Exam IV: Preanesthetic Eval, Premed, and Induction Flashcards by Linsley Lloyd

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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Q

Children 6 months to 6 years cling to ______

A

parents

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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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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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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Dependent or withdrawn affect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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Q

Children older than 6 years (who have attended school)

accept ______

A

separation

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Q

Children older than 6 years (who have attended school)

more ______

A

independent

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Q

Children older than 6 years (who have attended school)

understand _____ about the hospital environment

A

more

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Q

Children older than 6 years (who have attended school)

communicate _____ and more _____

A

better
openly

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Q

Children older than 6 years (who have attended school)

curiosity can be used, more _____

A

trusting

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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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Q

Adolescents

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

A

immature child

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Q

Adolescents

Fragile _______ (self-esteem and body image).

A

psychologically

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Q

Adolescents

want to be in _____, may dislike _____

A

control
sedation

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Q

Adolescents

usually can be _____ with

A

reasoned

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Q

Techniques to Prepare Patients/Families for Anesthesia

______ explanation

A

honest

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Q

Techniques to Prepare Patients/Families for Anesthesia

include _____, parents, siblings, and _____ _____

A

patient
teddy bears

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Q

Techniques to Prepare Patients/Families for Anesthesia

allow ____/____ items

A

comfort/security

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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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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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Q

Pre-Anesthetic Evaluation - Medical history

History of _____ or _____

A

apnea or bradycardia

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Q

Pre-Anesthetic Evaluation - Medical history

History of c_____

A

croup

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Q

Pre-Anesthetic Evaluation - Medical history

Contacts with _____ diseases

A

infectious

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Q

Pre-Anesthetic Evaluation - Medical history

Review _____, _____ records

A

anesthetic, hospital

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Pre-Anesthetic Evaluation - (7)

- airway management - venous access - hypotension - bradycardia - oxygen saturation - agitation - premedication

Pre-Anesthetic Evaluation - family hx (6)

- 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)

Smoking/Environmental Tobacco Smoke: WHO: _____ million children (almost ½ of children world-wide) exposed to ETS

700

Smoking/Environmental Tobacco Smoke: ______ US teens/day smoke 1st cigarette; ____ become regular smokers

3,800 50%

Smoking/Environmental Tobacco Smoke: ↑ risk of _____, otitis media, eczema, hay fever and ____ ____

asthma dental caries

Smoking/Environmental Tobacco Smoke: Evidence: ↑ airway complications during induction and emergence with _____ _____ inhalation

passive ETS

Smoking/Environmental Tobacco Smoke: Include ETS exposure in _____ _____

preop evaluation

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

2-3 15

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

↑ lipid content

Fasting Guidelines Formula, milk, solids – wait ____ hours*

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

Fasting Guidelines No gum or candy after midnight (increases ____ _____)

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.

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

hypoglycemia

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

start an IV clear liquids

Fasting Considerations Explain why ___ ___. Don’t trust them!

no food

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

2.5 0.4

Fasting Considerations beware of _____

hypovolemia

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

- Upper Respiratory Tract Infection - Anemia - Fever - Sickle cell disease - Developmentally delayed - Type I Diabetes - Seizure disorders - Hyperalimentation - Asthma

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

Asymptomatic

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

consider postponing

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

Acetaminophen, ibuprofen Inhalation agents

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

2-7 Bronchospasm Laryngospasm Hypoxemia Atelectasis Croup Stridor

URI: when to postpone sx?

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

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

Bronchial reactivity can last 7 weeks Practical time: 2 weeks

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 _____

safe spasms and desaturations morbidity

URI: allergic rhinitis (3)

Seasonal in character Clear nasal drainage No fever

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

Investigate history

Asthma: Bronchodilators/asthma meds the ______ of _____

morning of surgery

Asthma: Consider avoiding ______ or extubate while _____

intubation deep

Asthma: Postpone surgery for significant ______

wheezing

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

weigh risks v. benefits 45

will we be getting ABGs on an asthma pt?

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

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

mechanical ventilation/barotrauma/O2 toxicity

Bronchopulmonary Dysplasia Sx:

Tachypnea, dyspnea, reactive airway, O2 dependence

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

airway obstruction exercise or stimulation

Bronchopulmonary Dysplasia May need pre-op labs if on _____

diuretics

Bronchopulmonary Dysplasia Avoid ____ d/t chronic air trapping

N2O

Bronchopulmonary Dysplasia Subglottic stenosis may require _____ _____

smaller ETT

Bronchopulmonary Dysplasia Chronically _____carbic - avoid _____ventilation

hyper hyper

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

25 lower

Anemia: Chronic anemia compensation

- increased 2,3-DPG - increased oxygen extraction - increased cardiac output

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

30 blood-borne disease transmission

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

should be tested (also get a full fam hx)

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

hemoglobin electrophoresis

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

Hgb of 10 g/dL

Sickle Cell Disease Anesthetic implications:

warm, wet, and green

Cardiac Murmurs - quote that LISA loves

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

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

innocent

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

delayed until after

Cardiac Murmurs _____ _____ not usually associated with other symptoms.

Innocent murmurs

Cardiac Murmurs Only certain way to rule out structural defect:

ECHO

Seizure Disorders Determine the....

Determine the medication, normal dosage routine, last dose.

Seizure Disorders Determine type of _____

seizure

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

seizure threshold

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

induce

Insulin-Dependent Diabetic Children: Maintain normal regimen up to ____ _____ _____

day before surgery

Insulin-Dependent Diabetic Children: consult _______

endocrinologist

Insulin-Dependent Diabetic Children: schedule for

first case of the day

Insulin-Dependent Diabetic Children: Common: Preop IV access, 5% glucose (maintenance rate), ___ usual insulin dose

½ Alternative: Continuous infusion of glucose and insulin

Insulin-Dependent Diabetic Children: monitor:

Monitor serum BG preop, intraop and postop

Hyperalimentation Know what type (___ ____) and rate.

% glucose

Hyperalimentation ____ ____ with central lines

Aseptic technique

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

hypoglycemia

Hyperalimentation ALWAYS use ____ to control

pump

Hyperalimentation monitor

BG, electrolytes perioperatively

Developmentally Delayed Children Ability to _____ with these patients may be altered.

reason

Developmentally Delayed Children May have ____ ____ – DHR custody, foster parents

consent issues

Developmentally Delayed Children Pharmacologic capture (2 points)

- Oral or nasal midazolam - Oral or IM “cocktail” (ketamine and glycopyrrolate)

Latex Allergy - most common cause of

intra-op anaphylaxis in peds

Latex Allergy ____-threatening, ____-mediated

life IgE

Latex Allergy At risk:

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

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

H2 blockers and steroids

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

Latex-free environment

Latex Allergy Treatment: _______

Epinephrine

Informed Consent for Elective Procedures

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”???

Premedications decrease ____ and allow smooth _____ and _____

anxiety induction emergence

Premedications reduce _____

MAC

Premedications - aspiration ______

prophylaxis

Premedications - allow for pleasant ____ ____

PACU stay

Premedications - NEED TO ______

INDIVIDUALIZE

Midazolam - ____ ____ used

most commonly

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

0.3-0.5 15

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

clear liquid, acetaminophen or ibuprofen

Midazolam Sedation lasts about ____ _____

60 minutes

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

10 minutes

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

3-5 5 minutes

Ketamine - the dart To prevent _____, give midazolam.

nightmares

Ketamine - the dart To prevent excessive secretions, give ______.

anticholinergic

Ketamine - the dart (Dart with ketamine, give midazolam and glycopyrrolate after ____ ____)

IV started

EMLA Cream - what is it?

Eutectic Mixture of Local Anesthetics lidocaine and prilocaine

EMLA Cream Topical, applied under occlusive dressing for ___-___ _____

45-60 minutes

EMLA Cream _____ to minimize pain of IV start or venipuncture

Numbing

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

vagal effects secretions 0.1 mg 6

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

Opioid 10-20 non-IV Others: Dex, clonidine, diazepam, diphenhydramine, ibuprofen

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

emergence delirium 2 - 4 MAP and HR

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

emergence delirium 2 - 4 MAP and HR

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

standard open 8-10

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

2 8 IV access obtained

Inhalation Induction - ____ and/or ___ ___ for upper a/w obstruction - Return ultimately to _____ concentration

PEEP and/or oral a/w maintenance

Inhalation Induction Increasing the concentration too rapidly: (3)

- Irritates airway, causes coughing - Smell is noxious - Hemodynamic effects

Inhalation Induction Increasing the concentration too slowly:

- Prolongs induction including excitation period - Increased risk of airway obstruction, laryngospasm, vomiting

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

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

concentration 100

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

address cause

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

STAT dysrhythmias CV arrest

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

jaw thrust, oral airway

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

5-10

Airway Obstruction Do ___ ___ ___ ventilation before IV access obtained.

not take over

Airway Obstruction Once IV access obtained, treat significant obstruction with:

positive pressure, lidocaine, propofol, sux, etc

tricks of the trade _____ masks - Control and active participant

Scented

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

Distraction

tricks of the trade Hypnotic:

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

Modified Single-breath Induction Requires child’s ______. Coach & practice before induction. Requires _____ _____ (high flow/8%)

cooperation circuit priming

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

maximum concentration

Modified Single-breath Induction ____ _____ than traditional inhalation induction.

3 x faster

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

50 volatile agent (Common technique for MH susceptible or RSI patients.)

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

IM cardiovascular 5 mg/kg IM (Also used when IV access not obtainable to get CVL placed.)

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.

100% O2 ETT in place +

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

15

Parental Presence at Induction For the ____ not the _____

child parent

Parental Presence at Induction Minimize anxiety, reduce ______

premedication

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

Parental presence least effective method

Parental Presence at Induction Controversy: Increased _____ risk and _____ anxiety level

patient provider