Pediatric anesthesia

Pediatric Anesthesia:

Anatomic and physiologic differences among neonates, children and adults require differences in the administration of anesthesia compared to adults.

Preoperative Preparation:

The anesthesiologist first assesses the medical condition of the child and psychological status of the child and family while considering the surgical procedure. The anesthesia induction plan is made and explained to the family in order to alleviate fears the child and family may have. Chart review, physical examination is performed. Any medications to be used and equipment monitoring should be explained to patient. Informed consent should be obtained. Care should be taken to alleviate the anxiety of a child and parents, as anxiety felt by the parents my be transferred to the child. For the extremely anxious child that cannot be consoled by these methods heavy premedication is often used. Premedication combination is often midazolam,ketamine, and atropine.

Fasting: Infants and children have a higher metabolic rate and a larger body surface area:weight than adults. As such they become dehydrated more easily than adults. Studies have not found a difference in gastric residual volume and pH in children permitted unlimited clear liquids 2 to 3 hours prior to anesthesia induction anesthesia induction.

Current Fasting guidelines by the American Association of Anesthesiologists:

Ingested Material Minimum Fasting Period

Clear liquids 2 h

Breast milk 4 h

Infant formula 6 h

Nonhuman milk 6 h

Light meal 6 h

Premedication: Premedication is not often necessary for children 6 months and younger. Premedication is often used in the extremely fearful child or 10-12 month olds as this is the peak time a child has severe separation anxiety from parents. Oral midazolam is most commonly used .25-.33 mg/Kg in the US. Premedications may be administered orally, intravenously, intramuscularly, nasally, rectally and sublingually. Premedication in infants in children typically consists of midazolam, ketamine, and atropine. Except for atropine, anticholinergics are not commonly used in infants and children as they often do not reduce laryngeal reflexes during anesthesia induction. However, atropine in infants less than 6 months of age less than 45 minutes before induction reduces hypotension during induction with inhaled anesthetics. As such, it is included during premedication.

Pediatric Anesthesia Induction: There are different methods of induction of anesthesia in a pediatric patient: inhalation induction, intravenous induction, intramuscular induction, and rectal induction. The method of induction of anesthesia is chosen based on: the medical condition and surgical procedure of the child; the ability of the patient to cooperate and communicate; level of anxiety of the child often influencing their ability to cooperate; and whether or not the stomach is full.

Inhalation Induction of Anesthesia: Inhalation anesthesia with inhalation anesthetics and moderated to high dose opioids has been the standard of pediatric anesthesia.

Infants: Infants newborn to 12 months often require mask induction. Mask induction is performed by holding the masked end of the anesthesia air circuit off the face and with the other hand adjusting the concentration of anesthetic. In neonates and small infants, a rubber nipple or gloved finger is often provided for suckling in order to prevent crying during induction. As the infant loses consciousness, the mask is maneuvered to an appropriate location to improve delivery of the anesthetic and decrease anesthetic pollution in the operating room. After anesthesia is induced, a pediatric anesthesiologist reduces the inspired concentration of inhaled anesthetic, usually halothane or sevoflurane to an appropriate level while placing an intravenous line. Once the intravenous line is placed, the pediatric anesthesiologist has the option of increasing the depth of anesthesia or add a muscle relaxant. During this process endotracheal intubation occurs. Vaporizer of the laryngoscopy is closed. All anesthetics are discontinued until endotracheal intubation has been completed.

Children: Children 1-4 years of age often require premedication as it is difficult for them to understand and cooperate with mask anesthesia. Often games are used to distract the child to help the child cooperate. For example, telling the child he or she is an astronaut and they are breathing in their special astronaut mask. With the mask, every 3-4 breaths the inspired amount of anesthetic is increased. In pediatrics, flavored masks are often used to reduce the unpalatable smell of anesthetics. Occasionally, children will hold their breath. It is not accepted practice to attempt to assist with respiration when a child holds their breath as this typically elicits laryngospasm. However, before the pediatric anesthesiologist proceeds breath holding must be differentiated from laryngospasm or airway obstruction. When this is determined, the inspired concentration of anesthetic may be increased until the child loses consciousness.

If there is a laryngospasm or airway obstruction a few methods may be used to alleviate: 1) close the valve and set 10 cm H₂O of positive pressure and then let the child attempt to breath on his or her own; 2) administer positive pressure breaths, while preventing inflation of the stomach; 3) Administer succinylcholine a muscle relaxer to alleviate the laryngospasm.

Older Children: A single breath technique is also often used with older children as this requires a cooperative child that can follow instructions. Have the child follow the following steps: 1) take a full inspiration breath in and hold it into the mask; 2) exhale the full expiration into the mask; 3) take another full expiration breath into the mask; 4) then resume normal breathing into mask. These are the steps during induction. During induction the Y-piece of the anesthesia circuit is attached to the mask and steps 1-4 are repeated until induction complete. Typically the anesthesia circuit is filled with either 8% sevoflurane or 5% halothane.

Intravenous Induction of Anesthesia: Total intravenous anesthesia induction is the most rapid and reliable method. This method is increasingly becoming available with the development of propofol, midazolam,and short acting opioids. Intravenous induction is often indicated when inhalation induction of anesthesia is contraindicated, such as a full stomach. The method varies with the age of the patient. For younger children, a common method is a utilization of a two needle with a butterfly catheter with a 25 gauge needle in order to access vein. Once anesthesia is induced, an intravenous catheter is placed. Older children will often permit the placement of the intravenous catheter after just local anesthestic and 50% nitrous oxide. Many children will cry or become hysterical when they see the intravenous catheter. Many pediatric anesthesiologists handle this by not permitting the child to see the intravenous catheter.

Intramuscular Induction of Anesthesia: Intramuscular induction of anesthesia is obtained by a shot to the muscle. In pediatric patients, methohexital, ketamine, midazolam, atropine or midazolam are often given intramuscularly. This method is not as common as inhalation or intravenous. This method is very reliable.

Rectal Induction of Anesthesia: This approach is mainly used in children that are still in diapers. The advantage of this approach is that it permits a very young child to fall asleep from anesthesia in a parent's arms. Many medications may be administered in this fashion: methohexital, ketamine, midazolam, thiopental and midazolam. The disadvantage of this technique is that medication absorption is not uniformly absorbed.

Apfelbaum JL, Caplan RA, Connis RT, Epstein BS, Nickinovich DG, Warner MA. An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology 2011:114 (3): 495-511.

Christiansen E. Induction of anesthesia in a combative child;management and issues. Peds Anaesthesia 2005;421-425

Cote CJ: Preoperative preparation and premedication. Br J Anaesth 83:16-28.

Davis, P, Tome J, McGowan FX, Cohen IT, Latta K, and Felder H. Preanesthetic Medication with Intrasal Midazolam for Brief Pediatric Surgical Procedures: Effect of Recovery and Hospital Discharge Times. Anesthesiology 1995 82 (1):2-5.

Hackel A, Gregory, GA. Committee on Pediatric Anesthesiology. Providing Anesthesia for Pediatric Patients. American Society of Anesthesiolgists. 2005: 69 (3): https://www.asahq.org/For-Members/Publications-and-Research/Newsletter-Articles/2005/March2005/providing-anesthesia-for-pediatric-patients.aspx

Kain ZN. Parental presence and a sedative premedicant for children undergoing surgery. Anesthesiology 2000;92:939-46

Lerman JB. Anxiolysis – by the parent or for the parent? Anesthesiology 2000;92:925-928

Miller BR, Friesen RH. Oral atropine premedication in infants attenuates cardiovascular depression during halothane anesthesia. Anesth. Analg 1988: 67:180-185{reflist|2}}

Miller R Ed. Fleisher LA, Johns RA, Savarese JJ, Wiener-Kronish JP, and Young WL. Miller's Anesthesia 8th ED. Elsevier, Philadelphia, PA

Wong, GL and Morton NS. Total intravenous anesthesia (TIVA) in pediatric cardiac anesthesia. Paediatr Anaesth 2011 (5):560-566.