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Expect the Unexpected Neonatal Oral Mass Diagnosed at Birth Anesthesiology May 2013 A full-term, 3.5-kg neonate was transferred for management of a large, mobile intraoral mass. The infant demonstrated no signs of airway obstruction or respiratory  distress and had normal oxygen saturation without support. The child did not seem dysmorphic and the mass was isolated  to the anterior maxillary alveolar ridge, easily mobilized out of mouth. A prenatal ultrasound at 20 weeks did not identify any anomalies. Adequate ventilation was achieved after mobilizing the mass extraorally and achieving adequate mask seal. At this point, a mask induction with spontaneous ventilation was performed, followed by uneventful intubation. The mass was considered low risk for airway obstruction during induction  because it did not disturb the airway anatomy, and was easily mobilized out of the mouth. Epulis, or congential granular cell tumor, is a rare tumor of variable size and number ori...

Pre-ductal and post-ductal pulse O2 saturation (SpO2) monitors (to detect R → L shunting at ductus arteriosus). A difference of ≥10% suggests marked pulmonary hypertension or PDA dependent leison. Pre-ductal and post-ductal pulse O2 saturation (SpO2) can be used as screening for cyanotic heart disease for NB befor discharge hom fro postnatal ward. For preductal circulation usually the spo2 probe applied right hand ,however recent studies showd the left UE can be used for preductal circulation assessement. The post ductal circulation applied at at lower extremities.

Neonates are at risk of developing hypoglycemia, particularly neonates of diabetic mothers.  Hypoglycemia is defined by a plasma glucose concentration less than 40 mg/dL in the preterm neonate, less than 50 mg/dL for the term neonate younger than 3 days old, and less than 60 mg/dL in the term neonate older than 3 days of age.  Neonates are at risk of hypoglycemia secondary to their poorly developed system for the maintenance of adequate plasma glucose concentrations. In addition, patients receiving total parenteral nutrition with high dextrose concentrations are at risk for hypoglycemia if the infusion is interrupted. Also, patients with poor nutritional status or liver disease often have inadequate hepatic glycogen stores and are also at risk.  Preterm neonates also are at risk of developing hypocalcemia.  Hypocalcemia in the neonate is defined by a plasma ionized calcium concentration less than about 1.1 mEq/dL.  Fetuses develop their calcium ...

  If child is <6 months think: laryngomalacia and    if >6y-3y/o think croup   - The differential of child with stridor <6m:  laryngomalacia vocal cord paralysis subglottic stenosis  vascular ring structures - Other causes of stridor: tracheitis, epiglottitis, trauma, foreign body, deep neck space infection   - Tips for the treatment of croup:   Dexmethasone is superior to prednisolone. Start dexmethasone  at 0.15-0.6 mgkg. Typically one time dosing is sufficient. PO/IM forms are considered equivalent. A 2011 Cochrane review found no difference in the type of nebulized epinephrine used.  If regular epinephrine dosing is 0.5 ml/kg of 1:1000. If 2.25% racemic epinephrine, give 0.05 ml/kg

When using Pediatric bougie there is  concern about tracheal rupture and used when ETT size >3 mm. To avoid bleeding from large adenoids, do not place nasal airway in child <1 yr of age Always during  transport  apply cervical collar in child with ETT, even if just moving from one bed to another,  to avoid displacement of ETT  Cuffed ETTs —now considered beneficial due to lower pressures. Children highly dependent on diaphragm; once airway secured, insert nasogastric tube (NGT) or orogastric tube (OGT) as soon as possible to decompress stomach (NGT or OGT should be twice ETT size)  Proper bag-valve mask (BVM) technique — if attempting to use BVM on child with low O2 saturation, first action to place oral airway. straight blade 0 used only in just-born newborn or premature infant, otherwise straight blade 1 used and shift to blade 2 at 2(years).. 2 times ETT size for NGT, OGT, and Foley catheter 3 times ETT size for tube...

Different formulas have been  developed using body weight to calculate the distance (D) from the skin to the lumbar  epidural space: Depth(mm) = (weight in kg + 10) x 0.8 For example, in a 20-kg child the Depth would be calculated as follows: (20 + 10) 0.8 (30) 0.8 = 24 mm or  2.4 cm distance to the epidural space.  An alternative simpler  approximation is Depth (mm) = 1 mm/kg body weight. So in the 20-kg child D would be  20 mm or 2 cm Suresh S, Wheeler M. Practical pediatric regional anesthesia.  Anesthesiol Clin  North Am 2002;20(1):83–11 3.

Is acetaminophen responsible for the worldwide rise in childhood asthma over the past 30 years? Citing a mounting pile of circumstantial evidence from epidemiologic observational studies,  John McBride  of  Akron’s Children’s Hospital in Ohio  believes so, and that it’s time to officially push the worry button. The theory is that the fear of aspirin-induced Reye’s syndrome in the 1980s resulted in a large increase in the amount of acetaminophen prescribed to children, causing the observed spike in asthma incidence we’ve seen since then. How? Acetaminophen depletes glutathione, an antioxidant peptide that can curb inflammation in the airways. This hypothetical etiology was proposed by  Varner back in 1998 , and McBride reiterated it in his  review in the November  Pediatrics ,  in which he argues the acetaminophen-asthma link is now strong enough that doctors should counsel the parents of children with asthma (or at risk for as...

Intraventricular haemorrhage occurs in 25% of very low birth weight infants, mostly within the first 72 hours of life . Intraventricular haemorrhage may be complicated by ventricular dilation, which can progress to hydrocephalus, parenchymal infarction, or cystic periventricular matter injury.   The risk factors include RDS, hypotension, aggressive fluid resuscitation, fluctuating blood pressure and hypertonic infusions. Periventricular leucomalacia describes changes in white matter associated with hypoxia, hypotension, severe hypocarbia, large PDA, toxic injury or infection. It is a strong predictor for later cerebral palsy. Research has shown pain receptors develop by 20 weeks GA and pain pathways develop by 26 weeks. A foetus of 26 weeks may demonstrate a stress response in response to stimulation.   There has been recent concern about that anaesthetic agents may have an effect on the developing brain leading to later memory and learning impairment. ...

I like it, so i wanna share it with you, This is a term used to describe an acute abdomen due to intussusception with syncope. Numerous case reports, retrospective studies, and clinical reviews document prominent neurologic features in the absence of common gastrointestinal symptoms of intussusception. Although lethargy is most common, other neurologic symptoms include apathy, listlessness, hypersomnolence, impaired reaction to painful stimuli, and fluctuating levels of consciousness.   Neurologic intussusception is particularly common in infants. The pathophysiology of neurologic intussusception is not well understood. Proposed mechanisms include release of neuropeptides from strangulated bowel, absorption of toxic metabolites, dehydration and electrolyte imbalance as a result of vomiting, and progressive bowel obstruction. It is also possible that neurologic impairment is simply a normal behavioral reaction of an infant to severe abdominal pain.

A study in Resuscitation looking at the efficacy of LMA’s in neonatal resuscitation. Usually we use a face mask and bag them. This study shows a tiny LMA might be a better choice. So get your LMA size 1 ready for the newborn resus trolley. Objective : To study the feasibility, efficacy and safety of using the laryngeal mask airway (LMA) in neonatal resuscitation. Methods : In total, 369 neonates (gestational age≥34 weeks, expected birth weight≥2.0 kg) requiring positive pressure ventilation at birth were quasi-randomised to resuscitation by LMA (205 neonates) or bag-mask ventilation (164 neonates). Results : (1) Successful resuscitation rate was higher with the LMA compared with bag-mask ventilation (P < 0.001) and the total ventilation time was shorter with the LMA than with bag-mask ventilation (P < 0.001). Seven of nine neonates with an Apgar score of 2 or 3 at 1 min after birth were successfully resuscitated in the LMA group, while in the BMV group all six...

Doctors Luscombe and Owens tell us in a recent article that we need a new formula for estimating kids’ weight, They suggest (age x 3)+7.  Apparently that formula is more precise than the old  (age x 2 + 8 ) which is so nineties. click here to access the article in PDF format                                                                              Click here please

Dr Sprung et al published a paper in the Mayo Clinic Proceedings entitled: ”Attention-Deficit/Hyperactivity Disorder After Early Exposure to Procedures Requiring General Anesthesia” Abstract Objective To study the association between exposure to procedures performed under general anesthesia before age 2 years and development of attention-deficit/hyperactivity disorder (ADHD). Patients and Methods Study patients included all children born between January 1, 1976, and December 31, 1982, in Rochester, MN, who remained in Rochester after age 5. Cases of ADHD diagnosed before age 19 years were identified by applying stringent research criteria. Cox proportional hazards regression assessed exposure to procedures requiring general anesthesia (none, 1, 2 or more) as a predictor of ADHD using a stratified analysis with strata based on a propensity score including comorbid health conditions. Results Among the 5357 children analyzed, 341 ADHD cases were identified (estimated cumulative incidenc...

PDA Provides Systemic Flow Critical coarctation of the aorta Interrupted aortic arch Hypoplastic left heart syndrome         Critical aortic stenosis PDA Provides Pulmonary Flow Pulmonary atresia Critical pulmonic stenosis Severe subpulmonic stenosis with ventricular septal defect Tricuspid atresia with pulmonic stenosis  

Obese pediatric patients do worse than their lean counterparts with respect to: Critical care (1)Obese children have longer ICU stays and. (2)Obese children have more complications ( sepsis and post-operative fistulas) . Surgical conditions (ex. Appendectomy) (1)Diagnosis is more difficult – more likely to have CT scans versus U/S (2)Increased risk for conversion of laproscopic to open procedure (3)Have increased surgical times (4)Have increased risk for wound infections Pulmonary conditions   (1)Longer length of stay for obese children admitted to ICU for status asthmaticus. (2)Increased risk for developing atelectasis (3)Have decreased chest wall compliance (4)Sleep-disordered breathing (OSA) is very common cause of morbidity affecting 37-46% of the obese pediatric population (45% of these patients still had symptoms even after tonsillectomy). Cardiopulmonary arrest (1)Obesity is independently associated with worse odds of event survival and surviving to hospital d...

The main advantage of sevoflurane over halothane is its remarkable cardiovascular safety. The cardiovascular effects of sevoflurane are similar to those of isoflurane. It does not sensitize the myocardium to exogenous or endogenous catecholamines, and thus promotes less arrhythmias than halothane especially during ENT surgery, dental surgery or endoscopies. Sevoflurane does not modify atrio-ventricular conduction time. Therefore, the incidence of bradycardia is much lower with sevoflurane than with halothane, especially in infants. Sevoflurane depresses myocardial contractility to a lesser extent than halothane does in infants and children . The latter is of greatest importance during induction especially in children with compromised cardiovascular function. Sevoflurane, as well as halothane and isoflurane, markedly depresses baroreflex control of heart rate in infants and children . On recovery, baroreflex control of heart rate is more rapidly restored after sevoflura...

Epidural Test dose are as important in Children as in adults. However since epidural block always done under general anesthesia, GA decrease test dose sensitivity. For example during halothane anesthesia administration of IV adrenaline causes hypertension and bradycardia not tachycardia. Prior administration of Atropine 0.01mg/kg increase the reliability of test dose during halothane anesthesia. During Sevoflurane anesthesia, the reliability of IV adrenaline test dose 0.01mg/kg is 100% using the 10 beat per minute increase in HR as definition of positive test dose. Atropine is not needed to achieve this sensitivity. There is no data regarding test dose during isoflurane   or desflurane anesthesia  

Recent evidence suggests equivalent, and possibly superior, outcomes when neonatal resuscitation is initiated with room air. Evidence of harm from oxygen therapy includes oxidative damage, as well as a possible association with increased rates of childhood malignancy. In 2010, the American Heart Association and the European Resuscitation Council recommend initial resuscitation with air rather than oxygen. The need for supplemental oxygen should be guided by a pulse oximeter attached to the right upper extremity (preductal). Blended air and oxygen should only be used if there is no improvement in oxygenation. Dawson et al. used a prospective cohort of 468 term and preterm infants to create reference ranges (3rd to 97th percentiles) for oxygen saturation measurements in the first 10 minutes of life. It is important to note that in term infants, it takes approximately 8 minutes to reach an oxygen saturation 90%, and slightly longer in preterm infants. The table below shows targeted oxyge...

The midline approach is most commonly used. The ligamentum   flavum is considerably thinner and less dense in infants than in older children and adults. This makes recognition of engagement in the ligament more difficult and requires both extra care and slower, more deliberate passage of the needle to avoid subarachnoid puncture. The angle of approach to the epidural space is slightly more perpendicular to the plane of the back than in older children and adults, owing to the orientation of the spinous   processes in infants and small children. The loss of resistance technique should be used, but only with saline, not air. There are several reports of venous air embolism in infants and children when air was used to test for loss of resistance Use a short (5 cm) 18-gauge Tuohy needle and a 20- or 21-gauge catheter in infants and children. Epidural kits specifically for infants and children are available Maximum of 0.4 mg/kg/hr of bupivacaine after the initial block is estab...

The dicision whether to proceed with surgery in any child with URTI requires careful risk/benefit analysis on an individual basis and is summarized in the table below. Schedule Cancel Clear runny nose Child < 1 yr Dry cough Purulent nasal discharge Minor surgery Productive cough Wheezing/crepitations on auscultation Systemic features of being unwell, i.e. fever>38, malaise, headache, feeding problems Parental confirmation of child being unwell Also consider patient co-morbidities, type or urgency of surgery, and experience of anaesthetist.

Transfer of drugs from mother to fetus takes place at the level of the placenta mainly by diffusion. Thus, keeping maternal blood levels of drugs as low as possible is a major strategy for decreasing the amount of drug that reaches the fetus.  In addition, since 75% of the blood in the umbilical vein travels to the liver, a large portion of drug can be metabolized before reaching vital fetal organs.  Drug in the unbilical vein that travels via the ductus venosus to access the inferior vena cava will be diluted with blood from the lower extremities (which has no drug) and this further reduces concentration of drugs inthe fetal blood. Two things work against this "safety feature": (1) fetal acidosis during times of distress causes increased perfusion of the heart and brain and thus increases delivery of drug to these important organs. (2) Fetal pH is lower than maternal pH and results in basic drugs (such as local anesthestics) becoming more ionized when they rea...