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PEDIATRIC ANESTHESIA
PREPARED BY: Korme G
 INTRODUCTION
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 IMPORTANCE
 Children are very special people who require
special care
 One of the most difficult specialty but one of
the most satisfying medical discipline
 Pediatric anesthesia involves more than simply
adjusting drug doses and equipment for
smaller patients as „Childrens are not small
adults‟
 Risk is generally inversely proportional to age
 INTRODUCTION cont…
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 Neonates, infants, toddlers, and young children have differing

anesthetic requirements.
 Neonates: 0–1 months
 Infants: 1–12 months
 Toddlers:12–24 months and
 Young children: 2–12 years of age

 Safe anesthetic management depends on full appreciation of

the physiological, anatomic, and pharmacological
characteristics of each group
 ANATOMIC & PHYSIOLOGICAL DEVELOPMENT
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Respiratory
 Compared with older children and adults, neonates and infants have
Weaker intercostal muscles and weaker diaphragms (due to a paucity
of type I fibers)
 Do not achieve the adult configuration of type I muscle fibers until the
child is approximately 2 years old
Less efficient ventilation
Horizontal and pliable ribs and protuberant abdomens
RR and MV are increased
TV and dead space per kg are nearly constant during development.
 Respiratory
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The presence of fewer, smaller airways

Produces increased airway resistance
The alveoli are fully mature by late childhood (about 8 years
of age).
The work of breathing is increased (by three times in preterm
infant)
Respiratory muscles easily fatigue
 Respiratory cont..
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 Fewer and smaller alveoli reducing lung compliance

 Cartilaginous rib cage makes their chest wall very compliant
 Chest wall collapse during inspiration
 Low residual lung volumes at expiration.
 Decrease in FRC
 Limits oxygen reserves during periods of apnea (eg, intubation attempts)

 Predisposes neonates and infants to atelectasis and hypoxemia.

This may be exaggerated by their relatively higher rate of oxygen

consumption
 Respiratory cont..
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 The increased alveolar ventilation

 Arises from the increased oxygen consumption up to 7ml per Kg
 The increased alveolar ventilation to FRC
 Increases the risk of desaturation
 Hypoxic and hypercapnic ventilatory drives are not well developed in
neonates and infants.
 Implication
 hypoxia and hypercapnia may depress respiration in these patients
 Post operative apenia can occur in this group of patients which depends on
many factors eg: Ax duration, Anemia
 Respiratory cont..
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 Neonates and infants have, compared with older children and adults,
A proportionately larger head and tongue,
 Increases the likelihood of airway obstruction and technical difficulties during
laryngoscopy.
 Put head on neutral position during laryngoscopy

An anterior and cephalad larynx

 C3 in a premature infant and Implication
 C4 in a child Intubation may be easier in
infants and young children using
 C5-6 in the adult
a straight bladed laryngoscope
A large, floppy and U shaped epiglottis
 Respiratory cont..
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 A shorter trachea and neck

 Implication
 Accidental endobronchial intubation
 Neonates and young infants are obligate nasal breathers until about 5 years
of age.
 Narrow nasal passages
 Poorly developed body support
 Implication
 Difficulty in positioning eg:Prone, sitting position
 Respiratory cont..
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 The cricoid cartilage

 The only solid cartilaginous structure in the upper airway

 Is the narrowest point of the airway in children younger than 5 years

of age;
 In adults, the narrowest point is the glottis.
 One mm of mucosal edema will have greater effect on gas flow in children
because of their smaller tracheal diameters.
 Implication
 uncuffed endotracheal tubes
 Respiratory cont..
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 Respiratory cont..
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13
 Cardiovascular System
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Fetal circulation is well adopted to intrauterine hypoxic environment

which differs in many ways from extra uterine life
Example: Fetal Hgb is disadvantageous postnatally
Birth and initiation of spontaneous ventilation initiate circulatory
changes for survival of the neonate
Placenta removal  increases SVRDA closed due to rapid
exposure to Oxygen, functionally 15hrs after birth but
anatomically after 2 to 3wks
Decreased PVR  Increased Left side pressure  FO closure
functionally at birth, anatomically at 6wks
DV functionally within 3 to 7days but anatomically 2 to 3 months
 Cardiovascular System
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Certain risk factors may increase time of transition of circulation such as:
 Prematurity
 Infection

 Acidosis

 Pulmonary diseases

 Hypothermia

 Congenital heart disease

 Cardiovascular System
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Resting cardiac output is high in neonates compared to that of child

and adult to meet oxygen demand.
CO is 200ml per Kg per min at birth but decreased to 100 by
adolescence
Cardiac stroke volume is relatively fixed due to immature LV
Immature left ventricle is characterized by poor compliance and
reduced contractility in neonates and infants.
The CO is therefore very sensitive to changes in HR
Basal HR is greater than in adults
 Cardiovascular System
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 The following can quickly trigger bradycardia and profound reductions in CO

 Activation of the parasympathetic nervous system
 Anesthetic overdose or
 Hypoxia
 Sick infants undergoing emergency or prolonged surgical procedures
appear particularly prone to episodes of bradycardia that can lead to
 Hypotension
 Asystole and
 Intraoperative death
 The sympathetic nervous system and baroreceptor reflexes are not fully
mature.
 Cardiovascular System
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 The infant CVS displays a blunted response to exogenous

catecholamines.(why?? Any implication???)
 because of reduced endogenous catecholamines stores and displays.
 So, Intravascular volume depletion in neonates and infants may be signaled
by hypotension without tachycardia
 The immature heart
 Is more sensitive to depression by volatile anesthetics and to opioid-induced
bradycardia.
 The vascular system
 Is less able to respond to hypovolemia with compensatory vasoconstriction
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 ECG findings in pediatrics:

 Marked right axis deviation compared to adults(why?)
 Tall R wave but shorter QRS duration and PR interval

 Systolic murmur is normal but diastolic murmur is pathological

 Cardiovascular System
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 Metabolism & Temperature Regulation
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 Pediatric patients have a larger surface area per Kg than

adults (increased surface area/weight ratio).
 Metabolism and its associated parameters correlate better
with surface area than with weight.
 Eg.

Oxygen consumption
CO2 production
Cardiac output and
Alveolar ventilation
 Metabolism & Temperature Regulation
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 Greater heat loss to the environment in neonates

 This is mainly due to:
 Thin skin
 Low fat content and
 A higher surface relative to weight
 This problem is compounded by
Cold operating rooms
Wound exposure
IV fluid administration
Dry anesthetic gases, and
The direct effect of anesthetic agents on temperature regulation.
 Metabolism & Temperature Regulation
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 Hypothermia is a serious problem that has been associated with

 Delayed awakening from anesthesia
 Cardiac irritability
 Respiratory depression
 Increased pulmonary vascular resistance and
 Altered drug responses
 Metabolism & Temperature Regulation
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 The major mechanisms for heat production in neonates are

nonshivering thermogenesis by metabolism of brown fat
 minimal ability to shiver during the first 3 months of life
 Metabolism of brown fat is severely limited in premature infants
and in sick neonates who are deficient in fat stores.
 Volatile anesthetics inhibit thermogenesis in brown adipocytes

 Therefore patients unde GA are at greatest risk of developing

hypothermia as energy consumption and production is not
maching
 Renal & Gastrointestinal Function
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 Normal kidney function is not present until 6 months of age;

 Renal function may not achieve adult levels until the child is 2 years
old.
 Premature neonates possess multiple renal defects, including
 Decreased creatinine clearance
 Impaired sodium retention: Na+ supplement

 Glucose excretion, and bicarbonate reabsorption; and

 Poor diluting and concentrating ability.

 Implications of these abnormalities:

 Attention to fluid administration and drug dosage in the early days of life.
 Cont‟d
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 Hepatic
 Functionalmaturity is incomplete so degradation reaction is decreased
leading to prolonged half life of drugs
 Lowe plasma albumin and other proteins

 Minimal glycogen store

 Unable to handle large protein loads so prone for acedemia

 As neonate grows ability to metabolise drugs increases rapidly in 2

ways
 HBF increases and more drug delivered to liver
 The enzyme systems developed and are induced
 Cont‟d
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 Abdomen:
 At birth gastric PH is alkalotic but gastric acid production reaches adult level
within 2 days
 LES tone is decreased

 Ability to coordinate swallowing with respiration is not fully matured till 4 to

5 months
 Implication: they have increased gastroesophageal reflux incidence
 Glucose Homeostasis
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 Neonates have low glycogen stores that predispose them to

hypoglycemia.
 Impaired glucose excretion by the kidneys may partially offset this
tendency.
 Neonates at greatest risk for hypoglycemia are
 Prematureor small for gestational age
 Were born to diabetic mothers
 Fluids
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 At birth total body water constitutes 80 to 85% which will be decreased to

that of adult 65% at age of 3
 MF requirements are related to metabolic rate, and 4%dextrose should be
added.
 Even though dextrose provides only 20% of total calories required for a
child <10kg,it is sufficient to prevent ketosis
 They are at risk of both fluid deficit and overload so care should be
undertaken during replacement
 Blood loss has to be replaced according to ABL calculation with minimum
Hct of 28 to 30%
 Remember: For 1ml of blood loss replace with 3ml for crystalloid,1ml for
colloid Or whole blood and 0.5ml for PRBC
 Cont‟d
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 Neonatal Hemoglobin are primarily the Fetal type(HbF) which has

higher affinity for oxygen
 Its value remains 16-19gm/dl up to 2month

 The Hgb value will decrease to 12g/dl by 6 months of age

Implication of HbF???
Poor oxygen delivery to the tissue by shifting oxygen dissociation curve
to the left
 Nervous System
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 Nervous system is anatomically complete at birth, functionally it remains

immature but myelination continues up to age of 7
 Brain solely dependent on glucose for its energy source at 6.8mg glucose
per 100mg/min in child. But it doesn‟t store so brain glucose reserve can
only secure for 3minutes
 CBF is reduced with increase in age due to loss of synapses or drop their
activities rather than anatomic loss
 Immature BBB permits larger,lipid soluble drugs which should not have to be
during adulthood
 Spinal cord ends at L3 but reaches the adult level at age of 8 which is L1
 Pharmacological changes
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 Pediatric drug dosing is typically adjusted on a per kg basis for

convenience.
 In early childhood a patient‟s weight can be approximated based on
age:
 50th percentile weight (kg) =(Age × 2) +9 OR

 (Age+4) × 2
 Pharmacological changes
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 Weight-adjustment of drug dosing is incompletely effective because it

does not take into account
 The disproportionately larger pediatric intravascular and extracellular fluid
compartments
 The immaturity of hepatic biotransformation pathways

 Increased organ blood flow

 Decreased protein for drug binding or

 Higher metabolic rate

 Pharmacological changes
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 Volume of distribution
 Neonates and infants have a proportionately greater total
water content (80–85%) than adults (60–65%).
 Total body water content decreases while fat and muscle
content increase with age.
 Thevolume of distribution for most IV drugs is greater in neonates,
infants, and young children, and the optimal dose (per kilogram) is
usually greater than in older children and adults.
 Pharmacological changes
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 Fat and muscle content

A smaller muscle mass in neonates prolongs the
duration of action of drugs.
By delaying redistribution to muscle
 eg.
Prolonged action with Barbiturates(thiopental) and
Respiratory depression with narcotics(Fentanyl)
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 Metabolism and excretion

 Neonates have decreased
 GFR
 Renal tubular function
 Hepatic blood flow and
 Immature hepatic enzyme systems
 All these factors may impair renal drug handling, hepatic metabolism, or biliary
excretion of drugs in neonates and young infants.
 Pharmacological changes
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 Glomerular filtration is significantly impaired

at birth but develops rapidly during the first
year of life.
 The ability of the kidney to regulate large
amounts of solutes and water is also limited
during the first several months of life.
 These developmental changes have
significant implications for drug excretion and
fluid therapy, particularly during the first 4
weeks of life.
 Maturation of renal function may be delayed
in sick and preterm neonates.
 Pharmacological changes
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 Protein binding
 Neonates also have decreased protein binding for some drugs
 E.g
 Thiopental
 Bupivacaine and
 Many antibiotics.
 Thiopental
 increased free drug enhances potency and reduces the induction dose in neonates
compared with older children.
 Bupivacaine
 An increase in free drug might increase the risk of systemic toxicity.
 Inhalational Anesthetics
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 Greater alveolar ventilation and reduced FRC compared with older

children and adults.
 Greater MV-to-FRC ratio and relatively greater blood flow to vessel-
rich organs
 Rapid increase in alveolar anesthetic concentration
 Speeds inhalation induction
 Reduced blood/gas coefficients of volatile anesthetics in neonates
 Resultsin faster induction times
 Increases the risk of accidental overdosage
 Cont‟d…
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 The MAC for halogenated agents is greater in infants than in

neonates and adults.
 Incontrast to other agents, no increase in sevoflurane MAC can be
demonstrated in neonates and infants.
 Nitrous oxide does not appear to reduce the MAC of
desflurane or sevoflurane in children to the same extent as it
does for other agents.
 Cont‟d…
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 Cont‟d…
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 The BP of neonates and infants appears to be especially

sensitive to volatile anesthetics. WHY??
 Less-well-developed compensatory mechanisms (eg,
vasoconstriction, tachycardia)
 Greater sensitivity of the immature myocardium to myocardial
depressants.
 Cont‟d…
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 Halothane sensitizes the heart to catecholamines.

 The maximum recommended dose of epinephrine in LA solutions during
halothane anesthesia is 10 mcg/kg.
 Cardiovascular depression, bradycardia, and arrhythmias
 Less frequent with sevoflurane than with halothane.
 Halothane and sevoflurane
 Are less likely than other volatile agents to irritate the airway or cause
breath holding or laryngospasm during induction.
 Cont‟d…
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 Sevoflurane appears to produce the least respiratory

depression.
 The risk for halothane-induced hepatic dysfunction

 Much reduced in prepubertal children compared with adults.

 There are no reported instances of renal toxicity
attributed to inorganic fluoride production during
sevoflurane anesthesia in children.
 Cont‟d…
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 Sevoflurane
 Appears to have a greater therapeutic index than halothane
 Preferred agent for inhaled induction in pediatric anesthesia

 Desflurane or sevoflurane
 Emergence is fastest
 Both agents are associated with a greater incidence of agitation or
delirium upon emergence, particularly in young children.
 some clinicians switch to isoflurane for maintenance anesthesia following a
sevoflurane induction
 Nonvolatile Anesthetics
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PROPOFOL
 Larger doses of propofol
 because of a larger volume of distribution
 Shorter elimination half-life and higher plasma clearance
 Propofol is not recommended for prolonged sedation of critically ill
pediatric patients in the ICU due to an association with greater
mortality than other agents.
 “Propofol Infusion Syndrome”
 Reported more often in critically ill children,
 It has also been reported in adults undergoing long-term propofol infusion
(>48 h) for sedation, particularly at increased doses (>5 mg/kg/h).
 Cont‟d…
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 Its essential features of propofol infusion syndrome include

 Rhabdomyolysis
 Metabolic acidosis
 Hemodynamic instability
 Hepatomegaly and
 Multiorgan failure
 Dose of propofol to insert an LMA in children
 3.5 - 5.4 mg/kg
 The dose of propofol to facilitate tracheal intubation in children during
sevolurane anesthesia
 1 to 2 mg/kg
 Cont‟d…
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Theopentone
 Children require relatively larger doses of thiopental compared with
adults.
 The elimination halflife is shorter

 The plasma clearance is greater than in adults

 Neonates appear to be more sensitive to barbiturates

 Less protein binding, a longer half-life, and impaired clearance.

 The thiopental induction dose for neonates is 3–4 mg/kg compared
with 5–6 mg/kg for infants
 Cont‟d…
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 Total serum protein and albumin values

change with maturation.

 Total protein and albumin are less in preterm

infants than in term infants and less in term
infants than in adults.

 The result may be pharmacokinetic and

pharmacodynamic alterations for drugs with
a high degree of protein binding because
less drug is protein bound and more is
available for clinical effect.
50

Opioids
 Opioids appear to be more potent in neonates than in
older children and adults.
 Unproven (but popular) explanations include

 “easier entry” across the blood–brain barrier

 Decreased metabolic capability(drug metabolism)
 Increased sensitivity of the respiratory centers
 Cont‟d…
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 Morphine sulfate, particularly in repeated doses, should be

used with caution in neonates because
 Hepatic conjugation is reduced
 Renal clearance of morphine metabolites is decreased

 The cytochrome P-450 pathways mature at the end of the

neonatal period.
 Older pediatric patients have relatively greater rates of

biotransformation and elimination as a result of high hepatic

blood flow.
 Cont‟d
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 Sufentanil, alfentanil, and, possibly, fentanyl clearances may be

greater in children than in adults.
 Remifentanil clearance is increased in neonates and infants but
elimination half-life is unaltered compared with adults.
 Fentanyl clearance in premature infant is markedly decreased
 Midazolam has the fastest clearance of all the benzodiazepines;
however, midazolam clearance is significantly reduced in neonates
compared with older children.
 The combination of midazolam and fentanyl can cause hypotension
in patients of all ages
 Local anesthetics
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 Given according to weight scale basis

 However pediatric groups has shorter block duration so require larger
dose even up to 3 to 4 folds of calculated dose which may be due to:
 Increased volume of CSF
 Related to myelination of nerves
 Length of nerve exposed to LA

 But increasing the dose also has increased risk of systemic toxicity
 Therefore to get adequate analgesia it is recommended to mix with
additives or using those LA with less toxicity eg: Using ropivacaine over
bupivacaine
 Muscle Relaxants
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 Less commonly used during induction of anesthesia in pediatric than in

adult patients.
 Many children will have a laryngeal mask airway (LMA) or
endotracheal tube placed after receiving a sevoflurane inhalation
induction, placement of an IV cannula, and administration of various
combinations of propofol, opioids, or lidocaine.
 Cont‟d…
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 All muscle relaxants generally have a faster onset (up to 50% less
delay) in pediatric patients
 Because of shorter circulation times than adults.
 In both children and adults, IV succinylcholine (1–1.5 mg/kg) has the
fastest onset
 Infants require significantly larger doses of succinylcholine (2–3
mg/kg) than older children and adults
 Because of the relatively larger volume of distribution.
 This discrepancy disappears if dosage is based on body surface area.
 Cont‟d…
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 The relative immaturity of neonatal hepatic function prolongs the

duration of action for drugs that depend primarily on hepatic
metabolism
eg, pancuronium, vecuronium, and rocuronium
 Atracurium and cisatracurium do not depend on hepatic
biotransformation and reliably behave as intermediate-acting muscle
relaxants.
 Cont‟d…
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 After administration of succinylcholine Children are more

susceptible than adults to
 Bradycardia
 Cardiac arrhythmias
 Hyperkalemia
 Rhabdomyolysis
 Masseter spasm
 Malignant hyperthermia
 Cont‟d…
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 When a child experiences cardiac arrest following

administration of succinylcholine, immediate treatment for
hyperkalemia should be instituted.
 Succinylcholine is avoided for routine, elective paralysis for
intubation in children and adolescents
Children may have profound bradycardia and sinus
node arrest following the first dose of sux without
atropine pretreatment.
Atropine must always be administered prior to
succinylcholine in children.
 Cont‟d…
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 Indications for IV succinylcholine in children include

 Rapid sequence induction with a “full” stomach and
 Laryngospasm that does not respond to positive-pressure ventilation.

 When rapid muscle relaxation is required prior to intravenous access

(eg, with inhaled inductions in patients with full stomachs), IM
succinylcholine (4–6 mg/kg) can be used.
 IM atropine (0.02 mg/kg) should be administered with IM succinylcholine
 To reduce the likelihood of bradycardia
 Cont‟d…
60

 Consider Rocuronium (0.6 mg/kg intravenously) to be the drug of

choice (when a relaxant will be used) during routine intubation in
pediatric patients with IV access
 Because it has the fastest onset of NDNMBA
 Larger doses of rocuronium (0.9–1.2 mg/kg) may be used for RSI but
a prolonged duration (up to 90 min) will likely follow.
 Rocuronium is the only NDNMBA that has been adequately studied for
IM administration (1.0–1.5 mg/kg), but this approach requires 3–4
min for onset.
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