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Proceeding of the NAVC

North American Veterinary Conference


J an. 8-12, 2005, Orlando, Florida










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Small Animal - Anesthesia


53
ANESTHESIA OF THE PEDIATRIC PATIENT

Victoria M. Lukasik, DVM, DACVA
Southwest Veterinary Anesthesiology and the
Southern Arizona Animal Pain Center
Tucson, AZ

Puppies and kittens are considered neonates until 4 to
5 weeks of age and are classified as pediatric until about
12 weeks old. Anesthesia of neonates may be necessary for
urgent correction of congenital anomalies or for necessary
(not elective) diagnostics. Anesthesia of pediatric patients
may be undertaken for elective early ovariohysterectomy or
castration or for urgent procedures. The physiology of
neonates and pediatric patients is different in several ways
compared to adult dogs and cats. These differences need to
be understood to formulate optimal anesthetic plans that
incorporate balanced drug combinations and appropriate
dosing of those drugs. Postoperative analgesia for elective
procedures and peri-operative analgesia for urgent situations
are a very important part of the anesthetic experience
because a life long over sensitivity (alloydinia) can develop if
pain in neonatal and pediatric patients is not managed
appropriately. Studies in infant boys undergoing circumcision
indicate that a sensitivity to pain can be precipitated at even a
few days of age if proper analgesia is not provided.

THERMOREGULATION
Smaller size, minimal fat reserves, and a higher body
surface area to mass ratio all contribute to the development
of hypothermia during the entire peri-anesthetic period.
Of the three most common anesthetic complications
(hypothermia, hypotension, hypoventilation), hypothermia is
the easiest to document without the aid of expensive
equipment. All that is needed is a hand held thermometer.
Rectal temperature is usually 1 to 2 F lower than core
temperature due to loss of muscle tone under anesthesia.
It may be lower during procedures that expose the peri-rectal
tissues: caudal abdominal, perineal, etc. Tympanic
membrane temperatures can be very accurate because the
middle ear shares the same vascular supply as the
hypothalamus. However, ear thermometers can be
technically challenging to properly use in most species.
Esophageal readings reflect the temperature of the great
vessels. Other methods of monitoring temperature: oral,
axillary, and skin surface are not accurate.
Almost all patients that are sedated or anesthetized will
lose body temperature. The exceptions are the adult Nordic
breeds of dog (Husky, Malamute, Samoyed, etc.) that may
actually become hyperthermic under general anesthesia.
Some patients develop hypothermia so severe that normal
physiology is wrecked. The adverse effects of inadvertent
hypothermia include: (1) immune system depression:
impaired leukocyte mobility and phagocytosis, (2) decreased
T-cell antibody production, (3) depressed non-specific host
defenses, (4) post-operative infection rate is increased to
three times the normal rate in patients experiencing mild
intra-operative hypothermia, (5) coagulopathy, which is
independent of clotting factor levels (more severe in factor
deficient patients), (6) blood viscosity is increased and
sludging can occur, (7) systemic vascular resistance and
afterload are increased, (8) myocardium is depressed and
more prone to arrhythmias and hypoxia, (9) CO
2
production is
decreased and may lead to alkalemia, (10) respiratory drive
is diminished, (11) physiologic response to hypoxemia and
hypercarbia is blunted, (12) CNS: delayed recovery from
anesthesia, confusion, stupor, or coma, (13) hyperglycemia
due to catecholamine release, (14) hypovolemia due to cold
diuresis (may be seen as profound hypotension after re-
warming), (15) MAC is decreased approximately 5% per
degree centigrade below normal body temperature:
anesthetic overdose may easily occur, (16) drug metabolism
can be significantly delayed, and (17) liver metabolism can
be greatly decreased, leading to drug toxicity.
Skin surface temperature rises and falls with the
environmental temperature. Core body temperature is closely
regulated by the hypothalamus; however, this regulation is
immature and inefficient in pediatric patients. There are three
tissue layers designed to insulate the body and prevent heat
loss. These consist of the skin, subcutaneous fat, and hair.
These layers are more or less efficient in different patients
depending upon their thickness. Overall, most pediatric
patients lack thickness in all three layers. Heat transfer
through the insulating layers and to the environment occurs
in two stages. In stage one, heat is transferred from the core
to the skin. In stage two, heat is lost to the environment by
radiation, conduction, convection, and evaporation.
In awake animals, there are several reactions to cold.
Behavioral reactions include seeking shelter and curling up.
Physiologic reactions also occur. These include piloerection,
vasoconstriction, and shivering. Piloerection increases the
depth of insulation by forming a stagnant layer of air around
the animal. Vasoconstriction of the skin arterioles and
arteriovenous anastamoses limits heat loss from the
extremities. Shivering increases heat production in all muscle
groups. There is also a chemical excitation for heat
production. This includes the release of epinephrine,
norepinephrine, and thyroxin. Pediatric patients lack the
ability to effectively respond to cold using these physiologic
mechanisms. The anesthetic drugs effect the
thermoregulatory center and all compensatory reactions are
further blunted or abolished during sedation and anesthesia.
Causes of inadvertent hypothermia include: (1) general
anesthesia: all anesthetics decrease the threshold for
thermoregulatory vasoconstriction, (2) basal metabolic rate is
decreased, (3) muscle tone is decreased, (4) operating room
temperature is often well below body temperature, (5) skin
prep solutions at room temperature and evaporation, (6) cold
irrigation solutions at room temperature and evaporation,
(7) IV fluids at room temperature, (8) exposed serous
surfaces: evaporation, (9) prolonged surgical procedures:
patients become more unstable and continue to cool as
anesthesia time increases, and (10) patient becomes wet
during anesthesia: urine, flush, or bathed.
It is in the best interest of all patients (except those needing
deliberate hypothermia) to be kept normothermic pre-
operatively, during anesthesia and post-operatively. Post-
operative shivering will increase oxygen consumption by as
much 200% to 600% at a time when lung and circulatory
function may not be optimal. Post-operative shivering also
increases intraocular pressure, increases intracranial
pressure, and increases wound pain. Hemorrhage may be
increased by the disruption of clots. Carbon dioxide
production is greatly increased and may cause acidemia.
Ventilation may be decreased, leading to hypoxemia (tissue
hypoxia). Hypothermia must be differentiated form post-
operative pain, which may also cause shivering.
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The North American Veterinary Conference 2005 Proceedings


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The prevention of inadvertent hypothermia is more
desirable than trying to re-warm patients once they become
cold. Effective re-warming cannot happen unless at least
60% of body surface area is in contact with an external heat
source. Desirable methods for preventing inadvertent
hypothermia include: (1) controlling ambient temperature:
keep the OR temperature at least 75 F, (2) insulate patients
using bubble wrap, plastic wrap, or warm blankets, (3) warm
skin prep and irrigation solutions, avoid alcohol (4) warm all
intravenous fluids, (5) humidify and heat inspired gasses by
using an artificial nose like the Humid-Vent

(Gibeck;
Upplands Vaesby, Sweden) (6) use circulating hot water
blankets at 105 to 107 F, (7) forced air heat exchange
blanket like the Bair Hugger

(Arizant; Eden Prairie, MN,


USA), and (8) keep patients dry or actively dry them post-
operatively: hand held blow dryer.
There are other available methods for providing an external
heat source, but they are not desirable due to the potential
for thermal injury or electrocution. Radiant heaters or heat
lamps (French Fry lamps) cannot be easily regulated and
can cause severe thermal injury to the skin. Electric heating
pads and electric heating boards can develop hot spots or
become wet and shock/electrocute a patient. Hot water
bottles can be used provided that they are not above 107 F
and are removed when they become cool.
It is important to monitor a patients temperature closely
because of the possibility of overshoot. Hyperthermia during
surgery or re-warming can occur because the blood vessels
in the periphery are vasodilated due to the anesthetic drugs.
Heat is easily transferred to the core when peripheral vessels
are vasodilated. The adverse effects of hyperthermia are also
numerous and can be detrimental to a patients well being.

CARDIOVASCULAR AND PULMONARY PHYSIOLOGY
With the first breath of life, a profound and necessary
change in circulatory physiology takes place. Expansion of
the pulmonary tissues by inflation of the alveoli creates the
supportive structure necessary for pulmonary circulation to
occur. Pulmonary vascular resistance decreases dramatically
and the exchange of oxygen and carbon dioxide by the lungs
commences. There is a much higher metabolic demand for
oxygen in the first few weeks of life, approximately three
times greater compared to adults. An increased respiratory
rate helps to meet this increased demand for oxygen. Any
decrease in respiratory rate or depth, which is very common
during anesthesia, will have an effect upon tissue
oxygenation. Cardiac output is dependant upon heart rate.
Induced bradycardia may profoundly affect cardiac output
and blood pressure. Increases in preload and afterload are
poorly tolerated and blood loss as little as 5 ml/kg can
precipitate profound hypotension. Hematopoesis does not
effectively begin until two to three months of age, further
limiting the pediatric patients ability to withstand hemorrhage.
Blood loss needs to be prevented by adequate surgical
hemostasis or treated aggressively before severe physiologic
insult occurs due to tissue hypoxia.

PREPARATION FOR GENERAL ANESTHESIA
Pediatric patients have minimal glycogen stores in the liver
and should be minimally fasted. Approximately four hours off
of food is sufficient for gastric emptying. Water should be
withdrawn when the pre-medication is given. Laboratory
testing for young, healthy patients should include a packed
cell volume (PCV), total plasma solids (TPS), blood urea
nitrogen (BUN), and blood glucose. This minimal laboratory
evaluation is designed to aid in the recognition of disease
processes not related to the surgical problem. Premedication
with a balanced drug combination is the most desirable.
(Table 1) Combining drugs from different classes will enable
individual drug doses to be reduced, limiting unwanted side
effects while still providing optimal stress reduction and pre-
emptive analgesia.
After premedication, patients should be placed in a quiet,
warm environment and be observed, but undisturbed, until
maximal drug effects have occurred. This may be as long as
60 minutes after SQ injection. The environmental
temperature in the pre-surgical holding area should be
relatively warm or an external heat source should be supplied
because hypothermia is common after sedation. The patient
should also be placed on towels or shredded paper to absorb
urine or feces.
It is important to have all necessary drugs and equipment
ready in advance. This includes the appropriate breathing
circuit, correct size endotracheal tube and reservoir bag,
changing CO
2
absorbent if necessary, leak checking the
anesthesia machine, and ensuring an adequate oxygen and
liquid anesthetic supply. Being prepared for any complication
before drug administration is the key to a successful
anesthetic. This includes knowing the dose and route of
administration of any appropriate reversal drugs. (Table 3)
In general, non-rebreathing circuits (Bain, Norman elbow,
Jackson-Reese, Ayers T-piece, etc.) are recommended for
patients with lean body weights less than 5 kg and
rebreathing or circle systems (Wye, Universal-F, etc.) are
used in patients weighing more than 5 kg. Pre-induction
support should include pre-oxygenation via facemask, IV
fluids, pre-emptive analgesia, external heat source, and
proper padding. Removing the rubber diaphragm from the
mask may prevent some of the resistance to it.

INDUCTION TO GENERAL ANESTHESIA
General anesthesia is a reversible process that induces
immobilization, muscle relaxation, unconsciousness, and
freedom from pain. Induction of general anesthesia in
pediatric patients is best accomplished using injectable
drugs, rather than by the administration of inhalant anesthetic
by facemask.(Table 2) Injectable inductions are preferred
because they allow a more rapid loss of consciousness, less
patient struggling, earlier control of the airway, and less
danger of injury to the patient and staff. Popular drugs for IV
induction include propofol and the combination of diazepam
and ketamine. The author prefers a 2:1 volume ratio of
diazepam:ketamine dosed at 0.5 to 1 ml/10 kg (diazepam
0.165 to 0.33 mg/kg and ketamine 1.65 to 3.3 mg/kg) to
reduce muscle stiffness. Ketamine causes a central release
of catecholamines resulting in tachycardia, increased cardiac
output, and increased blood pressure. In catecholamine
depleted patients, ketamine will act as a direct myocardial
depressant and decrease cardiac output. Etomidate may also
be used, especially in patients with cardiovascular instability.
Immediately after anesthetic induction, the endotracheal
tube is placed and the cuff inflated. Avoid overinflation of the
endotracheal tube cuff, as tracheal crush injury or tracheal
rupture may occur. The patients respiratory rate, heart rate
and rhythm, MM color, CRT and other monitoring parameters
are checked immediately after anesthesia induction and at
intervals of 5 minutes or less throughout anesthesia.
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Small Animal - Anesthesia


55
MAINTENANCE
Most patients are maintained on inhalant anesthetics and
they are preferred to injectable drugs in pediatric dogs and
cats. The most commonly used inhalant anesthetic today is
isoflurane. Halothane, sevoflurane, and desflurane are also
used with some frequency. All inhalant anesthetics cause
some degree of vasodilation, hypotension, myocardial
depression, and respiratory depression. Other adverse
effects include nausea, vomiting, ileus, and cardiac
arrhythmias. Modern inhalant anesthetics undergo very little
hepatic metabolism. Elimination is via the lung, so awakening
is usually rapid after discontinuing inhalant administration.
RECOVERY
Patients need to be supported and monitored in the
immediate post-operative period. It is also vitally important to
provide appropriate analgesia.(Table 4) The administration of
analgesics to pediatric patients is often overlooked or
inappropriately under dosed because these patients do not
show overt outward signs of pain due to survival instincts.
The need for post-operative analgesia cannot be overlooked
because of the pediatric patients lack of overt, outward signs
of pain. Analgesic protocols should be devised based upon
the invasiveness of the surgical procedure and the
anticipated degree of pain postoperatively. Analgesics should
be provided for a minimum of 48 to 72 hours.



Table 1. Drugs Used for Premedication. Balanced premedication combinations usually include one drug
from each group based upon individual patient needs.
Group Drug Dose Route Comments
Anticholinergics Glycopyrrolate 0.01 0.02 IM, IV Does not cross blood-brain
barrier
Atropine 0.02 to 0.04 IM, IV Therapy for profound
bradycardia
Tranquilizers Midazolam 0.1 to 0.3 IM, IV IM uptake rapid and
complete
Diazepam 0.1 0.4 IV IV only, IM uptake not
reliable
Xylazine 0.5 2 IM, IV Not in patients under 12
weeks
Medetomidine 0.005 0.02 IM More potent than xylazine
Acepromazine 0.005 0.03 IM Not in patients under 8
weeks or in dehydration
Opioid Analgesics Morphine 0.05 0.25 IM Emesis common
Hydromorphone 0.03 0.075 IM, IV Good analgesic
Oxymorphone 0.03 0.075 IM, IV Good analgesic
Buprenorphine 0.01 0.05 IM For mild pain only
Butorphanol 0.2 to 0.4 IM, IV Very poor analgesia, good
sedative properties

Table 2. Induction Drugs
Drug(s) Dose mg/kg Route Comments
Propofol 1 4 IV Apnea and hypotension common
Diazepam/Ketamine 0.15-0.3/1.5-3 IV Retain laryngeal reflexes
Etomidate 1 - 2 IV Good in unstable cardiac patients

Table 3. Reversal Drugs
Drug Dose mg/kg Route Drug Class Reversed
Flumazenil 0.1 IV Benzodiazepines
Atipamezole 0.2 to 0.4 IM Alpha-2 Agonists
Naloxone 0.01 to 0.1 IM, IV Opioids: all analgesia reversed

Table 4. Analgesic Drugs given SQ to patients less than 4 weeks of age
Species Mild pain Dose mg/kg Moderate to severe pain Dose mg/kg

Canine Oxymorphone 0.02 0.05 Oxymorphone 0.05 0.1
Morphine 0.2 0.5 Morphine 0.5 - 1
Methadone 0.2 0.5 Methadone 0.5 - 1
Buprenorphine 0.005 0.01 Fentanyl 0.005 0.01

Cats Oxymorphone 0.02 0.05 Oxymorphone 0.05 0.1
Morphine 0.05 0.1 Morphine 0.1 0.3
Buprenorphine 0.005 0.01

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