Physiological Changes:

Anesthesia Techniques:

Emergency exploration: Rapid sequence intubation with cricoid pressure until a tracheal tube is securely in place to reduce the risk of pulmonary aspiration of gastric contents. Peripheral intravenous access should be obtained in all patients to allow continued hydration and drug administration.

Monitoring:
Small children have a high body surface area to mass ratio and little subcutaneous fat or body hair to retain heat. Continuous insufflation of large volumes of cold, non-humidified CO2 directly in to the abdominal cavity also contributes to a major risk of hypothermia. A warming mattress, heated humidifier or a convective forced air warmer might be used, if available. An oro-nasogastric tube should be inserted after induction to permit deflation of the stomach, thus minimizing the chances of Verres needle accidentally perforating the inflated viscus.

Peri-operative Care: A balanced technique with controlled ventilation using inhalational agents, intravenous opioids, non-depolarizing neuromuscular blocking agents is preferred. The chief difference in anesthetic management between Laparoscopy and other abdominal procedures in children relates to the cardiorespiratory resulting from pneumoperitoneum and positioning. Ventilation should be controlled because this facilitates removal of exogenous CO2 and minimizes the reduction in FRC caused by a combination of increased IAP, Trendelenburg position and the use of volatile anesthetic agents. Minute ventilation needs to be increased by 20% or more to maintain normocapnia.

Pain Management: Pain following Laparoscopy results from a variety of maneuvers
Pain is best controlled by multimodal approach of local anesthetics, NSAIDs and opioids. Local anesthetics can be injected intraperitoneally as well as infiltrated on the puncture sites. NSAID can be given oral, rectal, intramuscular and intravenous routes.

Post-operative Nausea And Vomiting (PONV): PONV is a common complication following Laparoscopy, delaying discharge from the hospital. A combination of drugs including 5-HT3 antagonist - ondansetron, dexamethasone and droperidol can be used.

Use Of LMA: The use of LMA is a remarkably useful adjunct to anesthesia for patients undergoing Laparoscopy. Although aspiration with LMA is low there has been no report with Laparoscopy and positive pressure ventilation.

High Risk Patients With Severe Myocardial Disease:
Summary: Knowledge of pathophysiological changes, adequate monitoring and good planning makes anesthesia for Laparoscopy safe in pediatrics.

Last updated on 01-04-2005 Vol 2 Issue 4 Art # 16

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