Pediatric Anesth

Pediatric Anatomy, Physiology &
Pharmacology
Introduction
Of primary importance to the pediatric anesthesia
provider is the realization that infants and children
are not simply a small adult.
Their anesthetic management depends upon the
appreciation of the physiologic, anatomic and
pharmacologic differences between the varying ages
and the variable rates of growth.
Also of importance is a general knowledge of the
psychological development of children to enable the
anesthetist to provide measures to reduce fear and
apprehension related to anesthesia and surgery.
Definitions
• Preterm or Premature Infant: < 37 weeks
• Term Infant: 37-42 weeks gestation
• Post Term Infant: > 42 weeks gestation
• Newborn: up to 24 hours old
• LBW: <2.5 kg
• VLBW: <1.5 kg
• Neonate: 1-28 days old……(early/late)
• Infant: 1-14 months old
• Child: 14 months to puberty (~12-13 years)
Body Size
• The most obvious difference between children & adults
is size
• It makes a difference which factor is used for
comparison: a newborn weighing 3kg is
– 1/3 the size of an adult in length
– 1/9 the body surface area
– 1/21 the weight
• Body surface area (BSA) most closely parallels
variations in BMR & for this reason BSA is a better
criterion than age or weight for calculating fluid &
nutritional requirements
• LENGTH
• 0y….50cm
• 3m….60 cm
• 9m….70cm
• WEIGHT • 4y….100cm
• 0 mth 3kg • Then 5cm per yr till 10y
• 5mth 6kg
• 1y 9kg • HC
• 2y 12kg • 0y..35cm
• 3m….40cm
• 12m….45cm
• 2y….48cm
• 12y….52cm
Fetal Development
• The circulatory system is the first to achieve a
functional state in early gestation
• The functioning heart grows & develops at the

same time it is working to serve the growing fetus
– At 2 months gestation the development of the heart and
blood vessels is complete
– In comparison, the development of the lung begins later
& is not complete until the fetus is near term
Fetal Circulation
• Placenta
– Gas exchange
– Waste elimination
• Umbilical Venous Tension is 32-35mmHg
– Similar to maternal mixed venous blood
– Result:
• O2 saturation of ~65% in maternal blood, but ~80% in the fetal
umbilical vein (UV)
– Low affinity of fetal Hgb (HgF) for 2,3-DPG as compared
with adult Hgb (HgA)
– Low concentration of 2,3-DPG in fetal blood
• O2 & 2,3-DPG compete with Hgb for binding, the
reduced affinity of HgF for 2,3-DPG causes the Hgb to
bind to O2 tighter
– Higher fetal O2 saturation
Fetal Circulatory Flow
• Starts at the placenta with the umbilical vein
– Carries essential nutrients & O2 from the placenta to
the fetus (towards the fetal heart, but with O2 saturated
blood)
• The liver is the first major organ to receive blood
from the UV
– Essential substrates such as O2, glucose & amino acids
are present for protein synthesis
– 40-60% of the UV flow enters the hepatic
microcirculation where it mixes with blood draining
from the GI tract via the portal vein
• The remaining 40-60% bypasses the liver and
flows through the ductus venosus into the upper
IVC to the right atrium (RA)
• The fetal heart does not distribute O2 uniformly
– Essential organs receive blood that contains more oxygen than
nonessential organs
– This is accomplished by routing blood through preferred pathways
• From the RA the blood is distributed in two directions:
– 1. To the right ventricle (RV)
– 2. To the left atrium (LA)
• Approximately 1/3 of IVC flow deflects off the crista
dividens & passes through the foramen ovale of the
intraatrial septum to the LA
• Flow then enters the LV & ascending aorta
– This is where blood perfuses the coronary and cerebral arteries
• The remaining 2/3 of the IVC flow joins the desaturated
SVC (returning from the upper body) mixes in the RA
and travels to the RV & main pulmonary artery
• Blood then preferentially shunts from the right to the left
across the ductus arteriosus from the main pulmonary
artery to the descending aorta rather than traversing the
pulmonary vascular bed
– The ductus enters the descending aorta distal to the innominate
and left carotid artery
– It joins the small amount of LV blood that did not perfuse the
heart, brain or upper extremities
• The remaining blood (with the lowest sat of 55%)
perfuses the abdominal viscera
• The blood then returns to the placenta via the
paired umbilical arteries that arise from the
internal iliac arteries
– Carries unsaturated blood from the fetal heart
• The fetal heart is considered a “Parallel”
circulation with each chamber contributing
separately, but additively to the total ventricular
output
– Right side contributing 67%
– Left side contributing 33%
• The adult heart is considered “Serial”
• Summary:
– Ductus Venosus shunts blood from the UV to
the IVC bypassing the liver
– Foramen Ovale shunts blood from the RA to
the LA
– Ductus Arteriosus shunts blood from the PA to
the descending aorta bypassing the lungs
– Fetal circulation is parallel
– Blood from the LV perfuses the heart & brain
with well oxygenated blood
Fetal Pulmonary Circulation
• Fetal Lungs
– Extract O2 from blood with its main purpose to
provide nutrients for lung growth
• Neonatal Lungs
– Supply O2 to the blood
• Fetal lung growth requires only 7% of
combined ventricular output
Transitional & Neonatal
Circulation
• There are 3 steps to understanding transitional
circulation
– 1. Foramen Ovale: ductus arteriosus & ductus venosus
close to establish a heart whose chambers pump in
series rather than parallel
• Closure is initially reversible in certain circumstances & the
pattern of blood flow may revert to fetal pathways
– 2. Anatomic & Physiologic: Changes in one part of the
circulation affect other parts
– 3. Decrease in PVR: The principal force causing a
change in the direction & path of blood flow in the
newborn
Circulation
• Changes that establish the newborn
circulation are an series of interrelated
events
– As soon as the infant is separated from the low
resistance placenta & takes the initial breath
creating a negative pressure (40-60cm H2O),
expanding the lungs, a dramatic decrease in
PVR occurs
– Exposure of the vessels to alveolar O2
increases the pulmonary blood flow
dramatically & oxygenation improves
Circulation
• Most of the decrease in PVR (80%) occurs in the
first 24 hours & the PAP usually falls below
systemic pressure in normal infants
• PVR & PAP continue to fall at a moderate rate
throughout the first 5-6 weeks of life then at a
more gradual rate over the next 2-3 years
• Babies delivered by C-section have a higher PVR
than those born vaginally & it may take them up to
3 hours after birth to decrease to the normal range
Circulation
Closure of the Ductus Arteriosus,
Foramen Ovale & Ductus
Venosus
Ductus Arteriosus
• Closure occurs in two stages
– Functional closure occurs 10-15 hours after birth
• This is reversible in the presence of hypoxemia or hypovolemia
– Permanent closure occurs in 2-3 weeks
• Fibrous connective tissue forms & permanently seals the lumen
– This becomes the ligamentum arteriosum
– {FACTORS FACILITATING CLOSURE OF D.A. ;:: Incr

in pO2,NE,Epi,Ach,Bradykinin.}
Foramen Ovale
• Increased pulmonary blood flow & left atrial
distention help to approximate the two margins of
the foramen ovale
– This is a flap like valve & eventually the opening seals
closed
– This hole also provides a potential right to left shunt
– Crying, coughing & valsalva maneuver increases PVR
which increases RA & RV pressure
– A right to left atrial & intrapulmonary shunt may
therefore readily occur in newborns & young infants
Ductus Venosus
• This has no purpose after the fetus is
separated from the placenta at deliveryos
• Fnal closure : within frst week
• Anat closure:2-3 mths:
• {{Patent DV=> Decr delv of drugs to liver, and thrfr may

prolong their elimination t1/2 in first few days of birth}}
• RISK OF INCRSING LIKLIHOOD OF
PROLONGED FETAL CRCULTION::
• PREMATURITY
• INFECTION
• ACIDOSIS
• DECR OXYGEN
• INCR CO2
• HYPOTHERMIA
• CONG HEART DISEASE
Cardiovascular Differences in the Infant
• There are gross structural differences & changes in the
heart during infancy
– At birth the right & left ventricles are essentially the same in size
& wall thickness
– During the 1st month volume load & afterload of the LV
increases whereas there is minimal increase in volume load &
decrease in afterload on the RV
• By four weeks the LV weighs more than the RV
• This continues through infancy & early childhood until the LV is
twice as heavy as the RV as it is in the adult
(incr in heart size initially is mainly b coz of

myocyte hyperplasia, After 6 mnths of age,
DNA disappears from myocyte , and so ventr
grth after 6 mnths is due to hypertrophy)
Cardiovascular Differences in the Infant
• Cell structure is also different
– The myocardial tissues contain a large number of nuclei
& mitochondria with an extensive endoplasmic reticulum
to support cell growth & protein synthesis during infancy
– The amount of cellular mass dedicated to contractile
protein in the neonate & infant is less than the
adult….30% vs. 60% (primarily cartilagenous)
– These differences in the organization, structure &
contractile mass are partly responsible for the decreased
functional capacity of the young heart
Evidence has also been forthcoming to suggest that intra

cellular Ca flu and ca sensitivity of contractile proteins
are decresd in NN myocardium.(Endog Ca stores are less
• CO depends on HRxSV
• SV dep on: Myocard contrctility
Preload
Afterload.
In PT and FT NN’s, HR is the primary determinant of CO.
The low compliance of the ventr myocardium in the NN limits the

role of PL in determining SV. In response to hypoxemia, CO incr
via an incr in HR. In response to hypercapnia or lactic acidosis,
SV decreases.
Afterload is determined by the resist of the large arterial bld vsls and
the tone of the periph vasc bed. B’coz sympth tone is poorly
devolped in the NN, afterload is low in the neonate but increases
in parallel with incr in systm BP with aging.
In Summary, CO in the NN depends primarily on rapid HR and to
a lesser extent on an adequate PL and adequate myocard
contractility.
Cardiovascular Differences in the
Infant
• Both ventricles are relatively noncompliant
& this has two implications for the
anesthesia provider
– 1. Reduced compliance with similar size & wall
thickness makes the interrelationship of the
ventricular function more intimate
(INTERVENTRICULAR DEPENDANCE)
• Failure of either ventricle with increased
filling pressure quickly causes a septal shift
& encroachment on stroke volume of the
opposite ventricle
Infant
– 2. Decreased compliance makes it less sensitive
to volume overload & their ability to change
stroke volume is nearly nonexistent
• CO is not rate dependent at low filling pressures but
small amounts of fluid rapidly change filling
pressures to the plateau of the Frank-Starling length
tension curve where stroke volume is fixed
– This changes the CO to strictly being rate dependent
– Additional small amounts of fluid can push the filling
pressure to the descending part of the curve & the
ventricles begin to fail
– The normal immature heart is sensitive to volume
overloading
Infant
• Functional capacity of the neonatal & infant
heart is reduced in proportion to age & as
age increases functional capacity increases
– The time over which growth & development
overcome these limitations is uncertain &
variable
– When adult levels of systemic artery pressure &
PVR are achieved by age of 3 or 4 years the
above limitations probably no longer apply
Autonomic Control of the Heart
• Sympathetic innervation of the • Parasympathetic
heart is incomplete at birth with
decreased cardiac catecholamine innervation has been
stores & it has an increased shown to be complete
sensitivity to exogenous
norepinephrine at birth therefore we
– It does not mature until 4-6 months of age
see an increased
sensitivity to vagal
stimulation
• The imbalance between sympathetic &
parasympathetic tone predisposes the infant
to bradycardia
– Anything that activates the parasympathetic
nervous system such as anesthetic overdose,
hypoxia or administration of Anectine can lead
to bradycardia
– If bradycardia develops in neonates & infants
always check oxygenation first
• Atropine may inhibit vagal stimulation
– Is always given prior to, or at the same time,
that Anectine is given or anytime that vagal
stimulation will be present such as in an awake
intubation
• Dose of Atropine is 20mcg/kg where the minimum
dose for children is 0.1mg
– Anything less than 0.1mg can cause paradoxical
bradycardia which may occur secondary to a dose
dependent (low dose) central vagal stimulating effect of
the drug
Circulation
• The vasomotor reflex arcs are functional in
the newborn as they are in adults
– Baroreceptors of the carotid sinus lead to
parasympathetic stimulation & sympathetic
inhibition
– There are less catecholamine stores & a blunted
response to catecholamines
• Therefore neonates & infants can show vascular
volume depletion by hypotention without
tachycardia
Cardiovascular Parameters
• Parameters are much different for the infant than
for the adult
– Heart rate: higher
• Decreasing to adult levels at ~5 years old
– Cardiac output: higher
• Especially when calculated according to body weight & it
parallels O2 consumption
– Cardiac index: constant
• Because of the infants high ratio of surface area to body weight
– O2 consumption: depends heavily on temperature
• There is a 10-13% increase in O2 consumption for each degree
rise in core temperature
IN TOTO:
*Tendency towrds Biventr Failure

*Sensitive to volume overloading
*Poor tolerance of Incrsd AL
*HR dependant CO
*Greater dep on exogenous Ca &thrfr
incrsd susceptibility to myocard
depression
by inhal agents havin CCB properties.
Circulation Variables in InFANTS
CAUSES OF BRADYCARDIA IN
INFANTS:
CAUSES OF BRADYCARDIA IN
INFANTS
• HYPOXIA
• LARYNGOSCOPY
• INTUBATION
• HYPOTHERMIA
• ENDOTRACHEAL SUCTIONING
• TRACTION ON INTRA OC MSLS
• VARIOUS DRUGS: HALO, FENTANYL
NEOST
SCHOLINE.
. PASSAGE OF N.G. TUBE
CAUSES OF TACHYCARDIA IN
INFANTS
• PAIN
• HYPOVOLEMIA
• DRUGS:ATR. EPINEPH, LOCAL INFILTRN OF
XYLO-ADR
• HYPOXEMIA
• HYPERCARBIA
• ANXIETY
• FEVER
• FULL BLADD
Neonatal and adult myocardium
• CO: HR dependent • HR and SV dependant
• Contractility: decreased • Normal
(ratio of contractile tiss to conn
tiss is 50% act adults, thrfr
contrcn power is less, and so
is compliance) • Normal
Starling Response:Limited • Normal
Compliance: decresd • Low
Ventr Interdpndnce: High
(decrsd complnce+vol
overload→No ↑ in SV
→↑↑chances of CCF.)
* NN Purkinje fibres repolarise
faster and AP’s are faster,thrfr
allowing effective HR >200.
* Need of Exo Ca.
Circulating Blood Volume decreses with
age
PT: 90-100 ml per kg

FT:80 ml per kg
Adult: 70 ml per kg.
• Hb F
30 weeks:95%
40 weeks:80%
6 mnths of birth:5%
Since, 2,3 DPG binds poorly to γ chains of Hb F, Hb F has ↑ed

affinity for O2, i.e. p50 in ODC:
PT=15-18, FT=19.4, 8-12 mnths=31, Adult:27.7
(low p50 optimises uptake of O2 from placenta, but it prevents

release of o2).i.e. left shift of ODC,
But this LEFT shift of ODC is compensated by:
↑ Hb
Expanded red cell volume
↑ CO
RESP
SYSTEM
Lungs begin to devolp by 4 weeks of gestation:
Lobar airways…..5
Segmental Aw…..6
Subsegmental aw..7
Trachea/ Bronchus..8 wks of gestn.
Division of Bronchus into 16 branches: shuld finish by 16
weeks:otherwise leads to “pulmonary hyperplasia”.
Gas Exchange function : 16-25 weeks.
Surfactant:Starts prod in 2nd TM, but peak at 34-36 weeks.
• During the early years of childhood,
development of the lungs continues at a
rapid pace
– This is with respect to the development of new
alveoli(Birth= 20 million)
• By 12-18 months the number of alveoli
reaches the adult level of 300 million or
more
– Subsequent lung growth is associated with an
increase in alveolar size (Adult size by 8 years)
• Functional Residual Capacity (FRC)
– Determined by the balance between the
outward stretch of the thorax & the inward
recoil of the lungs.
• In infants, outward recoil of the thorax is very low
– They have cartilaginous chest walls that make their chest
walls very compliant & their respiratory muscles are not
well developed
• Inward recoil of the lungs is only slightly lower than
that of an adults
• Walls of Bronchi:
NN have incr cartilage, incr conn tissue, and incr
glands, with minimal smooth muscles…thrfr minimal
effect of nebulsn.
(Small Aw obstrcn in NN=inflammation and
edema///////act adults= Muscle spasm)
************************************
Mechanics”
NN have horizontal noncalcified ribs== Decrs A-P

movement
And decr bucket handle movement, thrfore decr
transverse movement.
SO, DIAPHRAGM STAYS THEMAIN MS FOR
RESPRN
Also, Diaphragm has decr type I Ms fibres, (slow
contracting, low oxidative fibres adapted for sustained
activity)(NN=25%, PT=10%, Ad=55%)
THRFORE MORE CHANCES OF MUSCLE FATIGUE

1.Oxygen consumption 6.4 ml/kg/min 3.5
2. CO2 production 6ml/kg/min 3
3.Exhaled MV 210ml/kg/min 90
4.Va 130ml.kg/min 60
5.TV 6ml/kg 7
6.FRC 30ml/g 34
7.FRC/Va .23 .57
8.V/Q .4 .8
• COMPLIANCE:
Birth: 1.5ml per cm H2O
NN: 5.0
Ad: 200
Cm incr with incr in lung size.

LOW LUNG COMPLIANCE AND HIGH CW
COMPLIANCE
↓
LESS –VE INTRA THORACIC PRESSURE IS PROD
↓
↓ SMALL Aw PATENCY
↓
AIRWAY CLOSURE……………. {CV>> FRC}
• With the first few breaths after delivery, initial
resp efforts generate large intra pl pr in order to
inflate the fluid filled alveoli. With these efforts ,
alv r recruitd in increasing numbers, with the
assistance of ST lowering properties of surfactant.
(Most of the fluid with in the alveoli is cleared rapidly thro the upper Aw,
altho any residual fluid is cleard slowly over subsequent 24-72 hrs by
trans cap and trans lymphatic routes)
• Neural & chemical controls of breathing in older
infants & children are similar to those in
adolescents & adults
– A major exception to this is found in neonates and
young infants, especially in premature infants less than
40-44 weeks postconception
• In these infants, hypoxia is a potent respiratory depressant,
rather than a stimulant
• This is due either to central mediation or to changes in
respiratory mechanics
• These infants tend to develop periodic breathing or central
apnea with or without apparent hypoxia
– This is most likely because of immature respiratory control
mechanisms
CHEMORECPS
• Ventilatory resp to hypoxia is complex:
0-3 weeks: vent resp to hypoxia dep on temp.(via perph recps)

{normothermia….decr O2 ….incr ventln}
{hypothermia:…decr in O2…decr in ventln}
After 3 weeks: decr in O2.. Increases ventln irresp of temp.

*********************************** to increase v
Ventltry resp to CO2 is more mature: begin
CO2 resp curve is shifted to left.. i.e.:
Chemorecps begin to incrs ventln at lower CO2 levels.
MECHANORECPS
Resp centre is affected by reflexes and proprioceptive

informations from CW, muscle spindles., inflation
and deflation.
:::::::: Heads paradoxical resp (insp resp to partial infln

of lungs)
::::::::Hering Breur Reflex (initiation of passiv ehaln

with full infln of lungs)
• Why V/Q is low?
* due to gas trapping
* airway closure
* large physiological shunts
• Breathin pattern of NN, esp PT, is described
as “periodic”, i.e. normal breathing
punctated by occasional episodes of
apnea(5-15) seconds,
(Apnea episodes dt immature resp centre)
If apnea episodes last more than 15 seconds, it
can cause bradycardia and desatrn…. These
can occur upto 52 weeks post birth.)
• Breathing Patterns of Infants
– Less than 6 months of age
• Predominantly abdominal (diaphragmatic) and the rib cage
(intercostal muscles) contribution to tidal volume is relatively
small (20-40%)
– After 9 months of age
• The rib cage component of tidal volume increases to a level
(50%) similar to that of older children & adolescents,
reflecting the maturation of the thoracic structure
– By 12 months
• Chest wall compliance decreases
• The chest wall becomes stable & can resist the inward recoil of
the lungs while maintaining FRC
• This supports the theory that the stability of the respiratory
system is achieved by 1 year of age
Resp system is less efficient:
a) Small diam of airways increases resist to airflow
(Resist is inversely prop to radius)
a) CW is highly compliant, so ribs provide little support for the
lungs, i.e.the neg intra thor pressure is poorly maintained.,
leading to airway closure with each breath.
b) Oxygen consumption is 2-3 times higher.
c) Difference in composition of diaph and intercostal muscles.,
and sole reliance on diaphragmatic function.
d) Increased CV act FRC .with tidal breathing
e) Decreased FRC/Va(i.e. incrsed Va/FRC..thrfore it offsets the
fall in PaO2 resulting from low CV)
f) Decrsed surfactant g)Presence of HbF
g) Small and less number of alveoli h)Immature resp control
h) …airway closure
Anatomic
Differences
• Head is relativly large, occiput is prominent.
i.e. no need of pillow under the head, (infact they
might need a pillow under the shoulders.)
Chin is retrognathic.. (Diff BMV)

• Upper Airway: the nasal airway is the primary
pathway for normal breathing
– During quiet breathing the resistance through the nasal

passages accounts for more than 50% of the total airway
resistance (twice that of mouth breathing)
– Except when crying, the newborns are considered
“obligate nose breathers”
• This is because the epiglottis is positioned high in the pharynx
and almost meets the soft palate, making oral ventilation difficult
– If the nasal airway becomes occluded
(SECRETIONS/NG TUBE) the infant may not rapidly or
effectively convert to oral ventilation
• Nasal obstruction usually can be relieved by causing the infant to
cry
• The Tongue: is large & occupies most of the cavity
of the mouth & oropharynx
-With the absence of teeth, airway obstruction can easily occur
– The airway usually can be cleared by holding the mouth open
and/or lifting the jaw
– An oral airway may also be helpful
• Lymphoid tissue is scant in upper Aw of NN, thrfr

suscpt to URI.
• Pharyngeal Airway: is not supported by a
rigid bony or cartilaginous structure
– Is easily collapsed by:
• The posterior displacement of the mandible during
sleep
• Flexion of the neck
• Compression over the hyoid bone
– Chemoreceptor stimuli such as hypercapnia &
hypoxia stimulate the airway dilators
preferentially over the stimulation of the
diaphragm so as to maintain airway patency
• Laryngeal Airway: this maintains the airway &
functions as a valve to occlude & protect the lower
airway
– In the infant the larynx is located high (anterior &
cephlad) opposite C-4 (adults is C-6){Since neck is short}
– The body of the hyoid bone is between C2-3 & in the
adult is at C-4
– The high position of the epiglottis & larynx allows the
infant to breathe & swallow simultaneously
• The larynx descends with growth
• Most of this descent occurs in the 1st year but the adult position
is not reached until the 4th year
– Epigl= SHORT..STUBBY..OMEGA SHAPED
It projects post at angle of 45 degrees to BOT act
15-25 degrees in adults,
Thrfr it has to be lifted during Lx with straight
blade.
– The vocal cords of the neonate are slanted so that the

anterior portion is more caudal than the posterior
(Tube might get lodged in ant commisure than
passin into trachea)
• Cricoid Ring: “Achilles Heel” of upper Aw.(Most
vulnerable str )
*The only circumferential solid cartlg str in Aw.
*Funnel shaped, with caudal aperture being
narrowest.
*Covered with loose pseudostratified columnar
epith., suscpt to both inflammation and edema,
when irritated or traumatised. (2 fold decrease in
radius of lumen increases resist to airflow by 32
fold).
Anatomic Differences in the
Respiratory System
• Narrowest area of the airway
– Adult is between the vocal cords
– Infant is in the cricoid region of the larynx
• The cricoid is circular & cartilaginous and consequently not
expansible
• An endotracheal tube may pass easily through an infants vocal
cords but be tight at the cricoid area
– The limiting factor here becomes the cricoid ring
– This is also frequently the site of trauma during intubation
• 1mm of edema on the cross sectional area at the level of the
cricoid ring in a pediatric airway can decrease the opening 75%
vs. 19% in an adult
• There should be an audible air leak at 15-20cm H2O airway
pressure when applied
• Classical Teaching tells us:
Ad LX: Cylnd
NN Lx: Funnel shaped.
But, recent studies shows that the narrowest part in

adults(70)% is also subglottic at level of cricoid
ring., But the opening is so large that commonly
used tubes are nearly easy to pass the subglottic
area.
• Cote CJ, Lerman J, Todres ID: A practice of Anesthesia for Infants
and Children, Saunders Elsevier, 2009
Respiratory System
• Trachea
– Infant: the alignment is directed caudally &
posteriorly
– Adult: it is directed caudally
• Cricoid pressure is more effective in
facilitating passage of the endotracheal tube
in the infant
Respiratory System
• Newborn Trachea
– Distance between the bifurcation of the trachea &
the vocal cords is 4-5cm
• Endotracheal tube (ETT) must be carefully positioned &
fixed
• Because of the large size of the infant’s head the tip of the
tube can move about 2cm during flexion & extension of
the head
• It is extremely important to check the ETT placement
every time the baby’s head is moved
Respiratory System
• Tonsils & Adenoids
– Grow markedly during childhood
• Reach their largest size at 4-7 years & then recedes
gradually
• This can make visualization of the larynx more
difficult
Respiratory System
Respiratory System
Respiratory System
• ABG
NN
pO2:35
pCO2:65
pH:7.2
Why is pH decr IN NN?
After 24 hrs: *dt incrs CO2
pO2:70 * Immature kidneys not
pCO2:38
pH:7.36 able to retain HCO3-
Oxygen Transport
• Blood volume of a healthy newborn is 70-
90ml/kg
(PT=80-110, Adults=70)
• Hemoglobin tends to be high (approx. 19g/dl)
– Consisting primarily of HgF
– Hgb rises slightly in the first few days because of
the decrease in extracellular fluid volume
• Thereafter, it declines & is referred to as physiologic
anemia of infancy
– HgF has a greater affinity for oxygen than HgA
– After birth, the total Hgb level decreases rapidly as
the proportion of HgF diminishes (it can drop
below 10g/dl at 2-3 months) creating the anemia
Oxygen Transport
– The P-50 rapidly increases at the same time the HgF
is replaced by HgA which has a high concentration
of 2,3-DPG & so insures efficient oxygen off-
loading at the tissues
• The gradual decrease in O2 carrying capacity in the first
few months of life is thus well tolerated by normal,
healthy infants
– There is no consensus about the lowest tolerable
Hgb concentration for an infant
• The lowest limit will depend on factors such as duration
of anemia, the acuity of blood loss, the intravascular
volume & more important the impact of other conditions
that might interfere with O2 transport
Airway Management
• Distance or Depth to
Tape Tube
– If older than 2 years
• Age÷2+12
– If younger than 2 years
• 1-2-3-4 kg then it is
taped at 7-8-9-10cm
respectively
• Newborn to 6 months =
10cm
• 6 to 12 months = 11cm
• 1 to 2 years = 12cm
RENAL SYSTEM
Renal Differences
• Body Fluid
Compartments
– Full term infants have
a large % of TBW &
ECF
– TBW decreases with
age mainly as a result
of loss of water in
extracellular fluid
TOTAL BODY WATER
ECF ICF
• NN: 80%of weight: 45% 35%
• 3 mths :70% " 35% 35%
• Infant: 70 % 30% 40%
• Ad: 60% 20% 40%

• Significance for Anesthesia Provider
– Higher dose of water soluble drug is needed due to

the greater volume of distribution
• However, due to the immaturity of clearance &
metabolism the dose given is equal to the dose used in
adults
• The healthy newborn has a complete set of
nephrons at birth( By 36 Wks)
– The glomeruli are smaller than adults
– The filtration surface related to body weight is
similar
– The tubules are not fully grown at birth & may not
pass into the medulla
RESULT: a) LOW GFR

b) LOW RBF
c) POOR TUBULAR FUNCTION
Renal Differences
Maturation of the glomerular function
is complete at 5-6 months of age
PHYSIOLOGIC CONSIDERATIONS
Developmental Factors
RENAL:
• immature renal function at birth

↓ GFR
25% of adult level at term
adult level at age of 2 years
↓concentrating capacity of newborn kidney
term infant : max. 600-700 mOsm/kg
adult : max. 1200 mOsm/kg

↑free H2O clearance :

excrete markedly dilute urine up to 50
mOsm / kg vs. 70-100 Osm/kg in adults
↓ Na reabsorption
↓ HCO3 /H exchange
↑ urinary losses of K+ and Cl-
IMPLICATION:
Newborn kidney has limited

capacity to compensate for volume
excess or volume depletion
Renal Differences
• Creatinine
– Normal value is lower in infants than in adults
• This is due to the anabolic state of the newborn & the small muscle mass
relative to body weight (0.4mg/dl vs. 1mg/dl in the adult)
• Bicarbonate (NaHCO3)
– Renal tubular threshold is also lower in the newborn (20mmol/L
vs. 25mmol/L in the adult)
– Therefore, the infant has a lower pH, of about 7.34
• BUN
– The infants urea production is reduced as a result of growth & so
the “immature” kidney is able to maintain a normal BUN
HEPATIC SYSTEM
• Glucose from the mother is the main source of energy
for the fetus
– Stored as fat & glycogen with storage occurring mostly in
last trimester( PT are hypoglyc)
• At 28 weeks gestation the fetus has practically no fat
stored, but by term 16% of the body is fat & 35gms of
glycogen is stored
– In utero liver function is essential for fetal survival
• Maintains glucose regulation, protein / lipid synthesis &
drug metabolism
• The excretory products go across the placenta & are
excreted by the maternal liver
– Liver volume represents 4% of the total body weight in the
neonate (2% in adult)
• However, the enzyme concentration & activity are lower
in the neonatal liver
Hypoglycemia
• NN/FT • < 30 mg%
• PT(1-3d) • < 20 mg%
• ≥ 4d (FT/PT) • < 40 mg%
(Rx: 0.5-1 g/kg i.v. gluc bolus f/b

infusion of 5-6 mg/kg/min as maint )
Hepatic Differences
• Coagulation
– At birth, Vit K dependent factors (II, VII, IX &
X) are at a level of 20-60% of the adult volume
• This results in prolonged prothrombin times
– Synthesis of Vit K dependent factors occurs in
the liver which being immature leads to
relatively lower levels of these factors even
with the administration of Vit K
• It takes several weeks for the levels of coagulation
factors to reach adult values
• Administration of Vit K immediately after birth is
important to prevent hemorrhagic disease
Biotransformation of many drugs may b slower in
the NN than in adult. Many enz systems in the
liver r immature at birth.
Activity of phase I cto P450 dependant mixed fn
oxidases is immature in NN, matures by 6 mths.,
{Also the immaturiy is variable, thrfr variability exists in some drugs
being transformed at fast rates, some slower.}
Activity of phase II rns, are mainly conjugative

which r immature at birth .{Sulfation is mature at
birth,}... {Decr in phase II results in decr in bil breakdown, thus
causing jaundice and kernicterus}
GIT
1st day : pH: alkalotic

2nd day onwards: normal as adult.
Ability to coordinate swallowing with resprn fully

mature at 4-5 mths of age.
CNS
• The brain of the neonate is relatively large
– 1/10 of the weight as compared to 1/50 of adult
{Predom consists of water}
– The brain grows rapidly
• Doubles in weight by 6 months
• Triples in weight by 1 year
– At birth ~25% of the neonatal cells are present
– By one year the development of cells in the
cortex & brain stem is complete .
• Myelination & Elaboration of Dendritic
Processes
– Continue into the third year of life
– Incomplete myelinization is associated with
primitive reflexes such as motor and grasp
(BBB is immature at birth in NN, facilitating passage of
large, lipid soluble compds such as A drugs and free bil
into the brain.)
• Spinal Cord
– At birth the spinal cord extends to L-3
– By one year old the infant spinal cord has
assumed its permanent position at L-1
• Structure & Function of the Neuromuscular
System
– Incomplete at birth
• There are immature myoneural junctions & larger
amount of extrajunctional receptors
– Throughout Infancy:
• Contractile properties change
• The amount of muscle increases
• The neuromuscular junction & acetylcholine receptors
mature
• Junctions & Receptors
– The presence of immature myoneural junctions
might cause a predisposition to sensitivity
– A large number of extrajunctional receptors might
result in resistance
– Within a short interval, (< 1 month) this variation
diminishes & the myoneural junction of the infant
behaves almost like that of an adult
• Neural mechs resp for perception of noxious
stim (resp to stress and Sx), are present as early
as 6 wks of gestation
Also Neuro Endocr Axis in PT is also well

devolped.
Thrfore, both PT and FT require complete analgesia and

Ax during and after Sx.
Anatomical Differences:
1. Soft and pliable cranium

2. Non fused sutures
3. Two open fontanelles(PF= 6-9 mths, AF=18
mths)
4. Incomplete myelination (Until 2 yrs)
5. Poorly devolped cerebral cortex
6. Spinal core ends at L4(act L1) with fragile
sub ependymal vessels.
BLOOD CHEMISTRY
• Sodium 134-152 mmol/L
• Potassium 5.0-7.7 mmol/L
• Cl 92-114 mmol/L
• Gluc (F) 40-90 mg%
• TP 5.9-8.5 g%
• TEMP REGULATION
Temperature Regulation
• Body Temperature
– Is a result of the balance between the factors
leading to heat loss & gain and the distribution
of heat within the body
Body heat is lost more rapidly by NN :
1. Large BSA relative to Body Wt.

2. Thin layer of insulation.
3. Decreased ability to produce heat.
Central Temperature Control Mech NT CT
– This is intact in the newborn, but, is only

able to maintain a constant body PT 34 28
temperature within a narrow range of
environmental conditions. Term 32 23
– NEUTRAL TEMPERATURE: defined as Adult 28 1

the ambient temp which results in the least
O2 consumption.
-A deviation in either direction from
the NTE will increase O2 consumption
– CRITICAL TEMP: It is that ambient

temp below which an unanesthetised,
unclothed person cannot maintain a
normal body temperature.
• Important Mechanisms for Heat Production
– Metabolic activity
– Shivering
– Non-shivering thermogenesis
• Newborns usually do not shiver
– Heat is produced primarily by non-shivering thermogenesis
• Shivering does not occur until about 3 months of age
• Non-shivering Thermogenesis
{ Mtb of Brown Fat is stimulated by Nor Epinephrine and

results in TG hydrolysis and thermogenesis }
– Exposure to cold leads to production of Norepi
• This in turn increases the metabolic activity of brown fat
• Brown fat is highly specialized tissue with a great number
of mitochondrial cytochromes (these are what provide the
brown color)
• The cells have small vacuoles of fat & are rich in
sympathetic nerve endings
– They are mostly in the nape & between the scapulae but some are
found in the mediastinal (around the internal mammary arteries &
the perirenal regions (around the kidneys & adrenals)
– Once released Norepi acts on the alpha & beta
adrenergic receptors on the brown adipocytes
• This stimulates the release of lipase, which in turn splits
triglycerides into glycerol & fatty acids, thus increasing
heat production
• The increase in brown fat metabolism raises the
proportion of CO diverted through the brown fat
(sometimes as much as 25%), which in turn facilitates
the direct warming of blood
– The increased levels of Norepi also causes
peripheral vasoconstriction & mottling of the skin
• Heat Loss
– The major source of heat loss in the infant is
through the respiratory system
• A 3kg infant with a MV of 500ml spends 3.5cal/min
to raise the temperature of inspired gases
• To saturate the gases with water vapor takes an
additional 12cal/min
• The total represents about 10-20% of the total
oxygen consumption of an infant
– The sweating mechanism is present in the
neonate, but is less effective than in adults
• Possibly because of the immaturity of the
cholinergic receptors in the sweat glands
• Full term infants display structurally well developed
sweat glands, but these do not function
appropriately
• Sweating during the first day of life is actually
confined mostly to the head
• Heat Exchange Review
– 1. Conduction:
• The kinetic energy of the vibratory motion of the
molecules at the surface of the skin or other exposed
surfaces is transmitted to the molecules of the
medium immediately adjacent to the skin
– Rate of transfer is related to temperature difference
between the skin & this medium
– Use warm blankets, Bair huggers & warmed gel pads
– 2. Convection:
• Free movement of air over a surface
– Air is warmed by exposure to the surface of the body then
rises & is replaced by cooler air from the environment
– Increase OR temp, radiant warmers, wrap in saran wrap,
cover with blankets and/or OR drapes
– 3. Radiation:
• Radiation emitted from the body is in the infrared region of
the electromagnetic spectrum
– The quantity radiated is related to the temperature of the
surrounding objects
– Radiation is the major mechanism of heat loss under normal
conditions (same techniques to prevent as used in Convection)
– 4. Evaporation:
• Under normal conditions ~20% of the total body heat loss is
due to evaporation
– This occurs both at the skin & lungs
– Since the infant’s skin is thinner & more permeable than the older
child’s or adult’s evaporative heat loss from the skin is greater
– In the anesthetized infant the MV (relative to body weight) is high
thus increasing evaporative heat loss through the respiratory system
Pharmacological Differences
with Inhalation Anesthetics
• Review
– Factors that determine uptake & distribution of
inhaled agents
• Factors that determine the rate of delivery of gas to
the lungs
– Inspired concentration
– Alveolar ventilation
– FRC
• Factors that determine the rate of uptake of the
anesthetic from the lung
– CO
– Solubility of the agent
– Alveolar-to-venous partial pressure gradient
• In children there is a more rapid rise from
inspired partial pressure to alveolar partial
pressure than in adults
– This is due to 4 differences between children &
adults
• 1. The ratio of alveolar ventilation to FRC
– This a measure of the rate of “wash-in” of the anesthetic
into the alveoli
– In the neonate the ration is 5:1 compared to adults of 1.5:1
• 2. There is a higher proportion of CO distributed to
the VRG in the child
– In adults an increase in CO slows the rate of rise in
alveolar to inspired partial pressure, but in neonates it
speeds the rate of induction because the CO is
preferentially distributed to the VRG
– The VRG constitutes 18% of the body weight of the
neonate as opposed to only 6% in adults
– Therefore, the partial pressure in the VRG (which
includes the brain) equilibrates faster with the alveolar
partial pressure
• 3. Neonates have a lower blood/gas solubility of
inhaled anesthetics (the less soluble the greater the
amount that remains in the alveolus
– This allows a more rapid rise in the alveolar to inspired
partial pressure
• 4. Neonates have a lower tissue/blood solubility of
inhaled anesthetics
– Less agent is removed from the blood therefore the partial
pressure of the agent in the blood returning to the lungs
increases
•There are age related differences in MAC of inhalation

agents
PERIOPERATIVE FLUID
MANAGEMENT IN
PAEDIATRICS
Introduction
Fluid Management in Infants and

children can be challenging because of
their:
 Small size
 Large surface area to volume ratio
 Immature homeostatic mechanisms.
Introduction contd..
Meticulous fluid management is
required in small pediatric
patients because of extremely
limited margins of error
Perioperative Fluid Management
ISSUES
1. Developmental and Physiological Considerations
2. Distribution of body fluids and Electrolytes
3. Determining Fluid requirements
4. Preoperative deficit therapy
5. Intraoperative fluid management
6. Post operative fluid management
Developmental
and
Physiological
Considerations
RENAL
Renal function is markedly diminished

 low perfusion pressure
 Immature glomerular and tubular function.
 Complete maturation occurs by
about 2 years of age.
RENAL
 Urine Concentrating Capacity

is limited in neonates
 Increased Free Water Clearance

( Diluting Capacity )
RENAL
 Thus the ability to handle

free water & solute loads may
be impaired in the neonate.
 Its more so in the premature baby

who is less able to conserve Na+
RENAL
Fractional Excretion of Na+ is elevated in

premature infants and can lead to
 Negative sodium balance

 Hyponatremia
 Neurologic disturbances and
 Poor growth
RENAL
GFR is low at birth
 Low systemic arterial BP

 High renal vascular resistance and
 Low ultra filtration pressure together with
decreased capillary surface area for filtration.
Renal Parameters
Measurement Premature Term 1-2 wk 6m-1yr 1-3yr adult
GFR 14 40.6 65.8 77 96 125

{ml/min/ 1.73m2} ± ± ± ± ± ±
3 14.8 24.8 14 22 15
RBF 40 88 220 352 540 620
{ml/min/ 1.73m2} ± ± ± ± ± ±
6 4 40 73 118 92
Max conc. Ability
(mosm/kg) 480 700 900 1200 1400 1400
Sr creatinine
clearance (mg/dl) 1.3 1.1 0.4 0.2 0.4 0.8-1.5
Fractional
excretion of Na+ 2% - 6% <1 <1 <1 <1 <1
Cardiovascular
Infants and neonates are

more sensitive to hypovolemia
 Incomplete development
of the myocardium.
 Immature sympathetic nervous system.
Cardiac output is very dependent of HR

Cardiovascular
 The hallmark of intravascular fluid depletion

hypotension without tachycardia.
 In the perioperative period.

Maintenance of effective vascular volume
To sustain vital organ perfusion
Distribution of
Body fluids
and
Electrolytes
Fluid compartments
(% of body wt)
volume changes with age.
Compon Birth 3 Infant Children Adults
ent mths
Fat 16% 23% 30%
TBW 80 % 70% 70% 70% 55 – 60%
ECF 45 % 35% 30% 30% 20%
ICF 35% 35% 40% 40% 40%

Determining
fluid
requirements
Holliday and Segar’s( 4/2/1) formula
The basal caloric needs of
infant and children dictate their fluid requirement
Weight Calorie requirement Day Hour

(Kg)
<10 100Kcal/Kg/day 100mL/Kg 4mL/Kg
1000Kcal 1000mL 40mL

10-20 + + +
50 cal/Kg 50mL/Kga 2mL/Kga
1500Kcal 1500mL 60mL
>20 + + +
20cal/Kg 20mL/Kgb 1mL/Kgb
a= For every Kg >10Kg b=For every Kg >20Kg
Deficit therapy has three components:
 Estimating the
severity of Dehydration
 Determination of type of fluid deficit
 Repair of the deficit.

Fasting :
Allowing clear fluids up to two hours
No increase in the risk of aspiration

Prevents dehydration,
Keeps the period of starvation short.
Residual gastric volume was lower,
pH higher and
Decreased thirst and hunger
Severity of dehydration
Percent of Signs & symptoms Amount of body fluid
body wt lost,ml/kg[%]
lost
Infants Older children &
adults
Mild Vomiting, diarrhea 50 [ 5%] 30 [ 3%]

1 – 5% > 12-14hrs
Dry mouth,↓ urination
Moderate Skin tenting, sunken eyes, 100 [10%] 60 [ 6%]
6 – 10% depressed fontanelles
oliguria, lethargy
Severe CVS instability, mottling 150 [15%] 90 [ 9%]

11 – 15% hypotension,tachycardia,
anuria, sensorium changes
20% Coma, shock
Treatment of dehydration
Goals of preoperative rehydration

 Restoration of cardiovascular function
 CNS function
 Renal perfusion
Treatment of dehydration
 The fluid to replace this deficit
Isotonic Fluid
0.9% NaCl or Ringer lactate.

Composition of Intravenous fluids
Electrolyte N.Saline Ringers IsolyteP Dextrose Hexastarch 6%
meq/l 5%
Na+ 154 130 26 - 154
K+ - 4 21 - -
Cl- 154 109 21 - 154
Ca2+ - 3 - - -
Mg2+ - - 3 - -
Acetate - - 24 - -
Lactate - 28 - - -
Glucose - - - 5 -
(mg/dl)
Osmolarity 308 274 - 252 310
mosm/lit
Intraoperative
Fluid
Management
Intraoperative fluid requirement
Total EFR : Estimated Fluid Requirement
Intraoperative +
EFD : Estimated Fluid Deficit
fluid
+
replacement
IL : Intraoperative Loss
+
EBL : Estimated Blood Loss
Intraoperative fluid requirement
Number of hrs fasting x EFR
Estimated pre 1st hr infuse ½ EFD + EFR 1st hr
operative fluid deficit 2nd hr infuse ¼ EFD + EFR 2nd hr
3rd hr infuse ¼ EFD + EFR 3rd hr
[ EFD]
Minimal incision 3- 5ml/kg/hr

Intraoperative loses Moderate incision with viscous exposure
5 -10ml/kg/hr
[ IL]
Large incision with bowel exposure
8 - 20ml/kg/hr
Estimated blood loss Replace max. allowable blood loss

[ EBL] [ ABL] with crystalloid 3:1
Fluid & dextrose management
Children at risk of hypoglycemia
if non-dextrose containing fluid is given :
 Infants and children on parenteral nutrition

 Children of low body weight ( <3rd centile )
 Children having extensive regional anesthesia
 Children having prolonged surgery ( > 3hrs )
 Children receiving dextrose containing fluids
Management of Third space losses
 During surgery third space loss

 Sequestration of fluid from the vascular space
 Tissues around the site of surgery
 Replaced with an isotonic fluid
Management of Third space losses
 Third space loss is difficult to quantify

 1 - 2mL/Kg/Hr given for superficial surgery,
 4 - 7mL/Kg/Hr given for thoracotomy and
 5 -10mL/Kg/Hr for abdominal surgery
 Clinical signs :-
HR, BP and capillary refill time
to ensure adequate replacement
Monitoring of fluid therapy
 Heart sounds  ET CO2

 Breath sounds
 Body temperature
 ECG
 HR  Skin color
 BP  Urine output
 SPO2  Glucose infusion
Monitoring of fluid therapy
Reliable signs for Hypovolemia

• Poor tissue perfusion
• Capillary refill time
• Core-peripheral temperature difference
Fluid over load

• prominent veins, flushed skin, increased BP,
• decreased serum Na+
• loss of fold in the upper eyelids
Assessment of blood loss
Careful assessment of blood loss
 Weighing blood-soaked sponges,

 Blood and fluid loses using
miniaturized suction bottles
 Visual estimation of blood loss
on surgical drapes.
Assessment of blood loss
Factors determining allowable blood loses
 The patients estimated blood volume
 Preoperative and intraoperative haematocrit
 Cardio-pulmonary & general medical conditions
for adequate oxygen transport
 Risk versus benefits of the transfusion
MABL=EBV(Hp-Ht)/Hp
Blood loss replacement
• Crystalloid :
@ 3 times the volume of the blood loss (1:3)
• Colloid solution :
(albumin, plasma protein, FFP)
@ (1:1)
Concept of replacement after 10% blood loss

Changed to losses based on hematocrit
 Under 10% of blood loss no blood is required.

 Over 20% loses must be replaced with PRBC
 Between 10 - 20% one must consider case by case
 Maintenance of 40% hematocrit in neonates and
30% in older children is must.
 Replacement with
an isotonic fluid 0.9%NS, RL
a colloid or
a blood product
depending on the childs haematocrit.
 Children with cyanotic congenital heart disease

need a higher haematocrit
to maintain oxygenation
Post Operative
Fluid
Management
Post operative fluid management
 Salt and water retention is mainly due to

 continued capillary leak,
 third space accumulation &
 stress induced neuroendocrine activation
 Surgery, pain, nausea and vomiting

potent causes of ADH release.
 Ideal fluid for post operative maintenance

RL with added dextrose.
 Maintenance fluids are restricted to
60-70% of full maintenance.
 Hypotonic fluids not to be used
hyponatremia due to retention of free water
metabolism of dextrose from the solution.
 Losses from drains or nasogastric tubes

replaced with an isotonic fluid
0.9% NS with or with out added KCl.
 Loses should be measured hourly
replaced every 2-4 hrs
 All fluid intake to be recorded
 When oral intake = hourly maintenance rate
I.V fluids may then be discontinued.
Electrolyte imbalance
 Hyponatremia (Serum Na+<135mmol/L)

the most common electrolyte disturbance.
 May occur with any fluid regime
more so with hypotonic Fluids
 Types:
Hypovolemic / Hypervolemic / Isovolemic
Treatment:
 Symptomatic Hyponatremia
Infusion of 3% NS solution,
serum Na+ should be raised quickly
to a serum Na+ > 125mmol/L
 Asymptomatic Hyponatremia
Treated with enteral fluids
If not tolerated, with 0.9%NS solution I.V.
 Hypernatremia ( Serum Na+ >150 mmol/L )
 excessive water loss,

 restricted water intake,
 inability to respond to thirst
 Hypernatremia : Management
initial volume replacement with 0.9%NS
boluses of 20mL/Kg to restore normovolemia
 Complete correction
slowly over atleast 48hrs
prevent cerebral edema,
seizures and brain injury.
Hypocalcemia
 Serum calcium < 4.5 meq/L
 COMMON CAUSES:
1) Massive blood transfusion .
2) Acute hyperventilation
3) low albumin levels
 Symptoms :
 neuromuscular irritability ,
 weakness,
 paraesthesia,
 cardiac dysrhythmias
 prolonged QT interval in ECG
 carpopedal spasm
 Treatment :
 10% calcium gluconate 0.5ml/ kg to
 Maximum of 20ml over 10 mins
Conclusion
 Fluid therapy should be tailored

to the needs of the individual child.
 There is no replacement
for knowledge of basic physiology
and sound clinical judgment.
Conclusion
 Nothing can replace

a vigilant anaesthesiologist monitoring
the vital functions
close watch of the surgical procedures.
 Formulas for fluid therapy are guidelines

that need to be reevaluated
according to the child’s response.
Pediatric Regional Anesthesia
Caudal Anesthesia
Pediatric Regional Anesthesia
• How do children differ from adults?
• Why do regional anesthesia and analgesia
in children?
• Caudal Anesthesia and Analgesia
– Test dose
– Single dose local anesthetic or morphine
– Continuous Caudal/Epidural Infusion
• Spinal Anesthesia (if we have time)
How do children differ from adults?
• Psychologically and Parents

• Physiology
• Pharmacology
• Anatomy
Physiology
• Postoperative apnea in former premature
infants
• Implications
– Immature CNS and BBB
– Regional alone decreases risk
Pharmacology
• General and Implications
– Distribution
• CSF Volume
• Total Body Water
• Protein Binding
– Clearance
• Liver
• Renal
• Local Anesthetics
• Opioids
Approximate CSF Volume
16
14
12
10
8 ml/kg
6
4
2
0
Premature Full Term Child Adult
Cote´, A Practice of Anesthesia for Infants and Children

↑ CSF Volume: Implications
• Dosage of Drugs 200
– tetracaine 1 mg/kg + minutes

150
epinephrine for spinal
100
– bupivacaine 0.5-1.0
ml/kg for caudal 50
• Duration of action 0
– e.g. Spinal Tetracaine Adults

Infants
with epinephrine

Total Body Water
ICF
90%
ECF
80%
70%
60%
bodyweight
50%
% of
40%
30%
20%
10%
0%
<15 week Full Term 4-6 Adult

fetus months
Clin Pharm, 14:189, 1988

Protein Binding and Clearance
• Protein binding decreased at birth
– Albumin and α -glycoprotein levels decreased
– Adult levels at 1 year of age
• Clearance
– Liver: Phase I & Phase II decreased
– Renal: GFR 30% of adult
– Adult levels by 3-5 months of age
Clin Pharm, 14:189, 1988

General Pharmacology Implications
∀ ↑ CSF Volume  ↑ dose & ↓ duration

∀ ↑ Total Body Water  ↑ IV dose,
? ↓ toxicity
∀ ↓ Protein Binding  ↑ %drug available
 ↑ toxicity
∀ ↓ Clearance  ↑ t1/2  ↑ toxicity
Local Anesthetics
• BE CAREFUL with repeated dosing and infusions
• Neurologic symptoms > cardiac symptoms
– May not be able to illicit early neurologic symptoms in
small children
– First sign may be a grand mal seizure
• Case Reports of Toxicity with Infusion
– 4 children, 1 neonate
– Children all presented with grand mal seizures
– Neonate presented with cardiac arrest
Anesth Analg, 75:164, 1992; Anesth Analg, 75:284, 1992; Anesth Analg, 75:287, 1992
Opioids
• Morphine's t1/2 in neonates twice of adults
– Approaches adult by 2-4 months
• Implications: BE CAREFUL with opioids
and infants
• Recommendation for opioids
– For IV, <6 months of age  consider apnea
monitoring
– For CEI, <12 months of age  no fentanyl
Anesthesiology 66:1389, 1987

Anatomy

Why Regional Anesthesia and
Analgesia in Children?
• Regional Anesthesia only
• Combined Regional and General Anesthesia
• Contraindications
Regional Anesthesia Only!
• Reduce risk of postoperative apnea in former
premies
– Regional anesthesia alone will reduce risk of
postoperative apnea
– Still need to monitor overnight
– Techniques
• Caudal: 0.25% Bupivacaine (1ml/kg) + Clonidine (1 mcg/kg)
• Spinal: Tetracaine, surgical anesthesia for 60-90 minutes
• In other age groups, difficult to do regional alone
Anesthesiology 101:A1470, 2004

Combined Regional and General Anesthesia
• Usually regional anesthesia for

postoperative analgesia
• Types
– Single dose caudal
– Continuous Epidural/Caudal Infusion
– Peripheral nerve blocks
– Field blocks
– Local infiltration
Combined Regional and General Anesthesia:
Indications
• Malignant Hyperthermia
• Avoid need for opioids
– Sedation or respiratory depression
– DSU patients
• Better analgesia?
• for CEI
– Pulmonary disease (cystic fibrosis, rib fractures)
– Bladder surgery
– Abdominal &/or thoracic surgery
Contraindications to Regional
Anesthesia in Pediatrics
• Parental refusal
• Need for intact sensory system for
postoperative evaluation
• Sepsis
• Bleeding disorder
• Vertebral malformation or previous surgery
• Allergy
Pediatric Regional Anesthesia:
Neuroaxial Techniques
• Caudal anesthesia and analgesia
– Single dose local anesthetic
– Morphine
– Clonidine
– Continuous infusion
• Spinal anesthesia
Caudal Anesthesia – Technique
Caudal Anesthesia
Caudal Anesthesia
Caudal Anesthesia
Needle or Angiocath
Caudal Anesthesia
Where can it go?
Caudal in a …
http://www.cvm.okstate.edu/~users/aerrane/mandsagr/www/vms5422/lect22.htm
Single Dose:
Local Anesthetic Volume
• Traditional
– 0.05 ml/seg/kg
– 0.5 ml/kg  T10
– 1.0 ml/kg  T6
• For longer duration or lower concentration
– 1.5 ml/kg  T2

Single Dose:
Concentration of Local Anesthetic
• Balance analgesia with risk of motor block
• 0.25% Bupivacaine (max 1 mg/kg)
– Excellent analgesia
– Risk of some motor block
– Shorter duration cases
– Recommend: patients < 18 months of age
• 0.175% Bupivacaine (max 1.5 mg/kg)
– Less motor block with good analgesia
– Higher levels
– Longer duration
– Mix 10 ml = 7 ml 0.25% + 3 ml NS
Single Dose:
Caudal Morphine
• 30 – 40 mcg/kg
– Provides analgesia for 12-24 hours
– No respiratory depression in over 500 children
– Nausea incidence similar to general anesthesia
• Less labor intensive
• Does not require special pain service
• Side Effects
– Nausea
– Itching
– Propofol therapy single dose
• Do not need to go to PICU
J Clin Anesth 7:640, 1995
Local with Clonidine
• Clonidine in adults as oral sedative or
adjunct to spinal or epidural
• Enhances and increases the effect of single
shot bupivacaine caudal
• Risk: sedation with > 1mcg/kg
• At UTMB, we use for caudal alone for
premies and hernia repair

Awake Caudals in Neonates

Caudal/Epidural Anesthesia and Analgesia:
Continuous Infusion
• Technique and Dose
– Caudal
• 16g angiocath with 19g epidural catheter
• Thread up to thoracic level
• Guard with clear steridrape
– Epidural-lumbar
• Use LOR to saline and continuous pressure method
• If thread up to thoracic level, need epidurogram
– Initial Dose: 0.05 ml/seg/kg

Caudal/Epidural Anesthesia and Analgesia:
Continuous Infusion Rates and Types
• Rates
– <1 yoa: 0.1 to 0.2 ml/kg/hr
– >1 yoa: 0.1-0.4 ml/kg/hr
– *less than 0.5 mcg/kg/hr fentanyl to start
• Types
– <1 yoa: 0.1% bupivacaine
– >1 yoa: 0.1% bupivacaine + 3 mcg/ml fentanyl
Anesth Analg, 75:164, 1992

Continuous Caudal/Epidural Infusion:
Side Effects and Treatment
Naloxone*
Itching Diphenhydramine
0.5-2 mcg/kg
Nausea Metoclopramide
avoid sedating drugs
Naloxone
Urinary Retention Straight Cath prn Naloxone
Sedation Turn Down Infusion

Respiratory Naloxone
Depression 10 mcg/kg
*If infusion has fentanyl, then turn down infusion
& may use naloxone

Pediatric Regional Anesthesia:
Goals to Understand
• Identify differences between adults and
infants
• When indicated and contraindicated
• Techniques
• Side Effects and Complications
Spinal Anesthesia
• RARELY done
• Technique
– IV access
– 1.5" 22g beveled needle
• Dose
– Tetracaine 1 mg/kg and "whiff" (0.02 ml)
epinephrine
Approximate Distance:
Skin to Subarachnoid Space
50
40
30
MILLIMETERS
20
10
0
1 yr 3 yr 5 yr 10 yr 18 yr
Premie
Newborn5 months

Spinal Anesthesia
Positioning

Spinal Anesthesia
CSF Returns

Spinal Anesthesia
Injection

Spinal Anesthesia
• Complications
– No hypotension seen in children under 6 years of age
– If blood encountered, difficult to identify CSF
• Limitations
– Procedure
– Duration 45 minutes
– Surgeon
• Pearls
– Sugar Nipple
– Do not flex head
– Bovie Pad
Spinal Anesthesia
Bovie Pad Placement

Pediatric Anesth

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Pediatric Anesth

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Pediatric Anatomy, Physiology &

• The functioning heart grows & develops at the

– {FACTORS FACILITATING CLOSURE OF D.A. ;:: Incr

• {{Patent DV=> Decr delv of drugs to liver, and thrfr may

(incr in heart size initially is mainly b coz of

Evidence has also been forthcoming to suggest that intra

The low compliance of the ventr myocardium in the NN limits the

*Tendency towrds Biventr Failure

PT: 90-100 ml per kg

Since, 2,3 DPG binds poorly to γ chains of Hb F, Hb F has ↑ed

PT=15-18, FT=19.4, 8-12 mnths=31, Adult:27.7

(low p50 optimises uptake of O2 from placenta, but it prevents

NN have horizontal noncalcified ribs== Decrs A-P

THRFORE MORE CHANCES OF MUSCLE FATIGUE

Cm incr with incr in lung size.

• Ventilatory resp to hypoxia is complex:

0-3 weeks: vent resp to hypoxia dep on temp.(via perph recps)

After 3 weeks: decr in O2.. Increases ventln irresp of temp.

Resp centre is affected by reflexes and proprioceptive

:::::::: Heads paradoxical resp (insp resp to partial infln

::::::::Hering Breur Reflex (initiation of passiv ehaln

Chin is retrognathic.. (Diff BMV)

– During quiet breathing the resistance through the nasal

• Lymphoid tissue is scant in upper Aw of NN, thrfr

– The vocal cords of the neonate are slanted so that the

But, recent studies shows that the narrowest part in

• 3 mths :70% " 35% 35%

• Infant: 70 % 30% 40%

• Ad: 60% 20% 40%

– Higher dose of water soluble drug is needed due to

RESULT: a) LOW GFR

• immature renal function at birth

adult : max. 1200 mOsm/kg

↑free H2O clearance :

Newborn kidney has limited

• PT(1-3d) • < 20 mg%

• ≥ 4d (FT/PT) • < 40 mg%

(Rx: 0.5-1 g/kg i.v. gluc bolus f/b

Activity of phase II rns, are mainly conjugative

1st day : pH: alkalotic

Ability to coordinate swallowing with resprn fully

Also Neuro Endocr Axis in PT is also well

Thrfore, both PT and FT require complete analgesia and

1. Soft and pliable cranium

1. Large BSA relative to Body Wt.

– This is intact in the newborn, but, is only

– NEUTRAL TEMPERATURE: defined as Adult 28 1

– CRITICAL TEMP: It is that ambient

{ Mtb of Brown Fat is stimulated by Nor Epinephrine and

•There are age related differences in MAC of inhalation

Fluid Management in Infants and

Renal function is markedly diminished

 Urine Concentrating Capacity

 Increased Free Water Clearance

 Thus the ability to handle

 Its more so in the premature baby

Fractional Excretion of Na+ is elevated in

 Negative sodium balance

 Low systemic arterial BP

GFR 14 40.6 65.8 77 96 125

Infants and neonates are

Cardiac output is very dependent of HR

 The hallmark of intravascular fluid depletion