Pediatrics Anesthesia

Tadese T.
 Outline
• Objective

• Definition

• Anatomy & Physiology

• Pharmacology

• Equipments

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 Objective
At the end of this session, students will be able to;

• Define pediatrics by age

• Discuss the anatomic and physiologic changes in pediatrics

• Explain the pharmacologic considerations in pediatric anesthesia

• Discuss drug doses and preparations for pediatrics anesthesia

• Identify airway equipments and monitors used for pediatrics anesthesia

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Definitions of Age & Weight Estimation

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Anatomy & Physiology

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Respiratory System
• Weaker intercostal muscles and diaphragm

• More horizontal and pliable ribs, and protuberant abdomens

• Higher respiratory rate & oxygen consumption

• Fewer and smaller airways produces increased airway resistance

• Alveoli are fully mature by late childhood (about 8 years of age)

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 Resp…
• Work of breathing is increased and respiratory muscles easily fatigue

• Fewer and smaller alveoli, reducing lung compliance;

• Cartilaginous rib cage makes their chest wall very compliant

• These two characteristics promotes chest wall collapse during inspiration

and relatively low residual lung volumes at expiration

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Resp …
• The resulting decrease in FRC limits oxygen reserves during apnea
predisposes to atelectasis and hypoxemia

• Hypoxic and hypercapnic ventilatory drives are not well developed in

neonates and infants

• Unlike in adults, hypoxia and hypercapnia may depress respiration in

these patients

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 Cardiovascular System
• Stroke volume is relatively fixed by a noncompliant and immature left
ventricle

• Cardiac output is therefore very sensitive to changes in heart rate

• Although basal heart rate is greater than in adults

• Sympathetic and baroreceptor reflexes are not fully mature

• Blunted response to exogenous catecholamines

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 CVS …
• Sensitive to depression by volatile anesthetics and opioid-induced bradycardia

• Vascular tree is less able to respond to hypovolemia with compensatory

vasoconstriction

• Intravascular volume depletion may be signaled by hypotension without

tachycardia

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Metabolism & Temperature Regulation

Thin skin & low fat content

Greater surface area relative to weight promote greater heat loss to the
environment

Non shivering thermogenesis by metabolism of brown fat and shifting

of hepatic oxidative phosphorylation to more thermogenic pathway

Volatile anesthetics inhibit thermogenesis in brown adipocytes

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Renal & Gastrointestinal Function

• Renal immaturity until 6 months (but may delayed to 2 years old)

• Decreased GFR/blood flow

• Decrease concentrating capacity

• Relatively increased incidence of gastroesophageal reflux

• The immature liver conjugates drugs and other molecules less readily
early in life

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Glucose Homeostasis
• Relatively reduced glycogen stores, predisposing them to
hypoglycemia

• Impaired glucose excretion by the kidneys may partially offset this

tendency

• In general, neonates at greatest risk for hypoglycemia are:

Premature or small for gestational age

Receiving hyperalimentation

off springs of diabetic mothers

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 Pharmacology
• Disproportionately larger extracellular fluid compartments

• Immaturity of hepatic biotransformation pathways

• Increased organ blood flow

• Decreased protein for drug binding, or higher metabolic rate

• Greater total water content (70–75%) than adults (50–60%)

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 Pharm…
• Decreased glomerular filtration rate, hepatic blood flow, and renal tubular
function

• Immature hepatic enzyme systems

• Increased intraabdominal pressure

• Abdominal surgery further reduce hepatic blood flow

• Decreased protein binding for some drugs (eg; thiopental, bupivacaine, and
many antibiotics)
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Propofol – larger dose, not recommended for prolonged sedation in ICU

Thiopentone - lower dose (3 – 4mg/kg) in neonates, larger in children

Opioids - neonates are more sensitive

Benzodiazepines – midazolam has fast onset but reduced clearance in

neonates, midazolam + fentanyl causes hypotension in all age

Muscle relaxants – faster onset for all, larger dose of sux for infants (2-
3mg/kg), smaller dose relaxants in infants except sux & atracurium, more
sensitive for sux’s side effects, variable response for NDMR (prolonged duration
of action)
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Inhalational Anesthetics

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Summary of Pharmacologic Changes

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Preoperative Fasting guideline

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Airway Equipments

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Summary of Airway Equipments

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References
• Morgan 5th ed
• Barash 8th ed
• Update 30, 2015
• Open Anesthesia
• Safe pediatrics and Obstetrics Anesthesia

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 Thank You!

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