Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in...

Pediatric Anesthesia for the Occasional Pediatric Anesthetist

Kimberly Westra CRNA, DNP, MSN, MBA (c)

Pediatric Anesthesia

● Children are not little adults

● Reduced frequency of pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Pearls● Physiological &

anatomical variations require a availability of size appropriate equipment for Neonate to School Aged Child

● Invasive lines, regional procedures, airway devices are size specific

Pediatric Anesthesia

● Teams versus Generalist approach to Pediatrics

● Resources available ● Size appropriate

equipment color coded ● Monitors ● Airway ● Lines

Pediatric Anesthesia

● Large Heads ● Large Tongues ● Narrow Nasal

Passages ● Obligate Nose

Breathers till 5 months ● Position Head with

Support to align airway axis

Pediatric Airway & Obstruction Issues

Pediatric Airway & Overextension

Pediatric Airway Ideal Positions

Pediatric Airway

● Anterior Airway ● Glottis at C-4 and

cephalad ● Glottis U shaped &

long ● Trachea short ● Cricoid narrowest up

until about age 10 ● Glottic Abnormalities

Pediatric Respiratory ● Less alveoli & smaller

in parenchymal size ● Lung compliance

decreased ● Chest wall compliance

increased with cartilaginous rib cage

● Diaphragm easily fatigued

● Less type 1 muscles

Pediatric Respiratory

● Low Oxygen Reserves ● Underdeveloped

respiratory drive centers thus hypoxic & hypercarbia drives less effective

● Increase Oxygen consumption 7mg/kg/min

Pediatric Airway

● Pousielles Law for pediatric airways

● Resistance to airflow exponentially increased

● Mainstem risk ● Cuffed ETT vs Non

cuffed ETT

Pediatric Cardiac

● Fixed Stroke Volume ● Immature Sympathetic

& Baroreceptor response

● May see limited Tachycardia response to hypovolemia & hypotension

● Cardiac Output dependent upon HR

Pediatric Vital Sign Ranges

Pediatric Renal

● Decreased glomerular filtration rate

● Decrease creatinine clearance

● Decrease exertion of sodium, glucose, creatinine

● Decrease Bicarbonate Reabsorption

Pediatric RenalDecreased ability to regulate osmolarity! Close attention to fluid management Use of micro drip IV tubing versus drip chamber Use of stop cocks for easy flushing Access to close port on IV catheter

Pediatric Metabolic

● Low Glycogen Stores especially neonate & infants*

● Hypoglycemia: ● Neonates 30mg/dl ● Infant 40mg/dl ● Higher risk with Premies

and/or Hyperalimentation

Pediatric Metabolic● IV Fluids Neonate &

Infants: ● D5LR ● D5 ½ NSS ● D5 ¼ NSS ● Children: LR as

appropriate length/type of procedure

Pediatric Thermoregulation

● Risk of Hypothermia increased due to:

● Lack of Shivering under 1 yr.

● High body surface area to body weight

● Thin skin ● Low Fat content

Thermoregulation● Use Brown Fat for

thermogenesis ● Higher risk of

iatrogenic hypo/hyperthermia

● Must “prep room” with increasing temp in advance

● Use Active warming devices

Pediatric Pharmacology● Protein Binding

decreased ● Hepatic

Biotransformation reduced/impaired

● Neuromuscular junction immature

● Volume of distribution for water soluble meds70-75% children

Pediatric Pharmacology

● Use dose calculators to reduce risk of over or under dosing

● EHMR often have dose calculators

● pharmacy print outs to keep on paper charts

● Use of appropriate syringe size

● Label accuracy!

Inhalational Agents & Pediatrics

● Neonates very sensitive to hemodynamic effects of gases: caution for overdose

● Blood flow to vessel rich increase so rapid inhalation induction therefore rapid rise in alveolar concentration

Inhalational Agents & Pediatrics

● Neonates very sensitive to hemodynamic effects of gases: caution for overdose

● Blood flow to vessel rich increase so rapid inhalation induction therefore rapid rise in alveolar concentration

Pediatric Anesthesia Medications

● Ketamine: ● IV 1-2mg/kg ● IM 3- 5mg/kg ● IV Adjunct to propofol

for asthmatics ● Caution for peds with

cardiac issues/risks ● Dissociative effect/

caution if PTSD

Pediatric Anesthesia Medication

● Midazolam: ● IV 0.05-0.2mg/kg ● PO 0.3-0.7mg/kg

timing is essential for ideal anxiolytic effect

● Education for parents safety in preoperative holding

● Separation anxiety education

Pediatric Anesthesia Medications

● Propofol Induction Dosing may be higher

● Caution for Propofol infusion/TIVA cases for Propofol Infusion Syndrome! Cases as low as 90mcg/kg/minute as little as 8 hrs.

Propofol Infusion Syndrome

● Propofol Infusions may result in:

● Multisystem Organ Failure

● Metabolic Acidosis ● Hepatomegaly ● Rhabdomyolysis ● Death

Pediatric Anesthesia Medications● Opioids: ● Neonates very

sensitive to opioids ● Neonates have

increased bioavailibity ● Neonates opioids cross

blood brain barrier ● Neonate respiratory

center sensitive to opioids

Why? Cytochrome P 450 not

mature until 1 month Reduced Hepatic

Conjugation Reduced clearance of

Morphine Metabolites Concomitant Co

morbidities

Pediatric Anesthesia Medications

● Opioids: ● Children actually have

increased rates of flow thus rapid biotransformation & elimination

● Medication Labeling accuracy

● Dose Calculators in EHMR

Pediatric Anesthesia Pain Control

● Fentanyl IV ● Morphine IV caution

in neonates ● Tylenol Suppository ● Tylenol IV? (>2yrs) ● Local to field ● Regional ● Distraction & the

Digital Age

Pediatric Medications: Relaxants

● Faster Onset Time up to 50%! (30-60 sec)

● Succinylcholine (SUX) still only Depolarizing

● SUX: Hyperkalemia, Masseter Muscle Spasm, BRADY, Sinus Arrest! Must pretreat Atropine/Glyco

Pediatric Anthesis Medications● Non Depolarizing

Muscle Relaxants: ● Rocuronium: ● Ideal Induction Agent

rapid onset, can be used for Modified RSI

● Dosing 0.6 or 0.9mg/kg RSI

● Caution dosing may last up to 90 mins

Pediatric Muscle Relaxants

● Questions to ask: ● Do I really need to use

muscle relaxants, length of case, surgical skill, risk of recuraritization

● Can I combine Inhalational/IV technique to limit the need for NDMR?

Pediatric Anesthesia Medications

● Reversal Agents & Residual NDMR a significant concern!

● Monitor neuromuscular blockage Adductor Pollicis versus Orbicularis Oculi

Pediatric Anesthesia Medications

● Reversals: ● Neostigmine

0.03-0.07mg/kg must co administer anticholinergic! Vagal tonic pediatric physiology....separate syringes!

Pediatric Anesthesia Medications

● Reversal ● Anticholinergics: ● Atropine 0.01-0.02mg/

kg ● Glycopyrrolate

0.01mg/kg ● Pretreat & timing

Pediatric Anesthesia Medications

● Antiemetics: ● Zofran ● Reglan ● Promethazine ● Droperidol (black box) ● Multimodal technique:

use of nsaids, local, regional

Pediatric Anesthesia Adjuncts

● Locals: encourage use in surgical field

● Aspiration essential ● Remember max doses ● Lidocaine 3mg/kg ● Lidocaine w epi 7mg/

kg ● Marcaine 2-3mg/kg

Pediatric Preoperative Care

● NPO status? ● Keep peds hydrated ● NPO clears 2 hrs. ● NPO breast milk 4 hrs. ● NPO Formula 6 hrs. ● NPO Solids 8 hrs.

IV or Inhaled Induction IV discussion typically

around 8 or 9 yrs. Discuss with family/pt

Maturity of pt versus chronological age

IV access using Topical local/cream

Pediatric Preoperative Care

● Separation anxiety ● Educate family ● PO anxiolytics ● Distraction & Digital

Age ● Parental Presence?

Support, Assess Parents, Facility Protocols

Recent URI? ….more Febrile? Auscultate HR:

Murmur...innocent or symptomatic

Labs: type of procedure, childhood history: minimal labs, no labs

Pediatric Anesthesia

● URI? ● Infectious, Viral, Allergic,

Vasomotor Rhinitis ● Increased Risks must make

balanced decision risk versus benefit include family via education

Pediatric URI & General Anesthesia

● Risks: ● Increased risk of

wheezing up to 10X ● Increase risk of

Laryngospasm up to 5X

● Increased risks of hypoxemia, atelectasis, prolonged stay, ICU

Risks with URI 2-4 weeks time window for GA in pediatrics

Delay for non emergent cases to reduce risk of adverse event or outcome

Pediatric Anesthesia

● Environment: ● Preoperative limit

invasive interaction, allow child to remain in parents arm/hold

● Interactions age & developmental appropriate

Pediatric Anesthesia

● Environment ● OR: Limit noise, be

alert to visual fields, equipment, discussions

● Art of Distraction ● Language used

important: sleepy breeze versus put to sleep.

Pediatric Monitoring

● Pulse Oximeter!! ● HR typically too fast

or too slow ● BP cuff size

appropriate ● Neonates remember to

put pulse oximeter on right extremity or earlobe -Preductal

Pediatric Monitors

● Temperature! Accurate & early placement (MH)

● Invasive Lines available size appropriate

● Lab tubes size appropriate

Pediatric Anesthesia

● IV access challenging ● Often multiple sticks,

most experienced provider

● Vein illuminator ● Intraosseous

alternatively

Common Blades: Miller Wis Hipple Macintosh Phillips Video laryngoscopy

elective use

Pediatric Airway

● Endotracheal Cuffed versus Non cuffed

● Traditionally non cuffed ETT however in recently changing to cuffed ETT over 2 yrs.

● LMA used in variety of cases that traditionally ETT!

Pediatric Airway

● Neonate Uncuffed 2.5 to 4 ETT

● Uncuffed ETT: 4 + Age/4

● Cuffed ETT: 3 ½ + Age/4

● Depth is 3X ETT

Pediatric Anesthesia

● LMA pediatric sizes down to size 1 for neonate/infant

● Often forgotten as a bridge to ETT in problematic airway

● LMA placement gently to avoid damaging delicate tissues

Pediatric Ventilation● Volume ventilation

versus Pressure control modes?

● Volume Ventilation using circle systems newer machines 6-10cc/kg

● Pressure Control setting variable, conservative management

Pediatric Fluid Management

● Follow 4,2,1 Rule: ● First 10kg=4cc/kg/hr. ● Second 10kg=2cc/kg/

hr. ● >20kg=1cc/kg/hr. ● Replace 50% 1st hr. ● Replace 25% 2nd hr. ● Replace 25% 3rd hr.

Pediatric Fluid Management

● Minor Surgery add 2cc/kg

● Major Surgery add up to 10cc/kg

● Close calculation of EBL especially premies, neonates, infants

● Smaller folks have lower Allowable Loss!

Pediatric Blood Loss

● Estimated Blood Volume:

● Premies 95cc/kg ● Term Neonates 85cc/

kg ● Up to 1 yr. 80cc/kg Visualize, weight

sponges, labs

Pediatric Blood Loss● Initially replace with

NSS at 3X loss in cc ● What are the comorbid

conditions? ● PRBC replacement

usually starts @ 10cc/kg

● If EBL=1.5X blood volumes give FFP, platelets, possible cryo

FFP and platelets are 10cc/kg

Consider Coagulopathy Send advanced

coagulation studies: D dimer, bleeding time, fibrinogen levels

Pediatric Anesthesia Concerns

● Laryngospasm!! ● Involuntary spasm of

laryngeal musculature ● Stimulation of superior

laryngeal nerve ● Numerous causes:

light extubation, secretion on cords, recent URI, smoke exposure

Pediatric Anesthesia Concerns

● Laryngospasm: ● Positive Pressure

(CPAP) with mask seal ● SUX IV 0.1-0.5mg/kg ● SUX IM 2-4mg/kg ● Propofol 0.5-1mg/kg

(with CPAP)

Pediatric Anesthesia Concerns

● Post intubation stridor: ● Large ETT ● Repeated ETT

attempts ● Repeated ETT

movement ● Longer ENT

procedures/local Tonsils

Pediatric Anesthesia Concerns

● Post Intubation Stridor treatment:

● Preventative Dexamethasone

● Racemic EPI nebulized Treatment

● Cool mist in PACU ● Prolonged PACU/

admission

Pediatric Emergencies

● Pyloric Stenosis: ● male>female ● 4-6 weeks old ● Metabolic disarray: ● Hypochloremia,

hyponatremia, dehydration from vomiting

Correct metabolic issues prior to surgery

EMPTY stomach lateral, prone

RSI, ETT Careful lab monitoring

for lingering metabolic acidosis

Transfer?

Pediatric Foreign Body ● Foreign Body

Aspiration: ● Sudden onset ● Wheezing, respiratory

distress ● Supra versus

Subglottic location ● RSI, avoid further

advancing object, Magill's ready!

Rigid Bronchoscopy Multiple manipulations

of airway leading to possible trauma, iatrogenic injury, swelling of tissues, airway

Postoperative intubation, steroids

Pediatric Radiography of Foreign Body

Pediatric Foreign Body● Ingestion of object to

gastric pathway ● Avoid turning gastric

FB into airway FB ● Magill's ready ● Often multiple

attempts with Pediatric endoscopist

● Risk of injury upon removal

Malignant Hyperthermia● Children under 19 yrs.

account for 43-54% reported MH events

● 1:15,000 ● Triggering Agents: ● VOLATILES & SUX ● Genetic abnormality for

ryanodine receptor cause hypermetabolic state

Malignant Hyperthermia● Can Occur at

ANYTIME after exposure to trigger!

● MH Signs: Tachycardia, Hypercarbia, Hyperthermia, Cardiac disturbances, hemodynamic instability, rhabdomyolysis,

MH Signs: Myoglobinurinemia,

metabolic/respiratory acidosis, CK elevations, muscle rigidity

Atypical MH forms can be problematic to identify

Malignant Hyperthermia

● Treatment: ● Stop Offending Agents ● Call for Help: MH ● Hyperventilate with

“clean 100%” Oxygen ● Dantrolene 2.5mg/KG ● Revised Dantrolene

formulation

Contact MHAUS Support Cardiac

dysrhythmias (no calcium channel blockers)

NaHCO3 IV Active Cooling Invasive Monitors, ICU

Malignant Hyperthermia● Known History: ● Avoid triggering

agents ● Use TIVA & Nitrous as

needed. ● Cleanse machine based

on Manufacturer OEM guidelines

● Change circuit/sodasorb

Communication across all teams

Depending upon location/type of care facility...transfer to tertiary facility

MHAUS Hotline: 1-800-MH-HYPER

Malignant Hyperthermia

Pediatric Summary

● Pediatric Specialist versus Generalist

● Maintain Pediatric Anesthesia Proficiency to promote safety

● Use on site resources & cognitive aids for pediatrics

Pediatric Anesthesia Summary

● Smaller margin of safety with care of pediatric population

● What type of facility? ● Resources appropriate ● Transfer indicated? ● Ask for help in

pediatric cases if deskilled!

Summary

● Evolution of pediatric specialty centers & tertiary care facilities has lead to lower routine pediatric case volumes in community & non pediatric care centers

● Support for anesthesia providers knowledge base & skill sets!

Review & Reflect

Question: Pediatric anesthesia care

primary focuses on reduction in medication dosing due to smaller patient sizes? True of False.

Review & Reflect

● Pediatrics anesthesia care should include a comprehensive approach that reviews medical history, current clinical indicators/issues and psychosocial factors? True or False

Review & Reflect

● Malignant Hyperthermia considerations are less prominent in pediatric anesthesia care as compared to adult anesthesia care? True or False

Review & Reflect

● Malignant Hyperthermia considerations are less prominent in pediatric anesthesia care as compared to adult anesthesia care? True or False

Thanks for your Attention