Paediatric Anaesthesia - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

Paediatric Anaesthesia

Description:

Paediatric Anaesthesia G.K.Kumar ... During surgery all of these requirements should be managed by giving isotonic fluid in all children over 1 month of age 10. – PowerPoint PPT presentation

Number of Views:956
Avg rating:3.0/5.0
Date added: 8 August 2020
Slides: 48
Provided by: Presen51
Learn more at: http://isakanyakumari.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Paediatric Anaesthesia


1
Paediatric Anaesthesia
G.K.Kumar
2
Paediatric Anaesthesia
  • Gregory 4th edition
  • Smith 4th edition

3
Paediatric Anaesthesia
  • Introduction
  • Why?
  • What?
  • How?

4
Paediatric Anaesthesia
Its Different
5
Paediatric Anaesthesia
Its Different
Paediatric anaesthesia is a family affair.
6
Paediatric Anaesthesia
Not a miniature adult
7
Paediatric Anaesthesia
Its Different
  • Airway difference
  • Changes in cardiovascular system
  • Chest wall/Respiratory difference
  • Kidney and liver difference
  • GI system and thermoregulation difference
  • Pharmacology/dynamics difference

8
Paediatric Anaesthesia
Its Different
  • Airway difference
  • Large tongue
  • Epiglottis short and stubby
  • Higher located larynx
  • Angled vocal cords
  • Narrowest portion is cricoid cartilage

9
Paediatric Anaesthesia
Its Different
Pharmacology/dynamics
  • Increased total body water
  • Large initial dose required
  • Less fat ? longer clinical drugs effect
  • Redistribution of the drug into muscle will
    increase duration of clinical effect (fentanyl)
  • Consider liver and kidney immaturity

10
Changes in cardiovascular system
  • Removal of placenta from circulation
  • Increasing of systemic vascular resistance
  • Decreasing of pulmonary vascular resistance
  • True closure of PDA 2-3 weeks ? critical
    transitional circulation
  • Myocardial cell mass less developed ? prone to
    biventricular failure, volume loading, poor
    tolerance to afterload, heart rate-dependent
    CO
  • True for young infants

11
  • Changes in pulmonary system
  • Small airway diameter - increased resistance
  • Little support from the ribs
  • VO2 2x gt adults
  • Diaphragm and intercostal muscles do not achieve
    type-1 adult muscle fibers until age 2
  • Obligate nasal breathers

12
  • Kidney and liver difference
  • Low renal perfusion pressure, immature GF, TF,
    obligate Na loser in the 1st month of life
  • Complete maturation _at_ 2 years of age
  • Impaired liver enzymes, including conjugation
    react.
  • Lower levels of albumen and proteins - prone to
    neonatal coagulopathy, and less drug bound ?
    higher drug levels

13
  • GI system and thermoregulation
  • Full coordination of swallowing 4-5 months ?
    increased risk for GE reflux
  • Large body surface area/weight
  • Limited ability to cope stress
  • Minimal ability to shiver in 1st 3 months
  • Heat whole body including the head

14
Paediatric Anaesthesia
Its Different
  • Different environment
  • Different gadgets
  • Different techniques

15
Paediatric Anaesthesia
Its Different
  • Pre anesthetic evaluation
  • NPO order
  • Premedication
  • Fear of the unknown
  • Fear of parental separation
  • IV access
  • Anesthesia
  • Post anesthesia care
  • Post op pain relief

16
Paediatric Anaesthesia
Its Different
  • Psychological preparation of child and family
  • Premedication option
  • Induction technique
  • Intra operative considerations
  • Postoperative emergence, analgesia
  • Follow up

17
Preoperative preparation
  • The number one error in paediatric anaesthesia is
    inadequate preparation.
  • Planning prevents problems!
  • Absence of adequate pre-anaesthetic assessment is
    one of top three causes of lawsuits against
    anaesthesiologists.

18
Paediatric Anaesthesia
Its Different
  • Pre anesthetic evaluation

Airway?
IV Access
19
Premedication Options
  • Pharmacologic premedication
  • Midazolam

0.2 to 0.6 mg/kg up to 10 mg max.
0.5 to 1.0 mg/kg up to 10 mg max.
0.35 to 1.0 mg/kg
20
Premedication Options
  • Midazolam
  • PO 0.5 to 1.0 mg/kg up to 10 mg max.
  • Bioavailability 30
  • Peak serum levels after about 45 minutes
  • Peak sedation by about 30 minutes
  • 85 peaceful separation
  • Beware total volume of dose should probably not
    exceed 0.4-0.5 ml/kg (NPO!)
  • Nasal 0.2 to 0.6 mg/kg
  • Peak serum level in 10 minutes
  • 0.2 mg/kg same as 0.6 mg/kg except
  • 0.2 mg/kg did not delay recovery
  • 0.6 mg/kg may delay extubation
  • Sublingual 0.2-0.3 mg/kg as effective as 0.2
    mg/kg intranasal
  • Rectal 0.35 to 1.0 mg/kg
  • Some effect by 10 minutes, peak effect 20-30
    minutes.
  • 1.0 mg/kg did not delay PACU discharge.

21
Premedication Options
  • Pharmacologic premedication
  • Ketamine

6 to 10 mg/kg
3 to 4 mg/kg
22
Premedication Options
  • Ketamine
  • PO 6 to 10 mg/kg
  • May slightly prolong time to discharge after a
    short case
  • IM 3 to 4 mg/kg sedation
  • 2 mg/kg did not delay recovery
  • 6 to 10 mg/kg IM induction of general
    anesthesia
  • 10 mg/kg as effective as Midazolam 1 mg/kg but
    some delay in recovery may be expected

23
Premedication Options
  • Pharmacologic premedication
  • Midazolam
  • Ketamine
  • 100 successful separation
  • 85 easy mask induction

0.4 mg/kg 4 mg/kg
24
Premedication Options
  • Pharmacologic premedication
  • Fentanyl lollypops
  • (oral transmucosal Fentanyl)
  • 15 to 20 mcg/kg
  • Increased volume of gastric contents
  • Nausea and vomiting
  • Pruritus
  • Hypoventilation (SpO2 lt90)

25
Paediatric Anaesthesia
Its Different
Avoid over sedation
26
Parental presence
  • Parents and Toys-"Parents are often the best
    premedication."
  • The presence of the parents during induction has
    virtually eliminated the need for sedative
    premedication.
  • Helpful for children older than 4 years who have
    calm parents

27
Paediatric Anaesthesia
Its Different
  • Parental separation

28
Paediatric Anaesthesia
Parental separation
Its Different
  • Early infancy (up to7 m) Parents are the primary
    focus. Gentle, comfortable separation is almost
    always possible before induction of anesthesia.
  • 1 to 3 yr Separation anxiety is major
    consideration. Surgery outpatient bases if
    possible. Careful selection regarding parental
    presence.

29
Paediatric Anaesthesia
Parental separation
Its Different
  • 3 to 6 years Child becomes primary focus. Fear
    of unknown dealt with by explaining exactly what
    will happen what you will do. Then make sure you
    do it that way. (Be trustworthy!)
  • 6 years to adolescent Increasing involvement of
    patient.

30
NPO Guidelines
  • AGE MILK SOLIDS
    FLUIDS
  • lt 6 MTHS 4 HRS
    2 HRS
  • 6-36 MTHS 6-8 HRS
    3HRS
  • gt36 MTHS 6-8 HRS
    3HRS
  • This fasting regimen has made the preoperative
    fast a
  • much more humane process for both the
    patients
  • and the parents
  • BEWARE effects of STRESS DRUGS

COTWAF-2009
31
Paediatric Anaesthesia
  • IV Access

Its Different
Call for help
Use gadgets
32
Induction Techniques
  • Inhalational
  • Intravenous (IV)
  • Intramuscular (IM)
  • Rectal
  • Oral

33
Paediatric Anaesthesia
Its Different
Try your mask
34
Induction Techniques
Factors Influencing Choice of Technique
  • How old is the patient?
  • What is the underlying illness? General medical
    condition? ASA physical status?
  • What is the surgical procedure planned?
  • How cooperative is the patient?
  • Will a parent be present?
  • Does s/he have an IV?
  • What are the skills and preferences of the
    anaesthesiologist?

35
Peri operative Fluid Management

Maintenance of IN OUT
36
Peri operative Fluid Management
CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID
MANAGEMENT IN CHILDREN 2007
COTWAF-2009
37
Peri operative Fluid Management
APA Guidelines-2007
1.Children can safely be allowed clear fluids 2
hours before surgery without increasing the risk
of aspiration. 2. Food should normally be
withheld for 6 hours prior to surgery in children
aged 6 months or older. 3. In children under 6
months of age it is probably safe to allow a
breast milk feed up to 4 hours before surgery
COTWAF-2009
38
Peri operative Fluid Management
APA Guidelines-2007
4. Dehydration without signs of hypovolaemia
should be corrected slowly. 5. Hypovolaemia
should be corrected rapidly to maintain cardiac
output and organ perfusion. 6. In the child, a
fall in blood pressure is a late sign of
hypovolaemia.
COTWAF-2009
39
Peri operative Fluid Management
APA Guidelines-2007
7. Maintenance fluid requirements should be
calculated using the formula of Holliday and
Segar Body weight Daily fluid requirement 0-10kg
4ml/kg/hr 10-20kg 40ml/hr 2ml/kg/hr above
10kg gt20kg 60ml/hr 1ml/kg/hr above 20kg
COTWAF-2009
40
Peri operative Fluid Management
APA Guidelines-2007
8. A fluid management plan for any child should
address 3 key issues i. any fluid deficit which
is present ii. maintenance fluid
requirements iii. any losses due to surgery e.g.
blood loss, 3rd space losses
COTWAF-2009
41
Peri operative Fluid Management
APA Guidelines-2007
9. During surgery all of these requirements
should be managed by giving isotonic fluid in all
children over 1 month of age 10. The majority
of children over 1 month of age will maintain a
normal blood sugar if given non-dextrose
containing fluid during surgery
COTWAF-2009
42
Peri operative Fluid Management
APA Guidelines-2007
11.Children at risk of hypoglycaemia if
non-dextrose containing fluid is given are those
on parenteral nutrition or a dextrose containing
solution prior to theatre, children of low body
weight (lt3rd centile) or having surgery of more
than 3 hours duration and children having
extensive regional anaesthesia. These children
at risk should be given dextrose containing
solutions or have their blood glucose monitored
during surgery.
COTWAF-2009
43
Peri operative Fluid Management
APA Guidelines-2007
12. Blood loss during surgery should be replaced
initially with crystalloid or colloid, and then
with blood once the haematocrit has fallen to
25. Children with cyanotic congenital heart
disease and neonates may need a higher
haematocrit to maintain oxygenation.
COTWAF-2009
44
Peri operative Fluid Management
APA Guidelines-2007
13. Fluid therapy should be monitored by daily
electrolyte estimation, use of a
fluid input/output chart and daily weighing if
feasible. 14. Acute dilutional hyponatraemia is
a medical emergency and should be managed in PICU.
COTWAF-2009
45
Extubation-Always awake
Except
COTWAF-2009
46
Common PostoperativeProblems In Paediatric
Anaesthesia
  • Emergence Delirium
  • Upper Airway Obstruction
  • Laryngospasm
  • Post Intubation Croup
  • Bronchospasm
  • Aspiration

COTWAF-2009
47
Thank you
  • G.K.Kumar
About PowerShow.com