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60 Anaesthesia and Perioperative Care

recovery room and should be returned to the ward only after regaining Laryngospasm and bronchospasm may occur, especially if tracheal
full consciousness and protective reflexes. They should be pain-free, intubation is attempted under light planes of anaesthesia. Hypothermia
comfortable, have stable vital signs, and there should be no active and hypoglycaemia are common in preterm neonates and newborns of
bleeding from the surgical site. diabetic mothers. Bradycardia, when it occurs, is a late sign and should
Perioperative Anaesthesia Complications be promptly treated with atropine. Nausea and vomiting, postoperative
bleeding, pain, and emergence delirium following ketamine anaesthesia
Complications may occur during anaesthesia and in the immediate
are other complications that may be seen in the postoperative period.
postoperative period. The commonest complication is airway obstruc-
These can be recognised only by careful monitoring and should be
tion from failed or difficult intubation, wrong positioning, mucous plug,
treated promptly.
blood clot, or subglottic oedema following endotracheal extubation.
Most healthy children do well, have an uneventful stay in the PACU,
Table 10.3: Evidence-based research. and are quickly reunited with their parents. The need for adequate
recovery room nursing care should always be emphasized for the
Title Sedation with ketamine for paediatric procedures in the
emergency department: a review of 500 cases paediatric surgical postoperative patient. The anaesthesia care provider
must be readily available in case of a cardiorespiratory event and be in
Authors Ng KC, Ang SY
a position to respond quickly with a resuscitation trolley, which should
Institution Department of Emergency Medicine, K K Women and be located in this area of the theatre suite.
Children Hospital, Singapore
Reference Singapore Med J. 2002; 43(6):300–304 Evidenced-Based Research
Problem The severe shortage of anaesthesia providers in Tables 10.3 and 10.4, respectively, present a review article on the use
most developing countries leaves the surgeon in the of ketamine in children and a discussion of using ketamine in and out
unfortunate position of doubling up as the anaesthetist or of the operating room.
using supervising nurses to administer anaesthesia. In
this environment, ketamine has proven itself as a good Table 10.4: Evidence-based research.
anaesthetic agent with a commendable safety profile.
Familiarity with ketamine would seem to be necessary to Title Ketamine: a new look at an old drug
practice anaesthesia in Africa.
Authors Raeder JC, Stenseth LB
Comparison/ This is a review article. Institution Department of Anesthesia and General Practice Medicine,
control Ullevaal University Hospital, Oslo, Norway
(quality of
evidence) Reference Current Opinion in Anaesthesiology 2000; 13(4):463–468
Problem Although ketamine has proven itself to be a safe general
Historical This review article discusses the effectiveness of ketamine anaesthetic in poorly equipped conditions, recent research
significance/ for sedation in children during painful procedures. The suggests more uses both in and out of the operating room.
comments authors reviewed the use of intravenous and intramuscular
ketamine in 500 children for procedures ranging from repair Historical This article discusses how the clinical uses of ketamine
of lacerations, manipulation and reduction of fractures, significance/ have expanded beyond dissociative anaesthesia to its
incision and drainage of abscesses, to removal of foreign comments effects on immunofunction and more exploration of its
bodies. Ninety-six percent of their patients experienced no analgesic effects. The role of the N-methyl-d-aspartate
adverse effect with the use of ketamine and were discharged (NMDA) receptor in analgesia, wind-up phenomena, and
to home well. Only one patient had adverse effects and had possible opioid tolerance hints at more uses for ketamine.
to be admitted overnight. They conclude that ketamine is a
relatively safe and effective drug for use in children.

Key Summary Points

1. There are many cardiovascular, respiratory, and renal 4. A trained paediatric anaesthesia care provider will need
physiological differences between a neonate and an adult specialized anaesthesia training and skills to decrease the high
surgical patient. complication rate seen in paediatric surgical cases.
2. The neonate is more prone than an adult to cardiovascular and 5. Paediatric patients require supplies and equipment
respiratory complications in the perioperative setting. appropriately suited for their size and anatomical differences.
3. Fasting guidelines for the paediatric surgical patients need to
be strictly followed to avoid complications.

References

1. Ryan JF, Cotes CJ, Todres ID, Goudsouzian N. A Practice of 3. Rusy L, Usaleva E. Paediatric anaesthesia review. Update in
Anaesthesia for Infants and Children, 1st ed. Grune and Stratton Anaesthesia 1998; 8:2–14.
Inc., 1986.
2. Cherian VT, Jacob R. Recognition and management of the difficult
paediatric airway. In: Jacob R, ed. Understanding Paediatric
Anaesthesia, 2nd ed. B.I. Publications, 2008.