PEDIATRIC

ANESTHESIA
Adel J. Taradji
Post Graduate Intern

Patient Data
Patient K. J.
2 years old male
11 KG
12/5/2012
Child
Roman Catholic
CC: Scrotal Mass

History of Present Illness

1 year PTC onsent of bulging mass on left
inguinal area
Reducible
No consult done
Until, few months PTC, still with bulging
mass, prompted consult at ZCMC.
Evaluated and advised for admission.
Scheduled for surgery

Past Medical History

Delivered NSVD at a local institution
Complete Immunization
Mother with complete prenatal checkup
and TT immunization
No previous surgeries
No food and drug allergies

Personal and Social

1st child
Mother is a housewife
Father is a part time contractual worker

Physical Examination
Awake, Alert
Anicteric Sclera, Pink palpebral
conjunctiva
No cervical lymphadenopathies
No tonsilopharyngeal congestion
Equal chest expansion, clear breath
sounds
Adynamic precordium, Normal rate and
regular rhythm
Globular, soft, NBS, no tenderness
(+) inguinal scrotal mass L
Full pulses

Impression
Indirect Inguinal Hernia Left

Pre Anesthetic Evaluation

All systems within normal Limits

Mallampati Classification 1
NPO approx 8 hours
Risks discussed to parents
Patient examined and chart reviewed
Patient approved for anesthesia

Intraoperative Anesthetic Record

ASA: 1
Weight: 11kg
No allergies
GCS: 15
Awake, alert
Baseline VS:
BP 95/40
HR 150
SPO2 100

Intraoperative Anesthetic Record

Diagnosis: Indirect inguinal hernia L
Anesthiologist: Dr. Mendizabel
Anesthetic Technique: GA-mask + Caudal
Block
Surgeon: Dr. Mlee / Hassan
Induction time: 4:30 PM / 4:38 PM
Cutting time: 4:52 PM
Closing time: 5:45 PM

Intraoperative Anesthetic Record

P LLDP, skin asepsis antisepsis, sacral
hiatus identified, hypodermic needle g24
inserted, epidural space identified,
negative CSF, negative blood
X1 midazolam 1mg IV, fentanyl 11mcg
IV, AtSO4 0.2mg IV, Propofol 10mg IV,
Sevoflurane 3 volume %
X2 Bupivacaine isobaric 0.2 % given
with negative testdose at 3cc

Anatomic and Physiologic

Distinctions Between Adults and
Pediatric Patients
Variable

Child vs Adult

Anesthetic
Implication

Head size

Much larger head size

relative to body

Consider roll under

shoulders or neck for
optimal intubation
positioning

Tongue size

Larger size relative to

mouth

Makes airway appear

slightly anterior; oral airways
particularly helpful during
mask ventilation

Airway shape

Narrowest diameter is
below the glottis at
cricoid level in children

Uncuffed tubes can make

seal when appropriately
sized in children younger
than 8 years of age

Anatomic and Physiologic

Distinctions Between Adults and
Pediatric Patients
Variable

Child vs Adult

Anesthetic
Implication

Respiratory
Physiology

Oxygen consumption is 2
to 3 times greater in
infants than adults. FRC
ranges from 813 mL/kg
< 1/3 as large as adults

Oxygen desaturation is
extremely rapid following
apnea

Cardiac
Physiology

Relatively fixed stroke

volume in neonates and
infants

Bradycardia must be treated

aggressively in young age
groups; consider atropine
prior to airway
management; heart rates
less than 60 require
circulatory support

Renal
Function

Limited GFR at birth;

does not reach adult
levels until infancy; total
body water and %
extracellular fluid are
increased in the infant

Prolonged duration of action

for hydrophilic drugs,
particularly those that are
renally excreted

Anatomic and Physiologic

Distinctions Between Adults and
Pediatric Patients
Variable

Child vs Adult

Anesthetic
Implication

Hepatic
Function

P450 system not fully

developed in
neonates and infants;
liver blood flow
decreased in
newborns

Prolonged excretion for

drugs, depending on
hepatic metabolism

Body Surface
Area

Larger surface-tobody ratio in

newborn / infant /
toddler

Heat loss more

prominent problem for
these age groups

Psychological
Development

06 mostress on
family
8 mo4 yrseparation
anxiety
46 yr
misconceptions of
surgical mutilation
613 yrfear of not
waking up

Changes the manner in

which each patient and
family should be
approached; must
address issues with
personal and systemic
strategies

The Preoperative Evaluation

Pertinent maternal history

Birth and neonatal history
Review of systems
Physical examination
Height
Weight
Vital signs
Preoperative use of medications
Use of herbal medications
Malformations in the child and family

The Challenge
Anxiety in children in many forms:
Verbalization of fear
Scared
Agitated
Deep breathing
Trembling
Crying
These behaviors prolong the
induction of anesthesia

The Challenge
Management:
Behavioral
Pharmacologic
Behavioral interventions include
tours of the operating room, written
and audiovisual materials, coloring
books, music, acupuncture, hypnosis
Pharmacologic interventions such as
midazolam are very effective
treatment for preoperative anxiety.

Coexisting Health Conditions

Upper respiratory infection
Obstructive sleep apnea
Asthma
Former preterm infant

Coexisting Health Conditions

Upper respiratory infection
Increased risk of laryngospasm,
bronchospasm, oxygen
desaturation, postextubation
croup, and postoperative
atelectasis.
Mask anesthesia has significantly
lower rate of perioperative
complications as compared with
endotracheal tube.
LMA has same number of airway

Coexisting Health Conditions

Obstructive sleep apnea
At risk for airway obstruction with the
use of preoperative sedative predication
and during the induction process
Postoperatively, patients with severe
OSA may exhibit worsening of their
obstructive symptoms secondary to
tissue edema, altered response to
carbon dioxide, and residual effects of
anesthetic agents

Coexisting Health Conditions

OSA often accompanies obesity.
Obese children also have an
increased incidence of difficult
airway, upper airway obstruction
in the PACU, extended PACU stays,
and postoperative nausea and
vomiting.

Coexisting Health Conditions

Asthma
Should be under optimal medical
care prior to undergoing general
anesthesia and surgery
There is high probability of
perioperative complications
All oral and inhaled medications,
such corticosteroids and agonists, should be continued up
to and including the day of
surgery.

Coexisting Health Conditions

Recent data indicate that
administration of inhaled shortacting -agonists prior to induction
of anesthesia eliminates the
increase in airway pressure that is
typically associated with
intubation in asthmatic patients.

Coexisting Health Conditions

The Former Preterm Infant
(1) the impact that
bronchopulmonary dysplasia might
have on the patient's perioperative
course
(2) the presence of anemia and
the possibility of postoperative
apnea.
Perioperative complications from
bronchopulmonary dysplasia
involve reactivity of airways and
the risk of severe hypoxia that can

Laboratory Evaluation
Healthy children undergoing elective minor
surgery require no laboratory evaluation
Potassium evaluation in children on
digoxin or diuretics
For surgeries in which significant blood
loss may be expected, an arbitrary value
of 10 g/dL has been cited as acceptable
for infants older than 3 months or age and
higher values for younger infants and
neonates.

Laboratory Evaluation
Coagulation test should only be
done:
(1) history or medical condition
suggests a possible hemostatic
defect
(2) surgical procedures that
might induce hemostatic
disturbances (e.g.,
cardiopulmonary bypass)
(3) cases in which an intact
coagulation system is critical for
adequate hemostasis
(4) patients for whom even

Preoperative Fasting Period

Fasting period of pediatric patients
before surgery:

Solids - 8 hours
Formula milk - 6 hours
Breast milk - 4 hours
Clear liquids 2 hours of surgery

Rationale: Younger children have

smaller glycogen stores and are more
likely to develop hypoglycemia with
prolonged intervals of fasting.

Preoperative Sedatives
Sedation is widely used for children in
decreasing anxiety
Primary goal:
Facilitate smooth and anxiety-free
separation from parents and induction
of anesthesia

Preoperative Sedatives
Oral
Midazolam is the most commonly used
sedative premedicant
It has rapid onset and predictable effect
without causing cardiorespiratory
depression
Dose:
0.5 0.75 mg/kg peak effect is 30
mins after administration
0.75 mg/kg given to non responder
group of children age (4.2 2.3)

Preoperative Sedatives
Midazolam can be reversed with
flumazenil, which antagonizes
benzodiazepines competitively.
The initial recommended dose in
children is 0.05 mg/kg given
intravenously titrated up to 1.0 mg
total.
Oral ketamine - 5 to 6 mg/kg for
children 1 to 6 years of age.
Maximal sedation occurred within
20 minutes.

Preoperative Sedatives
Clonidine in combination with atropine,
produces satisfactory preoperative
sedation, easy separation from parents,
and mask acceptance within 45 minutes.
Clonidine dose: 4 g/ kg causes sedation,
decrease anesthetic requirements, and
decrease requirement for postoperative
analgesics.
The major disadvantage of this Clonidine
is slow onset as compared with
midazolam.

Preoperative Sedatives
Dexmedetomidine, a more selective 2agonist, creates a similar sedative and
anxiolytic effect to clonidine or midazolam.
Similar to clonidine, dexmedetomidine has
the effect of lowering pain scores in the
postanesthesia time frame.
Dexmedetomidine dose: 1 g/kg
transmucosally or 3 to 4 g/kg orally.

Preoperative Sedatives
Nasal
Advantage: Rapid absorption as well as
avoidance of first-pass hepatic
metabolism of medications
Major disadvantage: most children cry
because it transiently irritates the nasal
passages.
When required, midazolam can be
administered intranasally in a dose of 0.2
mg/kg.

Preoperative Sedatives
Rectal
0.5 to 1.0 mg/kg of midazolam
effectively reduces the anxiety of
children prior to induction.
Both methohexital and thiopental have
also been used in rectal formulations in
a dose of 25 mg/kg.
Onset of sedation requires approximately
10 minutes. Respiratory depression and
oxygen desaturation may occur because
of variable absorption of the medication in
the rectum.

Preoperative Sedatives
MEDICATION

Midazolam

Ketamine

Clonidine

ROUTE

DOSE TIME TO ELIMINATION

HALF-LIFE
(mg/kg) ONSET
T(hr)
(min)

Oral
0.251.010
Intranas 0.20.3 <10
al
Rectal
0.31.0 10

2
23

Oral
3.06.0 10
Intranas 3.05.0 <10
al
Rectal
5.06.0 2030

23
3

Oral

812

0.002 45
0.004

23

Preoperative Sedatives
Intramuscular
Midazolam 0.3 mg/kg provides
anxiolysis in 5 to 10 minute.
Ketamine 3 to 4 mg/kg provides a
quiet, breathing, yet minimally
responsive patient in
approximately 5 minutes.
Still, oral route is the most used and
preferred route of sedative
administration for children. Nasal,
rectal, and intramuscular routes
should be used only under special
circumstances such as cognitively

Anesthetic Agents
Mask Induction Pharmacology
Most common induction technique
for pediatric anesthesia
Safe but watch out for
bradycardia, hypotension and
cardiac arrest, especially in infants
younger than age 1 year old.
Thus, mask induction of
anesthesia in this age group
should be accompanied by
monitoring of blood pressure,
electrocardiogram, oxygenation,
and ventilation.

Anesthetic Agents
Minimal Alveolar Concentration
MAC of anesthetic required in
pediatric patients differs with age.
There is actually a small increase
in MAC between birth and 2 to 3
months of age, Then slowly
decreases with age.
For sevoflurane the change in MAC
is marked, with a value of
approximately 2.5% for young
infants compared with 2% for
adolescents and adults.30

Anesthetic Agents
Intracardiac Shunts
Children with unrepaired or
partially repaired congenital heart
malformations may safely undergo
inhaled induction of anesthesia.
R -> L shunt slows the inhaled
induction of anesthesia because
anesthetic concentration in the
arterial blood increases more
slowly.
L -> R shunt - volatile agent
induction is more rapid because
the rate of anesthetic transfer

Anesthetic Agents
Inhaled Agents for Induction of
Anesthesia
Sevoflurane, halothane,
Sevoflurane - rapid onset and low
frequency of dysrhythmias or
hypotension
Halothane

Anesthetic Agents
Isoflurane
safe and efficacious agent for
maintenance of anesthesia in
infants and children.
Disadvantage: pungent odor and
high incidence of laryngospasm
Desflurane
Also safe maintenance of
anesthesia in infants and children
unacceptable incidence of
coughing, increased secretions,
and laryngospasm preclude its use
as a mask induction agent

Intravenous Agents
Sedative Hypnotics
may be employed after inhaled
induction of anesthesia
may be used as primary induction and
maintenance agents in children who
have an intravenous line in place
Propofol, thiopental, methohexital,
etomidate, midazolam, and ketamine
have all been used to produce effective
intravenous induction of anesthesia or
sedation in infants and children.

Intravenous Agents
Propofol
most widely used agent for
induction and maintenance of
anesthesia or sedation in children
3 to 4 mg/kg - < 2 years
2.5 to 3 mg/kg - older children
Pain on injection of propofol is
marked
Medications prior to propofol to
decrease pain:
Lidocaine, fentanyl, ketamine,
and nitrous oxide inhalation.43

Intravenous Agents
Ketamine
It is the only intravenous agent that
offers both potent hypnosis and
analgesia.
Other unique aspects
preserves airway reflexes
maintains respiratory drive
increases endogenous
catecholamine release resulting in a
small amount of bronchodilation

Intravenous Agents
Induction doses of 1 mg/kg of ketamine
intravenously yields effective analgesia
and sedation with rapid onset.
Intramuscular doses of 3 to 4 mg/kg
result in a similar state, appropriate for
minor procedures such as intravenous
starts or fracture manipulation.
Side effects:
Diplopia, disturbing dreams, nausea
and vomiting
Midazolam (0.025 to 0.50mg/kg) is
used to decrease these side effects

Intravenous Agents
Opioids
important elements of balanced
anesthesia and sedation in
children.
Usual recommended doses include
fentanyl, 5 to 1 g/kg; morphine,
0.10 mg/kg; sufentanil, 1 g/kg;
and alfentanil, 50 to 100 g/kg.
Remifentanil has also been shown
to be an effective part of
anesthesia and sedation protocols
for a variety of procedures at 0.25
to 1.0 g/kg/min

Intravenous Agents
Newborns and infants < 6 months
susceptible to depression of
central respiratory effort
because of the immature blood
brain barrier and increased
levels of free drug.
Newborns after 6 months of age
no more susceptible to central
depression from opioids than
adults given equivalent doses.
Careful monitoring is necessary
and providers must be prepared in
giving muscle relaxants if the need

Intravenous Agents
Muscle Relaxants
Succinylcholine
Given in a dose of 1.5 to 2.0 mg/kg
Produces excellent intubating
conditions (reliably) in 60 seconds.
Recovery occurs in 6 to 7 minutes.
Succinylcholine can also be given
intramuscularly at 4 mg/kg in
emergencies when intravenous
access is not available.

Intravenous Agents
Absolutely contraindicated in a
variety of patients, particularly in
those with muscular dystrophy,
recent burn injury, spinal cord
transaction, and/or immobilization,
as well as any child with a family
history of malignant hyperthermia
because of the risk of
rhabdomyolysis, hyperkalemia,
masseter spasm, and malignant
hyperthermia.

Intravenous Agents
Pancuronium has a vagolytic effect. On
the other hand, it is dependent on renal
excretion and therefore may have a
markedly extended duration of action in
neonates when glomerular filtration rate
is relatively decreased.
Rocuronium has the lowest potency
and the fastest onset of action of the
currently available nondepolarizing
relaxants (60 seconds for a 1-mg/kg
dose) and is therefore the logical choice
for rapid-sequence intubation.

Intravenous Agents
Atracurium and cis-atracurium are
popular nondepolarizing muscle
relaxants for children
Muscle twitches should be
monitored and reversal agents
(i.e., neostigmine, 0.05 mg/kg,
with 0.015 mg/kg of atropine or
0.01 mg/kg of glycopyrrolate)
administered if residual weakness
is detected.
Clinical signs of adequate strength
for ventilation in this age group
include the ability to flex hips.

Dosage

Onset

Duration

Cardio
effects

Cost

considerati
on

Atracurium

500

Intermediat
e

Intermediat
e

Rare
hypotension

Intermediat
e

Mild
erythema
common

Cis-atrac

80-200

Slow to
Intermediat
intermediate e to long

Absent

Inexpensive

Mivacurium

250-400

Intermediat
e

Short

Rare
hypotension

Intermediat
e

Mild
erythema
common

Pancuronium

100

Intermediat
e

Intermediat
e long

Tachycardia
, occasional
hypertensio
n

Inexpensive

Effect
prolonged in
renal failure

Rocuronium

500
1200

Rapid

Intermediat
e

Slight
increase in
HR

Intermediat
e

Deltoid
injection
facilitates
tracheal
intubation

Vecuronium

100-400

Intermediat Intermediat Absent

e (rapid with e (long with
large doses) doses > 150
ug/kg)

Intermediat
e

 Antiemetics
postoperative nausea and vomiting
(PONV) rate can be twice as high as in
adults
All of the antiemetics used in adults
including phenothiazines,
antihistamines, anticholinergics,
benzamides, butyrophenones and 5HT3 antagonists have been used in
children

 The most effective prophylaxis strategy

in children at moderate or high risk for
PONV is to use combination therapy
that includes a 5-HT3 antagonist
(odansetron 0.05 to 0.15 mg/kg) and a
second drug such as low-dose
dexamethasone (0.15 to 1 mg/kg).

Fluid and Blood Product

Management
Maintenance Fluid Requirements for
Pediatric Patients
Weight(kg)

Hourly Fluid

24-hr Fluid

<10

4ml/kg

100ml/kg

11-20

40ml + 2ml/kg
>10kg

1000ml+50ml/kg
>10kg

>20

60ml + 1ml/kg >

20kg

1500ml +20ml/kg
>20

 In general, blood volume is estimated at

100 mL/kg for the preterm infant,
90 mL/kg for the term infant,
80 mg/kg for the child 3 to 12 months of
age, and
70 mg/kg for the patient older than 1
year.
These estimates of blood volume can be
used in calculating the individual patient's
blood volume by multiplying the child's
weight by the estimated blood volume
(EBV) per kilogram:

 Packed red blood cells have a hematocrit

between 55 and 70%. On the average, 1
mL/kg of packed red blood cells increases
the hematocrit by 1.5%. Units of blood can
be subdivided into pediatric packs of 50 to
100 mL; thus, the remainder of a single
unit is not wasted.

Airway Management
Appropriate airway management remains
the single most important aspect of
delivering safe pediatric anesthesia. At any
age, operative cases can be performed
with face mask, LMA, or endotracheal tube
placement.

Airway Management
As a general rule, endotracheal tubes are
preferred for premature infants and most
neonates in maintaining general
anesthesia because of the slightly greater
difficulty of providing effective face mask
ventilation and the risk of filling the
stomach with air while providing mask
ventilation.

Airway Management
Cases in which recent oral intake or
pathology (such as pyloric stenosis or
intestinal obstruction) raise the probability
that the stomach contains food or acid
(and therefore risk aspiration injury) are
best managed with a rapid-sequence
induction and intubation regardless of age.
LMAs and other pharyngeal airways come
in a range of sizes that can be employed in
infants, toddlers, and older children for
almost any procedure that does not
involve opening the abdomen or thoracic
cavity.

Airway Management
Although their use is standard for lower
extremity, inguinal, cutaneous, or eye
procedures, the application this airway for
oral procedures such as
tonsillectomy/adenoidectomy varies from
center to center.
Because the narrowest portion of the
pediatric airway is at the level of the cricoid
cartilage (and is therefore round), uncuffed
tubes can be used and will create a
functional seal when appropriately sized.68

Airway Management
Several formulas have been used for tube
selection in children older than age 1 year,
the most common being (16 + age)/4 or
variations thereof. One may also estimate
the size by comparing the size of the fifth
digit or the opening of a nare.
Once the tube is in place, it should be
checked to determine at what pressure air
can escape around the tube. Air should
leak out at no lower than approximately 10
cm H2O (to allow adequate ventilation) and
no higher than 25 to 30 cm H2O (to
minimize risk of postextubation croup).

Airway Management
Cuffed tubes can also be safely used in
infants and young children by selecting a
tube 0.5 mm smaller in internal diameter
than the uncuffed choice
Intubation in children can be safely
accomplished after inhaled induction with
or without the use of muscle relaxant.
Intubating conditions after 3 minutes of 8%
sevoflurane or a dose of propofol and
opiate may produce acceptable views of
the larynx.

Monitoring
The pediatric patient should be monitored
continuously with precordial or esophageal
stethoscope.
Allows the anesthesiologist to detect
changes in the rate, quality, and intensity
of the heart sounds.
Pulse oximetry, capnography, blood
pressure (measured appropriately sized
cuffs), temperature, and electrocardiogram
should also be monitored routinely in
children as in adults.

Pain Management and Regional

Anesthesia
The most common oral analgesic used in
children continues to be acetaminophen.
This medication has been shown to be
safe and efficacious in neonates as well as
older children.
Doses of 10 to 15 mg/kg orally every 4
hours or 30 to 40 mg/kg rectally as a
loading dose followed by 10 to 15 mg/kg
every 6 hours, with a maximum dose of 90
mg/24 hr, produce therapeutic plasma
levels with good analgesia.

Regional Anesthesia
Regional anesthetic techniques (e.g.,
spinal and epidural) may be used as the
sole anesthetic in premature infants at risk
for postoperative apnea undergoing
abdominal or lower extremity procedures.
Simple techniques such as ilioinguinal
iliohypogastric nerve block, ring block of
the penis, or caudal block can be very
useful for common pediatric surgical
procedures

Regional Anesthesia
The most commonly used form of regional
anesthesia in children is the caudal block.
This technique can provide postoperative
analgesia following a wide variety of lower
abdominal and genitourinary surgical
procedures. For single-dose administration
(outpatient surgeries) bupivacaine, 0.25 to
0.175%100 solution, or ropivacaine, 0.2 to
0.175%,101 at a dose of 1 mL/kg is
commonly used.

Regional Anesthesia
Postoperative analgesia typically lasts 4 to
6 hours and is not associated with a motor
paralysis at these concentrations. This
route can be used for either a single-dose
injection or for catheter advancement for
continuous infusion.
Spinal anesthesia may be used for
procedures involving surgical dermatomes
below T6.103 It is important to note that the
dural sac migrates cephalad during the
first year of life and in a neonate it is at S3
while over the age of 1 year it is at the S1
level.

Postanesthesia Care
Hypothermia is a common perioperative
problem, particularly in infants and young
children.
The inability to regulate body temperature
under general anesthesia, cold large
operating rooms, and continued heat loss
are major reasons for hypothermia.
More significant hypothermia can result in
increased oxygen consumption,
cardiovascular manifestations of
hypothermia, prolonged metabolism, and
excretion of anesthetic drugs and delayed
wound healing.

 Special attention should be paid to the

treatment of pain and nausea and vomiting
in the PACU.
Pretreatment with ondansetron, 0.15
mg/kg; droperidol, 0.075 mg/kg; or
metoclopramide, 0.15 mg/kg, has been
very successful in reducing nausea and
vomiting for patients at higher risk, such as
those undergoing tonsillectomy or
strabismus repair.