Diana Scolaro

Scolaro-Cook
-Cook RN,BSN,CCRN
Pediatric Intensive Care Nurse,
OHSU, Doernbecher Childrens Hospital

Pediatric Anesthesia
Issues
Children are not small adults
Differ physiologically and psychologically
Drug dosage different than adults
Size difference
Sometimes unpredictable response
Constant vigilance needed
Rapid deterioration of cardiorespiratory
mechanism

Pediatric Anesthesia
Issues
Goals of Presentation:
Basic understanding of pediatric

cardiac and respiratory physiology

Management of pediatric

emergency situations

Pediatric Cardiovascular
Physiology
Function of Heart: Deliver a sufficient

cardiac output to meet bodys

metabolic needs

Cardiac output (CO) = Heart Rate(HR) x

Stroke Volume (SV)

SV = Preload, Afterload, Contractility

Children usually heart rate dependent
Bradycardia in children should be presumed

to be due to hypoxia until proven otherwise

Stroke Volume
Preload:
Too high: diuretics, arrhythmias, poor cardiac
function
Too low: volume load
Afterload:
Too high: vasodilators
Too low: vasoconstrictors
Contractility:
Hyperdynamic: B Blockers
Depressed: Digoxin, Inotropes

Physical Examination
Impaired cardiac function often

recognized first by physical

examination techniques
Heart rate
Quality of pulses
Capillary refill
Skin temperature/color

Physical Examination
Reduced cardiac output
Difficulty in palpating distal pulses
Tachycardic/Bradycardic
Prolonged capillary refill (>3 sec)
Cool skin, mottled appearance

Physical Examination
Blood pressure
Remains within normal parameters
until decompensation

Physical Examination
Blood pressure
Physiological changes to maintain
blood pressure
Secretion of antidiuretic hormone
Heart rate increases
Secretion of aldosterone/renin

Cardiac Dysrhythmias
Not common in pediatrics
May be associated with congenital

heart disease
Usually classified as rapid/slow,
hemodynamically stable/unstable
Significant when associated with a
fall in cardiac output

Cardiac Dysrhythmias
May be associated with

sedation/anesthesia

Sinus bradycardia
Ventricular tachycardia
Supraventricular tachycardia

Pediatric Respiratory
Physiology
Anatomy of Pediatric Airway
Narrowest portion at cricoid
Larynx at C3-4 (Adult C4-5)
Cuffed endotracheal tube > 8

years of age
Lymphatic tissue present and may
lead to airway obstruction

Pediatric Respiratory
Physiology
Resistance Important
Childs airway smaller
Resistance to airflow inversely

proportional the 4th power of the

radius of the lumen
R=8nl/r4

Causes of Increased Airway

Resistance
Asthma
Upper respiratory tract infections
Allergies
Obstruction
Secretions in airway

Airway Obstruction
May occur with oral soft tissues
Tongue
Pharyngeal structures
Secretions
Airway swelling
Viral infections
Asthma
May present with stridor/wheezing

Respiratory Mechanics
Minute Ventilation (VE)
Tidal Volume (TV) X Respiratory Rate (RR)
Alveolar Ventilation (VA)
(Tidal Volume Dead Space) X RR
Dead space nose, pharynx, large airways:
No interchange of CO2/O2

Alveolar Oxygenation
(PaO2)
FiO2 (Barometric Pressure Water

Pressure) PaCO2/RQ

RQ = Respiratory Quotient
Important Concept
As PaCO2 increases, PAO2 decreases
SaO2 decreases

Decreased Oxygen
Saturation (SaO2)
Atelectasis V/Q mismatching shunts
Dead space ventilation
Pneumothorax
Tamponade
Pulmonary embolus
Loss of respiratory drive
Pleural effusions

Functional Residual Capacity

(FRC)
FRC is source of oxygen during

expiration until lungs reinflate with next

breath
When FRC decreased, then lung segments

are closed leading to atelectasis and

hypoxia

Segments are closed leading to

atelectasis and hypoxia

FRC reduced when closing capacity exceeds

FRC

Functional Residual Capacity

(FRC)

N Engl J Med 287:690-698, 1972.

Children < 6 years of age

and adults >40 years of
age have a closing
capacity > FRC in the
supine position

Pediatric Emergency
Issues

Loss of Airway
Maintain with BVM using head

tilt/chin lift or jaw thrust

Intubate if unable to manage

airway or if unable to
oxygenate/ventilate

Proper Endotracheal Tube

Placement
Fog in tube: not necessarily in tracheal
Chest rise: not necessarily in trachea
Bilateral breath sounds: gastric air can

mimic breath sounds

Detection of CO2 extremely useful but
Can be in esophagus with yellow (CO 2) color if

patient has taken NaHCO3 for any reason

Can be in trachea with lavender color (No CO 2)
Cardiac arrest
Pulmonary hypertension
Complete airway obstruction

Best Way to Assess Proper

Placement
See tube pass between cords
Chest rise
Presence of CO2
Breath sounds present bilaterally/none

over epigastrum
If bradycardic an increase in heart
rate
O2 saturations may be low or
unobtainable with vasoconstriction

Stridor
Epinephrine 1:1000 solution: 0.01

mg/kg up to 0.5 mg sub q

Decadron: 0.25-0.5 mg/kg IV
every 8 hours for 5 doses
Epinephrine nebs:0.05 cc/kg

Wheezing:Bronchospasm
Albuterol nebs:0.01-0.03 cc/kg

(2.5 mg)
Solumedrol: 1 mg/kg q 6 hours IV.
Atrovent nebs:2-4 puffs q 4 hours
MgSO4: 40 mg/kg IV
(Bronchodilation)
Epinephrine: 0.01 mg/kg sub q as
for stridor

Hypotension
Airway
Heart Rate-Avoid bradycardia:

Atropine 20 mcg/kg IV for vagally

induced bradycardia not to be <
0.1 mg OR epinephrine 0.01
mg/Kg 1:10000 IV

 Vasodilation: warm extremities,

increased capillary refill

Fluid boluses with 20 cc/kg LR/NS

Ephedrine:0.2 mg/kg IV (releases

endogenous catecholamines)

Phenylephrine:0.1-0.5mg/kg IV

 Vasoconstriction: Cold extremities,

delayed capillary refill

Fluid bolus as previously described

Epinephrine: 0.01 mg/kg 1:10000

IV

Cardiac Dysrhythmias
Supraventricular Tachycardia:
Hemodynamically stable: Vagal

maneuvers successful 25%

Adenosine:100-250 mcg/kg rapid
IV push

 Hemodynamically unstable:

hypotension, neurologically
compromised, mottled, etc

Cardioversion: 0.5-1.0 J/Kg

synchronized mode

 Hemodynamically unstable without

pulse: CPR, defibrillation 2 J/kg-4

J/kg.
Hemodynamically unstable with
pulse: Synchronized
cardioversion:0.5-1.0 J/Kg

Sinus Bradycardia
Eliminate hypoxia as cause
Atropine: 20 mcg/kg IV
Epinephrine: 0.01 mg/kg IV
Isoproterenol:0.1-0.2 cc/kg of

1:50,000 solution

Seizures
Correct hypoxemia/airway
Ativan:0.05-0.1 mg/kg IV
Midazoloam:0.1 mg/kg IV
Phenobarbitol: 20 mg/kg IV

 Fosphenytoin:15 mg/kg IV
Glucose:0.5 mg/kg D25 or 1 mg

glucagon IV/IM.

Summary
Children are not small adults
Differ physiologically,

psychologically and
developmentally from adults
Medication dosages are different
Rapid cardio-respiratory
decompensation is a possibility at
all times