Final Review Flashcards
1
Q
What is a pre-term infant’s gestational age?
A
< 37 weeks gestation
2
Q
What gestational age can a premie survive outside the womb?
A
24 weeks
3
Q
How does fetal hgb affect the oxyhemoglobin dissociation curve?
A
Shifts it left = “loves oxygen”
4
Q
Adaptation from fetal to infant breathing is found do be dependent on?
A
“Guppy breathing” intern & the diaphragm
5
Q
What is the primary event of fetal respiratory transition?
A
Initiation of ventilation
6
Q
Neonates are prone to lung collapse, how is this counteracted in anesthesia?
A
Addition of 5 cmH20 or PEEP
7
Q
What 2 things are the initial hyperpneic response abolished by?
A
Hypothermia & low levels of anesthetic gas
8
Q
What is the lowest acceptable hematocrit for a newborn or infant?
A
35
9
Q
Non-shivering thermogenesis is caused by? (2)
A
Cold & stress
10
Q
What does hypoxia cause in infants?
A
Profound bradycardia & decreased response to hypercarbia
11
Q
T/F infants have an increased oxygen consumption?
A
True (6 mL/kg)
12
Q
What are the 3 shunts of fetal circulation?
A
Ductus venosis, ductus arteriosus & foramen ovale
13
Q
PVR is _______ & SVR is _______ in fetal circulation
A
PVR is high; SVR is low
14
Q
What leads to reversal of fetal circulation shunts?
A
- Cutting umbilical cord (increases SVR) & 2. Onset of breathing (decreases PVR)
15
Q
What is persistent hypertension of newborn (PPHN)?
A
Persistence of fetal shunting beyond normal transition period & absence of structural heart defects
16
Q
What are 2 main causes of PPHN?
A
Hypoxia & acidosis
17
Q
Does shunt reversal happen even in normal infants under the right conditions? If so, what conditions?
A
Yes - coughing; bucking; straining (during anesthesia)
18
Q
What is the treatment of PPHN?
A
ADEQUATE VENTILATION - hyperventilate; pulmonary vasodilation (prostaglandins); minimal handling & stress
19
Q
Why are infants “obligate sodium losers?” What does this mean when caring for them?
A
They have an inadequate response to aldosterone —> fluids MUST have sodium
20
Q
What is urine sodium of a neonate vs. an adult?
A
Neonate = 20-25 mEq; adult = 5-10 mEq
21
Q
What about infants makes it so important to replace blood sooner than later (2)?
A
They have increased blood volume & CO per unit weight
22
Q
Why is it so important for infant’s hct to not drop below ______?
A
35% - increased oxygen demand with a decreased ability to increase CO
23
Q
What is the # 1 way heat loss occurs?
A
Through radiation
24
Q
What is non-shivering thermogenesis? Why is it important?
A
Metabolism of brown fat —> prevents shivering, so you do not know if infants are cold — OR at 80*F
25
What are the top 3 congenital heart disease?
1. Bicuspid aortic valve; 2. VSD; 3. ASD
26
What does preferential streaming in fetal circulation do?
Makes more oxygenated blood available to the brain and body, not lungs
27
Do infants have the ability to increase CO? Why or why not?
Limited ability; no change in SV; limited ability to increase HR due to an incomplete sympathetic nervous system & decreased ventricular compliance
28
What are normal infant VS?
HR = 120-160; RR = 30-60; premie BP = 50/25; neonate BP = 70/40
29
What is the most common ASD?
Secundum ASD - mostly asymptomatic
30
What is the most common VSD?
Perimembranous - treated if large/symptomatic; small use prophylactic antibiotics
31
What birth defect are AVSD’s most common in?
Trisomy 21 -
32
Which septal defect ALWAYS needs treated?
AVSD
33
What are 2 classic signs of aortic aoarctation?
1. Decreased or absent femoral pulse; 2. Hypertension in upper extremities
34
In the event of aortic coarctation what should be maintained?
Ductus arteriosis with prostaglandins
35
What are the 4 characteristics of tetralogy of Fallot?
1. Hole between ventricles; 2. Obstruction from heart to lungs; 3. Aorta lies over hole in lower chambers; 4. Thickened RV muscle
36
In the first week of life, what is the most common cause of cardiac cyanosis?
Destra-transposition of the great arteries
37
What does levocardia mean?
Heart is on the normal side of body (left)
38
What syndrome is characterized by elfin faces; endocrine abnormalities (hypercalcemia & hypothyroid); MR; growth deficiency; muscle weakness
William’s Syndrome
39
What is the #1 cause of cardiac arrest in perioperative cardiac arrest registry?
William’s Syndrome
40
Which 2 congenital disorders are associated with Aortic coarctation?
William’s Syndrome and Turner’s syndrome
41
What is the most important thing to consider regarding anesthesia and Trisomy 21?
They are very sensitive to volatile anesthetics & will become bradycardic quickly - ATROPINE
42
Which disease is associated with aortic dissection at any size?
Marfan Syndrome
43
Which disease is a mutation of the fibrillation gene (connective tissue)
Marfan syndrome
44
What is DiGeorge/Velocardiofacial syndrome also known as? What are the cardiac considerations?
CATCH 22 (deletion of 22q11.2 deletion syndrome) - conotruncal abnormalities & outflow tract problems —> also has immunodeficiency that requires irradiated blood products
45
What is Turner syndrome’s physical characteristics?
webbed neck; low set ears; short stature; pigmented moles; obesity; micrognathia
46
What is Noonan syndrome characterized by physically?
Neck webbing, low set ears, chest deformities, short
47
Which discussed disease is associated with bleeding diathesis?
Hypocoagubility - Noonan syndrome
48
What cardiac considerations are there for Kawasaki disease?
Coronary artery dilation; aneurysm formation; MI
49
What is VATER association? What anesthetic considerations?
VACTERL = Vertebral; Anal; Cardio; TrachEosophageal; Renal; Limb defects — difficult to intubate & vascular access
50
What does CHARGE stand for? What heart defects?
Coloboma; Heart defects; choAnal; Retardation ; Growth/Genitourinary; Ears — conotruncal & arch abnormalities — upper airway abnormalities
51
Hct > _______% impairs microvascular perfusion
65
52
R —> L shunt results in ?
Desaturation & will increase when SVR decreases or PVR increases
53
L—>R shunt will cause?
Substantial steal of systemic blood flow to pulmonary circulation
54
What are the following S&S indicative of? Failure to thrive; difficulty feeding; breathlessness; tachycardia; recurrent chest infections?
CHF
55
What special monitoring needs done for PDA corrections?
2 pulse ox - one on right hand & one on lower limb —> loss of pulse ox during test clamp may indicate clamped aorta
56
What 2 congenital defects is tetralogy of Fallot associated with?
Trisomy 21 & DiGeorge
57
What is the preferred treatment for congenital dislocation of hip?
Pavlick harness — other option is fluro guided reduction & Spica casting
58
What are 2 concerns for anesthetic management of congenital dislocation of hip sx? Which is the greatest?
Greatest is LOSS OF AIR WAY; the other is if LMA is used, to keep pt in deep stage III to prevent laryngospasm
59
What is one of the greatest anesthetic concern for congenital clubfoot sx?
Intraoperative glucose monitoring& glucose containing solution because of the age of these pts (3-6 months)
60
What should be known about pts with osteogenesis Imperfecta prior to sx?
How brittle they are
61
What are 2 anesthetic concern of the osteogenesis imperfecta pt?
DO NOT USE SUCCS - can cause dx; and these pts are hypermetabolic, NOT MH
62
Which group of common orthopedic sx pts are prone to seizures? And have problems with Laryngeal & pharyngeal reflexes (GERD)?
Cerebral palsy
63
If a cerebral palsy pt is to have surgery, should they continue taking their seizure medications?
YES
64
What anesthetic concern is there with pts who take phenobarbital?
Hepatic enzyme inducer (will metabolize drugs faster)
65
What is the concern of pt’s that take Dantrolene for anti-spasticity?
Inhibits release of Ca++ from SR
66
How does Baclofen work?
Inhibits excitatory neurotransmitters (skeletal muscle relaxant)
67
How does spina bifida; meningococcal; and myelomeningocele differ?
Spina bifida is a closed hole in spine; meningococcal has an outpocket, but SC remains in neural tube; myelomeningocele has the SC in the outpocket
68
What are 2 anesthetic concerns of pts with any degree of spina bifida?
Avoid pressure to the sac; avoid NDNMBs initially (neurometric monitoring)
69
What age group is scoliosis most common in?
> 10 years
70
What organ systems are affected by scoliosis?
Lungs and chest wall compliance; increased PVR
71
What anesthetic plan is the best choice for pt’s with scoliosis? Why?
TIVA - SSEPs monitored; IH agent kept at 0.5-1.0 MAC if used
72
What is the main anesthetic concern for scoliosis surgery?
BLOOD loss exceeds 25 mL/kg - DO NOT DO THESE CASES WITHOUT BLOOD IN THE ROOM; hourly H&H
73
Which is more common, gastrochisis or omphalocele?
Omphalocele
74
Which involves the umbilical cord, gastroschisis or omphalocele
Omphalocele
75
Which is typically more detrimental to the bowel, gastroschisis or omphalocele?
Gastroschisis - no sac = bowel is matted, thick & edematous
76
Which has a higher incidence of other anomolies, gastroschisis or omphalocele?
Omphalocele
77
What 2 different types of surgeries can be used to repair gastroschisis or omphalocele?
Primary closure or staged with the use of a silo/mesh chimney
78
What is special about monitor placement for gastroschisis and omphalocele sx?
2 pulse oximeter, pre & post ductal (right arm & left foot)
79
What inhaled agent should be avoided in MOST GI surgeries?
Nitrous
80
Most GI surgeries INDUCTIONS should involve??
RSI intubation - consider a full stomach
81
What is he triad of symptomsfor congenital diaphragmatic hernia?
Dyspnea; cyanosis; apparent dextrocardia
82
T/F muscle relaxant with TIVA or IH induction are good anesthetic plans for CDH?
True
83
What are some respiratory management considerations for pts with CDH?
Decrease tidal volumes (normally 10 ml/kg); avoid hypoxia & acidosis (worsen R—> L shunt); avoid bag mask ventilation; USE NITRIC OXIDE to decrease PVR
84
What are the clinical presentations of pyloric stenosis?
Nonbilious vomiting; dehydration; palpation of olive-sized mass in upper abdomen; metabolic alkalosis (decreased Na+, Cl-, H+)
85
Pyloric stenosis is what kind of emergency?
Medical, NOT surgical
86
What is the primary concern with pyloric stenosis?
Aspiration of gastric fluid - suction at least 3 x & RSI intubation
87
Which GI sx is nitrous oxide ok to use?
Pyloric stenosis
88
What medications should be avoided with pyloric stenosis?
NO NARCOTICS
89
What is the most common esophageal anomaly? What is it associated with?
Transesophageal Fistula; associated with VACTERL
90
What are the goal for intubation with transesophageal intubation?
ETT above carina, below fistula; consider awake intubation; try to avoid PPV; avoid Nitrous oxide
91
After transesophageal sx what is a major concern?
Do not put tension on anastomoses - limit head movement and be cautious with suctioning
92
What is the goal of hypoplastic left heart surgery?
RV becomes single ventricle & pulmonary blood flow is PASSIVELY supplied by the SVC & IVC
93
What are the 3 stages of hypoplastic left heart repair? What O2 saturation is associated with each stage?
Norwood stage 1 - 75%
Norwood stage 2 - 85%
Norwood stage 3 - 95%
94
What is key to manage well with hypoplastic left heart pts?
Keep PVR LOW - CO is dependent on adequate preload and LOW PVR
95
What heart medication is excellent to use in sick neonatal hearts?
Milrinone
96
What is the most common type of TE fistula?
IIIB
97
In a pt with CDH what should the PIP be?
30
98
How does a normal, healthy infant’s CO compare to an adults?
Infants is 2-3 times greater
99
What is normal hgb of full term neonate?
18-20 g/dL
100
What must infant be able to do in order to inflate lungs?
Generate a high negative pressure of -70 cmH2O
101
Once a premie, always a _______; what does this mean for airway?
Premie - means they are always prone to laryngospasm
102
In an uncooperative induction, what is ALWAYS the first monitor placed?
Pulse oximeter, then EKG, then BP
103
Where is the pediatric larynx located?
C3-C4
104
What is the narrowest portion of the pediatric airway?
Cricoid cartilage - airway is funnel-shaped
105
Length of trachea up to 1 year of age is??? What does this mean for ETT tube?
5-9 cm - DO NOT BURY ETT tube
106
What parameters are unsafe for primary closure of gastroschisis or omphalocele?
Intragastric pressures > 20 mmHg; Chang in CVP > 4 mmHg; EtCO2 > 50 mmHg; or PIP > 35 mmHg
107
What does a pt with scoliosis > 25 degrees require?
An echo to check for cardiac involvement?
108
What does a pt with scoliosis > 40 degrees require?
Surgical intervention
109
What does a pt with scoliosis > 65 degrees indicate?
Restrictive lung disease
110
How do you calculate ETT for peds? How do you know proper size once intubated?
(16+ age in years)/4 — always prepare calculated tube & 1/2 size smaller — there should be an audible leak around tube a pressure between 15-25 cm H2O
111
What is the dose of succinylcholine for laryngospasm?
Succs concentration is 20 mg/ml
4 mg/kg IM
0.4 mg/kg IV
112
Why is IV induction advantageous for children?
Children go to sleep without going through stage 2 —> Decreased r/o laryngospasm
113
What is the most common reason for bradycardia in a child?
Hypoxia
114
What are the NPO guidelines for pediatrics?
2 hours clears
4 hours breast milk
6 hours formula
8 hours solid food
115
What can cold stress lead to respiratory wise for infants?
Decreased surfactant —> alveoli collapse —> reopening of fetal circulation
116
In a pediatric trauma, what is tachycardia an early sign of?
CV compromise and impending shock - generally indicates at least 10% loss of circulating blood volume
117
Hypotension in a child should be recognized as a??
LATE sign of hypovolemia & hemorrhage
118
Hypotension in a pediatric trauma indicates what % loss of blood volume?
25% ~ 20 ml/kg
119
Brady cardia in a pediatric trauma indcates?
40% loss f blood volume — hypoxemia & impending arrest or increased ICP
120
What is included in primary survey of pediatric trauma?
ABCDE’s - Airway; Breathing; Circulation/CPR; Disability; Expose
121
What is the #1 cause of death in those 1-19 years of age?
Trauma
122
What kind of children is codeine essentially inactive? What is the other end of the spectrum?
These how lack or have significantly reduced CYP2D6 enzymes; conversely those with CYP2D6 gene duplication will rapidly metabolize codeine—> could result in resp. Depression & DEATH
123
What is different about infant breathing until about 3 to 5 months of age?
Obligate nasal breathers
124
Any time you are incubating a pt with concern for obstructed airway (foreign object, eppiglottitis) what special consideration should be taken?
Make sure they maintain spontaneous respirations
125
What is the peak day for delayed post-tonsillectomy bleeding?
Day 7
