Pediatric anesthesia is unique not just for its impossibly tiny equipment like this little endotracheal tube or this IV catheter that's only barely bigger than human hair, but also for special considerations for emergency situations, including reasons why we would cancel the surgery if a patient recently had a respiratory infection, whereas we wouldn't necessarily do that for adults. My name is Max Feinstein and I'm an anesthesiologist filming here at the Mount Sinai Hospital in New York City. and in this video I explain some of the unique considerations for pediatric anesthesiology.
If you find this video interesting or helpful, I'd really appreciate it if you liked it and subscribed to the channel. Let's dive in. The delivery of anesthetics can be quite different for pediatric patients, starting with the very first medication that we administer.
It's common for anesthesiologists to give a relaxing medication called midazolam, just before going into the operating room. While adults typically receive this medication through an IV, kids who won't tolerate having an IV placed will take this medication by mouth. Once we're in the operating room and it's time to induce general anesthesia, adults will typically get their medicine again through an IV. But because we don't want to traumatize little kids, we won't typically place IVs in them while they're awake.
So they'll start by getting their anesthesia through a mask that looks like this. The medications that kids receive through a mask is inhaled and that's what causes them to go under anesthesia. While it's possible to induce general anesthesia in adults using a mask, it's generally not preferable for a number of reasons which I get into in a video that I made which you can watch by clicking this link right here. After pediatric patients inhale the medication to have them go under anesthesia, typically the next step is placing an IV. Of course, the IVs that are used in pediatric populations tend to be much smaller, like this 24-gauge IV, which compares to this 20-gauge IV that would be used more commonly for adults.
But the size of the IV is actually not the most important difference for IVs in pediatric patients. It's the fact that any amount of air that goes through an IV could potentially cause a stroke or other problems for kids, whereas it wouldn't necessarily do that for adults. Obviously, for all patients, we try to avoid any amount of air going through an IV, but for pediatric patients, it's more common to have a hole in the heart that would allow air to travel up to the brain or other parts of the body, whereas that wouldn't necessarily happen in adults.
This is an important part of the video to point out that this is not medical advice. It's just a YouTube video. If you need medical advice, you should see your doctor.
Medication dosing for pediatric patients can also be quite different compared to that for adults. For adults, there are often medication doses that are more or less standard depending on what effect you want to achieve. For example, it's common to give 2 mg of IV midazolam prior to induction of anesthesia, and then several minutes prior to intubating, delivering 100 micrograms of fentanyl. These are more or less standard doses that are used for adults, relatively independent of how much they weigh.
But for pediatric patients, virtually all of the medications are dosed based on a patient's weight. So the difference being that instead of delivering a certain number of milligrams of midazolam, I would give 0.5 milligrams per kilogram of body weight of midazolam for a patient to take by mouth. And then for fentanyl, depending on the circumstances, I would want to give anywhere between 2 to 5 micrograms per kilogram of body weight. These differences mean that pediatric anesthesiologists need to have thoroughly memorized all of the weight-based drug dosing for everything that's used in an operating room. When things go wrong in a pediatric operating room, they tend to go wrong much faster than they would in an adult operating room.
This owes to the fact that pediatric patients tend to have less functional reserve than adult patients. For example, if we have an adult patient whose lungs are filled with 100% oxygen and they don't breathe, they'll probably maintain their oxygen saturation for 7, 8, 9 minutes depending on how healthy they are. Compare that with a healthy one-day-old who, even with their lungs filled with 100% oxygen, would probably start to desaturate after 10, 15, maybe 20 seconds. Suffice it to say that pediatric anesthesiologists need to be prepared to immediately treat emergencies because there tends to be a much smaller margin of safety, as far as time is concerned, compared to adult operating rooms. For that reason, it's common practice in pediatric operating rooms to have certain emergency medications already drawn up in syringes that are on intramuscular needles just in case there's a problem with IV access.
The two most common pediatric emergency medications include one called atropine which has the effect of increasing a patient's heart rate. This is really important because a patient's blood pressure is actually dependent more on their heart rate than it would be for an adult. The other emergency medication in the pediatric anesthesia world is a fast-acting paralytic called succinylcholine.
We keep this around because if there's an issue with the patient's airway, the margin of safety for us to be able to intervene is very small in terms of time. So this rapid-acting paralytic allows us to open the vocal cords really quickly so that we can establish a secure airway, for example using an endotracheal tube. It's not common to have to use these medications in pediatric anesthesia, but when the need arises there's basically no time to think about it, so it's essential to have these ready to go. In pediatric anesthesiology, one of the risk factors for an airway emergency is a respiratory infection in the last two to three weeks. That's associated with an increased risk of a phenomenon called laryngospasm, which is where the vocal cords, which can be open like this, end up closing.
which make it impossible for air to get into the patient's lungs. And because pediatric patients generally can't tolerate apnea for very long, this can quickly lead to a heart rate decreasing and can even lead to a cardiac arrest. For this reason, pediatric anesthesiologists tend to postpone surgeries if there's been a recent respiratory illness, unless it's an urgent or emergent surgery where the risk of postponing would actually cause a really significant problem.
Hi, surgery? Yes, anesthesia, what is it? We're going to have to cancel the case. Is he okay?
Yeah, he's in shock. This is normal. Why is he in shock? You just took surgery away from a surgeon. They're not used to that.
Another emergency that's more commonly associated with pediatric anesthesiology is a condition called malignant hyperthermia. This is a hypermetabolic state that can lead to severe injury and even death if not treated appropriately. Malignant hyperthermia is extremely rare and is a reaction to certain anesthesia medications like succinylcholine and some of the inhaled agents like sevoflurane or isoflurane.
I actually made a separate video going into a lot of detail about malignant hyperthermia which you can watch by clicking this link right here. The equipment that's used in pediatric anesthesiology is fundamentally very similar to that for adults. with the major difference of course being size. For example, here is a Macintosh 3 blade that is commonly used to intubate average size adults.
Compare that with this Miller 00 blade that's used to intubate small newborn babies. Speaking of intubating, here is a 7.5 millimeter internal diameter endotracheal tube that's often used for intubating adults. Compare that with this 2.5 millimeter internal diameter tube that can be used for intubating small neonates.
Another vital difference in pediatric operating rooms is the choice of scrub cap that the anesthesiologists wear. Because of course who doesn't love a surfing dog with sunglasses or an ear that's dancing with the top hat? Because that's a thing that kids like. And you can't forget about llamas because who doesn't love llamas?
In this video I've barely scratched the surface in terms of addressing differences between pediatric and adult anesthesiology. There are large textbooks dedicated to pediatric anesthesiology, and there's special training that anesthesiologists can pursue after completing residency to become pediatric anesthesiologists. That's actually what I'm doing right now, so in the not-too-distant future, I will be a pediatric anesthesiologist. If you enjoyed this video, you might want to check out this video that I made where I walked through the basic setup for pediatric anesthesiology in an operating room. Thanks very much for watching, I'll see you next time.