00 Barash Pedia

Pediatric Anesthesia Overview

Authors

  • Sally E. Rampersad

  • Bukola Ojo

  • Elizabeth E. Hansen

  • Erica L. Holland

  • Rachel M. Feldman

  • Katherine R. Gentry

Key Topics Covered

  • Anatomy and Physiology

  • Airway, Cardiovascular, Central Nervous System

  • Pharmacology and Developmental Pharmacology

  • Induction Techniques

  • Maintenance and Emergence

  • Complications and Recovery

Anatomical and Physiological Considerations

Airway Anatomy

  • Differences in pediatric airway compared to adults:

    • Infants have a larger head-to-body ratio.

    • Funnel-shaped larynx vs. cylindrical in adults.

    • Prominent occiput and large tongue in infants.

    • Cricoid ring narrowest part of airway.

Respiratory Considerations

  • Obligate nose breathing in young infants.

  • Common airway issues: laryngomalacia, upper airway obstruction.

Cardiovascular Differences

  • Higher dependence on heart rate for cardiac output.

  • Blood volume and pressure references vary significantly with age.

Pharmacology

Developmental Pharmacology

  • Differences in drug metabolism:

    • Immature liver function affects drug binding and clearance.

    • Variability in response to opioids: codeine no longer recommended.

Inhalational Anesthetics

  • Sevoflurane as the preferred agent for induction:

    • Avoidance of nitrous oxide due to environmental concerns.

  • Adjustments for pediatric differences in respiratory physiology in drug dosing.

Intravenous Anesthetics

  • Propofol as commonly used induction agent, special considerations for dosing (higher in younger children).

  • Ketamine used effectively for various routes with precautions on side effects (nausea, nightmares).

Anesthesia Techniques

Induction of Anesthesia

  • Inhalational induction with sevoflurane favored; techniques to ease anxiety, safety during procedures emphasized.

Maintenance of Anesthesia

  • Total intravenous anesthesia (TIVA) encouraged.

  • Regional anesthesia included as part of multimodal analgesia.

Recovery Phase

  • Highlights on extubation: deep vs. awake extubation considerations. Risk Managing post-anesthesia complications is essential.

Complications in Pediatric Anesthesia

Types of Adverse Events

  • Perioperative respiratory adverse events include:

    • Bronchospasm, laryngospasm, apneas

    • High-risk groups: neonates, children with recent URI, chronic lung diseases.

Emergence Delirium

  • Notable occurrence in post-anesthesia recovery, management strategies discussed.

Preoperative Assessment and Guidelines

Informed Consent

  • Emphasis on age and developmental capacity.

  • Engaging children in decision-making where appropriate.

Fasting Guidelines

  • Recent evidence advocating reduced fasting times for clear liquids.

Laboratory Testing Recommendations

  • Avoid routine preoperative tests unless clinically indicated.

Specialized Topics

Management of Specific Conditions

  • Guidance for patients with conditions like:

    • Obstructive Sleep Apnea, Diabetes, Autism, and others.

Malignant Hyperthermia

  • Risks in pediatric anesthesia; management protocols highlighted.

Sickle Cell Disease and Other Hematologic Disorders

  • Specific preoperative considerations for patients with these conditions.

Conclusion

  • Continuous updates and adherence to best practices are critical in pediatric anesthesia to mitigate risks and improve outcomes.