ANESTESI PEDIATRIK

Dr. Elizeus Hanindito dr.SpAn KIC KAP

Subspecialty Anaesthetics : Paediatric
Theyre not just small adults
. . . But . . .
Nor are they all just big neonates, either

2
 Pediatrik
Prematur (gestational age < 37 mgg , BB < 2500 g)
Neonatus lahir - < 27 hari
Infant 28 hari - 12 bulan
Toddlers 1 th - 3 th
Prasekolah 4 th - 6 th
Usia sekolah 7 yrs - 12 yrs
Remaja 13 yrs - <16(19) yrs

Anatomi , Fisiologi , Patologi , Psikologi

 Anatomi Jalan Nafas Pediatri
Perbedaan
Lidah/kepala besar
Massa adenoid
Floppy epiglottis
Larynx cephalad & anterior
Cricoid ring tersempit
Diameter tracheal kecil
Panjang trachea pendek
Airway sempit
Luas permukaan tubuh >
Implikasi
Sering mengakibatkan obstr.
airway
Gunakan blade lurus
Visualisasi glottis sulit
Natural seal (uncuffed ETT)
Intubasi mainstem
bronchus , mdh dislokasi
Resistensi aliran nafas >
Hipotermi
 Upper Airway Anatomy
CHILDREN ADULT

FUNNEL CYLINDRIC

C3 C5
Infant Laryngoscopy
Appropriate Size
 Fisiologi Pernafasan

Mekanik dinding dada & tracheobronchial mudah

kolaps.
Tidal volume/dead space ~ dewasa adults (ml/kg)
Pernafasan lebih cepat & minute volume lbh besar
FRC ~ dewasa (ml/kg) tapi konsumsi oksigen > , shg
bila apnea desaturasi lebih cepat.
Kontrol pernafasan imatur mudah apnea setelah
anestesi/pemberian narkotik.

9
 Normal parameter

Neonate-Infant : systolic blood pressure 60-70

1-10 years : 70 + (2 x age in year)
Palpable peripheral pulse ~ systolic blood pressure > 80 mmHg
Palpable central pulse ~ systolic blood pressure > 60 mmHg
 Apnea
Time

neonate
L
u
n
g
= 60 ml/kg

(18 months)
V
o
90 ml/kg
L (5 years)
u
m = 50% of TLC
may be only 15% of TLC
e in young infants
s = 25% TLC

Lawrence M. Hinman
6/29/2017 12
http://ethics.sandiego.edu
 Comparison of Cardiovascular Variables
5 Years
Neonate Infant of Age Adult
Weight (kg) 3 4-10 18 70
Oxygen consumption 6 5 4 3
(ml/kg/min)
Systolic blood pressure 65 90-95 95 120
(mmHg)
Heart rate (beats/min) 130 120 90 80
Blood volume (ml/kg) 85 80 75 65
Hemoglobin (g/dl) 17 11-12 13 14
Posisi Intubasi

Adapted from
Walls et al.
Manual of
Emergency
Airway Management.
2nd Ed. 2004.
 Endotracheal Tube
< 8 th : uncuffed tubes , kecuali jika lung compliance
rendah & airway resistance tinggi.
Uncuffed ETT = 4 + umur (thn)/4
Cuffed ETT = 3 + umur (thn)/4

Contoh: 4 th - uncuffed ETT = 4 + (1/4)4 = 5

jika memakai cuffed ETT = 4.5 (kurangi 0.5)
Pada situasi darurat dianjurkan pemasangan via oral.
 Kedalaman ETT
Kedalaman ETT (cm dibibir) :
Untuk usia > 1 tahun :
oral: 13 + (1/2)usia
nasal: 15 + (1/2)usia
Untuk bayi (berat - kg):
oral : 8 + (1/2)(berat)
nasal : 9 + (1/2)(berat)
 Glasgow Coma Scale
CRITERIA SCORE INFANT CHILD
Eye opening 4 Spontaneous Spontaneous
3 To loud noise To verbal stimuli
2 To pain To pain
1 No response No response
Verbal Response 5 Smiles, coos, cries appropriately Appropriate, oriented
4 Cries but consolable Confused
3 Persistently irritable, crying Inappropriate
2 Grunts or moans Incomprehensible
1 No response No response
Motor Response 6 Spontaneous Follows commands
5 Withdraws to touch Localizes pain
4 Withdraws to pain Withdrawal to pain
3 Decorticate (flexion) posturing Decorticate (flexion) posturing
2 Decerebrate (extensor) posturing Decerebrate (extensor) posturing
1 No Response No response
ANATOMI BAYI

Jarak Node of Ranvier <

dewasa

Neonatus : Conus medullaris & Dural sac

rendah LP ~ L4-5 atau L5-S1
 Perkiraan Volume CSF
16
14
12
10
8 ml/kg
6
4
2
0
Premature Full Term Child Adult

Cote, A Practice of Anesthesia for Infants and Children

Pengaruh SAB terhadap tekanan darah
sistolik

Dohi S et al. Anesthesiology 1979; 50:319-

Truffier's line
 Perkiraan Jarak
Kulit ke Subarachnoid Space
50

40

30

20

MILLIMETERS
10

0
1 yr 3 yr 5 yr 10 yr 18 yr

Premie Newborn 5 months

Cote, A Practice of Anesthesia for Infants and

The aim of anesthesia & surgery
is safety
Safety means accident
prevention

Accident prevention begin with

preoperative evaluation
 Goal of preoperative evaluation
Detection of unrecognized conditions that increase
the risk of surgery.
Optimize the patients current medical problems and
anticipate potential complications.
Fluid and electrolyte imbalance (shock , seizures ,
arrhythmias)
OSA , asthma , URI
Prematurity
Atlantoaxial instability (Downs)
Congenital Heart Disease
 PROBABILITY of APNEA

0.8
PROBABILITY OF APNEA

Gestational age = 28

0.4 anemia

Gestational age = 36

0.0

35 40 45 50 55 60
POST CONCEPTUAL AGE
Cote CJ , 1995
 Persiapan Anestesi

Kunjungan prabedah
Kondisi faal nafas & status hidrasi
Optimalisasi kondisi prabedah
Persiapan alat & obat
Tehnik anestesi yang sesuai
Meja Persiapan
Obat2an
 Anestesi
Premedikasi :
Intravena, oral, per rectal, sublingual, nasal
< 6 bulan tidak perlu premedikasi
Induksi :
Intravena : ketamine , propofol , etomidate
Inhalasi : halothane , sevoflurane
Rumatan :
Intravena : ketamine , propofol
Inhalasi : halothane , sevoflurane , isoflurane , desflurane
Anestesi regional : PNB , epidural/subarachnoid block
 ASA Monitoring Guidelines

During all anesthetics, the patients

oxygenation, ventilation, circulation and
temperature shall be continually evaluated.

http://www.asahq.org/publicationsAndServices/standards/02.pdf
 Stetoskop Precordial/oesophageal
Deteksi perubahan karakter , kecepatan denyut
jantung dan suara nafas.
Jenis pembedahan tentukan lokasi stetoskop
prekordial.
Posisi terbaik parasternal kiri , intercostal ke 2 - ke
4 diatas garis papilla mammae.
Posisi cadangan : Esophageal stethoscope (best
position?)
Induksi Inhalasi

LPCH Pediatric Anesthesia

Rotation Updated January
2012
Asisten Handal
Bayi laki-laki 5 minggu , BB 3.5 kg.
Kurus, pucat, mata cowong, turgor kulit jelek, nadi kecil.
Hetero Ax : muntah-muntah setiap habis minum susu
muntahnya semakin sering , proyektil. Teraba masa padat
sebelah dekat umbilicus sebesar kelereng.
Kejang +

Lab : Natrium 115 mmol/L

Kalium 2.1 mmol/L
Chlorida 86 mmol/L
HCO3 35 mmol/L
Base deficit + 12
pH 7.65
PaCO2 46 mmol/L

Bagaimana sikap saudara ?

Bayi wanita 1 tahun dibawa ke IRD dengan dugaan
intususepsi (invaginasi).
Bayi tampak lemah nadi kecil susah diraba pada nadi
brachialis.
Berat badan 10 kg
Pernafasan 40 permenit
Urine saat dikateter 25 ml, selanjutnya tidak ada produksi
urine lagi. Hb 16 g%
Analisa gas darah : pH 7.10 pCO2 25 pO2 76 BE 15

Bagaimana pengelolaan penderita ini ? Derajat dehidrasi?

Capillary Refill
Urine production

ATLS
Jalur intravena terpasang dalam waktu < 90 detik
 Kebutuhan Cairan Perioperatif
Kebutuhan Rumatan (Maintenance)
Kebutuhan Pengganti (Replacement) :
defisit prabedah (preop deficit)
defisit yang berjalan (ongoing losses)
 Kebutuhan Cairan Rumatan
RUMUS 4 2 1
Berat badan 1 10 kg : 4 ml/kg BB
+
Berat badan 10 20 kg : 2 ml/kg BB
+
Berat badan > 20 : 1 ml/kg BB
 Contoh
Anak BB 23 kg
Hitung kebutuhan rumatan :
10 x 4 = 40
10 x 2 = 20
3x1=3
Kebutuhan cairan rumatan total
63 cc/jam
63 x 24 cc/hari
 Kebutuhan Pengganti
(ECF Deficit Isotonic Dehydration))
Perkiraan defisit :
Kehilangan berat badan (kg = liter).
Estimasi dari tanda klinis.
Ringan Sedang Berat
Bayi : < 5% BB 5-10% BB >10% BB
Anak : < 3% BB 3- 6% BB > 6% BB

6/29/2017 44
 Clinical Picture of Dehydration
Mild 3-5% Moderate 6-9% Severe > 10%

Peripheral Normal Rapid and weak Rapid, thready

perfusion/pulses

Breathing Normal Rapid Deep, rapid

Fontanelle Normal Sunken Very sunken

Capillary Refill < 2 Seconds Prolonged 3-4 sec Very prolonged > 4
sec

Blood Pressure Normal Normal Hypotension

All the calculation made are estimates !!

Mekanisme kompensasi bayi
Ukuran cuff
 Phase I Resuscitation Phase
Goal: Restore circulation, reperfuse brain, kidney
Moderate :
20 mL/kg bolus given over 30 60 minutes
Severe :
May repeat bolus as needed (ideally up to
60ml/kg)
Fluids something isotonic such as NS or lactated
ringers (LR)
Determinants of Oxygen Delivery (DO2)
 Phase II: Replacement Phase
Phase III: Stabilization Phase
(For Isotonic/Hypotonic Dehydration)

Goal: slow replacement deficit of fluids and electrolytes

Replacement Phase Stabilization Phase
1st 8 hrs Next 16 hrs

MIVF and 1/3 2/3

Maint Na

Deficit Fluid & 1/2 1/2

Deficit Na
 Ongoing Losses

Evaporation
Weeping surfaces
Edema
Drainage from body cavity
Surgical Loss :
Abdominal : 10-15 ml/kg/hr for 1st 3 hours
Hernia Inguinalis : 2-5 ml/kg/hr
 Kebutuhan Tambahan Karena
Pembedahan
Derajat Trauma Jaringan Kebutuhan Cairan Tambahan

Minimal 3-5 ml/kg/jam

Moderat 5-10 ml/kg/jam
Berat 8-20 ml/kg/jam
 Pedoman Puasa
Minimum Fasting Periods:

Air/teh 2 jam
ASI 4 jam
Susu formula 6 jam
Makan ringan 6 jam
Makan bubur 8 jam
Kapan transfusi diperlukan kelompok pediatri ?

Decompensated anemia (top up transfusion)

Pembedahan terrencana preop/op/postop :
Neonatal surgery
Cardiac surgery
Neurosurgery
Craniomaxillofacial surgery
Trauma , bedah darurat + perdarahan.

RARE
Blood is RED EXPENSIVE
DANGEROUS
 Transfusi top up neonatus
Transfusi jika Hct < 35-40% (Hb < 12 g/dL):
Bayi perlu ventilator
Terapi oxygen > 35%
Transfusi jika Hct < 30% (Hb < 10 g/dl):
Bayi dengan CPAP
Terapi oxygen < 35%
Apnea of prematurity
Tachycardia , tachypnea
Transfusi jika Hb < 7 g/dL pada kondisi stabil.
Newcastle Neonatal Service Guideline ,
2009
Sunder-Plasman (1968)

Hb 7-15

Jika faal
kardiopulmoner
normal
|
Hb 7 -15 gm/dl
Hct 20-40%

Kapasitas transport
O2 sama
 Transfusi top up dgn PRC
Eggert,L.,et al. Neonatal Transfusion Guidelines 2009

Volume of 1 unit 150-200 mL (Hct 60-70%)

Dose
10-20 mL/kg; may repeat 8-12 hrs apart
Infuse over 2 to 4 hours ; 3-5 ml/kg/hour
May infuse faster if acute blood loss
Each 10-20 mL/kg infused should raise Hct by 5
Monitor effectiveness with Hct or Hb about 4 h after the
transfusion

Packed cells (mls) = wt (kg) x Hb rise required(g/dL) x 4

 Transfusi Darah Perioperatif
(bedah terrencana)
Maximum Allowable Blood Loss (MABL)
Hct patient - Hct target X EBV
Hct patient
Normal Acceptable EBV
(%) (%) (ml/kg)

Premature 40 45 35 90 100
Newborn 45 65 30 35 80 90
3 Months 30 42 25
1 Year 34 42 20 25 70 80
6 Years 35 43 20 25 70

* Continuing Education in Anaesthesia,Critical Care & Pain vol 1,2,3 Collected Ed

2004.
CONTOH :
Anak 10 kg , Hct 42%.
Berapa maximal allowable blood loss jika diharapkan Hct
terrendah 25% ?

EBV = 70 ml/kg = 700 ml

MABL = 700 x (42 25)

42
= 285 ml

Ganti perdarahan : 2-3 x kristaloid atau 1 x koloid/albumin

5%
Jika perdarahan > MABL atau Hct < target : beri PRC.
Jika 1 unit telah diberikan , tambahkan 5-10% daripada
transfusi lagi tapi dgn unit lain.
Jika resiko perdrhan postop besar naikkan Hct target.
 RUMUS MABL

6/29/2017 62
 Guidelines for Platelet transfusion*
Platelets < 100,000/ul and bleeding or clinically
unstable
Platelets < 50,000/ul and invasive procedure
Platelets < 20,000/ul and no bleeding and clinically
stable
5-10 ml/kg Platelet Rich Plasma

* from Strauss, Chap 20 Neonatal Transfusion in Anderson, Ness Scientific

Basis of Transfusion Medicine
 Hypothermia
Impaired thermoregulation
Lack of fat insulation
Larger surface to volume ratio
Fewer brown fat cells
Thin skin increased heat loss

apnea , bradycardia , metabolic acidosis ,

hypoglycemia
 Regulasi Pengaturan Suhu Tubuh
Kontrol suhu tubuh : hypothalamus
Mengatur keseimbangan heat loss & heat
production
Produksi panas :
Shivering (menggigil) - dewasa
Metabolic thermogenesis (brown fat) - neonatus
Lingkungan dg suhu netral :
Konsumsi O2 minimal
Mis: bayi aterm tanpa baju ~ 33C
 Faktor resiko hipotermia
Jumlah cairan irigasi
Jumlah perdarahan atau kehilangan cairan
Rongga tubuh terbuka
Usia penderita
Status fisik dan kondisi perioperatif
Ruangan dingin
Lama dan jenis pembedahan/prosedur
 Suhu Kamar Bedah
Suhu kamar bedah merupakan faktor
terpenting penyebab kehilangan suhu tubuh
selama pembedahan bayi (terutama bayi
prematur)
Suhu kamar bedah untuk bayi & anak diatur >
26 C agar suhu tubuh tetap normal
(normothermia)
 Hipotermi

Klasifikasi hipotermi berdasarkan suhu sentral

(core temperature)
NORMAL : 36.5 to 37.3C
Cold Stress : 36.0 to 36.4C
Waspada
Moderate hypothermia : 32 35.9C
Bahaya hangatkan !
Severe hypothermia : below 32C
Mengancam jiwa (skilled care urgently needed)
 Pencegahan Hipotermi
Hangatkan kamar bedah
Radiant warmer
Matras penghangat/padding penghangat
Tutup kepala/topi (40% kehilangan panas)
Hangatkan infus
Hangatkan dan lembabkan gas anestesi
Pain Management

Pain
Pain therapy
assessment

Pain
documentation

72
 Diagnosa Nyeri

SYARAT KOMUNIKASI, KOGNISI, KOMPARASI

(Anak usia > 3 tahun)
ORourke, 2004
73
 Non-Verbal
Age

Pain Definition
Is not for baby!
(G.Noia et al, 2008)
Non-verbal Pain Assessment

behavioural parameters
physiological parameters
biochemical parameters

Pain Assessment Tool/Scale

Uni/Multi Dimensional

Cohen LL , 2008
 Behavioural Parameters
Crying characteristics.
Facial expressions.
Simple motor responses.
Complex behavioural responses.

More specific and

consistent than
physiological
parameters.
Physiological Parameters
Heart rate.
Respiratory rate.
Blood pressure.
Palmar sweating.
Vagal tone.

Objective,
Precise , but
not specific for pain
 Developmentally approprite tool

PAIN ASSESSMENT TOOL

PRETERM 2 mo 7 yrs 5 yrs 12 yrs > 7 yrs 3 18 yrs
FULL TERM (non-verbal)

PIPP FLACC FACES NRS NCCPC

SCALE
 Skala FLACC (Merkel,1997)
Kategori Nilai
0 1 2
Face Ekspresi biasa Menyeringai Merengut
Senyum Merengut Otot rahang kontr.
Dahi mengerut Dagu gemetar
Legs Santai Gerak terus Menyepak
Normal Tegang Kaki ditekuk
Activity Tenang,posisi Menggeliat Posisi kaku
normal Bergerak terus Gerakan kejang
Gerak santai Tegang
Cry Tidak menangis Merengek Menangis terus
(sadar atau tidur) Menangis tdk terus Teriak, terisak2
Selalu mengeluh
Consolability Senang /santai Tenang dengan bicara , Tidak bisa dihibur
sentuhan,pelukan

No pain : 0 ; Mild pain : 1-3 ; Moderate pain : 4-6 ; Severe pain : 7-10
 Skala Nyeri FLACC (Merkel,1997)
Untuk penderita sadar : observasi & penilaian dilakukan 1-5
menit atau lebih. Penilaian dilakukan tanpa selimut. Nilai
aktivitas, tonus otot, hibur jika diperlukan. Reposisi nilai
lagi.
Untuk penderita tidur : observasi & penilaian dilakukan lebih
dari 5 menit. Penilaian dilakukan tanpa selimut. Raba
tubuhnya nilai tonus otot. Jika memungkinkan reposisi & nilai
lagi.

80
 Penilaian Derajat Nyeri Akut Pascabedah

Minimal setiap 2 jam dalam 24 jam pertama

Selanjutnya setiap 4 jam
Sesaat sebelum terapi atau intervensi nyeri
30-60 menit setelah terapi atau intervensi
nyeri
Penilaian lebih sering jika nyeri sulit dikontrol
Penilaian setiap 8 jam jika nilai konsisten
dibawah cut-off point
 Intervensi Farmakologis

Nonsteroidal antiinflammatory drugs.

Opioid (Intermittent/continuous).
Peripheral nerve block & Regional anesthetic .
 NSAIDs
Efektif untuk nyeri ringan-sedang.
Anti-inflammatory & antipyretic effects.
Opioid sparing effect.
NSAIDs + paracetamol analgesia lebih baik.
 Opioids
Morphine. Hindari Pethidine.
Nilai efektivitas dan efek samping.
Usia < 6 bulan observasi nafas:
* < 1 bulan : 9 jam Setelah dosis
* 1-6 bulan : 4 jam terakhir
 Dosis Morphine

Infus :
* 100 g/kg/jam (2 jam pertama).
* Kmnd 10-30 g/kg/jam.
Intermittent :
* 50-200 g/kg/dosis i.v. pelan.
* Ulangan biasanya setiap 4 jam.
Fentanyl 1-2 g/kg/jam
 Pendekatan Farmakologis
Around the clock dosing
PRN dosing hanya untuk nyeri yang
intermittent (termasuk breakthrough pain
dan nyeri karena aktivitas)
Pemberian intramuskuler tidak dianjurkan
Multimodal analgetik :
NSAID + acetaminophen : utk nyeri ringan-sedang
Non-opioid + opioid : utk nyeri sedang-berat
Multimodal approach pain therapy

NON-
PHARMACOLOGIC
APPROACH
Opioid intravena

BOLUS + INFUSION
BOLUS INFUSION

PCA
 Estimated Values for Vd t1/2 CL of
Morphine

Vd t1/2 CL
(L/kg) (h) (ml/min/kg)
Preterm 2.8 + 2.6 9.0 + 3.4 2.2 + 0.7

Term 2.8 + 2.6 6.5 + 2.8 8.1 + 3.2

Infants & 2.8 + 2.6 2.0 + 1.8 23.6 + 8.5

children

Kart T, Lona L. Recommended Use of Morphine in Neonates,Infants and Children Based on

Literature Review : Part 1 Pharmacokinetics.
Pediatric Anesthesia 1997.
 Pediatric Anesthesia 22 (2012)

PPPM
SCORE

CUTOFF
PPPM
SCORE

POSTOP
DAY

TONSILLECTOMY

ORCHIDOPEXY

HERNIOTOMY
 Analgesi Pre-emptif
Caudal epidural block
Ilio-inguinal ilio-hypogastric block
Penile block
Brachial plexus block
 Caudal epidural analgesia
Blok sentral paling sering
Mudah dilakukan & aman
Excellent analgesia-painfree awakening
Untuk semua kelompok usia pediatri
 Caudal Bupivacaine + Clonidine

1-2 ug/kg.
Durasi blok memanjang & kwalitas lbh baik.
Sedatif postoperatif .
Favorable analgesia-to-side effect profile.
 Caudal Bupivacaine + Opioids

Morphine : 20-40 ug/kg ; 75 -100 ug/kg.

Fentanyl : 0.5-1.0 ug/kg.
Sedasi pasca bedah.
Depresi nafas , mual/muntah , retensi urine.
Perlengkapan Caudal Epidural
Landmark Hiatus Sacralis
 Landmark Hiatus Sacralis

Cornu Sacralis

Spina iliaca Hiatus Sacralis

posterior superior
Landmark Hiatus Sacralis
 Armitages Scheme
Segmental level of Dose (ml/kg)
operation
Lumbo-sacral 0.5
Thoraco-lumbal 1.0
Mid-thoracic 1.25
Bupivacaine < 0.25%.
Tanpa Adrenaline.
Maximal 20 ml konsentrasi ~ max dose 3 mg/kg
EKG intoksikasi anestesi lokal
 Brachial Plexus Block
Interscalene approach.
Parascalene approach.
Subclavicular approach.
Supraclavicular approach.
Axillary approach.
Axillary approach
 Post
Thoracotomy
 Changes in Pediatric Anesthetic
Practice
Introduction of LMA
Volatile anesthetic agents : sevoflurane
More accurate delivery systems
Improved equipment design
Improvement in training
Improvement in monitoring
Improved understanding of risk management
Many studies have shown that incidents
and negative outcomes in pediatric
anesthesia are seen in healthy children !

It is not surprising that approximately 90% are

considered preventable !