Exam IV: Selected RA Topics for Infants/Children Flashcards
1999: First reports from animal studies lead to growing concerns r/t anesthesia effects on the ____ ____.
developing brain
Many of our anesthetic agents ‘cause’ anesthesia induced neuroapoptosis. Including:
- GABAA agonists (propofol, benzos, volatile agents)
- NMDA antagonists (ketamine, N2O)
- Children from birth to 3 years of age are possibly at risk, especially with anesthesia time > 3 hours and repeated exposures.
_____ & ______ techniques that allow for avoiding general anesthesia are growing.
Neuraxial and regional
Advantages of Regional Techniques in Children
Regional techniques: Safe and effective for intra-op and post-op analgesia in ____, _____ & _____ neonates.
infants, children and pre-term
Advantages of Regional Techniques in Children
Opioid related adverse effects avoided; promotes ______ ventilation and earlier _____.
spontaneous
extubation
Advantages of Regional Techniques in Children
Spinal
- Reduces risk of post-op apnea and respiratory dysfunction in _____ _____.
- Airway instrumentation can be _____.
- Enhances hemodynamic _____.
high-risk infants
avoided
stability
Advantages of Regional Techniques in Children
Continuous epidural analgesia
- Decreases time to extubation, promotes return of _____ function and decreases _____ _____ response.
- May decrease postoperative sedation needs leading to shorter ____ ____ of stay.
bowel
metabolic stress
ICU length
Advantages of Regional Techniques in Children
Combined with GA, regionals decrease intra-op _____, _____ and neuromuscular blocking agents (reduces risk of negative _____ outcomes).
volatiles
opioids
cognitive
Spinal Anesthesia
Indications:
Lower abdominal (urologic and hernias); lower extremity orthopedics; omphalocele, exploratory laparotomy; myelomeningocele
Spinal Anesthesia
Complications infrequent; no reports of permanent _____ ______ or _____ in children.
neurological injury or death
Spinal Anesthesia
Addition of _____ can double duration.
clonidine
Spinal Anesthesia
Can be combined with ____ ____ for complex procedures.
caudal catheter
Spinal Anesthesia
Continuous ______; fentanyl or midazolam boluses can be used for sedation.
dexmedetomidine
Subarachnoid Block
Anatomic & physiologic differences in children
- Conus medullaris (neonate & infant) more ____ (___); reaches adult level at around ____ ____
caudal (L3)
1 year
Subarachnoid Block
LP should be at ___-___ or ___-___ to avoid spinal cord trauma
L4-5 or L5-S1
Subarachnoid Block
_____ approach preferable
Midline
Subarachnoid Block
Sacrum more ____ and ____ making access to SA space from caudal canal more ____ (dural puncture more likely)
narrow and flat
direct
Subarachnoid Block
_____ _____ less dense
Ligamenta flava
Subarachnoid Block
CSF turnover rate much _____ (_____ block duration)
greater
shorter
Subarachnoid Block
Less than ____ ____ between skin and SA space
1.5 cm
Subarachnoid Block
Decreases incidence of post-op apnea in ____ ____
former premies
Subarachnoid Block
______ info has caused growing appeal for SABs in infants and young children
Neuroapoptosis
Subarachnoid Block
____ + _____ causes more apnea than GA
SAB + ketamine
Subarachnoid Block
Deafferentation: Sedation d/t decreased ____ ____ to RAS from periphery (can be advantage or disadvantage)
sensory input
Subarachnoid Block
For now, admission criteria same regardless of ____ ____
anesthetic technique
Peds SABs uncommon beyond _____
infancy
SAB Hemodynamics
Infants: SABs and epidural blocks _____ stable than in older children and adults
more
SAB Hemodynamics
Even with upper thoracic blocks, ____ ____
BP stable
SAB Hemodynamics
High spinals cause bradycardia that responds ____ to anticholinergic
well
SAB Hemodynamics
Infants rely more on ______ for TV, so respiratory fx is affected more than in children
diaphragm
SAB Hemodynamics
Most compensate and tolerate _____
well
SAB Technique
Usually sitting, local with ____ _____
1% lidocaine
SAB Technique
Midline LP @ L4-5 or L5-S1 with ___ gauge or smaller, ____ inch spinal needle (several available in peds sizes)
22
1.5
SAB Technique
After injection, MUST REMAIN ______ TO AVOID HIGH SPINAL (No ___ ____ - caution with grounding pad placement)
HORIZONTAL
leg raise
SAB Technique
Avoid sedation if possible, especially ______
ketamine
Post-SAB complications
- Total spinal anesthesia
- Apnea usually without hemodynamic events
- Can cause profound bradycardia, but easily treated with anticholinergic - Post-dural puncture headache or back-ache (difficult to assess)
- Spinal cord trauma (rare)
- Epidermoid tumors (usually when needle without stylet used)
Epidural Anesthesia
Historically, children at risk for ____ ____ ____ ____ (____). Per APSF, all due to high-dose bupivacaine infusions.
local anesthesia systemic toxicity (LAST).
Epidural Anesthesia
Prolonged _____ infusions in infants and young children have variable pharmacokinetics and increased risk of LAST.
amide
Epidural Anesthesia
Resurgence: _______
Metabolized by ____ ____; plasma half-life is seconds to minutes (amides can last for hours).
2-chloroprocaine
plasma esterases
Epidural Anesthesia
Can be ____ anesthetic or combined with ____.
sole
GA
Caudal epidural anesthesia
Most common regional technique in _____ (?)
children
Caudal epidural anesthesia
Used in conjunction with ____
GA
Caudal epidural anesthesia - Technique (aseptic)
- After induction, turn lateral or prone.
- Palpate posterior superior iliac spines/sacral cornu.
- Insert small gauge needle (22 or 23), 22 gauge angiocath, or Crawford needle at 45°angle
- After “pop”, drop to angle parallel to back and advance into caudal canal.
- For continuous, insert catheter.
- Test dose while watching EKG & BP.
- Inject local over approx. 2 minutes.
Caudal epidural anesthesia
Injection should be ____ ____.
very easy
Caudal epidural anesthesia
Watch/palpate for ____ _____.
sub-cu infiltration
Caudal epidural anesthesia
For continuous catheter placement, advance to _____ of surgical incision.
mid-level
Caudal epidural anesthesia
Some use ultrasound catheter ______.
confirmation
Caudal epidural anesthesia
Meticulous _____ for catheter placement
dressing
Caudal drugs
Dose dependent on desired _____ _____ and _____ – not concentration.
dermatome level and VOLUME
Caudal drugs
Generally: ____/____/dermatome
0.05 mL/kg
Caudal drugs
Common method for T4-6 sensory block: 0.5 – 1.0 mL/kg of ____ ______ or _____ _____ (less toxic than Bupivicaine)
0.25% Bupivicaine
0.2% Ropivicaine
Caudal drugs
Clonidine ___ _____ prolongs block (___ ____ causes increased incidence of apnea)
1 mcg/kg
2 mcg/kg
Caudal drugs
Catheters can be used ______ (Max: 0.4 mg/kg/hr. Reduce by 30% for < 6 months old)
post-op
Caudal CIs: (7)
- Parents refuse consent
- Surgeon preference
- Allergy to local anesthetics
- Skin infection/diaper rash in sacral area
- VP shunt in place
- History of spinal abnormality or surgery (relative)
- Sacral “dimple” (relative)
Post-epidural (caudal) Complications
Most common: Catheter _______ or _______
displacement or malfunction
Post-epidural (caudal) Complications
_____ or ______ injection can lead to CV arrest
IV or intraosseous
Post-epidural (caudal) Complications
Epidural abscess (_____)
Meningitis
emergent
Post-epidural (caudal) Complications
Epidural _______ (caution with thrombocytopenia, coagulopathy or pre-op anticoagulant therapy)
hematoma
Post-epidural (caudal) Complications
Urinary ______
Neuronal injury (_____)
retention
rare
Ultrasound Guided Fascial Blocks (4)
Transversus abdominis plane (TAP) block
Quadratus lumborum block (QLB)
Serratus anterior plane block (SAPB)
Erector spinae block (ESB)
Misc Blocks done Mostly by surgeon (5)
- Rectus Sheath
- Inguinal
- Penile
- Intercostal
- Paravertebral
Controversy: Is it safe to administer ____ _____ to anesthetized children?
regional blocks
Long-standing peds anesthesia practice: Conduct regional anesthesia ____ anesthetized patient.
with
Maintains ______; avoids uncooperative and distressed patient.
stillness
______ helps avoid accidental needle displacement/puncture of vital structures.
Immobility
Any advantages of patient feedback are lost with children who are unable to _____ usefully.
communicate
American Society of Regional Anesthesia and Pain Medicine (2008): With the exception of _____ blocks, providing regionals in anesthetized children may have an acceptable risk-benefit profile.
interscalene
