|
Things to consider with oxygen therapy: Many of us start with flow-by for our patients on the triage/exam table, and, if feasible, switch them to an oxygen cage, collar, or nasal cannula.
Anesthetic protocols by type
Opioids: Opioids offer the benefit of analgesia and sedation with the option of reversal (naloxone) should the need arise. Generally, opioids are considered "heart-friendly" because of their minimal effect on cardiovascular performance. However, opioids have a dose-dependent negative effect on heart rate. Because of the pediatric patients' dependence on heart rate to manage blood pressure, they may be less tolerant of opioid-induced bradycardia than a healthy adult. Anticholinergic agents should be used as needed for opioid induced bradycardia.
Additionally, for reasons already discussed, pediatric patients may have unpredictable responses to standard doses of opioids, and the duration of an opioid's effect may be prolonged. Pediatric patients given opioids should be monitored for bradycardia, hypotension, hypoventilation, and excessive sedation.
Pediatric patients given a lower opioid dose than one given to a healthy adult should be reassessed for pain and level of sedation after 30-60 minutes. If the patient is tolerating the opioid well, but its pain is not adequately controlled, consider increasing the dosage. In patients under six weeks old, it is appropriate to reduce the dose by up to 50 percent.
Benzodiazepines: Benzodiazepines offer sedation (when combined with other drugs), muscle relaxation, minimal cardiovascular depression, and reduce the amount of induction agent required. Be aware giving a benzodiazepine alone may induce excitement or dysphoria. Because of benzodiazepines' dependence on hepatic metabolism, this class of drugs has the potential to last longer and produce more pronounced sedation in pediatric patients than in healthy adults. Reverse with flumazenil (0.01-0.04 mg/kg IV or IM in canine and feline patients) as needed during recovery. Benzodiazepines are commonly avoided in patients less than six weeks old due to the risk of excessive CNS depression.
Ketamine: Ketamine is an NMDA antagonist that decreases central sensitization to painful stimuli. While ketamine is not typically used as a primary analgesic, it is highly effective as an adjunct analgesic in patients with preexisting pain. Ketamine's sedation properties reduce the necessary dose of induction drugs and the minimum alveolar concentration (MAC) of gas anesthetic. Ketamine may have a mild positive effect on heart rate, which can help counteract the bradycardic effects of other anesthetic drugs. When selecting a dose, keep in mind there is no reversal agent for ketamine. Ketamine is commonly avoided in patients under 4 weeks of age.
