TIVA in PEDIATRIC ANESTHESIA

TARGET CONTROLLED INFUSION (TCI)

FENTANYL

microprocessor-controlled infusion

system

LIMITED MODELS

BLOOD CONCENTRATION TARGETED

MODELS

Paedfusor - 1 year, 5kg

Kataria - 3 years, 15kg

EFFECT SITE TARGETED MODELS

Munoz study

Anesthesiology 2004; 101(6):1269-74

LOADING DOSE 1-10 mcg/kg

MAINTENANCE INFUSION 0.1-0.2 mcg/kg/min

balanced anesthesia

analgesia & sedation - post-op mechanical

ventilation

lowers stress response to surgery

relatively SHORT CSHT - increases

exponentially with longer infusion times

KETAMINE

ADVANTAGES

respiratory depression - RARE even in

OVERDOSE

patent airway

relaxes smooth muscles of airway

bronchodilator

sympathomimetic effects - increased

heart rate, cardiac index, SVR

RECENT LITERATURE

KETAMINE

DISADVANTAGES

negative inotropic effect - patients on

inotropic support

nystagmus

increased secretions

post-op vomiting - 33% incidence in children

dreaming/hallucinations

Efficacy and safety of intraoperative dexmedetomidine for acute postoperative pain in children: a meta-analysis of randomized controlled trials.

Paediatr Anaesth. 2013 Feb;23(2):170-9.

Effects of Dexmedetomidine on Postoperative Recovery Profile after Sevoflurane Anesthesia in Pediatric Patients: A Meta-analysis.

J Anesth Clin Res 2013 4: 369.

PHARMACOLOGIC

PRINCIPLES

KETAMINE

DISSOCIATIVE SEDATION & ANALGESIA

LOADING DOSE 1 mg/kg

MAINTENANCE INFUSION 0.1-0.2 mg/kg/hr

BOLUSES 1-2 mg/kg

ANESTHETIC DOSE with N2O or MIDAZOLAM

LOADING DOSE 2 mg/kg

MAINTENANCE INFUSION

7 mg/kg/hr - 1st 20 mins

5 mg/kg/hr - next 20 mins

4 mg/kg/hr - next 20 mins

3 mg/kg/hr - thereafter

RELATIVELY IMMATURE SYSTEMS

ELIMINATION slowed down

LOADING DOSE rapidly fills up VD

MAINTENANCE INFUSION sustains

serum drug level

MIDAZOLAM

LOADING DOSE 0.05-0.1 mg/kg

MAINTENANCE INFUSION

0.1-0.3 mg/kg/hr

PREEMIES <32wks AOG

0.5 mcg/kg/min

PREEMIES >32wks AOG & INFANTS

1 mcg/kg/min

MIDAZOLAM

Decreased Elimination

decreased hepatic blood flow

hypovolemic states

inotropic support

drugs - CCBs, protease inhibitors,

erythromycin

Prolonged Use

tolerance, dependency, withdrawal

3 COMPARTMENT MODEL

MIDAZOLAM

DESIRED EFFECTS

anxiolysis

amnesia

sedation

ADVERSE EFFECTS

decreased upper airway tone

decrease in SVR

respiratory depression

REVERSIBLE - FLUMAZENIL

This is Pediatric Advanced Life Support Class

PROPOFOL

Thank you!

PHARMACOLOGIC PRINCIPLES

NORMAL, HEALTHY - higher doses per

unit of body weight

CRITICALLY ILL - smaller doses

WIDE & COMPLEX VARIATION

between INDIVIDUALS and during DIFFERENT STAGES OF GROWTH & DEVELOPMENT

safety profile in neonates - use with caution

bradycardia

return to fetal circulation

egg allergy

relatively safe in majority of children with egg allergy/atopic disease WITHOUT A HISTORY OF EGG ANAPHYLAXIS

peanut allergy

5-10% cross-reactivity with soy allergy

DISADVANTAGES

cardiovascular effects

hiccups

nausea & vomiting

nystagmus

proconvulsant

respiratory depression & apnea

ADVANTAGES

anti-convulsant

anti-emetic

alternative to MH triggers

alternative to neuroapoptotic suspect agents

cardiovascular effects

lowers stress response to surgery

does not produce respiratory depression/apnea

patient-ventilator synchrony

PROPOFOL

Roberts manual Propofol infusion

concurrent with Alfentanil

LOADING DOSE 1 mg/kg

MAINTENANCE INFUSION

13 mg/kg/hr for the 1st 10 mins

11 mg/kg/hr for the next 10 mins

9 mg/kg/hr thereafter

PROPOFOL

Macfarlan manual Propofol infusion

LOADING DOSE 2.5 mg/kg

MAINTENANCE INFUSION

15 mg/kg/hr for first 15 mins

13 mg/kg/hr for the next 15 mins

11 mg/kg/hr for 30-60 mins

10 mg/kg/hr for 1-2 hours

9 mg/kg/hr for 2-4 hours

Roberts manual infusion scheme with Alfentanil

SETUP

2 3-way stopcocks

proximal end - 50 cc syringe

distal end - IV cannula

syringe pump

Lidocaine 0.5 - 1mg/kg preceding

Propofol

Fentanyl 2 mcg/kg

Atracurium 0.4 - 0.6 mg/kg OR

Rocuronium 0.6 mg/kg

PROPOFOL

Monitor with a TOF watch

Routine reversal is advised

Watch out during Induction:

Apnea

Bradycardia

Hypotension

CSHT (up to 8hr infusion) - <40 mins

titrate down to 3 mg/kg/hr during the last 15 mins of surgery

DEXMEDETOMIDINE

GOALS

Roberts manual Propofol infusion

LOADING DOSE 1 mg/kg

MAINTENANCE INFUSION

19 mg/kg/hr for 1st 10 mins

15 mg/kg/hr for the next 10 mins

12 mg/kg/hr thereafter

DEXMEDETOMIDINE

EXAMPLE: 15 kg patient for MRI

LOADING DOSE in 10 mins

15 kg x 1 mcg/kg = 15 mcg or

3.75 cc given in 10 mins

MAINTENANCE INFUSION

15 mcg divided by 4 mcg/cc (concentration)

= 3.75 cc

IVF MAINTENANCE RATE = 50 cc/hr

IVF (46.25 cc) + DEX (3.75 cc) = 50cc/hr

1 mcg/kg/hr

amnesia

analgesia

akinesia

loss of consciousness

DEXMEDETOMIDINE vs PROPOFOL

SETUP

Soluset - ugtts/min is cc/hr

Balanced salt solution

IV cannula with port

Dexmedetomidine 4 mcg/cc concentration

LOADING DOSE 1 mcg/kg in 10 mins

with continuous monitoring

MAINTENANCE INFUSION

1 mcg/kg divided by 4 mcg/cc = __cc/hr

To be included in IV MAINTENANCE RATE

SEDATION in CHILDREN with OSA

MRI Sleep Studies

FEWER episodes of DESATURATION & AIRWAY OBSTRUCTION REQUIRING INTERVENTION

Anesth & Analg 2009; 109(3):745-753

DEXMEDETOMIDINE

PROPOFOL

CONCURRENT USE WITH VOLATILE ANESTHETICS

SEVOFLURANE, DESFLURANE

1 MAC + LD 0.5 mcg/kg in 5 mins

decrease in SBP - 10%

LD 0.5-1 mcg/kg + MD 0.5 mcg/kg/hr

INITIAL decrease in HR

SEVOFLURANE - 30%

DESFLURANE - 15%

Pediatr Anesth 2009; 19:1119-1129

INDICATIONS

PROPOFOL INFUSION SYNDROME (PRIS)

administration >48hrs or >5mg/kg/hr (70mcg/kg/min)

metabolic acidosis

lipemia

hyperkalemia

rhabdomyolysis

cardiovascular collapse

Mortality rate - 80%

hemodialysis - improves survival rate

DEXMEDETOMIDINE

DRUG INTERACTIONS

ANTICHOLINERGICS

given to treat BRADYCARDIA

results in TRANSIENT but PROFOUND HYPERTENSION

mechanism unclear

KETAMINE

no decrease in HR

Anesthesia and Analgesia 2011; X:X.

airway procedures

radio or minimally invasive procedures

frequent repeated anesthesia

post-operative nausea & vomiting

malignant hyperthermia

neurosurgical procedures

spinal instrumentation

stress response to surgery

post-op mechanical ventilation

DEXMEDETOMIDINE

LOADING DOSE 1 mcg/kg

MAINTENANCE INFUSION 0.5-2.5 mcg/kg/hr

SEDATION

NONINVASIVE

LOADING DOSE 0.5-1 mcg/kg in 10 mins

MAINTENANCE INFUSION 0.5-1 mcg/kg/hr

MINIMALLY INVASIVE

LOADING DOSE 1-2 mcg/kg in 10 mins

MAINTENANCE INFUSION 1-2 mcg/kg/hr

TIVA in

PEDIATRIC

ANESTHESIA

Anne Michelle Salomon-Avelino, MD, FPBA

DEXMEDETOMIDINE

DEXMEDETOMIDINE AS TREATMENT FOR JUNCTIONAL ECTOPIC TACHYCARDIA & REENTRANT SVT

some success...

Anesth & Analg 2008; 107:1514-1522

DEXMEDETOMIDINE

CHILDREN WHO UNDERWENT ELECTROPHYSIOLOGICAL STUDIES FOR TACHYARRHYTHMIAS

COMPLICATIONS - 28%

transient AV block, hypotension, AV pacing

CAUTION!!!

very young infants, with CHD or conduction defects, on maintenance drugs with negative chronotropic effect

DEXMEDETOMIDINE

CHILDREN with CHD & IMMEDIATE POST-CARDIOTHORACIC SURGERY

LOADING DOSE 1 mcg/kg in 10 mins

MAINTENANCE INFUSION 1mcg/kg/hr

decrease in HR - 18%

Intensive Care Med 2010; 36:836-842

DEXMEDETOMIDINE

CHILDREN (1-24 mos) IN IMMEDIATE POST-CARDIAC SURGERY

Pharmacokinetic Indices - SAME with

those in HEALTHY CHILDREN

Clearance - lags behind healthy children

by 27%

Pediatr Anesth 2009;19:1119-29.

DEXMEDETOMIDINE

NORMAL, HEALTHY CHILDREN

Redistribution half-life 7-9 mins

Clearance ~15 mins

Elimination half-life - slow; 2 hours

METABOLISM

Glucoronidation - via UGT; 85%

cytochrome P450 2A6 - 15%

highly selective alpha 2 agonist

sites:

locus ceruleus - anxiolysis, sedation

spinal cord & peripheral nerves - analgesia

DEXMEDETOMIDINE

EFFECTS

CVS

transient hypertension - high doses

hypotension - low doses

bradycardia - 16%

decrease in HR - as low as 30 bpms

RESPIRATORY

blunts ventilatory response to CO2

but does not lead to hypoxia nor hypercarbia

AIRWAY

minimal effect on airway patency