Exam 1 - Pediatrics Flashcards
less than 37 weeks gestation or less than 2500 grams
premature
0-1 month
Neonate
1 month - 1 year
Infant
1 year to 3 years
Toddler
4 to 6 years
Small Child
6 to 12 years
Big Child
13 to 18 years
Adolescents
What are the differences in a pediatric airway (as compared to an adult airway)?
Pediatric airway:
- Large tongue and occiput
- Larynx is higher than it is in the adult: C2 to C4 instead of C3 to C6
- Epiglottis is Omega-shaped (U) and stiff
- Narrowest point of the peds airway = cricoid cartilage
Pediatric respiratory physiology
- airway resistance is greater
- immature CNS
- infants <60 weeks PCA: SpO2 monitoring overnight after general and neuraxial anesthesia
- the neonate’s chest wall is very compliant due to a lack of calcification of the ribs
- alveolar compliance is low
- higher risk of apnea in the preterm neonate <60 weeks PCA
- increased oxygen consumption
- early breathing fatigue (due to abundance of type 2 fibers)
What law describes resistance during laminar flow?
Poiseuille’s law
Trisomy 21 - special considerations
- atlanto-ccipital instability
- chronic upper respiratory infections
- large tongue or small oral cavity
Pediatric cardiovascular differences
- oxygen consumption is twice that of an adults (7mL/kg/min versus 3.5 mL/kg/min)
- C.O. is HEART RATE dependent
- increased susceptibility to myocardial depression by inhaled drugs
Fetal hemoglobin has a _________ affinity for oxygen than adult hemoglobin
higher
Pediatric body composition
- larger total body water %
- neonate is unable to conserve sodium
They are little bags of water, with a big ol’ head
Estimated Blood Volume: Premature
90-100 mL/kg
Estimated Blood Volume: Newborn (term)
80-90 mL/kg
Estimated Blood Volume: Infants
75-80 mL/kg
Estimated Blood Volume: School age children
75 mL/kg
Estimated Blood Volume: Adult
65-70 mL/kg
Thermoregulation in the pediatric patient
- thermoregulation is compromised because of a lack of the ability to shiver
How do pediatrics accomplish non-shivering thermogenesis?
They metabolize brown fat
(Heat producing energy is derived from brown adipose tissue)
Spinal cord in the pediatric patient ends at _____
L3
Pediatric Nervous System
- spinal cord ends at L3
- fontanelles are not fused
- the blood-brain barrier is incomplete
- myelination begins during the fetal period and extends progressively (Myelination of nerve cells is not complete until 2-3 years of age)
Pediatric Hypoglycemia:
An infant requires ______(mg/kg/min) of glucose and a neonate requires ______ (mg/kg/min)
3 to 4 mg/kg/min; 5 to 6 mg/kg/min
How many mL/hr does a 2 kg neonate require? (D5% = 50 mg/mL)
- A 2 kg neonate requires 5 mg/kg/min which equals 10 mg/min
- 10 mg/min = 600 mg/hr
- 600 mg/hr divided by 50 mg/mL = 12 mL/hr
Answer: 12 mL/hr
Pediatrics have _________ (increased or decreased) total body water as compared to adults
increased
CNS effects of opioids and barbiturates may be prolonged in the pediatric patient because of ___________________.
the immature blood-brain barrier
True or False. Pediatrics are very sensitive to opioid respiration depression
True
MAC (minimum alveolar, concentration) is higher in infants from ____ to _____ (ages), peaking at ________ (age).
one to six months; 3 months
Pediatrics have a ______ (larger or smaller) volume of distribution
larger
The dose of succinylcholine in children must be ________ due to the larger volume of distribution.
increased (more per kg)
Succinylcholine is often avoided in kids unless clinically indicated for a rapid sequence induction because of ______
reported cases of unanticipated cardiac arrest
(Boys with undiagnosed Duchenne’s muscular dystrophy—it can precipitate untreatable hyperkalemia.)
Fluid replacement for third spacing: Minor Surgery
2-4 mL/kg/hr
Ex. herniorrhaphy, clubfoot
Fluid replacement for third spacing: Moderate Surgery
4-8 mL/kg/hr
Ex. pyloromytotomy
Fluid replacement for third spacing: Extensive Surgery
8-10 mL/kg/hr
Ex. Bowel resection, NEC
Estimated Blood Volume (EBV) equation
EBV = body weight (kg) x average blood volume (mL/kg)
Allowable blood loss equation
EBV x (starting HCT - Target HCT) / starting HCT
What is your initial fluid bolus for mild to moderate hypotension in pediatrics? What solution?
10-20 mL/kg ; often 5% albumin or LR
Fasting Guidelines: Heavy Meal
8 hours before any anesthetic
(Heavy meal = a meal that includes any fatty foods)
Fasting Guidelines: Light Meal
6 hours before any anesthetic
(Light meal = toast and clear liquids)
Fasting Guidelines: Formula and Non-human milk
6 hours before any anesthetic
Fasting Guidelines: Breast milk
4 hours before any anesthetic
Fasting Guidelines: Clear Liquids
2 hours before any anesthetic
Formula for estimating weight in kilograms based on age:
(age x 2) + 9
Formula is for aged 2-9 years (age is in unit years)
ETT Size (uncuffed) for a Preemie <2.5 kg
2.5-3
ETT Size (uncuffed) for a Term Newborn
3-3.5
ETT Size (uncuffed) for a 3 month to 1 year old
3.5-4
ETT Size (uncuffed & cuffed) for a 2-year-old
4.5 (uncuffed)
4.0 (cuffed)
Formula for estimating ETT size (age >4 yr)
(age in years/4) + 4
Good for uncuffed tube size
Generally reduce by 0.5 to 1 size for cuffed ETT
Formula for estimating ETT depth (age >4 yr)
3 times the ETT size
OR
Age + 10 cm
What is included in a basic room set up for a pediatric patient
- Set the OR room to 80 degrees
- Put an under-body Bair hugger on the bed.
- Set out 3 lead EKG, NIBP, Pulse Ox, precordial stethoscope.
- Pediatric tonsil tip suction
- Paper tape for eyes. Cloth tape available for ETT especially if the ETT is going to remain after the procedure (Transport to NICU, PICU).
- MAC 1 and 2, Miller 1 and 2 blades. Miller 0 if less than 8 kg., ETT of several sizes (one bigger and one smaller than calculated to be needed), oral airways, and skin temp probe.
- IVF– less than one year old use Buritrol.
- Greater than 1 year old use a micro drip set. Preferred fluid is usually non-glucose containing isotonic fluid.
- Most at Vidant will use NS and perhaps add Dextrose but ask as this guideline has many practitioner dependent preferences and patient condition variables. - Several IV catheters 22 and 24 gauge with tourniquet, alcohol wipe, 2x2’s, tape, Tegaderm, “T” piece extension set.
- Emergency and induction drugs
What are the 3 main emergency drugs you should have set up for a pediatric case?
- Epinephrine 10 mcg/mL
- Atropine 0.4 mg/mL conc.
- Succinylcholine 20 mg/mL
What is the emergency drug setup and dosaging for Epinephrine for a pediatric patient?
Epinephrine 10 mcg/mL
- Epinephrine 1 mcg/mL if less than 10 kg
- Dose 2-10 mcg/kg (vasopressor)
- Dose 30mcg/kg (arrest)
What is the emergency drug setup and dosaging for Atropine for a pediatric patient?
Atropine 0.4 mg/mL concentration
- Dose 0.02- 0.04 mg/kg IM
- Dose 0.02 mg/kg IV
What is the emergency drug setup and dosaging for Succinylcholine for a pediatric patient?
Succinylcholine 20 mg/mL
- Dose 4 mg/kg IM
- Dose 2 mg/kg IV
Explain the steps of a basic inhalation induction
- To room, onto bed. Put on pulse ox and coax child to breath in mask with 70% nitrous 30% oxygen.
- Gradually add Sevoflurane up to 8%.
- Once the patient is unresponsive/minimally responsive, lay flat on the bed. Place precordial, NIBP, and EKG leads (in that order).
- One team member looks for an IV while you manage the airway. Once you have taken over respirations completely for the patient, shut off nitrous and go to 100% oxygen, turn Sevo down to 4-6%.
- Once IV established, give fentanyl and propofol.
- Establish airway. Listen for bilateral breath sounds. Listen for a leak at ETT/glottic opening at 20 cm H2O.
- Tape ETT. Listen again.
How are diaphragmatic and intercostal muscles different in the pediatric population?
Fewer type I muscles; easily fatigued
How much fluid should an 8 kg infant get in the first hour of a laparoscopic inguinal hernia repair?
- Maintenance: 4 mL/kg up to 10 kg = 32 mL/hr
- 3rd spacing: 2-4 mL/kg/hr = 16-32 mL/hr
- 1st hour: 48-64 mL/hr
What is a reasonable estimation for the weight of a two year old?
Equation for 2-9 yr olds: (age x 2) + 9
(2x2) + 9 = 13 kg
In general, how do you calculate the 4:2:1 rule for fluid replacement?
- 4 mL/kg for the first 10 kg
- 2 mL/kg for 10 kg to 20 kg
- 1 mL/kg for every kg over 20 kg
