pediatric anaesthesia management

1. Pediatric anaesthesia
Dr. Radhwan Hazem Alkhashab
Consultant anaesthesiologist & intensivist
2021

2. For all elective surgery, it should be possible to prepare the child and family for what is to be expected in
the perioperative period It is not unusual for a child to present with coryzal symptoms alone. There is an
increased incidence of airway problems during anaesthesia; these children are more at risk of laryngeal
spasm, breath-holding and bronchospasm, and in the postoperative period the chance of post-intubation
croup is increased.
Children who have active viral illnesses such as chickenpox should not have elective surgery, nor should
children who have recently been immunized using live vaccines, for two reasons: first, there is an
associated myocarditis or pneumonitis; and, secondly, to protect others on the ward who may be
immunocompromised.
It is extremely important that the child is weighed before arrival in theatre, because body weight is the
simplest and most reliable guide to drug dosage. Veins suitable for insertion of a cannula should be
identified and, if possible, local anaesthetic cream applied and covered with an occlusive dressing.

3. Preoperative Fasting
Morbidity and mortality caused by aspiration of gastric contents are extremely rare in
children undergoing elective surgery. Prolonged periods of starvation in children,
especially the very young infant, are harmful.
These children are at risk of developing hypoglycemia and hypovolemia.
Research has shown that children allowed unrestricted clear fluids up to 2 h before
elective surgery have a gastric residual volume equal to or less than that of children
who have been fasted overnight. Infants who are breast-fed may have their last
breastmilk 4 hours before induction of anesthesia . Solids ( formula milk) should not be
given for at least 6 h before the anticipated start of induction.

4. In the emergency setting, e.g. the child who has sustained trauma shortly after ingesting
food, it is probably best (if possible) to wait 4 h before inducing anaesthesia. If it is
surgically possible to wait 4 h, an I.V. infusion of a glucose-containing solution such
as 5% dextrose with 0.9% NaCl, must be commenced.

5. Premedication
The advent of local anaesthetic creams has reduced the necessity for sedative premedication.
Currently, two formulations are available:
1. EMLA (eutectic mixture of local anaesthetics) :
Venepuncuture is usually painless if it has been applied and an occlusive dressing placed over
the site at least 1 h before the planned procedure. It should not be used in the very small child
or on mucous membranes because of the danger of systemic absorption of prilocaine that
results in methaemoglobinaemia. It should not be left on the skin for more than 5 h. A major
disadvantage of EMLA is that it causes some venoconstriction and this may obscure the vein.
2. Tetracaine gel : It has the advantage of a quicker onset of action and also provides analgesia
for a considerable period of time after the occlusive dressing has been removed (4 h).

6. Occasionally, a sedative premedicant drug is required.
Premedication may be administered orally, intramuscularly, intravenously, rectally,
sublingually, or nasally
1. Midazolam given orally in a dose used is 0.5 mg kg. An effect occurs within 10 min,
with the peak at 20–30 min after administration.
2. Oral ketamine in a dose 3–10 mg kg.
3. An antisialagogue (e.g. atropine 0.02 mg kg-1) should be added to prevent excess
salivation. If profound degrees of sedation are required, it is possible to combine
midazolam and ketamine.

7. Routes of induction
1. Oral or sublingual premedication does not hurt but may have a slow onset or be spit out.
2. Intramuscular medications hurt and may result in a sterile abscess.
3. Intravenous medications may be painful during injection or at the start of infusion.
4. Rectal medications sometimes make the child feel uncomfortable, cause defecation, and
occasionally burn.
5. Nasal medications can be irritating, although absorption is rapid.
Midrange doses of intramuscular ketamine (2 to 4 mg/kg) combined with atropine (0.02mg/kg) and
midazolam (0.05mg/kg), or oral ketamine (4 to 6 mg/kg) combined with atropine (0.02mg/kg) and
midazolam (0.5 mg/kg, maximum of 20 mg), will result in a deeply sedated child.
Higher doses of intramuscular ketamine (up to 10 mg/kg) combined with atropine and midazolam
may be administered to children with anticipated difficult venous access

8. Anticholinergic drugs are not routinely administered intramuscularly to children because
they are painful on administration and do not significantly reduce laryngeal reflexes
during induction of anesthesia. On the other hand, atropine (0.02mg/kg) administered
orally or intramuscularly less than 45 minutes before induction does reduce the
incidence of hypotension during induction with potent inhaled anesthetics, but only in
infants younger than 6 months

9. The Child with an Upper Respiratory Tract
Infection
A child with a URI is a major concern for the anesthesiologist.
It is likely that a child with a URI has an irritable airway and is at increased
risk for laryngospasm, bronchospasm ,post intubation croup, atelectasis
,pneumonia, and episodes of desaturation an increased incidence of airway-
related problems in children who are passively exposed to tobacco smoke.
These complications can be reduced by avoiding endotracheal intubation or
using a supraglottic device such as an LMA. bronchial hyper reactivity may last
for up to 6 weeks after a URI, If the child is acutely ill and obviously getting
worse, the case is canceled .If the child has rhonchi and a productive cough,
the case is canceled

10. Airway Management
The Jackson–Rees modification of the Ayre’s T-piece is the breathing system used
traditionally for children under 20 kg in weight. It has been designed to be light
weight with a minimal apparatus dead space. The apparatus may be used for
both spontaneous and controlled ventilation. The open-ended reservoir bag is
used for manually controlled ventilation. This mode of ventilation is especially
useful in the neonate and infant, as the anaesthetist is able to detect changes in
compliance produced by tube displacement. A minimum gas flow
rate of 3 L min-1 is required to operate this apparatus satisfactorily. Fresh gas
flows of 300 mL /kg for spontaneous respiration and flows of 1000 mL plus 100
mL kg for controlled ventilation.

11. For the older child, it is satisfactory to use a Bain, circle absorber system. It is easy to
scavenge the waste gases from these systems with the resultant benefit of reducing
pollution of the theatre environment. In addition, the circle system offers economic
advantages because of the low fresh gas flows required.
The Guedel airway is a useful adjunct in maintaining the airway of a child undergoing
anaesthesia. It is important that the appropriate size of airway is used. If an airway is
too small or too large, it may obstruct the child’s airway completely.
The correctly sized airway should reach the angle of the mandible. The tongue should
be depressed using a depressor or even the blade of the laryngoscope and the airway
inserted. The method used in adults of rotating the airway through 180° during insertion
is not recommended for small children because of the possibility of damaging the
pharynx and subsequently compromising the airway.

12. It is mandatory to intubate the trachea during artificial ventilation. Intubation of the
trachea confers many advantages. The lungs are protected against aspiration of
gastric contents, ventilation is controlled and Broncho alveolar toilet may be
performed.

13. Anatomical description
The larynx of a child under the age of 2 years tends to sit higher in the neck opposite the vertebral bodies
of C3–4, whereas in the older child it is opposite C5–6. This results in the larynx being more anterior
during laryngoscopy. The epiglottis of the infant is relatively large and, because the cartilaginous
support is not fully developed, tends to be floppy. The anaesthetist cannot usually elevate the
epiglottis sufficiently in order to be able to see the vocal cords if a curved blade such as the
Macintosh is used. Instead, the anaesthetist has to use a straight blade and place it on the posterior
surface of the epiglottis whilst lifting. In addition to the above, gentle cricoid pressure helps to bring
the three axes into alignment.
In the adult, the narrowest part of the airway is the glottic opening. In the child, the narrowest part is
the cricoid ring, which cannot be seen during laryngoscopy. It is very important that the correct size of
tube is selected. If too large a tube is selected, the tracheal mucosa is damaged and the child may
develop post-intubation croup; if it is too small, excessive leak makes effective positive pressure
ventilation impossible.

14. Generally, cuffed tubes are used only in children above the age of 8 years. The reason for this is that the
pressure may render the underlying trachea ischemic and subsequently lead to post-intubation
croup. The laryngeal mask has eliminated the need for this. The following formulae are used to
calculate the internal diameter of the appropriate size of tube for children greater than one year:
(age/4) + 4.5 mm (uncuffed)
(age/4) = 3.5 mm (cuffed)
An alternative is to use a tube with an external diameter similar to that of the child’s little finger.
The tip of the tracheal tube should lie at the mid-trachea. For oral intubation, the measurement from the
alveolar ridge to the mid-trachea is about (age/2) + 12 cm. An alternative is three times the internal
diameter of the tube. For nasal intubation, the measurement is (age/2) + 15 cm.

15. *Inserting the endotracheal tube this distance from the alveolar ridge of the mandible or
maxilla places the distal end of the tube in the mid trachea

16. Induction of Anesthesia
1. Infants
Mask induction without premedication is generally used in infants younger than
10 to 12 months because this age group readily separates from their parents.
Once anesthesia has been induced, it is critical to rapidly reduce the inspired
concentration of halothane (down to 1.0%to 1.5%) or sevoflurane (down to 2%to
4%)and to keep it at this level or less until an intravenous line is in place.
After endotracheal intubation , the vaporizer should be closed before
laryngoscopy, it is easy to forget that a relatively high inspired concentration is
being delivered which may lead to cardiovascular collapse.

17. Older Pediatric Patients
Successful, psychologically atraumatic induction of anesthesia by mask in an older
pediatric patient requires that the child understand and cooperate. Premedication
is particularly helpful in the 1- to 4-year-old age group.

18. Rectal Induction of Anesthesia
A number of medications may be administered rectally for induction/premedication of
anesthesia (methohexital, thiopental, ketamine, midazolam).The main advantage of
this approach is that the child falls a sleep in the parent's arms.
Doses :
10%thiopental (20- 30 mg/ kg), midazolam (1mg/kg up to 20mg), and ketamine (6mg/kg).

19. Intramuscular Induction of Anesthesia
Many medications, such as methohexital (10mg/kg),ketamine(2 to 10mg/kg
combined with atropine [0.02mg/kg] and midazolam[0.5mg/kg),or midazolam
alone(0.15to 0.2mglkg),are administered intramuscularly for premedication or
induction of anesthesia. The main advantage of this route of administration is
its reliability ;its main disadvantage is that it is painful.

20. Intravenous Induction of Anesthesia
Intravenous induction of anesthesia is the most reliable and rapid technique. The
main disadvantage is that starting an intravenous line can be painful and
threatening for the child. Intravenous Induction maybe preferable when induction
by mask is contraindicated (e.g. ,in the presence of a full stomach)

21. Laryngoscopic blades
In general, straight blades are used in Neonates and
toddlers because of anatomic differences from older
children . Older children can be managed with either
curved or straight blades
.A laryngoscope blade with built-in oxygen delivery is
available in sizes0 and I and offers specific advantage
for awake or sedated intubation of neonate

22. Full stomach
A child with a full stomach must be treated the same as for an adult with a full stomach;
that is, both should undergo rapid sequence induction of anesthesia with the
application of cricoid pressure. Because oxygen consumption is much greater,
hemoglobin desaturation occurs more rapidly in a child than in an adult and more
rapidly in an infant than in a child

23. Technique of RSI
1. Atropine (0.02 mg/kg) is administered intravenously to prevent reflex- or
succinylcholine-induced bradycardia and to delay the bradycardia of hypoxemia.
2. Succinylcholine is still the muscle relaxant of choice in this circumstance and
should be administered at a dose of (1 to 2 mg/kg) immediately after thiopental
(5 to 6 mg/kg) or propofol (3 mg/kg). If succinylcholine is contraindicated,
rocuronium (1.2 mg/kg)
3. Cricoid pressure is gently applied after the child loses consciousness
4. In the hypovolemic child, ketamine (2 mg/kg) may be used for induction, where
as in a child with hemodynamic instability ,e.g. ,cardiomyopathy ,etomidate (0.2-
0.3mg/kg) may be a better choice

24. The Child with Stridor
A child with intrathoracic airway obstruction has expiratory Stridor and prolonged
expiration (bronchiolitis, asthma, intrathoracic foreign body).In contrast ,a child with
extra thoracic upper airway obstruction has inspiratory stridor (epiglottitis
,laryngotracheobronchitis , laryngeal or subglottic foreign body).When Agitated or
crying ,such children exhibit dynamic collapse of the airway ,which can markedly
worsen airway obstruction and lead to respiratory failure and hypoxemia.

25. The child is brought to the operating room with the mother or father who holds the child
during induction .Induction of anesthesia with halothane or sevoflurane in oxygen
by mask is the preferred method because maintaining spontaneous respirations is
critical. As soon as the child loses consciousness, the parentis escorted out of the
operating room. With the child lightly anesthetized an intravenous line is inserted.
This allows withdrawal of blood samples if indicated. Hydration is begun with
lactated Ringer's solution (15to 30 mL/kg),and atropine (0.02mg/kg)is given , If the
stridor worsens or mild laryngospasm occurs, the pop-off valve is closed sufficiently
to develop 10- 15cm H2Oof PEEP. This procedure relieves most instances of airway
obstruction caused by dynamic collapse of the airway and loss of pharyngeal muscle
tone when the child attempts to inspire against an obstructed airway
A child with laryngotracheobronchitis or epiglottitis usually requires an uncuffed
endotracheal tube that is 0.5 to 1.0mm (ID) smaller than normal.

26. Intravenous Fluid &Transfusion Therapy
Types of replacements:
1. Replacement of maintenance
2. Replacement of deficit.
3. Replacement of loss (3rd space loss , blood loss)
Fluid replacement as a maintenance should be as follow:
4ml/kg / hr, for the 1st 10 kg body weight
2ml/kg /hr, for the 2nd 10 kg body weight
1ml/kg / hr, for remaining body weight
This amount does not include fluid deficits, third-space losses.
In general, deficits caused by restriction of food and fluids are calculated by multiplying
the hourly maintenance rate by the number of hours of restriction; 50% of the
resulting deficit is replaced in the first hour and 25% in each of the next 2 hours.

27. 3rd space loss replenished according to the surgical procedure and may vary from
I ml/kg/hr for a minor surgical procedure to as much as 15ml/kg/hr for major
abdominal procedures (e.g., surgical repair of gastroschisis).
Type of fluids:
A balanced salt solution (e.g., lactated Ringer's solution) should be used for all
deficits and third-space losses. For maintenance replacement in child is thought
to be at risk for hypoglycemia, 5% dextrose in 0.45% normal saline should be
administered.

28. Fluid management of term and preterm infants must take into account other
variables. The amount of insensible water loss is inversely proportional to
gestational age. The younger and more physically immature the infant, the
higher the skin permeability, the ratio of body surface area to weight, and the
metabolic demand .
The daily fluid requirements for a term newborn in the days after birth are
70ml/kg on day 1,
80ml/kg on day3,
90ml/kg on day5,
120ml/kg on day7.

29. Packed Red Blood Cells
The use of blood products in pediatric surgical patients has diminished greatly
because of the fear of transmission of disease particularly human
immunodeficiency virus (HIV). The current estimated risk for transmission
of HIV HBV , or HCV is (1 in 81,000 - 1 in 1,600,000) units
Calculation of total blood volume (TBV) is as follow:
Blood volume is approximately
(100-I20 mL/kg) for a preterm infant
( 90ml/kg) for a full-term infant.
(80ml/kg) for a child (3 - 12months) old.
(70 mL/kg) for a child older than 1 year.

30. Maximal allowable blood loss MABL
Definition :
MABL Without Transfusion calculator suggests how much blood can be lost,
typically during surgery, before transfusion should be considered
MABL = EBV x (Starting hematocrit- Target hematocrit)
Starting hematocrit
*EBV = multiplying the child's weight by the estimated blood volume (EBV)
per kilogram
Example: if a3-year-old child weighs 15kg and has a starting
hematocrit of 38% and if clinical judgment estimates the desired
postoperative hematocrit to be 25%, the calculation would be as
follows:
MABL = (15x70)x (38-25) / 38= 1050x 13/ 38 = 360 mL

31. So MABL would be replaced with 3 mL of lactated Ringer's solution per milliliter of
blood loss; that is, 3 mL of lactated Ringer's solution times the 360mL of blood
loss equals approximately (1080 mL) of lactated Ringer's solution .
Postoperative vital signs monitoring is important for any blood loss may happen in
the word.
If the child has reached the MABL and significantly more blood loss is expected
during surgery, the child should receive PRBCs in sufficient quantity to
maintain the hematocrit in the (20% - 25%) range.
Hematocrit values in the low 20% range are generally well tolerated by most
children, the exception being preterm infants, term new borns, and children
with cyanotic congenital heart disease or those with respiratory failure in need
of high oxygen-carrying capacity .

32. Older children with a history of sickle cell disease may require preoperative transfusion
A simple formula for intraoperative or postoperative estimation of the volume of
PRBCs needed in a 15- kg child with a hematocrit of 20% as an example is
Volume of PRBCs to be transfused=
Desired Hct(35) - present Hct (20) x EBV(70ml/ kgx15kg)]
Hematocrit of PRBCs ( 60%.)
=( 35 - 2 0 ) x ( 7 0 x 1 5 )/ 60
= 262 mL PRBC
The typical dose for children weighing less than 15 kg is 10–20 mL/kg.

33. Fresh frozen plasma (FFP)
Fresh frozen plasma (FFP) is administered to replenish clotting factors lost:
1. During massive blood transfusion.
2. Disseminated intravascular coagulopathy.
3. Congenital clotting factor deficit.
Blood loss exceeding 1 to 1.5 blood volumes (replaced entirely with PRBCs and crystalloid,
albumin, or other nonblood-related products) often necessitates transfusion of FFP.
However, the decision to administer FFP should be based on observed coagulopathy and
documented prolongation of the PT and PTT. However, if PT exceeding(15)
seconds(international normalized ratio [INR] >1.4) or a PTT greater than 60
seconds (>1.5 times baseline) seems to warrant correction.

34. Transfusion of FFP at rates exceeding 1.0mL/kg/min is sometimes followed by severe
ionized hypocalcemia and cardiac depression with hypotension, especially if FFP
is administered during anesthesia with a potent inhaled anesthetic. Therefore
,exogenous calcium chloride (2.5to 5 mg/kg)or calcium gluconate (7.5to
15mg/kg) should be administer during rapid transfusion of FFP.
Ionized hypocalcemia occurs very frequently in neonates given FFP‘ possibly
because of their decreased ability to mobilize calcium and metabolize citrate

35. platelets
Thrombocytopenia may occur as a result of disease Processes (idiopathic
thrombocytopenic purpura, chemotherapy, infection, disseminated intravascular
coagulopathy) or dilution during massive blood loss.
. Children whose platelet count has fallen because of idiopathic thrombocytopenic purpura
or chemotherapy generally tolerate platelet counts as low as 15,000/mm'
without a need for platelet transfusion .In contrast, children whose platelet count has
decreased because of dilution (massive blood loss)generally require platelet
transfusion when the count is 50,000/mm or less. The initial volume of platelets
transfused is approximately 0.1 to 0.3U/kg

36. Monitoring Pediatric Patient
Routine monitoring:
Minimal monitoring during anesthesia should include:
1. Precordial or esophageal stethoscope, a
2. Blood pressure cuff
3. Electrocardiogram.
4. Temperature probe.
5. Pulse oximeter.
6. End-tidal carbon dioxide monitor.
7. Anesthetic agent analyzer.
Invasive monitoring includes: .If these monitors are
indicated, the anesthesiologist ,surgeon, cardiologist, or neonatologist should insert them.
1. Arterial catheter.
2. Central venous catheter: These devices facilitate the simultaneous intravenous administration of a
variety of fluids, vasopressors, and antibiotics
3. Peripherally inserted central catheters

37. SPECIFIC OPERATIONS IN THE
NEONATE

38. Pyloromyotomy
Pyloric stenosis usually presents in weeks 4–8 of life. A previously well male child
develops projectile vomiting. Untreated, the child becomes severely dehydrated with
a hypokalaemic, hypochloraemic metabolic alkalosis. Because the obstruction is
at the level of the pylorus, the body loses hydrogen and chloride ions
The kidney is thus presented with a large bicarbonate load, which exceeds its
absorptive threshold and this results initially in alkaline urine. As further
fluid depletion occurs, the renin-angiotensin-aldosterone axis is activated in an
attempt to preserve circulating volume. This results in an exchange of sodium
ions for hydrogen and potassium ions, which leads to a paradoxical aciduria with
a worsening hypokalaemia and metabolic alkalosis.

39. Preoperative Management
The initial management is insertion of a nasogastric tube and an intravenous cannula. A solution
of 5% glucose in 0.45% saline to which 40 mmol/L of potassium chloride has been added is
given at a rate of 6 mL kg/h. The nasogastric tube is aspirated and the aspirate replaced with
0.9% saline. The child is ready for surgery between 24 and 48 h after this regimen is started.
A normal serum potassium concentration and a bicarbonate concentration of 25 mmol/L are
used to indicate that sufficient volume replacement has taken place.
Children with pyloric stenosis can be managed with awake endotracheal intubation followed by
low-dose rocuronium (0.3mg/kg) or rapid-sequence induction of anesthesia with cricoid
pressure after atropine (0.02mg/kg), propofol (3 mg/kg), and succinylcholine(2 mg/kg)
Postoperative analgesia is provided by wound infiltration followed by either rectal or oral
paracetamol, depending on when the surgeon decides that the child may be fed.

40. Tracheo Esophageal Fistula
The commonest is C in which the proximal esophagus ends as a
diverticulum and the lower part exists as a fistula off the trachea
just above the carina. Cardiovascular anomalies such as a septal
defect or co-arctation of the aorta often coexist with this
condition. An echocardiogram should always be performed before
surgery.
The corrective surgery should be performed as a matter of urgency as
a one-stage repair because delay results in soiling of the lungs
and pneumonitis.

41. TE fistula…cont.
The major anesthetic issues include
(1) Evaluation for aspiration pneumonia;
(2) Over distention of the stomach from entry of air directly into the stomach through the fistula.
(3) Inability to ventilate the child because of the large size of the fistula.
(4) Problems associated with other anomalies, particularly a patent ductus arteriosus (shunting)
and other forms of congenital heart disease.
(5) The need for postoperative intensive care

42. TE fistula management
Preoperative management:
The child should be nursed in an upright position to prevent soiling of the lungs by
gastric fluid. It is important that a tube is placed in the diverticulum and
continuous suction applied to aspirate the saliva that the child cannot swallow.
If the lungs become soiled, then antibiotics and physiotherapy are required and
the operation should be performed as soon as the child’s condition has been
optimized.

43. TE fistula cont.
Induction of anaesthesia:
Generally, an "awake sedated“ intubation is performed. Usually administer 0.5
to 1 mic/kg of fentanyl and 25 to 50 mic/kg of midazolam. The endotracheal tube is intentionally passed
into the right main bronchus and then slowly withdrawn until breath sounds are heard on the left. Often
this technique ensures that the tip of the endotracheal tube is placed beyond the origin of the fistula,
thus avoiding massive distention of the stomach.
Postoperative management:
The lungs should be ventilated artificially so that adequate amounts of analgesia may be given and also
to prevent traction on the esophageal anastomosis by movement of the head
Postoperative pain may be managed with a caudal catheter threaded up to the thoracic level and either
intermittent bupivacaine (1 to 2 mL of 0.125%with epinephrine l:200,000) administered every 6 to 8
hours or a continuous infusion of chloroprocaine(I.5%o)with fentanyl (0.4mic/ml) infused at 0.3 to
0.8 mL /kg/hr. Note that such management may be undertaken only with the full support of a pediatric
pain service

44. Diaphragmatic Hernia
In this condition, the abdominal contents herniate through a defect in the diaphragm,
usually on the left side. The abdominal contents exert pressure on the developing lung
and, if the defect is large enough, the mediastinum is shifted to the right and the growth of the
contralateral lung is also impaired. Repair of the hernia is not an emergency and the child
should be managed medically. Problems which have to be managed include ventilation,
acidosis and pulmonary hypertension. Surgery is considered when the child’s condition has
been optimized medically.
Positive-pressure ventilation by bag and mask may expand the abdominal viscera and should be
avoided. Nitrous oxide should also be avoided for the same reason. It is wise to avoid
cannulation of veins in the lower extremity because the return of abdominal viscera
increases the pressure in the inferior vena cava. Infants who present soon after birth with
severe symptoms do not usually survive because they have inadequate amounts of lung
tissue to sustain life.

45. Exomphalos And Gastroschisis
Embryologically, these are two separate conditions. The abdominal contents, which have herniated
through the abdominal wall, offer a large surface area from which heat and fluid may be lost. It is
imperative that the abdominal contents are placed into a clear sterile polythene bag as soon as
possible after birth , The defects should be corrected as a matter of urgency.
The major problems with these defects include
(1) severe dehydration and massive fluid loss, both from the exposed visceral surfaces (gastroschisis is
chemical peritonitis) and from third-space losses caused by partial bowel obstruction;
(2) heat loss;
(3) the difficulty of surgical closure; and (a) the high association of this condition with prematurity and
other congenital defects, including cardiac abnormalities (with omphalocele, -20%.

46. Nitrous oxide should be avoided to facilitate surgery and a nasogastric tube must be
in place to decompress the stomach. Adequate intravenous access must be
ensured, and occasionally invasive monitoring is necessary if an associated
cardiac defect is present .The liberal use of muscle relaxants provides optimal
surgical conditions for closure of the defect
It is usual to ventilate the child’s lungs postoperatively because of the reduction
in compliance caused by return of the viscera to the peritoneum.

47. Meningomyelocele
Meningomyelocele (hernial protrusion of a part of the meninges and spinal cord
through a defect in the vertebral column) is a relatively common neonatal
abnormality. The following should be
considered in addition to the usual concerns for the management
of neonates:
(1) Special positioning for endotracheal intubation (defect placed on a'doughnut"
and towels under the head),
(2) the possibility of underestimating fluid and blood loss from the defect,
(3) the high association of this condition with hydrocephalus.
(4) the possibility of cranial nerve palsy resulting in inspiratory stridor
(5) the potential for brainstem herniation.

48. The anesthesiologist must establish adequate intravenous access and invasive
monitoring if appropriate; replace all fluid deficits, including loss from the defect
(usually with normal saline); and ensure that cross matched blood is available

49. Obstructive sleep apnea(OSA)
Defined as a "disorder of breathing during sleep characterized by prolonged upper
airway obstruction and/or intermittent complete obstruction (obstructive apnea)
that disrupts normal ventilation during sleep.
Children at particular risk include those with craniofacial abnormalities
,neuromuscular disorders ,obesity ,and adenotonsillar hypertrophy.
Abnormal sleep oximetry values (clusters of desaturation to <80%) have also
been shown to correlate with the severity of OSA
Even children undergoing surgery in the afternoon may be at greater risk than
those operated on in the morning

50. OSA …cont.
Cardiac dysfunction (cor-pulmonale) has developed and those in whom post
obstructive pulmonary edema could develop .These children may require
overnight ventilation in an ICU.
In general, risk factors for postoperative complications include
(1) Age younger than 3 years.
(2) Abnormal coagulation values.
(3) Evidence of OSA.
(4) Systemic disorders that place the child at increased perioperative risk (e.g.,cor
pulmonale, metabolic diseases).
(5) Presence of craniofacial or other airway abnormalities.
(6) Performance of the procedure is for peritonsillar abscess.
(7) Living a long distance from an adequate health care facility

51. Analgesia is generally provided with a combination of oral acetaminophen given
preoperatively or rectally after induction and low-dose morphine (50 mic/kg).
Some anesthesiologists prefer short-acting opioids such as fentanyl to minimize
respiratory depression and then supplement the analgesia with an additional
longer-acting opioid in the PACU
Ketorolac provides analgesia without adverse respiratory effects, but it is associated
with an increased incidence of postoperative bleeding if given before achieving
hemostasis.
Postoperative nausea and vomiting are generally treated with serotonin 5-HT3
antagonists, whereas postoperative swelling (plus vomiting) is treated with
dexamethasone(0.15mg/kg).

52. Regional anesthesia techniques
Most regional anesthesia techniques used in adults can be administered safely to
pediatric patients.
Caudal anesthesia, caudal narcotics, regional blocks, and child-parent-nurse-
controlled analgesia have all been accepted by anesthesiologists and children.
Recent advances in ultrasound equipment have further improved the accuracy of
nerve blocks. Even pediatric patient-controlled epidural analgesia has been used
successfully in children as young as 5 years.

53. Postoperative Care
Unless they are to be admitted to an ICU, all children should be nursed in a properly
equipped and staffed recovery unit. Oxygen should be administered until the
child has a good oxygen saturation breathing room air.
The child is returned to the ward when warm, pain-free and haemodynamically
stable. It is the anesthetist's responsibility to ensure that appropriate analgesia
and intravenous fluids have been prescribed.

54. Thanks!
Do you have any question?