1
Q
Neonate = ___
A
Up to 30 days
2
Q
Infant = ____
A
30 days to 1 year
3
Q
Toddler = ____
A
1-3 years
4
Q
Preschool = ____
A
4-6 years
5
Q
School Age = ____
A
6-13 years
6
Q
Adolescent = _____
A
13-18 years
7
Q
PEARLS of pediatric anesthesia
A
- Neonates do respond to painful stimuli and require anesthesia
- Infants and neonates have the highest adverse event rate
8
Q
Respiratory system of neonates
A
Have a proportionately larger head and tongue, narrower nasal passages, an anterior and cephalad larynx, a longer epiglottis, and a shorter trachea and neck
9
Q
Respiratory system of children under 5
A
Obligate nasal breathers
The cricoid cartilage is the narrowest part of the airway
10
Q
Glottis in adults vs. children
A
Glottis is at C6 in adults and C4 in children
*These anatomical differences help explain why a straight blade is preferred when intubating many pediatric patients
11
Q
Respiratory system in neonates & infants
A
- Have weaker intercostal muscles and diaphragms, and fewer alveoli
- Have reduced lung compliance and more compliant chest walls, which is responsible for inspiratory chest wall collapse
- Reduced functional residual capacity
- Higher rates of oxygen consumption
- Hypoxic and hypercapnic ventilatory drives are not fully developed
- Hypoxia and hypercapnia may depress respiration
12
Q
Respiratory rate is increased in neonates and gradually falls to adult values by ____.
A
adolescence
13
Q
Alveoli fully mature by ___.
A
age 8
14
Q
Cardiovascular system of neonates and infants
A
Have a noncompliant left ventricle, which results in a fixed cardiac stroke volume
Cardiac output is (very) dependent on heart rate
- Bradycardia can lead to hypotension, asystole and potentially death
- Bradycardia can be caused by parasympathetic nervous system, anesthetic overdose or hypoxia
- Unfortunately, the sympathetic nervous system and baroreceptor reflexes are not fully mature
15
Q
Normal vital signs for a neonate
A
RR: 40
HR: 140
Arterial BP
- Systolic: 65
- Diastolic: 40
16
Q
Normal vital signs for a 12 month old
A
RR: 30
HR: 120
Arterial BP
- Systolic: 95
- Diastolic: 65
17
Q
Normal vital signs for a 3 year old
A
RR: 25
HR: 100
Arterial BP
- Systolic: 100
- Diastolic: 70
18
Q
Normal vital signs for a 12 year old
A
RR: 20
HR: 80
Arterial BP
- Systolic: 110
- Diastolic: 60
19
Q
Kidney function usually approaches normal values by ___.
A
6 months of age
20
Q
The administration of sodium free fluids may lead to ___.
A
hyponatremia secondary to limited concentrating ability
21
Q
Reflux in young infants
A
Diminished lower esophageal sphincter tone
50% have daily emesis (usually remits by 18 months)
22
Q
Etiology of juandice
A
Immature liver cannot process bilirubin from RBC breakdown
23
Q
Colic occurs in infants ___
A
< 3 months
24
Q
Umbilical hernia = ___
A
Common, often resolve spontaneously
25
Teeth in pediatric patients
**Primary**: 7 months to 2 or 3 years
**Permanent**: 6 years to 20 years
26
Nervous system anatomically complete at \_\_\_\_.
birth except not all the nerves are myelinated
* Rapid for 2 years
* Complete by 7 years
27
Primitive reflexes disappear in \_\_\_.
few months
28
Closure of the fontenelles
* Posterior fontanelle closed by 4 months
* Anterior fontanelle closed by 18 months - 2 years
29
Anatomical location of the cranial sutures in neonates and infants
30
Neonates produce heat by \_\_\_\_.
metabolism of brown fat (nonshivering thermogenesis)
31
Pediatric patients lose heat quickly because of their \_\_\_.
larger surface area per kilogram, thin skin and low-fat content
32
Intraoperative hypothermia can occur due to \_\_\_.
inadequately warmed operating room environment, administration of room temperature intravenous fluid and dehumidified anesthetic gases
33
Hypothermia can cause \_\_\_
delayed awakening from anesthesia, cardiac arrhythmias and respiratory depression
34
Anesthesia professionals can prevent intraoperative hypothermia by\_\_\_.
using warm blankets/bair hugger, covering the patient’s head; and warming the OR, mattress and IV fluids
35
Fluid Compartments in Pediatrics
* Pediatric patients have a larger **ECF compartment and greater TBW** (total body water)
* **Larger loading dose of water-soluble drugs are required** due to dilutional effect lowering plasma drug concentration
* **Higher plasma concentrations for lipid-soluble drugs occur due to decreased fat and muscle volume**
36
TBW, ECF and ICF for a premature infant
TBW: 85%
ECF: 60%
ICF: 25%
37
TBW, ECF & ICF of an **term neonate**
TBW: 80%
ECF: 45%
ICF: 35%
38
TBW, ECF & ICF of an infant (1 yr)
TBW: 60%
ECF: 25%
ICF: 35%
39
TBW, ECF & ICF of an adult
TBW: 60%
ECF: 20%
ICF: 40%
40
Protein binding in Pediatrics
**Total plasma protein levels are lower in infants** (reach adult concentrations by 5-6 months of age)
•Protein binding of many anesthetic drugs are lower in young children
41
Organ development and organ blood flow in Pediatrics
_Organ development_
•Immature organ systems, metabolic degradation pathways, and blood brain barrier
_Organ blood flow_
•Greater blood flow to vessel-rich organs
42
What would the cardiac section of the pedi pre-op assessment include?
* heart murmur
* cyanosis
* hypertension
* exercise intolerance
43
What would the pulmonary section of the pedi pre-op assessment include?
* asthma/reactive airway disease (RAD)
* recent upper respiratory infection (\<4 weeks prior to surgery)
44
What would the hematologic section of the pedi pre-op assessment include?
* anemia
* bruising, abnormal bleeding, coagulopathy
* sickle cell anemia
45
After cardiac, pulm, and heme, what other things would be assess for in a pedi patient pre-operatively?
* neuromuscular disease including hypotonia
* congenital abnormalities including genetic syndromes
* Medications
* Family history of adverse reactions to anesthesia
* Malignant hyperthermia
* prolonged paralysis or need for ventilation after anesthesia
* Allergies
46
In general, routine laboratory studies are usually not required in healthy children. What are the exceptions?
_Hematologic testing_
CBC and coagulation studies should be performed in patients with a **suspected, known, or a family history of bleeding disorders**, prior to surgery that is likely to result in significant bleeding, such as **tonsillectomy/adenoidectomy, cleft palate repair, and intracranial procedures**
_Electrolytes_
Electrolytes should be performed in children with **renal insufficiency, endocrine disorders, and those with history of vomiting/diarrhea**
47
The prevalence of a positive preoperative pregnancy test in adolescents has been reported to be \_\_\_.
0.5 to 1.2 percent
48
Healthy pediatric patients (ASA ___ or \_\_\_) are usually appropriate candidates for ambulatory surgery. What are the exceptions?
ASA 1 or 2
**Significant OSA** (especially those \< 3 years old) are at significant risk for airway obstruction and desaturation after adenotonsillectomy; these patients should have inpatient monitoring after surgery
**Ex-premature infants** (born before 37 weeks gestation) are at risk for apnea after anesthesia or sedation. This risk decreases with increasing postmenstrual age (PMA) (ie, gestational age plus chronological age) with minimal risk between 56 and 60 weeks postconception. Ex-premature infants may require recovery room level of care overnight after anesthesia.
**Neonates** - Most institutions require inpatient observation after anesthesia for infants ≤44 weeks PMA, since full term infants may be at risk for apnea after anesthesia in the first few weeks of life
49
Children who appear likely to exhibit uncontrollable separation anxiety may be given \_\_\_.
a sedative, such as midazolam (0.3–0.5 mg/kg, **15 mg maximum**). Of note, the **onset of oral midazolam is 20 – 45 minutes**.
50
An uncooperative pediatric patient may be given ___ pre-operatively.
Intramuscular midazolam
or
Ketamine with atropine may be helpful.
51
Monitoring during pediatric cases
* **Alarm limits should be appropriately adjusted**
* A precordial or esophageal stethoscope and smaller ECG pads and BP cuff (potentially placed on the lower extremity) may be used
* **Temperature must be closely monitored** because of greater risk for malignant hyperthermia and greater susceptibility for intraoperative hypothermia or hyperthermia
* **Air bubbles should be removed from pressure tubing** and small volume flushes should be used to avoid air embolism, unintended heparinization, or fluid overload
* **Glucose measurement** may be warranted in premature or small-for-gestational-age neonates
* Monitors **may sometimes need to be first attached following induction** of anesthesia in less cooperative patients
52
Induction of General Anesthesia for Pedi patient
**Intravenous**: The advantages of an intravenous technique include availability of intravenous access if emergency drugs need to be administered and rapidity of induction in the child at risk for aspiration.
**Inhalational**
* Many children do not arrive in the operating room with an intravenous line in place
* **The child breaths an odorless mixture of nitrous oxide (70%) and oxygen (30%). Sevoflurane (or halothane) can be added to the gas mixture in 0.5% increments every few breaths.**
* An intravenous line can be started after an adequate depth of anesthesia has been achieved.
53
During inhalational induction of a pedi pt, what should be available for emergency?
**Intramuscular succinylcholine** (4 mg/kg, not to exceed 150 mg) and **atropine** (0.02 mg/kg, not to exceed 0.4 mg) should be available if laryngospasm or bradycardia occurs before an intravenous line is established.
54
Nitrous Oxide in Pedi patients
Nitrous oxide is a **relatively odorless gas** that is generally very well tolerated in healthy children, as either a primary agent or adjunct to the delivery of halogenated compounds.
Nitrous oxide may be administered to achieve unconsciousness, but is **not potent enough to allow airway manipulation when used as a sole agent**.
Nitrous oxide speeds the induction of high solubility gases like halothane but adds little to the speed of induction of less soluble gases such as sevoflurane.
Introduction of nitrous oxide is odorless and if the patient accepts the mask, several minutes of nitrous oxide may decrease the aversive response to the introduction of the more malodorous sevoflurane. **Often an inhalational induction will include either high concentrations of nitrous oxide and oxygen (limited to 70 percent N2O and 30 percent O2 to prevent hypoxemia), or a combination of N2O, O2, and sevoflurane.**
55
Sevo in Pedi patients
**Sevoflurane is the most commonly used agent for inhalation**.
**It is relatively insoluble, which provides a rapid onset.** It is less pungent, and less irritating to the airway than desflurane and isoflurane, and is associated with less airway related problems (ie, laryngospasm and bronchospasm) during induction and emergence.
56
Inhalational induction technique for infants
Infants are usually upset by having a mask placed over their face, regardless of the odor of the gas. The mask is gradually applied while administering sevoflurane 5% with or without 70% nitrous oxide in oxygen. Sevoflurane is increased to 8% as tolerated.
57
Inhalational induction technique for toddlers
Toddlers are induced similarly to infants, although nitrous oxide alone with oxygen may be used for the first several breaths prior to introducing sevoflurane to achieve some level of "stunning" prior to the "smelly gas". Some institutions apply a pleasant smelling ointment (usually fruit flavor lip balm) to the inner surface of the face mask to obscure the odor of the anesthetic gas.
58
Inhalational induction technique for school age children
Older children can often be engaged by telling them the mask is like an astronaut's mask and that they are like an astronaut blasting into space, breathing oxygen to protect them. Similar to toddlers, a pleasant smelling lip balm is added to the mask, and sevoflurane is administered with or after nitrous oxide in oxygen, depending on their degree of cooperation.
59
Inhalational induction technique for teenagers
Teenagers may be induced in a manner similar to school age children. Alternatively, if cooperative, they may be able to perform a single breath induction. For a single breath induction, the breathing circuit is primed with 8% sevoflurane and 70% N2O. The patient expires completely, the mask is placed tightly over his or her face, and the patient then inspires fully and holds his or her breath. This achieves rapid loss of consciousness, but is often followed by return to Stage II anesthesia.
60
Once anesthesia deepens and the patient has reached Stage III anesthesia, \_\_\_.
the concentration of sevoflurane should be reduced to minimum alveolar concentration (MAC) level, closer to 3 percent. **The signs of reaching Stage III include a slower, regular rate of respiration, decreased heart rate, and cessation of muscle movements. Eyes are midline, not divergent.**
Although it is possible to achieve a depth of anesthesia sufficient for endotracheal intubation with sevoflurane alone, it can take several minutes for this to occur. Most commonly depth of anesthesia is increased by the administration of **propofol 2 to 3 mg/kg** after the intravenous catheter is placed. Alternatively, muscle relaxant can be given, if indicated by the procedure.
61
What is the MAC for the different gases for neonates?
Sevoflurane: 3.2
Isoflurane: 1.6
Desflurane: 8-9
62
What is the MAC for the different gases for infants?
Sevoflurane: 3.2
Isoflurane: 1.8-1.9
Desflurane: 9-10
63
What is the MAC for the different gases for small children?
Sevoflurane: 2.5
Isoflurane: 1.3-1.6
Desflurane: 7-8
64
Pedi IV Access
* The saphenous vein has a consistent location at the ankle
* Twenty four-gauge catheters are adequate in neonates and infants when blood transfusions are not anticipated
* All air bubbles should be removed from the intravenous line
65
Tracheal intubation in Pedi (technique tips)
* The infant’s prominent occiput tends to place the head in a flexed position prior to intubation. This is easily corrected by slightly elevating the shoulders on towels and placing the head on a doughnut-shaped pillow.
* **Straight laryngoscope blades** can be helpful for intubation of the anterior larynx in neonates, infants, and young children
66
Choosing ETT size in kids
* The appropriate **diameter** inside the endotracheal tube can be estimated by a formula based on age: **4 + (Age/4) = Tube diameter (in mm)**
* Endotracheal tubes 0.5 mm larger and smaller than predicted should be readily available in or on the anesthetic cart
* **Estimate of endotracheal length: 12 + (Age/2) = Length of tube (in cm)**
* The CRNA can intentionally advance the tip of the endotracheal tube into the right mainstem bronchus and then withdraw it until breath sounds are equal over both lung fields
67
Anesthesia Machine Settings for kids
* Pressure control ventilation- set peak inspiratory pressures of 15 to 18 cm H2O should be used for neonates, infants, and toddlers to prevent barotrauma.
* Volume control ventilation (6 to 8 mL/kg) may be used for larger pediatric patients
68
Airway equipment considerations for kids
* Small tidal volumes can also be manually delivered with greater ease with a 1-L breathing bag rather than with a 3-L adult bag.
* Pediatric breathing circuits are usually shorter, lighter, and stiffer
69
Maintenance requirements for pediatric patients
Can be determined by the “4:2:1 rule”
4 mL/kg/h for the first 10 kg of weight, 2 mL/kg/h for the second 10 kg, and 1 mL/kg/h for each remaining kilogram.
(practice some examples of this for the exam)
70
Fluid deficits
* In addition to a maintenance infusion, any preoperative fluid deficits must be replaced
* Preoperative fluid deficits are often administered with hourly maintenance requirements in aliquots of 50% in the first hour and 25% in the second and third hours
71
Blood Volume - neonates, full term infant, infant and adult
premature neonates (100 mL/kg)
full-term neonates (85–90 mL/kg)
infants (80 mL/kg)
adults (65–75 mL/kg)
72
Hct and Hgb changes with neonates
•An initial hematocrit of 55% in the healthy full-term neonate gradually falls to as low as 30% in the 3-month-old infant before rising to 35% by 6 months.
Hemoglobin (Hb) type is also changing during this period: from a 75% concentration of HbF (greater oxygen affinity, reduced PaO2, poor tissue unloading) at birth to almost 100% HbA (reduced oxygen affinity, high PaO2, good tissue unloading) by 6 months
73
Blood loss replacement ratios
3: 1 - crystalloid: blood loss
1: 1 colloid: blood loss
•Blood loss has been typically replaced with non–glucose-containing crystalloid (eg, 3 mL of lactated Ringer’s injection for each milliliter of blood lost) or colloid solutions (eg, 1 mL of 5% albumin for each milliliter of blood lost) until the patient’s hematocrit reaches a predetermined lower limit.
74
Recent recommendations on blood loss replacement
•In recent years there has been increased emphasis on **avoiding excessive fluid administration**; thus blood loss is now commonly replaced by either **colloid** (eg, albumin) or **packed red blood cells.**
75
Target HCT for sick neonates and healthy children
In premature and sick neonates, the target hematocrit (for transfusion) may be as great as 40%
healthy older children a hematocrit of 20% to 26% is generally well tolerated.
76
What are neonates and infants at high risk for in terms of blood transfusion?
•Because of their small intravascular volume, neonates and infants are at an increased risk for electrolyte disturbances (eg, hyperglycemia, hyperkalemia, and hypocalcemia) that can accompany rapid blood transfusion.
77
When should PLT and FFP be given?
Platelets and fresh frozen plasma, 10 to 15 mL/kg, should be given when blood loss **exceeds** **one to two blood volumes.**
Recent practice, particularly with blood loss from trauma, favors “earlier” administration of plasma and platelets as part of a massive transfusion protocol.
78
PLT increases PLT count by how much?
One unit of platelets per 10 kg weight raises the platelet count by about 50,000/μL. The pediatric dose of cryoprecipitate is 1 unit/10 kg weight.
79
Allowable blood loss formula
**ABL = EBV (Hi - Hf) divided by Hi**
Hi = initial hct
Hf = final lowest accceptable
80
Third Space Lost - fluid replacement guidelines
**relatively atraumatic surgery = 0 to 2 mL/kg/hr**
(eg, strabismus correction where there should be no third-space loss)
**traumatic procedures = 6 to 10 mL/kg/hr**
(eg, abdominal abscess)
81
Third space fluid of choice?
Lactacted Ringers
82
Methods to prevent emergence delirium and agitation?
* Administration of an opioid: **Fentanyl, 1–1.5 mcg/kg**
* **Dexmedetomidine: 0.5 mcg/kg,** (given slowly with heart rate monitoring) **15 to 20 min before the end of the procedure** can reduce the incidence of emergence delirium and agitation if the surgical procedure is likely to produce postoperative pain
83
Awake vs deep extubation
•The choice between awake and deep extubation is based on patient factors and clinician preference.
- **Awake extubation** allows the return of airway tone and airway protective reflexes, and theoretically reduces the risk of post-extubation airway obstruction and laryngospasm.
- **Deep extubation** may be preferred children with risk factors for bronchospasm, or in whom coughing should be avoided for surgical reasons.
84
Awake extubation may be preferred for children at risk for the following:
* Aspiration (eg, ileus, upper gastrointestinal bleeding)
* Airway obstruction (eg, after cleft palate repair, craniofacial anomalies, obstructive sleep apnea)
* Airway muscle weakness associated with neuromuscular or cranial nerve disorders
85
Deep extubation may be associated with ___ and is preferred with:
less coughing
* Patients at high risk of bronchospasm (eg, asthma, recurrent wheezing)
* After thyroidectomy, due to risk of hematoma at surgical site, and airway compromise
* After tracheal surgery, to avoid disruption of the suture line
86
Awake extubation with an ETT
* Prior to awake extubation, the neuromuscular blocking agent (if used) should be completely reversed
* the oropharynx should be suctioned
* the patient's eyes should be conjugate (rather than deviated) as a sign of recovery from anesthesia
* patient should respond by grimacing or opening eyes in response to stimulation or suctioning
87
Deep Extubation with an ETT requirements
•Prior to deep extubation, the patient should be
1. **breathing spontaneously**
2. regular respirations
3. adequate tidal volumes
88
Confirm deep anesthesia before extubation by….
by lack of coughing or change in ventilatory pattern with the following maneuvers:
1. Move the endotracheal tube in the trachea to mimic the stimulation of extubation
2. Thoroughly suction the oropharynx. Retained oropharyngeal secretions may precipitate laryngospasm during emergence after deep extubation
3. Empty the stomach with an orogastric tube.
89
After deep extubation you should have ____ **and transport in** _ position
• a patent **mask airway** should be established and maintained during emergence and transport to the post-anesthesia care unit (PACU).
We transport patients to the PACU in the **lateral decubitus position**, slightly head down, to maintain airway patency and allow secretions to drain.
90
LMA emergence plan
•Some instutions remove most supraglottic airways (SGAs) while the patient is still deeply anesthetized.
**Awake** removal of an SGA allows **return of airway tone** and **protective reflexes** while a patent airway is maintained. However, an *SGA does not protect against aspiration or laryngospasm during emergence*, and the patient may cough, bite on the LMA tube, gag, or vomit during emergence. If the patient bites on the tube while emerging, it may be impossible to remove the device, or to ventilate.
•The decision to remove an SGA deep or awake should be based on patient factors and clinician preference, and data to support either choice is inconclusive
91
**Awake SGA removal**
Awake removal of an SGA is similar to awake extubation. The oropharynx should be suctioned on either side of the SGA.
92
**Deep SGA removal**
Prior to deep removal of an SGA, the patient should be **breathing spontaneously with regular respirations** and **adequate tidal volume**. If the patient has been maintained on pressure support, the mode of ventilation should be changed to **spontaneous**.
93
Adequate depth of anesthesia should be confirmed as follows for LMA removal
1. Maintain expired anesthetic gas concentration at ≥1 MAC
2. Suction the oropharynx on both sides of the SGA, and verify no change in ventilatory pattern or movement in response to suction
3. After removal of the SGA, an oral airway should be placed, ventilation should be maintained by mask, and the anesthetic agent should be discontinued.
94
Transfer to PACU
The patient should be transferred to the PACU stretcher or bed with care taken to **avoid neck flexion**, which could **cause stimulation of the larynx** by the oral airway with positioning to ensure continued airway patency.
95
Emergence Laryngoaspasm & Prevention Strategies
*Laryngospasm is more common during emergence from anesthesia than during induction.*
•**Prevention** – Strategies for prevention of laryngospasm on emergence include the following:
1. **Suction** the oropharynx thoroughly to remove secretions, either while the patient is still deeply anesthetized, or awake, but **not** during light anesthesia.
2. Avoid extubation or airway manipulation during a light level of anesthesia.
3. Administer **lidocaine** via laryngotracheal atomizer at and below the vocal cords immediately prior to intubation, or lidocaine 1 to 1.5 mg/kg IV two to five minutes prior to extubation
4. Administer a **positive pressure breath** while extubating awake, to force secretions away from the vocal cords, and to abduct vocal cords.
96
Laryngospasm Treatment - initial
*Treatment of laryngospasm during emergence depends on the severity of the episode.*
1. Initial treatment includes administration of 100 percent oxygen by face mask, with gentle positive pressure ventilation
2. A small dose of propofol (0.25 to 0.8 mg/kg IV) may reverse laryngospasm in this setting.
97
Laryngospasm Treatment: Severe
For severe laryngospasm unresponsive to these maneuvers:
* succinylcholine should be administered
* succinylcholine 0.25 to 0.5 mg/kg IV
* Bradycardia -→ Atropine 0.02 mg/kg IV
* Once laryngospasm breaks, the airway must be supported with mask ventilation, and if necessary, intubation.
98
Laryngospasm Postanesthesia Care
•If laryngospasm is recognized and relieved *quickly*, in most cases *no special post-anesthesia care is required*.
However, **postoperative oxygen desaturation** should be evaluated with **auscultation** of the chest and a CXR to rule out **negative pressure pulmonary edema (NPPE)**.
99
NPPE commonly occurs with \_\_?
This complication occurs more commonly in older children and adults, who can develop more forceful inspiration against closed vocal cords, than in young children.
100
NPPE postop care
•Patients should be monitored in the PACU for **two or more hours afte**r an episode of severe laryngospasm.
If NPPE occurs, a longer period of observation or overnight hospital **admission** may be required to allow time for resolution.
101
Postop pan pain management: parenteral opioids
use of regional anesthetic and analgesic techniques has greatly increased. Commonly used include:
* fentanyl (1–2 mcg/kg)
* morphine (0.05–0.1 mg/kg)
* hydromorphone (15 mcg/kg)
\*don't need to know the doses
102
Non opioid pain management:
* A multimodal technique incorporating **ketorolac** (0.5–0.75 mg/kg) and intravenous **dexmedetomidine** will reduce opioid requirements.
* Oral, rectal, or intravenous **acetaminophen** will also reduce opioid requirements and can be a helpful substitute for ketorolac
103
Patient-controlled analgesia
•Patient-controlled analgesia can also be successfully used in patients as young as **5 years old**, depending on their maturity and on preoperative preparation.
* Commonly used opioids include morphine and hydromorphone.
104
Epidural Infusions
Epidural infusions for postoperative analgesia often consist of a local anesthetic combined with an opioid.
* Bupivacaine, 0.1% to 0.125%, or ropivacaine, 0.1% to 0.2%, are often combined with fentanyl, 2 to 2.5 mcg/mL (or equivalent concentrations of morphine or hydromorphone).
* Recommended infusion rates depend on the size of the patient, the final drug concentration, and the location of the epidural catheter
* Local anesthetic infusions can also be used with continuous nerve block techniques, but this is less common than in adults.
105
How would you test to see if you have an appropriate ETT size in children?
Correct tube size and appropriate cuff inflation is confirmed by easy passage into the larynx and the development of a gas leak at 15 to 25 cm H2O pressure.
