Young's Pediatric Anesthesia Reference Sheet - FAQs
Q: How did you select the drugs and drug dosages?
A: Drugs and dosages were chosen based upon their wide spread use in pediatric anesthesia as well as manufacture recommendations. Dosages should not solely be based upon the numbers on the sheet. Clinical judgment, research, and consultation should all come into the equation when finally choosing an appropriate dose. It was very difficult to decide on a specific dosage in the case of many drugs. In some instances there was great variability from reference to reference. Drug dosages also vary depending on use. Dexamethasone, for example, has a dose of 0.15 mg/kg for antiemetic use, and a dose of 0.5 mg/kg for airway swelling and allergic reaction.
Q: Why are some drugs not include?
A: Some drugs were excluded based upon infrequent use in pediatric anesthesia and/or package insert recommendations. I am willing to consider any recommendations for additions or deletions.
Q: Some drugs say that safety in a particular age has not been established. What does that mean?
A: One area of concern has been the general lack of approval of many medications for populations of pediatric patients. Nearly 80% of currently approved medications have language within the drug package insert that excludes children of varying ages. Many of the drugs we use in the operating room and the intensive care unit have similar language. Common examples of drugs used in our daily practice include bupivacaine (until further experience is gained in children younger than 12 years, administration of bupivacaine injection is not recommended) and Alfenta (clinical data to support the use of Alfenta in patients under 12 years of age are not presently available. Therefore, such use is not recommended). Such disclaimers are placed in the package insert because the contents of the package insert must by law be based on adequate, well-controlled studies involving children. Any use of a drug that is not specifically described in the package insert is considered "unapproved" or "off label." The reason for the lack of labeling for children is that the appropriate controlled clinical trials were never supported by industry, and the Food and Drug Administration (FDA) did not have the legislative power to force the pharmaceutical companies to perform pediatric studies (Litman, 2004).
Q: Why are no dosages given for etomidate in children less than 10 years old? I see others using it on patients much younger.
A: They are using it "off label" and it has been used as such for years (see previous question for details). The drug package insert for etomidate (Amidate®) states, "There is inadequate data to make dosage recommendations for induction of anesthesia in pediatric patients below the age of ten years; therefore, such use in not recommended."
Q: Which inhalation agent should I use with pediatric patients?
A: With pediatric anesthesia sevoflurane dominates the US market. Inhalation induction is best accomplished with sevoflurane. An absence of pungency facilitates such an induction and only sevoflurane and halothane are not pungent. Sevoflurane provides a more rapid induction of, and recovery from, anesthesia than does halothane. It also may be safer (halothane sensitizes the myocardium to catecholamines and causes myocardial depression). Sevoflurane produces less postoperative nausea and vomiting. The major disadvantages of sevoflurane relative to halothane are the greater cost of sevoflurane and a greater tendency to postoperative agitation, particularly in preschool children, including a greater incidence of behavioral changes after discharge. After induction, many providers switch to desflurane or isoflurane for maintenance of anesthesia. (Eger, Eisenkraft, Weiskopf, 2002).
Q: A word about bolus dosing opioids to pediatric patients.
A: Chest wall rigidity is not uncommon when administering bolus opioids, especially to drug-naïve neonates & infants. Opioids also depress central respiratory effort. Newborns and infants less than 6 months old are particularly susceptible. Greater than 6 months old there is no difference from an adult (Duke, 2000).