% vol = 14 number = 4 prevlink = 171 nextlink = 178 titolo = "THE PATHOLOGIES OF CHILDHOOD TREATED IN OUR CENTRE AND SOME SPECIFIC FEATURES OF ANAESTHESIA " volromano = "XIV" data_pubblicazione = "December 2001" header titolo %>
SUMMARY. A panoramic view is given of the surgical pathologies of childhood treated in the Clinic of Burns and Plastic Surgery in Tirana, Albania. Three main groups of surgical pathologies are evident: consequences of burns and trauma, surgical treatment of burns, and surgery of avulsion trauma. The children were divided into groups according to age. The observations indicate that more than half of the interventions concerned the age group 5-14 yr. The article pays particular attention to the types of anaesthetic techniques used. Emphasis is laid on the selection of medicaments for pre-medication, induction, and maintenance of anaesthesia.
In the Clinic of Burns and Plastic Surgery at the Tirana University Hospital Centre, we treat a variety of child pathologies, including burns, their consequences, traumatic wounds, and congenital anomalies.
While anaesthesia for the various procedures of plastic surgery varies little from those seen in general surgery, in the treatment of paediatric patients certain specific features are of great importance. The evaluation of the childs pre-operative condition and of the surgical procedure required helps the anaesthesiologist to adopt the appropriate anaesthetic technique according to the necessities of individual cases.
The establishing of a correct relationship with the child and his or her family, characterized by co-operation and confidence, is also of great significance in burn situations that may continue for years.
This study analyses 739 children operated on in our clinic during the three-year period 1998-2000. The cases are divided into three groups:
The interventions were evaluated statistically according to the patients age group and the three types of anaesthesia used (Tables I, II). Interventions in childhood make up approximately one-third of the total number of interventions performed annually in our clinic.<% createTable "Table I","Types of intervention according to age group","§1,5§Age group@;#Intervention;#0-1 yr;#1-5 yr;#5-14 yr;#Total@;Plastic surgery;30;190;290;510@;Burn surgery;16;84;54;155@;Emergency surgery;0;16;59;74@;Total;46 (6.2%);290 (39.2%);403 (56.6%);739","",4,300,true %> <% createTable "Table II","Anaesthetics technique according to age group","§1,5§Age group@;#Anaesthesia;#0-1 yr;#1-5 yr;#5-14 yr;#Total@;Local anaesthesia;0;2;40;42@;Intravenous (ketamine);22;256;284;562@;Intravenous (thiopental);0;3;17;20@;Inhalation (halothane + O2);21;12;11;44@;Endotracheal;3;17;51;71@;Total;46;290;403;739","",4,300,true %>
Table I presents an analysis of the surgical pathologies dealt with. Out of the total number, 510 (69.0%) of the interventions were in the field of plastic and reconstructive surgery, 155 (20.9%) in burns surgery, and 74 (10.1%) in emergency surgery. More than half of the interventions concerned the third age group (5-14 yr).
In the first group of plastic surgery (age, 0-1 yr), the children mainly presented for congenital anomalies, while in the other age groups they mainly came for the reconstruction of late consequences of burn or trauma.
In the group of patients undergoing burn surgery, two main surgical procedures were performed: early necrectomy and skin grafting. This group also included all cases that needed amputations after electrical burn.
The third group (emergency surgery) consisted of cases with traumatic avulsions and gun-shot injuries. The age group most affected was that of 5-14 yr.
Table II presents the different anaesthesia techniques used in the three age groups. Our results show the use of inhalation anaesthesia in the youngest age group (0-1 yr). With growth of the child there was a greater possibility of using intravenous and endotracheal anaesthesia. The 5-14-yr age group offered the greatest possibilities for using nearly all available anaesthetic techniques.
As said, we divided our patients into three groups according to the surgery performed:
In our discussion we shall concentrate on two moments: pre-operative evaluation and anaesthesia (pre-medication, induction, and maintenance of anaesthesia).
Pre-operative evaluation. The successful performance of plastic surgery operations requires close co-operation between anaesthesiologists and surgeons. It is necessary to be aware of the bilateral risks involved and to alleviate problems that may arise during the peri-operative period.1,2
For children in the first group, the pre-operative evaluation includes:
During anamnesis taking, we should first pay attention to the childs present medical condition, the pathologies presented, previous anaesthetic experience, and the existence of peri-natal problems such as asphyxia, apnoea, or bradycardia. Children who have had these problems run a higher risk of apnoea after surgery.
We must here consider an important point. Anaesthesia in a child with a running nose is a problem that needs differential diagnosis. It is necessary to distinguish between infection and allergy. We believe a child should be operated on two weeks to one month after treatment. If the child is subjected to surgery without these measures, there is a high probability of laryngospasma during the induction of anaesthesia, owing to irritation of the airways.4,5
With regard to laboratory tests there are three essential analyses: complete blood count, coagulation analysis, and definition of the blood group.
In children with other concomitant diseases it is also necessary to perform a biochemical examination of the blood and a radiological examination of the lungs. In certain operations in which considerable loss of blood is expected, it is important to secure a blood donor.
In the second group of burn surgery patients, the pre-operative evaluation includes the following considerations:
Children with more than 10% TBSA burned require not only surgical treatment but also careful attendance from the anaesthesiologist in the first 48 h (shock phase) and later during the septic phase in order to minimize post-burn complications.
In the evaluation of the correct moment for intervention, we insist on the stabilization of the haemodynamic, electrolytic, acid-base, and haematological balances.6 In particular, we try to maintain haemoglobin > 10/dl and haematocrit > 30 g/% with the aim of preventing and correcting burn anaemia.
Careful reanimation must be followed by a thorough evaluation of the proper time for debridement or coverage of the wounds. Generally speaking, such children require several interventions. Burn traumas need a long period of treatment and also predispose children to multi-organ failure. The childs overall prognosis depends on the success of the surgical intervention.
In the third group of emergency surgery, the most important thing to do is to prepare the child for the operation. The child may present acute or chronic concomitant diseases. He may have a full stomach. The anaesthesiologist makes an anamnesis and performs appropriate hydric and haemodynamic stabilization of the child, opting for the least traumatic procedure. These patients are usually operated upon in two stages. The first operation consists of debridement performed with superficial anaesthesia, while the second operation requires deep anaesthesia for better tissue reconstruction.
Anaesthesia. We shall now discuss the principal moments of anaesthesia: pre-medication, induction, and the maintenance of anaesthesia.
Pre-medication. We perform pre-medication in the presence of one parent. The route of administration is intramuscular, 30 min before the intervention. The most practical combinations are atropine and diazepam or atropine and fentanyl (this last combination in older children). The aim of this pre-medication is:
We prefer the intramuscular route, which satisfies our needs.
The emotional state of children differs from age group to age group. Children aged 0-5 yr stay close to their parents. After pre-medication they seem quiet. Children aged 5-14 yr need friendly behaviour on the part of the anaesthesiologist, a careful explanation of the intervention, and - if possible - their willing acceptance.
The doses of the medicaments are as follows:
NB: Atropine should be avoided when possible in febrile children as the body temperature may be further increased.
Induction and maintenance of anaesthesia. Anaesthesiologists must select the type of anaesthesia according to the timing and the difficulties of the intervention. For shorter procedures in which there is no change in position and considerable loss of blood is not foreseen, we use ketamine, which is a good cardiovascular stabilizer. In longer procedures we prefer general endotracheal anaesthesia after induction with ketamine or thiopental Na followed by reduced doses of myorelaxine.7,8
In children aged 0-1 yr we perform mainly two types of anesthesia. Induction is the same in both: ketamine i.m. 25-50 mg. The child is rapidly disoriented, does not cry, and is sedated. In the operating room we immediately perform venous catheterization and begin maintenance of anaesthesia. This is done according to the anaesthesiologists preference: inhalation or intravenous anaesthesia. Inhalation anaesthesia is performed with nitrous oxide, oxygen, and halothane, while intravenous anaesthesia is done mainly with ketamine.
In many cases we also perform inhalation anaesthesia for induction and maintenance. The patient is induced to sleep by breathing a mixture of halothane and oxygen via a close-fitting mask, with a progressively increasing concentration of halothane 0.5% every 4-5 respirations. Halothane is well tolerated and gives rapid induction at a concentration of 3%, reduced to 2% for maintenance. When available, nitrous oxide is commonly used for analgesia. Supplementary oxygen is mandatory when using halothane in order to avoid hypoxia.
Endotracheal anaesthesia in this age group is generally reserved to patients with congenital anomalies. Table II shows that these cases were few in number.
In children in the 1-5 and 5-14 yr age groups we applied intravenous anaesthesia with ketamine in the induction and maintenance of anaesthesia. Ketamine is frequently described as a unique drug because it is hypnotic (sleep-producing), analgesic (pain-relieving), and amnesic (causes short-term memory loss). A dose of 1-2 mg/kg is required for induction of anaesthesia and this should be given slowly. Surgery can start two minutes after injection with anaesthesia lasting 10-15 min. If the duration of anaesthesia needs to be extended, further doses of 0.5 mg/kg may be given when the depth of anaesthesia decreases.
In all, 562 patients were subjected to plastic and reconstructive surgery. In this type of anaesthesia the use of fentanyl at doses of 12.5-25 micrograms during maintenance of anaesthesia reduced the side effects of ketamine and induced an equilibrated reawakening. We also used general endotracheal anaesthesia, especially in the third age group. This group had better tolerance and presented clinical and laboratory features similar to those of adults. The doses of medicaments were calculated according to age.
During anaesthesia the monitoring of the child must include vital signs, temperature, and urine output. Invasive monitorization may be necessary. In severe situations we performed vesical catheterization in order to control i.v. therapy and to prevent pulmonary oedema.
In children with massive burns we also applied a second venous route that was ready for use in critical moments for the increase of the amount of liquids. Correction of loss of blood at the proper time and in proper amounts prevents anaemia, which has severe effects not only locally but also in the general prognosis of the burned child.
We shall now briefly mention some important moments that influence the normal course of anaesthesia.
Burn pathologies. In severe burns with high TBSA it is advisable to avoid surgical intervention during the shock phase (i.e. the first 48 h). We perform necrectomy (releasing incisions) only in cases with deep circumferential burns, using a superficial anaesthesia. This intervention is performed in order to improve circulation to distal extremities or to permit adequate breathing if the chest wall is burned. In such cases the patient is first reanimated and when circulation is stabilized he is taken to the operating room without any necessity of standard pre-medication or induction.
Necrectomy or the coverage of wounds with skin grafts needs clinical stabilization of the child and a precise plan for surgery and anaesthesia.9 The surgery plan consists in the determination of the zones of excision and their surface. The anaesthesiologist calculates i.v. therapy (liquids, colloids) and blood loss with the aim of precise replacement. In the evaluation of the patient, the altered pharmacokinetics of the burned child must be taken into consideration:
Although the anaesthesia used is deep, the intervention should not be traumatic - the anaesthesiologist must advise on the continuation or suspension of the procedure.
The days following total recovery of the child are the time for planning a second possible intervention, according to specific indications.
Electrical burns, in several cases, require amputations of the extremities at different levels.10 The anaesthetic technique depends on the level of the amputation and the childs medical condition. Amputations in the femoral, brachial, or axillary region require long and deep anaesthesia.
Contractive pathologies of the neck and flexor part of the articulations
Contractures of the neck create extreme problems during anaesthesia. They cause anatomic disorders and difficulties in intubation, from opening of the mouth to possible movements of larynx. When it is impossible to perform a normal procedure, we recommend release of the contracture under local anaesthesia, after use of total anaesthesia. During these procedures the anaesthesiologist must prevent precocious extubation when the patient is moved. Interventions in the neck must be regarded as operations causing massive haemorrhage, and it is therefore necessary to dispose of reserve supplies of blood for every eventuality.11
In pathologies of the flexor part of the articulations, the anaesthesiologist must avoid placing venous catheters near the operation field. He should also endeavour to place all the patients body in a physiological position in order to ensure a better and more normal intervention.
Congenital craniofacial anomalies
Congenital craniofacial anomalies requiring reconstructive surgery are part either of a syndrome or of a concomitant anomaly. In their assessment the anaesthesiologist must perform not only a careful anamnesis but also consider the possible inclusion of other specialists in the team. The most frequent anaesthetic problems are haemorrhage, the continuity of respiratory airways, and the existence of possible advance intracranial pathology. We prefer inductive hypotension with a gradual increase to normal values.
In patients with haemangioma, we must bear in mind the fact that even minor surgery can lead to a massive haemorrhage.12
Repair of the lips and palate requires the anaesthesiologist, as always, to keep the airways unobstructed and to prevent gastric regurgitation. These manipulations are performed in the operative field. For intubation we use an RAE tube over the face.13,14 During these interventions we must consider the presence of cardiac diseases as part of the syndrome, the possibility of haemorrhage, and the non-use of halothane together with adrenaline.15
Especially in severely burned children, we believe in the necessity of vigorous emotional support from the anaesthesiologist. Maximum understanding and care are necessary, beginning from the very first moments of reanimation and continuing throughout the course of the disease. This includes repeated catheterizations, treatment of pain during everyday medication of the wounds, and even recurrent anaesthetic procedures.
After improvement of the childs health, we attend to him regularly in order to observe the results of our treatment and to plan future interventions, if necessary. We now have established a good understanding with the child and he is aware that we are doing all our best for him.
RESUME L'Auteur présente un examen panoramique des pathologies chirurgicales de lenfance traitées dans la Clinique des Brûlures et de la Chirurgie Plastique à Tirana (Albanie). Il y a trois groupes principaux évidents de pathologies chirurgicales: les conséquences des brûlures et des traumatismes, le traitement chirurgical des brûlures, et la chirurgie des traumatismes causés par lavulsion. Les enfants ont été divisés en groupes selon lâge. Les observations indiquent que plus de la moitié des interventions chirurgicales concernaient le groupe des enfants âgés de 5 à 14 ans. LAuteur considère en particulier les types et les techniques anesthésiques employés et souligne la sélection des médicaments pour la prémédication, ladministration et la continuation de lanesthésie.