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Paediatric stuff

Metabolism

basal metabolic rate is higher, larger surface area means higher heat losses, 02 consumption 5-6ml/kg.min
About 20% higher than adults. This compounds reduced FRC and hypoxia rapidly sets in.
Hb dissociation curve moved to the left, P50 of 2.8kPa, Hb falls from 18 at birth to 11 by 6 months.

Classified

Neonate
Infant
Child
Adolescent

Airway and respiratory system

within 44 weeks of conception


upto 12 months
1 to 12 years
12 16
ayres T piece upto 25kg

Large head, prominent occiput, short neck


Relatively large tongue
Larynx high and anterior C3-4 (c3-6 in adults), bronchi at same angle
Epiglottis is long, stiff and U shaped tends to flop posteriorly.
Head position needs to be neutral as the sniffing the morning air position hinders the view and bagging a patient
Neonates are obligate nasal breathers mucous/trauma from Ng tubes can cause compromise, 50% of airway
resistance is from the nasal passages
Airway is narrowest at the cricoid ring (as opposed to the glottis in adults), it is covered with pseudostratified
Epithelium, trauma causes oedema easily. 1mm of swelling can reduce the airway by 60%,
Suggested leak around an et tube to reduce trauma and swelling and post extubation stridor.
Trachea 4-5cm long and funnels shaped, et tube must sit at least 1cm above carina to prevent dislodgement or
endobronchial intubation with head movement
Limited respiratory reserve
Ribs horizontal preventing the bucket handle movements of adults, reducing tidal volumes.
Ventilation is predominantly diaphragmatic bulky abdominal organs and distended stomach from poor bag
mask technique can impinge on respiratory function. Pulmonary compliance is LOW.
Muscles of ventilation fatigue easily due to reduced numbers of Type 1 muscle fibres.
Chest wall compliance is high reducing FRC by allowing atelectasis, worsened by anaesthesia
Minute ventilation is rate dependent with little available increase in tidal volume.
Closing volume larger than FRC until age 6-8yrs, hence neonates and infants generally need IPPV during
Anaesthesia, higher rate and PEEP. CPAP if spont helps oxygenation.
Work of respiration may be 15% of oxygen consumption!
Alveoli are thick walled and only present at 10%, increasing to adult numbers by age 8yrs
Apnoea is common, post operatively upto age 50 weeks post conception age (60 weeks in ex-prems), significant
if longer than 15 seconds or associated with bradycardias or desaturations. CONSIDERATION FOR
DISCHARGE HOME
Resp rate = 24-(age/2), (over 1 year)
Tidal vol = 6-8ml/kg
Physiological dead space is 30% and increased by anaesthetic equipment.
Cardiovascular

Neonate
Infant
4 yrs
8 yrs
14 yrs

cardiac output is 3-400ml/kg/min at birth and settles to 200ml/kg/min by a few months


Neonates less contractile with less compliant ventricles = limited stroke volume therefore output can
Only be increased by increasing rate.
Parasympathetic tone is dominant predisposing to bradycardias
Bradycardia is associated with falling cardiac output, (difficult to cannulate)
Sinus arrhythmias are common all others are abnormal
HR
130
120
100
90
80
(AGE X 2) + 80

Mean systolic
50-90
85-105
95-110
95-110

Normal blood volumes

Age
Neonate
Upto 2yr
Upto 16yr

Volume ml/kg
85-90
85
80

Weight calculations

Birth (term)
3-12 months
1-6 yrs
9-13 yrs

3-4.5 Kg
age in months + 9 / 2
(age in yrs +4) x 2
3 x age in years

Fluid maintenance regime


(Sagar and Halliday)

4ml/kg
2ml/kg
1ml/kg

first 10kg
next 10 kg
every kg thereafter

Resuscitation

20ml/kg boluses
Blood

atropine
Adrenaline
Amiodarone
Neostigmine
Glycopyrolate

crystalloid
when HCT 25% (or higher for neonate of congenital heart
disease(NB 4ml/kg PRBC will increase Hb 1gm Approx)
15ml/kg
neonates
20mcg/kg
sux
1-2mg/kg
2-3mg/kg
10mcg/kg
vec
0.1mg.kg
5mg/kg
trac
0.3-0.6mg/kg 1mg/kg intubate
50mcg/kg
roc
0.6mg/kg
1mg/kg intubate
10mcg/kg

Thio
Propofol
Ketamine

2-5mg/kg
3-7mg/kg
1-2mg/kg

FFP
Drug doses
PLEASE REFER TO GUIDELINES
WRITTEN BY DR KING

Morphine
Diamorphine
Fentanyl
Midazolam

)
)
) Approximations
)

(5-7mg in Neonates)
cycliz
1mg/kg
dex
0.15mg/kg
Ondans 0.15mg/kg
0.1-0.2mg/kg
paracet
15mg/kg
0.1 mg/kg
diclofenac 1mg/kg (over 1yr)
1-5mcg/kg
codeine 1mg/kg (over 6 months)
0.5 mg/kg 20 min prior to induction.

Renal system

renal blood flow and GFR are low in the first 2 years of life high renovascular resistance
Tubular function is low until 8 months of age cannot excrete large sodium or water loads
Dehydration is poorly tolerated, large surface area with high insensible losses.
40% body weight is ECF (20 in adults), TBW higher
Maintenance = 4ml/kg for 10kg, then 2ml/kg for 10kg then ml/kg (4,2,1)
Urine output is high 1-2ml/kg

Liver

immature, lower protein synthesis, slower drug metabolism.

Glucose

hypoglycaemia is common in stressed neonate, can cause neurological damage


Glycogen stored in liver and MYOCARDIUM

Haematology

at birth 70-90% is HbF HCT 0.6, Hb 18-20gm/dL, HbF reduced to 5% by 3 months


Moves oxygen dissociation curve to left (P50 of 2.4kPa), readily combines but lack of 2-3DPG inhibits
It giving the oxygen up again in the tissues.
Hb F is protective against sickling.
Vit K factors (2/7/9/10) and platelets deficient, vit K given at birth to prevent haemorrhagic disease of newborn.
Transfuse when lost 15% blood vol. (80-90ml/kg is TBV) dependent upon starting Hb, can use target Hb and
calculate loss to reach this transfusion target.

Temperature

Large surface area to weight ratio, minimal subcutaneous fat.


Poor shivering, sweating and vasoconstrictor responses.
Brown fat around scapula, mediastinum, kidneys and adrenals metabolised to generate
non-shivering thermogenesis about 2-6% neonatal weight
Increases oxygen demand
Heat lost in theatre mostly radiation, conduction & evaporation during laporotomy.
Low body temp causes respiratory depression, acidosis, reduced cardiac output, prolongs drug action, increases
infection and reduces clotting and platelet function

CNS

neonates feel pain, narcotics depress ventilation response to increased PC02 and hypoxia.
BBB poorly formed barbiturates, opiates, antibiotics and bilirubin easily cross
Cerebral vessels are thin walled and fragile in neonate prone to intraventricular haemorrhages
Risk increased if hypoxic, hypercarbic, low HCT, awake airway manipulations, rapid bicarb
infusions, fluctuant BP. Cerebral autoregualtion present and working from birth may not be working in
neonates.

Psychology

infants less than 6 months are generally not that upset and accept strangers well.
Up to age 4 upset by strangers and new surroundings unpredictable and difficult to rationalise
School age more afraid of procedure mutilation and pain
Adolescent narcosis, pain, loss of control, not being able to cope with effects of illness.
Parental anxiety is perceived and acted upon by child.

Practicalities of anaesthetising children


1. Pre-op visit

time, develop rapport, trust of pt and parent, address child first and then parent. However pre-school children
often happier if talk to parent first. Address fears and questions, explain procedure, medical and

anaesthetic
history. FH. Allergies, medication, recent respiratory illness, immunisations, fasting, loose teeth.
Childs weight.
2. Investigations

Hb if expected blood loss, premature infant, systemic illness, congenital heart disease, haemoglobinopathies
U&E renal or metabolic disorders

3. Analgesia

discuss PR, post op plans and breakthrough, use pain nurse/leaflets.

4. Fasting

2hr
4hr
6hr

5. Premedication

now infrequent, pre-op visit and parental help.


Sedation has a significant failure rate
Most commonly analgesic pre-med paracetamol, brufen, codeine given 30 min prior to theatre
EMLA/ Ametop.
Sedative midazolam 0.5mg/kg upto 15mg (short acting therefore timing important, can have second half dose)
, temazepam 0.5-1mg/kg 1hr pre-op need monitoring - Can cause apnoea!

6. theatre prep

PUT CHILD FIRST ON LIST


warm, appropriate staff and parent to accompany pt
Emergency drugs available, calculate dose of induction agents prior.
Equipment checks
Appropriate breathing circuit and monitoring including temperature

7. Induction

inhalation can be excellent method if fear of needles or poor access, 2 person technique, skilled person to
maintain airway whilst iv access is gained if possible.
(Halothane sweet smell, well tolerated, moderately slow onset improved with 50% N20,
Duration longer and off set slower, arrythmias more common not often used)
Sevoflurane non-irritant, rapid onset and offset as less soluble, N20 increases rate of onset, improved CVS
stability. Mac 3.3 for infants and 2.5 in children

8. IV access

back of hand, inner wrist, long saphenous, dorsum of foot. ACF difficult and tissue easily
Pre-02 can be difficult struggling increases 02 consumption!

9. Intubation

straight magill may be easier for neonates and infants. Mackintosh easier when 6-12 months.
Uncuffed until 8-10yrs, small leak should be present at 20cmH20.
Age/4 + 4/4.5
Length = age/2 + 12 for oral and +14 for nasal
LMA

clear fluids
breast and formula milk if aged less than 12months
solids and formula milk if over 12months

size 1
Size 1.5
Size 2

upto 5kg
upto 10kg
upto 20kg

Size 2.5
Size 3

upto 30kg
for over 30kg

NOTE more sensitive to non depolarising neuromuscular blocker but resistant to depolarising agents
10. Regional

Use regional/Local where able to reduce opioid requirements.


CAUDAL spinal cord extends to L3 at birth receding to L2
Pt lateral, knees at 90 degrees to hips, sacral hiatus at third point of triangle from posterior superior
sacral spines Often a skin dimple Aseptic technique needle inserted cranially through the hiatus
click of sacrococcygeal membrane Maybe felt, then advance NO MORE than 2cm Aspirate to
confirm no blood or CSF. Avoid advancing cannula to far as may puncture dura especially in
neonates.
0.25% bupivicaine Levo has better safety profile.
0.5ml/kg for sacrolumbar blockade
)
1.0ml/kg for upper abdominal
) But variable
1.25ml/kg volume for thoracic blockade
)
Note
max dose is 1mg/kg made up with saline
S-Ketamine 0.5mg/kg will prolong block. Note all drugs need to be preservative free
Post op monitoring especially sP02 and apnoea

Paediatric fluids

NPSA 2008 and paeds anae 2007

1. Removal of 0.18% NaCl and 4% dextrose from general wards only available in specialist areas
2. Produce guidelines for fluid management
3. Adequate training and supervision
4. Review of present prescription and fluid charts
5. Promote reporting of hyponatraemia
REMEMBER
Advises

ORAL IN BEST MOST OF THE TIME ward iv fluid often 0.9% saline with 5% dex and 10mmol KCL

1. Regular monitoring of blood levels


2. Resusitation fluids should be isotonic ie 0.9% NaCl/Hartmanns
3. Fluid deficits should be replaced with saline +/- 5% dextrose
4. MOST CHILDREN can have 0.45% and 5% or 2.5% dextrose without risk hyponatraemia
5.ONLY ISOTONIC FLUIDS = 0.9% saline +/- 5% dextrose and Hartmanns
Sodium at lower end normal range
Volume deplete/ hypotensive
CNS infection/ head injury
Pre-peri operative patients
Bronchiolitics
Septic/ GI losses/ Salt wasting syndromes
DM/ CF/ pituitary deficiencies
6. Hypernatraemia only use isotonic fluids
7. Regular assessment = 4 hourly and fluid regime to match
8. Blood estimation same methods, same machine at least every day. More frequent as indicated.

Paediatric anaesthetist executive summary


1. Clear fluids until 2hrs before
2. Breast milk until 4 hours before if <6/12 old
3. No food /milk/ formula 6 hours if over 6/12
4. Dehydration without signs of hypovolaemia can be corrected slowly
5. Hypovolaemia correct rapidly
6. Fall in blood pressure is a LATE sign
7. Maintenance regime = 4/2/1
8. Replace deficit/ maintenance and losses
9. During surgery ALL fluids should be isotonic
10. MOST children over 1 month old will maintain blood glucose without dextrose infusions monitor.
11. RISK OF HYPOGLYCAEMIA = pts on TPN or IV dextrose prior to theatre, low weight <3 centile, surgery greater
than 3 hours, prolonged regional anaesthesia,
12. Blood loss replace with crystalloid until HCT 25% (higher in cyanotic heart disease and neonates)
13. Monitor daily bloods, fluid input and output, daily weight
14. Acute dilutional hyponatraemia is medical emergency and should be managed in PICU.

Paediatric pre operative assessment


Present
PMH
FH
Drugs
Exam

IX

Patient previous experience (likes/dislikes) and behaviour.

illness, age, maturity, post-conception age, consent Gillick (ability to give consent)
CVS murmers, congenital,
Resp cough/colds/asthma/ sleep apnoea/ CF
Misc fluid status, hernia, epilepsy, cerebral palsy, spina bifida, dystrophys, anaemias
sickle, dystrophies, sux
allergies/ medication ensure has had inhalers etc.
Dehydration Mild <5% = decreased urine, dry mouth. Mod = 5-10% decreased urine, reduced turgor, sunken fontanelles
and eyes, tachycardic and tachypnoeic, drowsy. Severe all above plus acidostic
Deficit = % dehydrated X wt in kg x 10 (resus then rehydrate over 24-48hrs)
Airway tonsils, snoring, hunter hurlers, Pierre robin, goldenhar, laryngomalacia, cystic hygroma
ECG, echo, sickle test, U&E, Hb esp physiological anaemia if indicated

Patient fears

Pre school age = parental separation


Young = pain, older = death
Remember pets going to sleep
Pre-med benzo midaz 0.5mg/kg or temaz 1mg/kg, (chloral hydrate 25-50mg/kg in good time most used for sedation in infants
Antisialogogic, vagolytic, bronchodilators
Starvation time to injury/opiates

Paediatric surgical conditions


1. TOF

1:4000 births,
Diagnosis
Usually

polyhydramnios, prenatal scan, choking on first feed


oesophageal atresia with distal connection to trachea 85% cases

Associated

abnormalities in 50-70% cases (Vertebral Anus Cardiac T Esophageal Renal Limb)


Cardiac upto 20% of cases

Management

nil by mouth, nurse head up REPLOGE tube in upper pouch (double lumen often with suction)
IV fluids, IM Vit K
ECHO. CXR = NG in upper pouch and gas in gut

Note

ET tube and ventilation can inflate stomach with over spill into trachea
therefore try and avoid until surgery

Intra-op

main aim to avoid inflating stomach.


Several induction methods described iv and gaseous the key is avoiding inflating stomach
Bronchoscopy to identify position of fistula.
Tube should be placed distal to fistula
Thoracotomy extra pleural primary anastomosis
Ligation of fistula
Chest drain
Trans-anastomotic NG tube
NOTE

Post-op

may need urgent gastrotomy to deflate stomach


Surgeon may request hypovent during procedure

analgesia , opiate, Paravertebral, epidural


Often ventilated especially if difficult or prolonged surgery.
Feed via trans anastomotic tube
Re-intubation via experience person as malpositioned tube can put pressure on suture lines.
NOTE may later develop TOF Cough due to tracheomalacia
Many have reflux and some need further surgery for oesophageal dilatation.

Pyloric stenosis

THIS IS NOT AN EMERGENCY OPERATION. It is often a medical emergency!

RAMSTEDTS PROCEDURE

longitudinal incision along muscle

Presentation

2-6/52 old, males 85%, 1:350 births


Dehydrated, oliguric, dry mucouse membranes, sunken fontanelle, loss skin turgor

Classically

hypochloraemic hypokalaemic alkalosis


Loss gastric H+K+ Mg+ Na+ and ClUrine is high in Na+ & K+ trying to conserve H+
(severe cases start to loss H+ trying to conserve water by conserving Na+)

Treatment

restoration of circulating volume with saline


Rehydration and correction of electrolytes

Aim

pH normal/ Bicarb 25-28/ Cl>90/ Na+ >135 BEFORE THEATRE

Fluids

Maintenance saline with potassium


Rehydration = percentage loss/kg over 2-3 days
Continued NG losses as saline

Monitor

blood levels and correct accordingly

Induction

empty stomach via NG


Pre02 Gas or IV induction (usually with non-depolarising relaxant as rapid onset in this age group))
Cricoid not that effective in neonates

Post op

Not that painful so avoid opiates as prolonged recovery, esp prems


Apnoea monitor (high associated incidence)
Paracetamol 20-40mg/kg PR or 7.5mg/kg iv, local anaesthetic infiltration
Codeine PO/PR

BLEEDING TONSIL
Presenting problems -hypovolaemia (may be occult), residual sedation from first anaesthetic, stomach full with blood,
Potential difficult airway due to blood and oedema, patient agitated/ anxious.
Treatment

fluid resuscitation, assessment of fluid status with cap refill etc, Xmatch, Good IV access.

Induction

RSI with cricoid pressure, may need SMALLER tube than previous, consider atropine, orogastric
tube when intubated
to empty stomach. Suction available.
Classical description is inhalational with halothane in left lateral decubitous position, intubating
Deep( difficult to hold airway, if deep enough to intubate will exacerbate hypotension,
unfamiliar position to intubate a potentially difficult airway)
extubate head down, AWAKE, vomiting common. 02, fluids. Consider area discharged to.

Post op

Diaphragmatic hernia
Occurs

1:2000 live births, 85% left sided, 15-25% associated abnormalities.

Presentation
Signs

post natal depends upon degree of lung hypoplasia.


1/3 cyanosed at birth. Only 1/3 lung tissue = poor prognosis

mediastinal shift, intercostals recession, respiratory distress


Reduced breath sounds on affected side, scaphoid abdomen.

NEED an ECHO pre operatively


CXR

bowel loops in thoracic cavity

Problems lung hypoplasia, pulmonary hypertension, respiratory failure


BRITTLE response to crystalloids
Management AVOID facemask ventilation as this tends to distend the stomach
HFO ventilation may be useful
NG tube to decompress stomach
Correct acidosis (if PC02> 5.2 despite hyperventilation has mortality of 70%)
Surgery

ONCE BABY IS STABLE


Good oxygenation reduces pulmonary vasoconstriction
AVOID NITROUS
Try to avoid over distension of hypoplastic lung = pneumothorax/ barotrauma

Post-op

30% need prolonged ventilatory support


60% of those borne alive survive

ABDOMINAL WALL DEFECTS


Exomphalos

1:5000, membrane covering. Umbilical cord at sac apex

Is

failure of GUT to return to abdomen after 10 weeks of foetal development.

Assoc

cardiac abnormalities NEEDS ECHO,


40% have syndromes

Management similar to Gastroschisis, less fluid etc losses.


Gastroschisis

1:5000, often prems, NO ASSOCIATED SYNDROMES. Umbilical cord at side.


NO COVERING MEMBRANE, gut often thickened/ covered in exudate

Assoc

GI abnormalities atresia, stenosis an malrotation approx 15%

NOTE

as no covering there is increased loss of fluid, heat, increased incidence of infections


Loss protein rich fluid.
Often have bowel wrapped in plastic covering to reduce losses.
Risk of liver prolapse
Muscles are intact

Anae

RSI,

Intraop

decompression of gut, avoid nitrous


Tight closure = ALERT surgeon if airway pressures high after closure ,reduced venous return, oedematous
lower limbs, reduced GFR/function, Hypertension, reduced respiratory reserve due to splinting.
?long line insertion for TPN
Staged closure allow stretching and reduces intra-abdominal pressures but increased infection risk.

Postop

ventilated, TPN,