ocuklarda Ameliyat Sonrasi Agri Tedavisi

1. 06.09.2012 1 �ocuklarda Ameliyat Sonrasi Agri Tedavisi Pediyatrik Anestezi Kursu 27 Subat / 6 Mart 2010 Dr. G�ner Kaya I� Cerrahpasa Tip Fak�ltesi

2. 06.09.2012 2 Konu Akisi �ocuklarda Agri Genel bilgiler-Degerlendirme Sistemik Analjezikler Rejyonel Y�ntemlerle Analjezi Pratik �neriler

3. �ocuklarda  ANALJEZI...? Hedef Travma baslamadan Agrinin iletim yollarinda her seviyede agri ile m�cadele etmek �ocugu ameliyattan agrisiz uyandirmak Yes we needed because of humanistic goals...Yes we needed because of humanistic goals...

4. It�s not pleasing to see fighting and chaos in the hospitalIt�s not pleasing to see fighting and chaos in the hospital

6. Canadian Journal of�Anesthesia, Vol 27, 248-253, 1980 The Anaesthetic Management of Preterm Infants Undergoing Ligation�of Patent�Ductus�Arteriosus��The Children's Hospital Medical Center Boston The authors reviewed the records of seventy preterm infants�suffering from respiratory distress syndrome and, in most cases,�refractory congestive heart failure, who underwent ligation�of patent ductus�arteriosus. The peri-operative management of�these patients is described. The anaesthetic technique consisted�of nitrous oxide and oxygen supplemented with a relaxant. All�patients were ventilated manually with a humidified Jackson�Rees system. The operations were performed in the main operating�suite. There were no deaths during operation. The infants were�protected from significant temperature fluctuations by various�methods which are described. The overall survival rate of all�preterm infants with respiratory distress syndrome. The management�presented is considered acceptable to the infants, to the surgeons�and to the anaesthetists.

7. �ocuklar Hakkinda Yanlislar Bebekler n�rolojik olarak immat�rd�r ! Agri impulslarini iletemezler! Bebekler kortikal immat�rite nedeniyle agriyi hatirlayamazlar GER�EK: Esdeger doku hasari bebeklerde eriskinlerden daha kuvvetli agri olusturur Intrauterin25. Haftada agriyi algilayacak str�kt�rel komponentler var fakat endojen desendan inhibit�r yollar orta bebeklik �agina kadar tam gelisemez . Opioid ve diger resept�rler yaygin sekilde bulunur. yenidoganda endojen agri inhibit�r sistemi az gelismis, gelismekte olan sistemlerin plastisitesi y�ksektir, sonu� olarak; esit doku hasari �ocuklarda daha g��l� agriya neden olur) spinal kordda Intrauterin kan degisimi Transhepatik igne Davranis degisiklikleri Hormonal stres cevabi The structural components necessary to perceive pain are already present at about 25 weeks gestation whereas the endogenous descending inhibitory pathways are not fully developed until mid-infancy .2 4 164 Opioid and other receptors are much more widely distributed in fetuses and neonates.52 53 62 66 127 Fetuses subjected to intrauterine exchange transfusion with needle transhepatic access will show both behavioural signs of pain as well as a hormonal stress response.64 Significant pain stimulation without proper analgesia, for example circumcision, will not only cause unacceptable pain at the time of the intervention but will produce a �pain memory� as illustrated by an exaggerated pain response to vaccination as long as 6 months following the circumcision.148�150 Intrauterin25. Haftada agriyi algilayacak str�kt�rel komponentler var fakat endojen desendan inhibit�r yollar orta bebeklik �agina kadar tam gelisemez . Opioid ve diger resept�rler yaygin sekilde bulunur. yenidoganda endojen agri inhibit�r sistemi az gelismis, gelismekte olan sistemlerin plastisitesi y�ksektir, sonu� olarak; esit doku hasari �ocuklarda daha g��l� agriya neden olur) spinal kordda Intrauterin kan degisimi Transhepatik igne Davranis degisiklikleri Hormonal stres cevabi The structural components necessary to perceive pain are already present at about 25 weeks gestation whereas the endogenous descending inhibitory pathways are not fully developed until mid-infancy .2 4 164 Opioid and other receptors are much more widely distributed in fetuses and neonates.52 53 62 66 127 Fetuses subjected to intrauterine exchange transfusion with needle transhepatic access will show both behavioural signs of pain as well as a hormonal stress response.64 Significant pain stimulation without proper analgesia, for example circumcision, will not only cause unacceptable pain at the time of the intervention but will produce a �pain memory� as illustrated by an exaggerated pain response to vaccination as long as 6 months following the circumcision.148�150

8. Cerrahi travma ve tedavi edilmemis agrinin fizyolojik sekelleri Kardiyovask�ler stres Otonom hiperaktivite Doku yikimi Metabolik hiz artisi Anksiyete Psikolojik Travma Akciger fonksiyonlarinin k�t� etkilenmesi Hiperkoag�labilite Sivi retansiyonu Immun s�presyon Ileus Etik ve H�manistik nedenlerle Etik ve H�manistik nedenlerle

9. 06.09.2012 9

10. �ocuklarda Agri- 3T Tani Tedavi Takip Sabit araliklarla Degerlendirme D�k�mantasyon Monitorizasyon Analjezik etkinlik Yan etki tespit et tedavi et Ekipmanin dogru �alismasi

11. Here I would like to have your attention on behavioral and physiological signs of the pain measurement in infants and children. One of them is facial expression: Here I would like to have your attention on behavioral and physiological signs of the pain measurement in infants and children. One of them is facial expression:

12. Bebeklerin Agri Semptomlari Agrinin Y�z Belirtileri Sikica kapali g�zler D�s�k kaslar Burun ve dudak k�sesi arasi olugun derinlesmesi Kare agiz �ukur Dil Assessment of pain in infant is well expressed with crying feature -aglama sesi- and facial expressionAssessment of pain in infant is well expressed with crying feature -aglama sesi- and facial expression

13. Various self reporting scales are widely used for pain assessment in children.Various self reporting scales are widely used for pain assessment in children.

14.  Rejyonel Bloklar Parasetamol NSAID�ler Toksik dozlara ulasmamak veya motor blokdan ka�inmak i�in lokal anestezigin dozunu azaltmak ve de tedaviye ilave ederek Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children Toksik dozlara ulasmamak veya motor blokdan ka�inmak i�in lokal anestezigin dozunu azaltmak ve de tedaviye ilave ederek Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children

15. Parasetamol Beyin ve medulla spinaliste  siklooksijenaz enzimi (COX3) inhibisyonu Yeni �alismalar: Analjezik etkinlik: 35-60 mg/kg ile m�mk�n Analjezik konsantrasyonu net ? Oral 40 mg/kg doz 20-67 mg/L plazma seviyesinde analjezi Bu dozun hepatotoksisitesi yok Oral 40 mg/kg doz 20-67 mg/L plazma seviyesine ulastiginda analjezi saglandigi bildirilmistir. Bu dozun hepatotoksisite a�isindan problem olmadigi bilinmektedir Antipiretik etki: etkili plazma konsantrasyonu 10-20 mg/l *40-45 mg/kg rektal dozdan 2-3 saat sonra *10-15 mg/kg oral dozdan 1 saat sonra Oral 40 mg/kg doz 20-67 mg/L plazma seviyesine ulastiginda analjezi saglandigi bildirilmistir. Bu dozun hepatotoksisite a�isindan problem olmadigi bilinmektedir Antipiretik etki: etkili plazma konsantrasyonu 10-20 mg/l *40-45 mg/kg rektal dozdan 2-3 saat sonra *10-15 mg/kg oral dozdan 1 saat sonra

16. Parasetamol Analjezik etkinlik az, Tavan etkisi Ince barsaklardan hizla emilim S�ppozutuarin kompozisyon ve biyoyararliligi degisebilir Rektumdan absorbsiyon: Yenidoganlarda : iyi Daha b�y�klerde: yavas ve tam degil KULLANIM Hafif ve orta dereceli agrilarda Daha siddetli agrilarda NSAID veya kodein veya zayif opioidlerle kombine edilerek Morfin azaltici (sparing) etki daha y�ksek dozlarda � Parasetamolun analjezik etkinlik r�latif olarak d�s�kt�r Tavan etkisi vardir ve doz artirimi ile daha fazla analjezi veya antipiretik etki elde edilemez Hafif ve orta dereceli agrilarda NSAID veya kodein gibi zayif opioidlerle kombine edilerek daha siddetli agrilarda Morfin azaltici etkisi daha y�ksek dozlarda g�r�l�r� Ince barsaklardan hizla emilir S�ppozutuar seklinin kompozisyon ve biyoyararliligi degisebilir, Yenidoganlar disinda rektumdan absorbsiyon yavas ve tam degildir Parasetamolun analjezik etkinlik r�latif olarak d�s�kt�r Tavan etkisi vardir ve doz artirimi ile daha fazla analjezi veya antipiretik etki elde edilemez Hafif ve orta dereceli agrilarda NSAID veya kodein gibi zayif opioidlerle kombine edilerek daha siddetli agrilarda Morfin azaltici etkisi daha y�ksek dozlarda g�r�l�r� Ince barsaklardan hizla emilir S�ppozutuar seklinin kompozisyon ve biyoyararliligi degisebilir, Yenidoganlar disinda rektumdan absorbsiyon yavas ve tam degildir

17. Ameliyat sonrasi Parasetamol mg/kg Yaklasik 50 �ocukta hepatotoksisite g�r�lm�s. Yanlis doz , etiket vs nedeniyle Doza uyulursa emniyetli bir ajandir.Yaklasik 50 �ocukta hepatotoksisite g�r�lm�s. Yanlis doz , etiket vs nedeniyle Doza uyulursa emniyetli bir ajandir.

18. Proparasetamol Perioperatif IV verilebilir 1gr = 500 mg parasetamol plazma esterazlari ile metabolize olur DOZ : 15 mg / kg /4-6 saat 15 dakikada inf�zyon (10 kg dan b�y�k �ocuklarda) Peak etki 1 saatte Ameliyat sonrasi i�in y�kleme doz Son zamanlarda aktif drogun iv formu bulunmustur Bebekler, hasta �ocuklar ve preterm YD doz ayarlamasi Son zamanlarda aktif drogun iv formu bulunmustur Bebekler, hasta �ocuklar ve preterm YD doz ayarlamasi

19.  INTRAVEN�Z PARASETAMOL Perfalgan 10 mg/ml  En az 15 dakikada yavas inf�zyon

20. NONSTEROID ANTIENFLAMATUAR AJANLAR - NSAID�ler COX 1 ve 2 inhibisyonu: Perifer ve SSS de =tromboksan prostoglandin sentez inhibisyonu = enflamasyonu azaltirlar Periferik agri resept�rlerinin sensitivitesi ve agriya santral cevabi azaltirlar � �ekinceler Gastrik sekresyon ve mukozal permeabiliteyi arttirirlar Renal kan akimini azaltirlar Trombosit fonksiyonlarini bozarlar Predispozisyonu olan �ocuklarda bronkospazm ? Celecoxib ve rofecoxib, COX-2 yi 100 kez daha selektif inhibe ederler:�ocuklarda kullanim izni vardir�ocuk >10 yas solunum yolu ve burun hastaliklarini agirlastirabilirler �ocuk <10 yas daha k���klerde bu �zellik daha seyrek Naproxen, ibuprofen, tolmetin ve kolin magnezyum salisilat in �ocuklar i�in FDA izni vardir Celecoxib ve rofecoxib, COX-2 yi 100 kez daha selektif inhibe ederler:�ocuklarda kullanim izni vardir�ocuk >10 yas solunum yolu ve burun hastaliklarini agirlastirabilirler �ocuk <10 yas daha k���klerde bu �zellik daha seyrek Naproxen, ibuprofen, tolmetin ve kolin magnezyum salisilat in �ocuklar i�in FDA izni vardir

21. NSAID�ler-�ekinceler Birka� g�nl�k tedavide b�brekler, kemik iligi ve mide �zerine yan etkileri ihmal edilebilir Tonsillektomi vb ( metaanaliz ! ) hemostaz zor kanama �nemli Astim Kemik iyilesmesi Birka� g�n akut agri tedavisi d�nemi i�in NSAID lerin; b�brekler, kemik iligi ve mide �zerine bilinen yan etkileri ihmal edilebilir Fakat tonsillektomi gibi yeri a�isindan hemostazin zor, kanamanin �nem kazandigi ameliyat cinslerinde NSAID lerin trombosit fonksiyonlarini etkileyerek kanamayi arttirabilecegi d�s�ncesi g�z�n�nde bulundurulmalidir NSAID lerin trombosit fonksiyonlarini etkileyerek kanamayi arttirabilecegi !!! Birka� g�n akut agri tedavisi d�nemi i�in NSAID lerin; b�brekler, kemik iligi ve mide �zerine bilinen yan etkileri ihmal edilebilir Fakat tonsillektomi gibi yeri a�isindan hemostazin zor, kanamanin �nem kazandigi ameliyat cinslerinde NSAID lerin trombosit fonksiyonlarini etkileyerek kanamayi arttirabilecegi d�s�ncesi g�z�n�nde bulundurulmalidir NSAID lerin trombosit fonksiyonlarini etkileyerek kanamayi arttirabilecegi !!!

22. NSAID� ler Orta-hafif dereceli agri tedavisinde �nemli G�n�birlik cerrahide lokal veya rejyonel sinir bloku ile �ok iyi kombinasyon Siddetli agrida : Opioidlerle kombinasyonu * Opioidlerin dozunu % 30-40 azaltabilir * Kombine edilerek - Opioidlerin ileus, safra kesesi spazmi, iskelet kasi spazmi etkileri azalir - Opioid inf�zyonuna g�re daha hizli weaning

23. Ibuprofen Diklofenak Patent duktus arteriosus - uzun s�re kullanim ! YD da GFR yi % 20 azaltir Kanama olasiligi kullanimini �ok sinirlayici degil Doz: 4-6 mg/kg (6-8 /s oral) Maks: 30 mg/kg/g�n <6 ay bebek: 5 mg/kg Doz: 1 mg/kg im - rektal 0.5 mg/kg - oral > 6ay bebek: d�zenli kullanim �nerilmez Gastrointestinal yan etkiler ! Bu Hayvan �alismalarinda kemik iyilesmesine negatif etkileri �ok desteklenmemis t�r ila�larin yan etkileri i�in �ok b�y�k serili arastirmalar yapilmasi gerekmektedir. � Bu Hayvan �alismalarinda kemik iyilesmesine negatif etkileri �ok desteklenmemis t�r ila�larin yan etkileri i�in �ok b�y�k serili arastirmalar yapilmasi gerekmektedir. �

24. Kombinasyonlar Parasetamol + Diklofenak - kodein kadar analjezik etki - daha az yan etki Parasetamol + Ketorolak - tonsillektomi sonrasi morfin kadar etkin Parasetamol + ketorolak kombinasyonu tonsillektomi sonrasi morfin kadar etkin oldugu bildirilmektedir. Fakat bu t�r kombinasyonlarin sonu�lari her vaka i�in ayni degildir. Parasetamol + ketorolak kombinasyonu tonsillektomi sonrasi morfin kadar etkin oldugu bildirilmektedir. Fakat bu t�r kombinasyonlarin sonu�lari her vaka i�in ayni degildir.

25. NSAID�ler - DOZLAR

26. Ketamin Analjezik, sedatif, ind�ksiyon ajani Analjezik etki 40 dk amnezik etkisi 2 saat IV ve IM, oral, rektal ve nazal yolla kullanilabilir Subanestezik dozlarda inf�zyon seklinde - iyi analjezik - kisa s�reli agrili islemlerde Belirtilen dozlarda ??? Belirtilen dozlarda ???

27. Morfin Kullanim Teknigi10-30 �g /kg/saat inf�zyon   K���k bebeklerde oksimetri ve apne monit�r� kullanilmali Ciltalti, iv yola alternatif PCA: -5 yas �zeri �ocuklar -major cerrahi girisimlerde Yenidoganda: NCA: bazal inf�zyon (-) Morfin pompalari kullanilirken Agri, Sedasyon Bulanti skorlari izlenmelidir Konstipasyon Kasinti Tedavisi gerekir

28. Morfin Morfin iv Bolus doz:100 �g/kg gerektik�e tekrar edilebilir Bolus doz + s�rekli inf�zyona ge�ilebilir Morfin PCA �rnegi: Bolus: 15 �g/kg; Kilit s�resi: 5 - 7 dak; 4 saatlik limit: 25 �g/kg Diklofenak ilavesi: -doz azalmasi -daha iyi agri skorlari

29. PRATIK �RNEK: Morfin Inf�zyonu 20 �g/kg/saat dozda sol�syon hazirlanmasi 1 mg/kg Morfin, 50 ml SF 1ml/saat = 20 �g / kg / saat �nce bolus y�kleme dozu: 100-200 �g / kg 5-10 dak i�inde 10 �g/kg/saat dozda sol�syon hazirlanmasi 0.5 mg/kg morfin 50 ml SF, 1 ml/saat seklinde inf�zyon (10 �g/kg/saat dozu saglar) 0216 5281133 www.kosmodisk.web.tr

30. Dolantin Analjezik kullanimi �nerilmez Bulanti kusma orani y�ksek Metaboliti norpethidin Uzun s�re kullanim ile tremor, kas seyirmeleri, konv�lsiyonlar, toksik etkiler g�r�lebilir Doz: 0.5 mg/kg

31. Fentanil Etki baslama ve etki s�resi morfinden kisa Kisa s�reli islemlerde Islem sonrasi minimal agrili olgularda Doz: iv 0.5-1 �g /kg EBS: 1 dak ES: 30-45 dak Fentanil lolipopu � Dikkat ! Bulanti-kusma Toraks rijiditesi Verilis hizi ve dozu (3-5 �g / kg ) ile iliskili Nalokson Solunum depresyonu Fentanil, yagda y�ksek oranda eriyen sentetik opioiddir. Etki baslama ve etki s�resi morfinden kisadir. Kisa s�reli islemlerde ve islem sonrasi minimal agri olan olgularda morfine tercih edilir. Se�ilmis vakalarda kullanilabilir; bulanti-kusma ve toraks rijidite etkisi hatirda tutulmalidir. Doza bagli olarak solunum depresyonu yapabilir. Verilis hizi ve dozu ( 3-5 mcg/ kg ) ile iliskili olarak toraks rijiditesi yapabilir. Toraks rijiditesi nalokson ile ��z�lebilir. Fentanilin iv dozu 0.5-1 mcg/kg, etki baslama s�resi 1 dakika , etki s�resi 30-45 dakikadir. Fentanilin lolipop seklinde preparatlari da vardir. � Fentanil, yagda y�ksek oranda eriyen sentetik opioiddir. Etki baslama ve etki s�resi morfinden kisadir. Kisa s�reli islemlerde ve islem sonrasi minimal agri olan olgularda morfine tercih edilir. Se�ilmis vakalarda kullanilabilir; bulanti-kusma ve toraks rijidite etkisi hatirda tutulmalidir. Doza bagli olarak solunum depresyonu yapabilir. Verilis hizi ve dozu ( 3-5 mcg/ kg ) ile iliskili olarak toraks rijiditesi yapabilir. Toraks rijiditesi nalokson ile ��z�lebilir. Fentanilin iv dozu 0.5-1 mcg/kg, etki baslama s�resi 1 dakika , etki s�resi 30-45 dakikadir. Fentanilin lolipop seklinde preparatlari da vardir. �

32. Alfentanil, Remifentanil Kisa etkili Kisa s�ren islemlerde analjezik Titre edilerek verilebilirler Bolus ve inf�zyonlar - apne, - havayolu obstr�ksiyonu - toraks rijiditesi yapabilir Yetkili ve deneyimli hekimler tarafindan yogun bakimda kullanilabilir

33. Tramadol Etkisi kismen CYP2D6 enzimine bagli oldugu i�in sahsa bagli etki g�sterir Klirens: 44. haftada mat�re olur Doz: 50-100 mg/6 saat veya 1-2 mg/kg Oral , IM veya IV Diger narkotiklere g�re: - Sol. depr az - Bulanti � kusma, konstipasyon benzer �ocuklarda kinetik bilgiler arttik�a tramadolun daha k���k �ocuklarda faydali oldugu kanitlanabilir�ocuklarda kinetik bilgiler arttik�a tramadolun daha k���k �ocuklarda faydali oldugu kanitlanabilir

34. Narkotikler

35. Ameliyat Sonrasi Agrinin En Etkin Tedavisi Rejyonel Santral Bloklar  Periferik Sinir Bloklari Rejyonel Bloklar Parasetamol NSAID�ler Toksik dozlara ulasmamak veya motor blokdan ka�inmak i�in lokal anestezigin dozunu azaltmak ve de tedaviye ilave ederek Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children Toksik dozlara ulasmamak veya motor blokdan ka�inmak i�in lokal anestezigin dozunu azaltmak ve de tedaviye ilave ederek Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children Pain after minor surgery may be controlled with NSAIDs and paracetamol given on a regular basis for the first 48 to 72 hours after surgery and as needed thereafter. Safe and effective analgesia for children

36. Volume of Extracellular fluid is higher in infants than compared to adult. It goes down with age.Volume of Extracellular fluid is higher in infants than compared to adult. It goes down with age.

37. Farmakoloji-1 Distrib�syon vol�m� b�y�k Plazma seviyeleri d�s�k SONU�: MG/KG TEMELINDE DAHA B�Y�K DOZLAR Yenidogan ve Bebekler < 3 ay Hepatik klirens Alb ve Alfa-1 AG az LA i�in sonu� Baslangi� dozu az artis yavas Devam dozlari az . Larger doses of LA are required in children, due to greater volume of distrubition and lower peak plasma levels. . Larger doses of LA are required in children, due to greater volume of distrubition and lower peak plasma levels.

38. Farmakoloji - 2 Bebeklerde S�rekli Inf�zyon Ilk 6 s sonra, LA serbest konsantrasyonu artmaya baslar 36-48 s sonra belirgin toksik konsantrasyon Continuous infusion in infants shows some special characteristics effects in clinical use. After.... After 36-48......appears Infants with right to left cardiac shunts may be more likely to suffer LA toxicity Because the first-pass clearence of the lung may be bypassed Continuous infusion in infants shows some special characteristics effects in clinical use. After.... After 36-48......appears Infants with right to left cardiac shunts may be more likely to suffer LA toxicity Because the first-pass clearence of the lung may be bypassed

39. We can see the elimination half - life of LAs. in infants and adults. Elimination half life of bupivacaine is quite longer in newborn than adult. We can see the elimination half - life of LAs. in infants and adults. Elimination half life of bupivacaine is quite longer in newborn than adult.

41. Dr Ivani has investigated motor block degree after caudal analgesia and he decided that Motor block was less with ropivacaine compared bupivacaine, there was no difference among L-bupivacaine and ropi. Dr Ivani has investigated motor block degree after caudal analgesia and he decided that Motor block was less with ropivacaine compared bupivacaine, there was no difference among L-bupivacaine and ropi.

42. Hangi lokal anestezik ? �Racemic bupivacaine� giderek �ropivacaine� veya �levobupivacaine� ile yer degistirmektedir Avantaj: - daha az sistemik toksisite - motor blok riski azligi L�nnqvist, Morton 2005 The use of LA depends on to experience of anesthesiologist. L�nnq and morton stated that racemic bup ... There are new LA which less toxic to CVS like levobupivacaine or Ropivacaine . The use of LA depends to experience Of anesthesiologist The use of analgesic adjuvans in neuroaxials anesthesia has improved the care we can provide by improving the reliability and quality of nero axial blockade, reducing LA dose and systemic plasma levels and providin postoperative analgesia. The addition of clonidine, ketamine, to bupivacaine significantly increases the duration of caudal analgesia and decreases postoperative morphine requirements in children. The use of LA depends on to experience of anesthesiologist. L�nnq and morton stated that racemic bup ... There are new LA which less toxic to CVS like levobupivacaine or Ropivacaine . The use of LA depends to experience Of anesthesiologist The use of analgesic adjuvans in neuroaxials anesthesia has improved the care we can provide by improving the reliability and quality of nero axial blockade, reducing LA dose and systemic plasma levels and providin postoperative analgesia. The addition of clonidine, ketamine, to bupivacaine significantly increases the duration of caudal analgesia and decreases postoperative morphine requirements in children.

43. PRA&A Uygulamalari ANAT � FIZY- FARM EPIDURAL A&A KAUDAL, LOMBER, TORAKAL SPINAL ANESTEZI SINIR BLOKLARI Aksiller, Interskalen, Femoral, Iskiadik, Fasya iliaka Interkostal, ilioinguinal Dorsal penil DIGER Topikal, infiltrasyon REGIONAL ANESTHESIA is a part of general A in children . Main rules in Orthopaedic Anaesthesia in children are not different from general pediatric RAA PRAA is a very large topic. In this presantation I will only talk abouth these topics. Introduction: Anesthetic techniques should be tailored to address the special needs of children with orthopedic conditions. PLACE IN PEDIATRIC ANESTHESIA AS IN ADULT ANESTHESIA. Regional anesthesia well established in ped anesthetic practice. The primary reason for its reintroduction into pediatric practice in the 1980s was for postoperative pain management. THE SKILLS LEARNED IN ADULT PATIENTS CAN EASILY BE TRANSLATED INTO REGIONAL BLOCKS IN PEDIATRIC PATIENTS SOME REGIONAL TECHNIQUES SUCH AS CAUDALS ARE ACTUALLY EASIER IN PEDIATRIC PATIENTS Over 20 yr ago, a survey reported that 40% of paediatric surgical patients experienced moderate or severe postoperative pain and that 75% had insufficient analgesia.106 Since then, a range of safe and effective techniques have been developed.  REGIONAL ANESTHESIA is a part of general A in children . Main rules in Orthopaedic Anaesthesia in children are not different from general pediatric RAA PRAA is a very large topic. In this presantation I will only talk abouth these topics. Introduction: Anesthetic techniques should be tailored to address the special needs of children with orthopedic conditions.

44. Basit Lokal Anestezik Teknikleri LA jel: s�nnet infiltrasyon, instilasyon: k���k yaralara Yara perf�zyonu: iliak kanat kemik grefti Pansuman perf�zyonu: Deri grefti donor alan Maks. Doza Dikkat !!!...

45. The application of Caudal Block The application of Caudal Block

46. This is the Armitage formula. Please be aware that the volume of LA is effective on the level of anesthesia. This is the Armitage formula. Please be aware that the volume of LA is effective on the level of anesthesia.

47. RA&A � Major spine surgeryReview: Tobias 2004 Intrathecal morphine analgesia Dalens 1988, Blackman 1991, Goodarzi 1998 0.025 mg/kg- 6 h analgesia Epidural morphine analgesia - single or double catheter Double Catheter Technique: is used to allow the use of lipophilic opioids and thereby avoiding the adverse effects of hydrophilic opioids (Tobias 2001) Tobias has reviewed Major Spine Surgery and need of analgesia. He stated that Intrathecal morphine analgesia is effective but has short duration. Epidural morphine analgesia is possible with - single or double catheter Double Catheter Technique is used to allow the use of lipophilic opioids and thereby avoiding the adverse effects of hydrophilic opioids (Tobias 2001) Tobias has reviewed Major Spine Surgery and need of analgesia. He stated that Intrathecal morphine analgesia is effective but has short duration. Epidural morphine analgesia is possible with - single or double catheter Double Catheter Technique is used to allow the use of lipophilic opioids and thereby avoiding the adverse effects of hydrophilic opioids (Tobias 2001)

48. Kaudal ve Epidural Dozlar ( Bupi, Levo, Ropi ) Kons % Doz Aditifler Tek Doz Kaudal 0.175-0.5 0.75-1.25 ml/kg Epin. 2.5-5 �g /ml Clonid. 1-2 �g /kg Morfin 30-70 �g/kg Kontin. Kaudal veya Lumbar Epidural Katet 0.1-0.25 0.4ml/kg/h veya Fentanyl 2-5 �g/ml 0.2-0.4 mg/kg/h Kontin Torak. Epidural Katet 0.1-0.25 0.3 ml/kg/h Hydromorphone 5-10 �g/ml veya 0.1-0.2 mg/kg/h This table shows us LA doses for different procedures , Notice that the Bup, Levo, Ropi doses are same.This table shows us LA doses for different procedures , Notice that the Bup, Levo, Ropi doses are same.

49. �ocuklarda  LOKAL ANESTEZIK Maksimal Dozlar Tek Doz Inf�zyon Inf�z < 6 ay mg/kg mg/kg/s mg/kg/s Bupivacaine 3 0.4-0.5 0.2-0.25 Levobupivacaine 3 0.4-0.5 0.2-0.25 Ropivacaine 3 0.4-0.5 0.2-0.25 Lidocaine 5 1.6 0.8 Lidocaine + Epin 7 -- -- This table also shows maximal doses in children. An Infant less than 6 mounts need half dose for infusion.This table also shows maximal doses in children. An Infant less than 6 mounts need half dose for infusion.

50. G�n�birlik Cerrahi-Analjezi 1) Oral parasetamol ile premedikasyon 2) Ameliyatta: Lokal anestezi: - yara yeri infiltrasyonu veya - uygun sinir bloku veya - kaudal epidural blok (additif: klonidin veya ketamin ) Diklofenak iv veya rektal 3) 48 saat d�zenli: diklofenak veya piroksikam ve parasetamol * S�nnette ilave olarak �ocuk uyurken topikal lignokain jel 24 saat uygulamalari i�in aileye �gretilmesi * Ameliyat sirasinda opioidden ka�inma

51. Tonsillektomi ve Adenotonsillektomi-Analjezi 1) Oral parasetamol ile premedikasyon 2) Ameliyatta fentanil veya alfentanil, iv veya rektal diklofenak - 48 saat d�zenli diklofenak ve parasetamol -ASBK �nlemek: narkotikten sakin deksametazon 0.15 mg/kg IV

52. Ortopedik Cerrahi-Analjezi 1) Parasetamol ile premedikasyon 2) Rejyonel anestezi; periferik sinir b, pleksus b, epidural b Tek doz epidural+ klonidin veya ketamin LA inf�zyonu i v veya rektal diklofenak AS: 48 saat oral diklofenak ve parasetamol Skolyoz cerrahisinde: intratekal morfin 2-20 �g/kg d�s�n�lebilir Alternatif: PCA veya hemsire kontroll� PCA

53. Toraks-Kalp Cerrahi-Analjezi TORAKS Epidural analjezi y�kleme dozu ve 36-48 s inf�zyon birlikte d�zenli diklofenak ve parasetamol VEYA-kontrendike-red interkostal sinir bloku veya paravertebral bloku Alternatif: Morfin PCA veya NCA KALP Ameliyatta kisa etkili potent opioid, ve morfin y�kleme dozu AS Morfin inf�zyonu PCA veya NCA D�zenli parasetamol Ilk 24 saat sonrasi kanama riski d�s�k ise diklofenak Kapali girisimlerde s�rekli epidural analjezi yi d�s�n A�ik girisimlerde s�rekli epidural veya intratekal analjezi yi d�s�n Kapali girisimlerde s�rekli epidural analjezi yi d�s�n A�ik girisimlerde s�rekli epidural veya intratekal analjezi yi d�s�n

54. Abdominal Cerrahi-Analjezi Ameliyatta: Epidural analjezi (uygun dermatom) diklofenak ve parasetamol AS: 36-48 saat inf�zyon D�zenli diklofenak ve parasetamol Epidural teknik kontrendike veya hasta kabul etmedi ise, alternatif:Morfin PCA veya NCA yi

55. SON S�Z ! �ocugun optimum konforunun saglanmasi i�in farmakolojik, psikolojik ve davranis y�ntemlerinin bir arada uygulanmasi gerekir

56. It�s worth to perform reg an and analg. She will show her gratefulness.It�s worth to perform reg an and analg. She will show her gratefulness.

58. I would like to talk about some anatomic differences which is technically effective for performing Ped Reg Block.The end of the spinal cord is at L3 in a newborn whereas(veres) it is at L1 in one a year old infant. End of the dural sac and spinal cord extends approximately two interspaces lower in the newborn and infant. Ep. space less adipose and dense, both of them favors the rostral spread of LA and allows the passage of ep.cath to greater distance in the space. I would like to talk about some anatomic differences which is technically effective for performing Ped Reg Block.The end of the spinal cord is at L3 in a newborn whereas(veres) it is at L1 in one a year old infant. End of the dural sac and spinal cord extends approximately two interspaces lower in the newborn and infant. Ep. space less adipose and dense, both of them favors the rostral spread of LA and allows the passage of ep.cath to greater distance in the space.

59. In this slide you can see the comparison of the newborn and adult columna wertebralis in lateral wiew. Beware that the CV has a S shape in adult In this slide you can see the comparison of the newborn and adult columna wertebralis in lateral wiew. Beware that the CV has a S shape in adult

60. The ability to predict the depth of the target area greatly increases the succes and safety of performing the block. As you seen target nerves and areas are closer to skin in children. The distance increases with age. The ability to predict the depth of the target area greatly increases the succes and safety of performing the block. As you seen target nerves and areas are closer to skin in children. The distance increases with age.

61. Volume of Extracellular fluid is higher in infants than compared to adult. It goes down with age.Volume of Extracellular fluid is higher in infants than compared to adult. It goes down with age.

62. GFR is low at birth and at the end of the first year of life it increases dramatically . reaching almost adult values. GFR is low at birth and at the end of the first year of life it increases dramatically . reaching almost adult values.

63. Generally all proteins , especially albumin and alfa one acid glycoprotein are low in children.Generally all proteins , especially albumin and alfa one acid glycoprotein are low in children.

64. Pharmacology-1 Greater volume of distrubition Lower peak plasma levels RESULT: LARGER DOSES ON MG/KG BASIS . Larger doses of LA are required in children, due to greater volume of distrubition and lower peak plasma levels. . Larger doses of LA are required in children, due to greater volume of distrubition and lower peak plasma levels.

65. Pharmacology-2 Neonates and infants less than 3 months Decreased hepatic clearance Reduced alb and Alfa-1 AG Higher peak plasma level Greater free unbound fraction RESULT for LA Initial doses should be reduced Should be increase slowly Maintenance dose should be reduced Neonates and infants less than 3 months show some characteristics Decreased hepatic clearance .... .....Neonates and infants less than 3 months show some characteristics Decreased hepatic clearance .... .....

66. �ocuklarda Ameliyat Sonrasi Agri Tedavisi Pediyatrik Anestezi Kursu 27Subat/6Mart 2010 Dr. G�ner Kaya I� Cerrahpasa Tip Fak�ltesi