PEDIATRIC ANESTHESIA

• HOSSAM M. ATEF ; MD
Resources
- Miller’s Anesthesia
- Chapters 82, 83, 84
• - A Practice of Anesthesia for Infants & Children – Charles
Cote
- UPMC Presentation – Dr. James Cain
- Stanford (pedsanesthesia.Stanford.edu)
- Essentials of Pediatric Anesthesia – Alan David Kearne
- Big Blue – Dr. Neils Jensen
- The World Wide Web
- Open Anesthesia Keywords
Age Definitions

 Neonates: 0-30 days old

 Infants: 1 month to 1 year
 Children: older than 1 year

 Post-Conceptual Age (PCA):

• Actual age – Pre-maturity (# weeks)

• Used up until age 2 yo
Learning Objectives

I. Review of Systems
II. Anesthetic Management Essentials
III. Pre-Term (PT) Neonatal Emergencies
IV. Full-Term (FT) Neonatal Emergencies
V. Pediatric Issues
Review Of Systems
Neuro

  Skull rigidity (fontanelles)

  Cortical neurons (2 x 10^9)
• Originate at 22 weeks, maximum at 29 weeks
• Thalamacortical connections (until 5 yrs of life)
• Sleep-wake at 32 weeks
• PNS mature at 37 weeks
  Myelination
 Reaches adult size at 40 kg / 11-12y
  BBB integrity
 Neuro
Spinal Cord & Dura
Neuro

  Pain threshold
•  Nerve endings / cm2 of skin
•  Dorsal horn receptor fields, decrease at 42 weeks
•  Dorsal horn receptor NMDA concentration
• Immature inhibitory pathways

 GABA depolarizes based on intracellular Cl-

  Hypersensitive until 2-6 months
•  Increased stress response to pain (cortisol, glucagon, GH,
aldosterone, O2 consumption/SpO2/PaO2
•  Autoregulation
•  Sensitivity to respiratory depressant effect of opioids
Neuro
MAC
 (0 months  9-12 months)  1.5x adult
 (prematurity, 12 months +), ~linear
 Exception: sevoflurane
 NMJ maturity /  sensitivity
 Shorter onset time offset by  Vd
o #1 utilizer of glucose
Respiratory
• Anatomical - Upper Airway

  Head
•  Occiput
•  Face and lower jaw

  Neck length
•  Trachea length (~5 cm in newborns)
•  Cords-to-carina length (2 cm)
• Short trachea directed downwards and posteriorly
• Right main bronchus less angled than left
Respiratory
• Anatomical - Upper Airway
•  Nostrils / nasal passages
­ Tongue size, length
­ Adenoids
 Loose teeth or awkward dentition
•  Floppy OR stiff horseshoe (U)-shaped epiglottis
Respiratory
 Larynx
 Anterior & Cephalad
 C3 preemie, C3-4 neonate, C5-6 in adult
 Narrowest
 Cricoid (neonate – age 10)
 Edema
 La Poiseuille’s law
 Vocal cords (puberty)
 Larynx has a gradually
tapering shape
Respiratory
• Anatomical - Lower Airway

 Alveoli increased starting 32 weeks GA, increased over 18

months, continues for 10 years
•  Chest wall compliance
 Stiffens ( compliance) thereafter
  Lung compliance,  Compliance thereafter
 Soft chest wall
 Horizontal ribs
 Circular chest
  Diaphragm endurance
  Type 1 muscle fibers
Respiratory
• Physiological Differences

 Obligate nose breathers until 3-5 months

 Abdominal > thoracic breathing
• NO CHANGE (per / kg)
 TLC (90 ml/kg) Dead space (2 ml/kg)
 Vt (7-9 ml/kg) VC (90 ml/kg)
 FRC
•  RR
• Controlled expiration (laryngeal braking)
• Tonic activity of ventilatory muscles
• PEEP helps during controlled ventilation
Respiratory
Physiological Differences
  INCREASE
 FA/FI due to
  RR   MV
  Tissue/blood partition coefficients
  CO (opposite of adults due to VRG)
 Closing volumes
  DECREASE
 Blood: gas coefficient
  Solubility
 FRC buffering capacity
  Time to desaturation
 Hypoxic respiratory drive
 Hypercapnic respiratory drive
Cardiovascular

  Muscle fiber
  Myocyte glycogen
 No change CO
•  Contractile elements    SV
•  HR (dependent)
•  Vagal tone / Avoid bradycardia
 Vagal stimulation with laryngoscopy
 Hypoxemia
•  Sympathetic tone
•  Baroreceptor tone and response
Cardiovascular

  BP, MAP
  RR
  Incidence of hypoxemia-induced dysrhythmias (bradycardia)
 Vessel-rich group as a % of CO
  PR, QRS intervals during infancy
 T-wave inverted in V1-V4 until adolescence
Hematologic
 Hct: Preterm > Neonate > Infant
• HbF breakdown,  erythropoisis,  plasma volume
• Erythropoesis shifts from liver to BM at 24wk GA
• HbF: Leftward shift on oxyhemoglobin dissociation curve
•  P50 (19 mmHg vs 26 mmHg)
 Granulopoiesis occurs in BM
•  Platelets over the few days but then return  to normal levels after the
1st week of life
Temperature Regulation

  Body surface area : volume

•  radiant heat loss)
Thin skin
•  Subcutaneous body fat
•  Shivering thresholds (i.e. occurs at lower temperatures) in
children
 Neonates do NOT shiver
•  norepinephrine  brown adipose tissue metabolism
• Found scapulae, mediastinum, kidneys, adrenal glands
 Thermoregulatory center not well developed
Hepatic / Metabolism

  Homeostatic metabolism
•  O2 consumption (7-8 ml/kg/min FT vs
• 3-4 ml/kg/min Adult ; ~ 2x of adults)
•  Glucose consumption (6-7 mg/kg/min PT vs
• 4-5 FT vs 3 mg/kg/min Adult)

  Drug metabolism until 3 months

•  Hepatic size/blood flow : body weight ( with age)
•  CyP450 (adult at 1 mo) (Enzyme systems not induced)
•  Oncotic proteins (e.g. albumin)  Protein binding
Hepatic / Metabolism
  bilirubin load
  Hepatic cell uptake & conjugation
 reaches adult levels at 6 months.
  Pseudocholinesterase activity until 6 months
  Phase II block after succinylcholine
  Hepatic glycogen (FT 30 mg/dl vs infant 40 mg/dl)
•  Gluconeogenesis (primary in muscles)
•  Glycogenesis / g liver mass
  Blood glucose d/rt use
•  With maternal DM (insulin Ab)
• Utilizer: Brain > Heart, ~ adult use at 40kg
  Fetal calcium stores (until 3mo)
Renal

  Volume of distribution (water-soluble drugs)

  Diluting ability
  Creatinine clearance
  GFR (67% reduction)
• Reaches adult values by 1-2 years of age
• Tubular function by 7th month
• More decreased by hypoxia, hypothermia, and CHF
 Renal

  Urine concentrating ability (6 months)

•  Glucose excretion
•  FeNa
 Responsible for 10% loss of body weight over first 7-19 days
• Followed by  Sodium excretion
  H+ excretion
•  Morphine metabolite excretion
•  HCO3- resorption threshold
  TBW (70-75%) , ECF
•  TBW with age
• 1 mo: 75%, 1 yr: 70%, 10 yrs: 65%
Anesthetic Management
GI
  pH on DOL 1  normal on DOL 2+

 Delayed gastric emptying

 Delayed absorption

  GERD
• Coordination of swallowing with respiration occurs at 4-5 months
Face Masks & Circuits
 Mapleson Circuits

Adult, SV

Adult + Pediatric, CV FGF

 Spont: 2 -3x /
minute ventilation

 PPV: 220 ml/kg

(up to 20 kg)

Pediatric, SV
Pre-Operative
Assessment
 Pediatric Pain Assessment

NRS
8 yo +

Wong-Baker 3 yo +
Scale

FLACC
2 mo – 7 yo
NPO Time
- Bottled milk, formula,
feeds = SOLIDS

- Clear liquids 2 hours

before surgery:
- NO CHANGE in
Gastric volume &
PH
Estimating Weight /Height

 Weight
 Always have all medications calculated out for
patients < 20 kg
 Estimating weight
 2 x (age + 4)
 (2 x age) + 8 or 9

Breslow Tape (ED)

Monitors

Anchor to arm to prevent hyperextension

Pre-ductal vs . Post-ductal considerations
Monitors

Pediatric
Vital Signs (VS)
Venous Air Embolism
• (In order of sensitivity)
1. TEE
2. Doppler (left or right parasternal, between 2nd and 3rd rib, mill wheel murmur)
3. ETCO2 and/or PA pressure
4. Cardiac output
and/or CVP
5. Blood pressure,
EKG (RV Strain
pattern, ST
depression),
stethoscope
(least sensitive)
Preventing Heat Loss
Table Setup
Perioperative Fluid Replacement

 1st 0-10 kg → 4 cc/kg/hr

 2nd 10-20 kg → 2 cc/kg/hr
 20 kg → 1 cc/kg/hr Calculate preoperative deficit

• Replace 50% first hour

• Replace 25% second hour
• Replace 25% third hour

 Minor surgery → additional 2 cc/kg/hr

 Major surgery → up to additional 10 cc/kg/hr
 Transfusion threshold: Hgb 9-10 ( O2 consumption)
Estimated Allowable Blood Loss
(EBL)

• Blood volume
• Premies → 95 ml/kg
• Term neonates → 90 ml/kg
• Up to 1 year → 80 ml/kg
• > 1 year old → 70 ml/kg
• EABL → wt kg x est blood vol x (starting Hct- allowable Hct) /
ave Hct
Airway Management

• Water volume
• Laryngoscopy
• Blades
• – Straight most common
• Miller Phillips Wis-Hipple
• Curved available
• Fiberoptic
• Bullard Glide
ETT Tube Sizing

• ETT tube size ETT tube length

 < 2 yrs:  Neonates: 7 – 9cm
 2.5 – 3 (premature)  Other
 3 – 3.5 (neonate – 6 month)  Height (cm) / 10
 3.5 – 4.0 (6 month – 1 year)  Weight (kg) / 12
 4.0 – 5.0 (1 – 2 year)
 (Age / 2) + 12
 > 2 yrs:
 (Age / 4)
o +4 (cuffed)
o +4.5 (uncuffed)
Laryngoscopy

 Neonate to 3 months: Miller 0

 3 months to 18 months: Miller 1
 18 month- 3 years: Miller 1.5, Mac 1
 3-5 years: Miller 1.5, Mac 2
 >5 years: Miller 2, Mac 2-3

Straight blade necessary for neonates and young infants, can be used
as a Mac blade
LMA Sizing

iGel
Medication Management

• Higher doses needed for younger rather than older children

 Hepatic blood flow

 Decreased filtration until 3-4 months

 Decreased CYP450 activity

 Increased Vd

 Decreased pseudocholinesterase activity

Airway Management Table
Medication Management
Medication Management
ç
Medication Management
Medication Management
Medication Management
Emergency Medications
Perioperative Analgesia
Intraosseous (IO)

- IO kit or bone marrow bx

needle
- 1-2 cm below tibial tuberosity
- Insert with screwing motion
until lack of resistance
- Aspirate marrow to confirm
placement
- Secure needle Volume
replacement Labs
- Drug administration
Intravenous (IV) Placement

De-airing filters IV “leashes” with stopcock

 Invasive monitoring

• Require expertise and caution UA/UV may be

• CVL most often IJ or femoral considered
• A-line most often right radial artery
– Preductal - Mirrors carotid &
retinal
Pre-Term
Neonatal Emergencies
Incidences of Disorders & Syndromes

Disorder Incidence Disorder Incidence Disorder Incidence

PPH 1:20 TEF 1:3000 Biliary atresia 1:12500
Cryptoorchidism 1:50 OWR 1:3000 BWS 1:13700

Laryngeal papillomatosis 1:400 DMD 1:3000 Williams 1:20000

Congenital
Pyloric stenosis 1:500 Hypothyroid 1:4000 CCAM 1:30000
Intestinal malrotation 1:500 CDH 1:4000 SCT 1:40000
Duplication
CP 1:5000 cysts 1:4500 Prune belly syndrome 1:40000
T21 / Downs 1:800 TTTS 1:5000 KFS 1:42000
Myelomeningocele 1:1000 Graves 1:5000 TCS 1:50000

Amniotic Band 1:1200 T18/Edwards 1:5000 Sirenomelia 1:100,000

CF 1:2000 DiGeorge 1:5000 Hurlers 1:100,000

CMT 1:2500 Omphalocele 1:6000 Conjoined twins 1:100,000

Turner's 1:2500 PRS 1:8500 Crouzon 1:600,000
PDA 1:2500 CHARGE 1:12500 Apert 1:700,000
Neonatal Apnea

 Anemia
 Sepsis
 Intracranial bleeding
 PDA
 Following GA
 Hypoglycemia, hypothermia, hypoxia

• No elective procedures until 46 weeks GA, 56-60 weeks

PCA (institution-specific)
 Prematurity (GA and PCA) Anemia
 Apnea at home Weight at birth
Others
 Retinopathy of prematurity
• Hypoxia & hypercarbia
 Maintain PaO2 50-80 mmHg
 Low birth weight

 Kernicterus
• Hypoxia, acidosis, hypothermia, hypoalbuminemia
Intraventricular Hemorrhage

 Intraventricular hemorrhage
• Hypoxia & hypercarbia
• Hypernatremia
• Fluctuation of arterial and venous pressures
• Low Hct
• Rapid administration of hypertonic fluids
Bronchopulmonary Dysplasia

 Bronchopulmonary dysplasia
• Supplemental oxygen after the age of 6 months
• CXR—> cystic emphysema, fibrosis, hyperinflation; alveolar duct dilation
• Prematurity, pressure ventilation, genetics, inflammation, infection, oxygen
radicals
• Permissive hypercapnia

 PDA with pulmonary overcirculation

• PGE2 keep it open
• Starts closing at 12 hours, completely closes at 4 days, ductus arteriosis at 3
weeks
Necrotizing Enterocolitis

 Pre-mature babies, low birth weight, lack of enteral

nutrition
 Not seen in fetus
 Pneumatosis intestinal (terminal ileum, cecum, ascending
colon)
 Sudden increase in CRP / Abdominal wall distension/
erythema—> severe inflammatory condition
 Thrombocytopenia, coagulopathy, metabolic acidosis
 LLD AXR to show free air
 1/3 need surgery
Full-Term (FT)
Neonatal Emergencies
Neonatal
Resuscitation
Omphalocele & Gastroschisis

 Induce RSI / awake

• Treat acidosis when pH < 7.0
• Don’t extubate (unless staged bedside silo
placement in ICU)
• Decompress stomach
 Muscle relaxant to assist reduction
 Criteria for closure
• Intragastric or intravesical pressure <
20
• PIP < 35
• EtCO2 < 50
CDH

 Gut herniates into chest

• Left (most common ~ 90%) or right posterolateral foramen
of Bochdalek
• Anterior foramen of Morgagni
 Hallmarks
• Hypoxia
• Scaphoid abdomen
• Bowel sounds in chest
 Respiratory support

 ECMO
CDH
 NG tube
 Avoid high PPV
 Intubate
 PIP < 30
 Avoid aggressive
lung re-expansion
 Consider PTX if
sudden change in
compliance
CDH
 Cardiac defects 25%, pulmonary hypoplasia + PHTN ~
100%
 Scoliosis association

 PTX, avoid N2O

 Severe acidosis, dehydration

• Place IV in upper extremity (increased abdominal
pressure can compress IVC)
• IV fluids = D5 ½ NS

 Permissive hypercapnia, fluid resuscitation, watch PIP,

muscle relaxation
 Malrotation & Volvulus

 True surgical emergency

 Compromised intestinal blood supply

 1/3 occur in 1st week of life

 Bloody diarrhea → bowel infarction

FT Neonatal Emergencies

 Choanal atresia
• Cannot pass a 3.5 Fr catheter through nares
• Cyclical crying
 Hypoxia  crying and open mouth relieves obstruction
 relief/close mouth  hypoxia
 Rule out: neck mass, vascular anomaly, RDS, PE
 Vomiting in infants
• Non-bilious: Pyloric Stenosis
• Bilious: Duodenal obstruction, atresia, malrotation,
Meckel’s diverticulum (rule of 2’s)
Pyloric Stenosis
 4-6 weeks old
 M>F
 Persistent vomiting
 Metabolic disarray

•
orokalemic hypokalemic
•
Vomiting depletes hydrogen ions
•
Kidney compensates by excreting NaHCO3 Hyponatremia and
dehydration worsen
•
Kidney conserves sodium at expense of
• hydrogen →doxic aciduria

o Correct meta12-72 hrs to correct electrolyte deficiencies

 Na > 130, K > 3, UOP 1-2 cc/kg/hr
 Balanced salt solution, add K+ when good UOP
Sacrococcygeal
Teratomas

 Hensen’s node
• High-output cardiac failure,
pre-term delivery
• Procedure:
 EXIT vs. fetoscopic
 Middle sacral artery,
other II
branches
 Coccyx must be removed
 Injury to bowel, bladder,
and presacral nerve
plexus
Myelomeningocele

 Failure of full closure of “embryonic ridge”

 Folate deficiency
 Intubate supine with cushion, OR lateral
 Associations with AC malformation, latex allergy
• Consider if apnea, HTN
 Extracellcular fluid loss  IV fluids – balanced salt
Pediatric Issues - Anesthesia
Pediatric Pre-Operative URI
 Pre-operative URI
• Infectious vs. allergic vs vasomotor?
• Viral infection within 2 weeks
• Wheezing – 10x
 Laryngospasm – 0-5x
 Breath holding
 Hypoxemia
 Atelectasis
 PACU stay
 Poor prognosticators
• ETT – 10x
• Purulent (green) secretions + wet cough – 5x
• Smoking at home
Pediatric Pre-
Operative URI
Pediatric Pre-Operative Anxiety
 Personality: Children who are shy,
inhibited, introverted are at Increased risk

 Age > 7 years

 Children who have anxious

parents

 Prior upsetting hospital

experience

 Only children (children without

siblings)

 Children who did not attend

pre-school
Pediatric Pre-Operative Anxiety

Why treat it?

 Delay anesthetic induction and recovery
 ~ 10 % of children can have behavior problems up to 1 year after
surgery
Laryngospasm

 Stimulation of superior laryngeal nerve

 involuntary spasm
 Immediate post-extubation
 Poor depth of anesthesia, secretions, tobacco exposure,
infancy, +/- URI
 Tx: Positive pressure, succinylcholine
Post-Intubation Croup

 Cricoid > tracheal > glottic edema

 Barking cough, inspiratory + expiratory stridor
 “Steeple” sign
 ~ 3 hours post-extubation
Post-Extubation Stridor

 Glottic > cricoid edema  dexamethasone

 Large ETT  decreased by 0.5mm
 Repeated intubation  consider LMA
 Prolonged surgery  check manometry
 ENT procedures
 Excessive tube manipulation
Epiglottitis

 2yo – 6yo
 Hib, GAS
 “Thumb print” sign
 Fever, Sore throat, dysphagia, drooling, inspiratory stridor,
leaning forward/tripod, NO COUGH/rhinnorhea
 Prep: DL, bronchoscope, ENT on standby, ASA monitors
applied
 Induction: Inhalational, CPAP 10-15 cm H2O, no muscle
relaxants, + atropine
 Intubation: ETT 1-2mm smaller, chest compressions to
visualize glottis,keep ETT in place until swelling subsides
 Abx therapy (i.e. ampicillin)
Foreign body Aspiration/Ingestion
 Acute onset Ingestion
 Toxic: Nuts, lithium batteries
 Supraglottic/glottic
 Stridor

 Subglottic
 Wheezing o Location of FB
 Esophageal  Bronchus: either, but initiate
 IV induction/RSl PPV is dislodged in trachea
 Age < 6 and battery 15mm or larger with resultant complete
 +magnet
 GI sx obstruction during removal
 >4 days without passing it  Trachea: spontaneous
ventilation
 Above vocal cords: RSI
Pediatric Issues - Other
 Natural upper airway obstruction
 Pharyngeal dilator muscle collapse + genioglossus

 Periodic breathing (5-10s)

 93% PT / 78% of FT
 Normal

 Propofol infusion syndrome

-  in neonates > pediatrics > adults
- 90 mcg/kg/min x > 8hrs
Cleft Palate Associations

 PRS
 DiGeorge
 Klippel-Feil
 Turners
 Apert
 Treacher Collin
 Goldenhaar
Pierre Robin Sequence
 Mandibular hypoplasia  posterior/downward retraction 
OBSTRUCTION

 Abnormalities
• Micrognathia Glossoptosis
• Airway obstruction +/- cleft palate

 Associations
• SticklerTreacher Collins
• FAS 22q11 / VCF

 25-50% surgical
• Lip/tongue adhesion
• MDO
• Trach/PEG
Trisomy 21

 Macroglossia, Tonsillar & adenoid hypertrophy,

OSA
 Short neck, AO instability (9%), Small trachea
 CHD (50%)
 (endocardial cushion defects/AV canal > ASD >
VSD, TOF)
 PHTN
 Developmental delay, hypotonia
VATER / VACTERL
o Gastrostomy,
o fistula ligation,
o esophageal anastomosis
THANK YOU