1. Improve outcomes in pediatric anesthesia
Presented by :Muhammad Hamdy
Lecturer of anesthesia -Ain Shams University

2. Our GOAL

3. Are we practicing safe pediatric anesthesia?

4. “Safe and effective anesthesia for pediatric undergoing surgery is one of the most challenging tasks presented to anesthesiologist.”
1`````````````````````

5. Knowledge
Continuous practice
Adequate monitoring
Outcome

6. Anesthesia-Related Factors
Cardiac
Arrest
Anesthesia-Related Factors
Medication 18% (ASA I,II)
Respiratory 27%
Cardiovascular 41%

7. Cardiovascular 41% Hypovolemia with blood loss 12% Air embolism 2%
Other CV 6%
Unclear CV mechanism 13%
Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007

8. Alarm Signs of Hypovolemia under Anesthesia
Hypotension (low for age, narrow pulse pressure, vary with respiration)
Persistent tachycardia
Capillary filling not brisk
Skin mottling, cold extremities
Reduced urine output
Jenkins&Mathur,2011 15 15 18

9. Respiratory 27% Airway obstruction-laryngospasm 6%
Difficult intubation 1%
Bronchospasm 2%
Pneumothorax 1%
Aspiration 1%
Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007

10. Medication 18% (more in ASA I,II)
Halothane induced CV depression 5%
Sevoflurane CV depression 3%
Allergic reaction 1%
Intravascular injection of local anesthetics 1%
Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007

11. Five Golden Rules of Safe Injection of Local Anesthetics
1- Aspirate before injection.
2- Give test dose 1-2 ml with epinephrine 1µ/ml→tachycardia)
3- Slow injection rate < 10 ml/min → high plasma level
4-Verify usual resistance throughout injection
5- Repeat aspiration every 5 ml at least
Aboulghar e.a. Hum. Reprod 2011

12. Anesthesia-Related. kinked or plugged ET tube 1%
Inadequate peripheral venous access 22%
Central catheter (pneumoth., hemoth.) 3%
Breathing circuit 1%
Anesthesia-Related Cardiac Arrest in Children Bananker et al, Anesthesia & Analgesia, August 2007

13. Prediction or anticipation of potential complications is crucial to improve outcomes in pediatric anesthesia.

14. Anesthesia During the First Year of Life

15. Neonatal Anesthesia Children < 1 year old have more complications:
I. Oxygenation
II. Ventilation
III. Airway management
IV. Response to volatile agents and medications
Stress response is poorly tolerated
Consider:
1. Organ system immaturity
2. High metabolic rate.
3. Ease of miscalculating a drug dose
Schenker and Weinstein, 2011

16. Neonatal Anesthesia Be aware of: Sudden changes in hemodynamics
Unexpected responses
Unknown congenital problem

17. Cardiac output is rate dependent ((can’t increase stroke volume
Immature baroreceptor reflex and limited ability to compensate for hypotension by increasing heart rate. They are more susceptible, to the cardiac depressant effects of volatile anesthetics

18. Hypovolemia with blood loss accounts for 12% of causes of cardiac arrest in OR with almost half of it due to under estimation of blood loss
Anesthesia-Related Cardiac Arrest in Children: Bananker et al, Anesthesia & Analgesia, August 2007

19. Immature hepatic function (drug dosing intervals &maintenance)
Immature renal function (poor toleration of fluid restriction/overload)
Golan et al, 2010

20. Age-specific considerations Fast desaturation
Low FRC, high closing volume, highly compliant airways► atelectasis
High oxygen consumption + can’t do forced inspiration ► increase R.R. ►high work of breathing
Diaphragmatic breathing► easily fatigue (less type I muscle fibers)►fast desaturation
Schenker and Weinstein, 2011

21. How Long Pre-oxygenation?

22. (Morrison JE et al: Pediatric Anaesthesia2008:8;293)
60 seconds 6L/min (gives seconds before desaturation)
(Morrison JE et al: Pediatric Anaesthesia2008:8;293)

23. Spontaneous Vs controlled?
-Spontaneous: more than 6 mos, less than 30 min
Pressure Vs volume control?
Pressure control: First few days, premature
Volume control: surgical manipulations interfere with ventilation
Peep 3-5 is routine
“ Whatever the technique, an expired tidal volume & PIP should be tailored to the desired levels”
Schenker and Weinstein, 2011

24. Competent nociceptive system
AVOID
(nonanalgesic practice)
AVOID

25. Bosenberg AT et al, Pediatr Surg Int2010:7, 289
“The use of light general volatile anesthetic with a central or peripheral nerve block has proved to be of great benefit in neonatal surgery”
Bosenberg AT et al, Pediatr Surg Int2010:7, 289

26. Monitoring equipment

27. Monitoring equipment
ECG
NIBP
ETCO2
Pulse oximetry
Temperature

28. Monitoring equipment precordial stethoscope esophageal stethoscope
CVP (vasoactive drugs)
Direct BP (accurate, intravascular volume status)

29. Monitors Predicting Complications .
Webb et al,2011: The Australian Incident Monitoring Study

30. Trained Anesthesiologist
Prediction of complication
Adequate monitoring
Outcome

31. THANKS