Chapter 10

### Key Points

1. Analgesic dosing is administered to perioperative children based on age-specific pain assessment scoring.

2. Analgesics available to children include all dosage routes, specific drug concentrations, and dosing frequencies based on pediatric age-specific drug distribution and utilization differences.

3. Regional anesthetic techniques can often be combined with perioperative analgesics, assuring continued pain control well into the postoperative period.

4. Use of the patient-controlled analgesia (PCA) is both effective and safe in pediatric pain control.

5. Clear fluids administered PO in healthy infants and children 3 to 4 hours before the induction of general anesthesia is safe.

6. The uptake of inhalational anesthetics occurs more rapidly in children than in adults.

### Goals of Pediatric Anesthesia

The goals of pediatric anesthesia are to maintain physiological homeostasis, providing analgesia (elimination of the sensation of pain), amnesia (loss of memory), and akinesia (absence of movement) during the operative procedure.

### Anesthetic Risks

Complications associated with anesthesia in children are numerous. They can include sore throat, dental damage, nausea and vomiting, aspiration, drug reactions or anaphylaxis, dysrhythmias, and unanticipated intraoperative crises (eg, airway, bleeding) that could cause further morbidity and even death.

The American Society of Anesthesiologist (ASA) Physical Status Classification provides a means to describe and stratify the patient's preoperative physical condition. It is not a risk assessment system and has never been validated as such, but rather is designed to concisely describe the health status of the patient prior to the induction of anesthesia. There are 6 categories within this classification system: I, healthy patient; II, mild systemic disease with no functional limitations; III, severe systemic disease with definite functional limitation; IV, severe systemic disease that is a constant threat to life; V, moribund patient who is not expected to survive 24 hours with or without surgery; and VI, brain-dead patient who is an organ donor. A classification of “E” is added to any of the above categories if the surgical procedure is emergent. The rate of complications may increase with ASA scores III and above and the number and nature of coexisting diseases. There may also be an increased rate of complications for emergency procedures, and when the duration of preoperative fasting was less than 8 hours.

A study beginning in 1954 and reflecting more than 150,000 patients from 0 to 20 years of age indicated a mortality of 1.8/10,000 in the 0- to 10-year age range from 1954 to 1966 and decreasing to 0.8/10,000 in the same age range from 1966 to 1978. From 1966 to 1978, the mortality was 0.6/10,000 in the 10- to 20-year age range. In the current era, anesthetic mortality in adults has been estimated to have decreased an additional order of magnitude, but good pediatric data are still lacking. Although studies have placed the perioperative mortality risk at 0.2 to 1.8/10,000, these numbers reflect the unstratified increased risk, including infants with congenital heart disease, ...

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