Presented May 2003

Pediatric Anesthesia
Darko J Vodopich MD
Resident @ CWRUMHMC
Revised by: Greg Gordon MD, and Susan Sweda MD

Development:

Organogenesis - 1st 8 weeks Organ function - 2nd trimester Body mass - 3rd trimester

Changes in cardiovascular system:

Removal of placenta from circulation Increasing of systemic vascular resistance Decreasing of pulmonary vascular resistance True closure of PDA ~ 2-3 weeks critical transitional circulation Myocardial cell mass less developed prone to biventricular failure, volume loading, poor tolerance to afterload, heart rate-dependent CO*
* True for young infants

Changes in pulmonary system:

Small airway diameter - increased resistance Little support from the ribs VO2 2x > adults Diaphragm and intercostal muscles do not achieve type-1 adult muscle fibers until age 2 Obligate nasal breathers

Airway difference:
Large tongue Higher located larynx Epiglottis short and stubby, angled over the inlet Angled vocal cords we must rotate ETT to correct lodging at anterior comissure Narrowest portion is cricoid cartilage

Chest wall/Respiratory difference:

Ribs are horizontal in neonates (vertical in adults) Ribs and cartilages are more pliable Chest wall collapse more with increased negative intrathoracic pressure Atelectasis is more common
FRC number of alveoli

Alveolar ventilation/FRC: Adults = 1.5:1 Infants = 5:1 ( respiratory rate)

Kidney and liver difference:

Low renal perfusion pressure, immature GF, TF, obligate Na loser in the 1st month of life Complete maturation @ 2 years of age Impaired liver enzymes, including conjugation react. Lower levels of albumen and proteins - prone to neonatal coagulopathy, and less drug bound higher drug levels

GI system and thermoregulation:

Full coordination of swallowing ~ 4-5 months increased risk for GE reflux Large body surface area/weight Limited ability to cope stress Minimal ability to shiver in 1st 3 months Heat whole body including the head

Pharmacology/dynamics:
Increased total body water: Large initial dose required Less fat longer clinical drugs effect Redistribution of the drug into muscle will increase duration of clinical effect (fentanyl) Consider liver and kidney immaturity

Volatile anesthetics Isoflurane:

Less myocardial depression than Halothane Preservation of heart rate CMRO2 reduction rate

Desflurane:
Increased incidence of coughing, laryngospasm, secretions Concern of hypertension and tachycardia from sympathetic activation

Volatile anesthetics (2) Sevoflurane

Less pungent than Isoflurane Concern of compound A (nephrotoxicity) Most suitable for induction

Remember: MAC for potent volatile anesthetics is increased in neonates, but may be lower for sicker neonates and premies

Induction drugs:
Methohexital:
1-2 mg/kg i.v. or 25-30 mg/kg per rectum Side effects: burning hiccup apnea extrapyramidal syndrome Contraindication: temporal lobe epilepsy

Thiopental:
5-6 mg/kg i.v. Caution in low fat children and malnourished

Induction drugs:
Propofol:
3 mg/kg i.v. (until 6 years of age) Pain on injection - 0.2 mg/kg Lidocaine i.v.

Ketamine:
10 mg/kg IM, PR, orally Increased salivation Contraindications: Increased ICP Open globe injury

Induction drugs:
Benzodiazepines:
Diazepam: 0.1-0.3 mg/kg orally T1/2 80 hours contraindicated < 6 months Midazolam: Only FDA benzodiazepine approved in neonates 0.1-0.15 mg/kg IM 0.5-0.75 mg/kg orally 0.75-1.0 mg/kg rectally Reduce dose in drugs B cause Cytochrome P450 inhibition

Induction drugs:
Narcotics:
Morphine: Increased permeability of blood/brain barrier 50 mcg/kg IV Meperidine: Less respiratory depression than morphine Be cautious in long term administration because of its metabolite normeperidine

Induction drugs:
Narcotics(2):
Fentanyl: 12.5 mcg/kg IV during induction provides stable cardiovascular response 1-2 mcg/kg adjuvant to anesthesia Stable cardiovascular response Alfentanyl and Sufentanyl: More rapid clearance than adults Can cause parasympatholysis bradycardia, hypotension

Induction drugs:
Muscle relaxants:
Succinylcholine: 2.0 mg/kg IV; 4.0 mg/kg IM Consider Atropine 10-15 mcg/kg given prior SUX Potential side effects: Rhabdomyolysis Hyperkalemia Masseter spasm MH

Induction drugs:
Muscle relaxants(2):
If tachycardia desired - Pancuronium Mivacurium - brief surgeries, beware of histamine release, bronchospasm Rocuronium - useful for modified RSI, and can be administered IM (1 mg/kg)

Muscle relaxants - Summary:

 
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Muscle relaxa ta d- u curari e a cur i u Met curi e tracuriu i satracuriu ecur i u Mivacuriu x acuriu i ecur i u eversal age ts

0.60 0.08 0.34 0.30 0.10 0.08 0.10 0.030 0.080 (0.31.0 g/kg) + atr i e (0.010.02 g /kg) (0.020.06 g/kg) + atr i e (0.01 0.02 g /kg)

0.30 0.06 0.15 0.20 0.080 0.06 0.10 0.030 0.080

0.80 0.100.15 0.500.60 0.500.60 0.10 0.100.15 0.200.25 0.0500.060 0.0800.120

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Premedication:
Almost all sedatives are effective Usually not necessary < 6 months Most common route used is oral Side effects: Oral - slow onset IM - pain, sterile abscess Rectal - uncomfortable, defecation, burn Nasal -irritating Sublingual -bad taste

Pharmacological premedication options

1. Role when awa e separation of child from parent before induction is planned. 2. Its success may be judged by the peacefulness of the separation. 3. Large volume of literature indicates lack of clearly ideal technique

http://metrohealthanesthesia.com/edu/ped/pedspreop6.htm

Pharmacological premedication options

Midazolam (Versed) PO: 0.5 to 1.0 mg/kg up to 10 mg max. Bioavailability = 30% Pea serum levels after about 45 minutes Pea sedation by about 30 minutes 85% peaceful separation Mix with grape concentrate or acetaminophen (Tylenol) syrup or elixir or Motrin Suspension (10 mg/kg of the 2% suspension)

Pharmacological premedication options (3)

Midazolam (Versed)(2) Nasal: 0.2 to 0.6 mg/kg Pea serum level in 10 minutes 0.2 mg/kg same as 0.6 mg/kg except 0.2 mg/kg did not delay recovery 0.6 mg/kg may delay extubation

Possible concern: animal studies reveal neurotoxicity after topical applicaton.

Pharmacological premedication options (4)

Midazolam (Versed)(3) Sublingual: 0.2-0.3 mg/kg as effective as 0.2 mg/kg intranasal Rectal: 0.35 to 1.0 mg/kg Some effect by 10 minutes, peak effect 20-30 minutes. 1.0 mg/kg did not delay PACU discharge.

Pharmacological premedication options (5)

Methohexital (Brevital) Rectal 25 to 30 mg/kg as 10% solution in warm tap water 85% sleeping within 10 minutes = rectal induction of GA (very peaceful separation) Sleep duration: about 45 to 90 minutes 25 mg/kg did not delay recovery in one study, but some delay may be expected after a short (less than 30-minute) case.

Pharmacological premedication options (6) Ketamine PO: 6 to 10 mg/kg May slightly prolong time to discharge after a short case IM: 3 to 4 mg/kg sedation; 2 mg/kg did not delay recovery 6 to 10 mg/kg = IM induction of general anesthesia 10 mg/kg: as effective as Midazolam 1 mg/kg but some delay in recovery may be expected

Pharmacological premedication options (7) Midazolam + Ketamine: PO 0.4 mg/kg 4 mg/kg respectively

100% successful separation 85% easy mask induction Doubling dose leads to "oral induction of general anesthesia" in most cases. Lasts 30 to 60 minutes.

Pharmacological premedication options (8) Fentanyl "lollipops" (oral transmucosal Fentanyl) 15 to 20 mcg/kg Increased volume of gastric contents Nausea and vomiting Pruritus Hypoventilation (SpO2 <90)

Pharmacological premedication options (9)

1. Metoclopramide (Reglan) PO or IV: 0.2 mg/kg 2. Ranitidine (Zantac) PO 2.5 mg/kg 3. EMLA cream: Eutectic mixture of Lidocaine and Prilocaine. For cutaneous application by occlusive dressing one hour preoperative 4. Glycopyrrolate: consider for selected patients for planned airway instrumentation; e.g.: fiberoptic endoscopy, oral or upper airway surgery, cleft palate)5-10 mcg/kg IV or 10 mcg/kg IM

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Fasting:
Clear liquids - 2-3 h before the procedure If infants are breast fed - 4 h before the procedure For older patients = the adults rule Be aware of dehydration

Induction of Anesthesia:
Inhalational induction: Younger than 12 months After the induction, place the intravenous catheter Use suggestions in older child (pilots mask) In a case of difficult airway - Fiberoptic intubation

Induction of Anesthesia:
Rectal induction: Methohexital Thiopental Ketamine Midazolam Technique no more intimidating than rectal temperature measurement Usual time of onset ~ 10-15 min

Induction of Anesthesia:
Intramuscular induction: Most common used Ketamine Disadvantage painful needle insertion Advantage: reliability

Induction of Anesthesia:
Intravenous induction: The most reliable and rapid technique Disadvantage - starting intravenous line If patient is older ask the patient If you insert IV line: I. Do not allow the patient to see it II. Use EMLA cream III. If use local - ask the patient if there is any sensation on puncture

Patient with full stomach:

Treat the same as adult with full stomach: RSI with ODL using cricoid pressure Tell the patient that will feel touching on the neck Be aware of VO2 (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 short duration (difficult airway)

Endotracheal tubes:
Recommended Sizes and Distance of Insertion of Endotracheal Tubes and Laryngoscope lades for se in Pediatric Patients RECO ENDED Age Of The Diameter Size of the Patient Distance (internal) lade Premature 2.5 0 67 (<1,250 g) Full term 3.0 01 810 1y 4.0 1 11 2y 5.0 11.5 12 6y 5.5 1.52 15 10 y 6.5 23 17 18 y 78 3 19

4 + (1/4) (age) = size;

12 + (1/2) (age) = depth

Intravenous fluids:
Calculation of Maintenance Fluid Require ents for ediatric atients Wei t Fluids ( L/h o u r) 24-H Fluids ( L) (k ) <10 4 /kg 100 /kg 1120 40 +2 /kg 10 1,000 + 50 /kg 10 20 60 +1 /kg 20 1,500 + 20 /kg 20

Include if present: Fluid deficits Third spaces losses Hypo/hyperther ia Unusual etabolic fluids de ands

Fluid re uirements in neonates:

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 The volume of extracellular fluids in neonates is large Consider use of radiant warmers, and heated humidifiers - decrease insensible water loss Use LR for replacement, D5% with 0.45 NS by piggyback

Pac ed Red lood Cells:

The use has diminished because of disease transmission (HIV, Hep C,B. etc) 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 EBV (starting Hct - target Hct) MABL = Starting Hct

Pac ed Red lood Cells (2):

Child usually tolerates Hct ~ 20 in mature children If: Premature, Cyanotic congenital disease Hct ~ 30 O2 carrying capacity No one formula permits a definitive decision Replace 1ml blood with 3 ml of LR Lactic acidosis is a late sing of decreased O2 carrying capacity Be aware of blood disorders (sickle cell disease)

Fresh Frozen Plasma:

Use to replenish clotting factors during massive transfusion, DIC, congenital clotting factor deficits Usually replenished if EBL = 1-1.5 TBV A patient should be never given FFP to replace bleeding that is surgical in nature If transfused faster than 1.0 ml/kg/min severe ionized hypocalcemia may occur If occurs - Rx. with 7.5-15 mg/kg Ca gluconate Ionized hypocalcemia can occur in neonates frequently because of decreased ability to mobilize Ca++ and metabolize citrate

Ionized Hypocalcemia:

Platelets:
Find etiology - TTP, ITP, HIT, DIC, hemodilution after massive blood transfusion Consider transfusion if Platelets < 50.000 In certain hospitals platelet function test is available If Platelets < 100.000 and EBL = 1-2 TBV transfusion more likely If Platelets > 150.000 and EBL > 2 TBV transfusion more likely

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

Special Monitoring the Pediatric Patients:

Intraarterial 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 Multilumen catheters are valuable in ICU patients In a case of rapid fluid replacement peripheral venous catheter might be very useful Short-term cannulation of femoral/brachiocephalic or umbilical vein may be life-saving

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

Mapleson D Circuit:

Gas disposition at end-expiration during spontaneous ventilation

Gas disposition at controlled ventilation

Neonatal Anesthesia:
Understand differences in Physiology Pharmacology Pharmacodynamic response Most of the complications that arise are attributable to a lack of understanding of these special considerations prior to induction of anesthesia Be aware of: Sudden changes in hemodynamics Unexpected responses Unknown congenital problem

Neonatal Anesthesia (2):

Children < 1 year old have more complications: I. Oxygenation II. Ventilation III. Airway management IV. Response to volatile agents and medications Stress response is poorly tolerated Consider: 1. Organ system immaturity 2. High metabolic rate 3. Large ratio body surface/weight 4. Ease of miscalculating a drug dose

Neonatal Anesthesia (3):

Prevention of paradoxical air emboli Fluids instituted with volume-limiting devices Minimize thermal stress Use flow-through capnograph if possible Prevent retinopathy of prematurity by: Lower FiO2 Keep CO2 within normal range

Neonatal Anesthesia (4):

Stress Response:
Poorly tolerated Use opioid technique (blunt pain response) Ketamine is excellent choice stable intraoperative hemodynamics Potent volatile anesthetics are poorly tolerated No one should be denied anesthesia because of the age or weight

Special Problems in Neonatal Anesthesia:

Meningomyelocele:

Underestimating fluid or blood loss from the defect High association with hydrocephalus Possibility of cranial nerve palsy Potential for brain-stem herniation

Special Problems in Neonatal Anesthesia (2):

Pyloric stenosis:
First 3-6 weeks in life Anesthesiologist concern: I. Full stomach with barium II. Metabolic alkalosis with Hypochloremia and Hypokalemia III. Severe dehydration Surgery is never emergency Metabolic correction mandatory before the surgery Suction the stomach before induction Consider awake intubation or RSI

Special Problems in Neonatal Anesthesia (3): Omphalocele and Gastroschisis:

Omphalocele occurs because of failure of the gut to return to the abdominal cavity at 10th week of life Fine membrane covers intestines and abdominal contents Gastroschisis develops later in life after gut has returned into abdominal cavity Abdominal contents and organs are not covered with any membrane risk of infection

Special Problems in Neonatal Anesthesia (3): Omphalocele

Special Problems in Neonatal Anesthesia (3): Gastroschisis

Special Problems in Neonatal Anesthesia (3): Omphalocele and Gastroschisis(2):

Anesthesiology concern: 1. Dehydration 2. Massive fluid loss (exposed viscera and 3rd space loss) 3. Heat loss 4. Difficulty of surgical closure 5. High association with prematurity, congenital defects, including cardiac anomalies Minimize infection, Replenish fluids, be liberal in muscle relaxants, consider hypotension and difficulty ventilation

Special Problems in Neonatal Anesthesia (3):

Omphalocele and Gastroschisis(3):
During closure consider * difficulty ventilation * hypotension * abdominal pressure may compromise liver function and alter drug metabolism During closure of big defects monitoring of the bladder pressures is important: if the pressure is < 20 cm H2O attempt is to close, > 20 cm H2O closing in stages.

Special Problems in Neonatal Anesthesia(3):

Omphalocele and Gastroschisis (4):
Be aware of Beckwith-Wiedemann syndrome: Profound hypoglycemia Hyperviscosity syndrome Associated visceromegaly

Special Problems in Neonatal Anesthesia(3):

Omphalocele and Gastroschisis ddx. (5):
1. Much greater associated defects with Omphalocele

2.

More fluid loss associated with Gastroschisis

Special Problems in Neonatal Anesthesia(4):

Tracheoesophageal fistula anomaly(1):
90 % proximal atresia of esophagus with distal fistula Consider aspiration pneumonitis. VATER syndrome: I. Vertebral II. Anal III. Tracheoesophageal IV. Renal MCC of death cardiac anomalies

Trachea T-type

Special Problems in Neonatal Anesthesia(4):

Tracheoesophageal fistula anomaly(1):
90 % proximal atresia of esophagus with distal fistula Consider aspiration pneumonitis. VATER syndrome: I. Vertebral II. Anal III. Tracheoesophageal IV. Renal MCC of death cardiac anomalies

Trachea T-type

Special Problems in Neonatal Anesthesia(4):

Tracheoesophageal fistula anomaly(2):
Major issues are: Aspiration pneumonia
Trachea

Overdistention of the stomach

T-type

Inability to ventilate Postoperative intensive care

Special Problems in Neonatal Anesthesia (4):

Tracheoesophageal fistula anomaly(3):
Induction: Awake intubation Deliberate right main stem intubation Catheter in esophagus Trachea Prone position with head-up T-type Avoid massive distention of the stomach by gentle ventilation Careful confirmation of tube position by moving tube mm by mm (position must be between fistula and tracheal bifurcation) Tape precordial stethoscope over the left chest

Special Problems in Neonatal Anesthesia (5):

Diaphragmatic hernia:
Usually presentation on 1st day of life Almost all viscera can be in the chest cavity Anesthesia concerns: I. Hypoxemia II. Hypotension III. Stomach herniation IV. Pulmonary hypertension V. Systemic hypotension

Shifted mediastinum
Diaphragmatic hernia

Special Problems in Neonatal Anesthesia (5):

Diaphragmatic hernia (2):
1. Awake intubation 2. Intraarterial catheter 3. Use opioids (stress response) 4. Use Pancuronium Shifted mediastinum 5. Avoid hypothermia Diaphragmatic hernia 6. Avoid any myocardial depressant 7. Avoid N2O (abdominal distention) 8. Aware of barotrauma-induced pneumothorax 9. Adequate intravenous access 10. Plan postoperative care

Special Problems in Neonatal Anesthesia (6):

Former preterm infant (<37 weeks):
High incidence of apnea risk factors: Respiratory distress syndrome Bronchopulmonary dysplasia Neonatal dyspnea Necrotizing enterocolitis Ongoing apnea at the time of surgery Use of narcotics Long acting muscle relaxants Anemia (Hct < 30)

Regional Anesthesia and Anesthesia:

(brief overview)

Most regional anesthetics are safe to use Strict attention to: Dose Route of administration Proper equipment used Common: Caudal blocks