Boston Children's Questions

Question 1

What are the oxygenation goals for prevention of ROP in neonates?

Answer 1

Maintain SaO2 89 - 94% (paO2 50 - 70 mmHg)

Question 2

At what age is the nadir of physiologic anemia of infancy in a term infant and what Hgb levels would you expect?

Answer 2

8 - 12 weeks of age (most books say 3 months) with levels Hgb = 9 - 11 g/dL

Question 3

At what age is the nadir of physiologic anemia of infancy in a premature infant?

Answer 3

3 - 6 weeks of age with levels 6 - 8 g/dL

Question 4

How does a fetus maintain temperature in utero?

Answer 4

The fetus is dependent on maternal thermoregulation to maintain normal temperature!

Question 5

What is the blood volume of a fetus in terms of cc/kg?

Answer 5

120 - 160 cc/kg at mid-gestation then decreases as the fetus approaches term

Question 6

How does fetal myocardium primarily differ from adult myocardium?

Answer 6

Fetal myocardium has a greater proportion of non-contractile elements relying on heart rate to maintain cardiac output.

Question 7

What physiologic evidence is consistent with the claim that fetuses experience pain?

Answer 7

Fetuses have a physiologic response to painful stimuli resulting in increased cortisol and endorphin levels.

Question 8

What is a normal fetal heart rate?

Answer 8

120 - 160 bpm

Question 9

What is the parkland formula?

Answer 9

A formula for calculating fluid resuscitation in burn victims. Specifically: (4cc)*(patient_weight_in_kg)*(percent_BSA_burned) = cc_to_be_given_over_24_hours First 8 hours = 1/2 total fluid Next 16 hours = the other 1/2 of fluid

Question 10

How does the “rule of nines” for calculating burn BSA differ between children and adults?

Answer 10

The primary differences are 1) that an adults face = 9% while a child’s face = 18% 2) each adult leg counts for 18% while a child’s leg counts for 14%

Question 11

How will a left to right shunt affect the kinetics of inhaled induciton?

Answer 11

Left to right shunts tend NOT to have appreciable effects on the kinetics of inhaled induction.

Question 12

How many liters of oxygen and what psi correspond to a full E cylinder of oxygen?

Answer 12

660L at 1900 psi

Question 13

How are ester group local anesthetics metabolized?

Answer 13

By plasma cholinesterases

Question 14

How do plasma cholinesterase levels differ in infants as compared to adults?

Answer 14

Under 6 months of age, plasma cholinesterases are half of adult values.

Question 15

How are amide group local anesthetics metabolized?

Answer 15

By the liver.

Question 16

Why are neonates and infants at greater risk of local anesthetic systemic toxicity with amide local anesthetics?

Answer 16

Lower levels of albumin and alpha 1 glycoprotein result in higher levels of free local anesthetic and it is this free level that contributes to toxicity.

Question 17

What is the initial dose of intralipid after starting PALS for local anesthetic systemic toxicity?

Answer 17

1.5cc/kg of 20% intralipid

Question 18

How and when might hypocalcemia present after thyroidectomy?

Answer 18

12 to 18 hours after surgery as any of the following: 1) inspiratory stridor 2) laryngospasm 3) perioral numbness 4) hypotension

Question 19

What are the two main causes of stridor after thyroidectomy and when would you expect each to cause stridor?

Answer 19

1) Bilateral recurrent laryngeal nerve paralysis with stridor in the immediate extubation/PACU period 2) Hypocalcemia due to hypoparathyroidism presenting 12 to 18 hours after surgery

Question 20

What is treacher-collins syndrome and what are the primary anesthetic concerns?

Answer 20

aka Mandibulofacial dysostosis with bilateral 6, 7, 8 craniofacial clefts, hearing loss 1) difficult or impossible BMV 2) High risk for orbital compression in the prone position 3) associated CHD (uncommon) 4) OSA

Question 21

Name the likely syndrome.

Answer 21

Treacher Collins

Question 22

What anomalies characterize Pierre Robin sequence?

Answer 22

1) retrognathia
2) glossoptosis (tongue falling to back of throat)
3) Airway obstruction

Question 23

Pierre Robin sequence is most commonly associated with what syndromes?

Answer 23

Most commonly with Stickler syndrome, characterized by micrognathia, poor vision, and a collagen disorder with hyperflexible joints.

Also associated with velocardiofacial syndrome, fetal alcohol syndrome, and bilateral hemifacial microsomia.

Question 24

Name the likely syndrome.

Answer 24

Apert syndrome

Question 25

What is another name for Apert syndrome?

Answer 25

Acrocephalosyndactyly

Question 26

What are the clinical features of Apert syndrome?

Answer 26

1) Orbital hypertelorism
2) Turribrachycephaly
3) midface hypoplasia
4) CHD in 10% (common e.g., VSD, pulmonary stenosis)
5) fusion of digits 2 to 4
6) fusion of cervical vertebrae
7) MR is common

Question 27

Name the likely syndrome.

Answer 27

Crouzon syndrome

Question 28

What are the clinical features of Beckwith-Wiedemann Syndrome?

Answer 28

1) Macrosomia (birthweight > 90%, easily 4kg)
2) macroglossia
3) midline abdominal wall defects (omphalocele, umbilical hernia)
4) visceromegally
5) ear creases or ear pits
6) high risk neonatal hypoglycemia
7) association with Wilm’s tumor

Question 29

What is Shprintzen syndrome?

Answer 29

Velocardiofacial syndrome with 22q deletion

Question 30

What is a normal neonatal Hgb?

Answer 30

18 - 19 g/dL

Question 31

What is neonatal blood volume at birth a function of?

Answer 31

1) Gestational age
2) Timing of umbilical clamping at birth

Immediate clamping = 80cc/kg

Delayed clamping (2 - 3 minutes) increases blood volume by 20 - 40 cc/kg

Question 32

What are possible benefits of delayed clamping of umbilical cord?

Answer 32

Increased Hct

Increased iron stores

decreased risk of severe anemia