138 Pediatric Anesthesia B. Generally, infants less then 9 months of age require no premedication. C. If anticholinergics are consider (generally for children under 1 year of age) they can be administered IV at the time of induction. 5. Common coexisting disease/illnesses A. The child with a URI 1. A URI within 2-4 weeks of general anesthesia and endotracheal intubation can place the child at an increased risk of perioperative pulmonary complications (wheezing, hypoxemia, atelectasis, laryngospasm). 2. Factors favoring postponing surgery include purulent nasal discharge, upper airway stridor, croup, lower respiratory symptoms (wheezing), and fever. 3. Factors favoring performing surgery include clear ‘allergic ‘ reactions, economic hardship on family, few and short ‘URI-free’ periods, and scheduled surgery may itself decrease frequency of URI’s. B. History of prematurity 1. Prematurity is defined as birth before 37 weeks gestation or weight less than 2500 grams; premature infants are at increased risk for retinopathy of prematurity and apnea of prematurity. 2. The former premature infant is at increased risk for the development of postoperative apnea (apnea of prematurity) even after minor surgery and should be monitored overnight if their postconception age (gestational age plus chronological age) is less then 60 weeks. 3. Risk factors for apnea of prematurity include necrotizing enterocolitis, neurologic problems, anemia, hypothermia, and sepsis. 4. Regional anesthesia may be associated with a lower incidence. C. Intellectual impairment: children with severe developmental delay often have several coexisting disease, most often seizure disorders, gastroesophageal reflux, and chronic lung disease. D. Seizure disorders: anticonvulsant regimen and levels should be documented; anticonvulsants should not be withheld the day of surgery. E. Trisomy 21 (Down’s Syndrome): increased risk of difficult airways, postoperative airway obstruction/croup, sleep apnea and subluxation of the atlanto-occipital joint; routine screening cervical spine radiographs in the asymptomatic child are not indicated.
Anesthesia for Common Pediatric Conditions 1. Acute airway obstruction (see table) A. Causes: laryngotracheobronchitis (croup), epiglottis, and foreign-body aspiration. B. Pathophysiology: inspiratory stridor is the hallmark of upper airway , supraglottic, and glottic obstruction (croup); wheezing generally indicates intrathoracic airway obstruction (foreign-body aspiration). C. Contributing factors 1. Croup (including postintubation or traumatic croup): traumatic or repeated intubations, tight fitting ETT, coughing/straining on the ETT, change in patient’s position during surgery, intubation greater than one hour, head and neck surgery. D. Treatment 1. Total obstruction can occur, adequate preparation for a possible tracheostomy should be made prior to induction of anesthesia. 2. Epiglottis: a slow, gentle, inhalational induction followed by intubation