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Similar to paediatric anaesthesia.pptx 2.pptx
paediatric anaesthesia.pptx 2.pptx
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- 2. Children are notlittle adults! Neonates: 0-30 days old Infants: 1 month to 1 year small Children(toddler): 1 -4 yrs Old child:4-12 yrs Full term neonate: born between 37-40 weeks Premature neonate: child born before 37 weeks gestation A 10-12 yrs old child thought of anatomically and physiologically small adult 2
- 3. Different anatomy Different physiology Differentpharmacology 3
- 4. Respiratory system (Anatomical changes) Head large – 1/3 size of adult head short neck & prominent occiput. Tongue large Nasal passages narrow Obligate nose breathers until 5 month Epiglottis- Narrower, U-Shaped, flops posteriorly Larynx High & anterior Level of C3-C4. (C5-C6 in adult) 4
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- 6. Cricoid Moreconically shaped in infants, narrowest at cricoid ring whereas in adult it is at level of vocal cords Trachea Deviated posteriorly & downwards Become anatomically similar to adult between 8-10 yrs. 6
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- 9. Clinical implication Sniffingposition will not help bag mask ventilation or to visualise the glottis . Head needs to be in neutral position Straight blade for better visualisation. Tight fitting ETT may cause edema(1mm edema will narrow airway by 60% ) Uncuffed ETT preferred for patients < 8 years old Fully developed cricoid cartilage occurs at 10-12 years of age 9
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- 11. Respiratory system(physiological changes) • Alveolismall & limited number –↓↓ Lung compliance Cartilaginous rib cage –↑ Chest wall compliance Chest wall collapse during inspiration and relatively low residual volume • MV is rate dependant • Less efficient ventilation -Chest is circular shaped with horizontal ribs - Weaker intercostal muscle and the diaphragm (easily fatigue as Fewer type 1 muscle cells) -Abdominal muscle strength undeveloped 11
- 12. • Caliber ofairways is relatively narrow…..more airway R • Large rate of o2 consumption • Ventilator drive are not well developed, so hypoxia and hypercapnia depress respiration • Postop apnoea common(if >15 sec or with desaturation or↓HR 12
- 13. The closingvolume > FRC until 6-8 yrs of age Increase tendency for airway closure at end of expiration Need IPPV during anaesthesia with a higher RR & the use of PEEP (High RR to maintain FRC) CPAP during spontaneus ventilation improves oxygenation & ↓the work of breathing Work of respiration may be 15% of O2 Consumption 13
- 14. Cardiovascular system Inneonates myocardium less contractile → ventricles less compliant & less able to generate tension during contraction Limits the size of stroke volume Cardiac output therefore rate dependant Fixed Cardiac output in neonates - 300-400 ml/kg/min at birth - 200 ml/kg/min within few months 14
- 15. Vagal parasymphathetictone is most dominant Bradycardia: – with reduced cardiac output - If with hypoxia- O2 & Ventilation initially -Cardiac compression - in neonate with HR≤ 60 Sinus arrhythmia normal 15
- 16. Less maturesympathetic system -low catecholamine store -blunted response to exogenous catecholamines -vascular tree less responsive to hypovolemia with vasoconstriction HALLMARK OF INTRAVASCULAR FLUID DEPLETION-↓BP WITHOUT↑HR Innocent systolic murmur-common Diastolic murmur pathological 16
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- 19. Renal system ↓GFR&RBF (adult value by 2 yrs) ↓creatinine clearance ↓ sodium excretion ↓ glucose excretion ↓ bicarbonate resorption ↓ diluting capability ↓ concentrating ability Meticulous attention to fluid administration 19
- 20. Dehydration: Poorlytolerated , Premature infants have increased insensible losses( large surface area relative to weight) larger proportion of ECF in children (40% BW as compared to 20% in adult) Conclusion: – Newborn kidneys has limited capacity to compensate for Volume EXCESS or Volume DEPLETION 20
- 21. Hepatic system Cytochromep450(phase1) fully developed but impaired phase2(50%) till 1 yr→ so prolonged action of BZD,barbiturates,opoids ↑GO reflux 21
- 22. Glucose metabolism Highglucose utilization – Prematures 5-6 mg/kg/minute – Neonates 3-4 mg/kg/minute Low glycogen stores(liver&myocardium) – hypoglycemia - Neonates < 30 mg/dl , Infants < 40 mg/dl -Increased risk with prematurity,SGA,diabetic mother maintenance with glucose containg fluid – D5RL, D5 ½ NS, D5 ¼ NS Hyperglycemia-iatrogenic 22
- 23. Thermoregulation Greater heatloss – Thin skin - Low fat content -High surface area/weight No shivering,sweating,vasoconstrictive mechanism until 1 yrs Nonshivering Thermogenesis by brown fat (↓in premature,sick neonates,by volatile age 23
- 24. Warm ot,mattress, fluid,hot air blanket,warm anaesthetic gases Optimal ambient temp to prevent heat loss: Premature infant: 34⁰C Neonates: 32⁰C Adults: 28⁰C 24
- 25. Effect of Hypothermia respiratory depression Acidosis ↓cardiac output ,irritability ↑ duration of action of drugs ↓platelet function ↑ risk of infection delayed awakening 25
- 26. Central nervous system BBB is poorly formed – Drugs (barbiturates, opioids, antibiotics, bilirubin) cross BBB easily , prolong & variable duration of action Cerebral vessels in preterm infant are thin walled & fragile Prone to IVH –↑ with hypoxia, hypercarbia, hypernatraemia,low HCT, Awake airway manipulation, rapid bicarb administration & fluctuation in BP and CBF 26
- 27. Appreciate painwith ↑HR,BP and neuroendocrine response Myelination complete by 7yrs Nonmyelination ↓nerve size ↓distance between favour penetration,early onset LA and nodes of ranvier CEREBRAL AUTOREGULATION-functional from birth ↑CMR02-metabolism decreases with age(neonate to 4yrs↑) ↓CBF 27
- 28. Haematology HbF- Atbirth, 70-90% - 3 months 5% Hb –new born=18-20g/dL , HCT ~ 0.6 -3-6 Mo =9-12 g/dl( ↑in circulating volume is more rapid the bone marrow function) O2 disso. curve shifts to right as the level of HbA & 2,3-DPG↑ Vit K dependant clotting factor (II, VII, IX, X) & PLT are deficient in first few months Transfusion recommended when 15% of the circulating volume 28
- 29. pshycology <6mn-no fear 4yrs-separation from parents,unfamiliar surroundings School age-upset about surgical procedure,pain Adoloscent-pain,not able to cope illness 29
- 30. Pharmacological changes Totalbody water content ↑(70-75%) – Large Vd for water soluble meds – Increased dose/kg Hepatic biotransformation immature Protein binding decreased Neuromuscular junction immature less fat and muscle mass in neonates– Termination of action by redistribution prolonged LARGE LOADING,LESS MAINTAENANCE 30
- 31. Volatile anaesthetics ↑Minute ventilation to FRC ratio ↑ Blood flow to vessel rich groups – Rapid rise in alveolar anesthetic concentration ↓ Blood-gas coefficients lower in neonates Inhalation induction rapid – BP of neonates and infants more sensitive to hemodynamic effects of volatile agents – Caution against overdose of other agents 31
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- 34. Perioperative anaesthetic management preoperative Preop interview Recent URTI-Bronchial reactivity lasts 6 wks -URTI with afebrile,stable→proceed -acutely ill,rhonchi,productive cough →cancel -in emergency-anticholinergic,humidification of inspired gas,long recovery stay Laboratory tests-ECG Only if - symptomatic -harsh,loud,holosystolic,diastolic murmur,radiates -bounding pulse -congenital heart ds or chemotherapy 34
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- 36. 36 For grade3 and4 surgery
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- 38. IV ACCESS- bestsites-back of hand,inner wrist,dorsum of foot in difficulty -Saphenous vein(medial malleolous) -intraosseus(shin of tibia) 38
- 39. Pharmacological premedication 1.Midazolam +Ketamine: • PO- 0.2 to 0.3 mg/kg + 4 mg/kg respectively • IM-0.05-0.1 mg/kg +2-3 mg/kg + atropine 0.02 mg/kg • 100% successful separation • 85% easy mask induction 38
- 40. 2.Fentanyl "lollipops" (oraltransmucosal Fentanyl) • 5-15 mcg/kg • Nausea and vomiting,pruritus • IV -2 mcg/kg 3.Chloral hydrate -50mg/kg orally -sedation -unpleasant excitatory phase,bitter 4.Metoclopramide PO or IV: 0.2 mg/kg 5.Ranitidine PO 2.5 mg/kg 39
- 41. 6.EMLA cream: -Eutactic mixtureof Lidocaine and Prilocaine. - For cutaneous application by occlusive dressing 1 hr before 7.Glycopyrrolate: for selected patients - planned airway instrumentation; e.g.: fiberoptic oral or upper airway surgery( cleft palate) - 5-10 mcg/kg IV or 10 mcg/kg IM atropine:orally0.05 mg/kg IM 0.02 mg/kg IV 0.01 mg/kg ↓secretions and ↓bradycardia& hypotension during induction 40
- 42. MONITORING Small ECGelectrode NIBP PRECORDIAL STETHOSCOPE Pulse Oximetry(rt.hand/earlobe) Capnography Temperature Urine output Serum glucose Arterial canulation and ABG(RT.RADIAL,FEMORAL,UMBILICAL)-if required 42
- 43. INDUCTION Intravenous-familiarity ofdrug,rapid induction,availability of IV acess for emergency drugs. -propofol/thiopentone/ketamine Inhalational-N2o(70%)+O2(30%)+SEVO/HALOTHANE in 0.5 increments in every 3 to 5 breaths -single breath induction technique (Sevo7-8% in 70%N2O) -sevo-emergency delirum -halothane-arrythmia 43
- 44. Neonates-less musclemass nd fat→prolonged action eg:thiopentone-neonate-3-4 mg/kg infant-5-6mg/kg remifentanyl-only drug whose t half is shorter than old children variable response to muscle relaxant Midazolam-watersoluble,wait fr 3 mins to avoid stacking of effect -nasal avoided(CNS spread via olfactory nerve) Scholine-prior atropine Only in RSI,Laryngospasm,rapid relaxation prior to IV acess Alternate –rocuronium Both can be given IM 44
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- 46. ETT size? 1kg-7 cm 2kg-8cm 3kg-9 cm ETT length? 46 <6yr-age/3+3.5 >6yrs-age/4+4.5 Oral-age/2+12 Nasal-age/2+15
- 47. Maintenance-isoflurane/halothane+NDMR+OPOID -Controlled Ventilation(1litre BAG) -<10KG-PCVwith peak inspiratory pressure 15-18 cm H2O -Older child-VCV Reversal-neostigmine+atropine/glyco extubation-fully awake -deep (asthma,eye injury or surgery where cough may jeoparadise outcome) shifting to recovery-stable SPO2>95% in room air 47
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- 52. 52 Modified Aldrete scoringfor recovery from anaesthesia
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- 54. Fluid management Intravenous fluids Calculationof Maintenance Fluid Requirements for Pediatric Patients Weight (kg) Fluids (mL/hour) 24-H Fluids (mL) <10 4 mL/kg 100 mL/kg 11–20 40 mL + 2 mL/kg > 10 1,000 mL + 50 mL/kg > 10 >20 60 mL + 1 mL/kg > 20 1,500 mL + 20 mL/kg > 20 Include if present: Fluid deficits Third spaces losses Hypo/hyperthermia Unusual metabolic fluids demands 54
- 55. 5 COMPONENTS Use RL for replacement D5% with 0.45 NS for maintenance by piggyback Third space loss-RL Blood loss-nonglucose fluid/colloid -if bloodloss>1-2 bloodvolumes→platelet,FFP(10-15 ml/kg) 55
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- 58. Fluid requirements inneonates: During the 1st week reduced fluid requirements: Day 1 - 70 ml/kg Day 3 - 80 ml/kg Day 5 - 90 ml/kg Day 7 - 120 ml/kg Concern is immaturity of the neonatal kidney large ECF volume Consider use of radiant warmers, and heated humidifiers - decrease insensible water loss 58
- 59. Effective blood volume Prematureinfant - 100 -120 ml/kg Full-term infant - 90 ml/kg 3-12 month old child - 80 ml/kg 1 year and older child - 70 ml/kg EBV (starting Hct - target Hct) MABL = Starting Hct 59
- 60. Packed Red BloodCells Child usually tolerates Hct ~ 20 in mature children If: • Premature, • Cyanotic congenital disease Hct ~ 30 • O2 carrying capacity Replace 1ml blood with 3 ml of RL/NS Lactic acidosis is a late sign of decreased O2 carrying capacity 60
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- 63. 63 WONG- BAKER FACECPAIN RATING SCALE
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- 68. REFERENCES: Millers anaesthesia Paediatricanaesthesia by Rabecca Jacob Morgans Clinical Anaesthesia WFSA tutorial 68
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