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Metabolism
basal metabolic rate is higher, larger surface area means higher heat losses, 02 consumption 5-6ml/kg.min
About 20% higher than adults. This compounds reduced FRC and hypoxia rapidly sets in.
Hb dissociation curve moved to the left, P50 of 2.8kPa, Hb falls from 18 at birth to 11 by 6 months.
Classified
Neonate
Infant
Child
Adolescent
Neonate
Infant
4 yrs
8 yrs
14 yrs
Mean systolic
50-90
85-105
95-110
95-110
Age
Neonate
Upto 2yr
Upto 16yr
Volume ml/kg
85-90
85
80
Weight calculations
Birth (term)
3-12 months
1-6 yrs
9-13 yrs
3-4.5 Kg
age in months + 9 / 2
(age in yrs +4) x 2
3 x age in years
4ml/kg
2ml/kg
1ml/kg
first 10kg
next 10 kg
every kg thereafter
Resuscitation
20ml/kg boluses
Blood
atropine
Adrenaline
Amiodarone
Neostigmine
Glycopyrolate
crystalloid
when HCT 25% (or higher for neonate of congenital heart
disease(NB 4ml/kg PRBC will increase Hb 1gm Approx)
15ml/kg
neonates
20mcg/kg
sux
1-2mg/kg
2-3mg/kg
10mcg/kg
vec
0.1mg.kg
5mg/kg
trac
0.3-0.6mg/kg 1mg/kg intubate
50mcg/kg
roc
0.6mg/kg
1mg/kg intubate
10mcg/kg
Thio
Propofol
Ketamine
2-5mg/kg
3-7mg/kg
1-2mg/kg
FFP
Drug doses
PLEASE REFER TO GUIDELINES
WRITTEN BY DR KING
Morphine
Diamorphine
Fentanyl
Midazolam
)
)
) Approximations
)
(5-7mg in Neonates)
cycliz
1mg/kg
dex
0.15mg/kg
Ondans 0.15mg/kg
0.1-0.2mg/kg
paracet
15mg/kg
0.1 mg/kg
diclofenac 1mg/kg (over 1yr)
1-5mcg/kg
codeine 1mg/kg (over 6 months)
0.5 mg/kg 20 min prior to induction.
Renal system
renal blood flow and GFR are low in the first 2 years of life high renovascular resistance
Tubular function is low until 8 months of age cannot excrete large sodium or water loads
Dehydration is poorly tolerated, large surface area with high insensible losses.
40% body weight is ECF (20 in adults), TBW higher
Maintenance = 4ml/kg for 10kg, then 2ml/kg for 10kg then ml/kg (4,2,1)
Urine output is high 1-2ml/kg
Liver
Glucose
Haematology
Temperature
CNS
neonates feel pain, narcotics depress ventilation response to increased PC02 and hypoxia.
BBB poorly formed barbiturates, opiates, antibiotics and bilirubin easily cross
Cerebral vessels are thin walled and fragile in neonate prone to intraventricular haemorrhages
Risk increased if hypoxic, hypercarbic, low HCT, awake airway manipulations, rapid bicarb
infusions, fluctuant BP. Cerebral autoregualtion present and working from birth may not be working in
neonates.
Psychology
infants less than 6 months are generally not that upset and accept strangers well.
Up to age 4 upset by strangers and new surroundings unpredictable and difficult to rationalise
School age more afraid of procedure mutilation and pain
Adolescent narcosis, pain, loss of control, not being able to cope with effects of illness.
Parental anxiety is perceived and acted upon by child.
time, develop rapport, trust of pt and parent, address child first and then parent. However pre-school children
often happier if talk to parent first. Address fears and questions, explain procedure, medical and
anaesthetic
history. FH. Allergies, medication, recent respiratory illness, immunisations, fasting, loose teeth.
Childs weight.
2. Investigations
Hb if expected blood loss, premature infant, systemic illness, congenital heart disease, haemoglobinopathies
U&E renal or metabolic disorders
3. Analgesia
4. Fasting
2hr
4hr
6hr
5. Premedication
6. theatre prep
7. Induction
inhalation can be excellent method if fear of needles or poor access, 2 person technique, skilled person to
maintain airway whilst iv access is gained if possible.
(Halothane sweet smell, well tolerated, moderately slow onset improved with 50% N20,
Duration longer and off set slower, arrythmias more common not often used)
Sevoflurane non-irritant, rapid onset and offset as less soluble, N20 increases rate of onset, improved CVS
stability. Mac 3.3 for infants and 2.5 in children
8. IV access
back of hand, inner wrist, long saphenous, dorsum of foot. ACF difficult and tissue easily
Pre-02 can be difficult struggling increases 02 consumption!
9. Intubation
straight magill may be easier for neonates and infants. Mackintosh easier when 6-12 months.
Uncuffed until 8-10yrs, small leak should be present at 20cmH20.
Age/4 + 4/4.5
Length = age/2 + 12 for oral and +14 for nasal
LMA
clear fluids
breast and formula milk if aged less than 12months
solids and formula milk if over 12months
size 1
Size 1.5
Size 2
upto 5kg
upto 10kg
upto 20kg
Size 2.5
Size 3
upto 30kg
for over 30kg
NOTE more sensitive to non depolarising neuromuscular blocker but resistant to depolarising agents
10. Regional
Paediatric fluids
1. Removal of 0.18% NaCl and 4% dextrose from general wards only available in specialist areas
2. Produce guidelines for fluid management
3. Adequate training and supervision
4. Review of present prescription and fluid charts
5. Promote reporting of hyponatraemia
REMEMBER
Advises
ORAL IN BEST MOST OF THE TIME ward iv fluid often 0.9% saline with 5% dex and 10mmol KCL
IX
illness, age, maturity, post-conception age, consent Gillick (ability to give consent)
CVS murmers, congenital,
Resp cough/colds/asthma/ sleep apnoea/ CF
Misc fluid status, hernia, epilepsy, cerebral palsy, spina bifida, dystrophys, anaemias
sickle, dystrophies, sux
allergies/ medication ensure has had inhalers etc.
Dehydration Mild <5% = decreased urine, dry mouth. Mod = 5-10% decreased urine, reduced turgor, sunken fontanelles
and eyes, tachycardic and tachypnoeic, drowsy. Severe all above plus acidostic
Deficit = % dehydrated X wt in kg x 10 (resus then rehydrate over 24-48hrs)
Airway tonsils, snoring, hunter hurlers, Pierre robin, goldenhar, laryngomalacia, cystic hygroma
ECG, echo, sickle test, U&E, Hb esp physiological anaemia if indicated
Patient fears
1:4000 births,
Diagnosis
Usually
Associated
Management
nil by mouth, nurse head up REPLOGE tube in upper pouch (double lumen often with suction)
IV fluids, IM Vit K
ECHO. CXR = NG in upper pouch and gas in gut
Note
ET tube and ventilation can inflate stomach with over spill into trachea
therefore try and avoid until surgery
Intra-op
Post-op
Pyloric stenosis
RAMSTEDTS PROCEDURE
Presentation
Classically
Treatment
Aim
Fluids
Monitor
Induction
Post op
BLEEDING TONSIL
Presenting problems -hypovolaemia (may be occult), residual sedation from first anaesthetic, stomach full with blood,
Potential difficult airway due to blood and oedema, patient agitated/ anxious.
Treatment
fluid resuscitation, assessment of fluid status with cap refill etc, Xmatch, Good IV access.
Induction
RSI with cricoid pressure, may need SMALLER tube than previous, consider atropine, orogastric
tube when intubated
to empty stomach. Suction available.
Classical description is inhalational with halothane in left lateral decubitous position, intubating
Deep( difficult to hold airway, if deep enough to intubate will exacerbate hypotension,
unfamiliar position to intubate a potentially difficult airway)
extubate head down, AWAKE, vomiting common. 02, fluids. Consider area discharged to.
Post op
Diaphragmatic hernia
Occurs
Presentation
Signs
Post-op
Is
Assoc
Assoc
NOTE
Anae
RSI,
Intraop
Postop
ventilated, TPN,