ANESTHESIA FOR PEDIATRIC AND NEONATAL SURGERY
Preoperative Preparation
The preoperative visit and preparation of the child for surgery
are more important than the choice of premedication.[238]
During this time, the anesthesiologist evaluates
TABLE 60-4 -- Commonly used muscle relaxants and their reversal drugs in pediatrics
|
Muscle Relaxant
*
|
Average Intubation Dose (mg/kg) |
Category |
Approximate Duration |
|
Pancuronium |
0.1 |
Long acting |
45–60 min |
|
Cisatracurium |
0.1 |
Intermediate acting |
30 min |
|
Vecuronium |
0.1 |
Intermediate acting |
30 min |
|
Rocuronium |
|
Dose related: |
|
|
0.3 |
Short acting |
15–20 min |
|
0.6 |
Intermediate acting |
30–45 min |
|
1.2 |
Long acting |
45–75 min |
|
Mivacurium |
0.2–0.25 |
Short acting |
15–20 min |
|
Reversal Agents
†
|
|
|
|
|
Edrophonium |
0.3–1.0 mg/kg + atropine, 0.02 mg/kg |
|
|
|
Neostigmine |
0.02–0.06 mg/kg + atropine, 0.02 mg/kg |
|
|
*The
response of premature and term neonates (who may be more sensitive to the drugs)
to muscle relaxants varies greatly from patient to patient. Therefore, all doses
should be titrated to response. The recommended intubation doses may be reduced
30% to 50% in the presence of a potent inhaled drug.
†The
dose of reversal agent given to antagonize nondepolarizing neuromuscular blockade
should be determined by the degree of residual neuromuscular blockade (i.e., the
dose should be titrated to clinical effect).
the medical condition of the child, the needs of the planned surgical procedure,
and the psychological makeup of the patient and family. The anesthesiologist also
formulates the approach to induction of anesthesia, explains the possibilities regarding
induction, and helps soothe family concerns. Because anxiety felt by the parents
may be transferred to the child, any practice that reduces anxiety in the parents
may also reduce anxiety in the child. Therefore, the anesthesiologist should explain
in great detail what the child and family can expect and what will be done to ensure
the utmost safety. The more information the parents and child have, the more easily
they will deal with the stress of surgery and hospitalization. Presurgical programs
such as videotapes, literature, and hospital tours also help.
After chart review, physical examination, and furnishing of information
regarding the approximate time and length of surgery, the anesthesiologist should
describe to the child what anesthesia is and what will be done to ensure good care.
The purpose of all monitoring devices should be explained to both the patient and
family. Children need to understand that none of these devices will hurt and that
they can watch during their application. If an intravenous line will be started,
the child needs to be told that "numbing" medicine will be used. Any special monitoring
devices such as an arterial line, a central venous line, a nasogastric tube, or a
urine catheter should also be described to the parents, with assurances that these
devices will be inserted after induction of anesthesia. Part of this informed consent
is also a description of our role in the operating room. It is vital to explain
to the family that the anesthetic "prescription" will be tailored to meet their child's
medical as well as surgical needs. I like to use the phrase "anesthetic prescription"
because we are physicians, just as a surgeon or pediatrician, and it is important
for families to clearly understand this.
Children think in very concrete terms, so care must be taken to
avoid misunderstandings. It is important to explain to children that the "sleep"
caused by anesthetic drugs differs from "normal sleep." They should know that anesthesia
medicines keep them from awakening during surgery and from remembering the operation.
It should also be explained that the anesthesia medicines will be removed at the
end of surgery and that they will then wake up and return to their parents. This
kind of explanation does not require a significant amount of time and goes a long
way toward reassuring the child and family about the quality of care provided.
The issue of pain must not be avoided. Children need to be reassured
that everything possible will be done to minimize pain on awakening. Therefore,
it should be stressed that pain medications will be administered and that local infiltration
nerve blocks, patient-controlled analgesia, or continuous epidural or caudal infusions
will be used.[239]
Recovery room or intensive care
must also be described so that there are no surprises.
