1. Pediatric Perioperative Concepts
Emily Olsen, MD
Pediatric Anesthesiology
Denali Anesthesia, P.C.
June 20, 2016
----- Meeting Notes (6/19/16 12:41) -----
Several different peds related subjects
Overview
Happy to expand, or answer individual questions

2. Disclosures
None

3. Learning Objectives Knowledge Review NPO guidelines
Premedication, PPIA
Types of anesthesia induction
IV access
Basic developmental stages
Neonatal concerns
Common pediatric problems
Pediatric airway
Laryngospasm

4. Review NPO guidelines 2, 4, 6, 8 rule 2 hours for clears
4 hours for breast milk
6 hours for formula, other milk, or light meal
8 hours for full meal

5. Premedications Who? What, how? Why? > 6 months of age
Midazolam (oral, intranasal)
Onset
Risk paradoxical reaction
How to give
OSA, PACU stay
Ketamine (oral, intranasal, IM)
+/- midazolam and glycopyrrolate
Dexmedetomidine (Precedex) (intranasal)
Monitoring?
Why?
Separation anxiety, trauma prevention, facilitate induction and/or IV, and/or primary sedative
----- Meeting Notes (6/19/16 12:41) -----
Start with why.
Who - peak at 8 months to early school age.
Some older children are excited and curious about the experience and don't need a premed.
Peak for midazolam oral - 53 min, nasal 10 min
----- Meeting Notes (6/19/16 12:45) -----
**Nasal is a more concentrated midazolam - less volume
----- Meeting Notes (6/19/16 12:50) -----
Midazolam (in any form) can cause hiccups

6. Parental Presence at Induction of Anesthesia (PPIA)
Generally done only if no premed is given (no added benefit with both)
Distraction as a powerful tool
Set expectations and choose wisely!
Case of grandparent running off with unconscious child …. Have someone assigned to escort the parent/guardian out. Avoid if parent/guardian is anxious.
----- Meeting Notes (6/19/16 13:11) -----
CHOOSE WISELY

7. Types of Inductions Inhaled (mask induction) Intravenous (IV)
Sevoflurane +/- N2O
<40 kg
Intravenous (IV)
EMLA
+/- N2O, and/or premed
Full stomach, trauma, risk of malignant hyperthermia, >40 kg
Intramuscular (IM)
Ketamine +/- midazolam and glycopyrrolate “ketamine dart”
If not a good candidate for IV or inhaled induction

8. IV access
Umbilical lines
Hand, saphenous, scalp

9. Basic Developmental Stages
Age 8 months – 4 years: Peak for separation anxiety. Underdeveloped coping strategies
4 – 8 years: Separation anxiety. Magical thinking. Body integrity. Improved coping in new situations.
8-12 years: Fear of pain, body image/mutilation, loss of control, not waking up or waking up during surgery
12+ years: Similar to 8-12 year olds. Fear of the unknown. Try to behave like and “adult”

10. Neonatal Concerns Very sensitive to opioids
At risk of apnea (>15 sec) and bradycardia
Fixed stroke volume (don’t tolerate bradycardia)
CO = SV x HR
Immature organ function (slow to wake, no NSAIDs)
Dextrose
Risk oxygen toxicity
High oxygen consumption
Faster desaturations
----- Meeting Notes (6/19/16 13:21) -----
Neonate <1 month old
Infant <12 months old

11. Common Perioperative Problems
Monitoring
Physical exam!
Laryngospasm*
Emergence delirium
“dissociated state of consciousness in which children are inconsolable, irritable, uncompromising, and/or uncooperative.”
Highest incidence at age 1 – 5 years
Lasts minutes. Resolves spontaneously.
Distinguish from pain, “bad behavior” or immature coping
Pain management
Blocks, caudals/epidurals, spinals, opioids and other analgesics
Anesthesia Neurotoxicity?
Period of vulnerability?
Rectal APAP a good option up until school age. Oral (liquid) APAP another good pediatric option. No NSAIDs if <6 months old. Pediatric patients (neonates, OSA especially) more sensitive to opioids. Codeine as a poor choice for kids.

12. The Pediatric Airway

13. Forms of Airway Obstruction
Upper airway obstruction
Macroglossus
Enlarged tonsils, adenoids
Laryngospasm*
Vocal cord spasm
Lower airway obstruction
Subglottic edema
Tracheal stenosis
Tracheomalacia
Bronchospasm
Mucous plugs
Anatomic from mouth to trachea

14. Laryngospasm Reflex closure of false and true vocal cords
Complete laryngospasm:
Chest movement but silent with no air movement and no ventilation possible
Partial laryngospasm:
Chest movement with stridulous noise (stridor) with a mismatch between the patient’s respiratory effort and the small amount of air movement
Incidence: %
Pediatric laryngospasm is an anesthetic emergency. It is a relatively common phenomenon in un-intubated patients that most commonly occurs during induction or emergence from anesthesia. It is defined as glottic closure due to reflex constriction of the laryngeal muscles, resulting in complete cessation of air movement or noisy breathing. In the case of complete laryngospasm there will be silent chest movement with no air movement possible. Incomplete, or partial laryngospasm, is incomplete closure of the vocal cords that leaves a small gap posteriorly that is sufficient to permit minimal air movement associated with inspiratory stridor. Some argue that partial laryngospasm is not laryngospasm at all, but for treatment purposes this is a moot point as both are managed very similarly. The frequency of laryngospasm in children varies anywhere from 0.4% to 10%, depending on multiple factors.

15. Laryngospasm

16. Laryngospasm – Risk Factors
Young age (infants and young children)
History of reactive airway disease (eg. asthma)
Exposure to second-hand smoke
Recent URI (< 2 weeks)
Airway anomalies
Airway surgery (eg. T&A, bronchoscopy)
Airway devices (ETT)
Stimulation during a light plane of anesthesia (IV)
Secretions in the oropharynx (eg. blood, saliva, gastric juice)
Inhaled anesthesia (vs. IV anesthesia)
Inexperienced anesthesiologist

17. Laryngospasm management
Deliver 100% oxygen via face mask with continuous positive pressure (CPAP)
Remove offending agent
Mandibular jaw thrust
Call for HELP as initial steps above are being taken
Anticipate need for pharmacologic intervention (propofol, succinylcholine)
Anticipate equipment needed (oral airway, nasal trumpet, LMA, ETT)

18. Skills Station: Mask ventilation
Most pediatric codes are from primary respiratory arrests
Pediatric patients are more likely to laryngospasm – positive pressure ventilation and jaw thrust are the first line treatment
Kids come in many different sizes!

19. Mask ventilation

20. Airway Equipment
Nasal trumpet
Oral airway