Anesthesia for Pediatric General Surgery

Abstract

Children having general surgery present an enormous diversity of ages, conditions and procedures. Inguinal herniotomy is commonly performed in preterm infants. Issues related to anesthesia in these infants include the choice between general or regional anesthesia, management of the airway, providing analgesia and reducing the risk of apnea after anesthesia. Laparoscopic surgery is also frequently performed in children, perhaps most commonly for appendicectomy. Young children are susceptible to effects of pneumoperitoneum, and inflation pressures are kept at 10 mmHg in young children, and lower in neonates. Pyloromyotomy is also performed laparoscopically, usually in infants aged between 2 and 8 weeks. Pyloric stenosis causes a hypochloremic hypokalemic metabolic alkalosis, and the infant must be rehydrated with a chloride-containing fluid before surgery can safely proceed. Recent discussion has focused on whether modified rapid sequence induction or inhalational induction is best. Laparotomies in children are uncommon, but performed for acute conditions such as intussusception, which can make the infant extremely unwell and challenging to anesthetize, through to major surgery for tumors including Wilms tumor and neuroblastoma. Urinary tract anomalies are not uncommon in children. Sometimes they are detected by ultrasound in utero, and other times they may present with infections. Obstruction of the ureter may cause hydronephrosis, and some children require pyeloplasty surgery, while others require ureteric reimplantation into the bladder wall. These procedures are often performed on infants or young children, and analgesia after surgery is the main issue for anesthesia.

Review Questions

• 1. An 8 week old baby has pyloric stenosis. Fluid resuscitation has been performed and the baby is fit for anesthesia.

  • (a) What induction technique will you use and why?

  • (b) What size ETT would you use for intubation?

  • (c) What postop analgesia would you use, and what is the rationale for your treatment?

• 2. A 7 month old has a short history of vomiting and blood stained stools. You suspect intussusception. The infants pulse is 140 bpm, the peripheries are cool and blood pressure is 78/50 mmHg.

  • (a) Describe your immediate management

  • (b) What are the possible options if you are unable to insert a peripheral IV?

• 3. A 6 week old infant (born at 36 weeks gestation) presents for herniotomy. Can the infant be discharged home on the day of surgery? Justify your answer.

• 4. An otherwise well 7 year old boy who weighs 25 kg requires laparoscopic appendicectomy. List the drugs and doses you would use for induction. Discuss the steps during your induction up to intubation of the trachea.

• 5. Describe the anesthesia and analgesia considerations in an 18 month old boy for elective day case orchidopexy.