piece

100% OXYGEN

Position Patient and airway

Inflate lungs

Scenario 2Able to inflate with temporary improvement in

saturations

What is going on?

Maybe difficult to diagnose in children

Scenario 35 year old 23 kg in recovery for tonsillectomy for

obstructive sleep apnoea.

Noted on monitor to be bradycardic at 60 beats per minute.

How do we assess and manage?

Initial Action Buzzer

Mask, T-Piece

100% OXYGEN

Position Patient and airway

Inflate lungs

Are we starting CPR?

What is normal?

Arch Dis Child. August 2015

Normal Values

What is ViCTOR?

What is ViCTOR? National Standard 9: Recognition and

response of the deteriorating patient Key element - recording of patient

observations - greater emphasis on ‘Human Factor’ principles in the design of charts

Paediatric Clinical Network Initiative

Examples of Track and Trigger Charts

1 – 4 year old Observation and Response Chart: RESPIRATORY RATEService Normal Range

(white area)Clinical review trigger point (high)

MET or CODE trigger point

RCH *trial chart 20 – 40 41 High 56 / Low 16

Eastern Health

21 – 30 31 High 36 / Low 11

Barwon Health

20 – 40 41 Highest 60 / Lowest 15* 3 tier escalation

Bendigo Health

21 - 35 36 Highest 41 / Low 14

The Alfred 21 – 49 50 High 60 / Low 15

Austin Health 20 – 40 41 Highest 60 / Lowest 20* 3 tier escalation

NSW 20 – 40 41 Highest 60 / Lowest 15* 3 tier escalation

SA 20 – 34 35 Highest 40 / Lowest 12* 3 tier escalation

5 age groups• 0 - 3 months• 3 - 12 months• 1 - 4 years • 5 - 11 years• 12 - 18 years

Paediatric Clinical Network Initiative

Percentile curves for HR and RR in hospitalized children

Bonafide C P et al. Pediatrics 2013;131:e1150-e1157

©2013 by American Academy of Pediatrics

What is the point of ViCTOR for recovery?

What is the point of ViCTOR for recovery?

“Tool for communication and justification” Sharon Kinney PhD, RCH.

Forces the team to consider the patient with objective measurements (IN CONTEXT) outside ‘normal’ EARLY.

Provides communication framework between specialities, wards and hospitals.

Mandates response in a timeframe with suggested roles.

At the moment we use it in PACU just before transfer.

SummaryPhysiology link with Clinical Interpretation

By recognising human factors we can better recognise and managing critical incidents in recovery as a team.

PRACTICE with multi-disciplinary scenarios if possible!