Case Management Flashcards
Pre Op Assessment Keys:
Co-existing Medical conditions: URI, fever etc
Birth/Prematurity/Neonatal Complications Hx
Social Hx/smoke exposure
Anesthetic Hx
NPO Status (for healthy kids)
CLQ = 2 hrs // Breast milk = 4 hrs // Formula, juice, dairy milk = 6 hrs // solids = 8 hrs
Cows milk = longer digestion, curdled/solid aspirate
Breast milk = shorter digestion, liquid aspirate
Lab Testing Indications
Heme - <1yr if premie, hx CA, bleeding disorder
Chem - renal, adrenal, endo, CNS disorder
LFTs - Hx liver disorder
Coag - leukemia, hepatic disorder, malnutrition, bleeding disorder
Goals of Pre-medication
Decrease anxiety/fear / Produce amnesia/analgesia // Facilitate anesthetic induction // Facilitate separation from parents // Block vagal reflexes // decrease secretions // aspiration prophylaxis
Atropine and Central antiAch syndrome
Central nervous system (CNS) manifestations result from central cortical and subcortical muscarinic receptor antagonism. The degree of CNS manifestation is related to the drug’s ability to cross the blood-brain barrier. Physostigmine, a lipid soluble tertiary amine anticholinesterase drug administered in doses of 15 to 60 μg/kg IV, is a specific treatment for the central anticholinergic syndrome. Treatment may need to be repeated every 1 to 2 hours.
Signs/Symptoms of Central AntiAch syndrome
Red as a beet (flushing) Dry as a bone (no secretions) Blind as a bat (mydriasis) Hot as a hare (anhydrosis) Mad as a hatter (agitation, restlessness)
Atropine Dosing/Contraindications
Dose IV/PO 0.02 mg/kg, min is 0.1 mg. Careful with cardiac abnormalities and risk of MH (masks tachy signs). IV dose at induction, PO dose 30-60m prior, max dose 0.6 mg
Pre-Op Narcotics
Rarely used, OT with diff/variable dosing, IM diff to admin.
Overall disadvantages: vomiting, pruritis, excess sedation, hypoventilation/resp depression.
Barbiturates - gaba-mimetic, depress RAS
Not utilized d/t long duration and residual sedation. Methohexital PR most likely used. PR = 20-30 mg/kg, IM 6-10 mg/kg, IV 1-2 mg/kg. Duration up to 5 hrs. Not used if <6mo d/t very limited metab and variable PR uptake.
Bnezodiazepines - gaba-mimetic
Versed most widely used, most reliable, simple PO administration, PO = 0.5-0.75 mg/kg, max 20mg. May add tylenol for analgesia/amnesia/sedation combination.
Ketamine - NMDA antagonist, dissoc anesthetic
Not routinely used, poss proc sedation 0.2-1mg/kg IV, pre-emptive analgesia at 0.1-0.2 mg/kg IV. PO = 3-6 mg/kg, PR 6 mg/kg onset 10-30m. IM 4-5 mg/kg
Chloral Hydrate unknown MofA, cns depressant
Field trip sedation MRI/CT. 50-75 mg/kg PO/PR, variable onset 20-40m, long duration w/o reversibility, poss arrhythmias
GI prophylaxis
Metocloperamide - IV 0.1 mg/kg - dopa/sero antago in CTZ, incr tissue sens to Ach to incr GI motility, incr LES tone
Cimetidine - IV 5/10-20/20-30 mg/kg/day neo/inf/child - H2 rec antago on parietal cells, inh gastric secretions
Ranitidine - 0.75-1.5 mg/kg/day children - same
Sodium Bicitra - PO 0.4 ml/kg - non particulate antacid
Most need to be given 60m pre-op
Acetaminophen
Most widely used analgesic. Give prior to sx incision.
IV 30 mg/kg q6 / PO 20-30 mg/kg q8 / PR 40-60 mg/kg q8
Dental Evaluation
Rule of 6-2-6-12 first deciduous tooth @ 6 mo (letter top R-->L, bottom L-->R deciduous teeth complete @ 2 yrs first permanent tooth @ 6 yrs (molars) permanent teeth complete @ 12 yrs Suspect loose teeth at 5-12 yrs
Breathing Circuits: Mapelson
Most commonly used is “D” circuit
Adv: lightweight, low resistance, small Vd
Dis: heat/moist loss, no scavenging, high FGF (2-3x MVe), no CO2 absorbent
“D” –> basis for Bain Circuit
“F” –> Jackson Reese Circuit
Breathing Circuit: Bain
Adv: low Vd, conserves heat, scavenging present
Dis: unable to directly inspect insp limb, FRG tube rupture –> rebrth CO2, no CO2 absorbent = high FGF
Breathing Circuit: Circle system
Adv: conserves heat/humidity, use low flows, scavenging, CO2 absorbent
Dis: valve + CO2 abs == incr resistance, tubing incr Vd
Sources of Resistance: ETT, valves, CO2 absorbent
Reservoir Bag sizing
NB = 0.5L / 1-3yr = 1L / 3-5yr = 2L / 5+yr = 3L
Inhalation Induction Goals/Technique
Goals: Asleep fast & Ensuring progression stg 2–>3, marked by reg resp, eyes fixed/ML, extrems/abdo relaxed
Technique: FiO2 near 100% +/- N2O –> incr Sevo% quickly, stage 2 marked by excitement, irreg resp, breath holding, heighten AW reflexes (give sm amounts PPV). Should rec 100% O2 prior to intubation. Straight blade provides best lift of short/stiff epiglottis. Use OA, not NA as can damage adenoids (NP) and tonsils (OP).
Blade Sizes
Mac 1 = 1-2 yrs / Mac 2 = 3-5 yrs
Mil 00 = prem / Mil 0 = neo / Mil 1 = infant-2yrs / Mil 2 = >2yr
WisHip 1 = 1-2 yrs / WisHip 1.5 = 3-4 yrs
ETT Specifics
Age < 8 yrs = uncuffed ETT Air leak @ 15-20 cmH2o Cuff inflation pressure < 25 cmH2o Head Extension = ETT mvmt 1-2cm --> OP Head Flexion = ETT mvmt 1-2 cm --> lungs
ETT Sizing Internal Diameter
Prem 1000gm = 3.5
Neo - 3mo = 3.0
3-9mo = 3.5 / 9-18mo = 4.0
>2yr = age/4 +4
ETT Depth
** < 1yr trachea length 5-9cm, w/ = R/L bronch angles
*1kg = 6-7cm / 2kg = 8cm / 3kg = 9cm 4kg = 10cm /
4kg-1yr = 10cm / >1yr = age/2 +12
* Internal Diameter x3
* double black line of uncuffed tube passes thru vocal cord tip is proximal to carina
