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Good evening, everybody and welcome to another with academic lecture but um presented by Cigar Anesthesiologist, Cigars, resurgent Regroup Group of Africa. And my name is Dr KK Collins. I am the anesthesiology team leads and we are here with a lecture title. The unique challenges of providing anesthesia care to Children. And it will be presented by our speaker, Doctor Zipporah, got diarrhea CCP, pediatrics, anesthesia from Kenya. Um mom, please. You have the flow. Thank you. Thank you very much. I hope you can hear me. Collins. Can you hear me? Yes, I can hear you ma. Okay. So today we're going to talk about unique challenges of providing, providing anesthesia, careful Children. I'll start by saying that I serve on the Global Medical Advisory Board for Smile Train. I'm the Secretary for Global Initiative for Children Surgery and I'm gonna Nestea Jha volunteer for Children Surgery International. I have done a lot of work in pediatric anesthesia and now I'm doing a lot of work in public health as well. So this lecture is going to be divided into two parts. The first one is a clinical pediatric anesthesia and the other one is what I would call the public health clinical anesthesia. We'll go through this with these objectives. The first objective is to outline the challenges in pediatric anesthesia as a clinical specialty from an anatomy, physiology, pharmacological, cognitive, social and emotional aspects. And then to outline the challenges of pediatric anesthesia from a public health outlook, infrastructure, equipment and supplies workforce uh to propose ways of dealing with this and to outline how such solutions can be achieved. I'm sure you have had a lot of times uh many times that I use in dealing with Children and a lot of lay people are not very sure of what each means. So this I'm sure is something that you do very well. Uh But we use the term newborn for the 1st 24 hours. We say uh units after 28 days in front, after one year and uh some babies will be gestational age, uh 37 to 42 premature babies are less than 36 weeks, gestational age. And these are important when you're giving anesthesia to Children. And, and uh you'll see why when we come to core duct of anesthesia, the conduct of anesthesia for these Children equitable level, you classify them must be preceded by meticulous, very operative preoperative evaluation with history, uh physical examination and investigation. Why is this important? Uh most of the time when you have experiment yours? And I'll figure out extreme assures when a baby is born at 32 weeks and they go home, people start counting at that time. So they will come back after a month. Uh The gestational age will be 36 but the parents will tell you that this baby is a month old. So unless you're taking history to find out was this, they'd be born at term. You will miss a very significant part of your history. So you need to know how was, especially for the baby's uh less than six months before they catch up growth. You need to know what they born at time. What was the mode of delivery and why? Because sometimes you fight, they will tell you was born by Cesarean section and when you try to find out why they will say it was prolonged labor. Uh and then, oh there was meconium staining and all these have bearing for you as anesthesia in you need to take a history. And no, was this baby supported respiratory wise at the Peri Peri Natalie? So you will find that a baby was born at time. But if you don't ask, they will not tell you that the baby was put on the ventilator because they're happy that the people went home. And then maybe this is a kid who was intubated for a long time in NICU and you're coming to intubate and then you have track you stenosis. So there are many things that you can get from taking a good history and a physical examination the two systems that you must pay meticulous attention to respiratory system and cardiovascular system and the airway assessment. Let's remember that you need a prone to hypothermia and hypoglycemia. So you have to be wary about that. Even as you prepare, uh they're common concepts in pediatric anaesthesia. We shall not go into details with all of them, but we have while pre operative fasting. Uh This is uh the guidelines, how many hours NP you the Children must be again for, for pediatric anesthesia. It's interesting because we very well know, therefore, uh they're 64 to rule, but you find that sometimes you have noon, it's who are being fed every three hours for some other medical conditions for the like. And if you say that you're starving them for four hours, then they will be uh totally over starved. So it is good as you take your history to know how often does the baby feed so that you plan, how soon you're going to feed them the risk of uh aspiration. Uh The other controversy that comes, they're especially with the parents is the depreciation between uh formula milk and breast milk. And you know that these two have different times in terms of preoperative fasting guidelines. So you have to be careful about that pre medication. If you choose to use pre medication, then you need to be wary and know that you have to monitor those patients'. The other common thing is about pain control. Uh, there had been concepts that people teaching that new needs don't feel faith, but current research shows that they do feel pain and you're encouraged to do proper pain management. Even for all the Children. I said that sometimes, you know, set up, uh, pain for Children is badly managed and we have to take charge is pediatric and it's easier providers to do that uh, in an appropriate manner. Then in the code acct of anesthesia, we talk about induction. Are we doing uh gas induction or IV induction? You need to be aware about that. How are we maintaining our anesthetic? What are we using for reversal and the all important monitoring throughout the period of from before you induced to the time you said the ca pacu and also monitoring in pacu. When we talk about anatomy there, specific things that are important, specific for units and that are very different from the adult or the bigger tells. And we'll talk about this a little bit. They have a large head and a small neck with poor neck, muscle control. So that means they're floppy. You have to be very careful when you're doing your intubation and sometimes it can be a difficult intubation if you're not careful about how to do, remember that uh units, uh obligatory nesa breathers with the narrow nurse. So any form of obstruction of the laws will cause trouble for you. So you have to make sure that is you put them to sleep, that you've cleared the nurse and even if you have to put drops so bad, you don't have a problem with that. They also have a large time with large fluffy epiglottis which may present as uh difficult in intubation. The larynx are higher. Uh The three units coming down to about C four C five by six years and the normal adult position of 65, C five, C six uh is where it is, the length of the track is short. So that means the uh the amount of tube that you would inside must be very little. Otherwise you do the bronch, your education and they have a narrow cricoid uh diameter, which means that any amount of swelling of the larynx will be multiplied many times over. I'm sure you've seen that diagram about. Uh So any take in the diameter of the cricoid would increase, the pressure is very high. When you talk about the core duct of anaesthesia, you must remember about preparation, preparation, preparation. These Children who don't have a lot of breeds out. So, uh if you're not well prepared, they may not give you a lot of chance. So as you go to your operating room, you must think about how you're going to uh to prepare your theater, have appropriate sized equipment and supplies, including needles and syringes. I don't know whether where you come from, you have this problem where you go into the ore. And the only series is there are 10 CC syringes and you need to give uh to mix of fentaNYL. So uh uh the TB, the one CC series is available, they have needles, you have the small needles, you have the small vascular access cannulas. So you, you really need to prepare before you bring in the bedding. Uh temperature regulation and modalities. Remember, enemy of uh babies. Number one is hypothermia. Number two is hypothermia. Number three is hypothermia. Sometimes we get uh complacent because we think we're in Africa. It's a hot place. Uh The babies will not get cold but they actually do get cold and you have to pay attention, especially when you're doing vascular access. Sometimes you can have if you have difficult vascular access, everyone is trying Aleve and the baby's exposed and can be for a long time. As you prepare for your anaesthetic, please remember to have an able and skilled assistance because this will go a long way in helping you achieve what you want. When we talk about physiology, I don't know whether you can see that slide, but it's basically uh about the things that, that will help you. Remember. Number one, we talked about the blood brain barrier. It is immature. So how does that affect your product of anesthesia? If you think about the lungs, you have a high metabolic rate with a very high uh respiratory rate. So that also impute on your minute ventilation and your reserve volumes. When you talk about the large body surface area, it means that the head, uh just the head alone or they will lose a lot of fluids and heat. Uh So your insensible losses are very, very high. The skin is thin. So absorption of toxins or especially sometimes we apply local anesthetics like uh a lot of it will get absorbed. You're not careful. So you have to know how much you're giving uh kidneys, uh the head. So all these things, you have to think about the physiology because the physiology is developing, you will fight that the liver is not fully developed at bad. The enzyme system is not fully developed at bath, the kidneys, the same uh the capillary leakage and very, very important is about their circulation. So when babies are in utero, they have a photo circulation which closes with a fast bread. And sometimes when you stress them at uh anesthesia, they can reverse to that transitional a circulation which then gives you trouble and waking them up. When you think about uh what we're talking about is if you look at, then you need a kidney, for example, it receives only 5 to 6% of the cardiac output as opposed to the others, one that receives about 20 to 25%. So this has a bearing on your drug excretion. If you look at the high Albiol a minute polio, it things that they're breathing very fast. So when you do a gas induction, they will sleep very quickly. And when you're reversing, you'll also reversed very quickly as opposed to the adult. And if you look at the cardiac of food is actually very high, sometimes going up to 200 mils per kilo per minute. Uh as opposed to the adult one that is almost a bad replied at 70 mils per kilo. On, then there is the new discussion that has been discussed over the last 10 years or so above the effect of anaesthetics on the developing brain. And that there are many studies that have been shown that maybe the anesthetics would give uh to these Children may have an effect on their brain development. But again, it's that it's easier provider, you have to weigh uh the risk passes, benefit of the anesthetic that you're giving. So you only give anaesthetics when you need to because it has also been shown if we do surgery without anesthesia, that amount of stress is also not good for their developing brain. So then we come to pharmacology, you said that no one size fits it. You have to use, wait for those calculations. So for every patient, pediatric patient you take to the or you must have a weight and that is the way you're going to do your drug calculation with, then you have to think about the pharmaco kinetics. This is what the body does, the drugs and you have to think about the pharmaco dynamics about what the drug does to the body. You have to think about absorption, uh the effects that you desire. After excretion, you have to think about uh common terms that are used in pharmacology. And pharmaco kinetics is the metabolic is um uh phase one. Phase two. Sorry, there's a faith today is supposed to be phase two meta bill is um so phase one relies a lot on the cytochrome p 4 50 system and the system in the liver and it's about oxidation and reduction hydrolysized this and this in the newness. The cytochrome system is not fully developed in new zero and in the new next and we'll be ready about six months. So for Children be low, six months in your choice of drugs, you, you need to know that the drugs will not be metabolic ized. And that's why sometimes you find that the dose per kilo in the noon, it is higher than in the older child to account for that. And then phase two metabolic is um uh this is getting it ready for excretion, the conjugation and the growth validation as such elicitation. And and then this one rely a lot on the presence of proteins in the booty again, how much protein is available or determine about this. And then by your availability, we say it is about how much drug is available in the, in the blood to do what you expected to do, then you'll hear about fastpass effect. This is what happens to the drug within the first one circulation. And all these are important factors because uh Children are different ages, most of the systems will be ready uh for drug metabolism by two years. So Children below two years, you have to really be aware of the drugs you're using and how they're metabolized and how they are excreted because that will make a difference in your choice of drugs. Then of course, we have these other aspects, uh cognitive, social and emotional considerations. You have to think about separation anxiety noon. It's, they don't care who picks them so long as they have been picked, they will be happy to go. Uh try picking a two year old, they will be cleaning to the mother. You're not able to get the mouth. If you don't do a good job, it becomes very messy. You have to think about separation anxiety, how you're going to deal with it. Are you going to do primite? Are you going to do parental presence at induction? This is also an area with a lot of discussion because sometimes the way our operating rooms are designed, they do not allow for parental presence at interaction. And in other places, the parents themselves are not keen to come with itself when the child is, is going into the into the or I've had one incident where I was talking to a six year old with the mother. And I think they had Googled a lot and they were asking very, very intelligent questions. So I kept answering and some of them they're asking, is there a risk? But I can die. Uh, and I told them there, there's a risk. But it's like this before I knew the mother had painted. So, and I'll concentrate so much on the, this kid who was looking so bubbly and knowing it that I didn't realize that the matter had fainted. So you have to weigh and look at what your uh parent is like. So you have to know that when you're doing pediatric anesthesia from a social and emotional points of view, you almost have to patient's or more the patient you're dealing with and the community that uh that is there with the parents, the grandparents, the end we are in Africa. So the largest support system, sometimes you have so many of them and they all want to talk. So sometimes you're called to do more than your normal call of duty to do crowd control, to appease people. And the light as Children grow older depending on what their exposure in the hospital has been. They will have fear of hospital, fear of needles, fear of the white coats. I'm sure all these things you have seen, then we have the other group of peer pressure, especially, you know, setup where sometimes uh boys are circumcised in the hospital and uh some will say, oh uh my friends were put to sleep. I want to sleep. Uh Culture says, oh, they should feel the pain. So they don't want to, to do that what the appears, tell them or you know, you cried, you didn't cry or whatever. So you have to deal with all that. And then there are other myths. I don't know whether in Nigeria is there but from the time they're small boys at all, boys don't cry, don't cry. You're not a girl. All those things are important. When you're dealing with your NSF, you have to understand where your patient is coming from and the community there are. So then there is the communication model. The way you talk to a two year old is not the way you talk to a six year old is not the way you talk to a 12 year old. And this is what makes pediatric anesthesia interesting and uh challenging at the same time because you have, you have to make sure that you're communicating appropriately for the correct age and make sure that you get feedback from your communication that you're doing a good job. So basically that is your, your core duct of anesthesia. And, and uh we now go to the other part and before I get there, I would like to say that you have to be very good to give an x easier to Children. And that is why you are in school and that is why you finish anesthesia. And then we'll say now you need to do another one year fellowship just learning how to give anaesthesia two Children, because Children are not small adults and it's a whole different ballgame. However, it doesn't matter how good a pediatric and it's easy ologist or how good you are putting babies to sleep. Uh You are if you do not have the support of the system, so you need to talk about to think about infrastructure and this is where we are encouraging and this is why we are telling you at your level, these things. So not some of you can remain in the operating room giving anesthesia and some of you can get out to make the system better for those ones who are doing clinical work to do a better job. So access to safe anesthesia and sidedly for babies who rely on their ability to reach the hospital. So how are the roots in your catchment area? You have to think about provisions of clean water and electricity and oxygen. Our the the part that was exposed during COVID about how bad the oxygen ecosystem is in our setup. Sometimes these are not always guaranteed and then you have uh hospitals that are dealing with both adults and Children and uh I've worked in both in the children's hospital. Everything goes according to your prioritization as a pediatric anesthesiologist or is the pediatric sergeant where is there any seizure working there? When you come to the hospital that your share ing operating space, you're going to do an obstructed Hanya. Then a woman comes with a P hate. Of course, uh the A P H uh patient will get priority. Your baby starved, get dehydrated. So sometimes it will be good to have rooms that are dedicated for just Children. And sometimes you have intensive care units that are also combined. And for some reason or another, the adults always seem to get the priority maybe because they're the ones who pay the money, I wouldn't know. So, the other thing is about equipment and supplies. So they already exists a challenge in equipment and supplies. But when it comes to the pediatric, uh, system, it's even hard because remember, uh, you need, uh, things that are a wide, uh, spectrum if you're talking about, if you're running an adult service, even if you only got size 6.5 tubes, you can probably do like 80% of your procedures with us size 6.5. And if you added a seven, then you can do everybody, uh, in the new, in the pediatric age group, you need from 2.5 to almost about 5.5 and six. And you can tell you have to have each of them, you cannot say, as opposed to an adult if you're going to do as a Syrian section. Uh, and the only tube you have is a 6.5, you probably can use that in almost all the women. But if you are doing pediatric anesthesia and the only tube you had was a 4.5. It means all the baby's below two years, you're not able to intubate them, it will not even allow. So, uh when there is a problem with the supply chain and this is something we have to talk about the supply team for this equipment, uh and prioritization. Uh depending on who is doing what we must make sure that anesthesia and especially pediatric anesthesia equipment that supplies are prioritized, so that the supply team support you can have otherwise, then we have to keep setting the patient's to buy for themselves. When you look at the supplies, for example, if we look at drugs, most of the preparations come in adult preparation. So you have pen tinea. Well, I don't know whether it's the same in your setup, but you have mentally comes in 100 mix to a male. So what that means? If I have a new unit and I need five mix, I'll break the 100 mix. If I don't have another baby, then five mix I removed. And the 95 I twos are we very wasteful? If you look at paracetamol, if you have a 5 kg baby and you need to give 100 mg, the other 900 goosed waste. So, you know, we really need to talk to even the people in the farmer to have uh things that are prepared for the Children. So what happens is that when you have these drugs that you have to dilute two sat high levels, you increase the possibility of drug errors and you know, sometimes you just need an alignment of uh things to make you have an error. So if you have a fentaNYL 100 you only have a 10 CC series, it's very difficult that you're going to measure precisely five months to give to the baby. So we really need to have that. And if you, even if you look at laryngoscope blades, they range from triple zero to number two E T T tubes. So everything BP cups, you have the ones for new unit, you have for infant, you have four Children. So it is a very specialized place that we need to think about and there's no short cast to that. Then we come to the elephant in the room about workforce who is giving anesthesia to the Children. According to that be FSA uh you need about five anesthesia providers for 100,000 population, just the normal population. And this is indeed a pipe dream for most uh low and middle income countries. And even when you combined the physicians and the non physicians, we are still very far from attaining this ratio. Now, like, you know, set up most of the physicians and even the non physicians are concentrated around the urban areas because of other systems that don't work, you cannot send me to go and work in a remote place where there's no school for my Children, for example. So what happens is that most of those providers are concentrated in the, in the urban areas? So if you remove the numbers idea in in urban areas, then you fight that for the remote places, the availability of anesthesia providers is dire. And we haven't even touched specifically for people who are doing anesthesia for Children. So we really have a lot to do in as far as that is concerned. So, uh it is not only uh that there's a problem with the numbers, there's also a problem with training, there's no standardized training curriculum. So you don't know uh who can do what. And uh this leads to an increase in mortality and morbidity peri operative. They say that if you operated in L M I says you are more than 10 times likely to die than somebody who is a baby operated in the high income countries. And this is our reality, which we are planning to change when you're still talking about workforce. Then we have the other cutters were thinking specifically about the nursing care because there cannot be proper provision of safe anesthesia and surgery. Without nothing here, the nurses trained for preoperative care are very little and in short supply. And unfortunately, because this is not only in uh L M ISIS the high income countries because they can pay them better. Take all our better trained uh nurses, especially peri operative and critical care nurses. They have a very hot market in the West. So what happens to our people? So we really have to train more and see how we can do this. So what are the solutions that we had in terms of provision, the clinical product of anesthesia? There is no shortcut to that. You need to go to your books, you need to read the anatomy, you need to read the physiology, you have to read your pharmacology and you have to put that into practice as you increase your skills and knowledge. So, but the one thing I would say, but even with the loss of knowledge, you really need to learn to pay attention to detail. So and, and, and I know I have not done justice to the clinical part because that is what most of you are looking for that. There is no shortcut. You just have to read, you have to improve your knowledge, you have to improve your skills and you have to continuously update yourself on what is new and what is it uh in terms of infrastructure, we need a lot of advocacy, we need to entrench anesthesia and surgical provision in policies for a long time. Surgical people have been in there or that we haven't been on the table when decisions are being made. That's why you find that there are lots of interventions like for pediatrics, the general pediatrics, the diarrhea and vomiting, malaria and all those things because they realized and came out of the words to be on the table when they're making policies we need to do. Uh and this was a vision for developing the National Surgical Obstetric and Anesthesia uh plans when you have solutions such as the kids who are, where they have dedicated operation room for Children, that also goes a long way in ensuring that we have uh continuity. But we must emphasize about health systems strengthening to ensure that you have proper supply chains and uh that ensures continuous availability of what is needed. We cannot do this without budgetary allocation. So what that means is that we have to make sure that we're on the table when the money is being divided. Otherwise we'll continue being given the leftovers when it comes to workforce, we need to train more people. There needs to be collaboration. You need to think about short courses. Because if you're thinking about training an anesthesia physician, it takes a long time, it will take a long time to cover that gap that we have there. And we have to make sure that there's a way of keeping the skilled workforce in the L M I see in terms of compensation and quality of work, what they feel they need. Uh designing curriculum means that we can train the same. So if you have a curriculum that trains the people in West Africa, in East Africa and South Africa, it means uh there, there can be movements even within our region. And we must remember in terms of training, there's a lot of goodwill people have realized there's a problem with workforce, but then we must not succumb to the goodwill of increasing numbers at the expense of quality of training and skill acquisition. All the trainings that at none, we must make sure that they're up to date. Their quality is good. So this is why we are saying we advocate for short courses even as we plan to do the full thing. And this is a place where uh surgery can help us surgery. They have gone a long way in, in, in their trainings, but most of the time they will realize that anesthesia is a rate limiting step for them. So we need to continue doing CMS uh and making sure we support our workforce, especially mental health support. We need to have a culture change and prioritize safety even in constrained environment. Let's when we give care to those Children, let's do our best. Yes. And let's bring to the table or innovations uh vertically, horizontally so that we avoid double location. Well, other areas like so you might find that there are people who are doing the same thing using money that maybe could have been used to doing. But because the left hand doesn't know what the right hand is doing. Then those kinds of things happen. And a lot has been done to improve anaesthesia. There are a lot of collaborations and uh the World Federation of Societies uh Venice, he has been very supportive, the implementation of the safe courses. And at the end of the day, we realize that it takes a village to raise a child. We must collaborate to improve the provision of pediatric anesthesia care in this, in this part of the world. And we must have global health practitioners emphasizing more on the provision of anesthesia. They have done a lot for global surgery but not as much for anesthesia. And this is where we need to come out and say, yeah, we know you're doing so much for surgery, but you're literally meeting step will be anesthesia. What are you going to do to improve that? And, and somebody I'll say that pediatric anesthesia and pre operative care, pre operative care has a lot of challenges, but these have been identified and they are consulted efforts to address them. We need to work together and encourage ourselves in L M I see with our friends from H I see so that we can come up with solutions that are best feet for all of us. Thank you very much so we can have questions or anything else. You're muted, you're muted. Collins. No, you're still muted. It shows you're muted. Yeah, I can't hear you, sir. It's showing a triangle where your microphone should be. Maybe you missed it. Are you still there? It still shows your music. I am in now. Yes, I can hear you now. Okay. Uh Thank you very much for the wonderful lecture. Um Also about the meat that boys don't feel pain or don't cry. Uh I think it doesn't stay applied for only Children up to. This is the feel some of us that your uh man, you're not supposed to cry or you're not supposed to hit pain or you're not supposed to show that you're actually feeling pain. So that state actually gotten because it's still the same thing that I keep hearing even up to the state. Um I have some few questions on board. I think I will allow the those that joined us in defeat in this way, you know, to learn. I want to know if any of them have some questions, please. If you have any questions, please and be getting the tablets are invited to the state. Thank you. Thank you, please. If you have any questions indicate on the chat boss, let me invite you to the States or you can drop your question on the chart boss. Thank you. Okay. My I think I will go ahead with my question. Maybe when they get interest, I can't invite them to the state. Mhm. Okay. My, my want to go ahead with my question, ask uh Huh. Okay. Mom. Um, I want to know if there's any ethical consideration, uh, regarding providing care to a child that, um, it, it said that, that the parents don't have any, the best interest of the child. That sounds so if, if you are, say healthcare provider can stepping on, you know, take decisions for the child that is best for, for, that is the best. Uh, that's actually a very good question because we know that when we deal with Children, they're not able or legally allowed to consent for the procedures that we do. So, unlike in adult practice, we take consent from the parents on behalf of the Children. And we hope that the parents have the best interest at heart. However, there are cases where we know that we need to do something from a clinical perspective and the parents are not uh keen to do that. For example, we have uh maybe a kid who we need to take two theatre and we know we're going to need transfusion and the parents are doable witnesses and they said they do not want their child transfused and in the best interests of the child, you know that the child will need the flat. So in my country, we have Children, officers, uh social workers that will allow you to do that and get consent from, from uh caught like a court to order to go ahead and do that in cases of emergencies, they have vested that power with specific people in the hospital or in the healthcare system. And that also occurs where uh you need not only the transfusion but any life saving procedure that the parents are not keen to have. And it's also the same uh process that we use when Children uh have been brought, but they don't have a legal person who can sign the consent for them. So, ethically, you need to find out what is the procedure in your country about those kinds of uh things for us. You have to use their children's officers and the social workers. I hope I've answered your question. Yes, ma'am. You did, man. Okay. My husband. Another another question. OK. Um Majority of the not only in if you throw, do show those earlier, I think it's, this is based on a healthy child. So I'm not asking is care for a child that is practically or disabled. Is it different from critically or chronically? Is it different from caring for healthy child? Yes. So uh the reason I showed you the normal is that because you have to start from the normal before you walk back with the abnormal? Okay. So we know uh not when we are talking about, let's say the Sikh laparotomy, the kid who with intestinal obstruction O N E C, but the physiology is really, really dear itched. So and the degree to which it is, the race will also determine your even your risk classification for that child. If we take, for example, a kid who is uh severely dehydrated, going for surgery that is emergent or then you know that you know what is the normal blood volume? So now you know that the blood volume has been decreased by this much. And how are you going to deal with that? When you talk about a kid with fevers or very sick? Then you know that they're uh, metabolic rate is even higher than it normally is. So, you're talking about respiratory uh support. You're talking about adding glucose to their water, water's because they're not able to generate. Uh, there is, I know. Uh, look at that. Okay. Hello? Right. Okay. Yeah. Okay.