Important information about anesthesia in children. Anesthesia for children: consequences and contraindications Can children be given anesthesia

Very often anesthesia scares people even more than the operation itself. They are afraid of the unknown, possible discomfort when falling asleep and waking up, and numerous talks about the consequences of anesthesia that are harmful to health. Especially if it's all about your child. What is modern anesthesia? And how safe is it for the child's body?

In most cases, we only know about anesthesia that the operation under its influence is painless. But in life it may happen that this knowledge is not enough, for example, if the issue of an operation for your child is decided. What do you need to know about anesthesia?

anesthesia, or general anesthesia, is a time-limited drug effect on the body, in which the patient is in an unconscious state when painkillers are administered to him, followed by the restoration of consciousness, without pain in the operation area. Anesthesia may include giving the patient artificial respiration, providing muscle relaxation, setting up droppers to maintain the constancy of the internal environment of the body with the help of infusion solutions, control and compensation of blood loss, antibiotic prophylaxis, prevention of postoperative nausea and vomiting, and so on. All actions are aimed at ensuring that the patient undergoes surgery and "wakes up" after the operation, without experiencing a state of discomfort.

Types of anesthesia

Depending on the method of administration, anesthesia is inhalation, intravenous and intramuscular. The choice of anesthesia method lies with the anesthesiologist and depends on the patient's condition, on the type of surgical intervention, on the qualifications of the anesthesiologist and the surgeon, etc., because different general anesthesia can be prescribed for the same operation. The anesthetist can mix different types anesthesia, achieving the ideal combination for this patient.

Narcosis is conditionally divided into "small" and "large", it all depends on the number and combination of drugs of different groups.

The "small" anesthesia includes inhalation (hardware-mask) anesthesia and intramuscular anesthesia. With hardware-mask anesthesia, the child receives an anesthetic in the form of an inhalation mixture with spontaneous breathing. Painkillers administered by inhalation to the body are called inhalation anesthetics (Ftorotan, Isoflurane, Sevoflurane). This type of general anesthesia is used for low-traumatic, short-term operations and manipulations, as well as for various types research, when a short-term shutdown of the child's consciousness is necessary. Currently, inhalation anesthesia is most often combined with local (regional) anesthesia, since it is not effective enough in the form of mononarcosis. Intramuscular anesthesia is now practically not used and is becoming a thing of the past, since the anesthesiologist absolutely cannot control the effect of this type of anesthesia on the patient's body. In addition, the drug, which is mainly used for intramuscular anesthesia - Ketamine - according to the latest data, is not so harmless to the patient: it turns off long-term memory for a long time (almost six months), interfering with full-fledged memory.

"Big" anesthesia is a multicomponent pharmacological effect on the body. Includes the use of such drug groups as narcotic analgesics (not to be confused with drugs), muscle relaxants (drugs that temporarily relax skeletal muscles), sleeping pills, local anesthetics, a complex of infusion solutions and, if necessary, blood products. Medicines administered both intravenously and inhaled through the lungs. The patient undergoes artificial lung ventilation (ALV) during the operation.

Are there any contraindications?

There are no contraindications to anesthesia, except for the refusal of the patient or his relatives from anesthesia. At the same time, many surgical interventions can be performed without anesthesia, under local anesthesia (pain relief). But when we talk about the patient's comfortable condition during the operation, when it is important to avoid the psycho-emotional and physical, anesthesia is necessary, that is, the knowledge and skills of an anesthesiologist are needed. And it is not at all necessary that anesthesia in children is used only during operations. Anesthesia may be required for a variety of diagnostic and therapeutic measures, where it is necessary to remove anxiety, turn off consciousness, enable the child not to remember about unpleasant sensations, about the absence of parents, about a long forced position, about a dentist with shiny tools and a drill. Wherever a child's peace of mind is needed, an anesthesiologist is needed - a doctor whose task is to protect the patient from operational stress.

Before a planned operation, it is important to take into account the following point: if the child has a concomitant pathology, then it is desirable that the disease is not exacerbated. If a child has had an acute respiratory viral infection (ARVI), then the recovery period is at least two weeks, and it is advisable not to carry out planned operations during this period of time, since the risk of postoperative complications and breathing problems may occur during the operation, because respiratory infection primarily affects the respiratory tract.

Before the operation, the anesthesiologist will definitely talk with you on abstract topics: where the child was born, how he was born, whether he was vaccinated and when, how he grew up, how he developed, what he was ill with, whether he will examine the child, get acquainted with the medical history, scrupulously study all the tests . He will tell you what will happen to your child before the operation, during the operation and in the immediate postoperative period.

Some terminology

Premedication- psycho-emotional and drug preparation of the patient for the upcoming operation, begins a few days before surgery and ends immediately before the operation. The main task of premedication is to relieve fear, reduce the risk of developing allergic reactions, prepare the body for the upcoming stress, and calm the child. Medicines can be administered by mouth as a syrup, as a spray into the nose, intramuscularly, intravenously, and also in the form of microenemas.

Vein catheterization- placing a catheter in a peripheral or central vein for repeated administration of intravenous medications during surgery. This manipulation is performed before the operation.

Artificial lung ventilation (ALV)- a method of delivering oxygen to the lungs and further to all tissues of the body using a ventilator. During the operation, temporarily relaxing the skeletal muscles, which is necessary for intubation. Intubation- introduction of an incubation tube into the lumen of the trachea for artificial lung ventilation during surgery. This manipulation of the anesthesiologist is aimed at ensuring the delivery of oxygen to the lungs and protecting respiratory tract patient.

Infusion therapy - intravenous administration sterile solutions to maintain the constancy of the water and electrolyte balance of the body, the volume of circulating blood through the vessels, to reduce the consequences of surgical blood loss.

Transfusion therapy- intravenous administration of drugs made from the patient's blood or donor's blood (erythrocyte mass, fresh frozen plasma, etc.) to compensate for irreparable blood loss. Transfusion therapy is an operation for the forced introduction of foreign matter into the body, it is used according to strict vital indications.

Regional (local) anesthesia- a method of anesthetizing a certain part of the body by bringing a solution of a local anesthetic (pain medication) to large nerve trunks. One of the options for regional anesthesia is epidural anesthesia, when a local anesthetic solution is injected into the paravertebral space. This is one of the most technically complex manipulations in anesthesiology. The simplest and most well-known local anesthetics are Novocaine and Lidocaine, and the modern, safe and longest acting one is Ropivacaine.

Preparing a child for anesthesia

The most important is the emotional sphere. It is not always necessary to tell the child about the upcoming operation. The exception is cases when the disease interferes with the child and he consciously wants to get rid of it.

The most unpleasant thing for parents is a hungry pause, i.e. six hours before anesthesia, you can’t feed a child, four hours you can’t even drink water, and water is understood as a transparent, non-carbonated liquid, odorless and tasteless. A newborn who is on can be fed for the last time four hours before anesthesia, and for a child who is on, this period is extended to six hours. The fasting pause will avoid such a complication during the onset of anesthesia as aspiration, i.e. entry of the contents of the stomach into the respiratory tract (this will be discussed later).

Do an enema before surgery or not? The patient's intestines must be emptied before the operation so that during the operation, under the influence of anesthesia, involuntary stool discharge does not occur. Moreover, this condition must be observed during operations on the intestines. Usually, three days before surgery, the patient is prescribed a diet that excludes meat products and products containing vegetable fiber, sometimes a laxative is added to this on the day before the operation. In this case, an enema is not needed unless requested by the surgeon.

In the arsenal of the anesthesiologist, there are many devices to divert the attention of the child from the upcoming anesthesia. These are breathing bags with the image of different animals, and face masks with the smell of strawberries and oranges, these are ECG electrodes with the image of cute muzzles of favorite animals - that is, everything for a comfortable falling asleep for a child. But still, parents should be next to the child until he falls asleep. And the baby should wake up next to the parents (if the child is not transferred after the operation to the intensive care unit and intensive care).

During the operation

After the child has fallen asleep, anesthesia deepens to the so-called "surgical stage", at which the surgeon begins the operation. At the end of the operation, the "strength" of anesthesia decreases, the child wakes up.

What happens to the child during the operation? He sleeps without experiencing any sensations, in particular pain. The condition of the child is assessed clinically by the anesthesiologist. skin, visible mucous membranes, eyes, he listens to the lungs and heartbeat of the child, monitoring (observation) of the work of all vital organs and systems is used, if necessary, laboratory express tests are performed. Modern monitoring equipment allows you to monitor the heart rate, arterial pressure, respiratory rate, the content of oxygen, carbon dioxide, inhalation anesthetics in the inhaled and exhaled air, blood oxygen saturation as a percentage, the degree of sleep depth and the degree of pain relief, the level of muscle relaxation, the possibility of conducting a pain impulse along the nerve trunk and much, much more. The anesthetist conducts infusion and, if necessary, transfusion therapy, in addition to drugs for anesthesia, antibacterial, hemostatic, and antiemetic drugs are administered.

Getting out of anesthesia

The period of recovery from anesthesia lasts no more than 1.5-2 hours, while the drugs administered for anesthesia are in effect (not to be confused with postoperative period, which lasts 7-10 days). Modern drugs can reduce the period of recovery from anesthesia to 15-20 minutes, however, according to the established tradition, the child should be under the supervision of an anesthetist for 2 hours after anesthesia. This period may be complicated by dizziness, nausea and vomiting, painful sensations in the area of ​​the postoperative wound. In children of the first year of life, the usual sleep and wakefulness pattern may be disturbed, which is restored within 1-2 weeks.

The tactics of modern anesthesiology and surgery dictate the early activation of the patient after surgery: get out of bed as early as possible, start drinking and eating as early as possible - within an hour after a short, low-traumatic, uncomplicated operation and within three to four hours after a more serious operation. If the child is transferred to the intensive care unit after the operation, then the resuscitator undertakes further monitoring of the child's condition, and continuity in the transfer of the patient from doctor to doctor is important here.

How and what to anesthetize after surgery? In our country, the appointment of painkillers is carried out by the attending surgeon. These may be narcotic analgesics (Promedol), non-narcotic analgesics(Tramal, Moradol, Analgin, Baralgin), non-steroidal anti-inflammatory drugs (Ketorol, Ketorolac, Ibuprofen) and antipyretics (Panadol, Nurofen).

Possible Complications

Modern anesthesiology seeks to minimize its pharmacological aggression by reducing the duration of action of drugs, their number, removing the drug from the body almost unchanged (Sevoflurane) or completely destroying it with the enzymes of the body itself (Remifentanil). But, unfortunately, the risk still remains. Although it is minimal, complications are still possible.

The question is inevitable: what complications can arise during anesthesia and what consequences can they lead to?

Anaphylactic shock is an allergic reaction to the administration of drugs for anesthesia, transfusion of blood products, the administration of antibiotics, etc. The most formidable and unpredictable complication that can develop instantly can occur in response to the administration of any drug in any person. Occurs with a frequency of 1 per 10,000 anesthesia. It is characterized by a sharp decrease in blood pressure, disruption of the cardiovascular and respiratory systems. The consequences can be the most fatal. Unfortunately, this complication can be avoided only if the patient or his close relatives had a similar reaction to this drug earlier and he is simply excluded from anesthesia. An anaphylactic reaction is difficult and difficult to treat, the basis is hormonal preparations(eg Adrenaline, Prednisolone, Dexamethasone).

Another formidable complication, which is almost impossible to prevent and prevent, is malignant hyperthermia - a condition in which, in response to the introduction of inhalation anesthetics and muscle relaxants, body temperature rises significantly (up to 43 ° C). Most often, this is an inborn predisposition. The consolation is that the development of malignant hyperthermia is an extremely rare situation, 1 in 100,000 general anesthesia.

Aspiration - the entry of stomach contents into the respiratory tract. The development of this complication is most often possible during emergency operations, if little time has passed since the last meal by the patient and the stomach has not completely emptied. In children, aspiration may occur during mask anesthesia with passive flow of stomach contents into the oral cavity. This complication threatens with the development of severe bilateral pneumonia and burns of the respiratory tract with acidic stomach contents.

Respiratory failure is a pathological condition that develops when there is a violation of oxygen delivery to the lungs and gas exchange in the lungs, in which the normal blood gas composition is not maintained. Modern monitoring equipment and careful observation help to avoid or diagnose this complication in time.

Cardiovascular insufficiency is a pathological condition in which the heart is unable to provide adequate blood supply to the organs. As an independent complication in children, it is extremely rare, most often as a result of other complications, such as anaphylactic shock, massive blood loss, insufficient anesthesia. A complex of resuscitation measures is being carried out, followed by a long-term rehabilitation.

Mechanical damage - complications that may occur during the manipulations performed by the anesthetist, whether it be tracheal intubation, vein catheterization, staging gastric tube or urinary catheter. A more experienced anesthetist will experience fewer of these complications.

Modern drugs for anesthesia have undergone numerous preclinical and clinical trials - first in adult patients. And only after a few years safe application they are allowed in children's practice. Main Feature modern drugs for anesthesia is the absence adverse reactions, rapid excretion from the body, predictability of the duration of action from the administered dose. Based on this, anesthesia is safe, has no long-term effects and may be repeated many times.

Without a doubt, the anesthesiologist has a huge responsibility for the life of the patient. Together with the surgeon, he seeks to help your child cope with the disease, sometimes single-handedly responsible for saving life.

Vladimir Kochkin
Anesthesiologist-resuscitator,
Head of the Department of Anesthesiology and Resuscitation and the Operating Unit of the Russian Children's Clinical Hospital

Dear colleagues!

We present you a professional non-profit organization - "Association of Anesthesiologists-Resuscitators". It has the status of a legal entity and spreads its activities throughout the Russian Federation.
What are the key features of this organization?

• in individual conscious membership, the registration, extension or termination of which depends on the desire of a particular person;
• in an equal opportunity to realize their creative, scientific, managerial and human potential through the achievement of the goals of the organization;
• in a respectful attitude to the views and opinions of everyone;
• in the exclusive practical orientation of the tasks being solved.

The organizational and legal form we have chosen makes it possible to do without statistical data on the number of members, regional branches and territorial units of the Russian Federation involved in its activities. We do not need to hold constituent, reporting and other meetings in the regions. Everyone decides for himself on interaction with the Association on his own, regardless of what other professional organizations he is still a member of. To become a member, you must directly on this site (by pressing the button "Become a member of the Association" or "Join the Association") fill out an application for membership and pay the entrance and membership fees. Any organization with the status of a legal entity (and not only a public one) can become a member of the Association, and it does not matter to us how many members it has. Any "person" - both physical and legal, within the Association have almost equal rights.
What areas of work do we want to focus on now? First of all, on those measures that reduce the risk of a doctor falling into the zone of legal responsibility. This, of course, is a diverse activity in the field of additional professional education, expanding the horizons of a doctor, incl. on legal issues, the formation of an information portal; facilitating the transition to a system of continuous medical education as well as individual accreditation. A significant role will be assigned to aspects of legal protection, incl. work of mechanisms of pre-trial settlement of conflicts. Another block of issues that the Association has already taken up will be related to strengthening and improving interdisciplinary interaction and mutual understanding.
How do we plan to solve these problems and achieve the goals of the organization? - through the active participation of caring and proactive, young and experienced members of our Association and other organizations that unite such people who are ready to develop domestic anesthesiology and resuscitation with us.
We understand that the solution of even the outlined range of tasks requires considerable effort and will certainly encounter many obstacles along the way. We have no desire to idealize the situation and our possibilities, as well as to increase the attractiveness of the Association by drawing utopian programs. But we have no reason to doubt that looking for new approaches to work, moving in the chosen direction is not only necessary, but also quite realistic, especially if this is done together.
The new community should not be perceived as an alternative to the Federation of Anesthesiologists and Resuscitators. The presence of several organizations within the same direction in medicine is the rule rather than the exception, and this is typical for many countries. There are quite a lot of unresolved tasks and problems in our specialty, which should be solved through the consistent, painstaking and constructive work of all those who are interested in this.

Surgery in children and anesthesia has its own characteristics. This is due to the AFO of the child, as well as the imperfection immune system child.

The child's cardiovascular system is resistant to the effects that occur during surgery, but the regulation of vascular tone is not perfect, which leads to the development of collapse.

The blood volume of a child at birth is 85 ml/kg (in adults: M - 70 ml/kg, F - 65 ml/kg). In cases of blood loss in a child, it is necessary to carry out blood transfusion therapy - “drop by drop”, since 50 ml of a child’s blood corresponds to 1 liter of an adult’s blood.

The pulse in children is frequent, tachycardia. Blood pressure is low and is determined by the Molchanov formula:

BP = 80 + age × 2.

Diastolic pressure is 1/3 or 1/2 systolic.

The speed of blood flow in children is 2 times faster than in adults, so the tendency to edema of the mucous membranes, skin, brain is much faster.

The heart muscle in a child is mainly supplied with blood from the left coronary artery, has the same properties as in adults (excitability, conductivity, contractility, automatism). The pacemaker is the sinus node. For kids physiological feature is sinus tachyarrhythmia. On exhalation, the pulse quickens, and on inspiration it slows down, respiratory arrhythmia occurs. All other rhythm disturbances are pathological.

Peripheral BP is maintained by heart rate rather than stroke volume as in adults. The volume of non-contracting muscle mass of the heart in a child is 60% (up to 14 years), in an adult - 15-20%.

Bradycardia is not typical for children. Given this fact, metacin is introduced into premedication instead of atropine, which does not increase heart rate.

Respiratory system extremely unstable compared to the cardiovascular system.

Big head

short neck

big tongue

narrow nasal passages

High anterior larynx

"U" - figurative form of the epiglottis

A small glottis - all this makes intubation in children difficult, therefore, when choosing anesthesia in children, they proceed from the volume of surgical intervention. 1st place is occupied by non-inhalation anesthesia, 2nd - mask, 3rd in extreme cases - endotracheal.

A laryngoscope in pediatrics is used with a straight blade, and an endotracheal tube without a cuff is better than a Cole tube. The length of the child's trachea is 4 cm. [diameter is the same]

The diaphragm is high. The tidal volume is severely limited due to the horizontal ribs and the relatively large abdomen. Therefore, anesthesia and respiratory equipment should be selected individually and carried out only in a special nursery, where there should be the least resistance to inhalation, and for small children a pendulum system should be used.

Oxygen consumption in children is 2 times greater than in adults. Per 1 kg is 6 ml / min, and in adults 3 ml / min. Due to the narrowness of the choanae, the presence of adenoids, hypertrophied tonsils, an abundance of mucus, hypersecretion of glands oral cavity and tracheobronchial tree, each intubation is thought out to the smallest detail. The length of the endotracheal tube is calculated by the formula: from the earlobe to the wing of the nose × 2. The endotracheal tube is lubricated only with hormonal ointment.

Bifurcation of the trachea at the level of the 2nd rib. The continuation of the trachea is the right bronchus, and the left one is at an angle. The respiratory center is located in medulla oblongata but is more sensitive to narcotic analgesics. The type of breathing is mixed.

The nervous system of a child is immature and very sensitive to external stimuli. Children are prone to generalized reactions, the child reacts violently even to touch. It is difficult to establish psychological contact with a child, so it is advisable to give children general anesthesia, rather than using local or regional anesthesia. Children often undergo basic anesthesia and it should be gentle and exclude painful manipulations.

The immaturity of the nervous system is manifested by apnea. Anesthetics easily depress the respiratory center and change its susceptibility to carbon dioxide. Therefore, children develop hypoxia and hypercapnia faster than adults. Children are more sensitive to muscle relaxants, especially to non-depolarizing muscle relaxants, but both are used if necessary.

The child feels pain from the 1st minute of life and reacts with crying and movements, so if necessary in postoperative period any additional manipulations, then they are in no hurry with the awakening.

Thermoregulation in a child is unstable. Body temperature depends on temperature environment. This is explained:

1) Small fat layer

2) Underdeveloped muscle mass

3) Immaturity of the nervous system

It must be remembered that the surface of the child's head is a significant part of the total surface area of ​​the body. If you cool the child's head, then this will lead to a general cooling, that is, the temperature of the child's body will decrease. Usually, full-term babies cope with minor changes in the external environment on their own, while premature and debilitated babies do not. Therefore, children should be in incubators, the temperature in which is ~ 28 0 C. Overheating of the child is just as dangerous as cooling. Overheating is possible due to:

1) Underdevelopment of sweat glands

2) Immaturity of the nervous system

The constancy of temperature and humidity in the inhaled air-gas or gas-narcotic mixture is very important. For kids early age heated operating tables are used, and the constancy of temperature and humidity of the gas-narcotic mixture is achieved using an electric ventilometer, which is installed on the inhalation line.

An increase or decrease in temperature by 1 0 C leads the child to the development of acidosis.

Syndrome in children under 14 years of age thymus(immunodeficiency syndrome) - an inadequate response of the body to an irritant. Therefore, in children under 14 years of age, prednisone is introduced into premedication. Allergic reactions in children are always violent and the use of prednisolone (25 mg) is always justified.

Great importance in the preoperative preparation of children, the completeness of the examination plays with the obligatory review of the otorhinolaryngologist.

Drug preparation up to 14 years of age is not carried out the day before, and they try to carry out premedication in a painless way (skin application, chewing sweets). Premedication is always METOCIN, and Promedol is rarely used, replacing it with Diphenhydramine.

Venepuncture is performed either after local anesthesia using the application method, or during mask anesthesia.

Hypnotics choose the least toxic, and more often use the inhalation method.

Basic anesthesia N 2 O + O 2 + traces of halothane or azeotropic mixture.

Then the I/O system is connected.

Short-acting relaxants (ditilin) ​​are introduced.

Intubation. Children are intubated through the lower nasal passage. The time spent on intubation is 2 times less (~ 7 sec). Must have Megill forceps or forceps.

The anesthetic should be mild and not irritate the upper respiratory tract.

IVL is carried out in the mode of moderate hyperventilation, and if the pendulum system, then double the volume.

Anesthesia-respiratory equipment used in pediatrics must meet certain requirements:

ü Have minimal inspiratory resistance

ü Have minimal dead space

ü The gas-narcotic mixture must be supplied at a constant temperature and humidity

ü The operating table must be heated

ü Oxygen in the inhaled mixture must be at least 60%, and the circuit is semi-open or pendulum

Hypoxia and hypercapnia, which can develop during anesthesia very quickly leads (especially in young children) to cerebral edema. Therefore, all anesthesia in pediatric practice is carried out only in the presence of a doctor and careful monitoring in accordance with the Harvard monitoring standard.

Infusion therapy is calculated in children taking into account the initial state of the child, preoperative preparation, intraoperative losses and postoperative needs. With blood loss, infusion therapy "drop by drop". For children under one year old, infusion therapy includes colloid solutions with a minimum salt content, since children have functional insufficiency of the renal parenchyma. For 1 minute should be 1 ml of urine. General anesthesia affects the kidneys in direct proportion, that is, the deeper the anesthesia, the more the functional state of the kidneys is inhibited.

In the postoperative period, especially in children under 5 years of age, if the volume of surgical intervention allows, after 3 hours the child is transferred to enteral nutrition, since children are prone to hypoglycemia, and their blood sugar quickly decreases up to 5-6 hours.

The daily fluid requirement for a child up to 10 kg is 100 ml / kg

10-20 kg - 150 ml/kg

the calculation takes into account the disease, age and physiological losses.

The need for electrolytes (Na +, K +) - 3 mmol / kg per day

P.S.: In weakened children, the dose of relaxants is reduced by half from the due one. Anesthesia is carried out at stage III: 1st and 2nd levels. The younger the child, the faster the transition from the 1st level to the 2nd. The breathing bag is designed to control breathing. After any anesthesia, the child is transported to the ward only with a doctor and an Ambu bag.

When introducing and withdrawing from anesthesia in pediatric practice, more attention is paid. There is no need to rush to wake up.

The ventilation capabilities of a child's lungs can be significantly reduced by the surgeon's hands or instruments (just press down on the chest).

Features of anesthesia in children and newborns are associated with their anatomical, psychological and physiological characteristics.

Anatomical features

A child is a growing organism and the ratio of its weight, height, body surface varies significantly from birth. A newborn weighs about 1/21 of an adult's weight. The most constant value in a child should be considered the surface of the body.

The proportions of the body of a child are very different from those of an adult: a large head and a short neck (often the chin reaches the second intercostal space), a small chest, small limbs with poorly developed veins.

The central nervous system develops only with age. Myelination in newborns is not complete: sensitive nerve fibers and myelination of motor fibers is not completed. The spinal cord of a newborn reaches the III lumbar vertebra and only by the 2nd year of life takes a position corresponding to the position in adults (I lumbar vertebra), which must be taken into account during spinal puncture.

Differences in the respiratory system are especially important: the upper respiratory tract of children is narrow. Their free permeability is easily disturbed by profuse saliva secretion, a large tongue, hypertrophied tonsils or adenoid tissue. Intubation is more difficult than in adults, as the glottis in children is obliquely posterior. Immediately under the vocal cords, they have a pronounced narrowing in the region of the cricoid cartilage. The mucous membrane covering the pharynx in children is prone to develop due to trauma or overhydration.

The chest of a child is a classic example of "underdevelopment": it is small, the sternum is soft, the ribs are horizontal. This makes it impossible to expand the chest when breathing in the lateral and anteroposterior direction. Its volume during inspiration increases only due to the movements of the diaphragm. The movements of the diaphragm are limited due to the relatively large abdomen, which is typical even for healthy children. Respiratory muscles are poorly developed.

In children under 3 years of age, the bronchi depart at the same angle from the trachea (55 °), therefore, during intubation, the tube can easily pass into the right and left bronchus. As in adults, dead space is approximately 2.5 ml per 1 kg of body weight.

The cardiovascular system of a child, which functioned even in the prenatal period, has large reserves. There are no degenerative processes in the heart muscle, which are often observed in adults. Functions of cardio-vascular system, violated for any reason, quickly normalize after the elimination of the factor that caused the changes.

Heart rate, systolic and diastolic blood pressure are highly variable and differ not only in different ages, but also in children of the same age groups within a very wide range.

The volume of blood in children exceeds the volume of blood in adults in relation to body weight - respectively 84 ml / kg in children and 80 ml / kg in adults.

The liver and kidneys complete development after the birth of a child. However, liver function, even in newborns, is highly developed. Kidney function in young children is insufficient. The child is practically on the verge of " kidney failure", therefore, due to various pathological conditions children very quickly develop dehydration and, conversely, hyperhydration. This leads to prefer the oral route of replacement of water losses and with great care to make intravenous infusions.

Despite the relatively large size of the adrenal glands, the production of glucocorticoids in infants childhood insignificant. During the first 2 weeks, the protective reaction of the child's body is based on glucocorticoids received from the mother. In the future, the reaction of the adrenal cortex to injury only gradually approaches the reaction of an adult. The adrenal medulla in newborns secretes norepinephrine only.

Peculiarities of pediatric anesthesia

The exact age at which the child begins to respond psychologically to anesthesia and is unknown. It can be assumed that mental perceptions appear very early, in any case, a negative effect on the central nervous system anesthetized factors such as surgery without anesthesia, inhalation of ether vapors.

At the age of 2-3 years, children react violently to all the unpleasant moments of anesthesia and surgery, and it is extremely difficult to establish psychological contact with them. At this age, sparing methods of induction anesthesia are especially indicated - lulling with the help of a toy mask, rectal basis anesthesia.

Excessive mental reactions with age gradually decrease to normal; A 5-year-old child can already be brought to the anesthesia room awake, and he can actively participate in the induction of anesthesia: hold the mask with his hands (self-narcosis), blow into the anesthesia mask (exhalation will be followed by an active deep breath).

Anatomical and physiological features of the respiratory system cause changes in pulmonary ventilation during anesthesia and surgery in children: the slightest increase in dead space and an increase in breathing resistance due to the apparatus quickly cause a sharp violation of alveolar ventilation if the child breathes on his own.

When crying, straining, after the introduction of atropine, the heart rate can reach 170-190 per minute. In children, sinus is often observed, but gross rhythm disturbances are rare. The predominance of the right heart is recorded on the electrocardiogram, gradually changing to a levogram.

Thermoregulation is the most imperfect in children. Newborns, especially premature ones, are poikilothermic. During a 1-2 hour operation, body temperature may drop by 2°. This can cause severe scleroma in newborns as their fat subcutaneous tissue It has low temperature melting. Even more important is the tendency to hyperthermia observed in children. This is especially facilitated by the use of high doses of anticholinergic substances in premedication, which reduce heat loss with evaporation.

Oxygen consumption is especially high: it reaches 7 ml per 1 kg of weight in children versus 4 ml per 1 kg in adults. Therefore, any hypoxia can cause severe changes in the body, which forces the use of gas-narcotic mixtures with a high oxygen content in children.

Preparing a child for surgery

It consists of psychological, sanitary-prophylactic and medical preparation. Visiting the child on the eve of the operation, or at least talking (playing) with him before anesthesia in emergency cases, significantly improves the course of induction of anesthesia.

The child's stomach must be empty before anesthesia, as vomiting and regurgitation are especially dangerous in children due to their narrow airways and tendency to laryngospasm.

It is necessary to follow the rules of feeding:

• the last feeding of infants should be no later than midnight; 4 hours before the operation, the child can be given some water;
• children over 3 years of age are not allowed to eat after dinner;
• if the operation is scheduled after 12 o'clock, then at 7 o'clock in the morning you can give a light breakfast. In cases where there is no certainty that the stomach is empty, you need to empty it with a probe;
• warn the mother about the prohibition of feeding before anesthesia.

All children are given an enema the evening before the operation.

Premedication and general principles of drug dosage in children

Features of metabolism, excretion of substances from the child's body and the discrepancy between the ratios of his weight, height and body surface require a special choice of dosages of medicinal substances. It is most appropriate to use the "dose factor", which is a coefficient calculated on the basis of the ratio of weight gain and body surface area at different ages. By multiplying the dose of the drug, calculated per 1 kg of adult weight, by the "dose factor", you can quite accurately determine the single dose of this substance for the child.

In premedication in children, anticholinergics, analgesics, short-acting barbiturates are most often used. Morphine is not recommended. due to the expressed side effects. In children under 6 months of age, morphine should be strictly prohibited. Nembutal in children under 9 years old is advisable to use per rectum, diluting the powder in 10 ml of water and injecting the solution 90 minutes before the start of the operation. Cholinolytics and analgesics are administered 45 minutes before surgery subcutaneously and 30 minutes intramuscularly.

Relatively small dosages of anticholinergics are used due to the fact that large doses of them can contribute to the development of hyperthermia due to a sharp decrease in sweating.

It is advisable to include in premedication and ataractic preparations. Antihistamines are prescribed at the rate of 2.5 mg per year of life and administered intramuscularly 90 minutes before surgery. Meprotan (Andaxin) is administered orally at doses of 50 mg per year of life 3 hours before surgery. If the indicated dose does not give the desired effect, it is repeated for an hour before anesthesia.

Features of anesthesia machines and instruments used in children

Of the semi-open systems, the Ayre system or its modifications are most often used. The system consists of a Y-shaped (in children under 1 year old) or a T-shaped connector, one end of which is connected to the endotracheal tube, and a gas-narcotic mixture is supplied to the other. When conducting anesthesia with spontaneous breathing, hypercapnia is prevented by a high flow of gas-narcotic mixture: in newborns - 1.5-2 l / min, in children under 1 year old - 4 l / min, in 3 years - 7 l / min, in 9-year-olds - 10-12 l/min.

In neonates, the Ayre system can be used not only with an endotracheal tube, but also with a minimally sized mask.

When anesthesia is carried out in a semi-open way, special valves can also be used, but in this case it is more advisable to carry out controlled ventilation of the lungs, since the resistance of the valves is minimal when anesthesia is performed using the Eyre system.

Conducting anesthesia in a closed way is carried out either with the help of a pendulum-like system, or with the help of special circulation attachments. When using a pendulum system, small absorbers are used for children under 3 years old, and medium absorbers for older children. Two identical, well-purged dusty absorbers should be prepared for work. When the absorber is heated, it must be changed to avoid burning the respiratory tract.

A feature of the circulation system used in children is that it minimizes dead space (minimum face mask, placing valves directly on the connector - tee) and provides forced ventilation of the mask space. For children under 6 years of age, it is advisable to use a pendulum system, and for older children, a conventional circulation system, provided that the valve boxes are fully functional and the valves are made of the lightest material.

Anesthesia instruments include a laryngoscope with blades for premature babies (length 75 mm), children under 3 years old (length 100 mm) and older children (length 150 mm). In premature A newborns, it is more convenient to use a straight blade.

In newborns, children up to 6 months, it is convenient to use special tubes with Cole-type restrictors. Up to 7 years, smooth tubes are used; in older children, according to indications, tubes with cuffs can be used. When choosing tubes, three sizes are prepared before intubation: a tube, the size of which corresponds to the age of the child, and two tubes of adjacent - larger and smaller - sizes. When anesthesia is performed by the endonasal method, a smooth tube is prepared by a number less than during endotracheal anesthesia, and 20% longer.

A mandatory tool for anesthesia in children is a stethoscope, which is fixed with a sticky patch in the area of ​​​​the cardiac impulse. They control cardiac activity, especially during induction of anesthesia. It is advisable to use an esophageal stethoscope during operations in the chest.

When conducting anesthesia in children under one year old, a thermometer is also needed, and in premature babies and newborns, equipment for the operating table is heated. In recovery rooms, cuvettes are supplied with humidified oxygen.

The anesthesia room and wards should have toys that are easy to sanitize.

Introductory anesthesia

In children under 3 months of age, induction anesthesia can be performed by an open method. The cry of the child, movements of the arms and legs accelerate the onset of anesthesia. It is necessary to take measures so that anesthesia in this way is carried out in a separate room (do not disturb other children who will have surgery on that day). Holding the breath during the induction of anesthesia for 10-15 seconds dictates the cessation of drug instillation until the respiratory movements are restored. Otherwise, severe hypoxia may develop. The duration of the introductory period in children is 10-15 minutes with this method. It is necessary to cover the child's eyes with a protective bandage made of thin rubber and a napkin to prevent damage to the cornea.

Introductory apparatus-mask anesthesia in children of these groups is carried out using nitrous oxide (with oxygen), cyclopropane (with oxygen) or a mixture of cyclopropane, oxygen and nitrous oxide (Shane-Ashman mixture), halothane and nitrous oxide. The dangers of induction anesthesia in this case are associated with the characteristics of the anesthetics used.

Introductory anesthesia in children older than 6 months is carried out using intravenous or rectal anesthesia.

Features of induction intravenous anesthesia in young children - its rare use due to the difficulties of venipuncture and possible respiratory depression, which makes it difficult to saturate with the main anesthetic; the use of less concentrated solutions of hexenal and sodium thiopental, slow administration of drugs; stopping the administration of drugs when “floating” appears eyeballs”, which indicates the onset of stage 2. Basis anesthesia is carried out by introducing into the rectum narcolan or a solution of barbiturates, or by introducing suppositories with barbiturates.

Thiopental-sodium is used in a 5% solution at the rate of 25 mg per kg of body weight. The drug is injected into the rectum using a catheter. Narcotic sleep occurs in a few minutes. In a similar dosage, suppositories prepared from barbiturates are used. When using hexenal, the dosage is increased to 40 mg / kg.

Carrying out a maintenance period

During anesthesia with a mask, it is necessary to ensure free airway patency with an air duct and extension of the head.

Features of endotracheal anesthesia in children

Tube insertion is more difficult in children than in adults; the tube narrows the lumen of the larynx relatively more; the danger of its edema is much greater than in adults; Intubation through the nose is often accompanied by bleeding, the likelihood of laryngospasm during extubation is no less great than during intubation.

Intubation is absolutely indicated in children with intrathoracic operations, in children with intestinal obstruction, with intracranial operations and with major operations in the position of the child on the stomach. Intubation is preferred for major operations on the face, head, and neck; during operations in the lateral position, as well as on the upper abdomen, with tonsillectomy performed under anesthesia in a sitting position, with pneumoencephalography.

Due to the high risk of complications during tracheal intubation in children, it is contraindicated in small operations on the limbs, perineum during hernia repair and appendectomy.

Features of anesthesia for tracheal intubation

It is more expedient to intubate under anesthesia. When using muscle relaxants, the technique of induction anesthesia does not differ from the technique used in adults, with the exception of two points: the use of predominantly inhalation induction anesthesia and large doses of muscle relaxants. Ditilin is used for this purpose at a dose of 2.5 mg per kg of the child's weight.

It is most advisable to intubate children in an "improved" position. After intubation, the tube is attached to the anesthesia machine and fixed with an adhesive plaster or bandage. It is necessary to fix the tube, not the connector, otherwise the tube and adapter may be separated and the tube may slip into the trachea.

Extubation is performed after the restoration of spontaneous breathing very gently so as not to cause laryngospasm. After extubation and until the child wakes up, an oral airway is inserted.

Anesthesia with the use of muscle relaxants and controlled ventilation of the lungs

This technique is the most expedient for all major operations and absolutely obligatory for intrathoracic operations. Switching off spontaneous breathing in children is also achieved with the help of muscle relaxants. However, their use should be more cautious, given the greater risk associated with tracheal intubation and the difficulty of determining anesthesia when spontaneous external respiration is turned off.

Muscle relaxants are indicated for operations in the chest cavity, upper abdomen, for tracheal intubation. They are also indicated for inducing short-term apnea during bronchography, angiography, fracture reduction and other similar procedures. Indications for the use of muscle relaxants in children are laryngospasm and convulsive syndrome. Tubarine (d-tubocurarine chloride) has a stronger curarizing effect in children than in adults, so it is used in lower doses. Ditilin has to be used in much larger doses.

In most cases, muscle relaxants are administered intravenously. Ditilin and pyrolaxone can be used intramuscularly (bronchoscopy, fracture repositioning, management of seizures), especially in young children when the veins are poorly developed. Dosage of muscle relaxants intramuscular application should be tripled. It is more advisable to use muscle relaxants when used intramuscularly in combination with hyaluronidase (20-40 units).

Conducting anesthesia with muscle relaxants in children requires continuous monitoring of the state of hemodynamics, which remains almost the only criterion for the quality of anesthesia.

Artificial ventilation should be continued until complete recovery. muscle tone. Therefore, in all cases of the use of antidepolarizing relaxants, at the end of anesthesia, prozerin should be administered. The calculation is made based on the dose of an adult, taking into account the "dose factor". As in adults, prozerin is administered after a preliminary injection of atropine against the background of recovering spontaneous respiration.

Post-anesthetic period

It is desirable to wake up as early as possible, especially if it is impossible to continuously nursing care. The child is placed in a warm bed on its side, preventing aspiration of vomit and retraction of the tongue,

In the first hour every 15 minutes determine the pulse and pressure. Then these indicators are determined every hour for 4 hours, then after 4 hours during the day. In children under one year old, temperature is measured every hour for 4 hours, then measurements are taken every 4 hours. This allows timely diagnosis of hyperthermia.

After major operations, compensation for blood and water losses continues with slow intravenous infusion of blood or 5% glucose (8-10 ml per minute).

Analgesics are used during the first 4 hours at a half dose, then during the day at a dose of 0.75 mg per year of a child's life. After severe operations and in weak children, oxygen therapy is performed. Newborns are placed in heated incubators.

With the development of hyperthermia, pyramidon is administered intramuscularly at the rate of 30-40 mg per year of life or an enema with aspirin is made - 50 mg in newborns and up to 500 mg in older children. With more pronounced and persistent hyperthermia, additionally administered antihistamines, blowing the child with cold air. Apply ice packs, inject.

The subject of anesthesia is surrounded by a considerable number of myths, and all of them are quite frightening. Parents, faced with the need to treat a child under anesthesia, as a rule, worry and fear negative consequences. Vladislav Krasnov, an anesthesiologist at the Beauty Line group of medical companies, will help Letidor figure out what is true and what is a delusion in the 11 most famous myths about children's anesthesia.

Myth 1: the child will not wake up after anesthesia

This is the most terrible consequence that moms and dads are afraid of. And quite fair for a loving and caring parent. medical statistics, which mathematically determines the ratio of successful and unsuccessful procedures, is also in anesthesiology. A certain percentage, albeit fortunately negligible, of failures, including fatal ones, does exist.

This percentage in modern anesthesiology according to American statistics is as follows: 2 fatal complications per 1 million procedures, in Europe it is 6 such complications per 1 million anesthesias.

Complications in anesthesiology happen, as in any field of medicine. But the meager percentage of such complications is a reason for optimism in both young patients and their parents.

Myth 2: the child will wake up during the operation

Using modern methods anesthesia and its monitoring, it is possible with a probability close to 100% to ensure that the patient does not wake up during the operation.

Modern anesthetics and anesthesia control methods (for example, BIS technology or entropy methods) make it possible to accurately dose drugs and track its depth. Today there are real opportunities to get feedback on the depth of anesthesia, its quality, and the expected duration.

Myth 3: The anesthesiologist will “do a prick” and leave the operating room

This is a fundamental misconception about the work of an anesthesiologist. An anesthesiologist is a qualified specialist, certified and certified, who is responsible for his work. He is obliged to be inseparably during the entire operation next to his patient.

The main task of the anesthesiologist is to ensure the safety of the patient during any surgical intervention.

He cannot "take a shot and leave," as his parents fear.

Also deeply wrong is the ordinary idea of ​​an anesthesiologist as a "not quite a doctor". This is a doctor medical specialist, which, firstly, provides anelgesia - that is, the absence of pain, secondly - the comfort of the patient in the operating room, thirdly - the complete safety of the patient, and fourthly - the calm work of the surgeon.

Protecting the patient is the goal of the anesthesiologist.

Myth 4: Anesthesia destroys a child's brain cells

Anesthesia, on the contrary, serves to ensure that brain cells (and not only brain cells) are not destroyed during surgery. Like any medical procedure, it is performed according to strict indications. For anesthesia, these are surgical interventions that, without anesthesia, will be detrimental to the patient. Since these operations are very painful, if the patient is awake during them, the harm from them will be incomparably greater than from operations that take place under anesthesia.

Anesthetics undoubtedly affect the central nervous system - they depress it, causing sleep. This is the meaning of their use. But today, in conditions of compliance with the rules of admission, monitoring of anesthesia with the help of modern equipment, anesthetics are quite safe.

The action of the drugs is reversible, and many of them have antidotes, by introducing which the doctor can immediately interrupt the effect of anesthesia.

Myth 5: Anesthesia will cause an allergy in a child

This is not a myth, but a fair fear: anesthetics, like any medical preparations and foods, even plant pollen, can cause allergic reaction which, unfortunately, is rather difficult to predict.

But an anesthetist has the skills, drugs, and technology to deal with the effects of an allergy.

Myth 6: Inhalation anesthesia is much more harmful than intravenous anesthesia

Parents are afraid that the inhalation anesthesia machine will damage the child's mouth and throat. But when the anesthesiologist chooses the method of anesthesia (inhalation, intravenous, or a combination of both), it comes from the fact that this should cause minimal harm to the patient. The endotracheal tube, which is inserted into the child's trachea during anesthesia, serves to protect the trachea from foreign objects: fragments of teeth, saliva, blood, stomach contents.

All invasive (invading the body) actions of the anesthesiologist are aimed at protecting the patient from possible complications.

Modern methods of inhalation anesthesia involve not only intubation of the trachea, that is, the placement of a tube into it, but also the use of a laryngeal mask, which is less traumatic.

Myth 7: Anesthesia causes hallucinations

This is not a delusion, but a completely fair remark. Many of today's anesthetics are hallucinogenic drugs. But other drugs that are administered in combination with anesthetics are capable of neutralizing this effect.

For example, the well-known drug ketamine is an excellent, reliable, stable anesthetic, but it causes hallucinations. Therefore, a benzodiazepine is administered along with it, which eliminates this side effect.

Myth 8: Anesthesia is instantly addictive, and the child will become a drug addict

This is a myth, and a rather absurd one at that. In modern anesthesia, drugs are used that are not addictive.

Moreover, medical interventions, especially with the help of any devices, surrounded by doctors in special clothes, do not cause any positive emotions in the child and the desire to repeat this experience.

Parents' fears are unfounded.

used for anesthesia in children medications, which differ in a very short period of action - no more than 20 minutes. They do not cause the child any feelings of joy or euphoria. In contrast, the child using these anesthetics has virtually no memory of events since anesthesia. Today it is the gold standard of anesthesia.

Myth 9: the consequences of anesthesia - deterioration of memory and attention, poor health - will remain with the child for a long time

Disorders of the psyche, attention, intelligence and memory - that's what worries parents when they think about the consequences of anesthesia.

Modern anesthetics - short-acting and yet very well controlled - are eliminated from the body as soon as possible after their administration.

Myth 10: anesthesia can always be replaced with local anesthesia

If the child is to surgery, which, due to its soreness, is performed under anesthesia, refusing it is many times more dangerous than resorting to it.

Of course, any operation can be carried out with local anesthesia– and it was still 100 years ago. But in this case, the child receives a huge amount of toxic local anesthetics, he sees what is happening in the operating room, understands the potential danger.

For the still unformed psyche, such stress is much more dangerous than sleeping after the administration of an anesthetic.

Myth 11: anesthesia should not be given to a child under a certain age

Here the opinions of parents differ: someone believes that anesthesia is acceptable no earlier than 10 years old, someone even pushes the border of acceptable to 13-14 years old. But this is a delusion.

Treatment under anesthesia in modern medical practice is carried out at any age, if indicated.

Unfortunately, a serious illness can affect even a newborn baby. If he is going to have a surgical operation during which he will need protection, then the anesthesiologist will provide protection regardless of the age of the patient.