Anesthesia During the First Year of Life

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Anesthesia During the First Year of Life

• Hany El-Zahaby, MD
• Dept. of Anesthesia, Ain Shams University

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• Safe and effective anesthesia for neonates
  infants undergoing surgery is one of the most
  challenging tasks presented to anesthesiologist.
• Knowledge
• Manual skills
• Continuous practice
• Adequate monitoring
• ?
• Outcome

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Age-specific considerations Airway
differences Infant Vs Adult Big head , small
body Tongue/Epiglottis relatively
larger Glottis more superior, at level of C3 (vs
C4 or 5) Cricoid ring narrower than vocal cord
aperture
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Age-specific considerations Fast desaturation

• Low FRC, high closing volume, highly compliant
  airways? atelectasis
• High oxygen consumption cant do forced
  inspiration ? increase R.R. ?high work of
  breathing
• Diaphragmatic breathing? easily fatigue (less
  type I muscle fibers)?fast desaturation

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Age-specific considerations

• Cardiac output is rate dependent (cant increase
  stroke volume)
• Immature baroreceptor reflex and limited ability
  to compensate for hypotension by increasing heart
  rate. They are more susceptible, therefore, to
  the cardiac depressant effects of volatile
  anesthetics (parasympathetic predominance)
• Immature hepatic function (drug dosing intervals
  maintenance)
• Immature renal function (poor toleration of fluid
  restriction/overload)

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Age-specific considerations

• High volume of distribution of drugs
• Temperature control (easily loose heat under GA)
  due to high surface area to body weight ratio, no
  shivering
• Competent nociceptive system (nonanalgesic
  practice is no longer accepted)

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Premedication

• Atropine (10-20µ/kg IV, minimum 100µ) to
  counteract parasympathetic reflexes.
• Pain (increments of morphine 10-20µ/kg IV up to
  100µ/kg)

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Monitoring

• FiO2, ECG, NIBP, ETCO2, Pulse oximetry,
  Temperature
• Direct BP (accurate, intravascular volume status
  e.g. undulations with ventilation and reduced
  upstroke of the BP curve in case of hypovolemia)
• CVP (vasoactive drugs)
• Urine output (1 ml/kg/h)

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• How Long Pre-oxygenation?
• 60 seconds 6L/min (gives 80-90 seconds before
  desaturation)
• (Morrison JE et al Pediatric
  Anaesthesia19988293)
• Inhalation VS Intravenous Induction?
• IV access hemodynamically stable? STP 4-8mg/kg
  (prolonged emergence postoperative apnea)-
  Propofol 3-3.5mg/kg
• IV access hemodynamically unstable ? Ketamine
  1.5-3mg/kg
• Difficult IV access or compromised airway ?
  Sevoflurane or halothane
• Combined technique ? (opioid nondepolarizing
  MR inhalation agent)

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• LMA VS ETT?
• LMA less than 30-45 min
• Size 1 ( 50 misplacement, NGT, small dose of
  MR, large dead space hypercapnea, helpful for
  ex-premis with BPD)
• ETT longer surgeries
• No awake intubation (very
  stressful/painful stimulus with suboptimal
  conditions)
• Relaxation?
• Succinyl choline (RSI) (higher doses than
  adults), large ECF volume
• Nondepolarizing MR (similar doses as adults),
  sensitivity offset by large ECF
• Deep inhalation anesthesia, disadvantages?

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• Technique?
• Oral Vs nasal? (lateral/prone/limited head
  access)
• Straight blade- go deeper then withdraw
• Level term neonate (9cm oral/11cm nasal), 1 year
  11-12cm
• Leak pressure? 20-25cmH2O, affected by head
  position MR
• 50 decrease in flow from size 3.5 to 3
• Non-cuffed/cuffed 8y (upper abdominal thoracic
  surgery, poor lung compliance)
• After intubation ? VCM (40cmH2O/15 sec) or TRIM
  (30cmH2O/10 sec)

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• Spontaneous Vs controlled?
• -Spontaneous more than 6 mos, less than 30 min
• Pressure Vs volume control?
• -Pressure control First few days, premature,
  respiratory distress or lung pathology
• -Volume control surgical manipulations
  interfere with ventilation
• -Peep 3-5 is routine
• Whatever the technique, an expired tidal volume
  PIP should be tailored to the desired levels

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Maintenance

• Halothane/sevoflurane/isoflurane all depress
  baroreceptor reflex
• Halothane depress the myocardium more
• Halothane decrease the heart rate more
• (Hypotension is treated by atropine lowering
  halothane)
• Sevo/Isoflurane decrease PVR more (treated by
  5-10ml/kg fluid bolus)
• Nitrous oxide 60 decreases MAC of halothane,
  isoflurane sevoflurane by 60, 40 25
  respectively
• Narcotics -Fentanyl 1-2µ/kg if regional block
  was done
• -Fentanyl based anesthesia for prolonged major
  surgery with postoperative ventilation

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• The use of light general volatile anesthetic
  with a central or peripheral nerve block has
  proved to be of great benefit in neonatal
  surgery
• Bosenberg AT et al, Pediatr Surg Int, 19927, 289
• Larsson BA et al, Anesth Analg 199784, 501

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Intraoperative Volume Replacement

• Hypovolemia with blood loss accounts for 12 of
  causes of cardiac arrest in OR with almost half
  of it due to under estimation of blood loss.
• Anesthesia-Related Cardiac Arrest in Children
  Update from the Pediatric Perioperative Cardiac
  Arrest RegistryBananker et al, Anesthesia
  Analgesia, August 2007

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Assessment of dehydration
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Fluid blood loss

• Type of fluid? Dextrose? BSS?
• Weighing swabs before it dries.
• Intraoperative blood loss should be replaced with
  balanced salt solution (13), or colloid (11)
• Estimated maximum allowable blood loss
• EBV x (Hctstarting Hctacceptable)
• Hctstarting

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Prevention of Heat Loss
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Prevention of Heat Loss

• Room temp. 76-78 F
• Avoid unnecessary exposure cover cotton wraps
  as much as possible
• HME (active or passive) IVF warm
• Active warming mattress
• Cover exposed viscera with warm wet towels
• Incubator keep plugged

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Emergence

• Reversal of MR after spontaneous movement even
  with adequate time after last dose
• Extubation
• Regular spontaneous breathing
• Vigorous movements of all limbs
• Gagging
• Eye opening or pronounced grimacing
• Stable hemodynamics good oxygen saturation
• Absence of significant hypothermia

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Case-specific considerations Hydrocephalus

• Burr hole over a dural venous sinus
• Bowel injury (re-do)
• Perforation of chest wall/neck vessels/occipital
  bone
• Hemodynamic instability/arrhythmias (acute
  decompression)

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Craniosynostosis

• Premature fusion of cranial suture ? lack of
  growth perpendicularly compensated overgrowth
  in normal areas affecting mental development
  vision due to intracranial hypertension
• Difficult airway if syndrome
• Positioning (Supine ? RAE or reinforced, Prone ?
  nasal T. sutured to nasal septum with 4-0 nylon)
• Blood loss (Donation, coag. Profile, 2 Ivs, A
  line)
• Prolonged surgery hypothermia
• Venous air embolism
• Raised ICP

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Encephalocele
Neural tube defect with variable neural
dysfunction Hydrocephalus Arnold Chiari type
II

• Wet/soft covering
• Avoid pressure
• Antibiotics
• Prone (nasal intubation)
• Blood loss
• Hypothermia
• Latex free procedure
• Document spontaneous breathing postoperatively

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Myelomeningocele

• Neural tube defect with variable neural
  dysfunction
• Hydrocephalus Arnold Chiari type II
• Wet covering
• Avoid pressure
• Antibiotics
• Prone (nasal intubation)
• Blood loss
• Hypothermia
• Latex free procedure

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Neonatal Conditions Requiring SurgeriesAirway
Obstruction

• Inspiratory stridor with jugular
  intercostal/subcostal retractions
• -Bilateral choanal atresia
• -Laryngomalacia
• -Supraglottic papillomatosis
• -Subglottic hemangioma
• -Cystic hygroma
• -The Pierre Robin Syndrome

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Choanal atresia
CHARGE Syndrome(Coloboma-Heart
Atresia-Retarded-Genital-Ear)
OGT
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Laryngomalacia
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Supraglottic Papillomatosis

• Subglottic Hemangioma

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Cystic Hygroma
?

• Cystic Hygroma( Recurrence)

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The Pierre Robin Syndrome

• Typical Anesthestic Management of
• a Neonate Presenting with Stridor
• ABG, chest x-ray
• IV access, atropine, preoxygenation
• Inhalation induction (deep)
• CPAP
• Smaller ETT or inhaled gases through side port of
  bronchoscope
• Hydrocortisone 1-2 mg/kg
• ICU or high dependency area for 12-24 h

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Neonatal Conditions Requiring SurgeriesAirway
ObstructionCleft Lip/Palate

• Echocardiography
• Blood?
• Atropine 10µ/kg
• Difficult intubation
• RAE tubes
• Throat pack
• Infra-orbital N. block
• Extubation

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Thoracic SurgeriesEsophageal Atresia/TEF
1cm
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Thoracic SurgeriesEsophageal Atresia/TEF
13000 MF 253 First fed chocking, cyanosis CHD,
VACTERL association 13
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Thoracic SurgeriesEsophageal Atresia/TEF

• Management
• Head up
• Continuous low suction on blind pouch
• Echocardiography
• Antibiotics
• Vit K
• Next day surgery

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Thoracic SurgeriesCongenital Lobar Emphysema

• Unilateral disease due to bronchomalacia,
  vascular anomaly, bronchial obstruction)
• Present with respiratory distress cyanosis with
  mediastinal shift
• Coexisting CHD in 35
• Anesthesia
• Spontaneous ventilation should be maintained
  with 100 oxygen Ketamine Inotropes
• Expand lungs before closure
• Intercostal block
• Extubate (spontaneous breathing)

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Thoracic SurgeriesPatent Ductus Arteriosus

• A disease of Prematurity with Lt to Rt shunt
  resulting in
• 1- Pulmonary over-circulation, high load on lt
  side, high output cardiac failure
• 2- In severe cases, reversal of diastolic aortic
  blood flow in the descending aorta resulting in
  splanchnic hypoperfusion and NEC
• Treatment
• Fluid restriction/diuretics (hypovolemia
  hypokalemia)
• Endomethacin (transient renal dysfunction,
  platelet dysfunction)
• Ligation

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Thoracic SurgeriesPatent Ductus Arteriosus

• Preoperative
• Echo (ht failure, hypovolemia)
• Head ultrasound (intracranial pathology)
• Routine labs (hypokalemia)
• 1 unit PRBCs, 1 unit plasma
• Last 24h urine output
• Anesthesia
• Atropine
• Low dose Sevoflurane opioids relaxant
• If not intubated, nasal intubation is preferred
• Tolerate desaturation for progress of surgery
  (limit is bradycardia)
• Treat hypotension with plasma expander
  inotrope
• Intercostal block by surgeon
• No immediate extubation

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Abdominal Surgeries Congenital Diaphragmatic
Hernia
15000 MF 11.8
Resp. distress Scaphoid abdomen Shifted heart
sounds
Bil. Pulmonary hypoplasia Hypoxia,
hypercarbia Pulmonary HTN, shunting
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Abdominal Surgeries Congenital Diaphragmatic
Hernia

• Management
• Gentle ventilation Limiting PIP, Oscillator (
  preductal SpO2gt 90)
• Delayed repair (gt100h) until medical
  stabilization
• Reversal of duct shunting
• Oxygenation Index lt 40
• PaCO2 lt 40
• Stable hemodynamics
• Poor Predictors
• Overall survival 63
• Polyhydramnios
• Immediate need for ventilation
• Immature RBCs (intrauterine ?COP)

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Abdominal Surgeries Congenital Diaphragmatic
Hernia

• Anesthesia
• Working NGT
• 2 pulse oximeters
• Atropine
• Inhalation/ slow opioid
• Treat hypotension with fluids/inotropes
• Treat pneumothorax on the other side immediately
• Treat the increased Rt to Lt shunt with
  fentanyl, higher FiO2, hyperventilation,
  correction of acidosis, Nitric oxide

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Omphlocele15000Hernial sacCHD 30-40Blood
lossHypothermiaHigh abdominal
pressureRSIInsensible water loss
10ml/kg/hUOPgt 30 mmHg (Ventilation )
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Gastroschisis
Midline above umbilicus Other abnormalities are
rare No hernial sac Coverage Heating I.V
fluids Abdominal pressure
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Gastrointestinal ObstructionPyloric Stenosis

• Forceful projectile vomiting 4-6 weeks of age,
  palpable olive-like mass in epigastrium
• Loss of hydrogen, chloride potassium
• Dehydration, electrolyte imbalance acid-base
  disorder
• Hypochloremic, hypokalemic alkalosis
• Rehydration (do not accept base excess gt 2)
• Functioning NGT
• RSI
• No narcotics, local wound infiltration

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Gastrointestinal Obstruction Malrotation

• Rehydration
• Functioning NGT
• Cross match PRBCs, FFP
• RSI (ketamine)
• If hypotension, give boluses of FFP, albumin 5
  or PRBCs dopamine
• Untwisting malrotated gut releases vasoactive
  substances lactic acid causing hypotension

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Inguinal Hernial RepairHydroceleUndescended
Testis

• Wiener ES et al Hernia survey of the Section on
  Surgery of the American Academy of Pediatrics. J
  Pediatr Surg 199631, 1166
• 70 GA (face mask or LMA) Caudal epidural or
  spinal An.
• 15 Spinal anesthesia alone
• 11 Caudal anesthesia alone

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Necrotizing Enterocolitis

• Its a disease of prematurity due to intestinal
  ischemia with secondary bacterial overgrowth ?
  abdominal distention, increasing gastric
  aspirate, gastrointestinal bleeding generalized
  sepsis.
• Antibiotics
• TPN
• Volume replacement (Albumin 5, FFP, PRBCs)
• Functioning NGT
• Check coagulation profile
• Ecchocardiography
• Chest x-ray for BPD
• Inotropes (do not interrupt)
• Maintain UOP (volume, Lasix 0.5 mg/kg)

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Bladder Extrophy

• Wet covering
• Antibiotics
• Blood loss
• Hypothermia
• Latex free procedure
• Postoperative immobility

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Surgery on the NICU Graduate

• First group Uneventful prematurity ? straight
  forward anesthesia
• Second group Ventilatory support-sepsis-PDA-IVH-N
  EC-multiple medications-BPD/chronic lung disease
  of the newborn-extubated with great difficulty.
• The main concern is postoperative apnea until
  6-12 Mon.
• Goals Avoid intubation/ventilation
• Avoid postoperative apnea
• Common surgeries
• 1- Laser/cryosurgery for ROP ? Face mask/LMA,
  avoid IV drugs in general
• 2- Inguinal hernia repair ? awake caudal without
  any drug supplementation or combined with
  inhalation anesthesia via LMA
• 3- Circumcision ? face mask with penile block

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