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
Thank You!Thank You! Thank You!Thank You!