NEONATAL AND PEDIATRICS

ANAESTHESIA PART-1

Prepared by Nigatu M.
 NEONATAL AND PEDIATRICS ANAESTHESIA

Objective;

•At the end of this session the student be able to;

– Explain the clinical implication of anatomical physiologic and
pharmacologic difference of paediatrics organ/ system.
– Perform pre-anesthetic preparation for paediatrics age groups
 Introduction
Children are not small adults and pediatric patients vary
considerably and include the following groups:

New born – is a baby in the first 24hrs of life after birth.

Neonatal – period is the first 28days of extra-uterine life Or 44
wks post conception.
Infant – is a baby less than 1 year of age
Child – 1 – 12 years of age
Adolescent – 13 – 16 years of age
Adult – Greater than 16 years of age

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 Introduction cont.…
• The differences between paediatric and adult anaesthetic
practice are reduced as the patients become older.

• The important anatomical and physiological differences will

be considered below followed by a discussion of how these
will affect anaesthetic practice.

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 Neonatal Transition/adaptation period to extra-utrine:

• The journey down the birth canal is the most dangerous trip in a
person's life.
• The first year of life is characterized by a miraculous growth in size
and maturity.
• This change, from fetal to extrauterine life, is called the period of
transition or adaptation (most significantly in the 1st 24-72 hrs after
birth).

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A. Transition of Circulatory system (CVS)

• CVS exists to efficiently deliver oxygen and other metabolic

nutrients to tissues throughout the body.
==>Fetal circulation …overview
• Umbilical vessels caries blood to and from Fetus;
– oxygenated blood from placenta through umbilicus vein.
– blood containing waste & little O2 were taken from fetus to
placenta through two Umbilical Arteries

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 Transition of Circulatory system (CVS) cont…

• 55% of fetal cardiac output goes to placenta.

• Blood in umbilical vein is 80% saturated with O2.
• Fetal blood in portal and systemic venous is 26% saturated.
• A mixture of blood returned to heart – 67% saturated.

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• Deoxygenated blood is pumped down the fetal
descending aorta to the umbilical artery (pair) and
then to the placenta; at which it branched to
arterioles, capillaries, and venules in the
intervillous spaces of placenta, where oxygen and
nutrient exchange occurs.

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 Transition of Circulatory system (CVS) cont…

Circulation transition from fetal to neonate

 This (parallel) Fetal circulation is changed to series
circulation immediately after delivery.
• As the infants inhales the first time, the pulmonary vascular
resistance falls dramatically & increases systemic vascular
resistance.
• This result in a greater amount of blood flow through lung
 therefore more blood returns to the left atrium.

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• Because these shunts are not anatomically closed immediately after
birth, certain clinical conditions may result in the persistence or
return of patency of foramen ovale & ductus arteriosus.
 Hypoxemia, acidosis and sepsis/infection are main known
causes; to reverse shunt patency.
• Infants who are at high risk for persistent pulmonary hypertension
syndrome , formerly known as persistent fetal shunting, includes:
 Preterm
 Meconium aspiration or sepsis (infection)
 Congenital tracheoesophageal fistula, diaphragmatic hernia
 Neonatal respiratory failure or acidosis
 hypothermia
– These all significantly affects ventilation adequacy.

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CVS Physiologic Consideration in Pediatrics

•The cardiac muscle is immature at birth.

•It has non contractile tissue which render the myocardium stiff & non
compliant.
– This leads to sensitivity to volume over loading, poor tolerance
of afterload
– The ventricle’s contractility and compliance is not mature to
increase stroke volume
•So, stroke volume is relatively fixed and cardiac output is maintained
by a relatively high resting HR
Therefore; bradycardia results in a rapid fall of cardiac output.

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 CVS Physiologic Consideration in Pediatrics Cont...

• Parasympathetic (Vagal tone ) is well developed than sympathetic

in infants and they are prone to reflex bradycardias
• Neonate’s myocardium is more sensitive to the depressant effects
of anaesthetic agents.
• The main cause of bradycardia in infant are hypoxia,
hypercapnia & vagal (surgical).

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• The blood pressure in newborns is 60-90mmHg and increases with
increasing sympathetic tone to reach adult levels by 8-10 years of
age.

Systolic mmHg Diastolic mmHg HR

Neonate 65 40 160 -200
1yr 95 65 100-180
3yrs 100 70 80-120
12yrs 110 70 70-100

• Can be estimated using;

• Baroreceptor reflex are immature & so infants may not be able to
compensate for decreased in BP.

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 B. Pulmonary System Transition

• Fetal lung is filled by fluid

- At birth the lungs are partially filled with liquid approximately
equal with newborn`s FRC.
- This fluid is originated from the alveolar cell during fetal
development.

- At birth the fluid is removed from the lung during the first 24hrs
by following mechanism;
1. about 1/3 is squeezed out of the lung as the fetus passes
through the birth canal.
2. about 1/3 of fluid is absorbed by pul. capillaries
3. about 1/3 is removed by lymphatic system.

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 Pulmonary System Transition cont…

• As the infant inhales the first breath the lungs are changed
from the fluid filled state into air filled.

• This is bombarded by a variety of external sensory stimuli

(thermal, tactile, visual…) and;
 At the time placenta cease function  PO2↓ed, PCO2 ↑ed
& the PH ↓ed
 And the sensitivity of both central and peripheral
chemoreceptor of new born ↑ed dramatically
==> in response to these all stimuli infants inhales.

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 Normal blood gas values in new born

subject age PO2 mmHg PCO2 mmHg PH

Fetus (Term) Before labor 25 40 7.37

Fetus (Term) End of labor 10 - 20 55 7.25
New born (term) 10 min. 50 48 7.20
‘’ ‘’ ‘’ 1hr 70 35 7.35
‘’ ‘’ ‘’ 1week 75 35 7.4
New born 1week 60 38 7.37
(preterm)

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 1. Anatomic differences of pediatrics
• The major differences affecting airway management in neonates
and infants are:
– Relatively large head and prominent occiput
– Relatively large tongue
– epiglottis is shaped differently and angled over the laryngeal
inlet
– High and Anteriorly located larynx
– The vocal cord is angled, so a “blindly” passed endotracheal tube
may easily lodge away of larynx
– The infant larynx is funnel shaped, the narrowest portion
occurring at the cricoid cartilage

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• Neonates are obligatory nose breathers Any thing that obstruct
nares will compromise neonate’s ability to breath.
• The relatively large occiput result in head being flexed forward
onto the chest when the infant is lying supine.
• Extreme extension can also obstruct airway; so mid positioning
of the head with slight extension is preferred.
• This is accomplished by placing a small roll at the base of the
neck & shoulder.
• The large tongue occupies space in the neonate’s/infant’s airway
and makes it difficult laryngoscopy.

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• They have large, floppy, and U-shaped epiglottis, which is located
at high level – C4 in full term infant and C3 in premature (at C5 in
adult)
• Tends to fall back over the laryngeal inlet
– Difficulty of cord visualization; difficulty in making alignment
of the three axis.
– Intubation is best achieved with a straight than curve blade
laryngoscope; by lifting up it directly.

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• The larynx is conical in shape, with the narrowest portion at the
cricoid cartilage.
• An endotracheal tube that can easily pass through vocal cord may be
trapped in cricoid ring .
Therefore tube selection is critical in Pedi;
 The tight fit endotracheal tube at cricoid ring  temporary or
permanent damage to cricoid cartilage So, leak should be allowed
at 20-25cmH2O (recommended).
 Uncuffed ETT usually preferred in a pt <10 yrs of age to prevent
subglottic edema/stridor

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• The airways are very small (narrow) in neonates(4-5mm ID),
and easily obstructed.
• The trachea is short (Neonatal trachea = 4cm long Vs 10-14cm
in adult); care must be taken to avoid main stem intubation and
or accidental extubation.

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 2. Respiratory physiology
•Neonates have a high metabolic rate and twice oxygen consumption
compared to older children and adults (7 Vs 3ml.kg-1.min-1)
•They have equal VT with that of adult but three times greater of
respiratory rate.
•This result in ratio of high minute ventilation to FRC; 5:1 in neonate
& 1.5:1 in older.

 Rapid induction &/ recovery from IAA

 They have high closing volume.
 They have low FRC; low lung elasticity, pliable rib cage

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• The respiratory exchange surface is immature and lack respiratory
surfactant;
 predisposes them to airway collapse, poor gas exchange and
increased work of breathing.
 Ventilation with high airway pressures and high-inspired
oxygen concentration predisposes to bronchopulmonary
dysplasia and chronic lung disease.
• The physiological dead space is approx. 30% of the tidal volume,
as in adults, but the absolute volume is small,
 so that any increase caused by apparatus dead space has a
proportionally greater effect on small children.

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• Respiratory mechanics in the neonates are not efficient.
Alveoli mature after birth, continue to ↑ in number until 8
yrs of age
The elastic tissue of the lung poorly developed & result in
the decreased lung compliance.
Ribs are horizontal in neonates (vertical in adults).
The rib cage is soft and compliant, and the ribs move in the
horizontal plane only i.e. MV is increased by only
respiratory rate.

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• The soft rib cage means that the chest wall is highly compliant, and
there is less ‘outward spring’ exerted by the rib cage, and less
negative intrapleural pressure to keep the lungs expanded.
– This results in a relatively low FRC and high airway closure may
occur during normal breathing.
• With a pliable rib cage, an increase in intrathoracic negative
pressure result in retraction of ribs, subcostal & supraclavicular area
inefficient ventilation and high energy demand.
• This is why neonates are fatigue with mild airway obstruction,
pneumonia m

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• The diaphragm is the predominant respiratory muscle in neonates
but is more easily fatigable than in adults.
 due to lack of type 1 (oxidative, fatigue resistant) muscle
fibers.
 Ventilation under anaesthesia should be at least assisted and
infants should not be left to breath spontaneously through a
tracheal tube.
 Gastric distension after facemask ventilation will splint the
diaphragm, compromise respiration and increase the
possibility of aspiration.
• A NG tube should be passed to relieve gastric
distension.

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• The control of respiration is immature in neonates. Responses to
hypercarbia and hypoxia are blunted and poorly sustained, and
neonates often respond to hypoxia by stopping breathing
Parameter Infant Adult
RR/min 30-50 12-16
Vt. ml/kg 7 7
Dead space 2-2.5 2.2
Alveolar ventilation ml/kg/min 6-9 3
Compliance ml/cmH2O 5 100

N.B Avoid hypoxia in neonate & small child.

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C. Body fluids:
The TBW comprises approximately 80% of body weight at birth &
down to 65% in adults (ICF vs ECF)

•Infants' and children’s higher body water content, along with their
higher metabolic rates and increased body surface area to mass
index, contribute to their higher turnover of fluids and solute.
 Require proportionally greater volumes of water (more
susceptible to volume depletion). Also because of immature
CVS they are susceptible to fluid overload ---> pulm. Edema.
 Should not be fasted for a long time (2hrs clear fluid).

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• In neonate most of body water is in the extracellular compartment.
• So during dehydration initially extracellular is lost & fluid shift
from relatively lower intracellular compartment to ECF
compartment.
===> fluid lose in this age should be critically evaluated and replaced.

Distribution of water as percentage of body weight

compartment premature Neonate infant adult

ECF (%) 50 40 30 20
Plasma (%) 5 5 5 5
ICF(%) 30 35 40 40
Total (%) 85 80 75 65

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 D. Hematology:

 At birth 75-80% of the neonate’s Hg is HgF which has

higher affinity for oxygen than that of adult HgbA.
 The high blood volume, increased CO & high Hgb content
compensate a decreased O2 delivery to tissue
 “Physiologic anemia of infancy” due to progressive HgF
removal to be replaced with HbA by 3-6 months.
 Hg levels rise to 12–13 g/dL by age 2yrs; in adults,
they reach 14 g/dL for females & 15.5 for males

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• Blood transfusion should be considered when there is a 10–
15% loss in blood volume. OR Hct decrement by 25%
• Circulating blood volume using the formula;
 Newborn 90ml/kg
 Infant 85ml/kg
 Child 80ml/kg
 Adult 70 ml/kg
 If an adult lost 200ml of blood it would not be significant but a
child losing 60ml would need a transfusion.

• Acceptable Hg level for anemic neonate; 8 g/dL, 10g/dl &

12g/dl; older than 3month, 2month & one week life,
respectively.

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 E. Renal system
• At birth GFR = 15–20% of adult level s; reaches 50% within 2 wks
& 100% by 1 yr and the renal tubular transport system is not fully
developed.
• By the end of first month after birth 80-90% of renal function
mature & at 2 yrs kidney maturation is completed equivalent with
adult.
• Renal immaturity reduces the ability of neonates to excrete free
water (increase UOP) in case of fluid over load==> therefore, over
infusion of fluid / blood  pul.edema & cardiac failure.

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 – Poor water conserving mechanisms  rapid dehydration if kept
fasted for a long time.

– Ability to concentrate urine is poorly developed as the renal

cortical tubules are immature
– Decrement of GFR may delay excretion of some drugs & prolong
their effect---be careful in repeating dose.
– Stress response to surgery --> release of (ADH) --> hyponatremia
• Use only isotonic solution—eg: NS/ RL
• Neonates have limited glycogen stores and are prone to
hypoglycaemia.
– Add dextrose (5% dextrose in 0.9% saline) should be considered
for neonates and other children requiring a dextrose infusion
prior to surgery to maintain blood glucose.
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 F. Thermoregulation
• Neonates and infants body lost heat more rapidly because of:
– large surface area relative to body weight ratio
– thin layer of insulating subcutaneous fat and skin
– decreased ability to produce heat

• Shivering is of little significance during heat production in

neonates; instead they use non shivering thermogenesis --- brown
fat metabolism neurally mediated (ß3 adrenoreceptors) (with the
product of heat & fatty acid).

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 Brown fat accounts 5% of a neonate’s body weight and is
distributed around the scapulae, kidneys, adrenals and
mediastinum. This is inefficient and increases oxygen consumption.
 The dangers of hypothermia include clotting abnormalities, delayed
drug metabolism, impaired wound healing and infection
 So active measures should be taken to minimise heat loss, at the
same time avoiding hyperthermia, like....
– ↑ ambient room temp, cover infant with thermal insulator, use of
heat lamp, warming IV fluids,

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 G. Nervous system

• The CNS is immature at birth and cerebral myelination continues

for up to 3 years.
• The process of maturation continues during fetal and neonatal
development, but the ability to feel pain is well developed even
before birth.
• Pain in neonates is associated with behavioural changes
• There is concern about the effect of anesthetics on the developing
brain, and unnecessary anesthetics should be avoided in infancy

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 Pharmacologic difference:
 Pharmacologic responses and requirment to drugs may differ
pediatric patients from adults.
• This is determined by;
body composition,
protein binding,
body temperature,
distribution of cardiac output,
functional maturity of the heart,
maturation of the blood-brain barrier,
the relative size (as well as functional maturity) of the liver
and kidneys, and
the presence or absence of congenital malformations
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 Neonates particularly preterm infants have a lower plasma
concentration of albumin as well lower qualitative binding ability
so high plasma concentration of active drugs.

 The BBB is immature at birth & more permeable to drugs.

 On top of that the neonate’s brain receive large proportion of CO

than does the adult brain so that brain concentration of drugs are
higher in neonate/ infants.

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 The neonate and infant have large extracellular fluid volume so
larger volume of distribution for water soluble drugs and require
an increased dose compared to adults.
 Drugs that are primarily eliminated through hepatic metabolism
may have prolonged action because of hepatic immaturity in
neonate.
 Similarly drugs that are eliminated through the renal system
may have the same effect because of poorly developed excreting
effect of the kidney.

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• Neonates are more sensitive to IAA than older children, and the
MAC values are decreased by 30% in neonates but increased by up
to 50% at 6 month compared to adult pts.
• Because; immature nervous system, progesterone from the mother,
and elevated blood levels of endorphins, coupled with an immature
blood-brain barrier
 MAC of halothane 0.87% in neonate, 1.5% in infants 1-6
months of age.
 Halothane and sevoflurane remain the agents most popular for
inhalational induction of anaesthesia

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 Sedatives and hypnotics
•Children are particularly sensitive to sedative and hypnotic drugs such
as barbiturates and benzodiazepines due to the immature
BBB, low plasma protein and reduced drug metabolism/ excretion;
these drugs should be used with caution, in weight appropriate doses,
titrated according to effect.
•Propofol infusions may be used in children older than 3 years.
•The analgesic properties of ketamine make it suitable for many
patients for procedural sedation.

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• LA and Analgesics are well absorb Neonates and infants (due to
high tissue blood flow and cardiac output); and hence drug doses
need to be reduced, because:
 immature metabolism, and
 low quality and quantity of protein binding
• Take extra care not to exceed maximum doses or dose intervals of
analgesics such as paracetamol, ibuprofen, opioids or local
anaesthetics.

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 Muscle relaxants
•The volume of distribution of water soluble drugs is higher at birth
due to the increased extracellular fluid volume.
 This explains the need for a higher dose of suxamethonium in
infants relative to adults (2mg.kg-1vs 1mg.kg-1).
 A second dose of suxamethonium may provoke bradycardia due
to the high parasympathetic tone in infants; atropine should
always be available.
•The receptors in Neonates and infants are more sensitive to non-
depolarizing neuromuscular blocking drugs.
 A normal loading dose is required, but subsequent doses should
be reduced.

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 Part two
Preoperative evaluation

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