Peds Anesthesia Flashcards
adverse events in infants <1 getting anesthesia
- bradycardia secondary to hypoxia and high inhalation anesthetic concentration
- respiratory complications like bronchospasm, laryngospasm, apnea
- cardiac arrest (8 out of 10 result from hyperkalemia following transfusion)
- medication related
- equipment related (CVC placement)
psychological preparation for kids
- IMPORTANT
- may have child-life, videos, tours etc
- basic objective = explain to child and parents in respectful, simple, understandable and reassuring terms
- bond with child to reduce their anxiety as well as their parents
0-6 months psychological aspect
not usually upset by separation from parents, prolonged separation may impair parent-child bonding
6 months-4 years psychological aspect
separation anxiety, fear of hospitalization; may show regressive behavior
School age children psychological aspect
less upset by separation from parents, asks questions, involved, wants choices, more concerned with surgical procedures and its possible effects on body image
adolescents psychological aspect
fear of the process of narcosis, loss of control, waking up during surgery, and pain of surgery; value modesty; HCG test in females
parents psychological aspect
provide an explanation of what to expect
parental presence on induction not appropriate when…
- adequate preop sedation
- parent’s level of anxiety
- language barrier
- emergency/RSI cases
- anticipated difficult airway or unstable patient
- pregnant mother (due to N2O exposure)
interview and physical exam peds
- sources of information include the EMR, parents, and the child
- NPO status
- current weight
- auscultate heart and lungs
- evaluation of the airway, inquire about loose teeth
- PMH/previous anesthetics/MH
- recent URIs or fevers
- cigarette exposure in the home
- possibility of pregnancy
- allergies and current meds
preop lab considerations for peds
- often not necessary
- consider if the labs could wait until they are under anesthesia
- Hgb on certain patients
- glucose in prolonged fasting and metabolic disorder
- pregnancy test in females
patient who may need Hgb
- neonate
- premie
- cardiopulmonary disease
- known heme dysfunction
- anticipated major blood loss during procedure
child with URI
- may be simple infection or much more serious
- LMA over ETT if appropriate
- consider rescheduling surgery for 2-4 weeks or 6-8 weeks if lower resp tract
URI is more irritable and at increased risk for
- laryngospasm
- bronchospasm
- post-intubation croup
- atelectasis
- pneumonia
- desats
reasons to post-pone surgery for URI
- elective
- febrile
- elevated WBC
- productive/purulent sputum
- getting worse
- acutely ill
- malaise
- tachypnea
- wheezing
anesthetic management with URI
- adequate hydration and oxygenation
- reduce secretions
- limit airway manipulation
- bronchodilators (beta-2-agonists) for wheezing
- anticholinergics (inhibits cholinergic mediated bronchospasm)
- muscle relaxants for laryngospasm
what symptoms combined with a murmur might mean something more
- difficulty feeding, SOB
- poor exercise tolerance, can’t match peers
- family history of CHD
- cyanotic episodes
- abnormal peripheral pulses
- unequal blood pressures in upper vs lower extremities
oral premedication
- individualize (not everyone needs it esp <6-12 months because they don’t get separation anxiety)
- may prolong time to discharge
- midaz 0.5 mg/kg PO max 20 mg
- careful sedating child with congenital heart defect, increased ICP, OSA, sepsis, trauma, or suspected difficult airway
nasal premeds
- midaz 0.2 mg/kg
- ketamine 3 mg/kg
- precedex 1-2 mcg/kg
set-up and monitoring
- BP cuff (appropriate size)
- ECG (often 3 lead, but 5 for cardiac patients)
- pulse ox
- capnography
- temperature
- neuromuscular function
- temperature
prep for induction of anesthesia in peds
- warm room
- pre induction checklist
- chair or stool if parent is present
- ensure quiet, calm OR
- variety of techniques exist
set up of peds case
- mask x2-3 (one bigger/one smaller)
- ETT x3 (onse size above and below)
- blades (several)
- appropriately sized breathing circuit, BP cuff, ECG, SpO2
- appropriate syringe sizes for weight based dosing
- IM needles (for succ and atropine)
- warming devices
- shoulder roll
- sevo in line and filled
- IV set ups
- soft ETT suction appropriate for ETT size
- appropriate sized OGT
LMA size 1
neonate/infant up to 5 kg
max cuff volume 4 mL
LMA size 1.5
infant 5-10 kg
cuff volume 7 mL
LMA size 2
infants/children 10-20 kg
cuff volume 10 mL
LMA size 2.5
children 20-30 kg
cuff volume 14 mL
LMA size 3
children 30-50 kg
cuff volume 20 mL
LMA size 4
adults 50-70 kg
cuff volume 30 mL
premie ETT size
2-2.5 mm uncuffed
term infant ETT size
3 mm
3-9 months ETT size
3-3.5 mm
9-18 months ETT size
3.5-4 mm
18-36 months ETT size
4-4.5 mm
> 36 months ETT size
age/4 + 3.5 = cuffed size
ETT depth calculation < 3 kg
1-2-3 kg –> 7-8-9 cm depth at lips
ETT depth calculation > 3 kg
internal diameter of ETT (ID) x 3
emergency meds for peds case
- atropine –> 0.4 mg/mL [<10 kg place in 1 cc syringe; > 10 kg place in 3 cc syringe]; with 22G IM needle
- succ - 20 mg/mL in 3 cc syringe; 22G IM needle
- epi - 100 mcg/mL (abboject), 10 mcg/mL, 1 mcg/mL (for neonates)
pediatric breathing circuits
- small enough for sensitivity to small tidal volume
- big enough to give a vital capacity breath
- neonatal circuit
- peds circuit 1 L bag < 30 kg
- adult circult 3 L bag > 30 kg
inhalation induction
- most common method of inducing anesthesia in kids
- sevo = agent of choice
- paci OK to leave in
- OK to have child lay down, sit up, or sit in someones lap
- mask gently placed over child’s face, with admin of N2O and O2 for 1-2 minutes, sevo introduced and rapidly increased to 6-8%
- after GA induced, sevo should be decreased to around 4-5% to prevent OD
- IV then placed following stage 2 and prior to instrumentation of airway; consider 100% FiO2 during IV (ie d/c the nitrous)
mask induction aids and distraction techniques
- scented mask
- bubble
- playing video games or watching a movie
- use of elbow without a mask and tenting with the hand
- music
- jokes
- steal induction in asleep child
- single-breath induction
IV induction for peds
- most reliable and rapid
- main disadvantage is starting IV can be painful and traumatic for child (reserved for age 8 or older)
- necessary when inhalation induction is contraindicated
- may place IV under N2O
- topical anesthetic (EMLA, or spray)
- ideally all children preoxygenated with 100% oxygen before IV induction, but this is not always possible
when to do IV induction
- at risk for aspiration requiring RSI (full stomach)
- anticipated difficult airway
- potential cardiac instability
intramuscular induction
- preferred that all IM injections are avoided in kids
- may be indicated in uncooperative children who refuse other routes of sedation
- also may need rescue meds if patient develops laryngospasm during inhalation induction
infant IM max recommended volume
- deltoid - not recommended
- vastus lateralis - 0.5 mL
toddler IM max recommended volume
- deltoid - 0.5 mL
- vastus lateralis - 0.5-1 mL
preschool age IM max recommended volume
- deltoid - 0.5 mL
- vastus lateralis - 1 mL
school age IM max recommended volume
- deltoid - 0.5-1 mL
- vastus lateralis - 1.5-2 mL
mask anesthesia
- always have age and size appropriate equipment for intubation/LMA placement
- appropriately sized mask
- oral airways and tongue blade
- avoid applying pressure over soft tissue of the chin and neck during mask anesthesia
- monitor breath sounds, ETCO2, movement of reservoir bag
- precordial!!!!
two most commonly used veins for IVs in kiddos
- superficial dorsal hand veins off the basilic vein
- saphenous vein at the ankle
IV catheter sizes for art lines
- 22g for > 2 years
- 24g for < 2 years
caudal anesthesia
-caudal space, continuous caudal catheters
benefits of caudal
- intraop and postop analgesia
- reduction in systemic opioid requirements and side effects
- reduction in anesthesia requirements
procedures that could use a caudal
- circumcision
- inguinal hernia repair
- hypospadias
- anal surgery
- clubfoot repair
- other sub umbilical procedures
contraindications to caudal
- infection around the site
- coagulopathy
- anatomic abnormalities
- parental refusal
caudal landmarks
- sacral hiatus
- 2 posterior superior iliac spine (PSIS)
caudal dosing
- genital and anal surgery = 0.5-0.75 mL/kg
- lower abdomen, extremity = 1 mL/kg
- abdominal incision = 1-1.25 mL/kg
caudal additives
- epi –> intravascular test dose 0.5 mcg/kg; increase duration; theoretical neurologic complications
- clonidine –> 1-2 mcg/kg; increase DOS
- narcotics
things to bring when taking peds patient to PACU
- appropriately sized ambu bag
- oxygen source
- monitoring (pulse ox, ECG, BP)
- emergency meds (at the least atropine, succ, epi)
- pain meds
- treatment for emergence delirium (precedex, propofol, fentanyl)
- lateral position
