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Pediatric Anesthesia
Darko J Vodopich MD
Resident @ CWRUMHMC
Revised by: Greg Gordon MD, and Susan Sweda MD
Development:
Organogenesis - 1st 8 weeks
Diaphragm and intercostal muscles do not achieve type-1 adult muscle fibers until age 2 Obligate nasal breathers
Airway difference:
Large tongue Higher located larynx Epiglottis short and stubby, angled over the inlet
Angled vocal cords we must rotate ETT to correct lodging at anterior comissure Narrowest portion is cricoid cartilage
Pharmacology/dynamics:
Increased total body water: Large initial dose required Less fat longer clinical drugs effect
Redistribution of the drug into muscle will increase duration of clinical effect (fentanyl) Consider liver and kidney immaturity
Desflurane:
Increased incidence of coughing, laryngospasm, secretions Concern of hypertension and tachycardia from sympathetic activation
Remember: MAC for potent volatile anesthetics is increased in neonates, but may be lower for sicker neonates and premies
Induction drugs:
Methohexital:
1-2 mg/kg i.v. or 25-30 mg/kg per rectum Side effects: burning hiccup apnea extrapyramidal syndrome Contraindication: temporal lobe epilepsy
Thiopental:
5-6 mg/kg i.v. Caution in low fat children and malnourished
Induction drugs:
Propofol:
3 mg/kg i.v. (until 6 years of age) Pain on injection - 0.2 mg/kg Lidocaine i.v.
Ketamine:
10 mg/kg IM, PR, orally Increased salivation Contraindications: Increased ICP Open globe injury
Induction drugs:
Benzodiazepines:
Diazepam:
0.1-0.3 mg/kg orally T1/2 80 hours contraindicated < 6 months
Midazolam:
Only FDA benzodiazepine approved in neonates 0.1-0.15 mg/kg IM 0.5-0.75 mg/kg orally 0.75-1.0 mg/kg rectally Reduce dose in drugs cause Cytochrome P450 inhibition
Induction drugs:
Narcotics:
Morphine:
Increased permeability of blood/brain barrier 50 mcg/kg IV
Meperidine:
Less respiratory depression than morphine Be cautious in long term administration because of its metabolite normeperidine
Induction drugs:
Narcotics(2):
Fentanyl:
12.5 mcg/kg IV during induction provides stable cardiovascular response 1-2 mcg/kg adjuvant to anesthesia Stable cardiovascular response
Induction drugs:
Muscle relaxants:
Succinylcholine:
2.0 mg/kg IV; 4.0 mg/kg IM Consider Atropine 10-15 mcg/kg given prior SUX Potential side effects: Rhabdomyolysis Hyperkalemia Masseter spasm MH
Induction drugs:
Muscle relaxants(2):
If tachycardia desired - Pancuronium Mivacurium - brief surgeries, beware of histamine release, bronchospasm Rocuronium - useful for modified RSI, and can be administered IM (1 mg/kg)
N2O/O2
HALOTHANE
Muscle relaxanta d-Tubocurarine Pancuronium Metocurine Atracurium Cisatracurium Vecuronium Mivacurium Doxacurium Pipecuronium Reversal agentsb Edrophonium Neostigmine
0.60 0.08 0.34 0.30 0.10 0.08 0.10 0.030 0.080 (0.31.0 mg/kg) + atropine (0.010.02 mg/kg) (0.020.06 mg/kg) + atropine (0.01 0.02 mg/kg)
Premedication:
Almost all sedatives are effective Usually not necessary < 6 months Most common route used is oral Side effects: Oral - slow onset IM - pain, sterile abscess Rectal - uncomfortable, defecation, burn Nasal -irritating Sublingual -bad taste
2. Its success may be judged by the peacefulness of the separation. 3. Large volume of literature indicates lack of clearly ideal technique
http://metrohealthanesthesia.com/edu/ped/pedspreop6.htm
Midazolam (Versed)
PO: 0.5 to 1.0 mg/kg up to 10 mg max. Bioavailability = 30% Peak serum levels after about 45 minutes Peak sedation by about 30 minutes 85% peaceful separation Mix with grape concentrate or acetaminophen (Tylenol) syrup or elixir or Motrin Suspension (10 mg/kg of the 2% suspension)
Midazolam (Versed)(2)
Nasal: 0.2 to 0.6 mg/kg Peak serum level in 10 minutes 0.2 mg/kg same as 0.6 mg/kg except 0.2 mg/kg did not delay recovery 0.6 mg/kg may delay extubation
Midazolam (Versed)(3)
Sublingual: 0.2-0.3 mg/kg as effective as 0.2 mg/kg intranasal Rectal: 0.35 to 1.0 mg/kg Some effect by 10 minutes, peak effect 20-30 minutes. 1.0 mg/kg did not delay PACU discharge.
Methohexital (Brevital)
Rectal 25 to 30 mg/kg as 10% solution in warm tap water 85% sleeping within 10 minutes = rectal induction of GA (very peaceful separation) Sleep duration: about 45 to 90 minutes 25 mg/kg did not delay recovery in one study, but some delay may be expected after a short (less than 30-minute) case.
Doubling dose leads to "oral induction of general anesthesia" in most cases. Lasts 30 to 60 minutes.
Pruritus
Hypoventilation (SpO2 <90)
Preoperative interview:
SAY GOOD, YES sleepy breeze anesthetic vapors pinch hug your arm stickers will be neat! fun! might get the giggles make you laugh feels funny take a little nap good job, good boy/girl proud of you cool, refreshing nice little back rub NOT BAD, NO gas bad smell, stink, stench, bee sting take blood pressure ekg pads won't hurt don't cry make you cry feels bad put you to sleep don't be bad cold solution press on your back
http://metrohealthanesthesia.com/edu/ped/pedspreop4.htm
Fasting:
Clear liquids - 2-3 h before the procedure If infants are breast fed - 4 h before the procedure For older patients = the adults rule Be aware of dehydration
Induction of Anesthesia:
Inhalational induction:
Younger than 12 months
After the induction, place the intravenous catheter Use suggestions in older child (pilots mask) In a case of difficult airway - Fiberoptic intubation
Induction of Anesthesia:
Rectal induction:
Methohexital Thiopental Ketamine Midazolam Technique no more intimidating than rectal temperature measurement Usual time of onset ~ 10-15 min
Induction of Anesthesia:
Intramuscular induction:
Most common used Ketamine
Disadvantage painful needle insertion Advantage: reliability
Induction of Anesthesia:
Intravenous induction:
The most reliable and rapid technique Disadvantage - starting intravenous line If patient is older ask the patient If you insert IV line: I. Do not allow the patient to see it II. Use EMLA cream III. If use local - ask the patient if there is any sensation on puncture
Endotracheal tubes:
Recommended Sizes and Distance of Insertion of Endotracheal Tubes and Laryngoscope Blades for Use in Pediatric Patients RECOMMENDED Age Of The Diameter Size of the Patient Distance (internal) Blade Premature 2.5 0 67 (<1,250 g) Full term 3.0 01 810 1y 4.0 1 11 2y 5.0 11.5 12 6y 5.5 1.52 15 10 y 6.5 23 17 18 y 78 3 19
Intravenous fluids:
Calculation of Maintenance Fluid Requirements for Pediatric Patients Weight Fluids (mL/hour) 24-H Fluids (mL) (kg) <10 4 mL/kg 100 mL/kg 1120 40 mL + 2 mL/kg > 10 1,000 mL + 50 mL/kg > 10 >20 60 mL + 1 mL/kg > 20 1,500 mL + 20 mL/kg > 20
Include if present: Fluid deficits Third spaces losses Hypo/hyperthermia Unusual metabolic fluids demands
Ionized Hypocalcemia:
Platelets:
Find etiology - TTP, ITP, HIT, DIC, hemodilution after massive blood transfusion Consider transfusion if Platelets < 50.000 In certain hospitals platelet function test is available If Platelets < 100.000 and EBL = 1-2 TBV transfusion more likely If Platelets > 150.000 and EBL > 2 TBV transfusion more likely
Anesthesia Circuits:
Nonrebreathing circuits: 1. Minimal work of breathing 2. Speeds-up rate of inhalational induction 3. Compression and compliance volumes are less (small circuit volume) Use of Mapleson D system is recommended in children < 10 kg More sensitive to changes in gas flow More sensitive to humidification Actual delivered volume is greater than other systems
Mapleson D Circuit:
Neonatal Anesthesia:
Understand differences in
Prevent retinopathy of prematurity by: Lower FiO2 Keep CO2 within normal range
Stress Response:
Poorly tolerated
Underestimating fluid or blood loss from the defect High association with hydrocephalus Possibility of cranial nerve palsy Potential for brain-stem herniation
Pyloric stenosis:
First 3-6 weeks in life Anesthesiologist concern: I. Full stomach with barium II. Metabolic alkalosis with Hypochloremia and Hypokalemia III. Severe dehydration Surgery is never emergency Metabolic correction mandatory before the surgery Suction the stomach before induction Consider awake intubation or RSI
Omphalocele
Gastroschisis
Anesthesiology concern: 1. Dehydration 2. Massive fluid loss (exposed viscera and 3rd space loss) 3. Heat loss 4. Difficulty of surgical closure 5. High association with prematurity, congenital defects, including cardiac anomalies Minimize infection, Replenish fluids, be liberal in muscle relaxants, consider hypotension and difficulty ventilation
Profound hypoglycemia
Hyperviscosity syndrome Associated visceromegaly
Diaphragmatic hernia:
Usually presentation on 1st day of life Almost all viscera can be in the chest cavity Anesthesia concerns: I. Hypoxemia II. Hypotension III. Stomach herniation IV. Pulmonary hypertension V. Systemic hypotension
Shifted mediastinum
Diaphragmatic hernia
1. Awake intubation 2. Intraarterial catheter 3. Use opioids (stress response) 4. Use Pancuronium Shifted mediastinum 5. Avoid hypothermia Diaphragmatic hernia 6. Avoid any myocardial depressant 7. Avoid N2O (abdominal distention) 8. Aware of barotrauma-induced pneumothorax 9. Adequate intravenous access 10. Plan postoperative care
Most regional anesthetics are safe to use Strict attention to: Dose Route of administration Proper equipment used Common: Caudal blocks