In this 116th episode I welcome Dr. Bommy Mershon to the show. We discuss pediatric anesthesiology including how kids differ from adults, pre-op meds, IV vs. inhaled inductions, parental presence, choosing a tube, when to put on monitors, how to do an inhaled induction, controversies around succinylcholine, weight-based dosing, deep extubation, laryngospasm, emergency delirium, regional anesthesia and pressers. Please note the original release referred to intranasal dexmedetomidine dosing as mg/kg instead of mcg/kg. The correct units are mcg/kg and the audio has now been updated to reflect that.
CME: https://earnc.me/UpmjW3
We also launch our ACCRAC theme music composed by Dr. Dennis Kuo! Check out his website at studymusicproject.com
References:
- Cote and Lerman’s A Practice of Anesthesia for Infants and Children. Fifth Edition.
- Kain, Zeev. 2013 ASA Anesthesiology 2013 Refresher Course: Preoperative Evaluation, Premedication, and Induction of Anesthesia in Infants and Children https://www.apsf.org/article/in-my-opinion-a-debate-is-succinylcholine-safe-for-children/
- McAuliffe G1, Bissonnette B, Boutin C. Should the routine use of atropine before succinylcholine in children be reconsidered? Can J Anaesth. 1995 Aug;42(8):724-9.
- Patel, Davantral. Epidural anesthesia for children. Continuing Education in Anaesthesia Critical Care & Pain. 2006 April;6(2):63-66. https://academic.oup.com/bjaed/article/6/2/63/305090
- McCann ME, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, muticentre, randomised, controlled equivalence trial. Lancet. 2019 Feb;393(10172):664-677 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32485-1/fulltext
- Andrew J. Davidson, M.B.B.S., M.D., F.A.N.Z.C.A.; Lena S. Sun, M.D., F.A.A.P., D.A.B.A.. Clinical Evidence for Any Effect of Anesthesia on the Developing Brain Anesthesiology 2018 April; 128(4):840-853. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2664912&resultClick=1
Dear Jed,
I´ve just had the opportunity to listen to your excellent summary on paediatric anesthesia with Prof. Mershon. Just one possible remark, I think the Dexmedetomidine dosis for intranasal premedication should be in “µg” measured, it´s been as “mg” quoted in the Podcast. When I heard that wrong, I do appologise for the inconvenience. All the Best, and many thanks for your great podcastseries!
Thanks for pointing that out, yes, the dose should be micrograms. Thanks!
Really enjoyed the paediatric anesthesia overview with Dr. Mershon. She had so many helpful hints.
Would be very interested in a part 2!
I think this was a wonderful overview of pediatric anesthesia. I am an attending who practices pediatric anesthesia at a major children’s hospital and have a few points that I think are important and slightly different than Dr. Mershon’s approach.
1) Laryngospasm- Unfortunately, laryngospasm is often not detected immediately, and is initially confused for upper airway obstruction, poor bag-mask technique, etc as laryngospasm is not always preceded by a detectable cough. When children-especially smaller kids, infants and neonates- laryngospasm, they desaturate very quickly, and the pulse ox monitors are delayed ~10-20 seconds. For example, when a kid is having a laryngospasm, and the monitor shows SpO2 of 80%, the tiny patient is in fact more hypoxemic in real-time, which will be reflected in blue or dusky appearing lips and a weaker and slower pulse. Hypoxia is a myocardial depressant, as is propofol. I would caution against using propofol in scenarios where you have a hypoxemic laryngospasm, as this could lead to cardiac arrest from myocardial depression- especially in a neonate or sick child. I would therefore encourage giving succinylcholine (1-2mg/kg IV or 4mg/kg IM) quickly in these scenarios- not propofol- to quickly relax the vocal cords, resume oxygenation/ventilation and avoid further myocardial depression. Late detection of laryngospasm is probably more likely in medical supervision settings, as “the educated hand” of the attending or senior CRNA will probably detect a laryngospasm faster with their hands on the patient vs.when they are “hands off” and supervising a resident, fellow or less experienced pediatric provider.
Thanks for sharing that Matt!