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Pediatric Anesthesia for the Occasional Pediatric Anesthetist Kimberly Westra CRNA, DNP, MSN, MBA (c)

Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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Page 1: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia for the Occasional Pediatric Anesthetist

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

Page 2: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia

● Children are not little adults

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

Page 3: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · 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

Page 4: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia

● Teams versus Generalist approach to Pediatrics

● Resources available ● Size appropriate

equipment color coded ● Monitors ● Airway ● Lines

Page 5: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia

● Large Heads ● Large Tongues ● Narrow Nasal

Passages ● Obligate Nose

Breathers till 5 months ● Position Head with

Support to align airway axis

Page 6: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Airway & Obstruction Issues

Page 7: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Airway & Overextension

Page 8: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Airway Ideal Positions

Page 9: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 10: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 11: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Respiratory

● Low Oxygen Reserves ● Underdeveloped

respiratory drive centers thus hypoxic & hypercarbia drives less effective

● Increase Oxygen consumption 7mg/kg/min

Page 12: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Airway

● Pousielles Law for pediatric airways

● Resistance to airflow exponentially increased

● Mainstem risk ● Cuffed ETT vs Non

cuffed ETT

Page 13: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Cardiac

● Fixed Stroke Volume ● Immature Sympathetic

& Baroreceptor response

● May see limited Tachycardia response to hypovolemia & hypotension

● Cardiac Output dependent upon HR

Page 14: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Vital Sign Ranges

Page 15: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Renal

● Decreased glomerular filtration rate

● Decrease creatinine clearance

● Decrease exertion of sodium, glucose, creatinine

● Decrease Bicarbonate Reabsorption

Page 16: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 17: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Metabolic

● Low Glycogen Stores especially neonate & infants*

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

and/or Hyperalimentation

Page 18: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Metabolic● IV Fluids Neonate &

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

appropriate length/type of procedure

Page 19: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 20: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Thermoregulation● Use Brown Fat for

thermogenesis ● Higher risk of

iatrogenic hypo/hyperthermia

● Must “prep room” with increasing temp in advance

● Use Active warming devices

Page 21: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Pharmacology● Protein Binding

decreased ● Hepatic

Biotransformation reduced/impaired

● Neuromuscular junction immature

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

Page 22: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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!

Page 23: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 24: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 25: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 26: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 27: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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.

Page 28: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Propofol Infusion Syndrome

● Propofol Infusions may result in:

● Multisystem Organ Failure

● Metabolic Acidosis ● Hepatomegaly ● Rhabdomyolysis ● Death

Page 29: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 30: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Medications

● Opioids: ● Children actually have

increased rates of flow thus rapid biotransformation & elimination

● Medication Labeling accuracy

● Dose Calculators in EHMR

Page 31: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Pain Control

● Fentanyl IV ● Morphine IV caution

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

Digital Age

Page 32: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 33: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 34: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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?

Page 35: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Medications

● Reversal Agents & Residual NDMR a significant concern!

● Monitor neuromuscular blockage Adductor Pollicis versus Orbicularis Oculi

Page 36: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Medications

● Reversals: ● Neostigmine

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

Page 37: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Medications

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

kg ● Glycopyrrolate

0.01mg/kg ● Pretreat & timing

Page 38: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Medications

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

use of nsaids, local, regional

Page 39: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 40: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 41: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 42: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia

● URI? ● Infectious, Viral, Allergic,

Vasomotor Rhinitis ● Increased Risks must make

balanced decision risk versus benefit include family via education

Page 43: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 44: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia

● Environment: ● Preoperative limit

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

● Interactions age & developmental appropriate

Page 45: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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.

Page 46: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 47: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Monitors

● Temperature! Accurate & early placement (MH)

● Invasive Lines available size appropriate

● Lab tubes size appropriate

Page 48: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 49: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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!

Page 50: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Airway

● Neonate Uncuffed 2.5 to 4 ETT

● Uncuffed ETT: 4 + Age/4

● Cuffed ETT: 3 ½ + Age/4

● Depth is 3X ETT

Page 51: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 52: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Ventilation● Volume ventilation

versus Pressure control modes?

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

● Pressure Control setting variable, conservative management

Page 53: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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.

Page 54: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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!

Page 55: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Blood Loss

● Estimated Blood Volume:

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

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

sponges, labs

Page 56: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 57: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 58: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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)

Page 59: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Concerns

● Post intubation stridor: ● Large ETT ● Repeated ETT

attempts ● Repeated ETT

movement ● Longer ENT

procedures/local Tonsils

Page 60: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Anesthesia Concerns

● Post Intubation Stridor treatment:

● Preventative Dexamethasone

● Racemic EPI nebulized Treatment

● Cool mist in PACU ● Prolonged PACU/

admission

Page 61: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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?

Page 62: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 63: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Radiography of Foreign Body

Page 64: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 65: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 66: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 67: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 68: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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

Page 69: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Malignant Hyperthermia

Page 70: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Pediatric Summary

● Pediatric Specialist versus Generalist

● Maintain Pediatric Anesthesia Proficiency to promote safety

● Use on site resources & cognitive aids for pediatrics

Page 71: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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!

Page 72: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

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!

Page 73: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Review & Reflect

Question: Pediatric anesthesia care

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

Page 74: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Review & Reflect

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

Page 75: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Review & Reflect

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

Page 76: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Review & Reflect

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

Page 77: Pediatric Anesthesia for the Occasional Pediatric Anesthetist · pediatric cases results in exposure to pediatric cases, deskilling, reduced pediatric crisis management scenarios

Thanks for your Attention