Pediatric Part 2
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Methohexital: dosing and SE
- 1-2mg/kg IV. (1%) (may cause hiccupping, burning, apnea, and extrapyramidal movement)
- Shorter elimination half-time than thiopental
- 25-30mg/kg rectal dose (10%). (may cause apnea) produces sleep in 8-10 mins.
- May cause seizures (contraindicated in children with temporal lobe epilepsy)
- 5 to 6mg/kg IV.
- Termination via redistribution into muscle and fat. (reduce doses for infants with low fat stores)
- 30mg/kg rectally if methohexital is contraindicated.
- Lipophilic (its rapid redistribution, hepatic glucuronidation, and high renal clearance account for the short duration of its effect).
- 2.9 mg/kg for infants younger than 2 years
- 2.2 mg/kg for patients 6 to 12 years old.
- May mildly decrease SBP
- Burning on induction
- IV 1-2 mg/kg.
- IM 6-10mg/kg, rectally (10 mg/kg), orally (6 to 10 mg/kg), or intranasally (3 to 6 mg/kg).
- 0.25 to 0.5 mg/kg effective sedation dose for painful procedures.
- 10mg/kg IV may be sufficient for invasive procedures
When might Ketamine be useful?
- May be used in combination with oral midazolam for sedation.
- Useful for induction in hypovolemic patients.
- Patients with cognitive impairment
What are some problems with Ketamine?
- Large patient to patient variability in response to drug.
- Increased oral secretions, vomiting, post operative hallucinations and nightmares.-can last for days in pedi patients
- Contraindicated in the presence of an active upper respiratory tract infection, increased intracranial pressure, open-globe injury, and the presence of a psychiatric or seizure disorder.
What should we know about Diazepam?
- 0.1 to 0.3 mg/kg orally usually provides excellent peak sedation within 1 hour (more rapid than adults)
- Painful on injection and poorly tolerated
- Liver is main site of degradation
- Long half life (80 hours) in neonates (contraindicated until child is 6 mos old)
Why is midazolam good in pediatrics?
- Water soluble
- The short elimination half-life (≈2 hours) in comparison to diazepam (18 hours) offers an advantage for use as a premedicant in children.
- FDA approved for use in neonates (only benzo for neonates) with half life of 6-12 hours.
Doses of Midazolam
Rapidly absorbed after intramuscular or IV (0.1 to 0.15 mg/kg, maximum of 7.5 mg), oral (0.25 to 1.0 mg/kg, maximum of 20 mg), rectal (0.75 to 1.0 mg/kg, maximum of 20 mg), nasal (0.2 mg/kg), or sublingual (0.2 mg/kg) administration.
What important interaction should we know about with Midazolam???
One important interaction is that erythromycin, calcium channel blockers, protease inhibitors, and even grapefruit juice produce a clinically important delay in midazolam metabolism because of cytochrome P450 inhibition.
What should we know about Morphine and the pediatric patient?
- Most commonly used long acting narcotic (think instead of dilaudid)
- Respiratory depression in neonates (more than meperidine)
- Permeability of blood brain barrier.
- Newborns with lower clearance of morphine (infants older than 10 days probably clear morphine at a similar rate as in adults.
- Caution with neonates in nonmonitored settings
What should we know about meperidine and pediatric patients?
- 1mg/kg less respiratory depression than morphine
- More lipophilic than morphine
- Brain brain barrier not a factor as with Morphine
What should we know about Fentanyl and pediatric patients?
- Most commonly used narcotic in infants and children
- Rapid onset and brief duration.
- Low doses-termination depends on redistribution; high doses depend on elimination.
- Stable CV response
- Neonates-longer half life with abdominal surgery
- Factors the increase or decrease hepatic blood flow
What is the dosing of Fentanyl in pediatrics?
- Full term neonate-12.5 mcg/kg having abdominal surgery vs. 100mcg/kg for cardiac surgery
- 2-10mcg/kg for most surgeries where extubation is expected.
- Fentanyl induced bradycardia (atropine or pancuronium)
- Transmucosal 5-15 mcg/kg (max 400mcg).
What should we know about Alfentanil and the pediatric patient?
- Eliminated more rapidly than fentanyl
- Pharmacokinetics are independent of dose
- Clearance may be increased in children compared to adults.
- Important patient-to-patient variability in pharmacokinetics and pharmacodynamics in neonates and in patients with impaired hepatic blood flow.
What should we know about Sufentanil and the pediatric patient?
- Cardiac anesthesia
- Age dependent kinetics (first month of life)
- Children clear drug more rapidly than adults
- Bradycardia and asystole without vagolytic drugs
What should we know about the 1/2 life and clearance of Remifentanil in the pediatric patient?
- Very brief half life
- 4 mins for 50% reduction in half life after cont infusion (adults = children).
- Age related differences in clearance and volume of distribution (not half life)
- NEONATES CLEAR DRUG MORE RAPIDLY THAN ADULTS
Does remifentanil have a lot of patient to patient variability? Why is this?
Small patient to patient variability because it is broken down by non- specific cholinesterases (tissue and plasma) --not dependent on liver flow/function
What is the dosing for Succinylcholine?
- Dose for infants (2.0mg/kg) twice that for adults and older children (1.0mg/kg).
- Can be given intramuscularly 5mg/kg in infants/ 4mg/kg for children older than 6 mos.
What medication should we give w/succinylcholine?
- Cardiac arrest may follow first or repeated doses. (give with atropine---severe bradycardia!)
- Atropine: IV administration reduces the incidence of arrhythmias but not IM atropine. IM atropine may reduce the bradycardia but not the incidence of arrhythmias. Atropine should therefore be given IV before succs, including in teenagers
We still use succinylcholine in pediatrics for RSI but in general we try to stay away from it, why??
Potential for rhabdomyolysis, hyperkalemia, masseter spasm, MH.
What should we know about the non-depolarizing MR in pediatrics??? (regarding metabolism/clearance)
- Cisatricurium– Hoffman elimination Vecuronium– No histamine release. Duration of action= to Pancuronium in newborns.
- Mivacurium—Metabolized by plasma cholinesterases.
- Rocuronium—Can be used for RSI. Can be given intramuscularly.– tachycardia may be desired (vagolysis)
What should we remember about the non-depolarizing MR in infants/neonates?
- Infants are generally more sensitive and response varies to a greater degree.
- Initial dose similar but slower excretion and prolonged effects in neonates
What is a neonate???
Neonate—First 30 days of an infant’s life
What are the three main shunts???
3 main shunts- placenta, foramen ovale, and ductus arteriosus
Transition from fetal circulation to adult circulation happens with clamping of umbilical cord and initiation of ventilation. What happens to the PVR and the shunts???
- Takes 3 to 4 days for pulmonary vascular resistance to decrease to normal levels.
- Constriction of the ductus arteriosis
- Ductus arteriosis and foramen ovale usually close permanently within the first few months of life.
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