1. Anesthesia During the First Year of Life
Hany El-Zahaby, MD
Dept. of Anesthesia, Ain Shams University

2. “Safe and effective anesthesia for neonates & infants undergoing surgery is one of the most challenging tasks presented to anesthesiologist.”
Knowledge
Manual skills
Continuous practice +
Adequate monitoring ↓
Outcome

3. Anesthetic Considerations
during the first year of life
for surgeries
Age-specific considerations
Case-specific considerations

4. Age-specific considerations Airway differences –Infant Vs Adult
Big head , small body
Tongue/Epiglottis relatively larger
Glottis more superior, at level of C3 (vs C4 or 5)
Cricoid ring narrower than vocal cord aperture

5. 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

6. Age-specific considerations
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, therefore, to the cardiac depressant effects of volatile anesthetics (parasympathetic predominance)
Immature hepatic function (drug dosing intervals &maintenance)
Immature renal function (poor toleration of fluid restriction/overload)

7. Age-specific considerations
High volume of distribution of drugs
Temperature control (easily loose heat under GA) due to high surface area to body weight ratio, no shivering
Competent nociceptive system (nonanalgesic practice is no longer accepted)

8. Premedication
Atropine (10-20µ/kg IV, minimum 100µ) to counteract parasympathetic reflexes.
Pain (increments of morphine 10-20µ/kg IV up to 100µ/kg)

9. Monitoring FiO2, ECG, NIBP, ETCO2, Pulse oximetry, Temperature
Direct BP (accurate, intravascular volume status e.g. undulations with ventilation and reduced upstroke of the BP curve in case of hypovolemia)
CVP (vasoactive drugs)
Urine output (1 ml/kg/h)

10. How Long Pre-oxygenation?
60 seconds 6L/min (gives seconds before desaturation)
(Morrison JE et al: Pediatric Anaesthesia1998:8;293)
Inhalation VS Intravenous Induction?
IV access + hemodynamically stable→ STP 4-8mg/kg (prolonged emergence & postoperative apnea)- Propofol 3-3.5mg/kg
IV access + hemodynamically unstable → Ketamine 1.5-3mg/kg
Difficult IV access or compromised airway → Sevoflurane or halothane
Combined technique → (opioid + nondepolarizing MR + inhalation agent)

11. LMA VS ETT?
LMA: less than min
Size 1 ( 50% misplacement, NGT, small dose of MR, large dead space & hypercapnea, helpful for ex-premis with BPD)
ETT: longer surgeries
No awake intubation (very stressful/painful stimulus with suboptimal conditions)
Relaxation?
Succinyl choline (RSI) (higher doses than adults), large ECF volume
Nondepolarizing MR (similar doses as adults), sensitivity offset by large ECF
Deep inhalation anesthesia, disadvantages?

12. Technique? Oral Vs nasal? (lateral/prone/limited head access)
Straight blade- go deeper then withdraw
Level: term neonate (9cm oral/11cm nasal), 1 year 11-12cm
Leak pressure? 20-25cmH2O, affected by head position& MR
50% decrease in flow from size 3.5 to 3
Non-cuffed/cuffed: 8y (upper abdominal & thoracic surgery, poor lung compliance)
After intubation → VCM (40cmH2O/15 sec) or TRIM (30cmH2O/10 sec)

13. Spontaneous Vs controlled?
-Spontaneous: more than 6 mos, less than 30 min
Pressure Vs volume control?
-Pressure control: First few days, premature, respiratory distress or lung pathology
-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”

14. Maintenance:
Halothane/sevoflurane/isoflurane all depress baroreceptor reflex
Halothane depress the myocardium more
Halothane decrease the heart rate more
(Hypotension is treated by atropine & lowering halothane)
Sevo/Isoflurane decrease PVR more (treated by 5-10ml/kg fluid bolus)
Nitrous oxide 60% decreases MAC of halothane, isoflurane & sevoflurane by 60%, 40% & 25% respectively
Narcotics: -Fentanyl 1-2µ/kg if regional block was done
-Fentanyl based anesthesia for prolonged major surgery with postoperative ventilation

15. “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 Int, 1992:7, 289
Larsson BA et al, Anesth Analg 1997:84, 501

16. Intraoperative Volume Replacement
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: Update from the Pediatric Perioperative Cardiac Arrest Registry Bananker et al, Anesthesia & Analgesia, August 2007

17. Assessment of dehydration
Severe
(150ml/kg)
Moderate
(100ml/kg)
Mild
(50ml/kg) 15
++irrit/lethargic
Intense
Parched
Absent
Sunken
Increased
<0.5ml/kg/hr 10
Irritable
Dry +
<1ml/kg/hr 5
Normal
Slight
Flat
<2ml/kg/hr
Wt loss%
Behavior
Thirst
Mucous memb.
Tears
Anterior fontanel
Skin turgor
Urine output

18. EBV x (Hctstarting – Hctacceptable)
Fluid & blood loss
Type of fluid? Dextrose? BSS?
Weighing swabs before it dries.
Intraoperative blood loss should be replaced with balanced salt solution (1:3), or colloid (1:1)
Estimated maximum allowable blood loss =
EBV x (Hctstarting – Hctacceptable)
Hctstarting

19. Prevention of Heat Loss
Radiation
Evaporation
Conduction
Convection

20. Prevention of Heat Loss
Room temp.: F
Avoid unnecessary exposure & cover cotton wraps as much as possible
HME (active or passive) IVF: warm
Active warming mattress
Cover exposed viscera with warm wet towels
Incubator: keep plugged

21. Emergence
Reversal of MR after spontaneous movement even with adequate time after last dose
Extubation:
Regular spontaneous breathing
Vigorous movements of all limbs
Gagging
Eye opening or pronounced grimacing
Stable hemodynamics & good oxygen saturation
Absence of significant hypothermia

22. Case-specific considerations Hydrocephalus
Burr hole over a dural venous sinus
Bowel injury (re-do)
Perforation of chest wall/neck vessels/occipital bone
Hemodynamic instability/arrhythmias (acute decompression)

23. Craniosynostosis Difficult airway if syndrome
Premature fusion of cranial suture → lack of growth perpendicularly & compensated overgrowth in normal areas affecting mental development &vision due to intracranial hypertension
Difficult airway if syndrome
Positioning (Supine → RAE or reinforced, Prone → nasal T. sutured to nasal septum with 4-0 nylon)
Blood loss (Donation, coag. Profile, 2 Ivs, A line)
Prolonged surgery & hypothermia
Venous air embolism
Raised ICP

24. Encephalocele Wet/soft covering Avoid pressure Antibiotics
Neural tube defect with variable neural dysfunction
+ Hydrocephalus + Arnold Chiari type II
Wet/soft covering
Avoid pressure
Antibiotics
Prone (nasal intubation)
Blood loss
Hypothermia
Latex – free procedure
Document spontaneous breathing postoperatively

25. Myelomeningocele Wet covering Avoid pressure Antibiotics
Neural tube defect with variable neural dysfunction
+ Hydrocephalus + Arnold Chiari type II
Wet covering
Avoid pressure
Antibiotics
Prone (nasal intubation)
Blood loss
Hypothermia
Latex – free procedure

26. Neonatal Conditions Requiring Surgeries Airway Obstruction
Inspiratory stridor with jugular &intercostal/subcostal retractions
-Bilateral choanal atresia
-Laryngomalacia
-Supraglottic papillomatosis
-Subglottic hemangioma
-Cystic hygroma
-The Pierre Robin Syndrome

27. Choanal atresia
CHARGE Syndrome (Coloboma-Heart –Atresia-Retarded-Genital-Ear)
OGT

28. Laryngomalacia

29. Supraglottic Papillomatosis
Subglottic Hemangioma

30. Cystic Hygroma ↑
Cystic Hygroma( Recurrence)

31. The Pierre Robin Syndrome
Typical Anesthestic Management of a Neonate Presenting with Stridor: ABG, chest x-ray IV access, atropine, preoxygenation Inhalation induction (deep) CPAP Smaller ETT or inhaled gases through side port of bronchoscope Hydrocortisone 1-2 mg/kg ICU or high dependency area for h

32. Neonatal Conditions Requiring Surgeries Airway Obstruction Cleft Lip/Palate
Echocardiography
Blood?
Atropine 10µ/kg
Difficult intubation
RAE tubes
Throat pack
Infra-orbital N. block
Extubation

34. Thoracic Surgeries Esophageal Atresia/TEF
1cm

35. Thoracic Surgeries Esophageal Atresia/TEF
1:3000
M:F 25:3
First fed chocking, cyanosis
CHD, VACTERL association 13%

36. Thoracic Surgeries Esophageal Atresia/TEF
Management:
Head up
Continuous low suction on blind pouch
Echocardiography
Antibiotics
Vit K
Next day surgery

37. Thoracic Surgeries Congenital Lobar Emphysema
Unilateral disease due to bronchomalacia, vascular anomaly, bronchial obstruction)
Present with respiratory distress & cyanosis with mediastinal shift
Coexisting CHD in 35%
Anesthesia:
Spontaneous ventilation should be maintained with 100% oxygen + Ketamine + Inotropes
Expand lungs before closure
Intercostal block
Extubate (spontaneous breathing)

38. Thoracic Surgeries Patent Ductus Arteriosus
A disease of Prematurity with Lt to Rt shunt resulting in:
1- Pulmonary over-circulation, high load on lt side, high output cardiac failure
2- In severe cases, reversal of diastolic aortic blood flow in the descending aorta resulting in splanchnic hypoperfusion and NEC
Treatment:
Fluid restriction/diuretics (hypovolemia + hypokalemia)
Endomethacin (transient renal dysfunction, platelet dysfunction)
Ligation

39. Thoracic Surgeries Patent Ductus Arteriosus
Preoperative:
Echo (ht failure, hypovolemia)
Head ultrasound (intracranial pathology)
Routine labs (hypokalemia)
1 unit PRBCs, 1 unit plasma
Last 24h urine output
Anesthesia:
Atropine
Low dose Sevoflurane + opioids + relaxant
If not intubated, nasal intubation is preferred
Tolerate desaturation for progress of surgery (limit is bradycardia)
Treat hypotension with plasma expander + inotrope
Intercostal block by surgeon
No immediate extubation

40. Abdominal Surgeries Congenital Diaphragmatic Hernia
1:5000
M:F
1:1.8
Resp. distress
Scaphoid abdomen
Shifted heart sounds
Bil. Pulmonary hypoplasia
Hypoxia, hypercarbia
Pulmonary HTN, shunting

41. Abdominal Surgeries Congenital Diaphragmatic Hernia
Management:
Gentle ventilation: Limiting PIP, Oscillator ( preductal SpO2> 90%)
Delayed repair (>100h) until medical stabilization
Reversal of duct shunting
Oxygenation Index < 40
PaCO2 < 40
Stable hemodynamics
Poor Predictors:
Overall survival 63%
Polyhydramnios
Immediate need for ventilation
Immature RBCs (intrauterine ↓COP)

42. Abdominal Surgeries Congenital Diaphragmatic Hernia
Anesthesia:
Working NGT
2 pulse oximeters
Atropine
Inhalation/ slow opioid
Treat hypotension with fluids/inotropes
Treat pneumothorax on the other side immediately
Treat the increased Rt to Lt shunt with fentanyl, higher FiO2, hyperventilation, correction of acidosis, Nitric oxide

43. Omphlocele 1:5000 Hernial sac CHD 30-40% Blood loss Hypothermia High abdominal pressure RSI Insensible water loss 10ml/kg/h UOP > 30 mmHg (Ventilation )

44. Gastroschisis Midline above umbilicus Other abnormalities are rare
No hernial sac
Coverage
Heating
I.V fluids
Abdominal pressure

45. Gastrointestinal Obstruction Pyloric Stenosis
Forceful projectile vomiting 4-6 weeks of age, palpable olive-like mass in epigastrium
Loss of hydrogen, chloride & potassium
Dehydration, electrolyte imbalance & acid-base disorder
Hypochloremic, hypokalemic alkalosis
Rehydration (do not accept base excess > +2)
Functioning NGT
RSI
No narcotics, local wound infiltration

46. Gastrointestinal Obstruction & Malrotation
Rehydration Functioning NGT Cross match PRBCs, FFP RSI (ketamine) If hypotension, give boluses of FFP, albumin 5% or PRBCs + dopamine Untwisting malrotated gut releases vasoactive substances & lactic acid causing hypotension

47. Inguinal Hernial Repair Hydrocele Undescended Testis
Wiener ES et al: Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg 1996:31, 1166
70% GA (face mask or LMA) + Caudal epidural or spinal An.
15% Spinal anesthesia alone
11% Caudal anesthesia alone

48. Necrotizing Enterocolitis
It’s a disease of prematurity due to intestinal ischemia with secondary bacterial overgrowth → abdominal distention, increasing gastric aspirate, gastrointestinal bleeding & generalized sepsis.
Antibiotics
TPN
Volume replacement (Albumin 5%, FFP, PRBCs)
Functioning NGT
Check coagulation profile
Ecchocardiography
Chest x-ray for BPD
Inotropes (do not interrupt)
Maintain UOP (volume, Lasix 0.5 mg/kg)

49. Bladder Extrophy Wet covering Antibiotics Blood loss Hypothermia
Latex – free procedure
Postoperative immobility

50. Surgery on the NICU Graduate
First group: Uneventful prematurity → straight forward anesthesia Second group: Ventilatory support-sepsis-PDA-IVH-NEC-multiple medications-BPD/chronic lung disease of the newborn-extubated with great difficulty. The main concern is postoperative apnea until 6-12 Mon. Goals: Avoid intubation/ventilation Avoid postoperative apnea Common surgeries: 1- Laser/cryosurgery for ROP → Face mask/LMA, avoid IV drugs in general 2- Inguinal hernia repair → awake caudal without any drug supplementation or combined with inhalation anesthesia via LMA 3- Circumcision → face mask with penile block

51. THANK YOU