1. Pitfalls in Pediatric Anaesthesia
M Pearson 2018

2. Anatomy and Physiology
Not just a small adult!
Assume familiar with anatomical and physiological differences

3. Pharmacology Not a homogeneous population
Depends on age, maturity of organs and enzymes
Deliver an age appropriate plan

4. Fasting guidelines 6 hours: solids/ formula milk 4 hours: breast milk
2 hours: clear fluids
? Even more liberal
Child with supracondillar # with no pulses

5. Potential full stomach
Eg Trauma patient
RSII in children remains controversial
Sometimes impossible to insert iv before induction
Inhalation induction ONLY
if difficult airway OR
difficult vascular access

6. Anxious child Anxious parents Behavioural problems ( ADD, Autism)
Repeated previous procedures
Preparation and explanation during premed
Give premed enough time to work
Combination Px:
Ketamine 3mg/kg po+
Midazolam 0,3 mg/kg
Midazolam has high dose in younger pts

7. The resistant child
How much restraint is ok if child refuses interventions?
Who must restrain the child?
Let mom hold child on lap
Start induction only with N2O/ O2 mixture
Cupped hand no mask
Slowly introduce Sevo in low concentrations

8. Inhalation induction Faster wash in in children
More rapid uptake unmask negative inotropic effects
Negative feedback loop: Maintain spontaneous breathing as long as possible
Stages ( eye signs)
Halothane potency vs BGDC
Sevo > 6 convulsions
MAC depends on age ( highest 1-6 months)

9. Inhalation induction Halothane: "Slow in slow out"
Increasing MAC will not speed up induction
N2O potentiate 70%
Reduce MAC to prevent CVS depression
Sevoflurane:
Seizures if 8% is given
Especially if combined with hyperventilation
Maximum 6%

10. Ketamine induction Paradoxical fall in BP , HR
Can loose airway if compromized
Can accumulate, active metabolite

11. Airway management Preparation+ equipment ready!
Different sizes masks, airways, ETTs
Preoxygenation may not prevent desaturation
Modified /controlled RSI
Cricoid pressure
- prevent insufflation stomach
BUT
-more difficult intubation
-INCREASE REGURGITATION!!!

12. Difficult airway Beware of syndromic child
> 2 attempts at direct laryngoscopy associated with life threatening events
Maintain spontaneous respiration
Provide apneic oxygenation during intubation

13. Cuffed ETT Previously concerns about airway injury
New HVLP cuffs not increased risk anymore
High exchange rate of uncuffed ETT (2 vs 31 %)
Measure cuff pressure < 10 cmH2O
Use 1/2 size smaller than calculated
Formula generally underestimate size airway
Safe and indicated in aspiration risk

14. Uncuffed : age/4 + 4 Cuffed : age/4+ 3 Length: age/2 + 12
Calculate ETT size
Uncuffed : age/4 + 4
Cuffed : age/4+ 3
Length: age/2 + 12

15. Laryngospasm Stridor = partial obstruction CPAP with 100% oxygen
Deepen with Propofol 0,5-1 mg/kg
Complete larygospasm= SILENCE !
EMERGENCY- ACT IMMEDIATELY!
Quick trial of CPAP
If no response Propofol 3-4 mg/kg
Sux 0,1-0,2 mg/kg

16. Controlled RSI IV ACCESS MANDATORY IN AT RISK PT
Continuous suction on NGT if in situ
20 degree head up position
TITRATION of induction agent
NDMR to guarantee optimal relaxation
Gentle bag mask ventilation < 12 cmH2O
Intubate when no response on TOF

17. Fluids Liberal NPO guidelines- no dehydration
Resuscitation: crystalloid bolus 20ml/kg < 10 min
Do not use tetrastarch
Seek expert advice if > ml/kg needed
Maintenance : Use isotonic crystalloids
No dexstrose containing maintenance to healthy infants
Monitor glucose in critically ill, prolonged procedures, pts at risk for hypoglycemia

18. Postoperative fluids
Risk of water retention and hyponatremia due to SIADH
Calculate maintenance 4:2:1 rule
BUT
restrict to 50-80% of routine maintenance
Measure electrolytes and glucose daily

19. Child for Ts and As Main indication now sleep disordered breathing
Beware of OSA and PULMONARY HTS!
Overnight oximetry and HR preop
Optimize with O2 and CPAP preop
First on list early in morning
Not done as day case surgery
ICU bed if severe pulm HTS
Prepare for intraop shunting
Airway obstruction WORSE first night postop due to swelling

20. Obesity Use percentiles not BMI Screen for co- morbidities! (OSA)
Induction dose: start low and titrate to effect
Opioids: start low and titrate to effect
Iv induction with modified RSI
Airway: ETT not LMA
PPV with PEEP
Awake extubation
Beware of codein for postop analgesia

21. Trauma Re examine preop, picture could have changed
Often multiple injuries
Seldom isolated head injury
Hypotension is a LATE sign of hypovolemia!
Damage control resuscitation

22. Damage control resuscitation
Prevent the lethal triad of trauma
Establish rapid iv access
Correct hypothermia and acidosis
Judicious approach to crystalloids
Early use of blood products 1:1:1
Permissive hypotension
Aggressive early control of bleeding