paediatric)anaesthesia) - frca success strategyfrcaheadstart.org/finalfrca_8216.pdf ·...

Paediatric Anaesthesia

Final FRCA Teaching Program

East Coast School of Anaesthesia

Nirmala Soundararajan 8th February 2016

Session ObjecBves

•  Final FRCA – Syllabus Annex C – Pages 48 -‐ 50 •  Resources for further reading •  Paediatric SOE quesBons – Clinical – Applied sciences

•  Sample ‘Paediatric’ SAQs •  ‘Paediatric’ SBA samples


Paediatric Anaesthesia Assessment Final FRCA

•  MCQ/SBA – possible •  One paediatric quesBon (1/12 SAQs – definite) •  Clinical SOE – Long case •  Clinical SOE – Short case •  Applied Sciences SOE (Neonates) – Physiology – Pharmacology – Equipment and Safety


Paediatric module Read & discuss

•  eLA – module 04b (01 – 05) •  ePain – module 08 – 02 (01 – 05) – Special populaBons – Paediatric pain

•  APA virtual paBent cases •  APA Trainee secBon – Final FRCA preparaBon – Hot topics


Paeds resources – one stop shop

•  hYp://www.apagbi.org.uk/professionals/educaBon-‐and-‐training/web-‐resources

•  Includes a free textbook


hYp://www.frcamindmaps.org/resources/resources.html


InformaBve 58 pages

•  hYp://www.apagbi.org.uk/sites/default/files/images/APA%20Guide%20latest%20Version%2011_9_13.pdf

Top Tip ‘Know what is expected of you’ Discuss previous ques9ons – check out the chairman’s report


September 2015 – QuesBon 10 (page 55)

You are called to the Emergency Department to see a 2 year-‐old child who presents with a 4-‐hour history of high temperature and drowsiness. On examinaBon there is prolonged capillary refill Bme and a non-‐ blanching rash. A presumpBve diagnosis of meningococcal sepBcaemia is made. •  a) What are the normal weight, pulse rate, mean arterial blood

pressure and capillary refill Bme for a child of this age? (4 marks)

•  b) Define appropriate resuscitaBon goals for this child (2 marks) and outline the management in the first 15 minutes ajer presentaBon. (7 marks)

•  c) Ajer 15 minutes, the child remains shocked and is unresponsive to fluid. What is the most likely pathophysiological derangement in this child’s circulaBon (2 marks) and what are the important further treatment opBons? (5 marks) Nirmala Soundararajan 8th February 2016

Chairman’s report QuesBon 10: Paediatric meningiBs Pass rate 56.9% The pass rate for this quesBon was the second highest in the paper but the examiners sBll felt that it was not parBcularly well answered. Many candidates lost marks because they wrote similar answers for parts (b) and (c), despite the fact that in part (c) they were asked to comment on what they would do if the measures used in (b) were not successful in resuscitaBng the child. Incorrect dosages of drugs, parBcularly anBbioBcs were ojen quoted.


March 2015 -‐ QuesBon 2 (Page 19)

•  A 5 year-‐old boy with AuBsBc Spectrum Disorder (ASD) is listed for dental extracBons as a day case.

•  a) What consBtutes ASD (1 mark) and what are the key clinical features? (6 marks)

•  b) List the important issues when providing anaesthesia for dental extracBons in children. (6 marks)

•  c) Give the specific problems of providing anaesthesia for children with ASD and outline possible soluBons. (7 marks)


Chairman’s report

QuesBon 2 AuBsBc Spectrum Disorder Pass Rate 46.2%, 22.1% of candidates received a poor fail It was anBcipated that candidates would find this subject maYer to be difficult and this was borne out by the pass and poor fail rates. AuBsBc Spectrum Disorder (ASD) is an important issue within paediatric anaestheBc pracBce, and this result suggests specific teaching on the topic needs to be undertaken in all Schools of Anaesthesia. Failure to read secBon (b) correctly led to low scores as candidates did not realise that the quesBon referred to all children not just individuals with ASD.


QuesBon 6 – September 2014 ,16 & CEACCP arBcle Nov 2012+ NICE 64

A 5 year-‐old child presenBng for day case dental surgery under general anaesthesia is found to have a heart murmur that has not been documented previously. a) What features of the history (5 marks) and examinaBon (5 marks) might suggest that the child has a significant congenital heart disease (CHD)? b) If the murmur is caused by an atrial septal defect (ASD) what ECG findings would you expect? (2 marks) c) Which imaging modaliBes might be used in the assessment of the ASD (2 marks) and what specific addiBonal informaBon may be obtained? (2 marks) d) List the current naBonal guidelines regarding prophylaxis against infecBve endocardiBs in children with CHD undergoing dental procedures. (4 marks)


Chairman’s report

•  Ques6on 6 Pass Rate 39.1% •  This quesBon was poorly answered by many candidates who could not list the history and examinaBon findings in such a paBent. Many felt that congenital heart disease only caused lej sided cardiac abnormaliBes and were ignorant of naBonal guidelines on infecBve endocardiBs prophylaxis although the need for the laYer must be encountered on a regular basis in adult subjects


Take a break


QuesBon 6 – March 2014 A 5-‐year-‐old paBent presents for a myringotomy and grommet inserBon as a day case. During your pre-‐operaBve assessment you noBce that the paBent has a nasal discharge. •  a) Why would it be inappropriate to cancel the operaBon on the basis of this informaBon alone? (25%)

•  b) List the features in the history (35%) & examinaBon (25%) that might cause you to postpone the operaBon due to an increased risk of airway complicaBons in this paBent.

•  c) What social factors would preclude this child’s treatment as a day case? (15%)


Chairman’s report Ques%on 6 Pass Rate 44.7% This quesBon was answered poorly considering the issue is “meat and drink” to paediatric day case pracBce. The majority of candidates did not menBon; emoBonal aspects, financial losses, parental work absence, school absence and inefficient use of hospital resources in the answer. The history secBon was poorly answered although examinaBon features were more typically known. Surprisingly, social factors were infrequently given although these have a major impact on suitability as a daycase. Overall, there seem to be few candidates thinking about the organisaBonal and logisBcal aspects of bringing a child in for daycase surgery.


QuesBon 10 -‐ March 2013

An 8-‐year-‐old child with severe cerebral palsy is scheduled for an elecBve femoral osteotomy. •  a) Define cerebral palsy? (15%) •  b) List the clinical effects of cerebral palsy on the central nervous, gastro-‐intesBnal, respiratory and musculoskeletal systems with their associated anaestheBc implicaBons. (50%)

•  c) What are the specific issues in managing postoperaBve pain in this paBent? (35%)


Chairman’s report 36.4% pass rate. •  This quesBon was poorly answered. Adult and paediatric paBents with cerebral

palsy presenBng for surgery are not uncommon. Many examinees had liYle or no knowledge of the definiBon of cerebral palsy and could not put forward a coherent answered regarding the anaestheBc management. Awake-‐fibreopBc intubaBon was an inappropriate method of establishing the airway in this paBent and the menBon of sexual dysfuncBon was irrelevant.

•  A snapshot from the model answer below highlights the level of knowledge that was required. Focusing on the gastrointesBnal system involvement:

Clinical effects Anaesthe6c relevance •  Flexion deformiBes/spasBcity PosiBoning problems; pressure sores; difficult IV

access •  Scoliosis RestricBve respiratory paYern •  Immobility Unable to assess cardiopulmonary reserve •  Low muscle bulk Temperature control difficulBes •  One mark was available for each pair of answers (maximum 2)


Philosophy


QuesBon 5 – September 2012

A 4-‐year-‐old child is admiYed to the Emergency Department with suspected meningococcal sepBcaemia. You are asked to help resuscitate the paBent prior to transfer to a terBary centre. •  a) List the clinical features of meningococcal sepBcaemia. (35%)

•  b) Outline the iniBal management of this paBent? (45%)

•  c) Which invesBgaBons will guide care? (20%)


Chairman’s report

•  Ques6on 5: Paediatrics/management of meningococcal sepBcaemia.

•  67.6% pass rate. •  This paediatric emergency is commonly encountered both in Secondary and TerBary centres. Although the quesBon was answered saBsfactorily, marks were lost by not calling for help and inappropriate fluid resuscitaBon. Many candidates failed to communicate with the terBary centre for advice or to summon the paediatric retrieval team.

•  This quesBon was a very good discriminator


SAQ – April 2002 PA_IK_12 Describes the special problems of the premature and expremature neonate

Page -‐ 10

A ten week old male infant weighing 3.5 kg is scheduled for inguinal hernia repair. He was delivered prematurely at thirty-‐four weeks. List the risk factors and state how these can be minimised.


Prematurity – risk factors Respiratory distress syndrome •  ImplicaBons: •  High RR, Short Insp •  Small TV •  Avoid

equipment deadspace •  Post-‐op apnoeas Patent ductus arteriosus – transiBonal circulaBon •  Avoid hypoxia, hypercarbia, acidosis and hypothermia SuscepBble to NEC •  ImplicaBons •  <1.5kg, unwell •  Need fluid resus •  Monitor

Glu •  Inotropes, Ca2+ •  X match blood (friable Bssue)


SAQ May 2005 PA_IK_02 Recalls/explains the implicaBons of paediatric problems including major congenital abnormaliBes (eg tracheoesophageal fistula, diaphragmaBc hernia,)

A one day old term neonate has arrived at your regional paediatric intensive care unit. A congenital diaphragmaBc hernia has been diagnosed. The baby is already intubated and receiving arBficial venBlaBon. Outline, with reasons the principles of preoperaBve management.


Congenital DiaphragmaBc Hernia Ref: ConBnuing EducaBon in Anaesthesia, CriBcal Care & Pain | Volume 5 Number 5

2005

Aim of pre-‐operaBve management •  PICU care for clinical stabilizaBon and a fall in pulmonary vascular

resistance. (Timing of surgery per se does not affect survival) –  VenBlatory support to improve oxygenaBon –Gentle venBlaBon with

limited inspiratory pressures & permissive hypercapnia. May need HFOV/iNO/ ECMO for this

–  Echo to esBmate severity of Pulmonary Hypertension (severe PA pressures associated with worse prognosis) – measures to manage pulmonary vascular tone – iNO/ ECMO

–  esBmate lung volume using 3D ultrasound or MRI, as the degree of pulmonary hypoplasia largely determines outcome.


Life long learning


SBA – 1 PA_IK_09 Calculates the analgesic requirements

A previously fit 5-‐year-‐old girl is distressed & in severe pain in the recovery room following emergency appendicectomy. She is awake and cardiovascularly stable. IntraoperaBvely, she received fentanyl 2 mcg kg-‐1 iv, paracetamol 15 mg kg-‐1 iv & diclofenac 1mg kg-‐1PR. What would be the most appropriate analgesia op%on for her now? A. Adminster Entonox unBl the child calms down B. Codeine phosphate 1 mg kg-‐1 orally C. Codeine phosphate 1 mg kg-‐1 intramuscularly D. An intravenous morphine infusion at 10 mcg kg-‐1 hour-‐1 E. Morphine 0.1 mg kg-‐1 intravenous bolus


SBA -‐ 2 PA_IK_02 Recalls/explains the implica6ons of paediatric problems eg Down’s for

anaesthesia

A 10 year-‐old girl with Down’s syndrome presents for adenotonsillectomy. Her family are refugees and have recently arrived in the UK from Somalia. She has recurrent respiratory infecBons and Bres easily when playing. On examinaBon SpO2 is 93% in air, aural temperature 37.2°C and she has a non-‐radiaBng grade 3/6 systolic murmur. What is the most appropriate management of this case? •  A. Reassure parents that this is probably an innocent flow murmur and surgery

may proceed today •  B. Defer the case pending a full cardiological assessment including an

echocardiogram •  C. Ask the paediatric StR to examine the paBent and proceed if they think the

murmur is innocent •  D. Proceed with the case but ensure that the paBent receives anBbioBc

endocardiBs prophylaxis •  E. Measure her BP and obtain a 12-‐lead ECG and proceed with surgery if these are

both normal


SBA – 3 PA_IK_01 Recalls/explains the relevance of the knowledge of applied basic sciences

to all age groups including neonates

In the fetus, blood supplying the brain has a higher oxygen content than blood supplying the trunk and lower limbs. Which of the following statements is the best explana6on for this? A Fetal haemoglobin has a higher oxygen affinity than adult haemoglobin, thereby maximising oxygen transfer in the placenta B Metabolic autoregulaBon of the cerebral circulaBon C The fetal circulaBon is so arranged that blood with a higher oxygen content flows preferenBally across the foramen ovale and is ejected via the lej ventricle into the caroBd arteries D The ductus arteriosus ensures that most of the blood ejected from the pulmonary artery bypasses the collapsed fetal lungs E The ductus venosus ensures that a majority of oxygenated blood from the umbilical vein bypasses the portal hepaBc circulaBon


The Journey


Hot Topics

hYp://www.apagbi.org.uk/professionals/educaBon-‐and-‐training/apa-‐hot-‐topics •  Residual AnaestheBc Drugs in Cannulae and Intravenous Lines •  The Difficult Airway Trolley •  The recovery posiBon Risk of death and serious harm from delays in recognising and trea9ng inges9on of buFon baFeries – Pa9ent safety alert December 2014


Safety consideraBons


Risk of serious injury from buYon baYery ingesBon


hYp://www.poison.org/baYery/guideline.asp

•  Treat as a medical emergency •  symptoms of Bssue damage such as haematemesis, haemoptysis and respiratory difficulBes can manifest up to 28 days ajer ingesBon

•  Removal of the baYery alone may be insufficient acBon to prevent further damage, with further symptoms manifesBng later; paBents need expert input, and careful monitoring and follow-‐up


Enjoy Exams


‘Paediatric’ SAQ list Past Papers

Burning QuesBons?


Resources

•  hYp://www.apagbi.org.uk/professionals/trainee-‐secBon/educaBonal-‐materials/frca-‐exam-‐preparaBon

•  eLA – Module 04b – paediatrics •  Anaesthesia tutorial of the week •  hYp://www.nischoolofanaesthesia-‐finalfrca.org.uk/pastSAQs/paedspast/index.html


Session ObjecBves

•  Final FRCA – Syllabus Annex C – Pages 48 -‐ 50 •  Resources for further reading •  Paediatric SOE quesBons – Clinical – Applied sciences

•  Sample ‘Paediatric’ SAQs •  ‘Paediatric’ SBA samples


Thank You


paediatric)anaesthesia) - frca success strategyfrcaheadstart.org/finalfrca_8216.pdf ·...

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