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Peds Anesthesia Boards > ACE 6A > Flashcards

ACE 6A Flashcards

1
Q

What is the first recommended therapy in a patient with VT who has a pulse?

A

Synchronized cardioversion

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2
Q

What dose of lidocaine should be used for the treatment of VT with a pulse?

A

Lidocaine is no longer part of the PALS guidelines for the treatment of VT with a pulse.

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3
Q

What dose of amiodarone should be given for VT with a pulse?

A

5 mg/kg IV over 20 - 60 minutes. This is given if cardioversion was ineffective. Find a pediatric cardiologist is possible.

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4
Q

What dose of procainamide should be given for VT with a pulse?

A

15 mg/kg IV over 30 - 60 minutes. This is given if cardioversion was ineffective. Find a pediatric cardiologist is possible.

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5
Q

What energy levels should be used for synchronized cardioversion of VT?

A

0.5 to 1 J/kg. If not effective, increase to 2 J/kg

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6
Q

Describe R-R and PR intervals in sinus tachycardia.

A

Variable R-R; constant P-R

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7
Q

What HR do you expect in infants and children with SVT? Sinus tachycardia?

A

Infants: SVT usually >= 220; sinus tach < 220
Children: SVT usually >= 180; sinus tach < 180

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8
Q

How does one treat probably SVT in an infant or child?

A
  1. Consider vagal maneuvers
  2. If IV access: adenosine 0.1 mg/kg (max 1st dose 6mg) by rapid bolus. May double 2nd dose and give once (max 2nd dose 12mg)
  3. Or can do synchronized cardioversion 0.5 - 1 J/kg; if not, effective increase to 2 J/kg
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9
Q

How does synchronized cardioversion for SVT and synchronized cardioversion for VT differ in pediatrics?

A

They don’t differ. They are identical. 0.5 - 1 J/kg. If not effective increase to 2 J/kg.

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10
Q

How often does antibiotic prophylaxis prevent infective endocarditis?

A

Rarely.

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11
Q

Which is more likely to case infective endocarditis: surgical procedures or daily activities?

A

Daily activities and poor oral hygiene

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12
Q

Which is more effective in the prevention of infective endocarditis: antibiotic prophylaxis or proper oral hygiene?

A

proper oral hygiene

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13
Q

What cardiac conditions are associated with the greatest risk of adverse outcome if endocarditis occurs?

A
  1. Presence of prothetic valve or materials
  2. prior hx of infective endocarditis
  3. unrepaired cyanotic congenital heart disease
  4. CHD repaired using prosthetic materials less than six months ago
  5. repaired CHD with residual defects
  6. heart transplant with evidence of valvulopathy
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14
Q

What surgical procedures are associated with the highest risk of producing bacteremia?

A
  1. dental procedures involving gingival, periapical, and oral mucosa
  2. procedures involving infected skin and musculoskeletal tissues
  3. procedures involving incision or biopsy of the respiratory tract
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15
Q

A patient with a known PDA is to undergo a dental procedure. Should the patient receive infective endocarditis prophylaxis?

A

Yes.

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16
Q

A patient who underwent PDA ligation 7 months ago is to undergo a bronchoscopy with biopsy. Should the patient receive infective endocarditis prophylaxis?

A

No. IE prophylaxis is indicated if the procedure was within the last six months.

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17
Q

A patient who underwent PDA ligation five months ago presents for a GU deflux procedure due to recurrent UTIs. Should the patient receive infective endocarditis prophylaxis?

A

No. IE prophylaxis is not indicated for patients undergoing genitourinary or gastrointestinal procedures

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18
Q

What pediatric patients are classically at increased risk for developing sensitivity to latex?

A

Patients with spina bifida or urinary tract anomalies.

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19
Q

Where does the ductus arteriosus usually exist?

A

The ductus arteriosus joins the mPA to the aorta at approximately the level of the left subclavian artery.

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20
Q

What is the difference between a “high” and “low” umbilical artery catheter?

A

Both are in the descending aorta, just in different locations. A high catheter is positioned with the tip of the catheter between the left SCA and the diaphragm. A low catheter is positioned with the tip between the renal arteries and the aortic bifurcation.
A low catheter

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21
Q

Can you sample preductal blood with a UAC?

A

Theoretically one could but virtually all catheters are placed with the tip somewhere in the descending aorta so in practice, the answer is no.

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22
Q

How does increased myocardial contractility affect blood flow in tetralogy of Fallot?

A

Increased myocardial contractility tends to increase infundibular RVOT obstruction which results in greater R to L shunting.

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23
Q

How does one treat a hypercyanotic episode in an awake child with Tetralogy of Fallot?

A
  1. Administer 100% O2
  2. Assume knee-chest position
  3. Administer morphine
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24
Q

Does heart rate become bradycardic, tachycardic or remain within normal limits during a hypercyanotic episode of tetralogy of fallot?

A

Tachycardia is a common manifestation of hypercyanotic episodes.

25
Q

Would you expect an inotrope to be helpful or harmful during a “tet spell?” Why?

A

Harmful. The increased myocardial contractility will increase the dynamic component of infundibular obstruction and worsen the right-to-left shunt and thus worsen cyanosis.

26
Q

What is a more technical term for “croup?”

A

Laryngotracheobronchitis

27
Q

What is the etiology of croup?

A

Vast majority of cases are infectious in etiology but a small percentage have an allergic etiology.

28
Q

Describe the history and presentation of viral croup.

A

Gradual onset following a URI. Low-grade fever is common. Stridorous, tachypneic, retractions, hoarseness, high-pitched barking cough.

Compared to epiglottits a child with croup is more likely to be less than 3 years old, less likely to have a high fever, more likely to be tachypneic.

29
Q

Describe the history and presentation of epiglottis.

A

Tends to occur in children older than 3 years without any kind of viral prodrome. They often appear toxic with high fever. Classically they present with drooling, dysphagia and distress. They often have a muffled voice and a barking cough.

30
Q

What is the incidence of trisomy 21 in terms of live births?

A

1 in every 600 - 800 live births

31
Q

Describe the typical appearance of down’s syndrome.

A 
Hypotonia
Flat face
midface hypoplasia
slanted palpebral fissures
epicanthal folds
shortened digits (brachydactyly)
curved digits (clinodactyly)
microcephaly
simian creases
32
Q

What percentage of down’s syndrome infants have congenital heart disease?

A

44%

33
Q

What is the most common cardiac lesion in infants with trisomy 21?

A

Endocardial cushion defects (AV septal defects) account for 45% of the cases of CHD in children with trisomy 21 and CHD.

34
Q

How does thyroid function in children with trisomy 21 compare with that of the general population?

A

HYPOthyroidism occurs in 30% of the trisomy 21 population (a far higher prevalence than the general population).
HYPERthyroidism occurs to a much lesser extent (0.6% of the trisomy 21 population) but this is still a higher prevalence of HYPERthryoidism than in the general population.

35
Q

Do Down’s syndrome patients have an increased prevalence of tracheomalacia?

A

No, but they do seem more likely to experience postextubation stridor.

36
Q

What are the cardiovascular anomalies associated with trisomy 21?

A
  • CHD of which endocardial cushion defects account for 40% of the defects
  • Mitral valve prolapse (50% of adults with Down’s)
  • Aortic insufficiency (15% of adults with Down’s)
37
Q

What are the respiratory anomalies associated with trisomy 21?

A 
TEF
Pulmonary hypoplasia
Macroglossia
Increased risk of postextubation stridor
OSA
Subglottic stenosis
Narrow nasopharynx
tonsillar and adenoid hypertrophy
38
Q

What are the CNS anomalies associated with trisomy 21?

A 
Hypotonia
Developmental Delay
Atlantoaxial instability
Abnormal fontanelles (delayed closure, three fontanelles)
Seizure disorder
Hearing loss (conductive and/or sensorineural)
Alzheimer's
ADHD
39
Q

What are the GI anomalies associated with trisomy 21?

A 
Duodenal atresia
Annular pancreas
Imperforate anus
GERD
Hirschsprung's
Obesity
Celiac disease (aka gluten enteropathy, aka nontropical sprue)
40
Q

What are the hematologic anomalies associated with trisomy 21?

A

Polycythemia (at birth)
Acute lymphocytic leukemia
Lymphomas

41
Q

What are the endocrine anomalies associated with trisomy 21?

A

Hypothyroidism

Diabetes mellitus

42
Q

What are the five most common congenital heart lesions in patients with trisomy 21 from most common to least?

A 
AV septal defect (45%)
VSD (35%)
ASD (8%)
PDA (7%)
TOF (4%)
43
Q

Describe the anatomy of a persistent left superior vena cava (i.e., connections to/from) ?

A

A PLSVC is a congenital abormality in which the left jugular and left subclavian venous systems drain in to a left superior vena cava which empties directly into the coronary sinus.

44
Q

What is the prevalence of a persistent left superior vena cava?

A

0.3% of the population

45
Q

A persistent left superior vena cava is derived from what embryonic structures?

A

Derived from left superior caval veins and part of the left common caval veins

46
Q

The bridging vein that connects a right SVC and a persistent left superior vena cava corresponds to that normal venous structure?

A

Innominate vein

47
Q

What is the clinical significance of persistent left superior vena cava?

A

Catheters placed in the left jugular or left subclavian veins will travel along a path on the left side of the chest toward the heart and infusions through these catheters will enter the right atrium through the coronary sinus. It would be difficult to correctly position a PAC from this side.

48
Q

How would retrograde cardioplegia delivery be affected by a persistent left superior vena cava?

A

Delivery of cardioplegia using a retrograde catheter placed into the coronary sinus is not likely to be effective as the cardioplegia would flow preferentially into the larger left subclavian and left jugular veins instead of the smaller coronary vessels.

49
Q

How would you diagnose persistent left superior vena cava by chest radiography?

A

If you were to see a central venous catheter placed in the left jugular or left subclavian vein in the patient’s left chest.

50
Q

How would you diagnose persistent left superior vena cava by TEE?

A

Agitated saline shows up in the coronary sinus after the contrast is injected into a vein in the left upper extremity.

51
Q

Define closing capacity.

A

The volume of gas in the lungs at which small airways begin to close. When closing capacity exceeds FRC, atelectasis will be present.

52
Q

In a cc/kg basis, how does FRC in the neonate compare with that of the adult?

A

In an awake and healthy neonate, FRC is dynamically maintained and is identical on a cc/kg basis as the FRC of an adult. However in the setting of apnea/general anesthesia/paralysis/sedation, the FRC of the neonate is markedly less than that of the adult due to decreased lung compliance and increased chest wall compliance.

53
Q

How does the number of alveoli in a neonate compare with that of an adult?

A

Neonates have fewer alveoli as compared with adult and this remains true throughout childhood until reaching adult levels at approximately 8 years old.

54
Q

At what age will children have developed the same number of alveoli as adults?

A

Approximately 8 years of age.

55
Q

What is the incidence in terms of live births of pyloric stenosis?

A

2.4 per 1000 live births

56
Q

Which sex is more likely to develop pyloric stenosis?

A

Boys

57
Q

What is the preferred method for establishing the diagnosis of pyloric stenosis?

A

Ultrasound (before ultrasound radiographic contrast studies were used to demonstrate “string” sign - contrast narrowly exiting the pylorus)

58
Q

Describe the classic acid-base status of a child presenting with pyloric stenosis and its cause.

A

Hypochloremic, hypokalemic metabolic alkalosis caused by protracted vomiting resulting in the loss of gastric fluid with a consequent loss of hydrochloric acid. The resulting hypochloremia impairs renal excretion of sodium bicarbonate.

59
Q

What is the crystalloid of choice to begin resuscitation of a child presenting pyloric stenosis?

A

Normal saline (potassium is added once urine output is confirmed).

Peds Anesthesia Boards (5 decks)

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