PEDIATRIC CHALLENGES
| ANESTHESIA FOR COMMON PEDIATRIC EMERGENCIES —Daniel E. Lee, MD, PhD, Assistant Clinical Professor
of Anesthesiology and Pediatrics, University of California, San Diego, School of Medicine
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| Foreign body aspiration: most common in toddler age group, or infants with toddler in home; history of coughing or
choking while eating, followed by signs of respiratory distress, wheezing, or stridor; physical examination helps determine
level of airway obstruction for planning anesthetic and surgical management; usually requires surgical retrieval;
stridor may be caused by foreign body lodged in esophagus at cricoid level; severe obstruction and cyanosis may be
caused by large foreign body trapped at level of glottis or trachea; unilateral wheezing may be heard when food particles
aspirated into distal airways; preoperative preparation should include discussion of timing with surgical specialist; before
induction of anesthesia, premedicate with atropine 20 µg/kg given intravenously (IV) or intramuscularly (IM); minimizes
secretions, facilitates action of topical airway anesthesia, and helps to maintain heart rate; sevoflurane or halothane inhalational
induction with spontaneous ventilation preferred initially; positive-pressure ventilation may become necessary;
under deep inhalational anesthesia, direct laryngoscopy used to visualize and remove supraglottic foreign body; topical
lidocaine 2% to 4% (maximum 5 mg/kg) then sprayed onto vocal cords and into trachea; in cases of intermittent airway
obstruction, supplemental IV anesthesia may be necessary (eg, propofol); deeper anesthesia may be necessary using
short-acting narcotic (eg, alfentanil 5 µg/kg per dose or remifentanil 0.5 to 1.0 µg/kg per dose) or paralytic; controlled
ventilation accomplished via rigid bronchoscope or intermittently by mask; if esophagogastroduodenoscopy (EGD) indicated,
secure airway with endotracheal tube (ETT)
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| Epiglottitis: life-threatening airway emergency; less common with Haemophilus influenzae type B vaccine; caused by
Group A β-hemolytic Streptococcus and Staphylococcus aureus; occasionally, symptomatology mistaken for croup;
rapid onset; characterized by high fever; symptoms include stridor, tachypnea, no cough, drooling, and sitting in tripod
position with upper body leaning forward; make every effort to keep child calm and comfortable; surgical specialist
should be in room when anesthesia induced for possible emergency tracheostomy; inhalation induction while keeping
child in comfortable sitting position; escort parents out of room after child anesthetized; start IV line; give atropine 20 µg/
kg; start fluid bolus while deepening anesthetic; when child has reached deep plane of anesthesia, intubate with normal
laryngoscopy and ETT ≥0.5 mm smaller than usual; if laryngeal structures cannot be identified, external compression
may be attempted; intensive care unit management includes IV antibiotics for 24 to 48 hr with ETT in place; once swelling
sufficiently resolved, trial of extubation appropriate; before removal of ETT, preparations should be made for rapid
reintubation
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| Peritonsillar abscess: most common in children and young adults; presentation includes fever, throat pain, difficulty
swallowing, and trismus; physical examination reveals deviation of uvula and swelling in tonsillar bed; IV antibiotics treatment
of choice; if child unresponsive, surgical incision and drainage necessary; in cooperative young adult, this may be accomplished
without anesthesia; younger child requires general anesthesia for procedure; if minimal airway distortion and no
difficult intubation anticipated, IV induction with short-acting muscle relaxant appropriate; gentle laryngoscopy to avoid
premature rupture of abscess; if abscess ruptures prematurely, place child in head-down position and suction immediately to
avoid soiling lungs with inflammatory tissue; cuffed ETT and head-down position during surgical lancing of abscess can
help decrease chances of soiling airway; if trismus severe or airway seems difficult, inhalational induction with sevoflurane
or halothane allows for maintenance of spontaneous ventilation; gentle laryngoscopy can facilitate oral endotracheal intubation;
back-up emergency airway equipment should be available before induction; have surgical specialist present for possible
surgical airway; postoperatively, clear airway of all inflammatory material and extubate child awake
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| Retropharyngeal abscess: more concerning; infection and inflammation in posterior pharynx may push forward to obstruct
upper airway; presentation includes fever, painful swallowing, and trismus; posterior pharyngeal mass easier to evaluate
with lateral x-ray or computed tomography (CT); physical examination may show “tremendous erythema and signs of upper
airway obstruction”; anesthetic management essentially same as with peritonsillar abscess, although have higher index of
suspicion for losing airway upon induction of anesthesia; if concerned about airway compromise before induction, inhalational
technique should be used and spontaneous ventilation maintained; evaluate airway with gentle laryngoscopy; advanced
airway techniques or tracheostomy should be available; postoperatively, clear airway of all inflammatory material and extubate
child fully awake
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| Posttonsillectomy hemorrhage: surgical emergency; may occur in first 24 hr or after 5 to 10 days when tonsillar bed
eschar retracts; presents with anemia, hypovolemia, and stomach full of blood; preoperative preparation should include hematocrit,
blood type and crossmatch, and fluid resuscitation (20 to 40 mL/kg); anesthetic induction should be prepared for
airway obscured by blood; have large-bore suction, multiple laryngoscope blades, and styletted ETT available; hypovolemia
may persist; use hemodynamically neutral induction agents; rapid sequence IV induction with ketamine 2 mg/kg or etomidate
0.2 mg/kg and succinylcholine provides good rapid intubating conditions; minimizes risk for hemodynamic embarrassment
with induction; intraoperatively, protect airway with cuffed ETT; send for clotting studies and replace clotting factors
as necessary in case of ongoing hemorrhage; postoperatively, suction stomach and extubate child fully awake; repeat hematocrit
and closely monitor for airway obstruction or recurrent hemorrhage
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| Hypertrophic pyloric stenosis: occurs in ≈1 in 500 live births; presents at 6 wk of age; more common in boys than
girls; causes gastric outlet obstruction; presents with dehydration, hypochloremic metabolic alkalosis (promotes postoperative
hypoventilation), hypokalemia, hyponatremia, and hypocalcemia; not surgical emergency, and adequate resuscitation
must occur before surgical correction; preoperative management includes rehydration, nasogastric suctioning, and
correction of electrolyte imbalance; sufficient resuscitation indicated by sodium bicarbonate <30 mEq/L, potassium >3.2
mEq/L, adequate urine output (1 to 2 mL/kg per hour), and sodium chloride >90 mEq/L; anesthetic induction includes
premedication with atropine to minimize bradycardic response; rapid sequence induction and intubation indicated (with
propofol and succinylcholine); if difficult airway anticipated, awake intubation may be attempted; on emergence, suction
stomach contents and have child fully awake before extubation; postoperative considerations involve risk for apnea (due
to cerebrospinal fluid [CSF] alkalosis); overnight apnea monitoring indicated; local anesthesia during surgery (eg, bupivacaine
2.5 mg/kg) and rectal acetaminophen (30 to 40 mg/kg loading dose) should minimize apnea risk by avoiding narcotics;
maintain apnea monitoring 12 to 24 hr postoperatively
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| EMERGENCE AGITATION —Gary M. Scott, MD, Associate Professor of Clinical Anesthesiology and Pediatrics, Keck
School of Medicine of the University of Southern California, Los Angeles and Staff Anesthesiologist, Childrens Hospital
Los Angeles
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| Definitions: clinical state in which patients “awake” but have alterations in mental status that may manifest as disorientation,
confusion, lethargy, and physical behavior that may be violent and harmful; disturbance in child’s awareness of, and
attention to, his or her environment, with disorientation and perceptual alterations, including hypersensitivity to stimuli
and hyperactive motor behavior, in immediate postanesthesia period
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| Scoring scale: pediatric anesthesia delirium scale consists of 5 components (each component has associated numeric
value), 1) eye contact with caregiver, 2) purposeful actions, 3) familiarity with surroundings, 4) restlessness, and 5) inconsolability
|
| Clinical review: reported incidence as low as 10% to as high as 80%; occurs most often immediately upon entering postoperative
period; tends to be short-lived; also may be associated with onset of postoperative maladaptive behavior; associated
drugs include atropine, barbiturates, scopolamine, droperidol, benzodiazepines, and ketamine; factors associated with development
of emergence delirium include 1) preschool-aged child (2 to 6 yr of age), 2) difficult temperament, 3) increased preoperative
anxiety, 4) use of inhalation anesthesia, and 5) otorhinolaryngologic procedure; role of pain in development of
emergence delirium remains unclear; study of sevoflurane vs propofol found those who received sevoflurane as maintenance
anesthesia had 38% incidence of emergence delirium (≈8 min duration); no child who received propofol for maintenance anesthesia
had emergence delirium; another study looking at children having magnetic resonance imaging (MRI) procedures
found 80% of those receiving sevoflurane had inconsolable crying, 30% developed thrashing behavior; with halothane, only
12% had inconsolable crying, and no child progressed to thrashing behavior
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| Potential etiologies: inadequate preoperative sedation and high level of anxiety during preoperative period and induction;
postoperative pain; rapid emergence in unfamiliar surrounding, especially with sevoflurane; misperception of environmental
stimuli; differing central nervous system effects; sympathetic activation; psychomotor side effects
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| Potential adverse effects: physical injury (remove IV catheters, drains, or sutures); hypertension and tachycardia; behavior
requires constant supervision by postanesthesia care unit (PACU) nurse and may affect ability to provide care for
another recovering patient; negative psychologic impact on parents or other children; patient and parent dissatisfaction
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| Management strategies: avoid high levels of preoperative anxiety; selective use of inhalation anesthesia; use of propofol,
clonidine, and dexmedetomidine; patient comfort; quiet perioperative environment; parental presence; calming
voices; optimal analgesia; if necessary, administer midazolam, propofol, flumazenil, or fentanyl; prevention key; potentially
life-threatening conditions (eg, hypoxia, severe hypercarbia, hypotension, hypoglycemia) along with pain, increased
intracranial pressure, and bladder distention may result in agitation
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| COMMON POSTOPERATIVE PROBLEMS: WHAT THE PEDIATRICIAN NEEDS TO KNOW —Myron Yaster, MD, Richard
J. Traystman Professor, Departments of Anesthesiology, Critical Care Medicine, and Pediatrics and Clinical Director, Pediatric
Anesthesiology and Pain Management, Johns Hopkins Medical School, Baltimore, MD
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| Outpatient surgery: criteria—relatively uncomplicated surgery, without excessive bleeding or involvement of body
cavities; responsible parent (with phone) available to care for child at home; mild to moderate postoperative pain; American
Society of Anesthesiologists (ASA) physical status—level 1, healthy individual; level 5, imminent death; patients at
ASA level 4 inappropriate for outpatient surgery
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| Postoperative hospitalization: preterm infants (born at <37 wk) have increased risk for postoperative apnea until ≈60
wk of age (postconceptional); postoperative admission recommended (even for healthy infants); all infants <60 wk of age
(postconceptional) at increased risk for respiratory depression with exposure to opioids for postoperative pain management
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| Therapeutic index: difference between effective dose and toxic dose; wide therapeutic index indicates minimal adverse
effects, even at large doses (eg, penicillin); many drugs used for analgesia (eg, morphine) have narrow therapeutic index
|
 | Anesthesia: general anesthetics have virtually no therapeutic index; death may occur if intubation not achieved; safety and
standardization—anesthetic agents tightly controlled; delivery machines standardized; speed of action—although agents
that have fast onset and fast clearance beneficial in many ways, waking up too quickly can cause delirium and nightmares;
all these agents associated with nausea and vomiting
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| Nausea and vomiting: affects ≈30% of patients; frequently causes delayed discharge from recovery room or unanticipated
admission to hospital after outpatient surgery
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| Causes: surgical procedure; patient predisposition; anesthetic agent (opioids especially problematic); skill of anesthesiologist;
motion; forcing oral intake
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| Prevention: avoiding triggering agents; prophylaxis; limiting oral intake
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| Treatment: serotonin antagonists (eg, ondansetron, dolasetron, granisetron); phenothiazines (eg, prochlorperazine, chlorpromazine)
no longer recommended; agents with sedating effects (eg, antihistamines) may help; speaker recommends
prophylactic treatment with serotonin antagonist for all patients; dilution with dexamethasone helps reduce cost
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| Oral intake: only patients who express hunger or thirst should take fluids before leaving hospital; forcing oral intake postoperatively
greatly increases risk for vomiting (and subsequent readmission to hospital)
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| Experience of pain: perception and individual experience of pain affected by age, personal and cultural values, and previous
experience of pain; sleep disturbances, anxiety, and anger exacerbate pain
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| Medications: most antipyretics with weak analgesic properties work by blocking cyclooxygenase (COX) receptors; acetaminophen
acts centrally, ibuprofen acts peripherally (increased analgesic effect with simultaneous administration); acetaminophen
effective if given rectally at right dose (30 mg/kg), with maximum daily dose 90 mg/kg tid; although ibuprofen
superior to acetaminophen for analgesia, it increases risk for postoperative bleeding and interferes with bone healing;
ketorolac—good alternative to IV opioids for inpatients; opioid agonists—most important drugs for managing postoperative
pain; meperidine (Demerol) associated with same degree of respiratory depression and biliary spasm as morphine,
when given at equianalgesic doses; analgesic effect of codeine occurs only after metabolism to morphine in liver; no therapeutic
effect in patients who lack conversion enzyme
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| Behavioral disturbances: after undergoing surgery, many children experience nightmares, separation anxiety, problems
eating or sleeping, and increased fear of physicians; risk affected by age, baseline anxiety, and previous experience
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Educational Objectives
| The goal of this program is to educate the listener about anesthesia for common pediatric emergencies, emergence agitation,
and common postoperative problems in pediatrics. After hearing and assimilating this program, the participant
will be better able to:
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| 1. Discuss common pediatric surgical emergencies and special considerations in their anesthetic management.
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| 2. Review the etiology and differential diagnosis of emergence agitation.
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| 3. Summarize anesthetic management plans for the prevention and treatment of emergence agitation.
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| 4. Educate patients and families about common postoperative problems.
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| 5. Prevent and treat postoperative nausea and vomiting in children.
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Discussed on This Program
Acetaminophen (several formulations and trade names)
Alfentanil HCl [Alfenta]
Atropine sulfate (several trade names)
Bupivacaine HCl (several trade names)
Chlorpromazine HCl [Thorazine]
Codeine (several formulations and trade names)
Desflurane [Suprane]
Desmopressin acetate (1-deamino-8-D-arginine vasopressin) [DDAVP, Stimate]
Dexmedetomidine HCl [Precedex]
Diazepam [Diastat, Diazepam Intensol, Valium]
Diphenhydramine HCl (Benadryl, others)
Dolasetron mesylate [Anzemet]
Droperidol [Inapsine]
Etomidate [Amidate]
Fentanyl (several formulations and trade names)
Flumazenil [Romazicon]
Granisetron HCl [Kytril]
Halothane [Fluothane]
Hydrocodone (several formulations and trade names)
Ibuprofen (various formulations and trade names)
Isoflurane [Forane]
Ketamine HCl [Ketalar]
Ketorolac tromethamine [Acular, Acular LS, Acular PF, Toradol
Lidocaine HCl (several trade names)
Meperidine HCl [Demerol]
Midazolam HCl [Versed]
Ondansetron HCl [Zofran, Zofran ODT]
Oxycodone HCl (several trade names)
Penicillin (several formulations and trade names)
Prochlorperazine [Compazine, Compro]
Promethazine HCl [Phenadoz, Phenergan]
Propofol [Diprivan]
Remifentanil HCl [Ultiva]
Scopolamine, oral [Scopace]
Sevoflurane [Ultane]
Succinylcholine chloride [Anectine, Anectine Flo-Pack, Quelicin]
Suggested Reading
Aono J et al: Greater incidence of delirium during recovery from sevoflurane anesthesia in preschool boys. Anesthesiology
87:1298, 1997; Aouad MT et al: Emergence agitation in children: an update. Curr Opin Anaesthesiol
18:614, 2005; Aouad MT et al: Preoperative caudal block prevents emergence agitation in children following
sevoflurane anesthesia. Acta Anaesthesiol Scand 49:300, 2005; Benjamin B: Anesthesia for pediatric airway endoscopy.
Otolaryngol Clin North Am 33:29, 2000; Cravero JP et al: Emergence characteristics of sevoflurane compared
to halothane in pediatric patients undergoing bilateral pressure equalization tube insertion. J Clin Anesth 12:397,
2000; Cravero JP et al: The effect of small dose fentanyl on the emergence characteristics of pediatric patients after
sevoflurane anesthesia without surgery. Anesth Analg 97:364, 2003; Doyle DJ et al: Upper airway diseases and
airway management: a synopsis. Anesthesiol Clin North America 20:767, 2002; Gorelick MH et al: Epiglottitis in
children, 1979 through 1992. Effects of Haemophilus influenzae type b immunization. Arch Pediatr Adolesc Med
148:47, 1994; Kain ZN et al: Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.
Anesth Analg 99:1648, 2004; Kain ZN et al: Sevoflurane versus halothane: postoperative maladaptive behavioral
changes: a randomized, controlled trial. Anesthesiology 102:720, 2005; Lerman J et al: Induction, recovery,
and safety characteristics of sevoflurane in children undergoing ambulatory surgery. Anesthesiology 84:1332, 1996;
Morray JP et al: Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac
Arrest (POCA) Registry. Anesthesiology 93:6, 2000; Oh AY et al: Delayed emergence process does not result
in a lower incidence of emergence agitation after sevoflurane anesthesia in children. Acta Anaesthesiol Scand 49:297,
2005; Sikich N. Lerman J: Development and psychometric evaluation of the pediatric anesthesia emergence delirium
scale. Anesthesiology 100:1138, 2004; Touloukian RJ et al: The spectrum of serum electrolytes in hypertrophic
pyloric stenosis. J Pediatr Surg 18:394, 1983; Verghese ST et al: Pediatric otolaryngologic emergencies.
Anesthesiol Clin North America 19:237, 2001; Voepel-Lewis T et al: A prospective cohort study of emergence agitation
in the pediatric postanesthesia care unit. Anesth Analg 96:1625, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Lee was recorded in San Diego, CA, at Anesthesiology Update 2006, sponsored by the University of California,
San Diego, School of Medicine, and held January 11-14, 2006; Dr. Scott, in Anaheim, CA, at the 44th Clinical Conference
in Pediatric Anesthesiology, sponsored by the Pediatric Anesthesiology Foundation, Childrens Hospital Los Angeles,
and held February 3-5, 2006; The Audio-Digest Foundation thanks the speakers and the sponsors for their
cooperation in the production of this program.
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