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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