Exam2:fluid, blood, CHD, congenital heart surgery Flashcards
1
Q
what is the incidence of congenital heart issues
A
7-10/1000
2
Q
what is risk of congenital heart defet in premature compared to normal
A
2-3x higher
3
Q
what percent of congenital diseases are heart diseases
A
30%
4
Q
what percent of congenital heart disease survive to adulthood without treatment
A
15%
5
Q
R to L shunts are (cyanotic/acyanotic)
A
cyanotic
6
Q
L to R shunts are (cyanotic/acyanotic)
A
acyanotic
7
Q
what kind of cardiac anomalies require a simple repair
A
PDA, AD, VSD
8
Q
what kind of cardiac anomalies require a complex repair with baffles and conduits
A
tetralogy of fallot
severe AS
severe PS
mitral stenosis
9
Q
a shunt is a (resp/blood) problem
A
resp
10
Q
deadspace is a (resp/blood) problem
A
blood
11
Q
what kind of repair is curative meaning that cyanosis is fixed
A
anatomic
12
Q
what kind of repair is cyanosis relieved
A
physiologic repair
13
Q
what kind of repair is usually univentricular or reversed ventricles
A
physiologic
14
Q
what kind of repair is for single ventricles that ar overloaded
A
physiologic repair
15
Q
how is anesthesia in anatomic repair post repair
A
normal
16
Q
how is anesthesia in physiologic repair
A
significant changes in anesthesia care with increased perioperative risk
17
Q
what kind of repair has increase perioperative risk
A
physiological
18
Q
what type of repair is palliative in nature
A
physiological
19
Q
shunt is all _______ with no ______
A
blood
air
20
Q
dead space is all ________ with no _______
A
air
blood
21
Q
what is communication between systemic and pulmonary circulation
A
shunting
22
Q
what is mixing of arterial and venous blood
A
shunting
23
Q
what kjnd of shunting is PVR and SVR less important
A
small communication
24
Q
what is an example of a small shunt where flow is limited
A
ASD/VSD or small PDA
25
what kind of shunt dose size and direction depend on PVR and SVR
dependent shunt
26
what kind of shunt is between two nearly equal pressures
dependent shunt
27
what kind of shunt can anesthesia control by manipulating SVR and PVR
dependent
28
what kind of shunt is a PDA (dependent vs obligatory)
dependent
29
what kind of shunt is SVR/PVR pressure significant so is no longer dependent of PVR/SVR relationsip
obligatory
30
what kind of shunt is AV canal Defect (obligatory vs dependent)
obligatory
31
what can we give to manipulate SVR
phenylephrine, phentolamine
32
what way does blood ravel if PVR>SVR
R to L
33
what way does blood travel if SVR> PVR
L to R
34
what direction of shunt is cyanotic
R to L
35
what kind of shunt is deoxygenated blood bypassing the lungs and entering systemic circulation
cyanotic (R to L)
36
what kind of shunt is an Acyanotic shunt
L to right
37
what kind of shunt does oxygenated blood recirculated into pulmonary circulation
acyanotic shunt
38
what are acyanotic shunts with increased pulmonary blood flow
ASD
VSD
PDA
AV canal defect
(L to R shunts)
39
what are acyanotic shunts from obstructions to blood flow from ventricles
coarctation of the aorta
aortic stenosis
pulmonic stenosis
(outflow obstructions)
40
what are cyanotic shunts with decreased pulmonary blood flow
tetralogy of fallot
tricuspid atresia
41
what are cyanotic shunts with mixed blood flow
transposition of great arteries
total anomalous pulmonary venous return
truncus arteriosus
hypoplastic L heart syndrome
42
what is the HCT limit afterwhich there is decreased oxygen carrying capacity, sludging, increased workload on heart, and clotting
65%
43
what factors affect shunt
size of shunt orifice
pressure gradient
LV and RV compliance
PVR to SVR ratio
Blood viscosity (Hct)
44
when PVR is > SVR this is a ______ to _____ shunt
R to L
45
when SVR > PVR this is a _____ to _____ shunt
L to R
46
what is PVR calculation
PVR= (mPAP-PAOP)/CO x 80
47
what is normal PVR
150-200 dynes/sec/cm-5
48
what is SVR calculation
SVR= (MAP-CVP)/CO x80
49
what is normal SVR
800-1500 dynes/sec.cm-5
50
increased decreased PVR
51
increased decreased SVR
52
what shunt bypasses pulmonary circulation
cyanotic shunt
53
what are examples of cyanotic shunt
tetralogy of Fallot
transposition of great arteries
epsteins anomaly
truncus arteriosus
totally anomalous pulmonary venous connection
54
what is patho of cyanotic shunt
decreased pulmonary flow
hypoxemia
LV volume overload
LV dysfunction
55
what are hemodynamic goals of cyanotic shunts
Maintain SVR
Decrease PVR (hyperoxia, hyperventilation, avoid lung hyperinflation)
56
how is inhalation induction in cyanotic shunt
slowed
57
how is IV induction in cyanotic shunt
faster
58
how do children with cyanotic cardiac defects compensate for chronic hypoxia
increased erythropoiesis (polycythemia increased SVR/PVR)
increased circulating blood volume
vasodilation
59
T/F coagulopathies are common in cyanotic shunts
true
60
T/F keep child with cyanotic shunt NPO
F, do not want dehydration 2/2 increased viscosity of blood
61
transposition of great arteries
62
what congenital heart defect has
aorta connected to RV
PA connected to LV
PFO
may have VSD and subpulmonic stenosis
characterized by recirculation of systemic and pulmonary blood
transposition of great arteries
63
what does survival of transposition of great arteries rely on
communication between circuits
PFO
VSD
PDA
ASD
64
what meds do we avoid in Transposition of Great arteries because they may close PFO/VSD/PDA/ASD
NSAIDS
65
what meds do we give in Transposition of Great arteries because they keep PFO/VSD/PDA/ASD open
prostaglandin
66
in transposition of Great Arteries, what kind of shunt does VSD and PDA allow
R to L
67
in transposition of great arteries what kind of shunt does PFO and ASD allow
L to R
68
transposition of great arteries shunts
69
what is O2 of TGA at birth
<70%
70
what infusion do we give to maintain PDA in TGA
PGE1
71
how do we manage vent in transposition of great arteries
hyperventilation to decrease PVR
72
what are treatments at birth for TGA
PGE1 infusion
Balloon Atrial Septoplasty
ECMO may be necessary
73
what is the physiologic correction procedure for TGA
Mustard and Senning procedure
74
describe Mustard and Senning procedure for TGA
atrial switch
atrial baffles direct systemic blood to LV and PA and pulmonary blood to RV then Aorta
75
Mustard and Senning Procedure for TGA
76
what is the anatomic repair for the TGA
jatene switch
77
Jatene switch for TGA
78
what is risk of Jatene Switch for TGA
single RCA-> risk of postop MI/death
79
what is Anesthetic Management of TGA
maintain CO, HR, preload
maintain adequate intercirculatory mixing
AVOID
decrease PVR and hypocarbia/alkalosis
increased PVR (compromise venous return and mixing)
80
how long do we continue PGE1 infusion in TGA
until shortly before CPB
81
what anesthetic do we avoid in anesthesia induction and maintanence in TGA
inhalational induction and maintenance (cause myocardial depression)
82
what is anesthesia management of TGA
high dose fentanyl or sufenta
small doses of benzos
low dose volatiles
Volume expansion
inotropic support (dopamine)
83
what is risk of sufenta
bradycardia
84
what is dose of fentanyl for TGA
75 mcg/kg
85
what is dose of sufenta for TGA
25 mcg/kg
86
what is anesthetic management for post CPB of TGA
maintain HR (pacing)
controlled BP to reduce bleeding at suture lines
milrinone
watch for myocardial ischemia (aggressive)
87
what is the most common congenital heart defect
Tetrology of Fallot
88
what are characteristics of Tetralogy of Fallot
VSD
Overridig aorta
RV hypertrophy
Pulmonic Stenosis
RVOT stenosis
89
what does an increased RVOT stenosis lead to
increased shunt through VSD
erythropoesis???
90
tetralogy of fallot
91
what are s/s tetralogy of fallot
cyanosis
LSB ejection murmur (stenotic pulm valve)
Squatting in older children
92
what does squatting with ToF lead to
increases SVR
decreases R to L shunt
increases pulmonary blood flow
improved oxygenation
93
what is hypercyanotic/hypoxic episode with TOF
TET spells
94
what are causes of TET spells
stress
exercise
crying
defecation
IV placement
Induction
taking kid from parent in preop
95
what are S/S Tet Spells
paroxysmal hyperpnea
deleterious effects
cyanosis
increased O2 consumption
decreased SVR 2/2 cyanosis
increased venous return
increased shunt
96
how do we treat TET spell
100% O2
knee to chest position
manual compression of abd aorta
morphine 0.1 mg/kg (sedation/depress ventilation)
crystalloid 15 ml/kg
phenylephrine (increase SVR)
reduce SNS stimulation
BB (esmolol)
Avoid inotropes
ECMO
97
when does surgical correction of TOF occur
2-10 months of age
98
what is goal of TOF sx
reduce RV pressure
avoid RV overload (regurg)
close VSD
99
what is anesthetic management of TOF
avoid dehydration
premedicated before IV placement
IV induction preferred
Sevo induction is ok
avoid systemic hypotension
Fentanyl or Ketamine induction
volume expansion
100
what is dose of ketamine induction for TOF
ketamine 102 mg/kg IV
101
anesthesia for TOF
102
tx of TOF
103
truncus arteriosus
104
describe truncus arteriosus
single great vessel
VSD
complete intracardiac mixing
increase in flow to one vessel will reduce flow to the other
105
what is normal SpO2 in Truncus arteriosus pre fontan procedure
75-80%
106
what happens to pulmonary blood flow and PVR at first breath
increases blood flow, decreases PVR
107
what happens at birth with TA
PBF is high-CHF signs with mild cyanosis (metabolic acidosis)
risk of pulmonary veno-occlusive disase (PVOD) which is a type of pulmonary HTN
108
what is repair of TA
Rastelli repair with patched septum and new pulm valv/artery
109
describe rastelli repair
patch to the VSD
Graft PA to RV
Valvuplasty
110
what is management of Truncus Arteriosus similar to
same as single ventricle physiology/hypoplastic L heart syndrome
111
what can happen post CPB of Truncus Arteriosus
RV dysfunction likely
LV overload may occur
TX;
maintain HR, reduce PVR, inotropic support
112
what is the most common congenital defect of tricuspid valve
ebsteins anomaly
113
describe ebsteins anomaly
abnormality of the tricuspid valve, leaflets are down in RV,
0atrialized RV
-stenotic or rregurgitant TV
-ASD, PFO with R to L shunt
114
ebsteins anomaly
115
what issues occur in RV with ebsteins anomally
sludging and bloodclots in RV
116
what does magnitude of R to L shunt from ASD or PFO in ebsteins anomaly depend on
RV dysfunction and tricuspid severity
117
what are s/s Ebsteins anomaly in neonate
CHF
systemic venous congestion
cyanosis after PDA closure
118
what are s/s ebsteins anomaly in adults
asymptomatic
119
what are risks of ebsteins anomaly with PFO
paradoxical emboli
brain abscess
CHF
sudden death
120
what is single ventricle physiology
complete mixing of pulmonary venous and systemic venous blood
121
what is formula for output of single ventricle physiology
output= pulmonary bf+systemic bf
122
what is distribution of blood flow in single ventricle physiology dependent on
resistance to flow
123
in single ventricle physiology the oxygen saturation in the PA is __________ as the Aotra
the same
124
what congenital heart issues have single ventricle physiology with two well formed ventricles
tet of fallot with pulmonary atresia
truncus arteriosus
sever aortic stenosis with PDA suppling system flow
125
tricuspid atresia
126
HLHS (hypoplastic left heart syndrome)
127
where does HLHS get aortic blood flow from
PDA
128
where does HLHS get pulmonary BF from
RV
129
where does sever neonatal aortic stenosis get aortic blood flow from
PDA
130
where does Severe neonatal aortic stenosis get pulmonary BF from
RV
131
where does Tetralogy of fallot with pulmonary atresia get aortic blood flow from
LV
132
where does Tetralogy of fallot with pulmonary atresia get pulmonary BF from
PDA
133
where does truncus arteriosus get aortic blood flow from
LV/RV
134
where does truncus arteriosus get pulmonary BF from
aorta
135
where does tricuspid atresia 1b/1c get aortic blood flow from
LV
136
where does tricuspid atresia 1b/1c get pulmonary BF from
LV through VSD to RV
137
what is anesthesia management of single ventricle (three steps)
1-optimization of systemic oxygen delivery and perfusion (blalock shunt)
2- reducing the volume load on the ventricle (superior cavopulmonary connection or bidirectional glenn procedure)
3- acheiving a series circulation with fully saturated systemic arterial blood (fontan procedure)
138
what is norwood procedure for HLHS
aortic arch reconstruction
atrial septectomy
Blalock Taussig shunt (BTS)
139
blalock shunt for HLHS
140
when is Bidirectional Glenn procedure completed
6-8 months
141
what does blalock taussig shunt connect
SCL (from aorta) to PA
142
what does Bidirectional Glenn conect
IVC to CA
143
bidirectional Glenn
144
when is fontan procedure completed
2-3 years
145
describe fontan procedure
add tube from IVC to PA
creates completely pasive blood flow into RA
146
what is important with fontan procedure and PVR
has to have a very low PVR, flow is completely dependent on preload
IF PVR is too high, blood will back up systemically
147
what is management of SV physiology BEFORE CPBP
-PGE1 infusion (maintain sats)
-induce with high dose narcotic, muscle relaxant, versed
-Target PaO2 40-45 and PaO2 70-80
-SpO2 70-80
-Increase PVR with hypercarbia (45-55)
-21% FiO2 (avoid high FiO2 decreases PVR)
-may require inotropes
-avoid tachycardia >140-150
148
T/F do inhalation induction in SV physiology
F
149
what are major problems with SV physiology AFTER CPBP
hypoxemia
hypotension
low systemic perfusion
gas exchange dsfxn
bleeding (suture lines, coagulation factors/PLT consumption)
high PVR
reduced pulm BF
hypoxemia
myocardial/tissue edema
myocardial dysfunction is common (low CO)
150
what happens if there is too large of a shunt after CPBP
pulmonary overload
151
what happens if there is too small of a shunt after CPBP
cyanosis
152
how do you treat myocardial/tissue edema after CPBP
maintain open chest?
153
what special medication may be necessary after CPBP
NO (nitric oxide)
154
myocardial dysfunction from low CO is common after stage 1 HLHS, how do we treat
may require dopamine of epinephrine
155
what happens with too large of shunt after CPBP
too much pulmonary blood flow= no enough to the body
high SpO2
hypotension
hypoperfusion
EKG= ischemia
156
how do we treat too large shunt after CPBP
increase PVR, increase inotropic support, Narrow the shunt
157
what happens with too small shunt after CPBP
low SaO2
normal or elevated systemic BP
158
how do we treat to small shunt after CPBP
decrease PVR
improve ventilation
increase systemic SVR
159
which is more common, too large or too small shunt after CPBP
too small
160
what is most common complication after CPBP
los SaO2 or hypotension
161
how do we treat low SaO2 or Hypotension after CPBP
optimize
vent parameters
HCT 35-40
CO
Arterial BP
162
tricuspid atresia
163
describe tricuspid atresia
atretic tricuspid valve
hypoplastic RV
ASD
VSD
restricted pulm BF
R to L shunt
single ventricle physiology
complete obstruction to RV outflow
obligatory ASD or PFO
164
what are S/S tricuspid Atresia
cyanosis
dyspnea
hypoxic spells
clubbing in childhood
harsh ejection systolic murmur
EKG: LAD, LVF, abnormal P-wave
R atrial overload
165
what causes abnormal P wave in tricuspid atresia
2/2 no RV
166
what is treatment for tricuspid atresia
PGE 1
atrial septostomy & BT shunt
Fontal procedure (18-30 months)
hemi fontan 6 months
167
tricuspid atresia with blalock shunt
168
tricuspid atresia fontan procedure
169
what is anesthetic management of tricuspid atresia
-IV induction
-opioids, low concentration volatile, muscle relaxant
-ductal dependent for pulmonary BF
-preserve cardaic contractility /CO balanced PVR/SVR to maintain SaO2 70-80%
170
what happens with an increased R to L shunt in tricuspid atresia
hypoxemia, cyanosis
171
what happens with an increased L to R shunt in tricuspid atresia
increased arterial oxygen, wide pulse pressure, hypotension (compromised systemic perfusion)
172
what is SaO2 after BT shunt
75-85%
173
what would cause a lower SaO2 after BT shunt
high PVR, R-L shunt
174
what is management after BT shunt
may need inotropes
controlled ventilation post op
potential for excessive PBF
-support systemic CO
-prevent increase in PBF
-avoid increase FiO2 and hypocarbia
175
hypoplastic L heart
176
hypoplastic L heart
177
describe hypoplastic L heart
-hypoplasia of all L heart structures
-possible Mitral/Aortic Atresia
-Hypoplasia of aorta, coarctation
-PDA provides blood flow to systemic circulation and retrograde to coranaries
-single ventricle with complete mixing
178
what are s/s hypoplastic L heart
grayish-blue skin color
rapid-difficult breathing
poor feeding
cold hands and feet
lethargy
failure to thrive
179
what are signs of worsening congenital heart defect
nutritional status
poor feeding
FTT
180
what is goal management of hypoplastic left heart with single ventricle physiology
-optimization of systemic O2 delivery and perfusion pressure
-prevent end-organ ischemia/injury
-balanced systemic/pulmonary circulation
181
what is treatment Hypoplastic left heart with single ventricle physiology
PGE1 infusion to maintain PDA
atrial septoplasty if there is resitriction
palliative procedure (BT shunt, aortic arch reconstruction)
182
norwood, bi directional glenn, fontan for HLHS
183
what does bidirectional glenn connect in HLHS
SVC to R PA
184
when is bidirectional glenn done for HLHS
3-8 months (when PVR decreased)
185
bidirectional glenn for HLHS
186
what is an indicator for outgrowing BDG and having a decreased PBF
baseline O2 saturation is a good indicator
187
when can HLHS who have had BDG procedure get CPBP
infants have grown and gain weight (less likely to develop excess PBF after induction)
BUT if outgrown BG shunt, may have decreased PBF
188
what are managment for LHS who have had BDG procedure before CPBP
IV induction with etomidate or ketamine
volume expansion prior to induction
may need inotropic support
189
what is post-CPB managment of BDG patients
SVC need unimpeded flow and pressure for forward flow
control HR, NSR, contractility
appropriate preload
inotropic support (dopamine, milrinon)
normocarbia (avoid hypercarbia)
SaO2 goal of 76-85 (same as before BDG)
190
when is fontan procedure completed
2-3 years
191
what is fontan procedure
total cavopulmonary connection
final staged correction to a series or normal circulation
passive flow from IVC/SVC to PA
192
what are absolute contraindications for fontan procedure
early infancy
pulmonary htn
sever PA hypoplasia
EF<30%
193
fontan procedure
194
what is pre-fontan anesthetic management
same as post BDG
SaO2-75-85%
IV induction with opioids and benzos
KEY:
maintain filling and function of systemic ventricle
195
how do we maintain filling and function of systemic ventricle pre fontan
adequate preload
low PVR
low intrathoracic pressure
SR
normal vent function
low afterload
196
what is versed dose for prefontan procedure
20-30 mg PO (1 mg/kg)
197
do kids <6 need pre meds for fontan procedure
no, they have had major surgeries before
198
do older kids need pre meds for fontan procedure
yes, anxiety
199
what causes of increased PVR do we avoid pre fontan
stress
hypercarbia
hypoxia
acidosis
atelectasis
increased intrathoracic pressure
200
what is induction for pre fontan
volume expansion
etomidate
high opioids
benzos
etomidate
muscle relaxer
201
what is maintanence for pre fontan
opioids
benzos
low dose volatiles
MR
202
what lines do we want for pre fontan
art line
IJ CVC
203
what is post fontan management
maintain HR, contractility, preload to maintain CO
need volume
inotropic support
204
how is pt oxygenation post fontan
patients are fully saturated (unless fenestrated where deoxygenated blood is crossing over)
205
what are examples of acyanotic shunts
VSD, ASD, PDA, coarctation of aorta, PFO, AV canal defect
206
what shunt does oxygenated blood recirculate back to lungs
acyanotic, L to R
207
what is patho of acyanotic shunt
decreased systemic blood flow
low cardiac output
hypotension
increased pulmonary blood flow
pulmonary htn
RVH
CHF
208
what are hemodynamic goals of acyanotic shunt
avoid increased PVR
avoid decreased PVR (decrease FiO2, hypoventilation)
209
what is the most common CHD
VSD
210
what CHD is detected in 1/3 of adults
ASD
211
what CHD is common in premies
PDA
212
what congenital issue has more CHD
trisomy 21
213
what are effects of L to R shunt
increased pulmonary blood flow
increased PAP
increased PVR
increased volume overload
increased LA pressure/volume
pulmonary congestion/edema
BiVentricular failure
214
what kind of shunt is ASD
L to R
215
what are direction and magnitude of ASD shunt dependent on
size of the defect
relative compliance of the ventricles
216
if a heart chamber has INCREASED compliance, how is its pressure
decreased
217
what are s/s ASD
systolic ejection murmur at pulmonic valve (increased flow)
split/fixed second heart shound
EKG: RAD, imcomplete BBB, Afib, SVT
218
what causes afib in ASD
atrial dilation from increased pressure stretches nerves, causing AFIB
219
what is is the most common congenital cardiac abnormality in infants and children
VSD
220
when do most VSDs spontaneously close
by 2 years
221
ASD
222
VSD
223
what happens with PVR after birth
PVR falls, pulmonary overcirculation and congestive heart failure (CHF)
224
what are s/s VSD
tachypnea
increased work of breathing
poor feeding
poor growth
hepatomegaly
225
what is treatment for VSD
closed with patch
226
what is eisenmengers syndrom
L to R shunt from VSD, if unrepaired, leads to high PVR, R to L shunt, low pulmonary flow, and cyanosis
227
how does body respond to cyanosis from eisenmengers syndrome
bobe marrow compensatory erthrocytosis
228
what are systemic effects of cyanosis from eisenmengers
leucocytosis (infection)
platelets (bleeding)
skin (acne)
cholelithiasis
gout
bones (scoliosis)
229
eisenmengers
230
what is a narrowing of the aorta
Coarctation of the aorta
231
what is coarctation of the aorta usually associated with
aortic stenosis
bicuspid aortic valve
VSD
232
what is most common cause of aortic stenosis
bicuspid aortic valve and calcification; calcifies earlier than tri-leaflet valve
233
what are tx for coarctation of the aorta
PGE1 infusion
inotropes
preload
increase PVR (to maintain R to L shunt)
234
what at surgeries for coarctation of the aorta
balloon angioplasty
resection
flab
235
what is induction for coarctation of the aorta
benzos
high dose narcotics
236
what drug do we avoid in coarctation of the aorta
ketamine
237
T/F neonates are canditates for volatiles for coarctation of the aorta
False
238
what are som preop assessments for children undergoing heart sx
prescriptions
create relationship with parent/child
formulate a plan
nutritional state
aprotonin dose
239
what is poor growth and development associated with
severe CHD
240
what is a consideration if a patient is having a repeat sternotomy
may require peripheral CPB
241
if patient BT shunt is being placed on L, where do we place a-line
on right to avoid SC cross clamping
242
where do we put preductal pulse ox
R side
243
where do we put post ductal pulse ox
foot, tests perfusion to see how shunts are doing
244
do we premedicate <6 months
no
245
do we premedicate older kids with no anxiety
no
246
do we premedicate older kids with multiple sxs, anxiety, parental anxiety
yes
247
do we premedicate in severe CHF
avoid or judicial use
248
do we premidicate in dynamic outlet obstruction or tetralogy of fallot
premedicate to avoid increase cyanosis 2/2 crying/struggling on induction
249
what is rule of thumb with elective cardiac surgeries in a patient with URI
postpone
250
URI and cardiac patient
251
why do glenn shunt and fontan have increased risk of URI
increased PVR
252
what does cyanosis lead to systemically
erythropoiesis
253
what are complications of erythropoiesis
increased viscosity leads to sludging, thrombosis, increased PVR> SVR
254
how does NPO affect erythropoiesis
makes it worse, do not limit clear liquids for long periods
255
at what HCT does viscosity outweigh benefit of increased oxygen carrying capacity
Hct>65%
256
what is anesthesias biggest concern with shunting
control of shunting via hemodynamics and control of vascular resistance is anesthesias biggest concern
257
what are side effects of CPBP
hemodilution
consumption of clotting factor
immature coagulation factor synthesis
decreased vitamin-K dependent coag factors
258
what is priming dose of CPBP in children
3x the blood volume of child
259
what is tx of hemodilution and hypocoag state of CPBP
plt 10ml/kg
cryo
txa
desmopressin
260
what does FFP lead to
hemodilution
261
what factors does DDAVP help replace
factor 8
vWF
262
what do we monitor in CPBP
ionized calcium (Ca++ used by heart)
temperature (cooling and rewarming)
art line
TEE
263
what is the best core temp
swan then esophagus
264
what is best brain temp
nasopharyngeal
265
what is issue with trisomy 21 and art line
altered anatomy
266
what is side effect of protamine
vasodilation
267
how does art line read in CPBP
flat line, shows map
268
what is equivalent to CO on pump
flow rate
269
what medication should be given before going on pump
heparin
270
what is ACT goal of hepranization for bypass
ACT 3x baseline
271
why do we avoid nitrous oxide in CPBP
enlarge emboli
increases PBR
microbubbles
272
what does ketamine cause
SNS activation
273
what induction is preferred for CPBP
IV induction (not propofol)
274
on and off pump meds
275
when is pediatric hemoglobin formed
6 months
276
T/F fetal hgb is the same as adult hgb
false
277
what is changed in fetal hgb
beta unit is switched for gamma unit (2 each)
278
fetal hgb holds on to O2 (more/less) than adult hgb does
more (so that it does not release O2 to mother)
279
a left shift in oxy hgb curve means it holds onto O2 (more/less)
more
280
what factor is absent in fetal hgb
binding site for 2, 3 DPG
281
B is normal adult
A is fetal shift
282
what is P50 at term
19mmhg
283
what is P50 at 6 months
26mmhg
284
when does hgb begin to increase in peds
4 months
285
what blood complication are premis ar risk for
anemia
286
blood types and antigens
287
what do we ask if child needs blood
have they had a blood transfusion before?
288
what blood types can A receive
A O
289
what blood types can b receive
B O
290
what blood types can AB receive
A, B, AB, O
291
what blood types can O receive
O
292
what happens when an Rh- receives Rh + blood
produce anti Rh antibodies
if mother has anti-Rh antibodies and fetus is Rh positive, antibodies will cross placenta and damage fetal RBGs
293
T/F Rh antibodies affect first pregnancy
F, second
294
what is treatment for Rh Antibodies
RhoGAM
295
when do we give RhoGAM
between 26-28 weeks
3 days after delivery
296
T/F only Rh+ moms receive RhoGAM
F, only Rh- moms, then if baby is Rh + then they get additional shot after birth
297
what population may refuse RhoGAM
JW, contains blood protiens
298
what kind of blood do all infants receive
Type O Rh - OR
ABO and RH D compatible
299
blood component effect table
300
what is dose of PRBCs
10-15 ml/kg
301
what is effects of PRBCs
increases HGB by 2-3 g/dl
302
what is HCT of PRBCs
60%
303
what is dose of platelets
5-10 ml/kg
304
what is effect of platelet admin
increase platelet count by 50-100,000/mm3
305
what is dose of FFP
10-15 mL/kg
306
what is effect of FFP
factors increase 15-20%
307
what is dose of Cryo
1-2 units/kg
308
what is effect of cryo
increase fibrinogen by 60-100 mg/dl
309
what is dose of fibrinogen concentrate
70 mg/kg
310
what is effect of fibrinogen concentrate
increase level of 120 mg/dL
311
what is trigger for blood transfusion for <3 months old healthy patient
25% hct
312
what is trigger for >3 months old if post op bleeding is not expected
20% hct
313
transfusion ars rarely indicated when Hgb is >
10 g/dL
314
transfusions are always indicated when Hgb is <
6 g/dL
315
what other factors do we consider when hgb is 6-10 to determine if transfusion is needed
ongoing blood loss, evidence of organ ischemia (kidneys), risk of complications from inadequate oxygenation, shunting
316
what is calculations for allowable blood loss
EBV x ( Hct- minimal Hct)/ (avg of hct)
317
what is EBV of premature infant
90-100 ml/kg
318
what is EBV of term newborn
80-90 ml/kg
319
what is EBV of infants younger than 1 yr
75-80 ml/kg
320
what is EBV of older children
70-75 mL/kg
321
what is normal minimal accepted HCT
24%
322
what is formula for age based weight in Kg <12 months old
age in months +9/2
323
what is formula for age based weight for 1-5 years yr
age in years +5 x2
324
what is formula for age based weight for 5-14 years
age x4
325
what is formula for volume of PRBCs to give
EBVx (desired HCT-present HCT) (HCT of PRBCs (60))
326
what hgb do we want cyanotic congenital heart disease at
13-18
327
what are examples of cyanotic heart disease
Tet of Fallot
Transposition of Great Arteries
Tricuspid Atresia
total anomalous pulmonary vein connection
328
what are risks of transfusion of blood
viral infections
bacterial infections
hyperkalemia
TRALI
329
what is chance of getting HIC, HEP C from blood
1 in 1.1 million
330
what are s/s TRALI
ARDS- dyspnea, hypoxia, pulmonary edema, onset 4-6 hours after transfusion
331
what type of plasma donors helps prevent TRALI
male
332
what do you do if you start having transfusion reaction
surgeon and nurse
blood bank- send blood back to blood bank for testing
333
risks of massive transfusion chart
334
what are risks of acidosis from blood transfusion
poor oxygen delivery
lactate
335
what are risks of alkalosis from blood transfusion
citrate metabolism to bicarb by liver
336
what are risks of hypocalcemia from blood transfusion
citrate binding of calcium
337
what are risks of hyperglycemia from blood transfusion
dextrose preservation in packed RBC
338
what are risks of hypothermia from blood transfusion
transfusion of cold blood products
339
what are risks of hyperkalemia from blood transfusion
multifactorial
340
what are s/s bleeding risk
easy bruising
petechia
nose bleeds
mucusal bleeding
heavy period
excessive bleeding with umbilical stump
bleeding after circumcision
bleeding after dental work
low factory 8
341
what do you do if you have a patient with high bleeding risk getting a tosillectomy
contact hematology, possibly reschedule
342
what do you give for severe bleeding with VWF
factor 7
343
what do we give to increase VWF (8)
DDAVP
344
what are preopconsiderations for patients with VWF disease
-Consultation with hematologist: establish correct diagnosis and response to desmopressin (DDAVP);
administer DDAVP or viral attenuated factor concentrates containing factor VIII and von
Willebrand factor (vWF) such as Humate-P for severe vWD or for those types not responsive to
DDAVP186
-Determination of actual and desired factor concentrations and expected duration of postoperative
therapy191
-Discontinuation of any platelet-inhibiting medication (e.g., aspirin)
345
what are intraop considerations for patients with VWF disease
-Judicious use of regional anesthesia, intramuscular medications, nasogastric tubes, nasal intubation,
and other procedures that may cause bleeding
-Limited use of medications with potential bleeding risk (e.g., ketorolac)
-Coagulation profiles, including platelet counts for more invasive surgeries
-Treatment of bleeding with appropriate blood products
-Consider use of antifibrinolytic agents (i.e., ε-aminocaproic acid, tranexamic acid)190
-Possible use of recombinant factor VIIa for severe bleeding episodes in severe vWD type 3 or
patients with inhibitors
346
what are postop considerations for patients with VWF disease
-Follow factor concentrations (i.e., factor VIII and vWF)
-Availability of blood products and factors
-Appropriate treatment of bleeding episodes
-Monitor for thromboembolism in children receiving multiple concentrates or antifibrinolytic agents,
or both186
347
what factor is hemophilia A
factor 8
348
what factor is hemophilia B
factor 9
349
what are signs of hemophilia A B
bleeding from heel sticks, circumcision, delivery intracranial hmmged
isolated prolonged aPTT
normal PT, thrombin time, platelet count, and bleeding time
350
table 10.13
351
when do we treat patient with ITP
below 10-20,000?
352
what is ITP
low platelets 2/2 life span of only a few hours
353
what do we want patient with G-6-PDD to aboid
stressors
pain, anxiety
infection, triggering things like prilocaine, benzocaine, sodium nitroprusside, hydralazine, procainamide, ASA, methylene blue, sulfa drug (10.8)
354
table 10.8
355
what is anesthetic management of thalassemia
facial deformities
osteoporosis
hyperdynamic circulation
cardiac dysfunction
hepatic disease
pulm htn
thrombosis risk
356
what do we do preop for patient with SCD
Screening if unknown status in at-risk children
Primary management by hematology service (in most circumstances)
History of acute chest syndrome, vasoocclusive pain crises, hospitalizations, transfusions,
transfusion reactions
Neurologic assessment (e.g., strokes, cognitive limitations)
History of analgesic and other medication use
Hematocrit
Oxygen saturation (on room air), chest radiograph
Pulmonary function tests (when appropriate)
Practice incentive spirometry at home
Work with child-life specialist if indicated
Echocardiography (when appropriate)
Neurologic imaging (for recent changes)
Renal function studies
Transfusion crossmatch (e.g., antibody-matched, leukocyte-reduced, sickle-negative)
Transfusion to correct anemia (in most circumstances)
Parenteral hydration for nil per os (NPO) status
Pain management
Aggressive bronchodilator therapy
Appropriate antibiotic therapy, including presplenectomy antibiotics and immunizations (as
indicated)
357
what are intraop consideration for SCD
Maintenance of oxygenation, perfusion, normal acid-basis status, temperature, hydration
Availability of appropriately prepared blood (as indicated)
Replacement of blood loss
Anesthetic technique appropriate for procedure and postoperative analgesic requirements
Attention to physiologic effects of laparoscopy on circulatory and respiratory function
Appropriate antibiotic therapy
Judicious use of tourniquets, cell saver, and cardiopulmonary bypass
358
what are postop considerations for SCDs
Management by hematology service
Monitoring for complications, especially acute chest syndrome and vasoocclusive pain crises
Maintenance of oxygen saturation monitoring and supplementation as needed, including
prophylactic supplemental oxygen the first 24 hours regardless of oxygen saturation
Appropriate hydration (oral plus parenteral)
Appropriate antibiotic therapy
Aggressive pain management—must ensure ability to breathe deep and do incentive spirometry
Early mobilization
Incentive spirometry (possibly with continuous or bilateral positive airway pressure) and
bronchodilator therapy
359
what does sickle cell trait produce
Hb A HbS (hetero)
360
what does sickle celll anemia produce
only Hb S
361
which type of sickle patient has crisis
sickle cell anemia (HbS)
362
what is the hallmark signs of sickle cell anemia
chronic hemolytic anemia
hgb 5-9
hgb S
sickled hgb
363
what can lead to sickle cell crisis
hypoxia
emotional stress
pain
infection
surgical stress
hypothermia
dehydration
leukocytosis
inflammation
acidosis
thrombosis
364
what surgery is common for sickle cell anemia
cholecystectomy-have gallstones
365
what is life span of sickled RBCs
10-12 days
366
what are complications of sickle cell anemia
vaso occlusive crisis
gallstones
organ dysfunction
pulm htn
priapism
skin ulcers
reactive airway from decreased nitric oxide
stroke
acute splenic sequestration
pulmonary and neurological complications
367
what med is helpful in sickle cell crisis
NO
368
what do we avoid in sickle cell anemia to avoid stroke
hyperventilation
369
what are the leading causes of morbidity and mortality in sickle cell anemia
pulmonary and neurologic complications
370
ACS
371
what is a new pulmonary inflitrate of at least one complete lung segment on chest X-ray and is the leading cause of death with SCD
acute chest syndrome
372
what are triggers of acute chest syndrome
infection, fat embolism from bone marrow infarction, pulmonary infarction, surgery induced stress
373
what are s/s acute chest syndrome
chest pain, fever, tachypnea, wheezing, coughing, and hypoxemia
374
what is treatment of acute chest syndrome
broad-spectrum ABX
O2
adequate analgesia
bronchodilators
incentive spirometry
375
what is hallmark of pain pattern in SCD
occlusion-> pain and pain-> more occlusion
376
what is treatment for pain from acute chest syndrom?
APAP
NSAIDS
Steroids
opioids
psychotropics
regional anesthesia
377
what are indicators for transfusion of SCD
correction of preexisting anemia
dilution of HGB S (to less than 30%)
378
what factors are in FFP
2, 7, 8, 9, 10, 11
379
what factors are in PCC
2,7,9, 10, 12, proteins C and S
380
what factors are in cryo
vWF
fibrinogen
381
table 12.7
382
FFP must be transfused with _______ hours of thawing
24
383
what is dose of FFP
20ml/kg will replace 50% of factors
10-15 will increase by
384
what is used for the reversal of warfarin in emergencies
FFP
385
what is platelet level for surgery
50,000
386
T/F give platelets through platelets through filter and warmer system
F, will destroy them
387
MAC of volatiles is (higher/lower) in peds
higher
388
Highly water soluble drugs are confined to the __________ space and as such have a (larger/smaller) volume of distribution
intravenous
smaller
389
lipophilic drugs have a (smaller/larger) volume of distribution as they can disseminate into the _________
larger
tissues
390
neonates and infants have larger distribution volumes for _________ soluble drugs
water
391
neonates and infants have smaller distribution volumes for _________ soluble drugs
lipid
392
neonates have more _________ weight
water
393
what are examples of water soluble drugs
antibiotics
anectine
digoxin
394
a greater water soluble Vd in infants means an (increased/decreased) loading dose
increased
395
although infants/neonates have a higher Vd, they are (more/less) sensitive to medication effects
more
396
T/F preterm infants are more sensitive to medication effects
true
397
what is the most important organ for water-soluble drug elimination
kidney
398
what is GFR in neonate
5ml/min
399
what is GFR in preterm
1ml/min
400
when does GFR mature by
20 weeks
401
as age increases, GFR _________
increases/matures
402
what determines renal drug clearance
GFR, active tubular secretion, active and passive tubular reabsorption
403
what drugs are metabolized by liver
sedatives
404
what leads to greater volume of distribution of hydrophilic drugs in infants
greater total body water and larger extracellular fluid spaces= larger volume of distribution and lower intravascular drug concentrations
405
how are lipophilic drugs effected by maturation
increases in volume of distribution of fat-soluble drugs as propofol and thiopental
406
what drug class causes rapid induction of hypnosis with minimal relaxation or analgesia
barbiturates
407
neonates have a (increased/decreased) ability to metabolize barbiturates
decreased
408
what are examples of barbiturates
thiopental
methohexital (brevital)
Diazepam (valium)
Midazolam (versed)
409
T/F give barbiturates in prophyria
false
410
what barbiturate do we use for ECT
methohexital
411
what is benefit of methohexital
fast on and off
412
how does methohexital effect BP
high BP after
413
what do you watch for in methohexital
watch airway
414
what barbiturate do we avoid in preterm
versed
415
what oral drugs are good for special needs
versed and benadryl
416
which barbiturate has the lowest clearance in preterm
versed
417
versed has extensive __________ metabolism
hepatic
418
what is reversal for benzos
Flumazenil
419
what is dose of flumazenil
0.01 mg/kg
420
what are SE of flumazenil
nausea
vomiting
blurred vision
sweating
anxiety
emotional lability
421
what two sedatives do we avoid in seizures
etomidate and lidocaine (lower the seizure threshold)
422
what sedative do we avoid in addisons and congenital adrenal hypoplasia
etomidate
423
what three conditions do we avoid etomidate in
addisons
congenital adrenal hypoplasia
seizures
424
what can we give with etomidate to help offset adrenocorticotropic supression
versed
425
what are SE of etomidate
myoclonic movements
pain
adrenocorticol suppression
N/V?
426
what procedure can you do before giving propofol in peds
baby-beer block- give lidocaine and squeeze arm to numb vein before giving propofol
427
how do you treat hypotension from propofol
fluids
428
what are rates of propofol infusion to cause PRIS
>4 mg/kg/hr or 67 mcg/kg/hr over a long period of time
429
what are s/s PRIS
bradycardia = one or more: lipemic plasma, hepatomegaly, metabolic acidosis with or without increase in serum lactate, rhabdomyolysis with myoglobinuria
green urine?
430
what is metabolism of propofol
redistribution, hepatic/lung/kidney clearance
431
what are SE of propofol
involuntary motor movements
pain on injection
hypotension
432
which has less NV etomidate or propofol
propofol
433
what sedative is an NMDA antagonists that causes dissociation of the cerebral cortex from the limbic system
ketamine
434
what can we give to dry up secretions from ketamine
atropine, robinol
435
what can we give to stop PTSD from ketamine
versed
436
what are SE of ketamine
increased HR, SBP
437
T/F ketamine causes resp depression
no
438
what are contraindications for ketamine
increased ICP, full stomach
439
what is drug class of precedex
selective a2 agonists
440
what is ratio of a2 to a1 in precedex
1600:1
441
precedex causes (hyper/hypo) polarization of noradrenergic neurons in the locus coeruleus
hyper
442
T/F precedex causes resp depression
false
443
what stage of anesthesia do we not touch kids during
stage 2 (delirium)
444
what can happen when kid is moved in stage 2
laryngospasm
445
T/F use des for inhalation induction in peds
F, causes spasms
446
what 6 things affect the uptake of anesthetic gases
1-inspired concentration
2- alveolar ventilation
3-FRC
4- CO
5-solubility
6-alveolar to venous partial pressure gradient
447
how does a decrease in CO affect FA/FI
increases FA/FI ratio, causing a buildup in alveoli, gas is not carried away
448
Fa/FI equilibrates (faster/slower) in children than adults
faster
449
wash in of volatiles is (faster/slower) in adults than children
slower
450
what four factors cause a faster uptake (FE/FI) in neonates/ infants
1VA:FRC 5:1 in child compared to 1:4:1 in adults
-tissue solubility is decreased
-CO increased to vessel rich group
-blood gas solubitlity coefficient lower in infants and neonates (except sevo)
451
wash out increases as blood solubility (increases/decreases)
decreases
452
what is the preferred anesthetic gas for peds
sevo
453
what volatile has the fastest wash in of all volatiles
des
454
what cases do we avoid Nitrous Oxide in
neuro
455
what effects is caused by Nitrous Oxide
second gas
456
what SE does Nitrous Oxide cause
N/V
457
use a (higher/lower) concentration of oxygen in premature
lower
458
what can high concentrations of oxygen cause in premature
retinopathy of prematurity
459
what are risk factors for retinopathy of prematurity
Gestational diabetes
bright light
maternal antihistamine before delivery
460
what opioid do we use precaution on in peds
sufentanil
461
what opioids cause the most post op N/V
morphine/dilaudid
462
T/F giv meperidine for seizures
false
463
what opioid is good for shivering
merperidine
464
if a patient is bradycardic and you want give fentanyl, what do you pretreat patient with
atropine/robinol
465
what is dose of Naloxone
0.01 mg/kg repeated every 2-3 minutes
466
what is opioid reversal
naloxone
467
when do we avoid NSAIDS
asthma
bleeding
kidney problems
allergies to aspirin
468
what is dose of IV APAP
7.5-15 mg/kg IV
469
what is max dose of APAP for <2 yo
60 mg/kg/day
470
what is max dose for APAP > 50 kg
4 gm day and 1 gm doses
471
which anticholinergics cross the BBB
atropine and scopolamine
472
which anticholinergic does not cross the BBB
robinol
473
what is dose of succs for laryngospasm
0.1-0.2 mg/kg
474
what parlytic has a blackbox warning in peds
succs
475
what can happen with succs and undiagnosed duchennes muscular dystrophy
intractable, unexpected cardiac arrest with 50% mortality
476
what are SE succs
sinus brady
increased intragastric pressure
increased ICP
477
T/F it is routine to give parlytic in peds
false
478
what are absolute contraindications for succs
patient or FH of MH
suspected myopathy
burn victims
disuse atrophy
479
what are relative contraindications of succs
plasma cholinesterase deficiency
hypercarbia
intraabdominal sepsis
hyperkalemia
480
what paralytic is good for renal patient
nimbex
481
where do we check TOF for reversal
adductor pollicus
482
what is blood volume of preemie
90ml/kg
483
what is blood volume of infants <6 months
80ml/kg
484
what is blood volume of 6months-2 years
75 ml/kg
485
what is blood volume of 2-12 years
72 ml/kg
486
what is blood volume in adulthood
60 ml/kg
487
why are young children more susceptible to severe hyponatremic encephalopathy
larger brain-to skull
488
what is best fluid for peds
LR or plasmalyte (balanced)
489
what is fluid calculation 4-2-1
4 ml/kg/hr first 10 kg
2 ml/kg/hr second 20 kg
1 ml/kg/hr for kgs >20kg
490
what is loss of minimal incision
3-5 ml/kg/hr
491
what is loss of moderate incision
5-10 ml/kg/hr
492
what is loss of large incision
8-10 ml/kg/hr
493
what is total hourly requirement for fluid
estimated hourly requirement + estimated deficit + insensible loss + EBL
494
how do we treat mild dehydration (<10%)
oral rehydration with pedialyte
495
what kind of fluids do we avoid until dehydration is corrected
hypotonic like 0.45 NS and 0.22 NS
496
what is process for correcting dehydration
20-40 ml-kg of balanced salt solution (NS, LR, plasmalyte)
40ml/kg of 0.9 NS over 2-4 hours
reamainder of deficit as 0.9% Na over 24 hours
497
what kind of induction do we do for dehydration
no inhalation
RSI
have a reactive airway
498
Morphine dose
IV 0.1 mg/kg
499
fent dose
IV bolus analgesic 1-2 mcg/kg
IV loading dose 5-10 mcg/kg
IV infusion 1-3 mcg/kg/hr
500
robinol dose
0.01 mg/kg (5 mcg/kg for reversal)
501
atropine dose
0.02 mg/kg (7-10 mcg/kg for reversal)
502
neostigmine dose
50 mcg/kg
503
narcan dose
0.01 mg/kg every 2-3 minutes
504
romazicon (flumazenil) dose
0.01 mg/kg
505
succs dose
infants 3-4 mg/kg
children 2 mg/kg
laryngospasm 0.1-0.2 mg/kg
506
BG coefficient Sevo
0.59
507
BG coefficient Des
.42
508
BG coefficient Iso
1.4
509
BG coefficient nitrous oxide
.46
510
rate of increase in FA/FI in (inversely/directly) related to CO
inversely
