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Anesthesia during the first year of Life


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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>