So, other considerations in pediatric
anesthesia include Temperature Regulation.
Children lose heat much more rapidly than adults.
And small children have trouble producing
heat. They actually, newborns
have something called brown fat, which
is used to generate heat, where heat
is generated in the rest of us and in older people, by muscle
activity. So it's hard to regulate temperature in children,
but it's very critical that it is regulated, because
they do very poorly if they're hypothermic.
So, if you ever have to work in a pediatric
operating room, you'll be surprised how
hot it is, how warm it is. It's quite honestly not very
comfortable and I'm glad I work in adult operating room
where we all freeze, but it is very warm
in the pediatric OR's to prevent heat loss.
Drug Management is much
more critical. Children dosing
is totally different from adult dosing and much,
to many people's surprise, the actual
dose of induction drug and maintenance drug
required by children is proportionately much greater
than that in adults. So, very small children,
require quite large doses and then, as they get older,
the proportional dose actually decreases.
Other drugs however are totally unpredictable
and you have to dose your drugs according
to the child's weight or body surface
area. You cannot just guesstimate
how much you're going to give.
Fluid Management in children is difficult because
it's extremely easy to overload a child
and put them into heart failure. So you have to be skilled at this,
you have to know what you're doing, and you have to pick
your IV solutions and blood products very carefully.
So instead of giving a unit of blood, you might only give
30 cc's of blood, or 60 cc's
of blood. And you might give it
slowly, and very carefully, and heated
before you deliver it, in a totally different
way than we do it with adults.
Children often develop laryngospasm
when recovering. And laryngospasm
is spasm of the muscles in the larynx
and in the trachea. And this can cause complete
obstruction of the airway This is particularly
likely to occur if you manipulate the tube
when the patient's just starting to wake up,
when they're still lightly anesthetized, they haven't
fully recovered. If you manipulate the tube
at that time it can set off a reflex that makes it
very difficult to ventilate the child. It's much better
to wait until the child is completely awake
before you take the tube out. If they do develop
laryngospasm, they tend to desaturate very quickly,
because their lung capacity is very small and their
oxygen demand is very high, higher than in adults.
The best way to do it, if they develop
laryngospasm and they're desaturing, is to apply
CPAP when you bag and mask. And CPAP just
means that you maintain steady pressure
at the end of expiration. And in most
children, that will overcome the spasm in
the larynx and cause it to open and you
can ventilate quite adequately at that point.
If it doesn't work, you have to paralyze
the child and consider reintubating.
As children get a little older, needle phobia
is very common. The commonest age
for really severe needle phobia is,
in girls around 13-14, and in boys
around 19 to about 24. So the boys,
as one might expect, mature
a little less quickly than the girls.
Pain management must be customized
to the personality, size and conditions
of the child. They sometimes need quite
large amounts of pain medications, and you have
to adjust according to the needs of the child.
Anesthesiologists who provide
care to premature babies
or children requiring highly sophisticated surgical
procedures like cardiac surgery, or neuro-surgery,
burn surgery, thoracic surgery, or other highly
specialized areas of surgery, the anesthesiologists
require extra training. And in my country,
the average pediatric anesthesiologist
working in a pediatric hospital has done
an additional two years of training beyond
the usual five years already required
for anesthesia training.