Paediatric Anaesthesia

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Paediatric Anaesthesia
G.K.Kumar
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Paediatric Anaesthesia

• Gregory 4th edition
• Smith 4th edition

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Paediatric Anaesthesia

• Introduction
• Why?
• What?
• How?

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Paediatric Anaesthesia
Its Different
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Paediatric Anaesthesia
Its Different
Paediatric anaesthesia is a family affair.
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Paediatric Anaesthesia
Not a miniature adult
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Paediatric Anaesthesia
Its Different

• Airway difference
• Changes in cardiovascular system
• Chest wall/Respiratory difference
• Kidney and liver difference
• GI system and thermoregulation difference
• Pharmacology/dynamics difference

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Paediatric Anaesthesia
Its Different

• Airway difference
• Large tongue
• Epiglottis short and stubby
• Higher located larynx
• Angled vocal cords
• Narrowest portion is cricoid cartilage

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Paediatric Anaesthesia
Its Different
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

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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

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

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• Kidney and liver difference
• Low renal perfusion pressure, immature GF, TF,
  obligate Na loser in the 1st month of life
• Complete maturation _at_ 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

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• 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

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Paediatric Anaesthesia
Its Different

• Different environment
• Different gadgets
• Different techniques

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Paediatric Anaesthesia
Its Different

• Pre anesthetic evaluation
• NPO order
• Premedication
• Fear of the unknown
• Fear of parental separation
• IV access
• Anesthesia
• Post anesthesia care
• Post op pain relief

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Paediatric Anaesthesia
Its Different

• Psychological preparation of child and family
• Premedication option
• Induction technique
• Intra operative considerations
• Postoperative emergence, analgesia
• Follow up

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Preoperative preparation

• The number one error in paediatric anaesthesia is
  inadequate preparation.
• Planning prevents problems!
• Absence of adequate pre-anaesthetic assessment is
  one of top three causes of lawsuits against
  anaesthesiologists.

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Paediatric Anaesthesia
Its Different

• Pre anesthetic evaluation

Airway?
IV Access
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Premedication Options

• Pharmacologic premedication
• Midazolam

0.2 to 0.6 mg/kg up to 10 mg max.
0.5 to 1.0 mg/kg up to 10 mg max.
0.35 to 1.0 mg/kg
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Premedication Options

• Midazolam
• PO 0.5 to 1.0 mg/kg up to 10 mg max.
• Bioavailability 30
• Peak serum levels after about 45 minutes
• Peak sedation by about 30 minutes
• 85 peaceful separation
• Beware total volume of dose should probably not
  exceed 0.4-0.5 ml/kg (NPO!)
• Nasal 0.2 to 0.6 mg/kg
• Peak 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
• 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.

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Premedication Options

• Pharmacologic premedication
• Ketamine

6 to 10 mg/kg
3 to 4 mg/kg
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Premedication Options

• 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

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Premedication Options

• Pharmacologic premedication
• Midazolam
• Ketamine
• 100 successful separation
• 85 easy mask induction

0.4 mg/kg 4 mg/kg
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Premedication Options

• Pharmacologic premedication
• Fentanyl lollypops
• (oral transmucosal Fentanyl)
• 15 to 20 mcg/kg
• Increased volume of gastric contents
• Nausea and vomiting
• Pruritus
• Hypoventilation (SpO2 lt90)

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Paediatric Anaesthesia
Its Different
Avoid over sedation
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Parental presence

• Parents and Toys-"Parents are often the best
  premedication."
• The presence of the parents during induction has
  virtually eliminated the need for sedative
  premedication.
• Helpful for children older than 4 years who have
  calm parents

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Paediatric Anaesthesia
Its Different

• Parental separation

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Paediatric Anaesthesia
Parental separation
Its Different

• Early infancy (up to7 m) Parents are the primary
  focus. Gentle, comfortable separation is almost
  always possible before induction of anesthesia.
• 1 to 3 yr Separation anxiety is major
  consideration. Surgery outpatient bases if
  possible. Careful selection regarding parental
  presence.

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Paediatric Anaesthesia
Parental separation
Its Different

• 3 to 6 years Child becomes primary focus. Fear
  of unknown dealt with by explaining exactly what
  will happen what you will do. Then make sure you
  do it that way. (Be trustworthy!)
• 6 years to adolescent Increasing involvement of
  patient.

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NPO Guidelines

• AGE MILK SOLIDS
  FLUIDS
• lt 6 MTHS 4 HRS
  2 HRS
• 6-36 MTHS 6-8 HRS
  3HRS
• gt36 MTHS 6-8 HRS
  3HRS
• This fasting regimen has made the preoperative
  fast a
• much more humane process for both the
  patients
• and the parents
• BEWARE effects of STRESS DRUGS

COTWAF-2009
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Paediatric Anaesthesia

• IV Access

Its Different
Call for help
Use gadgets
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Induction Techniques

• Inhalational
• Intravenous (IV)
• Intramuscular (IM)
• Rectal
• Oral

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Paediatric Anaesthesia
Its Different
Try your mask
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Induction Techniques
Factors Influencing Choice of Technique

• How old is the patient?
• What is the underlying illness? General medical
  condition? ASA physical status?
• What is the surgical procedure planned?
• How cooperative is the patient?
• Will a parent be present?
• Does s/he have an IV?
• What are the skills and preferences of the
  anaesthesiologist?

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Peri operative Fluid Management

Maintenance of IN OUT
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Peri operative Fluid Management
CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID
MANAGEMENT IN CHILDREN 2007
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Peri operative Fluid Management
APA Guidelines-2007
1.Children can safely be allowed clear fluids 2
hours before surgery without increasing the risk
of aspiration. 2. Food should normally be
withheld for 6 hours prior to surgery in children
aged 6 months or older. 3. In children under 6
months of age it is probably safe to allow a
breast milk feed up to 4 hours before surgery
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Peri operative Fluid Management
APA Guidelines-2007
4. Dehydration without signs of hypovolaemia
should be corrected slowly. 5. Hypovolaemia
should be corrected rapidly to maintain cardiac
output and organ perfusion. 6. In the child, a
fall in blood pressure is a late sign of
hypovolaemia.
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Peri operative Fluid Management
APA Guidelines-2007
7. Maintenance fluid requirements should be
calculated using the formula of Holliday and
Segar Body weight Daily fluid requirement 0-10kg
4ml/kg/hr 10-20kg 40ml/hr 2ml/kg/hr above
10kg gt20kg 60ml/hr 1ml/kg/hr above 20kg
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Peri operative Fluid Management
APA Guidelines-2007
8. A fluid management plan for any child should
address 3 key issues i. any fluid deficit which
is present ii. maintenance fluid
requirements iii. any losses due to surgery e.g.
blood loss, 3rd space losses
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Peri operative Fluid Management
APA Guidelines-2007
9. During surgery all of these requirements
should be managed by giving isotonic fluid in all
children over 1 month of age 10. The majority
of children over 1 month of age will maintain a
normal blood sugar if given non-dextrose
containing fluid during surgery
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Peri operative Fluid Management
APA Guidelines-2007
11.Children at risk of hypoglycaemia if
non-dextrose containing fluid is given are those
on parenteral nutrition or a dextrose containing
solution prior to theatre, children of low body
weight (lt3rd centile) or having surgery of more
than 3 hours duration and children having
extensive regional anaesthesia. These children
at risk should be given dextrose containing
solutions or have their blood glucose monitored
during surgery.
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Peri operative Fluid Management
APA Guidelines-2007
12. Blood loss during surgery should be replaced
initially with crystalloid or colloid, and then
with blood once the haematocrit has fallen to
25. Children with cyanotic congenital heart
disease and neonates may need a higher
haematocrit to maintain oxygenation.
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Peri operative Fluid Management
APA Guidelines-2007
13. Fluid therapy should be monitored by daily
electrolyte estimation, use of a
fluid input/output chart and daily weighing if
feasible. 14. Acute dilutional hyponatraemia is
a medical emergency and should be managed in PICU.
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Extubation-Always awake
Except
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Common PostoperativeProblems In Paediatric
Anaesthesia

• Emergence Delirium
• Upper Airway Obstruction
• Laryngospasm
• Post Intubation Croup
• Bronchospasm
• Aspiration

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Thank you

• G.K.Kumar