Pediatrics Anesthesia

Senay Zerihun, MD , MPH

(Assistant Professor of Pediatrics and Child Health)

BAHIRDAR UNIVERSITY
Goals of Anesthesia
 Analgesia
 Amnesia and a decreased level of
consciousness(hypnosis)
 Akinesia–absence of movement in response to painful
stimuli
 Physiologic support and homeostatic management
throughout the perioperative process
• Vigilance -Constant, critical attention for any change in
physiologic status
 SEDATION
Minimal Sedation (Anxiolysis)
• Anxiolysis with the maintenance of consciousness
Example: Intranasal midazolam for short and brief
procedures e.g., laceration repair in a child who is crying
and very anxious
Moderate Sedation (Conscious Sedation)
• Controlled depressed consciousness
• Airway reflexes and airway patency are maintained
• Patient responds appropriately to age-appropriate
commands (“Open your mouth”) and to touch
Deep Sedation
• Controlled depressed consciousness
• Airway reflexes and airway patency may not be maintained
• Ability to independently maintain ventilatory function may be
impaired
• Patient not easily aroused but responds purposefully following
repeated or painful stimulation
General Anesthesia
• Loss of consciousness occurs.
• Impaired airway reflexes, airway patency, and ventilatory function.
• Children are not arousable.
• Not responsive to painful stimulation
• Recommendations for fasting or nothing by
mouth (NPO) before sedation and anesthesia
– 2 hours fasting for clear liquids
– 4 hours fasting for breast milk
– 6 hours fasting for formula
– 8 hours fasting for solids
Medications for Procedural Sedation
• Opioid analgesics ➔ morphine sulfate,
fentanyl
• Benzodiazepines ➔ midazolam, diazepam
• Barbiturates ➔ pentobarbital, methohexital,
thiopental
• Miscellaneous agents ➔ nitrous oxide,
ketamine, propofol, dexmedetomidine
 Fentanyl
• Rapid onset of action opioid
• Most commonly used opioid for short, painful procedures
• Intranasal fentanyl is a good option for children with severe pain
seen in the emergency department and prehospital settings
• Doses of fentanyl delivered via a transmucosal route have
similar analgesic action to intravenous opioids
• Fentanyl is preferred over morphine in patients with renal
insufficiency
• Chest wall rigidity can occur with even low doses, especially in
neonates and infants, and can lead to significant impairment of
ventilation
 Midazolam
• Rapid and predictable onset of action
• Short recovery time
• Causes amnesia
• Mild depression of hypoxic ventilatory drive
 Ketamine
• Commonly used for procedural sedation
• Preserves the airway reflexes
• Minimal effect on the respiratory drive
• Bronchodilatory effects and is especially
effective with bronchospasms
• Good safety profile in children
 Propofol
• A purely sedative agent without any analgesic
or amnestic properties
• Rapid onset of action (within 40 s)
• Used for induction and maintenance of
general anesthesia
• Used for procedural sedation
 Nitrous oxide
• Causes anxiolysis, amnesia, and mild-to
moderate analgesia.
• Administered as an inhalant via a handheld
mask or mouthpiece.
• Effects are rapidly lost once inhalation ceases,
and recovery occurs within 5 min.
• Nitrous oxide has little effect on the
cardiovascular and respiratory systems.
 Sedation Protocol
• Ketamine ➔ Lowest rate of adverse effects if
used alone
• Ketamine + midazolam + atropine ➔ Adding
midazolam counter the emergence delirium
• Midazolam + Fentanyl ➔ High risk of
respiratory depression (decrease the
frequency of fentanyl infusion to no more
than every 3 min)
Reversal Agents
• Opioids ➔ Naloxone
• Benzodiazepine ➔ Flumazen
 Preprocedural Evaluation
• History and physical examination are critical before clearing a
child for sedation or anesthesia
• Ask about past medical history, previous sedation or anesthesia
• Last solid and liquid oral intake
• Recent illness
• Current medications, allergies, or side effects of medications
• Family history
• Upper respiratory infection symptoms; history of reactive
airway disease
• Airway, cardiac, pulmonary, and neurological examination
 Intraprocedural Monitoring
Monitoring during procedural sedation
• Continuous oxygen saturation and heart rate
monitoring
• Monitor vital signs and blood pressure every
15 min for conscious sedation and every 5 min
for deep sedation
• Monitor state of consciousness and response
to stimulation
Specific Pediatric Diseases and
Their Anesthetic Implications
 Asthma
• Intraoperative bronchospasm that may be
severe and even fatal
• Optimal preoperative medical management is
essential; preoperative steroids may be
required
• Pneumothorax or atelectasis
 Difficult airway
• Special equipment and personnel may be
required
• Should be anticipated in children with
dysmorphic features or acute airway
obstruction, as in epiglottitis or
laryngotracheobronchitis or with an airway
foreign body
• Patients with Down syndrome may require
evaluation of the atlantooccipital joint
 Cystic fibrosis
• Airway reactivity, bronchorrhea, increased
intraoperative pulmonary shunt and hypoxia
• Risk of pneumothorax, pulmonary
hemorrhage
• Atelectasis
• Risk of prolonged postoperative
ventilation
 Sleep apnea
• Pulmonary hypertension and cor pulmonale
must be excluded
• Careful postoperative observation for
obstruction required
 CARDIAC

• Need for antibiotic prophylaxis for bacterial

endocarditis
• Use of air filters; careful purging of air from the
intravenous equipment
• Physician must understand the effects of various
anesthetics on the hemodynamics of specific lesions
• Preload optimization and avoidance of hyperviscous
states in cyanotic patients
• Possible need for preoperative evaluation of myocardial
function and pulmonary vascular resistance
 Oncology Diseases
• Pulmonary evaluation of patients who have
received bleomycin,methotrexate, or radiation
to the chest
• Avoidance of high oxygen concentration
• Cardiac evaluation of patients who have
received anthracyclines; risk of severe
myocardial depression with volatile agents
• Potential for coagulopathy
 Liver diseases
• High overall morbidity and mortality in
patients with hepatic dysfunction
• Altered metabolism of many anesthetic drugs
• Risk of coagulopathy and uncontrollable
intraoperative bleeding
 RENAL DISEASES
• Altered electrolyte and acid–base status
• Altered clearance of many anesthetic drugs
• Need for preoperative dialysis in selected
cases
• Succinylcholine to be used with extreme
caution and only when the serum potassium
level has recently been shown to be normal
 Seizure disorder
• Avoidance of anesthetics that may lower the
seizure threshold
• Preoperative serum anticonvulsant
measurements
• Avoidance of agents that increase cerebral
blood flow ( ICP INCREAMENT )
 Neuromuscular disease

• Avoidance of depolarizing relaxants;

• at risk for hyperkalemia
• Patient may be at risk for malignant
hyperthermia
 Developmental delay

• Patient may be uncooperative during

induction and emergence
 Diabetes Mellitus
• greatest risk is unrecognized intraoperative
hypoglycemia
• if insulin is administered, intraoperative blood
glucose level monitoring needed
• glucose and insulin must be provided, with
adjustment for fasting condition and surgical
stress
 Burn
• Difficult airway
• Risk of rhabdomyolysis and hyperkalemia from
succinylcholine following burns for many
months
• Fluid shift
• Bleeding and coagulopathy
 Down Syndrome
• Children with Down syndrome are occasionally
behaviorally difficult and are fearful of medical caregivers
• Their cardiac anomalies, macroglossia, and upper airway
obstruction can be challenging.
• Children with Down syndrome have atlantoaxial instability
• In younger children, extension of the neck, routinely used
to maintain and intubate the airway, may lead to cervical
dislocation and spinal cord trauma.
• Some anesthesiologists recommend extension and flexion
lateral neck films to detect instability before anesthesia.
 PAIN MANAGEMENT
Pain Management in Neonates
Pharmacologic pain management
• Topical anesthetic for painful procedures, e.g., lumbar puncture
• Topical anesthetics can effectively reduce pain, e.g., lidocaine
• Give sufficient length of time before the procedure (usually 30 min for
neonates)
Acetaminophen
• Administered orally postoperatively has beenshown to reduce morphine
requirements.
• Should not be used alone for severe pain.
• Use during the later postoperative period.
• Use after minor procedures, e.g., circumcision.
• Morphine for postoperative pain
Pain Management in Older Children
• Pain scale assessment needed first
Postoperative pain management
Morphine IV
• Moderate-severe pain after surgeries
• Use the lowest effective dose
• Acute pain may counteract the respiratory depression induced by
morphine
• Repeated doses every 4 to 6 hrs based on additional pain assessment
• Using appropriate dosing of acetaminophen after surgery may reduce
the requirements for morphine or opioids in general
Ketorolac IV
• Nonsteroidal anti-inflammatory drug
• Not associated with common opioid side
effects, such as respiratory depression, nausea,
vomiting, urinary retention, or sedation
• Attention must be paid to postoperative bleeding
after tonsillectomy
Acetaminophen (rectal)
• Provides good analgesic and morphine-sparing effects,
even in neonates and infants, after major surgery
Post-operative pain management with
conversion to oral agents
• Ibuprofen
• Acetaminophen
• Hydrocodone
Opioids as outpatient
• In mild to moderate pain, may alternate
ibuprofen and acetaminophen instead
• Appropriate dosing of acetaminophen and
ibuprofen may reduce postoperative opioid
requirements
• Reserve opioids for moderate to severe pain,
e.g., after bone surgeries
Codeine
• No longer recommended in pediatrics
• Can cause severe nausea and vomiting
• 3% to 5% of population over metabolize,
potentially leading to catastrophic overdose
 Malignant hyperthermia
• is an acute hypermetabolic syndrome that is triggered by inhalational
anesthetic agents and succinylcholine.
• It resembles neuroleptic malignant syndrome.
• The onset of malignant hyperthermia may be acute, and its course may
be fulminant and rapidly fatal.
• This condition, albeit rare (approximately 1 in 60,000 pediatric patients
given anesthesia) is a constant concern.
• The disease is familial, and a family history of death or a febrile reaction
during anesthesia should alert the anesthesiologist to its potential.
• Its clinical course is characterized by rapid onset of fever, acidosis,
hypercarbia, and increased expired CO2.,high fever (38.5-46.0°C [101.3-
114.8°F]
 Parental Presence During Induction of Anesthesia (PPI)
• Parents may expect to be with their child during the induction
of anesthesia.
• Removing a terrified child from the comforting arms of a
parent is stressful for the child, the parent, and the caregivers.
• If this parental separation cannot be achieved comfortably
with preoperative psychoprophylaxis and behavioral
modification, including education and desensitization to the
operative environment, or with pharmacologic aids, such as
preoperative medications including benzodiazepin and
barbiturates, then there may be a need to defer parent–child
separation until general anesthesia is induced
• Preoperative medication with oral benzodiazepine more
frequently provides calm, smooth induction conditions than
PPI without pharmacologic preparation.
• Although the use of PPI in the hands of a confident, competent
anesthesia practitioner can replace the need for preoperative
medication, it does not reliably predict smooth induction.
• PPI appears to decrease neither emergence phenomena nor
the incidence of postoperative behavioral changes, and it does
not appear to add an advantage for the child over that
provided by preoperative sedative medication, such as with
oral midazolam.