Anestesia

C H A P T E R 3
Anesthetic Considerations for

Pediatric Surgical Conditions
Laura K. Diaz • Lynne G. Maxwell
Anesthetizing children is an increasingly safe undertak- the risk of a motor vehicle collision on the way to the
ing. When discussing the risks and benefits of a child’s hospital or surgery center is greater than the risk of death
operation with his or her family, surgeons should feel under anesthesia. However, risks of mortality and mor-
confident that their anesthesiology colleagues can provide bidity are increased in neonates and infants less than one
an anesthetic that facilitates the procedure while ensuring year of age, those who are ASA (American Society of
the child’s safety. Providing optimal perioperative care for Anesthesiologists) status 3 or greater, and those who
children requires close collaboration between the surgeon require emergency surgery.5
and anesthesiologist on issues both large and small. This
chapter is designed to inform surgeons about the consid-
erations important to anesthesiologists. PREOPERATIVE ANESTHESIA
EVALUATION
RISKS OF ANESTHESIA All patients presenting for operations under anesthesia
benefit greatly from a thorough preanesthetic/preopera-
In an effort to reduce patient complications, anesthesi- tive assessment and targeted preparation to optimize any
ologists have carefully analyzed anesthetic morbidity coexisting medical conditions. The ASA physical status
and mortality over the past generation. Whereas anesthe- (PS) score is a means of communicating the condition of
sia was historically considered a dangerous enterprise, the patient. The PS is not intended to represent operative
serious anesthesia-related complications are now rela- risk and serves primarily as a common means of commu-
tively rare, especially in healthy patients. The reasons for nication among care providers (Table 3-1). Any child with
this improvement include advances in pharmacology, an ASA classification of 3 or greater should be seen by an
improved monitoring technology, increased rigor of sub- anesthesiologist prior to the day of surgery. This may be
specialty training, and the ability to target problems using modified in cases of hardship due to the distance from the
an analysis strategy. surgical venue or when the patient is well known to the
Quantifying the risk of pediatric anesthesia is difficult anesthesia service, and the child’s health is unchanged.
due to the difficulty in determining whether complica- Finally, outstanding and unresolved medical issues may be
tions are attributable to the anesthetic, and if so, to what significant enough to warrant cancellation of the proce-
degree. The risk of cardiac arrest for children undergoing dure for optimization of anesthesia and/or further diag-
anesthesia was estimated in the 1990s to be 1 : 10,000.1,2 nostic workup.
However, these studies did not take patient co-morbidity
or the surgical condition into consideration. The risk of
a healthy child suffering cardiac arrest during myrin-
Criteria for Ambulatory Surgery
gotomy tube placement is significantly less than the like- Ambulatory surgery comprises 70% or more of the
lihood of a child with complex cardiac disease arresting caseload in most pediatric centers. Multiple factors
during a complex cardiac repair.3 should be considered when evaluating whether a child is
A recent review of cardiac arrests in anesthetized chil- suitable for outpatient surgery. Some states regulate the
dren compared 193 events from 1998–2004 to 150 events minimum age allowed in an ambulatory surgical center.
from 1994–1997.4 A reduction in medication-caused For example, the minimum age in Pennsylvania is six
arrests from 37% to 18% was identified, and was attrib- months. In most cases, the child should be free of severe
uted to the decline in halothane use (that causes myocar- systemic disease (ASA PS 1 or 2). Other factors that may
dial depression) and the advent of using sevoflurane (that determine the suitability of a child for outpatient surgery
is not associated with myocardial depression). There was are family and social dynamics. Some institutions utilize
also a reduction in unrecognized esophageal intubation a telephone screening evaluation process to determine
as a cause of arrest, due in large part to the advent of whether a patient can have their full anesthesia history
end-tidal carbon dioxide (ETCO2) monitoring, pulse oxi- and physical on the day of surgery rather than being
metry, and an increased awareness of the problem. evaluated in a preoperative evaluation clinic prior to
Recent large single center reports yield a current esti- surgery.6
mate of anesthesia-related mortality of 1 : 250,000 in Well-controlled systemic illnesses do not necessarily
healthy children. To put this into perspective for parents, preclude outpatient surgery, but any concerns must be
34
3 Anesthetic Considerations for Pediatric Surgical Conditions 35
TABLE 3-1 ASA Physical Status Classification Patient History

ASA Classification Patient Status
Documentation of allergy status is an essential part of the
preoperative evaluation, particularly as prophylactic anti-
1 A normal healthy patient biotics may be administered prior to incision. Allergies
2 A patient with mild systemic disease
3 A patient with severe systemic
to certain antibiotics (especially penicillin, ampicillin and
disease cephalosporins) are the most common medication aller-
4 A patient with severe systemic gies in children presenting for surgery. Anaphylactic
disease that is a constant threat to allergic reactions are rare, but can be life threatening if
life not diagnosed and treated promptly. Latex allergy is the
5 A moribund patient who is not
expected to survive without the most common etiology for an anaphylactic reaction, and
operation children with spina bifida (myelomeningocele), bladder
6 A declared brain-dead patient exstrophy, or those who have undergone multiple opera-
whose organs are being removed tions (such as repeated ventriculoperitoneal shunts) are
for donor purposes
E An emergency modifier for any ASA
at greatest risk for such reactions.
classification when failure to In general, parents should be instructed to continue
immediately correct a medical routine administration of anticonvulsant medications,
condition poses risk to life or cardiac medications, and pulmonary medications even
organ viability while the child is fasting.
The family history should be reviewed for pseudo-
cholinesterase deficiency (prolonged paralysis after suc-
cinylcholine) or any first-degree relative who experienced
addressed in advance in a cooperative fashion between malignant hyperthermia (MH). A complete review of
the surgical and anesthesia services. If a child has a mod- systems is important and should focus on those areas in
erate degree of impairment, but the disease is stable and which abnormalities may increase the risk of adverse
the surgical procedure is of minimal insult, outpatient events in the perioperative period.
surgery may be acceptable.
Miscellaneous Conditions
General Principles
Malignant Hyperthermia Susceptibility
In addition to the physical examination, the essential ele-
ments of the preoperative assessment in all patients are MH is an inherited disorder of skeletal muscle calcium
listed in Box 3-1. Patients and parents may be anxious channels, triggered in affected individuals by exposure to
about recurrence of adverse perianesthetic events such as inhalational anesthetic agents (e.g., isoflurane, desflu-
those listed, and they should be reassured that efforts will rane, sevoflurane), succinylcholine, or both in combina-
be made to prevent these events. tion, resulting in an elevation of intracellular calcium.
The incidence of an MH crisis is 1 : 15,000 general anes-
thetics in children. Fifty per cent of patients who have an
MH episode have undergone a prior general anesthetic
Essential Elements of the Preopera- without complication. The resulting MH crisis is char-
BOX 3-1 tive Assessment (In Addition to acterized by hypermetabolism (fever, hypercarbia, acido-
Physical Examination) sis), electrolyte derangement (hyperkalemia), arrhythmias,
and skeletal muscle damage (elevated creatine phosphoki-
Vital signs nase [CPK]). This constellation of events may lead to
Height/weight death if unrecognized and/or untreated. Dantrolene,
Heart rate which reduces the release of calcium from muscle sarco-
Respiratory rate plasmic reticulum, when given early in the course of an
Blood pressure
Pulse oximetry (both in room air and with supplemen-
MH crisis, has significantly improved patient outcomes.
tal O2 if applicable) With early and appropriate treatment, the mortality is
Allergies now less than 10%. Current suggested therapy can be
Medications remembered using the mnemonic ‘Some Hot Dude
Cardiac murmur history Better GIve Iced Fluids Fast” and is summarized in Box
Previous subspecialty encounters 3-2.7 It should be noted that dantrolene must be prepared
Past anesthetic history including any adverse perianes- at the time of use by dissolving in sterile water. It is
thetic events notoriously difficult to get into solution and the surgeon
Emergence delirium may be asked to help with this process.
Postoperative nausea and vomiting Patients traditionally thought to be MH susceptible
Difficult intubation
Difficult IV access
are those with a spectrum of muscle diseases listed in Box
Past surgical history 3-3. However, many patients who develop MH have a
Family history of pseudocholinesterase deficiency or normal history and physical examination. In the past,
malignant hyperthermia patients with mitochondrial disorders were thought to be
at risk. Anesthetic gases appear safe in this population,
36 SECTION I General
Treatment of Malignant condition is controversial. However, even if the radio-

BOX 3-2 graphic examination is normal, care should be taken peri-
Hyperthermia Crisis:
operatively to keep the neck in as neutral a position as
‘SOME HOT DUDE BETTER GIVE ICED possible, avoiding extreme flexion, extension or rotation,
FLUIDS FAST’12 especially during tracheal intubation. Any patient with
trisomy 21 who has neurologic symptoms such as sensory
Stop all triggering agents, administer 100% oxygen or motor changes, or loss of bladder or bowel control,
Hyperventilate: treat Hypercarbia should have preoperative neurosurgical consultation to
Dantrolene (2.5 mg/kg) immediately exclude cervical cord compression.
Bicarbonate (1 mEq/kg): treat acidosis
Glucose and Insulin: treat hyperkalemia with 0.5 g/kg
glucose, 0.15 units/kg insulin Preoperative Fasting Guidelines
Iced Intravenous fluids and cooling blanket
Fluid output: ensure adequate urine output: Furosemide Violation of fasting guidelines is one of the most common
and/or mannitol as needed causes for cancellation or delay of surgeries. Preoperative
Fast heart rate: be prepared to treat ventricular fasting is required to minimize the risk of vomiting and
tachycardia aspiration of particulate matter and gastric acid during
anesthesia induction. While the risk of aspiration is gen-
erally small, it is a real risk that may be associated with
but succinylcholine should still be avoided as some severe morbidity or death.
patients may have rhabdomyolysis (elevated CPK, hyper- Research performed at our institution has demon-
kalemia, myoglobinuria) with hyperkalemia without strated that intake of clear liquids (i.e., liquids that print
having MH. can be read through, such as clear apple juice or Pedia-
lyte) up until two hours prior to the induction of anesthe-
Trisomy 21 sia does not increase the volume or acidity of gastric
contents.8 Our policy is to recommend clear liquids until
Perioperative complications occur in 10% of patients with two hours prior to the patient’s scheduled arrival time.
trisomy 21 who undergo noncardiac surgery and include Breast milk is allowed up to three hours before arrival for
severe bradycardia, airway obstruction, difficult intuba- infants up to 12 months of age. Infant formula is allowed
tion, post-intubation croup, and bronchospasm. Patients until four hours before arrival in infants less than 6
may have airway obstruction due to a large tongue and months old, and until six hours before arrival in babies
mid-face hypoplasia. The incidence of obstructive sleep 6–12 months old. All other liquids (including milk), solid
apnea (OSA) may exceed 50% in these patients, and may food, candy, and gum are not allowed less than eight
worsen after anesthesia and operation. Airway obstruction hours before induction of anesthesia. Although these are
may persist even after adenotonsillectomy. Many patients the guidelines for our institution, the surgeon should be
with trisomy 21 have a smaller caliber trachea than chil- aware that NPO (nil per os) guidelines are variable and
dren of similar age and size; therefore, a smaller endotra- institutionally dependent.
cheal tube (ETT) may be required. Mitigating circumstances for NPO rules are limited to
Congenital heart disease (CHD) is encountered in emergency operations, in which steps are taken to protect
40–50% of patients with trisomy 21. The most common the airway from aspiration through the use of rapid
defects are atrial and ventricular septal defects, tetralogy sequence intubation. Nonemergent patients at particular
of Fallot, and atrioventricular (AV) canal defects. Chil- risk for dehydration should be scheduled as the first case
dren with a cardiac history should have records from of the day when possible, and administration of clear
their most recent cardiology consultation and echocar- liquids by mouth until two hours prior to arrival at the
diogram available for preoperative evaluation. Recent surgical facility should be encouraged. Insulin-dependent
clinical changes in their condition may warrant an assess- diabetics, infants, and patients with cyanotic or single
ment by their cardiologist prior to operation. ventricle cardiac disease are among those requiring careful
Cervical spine instability can lead to spinal cord injury planning so that fasting times are not prolonged.
in the perianesthetic period. Patients with trisomy 21
have laxity of the ligament holding the odontoid process
of C2 against the posterior arch of C1. This can lead to
Laboratory Testing
atlanto-axial instability that occurs in about 15% of these At the time of consultation, selected laboratory studies
patients. The need for preoperative screening for this may be ordered, but routine laboratory work is usually
not indicated. Policies vary among institutions regarding
the need for preoperative hemoglobin testing. In general,
Muscle Diseases Associated with any patient undergoing a procedure with the potential for
BOX 3-3
Malignant Hyperthermia significant blood loss and need for transfusion should
have a complete blood count (CBC) performed in the
Central core myopathy
preoperative period. Certain medications, particularly
Becker muscular dystrophy
Duchenne muscular dystrophy anticonvulsants (tegretol, depakote), may be associated
Myotonic dystrophy with abnormalities in blood components (white blood
King–Denborough syndrome cells, red blood cells, platelets), making a preoperative
CBC desirable.
Although serum electrolytes are not routinely screened, the scheduled surgery. These economic and social con-
electrolytes may be helpful in patients on diuretics. Pre- siderations deserve respectful attention. Symptoms that
operative glucose should be monitored in insulin- would tip the scales toward cancellation include the
dependent diabetic patients, and also in any patient who severity of illness, as measured by an intractable or pro-
has been receiving parenteral nutrition or intravenous ductive cough, bronchospasm, malaise, fever, or hypoxia
(IV) fluids with a dextrose concentration greater than 5% on pulse oximetry. In contrast, clear rhinorrhea with a
prior to surgery. simple cough is usually not sufficient grounds for cancel-
Routine screening for pregnancy in all females who lation, provided the family understands the very small
have passed menarche is strongly recommended. An age- chance of needing postoperative supplemental oxygen
based guideline (at our institution, any female 11 years of and bronchodilator therapy.
age or older) may be preferable. Although it is easiest to
perform a urine test for human chorionic gonadotropin The Former Preterm Infant
(hCG), if a patient cannot provide a urine sample, blood
can be drawn for serum hCG testing. Institutional policy Infants born prematurely (<37 weeks gestation) may
may allow the attending anesthesiologist to waive preg- exhibit sequelae such as bronchopulmonary dysplasia
nancy testing at their discretion. (BPD), gastroesophageal reflux, intraventricular hemor-
Certain medications, particularly anticonvulsants, rhage/hypoxic–ischemic encephalopathy (IVH/HIE), or
should be individually assessed regarding the need for laryngo/tracheomalacia or stenosis. Preterm infants are
preoperative blood levels. The nature of the planned also at increased risk for postoperative apnea after expo-
operation may also require additional studies. sure to anesthetic and analgesic agents.
Respiratory and Airway Considerations

CLINICAL SCENARIOS AND HIGH
Although the incidence of BPD has fallen over the past
RISK POPULATIONS two decades as the use of surfactant and new ventilation
Upper Respiratory Tract Infection strategies have been introduced, it remains the most
common form of chronic lung disease in infants, and
One of the most common questions confronting an significantly complicates the perioperative management
anesthesiologist is whether to cancel a procedure because of ex-premature infants. BPD is associated with airway
of an upper respiratory infection (URI). It is not uncom- hyper-reactivity, bronchoconstriction, airway inflamma-
mon for some patients to spend much of their childhood tion, pulmonary edema, and chronic lung injury.
catching, suffering from, or recovering from a URI, with Several effects of anesthesia, together or separately,
the highest frequency occurring in children under age 6 may have life-threatening consequences. After anesthetic
who attend day care or preschool.9 Patients with a current induction, pulmonary vasoconstriction can aggravate
or recent URI undergoing general anesthesia are theo- ventilation-perfusion mismatch and lead to profound
retically at increased risk for perioperative respiratory hypoxemia. Anesthetic effects on myocardial contractility
complications, including laryngospasm, bronchospasm, can result in impaired right ventricular function, reduced
and hypoxia, with the youngest patients (<2 years of age) cardiac output, decreased pulmonary blood flow, and
being at greatest risk.10,11 However, anesthetic manage- profound cardiovascular compromise with hypoxemia.
ment may also be tailored to reduce stimulation of a Increased airway reactivity during anesthetic induction or
potentially hyper-reactive airway. In addition, cancella- emergence from anesthesia can result in severe exacerba-
tion of a procedure imposes an emotional and/or eco- tion of bronchoconstriction, impairing ventilation and
nomic burden on patients and families, physicians, and pulmonary blood flow. Increased oral and bronchial
operating rooms. Unless the patient is acutely ill, it is secretions induced by the anesthetic can compromise
often acceptable to proceed with the anesthetic. Patients airflow and lead to airway or endotracheal tube plugging.
with high fever, wheezing, or productive cough may actu- Because of diminished respiratory reserves in these
ally have a lower respiratory tract infection and the patients, such plugging can quickly cause profound
planned procedure is more likely to be cancelled. Our hypoxia and acute right-sided heart strain, arrhythmias,
approach is to discuss the urgency of the scheduled oper- and possibly death.
ation with the surgeon, and then to review the risks and Preoperative measurement of electrolytes is warranted
benefits of proceeding versus rescheduling with the in children taking diuretics such as furosemide and
parents, taking into consideration the possibility that the spironolactone on a chronic basis, In addition, 48–72
child may have another URI at the time of the resched- hours of steroid administration may provide anti-
uled procedure. Allowing the parents to participate in the inflammatory coverage which may reduce the risk of
decision-making process (when appropriate) usually leads perioperative bronchospasm. If the child has received
to mutual satisfaction among all involved parties. large doses of or continuous treatment with steroids,
The decision to cancel or postpone a procedure perioperative stress doses may be necessary.
(usually a delay of four to six weeks because of concern
for prolonged hyperreactivity of the bronchi) should not
Postanesthetic Apnea
be made lightly. Families have often sacrificed time away
from work, taken children out of school, arranged child The risk of apnea is increased in ex-premature infants
care for other children, or have planned a vacation around because of immaturity of the central and peripheral
chemoreceptors with blunted responses to hypoxia and dysfunction may, or may not, be present. However, the
hypercapnia, even without the additional burden of absence of signs and symptoms does not preclude the
anesthetic/opioid-induced respiratory depression. In possibility of life-threatening collapse of the airway or
addition, anesthetic agents decrease muscle tone in the cardiovascular obstruction upon induction of anesthesia.
upper airway, chest wall, and diaphragm, thereby further Patients presenting with anterior mediastinal masses
depressing the ventilatory response to hypoxia and hyper- (e.g., lymphoma) are at particularly high risk of airway
capnia. In the immediate neonatal period, immaturity of compromise and cardiovascular collapse with the induc-
the diaphragmatic musculature causes early fatigability, tion of general anesthesia due to compression of the
which may also contribute to apnea.12 Although postanes- trachea or great vessels when intrinsic muscle tone is lost
thetic apnea may be brief and resolve either spontane- and spontaneous respiration ceases.15–17 When this occurs,
ously or with minor stimulation, in ex-premature infants there may not be airway compromise, but rather obstruc-
even brief apnea may result in significant hypoxia. tion of vascular inflow to the right atrium and/or outflow
Although most apneic episodes occur within the first two tract obstruction from the right or left ventricle.
hours after anesthesia, apnea can be seen up to 18 hours Preoperative evaluation should begin with a careful
postoperatively. history to elicit any respiratory symptoms. Common
This increased risk of apnea affects the postanesthetic symptoms of tracheal compression and tracheomalacia
care of infants born prematurely, mandating that those include cough, dyspnea, wheezing, chest pain, dysphagia,
at risk be admitted for cardiorespiratory monitoring. orthopnea, and recurrent pulmonary infections. Cardio-
Despite numerous studies on this issue, the postnatal age vascular symptoms may result from infiltration of the
at which this increased risk of apnea disappears is still pericardium and myocardium or compression of the
being debated. The results of a meta-analysis of pertinent pulmonary artery or superior vena cava. The diagnostic
studies indicated that a significant reduction occurred in evaluation includes chest radiographs and/or computed
the incidence of apnea at 52 to 54 weeks’ postconceptual tomography (CT) scans. Echocardiography may be useful
age.13 A hematocrit less than 30% was identified as an to assess the pericardial status, myocardial contractility,
independent risk factor, and it was recommended that and compression of the cardiac chambers and major
ex-premature infants with this degree of anemia be hos- vessels. Flow-volume loops and fluoroscopy can provide
pitalized postoperatively for observation regardless of the a dynamic assessment of airway compression that other
postconceptual age. However, conclusions drawn from tests cannot assess. Chest CT is helpful in planning the
this meta-analysis have been challenged. Moreover, the anesthetic technique and in evaluating the potential for
sample size of this study may not have been large enough airway compromise during anesthesia. Tumor-associated
to draw valid conclusions.14 superior vena cava syndrome develops rapidly and is
Until more patients are systematically studied, the poorly tolerated.
choice of when a former preterm infant can undergo an Premedication is inadvisable in most patients with an
outpatient operation is up to the discretion and personal anterior mediastinal mass as any loss of airway muscle
bias of the anesthesiologist and surgeon. Institutional tone may upset the balance between negative intratho-
policies most commonly mention ages of 44 weeks for racic pressure and gravity, resulting in airway collapse.
infants born at term (>37 weeks), and from 52 weeks to Once the decision is made to sedate or anesthetize the
60 weeks postconceptual age for infants born at <37weeks. child, maintenance of spontaneous respiration, regardless
Legal issues direct these practices in many institutions, of induction technique, is paramount. It is essential to
but regardless of the postconceptual age at the time of avoid the use of muscle relaxants because the subsequent
surgery, an infant should be hospitalized if any safety airway collapse can be fatal.
concerns arise during the operative or recovery period. Positioning the child is an important part of the anes-
Although the risk of apnea can be decreased with thetic plan for these patients. The sitting position favors
regional anesthesia and/or caffeine, our practice is to gravitational pull of the tumor toward the abdomen
admit all at-risk patients (those with a postconceptual age rather than allowing the tumor to fall posteriorly onto
of younger than 60 weeks), regardless of the anesthetic the airway and major vessels as occurs in the supine posi-
technique used, to monitored, high-surveillance inpatient tion. However, the sitting position makes intubation
units for 23 hours after anesthesia and operation. Simi- challenging. Thus, positioning the symptomatic child in
larly, infants born at term must be at least 1 month of age the lateral decubitus position is recommended. Turning
to be candidates for outpatient surgery because postanes- the child lateral or prone, or lifting the sternum, have
thetic apnea has been reported in full-term infants up to been shown to alleviate acute deterioration in ventilation
44 weeks postconceptual age.13 Figure 3-1 shows an algo- or cardiovascular collapse secondary to tumor compres-
rithm useful for decision making regarding eligibility for sion.18,19 In any patient with an increased potential for
day surgery in young infants. such obstruction, provision should be made for the avail-
ability of a rigid bronchoscope, the ability to move the
Anterior Mediastinal Mass operating room table to effect position changes, and the
ability to institute cardiopulmonary bypass or extracor-
It has long been recognized that the anesthetic manage- poreal membrane oxygenation (ECMO). Compression of
ment of the child with an anterior mediastinal mass is greater than 50% of the cross-sectional area of the trachea
very challenging and fraught with the risk of sudden on CT imaging has been suggested to identify a popula-
airway and cardiovascular collapse. Signs and symptoms tion at risk of airway collapse during induction of general
of positional airway compression and cardiovascular anesthesia.20
Premature birth?
<37 weeks
Yes No
Postconceptual age Postnatal age
<60 weeks >60 weeks <4 weeks >4 weeks
Hospitalize Home cardiorespiratory Hospitalize Home cardiorespiratory

overnight monitor? overnight monitor?
Yes No Yes No
Hospitalize Day surgery Hospitalize Day surgery

overnight overnight
FIGURE 3-1 ■ This algorithm is useful for decision making regarding eligibility for outpatient surgery.
When possible, percutaneous biopsy of the mass using Preoperative Preparation and Evaluation
local anesthesia with or without judicious doses of seda-
tive medication is often ideal and poses the least risk to The spectrum of congenital and acquired cardiac lesions
the patient. In patients who have additional tissue sites is so varied that formulating one set of rules for evalua-
from which a biopsy can be obtained (e.g., cervical, axil- tion and perioperative care is nearly impossible. Children
lary, or inguinal lymph nodes), it may be safer to proceed with unrepaired or palliated heart disease, children
with the patient in a semi-sitting position using local requiring operation as a result of their cardiac disease,
anesthesia and carefully titrating sedation so that sponta- and children undergoing emergency surgery tend to be
neous ventilation is preserved. Recently, ketamine and more critically ill and require more intensive preopera-
dexmedetomidine have been shown to provide good tive preparation and assessment.
sedation with preservation of airway patency and sponta- Patients with CHD may be receiving antithrombotic
neous respiration in this setting.21 If progression to therapy for a variety of reasons, including the presence
general anesthesia is required and airway and/or vascular of systemic-to-pulmonary shunts, mechanical or biologi-
compression exists, standby ECMO capability is strongly cal prosthetic heart valves, a history of thrombosis involv-
recommended. ing a conduit or a shunt, recent transcatheter interventions
The inherent conflict between the need to obtain an or device placement, treatment of Kawasaki disease, and
accurate and timely tissue diagnosis and the very real the presence of risk factors for thromboembolic events
concern regarding the safe conduct of the anesthetic including Fontan physiology. No specific pediatric guide-
requires an open dialogue between the anesthesiologist, lines exist for the discontinuation of antithrombotic
surgeon, and oncologist to reach an agreement on strate- medications prior to an elective operation, and manage-
gies to achieve these goals. Many experts recommend ment strategies ideally should be coordinated between
the development and utilization of an algorithm for the child’s cardiologist, surgeon, and anesthesiologist.
anesthetic management of the child with an anterior An emergency operation presents additional manage-
mediastinal mass (Fig. 3-2). The algorithm addresses ment issues and often adds risk in several areas. There
assessment of signs and symptoms, evaluation of cardio may be little time preoperatively to optimize the patient’s
pulmonary compromise, and treatment options.18,22,23 cardiac condition, along with difficulty in quickly obtain-
ing complete cardiology and surgical records. In these
cases, the anesthetic preoperative evaluation is distilled
Patients with Congenital Heart Disease into the most important factors, including the nature and
Each year in the U.S., nearly 32,000 children are born duration of the present illness, the child’s underlying
with CHD. Extracardiac anomalies are seen in up to 30% cardiac disease, baseline status, and medications. Patients
of infants with CHD,24,25 and may necessitate operative with cyanosis, or those who depend on shunts for pulmo-
intervention in the neonatal period prior to repair nary blood flow (PBF), or those with single ventricle
or palliation of the cardiac lesion. Although physiologi- physiology who have undergone total cavopulmonary
cally well-compensated patients may undergo noncardiac anastomosis (Fontan procedure) require intravenous
surgery with minimal risk, certain patient groups hydration prior to induction of anesthesia if they are
have been identified as high risk: children less than 1 year hypovolemic. Based on the child’s condition and the
of age, especially premature infants; patients with nature of the emergency, a decision can be made as to
severe cyanosis, poorly compensated congestive failure whether to proceed with the case with no further workup
or pulmonary hypertension; patients requiring emer- or a review of available old records, or whether new
gency surgery and patients with multiple coexisting consultations and studies should be obtained prior to
diseases.26 surgery.
Chest radiograph
History and physical exam
Investigation Cardiac echo, ECG, CT

scan, flow-volume loop
Anesthesia for investigation

or surgical procedure
Cooperative/mature child Uncooperative/young child
Accessible site Inaccessible site Symptomatic Asymptomatic
Local anesthetic GA with GA with

and sedation std precautions std precautions
Cardiovascular Respiratory SVCS
Syncope, compromised Orthopnea CT scan Preoperative radiation

cardiac output or 12-24 hr steroids
Cardiac echo Yes No Tracheal/bronchial

compression
Negative Positive
or 50% 50% None
GA with Lower limb IV Local

std precautions anesthesia
+ sedation
12-24 hr steroids
or
GA with • Left decubitus or sitting Extubate awake

standard precautions • Spontaneous ventilation Transfer to recovery in lateral decubitus
• No muscle relaxants
• Ancillary support
FIGURE 3-2 ■ This algorithm describes management of the patient with a large anterior mediastinal mass. GA, general anesthesia.
SVCS, superior vena cava syndrome. (Adapted from Cheung S, Lerman J. Mediastinal masses and anesthesia in children. In: Riazi J,
editor. The Difficult Pediatric Airway. Anesthesiol Clin North Am 1998;16:893–910.)
Endocarditis Prophylaxis prophylaxis for any other form of CHD. For a more
comprehensive discussion, the reader is referred to the
The most recent American Heart Association (AHA) original publications.31,32
guidelines for perioperative antibiotic prophylaxis
emphasize evidence-based practice. Current opinion
reflects the view that endocarditis is more likely to Special Issues in Patients with CHD
result from frequent exposure to bacteremias occurring
Pulmonary Hypertension
as a consequence of activities of daily living than those
due to dental, gastrointestinal, or genitourinary tract Prolonged exposure of the pulmonary vascular bed to
procedures.27–30 Except for the conditions listed in Box high flows secondary to left-to-right shunting, pulmo-
3-4, the AHA no longer recommends routine antibiotic nary venous obstruction, or high left atrial pressures can
Cardiac Conditions for Which Cyanosis and Polycythemia

Antibiotic Prophylaxis with Dental, Cyanosis in patients with CHD can be the result of either
BOX 3-4
Respiratory Tract, Gastrointestinal, right-to-left shunting with inadequate PBF or admixture
and Genitourinary Procedures of oxygenated and deoxygenated blood in the systemic
circulation. Severe, longstanding cyanosis causes a variety
Congenital heart disease (CHD)a
of systemic derangements including hematologic, neuro-
Unrepaired cyanotic CHD, including palliative shunts
and conduits logic, vascular, respiratory, and coagulation abnormali-
Completely repaired congenital heart defect with pros- ties. During preoperative evaluation, the child’s baseline
thetic material or device, whether placed by surgery range of hemoglobin–oxygen saturation, heart rate, and
or by catheter intervention, during the first 6 months blood pressure should be noted along with any history of
after the procedureb stroke, seizure, or pre-existing neurologic defects. Care
Repaired CHD with residual defects at the site or should be taken intraoperatively to maintain normal fluid
adjacent to the site of a prosthetic patch or pros- balance and cardiac function. The use of air filters in IV
thetic device (which inhibit endothelialization) lines and meticulous attention to air in volume lines
Cardiac transplantation recipients who develop cardiac without filters is essential to avoid the occurrence of
valvopathy
paradoxical emboli in children with right-to-left shunts.
Prosthetic cardiac valves
Previous infective endocarditis Controlled ventilation is recommended for all but the
shortest procedures due to the ventilatory abnormalities
a
Except for the conditions listed above, antibiotic prophylaxis is no in these patients.
b
longer recommended for any other form of CHD. One of the initial responses to cyanosis is an increase
Prophylaxis is recommended because endothelialization of prosthetic in erythropoietin levels with a subsequent increase in
material occurs within 6 months of the procedure.
Adapted from Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective hemoglobin and hematocrit. At hematocrit levels greater
endocarditis. Guidelines from the American Heart Association Rheumatic than 65%, increased blood viscosity can result in a
Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardio- decrease in the delivery of oxygen to tissues. Preoperative
vascular disease in the Young, and the Council on Clinial Cardiology, phlebotomy is recommended only in patients who have
Council on Cardiovascular Surgery and Anesthesia, and Quality of Care
and Outcomes Research Interdisciplinary Working Group. Circulation
hematocrit greater than 65%, are experiencing symptoms
2007;116:1736–54. of hyperviscosity, and are not dehydrated. Acute onset of
symptomatic hyperviscosity syndrome can be seen in
cyanotic patients whose hematocrit abruptly increases
due to dehydration. In these patients, rehydration is rec-
ommended rather than phlebotomy.
lead to elevated pulmonary artery (PA) pressures and the Increased bleeding tendencies, and a variety of associ-
development of pulmonary veno-occlusive disease. ated laboratory abnormalities, have long been noted in
The pathophysiology and anesthetic implications of cyanotic patients. When compared to acyanotic children
pulmonary hypertension have been well reviewed,33–35 a disproportionate number of cyanotic children are
and there is no ideal sedative/anesthetic agent for these thrombocytopenic, with the degree of thrombocytopenia
patients. A frank discussion of the high risk of anesthesia directly related to the severity of polycythemia. Abnor-
in these patients should be held with the patient’s family malities in prothrombin time, partial thromboplastin
when the anesthetic consent is obtained. time, and individual factor deficiencies have also been
Anesthetic management strategies are guided by three described and defy simple classification.39 Although these
considerations: (1) appropriate manipulation of factors deficiencies may cause no symptoms other than bruising,
affecting pulmonary vascular resistance (PVR); (2) the severely cyanotic patients should have clotting studies
effect of anesthetic agents on PVR; and (3) maintenance prior to operation.
of cardiac output (CO) and coronary perfusion pressures.
Increases in PVR can potentially culminate in right ven-
Pacemakers/Implantable
tricular (RV) failure if excessive.36–38 Ventilatory strategies
Cardioverter-Defibrillators
can profoundly alter cardiovascular pathophysiology via
complex interactions influencing cardiac function and Increasing numbers of infants and children have pace-
output due to alterations in RV preload and afterload. makers or implantable cardioverter-defibrillators (ICDs).
Given the propensity for desaturation and increases in In recent years increasing numbers of children have had
PCO2 with spontaneous ventilation, controlled ventila- ICDs placed for prevention of sudden cardiac death due
tion is recommended intraoperatively with maintenance to congenital or acquired long QT syndrome.40 Neces-
of lung volumes at or around functional residual capacity sary preoperative information for these patients includes
(FRC) with minimal positive end expiratory pressure the indication for device placement, the date of last device
(PEEP) and avoidance of high inspiratory pressures, check, and the current underlying cardiac rate and rhythm
hypercarbia, or hypoxemia. Normal preload should be without device support. Indications for permanent pace-
maintained and hypotension avoided in these patients in makers in patients with CHD include congenital or post-
order to optimize CO, coronary artery flow, and oxygen surgical complete heart block, and sinus node or AV node
supply to the RV. Dopamine, epinephrine, and milrinone dysfunction.
should be available to further improve cardiac function if The American College of Cardiology/American Heart
necessary. Association (ACC/AHA) guidelines advocate pre- and
postoperative interrogation of permanent pacemakers.41 from the heart. However, systemic hypertension is fre-
All patients with an ICD should undergo preoperative quently seen in these children. At 18 months to 3 years
device interrogation with disabling of defibrillation capa- of age, a total cavopulmonary anastomosis, or Fontan
bility intraoperatively and resumption in the postopera- procedure, is performed. Surgeons usually choose to
tive period. Bipolar electrocautery should be utilized place a fenestration in the atrial baffle allowing right-to-
whenever possible in the patient with a pacemaker or left shunting to occur, and these patients often have
ICD. If monopolar electrocautery is used, the electrocau- hemoglobin-oxygen saturation of 80–90%. The presence
tery return pad should be placed as far away from the of aorto-pulmonary collaterals or baffle leaks may also
pacing generator as possible, and the pacemaker result in decreased systemic oxygen saturation.
generator/leads axis should not be located between the It is clear that the patient’s volume status must be
operative site and the grounding pad. If the pacemaker assessed preoperatively. Patients with dehydration should
cannot be placed in an asynchronous mode and electro- have an IV placed and adequate hydration assured prior
cautery adversely affects it, cautery current should be to induction of anesthesia. Care should be taken to avoid
applied for not more than 1 second at a time, with 10 hypovolemia as PBF is dependent on preload. Normal
seconds between burses of current, to allow for mainte- sinus rhythm should be maintained if possible. Control-
nance of CO.42,43 led ventilation is appropriate for most procedures as long
as excessive airway pressures are avoided, and physiologic
levels of PEEP may be used to avoid atelectasis without
Single Ventricle Physiology
impairing PBF.
A brief review of the anatomy and physiology of patients Although many children with SV physiology may
with single ventricle (SV) abnormalities is essential to appear well, they are uniquely susceptible to physiologic
understanding the consequences of anesthesia in this perturbations, especially hypovolemia. Laparoscopic pro-
population. The anatomy of patients classified as having cedures, while presenting many advantages, should be
SV physiology may include any lesion or group of lesions carefully undertaken in these patients
in which a two-ventricle cardiac repair is not feasible.
Generally, either both AV valves enter a single ventricular
chamber, or there is atresia of an AV or semilunar valve.
The Difficult Pediatric Airway
Intracardiac mixing of systemic and pulmonary venous The patient with a ‘difficult airway’ may require advanced
blood flow occurs, and the SV output is shared between airway management techniques in order to secure his/her
the pulmonary and systemic circulations. Patients with airway including the lighted stylet, the fiberoptic intubat-
relative hypoplasia of one ventricle, such as an unbal- ing stylet, the flexible fiberoptic bronchoscope, direct
anced AV canal defect or severe Ebstein anomaly, may laryngoscopy with intubating stylet, fiberoptic rigid
also undergo SV palliation operations. laryngoscopy, an anterior commissure scope, the laryn-
A series of three separate staged palliative cardiac sur- geal mask airway, cricothyrotomy, and tracheostomy.
geries are generally performed for most children with SV Anesthesiologists and facilities do not need availability of
physiology. After initial stage I palliation, patients are all of the listed techniques. When a difficult airway is
dependent on either a modified systemic-to-pulmonary anticipated, it is important to have all necessary airway
shunt or an RV to PA conduit to provide PBF. The ratio equipment present in the operating room (OR) before
of pulmonary to systemic blood flow is then dependent induction of anesthesia, as well as communication of the
on the balance between systemic vascular resistance difficult airway potential to all members of the OR team.
(SVR) and PVR, with patients vulnerable to perturba- Indirect intubation methods should be utilized rather
tions in PO2, PCO2, acid–base status, temperature, and than repeated attempts at direct laryngoscopy because
volume status. Oxygen saturations greater than 85% airway edema and bleeding increase with each attempt,
indicate pulmonary overcirculation and patients may decreasing the likelihood of success with subsequent indi-
exhibit symptoms of congestive heart failure (CHF). rect methods.44
Once the patient is anesthetized and mechanically venti- Patients that require additional approaches to obtain
lated, their oxygen saturation often increases, requiring an airway require additional OR time and, in certain
the adjustment of the FiO2 and PCO2 to target oxygen cases, continuation of intubation postoperatively may be
saturations between 75–85%. An acute drop in oxygen necessary, mandating ICU admission. Most difficult
saturation along with the absence of a murmur indicates airways in the pediatric age group can be anticipated.
loss of shunt flow and is catastrophic. Immediate echocar- Unlike in adults, it is rare to encounter an unanticipated
diographic confirmation of shunt flow is crucial, with difficult airway in a normal-appearing child. Some con-
rapid institution of ECMO if necessary. genital syndromes associated with difficult airway man-
Patients usually undergo a second stage procedure, or agement are listed in Table 3-2.
bidirectional cavopulmonary anastomosis, at 3 to 6 The ASA has developed practice guidelines and an
months of age, with the anastomosis of the superior vena algorithm for management of the difficult airway. This
cava to the pulmonary circulation replacing the systemic- guideline and algorithm are continually updated and well
to-pulmonary shunt created during the first stage surgery. known to anesthesiologists.44 Although the guidelines
Oxygen saturations will continue to range from 75–85% and algorithm are intended for use in adult patients, their
as patients are still mixing oxygenated and deoxygenated emphasis on the importance of having a clear primary
blood for ejection from the SV. Ventricular function is plan with multiple back-up contingency plans is equally
generally improved as the volume load has been removed applicable to infants and children.
Two features of laparoscopic intervention create

TABLE 3-2 Syndromes and Craniofacial
concern in the anesthetic management of infants and
Abnormalities Associated with
children: (1) the creation of a pneumoperitoneum with
Difficult Intubation
the concomitant increase in intra-abdominal pressure
Syndrome Associated Features and resultant changes in ventilatory parameters; and
(2) the extremes of patient positioning that may be
Arthrogryposis Limited mouth opening
and cervical mobility required for optimal exposure of intra-abdominal struc-
Beckwith–Wiedemann Macroglossia tures.46 An appreciation of the physiologic, hemody-
Freeman–Sheldon (whistling Microstomia namic, and ventilatory consequences during and after a
face) laparoscopic operation is an important part of careful
Goldenhar syndrome Hemifacial microsomia,
(hemifacial microsomia) mandibular hypoplasia
patient selection.
(uni- or bilateral) Carbon dioxide is the gas of choice for insufflation for
Klippel–Feil Limited cervical mobility several reasons. Carbon dioxide is noncombustible and is
Mucopolysaccharidoses Macroglossia, limited cleared more rapidly from the circulation than the other
(e.g., Hurler) cervical mobility, options. The cardiovascular consequences of intravascu-
Infiltration of tongue,
supraglottis lar gas embolism present less risk with CO2 than with an
Pierre–Robin Micrognathia, glossoptosis, insoluble gas such as helium or air. However, cardiovas-
cleft palate cular collapse has been reported in several infants follow-
Treacher–Collins Maxillary/mandibular ing insufflation, with end-tidal gas monitoring implying
hypoplasia
that these events were due to gas embolism.47,48 Neonates
Trisomy 21 (Down) Macroglossia, subglottic
stenosis, atlanto-axial and very young infants may be uniquely at risk for such
instability events because of possible patency and large caliber
of the ductus venosus. Carbon dioxide uptake may be
significantly greater in children, owing to the greater
absorptive area of the peritoneum in relation to body
weight, and the smaller distance between capillaries and
INTRAOPERATIVE MANAGEMENT peritoneum. Regardless, hypercarbia has been demon-
strated in pediatric studies during CO2 insufflation.49
Monitoring and Vascular Access Increases in minute ventilation by as much as 60% may
be required to maintain baseline ETCO2, but the goal for
Standard monitoring in pediatric anesthesia follows the an appropriate CO2 level need not be the baseline value.
ASA ‘Standards for Basic Anesthetic Monitoring’45 and Instead, ETCO2 can safely rise into the 50s.
includes pulse oximetry, noninvasive automated blood Hydrocephalic patients warrant special mention in
pressure measurement, electrocardiography, capnogra- regard to CO2 insufflation. Although patients with VP
phy, and temperature monitoring. Temperature monitor- shunts have been shown to have intracranial pressure
ing is indicated in most pediatric anesthetics because of increases associated with a modest decrease in cerebral
the increased prevalence of both MH and, more com- perfusion pressure at an intra-abdominal pressure of
monly, hypothermia in infants and children exposed to 10 mmHg or less,50 a recent review of laparoscopic com-
ambient OR temperatures. pared to open abdominal surgery in children with shunts
Oxygenation is measured indirectly by pulse oximetry showed no pneumocephalus or increase in the incidence
with an audible and variable pitch tone and low threshold of shunt infection in the laparoscopic group.51 This is due
alarm. Measurement of inspired oxygen concentration is to the fact that most VP shunts now have a one-way valve
standard with the use of an anesthesia machine. Depend- that will not allow gas entry. Interestingly, one group
ing on the duration and magnitude of the planned opera- recently reported a case of pneumocephalus that occurred
tion, as well as the child’s preoperative condition, more in a patient with such a shunt and valve that was inserted
invasive monitoring with placement of an arterial or 20 years earlier.52
central venous line may be necessary. The surgeon should The increase in intra-abdominal pressure seen with
communicate his or her expectations regarding the laparoscopy is associated with well-documented cardi-
expected duration of surgery, the potential for blood loss, orespiratory changes. Changes in ventilatory dynamics
and the need for invasive monitoring intraoperatively occur due to cephalad displacement of the diaphragm.
and/or postoperatively. In cases where large fluid shifts This results in a reduction in lung volume, ventilation-
or blood loss are expected, the placement of a urinary perfusion mismatch, and altered gas exchange. Bozkurt
catheter aids in assessing ongoing urine output and fluid and coworkers demonstrated statistically significant
balance. decreases in pH and PaO2 and increased PaCO2 after 30
minutes of pneumoperitoneum.53 These changes are
Anesthetic Considerations for Specific additive to the 20% reduction in FRC that occurs with
induction of general anesthesia. The magnitude of the
Surgical Approaches pulmonary effects correlates directly with intraperitoneal
The successful application of minimally invasive tech- pressures, and may be further exacerbated by steep Tren-
niques is now commonplace in infants and children. delenburg positioning.54
Anesthetic concerns center around the effects of abdomi- Significant cardiovascular changes have been demon-
nal insufflation on ventilation and hemodynamics. strated in response to increased intra-abdominal pressure
and patient position. In the supine or Trendelenburg duration of the insufflation. These factors should be con-
position, the venous return is less impaired when the sidered along with any pre-existing preoperative respira-
intra-abdominal pressure is kept below 15 mmHg. The tory or cardiovascular compromise in planning the
position preferred for upper abdominal procedures is operation and anesthetic management. The magnitude of
reverse-Trendelenburg or supine. The head-up position the physiologic changes induced by either one-lung or
reduces venous return and CO.55 Several pediatric studies two-lung ventilation with insufflation is impacted by the
have utilized echocardiography (supine),56 impedance patient’s age, underlying co-morbid conditions, and anes-
cardiography (15° head-down),57 and continuous esopha- thetic agents utilized.
geal aortic blood flow echo-Doppler (supine)58 to assess Many thoracic procedures require lung deflation and
hemodynamic changes during laparoscopic surgery. minimal lung excursion on the operative side while ven-
These studies demonstrated significant reductions in tilating the contralateral lung. OLV is useful if the
stroke volume and cardiac index (CI), along with a sig- surgeon requires additional exposure. In the pediatric
nificant increase in SVR. Pneumoperitoneum was found patient, there are several options for attaining unilateral
to be associated with significant increases in left ventricu- lung isolation (Fig. 3-3).61
lar end-diastolic volume, left ventricular end-systolic Complications related to anesthetic management are
volume, and left ventricular end-systolic wall stress.56 All usually related to mechanical factors such as airway injury
three studies demonstrated a decrease in cardiac per- and malposition of the ETT. Additional problems related
formance and an increase in vascular resistance in healthy to physiologic alterations include hypoxemia and hyper-
patients undergoing laparoscopy for lower abdominal capnia. An unusual complication was reported during
procedures. The cardiovascular changes seen with attempted thoracoscopic resection of a congenital cystic
pneumoperitoneum (Box 3-5) occur immediately with adenomatoid malformation in a 3.5 kg infant.62 During
creation of the pneumoperitoneum and resolve on CO2 insufflation, there was a sharp rise in ETCO2 accom-
desufflation. panied by severe hypoxemia and bradycardia. This was
due to occlusion of the ETT by blood. After immediate
conversion, it was discovered that there had been direct
Thoracoscopy insufflation into the cyst and that the cyst communicated
Thoracoscopy has advantages over open thoracotomy, directly with the tracheobronchial tree.
including reduced postoperative pain, decreased dura- Blood obstructing the ETT is a common occurrence
tion of hospitalization, improved cosmetic results, and during thoracic procedures, whether open or thoraco-
decreased incidence of chest wall deformity.59,60 An scopic, especially in infants in whom the ETT inner
optimal anesthetic plan considers potential respiratory diameter is so small and therefore at high risk for
derangements including ventilation-perfusion mismatch obstruction. Ventilatory parameters, such as increasing
which may result from positioning, CO2 insufflation into airway pressure during volume ventilation or decreasing
the pleural cavity, and single-lung ventilation. In addi- tidal volume during pressure ventilation, may precede
tion, much like insufflation during laparoscopy, hemody- desaturation and an increase in ETCO2 due to compro-
namic changes during chest insufflation can compromise mised ventilation associated with ETT obstruction.
preload, stroke volume, CI, and blood pressure.60 ETT suctioning, and if necessary, ETT lavage may be
In a study of 50 pediatric patients undergoing thora- required during the procedure to remove blood and/or
coscopy for a variety of operations, systolic and diastolic secretions.
blood pressures were significantly lower, and ETCO2 It is important to try to maintain a reasonable range
was significantly higher during thoracoscopy.60 After of elevated CO2 in neonates undergoing thoracoscopic
intrapleural CO2 insufflation, there was a statistically sig- procedures. Mukhtar and colleagues reported that per-
nificant increase in ETCO2 during one-lung ventilation missive hypercapnia with ETCO2 50–70 mmHg was
(OLV) compared with two-lung ventilation. On the other associated with improved cardiac output and arterial
hand, two-lung ventilation with CO2 insufflation was oxygen tension in neonates undergoing thoracoscopic
associated with a lower systolic and diastolic pressure ligation of patent ductus arteriosus.63 A case series in
than OLV. The increase in ETCO2 correlated with the which high-frequency oscillating ventilation (HFOV)
was used in neonates undergoing thoracoscopic proce-
dures has been reported.64 HFOV enables better CO2
elimination while optimizing the visualization for the
Physiologic Effects of Creation of a surgeons.
BOX 3-5
Pneumoperitoneum
↑ Systemic vascular resistance POSTANESTHESIA CARE
↑ Pulmonary vascular resistance
↓ Stroke volume The recovery period for infants and children may be
↓ Cardiac index more crucial than for adult patients with 3–4% of infants
↑ PCO2
and children developing major complications in the
↓ Functional residual capacity
↓ pH recovery period, compared to only 0.5% of adults. Most
↓ PO2 of these complications occur in the youngest children
↓ Venous return (head up) (<2 years of age) and are most commonly respiratory
in nature.65
A B
FIGURE 3-3 ■ There are several methods available for single-lung ventilation in infants and children. (A) The most common method
is to use a conventional single-lumen endotracheal tube to intubate a main-stem bronchus. (B) Another technique is to position the
endotracheal tube in the trachea followed by insertion of a balloon-tipped bronchial blocker that is passed along the endotracheal
tube and occludes the ipsilateral main-stem bronchus. The position of the bronchial blocker is usually confirmed using fiberoptic
bronchoscopy.
Postintubation croup, or postextubation subglottic

Common Postanesthesia Problems edema, has been a well-recognized entity since airways
Postoperative events can include pain, emergence delir- were first secured with endotracheal tubes. Children are
ium, nausea and/or vomiting, stridor which may be due more prone to develop croup following intubation than
to laryngospasm or subglottic edema, and hypoxia. Per- adults because of the differences in their airway anatomy.
sistence of these conditions can delay discharge. The Children have narrower laryngeal and tracheal lumens
most common minor adverse effects of anesthesia include that are more easily compromised by mucosal edema.
throat pain or discomfort from airway tubes, and postop- Children with trisomy 21 may be at increased risk for this
erative nausea and vomiting (PONV). These issues complication due to the increased incidence of occult
should be discussed with families preoperatively, along subglottic narrowing. Other contributing factors to the
with assurances of prophylaxis and/or treatment if development of croup include traumatic or repeated
necessary. intubation attempts, coughing (‘bucking’) on the ETT,
changes in patient position after intubation, and general
anesthesia in children with a current or recent upper
Postoperative Nausea and Vomiting
respiratory tract infection.71–73
PONV is the most common cause of delayed discharge The incidence of post-intubation croup has decreased
from the postanesthesia care unit (PACU) and the most from 6% to 1% of all endotracheally intubated children.74
common reason for unanticipated hospitalization follow- This reduction has occurred because of the development
ing outpatient surgery.66,67 Certain procedures, such as and use of sterile, implant-tested ETTs, the routine
strabismus surgery, middle ear surgery, orchiopexy, and intraoperative use of humidified gases, and by using
umbilical hernia repair are associated with a greater than an appropriately sized (air leak pressure of less than
50% incidence of postoperative vomiting. Similarly, the 25 cm water) ETT in children younger than 5 years
perioperative use of any opioid is associated with a very of age.
high incidence of PONV, even when general anesthetic Laryngospasm, while possibly life threatening, is
drugs associated with a lower incidence of nausea, such almost always transient and treatable by early application
as propofol, are used.68 Common approaches to treat or of continuous positive airway pressure (CPAP) by mask
prevent PONV include alteration of the anesthetic tech- combined, if necessary, with a small dose of propofol
nique, perioperative administration of antiemetics (either (1–2 mg/kg). Rescue with succinylcholine is indicated if
prophylactically or as treatment), and limitation of post- oxygen desaturation persists despite CPAP and propofol.
operative oral intake.69,70 Laryngospasm may also occur in the OR during anes-
thetic induction or emergence from anesthesia. Effective
maneuvers for management of laryngospasm have
Respiratory Complications
recently been outlined in a helpful algorithm accompany-
Respiratory complications are the most serious of the ing a case scenario publication.75 Bronchospasm is more
common problems seen postoperatively in infants and common in children with poorly controlled asthma and
children. All respiratory complications are more common those exposed to second hand smoke. It is most often
in children with a recent history of respiratory tract managed with administration of nebulized β-agonists
infection. such as albuterol.73
Intraoperative Awareness TABLE 3-3 Equianalgesic Opioid Doses

Intraoperative awareness is a rare but disturbing condi-
Equipotent IV Equipotent PO
tion in which patients undergoing an operation and Name Dose (mg/kg) Dose (mg/kg)
anesthesia can recall surroundings, sounds, events, and
sometimes even pain. The definition of intraoperative Morphine 0.l 0.3
Fentanyl 0.001 N/A
awareness is becoming conscious during a procedure Hydromorphone 0.015 0.04
performed under general anesthesia, with subsequent Methadone 0.1 0.1
explicit memory of specific events that took place during Nalbuphine 0.1 N/A
that time. A Sentinel Event Alert was issued by the Hydrocodone N/A 0.1
Joint Commission (JC) regarding the prevention and Oxycodone N/A 0.1
management of intraoperative awareness in October
2004. The ASA published a Practice Advisory for Intraop-
erative Awareness and Brain Functioning Monitoring in The management of pain in infants and children is
April 2006.76 hampered by the difficulty that exists in assessing pain.
The incidence of intraoperative awareness in adults Many children may respond to pain by emotionally with-
has been reported to be 0.1–0.9% in older studies, and drawing from their surroundings, and this may be misin-
0.0068% or 1 per 14,560 patients in a 2007 report of terpreted by the medical and nursing staff as evidence
87,361 patients.77 Most experts estimate the true inci- that they have no pain. In addition, when questioned as
dence in adults to be 0.1–0.2%. There is a dearth of lit- to their degree of pain, children may not volunteer useful
erature about intraoperative awareness in infants and information for fear of painful interventions (e.g., ‘shots’).
children, but there is a 2005 study of 864 children in To circumvent these difficulties, pain assessment scales
which the incidence was reported as 0.8%.78 Some of have been developed for use in infants and children that
these data may be confounded by the memory of entering are more objective and depend on caregiver assessment
the OR after administration of preoperative sedation or of body positions, facial expression, and physiologic
a memory of events and sensations during emergence. variables. Although there are many scales available, an
Certainly, the likelihood of a clear memory of a painful institution should adopt one scale for each stage of
event during surgery is a much rarer event than the other development, and ensure that caregivers are trained so
events more commonly reported. However, there are that they are used reproducibly in settings where pain is
multiple adverse consequences of intraoperative aware- treated. Examples of these pain scales include CRIES for
ness, including post-traumatic stress disorder and neonates (until 1 month of age), FLACC from 1 month
medical-legal implications. to age 4 years, FACES for age 5 to 9 years and in children
who are developmentally appropriate, and a numerical
Pain Management scale for those older than 10 years of age.81,82
The goal of postoperative pain management should be to

Opioids
achieve good pain relief with minimal adverse effects.
Effective pain management is associated with early mobi- The mainstay in pain control remains the use of opioids,
lization, more rapid recovery, and faster return to work, although increasingly regional analgesic techniques (epi-
school, and play. dural or peripheral nerve block) are being used in infants
The incidence of postoperative pain in the pediatric and children. There are many opioids available for both
population, although difficult to evaluate objectively, is IV and oral administration, but they all have common
probably similar to that in the adult population. It is adverse effects. These include dose-dependent respira-
reasonable, therefore, to assume that about 75% of chil- tory depression as mentioned above, which may be more
dren will report significant pain on the first postoperative prominent in neonates and young infants and in patients
day.79 Many studies looking at pain in hospitalized chil- with OSA.12,83,84 Other side effects that vary in prevalence
dren report under-treatment in both medical and surgical among drugs and patients are dysphoria, somnolence,
patients.80 This under-treatment may be related to: nausea and vomiting, pruritus, constipation, and urinary
(1) inadequate analgesia provided intraoperatively; retention.
(2) underestimation of an infant’s ability to experience Morphine remains the standard by which the potency
pain (primarily in neonates who are erroneously believed of other opioids is measured. Equipotent analgesic doses
to be incapable of experiencing or remembering painful of commonly used IV opioids are listed in Table 3-3. As
experiences); (3) fear of analgesic (primarily opioid) side the plasma concentration of morphine correlates poorly
effects; (4) fear of addiction by both caregivers and with its desired analgesic effect—a fourfold variation has
parents; (5) inadequate knowledge or utilization of pain been measured in the plasma concentration of morphine
assessment scales in children who are either pre-verbal or at which patients express the need for additional pain
unable to use numerical rating scales; (6) failure to appre- medication—many clinicians believe that morphine is
ciate the benefit of nonopioid analgesics in provision of best administered in a patient-controlled device (patient-
effect pain relief while reducing total opioid dose and controlled analgesia [PCA]) to allow self-titration of
attendant adverse effects; and (7) failure to utilize basic medication according to the level of pain experienced.
regional analgesic techniques that are easily applied even A discussion of patient selection and dosing for PCA
in the ambulatory setting. is beyond the scope of this chapter, but can be found in
many textbooks of pediatric anesthesiology and pain history of gastric ulcers. As NSAIDs such as ketorolac
management.81 Patients receiving PCA should be con- and ibuprofen affect platelet aggregation and adhesive-
tinuously monitored for cardiorespiratory depression by ness, their use is limited in many patients that are at risk
monitoring the echocardiogram, respiratory rate, and for postoperative bleeding, particularly children who
pulse oximetry.85 have undergone tonsillectomy.93,97 In addition, many
When PCA devices are not used, the intermittent orthopedic surgeons forbid the use of NSAIDS during
bolus administration of morphine to opioid-naive chil- and after operations in which new bone formation is
dren should be started at 0.05–0.1 mg/kg every two to important (fractures, spine fusions) because NSAIDS
four hours. If the treatment of pain is initiated in the have been shown to impair osteoblastic activity.98 The
PACU or intensive care setting, similar doses may be extent to which this effect is clinically important is
administered every five to ten minutes until the child is unclear.99,100
comfortable.
Fentanyl is a synthetic opioid that usually has a rela- Regional and Local Anesthetic Techniques
tively short duration of action as a result of its rapid
distribution into fat and muscle due to its high lipid solu- As general anesthesia is nearly universal in children, pure
bility. With repeated dosing, the duration of action regional anesthesia is less common than in adults.
appears to increase.86 When compared with morphine, However, pediatric patients, including outpatients, are
fentanyl is about 100 times more potent. (Fentanyl excellent candidates for a host of regional blocks.101–103
dosages are calculated in micrograms rather than milli- Some blocks require specialized equipment like a nerve
grams.) In controlled comparisons with equipotent stimulator or ultrasound, but others such as an ilioin-
dosages, morphine is generally found to provide guinal block can be performed by landmarks alone. Local
better, more long-lasting analgesia than fentanyl, but infiltration by the surgeon is encouraged when a neurax-
with more side effects such as pruritus, nausea, and ial or peripheral block is not performed.
vomiting.87–89 Opioids with short half-lives like fentanyl Regional anesthetic techniques used concomitantly
may also demonstrate the development of much more with general anesthesia have had resurgence in both adult
rapid tolerance to its analgesic effects than morphine or and pediatric patients. These techniques include periph-
hydromorphone. eral nerve blocks, and caudal, epidural, or spinal blocks.
Hydromorphone is a well-tolerated alternative to These blocks include the rectus sheath block for umbili-
morphine and fentanyl, and is felt to cause less pruritus cal procedures, ilioinguinal block for inguinal procedures,
and sedation than morphine, with the few adult studies and the transversus abdominis plane block for lower
that exist suggesting equivalence rather than superior- abdominal procedures.104–106
ity.90 It is five to seven times more potent than morphine, Clonidine has gained favor as an adjunct in regional
and its duration of action is similar to morphine, and anesthesia. A centrally acting alpha-2 agonist with anti-
longer than fentanyl. emetic and mild sedative effects, clonidine confers an
analgesic benefit as well. It has been shown to increase
the analgesic duration of caudal blocks to as long as 18
Nonsteroidal Anti-Inflammatory
hours.107 Clonidine has also been used effectively in epi-
Drugs (NSAIDs)
dural infusions. Moreover, rather than causing nausea or
As more and more pediatric operations are being per- pruritus, clonidine actually decreases the incidence of
formed on an outpatient basis, and with the goal of mini- postoperative nausea. In higher doses (≥2 µg/kg) given
mizing opioid dosing to reduce adverse effects, significant epidurally, clonidine may cause sedation, with some
interest has developed in the role of nonopioid analgesics authors recommending that children receiving this dose
for management of postoperative pain. Acetaminophen is be admitted for observation. Clonidine is not recom-
an effective analgesic for mild to moderate pain, and can mended for use in infants under 6 months of age.
be administered rectally in the perioperative period, In selected cases, peripheral nerve blocks appear to be
especially to infants. Rectal absorption is variable and a superior pain control modality. They offer the benefit
bioavailability is lower, mandating a higher initial dose of no systemic side effects (nausea, pruritus, sedation,
(30–40 mg/kg) than that administered orally (10–15 mg/ urinary retention) and often allow for faster recovery. It
kg).91,92 A rectal dose of 30 mg/kg of acetaminophen has is increasingly common for these blocks to be performed
proved to have analgesic properties similar to 1 mg/kg of under ultrasound guidance, which confers increased
ketorolac.93 In 2011, intravenous acetaminophen was accuracy of placement, which in turn allows the use of
approved for use in adults and children older than 2 years reduced local anesthetic volume, greater efficacy, and
of age in the U.S. improved efficiency. For orthopedic extremity surgery,
Ketorolac is an oral and parenteral NSAID shown to some children are being discharged home with peripheral
have excellent pain control characteristics unassociated nerve catheters which are removed at home by the parents
with PONV, or respiratory depression.94–96 Dosage rec- two days postoperatively.108
ommendations are 0.5 mg/kg intravenously (maximum
dose 30 mg) every 6 to 8 hours for 48 hours. Due to its Prescribing Discharge Analgesics
effects on renal blood flow and tubular function, ketoro-
lac is contraindicated in patients with pre-existing impair- The surgeon or surgeon’s designee must take seriously
ment of renal function. Likewise, it should not be the responsibility of prescribing pain medications to be
administered to patients at risk for coagulopathy or a administered by the parents at home after discharge. This
TABLE 3-4 Components of the Modified Aldrate Score

0 1 2
Motor activity None Two extremities Four extremities
Respiration Apnea Dyspnea Normal
Circulation (BP) ± 50% baseline ± 20–49% baseline ± 20% baseline
Consciousness Unresponsive Arousable Awake
Oxygen saturation SpO2 < 90% despite O2 SpO2 > 90% with O2 SpO2 > 92% in room air
is important for all patients, but especially for ambulatory Criteria for Discharge Home from
surgery patients because of the rapid transition from BOX 3-6
the Postanesthesia Care Unit
PACU to home. It is imperative to clearly communicate
with the parent/guardian regarding the nature of the Return to preoperative level of consciousness
medications prescribed, assessment of pain, and realistic Normothermia (≥35.5°C)
expectations for the course of pain in the days after No oxygen requirement (or return to baseline oxygen
surgery. It is important to emphasize the same issues that requirement)
are of concern when giving analgesics in the hospital: Return to preoperative level of motor function (excepting
right drug, right dose, right time. expected effects of nerve block)
Numerous studies looking at parental home analgesic Acceptable pain control
No ongoing vomiting, minimal nausea
administration after surgery have shown that parents Absence of surgical bleeding
commonly do not understand that some children may At least 30 minutes after last administration of opioid
become withdrawn and immobile in response to pain Discharge acceptable to surgeon
instead of crying.109 In addition, many parents fail to Oral intake (if required by surgeon)
administer prescribed pain medication even when they
recognize their child is having pain, in part because of
lack of specific instructions or because of fear of adverse
effects, including misperceptions about the potential for
‘addiction’.110,111 Care must be taken to avoid advising
DISCHARGE CRITERIA
time-contingent (especially around the clock) dosing of
In general, children should be comfortable, awake, and
opioids because of the increased risk of nausea, vomiting,
stable, on room air or back to baseline oxygen supple-
constipation, but most importantly somnolence and res-
mentation, have age-appropriate vital signs, and be well
piratory depression.112
hydrated before discharge from outpatient surgery. These
With regard to choice of opioid, prescribers should be
variables have been quantified with the modified Aldrete
knowledgeable about recommended dosage and formula-
score (Table 3-4), which lists the important factors taken
tions available for various oral opioids. The most com-
into consideration for discharge. Most institutions require
monly prescribed opioid in children has been codeine
a modified Aldrete score of 9 or greater for discharge to
(more specifically acetaminophen with codeine). A recent
floor, but criteria for discharge home should be stricter,
publication has noted concerns about a number adverse
comprising the elements listed in Box 3-6.
effects of codeine administration.113 These include lack
of analgesic efficacy in approximately 5–10% of the pop-
ulation in whom low CYP2D6 activity leads to low or no
conversion of codeine to morphine in the body, which is
CONCLUSION
required for analgesia.114 More worrisome is the fact that
Many children who present for surgery are frightened
up to a third of individuals (depending on their ethnic
and uncomfortable. It is the pediatric surgeon’s and
origin) are ultrarapid metabolizers because of increased
anesthesiologist’s privilege to help calm and comfort
CYP2D6 activity. Codeine administration in these indi-
these children and their families in addition to providing
viduals results in high plasma levels of morphine which
the best possible anesthetic experience. Guiding the child
can cause respiratory depression, which is especially wor-
through an operation safely, with provision for analgesia
risome in children and especially in children with OSA.
and amnesia, are goals shared by both the anesthesiolo-
The risk of codeine administration to children who may
gist and surgeon alike. Open communication between
be unidentified ultrarapid metabolizers led the U.S. Food
surgical and anesthesia services from the time of schedul-
and Drug Administration to issue a safety alert in August,
ing through the peri- and postoperative periods facilitates
2012 regarding the risk of adverse events or death in
the achievement of these goals, and helps to ensure the
children given codeine after tonsillectomy and/or
best possible outcome for patients and their families.
adenoidectomy.115,116
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C H A P T E R 3

Anesthetic Considerations for

TABLE 3-1 ASA Physical Status Classification Patient History

Treatment of Malignant condition is controversial. However, even if the radio-

Respiratory and Airway Considerations

Postconceptual age Postnatal age

<60 weeks >60 weeks <4 weeks >4 weeks

Hospitalize Home cardiorespiratory Hospitalize Home cardiorespiratory

Hospitalize Day surgery Hospitalize Day surgery

Investigation Cardiac echo, ECG, CT

Anesthesia for investigation

Cooperative/mature child Uncooperative/young child

Accessible site Inaccessible site Symptomatic Asymptomatic

Local anesthetic GA with GA with

Cardiovascular Respiratory SVCS

Syncope, compromised Orthopnea CT scan Preoperative radiation

Cardiac echo Yes No Tracheal/bronchial

GA with Lower limb IV Local

GA with • Left decubitus or sitting Extubate awake

Cardiac Conditions for Which Cyanosis and Polycythemia

Two features of laparoscopic intervention create

Postintubation croup, or postextubation subglottic

Intraoperative Awareness TABLE 3-3 Equianalgesic Opioid Doses

The goal of postoperative pain management should be to

TABLE 3-4 Components of the Modified Aldrate Score

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