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Hany El-Zahaby, MD.  Fear pain, threat of needles, parental separation, no experience to place.  “The greater understanding and amount of information.

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Presentation on theme: "Hany El-Zahaby, MD.  Fear pain, threat of needles, parental separation, no experience to place.  “The greater understanding and amount of information."— Presentation transcript:

1 Hany El-Zahaby, MD

2  Fear pain, threat of needles, parental separation, no experience to place.  “The greater understanding and amount of information available to the parents, the less anxiety and the better attitude reflected in the child”.  “Anesthesia is a type of deep sleep in which you feel no pain from surgery and from which you’ll definitely awaken”.  Smiling, eye contact, holding the child’s hand.

3  “A blood pressure cuff will check your blood pressure”  “ECG will watch your heart beats”.  “A stethoscope will continuously listen to the heart sounds”.  “A pulse oximeter will measure the oxygen in the your blood”.  “A carbon dioxide analyzer will monitor the breathing”.  Discuss anesthetic risks in clear terms.

4 Problems with neonatesMaternal history Hemolytic anemia, hyperbillirubinemia, kernicterus Rh - ABO incompatibility SGAToxemia - hypertension Sepsis, thrombocytopeniaInfection Hypoglycemia, birth trauma, LGA, SGA Diabetes Anemia, shockHemorrhage TEF, anencephaly, multiple anomaliesPolyhydramnions Renal hypoplasia, pulmonary hypoplasia Oligohydramnions Pelvic traumaCephalopelvic disproportion Hypoglycemia, congenital malformation, SGA Alcoholism

5 Anesthetic implicationsQuestions to askSystem Irritable airway, bronchospasm, medications, atelectasis Subglottic narrowing Postoperative apnea Cough, asthma, recent cold Croup Apnea / bradycardia Respiratory Septal defect, airbubbles Right to left shunt Tetrology of Fallot Coarctation, renal disease Valvular heart disease CHF, cyanosis Murmur Cyanosis Squatting Hypertension Rheumatic fever Exercise intolerance Cardiovascular Medications Intracranial hypertension Aspiration, ER, HH Relaxant sensitivity, MH Seizures Head trama Swallowing incoordination Neuromuscular disease Neurologic

6 Electrolyte imbalance, dehydration, full stomach Anemia Anemia, hypovolemia Full stomach Drug metabolism / hypoglycemia Vomiting, diarrhea Malabsorption Black stools Reflux jaundice Gastrointestinal / Hepatic UTI, diabetes, hypercalcemia State of hydration Evaluate RF Frequency Last urination Frequent UTI Genitourinary Hypothyroidism, DM Hypoglycemia, adrenal insuff. Abnormal development Hypoglycemia, steroid Endocrine / metabolic Transfusion Coagulopathy Hydration, transfusion Anemia Bruising SCD Hematologic Drug interactionMedicationsAllergic Teeth aspiration, SBE prophylaxis Loose teethDental

7  Hospitalization, immunization, illnesses, medications  Prematurity, apnea, bradycardia  Croup, prolonged intubation  Records, previous anesthesia and surgery

8  Prolonged paralysis with anesthesia (pseudocholinesterase deficiency)  Unexpected death (sudden infant death syndrome, MH)  Genetic defects  Muscle dystrophy, cystic fibrosis, SCD, hemophilia, von Willebrand disease (familial)  Allergic reactions  Drug addiction (drug withdrawal, HIV)

9  Children interaction with parents and health care givers  Pallor, cyanosis, sweating, jaundice, apprehension, pain, signs of previous operations  Signs of URTI  Signs of respiratory difficulty: Nasal flaring grunting, stridor,retractions, wheezing  abdominal distension.  Congenital abnormalities.

10  Warm the stethoscope and your hands before examination  Fever, loose teeth, micrognathia, nasal speech  Heart murmurs  Edema  Signs of dehydration

11  CBC: <6M, hemoglobinopathy, former premature.  Bleeding profile: reconstructive surgery  Electrolytes, RFT, ABG,ECG, echo, LFT, anticonvulsants levels, digoxin level, PFT when appropriate

12  Hypoglycemia is unlikely in healthy pediatric patients, only in debilitated, poorly nourished child with metabolic dysfunction.  Clear fluids:2h  Breast milk: 4h  Milk formula & solid food:6h  High risk patients: GERD, previous esophageal surgery, difficult airway, morbid obesity (Cimetidine 7mg/kg, metoclopramide 0.1 mg/kg, clear antacid 30 ml)

13  The most common problem in pediatric anesthesia  4 positions suctioning for fluids  Prepare 2 laryngoscopes, 2 suctions  IV access  Atropine 0.02 mg/kg, preoxygenation, STP 5-6 mg/kg or propofol 3 mg/kg or ketamine 1-2 mg/kg (hypovolemia), succinyl choline 1-2 mg/kg.  Sellick maneuver?  Consider fasting hours only till time of injury.

14  Chronic anemia?  HCT? 25? Risks of blood transfusion to raise it to 30 is unjustified.  Minor surgery?  Elective with significant anticipated blood loss?  Anemic former premature needs postoperative apnea monitoring.

15  Allergic rhinitis or URTI? (seasonal, clear discharge, no fever, not a contraindication for surgery)  Accept: clear nasal discharge, mild cough, no wheezes or crepitus, no fever, active and happy child, clear rhinorrhea, clear lungs, older child  Postpone: fever 38 0, malaise, cough, poor appetite, just developed symptoms last night, lethargic, ill-appearing, wheezes, purulent nasal discharge, lower airway affection, leucocytosis, child <1 year, ex-premie, history of reactive airway disease, major operation, endotracheal tube required  Keep: albuterol, succinyl choline, inhalation agent in oxygen  If postoned: how long?

16 Vaccine-driven adverse events (fever, pain, irritability) might occur but should not be confused with postoperative complications. Appropriate delays for the type of vaccine between immunization and anesthesia are recommended to avoid misinterpretation of vaccine-associated adverse events as postoperative complications. Likewise, it seems reasonable to delay vaccination after surgery until the child is fully recovered.

17  degree is without symptoms is not a contraindication to GA  Symptoms: rhinitis- pharyngitis - otitis media – dehydration or any other symptoms of impending illness  Emergency: paracetamol

18  SCT, SCD by hemoglobin electrophoresis?  SCD, Frequent sickler, morphine addiction?  Start IV fluids the night before with 1.5 times maintenance fluid volume  Keep warm, well oxygenated  Hematologic consultation (usually HCT 30 is targeted)

19  Extensive medical and surgical histories should be taken with great patience  Continue medications  Sedation: oral midazolam  Family member presence  If markedly scared: IM ketamine 3-4mg/kg, atropine 0.02mg/kg, midazolam mg/kg

20  Sick-low birth weight septic infants <1000 g with long oxygen therapy  No correlation with specific PaO2  Appear in infants with cyanotic heart disease who never received oxygen  Avoid hyperoxia under anesthesia?

21  “Neonates and especially ex-premature infants have a tendency toward periodic breathing that is accentuated by anesthetics, increasing the risk of postoperative apnea until approximately weeks post-conceptual age and require continuous monitoring of blood oxygen saturation and heart rate until 12-hours of apnea free period”.  Apnea  Apnea (1) central apnea, due to immaturity or depression of the respiratory drive; (2) obstructive apnea, due to an infant's inability to maintain a patent airway; and (3) mixed apnea, a combination of both central and obstructive apnea.

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24 Susceptibility to Central apnea is exacerbated by hypothermia, hypoglycemia, and hypocalcemia, anemia, opioids. Treatment: xanthines (caffeine & theophylline) ▲ Hct ▲ FiO 2 Never give caffeine & send the neonate home as being “safe now”. Even patients treated with naloxone require continuous monitoring of blood oxygen saturation and heart rate until 12- hours of apnea free period. Obstructive apnea is treated by changing the head position, inserting an oral or nasal airway, placing the infant in a prone position or by applying continuous positive airway pressure (CPAP)

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27  Chronic lung disease associated prolonged mechanical ventilation (barotrauma) & oxygen toxicity in a premature neonate with hyaline membrane disease.  Chronic hypoxemia-hypercarbia-abnormal functional airway growth-tracheomalacia-bronchomalacia-reactive airway disease- propensity toward atelectasis and pneumonia-increased pulmonary vascular resistance + IVH.  Commonly on diuretic/steroid therapy.  May need oxygen on transport to OR.  Allow adequate time for expiration.  Avoid ETT if possible.  Awake spinal/caudal/penile block.  Postoperative apnea monitoring.

28 With expansion of the lungs during the first breath, pulmonary vascular resistance decreases and blood flow to the lungs increases. Neonatal hypoxia, hypercarbia, or acidosis increase PVR & may result in a return to the fetal-type circulatory pattern with right-to-left shunt via the PFO or PDA (PA to AO). Persistent PDA after declining of pulmonary vascular resistance causes left to right shunt with pulmonary hypertension and increased ventilatory support. PDA is diagnosed by bounding peripheral pulses, a harsh systolic ejection murmur at the left sternal border and a large pulse-pressure, Echo. PDA is treated by indomethacin, coiling or surgical ligation.

29  Medication-schedule-possible interaction with anesthetic drugs.  Stress may reduce seizure threshold.  Continue all medications.  Emergency with missing 1-2 doses: no problem but if longer periods consider IV therapy.  Blood levels: seizure free with sub-therapeutic levels for one year.  Methohexital exacerbate temporal lobe epilepsy.

30  Avoid contaminating the line  Avoid sudden stoppage  Use infusion pump & decrease the rate by 33-50% (lower metabolic rate)  Monitor glucose, potassium, sodium, calcium, acid-base  Check proper IV line placement

31 Wheezing, ER visit, medications Continue all medications till morning of surgery Theophylline level microgram/ml Short term oral steroid therapy Minimal airway intervention ETT adaptors for metered dose inhalers better than simple spraying through ETT PaCO2 > 45 (incipient respiratory failure) Emergency: oxygen-hydration-SC epinephrine-aminophylline-ventolin- steroids-antibiotics

32 Is the child metabolic control acceptable? No ketonuria Normal serum electrolytes HbA1c <7.5 Choose protocol according to : Split-mixed insulin regimen (50%) Basal-bolus insulin therapy (Levemir 75%, Lantus 100%) once daily Insulin pump Oral agent + insulin for type 2 DM

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35 The calculation for insulin correction factor : 1. Divide 1500 by child's total daily dose (TDD). 2. Example: if TDD = 50 units, then insulin correction factor is 1 unit regular insulin to lower blood glucose by 30 mg/dL.

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42 PREOPERATIVE PROTOCOL FOR ALL PATIENTS: Hold oral hypoglycemics and morning doses of insulin Omit breackfast Child should arrive in the early morning First case of the day Labs needed: RBS, electrolytes,K.B Keep RBS <250mg/dl using SC rapidly acting insulin using correction method

43 A-FOR BASAL BOLUS INSULIN THERAPY (LANTUS)-(LEVEMIR) OR SPLIT MIXED DOSAGES If night dose was not given: give 75% of (levemir) or 100% of(lantus), 50% of (NPH) or (lantus) in split-mixed insulin regimen If given: Check RBS/h, if 250 give SC insulin using correction factor

44 B- INSULIN SC PUMP In procedures<2hrs continue SC pump at its usual rate with adminstration of additional SC units if needed In procedures >2hrs keep infusion regimen as follows – maint. Fluid (D10% + 1/2N.S)with Ins. inf.(1unit/ml)  <12kg-1unit/5gm dex.  >12kg-3gm dex. C-TYPE И D.M STOP oral hypoglycemics 24 hrs befor procedure Give 50% of NPH or lantus if used Control RBS intraoperative by SC regimen as usual

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