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EDRA > 6.2 Paediatrics > Flashcards

6.2 Paediatrics Flashcards

1
Q

Regional anaesthesia

A

Regional anaesthesia in children
is usually done under
general anaesthesia or sedation.

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2
Q

In neonates

Metabolism and effect

A

In neonates,

the liver enzymes
and metabolic processes are immature,

hence there is 
less metabolism of 
local anaesthetics and 
greater chances of 
toxicity as compared to adults.
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3
Q

A1 acid glyco levels

effects

A

In neonates,
α1 acid glycoprotein levels
are 20%–40% of adult levels,

hence higher plasma levels
of unbound free drug
contributes to toxicity as well

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4
Q

When does conjugation of LA reach adult level

A

Around 3 months of age,

the conjugation of
local anaesthetics reaches
adult value,

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5
Q

When does clearance reach adult level

A

whereas full maturation
and clearance equivalent to adults
occur by around 8 months.

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6
Q

is there diff in plasma concentrations when LA injected

A

In children, there may be

higher vascular absorption of
local anaesthetics and

higher plasma concentration.

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7
Q

Is the paediatric nerve equally sensitive to LA

A

As myelination is incomplete up to
the age of 12 years,

local anaesthetic can penetrate
better in the nerves.

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8
Q

Is the mg/kg dose the same vs adults

A

Because of
greater sensitivity and
potential for toxicity,

the dose of local anaesthetic in
children (mg/kg) is less than adults.

Because of loose fascial layers,
volume of LA is a key factor
for spread than dose.

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9
Q

Ester local anaesthetics metabolism

vs amide

why diff

A

Ester local anaesthetics

do not depend on liver
for their metabolism

and have more rapid clearance
than amide local anaesthetics in neonates.

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10
Q

Ester LA and neonates dose

why

A

However, because of

low levels of plasma
cholinesterases in neonates,
ester local anaesthetics
should be used with caution.

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11
Q

Local anaesthetics with their recommended doses

Lignocaine

A

Lignocaine 7 mg/kg (with adrenaline)

5 mg/kg (without adrenaline

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12
Q

Bupivacaine/ropivacaine/levo-bupivacaine dose

A

Bupivacaine/ropivacaine/ 2–4 mg/kg

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13
Q

Procaine

A

Procaine 10 mg/kg

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14
Q

2-Chloroprocaine dose

A

2-Chloroprocaine 20 mg/kg

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15
Q

Bupivicaine and neonates

A

There is
greater risk of toxicity
with bupivacaine in neonates
than adults because of:

1
Liver enzymes being immature –
less metabolism of bupivacaine.

2
Low levels of alpha-1 glycoprotein –
higher free fraction of
bupivacaine.

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16
Q

Early signs of LAST in paeds

A

Regional blocks are usually done
under sedation in paediatric patients.

Therefore, the central nervous system 
signs of local anaesthetic toxicity are
usually masked and the
first sign usually detected is 
cardiorespiratory arrest.
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17
Q

Some anatomical facts in neonates and children

Spinal cord terminates

reaches adult level

A

Spinal cord terminates at L3

and reaches adult level of
L1 by 1 year of age.

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18
Q

Dural sac

neonates ends @

reaches adult level by

A

Dural sac ends at S4 in neonates

and reaches adult level S2 by 1 year of age.

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19
Q

sacrum formed by

A

Sacrum is formed by fusion of sacral vertebrae by 8 years of age.

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20
Q

Tuffier’s line neonates

what level @1

A

Tuffier’s line passes through L5/S1
junction in neonates

and lies at L4/L5 by 1 year.

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21
Q

Epidural space found how estmiation

A

Epidural space may be found at 1 mm/kg body weight.

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22
Q

Are epidural contents the same

A

There is easy passage of catheter in
epidural space, as epidural fat is
less densely packed than adults.

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23
Q

what does spread of LA correlate well with

A

Spread of local anaesthetic correlates
better with body weight than
age in paediatric patients.

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24
Q

Optimum doses for caudal block in children are

A

Optimum doses for caudal block in children are:

0.2% ropivacine 1 mL/kg

or

0.125%–0.175% bupivacaine 1 mL/kg

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25
Q

Epidural opiods in DOSA

A

Epidural opioids are avoided in day-case surgery because of side
effects like nausea, vomiting, respiratory depression and urinary
retention.

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26
Q

Local anaesthetic adjuvants for epidural in children

most common

A

most common adjuvant used is epinephrine

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27
Q

Epidural opioids

dosa?

s/e

A

Avoided in day-case surgeries

Side effects like nausea, vomiting, respiratory depression and urinary retention

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28
Q

adjuvants for epidural

Clonidine

dose

s/e

A

Clonidine

1–5 mcg/kg

Side effects:
hypotension and sedation

Ventilatory response to
increasing levels of carbon dioxide is blunted

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29
Q

adjuvants for epidural

Ketamine

dose

solution

safety?

s/e

A

Ketamine

0.25–0.5 mg/kg

Preservative-free solution must be used

Its safety for epidural use is not established

There are few animal studies suggesting neurotoxicity

Side effects: psychomimetic effects

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30
Q

adjuvants for epidural

Midazolam

dose

solution

safety

A

Midazolam

0.05 mg/kg

Preservative-free solution must be used
Its safety for epidural use is not established

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31
Q

adjuvants for epidural

Neostigmine

dose

solution

safety

s/e

A

Neostigmine

2 mcg/kg

Preservative-free solution must be used

Its safety for epidural use is not established

Side effects: nausea and vomiting

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32
Q

complication of epidural block

predominant organism colonising epidural catheter

A

predominant organism colonising epidural catheter is

Staphylococcus epidermidis.

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33
Q

The treatment of post-dural puncture headache in children involves

A

The treatment of post-dural puncture headache
in children involves

1
bed rest, sedation and

2
analgesics like non-steroidal antiinflammatory
drugs.

3
Blood patch may be used if medications fail.

34
Q

EBP in paeds dose

A

The optimum dose of blood for

blood patch is 0.3 mL/kg.

35
Q

cardiac instability and epidural

A

Unlike adults,

use of epidural in children is cardiostable

and presence of hypotension may
indicate intrathecal location
of catheter or
local anaesthetic toxicity.

36
Q

How are test doses monitored in paeds epidurals

A

Test dose must always be
used for epidural catheter,

with continuous
ECG monitoring
for T-wave changes.

37
Q

Confirmation of epidural catheter position can be done with

A

1
Ultrasonography:

2
Epidural ECG:

3
Electrical stimulation test (Tsui test)

38
Q

Ultrasonography

A

aids in identifying relevant anatomic structures and
placement of epidural catheter. It is reliable only in children aged
< 6 months, as calcification of vertebral bodies prevents visualisation
after this age.

39
Q

Epidural ECG

what changes

A

Epidural ECG:

T-wave changes help in
identifying intravascular
location of catheter.

It may not identify intrathecal placement.

40
Q

Epidural ECG

Electrode connected to catheter

A 
The
right-arm electrode is connected 
to the epidural catheter, and
epidural ECG is compared 
with standard reference ECG.
41
Q

QRS amplitude

Epidural ECG

A

The amplitude of QRS complex in

ECG obtained from epidural catheter
increases as the tip reaches thoracic region,

where it is comparable to the reference ECG.

42
Q

Epidural ECG

can it be used to confirm placement

A

It can be used to confirm placement of epidural catheter after neuromuscular blockers have been given or local anaesthesia given in epidural space.

43
Q

Electrical stimulation test (Tsui test)

cathode to anode to

A

Electrical stimulation test (Tsui test):

cathode attached to epidural
catheter while the anode
is attached to skin.

44
Q

Electrical stimulation test (Tsui test)

Change after LA if correct

A

Within the epidural space,
after correct placement of
local anaesthetic,

there would be increase in the current threshold current required to produce the motor response.

45
Q

Electrical stimulation test (Tsui test)

No change after dose

not useful when

A

No change in threshold current
indicates intravascular placement of
catheter.

It is not useful if neuromuscular blockers have been
administered or
local anaesthetics given in epidural space.

46
Q

Nerve stimulators for epidural stim

what current

same as peripheral?

A

Nerve stimulators used for
epidural stimulation test must be able to

deliver a current up to 10 mA.

As the nerve stimulators used for
peripheral nerve blocks usually deliver a current up to 5 mA, they are unsuitable.

47
Q

What element can be added to stim catheter to help

Nerve stimulators used for epidural stimulation

A

Epidural-stimulating catheter containing

metal element helps in
proper electrical conduction
and decreases the resistance to flow of the
current.

48
Q

Stylet epidural catheter use?

Nerve stimulators used for epidural stimulation

A

The epidural catheter with stylet
protects the tip and
helps in easy threading of the catheter

49
Q

Stylet ends how far from tip

what shape does that produce

Nerve stimulators used for epidural stimulation

A

The stylet ends 10 mm proximal to tip,

forming a J shape during insertion.

50
Q

Where is ground electrode placed

Nerve stimulators used for epidural stimulation

why

A

The ground electrode must be

placed on
upper limb and
lower limb for
lumbar and thoracic epidural catheter,

respectively, to avoid any error
from direct muscular stimulation
by the electrical current

51
Q

Caudal block

needles with stylet

A

Caudal block can be done with

needles with stylet, 
as they provide
good tactile sensation and 
prevent contamination of 
epidural space
with skin tags
52
Q

Caudal block

IV cannulae

A

Intravenous cannula can be used,
as they aid to detect placement in
the blood vessel or bone.

53
Q

Caudal block position

A

Caudal block can be performed

in prone (adults) or

lateral decubitus position (children)

54
Q

How to identify sacral hiatus

margins

A

Proper identification of

sacral hiatus is done by

drawing a line between the

two posterior superior iliac spines.

This line forms the base of an
equilateral triangle whose apex is
formed by the sacral hiatus

55
Q

The needle angle for the skin puncture

change after what is punctured

Caudal block

A

The needle for the
skin puncture must be
angulated at an

angle of 70°– 80° and

the angle must be decreased to

20°–30° once the
sacrococcygeal ligament
is punctured.

56
Q

Cannula over needle technique

aids

how

A

For caudal block,

the cannula-over-needle technique

aids in proper identification
of the caudal space.

The cannula slides off easily
in the caudal space if the needle
is in the right location.

57
Q

Cannula over needle technique

helps also ID what

decreases risk of

A

It also helps in identifying needle
placement in the bone or blood vessel.

It decreases the risk of intrathecal
placement.

58
Q

epidural block in paediatric

skin to epidural space distance in children vs adults

A

skin to epidural space distance in children

is less than in adults

59
Q

skin to epidural space distance in neonates

mean

A

mean distance in neonates is around 1 cm.

60
Q

Puncturing lig flavum vs adults

A

There is less tactile sensation on puncturing the ligamentum flavum
as compared to adults

61
Q

is hypotension common in epdural block

A

Sympathetic blockade is
well tolerated in the paediatric population,

and presence of hypotension
must prompt suspicion of
intravascular or
intrathecal placement.

62
Q

distance of the epidural space from skin may be dependen

A

distance of the epidural space from skin
may be dependent on age
and body weight of the child.

63
Q

Tip of epidural catheter location

A

tip of the catheter must be
at the surgical site,

as the distance in
children between adjacent
vertebrae is very small

64
Q

Threading the catheter into a

thoracic location from a lumbar insertion site

A

Because of formation of lumbar curvatur
as the child grows,

threading the catheter into a
thoracic location from a lumbar insertion site
becomes difficult

65
Q

Approach for thoracic epidurals

A

Thoracic epidural block is done via
median approach in children,
compared with paramedian approach in adults.

66
Q

CSF volume infants v adults

A

Cerebrospinal fluid volume in
infants is 4 mL/kg,

whereas in adults it
is 2 mL/kg.

in neonates in mL/kg is larger than
adults

67
Q

Duration of spinal in paeds vs adults

dose

block duration increases with

A

duration of spinal anaesthesia is

shorter than for adults and

they require higher dose of local anaesthetic.

Duration of block increases with age.

68
Q

Spinal positioning in paeds vs adults

why

A

For proper positioning in sitting position,
neck flexion,
required in adults,
must be avoided in infants.

Neck flexion may compromise the
airway in infants and is
not very helpful for spinal anesthesia.

69
Q

Hypobaric soln and infants

A

Hypobaric solutions are not routinely used in infants

70
Q

What scale can be used to assess block <2yo

A

Bromage scale can be used to
assess spinal block in
children under 2 years of age

71
Q

Modified Bromage score

A

1 Complete block (unable to move feet or knees)

2 Almost complete block (able to move feet only)

3 Partial block (just able to move knees)

4 Detectable weakness of hip flexion while supine (full flexion of knees)

5 No detectable weakness of hip flexion while supine

6 Able to perform partial knee bend

72
Q

PDPH kids v adults

A

In children,

the incidence of PDPH is less than for adults.

73
Q

Sympathetic block

HD changes

A

Sympathetic blockade is better
tolerated in infants,

and changes in
heart rate and blood pressure are rare.

74
Q

Preloading in infants

A

Preloading is rarely required in infants prior to spinal blockade

75
Q

Is spinal in prem a relative C/I

A

Spinal anaesthesia is

preferred in preterm infants,

as it reduces but
does not eliminate the risk of post-operative apnea

76
Q

Spinal anaesthesia and post op apnoea in prem eliminated

A

reduces but

does not eliminate the risk of post-operative apnea

77
Q

Relative contraindications to spinal anaesthesia in paeds

A

Relative contraindications to spinal anaesthesia include

coagulation abnormalities,

local infection,

raised intracranial pressure,

degenerative neurological disease,

refusal by parents and

presence of ventriculoperitoneal shunts.

78
Q

Scalene approach in paeds

A

Parascalene approach is preferred
over interscalene in children to
reduce risk of complications

79
Q

In parascalene approach

whats blocked

A

In parascalene approach,

roots and trunks of brachial plexus are blocked.

80
Q

Needle approach

In parascalene approach

A

The needle is inserted at the
junction of upper two thirds
and lower one third of an imaginary

line drawn from C6 to the midpoint of
clavicle.

81
Q

Commonest BP block approach in paeds

A

Axillary block is the most common approach to brachial plexus
block in the paediatric population

82
Q

change in complication in paeds given performed under GA

A

Despite performance of blocks under general anaesthetic, the incidence
of complications is not increased

EDRA (26 decks)

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