Pediatric Anesthesiology

▪General Guidelines for Pediatric Patients

General Guidelines

	Preemie	Birth	6 mo	1 yo	2 yo	3 yo	4 yo	5 yo	6 yo	7 yo	8 yo	10 yo	12 yo	> 15 yo
kg	1.5	3.5	7	10	12	14	17		20		25	33	40	50+
lb	3.5	7.5	15	22	26	31	37	40	44	49	55	73	88
SBP	40-60	50-70	60-110	60-115	65-115	75-125	80-120	80-120	90-120	90-120	94-130	95-135	100-140
Lowest accept SBP (age) 2 + 70
HR	120-180	100-145	110-180	100-130	90-120	90-120	80-110	65-135	70-115		60-110	60-100	55-105
RESP	55-60	30-50	25-40	25-40	20-30	15-25	14-25	14-24	14-22		13-20	13-20	10-16
Oral airway	0	0	1	1	2	2	3		3		4	4	5
ETT	2.5	3.0-3.5	3.5-4.0	3.5-4	4-4.5	4.5-5	5-5.5		5.5-6		6.0-6.5	6.0-6.5	6.0-6.5
											cuffed	cuffed	cuffed
LMA	1	1	1	1.5	2	2	2	2	2.5	2.5	2.5	3	3	4
Cuff volume	2-4 ml		7		≥10				14			20		30
DLEBT											26	26-28	32	35
Blade	0-1 Miller			1 Miller	1.5 Wis Hipple, 1 Phillips, 2 Miller, 1-3 MAC		1.5 Miller		2 Flagg		> 8 yo:	2 Phillips
	Miller				1 Phillips, 2 Miller, 1-3 MAC			2 Mac			2 Miller or 3 Mac
Vent bag	0.5 L		1 L			2 L				3 L
IVF		D5.2NS via syringe pump						Lactated Ringers…..>
NG/O	5F	5-8F	8F	8-10F	8-10F	8-10F	8-10F		10-12F		10-12F	14-18F	14-18F
2 blades, 2 handles, suction!! CPAP + 4 in child < 2 yrs old.
Approx. weight = 2× age + 9
ETT = age + 16 (or 18) / 4
ETT length = ETT size (calc) × 3; Distance with nasal: ETT × 4.
Response to hypoxia is biphasic: initial hyperpnea followed by depress of respirations in about 2 minutes. Bradycardia indicates hypoxia.

▪Pediatric Inhalation Induction

MAC Values for Common Inhaled Agents

Agent	Neonate	Infant	Child
Halothane	0.87%	˜1.0%	0.91%
Isoflurane	1.3	1.7%	1.6%
Des—bad indxn due to laryngospasm, great maintenance
Sevoflurane	3.3%	3.2%	2.5%

Textbook indxn: O₂ 2 L, N₂O 4 L, increase halothane in 0. 5% increments q 2-3 breaths.

We found the best is: O₂ 2 L, N₂O 4 L; Sevo 8% until IV start & BP decreases to WNL.

Uptake of inhaled anesthetics is more rapid in infants and children than adults. This is related to: increased minute ventilation, alveolar ventilation (esp. in relation to FRC—the alveolar/ventilation to FRC ratio in infants is about 5:1, adults is 1.4:1), distribution of CO, body composition (small body mass), and B:G solubility coefficients.

MAC decreased in neonates up to 1 month old

MAC increases in the first 6 mos of life and decreases thereafter

MAC increased in adolescents

▪General Information: Inhaled Anesthetics

Higher incidence of bradycardia, hypotension, and cardiac arrest during induction with infants.
Premature infants and neonates have limited baroreceptor reflexes. Anesthetics further these limits.
Halothane overdose: muffled heart tones, bradycardia, and hypotension are initial signs.
Desflurane and sevoflurane cause a high incidence of emergence delirium in pediatrics. Sevoflurane
also causes marked agitation following emergence unless fentanyl or midazolam used as premedication.
R-L shunts (Tetralogy of Fallot, transposition of great vessels, etc.) slows uptake of agents. Slow on and slow off.
L-R shunts (ASD,VSD, PDA, BT shunt) uptake is faster. Increase depends on size of shunt.
Pediatric gas leak at 15-20 cm H₂O airway pressures. No leak indicates oversized tube; excessive leak indicates inadequate ventilation.

Pediatric Medications

Medication	Dose
Premedication and Induction Agents, and Romazion
Glycopyrrolate	0.01 mg/kg IV (antisial) 0.04-0.1 mg/kg PO
Midazolam	0.1 mg/kg IV 0.15-0.2 mg/kg IM 0.2-0.3 mg/kg IN 0.5-1 mg/kg PO
Romazicon	> 1 yo: 0.01 mg/kg (0.2 mg max)
Ketamine	1-2 mg/kg IV 5 mg/kg PO/IM
Propofol	2-3 mg/kg
Etomidate	300 mcg/kg
Pentothal	4-7 mc/kg
Opioids and Pain Medications, and Naloxone
Fentanyl	1 mcg/kg/dose IV/IM 2 mcg/kg dose nasal O 30s, D 30-60m
Remifentanil	0.05-0.1 mcg/kg/min (pain) 0.25-0.4 mcg/kg/min (anes)
Morphine	0.05-0.1 mg/kg/dose IV/IM
Meperidine	0.5-1 mg/kg dose IV
Methadone	0.1-0.2 mg/kg IV load 0.05 mg/kg IV q 4-12 hrs
Hydromorphone	0.015 mg/kg IV q 4-6 hrs 0.03-0.08 mg/kg PO q 6 hrs
Naloxone	1-10 mcg/kg increments
Toradol	> 6 months: 0.5-1 mg/kg IV/IM Max 15 mg IV; max 30 mg IM
Tylenol	10 mg/kg PR
Muscle Relaxants (Intubating Doses)
Succinylcholine^*	2 mg/kg IV 4 mg/kg IM
Mivacurium	0.2 mg/kg IV
Rocuronium	0.6 mg/kg IV
Atricurium	0.5 mg/kg
Cisatriurium	0.1 mg/kg
Vecuronium	0.1 mg/kg
Pancuronium	0.1 mg/kg
NM Reversal^**
Neostigmine	0.07 mg/kg
Edrophonium	0.5-1 mg/kg
Glycopyrolate	0.01 mg/kg
	0.2 mg/cc = 200 mcg/cc = 20 mcg/0.1 cc
Atropine	0.02 mg/kg
	0.4 mg/cc = 400 mcg/cc = 40 mcg/0.1 cc
PONV Prophylaxis
Anzemet	0.35 mg/kg IV
Ondansetron	0.15 mg/kg
Metoclopramide	0.1-0.15 mg/kg
Dexamethasone	0.25 mg/kg
Droperidol	10-20 mcg/kg
Promethazine	0.25-0.5 mg/kg
Diphenhydramine	0.75-1 mg/kg
Hydrate
Antibiotics
Ampicillin	50 mg/kg
Cefazolin	25 mg/kg
Cefoxitin (Mefoxin)	30-40 mg/kg
Clindamycin	5-10 mg/kg
Gentamycin	1.5 mg/kg
Metronidazole (Flagyl)	15 mg/kg
Tobramycin	1 mg/kg IM
Vancomycin	10-20 mg/kg
^If have to give SCh, give atropine first to help prevent profound bradycardia/asystole. ^*Draw reversals in separate syringes.