Exam 1: growth&development, preop eval, gen approach Flashcards
what is a question we always ask about baby in preop
-term/how many weeks it was born
-troubles after birth
-problems with pregnancy
what is definition of pre-term infant
<37 weeks
what is definition of term infant
37-40 wks
what is definition of post term infant
> 42 weeks
what is considered extremely low birth weight
<1000g
what is considered very low birth weight
<1500 g
what is considered low birth weight
<2500 g
what is premature
<37 weeks
what are anesthesia concerns with premature babies
airway control
fluid management
temperature regulation
retinopathy of prematurity
apnea of prematurity
<60 weeks PCA highest incidence of post anesthetic complications
what patient has the highest incidence of post anesthetic complications
<60 weeks PCA
what is definition of small for gestational age
<10% for gestational age at birth
what is a cause of small for gestational age
chronic placental insufficiency
chromosomal abnormalities
mother:
-smoking
-DM
-chronic disease
how can we prep the OR for small for gestational age/ all pediatric patient
warm room, warm them throughout case
what is a common hematology issue with small for gestational age
polycythemia leading to hyperviscosity syndrome
how do we manage hyper-viscosity syndrome intraop
maintain or slightly elevate BP
SGA/LGA issues
what is definition of LGA infant
> 90% for gestational age
what are common issues with LGA infants
birth injuries
hypoglycemia
hypocalcemia
difficult intubation/IV sticks
what are issues with SGA infants (chart)
congenital anomalies
chromosomal abnormalities
chronic intrauterine infection
heat loss
asphyxia
metabolic abnormalities
hypoglycemia
hypocalcemia
polycythemia
hyperbilirubinemia
what are issues with LGA infants (chart)
birth injuries
asphyxia
meconium aspiration
metabolic abnormalities
hypoglycemia
hypocalcemia
polycythemia
hyperbilirubinemia
what are common birth injuries with LGA infant
brachial
phrenic nerve
fractured clavicle
what is the most sensitive indicators of a babies well being
weight
what issues can cause changes in babies weight
CHF
endocrine
malignancy
infection
malabsorption
what issues can we find through head circumfrence
severe malnutrition
hydrocephalus
what can cause a sunken fontanelle
fluid status changes
hemorrhage, fluid loss, dehydration
what three measurements do we use to assess baby
weight
length
head circumference
how does newborn weight change in first week after birth
decrease by 10%
how do you calculate length in cm using age
(age in years x 6) + 77
by 6 month an infants weight is _______x
2
by 1 year an infants weight is __x
3
when does a baby regain its weight after its initial loss
2nd week
30g/day then
12g/day 1st year
what is the rule of 10s for males
10 lbs per year until 16
what is the rule of 10s for females
10 lbs a year until 12
how much weight does a preterm infant lose in first week
15% then gain it back slower than term
T/F SGA infants lose more weight than others
F, dont lose weight, gain weight in first week
preop screening chart
what are preop of screenings for airway
history of difficult airway, adjuncts for ventilation and intubation
what are preop of screenings for cardiovascular: murmur with pathologic findings
preop echo
what are preop of screenings for History of syncope or poor functional capacity:
preop ECG, consider preop echo and cardiology eval
what are preop of screenings for asthma
preop albuterol if not well controlled
delay elective for poorly controlled
stress dose steroid if prolonged steroid exposure (>7 days) in last 12 months
what are preop of screenings for cystic fibrosis
V/Q mismatch common,
preop oxygen sat,
bronchial hyper reactivity,
evaluate recent CXR and PFTs,
Echo if pulm htn suspected\may have liver disease,
total bili,
INR,
albumin
may have renal insufficiency from aminoglycosides
what are preop of screenings for severe OSA
overnight observation
what are preop of screenings for seizures
continue meds day of sx
AED (antiepileptic drug) interactions with NMB blockade
AED induced metabolic acidosis
what are preop of screenings for ADHD
continue meds day of sx, consider alpha 2 agonist premedication
what are preop of screenings for CP?
constinue seizure and reflux medications day of sx
consider preop warming giving airway hypotonia
consider ICU or step down for recovery
what are preop of screenings for muscular dystrophy
preop ECG, ECHO, CPK, room air O2 sat, FVC
what are preop of screenings for gastointestinal
continue reflux medications preop
what are preop of screenings for renal
check K
anemia may be present: preop HCT
continue HTN meds preop
assess most recent dialysis
volume status
what are preop of screenings for sickle cell
preop admission
IV hydration
tranfuse if hb<10 g/dl
consider echo for pulm htn
what are preop of screenings for oncology
evaluate for lesion location
evaluate end organ dysfunction from chemo
what are preop of screenings for mitochondrial myopathy
avoid prolonged fasting,
use dextrose containing IVF at maintenence rate,
consider peop echo and ECG
consider anxiolytic premedications midazolam, dexmetomidine, or ketamine
what are preop of screenings for type 1 diabetes
HbA1C prior to day of sx
continue long acting insulin (glargine)
continue insulin pump without reduction
reduce evening NPH by 50%
check awakening and preop BS
what are preop of screenings for trauma/emergency
full stomach precautions
preop HCT
coagulation studies
C-spine films/precautions
what are preop of screenings for apnea of prematurity
require apnea-bradycardia monitoring post op (44-54 weeks PCA)
what are preop of screenings for prematurity, bronchopulmonary dysplasia, OLD
inflammation, smooth muscle hypertrophy, fibroproliferation
what are preop of screenings for prematurity, bronchopulmonary dysplasia, NEW
O2 dependence, >28 days old and disruption of lung growth
what are preop of screenings for prematurity, subglottic stenosis
prolonged intubation, stridor may be present
what are preop of screenings for prematurity, airway
predict difficult airway
mucopolysaccharoidosis
pierre robin
treachear collins
goldernhar
what are preop of screenings for prematurity, others
intraventricular hmmg, hypoglycemia
how do we calculate age for premature infants
Post-Conceptual Age = gestational age + post-maternal age
u: How do we differentiate a benign murmur vs congenital pathology?
Functional capacity history
-can they play/run
-cyanosis/poor activity
what congenital issues require cardiac consult
williams
noonan
trisomy 21
turner
marfan
how can the CRNA prevent subacute bacterial endocarditis
preop abx
amoxicillin or clindamycin 60 min before dental case
how can we distinguish an innocent murmur
*Still’s: left lower sternal border and may radiate to the base of the heart. Heard supine and diminished when sitting
how can we distinguish a pathological murmur
*Congenital Disease: pansystolic, Grade 3 or above, Left upper sternal border, harsh, abnormal 2nd heart sound, early or midsystolic click
*Diastolic murmur
what volatile do we avoid in asthma
des
if a patients asthma is not well controlled and asymptomatic, what do we do
proceed with anesthetic after short- acting beat agonists
T/F a patient with asthma can have surgery with minimal risk
T
if a patients asthma is well controlled and they have an expiratory wheese what do we do
if expiratory wheeze is resolved with SABA, proceed with sx
if a patient has poorly controlled asthma what do we do
consider reschedule
preop asthma care
controlled vs not well controlled vs poorly controlled chart
what are risk factors for URI
intubation < 5 years
reactive airway disease
paternal smoking
premature
airway sx
copious secretions
nasal congestions
a patient has moderat to severe URI with additional URI risk factors, what do you do
postpone for 2 weeks
what can happen when a patient with URI is anesthetized
laryngospasm
bronchospasm
oxygen desaturation
severe coughing
how do we manage autism patient
minimize stimulation
maximize routine
preop oral precedex, clonidine, ketamine, versed- mix with juice
how do we manage ADHD patient
premedicate with versed or alpha 2 agonist
continue meds
stimulants can cause more tachy with ephedrine
how do we manage seizures
ID baseline sz
continue AEDs day of surgery
oral or IV midazolam
what medication do we avoid in Cerebral palsy
Versed-airway obstruction
what are cerebral palsy patients at risk for
seizures
reflux
visual dysfunction
cognitive dysfunction
hypo/hyperthemia
airway obstruction
what are s/s cerebral palsy
spasticity, dystonia, ataxia
what heart issue is common with duchene and becker muscular dystrophy
cardiomyopathy (do preop TTE, EKG)
what muscular dystrophy may be difficult to intubate
duchenne
what resp test might be done preop for duchene and becker muscular dystrophy
proep PFC (FVC)
if FVC is <50% what is risk
increased risk of respiratory complications
if FVC is <30% what is risk
severe risk of postop resp complications
what do we treat hemophilia A with
recombinant factor 8
what do we treat hemophilia B with
recombinant factor 9
what do we treat von willebrands with
DDAVP
Humate
what do stressors induce in mitochondrial myopathy
metabolic acidosis
what are triggers for mitochondrial myopathy
prolonged fasting
hypoglycemia
hypothermia
prolonged tourniquets
hypovolemia
NV
what do we premedicate mitochondrial myopathy patients with
versed and alpha 2 agonists
what do we do preop of mitochondrial myopathy patients
EKG
echo
what medications are okay to take day of sx
AntiEpileptic Drugs
asthma medications
GERD meds
what medications do we hold for sx
anticoagulants, ACEI, ARB
T/F stop BB intra op
F, continue
what are most common cause of anaphylaxis intraop
abx and NMBs
how do we pretreat allergies
benadryl
pepcin
decadron
how do we treat anaphylaxis
benedryl
pepcin
decadron
epinephrine
who is at risk for latex allergy
Children with spina bifida
He of multiple surgeries
meningomyelocele
what are s/s allergic response
rash
pruritis
facial swelling
anaphylaxis
what is the most common inherited disease
von willebrand
what gender is more at risk for hemophilia
males, X-linked recessive
risk of PONV
what are pediatric predictors of difficult airway
craniofacial syndromes
facial asymeetry
micrognathia
cleft pallate
large tonsil size
loose teeth
airway/tongue masses
high arched pallate
what can large tonsil size lead to
OSA
difficult mask
airway obstruction
when do we chart dentition in peds
pre and post op
airway in and out
what is normal HR BP for preterm
120-180 BPM
45-60/30
what is normal HR BP for term
100-180 bpm
55-70/40
what is normal HR BP for 1 year
100-140 bpm
70-100/60
what is normal HR BP for 3 years
85-115
75-110/70
what is normal HR BP for 5 years
80-100
80-120/70
how do we find high systolic in peds
low systolic
age in years x2 +90
age in years x2 +70
pediatric VS chart
NPO chart
what is NPO for clear liquids
2 hrs
what is NPO for breast milk
4 hrs
what is NPO for formula
6 hrs
what is NPO for light meal
6 hrs
what is NPO for heavy meal
8 hrs
what are clear liquids for pediatric
water,
Pedialyte,
carbonated beverages,
clear tea,
plain gelatin,
and fruit juices without pulp
when does seperation anxiety in children peak
1 year
what are the high risk patients for preoperative anxiety
1-5 years
parents with poor coping skills
risk for preop anxiety chart
premeds pediatric doses
what is oral dose of midazolam
0.25-1 mg/kg
what is IV dose of midazolam
0.05-0.1 mg/kg
what is transmucosal (nasal) dose of midazolam
0.2-0.3 mg/kg
what is the IM dose for midazolam
0.1-0.15 mg/kg
what is the IV dose for fentanyl
0.5-1 mcg/kg
what is the transmucosal (oral) dose for fentanyl
10 mcg/kg
what is the oral dose of ketamine
6-10 mg/kg
what is the IV dose of ketamine
1-2mg/kg
what is the transmucosal dose for ketamine
5-10 mg/kg
what is the IM dose for ketamine
3-7 mg/kg
what is the oral dose for clonidine
2.5-5 mcg/kg
what is the IV dose for clonidine
1-2 mcg/kg
what is the IV dose for precedex
0.25-1 mcg/kg
what is the transmucosal (nasal) dose for precedex
1-2 mcg/kg
what is the IM dose for precedex
1-2 mcg/kg
what are complications with down syndrome
large tongue, increased secretions
what do we do special for set up in peds
2 sizes up and down of ett
warm the OR
emergency drugs: atropine and anectine on IM needles in bag
how do we decide if parent should be there for induction
parent in good mindset not freaking
not parent if they will freak out in OR or are anxious
parents of 1 YO patient
how do we prepare parent for taking patient in OR
tell them what to expect
tell them their role
what are contraindications for inhalation inductions
MH, muscular dystrophies, central core disease, full stomach
what is preferred inhaled induction
nitrous oxygen mix 2:1 for 2 min then
sevo 2, 4, 6, 8
nitrous oxygen blend 7:3
what patients can you do single breathe induction on
older children >9
how do you do single breathe induction
prime with 8% sevo and take VC breathe
when do we start IV in peds after inhalation induction
after 2 minutes of loss of eyelash reflex
what is induction steps of inhaled anesthetic
nystagmus
eyes close
limbs relax
slow/deep breaths
fast/shallow breaths
excitatory/uncontrolled movements
snoring/upper airway obstruction
eyelash reflex gone
when do we let go of ETT in peds
only after taped
when can peds patient be moved after inhalation induction
after IV and meds in
when do we do IV induction
older children 6-7 years and up
obese child
what is the induction dose of propofol for peds
2.5-3.0 mg/kg (unpremedicated ages 3-12)
what is the induction dose of etomidate for peds
0.3 mg/kg
what is the induction dose of ketamine for peds
2 mg/kg
what is the robinol dose for peds with ketamine
0.1 mg/kg
what is the versed dose for peds with ketamine
0.5 mg/kg
what weird effects does lidocaine cause
ears ringing
lips tingle
taste in mouth
what induction drug is good for asthmatics
ketamine, bronchodilates
how do we treat pediatric laryngospasm
avoid vigorous PPV
moderate continuous PPV with 100% O2
prop 0.5 mg/kg
severe hypoxemia and bradycardia
IV succs 2 mg/kg and atropine 0.02 mg/kg
IM succs 4 mg/kg
do children/infants have a higher or lower MAC%
higher
what are contraindications of Nitrous oxide
pulmonary htn
pneumothorax
pneumocephalus
middle ear surgery
small bowel obstruction
severe anemia
decreased Cerebral blood flow
shock
where is nitrous oxide metabolized
in gut? aerobic bacteria
what is MAC of iso in infant
1.7
what is Mac of iso in child (3-10)
1.6
what is mac of des in infant
9.4
what is mac of des in child (3-10)
8.0
what is mac of sevo in infant
3.3
what is mac of sevo in child (3-10)
2.5
what is the volatile of choice in peds
sevo
how does sevo effect heart
little effect
how does sevo affect QTC
prolongs
how does sevo affect MV/RR
decreases
how does Sevo affect lungs
bronchodilator
what does sevo compare with emergence
prolonged
what gas do you avoid in asthma
des
what are cardiovascular effects of des
decreased SVR
decreased BP
increased HR
no change CO
how is emergence with des
rapid
what is morphine dose for peds
0.05 to 0.1 mg/kg/hr
what is fent dose for peds
1-3 mcg/kg/hr
what is sufentanil dose for peds
0.1-0.3 mcg/kg/hr
what is alfentanil dose for peds
1-3 mcg/kg/min
what is remifentanil dose for peds
0.1-0.4 mcg/kg/min
what is hydromorphone dose for peds
3-5 mcg/kg/hr
What opioids cause histamine release?
morphine
Dilaudid
-also increased risk NV-
what are side effects of fentanyl
chest wall rigidity/bradycardia
what is best opioid for neonates
fentanyl
what are side effects of morphine
urticaria
histamine release
resp depression (especially in kidney failure)
PONV
what is DOA of fentanyl
1 hr
what is the metabolite of morphine
morpine-6-glucuronide
what is the IV dose of succs
1-2 mg/kg
what is IM dose of Succs
4 mg/kg
what cardiac complications are possible with succs
bradycardia, asystole
what patients do you avoid succs in do to high K
NM disorders
burns
dysrhythmias
muscle rigidity
masseter spasm
postop myalgias
what is dose of roc
0.6 mg/kg,
what is onset of roc
2 min
what is DOA of roc
30 min
what is RSI dose of roc
1.2 mg/kg
how do you know you pass from stage 2 to stage 1
grimacing
spontaneous eye opening
purposeful movement (reach for tube)
when do we not wake kids up
stage 2
what is NMB reversal doses in peds
robinol 0.01 mg/kg
neostigmine 0.06 mg/kg
what are signs of adequate reversal
nonparadoxic breathing
NIP >30 cm H2O
hip flexion with leg elevation for 10 sec
head lift for 10 seconds
T/F move patient during stage 2
no, can cause spasm
how do you extubate peds
deep (unless difficult airway and full stomach)
when do laryngospasms occur
stage2
T/F use 100% O2 with kids
F, prevent absorption atelectasis
what do you take to travel with peds patient
jackson reece, mask, O2, emergency drugs (atropine, anectine drawn up)
what is the ranking of desaturation time in infants children, adults
longer in infants than children than adults
what do we treat post op delirium with
versed
what can help with emergence delirium
precedex
what drug increases risk of emergence delierium
ketamine
what factors increase risk of emergence delirium
young age
previous surgeries
type of procedures
type of anesthetic
What are S/S of Emergence Delirium?
Restless
Agitated
Disoriented
Thrashing
moaning
crying
parameters for PACU discharge
what is definition of neonate
first 28 days of full term birth
what temp to we raise OR to for neonatal sx
80-85*
what do we use to warm OR and neonate in OR
radiant warmer
bair hugger
warmed/humidified circuit
warmed fluid/blood
insulate head
what Spo2 for neonatal sx
83-95%
how long can we have umbilical lines for
5-7 days
what are considerations for IVF for neonates
free of bubbles
drugs proximal to patient
minimize flushes
buritrol to limit flow
equipment for neonatal anesthesia
do males or females have more choanal atresia
females
what syndome is choanal atresia often associated with
CHARGE
Treacher Collins
Pfeiffer & Vater
what is CHARGE syndrome
Coloboma
Heart disease
Atresia choanae
Retarded growth
Genital anomalies
Pfeiffer & Pfeiffer
Veterbral defects
Anal atresia
Tracheoesophageal fistula with Esophageal atresia
Radial and renal anomalies
what type of choanal atresia is an emergency
bilaateral, surgery within 1st days of life
what are s/s of bilateral choanal atresia
resp distress and cyanosis with feeds, relieved with crying
what airway intervention do we do early on in induction for choanal atresia
OA
what kind of choanal atresia is diagnosed in later childhood and adulthood
unilateral
what are causes of laryngeal and upper tracheal obstruction
webs
congenital subglottic stenosis
subglottic hemangioma
tracheoesophageal fistula/esophageal atresia
what is the procedure for laryngeal web identified intrautero
EXIT procedure
what symptoms present with laryngeal or tracheal web
resp distress
stridor
what complication can accompany anterior webs
subglottic stenosis
what is the most common indication for neonatal tracheostomy
congenital subglottic stenosis
what are treatments for subglottic stenosis
trache
endoscopic steroids and dilators
cricotracheal resection and laryngotracheoplasty
what is the most common infantile vascular tumor
hemangiomas
what should we suspect iwth V3 beard distribution on the face
subglottic hemangioma
when do subglottic hmeangioma patients have resp distress and stridor
6 and 12 weeks of life
what syndrome is subglottic hemangioma associated with
PHACES
*Posterior fossa malformation, Hemangioma, Arterial lesions of head and neck, Cardiac abnormalities, Eye abnormalities, Sternal cleft, or Supraumbilical hernia
what is treatment of subglottic hemanagioma
propranolol and steroids
surgery with laser or open
graft with rib or thyroid cartilage
what do we anticipate when intubating subglottic hemangioma patient
bleeding
what is an error in the separation of the trachea from the floor of the foregut
*TRACHEOESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA
what syndrome is associate with *TRACHEOESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA
*VACTERL Vertebral anomalies, Anus imperforate, Congenital heart disease, Tracheoesophageal fistula, Renal abnormalities, Limb abnormalities
what is themost common type of *TRACHEOESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA
dilated proximal esophageal pouch and a fistula between the distal trachea and distal esophagus
what are signs symptoms of *TRACHEOESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA in newborn
excessive secretions
spits up during initial feedings
cant pass NGT
how do we optimize *TRACHEOESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA patient for surgery
anemia
lytes
T &C
anomaly eval
G-tube
how do we intubate *TRACHEOESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA
awake intubation with videoscope
maintain SV
ETT above carina but distal to fistula
Calculation for internal diameter of ETT
(Age in years/4)+4
Calculation to advance the ETT
3x the internal diameter
(Age in years/2)+12
