BASIC

PEDIATRIC
ANESTHESIA
MANAGEMENT

ANNE MICHELLE SALOMON, MD, FPBA

 HISTORY for NEONATE
• Birth History (BH)
– PT/FT, SVD/CS, indication for CS, __yo GxPx
(xxxx), at the hospital/lying-in clinic/at
home, by physician/midwife/traditional birth
attendant
– Apgar score – if in hospital
– Good activity, good cry and color upon birth –
if at lying-in clinic/home
– Chief complaint
– Vitamin K given, antibiotic given prior to
transfer
 HISTORY for NEONATE
• History of Present Illness
– Organ systems – emphasis on involved organ
in surgery
– Medications
– Prior admissions and therapeutics related to
problem
– NPO time, time of last urination, time of
vomiting/diarrhea, decreased GI motility
 HISTORY for NEONATE
• Maternal history
– Regular PNCUs, MV/FeSO4 intake, USG,
maternal illness
• Family history
• Immunization history
– BCG, OPV1, DPT1, HepB1
• Feeding history
– Breastfed vs bottle-fed – NPO time
• Developmental history
– Rooting/sucking reflex, Moro reflex
PHYSICAL EXAM for NEONATE
• Activity – limp vs active
• Weight
• HEENT – sunken/flat/bulging
fontanelles, downward slanting eyes,
formed vs floppy ears, low-set ears, dry
vs moist oral mucosa, mouth opening,
cleft lip/palate, tongue size, short neck
and cervical spine instability,
mandibular hypoplasia
 PHYSICAL EXAM for NEONATE
• Respiratory – symmetric chest wall expansion
and good musculature, good vs tight air
entry, clear bilateral breath sounds, alar
flaring/grunting, retractions
• CV – AP, distinct s1, s2, NRRR, PMI at LLSB,
murmurs, gallops, thrills, heaves
• Abdomen – soft, nondistended, and globular
vs tight, distended with engorged veins,
abdominal girth, hypo- vs normoactive bowel
sounds, masses or tumors
 PHYSICAL EXAM for NEONATE
• GU – grossly male/female vs ambiguous genitalia,
hypospadia, rectovaginal fistula with imperforate
anus
• Extremities – simian crease, clubfoot deformity,
syndactyly, polydactyly, visible veins vs small
vessel disease, limb contractures, full and equal
pulses vs weak and thready pulses
• Back – sacral cleft, dimple, tuft of hair,
lumbosacral meningocoele, hemangioma
• Skin-jaundice, cyanotic vs pallid vs robust color,
dry vs moist skin, poor vs good turgor, warm vs
cool extremities, CRT < 2sec
 NEUROLOGIC EXAMINATION
• Alertness - depend upon the time after
delivery, and whether the infant is
sleeping or hungry
– ABNORMAL - persistent irritability or lethargy
• Spontaneous motor
activity — symmetric, smooth, and
spontaneous movements; jitteriness or
tremulousness still normal usually after a
startle
 NEUROLOGIC EXAMINATION
• Tone and muscle strength - increased flexor
tone
– Resting posture - the extremities in moderate
flexion
– Tone and muscle strength - assessed by the pull-
to-sit maneuver
• NORMAL - infant will offer some resistance, with
flexion at the knees, elbows, and ankles, head should
move with the body and head lag should be minimal.
• ABNORMAL - pronounced head lag may indicate
hypotonia
– Muscle strength - tested by holding the infant in
a vertical position with the feet on a flat surface
• NORMAL - should be able to bear weight on the lower
extremities while attempting to stand
 NEUROLOGIC EXAMINATION
• Reflexes - many primitive reflexes
should be tested during the routine
examination
– Moro
– Rooting
– Palmar
– Plantar
– Stepping
– Placing
 HISTORY for PEDIATRIC
• History of Present Illness
– Organ systems – emphasis on involved organ
in surgery
– Medications
– Prior admissions and therapeutics related to
problem
– NPO time, time of last urination, time of
vomiting/diarrhea, decreased GI motility
 HISTORY for PEDIATRIC
• Past Medical history
– Previous admissions
– Previous surgeries and anesthetic experiences
– Blood transfusions
– Medications
• Digitalis – congestive heart failure
• Diuretics – congestive heart failure
• B-blockers
– control of infundibular spasm in TOF or
– subaortic spasm in idiopathic hypertrophic subaortic
stenosis
 HISTORY for PEDIATRIC
• Review of systems
– Respiratory – asthma, URTI, pneumonia,
apneic spells
– Cardiac – murmurs, cyanosis, bradycardia
– Neuro – seizures, mental retardation/autism,
motor deficits, loss of consciousness
– GI – jaundice, vomiting, diarrhea/constipation
 HISTORY for PEDIATRIC
• Birth History (BH)
– PT/FT, SVD/CS, indication for CS, __yo GxPx
(xxxx), at the hospital/lying-in clinic/at
home, by physician/midwife/traditional birth
attendant
– Apgar score – if in hospital
– Good activity, good cry and color upon birth –
if at lying-in clinic/home
 HISTORY for PEDIATRIC
• Maternal history
– Regular PNCUs, MV/FeSO4 intake, USG, maternal
illness
• Family history
• Immunization history
– BCG, OPV3, DPT3, HepB3, measles, MMR, boosters
• Feeding history
– Breastmilk vs formula milk; weaning
– Solids started __mos; good appetite vs picayunish
eater
• Developmental history
– Gross motor, fine motor, language, behavior, school
level
– MR, ADHD, autism-spectrum disorders
PHYSICAL EXAM for PEDIATRIC
• Activity – limp vs active
• Weight ; __% stunted, __% wasted
• HEENT – sunken/flat/bulging fontanelles,
hydrocephalus, downward slanting eyes,
low-set ears, dry vs moist oral mucosa,
mouth opening, narrow, cleft lip/palate,
tongue size, short neck and cervical spine
instability, jugular vein distention,
micrognathia, mandibular hypoplasia,
enlarged tonsils, good vs poor/loose
dentition, abnormal teeth, subglottic
narrowing
 PHYSICAL EXAM for PEDIATRIC
• Respiratory – symmetric chest wall expansion
and good musculature, retractions, good vs
tight air entry, clear bilateral breath sounds,
rales, wheezes
• CV – AP, distinct s1, s2, NRRR, PMI at 4th ICS
LMCL (children < 4yo), 5th ICS LMCL (older
children), gallops, thrills, heaves
• Abdomen – soft, nondistended ,and flat vs
tight, distended with engorged veins,
abdominal girth, hypo- vs normoactive bowel
sounds, masses or tumors
 PHYSICAL EXAM for PEDIATRIC
• GU – grossly male/female, hypospadia
• Extremities – clubbing, clubfoot deformity,
syndactyly, polydactyly, visible veins vs small
vessel disease, limb contractures, full and
equal pulses vs weak and thready pulses,
variations in BP of upper and lower
extremities
• Back – sacral cleft, dimple, tuft of hair,
scoliosis
• Skin-cyanotic vs pallid vs robust color, dry vs
moist skin, poor vs good turgor, warm vs cool
extremities
 LABORATORY EXAMS
• Routine CBC or urinalysis
– not indicated for most elective procedures in
children
– Indicated for patients undergoing procedures
with potential blood loss, with specific risk
factors for hemoglobinopathy, former PT
infants, younger than 6 mos
• Routine CXR
– Unnecessary
 LABORATORY EXAMS
• In the child w CHD, CXR should be
evaluated with the following parameters:
– Position
– Cardiac size
– Cardiac shape
– Pulmonary artery position
– Pulmonary arterial vascularity
– Aortic contour
Egg on its side
Boot-shaped
Snowman or Figure of 8
 LABORATORY EXAMS
• 2D-echo
• Intracardiac anatomy
• Blood flow patterns
• Estimates of physiologic data
• Cardiac MRI
• Ventricular & valve function
• Regional wall motion
• Velocity flow mapping
 LABORATORY EXAMS
• Electrolytes
• Blood glucose level
• Renal function tests (BUN, creatinine)
• ABG
• ECG
• Liver function tests (AST,ALT,albumin)
• CT/MRI
• PFTs
 LABORATORY EXAMS
• Baseline O2 saturation
– < 95% suggests clinically impt CP compromise
– Warrants further indication
• Coagulation studies (PT, PTT,INR)
– Major surgeries
• Preoperative type-and-crossmatch
– Indicated for potential blood transfusions
– Depends on type of surgery and anticipated
blood loss
 ANESTHETIC CONSIDERATIONS
• Neonate
– Hyponatremia
– Hypocalcemia
– Hypoglycemia
– Hypothermia
– Hypoalbuminemia *
– Hypovolemia
– Functional shunts maybe closed but
anatomically open *
 ANESTHETIC PLAN
NORMAL FOR COEXISTING PATHOPHYSIO- PROCEDURE ANESTHETIC
AGE DISORDERS LOGY MANAGEMENT
Anatomical Hypnosis NPO
features
Physiology Aspiration risk Optimization
Pharmacologic Shared airway Preparation
responses
Biochemical Position
features
Psychological/ Muscle
behavioral relaxation
Bloody
Fluid shifts
Trauma/
inflammation
Length of time
Surgeon
Post-op pain
 OPTIMIZATION
• NEONATE
– Hyponatremia – Balanced salt solution for IV
– Hypocalcemia – Calcium gluconate 30-60mg/
kg
– Hypoglycemia - Dextrose 10% 3-4cc/kg, 50%
1-2cc/kg IV bolus
– Hypothermia – room temp 26-28 C, fluid
warmer, thermoregulated intraop heating,
plastic wrap
 OPTIMIZATION
• NEONATE
– Hypoalbuminemia – prolonged local
anesthetic effect
– Hypovolemia – deficit correction or 10cc/kg
IV replacement bolus
 PREPARATION
• Monitors
• Basic – BP, ECG, SpO2, Temp, EtCO2, precordial /
esophageal stethoscope
• Need for invasive monitoring – depends on type of
surgery and anticipated blood loss

• Induction technique
• GETA vs GETA-RSI vs GETA-Regional

• Maintenance
• Inhalational vs Intravenous anesthesia
 PREPARATION
• Modified Rapid Sequence Induction
– Application of gentle positive pressure
ventilation while doing the traditional RSI
technique

– Cricoid pressure in children

• Laryngoscopist must use middle or ring finger
• 2.5 kg or 20-30 Newtons

– Reverse Trendelenburg position

• Conflicting evidence
 PREPARATION
• REGIONAL ANESTHESIA COMPUTATION
– Compute for the MAXIMUM TOXIC DOSE
• Bupivacaine, Ropivacaine 2.5 mg/kg
• Lidocaine without Epinephrine 5 mg/kg
• Lidocaine with Epinephrine 7 mg/kg
• Epinephrine – volume (cc) / 200; use 0.1 cc
1:1000,diluted to 1cc

• Compute for the LEVEL of BLOCKADE

– Single-shot caudal /epidural- Takasaki, Armitage
– Continuous caudal/epidural - Schultze-Steinberg,
Cousins
 PREPARATION
• REGIONAL ANESTHESIA COMPUTATION
• Takasaki vs. Armitage?
• Takasaki – neonates/infants to small kids

• Use DILUTED VERSION

• Bupivacaine 0.25% (intraop) & 0.125% (postop)
• Levobupivacaine 0.25% (intraop) & 0.125%
(postop)
• Lidocaine 1% (intraop)
• Always use with Epinephrine!
• Decrease in systemic absorption
CUFFED ET TUBE SIZE FORMULA
 PREPARATION
• Lines
• Requires 2 peripheral lines or 1 central + 1
peripheral lines – one for maintenance, other for
replacement

• Use balanced salt solutions

– neonates are obligate sodium losers

• Dextrose-containing solutions as maintenance fluid

– Prevents hypoglycemia
 PREPARATION
• GOALS OF MAINTENANCE IV FLUID
ADMINISTRATION
• Daily metabolic requirements
• Electrolyte balance
• Limitation of fluid overload
 PREPARATION
• GOALS OF REPLACEMENT IV FLUID
ADMINISTRATION
• Restoration of circulating blood volume
• Maintenance of intravascular volume and
ongoing blood loss
• Replacement of massive evaporative losses
 Endotracheal Tube Insertion
Distance
• Neonate – range 5-9cm; 10cm
• <1yo – 11cm
• <2yo – 12cm

• <2yo
– Weight (kg) + 6
• >2yo
– Age (years)/2 + 12

• All are approximations; auscultation for bilateral

breath sounds, especially at the bases (mid-
axillary)
PREPARATION
PREPARATION
 PREPARATION
BLOOD COMPONENT VOLUME PER EFFECT
ALIQUOT

PRBC 10 – 15 cc/kg Increased 2 – 3 g/dl

PLATELET 5 – 10 cc/kg Increased 50,000 –

100,000

FFP 10 – 15 cc/kg Increased 15 – 20%

factor level

CRYOPRECIPITATE 1 – 2 u/kg Increased 60-100 mg/

dl fibrinogen
 PREPARATION
• Ambulatory vs Admitted patients

• Pain medications
• Paracetamol PO/IV/rectal
• Ketorolac IV
• Ibuprofen PO
• Nalbuphine IV
 PREPARATION
• Post-op
• NICU stay admission
• Mechanical ventilation
– Pressure mode
– Peak inspiratory pressure – start at 16 – 18 cm H20
(range 18-28 cm H20)
– Peak end-expiratory pressure – physiologic 3-5 cm H20
– BUR – RR for neonates 40 – 60 cpm; infants 30 cpm;
toddlers 20-25 cpm
– SIMV
INTRAOP
INTRAOP
INTRAOP
INTRAOP
INTRAOP
INTRAOP
INTRAOP
 INTRAOP
• REPLACEMENT
– Mild tissue trauma – 3-4 ml/kg/hr
– Moderate tissue trauma – 5-7 ml/kg/hr
– Large tissue trauma – 8-10 ml/kg/hr

– Shed blood
• Crystalloids – 1 cc blood: 3 cc crystalloid
• Colloids – 1cc blood: 1 cc albumin
 INTRAOP
•Assess the surgical field & communicate with
surgeon

•If there is continuing acute blood loss and half of

the MABL has been lost, it is prudent to have the
blood
products brought up

•Safer to exceed transfusion of 5-10% of the blood

product rather than risk exposing the patient to
another
blood unit
 POST-OP
• FLUID MANAGEMENT
• Balanced salt solutions
• Prevent post-operative hyponatremia
• High rates of childhood deaths
• Iatrogenic Hyponatremia
• Extensive loss of electrolyte containing fluid
• Intravenous replacement with hypotonic fluid
• Solution
• Minimize hypotonic fluid administration post-
operatively
• Replace ongoing losses
• Serial electrolyte measurement
 POST-OP
• Keep thermoregulated
• Measure OGT output and replace with PNSS
• Measure urine output & maintain at 1cc/kg/hr
• Maintain positive fluid balance
• Reassess with: CBC, electrolytes (Na, K, Ca,
Mg), ABGs (if contemplating delayed
extubation), CBGs
• Reassess pain management &/or sedation while
on mechanical ventilation
 Sources
• Hagberg, C, Benumof’s Airway
Management, 2007
• Cote, C.J., et al. A Practice of
Anesthesia for Infants and Children, 4th
ed., 2009
• Lake, C. Pediatric Cardiac Anesthesia,
4th ed. 2005
• Saint Maurice, C, Schultze-Steinberg, O,
et al. Regional Anesthesia in Children,
1990
 “When the child
has one
congenital
malformation,
the likelihood of
another is
increased.”

Greeley, W, Steven, J, Nicolson, S, et al. Anesthesia for

Pediatric Cardiac Surgery. In: Miller RD, ed. Anesthesia,
5th ed. New York: Churchill Livingstone, 2000:1805-1815.