| Abstract | Odabir lijekova u anesteziji djece definiran je anatomskim, fiziološkim, patofiziološkim i psihološkim osobitostima djece. U pravilu se u dječjoj anesteziji koriste isti lijekovi kao u odraslih, ali su odabir lijekova, doze i interval između doza za pojedini lijek prilagođeni osobitostima dobnih skupina djece.
U prvom, uvodnom poglavlju, opisane su najvažnije anatomske i fiziološke karakteristike djeteta koje zahtijevaju drukčiji pristup nego u odraslih. Drugo je poglavlje posvećeno općoj anesteziji: premedikacija, uvod i održavanje anestezije, uz poseban osvrt na primjenu opioida i mišićnih relaksatora. Pravilnom pripremom djeteta premedikacija u pravilu nije potrebna. U djece starije od 6 mjeseci može se primijeniti sedativna premedikacija, najčešće midazolamom peroralno 20-ak minuta prije uvoda u anesteziju. Za odabir vrste anestezije vrijede ista pravila kao i kod odraslih uz poštivanje osobitosti djece i njihove fiziologije. U manje djece najčešće se rabi inhalacijski uvod u anesteziju sevofluranom koji u odnosu na ostale inhalacijske anestetike ima najmanje neželjenih učinaka. Za intravenski uvod koristi se najčešće propofol, a mogu se primijeniti i drugi lijekovi (tipental, etomidat, ketamin). Balansirana anestezija podrazumijeva primjenu inhalacijskog anestetika (najčešće sevofluran, može i izofluran) uz dodavanje opioida tijekom kirurškog zahvata. TIVA (totalna intravenska anestezija) je poštedna metoda anestezije koja podrazumijeva kontinuiranu intravensku primjenu sedacijsko-hipnotičkog sredstva (propofol), analgetika (opioida) i mišićnog relaksatora. TCI (Target Controlled Infusion) anestezija omogućuje postizanje ciljne koncentracije lijeka u plazmi. Danas postoje modeli TCI – sustava prilagođeni djeci. Uporaba opioida u djece danas je rutinska. Prednost se daje fentanilu i njegovim derivatima (remifentanil, sufentanil, alfentanil). Najozbiljnija nuspojava svih opioida je respiracijska depresija pri čemu sufentanil najmanje utječe na njen nastanak. Ovisno o potrebi kirurškog zahvata primjenjuju se mišićni relaksatori (atrakurij, pankuronij, vekuronij, rokuronij). Sukcinilkolin, jedini depolarizirajući mišićni relaksator u kliničkoj upotrebi, zbog brzog nastupa djelovanja ostaje lijek izbora u okolnostima žurnog zbrinjavanja dišnog puta intubacijom. U trećem se poglavlju raspravlja o regionalnoj anesteziji koja ima mnoge prednosti u odnosu na opću te se danas sve češće izvodi u djece. Najčešće se izvode kaudalni blokovi, a najbolji lokalni anestetici jesu lidokain, za dulje zahvate levobupivakain i ropivakain. |
| Abstract (english) | Drug selection in pediatric anesthesia has been defined by anatomical, physiological, pathophysiological and psychological particularities of children. Generally, all the drugs that are used in adults are also used in pediatric anesthesia, but their selection, doses and the interval between the doses for each drug are adjusted to the particularities of a child’s age group. In the first, introductory chapter, main anatomical and physiological characteristics of a child which require a different approach have been described. The second chapter is dedicated to general anesthesia: premedication, induction and maintenance, with a special review of the appliance of opioids and muscle relaxants. With the right preparation of a child premedication is generally not necessary. In children older than 6 months sedative premedication can be used, usually with midazolam administrated orally approximately 20 minutes before the induction of anesthesia. While choosing a type of anesthesia, main rules are applied as for the adults, with the respect of specificities and physiology of children. Inhalational induction is usually applied in smaller children using sevoflurane which has least adverse effects compared to other volatile anesthetics. For intravenous induction propofol is most commonly used and other drugs can be applied as well (thiopental, etomidate, ketamine). Balanced anesthesia means using an inhalational anesthetic (usually sevoflurane, either isoflurane) with the addition of opioid during a surgical procedure. TIVA (total intravenous anesthesia) is a spare method of anesthesia which includes a continuous intravenous appliance of a sedative-hypnotic agent (propofol), analgesic (opioid) and a muscle relaxant. TCI (Target Controlled Infusion) anesthesia allows the acquirement of target concentration of a drug in the blood. Today there are TCI – models adjusted to children. The use of opioids in children is a routine nowadays. Fentanyl and its derivates (remifentanil, sufentanil, alfentanil) have a precedence. The most serious side effect using opioids is respiratory depression while sufentanil least affects its occurrence. Depending on the need of surgical procedure, muscle relaxants are used (atracurium, pancuronium, vecuronium, rocuronium). Succinylcholine, the only depolarizing muscle relaxant in clinical use, is a drug of choice in the urgent airway care using intubation. In the third chapter regional anesthesia is discussed, which has a lot of advantages compared to general anesthesia and is more and more often used in children. Caudal blocks are usually performed and the best local anesthetics are lidocaine, for longer procedures levobupivacaine and ropivacaine. |
