The Deteriorating Child
– what is our vector,
Victor?
Adam Skinner
Staff Anaesthetist
Royal Children’s Hospital
30th July 2015
Aims
 Review anatomical and physiological differences
between adults and children and link with clinical
features seen in children in recovery.
 Discuss the (my) thought process when managing
acute hypoxia and bradycardia in a child.
 Discuss ViCTOR and its current practical role in
recovery.
Children vs Adults
 Airway differences
 Oxygen balance differences
 Cardiac differences
Children vs Adults
 Airway differences
 Oxygen balance differences
 Cardiac differences
The ‘Normal’ Airway
Adult
Infant
Holding an Airway
Airway Oedema
Laryngospasm
Children vs Adults
 Airway differences
 Oxygen balance differences
 Cardiac differences
Demand vs Supply
Oxygen Consumption
Demand vs Supply
Oxygen Uptake
 Respiratory Drive
 Rib Cage and diaphragm mechanics
 Volumes and Elastic forces
Oxygen Uptake
 Respiratory Drive
 Rib Cage and diaphragm Mechanics
 Volumes and Elastic forces
Oxygen uptake – Respiratory
drive
 Immature Respiratory Centre (Neonates)
 Opioid Sensitivity
 Neonates
 Genetics
 Co-morbidity (eg CP, OSA)
Opioid sensitivity - codeine
Codeine Variability
Oxygen Uptake
 Respiratory Drive
 Rib Cage and diaphragm Mechanics
 Volumes and Elastic forces
Chest Mechanics
Chest wall differences
Infant
Adult
Oxygen Uptake
 Respiratory Drive
 Rib Cage and diaphragm Mechanics
 Volumes and Elastic forces
Elastic Forces
Cardiac Differences
Bradycardia– GIVE
OXYGEN!!
Scenario 1:
 5 year old 23 kg in recovery for tonsillectomy for
obstructive sleep apnoea.
 Rapid desaturation to 60%, cyanosed
Initial Action
 Buzzer
 Mask, T-Piece
 100% OXYGEN
 Position Patient and airway
 Inflate lungs
Scenario 1
 Can’t inflate lungs
 Why?
 What do we need?
 Who do we need?
Laryngospasm
Scenario 2:
 5 year old 23 kg in recovery for tonsillectomy for
obstructive sleep apnoea.
 Saturation 78%, shallow breathing.
Initial Action
 Buzzer
 Mask, T-Piece
 100% OXYGEN
 Position Patient and airway
 Inflate lungs
Scenario 2
 Able to inflate with temporary improvement in
saturations
 What is going on?
Maybe difficult to diagnose in
children
Scenario 3
 5 year old 23 kg in recovery for tonsillectomy for
obstructive sleep apnoea.
 Noted on monitor to be bradycardic at 60 beats per
minute.
 How do we assess and manage?
Initial Action
 Buzzer
 Mask, T-Piece
 100% OXYGEN
 Position Patient and airway
 Inflate lungs
Are we starting CPR?
What is normal?
Arch Dis Child. August 2015
Normal Values
What is ViCTOR?
What is ViCTOR?
 National Standard 9: Recognition and
response of the deteriorating patient
 Key element - recording of patient
observations
- greater emphasis on ‘Human Factor’
principles in the design of charts
Paediatric Clinical Network Initiative
Examples of Track and Trigger Charts
1 – 4 year old Observation and Response Chart:
Service
Normal Range
(white area)
RESPIRATORY RATE
MET or CODE trigger point
Clinical review
trigger point (high)
RCH *trial chart
20 – 40
41
High 56 / Low 16
Eastern Health
21 – 30
31
High 36 / Low 11
Barwon Health
20 – 40
41
Highest 60 / Lowest 15
* 3 tier escalation
Bendigo Health
21 - 35
36
Highest 41 / Low 14
The Alfred
21 – 49
50
High 60 / Low 15
Austin Health
20 – 40
41
Highest 60 / Lowest 20
* 3 tier escalation
NSW
20 – 40
41
Highest 60 / Lowest 15
* 3 tier escalation
SA
20 – 34
35
Highest 40 / Lowest 12
* 3 tier escalation
5 age groups
• 0 - 3 months
• 3 - 12 months
• 1 - 4 years
• 5 - 11 years
• 12 - 18 years
Paediatric Clinical Network Initiative
Percentile curves for HR and RR in hospitalized children
Bonafide C P et al. Pediatrics 2013;131:e1150-e1157
©2013 by American Academy of Pediatrics
What is the point of ViCTOR
for recovery?
What is the point of ViCTOR
for recovery?
 “Tool for communication and justification”
 Sharon Kinney PhD, RCH.
 Forces the team to consider the patient with objective
measurements (IN CONTEXT) outside ‘normal’ EARLY.
 Provides communication framework between specialities,
wards and hospitals.
 Mandates response in a timeframe with suggested roles.
 At the moment we use it in PACU just before transfer.
Summary
 Physiology link with Clinical Interpretation
 By recognising human factors we can better recognise
and managing critical incidents in recovery as a team.
 PRACTICE with multi-disciplinary scenarios if possible!