Improve outcomes in pediatric anesthesia Presented by :Muhammad
Hamdy Lecturer of anesthesia -Ain Shams University
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Our GOAL
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Are we practicing safe pediatric anesthesia?
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Safe and effective anesthesia for pediatric undergoing surgery
is one of the most challenging tasks presented to anesthesiologist.
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Knowledge Continuous practice Adequate monitoring Outcome
Anesthesia-Related Cardiac Arrest in Children: Bananker et al,
Anesthesia & Analgesia, August 2007 Hypovolemia with blood loss
12% Air embolism 2% Other CV 6% Unclear CV mechanism 13 %
Cardiovascular 41%
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A larm Signs of Hypovolemia under Anesthesia Hypotension (low
for age, narrow pulse pressure, vary with respiration) Persistent
tachycardia Capillary filling not brisk Skin mottling, cold
extremities Reduced urine output Jenkins&Mathur,2011
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Anesthesia-Related Cardiac Arrest in Children: Bananker et al,
Anesthesia & Analgesia, August 2007 Airway
obstruction-laryngospasm 6% Difficult intubation 1% Bronchospasm 2%
Pneumothorax 1% Aspiration 1% 9 Respiratory 27%
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Anesthesia-Related Cardiac Arrest in Children: Bananker et al,
Anesthesia & Analgesia, August 2007 Halothane induced CV
depression 5% Sevoflurane CV depression 3% Allergic reaction 1%
Intravascular injection of local anesthetics 1% Medication 18%
(more in ASA I,II)
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Five Golden Rules of Safe Injection of Local Anesthetics 1-
Aspirate before injection. 2- Give test dose 1-2 ml with
epinephrine 1/mltachycardia) 3- Slow injection rate < 10 ml/min
high plasma level 4-Verify usual resistance throughout injection 5-
Repeat aspiration every 5 ml at least Aboulghar e.a. Hum. Reprod
2011
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Anesthesia-Related Cardiac Arrest in Children Bananker et al,
Anesthesia & Analgesia, August 2007 kinked or plugged ET tube
1% Inadequate peripheral venous access 22% Central catheter
(pneumoth., hemoth.) 3% Breathing circuit 1%
Anesthesia-Related.
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Prediction or anticipation of potential complications is
crucial to improve outcomes in pediatric anesthesia.
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Neonatal Anesthesia Children < 1 year old have more
complications: I. Oxygenation II. Ventilation III. Airway
management IV. Response to volatile agents and medications Stress
response is poorly tolerated Consider: 1. Organ system immaturity
2. High metabolic rate. 3. Ease of miscalculating a drug dose
Schenker and Weinstein, 2011
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Neonatal Anesthesia Be aware of: Sudden changes in hemodynamics
Unexpected responses Unknown congenital problem
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Cardiac output is rate dependent ((cant increase stroke volume
Immature baroreceptor reflex and limited ability to compensate for
hypotension by increasing heart rate. They are more susceptible, to
the cardiac depressant effects of volatile anesthetics
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Hypovolemia with blood loss accounts for 12% of causes of
cardiac arrest in OR with almost half of it due to under estimation
of blood loss Anesthesia-Related Cardiac Arrest in Children:
Bananker et al, Anesthesia & Analgesia, August 2007
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Golan et al, 2010 Immature hepatic function (drug dosing
intervals &maintenance) Immature renal function (poor
toleration of fluid restriction/overload)
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Age-specific considerations Fast desaturation Low FRC, high
closing volume, highly compliant airways atelectasis High oxygen
consumption + cant do forced inspiration increase R.R. high work of
breathing Diaphragmatic breathing easily fatigue (less type I
muscle fibers)fast desaturation Schenker and Weinstein, 2011
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How Long Pre-oxygenation?
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60 seconds 6L/min (gives 80-90 seconds before desaturation ) (
Morrison JE et al: Pediatric Anaesthesia2008:8;293) 60 seconds
6L/min (gives 80-90 seconds before desaturation ) ( Morrison JE et
al: Pediatric Anaesthesia2008:8;293)
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Spontaneous Vs controlled? -Spontaneous: more than 6 mos, less
than 30 min Pressure Vs volume control? Pressure control: First few
days, premature Volume control: surgical manipulations interfere
with ventilation Peep 3-5 is routine Whatever the technique, an
expired tidal volume & PIP should be tailored to the desired
levels Schenker and Weinstein, 2011
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C ompetent nociceptive system AVOID ( non analgesic practice)
AVOID
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Bosenberg AT et al, Pediatr Surg Int2010:7, 289
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Monitoring equipment
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ECG NIBP ETCO2 Pulse oximetry Temperature Monitoring
equipment
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precordial stethoscope esophageal stethoscope CVP (vasoactive
drugs) Direct BP (accurate, intravascular volume status) Monitoring
equipment
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M onitors Predicting Complications. 29 Webb et al,2011: The
Australian Incident Monitoring Study
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Trained Anesthesiologist Prediction of complication Adequate
monitoring Outcome
