PEDIATRIC ANESTHESIA

RADEN MUHAMMAD AGUNG

Pembimbing : dr. Wijanarko Satrio, Sp. An

K E PA N I T E R A A N K L I N I K I L M U A N E S T E S I D A N T E R A P I I N T E N S I F

FA K U LTA S K E D O K T E R A N U N I V E R S I TA S M U H A M M A D I YA H P U R W O K E R T O

R S U D D R . S O E S E L O S L AW I K A B U PAT E N T E G A L
Anatomi dan fisilogi

2
Sistem respirasi
Neonatus dan infan memiliki alveli yang lebih sedikit dan kecil, yang akan menurunkan beban
dari paru-paru. Sebaliknya rangka dari rusuk yang terbuat dari cartilago menyebabkan dinding
dada collapse saat inspirasi dan menurunkan volume residual dari paru saat expirasi.

neonatus dan infant memiliki proporsi kepala dan lidah , saluran hidung yang sempit, laring yang
lebih mengarah ke kepala, epligotis yang panjang dan trachea leher pendek.
sistem kardiovaskular
Stroke volume dari neonatus dan infan lebih stabil dikarenakan dari ventricle kiri yang tidak
memiliki beban dan belum matang. cardiac output sangat snesitif dalam perubahan pada heart
rate. Walaupun basal heart rate lebih tinggi daripada dewasa, pengaktifan sistem saraf
parasimpathetic, overdosis anestesi, atau hipoksisa, dapat menyebakan bradikardi dan
menurunkan cardiac output
Metabolisme dan termoregulasi
Pasien pediatric memiliki luas area penampang per gram yang lebih besar daripada dewasa
sehingga metabolisme dan parameter yang berhubungan (konsumsi oksigen, produksi CO2,
cardia output, dan ventilasi alveolar) yang lebih baik.

Kulit yang tipis, kadar lemak yang rendah, luas penampang yang besar, dapat menyebabkan
hilangnya panas lebih besar ke lingkungan.
Fungsi ginjal dan gatrointestinal
Fungsi ginjal akan normal ketika usia 6 bulan, tetapi dapat tertunda sampa usia 2 tahun.
Neonatus yang prematur sering menunjukkan banyak bentuk renal immaturiti, termauk
penurunan GFR, retensi sodium yang buruk, ekskresi glukosa yang buruk, reabsorsi bicarbonat
yang buruk.

Neonatus memiliki kecenderungan gerd. Belum matangnya conjugasi dari liver terhadap obat
dan molekul lainnya pada awal kehidupan.
Homeostatis Glukosa
Neonatus memiliki kecenderungan penurunan penyimpanan glikogen sehingga dapat
menyebabkan hipoglikemi. Ekskresi glukosa yang buruk dari ginjal sebagian penyebab keadaan
ini.
Pharmacologi
Obat pediatri dosisnya bergantung dengan berat. pada awal masa kecil pasien berat pasien
dapat dikira-kira berdasarkan usia:
50 % berat (kg) = (usia x 2) + 9
Anestesi Inhalasi
neonatus, infan , dan anak-anak yang lebih muda biasanya memiliki ventilasi alveolar yang lebih
dan capasitas residual yang lebih rendah menyebabkan bertambah konsentrasi anestesi di
alveolar dan cepatnya induksi.
Anestesi nonvolatile
Setelah perhitungan dosis, infant dan anak-anak membutuhkan propofol dengan dosis lebih
banyak daripada dewasa disebakan volume distribus yang besar daripada dewasa.
Muskulus relaksan
Musculus relaxan memiliki onset lebih cepat
pada pediatric daripada dewasa.
Resiko anestesi pediatric
The Pediatric Perioperative Cardiac Arrest
(POCA) paling sering
Teknik Anestesi pada pediatric
Pertimbang preoperatif Intubasi tracheal
monitoring Maintenance

induksi Cairan yang dibutuh sebelum operasi

◦ induksi intravenous Regional anestesi dan analgesia
◦ induksi inhalasi Prosedur sedasi saat masuk dan keluar
dari ruang operasi
akses intravenous
Emergency dan recoveri
Pertimbang preoperatif

1. Interview Pre operatif

2. Riwayat infeksi saluran nafas atas
3. Test Laboratorium
4. Puasa Preoperatif
5. Premedikasi
Monitoring
TTV (TD, N, RR, T)
SPO2
Stetoschope (Heart rate, Sound, Airway)
Urin Output
AGD
Induksi
Intravenous (Propofol 2-3mg/kg)
Inhalasi (Nitrous Oxide 70%, O2 30%) + hallothane
Intramusular (Ketamine 5-10mg/kg)
Cairan Preoperatif
Kebutuhan cairan “4:2:1 rule”: 4 mL/kg/h untuk 10 kg pertama, 2 mL/kg/h 10 kg kedua , and 1
mL/kg/h untuk sisa kilogram. Anak-anak usia 8 tahun membutuhkan 6 mg/kg/min of glucose
untuk menjaga euglycemia (40–125 mg/dL); premature neonates membutuhkan 6–8
mg/kg/min. Anak lain dan dewasa hanya 2 mg/kg/min
Defisit cairan (usia x 4ml/kg/jam x waktu (jam))
1. Kehilangan darah- premature neonates (100 mL/kg), full-term neonates (85–90 mL/kg), and
infants (80 mL/kg) is proportionately larger than that of adults (65–75 mL/kg).
2. “Third-space” loss — Operasi non traumatik 0–2 mL/kg/h dan traumatik 6–10 mL/kg/h. Third
space loss hanya meggunakan Ringer Lactatee
Emergency dan recoveri

A. Laryngospasm
B. Postintubation Croup
C. Postoperative Pain Management
Pertimbangan anestesi pada kondisi
spesifik
prematur
intestinal malrotasi dan volvulus
hernia diaghfragma kongenital
fistula tracheoesophageal
GASTROSCHISIS & OMPHALOCELE
HYPERTROPHIC
PYLORIC STENOSIS
INFECTIOUS CROUP, FOREIGN
BODY ASPIRATION, & ACUTE
EPIGLOTTITIS
TONSILLECTOMY & ADENOIDECTOMY
MYRINGOTOMY & INSERTION
OF TYMPANOSTOMY TUBES
TRISOMY 21 SYNDROME
DOWN SYNDROME
CYSTIC FIBROSIS
SCOLIOSIS
Prematur
Patofisiologi: Lahir sebelum 37 minggu
Pertimbangan anestesi: Dosis kecil ( <1000 g)
Premature infants usia kurang dari 50 minggu setelah concepsi cenderung menjadi obstructive
dan central apneu. Faktor resiko postanesthetic apnea usia kehamilan muda, anemia (<30%),
hypothermia, sepsis, and neurological abnormalities . Resiko dapat diturunkan dengan caffeine
(10 mg/kg) or aminophylline.
Intestinal malrotasi dan volvulus
Pathofisiologi: Malrotation dari usus disebabkan perkembangan abnormal oleh abnormalitas
rotasi midgut
Pertimbangan anestesi:
Preoperative preparation termasuk stabilisasi pada segala kondisi , insertion of a
nasogas_x0002_tric (or orogastric tube) to decompress the stomach, broad-spectrum
antibiotics, fluid and electrolyte replacement, and prompt transport to the operating room.
Hernia diaghfragma kongenital
Pathophysiology: During fetal development, the gut can herniate into the thorax through one of
three possible diaphragmatic defects: the left or right posterolateral foramen of Bochdalek or
the anterior foramen of Morgagni.

Anesthetic Considerations: peak inspiratory airway pressures should be less than 30 cm H 2O. A
sudden fall in lung compliance, blood pressure, or oxygenation may signal a contralateral
(usually right-sided) pneumothorax and necessitate placement of a chest tube .
Fistula tracheoesophageal
 Anesthetic Considerations: These neonates tend to have copious pharyngeal secretions that
require frequent suctioning before and during surgery. Positive-pressure ventilation is avoided
prior to intubation, as the resulting gastric distention may interfere with lung expansion.
Intubation is often performed awake and without muscle relaxants. These neonates are often
dehydrated and malnourished due to poor oral intake.
GASTROSCHISIS & OMPHALOCELE
Pathophysiology: Gastroschisis and omphalocele are congenital disorders characterized by
defects in the abdominal wall that allow external herniation of viscera.
Omphaloceles occur at the base of the umbilicus, have a hernia sac, and are oft en associated
with other congenital anomalies such as trisomy 21, diaphragmatic hernia, and cardiac and
bladder malformations.
Anesthetic Considerations: Third-space fluid losses are replaced with a balanced salt solution
and 5% albumin . The neonate remains intubated aft er the procedure and is weaned from the
ventilator over the next 1–2 days in the ICU.
HYPERTROPHIC PYLORIC STENOSIS

Pathophysiology
Hypertrophic pyloric stenosis impedes emptying of gastric contents. Persistent vomiting
depletes potassium, chloride, hydrogen, and sodium ions, causing hypochloremic metabolic
alkalosis .
Anesthetic Considerations
Surgery should be delayed until fl uid and electrolyte abnormalities have been corrected.
INFECTIOUS CROUP, FOREIGN BODY
ASPIRATION, & ACUTE EPIGLOTTITIS
Pathophysiology: Infectious croup usually follows a viral URI in children aged 3 months to 3
years. The airway below the epiglottis is involved (laryngotracheobronchitis). Infectious croup
progresses slowly and rarely requires intubation.
Acute epiglottitis is a bacterial infection (most commonly Haemophilus infl uenzae type B)
classically affecting 2- to 6-year-old children but also occasionally appearing in older children
and adults.
Anesthetic Considerations:
Patients with croup are managed conservatively with oxygen and mist therapy. Nebulized
racemic epinephrine (0.5 mL of a 2.25% solution in 2.5 mL normal saline) and intravenous
dexamethasone (0.25–0.5 mg/kg) are used. Indications for intubation include progressive
intercostal retractions, obvious respiratory fatigue, and central cyanosis.
TONSILLECTOMY &
ADENOIDECTOMY
Pathophysiology: Lymphoid hyperplasia can lead to upper airway obstruction, obligate mouth
breathing, and even pulmonary hypertension with cor pulmonale.
Although these extremes of pathology are unusual, all children undergoing tonsillectomy or
adenoidectomy should be considered to be at increased risk for perioperative airway problems.

Anesthetic Considerations :Surgery should be postponed if there is evidence of acute infection

or suspicion of a clotting dysfunction (eg, recent aspirin ingestion). A reinforced or preformed
endotracheal tube (eg, RAE tube) may decrease the risk of kinking by the surgeon’s selfretaining
mouth gag.
MYRINGOTOMY & INSERTION
OF TYMPANOSTOMY TUBES
Pathophysiology
Children presenting for myringotomy and insertion of tympanostomy tubes have a long history
of URIs  that have spread through the eustachian tube, causing repeated episodes of otitis
media.

Anesthetic Considerations
These are typically very short (10–15 min) outpatient procedures. Inhalational induction is a
common technique. Unlike tympanoplasty surgery, nitrous oxide diff usion into the middle ear is
not a problem during myringotomy because of the brief period of anesthetic exposure before
the middle ear is vented.
TRISOMY 21 SYNDROME
DOWN SYNDROME
Pathophysiology :An additional chromosome 21—part or whole—results in the most common
pattern of congenital human malformation: Down syndrome. Characteristic abnormalities of
interest to the anesthesiologist include a short neck, irregular dentition, mental retardation,
hypotonia, and a large tongue.

Anesthetic Considerations Because of anatomic diff erences, these patients oft en have diffi
cult airways, particularly during infancy. Th e size of the endotracheal tube required is typically
smaller than that predicted by age.
Respiratory complications such as postoperative stridor and apnea are common. Neck fl exion
during laryngoscopy and intubation may result in atlantooccipital dislocation because of the
congenital laxity of these ligaments.
CYSTIC FIBROSIS
Pathophysiology
Cystic fibrosis is a genetic disease of the exocrine glands primarily aff ecting the pulmonary and
gastrointestinal systems. Abnormally thick and viscous secretions coupled with decreased ciliary
activity lead to pneumonia, wheezing, and bronchiectasis.

Anesthetic Considerations
Premedication should not include respiratory depressants. Anticholinergic drugs have been
used in large series without ill effects, and the choice either to use or not to use them appears
to be incon_x0002_sequential. Induction with inhalational anesthetics may be prolonged in
patients with severe pulmonary disease. Intubation should not be performed until the patient is
deeply anesthetized to avoid coughing and stimulation of mucus secretions.