TIVA In ChildrenTIVA In Children

PIP MeetingPIP MeetingThursday 4Thursday 4thth June 2009 June 2009

Dr Oliver BagshawDr Oliver Bagshaw

DefinitionsDefinitions

TIVA – anaesthetic technique involving TIVA – anaesthetic technique involving no inhalational agents, including no inhalational agents, including volatiles and nitrous oxidevolatiles and nitrous oxide

TCI - Infusion by a microprocessor-TCI - Infusion by a microprocessor-controlled syringe pump, which controlled syringe pump, which automatically and variably controls the automatically and variably controls the rate of infusion of a drug to attain a rate of infusion of a drug to attain a user-defined target level in an effect user-defined target level in an effect site in the patient (usually blood) site in the patient (usually blood)

TIVA – Indications in TIVA – Indications in ChildrenChildren Known MH patientKnown MH patient MH susceptibility – central core MH susceptibility – central core

disease, multiminicore disease, disease, multiminicore disease, KD syndromeKD syndrome

MH risk – muscular dystrophies, MH risk – muscular dystrophies, arthrogryposis, osteogenesis arthrogryposis, osteogenesis imperfectaimperfecta

Patients requiring muscle biopsy Patients requiring muscle biopsy

TIVA – Indications in TIVA – Indications in ChildrenChildren Previous N&V post anaesthesiaPrevious N&V post anaesthesia High risk of N&V post anaesthesia, High risk of N&V post anaesthesia,

e.g. strabismus, Ts&As, e.g. strabismus, Ts&As, orchidopexyorchidopexy

Scoliosis surgeryScoliosis surgery Myasthenia gravisMyasthenia gravis Reduce blood loss – e.g. FESS Reduce blood loss – e.g. FESS

procedureprocedure

TIVA in childrenTIVA in children

AdvantagesAdvantages

Less pollutionLess pollution Less N&VLess N&V Improved quality of Improved quality of

recovery - deleriumrecovery - delerium No laryngospasmNo laryngospasm No risk of MHNo risk of MH

DisadvantagesDisadvantages

Need IV accessNeed IV access Can’t monitor blood Can’t monitor blood

levelslevels Delivery problems Delivery problems

may go unrecognisedmay go unrecognised Requires ‘metabolism’Requires ‘metabolism’ Risks of large doses of Risks of large doses of

propofol – PRISpropofol – PRIS More ‘fiddly’ & More ‘fiddly’ &

wastefulwasteful

TIVA in children – TIVA in children – Practical issuesPractical issues

Can’t always establish IV access Can’t always establish IV access prior to inductionprior to induction

Propofol induction often prolonged Propofol induction often prolonged with TCI – kids may squirm a bit!with TCI – kids may squirm a bit!

Try and avoid relaxantsTry and avoid relaxants Can’t always have IV cannula Can’t always have IV cannula

exposedexposed

TIVA in children - TIVA in children - OptionsOptions

Manual infusion regimeManual infusion regime

TCI regimeTCI regime

Manually Controlled Manually Controlled InfusionInfusion Traditionally 10, 8, 6 regime – Traditionally 10, 8, 6 regime –

decreasing every 10 minutesdecreasing every 10 minutes Adapted in children – 15, 13, 11, Adapted in children – 15, 13, 11,

10, 9 regime – decreasing at 10, 9 regime – decreasing at variable intervals (15 mins to 1 variable intervals (15 mins to 1 hr)hr)**

Estimated CEstimated Cpp of 3mcg/ml of 3mcg/ml

*McFarlan et al. Paediatr Anaesth 1999; 9: 209-16

Manually Controlled Manually Controlled Infusion – Effect of ageInfusion – Effect of age

DuratioDurationn

(mins)(mins) AgeAge

0-3 0-3 monthsmonths

3-6 3-6 monthsmonths

6-9 6-9 monthsmonths

9-12 9-12 monthsmonths

1-3 years1-3 years

0-100-10 2525 2020 1515 1515 1212

10-2010-20 2020 1515 1010 1010 99

20-3020-30 1515 1010 1010 1010 66

30-4030-40 1010 1010 1010 1010 66

40-5040-50 55 55 55 55 66

50-6050-60 55 55 55 55 66

>60>60 2.52.5 2.52.5 2.52.5 2.52.5 66

*mg/kg/hr Steur et al. Paediatr Anaesth 2004: 14: 462-7

Manual Infusion – 3mManual Infusion – 3m

1201101009080706050403020100

Con

cent

ratio

n µg

/ml

11

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000

Manual Infusion – 2yManual Infusion – 2y

1201101009080706050403020100

Con

cent

ratio

n µg

/ml

11

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

200100

0

Manual Infusion – 6yManual Infusion – 6y

1201101009080706050403020100

Con

cent

ratio

n µg

/ml

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000900

800700

600500

400300

200100

0

TCITCI

Advantages:Advantages: Uses valid Uses valid

pharmacokinetic pharmacokinetic datadata

Bolus incorporatedBolus incorporated Can quickly adjust Can quickly adjust

target leveltarget level More accurate More accurate

estimate of estimate of plasma/effect site plasma/effect site concentrationsconcentrations

Disadvantages:Disadvantages: Need specific TCI Need specific TCI

pumpspumps Data sometimes not Data sometimes not

available for younger available for younger childrenchildren

May be less accurate May be less accurate in younger patientsin younger patients

Need some Need some knowledge of knowledge of appropriate targetsappropriate targets

Paediatric TCI modelsPaediatric TCI models

PaedfusorPaedfusor – developed in 1990s – developed in 1990sShowed need for larger bolus and Showed need for larger bolus and greater infusion rates in childrengreater infusion rates in childrenCan be used down to 5kgCan be used down to 5kg

KatariaKataria – also developed in 1990s – also developed in 1990sBased on samples from >50 Based on samples from >50 childrenchildrenAge range 3-16 yearsAge range 3-16 yearsMinimum weight 15kgMinimum weight 15kg

Marsh vs Kataria vs Marsh vs Kataria vs PaedfusorPaedfusor

MarshMarsh KatariaKataria PaedfusorPaedfusorV1 0.228 L/kg 0.52 L/kg 0.458 L/kg

V2 0.463 L/kg 1.0 L/kg 1.34 L/kg

V3 2.893 L/kg 8.2 L/kg 8.20 L/kg

K10 (min –1) 0.119 0.066 70 x Weight -0.3/458.4

K12 (min –1) 0.112 0.113 0.12

K13 (min –1) 0.042 0.051 0.034

K21 (min –1) 0.055 0.059 0.041

K31 (min –1) 0.0033 0.0032 0.0019

Why Paediatric Why Paediatric models?models?

1201101009080706050403020100

Con

cent

ratio

n µg

/ml

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000800

600400

2000

1201101009080706050403020100

Con

cent

ratio

n µg

/ml

14

12

10

8

6

4

2

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000800

600400

2000

Paedfusor

Marsh

Plasma vs Effect Site Plasma vs Effect Site TargetingTargeting CCpp = most commonly used = most commonly used CCee depends on accuracy of PK models depends on accuracy of PK models CCee targeting leads to much higher targeting leads to much higher

plasma concentrations initiallyplasma concentrations initially Concentration gradient needed to Concentration gradient needed to

drive drug into effect sitedrive drug into effect site Overshoot determined by model (kOvershoot determined by model (ke0e0)) Fast kFast ke0e0 = less overshoot = less overshoot CCee targeting more accurately predicts targeting more accurately predicts

loss of consciousnessloss of consciousness

Plasma TCIPlasma TCI

6050403020100

Con

cent

ratio

n µg

/ml

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

600500

400300

200100

0

Effect site TCIEffect site TCI

6050403020100

Con

cent

ratio

n µg

/ml

12

11

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

600500

400300

200100

0

Adult propofol target Adult propofol target concentrations (effect concentrations (effect site)site)

Target (CTarget (Cee) ) mcg/mlmcg/ml

Plane of Plane of anaesthesiaanaesthesia

Clinical Clinical applicationapplication

<0.5<0.5 Light sedationLight sedation Insertion of lines, Insertion of lines, awake fibreoptic awake fibreoptic intubationintubation

0.5-1.50.5-1.5 Heavy sedationHeavy sedation Radiological Radiological imaging, imaging, endoscopy, endoscopy, surgery with LAsurgery with LA

1.5-3.01.5-3.0 Light anaesthesiaLight anaesthesia Surgery with Surgery with analgesia analgesia adjunctsadjuncts

4.0-6.04.0-6.0 General General anaesthesiaanaesthesia

Major surgeryMajor surgery

CCpp/C/Cee Equilibration Equilibration Times – Manual Times – Manual InfusionsInfusions

Propofol:Propofol:Manual infusion alone – 20-30 minsManual infusion alone – 20-30 minsBolus & manual infusion Bolus & manual infusion ≈5 mins≈5 mins

Remifentanil:Remifentanil:Manual infusion alone – 5-10 minsManual infusion alone – 5-10 minsBolus & manual infusion <2Bolus & manual infusion <2 mins mins

CCpp/C/Cee Equilibration Equilibration Times – Targeted Times – Targeted InfusionsInfusions

Propofol:Propofol:

Plasma TCI – 15-20 minsPlasma TCI – 15-20 mins

Effect site TCI <Effect site TCI <5 mins5 mins

Remifentanil:Remifentanil:

Plasma TCI – 5-7 minsPlasma TCI – 5-7 mins

Effect site TCI Effect site TCI ≈1 min≈1 min

How accurate are TCI How accurate are TCI systems?systems?

Assessment of accuracyAssessment of accuracyMeasurement or predictive Measurement or predictive performance of a TCI systemperformance of a TCI system

BiasThis value represents the direction (over or under-prediction)

of the performance error (median performance error)

Calculated concentration

Measured concentration

No Bias Significant bias

Assessment of accuracyAssessment of accuracyMeasurement or predictive Measurement or predictive

performance of a TCI systemperformance of a TCI system

Calculated concentration

Measured concentration

PrecisionThis is an indication of the size of the typical error from the

predicted concentration (median absolute performance error)

Small Scatter(No Bias)

Large Scatter(No Bias)

Accuracy of PaedfusorAccuracy of Paedfusor

Bias (MPE) – 4.1% (10%)Bias (MPE) – 4.1% (10%) Precision (MAPE) – 9.7% (20%)Precision (MAPE) – 9.7% (20%) ‘‘Wobble’ – 8.3% Wobble’ – 8.3% Performs better than adult modelsPerforms better than adult models Also better than ET volatile Also better than ET volatile

concentration monitoring (20% concentration monitoring (20% bias)bias)

Arterial isoflurane tension = 45 – 80% of end-tidal!!!

Context Sensitive Half-Context Sensitive Half-timetime

Context Sensitive Half-Context Sensitive Half-time - propofoltime - propofol

Opioid – hypnotic Opioid – hypnotic interactionsinteractions

Isobolograms

DrugDrug A

Dru

g B

Propofol-Remifentanil Propofol-Remifentanil InteractionInteraction

0

1

2

3

4

5

6

7

8

9

10

0 2 4 6 8 10 12 14 16

Blood propofol (µg/ml)

Pla

sma

rem

ifent

anil

(ng/

ml) Adequate anesthesia

Awakening

0

1

2

3

4

5

6

7

8

9

10

0 2 4 6 8 10 12 14 16

Blood propofol (µg/ml)

Pla

sma

rem

ifent

anil

(ng/

ml) Adequate anesthesia

Awakening

66 min min

7 min7 min

12 min12 min

Vuyk et al. Anesthesiology 1997; 87: 1549-62

RemifentanilRemifentanil

May reduce clearance of propofolMay reduce clearance of propofol Can lead to under prediction of Can lead to under prediction of

target concentrationstarget concentrations Synergistic effect with propofolSynergistic effect with propofol Does it produce tolerance?Does it produce tolerance?

Influence of remifentanil Influence of remifentanil on propofol Cp50on propofol Cp50

RemifentanilRemifentanil

0 ng/ml0 ng/mlRemifentanilRemifentanil

2 ng/ml2 ng/mlRemifentanilRemifentanil

4 ng/ml4 ng/ml

LORLOR Verbal Verbal 2.9 2.9 g/mlg/ml 2.4 2.4 g/mlg/ml 2.2 2.2 g/mlg/ml

LORLOREyelashEyelash 2.8 2.8 g/mlg/ml 1.8 1.8 g/mlg/ml 1.7 1.7 g/mlg/ml

LORLORNoxiousNoxious 4.1 4.1 g/mlg/ml 1.8 1.8 g/mlg/ml 1.3 1.3 g/mlg/ml

Struys. Anesthesiology 2003; 99: 802-12

Effect of remifentanil Effect of remifentanil and RA on propofol Cand RA on propofol Cee

Propofol CPropofol Cee NilNil RemifentanRemifentanilil

Nitrous Nitrous oxideoxide

RegionalRegional

anaesthesiaanaesthesia

SedationSedation 1-1.5 1-1.5 mcg/mlmcg/ml

<1 mcg/ml<1 mcg/ml N/AN/A <1 mcg/ml<1 mcg/ml

MaintenanceMaintenance

of of anaesthesiaanaesthesia

4-6 mcg/ml4-6 mcg/ml 3-4 mcg/ml3-4 mcg/ml 4-5 mcg/ml4-5 mcg/ml 3-4 mcg/ml3-4 mcg/ml

Propofol-remi Propofol-remi interactionsinteractions 32 children; 3-10yrs UGIE32 children; 3-10yrs UGIE Three remi groups – 0.025, 0.05 and Three remi groups – 0.025, 0.05 and

0.1 mcg/kg/min0.1 mcg/kg/min Propofol EDPropofol ED5050 decreased from 3.7 to decreased from 3.7 to

2.8 mcg/ml with addition of remi2.8 mcg/ml with addition of remi No benefit from increasing dose No benefit from increasing dose

above 0.025mcg/kg/min – more above 0.025mcg/kg/min – more complicationscomplications

Drover D et al. Anesthesiology 2004; 100: 1382-86

Propofol-remi Propofol-remi interactionsinteractions

Drover D et al. Anesthesiology 2004; 100: 1382-86

Propofol-remi Propofol-remi interactions interactions – effect on – effect on awakening (Cp50 – 2.2)awakening (Cp50 – 2.2)

6050403020100

Con

cent

ratio

n µg

/ml

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000800

600400

2000

6050403020100

Con

cent

ratio

n ng

/ml

14

12

10

8

6

4

2

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000800

600400

2000

Propofol-remi Propofol-remi interactions interactions – effect on – effect on awakening (Cp50 – 2.7)awakening (Cp50 – 2.7)

6050403020100

Con

cent

ratio

n µg

/ml

10

9

8

7

6

5

4

3

2

1

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000800

600400

2000

6050403020100

Con

cent

ratio

n ng

/ml

14

12

10

8

6

4

2

0

Inf. Rate(m

l/hr) + Decr. Tim

e

1000800

600400

2000

Propofol-remi Propofol-remi interactions interactions – effect on – effect on recoveryrecovery propofol 6mg/kg/hr and remi propofol 6mg/kg/hr and remi

0.15mcg/kg/min vs propofol 0.15mcg/kg/min vs propofol 3mg/kg/hr and remi 0.45mcg/kg/min3mg/kg/hr and remi 0.45mcg/kg/min

No significant difference in recovery No significant difference in recovery times if propofol or remi pronouncedtimes if propofol or remi pronounced

Less variation in recovery times if Less variation in recovery times if remi pronouncedremi pronounced

Hackner C et al. BJA 2003; 91: 580-2

Remifentanil – Remifentanil – Spontaneously breathingSpontaneously breathing

32 children (2-7 yrs); dental R32 children (2-7 yrs); dental Rxx

Big variation in dose tolerated – Big variation in dose tolerated – 0.05 -0.3mcg/kg/min0.05 -0.3mcg/kg/min

Median 0.127mcg/kg/minMedian 0.127mcg/kg/min RR <10 = best predictor of RR <10 = best predictor of

apnoeaapnoea

Ansermino JM et al. Pediatric Anesthesia 2005; 15: 115-121

Remifentanil – Remifentanil – Spont breathing & effect of Spont breathing & effect of ageage 45 children for stabismus surgery – 6m 45 children for stabismus surgery – 6m

to 9yrsto 9yrs Propofol – State entropy value 40-45Propofol – State entropy value 40-45 Final propofol rate about 12mg/kg/hrFinal propofol rate about 12mg/kg/hr Remifentanil – RDRemifentanil – RD5050 to RR to RR ≤≤10 10

(mcg/kg/min)(mcg/kg/min) No obvious relationship to age, weight No obvious relationship to age, weight

or heightor height

Barker N et al. Pediatr Anesth 2007; 17: 948-55

Remifentanil SV – Remifentanil SV – RDRD5050

0.192

0.0950.075

0

0.05

0.1

0.15

0.2

6m-3yr 3yr-6yr 6yr-9yr

Barker N et al. Pediatr Anesth 2007; 17: 948-55

Remifentanil SV – Remifentanil SV – Maximum tolerated Maximum tolerated dosedose

0.35

0.167 0.166

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

6m-3yr 3yr-6yr 6yr-9yr

Barker N et al. Pediatr Anesth 2007; 17: 948-55

Remifentanil infusion Remifentanil infusion rates – Adults vs rates – Adults vs ChildrenChildren

Adults (20-60yrs) vs children (3-Adults (20-60yrs) vs children (3-11yrs)11yrs)

IRIR5050 block somatic response to block somatic response to skin incisionskin incision

Propofol 6mcg/ml 3mcg/mlPropofol 6mcg/ml 3mcg/ml IRIR5050 adults = 0.08mcg/kg/min adults = 0.08mcg/kg/min IRIR5050 children = 0.15mcg/kg/min children = 0.15mcg/kg/min

Munoz H et al. Anesth Analg 2007; 104: 77-80

Propofol/remifentanil – Propofol/remifentanil – spontaneously breathingspontaneously breathing

100 children for MRI – mean age about 3 yr100 children for MRI – mean age about 3 yr Propofol (10mg/ml) and remifentanil Propofol (10mg/ml) and remifentanil

(10mcg/ml)(10mcg/ml)

Tsui BC et al. Pediatric Anaesthesia 2007; 15:397-401

Remifentanil – Timing Remifentanil – Timing of Morphine Bolusof Morphine Bolus 120 adult120 adult patients – lap chole Morphine bolus at various time

intervals from end of surgery (<20 mins to >40 mins)

Pain scores similar in all groups Least postoperative morphine

consumption in >40 mins group

Munoz H et al. Br J Anaesth 2002; 88: 814-8

TIVA – What I doTIVA – What I do

Manual infusion regime:Manual infusion regime: Propofol 1% 50mls/Remifentanil Propofol 1% 50mls/Remifentanil

1mg/Ketamine 25mg1mg/Ketamine 25mg 15-12-10-8mg/kg/hr - <6yo15-12-10-8mg/kg/hr - <6yo 12-10-8-6mg/kg/hr - >6yo12-10-8-6mg/kg/hr - >6yo Aiming for target of about 3mcg/mlAiming for target of about 3mcg/ml

TIVA – What I doTIVA – What I do

TCI:TCI: Propofol 1% 50mls/Ketamine 25mgPropofol 1% 50mls/Ketamine 25mg Target 10-6-3mcg/ml - <6yoTarget 10-6-3mcg/ml - <6yo Target 8-5-3mcg/ml - >6yoTarget 8-5-3mcg/ml - >6yo Remifentanil 1-3mg in 50mlsRemifentanil 1-3mg in 50mls Target 6-4ng/ml - <6yoTarget 6-4ng/ml - <6yo Target 6-3ng/ml - >6yoTarget 6-3ng/ml - >6yo

Spontaneous Spontaneous breathingbreathing Avoid remifentanilAvoid remifentanil Add ketamine to propofolAdd ketamine to propofol Use local/regional anaesthesiaUse local/regional anaesthesia Greater propofol requirements – Greater propofol requirements –

may need to start at may need to start at 18-20mg/kg/hr; don’t go below 18-20mg/kg/hr; don’t go below 10-12mg/kg/hr10-12mg/kg/hr

Propofol Infusion Propofol Infusion Syndrome (PRIS)Syndrome (PRIS)

First reported in children in 1992First reported in children in 1992 Age 4 weeks to 6 yearsAge 4 weeks to 6 years All had respiratory illnessesAll had respiratory illnesses Propofol 7.4-10.0 mg/kg/hrPropofol 7.4-10.0 mg/kg/hr Metabolic acidosis, bradycardia, Metabolic acidosis, bradycardia,

myocardial failure, lipaemic blood, myocardial failure, lipaemic blood, enlarged liverenlarged liver

PRIS - PathophysiologyPRIS - Pathophysiology

Like mitochondial cytopathyLike mitochondial cytopathy Impaired fatty acid oxidationImpaired fatty acid oxidation Accumulation of acylcarnitine Accumulation of acylcarnitine

estersesters Propofol 1% at 4mg/kg/hr = Propofol 1% at 4mg/kg/hr =

2-3g/kg/day lipid2-3g/kg/day lipid Worse if inadequate glucose Worse if inadequate glucose

supplemention (6-8mg/kg/min), supplemention (6-8mg/kg/min), steroids and catecholaminessteroids and catecholamines

PRIS – Where is the PRIS – Where is the Evidence? – Case Report Evidence? – Case Report 11

Wolf et al. Lancet 2001; 357:606Wolf et al. Lancet 2001; 357:606 2yo head injury 2yo head injury mean propofol dose 5.2mg/kg/hrmean propofol dose 5.2mg/kg/hr Developed signs of PRIS on D4Developed signs of PRIS on D4 Propofol stopped and CVVH instigatedPropofol stopped and CVVH instigated High levels of carnitines (malonyl and High levels of carnitines (malonyl and

acyl)acyl) Mean glucose intake Mean glucose intake ≈ 2.5mg/kg/min≈ 2.5mg/kg/min Child survived – markers of fatty acid Child survived – markers of fatty acid

oxidation normal at 9 month follow-upoxidation normal at 9 month follow-up

PRIS – Where is the PRIS – Where is the Evidence? – Case Report Evidence? – Case Report 22Withington et al. Pediatr Anesth 2004; Withington et al. Pediatr Anesth 2004; 14:505-814:505-8

5m old post cleft lip repair (35m old post cleft lip repair (3rdrd attempt) attempt) Mean propofol dose 11.7mg/kg/hrMean propofol dose 11.7mg/kg/hr Developed signs of PRIS on D3Developed signs of PRIS on D3 Propofol stopped and charcoal HP instigatedPropofol stopped and charcoal HP instigated Glucose intake <3mg/kg/hrGlucose intake <3mg/kg/hr Child survivedChild survived Samples showed elevated acylcarnitines – Samples showed elevated acylcarnitines –

normal at follow-upnormal at follow-up

PRIS – Does it occur PRIS – Does it occur with Anaesthesia?with Anaesthesia? 3 recent case reports in children:3 recent case reports in children:

A - Acidosis; L – Lactic, HT – Hypotension; CPK – creatine A - Acidosis; L – Lactic, HT – Hypotension; CPK – creatine phosphokinasephosphokinase

Age (yrs)Age (yrs) DiagnosisDiagnosis Prop dose Prop dose (mg/kg/hr)(mg/kg/hr)

Prop Prop duration duration (hours)(hours)

Signs of Signs of PRISPRIS

33 Cerebral Cerebral aneurysmaneurysm

6.56.5 88 A, HT, A, HT, ↑CPK↑CPK

77 OsteogenesOsteogenesis is

imperfectaimperfecta

13.513.5 2.52.5 LALA

1212 Mitral valve Mitral valve diseasedisease

<3<3 1515 LALA

1616 Mitral valve Mitral valve diseasedisease

<3<3 88 LALA

PRIS – What can we do PRIS – What can we do to prevent it?to prevent it? Avoid propofol!Avoid propofol! Avoid in high risk cases – PICU Avoid in high risk cases – PICU

patients, steroids, catecholamines, patients, steroids, catecholamines, fatty acid oxidation disorderfatty acid oxidation disorder

Use 2% propofolUse 2% propofol Limit dose – adjuncts, avoid for Limit dose – adjuncts, avoid for

postoperative sedationpostoperative sedation Maintain adequate glucose intake – 6-Maintain adequate glucose intake – 6-

8mg/kg/min8mg/kg/min Monitor for lactic acidosisMonitor for lactic acidosis

QuestionsQuestions

??