Final Review Flashcards
What is a pre-term infant’s gestational age?
< 37 weeks gestation
What gestational age can a premie survive outside the womb?
24 weeks
How does fetal hgb affect the oxyhemoglobin dissociation curve?
Shifts it left = “loves oxygen”
Adaptation from fetal to infant breathing is found do be dependent on?
“Guppy breathing” intern & the diaphragm
What is the primary event of fetal respiratory transition?
Initiation of ventilation
Neonates are prone to lung collapse, how is this counteracted in anesthesia?
Addition of 5 cmH20 or PEEP
What 2 things are the initial hyperpneic response abolished by?
Hypothermia & low levels of anesthetic gas
What is the lowest acceptable hematocrit for a newborn or infant?
35
Non-shivering thermogenesis is caused by? (2)
Cold & stress
What does hypoxia cause in infants?
Profound bradycardia & decreased response to hypercarbia
T/F infants have an increased oxygen consumption?
True (6 mL/kg)
What are the 3 shunts of fetal circulation?
Ductus venosis, ductus arteriosus & foramen ovale
PVR is _______ & SVR is _______ in fetal circulation
PVR is high; SVR is low
What leads to reversal of fetal circulation shunts?
- Cutting umbilical cord (increases SVR) & 2. Onset of breathing (decreases PVR)
What is persistent hypertension of newborn (PPHN)?
Persistence of fetal shunting beyond normal transition period & absence of structural heart defects
What are 2 main causes of PPHN?
Hypoxia & acidosis
Does shunt reversal happen even in normal infants under the right conditions? If so, what conditions?
Yes - coughing; bucking; straining (during anesthesia)
What is the treatment of PPHN?
ADEQUATE VENTILATION - hyperventilate; pulmonary vasodilation (prostaglandins); minimal handling & stress
Why are infants “obligate sodium losers?” What does this mean when caring for them?
They have an inadequate response to aldosterone —> fluids MUST have sodium
What is urine sodium of a neonate vs. an adult?
Neonate = 20-25 mEq; adult = 5-10 mEq
What about infants makes it so important to replace blood sooner than later (2)?
They have increased blood volume & CO per unit weight
Why is it so important for infant’s hct to not drop below ______?
35% - increased oxygen demand with a decreased ability to increase CO
What is the # 1 way heat loss occurs?
Through radiation
What is non-shivering thermogenesis? Why is it important?
Metabolism of brown fat —> prevents shivering, so you do not know if infants are cold — OR at 80*F
What are the top 3 congenital heart disease?
- Bicuspid aortic valve; 2. VSD; 3. ASD
What does preferential streaming in fetal circulation do?
Makes more oxygenated blood available to the brain and body, not lungs
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
What are normal infant VS?
HR = 120-160; RR = 30-60; premie BP = 50/25; neonate BP = 70/40
What is the most common ASD?
Secundum ASD - mostly asymptomatic
What is the most common VSD?
Perimembranous - treated if large/symptomatic; small use prophylactic antibiotics
What birth defect are AVSD’s most common in?
Trisomy 21 -
Which septal defect ALWAYS needs treated?
AVSD
What are 2 classic signs of aortic aoarctation?
- Decreased or absent femoral pulse; 2. Hypertension in upper extremities
In the event of aortic coarctation what should be maintained?
Ductus arteriosis with prostaglandins
What are the 4 characteristics of tetralogy of Fallot?
- Hole between ventricles; 2. Obstruction from heart to lungs; 3. Aorta lies over hole in lower chambers; 4. Thickened RV muscle
In the first week of life, what is the most common cause of cardiac cyanosis?
Destra-transposition of the great arteries
What does levocardia mean?
Heart is on the normal side of body (left)
What syndrome is characterized by elfin faces; endocrine abnormalities (hypercalcemia & hypothyroid); MR; growth deficiency; muscle weakness
William’s Syndrome
What is the #1 cause of cardiac arrest in perioperative cardiac arrest registry?
William’s Syndrome
Which 2 congenital disorders are associated with Aortic coarctation?
William’s Syndrome and Turner’s syndrome
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
Which disease is associated with aortic dissection at any size?
Marfan Syndrome
Which disease is a mutation of the fibrillation gene (connective tissue)
Marfan syndrome
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
What is Turner syndrome’s physical characteristics?
webbed neck; low set ears; short stature; pigmented moles; obesity; micrognathia
What is Noonan syndrome characterized by physically?
Neck webbing, low set ears, chest deformities, short
Which discussed disease is associated with bleeding diathesis?
Hypocoagubility - Noonan syndrome
What cardiac considerations are there for Kawasaki disease?
Coronary artery dilation; aneurysm formation; MI
What is VATER association? What anesthetic considerations?
VACTERL = Vertebral; Anal; Cardio; TrachEosophageal; Renal; Limb defects — difficult to intubate & vascular access
What does CHARGE stand for? What heart defects?
Coloboma; Heart defects; choAnal; Retardation ; Growth/Genitourinary; Ears — conotruncal & arch abnormalities — upper airway abnormalities
Hct > _______% impairs microvascular perfusion
65
R —> L shunt results in ?
Desaturation & will increase when SVR decreases or PVR increases
L—>R shunt will cause?
Substantial steal of systemic blood flow to pulmonary circulation
What are the following S&S indicative of? Failure to thrive; difficulty feeding; breathlessness; tachycardia; recurrent chest infections?
CHF
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
What 2 congenital defects is tetralogy of Fallot associated with?
Trisomy 21 & DiGeorge
What is the preferred treatment for congenital dislocation of hip?
Pavlick harness — other option is fluro guided reduction & Spica casting
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
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)
What should be known about pts with osteogenesis Imperfecta prior to sx?
How brittle they are
What are 2 anesthetic concern of the osteogenesis imperfecta pt?
DO NOT USE SUCCS - can cause dx; and these pts are hypermetabolic, NOT MH
Which group of common orthopedic sx pts are prone to seizures? And have problems with Laryngeal & pharyngeal reflexes (GERD)?
Cerebral palsy
If a cerebral palsy pt is to have surgery, should they continue taking their seizure medications?
YES
What anesthetic concern is there with pts who take phenobarbital?
Hepatic enzyme inducer (will metabolize drugs faster)
What is the concern of pt’s that take Dantrolene for anti-spasticity?
Inhibits release of Ca++ from SR
How does Baclofen work?
Inhibits excitatory neurotransmitters (skeletal muscle relaxant)
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
What are 2 anesthetic concerns of pts with any degree of spina bifida?
Avoid pressure to the sac; avoid NDNMBs initially (neurometric monitoring)
What age group is scoliosis most common in?
> 10 years
What organ systems are affected by scoliosis?
Lungs and chest wall compliance; increased PVR
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
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
Which is more common, gastrochisis or omphalocele?
Omphalocele
Which involves the umbilical cord, gastroschisis or omphalocele
Omphalocele
Which is typically more detrimental to the bowel, gastroschisis or omphalocele?
Gastroschisis - no sac = bowel is matted, thick & edematous
Which has a higher incidence of other anomolies, gastroschisis or omphalocele?
Omphalocele
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
What is special about monitor placement for gastroschisis and omphalocele sx?
2 pulse oximeter, pre & post ductal (right arm & left foot)
What inhaled agent should be avoided in MOST GI surgeries?
Nitrous
Most GI surgeries INDUCTIONS should involve??
RSI intubation - consider a full stomach
What is he triad of symptomsfor congenital diaphragmatic hernia?
Dyspnea; cyanosis; apparent dextrocardia
T/F muscle relaxant with TIVA or IH induction are good anesthetic plans for CDH?
True
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
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+)
Pyloric stenosis is what kind of emergency?
Medical, NOT surgical
What is the primary concern with pyloric stenosis?
Aspiration of gastric fluid - suction at least 3 x & RSI intubation
Which GI sx is nitrous oxide ok to use?
Pyloric stenosis
What medications should be avoided with pyloric stenosis?
NO NARCOTICS
What is the most common esophageal anomaly? What is it associated with?
Transesophageal Fistula; associated with VACTERL
What are the goal for intubation with transesophageal intubation?
ETT above carina, below fistula; consider awake intubation; try to avoid PPV; avoid Nitrous oxide
After transesophageal sx what is a major concern?
Do not put tension on anastomoses - limit head movement and be cautious with suctioning
What is the goal of hypoplastic left heart surgery?
RV becomes single ventricle & pulmonary blood flow is PASSIVELY supplied by the SVC & IVC
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%
What is key to manage well with hypoplastic left heart pts?
Keep PVR LOW - CO is dependent on adequate preload and LOW PVR
What heart medication is excellent to use in sick neonatal hearts?
Milrinone
What is the most common type of TE fistula?
IIIB
In a pt with CDH what should the PIP be?
30
How does a normal, healthy infant’s CO compare to an adults?
Infants is 2-3 times greater
What is normal hgb of full term neonate?
18-20 g/dL
What must infant be able to do in order to inflate lungs?
Generate a high negative pressure of -70 cmH2O
Once a premie, always a _______; what does this mean for airway?
Premie - means they are always prone to laryngospasm
In an uncooperative induction, what is ALWAYS the first monitor placed?
Pulse oximeter, then EKG, then BP
Where is the pediatric larynx located?
C3-C4
What is the narrowest portion of the pediatric airway?
Cricoid cartilage - airway is funnel-shaped
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
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
What does a pt with scoliosis > 25 degrees require?
An echo to check for cardiac involvement?
What does a pt with scoliosis > 40 degrees require?
Surgical intervention
What does a pt with scoliosis > 65 degrees indicate?
Restrictive lung disease
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
What is the dose of succinylcholine for laryngospasm?
Succs concentration is 20 mg/ml
4 mg/kg IM
0.4 mg/kg IV
Why is IV induction advantageous for children?
Children go to sleep without going through stage 2 —> Decreased r/o laryngospasm
What is the most common reason for bradycardia in a child?
Hypoxia
What are the NPO guidelines for pediatrics?
2 hours clears
4 hours breast milk
6 hours formula
8 hours solid food
What can cold stress lead to respiratory wise for infants?
Decreased surfactant —> alveoli collapse —> reopening of fetal circulation
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
Hypotension in a child should be recognized as a??
LATE sign of hypovolemia & hemorrhage
Hypotension in a pediatric trauma indicates what % loss of blood volume?
25% ~ 20 ml/kg
Brady cardia in a pediatric trauma indcates?
40% loss f blood volume — hypoxemia & impending arrest or increased ICP
What is included in primary survey of pediatric trauma?
ABCDE’s - Airway; Breathing; Circulation/CPR; Disability; Expose
What is the #1 cause of death in those 1-19 years of age?
Trauma
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
What is different about infant breathing until about 3 to 5 months of age?
Obligate nasal breathers
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
What is the peak day for delayed post-tonsillectomy bleeding?
Day 7
