Pediatric Anesthesia.pptx

PEDIATRIC ANESTHESIA
Moderator: Dr.Tasew (MD,Consultant
Anesthesiologist)
Presenter: Dr.Habtamu M. (R2, ACCPM )
Tuesday, January 24, 2023 Ped. anesthesia 1

outline
◦ Introduction
◦ Anatomic & physiological differences
◦ Pharmacological difference
◦ Preoperative consideration
◦ Iv fluid & transfusion therapy
◦ Pediatric anesthetic risks
◦ Pediatric Airway management
◦ Premedication
◦ Induction& maintenance of anesthesia
◦ Emergence & recovery

OBJECTIVES
◦At the end of this Seminar, you will be
able to;
Appreciate anatomic, physiologic and
pharmacologic differences of pediatric
population
Understand anesthetic concerns of
pediatric patients.
Familiarize with periop management of
pediatric pts
Provide safe pediatric anesthesia care.

Pediatric Anesthesia
Introduction:
Pediatric patients are not small adults.
Neonates (0–1 months)
Infants (1–12 months)
Toddlers (1–3 years)
Small children (4–12 years of age)
Have differing anesthetic requirements.
4
Tuesday, January 24, 2023 Ped. anesthesia

ANATOMIC & PHYSIOLOGICAL
DEVELOPMENT
Respiratory System
Airway
Large head, prominent occiput
 ?Large tongue
Narrower nasal passages -50% of airway
resistance
Preferential nose breathers until 5 months.
Shorter neck.

Larynx
 Anterior,&Cephalad(@C 3-4 level)
 Epiglottis; short,stubby&Ʊ shaped, stiff(NB)
 long,floppy,& omega shaped-
infants/children
 Cricoid → Narrowest point until 10 years old
Trachea and Bronchi
 Trachea –short(4-5cm).
 In children the angle of both right and left bronchus is
same( i.e 55 degree up to the age of 3 yrs)

Respiratory System
• Weak intercostal and diaphragmatic musculature (do
not achieve type-1 muscle fibers until age 2)
• Highly compliant chest wall & ribs provide little
support to the lungs
negative intrathoracic pressure is poorly maintained.
• Alveolar maturation is not complete until late
childhood (about 8 years of age).
7

…Respiratory System
Have less efficient ventilation because of:
 Atelectasis is more common
  FRC
  number of alveoli
 Higher rate of oxygen consumption (2-3x >
adults)=6-8 ml/kg/min
 The work of breathing is increased
 Respiratory muscles easily fatigued
 Hypoxia and hypercapnia depress respiration
8

Differences b/n adult and infant respiratory physiology
Adult Infant
FRC(ml/kg) 30-45 25-30
TV(ml/kg) 7 7
MV(ml/kg/min) 60 100 to 150
RR(/min ) 12 to 16 30 to 50
O2 Consumption(ml/kg/min) 3 to 4 7 to 9

Cardiovascular System
 Increased basal heart rate
 Stroke volume is relatively fixed by a noncompliant and
immature left ventricle in neonates and infants.
 The CO is therefore very sensitive to changes in heart rate.
 The PNS stimulation, anesthetic overdose, or hypoxia can
quickly trigger bradycardia.
Hypotension, asystole, & intra-op death will ensue.

CVS..
 The SNS and baroreceptor reflexes are not fully
mature.
 Lower catecholamine stores, and a blunted
response to exogenous catecholamines.
 More sensitive to the calcium channel blocking
properties of volatile anesthetics and opioid-
induced bradycardia.
 The vascular tree is less able to respond to
hypovolemia with vasoconstriction.
 The hallmark of intravascular fluid depletion in
neonates and infants is therefore hypotension
without tachycardia.

Temperature Regulation
Hypothermia: even mild degree of hypothermia can
cause periop problems
delayed awakening
cardiac irritability,
respiratory depression,
increased pulmonary vascular resistance,
altered drug responses.
12

Renal Function
 Normal kidney function is not present until 6 months of
age.
 Complete maturation @ 2 years of age
 Meticulous attention to fluid administration in the early
days of life.
 total body water and % extracellular fluid are increased in
the infant
 Prolonged duration of action for hydrophilic drugs,
particularly those that are renally excreted
13

Gastrointestinal function
 Full coordination of swallowing with respiration
~ 4-5 months ,increased risk for GE reflux
 Lower levels of albumen and proteins - prone to
neonatal coagulopathy, and less drug bound
,higher drug levels
 liver blood flow decreased in newborns
Prolonged excretion for drugs
14

Glucose Homeostasis
Neonates have relatively reduced glycogen stores,
predisposing them to hypoglycemia.
Impaired glucose excretion by the kidneys may partially
off set this tendency.
In general, neonates/children at greatest risk for
hypoglycemia are;
 premature or SGA,
 receiving hyper alimentation, and
 the offsprings of diabetic mothers.
 Endocrine/metabolic disorders

PHARMACOLOGICAL DIFFERENCES
 Pediatric drug dosing is typically adjusted on a per kilogram.
◦ Early childhood a patient’s weight can be approximated based on age:
50th percentile weight (kg) = (Age × 2) + 9
 Wt’ can also be estimated by;(age+4)x2,but less accurate over 10
yrs.
 Weight-adjustment of drug dosing is incompletely effective because
the disproportionately larger pediatric intravascular and ECF
compartments
The immaturity of hepatic biotransformation pathways
decreased protein for drug binding eg. thiopental, bupivacaine
 higher metabolic rate
Relatively lower GFR,
 Higher total water content (70–75%)

Weight estimation at different ages.
Age of child Formula to estimate weight in Kg
0-12months (0.5xage in months)+4
1-5yrs (2xage in yrs)+8
6-12yrs (3xage in yrs)+7

Preoperative Considerations
 Depending on age, past experiences, and maturity, children
present with varying degrees of fright (even terror) when
faced with the prospect of surgery.
 Adults are usually most concerned about the possibility of
death, but children are principally worried about pain and
separation from their parent.

Box 8-1 Risk Factors for Preoperative
Anxiety
Child Related
• Young age (1 to 5 years of age) ,
• Poor previous experience
• Shy and inhibited temperament ,
• Lack of developmental maturity and social adaptability
• High cognitive levels
• Not enrolled in daycare
Parent Related: High trait and state anxiety ,Divorced parents,
Multiple surgical procedures for parents
Environment Related: Sensory overload ,Conflicting messages.

The Preoperative Evaluation
• Pertinent maternal history, birth and neonatal
history
• Level of anxiety
• Review of systems, physical examination, height,
weight, and vital signs.
• Use of medications such as bronchodilators,
steroids, and chemotherapeutic agents
• Malformations in the child and family.
• Anesthetic risks, anesthetic plans, recovery
phenomena, postoperative analgesia, and
discharge criteria have to be discussed in detail.
20

Preoperative Fasting Period
 Smaller glycogen stores and are more likely to
develop hypoglycemia with prolonged
intervals of fasting.
 Increased risk for aspiration ?
 delayed gastric-emptying times
 abdominal masses-outlet obstruction
(pyloric stenosis)
 ileus, vomiting, or electrolyte disorders.
 Outcome of children who developed
aspiration pneumonia is excellent, unless
these children had some major underlying
problem such as abdominal or thoracic
trauma
◦ .
21

Laboratory evaluation
Current standard of care dictates that healthy children undergoing
elective minor surgery require no laboratory evaluation,
Group and screen / type and cross if blood loss expected
blood chemistry analyses, chest radiographs and urinary analysis are
performed only for specific indications
For surgeries in which significant blood loss may be expected, a
hemoglobin of 10 g/dL has been cited as acceptable for infants older
than 3 months of age.
Coagulation studies (INR/PTT) for operations where blood loss may
occur in sensitive areas (ENT, neuro.)
Ionized potassium in children on digoxin or diuretics
22

IV fluid & transfusion
Must consider high metabolic demands and high ratio of BSA to Wt.
4-2-1 rule does not include deficits, third-space ,modifications because
of hypo or hyperthermia, or requirements caused by unusual metabolic
demands.
Third-space losses vary from 1 mL/kg/hr for 15 mL/kg/hr .
4-2-1 is problematic for children who are acutely ill or with cardiac or
renal dysfunction.
Tuesday, January 24, 2023 23
Ped. anesthesia

Fluid Management
Take into account:
fluid deficits
translocation of fluids
blood loss during surgery
maintenance fluid requirements
24

Fluid Management…
Little evidence of hypoglycemia related to fasting prior to
surgery.
 Hyperglycemia has been documented in children given 5%
dextrose solutions to replace deficits or fluid losses
problematic for patients with intracranial injury
significant hyperglycemia can cause hyperosmolar diuresis
To optimize fluid administration and glucose delivery, a
balanced salt solution containing 2.5% glucose may be
used
Intraoperative monitoring of blood glucose is appropriate
for newborns,
25

Perioperative Fluid Requirements
A. Maintenance Fluid Requirements
The choice of maintenance fluid remains
controversial.
A solution such as D 5 ½ NS with 20mEq/L of
KCL provides adequate dextrose and electrolytes
at these maintenance infusion rates.
 D 5 ¼ NS may be a better choice in neonates
because of their limited ability to handle sodium
loads.

MAINTAINANCE..

B.Deficit
 The balance of the calculated fluid deficit can be
provided over 1 or 2 hours and is often provided in the
form isotonic fluid or a 5% dextrose solution in 0.9%
normal saline.
 Immediate intravascular volume expansion ;10-15
mL/kg bolus of isotonic fluid

C.Replacement
 Blood loss has been typically replaced with non–glucose-
containing crystalloid (3:1) or colloid solutions (eg, 1 mL of
5% albumin for each milliliter of blood lost) until the
patient’s hematocrit reaches a predetermined lower limit.
 The target hematocrit (for transfusion) may be as great as
40%, whereas in healthy older children a hematocrit of 20–
26% is generally well tolerated.

D. Third-space loss
◦ Losses that are impossible to measure and must be estimated
by the extent of the surgical procedure.
◦ Estimated third-space loss
- intra-abdominal surgery -6 to 10 mL/kg/hr,
-intrathoracic surgery -4 to 7 mL/kg/hr
- intracranial or cutaneous surgery-1 to2L/kg/hr
◦ RL is preferred, as NS contains an excessive chloride
and acid load for infants.

Blood or blood component
therapy
31
 Indications not always clear-cut.
 Blood volume:
 Premature infant - 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
MABL = EBV (starting Hct - target Hct)
Starting Hct

Blood Component..
 Equivalent hemoglobin concentrations for the same tissue oxygen
delivery are;
 8g/dl, (adult)
 6.5g/dl(infant) and
 12g/dl(neonate)
 An infant tolerates anemia fairly well, a neonate does not.
 If a child does require transfusion, they should be transfused if
possible from one donor unit.
A useful formula for transfusion is:
 4 ml/kg PRBC raises the Hb by 1g/dl
 8ml/kg WB raises the Hb by 1 g/dl

Packed RBCs
 MABL takes into account the effect of patient age, weight,
and starting hematocrit on blood volume.
 If the child has reached the MABL PRBC is given to maintain
the HCT in the 20% to 25% range.
 Hct < 20% is generally well tolerated by most children, the
exception being preterm infants, term newborns, and
children with cyanotic CHD or those with respiratory failure.
 Incidence of apnea is high in neonates and preterm infants
who have HCT of less than 30%.
 children with a history of sickle cell disease may require
preoperative transfusion.
Ped. anesthesia

Platelets
Thrombocytopenia may occur as a result of disease
processes or dilution during massive blood loss.
PLT count >50,000 will be probably sufficient for invasive
procedure if the rest of coagulation system is normal
 The preoperative platelet count is extremely valuable in
predicting intraoperative platelet requirements.
Clinical oozing is the typical indication for platelet
transfusion
 Neurosurgery, cardiac surgery, or major organ
transplantation.
Dosing ;one WBD unit/10kg, OR 5-10ml/kg (apheresis)
Ped. anesthesia

Fresh frozen plasma
 Is given to replenish clotting factors lost during
massive transfusion ,DIC, or for congenital clotting
factor deficit.
 children given whole blood will not need FFP.
 Usually replenished if EBL = 1-1.5 TBV
 A child should never be given FFP to correct bleeding
that is surgical in nature.
 FFP volume given is 30% or more of the child’s blood
volume.
 Transfusion of FFP at rates exceeding 1 mL/kg/min can
lead to severe ionized hypocalcemia and cardiac
depression.
Ped. anesthesia

Monitoring the Pediatric Patients:
Must be consistent with the severity of the underlying
medical condition
 Minimal monitoring:
I. 5 ASA monitors
II. Precordial stethoscope
III. Anesthetic agent analyzer
 Use of capnograph and O2 analyzers is associated with
high incidence of false alarms from:
movement artifact
light interference
electrocautery
36

Special Monitoring the Pediatric
Patients:
 Intra-arterial catheter - most common radial
 Pulmonary artery catheters are rarely indicated
because equalization of the pressure right/left heart
 In a case of severe multisystem organ failure insertion
of PAC might be particularly useful
 Multi-lumen catheters are valuable in ICU patients
37

Anesthesia Circuits
 Nonrebreathing circuits:
1. Minimal work of breathing
2. Speeds-up rate of inhalational induction
3. Compression and compliance volumes are
less (small circuit volume)
 Use of Mapleson D system is recommended in children < 10 kg
More sensitive to changes in gas flow
More sensitive to humidification
Actual delivered volume is greater than
other systems
38

Pediatric airway management
Uncuffed ETT were traditionally preferred for less than 6 yrs.
For 1 to 8 yrs old;
4+(age in yrs/4)=for uncuffed ETT
3.5+(age in yrs/4)=for cuffed ETT
A correctly sized ETT will have an audible air leak at, or close to, 20
cm H2O airway pressure.
If no leak=too large ETT
If an uncuffed tube is used, appropriate size allows a small gas
leak at peak inflation pressures of 20 to 30 cm H2O.
A large leak at low AWP=too small ETT, replace with next larger
Depth: 3x ID in mm (uncuffed), (3xID in mm+1.5cm)=cuffed
Intra-cuff pressure=measure (manometer)& maintain <20 cmH2O.
Ped. anesthesia

Supraglottic airway sizing
Device size(LMA) Patient weight(kg) Max.cuff volume(ml)
1 Up to 5 4
1.5 5 - 10 7
2 10 - 20 10
2.5 20 - 30 14
3 30 -50 20
4 50 -70 30
5 70 - 100 40
6 >100 50

Pediatric difficult airway
• Most non-syndromic children are easy to intubate.
• Any dysmorphic child may need special attention
• Eg. Pierre –Robin sequence, Treacher Collin SXX, Klippel fail SXX
Anesthetic mgt;
Avail different size fiberoptic scopes, LMAs, ETTs
Consider awake fiber optic intubation
Glycopyrolate
Maintain spontaneous ventilation

Premedication
SEDATIVE AND ANXIOLYTICS
Anti emetics
antiacids
EMLA cream
Glycopyrrolate/atropine
42

PREMEDICATION..
Pre medications may be administered IM, IV, rectally,
sublingually, or nasally.
ketamine PO(4 to 6 mg/kg),IM (2-4mg/kg)
Atropine (0.02 mg/kg)
Midazolam PO (0.5 mg/kg, maximum of 20 mg, 0.3mg/kg if
combined with ketamine) will result in a deeply sedated child.
 Diazepam PO( 0.1-0.5 mg/kg), PR(0.5 mg/kg), IV (0.05-
0.3 mg/kg)
 CLONIDINE ( PO-2.5-4micg/kg)
 DEXMEDETOMIDINE PO- 3micg/kg, IN- 1-2micg/kg
Tuesday, January 24, 2023
Ped. anesthesia
43

Premedication…
Sedative premedication is generally omitted for neonates and
sick infants.
Children who appear likely to exhibit uncontrollable
separation anxiety should be given sedative, such as
midazolam (0.3–0.5 mg/kg, 15 mg maximum).
The oral route is generally preferred, but it requires 20–45
min for effect.
Smaller doses of midazolam have been used in combination
with oral ketamine (4–6 mg/kg) for inpatients.

Midazolam
 Is the only benzodiazepine approved by the U.S. FDA for
use in neonates; the half-life is significantly longer (6 to 12
hours) in this population.
 Unlike diazepam Midazolam is water soluble and not
painful .
 Midazolam has the fastest clearance of all the
benzodiazepines
 The shorter elimination half-life (∼2 hours) of midazolam
than diazepam (∼18 hours) offers an advantage for use as a
premedication in children.
 Is given IM(0.1-0.15 mg/kg, max of 7.5 mg), oral (0.25 - 1.0
mg/kg, maximum of 20 mg), rectal (0.75 -1.0 mg/kg,
maximum of 20 mg), nasal (0.2 mg/kg), or sublingual (0.2
mg/kg) .
Ped. anesthesia

PREMEDICATION…
Atropine, 0.02 mg/kg IM
Infants <1 yr of age to prevent vagally induced bradycardia
Infants and children with septic or late stage hypovolemic shock
Childern </=5yrs of age receiving succinylcholine and children
>5 yrs of age receiving second dose of succinylcholine
accumulation of secretions that can block small airways and
endotracheal tubes.
particularly problematic for patients with URIs or those who have
been given ketamine.
NB; Will be ineffective for hypoxemia induced secondary bradycardia.

Premedication..
Diazepam
 Has an extremely long half-life in neonates (80 hours) and may not
be indicated until 6 months of age.
Should be given with caution to any child with hepatic disease.
Dexmedetomidine
Is a selective α2-agonist with anxiolytic, sedative, and
analgesic properties.
 Facilitates fiberoptic intubation, Sedation for a child
undergoing awake craniotomy, reduces the incidence of
emergence agitation.
Also used for cardiac catheterization & radiologic
procedures.
Ped. anesthesia

Narcotics
 More potent in neonates than in older children and adults.
 Unproven (but popular) explanations include “easier
entry” across the BBB, decreased metabolic capability, or
increased sensitivity of the respiratory centers.
 Important elements of balanced anesthesia and sedation in
children
decrease MAC of inhaled agents, smooth hemodynamics
and provides postoperative analgesia.
depress central respiratory effort(<6 months)
need to carefully monitor pediatric patients given opioids
rather than withholding pain medications.

Narcotic …
Usual recommended doses include fentanyl,1 to 2
µg/kg; morphine,0.05- 0.10 mg/kg; sufentanil, 1
µg/kg; and alfentanil, 50 to 100 µg/kg.
Morphine=with caution in neonates because hepatic
conjugation is reduced and renal clearance of it’s
metabolites is decreased.
Meperidine:
• Less respiratory depression than morphine
• Be cautious in long term administration
because of its metabolite normeperidine.
49

Antiemetics
In children, the postoperative nausea and vomiting (PONV)
rate can be twice as high as in adults
after certain surgeries such as orchidopexy, strabismus
surgery, and tonsillectomy.
phenothiazines, antihistamines, anticholinergics,
benzamides, butyrophenones and 5-HT3 antagonists can
be used in children
Dexamethasone, 0.15 to 1.0 mg/kg, after oral pharyngeal
surgery
Propofol
the use of analgesics like acetaminophen and NSAIDs and
regional anesthesia will likely decrease the overall risk of
PONV.
50

Induction
Inhalation
 Sevoflurane
Halothane
Intravenous
Propofol
Thiopental
Ketamine
Intramuscular
 Ketamine
• Intravenous access
Challenging
 Small veins
 Subcutaneous fat
 Multiple sticks
 Saphenous
 Intraosseoous

Maintenance
 Anesthesia can be maintained in pediatric patients with the
same agents as in adults.
 Some clinicians switch to isoflurane following a sevoflurane
induction in the hope of reducing the likelihood of emergence
agitation or postoperative delirium.
Administration of an opioid (e.g., fentanyl, 1–1.5 mcg/kg)
15–20 min before the end of the procedure can reduce the
incidence of emergence delirium and agitation.
 Use of muscle relaxant according procedure

IV/IM Anesthetics
Propofol
 Its rapid redistribution, hepatic glucuronidation,
and high renal clearance account for the short
duration of its effect.
 Induction dose is larger in younger children (2.9
mg/kg for infants younger than 2 years of age).
 Its major drawback is pain on intravenous
administration.
 Reduces the incidence of postoperative
vomiting

Propofol cont..
 It should be avoided in children with
anaphylactic reactions to eggs.
 The major concern with propofol is the potential
for propofol infusion syndrome, eg.
lactic acidosis,
rhabdomyolysis,
cardiac and renal failure
Long term propofol infusion (> 48 h) for
sedation in ICU at high doses (> 5 mg/kg/h).

Thiopental
 5 to 6 mg/kg (for infants&older children)
 Children require relatively larger doses of thiopental
compared with adults.
 In contrast, neonates, appear to be more sensitive to
barbiturates
 Termination is through redistribution into
muscle and fat.
 should be reduced to (3 to 4 mg/kg) in children
who have low fat stores, such as neonates or
malnourished infants.
Ped. anesthesia

Methohexital
Given as 1 - 2 mg/kg iv.
Problems associated with iv administration include burning,
hiccups, apnea, and extrapyramidal-like movements.
Contraindicated in children with temporal lobe epilepsy
Has shorter elimination half life than thiopental.
Can be used rectally for sedation in some procedures.
Obstructive or central apnea may occur occasionally.
Ped. anesthesia

Ketamine
• Many routs of administration..
• 0.25 to 0.5 mg/kg may be used to provide sedation and
analgesia for painful procedures.
• useful for the induction of anesthesia in hypovolemic
children.
• Unwanted effects include vomiting , secretions and
hallucinations.
• Concomitant administration of benzodiazepines decrease
risk of hallucination
• Not good to use in active URI, ICP, open-globe injury, and
a psychiatric or seizure disorder.
Ped. anesthesia

Ketamine cont..
• Apnea & laryngospasm may occur.
• Does not preserve gag reflex.
• Can be used as adjunct in epidural analgesia
(preservative free preparation)
• Neonates and infants may be more resistant to the
hypnotic effects of ketamine
• It may be the optimal premedication for children with
significant CVDs such as children with CHD.
Ped. anesthesia

Etomidate
Etomidate has not been studied adequately in pediatric
patients less than 10 years old.
 It’s profile in older children is similar to adults
• Minimal cardiovascular suppression
• Useful for critically ill and children with head injury.
• S/E; adrenal suppression, pain on injection, myoclonus

Inhalational Anesthetics
The MAC for halogenated agents is higher in
infants
Have faster induction times and potentially
increasing the risk of overdosing
• Minute ventilation to FRC ratio increased
• Blood flow to vessel rich groups increased.
• Rapid rise in alveolar anesthetic concentration
• Blood-gas coefficients lower in neonate

Approximate MAC 1 values
for pediatric patients reported in % of an
atmosphere.

Halothane
Does not have a noxious smell.
Sensitization of the myocardium to arrhythmias.
The dose of adrenaline should be limited to 1µg/kg/30min
with halothane and to 3µg/kg/30min in the presence of
enflurane or isoflurane.
The maximum recommended dose of epinephrine in local anesthetic
solutions during halothane anesthesia is 10mcg/kg.
Potent myocardial depressant (bradycardia & hypotension)
Atropine(IV/IM) premedication may be needed.
Ped. anesthesia

Isoflurane
Isoflurane may have some advantages over halothane:
 Less myocardial depression
 Preservation of heart rate
 Larger reduction in CMRO2
The major disadvantages of isoflurane are its noxious smell.
Occasional Hypertension=stimulation of pulmonary irritant
receptors, causing increased sympathetic activity and
stimulation of the RAAS.
Ped. anesthesia

Sevoflurane
 Less pungent than isoflurane and desflurane;
 May be superior or equivalent to halothane for
inhaled induction of anesthesia.
 Equivalent to halothane in terms of airway
complications during induction.
Decreases both the respiratory rate and the tidal
volume.
Emergence agitation with sevoflurane can be
reduced with midazolam .
Halothane is a superior than sevo for
bronchoscopy.
Ped. anesthesia

Desflurane
 Has high incidence of laryngospasm during induction.
 The more rapid awakening is advantageous for
neurosurgical procedures.
 The MAC for desflurane is dependent on age: 9.2% for
neonates, 9.4% for 1 to 6 months , 9.9% for 6 to 12
months of age, 8.7% for 1 to 3 year olds, and 8% for 5
to 12 year olds.
 Desflurane, unlike other volatile anesthetics, has
virtually no hepatic metabolism.
 Also has high incidence of emergence agitation.
Ped. anesthesia

Muscle relaxants
Suxamethonium
Highly water soluble ,as a result higher dose is required.
1.5 to 2.0 mg/kg IV,4 mg/kg IM in emergencies
Infants require significantly larger doses of succinylcholine (2–3 mg/kg)
Submental (intralingual) administration is possible.
Cardiac arrhythmias frequently follow IV administration, especially
during halothane anesthesia.
All children, including teenagers need atropine before sux.(0.1 mg
minimum)
Should not be routinely used in children, due to risk of
rhabdomyolysis . hyperkalemia , masseter spasm and MH, & cardiac
arrythmia.
large-dose rocuronium, 1.2 mg/kg is under study to substitute sux.
Ped. anesthesia

Muscle relaxants ….
Suxamethonium….
If cardiac arrest happens following administration of sux.,
immediate treatment for hyperkalemia should be instituted
 Profound bradycardia and sinus node arrest can develop
following the first dose of succinylcholine without atropine
pretreatment.
Absolutely contraindicated -muscular dystrophy, recent
burn injury, spinal cord transaction, immobilization, as well
as any child with a family history of malignant
hyperthermia.
 Relatively contraindicated for use in all children by the
FDA.

Muscle Relaxants…
The duration of action of all nondepolarizing muscle relaxants tends
to be slightly longer.
Pancuronium has a vagolytic effect that may be desirable in many
neonates.
Atracurium and cisatracurium are useful in newborns and
children with immature or abnormal hepatic or renal function.
(Hofmann elimination and ester hydrolysis)
Vecuronium is valuable because no histamine is released; however,
its duration of action is prolonged in newborns.
Rocuronium can be administered intramuscularly.
Mivacurium - brief surgeries, beware of
histamine release, bronchospasm
68

Induction in infants
 Induction of anesthesia via a mask without premedication
is generally used in infants younger than 10 to 12 months.
 Allowing them to suck on a rubber nipple or gloved finger
prevents crying .
 Avoid deep anesthesia without having an iv line.
 vaporizer should be closed before laryngoscopy.
 In contrast to circle system With a Mapleson D circuit, a
high concentration of anesthetic can more easily be
delivered .
 Myocardial depressant effects of drugs is additive.
Ped. anesthesia

Induction in older pediatric patients
 Successful induction of anesthesia by mask in an older child requires the
child understand and cooperate.
 Premedication is helpful in the 1- to 4 year-old age group.
 Several different techniques may be used.
 To play game or use hypnotic suggestions
 Use of flavored masks
 The single breath technique
.
Tuesday, January 24, 2023
70
Ped. anesthesia

Inhalational induction
Younger than 12 months
The incidence of bradycardia, hypotension, and cardiac
arrest is higher in infants younger than age 1 year than in
older children and adults
 After the induction, place the intravenous catheter
 In a case of difficult airway - Fiberoptic intubation
It is contraindicated in the presence of full stomach.
71

IV induction
Iv induction of anesthesia is the most reliable and
rapid technique.
The main disadvantage is that securing an iv line can
be painful and threatening for the child.
Older children will often allow insertion of iv
catheter after administration of 50% nitrous oxide or
topical anesthetic creams.
Ped. anesthesia

Intramuscular induction
Many medications, such as methohexital , ketamine
combined with atropine and midazolam, or midazolam
alone are intramuscularly administered for premedication
or induction of anesthesia.
The main advantage of this route is its reliability.
Its main disadvantage is that it is painful.
Most common used Ketamine
Ped. anesthesia

Rectal induction
Is rarely used in current practice and is generally reserved for
children still in diapers.
child should not see the rectal catheter or syringe.
10% methohexital (20 - 30 mg/kg) reliably induces anesthesia
within 8 to 10 minutes in 85% of young children and toddlers.
The main disadvantage of this technique is that drug absorption
unpredictable.
Other drugs rectally administered include 10% thiopental (20 to
30 mg/kg), midazolam (1 mg/kg up to 20 mg), and ketamine (6
mg/kg).
Technique no more intimidating than rectal
temperature measurement
 Usual time of onset ~ 10-15 min
Ped. anesthesia

Patient with full stomach
Treat the same as adult with full stomach:
• RSI using cricoid pressure
• Tell the patient that will feel “touching on the neck”
• Be aware of risk of desaturation
• 0.02 mg/kg of Atropine administer before SUX to avoid
bradycardia (usually after 2nd dose)
• Use Rocuronium 1.2 mg/kg
• Use Succinylcholine 1-2 mg/kg if really need .
75

Upper respiratory infections
 It is unclear how long surgery should be delayed
following a URI, however, bronchial hyper reactivity
may exist for up to 8 weeks after such an infection.
 Mask anesthesia has been shown to be associated
with a significantly lower rate of perioperative
complications as compared with ETT.
 Conversely, the use of the laryngeal mask airway
(LMA) has been associated with the same number of
airway complications as the ETT
76

URTIs…
 Has major anesthetic implications.
 Patients with URTIs have irritable airways leading to;
Laryngospasm
Bronchospasm
Atelectasis
Pneumonia
Desaturation
Post intubation croup
 So it is better to avoid intubation & use supraglottic
airways.
Ped. anesthesia

Obstructive Sleep Apnea(AHI >=5 /HR)
 STOP tool for risk assessment.
 Severe adenotonsillar hypertrophy with OSA is a frequent
indication for tonsillectomy and adenoidectomy.
 OSA also often accompanies obesity, peak 2-6yrs of age.
 OSA patients are at risk for airway obstruction with the use of
preoperative sedative predication and during the induction
process.
 Postoperatively, patients with severe OSA may exhibit
worsening of their obstructive symptoms secondary to tissue
edema, altered response to carbon dioxide, and residual effects
of anesthetic agents.
79

Anesthetic mgt for OSA
Upright/lateral position
IV induction with short acting anesthetics.
Careful titration of short acting opids
Rectal acetaminophen (30-40mg/kg) as adjuvant analgesics.
Dexamethasone 0.5mg/kg( 0.0625-1mg/kg)
Anti-emetic
Extubation- awake
Post op=,follow 3hrs more than non-OSA counter parts before
discharge, avoid opoids ( but with monitoring),

Epiglottitis
Anesthetic mgt;
Make the child calm
Maintain in sitting position
Avoid airway manipulation (unless in the controlled setting)
Otolaryngologist/anesthesiologist
ETT/Bronchoscope/& Crico/Tracheostomy set
GA with 100%O2 and Sevoflurane/Halothane
Maintain spontaneous ventilation /avoid opoids
Post op=Abcs & corticosteroids, ICU mgt (24-72hrs)

Asthma
 children with asthma should be under optimal
medical care prior to undergoing general anesthesia
and surgery.
 All oral and inhaled medications, such
corticosteroids and β-agonists, should be continued
up to and including the day of surgery
 inhaled short-acting β-agonists prior to induction of
anesthesia eliminates the increase in airway
pressure that is associated with intubation in
asthmatic patients.
82

The Former Preterm Infant
 the impact that broncho pulmonary dysplasia might have on
the patient's perioperative course
 the presence of anemia
 the possibility of postoperative apnea.
 are more likely following general anesthesia-overnight
hospital monitoring following general anesthesia
83

Perioperative pain control
◦ Acetaminophen
PO 10-15 mg/kg, PR 40 mg/kg
◦ Ketorolac
0.5-0.75 mg/kg IM/IV
◦ Opioids
Morphine 0.025-0.1 mg/kg
 Hydro morphone 15-20 mcg/kg
 Fentanyl 0.5-0.75 mcg/kg
◦

Regional Analgesia
 Caudal blocks have proved useful following a variety of
surgeries, including circumcision, inguinal herniorrhaphy,
hypospadias repair, anal surgery, clubfoot repair, and other sub
umbilical procedures.
 Many anesthetic agents have been used for caudal anesthesia in
pediatric patients, with 0.125– 0.25% bupivacaine (up to 2.5
mg/kg) or 0.2% ropivacaine being most common.
 Ropivacaine, 0.2%,can provide analgesia similar to bupivacaine
but with less motor blockade.

Risks of anesthesia
 Postoperative nausea and vomiting
 Perioperative respiratory adverse events (PRAEs)
 Anesthetic neurotoxicity ?
 Mortality
 very rare in healthy children (<1/200,000),but true incidence is unclear.
POCA and mortality are more common during cardiac procedures, in
child with significant comorbidity, and in infants and neonates.
Central line is the most common cause of equipment related cardiac
arrest.

Emergence & Recovery
◦ The goal should be to achieve smooth, controlled
emergence without PRAEs.
◦ Pediatric anesthesia practice varies widely, particularly
in regard to extubation following a general anesthetic.
◦ In some pediatric hospitals, all children who will be
extubated after a general anesthetic
◦ arrive in the post anesthesia care unit (PACU) with the
tube still in place.

Management of extubation
Is always elective.
Extubation should be planned in advance (awake Vs
deep)and executed when conditions are optimal.
ETT/SGA should not be removed during stage II anesthesia.
Risk stratification (risks of tolerating extubation, predicted
difficulty with reintubation),&individualized plan
Minimize cxns & eliminate preventable re-intubations.
Severe cough, HTN, Tachycardia, breath holding, and
laryngospasm are some of the physiologic responses to
extubation.

Extubation…
• The strategies to minimize physiologic response of
extubation include;
Administration of lidocaine, opoids, Dexmedetomidine,
esmolol
Administration of antihypertensive/antiarrhythmic
No touch technique-no stimulation, quite environment
Deep extubation
Bailey maneuver
• Cuff leak test, EACs and elective surgical tracheostomy are
techniques used for Higher risk extubation .

Predictors of successful extubation in children
1.Eye opening
2.Facial Grimace
3.Conjugate gaze
4.TV >5ml/Kg (Spontaneous),regular respiration.
5.purposeful movement
6.Pt movement other than coughing
7.End tidal anesthetic conc.; <0.2%(sevo),
<0.15%(Iso),<1%(Des)
8.SPo2>97%
9.Positive laryngeal stimulation test
Presence of one=88.4%PPV, Presence of above 5=100%PPV

Peri operative complication
A. Laryngospasm
• Laryngospasm is a forceful, involuntary spasm of the
laryngeal musculature caused by stimulation of the superior
laryngeal nerve.
• It may occur at induction, emergence, or any time in between
without an endotracheal tube.
• Presumably it can also occur when a tube is in place.
• More common in young pediatric patients (almost 1 in
50 anesthetized) than in adults, and is most common in
infants 1–3 months old.

Risk factors
Light anesthesia during airway manipulation
Vocal cord irritation by;
inhalational anesthetics
Secretions
Mucus/blood
Young age
Recent/recurrent URTIs
Passive smoke exposure
OSA
Airway Anomaly
Airway Procedures (eg.tonsillectomy)

Mgt of Laryngospasm…
1.Diagnose- stridor(I),Tracheal tug/retraction, paradoxical chest/abdominal mov’t.
2.Intervene Immediately;
Remove stimulus (eg. stop manipulation, suction secreteions)
Give 100% O2/CPAP with facemask with jaw thrust, neck extension ,mouth open,
laryngeal notch pressure
3.Complete (no air entry) Vs Incomplete (air entry)—Deepen Anesthesia
a) IV propofol 20% of induction dose, or increase Sevoflurane conc.=incomplete
b) Call for help ,IV propofol 20% of induction , Administer PPV.=Complete
4. Reassess
If no improvement ; succinylcholine 0.25-0.5mg/kg IV/ OR 3-4mg/kg IM /OR
Rocuronium 1.2mg/kg IV, Rocuronium 1mg/kg IM for <1yr / 1.8mg/kg for >1 yr
of age
 Intravenous lidocaine (1–1.5 mg/kg) can also be used.(2-5min before extubation)
◦ 5. Surgery or PACU

B. Postintubation Croup
Croup is due to glottic or tracheal edema.
Because the narrowest part of the pediatric airway is the
cricoid cartilage, this is the most susceptible area.
Croup is less common with endotracheal tubes that are small
enough to allow a slight gas leak at 10–25 cm H2O.
Postintubation croup is associated with early childhood
 age 1–4 years
repeated intubation attempts
overly large endotracheal tubes
Lack of an airway leak with >25 cmH2O AWP.
Non-supine position/changes in pt position during surgery

Postintubation Croup…
Risk Factors ;
prolonged surgery (>1hr)
head and neck procedures
excessive movement of the tube (eg, coughing with
the tube in place, moving the patient’s head)
IV dexamethasone (0.25–0.5 mg/kg) may prevent
formation of edema. And also Heliox, Mist…
Rx- 0.6mg/kg IV to a max.10mg, if not given intra-
op.
Inhalation of nebulized racemic epinephrine (0.25–0.5
mL of a 2.25% solution in 2.5 mL normal saline) is an
often effective treatment.
Laryngospasm will almost always appear within 3hrs
after extubation.

Post anesthesia Care
Restore normothermia
Emergence agitation - fentanyl, dexmedetomidine,
midazolam, and propofol, parental presence.
Nausea and vomiting-central causes (opiates), GI
malfunction (ileus or gastric distention), the surgical
procedure itself (eye and ear, most commonly), and
postoperative pain.
Analgesic
Calm and comfort the child
98

References
◦ Miller’s Anesthesia (9th edition)
◦ Morgan Clinical Anesthesiology (6th edition )
◦ Barash clinical anesthesia fundamentals 8th edition.
◦ Uptodate 2022.
◦ Hand book of pediatrics anesthesia,2015
◦ Update in Anesthesia 2015

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