This document discusses paediatric physiology and its implications for anaesthesia. Some key points:
- Children are not small adults and have significant physiological differences, especially neonates.
- Neonates have increased surface area, heat and fluid requirements compared to adults. Their cardiovascular and respiratory systems are also less developed.
- Fetal circulation changes at birth as lungs aerate and ductus arteriosus/foramen ovale close. Transitional circulation can occur if these remain patent.
- The paediatric airway has anatomical differences like a higher larynx that make intubation more challenging.
- Respiratory rate and oxygen needs are higher in children due to lower functional residual capacity and higher metabolic demands.
- Hyp
A short presentation covering most important anatomical differences along with physiological difference of pediatric population from adult. Also covers important aspects of anaesthesia consideration in pediatric patients.
I specifically made this presentation by using morgan and miller books.
ANATOMY-PHYSIOLOGY AND IT'S IMPLICATIONS IN PEDIATRIC ANESTHESIA by Dr M.Kart...MKARTHIKEMMANUEL
1.Pediatric Anesthesia
2.Pediatric Anatomy and Physiology
3.Anesthesia implications in pediatric cases
4.Pediatric Anesthesia is different from adult anesthesia
5.why bleeding risk is less ?
6. Why coagulation factors are reduced?
7. Movements of rib cage ?
8. Lung compliance in pediatric age group
A short presentation covering most important anatomical differences along with physiological difference of pediatric population from adult. Also covers important aspects of anaesthesia consideration in pediatric patients.
I specifically made this presentation by using morgan and miller books.
ANATOMY-PHYSIOLOGY AND IT'S IMPLICATIONS IN PEDIATRIC ANESTHESIA by Dr M.Kart...MKARTHIKEMMANUEL
1.Pediatric Anesthesia
2.Pediatric Anatomy and Physiology
3.Anesthesia implications in pediatric cases
4.Pediatric Anesthesia is different from adult anesthesia
5.why bleeding risk is less ?
6. Why coagulation factors are reduced?
7. Movements of rib cage ?
8. Lung compliance in pediatric age group
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This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
2. Introduction
A Child is not small adult
Especially neonates and infants younger than 6 months
Weight 1/20, Length 1/3 Surface area 1/9
3. Size of neonates
Most obvious difference
Head is 25% of body length
Surface area/volume ratio is 70 times that of adult
4. Increased surface area compared to an adult.
Increased Heat Loss
Increased Heat Production
Increased O2 consumption
Increased Fluid Requirements Increased CO2 Production
Increased Minute Ventilation
7. Fetal circulation
Oxygenated placental blood → ductus venosus → RA
→ Foramen ovale →LA →ascending aorta → head
and upper limbs
Deoxygenated superior venacava blood →RA → RV
→ pulmonary artery → ductus arteriosus →
descending aorta
Pulmonary circulation → high resistance and minimal
flow
8. Changes at birth
At Birth
Lungs become air filled, O2 tension increase and CO2
tension decrease → massive fall in PVR, increase in
pulmonary blood flow and increase in oxygenation of
blood
Umbilical cord is clamped and placental blood flow
stops → SVR increase and left atrial pressures exceed
right atrial pressure → foramen ovale closes
functionally
10. Until the true mechanical closure of shunts - a state of
transitional circulation can occur .
Risk factors for prolonged transitional state and “flip flop” of
circulation- increase inPVR or decrease in SVR
Prematurity
Sepsis
Acidosis
Pulmonary diseases causing hypoxia/hypercapnia
Hypothermia
Hypoglycemia
Hypocalcemia
Anesthesia induced changes
12. Cardiac output heart rate dependent.
Immature baroreceptors.
Cholinergic innervation well developed-makes
neonate more prone to bradycardia, associated with
reduced CO
Sympathetic poorly innervated
13. Cardiac calcium stores reduced in infants-depend on
extra cellular calcium-
susceptible to myocardial depression by volatile agents
and hypocalcemia with large volume blood transfusion
Neonates are both fluid dependent and fluid intolerant
14. Cardiac output is 350-400ml/kg/min in utero, falls to
200 ml/kg/min by 1 week and 70ml/kg/min in adult
15.
16.
17. Airway
Anatomical differences in paediatric airway
1. Larger occiput ; neck flexion not needed to attain
sniffing position
2. U shaped mandibular arch; angle between body and
ramus is more obtuse ; facilitates intubation
18.
19. Difference Between Neonatal & Adult Airway
Head Large head, short neck & a prominent occiput
Tongue Larger in proportion to the oral cavity than in adult
Epiglottis Longer, narrower, stiff, U-Shaped, flops posteriorly
Larynx High & anterior at level of C3-C4 (C5-C6 in adult)
Cricoid More conically shaped, narrowest at cricoid ring whereas
in adult it is at level of VCs
Trachea Deviated posteriorly & downwards
Large tongue causes obstruction to ventilation, obscures DL &
can make ETT placement more difficult
‘Sniffing the morning air’ position will not help BMV or to visualise glottis
21. Larynx in neonate and
a 2year old child
difference in epiglottis
and vocal cord.
22. • Airway is funnel shaped
• Narrowest at cricoid rather than VC
• ETT may be small enough to pass through
VCs but not cricoid
• Larynx is funnel shaped so secretions
accumulate in retropharyngeal space
23. Respiratory system
Obligate nasal breather untill 5 month .
Respiration is less efficient in neonates because-
respiratory mechanics different
Smaller airways-increased resistance and work of breathing
Lung compliance is low- elastic component is less but chest
wall is highly compliant-prone for collapse
Alveoli increase in size and number upto 8 yrs of age and
then only increase in size occurs (20-50 million alveoli in
newborn compared to 300 million in adult)
Physiologic dead space-30%
24. Chest wall is compliant – non calcified cartilage
,poorly developed muscles, ribs are incompletely
calcified.
Intercostal muscles are weak
Ribs are horizontal and lack bucket handle
movements (decreased AP and lateral thoracic
expansion)
Diaphragm is easily fatigued due to less % of type
1 muscle fibres
25.
26. Tidal volume is low at birth (6 ml/kg)
Dead space is proportionally similar to adults (30%) by
3 months (40 % in term neonates and 50 % in
preterms)
Due to small tidal volume and higher dead space
volume, any increase in apparatus dead space
significantly decrease efficiency of respiration
27. O2 consumption in neonates is 2-3 times that of adult
6.4 ml/kg/minute adult 3.5ml/kg minute
CO2 production is also increased in neonates
6ml/kg/minute adult 3 ml/kg/minute
MV and alveolar ventilation is 2-3 times that of adult
100 to 150 ml/kg/minute and adult 45 to 60
ml/kg/minute
28. Ratio of Minute ventilation to FRC is 5:1 in adult 1.5:1
FRC is relatively low- less reservoir
Closing volume is higher than FRC-as air passages are
compliant structures and tend to collapse during
expiration .
Prone for hypoxia
29. Hence faster inhalational induction
Early desaturation due to low FRC.
30. IPPV is preferred in an intubated neonates and infants
because
1. increased O2 demand
2. decreased respiratory reserves
3. high closing volume
4. higher proportion of dead space
32. Control of Respiration
Reflex mechanisms controlling respiration are well developed
Higher centres are immature & highly sensitive to respiratory
depressants
Ventilatory response to hypercapnia may be blunted in first few
weeks of life, especially in preterms
Hypoxemia produces a biphasic response in newborn infants with
initial hyperventilation (in 30 secs) followed by ventilatory
depression (over 5 mins).
Control of respiration matures by 3 wks in a term neonate
33. HEMATOLOGY
Hemoglobin concentration at birth is 18-19 g/dl
Physiological anemia of infancy .
By 3 to 4 months of age Hb 10 to 11 g/dl
At birth HbF forms 70-80% of total Hemoglobin.
By 3 months level of HbF falls to less than 5%
35. Haematology
Contd…
• 0DC shifted to left in neonate (P50 19 mm Hg) shifts to right as levels of HbA
& 2,3-DPG rise
• Vitamin K dependent clotting factors (II, VII, IX, X) & platelet function are
deficient in the first few months
• Vitamin K is given at birth to prevent haemorrhagic disease of the newborn
• Transfusion is generally recommended when 15% of the circulating BV lost
• Maintain neonate’s Hct closer to 40% than 30%
36. Pre-operative evaluation
Goals:
To decide if fit or unfit for surgery
To look for any disease which might require
preoperative treatment
To decide optimal anaesthetic regimen
Establish rapport with child
37. Pre-operative evaluation-
history
H/o Present illness- to know severity, planned
procedure & anaesthetic implications
Past H/o
Obstetric & perinatal history (eg : prematurity)
Growth & development milestones
Coexisting medical condition-details
38. Pre-operative evaluation-
history
H/o drug treatment, H/o allergy
H/o past anaesthetic exposure
Immunisation history
Maternal history- diabetes, maternal medications, drug
abuse and infections during pregnancy
Family history : genetic diseases
39. Pre-operative investigations
“ No Routine Investigations ”
Only selective and targeted investigations after a
detailed history taking & examination
42. Inhalational induction in
children
Techniques
single breath technique
(8% Sevoflurane or 5% halothane in 60% N2O)
incremental method : increasing concentration
breath by breath
As the child loses consciousness rapidly reduce the
concentration of inhaled anaesthetic.
43. Inhalational induction in
children
Secure an IV line
2 options
reduce/cut inhalational agent, give IV agents,
muscle relaxants and go for laryngoscopy & intubation
deepen inhalational induction – adequate depth -
turn off vapourizer - laryngoscopy & intubation
(turning off vapourizer prevents accidental overdose)
45. Intravenous induction
Rapid and more reliable
Emphasize to child that it wont be excessively painful
Advantages
-rapid, elimination of use of mask, reduced risk of
laryngospasm, reduced risk of excitement phase
46. Pediatric airway
management
Sizes of i-Gel airway for pediatric patients
Patient Weight (Kg) size
Neonate 2-5 1
Infant 5-10 1.5
Small children 10-25 2
Large children 25-35 2.5
47. Pediatric Airway
Size of the Endotracheal tube
Size of fifth finger tip
Cole’s Formula
Age/4 +4 : Uncuffed
Age/4 + 3 : Cuffed
<6 yrs : (Age/3) + 3.5
>6yrs : (Age/4) + 4.5
51. Maintenance of anaesthesia
Maintenance of depth :
Primarily by inhalational agents
Inhalational agents
-nitrous oxide
-sevoflurane
-halothane
Parenteral agents
propofol
52. Awake extubation preferred : quiet spontaneous
breathing, eye opening, purposeful movements
Deep extubation : potential airway compromise ,need
high quality nursing care in PACU
53. Temperature regulation
Hypothermia -a core temperature of less than 36.1° C
(97° F)
Subdivided into three categories
mild (33.9°-36.0° C [93.0°-96.8° F])
moderate (32.2°-33.8° C [89.9°-92.8° F]),
severe (below 32.2° C [89.9° F]).
54. Modes of heat loss
1)Radiation 39%
2)Convection 34%
3)Evaporation 24%
4)Conduction 3%
55. infants, are vulnerable to hypothermia because
- large body surface area to weight
- thinness of skin
- limited ability to cope with cold stress
56. Shivering thermogenesis is minimal during first 3
months of life
Infants compensate by non shivering thermogenesis.
Inhalational agents attenuate non shivering
thermogenesis (also propofol and fentanyl).
