Basic principles of Peds Flashcards
for a adolescent arriving for elective surgery what must be done?
Stop everything and get a pregnancy test
the major objectives of pre-anesthetic medication are too
(1) allay anxiety
(2) block autonomic (vagal) reflexes
(3) reduce airway secretions
(4) produce amnesia
(5) provide prophylaxis against pulmonary aspiration of gastric contents
(6) facilitate the induction of anesthesia
(7) if necessary, provide analgesia.
premedication may also decrease the stress response to anesthesia and prevent
cardiac arrhythmia
factors to consider when selecting a drug or a combination of drugs for premedication include:
the child’s age,
ideal body weight,
drug history, and allergic status;
underlying medical or surgical conditions and how they might affect the response to premedication or how the premedication might alter anesthetic induction;
parent and child expectations;
the child’s emotional maturity, personality, anxiety level, cooperation, and physiologic and psychological status
diazepam oral
0.1-0.5mg
diazepam Rectal
1mg
midazolam oral
0.25-0.75mg
midazolam nasal
0.2mg
midazolam rectal
0.5-1mg
midazolam IM
0.1-0.15
lorazepam oral
0.025-0.05mg
Ketamine oral
3-6mg/kg
ketamine nasal
3mg/kg
ketamine rectal
6-10mg/kg
ketamine intramuscular
2-10mg/kg
benzodiazepines how do we prevent neurotoxicity
use preservative free for nasal administration
Anticholinergic agents were used
1) to prevent the undesirable bradycardia associated with some anesthetic agents (halothane and succinylcholine)
(2) to minimize the autonomic vagal reflexes manifested during surgical manipulations (e.g., laryngoscopy, strabismus repair)
(3) to reduce secretions.
most commonly used anticholinergics
atropine
scopolamine
glycopyrrolate
undesirable effects of anticholinergics
tachycardia dry mouth skin erythema hyperthermia result of inhibited sweating
which two anticholinergics cross the BBB
atropine and scopolamine
the recommended doses of anticholinergics are
atropine,0.01 to 0.02 mg/kg
scopolamine,0.005 to 0.010 mg/kg
which anticholinergic does not cross the BBB
glycopyrollate
which anticholinergic used to block the vagus nerve
atropine
which is better for sedative
scopolamine
infants who are at risk for or show early evidence of slowing of the heart rate should receive
atropine before the heart rate actually decreases to ensure a prompt onset of effect to maintain cardiac output.
which drug is twice as potent as atropine in decreasing oral secretions and the duration is three times greater
glycopyrrolate.
the recommended dose of glycopyyrolate
0.01mg/kg half that of atropine
or 10mcg/kg
the routine use of an anticholinergic for the sole purpose of drying secretions is probably unwarranted why
dry mouth can be a source of extreme discomfort for a child
When is glycopyolate best used for
sialorrhea associated with ketamine.
what is as important as your laryngoscope
suction
Preparation for induction of anesthesia includes:
- warming the OR
- ensure warming devices work
- preinduction checklist (variety of sizes of masks, airways, blades, etc
- anesthesia machine and monitoring equipment are prepared
- precordial stethoscope
- ensure a quite and calm OR environment
inhalation induction in children
-what is the optimal induction sequence in toddlers?
what are some ways to do this?
- avoid making them feel vulnerable
- have them pick out a lip balm flavor for their mask
- allow them to sit in the lap of a parent
- distract them by having them “blow up the balloon”
what should be at hand to help position and hold the child when needed.
assistant.
do we let children bring their favorite toy or security blanket into the OR
Yes
how do we distract older children
allow them play electronic handheld games or to watch a movie on a portable electronic device
how is the tradition mask induction of anesthesia accomplished
nitrous oxide to 02 - 2:1
offering children the choice of a scented mask
bubble gum or strawberry flavor, applied to the inside of the face mask may disguise the odor of the plastic.
let them play with the mask ahead of time.
what can be seen with induction
Sevoflurane is then introduced and can be rapidly increased to 8% in a single stepwise increase, without significant bradycardia or hypotension in otherwise healthy children.
.The reason for maintaining delivery of a high concentration of sevoflurane is to minimize the risk of
awareness during the early period of the induction sequence.
IV induction is usually reserved for who?
What should the child be doing prior to iv induction?
reserved for : older kids, those who request it, those with a previously established IV , potential CV instability, and those who need RSI
ideally, child should be breathing 100% O2 before induction
iv induction dose of Thiopental
5-8mg/kg
iv induction dose of Methohexital
1-2.5 mg/kg
iv induction dose of propofol
2.5-3.5 mg/kg
iv induction dose of etomidate
0.2-0.3 mg/kg
iv induction dose of ketamine
1-2 mg/kg
airway obstruction during anesthesia or loss of consciousness appears to be most frequently related to loss of muscle tone in the pharyngeal and laryngeal structures rather than
apposition of the tongue to the posterior pharyngeal wall.
the progressive loss of tone with deepening anesthesia results in progressive airway obstruction primarily at the level of the
soft palate and the epiglottis
*in children, the pharyngeal airway space decreases in a dose dependent manner w/ increasing concentrations of both sevo and propofol anesthesia.
extension of the head at the atlantooccipital joint with anterior displacement of the c.spine (sniffing position) improves hypopharngeal airway patency but does not necessarily change
the position of the tongue
compared with chin lift and CPAP, the jaw thrust maneuver is the most effect means to do what?
improve airway patency and ventilation in children undergoing adenotonsillectomy
Laryngospasm is defined as the reflex closure of the
false and true vocal cords
complete laryngospasm is defined as closure of the false vocal cords and apposition of the laryngeal surface of the
epiglottis and interarytenoids
**net effect is complete cessation of air movement and noisy respiration, absence of movement of the reservoir bag, and an absent capnogram.
Review slide 33 - laryngospasm algorithm
-
IV fluid administration sets should be prepared before
the child arrives in the OR.
Appropriate size bag of LR and equipment for:
- young children
- infants < 1 yr old
young children: 500mL bag of LR with a graduated buretrol is appropriate
infants < 1 yr: 250mL bag with buretrol is preferable
**always use a buretrol
the use of a buretrol and IV fluid bag are intended to limit the risk of
adverse events should the entire bag inadvertently be infused in the child.
Initial blood loss may be replaced with balanced salt solution at a rate of
3mL of solution for every 1mL of blood loss.
3:1
For thrid space losses, replacement is based on teh severity of the losses:
minor: 1-2ml/kg
moderate: 2-5 ml/kg
major: 6-10 ml /kg
the smallest IV cannula through which blood can be infused rapidly:
22 g
Fluid management 4-2-1 rule
1st 10kg = 4 ml/kg
2nd 10kg = 2 ml/kg
each kg >20kg = 1 ml/kg
total ml/kg/ HOUR
deficit estimation:
hourly requirement x NPO hours
- give 50% in hour 1
- remainder in hours 2 and 3
deep tracheal extubation requires an organized plan.
in order to extubate the trachea deep, what must the depth of inhalational anesthesia be?
1.5 -2 x MAC
example: 2 yr old
-MAC of Sevo = 2%
deep extubation, MAC needs to be 3-4%
Emergence delerium has a peak incidence in children of what ages
2-6yrs
emergence delerium is more common after certain anesthetics. order of likelyhood:
sevo ~ des~ iso > halothane ~ TIVA
how long does emergence delerium usually last?
how can it be terminated?
last 10-15mins -terminate spontaneously OR after an IV dose of: propofol midazolam clonidine dexmedetomidine ketamine opioids
many parents express more concern about the risk of _____ than those of the surgery.
risks of anesthesia than those of the surgery
each child and family must be evaluated individually. what is good for one child and family…
may not be good for the next
max stress for parents. minimum on infant (not old enough to fear strangers)
likely age?
0-6mos
Max fear of separation.
significant post-op emotional upset and behavior regression
magical thinking
cognitive development and increased temper tantrums
likely age?
6mos - 4 yrs
Concern about body integrity
separation anxiety
understands processes and explanations
likely age?
8yrs - adolescence
independent
self esteem and body image issues
developing sexual characteristics
fears loss of dignity
likely age?
adolescence
cyanosis is likely associated with what CV condition?
right to left shunt
a murmur may be related to what CV condition?
septal defect
hx of neuromuscular dx? what might this indicate?
NMD sensitivity
r/o MH
hypoglycemia and adrenal insufficiency in childs hx may indicate use of what medication?
steroid
vaccinations may have been recent in a child presenting to surgery. what must anesthesia provider consider?
- whether the iummunomudulatory effects of anesthesia and surgery might affect the efficacy and safety of the vaccine.
- whether the inflammatory responses to the vaccine will alter the perioperative course
in peds, what anesthetic agents are associated with undesirable bradycardia?
to prevent the undesirable bradycardia associated with some anesthetic agents (halothane and succinylcholine)
to minimize the autonomic vagal reflexes manifested during surgical manipulations (e.g., laryngoscopy, strabismus repair) what agents are used?
anticholinergics
what is more commonly used and blocks the vagus nerve more effectively than scopolamine?
atropine
factors associated with laryngospasm include:
- age
- URTI recently
- hx of reactive airway disease
- second hand smoke exposure
- airway surgery
- airway devices (ETT, LMA)
- stimulation of glottis during light plane
- secretions in oropharynx
- inhaled anesthesia (des and iso)
- **inexperienced anesthesia provider
laryngospasm risk is greater in infants than older children and adults; the risk decreases with
increasing age
algorithm for laryngospasm doses;
IV access
IM access
IV: 1-2mg/kg Succ; 0.02mg/kg Atropine; consider propofol
IM: 3-4mg/kg Succ; 0.02mg/kg Atropine; and call for help
