Pediatric Preop, Set-up, & Induction Flashcards
What pediatric population has the highest adverse events rate?
Infants < 1mos
- Bradycardia
- Respiratory complications
- Cardiac arrest (hyperkalemia)
- Medicated related
- Equipment related
Pediatric Anesthesia M&M
Adverse events 35%
Adults only 17%
Newborns
1-28 days
Up to 1mos
Infants
1mos up to end 1st year
Children
2-5yo
Toddlers
School-Age
6-14yo
Adolescents
14-18yo
Psychological Aspects
0-6mos
Not usually affected by separation from parents
Prolonged separation potential to impair parent-child bonding
Minimal premedication requires
Psychological Aspects
6mos-4yo
Separation anxiety
Fear hospitals/hospitalization
Regressive behaviors common
Psychological Aspects
School-Age Children
Less upset by separation from parents
Ask questions, involved, want choices, more concerned w/ surgical procedure & potential affects on body image
Psychological Aspects
Adolescents
Fear narcosis process, loss control, waking-up during surgery, and pain
Value modesty
HCG testing in females (> 14yo)
Psychological Aspects
Parents
Provide what to expect explanations
Assent vs. Consent
Assent - agree to take part when unable to give legal consent to participate (< 18yo)
Consent - to give permission for something to happen (informed surgical consent given by parents or legal guardian)
Parental Presence at Induction
Considerations
Prepare parents what to expect Adequate preop sedation Parental anxiety level Language barriers Emergency or RSI Anticipated difficult airway Unstable patient Pregnant mother
Patients to check preop Hgb:
Neonates Premature infants Cardiopulmonary disease Known hematological dysfunction Anticipated blood loss
URI
Common viral infection or more serious RSV/COVID
Irritable airway ↑laryngospasm, bronchospasm, post-intubation croup, atelectasis, pneumonia, & desaturation risk
LMA > ETT
Reschedule elective surgery 2-4 weeks
Lower respiratory infection 6-8 weeks
When to postpone surgery?
Elective Febrile ↑WBC Productive/purulent sputum Worsening or acutely ill Malaise Tachypnea Wheezing Lethargy
URI Anesthetic Management
Adequate hydration & oxygenation ↓secretions Limit airway manipulation Bronchodilators β2 agonist Anticholinergics Muscle relaxants to treat laryngospasm
URI Complications Associated w/ GA
ETT
Asthma or reactive airway
↓tracheal mucociliary flow & pulmonary bactericidal activity
PPV potential to spread the infection from upper to lower airways
Still’s Murmur
2-6yo functional systolic murmur
Outgrow w/o intervention
When to follow-up undiagnosed murmur w/ cardiac evaluation?
Difficulty feeding SOB Poor exercise tolerance Family history CHD Cyanotic episodes Abnormal peripheral pulses Unequal BPs in upper vs. lower extremities
Midazolam
Most common oral premedication
0.5mg/kg PO
Max 20mg
Concentration 2 or 5mg/mL
What patients to avoid premedication?
CHD ↑ICP OSA Sepsis Trauma Suspected difficult airway
Nasal Premedications
Midazolam 0.2mg/kg
Ketamine 3mg/kg
Dexmedetomidine 1-2mcg/kg (delayed onset)
MAP Formula
[(DBP x 2) + SBP] / 3
Pediatric patients w/ potential unstable cervical spine:
Down syndrome - subluxation risk
Trauma
Straight Blade
Miller < 1yo
ETT Sizing
Premature 2-2.5 uncuffed Term 3 3-9mos 3-3.5 9-18mos 3.5-4 18-36mos 4-4.5 >36mos → (Age/4) + 3.5 = cuffed size
ETT Depth
< 3kg 1-2-3kg → 7-8-9cm @ lips
> 3kg internal diameter x3 (4.0 ETT @ 12cm)
Emergency Medications
Atropine 0.4mg/mL
Succinylcholine 20mg/mL
Epinephrine 1-100mcg/mL
What emergency medications require IM needles?
Atropine 22G
Succinylcholine 22G
Atropine
Dose 0.02mg/kg 0.4mg/mL < 10kg 1mL TB syringe > 10kg 3mL syringe 22G IM needle
Succinylcholine
Dose 0.25-2mg/kg
20mg/mL
3mL syringe
22G IM needle
Epinephrine
100mcg/mL 1:1,000 g:mL (Omnicell)
10mcg/mL 1:100,000 g:mL (pharmacy)
Neonate 1mcg/mL
Fluids < 30kg
Buretrol fill to 10mL/kg
Double stopcock, extension, & T-piece
Fluids > 30kg
Macro drip tubing
UNC Fluids
0-2yo → Buretrol
3-9yo → micro drip tubing
> 10yo → macro tubing
Anesthesia Circuit
Small enough to sense small Vt & large enough to administer vital capacity breath
Neonatal 0.5L
1L reservoir bag < 30kg
3L reservoir bag > 30kg
Inhalational Induction
Pacifiers okay (size-up mask)
1-2min N2O + O2
Then introduce Sevo & rapidly ↑6-8%
Reduce to 4-5% to prevent overdose & assist ventilation
Consider oral airway
Place IV after stage 2 & prior to airway instrumentation
100% FiO2 during IV placement
IV Anesthesia Induction
Most reliable & rapid
Necessary when inhalation induction contraindication (difficult airway, full stomach, or cardiac instability)
N2O w/ IV placement to provide analgesia
Topical anesthetics EMLA or ethyl-chloride spray
Ideal to pre-oxygenate w/ 100% FiO2 prior to IV induction, but not always possible w/ uncooperative patients
Maximum IM Administration Volume
Infant 0.5mL (vastus lateralis)
Toddler 0.5mL (deltoid) or 0.5-1mL (vastus lateralis)
Pre-school 0.5mL (deltoid) or 1mL (vastus lateralis)
School-age 0.5-1mL (deltoid) or 1.5-2mL (vastus lateralis)
IV Gauges
Neonate 24G
Infants 22-24G
Children 20-22G
Arterial Line
IV catheter vs. A-line device
> 2yo 22G
< 2yo 24G
Babywire 0.012 (24G)
Caudal Anesthesia +
Epidural
- Intra/postop analgesia
- ↓systemic opioid requirements & associated side effects
- ↓anesthesia requirements
Caudal Anesthesia
Procedures
Circumcision Inguinal herniorrhaphy Hypospadias Anal surgery Clubfoot repair Sub-umbilical procedures
Caudal Anesthesia
Contraindications
Infection around the site
Coagulopathy
Anatomic abnormalities
Parent refusal
Caudal Dosing
Genital & anal surgery 0.5-0.75mL/kg
Lower abdomen or extremity 1mL/kg
Abdominal incision 1-1.25mL/kg
Caudal Local Anesthetics
Lidocaine 5mg/kg or 7mg/kg + Epi
Bupivacaine 2.5mg/kg or 3mg/kg + Epi
Ropivacaine 2.5mg/kg or 3mg/kg + Epi
Epinephrine 5mcg/kg
Caudal + Clonidine
1-2mcg/kg
↑DOA 2-3hrs
Sedation, hypotension, respiratory depression
Avoid co-admin w/ Dexmedetomidine
PACU
Ambu-bag Oxygen source Monitoring Emergency medications Pain medication Emergence delirium Lateral position
Emergence Delirium
Treatment
Dexmedetomidine
Propofol
Fentanyl
