CHAPTER 57 Pediatric Anesthesia
1 What are the differences between the adult and pediatric airways?
Infant Airway | Significance |
---|---|
Obligate nose breathers, narrow nares | Infants can breathe only through their noses, which can become easily obstructed by secretions. |
Large tongue | May obstruct airway and make laryngoscopy and intubation difficult. |
Large occiput | Sniffing position achieved with roll under shoulder. |
Glottis located at C3 in premature babies, C3-C4 in newborns, and C5 in adults | Larynx appears more anterior; cricoid pressure frequently helps with laryngeal visualization. |
Larynx and trachea are funnel shaped | Narrowest part of the trachea is at the vocal cords; the patient should have an ETT leak of <30 cm H2O to prevent excessive pressure on the tracheal mucosa, barotrauma. |
Vocal cords slant anteriorly | Insertion of ETT may be more difficult. |
ETT, Endotracheal tube.
2 Are there any differences in the adult and pediatric pulmonary systems?
Pediatric Pulmonary System | Significance |
---|---|
Decreased, smaller alveoli | Thirteenfold growth in number of alveoli between birth and 6 years; threefold growth in size of alveoli between 6 years and adulthood |
Decreased compliance | Increased likelihood of airway collapse |
Increased airway resistance, vulnerability to smaller airways | Increased work of breathing and disease affecting small airways |
Horizontal ribs, pliable ribs and cartilage | Inefficient chest wall mechanics |
Less type 1, high-oxidative muscle | Babies tire more easily |
Decreased total lung capacity, faster respiratory and metabolic rate | Quicker desaturation |
Higher closing volumes | Increased dead-space ventilation |
3 How does the cardiovascular system differ in a child?
Newborns are unable to increase cardiac output (CO) by increasing contractility; they can increase CO only by increasing heart rate.
Babies have an immature baroreceptor reflex and limited ability to compensate for hypotension by increasing heart rate. Therefore they are more susceptible to the cardiac depressant effects of volatile anesthetics.
8 Describe the commonly used induction techniques in children
Inhalational induction is the most common induction technique in children younger than 10 years who do not have intravenous (IV) access. The child is asked to breathe 70% nitrous oxide (N2O) and 30% oxygen for approximately 1 minute; sevoflurane is then turned on. The sevoflurane concentration can be increased slowly or rapidly.
Rapid inhalational induction is used in an uncooperative child. The child is held down, and a mask containing 70% N2O, 30% oxygen, and 8% sevoflurane is placed on the child’s face. This unpleasant technique should be avoided if possible. Once anesthesia has been induced, the concentration of sevoflurane should be decreased.
Steal induction may be used if the child is already sleeping. Inhalational induction is accomplished by holding the mask near the child’s face while gradually increasing the concentration of sevoflurane. The goal is to induce anesthesia without awakening the child.
IV induction is used in a child who already has an IV line in place and in children >10 years. Typical medications used in children are thiopental, 5 to 7 mg/kg; propofol, 2 to 3 mg/kg; and ketamine, 2 to 5 mg/kg. EMLA cream (eutectic mixture of local anesthesia) applied at least 90 minutes before starting the IV infusion makes this an atraumatic procedure.
9 How does the presence of a left-to-right shunt affect inhalational induction and intravenous induction?
11 What other special precautions need to be taken in a child with heart disease?
The anatomy of the lesion(s) and direction of blood flow should be determined. Pulmonary vascular resistance (PVR) needs to be maintained. If the PVR increases, right-to-left shunting may increase and worsen oxygenation, whereas a patient with a left-to-right shunt may develop a reversal in the direction of blood flow (Eisenmenger’s syndrome). If a patient has a left-to-right shunt, decreasing the PVR may increase blood flow to the lungs and lead to pulmonary edema. Decreasing the PVR in patients with a right-to-left shunt may improve hemodynamics. Conditions that can increase shunting are listed in Table 57-5.
Air bubbles should be meticulously avoided. If there is a communication between the right and left sides of the heart (ventricular septal defect, atrial septal defect), air injected intravenously may travel across the communication and enter the arterial system. This may lead to central nervous system symptoms if the air obstructs the blood supply to the brain or spinal cord (paradoxical air embolus).
Prophylactic antibiotics should be given to prevent infective endocarditis. Recommendations for medications and doses can be found in the American Heart Association guidelines.