PEDIATRIC ANESTHESIA

MICHAEL ARITONANG MD

CHILDREN VS ADULT
1. Specific anatomic
2. Developing physiologic
3. Physiologic issues
This distinctive features form the basis for
the techniques and pharmacologic outline

TERMINOLOGY

Newborn: 1st 24 hours

Neonates : 1st month
Infants : 1st 12 months
Toddler: 1st 3 years
Small children: 4th 12 years
Child : 1st - 12 years
Adolescent : 13 - 16 years

ANATOMIC AND
PHYSIOLOGIC DISTINCTIONS
BETWEEN ADULT AND
PEDIATRIC PATIENT

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
1. Head size : much larger head size to
the body and prominent occiput
2. Tongue size: Larger size relative to
mouth
3. Retrognathic chin/ obtuse angle of jaw
4. Narrow nares: 50% of airway resistance
is from the nasal passages
5. Obligatory nasal breathers
6. Non ossified palate

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
7. Epiglottis: omega shaped (large, narrow
and short)
8. Glottis: anterior and cephalad
Full term: C4
Preterm infant: C3
3 years: C4 - C5
Adult: C6

9. Vocal cords are slanted

10. Airway shape: Narrowest diameter is
below the glottis at cricoid level in children.

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
11.
12.
13.
14.

Tracheal length : 2-5cm (compliant)

Sternum and Thoracic cage: Compliant
Horizontally place pliable ribs
Diaphragm:
Type I fibers
Adult 55%, full term infant 25%,premature 15%
15. Pulmonary surfactant
insufficient (premature) and delayed (DM
mother)

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
16. Alveoli:
Newborn 20-50million
8 years old: 300 million (adult)
Atelectasis common-underdeveloped alveoli
-less surfactant
-compliant chest wall
17. Respiratory physiology:
O2 consumption is 2 3x in infants >
adults.

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
Fetal circulation:
Inc pul vas resistant
Dec pul blood flow
Dec systemic vas
resistance
Right to left blood
flow through FO and
PDA

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
After birth circulation:
Dec pul vascular
resistant
Increase pul blood flow
Increase systemic
vascular resistance
Left to Right blood flow
and closure FO and
PDA

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
Fetal Hemoglobin
At 36wk gestation: 90-95%
Birth: 75-80%
6mths-negligible
High hb & hct
Full term: 18-19g/dl
Preterm:
Estimate Blood Volume
Preterm 90ml/kg
Fullterm 80ml/kg
Infant 70-80ml/kg
Adult 55-65ml/kg

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
18. Cardiac physiology:
The neonatal cardiac myocyte has less
organized contractile elements
1st 3 months of life, PNS influence on
the heart is more mature than the SNS
Relatively fixed stroke volume in
neonates and infants

EVALUATION OF
CARDIOPULMONARY FUNCTION
Physical examination:
Skin
Capillary filling time
Trends in blood pressure
Heart rate
Intensity of peripheral pulses
Presence of murmur
Respiratory rate and effort
Breath sounds
Urine output
Metabolic acidosis

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
19. Renal function:
Limited GFR at
birth; does not reach
adult levels until
infancy; TBW and %
ECF are inc in the
infant.

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
20. Hepatic function:
P450 system not
fully developed in
neonates and
infants; liver blood
flow decreased in
newborns.
Few gylcogen store
and prone to
hypoglycemia

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
21. Thermoregulation
Newborns and infants have a large surface area
to weight ratio with minimal subcutaneous fat.
They have poorly developed shivering, sweating
and vasoconstriction mechanisms.
Heat loss:

Conduction
Radiation
Evaporation
Convection
Respiration

ANATOMIC AND PHYSIOLOGIC

DISTINCTIONS
23. Psychological development
06 mostress on family
8 mo4 yrseparation anxiety
46 yrmisconceptions of surgical mutilation
613 yrfear of not waking up
13 yrfear of loss of control, body image
issues

PREOPERATIVE
EVALUATION

Pertinent maternal history

Birth and neonatal history
Review of systems
Physical examination: height, weight,
and vital signs.
Preoperative home use of
medications
Existence of malformations in the
child and family

PREOPERATIVE
EVALUATION
Issues such as anesthetic risks,
anesthetic plans, recovery
phenomena, postoperative
analgesia, and discharge criteria
have to be discussed in detail.

PREOPERATIVE
EVALUATION
COEXISTING HEALTH CONDITION
1. Upper Respiratory Infection
2. Obstructive Sleep Apnea
3. Asthma
4. The Former Preterm Infant

PREOPERATIVE
EVALUATION
Laboratory Evaluation
Current standard of care dictates that
healthy children undergoing elective minor
surgery require no laboratory evaluation
Hb : 10 g/dL ( for infant > 3 months of age)

Routine versus selective testing is a matter

of policy at individual facilities.

PREOPERATIVE
EVALUATION
Preoperative Fasting Period (ASA GUIDELINES)

Solids: 6 - 8
Formula: 6 hours
Breast milk: 4 hrs
Clear liquids: 2 hrs

Clear liquids such as apple or grape juice, flat cola, and

sugar water may be encouraged up to 2 hours prior to
the induction of anesthesia as their consumption has
been shown to decrease the gastric residual
volume.

PREOPERATIVE
EVALUATION

ANESTHETIC AGENTS
Potent Inhalation Agents
Mask Induction Pharmacology
most common used

Minimal Alveolar Concentration

higher MAC in infant compare than adult

Intracardiac Shunts
R-L shunt : slow induction time
L-R shunt : fasten induction time

Inhaled Agents for Induction of Anesthesia

Sevofluraine vs Halothane
sevofluraine:
3.3% for neonates, 3.2% for infants 1 to 6 months old, and 2.5% for
children older than 6 months

ANESTHETIC AGENTS

ANESTHETIC AGENTS
Intravenous agents
Sedative hypnotic
Propofol, thiopental, methohexital,
etomidate, midazolam, and ketamine
Propofol is the most widely used agent for
induction and maintenance of anesthesia or
sedation in children.
Ketamine are useful in hypovolemic pt and to
preserve spontaneous respiration

ANESTHETIC AGENTS
Opioids
use for surgical anesthesia will decrease MAC of inhaled
agents, smooth hemodynamics during airway management,
or stimulating procedures, and provides postoperative
analgesia.
Chest wall rigidity is not uncommon when administering bolus
opioids
Opioids are also well known to depress central respiratory
effort. Newborns and infants younger than 6 months are
particularly susceptible to this effect because of the immature
bloodbrain barrier and increased levels of free drug.

ANESTHETIC AGENTS
Muscle Relaxants
Succinylcholine
Dosage: 1.5 to 2.0 mg/kg IV in 60 seconds.
Recovery: 6 to 7 minutes.
Emergency: 4 mg/kg IM
Non depolarizing NMD
Rocuronium has fastest onset of action 60 seconds for a 1mg/kg dose and goodchoice for rapid-sequence intubation.
Atracurium and cis-atracurium are eliminated by Hofmann
elimination, a process only dependent on pH and temperature.

FLUID AND BLOOD PRODUCT