Department of Anaesthesia

University of Cape Town

Lecture 22
Paediatric Anaesthesia

Introduction
Children, especially those under the age of 8 years, are not small adults. When children present for
surgery, there are many factors that are important to consider. The effects of hospitalisation and
medical interventions may have profound emotional consequences for children. Some show
behavioural disturbances that persist long after the event. The age of the child, the emotional
maturity, cultural background and parental influence will each contribute to this. Infants under six
months of age have minimal separation anxiety and will readily accept another person in place of their
mother. Older infants and young children are much more affected, and separation from parents,
home, siblings, and their favourite toy or blanket is frightening, and psychosocial issues may become
problematic. With children up to 4

5 years of age, considerable regression may occur because one
is unable to reason with, or explain to them, what is happening. Once they reach school-going age,
their fears are different:; pain, what effect surgery will have on their looks, and the loss of control over
what is happening to them.
One symptom all children fear is pain, although this may have different meanings for different
individuals at different ages. The environment for children needs to be child-friendly and appropriate
for the different ages of patients who will be treated at that particular unit. Staff caring for ill children
and their parents should be adequately trained to do so.
Paediatric anaesthesia requires meticulous attention to detail for every aspect of care.

Definition of age groups
Prematurity: Less than 37 weeks gestational age
Neonate: 0

28 days (first 28 days of life for a full term baby)
Infants: 1 month

1 year
Toddlers: 1 year

3 years
Children: 3

7 years
Older children: 7

12 years
Adolescents: 13

18 years

These subsets have different anatomic, physiological and pharmacological parameters. A specific
approach is needed for each group. The most marked differences are in the youngest age groups
less than 3 years.

Anatomy & physiology: Differences between adults & children

Cardiovascular system (CVS)
The neonate has a poorly developed and non-compliant myocardium.
The stroke volume (SV) is fixed and therefore cardiac output (CO) is heart-rate (HR) dependent
(CO =SV x HR).
Sympathetic innervation is limited at birth and vagal tone predominates; this may result in
significant bradycardia during stressful situations (hypoxia, hypovolaemia, acidosis, large
anaesthetic doses and vagal stimulation).
Immature baroreceptors also limit a compensatory increase in HR when hypovolaemia is
present.
Always consider the possibility of anatomical defects, especially in premature babies a patent
ductus arteriosum (PDA) is common.

Respiratory system
Anatomic differences are important: Neonates have a large floppy head, tongue and epiglottis;
the narrowest part of the airway is sub-glottic at the cricoid ring (diameter of 3

4 mm!); this is
different from adults where the narrowest part is at the vocal cords.
Neonates and infants up to 6 months are obligate nasal breathers.
Lung volumes are much smaller: V
T
of 6

8 ml kg
-1
in a 4 kg neonate will be 24

32 ml vs. an
adult V
T
of 500 ml!
Paediatric anaesthesia

22 - 2
Respiratory rate (RR): 30

40 breaths min
-1
.
O
2
consumption: 6

9 ml kg
-1
min
-1
vs. adults 3

4 ml kg
-1
min
-1
. Hence prone to desaturation.
Reduced functional residual capacity (FRC) with decreased O
2
reserve.
Alveoli are immature with resultant decreased lung compliance.
Chest wall is soft and they respond to respiratory compromise and distress with tracheal tug
and intercostal recession.
Neonates rely on good diaphragmatic function to allow decent respiratory excursion and any
increased intra-abdominal pressure from space-occupying lesions may hinder breathing.
The control of breathing in full-term neonates is usually not a problem; however premature
neonates are prone to apnoea. Anaesthesia in the premature increases the risk of apnoeas
post-operatively.

Haematology
Blood volume: 90

100 ml kg
-1
in the neonate and drops to normal adult value of 80 ml kg
-1
by
1 year.
Haemoglobin (Hb): 18

20 g dl
-1
at birth and 75

80 % is foetal Hb.
Foetal Hb is gradually replaced by adult Hb A.
A physiological anaemia is present at 2

3 months because erythropoietin stops being
produced temporarily at birth and the Hb drops to 10 g dl
-1
; at 1 year Hb reaches normal levels.
Foetal Hb has a high affinity for Oxygen and offloads it poorly to the tissues, with a left-shifted
Oxygen haemoglobin dissociation curve.
Coagulation in neonates can also be a problem as the liver is immature and the vitamin K
dependent clotting factors (II, VII, IX and X) are at low levels; all newborns are given a vitamin K
injection routinely.

Liver and renal
Both liver and renal function is immature at birth.
Metabolism and excretion of anaesthetic drugs are reduced.
Neonates have a tendency to hypoglycaemia due to low glycogen stores.

Central nervous system (CNS)
Although the CNS is not fully-developed at birth, neonates can see, smell, hear and feel pain!
Drug requirements for IV agents, opioids and muscle relaxants vary according to the age of the
patient but neonatal minimum alveolar concentration (MAC) is the same as- if not lower than-
adults, whilst the MAC for infants and children is higher than adult MAC.
The fontanelles are open for the first couple of months and therefore the cranium is not a rigid
box as in adults and can better accommodate increases in intra-cranial pressure.

Thermoregulation
Hypothermia is a serious problem, especially in neonates.
They have greater heat loss through a relatively large head and large organs close to the skin
surface (e.g. liver); and their heat production is reduced due to an inability to shiver, or move in
response to cold. Their only mechanism of heat production is brown fat thermogenesis.
Be aware of this risk in theatre and take steps to keep baby warm.

Pre-operative assessment
The pre-operative assessment of children is different from adults and different for each age group. A
complete medical and surgical history is vital. Other concerns include a family history, allergies, any
medications the child is taking and the time of the last meal. In infants and toddlers, an obstetric and
birth

/

perinatal history is imperative to identify early problems and ex-premature babies. Immunisation
and growth charts are important in children; ask to see their Road-to-Health cards.
Always exclude any congenital abnormalities and syndromes, as these children can have complicated
defects that lead to a multitude of anaesthetic problems.
Identify those children who have had a recent upper respiratory tract infection (URTI) as they may
have intra-operative respiratory problems e.g. increased secretions, breath-holding, laryngospasm or
Paediatric anaesthesia

22 - 3
bronchospasm. If a child has an URTI it is best to postpone elective surgery for at least 2 weeks, and
for a lower respiratory tract infection (LRTI) postpone for 4 weeks minimum.
It is difficult to assess the airway in very small children and babies. The Mallampati score has not
been validated in children. Try to look for good mouth opening and good movement of the neck. Look
at the teeth; ask if any are loose and coming out currently! This is important to document, as there is
a danger of knocking out loose teeth with airway manipulation and potential aspiration into the lungs
a serious complication!
The remainder of the pre-operative assessment involves a general examination plus relevant special
investigations. Most healthy children undergoing minor surgery require no blood work except a finger-
prick Hb.
The art of paediatric anaesthesia begins during the preoperative interview! This interview involves the
child and parents

/

caregiver. If the child is old enough to understand and communicate, you should
explain the anaesthetic to them in age-appropriate terms. Make it fun, exciting and reduce possible
anxiety. It is useful to show the child the mask and bag of the T-piece breathing system so that they
know how the gas induction will proceed. A video of the theatre experience is also very educational.
Communication with the child and parents about the anaesthetic, operation and post-operative pain
management encourages discussion about fears they may have about the entire proceedings.
Verbal consent and documentation of this in the anaesthetic chart, for insertion of rectal suppositories
is advised, although not legally required in South Africa. If regional anaesthetic techniques are to be
used, explanations and consent should be obtained.

Premedication
No premedication is given to infants under 6 months to 1 year old (or <6 kg), as they do not
experience parental separation anxiety. Avoid sedative premedication in children with obstructive
sleep apnoea (commonly with large tonsils and adenoids) or any other cause of potential airway
obstruction.
Premedication may range from minimal light sedation to heavy sedation. Not all children require
premedication. Simple re-assurance and the presence of a parent, plus the pre-operative visit are
sufficient to allay anxiety. There should be no so-called standard premed; each child should be
assessed individually and the premedicatiom chosen to suit the child, the pathology and any
associated disease.

Options for oral premedication:
Midazolam (Dormicum

) 0,25

0,5 mg kg
-1
(max 15 mg) PO half-hour pre-operation. The
dose is achieved by cutting a 15 mg tablet and crushing it. It tastes extremely bitter and must
be given with something sweet e.g. Darrows Dextrose fluid or 50 % Dextrose. Short-acting.
Or
Trimeprazine (Vallergan forte

) 2

3 mg kg
-1
(max 90 mg) PO 2 hours pre-operation. This
is a potent, long-acting sedative, with antisialogogue and antiemetic properties. Useful in
burns children. Avoid if children are sensitive to tartrazine

and, if needed add

Droperidol 0,1

0,2 mg kg
-1
(max 5 mg) PO 2 hours pre-operation. A good antiemetic.
Or
Ketamine 10 mg kg
-1
Po 1 hour pre-operation. This should only be administered in theatre
as it is an anaesthetic induction dose, and the child should then be monitored prior to surgery.

Stopayne

syrup (each 5 ml contains 120 mg Paracetamol, 5 mg Codeine, 6,25 mg

Promethazine [a sedative], and 10 % alcohol) has excellent analgesic, sedative, anti-emetic and
anti-pruritic properties. It is sometimes mixed with the premedication to alleviate the bitter taste of
Midazolam and ensures pre-emptive analgesia before the operation starts.

Paediatric anaesthesia

22 - 4
Fasting rules
6 hours for food or formula milk (cows milk curdles in the stomach to form a solid)
4 hours for breast milk
2 hours for clear fluid (uncarbonated apple-

/

grape- juice, Oros or Darrows Dextrose fluid)
We encourage children to take orally up to 2 hours pre-operatively to avoid long fasting periods. Ward
staff or parents can administer 10 ml kg
-1
of apple juice or Darrows Dextrose (a Dextrose containing
paediatric IV maintenance fluid). This avoids thirsty, irritable, hypoglycaemic children in theatre pre-
operatively. It is good practice to do the youngest children first on the morning theatre slates.
The child after trauma should be regarded as having a full stomach prior to surgery as gastric
emptying is delayed due to pain, anxiety and potential opiate use in trauma unit.

Preparation of theatre for paediatric surgery
In a paediatric hospital, the theatre suites are well stocked with a range of paediatric equipment.
However at other hospitals, where paediatric cases are performed infrequently it may be difficult to
find all the equipment you will need for a paediatric case. Often the anaesthetic staff will have a
specific paediatric trolley with a selection of the equipment below on it. It is important to be
meticulous in your pre-operative preparation of theatre and ensure that you will have everything you
need and more. This is the practise of safe anaesthesia and entirely the anaesthetists responsibility.
a) Breathing circuits
The Jackson-Rees modification of the Ayres T-piece is a light-weight circuit with no valves
and an open-ended reservoir bag. The O
2
is delivered close to the childs face and the reservoir
bag can be used to assist ventilation manually as well as monitor spontaneous breathing. The
T-piece can be used for children <20 kg or 6 years. Fresh gas flow (FGF) is 2

3 x minute
volume (MV) for spontaneous breathing mode. For example: a 10 kg child with VT of 80 ml (8
ml kg
-1
) and RR of 25 will have a MV of 2 l min
-1
and thus FGF = 4

6 l min
-1
.
Paediatric circle circuits (which are closed and contain the Soda lime absorber together with
inspiratory- and expiratory- valves that ensure unidirectional flow). The tubing has a reduced
diameter and is lighter. There is a universal trend towards low-flow anaesthesia and circle
absorber systems provide cost-effective anaesthesia with less pollution, but appropriate
inhalational agent and gas monitoring must be available.
Both breathing circuits should be attached to the anaesthetic machine and checked prior to
anaesthesia as part of the full machine check.
b) Paediatric ventilators
Must be able to deliver small volumes; preferably with volume- and pressure- controlled modes.
We tend to use pressure controlled ventilation (PCV) in paediatrics, as it compensates for leaks.
c) Face masks
Specially designed paediatric face-masks with a shallow body minimise equipment dead space.
Children have flatter faces and noses.
Face masks should be transparent and flavoured to make gas induction more acceptable.
A selection of face mask sizes must be available.
d) Oropharyngeal airways (Guedel airways)
Selection of sizes.
Measure the size from the middle of the incisors to the angle of the jaw.
If the airway is too small it will not lift the tongue off the floor of the oropharynx and the airway
will remain obstructed.
e) Laryngoscopes
Selection of sizes and blade types once again.
Types: Curved MacIntosh or straight Seward / Miller / Wisconsin blades. (See appendix)
The straight blades are often easier to use for neonates.
f) Endotracheal tubes (ETTs) and suction
The tubes for children range from 2

6,5 mm internal diameter. A term neonate will take a 3

3,5 mm tube.
Most ETTs are uncuffed and this is to prevent post-intubation oedema. From size 5 mm
upwards the tubes come with cuffs if required. It is good practise to avoid cuffed tubes until the
Paediatric anaesthesia

22 - 5
child is over 8

10 years old. A size 5,5 cuffed ETT is useful for the child over 6 when you are
not sure which size to use as a fail-safe.
Choosing the appropriate size:
4 + age

/

4 = tube diameter (mm)
All children are different so have a 0,5 mm size above and below your predicted choice readily
available. Example: A 4 year old needs a size 5 mm ETT according to the formula; plus a 4,5
mm and 5,5 mm as alternatives on the airway trolley.
Correct tube placement is confirmed by easy passage into the larynx and the development of a
leak at 10

20 hPa (cm H
2
0). No leak indicates that the tube is too big, and should be
replaced, as oedema can result in post-intubation stridor. Remember the narrowest part of the
airway is below the cords at the cricoid ring.
The formula to estimate ETT length at the teeth

/

gums:
12 + age

/

2 = length in mm
This formula is once again a guideline and the tube length must be confirmed with equal
bilateral auscultation in axillae. A useful guide to placement: Length of ETT distal to the cord
(cm) = diameter of the tube (mm). Example: A 3 mm ETT should be 3 cm in at the cords.
A paediatric Yankauer suction nozzle for mouth suctioning under direct vision must be available,
as well as suction catheters of varying sizes to pass down the ETT for airway suctioning of
secretions.
g) Introducers and Magills forceps
Paediatric-appropriate sizes.
h) Laryngeal mask airways (Brain airways)
Sizes 1, 1, 2, 2 and even 3 will be appropriate for children.
Sizes 1 and 1 are meant for infants up to 10 kg, however these are difficult to position properly
and easily displace resulting in laryngospasm and hypoxia; it is often safer to secure the airway
with an ETT or hold the face mask for a short anaesthetic.
i) Intra-venous (IV) cannulas, central venous pressure (CVP) lines and arterial lines
A range of sizes and safety cannulae should be available for the child.
Common sizes are 22 G (blue) and 24 G (yellow) cannulae for peripheral venous access.
j) IV fluid and lines
200 ml bags of fluid are more appropriate than 1 litre bags.
The fluid giving set should be a 60-dropper, to limit the rate of administration.
A buretrol

/

paedatrol (volume-control device) is important so that the fluid volume administered
can be controlled for all children <10 kg.
For short-term IV access we often draw up flush lines with a 10 ml syringe of Normal saline.
Dead space of the thin flush lines varies depending on the make; usually 1,4

1,8 ml. (Check
the back of the packet). An elbow or short extension set is useful in tiny babies as it is easier
to secure with even less dead space.
Drugs are usually diluted with Normal saline as opposed to water, as this is more physiological.
Ensure meticulous de-airing of all lines and intravenous tubing.
k) Feeding tubes, nasogastric tubes (NGT), urinary catheters
Use the smaller nostril for feeding or NGT and secure well; the larger nostril is for breathing!
l) Paediatric temperature probes
Oral, nasopharyngeal, rectal (with covering glove) probes, or tympanic membrane thermometer.
m) Warming equipment
Forced air warmer: convection warm air devices (Bair Hugger, Warm-Touch).
Overhead radiant heaters.
Ability to increase theatre temperature.
Heated underblankets.
In-line fluid warmers.
Humidifiers and paediatric heat moisture exchange filters (HMEFs).
Selection of hats, gamjees (cottonwool and gauze pads) and plastic sheets for insulation.
n) Monitors
Size-appropriate ECG stickers and leads, non-invasive BP cuffs, pulse oximeter probes.

Paediatric anaesthesia

22 - 6
Induction
Most children do not arrive in theatre with an IV line, and dread the prospect of being stuck with a
needle. There are two options for induction, IV or inhalational:
Intravenous induction if an IV line is present, or when EMLA (local anaesthetic cream) has
been placed on the hand or arm 1 hour pre-operatively to anaesthetise the skin and render IV
cannulation painless. This technique is an art in distracting the child so they are unable to see
the needle going in! Commonly used IV agents are Propofol and Ketamine.
Inhalational induction where the potent and non-irritant volatile anaesthetic agents,
Sevoflurane or Halothane, will render a child unconscious within minutes. Older children will
often co-operate and breathe in and out blowing up the bag or pretending to be a spaceman
breathing special air until they drift off to sleep. A light premedicant does aid co-operation. The
smaller children may resist a little more as they may not understand what is happening.
Inhalational induction is commonly practised at childrens hospitals and the student should have
the opportunity to observe and perform several inductions. This is also a good opportunity to
witness the different stages of anaesthesia.
Parental presence in theatre is helpful for co-operation of the child over 6 months. They fear
separation from their parents or caregiver. Mom or dad (one parent) can hold the little one on
their lap as they go off to sleep or stand alongside the theatre table holding their hand. Once
the child is asleep the parents are often filled with emotion and need to be re-assured that their
child will be well-cared for, they may want to give a little good-luck kiss (dont ask them to kiss
their child goodbye as this has dreadful connotations), and they should be escorted back to the
theatre door. As mentioned, children less than 6 months do not suffer from separation anxiety;
it is easier to take these infants into theatre without the parent.
A choice of induction can be offered to older children who are not afraid of IV lines, or those
who have had multiple procedures. They may have a preference for inhalation or IV induction
depending on their particular fears or phobias of mask or needle.
Muscle relaxation is not routinely required to intubate children and Suxamethonium has many
side-effects which we would like to avoid in paediatrics, especially bradycardia and malignant
hyperthermia. Spraying the cords with 2 % Lignocaine or an IV dose of Propofol (1

2 mg kg
-1
)
once an IV line is established, is helpful in abolishing airway reflexes prior to intubation. Non-
depolarising muscle relaxants are given once the airway is secure, if required for the surgery.

Maintenance
Maintenance of anaesthesia is a choice between an inhalational or intravenous method. Frequently in
children, we choose the inhalational method. If Sevoflurane has been used as the induction agent,
change to Halothane or Isoflurane for maintenance as they are more cost-effective and may minimise
the incidence of post-Sevoflurane emergence delirium/

agitation.

a) Doses of drugs: mg kg
-1
!
Children vary dramatically in size, from the 1 kg premature to the 30

40 kg adolescent. Drug
dosing must be adjusted accordingly. It is useful to have a calculator in paediatric lists to work
out the mg kg
-1
dose accurately. Drugs may need serial dilutions for very small babies.
A useful book to have is the Frank Shann Paediatric Drug Doses Book. It contains all drugs
and doses, plus information on childrens weights, heights, size of ETT, LMA, IV lines, how to
work out infusion schedules and much, much more!

b) Monitoring
The level of monitoring depends on the nature of the case. Routine monitoring in children is
often no different from adults, however all the equipment is smaller!
Pulse oximeter probes are often the only monitor, if any, that can be placed before the induction
proceeds because exposing the child and applying monitors may frighten and distress them.
Probes are wrap-around or clip-on probes. It is advisable to place 2 probes with every
anaesthetic as it is not unusual for 1 to be lost or unreliable during the procedure. ECG, NIBP
(appropriate size), capnograph and temperature probes are routine. Anaesthetic agent
monitoring is standard on the new machines and mandatory for low-flow anaesthesia. Nerve
stimulators are under-utilised in paediatrics, and are particularly useful in assessing the child
with post-operative apnoea, and excluding muscle paralysis as a cause. Invasive monitoring
such as arterial lines and CVPs will be dictated by the case.
Paediatric anaesthesia

22 - 7
Anaesthesia in children requires attention to detail small ETTs can be displaced or kink in a
matter of seconds, and lines and monitors can be removed accidentally. Securing the airway
equipment, monitoring and IV access and your access to these is imperative before the patient
is cleaned and draped. A metal screen is invaluable in paediatrics to allow access to the small
patient under the drapes. Vigilance is the watchword of monitoring!
Another important consideration is that of pressure care. Ensure that the child is not lying on
any ECG or other monitoring wires, drip tubing is not pressing against the skin and place soft
cottonwool gamjee under their head, elbows and heels particularly with long procedures.

c) Temperature control
Hypothermia is defined as a body temperature <

36 C.
Any person undergoing a general or regional anaesthetic will become hypothermic over time,
unless preventative steps are taken. As alluded to earlier, children have abnormal
thermoregulatory reflexes and are more likely to lose heat. Hypothermia carries with it
significant morbidity and mortality, namely the potential for cardiac dysrhythmias, increased
systemic vascular resistance, left shift of the oxygen-haemoglobin dissociation curve, a
reversible coagulopathy and platelet dysfunction, apnoea, respiratory depression, post-
operative shivering with a 200 % increase in Oxygen consumption, impaired renal and liver
function, impaired drug metabolism, lethargy post-operatively with poor sucking in neonates and
poor wound healing.
Temperature probes must be inserted for all children undergoing anaesthetics longer than 15
minutes. Avoid hypothermia: transport neonates in incubators, cover the head with a cap and
body with gamjees, use forced air warmers, warm theatre temperature, warm IV fluids and
inspiratory gases. Theatre temperatures are usually 16

20 C and this allows for comfort of
the surgeon and reduces microbial growth; however paediatric theatres are routinely set at
higher temperatures of 22

24 C to benefit the children.
Hyperthermia with a body temperature >

38 C is also a concern, although rare unless the
child is septic. Malignant hyperthermia (MH), although also very rare, is more common in
children as this is often their first anaesthetic and therefore the first manifestation of this
pharmacogenetic disorder. If you suspect MH, CALL FOR HELP!

d) Fluids
All children require venous access and intravenous fluid therapy for anaesthesia. Some may
require blood transfusions. Your aim is to maintain the intravascular volume in the peri-
operative period.
Peri-operative fluid therapy includes replacement of normal losses (maintenance requirements),
pre-existing fluid deficits, and ongoing surgical fluid losses (blood and third space).
Estimate maintenance fluid with the simple 4

:

2

:

1 rule for the childs body weight:
For the first 10 kg: 4 ml kg
-1
hr
-1

For the next 10

20 kg: 2 ml kg
-1
hr
-1

For each kg above 20 kg: 1 ml kg
-1
hr
--1

Example: What are the maintenance fluid requirements for a 25 kg child?
Answer: 40 + 20 + 5 = 65 ml hr
-1

Most intra-operative fluids are isotonic crystalloids or colloids. In children, it may also be
necessary to run a glucose-containing hypotonic crystalloid in addition to prevent
hypoglycaemia, e.g. Darrows Dextrose or Normal saline with 5 % Dextrose. When
administering fluid, meticulous attention should be paid to the removal of all air bubbles from the
lines as right-to-left cardiac shunts are more common in children with small probe-patent
foramen ovales, or atrial-

/

ventricular- septal defects (ASD

/

VSD).
A childs estimated blood volume is 80 ml kg
-1
. If intra-operative blood loss occurs, crystalloid
replacement should be 3

4 ml for every 1 ml blood lost, and colloid replacement is 1 ml for 1
ml blood loss. If surgical losses are heavy and colloid replacement is required, we use
stabilised human serum (SHS) or a synthetic colloid (e.g. Voluven

) if they are not neonates.

Blood transfusion may be required if the Hb falls below 10 g dl
-1
.
4 ml kg
-1
of packed red blood cells or 8 ml kg
-1
of whole blood will raise the Hb by 1 g dl
-1
.

Paediatric anaesthesia

22 - 8
e) Analgesia
Analgesia forms part of the triad of anaesthesia. Children feel pain, but young children are not
able to express themselves as well as adults. We can assess babies pain by looking at their
vital signs, movements, grimacing and overall mood with the comfort scale. The visual
analogue scale for pain where pain is rated by adults from 0 (no pain) to 10 (the worst pain
imaginable) is replaced in older children with the faces scale. Ideally children should awaken
from anaesthesia pain-free and a multi-modal approach can be used to achieve this:
Simple analgesics:
Paracetamol: This can be given orally, rectally and now most effectively, IV.
o RECTAL: Suppositories are available as 125 mg and 250 mg units.
Initial

/

loading dose =40 mg kg
-1
with subsequent doses of 15 mg kg
-1
6-hrly
o ORAL: 20 mg kg
-1
6-hrly
o Maximum daily dose for oral and rectal routes =90 mg kg
-1
day
-1
if >1month old; reduce
to 60 mg kg
-1
day
-1
in neonates (liver function immaturity).
o IV =PERFALGAN

: 15 mg kg
-1
6-hrly reduce to 7,5 mg kg
-1
6-hrly if <1 month old
NSAIDs: These should be avoided in children less than 1 year of age unless pain is poorly
controlled with Paracetamol alone.
Remember to ask the parents or caregivers about any allergies and be particularly
cautious should there be a history of asthma.
Ensure adequate hydration before administering NSAIDs as they may compromise renal
perfusion

/

function in dehydrated, hypovolaemic patients.
o Diclofenac (Voltaren

): 1 mg kg
-1
rectally (PR) / orally (PO) 8

12-hrly.
Suppositories are available as 12,5 mg and 25 mg units
o Ibuprofen (Brufen

): 5

10 mg kg
-1
PO 8-hrly
A note on use of suppositories: It is inadvisable to break or cut suppositories into smaller
pieces. The drug is not necessarily evenly distributed in the suppository and so you may
end up under- or over- dosing.
Regional analgesia:
Blocks are performed once the child is anaesthetised. Part of the anaesthetic explanation pre-
operatively to the parents should include the insertion of suppositories and the block. There are
many different types of neuraxial and peripheral nerve blocks, however the following are those
most commonly performed and most useful. It is advisable to to actively seek training and
supervision with these blocks as an intern to prepare you for community service:
Caudals for any upper or lower abdominal surgery or lower limb surgery. Can cover from T
4

(thoracic dermatome 4) downwards.
Penile blocks for circumcisions.
Ilio-inguinal blocks for hernia repairs.
Digital nerve blocks (ring blocks) for finger surgery.
Axillary nerve blocks for forearm and hand surgery.
Local anaesthetic infiltration of surgical site, Bupivacaine 0,25 % (max. dose =2 mg kg
-1
).
Opioids
Fentanyl: 1

3 g kg
-1
IV (short-lived)
Morphine: 0,05

0,2 mg kg
-1
IV 4-hrly
Tilidine (Valoron

) drops: 1 mg kg
-1
(2,5 mg per drop) PO 6-hrly

Ketamine
Induction: 1

2 mg kg
-1
IV or 6-10 mg kg
-1
IM
Analgesia: 0,25

0,5 mg kg
-1
IV intra-operatively or as rescue analgesia in recovery
Infusion: 200 mg in 50 ml Normal saline (4 mg ml
-1
) and run at body weight (kg) =ml hr
-1
;
i.e. 1 ml kg
-1
hr
-1
=4 mg kg
-1
hr
-1
; so for 12 kg child, 12 ml hr
-1
intra-opertively; very useful for
burns cases; tachyphylaxis (tolerance) does occur
Oral: 10 mg kg
-1
, takes 15 minutes to work. Always give under supervision.
Neonates and infants under 6 months are sensitive to opiate-induced respiratory depression
and these drugs are avoided intra-operatively. Ketamine is a good intra-op alternative
especially for the very sick neonate. Tilidine (Valoron

) drops are better for neonates and

infants post-operation, if absolutely necessary, as they can be given orally. Often the
combination of regional anaesthesia with or without Paracetamol PR, or IV (Perfalgan

) and
then back to mom post-operation for breastfeeding, is sufficient analgesia and comfort.
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22 - 9
A plethora of analgesic combinations exist on the market. What weve done here is to give you
a simple and safe recipe for analgesia in children. Each hospital may have a different selection
of analgesics. If these are combination analgesics such as Stopayne

syrup, Panadeine

or
Myprodol

, please check carefully what the constituents are and what dose (mg ml
-1
) before
using. As mentioned, a useful tactic is to give the premedication with analgesic syrup to pre-
empt any surgical pain.
Post-op analgesia is the anaesthetists responsibility. During the operation, you should check
the prescription chart and write up appropriate analgesia for the post-operative period. A
suggested regimen is Paracetamol 6-hrly plus Tilidine (Valoron

) drops 6-hrly (alternating 3-hrly,

i.e. child gets something every 3 hrs) and a NSAID 8-hrly (children do not like injections!).

Emergence and recovery
The emergence from anaesthesia can be fraught with difficulties. It is also a time when the rest of the
theatre staff are relaxing as the operation is over and you may not have the necessary attention from
them. Your anaesthetic assistant should be in theatre at this time. Airway complications are the most
common. Suction well under direct vision and down the ETT if necessary. Make sure you have the
childs face mask and an appropriate sized oropharyngeal airway ready should airway obstruction
occur. It is better to change back to the T-piece circuit now as you have better control over the childs
ventilation with this light-weight circuit. Partial laryngospasm is common if the LMA or ETT is removed
at the wrong stage; usually this is easily rectified by applying PEEP by closing off the open-end of the
reservoir bag and sitting it out. If the laryngospasm is more severe, a small IV dose of Propofol is
useful. Avoid muscle relaxants if at all possible. It is best to wait until the child is wide-awake and
breathing well, without periods of breath holding, before extubating!
Once the child is awake and maintaining their own airway; they should be placed on their side and
transferred to the recovery room for further monitoring of vital signs: HR, O
2
saturation and BP if
necessary. Suction should be available and functioning. The child should be comfortable and pain-
free; have normal vital signs and no nausea or vomiting, before being discharged back to the ward.
Sucrose for dummies provides both comfort and analgesia to little ones.
For day-case surgery, the home-discharge criteria are more stringent. Usually the child stays for 2

4
hours post-op depending on the surgery. The child must have normal vital signs, be able to take
orally, have no nausea or vomiting, be pain-free and able to ambulate. If the child has had a caudal,
they should be moving their legs and able to urinate. The surgical site must also be inspected and
should not be bleeding.

Common procedures
The procedures you will see and do as a medical officer:
Dental: Extractions
ENT: Tonsillectomy and adenoidectomy
Myringotomy and insertion of grommets
Eye surgery: Squint repair
Corneoscleral lacerations
Meibomian cyst +molluscum contagiosum removal
General surgery: Inguinal hernias
Appendicectomies
Gastroscopies for foreign body removal
Burn surgery: Debridements +split skin grafts (SSGs)
Contracture release
Orthopaedics: Manipulations and open reduction with external fixation (ORIF) of forearms
and lower limbs
Urology: Circumcision

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22 - 10
Who to refer
Here are some guidelines as to which children you should refer as a post internship community
service officer or medical officer performing unsupervised anaesthesia :
Doctors who are not familiar with anaesthetising children should not do so. Avoid
anaesthetising those under the age of 3 years without direct senior supervision.
As a medical officer, unsupervised, you should only anaesthetise ASA I

II children.
Congenital anomalies are common, especially in the younger ages. Syndromes need to be
identified and potential problems for anaesthesia anticipated. Many uncommon syndromes
present for surgery, and a good reference book of genetic and metabolic disorders and their
impact on anaesthesia is vital in any department that anaesthetise children. Do not attempt to
anaesthetise a syndromic child, even a Downs syndrome or cerebral palsy child, as a medical
officer unsupervised.
Instruments and equipment used on children need to be age- and size- appropriate. If these
are not available, the child should be transferred to a centre where children can be safely
anaesthetised and managed.
The younger the child is, the higher the morbidity and mortality.
Avoid any children with potential for airway problems or airway abnormalities. Ask specifically
about obstructive sleep apnoea on your tonsillectomy and adenoidectomy lists, as these
children should be referred to a tertiary centre.
Children with complicated disease processes or organ failure (cardiac, respiratory, liver, renal,
endocrine, metabolic etc.) should be transferred to tertiary centres.
Refer any children with suspected or undiagnosed muscle disorders, myopathies or
dystrophies. Some of these disorders have an increased incidence of MH.
If you are ever uncertain or need some advice, it would be wise to contact the nearest training hospital
and speak to an anaesthesia consultant

/

registrar, who will hopefully put you in touch with the
appropriate person.
(E.g. If in the Western Cape, South Africa - Red Cross Childrens Hospital on 021 658 5003 (theatre)
or Groote Schuur Hospital on 021 404 9111 and ask them to page the anaesthetist on call.)

Conclusion
These notes are designed to give you a practical approach to anaesthetising children. They will serve
as an introduction to this field for the 4
th
and 5
th
year students, and hopefully be a more practical guide
and reference to the interns, community service officers and Diploma in Anaesthesia candidates.
Paediatric anaesthesia is both a challenging and rewarding sphere of anaesthesia practise. It requires
sound knowledge of paediatric medicine and surgery and a solid base of anaesthesia.
Professor Alistair Miller, paediatric surgeon at Red Cross Childrens Hospital once wrote:
Operations on infants and small children should be performed by those who have made it their
business to become familiar with paediatric surgery
and this applies to anaesthetists and nurses as well, with regard to the peri-operative care of children.

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22 - 11
Appendix
LMA size selection:
Choose size 2 for children 10

20 kg
Choose size 2 for children 20

30 kg
Choose size 3 for children >30 kg

ETT selection and depth guide:

AGE Wt (kg) ETT size At lip (cm) At nose (cm)
Newborn <0,7 2,0 5,0 6
Newborn <1 2,5 5,5 7
Newborn 1,0 3,0 6 7,5
Newborn 2,0 3,0 7 9
Newborn 3,0 3,0 8,5 10,5
Newborn 3,5 3,5 9 11
3 month 6,0 3,5 10 12
1 year 10 4,0 11 14
2 years 12 4,5 12 15
3 years 14 4,5 13 16
4 years 16 5,0 14 17
6 years 20 5,5 15 19
8 years 24 6,0 16 20
10 years 30 6,5 17 21
12 years 38 7,0 18 22
14 years 50 7,5 19 23

Types of laryngoscope blades:

MacIntosh blades Miller blades

Seward blade

Wisconsin blade

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Notes: