Presented May

2003

Abdulaziz Hisham Al
Gain
 Development:

 Organogenesis - 1st 8
weeks

 Organ function - 2nd

trimester

 Body mass - 3rd

trimester
 Changes in cardiovascular
system:

 Removal of placenta from

circulation

 Increasing of systemic vascular

resistance
 Decreasing of pulmonary vascular
resistance

 True closure of PDA ~ 2-3 weeks 

critical transitional
circulation
Changes in pulmonary system:
 Small airway diameter - increased
resistance

 Little support from the ribs

 VO2 2x > adults

 Diaphragm and intercostal muscles

do not achieve type-1 adult muscle
fibers until age 2

 Obligate nasal breathers

 Airway difference:
 Large tongue

 Higher located larynx

 Epiglottis short and stubby,

angled over the inlet

 Angled vocal cords  we must

rotate ETT to correct lodging at
anterior comissure

 Narrowest portion is cricoid

 Chest wall/Respiratory
difference:
 Ribs are horizontal in neonates
(vertical in adults)
 Ribs and cartilages are more
pliable
 Chest wall collapse more with
increased negative intrathoracic
pressure
 Atelectasis is more common
  FRC
  number of alveoli
 Alveolar ventilation/FRC:
 Kidney and liver
difference:
 Low renal perfusion pressure,
immature GF, TF, obligate Na
loser in the 1st month of life

 Complete maturation @ 2 years of

age

 Impaired liver enzymes,

including conjugation
react.
 GI system and
thermoregulation:
 Full coordination of swallowing
~ 4-5 months  increased
risk for GE reflux

 Large body surface area/weight

 Limited ability to cope stress

 Minimal ability to shiver in 1st

3 months
 Pharmacology/dynamics:
 Increased total body water:

 Large initial dose required

 Less fat  longer clinical

drugs effect

 Redistribution of the drug

into muscle will increase
duration of clinical effect
(fentanyl)
 Volatile anesthetics
Isoflurane:
 Less myocardial depression than
Halothane
 Preservation of heart rate
 CMRO2 reduction rate

Desflurane:
 Increased incidence of coughing,
laryngospasm, secretions
 Concern of hypertension and
tachycardia from sympathetic
activation
 Volatile anesthetics (2)

Sevoflurane
 Less pungent than Isoflurane

 Concern of compound A
(nephrotoxicity)

 Most suitable for induction

Remember: MAC for potent volatile

anesthetics is increased in
neonates, but may be lower for
sicker neonates and premies
 Induction drugs:
Methohexital:
 1-2 mg/kg i.v. or 25-30 mg/kg
per rectum
 Side effects:
burning
hiccup
apnea
extrapyramidal syndrome
 Contraindication: temporal lobe
epilepsy

Thiopental:
 5-6 mg/kg i.v.
 Induction drugs:
Propofol:
 3 mg/kg i.v. (until 6 years of
age)
 Pain on injection - 0.2 mg/kg
Lidocaine i.v.

Ketamine:
 10 mg/kg IM, PR, orally
 Increased salivation
Contraindications: Increased ICP
Open globe injury
 Induction drugs:
Benzodiazepines:
Diazepam:
 0.1-0.3 mg/kg orally
 T1/2 80 hours  contraindicated
< 6 months

Midazolam:
 Only FDA benzodiazepine approved
in neonates
 0.1-0.15 mg/kg IM
 0.5-0.75 mg/kg orally
 0.75-1.0 mg/kg rectally
 Reduce dose in drugs  cause
 Induction drugs:
Narcotics:

Morphine:
 Increased permeability of
blood/brain barrier
 50 mcg/kg IV

Meperidine:
 Less respiratory depression than
morphine
 Be cautious in long term
administration because of
its metabolite normeperidine
 Induction drugs:
Narcotics(2):

Fentanyl:
 12.5 mcg/kg IV during induction
provides stable
cardiovascular response
 1-2 mcg/kg adjuvant to
anesthesia
 Stable cardiovascular response

Alfentanyl and Sufentanyl:

 More rapid clearance than adults
 Can cause parasympatholysis 
 Induction drugs:

Muscle relaxants:

Succinylcholine:
 2.0 mg/kg IV; 4.0 mg/kg IM
 Consider Atropine 10-15 mcg/kg
given prior SUX
 Potential side effects:
Rhabdomyolysis
Hyperkalemia
Masseter spasm
MH
 Induction drugs:

Muscle relaxants(2):

 If tachycardia desired -
Pancuronium

 Mivacurium - brief surgeries,

beware of histamine
release, bronchospasm

 Rocuronium - useful for modified

RSI, and can be
 Muscle relaxants - Summary:
MAIN TEN ANCE DOSE (ED 95)
(mg/ kg) DURIN G AN ESTH ESIA SUGGESTED DOSE (mg/ kg) FOR
WITH TRACHEAL IN TUBATION
(2 × ED 95)
N 2O/ O 2 HALOTHAN E
Muscle relaxanta
d-Tubocurarine 0.60 0.30 0.80
Pancuronium 0.08 0.06 0.10–0.15
Metocurine 0.34 0.15 0.50–0.60
Atracurium 0.30 0.20 0.50–0.60
Cisatracurium 0.10 0.080 0.10
Vecuronium 0.08 0.06 0.10–0.15
Mivacurium 0.10 0.10 0.20–0.25
Doxacurium 0.030 0.030 0.050–0.060
Pipecuronium 0.080 0.080 0.080–0.120
Reversal agentsb
(0.3–1.0 mg/ kg) +
Edrophonium atropine (0.01–0.02
mg/ kg)
(0.02–0.06 mg/ kg)
Neostigmine + atropine (0.01–
0.02 mg/ kg)
 Premedication:
 Almost all sedatives are
effective
 Usually not necessary < 6 months
 Most common route used is oral
 Side effects:
Oral - slow onset
IM - pain, sterile abscess
Rectal - uncomfortable,
defecation, burn
Nasal -irritating
Sublingual -bad taste
 Pharmacological
premedication options

1.Role when awake separation of

child from parent before
induction is planned.

2.Its success may be judged by the

peacefulness of the separation.

3.Large volume of literature

indicates lack of clearly ideal
technique http://metrohealthanesthesia.com/edu/ped/pedspreop6
Pharmacological premedication options

Midazolam (Versed)

• PO: 0.5 to 1.0 mg/kg up to 10 mg

max.
• Bioavailability = 30%
• Peak serum levels after about 45
minutes
• Peak sedation by about 30
minutes
• 85% peaceful separation
• Mix with grape concentrate or
acetaminophen (Tylenol) syrup or
Pharmacological premedication
options (3)

Midazolam (Versed)(2)

• Nasal: 0.2 to 0.6 mg/kg

• Peak serum level in 10 minutes
• 0.2 mg/kg same as 0.6 mg/kg
except
• 0.2 mg/kg did not delay
recovery
• 0.6 mg/kg may delay extubation

• Possible concern: animal

Pharmacological premedication options
(4)

Midazolam (Versed)(3)

• Sublingual: 0.2-0.3 mg/kg as

effective as 0.2 mg/kg
intranasal
• Rectal: 0.35 to 1.0 mg/kg
• Some effect by 10 minutes, peak
effect 20-30 minutes.
• 1.0 mg/kg did not delay PACU
discharge.
Pharmacological premedication options
(5)

Methohexital (Brevital)

• Rectal 25 to 30 mg/kg as 10%

solution in warm tap water
• 85% sleeping within 10 minutes =
rectal induction of GA (very
peaceful separation)
• Sleep duration: about 45 to 90
minutes
• 25 mg/kg did not delay recovery
in one study, but some delay
Pharmacological premedication
options (6)

Ketamine

• PO: 6 to 10 mg/kg
• May slightly prolong time to
discharge after a short case
• IM: 3 to 4 mg/kg sedation;
• 2 mg/kg did not delay recovery
• 6 to 10 mg/kg = IM induction of
general anesthesia
• 10 mg/kg: as effective as
Midazolam 1 mg/kg but some
Pharmacological premedication
options (7)

Midazolam + Ketamine:

• PO 0.4 mg/kg + 4 mg/kg

respectively

• 100% successful separation

• 85% easy mask induction

• Doubling dose leads to "oral

induction of general
Pharmacological premedication
options (8)

Fentanyl "lollipops" (oral

transmucosal Fentanyl)

• 15 to 20 mcg/kg

• Increased volume of gastric

contents

• Nausea and vomiting

• Pruritus
Pharmacological premedication
options (9)

1. Metoclopramide (Reglan) PO or IV:

0.2 mg/kg

2. Ranitidine (Zantac) PO 2.5 mg/kg

3. EMLA cream: Eutectic mixture of

Lidocaine and Prilocaine. For
cutaneous application by occlusive
dressing one hour preoperative

4. Glycopyrrolate: consider for

selected patients for planned
Preoperative interview:
SAY N OT

GOOD, YES BAD, NO

sleepy breeze gas

anesthetic vapors bad smell, stink, stench,
pinch bee sting
hug your arm take blood pressure
stickers ekg pads
will be neat! fun! won't hurt
might get the giggles don't cry
make you laugh make you cry
feels funny feels bad
take a little nap put you to sleep
good job, good boy/ girl don't be bad
proud of you
cool, refreshing cold solution
nice little back rub press on your back
http://metrohealthanesthesia.com/edu/ped/pedspreop4
 Fasting:

 Clear liquids - 2-3 h before the

procedure

 If infants are breast fed - 4 h

before the procedure

 For older patients = the adults

rule

 Be aware of dehydration
 Induction of Anesthesia:

Inhalational induction:

 Younger than 12 months

 After the induction, place the

intravenous catheter

 Use suggestions in older child

(pilot’s mask)

 In a case of difficult airway -

 Induction of Anesthesia:
Rectal induction:

 Methohexital
 Thiopental
 Ketamine
 Midazolam
 Technique no more intimidating
than rectal temperature
measurement
 Usual time of onset ~ 10-15 min
 Induction of Anesthesia:

Intramuscular induction:

 Most common used Ketamine

 Disadvantage painful needle

insertion

 Advantage: reliability
 Induction of Anesthesia:

Intravenous induction:

 The most reliable and rapid

technique
 Disadvantage - starting
intravenous line
 If patient is older ask the
patient
 If you insert IV line:
I. Do not allow the
patient to see it
 Patient with full stomach:

Treat the same as adult with full

stomach:

 RSI with ODL using cricoid

pressure
 Tell the patient that will feel
“touching on the neck”
 Be aware of  VO2 (desaturation)
 0.02 mg/kg of Atropine administer
before SUX to avoid bradycardia
(usually after 2nd dose)
 Endotracheal tubes:
Recommended Sizes and Distance of Insertion of Endotracheal
Tubes and Laryngoscope Blades for Use in Pediatric Patients
RECOMMEN DED
Age Of The
Patient Diameter Size of the
Distance
(internal) Blade
Premature
2.5 0 6–7
(<1,250 g)
Full term 3.0 0–1 8–10
1y 4.0 1 11
2y 5.0 1–1.5 12
6y 5.5 1.5–2 15
10 y 6.5 2–3 17
18 y 7–8 3 19
4 + (1/4) (age) = size; 12 +
(1/2) (age) = depth
 Intravenous fluids:
Calculation of Maintenance Fluid Requirements for Pediatric
Patients
Weight
Fluids (mL/ hour) 24-H Fluids (mL)
(kg)
< 10 4 mL/ kg 100 mL/ kg
11–20 40 mL + 2 mL/ kg > 10 1,000 mL + 50 mL/ kg > 10
> 20 60 mL + 1 mL/ kg > 20 1,500 mL + 20 mL/ kg > 20

e if present: Fluid deficits

Third spaces losses
Hypo/hyperthermia
Unusual metabolic fluids dema
 Fluid requirements in
neonates:
During the 1st week reduced fluid
requirements:
Day 1 - 70 ml/kg
Day 3 - 80 ml/kg
Day 5 - 90 ml/kg
Day 7 - 120 ml/kg
 Concern is immaturity of the
neonatal kidney
 The volume of extracellular
fluids in neonates is large
 Consider use of radiant warmers,
and heated humidifiers -
 Packed Red Blood Cells:
The use has diminished because of
disease transmission (HIV,
Hep C,B. etc)
Blood volume:
Premature infant - 100 -120
ml/kg
Full-term infant - 90 ml/kg
3-12 month old child - 80 ml/kg
1 year and older child - 70
ml/kg

EBV (starting Hct - target

Hct)
 Packed Red Blood Cells :
(2)

 Child usually tolerates Hct ~ 20

in mature children
 If:
Premature,
Cyanotic congenital disease
Hct ~ 30
 O2 carrying capacity
 No one formula permits a
definitive decision
 Replace 1ml blood with 3 ml of LR
 Lactic acidosis is a late sing of
decreased O2 carrying capacity
 Fresh Frozen Plasma:
 Use to replenish clotting factors
during massive transfusion,
DIC, congenital clotting factor
deficits
 Usually replenished if EBL = 1-1.5
TBV
 A patient should be never given FFP
to replace bleeding that is surgical
in nature
 If transfused faster than 1.0
ml/kg/min severe ionized
hypocalcemia may occur

Ionized Hypocalcemia:
 Platelets:
 Find etiology - TTP, ITP, HIT,
DIC, hemodilution after massive
blood transfusion

 Consider transfusion if Platelets

< 50.000

 In certain hospitals platelet

function test is available

 If Platelets < 100.000 and EBL =

1-2 TBV - transfusion more
 Monitoring the Pediatric
Patients:
 Must be consistent with the
severity of the
underlying medical condition
 Minimal monitoring:
I. 5 ASA monitors
II. Precordial stethoscope
III. Anesthetic agent
analyzer
 Use of capnograph and O2
analyzers is associated with high
incidence of false alarms from:
 Special Monitoring the
Pediatric Patients:
 Intraarterial catheter - most
common radial
 Pulmonary artery catheters are
rarely indicated because
equalization of the pressure
right/left heart
 In a case of severe multisystem
organ failure insertion of PAC
might be particularly useful
 Multilumen catheters are valuable
in ICU patients
 Anesthesia Circuits:
 Nonrebreathing circuits:
1. Minimal work of breathing
2. Speeds-up rate of
inhalational induction
3. Compression and compliance
volumes are less (small
circuit volume)
 Use of Mapleson D system is
recommended in children < 10
kg
More sensitive to
changes in gas flow
 Mapleson D Circuit:

Gas disposition at end-expiration during spontaneous ventilation

Gas disposition at controlled ventilation

 Neonatal Anesthesia:
 Understand differences in
Physiology
Pharmacology
Pharmacodynamic
response
 Most of the complications that
arise are attributable to a lack of
understanding of these special
considerations prior to induction
of anesthesia
 Be aware of:
Sudden changes in
 Neonatal Anesthesia :
(2)

 Children < 1 year old have more

complications:
I. Oxygenation
II. Ventilation
III. Airway management
IV. Response to volatile
agents and medications
 Stress response is poorly
tolerated
 Consider:
1. Organ system immaturity
2. High metabolic rate
 Neonatal Anesthesia :
(3)

 Prevention of paradoxical air

emboli

 Fluids instituted with volume-

limiting devices

 Minimize thermal stress

 Use flow-through capnograph if

possible

 Prevent retinopathy of
 Neonatal Anesthesia :
(4)
Stress Response:
 Poorly tolerated

 Use opioid technique (blunt pain

response)

 Ketamine is excellent choice –

stable intraoperative
hemodynamics

 Potent volatile anesthetics are

poorly tolerated
 Special Problems in
Neonatal Anesthesia:
Meningomyelocele:

 Underestimating fluid or blood

loss from the defect
 High association with
hydrocephalus
 Possibility of cranial nerve
 Special Problems in Neonatal
Anesthesia (2):

Pyloric stenosis:
 First 3-6 weeks in life
 Anesthesiologist concern:
I. Full stomach with barium
II. Metabolic alkalosis with
Hypochloremia and Hypokalemia
III. Severe dehydration
 Surgery is never emergency
 Metabolic correction mandatory
before the surgery
 Suction the stomach before
 Special Problems in Neonatal
Anesthesia (3):

Omphalocele and Gastroschisis:

 Omphalocele occurs because of

failure of the gut to return to
the abdominal cavity at 10th week of
life
 Fine membrane covers intestines and
abdominal contents

 Gastroschisis develops later in

life after gut has returned into
 Special Problems in Neonatal
Anesthesia (3):

Omphalocele
 Special Problems in Neonatal
Anesthesia (3):

Gastroschisis
 Special Problems in Neonatal
Anesthesia (3):

Omphalocele and Gastroschisis(2):

 Anesthesiology concern:
1. Dehydration
2. Massive fluid loss (exposed
viscera and 3rd space loss)
3. Heat loss
4. Difficulty of surgical closure
5. High association with
prematurity, congenital
defects, including cardiac
anomalies
 Special Problems in Neonatal
Anesthesia (3):

Omphalocele and Gastroschisis(3):

 During closure consider

* difficulty ventilation
* hypotension
*  abdominal pressure may
compromise liver function and
alter drug metabolism

 During closure of big defects

monitoring of the bladder
 Special Problems in Neonatal
Anesthesia(3):

Omphalocele and Gastroschisis

(4):

 Be aware of Beckwith-Wiedemann
syndrome:

Profound hypoglycemia

Hyperviscosity syndrome
 Special Problems in Neonatal
Anesthesia(3):

Omphalocele and Gastroschisis

ddx. (5):

1. Much greater associated defects

with Omphalocele

2. More fluid loss associated with

Gastroschisis
 Special Problems in Neonatal
Anesthesia(4):

Tracheoesophageal fistula
anomaly(1):

 90 % proximal atresia ofTrachea

esophagus
with distal fistula
 Consider aspiration pneumonitis.
T-type
 VATER syndrome:
I. Vertebral
II. Anal
III. Tracheoesophageal
IV. Renal
 Special Problems in Neonatal
Anesthesia(4):

Tracheoesophageal fistula
anomaly(1):

 90 % proximal atresia ofTrachea

esophagus
with distal fistula
 Consider aspiration pneumonitis.
T-type
 VATER syndrome:
I. Vertebral
II. Anal
III. Tracheoesophageal
IV. Renal
 Special Problems in Neonatal
Anesthesia(4):

Tracheoesophageal fistula
anomaly(2):

 Major issues are: Trachea

 Aspiration pneumonia
T-type

 Overdistention of the stomach

 Inability to ventilate
 Special Problems in Neonatal
Anesthesia (4):

Tracheoesophageal fistula
anomaly(3):
Induction:
 Awake intubation Trachea
 Deliberate right main stem T-type
intubation
 Catheter in esophagus
 Prone position with head-up
 Avoid massive distention of the
stomach
by gentle ventilation
 Special Problems in Neonatal
Anesthesia (5):

Diaphragmatic hernia:
 Usually presentation on
1st day of life
 Almost all viscera can be Shifted
in the
chest cavity mediastinum

 Anesthesia concerns: Diaphragmatic herni

I. Hypoxemia
II. Hypotension
III. Stomach herniation
IV. Pulmonary hypertension
V. Systemic hypotension
 Special Problems in Neonatal
Anesthesia (5):

Diaphragmatic hernia (2):

1. Awake intubation
2. Intraarterial catheter
Shifted
3. Use opioids (stress response)
mediastinum
4. Use Pancuronium Diaphragmatic herni
5. Avoid hypothermia
6. Avoid any myocardial depressant
7. Avoid N2O (abdominal distention)
8. Aware of barotrauma-induced
pneumothorax
 Special Problems in Neonatal
Anesthesia (6):

Former preterm infant (<37 weeks):

 High incidence of apnea risk

factors: Respiratory distress
syndrome
Bronchopulmonary dysplasia
Neonatal dyspnea
Necrotizing enterocolitis
Ongoing apnea at the time of
surgery
Use of narcotics
 Regional Anesthesia and
Anesthesia:
(brief overview)

 Most regional anesthetics are

safe to use

 Strict attention to:

Dose
Route of administration
Proper equipment used

 Common: