Congenital and Acquired Pediatric Disease: Anesthetic Implications
Systems approach
Anesthetic planning hinges on which organ system is compromised and how it interacts with induction, ventilation, and hemodynamics.
- Congenital heart disease: know shunt direction and whether pulmonary blood flow depends on ductal patency. In cyanotic lesions, avoid increases in pulmonary vascular resistance (hypoxia, hypercarbia, acidosis, high airway pressure) and decreases in systemic vascular resistance. Single-ventricle physiology is preload- and afterload-sensitive.
- Prematurity/apnea of prematurity: former preterm infants are at risk for postoperative apnea; caffeine prophylaxis and overnight monitoring are considered.
- Asthma/reactive airway: optimize, use deep extubation or laryngeal mask, avoid histamine-releasing agents.
- Neuromuscular disease: succinylcholine contraindicated; sensitivity to nondepolarizing relaxants; risk of malignant hyperthermia in specific myopathies.
- Sickle cell disease: avoid hypoxia, dehydration, acidosis, and hypothermia; transfuse to target hemoglobin per protocol.
- Obesity/OSA: increased sensitivity to opioids, risk of postoperative respiratory events; consider opioid-sparing techniques.
Traps
Questions often hide a shunt or a single-ventricle patient behind a routine procedure. Another trap is missing the ex-preterm infant's apnea risk when the child "looks healthy." Always ask whether the child is at risk for hyperkalemia, MH, or pulmonary hypertensive crisis.
Rule of thumb
For any child with congenital heart disease, ask: does pulmonary blood flow depend on the ductus, and what happens to PVR and SVR with my induction plan?
Worked example
A 6-month-old with a large VSD and failure to thrive. Avoid agents that drop SVR sharply (which worsen left-to-right shunt); maintain systemic pressure, avoid hypoxia and hypercarbia, and plan postoperative monitoring for pulmonary overcirculation.