Common Pediatric Pitfalls

Educational Objectives

The goal of this program is to improve management of common issues in pediatric anesthesiology. After hearing and assimilating this program, the clinician will be better able to:

1. Distinguish nervous system response to stress in children from the response in adults.
2. Recognize risk factors for emergence delirium in children.

Summary

Physiologic differences in children: the imbalance between the sympathetic and parasympathetic nervous systems is larger in children; infants are focused on “rest and digest” (ie, the parasympathetic system) and do not have the sympathetic tone used to pump blood against gravity because they are not yet standing erect; sympathectomy has no effect in infants (neuraxial anesthesia does not cause vasodilation and hemodynamic change); children exhibit a greater parasympathetic response to physiologic stress, eg, bradycardia rather than tachycardia, bronchoconstriction and laryngospasm rather than bronchodilation; blood pressure is a combination of sympathetic vascular resistance and cardiac output; the hearts of children do not respond to volume changes by altering stroke volume

Upper respiratory tract infection (URI): 25% to 45% of children presenting for surgery have recent or active URI; respiratory tract infections increase the incidence of adverse events

Management: sevoflurane is an effective bronchodilator; preoperative albuterol is effective; clinical data are less conclusive about intravenous (IV) or topical lidocaine; Regli et al (2017) recommended stratifying children with URI into mild URI (nasal discharge, cough), moderate URI (nasal congestion, productive cough), and severe URI (fever, lethargy, wheezing) groups; surgery should be delayed for cases of severe URI; surgery may proceed in cases of mild URI after mitigating risk factors by, eg, avoiding airway instrumentation, using albuterol, maintaining with a bronchodilator; surgery may proceed in cases of moderate URI depending on clinician experience and if equipment to monitor the child is available; a delay in surgery should be considered if the child is younger with risk factors, eg, history of prematurity, smoking exposure, asthma

Preoperative anxiety: nonpharmacologic options — earlier studies reported that parental presence during induction is less effective than oral premedication; coaching of the parent and patient is beneficial; however, parental anxiety may lead to disruptive behavior and contamination of sterile equipment; a child life specialist may coach the patient with age-appropriate play; pharmacologic options — midazolam provides consistent anxiolysis with a short onset time and good amnestic effect; midazolam produces paradoxical effects in ≤10% of pediatric patients; ketamine has low oral bioavailability and requires higher dosing, but produces good dissociative sedation without eliminating respiratory drive and provides analgesia; dexmedetomidine (Precedex) may have antiemetic properties and produces a compliant state and maintains respiratory drive; may be given nasally

Laryngospasm: risk factors include stimulation at a light depth of anesthesia and volatile anesthetic agents; sevoflurane is preferred; halothane is acceptable; desflurane is a strong airway stimulator and is more likely to cause laryngospasm; isoflurane is associated with medium risk for laryngospasm; multiple attempts at airway instrumentation may cause laryngospasm; younger patients are at higher risk; asthma and exposure to secondhand smoke increase risk ≤10-fold

Management: 100% oxygen via facemask should be delivered in conjunction with jaw thrust; secretions should be suctioned if necessary; anesthesia may be deepened with sevoflurane or intravenous (IV) propofol in cases of partial laryngospasm (ie, ventilation is possible); full laryngospasm requires aggressive management; succinylcholine should be given as soon as possible; atropine is recommended to reduce vagal tone because succinylcholine may worsen bradycardia; endotracheal intubation may be necessary; postanesthesia care unit — continuous positive airway pressure should be consistently used; Mapleson circuits are preferred to bag-valve masks

Difficult IV access: predisposing factors include Black non-Hispanic ethnicity, younger age, obesity or overweight, and American Society of Anesthesiologists (ASA) class III status; the best vein should be used for the first attempt; the patient should be put in an ergonomic position; the operator or the equipment should be changed if the attempt fails; mask induction and use of ultrasound guidance should be considered if access is anticipated to be difficult; help should be requested if the second attempt fails

Predictors of difficult airway management: mask ventilation — more difficult in younger patients; tracheal intubation — difficult in patients <1 yr of age, with higher ASA status (>3), malnourishment, and craniofacial syndromes; supraglottic airway placement — difficult in patients undergoing ear, nose, or throat surgery or with known anomalies; oxygenation, ventilation, and anesthetic depth must be maintained; placing a supraglottic airway is a rescue tool that provides time to arrange resources and send for help; multiple attempts should not be made without changing the approach

Hypotension: a late finding in children; hypovolemia is indicated by, eg, delayed capillary refill time, “dry” appearance, tachycardia, and should be aggressively identified and treated

Extubation: criteria for success include spontaneous breathing with tidal volume >5 mL/kg, conjugate gaze, grimace, eye opening, and purposeful movement; the presence of 4 or 5 criteria significantly reduces the risk for complications

Emergence delirium: the Pediatric Anesthesia Emergence Delirium Scale uses a score of 0 to 4 for each criterion; a score >12 indicates emergence delirium; risk factors include preschool age, use of volatile anesthetic agents, history of anxiety, short anesthesia time, and postoperative pain; prevention — patients should be made comfortable; total IV anesthesia should be considered; midazolam (with dexmedetomidine) may be used preoperatively

Post extubation stridor: patients exhibit high-pitched squeaking retractions because of increased resistance to flow; risk factors include younger age, use of large endotracheal tube, and multiple intubation attempts; cuffed tubes are protective; racemic epinephrine may be used to reduce edema while waiting for onset of dexamethasone; however, racemic epinephrine may cause rebound edema

Readings

Amaha E, Haddis L, Aweke S, Fenta E. The prevalence of difficult airway and its associated factors in pediatric patients who underwent surgery under general anesthesia: An observational study. SAGE Open Med. 2021;9:20503121211052436. Published 2021 Oct 20. doi:10.1177/20503121211052436; Kanaya A. Emergence agitation in children: risk factors, prevention, and treatment. J Anesth. 2016;30(2):261-267. doi:10.1007/s00540-015-2098-5; Kim EH, Song IK, Lee JH, et al. Desflurane versus sevoflurane in pediatric anesthesia with a laryngeal mask airway: A randomized controlled trial. Medicine (Baltimore). 2017;96(35):e7977. doi:10.1097/MD.0000000000007977; Kondo T, Izumi H, Kitagawa M. Comparison of the effects of desflurane, sevoflurane, and propofol on the glottic opening area during remifentanil-based general anesthesia using a supraglottic airway device. Anesthesiol Res Pract. 2020;2020:1302898. Published 2020 Jun 19. doi:10.1155/2020/1302898; Patak LS, Stroschein KM, Risley R, et al. Patterns and predictors of difficult intravenous access among children presenting for procedures requiring anesthesia at a tertiary academic medical center. Paediatr Anaesth. 2019;29(10):1068-1070. doi:10.1111/pan.13734; Regli A, Becke K, von Ungern-Sternberg BS. An update on the perioperative management of children with upper respiratory tract infections. Curr Opin Anaesthesiol. 2017;30(3):362-367. doi:10.1097/ACO.0000000000000460; Sadeghi A, Khaleghnejad Tabari A, Mahdavi A, et al. Impact of parental presence during induction of anesthesia on anxiety level among pediatric patients and their parents: a randomized clinical trial. Neuropsychiatr Dis Treat. 2017;12:3237-3241. Published 2017 Feb 20. doi:10.2147/NDT.S119208; Zeytinoglu S, Calkins SD, Leerkes EM. Autonomic nervous system functioning in early childhood: Responses to cognitive and negatively valenced emotional challenges. Dev Psychobiol. 2020;62(5):657-673. doi:10.1002/dev.21926.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Sisk's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Sisk was recorded at Carolina Refresher Course 2023: 34th Annual Update in Anesthesiology, Pain, and Critical Care Medicine, held June 18-22, 2023, on Kiawah Island, SC, and presented by the University of North Carolina at Chapel Hill, School of Medicine. For information on future CME activities from this presenter, please visit https://www.med.unc.edu/cpd. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

AN660302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.