Pediatric Perioperative 2022 Student Notes PDF

Ideal Analgesia/Sedation Efficacious Safe in eliminating pain Producing amnesia Easy to administer Predictable in its action Reliable for a wide range of ages Rapid onset Short duration of action No complications or side effects Rapidly reversible Relatively inexpensive Completely satisfactory to th...

Ideal Analgesia/Sedation Efficacious Safe in eliminating pain Producing amnesia Easy to administer Predictable in its action Reliable for a wide range of ages Rapid onset Short duration of action No complications or side effects Rapidly reversible Relatively inexpensive Completely satisfactory to the child and his or her parents 2 Under-treatment of Pain in Children Lack of familiarity with the methods of anesthesia and sedation Apprehension of complications 3 Over-Sedation Loss of the airway Impaired protective reflexes Can lead to: Aspiration Cardiopulmonary arrest 4 “Conscious Sedation” ✦Pharmacologically controlled, altered state of consciousness in which patients maintain their ability to respond purposefully to verbal commands ✦Nonverbal patients or young infants, conscious sedation implies the ability to respond purposefully to physical stimulation, not simply by reflex withdrawal to pain 5 Current Classification and Terminology Two Levels of Sedation ✦Moderate (previously termed conscious) State of depressed consciousness in which a patent airway and protective reflexes are maintained The individual can be aroused by physical stimulation or verbal command ✦Deep sedation More profound state of unconsciousness Loss of protective airway reflexes 6 Head Position Flex forward airway obstruction as the child begins to fall asleep Maintaining patients in the so-called “sniffing” position Children younger than 3 years of age Relatively large head in proportion to the size of their trunk and do not require padding under the occiput 7 Pre-Op Considerations Acceptable clear liquids Apple juice, water, sugar water, sport/electrolyte drinks, and gelatin. Milk (including breast milk), milk products, and juices with pulp are not considered clear liquids For elective procedures in children, most anesthesia and nursing protocols “2-4-6-8 rule” regarding PO intake Clear liquids to 2 hours before the start of an elective procedure requiring anesthesia Breast milk to 4 hours Baby formula (cow's milk) to 6 hours Solid food to 8 hours prior 8 Emergency Procedures Higher risk for aspiration Children injured within 1 to 2 hours after eating have been shown to have large gastric volumes Gastric emptying may be further slowed in a child with a fracture by the presence of pain and anxiety and the administration of opioid pain relievers. If circumstances of the injury permit and the procedure can wait, a minimal fasting period of 4 hours is generally recommended 9 Medications 10 Benzodiazepines in Pediatric Sedation Method of Administration Diazepam ✦0.1 to 0.3 mg/kg IV or PO IM administration should be avoided because it is painful. Midazolam ✦1. PO: 0.5–0.75 mg/kg ✦2. Nasal: 0.3–0.4 mg/kg* ✦3. IM: 0.03–0.1 mg/kg ✦4. IV: 0.05–0.1 mg/kg Contraindications Previous unfavorable experience with benzodiazepines Altered state of consciousness III. Advantages Generally provide excellent sedation and amnesia Reversible if necessary (flumazenil, 10 μg/kg, up to a total dose of 1.0 mg) Disadvantages No analgesic effect Respiratory depression, especially with parenteral administration Combination with narcotics may lead to oversedation or respiratory arrest 11 Opioids in Pediatric Sedation Method of Administration Advantages Morphine: 0.05–0.1 mg/kg IM or IV Provide excellent analgesia Meperidine: 0.5–1.0 mg/kg IM or IV Reversible if necessary (naloxone 0.001–0.005 mg/kg IVtitrated to effect) Fentanyl: In increments of 0.001 mg/kg IV (maximum total dose, 0.004–0.005 mg/kg) Disadvantages Nalbuphine: 0.1 mg/kg IM or I Risk of respiratory depression and apnea Patients younger than 3 months old should be given no more than half of these doses initially Increased risk of respiratory depression and apnea when combined with other sedatives IV titration to desired effect is the ideal way to administer all sedative medications No amnestic effects Contraindications Altered state of consciousness Previous unfavorable experience Additional side effects (more likely when used in recurrent doses for treatment of pain) Nausea, vomiting, pruritus, constipation, decreased gastric motility Sedation for nonpainful procedure 12 Ketamine 13 Oral Opioids in Children Agent Dose Pediatric Formulations 14 Oral Opioids in Children Agent Dose Pediatric Formulations 15 Oral Opioids in Children Agent Dose Pediatric Formulations 16 Oral Opioids in Children Agent Dose Pediatric Formulations 17 Recommended Discharge Criteria after Sedation Cardiovascular function and airway patency are satisfactory and stable The patient is easily rousable protective reflexes are intact The patient can talk (if age-appropriate) The patient can sit up unaided (if ageappropriate) For a very young or handicapped child incapable of the usually expected responses, the pre-sedation level of responsiveness or a level The state of hydration is adequate 18 Asthma Wheezing is associated with a greater risk of perioperative bronchial hyper-reactivity Elective surgery should be postponed if the child has had a chest infection or an exacerbation of asthma within 2-4 weeks prior to the date of surgery There is evidence to suggest that nonsteroidals have no detrimental effect in mild asthmatics but should probably be avoided in brittle asthmatics, particularly in those with nasal polyps 19 Upper respiratory tract infection (URTI) The average child has up to seven episodes of URTI a year Although it is advisable to avoid an anaesthetic for 2-4 weeks after an URTI due to airway irritability, morbidity remains low in otherwise well children Adverse events such as laryngospasm, bronchospasm and airway obstruction are more likely Children under 1 year of age Asthmatics Having airway surgery Endotracheal tube is used 20 The Anxious Child 40-60% of children experience significant preoperative anxiety Preoperative anxiety leads to adverse postoperative clinical outcomes Short-Term (emergence delirium) Long-term (Behavioural issues…sleep disturbance and separation anxiety) Strategies to reduce anxiety Sedative premedication Behavioural interventions such as computer packages, video games, clowns and play therapist 21 Postoperative Emergence Delirium Transient state of irritation and disassociation after anaesthesia Crying, kicking or thrashing The incidence is unknown as there is not a definite threshold for diagnosis With the increasing use of short-acting volatile agents (sevoflurane and desflurane) and short-acting opioids, emergence issues are not unusual It is more likely to occur in the 2-5 year age range especially after painful procedures Preoperative anxiety is a risk factor and children who are more emotional or impulsive Self-limiting 22 Obstructive Sleep Apnea (OSA) Adenotonsillar hypertrophy is the most common cause of snoring in children About 15% of children who snore have OSA If the clinical features of OSA are present ECG Pulse oximetry Anesthetic considerations Avoidance of sedative premedication Long-acting opioids that can cause airway obstruction Postoperatively, sleep apnea can worsen 23 The Anticipated Difficult Intubation Ample time for planning Relative risk/benefit of doing the procedure Primary plan Contingency plans The point at which to abandon and wake the child up 24 Laryngospasm More commonly encountered in pediatric practice rather than adults More common in the hands of less experienced anesthetists 25 Perioperative Fluids Perioperative hyponatremia Hypotonic fluids are given at a time of increased anti-diuretic hormone (ADH) release 0.45% Normal Saline 0.45% NaCl Hyponatraemia is defined as a plasma sodium (Na) less than 135 mmol/liter Children develop symptoms of hyponatraemia at higher plasma sodium concentrations than adults Isotonic fluids (Lactated Ringer’s, 0.9% saline) administered perioperatively should prevent the development of hyponatraemia 26 Allowable Blood Loss A normal, well child older than 3 months will tolerate a Hb of 7.0 or a hematocrit of 25% There is no consensus under that age as it depends on the degree of pre-maturity and condition of the child After the ABL has been exceeded Blood should be given in the ratio 2:1 packed red cells:colloid Packed red cells 4 mL/kg raises the Hb by 1 g/dL Fresh frozen plasma (FFP) After loss of 1/2 blood volume (10-20 mL/kg) Platelets After loss of 1 blood volume (10-20 mL/kg) 27 Thank You! 28