Anesthesia, Perioperative Care, and Sedation: Randall C. Wetzel

416 Part VIII ◆ Pediatric Drug Therapy
Table 61-2 The Preanesthetic History

Child’s previous anesthetic and surgical procedures:
• Review the anesthetic record for information about the mask and
endotracheal tube size; the type and size of laryngoscope used;
difficulties with mask ventilation or intubation; prolonged
emergence (awakening) from anesthesia; postoperative vomiting,
postoperative agitation and disordered postoperative behavior in
the days following anesthesia/surgery. In addition, a history of
hyperthermia or acidosis in the child or family member should be
sought.
Perinatal problems (especially for infants):
• Need for prolonged hospitalization
• Need for supplemental oxygen or intubation and ventilation
• History of apnea and bradycardia
Chapter 61 • History of cardiovascular compromise
Other major illnesses and hospitalizations
Anesthesia, Perioperative Family history of anesthetic complications, malignant hyperthermia,

or pseudocholinesterase deficiency
Respiratory problems:
Care, and Sedation • Long-term exposure to environmental tobacco smoke
• Obstructive apnea, breathing irregularities, or cyanosis (especially
in infants younger than 6 mo of age)
Randall C. Wetzel • History of snoring or an obstructive breathing pattern
• Recent upper respiratory tract infection
• Recurrent respiratory infections
• Previous laryngotracheitis (croup) or laryngomalacia
• Asthma or wheezing during respiratory infections
• Airway abnormalities, facial anomalies, mucopolysaccharidosis
The primary purpose of general anesthesia is to suppress the conscious Cardiac problems:
perception of, and physiologic response to, noxious stimuli and to • Murmur or history of congenital heart disease—ask for details
render the patient unconscious. Potent drugs are used to blunt physi- • Dysrhythmia
ologic responses to what would otherwise be life-threatening trauma • Exercise intolerance
(surgery). Intraoperatively, the anesthesiologist is responsible for pro- • Syncope
viding analgesia as well as physiologic and metabolic stability (Table • Cyanosis
61-1). This responsibility is facilitated by obtaining an adequate pre- Gastrointestinal problems:
anesthesia history (Table 61-2). Although anesthetic risk has greatly • Reflux and vomiting
• Feeding difficulties
decreased, the increased risk of morbidity and mortality in the peri-
• Failure to thrive
operative period demands the utmost vigilance. The risk is even higher • Liver disease
in certain disease states (Table 61-3). Exposure to exanthems or potentially infectious pathogens
Neurologic problems:
GENERAL ANESTHESIA • Seizures
Analgesia • Developmental delay
Providing analgesia for procedures both in and out of the operating • Neuromuscular diseases
room is a major responsibility and functions within a spectrum of care • Increased intracranial pressure
(Table 61-4). Techniques exist to provide profound pain relief during Hematologic problems:
• Anemia
operative procedures for all patients, including the most critically ill • Bleeding diathesis
infants. Blunting the physiologic responses to painful stimuli inhibits • Tumor
the stress response and its multiple deleterious physiologic and meta- • Immunocompromise
bolic consequences. The response to painful and stressful stimuli is a • Prior blood transfusions and reactions
potent stimulus of the systemic inflammatory response syndrome, Renal problems:
which leads to increased catabolism, physiologic instability, and • Renal insufficiency, oliguria, anuria
increased mortality (see Chapter 70). Appropriate use of medication, • Fluid and electrolyte abnormalities
such as fentanyl anesthesia in neonates, reduces the incidence of post- Psychosocial considerations:
operative bradycardia, hypotension, acidosis, interventricular hemor- • Posttraumatic stress
• Drug abuse, use of cigarettes or alcohol
rhage, coagulation abnormalities, hypoglycemia, and death. • Physical or sexual abuse
• Family dysfunction
Hypnosis and Amnesia • Previous traumatic medical or surgical experience
The blunting of both consciousness (hypnosis) and conscious recall • Psychosis, anxiety, depression
(amnesia) is a crucial feature of pediatric anesthesia care. Awareness Gynecologic considerations:
of painful, anxiety-provoking, and stressful conditions for children is • Sexual history (sexually transmitted infections)
• Possibility of pregnancy
Current medications:
• Prior administration of corticosteroids
Allergies:
Table 61-1 Goals of Anesthesia • Drugs
• Iodine
Analgesia • Latex products
Amnesia and a decreased level of consciousness • Surgical tape
Akinesia–absence of movement in response to painful stimuli • Food (especially soya and egg albumin)
Physiologic support and homeostatic management throughout the Dental condition (loose or cracked teeth)
perioperative process When and what the child last ate (especially in emergency
Vigilance procedures)
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Chapter 61 ◆ Anesthesia, Perioperative Care, and Sedation 417
Table 61-3 Specific Pediatric Diseases and Their Anesthetic Implications

DISEASE IMPLICATIONS DISEASE IMPLICATIONS
RESPIRATORY SYSTEM GASTROINTESTINAL
Asthma Intraoperative bronchospasm that may be severe Esophageal, Potential for reflux and aspiration
and even fatal gastric
Preoperative control is essential Liver High overall morbidity and mortality in patients
Pneumothorax or atelectasis with hepatic dysfunction
Optimal preoperative medical management is Altered metabolism of many anesthetic drugs
essential; preoperative steroids may be Potential for coagulopathy and uncontrollable
required intraoperative bleeding
Difficult airway Special equipment and personnel may be
required RENAL
Should be anticipated in children with Altered electrolyte and acid–base status
dysmorphic features or acute airway Altered clearance of many anesthetic drugs
obstruction, as in epiglottitis or Need for preoperative dialysis in selected cases
laryngotracheobronchitis or with an airway Succinylcholine to be used with extreme caution
foreign body and only when the serum potassium level has
Patients with Down syndrome may require recently been shown to be normal
evaluation of the atlantooccipital joint NEUROLOGIC
Patients with storage diseases may be at high Seizure disorder Avoidance of anesthetics that may lower the
risk seizure threshold
Bronchopulmonary Barotrauma with positive pressure ventilation Optimal control ascertained preoperatively
dysplasia Oxygen toxicity, pneumothorax a risk Preoperative serum anticonvulsant
Cystic fibrosis Airway reactivity, bronchorrhea, increased measurements
intraoperative pulmonary shunt and hypoxia Increased Avoidance of agents that increase cerebral
Risk of pneumothorax, pulmonary hemorrhage intracranial blood flow
Atelectasis, risk of prolonged postoperative pressure Avoidance of hypercarbia
ventilation Neuromuscular Avoidance of depolarizing relaxants; at risk for
Patient should be assessed for cor pulmonale disease hyperkalemia
Sleep apnea Pulmonary hypertension and cor pulmonale must Patient may be at risk for malignant hyperthermia
be excluded Developmental Patient may be uncooperative during induction
Careful postoperative observation for obstruction delay and emergence
required Psychiatric Monoamine oxidase inhibitor (or cocaine) may
CARDIAC interact with meperidine, resulting in
Need for antibiotic prophylaxis for bacterial hyperthermia and seizures
endocarditis Selective serotonin reuptake inhibitors may
Use of air filters; careful purging of air from the induce or inhibit various hepatic enzymes that
intravenous equipment may alter anesthetic drug clearance
Physician must understand the effects of various Illicit drugs may have adverse effects on
anesthetics on the hemodynamics of specific cardiorespiratory homeostasis and may
lesions potentiate the action of anesthetics
Preload optimization and avoidance of ENDOCRINE
hyperviscous states in cyanotic patients Diabetes Greatest risk is unrecognized intraoperative
Possible need for preoperative evaluation of hypoglycemia; if insulin is administered,
myocardial function and pulmonary vascular intraoperative blood glucose level monitoring
resistance needed; glucose and insulin must be provided,
Provide information about pacemaker function with adjustment for fasting condition and
and ventricular device function surgical stress
HEMATOLOGIC SKIN
Sickle cell disease Possible need for simple or exchange transfusion Burns Difficult airway
based on preoperative hemoglobin Risk of rhabdomyolysis and hyperkalemia from
concentration and percentage of hemoglobin S succinylcholine following burns for many
Importance of avoiding acidosis, hypoxemia, months
hypothermia, dehydration, and hyperviscosity Fluid shifts
states Bleeding
Oncology Pulmonary evaluation of patients who have Coagulopathy
received bleomycin, bis-chloroethyl-
nitrosourea, chloroethyl-cyclohexyl-nitrosourea, IMMUNOLOGIC
methotrexate, or radiation to the chest Retroviral drugs may inhibit benzodiazepine
Avoidance of high oxygen concentration clearance
Cardiac evaluation of patients who have received Immunodeficiency requires careful infection
anthracyclines; risk of severe myocardial control practices
depression with volatile agents Cytomegalovirus-negative blood products,
Potential for coagulopathy irradiation, or leukofiltration may be required
RHEUMATOLOGIC METABOLIC
Limited mobility of the temporomandibular joint, Careful assessment of glucose homeostasis in
cervical spine, arytenoid cartilages infants
Careful preoperative evaluation required
Possible difficult airway
Table 61-4 Definitions of Anesthesia Care

MONITORED ANESTHESIA CARE
A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or
therapeutic procedure.
Monitored anesthesia care includes all aspects of anesthesia care: a preprocedure assessment, intraprocedure care, and postprocedure
anesthesia management.
During monitored anesthesia care, the anesthesiologist or a member of the anesthesia care team provides a number of specific services, which
may include some or all of, but are not limited to, the following:
• Discussing anesthesia care with the family and child, obtaining consent, allaying anxiety and answering questions—family centered
anesthesia care.
• Monitoring of vital signs, maintenance of the patient’s airway, and continual evaluation of vital functions.
• Diagnosing and treating clinical problems that occur during the procedure.
• Administering sedatives, analgesics, hypnotics, anesthetic agents, or other medications as necessary to ensure patient safety and comfort.
• Providing other medical services as needed to accomplish the safe completion of the procedure.
Anesthesia care often includes the administration of medications for which the loss of normal protective reflexes or loss of consciousness is
likely.
Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the
procedure.
If the patient is rendered unconscious and/or loses normal protective reflexes for an extended period, this is considered a general anesthetic.
LIGHT SEDATION
Administration of anxiolysis and/or analgesia that obtunds consciousness but does not obtund normal protective reflexes (cough, gag, swallow,
hemodynamic reflexes), or spontaneous ventilation.
DEEP SEDATION
Sedation that obtunds consciousness and normal protective reflexes or possesses a significant risk of blunting normal protective reflexes
(cough, gag, swallow, hemodynamic reflexes), hemodynamic and respiratory insufficiency may occur.
GENERAL ANESTHESIA
Administration of hypnosis, sedation, and analgesia that results in the loss of normal protective reflexes.
REGIONAL ANESTHESIA
Induction of neural blockade (either central, neuraxial, epidural, or spinal; or peripheral nerve block, e.g., digital nerve block, brachial plexus
block), which provides analgesia and is associated with regional motor blockade.
Consciousness is not obtunded.
Special expertise is required.
Frequently, in children, anxiolysis and sedation are also necessary for this technique to be successful.
Regional anesthesia (e.g., caudal epidural blockade) is used to supplement general anesthesia and provide postoperative analgesia.
LOCAL ANESTHESIA
Provision of analgesia by local infiltration of an appropriate anesthetic agent.
Does not require the presence or involvement of an anesthesiologist, although an anesthesiologist may provide local anesthesia services.
NO ANESTHESIOLOGIST
An anesthesiologist will not be involved in the care of the child in any way.
just as deleterious, physically and psychologically, as the painful pro- and general anesthesia and be prepared to manage the child’s airway
cedures themselves. Management is aimed at blunting the fear and and circulation, and provide CPR if required.
emotional response during surgery, painful procedures (bone marrow
aspiration, lumbar punctures), or nonpainful but anxiety-provoking Akinesia (Immobility or Muscular Relaxation)
procedures (MRI, CT). Many drugs provide anxiolysis, blunting of Akinesia is the absence of movement. It is necessary to ensure safe and
recall, and amnesia for such events (Table 61-5). Obtundation of con- adequate operative conditions and to provide ideal conditions for
sciousness may accompany the provision of analgesia. Hypnotic and advanced and meticulous surgery. Akinesia is often produced with
sedative agents can induce altered consciousness without producing muscle relaxants (see Table 61-5). These agents facilitate respiratory
any analgesia; analgesia and obtunded consciousness are not synony- management in the perioperative period and in critically ill patients.
mous. It is also possible to provide analgesia (local, spinal, or epidural The absence of movement is neither the absence of pain nor the pres-
analgesia) without obtunding consciousness. ence of amnesia. Whenever neuromuscular blocking agents are used,
Sedation describes a medically induced state that is on a continuum analgesia and sedation must be provided.
between the fully alert, awake state and general anesthesia (see Table
61-4). In addition to inducing unconsciousness and amnesia, general Physiologic Support
anesthesia obtunds or ablates critical physiologic reflexes; the most The need for anesthesia increases the need to monitor and support
important are airway-protective reflexes: coughing, gagging, and physiologic integrity and homeostasis. Sedation and anesthesia have
swallowing. Cardiorespiratory reflexes are also obtunded with general significant and potentially life-threatening physiologic consequences
anesthesia; respiratory depression and hemodynamic compromise may (see Tables 61-4 and 61-5). Maintenance of adequate cardiorespiratory
occur and may be profound. As sedation deepens toward general anes- function, fluid management, electrolyte control, thermoregulation,
thesia, loss of airway patency, loss of airway-protective reflexes, and and concern for all aspects of the child’s health are critical during
loss of cardiovascular stability occur. Light (minimal) sedation is anx- anesthesia.
iolysis without loss of these reflexes or airway patency. Deep sedation
occurs when these reflexes are obtunded or lost (see Table 61-4). Ade- Vigilance
quate sedation in children may be accompanied by the actual or Constant, critical attention by physicians who understand the demands
potential loss of vital reflexes. It is mandatory that those providing of the surgical procedure, as well as the changes in physiologic status
sedation for a child be able to detect the transition into deep sedation and their implications, is mandatory to provide safe perioperative care
Table 61-5 Selected Drugs Used in Anesthesia

DRUG USES AND IMPLICATIONS
MUSCLE RELAXANTS
Succinylcholine Used to facilitate endotracheal intubation and maintain muscle relaxation in emergency situations; now virtually never
given routinely
A depolarizing neuromuscular blocking agent with rapid onset and offset properties
Associated with the development of malignant hyperthermia in susceptible patients
Degraded by plasma cholinesterase, which may be deficient in some individuals; such a deficiency may result in
prolonged effect
Fasciculations may be associated with immediate increases in intracranial and intraocular pressures as well as
postoperative muscle pain
Vecuronium, Nondepolarizing neuromuscular blockers
rocuronium, Have less-rapid onset than succinylcholine but are longer-acting
mivacurium, Prolonged ICU use may lead to profound muscle weakness
cis-atracurium, all Vecuronium and rocuronium are metabolized by the liver and excreted in bile; they are the most commonly used
aminosteroids neuromuscular blocking agents
cis-Atracurium is metabolized by plasma cholinesterase and therefore may be of benefit in patients with hepatic or
renal disease
HYPNOTICS
Propofol Rapidly acting hypnotic; amnestic, but not analgesic, a general anesthetic agent
Like pentothal, may cause hypotension
Causes respiratory depression
May increase the seizure threshold
Great utility in titrated doses for sedation and with local anesthetic and short-acting opioid for outpatient procedures
May suppress nausea
Associated with the often fatal propofol infusion syndrome when used in prolonged intravenous infusion (>24 hr) and
therefore not used for ICU sedation in children
Etomidate Cardiovascular stability on induction with no increase in intracranial pressure
Inhibits corticosteroid synthesis and increases ICU mortality
Associated with myoclonus, potential difficulty with assisted ventilation, and pain on injection
Ketamine Hypnotic analgesic and amnestic
Causes sialorrhea and should be coadministered with an antisialagogue, such as atropine or glycopyrrolate
May be associated with laryngospasm
Causes endogenous catecholamine release, tachycardia, and bronchodilation
Increases intracranial and intraocular pressures
Decreases the seizure threshold
SEDATIVE–ANXIOLYTICS
Benzodiazepines Produce sedation, anxiolysis, or hypnosis, depending on the dose
May produce antegrade, but not retrograde, amnesia
All agents raise the seizure threshold, are metabolized by the liver, and depress respiration, especially when
administered with opioids
Frequently administered as premedications
Diazepam may be painful on injection and has active metabolites
Midazolam can be administered by various routes and has a short half-life
Lorazepam has no active metabolites
Sedation effected by all benzodiazepines may be reversed by flumazenil, but respiratory depression may not be
reliably reversed
Dexmedetomidine Produces anxiolysis, sedation, sympatholysis, by α2-receptor stimulation centrally; has mild analgesic properties
Side effects include hypotension and bradycardia
Commonly used for procedural and ICU sedation
Continuous infusion for ICU sedation; currently limited to 24 hr
ANALGESIC–SEDATIVES
Opioids Gold standard for providing analgesia
All cause respiratory depression
Morphine and, to a lesser extent, hydromorphone may cause histamine release
The synthetic opioids fentanyl, sufentanil, and short-acting alfentanil may have a greater propensity to cause chest wall
rigidity when administered rapidly or in high doses and are also associated with the rapid development of tolerance;
these 3 drugs have particular utility in cardiac surgery because of the hemodynamic stability associated with their use
Remifentanil is an ultra–short-acting synthetic opioid that is metabolized by plasma cholinesterase; it may have
particular utility when deep sedation and analgesia are required along with the ability to assess neurologic status
intermittently
INHALATIONAL AGENTS
Nitrous oxide Causes amnesia and mild analgesia at low concentrations
Danger of hypoxic mixture if the oxygen concentration is not monitored and preventive safety mechanisms are not in
place
Potent vapors, “Complete anesthetics”—they induce a state of hypnosis, analgesia, and amnesia
sevoflurane, All are myocardial depressants, and some are vasodilators
desflurane, May trigger malignant hyperthermia in susceptible individuals
isoflurane Sevoflurane is almost universally used for inhalation induction of anesthesia in children
All are bronchodilators at equipotent concentrations
Isoflurane, and especially desflurane are associated with a higher incidence of laryngospasm, when used for anesthetic
induction, than sevoflurane
for all children. Careful attention to a child’s preoperative condition is Respiratory Effects
mandatory for minimizing the risk during perioperative care (see The advantages of inhalational anesthesia are rapid onset, rapid offset,
Tables 61-3 and 61-4). convenient route of delivery and excretion (respiratory), and the ability
to provide profound analgesia and amnesia. Inhalational anesthetics
INDUCTION OF GENERAL ANESTHESIA are all airway irritants and, in low doses, can cause laryngospasm.
The goal of induction of general anesthesia is to rapidly achieve surgi- All inhalational anesthetics depress ventilation in a dose-dependent
cal anesthesia by using IV or, more commonly in children, inhalational manner. Thus, expired CO2 and Paco2 (arterial partial pressure of
induction agents. In children who are too young to tolerate the estab- carbon dioxide) increase in spontaneously breathing children. In addi-
lishment of vascular access before the induction of anesthesia, it is tion, anesthesia also decreases end-expiratory lung volume. Small lung
routine to induce anesthesia by mask inhalation of volatile anesthetics. volumes result in a decrease in lung compliance, increases in total
In the operating room, a child is often accompanied by the parents pulmonary resistance, work of breathing, and intrapulmonary arterio-
(parental presence during induction [PPI]) and placed on the operat- venous shunting, and a restrictive lung defect. Inhalational anesthetics
ing room table. Before the induction of anesthesia, monitors are usually also shift the CO2 response curve to the right, thus decreasing, but not
applied to the child. These include a pulse oximeter, electrocardiogram ablating, the increase in minute ventilation with increasing Paco2.
electrodes, and a blood pressure cuff. The child is then cautiously Inhalational anesthetics, which may induce apnea and hypoxia in
introduced to the face mask, which contains a high gas flow (5-7 L/ premature infants and newborns, are less frequently used in premature
min of oxygen), frequently mixed with nitrous oxide. Inhalation of infants and children. In neonates and young infants, general anesthesia
nitrous oxide and oxygen for 60-90 sec induces a state of euphoria. The always necessitates endotracheal intubation and controlled mechanical
airway responses to inhalational anesthetics are now blunted, and sevo- ventilation. In older children, spontaneous breathing through a mask
flurane can be introduced into the inhaled gas mixture. This leads to or a laryngeal mask airway without controlled ventilation is possible
unconsciousness within 30-60 sec while the child continues to breathe for shorter operations. The decreased end-expiratory lung volume and
spontaneously. increased work of breathing always necessitate higher inspired oxygen
The child is now “asleep,” and the parents can be asked to leave. An tension.
IV line is then started, and comprehensive intraoperative monitoring
initiated. Surgical anesthesia can be maintained by spontaneous Cardiovascular Effects
ventilation with a mask; this is safe only when the airway is secure Cardiovascular effects of inhalational anesthesia include depressed
and patent, the stomach is empty, and the child is older than 6 mo cardiac output and peripheral vasodilation; hypotension is frequent.
of age. Procedures longer than 1 hr are not usually performed with This is accentuated in hypovolemic patients. This hypotensive effect is
mask inhalational anesthesia. If these conditions are not met, if the more pronounced in neonates than in older children and adults. Inha-
surgeon needs to approach the airway, or if muscular paralysis is lational anesthetics also decrease baroreceptor and heart rate responses.
required, then the airway must be secured with endotracheal intuba- Inhalational anesthesia blunts the hypoxic pulmonary vasomotor
tion. Although endotracheal intubation can be performed under deep response in the pulmonary circulation, an effect that may contribute
inhalational anesthesia with respiratory depression and obtunded to hypoxemia.
cough and gag reflexes, the depth of anesthesia required to ablate The net effect of inhalational anesthesia is decreased oxygen delivery.
airway reflexes is very close to the level that induces hemodynamic Perioperatively, catabolism is enhanced and oxygen demand is
instability. Therefore, muscle relaxation with IV, nondepolarizing increased; there may be a profound imbalance between oxygen demand
muscle relaxants is induced to facilitate endotracheal intubation. and oxygen delivery. Development of a metabolic acidosis intraopera-
Succinylcholine is rarely, if ever, used. After paralysis is induced, direct tively may reflect this imbalance. Because the cardiovascular depres-
laryngoscopy and airway intubation can be performed. Correct endo- sant effects of inhalational anesthesia are greater in premature and
tracheal tube placement is confirmed by direct laryngoscopy, end-tidal newborn infants, these agents are of limited use in such patients.
CO2 measurement, endotracheal tube fogging, and the finding of bilat- All inhalational anesthetic agents cause cerebrovasodilation. Sevoflu-
erally equal breath sounds during positive-pressure ventilation. If nec- rane is a more potent cerebrovasodilator than isoflurane. Thus, in
essary, fiberoptic airway endoscopy and chest radiograph, in addition children with elevated intracranial pressure, impaired cerebral perfu-
to these measures, can be used to confirm correct endotracheal tube sion, or head trauma, and in premature neonates at risk for intraven-
placement. tricular hemorrhage, inhalational anesthetics should be used with
After endotracheal intubation, spontaneous ventilation may be per- extreme caution. Although inhalational anesthetics decrease cerebral
mitted, if muscle relaxants are not used or have worn off; it is routine oxygen consumption, they may disproportionately decrease blood
to provide controlled mechanical ventilation. When the child is com- flow, thus worsening oxygen delivery.
pletely anesthetized, positioned for surgery, and hemodynamically
stable, and maintenance anesthesia is achieved, the surgery can begin. Specific Anesthetics
Sevoflurane
Inhalational Anesthetics Sevoflurane is the most commonly used inhalational anesthetic in
General anesthesia may be induced and maintained by either inhala- children for both induction and maintenance of general anesthesia. It
tion or the IV route. The inhalational anesthetics used in children is not a significant airway irritant and leads to smoother induction than
include sevoflurane, isoflurane, and desflurane. Although halothane is isoflurane. Emergence from sevoflurane anesthesia is quite rapid; there
the prototypical pediatric inhalational anesthetic agent, it has been is a significant amount of emergence delirium, especially if pain has
replaced by sevoflurane and is no longer used in the United States. been inadequately controlled or induction was stormy and preopera-
The minimal alveolar concentration (MAC) of an inhalational anes- tive anxiety high. This effect can be blunted by pretreatment with
thetic is the alveolar concentration (expressed as percent at 1 atmo- midazolam and adequate use of opioids, although the latter delay
sphere) that provides sufficient depth of anesthesia for surgery in 50% recovery from anesthesia. Metabolism of sevoflurane yields free fluo-
of patients. For potent inhalational agents, the alveolar concentration ride, which may cause renal damage; consequently, the FDA has
of an anesthetic reflects the arterial concentration of anesthetic in the restricted the use of sevoflurane to <2 MAC hr, preferably with fresh
blood perfusing the brain. Thus, the MAC is an indication of anesthetic gas flow rates >2 L/min.
potency and is analogous to the ED50 (effective dose in 50% of recipi-
ents) of a drug. MAC is age-dependent, is lower in premature infants Isoflurane
than in full-term infants, and decreases from term through infancy to Isoflurane maintains cardiac output and cerebral perfusion more effec-
preadolescence. In adolescence, MAC again increases, falling thereaf- tively than sevoflurane. Isoflurane is pungent and a significant airway
ter. Inhalational anesthetic agents are poorly soluble in blood but irritant, with an unacceptably high incidence of complications, such as
rapidly equilibrate between alveolar gas and blood. laryngospasm during induction. Emergence from anesthesia with
isoflurane is quite smooth, but slower than for sevoflurane. Cerebral infusion syndrome). Its use for prolonged sedation (>12 hr) in the
blood flow is only minimally affected, and cerebral oxygen delivery is critical care setting in children is contraindicated.
maintained. Because isoflurane is not a suitable induction agent, induc-
tion with sevoflurane or with an intravenous agent, and maintenance Barbiturates
with isoflurane is a common pediatric anesthesia practice. The most commonly used barbiturate for IV induction is sodium thio-
pental, although it is now rarely used. Although loss of consciousness
Desflurane is rapid, barbiturates do not provide analgesia. Thiopental depresses
A potent airway irritant, desflurane causes coughing, breath holding, respiration, induces apnea, and can cause hypotension in the hypovo-
and laryngospasm during induction and therefore is unsuitable for lemic patient. Induction with 3-5 mg/kg of thiopental usually produces
induction. It is frequently used for maintenance of anesthesia, and 5-10 min of unconsciousness within seconds. After IV induction with
emergence from desflurane anesthesia is rapid. sodium thiopental, maintenance anesthesia can be established using
benzodiazepines, IV opioids, or inhalational anesthetics.
Nitrous Oxide Pentobarbital is commonly used for sedation in children. It is an IV
Nitrous oxide is a tasteless, colorless, odorless gas with potent analgesic drug that induces loss of consciousness. It is also a potent respiratory
properties. It induces a state of euphoria (hence its nickname, “laughing depressant, particularly when used in conjunction with opioids and
gas”). The MAC of nitrous oxide is >100; consequently, it is not suitable benzodiazepines. Pentobarbital has a very prolonged effect. It is not an
as a sole agent to maintain anesthesia. Nevertheless, nitrous oxide has analgesic agent, and painful procedures cannot be performed with
few complications and produces little or no hemodynamic or respira- pentobarbital sedation without supplemental analgesia. Pentobarbital
tory depression. Commonly, during maintenance of general anesthesia, sedation that is deep enough for anxiolysis and nonpainful procedures
the inhalational gas mixture is 70% nitrous oxide and 30% oxygen, with generally results in prolonged sleep. Its potency and long duration of
the addition of an inhalational anesthetic or potentiation of analgesia action make it difficult to titrate. It is not an ideal drug for sedation for
with an opioid or a hypnotic agent. The deleterious effects of nitrous short or painful procedures.
oxide are increased postoperative nausea and vomiting and, with long- Sodium methohexital (Brevital) is another IV induction agent. It is
term use (days), bone marrow suppression. Although there is no evi- similar to sodium thiopental and has a similar spectrum of respiratory
dence of harmful sequelae of the use of nitrous oxide for routine depression.
anesthesia, its use has decreased because of the greater incidence of
nausea and vomiting associated with it. Nitrous oxide is a potent anal- Etomidate
gesic that is safely used in a mixture of 50% nitrous oxide and oxygen Etomidate is an imidazole derivative used for the induction of anes-
(Entonox) in obstetrics and in emergency departments to provide anal- thesia, frequently in emergency situations. Its action is not as rapid
gesia. Although this combination appears to be safe, it potentiates the as that of propofol. The lack of cardiovascular depression has led
respiratory depressive effects of opioids, and its use, in combination to the use of etomidate in patients with hemodynamic compromise,
with any other sedative, hypnotic, or opioid agent, requires very close cardiac disease, and septic shock. Unfortunately, by inhibition of
monitoring because it may produce general anesthesia. 11β-hydroxylase, this agent depresses synthesis of both mineralocor-
ticoids and glucocorticoids for up to 72 hr following a single induction
Intravenous Anesthetic Agents dose. Etomidate increases mortality when used as a sedative in ICUs
Anesthesia can be both induced and maintained with either intermit- (for which it is now contraindicated) and when used in patients who
tent boluses or continuous infusions of IV anesthetic agents. Intrave- receive merely an induction dose. Adrenal suppression by etomidate
nous anesthetics include barbiturates, opioids, benzodiazepines, and further complicates the management of the very patients with hemo-
miscellaneous drugs, such as propofol and ketamine. Intravenous anes- dynamic compromise in whom the agent has been indicated. The deci-
thetic agents can induce anesthesia more rapidly than inhalational sion to continue use of this agent must weigh the serious risks against
anesthetics, with fewer complications. Vascular access is required, so the short-term benefit of hemodynamic stability during anesthesia
unless IV access has already been obtained, inhalation induction is the induction and sedation.
preferred route. For children arriving in the operating room with vas-
cular access, IV induction should be routine, because it rapidly takes Ketamine
the child from the awake state to the anesthetized state with less psy- Ketamine rapidly induces general anesthesia that lasts for 15-30 min
chologic and cardiorespiratory compromise than occurs with inhala- when given at 1-3 mg/kg IV. It has few side effects and can maintain
tional induction. All IV agents affect cardiorespiratory function. The 1 adequate blood pressure and cardiac output. Ketamine is also effective
exception to this may be ketamine, which, in lower doses, releases when given intramuscularly, subcutaneously, nasally, or orally; the
catecholamines, which maintain cardiac function and blood pressure. dose must be increased for these alternative routes. Ketamine dissoci-
ates the connections between the cortex and limbic system (dissociative
Propofol anesthesia) by its inhibition of N-methyl-d-aspartate receptors, pro-
Propofol is the most commonly used IV induction agent in pediatric ducing a unique anesthetic state. Ketamine is not only a hypnotic agent,
anesthesiology and has a rapid onset. In doses of 2-3 mg/kg, propofol providing obtundation and loss of consciousness, but also an analgesic
induces both respiratory depression and hypotension. Propofol can agent, and can act as a sole IV agent to provide general anesthesia. With
sometimes burn and itch on injection. It is formulated in 10% soy low doses of this agent, airway reflexes and spontaneous ventilation
emulsion with egg emulsifiers, so is contraindicated in patients with may be maintained; at higher doses, loss of airway reflexes, apnea, and
soy or egg allergy. After induction of anesthesia, propofol is also a respiratory depression occur. It is unwise to rely on ketamine to prevent
useful agent for maintaining hypnosis and amnesia, and can be used aspiration of gastric contents during deep sedation. Intravenous ket-
as a sole anesthetic agent for nonpainful procedures, such as radiation amine is a useful general anesthetic agent for short procedures.
therapy, MRI, and CT studies. Combined with opioids, it provides Ketamine produces disturbing postanesthetic dreams and hallucina-
excellent, brief anesthesia for painful procedures, such as lumbar punc- tions. These can occur at the time of emergence from anesthesia and
ture and bone marrow aspiration. Propofol is a general anesthetic agent for several weeks. In adults, the incidence of this effect is 30-50%; in
that obtunds airway reflexes, respiration, and hemodynamic function; prepubertal children, it may be 5-10%. Premedication with a benzodi-
it should not be considered a “sedation agent.” Although hemodynamic azepine, such as midazolam, greatly reduces these sequelae; a benzo-
stability, and even spontaneous respirations, can be maintained with diazepine is routinely given to children receiving ketamine anesthesia.
cautious propofol sedation, its use for prolonged sedation over several The other side effect of ketamine is that it is a potent secretagogue,
hours to days in children younger than 12 yr is associated with hemo- enhancing oral and bronchial secretions. A drying agent, such as atro-
dynamic collapse, bradycardia, metabolic acidosis, cardiac failure, pine or glycopyrrolate, is administered before the administration of
rhabdomyolysis, hyperlipidemia, profound shock, and death (propofol ketamine.
A bronchial smooth muscle relaxant (bronchodilator), ketamine is and is approximately 4 times more potent than diazepam. In anxiolytic
a useful agent for sedating asthmatic patients and others in the ICU. doses, midazolam (0.15 mg/kg) has no effect on respiratory rate, heart
Ketamine has been reported to increase intracranial pressure and rate, or blood pressure, and provides excellent preoperative sedation
therefore is not indicated in patients at risk for elevated intracranial that is frequently accompanied by amnesia. It can be administered
pressure. Ketamine can increase myocardial oxygen demand and orally, nasally, rectally, intravenously, or intramuscularly. Use of oral
should be used cautiously in patients with impaired myocardial oxygen midazolam at a dose of 0.5-1.0 mg/kg, mixed in sweet, flavored syrup,
delivery or cardiac outflow tract obstruction. induces anxiolysis in approximately 90% of children. This agent has no
hemodynamic, oxygenation, or respiratory depressant effects at this
Opioids dose level, but when midazolam is used as a sole agent, children may
Opioids are superb analgesic agents, providing analgesia for painful frequently lose their balance and head control, may have blurred
procedures and postprocedural pain (see Chapter 62). Large doses of vision, and, rarely, may become dysphoric. A child sedated with mid-
morphine (0.5-2 mg/kg), combined with nitrous oxide, provide ade- azolam should not be left unattended and is not safe walking. Most
quate analgesia for painful procedures and surgery. Opioids suppress children rapidly accept an inhalational anesthetic mask after oral mid-
the CO2 response, can induce apnea, and are respiratory depressants. azolam premedication. The widespread use of preoperative oral mid-
Morphine is often associated with hypotension and bronchospasm azolam has decreased the practice of PPI to calm younger children.
from histamine release; it is used with caution in children with asthma.
Morphine is a long-acting agent, and an equivalent dose per kilogram Dexmedetomidine
gives much higher blood levels in neonates than in older children, with Dexmedetomidine is an IV agent that obtunds consciousness through
plasma concentrations approximating 3 times those in adults. This central α2-receptor stimulation, much like clonidine. It appears to
reason for this difference is the longer elimination half-life (14 hr) in cause no respiratory depression and produces anxiolysis, sedation, and
children than in adults (2 hr). Because of the prolonged activity and mild analgesia. It is a sympatholytic, and its side effects include hypo-
hemodynamic instability induced by morphine, the fentanyl class of tension and bradycardia. Dexmedetomidine is commonly used for
synthetic opioids has replaced it. sedation in ICU patients as well as for procedures; it is being explored
Fentanyl is an effective agent to provide pain relief, analgesia, and as an adjuvant for general anesthesia, especially in cardiac patients.
sedation for painful procedures, with a shorter duration of action and
a more stable hemodynamic profile than morphine. In equal analgesic Complications During Induction of Anesthesia
doses, all opioids are equally potent respiratory depressants. Other The period between full wakefulness, with the child in control of
anesthetic agents potentiate this respiratory depression, whether they airway reflexes, and general anesthesia, with total loss of control, is
are inhalational anesthetics or IV barbiturates or benzodiazepines. fraught with difficulty. During induction, laryngospasm, broncho-
Fentanyl use at 30-50 µg/kg obtunds the hemodynamic response to spasm, vomiting, pulmonary aspiration of gastric contents, and subse-
surgery and provides stable operating conditions. Effective analgesia quent aspiration pneumonitis pose a constant threat although they
and anesthesia can be provided with IV fentanyl in a 2-3 µg/kg bolus rarely occur. Concern about vomiting and aspiration dictates the use
followed by a 1-3 µg/kg/hr continuous infusion. Hemodynamic effects of preanesthetic fasting (NPO [nothing by mouth]) guidelines and
can be blunted and recall totally obtunded with use of a nitrous- indicates rapid sequence anesthetic induction.
narcotic anesthetic technique, although muscle tone may remain high Laryngospasm is the most common complication. During induc-
and spontaneous movements can occur. Nitrous-narcotic anesthetics tion of anesthesia, especially with inhalational anesthetics, a period of
usually are supplemented with a nondepolarizing muscle relaxant excitement may occur. This period is associated with heightened
during maintenance anesthesia. If the patient will be extubated and airway reflexes, which can lead to coughing, gagging, laryngospasm,
resume spontaneous ventilation, reversal of the muscle relaxant is and bronchospasm. Laryngospasm is reflex closure of the larynx,
necessary. which makes it impossible for the child to breathe or for assisted ven-
Other synthetic opioids (sufentanil, alfentanil, remifentanil) are tilation to be used. The child may make violent inspiratory efforts
available, but fentanyl is the most commonly used opioid. Both sufen- against a closed glottis, generating significantly negative intrathoracic
tanil and alfentanil have been used for cardiac anesthesia; their potency pressure. This may affect cardiovascular function and cause postob-
is different from that of fentanyl. Alfentanil appears to cause an structive pulmonary edema. Laryngospasm can be prolonged, and
increased incidence of muscle rigidity, convulsions, and prolonged hypoxia may ensue. Laryngospasm occurs in up to 2% of all anesthetic
respiratory depression compared with fentanyl, and is not used in inductions in children younger than 9 yr and is half as common in
children. older patients. Laryngospasm occurs twice as frequently in children
Remifentanil has very rapid onset and offset of action. In doses of with active or recent upper respiratory tract infection (URI). A history
0.25 µg/kg/min, surgical anesthesia can be maintained with this agent. of passive smoking from environmental (parental) tobacco smoke
Its short half-life and rapid offset are advantageous for rapid emergence increases the likelihood of laryngospasm 10-fold, and even more if the
from anesthesia. Unfortunately, its rapid offset of action also leads to smoker is the child’s mother.
postprocedural and postoperative pain and requires analgesic supple- Laryngospasm can be relieved during induction of anesthesia by
mentation, frequently with an opioid, which removes the advantage of increasing the anesthetic dosage, either intravenously or through inha-
anesthesia with a short-acting opioid. Remifentanil may have a role in lation (although with the glottis closed, further administration of
providing rapidly deepening anesthesia for particularly painful events inhalational anesthesia is not possible). Muscle relaxation relieves
or rapidly inducing analgesia. It is also used intraoperatively by con- laryngospasm, and in an acute situation, this situation may be an indi-
tinuous infusion to maintain anesthesia. It is a potent respiratory cation for succinylcholine. Constant positive airway pressure adminis-
depressant and provides no postprocedural analgesia, features that tered by someone skilled in airway management to ensure patency of
limit its use. the soft tissues of the oropharynx may be beneficial in alleviating
laryngospasm. Laryngospasm may also occur during emergence from
Benzodiazepines anesthesia, because a state of excitement is again traversed between
Benzodiazepines induce hypnosis, anxiolysis, sedation, and amnesia, deep anesthesia and wakefulness.
and have anticonvulsant activity. In larger doses, they cause respiratory Bronchospasm can occur during induction, either in response to
depression and apnea; they are synergistic with opioids and barbitu- histamine release as a result of many of the anesthetic agents or as part
rates in their respiratory depressant effects. Benzodiazepines are of a hyperexcitable stage. Endotracheal intubation may also induce
γ-aminobutyric acid agonists. bronchospasm during induction. Bronchospasm during induction is
The most commonly used benzodiazepine in pediatric anesthesia is particularly common in children with asthma. Bronchospasm second-
midazolam. Short acting and water soluble, it can be injected intrave- ary to intubation in a patient with reactive airway disease can be severe,
nously without pain. It is a potent hypnotic–anxiolytic–anticonvulsant may be associated with life-threatening hypoxemia, and may make it
impossible to ventilate the child. The use of histamine-releasing anes- intubation and positive-pressure ventilation. For long procedures,
thetic agents has been associated with total airway obstruction, respira- spontaneous breathing through a mask is possible; in smaller children,
tory failure, and cardiac arrest. Environmental tobacco smoke is a risk in whom the surgical field and the airway may be close together,
factor. the need to maintain a patent airway necessitates endotracheal
Other pulmonary problems with induction of anesthesia include intubation.
massive atelectasis with hypoxemia, impaired ventilation and perfu- Muscle relaxation to facilitate endotracheal intubation was once
sion, blunted hypoxic pulmonary vasoconstriction, and increased accomplished with succinylcholine. This agent has a high-risk profile,
airway secretions with decreased bronchociliary function. Hyperse- however, and is associated with postoperative pain (muscle spasms);
cretion is prevented by the routine use of antisialagogues, such as hyperkalemia; elevated intracranial, intraocular, and intragastric pres-
atropine. The newer inhalation agents are less-potent secretagogues, sures; malignant hyperthermia; and myoglobinuria and renal damage.
and the use of atropine premedication is much less common, but is Succinylcholine is now rarely used, except to provide rapid relief of
probably indicated if ketamine is used. laryngospasm. Intubation of the airway is facilitated with a nondepo-
Hemodynamic complications upon anesthesia induction include larizing, short-acting muscle relaxant. Rocuronium is the drug most
hypotension, which can be profound in hypovolemic patients; commonly used for intubation. For procedures that last longer than
decreased myocardial function, which can be severe in patients with 40 min, vecuronium and alcuronium are suitable to induce muscle
compromised cardiac function; and tachycardia and cardiac dysrhyth- relaxation for intubation. After intubation of the airway, the decision
mias. Inhalational anesthetics sensitize the myocardium to circulating must be made whether to maintain muscle relaxation to facilitate
catecholamines, and induction and excitement are associated with a surgery or to allow the child to resume spontaneous respiration. Pro-
hypercatecholaminergic state. longed use of a nondepolarizing muscle relaxant is common practice
but may contribute to postoperative respiratory compromise if it is not
Parental Presence During Induction fully reversed with appropriate agents.
of Anesthesia Reversal of neuromuscular blockade is standard anesthetic prac-
Parents may expect to be with their child during the induction of tice. Effects of nondepolarizing muscle relaxants are reversed by
anesthesia. Removing a terrified child from the comforting arms of a increasing the concentration of acetylcholine with neostigmine (ace-
parent is stressful for the child, the parent, and the caregivers. If this tylcholine esterase inhibitor) and either atropine or glycopyrrolate to
parental separation cannot be achieved comfortably with preoperative prevent the vagal effects. With the virtual abandonment of succinyl-
psychoprophylaxis and behavioral modification, including education choline, only nondepolarizing muscle relaxants are routinely used for
and desensitization to the operative environment, or with pharmaco- intubation. The termination of their action depends on metabolism
logic aids, such as preoperative medications including benzodiazepine and elution away from the neuromuscular junction. This process, even
and barbiturates, then there may be a need to defer parent–child sepa- for the shortest-acting muscle relaxants (rocuronium), can take several
ration until general anesthesia is induced. Preoperative medication minutes. An intubating dose of rocuronium to rapidly induce paralysis
with oral benzodiazepine more frequently provides calm, smooth in emergency situations may not spontaneously reverse for 20 min or
induction conditions than PPI without pharmacologic preparation. longer (compared with ≈3 min for succinylcholine). If the airway
Although the use of PPI in the hands of a confident, competent anes- cannot be secured, disaster may follow in the child who is unable to
thesia practitioner can replace the need for preoperative medication, it breathe spontaneously and in whom blockade cannot be reversed.
does not reliably predict smooth induction. PPI appears to decrease Thermoregulation is critical during anesthesia. The absence of
neither emergence phenomena nor the incidence of postoperative movement and the inhibition of shivering lead to difficulty in thermo-
behavioral changes, and it does not appear to add an advantage for the genesis. All the contributors to heat loss—convection, radiation, evap-
child over that provided by preoperative sedative medication, such as oration, and conduction—occur during anesthesia. Humidification
with oral midazolam. and warming of inspired air are required. Additional warming devices
are commonly used, such as rewarming blankets. General anesthetic
MAINTENANCE OF ANESTHESIA agents increase the interthreshold range (the minimal temperature
Maintenance of anesthesia is the period between induction and emer- change that will lead to sympathetic response, generally 0.3°C [0.5°F]).
gence. The child should be asleep, unaware of pain, unresponsive with Although temperature sensing may remain normal, an autonomic
either motion or hemodynamic responses to painful stimuli, and response to hypothermia is not triggered. Anesthetic agents cause
homeostatically supported. The child is comatose, without airway- vasoparesis, which further impairs thermoregulation and increases
protective reflexes and with suppression or absence of respiration, and heat loss. In newborns, inhalational anesthetics inhibit nonshivering
has received drugs that suppress hemodynamic adaptive responses. thermogenesis from brown fat, putting them at higher risk for
The child is also exposed to surgical trauma, and there may be blood hypothermia.
loss and significant fluid shifts (third spacing), decreased intravascular
volume, and hypothermia. Fluid Maintenance During Surgery
Anesthesia is usually maintained with or without nitrous oxide, an and Anesthesia
inhalational anesthetic such as isoflurane or sevoflurane, and an opioid Patients who are unconscious and immobile have lost venous pump
for intraoperative analgesia, potentiation and deepening of anesthesia, mechanisms and have peripheral venous pooling. Anesthetic agents
and postoperative analgesia. A benzodiazepine is added either during cause vasodilation, and anesthetized patients have relative hypovole-
premedication or intraoperatively to supplement hypnosis and amnesia. mia. Intravascular volume expansion is frequently required after the
A nondepolarizing muscle relaxant (vecuronium or rocuronium) com- induction of anesthesia to maintain adequate perfusion, tissue oxygen-
pletes the pharmacologic maintenance of anesthesia. Agents can be ation, urine output, and blood pressure. Volume expansion is most
given by continuous inhalational anesthesia or by continuous or bolus commonly provided by isotonic salt-containing solutions (normal
IV infusion. saline, lactated Ringer solution). Autonomic responses may be
During maintenance, the child may breathe spontaneously through increased as part of the surgical stress response, with vasoconstriction
an anesthetic mask or endotracheal tube or may be mechanically ven- and intravascular volume contraction caused by diuresis, intravascular
tilated. All general anesthetic agents decrease end-expiratory lung volume loss from hemorrhage, evaporation (insensible loss, increased
volume, which is generally lower than functional residual capacity, during surgery), and third space (interstitial space) fluid losses result-
with increases in pulmonary closing capacity and intrapulmonary ing from the inflammatory response. Abnormalities in the distribution
shunt. Hypoxia would occur without supplemental oxygenation. These of renal blood flow and secretion of antidiuretic hormone further
effects are compounded by respiratory depressant effects and the complicate the regulation of intravascular volume.
depressed CO2 response curve. Therefore, it is generally considered The concern about hypoglycemia as a result of preoperative fasting
that use of anesthetics for longer than 1 hr requires endotracheal led to the recommendation that infants and small children receive
emergence. Normal physiologic functions, such as spontaneous venti-

Table 61-6 Intraoperative Pediatric Fluid Replacement lation, resume and hemodynamic function improves. After routine
4 mL/kg/hr 1-10 kg elective procedures, the child should be fully conscious before leaving
the operating room, with intact airway reflexes, the ability to follow
2 mL/kg/hr 10-20 kg simple commands, the effects of muscle relaxants reversed, and airway
1 mL/kg/hr per kg >20 kg patency maintained. If the child is going to the ICU, or if for surgical
reasons the decision is made to leave the child intubated, analgesia and
Example: a 22-kg child requires: (4 × 10) + (2 × 10) + (1 × 2) =
62 mL/hr
sedation should be maintained, along with mechanical ventilation, in
the postoperative period. Ideally, emergence should be as brief as pos-
sible, with maintenance of analgesia and anxiolysis and restoration of
isotonic solutions with 5% glucose. The occurrence of hyperglycemia cardiorespiratory function. Inhalational anesthetic agents leave the
and potential neurologic injury during cardiopulmonary bypass, or system rapidly during ventilation, and muscle relaxants can be reversed;
during neurosurgery and other situations in which central nervous however, the effects of opioids, benzodiazepines, and IV hypnotic
system injury can occur, however, along with the recognition that agents may be prolonged.
hypoglycemia is rare in nonneonates, has called into question the During emergence, the decision must be made whether to reverse
routine use of glucose-containing solutions. In neonates, glucose mon- the effects of muscle relaxants. The effects of long-acting, nondepolar-
itoring during and after anesthesia is indicated. In older children with izing muscle relaxants (vecuronium and pancuronium) are invariably
normal nutritional status, isotonic salt solutions without additional reversed. If the child appears to be weak or to have respiratory depres-
glucose are adequate. In children who are receiving parenteral alimen- sion in the postoperative phase, prolonged neuromuscular blockade
tation with a solution containing a high glucose concentration (>10%), should be considered.
continuation of the glucose concentration should be ensured to avoid
rebound hypoglycemia, which would occur if the high-glucose solu- POSTANESTHESIA CARE UNIT
tion was stopped. In the postanesthesia care unit (PACU), the child is observed until
Intraoperative fluid maintenance includes (1) current maintenance there is adequate recovery from anesthesia and sedation. Parents
fluids and replacement of usual deficits during the NPO period; (2) should be permitted to comfort their children in the PACU. Achieve-
replacement of third space losses; and (3) replacement of extraordinary ment of spontaneous breathing, adequate arterial saturation (>95%),
losses (hemorrhage). Infants should receive glucose-containing iso- and hemodynamic stability are key recovery end points. The child
tonic fluids, such as 5% dextrose in water with either 0.25 normal saline should be arousable, responsive, and oriented before discharge from
or isotonic crystalloid solutions. Table 61-6 is a guideline for determin- the PACU. The amount of time spent in the PACU depends on whether
ing fluid deficits and maintenance requirements in the operating room. the child is being discharged to an inpatient nursing unit, to an ICU,
Fluid deficits should be replaced over the 1st 2 or 3 hr of intraoperative to a postrecovery area, or directly home. Discharge from the PACU
management. Deficits are generally calculated as the number of hours depends on the child’s overall functional status—not merely the physi-
of NPO status multiplied by the hourly maintenance rate for the child. ologic end points, but also the behavioral end points as well as the
Half of this deficit is replaced during the 1st hr and half during each adequate provision of analgesia and control of postoperative nausea
of the subsequent 2 hr. If hypotension or tachycardia occurs or persists and vomiting. There are several scoring systems (Table 61-7) for deter-
in the early stages of anesthesia, more rapid replacement of the fluid mining whether a child is ready to be discharged from the PACU.
deficit is indicated. The deficit is replaced with isotonic crystalloid
solutions. Complications in the Postanesthesia Care Unit
Third space losses are replaced with isotonic salt solutions. For large Respiratory Depression
operations, such as abdominal or thoracic procedures, during which Prolonged emergence from anesthesia and respiratory depression can
there may be a large amount of evaporative loss as well as a significant be caused by opioids or inadequate antagonism of neuromuscular
amount of third space loss, 8-10 mL/kg per hr of surgery is generally blocking agents. Pain can cause significant hypoventilation, especially
given as IV fluid replacement. For smaller operations, such as hernior- after thoracic or abdominal surgery. Delayed emergence from anesthe-
rhaphy, pyloromyotomy, and minor procedures, fluid replacement at sia can occur as a result of retention of inhaled anesthetic agents
3-5 mL/kg/hr is indicated for third space losses. Even when surgery worsened by hypoventilation. Hypothermia, especially in neonates,
involves the extremities and third space losses are minor, it is wise to delays metabolism and excretion of anesthetics and also aggravates
give an additional 1-2 mL/kg/hr to replace them. neuromuscular blockade. If respiratory depression is profound, then
A crystalloid solution is indicated for blood loss, at 3 mL per mL of maintenance of the airway may require an oral airway. If the depression
blood lost. This formula could be reduced somewhat if blood is is severe, endotracheal intubation and mechanical ventilation are
replaced on an mL-per-mL basis with packed red blood cells or whole indicated.
blood equivalent. The use of albumin or other suitable colloid, such as Only in rare cases, in which opioid suppression is suspected, is
fresh-frozen plasma in neonatal surgery, also decreases the amount of reversal of the effects of opioid with naloxone indicated. Opioid rever-
crystalloid replacement needed for blood loss. During maintenance sal with naloxone reverses not only the respiratory depression but also
anesthesia, if large-volume transfusions are required, warming the the analgesia. A somnolent child with respiratory depression may
blood and crystalloid solutions avoids hypothermia. With major become excited, agitated in severe pain, uncontrollable, and/or hyper-
surgery and the resultant systemic inflammatory response syndrome, tensive after naloxone. Opioid reversal necessitates bedside attention
capillary integrity is lost and third space losses are common. Failure to by the physician to monitor the child’s behavioral, hemodynamic,
replace this third space loss and restore intravascular volume leads to and respiratory status. Naloxone is shorter-acting than most opioid
hypotension, shock, acidemia, and renal failure, and further stimulates analgesics.
the systemic inflammatory response syndrome. Atelectasis is another respiratory complication occurring in the
1st 48 hr after anesthesia. Although atelectasis suggests an inhaled
RECOVERY FROM ANESTHESIA foreign body, it is most likely caused by secretions and decreased respi-
Recovery from anesthesia includes emergence and postoperative ratory effort secondary to pain. Microatelectasis may lead to post
recovery from surgery and anesthetics. Emergence describes the time operative infections. Aspiration pneumonia is another postoperative
and the physiologic response to decreasing depth of anesthesia during complication.
return to consciousness. During emergence, patients experience Postoperative stridor occurs in up to 2% of all pediatric patients.
decreased anesthetic effect, increased stress responses, physiologic and The use of uncuffed, atraumatic, nonirritant endotracheal tubes has
psychologic responses to painful stimuli, excitement, and anxiety. Con- decreased the incidence of airway trauma. The use of appropriately
scious realization of pain may lead to physiologic responses during sized endotracheal tubes and assurance of an air leak <30 cm H2O
be ruled out. Occasionally, it is necessary to sedate the child with

Table 61-7 Recovery Scores benzodiazepines, although these agents prolong postanesthesia recov-
>9 REQUIRED FOR ery time and when they wear off, emergence delirium may recur.
ALDRETE RECOVERY SCORE DISCHARGE
Awareness During Anesthesia
ACTIVITY—VOLUNTARILY OR ON COMMAND A primary goal of anesthesiology is obtunding consciousness to ablate
Moves 4 extremities 2
awareness during procedures and recall afterward. In adults, certain
Moves 2 extremities 1
No motion 0 anesthetic techniques are associated with an unacceptably high inci-
dence of recall during anesthesia. Awareness and recall of events
BREATHING during a surgical procedure can be unpleasant and terrifying; the long-
Deep breath, cough, cry 2 term sequelae of such recall in children are unknown. Continuous
Dyspnea or shallow breathing 1 monitoring of cerebral electroencephalographic function by monitor-
Apnea 0
ing of the bispectral index has been recommended. Unfortunately, data
BLOOD PRESSURE in children do not confirm the efficacy of bispectral index monitoring
Within 20% of preanesthetic value 2 as a means of determining anesthetic depth, and this fact, combined
Within 20–50% of preanesthetic value 1 with the absence of meaningful data on intraoperative awareness and
>50% outside preanesthetic value 0 recall in infants and children, does not currently support the routine
COLOR use of bispectral index monitoring.
Pink 2
Pale, blotchy, dusky 1 Postoperative Nausea and Vomiting
Cyanotic 0 After general anesthesia, 40-50% of children may experience nausea
CONSCIOUSNESS and vomiting. More than 80% of all high-risk children receiving inha-
Fully aware, responds 2 lational anesthesia experience postoperative nausea and vomiting
Arouses to stimulus 1 (PONV). It may occur in the immediate postoperative period, within
Unresponsive 0 the 1st 1-2 hr, or several hours after surgery and anesthesia. The etiol-
6 REQUIRED FOR ogy may be related to the stress and trauma of surgery combined with
STEWARD RECOVERY SCORE DISCHARGE the emetic effects of anesthetic agents. Pain is an important cause of
nausea and vomiting. Opioid analgesics also induce nausea and vomit-
ACTIVITY ing. Preoperative fasting does not decrease the incidence of nausea and
Moves limbs purposefully 2
vomiting. Indeed, hydration and glucose supplementation appear to be
Nonpurposeful movement 1
Still 0
important factors in decreasing PONV. The use of analgesic agents
other than opioids (acetaminophen, ketorolac) and regional or local
CONSCIOUSNESS anesthesia is associated with decreased PONV.
Awake 2 This complication prolongs recovery room times, requires signifi-
Responsive 1 cant nursing attention, and increases the use of potent antiemetic
Unresponsive 0
agents (ondansetron, other serotonin antagonists). Ondansetron is
AIRWAY very efficacious as a prophylactic and in the treatment of PONV.
Coughing on command or crying 2 Ondansetron and other serotonin antagonists are recommended for
Maintaining patent airway 1 high-risk patients (strabismus surgery) or for actual treatment of
Requires airway maintenance 0 PONV. They are contraindicated in children taking serotonin reuptake
inhibitors for migraine headaches. Metoclopramide is useful prophy-
lactically. Droperidol (which has an FDA-required black box label
warning) must be used with caution because of the rare occurrence
pressure further decreases the risk of airway trauma. A history of of prolonged QT interval and ventricular arrhythmias associated with
stridor increases the likelihood of postoperative complications. Stridor its use.
may be severe enough after extubation to require reintubation. Retrac-
tions and respiratory distress in the postoperative period should Thermoregulation and Malignant Hyperthermia
suggest this complication, and stridor or wheezing should confirm the For patients in the PACU, thermoregulation remains abnormal for
diagnosis. Racemic epinephrine aerosols are effective therapy; their use several hours. Shivering is common in the postoperative state, and a
requires prolonged observation because of the potential for recurrence feeling of extreme cold is common. Warm blankets are very comforting
of the airway obstruction. Stridor in infants suggests the need for and seem to decrease shivering. Hypothermia, especially in neonates,
overnight observation. leads to hypotension, bradycardia, acidosis, apnea, and prolongation
Hemodynamic instability is much less common in the PACU. of the effect of opioids and neuromuscular blocking agents. Although
Volume expansion may be required to maintain adequate blood pres- hypothermia has deleterious effects, rewarming must be done cau-
sure, peripheral perfusion, and urine output. Requirement for excessive tiously to avoid burning and cutaneous hyperthermia. Hyperthermia,
volume replacement (>30 mL/kg) to maintain blood pressure, perfu- with temperatures in excess of 39°C (102.2°F), is of concern in the
sion, and urine output in the postoperative period is an indication of postoperative period. If it occurs within hours of the use of an inhala-
shock and occult bleeding, and it necessitates surgical consultation. tional anesthetic, especially if succinylcholine was used, malignant
Emergence delirium is noted in <3% of children and is more hyperthermia must be suspected.
common in those 3-9 yr old. In the immediate hour after surgery, Malignant hyperthermia is an acute hypermetabolic syndrome that
children may become extremely restless, combative, and disoriented, is triggered by inhalational anesthetic agents and succinylcholine. It
and may be screaming, inconsolably crying, or poorly communicative. resembles neuroleptic malignant syndrome. The onset of malignant
These children pose a danger to themselves. This phenomenon is more hyperthermia may be acute, and its course may be fulminant and
common when barbiturates are used as part of premedication or rapidly fatal. This condition, albeit rare (approximately 1 in 60,000
induction and inhalational anesthetics or ketamine forms part of the pediatric patients given anesthesia) is a constant concern. The disease
maintenance anesthetic. Although disorientation is common in the is familial, and a family history of death or a febrile reaction during
postanesthetic stage, erratic, delirious behavior requires attention, with anesthesia should alert the anesthesiologist to its potential. Its clinical
gentle restraint, a quiet environment, and comforting. Potential post- course is characterized by rapid onset of fever, acidosis, hypercarbia,
operative complications, such as hypoglycemia and hypoxemia, should and increased expired CO2. High fever (38.5-46.0°C [101.3-114.8°F],
rising 1°C [1.8°F] every 5 min), muscle rigidity, metabolic acidosis, respiratory control in neonates. Apnea is also a recognized stress
and hemodynamic collapse can occur. Death ensues from shock and response in neonates, and inadequate anesthesia is associated with
cardiac dysrhythmias with ventricular fibrillation that is unresponsive increased apnea and respiratory complications.
to treatment. The mortality rate for malignant hyperthermia was once The risk of postoperative apnea in premature neonates is inversely
>70%. Aggressive therapy, including discontinuation of all inhalational proportional to postconceptual age at the time of surgery. This risk is
anesthetic administration, correction of the metabolic acidosis, and minimal by the time premature infants have reached the postconcep-
treatment with the muscle relaxant sodium dantrolene, has reduced tual age of 60 wk. Apnea is most common within the 1st 12 hr after
the mortality rate to <5%. Dantrolene and a kit containing supplies surgery; postanesthetic apnea has been reported in premature infants
necessary to treat malignant hyperthermia should be present at every up to 48 hr later. The incidence of apnea in full-term infants is debat-
site where pediatric anesthesia is provided. able and has not been clearly demonstrated. It is generally agreed that
Malignant hyperthermia is probably genetically heterogeneous, with general anesthesia should be avoided, except for emergency surgery, in
more than 10 genes contributing to susceptibility. Genetic mutations full-term children younger than 44 wk postconceptual age. If surgery
in the ryanodine receptor (the calcium channel of the sarcoplasmic is required within the 1st mo of life, overnight observation and moni-
reticulum) have been reported in 20-40% of humans with malignant toring are indicated. Theophyllines decrease the incidence of postop-
hyperthermia. Certain myopathies are associated with the risk of erative apnea; they do not ablate it and therefore are not routinely used.
malignant hyperthermia; these include Duchenne muscular dystrophy, The safest course is to monitor premature infants younger than 60 wk
Noonan phenotype, and, in children with a history of ptosis, squint, postconceptual age and full-term infants younger than 1 mo for at least
scoliosis, and muscle cramping. It is wise to avoid the use of succinyl- 24 hr after anesthesia.
choline in children with myopathies.
Malignant hyperthermia appears to occur from a massive triggering PREANESTHETIC EVALUATION
of excitation contraction coupling, sarcolemmal calcium release, and Most previously healthy children require minimal preoperative assess-
propagation of contraction by a complex biochemical process. The ment. The American Society of Anesthesiologists (ASA) classification
prolonged ischemic contraction leads to myolysis, with release of myo- system for anesthetic care is the American Society of Anesthesiologists
globin, very high serum creatine phosphokinase levels, and renal Physical Status classification (Table 61-8).
failure secondary to myoglobinuria. Malignant hyperthermia generally For American Society of Anesthesiologists Physical Status 1 patients,
occurs within the 1st 2 hr of anesthesia, but (rarely) can occur up to a brief history, notation of medical allergies, and a physical examina-
24 hr later. tion focusing on the airway, lungs, and cardiac function are sufficient.
Certain phenomena are clues to the risk of malignant hyperthermia. For all children who are being assessed for anesthesia risk, a family
The occurrence of masseter spasm during induction, with rigid clench- history should be obtained, for reactions to anesthetics, for drug aller-
ing of the masseter muscles and an inability to open the mouth, may gies, and for sudden intraoperative death or hyperthermia after surgery,
presage full-blown disease. Acute myoglobinuria associated with a which may indicate a risk of malignant hyperthermia. In previously
malignant hyperthermia triggering agent is another clue. The child anesthetized children, questions should be asked regarding intraopera-
may not be hypermetabolic or febrile, but may have dark urine and tive anesthetic complications. The history should focus on determining
high serum creatine phosphokinase levels, with the risk of myoglobin- whether the child is at risk for anesthetic or surgical stress as well as
induced renal tubular damage. The finding of dark urine after cardiorespiratory disease and airway compromise.
administration of an anesthetic requires investigation for malignant Recent URIs should be noted. A URI is an upper respiratory illness
hyperthermia. An elevated creatine phosphokinase value and heme- associated with fever, mucopurulent green or yellow nasal discharge,
positive urine in the absence of red blood cells in the urine indicate a productive cough, injected sclerae, and increased mucous secretions.
need for renal protection with mannitol and alkaline diuresis. Clear rhinorrhea is generally not a concern. URIs can increase airway
Rapid therapy is essential. All known triggering agents must be reactivity for up to 6 wk in both normal children and children with a
stopped. Intravenous administration of dantrolene sodium (2.5 mg/ history of reactive airway disease. URIs can also increase the risk of
kg IV as an initial dose) is begun as soon as possible. The need for laryngospasm and bronchospasm, reduce mucociliary clearance, and
repeated doses is indicated by the persistence of muscle rigidity, aci- raise the risk of intraoperative atelectasis and hypoxemia. It is generally
dosis, and tachycardia, up to a maximum dose of 10 mg/kg. Once the recommended to avoid general anesthesia for elective procedures for
symptoms are controlled, the patient should be observed for at least 4-6 wk after a URI. In patients with chronic sinusitis and nasal polyps,
24 hr after the laboratory values have returned to normal, because infection should be thoroughly treated before elective anesthesia.
relapse can occur. Acute, fatal bronchospasm can occur during induction of anesthesia
Prevention of malignant hyperthermia in susceptible patients and endotracheal intubation for routine, minor surgery in children
requires the avoidance of triggering agents, which include inhalational with asthma. Those children at particular risk for anesthetic complica-
anesthetics. Most anesthesiology departments are capable of delivering tions with asthma are those who were (1) admitted to the hospital
general anesthetics using anesthesia machines from which all traces of within the previous year for their asthma, (2) seen in an emergency
anesthetic vapors have been removed. Intravenous anesthesia and a department in the last 6 mo, (3) admitted to an ICU, or (4) treated with
nitrous-opioid technique are safe. Dantrolene prophylaxis is not rec-
ommended because the disease is rapidly treatable and because the
drug causes respiratory depression and muscle weakness. For a child Table 61-8 American Society of Anesthesiology
in whom malignant hyperthermia is suspected, the malignant hyper- Physical Status Classification
thermia hotline, 1-800-MHHYPER (1-800-644-9737), should be used
to notify the Malignant Hyperthermia Association of the United States Class 1: Healthy patient, no systemic disease
(MHAUS). The Malignant Hyperthermia Association registers suscep- Class 2: Mild systemic disease with no functional limitations (mild
chronic renal failure, iron deficiency anemia, mild asthma)
tible patients and provides diagnostic and therapeutic information.
Class 3: Severe systemic disease with functional limitations
Preanesthesia susceptibility testing includes genetic analysis of the (hypertension, poorly controlled asthma or diabetes, congenital
ryanodine receptor gene, muscle biopsies, in vitro contraction studies, heart disease, cystic fibrosis)
and, possibly, measurement of muscle CO2 production in response to Class 4: Severe systemic disease that is a constant threat to life
intramuscular caffeine. (critically and/or acutely ill patients with major systemic disease)
Class 5: Moribund patients not expected to survive 24 hr, with or
Postoperative Apnea without surgery
Apnea within the 1st 48 hr after surgery and anesthesia in premature Additional classification: “E”—emergency surgery
infants is common; both central apnea and obstructive apnea (mixed Copyright American Society of Anesthesiology, http://www.asahq.org. Used
apnea) may occur. The use of respiratory depressants may impair with permission.
parenteral systemic steroids. The child should be free of wheezing for Biopsy with the child under local anesthesia may be indicated. If anes-
at least several days before surgery, even if this necessitates an increase thesia is required, cardiopulmonary bypass should be considered, in
in β-agonist dosage and the addition of steroids. Preoperative steroids case it becomes impossible to ventilate the child during surgery.
are indicated for all children with asthma who are receiving asthma In high-risk children, consideration should be given to initiating
therapy or who have received such therapy within the last year. treatment with steroids, radiation therapy, and chemotherapy before
Prednisone, 1 mg/kg given 24 and 12 hr before surgery, significantly obtaining a tissue diagnosis.
decreases airway reactivity perioperatively. Active wheezing is an indi-
cation for canceling elective surgery. If wheezing cannot be controlled Down Syndrome
on an outpatient basis with β-agonists, steroids, and other asthma Children with Down syndrome are occasionally behaviorally difficult
therapy, then hospital admission of the child for more aggressive and are especially fearful of medical caregivers (see Chapter 81). Their
therapy before surgery is indicated. cardiac anomalies, macroglossia, and upper airway obstruction can be
Bronchopulmonary dysplasia also poses significant intraoperative challenging. Children with Down syndrome have atlantoaxial instabil-
risks. The same applies to cystic fibrosis and other chronic lung dis- ity due to odontoid hypoplasia and joint laxity (see Chapter 680.3). In
eases. Every effort should be made to ensure that children with such younger children, extension of the neck, routinely used to maintain
disorders achieve the best possible respiratory status before surgery. and intubate the airway, may lead to cervical dislocation and spinal
Infections should be treated and reactive airways optimally treated cord trauma. Some anesthesiologists recommend extension and flexion
without evidence of wheezing. lateral neck films to detect instability before anesthesia. In children
with Down syndrome, it is wise to exercise caution in stabilizing the
Airway Evaluation cervical spine and also to avoid cervical flexion and extension.
Because the induction of anesthesia is associated with loss of spontane-
ous ventilation and airway reflexes, predicting the inability to bag-and- Cardiovascular System
mask ventilate or endotracheally intubate a child before anesthesia is Because of the depressant effects of anesthetics and the increased meta-
critical. The anesthesiologist must be told if the child has congenital bolic demands of surgery, any compromise of myocardial function
anomalies that affect the airway (Table 61-9). Such anomalies include should be clearly delineated preoperatively. A preoperative electrocar-
micrognathia syndromes, macroglossia syndromes, and some thoracic diogram, an echocardiogram, and a cardiology consultation are indi-
anomalies. Congenital anomalies associated with airway compromise cated for children with a history of heart disease. An intracardiac shunt
should be diagnosed preoperatively. Conditions that impair mouth will affect oxygenation status intraoperatively. Because of the signifi-
opening (temporomandibular joint disease) should be noted. A history cant effect on the oxygen supply-and-demand relationship caused by
of wheezing or stridor may indicate postoperative airway complica- general anesthesia and surgical stress, obstructive lesions, such as a
tions and difficult intraoperative airway management. valvular stenosis, must also be clearly defined. A history of cardiac
dysrhythmias should be clearly understood, because inhalational anes-
Mediastinal Masses thetics are dysrhythmogenic.
Children with anterior mediastinal masses, such as lymphomas and In neonates, ductus arteriosus, myocardial compromise, pulmonary
primary mediastinal tumors, are at serious risk for airway compromise, edema, or congenital heart disease can significantly complicate oxygen
cardiac tamponade, and vascular obstruction. Induction of general delivery during anesthesia. Accurate diagnosis of cardiac murmurs in
anesthesia and even mild sedation can lead rapidly to total loss of the neonates is essential. Any preoperative cardiovascular compromise will
airway, with inability to ventilate the child and cardiovascular collapse. be worsened intraoperatively and can catastrophically complicate the
These patients often present in a semiemergency fashion, with the need perioperative course.
for both a tissue diagnosis of the mass before treatment is initiated and Anemia should be diagnosed and corrected preoperatively if pos-
a surgically placed central venous line. sible. A hematocrit value >30% is generally acceptable for routine
Significant compression of vital structures can occur with seemingly elective anesthesia. If there are reasons to expect significant blood loss
mild symptoms. Tachypnea, orthopnea, wheezing, and sleep distur- or prolonged convalescence, anemia should be corrected preopera-
bances or avoidance of prone or supine positions are significant indica- tively. In the emergency setting, transfusion may be required. Although
tions of serious risk. Pericardial tamponade or superior vena cava lower hematocrit values can be tolerated in unstressed children, the
syndromes are more concerning findings. A CT scan showing >50% significant threat to oxygen delivery posed by anesthesia and surgery,
compression of the airway at the carina is an indication to prohibit especially if blood loss is expected, requires maintenance of an ade-
general anesthesia and provide only mild sedation. Echocardiographic quate hemoglobin concentration perioperatively.
or CT evidence of pericardial tamponade, right ventricular compres- Evidence of coagulopathy should be sought. Easy bruising, the use
sion, or compression of the pulmonary artery suggests severe risk. of aspirin, and familial bleeding disorders should be discussed. Intra-
operative hemorrhagic bleeding can be difficult to control; massive
perioperative blood transfusions have significant risk of morbidity and
Table 61-9 Difficult Airway Syndromes mortality. Preoperative correction of coagulopathic disorders is indi-
cated. In neonates, assurance of vitamin K prophylaxis and adequate
Achondroplasia coagulation status is critical before any significant surgery. In neonates
Airway tumors, hemangiomas and critically ill children, adequacy of platelet count and, where indi-
Apert syndrome cated, coagulation factors, prothrombin time, and partial thromboplas-
Beckwith-Wiedemann syndrome tin time should be assured.
Choanal atresia
Cornelia de Lange syndrome Neurobehavioral Considerations
Cystic hygroma/teratoma
DiGeorge syndrome
Seizures, significant neurologic impairment, altered level of conscious-
Fractured mandible ness, respiratory airway compromise secondary to neurologic disease,
Goldenhar syndrome and neuromuscular disease should be sought and evaluated. Anticon-
Juvenile rheumatoid arthritis vulsant drug metabolism is often altered perioperatively, and this
Mucopolysaccharidosis change may affect anticonvulsant drug levels. Anticonvulsants may also
Pierre Robin syndrome complicate anesthetic management. Maintenance of appropriate anti-
Smith-Lemli-Opitz syndrome convulsant therapy postoperatively is important to avoid new seizures.
Treacher-Collins syndrome Cerebrospinal fluid secretion is increased during surgery and general
Trisomy 21 anesthesia. This fact is significant in patients in whom elevated intra-
Turner syndrome
cranial pressure is suspected and in children with ventriculoperitoneal
shunts. In infants or older children with ventriculoperitoneal shunts, The Full Stomach
shunt patency and function should be assured before surgery. Because of the serious complications of aspiration of gastric contents,
Illness and the need for surgery or painful medical procedures are it is desirable to secure the airway as rapidly as possible after obtunda-
psychologically traumatic events for children and their families. Chil- tion in patients at risk for having a full stomach. Gastric emptying may
dren are also remarkably adept at sensing stressful signals from their be delayed for up to 96 hr after an acute episode of trauma or surgical
parents and caregivers. Many children who require anesthesia may illness. Under these circumstances, induction of general anesthesia and
have significant levels of fear and anxiety. Most children undergoing endotracheal intubation are performed in a rapid sequence (rapid
surgery have new-onset negative behavioral changes in the postopera- sequence induction; see Chapter 67).
tive period, such as maladaptive behavioral responses that include The risks of rapid sequence induction include the possibility that if
generalized anxiety, enuresis, enhanced separation anxiety, temper tan- the airway cannot be intubated, the child is paralyzed without a pro-
trums, nighttime crying, and fear of strangers, doctors, and hospitals. tected airway and ventilation may be hazardous or impossible. Rapid
Approximately 20% show these negative behavioral adaptations for sequence induction should be performed by those who can definitely
6 mo after surgery. Sleep quality is also altered postoperatively, result- achieve endotracheal intubation quickly. It should be avoided in
ing in further behavioral compromise. patients with a history of failed oral endotracheal intubation or with
The risk factors for postoperative behavioral changes include pre- any of the many syndromes (micrognathia) associated with difficult
operative or induction anxiety and behaviors indicating extreme intubation. Under these circumstances, bronchoscopic awake intuba-
stress, as well as emergence excitation. The type of surgery may be tion may be indicated.
important, with tonsillectomy and genitourinary surgery having a Before rapid sequence anesthesia induction, the child should be
high incidence of postoperative behavioral changes, whereas simple preoxygenated by breathing 100% oxygen for 2 min to give an extra
procedures (tympanostomy tubes) seem to be associated with fewer margin of safety if intubation is difficult. The child should not receive
changes. Another risk factor is recurrent procedures, such as anesthe- assisted ventilation either before or after the administration of drugs
sia for laser surgery, strabismus surgery, or repeated eye examinations, because this may lead to increased gastric air and actually increase the
which lead to difficult behavioral changes and have a significant effect likelihood of vomiting, regurgitation, and aspiration.
on family dynamics. One common regimen for rapid sequence induction includes the
Preoperative psychologic preparation programs decrease the inci- administration of 1.5-3 mg/kg of propofol concurrently with either
dence of postoperative behavioral changes, which last for up to 1 mo. 0.9-1.2 mg/kg of rocuronium or 1.5 mg/kg of vecuronium. Immedi-
PPI does not improve postoperative behavior. Oral midazolam (0.5 mg/ ately after the administration of sedation and muscle relaxants, the
kg) may decrease negative behavioral changes after surgery. Mid- Sellick maneuver (cricoid pressure) should be performed by applying
azolam has the benefit of providing not only rapid-onset anxiolysis in firm pressure in a posterior direction against the cricoid cartilage. This
10-20 min but also very effective and rapid (10 min) amnesia. displaces the cricoid cartilage into the esophagus, forming an artificial
sphincter to prevent reflux of the gastroesophageal contents. Cricoid
Preoperative Preparation pressure should be maintained until correct placement of the endotra-
The child should be in the best possible nutritional state, and nutri- cheal tube is verified by direct visualization, fogging of the tube, and,
tional supplementation, even hyperalimentation in chronically ill chil- in all circumstances, positive end-tidal CO2.
dren, may be worthwhile.
POSTOPERATIVE PAIN MANAGEMENT
Preoperative Fasting Continuation of analgesia and anxiolysis should follow surgery or
Aspiration of gastric contents is a perioperative disaster and, if super- painful procedures (see Chapter 62). Complete freedom from pain is
imposed on lung disease, may be rapidly fatal. Aspiration may lead to not possible. Preoperative education about the surgery and a pain
laryngospasm and bronchospasm, with hypoxemia and hypoxic isch- management plan, development of skills designed to decrease anticipa-
emic encephalopathy. It may also produce intraoperative atelectasis tory anxiety, and active participation in treatment planning can be
and postoperative pneumonia. It is vital to ensure that the stomach is helpful for some children and families. Adjunctive therapy, such as
as empty as possible before the induction of anesthesia. Acid aspiration virtual reality, hypnosis, pet therapy, and play therapy, also can decrease
is less likely with an empty stomach. Table 61-10 lists preoperative the need for potent analgesics postoperatively.
fasting (NPO status) guidelines. The combination of opioid and nonopioid analgesic agents and an
Clear, sweet liquids (Pedialyte, 5% dextrose in water) facilitate understanding of the benefits and risks provide the foundation of pain
gastric emptying, help avoid hypoglycemia, and can be given up to 2 hr management. A judicious combination of nonsteroidal antiinflamma-
before anesthesia in any child. For older infants and children, a fasting tory drugs, cyclooxygenase-2 inhibitors, intravenous acetaminophen,
period of 4 hr for liquids provides optimal safety and minimal discom- opioids, and regional analgesia has a role in postoperative pain man-
fort. Solids must be avoided for at least 8 hr before surgery. Because agement. Repeated evaluation is as important as the modality of pain
surgery is frequently scheduled in the morning, and for ease and clarity management. Continuous and repetitive small doses of analgesia
of understanding, the general guideline is no consumption of solids around the clock are more effective at reducing pain than occasional
after midnight. Many conditions delay gastric emptying, and pro- prn dosing intervals.
longed periods of fasting may be required in the presence of stress, Patient-controlled analgesia (PCA), nurse-controlled analgesia, and
anxiety, illness, trauma, gross obesity, or biliary atresia, or in children parent-controlled analgesia are all used postoperatively (see Chapter
with delayed gastric emptying for other reasons. 62). PCA provides continuous pain treatment and self-medication (vs
intermittent or prn pain control) as well as control and comfort in an
otherwise personally uncontrolled circumstance. PCA provides both a
Table 61-10 Guidelines for Preoperative Fasting background low-dose infusion rate of a continuous opioid and the
(“2-4-6-8 Rule”)* opportunity to supplement analgesia with bolus doses as needed. The
practitioner can determine the continuous infusion rate, the bolus
TIME BEFORE SURGERY (hr) ORAL INTAKE dose, the lockout interval, and the number of boluses per unit time
2 Clear, sweet liquids
that the patient may receive. PCA relies on the theory that patients
cannot or will not overdose themselves because somnolence will
4 Breast milk decrease repeated self-administration. In young children, the use of the
6 Infant formula, fruit juices, gelatin pain button (for pain relief) may be more difficult to ensure; children
as young as 5 yr old have been able to use PCA successfully. In older
8 Solid food
children and adolescents, PCA should be a standard modality of post-
*These are general guidelines and may differ among hospitals. operative pain management.
Regional Anesthesia
Regional anesthesia is the use of anesthetics to block the conduction Table 61-11 Systematic Approach to Sedation in
of afferent neural impulses to the central nervous system. These can be Children
local analgesic techniques, peripheral nerve blocks, nerve plexus Thorough medical history, anticipating underlying medical
blocks, or epidural and subarachnoid (spinal) nerve blocks. They may problems that predispose the patient to sedation problems
be administered either through a single injection (single shot) or Careful physical examination focused on the cardiorespiratory
through continuous infusion, as is common with epidural and occa- system and airway
sionally subarachnoid blocks. They may be used for intraoperative Appropriate fasting
anesthesia and postoperative analgesia, and they have the potential to Informed consent
decrease intraoperative analgesia and anesthetic use, as well as to Pediatric drug dosing (mg/kg)
provide postoperative pain management. Increased use of regional Appropriately sized equipment
A separate, dedicated observer to monitor sedated patients who
indwelling catheters to deliver continuous analgesia has shortened
may have airway compromise (induced or preexisting)
recovery times and hospital stays in children. Documentation of vital signs and condition on a time-based record
Analgesia at the site of need, without central cardiorespiratory Emergency backup system, “code” team, and “crash cart”
depressant effects, can be valuable. Local anesthesia, with injection of Fully equipped and staffed recovery area
lidocaine or bupivacaine into the affected area, can provide procedural Discharge criteria documenting recovery from sedation
analgesia that lasts for several hours. Infiltration of the wound site and
the edges of an incision decreases postoperative pain in the initial
hours after surgery. This can be performed by the surgeon at the con-
clusion of surgery and may supplement postoperative analgesia. responses to painful stimuli persist. Sedation that is sufficient to obtund
Epidural analgesia is common in pediatric practice. The epidural painful responses is most likely deep sedation. Deep sedation is a state
space lies between the dura and the pia and arachnoid membranes, an of unarousability to voice and is accompanied by suppression of reflex
area through which all nerve roots pass. Bathing these nerve roots in responses. Management of sedated children requires vigilance and
local anesthetics inhibits conduction of pain impulses centrally. A knowledge to ensure their safety and is governed by the same guide-
single dose of epidural anesthetic may provide hours of pain relief, and lines as anesthesia care (Table 61-11). A dose of sedative medication
a continuous infusion may provide effective pain relief for hours to that causes minimal sedation in one subject may produce complete
days. The epidural injection of opioids can provide analgesia for unconsciousness and apnea in another. Careful attention to guidelines
12-24 hr and is a potential supplement to postoperative analgesia. for appropriate monitoring and management of sedation in children is
A lumbar epidural injection is placed in the lumbar area to provide imperative. For threatening and nonpainful procedures, anxiolysis or
analgesia for labor and for surgery below the thorax. Caudal epidural light sedation is frequently sufficient. For painful procedures (e.g.,
analgesia is placed through the sacral hiatus, inferior to the distal end bone marrow aspiration, insertion of percutaneous IV catheter lines,
of the spinal cord. This is the site most commonly used for regional lumbar punctures), the combination of sedation with analgesia that is
anesthesia and analgesia in children and is efficacious for the provision required in children produces deep sedation.
of pelvic and lower limb anesthesia as well as beneficial in orthopedic Many specialists provide sedation and anesthesia care for children.
and urologic surgery. A continuous infusion of bupivacaine is the most The use of anesthetic agents is not limited to anesthesiologists, but a
common means of providing postoperative epidural pain relief; it may hospital’s department of anesthesiology provides expertise in develop-
be mixed with an opioid (fentanyl or preservative-free morphine). It is ing and managing systems of anesthesia care, including sedation. With
also possible to provide epidural PCA with a continuous infusion the widespread use of the deceptively safe general anesthetic agent
pump and the ability of the patient to self-medicate with bolus prn propofol to provide sedation, hospitals, pediatricians, and other care
dosing. Epidural analgesia can also provide pain relief in patients with providers must ensure that credentialing, oversight, quality assurance,
chronic pain or pain caused by advanced malignant conditions. and protocols for administration of anesthetic agents provide safe care.
The most serious complications of neuraxial anesthesia include Involvement of anesthesiologists in organizing services, training other
cephalad spread of blockade with respiratory depression, paralysis of practitioners, overseeing safety, systems, and quality, and remaining
respiratory muscles, and, in extreme cases, brainstem analgesia and involved in the delivery of such care is sound practice. The elements
depression. The most common complications of neuraxial analgesia of a safe system to provide procedural sedation for children are as
include mild discomfort; a paresthesia-like feeling of numbness and follows:
tingling; pruritus, which, if opioids are used, can be quite distressing; ◆ Defining the required knowledge set
and occasional nausea and vomiting. Infection and epidural hematoma ◆ Defining the required skill set
are extremely rare. Neuraxial opioids, especially when administered ◆ Determining the appropriate requisite training
intrathecally, can cause respiratory depression; their use requires post- ◆ Ensuring adequate understanding of the drugs and their effects
operative monitoring. The use of neuraxial opioids often requires treat- (desired and undesired) and interactions
ment with antipruritic as well as antiemetic drugs. ◆ Credentialing providers
◆ Ensuring ongoing maintenance of skills
Bibliography is available at Expert Consult. ◆ Reviewing the practice
◆ Ensuring that the sites where anesthesia care is provided meet
recognized standards
◆ Last but not least, overseeing a process of continuous quality
61.1 Sedation and Procedural Pain improvement
Randall C. Wetzel Sedation with chloral hydrate (not approved by the FDA in the
United States or the European Medicines Agency in the European
The same drugs that induce general anesthesia are often used to provide Union), pentobarbital, or benzodiazepines is often adequate for non-
sedation (see Table 61-5). Sedation care requires a presedation evalu- painful procedures. Nevertheless, there can be a high failure rate as
ation, intraprocedural monitoring, and postsedation recovery, analo- well as complications by using this method, such as prolonged seda-
gous to the provision of anesthesia. Sedation is on the continuum tion (hours to overnight), ataxia, nausea and vomiting, desaturation,
between wakefulness and general anesthesia (see Table 61-4). The term and the occasional need for rapid intervention. The temptation to
conscious sedation refers to a condition in which a patient is sleepy, add opioids and deepen sedation increases the risk of complications.
comfortable, and cooperative but maintains airway-protective and ven- The use of dexmedetomidine for procedural sedation is safe; recovery
tilatory reflexes. Unfortunately, for most children, this level of sedation time can be prolonged, and success can be variable. The quickest way
provides little or no analgesia, and both psychologic and physiologic to ensure safely reversible sedation is with potent anesthetic agents.
Chapter 61 ◆ Anesthesia, Perioperative Care, and Sedation 429.e1
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The ultra–short-acting anesthetics (propofol, methohexital, remifent-
anil) provide effective procedural sedation, but their use carries a
higher likelihood of inadvertent oversedation and induction of general
anesthesia. These anesthetics offer efficient and rapidly reversible
procedural sedation. However, their use requires the presence of an
anesthesiologist and/or specially trained, experienced, and qualified
physicians.
Bibliography is available at Expert Consult.
61.2 Anesthetic Neurotoxicity

Randall C. Wetzel
There is compelling experimental evidence that anesthesia-induced

neurodegeneration with developmental impairment occurs in neonatal
animals. Pediatric anesthesiologists have become deeply concerned by
the demonstration of anesthetic-induced apoptotic neuronal cell death,
central nervous system neurodegenerative changes, and their effects on
the developing brain. These studies demonstrate both histopathologic
changes and developmental defects from both inhalational and IV
anesthetics, including isoflurane, ketamine, benzodiazepines, and pro-
pofol given to newborn animals. Combinations of drugs may cause
more injury. Existing nonclinical data implicate both N-methyl-d-
aspartate and γ-aminobutyric acid pathways in apoptosis and cell death
in neonates.
The studies reporting these results were performed in animals
(largely rodents), and great controversy exists concerning dose,
duration of treatment, species differences, and experimental design.
Although there is cause for concern and further study, alternatives to
general anesthesia for many procedures in infants do not exist. Perhaps
regional anesthetic techniques and narcotic-based anesthetics will be
increasingly used. Interestingly, dexmedetomidine appears to block the
neurotoxic effects of other anesthetics. There is insufficient current
data for suggesting the safety of one anesthetic approach over another.
The potential for this neurotoxicity must be balanced against the neces-
sity of providing adequate anesthesia for neonates.
Bibliography is available at Expert Consult.
Chapter 61 ◆ Anesthesia, Perioperative Care, and Sedation 430.e1
Bibliography Langhan ML, Mallory M, Hertzog J, et al: Physiologic monitoring practices during
Cramton REM, Gruchala NE: Managing procedural pain in pediatric patients, pediatric procedural sedation: a report from the Pediatric Sedation Research
Curr Opin Pediatr 24:530–538, 2012. Consortium, Arch Pediatr Adolesc Med 166(11):990–998, 2012.
Doctor K, Roback MG, Teach SJ: An update on pediatric hospital-based sedation, Sahyoun C, Krauss B: Clinical implications of pharmacokinetics and
Curr Opin Pediatr 25:310–316, 2013. pharmacodynamics of procedural sedation agents in children, Curr Opin
Harrison D, Beggs S, Stevens B: Sucrose for procedural pain management in Pediatr 24:225–232, 2012.
infants, Pediatrics 130:918–925, 2012. Tobias JD: Dexmedetomidine and ketamine: an effective alternative for procedural
Havidich JE, Cravero JP: The current status of procedural sedation for pediatric sedation? Pediatr Crit Care Med 13(4):423–427, 2012.
patients in out-of-operating room locations, Curr Opin Anaesthesiol 25(4):453– Wetzel RC: Who is doing what to whom: a large prospective study of propofol
460, 2012. anesthesia in children, Anesth Analg 108(3):695–698, 2009.
430.e2 Chapter 61 ◆ Anesthesia, Perioperative Care, and Sedation
Bibliography Sun L: Early childhood general anaesthesia exposure and neurocognitive

Flick RP, Katusic SK, Colligan RC, et al: Cognitive and behavioral outcomes after development, Br J Anaesth 105(Suppl 1):i61–i68, 2010.
early exposure to anesthesia and surgery, Pediatrics 128(5):e1053–e1061, 2011.

Anesthesia, Perioperative Care, and Sedation: Randall C. Wetzel

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416 Part VIII ◆ Pediatric Drug Therapy

Table 61-2 The Preanesthetic History

Anesthesia, Perioperative Family history of anesthetic complications, malignant hyperthermia,

Table 61-3 Specific Pediatric Diseases and Their Anesthetic Implications

Table 61-4 Definitions of Anesthesia Care

Table 61-5 Selected Drugs Used in Anesthesia

emergence. Normal physiologic functions, such as spontaneous venti-

be ruled out. Occasionally, it is necessary to sedate the child with

Bibliography is available at Expert Consult.

61.2 Anesthetic Neurotoxicity

There is compelling experimental evidence that anesthesia-induced

Bibliography is available at Expert Consult.

Bibliography Sun L: Early childhood general anaesthesia exposure and neurocognitive

You might also like

Anesthesia, Perioperative Care, and Sedation: Randall C. Wetzel

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Copyright

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Anesthesia, Perioperative Care, and Sedation: Randall C. Wetzel

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﻿416 Part VIII ◆ Pediatric Drug Therapy

Table 61-2 The Preanesthetic History

Anesthesia, Perioperative Family history of anesthetic complications, malignant hyperthermia,

Table 61-3 Specific Pediatric Diseases and Their Anesthetic Implications

Table 61-4 Definitions of Anesthesia Care

Table 61-5 Selected Drugs Used in Anesthesia

emergence. Normal physiologic functions, such as spontaneous venti-

be ruled out. Occasionally, it is necessary to sedate the child with

Bibliography is available at Expert Consult.

61.2 Anesthetic Neurotoxicity

There is compelling experimental evidence that anesthesia-induced

Bibliography is available at Expert Consult.

Bibliography Sun L: Early childhood general anaesthesia exposure and neurocognitive

You might also like

416 Part VIII ◆ Pediatric Drug Therapy