4/9/2015 1 Pediatric Anesthesia for the Generalist Ellen R. Basile, DO Assistant Professor Department of Anesthesia OU Medical Center The CV • My Background • Pediatric Anesthesiologist • Medical School in Philadelphia • Anesthesia Residency in Philadelphia • Pediatric Fellowship in Philadelphia • I have no financial disclosures
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4/9/2015
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Pediatric Anesthesia for the Generalist
Ellen R. Basile, DOAssistant ProfessorDepartment of AnesthesiaOU Medical Center
The CV
• My Background
• Pediatric Anesthesiologist
• Medical School in Philadelphia
• Anesthesia Residency in Philadelphia
• Pediatric Fellowship in Philadelphia
• I have no financial disclosures
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Objectives for our Pediatric Anesthesia for the Generalist
• To review everyday pediatric topics
• Identify areas of Morbidity and Mortality in Pediatrics
• Review Pediatric Anesthesia Recommendations
• Provide an opportunity to ask / answer pediatric anesthesia questions
Everyday Topics• Premedication• NPO Guidelines• Emergency Rx’s• Narcotics• To Cancel or Not?• Laryngospasm• Asthma• T&A’s• Emergence Delirium• X-Premies• Difficult Airways• NOT EVERY DAY TOPICS
M&MSmart TotsPediatric Recommendations
Premed Anyone?
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Premedication
• 40-60% children develop anxiety pre-op
• Separation from parents & induction
• Around 9 mos: separation anxiety• Cote
Premedication
• Pharmacological vs Behavioral Interventions• Versed, midazolam most common Rx
0.5 mg/kg PO , max doseonset 15-30min
??delayed emergence, increased irritability PACU??• Parental Presence• Child Life• Studies show parental presence no additional benefit
when compared with Rx
Happy Meal, good times!
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NPO Guidelines
• 2,4,6,8 --Who do we appreciate?
• Clears 2 hours
• Breast Milk 4 hours
• Formula, G-Tube,
• milk, Light meal 6 hours
• Full/fatty meal 8 hours
Anesthesia STAT
Pediatric Emergency Rx
• Atropine 20mcg/kg
• Succinylcholine 1-3mg/kg
• Epinephrine 1-10mcg/kg
• PRBC’s, O2, Epi, Calcium
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Succinylcholine
• Not used routinely in Pediatrics
• Indications: Airway emergencies (RSI)
Black Box WarningSuccinylcholine
• WARNING• RISK OF CARDIAC ARREST FROM HYPERKALEMIC RHABDOMYOLYSIS• There have been rare reports of acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias,
cardiac arrest, and death after the administration of succinylcholine to apparently healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy.
• This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or younger). There have also been reports in adolescents.
• Therefore, when a healthy appearing infant or child develops cardiac arrest soon after administration of succinylcholine not felt to be due to inadequate ventilation, oxygenation, or anesthetic overdose, immediate treatment for hyperkalemia should be instituted. This should include administration of intravenous calcium, bicarbonate, and glucose with insulin, with hyperventilation. Due to the abrupt onset of this syndrome, routine resuscitative measures are likely to be unsuccessful. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation in some reported cases. In addition, in the presence of signs of malignant hyperthermia, appropriate treatment should be instituted concurrently.
• Since there may be no signs or symptoms to alert the practitioner to which patients are at risk, it is recommended that the use of succinylcholine in children should be reserved for emergency intubation or instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible (see PRECAUTIONS: Pediatric Use andDOSAGE AND ADMINISTRATION).
• This drug should be used only by individuals familiar with its actions,
Epinephrine
• PALS code dose 10mcg/kg
• If using 1:10,00 Epi, dose is 0.1mL/kg
• Bradycardia 2° Hypoxia in peds, Epi now recommended over atropine
• Incidence 1.4: 10,000 (mortality 26%)• 37% Rx related
• 32 % CV related
ASA 1-2 64% cardiac arrests related to RX
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Morbidity & MortalityPOCA registry
• Infants < 1 yo were 55% of anesthesia related arrests
• Two predictors of mortality
ASA 3-5
Emergency StatusAnesthesia-related cardiac arrest in children: initial findings of Pediatric Perioperative Cardiac Arrest (POCA) registry, Morray.
2003
Pediatric Recommendations
• Increased risk anesthetic complications in pediatric patients
• Studies support decreased risk M&M with Pediatric Anesthesiologist
• ASA has no clearly defined recommendations
• American College of Surgeons has recommendations
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ASA Recommendations
ASA Recommendations• 2011
• Written policies on types of pediatric surgeries
• Determine criteria for anesthesia care of pediatric patients
• Increased anesthetic risk should be staffed by peds fellowship trained anesthesiologist
American College of Surgeons
• Surgical Centers determined by level of care
I- ASA 1-5, any age, must have 2 pediatric anesthesiologist on staff
II- ASA 1-3, any age, must have 1 pediatric anesthesiologist on staff
III- ASA 1-3, age > 6yo, must have anesthesiologist with pediatric expertise #25
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American College of Surgeons
• Ambulatory Surgical Center Recommendations:– Focus on pre-term infants (54 wks PGA)
– Pediatric anesthesiologist OR Surgeon as med director
– <2 yo either peds anesthesiologist OR expertise in pediatric anesthesia
– 1 or more PALS certified staff for PACU
– FT infant >4wks < 6 mos 2-4 hours in PACU• Longer for infant <3mos old with opioid exposure
www.pedsanesthsia.org
IARS + FDA
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Smart Tots• 2012 Consensus Statement:
“Animal studies show long-term and possible permanent adverse effects on developing brain”
behaviorlearningmemory
Further research is required
QUESTIONS?
References• Cote. A Practice of Anesthesia for Infants and Children. Philadelphia, Elsevier,
2009.
• ASA, Statement on Practice Recommendations for Pediatric Anesthesia,Oct 19,2011.
• Gregory. Providing Anesthesia for Pediatric Patients, American Society Of Anesthesiologist, Vol 69, Number 3, 2005.
• Posner,KL. Unexpected cardiac arrest among children during surgery: a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest. Qual Saf Health Care; 2002;11:252-257.
• Morry,JP. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesthesiology, Jul;93 (1); 6-14.
• Jimenez, N. An update on pediatric anesthesia liability: a closed claims analysis. Anesth Analg, 2007 Jan; 104 (1); 147-53.
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References
• Optimal Resources for Children’s Surgical Care, From the Committee on Children’s Surgery, American College of Surgeons, Nov 20, 2014.