Pediatric Perioperative Concepts EMILY OLSEN MD PEDIATRIC ANESTHESIOLOGY

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Pediatric Perioperative Concepts EMILY OLSEN, MD PEDIATRIC ANESTHESIOLOGY DENALI ANESTHESIA, P. C. JUNE 20,

Pediatric Perioperative Concepts EMILY OLSEN, MD PEDIATRIC ANESTHESIOLOGY DENALI ANESTHESIA, P. C. JUNE 20, 2016

Disclosures �None

Disclosures �None

Learning Objectives �Knowledge Review NPO guidelines Premedication, PPIA Types of anesthesia induction IV access

Learning Objectives �Knowledge Review NPO guidelines Premedication, PPIA Types of anesthesia induction IV access Basic developmental stages Neonatal concerns Common pediatric problems Pediatric airway Laryngospasm

Review NPO guidelines � 2, 4, 6, 8 rule 2 hours for clears 4

Review NPO guidelines � 2, 4, 6, 8 rule 2 hours for clears 4 hours for breast milk 6 hours formula, other milk, or light meal 8 hours for full meal

Premedications � Who? > 6 months of age � What, how? Midazolam (oral, intranasal)

Premedications � Who? > 6 months of age � What, how? Midazolam (oral, intranasal) Onset � Risk paradoxical reaction � How to give � OSA, PACU stay � Ketamine (oral, intranasal, IM) � +/- midazolam and glycopyrrolate Dexmedetomidine (Precedex) (intranasal) Onset � Monitoring? � � Why? Separation anxiety, trauma prevention, facilitate induction and/or IV, and/or primary sedative

Parental Presence at Induction of Anesthesia (PPIA) �Generally done only if no premed is

Parental Presence at Induction of Anesthesia (PPIA) �Generally done only if no premed is given (no added benefit with both) �Distraction as a powerful tool �Set expectations and choose wisely!

Types of Inductions �Inhaled (mask induction) Sevoflurane +/- N 2 O <40 kg �Intravenous

Types of Inductions �Inhaled (mask induction) Sevoflurane +/- N 2 O <40 kg �Intravenous (IV) EMLA +/- N 2 O, and/or premed Full stomach, trauma, risk of malignant hyperthermia, >40 kg �Intramuscular (IM) Ketamine +/- midazolam and glycopyrrolate “ketamine dart” If not a good candidate for IV or inhaled induction

IV access �Umbilical lines �Hand, saphenous, scalp

IV access �Umbilical lines �Hand, saphenous, scalp

Basic Developmental Stages �Age 8 months – 4 years: Peak for separation anxiety. Underdeveloped

Basic Developmental Stages �Age 8 months – 4 years: Peak for separation anxiety. Underdeveloped coping strategies � 4 – 8 years: Separation anxiety. Magical thinking. Body integrity. Improved coping in new situations. � 8 -12 years: Fear of pain, body image/mutilation, loss of control, not waking up or waking up during surgery � 12+ years: Similar to 8 -12 year olds. Fear of the unknown. Try to behave like and “adult”

Neonatal Concerns �Very sensitive to opioids �At risk of apnea (>15 sec) and bradycardia

Neonatal Concerns �Very sensitive to opioids �At risk of apnea (>15 sec) and bradycardia Fixed stroke volume (don’t tolerate bradycardia) CO = SV x HR �Immature organ function (slow to wake, no NSAIDs) �Dextrose �Risk oxygen toxicity �High oxygen consumption Faster desaturations

Common Perioperative Problems �Monitoring Physical exam! �Laryngospasm* �Emergence delirium “dissociated state of consciousness in

Common Perioperative Problems �Monitoring Physical exam! �Laryngospasm* �Emergence delirium “dissociated state of consciousness in which children are inconsolable, irritable, uncompromising, and/or uncooperative. ” Highest incidence at age 1 – 5 years Lasts 10 -20 minutes. Resolves spontaneously. Distinguish from pain, “bad behavior” or immature coping �Pain management Blocks, caudals/epidurals, spinals, opioids and other analgesics �Anesthesia Neurotoxicity? Period of vulnerability?

The Pediatric Airway

The Pediatric Airway

Forms of Airway Obstruction Upper airway obstruction � Macroglossus � Enlarged tonsils, adenoids Laryngospasm*

Forms of Airway Obstruction Upper airway obstruction � Macroglossus � Enlarged tonsils, adenoids Laryngospasm* � Vocal cord spasm Lower airway obstruction � Subglottic edema � Tracheal stenosis � Tracheomalacia � Bronchospasm � Mucous plugs Anatomic from mouth to trachea

Laryngospasm � Reflex closure of false and true vocal cords � Complete laryngospasm: o

Laryngospasm � Reflex closure of false and true vocal cords � Complete laryngospasm: o Chest movement but silent with no air movement and no ventilation possible � Partial laryngospasm: o Chest movement with stridulous noise (stridor) with a mismatch between the patient’s respiratory effort and the small amount of air movement � Incidence: 0. 4 -10%

Laryngospasm

Laryngospasm

Laryngospasm – Risk Factors Young age (infants and young children) History of reactive airway

Laryngospasm – Risk Factors Young age (infants and young children) History of reactive airway disease (eg. asthma) Exposure to second-hand smoke Recent URI (< 2 weeks) Airway anomalies Airway surgery (eg. T&A, bronchoscopy) Airway devices (ETT) Stimulation during a light plane of anesthesia (IV) Secretions in the oropharynx (eg. blood, saliva, gastric juice) � Inhaled anesthesia (vs. IV anesthesia) � Inexperienced anesthesiologist � � � � �

Laryngospasm management • • • Deliver 100% oxygen via face mask with continuous positive

Laryngospasm management • • • Deliver 100% oxygen via face mask with continuous positive pressure (CPAP) Remove offending agent Mandibular jaw thrust Call for HELP as initial steps above are being taken Anticipate need for pharmacologic intervention (propofol, succinylcholine) Anticipate equipment needed (oral airway, nasal trumpet, LMA, ETT)

Skills Station: Mask ventilation �Most pediatric codes are from primary respiratory arrests �Pediatric patients

Skills Station: Mask ventilation �Most pediatric codes are from primary respiratory arrests �Pediatric patients are more likely to laryngospasm – positive pressure ventilation and jaw thrust are the first line treatment �Kids come in many different sizes!

Mask ventilation

Mask ventilation

Airway Equipment Nasal trumpet Oral airway

Airway Equipment Nasal trumpet Oral airway