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TIVA in PEDIATRIC ANESTHESIA

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Maik Salomon

on 2 June 2014

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Transcript of TIVA in PEDIATRIC ANESTHESIA

INDICATIONS
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
PHARMACOLOGIC
PRINCIPLES
RELATIVELY IMMATURE SYSTEMS
ELIMINATION slowed down

LOADING DOSE rapidly fills up VD
MAINTENANCE INFUSION sustains
serum drug level
TARGET CONTROLLED INFUSION (TCI)
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
PROPOFOL
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
TIVA in
PEDIATRIC
ANESTHESIA


Anne Michelle Salomon-Avelino, MD, FPBA

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
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
GOALS
amnesia

analgesia

akinesia

loss of consciousness
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
DISADVANTAGES
cardiovascular effects
hiccups
nausea & vomiting
nystagmus
proconvulsant
respiratory depression & apnea
3 COMPARTMENT MODEL
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
PROPOFOL
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
PROPOFOL
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
PROPOFOL
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
FENTANYL
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
KETAMINE
DISADVANTAGES

negative inotropic effect - patients on
inotropic support
nystagmus
increased secretions
post-op vomiting - 33% incidence in children
dreaming/hallucinations
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
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
MIDAZOLAM
Decreased Elimination
decreased hepatic blood flow
hypovolemic states
inotropic support
drugs - CCBs, protease inhibitors,
erythromycin

Prolonged Use
tolerance, dependency, withdrawal

MIDAZOLAM
DESIRED EFFECTS
anxiolysis
amnesia
sedation
ADVERSE EFFECTS
decreased upper airway tone
decrease in SVR
respiratory depression

REVERSIBLE - FLUMAZENIL
DEXMEDETOMIDINE
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

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%
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
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 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

Thank you!
This is Pediatric Advanced Life Support Class
DEXMEDETOMIDINE
DEXMEDETOMIDINE AS TREATMENT FOR JUNCTIONAL ECTOPIC TACHYCARDIA & REENTRANT SVT

some success...

Anesth & Analg 2008; 107:1514-1522
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
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.
DEXMEDETOMIDINE
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
DEXMEDETOMIDINE vs PROPOFOL
SEDATION in CHILDREN with OSA
MRI Sleep Studies

FEWER episodes of DESATURATION & AIRWAY OBSTRUCTION REQUIRING INTERVENTION

Anesth & Analg 2009; 109(3):745-753
DEXMEDETOMIDINE
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
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
RECENT LITERATURE
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.
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