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

1. WHATS NEW IN PAEDIATRIC
ANAESTHESIA
DRUGS

2. Dr. Mrs. Minnu M Panditrao
Consultant
Department of Anaesthesiology &
Intensive Care
Public Hospital Authority’s
Rand memorial hospital,
Freeport, Bahamas

3. INTRODUCTION
Paediatric Anaesthesia
• Challenging subspecialty
• Smaller size & weight
• Difference in pharmacokinetics

4. NEONATES & INFANTS
• Do they really need anaesthesia?
• Yes, they do
• Precision & accuracy very important
for safety

5. What is new?
CURRENT PRACTICES
• Pre anaesthetic preparation & medication
• Anaesthesia Induction agents
 Inhalation agents
 IV Induction agents
• Neuromuscular blocking drugs
• Reversal agents
• Analgesics - Opioids/Non Opioids
• Local anaesthetics
• Miscellaneous drugs

6. PRE OPERATIVE
PREPARATION
• Pre operative checkup / visit
• Counseling of patients / parents
• General explanation of place,
equipment & procedure

7. PREMEDICATION
• Injectables are not preferred
• Other routes
– Oral :- Triclofos, Promethazine,
Midazolam, Ketamine
– Sublingual/Trans Mucosal :- Fentanyl
– Intra nasal :- Midazolam, Ketamine,
Sufentanil
– Rectal :- Midazolam, Methohexital,
Diazepam, Ketamine
– IM :- Ketamine (2 mg/kg)

8. INDUCTION AGENTS
• Inhalational – for routine surgeries,
uncooperative patients, incremental induction/
starting with high concentrations.
• Intravenous – for rapid sequence induction in
emergency surgeries, patients with i.v. lines in
situ, cooperative patients.

9. SEVOFLURANE
• Polyflurinated methyl isopropyl ether
• Inhalational agent of choice for
induction
• Rapid induction & recovery - low blood
gas solubility
• Techniques of induction
• MAC
• Metabolism
• Disadvantages

10. HALOTHANE
• Still used ‘coz of cost restraints
• Advantages
• Techniques of induction
• Disadvantages

11. ISOFLURANE
• Maintenance Inhalational
Anaesthetic Agent
• Advantages
• Disadvantages
• MAC/ Metabolism

12. DESFLURANE
• Most recent inhalational anaesthetic
agent
• More suitable for Maintenance
• Advantages
• Disadvantages
• MAC/ Metabolism

13. INTRAVENOUS INDUCTION
AGENTS
PROPOFOL
• Rapidly acting Alkyl Phenol
• Potent, No analgesia
• Dosage bolus : 2.5 – 4 mgKg
infusion : 0.1 – 0.2 mgKgmin
• Advantages
• Propofol infusion syndrome
• For TIVA - Paedfusor

14. KETAMINE
• Water soluble, non irritant
• Good analgesic, CVS stability
• Routes of administration
I.V. / I.M. (for induction)
Oral, Intra nasal
IV infusion
Additive in neuraxial, regional
blocks
• Disadvantages

15. THIOPENTONE
• Still has a place where other IV
agents are contraindicated i.e.
• Neuroanaesthesia in neonates
• Convulsive disorders etc.

16. NEURO MUSCULAR
BLOCKING DRUGS
• Paediatric patients are
 Resistant to depolarizing NMBDs
 Sensitive to non-depolarizing NMBDs
• Metabolism in the liver delayed

17. • Succinyl Choline
• Atracurium / Cisatracurium
• Mivacurium
• Doxacurim

18. • Vecuronium/Pancuronium
• Rocuronium
• Rapacuronium
• Priming with NMBDs

19. REVERSAL AGENTS
• Neostigmine / Edrophonium +
Atropine / Glycopyrrolate
• Sugmadex – Modified γcyclodextrin
sodium salt, specific for reversal of
rocuronium. No need to combine with
Atropine. Reports of use in adults.
Dose: 12-15 mgKg

20. ANALGESICS
OPIOIDS- µ agonists
• Fentanyl
• Alfentanyl
• Sufentanil
• Remifentanyl

21. OPIOIDS
• Butorphenol
• Buprenorphine
• Tramadol
• Codiene

22. NSAIDS
For mild – moderate pain relief
Drug Oral dose Rectal dose IM dose IV dose
Paracetamol 10-15 mgKg 20-40 mgKg 15 mgKg
6 hrly 12 hrly 12 hrly
Diclofenac 1-1.5 mgKg 1-1.5 mgKg 1-1.5 1 mgKg
12 hrly 12 hrly mgKg
Ibuprofen 5-10 mgKg
6 hrly
Ketorolac 0.5 mgKg 0.5 mgKg

23. LOCAL ANAESTHETICS
Neonates and infants - prone to L.A. toxicity
Local Anaesthetic Doses
Drugs Single Continues Max. dose
shot infusion 4 hr period
technique MgKghr MgKg
MgKg
Lignocaine 3-5
Bupivacaine 2-2.5 0.2-0.5 2
Levobupivacaine 2 0.125-0.4 2
Ropivacaine 3 0.2-0.4 1.6

24. MISCELLANEOUS
DRUGS
Clonidine
• α2 adrenergic agonist
• Co-analgesic
 Routes of administration
 Oral (1-2 µg Kg 8 hrly)
 IV ( 0.1- 0.5 µg Kg hr)
 Spinal/epidural (2 µg Kg)
 Regional nerve blocks

25. Dexmedetomidine
 A newer α2 adrenergic agonist
 Has hypnotic & analgesic properties
 Reported use – as a sedative for
Radiological investigative procedures
Cardio-catheterisation
Awake craniotomies
Burn dressings
Sevoflurane emergence agitation
Also co-administered in paediatric cardiac
anaesthesia

26. Dexmedetomidine
• Given as an I.V infusion
• Dose:
• Loading dose 1-4 µg Kg
• Infusion rate 0.5-1 µg Kg hr
• Onset of action 10-20 min
• Recovery time 20-60 min
• Side effects
 ↓ HR (15 %)
 ↓ MAP (15%)

27. Gabapentin
• Has an analgesic and opioid sparing
effect
• Dose 10-20 mgKg orally
• Side effects
 Gastritis
 Nausea, Vomiting
 Dizziness

28. Melatonin -for sedation
Satisfactory effect in elderly patients.
Unsatisfactory in children
Dose- 5-10 mg
Caffeine- for apoenic spells
Dose- 10 mgKg24 hrs
Side effects: Tachycardia, Sympathetic
stimulation

29. Thank You!