exam 4 Flashcards by Grace Prinsell

what 2 age groups do not need sedation

< 6 months

6-12 years (may worsen overall experience)

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goal

pH > ___
volume < ____

pH > 2.5
volume < 0.4 ml/kg

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true or false

allergic rhinitis has NO fever

true

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Hct > ___

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exceptions for Hct being LOWER

chronic renal failure
2-4 months old

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anemia shifts to the

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true or false

Do NOT transfuse preop to get Hct up

true

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asymptomatic fever of ___-___ OKAY to do fever!

0.5-1

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sickle cell tranfuse to Hgb of

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asthma

extubate ______**

DEEP

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asthma

PaCO2 > ____ = increased risk for postop respiratory FAILURE

> 45

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Chronic lung disease related to prolonged mechanical ventilation/barotrauma/O2 toxicity

bronchopulmonary dysplasia

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bronchopulmonary dysplasia

use:
_______ ETT
______capnia

SMALLER ETT
HYPERcapnia/hypoventilation

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what is the ONLY certain way to rule out structural defect

ECHO

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type 1 diabetes

___% glucose
____ of usual insulin dose

__________ infusion of glucose + insulin

5% glucose
1/2 usual insulin dose

continuous infusion of glucose + insulin

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hyperalimentation

decrease rate by ___ to ___

decrease
1/3 to 1/2

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true or false

H2 blockers and steroids do NOT prevent anaphylaxis

true

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EMLA cream is what 2 LAs

lidocaine
prilocaine

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atropine

____ in infants < 6 months

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Maintain high sevo with SPONTANEOUS ventilation, until ___ access obtained

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Treat ____________ STAT

bradycardia

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What are children dependent on

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airway obstruction

slightly _______ APL valve to generate 5-10 cm PEEP

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true or false

do NOT take over ventilation/mechanically ventilate BEFORE IV access is obtained

true

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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

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

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

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

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 ___

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

angle is _________ after pop of ligamentum flavum

parrelel

inject LA over ___ min

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**

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