Infant

MAIN PRINCIPLES OF ANESTHESIA
IN NEONATES AND INFANTS

Dr. Omar Mohamed Danfour
Senior Lecturer Specialist of Anesthesia & Intensive Care
(MSU-IMS-Anesthesia Department)

-Anatomic variations
-Physiologic variations
-Respiratory system.
-CVS.
-Blood.
-Renal.
-Fluid.
-Nervous system
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative assessment.
-Fasting guidelines.
-I ntraoperative monitoring.
-Pain management.
-URTI .
-Special Problems in 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
hemodynamics
Unexpected responses
Unknown congenital
problem
Neonatals & Infants Anesthesia

Children < 1 year old have more
complications:
I. Oxygenation
II. Ventilation
III. Airway management
IV. Response to volatile
agents and medications

Consider:
1. Organ system immaturity
2. High metabolic rate
3. Large ratio body
surface/weight
4. Ease of miscalculating a
drug dose
5. Stress Response IS Poorly
tolerated

Neonatals & Infants Anesthesia

Prevention of paradoxical air
emboli

Fluids instituted with volume-
limiting devices

Minimize thermal stress

Prevent retinopathy of
prematurity by:
Lower FiO
2

Keep CO
2
within normal
range

No one should be denied
anesthesia because of the age or weight
Anatomical variations
OMore resistance to breathing.
Resistance increases with tracheal
intubation.
O Obligate nasal breathers
I mpair proper visualization
of larynx
O More incidence of accidental
extubation or endobroncheal
intubation with movement.
Severe airway obstruction can
occur with minimal decrease in
diameter
Physiologic variations
I ndependent life becomes possible
after 24-26 weeks of gestational life.
O2 consumption is 7ml\kg\min. (adult
3.5ml\kg\min).
Minute volume is 200ml\kg\min (adult
100ml\kg\min).
Smaller FRC.
-Anatomic variations
-CVS.
-Blood.
-Renal.
-Fluid.
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative assessmnet.
-I ntraoperative monitoring.
-Pain management.
-URTI .
-Take home message.
Respiratory system.
Increased airway resistance, decreased
lung compliance, and increased chest wall
compliance

Increased work of breathing
Smaller number of type I fatigue
resistance fibers

More incidence of developing respiratory
failure.
Immature baroreceptor response to
hypoxia

Hypoxia and hypercarbia depresses
respiration.
-Anatomic
variations
-CVS.
-Blood.
-Renal.
-Fluid.
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-I ntraoperative
monitoring.
-Pain management.
-URTI .
-Take home message.
Respiratory system.
They are more prone to hypoxemia because:
Infants have narrow margin of hypoxemic safety because
of small oxygen store and high oxygen demand.
Neonates have less sensitive chemorephlex response to
hypoxemia.
Neonates may respond to hypoxia in unpredictable ways.
Anesthetics and hypothermia abolish hypoxic
hyperventilation. Hypoxia may depress neonatal
ventilation.
Upper airway obstruction is common among neonates.
Neonates have immature respiratory control resulting in
irregular breathing and spontaneous apnea.
Nasogastric tube in neonates may compromise breathing
considerably.
Neonatal Hb in 60% consists of fetal Hb, which has a blow
unloading oxygen ability
Respiratory system.
Postoperative apnea
Premature newborns
especially those with
h\o apnea are at high
risk (20-40%) of
developing
postoperative apnea.
It occurs mostly within
12 hours
postoperatively.
Postoperative apnea
Factors associated with
development of
postoperative apnea are:
extent of surgery.
anesthetic technique.
anemia (Hct <30%)
postoperative
hypoxemia.
Respiratory system.
Postoperative apnea
Both theophylline and caffiene are effective in
reducing incidence of apnea in premature.
strengthening muscle contractility.
prevent fatigue.
stimulate respiration.
Respiratory system.
Fetal circulation has
persistence of right to
left shunt due to high
pulmonary vascular
resistance.
This shunt is through
foramen ovale and
ductus arteriosus.
With first breath after
delivery pulmonary
vascular resistance
falls rapidly closure
of foramen ovale.
ductus arteriosus also
closes due to increased
O2 tension.
CVS Physiologic variations
The Newborn Heart
Near peak of Starling curve
Stroke volume relatively fixed
C.O. relatively heart rate dependent
Factors associated with
prolonged transitional
(fetal) circulation
include:
Prematurity.
Infection.
Acidosis.
Pulmonary disease
resulting in hypoxia
and hypercarbia.
Hypothermia.
Congenital heart
disease.
-Anatomic
variations
-Physiologic
variations
-Respiratory
system.
-CVS.
-Blood.
-Renal.
-Fluid.
-Thermoregulatio
n.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-Fasting
guidelines.
-I ntraoperative
monitoring.
-Pain
management.
-URTI .
-Take home
message.
Reversal from
adult to fetal
circulation
(persistent
circulation) can
occur due to:
Hypoxia.
Hypercarbia.
Anesthetic
induced change
in peripheral
vascular
resistance tone
Blood volume
~85ml\kg in
term neonates
& 105ml\kg
in preterm.
Predominant
hemoglobin
type is HbF.
Hb is 16g\dl
with Hct
55%.
Blood
Kidney function is immature & both
GFR & tubular functions are reduced.
Ability to handle free water & solute
load is impaired.
Premature neonates often posses
multiple renal defects:
decreased creatinine clearance
impaired sodium retention.
impaired glucose excretion.
impaired bicarbonate reabsorption.
poor dilution and concentration
ability.
-Anatomic
variations
-Physiologic
variations
-CVS.
-Blood.
-Renal.
-Fluid.
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-Fasting
guidelines.
-I ntraoperative
monitoring.
-Pain management.
-URTI .
-Take home
message.
Renal
Perioperative fluid
maintenance is divided into
maintenance deficit and
third space loss.
I- maintenance
- Can be achieved by
Holiday & Segar rule
(4:2:1).
- 18% NaCl in 4% dextrose
is usually sufficient to
provide energy and prevent
ketosis.
Fluid
Total body water
constitutes 80-85% of
body weight.
II- deficit
- Fluid deficits are calculated
and replaced based on:
O duration of fasting.
O presence of associated
conditions like fever,
vomiting, diarrhea,
sweating.
O particular disease state or
surgical problem likely to
affect fluid status (bowel
obstruction, peritonitis etc).

III- Intraoperative loss
Divided into third space
loss and blood loss.
Third space loss
O Surgical trauma, blunt
trauma, infection.
O Are associated with the
isotonic transfer of fluid
from the ECF to a non
functional interstitial
compartment.
O Impossible to estimate
accurately.
Third space loss
- Approximate estimate can be as
follow:
Intraabdominal surgery
6-10ml\kg\hr
Intrathoracic surgery
4-7ml\kg\hr
Eye surgery
Neurosurgery
Superficial surgery
Ringer lactate is an adequate
replacement solution.
Required clinical response is
adequate BP, HR, tissue
perfusion, and UOP 1-2ml\kg\hr.
1-2 ml\kg\hr
Blood loss
O The anesthesiologist
should have
a preoperative plan
regarding blood loss
replacement, based on
the patients preoperative
condition, preoperative
hematocrit and nature of
surgery.
O Generally, a hematocrit
of 28-30% is acceptable.
O An estimate of blood
volume (EBV) must be
first made:
I I I - I ntraoperative loss

Blood loss
Premature neonate
90-100 ml\kg
Term neonate
80-90 ml\kg
3 months to 1 year
75-80 ml\kg
3-6 years
70-75 ml\kg
> 6 years 65-70 ml\kg
Blood loss
- ABL is calculated using the
formula:

Ho is the starting hematocrit
H1 is the lowest acceptable
hematocrit
Ha is the average hematocrit
Ho+H1\2
O example: body Wt. 3.5kg,
starting Hct. 50, acceptable
Hct. 40
allowable bl. Loss = 3.5 x 85
x 50-40\45 = 66ml.
ABL = Weight X EBV X (Ho-H1)/Ha

Sympathetic and
parasympathetic functions do
exist in neonates but do not
mature until later in infancy.

There is a predominance of
parasympathetic response
system.

New born also respond to
noxious stimuli with facial
grimaces as well as
cardiovascular and metabolic
stress responses.

Nervous system
Retinopathy of Prematurity
Immature development of retinal
vasculature
Results in retinal scarring and
secondary blindness
Risk Factors:
Extreme prematurity
Low birth weight
Prolonged oxygen exposure
Mechanical ventilation
SpO2 90-94% intraoperatively

O The infant is particularly
vulnerable to hypothermia
because of both the large
ratio of body surface area to
weight and a limited ability to
cope with cold stress.

premature infant is even
more susceptible because of
very thin skin and limited fat
stores.

Compensatory mechanisms to
this may be shivering and non
shivering (cellular metabolic)
& vasoconstriction
thermogenesis.
Thermoregulation
Minimize heat loss can be
achieved by various
devices like use of :
+ Warming mattresses,
blankets,
+ Warm IV fluids and blood,
warming and humidifying
anaesthetic gases,
+ Over head radiant heaters
or incubators for transport,
+ Use of plastic wrap to
decrease evaporative loss,
+ Warming of preparation
solution, and
+ Increasing the operating
room temperature.

At birth, the
functional
maturity of the
liver is
incomplete.
Most enzyme
systems for
drug
metabolism
although
developed, are
not yet induced
(stimulated) by
the agents they
metabolize.
GI T
O Minimal glycogen stores, inability to
handle large protein loads, and lower
levels of plasma albumin and other
drug binding proteins.
O These factors account for tendency to
hypoglycemia and acidosis.
O The lower albumin levels contribute
to neonatal coagulopathy, decreased
drug binding and higher levels of free
drug.
O In neonates, infants, lower esophageal
sphincter tone is decreased. Also the
ability to co-ordinate swallowing with
respiration is not fully matured till 4-
5 months of age.
O These two factors increase the
incidence of gastroesophageal reflux.
Cardivascular:
- Decrease in pulmonary vascular resistance.
- Closure of PDA.
- Closure of foramen ovale.
- Cardiac output is dependent mainly on heart rate and LV filling.
Respiratory:
- Increased WOB.
- Narrow margin of hypoxia.
- Periodic breathing.
Metabolic:
- Physiologic jaundice.
Renal:
- Decreased GFR.
- Poor ability to concentrate or dilute urine.
- Obligatory sodium loss.
Temperature:
- Non-shivering thermo-genesis and susceptibility to hypothermia.
Neurologic:
- Immature autonomic nervous system with parasympathetic predominance
and poor sympathetic tone.
- Immature central nervous system.
- Incomplete myelination.
O Changes in drug distribution during growth are associated
with the changes in body composition
O Water-soluble drugs should be given in increased dose
per kilogram of body weight.
O Plasma protein binding of drugs is less in newborns - this
results in higher concentration of the unbound free
drugs.
O The blood-brain barrier is more permeable in newborn
for most of anesthetics and opioids.
O The maintenance dose of a drug depends on body
clearance - these processes tends to be very slow in
newborn.
Pahrmakokinetics and pharmakodynamics
O Distribution - increased
O Biottransformation decreased
O Renal excretion - decreased
O The uptake of volatile anesthetics is faster in children
than in adults

O The MAC is higher in infants than in neonate &
adult

O Blood pressure of neonates & infants tends to be
more sensitive to volatile anesthetics (not fully
developed compensatory mechanism e.g V.C &
tachycardia)

O volatile anesthetics depress ventilation more in
infants.

O Sevofurane has become a preferred induction agent
in pediatric Anesthesia.

-Anatomic
variations
-Physiologic
variations
-Respiratory
system.
-CVS.
-Blood.
-Renal.
-Fluid.
-Nervous system
-Thermoregulation
.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-Fasting
guidelines.
-I ntraoperative
monitoring.
-Pain
management.
-URTI .
-Take home
message.
Volatile anesthetics
Thiopentone
A significantly larger volume of distribution in the infant,
makes the ED-50 of thiopentone in infants significantly
greater (6mg\kg) than that in adults (4 mg\kg).

In neonates due to their low body fat and muscle content,
less thiopentone (3-4mg/kg)is apportioned to these
tissues; so concentration in the CNS may remain high and
delay awakening.
Benzodiazepines
The premature and the mature infant at term eliminate
diazepam at a slower rate than adults do.
EMLA cream (Eutectic mixture of lidocaine and prilocaine)
For cutaneous application one hour preop

Propofol
Younger children demonstrated a larger Vd
with a similar rate of clearance.

Children require larger doses of propofol
compared to adult.
-Anatomic
variations
-Physiologic
variations
-CVS.
-Blood.
-Renal.
-Fluid.
-Nervous system
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-Fasting
guidelines.
-I ntraoperative
monitoring.
-Pain
management.
-URTI .
-Take home
message.
Ketamine
In infants less than 3 months of age, the Vd
is similar to that in older infants but the
elimination half-life is prolonged. Hence,
clearance is reduced in the younger infants.
Reduced metabolism and renal excretion in
the young infant are the likely causes.
Narcotics
O More potent in neonates than in older children &
adult because it is easier entry BBB, decrease
metabolic capability & increase sensitivity of
respiratory centers
Morphine :
+ Should be used with caution in neonates because
hepatic conjugation is reduced & renal clearance is
decreased.
O Pethidine :
+ It produces only 1/10 the respiratory depression and
less sedation than morphine.

Fentanyl: In the neonate, fentanyl clearance seems
comparable to that of the older child or the adult,
while in the premature infant fentanyl clearance is
markedly reduced
-Anatomic
variations
-Physiologic
variations
-CVS.
-Blood.
-Renal.
-Fluid.
-Nervous system
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-Fasting
guidelines.
-I ntraoperative
monitoring.
-Pain
management.
-URTI .
-Take home
message.
Neuromuscular blocking drugs (NMBD)
Depolarizing muscle relaxants:
+ On a weight basis more succinylcholine is needed in infants than in
older children or adults because of relatively large volume of
distribution (extracellular space)

+ The recommended dose is twice that of adults (2 mg\kg).

+ Succinylcholine is best avoided for routine elective surgery in children
& Atropine must always administered prior Succinylcholine.

Non depolarizing muscle relaxants (NDMR):
+ There is an increased sensitivity of neuromuscular junction to NDMR
which is balanced by increased Vd, so the required dose is unaffected.
+ However, because of a prolonged elimination time (hepatic
metabolism), doses of additional relaxants should be reduced and
given less frequently.
+ Children of all ages are more resistant than adults to pancuronium.
Neuromuscular blocking drugs (NMBD)
Anticholinesterases:
+ Neuromuscular blockade in children is
antagonized much faster and by much smaller
doses of anticholinesterases as compared to
adults.
+ Both cholinesterase and pseudocholinesterase
levels are reduced in premature and term
newborns.
+ Adult levels are not reached until one year of
age.
+ Inspite of the reduced pseudocholinesterase
levels, newborns are more resistant to
succinylcholine than adults are.
-Anatomic
variations
-Physiologic
variations
-CVS.
-Blood.
-Renal.
-Fluid.
-Nervous system
-Thermoregulation.
-GI T.
-Pharmacology.
-Preoperative
assessmnet.
-Fasting
guidelines.
-I ntraoperative
monitoring.
-Pain
management.
-URTI .
-Take home
message.
Preoperative assessment
A careful history and examination will reveal the presence of :
Preoperative risk
1. Airway problems (anatomical, physiological, allergic, asthma, etc).
2. Convulsions, sleeping disturbances (obstructive sleep apnea,
particularly in children coming for tonsillectomy).
3. Cardio-respiratory problems.
4. Prematurity
5. Haematological problems like thalassaemia major and minor,
clotting factor deficiencies, sickle cell disease etc.,
6. Inborn errors of metabolism or deficiencies may run in families or
communities, like pseudocholinesterase deficiency.
Intraoperative risk
Blood transfusion.
Hypothermia.
Hypoxia.
Postoperative risk
Postoperative admission.
Prolonged mechanical ventilation.

Laboratory
- According to
medical condition
and nature of
surgery.
- Some practitioners
recommend Hb\Hct
for all of them.

Premedication
- Anti-cholinergic.
- Antibiotic
prophylaxis.
Fasting guidelines
No water and other clear
liquids for 2 hour prior to
surgery
No breast milk for 4 hours
prior to surgery.
No solids or formula milk for
6 hours prior to surgery.

Children may receive
medications 30 min before
surgery with up to 50 ml of
water.
Children should refrain from
gum-chewing 2-4 hours
before surgery.

Endotracheal Tubes
Age Size (mm ID)
Preterm
1000 g 2.5
1000-2500 g 3.0
Neonate-6
months
3.0-3.5
6 months-1
year
3.5-4.0
1-2 years 4.0-5.0
Beyond 2
years
(age in years /4+4
Oral airway use
Endotracheal tube size
Uncuffed vs. cuffed
Assessment for leak

Intraoperative monitoring
O Must be consistent with the
severity of the underlying
medical condition
O Minimal monitoring:
A. 5 ASA monitors
ECG.
Sa O
2.

Capnography.
NIBP or IBP in major surgery.
Temperature monitoring (core and
skin)
B. Precordial stethoscope.
C. Anesthetic agent analyzer

Postoperative pain management
Narcotic
analgesics.
Non-narcotic
analgesics.
Regional
anesthetic
techniques
Narcotic analgesics

Morphine may be used with Careful
respiratory monitoring and facilities for
resuscitation must be available because
of the problem of respiratory
depression.

Common side effects encountered with
opioids are nausea, vomiting, dyspepsia,
constipation, urinary retention,
respiratory depression, drowsiness,
euphoria etc.

Continuous iv infusion or PCA can be
used with continuous apnea monitoring

Non-narcotic analgesics
They are effective with
few side effects and
produce an opioid sparing
action.

These drugs act
peripherally by inhibiting
prostaglandin (PGs) and
thereby, blocking the
afferent pain mediators
and impulses.

These are useful for mild
to moderate pain or as
adjuncts with narcotics to
decrease the side effects
of narcotics.

Paracetamol (Acetaminophen) : This
is the most common analgesic used
in the children.
+ It is very useful as a postoperative
analgesic specially if used with
Ibuprofen. 15-20 mg\kg can be used
safely orally every 4 hours.
+ Nephrotoxicity and hepatotoxicity
are the commonly encountered
complications but, are not seen with
short term use.

Ibuprofen : This is a better analgesic
than acetaminophen. Oral
formulations are available and 4-10
mg/kg-1dose-every 6-8 hours is
quite effective.
Diclofenac : This is more powerful antiinflammatory drug than
acetaminophen and ibuprofen. However, the incidence of
nephrotoxicity and GI complications are also higher with
this drug. It is available in tablet, syrup as well as suppository
form. The oral dose is 1-1.5 mg\kg 12 hourly.

Ketorolac : Ketorolac is a very useful analgesic in children, and its
opioid sparing effect has been confirmed. The IV or IM dose of
ketorolac is 0.2-0.5 mg\kg every 6 hours for 48 hours. Maximum
permitted total dose per day is 120 mg.

The commonly seen side effects with NSAIDs are
increased chances of bleeding, thrombocytopenia,
precipitation of asthma attacks, increase in heart rate,
retension of sodium and water, GI ulcerations, bleeding,
hepatotoxicity, nephrotoxicity, nausea, vomiting, and
dyspepsia etc.

Regional analgesic
techniques
Also known that
supplementing general
anaesthetic with regional or
nerve blocks:
decreased requirements for
general anaesthesia drugs

pain free awakening

avoidance of potentially
deleterious side effects that
may occur with parenteral
administration of narcotics
during surgery.

An excellent post operative
pain relief.
Regional analgesic
techniques
Various regional
techniques which
have been used in
children are:
+ lumbar epidural
+ caudal epidural
+ Intercostal
+ ilio inguinal and ilio
hypogastric
+ 3 in l block, sciatic
nerve block
+ fascia iliaca block
+ brachial plexus block
+ wrist block
+ penile block
+ infiltration block and
topical analgesia.
I felt loss
of
resistance
but no
CSF is
coming
Special Problems in Neonatal Anesthesia
(1)
:
Meningomyelocele:

Underestimating fluid or blood loss from the defect
High association with hydrocephalus
Possibility of cranial nerve palsy
Potential for brain-stem herniation
(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 induction
Consider awake intubation or Rapid Sequence Induction
Omphalocele and Gastroschisis:

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

Gastroschisis develops later in
life after gut has returned into
abdominal cavity
Abdominal contents and
organs are not covered with
any membrane risk of infection
(3)
:

Omphalocele and Gastroschisis
(3)
:

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
Minimize infection, Replenish
fluids, be liberal in muscle relaxants,
consider hypotension and difficulty
ventilation
Omphalocele and Gastroschisis
(3)
:

During closure consider
* difficulty ventilation
* hypotension
* ^ abdominal pressure may compromise liver
function and alter drug metabolism
Be aware of Beckwith-Wiedemann syndrome:
Profound hypoglycemia
Hyperviscosity syndrome
Associated visceromegaly

Much greater associated defects with
Omphalocele
More fluid loss associated with Gastroschisis

Tracheoesophageal fistula
anomaly
(1)
:
90 % proximal atresia of
esophagus
with distal fistula
Consider aspiration
pneumonitis.
VATER syndrome:
I. Vertebral
II. Anal
III. Tracheoesophageal
V. Renal
Most common cause of
death cardiac anomalies
T-type
Trachea
O Major issues are:

Aspiration pneumonia
Over distention of the
stomach
Inability to ventilate
Postoperative intensive care
(4)
:
Usually presentation
on 1
st
day of life
Almost all viscera can
be in the chest cavity
Anesthesia concerns:
I. Hypoxemia
II. Hypotension
III. Stomach
herniation
IV. Pulmonary
hypertension
V. Systemic
hypotension
Shifted
mediastinum
Diaphragmatic hernia
Anesthesiology
concern:
1. Awake intubation
2. Avoid hypothermia
3. Avoid any myocardial
depressant
4. Avoid N
2
O
(abdominal distention)
5. Aware of barotrauma-
induced pneumothorax
6. Adequate intravenous
access
7. Plan postoperative
care
(5)
:
Diaphragmatic hernia:

(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
Long acting muscle relaxants
Anemia (Hct < 30)
SUMMARY
Whenever neonates is anaesthetized consider:
- Possible difficulty in laryngeal exposure.
- Importance of keeping adequate hart rate.
- Relative higher incidence of:
Hypoxia
Airway obstruction
Perioperative apnea
Hypothermia
Hypoglycemia
Impaired drug handling (renal and hepatic factors)
Hypocoagulation
Immature sympathetic response and predominance of
parasympathetic response.
Hypotension due to volume depletion ( evaporation, "third-spacing", blood
loss) or bradycardia
Bradycardia due to hypoxia, hypercarbia, volatile anesthetic overdose, vagal
stimulation.

Infant

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MAIN PRINCIPLES OF ANESTHESIA

IN NEONATES AND INFANTS

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