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Physiologic differences

Preoperative evaluation

NPO requirements


Anesthetic techniques
Important Concept
The pediatric patient is not a
small adult
Pediatric Anatomy and
The Pediatric Airway

Varies greatly from neonate to teen

Neonatal Airway
Small nares / nose breather
Small mandible
Small oral cavity
Short neck
Long, narrow, stiff
Strong laryngeal reflex
Neonatal Body Mass

Large body surface area to weight ratio

1/9 BSA of adult

1/20 weight of adult

1/3 length of adult

Central Nervous System

Brain weight doubles at 6 mo. And triples by 1 year

Cell in cortex and brain system completely developed by 1
Myelinization complete by 3 years
Spinal cord
Birth L-3
1 year L-1

PNS fully developed at birth

SNS developed at 4-6 months
Respiratory System

Lungs still developing at birth

Alveolar ventilation is double in neonates to meet O2 demands

Achieve by high respiratory rate.

Hypoxia and hypercarbia will depress respiratory drive in

the infant rather than stimulate as in adults.

Neonate respiratory muscles are weak and fatique easily

Respiratory System

Infant versus Adult

Lower FRC

Lower closing volume

Lower lung compliance (sm. Alveoli)

Greater chest wall compliance

O2 requirement 2x adult (6 ml/kg)

CO2 production 2x adult (ml/kg)


Change from fetal to adult circ.

Foramen ovale closes

Ductus venosis closes

Ductus arteriosis closes

High cardiac output(ml/kg/min)

Newborn CO = 4 ml/beat

Important: the main determinant of cardiac output up

to age 2 is heart rate.
Renal Function

Kidneys are immature at birth continue to mature for 6

months GFR increases 2x-3x in first 3 months

Pre term can not conserve sodium

ECF 40% of newborn body wt.

Hypovolemia - <BP without>HR

Hourly Maintenance Fluids

4:2:1 Rule

4 ml/kg/hr 1st 10 kg +

2 ml/kg/hr 2nd 10 kg +

1 ml/kg/hr for each kg > 20

Maintenance Fluid Therapy

Term Newborn (ml/kg/day)

Day 1 50-60 D10W

Day 2 100 D10 NS

> Day 7 100-150 D5-D10 NS

Older Child: 4-2-1 rule

Normal Blood Volumes

Premature = 100 ml/kg

Full term = 85-90 ml/kg

Infant = 80 ml/kg

Adult = 65-70 ml/kg

Normal Hematocrit

Full term = 55%

3 months = 30%

6 months = 35%

Prolonged PT and PTT are common but coagulation is

Fetal hemoglobin

Neonate = 60-90% HgB F

Reduced 2,3 DPG

O2 curve shifts left Hg affinity for O2

Impairs O2 release at the tissues

Offset by increased Hct

O2 curve at adult level by 4 months

Temperature Regulation

Infants lose heat rapidly

Infants do not shiver

Able to shiver by 1 year

Brown fat metabolism

Non-shivering thermogenesis

Prevention of hypotermia is essential

Infant Heat Loss

Greatest loss via radiation

Due to relatively large BSA

Hypotermia Causes:
Increased oxygen consumption

Increased PVR

Increased SVR

R to L shunting
Preventing Hypothermia

Heat the operating room

Use radiant heaters

Warming pad on bed

Cover the head (40% of heat loss)

Warm IV fluids

Humidify gases
Preoperative Evaluation

Pertinent maternal history, birth and neonatal history

Review of systems review
Physical examination; focus on cardiopulmonary problems
Always ask about medications and drugs allergies
Current status of the disease: require consultation with the
pediatrician and other physician?
Congenital malformations
Previous anesthetics experience,discussion of anesthetic risk,
anesthetic plans, postoperative analgesia
Address preoperative anxiety (child and parents)
Preoperative Evaluation

Preop Preparation

Pediatric anesthesia is a family affair.

Psychological preparation involves stress reduction

the two most important sources of stress are:

1. Fear of the unknown

2. Fear of separation

These stresses are best dealt with by:

simple, honest communication maintain parental presence

during induction of anesthesia in selected cases.
Approach depends on age of patient:
Early infancy (neonate to about 7 months of age):

Parents are the primary focus gentle, comfortable separation is usual

Later infancy to about 3 years:

Separation anxiety major

Surgery ought be outpatient

Selected parental presence Gentle, comfortable separation is usual

3 to 6 years: child become primary focus.

explain exactly what will happen; what you will do then do it that way.

(Be trustworthy!)

From 3 of 4 years through adolescence:

Give child choices

Parental presence often helpful

Physical Exam

Upper airway


General body habitus

Coexisting disease
Lab Testing

Healthy children for routine elective surgery DO NOT

need routine lab testing

Order tests only if indicated.

NPO Status

NPO orders vary with age

Give specific instructions

2 hours sufficient for clear liquids

4 hours for breast milk

NPO after midnight for solid food

Pediatric Premedication

Many drugs and many routes

IM, IV, nasal ; oral, rectal.

Narcotics, sedatives are most common

Learn from those with experience.

Pediatric Premedication
Preoperative sedatives in children
Midazolam (0,5-0,75 mg/kg, onset 30 minutes and lasts
approximately 30 minutes)
Ketamine (5-6 mg/kg)
transmucosal fentanyl (facial pruritus, nausea and vomiting,
oxygen desauration)
clonidine (4 g/kg)
midazolam (0,2 mg/kg, rapid absorption as avoids first pass
metabolism, disadvantage is transient nasal irritation)
Midazolam (0,5-1,0 mg/kg)
Midazolam (0,3 mg/kg, anxiolysis in 5-10 minutes)
ketamin (3-4 mg/kg)
Pediatric Induction

Inhalation is most common for small children

All types of adult inductions have been used for children

Key is to have fun and work with the child

Inhalation Induction
Each staff have their own technique

Pre-oxygenate ?

Nitrous oxide ?

Which agent ? X

Start IV prior to intubation

Have unit doses available

Airway Control

Mask management

Fingers on mandibule (not neck)

Gentle chin lift

Endotrachial intubation

Pediatric blade

Proper tube size

Tube Size

For children over age 2:

Age + 16

No cuff until at least age 8

Cuff increases size by 0,5
Tube Size

Check for air leak

How much pressure?

Tube depth:
(Age divided by 2) + 12

Check bilateral breath sounds

Bronchi equal angels under age 3

Intravenous Induction

Older children will allow IV

Drugs and doses are similar to adult on mg/kg basis

Consider use of EMLA cream

Required on small children who require rapid sequence


Children have post op pain too!

Too much may depress respiration

May slow wake-up

Most children tolerate small doses of fentanyl and still

wake up quickly
Muscle Relaxants


Use only for emergency

May use IV or IM

Increased dose / kg required

Consider atropine premedication

Infants do not fasiculate

Muscle Relaxants

Non depolarizing relaxants

Receptors are more sensitive

Response is variable

Large ECF volume dilutes drug

Duration may be prolonged due to immature liver

Breathing Systems
Should :
Prevent rebreathing of CO2

Offer low resistance to breathing

Be light weight

Have unidirectional valve or high gas flow

Nonrebreathing circuits minimize the work of breathing

Pediatric circle system can also be used very effectively

in infants and children

Should be monitored continuously with precordial or

esophageal stetoschope.

Pulse oximetry, capnography,blood pressure, monitored

routinely in children
Postanesthesia Care

Challenges during recovery of the young child in the

postanesthesia care unit

Nausea and vomiting (prophylactic ondansteron)
Postoperative pain (self reported or physiologic signs
including hypertension, tachycardia, agitation, nausea and
vomiting; treat severe pain with fentanyl or morphine iv)
Fear associated with awakening in a strange environment
(permit parent to be present)