Pediatric Anesthesia

Blood substitution

Blood volume in children: 70-90 ml/kg

Bleeding is replaced by (% of blood volume)

  • > 5 %: substitute with Ringer’s Acetate or similar crystalloid
  • > 10% as above + Albumin 5%
  • > 20% as above + Blood
  • > 50% as above + Plasma

Massive bleeding:

  • Monitor with thromboelastogram peroperatively!
  • If without thromboelastogram:
  • Blood: Plasma: Platelets – 1:1:0.5

Coagulation:

  • + Platelets 5-10 ml/kg
  • + Fibrinogen 30-70 mg/kg
  • + Tranexamic acid (Cyclocapron) 15 mg/kg
  • NOTE:
    • Temperature 36.5 °C
    • pH above 7.2
    • Follow s-Calcium
    • Hgb > 9 g/dL

Calculation of Correct Pediatric Anesthetic Drug Doses

This doses calculator was constructed by Carina Malmqvist Head Nurse of Intensive Care. Sahlgrenska University Hospital and Sara Eriksson Nurse of Intensive Care. Sahlgrenska University Hospital.

Updated 2018-12-21


Enter the weight of the child and get recommended drug doses for anesthesia.

HEADERPatient data (date of birth - age)EMPTYEMPTY
Weight (kg)EMPTY
EMPTY_ROW
SECTIONDrugs - InjectionsEMPTY
HEADERNameStandard dosageConcentrationDose in mgDose in mlNotes
CALC1Adrenaline (Epinephrine)0,01 mg/kg0,1 mg/mlIn acute situations!
CALC1Atropine0,01 mg/kg0,5 mg/ml
CALC1Fentanyl2 µg/kg50 ug/mlN.B.! dose in µg!
CALC1Midazolam0,1 mg/kg1 mg/ml
CALC1Morphine0,1 mg/kg1 mg/ml
CALC1Naloxone0,02 mg/kg0,02 mg/ml
CALC1Propofol2 mg/kg10 mg/ml>3 years of age
CALC1Rocuronium0,6 mg/kg10 mg/ml
EMPTY_ROW
SECTIONFluid therapyEMPTY
HEADERml/kg/hourml/hourml/dayEMPTY
CALC2Low2 ml/kg/hourEMPTY
CALC2Normal3 ml/kg/hourEMPTY
CALC2Hög4 ml/kg/hourEMPTY
EMPTY_ROW
SECTIONTidal volume in the ventilatorEMPTY
EMPTYml/breathEMPTYEMPTY
CALC38 ml/kgEMPTYEMPTY


Circulation and Hemodynamics

By Fredrik Söderlund, Chief Physician, Anesthesia & Intensive Care. DSBUS, Sahlgrenska University Hospital.

Updated 2020-01-10


  • There are no good scientific data on blood pressure limits for children (partly because complications are unusual)
  • Circulation and perfusion may be assessed using several modalities (lactate, diuresis, etc.)
  • You have to do without PA catheters and also most other invasive CO measurements
  • NIRS is widely used
  • Do not forget about capillary refill! Most useful in emergency situations (can be used to estimate CO, but not SVR)

Rules of thumb for peroperative MAP

  • Normal MAP: 1.5 x year + 55 mmHg
  • Premature or newborn: MAP ≥ number of gestational weeks
  • Up to one year of age: MAP ≥ 45 mm Hg
  • 1-5 years: MAP ≥ 50 mm Hg
  • 5 years and up: MAP ≥ 50-60 mm Hg

Target values for blood pressure in children in general anesthesia (MAP in mmHg)

AgeDuring anesthesiaAwake
0-3 months42-4752
3-6 months45-5257
6-12 months51-5763
1-3 years51-5763
3-6 years54-6168
6-14 years58-6570
> 14 years58-6573

Antihypertensive and inotropic drugs

  • The same drugs can be used as for adults
  • Noradrenaline is normally the first choice, starting dose 25-100 ng/kg/min
  • Adrenaline can be given as inotropy, 10-30 ng/kg/min
  • Dopamine is an alternative, 5-20 ng/kg/min
  • Milrinone for inotropy + afterload reduction, 0.3-0.7 µg/kg/min
  • Ca2+ infusion can be used if S-Ca is low

Vasopressor/inotropy

  • Calcium gluconate iv 0.25-0.5 ml/kg (10 ml = 2.25 mmol Ca2+)
  • Phenylephrine i.v. 1-5 ug/kg (100 µg/ml)
  • Ephedrine i.v. 0.1 mg/kg (50 mg/ml → dilute to 5 mg/ml)
  • Noradrenaline inf 0.05-0.5 µg/kg/min (20 ug/ml – should be given in CVC)
  • Adrenaline iv 0.1 → 1 → 10 µg/kg (0.1 mg/ml) bolus
    • 20 µg/ml – should be given in CVC
    • Infusion 0.01-0.5 µg/kg/min

Clinical Aspects of Pediatric Anesthesia

Some practical anesthesia routines

  • Only one (1) parent accompanies to the operating room if the child is over 4 months.
  • Limit for outpatient care: 3 months of age (corrected age).
  • Atropine given only on specific indication
  • Always endotracheal tubes with a cuff
  • Endotracheal tube positioning (cm from lips) = patient length (cm)/10 + 5. Nasal: + 20%
  • Recommended concentration of Propofol is always 5 mg/ml, lidocaine is not required
  • Volume pumps (20 kg limit), no children’s units
  • Often TIVA mode for children but never TCI <16 years of age
  • A lot of topical anesthesia (transdermal) EMLA, even newborn.

Some common anesthetic procedures for children

  • Induction
    • Propofol 5 mg/ml (as 10 mg/ml infusion);
    • Thiopentone 25 mg/ml (for cardiac procedures only);
    • Esketamine (different concentrations depending on the size of the child, often 1 or 5 mg/ml)
  • Anesthetic volatile agent
    • Sevoflurane (induction by inhalation, laryngeal mask).
    • Isoflurane (for cardiac procedures or neurosurgery).
    • Desflurane (other anesthetic procedures).
  • Opioid
    • Fentanyl 50 µg/ml
    • Remifentanil 10 or 25 µg/ml.
    • Alfentanil is not routinely used.
    • Morphine is always available.
  • Muscle relaxants
    • Rocuronium 10 mg/ml.
    • Succinylcholine 50 mg/ml is always available, as well as atropine during anesthetic procedures.

Bronchospasm – acute treatment

  • 100% O
  • Pulmonary auscultation
  • Confirm tube position. Too deep?
  • Deepen anesthesia
  • Adrenaline iv 0.1 → 1 µg/kg
  • Hand ventilation (manual) with low RR
  • Beware of auto-PEEP!
  • Inhale a bronchodilator
  • Sevoflurane
  • Mg iv infusion 0.2-0.4 mmol/kg may be given
  • Ketamine 0.5 mg/kg
  • Hydrocortisone (Solu-Cortef) 8 mg/kg

Bronchial dilatation

  • Salbutamol (Ventoline) 5 alt 1 mg/ml 0.15 mg/kg x 4-6 max 5 mg/dose
  • Ipratropium (Atrovent) 0.25 mg/ml < 12 years: 0.25 mg ≥ 12 years: 0.5 mg
  • Salbutamol 2.5–5 mg and/or ipratropium 0.5 mg in nebulizer

Laryngospasm

Risk factors

  • Asthma
  • Low age
  • ENT surgery
  • Airway manipulations
  • Airway mucous secretions or bleeding
  • Respiratory infections (recent virosis)

Prophylaxis

  • IV induction + propofol upon awakening
  • Inhalation anesthesia
  • Avoid airway mucous secretions or bleeding
  • Nasal constringent drops (“Nezeril”)
  • Glycopyrridone (“robinul”) or atropine i.v.
  • Lidocaine iv 1 mg/kg

Treatment

  • Remove triggering stimuli
  • Jaw lift
  • 100% O2 by mask
  • Call a colleague
  • Mask ventilation by hand + PEEP
  • Muscle relaxation in pronounced cases – saturation below 90% (subclinical dose may be sufficient)
  • Atropine to avoid bradycardia and hypotension
  • Intubation when unsatisfactory airway
  • CPR finally

IV access

  • Propofol 0.5-3.0 mg/kg
  • Suxamethonium 0.25-2 mg/kg (subclinical dose may be sufficient)
  • + Atropine 10 micrograms/kg at high dose suxamethonium

No IV access

  • Think intraosseous needle!
  • i.o. Suxamethonium 4 mg/kg

Dosage of Infusions for Children

Recommended Dosage of Drug Infusions for Children

MedicationConcentrationInfusion doseNotes
Epinephrine (Adrenalin)20 μg/ml20-300 nanog/kg/minTo be given in CVC
Amiodarone (Cordarone)15 mg/mlA loading dose 5 mg/kg given for 1-4 hours. Maintenance dose 0.3-1 mg/kg/hMax 1200 mg/24 h. Total treatment dose 100 mg/kg
Dopamine2 mg/ml2,5-20 μg/kg/minTo be administered in CVC
Fentanyl50 μg/ml0.5-1 μg/kg/hourMaxiumum 6 μg/kg/hour
Furosemide10 mg/ml0,5-1 mg/kg/h
Potassium Chloride1 mmol/ml0,1-0,4 mmol/kg/hMax 15 mmol/h
Clonidine15 μg/ml0,5-2 μg/kg/h
Midazolam<15 kg 1 mg/ml ≥15 kg 5 mg/ml0,05-0,2 mg/kg/hBolus dose: 0,05-0,1 mg/kg.
Morphine<15 kg 0,1 mg/ml ≥15 kg 1 mg/ml5-30 μg/kg/hBolus dose: 0,05-0,1 mg/kg.
Norepinephrine (Noradrenalin)20 μg/ml20-300 nanog/kg/minTo be administered in CVC
Propofol (Propolipid)20 mg/ml1-4 mg/kg/hChildren> 3 years. Bolus: 1-3 mg/kg

Fasting rules before anesthesia

  • 6 hours fasting on anything other than clear liquids (2 hours)
  • Before the age of 6 months, 4 hours of fasting on breast milk applies (replacement?)
  • Breastfeeding after 6 months of age – 4 or 6 hours fasting?
  • Clear liquid up to 2 hours before
  • Ice-cream is not considered a clear liquid.

Fluid therapy for children

  • Crystalloid solutions such as Ringer’s Acetate works in most situations
  • Albumin 5% is standard for colloid volume requirements
  • Blood, platelets, etc. based on need
  • Everything can be given in boluses of 10 ml/kg over 1-4 hours
  • If it is in a hurry, it is easiest to give volume directly with a syringe (goes quickly to small children)
  • Hgb limits are discussed for healthy children, however, should cope with Hgb 8-9 g/dL

Clinical signs of dehydration in Children

Symptoms / signsMildModerateSevere
Weight loss< 5 %5–10 %> 10 %
Deficit (ml/kg)< 5050–100> 100
General conditionThirsty and worriedThirsty, anxious or lethargic, halonatedVery sluggish to comatose, cold, gray, cyanotic
Mucous membranesNormal, moistyDryVery dry
Skin turgorNormalReducedPronounced impaired
FontanelleNormalSunkenVery sunken
PulseNormalTachycardiaTachycardia, weak pulse
Capillary refill< 2 secSlow > 2 secVery slow
Blood pressure (systolic)NormalNormal / lowLow
BreathingNormalDeepDeep and fast
Diuresis (urinary output)< 2 ml/kg/h< 1 ml/kg/h< 0,5 ml/kg/h
NOTE! Higher dehydration can be used without all the characters being met. In hyperosmolar conditions with dehydration, the symptoms may appear different. Drops in blood pressure will often be late and are ominous.

The child's total fluid needs

Fluid requirements per kg body weight (Holliday-Segar)
Weight (kg)Amount per day
Children born before week 37 and during the neonatal periodSee MM for patients at Neonatal
< 5 kg150 ml/kg
5 to 10 kg100 ml/kg
11 to 20 kg1000 ml + 50 ml for each kg over 10 kg
> 20 kg1500 ml + 20 ml for each kg over 20 kg

Basic fluid requirement – The 4/2/1 rule

  • 0 – 10 kg → 4 ml/kg/h
  • 10 – 20 kg → 40 ml/h + 2 ml/kg/h for weight > 10 kg
  • > 20 kg → 60 ml/h + 1 ml/kg/h for weight > 20 kg

Bolus dose volume

  • Ringer’s Acetate 5 – 10 – 20 ml/kg
  • Albumin 5% 5 – 10 – 20 ml/kg
  • Blood 5 – 10 – 20 ml/kg

Peroperative fluid requirement (Ringer-Acetate = standard)

  • Children < 10 kg: 10 ml/kg first 1-2 hours
  • Children > 10 kg: 3-5 ml/kg first 1-2 hours
  • Then 1-2 ml/kg/h + measured/estimated losses
  • 3rd room loss: 1-10 ml/kg/h depending on type of surgery

Glucose supply peroperatively

  • Glucose 10% + 40 Na/20 K – 3 ml/kg/h → control for B-glucose!
  • Indications
    • Children < 1 week → Ongoing glucose-infusion preoperatively
    • Metabolic disease.
    • Generally low weight newborns

Postoperative fluid requirement

  • Give 75% of the 4/2/1 rule 1:st operation day (due to elevated ADH)
  • Ringer’s Acetate or similar crystalloid
  • Glucose 10% + 120 Na/20 K (reduce electrolytes for children < 6 months)

Urinary production

  • 0-2 years: 1.5-2 ml/kg/h
  • 3-5 years: 1-1.5 ml/kg/h
  • 6-12 years: 0.5-1 ml/kg/h

Bladder capacity:

  • Children < 12 years = Age x 30 ml + 30 ml
  • Children > 12 years: 350-500 ml

Urinary catheter size:

  • < 1 year: 6 fr
  • 1-6 years: 8 fr
  • 8-12 years: 10-12 fr
  • 13-16 years: 10-14 fr

Electrolyte content in losses of various body fluids in mmol/l

Body fluidNa (mmol/l)K (mmol/l)Cl (mmol/l)HCO3 (mmol/l)H (mmol/l)
Stomach (Gastric content)20–601414060–80
Bile145510530
Diarrhea / colostomy losses30–14030–7020–80
Losses from the ileum at high flows100–1404–575–1250–30
Losses from the ileum at low flows50–1004–525–750–30
Drainage or fistula from the pancreas125–13885685
Losses from the jejunum14051358
PolyuriaVariesVaries
Ref: Neilson J, O’Neill F, Dawoud D, Crean P, Guideline Development G. Intravenous fluids in children and young people: summary of NICE guidance. BMJ (Clinical research ed). 2015;351:h6388

Total intravenous fluid supply to emit during the first days of life

AgeVolume
Day of life 160–70 ml/kg/day
Day of life 2 70–80 ml/kg/day
Day of life 3 80–100 ml/kg/day
From the age of four days100 ml/kg/day

Estimated fluid needs for intravenous maintenance treatment of children and adolescents

Weight Daily fluid needs(ml/24 h) Fluid demand per hour (ml/h)
< 10 kg 100 ml/kg/24 hours4 ml/kg/h
10–20 kg 1,000 ml + (50 ml/kg/24 h for each kg more than 10 kg)40 ml/h + (2 ml/kg/h for each kg more than 10 kg)
> 20 kg 1 500 ml + (20 ml/kg/24 tim för varje kg över 20 kg*) 60 ml/tim + (1 ml/kg/tim för varje kg över 20 kg)*
* Girls rarely need more than 2,000 ml / day and boys rarely need more than 2,500 ml / day as maintenance treatment even at weights exceeding 45 and 70 kg respectively.

Preoperative supply of volume of maintenance fluid

Patient weightVolume needs according to Holliday and Segar/dayExample basic supply (ml/day)Preoperative maintenance fluid (ml/day)
≤ 10 kg 100 ml/kg 8 kg 8 × 100 = 800800 × 0,8 = 640
10–20 kg 1,000 ml + 50 ml/kg for each kg over 10 kg15 kg 1 000 + 5 × 50 = 1 2501 250 × 0,8 = 1 000
≥ 20 kg 1 500 ml + 20 ml/kg for each kg over 20 kg25 kg 1 500 + 5 × 20 = 1 6001 600 × 0,8 = 1 280

Peroperative fluid requirement

Patient weight Basic volume requirementAfter 1-2 hoursAdd for 3rd room loss:
≤ 10 kg 10 ml/kg first 1-2 hours1-2 ml/kg/h + measured/estimated losses1-10 ml/kg/h depending on type of surgery
10–20 kg3-5 ml/kg first 1-2 hours1-2 ml/kg/h + measured/estimated losses1-2 ml/kg/h + measured/estimated losses
≥ 20 kg 3-5 ml/kg first 1-2 hours1-2 ml/kg/h + measured/estimated losses1-2 ml/kg/h + measured/estimated losses

Volume postoperative maintenance maintenance fluid

Patient weightBasic volume requirement,/dayExample basic supply (ml/day)After postoperative reduction (ml/day)
≤ 10 kg 100 ml/kg 8 kg 8 × 100 = 800800 × 0,7 = 560
10–20 kg 1 000 ml + 50 ml/kg for each kg over 10 kg15 kg 1 000 + 5 × 50 = 1 2501 250 × 0,7 = 875
≥ 20 kg 1 500 ml + 20 ml/kg for each kg over 20 kg25 kg 1 500 + 5 x 20 = 1 6001 600 × 0,7 = 1 120



Inhalation of Racemic Epinephrine

In case of croup, pseudocroup or severe bronchospasm.

Dosage for Inhalation Therapy

Body WeightRacepinephrine 22,5 mg/ml
< 5 kg0,25 ml
5-10 kg0,3 ml
10-15 kg0,5 ml
15-20 kg0,7 ml

Laryngospasm in children

Risk factors

  • Upper airway infection (recent virosis)
    • Fever
    • Productive cough
    • Colored mucous secretion within 2 weeks
  • Asthma
  • Low age
  • ENT surgery
  • Airway manipulations
  • Airway mucous secretions or bleeding

Prophylaxis

  • IV induction
  • Nasal constringent drops (“Nezeril”)
  • Anticholinergics; Glycopyrronium (Robinul) or Atropine i.v.
  • Extubation in sideway body position
  • Small doses of propofol upon awakening and extubation
  • Inhalation anesthesia
  • Avoid airway mucous secretions or bleeding
  • Lidocaine iv 1 mg/kg
  • Racepinephrine

Treatment

  • Remove triggering stimuli
  • Jaw lift
  • 100% O2 by mask
  • Call a colleague
  • Mask ventilation by hand + PEEP
  • Muscle relaxation in pronounced cases – saturation below 90% (subclinical dose may be sufficient)
  • Atropine to avoid bradycardia and hypotension
  • Intubation when unsatisfactory airway
  • CPR finally

IV access

  • Propofol 0.5-3.0 mg/kg
  • Suxamethonium 0.25-2 mg/kg (subclinical dose may be sufficient)
  • + Atropine 10 micrograms/kg at high dose suxamethonium

No IV access

  • Consider intraosseous cannula!
  • i.o. Suxamethonium 4 mg/kg

MAC-values for Children

Age effect on MAC for children

Age of Patient (Years)Sevoflurane in oxygen (%)Sevoflurane in 65% N2O/35% O2
0 - 1 months*3.3%Undetermined
1 - <6 months3.0%Undetermined
6 months - <3 years2.8%2,0 %**
3 to 12 years2.5%Undetermined
* Newborns after the end of pregnancy. MAC in prematures has not yet been established.
** In pediatric patients 1 - <3 years old, 60% N2O/40% O2 was used.

Maximum doses of local anesthetic for children

Local anaesthetics – maximum doses

Children above 3 months of age, based on ideal weight

  • Lidocaine: 5 mg/kg
  • Lidocaine + adrenaline: 7 mg/kg
  • Ropivacaine: 2-3 mg/kg
  • Mepivacaine: 5 mg/kg
  • Bupivacaine 2 mg/kg
  • Levobupivacaine: 2 mg/kg
Weight (kg)Bupivacaine 2,5 mg/mlBupivacaine 2,5 mg/ml + adrenalinBupivacaine 5 mg/mlBupivacaine 5 mg/ml + adrenalinLidocaine 10 mg/mlLidocaine 10 mg/ml + adrenalinMepivacaine 5 mg/mlMepivacaine 5 mg/ml + adrenalinWeight (kg)
108,0 ml12,0 ml--5 ml7,0 ml10 ml14,0 ml10
129,6 ml14,4 ml--6 ml8,4 ml12 ml16,8 ml12
14--5,6 ml8,4 ml7 ml9,8 ml14 ml19,6 ml14
16--6,4 ml9,6 ml8 ml11,2 ml16 ml22,4 ml16
18--7,2 ml10,8 ml9 ml12,6 ml18 ml25,2 ml18
20--8,0 ml12,0 ml10 ml14,0 ml20 ml28,0 ml20
22--8,8 ml13,2 ml11 ml15,4 ml22 ml30,8 ml22
24--9,6 ml14,4 ml12 ml16,8 ml24 ml33,6 ml24
26--10,4 ml15,6 ml13 ml18,2 ml26 ml36,4 ml26
28--11,2 ml16,8 ml14 ml19,6 ml28 ml39,2 ml28
30--12,0 ml18,0 ml15 ml21,0 ml30 ml42,0 ml30
32--12,8 ml19,2 ml16 ml22,4 ml32 ml44,8 ml32
34--13,6 ml20,4 ml17 ml23,8 ml34 ml47,6 ml34
36--14,4 ml21,6 ml18 ml25,2 ml36 ml50,4 ml36
38--15,2 ml22,8 ml19 ml26,6 ml38 ml53,2 ml38
40--16,0 ml24,0 ml20 ml28,0 ml40 ml56,0 ml40

Morphine and other strong analgesics for children

Morphine for Pediatric Use
AgeLoading dose morphine (mg/kg)Cont. infusion morphine (μg/kg/h)
0 - 3 months0.055-15
3 - 12 months0.110-20
1 - 5 years0.1510 - 40
6 -12 years0.210 - 40
12 - 16 years0.2510 - 40
Dosage of Morphine for Children
Morphine 1 mg/ml i v
AgeDosage
<3 months50 µg/kg (0,05 mg/kg = 0,05 ml/kg of morphine 1 mg/ml)
3-12 months100 µg/kg (0,1 mg/kg = 0,1 ml/kg of morphine 1 mg/ml)
1-5 years150 µg/kg (0,15 mg/kg = 0,15 ml/kg of morphine 1 mg/ml)
5-12 years200 µg/kg (0,20 mg/kg = 0,20 ml of morphine 1 mg/ml)
12-15 years250 µg/kg (0,25 mg/kg = 0,25 ml/kg of morphine 1 mg/ml)
Oxycodone to Children
Oxycodone1 mg/ml
Oral solution0,1-0,2 mg/kg (max 10 mg) up til 4 times/day
Given against severe opioid-sensitive pain.NOTE! At least one hour of monitoring after the last dose!
Fentanyl to Children
Fentanyl50 µg/ml (0.05 mg/ml)
Intravenously1 µg/kg
Continuous infusion0.5-1 μg/kg/hour
Nasally>3 years 1,5 µg/kg
Naloxone to Children
Naloxone i vDosage 2 µg/kgThe dose may be repeated if necessary
Weight (kg)Solution 20 µg/mlSolution 0,4 mg/ml (children > 20 kg)
3 - 5 kg0,3 - 0,5 ml
5 - 10 kg0,5 - 1,0 ml
10 - 20 kg1,0 - 2,0 ml
20 - 40 kg2,0 - 4,0 ml0,1 - 0,2 ml
40 - 80 kg4,0 - 8,0 ml0,2 - 0,4 ml

Normal Physiological Values for Children

Normal Length and Weight of Children

AgeLength (cm)Weight (kg)
Newborn503,5
3 month 606
1 year7510
3 year9515
7 year12025
10 year14030

Normal Reference Values for Children

 Pulse
hr/min
Blood pressure
syst/dia
Respiratory Rate
Blood VolumeHgb-values
(g/l)
Newborn100-18060/35 (MAP 40-45)40-6085 ml/kg150-180
0-6 months100-16060-90/30-6030-6085 ml/kg90-100
6-12 months100-16080-95/45-6525-5085 ml/kg100
1-2 years old100-15085-105/55-6525-3580 ml/kg100
Preschool70-11095-105/55-6520-3575 ml/kg100-110
School age (7-12)65-11095-115/55-7018-3075 ml/kg110-120
Teen Age60-90110-130/65-8012-1675 ml/kg120-130

Target values for blood pressure in children in general anesthesia (MAP in mmHg)

AgeDuring anesthesiaAwake
0-3 months42-4752
3-6 months45-5257
6-12 months51-5763
1-3 years51-5763
3-6 years54-6168
6-14 years58-6570
> 14 years58-6573


Nutrition for children

Fluid and calorie needs

  • Full-term infants > one week of age: 100-150 ml/kg/day (in normal cases for ICU patients, the lower range should be maintained)
  • One year of age: about 100 ml/kg/day
  • 10 years of age: about 50 ml/kg/day
  • Adjustments to the current condition may of course be made. Postoperatively after major surgery, 2-3 ml/kg/h is recommended for the first 24 hours

Normal energy needs at different ages

  • Full-term newborn – 1 month: 90-100 kcal/kg/day
  • 1-7 months: 75-90 kcal/kg/day
  • 7-12 months: 60-75 kcal/kg/day
  • 12-18 months: 30-60 kcal/kg/day

Enteral nutrition

  • Enteral nutrition can be started immediately, if no surgeon has any objections
  • For smaller children, give 5 ml x 6-8, escalate if gastric retention is reasonable
  • Addex-Na and Kajos can be added, preferably when you have come up a little in food quantities to avoid stomach cramps
  • Naloxone APL (10 mikrog/kg x 4 p.o.) is given enterally to anyone who has an infusion of opioids (motility agents are not usually used)

Parenteral nutrition

Initiation of parenteral nutrition

  • Slightly unclear when it is optimal to use parenteral nutrition, probably inappropriate in the first days in seriously ill children
  • Recommended “if the enteral energy supply is expected to be < 50% for > 2-5 days”
  • Three-chamber systems can be used for children > 2.5 kg (eg Numeta G16E). Energy content 1 kcal/ml. Not suitable
    in case of liver or kidney failure (then use separate infusions)
  • Until recently, separate infusions of Clinoleic, Vamin and glucose were used
  • Older children (teenagers) can get Kabiven or equivalent in the same way as adults
  • All mixtures should be stepped up over three days. Follow plasma transaminases, bilirubin and triglycerides

Indications for initiation of PN

Parenteral nutrition is used when the child’s nutritional needs cannot be met with oral and/or enteral nutrition. To the extent possible, PN should be combined with enteral nutrition. Start PN if the nutrient intake is less than 50% of the need for a longer time than indicated in table 1 (rule of thumb). The exception is premature babies where nutritional treatment is started immediately after birth.

Maximum time period with nutrient intake less than 50% of energy needs before PN is started

The age of the childDays
Premature babies Begins immediately after birth
Full-term children
< 1 month 2 days
1 month – 1 year 3 days
> 1 year4-5 days

In case of losses from the intestine (drain, stoma), pleura (drain) or central nervous system (cerebrospinal fluid drainage), these losses should be compensated separately by isotonic infusion fluids and not within prescribed PN volumes.

Fluid and nutritional needs

The child’s energy needs control the amount of PN prescribed. PN solutions are energy-dense and a prescription based on fluid needs results in too high intakes of energy and nutrients. If the patient needs additional fluid supply, it is prescribed in the form of another infusion fluid. Check for dehydration, acid / base disturbance, electrolyte disturbance or effect on kidney or liver function before starting PN. Dehydration, acid / base or electrolyte disturbance should be corrected before starting PN treatment. If the child has a significant decrease in kidney or liver function, PN may need to be modified (eg reduction of protein or fat). This should be discussed with a gastrointestinal consultant.

Energy needs are affected by nutritional status and disease state. In critically ill children with metabolic stress (sepsis, intensive care), the energy requirement is reduced to about 50-70% of normal. According to the latest research, it is not beneficial to start PN treatment within the first 24 hours in very seriously ill children in the intensive care unit 3.

The child's total protein needs

Age group Gram/kg body weight/day
Children born before week 37 and during the neonatal period1,5 - 4,0
Full-term infants1,5 - 3,0
2 months – 3 years1,0 - 2,5
3-18 years1,0 - 2,0

The child's total fluid needs

Fluid requirements per kg body weight (Holliday-Segar)
Weight (kg)Amount per day
Children born before week 37 and during the neonatal periodSee MM for patients at Neonatal
< 5 kg150 ml/kg
5 to 10 kg100 ml/kg
11 to 20 kg1000 ml + 50 ml for each kg over 10 kg
> 20 kg1500 ml + 20 ml for each kg over 20 kg

Normal energy needs in children per kg body weight by age

Age (years)Kcal/kg/day
Premature birth - neonatal:120-110 kcal/kg/day
Full-term newborn - 1 year:100-90 kcal/kg/day
1-7 years90-75 kcal/kg/day
7-12 years75-60 kcal/kg/day
12-18 years60-30 kcal/kg/day

Parenteral nutrition to children by weight and age

The child's total energy needs with ml per kg. The energy content is about 1 kCal/ml
Age (years)Kcal/kg body weight/dayml/body weight/day
Full term newborns - 1year100-90 100-90
1 to 7 years90-75 90-75
7 to 12 years75-60 75-60
12 to 18 years60-30 60-30

Vitamins and minerals must be included in full amounts from day 1 at the start of PN. In the products ordered from tha pharmacy, these are already added, but in the standardized three-chamber bags, these need to be added. The additives used in combination are Soluvit, Vitalipid and Peditrace / Addaven.

Dosage of vitamins and trace elements per day

AgeYounger than 11 yearsOlder than 11 years
Weight< 10 kg 10-15 kg > 15 kg
Soluvit® 1 ml/kg 10 ml 10 ml 10 ml
Vitalipid infant® 10 ml 10 ml 10 ml
Vitalipid adult® 10 ml
Peditrace® 1 ml/kg 1 ml/kg
Addaven® 0,1 ml/kg (max 10 ml) 0,1 ml/kg (max 10 ml)

Part of bag

A patient who is 2 months old and weighs 4 kg is prescribed 400 ml Numeta G16E® (= 412 kCal). The bag size is 500 ml so only 80% of the bag is given to the patient. In order for the daily need for vitamins and minerals to be met, the additives need to be adapted.

Several bags

If more than one three-chamber bag is given during the same day, vitamin supplements must be made in the first bag.

Escalation of PN

Escalation of parenteral nutrition takes place based on the child’s condition. During the escalation, the remaining amount of fluid taken to meet the fluid requirement should be given separately. Below is a proposal for escalation of PN. Day 1 33%, Day 2 67%, Day 3 100%. The prescribed amount should be given for as large a part of the day as possible, the full amount should not be given for less than 16 hours/day. Recommended infusion time is 20 hours. PPN can be given in a shorter time, but the infusion rate must not exceed the maximum infusion rate according to the SPC which is 5.5 ml/kg/hour.

Determine the child’s total energy needs, see below. Take into account the patient’s disease state to determine energy needs. As the energy content is approximately 1 kCal / ml, it can easily be converted to volume, see below.

The child's total energy needs

Age (years)Kcal/kg body weight/dayml/kg/day
1 - 7 years90-75 90-75
7 - 12 years75-60 75-60
12 - 18 years60-30 60-30

Development of increased liver values ​​during PN treatment usually signals ongoing inflammation, steatosis (accumulation of fat in liver cells) and / or impaired bile flow (cholestasis) in the liver. One should be particularly observant for the development of cholestasis (ie conjugated bilirubin> 20 micromol / L), but even a slight increase in other liver values ​​that last more than a few days is a reason to contact a gastroenterologist for discussion about appropriate treatment and position on investigation needs regarding any other underlying causes. If this assessment is based on the fact that the cause of the liver effect is PN-related, it may be necessary to adjust the amount and type of fat in the PN solution, often in combination with adjustments also regarding the amount of glucose and protein. This type of hepatic impairment that occurs with relatively short-term use of PN is generally benign and reversible.

The most serious form of liver disease seen during PN treatment is that which affects intestinal failure patients during long-term PN. This condition is called Intestinal failure associated liver disease, IFALD (formerly also known as parenteral nutrition associated liver disease/cholestasis, PNALD/PNAC) and refers to a progressive liver disease seen in these patients. The diagnosis is clinical and requires, in addition to intestinal failure and long-term PN, the presence of cholestasis (conjugated bilirubin> 20 micromol / L). Genesis is multifactorial, but the risk of developing IFALD can be reduced, among other things. a. by using optimally composed PN solution mainly for fat. Modified fat composition (fish oil-based fat emulsion) in PN also forms the basis for the treatment of already developed IFALD.

Complications under treatment with TPN

Complication to TPNCauseProposed action
Infection in central entranceBacterial contamination of entranceAntibiotic treatment
Consider changing the entrance
Taurolock® can be used to prevent infections
HyperglycemiaHigh glucose supply
For fast delivery
Diabetes
Reduce the feed rate
If necessary, give insulin
NauseaFor fast delivery
Too high energy level
Dehydration
Exclude reasons other than PN
Lower energy level and speed
Provide solution with lower osmolality
Ev. antiemetics
Tachycardia
Fever
Rapid weight gain
Refeeding syndrome
Fat overload syndrome
Kidney failure
Infection
Lower energy level and speed
Weight control 1 time / day
Temp controls
Check electrolytes (phosphate, magnesium and potassium drops, in refeeding syndrome)
Sepsis investigation, infection tests
Coagulation tests in Fat overload syndrome
Rising liver valuesCholestasis
Liver steatosis
Hypertriglyceridemia
Chronic inflammation
Change fat emulsion (for example Omegaven®)
Stimulate the gut with enteral nutrition
Reduce fat content and speed
Put possibly. in Ursofalk®
Consider antibiotic treatment
Rising ureaImpaired renal function
Too high nitrogen supply
Too low energy supply
Investigation of kidneys / urinary tract
Reduce nitrogen supply
Increase energy supply
HypertriglyceridemiaIncorrect sampling
Too high fat supply
Liver failure
Recheck of S-TG
Discuss ev. fat reduction with gastroconsultation

Optiflow for children

Flow in Highflow Grid (Optiflow) for children.

WeightFlow (l/min)
2-6 kgChild's weight + 1 l up to 2 l/kg
7-9 kgChild's weight + 1-2 l
10-14 kgStart at 10 l / min increase as required to 15 l / min
15-19 kgStart at 15 l / min increase as required to 20 l / min
20-49 kg20-25 l/min
>50 kg25 l/min up to 40 l/min

Pain Assessment Scales for Children 0-7 years

FLACC – Face, Legs, Activity, Cry, Consolability

For pain estimation of children 0-7 years, a behavioral scale for pain estimation is used, it can also be used for children with multiple disabilities.

  • Note the child for a few minutes and then look at face/legs/activity/cry/comfortability and decide whether the scoring graduation 0, 1 or 2 suits the child.
  • Then add the score, to a maximum of 10 points.
  • A value of <3 is sought. At values ​​<4, nursing measures may be sufficient, at values > 4, pain relief should be considered.
  • When any pain is suspected and nursing measures do not help the child, a test of analgesic delivery is done.
  • Evaluate the result with a new pain estimation.

FLACC Behavioral Scale Children

Try to observe the child for at least
2 minutes
0 points1 points2 points
FaceNeutral facial expressions or smilesBister eyesight, wrinkles the forehead occasionally, withdrawn, uninterestedFrequent or constantly wrinkled brow, trembling chin, bumpy jaws
LegsNormal position or relaxedWorried, restless or tense legsKicking or legs drawn
ActivityStands calm, normal position, moves unobstructedScrews, often changes position, tenseArc, raises or stems
CryingNo crying (awake or sleeping)Gnaws or smells, complains off and onCrying persistently, screaming or sneaking, complaining often
Ability to comfortSatisfied, relaxedCan be calm with touch, hugs or chatting. Distractable.Hard to comfort or calm

AS – Facial Expression Scale

AS is a modified VAS scale for children 5-18 years. It consists of six faces, 1st face counting as 0 points and 6th face as 10 points. At 4 points and above, consideration should be given to pain relief. Keep in mind that some children may confuse state of mind with pain. Do not ask “Does it hurt” ask instead “Do you feel anything from the wound. If the answer becomes “Yes”, then ask “How does it feel “? If the child replies pain ask “How bad are you?” “Can you show on this scale?”


Parenteral Antibiotics for Children

Recommended Doses of Parenteral Antibiotics to Children

MedicationConcentrationDoseNote
Erythromycin 10-15 mg/kg x 3Caution in liver failure and in heart disease (arrhythmias). Dose reduction in renal impairment.
Phenoxymethylpenicilline (Bensyl PCV)100 mg/ml25-50 mg/kg x 3 (3g x 3) alt. 50-100 mg/kg x 4 (3 g x 4)
Cefotaxime 100 mg/ml30 mg/kg x 3. (1g x 3) alt. 75-100 mg/kg x 3 (3 g x 3)
Ceftazidime 100 mg/ml25 mg/kg x 3 (1 g x 3) alt. 50 mg/kg x 3 (2 g x 3) alt. 35 mg/kg x 3 (2 g x 3) Children< 2 months: 25 mg/kg x 2 Diluted with sterile water. Given for 3-5 min.
Cefuroxime 100 mg/ml20-30 mg/kg x 3 (0,75-1,5 g x 3)Diluted with sterile water. Given for 3-5 min.
Clindamycin 10 mg / kg x 3 (600 mg x 3)
No child <4 weeks age
Cloxacillin 50 mg/mlDiluted with sterile water. Given in CVC 3-5 min. All infusion in pvc: Then dilute once more with NaCl 9mg/ml to 20 mg/ml. 20-30 min.
Meropenem 50 mg/ml40 mg/kg x 3 (2 g x 3) alt. 20 mg/kg x 3-4 (2 g x 3-4) alt. 10-20 mg/kg x 3 (0,5-1 g x 3)Diluted with sterile water. Given for 3-5 min.
Tobramycin10 mg/ml7.5 mg/kg x 1. Higher dose 8-10-(12) mg/kg x1
can be used in CF and neutropenic fever.
Nebcina 40 mg/ml is diluted with NaCl 9 mg/ml alt. Glucose 50 mg/ml. Infusion for 20-60 min.
Vancomycin 5 mg/ml20 mg/kg x 2 (-3) (1 g x 2) ev x 3Diluted in two steps. First stock solution with sterile water to 50 mg/ml. Then dilute with sodium chloride 9 mg/ml or glucose 50 mg/ml to 5 mg/ml. Infusion for at least 60 minutes.
Piperacillin/Tazobactam80 mg/kg x 3-4 alt. 100 mg/kg x 3-4 (4 g x 3-4)
Ceftriaxone 100 mg/kg x 1. (2 g x 1)
Linezolid 10 mg/kg x 2 (600 mg x 2)(max 28 days)


Pocket Guide Pediatric Anesthesia

Edited by Patrik Martner, Specialist Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.

Updated 2019-10-14


Click on Pic to retrieve PDF-file


PONV and Antiemetics

PONV increased risk

  • > 3 years of age
  • Long anesthesia
  • Eye / ENT surgery
  • Motion sickness
  • Formerly PONV

Prophylaxis

  • Propofol induction
  • Evacuate air from the stomach
  • Keep the patient well oxygenated

Treatment

  • Ondansetron i.v. 0.1 mg/kg (max 4 mg)
  • Betametason i.v. 0.2 mg/kg (max 4 mg)
  • Droperidol (not for children < 2 years) i.v. 0.02 mg/kg (max. 1.25 mg)
Ondansetron to Children (Dose 0,1 mg/kg)
Weight (kg)Intravenous Dose
Solution 2 mg/ml
Weight (kg)Oral dose
Solution 0,8 mg/ml
Oral dose
Tablet
≥1 months: 0,1 mg/kgMax 4 mg x 4≥1 months: 0,2 mg/kgMax 8 mg x 4
8 - 14 kg1 mg = 0,5 ml< 15 kg2 mg = 2,5 ml2 mg
15 - 24 kg2 mg = 1 ml15 - 30 kg4 mg = 5 ml4 mg
25 - 34 kg3 mg = 1,5 ml> 30 kg8 mg = 10 ml8 mg
> 35 kg4 mg = 2 ml
Other Antiemetics for Children
Betametasone 4 mg/mlIntravenous injection 
Dosage2 mg/kgMax dose 4 mg x 1
Metoclopramide  5 mg/mlIntravenous injectionChildren ≥ 1 year
Dosage0,15 mg/kg/doseMax dose 10 mg x 3
Phenergan  25 mg/mlChildren ≥ 1 year
Intravenously0,5 mg/kg
OrallyTablet or Solution Children ≥ 1 year. Max dose 25 mg x 4
Droperidol 2,5 mg/mlIntravenously 0,010 - 0,075 mg/kgMax dose 1,25 mg x 4-6

Urinary output in children

Urine production (ml/kg/h)

  • 0-2 years: 1.5-2
  • 3-5 years: 1-1.5
  • 6-12 years: 0.5-1

Bladder capacity

  • Children < 12 years = age x 30 ml + 30 ml
  • Children 12 years 350-500 ml

Catheter size

  • < 1 year: 6 fr
  • 1-6 years: 8 fr
  • 8-12 years: 10-12 fr
  • 13-16 years: 10-14 fr

Practical advice for anesthesia of children

Some anesthesia clinical practice routines

  • One (1) parent accompanies child to the operating room if the child is over 4 months old.
  • Limit for outpatient care: 3 months of age (corrected age).
  • Atropine only on specific indication
  • Always cuffed tubes
  • Tube position (cm in the corner of the mouth) = patient length (cm)/10 + 5. Nasal tube: + 20%
  • Propofol at a concentration of 5 mg/ml, lidocaine is not required
  • Volume pumps (20 kg limit), no child units
  • Often TIVA but never TCI < 16 years of age
  • Plenty of topical anesthesia as “EMLA”, also newborns.

Some common forms of anesthesia for children

  • Anaesthesia induction:
    • Propofol iv 3-6 mg/kg 5 mg/ml (as infusion 10 mg/ml)
    • Thiopentone (Pentothal) 25 mg/ml
    • Esketamine (different concentrations depending on the size of the child, often 1 or 5 mg/ml)
  • Inhalation anesthesia agent:
    • Sevoflurane (induction by face mask, laryngeal mask)
    • Isoflurane (cardiac anesthesia, neurosurgery)
    • Desflurane (other intubation anesthetics)
  • Opioid:
    • Fentanyl 50 mcg/ml;
    • Remifentanil 10 or 25 mcg/ml.
    • Alfentanil is not used routinely.
    • Morphine is available.
  • Relaxants:
    • Rocuronium 10 mg/ml.
    • Suxamethonium (succinylcholine) 50 mg/ml is always available (as is atropine)

Induction of anesthesia

  • Propofol as startup bolus iv 3-6 mg/kg (10 mg/ml = 0,3-0,6 ml/kg)
  • Propofol as a continuous infusion 15-12-9-6 mg/kg/h (diminish every 10 min)
  • Ketamine iv 2 mg/kg im 5-10 mg/kg (10 mg/ml = 0,2 ml/kg)
  • Thiopentone (Pentothal) iv 5 mg/kg (25 mg/ml = 0,2 ml/kg)
  • Atropine iv 10 mikrog/kg (max 0,5 mg) (0,5 mg/ml = 0,02 ml/kg)
  • Glycopyrridone (Robinul) iv 5 mikrog/kg (max 0,2 mg) (0,2 mg/ml = 0,025 ml/kg)
  • Anticholinergics only given when needed

Muscle relaxants

  • Suxamethonium iv 1-2 mg/kg (50 mg/ml = 0,03 ml/kg) always give atropin since histamin release may cause broncospasm)
  • Rocuronium (iv 0,6 mg/kg (10 mg/ml = 0,06 ml/kg)
  • Reversal: Glycopyrridone/Neostigmin (Robinul/Neostigmine) iv 0,02 ml/kg (max 2,5 mg) 2,5 mg/ml
  • With measurement of TOF: adjust power to 30 mA in children under 2 years of age

Opioids

  • Fentanyl for induction: iv 2 ug/kg (50 ug/ml=0,04 ml/kg)
  • Alfentanil
    • Induction: iv 10-20 ug/kg
    • Maintenance TIVA: 30 ug/kg/h
  • Morphine as bolus:
    • < 3 months: iv 30-50 ug/kg
    • 3-12 months: iv 50-100 ug/kg
    • >12 months: iv 100-200-(300) ug/kg
    • Infusion iv: 5-30 ug/kg/h
  • Remifentanil (Ultiva)
    • Induction with muscle relaxant: iv 1-3 ug/kg
    • Intub without relax (> 6 months): iv 4 ug/kg
    • Maintenance TIVA: 0,25-1 ug/kg/min
    • Not intubated child: iv 0,2-0,3 ug/kg
  • Naloxone iv 2-4-(10) ug/kg (400ug/ml -10 kg ≈ 0,075ml)

Inhalation anaesthesia

Sevoflurane Mac

  • Newborn: 3.3%
  • 6 months: 3%
  • 12 years: 2.5%

Antiemetics

  • PONV risk: > 3 years of age, long anesthesia, eye/ENT surgery, motion sickness, earlier PONV
  • Prophylaxis: Propofol induction – Evacuate air from ventricle – Keep patient well oxygenated
  • Ondansetron iv 0.1 mg/kg (max 4 mg)
  • Betametason (Betapred) iv 0.2 mg/kg (max 4 mg)
  • Droperidol (Dridol) (not for children < 2 years) iv 0.02 mg/kg (max. 1.25 mg)

Peripheral analgesics

  • Ketorolac (Toradol) (not < 3-6 months, COX 1 + 2) iv 0.3 mg/kg x 4
  • Parecoxib (Dynastat) (not < 3-6 months COX 2) iv 0.5 mg/kg x 1
  • Ibuprofen (not < 3 months COX 1 + 2) po 7.5 mg/kg x 3-4
  • Paracetamol orally 15 mg/kg x 4 (first 3 days 20-25 mg/kg x 4)
  • Paracetamol iv 15 mg/kg x 4 (use iv first post op-day)
  • Reduce dosage to children less than 3 months old

Premedication. Paracetamol (acetaminophene)

There are a variety of medicines used in premedication to children to get analgesia and anxiolysis. The main principle is that these medicines should be pain relieving and relaxing. The general preoperative care of children with parents is essential to gaining trust from the patient and parents with good and safe anesthesia. Scared and anxious parents can easily spread their concern to the child, preoperative information is essential. During anesthesia induction, it is advisable if only a parent who is calm is present.

Premedication

  • Midazolam (approx. 20 min before – t1⁄2 2 h) orally 0.5 mg/kg (max 15 mg)
    • rectally 0.3 mg/kg
  • Ketamine (combine with midazolam) orally 5 mg/kg (max 300 mg)
  • Clonidine (apply approx. 90 min before – t 1⁄2 5-10h) at 4-6 μg/kg
  • Dexmedetomidine (Dexdor) (apply 30-60 min before – t 1⁄2 2 h) nasally 2-4 μg/kg
  • Sufentanil (Approx. 10-15 min before) nasally 1-2 μg/kg

Clonidine

Dosage: 2-5 μg/kg orally, provides good sedation in the premedication. The disadvantage is that the drug has a slow onset and must be given in good time, at least 60-90 minutes in advance. Premedication with Mixtur Clonidine Hydrochloride 20 μg/ml or Tablet Clonidine 75 μg.

Dexmedetomidine and Clonidine for Children. Sedation ("Sedanalgesia").

Dexmedetomidine 100 µg/ml Clonidine 150 µg/ml(Catapres)  
IntravenouslyIntranasallyIntravenouslyOrallyEpidurally (EDA)
1 µg/kg (max 200 µg) in an infusion or by a slow injection 1,5-2 µg/kg (MR 4 µg/kg) Max 200 µg1-4 µg/kg x 31-4 µg/kg x 30,1-0,3 µg/kg/tim

Dosage

Dosage interval: 2-4- (6) μg/kg. Dose: We recommend 3 μg/kg. Children <3 years and all children with ENT surgery 2-3 μg/kg. For an eample; the weight of a child is 15 kg x 3 μg/kg = 45 μg gives 2.2 ml (20 μg/ml) clonidine hydrochloride.

Dexmedetomidine

Provides a good premedication for small children who come for ENT surgery and anesthesia. Injection dexmedetomidine (Dexdor®) 100 μg/ml can be given both nasally and buccally. Nasal administration is preferred as it provides better absorption and faster effect. The solution has no taste and does not scratch the nose. Dexmedetomidine is a specific alpha2 receptor agonist and its effect is similar to Clonidine, but more pronounced. The main effects are sedation and some analgesia. Dexmedetomidine has a shorter half-life, approximately 2 hours versus Clonidine 5-10 hours. Onset time is significantly longer compared to orally administered Midazolam, approximately 20-40 minutes.

Dosage

Children 1-3 years are given 1 μg /kg. Children 3-10 years are given 1-2 μg/kg. Children over 10 years of age are given 1-3 μg/kg. The dose may be increased with increasing age to a maximum of 3 μg /kg. Easily, nasal administration is performed with MAD (Mucosal Atomization Device) or MADdy (Pediatric Version) connected to a syringe. Ordinary dose of drug is diluted to the desired volume (usually 0.3-0.5 ml) with physiological saline.

Monitoring

The children must have the presence of parents or staff during the waiting period after application. Peroperative monitoring of blood pressure and ECG. The child may need a prolonged awakening time compared to patients without premedication.

Paracetamol (acetaminophen)

Administered alone or in combination. Common combinations of premedication in children usually contain paracetamol (30 mg/kg x 1) with benzodiazepines or benzodiazepine-like drugs, sometimes with the addition of an NSAID preparation or atropine. Paracetamol is given either as a tablet, oral suspension or as a suppository (Table 6). Children under 6 months are usually not premedicated. Several different drug combinations are common. Different variants of sedative sympathetic stimulants have become more common lately as premedication, such as clonidine and dexmedetomidine. These are usually given as oral solutions but may also be administered intravenously. Routinely, dosage of paracetamol (max oral 30 ml/kg) is given in premedication. Common practice is to give oral paracetamol 24 mg/ml, 1 ml/kg in the care department for most operations. Prior to more painful surgery, children >6 months often receive NSAIDs.

Premedication and Maintenance Therapy with Paracetamol for Children 6-25 kg
 Premedication Maintenance first 2 days
dosage 20 mg/kg body weight
Child weight (kg)Oral solution Paracetamol 24 mg/mlSupp Paracetamol (mg)Tablet Paracetamol (mg)Oral solution Paracetamol 24 mg/mlTablet Paracetamol (mg)Supp Paracetamol (mg)
6 - 8 kg8,5 ml250 mg-2,5 ml x 4-60 mg x 4
8 - 10 kg12 ml310 mg-3,5 ml x 4-125 mg x 3
10 - 12 kg14 ml375 mg-5 ml x 3-125 mg x 4
12 - 15 kg17,5 ml500 mg-5 ml x 4-185 mg x 4
15 - 20 kg22 ml625 mg-7,5 ml x 4-250 mg x 3
20 - 25 kg28 ml750 mg500 mg10 ml x 4500 mg x 3250 mg x 4
Intravenous Paracetamol Dosage for Children
Paracetamol intravenously10 mg/ml
Weight (kg)Dosage
<1 mån7,5 mg/kg
>1 mån15 mg/kg
4 - 10 kg6 - 15 ml x 4
10 - 20 kg15 - 30 ml x 4
20 - 33 kg30 - 50 ml x 4
33 - 50 kg50 - 75 ml x 4
50 - 66 kg75 - 100 ml x 4
>66 kg100 ml x 4
Paracetamol Dosage for Children Orally or Rectally
Loading dose  Maintenance dose  
Weight (kg)Oral solution 24 mg/mlSupp.Weight (kg)Oral solution 24 mg/mlSupp.
32,5 mlS. 60 mg32,5 ml x 3S. 60 mg x 3
43,5 mlS. 60 mg43,5 ml x 3S. 60 mg x 4
55 mlS. 125 mg54 ml x 4S. 125 mg x 3
6 - 87 mlS. 250 mg6 - 85 ml x 4S. 125 mg x 4
9 - 1212 mlS. 310 mg9 - 127,5 ml x 4S. 185 mg x 4
13 - 1516 ml13 - 1511 ml x 4
Weight (kg)Oral solutionTabletWeight (kg)Oral solutionTablet
16 - 1920 mlT. 500 mg16 - 1913 ml x 4T. 250 mg x 4
20 - 2425 mlT. 500 mg20 - 2417 ml x 4T. 500 mg x 3
25 - 3030 mlT. 750 mg25 - 3021 ml x 4T. 500 mg x 4
31 - 3440 mlT. 1000 mg31 - 3425 ml x 4T. 750 mg x 3
35 - 4240 mlT. 1000 mg35 - 4230 ml x 4T. 750 mg x 4
43 - 5050 mlT. 1250 mg43 - 5035 ml x 4T. 1000 mg x 3
50 - 7060 mlT. 1500 mg50 - 7040 ml x 4T. 1000 mg x 4
>70 kg80 mlT. 2000 mg>70 kg40 ml x 4T. 1000 mg x 4

Benzodiazepines – alone or in combination.

A common combination for small children (< 20 kg) is midazolam + atropine in a solution as premedication. This combination is dosed according to a schedule based on weight. Midazolam often leads to a trouble-free peripheral venous catheterization (PVC) if a topical analgetic such as EMLA has been used initially. Midazolam can be given either rectally, 0.3 mg/kg (max 10 mg), or as nasal spray 0.2 mg/kg (max 5 mg) and orally 0.5 mg/kg (max 15 mg).

Midazolam Dosage for Sedation of Children
IntravenouslyRectallyNasallyOrally/PEG 
0,1 mg/kg (max 5 mg)0,2-0,3 mg/kg (max 7,5-10 mg)0,2 mg/kg (max 5 mg)0,3-0,5 mg/kg (max 10-15 mg)
An additional dose can be given according to the schedule below
0,05 mg/kg (after 5 minuter)0,05 mg/kg (after 20 minuter)0,05 mg/kg (after 10 min)0,05 mg/kg (after 20 min)
At least one hour of monitoring after the last doseAt least one and a half hour of monitoring after the last doseAt least one hour of monitoring after the last dose

Some children, such as very anxious or who have previously experienced some anesthesia related pain may require heavier premedication. Flunitrazepam in tablet form 0.05 mg/kg, gives about 20 minutes heavy sedation with moderate effect lasting at least 1 hour. This premedication can be given at the care giving department and the time must be coordinated with the operation department. In some cases, midazolam may be given by the anesthetic staff themselves to facilitate a difficult induction. The child must not be left alone after receiving flunitrazepam or midazolam. Older children may experience moments before the operation to be long and worrisome. Diazepam (Stesolid), tablet or suppository, 0.5 mg/kg, max 25 mg rectally, may cause some relief. Atropine is given by the physician’s ordinance before surgery, either intravenously, p o, s c, rectally or sublingually.

Premedication with midazolam

A common standard mix for children is midazolam + atropine in mixtures given orally (children 10-25 kg). In addition, paracetamol is usually given 30 mg/kg x 1. Pharmacy prepared oral solution Midazolam 1 mg/ml + Atropine 0.05 mg/ml. Dosage: 0.4 mg (= 0.4 ml)/kg according to list below. Maximum dose for the mixture is 10 ml (orange flavor).

Premixed Oral Solution of Midazolam 1 mg /ml with Atropine 0.05 mg/ml for Children 10-25 kg.
Weight (kg)Dose in ml Midazolam/Atropine
104,0
114,5
125,0
135,0
145,5
156,0
166,5
177,0
187,0
197,5
208,0
218,0
228,5
239,0
249,5
2510,0

Premedication with midazolam (children 10-25 kg).

Midazolam + Atropine in mixtures that are mixed in the operating department by the anesthesia staff. Midazolam 1 mg/ml is mixed with Atropin 0.5 mg/ml and fruity juice to a solution of 5-12 ml. Dosage: Midazolam 0.4 mg/kg + Atropine 0.02 m /kg orally according to the list below. In addition, paracetamol is usually given at 30 ml/kg x 1.

Premedication with a blend of Midazolam 1 mg/ml + Atropine 0.05 mg/ml mixed by the Anaesthesia Staff
Weight (kg)Volume in ml of the solutionDose of respective drugs in the solution
Midazolam/Atropine (mg)
104,44,0/0,20
114,94,5/0,225
125,55,0/0,25
135,55,0/0,25
145,555,5/0,275
156,66,0/0,30
167,156,5/0,325
177,77,0/0,35
187,77,0/0,35
198,257,5/0,375
208,88,0/0,40
218,88,0/0,40
229,358,5/0,425
239,99,0/0,45
2410,459,5/0,475
251110,0/0,50

Premedication for rectal administration of midazolam (children 5-20 kg).

Midazolam + atropine in mixtures that are prepared by the anesthesia staff. Midazolam 5 mg/ml is mixed with 2 ml NaCl to the concentration of 3 mg/ml. Dosage 0.3 mg/kg = 0.1 ml/kg + Atropine 0.5 mg/ml is mixed.

Dose of premedication for Rectal Administration of Midazolam/Atropine to Children 5-20 kg
Weight (kg)Midazolam 3 mg/ml
Dose (mg)
Midazolam 3 mg/ml
Volume (ml)
Atropine 0,5 mg/ml
Dose (mg)
Atropine 0,5 mg/ml
Volume (ml)
51,50,50,150,3
7,52,250,750,150,3
10310,150,3
12,53,751,250,250,5
154,51,50,250,5
206,020,250,5
Flumazenil for Reversal of Bensodiazepines
Flumazenil 0,1 mg/ml ivAntidote for bensodiazepine overdose    
5 µg/kg (0,05 ml/kg) intravenously once per minute up to 40 µg/kg (maximum dose 2 mg)If lack of effect: continous infusion 2-10 µg/kg/hour

Ketamine

Another option, especially for children with heart diseases aged 1-4 years, is ketamine in a dosage of 7 mg/kg mixed with midazolam 0.3 mg/kg. In cases where the child does not participate at all, ketamine may be administered intramuscularly. It is possible to give 3-5 mg/kg, occasionally up to 10 mg/kg, preferably as an injection in the deltoid muscle. If you do not want to inject and the child does not cooperate, ketamine may be given orally. Oral induction is time consuming, 20 minutes is needed, until peripheral venous catherization can occur. You can give 6 mg/kg blended in small amounts of liquid, eg. Coca-Cola for oral administration.

Ketamine for Sedation of Children
Ketamine 10 mg/ml50 mg/ml
Iv bolus:0,5 mg/kgIv infusion 0,02-0,12 mg/kg/hour
Rectally4-5 mg/kg
Esketamin (S-Ketamine)5 mg/ml25 mg/ml
Rectally3 mg/kg
Nasally1,5 mg/kg
Must be combined with Midazolam or Dexmedetomidine!

Barbiturates – Sodium thiopental (thiopentone)

Rectal induction with thiopental (Trapanal, Pentocur – “Pentorect”/”Sleeping tail”) can be given to small children 1-4 years old (10-20 kg) if you do not want to insert a needle when the child is awake. This is an older form of anesthetic that is hardly used anymore. Thiopental (thiopentone) can be given rectally at the dose of 30 mg/kg from a concentrated solution (100 mg/ml). This premedication works well as an anesthetic induction and is given in the operating department. Weight limits are not sharp, this induction often works well for sensitive children weighing 5-30 kg. Maximum dose rectally is 600 mg Thiopental. Thiopental can be used as the sole drug for minor surgical procedures or when you only want the child to lie still, for example, during x-ray examinations and some radiological interventions.

NSAID-drugs

Some medications that can be used for smaller children are ibuprofen (Brufen) and supp diclofenac (Voltaren).

Premedication with Oral Ibuprofen 20 mg/ml for Children 6-10 kg (> 6 months)
Weight (kg)Dose (ml)
7 kg2,5 ml x 3
8 kg3,0 ml x 3
9 kg3,5 ml x 3
10 kg4,0 ml x 3
Ibuprofen for Treatment of Postoperative Pain in Children
IbuprofenOral suspension 20 mg/ml
≥ 6 months 7,5 mg/kg x 4 alt. 10 mg/kg x 3Max 1200 mg/day
0,375 ml/kg x 4 alt. 0,5 ml/kg x 3.Max 60 ml/day
Premedication with Suppositories Diclofenac (Voltaren) 25 mg (>1 year and >10 kg)
Weight (kg)Dosage of suppositories (number)
10 kg½ supp x 2
12,5 kg½ supp x 2
15 kg½ supp x 3
20 kg1 supp x 2
25 kg1 supp x 3
30-40 kg1½ supp x 3
Oral or Rectal Administration of Diclofenac to Children (Only to children ≥ 6 months)
Weight (kg)Supp.Tablet
8-14 kg25 mg25 mg
15-1925+0+25 mg25+0+25 mg
20-2425+0+25 mg25+0+25 mg
25-2750+0+25 mg25+0+25 mg
30-3450+0+25 mg50+0+25 mg
35-4050+0+50 mg50+0+50 mg
40-5050+0+50 mg50+0+50 mg
>50 kg50+50+50 mg50+50+50 mg

Premedication with intranasal sufentanil for day care surgery

By Kai Knudsen, Chief Physician, Associate Professor of Anesthesia & Intensive Care. Sahlgrenska university hospital.

Updated 2018-12-10


Indication

Children who are to receive anesthesia where sedation is considered appropriate before induction.

Contraindication

Ongoing nosebleeds or other nasal obstruction.

Administration of sufentanil intranasally presupposes the presence of anesthesia staff, the possibility of continuous monitoring and possible ventilation support.

Effect

Sedation is usually achieved within 10 – 15 minutes and maximum analgesic effect occurs after 20 – 25 minutes. In some patients, the effect may occur within a few minutes.

Dosage/Administration

  • Sufentanil 1 microgram/kg (50 micrograms/ml) is given with 2 ml syringe-connected Mucosal Aerosol Device (MAD). Use the Luer Lock syringe to prevent MAD from coming loose during the injection.
  • Total dose 1 – 2 micrograms/kg: Half the dose is administered in each nostril.
  • Give a syringe of 0.1 – 0.2 ml at a time. When applying, aim upwards inside the nostril in the direction of the eyes (in the cranial direction).
  • Apply to both nostrils as quickly as possible. It is important to use force on the piston to achieve aerosol.
    Uncertain effect at higher volumes, as part of the dose passes past the nasal mucosa and is swallowed.

Nasal Sufentanil to children - 50 micrograms/ml

KiloMikrogramVolume (ml)
10200.4
13260.5
15300.6
18360.7
20400.8
23460.9
25501
28561.1
30601.2
35701.4
40801.6
45901.8
501002
551102.2
601202.4

References

  1. Bayrak F, Gunday I, Memis D, Turan A. A comparison of oral midazolam, oral tramadol, and intranasal sufentanil premedication in pediatric patients. J Opioid Manag. 2007 Mar-Apr;3(2):74-8.
  2. Zedie N, Amory DW, Wagner BK, O’Hara DA. Comparison of intranasal midazolam

Product Information on Medicines verified for Children.

The presence or absence of information in the product information specific for children are seen here. For nasal use, information is not available for all medicines. The information may differ between different preparations with the same active substance.

Pharmaceutical Information for Children
Substance / substance groupDosage for children in product informationAge of dosage or other relevant information in product information
Lidocaine/prilocaine YesCream / patches. Premature children or children with increased risk of methemoglobinemia.
Lidocaine/tetracain YesPlaster: Children > 3 years.
LidocaineYesInjection solution: Children >1 year.
Glucose 300 mg/mL NoIndications for the treatment of pain are missing
Paracetamol YesFullterm newborns
Ibuprofen YesChildren >3 months or >5 kg
Diclofenac YesChildren > 6 years. Gel: Contraindicated to children <14 years
MorphineNo
Ketobemidone No
Oxicodone YesTablets for children > 12 years. Oral solution: Not approved for children
Fentanyl YesDosage for children > 2 years is available for i.v. use
Dexmedetomidin NoApproved for sedation of adults in the intensive care department
Ketamine Yes
Nitrous OxideYes
Clonidine NoPain / sedation is not accepted indications for any age group
Midazolam YesChildren < 5 years may require higher doses (mg/kg) than older children
Diazepam YesChildren > 1 year rectally. Children may require higher doses (mg/kg) than adults.
NaloxoneYes
* Product information (Summary of Products Characteristics) for all authorized drug substances is available at www.lakemedelsverket.se

Regional anesthesia for children

Spinal anesthesia

  • Bupivacaine  (Marcain spinal®): 0.3-0.4 mg/kg

Sacral block

  • Ropivacaine 1-2 mg/kg

Epidural (1-12 years)

  • Ropivacaine Bolus: 2 mg/kg
  • Ropivacaine Infusion 0.4-1 mg/kg/h

Respiration of Children

By Fredrik Söderlund, Chief Physician, Anesthesia & Intensive Care. DSBUS, Sahlgrenska University Hospital.

Updated 2020-01-10


  • Smaller lung volume/kg, larger anatomically dead space, and greater breathing work than adults
  • Higher metabolism = higher O2 consumption
  • A normal expiration at rest causes the lung to fall below its closing capacity
  • Lack of bronchioalveolar connections (increased risk of atelectasis)
  • Young children desaturate quickly in apnea
  • Preoxygenation can be difficult during induction
  • You rarely have time to look for the right stuff when it gets serious…

Ventilation and ventilator settings

  • Usually pressure-controlled ventilation on children (PC, PA or PCPS most common mode)
  • Tidal volume usually 6-7 ml/kg, PEEP 5 as standard (sometimes higher)
  • Preferably FiO2 <0.5
  • Recruitments can (and should) be done as usual but often do not give as good results as in adults
  • How much leakage can be tolerated from an uncuffed tube is a controversial issue…
  • NAVA ventilation is used occasionally (perhaps too infrequently)

NIV (Non-Invasive Ventilation)

  • Can be run with full mask, nasal mask, “plug” or nasal tube
  • Whole face mask works best on older children, nasal mask or nostril plug on small children
  • Nasal tube can work but often disturbs patients => very fencing and poor breathing best conditions if the patient goes from nasal intubation to NIV
  • NIV has become unusual in pediatric ICU after the high-flow systems were introduced
  • Requires competent nursing to work properly

Ventilation – advice before extubation

  • Young children need to be quite awake to avoid apnea after extubation
  • Preferably PEEP 5 and TU 5-7, FiO2 < 0.35
  • Suck clean in throat and nostrils, give nose drops as needed.
  • Hydrocortisone (Solu-Cortef) 5 mg/kg (max. 100 mg) can be given i v when the patient has been on a ventilator for a few days
  • Micronephrine (racemic adrenaline) in nebulizer is good for smaller children as bloating in the upper respiratory tract, 0.05 ml/kg, max 0.75 ml (not in a tube or in a tight mask)
  • High-flow hose system is very useful if you think it will be difficult for the patient after extubation

Resuscitation of Children

If the child shows no signs of life:

  • Start cardiac and pulmonary resuscitation (CPR) with five insufflations
  • Then make three series with 30 compressions and two insufflations
  • Alarm others
  • Continue CPR switching between 30 compressions and two insufflations until help is in place or the child breathes normally

Cardiopulmonary Resuscitation (CPR) to infants

CPR is going to last all the time. Do not stop breathing or pulse control. If possible, replace the one that compresses every two minutes. Just quit CPR if the child begins to breathe normally. Keep in mind that you should not take too long between compression and inflation.

Check in turn: Consciousness. Breathing. Are there any signs of life? Does the baby touch, swallow or breathe normally? Then give the necessary help.

  • Is the child aware? Shout to the baby and nip or shake it gently in the shoulders. If the child does not respond, cry out loudly for help from the surrounding area. Put the child on the back.
  • Does the child breathe?
  • Create open airway
  • See if the chest and stomach moves and what color the child has. Listen if air flows in and out through the mouth and nose. Feel the airflow against your chin. If the child breathes normally: put it in a stable side body position. Continue to check that the baby is breathing. Alarm. If the child does not breathe: Give five slow insufflations. If it is not possible to insufflate air or if the chest is not raised when blowing, there may be some objects in the child’s throat.

The open airway can be created in two different ways: Jaw lift. Carefully bend the child’s head backwards by placing one hand on the child’s forehead. Lift the child’s jaw with the other hand’s pointer and middle finger. In younger infants it is important not to bend the head too far backwards. Bending the head back too strongly may cause airway blocking. Lift the jaw manually. Put one hand on the child’s forehead. Now use the other hand’s thumb to grab the point of the chin of the little child and the mandibel of children over a year. Hold your index finger over the chin and lift the chin upwards. Ventilations.

Infants zero to one years old

Make a jaw lift. Put your mouth over the baby’s mouth and nose. Blow slowly in air for 1-1.5 second, five times. Blow in so much air that the chest is raised and lowered. Check signs of life, any spontaneous movements, swallowing or normal breathing in conjunction with the insufflations.

Infants zero to one years old

The baby can lay on hard surfaces. Start with five insufflations. Use the pointer and middle finger and press the lower third of the sternum. Press 30 times, almost two compressions per second. Each time you push down the baby’s chest a third. Release the chest between the compressions. After 30 compressions, you make two blowouts. Then start over again, with 30 compressions followed by two insufflations. If you’re alone, call 911 (local alarm number) after three series with 30 compressions and two insufflations. Then continue with cardiovascular and pulmonary resuscitation, 30 compressions and two insufflations until the helper is in place or the child breathes normally.

Children 1 years old to puberty

Clamp the nostrils with thumb and index finger. Put your mouth over the baby’s mouth and slowly blow it in for 1-1.5 second, five times. Blow in so much air that the chest is raised and lowered. Check signs of life, movements, swallowing or normal breathing in conjunction with the insufflations .

Does the child show life signs?

If the child shows signs of life but does not breathe normally: Make 20 insufflations for one minute and then call 112. If possible, carry the child to the phone if you are alone. Then continue with insufflations. About 20 insufflations per minute are right. If the child does not show any signs of life: Give cardiac and pulmonary resuscitation (CPR).

 


Resuscitation of Critically Ill Children

Medications at cardiac arrest in children

Age03 months1 year5 years9 years12 years14 years15 years and older 
Weight3 kg5 kg10 kg20 kg30 kg40 kg50 kg> 50 kg
Epinephrine (0,1 mg/ml)* 0,01 mg/kg, 0,1 ml/kg0.30.51234510ml
Amiodarone (15 mg/ml)* 5 mg/kg,
0,33 ml/kg
11.73710131720ml
Glucose 100 mg/ml, 2 ml/kg61020406080100ml
Ringer's Acetate 20 ml/kg601002004006008001000ml
Tribonate (0,5 mmol/ml) 2 ml/kg61020406080100100ml
Defibrillation 4 J/kg12204080120150-200150-200150-360J
Endotracheal tube inner diameter33.5456777mm
*Amiodarone 50 mg/ml. 6 ml diluted with 14 ml glucose 50 mg/ml = 15 mg/ml

Drugs delivered during CPR

At asystole/bradycardia/PEA:

  • Epinephrine 0.01 mg/kg imediately
  • Repeat every four minutes

At VF/pulseless VT:

  • Epinephrine 0.01 mg /kg after third defibrillation. Repeat every four minutes.
  • Amiodarone 5 mg/kg after third defibrillation.
  • Repeat the same dose after the fifth defibrillation.

Correct reversible causes

  • Hypoxia
  • Hypovolaemia
  • Hypothermia
  • Hyper/hypokalaemia
  • Hypoglycemia
  • Cardiac tamponade
  • Pressure pneumothorax
  • Toxic conditions
  • Thromboembolic events

Sedation on a ventilator

By Fredrik Söderlund, Chief Physician, Anesthesia & Intensive Care. DSBUS, Sahlgrenska University Hospital.

Updated 2020-01-10


Objective

  • Goal is a calm child without stress or pain
  • Feel free to be fully awake if they can stand it
  • Smaller children often tolerate being awake with a tube clearly better than adults
  • It is important to explain the goal to the parents
  • Pain can be difficult to interpret (stomach cramps, for example)
  • Convince colleagues on surgery to apply an epidural as often as possible (greatly simplifies)

Treatment

  • Morphine is the standard treatment as analgesia (normally up to 30 micrograms/kg/h)
  • You can switch to ketobemidone or oxycodone after one week
  • Dexmedetomidine is now the first choice for sedation, normally 0.4 -1.4 micrograms/kg/h (Children < 3 months should probably have a maximum of 1.0 microg/kg/h)
  • Propofol can be used, preferably not for children < 1 year and preferably not > 4 mg/kg/h, however, facilitates extubation of older children
  • Phenemal (phenobarbitone) is a good supplement that rarely affects breathing or circulation; 5 mg/kg, max 3 times/day can be given

Proposed strategy for extubation

  • Turn down the opioid supply to the lowest level you think is needed, preferably the day before
  • Supplement with paracetamol
  • Lower dexmedetomidine to 0.4-0.8 micrograms/kg/h, switch to propofol or combine them
  • If midazolam is used, put this out early in the morning (a job on call)
  • When the ventilator settings allow it, turn off propofol, keep some dexmedetomidine in place, and wait for the patient to wake up
  • Larger patients can be extubated with a little propofol left (1-2 mg/kg/h) for a calmer awakening

Sedation by infusion for children

DrugInfusion doseConcentrationCaution
Dexmedetomidine0,4 - 1,4 μg/kg/h< 15 kg 4 μg/ml
> 15 kg 8 μg/ml
Starting dose usually 0.7 μg/kg/h.
Never give bolus.
Treatment time max 2 weeks.
Caution bradycardia, hyperthermia
Clonidine0,5 - 2 μg/kg/h15 μg/ml
Midazolam0,05 - 0,2 mg/kg/h< 15 kg 1 mg/ml
> 15 kg 5 mg/ml
Bolus: 0,05-0,1 mg/kg
Morphine5 - 30 μg/kg/h< 15 kg 0,1 mg/ml
> 15 kg 1 mg/ml
Bolus: 0,05-0,1 mg/kg
Propolipid1 - 4 mg/kg/h20 mg/mlChildren > 3 years.
Bolus: 1-3 mg/kg
Fentanyl0,5 - 1 μg/kg/h50 μg/mlHigher doses may need to be given.
Max 6 μg/kg/h.

Skin anesthesia (topical anesthesia)

EMLA (Medical patch: 25 mg lidocaine/25 mg prilocaine)

  • 0-3 months 1 patch 1 h, no longer!
  • 3-12 months 1-2 patches 1 h
  • > 1 year 1 or more (max. 10 patches according to surgery) 1-5 h

Rapydan (70 mg lidocaine/70 mg tetracaine)

  • Children > 3 years 1-2 patches (max 2/day) 30 min to maximum effect

Steroid Substitution for Children

Children’s steroid substitution schedule is recommended for children < 30 kg. For children weighing 30-60 kg, the half-adult schedule is recommended. Children over 60 kg are counted as adults and recommended adult schedule.

Injection betametason 1 mg/mlDose (ml)Dose (mg)
Day 12 ml x 22 mg x 2
Day 22 ml x 22 mg x 2
Day 31 ml x 21 mg x 2
Day 41 ml x 21 mg x 2
Day 50,5 ml x 10,5 mg x 1
Day 60,5 ml x 10,5 mg x 1
OrallyTablet 0,5 mgDose (mg)
Day 14 st x 22 mg x 2
Day 24 st x 22 mg x 2
Day 32 st x 21 mg x 2
Day 42 st x 21 mg x 2
Day 51 st x 10,5 mg x 1
Day 61 st x 10,5 mg x 1

 


Syringe Sizes for Pediatric Use

Recomended Syringe Sizes for Children up to 15 kg

MedicationSyringe size
Propofol 5 ml syringe
Ketamine 5 ml syringe
All muscle relaxants1 ml syringe
Fentanyl 1 ml syringe
Morphine 1 ml syringe
Alfentanil 1 ml syringe
Anticolinergics (Atropine, Glycopyrrolone)1 ml syringe
(Robinul-Neostigmine®)1 ml syringe
Sodium Thiopentone (Pentothal®) 5 ml syringe (sodium thiopentone)

Recomended Syringe Sizes for Children over 15 kg

MedicationSyringe Size
Propofol 10 ml syringe
Ketamin 10 ml syringe
All muscle relaxants3 ml syringe
Fentanyl 3 ml syringe
Morphine 3 ml syringe
Alfentanil 3 ml syringe
Anticolinergics (Atropine, Glycopyrrolone)1 ml syringe
Robinul-Neostigmine®1 ml syringe
Sodium Chloride10 ml alternativt 5 ml syringe
SuccamethoniumBranded with white syringe label with red text.
Sodium Thiopentone (Pentothal®) 10 ml syringe (thiopentalnatrium)

Thrombosis prophylaxis during immobilization

  • No immobilization prophylaxis in children before puberty
  • After this dalteparin (Fragmin) approx. 100 U/kg x 1 up to normal adult doses
  • In the treatment of pre-existing thrombosis, higher doses are often required, especially for young children. Monitor anti-Xa (should be 0.5 –1.0)
  • We also control antithrombin and keep the value > 0.7 in all heparin treatment

Total Intravenous Anaesthesia (TIVA) for Pediatric Anesthesia

Practical advice

  • Fixed placement of syringe pumps with drugs: remifentanil at the top and propofol at the bottom.
  • The syringe pump with remifentanil should be set to micrograms/kg/minute.
  • The syringe pump with propofol must be set to mg/kg/hour.
  • Check valves for infusion with remifentanil.
  • Avoid blood pressure cuff on the same arm.

Induction of anesthesia

Preoxygenation is given with 80% oxygen. The patient is ventilated with a ventilator and bag until the patient is ready for introduction of the laryngeal mask or intubation.

  • Bolus propofol 5 mg/ml (“pediatric concentration of propofol”) 3 – 6 mg/kg iv.
  • Bolus fentanyl 1 – 3 micrograms/kg iv during induction.
  • Start the infusion of remifentanil 0.5 micrograms/kg/min after the child has fallen asleep
  • Atropine 0.01 mg/kg iv is given on indication only.

If anesthesia begins with sevoflurane by inhalation (for example, when venous cannula is absent), it can be converted to TIVA after the child has fallen asleep. Half the bolus dose of propofol is then given and other medications according to previous protocols.

Intubation

  • Minimize the use of muscle relaxants.
  • Remifentanil 4 micrograms/kg usually provides good intubation conditions in combination with
  • Propofol 3.5 mg/kg
  • Note! Do not intubate when the vocal cords are centered! This can damage the vocal cords.

Maintenance

  • Remifentanil 0.5 – 1.0 micrograms/kg/min
  • Propofol 8 – 12 mg/kg/h which can be gradually reduced to 6 mg/kg/h.

The doses are adjusted in relation to the clinical picture and anesthesia depth.

Termination

Infusions of propofol and remifentantil are discontinued as the end of surgery approaches.
Remember to give bolus fentanyl 1-2 micrograms/kg iv for postoperative pain relief.

The ventilator continues to run until the patient wakes up and can be extubated or the laryngeal mask is removed.

Local anesthesia

Good local anesthesia/regional anesthesia should be given to as many patients as possible. For skin closure of surgical wounds, local wound infiltration can be given with bupivacaine 2.5 mg/kg 0.5 ml/kg.

Drug mixture

  • Remifentanil 50 micrograms/ml: Dissolve 2 mg remifentanil in 40 ml 0.9% NaCl.
  • Propofol is given at a concentration of 5 mg/ml

References

  1. Solheim A, Raeder J. Remifentanil versus fentanyl for propofol-based anesthesia in outpatient surgery in children. Outpatient surgery. March 2011; 17 – 20.
  2. Klemola UM, Hiller A. Tracheal intubation after induction of anesthesia children with propofol – remifentanil or propofol rocuronium. Can J Anaesth. 2000 September, 47 (9): 854 – 9.
  3. Procedures from Ahus: “Anesthesia for children – TIVA in patients under 16 years”, version 1.4, date 24.01.2014.

Tube Sizes for Children

Recomended sizes of Endotracheal Tubes for Children.

Tube position (cm in the corner of the mouth) = Patient length (cm)/10 + 5. Nasal tube: + 20%
Age03 months1 year5 years9 years12 years14 years> 15 years
Weight3 kg5 kg10 kg20 kg30 kg40 kg50 kg> 50 kg
Endotracheal tube inner diameter (mm)33.5456777
  • Uncuffed tube size > 2 years ≈ (4 + age/4)
  • Cuffed tube ≈ 0.5 mm smaller
  • Tube depth for children < 1 year:
    • Oral = kg/2 + 8
    • Nasal = kg/2 + 9
  • Tube depth for children > 1 year:
    • Oral = year/2 + 12
    • Nasal = year/2 + 15
  • LMA for children < 1 year should only be used by a pediatric anesthesiologist
    (however, always an alternative for difficult mask ventilation regardless of age)

Common Parenteral Medications for Children

Recommended Dosage of Parenteral Medications for Children

MedicationConcentrationDose
Adenosine1 mg/ml100 μg/kg, increased by 50 μg/kg for each dose, step up to 300 μg/kg. Quick flush. Preferred in CVC.
Epinephrine (Adrenalin)0,1 mg/mlFor anaphylaxis: 1-2 μg/kg. At heart stop: 10 μg/kg
Atropine0,5 mg/ml10 μg/kg. Max 0,5 mg/dose.
Betametasone (Betapred)4 mg/ml0,2 mg/kg. Max dose: PONV 4 mg Max dose: anafylaxi 8 mg
Calcium gluconate0,5 ml/kgMax 10 ml/dose.
Fentanyl50 μg/ml1-2 μg/kg
Furosemide10 mg/ml0,1-0,5 mg/kg
Clonidine15 μg/ml1-2 μg/kg x 3-6/day.
Midazolam1 mg/ml0,05-0,1 mg/kg
Morphine1 mg/ml0,05-1 mg/kg
Naloxone0,02 mg/ml10 μg/kg (adult 0.1-0.2 mg) Repeat as needed at 2 min intervals
Esomeprazole (Nexium)8 mg/ml0,5 mg/kg x 2
Ondansetrone2 mg/ml0,1 mg/kg. Max x 4/day.
Paracetamol10 mg/ml<1 year or 10 kg: 7.5 mg/kg.
>1 year: 15 mg/kg. Max x 4 / day
Hydrocortisone (Solu-Cortef)50 mg/ml5 mg/kg. Max 100 mg/dose.
Diazepam (Stesolid)5 mg/ml0,2-0,3 mg/kg
Klemastine (Tavegyl)1 mg/ml0,05 mg/kg. Max x 2/day. Slow infusion.
Sodium Bicarbonate (Tribonat)0,5 mmol/mlWeight x BE x 0.3 = mmol buffer. Start giving half the amount. At heart stop: 2 mmol/kg
Budesonide (Pulmicort)0,25 mg/ml 0,25 mg x 2
Salbutamol (Ventoline)1 mg/ml or 5 mg/ml0,15 mg/kg x 4 – 6 (max x 24) Max 5 mg/dose.
Micronefrin-RacepinephrineRacepinephrine conc: 22,5 mg/ml0,05 ml/kg/dose (max 0,75 ml/dose) <5 kg 0,25 ml
Remember to pull up drugs in as small syringes as possible! If the dose is <0.5 ml then pull into 1 ml syringe
These are no general ordinances but rather an aid in the work with children. All medicines must be prescribed in writing on the daily record by name, strength and amount.

Vascular access

Central vascular access

  • Do not be afraid to put CVC on anesthetized children! Waking up is trickier…
  • Check if UCG has been performed, especially in children with a syndrome (abnormal vein anatomy)
  • Technology largely as in adults for older children (> 10 kg)
  • Choose a vessel you feel comfortable with – but for smaller children, v. jug. int. dx. is safest
  • Aim with the tip of the catheter at the right atrium or the transition v cava superior/right atrium
  • Use X-ray if you are unsure

Central vascular entrances – smaller children

  • When you get backflow, remove the syringe and release the needle
  • Check that blood is still flowing back out of the needle
  • Feel free to use a Nitinol Conductor (already in the smaller CVC sets that Arrow manufactures) – safer and successfully increases the frequency
  • Remove the conductor from the plastic pretzel before you start
  • Straight end first of conductor on smaller children (the bend does not fit in the vessel)
  • Be light on your hand when inserting the conductor

CVC size (Central venous line)

  • < 10 kg / 3-5 fr / 4-6 cm
  • 10-30 kg / 5-6 fr / 6-8 cm
  • > 30 kg / 7 fr / 10-15 cm

CVC depth – IJV dx (cm)

  • 1.7 + (0.07 x cm length)

Arterial needles

  • Can be placed in the same arteries as in adults
  • Brachial artery is a good alternative to the radial artery, but can cause poor circulation in the arm
  • Femoral artery is usually best if you are in a hurry or you want high reliability (can also cause impaired circulation – should possibly be avoided in children < 3 kg)
  • Heparin is recommended in the flush drop for arterial pressure on PICU (so you can not check on APT etc. from the arterial line)
  • Ultrasound is often useful for hospitalization

Arterial needle size

  • < 6 months – 0.7 mm (yellow cannula)
  • > 6 months – 0.9 mm (blue cannula)
  • > 25 kg – adult needle