Anesthesia during the first year of Life

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  • Dear sir , the paper is easy for me to apply in my practice and well informed to me. Thank you so much if you can give the copy of this better
    information .( Hari Anggoro anesthesiologist of Medical Faculty in Surabaya Indonesia)
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  • Dear Sir, Thanks for your very informative presentation. It will be really helpful for pediatric anesthesiologist. I am Dr Azad pediatric anesthesiologist from bangladesh, will be happy if you send me the copy of this presentation! Thanks once again. Your cooperation is highly solicited!
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Anesthesia during the first year of Life

  1. 1. Anesthesia During the First Year of Life Hany El-Zahaby, MD Dept. of Anesthesia, Ain Shams University
  2. 2. <ul><li>“ Safe and effective anesthesia for neonates & infants undergoing surgery is one of the most challenging tasks presented to anesthesiologist.” </li></ul><ul><li>Knowledge </li></ul><ul><li>Manual skills </li></ul><ul><li>Continuous practice </li></ul><ul><li>+ </li></ul><ul><li>Adequate monitoring </li></ul><ul><li>↓ </li></ul><ul><li>Outcome </li></ul>
  3. 4. Age-specific considerations Airway differences –Infant Vs Adult Big head , small body Tongue/Epiglottis relatively larger Glottis more superior, at level of C3 (vs C4 or 5) Cricoid ring narrower than vocal cord aperture
  4. 5. Age-specific considerations Fast desaturation <ul><li>Low FRC, high closing volume, highly compliant airways► atelectasis </li></ul><ul><li>High oxygen consumption + can’t do forced inspiration ► increase R.R. ►high work of breathing </li></ul><ul><li>Diaphragmatic breathing► easily fatigue (less type I muscle fibers)► fast desaturation </li></ul>
  5. 6. Age-specific considerations <ul><li>Cardiac output is rate dependent (can’t increase stroke volume) </li></ul><ul><li>Immature baroreceptor reflex and limited ability to compensate for hypotension by increasing heart rate. They are more susceptible, therefore, to the cardiac depressant effects of volatile anesthetics (parasympathetic predominance) </li></ul><ul><li>Immature hepatic function (drug dosing intervals &maintenance) </li></ul><ul><li>Immature renal function (poor toleration of fluid restriction/overload) </li></ul>
  6. 7. <ul><li>High volume of distribution of drugs </li></ul><ul><li>Temperature control ( easily loose heat under GA ) due to high surface area to body weight ratio, no shivering </li></ul><ul><li>Competent nociceptive system (nonanalgesic practice is no longer accepted) </li></ul>Age-specific considerations
  7. 8. Premedication <ul><li>Atropine (10-20µ/kg IV, minimum 100µ) to counteract parasympathetic reflexes. </li></ul><ul><li>Pain (increments of morphine 10-20µ/kg IV up to 100µ/kg) </li></ul>
  8. 9. Monitoring <ul><li>FiO2, ECG, NIBP, ETCO2, Pulse oximetry, Temperature </li></ul><ul><li>Direct BP (accurate, intravascular volume status e.g. undulations with ventilation and reduced upstroke of the BP curve in case of hypovolemia) </li></ul><ul><li>CVP (vasoactive drugs) </li></ul><ul><li>Urine output (1 ml/kg/h) </li></ul>
  9. 10. <ul><li>How Long Pre-oxygenation? </li></ul><ul><li>60 seconds 6L/min (gives 80-90 seconds before desaturation) </li></ul><ul><li> ( Morrison JE et al: Pediatric Anaesthesia1998:8;293) </li></ul><ul><li>Inhalation VS Intravenous Induction? </li></ul><ul><li>IV access + hemodynamically stable-> STP 4-8mg/kg (prolonged emergence & postoperative apnea)- Propofol 3-3.5mg/kg </li></ul><ul><li> </li></ul><ul><li>IV access + hemodynamically unstable -> Ketamine 1.5-3mg/kg </li></ul><ul><li>Difficult IV access or compromised airway -> Sevoflurane or halothane </li></ul><ul><li>Combined technique -> (opioid + nondepolarizing MR + inhalation agent) </li></ul>
  10. 11. <ul><li>LMA VS ETT? </li></ul><ul><li>LMA: less than 30-45 min </li></ul><ul><li>Size 1 ( 50% misplacement, NGT, small dose of MR, large dead space & hypercapnea, helpful for ex-premis with BPD) </li></ul><ul><li>ETT: longer surgeries </li></ul><ul><li> No awake intubation (very stressful/painful stimulus with suboptimal conditions) </li></ul><ul><li>Relaxation? </li></ul><ul><li>Succinyl choline (RSI) (higher doses than adults), large ECF volume </li></ul><ul><li>Nondepolarizing MR (similar doses as adults), sensitivity offset by large ECF </li></ul><ul><li>Deep inhalation anesthesia, disadvantages? </li></ul>
  11. 12. <ul><li>Technique? </li></ul><ul><li>Oral Vs nasal? (lateral/prone/limited head access) </li></ul><ul><li>Straight blade- go deeper then withdraw </li></ul><ul><li>Level: term neonate (9cm oral/11cm nasal), 1 year 11-12cm </li></ul><ul><li>Leak pressure? 20-25cmH 2 O, affected by head position& MR </li></ul><ul><li>50% decrease in flow from size 3.5 to 3 </li></ul><ul><li>Non-cuffed/cuffed: 8y (upper abdominal & thoracic surgery, poor lung compliance) </li></ul><ul><li>After intubation -> VCM (40cmH 2 O/15 sec) or TRIM (30cmH 2 O/10 sec) </li></ul>
  12. 13. <ul><li>Spontaneous Vs controlled? </li></ul><ul><li>-Spontaneous: more than 6 mos, less than 30 min </li></ul><ul><li>Pressure Vs volume control? </li></ul><ul><li>-Pressure control: First few days, premature, respiratory distress or lung pathology </li></ul><ul><li>-Volume control: surgical manipulations interfere with ventilation </li></ul><ul><li>-Peep 3-5 is routine </li></ul><ul><li>“ Whatever the technique, an expired tidal volume & PIP should be tailored to the desired levels” </li></ul>
  13. 14. Maintenance: <ul><li>Halothane/sevoflurane/isoflurane all depress baroreceptor reflex </li></ul><ul><li>Halothane depress the myocardium more </li></ul><ul><li>Halothane decrease the heart rate more </li></ul><ul><li>(Hypotension is treated by atropine & lowering halothane) </li></ul><ul><li>Sevo/Isoflurane decrease PVR more (treated by 5-10ml/kg fluid bolus) </li></ul><ul><li>Nitrous oxide 60% decreases MAC of halothane, isoflurane & sevoflurane by 60%, 40% & 25% respectively </li></ul><ul><li>Narcotics: -Fentanyl 1-2µ/kg if regional block was done </li></ul><ul><li>-Fentanyl based anesthesia for prolonged major surgery with postoperative ventilation </li></ul>
  14. 15. <ul><li>“ The use of light general volatile anesthetic with a central or peripheral nerve block has proved to be of great benefit in neonatal surgery” </li></ul><ul><li>Bosenberg AT et al, Pediatr Surg Int, 1992:7, 289 </li></ul><ul><li>Larsson BA et al, Anesth Analg 1997:84, 501 </li></ul>
  15. 16. Intraoperative Volume Replacement <ul><li>Hypovolemia with blood loss accounts for 12% of causes of cardiac arrest in OR with almost half of it due to under estimation of blood loss. * </li></ul><ul><li>* Anesthesia-Related Cardiac Arrest in Children: Update from the Pediatric Perioperative Cardiac Arrest Registry Bananker et al, Anesthesia & Analgesia, August 2007 </li></ul>
  16. 17. Assessment of dehydration Severe (150ml/kg) Moderate (100ml/kg) Mild (50ml/kg) 15 ++irrit/lethargic Intense Parched Absent Sunken Increased <0.5ml/kg/hr 10 Irritable Moderate Dry + + + <1ml/kg/hr 5 Normal Slight Normal Normal Flat Normal <2ml/kg/hr Wt loss% Behavior Thirst Mucous memb. Tears Anterior fontanel Skin turgor Urine output
  17. 18. Fluid & blood loss <ul><li>Type of fluid? Dextrose? BSS? </li></ul><ul><li>Weighing swabs before it dries . </li></ul><ul><li>Intraoperative blood loss should be replaced with balanced salt solution (1:3), or colloid (1:1) </li></ul><ul><li>Estimated maximum allowable blood loss = </li></ul><ul><li>EBV x (Hctstarting – Hctacceptable) </li></ul><ul><li> Hctstarting </li></ul>
  18. 19. Prevention of Heat Loss Radiation Evaporation Conduction Convection
  19. 20. Prevention of Heat Loss <ul><li>Room temp .: 76-78 F </li></ul><ul><li>Avoid unnecessary exposure & cover cotton wraps as much as possible </li></ul><ul><li>HME (active or passive) IVF : warm </li></ul><ul><li>Active warming mattress </li></ul><ul><li>Cover exposed viscera with warm wet towels </li></ul><ul><li>Incubator : keep plugged </li></ul>
  20. 21. Emergence <ul><li>Reversal of MR after spontaneous movement even with adequate time after last dose </li></ul><ul><li>Extubation: </li></ul><ul><li>Regular spontaneous breathing </li></ul><ul><li>Vigorous movements of all limbs </li></ul><ul><li>Gagging </li></ul><ul><li>Eye opening or pronounced grimacing </li></ul><ul><li>Stable hemodynamics & good oxygen saturation </li></ul><ul><li>Absence of significant hypothermia </li></ul>
  21. 22. Case-specific considerations Hydrocephalus <ul><li>Burr hole over a dural venous sinus </li></ul><ul><li>Bowel injury (re-do) </li></ul><ul><li>Perforation of chest wall/neck vessels/occipital bone </li></ul><ul><li>Hemodynamic instability/arrhythmias (acute decompression) </li></ul>
  22. 23. Craniosynostosis <ul><li>Premature fusion of cranial suture -> lack of growth perpendicularly & compensated overgrowth in normal areas affecting mental development &vision due to intracranial hypertension </li></ul><ul><li>Difficult airway if syndrome </li></ul><ul><li>Positioning (Supine -> RAE or reinforced, Prone -> nasal T. sutured to nasal septum with 4-0 nylon) </li></ul><ul><li>Blood loss (Donation, coag. Profile, 2 Ivs, A line) </li></ul><ul><li>Prolonged surgery & hypothermia </li></ul><ul><li>Venous air embolism </li></ul><ul><li>Raised ICP </li></ul>
  23. 24. Encephalocele <ul><li>Wet/soft covering </li></ul><ul><li>Avoid pressure </li></ul><ul><li>Antibiotics </li></ul><ul><li>Prone (nasal intubation) </li></ul><ul><li>Blood loss </li></ul><ul><li>Hypothermia </li></ul><ul><li>Latex – free procedure </li></ul><ul><li>Document spontaneous breathing postoperatively </li></ul>Neural tube defect with variable neural dysfunction + Hydrocephalus + Arnold Chiari type II
  24. 25. Myelomeningocele <ul><li>Neural tube defect with variable neural dysfunction </li></ul><ul><li>+ Hydrocephalus + Arnold Chiari type II </li></ul><ul><li>Wet covering </li></ul><ul><li>Avoid pressure </li></ul><ul><li>Antibiotics </li></ul><ul><li>Prone (nasal intubation) </li></ul><ul><li>Blood loss </li></ul><ul><li>Hypothermia </li></ul><ul><li>Latex – free procedure </li></ul>
  25. 26. Neonatal Conditions Requiring Surgeries Airway Obstruction <ul><li>Inspiratory stridor with jugular &intercostal/subcostal retractions </li></ul><ul><li>-Bilateral choanal atresia </li></ul><ul><li>-Laryngomalacia </li></ul><ul><li>-Supraglottic papillomatosis </li></ul><ul><li>-Subglottic hemangioma </li></ul><ul><li>-Cystic hygroma </li></ul><ul><li>-The Pierre Robin Syndrome </li></ul>
  26. 27. Choanal atresia OGT CHARGE Syndrome (Coloboma-Heart –Atresia-Retarded-Genital-Ear)
  27. 28. Laryngomalacia
  28. 29. Supraglottic Papillomatosis <ul><li>Subglottic Hemangioma </li></ul>
  29. 30. Cystic Hygroma <ul><li>Cystic Hygroma( Recurrence) </li></ul>↑
  30. 31. The Pierre Robin Syndrome <ul><li>Typical Anesthestic Management of </li></ul><ul><li>a Neonate Presenting with Stridor: </li></ul><ul><li>ABG, chest x-ray </li></ul><ul><li>IV access, atropine, preoxygenation </li></ul><ul><li>Inhalation induction (deep) </li></ul><ul><li>CPAP </li></ul><ul><li>Smaller ETT or inhaled gases through side port of bronchoscope </li></ul><ul><li>Hydrocortisone 1-2 mg/kg </li></ul><ul><li>ICU or high dependency area for 12-24 h </li></ul>
  31. 32. Neonatal Conditions Requiring Surgeries Airway Obstruction Cleft Lip/Palate <ul><li>Echocardiography </li></ul><ul><li>Blood? </li></ul><ul><li>Atropine 10µ/kg </li></ul><ul><li>Difficult intubation </li></ul><ul><li>RAE tubes </li></ul><ul><li>Throat pack </li></ul><ul><li>Infra-orbital N. block </li></ul><ul><li>Extubation </li></ul>
  32. 34. Thoracic Surgeries Esophageal Atresia/TEF 1cm
  33. 35. Thoracic Surgeries Esophageal Atresia/TEF 1:3000 M:F 25:3 First fed chocking, cyanosis CHD, VACTERL association 13%
  34. 36. Thoracic Surgeries Esophageal Atresia/TEF <ul><li>Management: </li></ul><ul><li>Head up </li></ul><ul><li>Continuous low suction on blind pouch </li></ul><ul><li>Echocardiography </li></ul><ul><li>Antibiotics </li></ul><ul><li>Vit K </li></ul><ul><li>Next day surgery </li></ul>
  35. 37. Thoracic Surgeries Congenital Lobar Emphysema <ul><li>Unilateral disease due to bronchomalacia, vascular anomaly, bronchial obstruction) </li></ul><ul><li>Present with respiratory distress & cyanosis with mediastinal shift </li></ul><ul><li>Coexisting CHD in 35% </li></ul><ul><li>Anesthesia: </li></ul><ul><li>Spontaneous ventilation should be maintained with 100% oxygen + Ketamine + Inotropes </li></ul><ul><li>Expand lungs before closure </li></ul><ul><li>Intercostal block </li></ul><ul><li>Extubate (spontaneous breathing) </li></ul>
  36. 38. Thoracic Surgeries Patent Ductus Arteriosus <ul><li>A disease of Prematurity with Lt to Rt shunt resulting in: </li></ul><ul><li>1- Pulmonary over-circulation, high load on lt side, high output cardiac failure </li></ul><ul><li>2- In severe cases, reversal of diastolic aortic blood flow in the descending aorta resulting in splanchnic hypoperfusion and NEC </li></ul><ul><li>Treatment: </li></ul><ul><li>Fluid restriction/diuretics (hypovolemia + hypokalemia) </li></ul><ul><li>Endomethacin (transient renal dysfunction, platelet dysfunction) </li></ul><ul><li>Ligation </li></ul>
  37. 39. Thoracic Surgeries Patent Ductus Arteriosus <ul><li>Preoperative: </li></ul><ul><li>Echo (ht failure, hypovolemia) </li></ul><ul><li>Head ultrasound (intracranial pathology) </li></ul><ul><li>Routine labs (hypokalemia) </li></ul><ul><li>1 unit PRBCs, 1 unit plasma </li></ul><ul><li>Last 24h urine output </li></ul><ul><li>Anesthesia: </li></ul><ul><li>Atropine </li></ul><ul><li>Low dose Sevoflurane + opioids + relaxant </li></ul><ul><li>If not intubated, nasal intubation is preferred </li></ul><ul><li>Tolerate desaturation for progress of surgery (limit is bradycardia) </li></ul><ul><li>Treat hypotension with plasma expander + inotrope </li></ul><ul><li>Intercostal block by surgeon </li></ul><ul><li>No immediate extubation </li></ul>
  38. 40. Abdominal Surgeries Congenital Diaphragmatic Hernia 1:5000 M:F 1:1.8 Resp. distress Scaphoid abdomen Shifted heart sounds Bil. Pulmonary hypoplasia Hypoxia, hypercarbia Pulmonary HTN, shunting
  39. 41. Abdominal Surgeries Congenital Diaphragmatic Hernia <ul><li>Management: </li></ul><ul><li>Gentle ventilation: Limiting PIP, Oscillator ( preductal SpO2> 90%) </li></ul><ul><li> Delayed repair (>100h) until medical stabilization </li></ul><ul><li>Reversal of duct shunting </li></ul><ul><li>Oxygenation Index < 40 </li></ul><ul><li>PaCO2 < 40 </li></ul><ul><li>Stable hemodynamics </li></ul><ul><li>Poor Predictors: </li></ul><ul><li>Overall survival 63% </li></ul><ul><li>Polyhydramnios </li></ul><ul><li>Immediate need for ventilation </li></ul><ul><li>Immature RBCs (intrauterine ↓COP) </li></ul>
  40. 42. Abdominal Surgeries Congenital Diaphragmatic Hernia <ul><li>Anesthesia: </li></ul><ul><li>Working NGT </li></ul><ul><li>2 pulse oximeters </li></ul><ul><li>Atropine </li></ul><ul><li>Inhalation/ slow opioid </li></ul><ul><li>Treat hypotension with fluids/inotropes </li></ul><ul><li>Treat pneumothorax on the other side immediately </li></ul><ul><li>Treat the increased Rt to Lt shunt with fentanyl, higher FiO2, hyperventilation, correction of acidosis, Nitric oxide </li></ul>
  41. 43. Omphlocele 1:5000 Hernial sac CHD 30-40% Blood loss Hypothermia High abdominal pressure RSI Insensible water loss 10ml/kg/h UOP > 30 mmHg (Ventilation )
  42. 44. Gastroschisis Midline above umbilicus Other abnormalities are rare No hernial sac Coverage Heating I.V fluids Abdominal pressure
  43. 45. Gastrointestinal Obstruction Pyloric Stenosis <ul><li>Forceful projectile vomiting 4-6 weeks of age, palpable olive-like mass in epigastrium </li></ul><ul><li>Loss of hydrogen, chloride & potassium </li></ul><ul><li>Dehydration, electrolyte imbalance & acid-base disorder </li></ul><ul><li>Hypochloremic, hypokalemic alkalosis </li></ul><ul><li>Rehydration (do not accept base excess > +2) </li></ul><ul><li>Functioning NGT </li></ul><ul><li>RSI </li></ul><ul><li>No narcotics, local wound infiltration </li></ul>
  44. 46. Gastrointestinal Obstruction & Malrotation <ul><li>Rehydration </li></ul><ul><li>Functioning NGT </li></ul><ul><li>Cross match PRBCs, FFP </li></ul><ul><li>RSI (ketamine) </li></ul><ul><li>If hypotension, give boluses of FFP, albumin 5% or PRBCs + dopamine </li></ul><ul><li>Untwisting malrotated gut releases vasoactive substances & lactic acid causing hypotension </li></ul>
  45. 47. Inguinal Hernial Repair Hydrocele Undescended Testis <ul><li>Wiener ES et al: Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg 1996:31, 1166 </li></ul><ul><li>70% GA (face mask or LMA) + Caudal epidural or spinal An. </li></ul><ul><li>15% Spinal anesthesia alone </li></ul><ul><li>11% Caudal anesthesia alone </li></ul>
  46. 48. Necrotizing Enterocolitis <ul><li>It’s a disease of prematurity due to intestinal ischemia with secondary bacterial overgrowth -> abdominal distention, increasing gastric aspirate, gastrointestinal bleeding & generalized sepsis. </li></ul><ul><li>Antibiotics </li></ul><ul><li>TPN </li></ul><ul><li>Volume replacement (Albumin 5%, FFP, PRBCs) </li></ul><ul><li>Functioning NGT </li></ul><ul><li>Check coagulation profile </li></ul><ul><li>Ecchocardiography </li></ul><ul><li>Chest x-ray for BPD </li></ul><ul><li>Inotropes (do not interrupt) </li></ul><ul><li>Maintain UOP (volume, Lasix 0.5 mg/kg) </li></ul>
  47. 49. Bladder Extrophy <ul><li>Wet covering </li></ul><ul><li>Antibiotics </li></ul><ul><li>Blood loss </li></ul><ul><li>Hypothermia </li></ul><ul><li>Latex – free procedure </li></ul><ul><li>Postoperative immobility </li></ul>
  48. 50. Surgery on the NICU Graduate <ul><li>First group: Uneventful prematurity -> straight forward anesthesia </li></ul><ul><li>Second group: Ventilatory support-sepsis-PDA-IVH-NEC-multiple medications-BPD/chronic lung disease of the newborn-extubated with great difficulty. </li></ul><ul><li>The main concern is postoperative apnea until 6-12 Mon. </li></ul><ul><li>Goals: Avoid intubation/ventilation </li></ul><ul><li> Avoid postoperative apnea </li></ul><ul><li>Common surgeries: </li></ul><ul><li>1- Laser/cryosurgery for ROP -> Face mask/LMA, avoid IV drugs in general </li></ul><ul><li>2- Inguinal hernia repair -> awake caudal without any drug supplementation or combined with inhalation anesthesia via LMA </li></ul><ul><li>3- Circumcision -> face mask with penile block </li></ul>

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