Pediatric PACU issues
(Melissa Ehlers, MD. 7/04)
Ref: A Practice of Anesthesia for Infants and Children, Cote, Ch. 11
1. Transport to PACU with oxygen whenever possible – helps avoid episodic hypoxia, gives you a greater margin of safety
2. Try to avoid giving narcotics on the way to PACU (unless child is absolutely wild) as they may occasionally become apneic
3. Emergence agitation – commonly seen after Sevoflurane anesthesia, occasionally also with desflurane, especially in grade-school children. Whenever possible, avoid “short-acting” volatile anesthetics, sedation and adequate pain control help. For severe cases, a dose of physostigimine will usually stop it (possibly it is due to overstimulation of cholinergic receptors?)
4. Pain – ideally pre-emptive analgesia has occurred intra-operatively through the use of caudal anesthesia, other regional blocks, local infiltration, pre- and intraoperative administration of Tylenol (and possibly Vioxx), Toradol, (contraindications: < 6 mo. old, kidney disease, bleeding disorder. Always check with your attending first!). In the PACU, make sure the nursing staff has appropriate orders for pain control;
fentanyl 1 mcg/kg x 3 doses for any outpatient procedure, consider adding morphine for inpatients at 0.05mg/kg x3).
5. Nausea/vomiting – also ideally treated with pre-emptive anti-emetics. In any procedure which may leave blood in the stomach (i.e. tonsillectomy) consider Reglan (0.15 mg/kg) to aid gastric motility. Highly emetic procedures warrant at least two anti-emetics, don’t forget that decadron (0.25 - 0.5 mg/kg, max 10mg) which is commonly given in T&A’s is a strong anti-emetic. Another option is benadryl (0.5mg/kg). If patients have prior history of N/V or are receiving chemotherapy, consider zofran (0.15 mg/kg -may need to be higher with chemo). Also, don’t forget to empty the stomach before emergence!
Hypothermia –1.causes increased metabolic demands in patients who are shivering. 2. Neonates are at much greater risk of apnea/bradycardia when hypothermic. 3. has been implicated in delayed wound healing, increased rate of wound infection, and up-regulation of the inflammatory response