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Anaesthesia for Paediatric Laparoscopy

Aparna Deshpande
 

Introduction
Today is the era of minimally invasive surgery.
Most of the Paediatric Surgeons are well versed with laparoscopic surgery. Parents are also aware of it and demand it for their children due to obvious advantages such as minimal scarring, faster postoperative recovery, less pain and shorter hospital stay.

Preoperative evaluation
Parents fear anaesthesia more than surgery. The anaesthetist must visit the child on previous day and explain to the parents about anaesthesia, nil by mouth period and premedication. One should check out all the investigations and if surgery is major or supramajor that the postoperative ICU and arrangement for blood is made. Fitness from the child’s paediatrician should be checked also.

Preoperative evaluation of the child is important to ensure smooth course of anaesthesia. The minimal investigations required are
Weight
Complete blood count
Urine routine
X-ray chest

For major surgery
Total body profile
S. electrolytes
Blood grouping and cross matching

Premedication is given 45 minutes before the procedure and includes either of Vallergan, Tricloryl, Ketamine or Midazolam to be given orally according to the weight of the child. We prefer Syp. Trichoryl 50 mg/kg and atropine 0.04 mg/kg to be given orally 1-2 hours before induction.

Techniques
Local anaesthesia
Local anaesthesia with IV or IM ketamine
General anaesthesia – endotracheal tube, mask and airway or laryngeal mask
Regional anaesthesia – spinal, caudal or epidural
In children general anaesthesia with endotracheal intubation is preferred. It is 1) safe, 2) the duration of surgery may be prolonged, 3) the operation may be converted to open surgery and 4) head low or head high position may be required depending on the surgical procedure.

Monitoring
E C G
Pulse Oxymetry
End tidal CO2
BP monitoring
Temperature monitoring
Warming blanket

Induction
Children hate needles
Intubation using mask on JR circuit with halothane/isoflurane/sevflurane and O2.
Intravenous with ketamine / propofol / pentothal
Intramuscular ketamine
Per rectal

Procedure
The child is taken well sedated to OT. JR circuit mask is held with halothane, O2 / isoflurane. IV is secured with angiocath and bivalve. Atropine or glycopyrrolate is given. Ketamine 1-2 mg/kg, pentothal 2-4 mg /kg, propofol 1-2 mg/kg is used. For prolonged procedures intubation with appropriate endotracheal tube is performed after giving scoline 1-1.5 mg/kg, atracurium 0.5 mg/kg or norcuron are used. Ryle’s tube is inserted for prolonged procedures. After endotracheal intubation the ET tube is connected to Ohmeda/Boyle’s machine/respirator which is adjusted according to weight. The tidal volume is 10 ml/kg

Total intravenous maintenance, epidural anaesthesia techniques can be used in older children. Any change in monitoring is told to the surgeon so that the gas flow is reduced.

Intravenous fluids – 2-5 ml/kg for minor, 4-6 ml/kg for major and 8-10 ml/kg for supramajor are given. IV sets with microdrip or burette sets are used.

Complications
Bradycardia
Hypercarbia
Hypoxia
Hypertension
Hypotension

If at any stage there is any complication not responding to treatment, laparoscopic approach should be abandoned and surgery is converted to open.

Termination
At the end of the surgery all the inhalation gases are shut off. Oxygen is increased. Local anaesthesia 0.25% sensorcaine is injected at the port site along with zonac or paracetamol suppository. After extubation the child is kept in the recovery and pulse, respiration, temperature and oxygen saturation are monitored. Once the child is well awake then only he is shifted out of recovery to the respective ward. Patients are kept in postoperative ICU if surgery is prolonged, major or supramajor or if the child is sick.

 

PEFG FOR PANCREATIC CANCER

‘PEFG might be a feasible and effective first-line treatment for patients with locally advanced or metastatic pancreatic adenocarcinoma’

Pancreatic adenocarcinoma is associated with a poor prognosis. In the June issue of The Lancet Oncology, an Article by Michele Reni and colleagues compares the effects of gemcitabine with those of cisplatin, epirubicin, gemcitabine, and fluorouracil (PEFG) in 52 patients with advanced pancreatic carcinoma. They found that patients allocated PEFG had better progression-free survival and overall survival compared with those allocated gemcitabine, and conclude that PEFG could thus be considered for treatment of advanced pancreatic adenocarcinoma. In a linked Comment, Matthew Kulke discusses the Article in the context of other clinical trials for this disease.

Lancet, 2005; 6 : 369-76, 352-53.

Honorary Consultant Anaesthetist, Bombay Hospital, Mumbai.
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