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NUNA 692 Principles III > Exam IV: Selected RA Topics for Infants/Children > Flashcards

Exam IV: Selected RA Topics for Infants/Children Flashcards

1
Q

1999: First reports from animal studies lead to growing concerns r/t anesthesia effects on the ____ ____.

A

developing brain

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2
Q

Many of our anesthetic agents ‘cause’ anesthesia induced neuroapoptosis. Including:

A
  • 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.
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3
Q

_____ & ______ techniques that allow for avoiding general anesthesia are growing.

A

Neuraxial and regional

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4
Q

Advantages of Regional Techniques in Children

Regional techniques: Safe and effective for intra-op and post-op analgesia in ____, _____ & _____ neonates.

A

infants, children and pre-term

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5
Q

Advantages of Regional Techniques in Children

Opioid related adverse effects avoided; promotes ______ ventilation and earlier _____.

A

spontaneous
extubation

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6
Q

Advantages of Regional Techniques in Children

Spinal
- Reduces risk of post-op apnea and respiratory dysfunction in _____ _____.
- Airway instrumentation can be _____.
- Enhances hemodynamic _____.

A

high-risk infants
avoided
stability

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7
Q

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.

A

bowel
metabolic stress
ICU length

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8
Q

Advantages of Regional Techniques in Children

Combined with GA, regionals decrease intra-op _____, _____ and neuromuscular blocking agents (reduces risk of negative _____ outcomes).

A

volatiles
opioids
cognitive

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9
Q

Spinal Anesthesia

Indications:

A

Lower abdominal (urologic and hernias); lower extremity orthopedics; omphalocele, exploratory laparotomy; myelomeningocele

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10
Q

Spinal Anesthesia

Complications infrequent; no reports of permanent _____ ______ or _____ in children.

A

neurological injury or death

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11
Q

Spinal Anesthesia

Addition of _____ can double duration.

A

clonidine

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12
Q

Spinal Anesthesia

Can be combined with ____ ____ for complex procedures.

A

caudal catheter

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13
Q

Spinal Anesthesia

Continuous ______; fentanyl or midazolam boluses can be used for sedation.

A

dexmedetomidine

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14
Q

Subarachnoid Block

Anatomic & physiologic differences in children
- Conus medullaris (neonate & infant) more ____ (___); reaches adult level at around ____ ____

A

caudal (L3)
1 year

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15
Q

Subarachnoid Block

LP should be at ___-___ or ___-___ to avoid spinal cord trauma

A

L4-5 or L5-S1

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16
Q

Subarachnoid Block

_____ approach preferable

A

Midline

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17
Q

Subarachnoid Block

Sacrum more ____ and ____ making access to SA space from caudal canal more ____ (dural puncture more likely)

A

narrow and flat
direct

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18
Q

Subarachnoid Block

_____ _____ less dense

A

Ligamenta flava

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19
Q

Subarachnoid Block

CSF turnover rate much _____ (_____ block duration)

A

greater
shorter

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20
Q

Subarachnoid Block

Less than ____ ____ between skin and SA space

A

1.5 cm

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21
Q

Subarachnoid Block

Decreases incidence of post-op apnea in ____ ____

A

former premies

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22
Q

Subarachnoid Block

______ info has caused growing appeal for SABs in infants and young children

A

Neuroapoptosis

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23
Q

Subarachnoid Block

____ + _____ causes more apnea than GA

A

SAB + ketamine

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24
Q

Subarachnoid Block

Deafferentation: Sedation d/t decreased ____ ____ to RAS from periphery (can be advantage or disadvantage)

A

sensory input

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25
Q

Subarachnoid Block

For now, admission criteria same regardless of ____ ____

A

anesthetic technique

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26
Q

Peds SABs uncommon beyond _____

A

infancy

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27
Q

SAB Hemodynamics

Infants: SABs and epidural blocks _____ stable than in older children and adults

A

more

28
Q

SAB Hemodynamics

Even with upper thoracic blocks, ____ ____

A

BP stable

29
Q

SAB Hemodynamics

High spinals cause bradycardia that responds ____ to anticholinergic

A

well

30
Q

SAB Hemodynamics

Infants rely more on ______ for TV, so respiratory fx is affected more than in children

A

diaphragm

31
Q

SAB Hemodynamics

Most compensate and tolerate _____

A

well

32
Q

SAB Technique

Usually sitting, local with ____ _____

A

1% lidocaine

33
Q

SAB Technique

Midline LP @ L4-5 or L5-S1 with ___ gauge or smaller, ____ inch spinal needle (several available in peds sizes)

A

22
1.5

34
Q

SAB Technique

After injection, MUST REMAIN ______ TO AVOID HIGH SPINAL (No ___ ____ - caution with grounding pad placement)

A

HORIZONTAL
leg raise

35
Q

SAB Technique

Avoid sedation if possible, especially ______

A

ketamine

36
Q

Post-SAB complications

A
  1. Total spinal anesthesia
    - Apnea usually without hemodynamic events
    - Can cause profound bradycardia, but easily treated with anticholinergic
  2. Post-dural puncture headache or back-ache (difficult to assess)
  3. Spinal cord trauma (rare)
  4. Epidermoid tumors (usually when needle without stylet used)
37
Q

Epidural Anesthesia

Historically, children at risk for ____ ____ ____ ____ (____). Per APSF, all due to high-dose bupivacaine infusions.

A

local anesthesia systemic toxicity (LAST).

38
Q

Epidural Anesthesia

Prolonged _____ infusions in infants and young children have variable pharmacokinetics and increased risk of LAST.

A

amide

39
Q

Epidural Anesthesia

Resurgence: _______
Metabolized by ____ ____; plasma half-life is seconds to minutes (amides can last for hours).

A

2-chloroprocaine
plasma esterases

40
Q

Epidural Anesthesia

Can be ____ anesthetic or combined with ____.

A

sole
GA

41
Q

Caudal epidural anesthesia

Most common regional technique in _____ (?)

A

children

42
Q

Caudal epidural anesthesia

Used in conjunction with ____

A

GA

43
Q

Caudal epidural anesthesia - Technique (aseptic)

A
  • 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.
44
Q

Caudal epidural anesthesia

Injection should be ____ ____.

A

very easy

45
Q

Caudal epidural anesthesia

Watch/palpate for ____ _____.

A

sub-cu infiltration

46
Q

Caudal epidural anesthesia

For continuous catheter placement, advance to _____ of surgical incision.

A

mid-level

47
Q

Caudal epidural anesthesia

Some use ultrasound catheter ______.

A

confirmation

48
Q

Caudal epidural anesthesia

Meticulous _____ for catheter placement

A

dressing

49
Q

Caudal drugs

Dose dependent on desired _____ _____ and _____ – not concentration.

A

dermatome level and VOLUME

50
Q

Caudal drugs

Generally: ____/____/dermatome

A

0.05 mL/kg

51
Q

Caudal drugs

Common method for T4-6 sensory block: 0.5 – 1.0 mL/kg of ____ ______ or _____ _____ (less toxic than Bupivicaine)

A

0.25% Bupivicaine
0.2% Ropivicaine

52
Q

Caudal drugs

Clonidine ___ _____ prolongs block (___ ____ causes increased incidence of apnea)

A

1 mcg/kg
2 mcg/kg

53
Q

Caudal drugs

Catheters can be used ______ (Max: 0.4 mg/kg/hr. Reduce by 30% for < 6 months old)

A

post-op

54
Q

Caudal CIs: (7)

A
  • 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)
55
Q

Post-epidural (caudal) Complications

Most common: Catheter _______ or _______

A

displacement or malfunction

56
Q

Post-epidural (caudal) Complications

_____ or ______ injection can lead to CV arrest

A

IV or intraosseous

57
Q

Post-epidural (caudal) Complications

Epidural abscess (_____)
Meningitis

A

emergent

58
Q

Post-epidural (caudal) Complications

Epidural _______ (caution with thrombocytopenia, coagulopathy or pre-op anticoagulant therapy)

A

hematoma

59
Q

Post-epidural (caudal) Complications

Urinary ______
Neuronal injury (_____)

A

retention
rare

60
Q

Ultrasound Guided Fascial Blocks (4)

A

Transversus abdominis plane (TAP) block
Quadratus lumborum block (QLB)
Serratus anterior plane block (SAPB)
Erector spinae block (ESB)

61
Q

Misc Blocks done Mostly by surgeon (5)

A
  • Rectus Sheath
  • Inguinal
  • Penile
  • Intercostal
  • Paravertebral
62
Q

Controversy: Is it safe to administer ____ _____ to anesthetized children?

A

regional blocks

63
Q

Long-standing peds anesthesia practice: Conduct regional anesthesia ____ anesthetized patient.

A

with

64
Q

Maintains ______; avoids uncooperative and distressed patient.

A

stillness

65
Q

______ helps avoid accidental needle displacement/puncture of vital structures.

A

Immobility

66
Q

Any advantages of patient feedback are lost with children who are unable to _____ usefully.

A

communicate

67
Q

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.

A

interscalene

NUNA 692 Principles III (20 decks)

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