Paediatric anaesthesia

From greek.doctor

Paediatric anaesthesia is complicated and demanding on the clinician.

Before anaesthesia

Repeated or lengthy general anaesthesia in children can negatively affect their brain development, but short courses have no negative effect. The risk is higher in preterms and newborns.

As always, a detailed history should be taken. It’s important to know about the vaccines, as 2 – 10 days must pass between vaccines and anaesthesia. Recent upper respiratory tract infection may also be a contraindication for anaesthesia.

It’s important to prepare the child and parents mentally, and to explain the procedure in detail, so they know what to expect. Written, informed consent is needed.

Children have more rapid gastric emptying than adults. They must stop eating 6 hours before and stop drinking 1 hour before. Breast milk must be stopped 3 hours before.

Premedication to prevent pain and anxiety is used. Oral, nasal, or rectal midazolam or dexmedetomidine is used, IV and IM are not. Non-pharmacological ways of decreasing pain and anxiety like games and distractions are also important.

It’s important to prepare the proper equipment for the age of the child before anaesthesia. Tubes, masks, laryngoscopes, dosages, etc. must be changed.

During anaesthesia

For children up to 6 – 8 year old, inhalational induction with mask is usually used to avoid needle puncture while the patient is awake. Sevoflurane is usually used.

For older children, intravenous induction can be used. Propofol or barbiturates are used. Cannulation of peripheral veins in children can be difficult, even for trained personnel. The cannula must be fixed tightly so that it does not come out if the child wakes up.

Regional anaesthesia is used in paediatric anaesthesia as well, but unlike for adult anaesthesia, the patient can not be awake (i.e., general anaesthesia is required as well). After general anaesthesia has been applied, the regional anaesthesia is applied. This allows for the amount of general anaesthetic to be reduced.

Regional-only anaesthesia is used only in very minor procedures, or if general anaesthesia is risky for the child.

Post-operative

NSAIDs or paracetamol are given as premedication, with the intention to prevent postoperative pain. Regional anaesthesia given during anaesthesia is also very good at preventing postoperative pain for 6 – 12 hours. After major surgeries, opioid analgesics are needed for sufficient pain management. Children as young as 8 years can operate a patient controlled analgesia (PCA) pump effectively.

Young children are less able to express pain, so we should use other parameters to evaluate how much pain they’re in. Elevated heart rate, respiratory rate, and blood pressure can indicate pain, but the most important changes are the behavioural changes in the child, e.g. how the child is moving, the facial expressions, crying, sleep:awake ratio, etc.

Older children can use pain scales like the visual analogue scale (VAS) to express their degree of pain.