Pediatric Events

Definition

Acute hemorrhage in the pediatric patient is the acute loss of a large volume of blood and can be either overt or covert.

• Overt

  • Can be visualized in the surgical field, on sponges, or in the suction containers

• Covert

  • No outward sign of bleeding (e.g., retroperitoneal hemorrhage, blood loss hidden in the drapes)

Etiology

• Bleeding from a large blood vessel (artery or vein) secondary to surgery, trauma, or disease

  • In pediatrics, massive blood loss is > 2 to 3 mL/kg/min or 50% of blood volume over 3 hours

• Underlying coagulopathy or therapeutic anticoagulation

• Loose connection in the IV, central line, or arterial line, leading to potentially hidden blood loss

Typical Situations

• Major trauma

• Procedural

  • Vascular, cardiac, thoracic, or major abdominal surgery

  • Major orthopedic surgery

  • Injury to fetus during delivery or cesarean section

  • Interventional radiologic or cardiac catheterization procedure

  • Covert hemorrhage is more likely where the surgical field is obscured by drapes or is distant from the anesthesia professional

• Coagulopathy, either acquired or therapeutic

• Occult blood loss (e.g., GI tract, long bone fractures, or into the retroperitoneal space)

• Acute hemorrhage may be a delayed complication of an earlier injury or invasive procedure

Prevention

• Identify and correct coagulopathy early

• Identify, institute prophylaxis for, and treat other potential bleeding sites (e.g., GI ulcers, fractures in acute trauma)

• In children, anticipate the need for massive transfusion and obtain adequate IV access prior to start of procedure

• Establish an institutional MTP

Manifestations

• Overt

  • Blood in surgical field

  • Blood on surgical sponges, on the drapes, and on the floor

  • Increased suction noise

  • Accumulation of blood in suction containers

  • Surgeon comments or concerns about bleeding, volume status, or transfusion

  • Changes in vital signs (decreased BP, increased HR)

• Covert

  • Changes in vital signs

    • Increased HR (or decreased HR if severe)

    • Decreased BP

    • Decreased CVP

    • Change in pulse oximeter reading due to poor perfusion

  • Physical examination if accessible

    • Increased RR if breathing spontaneously

    • Poor peripheral perfusion or capillary refill time

    • Poor pulses

    • Expanding soft tissue, abdomen, or thigh (i.e., retroperitoneal bleed, or long bone fracture)

    • Change in neurologic examination, bulging fontanelle, anisocoria (i.e., intracranial bleed)

  • Decreased NIRS monitor reading

  • Inadequate filling of ventricle on TEE or TTE

  • Decreased urine output

  • Increased fluid requirement above what is expected

  • Little or transient BP response to IV fluid bolus or vasopressor administration

  • Laboratory studies

    • Unexplained decreasing hematocrit

    • Increasing metabolic acidosis on ABG

Similar Events

• Hypotension (see Event 96, Hypotension in the Pediatric Patient )

• Anesthetic or vasodilator overdose (see Event 72, Volatile Anesthetic Overdose )

• Any cause of shock (see Event 91, Anaphylaxis in the Pediatric Patient , and Event 13, The Septic Patient )

• Cardiac failure

• Cardiac tamponade (see Event 18, Cardiac Tamponade )

• Pulmonary hypertension

• PE (see Event 21, Pulmonary Embolism )

• Arrhythmias

• Progressively inadequate volume replacement due to bleeding, insensible losses (e.g., urine, evaporative losses), or third spacing

• Occlusion of venous return by compression of IVC by surgical packing, pneumoperitoneum, or retraction

• Tension pneumothorax (see Event 35, Pneumothorax )

Management

Special pediatric considerations

• • IV access may be challenging, especially in young infants

    • Small-gauge IV catheters (24 and 22 g) typically placed in infants and young children may not withstand infusions of large volumes

    • Anticipate the need for transfusion and obtain adequate IV access prior to the start of the procedure

    • CVP line or cut-down may be necessary, especially if rapid volume administration is anticipated

  • Ensure that air bubbles are not injected into the patient

    • These may result in paradoxical air emboli to the heart or brain

    • All IV tubing must be meticulously debubbled

    • Special care should be taken with pressurized rapid-infusion devices

  • Hyperkalemia

    • Children are at much greater risk of morbidity from hyperkalemia than adults

      • Arrhythmias and cardiac arrest can occur in young children, particularly those with congenital heart disease

    • Older blood and blood that has been irradiated may contain dangerously elevated levels of K ⁺

    • Employ strategies to minimize the risk of hyperkalemia from transfusion of RBCs

      • Use freshest RBCs

      • Use washed RBCs

      • Slow rate of RBC transfusion if possible

      • Monitor serum K ⁺ levels and ABGs frequently and initiate treatments if K ⁺ rises over 4.5

        • Diuretics, Ca ²⁺ , NaHCO ₃ , Kayexalate, dialysis

        • Acidemia increases extracellular K ⁺ levels

  • Hypocalcemia

    • Secondary to transfusion of citrate-phosphate-dextrose-adenine (CPDA) blood products

      • CPDA present in higher levels in FFP than RBCs

  • Avoid hypothermia

    • Hypothermia will exacerbate coagulopathy and platelet dysfunction

    • Warm blood products

Preoperative

• Send type and cross (especially if two samples are needed) before surgery as samples may be difficult to obtain in children without central venous or arterial access

• Communicate the potential for significant bleeding and need for blood products with the blood bank

• Extra time may be required to locate appropriately matched products for patients with antibodies

• Determine acceptable values for HR and BP based on the child’s age

• Determine blood volume and “allowable” blood loss based on patient weight and hematocrit

Intraoperative

• Inform the surgeon of the problem

• Initial treatment

  • Deliver 100% O ₂

  • Consider reducing volatile anesthetic agents

  • Administer 10 to 20 ml/kg IV bolus of non–dextrose-containing isotonic fluid (e.g., saline, LR, 5% albumin, or blood) and watch for HR and BP response. Repeat as necessary to maintain adequate preload

  • Administer IV bolus of vasopressor (e.g., ephedrine, epinephrine, phenylephrine), carefully titrated to clinical effect

    • Vasopressors temporize the situation while administering IV fluids

    • Treatment of hypovolemic shock with vasopressors alone, without replacing volume, increases the risk of severe end organ damage

• Additional monitoring data may help guide volume replacement

  • Consider placement of an arterial line for ABG and BP monitoring

  • Consider TEE or TTE examination for cardiac function and ventricular filling

  • Consider placement of a CVP line

• If patient is not responding to initial therapy, or major fluid resuscitation is necessary

• Call for help

  • Inform all team members of the situation and plans for resuscitation

• Anesthesia professional’s role

  • Primary anesthesia professional should focus on leading and coordinating team members

  • Obtain additional IV access if necessary

    • Consider IO line early if IV access is difficult

  • Place arterial line if appropriate

  • Monitor patient hemodynamics and level of anesthesia

  • Operate rapid transfusion devices or push blood

  • Help to draw ABG and labs

• Sugeon’s role

  • Identify and control source of bleeding

  • Surgeons may have to pause surgery

    • To allow anesthesia professional access to the patient to place an IV, CVP line, or arterial line

    • To allow time for volume replacement

    • To perform a necessary procedure (e.g., place a difficult CVP line or perform a cut-down for IV access)

• Nurses’ role

  • Call for more nursing and tech help

    • Charge nurse may help coordinate resources

  • Order and arrange transport of blood products from blood bank

  • Help to check and administer blood or blood products

  • Ensure that a rapid infuser system is available

  • Set up cell saver if indicated

  • Consider activating MTP if available

• Monitor venous access lines and sites

  • Check all IV and central lines for loose connections and leaks

  • Check IV site frequently for soft tissue infiltration, especially when fluid is being infused under pressure, as opposed to a drip IV set

• For massive transfusion of blood or blood products

• Activate MTP if available

  • Notify blood bank of situation and anticipated needs as they may need to seek out additional sources of products

• Order of preference for blood products

  • Type-specific (or type-compatible) crossmatched unit

  • Type-specific (or type-compatible) but not crossmatched unit (e.g., patient has been screened, but there is not enough time to complete crossmatching)

  • Uncrossmatched, type-O, Rh-negative unit (O-neg RBCs)

• If patient has received > 1 blood volume of emergency release blood products (O-neg RBCs), keep transfusing O-neg RBCs. Testing for antibodies must be completed prior to switching back to patient’s type-specific blood

• Transfuse blood and blood products through fluid warmer to avoid hypothermia

  • Washed PRBCs, platelets, FFP, and cryoprecipitate are usually at room temperature but also need to be warmed

• Coagulopathy during massive transfusion is primarily due to dilution of clotting factors and/or platelets but may be due to fibrinolysis or DIC

• Blood and blood product administration

  • Platelets

    • Monitor for thrombocytopenia and consider transfusion of platelets after 1 to 1.5 blood volumes have been lost

    • Replacement should be 10 to 15 mL/kg of platelets for each blood volume replaced

    • Hypothermia causes platelet dysfunction even with normal platelet counts

  • Factors

    • Initiate transfusion of FFP after 1 blood volume of RBCs has been transfused

    • Transfusion of RBCs and FFP should be at a ratio of 2:1 (RBC:FFP)

• Monitor labs and hemodynamics to guide therapy

  • Hematocrit

  • Platelets

  • PT/aPTT

  • Ca ²⁺

  • K ⁺

  • ECG tracing for evidence of electrolyte abnormalities

  • HR and BP

  • CVP

  • TEE/TTE

Complications

• Arrhythmias

• Coagulopathy/DIC

• Acidosis

• Alkalosis

• Hypocalcemia

• Hyperglycemia

• Hyperkalemia

• Hypernatremia

• Hypothermia

• Transfusion-related infection

• Transfusion reaction/ABO incompatibility

• Transfusion-associated graft-versus-host disease

• ARDS/TRALI

• Volume overload and hypertension

• Cardiac arrest

Definition

Anaphylaxis in the pediatric patient is an IgE-mediated response that is caused by exposure to an antigenic substance in a sensitized pediatric patient.

Etiology

Administration of, or exposure to, an agent that the patient has been previously sensitized to, with production of antigen-specific IgE

Typical Situations

• In patients with a known allergy or sensitivity to a specific agent or a history of atopy or allergy to nondrug allergens

• After exposure to substances that can trigger anaphylaxis

  • Neuromuscular blocking drugs

  • Latex

  • Antibiotics

  • Opioids

  • Protamine

  • Amino-ester local anesthetic agents

  • Blood and blood products

  • Iodinated contrast material

  • Chlorhexidine preparation solutions

  • Sedative-hypnotics

  • Colloid administration (e.g., dextrans, hydroxyethyl starch)

• Patients with frequent latex exposure

  • Patients requiring multiple reconstructive surgical procedures (e.g., myelomeningocele repair for spina bifida, patients with congenital genitourinary abnormalities)

Prevention

• Avoid agents to which the patient has a documented allergy

• Minimize the use of latex products in health care

  • If there is a history of latex allergy, establish a latex-free environment

    • Avoid contact with, or manipulation, of latex devices

    • Use nonlatex surgical gloves

    • Use syringe/stopcock methods or unidirectional valves for injecting medications

    • Do not insert a needle through any multiple-dose vial with a natural rubber stopper

      • Take the top of the vial completely off

      • Use the same medication from a glass ampule, if available

    • Use glass syringes as an alternative to plastic syringes with natural rubber seal on plunger (plastic syringes may use nonlatex seals—check manufacturer’s information for syringe materials)

• Obtain a careful history of previous allergic reactions, atopy, asthma, or significant latex exposure

• Avoid transfusion of blood or blood products whenever possible

• If a specific drug must be administered to a patient known to be at risk of an allergic reaction, administer prophylaxis

  • Corticosteroids, H ₁ antagonists

• Administer test dose of drug

• Obtain consultation from an allergist if a critical allergy must be defined

Manifestations

Anaphylaxis has the potential for acute onset with catastrophic consequences. Severe hypotension, increased peak airway pressure, and hypoxemia are the most common initial signs but need not be present simultaneously.

• Cardiovascular

  • Severe hypotension

  • Tachycardia

  • Bradycardia may be initial sign

  • Arrythmias

  • Cardiac arrest

• Respiratory

  • Hypoxemia

  • Decreased lung compliance

  • Severe bronchospasm

• Cutaneous—may be obscured by surgical drapes

  • Flushing, hives, urticaria, pruritus

• Swelling of mucosal membranes, angioedema, head and neck swelling

Similar Events

• Medication causing direct histamine release (e.g., morphine)

• Anesthetic overdose or medication error (see Event 72, Volatile Anesthetic Overdose , and Event 63, Drug Administration Error )

• Cutaneous allergy (rapid urticarial reactions)

• Bronchospasm (see Event 29, Bronchospasm )

• Hypotension from other causes (see Event 9, Hypotension )

• Pulmonary edema from other causes (see Event 20, Pulmonary Edema )

• Cutaneous manifestations of mastocytosis, carcinoid syndrome, hereditary angioedema

• Transfusion reaction (see Event 50, Transfusion Reaction )

• Cardiac tamponade (see Event 18, Cardiac Tamponade )

• Stridor (see Event 97, Laryngospasm )

• PE (see Event 21, Pulmonary Embolism )

• Vasovagal reaction

• Septic shock (see Event 13, The Septic Patient )

• Aspiration of gastric contents (see Event 28, Aspiration of Gastric Contents )

• Pneumothorax (see Event 35, Pneumothorax )

• Esophageal intubation

Management

• Stop administration of any possible antigen (e.g., discontinue antibiotics)

  • Retain blood products for analysis

  • Identify all latex products and remove from contact with the patient

• Inform the surgeons and call for help

  • Check to see whether they have injected or instilled a substance into a body cavity

  • Consider aborting surgical procedure if severe or there is no response to initial treatment

    • Anaphylaxis can be biphasic and can recur after successful initial treatment

• Ensure adequate oxygenation and ventilation

  • Administer 100% O ₂

  • Intubate the trachea if not already intubated

    • The airway can rapidly become edematous, making intubation more difficult or impossible

• Anaphylaxis is treated with epinephrine (the drug of CHOICE in anaphylaxis) and IV fluid

  • Epinephrine dosing and route—drug calculations are CRITICAL

    • For patients with profound hypotension or shock and a KNOWN working IV/IO line, administer epinephrine 0.5 to 1 μg/kg and increase rapidly up to 10 μg/kg as needed; maximum dose 1000 μg

    • For patients in early phase without profound hypotension, shock or cardiac arrest, or for those patients in which IV/IO access HAS NOT BEEN OBTAINED, administer epinephrine IM, 10 μg/kg q5-15m; maximum 300 μg per dose

      • Given difficulty in obtaining IV access in children, the IM dose is preferred by some anesthesia professionals and clinicians who deal with pediatric emergencies

• For cardiovascular collapse or cardiac arrest, give epinephrine IV, 10 μg/kg (see Event 94, Cardiac Arrest in the Pediatric Patient )

• Consider epinephrine infusion (20-200 ng/kg/min) with increasing dose to maintain BP

• Rapidly expand the circulating blood volume

  • Administer 10-30 mL/kg NS or LR

  • Immediate fluid needs may be massive

• Decrease or stop the administration of anesthetic agents if hypotension is severe

• If bronchospasm is present

  • Administer bronchodilator

    • Inhaled β-agonist (e.g., albuterol MDI)

    • Volatile anesthetic agents may be administered for bronchodilation if the patient is normotensive

• Administer H ₁ and H ₂ histamine antagonists

  • Diphenhydramine IV, 1 mg/kg up to maximum of 50 mg

  • Famotidine IV, 0.25 mg/kg, or ranitidine IV, 1 mg/kg IV

• Administer corticosteroids

  • Methylprednisolone IV, 1 to 2 mg/kg, or dexamethasone IV, 0.2 mg/kg

• In the absence of any other cause, consider latex allergy

  • Ensure all latex products in contact with the patient have been removed from the surgical field

• Consider placement of an arterial line and urinary catheter to help guide vasopressor and fluid management

• Obtain blood sample for mast cell tryptase levels within 2 hours to confirm the diagnosis of anaphylaxis

• Arrange admission to ICU for continued postoperative management

• Consider referring patient to an allergist on discharge from the hospital

Complications

• Hypoxemia

• Inability to intubate, ventilate, or oxygenate

• Hypertension and tachycardia from vasopressors

• ARDS

• Renal failure

• Cardiac arrest

• DIC

• Death

Definition

• Aspiration of a foreign body into the respiratory tract

Etiology

• Child placing a foreign body into the mouth

• Tooth dislodged into the airway

• Material left in the airway after a surgical procedure

Typical Situations

• Occurs in children between 7 months and 4 years of age with peak incidence at 1 to 2 years

  • Foreign body aspiration is a leading cause of death in children < 1 year of age

  • Food is the most common foreign body in the infant/toddler age groups

  • Incomplete dentition and immature swallowing coordination increase susceptibility

  • Nonorganic material, such as disc batteries, beads, pins, tacks, coins, and parts of toys are common in older children

• After a surgical procedure

Prevention

• Encourage home-safety programs to keep food and small objects out of the reach of unsupervised toddlers

• Perform laryngoscopy carefully

• Consider extracting loose teeth prior to laryngoscopy

• Double check that all materials placed in the airway are removed before extubation

Manifestations

• Cough

• Dyspnea

• Cyanosis

• Decreased breath sounds

• Tachypnea

• Stridor

• Wheezing

• Hemoptysis

• Hoarseness

• Fever

• Aphonia

• Recurrent pneumonia

• Physical examination may be normal

• Radiographic visualization of the foreign body or of air trapping, infiltrates, or atelectasis

  • The right mainstem bronchus is the most common site for a foreign body to lodge

  • Organic material may be poorly visualized on CXR

  • High-resolution spiral CT scan can characterize disease severity distal to the foreign body

Similar Events

• Recurrent pneumonia not related to aspiration of a foreign body

• Foreign body in the esophagus

• Laryngospasm (see Event 97, Laryngospasm )

• Croup

• Anaphylaxis (see Event 16, Anaphylactic and Anaphylactoid Reactions )

Management

• Obtain history of onset of symptoms from witnesses

• Check the O ₂ saturation

  • Ensure adequate oxygenation and ventilation

    • This may not be possible until foreign body is removed emergently

• Confirm the diagnosis of foreign body aspiration

  • Perform a physical examination of the airway and chest

    • Examine upper airway anatomy

    • Check for uniformity and symmetry of breath sounds and adventitious sounds (e.g., bronchospasm)

  • Obtain a CXR looking for the presence and location of a foreign body

    • Air trapping

    • Atelectasis

    • Pneumonia

    • Postobstructive airway collapse

    • Overexpansion

• Anesthetic Induction for the Patient with a Foreign Body Aspiration

• Discuss the surgical approach and method of ventilation with the team in advance

  • In addition to an ENT surgeon, consider consultation with a cardiothoracic or general surgeon depending on location and severity of foreign body obstruction

• Obtain IV access

• Cardiovascular collapse may occur in response to movement of the foreign body causing severe hypoxemia

  • Consider the potential need for ECMO or CPB

    • Plan for this early as it takes time to set up

• Preoxygenate the lungs prior to induction of anesthesia

• Complete airway obstruction may occur at any time, and rigid bronchoscopy must be performed immediately to remove the obstruction or dislodge it to another site that permits ventilation

• Perform an inhalation induction with sevoflurane and 100% O ₂

  • Controlled or spontaneous ventilation may be appropriate, depending on the location of the obstruction and the surgical approach

  • IV induction may be an acceptable alternative, depending on the clinical scenario

• Following induction of anesthesia, the bronchoscopist should intubate the trachea with a ventilating bronchoscope in order to remove the foreign body

  • There may be increased resistance to ventilation when a telescopic lens is inserted through the bronchoscope

  • Ventilation may need to be alternated with attempts to locate and remove the foreign body

• Facilitate passage of the foreign body through the laryngeal inlet

  • Maintain an adequate depth of anesthesia to prevent patient movement or coughing

  • Total IV anesthesia will maintain a consistent level of anesthesia during frequent circuit interruptions

  • Consider administering a small dose of a short-acting muscle relaxant just prior to removing the foreign body

• If the foreign body cannot be removed through the bronchoscope and ventilation is inadequate, an emergency thoracotomy and bronchotomy may be necessary

• Examine the tracheobronchial tree after removal of the foreign body

• Following endoscopic examination, intubate the trachea with an ETT or allow the patient to awaken with a natural airway

  • The usual criteria for awake extubation should be applied

  • Allow the child with a natural airway to completely emerge prior to movement to the PACU

Complications

• Hypoxemia

• Hypercarbia

• Laryngospasm

• Pneumonia

  • Chemical pneumonitis

  • Bacterial infection

• Hypotension

• Massive hemoptysis

• Severe bronchospasm

• Pneumothorax

• Airway rupture

• Pneumomediastinum