exam 4 Flashcards
what 2 age groups do not need sedation
< 6 months
6-12 years (may worsen overall experience)
goal
pH > ___
volume < ____
pH > 2.5
volume < 0.4 ml/kg
true or false
allergic rhinitis has NO fever
true
Hct > ___
25
exceptions for Hct being LOWER
chronic renal failure
2-4 months old
anemia shifts to the
R
true or false
Do NOT transfuse preop to get Hct up
true
asymptomatic fever of ___-___ OKAY to do fever!
0.5-1
sickle cell tranfuse to Hgb of
10
asthma
extubate ______**
DEEP
asthma
PaCO2 > ____ = increased risk for postop respiratory FAILURE
> 45
Chronic lung disease related to prolonged mechanical ventilation/barotrauma/O2 toxicity
bronchopulmonary dysplasia
bronchopulmonary dysplasia
use:
_______ ETT
______capnia
SMALLER ETT
HYPERcapnia/hypoventilation
what is the ONLY certain way to rule out structural defect
ECHO
type 1 diabetes
___% glucose
____ of usual insulin dose
or
__________ infusion of glucose + insulin
5% glucose
1/2 usual insulin dose
continuous infusion of glucose + insulin
hyperalimentation
decrease rate by ___ to ___
decrease
1/3 to 1/2
true or false
H2 blockers and steroids do NOT prevent anaphylaxis
true
EMLA cream is what 2 LAs
lidocaine
prilocaine
atropine
____ in infants < 6 months
IM
Maintain high sevo with SPONTANEOUS ventilation, until ___ access obtained
IV
Treat ____________ STAT
bradycardia
What are children dependent on
HR
airway obstruction
slightly _______ APL valve to generate 5-10 cm PEEP
CLOSE
true or false
do NOT take over ventilation/mechanically ventilate BEFORE IV access is obtained
true
single breath induction
requires
_____ flow
__% sevo
HIGH flow
8% sevo
IV induction
____% nitrous, ____% oxygen
50%
true or false
RSI
NO positive pressure ventilation until ETT placement is confirmed
true
modified RSI
USE positive pressure (< ___)
< 15
true or false
laryngospasm:
can occur anytime,
have NO cause
any technique
any patient
true
biggest cause of laryngospasm
stage 2 (secretions/stimulation)
when does bronchospasm occur
emergence, before extubation
best airway maneuver for upper airway obstruction (tongue)
jaw thrust
best Prophylaxis
IV fluids +
5-HT3 antagonist + dexamethasone
best Rescue
5-HT3 antagonist
Phenergan
Non-opioid analgesics
HYPOtension is UNCOMMON in peds
2 exceptions
CHD
hypovolemia
hypothermia
< ___
< 36
emergence delirium
< ___ years old
___-___ minutes
< 6 years
5-15 min
ETT cuff pressure
soft max
hard max
soft = 20
hard = 25
laryngeal edema (pressure) leads to
subglottic stenosis
treatment for laryngeal edema/subglottic stenosis
laryngeal tracheal reconstruction (LTR) with cartilage grafting
low birth weight
< 2500
VERY low birth weight
< 1500
EXTREMELY low birth weight
< 1000
when is surfactant production complete
36 weeks
Incidence of apnea significantly decreases at ___ weeks post-conceptual age
55
types of apnea
central
obstructive
mixed
3 factors for apnea
post-conceptual age*
Hct
surgical procedure
patent ductus arteriosus (PDA) =
pulmonary HTN + CHF
Pain receptors begin developing at ___ weeks’ gestation
19
when does pain perception and memory begin?
regardless of gestational age
Premie method of heat production:
NON-shivering thermogenesis
dependent on brown fat
peds
__________ renal function
_____natremia
____________
DECREASED renal function
HYPOnatremia
thrombocytopenia
PREductal **
R hand
POSTductal **
L or R foot preferably
Choanal Atresia + Stenosis
“CHARGE” syndrome
biggest issue*
heart disease
(nose issue)
biggest thing to remember with laryngeal webs*
NEVER proceed without ENT available for tracheostomy
subglottic stenosis
_________ ETT needed**
__________ in airway resistance
SMALLER ETT
INCREASE in airway resistance
Tracheoesophageal Fistula
frequently with __________ syndrome
VACTERL
Tracheoesophageal Fistula (TEF) has risk of**
Congenital heart disease*
Tracheoesophageal Fistula
most common =
blind esophageal pouch
Tracheoesophageal Fistula
correct ETT is crucial:
BELOW _______ and ABOVE ________
below fistula
above carina
Tracheoesophageal Fistula
confirmation of ETT with
fiberoptic scope
Congenital Diaphragmatic Hernia (CDH)
inability to oxygenate with mediastinal shift!
huge _____________**
EMERGENCY**
congenital diaphragmatic hernia
TREATMENT**
pulmonary vasodilators (nitric)
ECMO
oscillators, HFJV
EXIT procedure
congenital diaphragmatic hernia
heart is shifted to the ___
require high PIPS, risk = ____*
heart = R
risk of PTX
true or false
intestinal obstruction
has other anomalies!
true
intestinal obstruction
needs:
RSI
intestinal obstruction
issues
Abdominal distension with 3rd spacing, vomiting, electrolyte imbalance*
Sepsis*
anemia
other anomalies
true or false
pyloric stenosis
MEDICAL emergency
NOT a SURGICAL emergency!
true
3 symptoms of pyloric stenosis
HYPOkalemic
HYPOchloremic
metabolic ALKALOSIS
true or false
imperforate anus
should have CV evaluation with ECHO preop*
true
Very sick patient*
necrotizing enterocolitis
5 symptoms of necrotizing enterocolitis
ACIDOSIS
coag dysfunction
HYPOtensive
ANEMIA
3rd spacing, fluid loss
GI organs outside abdominal wall
omphalocele
gastroschisis
which is the worst*
omphalocele
(CV, renal issues)
what drug is omphalocele treated with preop
silo
Incomplete migration or malrotation of intestines from yolk sac into abdomen
Emergent if strangulation is suspected
volvulus
CONTRAindication with all intestinal obstructions
nitrous
3 symptoms with volvulus
HYPOtensive
HYPOvolemic
electrolyte imbalance
Most common neonatal colonic obstruction
hirschsprung disease
hirschsprung disease
absence of ____
PNS
what is a CONTRAindication for hirschsprung**
NMBs (due to nerve monitoring)
PDA ligation
with L to R shunting,________ can occur
CHF + respiratory failure
With persistent pulmonary HTN of the newborn (PPHN),
______________________
can occur
R to L shunting (cyanotic)
PDA ligation
consider what kind of monitoring
pre-ductal
post-ductal
5 common neonatal procedures
shunts
CVLs
trachs
fundoplication
gastrostomy tubes
LASER
VP shunts, EVDs
bronchoscopies/esohphagoscopies
L to R ***
INCREASING pulm flow
NON-cyanotic
R to L ***
DECREASING pulm flow
cyanotic
Mixed
cyanotic
3 types of L to R
CHD
atrial septal defect (ASD)
ventricular septal defect (VSD)
patent ductus arteriosis (PDA)
1 type of R to L
CHD
TOF
2 types of Mixed
CHD
transposition of great arteries (TGA)
hypoplastic L heart syndrome (HLHS)
2 types of obstructive
CHD
aortic stenosis (AS)
coarctation of aorta (CoA)
what is the type of
atrial septal defect
patent foramen ovale
biggest precaution
for atrial septal defect
bubble precautions
Most common CHD in children
VSD
what type of VSD is most common
perimembranous
which is WORST type of VSD
NON-restrictive (high flow, more problems)
VSD
severity and management dependent on
(4)
defect SIZE
degree of SHUNT
pulm VR
SVR
decreased pulmVR = ____________ L to R flow + pulmonary steal
INCREASED
where is the PDA
pulmonary artery + aorta
after birth, pulmVR ___________**
decreases
treatment for PDA
ligation with L thoracotomy
VATS
measures arterial O2 AFTER leaving the heart
but BEFORE it reaches the ductus
pre-ductal
measures arterial O2 AFTER leaving the heart
and AFTER it passes the ductus
post-ductal
PRE-Ductal SaO2 > __% ABOVE POST-ductal =
R to L ductal shunting**
> 3%
4 features of TOF
RV outflow obstruction
(lung issue)
RV hypertrophy
overriding aorta
VSD
cyanosis (R to L) for TOF
dependent on (2)
RVOTO (RV obstruction)
SVR
2 drugs for TET spell
phenylephrine (1 mcg/kg)
beta blocker (propranolol)
anesthetic implications for TOF
keep pulmVR LOW
keep SVR NORMAL
INCREASE preload
AVOID tachy
Aorta rises from the R ventricle; pulmonary artery arises from the L ventricle
Transposition of the Great Arteries (TGA)
fetal circulation is
parallel
what is needed with transposition so a patient does not die
PDA
VSD
if not having a PDA or VSD, how is transposition kept open (2)
prostaglandins (PGE1)
surgical balloon septostomy
5 features of
hypoplastic L heart syndrome
1) hypoplastic/small LV
2) mitral stenosis/atresia
3) aortic stenosis/atresia
4) hypoplastic/small aorta
5) ductal-dependent circulation (PDA)
treatment for hypoplastic L heart syndrome
prostaglandins
RV becomes systemic pump
(3 stages: norwood)
transplant
4 anesthetic implications for
hypoplastic L heart syndrome
MAINTAIN CO
keep sao2 75-85%
LOW Vt
LOW PEEP
aortic stenosis
the HIGHER the gradient, the ________ it is to get blood across
HARDER/more risky
treatment for aortic stenosis
emergent valvuloplasty
biggest implication for aortic stenosis
AVOID tachycardia
2 types of
coarctation of aorta (CoA)
1) neonatal
2) > 1 year old
better diagnosis for CoA
> 1 year old
cardiopulm bypass
CONTRAindicatated fluids
dextrose
lactate
big thing to pay attention to with CHD patients
exercise tolerance
chronic hypoxia can lead to _______ Hct
higher (polycythemia)
increased viscosity, decreased organ perfusion
when do TET spells commonly occur
induction! (stress)
or emergence
avoid 3 things with pulm HTN
acidosis
HYPERcarbia
HYPOthermia
Paradoxical Air Embolus
occurs with what types of shunt
R to L
increased R sided pressure
For atrial arrhythmias, anticoags should be stopped ___-___ weeks preop
1-2
Anticoags should be restarted ___-___ days postop
1-3
Irreversible PULM VASCULAR disease, shunt reversal with severe hypoxemia
eisenmenger syndrome
what do eisenmenger syndrome die from
sudden ventricular dysrhythmias
post-transplant patients
USE
______-acting agents
DIRECT-acting
post-transplant patients
↑ HR due to _______________
↑ HR due to loss of PNS tone*
Bi-Atrial Repair
Dissect a portion of the RA from the donor heart, end up with a portion of 2 RAs, the SA node is now present in both, so you get double ___ waves
P
drug of choice for endocarditis
penicillin
cephalosporin, clindamycin
Urethra opens on the underside of the penis
Epispadias (top)
Hypospadias (bottom, more common)
Chordee
Undescended testes “pulled down” into scrotum
Orchiopexy
GU procedures
type of anesthetic
GA
sometimes with regional
______________ risk during foreskin, hernia and testes retraction
Laryngospasm
For reflux at the ureter/bladder junction
Ureteral reimplantation
always unilateral
do NOT use caudal or regional
pyeloplasty
2 symptoms of chronic kidney disease
anemia
HTN
positioning for nephrectomy
lateral/prone
Highly associated with CV defects*
Bladder and Cloacal Exstrophy
failure of abdominal wall to close over anterior bladder wall
true or false
Ears, kidneys, hearts are developing at the same time embryologically
true
which type of scoliosis has the highest risk
neuromuscular (duchenne)
Vital capacity begins to decrease at ___°, becomes severe at ___°
60
Severe at 100
neuromuscular has
prolonged ____
decreasing factor ___
prolonged PTT
decreasing factor VII
Long, bloody, high risk
Posterior Spinal Fusions
true or false
spinal surgery:
PRBCs MUST be available
and
Soft bite block*
true
Periop vision loss is usually due to
ischemic optic neuropathy
biggest risk factors for periop vision loss (2)
> 6 hrs
high blood loss
___° C drop in core temp = 3x increased risk of wound infection
2 C
Controlled hypotension (MAP of ___–___)
50-65
true or false
controlled hypotension
is CONTROVERSIAL, needs ALINE
true
dilutional thrombocytopenia
PLTs
replace factors
FFP
when are motor pathways most vulnerable to ischemia
during hardware insertion
what has replaced the “wake-up test”
SSEP and MEP
anesthetic agents
_________ amplitude
_________ latency
DECREASE amplitude
INCREASE latency
best type of anesthetic for spinal surgery
propofol + opioid (remi or suf)
2 CONTRAindications in spinal surgery
NMBs
N2O
child
large ratio for:
surface area : volume
common
hypo and hyper:
natremia and kalemia
Use volumetric chambers, micro-drips and/or pumps for children < ___ years old
< 10
- Headache
- Nausea
- Weakness
- Confusion
- Irritability
- Seizures
- Respiratory arrest
- Irreversible neurologic injury
HYPOnatremia
HYPOnatremia
correction:
asymptomatic =
acute =
asymptomatic = SLOW
acute = RAPID
- Irritability
- Coma
- Seizures
HYPERnatremia
treatment for HYPERnatremia
colloid or NS
SLOW correction
- Muscle weakness
- Prolonged QT**
- Dampened T waves
- U waves
Acute
* Vomiting
* Diarrhea
HYPOkalemia
treatment for HYPOkalemia
SLOW correction
oral if available
- Peaked T waves
- PR lengthening
- QRS widening
- Eventually, sinusoidal
Acute
* Renal insufficiency
* Massive tissue trauma
* Acidosis
* Sch with myopathies, burns, motor neuron disease, sepsis, massive transfusion, MH
HYPERkalemia
treatment for HYPERkalemia
IV calcium
bicarb
glucose/insulin
ratio for blood products or colloids
1:1
ratio for isotonic crystalloid
1: 1.5-3
best type of crystalloid for blood loss*
Plasmalyte or Normosol is preferred
what can NS cause
“Hyperchloremic Acidosis”
excess chloride
“Old” PRBCs have ______________ risk
hyperkalemia
2 increased risks for PRBCs hyperkalemia
irradiation
increased shelf time
causes of hyperkalemia
HYPOthermia**
HYPOcalcemia
true or false
better to use PIV
rather than CVL
true
Massive transfusion leads to _____calcemia
hypo
- Widened QRS
- Prolonged QT
- Peaked T waves
Hypocalcemia and/or Citrate Toxicity
best type of albumin
5%
massive blood transfusion
> ____ml/kg in 4 hrs
replacement of 1 or more BVs
> 30
best blood type for emergent
O -
O+ for males
coagulopathy from massive blood transfusion
3 causes
dilution**
fibrinolysis
DIC
Recommendation:
Give FFP after 1 BV loss, then __ FFP: __PRBCs
1 FFP: 2 PRBCs
fluid deficit
______________ x ____ NPO
maintenance rate x hrs NPO
preterm
100 ml/kg
full term - 1 year
90 ml/kg
1 - 3 years
80 ml/kg
toddler - 8 years
75 ml/kg
> 8 years
70 ml/kg
MABL = ____ x (________ -_______)
/ __________
EBV x (starting - trigger)
/
starting
***Do not exceed 20 ml/kg/hr
Unless:
replacing blood loss
or
actively bleeding
major indication for spinal
infants
what drug doubles DURATION for spinal
clonidine
conus medullaris in infant is more _________
CAUDAL
conus medullaris reaches adult level at age ___
1
puncture should be at
L__-__ or L__-S__
L4-L5
L5-S1
sacrum is _________ and ______
narrower
flatter
lagmenta flava is _____ dense
LESS
CSF turnover rate is _______
greater
shorter duration
cm between skin and SA space
< 1.5
SEDATION due to DECREASED sensory input to RAS from periphery
(can be advantage or disadvantage)
deafferentation
(sometimes, its good to have a little pain)
CONTRAindication for SAB
Ketamine, more apnea than GA!
true or false
NO leg raises to avoid high spinal
true
causes of LAST (2)
bupivacaine
amide
best drug for epidural
2-chloroprocaine
caudal
palpate
posterior superior iliac spines/sacral cornu
___ angle
45
angle is _________ after pop of ligamentum flavum
parrelel
inject LA over ___ min
2
Dose dependent on desired dermatome level
VOLUME
____% ropivacaine is BEST
0.2%
2nd best choice: bupivacaine
___-___ ml/kg of ___%
0.5**-1 ml/kg of 0.25%
Generally: ___ml/kg/dermatome
0.5
Clonidine __ mcg/kg**
1
sensory block for T__-__
T4-6
2 ABSOLUTE CONTRAindications to spinal
VP shunt
diaper rash
2 RELATIVE CONTRAindications to spinal
sacral dimple
history of spinal abnormality
How is a child is BEST provided with a regional technique?
deep sedation
or
after the induction of GA
