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Pediatric Anesthesiology
James Gordon Cain, M.D.
Immediate Past President, International TraumaCare
Past President, West Virginia Society of Anesthesiologists
Director, Perioperative Medical Services, Children's Hospital of Pittsburgh of UPMC
Director, Trauma Anesthesiology, Children's Hospital of Pittsburgh of UPMC
Associate Professor, University of Pittsburgh
Pediatric Anesthesiology
● Children are not little adults!
– Neonates: 0-30 days old
– Infants: 1 month to 1 year
– Children: older than 1 year
● Special pediatric considerations
● Pediatric anesthesiology on call
● Malignant hyperthermia
Airway
● Head large
– 1/3 size of adult
head
– 1/9 height of adult
– 1/27 weight of
adult
● Tongue large
● Nasal passages
narrow
● Obligate nose
breathers until 5 mo
Airway
● Larynx
– Anterior
– Cephalad
– C 4 level
● Epiglottis long & U
shaped
● Trachea short
– Neonates → 2 cm
cords to carina
● Cricoid → Narrowest
point until 10 yo
Breathing
● Alveoli small & limited number
– Lung compliance decreased
● Cartilaginous rib cage
– Chest wall compliance increased
● Chest is circular shaped with horizontal ribs
● Diaphragm easily fatigued
– Fewer type 1 muscle cells
● Abdominal muscle strength undeveloped
● Airway resistance increased→ Poiseuille's Law
Breathing
● Low residual lung volumes at expiration (FRC)
– FRC overlaps closing capacity → atelectisis
● Hgb P50 19 mm Hg contrasts to 26 Hg adults
● Increased oxygen consumption → 7 ml/kg/min
– Higher minute ventilation
– Higher blood flow to vessel rich group
● Hypoxic/hypercapneic respiratory drives not
well developed
● Oxygen reserve is limited
Circulation
● Equalization of biventricular pressures
● Stroke volume fixed
● Cardiac output dependent upon heart rate
● Immature sympathetic and baroreceptor
response
– Lack of tachycardia to hypovolemia/hypotension
● Dysrhythmias
– Bradycardia
● Hypoxemia
Normal vital signs
Age Heart rate SBP Resp rate
Newborn 110-170 > 60 30-50
1 year 100-160 > 80 < 40
5 years 80-130 > 90 < 30
> 10 years < 90 > 90 < 20
Renal
● Decreased glomerular filtration rate
– Decreased creatinine clearance
– Decreased sodium excretion
– Decreased glucose excretion
– Decreased bicarbonate resorption
– Decreased diluting capability
– Decreased concentrating ability
● 600 mosm
● Meticulous attention to fluid administration
Glucose management
● High glucose utilization
– Premies 5-6 mg/kg/minute
– Neonates 3-4 mg/kg/minute
● Low glycogen stores
– Predisposes to hypoglycemia
● Neonates < 30 mg/dl
● Infants < 40 mg/dl
– Increased risk with prematurity and/or hyperal
● Options at maintenance rate
– D5LR, D5 ½ NS, D5 ¼ NS
Thermoregulation
● Greater heat loss
– Thin skin
– Low fat content
– High surface area/weight ratio
● No shivering until 1 yo
● Thermogenesis by brown fat
● More prone to iatragenic hypo/hyperthermia
Pharmacotherapy
● Weight “guesstimate” = 2 x (age) + 9
● Total body water content increased (70-75%)
– Large volume of distribution for water soluble
meds
– Increased dose/kg
● Hepatic biotransformation immature
● Protein binding decreased
● Neuromuscular junction immature
● Muscle mass in neonates smaller
– Termination of action by redistribution prolonged
Volatile anesthetics
● Minute ventilation to FRC ratio increased
● Blood flow to vessel rich groups increased.
– 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
MAC
Agent Neonate Infant Children Adults
Halothane 0.87 1.1-1.2 0.87 0.75
Isoflurane 1.6 1.8-1.9 1.3-1.6 1.2
Sevoflurane 3.2 3.2 2.5 2
Desflurane 8-9 9-10 7-8 6
IV/IM Anesthetics
● Ketamine mg/kg → 1-2 IV, 3-5 IM, 5-8 PO
● Benzodiazepines
– Midazolam mg/kg → 0.3-0.7 PO, 0.05-0.2 IV,
0.2-0.5 IN
● Propofol
– Larger doses/kg
– Propofol infusion syndrome
● Opioids
● Muscle relaxants
Propofol infusion syndrome
● Higher incidence in pediatrics than adults
● 90 mcg/kg/minute for as little as 8 hours
● Metabolic acidosis
● Hemodynamic instability
● Hepatomegaly
● Rhabdomyolosis
● Multiorgan failure
Opioids
● More potent in neonates than children or adults
– Easier across blood:brain barrier
– Decreased metabolic capability
– Increased sensitivity of respiratory centers
– Caution in neonates
● Hepatic conjugation decreased
● Cytochrome P 450 pathways mature by 1 mo
● Renal clearance of morphine metabolites is
decreased
● Children have high rates of hepatic blood flow
– Increased biotransformation and elimination
Neuromuscular blockers
● Shorter onset time (as much as 50%)
– Shorter circulation time
● Depolarizing agent
– Succinylcholine
● Nondepolarizing agents
– Rocuronium
– Cisatricurium
– Vecuronium
Succinylcholine
● Fastest onset → 30-60 secs
● Children → 1-1.5 mg/kg IV, 4-6 mg/kg IM
● Infants → 2-3 mg/kg IV, 4-6 mg/kg IM
● Dysrhythmias
– Bradycardia and sinus arrest
– Atropine 10-20 mcg/kg
● Hyperkalemia
● Masseter spasm
Nondepolarizing NMB
Rocuronium
● Drug of choice for
intubation
– 0.6 mg/kg IV
– RSI 0.9-1.2 mg/kg
IV
● May last 90
min
● May be given IM
– 1-1.5 mg /kg
● Onset 3-4 min
Cisatricurium
● Consistently
intermediate duration
● 0.05-0.06 mg/kg IV
ED 95 for muscle relaxants
(Rapid intubating dose is 1.5-2 x ED 95)
Agents Infants mg/kg Children mg/kg
Succinylcholine 0.7 0.4
Rocuronium 0.25 0.4
Cisatricurium 0.05 0.06
Vecuronium 0.05 0.08
Reversal
● Monitor NMB
● Neostigmine 0.03-0.07 mg/kg
● Edrophonium 0.5-1 mg/kg
● Coadminstered with anticholinergic
– Glycopyrrolate 0.01 mg/kg
– Atropine 0.01-0.02 mg/kg
Preoperative considerations
History and physical
● Comorbid illness
● Recent URI
● Murmur
– Innocent
– New
– Symptomatic
● Anesth problems
● Labs → none routine
NPO
● Clears → 2 h
● Breast milk → 4 h
● Formula → 6 h
● Solids → 8 h
Separation anxiety
● Anxiolysis
● Premeds
● Parental presence
URI
● Symptoms new or chronic?
– Infectious vs allergic or vasomotor
● Viral infection within 2 - 4 weeks of GA with
intubation increases perioperative risk
– Wheezing risk increased 10x
– Laryngospasm risk increased 5x
– Hypoxemia, atelectisis, recovery room stay,
admissions and ICU admissions all increased
● If possible, delay nonemergent surgeries
Monitoring
● Age & size appropriate standard monitors
● Precordial stethoscope
– Heart rate, heart tones, respiratory quality
● Preductal pulse oximetry in neonates
– Right extremity or earlobe
● EtCO2 monitor
– Main-stream less accurate in < 10 kg
– Side-stream may falsely elevate iCO2 and
falsely lower EtCO2.
● Temperature
Invasive monitoring
● Require expertise and
caution
● CVL most often IJ or
femoral
● A-line most often right
radial artery
– Preductal
● Mirrors carotid
& retinal
UA/UV may be
considered
Induction
● Inhalation
– Sevoflurane
– Halothane
● Intravenous
– Propofol
– Thiopental
– Ketamine
● Intramuscular
– Ketamine
● Intravenous access
– Challenging
– Small veins
– Subcutaneous fat
– Multiple sticks
● Saphenous
● Intraosseoous
Intraosseous
● IO kit or bone marrow bx
needle
● 1-2 cm below tibial tuberosity
● Insert with screwing motion
until lack of resistance
● Aspirate marrow to confirm
placement
● Secure needle
● Volume replacement
● Labs
● Drug administration
Airway management
● Mask
● LMA
● Intubation
– Neonate – 1 y
● 3 – 4 ETT
– Uncuffed ETT
● 4 + age/4
– Cuffed
● 3 ½ + age/4
– Depth
● 3 x tube size
● Blades
– Straight most
common
● Miller
● Phillips
● Wis-Hipple
– Curved available
– Fiberoptic
● Bullard
● Glide
Maintenance
● Balanced anesthetic most common
● Semiopen circuits circuits traditional
– Low resistance
– Light weight
– Mapleson D, Bain
● Circle systems with new machines
– VT 8-10 ml/kg
– PC/PS 15-18 cm H20
Perioperative fluid replacement
●
1st
0-10 kg → 4 cc/kg/hr
●
2nd
10-20 kg → 2 cc/kg/hr
● > 20 kg → 1 cc/kg/hr
● Calculate preoperative deficit
– Replace 50% first hour
– Replace 25% second hour
– Replace 25% third hour
● Minor surgery → additional 2 cc/kg/hr
● Major surgery → up to additional 10 cc/kg/hr
Estimated allowable blood loss
● Blood volume
– Premies → 95 ml/kg
– Term neonates → 90 ml/kg
– Up to 1 year → 80 ml/kg
– > 1 year old → 70 ml/kg
● EABL → wt kg x est blood vol x (starting Hct-
allowable Hct) / ave Hct
Blood product replacement
● Age appropriate Hct
– Premies and sick neonates Hct 40-50%
– Nadir at 3-6 months of 30%
● Comorbid conditions
● Replace initially with 3 x BSS or 1 x colloid
● Usual starting dose of PRBC is 10 cc/kg
● EBL ~ 1.5 blood volumes give FFP/platelets
– FFP 10 cc/kg
– Platelets 1 unit/10 kg raises platelets by 50K
– Cryo 1 U/10 kg
Laryngospasm
Etiology
● Involuntary spasm of
laryngeal musculature
– Superior laryngeal
nerve stimulation
● Risk inceased
– Extubated while
lightly
anesthetized
– Recent URI
– Tobacco exposure
Treatment
● Positive pressure
ventilation
● Laryngospasm notch
● Propofol
– 0.5–1 mg/kg IV
● Succinylcholine
– 0.2-0.5 mg/kg IV
– 2-4 mg/kg IM
Postintubation stridor
● Glottic or tracheal edema
● Associated with
– Large ETT
– Repeated intubation attempts
– Prolonged surgery
– ENT procedures
– Excessive tube movement
● Preventive dexamethasone
● Racemic epi neb
Perioperative pain control
● Regional
● Acetaminophen
– PO 10-15 mg/kg, PR 40 mg/kg
● Ketorolac 0.5-0.75 mg/kg IM/IV
● Opioids
– Morphine 50-100 mcg/kg
● PCA 20 mcg/kg 10 min lockout
– Hydromorphone 10-20 mcg/kg
● PCA 5 mcg/kg 10 min lockout
– Fentanyl 0.5-0.75 mcg/kg
Regional
● Operative and postoperative utility
● Caudal is most common
● Options in adults available for children
– Peripheral blocks and catheters
● Epidural
– 0.2-0.3 cc/kg/hour covers ~ 4 dermatomes
– T wave changes may indicate toxicity
● Spinal
– Short duration even with tetracaine
Caudal
● Perioperative analgesia
– Ropivicaine 0.2% 1 cc/kg (up to 2 mg/kg)
– Bupivicaine 0.25% 1 cc/kg (up to 2.5 mg/kg)
– Opioids
● Duramorph 25-50 mcg/kg
● Hydromorphone 5-10 mcg/kg
– Clonidine 2 mcg/kg
● Minimal epidural fat
– May advance catheter to thoracic region
Prematurity
● Birth before 37 weeks gestation
– Pulmonary
● Hyaline membrane disease
● BPD
● Apneic spells
– 44 wks for minor surgery
– 52 wks for major surgery
– Cardiac → PDA
– GI → NEC
– Neurologic
● Intracerebral hemorrhage
● ROP
Trisomy 21: most common pattern
of human malformation
● Down's facies
● Short neck
● Irregular dentition
● Mental retardation
● Hypotonia
● Large tongue
● Narrow nasal passages
● Cervical spine → atlantooccipital instability
● Cardiac defects → endocardial cushion defects
Trisomy 21 anesthesia
● Difficult airway
● Postop intubation stridor and apnea common
● Neutral neck position
– Atlantooccipital dislocation risk
● Congenital laxity
● Bradydysrhythmias
– Atropine pretreatment
Tetrology of Fallot
Characteristics
● Overriding aorta
● Infundibular
pulmonary stenosis
● VSD
● RV hypertrophy
Hypercyanotic “Tet” spell
Etiology
● Infundibular spasm
● Decreased pulmonary
blood flow
Treatment goal
● Reduce right to left
shunt
Treatment
● 100% oxygen
● Volume
administration
● Increase SVR
● Increase pulm blood
flow
● Phenylephrine
● Relax infundibulum
Pediatric anesthesia on call
● Omphalocele and
gastroschisis
● Congenital
diaphragmatic hernia
● Intestinal malrotation
and volvulus
● Pyloric stenosis
● Foreign body
ingestion/aspiration
Omphalocele and gastroschisis
Omphalocele
● Base of umbilicus
● Hernia sac
● Other assoc defects
– Trisomy 21
– Cardiac
– Diaphragmatic
hernia
– Bladder
malformation
Gastroschisis
● Lateral to umbilicus
● No hernia sac
● Not associated with
other defects
● Increased risk of
infection
Omphalocele and gastroschisis
● Decompress stomach
● Muscle relaxant to
assist reduction
● Criteria for closure
– Intragastric or
intravesical
pressure < 20
– PIP < 35
– EtCO2 < 50
● Silo possible
Congenital diaphragmatic hernia
● Gut herniates into chest
– Left (most common ~ 90%) or right
posterolateral foramen of Bochdalek
– Anterior foramen of Morgagni
● Hallmarks
– Hypoxia
– Scaphoid abdomen
– Bowel sounds in chest
● Respiratory support
● ECMO
Congenital diaphragmatic hernia
● NG tube
● Avoid high PPV
● Intubate
● PIP < 30
● Avoid aggressive lung
reexpansion
● Consider PTX if
sudden change in
compliance
Intestinal malrotation and volvulus
● Developmental abnormality
– 1:500 live births
● Spontaneous rotation of midgut around
mesentary (SMA)
● Presentation
– Acute or chronic obstruction
– Bilious vomiting
– Abdominal distention and tenderness
– Metabolic acidosis
Midgut volvulus
● True surgical
emergency
● Compromised
intestinal blood
supply
●
1/3 occur in 1st
week
of life
● Bloody diarrhea →
bowel infarction
Malro and volvulus anesthesia
● Obstruction present without obvious volvulus
– Stabilize coexisting conditions
– Insert NG
– Broad spectrum abx
– Fluid and electrolyte management
● To OR ASAP
● Cautious induction and anesthesia if unable to
be preoperatively stabilized
Malro and volvulus anesthesia
● Usually hypovolemic and acidemic
– Aggressive fluid management
– Consider bicarb
● Full stomach precautions
– RSI → ketamine?
– Awake intubation
● Opioid based anesthetic
● Post op intubation common
– Significant bowel edema → Silo
Foreign body aspiration/ingestion
Aspiration
● Acute onset
● Supraglottic/glottic
– Stridor
– Inhalation
induction
● Subglottic
– Wheezing
– Inhalation
induction
–
Ingestion
● Inhalation induction
● RSI
● Intubation
● Don't turn esophageal
FB into airway FB!
Pyloric stenosis
● 4-6 weeks old
● Male > female
● Persistent vomiting
● Metabolic disarray
– Hypochloremic metabolic alkalosis
● Vomiting depletes hydrogen ions
● Kidney compensates by excreting NaHCO3
● Hyponatremia and dehydration worsen
● Kidney conserves sodium at expense of
hydrogen → paradoxic aciduria
● Correct metabolic issues prior to surgery
Pyloric stenosis anesthesia
● Empty stomach
– Supine, lateral and prone
● RSI
– Propofol or thiopental + NMB or remi
● Awake intubation
● Laparoscopic vs open
● Post op
– Increased risk for respiratory depression
● Persistent metabolic or CSF alkalosis
Malignant hyperthermia
● Acute hypermetabolic state in muscle tissue
● Triggering agents
– Volatile agents
– Succinyl Choline
● Incidence
– 1:15,000 peds
– 1:40,000 adults
● MH may occur at any point during anesthesia
or emergence
● Recrudescence despite treatment
MH anesthesia
● Family history
– Muscle bx →
caffeine
contracture test
– +/- Ryanodine
receptor
abnormality
● High flow O2 flush
circuit x 20 min
● Nontriggering
– TIVA, Nitrous
Increased risk of MH
● Duchenne's muscular
dsytrophy
● Central core disease
● Osteogenesis
imperfecta
● King Denborough
syndrome
Classic signs of MH
Specific
● Rapid rise in EtCO2
early sign
● Rapid increase in
temp late sign
● Muscle rigidity +/-
● Rhabdomyolosis
– Increase CK
● Myoglobinuria
Nonspecific
● Tachycardia
● Tachypnea
● Acidemia
– Metabolic
– Respiratory
● Hyperkalemia
● Dysrhythmias
MH treatment
● Discontinue triggering agents
● Hyperventilate with 100% FiO2
● NaHCO3 1-2 mEq/kg IV
● Dantrolene 2.5 mg/kg IV
● Cool patient
● Support as indicated → intropes, dysrhythmias
● Monitor labs
● Consider invasive monitoring
● 1 800-MH-HYPER
Questions?
Children's Hospital of Pittsburgh

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Pediatric anesthesiology board review

  • 1. Pediatric Anesthesiology James Gordon Cain, M.D. Immediate Past President, International TraumaCare Past President, West Virginia Society of Anesthesiologists Director, Perioperative Medical Services, Children's Hospital of Pittsburgh of UPMC Director, Trauma Anesthesiology, Children's Hospital of Pittsburgh of UPMC Associate Professor, University of Pittsburgh
  • 2. Pediatric Anesthesiology ● Children are not little adults! – Neonates: 0-30 days old – Infants: 1 month to 1 year – Children: older than 1 year ● Special pediatric considerations ● Pediatric anesthesiology on call ● Malignant hyperthermia
  • 3. Airway ● Head large – 1/3 size of adult head – 1/9 height of adult – 1/27 weight of adult ● Tongue large ● Nasal passages narrow ● Obligate nose breathers until 5 mo
  • 4. Airway ● Larynx – Anterior – Cephalad – C 4 level ● Epiglottis long & U shaped ● Trachea short – Neonates → 2 cm cords to carina ● Cricoid → Narrowest point until 10 yo
  • 5. Breathing ● Alveoli small & limited number – Lung compliance decreased ● Cartilaginous rib cage – Chest wall compliance increased ● Chest is circular shaped with horizontal ribs ● Diaphragm easily fatigued – Fewer type 1 muscle cells ● Abdominal muscle strength undeveloped ● Airway resistance increased→ Poiseuille's Law
  • 6. Breathing ● Low residual lung volumes at expiration (FRC) – FRC overlaps closing capacity → atelectisis ● Hgb P50 19 mm Hg contrasts to 26 Hg adults ● Increased oxygen consumption → 7 ml/kg/min – Higher minute ventilation – Higher blood flow to vessel rich group ● Hypoxic/hypercapneic respiratory drives not well developed ● Oxygen reserve is limited
  • 7. Circulation ● Equalization of biventricular pressures ● Stroke volume fixed ● Cardiac output dependent upon heart rate ● Immature sympathetic and baroreceptor response – Lack of tachycardia to hypovolemia/hypotension ● Dysrhythmias – Bradycardia ● Hypoxemia
  • 8. Normal vital signs Age Heart rate SBP Resp rate Newborn 110-170 > 60 30-50 1 year 100-160 > 80 < 40 5 years 80-130 > 90 < 30 > 10 years < 90 > 90 < 20
  • 9. Renal ● Decreased glomerular filtration rate – Decreased creatinine clearance – Decreased sodium excretion – Decreased glucose excretion – Decreased bicarbonate resorption – Decreased diluting capability – Decreased concentrating ability ● 600 mosm ● Meticulous attention to fluid administration
  • 10. Glucose management ● High glucose utilization – Premies 5-6 mg/kg/minute – Neonates 3-4 mg/kg/minute ● Low glycogen stores – Predisposes to hypoglycemia ● Neonates < 30 mg/dl ● Infants < 40 mg/dl – Increased risk with prematurity and/or hyperal ● Options at maintenance rate – D5LR, D5 ½ NS, D5 ¼ NS
  • 11. Thermoregulation ● Greater heat loss – Thin skin – Low fat content – High surface area/weight ratio ● No shivering until 1 yo ● Thermogenesis by brown fat ● More prone to iatragenic hypo/hyperthermia
  • 12. Pharmacotherapy ● Weight “guesstimate” = 2 x (age) + 9 ● Total body water content increased (70-75%) – Large volume of distribution for water soluble meds – Increased dose/kg ● Hepatic biotransformation immature ● Protein binding decreased ● Neuromuscular junction immature ● Muscle mass in neonates smaller – Termination of action by redistribution prolonged
  • 13. Volatile anesthetics ● Minute ventilation to FRC ratio increased ● Blood flow to vessel rich groups increased. – 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
  • 14. MAC Agent Neonate Infant Children Adults Halothane 0.87 1.1-1.2 0.87 0.75 Isoflurane 1.6 1.8-1.9 1.3-1.6 1.2 Sevoflurane 3.2 3.2 2.5 2 Desflurane 8-9 9-10 7-8 6
  • 15. IV/IM Anesthetics ● Ketamine mg/kg → 1-2 IV, 3-5 IM, 5-8 PO ● Benzodiazepines – Midazolam mg/kg → 0.3-0.7 PO, 0.05-0.2 IV, 0.2-0.5 IN ● Propofol – Larger doses/kg – Propofol infusion syndrome ● Opioids ● Muscle relaxants
  • 16. Propofol infusion syndrome ● Higher incidence in pediatrics than adults ● 90 mcg/kg/minute for as little as 8 hours ● Metabolic acidosis ● Hemodynamic instability ● Hepatomegaly ● Rhabdomyolosis ● Multiorgan failure
  • 17. Opioids ● More potent in neonates than children or adults – Easier across blood:brain barrier – Decreased metabolic capability – Increased sensitivity of respiratory centers – Caution in neonates ● Hepatic conjugation decreased ● Cytochrome P 450 pathways mature by 1 mo ● Renal clearance of morphine metabolites is decreased ● Children have high rates of hepatic blood flow – Increased biotransformation and elimination
  • 18. Neuromuscular blockers ● Shorter onset time (as much as 50%) – Shorter circulation time ● Depolarizing agent – Succinylcholine ● Nondepolarizing agents – Rocuronium – Cisatricurium – Vecuronium
  • 19. Succinylcholine ● Fastest onset → 30-60 secs ● Children → 1-1.5 mg/kg IV, 4-6 mg/kg IM ● Infants → 2-3 mg/kg IV, 4-6 mg/kg IM ● Dysrhythmias – Bradycardia and sinus arrest – Atropine 10-20 mcg/kg ● Hyperkalemia ● Masseter spasm
  • 20. Nondepolarizing NMB Rocuronium ● Drug of choice for intubation – 0.6 mg/kg IV – RSI 0.9-1.2 mg/kg IV ● May last 90 min ● May be given IM – 1-1.5 mg /kg ● Onset 3-4 min Cisatricurium ● Consistently intermediate duration ● 0.05-0.06 mg/kg IV
  • 21. ED 95 for muscle relaxants (Rapid intubating dose is 1.5-2 x ED 95) Agents Infants mg/kg Children mg/kg Succinylcholine 0.7 0.4 Rocuronium 0.25 0.4 Cisatricurium 0.05 0.06 Vecuronium 0.05 0.08
  • 22. Reversal ● Monitor NMB ● Neostigmine 0.03-0.07 mg/kg ● Edrophonium 0.5-1 mg/kg ● Coadminstered with anticholinergic – Glycopyrrolate 0.01 mg/kg – Atropine 0.01-0.02 mg/kg
  • 23. Preoperative considerations History and physical ● Comorbid illness ● Recent URI ● Murmur – Innocent – New – Symptomatic ● Anesth problems ● Labs → none routine NPO ● Clears → 2 h ● Breast milk → 4 h ● Formula → 6 h ● Solids → 8 h Separation anxiety ● Anxiolysis ● Premeds ● Parental presence
  • 24. URI ● Symptoms new or chronic? – Infectious vs allergic or vasomotor ● Viral infection within 2 - 4 weeks of GA with intubation increases perioperative risk – Wheezing risk increased 10x – Laryngospasm risk increased 5x – Hypoxemia, atelectisis, recovery room stay, admissions and ICU admissions all increased ● If possible, delay nonemergent surgeries
  • 25. Monitoring ● Age & size appropriate standard monitors ● Precordial stethoscope – Heart rate, heart tones, respiratory quality ● Preductal pulse oximetry in neonates – Right extremity or earlobe ● EtCO2 monitor – Main-stream less accurate in < 10 kg – Side-stream may falsely elevate iCO2 and falsely lower EtCO2. ● Temperature
  • 26. Invasive monitoring ● Require expertise and caution ● CVL most often IJ or femoral ● A-line most often right radial artery – Preductal ● Mirrors carotid & retinal UA/UV may be considered
  • 27. Induction ● Inhalation – Sevoflurane – Halothane ● Intravenous – Propofol – Thiopental – Ketamine ● Intramuscular – Ketamine ● Intravenous access – Challenging – Small veins – Subcutaneous fat – Multiple sticks ● Saphenous ● Intraosseoous
  • 28. Intraosseous ● IO kit or bone marrow bx needle ● 1-2 cm below tibial tuberosity ● Insert with screwing motion until lack of resistance ● Aspirate marrow to confirm placement ● Secure needle ● Volume replacement ● Labs ● Drug administration
  • 29. Airway management ● Mask ● LMA ● Intubation – Neonate – 1 y ● 3 – 4 ETT – Uncuffed ETT ● 4 + age/4 – Cuffed ● 3 ½ + age/4 – Depth ● 3 x tube size ● Blades – Straight most common ● Miller ● Phillips ● Wis-Hipple – Curved available – Fiberoptic ● Bullard ● Glide
  • 30. Maintenance ● Balanced anesthetic most common ● Semiopen circuits circuits traditional – Low resistance – Light weight – Mapleson D, Bain ● Circle systems with new machines – VT 8-10 ml/kg – PC/PS 15-18 cm H20
  • 31. Perioperative fluid replacement ● 1st 0-10 kg → 4 cc/kg/hr ● 2nd 10-20 kg → 2 cc/kg/hr ● > 20 kg → 1 cc/kg/hr ● Calculate preoperative deficit – Replace 50% first hour – Replace 25% second hour – Replace 25% third hour ● Minor surgery → additional 2 cc/kg/hr ● Major surgery → up to additional 10 cc/kg/hr
  • 32. Estimated allowable blood loss ● Blood volume – Premies → 95 ml/kg – Term neonates → 90 ml/kg – Up to 1 year → 80 ml/kg – > 1 year old → 70 ml/kg ● EABL → wt kg x est blood vol x (starting Hct- allowable Hct) / ave Hct
  • 33. Blood product replacement ● Age appropriate Hct – Premies and sick neonates Hct 40-50% – Nadir at 3-6 months of 30% ● Comorbid conditions ● Replace initially with 3 x BSS or 1 x colloid ● Usual starting dose of PRBC is 10 cc/kg ● EBL ~ 1.5 blood volumes give FFP/platelets – FFP 10 cc/kg – Platelets 1 unit/10 kg raises platelets by 50K – Cryo 1 U/10 kg
  • 34. Laryngospasm Etiology ● Involuntary spasm of laryngeal musculature – Superior laryngeal nerve stimulation ● Risk inceased – Extubated while lightly anesthetized – Recent URI – Tobacco exposure Treatment ● Positive pressure ventilation ● Laryngospasm notch ● Propofol – 0.5–1 mg/kg IV ● Succinylcholine – 0.2-0.5 mg/kg IV – 2-4 mg/kg IM
  • 35. Postintubation stridor ● Glottic or tracheal edema ● Associated with – Large ETT – Repeated intubation attempts – Prolonged surgery – ENT procedures – Excessive tube movement ● Preventive dexamethasone ● Racemic epi neb
  • 36. Perioperative pain control ● Regional ● Acetaminophen – PO 10-15 mg/kg, PR 40 mg/kg ● Ketorolac 0.5-0.75 mg/kg IM/IV ● Opioids – Morphine 50-100 mcg/kg ● PCA 20 mcg/kg 10 min lockout – Hydromorphone 10-20 mcg/kg ● PCA 5 mcg/kg 10 min lockout – Fentanyl 0.5-0.75 mcg/kg
  • 37. Regional ● Operative and postoperative utility ● Caudal is most common ● Options in adults available for children – Peripheral blocks and catheters ● Epidural – 0.2-0.3 cc/kg/hour covers ~ 4 dermatomes – T wave changes may indicate toxicity ● Spinal – Short duration even with tetracaine
  • 38. Caudal ● Perioperative analgesia – Ropivicaine 0.2% 1 cc/kg (up to 2 mg/kg) – Bupivicaine 0.25% 1 cc/kg (up to 2.5 mg/kg) – Opioids ● Duramorph 25-50 mcg/kg ● Hydromorphone 5-10 mcg/kg – Clonidine 2 mcg/kg ● Minimal epidural fat – May advance catheter to thoracic region
  • 39. Prematurity ● Birth before 37 weeks gestation – Pulmonary ● Hyaline membrane disease ● BPD ● Apneic spells – 44 wks for minor surgery – 52 wks for major surgery – Cardiac → PDA – GI → NEC – Neurologic ● Intracerebral hemorrhage ● ROP
  • 40. Trisomy 21: most common pattern of human malformation ● Down's facies ● Short neck ● Irregular dentition ● Mental retardation ● Hypotonia ● Large tongue ● Narrow nasal passages ● Cervical spine → atlantooccipital instability ● Cardiac defects → endocardial cushion defects
  • 41. Trisomy 21 anesthesia ● Difficult airway ● Postop intubation stridor and apnea common ● Neutral neck position – Atlantooccipital dislocation risk ● Congenital laxity ● Bradydysrhythmias – Atropine pretreatment
  • 42. Tetrology of Fallot Characteristics ● Overriding aorta ● Infundibular pulmonary stenosis ● VSD ● RV hypertrophy
  • 43. Hypercyanotic “Tet” spell Etiology ● Infundibular spasm ● Decreased pulmonary blood flow Treatment goal ● Reduce right to left shunt Treatment ● 100% oxygen ● Volume administration ● Increase SVR ● Increase pulm blood flow ● Phenylephrine ● Relax infundibulum
  • 44. Pediatric anesthesia on call ● Omphalocele and gastroschisis ● Congenital diaphragmatic hernia ● Intestinal malrotation and volvulus ● Pyloric stenosis ● Foreign body ingestion/aspiration
  • 45. Omphalocele and gastroschisis Omphalocele ● Base of umbilicus ● Hernia sac ● Other assoc defects – Trisomy 21 – Cardiac – Diaphragmatic hernia – Bladder malformation Gastroschisis ● Lateral to umbilicus ● No hernia sac ● Not associated with other defects ● Increased risk of infection
  • 46. Omphalocele and gastroschisis ● Decompress stomach ● Muscle relaxant to assist reduction ● Criteria for closure – Intragastric or intravesical pressure < 20 – PIP < 35 – EtCO2 < 50 ● Silo possible
  • 47. Congenital diaphragmatic hernia ● Gut herniates into chest – Left (most common ~ 90%) or right posterolateral foramen of Bochdalek – Anterior foramen of Morgagni ● Hallmarks – Hypoxia – Scaphoid abdomen – Bowel sounds in chest ● Respiratory support ● ECMO
  • 48. Congenital diaphragmatic hernia ● NG tube ● Avoid high PPV ● Intubate ● PIP < 30 ● Avoid aggressive lung reexpansion ● Consider PTX if sudden change in compliance
  • 49. Intestinal malrotation and volvulus ● Developmental abnormality – 1:500 live births ● Spontaneous rotation of midgut around mesentary (SMA) ● Presentation – Acute or chronic obstruction – Bilious vomiting – Abdominal distention and tenderness – Metabolic acidosis
  • 50. Midgut volvulus ● True surgical emergency ● Compromised intestinal blood supply ● 1/3 occur in 1st week of life ● Bloody diarrhea → bowel infarction
  • 51. Malro and volvulus anesthesia ● Obstruction present without obvious volvulus – Stabilize coexisting conditions – Insert NG – Broad spectrum abx – Fluid and electrolyte management ● To OR ASAP ● Cautious induction and anesthesia if unable to be preoperatively stabilized
  • 52. Malro and volvulus anesthesia ● Usually hypovolemic and acidemic – Aggressive fluid management – Consider bicarb ● Full stomach precautions – RSI → ketamine? – Awake intubation ● Opioid based anesthetic ● Post op intubation common – Significant bowel edema → Silo
  • 53. Foreign body aspiration/ingestion Aspiration ● Acute onset ● Supraglottic/glottic – Stridor – Inhalation induction ● Subglottic – Wheezing – Inhalation induction – Ingestion ● Inhalation induction ● RSI ● Intubation ● Don't turn esophageal FB into airway FB!
  • 54. Pyloric stenosis ● 4-6 weeks old ● Male > female ● Persistent vomiting ● Metabolic disarray – Hypochloremic metabolic alkalosis ● Vomiting depletes hydrogen ions ● Kidney compensates by excreting NaHCO3 ● Hyponatremia and dehydration worsen ● Kidney conserves sodium at expense of hydrogen → paradoxic aciduria ● Correct metabolic issues prior to surgery
  • 55. Pyloric stenosis anesthesia ● Empty stomach – Supine, lateral and prone ● RSI – Propofol or thiopental + NMB or remi ● Awake intubation ● Laparoscopic vs open ● Post op – Increased risk for respiratory depression ● Persistent metabolic or CSF alkalosis
  • 56. Malignant hyperthermia ● Acute hypermetabolic state in muscle tissue ● Triggering agents – Volatile agents – Succinyl Choline ● Incidence – 1:15,000 peds – 1:40,000 adults ● MH may occur at any point during anesthesia or emergence ● Recrudescence despite treatment
  • 57. MH anesthesia ● Family history – Muscle bx → caffeine contracture test – +/- Ryanodine receptor abnormality ● High flow O2 flush circuit x 20 min ● Nontriggering – TIVA, Nitrous Increased risk of MH ● Duchenne's muscular dsytrophy ● Central core disease ● Osteogenesis imperfecta ● King Denborough syndrome
  • 58. Classic signs of MH Specific ● Rapid rise in EtCO2 early sign ● Rapid increase in temp late sign ● Muscle rigidity +/- ● Rhabdomyolosis – Increase CK ● Myoglobinuria Nonspecific ● Tachycardia ● Tachypnea ● Acidemia – Metabolic – Respiratory ● Hyperkalemia ● Dysrhythmias
  • 59. MH treatment ● Discontinue triggering agents ● Hyperventilate with 100% FiO2 ● NaHCO3 1-2 mEq/kg IV ● Dantrolene 2.5 mg/kg IV ● Cool patient ● Support as indicated → intropes, dysrhythmias ● Monitor labs ● Consider invasive monitoring ● 1 800-MH-HYPER

Editor's Notes

  1. King- Denborough syndrome Short stature , MR, cryptorchidism, kyphoscoliosis,pectus, slanted eyes, low set ears, webbed neck, winged scapula