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

Our GOAL

Are we practicing safe pediatric anesthesia?

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

Knowledge Continuous practice Adequate monitoring Outcome

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

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

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

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

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

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

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

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

Anesthesia During the First Year of Life

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

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

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

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

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

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

How Long Pre-oxygenation?

(Morrison JE et al: Pediatric Anaesthesia2008:8;293) 60 seconds 6L/min (gives 80-90 seconds before desaturation) (Morrison JE et al: Pediatric Anaesthesia2008:8;293)

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

Competent nociceptive system AVOID (nonanalgesic practice) AVOID

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

Monitoring equipment

Monitoring equipment ECG NIBP ETCO2 Pulse oximetry Temperature

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

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

Trained Anesthesiologist Prediction of complication Adequate monitoring Outcome

THANKS