Presented at Egyptian Anesthesia 2011

1. PROBLEM BASED DISCUSSION Dr Moataz Abdelrahman Consultant Paediatric Anaesthetist Clinical Lead Theatres and Perioperative Services Royal Manchester Children’s Hospital

2. 4 week old Baby The anaesthetic resident has been informed about a 4 week old boy weighing 4.5 kg presenting with bilious vomiting for the last 24 hours Neonatal History: Born at 38 weeks NVD He had a laparotomy for malrotation repair 3 weeks ago Surgeons are having a discussion with you about taking the baby to theatre tonight It is 11 pm and the surgeons want to take another child to theatre for circumcision/meatotomy for phymosis in a 5 year old They are asking you to do the baby after the circumcision What is your opinion

3. TRIAGE

4. ASSESSMENT AND EVALEUATION

7. ASSESSMENT History Examination Investigations Other preparations Parents

8. History Delivery Neonatal Pervious GA Fluid status BP HR Cap refill Fluid therapy

9. PROBLEMS Age 4 weeks Obstructed bowel Fluid shifts and dehydration Full stomach Previous surgery Thermal control Distended abdomen/ventilation Pain management

10. PREPARATIONS Fluid resuscitation strategy Fluid status BP HR Cap refill Fluid therapy

11. PREPARATIONS FBC Hb 9.0 U&E Glucose Crossmatch blood Prepare HAS

12. PREPARATIONS Insert NG ICU/HDU Indications for HDU Indications for ICU & Ventilation

13. PLAN ANALGESIA No opiates only paracetamol/NSAID Morphine IOP dose Nothing IOP &(NCA) Morphine IVI postop Regional TAP block Caudal ---high catheter Epidural Local infiltration

14. MONITORING Minimal SpO2 ETCO2 BP ECG Temp Gas Urine Additional CVP Invasive BP Trans-oesophageal Doppler BIS ??

15. ADDITIONAL MONITORING CVP Arterial Line Trans-oesophageal Doppler

16. PLAN INDUCTION Inhalation IV RSI / cricoid pressure

17. MAINTENANCE Anaesthesia Intra-operative fluid management Fluid monitoring Capillary gases Fluid shifts HAS Blood transfusion/thresholds

18. CRITICAL CARE Major fluid shifts Changes in temp Tight abdomen with big incision Long duration of surgery Metabolic status

19. POSTOPERATIVE Analgesia Investigations