Pediatric Lecture 2

• Caution sedation
• Assess for difficult airway and mask
• Consult with surgeon and family
• Smooth, deep induction (communicate effectiveness of ventilation)
• Minimize narcotics and optimize non narcotic pain management
• Discuss emergence with surgeon (effective communication with OR personnel).
• Awake vs deep extubation.
• Strict monitoring while transporting and reporting to PACU

• Calm controlled induction (caution with preoperative medications)
• Assess ability to ventilate. May need to reposition or utilize another provider.
• Gentle, deep intubation.
• Prevent bleeding. (4ml/kg)
• Maintain correct level of anesthetic depth and prepare for incision.
• Actively communicate with surgeon and plan for emergence.
• Recognize proper emergence criteria:Establish plan for deep vs. awake extubation.
• Post operative pain may be severe after tonsillectomy (laser or electrocautery).
• Steroids have been found to be efficacious in decreasing pain from swelling.
• Local infiltration is more beneficial for blood loss reduction rather than pain reduction

• Increased resistance with spontaneous breathing (inspiratory and expiratory valves)
• Large volume of absorber system acts as a reservoir for anesthetic agents
• Large compression volume of tubing

• Nonrebreathing, open circuit (Mapelson D or Bain)
• Rebreathing is prevented with high flows (2-2.5 x MV)
• Useful for very small infants to breath spontaneously. (Capnography essential)

• 500 ml bag for newborns
• 1000ml bag for 1-3 years
• 2000 ml bag for children older than 3

• Children with URI, particularly less than 1 year of age, have an increased risk of respiratory related adverse events intraoperatively and postoperatively
• Symptomatic infants with URI have a decreased time to desaturation during apnea.
• Endotracheal intubation seems to be a major risk factor for hypoxemia, bronchospasm, and atelectasis in children with URI.
• Temporary airway hyperreactivity may exist for 6 weeks after a viral infection. Most complications seen in older children (> 1 year of age), with mild, nonacute, nonpurulent URI are mild and easily treatable.

BM is a solid but for kids younger than 6M it’s 4 hours, for those older than 6M to 3yr, it’s 6hr and then it’s 8 hours.

• Infant < 6months rarely need sedation
• Separation anxiety for children 1-3 years old. (stormy inductions)
• Incorporate play or active participation with preschool age children (3-6y). (Mastery and participation)
• Encouraging, supportive, complementary, positive comments with school age child.
• Protection from harm and embarrassment in older children.

altered mental status (acute), elevated ICP, difficult airway, hypovolemia, or respiratory dysfunction.

• 0.5-1 mg/kg po not to exceed 20 mg( peak effect in 30 minutes)
• 0.1- 0.3 mg/kg IM not to exceed 10mg.

Methohexital 20-30 mg/kg PR ( onset 5 mins. Unpredictable, duration 2 hours).

• Fentanyl lollipop 10-15 mcg/kg ( onset 5-20 mins.)
• Intranasal 2mcg/kg

• Ketamine 4-10mg/kg IM; 8mg/kg PO; 1-2 mg/kg IV (onset of IM=1 min.  
• Use with midazolam and glycopyrolate

• Atropine: 0.02mg/kg IM/PO; 0.01mg/kg IV (onset 2 mins)
• Metaclopramide: 0.1mg/kg po ( onset 1 hour)
• Ranitidine: 2 mg/kg PO, 0.5-1 mg/kg IV (onset 30 mins)

Iv pumps for Neonates, Buritrols for infants, minidrips for children < 3 yrs with 250 cc bags. REMOVE ALL AIR BUBBLES

• ETT and suction catheter size (see next slide)
• ET diameter = {16 + age (years)}/4.
• ET length at lip in cm =12 + Age/2 or Age + 10.

• Miller 0: Preterm, Neonate
• Miller 1: Neonate to age 1.5 years
• Miller 2: Age 3 and older
• Wis-Hippel: 1.5 Age 1.5 to 4
• Macintosh 2: Age 3-6

• Size 1.0: Neonate/Infants ? 5kg; 4ml
• Size 1.5: Infants 5 – 10 kg; 7ml
• Size 2.0: Infants/children 10 – 20 kg; 10ml
• Size 2.5: Children 20 – 30 kg; 14ml
• Size 3.0: Children/Small adult > 30 kg; 20ml
• Size 4.0: Normal/Large adolescent/adult; 30ml
• Size 5.0: Large adolescent/adult; 40ml

• Single VC breath of 8% Sevo with 70% N2O.
• Occlude circuit and fill with Agent, open APL.
• Flavor mask, stickers, or color mask (keep child engaged)
• Child takes a deep breath, blows it out, then holds his/her breath.
• Place mask, and let breath mixture.
• Hold breath again and repeat while keeping mask against child’s face

• Most common technique for children. (steal induction)
• Excitement stage1 to 3 L/min of O2 and N2O with volatile gradually increased in 0.5% increments.
• Initially, mask does not touch face until lid reflex disappears.

Fast inhalation in kids because lower FRC, higher alveoli ventilation, and higher blood flow to VRG. Rapid rise in FA/FI

Ensure slight tube leak (10-25 cm H2O)

• A dissociative state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolable crying, moaning, kicking, or thrashing.
• Typically lasts 5-15 mins post op and is self limiting.
• Reported in up to 5% of adult case but can be as high as 15 -50% in children (one study reported 80%)

• Rapid emergence
• Anesthetic choice
• Pain
• Surgical type– (Tonsils, thyroid, middle ear)Age (2-5)
• Preoperative anxiety
• Temperament

• Toradol 1 mg/kg
• Intranasal fentanyl 2 mcg/kg
• IV fentanyl 2.5 mcgs/kg
• Clonidine 3 mcg/kg
• Dexmetatomindine.

typically lasts 5-15min post-op and is self limiting

• 5-8 cc/kg/min in newborn
• 4-6 cc/kg/min in children
• 3-5 cc/kg/min in adults

• Use LR for fluid replacement in healthy child.
• Use 5% dextrose for premature, septic, infants of diabetic mothers and those receiving TPN. Measure blood glucose closely.

• Premature Infants = 100 ml/kg
• Term Newborn = 95 ml/kg
• 1 year age = 75 ml/kg
• 3 years age to adult 70 ml/kg
• Adult female = 65 ml/ kg
• Adult male = 70 ml/kg

3-4%

10-20 cc/kg FFP if bleeding is acute

1 ml of FFP contains1 unit of coagulation factor activity

2%

1 unit of platelets contains at least 5.5 x 10 platelets in 50 to 70 ml of plasma

1 unit/10kg or 20 ml/kg

• If EBL is 1/3 of ABL, replace with LR. If greater than 1/3, consider replacement with 5% Albumin.
• If EBL > ABL, Use PRBC with colloid. Platelets and FFP should be guided by blood tests.