Paediatric Anaesthesia

Dr Ang Chia Min

 Paediatric definitions
Term Age
Neonate Newborn up to first 28 days of life
Premature infant <37wks gestational age
Infant From 1-12 months of age
Children 1 – 12 years of age
Adolescent 13 – 16 years of age
Difference between paediatric
and adult airway
 Airway

• The head is relatively large with

a prominent occiput

• the neck is short and

the tongue is large.

• The airway is prone to obstruction

• Open the airway:

Infant – neutral position; child sniffing position
 Airway
• Open the airway:
Infant – neutral position; child sniffing
position
 Airway
• neonates breathe mainly through their nasal airway,
obligate nasal breather.
• Nasal passages are narrow
• Nasal obstruction can cause respiratory distress
 Airway
• The larynx is higher in the neck (C3-4 compared to C5-6 in adult),
cricoid ring at the level of C4 at birth, C5 at age of 6, compared to
C6 in the adult.
 Infant vs adult larynx

The epiglottis is large, U-shape, stiff and

flops posteriorly
Infant vs adult larynx
 Airway
• the narrowest part of the airway is at the
cricoid ring. (In the adult airway the narrowest
point is the vocal cords).

Adult’s airway Child’ airway

• The diameter of the trachea in the newborn is
4-5mm. tracheal oedema of just 1mm can
dramatically increase resistance to breathing.
 Airway
• The size of the endotracheal tube is critical,

• too large will exert pressure on the internal surface of

the cricoid cartilage resulting in oedema which could
lead to airway obstruction when the tube is removed.

• An uncuffed endotracheal tube which has an air leak

around it when positive pressure is applied to it should
be used in children under 8 years of age (traditionally).

• An uncuffed tube provides a larger internal diameter

compared with a cuffed tube.
Cuffed vs uncuffed ETT
• Cuffed vs Uncuffed Endotracheal Tubes for Pediatric
Patients: A Review
• Yim A1, Doctor J1, Aribindi S2, Ranasinghe L3*
1
Fourth-year Medical Student, California Northstate University College of Medicine, Elk Grove, CA,
USA
2
Pediatric Anesthesiologist, Kaiser Permanente, South Sacramento, CA, USA
3
Professor of Medical Education and Emergency Medicine, 
California Northstate University College of Medicine, Elk Grove, CA, USA

• Published date: 10 February 2021

• Debatable
• Use of cuffed ETT for brief duration
• not enough large, randomized controlled studies have been
performed providing high quality evidence in support of cuffed ETT
use
 Cuffed vs uncuffed ETT for neonates??

• Cochrane Database of Systematic Reviews

Cuffed versus uncuffed endotracheal tubes for
neonates
• published: 24 January 2022
• One RCT
• Lack of evidence
 Airway
• The trachea is short (approximately 4-5cm in
neonate)
• the right main bronchus is less angled than the left.
(Right angle: 30, left angle: 45)
• Right bronchus intubations are therefore more likely.
Airway

• Right bronchus
intubation – right lung
ventilation
 Airway
• peripheral airways with a diameter of less than
2mm contribute 50% of the airways resistance.
(adult: 20%)
• Disease of these small peripheral airways (e.g.
bronchiolitis) can cause severe respiratory
distress.
• Bronchospasm/asthma is uncommon in
neonate – less bronchial muscle is present
 Apnoea of prematurity
• Apnoeas are common post operatively in
premature infants up to 50-60 post
conceptional age/post gestational age/post
menstrual age

• Significant apnoeas :
>15sec + desaturation or bradycardia
Post conceptional age
Post conceptional age
 Apnoea of prematurity
• Apnoeas are common post operatively in
premature infants up to 50-60 week post
conceptional age/post gestational age
• Or 10-20 week corrected age

• Significant apnoeas :
>15sec + desaturation or bradycardia
 Cardiovascular system
• In neonates, the myocardium is less contractile
(higher proportion of non-contractile proteins) &
less able to generate tension during contraction
& ventricle less compliant
 limit the size of stroke volume
• Cardiac output is rate dependant
• To increase cardiac output  increase heart rate
 Cardiovascular system
• Vagal parasympathetic tone predominant
 prone to bradycardia
• Bradycardia  reduced cardiac output
• Cardiac output:
At birth : 300- 400 ml/kg/min
Few months: 200 ml/kg/min

• Sinus arrhythmia is common in children

 Desaturation & bradycardia
• Bradycardia occurs in response to hypoxia and
should give O2 rather than atropine

• Neonatal / infant HR < 60bpm require external

cardiac compression
Difference between paediatric and
adult Renal system
 Renal system
• Renal blood flow and GFR are low in the first 2
years of life due to high renal vascular
resistance.

• Tubular function is immature until 8 months,

so infants are unable to excrete a large
sodium load
 Maintenance fluid
Neonates :
•day 1 : 60ml/kg/day
•day 2 : 90ml/kg/day
•day 3 : 120ml/kg/day
•day 4 : 150ml/kg/day till 6 month of life
•6 month to 1 year : 120ml/kg/day
• 1 year old onward
• First 10kg - 4ml/kg/h,
second 10kg – add 2 ml/kg/h
subsequent kg - add 1 ml/kg/h
Renal System
 Renal System
• There is a larger proportion of ECF in children.

• Dehydration is poorly tolerated.

• Premature infants have increased insensible

losses as they have a larger body surface area
relative to weight

• Urine output 1-2 ml/kg/hour

Difference between paediatric and
adult hepatic system
 Hepatic System
• Liver function is initially immature with
decrease function of hepatic enzymes.

• Barbiturates and opioids have a longer

duration of action due to slower metabolism
 Glucose Metabolism
• Hypoglycaemia is common in the stressed neonate

• Glucose level should be monitored regularly

• Neurological damage may result from hypoglycaemia

• Infusion D10% may be used to prevent hypoglycaemia

• Infants and older children maintain blood glucose better

and rarely need glucose infusions.

• Hyperglycaemia is usually iatrogenic

Glucose Metabolism
Risks of neonatal hypoglycaemia
Difference between paediatric and
adult haematology system
 Normal blood volumes
•  blood volume varies according to age
Age Estimated bld volume

preterm 90-100 mls/kg

term 85-90 mls/kg

6 weeks to 2 years 85 mls/kg

2 years to puberty 80 mls/kg

 Haematology
• At birth, 70-90% of the haemoglobin molecules are HbF
• Within 3 months the level of HbF drop to around 5% and
HbA predominates
 Haematology
• HbF combines more readily with oxygen but oxygen is
released less readily as there is less 2,3-DPG
• Oxygen dissociation curve shifts to the right as levels of HbA
and 2,3-DPG rise
• HbF is protective against red cell sickling
 Haematology

• Newborn: Hb level ~18-20 g/dL

(Hct 60%)

• Increase in circulating volume

increases more rapidly than the
bone marrow function

• 3-6 months: Hb level ~9-12 g/dL

 Haematology
• Vitamin K dependent clotting factors (II, VII, IX, X)
and platelet function are deficient in the first few
months.
• Vitamin K is given at birth to prevent
haemorrhagic disease of the newborn
• Transfusion is generally recommended when 15%
of the circulating blood volume has been lost.
Difference between paediatric and
adult temperature control
 Temperature control
Why paeds / neonates easily loss heat?
•Poorly developed thermoregulatory mechanism,
limited sweating capacity
•High surface area to weight ratio
•Minimal subcutaneous fat and poor insulation
•Vasoconstrictor response is limited
•Neonates unable to shiver, rely primarily on non-
shivering thermogenesis to generate heat
 Temperature control
• Non shivering thermogenesis : metabolism in
brown fat found in the back, around the
scapulae, kidneys and adrenal glands and
mediastinum around major thoracic vessels.
Brown fat deficient in premature

• During GA, depress the thermoregulatory

response. Heat is lost from core to the cooler
peripheral compartment
Prolonged hypothermia can cause :
•Acidosis
•Impaired perfusion
•Impair platelet function
•Duration of opioid and muscle relaxant is
prolonged
•Respiratory depression
•Increases the risk of infection
Heat loss during surgery
 Temperature control

The optimal ambient temperature to prevent

heat loss is
• 34 C for premature infant
• 32 C for neonates
• 28 C for adolescents and adults
Difference between paediatric and
adult central nervous system
 Central Nervous System
• Neonates can appreciate pain and this is associated with
increased heart rate, BP and a neuro-endocrine response.

• Narcotics depress the ventilation response to a rise in the

PaCO2.

• The blood brain barrier is poorly formed

• Drugs such as barbiturates, opioids, antibiotics and

bilirubin cross the blood brain barrier easily causing a
prolonged and variable duration of action.
 Central Nervous System
• The cerebral vessels in the preterm infant are thin
walled, fragile. They are prone to intraventricular
haemorrhages.

• Risk of intraventricular haemorrhage: hypoxia,

hypercabia, hypernatraemia, low haematocrit, awake
airway manipulations, rapid bicarbonate administration,
fluctuations in BP and cerebral blood flow

• Cerebral autoregulation is present and functional from

birth.
 Perioperative
management of paediatric
patients
 Pre-operative visit

• To develop rapport and trust with the child and parent

• Age of the child

– in preterm baby, postconceptional age is important.

- Risk of laryngospasm is higher in children <2yo.

Post conceptional age
 Pre-operative visit
• Medical problems including congenital anomalies

• Recent respiratory illness

• Current medications

• Any previous problems with anaesthetics including family history

• Allergies

• Fasting time

• Presence of loose teeth

 Pre-operative visit
Examination:
• weight, general appearance, airway, respiratory systems, CVS
• Weight estimation= (age +4) x 2

Investigations:
• Hb – large expected blood loss, premature, congenital heart
disease, systemic illness
• BUSE – renal or metabolic disease, dehydration
• CXR – respiratory disease, scoliosis, heart disease
 Pre-operative visit
• Discuss with parent regarding post-operative pain
management and take consent – suppository, caudal
block, epidural, ivi morphine, PCA morphine

• Pre-operative fasting:
• 6 hours for solids and formula milk
• 4 hours for breast milk
• 2 hours for unlimited clear fluids

• Pre-medication: EMLA, midazolam (0.5mg/kg, max 15mg)

 Intraoperative
Preparation for anaesthesia
• Warm the theatre and prepare warming devices
• Emergency drugs
• Equipments ready and checked – MALES: Mask,
Airways, Laryngoscope, Endotracheal tube,
Suction
• Monitoring – ECG, BP, Sat, Capno, Temp
Airway equipments
Oropharyneal airway
•Size from 000 – 4 (4-10cm in length)
Oropharyneal airway
•Correct size = distance from incisor to the angle
of the jaw
•Incorrect size – may worsen the airway
obstruction
Nasopharyngeal Airway
•Limited application in paeds
•May be used during induction/recovery of some
congenital airway problems or obstructive sleep
apnoea
•Appropriate length = distance from the tip of
nostril to the tragus of the ear
•If ETT use as nasopharyngeal airway,
size=age/4 +3.5
Facemask
•Clear plastic mask with
inflatable rim, provide an
excellent seal for
spontaneous assisted
ventilation
•Also available “flavoured mask”
•Transparent design – allow for observation of
cyanosis/regurgitation and the presence of
breathing

•Size – to fit bridge of the nose to

the cleft of the chin
Laryngeal Mask Airway
Laryngoscope
•Size from 00 – 3

0
Straight blade vs
curve blade
Straight blade vs
curve blade

Curved blade – anterior to Straight blade – posterior to

Epiglottis, in the vallecula Epiglottis, Lift up the epiglottis
Curved blade vs straight blade
ETT size
 ETT size
Weight or age ETT size (mm Internal diameter)
< 2 kg 2.5
2 – 4 kg 3.0
Term neonate 3.5
3 month – 1 yr 4.0
> 2 yr Tube size = Age + 4 (uncuffed tube)
4
Age
+ 3.5 (cuffed tube)
4

•Correct size – when ventilation is adequate

but a small audible leak of air present when
positive pressure applied at 20cmH2O
Insertion depth (tube length in cm)
How deep should you anchor the ETT?
For children > 1 year:
Age
- 2 +12 (or tube size x 3) for oral ETT
Age
- 2
+15 for nasal tube

For children <1 year:

Age in month
- 2
+8
 Ventilation
Parameter Neonate Adult
Tidal volume (spontaneous) ml/kg 7 7-10

Tidal volime (IPPV) ml/kg 7-10 10

Dead space (ml/kg) 2.2 2.2
Respiratory rate 30-40 15
Compliance (ml/cmh2O) 5 100
Resistance (cmH2o/l/s) 25 5
Oxygen consumption (ml/kg/min) 7 3

Estimate RR from the formula = 24 – Age

2
 Anaesthetic breathing circuit
• Many older anaesthesia ventilators designed
for adults cannot reliably provide the low tidal
volumes and rapid respiratory rates required
for infants and small children.

• Unintentional delivery of large tidal volumes

to a small child can generate large airway
pressures and cause barotrauma (damage to
the lungs due to excessive inspiratory
pressure).
Paediatric circle circuit
 Circle system
Components :
•two one way valves (one inspiratory and
one expiratory),
•a reservoir bag,
•a fresh gas inlet,
•a canister of soda lime
•an expiratory spill valve.
Ayre’s T-piece with Jackson-Rees
modification (Mapleson F)
Ayre’s T-piece with jackson-Rees
modification (Mapleson F)
 T-piece
• Suitable for all children up to 20kg, beyond that become inefficient
• Advantage : low resistance, valveless, lightweight circuit
• The open ended 500mls reservoir bag allows
• Assessment of Tidal volume
• Ability to partially occlude bag for CPAP or PEEP
• Potentially for assisted controlled vent
• Qualitative appreciation of lung compliance
• Reduction of dead space during spontaneous breathing
• Disadvantages :
• scavenging is limited
• High fresh gas flow (FGF) in spontaneous breathing than controlled vent
• Need 2-3x minute volume for spontaneous vent
• FGF dependant on RR, rapid RR require higher FGF
 Paediatric circle circuit vs T-piece
• Low- flow anaesthesia is cost-efficient, reduces
atmospheric pollution and conserve warm &
moisture.
• Paeds circle system using 15mm lightweight
hose, suitable for children >5kg
• During controlled ventilation, the leak around the
ETT may require FGF to increased
• In general circle systems are bulky with increased
resistance making them less suitable for
spontaneously breathing children.
Heat loss during surgery
 Measures to conserve heat loss
• OT should heated before surgery to warm the wall and
to raise the ambient temperature
• Ambient temp : 28c for older children, 32 for neonates
• Avoid exposure of the child. Cover head with
cap/bonnet, the rest of the body can also be insulated
with warm gamgee
• Use active warming device : warming mattress,
convective warm air blanket, radiant heater
• Humidify and warm anaethetic gas (HME)
• All operative fluid / blood should be warmed
• Cleaning fluid should be kept warm
• Temperature monitoring essential for long op
• Transport small babies in the incubator
Measures to conserve heat loss
Measures to conserve heat loss
 Induction of Anaesthesia
• Inhalational induction
– no iv access or difficult iv access
- Require a skilled assistant to maintain the airway while iv
access is obtained
- Sevoflurane inhalational induction
- 8% sevo used in uncooperative child
- Increase sevo gradually in cooperative child
- Nitrous oxide may be used if no anticipated airway
problem
 Induction of Anaesthesia
- Correctly sized oropharyngeal airway may be
used as airway tend to be obstructed during
inhalational induction
- Iv access: dorsum of the hand, inner wrist,
dorsum of the foot, long saphenous vein, cubital
fossa
- IV Induction – fentanyl, propofol/thiopentone,
muscle relaxant
 Induction of Anaesthesia
- Rapid sequence induction in children – high risk of
aspiration such as distended abdomen, intestinal
obstruction. Rocuronium is preferred over
suxamethonium

- ‘Modified RSI’ – due to low FRC and high closing volume,

once the child is apneic, splinting of diaphragm by
distended abdomen will cause saturation to drop rapidly
without assist ventilation. Low pressure assist ventilation
may be required during rapid sequence induction
 Induction of Anaesthesia

- Intubation – straight blade vs curved blade,

ETT cuffed vs uncuffed, LMA,
- Monitors – ECG, SpO2, BP, Capno, Temp
- Ventilation
- Positioning of patient
- Warming devices – wrap the patient, warmer,
fluid warmer, etc
 Maintenance of Anaesthesia

• TIVA or inhalational agent

• Analgesia – suppository, regional analgesia, iv
narcotics
• Iv fluids – iv drips set used for surgery longer
than 30 mins. Fluid boluses for short surgery.
Fluid requirement for paediatric
 Fluid requirement

• Maintenance + deficit + ongoing losses

 Maintenance fluid
• Studies shown that using a solution containing
dextrose 5% during surgery invariably cause
hyperglycemia – leading to osmotic diuresis and
dehydration & electrolyte imbalance.
• If dextrose –free solutions are used, an intraop blood
glucose monitoring is required
• Fluid contains 1% or 2.5% dextrose will correct any
preop hypoglycemia & not produce intra op
hyperglycemia
 Maintenance fluid
Neonates :
•day 1 : 60ml/kg/day
•day 2 : 90ml/kg/day
•day 3 : 120ml/kg/day
•day 4 : 150ml/kg/day till 6 month of life
•6 month to 1 year : 120ml/kg/day
• 1 year old onward
• First 10kg - 4ml/kg/h,
second 10kg – add 2 ml/kg/h
subsequent kg - add 1 ml/kg/h
 Maintenance fluid
8kg Child (first 10kg is 4ml/kg/h)
8kg X 4mls/kg = 32mls/hour maintenance

12kg Child (is 10kg + 2kg)

10kg X 4mls/kg = 40 mls/hour
+ 2kg X 2mls/kg = 4 mls/hour
Total = 40 + 4 = 44mls/hour maintenance

25kg Child (is 10kg + 10kg + 5kg)

10kg X 4mls/kg = 40 mls/hour

+ 10kg X 2mls/kg = 20 mls/hour
+ 5kg X 1mls/kg = 5 mls/hour
Total = 40 + 20 + 5 = 65mls/hour
maintenance
 Deficit fluid
• Deficit: fasting, vomiting, diarrhoea, etc..
• Deficit due to fasting =
maintenance fluid x hours of fasting
• ½ deficit - replaced over first hour
• Another ½ replaced over next 2 hrs
• Use NS or hartmann
• Colloid in severe dehydration
Assessment of dehydration
 Ongoing loss
• losses of fluid from bleeding or
• "third space" loss and any pre-existing deficits. "Third space" loss
refers to an isotonic transfer of fluid from ECF to a non-functional
interstitial compartment

• Some of this fluid forms oedema in the area of the operation, some
may be lost into the bowel and there may also be losses from
evaporation.
• In general the more major the surgery the more replacement fluid
will be required. If without replacement, the plasma volume will
depleted
• commonly replaced by balanced salt solutions such as Hartmanns
solution or NS
• Colloid solutions are sometimes used when losses are heavy.
Ongoing loss
•The volume loss is impossible to measure
•Estimate for normal 3rd space loss ;
• Intraabdominal surgery : 6-10ml/kg/h
• Intrathoracic surgery : 4-7ml/kg/h
• Eye surgery/ superficial/neurosurgery :
1-2ml/kg/h

•Clinical response to replacement :

- Adequate BP & HR
- Adequate tissue perfusion
- Urine output of 1-2mls/kg/h
 Blood loss
•  blood volume varies according to age
Age Estimated bld volume
preterm 90-100 mls/kg
term 80-90 mls/kg
Infant 75-80 mls/kg
Older children 70-75 mls/kg

• In general blood replacement is required when the haematocrit

drops below 25% (around a Hb of 8  g/dl) or when the estimated
blood loss exceeds 15-20% of the calculated blood volume.
• Initial replacement can used crystalloid or colloid
• If crystalloid use, volume of three times the estimated blood loss
should be given. Usually use Hartmanns solution or 0.9% saline.
• Colloid replacement 1:1 (eg of colloid – gelatin, dextran, albumin)
• Allowable blood loss =
wt x EBV x ( Ho –Hi) / Ha
- Ho= pt’s original hct,
Hi = lowest acceptable hct
Ha = average hct = H0+Hi /2

Age Normal HCT Acceptable HCT

preterm 0.40-0.45 0.35
Term 0.45 – 0.65 0.30-0.35
3mo 0.30-0.42 0.25
1 yr 0.34-0.42 0.20-0.25
6 yr 0.35 – 0.43 0.20-0.25
 Calculation of blood loss

•collecting and measuring suction blood during the procedure.

• Swabs may be weighed on a simple pair of kitchen type scales.
•Volume of blood loss = total weight – weight of the dry swabs
The swabs should be weighed before they dry, because of
inaccuracies due to evaporation
Hemocue – Bedside estimation of
Hemoglobin
ABG / VBG hemoglobin level trend to estimate blood loss
 Fluid requirement
• 1st hour = Maintenance + ½ deficit + ongoing losses

• 2nd hour = maintenance + ¼ deficit + ongoing losses

• 3rd hour = maintenance + ¼ deficit + ongoing losses

Reversal/emergence from Anaesthesia
• Extubation laryngospasm occur less frequently
if the child is fully awake at the time of
extubation.

• Disconnect iv line and put a stopper to the

branula in case the child struggle during
emergence
 Deep vs awake extubation and
LMA removal in children

• both techniques have an acceptably low

frequency of complications
• adverse respiratory events could happen in
both awake and deep planes of anesthesia
after the removal of LMA in children
Laryngospasm
 Laryngospasm

• Iv propofol 1mg/kg

• +/- paralyse with sux 0.1-2mg/kg or muscle

relaxant and intubate
THANK YOU