What are the anesthesia considerations for pediatric patients undergoing procedures?

Anesthesia Considerations for Pediatric Patients

Pediatric patients require developmentally appropriate pain assessment, multimodal analgesia including regional blockade when feasible, and careful attention to airway anatomy, drug dosing based on age and weight, and the unique physiological vulnerabilities of children including risk of postoperative apnea in former preterm infants. 1

Pre-Anesthetic Assessment

Essential History Components

• Age, weight in kilograms, and gestational age at birth (preterm infants carry risk of apnea of prematurity) 1
• Medication history including prescription drugs, over-the-counter medications, and herbal supplements (St John's wort, kava, valerian can alter drug metabolism through cytochrome P450 inhibition, prolonging sedation with midazolam and other agents) 1
• Airway evaluation focusing on tonsillar hypertrophy, abnormal anatomy (mandibular hypoplasia), high Mallampati score, and signs of obstructive sleep apnea 1
• Cardiac symptoms including syncope with chest pain, exercise-triggered chest pain, palpitations with dizziness, or decreased exercise tolerance require immediate cardiology consultation before proceeding 2
• Pregnancy status must be ascertained in females aged 12 and older on the day of surgery 1
• Family history of malignant hyperthermia, muscular dystrophy, or pseudocholinesterase deficiency 1

Physical Examination Priorities

• Vital signs including heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 1
• Focused airway assessment to identify increased risk of obstruction (document if patient is too upset to cooperate) 1
• ASA physical status classification 1

Critical Safety Considerations

Neurotoxicity Concerns

• Avoid unnecessary sedation in procedures unlikely to change medical management (e.g., screening MRI in preterm infants), as anesthetic agents may affect the developing brain 1
• The window of vulnerability extends from the third trimester through approximately 3 years of age, though research remains preliminary 1, 3

Life-Threatening Risks in Specific Populations

• Pediatric patients with Pompe disease (glycogen storage disease type II) are at risk for life-threatening ventricular arrhythmias including severe bradycardia, torsade de pointes, and ventricular fibrillation with sevoflurane induction 3
• Patients with Down syndrome experience episodes of severe bradycardia and cardiac arrest during sevoflurane induction unrelated to congenital heart disease; incrementally increase inspired sevoflurane concentration and have anticholinergic and epinephrine immediately available 3
• Patients with latent neuromuscular disease (particularly Duchenne muscular dystrophy) are vulnerable to perioperative hyperkalemia with inhaled anesthetics, leading to cardiac arrhythmias and death 3

Malignant Hyperthermia Protocol

• Immediate recognition of signs (hyperthermia, muscle rigidity, tachycardia, hypercarbia) 3
• Discontinue triggering agents (volatile anesthetics, succinylcholine) 3
• Administer dantrolene sodium intravenously with supportive therapies including supplemental oxygen, hemodynamic support, fluid/electrolyte management, and temperature control 3

Airway Management

Equipment Requirements

• Age- and size-appropriate equipment must be immediately available including resuscitation drugs in pediatric concentrations 1
• Cuffed endotracheal tubes are preferred over uncuffed tubes as they reduce re-intubation rates for excessive leakage without increasing post-extubation complications 1
• Videolaryngoscopy should be used as first option for anticipated difficult intubation with possible mask ventilation, or after failed direct laryngoscopy 1

Difficult Airway Algorithm

• First step: Optimize head position, jaw thrust, insert oral/nasopharyngeal airway or supraglottic airway, decompress stomach with NG tube 1
• Second step: Attempt to wake child if SpO2 >80%; consider sugammadex 16 mg/kg if rocuronium/vecuronium used 1
• Third step (CICO scenario): Call for help and ENT, consider emergency tracheostomy or rigid bronchoscopy; cricothyroid approaches carry major risk of failure and complications in children <8 years 1

Local Anesthetic Dosing and Toxicity

Maximum Safe Doses

• Lidocaine: 7.0 mg/kg with epinephrine, 4.4 mg/kg without epinephrine 1
• Bupivacaine: 3.0 mg/kg with epinephrine, 2.5 mg/kg without epinephrine 1
• Ropivacaine: 3.0 mg/kg with epinephrine, 2.0 mg/kg without epinephrine 1
• Doses should be decreased by 30% in infants younger than 6 months 1

Local Anesthetic Systemic Toxicity Treatment

• Administer 1.5 mL/kg of 20% lipid emulsion over ~1 minute, repeat bolus once or twice for persistent cardiovascular collapse 1
• Initiate 20% lipid infusion at 0.25 mL/kg/min until circulation restored; double rate if blood pressure remains low 1
• Seizure management: Benzodiazepines preferred (IV midazolam 0.1-0.2 mg/kg); avoid propofol if cardiovascular instability 1
• Avoid vasopressin, calcium channel blockers, β-blockers; reduce epinephrine dosages 1

Multimodal Analgesia Approach

Systemic Medications

• NSAIDs (unless contraindicated): Ibuprofen 10 mg/kg PO/IV every 8 hours; Ketorolac 0.5-1 mg/kg (max 30 mg) single intraoperative dose, then 0.15-0.2 mg/kg (max 10 mg) every 6 hours for maximum 48 hours 1
• Acetaminophen: Loading dose 15-20 mg/kg IV, then 10-15 mg/kg every 6-8 hours (max 60 mg/kg/day); rectal loading dose 20-40 mg/kg (15 mg/kg if <10 kg) 1
• Opioids: Fentanyl 1-2 mcg/kg, morphine 25-100 mcg/kg titrated to effect, remifentanil 0.05-0.3 mcg/kg/min 1

Regional Anesthesia

• Caudal blockade with long-acting local anesthetics plus clonidine adjunct should be considered as part of multimodal approach 1
• Ultrasound guidance should be used when available for regional blocks 1
• Regional blockade reduces opioid requirements and improves postoperative pain control 1

Age-Specific Considerations

Former Preterm Infants

• Admission and monitoring required for at least 12 hours after anesthesia for infants younger than 50-60 weeks postconceptional age due to elevated risk of postoperative apnea 1
• Anemia and coexisting medical problems increase apnea risk 1

Infants and Young Children

• Higher doses of local anesthetics required with shorter duration of action compared to adults 4
• Spinal puncture must be performed at L4-L5 or L5-S1 spaces to prevent spinal injuries 4
• Emergence delirium is more common after short procedures; modify anesthetic techniques to minimize risk 1

Adolescents

• Concerns about loss of control, awareness, or not waking up should be directly addressed 1
• Venous thromboembolism prophylaxis should be considered 1

Sedation Protocols

Fasting Guidelines

• Clear fluids: 1 hour before anesthesia 1
• Solid foods: Follow standard NPO guidelines based on meal type 1

Monitoring Requirements

• Pulse oximetry with tone changes for immediate aural warning; newer oximeters less susceptible to motion artifacts 1
• Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation 1
• Pediatric Advanced Life Support training and certification required for recovery nurses 1

Cognitive Aids

• Pediatric-specific emergency checklists should be immediately available in operating room and PACU for management of infrequent crises 1

Postoperative Care

PONV Prevention

• High-risk procedures (strabismus surgery, tonsillectomy) require prophylactic strategies including minimizing opioid dosing and administering pediatric-appropriate antiemetics 1
• Dexamethasone or methylprednisolone reduces postoperative swelling 1

Pain Management

• Around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen unless contraindicated 1
• Rescue analgesia: Tramadol or nalbuphine (in infants; opioid of choice in older children) 1
• Patient-controlled analgesia with adequate monitoring for major reconstructive surgery 1