exam 3 Flashcards
what is the leading cause of cancer deaths in the US
bronchogenic cancer
COPD patients are __x more likely to get lung cancer
4x
___% needing resections are disqualified due to poor pulmonary function
40%
biggest risk factor for lung cancer
smoking
Consider __-week delay if coronary bypass needed
6-week
true or false
radiographic airway evaluation for mediastinal masses
is very important
true
neuroendocrine tumors cause
carcinoid syndrome
______calcemia occurs in up to 25% of lung cancer patients
HYPER
symptoms of HYPERcalcemia
polyuria
polydipsia
confusing
vomiting
abd cramping
bradycardia
Paradoxical breathing
Tympanic chest percussion
Rhonchi
Wheezing
COPD symptoms
Jugular vein distention
Peripheral edema
Split S2
Rales
cor pulmonale
CXR looks at
Evaluation for airway infringement*
Tracheal shift*
CHF
PTX
PA enlargement (signs of increased PulmVR)
Tall R in V1
RVH
Biphasic P in V1
R atrial hypertrophy
Pathologic Q waves + LVH
increased risk of ischemia/infarction
EKG
tall R
biphasic P
ST depression
BBB
T inversion
Pathologic Q wave
LVH
Best INITIAL tool for pulmonary HTN
echo
room air COPD
> ___ = poor function
> 45
spO2 < ___ = increased risk of postop complications
<90%
albumin < ____ = 2.5x risk
<3.6
BUN > ___
> 2
Pulm Function Tests
“Significant improvement” = ___% increase in FEV1 after bronchodilators
12%
true or false
NO single test is a good predictor or lung function
true
increased risk
PPO FEV1 & DLCO <___%
VO2 max <___-___
<40%
VO2 < 10-15*
Maximum volume of O2 utilization
vo2 max
vo2 max
Ability to climb 5 flights of stairs = >___
Inability to climb 1 flight = <____
> 20 for 5 flights
<10 for 0 flights
forced expiratory volume/1 second
FEV1
diffusion in the lung of carbon monoxide
DLCO
mortality for smokers with lung cancer
1.5% mortality
pack-year index***
packs/____ x ______
packs/day x years
pack year index
> ___ = increased complications over “moderate” smokers
> 20
cessation of smoking
<___ weeks has NO difference in outcomes
<4
best option for cessation of smoking
8 weeks
which lead EKG for dysrhythmias
Lead II
which lead EKG for ischemia
V5
which side should the aline be on
dependent
CVP should be inserted on*
NON-dependent, operative side
trachea
___-___ cm long
11-12
trachea begins
C6 (cricoid cartilage)
trachea bifurcates
T5 (stermomanubrial joint)
which bronchus is WIDER and has LESS of an angle
R mainstem bronchus
(20 degrees)
which bronchus is NARROWER and has STEEPER angle
L mainstem bronchus
(45 degrees)
3 lobes
R lung
*Orifice of R upper lobe:
__-__cm from carina
can be a major problem for double lumen tube
1-2cm
Orifice of L upper lobe:
__ cm from carina
5 cm
sitting up
zone 1
clavicle/apices
sitting up
zone 2
axillary
sitting up
zone 3
lower ribs/base
if you are LAYING down, on the L side, where is zone 3
mostly L lung
true or false
normal, sitting person
perfusion AND ventilation BOTH increase from apex to base
they are both HIGHEST at BASE
true
BASE is more compliant
most tidal breathing is here
true
lateral + awake
perfusion AND ventilation are higher/better in the _____________ lung
dependent
lateral + awake has NO change in V/Q
true
diaphargm is displaced
cephalad
lateral + anesthetized, spontaneous ventilation
which lung has better VENTILATION
NON-dependent
(better compliance)
lateral + anesthetized, spontaneous ventilation
which lung has better PERFUSION
dependent
(more gravity)
lateral + anesthetized, spontaneous ventilation
net result
V/Q mismatch
lateral + anesthetized + NMB, mechanical ventilation, chest closed
which lung has better VENTILATION
non-dependent
lateral + anesthetized + NMB, mechanical ventilation, chest closed
net result
GREATER V/Q mismatch
lateral + anesthetized + NMB, mechanical ventilation, chest closed
treatment
PEEP
lateral + anesthetized + NMB, chest open
net result
GREATEST V/Q mismatch
(large increase in ventilation for NON dependent lung)
lateral + anesthetized + chest open
mediastinum shifts ___________ due to
LOSS of negative intrathoracic pressure
downward
lateral + anesthetized + chest open
what is something that is a hypothetical situation that we do NOT want to occur (patient should be paralyzed)
“paradoxical” respiration
“paradoxical” respiration
what occurs during INSPIRATION
air FROM the open-chest non-dependent lung
moves into the
dependent lung
“paradoxical” respiration
what occurs during EXPIRATION
air moves FROM the dependent lung
to the
open-chest non-dependent lung
“paradoxical” respiration
air movement, net result
Vt moves back-and-forth between the lungs
treatment for “paradoxical” respiration
mechanical ventilation
PEEP
“paradoxical” respiration
net result
physiologic ________ in _____________ lung
physiologic SHUNT in DEPENDENT lung
which lung is better PERFUSED
dependent
which lung is better VENTILATED
non-dependent
PERFUSION without ventilation
SHUNT
dependent lung
VENTILATION without perfusion
DEAD space
NON-dependent lung
What is the worst V/Q mismatch?
Lateral + Anesthetized; Paralyzed; Chest Open
one-lung ventilation
we STOP ventilation to the _____-____________ lung
non-dependent is STOPPED
Non-dependent lung (which now has NO ventilation)
diverts/forces perfusion to dependent lung,
and DECREASES the shunt effect
hypoxic pulmonary vasoconstriction (HPV)
HPV
net result
less V/Q mismatch
less shunt
which lung is clamped
non-dependent = operative
what lumen tube is most often used
L
true or false
It does NOT matter what side the tube is in
it matters what lumen is clamped
true
sizing for females
35, 37
sizing for males
39, 41
what is sizing based on
height
external french range
26, 28, 35, 37, 39, 41
internal diameter
____-____mm
3.4-6.6 mm
DLT have large ______ diameter
outer
which lumen is BLUE
bronchial
which lumen is WHITE
tracheal
which lumen has the STYLET
bronchial
what type of blade
MAC
insert the DLT with an __________ curve
anterior
“shotgun”/over & under
once the DLT is through the vocal cords, turn it ____ degrees
turn it 90 degrees
advance DLT until resistance
females: ___ cm
27 cm
advance DLT until resistance
males: ___ cm
29 cm
true or false
inflate cuff
do F/O scope
position lateral
reverify with F/O
true
Up to ___% of DLTs are mal-positioned when verified by auscultation only
80%
absent/weak R breath sounds
tube is too shallow, occluding the distal trachea
where do you clamp
high, at the adapter
L DLT tube
R middle lobectomy, which side is clamped
tracheal (L) side
L DLT
L middle lobectomy, which side is clamped
bronchial (L) side
CONTRAindications for L DLT
distorted L main bronchus
compression of L main bronchus due to aortic aneurysm
L-sided:
pneumoectomy,
sleeve resection,
single lung transplant
*what is the most common DLT complication
malpositioning
Catheter with inflatable balloon to block operative lung bronchus
bronchial blockers
indications for bronchial blocker
difficult airways
ETT change risky
some children
infections/cysts/bullae
which lung would become shunt flow during OLV
this would be withOUT HPV kicking in
non-dependent=operative
a 40% shunt would result normally, without HPV
HPV occurs within
seconds
HPV improves SaO2 during ___-___% lung hypoxia: the usual condition present with OLV
20-80%
AVOID
______capnia with HPV
______thermia
HYPOcapnia
HYPOthermia
AVOID
> ____ MAC
> 1.5 MAC
which NMB agents are best for OLV
intermediate
true or false
regional sympathectomy does NOT effect HPV
true
Vt __-__ is ideal
6-8
limit PIP ___-___
20-25
it is BETTER to be HYPERcapnic
<___
< 60
use _________-limiting ventilation mode
pressure-limiting
true or false
R lung is larger than L, so hypoxemia will be WORSE in R-side procedures
true
The degree of drop when shifting to OLV is proportionate to perfusion of the ____-___________ lung:
non-dependent
The greater the initial drop in EtCO2 = the greater the chance of hypoxia during OLV!
what is most common cause of hypoxia
tube malposition
**if patient is hypoxic, which lung should be given PEEP 1st
NON-dependent = operative lung
start at 2 PEEP
unclamping, use PIP of ___-___ to re-inflate
30-40
which drugs are good to reinflate lung
nitriC oxide
prostacyclin
__________* to non-dependent lung + nitric to dependent lung = 100% increase in PaO2
Almitrine
promotes HPV in non-dependent lung
Carotid body chemoreceptor agonist
almitrine
mediastinal tumors
HTN
HYPERcalcemia
cushings
myasthenia
etc.
true or false
mediastinal mass surgery is very dangerous
true
Venous distention of thorax and neck
Redness/edema of face, neck, torso, airway, conjunctiva
SOB
Headache
Confusion
SUPERIOR Vena Cava Syndrome
place peripheral IVs in ______ extremities
lower
radiation ______ surgery
before
*MAJOR goal of mediastinal mass surgery
maintain SPONT ventilation
best choice for intubation
mediastinal mass surgery
awake F/O
what helps minimize turbulence
helium/O2 mixture
mediastinoscopy
you can knick something very easily!!!
true
which arm should be monitored due to pressure on innominate artery
R arm
For COPD patients with bullae
bullectomy
best anesthesia for bullectomy
low Vt
high RR
100% O2
PIP < 20
highest risk for complications
post-thoracotomy
> ___ years
FEV1 DLCO <___%
ASA status > or = ___
____ min surgery time
> 80 years old
FEV1 DLCO < 40%
ASA 3
80 min surgery time
highest risk factors for
acute lung injury
R pneumonectomy
overhydration*
high PIP
preop ETOH abuse
Chest tube drainage should NOT exceed
< 500 ml/day
____ ml/day = surgical exploration
200 ml/day
treatment for supraventricular dysrhythmias
beta blockers
which artery can lead to spinal cord injury
radicular
3 ABSOLUTE CONTRAindications to laparoscopic proceudres
diaphragmatic hernia*
CHF*
peritonitis*
ileus
intraperitoneal hemorrhage
severe cardiopulm disease?
bowel obstruction?
when does the uterus interfere
23rd week
we want a slightly _________ state for mother
alkalotic
___ degree L uterine displacement
30 degree
pregnancy
limit intraperitoneal pressures to < or = ____
12
what are the 4 potential causes of major physiologic changes during pregnancy
creation of pneumoperitoneum
Potential for systemic absorption of CO2
Initial trendelenburg position
Reverse trendelenburg position
best gas to use
CO2
HYPERcarbia leads to _____________ acidosis
respiratory
insufflate at a pressure <___ (3L)
<19
once distended, maintain pressure at ___
12 maintenance
> ___% of complications occur during entry and insertion of trocars
> 50%
___-___% of injuries from the beginning of the case are NOT diagnosed intraop, resulting in
mortality of 3.5-5%
30-50%
true or false
we canNOT control the volume of CO2 absorbed
true
pneumoperiteneum
INCREASED:
___
___
___
____
____
____
SVR,
MAP,
HR
CVP (initially, then decreased)
CBF
ICP
pneumoperiteneum
DECREASED:
_________ ________
___
___
___
___
___
_________ __________
______ __________
____ __________
venous return
SV
CVP
CI, initially
UOP
GFR
creatinine clearance
pulm compliance
lung volumes
what can help the decrease in SV
periop hydration
change patient position (put in t-burg)
compression stockings
bradycardia can occur with INITIAL insufflation
who is MOST at risk*
young, healthy patients
best treatment for bradycardia
stop insufflation
**_________ myocardial filling pressures INITIALLY, followed by sustained __________ in preload (decreased venous return)
Increased initially, followed by decrease
avoid _____ventilation
with pneumoperiteneum
avoid HYPOventilation/hypercarbia
true or false
pneumoperitenum
hypoxemia is NOT normally seen with healthy patients
true
best PEEP and Vt for laparoscopic **
5-8
how do we help the respiratory acidosis that occurs with laparoscopic procedures
increasing RR (this increases Mv)
max CO2 absorption pressure
10
PaCO2 reaches plateau ___ min after start of insufflation
40 min
rate of absorption
is determined by (3)
tissue solubility
blood flow
diffusion pressure
PaCO2
Increased absorption with _____peritoneal
extra
EtCO2 ACCURATELY predicts changes in PaCO2 with (2)
HEALTHY
mechanically ventilated patients
sick, pulm, cardiac patients need to check PaCo2 how
with aline (since EtCO2 is NOT accurate)
___-___ degrees t-burg for decreased risk with small/bowel
10-20 degrees
what can occur with t-burg
R mainstem intubation
Combined with pneumoperitoneal pressure, the trendelenburg position increased ICP ___% over baseline
150%
durant position
L lateral tilt
we want to avoid air bubble going to RV outflow
reverse t burg
head UP tilt
t burg
head DOWN tilt
reverse tburg
decreased:
venous return
LVEDV
EF (only in SICK)
reverse tburg
EF is _____________
maintained = healthy
decreased = sick
we like _______carbia for laparoscopic
normocarbia (35-45)
major concern for laparascopic
must PREVENT HYPERcarbia
premedicate with
anxiolytic
use _____% oxygen
100%
best anesthetic option for laparoscopic procedure
regional + GA
true or false
STOP ventilation during insertion of Veress needle
true
there is an INCREASED risk of PONV during laparoscopy
true (48%)
treatment for opioid spasm
glucagon
Deferred pain to SHOULDERS related to irritation of the
diaphragm
when does shoulder pain occur
1st day postop
why does bradycardia occur
due to vagal stimulation/stretching
what can occur during laparoscopic procedure (CV)
bradycardia
asystole
arrythmias
PEA
signs of CO2 emboli**
HYPOtension
JVD
tachy
mill-wheel
short increase in EtCO2, followed by decrease
hypoxemia
cyanosis
treatment for CO2 emboli*
stop insufflation
release pneumo
L side down (durant)
HYPERventilate
increase CVP (volume)
CVL (aspirate)
signs of lung rupture or PTX or pneumomediastinum
increase in pressure
hypoxemia
severe CV compromise
HYPOtension
SQ emphysema
there is LESS pulm dysfunction, but it can still occur
true
Diaphragmatic dysfunction may last up to ___ hr
24 hr
treatment for SQ emphysema
give ____% O2
100%
lithotomy w/ steep trendelenburg
pelvis, robotic
steep trendelenburg
prostatectomy, robotic
robotics
limit fluid to ___-___ L of crystalloid
1-2 L
better to use colloids
average age for radical prostatectomy
60 years
patient positioning for thoracoscopy
lateral decubitus
true or false
avoid LA with laparocopic, robotic
true
VATS requires
OLV
Uses no pneumoperitoneum; no gas, purely mechanical
Gasless laparoscopy
gasless lap
lifts abd wall ___-___ cm, with only __-__ IAP
10-15 cm
1-4 IAP
best indication for gas-less
ASA III-IV
true or false
GA is NOT preferred with hysteroscopy
true
what can cause TURP syndrome
resectoscope
best option of fluid for resectoscope
saline
what 2 things do we want to avoid with resectoscope (TURP)
HYPERvolemia
HYPOnatremia (HYPOosmolarity)
true or false
Must have a sodium level baseline*
true
HYPERvolemia
HYPOnatremia (HYPOosmolarity)
this causes
cerebral edema, which leads to TURP syndrome
turp syndrome
symptoms
HTN (both diastolic and sys)
BRADYcardia
CNS changes
N/V
headache
agitation
lethargy
cardiac arrest
AVOID GA with resectoscope**
true
cannot assess patient for TURP!
EKG changes with TURP
nodal/junctional
ST changes
U wave
widening of QRS
resectoscope
average rate of absorption is ___ ml/min (>__ L/hr)
20 ml/MIN
> 1 L/hr
best anesthetic with resectoscope
regional
try to limit surgical time to
< __ hr
< 1 hr
can occur within 15 min!
2 best drugs for TURP
saline
furosemide (lasix)
glycine deficits/absorption of ____ml
lead to decrease in Na of ____
500ml
Na decrease of 2.5
organogenesis occurs
1st 8 weeks
rapid growth
2nd trimester
preterm
<37 weeks
term
37-42 weeks
post-term
> 42 weeks
what is gestational age assessed by (4)
crown-rump length
1st trimester
ultrasound
1st day of LMP
Combination of physical and neuro characteristics to estimate gestational AGE
this is MORE accurate
dubowitz score
true or false
Gestational age is INDEPENDENT of weight
true
what type of age should be used
“corrected” gestational age
how long should “corrected” gestational age be used for
until 2 years old
current age of viability
22, 23-24 weeks
when are AIRWAYS formed
16th week
when are PULM VASCULATURE formed
16th week
(complete at late adolescence)
when are ALVEOLI formed
up to 8 years of age
3 stages of lung embryology
1) glandular
2) canalicular
3) alveolar
glandular stage
7-16 weeks
canalicular stage
16-24 weeks
alveolar stage
24 weeks to term
segmental airways, vessels, cartilage differentiation in the trachea and bronchi
glandular
Formation of gas exchange surface and beginning of surfactant production
Type II pneumocytes
canalicular
surface area grows quickly, membrane thins, surfactant levels in amniotic fluid becoming indicator of lung maturity
alveolar
Heart tube formed, connects to arterial and venous systems
Aorta divides
3rd week
Fetal circulation in place
7th week
Bronchial arteries develop between __-___ weeks
9-12
fetal circulation is _________
PARALLEL (2 at once)
bypass the LIVER
ductus VENOSUS
bypass the LUNGS
RA to LA
patent foramen ovale (PFO)
bypass the PULM ARTERIES
RV to AORTA
patent ductus ARTERIOSUS (PDA)
R sided pressure is high because pulm pressure is high; there is a whole between RA and LA, so there is no blood flow to the lungs
PFO
RV to aorta
PDA
2 unoxygenated
arteries
1 oxygenated
vein
1st critical event
1st gasp
1st gasp leads to***
_________ pulm blood flow
_________ pulm O2
_________ SVR
_________ pulmVR
INCREASE in blood flow, O2, SVR
DECREASE in pulmVR
true or false
normal, physiologic R to L shunting occurs for several hours after birth
true
LOW level of Type __
for infants
1
elastic recoil is _______ at infancy
LOWEST
big determinant of static lung volume
elastic recoil
Total lung capacity (TLC)
low
FRC
SIMILAR to other ages per kg
however, LOW elastic recoil makes it go to 10% of predicted
**Reason for rapid desaturation in infants with airway loss
disproportionately low O2 reserve
(TLC, FRC, low elastic recoil)
Closing volume is NOT able to be measured in children < ___ years of age
<5 years
airway dynamics
HIGH resistance =
even higher =
High resistance = newborns
even higher = premies
resistance DECREASES in peripheral airways (>___th) generation
around 5 years of age
> 12th generation
*Reason for severe respiratory impairment in very young children with only minimal airway inflammation (bronchiolitis)
high resistance
tracheal compliance
___x higher in infants
2x (but higher risk of collapse)
pulm
increased
PaCO2
Vt
RR
lung inflation
leads to
induced apnea (positive pressure extubation)
hering breuer reflex
periodic breathing
___-___ second pause
normal!
5-10 second
treatment for apnea
increase central ventilation drive (theophylline)
chest wall stabilization (PEEP)
tactile stimulation
**Apnea of ___________ has huge GA implications
prematurity
***when is the highest risk post-conceptual age for apnea
< 55 weeks
(normal preterm babies)
infant O2 consumption is >___x higher than adults
2x
compensation for increased O2 consumption
increased RR
PaO2 __________ in neonates**
DECREASES
(consumption increases)
why does PaO2 decrease
L shift
babies have _______ affinity for O2
HIGHER (less to the tissues)
newborn HR
120
1 month HR
160
adolescent HR
75
SYSTOLIC BP
6 weeks - 1 year
99
SYSTOLIC BP
1 year - 6 year
minimal change
CO
> ___-___x higher
> 2-3x higher
best measurement for CO
echo (doppler)
PR interval
QRS duration
increase with age
QRS axis is ___ at birth, rotates ___ during 1st month
QRS R = birth
rotates L
at birth, GFR is <___% of adults
< 30%
when is GFR normal
2 years old
infants have a normal, physiologic __________
acidosis
(bicarb is poorly reserved)
true or false
infants have NORMAL BUN
true
Biliary tract completed at ____th week gestation
10th
premies are at risk of _____glycemia
HYPOglycemia
jaundice is normal
true
encephalopathy due to increased bilirubin
kernicterus
cause of cholestatic jaundice
long-term TPN
GI tract “migrates and rotates” into abdominal position: __-__ weeks gestation
5-7 weeks
Duodenal motility maturation: ___-___ weeks’ gestation
29-32 weeks
Peristaltic waves absent in infant’s lower esophagus
cause
“spitting”
what can lead to inadequate swallowing
CNS damage
___% of newborns have reflux for several days
40%
should be passed in the 1st ___ hours
48 hours
3 symptoms of meconium aspiration
pneumonia
PTX
persistent pulm HTN
if a baby has increased insulin levels at birth, that can lead to
rapid HYPOglycemia
Maintain glucose at > ___-___ in newborns
40-45
symptoms of HYPERglycemia (2)
cerebral bleeding
infection
symptoms of HYPOglycemia (3)
jittery
lethargic
seizures
(may have NO symptoms!)
initial blood volume
___ mL/kg = immediate clamping
80
initial blood volume
premies: ___ mL/kg
90
newborn Hgb
14-20
3 month old Hgb
10
who has the greatest decrease in Hgb
premies at 2 months
3 month- 2 year old Hgb
12
true or false
anemia is NORMAL
true
as baby ages, they have a ___ shift of oxyhgb
R
Hct >___% is polycythemia
> 65%
vitamin K dependent factors
2, 7, 9, 10
true or false
Decreasing perinatal mortality has NOT led to a decrease in cerebral palsy
true
predictors of CP
LBW
congenital anom
low placental weight
fetal position
asphyxia
what can lead to handicapping?
malnutrition until the age of 2 years
this leads to impaired myelination
always assess by ___________ age
conceptual
What must be considered with motor deficits? (3)
drug interactions
hepatic/renal function
enzyme induction
drug dosing for infants
the SAME
more sensitive + larger Vd
key point for safe drug dosing**
titrate to effect!
metabolism
CP450 system
decreased
2 diseases that cause decreased metabolism
cystic fibrosis
celiac’s
elim 1/2 life
increases
drug clearance
prolonged
infants have an ___________ risk of toxicity
INCREASED
renal blood flow: ___-___% of CO
adult:
peds: 5-6% of CO
adults: 15-25%
true or false
creatinine is NOT a useful indicator
true
what must be considered when dosing infants
renal function
true or false
we can still USE unapproved drugs
true
neurons are genetically programmed to “commit suicide” if they fail to make synaptic connections on time
apoptosis
“anesthesia induced neuroapoptosis”
anesthetics cause
___________ death for good neurons
___________ death for weak neurons
abnormal = good
inhibited = weaker neurons
2 receptors involved**
N-methyl-D-aspartate (NMDA) glutamate
y-aminobutyric acid (GABA)A
NMDA antagonists (3)
ketamine
nitrous
ETOH
GABA antagonists (3)
benzos
inhalational agents
propofol
who is MOST at risk for brain issues with anesthetics (2)
with LENGTHYYYY procedures (> 3 hrs)
children < 3
pregnant in 3rd trimester
the rate of equilibrium of alveolar to inspired anesthetic partial pressures [FA/FI]
wash-in
wash-in is ______ ______ in neonates
more RAPID
why is wash-in more rapid in neonates
higher ventilation/FRC ratio
lower tissue/blood solubility
lower blood/gas solubility
lethal dose (LD50) is ___________ in neonates
very DECREASED
caution with centrally acting meds in children < __ year of age
< 1
EXTREMEEE caution with centrally acting meds in children < __ weeks post-conceptual
<48 weeks
volatiles
___________ cerebral blood flow
___________ CMRO2
increase blood flow
decrease CMRO2
best to use <___ MAC with mild HYPERventilation
<1 MAC
2 best volatiles
sevo
iso
true or false
BIS monitoring is not reliable in children
true
Overall, __________ margin of safety in children
decreased
** for every 1 MAC, there is a ___% DECREASE in SYSTOLIC for children
30%
hypoxia,
_______cardia,
dysrhythmias
lead to the death spiral
BRADYcardia
Hepatic metabolism reaches adult levels by ___ years old
2 years old
2 volatiles used for induction
sevo
halo
2 options for induction with sevo
sevo + ___-___% nitrous
sevo + ____% O2
sevo + 50-70% nitrous
sevo + 100% O2
biggest factor in emergence
NOT reducing agent in timely manner
true or false
NO difference for solubility, laryngospasm, vomiting between agents
true
what causes the worst emergence delirium
SEVO
des
risk factor for emergence delirium
< 6 years
best drug for emergence delirium
dexmedetomidine
What is the primary determinant of IV anesthetic agents duration of action?
re-distribution
**2 huge NEONATAL factors for redistribution
body maturation
BBB maturation
propofol
________ doses create good intubating conditions after inhalation induction
smaller
seen in children after prolonged propofol sedation
> 48 hours
>70 mcg/kg/hr
Propofol Infusion Syndrome (PRIS)
symptoms of
Propofol Infusion Syndrome (PRIS)
Refractory BRADYcardia
Metabolic acidosis
HYPERkalemia
Rhabdomyolysis
CV instability, refractory CV arrest
3 different routes for ketamine
PO
nasal
rectal
ketamine increases
HR
SBP
PA pressure
3 indications for ketamine
HYPOvolemia (trauma)
cyanotic R to L shunt
asthma/wheezing
ketamine
SVR is ____________
maintained
true or false
ketamine
maintains spont vent
neonates tolerate very well
true
3 indications for etomidate
TBIs, CV compromised
HYPOvolemia
cardiomyopathy
true or false
etomidate
must give steroids for stress coverage, especially for CRITICALLY ILL CHILDREN
true
80% of children < ___ will have BRADYCARDIAAAA after Sch
80% under < 10
what should you pre-treat with for Sch
vagolytic
(atropine)
2 major CONTRAindications with Sch
MH
hyperkalemia
(upper/lower motor neuron disease)
neuromuscular disorders (duchenne’s MD)
true or false
defibrillation is NOT helpful for Sch
true
true or false
Sch
fasciculation is NOT seen in infants
true
best RSI alternative to Sch
high dose roc (with sugg)
what type of metabolism for atracurium
hoffmann elimination
(NO plasma cholinesterase involved)
atracurium
___-___x the ED95
2-3x ED95
atracurium
intubating conditions ___min
2 min
atracurium
duration ___ min
20 min
atracurium
children generally require _______
MORE
atracurium
children recover _________ than adults
recover FASTER
indications for atracurium
hepatic/liver dysfunction**
continuous infusions
atracurium metabolite
laudanosine
true or false
atracurium
laudanosine can be ELEVATED in children with HEPATIC impairment
true
what does laudanosine cause
excitation, seizures
NO NMB properties
nimbex is ___x as potent
3x
slower onset
duration the same
nimbex
__________ recovery in children
FASTER
due to LARGER Vd
major advantage of Vec**
NO CV effects, even with large doses!
major DISadvantage of Vec**
metabolized by LIVER
roc
neonates are ______ sensitive with marked variability in duration of action
MORE
roc
why are neonates more sensitive
due to reduced clearance and P450 substrates
true or false
roc can be given IM
true
dose of roc for IM
1.8mg/kg
roc
how long does IM intubating conditions take
up to 4 min
pancuronium
__________ effects
vagolytic effects
there is NO histamine
what is the only NMB that has some histamine (minimal)
nimbex
PANC
indications/USES/GOOD FOR
cardiac surgery
high-risk infants/neonates
frequently used in NICU
PANC
true or false
Very predictable recovery in neonates, infants, and young children compared to vec and roc
true
even with a slight residual NM blockade, you can have ________ and ___________
hypoxia
HYPERcarbia
___________ elimination ½-life of NMBs
longer
babies have less of type __ fibers
less type I
true or false
observe preop clinical conditions and aim for “back to baseline” at emergence
true
4 things to assess for with antagonizing of NMB*
facial nerve
hip/arm flexing
leg lift
abd muscle tone
_____ infants before attempting antagonism
WARM
what drug do you give 1st BEFORE neostigmine
anticholinergic (robinul)
MUST wait for HR to increase
who is sugg approved for
> 2 and higher
who can sugg be used with
everyone
morphine**
who has RAPID/FAST clearance
children
morphine**
who has REDUCED/slower clearance
infants
opioids
what is the BIGGEST respiratory depressant
morphine
morphine
neonatal brain has ___x uptake of adult
this is due to:
3x
due to the immature BBB
AVOID morphine with < __ year old
< 1 year old
best drug for decreasing shivering
meperidine
meperidine
what is the elimination 1/2 life for NEONATES
3.3-60 hrs (huge variation!)
what metabolite with meperidine
normeperidine
what can normeperidine cause
seizures
true or false
many peds centers have REMOVED meperidine from their formularies
true
Most common opioid for peds GA
fentanyl
true or false
fentanyl
HUGE doses are tolerated well by premies/neonates for cardiac procedures
true
however, only give if you are NOT planning on extubating at the end of the case!
true or false
fentanyl
Dynamics VARIABLE in all peds age groups, especially premies
Titrate to effect!
true
___________ + _________ profound hypotension, especially in neonates
fentanyl + versed
fentanyl
what can occur in neonates
increased vagal tone
bradycardia
DECREASED CO
fentanyl
what route can be used with BMT for GA
nasal
what opioid has a very brief 1/2 life (<10 min)
remifentanil
for creating ideal intubating conditions, when Sch should be avoided
use _____________ + __________
remifentanil + propofol
Indication
Prevention of withdrawal symptoms when weaning from opioid infusions
methadone
true or false
methadone has elim variation in children
true
true or false
ketorolac (NSAID)
has NO respiratory depression
true
what is current evidence with T&A
OKAY to use ketorolac
CONTRAindications for ketorolac
ortho (especially spinal)
GI/renal/allergy
Most common benzo for peds
midazolam
midazolam
CONTRAindications (3) as
OSA
neuro patients (VP shunt issue)
increased ICP
Opioids
indications (2) for zofran
strabismus repair (eye)
ENT
4 indications for precedex
sedation, maintaining spontaneous ventilation
opioid-sparing
emergence delirium
ETT tolerance for weaning from vent
4 indications for atropine
decrease secretions (common for infants)
pre-treat Sch
block oculocardiac reflex
prevent/treat bradycardia
which form of atropine is given to infants < 6 months old
IM
atropine
IM
BEFORE
inhalational induction
for < 6 months old
true
(infrequent now with sevo)
true or false
atropine CROSSES the BBB
true
glycopyrollate
has MINIMAL BBB penetration
(mimimal CNS effects)
true
true or false
physostigmine is NOT for NMB blocker
true
instead, it is used for central cholinergic syndrome and delirium
narcan
brief 1/2 life, need to be monitored
neonates/children often need _______ doses
LARGE
3 side effects of narcan
HTN
dysrhythmias
pulm edema
