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Lung volumes Total lung capacity (90 ml/kg), dead space volume (2 ml/kg),
tidal volume (7-9 ml/kg) all similar to adult values on a per kg basis. Oxygen
consumption much higher in infants; 6-8 ml/kg/min compared to 3-4
ml/kg/min in adults. Closing volume much higher in infants may explain
lower normal values for PaO2 during infancy.
- Growth and development alveoli start to develop at ~32 weeks GA (terminal
bronchioles participate in gas exchange previous to this), number of alveoli
increase rapidly over first 18 months of life (near adult levels) but
morphologic and physiologic development continue through 1st decade
- Volatile gas induction infants more likely to develop laryngospasm (thus we
avoid deep extubation in most infants < 1yr of age), also have depression of
pharyngeal dilator muscles more quickly resulting in partial/complete airway
obstruction while diaphragm continues to attempt breathing.
- Uptake/distribution of volatile anesthetics 3x faster in infants than adults
because of: 1. Increased alveolar-ventilation to FRC ratio 2. Decreased
blood/gas partition coefficient. 3. Decreased tissue/blood partition coefficient
4. Increased C.O. (which should delay equilibration in adults, but in children
this is overcome by the vessel-rich-group being a much larger percent of body
weight in infants than in adults).
- MAC for Isoflurane and Desflurane steadily increases from 24 weeks
gestation and reaches a peak during infancy then steadily starts to decline. For
Sevoflurane, MAC is relatively constant for neonates and infants (3.2%), and
then decreases to 2.5% in children aged 6 mo. 12 years.
III. Cardiovascular System
- Fetal circulation oxygenated blood (PaO2 35!) returns from the placenta,
most bypasses the liver via the ductus venosus. From the IVC, flows through
the right atrium and majority streams across foramen ovale into left atrium.
From left ventricle goes out aorta to head and neck vessels. Deoxygenated
blood returning from head via SVC enters RA, majority into right ventricle
and out pulmonary artery. Because of high PVR, 80% of this blood flows
across ductus arteriosus (other 20% goes to lungs) and to remainder of body.
- Changes at birth PVR drops dramatically with first few breaths, flow
reversed in ductus arteriosus as SVR increases when placenta is removed from
circulation (prostaglandin supply shut off). Increased blood return via lungs
to LA causes increased left sided pressure (increased SVR also contributes)
which functionally closes foramen ovale (still patent in 25% of adults).
Ductus arteriosus usually closes within first 24 hours due to increased oxygen
saturation and removal of prostaglandins from circulation.
- Transitional circulation PDA doesnt close, shunting across it may be L>R,
R>L or bidirectional newborn may revert to this under stress such as sepsis,
hypoxia, hypercarbia, acidosis, congenital heart disease. By having a preductal and post-ductal pulse-oximeter, you can detect if PDA is open and
shunting R>L (i.e. lower extremities have lower O2 sat than upper
extremities). When PDA shunt is exclusively R>L, this is called persistent
fetal circulation.
Renal Function
- GFR is low at birth but rises rapidly over the first few weeks of life
and reaches adult levels by 2 years of age.Reductions in GFR are seen
with hypoxia, hypothermia or CHF.
- Newborn infants are unable to handle excessive fluid or solute loads
(which is why they typically are started on D10W at a lower rate for
the first few days of life)
- The capacity to excrete H+ increases with age
VI.
VII.
Temperature Homeostasis
- Infants have a large surface area:volume ratio which makes radiant
heat loss (the major cause of heat loss in the OR) proportionally
greater in the small infant.
- Convective heat gain (from an under-body bair-hugger which is turned
on before the patient enters the room) is probably the major force in
maintaining normothermia in infants and children.
- Infants are unable to shiver to raise their temperature, instead they are
dependent on brown adipose tissue metabolism which is stimulated by
norepinephrine release
- Brown fat is found around the scapulae, in the mediastinum, and
surrounding the kidneys and adrenal glands
Gastorintestinal Function
- At birth, gastric pH is alkalotic, but by the next day it has reached
typical levels of acidosis.
- Coordination of swallowing with respiration occurs at 4-5 months.
Therefore the incidence of gastroesophageal reflux is relatively high.