Paediatric Emergencies in the Recovery Room

Paediatric Emergencies in the Recovery Room
Good afternoon, I hope this presentation is helpful and thank you for your kind attention. Michelle McNamara

Proposed Learning Paediatric Emergencies A.B.C.D.E
Airway Breathing Circulation Disability (depressed consciousness, unresponsiveness). Exposure ( significant hypothermia, bleeding, shock). PALS 2005 guidelines For Primary Assessment of the Paediatric Patient.

Recovery Room Evolution Speciality Staffing Preparation Child Friendly
Birth of Recovery Room 1940’s Originally developed to centralize patients and staff postoperatively (World War 2) Evolved to a Speciality (PACU) Now Specifically Designed Space/s (phase 1,11,111) Critical Care Setting Flexible Staff Skill-Mix Safely & Efficiently Serves all Patient Populations & Acuity Levels (OPD, HDU/ICU) Recommended Staffing considerations Two registered nurses must be present in a phase 1 recovery room when a patient is receiving immediate post anaesthesia care. Of these, one R.N. must be competent in phase 1 post anaesthesia nursing. A 1:1 nurse/patient ratio is necessary for a paediatric patient from the time of admission until all the critical elements are met with a second R.N. available to assist if necessary.

Paediatric Challenges
Not ‘Small’ Adults Are Someone's Child Age groups – size, development Opiate use intra-op/Post-op Emergence delirium Families Fear of mistakes Different Developmental Stages & Compensatory Mechanisms Sizes Shapes Proportions

Paediatric Considerations
Higher Anaesthetic Morbidity & Mortality Higher Intra-operative Bradycardia (Infants) Higher Respiratory Complications (Recovery) Associated outcomes worse Complications occur in healthy children of normal weight Greater in Paediatrics than Adults (13/10,000 vs 5.9/10,000) respectively Not compromised

Paediatric Anaesthesia Report Patient specific additions
Defer verbal report if condition is unstable or emergency intervention is warranted. Birth history (premature birth, or congenital conditions). Developmental considerations (ensure personal comfort items are present, toy, blanket, religious items). Special needs (e.g. glasses, hearing implants) Pre-operative behaviour, (calm or anxious). Loose teeth (returned for tooth fairy). NAME, AGE, WEIGHT, ALLERGIES ASA PHYSICAL ASSESSMENT STATUS,TYPE OF ANAESTHESIA,TYPE OF SURGERY,MEDICATIONS GIVEN INC. LOCAL INFILTRATION, ANALGESIA GIVEN AND POST OP PLAN FOR PAIN MANAGEMENTANY EVENTS INTRA-OP REPORT FIRST SET OF VITAL SIGNS TO ANAESTHESIST POST REPORT

Approach to Paediatric Assessment
ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness PALS 2005 Guidelines for Systematic approach Decide is to Categorise Clinical Condition Based on Initial Assessment/Clinical condition and Nurses Scope of Practice/ Notify Anaesthesia/ERS/CPR as necessary. A Rapid Visual & Auditory Assessment of The Child / Infant Overall appearance Work of breathing Circulation To Be completed Within the first Few Seconds of Patient Arrival/Admission to Recovery

Assessment General Primary Secondary Tertiary SAMPLE Signs & Symptoms
Allergies Medication Past Medical History Last Meal Events General Rapid (within first few seconds of encounter), visual and auditory assessment of overall appearance, work of breathing, cirulation Primary ,hands on ABCDE approach including vital signs Secondary, mnemonic SAMPLE & thorough head to toe exanination Tertiary Advanced testing to confirm diagnosis, cxr, lab tests ABG

Paediatric Definitions
Premature Newborn – Birth before 37/40 Newborn – Birth to 72 hours Neonate - Infant during first 28 days of life Infant - 1st year of life (including neonate) Toddler 1-3yrs Preschooler 4-5yrs School Age 6 – 12yrs Adolescent > 13yrs

Airway

Anatomy and Physiology Airway
Large Tongue Narrow Nostrils Smaller Airway Opening Short Neck Neonates are obligatory nose breathers More Susceptible to Laryngeal / Bronchospasm Easily Obstructed Airway Post Intubation Oedema considerations for infants and children; due to irritation or infection may lead to significant narrowing of the airway. Paediatric patients do not have the same physiologic reserves of the adult patient hence when complications occur, serious untoward events can rapidly advance. The recovery room nurse must monitor for and efficiently react to any complication in a timely fashion. BCLS and PALS Certification recommended

Airway problems Tracheal intubation (under 5 years)
History of pre-term birth Reactive airway disease Airway surgery Excessive Secretions/Nasal Congestion Parents who smoke. Risk factors; Most common in the immediate post-operative period (e.g. upon emergence)

Breathing

Normal Respiratory Rate by Age
Breaths Per Minute Infant (< 1yr) Toddler (1 – 3yrs) Preschooler (4 – 5yrs) School Age (6 – 12yrs) Adolesent (13 – 18 years) 30 – 60 22 – 34 18 – 30 A respiratory Rate consistently > than 60 bpm in a child of any age is abnormal A respiratory Rate consistently > than 60 bpm in a child of any age is abnormal

Normal Spontaneous Ventilation
Minimal work Quiet breathing Easy inspiration Passive expiration Rapid in the neonate Decreases in older infants & children Breathing Rate is accomplished with Tachypnoea Bradypnoea Apnoea

Paediatric Considerations (Respiratory)
High metabolic rate Oxygen demand is higher Infant Oxygen Consumption is 6-8mls/kg per minute (compared to 4mls/kg for adults) Hypoxaemia more rapid in infants & children A room air Sao2 < 94% in a normal child indicates hypoxaemia. than adults (inadequate oxygenation) occurs

Causes of Respiratory Dysfunction Post Op
Residual effects of anesthetic agents Opiate Agents Sedative agents Excessive fluid volume Pain/ Anxiety Hypothermia/Hyperthermia Pre-existing Pulmonary Disease. Inadequate Ventilation (Anaesthesia, Opiate, Surgery Induced) Impaired Respiratory Drive Increased Co2 retention (Hypercarbia) Respiratory acidosis Agitation Anxiety (Breath Holding, can be due to lack of control/tantrum associated) Decreased responsiveness

Early Respiratory Distress
Increased Respiratory & Heart Rate; Decreased Oxygen Saturation, Nasal Flaring (Infants); Chest Retractions, use of Accessory Muscles; Poor chest rise Poor air entry Grunting Croup Stridor Wheezing Mottled Colour Clinical state characterised by; increased respiratory rate (tachypnoea) and effort ( nasal flaring, retractions and use of accessory muscles). Mild or Severe Increased Work of Breathing Severe respiratory distress can lead to respiratory failure. Respiratory failure is a clinical state of inadequate oxygenation, ventilation or both.

LATE Respiratory Distress
Bradypnoea No respiratory effort Apnoea Cyanosis Poor or absent distal air movement Coma Decreased or no respiratory effort

A Decreasing Respiratory Rate
Normal Abnormal A decrease in respiratory rate from a rapid to a more ‘normal’ rate can indicate overall improvement if associated with increased level of consciousness and reduction of work of breathing However a decrease in respiratory rate and regularity in a child with a deteriorating level of consciousness can be a sign of a deteriorating or worsening of the Childs clinical condition Context of clinical situation

Types of Respiratory Distress
Upper airway obstruction Lower airway obstruction Lung Tissue Disease Disordered control of breathing

Croup Inflammation of the upper airway Post-intubation croup
Presentation -'bark-like' cough Mild, Moderate, or Severe A group of conditions associated with Upper airway obstruction It is very common in children. It may present, (occasional), (often) (constant).

Causes of Croup Intubation (Traumatic Prolonged or Repeated)
Tight fitting E.T.T. Subglottic Injury Coughing (with E.T.T in place) Change of position (whilst Intubated) Surgery >1 hour Surgical trauma May be accompanied by Stridor Respiratory Distress

Stridor Shrill Harsh loud Crowing sounds
Heard during inspiration, expiration or both. A high pitched sound produced by the turbulent flow of air through a narrowed segment of the upper airway caused by tracheal and/or bronchial irritation and swelling/oedema.

Management of Croup / Stridor
Notify Anaesthetist Nebulised cool mist Steroid IV Humidified oxygen Keep N.P.O. Nebulised Epinepherine Keep Pt > 2hrs Re-intubate (size smaller ETT than calculated for the age of the child) Provide/ Consider giving a single dose of Dexamethazone (controversial) Administer racemic epinepherine (0.4mcg/kg of 1:1000 epinepherine) Observe for at least two hours post epinepherine for rebound recurrence If re-intubation required use a size smaller ETT than calculated for the age of the child.

Laryngospasm Involuntary muscle contraction of the laryngeal muscles causing the vocal cords to close. Dyspnoea Crowing sound on Inspiration Aphonia (no sound) Rocking Motion of Chest Use of Accessory Muscles. Upper airway obstruction

Laryngospasm Nursing Interventions
Notify Anaesthetist Administer 100% Humidified Oxygen Positive Pressure Ventilation by BVM Maintaining PEEP to Open Vocal Chords. Prepare for Intubation Oropharyngral Suction as required

Bag Mask ventilation

Signs & Symptoms Lower airway obstruction
Tachypnoea Wheezing, (expiratory most common) Increased respiratory effort Retractions Nasal flaring Prolonged expiration (with expiration being an active rather than a passive process). Tongue, foreign body surgical throat packs, aspirate emesis, airway oedema

Bronchospasm Causes Preexisting Airway Disease Asthma, Bronchiolitis
Allergy/Anaphalaxis Aspiration Mucous plug Foreign Body Pulmonary Edema. Sudden constriction in the walls of the muscles in the bronchioles Causes High Pitched Wheeze (Inspiratory & Expiratory) Increased Respiratory Rate Dyspnoea , Intercostal Retractions, Coarse Rales

Bronchospasm / Asthma Treatment
Notify Anaesthetist Humidified Oxygen 100% Suction Bronchodilators / Ventolin Support ventilation Intubate if necessary Admission overnight secretions AdministerAdminister humidified oxygen, titrate to pulse oximeter readings Administer Bronchodilator (Albuterol) by inhaler or nebuliser Administer corticosteroids For severe symptoms consider, Assisting ventilation (Bi-Pap in cooperative children) Further Bronchodilators, Steroids, Magnesium Sulphate, I.V. Bronchodilators, Endotreacheal intubation.

Aspiration Residual gastric volume (intra-op)
Causes Residual gastric volume (intra-op) Post op Nausea & Vomiting Inhalation of foreign body e.g. tooth Inability to protect airway Inhalation of Gastric or Oro-pharangeal Contents Surgical pack that cause irritation to the Treachea or Bronchi.

Aspiration Nursing Interventions
Position head down & turned to the side to promote drainage Humidified Oxygen/Suction Anti-emetic prophylaxis / rescue Notify anaesthetist Chest x-ray I.V. Antibiotic Prepare to re-intubate if necessary Aspiration pneumonia PONV more common in kids, fluids pre & intra-op surgical proceedure predisposition TIVA if necessary to prevent post op cpmplication,medicate 5ht3 antagonist with steroid combination most effective, reassure.

Respiratory Management Distress/Failure/Obstruction
Notify Anesthetist Reposition/Support the airway Open airway Clear the airway Insert an O.P.A. Or N.P.A. Assist ventilation High concentration O2 Monitor SAO2 / HR Nebulised Medication (Albuterol / Epinepherine) Prepare for Endotreacheal Intubation (allow the child to assume position of comfort) Stimulate Patient to Assess Responsiveness Crying in Infants & Younger Children can Foster Airway Clearance Reposition airway Encourage Deep Breathing & Coughing (if not contra indicated) Administer Oxygen /nursing interventions (perform manual airway manoeuvres per B.C.L.S. P.A.L.S. protocol) by suction (nose and mouth as indicated) opa or npaas indicated (Bag mask ventilation) if needed High concentration O2 with non re-breathing system for respiratory failure Monitor SAO2, HR & rhythm continuously Administer If needed

Circulation

Normal Heart Rate Mean Sleeping Rate
Age Awake Rate Mean Sleeping Rate Newborn to 3months 85 –205 3 months to 2 yrs 100 –190 2yrs to 10yrs 60 – 140 > 10yrs In healthy children the heart rate may fluctuate with the respiratory cycle increasing with inspiration and slowing with expiration, this is common in children and is called sinus arrhythmia. An irregular heart rate or rhythm not associated with the respiratory cycle can indicate an underlying cardiac dysrhythmia.

Normal Blood Pressure by Age (mm Hg)
Systolic Diastolic Neonate (1st day) Neonate (4th day) Infant ( 1 month) Infant ( 3 months) Infant ( 6 Months) Infant ( 1year) Child ( 2 years) Child ( 7years) Adolescent ( 15years) 60 – – – – – – – – – – – – – – – Typical systolic B/P/ in kids age 1-10yrs (50th percentile) is 90 mm hg + age in years x 2 {over 10yrs < 90 = lower end of normal acceptable] Lower limits (5th percentile ) 70mm Hg + (childs age in yrs X 2) eg. Child aged 3 yrs lowest acceptable systolic b.P. 70+3x2=76mm Hg

Cardiac Physiology Higher cardiac output Higher baseline heart rate
Infants – cardiac output dependent on heart rate DO NOT COMPENSATE for lower B/P Bradycardia in an infant ominous sign (CPR <60) May indicate hypoxaemia B/P lower than adults and increase with age H/R higher than adults and decrease with age Per Pals guidelines If HR < 60 infant perform CPR if despite oxygenation and ventilation h.r remains < 60bpm with poor perfusion Bradycardia algorithm approach.

Cardiac Arrest Assessment Broselow PaediatricTape
H’s Hypoxia Hypovolaemia Hydrogen Ion Hyper/Hypokalaemia Hypoglycaemia Hypothermia T’s Toxins Tamponade Tension Pneumothorax Thrombosis Trauma Cardiac arrest is rare in non cardiac children and predisposing factors include respiratory compromise May be associated with a reversible cause Broselow paediatric emergency tape is a guide to drug dosage calculations weight appropriated and is invaluable, includes ETT size, fluid resuscitation guidelines and more.

Circulation Assessment Cardiovascular
Vital signs Central and Peripheral Pulses Brain Perfusion (Mental Status) Skin Perfusion (Capillary refill <3 seconds) Renal Perfusion (Urine Output) Infants & Young Children 1.5 – 2ml/kg/hr Older Children & Adolescents 1ml/kg/hr Heart Rate, Rhythm, B/ P,Sao2 Colour & Temperature

Bradycardia Assess & Support ABC Hypoxemia What is the BP?
How is perfusion? Arrhythmias? Adolescent athlete Perform CPR if HR<60/min with poor perfusion Give o2 monitor iv, 12 lead ecg if practical Consider expert consultation, observe in the absence of cardio/respiratory compromise Epinepherine 0.01mg/kg 1:10,000=0.1ml/kg repeat 3-5minutes Atropine 0.02mg/kg may repeat max total dose for a child 1mg consider cardiac pacing Hypovolaemia, Hypoxia,Hydrogen Ion Hypo/Hyperkaqlaemia hypoglycaemia hypothermia Toxins,Tamponade Tension Pneumothorax thrombosis trauma

Tachycardia Assess & Support ABC Check Perfusion Crying ?Pain
Temperature ?Malignant hyperthermia Anxiety Full bladder Fluid overload Medications (glycopyrrolate, atropine) Sinus Tachycardia (Infants <220, Children< 180) O2 IV Monitor check perfusion capillary refill, BP Pals guidelines for SVT rates greater than sinus rates ( treat with adenosine 0.1mg/kg max first dose 6mg max 2nd dose 12mg, narrow or wide QRS (wide >0.08seconds) synchronised Cardioversion seek expert opinion.wide coplex amiodarone 5mg/kg iv over minutes.

Cardiac Arrest Asystole PEA VF Pulseless VT
Asystole & PEA most common initial arrest rhythms in under 12yrs Activate Emergency Response, commence CPR per BCLS/PALS guidelines Respiratory Failure (airway obstruction, Acute Pulmonary Oedema, Disordered Breathing) CONSIDER FAMILY AND GET INDEPENDAT CARER TO INFORM AND ALLOW OBSERVE Hypotension (Metabolic/Electrolyte,Acute M.I./Ischaemia, Toxicologic, PE Arrythmia Aed paed pads used for i> 1yr old adult pads used for onset of puberty 2 jules per kilo for shockable rythym VF pulseless VT then 4joules per kilo onward/ cpr/ epi iv or io 0.01mg/kg (1:10,000=0.1ml/kg Amiodarone 5mg/kg lidocaine 1mg/kg h’s t’s 15/2breaths

Disability

Depressed Consciousness Post op
Anesthetic, Opiates, Sedatives Hypoglycemia / Hyperglycemia Hypothermia / Hyperthermia Sepsis Seizure Neurological Disease / Head Injury Respiratory Depression Emergence Delirium Residual effects of Drugs anesthetic agents Narcan for narcotic reversal benzodiazipine reversal muscle relaxant reversal Agents Blood glucose level normal 4-7mmol/l in infant replacement D50 1-2ml/kg or D10w5-10ml/kgor gram/kg per unit policy (Pals) D.K.A. in the insulin dependant child/adolescent Temp< 36 core or > 38c Pre-existing

Paediatric Response Scales
Alert Voice Painful Unresponsiveness Modified Glasgow Coma Scale for Infants & children GCS (3 -15) Pupil Response to light PERRL (Pupils Equal Round Reactive to Light) Anaesthesia induced unconciousness means that normal reflexes are absent and temporary support is necessary (Airway) During semi-conciousness those reflexes ie gag, coughing, breathing, blinking) begin to return spontaneously until finally pt. Is fully awake/ oriented and in control. Careful observation is necessary for those pts with caudal anaesthesia for return of normal function/protection.

Emergence Delirium Post-Anesthesia Agitation, Emergence Agitation,
Post-Anesthetic excitement Non-purposeful movement Incidence 25-80% Preschool children (< 6) Lasts up to 45 minutes Associated with Sevoflurane Similar for painful and non-painful procedures Occurs in approx. 10% adult population.

Emergence Delirium treatment
R/o physiologic causes ( ABC / Pain/ Anxiety) Identify Emergence Delirium Include family at bedside promptly Protect from harm Calm environment Treat Airway, breathing , circulatory problems/ causes of agitation (hypoxia, hypercarbia, excessive bleeding etc). Reversal of opiates, benzo’s or more muscle relaxant reversal.. Alternatively Titrate with sedative/amnesic agents as required. Quickly transforms agitation to calm..continue to observe..

Exposure

Normal Temperature Age of child Core Temp (0c)
< 6 months months – 1yr yrs 37.2 – 37.0 > 6 yrs 36.6 – 36.8 Difference between core and body surface can be as much as 0.5 degrees celcius

Paediatric Temperature Concerns
Larger body surface area/kg Cold Theatre, IV fluids, Anaesthetic Gases Surgery > 1 hour (Wound Exposure) Hypothermia (Core Temperature < 36, infant) Delayed awakening Cardiac Irritability (Poor Perfusion) Respiratory depression High Temperature is a LATE sign of MH Infants have larger head ( loose 75% heat thru exposure of head to room air), large body surface area, decreased ability to produce heat and as they have less subcutaneous fat. ANAESTHETIC AGENTS AREMETABOLISED MORE SLOWLY WHEN HYPOTHERMIC SO ADDED RESPIRATORY SUPPORT NEEDED/SLOW EMERGNCE. Vasodilatng anaesthetic agents eg sevoflourane

Thermoregulation Shivering Increases metabolic rate & discomfort
Infants cannot shiver – to increase heat they; Metabolize brown fat Move Cry Pethidine calms shivering (Lowers seizure threshold) Treat (Bair Hugger) Shivering in the adolescent /child increases oxygen demand and is associated with longer Recovery time

Hypothermic Interventions
Warm Recovery Room Warm blankets Hat, Socks, Swaddle, Hold Close Infant Incubator Forced Air Warmer (Bair Hugger) Radiant Heat Lamp/s Hyperthermia, MH already covered Other reasons, overheated in OR, infection,

Shock In Shock, Tissue perfusion is Inadequate Relative to Metabolic Needs Hypovolaemic Shock Distributive Shock Cardiogenic Shock Obstructive Shock PALS Protocol Compensated/Uncompensated Shock Severe reaction to a Drug Vaccine Food Toxin Plant Venom Hypovolaemic Shock volume depletion Distributive Shock (inappropriate distributed blood volume e.g. septic shock, anaphalaxis) Cardiogenic Shock (impairment of cardiac contractility CHD, Myocarditis, poisioning) Obstructive Shock (obstructed Blood flow e.g. massive PE, Tension Pneumothorax, Cardiac Tamponade) In Shock, Tissue perfusion is Inadequate Relative to Metabolic Needs (inadequate blood volume, most common in children)

Hypovolaemia Fluid/Blood Volume Deficit Assess Imbalance
Treat underlying Cause & Correct Imbalance Blood Loss Mild< 30% Moderate 30%-45% Severe >45% NPO Status (Hours) Intra-operative fluids / Replacement IV Maintenance rate

A.S.A. Minimum Fasting Guidelines
2 Hours For clear Liquids 4 Hours For Breast Milk 6 Hours For Infant Formula, Non-Human Milk , Light Meal (Tea & Toast) 8 Hours For a Meal (Fried or Fatty Foods) A.S.A. Practice Guidelines for Preoperative Fasting (2002). Light Meal (Tea & Toast)

Fluid Requirement Formula
Body Weight kg Hourly Fluid Requirement 0 – 10 kg 4ml/kg/hr kg 40ml + 2 ml/kg/hr >20 kg 60ml + 1 ml/kg/hr e.g. 6 kg = 24 ml/hr e.g. 17 kg = 54 ml/hr e.g. 24 kg = 64 ml/hr Maintenance 0-10kg e.g. 6kg/4ml=24mls (4,2,1, rule) maintenance. Replacement is maintenance rate times the hours fasting Aim to give back half during the first hour of surgery..most surgery is < 1 hour. Completion of replacement often continues in the recovery room prior to starting maintenance.

Hypovolaemia Interventions
Fluid Resuscitation IV / IO access Bolus 20ml/kg of Isotonic Crystalloid N/S CSL Reassess & Repeat Transfusion RBC 10ml/kg E.G. 6kg = 24 ml/hr 12kg= 44mls/ hr Rapid Fluid resussitation for blood loss is 3mls/kg for every 1ml of blood loss due to isotonic solution distribution in the extracellular space. If, despite 3 bolus of 20ml/kg child is still haemodynamically unstable transfuse prbc 10ml/kg as whole blood is harder to obtain and has more risks associaated with reaction/longer wait.*Colloid is not routienly recommended for volume replacement however albumen has been successful for third space loss or albumen deficits* PALS guidelines.

I.V Access sites Older children & Adolescents may have fear of needles, emla prior to placement of I.V. Secure, Check patency of IV access as an unconsoleable infant/neonate may have an infiltrated IV Use of Buretrol IV pump for Fluid resussitation

Paediatric Postoperative care
ABCDE System Support Pain Management Anxiety Management Psychosocial Considerations Respiratory System poses the greatest risk of vital organ dysfunction postoperatively Nutritional Support to meet metabolic needs post stress of surgery and anaesthesia. Parent present induction Keep parents informed while child in surgery Amenities available Reunite parent(s) with child as soon as possible Make parents comfortable Rocking chairs Stools PillUp to 75% experience anxiety Induction most stressful time PACU stressors:Alarms/environment Crying babies and children Being separated from parent(s) Equipment Discomfort/distress Fears

Thank you!

References American Heart Association & American Academy of Paediatrics (2005) Paediatric Advanced Life Support Provider Manual. Illinois:Worldpoint ECC,INC. Aitkenhead, A., Smith, G. & Rowbotham, D.(2007) Textbook of Anaesthesia. 5th edn. London:Churchill Livingstone. De Fazio-Quinn, D.M. (2003) ‘Perianaesthesia nursing as a speciality’ in Drain, C.B. (ed) Peri Anaesthesia Nursing, A Critical Care Approach. Missouri: Elsevier,11:29.

References Contd. Johnson, D. (2004) ‘Care of the pediatric Patient’ in Drain, C.B. (ed) Peri Anaesthesia Nursing, A Critical Care Approach. Missouri: Elsevier, 661:681. Motoyama, E., Davis,P. & Smith, P. (1996) Anesthesia for Infants and Children. 6th edn. St Louis:Mosby. Schick, L. & Windle, P. (2010) PeriAnesthesia Nursing Core Curriculum:Preoperative, Phase 1 And Phase 11 PACU Nursing. Missouri:Saunders

References contd Smith, B. & O’Brien, D. (2004) ‘Space Planning and Basic Equipment Systems’, in Drain, C.B. (ed) Peri Anaesthesia Nursing, A Critical Care Approach. Missouri: Elsevier, 1:10. Stoddart, P. & Lauder, G. (2004) Problems in Anaesthesia Paediatric Anaesthesia. London:Taylor & Francis. Trigg, E. & Mohammed,T. (2007) Practices in Childrens Nursing; Guidelines for Hospital and Community. 2nd edn. London:Churchill livingstone.

Paediatric Emergencies in the Recovery Room

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