A short presentation covering most important anatomical differences along with physiological difference of pediatric population from adult. Also covers important aspects of anaesthesia consideration in pediatric patients. I specifically made this presentation by using morgan and miller books.

1. ANAESTHESIA IN
PEADS
BY DR SAUD ABBAS
PG-III
KTH, MTI

2. CONTENTS
 Anatomical Changes In Peads Patients
 Physiological Changes In Of Peads Patient
 Thermoregulation
 Age-related Changes In Vital Signs
 Approximate MAC 1 Values For Pediatric Patients
 Fluid Management In Peads Patient
 Fasting Recommendations
 Blood In Different Age Groups
 How To Calculate Appropriate Ett Size In Peads Pateint
 Case study

3. Anatomical Changes In Peads Patients

5. Airway
 Head size is greater in relation to the body
 Angle of the jaws greater
 Dimension of the upper airway are effectively narrowed by large
tongue
 Epiglottis in infant is longer, stiffer and U shaped
 Larynx is higher: C3/4 (C5/6 in adults)
 Larynx lies more anteriorly
 Cricoid ring is the narrowest part
 Trachea is short 4-5cm and narrow

6. Physiological Changes In Of Peads Patient

7. Cardiopulmonary System
 In the CVS system the capacity of the heart to increase
cardiac output by increasing stroke volume is limited.
 Cardiac output increases predominantly by increasing
heart rate
 The limbs are smaller in relation to the body
 This means that there is less blood volume to mobilize
from the periphery in response to hypovolemia.
 Infants have less reserves.

8. Surface area to body ratio
 A large surface area to body ratio is associated with increased heat loss.
 All infants are at a greater risk than adults or larger children of hypothermia
 The need to maintain body temperature via heat production results in a higher
metabolic rate and higher tissue oxygen demand. Desaturation occurs quicker
 The higher BMR is associated with higher resting heart rate and respiratory rate.

10. Thermoregulation
 Children are very prone for hypothermia because of their decreased ability to
produce and conserve heat and increased heat loss due to large body surface area.
 The only mechanism for heat production is metabolism of brown fat which is
special fat present in posterior neck, interscapular and vertebral areas and around
kidneys and adrenal glands.
 To prevent hypothermia the operation theater temperature should be maintained at
28°C (usually maintained at 21°c for adu lts).

11. Age-related Changes In Vital Signs

12. Approximate MAC 1 Values For Pediatric
Patients

13. Fluid Management In Peads Patient
Maintenance:
requirements for pediatric patients can be determined by the “4:2:1 rule”:
4 mL/kg/h for the first 10 kg of weight,
2 mL/kg/h for the second 10 kg,
1 mL/kg/h for each remaining kilogram.
 A solution such as D 5 ½ NS with 20 mEq/L of potassium chloride provides
adequate dextrose and electrolytes at these maintenance infusion rates.
 D 5 and N/S may be a better choice in neonates because of their limited ability to
handle sodium loads. Children up to the age of 8 years require 6 mg/kg/min of
glucose to maintain euglycemia (40–125 mg/dL)
 prematureneonates require 6–8 mg/kg/min.

14. Fluid Management In Peads Patient
Deficits
 In addition to a maintenance infusion, any preoperative fluid deficits must be replaced. For
example:
5-kg infant has not received oral or intravenous fluids for 4 h prior to surgery, a deficit of 80 mL has
accrued
 (5 kg × 4 mL/kg/h × 4 h). In contrast to adults, infants
 respond to dehydration with decreased blood pressure and without increased heart rate.
 Preoperative fluid deficits are often administered with hourly maintenance requirements in
aliquots of 50% in the first hour and 25% in the second and third hours. In
the example above, a total of 60 mL would be given
 in the first hour (80/2 + 20) and 40 mL in the second
 and third hours (80/4 + 20). Bolus administration of dextrose-containing solutions is avoided to
prevent hyperglycemia.

15. Fasting Recommendations

16. Blood In Different Age Groups
 Blood volume of premature neonates (100 mL/kg)
 full-term neonates (85–90mL/kg)
 infants (80 mL/kg) is proportionately larger than that of adults (65–75 mL/kg).
 An initial hematocrit of 55% in the healthy full-term neonate gradually falls to as
low as 30% in the 3-month-old infant before rising to 35% by 6 months.
Hemoglobin (Hb) type is also changing during this period: from a 75%
concentration of HbF (greater oxygen affinity, reduced Pa o 2 , poor tissue
unloading) at birth to almost 100% HbA (reduced oxygen affi nity, high Pa o 2 ,
good tissue unloading) by 6 months.

17. How To Calculate Appropriate ETT Size
In Peads Patient
 12 + Age/2 = Length of tube (in cm)
 4 + Age/4 = Tube diameter (in mm)
For example, a 4-year-old child would be predicted to require a 5-mm tube. This
formula provides only a rough guideline, however.
Exceptions include:
 premature neonates (2.5–3 mm tube)
 full-term neonates (3–3.5 mm tube).
 newborn takes a 2.5- or 3-mm tube.
 5-year-old takes a 5-mm tube. It

19. MANAGEMENT OF
NEONATAL
SURGICAL
EMERGENCIES

20. Diaphragmatic Hernia
Diaphragmatic Hernia:
 It results from incomplete closure of diaphragm
 leading to herniation of abdominal contents in thorax resulting in:
 pulmonary hypoplasia,
 pulmonary hypertension,
 hypoplasia of left ventricle,
 Prognosis is very poor.

21. Anesthetic Management
 After pre oxygenation awake intubation is done.
 Bag and mask ventilation is contraindicated (as it will increase the distension of
bowels leading to more compression of lung).
 Positive pressure ventilation should be done with airway pressure< 20 cm H20
otherwise
 pneumothorax can occur in hypoplastic lung.
 If available then ventilate with high frequency oscillatory ventilation.
 Anesthesia is maintained on oxygen and low dose volatile anesthetics or opioids
like fentanyl.
 Nitrous oxide is contraindicated as it can diffuse into gut loop causing their
distension and further compression of the lung.
 Postoperative elective ventilation is often required.

22. Tracheosophageal Fistula

23. Tracheosophageal Fistula
Anesthetic Management
 Rule out associated abnormalities like atrial septa defect (ASD), ventricular septal
Defect (VSD), tetralogy of Falot, coarctation of aona.
 Nurse the baby in propped up position to
 minimize gastric regurgitation.
 Aspirate the upper blind pouch of esophagus to remove secretion from it.
 Ventilation with bag and mask is contraindicated
 as air can reach stomach through
 fistula causing gastric distension and aspiration.
 Intubation can be awake or after intravenous anesthetic.
 The position of tube is most important; it should be below the fistula but above the
carina.
 These patients are very vulnerable for hypoxia as there occur significant V I Q
mismatchin lateral position.

24. Pyloric Stenosis (Intestinal
Obstruction)
 Due to repeated vomiting the patients with pyloric stenosis are
dehydrated with hypokalemic, hypochloremic alkalosis
 therefore, metabolic, fluid and electrolyte correction must be done before
taking them patient for surgery.
 Either awake intubation or rapid sequence
 intubation (crash intubation with Sellick's maneuver) is performed.
 Ventilation with bag and mask is contraindicated
 (can cause aspiration).

25. Thank You for your time