whats new in paediatric anaesthesia by dr. mrs. minnu m. panditrao

WHATS NEW IN PAEDIATRIC WHATS NEW IN PAEDIATRIC ANAESTHESIAANAESTHESIA

DRUGSDRUGS

WHATS NEW IN PAEDIATRIC WHATS NEW IN PAEDIATRIC ANAESTHESIAANAESTHESIA

DRUGSDRUGS

Dr. Mrs. Minnu M PanditraoConsultant

Department of Anaesthesiology &

Intensive CarePublic Hospital Authority’s

Rand memorial hospital, Freeport, Bahamas

INTRODUCTION

• Challenging subspecialty• Smaller size & weight • Difference in pharmacokinetics

Paediatric Anaesthesia

NEONATES & INFANTS• Do they really need anaesthesia?• Yes, they do• Precision & accuracy very

important for safety

What is new? CURRENT PRACTICES• Pre anaesthetic preparation &

medication• Anaesthesia Induction agents

Inhalation agents IV Induction agents

• Neuromuscular blocking drugs• Reversal agents• Analgesics - Opioids/Non Opioids • Local anaesthetics• Miscellaneous drugs

PRE OPERATIVE PREPARATION

• Pre operative checkup / visit • Counseling of patients / parents• General explanation of place,

equipment & procedure

PREMEDICATION• Injectables are not preferred • Other routes

– Oral :- Triclofos, Promethazine, Midazolam, Ketamine

– Sublingual/Trans Mucosal :- Fentanyl– Intra nasal :- Midazolam, Ketamine,

Sufentanil– Rectal :- Midazolam, Methohexital,

Diazepam, Ketamine– IM :- Ketamine (2 mg/kg)

INDUCTION AGENTS

• Inhalational – for routine surgeries, uncooperative patients, incremental induction/ starting with high concentrations.

• Intravenous – for rapid sequence induction in emergency surgeries, patients with i.v. lines in situ, cooperative patients.

•Polyflurinated methyl isopropyl ether•Inhalational agent of choice for induction•Rapid induction & recovery - low blood

gas solubility •Techniques of induction•MAC•Metabolism•Disadvantages

SEVOFLURANE

HALOTHANE

• Still used ‘coz of cost restraints • Advantages • Techniques of induction • Disadvantages

ISOFLURANE

• Maintenance Inhalational Anaesthetic Agent

• Advantages• Disadvantages• MAC/ Metabolism

DESFLURANE

• Most recent inhalational anaesthetic agent

• More suitable for Maintenance• Advantages• Disadvantages• MAC/ Metabolism

INTRAVENOUS INDUCTION AGENTS

• Rapidly acting Alkyl Phenol• Potent, No analgesia• Dosage bolus : 2.5 – 4 mg\Kg

infusion : 0.1 – 0.2 mg\Kg\min • Advantages• Propofol infusion syndrome• For TIVA - Paedfusor

PROPOFOL

KETAMINE

• Water soluble, non irritant• Good analgesic, CVS stability• Routes of administration

I.V. / I.M. (for induction)Oral, Intra nasal IV infusionAdditive in neuraxial, regional blocks

• Disadvantages

THIOPENTONE

• Still has a place where other IV agents are contraindicated i.e.

•Neuroanaesthesia in neonates•Convulsive disorders etc.

• Paediatric patients areResistant to depolarizing NMBDs Sensitive to non-depolarizing

NMBDs• Metabolism in the liver delayed

NEURO MUSCULAR BLOCKING DRUGS

• Succinyl Choline• Atracurium / Cisatracurium• Mivacurium• Doxacurim

• Vecuronium/Pancuronium• Rocuronium• Rapacuronium

• Priming with NMBDs

REVERSAL AGENTS

• Neostigmine / Edrophonium + Atropine / Glycopyrrolate

• Sugmadex – Modified γcyclodextrin sodium salt, specific for reversal of rocuronium. No need to combine with Atropine. Reports of use in adults.Dose: 12-15 mg\Kg

ANALGESICS

• Fentanyl• Alfentanyl• Sufentanil• Remifentanyl

OPIOIDS- agonists

OPIOIDS

• Butorphenol• Buprenorphine• Tramadol• Codiene

NSAIDS

For mild – moderate pain relief

Drug Oral dose Rectal dose IM dose IV dose

Paracetamol

10-15 mg\Kg 6 hrly

20-40 mg\Kg 12 hrly

15 mg\Kg 12 hrly

Diclofenac

1-1.5 mg\Kg 12 hrly

1-1.5 mg\Kg 12 hrly

1-1.5 mg\Kg

1 mg\Kg

Ibuprofen 5-10 mg\Kg 6 hrly

Ketorolac 0.5 mg\Kg 0.5 mg\Kg

LOCAL ANAESTHETICS

Drugs Single shot techniqueMg\Kg

Continues infusion Mg\Kg\hr

Max. dose \4 hr periodMg\Kg

Lignocaine 3-5

Bupivacaine 2-2.5 0.2-0.5 2

Levobupivacaine

2 0.125-0.4 2

Ropivacaine 3 0.2-0.4 1.6

Neonates and infants - prone to L.A. toxicity

Local Anaesthetic Doses

MISCELLANEOUS DRUGS

Clonidine• α2 adrenergic agonist• Co-analgesic Routes of administration

Oral (1-2 g\ Kg 8 hrly) IV ( 0.1- 0.5 g\ Kg\ hr) Spinal/epidural (2 g\ Kg) Regional nerve blocks

Dexmedetomidine

A newer α2 adrenergic agonist

Has hypnotic & analgesic properties

Reported use – as a sedative for

Radiological investigative procedures

Cardio-catheterisation

Awake craniotomies

Burn dressings

Sevoflurane emergence agitation

Also co-administered in paediatric cardiac anaesthesia

Dexmedetomidine

• Given as an I.V infusion• Dose:• Loading dose 1-4 g\ Kg• Infusion rate 0.5-1 g\ Kg\ hr• Onset of action 10-20 min• Recovery time 20-60 min• Side effects

↓ HR (15 %) ↓ MAP (15%)

Gabapentin

• Has an analgesic and opioid sparing effect

• Dose 10-20 mg\Kg orally• Side effects

Gastritis Nausea, Vomiting Dizziness

Melatonin -for sedationSatisfactory effect in elderly patients. Unsatisfactory in children Dose- 5-10 mg

Caffeine- for apoenic spellsDose- 10 mg\Kg\24 hrsSide effects: Tachycardia, Sympathetic stimulation

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