Peds Anesthesia

Preschoolers ( ___ to ____years) • Principal fear centered around _______________________. • "Band‐aid age": Concern over body integrity and degree of "mutilation" • Requires reassurance • May share some of the older school age concerns

Preschoolers (4 to 5 years) • Principal fear centered around the surgical procedure. • "Band‐aid age": Concern over body integrity and degree of "mutilation". • Requires reassurance • May share some of the older school age concerns

Minor risks that occur more with pediatric population include (3) Most deaths due to anesthesia occur during what time period?

• Minor risks that occur more with pediatric population include laryngospasm, bronchospasm or croup • Most deaths due to anesthesia occur during the 1st week of life

> Airway patency is also dependent upon lung stretch reflexes, central and carotid body chemoreceptor reflexes, and CNS arousal mechanisms. Pharyngeal patency is established and maintained through a delicate balance of CNS- derived dilating and collapsing forces upon the pharyngeal airway. > In the awake infant and child, the tongue, the upper airway muscles (i.e., genioglossus, geniohyoid, sternohyoid, & sternothyroid) interact to tent the pharynx, preventing collapse > The infant has a compliant chest wall, and because of forceful diaphragmatic contraction, the chest is noted to _________ with inspiratory efforts against partial pharynx collapse > A paradoxical movement of the chest and abdomen (i.e., the contraction of the chest with abdominal expansion) is also appreciated. This thoracoabdominal asynchrony is an important clinical sign of ________________________________. > CPAP 5 to 10 cm H2O is essential in

> Airway patency is also dependent upon lung stretch reflexes, central and carotid body chemoreceptor reflexes, and CNS arousal mechanisms. Pharyngeal patency is established and maintained through a delicate balance of CNS- derived dilating and collapsing forces upon the pharyngeal airway. > In the awake infant and child, the tongue, the upper airway muscles (i.e., genioglossus, geniohyoid, sternohyoid, and sternothyroid) interact to tent the pharynx, preventing collapse > The infant has a compliant chest wall, and because of forceful diaphragmatic contraction, the chest is noted to collapse with inspiratory efforts against partial pharynx collapse > a paradoxical movement of the chest and abdomen (i.e., the contraction of the chest with abdominal expansion) is also appreciated. This thoracoabdominal asynchrony is an important clinical sign of upper airway obstruction. > CPAP 5 to 10 cm H2O is essential in the reestablishment of a patent pharyngeal airway > lateral decubitus position

Acetaminophen • Can cause dose-dependent hepatocyte injury. • How is it Metabolized? • 80% of parent drug is conjugated with ___________ and _________ (phase ____ metabolism). • Small amount may undergo metabolism by P-450 system and produce an intermediate metabolite that conjugates with __________ and is excreted. • What happens if you have a depletion of this protein?

Acetaminophen • Can cause dose-dependent hepatocyte injury • Metabolized by hepatic microsomal enzyme system • 80% of parent drug is conjugated with glucuronic acid and sulfate (phase II metabolism) • Small amount may undergo metabolism by P-450 system and produce an intermediate metabolite that conjugates with glutathione and excreted • Glutathione depletion leads to accumulation of intermediate metabolite (acetaminophen-induced liver necrosis)

Acetaminophen • Safe administration at following doses: • Acetaminophen _____ mg/kg PO (prior to induction) • Acetaminophen _____ mg/kg PR (post induction) • Excessive doses can result in hepatic toxicity and death • Maintenance: ____--____ mg/kg PO/PR q ____--____ hrs/____ hrs

Acetaminophen • Safe administration at following doses: • Acetaminophen 30 mg/kg PO (prior to induction) • Acetaminophen 40 mg/kg PR (post induction) • Excessive doses can result in hepatic toxicity and death Maintenance: 10‐15 mg/kg PO/PR every 4‐6 hrs/24 hrs

Adolescents (____--____ yrs) • Principal fears _______________________. • Teens also fear losing control under the anesthetic. > Try to talk these kids about drugs and alcohol with out parents in the room.

Adolescents (13 to 18) • Principal fear is the operation will fail, they'll die while anesthetized or be awake during surgery. • Teens also fear losing control under the anesthetic > Try to talk these kids about drugs and alcohol with out parents in the room

Anesthesia Machine Reduce the inspired oxygen concentration to avoid _____________. •Should have air/N2O available

Anesthesia Machine Reduce the inspired oxygen concentration to avoid retinopathy of prematurity (ROP)

Review of Systems BOTH SIDES Genitourinary: Focus of questions: frequency, time of last urination, frequency of urinary tract infections. Anesthetic concerns: infection, hypercalcemia, hydration status, adequacy of renal function. Has the child had problems with the kidneys, ureters, or bladder? Any UTIs?

Review of Systems Endocrine/Metabolic: Focus of questions: abnormal development, hypoglycemia, steroid therapy. Anesthetic concerns: endocrinopathy, hypothyroidsim, DM, hypoglycemia, adrenal insufficiency. > Does the child have DM or hypoglycemia problems? > Does the child have any problems with the thyroid or adrenal glands?

Apnea Prevention and Treatment •Spinals have a high failure rate in neonates (up to 20%) •Consider which 2 gases? •Avoid which 2 classes of meds, if possible? •Which type of Regional anesthesia is great alternative? •Infants under 62 weeks' postgestational age (or if have significant history of apnea or respiratory disease) > Postoperatively monitor with these 2 types of monitors.

Apnea Prevention and Treatment •Spinals have a high failure rate in neonates (up to 20%) •Consider desflurane/sevoflurane. •Avoid opioids/IV sedatives, if possible. •Caudal anesthesia is great alternative. •Infants under 62 weeks' postgestational age (or if have significant history of apnea or respiratory disease) •Postoperatively monitor with an oxygen saturation monitor and an abdominal pressure transducer

Apnea in the Premature Infant (AOP) •Immature respiratory control systems = Unstable respiratory rhythm •Impaired ventilatory responses to __________and _________________. •Exaggerated inhibitory reflexes in neonate •Treatment strategies:- > Stabilize Respiratory rhythm • Methylxanthines (caffeine ___--___ mg/kg) - blockade of adenosine receptors •Continuous positive airway pressure (CPAP). •ROP resolves with ___________________. •Increased myelination of the brainstem

Apnea in the Premature Infant (AOP) •Immature respiratory control systems = Unstable respiratory rhythm •Impaired ventilatory responses to hypoxia and hypercarbia •Exaggerated inhibitory reflexes in neonate •Treatment strategies: > Stabilize Respiratory rhythm •Methylxanthines (caffeine 5-10mg/kg) - blockade of adenosine receptors. •Continuous positive airway pressure (CPAP) •ROP resolves with maturation. •Increased myelination of the brainstem

Succinylcholine • Children are more susceptible to side effects with Sux than adults: • Cardiac Arrhythmias • Hyperkalemia • Rhabdomyolysis • Masseter muscle spasm (cheek, lower jaw) • Malignant Hyperthermia • Any child that experiences cardiac arrest following administration of Sux should be immediately treated for what electrolyte disturbance? • Prolonged resuscitative measures may be required.

Succinylcholine • Children are more susceptible to side effects with succinylcholine than adults: • Cardiac arrhythmias • Hyperkalemia • Rhabdomyolysis • Masseter muscle spasm • Malignant hyperthermia • Any child that experiences cardiac arrest following administration of sux should be immediately treated for hyperkalemia • Prolonged resuscitative measures may be required

Anesthetic techniques with the lowest risk for postoperative apnea appear to be a __________anesthetic without sedation for _______ extremity procedures.

Anesthetic techniques with the lowest risk for postoperative apnea appear to be a spinal anesthetic without sedation for lower extremity procedures.

Antiemetics and Other Common Drugs Ondansetron ___ mg/kg Dexamethasone _______ mg/kg Cefazolin _____mg/kg Ketorolac __________ mg/kg (safety not establish for <_____years old)

Antiemetics and Other Common Drugs • Ondansetron • 0.1 mg/kg • Dexamethasone • 0.15 mg/kg • Cefazolin • 25 mg/kg • Ketorolac • 0.5 mg/kg (safety not establish for <2 years old)

Common Metabolic and Structural Problems in SGA and LGA Infants

Common Metabolic and Structural Problems in SGA and LGA Infants

Mask Induction • Most common approach for pediatric patients, except when RSI is indicated • An "________________ phase" is often encountered during mask induction. • Noise in OR should be minimized and parents should be aware of its potential occurrence, if they are present for induction. > Easily accomplished in infants less than ______ months of age, as well as children who do not have initial intravenous access. • Children can become frightened, uncooperative, even combative during inhalation induction • Should this occur, it is imperative to have a backup plan, such as an IM injection of a sedative or hypnotic

Mask Induction • Most common approach for pediatric patients, except when RSI is indicated • An "excitement phase" is often encountered during mask induction. • Noise in OR should be minimized and parents should be aware of its potential occurrence, if they are present for induction. > easily accomplished in infants less than 8 months of age, as well as children who do not have initial IV access.

Midazolam • Has the slowest/fastest clearance of all Benzodiazepines. • Clearance significantly greater/less in neonates than older children. • A combination of ____________and______________ can cause profound hypotension in neonates

Midazolam • Has the fastest clearance of all benzodiazepines. • Clearance significantly less in neonates than older children. • Combination of fentanyl and midazolam can cause profound hypotension in neonates

Midazolam Doses Premedication (PO): _____ mg/kg >>>> Max dose (PO): _______ mg Sedation (IV): _________mg/kg >>>>>> Loading (IV): ____-____ mcg/kg Sedation (IM): ____--____ mg/kg >>>>>>> Max dose (IM): ________ mg

Midazolam Doses Premedication(PO): 0.5 mg/kg >>>>> Max dose (PO): 20 mg Sedation (IV): 0.05 mg/kg >>>> Loading (IV): 50‐70 mcg/kg Sedation (IM): 0.1‐0.15mg/kg >>>>> Maximum dose (IM): 7.5 mg

Monitoring •Consider precordial/esophageal stethoscope. •HR, rhythm, sound, and extrapolating vascular volume. •Continuous ECG monitoring •Particularly with electrolyte imbalances. •Standard: pulse oximetry, BP, inspired O2 concentration, ETCO2, inhalation agent concentration, PAP and end-expiratory pressure •Neuromuscular monitoring may be difficult (small muscle mass) •U/O may be difficult (catheter size)

Monitoring xxx

Morphine • Why is morphine used with caution in neonates? • The CYP‐450 pathways mature at the end of the ___________ period.

Morphine • Used with caution in neonates because hepatic conjugation is reduced and renal clearance of morphine metabolites is decreased. • The CYP‐450 pathways mature at the end of the neonatal period.

Preoperative Testing Chest Radiograph: • Suspected intrathoracic pathology (ex. tumors, vascular ring) • Congenital heart disease • History of prematurity with residual bronchopulmonary dysplasia EKG: • Family history of prolonged QT interval • Congenital heart disease C-Spine radiograph: • Down syndrome (rule out subluxation of atlanto-occipital junction)** separation on the spinal column from the skull base.

N/A

Peds MACs

Peds MACs

CNS ASSESSMENT Characteristics & Anesthetic Implications Incomplete myelination > Judicious use of muscle relaxants Lack of cerebral autoregulation > Cerebral perfusion pressure control Cortical activity > Pain relief/adequate level of anesthesia. Retinopathy of prematurity (ROP) > Oxygen saturation (94%-98%) doesnt need to be 100%.

CNS ASSESSMENT Characteristics & Anesthetic Implications Incomplete myelination > Judicious use of muscle relaxants Lack of cerebral autoregulation > Cerebral perfusion pressure control Cortical activity > Pain relief/adequate level of anesthesia Retinopathy of prematurity (ROP) > Oxygen saturation (94%-98%) doesnt need to be 100%

CNS Abnormalities • Assess status of the infant's ICP and intracranial compliance > Intraventricular hemorrhage (IVH) is almost exclusively seen in _____________ babies. >>>> Result of RDS, hypoxic-ischemic injury, and/or episodes of acute blood pressure fluctuation (rapid changes in CBF) >>>>>Laryngoscopy in the presence of inadequate anesthesia >>>>>>Symptoms: Hypotonia, apnea, seizures, loss of sucking reflex, bulging anterior fontanelle • Evaluate neonate with myelomeningocele (spina bifida) > There is spontaneous bleeding into and around the lateral ventricles of the brain. The more preterm the neonate is and the smaller the weight, the more likely it is that intraventricular hemorrhage will be found

CNS Abnormalities • Assess status of the infant's intracranial pressure and intracranial compliance >>>>>>Intraventricular hemorrhage (IVH) is almost exclusively seen in preterm babies >>>>>>>Result of RDS, hypoxic-ischemic injury, and/or episodes of acute blood pressure fluctuation (rapid changes in cerebral blood flow) >>>>>>>Laryngoscopy in the presence of inadequate anesthesia • Symptoms: Hypotonia, apnea, seizures, loss of sucking reflex, bulging anterior fontanelle • Evaluate neonate with myelomeningocele (spina bifida) > There is spontaneous bleeding into and around the lateral ventricles of the brain. The more preterm the neonate is and the smaller the weight, the more likely it is that intraventricular hemorrhage will be found

Caudal Anesthesia > A _______gauge needle is placed bevel-up at a _______-degree angle to the skin • LOR felt with _____________ membrane puncture. • Reduce angle of the needle and advanced cephalad/caudad • Use saline • If aspiration is negative CSF or blood - administer LA > Saline should be used with the loss of resistance technique because the use of air has been reported to cause both intravascular air embolism as well as permanent spinal cord injury.

Caudal Anesthesia • 22-gauge needle is placed bevel-up at a 45-degree angle to the skin • LOR felt with sacrococcygeal membrane puncture • Reduce angle of the needle and advanced cephalad • Use saline • If aspiration is negative CSF or blood - administer LA > Saline should be used with the loss of resistance technique because the use of air has been reported to cause both intravascular air embolism as well as permanent spinal cord injury.

Caudal Anesthesia • Most commonly used regional block in pediatric anesthesia • Useful for procedures involving innervation from the which 3 dermatomes? > In the youngest patients, the caudal can be used as an adjunct w/GA or solely for postoperative analgesia. > In the neonate, it is most often placed after induction of general anesthesia prior to the beginning of the surgical procedure. > With ultrasound, it is now possible to visualize the injection of local anesthetics in the caudal space as well as monitor the cranial spread.

Caudal Anesthesia • Most commonly used regional block in pediatric anesthesia • Useful for procedures involving innervation from the sacral, lumbar, or lower-thoracic dermatomes > In the youngest patients, the caudal can be used as an adjunct w/GA or solely for postoperative analgesia. > In the neonate, it is most often placed after induction of general anesthesia prior to the beginning of the surgical procedure. > With ultrasound, it is now possible to visualize the injection of local anesthetics in the caudal space as well as monitor the cranial spread.

Caudal Anesthesia • Position: Lateral/Supine with the upper/lower knee flexed/extended • Landmarks: ----------------- Form an equilateral triangle with the tip resting over the __________________.

Caudal Anesthesia • Position: Lateral with the upper knee flexed • Landmarks: Tip of the coccyx and the sacral cornu on either side of the sacral hiatus. • Form an equilateral triangle with the tip resting over the sacralhiatus

Caudal Anesthesia ___________________of the LA determines height of block ____--____ mL/kg provide analgesia and anesthesia to the ____ ---_____dermatome. • Deliver no more than ___________ mg/kg of LA • Consider: Epinephrine (1:200,000) or Clonidine (___--___ mcg/kg) for block prolongation

Caudal Anesthesia • Volume of the LA determines height of block • 1.2 to 1.5 mL/kg provide analgesia and anesthesia to the T-4 to T-6 dermatome. • Deliver no more than 2.5 mg/kg of LA Consider: Epinephrine (1:200,000) or Clonidine (1 to 2 mcg/kg) for block prolongation

Depth of ETT Insertion • Black lines or markings on various commercial types of tubes help with placement of the ETT in the lower/mid trachea in average-sized children. • Suprasternal palpation of tip of the tube is possible. • The position of the tip should be just within the _______________________________.

Depth of ETT Insertion • Black lines or markings on various commercial types of tubes help with placement of the ETT in the mid-trachea in average-sized children • Suprasternal palpation of tip of the tube is possible • The position of the tip should be just within the suprasternal notch

Desflurane • Pungent! • Associated with adverse respiratory events (similar to isoflurane). • Dramatic increases in Des concentrations may induce what type of stimulation? Like? - 2 > Lowest/Highest blood-gas partition coefficient of all the inhalation anesthetics -How does that affect induction, anesthetic depth, and emergence? > Des, unlike other volatile anesthetics, has virtually no __________ metabolism.

Desflurane • Pungent! • Associated with adverse respiratory events (similar to isoflurane). • Dramatic increases in desflurane concentrations may induce sympathetic stimulation (tachycardia and hypertension) > Lowest blood-gas partition coefficient of all the inhalation anesthetics (0.42) - rapid induction, rapid alterations in anesthetic depth, and emergence > Desflurane, unlike other VAs, has virtually no hepatic metabolism

ETT Selection •Select ETT with an air leak at _________-________ H2O pressure to avoid post-extubation airway edema. •Length of trachea- vocal cords to carina, (infants to 1 year) = _____-_______ cm. •ETT at lip should be ___--___ cm. •Traditionally, cuffed/uncuffed tubes preferred up to age______. •Due to airway resistance and tracheal damage from inflated cuffs. •Smaller physiologic margin of safety = Be vigilant!

ETT Selection Select ETT with an air leak at 20 to 30 cm H2O pressure to avoid postextubation airway edema. •Length of trachea (infants to 1 year) = 5-9 cm •ETT at lip should be 8-10 cm. •Traditionally, uncuffed tubes preferred up to age 8. •Due to airway resistance and tracheal damage from inflated cuffs. •Smaller physiologic margin of safety = Be vigilant!

Emergence Delirium • Manifests as non-purposeful restlessness, crying, moaning, incoherence, and disorientation. • Self-limiting but may last as long as _____ minutes. • Composite of biologic, pharmacologic, psychological, and social components. • Propofol, ketamine, fentanyl, dexmedetomidine (_______mcg/kg over 5 mins), and preoperative analgesia had a prophylactic effect in preventing agitation. • Which 2 drugs/classes do not have a protective effect? Causes: rapid awakening in unfamiliar settings, pain, stress during induction, hypoxia, airway obstruction, noisy environment, anesthesia duration, child's personality, pre-medication, and type of anesthesia.

Emergence Delirium • Manifests as nonpurposeful restlessness, crying, moaning, incoherence, and disorientation • Self-limiting but may last as long as 45 minutes • Incidence: 10% - 80% • Composite of biologic, pharmacologic, psychological, and social components. • Propofol, ketamine, fentanyl, dexmedetomidine (0.5mcg/kg over 5 mins), and preoperative analgesia had a prophylactic effect in preventing agitation. • Midazolam and 5HT3 inhibitors do not have a protective effect Causes: rapid awakening in unfamiliar settings, pain, stress during induction, hypoxia, airway obstruction, noisy environment, anesthesia duration, child's personality, premedication, and type of anesthesia.

Factors Contributing to the Incidence of Apnea in the Premature Infant

Factors Contributing to the Incidence of Apnea in the Premature Infant

Family Anesthesia History • Familial history of high fevers in OR or unusual events (malignant hyperthermia) • Issues of prolonged paralysis or mechanical ventilation after surgery in family members might indicate______________________. • Family history of unexpected death, SIDS, genetic defects, or familial conditions such as muscular dystrophy, cystic fibrosis, sickle cell disease, bleeding tendencies and HIV infection.

Family Anesthesia History • Familial history of high fevers in OR or unusual events (malignant hyperthermia) • Issues of prolonged paralysis or mechanical ventilation after surgery in family members (pseudocholinesterase deficiencies)-If there is a deficiency in the plasma activity of pseudocholinesterase, prolonged muscular paralysis may occur, resulting in the extended need for MV. • Family Hx of unexpected death, SIDS, genetic defects, or familial conditions such as muscular dystrophy, CF, sickle cell disease, bleeding tendencies and HIV infection.

Fasting Status • Prolonged fasting also may alter fluid balance hypovolemia and hypoglycemia is especially problematic in premature infants >>> 2-4-6-8 Rule: • 2 hr fast for ____________ • 4 hr for ________________ • 6 hr for _____, ____________, __________ • 8 hr for a __________________. > No gum chewing past _____________. > Consider postponing surgery non-compliant patient with history of ________________. • Sodium Citrate (____ mL/kg), Metoclopramide (_____mg/kg), and/or Ranitidine (______ mg/kg) > Risk of pulmonary aspiration in the pediatric patient is extremely low (1 in 10,000) > Consider ERAS

Fasting Status • Prolonged fasting also may alter fluid balance hypovolemia and hypoglycemia is especially problematic in premature infants 2-4-6-8 Rule: • 2 hr fast for clear liquids (apple juice) • 4 hr for breast milk • 6 hr for infant formula, non-human milk, a light meal • 8 hr for a regular meal including fatty foods > No gum chewing past midnight > Consider postponing surgery non-compliant patient with history of hiatal hernia • Sodium citrate (0.5mL/kg), Metoclopramide (0.1mg/kg), and/or Ranitidine (2.5 mg/kg) > Risk of pulmonary aspiration in the pediatric patient is extremely low (1 in 10,000) > Consider ERAS

Fentanyl • Clearances may be lower/higher in children than adults. • Although cardiovascularly stable, why should you still use caution when administering Fentanyl to children? • Which drug might you need to give concomitantly with Fentanyl?

Fentanyl • Clearances may be higher in children than adults. • Although cardiovascularly stable, use caution in neonates due to heart‐rate dependent cardiac output. • May require concomitant vagolytic agent, such as atropine.

Gestational Age and Postgestational Age at Surgery Full term is considered to be _____ to ______ weeks' gestation Borderline preterm _____ to _____ weeks' gestation Moderately preterm _____to _____weeks' gestation Severely preterm _____ to_______ weeks' gestation LGA Weight above the _____th percentile SGA Weight below the _____th percentile LBW Weight below _______ g VLBW Weight below _________ g ELBW Weight below _________ g

Gestational Age and Postgestational Age at Surgery Full term is considered to be 37 to 42 weeks' gestation Borderline preterm 36 to 37 weeks' gestation Moderately preterm 31 to 36 weeks' gestation Severely preterm 24 to 30 weeks' gestation LGA Weight above the 90th percentile SGA Weight below the 10th percentile LBW Weight below 2500 g VLBW Weight below 1500 g ELBW Weight below 1000 g

Head and Neck Abnormalities • Airway management concerns! • Small mouth + large tongue = airway obstruction during BMV • Small nares can be obstructed • Do not convert to mouth breathing • NG tubes can obstruct nares (OG tubes preferred) • Pierre Robin/Treacher Collins - What is it? What do these make impossible to do? • Cleft lip/palate may be complicated • Cystic hygroma (fluid-filled sacs) or hemangioma (is a bright red birthmark that shows up at birth or in the first or second week of life. It looks like a rubbery bump and is made up of extra blood vessels in the skin.) of the neck = upper airway obstruction > ROP, glaucoma, cataracts - atropine may ↑ IOP

Head and Neck Abnormalities • Airway management concerns! • Small mouth + large tongue = airway obstruction during BMV • Small nares can be obstructed • Do not convert to mouth breathing\ • NG tubes can obstruct nares (OG tubes preferred) • Pierre Robin/Treacher Collins - Small, receding chins direct laryngoscopy and visualization of the glottis impossible • Cleft lip/palate may be complicated • Cystic hygroma(fluid filled sac) or hemangioma of the neck = upper airway obstruction- Hemangioma- is a bright red birthmark that shows up at birth or in the first or second week of life. It looks like a rubbery bump and is made up of extra blood vessels in the skin. > •ROP, glaucoma, cataracts - atropine may ↑ IOP

Hering Breuer reflex

Hering Breuer reflex- triggered to prevent the over-inflation of the lung. Pulmonary stretch receptors present on the wall of bronchi and bronchioles of the airways respond to excessive stretching of the lung during large inspirations.

Physical Exam Note hypotonia, spasticity, flaccidity, signs of _____________________ (gait disorders, altered mental status)

Increased ICP

Inhalation Agents • Neonates have a lower/higher MAC (peaks at around ___ days of age) • MAC is higher/lower in infants from age _____--_____ months of age and decrease/increase with increasing age • Increased requirements are due to increased ___________________. • Myocardial depression is attenuated/exaggerated! • Slow/Rapid rise in FA/FI ratio. • Smaller/Greater percentage of blood flow to the vessel-rich organs. • Lower/Higher administered anesthetic concentrations.

Inhalation Agents • Neonates have a lower MAC (peaks at around 30 days of age) • MAC is higher in infants from age 1 to 6 months of age and decrease with increasing age • Increased requirements are due to increased basal metabolic rate • Myocardial depression is exaggerated! • Rapid rise in FA/FI ratio. • Greater percentage of blood flow to the vessel-rich organs. • Higher administered anesthetic concentrations

Inhalation Agents • Rapid increase in alveolar concentration of inspired anesthetic is quantified by the ratio of the alveolar to inspired concentration (FA/FI) Factors that affect FA/FI Ratio • The delivered inspired anesthetic concentration • The inhalation agent blood-gas partition coefficient • Alveolar ventilation (VA) • Cardiac output (Q) • The distribution of Q to the vessel-rich organs (heart, brain, kidneys, and liver)

Inhalation Agents • Rapid increase in alveolar concentration of inspired anesthetic is quantified by the ratio of the alveolar to inspired concentration (FA/FI) Factors that affect FA/FI Ratio • The delivered inspired anesthetic concentration • The inhalation agent blood-gas partition coefficient • Alveolar ventilation (VA) • Cardiac output (Q) • The distribution of Q to the vessel-rich organs (heart, brain, kidneys, and liver)

Innocent Murmurs 4 characteristics of innocent murmurs: • ___________ systolic to ____________systolic • Softer than grade _____ of _____. • Pitch is ________ to_________. • Sound has musical/non musical, harsh/not harsh quality.

Innocent Murmurs 4 characteristics of innocent murmurs: • Early systolic to midsystolic • Softer than grade III of IV • Pitch is low to medium • Sound has musical, not harsh quality

Innocent Murmurs • May occur in more than 30% of normal children • Usually soft/loud, short/long, systolic/diastolic ejection murmurs that are best heard along the __________ or_______________ sternal border s/significant radiation. • Left upper = flow across ___________ valve • Left lower = from ______ to ________(Name of murmur)

Innocent Murmurs • May occur in more than 30% of normal children • Usually soft, short systolic ejection murmurs that are best heard along the left upper or left lower sternal border without significant radiation. • Left upper = flow across pulmonic valve • Left lower = from LV to aorta (Still's vibratory murmur)

Intravenous Agents • Because of decreased percentages of muscle and fat in infants and children, what happens to the DOA? • CNS effects of opioids may be shortened/prolonged , why? • Consider effect of increased body water! > As discussed previously, infants and children have a higher proportion of cardiac output delivered to vascular-rich tissues (i.e., heart, brain, kidneys, and liver).

Intravenous Agents • Prolonged DOA in infants and children because of decreased percentages of muscle and fat. • CNS effects of opioids may be prolonged (immature BBB) • Consider effect of increased body water! > As discussed previously, infants and children have a higher proportion of cardiac output delivered to vascular-rich tissues (i.e., heart, brain, kidneys, and liver). >So when you draw up drugs for peds.... Don't use a 20cc syringe for prop. Dilute your 100mcg fent in a 10cc syringe

Intravenous Fluid Therapy Fluid therapy is divided into: > preoperative deficit > maintenance > third-space/blood replacement > Perioperative fluid homeostasis is altered by many factors, including IA administration, the OR environmental temperature, iatrogenic hyperventilation, and surgical stress. > Surgical stress increases plasma ______________ levels. _________________ results in an osmotic-induced renal loss of free water. > ______________, which cleaves Angiotensin I to form Angiotensin II, a powerful vasoconstrictor that acts to increase systemic BP. > Renin stimulates the release of _________________________.

Intravenous Fluid Therapy Fluid therapy is divided into: > preoperative deficit > maintenance > third-space/blood replacement > Perioperative fluid homeostasis is altered by many factors, including inhalation agent administration, the operating room environmental temperature, iatrogenic hyperventilation, and surgical stress. > Surgical stress increases plasma glucose levels. Hyperglycemia results in an osmotic-induced renal loss of free water. > Renin, which cleaves angiotensin I to form angiotensin II, a powerful vasoconstrictor that acts to increase systemic blood pressure. Renin stimulates the release of aldosterone.- regulates sodium and water and thus BP

Intravenous Fluid Therapy • Deficit and maintenance fluids replaced with a balanced salt solution with or without glucose. • Avoid giving large amounts of hypo/hypertonic solutions or D5W---which can cause _________________. • Important to monitor glucose levels if glucose not included in IV regimen, especially in neonates and infants. Think of TBW changes Premature infants who have had less time to store glycogen in the liver than term infants are more susceptible to ______________. For this reason, premature infants may receive an infusion of ____% dextrose in _____% normal saline.

Intravenous Fluid Therapy • Deficit and maintenance fluids replaced with a balanced salt solution with or without glucose. • Avoid giving large amounts of hypotonic solutions or DSW--- hyponatremia. • Important to monitor glucose levels if glucose not included in IV regimen, especially in neonates and infants Think of TBW changes Premature infants who have had less time to store glycogen in the liver than term infants are more susceptible to hypoglycemia. For this reason, premature infants may receive an infusion of 10% dextrose in 0.2% normal saline.

Isoflurane • Inhalation induction results in more/less adverse respiratory events c/t Sevoflurane. >>>>> Describe respiratory shit that happens more with Iso than Sevoflurane. (4) • Iso has significant dose-dependent affects on HR, BP, and MAP. What are they? • Can the baby's heart compensate? Why? Why not? > Administration of Isoflurane to adults produces dose-dependent decreases in peripheral vascular resistance, so how do adults maintain blood pressure?

Isoflurane • Inhalation induction results in more adverse respiratory events compared to sevoflurane. • Breath-holding, coughing, and laryngospasm with copious secretions than sevoflurane • Significant dose-dependent decreases in heart rate, blood pressure, and mean arterial pressure. • Immature cardiovascular compensation. > Administration of Isoflurane to adults produces dose-dependent decreases in peripheral vascular resistance, whereas increases in heart rate maintain blood pressure

Ketamine • Neonates and infants may be more/less resistant to the hypnotic effects of ketamine, requiring slightly higher/lower doses than adults • Pharmacokinetics do not appear to be significantly different than adults. Contraindications: 4 Dose: • IV: ___---___ mg/kg • Intranasal: _______----________ mg/kg • IM: ____--____mg/kg

Ketamine • Neonates and infants may be more resistant to the hypnotic effects of ketamine, requiring slightly higher doses than adults • Pharmacokinetics do not appear to be significantly different than adults Contraindications: URI r/t inc. secretions open globe psych/seizure D/Os • Dose: • IV: 1-2 mg/kg • Intranasal: 0.15-0.3 mg/kg • IM: 5-10mg/kg

Laryngoscope Blades Selection of laryngoscope blade is largely a matter of user preference and familiarity. _______________blades are generally used for neonates, infants, and children under 2 years of age. ______________ blades in children over 5 years old and adolescents.

Laryngoscope Blades • Selection of laryngoscope blade is largely a matter of user preference and familiarity. • Straight blades are generally used for neonates, infants, and children under 2 years of age. • Curved blades in children over 5 years old and adolescents.

Mask Induction Techniques • "Single-breath" induction: Achieved with a few breaths of ___% Sevoflurane with N2O. • Circuit is prefilled with 70% N2O/ 30% O2 and 8% Sevo • Child instructed to do forced ____________________. • Mask is placed on child who is instructed to take a deep breath in. • ____--____ breaths necessary • LOC within _____ seconds for children > _____ yrs

Mask Induction Techniques "Single-breath" induction: Achieved with a few breaths of 8% Sevoflurane with N2O. Circuit is prefilled with 70% N2O/ 30% O2 and 8% Sevo. Child instructed to do forced exhalation Mask is placed on child who is instructed to take a deep breath in. 3-4 breaths necessary LOC within 60 seconds for children > 3 yrs

Mask Induction Techniques • Insufflation: Used in children ___ months to ____ years. • Premedication given • Face mask held near the face without touching > Anesthetic induction commonly begins with a ____:3____ mixture of which 2 gases via mask ---______flurane is added to the mixture beginning with a _____% concentration, with a rapid increase to __%. > Unconsciousness is produced with inspired sevoflurane concentrations of ____% to ____%. > Following the loss of consciousness, ___________ is discontinued, and sevoflurane is administered in _______%_________.

Mask Induction Techniques • Insufflation: Used in children 8 months to 5 years • Premedication given • Face mask held near the face without touching > Anesthetic induction commonly begins with a 70:30 mixture of N2O and O2 via mask Sevoflurane is added to the nitrous oxide-oxygen mixture beginning with a 2% concentration, with a rapid increase to 8% > Unconsciousness is produced with inspired sevoflurane concentrations of 6% to 8%. Following the loss of consciousness, nitrous oxide is discontinued, and sevoflurane is administered in 100%oxygen.

Most anomalies often occur in which 2 types of neonates?

Most anomalies often occur in which 2 types of neonates? SGA and LGA

4-2-1 Rule Maintenance requirements calculated by weight: First 10 kg: 10-20 kg: > 20 kg: 4 mL/kg/hr for 1st 10 kg + 2 mL/kg/hr for next 10 kg + 1 mL/kg/hr for next 10 kg • If patient is greater than 40 kg, add 40 mL to the weight in kg for maintenance

N/A

For IV Access • Assess hand veins by gently retracting skin of hands • Vein beds appear as dark lines • Other areas include inner aspect of distal forearm at the wrist, feet and saphenous veins in ankles.

N/A

Premedication • Generally, most stressful time for children during the perioperative period is induction of anesthesia • The decision to premedicate should be made on an individual basis and timed for the child's entry into the OR • Sedative premedication generally omitted for neonates and sick infants • Avoid medications in patients whose condition may not tolerated respiratory effects of sedation (ex. OSA)

N/A

Review of Systems Dental: Focus of questions: loose teeth, carous teeth Anesthetic concerns: aspiration of loose teeth, SBE prophylaxis (Subacute bacterial endocarditis) > Hx difficult intubation? Does the child have trouble opening the mouth? Are there any chipped, missing, or loose teeth?

N/A

Narcotics and Reversal Doses Fentanyl IV: ____--____ mcg/kg Intranasal: _____ mcg/kg Morphine ____--____ mg/kg Hydromorphone _____ mg/kg Naloxone _________ mg/kg

Narcotics and Reversal Doses • Fentanyl • IV: 1-2 mcg/kg • Intranasal: 2 mcg/kg • Morphine • 0.05-0.1 mg/kg • Hydromorphone • 0.015 mg/kg • Naloxone • 0.01 mg/kg

Neonates may be managed with a _____-gauge catheter, infants with a _____-gauge catheter, and children with a ____ or ____-gauge catheter. > The extremity is secured with a padded board, and the intravenous site is covered with a gauze DSG > The administration of a _______________________decreases the potential for the cardiovascular depression that accompanies the administration of high concentrations of inhalation agents that may be required to facilitate laryngoscopy and intubation. > Intubation conditions - inspired concentrations children ages 1 to 8 years is 3.54 ± 0.25%. The addition of 66% nitrous oxide decreases the required concentration by 40%

Neonates may be managed with a 24-gauge catheter, infants with a 22-gauge catheter, and children with a 20- or 22-gauge catheter > The extremity is secured with a padded board, and the intravenous site is covered with a gauze DSG > The administration of a neuromuscular relaxant decreases the potential for the cardiovascular depression that accompanies the administration of high concentrations of inhalation agents that may be required to facilitate laryngoscopy and intubation. > Intubation conditions - inspired concentrations children ages 1 to 8 years is 3.54 ± 0.25%. The addition of 66% nitrous oxide decreases the required concentration by 40%

Neuromuscular Blocking Drugs • Describe their ionization and lipophilicity. • Restricted distribution to the__________ compartment > The ECF compartment is larger/smaller in the neonate and infant than in the child and adult. What kind of effect does this cause and how does this affect VOD? > Ongoing maturation of neonatal skeletal muscle and acetylcholine receptors affect the pharmacokinetics and pharmacodynamics of neuromuscular relaxants.

Neuromuscular Blocking Drugs • NMBDs are highly ionized and have a low lipophilicity • Restricted distribution to the ECF compartment > The ECF compartment is larger in the neonate and infant than in the child and adult, causing a dilutional effect and thereby increasing the volume of distribution. > Ongoing maturation of neonatal skeletal muscle and acetylcholine receptors affect the pharmacokinetics and pharmacodynamics of neuromuscular relaxants.

Nondepolarizing Muscle Relaxants • Immaturity of hepatic function in neonate prolongs DOA for drugs depending on hepatic metabolism (2 examples) • Which 2 NMBDs do not depend on hepatic biotransformation and reliably behave as intermediate acting agents?

Nondepolarizing Muscle Relaxants • Immaturity of hepatic function in neonate prolongs duration of action for drugs depending on hepatic metabolism (pancuronium, vecuronium) • Atracurium and Cisatracurium, which do not depend on hepatic biotransformation, reliably behave as intermediate acting agents

Nondepolarizing Muscle Relaxants • Infants and children are more/less sensitive than adults- doesn't imply that lower dose is needed, just less redosing is needed. Describe the following: > plasma concentration needed > VOD > Drug clearance > Elimination half-life Neuromuscular function assessment: >>>>>> which muscle is preferred (more reflective of diaphragmatic activity)?

Nondepolarizing Muscle Relaxants • Infants and children are more sensitive than adults. • A lower plasma concentration of neuromuscular relaxant is required. • Larger VOD and slower drug clearance result in longer elimination half-life Neuromuscular function assessment: >>>>>> Adductor pollicis (thumb) muscle is preferred (more reflective of diaphragmatic activity) as opposed to the > orbicularis oculi

Nondepolarizing Muscle Relaxants Doses Rocuronium < 1 year: ____--____ mg/kg 1 year: ____--____ mg/kg > 1 year: ____--____ mg/kg IM: ____--____ mg/kg Vecuronium < 1 year: ____--____ mg/kg > 1 year: _____ mg/kg Atracurium ____--____ mg/kg Cisatracurium ____--____ mg/kg

Nondepolarizing Muscle Relaxants Doses Rocuronium: • < 1 year: 0.25-0.5 mg/kg • 1 year: 0.5-1.2 mg/kg • > 1 year: 1-1.3 mg/kg • IM: 1-1.8mg/kg • Vecuronium: • < 1 year: 0.05-0.1 mg/kg • > 1 year: 0.1 mg/kg • Atracurium • 0.3-0.6 mg/kg • Cisatracurium • 0.1-0.2 mg/kg

Older Infant and Preschoolers to 3 years of age • Principal fear ages 1‐3 is the ______________. • May not be able to communicate fears or anxieties. • Are they able to reason or accept explanation? • Regressive behaviors

Older Infant and Preschoolers to 3 years of age • Principal fear ages 1‐3 is the separation from parents and home • May not be able to communicate fears or anxieties • Can not reason or accept explanation • Regressive behaviors

Pediatric Pharmacology Pharmacodynamics/Pharmacokinetics- Describe each: • total body water (TBW) composition • metabolic degradation pathways • protein binding • blood-brain barrier • proportion of blood flow to the vessel-rich organs (i.e., brain, heart, liver, lungs) • glomerular filtration • FRC • minute ventilation • receptor responses > presence or absence of elevated intra-abdominal pressure >>> (gastroschisis or omphalocele closure) or congenital malformations.

Pediatric Pharmacology Pharmacodynamics/Pharmacokinetics: • Differences in total body water (TBW) composition • Immaturity of metabolic degradation pathways • Reduced protein binding • Immaturity of the blood-brain barrier • Greater proportion of blood flow to the vessel-rich organs (i.e., brain, heart, liver, lungs) • Reductions in glomerular filtration • Smaller FRC • Increased minute ventilation • Immature receptor responses >> body composition, protein binding, body temperature, distribution of cardiac output, functional organ (heart, liver, kidneys) maturity, maturation of the blood-brain barrier, the relative size of the liver and kidneys, and the presence or absence of elevated intraabdominal pressure >(gastroschisis or omphalocele closure) or congenital malformations.

Physical Exam • Heart murmurs, which may indicate flow through _________________. • Murmur may be innocent (ex. a flow murmur or murmur noted during a growth spurt) or pathological • Assess degree of hemodynamic compromise

Physical Exam • Heart murmurs, which may indicate flow through anatomic shunts • Murmur may be innocent (ex. a flow murmur or murmur noted during a growth spurt) or pathological • Assess degree of hemodynamic compromise

Pierre Robin/Treacher Collins

Pierre Robin is a condition present at birth, in which the infant has a smaller than normal lower jaw ( micrognathia ), a tongue that is placed further back than normal (glossoptosis), and an opening in the roof of the mouth ( cleft palate ). Treacher Collins Syndrome is a genetic disorder that most often affects the cheek bones, jaw, chin, and ears. Symptoms include downward-slanting eyes, a very small jaw and chin, hearing loss, and vision loss. Some babies may be born with a hole in the roof of their mouth (cleft palate).

Postgestational age (gestational age + postnatal age) should be determined at the time of the anesthetic evaluation. significant risk of postoperative apnea and bradycardia during the first __________hours after general anesthesia

Postgestational age (gestational age + postnatal age) should be determined at the time of the anesthetic evaluation. significant risk of postoperative apnea and bradycardia during the first 24 hours after general anesthesia

Postoperative Croup • Monitor for ______________ edema (postoperative croup). • Manifests as a "barky" cough and ____________ respirations with the first ____--____ hrs following tracheal extubation. • Mild cases require little therapy other than supplement humidified oxygen. > Patients who were born before ______ weeks' gestation and whose post-conceptual age is less than ______weeks have a greater risk of central apnea.

Postoperative Croup • Monitor for subglottic edema (postoperative croup) • Manifests as a "barky" cough and stertorous (noisy and labored) respirations with the first 2-4 hrs following tracheal extubation. • Mild cases require little therapy other than supplement humidified oxygen. > Patients who were born before 36 weeks' gestation and whose PCA is less than 60 weeks have a greater risk of central apnea.

Prematurity •Complications: > Hematologic- > Neuro- > Respiratory > Cardiac •Premature infants of less than ______weeks PGA have the greatest risk of experiencing postanesthetic complications. •Inadequate development of respiratory drive •Immature cardiovascular responses to hypoxia and hypercapnia.

Prematurity •Complications: •Anemia •Intraventricular hemorrhage •Periodic apnea accompanied by bradycardia and chronic respiratory dysfunction. •Premature infants of less than 60 weeks' PGA have the greatest risk of experiencing postanesthetic complications. •Inadequate development of respiratory drive. •Immature cardiovascular responses to hypoxia and hypercapnia.

Premedication For very uncooperative or unruly patients: Consider which 2 drugs? > ___________ extremity has more rapid uptake than ____________ extremity.

Premedication For very uncooperative or unruly patients: • Consider IM Midazolam or IM Ketamine (with antisialogue) • Upper extremity has more rapid uptake than lower extremity

Premedication • Consider alternatives to IM injection (oral, transmucosal, rectal) • PO route is generally preferred but may take ___-___minutes to take effect. • Rectal midazolam can be also used. > Midazolam _____---_____ mg/kg PR (____ mg max) > Midazolam most common premedicant in the pediatric pt.

Premedication • Consider alternatives to intramuscular injection (oral, transmucosal, rectal) • Oral route is generally preferred but may take 20-45 minutes to take effect Rectal midazolam can be also used > Midazolam 0.5-1 mg/kg PR (20 mg max) > Midazolam most common premedicant in the pediatric pt

Preoperative Fluid Deficit > Fluid deficit incurred during fasting should be replaced • Determined by multiplying the hourly maintenance requirement by the number of hours since the last oral intake. Deficit = Hrs NPO x hourly maintenance requirement > Mild dehydration is associated with a less than ____% decrease in body weight. > Moderate dehydration is associated with a ____--____% decrease in the patient's body weight. > Severe decreases in intravascular volume are associated with a greater than ____% decrease in body weight. Fluid management for dehydrated patients includes a ____-____ mL/kg fluid bolus over ____--____minutes.

Preoperative Fluid Deficit > Fluid deficit incurred during fasting should be replaced • Determined by multiplying the hourly maintenance requirement by the number of hours since the last oral intake. Deficit = Hrs NPO x hourly maintenance requirement Mild dehydration is associated with a less than 5% decrease in body weight. Moderate dehydration is associated with a 5% to 10% decrease in the patient's body weight. Severe decreases in intravascular volume are associated with a greater than 10% decrease in body weight. Fluid management for dehydrated patients includes a 10 to 20 mL/kg fluid bolus over 10 to 30 MINUTES

Preoperative Testing Hgb indicated for premature infants (less than ___ weeks' PCA), infants < ____ months, children c/ concurrent cardiopulmonary dx, children c/ known hematologic dysfunction (ex. sickle cell disease), and when significant surgical blood loss is anticipated. > "adequate" Hgb concentration is essential for O2 delivery and has been arbitrarily defined as a Hgb of ___ g/dL or a Hct of ___% CBC: · Recent radiation or chemotherapy · Renal disease · Anticoagulant therapy · Coexisting systemic disorders (e.g., CF, severe malnutrition, renal failure, hepatic disease) · Leukemia or lymphomas

Preoperative Testing Hgb indicated for premature infants (less than 60 weeks' postconceptional age), infants < 6 months, children c/ concurrent cardiopulmonary dx, children c/ known hematologic dysfunction (ex. sickle cell disease), and when significant surgical blood loss is anticipated > "adequate" hemoglobin concentration is essential for O2 delivery and has been arbitrarily defined as a Hgb of 10 g/dL or a Hct of 30% CBC: · Recent radiation or chemotherapy · Renal disease · Anticoagulant therapy · Coexisting systemic disorders (e.g., cystic fibrosis, severe malnutrition, renal failure, hepatic disease) · Leukemia or lymphomas

Propofol > Describe it's onset and duration > Propofol infusion syndrome - It frequently results in cardiovascular collapse and death. Mostly occurs in ICU, long term infusion. > Primarily in small children, but also reported in adults. > mini-Bier block technique > Mitochondrial defect - >>> Barth's syndrome - is a rare condition characterized by an enlarged and weakened heart (dilated cardiomyopathy), weakness in muscles used for movement (skeletal myopathy), recurrent infections due to small numbers of WBCs (neutropenia), and short stature. >>>> Leigh's disease- a rare inherited neurometabolic disorder that affects the CNS., >>>> Pyruvate Dehydrogenase Complex Deficiency - is a rare disorder of carbohydrate metabolism caused by a deficiency of one of the three enzymes in the pyruvate dehydrogenase complex (PDCD/PDH)

Propofol > Propofol has a rapid onset and a short duration. > Propofol infusion syndrome - It frequently results in cardiovascular collapse and death. Mostly occurs in ICU, long term infusion. > Primarily in small children, but also reported in adults. > mini-Bier block technique > Mitochondrial defect - barth's syndrome, Leigh's disease, PYRUVATE DEHYDROGENASE COMPLEX DEFICIENCY (PDCD/PDH)

Propofol • Infant induction dose: _____ to _____mg/kg • Children induction dose: _____to_____ mg/kg • Lidocaine _____ mg/kg to decrease POI • Antiemetic (useful for strabismus correction) • Shorter elimination half‐life and higher plasma clearance likely with infusions Propofol infusion syndrome - characterized by severe ____________, followed by (6). >>>>>> Proposed mechanism: > Inhibition of ______________ function and uncoupling oxidative phosphorilation. ******Caution with children with _______________defects!

Propofol • Infant induction dose: 2.5 to 3 mg/kg • Children induction dose: 2 to 2.5 mg/kg • Lidocaine 0.2 mg/kg to decrease pain on injection • Antiemetic (useful for strabismus correction) • Shorter elimination half‐life and higher plasma clearance likely with infusions Propofol infusion syndrome - characterized by severe lactic acidosis, followed by rhabdomyolysis, hepatomegaly, lipidemia, hemodynamic instability, and multiorgan failure. Proposed mechanism of Propofol Inf Syn: Inhibition of mitochondrial function and uncoupling oxidative phosphorilation. ***********Caution with children with mitochondrial defects!

Protein Binding • Largely theoretical - decreased protein binding relative to adults • The major factor affecting drug action is the reduced clearance/metabolism/solubility? • Ex. A highly protein-bound drug with a high extraction ratio and a narrow therapeutic index, such as lidocaine, requires reduced doses • Ultimately, the goal of drug metabolism is the production of a water-soluble compound that can be more easily excreted

Protein Binding • Largely theoretical - decreased protein binding relative to adults • The major factor affecting drug action is the reduced clearance • Ex. A highly protein-bound drug with a high extraction ratio and a narrow therapeutic index, such as lidocaine, requires reduced doses • Ultimately, the goal of drug metabolism is the production of a water-soluble compound that can be more easily excreted

Regional Anesthesia Babies at risk for postanesthetic apnea are excellent candidates for regional anesthesia: >>>>> Preterm baby with RDS >>>>>> Former preterm baby Two most common techniques: • Spinal • Caudal epidural block

Regional Anesthesia :Babies at risk for postanesthetic apnea are excellent candidates for regional anesthesia: > Preterm baby with RDS > Former preterm baby • Two most common techniques: • Spinal • Caudal epidural block

Regional Anesthesia • Consider terminal end of spinal cord, dural sac and volume of CSF. • Spinal cord extends to ________ in newborns (____ position by 1 year of age) • Dural sac extends to ____--____, (_____ position by 1 year of age) • CSF volume _____mL/kg (as compared to adult ____ mL/kg) >>>>> Greater amount of CSF Dilutes LAs injected. >>>>>Lower/Higher dose requirements >>>>>Shorter/Longer duration of analgesia

Regional Anesthesia • Consider terminal end of spinal cord, dural sac and volume of CSF • Spinal cord extends to L3 in newborns (L1 position by 1 year of age) • Dural sac extends to S3-S4 (S1 position by 1 year of age) • CSF volume 4mL/kg (as compared to adult 2 mL/kg) • Dilutes local anesthetics injected • Higher dose requirements • Shorter duration of analgesia

Regional Anesthesia • Stable CV response to regional anesthesia >>>>> Limited bradycardia/hypotension (may be due to immature SNS/decreased venous blood pooling) • Caution: ______-_________ block - intercostal weakness (resulting dependence on diaphragmatic breathing) Remember: > Smaller/Larger VOD > Immature hepatic degradation (affect which LAs), lower plasma cholinesterase (affects which LAs) >>>Require smaller/larger initial doses than adults >>>longer/Shorter duration of blocks > TV and RR - how are they affected? > Larger VOD-How does that affect initial plasma peak concentration? > Place RA before or after GA? > It is difficult to assess a dermatome level, because these patients are nonverbal.

Regional Anesthesia • Stable CV response to regional anesthesia • Limited bradycardia/hypotension (may be due to immature SNS/decreased venous blood pooling) • Caution: T2-T4 block - intercostal weakness (resulting dependence on diaphragmatic breathing) • Remember: Larger VOD, immature hepatic degradation (amide LA), lower plasma cholinesterase (ester LA) • Require larger initial doses than adults • Shorter duration of blocks > TV and RR are not usually affected > Larger VOD - resulting in a lower initial plasma peak concentration > Most neonates will have a regional technique performed after the induction of general anesthesia because of the age of the patient and the possibility of agitation and continuous movement affecting the placement and success of the block > It is difficult to assess a dermatome level, because these patients are nonverbal.

Respiratory Assessment The following are Inc or Dec: Lung compliance Elastic recoil Rigidity of chest wall V/Q due to lung fluid Fatigue of respiratory muscles Coordination of nose/mouth breathing -------------------------- > Response to hypercapnia not potentiated by ______________. Mechanical - Assist or control ventilation during GA Biochemical - Avoid hypoxia Hering Breuer reflex - Apnea/no desaturation/stimulation Periodic breathing - Stimulation/airway support

Respiratory Assessment ↓ Lung compliance ↓ Elastic recoil ↓ Rigidity of chest wall ↓ V/Q due to lung fluid ↑ Fatigue of respiratory muscles ↓ Coordination of nose/mouth breathing >Response to hypercapnia not potentiated by hypoxia Mechanical - Assist or control ventilation during general anesthesia Biochemical - Avoid hypoxia Maintain normothermia Hering Breuer Rflx-Apnea/no desaturation/stimulation Periodic breathing - Stimulation/airway support

Respiratory System Abnormalities • Incidence of respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) is inversely r/t ______. • RDS - can occur within _______ hours of birth. > S/S are: Tachypnea, retractions, grunting, and oxygen desaturation • BPD - 5 physical, metabolic manifestations are. • Requires supplemental O2 • What are the causes of Causes of BPD:----- 3 > These respiratory abnormalities are due to a lack of ________________!!! > Happens in which neonates? > When is RDS apparent? > What is BPD defined as? > When giving anesthesia, may need increased peak inspiratory pressure, and peep may be needed to maintain oxygenation during surgery.

Respiratory System Abnormalities • Incidence of respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) is inversely related to gestational age at birth • RDS - can occur within 6 hours of birth •Signs/Symp> Tachypnea, retractions, grunting, and oxygen desaturation • BPD - lower airway obstruction/air trapping, carbon dioxide retention, atelectasis, bronchiolitis, and bronchopneumonia • Requires supplemental O2 • Causes: oxygen toxicity, barotrauma of positive-pressure ventilation on immature lungs, and endotracheal intubation > These respiratory abnormalities are due to a lack of surfactant!!! Happens in preemies, rare in term babies. > RDS is apparent within minutes after birth \BPD is defined as O2 dependence > When giving anesthesia, may need increased peak inspiratory pressure, and peep may be needed to maintain oxygenation during surgery.

Reversal • Residual neuromuscular blockade places the infant and child at risk of hypoventilation/reduced airway patency! • Consider: increased basal oxygen consumption • A NIF of at least_____cm H2O - indicative of the adequacy of ventilatory reserve required before tracheal extubation. > Because of increased basal oxygen consumption, impaired respiratory function will lead to arterial oxygen desaturation and CO2 retention.

Reversal • Residual neuromuscular blockade places the infant and child at risk of hypoventilation/reduced airway patency! • Consider: increased basal oxygen consumption. • A NIF of at least −32 cm H2O - indicative of the adequacy of ventilatory reserve required before tracheal extubation. > Because of increased basal oxygen consumption, impaired respiratory function will lead to arterial oxygen desaturation and CO2 retention.

Reversal Doses Neostigmine _____ to _____ mg/kg Edrophonium _____--_____ mg/kg Glycopyrrolate _______ mg/kg Atropine _________ mg/kg (min dose 0.1mg)

Reversal Doses Neostigmine: 0.05 to 0.07 mg/kg Edrophonium 0.5-1 mg/kg Glycopyrrolate 0.01 mg/kg Atropine 0.02 mg/kg (min dose 0.1 mg) Sugammadex safety not established in pediatric patients

Review of Systems BOTH SIDES Hematologic: Focus of questions: Anemia, bruising, excessive bleeding Anesthetic concerns: Transfusion requirement, coagulopathy, thrombocytopenia, hydration status, possible exchange transfusion > Does the child have sickle cell anemia? Does the child bleed or bruise easily?

Review of Systems Allergies: Focus of questions: Medications, specific antibiotics, previous exposure to dental dams, balloons, bananas. Anesthetic concerns: Reactions, drug interactions, latex allergies. > Is the child currently on any medications or has he or she taken any within the last 3 months? Has the child taken steroids within the last year? If so, for what condition? > Is the patient allergic to any medication or food? Any problems with latex or other environmental items?

Review of Systems BOTH SIDES Respiratory: • Focus of questions: Cough, asthma, recent cold • Possible anesthetic concerns: Irritable airway, bronchospasm, atelectasis, pneumonia. > Does the child have asthma, bronchitis, or pneumonia? Does the child currently receive, or has received in the past, supplemental oxygen therapy? Has the child had a recent cold, cough, or respiratory infection?

Review of Systems Cardiovascular: Focus of questions: Murmur, cyanosis, history of squatting, hypertension, rheumatic fever, exercise intolerance Anesthetic concerns: Avoidance of air bubbles in IV, right-to-left shunt, Tetralogy of Fallot, coarctation, renal disease, CHF, cyanosis > Does the patient play at school without severe SOB or syncope? > Does the child have a heart murmur?

Review of Systems BOTH SIDES Neurologic: Focus of questions: Seizures, head trauma, swallowing problems Anesthetic concerns: Medication interactions, metabolic derangements, increased ICP, aspiration, neuromuscular relaxant sensitivity, hyperpyrexia >Has the child experienced any neurologic symptoms such as seizures?

Review of Systems GI/Hepatic: Focus of questions: Vomiting, diarrhea, malabsorption, black stools, gastroesophageal reflux, jaundice Anesthetic concerns: Electrolyte imbalance, dehydration, full stomach considerations (RSI), hypovolemia, hypoglycemia > Has the child had jaundice or liver problems? > Has the child had gastric acid reflux or a hiatal hernia? > Has the child experienced problems with diarrhea or vomiting?

School Age Children (____--___yrs) • Principal fear is the ________________________. • Uncertain about what should be appropriate behavior. • May worry about undressing, putting on strange clothes.

School Age Children (6 to 12 yrs) • Principal fear is the process of induced loss of consciousness • Uncertain about what should be appropriate behavior • May worry about undressing, putting on strange clothes

Several things should be considered in planning the fluid management in the neonatal surgical patient: • Dehydration present before preoperative fasting • Fluid deficit due to fasting • Maintenance requirements during anesthesia/surgery • Estimated third-space loss • Alterations in body temperature

Several things should be considered in planning the fluid management in the neonatal surgical patient: • Dehydration present before preoperative fasting • Fluid deficit due to fasting • Maintenance requirements during anesthesia/surgery • Estimated third-space loss • Alterations in body temperature

Sevoflurane • MAC of sevoflurane in oxygen is ____% for the infant up to 6 months. • Decreases to ______% to __________% up to 1 year of age. • How does Sevoflurane affect minute ventilation and respiratory rate? • Risk of __________ at high concentrations! • Sevoflurane has Concentration-dependent elevations in serum ____________ levels. • Sevoflurane is easily breathed and is readily accepted for mask induction.************Preferred choice of inhalation agent! • Sevoflurane produces a slow/rapid induction and emergence due to its low/high blood-gas partition coefficient. • How does Sevoflurane act on the myocardium in r/t the effects of endogenous and exogenous catecholamines. • Concerns regarding fluoride-induced renal damage have not been a clinical issue

Sevoflurane • MAC of sevoflurane in oxygen is 3% for the infant up to 6 months • Decreases to 2.5% to 2.8% up to 1 year of age • Sevoflurane depresses minute ventilation and respiratory rate (when deep). • Risk of apnea at high concentrations! • Concentration-dependent elevations in serum fluoride levels • Sevoflurane is easily breathed and is readily accepted for mask induction***** Preferred choice of inhalation agent! • Preferred choice - Sevoflurane produces a rapid induction and emergence due to its low blood-gas partition coefficient. • Sevoflurane is easily breathed and is readily accepted for mask induction. • Sevoflurane does not sensitize the myocardium to the effects of endogenous and exogenous catecholamines. • Concerns regarding fluoride-induced renal damage have not been a clinical issue

Spinal Anesthesia • Useful for patients at risk for AOP/lower abdomen procedures • Can be performed in which 2 positions? • Flex/Extend neck to prevent airway obstruction • Lumbar puncture at levels ____--____ or____--____ with 1½-inch, 22-gauge needle >>>>>>> Distance for LP is approximately _____cm/s >>>>>>> ________ mL/kg of Bupivacaine _______% • After placement how should you position neonate? Legs? > Resistance can be felt when the needle enters the ______________, and the characteristic "pop" occurs when the needle enters the _______________________.

Spinal Anesthesia • Useful for patients at risk for AOP/lower abdomen procedures • Can be performed sitting or lateral • Extend neck to prevent airway obstruction • Lumbar puncture at L3-L4 or L4-L5 with 1½-inch, 22-gauge needle • Distance is approximately 1cm • 0.14 mL/kg of bupivacaine 0.5% • Place neonate supine and secure legs to prevent leg raising > Resistance can be felt when the needle enters the ligamentum flavum, and the characteristic "pop" occurs when the needle enters the subarachnoid space

Succinylcholine • U.S. (FDA) restricts use to emergency airway management in children (<___years old) • Contraindicated with MH • Doses: • < 1 year: ________mg/kg • > 1 year: _____--____mg/kg • IM: ____--____mg/kg

Succinylcholine • U.S. (FDA) restricts use to emergency airway management in children (<8 years old) • Contraindicated with malignant hyperthermia • Doses: • < 1 year: 3 mg/kg • > 1 year: 1-2 mg/kg • IM: 4-6 mg/kg

Succinylcholine • As a rule, Which drug and at what dose should always be administered prior to the first dose of succinylcholine in children? What can happen if pt is not pretreated with this drug?

Succinylcholine • Unlike adults, profound bradycardia and sinus node arrest can develop in pediatric patients without atropine pretreatment. • As a rule, atropine (0.1 mg minimum) should always be administered prior to the first dose of succinylcholine in children.

Thiopental • Children require lower/higher doses due to smaller/larger VOD. • Elimination half-life is shorter/longer and plasma clearance greater/less than adults • Neonates more/less sensitive to barbiturates and have less/more protein binding, a longer/shorter half-life and impaired clearance. • Thiopental Dose: • IV: _____---_____mg/kg • PR: _________-----________mg/kg

Thiopental • Children require higher doses due to larger volume of distribution • Elimination half-life is shorter and plasma clearance greater than adults • Neonates more sensitive to barbiturates and have less protein binding, a longer half-life and impaired clearance. Thopental Dose: • IV: 3--6 mg/kg • PR: 23--30 mg/kg

Third Space Losses • End points of fluid therapy are: • Adequate blood pressure • Adequate tissue perfusion • Adequate urine output (____--____mL/kg/hr) What is the most sensitive indicator for fluid status in infants and small children?

Third Space Losses End points of fluid therapy are: • Adequate blood pressure • Adequate tissue perfusion • Adequate urine output (0.5-1 mL/kg/hr) What is the most sensitive indicator for fluid status in infants and small children? HR

Third Space Losses Similar in children and adults. Varies with surgical procedure: • Infants abdominal surgery = ____--_____ mL/kg/hr • Infants thoracic surgery = ____--____ mL/kg/hr • Which fluid is commonly used to replace third space losses? _____% albumin an option if losses are massive.

Third Space Losses Similar in children and adults. Varies with surgical procedure: • Infants abdominal surgery = 6-15 mL/kg/hr • Infants thoracic surgery = 4-7 mL/kg/hr Lactated Ringer's is commonly used to replace third space losses. 5% albumin an option if losses are massive.

Define Vagotonia What do vagolytics do?

Vagotonia- hyperexcitability of the vagus nerve, producing bradycardia, decreased heart output, and faintness. vagolytics- inhibit the action of the vagus nerve on the heart, gastrointestinal tract, and other organs

Volume of Distribution • Dilutional effect - lower/higher plasma drug concentrations occur immediately after administration of lipid soluble/water-soluble drugs >>>>>>> Therefore, a smaller/larger drug loading dose is required to achieve the desired plasma concentration • Decreased/Increased fat and muscle concentrations (compared to adult) >>>>>> Thus, Higher/Lower plasma concentrations occur for lipid-soluble drugs

Volume of Distribution • Dilutional effect - lower plasma drug concentrations occur immediately after administration of water-soluble drugs • Larger drug loading dose is required to achieve the desired plasma concentration • Decreased fat and muscle concentrations (compared to adult) • Higher plasma concentrations occur for lipid-soluble drugs

Young Infants • Psychological implications are assumed to be minimal < 6 months. > Separation anxiety not usually seen until ___-___ months. • Parents need reassurance • Do young infants usually need premedication or anticholinergic?

Young Infants • Psychological implications are assumed to be minimal < 6 months, as no separation anxiety until 6‐9 months • Parents need reassurance • No premedication or anticholinergic usually

Intubation of neonates • Due to upper airway anatomy, curved/straight blade preferred.

straight blade