ESSENTIALS OF PAEDIATRIC

ANAESTHESIA
 Paediatric population is not
homogenous

Infant
Neonate

Pre-schooler

School going child

Adolescent
 Premies
Developing physiology
 Hyaline membrane disease,
apnea of prematurity
 Patent PDA and R-L shunting
 Fetal Hb, Glucose,
Temperature
 Retinopathy of prematurity
Practical tips
 ↑ TBW and circulating blood  Ventilation strategy
volume
 Oxygen
 Glucose
 Temperature
 Volume : count bolus
Paediatric Population
- Evolves as they grow

Anatomy
Physiology
Pharmacology
Psychology
 Normal vital signs
Age Group HR (beats/min) RR (/min) Systolic BP mmHg
Preterm 120-170 40-60 40-55
MAP=GA

Neonates 120-160 40-60 >60 mmHg

Infants 100-120 25-50 >70 mmHg

Young Children 80-100 15-30

> 70 + (Age x 2)
Older Children 60-90 12-20
 Cardiac arrest in children
 Respiratory cause account for large majority of
cardiac arrest in children
c.f. cardiac cause in adults

 Children arrest due to hypoxia

Hypoxia rarely a sudden event
Recognize early signs of respiratory distress
Prevent cardio-respiratory arrest.
 General Anaesthesia

Effects of GA Un-physiological
 Airway
Infant & young child:
 Large head (prominent occiput)
 Short neck
 Large tongue
 Prominent adenoids and tonsils

Implications:
Upper airway obstruction occurs easily under GA
 Airway
Head position for intubation

Infant & young child: Older child & adolescent

Head in neutral position Head on “doughnut”
 Intubation
 Large head to body
 Anterior and cephalad larynx (C3/4 vs
 Long narrow epiglottis **
 Short neck and trachea

Implications:
No need for pillow under head in young child to align the
oropharyngeal and laryngeal axis.
Neonatal intubation with straight blade **
Potential for endobronchial intubation
 Breathing
Inefficient respiratory mechanics
Weak intercostal and diaphragmatic muscles
Very compliant chest wall
Horizontal ribs
Chest relatively small to abdomen
Protuberant abdomen with weak abdominal
muscles
 Breathing

• O2 consumption 2x adult
• Ventilation/unit lung volume is more
• Decreased lung compliance
• Small airways : airways edema result in increased resistance

Increased work of breathing 15% total O2 consumption

Laryngospasm
• Infants & young children
• Recent URTI
• Airway surgery
• Reactive airway disease
• Exposed to second- hand
smoke
 Cardiovascular system
Cardiac output is HR-dependent
CO= HR x SV
Parasympathetic system more developed than
sympathetic
Sinus arrhythmia is common in children

Implications
• Treat bradycardia
• Hypoxia is often the cause of bradycardia
 Circulation
Normal Blood Volumes Normal Haemoglobin
Blood volume
NB 85-90 ml/kg

Till 2 yrs 85 ml/kg At birth 18-20g/dl

(70-90% HbF)
> 2 yr to 80 ml/kg
puberty 3-6 month 9-12 g/dl
 The Paediatric Circulation

The Pediatric Circulation Clinical Implication

Limited cardiac stroke volume but able to Shock my manifest initially only by tachycardia. Actual drop in
compensate via increasing heart rate blood pressure is a late-sign of severe hypotension

Smaller absolute volume (70-80 ml/kg) With trauma actual blood loss is significant relative to weight
compared to adults compared to adults
First sign of shock = Tachycardia
180/min in child less than 5 yr
160/min in child more than 5 yr
ABC & DE of Paediatric Anaesthesia
 Pharmacokinetics of drugs
Age Premie Term One Adult  Protein binding is less
neonate Neonate year old (male)
 Reduced total serum
Total 85 80 60 60 proteins/specific proteins
Body
 Reduced biding capacity
water %
 Little fat/muscle
ICF water 25 35 35 40  Immature renal & hepatic
%
systems
ECF 60 45 25 20
water %

Practical points Practical points

Large initial dose required Higher free levels in blood
Longer duration of action
 Drugs in Neonates
Drugs P² kinetics Clinical implications

Inhalational agents ↑ AV/FRC Faster wash

MAC low NN
Peaks 6-12m
Thiopentone Higher free fraction Prolonged effect
Midazolam ↓ low clearance
Muscle blockers ↑ Vd ↑ Dose of sd
2mg/kg
NDB
↑sensitivity NMJ
Paracetamol ↑ Vd ↓Peak cone
Accum repeated doses
Bupivacaine ↓ Protein binding ↑Free concentration
Lower clearance ↑ Accumulation (infusions)
EMLA Skin more permeable LA toxicity
↑ skin surface area Methemoglobinemia
Morphine Brain ↑blood flow & BBB immature Morphine easier access to CNS
(lipid insoluble) ↑ sensitivity
Fentanyl ↓ metabolism
(lipid soluble)
Reduce enzymes to convert to active Shorter and reduced effect
Codeine metabolites
Inhalational drugs in infant & child
 MAC of inhalational increases with decreasing age, from adult
and peaks in infancy, then decrease in neonates and pre-term
infants
 The younger child, more rapid the uptake of inhalational
anaesthestics
 Avoid maintaining high concentrations in ventilated child
 Emergence agitation occurs most commonly in the young
children
 Drug Management in Chlidren
In general caution is particularly needed in the premature &
term neonatal population to avoid pharmacological errors.

The pharmacological variation amongst neonates and infants

emphasize the need to titrate many drugs to effect.

Onset of action is usually quicker because of more rapid

uptake & distribution.

Reduced metabolic and excretory capacity may prolong the

duration of action of some drugs.
 Glucose in Neonates
Hypoglycemia Hyperglycemia

Neonates
Higher metabolism
Lower glycogen stores Intraoperative
Impaired gluconeogenesis ↓O2 consumption & metabolism, glucose
requirements

Estimated glucose infusion 3-4 mg/kg/min

Pre-term. Hypoglycemia & inherrited Osmotic dehydration
metabolic disorders - Dehydration and electrolyte abnormalities
 Worsens neurologic outcome in hypoxic or
ischemic event
 Glucose during surgery
Neonates in first 48 hours
Preterm and term infants already receiving glucose pre-operatively
Infant /chlidren on parenteral nutrition
Children with chronic debilitating illnesses
Children <3rd precentile or surgery > 3 hours - check
 Fasting guidelines
 2 hours for clear non-carbonated liquids
 4 hours for breast milk (healthy neonates and infants)
 6 hours for formula milk, light meals (toast) & citrus juices
 8 hours fatty or fried meals
 Isotonic fluids
 Intraoperative fluid should have an osmolarity
close to the physiologic range in children in order
to avoid hyponatraemia,
1-2.5% instead of 5% glucose in order to avoid
hypoglycaemia. Lipolysis or hyperglycaemia
& should also include metabolic anions (i.e.
acetate, lactate or malate) as bicarbonate
precursors to prevent hyperchloraemic acidosis

2nd Congress of the European Society for Paediatric Anaesthesiology

Berlin, September 2010
Dextrose gets metabolised
and becomes hypotonic
 Hypotonic fluids in Post-operative period
Hyponatremic encephalopathy

Surgery, pain, nausea and vomiting are potent causes of ADH release
Ongoing losses from NG or drains – isotonic fluids
Measure losses and check electrolyte levels
 Thermoregulation
Loss of heat
 High body surface : body weight ratio
 Thin skin, low fat content
 Immature thermoregulatory mechanism

Temperature monitoring
 Passive heating devices : plastic wrap, caps, raising ambient OT
temperatures
 Active heating devices : “hot air” blankets, radiation warmers, heating &
humidification gases

**Over-heating from over-zealous warming

 “Emotions”

Psychological preparation
Family affair
“Fear of the unknown”
“Fear of separation”
 Psychological differences

Toddler and Preschooler

Stranger and separation anxieties
Schooling child
Age of some understanding &
reasoning, may have fears of pain
& other “unknowns”

Adolescents
Might appear cool.
Fears of loss of autonomy & pain
May have morbid thoughts
 Psychological Preparation
Young chlid  Simple explanation
suffices
 Explanation probably the
day before, not too early
 Self centered and need
for re-assurance
 Sense of mastery and
participation
 Be careful of the “silent
child and listening child”
 Psychological Preparation
Emotion > physical needs

 Well prepared in advance

 Careful explanation of entire process &
elicit their understanding of situation
 Encourage questions
 Be careful of the “silent child and listening
child”
 Psychological Preparation
Children with special needs

Myths about Down’s kids

• All retarded
• Always uncooperative or always compliant

 Be careful of the “silent child and listening child”

Pain management
Pain Assessment in Children - Challenges
Non-verbal
Fears of stranger, environment
Previous “bad” experience
Tantrums, hunger, emergence delirium
 Pain Scores
Observational assessment Self Report
• Cry • Numerical rating scales
• Facial expression • VAS
• Localisation & Posturing • Faces scales
• Consolability • Adjectives
• Behavious and Function • Colours
E.g. sleep patterns, activity, mood • Pieces of Hurt
 Pain Scores
Age group Scales
Age> 8 years Verbal Numerical Self report
Scale
Age 6-12 years Faces Pain Scales- Self report
revised Wong-
Baker Faces
2 months FLACC Observational
Infant full term up Neonatal/Infant Observational
to 12 months Pain Scale

Easy on both patient and assessor

Data is recordable, easy to interpret to all
Readily available, portable & inexpensive
Evidence based