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Pediatric Anesthesia for the Generalist

Ellen R. Basile, DOAssistant ProfessorDepartment of AnesthesiaOU Medical Center

The CV

• My Background

• Pediatric Anesthesiologist

• Medical School in Philadelphia

• Anesthesia Residency in Philadelphia

• Pediatric Fellowship in Philadelphia

• I have no financial disclosures

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Objectives for our Pediatric Anesthesia for the Generalist

• To review everyday pediatric topics

• Identify areas of Morbidity and Mortality in Pediatrics

• Review Pediatric Anesthesia Recommendations

• Provide an opportunity to ask / answer pediatric anesthesia questions

Everyday Topics• Premedication• NPO Guidelines• Emergency Rx’s• Narcotics• To Cancel or Not?• Laryngospasm• Asthma• T&A’s• Emergence Delirium• X-Premies• Difficult Airways• NOT EVERY DAY TOPICS

M&MSmart TotsPediatric Recommendations

Premed Anyone?

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Premedication

• 40-60% children develop anxiety pre-op

• Separation from parents & induction

• Around 9 mos: separation anxiety• Cote

Premedication

• Pharmacological vs Behavioral Interventions• Versed, midazolam most common Rx

0.5 mg/kg PO , max doseonset 15-30min

??delayed emergence, increased irritability PACU??• Parental Presence• Child Life• Studies show parental presence no additional benefit

when compared with Rx

Happy Meal, good times!

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NPO Guidelines

• 2,4,6,8 --Who do we appreciate?

• Clears 2 hours

• Breast Milk 4 hours

• Formula, G-Tube,

• milk, Light meal 6 hours

• Full/fatty meal 8 hours

Anesthesia STAT

Pediatric Emergency Rx

• Atropine 20mcg/kg

• Succinylcholine 1-3mg/kg

• Epinephrine 1-10mcg/kg

• PRBC’s, O2, Epi, Calcium

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Succinylcholine

• Not used routinely in Pediatrics

• Indications: Airway emergencies (RSI)

Black Box WarningSuccinylcholine

• WARNING• RISK OF CARDIAC ARREST FROM HYPERKALEMIC RHABDOMYOLYSIS• There have been rare reports of acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias,

cardiac arrest, and death after the administration of succinylcholine to apparently healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy.

• This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or younger). There have also been reports in adolescents.

• Therefore, when a healthy appearing infant or child develops cardiac arrest soon after administration of succinylcholine not felt to be due to inadequate ventilation, oxygenation, or anesthetic overdose, immediate treatment for hyperkalemia should be instituted. This should include administration of intravenous calcium, bicarbonate, and glucose with insulin, with hyperventilation. Due to the abrupt onset of this syndrome, routine resuscitative measures are likely to be unsuccessful. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation in some reported cases. In addition, in the presence of signs of malignant hyperthermia, appropriate treatment should be instituted concurrently.

• Since there may be no signs or symptoms to alert the practitioner to which patients are at risk, it is recommended that the use of succinylcholine in children should be reserved for emergency intubation or instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible (see PRECAUTIONS: Pediatric Use andDOSAGE AND ADMINISTRATION).

• This drug should be used only by individuals familiar with its actions,

Epinephrine

• PALS code dose 10mcg/kg

• If using 1:10,00 Epi, dose is 0.1mL/kg

• Bradycardia 2° Hypoxia in peds, Epi now recommended over atropine

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Not breathing? No problem

Narcotics

• Children are opioid naïve

• Narcotics =

• ADR’s: Airway, Airway, Airway

Narcotics

• Fentanyl- recommended doses 1-3mg/kg

• Morphine- recommended dose 0.1mg/kg

• Hydromorphone- 0.15-0.2 mg/kg

• Codeine- not often used in peds

wide variability in metabolismPoor Metabolizers= 10 % Whites, 30% Hong Kong Chinese

Ultra Metabolizers= 29% Ethiopian, 1% Swedish/German/ Chinese

Cote

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Narcotics

• GA cases I do not use any narcotics:Pyloric StenosisEGDColonoscopyDentalForeign Body RemovalExam under AnesthesiaSuture RemovalMRI / xRT / PET scans

Narcotics

• Consider alternatives to Opioids

– Tylenol

– Ketorolac

– Local Anesthetic

– Dexmetomidine

– Ketamine

Kid with a cold

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?To Cancel or Not?

• Is procedure purely “elective” ?

• Disposition: hospital vs surgery center

• $$$

• Will surgery improve current infection/process?

ie: otitis media- BMT, abscess-I&D

Strongly Consider Canceling

• Temp > 38.5

• Ill/ toxic appearing

• Active wheezing, **current URI**

• s/s lower respiratory tract infection

rhonchi, green/ yellow sputum

**Airway can remain reactive 4-6 weeks s/p URI

Current URI

• Increased risk

Bronchospasm 10X greater

Laryngospasm 5X greater

Respiratory Event 9X greater

Respiratory Events reduced with LMA vs ETT

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Laryngospasm

• = involuntary laryngeal closure, despite inspiratory effort

Risk of laryngospasm in pediatric population17:1000 vs 96:1000 (current URI)

Treatment: 100% O2, PPV, propofol, succinylcholine

No School tomorrow

T& A #2 ambulatory pediatric surgery

Indications: recurrent infection or OSA

ASA: AHI > 10 = severe

Mortality

#1- bleeding

approximately 1/3 deaths 2° bleeding

#2- Airway obstruction Complications more likely: craniofacial disorders, Down’s Syndrome, CP,

Major heart defect, bleeding diathesis, pt <3yo, proven OSA, obesity

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T & A Recommendations

• American Academy of Otolaryngology• Strong Recommendations for:

Intra-op dose dexamethasone

AGAINST intra-op Antibiotics Overnight Hospitalizations Recommended:

<3yoobese patientsOSA >10

T & A• Pain treatment recommendations

Tylenol

NSAID’s

*ketorolac not recommended

Codeine should be avoided

Intra-op LA injection in tonsillar fossa

*post op bleeding with ketorolac 4.4-18%

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Asthma Asthma 20-25% pediatric population, varies

geographically

Questions to Ask:

Triggers?

Rx? Nebulizer at home?

how often rescue inhaler used?

hospitalizations (ICU?) / intubations?

current URI?????????

Asthma in Oklahoma

• 2008 CDC Reports

Asthma prevalence in OK, all age groups:

> 38 participating states

M > F

African American significant>>> incidence

0-4yo highest Hospital Admissions

Asthma

• Increased risk bronchospasm in pediatrics

• Risk Increased with ETT

• Consider deep extubation when appropriate

• Tx: albuterol, deepen anesthesia, epi, paralysis

magnesium

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What the Hell is going on here?

Emergence Delirium

• = dissociated state of consciousness• Extremely Common Occurrence in Pediatrics

s/p inhalation induction 2-80%• 2-5 yo highest incidence• Multiple contributing factors

hx of emergence delirium, HEENT, 2-5yo• Tx: quiet, darken room, IV Rx (propofol,

***precedex)

Premies come with some baggage.

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X- Premies

• Premature Infant <37 weeks gestation

• How long was pt hospitalized, Intubated @ birth? ETT? How long? O2 ? Apnea monitor @ home? Bronchodilators?

• Most will have BPD, chronic obstructive disease• Developmental delays?? FTT, Ophthalmology

X-Premies

• Apnea of Prematurity

post conceptual age inversely related to apnea risk

Contributing factors

HCT < 30%= increased risk

Type of Surgery

Infant <36 weeks gestation @ birth

• Pre-term infant < 55-60 PGA will need 24hr observation

Difficult Airways

• Cranio-facial Syndromes (Pierre Robin/Goldenhar)

• Downs Syndrome…NOT

• Hunter’s/ Hurler’s

• Awake FO intubations in peds unlikely

Maintain SV (ketamine)

ETT via LMA (FOS as stylet)

Glidescope with Nasal ETT via FOS

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Goodnight, sweet prince…and flights of angels sing thee to thy rest

Shakespeare

Pediatric Morbidity & MortalityA comparison of Pediatric And Adult Anesthesia

• 1993 Study compared pediatric vs adult closed claims

re: mechanism of injury, outcome, $$, role of care judged substandard

• 2,400 total claims

10% pediatric (<15yo)

Pediatric vs Adult Anesthesia Closed Claims

PEDIATRIC ADULT

Respiratory Events 43% 30%

Mortality 50% 35%

Anes Care < appropriate 54% 44%

Complications preventable better monitoring

45% 30%

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Pediatric vs Adult Anesthesia• Distribution of payments

peds $111,234Adults $ 90,000

Cyanosis 49% and bradycardia 64% often preceded cardiac arrest

death 70%

brain damage 30%

89% peds claims related to inadequate ventilationA comparison of pediatric and adult anesthesia closed malpractice claims, Morray

Morbidity & MortalityAn Update on Pediatric Anesthesia Liability

• Malpractice claims 1973-2000• 532 pediatric malpractice claims (<16yo)

decrease in claims for death/ BDdeath 41% / BD 21% #1 and #2 reason50% claims <3yo1 out of 5 claims ASA 3-5

CV and Resp events were most common damaging events

An update on pediatric anesthesia liability: a closed claims analysis, Jimenez

Morbidity & MortalityAnesthesia-Related cardiac arrest in children

• 1994 Registry initiated, voluntary

• POCA= Pediatric Perioperative Cardiac Arrest Registry

• Cardiac Arrest Related to Anesthesia

• Incidence 1.4: 10,000 (mortality 26%)• 37% Rx related

• 32 % CV related

ASA 1-2 64% cardiac arrests related to RX

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Morbidity & MortalityPOCA registry

• Infants < 1 yo were 55% of anesthesia related arrests

• Two predictors of mortality

ASA 3-5

Emergency StatusAnesthesia-related cardiac arrest in children: initial findings of Pediatric Perioperative Cardiac Arrest (POCA) registry, Morray.

2003

Pediatric Recommendations

• Increased risk anesthetic complications in pediatric patients

• Studies support decreased risk M&M with Pediatric Anesthesiologist

• ASA has no clearly defined recommendations

• American College of Surgeons has recommendations

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ASA Recommendations

ASA Recommendations• 2011

• Written policies on types of pediatric surgeries

• Determine criteria for anesthesia care of pediatric patients

• Increased anesthetic risk should be staffed by peds fellowship trained anesthesiologist

American College of Surgeons

• Surgical Centers determined by level of care

I- ASA 1-5, any age, must have 2 pediatric anesthesiologist on staff

II- ASA 1-3, any age, must have 1 pediatric anesthesiologist on staff

III- ASA 1-3, age > 6yo, must have anesthesiologist with pediatric expertise #25

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American College of Surgeons

• Ambulatory Surgical Center Recommendations:– Focus on pre-term infants (54 wks PGA)

– Pediatric anesthesiologist OR Surgeon as med director

– <2 yo either peds anesthesiologist OR expertise in pediatric anesthesia

– 1 or more PALS certified staff for PACU

– FT infant >4wks < 6 mos 2-4 hours in PACU• Longer for infant <3mos old with opioid exposure

www.pedsanesthsia.org

IARS + FDA

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Smart Tots• 2012 Consensus Statement:

“Animal studies show long-term and possible permanent adverse effects on developing brain”

behaviorlearningmemory

Further research is required

QUESTIONS?

References• Cote. A Practice of Anesthesia for Infants and Children. Philadelphia, Elsevier,

2009.

• ASA, Statement on Practice Recommendations for Pediatric Anesthesia,Oct 19,2011.

• Gregory. Providing Anesthesia for Pediatric Patients, American Society Of Anesthesiologist, Vol 69, Number 3, 2005.

• Posner,KL. Unexpected cardiac arrest among children during surgery: a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest. Qual Saf Health Care; 2002;11:252-257.

• Morry,JP. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesthesiology, Jul;93 (1); 6-14.

• Jimenez, N. An update on pediatric anesthesia liability: a closed claims analysis. Anesth Analg, 2007 Jan; 104 (1); 147-53.

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References

• Optimal Resources for Children’s Surgical Care, From the Committee on Children’s Surgery, American College of Surgeons, Nov 20, 2014.

• IARS, Smart Tots

• www.pedsanesthesia.org