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NUNA 692 Principles III > Exam IV: Preanesthetic Eval, Premed, and Induction > Flashcards

Exam IV: Preanesthetic Eval, Premed, and Induction Flashcards

1
Q

Infants less than 6-10 months:

A
  • Tolerate separation for short periods
  • Accept inhalation induction with sucking or licking of mask
  • No premedication needed
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2
Q

Children 6 months to 6 years cling to ______

A

parents

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3
Q

Children 6 months to 6 years are very anxious even with ______ ______

A

parents present (higher parental anxiety = higher parent anxiety)

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4
Q

Children 6 months to 6 years - Can lead to postop nightmares (night terrors), ______ disturbances, new onset ____-____ (midazolam reduces these, but does not eliminate)

A

eating
bed-wetting

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5
Q

Predictors of problematic behaviors upon parental separation (2-6 years):

A
  • Have not taken preop family tour
  • Have had previous surgery (?)
  • Dependent or withdrawn affect
    (Consider sedation)
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6
Q

Children older than 6 years (who have attended school)

accept ______

A

separation

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7
Q

Children older than 6 years (who have attended school)

more ______

A

independent

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8
Q

Children older than 6 years (who have attended school)

understand _____ about the hospital environment

A

more

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9
Q

Children older than 6 years (who have attended school)

communicate _____ and more _____

A

better
openly

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10
Q

Children older than 6 years (who have attended school)

curiosity can be used, more _____

A

trusting

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11
Q

Children older than 6 years (who have attended school)

______ not necessary, may interfere with their ability to cooperate, may worsen overall experience

A

Sedation

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12
Q

Adolescents

Seem independent and self-confident, BUT…
Mood changes quickly to _____ _____.

A

immature child

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13
Q

Adolescents

Fragile _______ (self-esteem and body image).

A

psychologically

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14
Q

Adolescents

want to be in _____, may dislike _____

A

control
sedation

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15
Q

Adolescents

usually can be _____ with

A

reasoned

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16
Q

Techniques to Prepare Patients/Families for Anesthesia

______ explanation

A

honest

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17
Q

Techniques to Prepare Patients/Families for Anesthesia

include _____, parents, siblings, and _____ _____

A

patient
teddy bears

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18
Q

Techniques to Prepare Patients/Families for Anesthesia

allow ____/____ items

A

comfort/security

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19
Q

Techniques to Prepare Patients/Families for Anesthesia

discuss risks in _____ _____, give details of safety measures, the ____ ____??

A

clear terms
“D” word

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20
Q

Pre-Anesthetic Evaluation - Medical history

  • In _____ problems
  • Gestational age at birth, ____-_____ age
  • Hospitalization/_______ at birth
A

utero
post-conceptual
ventilation

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21
Q

Pre-Anesthetic Evaluation - Medical history

History of _____ or _____

A

apnea or bradycardia

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22
Q

Pre-Anesthetic Evaluation - Medical history

History of c_____

A

croup

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23
Q

Pre-Anesthetic Evaluation - Medical history

Contacts with _____ diseases

A

infectious

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24
Q

Pre-Anesthetic Evaluation - Medical history

Review _____, _____ records

A

anesthetic, hospital

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25
Q

Pre-Anesthetic Evaluation - (7)

A
  • airway management
  • venous access
  • hypotension
  • bradycardia
  • oxygen saturation
  • agitation
  • premedication
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26
Q

Pre-Anesthetic Evaluation - family hx (6)

A
  • Sudden Infant Death (SIDS) in family
  • Anesthetic complications (prolonged paralysis, malignant hyperthermia)
  • Genetic defects
  • Familial conditions (Sickle Cell, CF, MD, bleeding tendencies)
  • Allergic reactions
  • Drug addiction (withdrawals, HIV, Hep C)
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27
Q

Smoking/Environmental Tobacco Smoke:

WHO: _____ million children (almost ½ of children world-wide) exposed to ETS

A

700

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28
Q

Smoking/Environmental Tobacco Smoke:

______ US teens/day smoke 1st cigarette; ____ become regular smokers

A

3,800
50%

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29
Q

Smoking/Environmental Tobacco Smoke:

↑ risk of _____, otitis media, eczema, hay fever and ____ ____

A

asthma
dental caries

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30
Q

Smoking/Environmental Tobacco Smoke:

Evidence: ↑ airway complications during induction and emergence with _____ _____ inhalation

A

passive ETS

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31
Q

Smoking/Environmental Tobacco Smoke:

Include ETS exposure in _____ _____

A

preop evaluation

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32
Q

Fasting Guidelines

Clear liquids __-__ hours preop encouraged
Clear liquid ½ life: ___ minutes

A

2-3
15

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33
Q

Fasting Guidelines

Breast milk has ___ ____ ____ which leads to delayed emptying. NOT considered clear; wait 4 hours.

A

↑ lipid content

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34
Q

Fasting Guidelines

Formula, milk, solids – wait ____ hours*

A

6
(as a rule to be safe children’s says 7)

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35
Q

Fasting Guidelines

No gum or candy after midnight (increases ____ _____)

A

gastric secretions

However….
- No evidence that gum chewing during pre-anesthetic fasting increases volume or acidity of gastric juice significantly enough to increase risk
- Evidence that unreported swallowing of gum does not increase the risk of aspiration.
- Evidence that gum chewing promotes GI motility and physiologic emptying.

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36
Q

Fasting Considerations

Risk of ________ – FTT, debilitated, receiving ↑ glucose solutions preop

A

hypoglycemia

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37
Q

Fasting Considerations

If surgery delayed for infant, ____ an ____ or allow ____ _____ (if OR time known)

A

start an IV
clear liquids

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38
Q

Fasting Considerations

Explain why ___ ___. Don’t trust them!

A

no food

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39
Q

Fasting Considerations

Goal: pH >___, Volume < ___ mL/kg

A

2.5
0.4

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40
Q

Fasting Considerations

beware of _____

A

hypovolemia

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41
Q

Common Pediatric Concerns in the Pre-Anesthetic Evaluation (9)

A
  • Upper Respiratory Tract Infection
  • Anemia
  • Fever
  • Sickle cell disease
  • Developmentally delayed
  • Type I Diabetes
  • Seizure disorders
  • Hyperalimentation
  • Asthma
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42
Q

Fever

______ fever of 0.5 to 1.0 C – anesthesia is not contraindicated.

A

Asymptomatic

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43
Q

Fever

With symptoms of acute onset (rhinitis, sore throat, ear-ache, dehydration) - ______ ______.

A

consider postponing

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44
Q

Fever

If proceeding with a fever - reduce fever to decrease O2 demand.
A_______, i______
______ ______ blunt the febrile response.

A

Acetaminophen, ibuprofen
Inhalation agents

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45
Q

URI:

With URI (especially if <1 year old): ___-___ x ↑ risk of respiratory complications:

A

2-7
Bronchospasm
Laryngospasm
Hypoxemia
Atelectasis
Croup
Stridor

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46
Q

URI:

when to postpone sx?

A

Sx of lower respiratory involvement
Purulent rhinorrhea
Acute onset vs. chronic
Less than 1 year old
Fever

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47
Q

URI:

when to reschedule?
Bronchial reactivity can last:
Practical time:

A

Bronchial reactivity can last 7 weeks
Practical time: 2 weeks

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48
Q

URI:

Controversial findings -
Mild URI, not acute, for minor procedure, not intubated = ____ to anesthetize
Post-intubation: Increased _____ and _____, but no worse than without URI; no increased _____

A

safe
spasms and desaturations
morbidity

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49
Q

URI:

allergic rhinitis (3)

A

Seasonal in character
Clear nasal drainage
No fever

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50
Q

Asthma:

_____ _____ – ER visits, hospitalizations, medications, last doses, exacerbation triggers, steroid use, last wheezing

A

Investigate history

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51
Q

Asthma:

Bronchodilators/asthma meds the ______ of _____

A

morning of surgery

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52
Q

Asthma:

Consider avoiding ______ or extubate while _____

A

intubation
deep

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53
Q

Asthma:

Postpone surgery for significant ______

A

wheezing

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54
Q

Asthma:

Emergency: Try to optimize but _____ _____ vs _____
***PaCO2 > ____ = increased risk for post-op respiratory failure

A

weigh risks v. benefits
45

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55
Q

will we be getting ABGs on an asthma pt?

A

absolutely not because if they werent wheezing before, they will be now

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56
Q

Bronchopulmonary Dysplasia

Chronic lung dz r/t prolonged _____ _____/______/______ _____ (usually former premies)

A

mechanical ventilation/barotrauma/O2 toxicity

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57
Q

Bronchopulmonary Dysplasia Sx:

A

Tachypnea, dyspnea, reactive airway, O2 dependence

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58
Q

Bronchopulmonary Dysplasia

Decreased FRC, prone to ____ ____, become hypoxic with _____ or _____ (crying)

A

airway obstruction
exercise or stimulation

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59
Q

Bronchopulmonary Dysplasia

May need pre-op labs if on _____

A

diuretics

60
Q

Bronchopulmonary Dysplasia

Avoid ____ d/t chronic air trapping

A

N2O

61
Q

Bronchopulmonary Dysplasia

Subglottic stenosis may require _____ _____

A

smaller ETT

62
Q

Bronchopulmonary Dysplasia

Chronically _____carbic - avoid _____ventilation

A

hyper
hyper

63
Q

Anemia:

Most recommend a hematocrit > ____%, but if between 2-4 months of age or with chronic renal failure, a ____ value is acceptable.

A

25
lower

64
Q

Anemia:

Chronic anemia compensation

A
  • increased 2,3-DPG
  • increased oxygen extraction
  • increased cardiac output
65
Q

Anemia:

Do not transfuse pre-op to get Hct > ___%. (Unnecessary risk of ____-____ _____ _____)

A

30
blood-borne disease transmission

66
Q

Sickle Cell Disease

Susceptible patients ____ ____ ____(SC Dz in family, unknown patient status with low HCT). Should have results in state lab.

A

should be tested (also get a full fam hx)

67
Q

Sickle Cell Disease

If prep screen positive, a _____ _____ is needed to determine the severity. (+ screen can be SC trait)

A

hemoglobin electrophoresis

68
Q

Sickle Cell Disease

Hematology consult, transfused up to ___ of ___ g/dL - resulted in fewer SC-related complications

A

Hgb of 10 g/dL

69
Q

Sickle Cell Disease

Anesthetic implications:

A

warm, wet, and green

70
Q

Cardiac Murmurs - quote that LISA loves

A

“Never underestimate the potential implications of a newly diagnosed heart murmur”

71
Q

Cardiac Murmurs

May be previously detected by pediatrician and determined to be _____.

A

innocent

72
Q

Cardiac Murmurs

If not previously detected, elective procedure should be _____ _____ _____ CV consult.

A

delayed until after

73
Q

Cardiac Murmurs

_____ _____ not usually associated with other symptoms.

A

Innocent murmurs

74
Q

Cardiac Murmurs

Only certain way to rule out structural defect:

A

ECHO

75
Q

Seizure Disorders

Determine the….

A

Determine the medication, normal dosage routine, last dose.

76
Q

Seizure Disorders

Determine type of _____

A

seizure

77
Q

Seizure Disorders

Anesthesia may alter ____ ____ and cause increased activity post-op. (GA prevents seizure activity,)

A

seizure threshold

78
Q

Seizure Disorders

Some drugs may _____ seizures, seizure meds interact with some anesthetic agents. (Ex: Neuro- muscular blockade agents)

A

induce

79
Q

Insulin-Dependent Diabetic Children:

Maintain normal regimen up to ____ _____ _____

A

day before surgery

80
Q

Insulin-Dependent Diabetic Children: consult _______

A

endocrinologist

81
Q

Insulin-Dependent Diabetic Children: schedule for

A

first case of the day

82
Q

Insulin-Dependent Diabetic Children:

Common: Preop IV access, 5% glucose (maintenance rate), ___ usual insulin dose

A

½

Alternative: Continuous infusion of glucose and insulin

83
Q

Insulin-Dependent Diabetic Children:

monitor:

A

Monitor serum BG preop, intraop and postop

84
Q

Hyperalimentation

Know what type (___ ____) and rate.

A

% glucose

85
Q

Hyperalimentation

____ ____ with central lines

A

Aseptic technique

86
Q

Hyperalimentation

Stopping intraoperatively leads to _______. Decrease rate by 1/3 to 1/2.

A

hypoglycemia

87
Q

Hyperalimentation

ALWAYS use ____ to control

A

pump

88
Q

Hyperalimentation

monitor

A

BG, electrolytes perioperatively

89
Q

Developmentally Delayed Children

Ability to _____ with these patients may be altered.

A

reason

90
Q

Developmentally Delayed Children

May have ____ ____ – DHR custody, foster parents

A

consent issues

91
Q

Developmentally Delayed Children

Pharmacologic capture (2 points)

A
  • Oral or nasal midazolam
  • Oral or IM “cocktail” (ketamine and glycopyrrolate)
92
Q

Latex Allergy - most common cause of

A

intra-op anaphylaxis in peds

93
Q

Latex Allergy

____-threatening, ____-mediated

A

life
IgE

94
Q

Latex Allergy

At risk:

A

Neural tube defects, frequent GU caths, hx of multiple surgeries, health care workers, tropical fruit allergies

95
Q

Latex Allergy - ___ _____ and ______ do NOT reliably prevent anaphylaxis.

A

H2 blockers and steroids

96
Q

Latex Allergy

____-____ _____ is best prevention (Latex Allergy Protocol).

A

Latex-free environment

97
Q

Latex Allergy

Treatment: _______

A

Epinephrine

98
Q

Informed Consent for Elective Procedures

A

Legal Guardianship
DHR
Foster parents
Family members
Unmarried mother
Sedated/incapacitated mother
Emancipated minor
2 physician signatures
Risk Management policies
HIPAA
Language barriers
Do we use “the D word”???

99
Q

Premedications

decrease ____ and allow smooth _____ and _____

A

anxiety
induction
emergence

100
Q

Premedications reduce _____

A

MAC

101
Q

Premedications - aspiration ______

A

prophylaxis

102
Q

Premedications - allow for pleasant ____ ____

A

PACU stay

103
Q

Premedications - NEED TO ______

A

INDIVIDUALIZE

104
Q

Midazolam - ____ ____ used

A

most commonly

105
Q

Midazolam

___-___ mg/kg PO (20-30 min prior) with max dose of ____ mg

A

0.3-0.5
15

106
Q

Midazolam

Can mix with ____ ____, _____ or _____ to mask taste

A

clear liquid, acetaminophen or ibuprofen

107
Q

Midazolam

Sedation lasts about ____ _____

A

60 minutes

108
Q

Midazolam

Does not affect recovery or discharge times if the procedure >____ _____

A

10 minutes

109
Q

Ketamine - the dart

____-____ mg/kg IM causes amnesia and analgesia in ___ _____.

A

3-5
5 minutes

110
Q

Ketamine - the dart

To prevent _____, give midazolam.

A

nightmares

111
Q

Ketamine - the dart

To prevent excessive secretions, give ______.

A

anticholinergic

112
Q

Ketamine - the dart

(Dart with ketamine, give midazolam and glycopyrrolate after ____ ____)

A

IV started

113
Q

EMLA Cream - what is it?

A

Eutectic Mixture of Local Anesthetics
lidocaine and prilocaine

114
Q

EMLA Cream

Topical, applied under occlusive dressing for ___-___ _____

A

45-60 minutes

115
Q

EMLA Cream

_____ to minimize pain of IV start or venipuncture

A

Numbing

116
Q

Atropine

  • Block _____ _____ of drugs, laryngoscopy, surgical manipulations
  • Reduce _____
  • Minimal dose of _____ (except premies)
  • IM in infants <___ months old before induction?
A

vagal effects
secretions
0.1 mg
6

117
Q

Acetaminophen

  • Given pre-op for preemptive analgesia
  • _____ sparing
  • Dose ___-___ mg/kg PO preop or PR after induction
  • Good for ___-___ cases (ex: BMT)
  • IV Ofirmev®
A

Opioid
10-20
non-IV

Others: Dex, clonidine, diazepam, diphenhydramine, ibuprofen

118
Q

Dexmedetomidine

  • Opioid sparing
  • Evidence: Decreases ____ ____
  • Preop anxiolysis
  • Intranasal or PO
  • __-__ mcg/kg given 20 – 30 min. preop
  • Evidence: Attenuates ____ and ____ preop AND reduces pain scores postop when compared to midazolam
A

emergence delirium
2 - 4
MAP and HR

118
Q

Dexmedetomidine

  • Opioid sparing
  • Evidence: Decreases ____ ____
  • Preop anxiolysis
  • Intranasal or PO
  • __-__ mcg/kg given 20 – 30 min. preop
  • Evidence: Attenuates ____ and ____ preop AND reduces pain scores postop when compared to midazolam
A

emergence delirium
2 - 4
MAP and HR

119
Q

Inhalation Induction

  • ASA ______ monitoring (if patient allows)
  • Pop-off ____, high flow (___-___ L/min) via mask, 100% O2 (or N2O and ≥ 30% O2)
A

standard
open
8-10

120
Q

Inhalation Induction

  • Begin with Sevo at ___%, increase gradually (every 3-4 breaths) to ___%
  • Maintain high Sevo with spontaneous ventilation until ___ ____ ____
A

2
8
IV access obtained

121
Q

Inhalation Induction

  • ____ and/or ___ ___ for upper a/w obstruction
  • Return ultimately to _____ concentration
A

PEEP and/or oral a/w
maintenance

122
Q

Inhalation Induction

Increasing the concentration too rapidly: (3)

A
  • Irritates airway, causes coughing
  • Smell is noxious
  • Hemodynamic effects
123
Q

Inhalation Induction

Increasing the concentration too slowly:

A
  • Prolongs induction including excitation period
  • Increased risk of airway obstruction, laryngospasm, vomiting
124
Q

Why is inhalation induction considered a higher risk than IV induction?

A
125
Q

inhalation induction

With vital sign deterioration, decrease or D/C anesthetic _____, go to ____% O2.

A

concentration
100

126
Q

inhalation induction

With desaturation, go to 100% O2 and ____ ____ (a/w obstruction, etc.).

A

address cause

127
Q

inhalation induction

Treat bradycardia _____. Bradycardia leads to ______ which leads to ____ _____ QUICKLY in infants and young children

A

STAT
dysrhythmias
CV arrest

128
Q

Airway Obstruction

Obtain tight mask fit and seal, use airway opening maneuvers (____ ____, ____ ____).

A

jaw thrust, oral airway

129
Q

Airway Obstruction

Slightly close pop-off valve to generate __-__ cm PEEP.

A

5-10

130
Q

Airway Obstruction

Do ___ ___ ___ ventilation before IV access obtained.

A

not take over

131
Q

Airway Obstruction

Once IV access obtained, treat significant obstruction with:

A

positive pressure, lidocaine, propofol, sux, etc

132
Q

tricks of the trade

_____ masks - Control and active participant

A

Scented

133
Q

tricks of the trade

______ - “Blow up the balloon”, Competition, iPads and phones

A

Distraction

134
Q

tricks of the trade

Hypnotic:

A

Tell story about … flying carpet, spaceship ride, hot-air balloon ride

135
Q

Modified Single-breath Induction

Requires child’s ______.
Coach & practice before induction.
Requires _____ _____ (high flow/8%)

A

cooperation
circuit priming

136
Q

Modified Single-breath Induction

Inhale fully and hold, exhale fully and hold, apply mask with ______ ______, take a deep breath and hold, then breathe normally.

A

maximum concentration

137
Q

Modified Single-breath Induction

____ _____ than traditional inhalation induction.

A

3 x faster

138
Q

Intravenous Induction (with no IV access)

Consider pre-op sedation.
___% N2O/O2 (no _____ _____)
Start IV, proceed with IV induction

A

50
volatile agent

(Common technique for MH susceptible or RSI patients.)

139
Q

Intramuscular Induction

  • If no other way, ___ may be the least traumatic.
  • Also good for ______ patients.
  • Ketamine ___ ____, then start IV and proceed.
A

IM
cardiovascular
5 mg/kg IM

(Also used when IV access not obtainable to get CVL placed.)

140
Q

Rapid Sequence Induction

  • Pre-oxygenate, de-nitrogenate
  • IV induction with ____ ____
  • Cricoid pressure(???)applied with loss of consciousness and maintained until ____ in _____, confirmed, and cuff inflated.
  • No ____ pressure ventilation until ETT placement confirmed.
A

100% O2
ETT in place
+

141
Q

Modified Rapid Sequence

Same as above with rapid, + pressure ventilation with low PIPs (<___)to prevent desaturation before intubation.

A

15

142
Q

Parental Presence at Induction

For the ____ not the _____

A

child
parent

143
Q

Parental Presence at Induction

Minimize anxiety, reduce ______

A

premedication

144
Q

Parental Presence at Induction

2012: 6 studies (n=936, 1-12 years old, 2006-2010) Compared midazolam, behavior distraction and parental presence
Evidence: __________________________________

A

Parental presence least effective method

145
Q

Parental Presence at Induction

Controversy: Increased _____ risk and _____ anxiety level

A

patient
provider

NUNA 692 Principles III (20 decks)

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