138  Review Articles Medical Education

M. Jöhr
Principles and practice
of paediatric anaesthesia

Summary
General aspects
Anaesthetic risk is markedly higher in
children than in adult surgical patients. Concerns of the anaesthetist
To make correct decisions in daily General anaesthesia of small children
clinical work, it is therefore imperative puts an unusual strain on many anaes-
to possess basic knowledge of airway thetists; they are not familiar with the
management, the cardiovascular system small dimensions and the manual basics
and fluid therapy. Young children have a
of the discipline – such as intravenous
relatively active metabolism with high
access and intubation – suddenly be-
oxygen consumption. Apnoea tolerance
come difficult procedures. The fact that
is very limited. Desaturation can only
these patients are children, afraid and
be avoided by ventilating the child. The
often lacking compliance, accounts for
modified approach of rapid sequence in-
additional stress. Furthermore, anaes-
duction is becoming generally accepted.
thetists who usually do not take care of
Beyond neonatal age, cuffed tubes are
children or work in paediatric hospitals
widely used. When using a laryngeal
on a regular basis are often confronted
mask airway, an L-shape is advan­ -
ta­geous. Special attention should also be with questions and problems they never
given to blood pressure and perfusion have been asked to solve before, at least
because hypotension may have serious not in this particular age group, and the
consequences. If necessary, vaso­ active unknown causes fear.
drugs are indicated in pae­diatric patients
as well. The normal values for blood A familiar situation causes less fear,
pressure are age-dependent. The number and experience is useful – but the
of veins which can be easily punctured timely analysis of a problem can also
is often very limited, especially in help.
infants and chronically-ill children, but
anaesthesia without venous access must
remain an ultima ratio. Hyponatraemia The child‘s risk
is a latent threat, so that only solutions
The risk of general anaesthesia in
with a physiological saline concentra-
children is markedly higher than in
tion should be used. Altogether, daily
paediatric anaesthesia practice can be adults, although healthy children
The author declares the absence of any
markedly improved. “Good anaesthe­ without comorbidity are usually in- conflict of interest.
sia“ with perfection in every detail volved.
and maintained homeostasis is in the Keywords
focus of interest; differences between Complications such as cardiovascular Paediatric Anaesthesia – Air-
compounds or techniques as well as arrest [1,2] and airway problems are way – Circulation – Complica-
the theoretical question of neurotoxicity more common; it is assumed that the tions – Homeostasis
are of minor importance. occurrence of anaesthesia-related fatal
 Medical Education Review Articles 139

outcomes is 10 times higher in children • The large head, in particular, causes • The child doubles birth weight by
than in adults [3]. Obvious endpoints the potential for loss of body heat. five months,
such as cardiovascular arrest with fatal • Blood loss in children is latently • triples it by one year,
outcome are probably only the tip of underestimated. An isolated cranio­ • quadruples it by two years.
the iceberg – and severe disorders of cerebral injury – as opposed to adults
homeostasis with imponderable conse- – might lead to a hypovolemic shock
due to blood flowing into the galeal Whenever possible, therapy should
quences are still tolerated all too often. be based on the currently-measured
aponeurosis or into the cranium.
Much can be improved in the everyday body weight.
practice of children‘s general anaesthe- Tab. 1
sia – the so-called SAFETOTS Initiative Equation for estimating body weight (b.w.).
Equations to estimate body weight (Tab.
(SAFE ANAESTHESIA FOR EVERY TOT)
Age Equation 1) can be useful in emergency situations
refers to the necessity of perfection in the
Babies b.w. = (age in months + 9) : 2
and for preparing oneself mentally for
detail and maintenance of homeostasis
anaesthesia – especially if the patient has
[4]. The ”good anaesthesia“ stands in Children b.w. = (age in years + 4) x 2
not yet been seen, e.g. upon announce-
the centre of interest, and differences
ment that “the emergency physician is
between drugs or procedures or even
Length, weight and age bringing in a nine-month-old child.“
the question of neurotoxicity lose their
The anaesthetist should be able to esti­‑ External information might be useful to
importance.
mate whether the length/height and body determine the age in emergency situa-
weight (b.w.) of a child matches its age: tions (Tab. 2).
The common goal of paediatric
general anaesthesia is to achieve
”good anaesthesia“ while main- Tab. 2
taining homeostasis. Age determination and tube selection in emergency cases.

Finding Likely age Tube size

Structural changes including the transfer
Baby without teeth Less than 6 - 8 months 3.0 with cuff
of very young children to specialised
centres and treatment delivered by espe­ Baby with open fontanel Less than 18 - 24 months 3.5 with cuff
cially-experienced physicians, aiming for Toddler with diapers and apparently normal development Less than 4 years old 4.0 with cuff
high institutional and individual com- Child with missing frontal teeth 6 - 7 years old 5.0 with cuff
petence, are the subject of professional
and socio­political discussion. But, every
anaesthetist should be capable of anaes-
Fig. 1
thetising an older child for a common
intervention, with deliberation and as­‑
suredness, and bridging emergency
cases until help arrives.

The body of the child

Basic considerations
Babies have proportions which are dif-
ferent to those of adults; relatively, they
have a large head, a large abdomen, a Shoulder bolster
small chest and small limbs. This has (not visible)
clinical implications not only when it
comes to the evaluation of burns, but
also in other areas:
• The large, heavy head is unstable in
the supine position; here, a head ring
will be useful (Fig. 1). Due to the large Head ring
head, the intubation cushion is “built
A head ring stabilises the position of the head and facilitates the induction of general anaesthesia in
in”, but a bolster for the shoulders or children. The shoulders are supported by a rolled towel (not visible).
neck would instead be necessary.
140  Review Articles Medical Education

In addition, the anaesthetist should be the typical temperature rise in pro- Tab. 4
able to estimate whether the child‘s longed anaesthesias without exces- Time in seconds (s) until SpO2 without pre-
development is in agreement with its sive losses. oxygenation reaches 50 percent of the maxi-
age; smiling by 6 weeks, head-raising mum decline rate and then rapidly declines
further. Data derived from Nottingham phy­
by 2 months, eyes following movements
• An active heat supply is not regularly siology simulator [7].
by 3 months, sitting by 6 months,
required in the case of prolonged ear, SpO2 = arterial oxygen saturation determined
standing by 9 months, and walking by pulse oximetry.
nose and throat (ENT) interventions.
by 12 months. The anaesthetist should
• In examinations carried out by way Age Time
pay attention to speech development,
of magnetic resonance imaging
inquire about feeding (breastfeeding,   1 month 6.6 s
(MRI), the energy supply from the
bottled milk, at the table) and perhaps   1 year 10.8 s
magnetic field accounts for the fact
school attendance.   8 years 15.0 s
that infants do not become hypo-
thermic despite the cold environment 18 years 31.2 s
Thermoregulation
Newborns are already capable of ther- (without additional measures) – how-
moregulation and try to control the core ever, the hyperthermia feared by the
temperature of their bodies (BCT) – how- radiologists does not occur [5, 6].
High oxygen consumption despite
ever, their relatively large body surface Newborns, however, in the author‘s
small reserves results in a short
and thin skin facilitate heat loss. experience, do become hypothermic
apnoea tolerance [7].
during the course of an MRI examina-
tion. MRI examinations constitute a
The core temperature should be • Even short-term apnoea in a young
case of exception with respect to
measured or be known before, during baby inevitably results in a decline
thermoregulation.
and after the general anaesthesia of of SpO2 (arterial oxygen saturation
a child; an active supply of warmth determined by pulse oximetry) and
is advisable while the operation is in Respiratory system, airway- arterial oxygen content (Tab. 4).
progress. management and ventilation • Induction techniques, as well as di-
agnostic and therapeutic procedures
• Convective warming systems such as Special physiological and with phases of apnoea are not appro-
priate and potentially hazardous for
the Bair-Hugger™ or Warm-Touch™ anatomical features
small children [8].
have proven useful and should be Small children have a very active • The modified rapid sequence induc-
applied to all children weighing metabolism as characterised by a high tion (RSI) including pre-oxygenation
less than 5 kg, and regularly to older oxygen requirement and large alveolar and mask ventilation observes all
children undergoing interventions of ventilation (Tab. 3). The functional precautionary measures of a rapid
longer duration. residual capacity (FRC) is small; it is and deep induction; however, the
• Fever is a common symptom en- also relatively small in proportion to the children are ventilated, effectively
countered in children and it is essen- total lung capacity, because the still very oxygenated and subsequently intu-
tial that the anaesthetist is aware of elastic ribcage follows the lungs into the bated without hastiness. This devel-
what the child‘s BCT has been during expiration position. opment is an essential step forward
the intervention.

Tab. 3
Children with development disor-
Respiratory handicaps in childhood.
ders, e.g. cerebral palsy, have a slow- PEEP = positive end-expiratory pressure.
er metabolism and rapidly become
hypothermic. Facts Consequences
High oxygen consumption High consumption despite limited reserves results
(6 - 10 ml/kg b.w./min.) in a short apnoea tolerance
• The author‘s practice in cases like
Huge carbon dioxide production Extensive alveolar ventilation
these is to increase the temperature
Small functional residual capacity (FRC) – Limited reserves
of the theatre and invariably use two
absolute and relative
Bair-Huggers™ for supplying ”top and
Large closing capacity Strong tendency toward atelectasis formation –
bottom heat“. sufficient PEEP is essential
Narrow airway, unstable thorax, immature Designed for drinking, digesting and growth –
The active metabolism with huge respiratory muscles higher demand is not intended
endogenous heat production explains
 Medical Education Review Articles 141

towards a safer treatment of children Orotracheal or nasotracheal intubation

Tab. 5
and has proven its worth in clinical The three causes of difficulties in airway
routine work. management. The dislocation of the tube presents
In a clinical series, every second new- a problem – nasotracheal intubation
Cause Comments and permits a reliable fixation and thus
born desaturated after more than one proposed solutions
minute under 90% SpO2, and every decreases the risk.
1. Lack of Beginners work under
fourth after more than one minute under experience supervision; video-
80% SpO2 [9]. This must not necessarily laryngoscopy for It is therefore the author‘s practice to
have serious consequences, however, it instruction perform nasotracheal intubation on
shows that small children often approach 2. Inadequate Textbooks and courses, new-borns and babies, provided that
the potentially hazardous range. material standards and check the intervention allows for it. The risk
lists; optimal prepara­-
of haemorrhage is minimal in this age
Airway management using tion of instruments
group due to the absence of adenoids,
a tracheal tube 3. Great time Appropriate procedures
and long-term nasotracheal intubation
pressure and algorithms help to
Basic considerations optimally utilise the is also possible without the maxillary
short time available sinus problems often appearing in adults.
Airway management problems are On the other hand, other hospitals
carry out sophisticated interventions on
often the cause of serious complica-
orally-intubated newborns which are
tions. The smaller the child, the more ”children‘s teams“. Occasionally, it is
subsequently transferred to the intensive
often intubation becomes dif- demanded that all small children be in-
care unit this way.
ficult (Fig. 2). tubated invariably (rather than ventilated
via laryngeal mask airway) in order to Tracheal tube with or without cuff
Essentially, there are three reasons for create sufficient training opportunities for
The previous, very emotional discus-
this (Tab. 5). It is hard to compensate physicians who require practice, some-
sion on the significance of blocked
for a lack of experience. Possible ap- thing which profoundly contradicts the
tubes for the general anaesthesia of
proaches to a solution are the transfer author‘s opinion that every child should
children has abated to a great ex-
of newborns and babies in particular to get the best possible anaesthesia – and
tent. In neonatology, unblocked
hospitals that have pertinent experience, that oftentimes consists of a laryngeal
tubes are used nowadays almost
optimised advanced training and su- mask airway and not a tracheal tube without exception, whereas regularly
pervision, and/or the establishment of [10]. blocked tubes are applied in older
children.
Fig. 2
These tubes have considerably facilitated
airway management for the anaesthetist
responsible for e.g. older children in
matters concerning ENT. If the age
recommendation printed on the pack-
age is followed, the primarily-chosen
MicroCuff® tube will almost always fit,
a tube change will hardly ever become
necessary and postoperative stridor
does not occur more frequently [11].
However, neither does this apply if
Eyelid retractor actions are taken against the recom-
mendation; nor is the MicroCuff® tube
the right choice for newborns weighing
less than 3 kg b.w. It is also associated
with an increased incidence of stridor
[12].

The size of the tracheal tube depends

particularly on the child‘s age. The
The intubation of newborns and babies is difficult, for example, because of the existing narrow spa-
tial conditions; an eyelid retractor improves the insight of the examiner considerably and is regular- same also applies to nasotracheal
ly used at the Paediatric Hospital in Lucerne (inspired by Dr. Jörg Schimpf, Augsburg). intubation.
142  Review Articles Medical Education

Tab. 6 Tab. 8
Tube table for premature infants, newborns, babies and children up to 12 years of age. The optimum position of the tube tip.

Age and/or weight Tube without cuff Tube with cuff Oral insertion depth Age Optimum tube tip
position
Premature infants <600 g 2.0 - 2.5
Newborns 2 cm above the carina
Premature infants 1 kg 2.5 7 cm
tracheae
Premature infants 2 kg 2.5  - 3.0 8 cm
5-year-olds 3 cm above the carina
Newborns 3 kg 3.5 3.0 with cuff 9 cm tracheae
3 kg - 4 months 3.5 3.0 with cuff 10 cm Adults 4 cm above the carina
tracheae
4 months - 8 months 4.0 3.0 with cuff 11 - 12 cm
8 months - 2 years 4.5 (>1 year) 3.5 with cuff 12 - 13 cm
2 years - 4 years 5.0 4.0 with cuff 13 - 14 cm
In the case of newborns, the ”1, 2, 3
4 years - 6 years 4.5 with cuff 14 - 15 cm
kg – 7, 8, 9 cm rule“ is helpful; there
6 years - 8 years 5.0 with cuff 15 - 16 cm are equations that apply to older children
8 years - 10 years 5.5 with cuff 16 - 17 cm (Tab. 9).
10 years - 12 years 6.0 with cuff 18 - 19 cm The author is convinced that the Micro
Cuff® tubes adapted to children have
advantages, particularly in ENT appli-
• Tables are available for newborns lesions than minimal pressure just cations. If the tube is inserted to the
and babies in particular (Tab. 6). preventing leakage, as the flaccid corresponding mark, the size will fit and
• Equations may also be used after low-pressure cuff might flap back tube tip will never be too deep, provided
completion of the first year of life and forth with each breath of air and that the age recommendation printed on
(Tab. 7). thus injure the mucosa. the package is observed [15].
• In the case of children with develop-
ment disorders (e.g. 14 years / 12 kg Position of the tracheal tube
Tab. 9
b.w.), the tube size should preferably The expected insertion depth of the tube.
An optimal position of the tube‘s tip
be chosen according to age and not b.w. = body weight.
prevents both accidental extubation
to body weight – because of the
age-dependent growth of larynx and endobronchial intubation in the Age/weight Insertion depth
and trachea. event of position changes. Newborns 1, 2, 3 kg b.w. -
7, 8, 9 cm rule
The tube size is selected in such a • Inclination of the cervical spine will 1 kg 7 cm
manner that a small leakage occurs make the tube tip descend deeper, 2 kg 8 cm
without inflation of the cuff. After- whereas reclination will move it 3 kg 9 cm
wards, the cuff is blocked with a towards the plane of the vocal cords > 1 year, oral 12 cm + ½ cm per year
pressure of 20 cm H2O. – in a baby ± 1 cm, in a ten-year-old Nasal + 20%
child ± 2 cm [13]. Example: 2 years: 13 + 2.6
• A completely deflated and thus • The trachea of a term infant mea- = ca. 16 cm
ribbed cuff increases the risk of sures 4 cm in length; in this age class,
damaging the tracheal mucosa.
the objective is to place the tip of the
• Routinely blocking with 20 cm H2O
tube in the middle of the trachea
Airway management using
appears to cause fewer mucosal
(Tab. 8).
laryngeal mask airway
• In case of laparoscopic interventions, Basic considerations
Tab. 7
the pneumoperitoneum – especially
Equations to calculate the tube sizes in The laryngeal mask airway (LMA) is
children over 1 year of age. when performed in a head-down
associated with fewer postoperative
position – causes a relevant descent
Tube type Equation for internal complications than exist in endotra-
of the tube tip [14].
diameter in mm cheal intubation [16] and should be
With cuff 3.5 + (age in years : 4) taken into consideration whenever
Example: 6 years = 5.0 The expected insertion depth of the the risk of aspiration is not elevated
Without cuff 4.5 + (age in years : 4) tube should be known before induc- and excessive airway pressures are
Example: 2 years = 5.0) tion of general anaesthesia. not expected.
 Medical Education Review Articles 143

In the induction phase, it seems to provide

Fig. 3
protection against problems such as ob-
struction and desaturation as well, since
the airway can be secured very early and
even in moderately-deep general anaes-
thesia. On the other hand, the LMA and
other supraglottic airway devices have an
increased dislocation tendency as long as
the child possesses an anatomy optimised
for milk drinking. This speaks in favour of
a restrictive indication for newborns and
babies, whenever the access to the air­‑
way cannot be assured during the opera-
tion or complex positioning is necessary.
Nevertheless, the LMA is increasingly
chosen as the primary option in emer-
gency medicine – including the resus­
citation of newborns – unless physicians
with experience in paediatric anaesthe-
siology are available on site. Ventilation
proceeds with a higher efficiency than
L-shaped laryngeal mask airways have a lower dislocation tendency in children and should be pre-
with a face mask and the risks of endotra- ferred over the classical laryngeal mask.
cheal intubation (e.g. false intubation,
airway trauma or the necessity of a deep
general anaesthesia) cease to exist.
Tab. 10
Choosing the right laryngeal mask airway Choosing the right laryngeal mask airway (LMA). The tube (without cuff) as well as fitting gastric tube
The LMA in L-shape (Fig. 3) – such as matching with the respective LMA are shown. Ch. = Charrière; ID = internal diameter in mm.
LMA Supreme™ and Ambu® AuraGain™
Body weight LMA Size Tube (without cuff) Gastric tube for LMA
etc. – seem to have a lower disloca- Supreme™/
tion tendency in younger children as AuraGain™
compared to the classical LMA. LMAs 2-5 kg 1 3.0 ID 6 / 6 Ch.
possessing a channel designed for gastric
5-10 kg 1.5 3.5 ID 6 / 8 Ch.
tube placement probably provide an
additional safety measure since the inlying 10-20 kg 2 4.0 ID 10 / 10 Ch.
tube helps to prevent the dislocation of 20-30 kg 2.5 5.0 ID 10 / 10 Ch.
the LMA‘s tip from the upper oesophageal 30-50 kg 3 6.0 ID 14 / 16 Ch.
sphincter like a Seldinger guide wire. On
50-70 kg 4 14 / 16 Ch.
the other hand,, the i-gel®-LMA – well
suited for adults – has a high dislocation >70 kg 5 14 / 16 Ch.
tendency in babies and infants and cannot
be recommended [17].
• Choosing the right size traditionally
depends on the patient‘s body weight of a difficult intubation, provided Pushing the tube forward blindly is not
(Tab. 10), but is also determined by that the patient‘s mouth can be likely to produce the desired result [20].
the experience of the anaesthetist. opened and using an oral tube has Intubation through the LMA Supreme™
• The size of the patient‘s ear might been intended [19]. is impossible. The matching sizes of
give indication of size regarding clas- tube and LMA must be determined and
sical LMA [18]. known beforehand in every institution.
• The cuff pressure should be limited It is the author‘s method of approach to
to 40-60 cm H2O • introduce a tube into the trachea Ventilation
through the LMA using fibre-optics, Basic considerations
Laryngeal mask airway for fibre-optic
• subsequently remove the primarily-in-
intubation
troduced tube together with the LMA Tidal volume (6-8 ml/kg b.w.) and
A fibre-optic intubation through the using an exchange catheter, replacing airway pressures are similar in all
LMA is the method of choice in case the tube with the correct one. age groups. A greater alveolar venti-
144  Review Articles Medical Education

lation (in ml/kg b.w./min.) – and the • Air-flow curves permit an optimisa- parts of the body amounts to about 25
respiratory minute volume related tion of the inspiration time; a typical mmHg. When breathing begins and the
hereto – is achieved by a higher res- value for newborns is 0.5 s, for in- lungs expand, the vascular resistance of
piration rate. fants 1.2 s and for adolescents 2 s. the lungs decreases, the right-left shunt
Constant-volume flow-adapted venti- ceases to exist and the SpO2 rises suc-
lation modes are successfully applied cessively [21]:
In line with the awake child, the follow-
in babies and infants. The author uses
ing respiration rates are chosen: The preductal SpO2 is at 60% one
them intraoperatively, mainly to balance
• Newborns: 40/min., minute after birth, at 70% after 3
the inconsistent pressure of the surgeons
• 1-year-olds: 30/min., minutes, and at 80% after 5. A value
on chest and abdomen, but not for
• 10-year-olds: 20/min., of 90% is reached after 10 minutes.
induction or positioning – in this phase,
• Adolescents (and adults): 14/min. a bent tube, for example, should not be
Spontaneous ventilation is acceptable compensated automatically (and thus Myocardium and cardiac output
during general anaesthesia, provided unnoticed) by the respirator with higher
that airway resistances are low and ventilation pressures. As compared to an adult, the myocar-
drug-induced respiratory depression dium of the newborn and baby in
The respiratory minute volume is se-
must not be feared, for example, in cases particular contains fewer contractile
lected by adjustment of the respiration
when superficial inhalation anaesthesia elements and the compliance of the
rate and to a lesser extent of the tidal
and regional anaesthesia are combined. ventricles is lower – the cardiac out-
volume in such a manner that – at least
Otherwise, assisted and/or controlled put consequently depends predomi-
in a child without intracranial pressure
ventilation modes are applied. nately on the heart rate and less on
or pulmonary arterial hypertension –
an increase of inotropy.
high-normal to moderately-increased
Recruitment
end-tidal carbon dioxide values in the
range of 45 mm Hg will result. The positive inotropic effect of cate-
After securing the airway with a cholamines is thus lesser than in adults.
tube or LMA, a recruitment ma- A high inspiratory oxygen concentration
Under physiological conditions, how-
noeuvre should be carried out regu- is selected during induction for pre-
ever, there is no demand for an increase
larly in newborns and babies – and oxygenation. At the Paediatric Hospital
of inotropy or a massive increase of oxy­
in older infants most often – in order in Lucerne, FiO2 after completed
gen supply to the organs – nature calls
to expand atelectatic lung segments. airway management for newborns is
for drinking, digesting and growing, not
usually at 21-25% and for larger children for greater physical exertions.
at 30-60%; for extubation at 80%.
This is performed at the Paediatric Inhalation anaesthetics exert a much
Hospital in Lucerne either carefully by stronger cardiodepressive effect in new-
hand (when a LMA is in use) or with the Cardiovascular system and borns than in older children. This sen-
ventilator (in an intubated infant) using an blood pressure limits sitivity is opposed by a relatively high
adapted Lachmann manoever, whereby minimal alveolar concentration (MAC
a peak pressure of 30 cm H2O and PEEP Special physiological and value), at which one half of the patients
(positive end-expiratory pressure) of 20 anatomical features no longer responds to pain stimuli: the
cm H2O are applied over five respiratory heart is sensitive, the brain resistant.
Foetal blood circulation
cycles. During the entire duration of
In the foetus‘s circulatory system, the
anaesthesia, PEEP of at least 5 cm H2O is The leading cause of bradycardia is
blood which has been oxygenised in
regularly maintained, even when a LMA the placenta and loaded with nutrients hypoxia – this must be taken into
is used. flows through the umbilical vein to the consideration first.
inferior vena cava and the right atrium,
Respirator settings
from where the major proportion passes • Other causes (e.g. opioids or the
A pressure-controlled ventilation mode oculocardiac reflex) may be con-
over to the left atrium by the open oval
(PCV) is usually applied in paediatric foramen and reaches the foetal organs sidered only after hypoxia has been
anaesthesia. via the left ventricle. Ninety percent excluded.
• In children with healthy lungs, a peak of the small amount of blood which • In case of children with trisomy 21,
pressure of 14 cm H2O with PEEP of passes into the right ventricle is led induction with sevoflurane typically
5 cm H2O can be initially set in all by Botallo‘s duct into the descending leads to bradycardia – even without
age groups. aorta while bypassing the lungs. Under hypoxemia. The reason for this is
• The respiration rate is set according these conditions, the partial pressure unknown, the bradycardia seems to
to age (see above). of oxygen (pO2) in the best oxygenated be temporary and benign [22].
 Medical Education Review Articles 145

• Malignant tachycardiac arrhythmias

Fig. 4
appear only seldomly in children:
”a child‘s heart does not fibrillate.“
Exceptions are, for example, children
with myocarditis, hyperkalaemia, or
hereditary long-QT syndrome [23].

The high oxygen demand of the in-

fant (kg b.w.0,75 x 10 ml/min) requires
a high cardiac output.

The cardiac output of a baby lies at 250

ml/kg b.w. /min., whereas it amounts to
approx. 70 ml/kg b.w./min. in an adult
– the blood volume of a baby circulates
three times per minute, that of an adult
only once per minute. This has a massive
impact on pharmacokinetics:
• The distribution of drugs proceeds
Extremely delayed capillary refilling in a premature infant 10 s after thumb pressure release as a sign
very fast and the plasma levels de-
of massively impaired perfusion.
crease rapidly.
• As a result, higher doses are needed
in general – as compared to an adult
– to reach the same concentrations an indwelling central venous catheter,
Tab. 11
at the site of action. the central venous oxygen saturation Lower physiological boundaries of the
• The time until maximum effect sets can provide valuable information as to systolic pressure in awake children.
in (”time-to-peak“) is shorter. whether the global perfusion is sufficient
Age Systolic pressure
[24].
Blood pressure and perfusion Term newborns 60 mm Hg
The standard reference values for blood
Basic considerations Babies 70 mm Hg
pressure are age-dependent and defined 1-2 months
The tissues of the body depend pri- with only little accuracy. They rely on Infants 70 mm Hg +
marily on a sufficient supply of the systolic pressure – mostly for histo- 1-10 years (2 x age in years)
oxygen and thus on a sufficient per- rical reasons – because the mean arterial infants 90 mm Hg
fusion – the blood pressure level is pressure (MAP), which is of primary >10 years

secondary. However, a certain mini- interest, could not be measured exactly

mum blood pressure is necessary to before the introduction of oscillometric
guarantee sufficient perfusion espe- blood pressure measurement in the
Doing without blood-pressure mea­
cially in organs possessing autoregu- 1980s.
surements in shorter anaesthesias of
lation of the blood flow (e.g. the • MAP value (in mmHg) corresponding children, as used to be common
brain). to the gestation age (in weeks) is of- practice in the past, can no longer
ten demanded for premature infants. be advocated with good conscience
The actual organ perfusion interest can- • As premature birth does not con- – the blood pressure should be mea­
not be measured directly in the clinical stitute a physiological condition, sured in every anaesthesia of a child.
routine situation. Only surrogate param- standard values do not exist. At best,
eters are available; next to perfusion of there are values to aim for. Older
the skin, estimable by capillary refilling Low blood pressure as a risk
measurements suggest that cerebral
time (Fig. 4), the blood pressure is the autoregulation in non-anaesthetised
most important parameter. Low blood pressure values are asso-
premature infants is retained up to
ciated with serious consequences
In addition, there are metabolic pa- an MAP value of 30 mm Hg [25].
[26], particularly when they appear
rameters such as lactate concentration • For older children (Tab. 11), the crite- in combination with hypocapnia
in plasma and base excess (BE) which ria applicable to the resuscitation of [27].
must be observed. In the presence of children are often drawn upon.
146  Review Articles Medical Education

ferential diagnosis must always be taken

Fig. 5
into consideration.
• In case of additional regional an­ -
aesthesia, the requirement of anaes-
thetics is not seldomly overestimated
and inappropriately-deep anaesthe-
sia is applied.
• Concomitant diseases, which might
NIRS sensor induce strong hypotension, are e.g.
heart disease, anaphylaxis, tension
pneumothorax or cortisol deficiency,
but also cardiovascular suppression
by auto-PEEP due to excessive intra­
thoracic pressure.

If other causes are ruled out, infu-

sion therapy will usually be given
Axillary cava priority over administration of vaso-
catheter active substances and catecho­
lamines.
The oxygen concentration in brain tissue of this premature infant weighing 1,050g is being monitored
by near-infrared spectroscopy (NIRS), in addition to blood pressure.
Infusion therapy and its special circum-
stances will be described separately in
the next section.
Low blood pressure values occur very • For small children, the target-MAP is
often in the period after induction before >50 mm Hg, a MAP <40 mm Hg Apart from fluid supply, children also
the onset of surgery [28]. The decisive must be urgently treated. might need vasoactive substances and
question is about the minimum accept- • In school children the target-MAP catecholamines, the selection of which
able blood pressure. is >60 mm Hg, a MAP <50 mm Hg is often determined by personal ex­
• The proposed reliance on tolerating a perience and established local practice.
must be urgently treated.
• Bolus injections of 0.1 mg/kg b.w.
maximum decline of 20% or 30% of
Practical procedure in cases of ephedrine IV, for example, usually
the initial blood pressure [29] is diffi-
hypotension produce only a small and temporary
cult because it is often impossible to
improvement.
determine a reliable initial value in a
In case of low blood pressure, gener- • In Germany, cafedrine/theodrena-
baby or infant prior to the induction
al conditions such as anaesthetic line (Akrinor®), which has vasocon-
of general anaesthesia.
strictive as well as positive inotropic
• Measurements of cerebral blood depth and concomitant diseases must
actions, is frequently used as a bolus
circulation under 1 MAC sevoflurane be examined, followed by applica-
injection.
anaesthesia suggest that the lower tion of fluid and vasoactive sub-
• A case of protracted hypotension re-
autoregulation boundary in babies stances, if required (Tab. 12).
quires a continuous supply of medi-
younger than 6 months is reached at cation by means of a syringe pump.
a mean arterial pressure of about 40 Although a relative volume deficiency The infusion of dopamine (5-10 µg/
mm Hg [30]. will prevail in most cases, a broad dif- kg b.w./min. IV) is almost always
• The oxygen saturation measured with
near-infrared spectroscopy (NIRS;
Fig. 5) in brain tissue seems to decline Tab. 12
only when blood pressure values are Practical procedure in the case of hypotension in children.
somewhat lower [31;32]. Measure Comment
In the author‘s view the following thresh- Review of general conditions Anaesthetic overdose, concomitant disease
old limits appear to be practicable: Fluid supply 10 ml/kg b.w. plasma-adapted electrolyte solution,
• The target MAP for term newborns perhaps repeated 2 or 3 times
and babies is >40 mmHg; a MAP of Vasoactive substance e.g. dopamine, 5-10 µg/kg b.w./min.
<30 mmHg must be urgently treated.
 Medical Education Review Articles 147

successful. Dopamine is well estab­

Fig. 6
lished in paediatric medicine; the
substance enhances the cardiac
output and produces vasoconstric­
tion in higher doses. The accompa-
nying tachycardia and subsequent
increased cardiac output is almost
always appreciated in children.
The arrhythmogenic potential does
not present a problem outside of
paediatric cardiac anaesthesia,
and the endocrine effects are not
clinically relevant. Thus, the rea-
sons which have largely expelled
dopamine from adult medicine do
not apply to children. Furthermore,
dopamine can be safely applied
through peripheral veins.
• Instead of dopamine, other institu­
tions use a combination of dobu­
tamine (positive inotropic) and
noradrenaline (mainly vasoconstric- Examples of light sources with LED technology, which may be used for puncturing the veins of the
dorsum of the hand in babies and infants. Attention: Common flashlights or even cold light sources
tive) or adrenaline alone (positive might cause severe burns.
inotropic and vasoconstrictive).

Infusion therapy
If venous access fails in a case of There are situations in which only
Vascular access emergency or appears to be futile the best should carry out the punc-
Basic considerations right from the start, intraosseous ture, and trainees must stand back.
While successful peripheral vein (IO) access is required.
access in adults belongs to the basic • In the case of children receiving
skills of an anaesthetist, the same Nowadays, the EZ-IO® drill is almost medical treatment over a longer pe-
procedure in a child may turn out exclusively used for this purpose [34]; riod of time and requiring repetitive
to be very demanding. Even under the use of injection guns, special needles vein punctures while awake, easily-
optimal conditions – in anaesthetised with holders or thick metal cannulas is punctured veins, e.g. on the dorsal
children with experienced personnel at limited to exceptional cases. For severely surface of the hand, should be spared
a paediatric hospital – vein punctures ill children, the IO access can be used in an anaesthetised child. Alternative
do not succeed on the first attempt in to induce general anaesthesia in cases puncture sites can often be found on
20-30% of the cases; in children under of emergency [35], e.g. postoperative the trunk of the body, the wrists, or,
one year of age the failure rate is even tonsil bleeding or in a highly septic child. in cases of exception, on the scalp.
50%. Ultrasound and optical devices • Furthermore, it must always be re-
can help, but successful puncture The ”capital of veins“ considered whether venous access
depends primarily on the experience The number of veins that can be easily or blood samples are really neces-
and skill of the anaesthetist. Trans- punctured – the ”capital of veins“ – is sary – for example, an infant with
illumination by means of LED techno­ often limited, especially in babies and febrile convulsion needs neither
logy is very helpful for puncturing the chronically-ill children. In this context, an intraosseous cannula nor an
veins of the dorsum of the hand of babies it is of particular importance that the intubation. Infants with isolated
and infants (Fig. 6). Infrared devices (e.g. last available vessel is not entirely dam- fractures will probably receive anal­
AccuVein®), do not increase the success aged by an inexperienced colleague. gesia faster by way of nasal drug
of puncture [33], but they are useful for The provision of optimum conditions is application than by the attempt
training purposes and for locating the already important on the first puncture to gain intravenous access under
best puncture site. attempt. difficult conditions.
148  Review Articles Medical Education

disease, accident, operation – or stress metabolised to bicarbonate in the

Food for thought: Many anaesthe- – an increased amount of antidiuretic body, prevents dilution acidosis.
tists still exploit the veins of their hormone (ADH) is released and the • The addition of 1% glucose (10
patients in the same way that man- excretion of water limited. mg/ml; a rate of 10 ml/kg b.w./h
kind exploits the planet’s resources. is equivalent to a dose rate of 1.66
The exclusive supply of free water by mg/kg b.w./min.) helps to prevent
The question of whether vascular access means of infusion solutions or exces- low blood sugar concentrations and
is necessary in every elective general sive drinking results in hyponatremia catabolism.
anaesthesia of a child is a matter of con- with consequences which are poten- These solutions have already gained
troversial debate. Looking at it unemo- tially fatal – hyponatremia is a con­ acceptance in emergency and intensive
tionally, an inhalative induction is often stantly impending lethal risk in paedi- care medicine and will probably replace
possible – and experienced colleagues atric acute medicine. 0.9% NaCl to a great extent [45].
report that they occasionally carry out
short-term anaesthesia without vascular As a rule, children are also designed
access. Longer general anaesthesia, e.g. There are innumerable reports about for intermittent food uptake: a con-
for dental treatments, also proceed at children who have died as a result of tinuous glucose supply is therefore not
certain centres – in highly professional hyponatremia caused by inadequate absolutely necessary for babies and
environments – routinely without vas­ infusion therapy [42]. A fatal course infants. However, some children who
cular access [36]. On the other hand, within 24 hours – still in the immediate are ill or were fasted for a longer period
absent or lost access is often the be­‑ perioperative environment – is possible can develop very low blood sugar lev-
ginning of a downward spiral for an in- [43]. The understanding that only els, become catabolic and display an
experienced colleague. For this reason, infusion solutions with a physiological increase of free fatty acids and ketone
only very experienced colleagues should sodium concentration can help avoid bodies [46]. This can be prevented by
perform general anaesthesia without serious hyponatremias has prevailed in a moderate glucose supply of 1-2 mg/
vascular access and in exceptional cases paediatric medicine as well [44]. In kg b.w./min. [47] – at the Paediatric
only. North America, 0.9% sodium-chloride Hospital in Lucerne, a plasma-adapted
(NaCl) solution with added glucose is electrolyte solution supplemented with
Infusion therapy
still predominately used for this pur- 1% glucose has already been applied in
Basic considerations pose, although it is associated with the daily clinical routine for over 30 years.
Relative to their body weight, small risk of hyperchloraemic dilution acido- • Solutions containing 1% glucose are
children have larger extracellular space, sis. safe and only induce a moderate in-
larger blood volume, higher metabolic crease of plasma glucose levels, even
In Europe, plasma-adapted (synonymous:
rate, and higher fluid turnover. Homeo- after accidental hyperinfusion with,
balanced) solutions with a physiological
static disorders therefore occur sooner
sodium content (at least 120 mmol/l) are for example, 100 ml/kg b.w./h [48].
than in adults under inadequate fluid
nowadays usually preferred: • Children who are brought into the
supply – regarding both amount and
• Physiological saline prevents the oc- surgical theatre in a catabolic state,
composition – or underestimated fluid
currence of hyponatremias. displaying high metabolic rates or
loss.
• The addition of metabolisable anions very low glycogen reserves (e.g. new-
(acetate, malate or lactate), which are borns) require higher infusion rates
Intraoperative cardiovascular arrest
in children is caused relatively often
by underestimated blood loss.
Tab. 13
Information on dosage of glucose supply. These are empirical values; the target is a high-normal
In adult medicine, a well-considered re- blood sugar concentration. b.w. = body weight.
strictive infusion therapy is recommended
for major interventions [37], and a rather Situation Dosage and comments
generous supply of fluids for small Newborns, awake 5 mg/kg b.w./min. – in order to prevent hypoglycaemia
interventions in healthy patients [38]. It Newborns, intraoperative 3 mg/kg b.w./min.
must be assumed that similar principles
Children, intraoperative 1-2 mg/kg b.w./min
generally apply to children, although
Glycogenosis type I or disorders of 5-8 mg/kg b.w./min.
knowledge on this subject is still rather
fatty acid oxidation
scarce [39,40,41].
Children, intraoperative, if subject to Half of the preceding glucose supply
Type of infusion solution parenteral diet regimes
The body possesses distinctive water- Severe hypoglycaemia 200 mg/kg b.w. as mini bolus
saving mechanisms. In the event of
 Medical Education Review Articles 149

Tab. 14 Tab. 16
Practical calculation of the glucose dose. b.w. Rule of ten for rapid onset of fluid and volume therapy; later, individually-adapted doses are used.
= body weight. b.w. x 6 is equi­valent to the HES = hydroxyethyl starch; b.w. = body weight
infusion rate (in ml/h) of a 1 % solution in
order to reach 1 mg/kg b.w./min. Solution for infusion Initial and repetitive dose
Maintenance requirement Plasma-adapted electrolyte 10 ml/kg b.w./h
Step Statement
solution with 1% glucose
1 1 ml glucose 1% contains
Additional fluid therapy Plasma-adapted electrolyte 10-20 ml/kg b.w., repeatedly if
10 mg glucose
solution without glucose necessary
2 1 mg/kg b.w./min = 60 mg/kg/h
Forced volume therapy Colloids – HES, gelatines, 10 ml/kg b.w., repeatedly if
3 b.w. x 6 = ml/h of a 1% albumin necessary
solution, in order to achieve
Transfusion RBC concentrate, Platelet 10 ml/kg b.w., repeatedly if
1 mg/kg b.w./min.
concentrate necessary
4 b.w. x 30 = ml/h of a 1%
solution, in order to achieve
5 mg/kg b.w./min.
Example Target 1 mg/kg b.w./min. in a Infusion volumes
Urinary excretion is regularly redu-
child weighing 6 kg: The maintenance requirement can be
36 ml/h 1% sol. = 3.6 ml/h 10% ced during surgery – intraoperative
estimated beyond the newborn period
sol. = approx. 1 ml/h 40% diuresis is not a good measure for
by applying the 4-2-1 Rule (Tab. 15).
volume status, especially in the case
• In the clinical routine at the Paedi­
of pneumoperitoneum.
atric Hospital of Lucerne, volumes of
(Tab. 13). At the Paediatric Hospital 15-25 ml/kg b.w. are infused during
in Lucerne, a high-percentage glucose small interventions. Intravascular volume losses are initially
solution (usually 40%) is added to • In babies of <5 kg b.w., infusion substituted by a plasma-adapted electro-
the plasma-adapted electrolyte solu­ proceeds by means of a syringe pump, lyte solution without glucose supplement,
tion through a side connection like otherwise by an infusion pump. supplied at a rate of 10-20 ml/kg b.w.
a drug. • Gravity infusions should no longer be
• Synthetic colloids can be used in
applied; however, in the case of small
the event of insufficient effect [49].
Glucose should generally be han- interventions, older children and the
When applied for a short time, they
dled like a drug and should therefore use of small containers (maximum
250-500 ml) the risk of overinfusion have no disadvantageous effects on
be dosed with precision (Tab. 14).
should be minimal. renal function.
Pre-existing fluid deficiencies in de­ The rule of 10 can be applied in order
In the case of sick children or major
interventions, regular laboratory fol- hydrated children can often be best esti­‑ to rapidly achieve an initial adjustment
low-up mea­surements will be necessary, mated on the basis of the previously- of the syringe and infusion pumps (Tab.
e.g. hourly blood sugar and blood gas known body weight. In addition, clinical 16); therapy is subsequently adjusted
signs such as standing skin folds, sunken and optimised to the individually-re-
ana­lyses (including lactate); if required,
fontanel, and prolonged time to recapil- quired conditions [50].
the haemoglobin concentration and
larisation must be evaluated.
plasma electrolytes should be deter-
• Pre-existing fluid deficiencies must
mined as well. Conclusions
be balanced in addition to the main-
tenance requirement.
Paediatric anaesthesia belongs to the
most beautiful and demanding fields of
Tab. 15 anaesthesiology. Next to practical and
Maintenance requirement for an infusion fluid calculated by applying the 4-2-1 Rule. Special technical skills, the knowledge of paedi-
reference values apply to newborns in the first days of life. b.w. = body weight.
atric diseases belongs to the fundamen-
Age/b.w. Per hour Per day tal prerequisites, along with an ability
Newborns 100 - 150 ml/kg b.w./d and appreciation to communicate with
<10 kg 4 ml/kg b.w. 100 ml/kg b.w. children and their parents in a manner
that builds trust. Additionally, a theoret-
10-20 kg 40 ml plus 1,000 ml plus
2 ml/kg b.w. (per kg >10 kg b.w.) 50 ml/kg b.w. (per kg >10 kg b.w.) ical knowledge of airways, blood circu-
>20 kg 60 ml plus 1,500 ml plus lation and infusion therapy must be at
1 ml/kg b.w. (per kg >20 kg b.w.) 20 ml/kg b.w. (per kg >20 kg b.w.) hand when it comes to making the right
de­cisions in clinical routine situa­tions.
150  Review Articles Medical Education

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