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