ANAESTHETIC IMPLICATIONS IN PEDIATRIC PATIENTS

ANAESTHETIC ANAESTHETIC IMPLICATIONS IN IMPLICATIONS IN

PEDIATRIC PATIENTSPEDIATRIC PATIENTS

Dr Vishawjeet SinghDr Vishawjeet Singh

Moderator Dr Jyoti PathaniaModerator Dr Jyoti Pathania

PREOPERATIVE PREPARATIONPREOPERATIVE PREPARATION A– In addition to routine pre- anaesthetic A– In addition to routine pre- anaesthetic

evaluation, the following points should be evaluation, the following points should be stressed:stressed:

1- gestational age at birth- extent of prematurity.1- gestational age at birth- extent of prematurity. 2- congenital anomalies2- congenital anomalies 3- assessment of airway (cleft lip, micrognathia ) 3- assessment of airway (cleft lip, micrognathia ) 4- severity of coexistent disease-eg sepsis , resp. 4- severity of coexistent disease-eg sepsis , resp.

failure.failure. 5- degree of birth asphyxia, apneic spells.5- degree of birth asphyxia, apneic spells.

B- CHILD---B- CHILD--- Psychological preparation is very important. Psychological preparation is very important. 1- Children over 2-6 years are over 5 times more 1- Children over 2-6 years are over 5 times more

likely to have significant preoperative anxiety.likely to have significant preoperative anxiety. 2- parental anxieties concerning the surgical 2- parental anxieties concerning the surgical

procedures may be profound and can be transmitted procedures may be profound and can be transmitted to the child. to the child.

3- anaesthesiologist should formulate the plan for 3- anaesthesiologist should formulate the plan for smooth induction, explain the possibilities regarding smooth induction, explain the possibilities regarding induction and help soothe the family members.induction and help soothe the family members.

4- chidren are principally worried about pain and 4- chidren are principally worried about pain and separation from parents.separation from parents.

Presurgical prep. programmes such Presurgical prep. programmes such as brochures, videos or tour can be as brochures, videos or tour can be helpful. Reassurances to parent and helpful. Reassurances to parent and children is helpful.children is helpful.

In hospitals with appropriate facilities, In hospitals with appropriate facilities, separation anxiety can be avoided by separation anxiety can be avoided by inviting a parent to accompany the inviting a parent to accompany the child at induction of anaesthesia.child at induction of anaesthesia.

ANAESTHETIC ASSESSMENTANAESTHETIC ASSESSMENT Previous illness and operationPrevious illness and operation H/o allergyH/o allergy h/o apnoeic spells- more likely to develop apnoea following anaesthesia h/o apnoeic spells- more likely to develop apnoea following anaesthesia

and should not be accepted for day care procedres until they are atleast 50 and should not be accepted for day care procedres until they are atleast 50 wks gestation.wks gestation.

WEIGHT- influence the selection of anaesthetic eqipments.WEIGHT- influence the selection of anaesthetic eqipments. Upto 12 yrs wt= (age + 3) 5/2 or age x 2 +9Upto 12 yrs wt= (age + 3) 5/2 or age x 2 +9 h/o respiratory tract infectionsh/o respiratory tract infections URTI– H/O RTI within 4 wks of operation , or who have symtoms of URTI URTI– H/O RTI within 4 wks of operation , or who have symtoms of URTI

preoperatively are at increased risk of respiratory complications such as --- preoperatively are at increased risk of respiratory complications such as --- laryngospasm laryngospasm

bronchospasmbronchospasm atelectasis atelectasis hypoxemiahypoxemia it is usual to postpone elective srgery for 4-6 wks, which may not be it is usual to postpone elective srgery for 4-6 wks, which may not be

always practical. always practical.

URTI- If decision is taken to proceed URTI- If decision is taken to proceed with the surgery endotracheal tube with the surgery endotracheal tube should be used to control the should be used to control the airways.airways.

Postoperatively the pt needs Postoperatively the pt needs supplemental oxygen and careful supplemental oxygen and careful monitoring. monitoring.

Examination Examination Head and neck– for Head and neck– for loose deciduous teethloose deciduous teeth signs of potentially difficult signs of potentially difficult intubationintubation limited mouth openinglimited mouth opening micrognathiamicrognathia large tonguelarge tongue noisey breathingnoisey breathing A precordial murmur , circulatory instability or cyanosis point to a A precordial murmur , circulatory instability or cyanosis point to a

CHD in neonate.CHD in neonate. Preoperative cough, fever, malaise and audible chest signs Preoperative cough, fever, malaise and audible chest signs

suggests lower respiratory tract infections. Elective anaesthesia suggests lower respiratory tract infections. Elective anaesthesia should be postponed for 4-6 wks.should be postponed for 4-6 wks.

INVESTIGATIONSINVESTIGATIONS Neonates scheduled for elective minor surgery--- CBCNeonates scheduled for elective minor surgery--- CBC S. GlucoseS. Glucose Neonates with chronic illness and congenital defects– CBC, Neonates with chronic illness and congenital defects– CBC,

glucose, albumin, clotting profile, platelet count.glucose, albumin, clotting profile, platelet count. In a healthy child scheduled for minor surgery – no In a healthy child scheduled for minor surgery – no

investigations needed.investigations needed. Hb estimation– in pts of chronic diseases , Hb estimation– in pts of chronic diseases ,

hemoglobinopathies, anaemia.hemoglobinopathies, anaemia. Hb and cross matching- if significant blood loss anticipated.Hb and cross matching- if significant blood loss anticipated. Other investigations should be indicated only when Other investigations should be indicated only when

clinically indicated.clinically indicated.

PREOPERATIVE FASTINGPREOPERATIVE FASTING milk clear fluidsmilk clear fluids <6mths 4 2<6mths 4 2 6-36mths 6 36-36mths 6 3 >36 mths 8 3>36 mths 8 3 Preoperative fasting times for different types of Preoperative fasting times for different types of

liquid and solidsliquid and solids clear breast cow/formula solidclear breast cow/formula solid milk milkmilk milk< 3 mths 2 4 4 6< 3 mths 2 4 4 6> 3 mths 2 4 6 6 > 3 mths 2 4 6 6

Infants and young children become Infants and young children become dehydrated easily than adults.dehydrated easily than adults.

Preoperative fasting is required to minimize Preoperative fasting is required to minimize residual gastric volume at induction of residual gastric volume at induction of anaesthesia and reduce the risk of anaesthesia and reduce the risk of pulmonary aspiration of gastric contents.pulmonary aspiration of gastric contents.

Gastric emptying time with breast milk and Gastric emptying time with breast milk and cow milk is more and thus more chances of cow milk is more and thus more chances of aspiration. aspiration.

PREMEDICATIONPREMEDICATION No premedication is required for < 6 mthsNo premedication is required for < 6 mths The need for premedication should be The need for premedication should be

individualized according to-individualized according to- underlying medical conditionunderlying medical condition length of surgerylength of surgery desired induction of anaesthesiadesired induction of anaesthesia psychological make up of child and psychological make up of child and

family.family.

Drugs for premedicationDrugs for premedication MIDAZOLAM- MIDAZOLAM- Oral 0.5 - 0.75 mg/kgOral 0.5 - 0.75 mg/kg Nasal 0.2 - 0.3 mg/kgNasal 0.2 - 0.3 mg/kg Rectal 0.4 – 0.5 mg/kgRectal 0.4 – 0.5 mg/kg Im 0.1 – 0.15 mg/kgIm 0.1 – 0.15 mg/kg It takes 20 minutes for oral midazolam to be effectve.It takes 20 minutes for oral midazolam to be effectve. KETAMINE—KETAMINE— IM 2 mg/kg- in highly uncooperative ptsIM 2 mg/kg- in highly uncooperative pts Oral- 6 mg/kgOral- 6 mg/kg Nasal 3 mg/kgNasal 3 mg/kg ORAL TRANSMUCOSAL FENTANYL CITRATEORAL TRANSMUCOSAL FENTANYL CITRATE (OTFC)(OTFC) 15 -20 mg/kg onset 20 – 30 min15 -20 mg/kg onset 20 – 30 min duration 30 minduration 30 min disadvantages nausea, vomiting, pruritis, occasional desaturation.disadvantages nausea, vomiting, pruritis, occasional desaturation. advantages decreases intra and post operatine analgesic requirements.advantages decreases intra and post operatine analgesic requirements.

SUFENTANILSUFENTANIL Nasal 1.5 – 3 microgm/kgNasal 1.5 – 3 microgm/kg Onset 10 minOnset 10 min Adv dec analgesic requireementsAdv dec analgesic requireements early discharge from hospitalearly discharge from hospital Disadv burning sensation in the noseDisadv burning sensation in the nose dec in chest wall compliance dec in chest wall compliance and oxygen saturation.and oxygen saturation.

H2 BLOCKERSH2 BLOCKERS To decrease the potential for aspiration of gastric To decrease the potential for aspiration of gastric

contents. contents. ANTICHOLINERGICSANTICHOLINERGICS glycopyrrolate 5mic/kgglycopyrrolate 5mic/kg atropine 20 mic/ kgatropine 20 mic/ kg -- lessen incidence of bradycardia-- lessen incidence of bradycardia -- reduces incidence of hypotension during-- reduces incidence of hypotension during induction in neonates and infantsinduction in neonates and infants -- prevent accumulation of secretions for pts wiyh -- prevent accumulation of secretions for pts wiyh

URTI,URTI, and those given ketamine. and those given ketamine.

INDUCTION OF ANAESTHESIAINDUCTION OF ANAESTHESIA Choice of agent and technique must be Choice of agent and technique must be

based on the needs of the individual patient.based on the needs of the individual patient. Method/ technique of induction is Method/ technique of induction is

determined bydetermined by -- medical condition of the patient-- medical condition of the patient -- surgical procedure-- surgical procedure -- level of anxiety of the child-- level of anxiety of the child -- whether able to cooperate, communicate.-- whether able to cooperate, communicate. -- presence or absence of full stomach.-- presence or absence of full stomach.

A- INHALATION INDUCTIONA- INHALATION INDUCTION -Reduced requirement-Reduced requirement -incd incidence of bradycardia, hypotension and cardiac arrest To -incd incidence of bradycardia, hypotension and cardiac arrest To

attenuate this, HR maintained and preload optimized.attenuate this, HR maintained and preload optimized. Iv atropine 0.02 mg/kg.Iv atropine 0.02 mg/kg. BSS or albumin 10-20ml/kg before inductionBSS or albumin 10-20ml/kg before induction **Most dangerous time during inhalation induction as the child loses **Most dangerous time during inhalation induction as the child loses

consciousness- depress the heartconsciousness- depress the heart So once anesthesia is induced, dec halothane or sevoflurane conc. till iv So once anesthesia is induced, dec halothane or sevoflurane conc. till iv

line is securedline is secured Don’t proceed to deeper planes of anesthesia without iv line in place.Don’t proceed to deeper planes of anesthesia without iv line in place. 22ndnd most dangerous point- immediately after tracheal intubation If most dangerous point- immediately after tracheal intubation If

vaporizer vaporizer not closed before laryngoscopy-overdose of inhaled anestheticsnot closed before laryngoscopy-overdose of inhaled anesthetics DISCONTINUE ALL ANESTHETICS UNTIL LARYNGOSCOPY AND ET DISCONTINUE ALL ANESTHETICS UNTIL LARYNGOSCOPY AND ET

INTUBATION ACCOMPLISHEDINTUBATION ACCOMPLISHED

TECHNIQUESTECHNIQUES NEONATES AND INFANTSNEONATES AND INFANTS holding the end of anaesthesia circuit in a holding the end of anaesthesia circuit in a

cupped hand over the infants face, the other cupped hand over the infants face, the other hand can adjust the conc of anaesthetic .hand can adjust the conc of anaesthetic .

Allowing the neonate or infant to suck on a Allowing the neonate or infant to suck on a rubber nipple or on a finger generally prevents rubber nipple or on a finger generally prevents crying during induction.crying during induction.

As the infant loses consciousness, the As the infant loses consciousness, the anaesthesia mask is added to improve delivery anaesthesia mask is added to improve delivery and to decrease operating room pollution.and to decrease operating room pollution.

PEDIATRIC PATIENTSPEDIATRIC PATIENTS 1- BLOW UP THE BALLON1- BLOW UP THE BALLON 2- HYPNOTIC SUGGESTIONS2- HYPNOTIC SUGGESTIONS anesthesia mask- aeroplane pilots maskanesthesia mask- aeroplane pilots mask smell of halothane- aviation fuelsmell of halothane- aviation fuel The use of constant conversation and 0.25 – 0.5% increase in inspired The use of constant conversation and 0.25 – 0.5% increase in inspired

concentration for 3 – 4 breaths. concentration for 3 – 4 breaths. If child holds breath, avoid assisted respiration as it can cause If child holds breath, avoid assisted respiration as it can cause

laryngospasm, coughing.laryngospasm, coughing. 3- FLAVOURED MASK3- FLAVOURED MASK 4- SINGLE BREATH TECHNIQUES4- SINGLE BREATH TECHNIQUES Child is asked to take a full inspiration followed by a full expiration. Child is asked to take a full inspiration followed by a full expiration.

Placement of mask at the end of expiration, another full inspiration held as Placement of mask at the end of expiration, another full inspiration held as long as possible and then normal breathing.long as possible and then normal breathing.

Prior to inductioin– circuit is filled with 55 halothane in 60% n2o.Prior to inductioin– circuit is filled with 55 halothane in 60% n2o. Takes < 1 min for inductionTakes < 1 min for induction

HALOTHANEHALOTHANE Standard agent Standard agent Sweat, non pungent, allows smooth induction and Sweat, non pungent, allows smooth induction and

maintenance.maintenance. early onset and recovery.early onset and recovery. Lower MAC in neonates d/tLower MAC in neonates d/t A- immaturity of CNS.A- immaturity of CNS. B- attenuation of pain response d/t high levels of B- attenuation of pain response d/t high levels of

plasma peptides.plasma peptides. Higher MAC in infants d/t increase in brain water Higher MAC in infants d/t increase in brain water

content.content. In view of profound cvs effects of halothane in infants In view of profound cvs effects of halothane in infants

an incremental technique of induction is employed.an incremental technique of induction is employed.

Incremental technique- Incremental technique- Following the administration of 70% Following the administration of 70%

N2O in oxygen, halothane N2O in oxygen, halothane concentration is increased in 0.5% concentration is increased in 0.5% increments every 3-5 breaths.increments every 3-5 breaths.

Consciousness is usually lost after 1-Consciousness is usually lost after 1-2 min. this incremental technique 2 min. this incremental technique may occasionally be associated with may occasionally be associated with An exaggerated excitement phase. An exaggerated excitement phase.

ISOFLURANEISOFLURANE Less myocardial depressantLess myocardial depressant Preservation of heart ratePreservation of heart rate Greater reduction of CMRO2Greater reduction of CMRO2 Noxious smell and thus greater incidence Noxious smell and thus greater incidence

of airway related problems.of airway related problems. DESFLURANEDESFLURANE Unsuitable for inhalational induction as it Unsuitable for inhalational induction as it

has a pungent etheral odour.has a pungent etheral odour.

SEVOFLURANESEVOFLURANE DOC for inhalational induction in many centres DOC for inhalational induction in many centres

becoz of its- becoz of its- - --minimal pungency - --minimal pungency

---Relatively low BG solubility- rapid induction and ---Relatively low BG solubility- rapid induction and recovery. recovery.

A combinatioin of N20 70% in oxygen is given A combinatioin of N20 70% in oxygen is given initially to obtund the child. At this stage, 8% initially to obtund the child. At this stage, 8% sevoflurane can be introduced without any reaction sevoflurane can be introduced without any reaction from the patient and unconsciousness will be from the patient and unconsciousness will be produced after 4-6 breaths. In addition to produced after 4-6 breaths. In addition to increasing the speed of induction, the use of 8% increasing the speed of induction, the use of 8% sevoflurane results in less excitation than an sevoflurane results in less excitation than an incremental technique.incremental technique.

Disadvantages sevofluraneDisadvantages sevoflurane relatively higher rate of relatively higher rate of

metabolismmetabolism fluoride ionfluoride ion compound A .compound A .

NITROUS OXIDENITROUS OXIDE Sweet smelling, non irritant, non inflammable.Sweet smelling, non irritant, non inflammable. Occasionally premature and sick neonates Occasionally premature and sick neonates

may not tolerate cvs effects of nitrous in which may not tolerate cvs effects of nitrous in which case air may be substituted as a carrier gas case air may be substituted as a carrier gas for oxygen.for oxygen.

Main contraindication is h/o air pockets within Main contraindication is h/o air pockets within the body and the need for high inspired the body and the need for high inspired oxygen concentration. oxygen concentration.

INTRAVENOUS INDUCTIONINTRAVENOUS INDUCTION Important when induction with mask is contraindicated- full Important when induction with mask is contraindicated- full

stomach, reflux esophagitisstomach, reflux esophagitis i/v access.i/v access. Cannulation of tiny pediatric patient can be difficult.Cannulation of tiny pediatric patient can be difficult. Use of EMLA crème.Use of EMLA crème. All air bubbles should be removed from the i/v line since All air bubbles should be removed from the i/v line since

high incidence of patent foramen ovale increases the risk of high incidence of patent foramen ovale increases the risk of paradoxical air embolism.paradoxical air embolism.

In emergency situations where iv access is impossible fluids In emergency situations where iv access is impossible fluids can be effectively infused through an18 G needle inserted can be effectively infused through an18 G needle inserted into the medullary sinusoids within the tibial bone. This into the medullary sinusoids within the tibial bone. This intraosseous infusion can be used for all medications intraosseous infusion can be used for all medications normally given iv with rapid result.normally given iv with rapid result.

1- THIOPENTONE SODIUM1- THIOPENTONE SODIUM Lower dose in neonates than in infantsLower dose in neonates than in infants Neonates- 4-5 mg/kgNeonates- 4-5 mg/kg Infants - 7-8 mg/kgInfants - 7-8 mg/kg decreased dosage in neonates is due to decreased dosage in neonates is due to -- immature brain-- immature brain -- decreased plasma protein binding-- decreased plasma protein binding -- more permeable BBB.-- more permeable BBB.

INCREASED REQUIREMENT in infants d/tINCREASED REQUIREMENT in infants d/t increased cardiac output as this would be expected to increased cardiac output as this would be expected to

reduce the first pass concentration of thiopentone arriving reduce the first pass concentration of thiopentone arriving at the brain.at the brain.

PropofolPropofol Dose required is higher in childrenDose required is higher in children < 2 yrs – 2.9 mg/kg< 2 yrs – 2.9 mg/kg 6-12 yrs – 2.2 mg/kg6-12 yrs – 2.2 mg/kg

KETAMINEKETAMINE AS an induction agent in neonates especially AS an induction agent in neonates especially

those with cyanotic heart disease.those with cyanotic heart disease.

RECTAL INDUCTIONRECTAL INDUCTION Child falls asleep in parents arms Child falls asleep in parents arms Methohexital- 10% 25- 30 mg / kg Methohexital- 10% 25- 30 mg / kg Induction within 8-10 minutes.Induction within 8-10 minutes. THIOPENTONETHIOPENTONE 30mg/kg30mg/kg Ketamine 10 mg/kgKetamine 10 mg/kg Midfazolam 1mg/kg max 20 mgMidfazolam 1mg/kg max 20 mg

INTRAMUSCULAR INDUCTIONINTRAMUSCULAR INDUCTION Adv- reliabilityAdv- reliability Disadv- painfulDisadv- painful Methohexital – 10 mg/kgMethohexital – 10 mg/kg Ketamine -- 1 – 10 mg/kgKetamine -- 1 – 10 mg/kg Midazolam -- 0.1 mg/ kgMidazolam -- 0.1 mg/ kg

RAPID SEQUENCE INDUCTION WITH RAPID SEQUENCE INDUCTION WITH CRICOID PRESURECRICOID PRESURE

In full stomach patientsIn full stomach patients Rapid desaturationmay occur in child Rapid desaturationmay occur in child

because- oxygen consumption highbecause- oxygen consumption high child may refuse preoxygenationchild may refuse preoxygenation Atropine 0.02 mg/kg is given iv to prevent Atropine 0.02 mg/kg is given iv to prevent

reflux induced/ sch induced bradycardia.reflux induced/ sch induced bradycardia.

Prep. of intubating equipment and Prep. of intubating equipment and suctionsuction

Preoxygenation of lungsPreoxygenation of lungs Rapid induction using STP, propofol Rapid induction using STP, propofol

or ketamineor ketamine Application of cricoid pressureApplication of cricoid pressure Rapid onset of paralysis with sch, rocRapid onset of paralysis with sch, roc

MUSCLE RELAXANTSMUSCLE RELAXANTS SUCCINYL CHOLINESUCCINYL CHOLINE 1-- Highly water soluble, therefore increased dose 1-- Highly water soluble, therefore increased dose

requirement inrequirement in paediatric patients.paediatric patients. 2 – effective when given intramuscular. 2 – effective when given intramuscular. Infants – 5 mg/kg Infants – 5 mg/kg children 4 mg/kgchildren 4 mg/kg onset 3-4 min onset 3-4 min duration of relaxation 20 minduration of relaxation 20 min In an emergency situation scholine can be given In an emergency situation scholine can be given

intralingually. 2 mg/ kg in midline to avoid hematoma intralingually. 2 mg/ kg in midline to avoid hematoma formation. formation.

3– Children are more susceptible than adults 3– Children are more susceptible than adults to cardiac arrhythmias, hyperkalemia, and to cardiac arrhythmias, hyperkalemia, and malignant hyperthermia after Sch malignant hyperthermia after Sch administration due to underlying administration due to underlying unrecognized muscle dystrophy. So it should unrecognized muscle dystrophy. So it should be best avoided for routine elective surgery be best avoided for routine elective surgery in children.in children.

4– atropine should be given just prior to the 4– atropine should be given just prior to the first dose of scholine in all children including first dose of scholine in all children including teenagers.teenagers.

NON DEPOLARIZING MUSCLE RELAXANTSNON DEPOLARIZING MUSCLE RELAXANTS Immaturity of neuromuscular junctiontends to Immaturity of neuromuscular junctiontends to

increase senstivity.increase senstivity. Disproportionately large extracellular compartment Disproportionately large extracellular compartment

results in dilution of drug.results in dilution of drug. Greater volume of distribution in neonates result Greater volume of distribution in neonates result

inslower rate of excretion and prolongation of inslower rate of excretion and prolongation of effect.effect.

Drugs such as vecuronium which has hepatic Drugs such as vecuronium which has hepatic metabolism has increased duration of effect.metabolism has increased duration of effect.

Hoffman degradation of atracurium makes it useful Hoffman degradation of atracurium makes it useful but histamine release can be a problem.but histamine release can be a problem.

MIVACURIUMMIVACURIUM 0.2 – 0.3 mg/kg dose causes adequate relaxation 0.2 – 0.3 mg/kg dose causes adequate relaxation

within 2 minutes and thus is ideal for constant within 2 minutes and thus is ideal for constant infusion.infusion.

ROCURONIUMROCURONIUM 0.6 mg/kg for routine induction0.6 mg/kg for routine induction 0.9 – 1.2 mg/kg- rapid sequence induction but 0.9 – 1.2 mg/kg- rapid sequence induction but

prolonged duration 60-90 min should be expected.prolonged duration 60-90 min should be expected. It offers the advantage that it could be given It offers the advantage that it could be given

intramuscularly in deltoid. It produces intubating intramuscularly in deltoid. It produces intubating conditions in 3 – 4 minutes. conditions in 3 – 4 minutes.

im- 1mg/kg infantsim- 1mg/kg infants 1.8 mg/kg children > 1 yr1.8 mg/kg children > 1 yr

Because of the extreme variability in Because of the extreme variability in response, the doses of long acting response, the doses of long acting muscle relaxants should be titrated muscle relaxants should be titrated carefully starting from half to third of carefully starting from half to third of the usual dose.the usual dose.

The effect of the incremental doses The effect of the incremental doses of ms relaxants should be monitored of ms relaxants should be monitored with a peripheral nerve stimulator. with a peripheral nerve stimulator.

ANTAGONISM OF MS RELAXANTSANTAGONISM OF MS RELAXANTS IT is recommended in all neonates IT is recommended in all neonates

and infants even if they have and infants even if they have recovered clinically becoz any recovered clinically becoz any increase in the work of breathing may increase in the work of breathing may cause fatigue and respiratory failure. cause fatigue and respiratory failure. Useful signs of reversal are the ability Useful signs of reversal are the ability of infant to lift the legs and arms.of infant to lift the legs and arms.

PEDIATRIC AIRWAY PEDIATRIC AIRWAY MANAGEMENTMANAGEMENT

INTUBATIONINTUBATION Following inhalational induction, N20 and Following inhalational induction, N20 and

vaporizers should be discontinued prior to vaporizers should be discontinued prior to intubation so that that the lungs contain high intubation so that that the lungs contain high inspiratory concentration of oxygen to combat inspiratory concentration of oxygen to combat apnoea.apnoea.

Correct head positionCorrect head position Application of the external pressure at the Application of the external pressure at the

level of cricoid cartilage to push the larynx into level of cricoid cartilage to push the larynx into view.view.

LARYNGOSCOPE BLADELARYNGOSCOPE BLADE INFANTS- flat blades are more suitable as it INFANTS- flat blades are more suitable as it

flattens out the curvature of the epiglottis and flattens out the curvature of the epiglottis and can be used to lift it forward to expose the can be used to lift it forward to expose the larynx.larynx.

> 1 yr– medium sized curved badeswith the tip > 1 yr– medium sized curved badeswith the tip placed in the vallecula.placed in the vallecula.

Gentle insertion, avoid trapping the lips Gentle insertion, avoid trapping the lips between teeth and blade . Not to lever on between teeth and blade . Not to lever on upper tooth.upper tooth.

Tube sizeTube size Uncuffed tubes < 8 yrs of age.Uncuffed tubes < 8 yrs of age. Decreased incidence of post intubation croupDecreased incidence of post intubation croup Provide a leak tominimize the risk of Provide a leak tominimize the risk of

accidental barotauma. Allow a leak when 20- accidental barotauma. Allow a leak when 20- 30 cm of water pressure is applied.30 cm of water pressure is applied.

Size- < 6yrs – age/3 +3.5Size- < 6yrs – age/3 +3.5 >6 yrs – age/4 + 4.5>6 yrs – age/4 + 4.5 neonate 3 kg – 3 mmidneonate 3 kg – 3 mmid < 3kg – 2.5 mmid< 3kg – 2.5 mmid

Tube lengthTube length Length of the tube should be such that Length of the tube should be such that

the tip of the tube lies in midtrachea the tip of the tube lies in midtrachea while 2-3 cm protrudes from the mouth.while 2-3 cm protrudes from the mouth.

Length in cm = ID X 3Length in cm = ID X 3 > 2 yr = age/2 + 13> 2 yr = age/2 + 13 Neonate = 10 cmNeonate = 10 cm 1 yr = 12 cm1 yr = 12 cm

ANESTHESIA CIRCUITS FOR ANESTHESIA CIRCUITS FOR PEDIATRICSPEDIATRICS

A- dead space should be minimalA- dead space should be minimal B- weight and size be suitableB- weight and size be suitable C- no valves to cause undue obstructionC- no valves to cause undue obstruction D- humidified gases be usedD- humidified gases be used E- reservoir bag should be smaller to E- reservoir bag should be smaller to

monitor respiratory movements.monitor respiratory movements. F- facemask must fit well to contour of face.F- facemask must fit well to contour of face. G- work of breathing should be less while G- work of breathing should be less while

preventing rebreathing.preventing rebreathing.

NON REBREATHING CIRCUITSNON REBREATHING CIRCUITS 1- provide minimal WOB becoz they have no valves to be 1- provide minimal WOB becoz they have no valves to be

opened up by patients respiratory efforts.opened up by patients respiratory efforts. 2- rate of induction is rapid becoz2- rate of induction is rapid becoz - volume of non rebreathing circuit is less- volume of non rebreathing circuit is less - no equilibrium with CO2 absorber is required- no equilibrium with CO2 absorber is required - anaesthetic gases are delivered immediately in the - anaesthetic gases are delivered immediately in the

airway.airway. 3- as the volume of nonrebreathing circuit is small as 3- as the volume of nonrebreathing circuit is small as

compared to that of circle system,the compression and compared to that of circle system,the compression and compliance volumes are significantly less. This improves compliance volumes are significantly less. This improves the ability to observe respiratory efforts as reflected by the ability to observe respiratory efforts as reflected by movement of anaesthesia bag as well as the ability to movement of anaesthesia bag as well as the ability to estimate pulmonary compliance.estimate pulmonary compliance.

T – piece systemT – piece system Original T- piece ( Ayres) system Original T- piece ( Ayres) system

consists of light metal T tube with a consists of light metal T tube with a main lumen of 1cm diameter and of main lumen of 1cm diameter and of smaller side tube at right angle to the smaller side tube at right angle to the main lumen through which anaesthetic main lumen through which anaesthetic gas mixture was introduced. A length of gas mixture was introduced. A length of rubber tubing attached to open end of T rubber tubing attached to open end of T piece act as reservoir for anaesthetic piece act as reservoir for anaesthetic gases. gases.

Jackson Rees modificationJackson Rees modification Attached open tailed bag to the reservoir Attached open tailed bag to the reservoir

tube in order to facilitate controlled tube in order to facilitate controlled ventilation. ventilation.

ADV- simplicityADV- simplicity convenienceconvenience compact sizecompact size T Piece system rely on adequate FGF to T Piece system rely on adequate FGF to

eliminate CO2eliminate CO2 During spontaneous vent- FGF > 2 MVDuring spontaneous vent- FGF > 2 MV Controlled vent FGF = MVControlled vent FGF = MV

CIRCLE SYSTEMCIRCLE SYSTEM Consists of – Consists of – afferent and efferent breathing tubesafferent and efferent breathing tubes Reservoir bagReservoir bag Chemical absorberChemical absorber One way flow d/t unidirectional valvesOne way flow d/t unidirectional valves ADV- ADV- Economical use of anaesthetic gasesEconomical use of anaesthetic gases Conservation of heat and humidityConservation of heat and humidity

Provided ventilation is controlled in Provided ventilation is controlled in neonates and either controlled or neonates and either controlled or assisted in infants , a standard adult assisted in infants , a standard adult circle system fitted with low dead circle system fitted with low dead space connectors , a small bore tubing space connectors , a small bore tubing and a reduced capacity reservoir bag and a reduced capacity reservoir bag is suitable for maintenance of is suitable for maintenance of anaesthesia for pts of all ages.anaesthesia for pts of all ages.

MAINTENANCE OF MAINTENANCE OF ANAESTHESIAANAESTHESIA

The goals- The goals- Provision for adequate anesthesia and operating Provision for adequate anesthesia and operating

conditionsconditions Maintaining physiological hemostasis Maintaining physiological hemostasis Adequate fluid replacementAdequate fluid replacement Infants are poor candidates for anaesthesia with Infants are poor candidates for anaesthesia with

spontaneous ventilation becoz of poor pulmonary spontaneous ventilation becoz of poor pulmonary mechanics and increased susceptibility to cardiovascular mechanics and increased susceptibility to cardiovascular depressant effects of volatile anaesthetic agents.depressant effects of volatile anaesthetic agents.

Combination of tracheal intubation and balanced Combination of tracheal intubation and balanced anaesthesia with full dose of muscle relaxants , anaesthesia with full dose of muscle relaxants , controlled ventilation, minimum concentration of volatile controlled ventilation, minimum concentration of volatile anaesthetics and reduced dose of opioids is optimum.anaesthetics and reduced dose of opioids is optimum.

MONITORINGMONITORING

Pulse – temporal/ radial artery easily accessible.Pulse – temporal/ radial artery easily accessible. Precordial/ esophageal stethoscope auscu;ltationPrecordial/ esophageal stethoscope auscu;ltation ECG monitoringECG monitoring Respiratory monitoring by visual movements of chest wallRespiratory monitoring by visual movements of chest wall Pulse oximetryPulse oximetry ETCo2 for assessment of ventilation and confirmation of ETCo2 for assessment of ventilation and confirmation of

ETT placement and early warning of MH.ETT placement and early warning of MH. Temperature monitoringTemperature monitoring Urine outputUrine output FluidsFluids Glucose monitoringGlucose monitoring NIBP monitoringNIBP monitoring Invasive monitoringInvasive monitoring

POST OPERATIVE CAREPOST OPERATIVE CARE

Attention to the airwaysAttention to the airways Provision of oxygen therapyProvision of oxygen therapy Monitoring of pulse, respiration and blood Monitoring of pulse, respiration and blood

pressurepressure Completion of post anaesthetic recovery chartsCompletion of post anaesthetic recovery charts Recovery nurses should be trained to detect Recovery nurses should be trained to detect

early changes in respiration and circulation and early changes in respiration and circulation and should be able to initiate treatment while the should be able to initiate treatment while the anaesthesiologist is summoned.anaesthesiologist is summoned.

Once the child is awake , one of the patients Once the child is awake , one of the patients parent can come in the recovery. parent can come in the recovery.

PROBLEMS DURING RECOVERYPROBLEMS DURING RECOVERY

-- Hypoxemia – oxygen administered routinely to-- Hypoxemia – oxygen administered routinely to all ptsall pts -- Post operative apnea-- Post operative apnea -- Nausea and vomiting –-- Nausea and vomiting – perinorm-0.15 -0.25perinorm-0.15 -0.25 emeset- 0.05- 0.1 mg/kgemeset- 0.05- 0.1 mg/kg -- Post intubation croup-- Post intubation croup -- Post operative pain relief- -- Post operative pain relief- oral pcm= 15 mg/kgoral pcm= 15 mg/kg 0.5 mg/ kg0.5 mg/ kg -- Postoperative fluids-- Postoperative fluids

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