哈尔滨医科学临床麻醉学课件小儿麻醉-PP

PediatricAnesthesia

DepartmentofanesthesiologyCuiXiaoGuangPediatricAnesthesiaDepartmen1Theprovisionofsafeanesthesiaforpediatricpatientsdependsonaclearunderstandingofthephysiologic,pharmacologic,andpsychologicaldifferencesbetweenchildrenandadults.Theprovisionofsafeanesth2Neonates:0–1monthsInfants:1–12monthsToddlers:1–3yearssmallchildren:4–12yearsNeonates:0–1months3DEVELOPMENTALPHYSIOLOGYOFTHEINFANTDEVELOPMENTALPHYSIOLOGYOFTH4Thepulmonarysystem1Therelativelylargesizeoftheinfant'stongue

ThelarynxislocatedhigherintheneckTheepiglottisisshapeddifferently,beingshortandstubbyThevocalcordsareangledTheinfantlarynxisfunnelshaped,thenarrowestportionoccurringatthecricoidcartilage:uncuffedendotrachealtubes;patientsyoungerthan6years.Thepulmonarysystem1Therela5哈尔滨医科学临床麻醉学课件小儿麻醉-PP6Thepulmonarysystem2Alveoliincreaseinnumberandsizeuntilthechildisapproximately8yearsold.Functionalresiduralcapacity(FRC):thesamewithadult;inductionandpalinesthesiaofanesthesiaisrapidA-aDO2islarger:functionalairwayclosureLimitsoxygenreserves:hypoxemia.Theworkofbreathing:(Inprematureinfants)threetimesofadults,increasedbycoldstressorsomedegreeofairwayobstruction.RR:twotimesofadultsThepulmonarysystem2Alveoli7Thepulmonarysystem3Tidalvolume(VT)islittle;physiologicaldeadspaceis30%ofVTAirwayresistanceincreasing:secretion,upperairwayinfectionDiaphragmaticandintercostalmusclesdonotachievetheadultconfigurationoftypeImusclefibersuntilthechild2yearsold: apneaorcarbondioxideretentionandrespiratoryfailure.Infantshaveoftenbeendescribedasobligatenasalbreathers:<5monthsofage.Thepulmonarysystem3Tidalvo8TheCardiovascularSystem1Inuterus:foramenovale,ductusarteriosus(right→left)Atbirth:thefetalcirculationbecomesanadult-typecirculation.--transitionalcirculationProlongedtransitionalcirculation:prematurity,infection,acidosis,pulmonarydiseaseresultinginhypercarbiaor hypoxemia(aspirationofmeconium), hypothermia,congenitalheartdisease.TheCardiovascularSystem1Inu9TheCardiovascularSystem2Themyocardialstructureoftheheartislessdeveloped,producelesscompliantventriclesThisdevelopmentalmyocardialimmaturity: sensitivitytovolumeloading, poortoleranceofincreasedafterload, heartrate-dependentcardiacoutput.TheCardiovascularSystem2The10TheCardiovascularSystem3Bradycardiaandprofoundreductionsincardiacoutput:

activationoftheparasympatheticnervous systemhypoxiaanestheticoverdoseThesympatheticnervoussystemandbaroreceptorreflexesarenotfullymature.TheCardiovascularSystem3Brad11TheKidneysRenalfunctionismarkedlydiminishedinneonatesandfurtherdiminishedinpretermbabiesbecauseoflowperfusionpressureandimmatureglomerularandtubularfunction.Nearlycompletematuration:approximately20weeksafterbirthCompletematuration:about2yearsofagedehydrationTheKidneysRenalfunctionism12TheLiver1Thefunctionalmaturityoftheliverissomewhatincomplete.Mostenzymesystemsfordrugmetabolismaredevelopedbutnotyetinduced(stimulated)bythedrugsthattheymetabolize.Jaundice:decreasedbilirubinbreakdownTheLiver1Thefunctionalmat13TheLiver2Aprematureinfant'sliverhasminimalglycogenstoresandisunabletohandlelargeproteinloads:

hypoglycemia

acidemia

failuretogainweightwhenthediet containstoo muchprotein.Thelowerthealbuminvalue,thelessproteinbindingandthegreaterthelevelsoffreedrug.TheLiver2Aprematureinfant'14TheGastrointestinalSystemAtbirth,gastricpHisalkalotic;afterbirththesecondday,pHisinthenormalTheabilitytocoordinateswallowingwithrespirationdoesnotfullymatureuntiltheinfantis4to5monthsofage:gastroesophagealrefluxIfadevelopmentalproblemoccurswithinthegastrointestinalsystem,symptomswilloccurwithin24to36hoursofbirth.Upper--vomitingandregurgitation;Lower--abdominaldistentionandfailureto passmeconium.TheGastrointestinalSystemAt15ThermoregulationThinskin,lowfatcontent,andahighersurfacerelativetoweightallowgreaterheatlosstotheenvironmentinneonates.–保温Thermogenesis:shiveringandnonshivering(metabolismofbrownfat).Generalanesthesiaaffectsthemetabolismofbrownfat.--hypothermiaHypothermia:delayedawakeningfromanesthesia,cardiacirritability,respiratorydepression,increasedpulmonaryvascularresistance,andaltereddrugresponses.ThermoregulationThinskin,low16CentralnervoussystemMorefatisinthecentralnervoussystemPermeabilityofBloodbrainbarrierisgreat: opioid—decrement bilirubin—kernicterusMAC↑CentralnervoussystemMorefat17PharmacologicalDifferencesTheresponsetomedications:bodycomposition,proteinbinding,bodytemperature,distributionofcardiacoutput,functionalmaturityoftheheart,maturationoftheblood-brainbarrier,therelativesize(aswellasfunctionalmaturity)ofthe liverandkidneys,thepresenceorabsenceofcongenitalmalformationsPharmacologicalDifferencesTh18Alterationsinbodycompositionhaveseveralclinicalimplicationsforneonates

adrugthatiswatersoluble:largervolumeofdistributionandlargerinitialdose(e.g.,succinylcholine);lessfat:adrugthatdependson redistributionintofatforterminationofitsactionwillhavealongerclinicaleffect(e.g.,thiopental);adrugthatredistributesintomuscle:longerclinicaleffect(e.g.,fentanyl);OthersAlterationsinbodycompositio19InhaledAnestheticsNitrousoxideHalothaneEnfluraneIsofluraneSevofluraneDesfluraneInhaledAnestheticsNitrousox20Nitrousoxidelowerdissolubility:含气间隙的体积增大neonate:pneumothorax,emphysemacongenitaldiaphragmaticherniaor acromphalusnecroticenteritisNitrousoxidelowerdissolubili21EnfluraneIntheintroductionofanesthesia: breathholding,cough,laryngospasmAfteranesthesia:seizure-likeactivityEnfluraneIntheintroduction22IsofluraneIntroductionofanesthesiaandanalepsia: rapidrespiratorydepression,coughing,laryngospasmAfterextubate: incidenceoflaryngospasm<enfluraneIsofluraneIntroductionofane23Sevofluraneinductionisslightlymorerapidanesthesiaissteadyrespiratorytractirritation:smalltheproductionoftoxicmetabolitesasaresultofinteractionwiththecarbondioxideabsorbentmustbeconsidered.Introductionandshortanesthesia:sevofluraneProlongedanesthesia:electotheranestheticsSevofluraneinductionisslig24Desfluranerespiratorytractirritation:strong laryngospasm(≅50%)duringthe gaseousinductionofanesthesiaConcernforthepotentialforcarbon monoxidepoisoningHypertensionandtachycardiaDesfluranerespiratorytracti25IntravenousanestheticsKetamineThiopentalPropofolEtomidateBenzodiazepines:diazepam,midazolamOpioids:morphine,fentanyl,alfentanil, sufentanil,remifentanilIntravenousanestheticsKetamin26Ketamine1Routesofadministration:intravenous:2mg/kgintramuscular:5to10mg/kgrectally:10mg/kgorally:6to10mg/kgintranasally:3to6mg/kgKetamine1Routesofadministra27Ketamine2Undesirablesideeffects:increasedproductionofsecretionsvomitingpostoperative"dreaming"hallucinationsapnealaryngospasmincreasedintracranialpressureincreasedintraocularpressureKetamine2Undesirablesideeff28ThiopentalIntravenous:2.5%thiopental,5to6mg/kgTerminationofeffectoccursthroughredistributionofthedrugintomuscleandfatThiopentalshouldbeusedinreduceddoses(2to4mg/kg)inchildrenwhohavelowfatstores,suchasneonatesormalnourishedinfants.ThiopentalIntravenous:2.5%29PropofolPropofolishighlylipophilicandpromptlydistributesintoandoutofvessel-richorgans.Shortduration:rapidredistribution,hepaticglucuronidation,andhighrenalclearance.Dose:1-2mg/kg;higherininfantsyoungerthan2yearsPain:lidocaine,ketaminePropofolPropofolishighlylip30EtomidatePain,bucking.NocommonlyusedEtomidatePain,bucking.31Diazepam0.1-0.3mg/kg,orallyprovides;mayalsobeadministeredrectallyhasanextremelylonghalf-lifeinneonates (80hours)Contraindicat:untiltheinfantis6monthsof ageoruntilhepaticmetabolicpathways havematured.Diazepam0.1-0.3mg/kg,orally32MidazolamMidazolamiswatersolubleandthereforenotusuallypainfulonintravenousadministration.Administration:intravenous:0.05to0.08mg/kg,maximumof 0.8mg(weight<10kg)intramuscular:0.1to0.15mg/kg,maximumof 7.5mgoral:0.25to1.0mg/kg,maximumof20mgrectal:0.75to1.0mg/kg,maximumof20mgnasal:0.2mg/kgsublingual:0.2mg/kgMidazolamMidazolamiswaters33FentanylFentanyl:rapidonset;briefdurationofactionDosage:patientage,thesurgicalprocedure, thehealthofthepatient,andtheuseof anestheticadjuvants.FentanylFentanyl:34AlfentanilEliminate:morerapidlythanfentanylPharmacokinetics:independentofdoseMarginofsafety:thegreaterthe administereddose,thegreaterthe elimination.Clearanceofalfentanilmaybeincreasedin childrenincomparisontoadultsAlfentanilEliminate:morerap35SufentaniluseprimarilyforcardiacanesthesiaChildrenareabletoclearsufentanilmore rapidlythanadultsdo.Bradycardiaandasystole:whenavagolytic drugwasnotadministered simultaneously.Sufentaniluseprimarilyforc36RemifentanilOftenuseinpediatricanesthesiaRemifentanilOftenuseinpedia37MuscleRelaxants

DepolarizingMuscleRelaxant:succinylcholineNondepolarizingMuscleRelaxants:Pancuronium,Vecuronium,Atracurium,Pipecuronium,RocuroniumMuscleRelaxantsDepolarizing38Succinylcholinethedoserequiredforintravenousadministrationininfants(2.0mg/kg)isapproximatelytwicethatforolderpatientsIntravenousadministrationofatropinebeforethefirstdoseofsuccinylcholinemayreducetheincidenceofarrhythmiasSuccinylcholinethedoserequir39PancuroniumusefulforlongerproceduresnohistamineisreleasedThedisadvantage:tachycardiaAdministration:0.1mg/kgPancuroniumusefulforlonge40VecuroniumVecuroniumisusefulforshorter proceduresininfantsand childrennohistamineisreleasedAdministration:0.1mg/kgDuration:20–30minVecuroniumVecuroniumisuseful41AtracuriumUsefulforshorterproceduresininfantsandchildrenParticularlyusefulinnewbornsandpatientswithliverorrenaldisease.Why?

Administration:0.3–0.5mg/kgDuration:>30minAtracuriumUsefulforshorterp42RocuroniumRocuroniumhasaclinicalprofilesimilartothatofvecuroniumandatracuriumAdvantage:canbeadministeredintramuscularlyRocuroniumRocuroniumhasacl43PreoperativePreparation(1)

Thepreoperativevisitandpreparationofthechildforsurgeryaremoreimportantthanthechoiceofpremedication

chartreview,physicalexamination,andfurnishingofinformationregardingtheapproximatetimeandlengthofsurgeryPreoperativePreparation(1)Th44PreoperativePreparation(2)evaluatesthemedicalconditionofthechild,theneedsoftheplannedsurgicalprocedure,andthepsychologicalmakeupofthepatientandfamilyexplainingreatdetailwhatthechildandfamilycanexpectandwhatwillbedonetoensuretheutmostsafetyPreoperativePreparation(2)eva45Fasting

milkandsolids:before6hoursclearfluidsupto2-3hoursbeforeinductionInfantswhoarebreast-fedmayhavetheirlastbreastmilk4hoursbeforeanestheticinductionFastingmilkandsolids:befor46Premedication(1)Theneedforpremedicationmustbeindividualizedaccordingtotheunderlyingmedicalconditions,thelengthofsurgery,thedesiredinductionofanesthesia,andthepsychologicalmakeupofthechildandfamilyPremedication(1)Theneedfor47Premeditation(2)Apremedicationisnotnormallynecessaryfortheusual6-month-oldchildbutiswarrantedfora10-to12-month-oldwhoisafraidtobeseparatedfromparentsOralmidazolamisthemostcommonlyadministeredpremedication.Anoraldoseof0.25to0.33mg/kg(maximum,20mg)Premeditation(2)Apremedicati48Premeditation(3)Premedicationsmaybeadministeredorally,intramuscularly,intravenously,rectally,sublingually,ornasallyAlthoughmostoftheseroutesareeffectiveandreliable,eachhasdrawbacksPremeditation(3)Premedication49MeritsanddrawbacksOralorsublingual:nothurtbutmayhaveaslowonsetorbespitoutIntramuscularandIntravenous:painfulandmayresultinasterileabscessRectal:makethepatientfeeluncomfortableNasal:irritating,althoughabsorptionisrapidMeritsanddrawbacksOralorsu50Premeditation(4)Midrangedosesofintramuscularketamine(3to5mg/kg)combinedwithatropine(0.02mg/kg)andmidazolam(0.05mg/kg)willresultinadeeplysedatedpatientHigherdosesofintramuscularketamine(upto10mg/kg)combinedwithatropineandmidazolammaybeadministeredtopatientswithanticipateddifficultvenousaccesstoprovidebetterconditionsforinsertionoftheintravenousline

Premeditation(4)Midrangedose51InductionofAnesthesia

Themethodofinducinganesthesiaisdeterminedbyanumberoffactors:

◆themedicalconditionofthepatient,

◆thesurgicalprocedure,

◆thelevelofanxietyofthechild,◆theabilitytocooperateandcommunicate (becauseofage,developmentaldelay, languagebarrier),◆thepresenceorabsenceofafullstomach, andotherfactorsInductionofAnesthesiaTheme52RectalInductionofAnesthesiaRectaladministrationof10%methohexitalreliablyinducesanesthesiawithin8to10minutesin85%ofyoungchildrenandtoddlersThemainadvantage:thechildfallsasleepintheparent‘sarms,separatesatraumaticallyfromtheparents.Themaindisadvantage:drugabsorptioncanbeeithermarkedlydelayedorveryrapidRectalInductionofAnesthesia53IntramuscularInductionofAnesthesiaManymedications,suchasketamine(2to10mg/kgcombinedwithatropineandmidazolam),ormidazolamalone(0.15to0.2mg/kg),areadministeredintramuscularlyforpremedicationorinductionofanesthesiaThemainadvantage:reliabilitythemaindisadvantage:painfulIntramuscularInductionofAne54IntravenousInductionofAnesthesiaIntravenousinductionofanesthesiaisthemostreliableandrapidtechniqueIntravenousinductionmaybepreferablewheninductionbymaskiscontraindicated(e.g.,inthepresenceofafullstomach)Themaindisadvantage:painfulandthreateningforthechildIntravenousInductionofAnest55TheDifficultAirwayDifficultintubation:maintainspontaneousrespirations;placingastyletintheendotrachealtube;fiberopticbrochoscope.

TheDifficultAirwayDifficult56TheChildwithStridor(1)expiratorystridor:intrathoracicairwayobstruction,.suchas:bronchiolitis,asthma,intrathoracic foreignbodyinspiratorystridor:extrathoracicupperairwayobstruction,suchas:epiglottitis,laryngotracheobronchitis, laryngealforeignbody

TheChildwithStridor(1)expi57

Whenachildhasupperairwayobstruction(asinepiglottitis,laryngotracheobronchitis,andextrathoracicforeignbody)(shadedarea)andstrugglestobreatheagainstthisobstruction,dynamiccollapseofthetracheaincreases

Whenachildhasupperairway58TheChildwithStridor(2)maintainingspontaneousrespirationInductionofanesthesiawithhalothaneorsevofluraneinoxygenbymaskWiththepatientlightlyanesthetizedandafterinfiltrationoflocalanesthetic,anintravenouslineisinsertedIfstridorworsensormildlaryngospasmoccurs,thepop-offvalveisclosedsufficientlytodevelop10to15cmH2Oofpositiveend-expiratoryairwaypressure.TheChildwithStridor(2)main59

Whenachildhasupperairwayobstructioncausedbylaryngospasm(A)ormechanicalobstruction(B),theapplicationofapproximately10cmH2Oofpositiveend-expiratorypressure(PEEP)duringspontaneousbreathingoftenrelievestheobstruction.Thatis,PEEPhelpskeepthevocalcordsapart(A)andtheairwayopen(B,

brokenlines)

Whenachildhasupperairway60TheChildwithStridor(3)Achildwithlaryngotracheobronchitisorepiglottitisusuallyrequiresanuncuffedendotrachealtubethatis0.5to1.0mm(internaldiameter)smallerthannormaltotalairwayobstructionoccurandmaskventilationorendotrachealintubationnotbepossible-----tracheotomyTheChildwithStridor(3)Ach61TheChildwithaFullStomach1ChildrenwithafullstomachmustbetreatedthesameasadultswithafullstomachchildmaybeuncooperativeandrefusetobreatheoxygenbeforeinductionofanesthesiaTheChildwithaFullStomach62TheChildwithaFullStomach2enrichtheenvironmentwithahighflowofoxygenAdditionalequipment:twosuctioncatheters,twoappropriatelysizedlaryngoscopesWhilethechildisbreathingoxygen,atropine(0.02mg/kg,upto0.6mg)maybeadministeredintravenously

cricoidcartilage

TheChildwithaFullStomach63EndotrachealTubesFormostchildren,theproper-sizeendotrachealtubeandtheproperdistanceofinsertionrelativetothealveolarridgeofthemandibleormaxillaaremoderatelyconstant.EndotrachealTubesFormostchi64哈尔滨医科学临床麻醉学课件小儿麻醉-PP65Tubediameter(inmm)=age/4+4Infant3monthsto1year:10cmChild1year:11cmChild2year:12cmLengthoftube(incm)=age/2+12thetipoftheendotrachealtubeshouldpassonly1–2cmbeyondaninfant'sglottis.Tubediameter(inmm)=age/4+66TheDedicatedPediatricEquipmentRendell-Baker-SoucekmaskAyresTtubeJacksonReesimprovedtypeofAyresTtube:havereservoirbag;airflow:[1000ml+100ml×BW(kg)]/min(weight<10kg)LaryngealmaskTheDedicatedPediatricEquipm67EpiduralanesthesiaEpiduralblockprocedures:sacralintervertebralapproach(1),lumbarapproach(i.e.,midlineroute)(2),andthoracicapproach(i.e.,midlineroute)(3).EpiduralanesthesiaEpiduralb68LocalAnesthetics0.8%～1.5%lidocaine0.1%～0.2%tetracaine0.25%～0.5%bupivacaine0.25%～0.5%ropivacaineLocalAnesthetics0.8%～1.5%li69CaudalanesthesiaCaudalblockprocedure.A,Insertionoftheneedleatrightanglestotheskininrelationtothecoccyx(1)andthesacrococcygealmembrane(2).B,Cephaladredirectionoftheneedleafterpiercingthesacrococcygealmembrane.

CaudalanesthesiaCaudalblock70Spinalanesthesia-

*

LocalAnesthetic

0–5kg

5–15kg

>15kg

Plaintetracaine(1%)

Dose(mg/kg)

0.5

0.4

0.3

Volume

(mL/kg)

0.05

0.04

0.03

Duration(min)

75

80

85

Tetracaine(1%)withepinephrine

Dose(mg/kg)

0.5

0.4

0.3

Volume(mL/kg)

0.05

0.04

0.03

Duration(min)

120

120

125

Bupivacaine(0.5%)

Dose(mg/kg)

0.5

0.4

0.3

Volume(mL/kg)

0.1

0.08

0.06

Duration(min)

65–75

70–80

75–85

Spinalanesthesia-*LocalA71AxillaryapproachesAxillaryapproachestothebrachialplexus:classicapproach(A)andtranscoracobrachialisapproach(B),indicatingthepectoralismajormuscle(1),axillaryartery(2),andcoracobrachialismuscle(3).AxillaryapproachesAxillary72哈尔滨医科学临床麻醉学课件小儿麻醉-PP73Dose-

VolumesforSingle-ShotProceduresbyWeight

Block

2–10kg(mL/kg)

15kg(mL)

20kg(mL)

25kg(mL)

30kg(mL)

40kg(mL)

50kg(mL)

60kg(mL)

>70kg(mL)

Parascalene

1

12.5

15

17.5

20

22.5

25

27.5

30

Interscalene

1

12.5

15

17.5

20

22.5

25

27.5

30

Peri-subclavian

1

12.5

15

17.5

20

22.5

25

27.5

30

Axillary

0.5

7.5

10

10

12.5

15

17.5

20

25

Coracoid

0.5

7.5

10

10

12.5

15

17.5

20

25

Lumbarplexus

*

1

15

17.5

20

20

20

20

20

20

Femoral

0.7

8

12

15

15

17.5

20

22.5

25

Fasciailiaca

1

12.5

15

17.5

20

22.5

25

27.5

30

Proximalsciatic

1

15

17.5

20

22.5

25

27.5

30

32–35

Poplitealfossa

0.3

4

5

6

7.5

10

10

10

10

Dose-VolumesforSingle-S74MonitoringThecomplexityofmonitoringappliedtopediatricpatientsmustbeconsistentwiththeseverityoftheunderlyingmedicalconditionandtheplannedsurgicalprocedure.MonitoringThecomplexityofmo75RoutineMonitoringprecordialstethoscope,

↘esophagealstethoscope,bloodpressurecuff,electrocardiogram,temperatureprobe,pulseoximeter,end-tidalcarbondioxidemonitorRoutineMonitoringprecordial76InvasiveMonitoringArterialcatheterCentralvenouscatheterInvasiveMonitoringArterialc77IntravenousFluidthehighmetabolicdemandsthehighratioofbodysurfaceareatoweight.IntravenousFluidthehighmeta78Thebasisforcalculating-

Weight(kg)

HourlyFluidRequirements(mL)

24-hrFluidRequirements(mL)

<10

4mL/kg

100mL/kg

11-20

40mL+2mL/kg>10kg

1000mL+50mL/kg>10kg

>20

60mL+1mL/kg>20kg

1500mL+20mL/kg>20kg

Thebasisforcalculating-W79OtherFluiddeficits,Third-spacelosses,Modificationsbecauseof hypothermiaorhyperthermia,Requirementscausedbyunusual metabolicdemandsOtherFluiddeficits,8050%oftheresultingdeficitisreplacedinthefirsthourand25%ineachofthenext2hours.Losswiththesurgicalprocedure:from1mL/kg/hrforaminorsurgical proceduretoasmuchas15mL/kg/hrfor majorabdominalprocedures.50%oftheresultingdeficiti81ThecompositionoftheintravenousfluidChildwithgreaterhypoxicbraindamage:highbloodglucoselevels,recommendnotusingglucose-containing solutionsroutinely,especiallyforbriefoperative proceduresAlldeficitsandthird-spacelosses: Abalancedsaltsolution(e.g.,lactatedRinger's solution)Maintenancefluid: 5%dextrosein0.45%normalsaline

minimizethechanceofhypoglycemiaor accidentalhyperglycemiaThecompositionoftheintrave82Generalbloodvolumeprematureinfant:100to120mL/kgfull-terminfant:90mL/kgchild3to12monthsold:80mL/kgchildolderthan1year:70mL/kgThesearemerelyestimatesofbloodvolumeGeneralbloodvolumeprematur83Simpleformula

EBV:estimatedbloodvolumeTargethematocrit:childyoungerthan3months--->35%;childolderthan3months---25%-30%

EBV×(Startinghematocrit–Targethematocrit)MABL=StartinghematocritSimpleformulaEBV:esti84FluidreplacememtandbloodtransfusionBloodloss<1/3MABL: balancedsolution; balancedsolution:volumeofbloodloss=3:1Bloodloss>1/3MABL:colloid；colloid:volumeofbloodloss=1:1Bloodloss>1MABL:bloodtransfusion;Fluidreplacememtandbloodtr85VolumeofPRBCs(DesiredHct–PresentHct)×EBV×BW(kg)VolumeofPRBCs(ml)=HematocritofthePRBCs(～60%)VolumeofPRBCs86FreshFrozenPlasmaPT>15sorPTT>60s:FreshfrozenplasmaFreshFrozenPlasmaPT>15sor87PlateletsThrombocytopenia:<15×109/Lidiopathicthrombocytopenicpurpura, chemotherapy,infection,disseminatedintravascularcoagulopathyDilutionduringmassivebloodloss:<50×109/LPlateletsThrombocytopenia:<188PostoperativeManagementExtubateLaryngospasmBradycardiaGlossoptosisPostoperativeanalgesia:>9years,PCA<9years,Nursecontrolledanalgesia(NCA)morphine,20µg/kg/h,hypodermicalinjectionorIMPostoperativeManagementExtuba89Donotdeckyourselfupwithfineclothew,butenrichyourmindwithprofoundknowledge

Thankyou!Donotdeckyourselfupwith90谢谢！谢谢！91PediatricAnesthesia

DepartmentofanesthesiologyCuiXiaoGuangPediatricAnesthesiaDepartmen92Theprovisionofsafeanesthesiaforpediatricpatientsdependsonaclearunderstandingofthephysiologic,pharmacologic,andpsychologicaldifferencesbetweenchildrenandadults.Theprovisionofsafeanesth93Neonates:0–1monthsInfants:1–12monthsToddlers:1–3yearssmallchildren:4–12yearsNeonates:0–1months94DEVELOPMENTALPHYSIOLOGYOFTHEINFANTDEVELOPMENTALPHYSIOLOGYOFTH95Thepulmonarysystem1Therelativelylargesizeoftheinfant'stongue

ThelarynxislocatedhigherintheneckTheepiglottisisshapeddifferently,beingshortandstubbyThevocalcordsareangledTheinfantlarynxisfunnelshaped,thenarrowestportionoccurringatthecricoidcartilage:uncuffedendotrachealtubes;patientsyoungerthan6years.Thepulmonarysystem1Therela96哈尔滨医科学临床麻醉学课件小儿麻醉-PP97Thepulmonarysystem2Alveoliincreaseinnumberandsizeuntilthechildisapproximately8yearsold.Functionalresiduralcapacity(FRC):thesamewithadult;inductionandpalinesthesiaofanesthesiaisrapidA-aDO2islarger:functionalairwayclosureLimitsoxygenreserves:hypoxemia.Theworkofbreathing:(Inprematureinfants)threetimesofadults,increasedbycoldstressorsomedegreeofairwayobstruction.RR:twotimesofadultsThepulmonarysystem2Alveoli98Thepulmonarysystem3Tidalvolume(VT)islittle;physiologicaldeadspaceis30%ofVTAirwayresistanceincreasing:secretion,upperairwayinfectionDiaphragmaticandintercostalmusclesdonotachievetheadultconfigurationoftypeImusclefibersuntilthechild2yearsold: apneaorcarbondioxideretentionandrespi