Intraoperative Management
of Pediatric Anesthesia Intraoperative management of pediatric anesthesia presents unique challenges and is important because of the significant differences in physiological and psychological characteristics between children and adults. 1. Preoperative assessment 1. Detailed understanding of the child’s medical history-ask about birth history, including premature birth, low birth weight, asphyxia, etc. -Know the history of past diseases, such as congenital heart disease, asthma, epilepsy, etc. -Recent upper respiratory tract infection, fever, diarrhea and other symptoms, which may increase the risk of anesthesia. -Understand your child’s history of allergies, including allergies to drugs, foods, and other substances. 2. Assessment of physical condition-measure the weight, height and head circumference of children, and accurately calculate the dosage of drugs. -Check the child’s development, including nutritional status, motor and language development. -Assess the child’s cardiopulmonary function by auscultation, electrocardiogram, chest X-ray, etc. -Examine the child’s mouth, nose, and airway for potential airway difficulties. 3. Psychological assessment-for older children, understand their fear of surgery and anesthesia, and give appropriate psychological counseling. -Assess the child’s level of cooperation in order to select the appropriate anesthesia. 2. Preparation before anesthesia 1. Fasting and water deprivation-determine the time of fasting and water deprivation according to the age of the child and the type of operation. In general, infants are fasted from breast milk for 4 hours and from formula milk for 6 hours before surgery; infants and children are fasted from solid food for 6 hours and from water for 2 hours before surgery. -Strictly observe fasting and water deprivation time to reduce the risk of reflux and aspiration. 2. Drug preparation-prepare the drugs needed for anesthesia, including induction drugs, maintenance drugs, analgesics, muscle relaxants, etc. -Check the name, dosage and expiration date of the drug to ensure the safety of medication. 3. Equipment preparation-check whether the anesthesia machine, monitor and airway management equipment are in normal operation. -Prepare special airway equipment such as endotracheal tube, laryngeal mask and mask for children. -Ensure that first aid equipment and medicines are available, such as defibrillator, epinephrine, dopamine, etc. 3. Anesthesia induction 1. Choose the appropriate induction method-for cooperative children, inhalation induction can be used, such as sevoflurane inhalation. -For children who are uncooperative or have airway difficulties, intravenous induction can be chosen, such as propofol, ketamine, etc. 2. Closely observe the child’s response-closely observe the child’s vital signs during induction, such as heart rate, blood pressure, respiratory rate and oxygen saturation. -Pay attention to whether children have adverse reactions such as breath holding, cough and vomiting, and deal with them in time. 3. Ensure airway patency-After induction, airway can be established quickly, and tracheal intubation, laryngeal mask or mask ventilation can be chosen. -Check whether the airway is unobstructed to ensure effective ventilation. 4. Anesthesia maintenance 1. Choose the appropriate anesthetic-choose the appropriate anesthetic according to the type of operation and the condition of the child. Commonly used anesthetic drugs are propofol, remifentanil, sevoflurane and so on. -Pay attention to the dosage and concentration of drugs, and avoid overdosage or underdosage. 2. Maintain the stability of vital signs-continuously monitor the vital signs of children, such as heart rate, blood pressure, respiratory rate, oxygen saturation, body temperature, etc. -Adjust the dosage of anesthetic according to the change of vital signs, and maintain the vital signs within the normal range. -Pay attention to the urine volume and fluid intake and output of children, and maintain the balance of water and electrolyte. 3. Analgesia management-Children are highly sensitive to pain and need adequate analgesia. Choose opioids, non-steroidal anti-inflammatory drugs, etc. -Determine the dosage and mode of administration of analgesic drugs according to the child’s age, weight, and type of surgery. 4. Management of muscle relaxants-appropriate muscle relaxants should be given according to the needs of the operation to ensure the smooth operation. -Monitor the degree of neuromuscular blockade to avoid excessive or insufficient neuromuscular blockade. 5. Intraoperative monitoring 1. Basic vital signs monitoring-continuous monitoring of electrocardiogram, heart rate, blood pressure, respiratory rate and oxygen saturation. -Take your temperature regularly and avoid hypothermia or hyperthermia. 2. Monitoring the depth of anesthesia-Bispectral index (BIS) can be used to monitor the depth of anesthesia to avoid too deep or too shallow anesthesia. -Adjust the dose of anesthetic according to the monitoring results. 3. Respiratory function monitoring-monitoring respiratory rate, tidal volume, airway pressure, etc., to assess respiratory function. -Pay attention to the occurrence of complications such as respiratory tract obstruction and pneumothorax. 4. Circulatory function monitoring-monitoring central venous pressure, cardiac output, etc., to assess circulatory function. -Pay attention to the occurrence of arrhythmia, hypotension, hypertension and other complications. 6. Treatment of complications 1. Respiratory depression-If respiratory depression occurs, anesthetics should be stopped immediately and assisted breathing, such as mask ventilation or tracheal intubation, should be given. -Find out the causes of respiratory depression, such as drug overdose, airway obstruction, etc., and deal with them in time. 2. Hypotension-Reduce the dosage of anesthetic drugs and give pressor drugs, such as ephedrine, dopamine, etc. -Replenish fluids to maintain blood volume. 3. Arrhythmia-analyze the types and causes of arrhythmia and give appropriate treatment. Such as sinus tachycardia can be given esmolol and other drugs; ventricular arrhythmia can be given lidocaine and other drugs. 4. Abnormal body temperature-low body temperature can be given warm measures, such as using heating blankets, raising room temperature, etc. High body temperature can be given physical cooling, such as ice pack cold compress, alcohol sponge bath, etc. At the same time, we should find out the causes of high body temperature, such as infection, malignant high fever, and deal with them in time. 5. Reflux aspiration-Once reflux aspiration occurs, the child’s head should be turned to one side immediately, the respiratory tract should be cleared, and oxygen and respiratory support should be given. -Give antibiotics, glucocorticoids and other drugs according to the situation. 7. Postoperative management 1. Management during the recovery period-after the operation, the child was transferred to the recovery room for observation. -Closely observe the child’s recovery, such as consciousness, breathing, circulation, etc. -After the child is fully awakened, remove the endotracheal tube or laryngeal mask and give oxygen. 2. Pain management-assess the degree of pain in children and give appropriate analgesic drugs. -Oral, intravenous, local anesthesia and other analgesic methods can be used. 3. Nausea and vomiting management-to prevent the occurrence of nausea and vomiting, antiemetic drugs can be given. -In case of nausea and vomiting, clear the respiratory tract in time to prevent aspiration. 4. Fluid management-adjust the speed and amount of infusion according to the amount of urine and fluid in and out of the child. -Maintain water and electrolyte balance. In a word, the intraoperative management of pediatric anesthesia requires anesthesiologists to have rich professional knowledge and experience, fully understand the physiological and psychological characteristics of children, strictly follow the operating procedures, closely monitor vital signs, and timely deal with complications, so as to ensure the safety of children and the smooth operation.
