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Anesthesia for the Pediatric Patient — Transcript

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0:03the objectives for this lecture are as
0:06follows describe the anatomical and
0:08physiological differences of pediatric
0:10patients discuss the proper focused
0:13history and assessment of the pediatric
0:15patient and describe the anesthetic
0:17implications for Pediatrics with
0:19congenital deformities
0:28you
0:47children are not simply to be considered
0:50little adults they differ from adults
0:52anatomically physiologically
0:54psychologically and biochemically these
0:57differences are especially marked when
0:59comparing premature infants and neonates
1:01to adults and they only begin to recede
1:03around a child's tenth year many
1:06anesthetists who do not care for or
1:07administer to infants or small children
1:09on a daily basis are someone insecure
1:12with pediatric patients Pediatrics can
1:14be divided by age and their anesthetic
1:16requirements are different a preterm
1:18infant is one born before 37 weeks
1:20gestation a post mature infant is one
1:23born after 42 weeks gestation any infant
1:26born less than 2,500 grams is considered
1:28a low birth weight infant neonates are 0
1:31to 1 month infants are 1 to 12 months
1:34toddlers are 1 to 3 years and small
1:37children are 4 to 12 years
1:39safe anaesthetic management depends on
1:41the full appreciation of the
1:43physiological and atomic and
1:44pharmacological characteristics of each
1:47group these characteristics which
1:49differentiate them from each other and
1:51adults necessitate modification of
1:53anaesthetic equipment and technique
1:57this slide describes the relationship
1:59between gestational age body size and
2:02neonatal problems that occur with
2:04increased frequency pediatric anesthesia
2:08is a family affair depending on age past
2:11surgical experiences in maturity
2:13children suffer from varying degrees of
2:15Terror when faced with the prospect of
2:17surgery in contrast to adults who are
2:20usually more concerned about the
2:21possibility of death children are
2:23principally worried about what you're
2:25going to do to them if it's going to
2:26hurt and separation from their parents
2:28psychological preparation involves
2:30stress reduction the two most important
2:33sources of stress are fear of the
2:34unknown and fear of separation the best
2:37way to deal with the stress is by using
2:39simple honest communication this can be
2:42colored by a positive suggestion and
2:44should be modified according to the age
2:45of the patient let's go over the stages
2:49of development early infancy is from the
2:52neonatal period to around seven months
2:54in this stage parents are the primary
2:56focus and there is usually comfortable
2:57separation in the preoperative holding
2:59area later infancy is up to around three
3:02years this is where you are going to see
3:04some major separation anxiety children
3:07ages 3 to 6 think that the world
3:09revolves around them when dealing with
3:11these kids it is best to give them
3:13choices so that they feel like they have
3:14input in the process it is very
3:17important to explain to them what you
3:18are going to do and then follow through
3:20with it these patients are just old
3:22enough to know that there is something
3:24going on and it is important that they
3:25trust you as much as possible
3:27children 6 to adolescents are slightly
3:30easier to deal with there will be some
3:32baseline anxiety but you can typically
3:34reason with them to a degree be honest
3:37and what you're going to do and be sure
3:39to involve them in the process as much
3:41as possible
3:43neonates have low glycogen stores that
3:45predispose them to hypoglycemia impaired
3:48glucose excretion by the kidneys may
3:50partially offset this tendency neonates
3:53at greatest risk for hypoglycemia are
3:55premature or small-for-gestational-age
3:57have been receiving hyper alimentation
4:00or were born to diabetic mothers these
4:02infants should have frequent serum
4:04glucose determinations levels less than
4:0730 milligrams per deciliter in the
4:09neonate and less than 40 milligrams per
4:11deciliter in older children indicate
4:13hypoglycemia
4:18this slide lists some useful techniques
4:19for inhalational induction which is very
4:22common for same-day procedures for
4:23children try taking the mask with you
4:26when you do your preoperative visit and
4:27let the child try it on when you get to
4:29the operating room
4:30don't start strapping them down with a
4:32bunch of monitors be sure and praise
4:34them and use positive reinforcement turn
4:37on the nitrous and let the child start
4:38to breathe it you can prime the circuit
4:41by including the mask so that the
4:42concentration can build up and they can
4:44relax with the nitrous before you start
4:46working in any agent after your patient
4:48is asleep and sleeping soundly on the o
4:50our table is when all your monitors can
4:52be applied you can breathe a little sigh
4:54of relief just a helpful hint when you
4:57go to set the circuit to the side turn
4:59down the fresh gas flow instead of
5:01turning off the vaporizer so that the
5:03circuit stays primed and you don't
5:04anesthetize everyone in the room now for
5:09the technical part this slide describes
5:11normal baseline vital signs for healthy
5:13pediatric patients we will start with
5:16anatomy everyone's favorite neonates and
5:19infants have a proportionately large
5:20head and come narrow nasal passages an
5:23anterior and cephalad glottis along
5:26epiglottis and a short trachea and neck
5:29these anatomic features make neonates
5:32and most young infants obligate nasal
5:34breathers until about five months of age
5:36the cricoid cartilage is a narrowest
5:38part of the airway in children younger
5:40than five compared to adults and older
5:42children neonates and infants have less
5:44efficient ventilation because of weak
5:46intercostals and diaphragmatic
5:48musculature horizontal and more pliable
5:51ribs and a protuberant abdomen
6:01there are several formulas out there
6:03that
6:03help you determine the size of
6:05endotracheal tube that will be needed
6:06what popular formula is to take the
6:09child's age and divide it by four and
6:11then add four in a pinch you can look at
6:14the size of the child's pinky if you are
6:16going to use a cup tube
6:17they need to be a half a size smaller
6:19the correct tube has a small leak at 15
6:22to 20 centimeters of water when
6:24preparing for your case you will need a
6:26tube size one half size smaller and one
6:28half size larger as a backup and because
6:31of anatomical differences a shoulder
6:33roll may facilitate visualization and
6:35intubation emergency drugs also need to
6:38be readily available
6:39these include succinylcholine atropine
6:42and phenylephrine this chart can be used
6:46as a guide based on age or weight for
6:48the size airway that may be needed the
6:52respiratory rate is elevated in neonates
6:54and gradually falls to adult levels by
6:56adolescence tidal volumes of around 7 to
6:5910 mils per kilogram and dead space of
7:01around two to two and a half mils per
7:03kilogram remain constant through
7:05development alveolar maturation is not
7:08complete until late childhood around 8
7:10years old the compliant chest wall that
7:12we just described promotes chest wall
7:14collapse during inspiration and
7:16relatively low residual lung volumes at
7:18expiration the resulting decrease and
7:21functional residual capacity is more
7:23important because it limits oxygen
7:25reserves during periods of apnea and
7:27readily predisposes neonates and infants
7:30to add Alexis's in hypoxemia under
7:32general anesthesia the FRC declines by
7:3510 to 25 percent in healthy adults and
7:3735 to 45 percent in 6 to 18 year olds
7:41this may be exaggerated by their
7:43relatively higher rate of oxygen
7:45consumption the work of breathing is
7:47increase in respiratory muscles easily
7:49fatigued oxygen consumption is twice
7:52that of an adult so the ventilatory
7:54requirement per unit volume is increased
7:56so there is less reserve there is a
7:58faster drop in oxygen saturation with
8:01hypoventilation the absolute airway
8:03diameter is much smaller than in adults
8:05infants and toddlers are more prone to
8:07severe obstruction of the upper and
8:09lower Airways one millimeter of edema
8:11will have a proportionally greater
8:13effect in children because of their
8:15smaller tracheal diameters
8:17relatively mild inflammation edema and
8:20secretions lead to a greater degree of
8:22obstruction
8:25the cardiac output is dependent on heart
8:28rate because the stroke volume is
8:29relatively fixed by a non-compliant and
8:32poorly developed left ventricle in
8:33neonates and infants
8:35although pediatrics have a baseline
8:36heart rate typically higher than that of
8:38adults activation of the parasympathetic
8:40nervous system anesthetic overdose or
8:43hypoxia can cause bradycardia and a
8:46profound reduction in cardiac output
8:47this is exaggerated by an immature
8:50sympathetic nervous system and
8:51baroreceptor reflex the vascular tree is
8:54less able to respond the hypovolemia
8:56with razo constriction the hallmark of
8:59intravascular fluid depletion in
9:01neonates and infants is therefore
9:03hypotension without tachycardia
9:07pediatric patients have a larger surface
9:10area per kilogram than adults metabolism
9:13and its associated parameters such as
9:15oxygen consumption carbon dioxide
9:17production cardiac output and alveolar
9:19ventilation correlate better with
9:21surface area than with weight the thin
9:24skin lower fat content and a higher
9:26surface area relative to weight allow
9:29greater heat loss to the environment in
9:31neonates this problem is compounded by
9:33cold operating rooms cleaned exposure
9:35intravenous fluid administration drying
9:38anesthetic gases and the direct effect
9:40of anesthetic agents on temperature
9:42regulation hypothermia is a serious
9:45problem that has been associated with
9:46the lake awakening for me anesthesia
9:48cardiac irritability respiratory
9:51depression increased pulmonary vascular
9:53resistance and altered drug responses
9:56the major mechanisms working production
9:58and neonates
9:59are non shivering thermogenesis by
10:01metabolism of brown-bag and checking of
10:04hepatic oxidative phosphorylation to the
10:06thermogenic proton leak pathway
10:08metabolism of brown fat is severely
10:10limited in premature infants and
10:12Insignia needs for deficient and fat
10:15stores
10:17the normal kidney function is not
10:19present until six months of age renal
10:21function may not achieve adult levels
10:23until the child is two years old
10:25immature function includes a decreased
10:27glomerular filtration rate and decreased
10:30concentrating capacity decreased sodium
10:32reabsorption decreased bicarbonate and
10:35hydrogen exchange decreased free water
10:37clearance and increase urinary loss of
10:40potassium and chloride these
10:42abnormalities increase the importance of
10:43meticulous attention to fluid
10:45administration in the early days of life
10:47what does this mean this means that the
10:50newborn kidney has limited capacity to
10:52compensate for volume excess or volume
10:55depletion
10:57neonates have low glycogen stores that
11:00predispose them to hypoglycemia impaired
11:03glucose excretion by the kidneys may
11:04partially offset this tendency neonates
11:07at greatest risk for hypoglycemia are
11:10premature or small-for-gestational-age
11:11have been receiving hyper alimentation
11:14or were born to diabetic mothers these
11:17infants should have frequent serum
11:19glucose determinations levels less than
11:2130 milligrams per deciliter in the
11:23neonate and less than 40 milligrams per
11:26deciliter in older children indicate
11:28hypoglycemia pediatric drug dosing is
11:32typically based on a per kilogram
11:34recommendation weight however does not
11:36take into account the disproportionately
11:38larger pediatric intravascular and
11:41extracellular fluid compartments the
11:43immaturity of hepatic biotransformation
11:45pathways increased organ blood flow
11:48decreased protein binding or the higher
11:51metabolic rate neonates and infants have
11:53a proportionately higher total water
11:55content about seventy to seventy-five
11:57percent than adults who are 50 to 60
11:59percent total body water content
12:02decreases as fat and muscle content
12:04increase with age as a direct result the
12:06volume of distribution for most
12:08intravenous drugs is disproportionately
12:10higher in neonates infants and young
12:12children and the dose per kilogram is
12:15usually higher than in older children
12:17and adults
12:20neonates infants and young children have
12:22relatively higher alveolar ventilation
12:24and lower FRC compared with older
12:26children and adults this higher minute
12:28ventilation to frc ratio with relatively
12:31higher blood flow to vessel rich organs
12:33contributes to a rapid rise in alveolar
12:36anesthetic concentration and speeds
12:38inhalation induction furthermore the
12:40blood gas coefficients of volatile
12:42anesthetics are lower in neonates than
12:44in adults
12:45resulting in even faster induction times
12:47and potentially increasing the risk of
12:49overdosing the Mac for halogenated
12:51agents is higher in infants than in
12:53neonates and adults unlike other agents
12:56sevoflurane has the same Mac in neonates
12:58and infants the blood pressure of
13:00neonates and infants tends to be more
13:02sensitive volatile anesthetics probably
13:04because of not fully developing
13:06compensatory mechanisms such as
13:08vasoconstriction and tachycardia in an
13:10immature myocardium that is very
13:12sensitive to myocardial depressants
13:14cardiovascular depression bradycardia
13:17and arrhythmias are significantly less
13:19recibo than with older agents such as
13:21halothane sevoflurane is less likely to
13:24irritate the airway and cause breath
13:25holding and laryngeal and during
13:27induction as compared with desflurane or
13:29ISO flooring volatile anesthetics appear
13:32to depress ventilation more on infants
13:33than in older children
13:34sevoflurane is associated with the least
13:37respiratory depression there are no
13:39reported instances of renal toxicity for
13:42inorganic chloride production during
13:44single anesthesia in children overall
13:46SIBO appears to have a greater
13:48therapeutic index than other volatile
13:50agents and has become a preferred
13:51induction agent in pediatric anesthesia
13:55based on weight infants and young
13:57children require larger doses of
13:59propofol because of a larger volume of
14:01distribution compared to adults children
14:03also have a shorter elimination
14:05half-life and higher plasma clearance
14:07for propofol and may require higher
14:08rates of infusions for maintenance of
14:10anesthesia opioids appears to be more
14:12potent in neonates than in older
14:14children and adults possible
14:16explanations include easier entry across
14:19the blood-brain barrier decreased
14:20metabolic capability or increase in
14:23sative 'ti of the respiratory centers
14:24morphine should be used with caution and
14:26neonates because hepatic conjugation is
14:28reduced and renal clearance and morphine
14:30metabolites is decreased the cytochrome
14:32p450 pathways mature at the end of the
14:35neonatal period
14:36sufentanil al-fitnah and fentanyl
14:38classes may be higher in children men
14:40and adults rimy fentanyl clearance is
14:42increased in neonates and infants but
14:44elimination half-life is unaltered
14:46compared to adults neonates and infants
14:49may be more resistant to the hypnotic
14:50effects of ketamine requiring slightly
14:53higher doses than adults midazolam has
14:55the fastest clearance of all the
14:57benzodiazepines
14:58however midazolam clearance is
15:00significantly less in neonates men and
15:02older children
15:04all muscle relaxants generally have a
15:07shorter onset up to 50% less in
15:09pediatric patients because of shorter
15:11circulation times than adults
15:13if succinylcholine is being used infants
15:16require significantly higher doses of
15:17sux around 2 to 3 milligrams per
15:19kilogram than older children and adults
15:22because of the large extracellular space
15:24and subsequently relatively larger
15:26volume of distribution with the
15:27exclusion of succinylcholine and
15:29possibly sis atracurium infants require
15:32significantly less muscle relaxants than
15:34older children the response of neonates
15:36to 9 to polarising muscle relaxants is
15:39quite variable in maturity of the
15:41neuromuscular Junction particularly and
15:43premature neonates tends to increase
15:45sensitivity whereas a disproportionately
15:47larger extracellular compartment dilutes
15:50the drug concentration the relative
15:52immaturity of neonatal hepatic function
15:54prolongs the duration of action for
15:56drugs that depend primarily on hepatic
15:58metabolism children are more susceptible
16:00than adults to cardiac arrhythmias
16:02hyperkalemia
16:03rhabdomyolysis myoglobin emia and
16:06masseter spasm after the administration
16:08of sux
16:09if a child unexpectedly experiences
16:11cardiac arrest following the
16:13administration of sux
16:14immediate treatment of hyperkalemia
16:16should be instituted for this reason
16:18succinylcholine is best avoided for
16:20routine elective surgery and children
16:22and adolescents unlike an adult patients
16:24profound bradycardia and sinus node
16:26arrest can develop in pediatric patients
16:28following the first dose of
16:29succinylcholine without atropine
16:31pretreatment some clinicians consider
16:33rocuronium around 0.6 milligrams per
16:36kilogram to be the drug of choice for
16:38routine intubation and pediatric
16:40patients with IV access because it has
16:42the fastest onset of the nondepolarizing
16:44neuromuscular blocking agents rocuronium
16:47is the only nine to polariser that can
16:49be given I am a dose of around one to
16:51one and a half milligrams per kilogram
16:53but requires three to four minutes for
16:55onset as with adults the effect of
16:58incremental doses of muscle relaxant
16:59should be monitored with a peripheral
17:01nerve stimulator
17:03during the preoperative visit pediatric
17:06patients are assessed just like adults
17:08many times children frequently present
17:10for surgery with evidence of a
17:12coincidental viral upper respiratory
17:13tract infection like a runny nose with
17:16fever cough or sore throat attempts
17:18should be made to differentiate between
17:20an infectious cause of rhinorrhea and an
17:22allergic or vasomotor cause a viral
17:25infection within two to four weeks
17:26before general anesthesia and
17:28endotracheal intubation appears to place
17:30a child at an increased risk for
17:31perioperative pulmonary complications
17:33there is a tenfold increase in wheezing
17:36a five-fold increase in laryngeal spasm
17:38and an increased incidence of hypoxemia
17:40and AD electus --is and children with a
17:42recent uri the decision to proceed with
17:45surgery and these patients remains
17:47controversial and depends on the
17:48presence of other coexisting illnesses
17:50the severity of the upper respiratory
17:52tract infection and the urgency of the
17:55surgery most asymptomatic patients with
17:57murmurs do not have significant cardiac
17:59pathology innocent murmurs may occur in
18:02more than 30% of normal children they
18:05are usually soft short systolic ejection
18:07murmur that are best heard along the
18:09left upper or left lower sternal border
18:11without significant radiation further
18:14evaluation on new murmurs by a
18:16pediatrician or cardiologist may be
18:18necessary if the patient is symptomatic
18:20like for feeling failure to thrive or
18:23easily fatigued if the murmur is harsh
18:25loud or radiates widely or pulses are
18:29either bounding or markedly diminished
18:36because pediatric patients are more
18:39proud to be hydration their preoperative
18:41fluid restrictions has always been more
18:42lenient several studies however have
18:45documented low gastric PHS like less
18:47than 2.5 and relatively high residual
18:49volumes in pediatric patients scheduled
18:51for surgery suggesting the children may
18:54be at a higher risk for aspiration than
18:55previously thought the incidence of
18:58aspiration is reported to be
18:59approximately one in a thousand
19:01prolonged fasting does not necessarily
19:03decrease this risk in fact several
19:05studies have demonstrated lower residual
19:07volumes and higher gastric pH in
19:09pediatric patients who received clear
19:11fluids a few hours before induction
19:13typically clear liquids can be continued
19:15until two hours before surgery breast
19:17milk four hours before surgery in
19:19formula or light meals six hours before
19:22surgery these recommendations are for
19:24healthy neonates infants and children
19:26without risk factors for decreased
19:28gastric emptying or aspiration offering
19:30liquids of the two hours before
19:32induction has been shown to reduce
19:33hunger and irritability preserve
19:35hydration and lower the risk of
19:37hypoglycemia older children should be
19:39kept NPO after midnight and chewing gum
19:41should be considered a clear liquid
19:45premedication is very controversial
19:47sedative premedication is generally
19:50omitted for neonates ESSEC infants
19:52children who appear likely to exhibit
19:54uncontrollable separation anxiety can be
19:56given a sedative such as versed 0.3 to
19:590.5 milligrams per kilogram with a 15
20:01milligram maximum the oral route is
20:04generally preferred because it is less
20:05traumatic than I am but requires 20 to
20:0845 minutes to take effect
20:10smaller doses of midazolam may be used
20:12with the addition of oral ketamine
20:14around 4 to 6 milligrams per kilogram
20:16but the combination may not be suitable
20:18for outpatients the nasal route can be
20:20used with some medications but is
20:22unpleasant and some concerns exist over
20:25potential neurotoxicity of nasal
20:26midazolam fentanyl can also be
20:29administered as a lollipop if no levels
20:31continue to rise intraoperatively and
20:33can contribute the post-operative
20:34analgesia
20:36monitoring requirements for infants and
20:39children are generally similar to adults
20:40with some minor modifications smaller
20:43EKG pads may be necessary and the blood
20:45pressure cuff needs to fit properly a
20:47precordial stethoscope provides an
20:49inexpensive means to monitoring heart
20:51rate quality of heart sounds and airway
20:53patency small pediatric patients have a
20:55smaller allowable margin of error pulse
20:58oximetry and capnography assumed an even
21:00greater monitoring role in pediatric
21:02patients because hypoxia from inadequate
21:04ventilation is a major cause of
21:06perioperative morbidity and mortality in
21:08neonates the pulse oximeter probe should
21:10preferably be placed on the right hand
21:12or earlobe to measure productive oxygen
21:15saturation temperature must be closely
21:17monitored in pediatric patients because
21:19of a higher potential for both
21:20iatrogenic hypothermia and hyperthermia
21:24hypothermia can be prevented by
21:26maintaining a warm operating room
21:27environment warming and humidifying
21:29inspired gases using a warming blanket
21:32and warming intravenous fluids
21:36most children do not arrive in the
21:38operating room with an intravenous line
21:40in place and dread the prospect of being
21:42stuck with a needle
21:43if emilich ream is being used it must
21:45remain in contact with the skin for 30
21:47to 60 minutes
21:48fortunately modern code and model
21:50anesthetics can render small children
21:52unconscious within seconds this is
21:54usually easier in children who have been
21:55sedated prior to entering the operating
21:57room and who are sleepy enough to be
21:59anesthetized without ever knowing what
22:01has happened this is called steel
22:03induction there are many differences
22:05between adult and pediatric Anatomy that
22:08effect mask emulation and intubation
22:10neonates and most young infants are
22:12obligate nose breathers and obstruct
22:14easily oral Airways often help displace
22:17an oversized tongue typically the child
22:20is coaxed into breathing an odorless
22:21mixture of 70% nitrous and 30% oxygen
22:24sevoflurane can then be added in point
22:27by percent increments every three to
22:29five breaths or screams whatever you're
22:31dealing with some clinicians use a
22:33single breath induction technique with
22:34sevoflurane which is 7 to 8 percent SIBO
22:37and 60% nitrous to speed up induction
22:39after an adequate depth of anesthesia
22:42has been achieved an IV can be started
22:44and medication given patients typically
22:46pass through an excitement stage during
22:48which any stimulation can induce
22:49laryngoscope breath-holding must be
22:52distinguished from laryngeal spasm
22:54steady application of ten centimeters of
22:56positive and expiratory pressure can
22:58help overcome laryngeal spasm
23:01after the IV is placed and medications
23:04are given if needed it's time to
23:06intubate one suggestion is to turn your
23:08flows off instead of turning your agent
23:10off when you go to do your laryngoscopy
23:11this keeps the circuit filled with
23:13anesthesia gas and keeps you from
23:15flushing out everything that you've just
23:17primed the circuit with with high fresh
23:18gas flows a prominent occiput tends to
23:21place a head in a Flex position prior to
23:23intubation this is easily corrected by
23:25slightly elevating the shoulders with
23:27towels and placing the head on a pillow
23:29in older children prominent tonsillar
23:32tissues can obstruct visualization of
23:34the larynx a straight laryngoscope blade
23:36aids intubation of the anterior larynx
23:38and the neonates infants and young
23:40children to avoid endo bronchial
23:42intubation the tip of the endotracheal
23:44tube should pass only 1/2 centimeters
23:46beyond the glottis
23:49meticulous fluid management is required
23:51in small pediatric patients because of
23:53extremely limited margins of error a
23:55programmable infusion pump should be
23:57used for accurate measurements drugs are
24:00flushed through low dead space tubing to
24:02minimize unnecessary fluid
24:03administration fluid overload is
24:06diagnosed by prominent veins flush skin
24:08increased blood pressure decreased serum
24:10sodium and a loss of the folds in the
24:13upper eyelids maintenance requirements
24:15for pediatric patients can be determined
24:17by the four to one formula for
24:19milligrams per kilogram per hour for the
24:21first ten kilograms of weight two
24:22milligrams per kilogram per hour for the
24:24second ten kilograms and one mil per
24:27kilogram per hour for each remaining
24:28kilogram the choice of maintenance fluid
24:30remains controversial a solution such as
24:33d5 half normal saline with 20 mil
24:35equivalents of potassium chloride
24:37provides adequate dextrose and
24:39electrolytes at these maintenance and
24:40fusion rates defy 1/4 normal saline may
24:43be a better choice for neonates because
24:45of their limited ability to handle
24:47sodium loads neonates require 3 to 5
24:49milligrams per kilogram per minute of a
24:51glucose infusion to maintain you
24:53glycemia and premature neonates require
24:555 to 6 preoperative deficits also need
24:58to be replaced in contrast to adults
25:00infants respond to dehydration would
25:03decrease blood pressure but without an
25:04increased heart rate preoperative fluid
25:06deficits are typically administered with
25:08hourly maintenance requirements and
25:10allocates of 50% in the first hour and
25:1225% in the second and third hour third
25:15space loss is impossible to measure and
25:17has to be estimated by the extent of the
25:19surgical procedure one popular guideline
25:21is 0 to 2 mils per kilogram per hour for
25:24relatively a traumatic surgery up to 6
25:27to 10 mils per kilogram per hour for
25:29traumatic procedures blood loss is
25:31replaced like adults with a three-to-one
25:33ratio of crystalloid and a 1 to 1 ratio
25:35of colloid
25:39a laryngeal spasm is a forceful
25:42involuntary spasm of the laryngeal
25:44musculature caused by stimulation of the
25:46superior laryngeal nerve it may occur at
25:49induction emergence or any time in
25:51between without an endotracheal tube
25:53Clarinda spasm is more common in young
25:55pediatric patients than in adults being
25:58highest in infants 1 to 3 months old
26:00laryngeal spasm at the end of a
26:02procedure can be avoided by excavating
26:03the patient either while deeply
26:05anesthetized or awake excavation during
26:08the interval between these extremes
26:09however is generally recognized as
26:11hazardous a recent upper respiratory
26:14tract infection or exposure to
26:16secondhand smoke predisposes patients to
26:18Laurentiis chasm on emergence treatment
26:20of Laurentiis chasm includes gentle
26:22positive pressure ventilation forward
26:24jaw thrust IV lidocaine or paralysis if
26:27needed intramuscular succinylcholine of
26:304 to 6 milligrams per kilogram remains
26:33an acceptable alternative in patients
26:35without IV access and who more
26:36conservative measures have failed
26:38Clarinda spasm is usually an immediate
26:41post-operative event but may occur in
26:42the recovery room as the patient wakes
26:44up and chokes on Rangeela secretions
26:46for this reason recovery pediatric
26:49patient should be positioned in the
26:50lateral position when possible so that
26:52secretions pool and drain away from the
26:54vocal cords
26:58croup is due to glottis or tracheal
27:01edema because the narrowest part of the
27:03pediatric airway is the cricoid
27:05cartilage this is a known susceptible
27:07area croup is less common with
27:09endotracheal tubes that are uncuffed and
27:11small enough to allow a slight gas leak
27:13at 10 to 25 centimeters of water post
27:16intubation croup is associated with
27:18early childhood typically one to four
27:20years old
27:21repeated intubation attempts large
27:23endotracheal tubes or excessive movement
27:25of the tube like coughing with the tube
27:27in place or moving the patient's head
27:29while intubated intravenous
27:30dexamethasone 0.25 to 0.5 milligrams per
27:34kilogram may prevent the formation of
27:36edema and inhalation of nebulized
27:38racemic epinephrine zero-point-two-five
27:41to zero-point-five mils of 2.25 percent
27:44solution in 2.5 mils of normal saline is
27:47an effective treatment although post
27:49intubation croup is a complication that
27:51occurs later than laryngeal spasm it
27:53almost always appears within the first
27:55three hours of excavation
28:05now we will discuss some congenital
28:08malformations and their anesthetic
28:10implications now rotation of the
28:12intestines is a developmental
28:14abnormality that permits spontaneous
28:16abnormal rotation of the mid gut around
28:18the mesentery the incidence of
28:20malrotation is estimated to be about one
28:22in 500 live births the majority of
28:24patients with malrotation of the mid gut
28:26present during infancy with symptoms of
28:28acute or chronic bowel obstruction
28:30coiling of the duodenum with the
28:32a-singing colon can produce complete or
28:34partial duodenal obstruction the most
28:37serious complication of malrotation
28:39a mid gut volvulus can rapidly
28:41compromise intestinal blood slide mid
28:43get fabulous is a true surgical
28:45emergency that most commonly occurs in
28:47infancy with up to one third occurring
28:49in the first week of life patients
28:51typically present with bilious vomiting
28:53progressive abdominal distension and
28:55tenderness metabolic acidosis and
28:57hemodynamic instability bloody diarrhea
29:00may be indicative about infarction
29:04definitive treatment of malrotation and
29:07mid gut modulus is surgical correction
29:08if obstruction is present but obvious
29:11Bob Ulis has not yet occurred
29:13preoperative preparation may include
29:15stabilization of any coexisting
29:17condition including the insertion of a
29:20nasogastric tube to help you compress
29:21the abdomen broad-spectrum antibiotics
29:24fluid and electrolyte replacement an
29:26expedition of transport to the operating
29:28room patients are at high risk for
29:30pulmonary aspiration depending on the
29:33size of the patient after adequate
29:35pre-oxygenation awake intubation or
29:37rapid sequence induction should be
29:39employed patients with a volvulus are
29:41usually hypovolemic and acidotic and
29:43often tolerate anesthesia poorly in such
29:46instances ketamine may be the preferred
29:48anesthetic agent an opioid based
29:51anesthetic is also recommended as
29:53post-operative ventilation is usually
29:55necessary aggressive fluid resuscitation
29:57including blood products and sodium
29:59bicarbonate therapy are also usually
30:01necessary invasive monitoring is very
30:04helpful
30:05surgical treatment involves reducing the
30:07bob ulis freeing the obstruction
30:09widening the base of the mesenteric
30:11attachments and resetting the obviously
30:13necrotic bowel bowel edema can
30:15complicate abdominal closure and has the
30:17potential to produce a
30:19compartment syndrome the latter can
30:21impair ventilation hinder venous return
30:23and produce renal compromised a second
30:26look laparotomy may be required 24 to 48
30:28hours later to ensure viability of the
30:30remaining valve mortality of a mahvelous
30:33is as high as 25%
30:37during fetal development almost all of
30:39the abdominal viscera including the
30:41liver and spleen can her knee into the
30:43thorax through one of the three possible
30:45diaphragmatic defects the left or right
30:48posterior lateral foramen of built alike
30:50or the anterior foramen of Morgan II the
30:53gestational age at which herniation
30:55occurs may determine the degree of lung
30:57hypoplasia the reported incidents of
31:00diaphragmatic hernia is 1 in 3,000 to
31:035,000 high burst left-sided herniation
31:05is the most common and occurs 90% of the
31:08time and the most common side of the
31:10defect is the posterior lateral crural
31:12peritoneal canal hallmarks of
31:16diaphragmatic herniation include hypoxia
31:18a scaphoid abdomen and evidence of bowel
31:21and the thorax by auscultation or
31:23radiography congenital diaphragmatic
31:25hernia is often diagnosed during a
31:27routine ultrasound examination a
31:29reduction in alveoli and bronchiole I
31:32because of pulmonary hypoplasia and
31:34malrotation of the intestines are almost
31:36always present the ipsilateral lung is
31:39particularly impaired and the herniated
31:41gut can compress and [ __ ] the
31:42maturation of both lungs diaphragmatic
31:45hernia is often accompanied by marking
31:47pulmonary hypertension and is associated
31:49with 40 to 50 percent mortality
31:51post-operative prognosis parallels the
31:54extent of pulmonary hypoplasia and the
31:56presence of other congenital defects
31:58cardiopulmonary compromise is generally
32:00thought to be primarily due to pulmonary
32:02hypoplasia and pulmonary hypertension
32:05rather than to the mass effect of the
32:07herniated viscera treatment with
32:09prenatal intrauterine surgery appears
32:11promising congenital diaphragmatic
32:14hernias require a surgical correction
32:16after pulmonary hypertension stabilizes
32:19gastric distension must be minimized by
32:21placement of a nasal gastric tube and
32:23avoidance of high levels of positive
32:24pressure ventilation the neonate is pre
32:27oxygenated and intubated awake or
32:29without the aid of muscle relaxants
32:31anesthesia is maintained with low
32:32concentrations of volatile agents or
32:34opioids muscle relaxant and air is
32:37tolerated hypoxia and expansion of air
32:39in the bowel contraindicate the use of
32:41nitrous oxide if possible peak
32:44inspiratory airway pressure should be
32:45less than 30 centimeters of water a set
32:48fault and lung compliance blood pressure
32:50or oxygen
32:51may signal a contralateral usually
32:53right-sided pneumothorax and
32:55necessitates the placement of a chest
32:56tube arterial blood gases are preferably
32:59monitored by sampling a productive
33:01artery if an umbilical artery catheter
33:03is not already in place surgical repair
33:05is performed via a subcostal incision of
33:07the affected side the vowel is reduced
33:10into the abdomen and the diaphragm is
33:11closed aggressive attempts at expansion
33:14of the ipsilateral lung following
33:15surgical decompression are detrimental
33:17some centers employ permissive
33:20hypercapnia and accept mild hypoxemia in
33:22an effort to reduce pulmonary barotrauma
33:24high frequency oscillating ventilation
33:27can improve ventilation and oxygenation
33:29with less barotrauma
33:30if the pulmonary hypertension stabilizes
33:33and there is little right to left
33:34shunting early surgical repair may be
33:36undertaken if the patient fails to
33:39stabilize ECMO may be undertaken if it
33:41is available just as a refresher ECMO
33:44usually involves pumping blood from the
33:46right atrium through a membrane
33:47oxygenator and counter current heat
33:50exchanger before returning it to the
33:51ascending aorta
33:54there are several types of tracheal
33:57esophageal fistula most of which are
33:59manifested as an inability to swallow
34:01because of esophageal atresia the most
34:04common type the most common type 3b is
34:07the combination of an upper esophagus
34:09that ends in a blind pouch and a lower
34:11esophagus that connects to the trachea
34:13the incidence is one in 3,000 high burst
34:16and it's not specific for race or gender
34:18breathing results in gastric distension
34:21whereas feeding leads to choking
34:22coughing and cyanosis the three C's the
34:27diagnosis is suspected by failure to
34:29pass a catheter into the stomach and is
34:31confirmed by visualization of the
34:32catheter coiled in a blind upper
34:34esophageal pouch the condition is
34:36frequently associated with low birth
34:38weight premature 'ti and other
34:40congenital anomalies anomalies known as
34:43Vader syndrome may include the
34:44non-random Association of vertebral
34:46defects anal atresia tracheal esophageal
34:49fistula with esophageal atresia and
34:51radial dysplasia preoperative management
34:55is directed at identifying all
34:57congenital anomalies and preventing
34:59aspiration pneumonia
35:00this may include nursing in a head up
35:02position and oral esophageal tube and
35:05avoiding feedings
35:06in some instances gastronomy may be
35:08performed under local anesthesia
35:10definitive surgical treatment is usually
35:12postponed until any pneumonia clears or
35:15improves with antibiotic therapy these
35:19Nia needs tend to have copious
35:20pharyngeal secretions that require
35:22frequent suctioning before and during
35:24surgery positive pressure ventilation is
35:27avoided prior to intubation as the
35:29resulting gastric distension may
35:30interfere with lung expansion intubation
35:33is often performed awake and without
35:34muscle relaxants these neonates are
35:36often dehydrated and malnourished due to
35:38poor oral intake the infant is commonly
35:41placed prone in a head up position the
35:44key to successful management is correct
35:46endotracheal tube position it may be
35:48necessary to broccoli intubate the
35:50patient and then pull the tube back
35:51until front stops can be heard you
35:53should listen to make sure that the
35:54fistula was not intubated ideally the
35:57tip of the tube lies between the fistula
35:59and the current so that the anesthetic
36:01gases pass into the lungs instead of the
36:03stomach this is impossible if the
36:05fistula connects to the Carina or a main
36:07stem
36:08yes in these situations intermittent
36:10venting of a gastronomy tube that has
36:12been placed preoperatively may permit
36:14positive pressure ventilation without
36:16excessive gastric distension these
36:18infants are also predisposed to a
36:20recurrent laryngeal nerve injury with
36:22instrumentation
36:24care must be taken to avoid rupturing
36:26the stomach so spontaneous ventilation
36:28is often employed suctioning of the
36:30gastronomy tube and upper esophageal
36:32pouch helps prevent aspiration pneumonia
36:35surgical division of the fistula and
36:37esophageal anastomosis is performed via
36:40a right extra pleural thoracotomy with
36:42the patient in the left lateral position
36:44monitoring with the precordial
36:46stethoscope should be placed in the
36:47dependent or left axilla since
36:50obstruction of the main stem bronchus
36:51during surgical retraction is not
36:53uncommon a drop in oxygen saturation
36:56indicates that the retracted lung needs
36:58to be really a surgical retraction can
37:00also compress the great vessels trachea
37:03heart and vagus nerve blood pressure
37:05should be continuously monitored with an
37:07arterial life these infants usually
37:09require ventilation with 100% oxygen
37:11despite the risk of retinopathy of
37:13prematurity blood should be immediately
37:15available for transfusion post-operative
37:18complications include gastro esophageal
37:20reflux
37:20aspiration pneumonia tracheal
37:23compression and anastomotic leakage
37:25leading causes of mortality with these
37:27infants is due to pulmonary
37:28complications associated anomalies and
37:31anastomotic leaks most patients continue
37:34to require intubation and positive
37:36pressure ventilation in the immediate
37:37post-operative period neck extension and
37:40instrumentation such as suctioning of
37:42the esophagus may disrupt the surgical
37:44repair and should be avoided
37:47gastroschisis and impala seals are
37:49congenital disorders characterized by
37:51defects in the abdominal wall that allow
37:53external herniation of the viscera we
37:56will first discuss the Ambala seal the
37:58incident of a new fallacy is one in 2500
38:01lifers new ballast eels occur at the
38:03base of the humble itis have a hernia
38:05sac and are often associated with other
38:08congenital anomalies such as trisomy 21
38:11diaphragmatic hernia and cardiac and
38:13bladder malformations
38:16gastroschisis is an abdominal wall
38:19defect between the developing rectus
38:20muscles
38:21in contrast the gastroschisis defect is
38:24usually lateral to be on the Lycus does
38:26not have a hernia sack and is often an
38:28isolated finding the right side may be
38:31due to abnormal involution of the right
38:33under local veins the incidence of this
38:35defect is much more rare at 1 in 10,000
38:38lifers
38:41routine ultrasound examination may
38:43reveal these conditions and an elective
38:45caesarean section can be performed at 38
38:47weeks for immediate surgical repair the
38:50major problems with these defects
38:51include severe dehydration and massive
38:54fluid loss both from exposed visceral
38:56surfaces and from third spaced losses
38:58caused by a partial bowel obstruction
39:00heat loss the difficulty of surgical
39:02closure and the high Association of this
39:05condition with prematurity and other
39:06congenital defects including serious
39:09cardiac anomalies perioperative
39:11management centers around preventing
39:12hypothermia infection and dehydration
39:15these problems are usually more serious
39:17in gastroschisis as the protective
39:20hernial sac is absent these children
39:22should not be rushed to the operating
39:24room without an echocardiogram before
39:26anesthesia this slide compares
39:29gastroschisis and in fellow seal
39:31malformations the stomach is
39:35decompressed with the nasal gastric tube
39:36before induction intubation can be
39:39accomplished with the patient awake or
39:41asleep and with or without muscle
39:43relaxation volatile agents can be used
39:45but nitrous oxide should be avoided to
39:47prevent further valve Ascension muscle
39:49relaxation is required for replacing the
39:52balance of the abdominal cavity a once
39:54each closure is not always advisable and
39:56it can cause an abdominal compartment
39:58syndrome a stage closure may be
40:00necessary with the second procedure
40:02following a few days later third space
40:04fluid losses are aggressively replaced
40:06with a balanced salt solution and 5%
40:08albumin the neonate remains intubated
40:11after the procedure and is weaned from
40:13the ventilator over the next one to two
40:14days in the intensive care unit
40:18pyloric stenosis is a hypertrophy of the
40:20pyloric smooth muscle which causes
40:22increased gastric pressure this produces
40:25regurgitation and non bilious vomiting
40:27pyloric stenosis normally manifests in
40:30the first two to five weeks of life the
40:32incidence is one in 300 lifers males
40:35have a greater incidence than females
40:37and the operation is never a surgical
40:39emergency children should be evaluated
40:42carefully and severe metabolic
40:43imbalances should be corrected before
40:45surgery even if the child arrives with a
40:48nasal gastric tube it place the stomach
40:50should still be suctioned immediately
40:52before induction of the anesthesia
40:53suctioning the patient first supine bent
40:56left lateral and right lateral removes
40:5898% of the gastric contents these
41:01infants usually have many metabolic
41:03disturbances including hypo chlorine iya
41:05hypokalemia hyponatremia and metabolic
41:09acidosis which needs to be optimised
41:11prior to going to the o.r
41:14an aesthetic concerns include a full
41:16stomach
41:17occasionally filled with contrast
41:18material metabolic alkalosis with
41:21hypothermia and hypokalemia and severe
41:24dehydration surgery should be postponed
41:26until fluid and electrolyte
41:28abnormalities have been corrected
41:29children with pyloric stenosis can be
41:31managed with a waik endotracheal
41:33intubation or with a rapid sequence
41:35induction
41:37a cute epiglottitis is a bacterial
41:40infection most commonly caused by Hamas
41:42and fluence a type B they classically
41:45effects two to six year old children it
41:48rapidly progresses from a sore throat to
41:50dysphasia and complete airway
41:51obstruction a high fever of greater than
41:5439 degrees Celsius is commonly present
41:56it usually lasts two to four days
41:59the term supercut itis has been
42:00suggested because the inflammation
42:02typically involves all supraglottic
42:04structures patients present with
42:06difficulties following an inspiratory
42:08stridor exam of the airway should be
42:10limited to a respiratory rate work of
42:12breathing and level of respiratory
42:14distress a preoperative lateral neck
42:16radiograph may show a characteristics
42:18unlike epiglottis shadow which is very
42:20specific but not only seen endotracheal
42:23intubation and antibiotic therapy can be
42:26life-saving there should not be any
42:28manipulation of the airway attempted
42:30until you are in a controlled setting
42:31blood work and an IV should be postponed
42:34until the airway is secure treatment is
42:37ampicillin epiglottitis has increasingly
42:39become a disease of adults because of
42:41the widespread use of influenza vaccines
42:43in children
42:46children with impending airway
42:49obstruction from epiglottitis present in
42:51the operating room for definitive
42:52diagnosis by laryngoscopy followed by
42:54intubation total obstruction can occur
42:57at any moment and adequate preparations
42:59for a possible tracheostomy must be made
43:01prior to induction of general anesthesia
43:03in most cases an inhalational induction
43:07is performed with the patient in a
43:08sitting position using a volatile
43:10anesthetic and a high concentration of
43:12oxygen oral intubation with an
43:14endotracheal tube around a half to one
43:17size smaller than usual is attempted as
43:19soon as an adequate depth of anesthesia
43:21is established if intubation is
43:23impossible rigid bronchoscopy or
43:25emergency tracheostomy must be performed
43:29in conclusion providing anesthesia for
43:32children not only requires an
43:34understanding of the different surgical
43:35procedures that children undergo but
43:38also understanding their unique
43:39psychology development and physiology
43:42there are many obvious differences
43:44between adults and children that affect
43:46anaesthetic management apart from the
43:48differences of size communication skills
43:50and issues involving parents there are
43:53also multiple less obvious differences
43:55in the physiology psychology anatomy in
43:58pharmacology of children
44:01let's review a few key concepts from
44:04this lecture
44:06a recent study found that most parents
44:09are very much interested in receiving
44:11all possible information about their
44:12child's surgery and that the parents
44:14were not overly anxious as a result of
44:16the detailed discussion regarding
44:17anaesthetic plans and risk multiple
44:20investigations have found that a child
44:22with a current upper respiratory
44:23infection or recovering from such an
44:26infection is at increased risk for
44:28developing Lorenza spasm bronchospasm
44:30oxygen desaturation post excavation crew
44:33and post-operative atelectasis although
44:36most children who undergo tonsillectomy
44:38and adenoidectomy can be discharged home
44:40following four hours of post anesthesia
44:42care unit observation children with
44:44severe obstructive sleep apnea require
44:46post-operative observation in the
44:48hospital
44:51arrangements for overnight hospital
44:53monitoring following general anesthesia
44:54should be made for any infant considered
44:56to be at significant risk for
44:58post-operative apnea particularly those
45:00with a history of severe respiratory
45:01illness or previous problems with apnea
45:04and bradycardia regardless of their post
45:06conceptual age current standards
45:08appeared they paid the healthy children
45:10undergoing elective minor surgery
45:12require no laboratory evaluation and
45:14thus can be spared the anxiety and pain
45:16of a blood draw solids are prohibited
45:19within six to eight hours of surgery
45:21generally after midnight formula within
45:24six hours
45:24breast milk within four hours of surgery
45:26and clear liquids within two hours of
45:29surgery over 85% of all preoperative
45:32sedation in the United States is
45:34performed using midazolam it has a rapid
45:36onset and predictable effect without
45:38causing cardio respiratory depression
45:41Vasque induction of general anesthesia
45:44remains the most common induction
45:46technique for pediatric anesthesia in
45:47the United States there is no question
45:50that inhalation induction of anesthesia
45:51is safe but the incidence of bradycardia
45:54hypotension and cardiac arrest during
45:56this form of induction is higher in
45:58infants younger than age one men in
46:00older children and adults propofol is
46:02the most widely used intravenous agent
46:04for induction and maintenance of
46:06anesthesia or sedation and children
46:07although its safety is well established
46:09its youths and children is limited to
46:12the operating room environment and brief
46:13sedation outside the operating room
46:15prolonged infusion and the intensive
46:17care environment has been linked to
46:19acidosis heart failure and a number of
46:21fatalities chest wall rigidity is not
46:24uncommon when administering bolus
46:26opioids especially to drug naive
46:28neonates and infants post-operative
46:32nausea and vomiting is particularly
46:33prominent after certain surgeries such
46:36as or kiddo Pepsi strabismus surgery and
46:38tonsillectomy there is no single therapy
46:41that is universally accepted as safe and
46:43effective because the narrowest portion
46:45of the pediatric airway is at the level
46:47of the cricoid cartilage uncuffed tubes
46:49can be used and will create a functional
46:51seal when appropriately sized several
46:53formulas have been used for tube
46:55selection and children older than the
46:56age of one the most common being 16 + CH
47:00/ 4 or variations thereof the safety and
47:04efficacy of patient controlled analgesia
47:06for children as young as 6 years have
47:08been shown
47:09although routinely used in children's
47:11hospitals this technique is to be used
47:13only by highly trained medical personnel
47:15who are knowledgeable in pediatric pain
47:17management
47:18the small and limited number of alveoli
47:21and neonates and infants reduces lung
47:23compliance in contrast their
47:25cartilaginous ribcage makes our chest
47:27wall very compliant the combination of
47:29these two characteristics promotes chest
47:31wall collapse during inspiration and
47:33relatively low of residual lung volumes
47:35at expiration the resulting decrease and
47:38functional residual capacity is
47:40important because it limits oxygen
47:42reserves during periods of apnea and
47:44readily predisposes them to add Alexis
47:46and hypoxemia neonates and infants have
47:49a proportionately larger head and tongue
47:50narrow nasal passages and anterior and
47:53cephalad larynx a long epiglottis and a
47:56short trachea and neck these anatomic
47:59features make neonates and most young
48:00infants obligate nasal breathers until
48:03about five months of age the cricoid
48:05cartilage is a narrowest point of the
48:07airway in children younger than five
48:08stroke volume is relatively fixed by a
48:11non-compliant and poorly developed left
48:13ventricle and neonates and infants the
48:15cardiac output is therefore very
48:17dependent on heart rate
48:21thin-skinned low fat content and a
48:23higher surface relative to weight allow
48:25greater heat loss to the environment in
48:27yo needs this problem is compounded by
48:29cold operating rooms wound exposure
48:32intravenous fluid administration dry
48:34anesthetic gases and the direct effect
48:37of anesthetic agents on temperature
48:38regulation hypothermia has been
48:41associated with delayed awakening from
48:42anesthesia cardiac irritability
48:44respiratory depression increased
48:47pulmonary vascular resistance and
48:49altered drug responses neonates infants
48:52and young children have relatively
48:53higher alveolar ventilation and lower
48:55frc compared with older children and
48:57adults this higher minute ventilation to
49:00frc ratio with relatively higher blood
49:02flow to vessel rich organs contributes
49:04to a rapid rise in alveolar anesthetic
49:07concentration and speeds inhalation
49:17a viral infection within two to four
49:19weeks before general anesthesia and
49:21endotracheal intubation appears to place
49:24the child at an increased risk for
49:25perioperative pulmonary complications
49:27such as wheezing Lorenza spasm hypoxemia
49:30and atelectasis temperature must be
49:33closely monitored in pediatric patients
49:35because of their higher risk of mhm and
49:36the potential for both iatrogenic
49:38hypothermia and hyperthermia meticulous
49:42fluid management is required in small
49:44pediatric patients because of extremely
49:46limited margins of error a programmable
49:48infusion pump or a barrette with a micro
49:51drip should be used for accurate
49:53measurements drugs are flushed through
49:55low dead space tubing to minimize
49:56unnecessary fluid administration
50:06you

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