Whats new in paediatric anaesthesia by dr. mrs. minnu m. panditrao

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review by Dr. mrs. Minnu M. Panditrao about the recent advances in the challenging field of Paediatric anaesthesia

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Whats new in paediatric anaesthesia by dr. mrs. minnu m. panditrao

  1. 1. WHATS NEW IN PAEDIATRIC ANAESTHESIA DRUGS
  2. 2. Dr. Mrs. Minnu M Panditrao ConsultantDepartment of Anaesthesiology & Intensive Care Public Hospital Authority’s Rand memorial hospital, Freeport, Bahamas
  3. 3. INTRODUCTIONPaediatric Anaesthesia • Challenging subspecialty • Smaller size & weight • Difference in pharmacokinetics
  4. 4. NEONATES & INFANTS• Do they really need anaesthesia?• Yes, they do• Precision & accuracy very important for safety
  5. 5. What is new?CURRENT PRACTICES• Pre anaesthetic preparation & medication• Anaesthesia Induction agents  Inhalation agents  IV Induction agents• Neuromuscular blocking drugs• Reversal agents• Analgesics - Opioids/Non Opioids• Local anaesthetics• Miscellaneous drugs
  6. 6. PRE OPERATIVE PREPARATION• Pre operative checkup / visit• Counseling of patients / parents• General explanation of place, equipment & procedure
  7. 7. PREMEDICATION• Injectables are not preferred• Other routes – Oral :- Triclofos, Promethazine, Midazolam, Ketamine – Sublingual/Trans Mucosal :- Fentanyl – Intra nasal :- Midazolam, Ketamine, Sufentanil – Rectal :- Midazolam, Methohexital, Diazepam, Ketamine – IM :- Ketamine (2 mg/kg)
  8. 8. INDUCTION AGENTS• Inhalational – for routine surgeries, uncooperative patients, incremental induction/ starting with high concentrations.• Intravenous – for rapid sequence induction in emergency surgeries, patients with i.v. lines in situ, cooperative patients.
  9. 9. SEVOFLURANE• Polyflurinated methyl isopropyl ether• Inhalational agent of choice for induction• Rapid induction & recovery - low blood gas solubility• Techniques of induction• MAC• Metabolism• Disadvantages
  10. 10. HALOTHANE• Still used ‘coz of cost restraints• Advantages• Techniques of induction• Disadvantages
  11. 11. ISOFLURANE• Maintenance Inhalational Anaesthetic Agent• Advantages• Disadvantages• MAC/ Metabolism
  12. 12. DESFLURANE• Most recent inhalational anaesthetic agent• More suitable for Maintenance• Advantages• Disadvantages• MAC/ Metabolism
  13. 13. INTRAVENOUS INDUCTION AGENTS PROPOFOL• Rapidly acting Alkyl Phenol• Potent, No analgesia• Dosage bolus : 2.5 – 4 mgKg infusion : 0.1 – 0.2 mgKgmin• Advantages• Propofol infusion syndrome• For TIVA - Paedfusor
  14. 14. KETAMINE• Water soluble, non irritant• Good analgesic, CVS stability• Routes of administration I.V. / I.M. (for induction) Oral, Intra nasal IV infusion Additive in neuraxial, regional blocks• Disadvantages
  15. 15. THIOPENTONE• Still has a place where other IV agents are contraindicated i.e. • Neuroanaesthesia in neonates • Convulsive disorders etc.
  16. 16. NEURO MUSCULAR BLOCKING DRUGS• Paediatric patients are Resistant to depolarizing NMBDs Sensitive to non-depolarizing NMBDs• Metabolism in the liver delayed
  17. 17. • Succinyl Choline• Atracurium / Cisatracurium• Mivacurium• Doxacurim
  18. 18. • Vecuronium/Pancuronium• Rocuronium• Rapacuronium• Priming with NMBDs
  19. 19. REVERSAL AGENTS• Neostigmine / Edrophonium + Atropine / Glycopyrrolate• Sugmadex – Modified γcyclodextrin sodium salt, specific for reversal of rocuronium. No need to combine with Atropine. Reports of use in adults. Dose: 12-15 mgKg
  20. 20. ANALGESICS OPIOIDS- µ agonists• Fentanyl• Alfentanyl• Sufentanil• Remifentanyl
  21. 21. OPIOIDS• Butorphenol• Buprenorphine• Tramadol• Codiene
  22. 22. NSAIDSFor mild – moderate pain reliefDrug Oral dose Rectal dose IM dose IV doseParacetamol 10-15 mgKg 20-40 mgKg 15 mgKg 6 hrly 12 hrly 12 hrlyDiclofenac 1-1.5 mgKg 1-1.5 mgKg 1-1.5 1 mgKg 12 hrly 12 hrly mgKgIbuprofen 5-10 mgKg 6 hrlyKetorolac 0.5 mgKg 0.5 mgKg
  23. 23. LOCAL ANAESTHETICSNeonates and infants - prone to L.A. toxicityLocal Anaesthetic DosesDrugs Single Continues Max. dose shot infusion 4 hr period technique MgKghr MgKg MgKgLignocaine 3-5Bupivacaine 2-2.5 0.2-0.5 2Levobupivacaine 2 0.125-0.4 2Ropivacaine 3 0.2-0.4 1.6
  24. 24. MISCELLANEOUS DRUGSClonidine• α2 adrenergic agonist• Co-analgesic Routes of administration  Oral (1-2 µg Kg 8 hrly)  IV ( 0.1- 0.5 µg Kg hr)  Spinal/epidural (2 µg Kg)  Regional nerve blocks
  25. 25. Dexmedetomidine A newer α2 adrenergic agonist Has hypnotic & analgesic properties Reported use – as a sedative for Radiological investigative procedures Cardio-catheterisation Awake craniotomies Burn dressings Sevoflurane emergence agitation Also co-administered in paediatric cardiac anaesthesia
  26. 26. Dexmedetomidine• Given as an I.V infusion• Dose:• Loading dose 1-4 µg Kg• Infusion rate 0.5-1 µg Kg hr• Onset of action 10-20 min• Recovery time 20-60 min• Side effects  ↓ HR (15 %)  ↓ MAP (15%)
  27. 27. Gabapentin• Has an analgesic and opioid sparing effect• Dose 10-20 mgKg orally• Side effects  Gastritis  Nausea, Vomiting  Dizziness
  28. 28. Melatonin -for sedation Satisfactory effect in elderly patients. Unsatisfactory in children Dose- 5-10 mgCaffeine- for apoenic spells Dose- 10 mgKg24 hrs Side effects: Tachycardia, Sympathetic stimulation
  29. 29. Thank You!

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