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Pediatric Anesthesia > Final Review > Flashcards

Final Review Flashcards

1
Q

What is a pre-term infant’s gestational age?

A

< 37 weeks gestation

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2
Q

What gestational age can a premie survive outside the womb?

A

24 weeks

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3
Q

How does fetal hgb affect the oxyhemoglobin dissociation curve?

A

Shifts it left = “loves oxygen”

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4
Q

Adaptation from fetal to infant breathing is found do be dependent on?

A

“Guppy breathing” intern & the diaphragm

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5
Q

What is the primary event of fetal respiratory transition?

A

Initiation of ventilation

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6
Q

Neonates are prone to lung collapse, how is this counteracted in anesthesia?

A

Addition of 5 cmH20 or PEEP

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7
Q

What 2 things are the initial hyperpneic response abolished by?

A

Hypothermia & low levels of anesthetic gas

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8
Q

What is the lowest acceptable hematocrit for a newborn or infant?

A

35

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9
Q

Non-shivering thermogenesis is caused by? (2)

A

Cold & stress

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10
Q

What does hypoxia cause in infants?

A

Profound bradycardia & decreased response to hypercarbia

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11
Q

T/F infants have an increased oxygen consumption?

A

True (6 mL/kg)

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12
Q

What are the 3 shunts of fetal circulation?

A

Ductus venosis, ductus arteriosus & foramen ovale

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13
Q

PVR is _______ & SVR is _______ in fetal circulation

A

PVR is high; SVR is low

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14
Q

What leads to reversal of fetal circulation shunts?

A
  1. Cutting umbilical cord (increases SVR) & 2. Onset of breathing (decreases PVR)
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15
Q

What is persistent hypertension of newborn (PPHN)?

A

Persistence of fetal shunting beyond normal transition period & absence of structural heart defects

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16
Q

What are 2 main causes of PPHN?

A

Hypoxia & acidosis

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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)

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18
Q

What is the treatment of PPHN?

A

ADEQUATE VENTILATION - hyperventilate; pulmonary vasodilation (prostaglandins); minimal handling & stress

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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

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20
Q

What is urine sodium of a neonate vs. an adult?

A

Neonate = 20-25 mEq; adult = 5-10 mEq

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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

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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

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23
Q

What is the # 1 way heat loss occurs?

A

Through radiation

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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

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25
Q

What are the top 3 congenital heart disease?

A
  1. Bicuspid aortic valve; 2. VSD; 3. ASD
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26
Q

What does preferential streaming in fetal circulation do?

A

Makes more oxygenated blood available to the brain and body, not lungs

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27
Q

Do infants have the ability to increase CO? Why or why not?

A

Limited ability; no change in SV; limited ability to increase HR due to an incomplete sympathetic nervous system & decreased ventricular compliance

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28
Q

What are normal infant VS?

A

HR = 120-160; RR = 30-60; premie BP = 50/25; neonate BP = 70/40

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29
Q

What is the most common ASD?

A

Secundum ASD - mostly asymptomatic

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30
Q

What is the most common VSD?

A

Perimembranous - treated if large/symptomatic; small use prophylactic antibiotics

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31
Q

What birth defect are AVSD’s most common in?

A

Trisomy 21 -

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32
Q

Which septal defect ALWAYS needs treated?

A

AVSD

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33
Q

What are 2 classic signs of aortic aoarctation?

A
  1. Decreased or absent femoral pulse; 2. Hypertension in upper extremities
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34
Q

In the event of aortic coarctation what should be maintained?

A

Ductus arteriosis with prostaglandins

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35
Q

What are the 4 characteristics of tetralogy of Fallot?

A
  1. Hole between ventricles; 2. Obstruction from heart to lungs; 3. Aorta lies over hole in lower chambers; 4. Thickened RV muscle
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36
Q

In the first week of life, what is the most common cause of cardiac cyanosis?

A

Destra-transposition of the great arteries

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37
Q

What does levocardia mean?

A

Heart is on the normal side of body (left)

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38
Q

What syndrome is characterized by elfin faces; endocrine abnormalities (hypercalcemia & hypothyroid); MR; growth deficiency; muscle weakness

A

William’s Syndrome

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39
Q

What is the #1 cause of cardiac arrest in perioperative cardiac arrest registry?

A

William’s Syndrome

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40
Q

Which 2 congenital disorders are associated with Aortic coarctation?

A

William’s Syndrome and Turner’s syndrome

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41
Q

What is the most important thing to consider regarding anesthesia and Trisomy 21?

A

They are very sensitive to volatile anesthetics & will become bradycardic quickly - ATROPINE

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42
Q

Which disease is associated with aortic dissection at any size?

A

Marfan Syndrome

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43
Q

Which disease is a mutation of the fibrillation gene (connective tissue)

A

Marfan syndrome

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44
Q

What is DiGeorge/Velocardiofacial syndrome also known as? What are the cardiac considerations?

A

CATCH 22 (deletion of 22q11.2 deletion syndrome) - conotruncal abnormalities & outflow tract problems —> also has immunodeficiency that requires irradiated blood products

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45
Q

What is Turner syndrome’s physical characteristics?

A

webbed neck; low set ears; short stature; pigmented moles; obesity; micrognathia

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46
Q

What is Noonan syndrome characterized by physically?

A

Neck webbing, low set ears, chest deformities, short

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47
Q

Which discussed disease is associated with bleeding diathesis?

A

Hypocoagubility - Noonan syndrome

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48
Q

What cardiac considerations are there for Kawasaki disease?

A

Coronary artery dilation; aneurysm formation; MI

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49
Q

What is VATER association? What anesthetic considerations?

A

VACTERL = Vertebral; Anal; Cardio; TrachEosophageal; Renal; Limb defects — difficult to intubate & vascular access

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50
Q

What does CHARGE stand for? What heart defects?

A

Coloboma; Heart defects; choAnal; Retardation ; Growth/Genitourinary; Ears — conotruncal & arch abnormalities — upper airway abnormalities

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51
Q

Hct > _______% impairs microvascular perfusion

A

65

52
Q

R —> L shunt results in ?

A

Desaturation & will increase when SVR decreases or PVR increases

53
Q

L—>R shunt will cause?

A

Substantial steal of systemic blood flow to pulmonary circulation

54
Q

What are the following S&S indicative of? Failure to thrive; difficulty feeding; breathlessness; tachycardia; recurrent chest infections?

A

CHF

55
Q

What special monitoring needs done for PDA corrections?

A

2 pulse ox - one on right hand & one on lower limb —> loss of pulse ox during test clamp may indicate clamped aorta

56
Q

What 2 congenital defects is tetralogy of Fallot associated with?

A

Trisomy 21 & DiGeorge

57
Q

What is the preferred treatment for congenital dislocation of hip?

A

Pavlick harness — other option is fluro guided reduction & Spica casting

58
Q

What are 2 concerns for anesthetic management of congenital dislocation of hip sx? Which is the greatest?

A

Greatest is LOSS OF AIR WAY; the other is if LMA is used, to keep pt in deep stage III to prevent laryngospasm

59
Q

What is one of the greatest anesthetic concern for congenital clubfoot sx?

A

Intraoperative glucose monitoring& glucose containing solution because of the age of these pts (3-6 months)

60
Q

What should be known about pts with osteogenesis Imperfecta prior to sx?

A

How brittle they are

61
Q

What are 2 anesthetic concern of the osteogenesis imperfecta pt?

A

DO NOT USE SUCCS - can cause dx; and these pts are hypermetabolic, NOT MH

62
Q

Which group of common orthopedic sx pts are prone to seizures? And have problems with Laryngeal & pharyngeal reflexes (GERD)?

A

Cerebral palsy

63
Q

If a cerebral palsy pt is to have surgery, should they continue taking their seizure medications?

A

YES

64
Q

What anesthetic concern is there with pts who take phenobarbital?

A

Hepatic enzyme inducer (will metabolize drugs faster)

65
Q

What is the concern of pt’s that take Dantrolene for anti-spasticity?

A

Inhibits release of Ca++ from SR

66
Q

How does Baclofen work?

A

Inhibits excitatory neurotransmitters (skeletal muscle relaxant)

67
Q

How does spina bifida; meningococcal; and myelomeningocele differ?

A

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
Q

What are 2 anesthetic concerns of pts with any degree of spina bifida?

A

Avoid pressure to the sac; avoid NDNMBs initially (neurometric monitoring)

69
Q

What age group is scoliosis most common in?

A

> 10 years

70
Q

What organ systems are affected by scoliosis?

A

Lungs and chest wall compliance; increased PVR

71
Q

What anesthetic plan is the best choice for pt’s with scoliosis? Why?

A

TIVA - SSEPs monitored; IH agent kept at 0.5-1.0 MAC if used

72
Q

What is the main anesthetic concern for scoliosis surgery?

A

BLOOD loss exceeds 25 mL/kg - DO NOT DO THESE CASES WITHOUT BLOOD IN THE ROOM; hourly H&H

73
Q

Which is more common, gastrochisis or omphalocele?

A

Omphalocele

74
Q

Which involves the umbilical cord, gastroschisis or omphalocele

A

Omphalocele

75
Q

Which is typically more detrimental to the bowel, gastroschisis or omphalocele?

A

Gastroschisis - no sac = bowel is matted, thick & edematous

76
Q

Which has a higher incidence of other anomolies, gastroschisis or omphalocele?

A

Omphalocele

77
Q

What 2 different types of surgeries can be used to repair gastroschisis or omphalocele?

A

Primary closure or staged with the use of a silo/mesh chimney

78
Q

What is special about monitor placement for gastroschisis and omphalocele sx?

A

2 pulse oximeter, pre & post ductal (right arm & left foot)

79
Q

What inhaled agent should be avoided in MOST GI surgeries?

A

Nitrous

80
Q

Most GI surgeries INDUCTIONS should involve??

A

RSI intubation - consider a full stomach

81
Q

What is he triad of symptomsfor congenital diaphragmatic hernia?

A

Dyspnea; cyanosis; apparent dextrocardia

82
Q

T/F muscle relaxant with TIVA or IH induction are good anesthetic plans for CDH?

A

True

83
Q

What are some respiratory management considerations for pts with CDH?

A

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
Q

What are the clinical presentations of pyloric stenosis?

A

Nonbilious vomiting; dehydration; palpation of olive-sized mass in upper abdomen; metabolic alkalosis (decreased Na+, Cl-, H+)

85
Q

Pyloric stenosis is what kind of emergency?

A

Medical, NOT surgical

86
Q

What is the primary concern with pyloric stenosis?

A

Aspiration of gastric fluid - suction at least 3 x & RSI intubation

87
Q

Which GI sx is nitrous oxide ok to use?

A

Pyloric stenosis

88
Q

What medications should be avoided with pyloric stenosis?

A

NO NARCOTICS

89
Q

What is the most common esophageal anomaly? What is it associated with?

A

Transesophageal Fistula; associated with VACTERL

90
Q

What are the goal for intubation with transesophageal intubation?

A

ETT above carina, below fistula; consider awake intubation; try to avoid PPV; avoid Nitrous oxide

91
Q

After transesophageal sx what is a major concern?

A

Do not put tension on anastomoses - limit head movement and be cautious with suctioning

92
Q

What is the goal of hypoplastic left heart surgery?

A

RV becomes single ventricle & pulmonary blood flow is PASSIVELY supplied by the SVC & IVC

93
Q

What are the 3 stages of hypoplastic left heart repair? What O2 saturation is associated with each stage?

A

Norwood stage 1 - 75%
Norwood stage 2 - 85%
Norwood stage 3 - 95%

94
Q

What is key to manage well with hypoplastic left heart pts?

A

Keep PVR LOW - CO is dependent on adequate preload and LOW PVR

95
Q

What heart medication is excellent to use in sick neonatal hearts?

A

Milrinone

96
Q

What is the most common type of TE fistula?

A

IIIB

97
Q

In a pt with CDH what should the PIP be?

A

30

98
Q

How does a normal, healthy infant’s CO compare to an adults?

A

Infants is 2-3 times greater

99
Q

What is normal hgb of full term neonate?

A

18-20 g/dL

100
Q

What must infant be able to do in order to inflate lungs?

A

Generate a high negative pressure of -70 cmH2O

101
Q

Once a premie, always a _______; what does this mean for airway?

A

Premie - means they are always prone to laryngospasm

102
Q

In an uncooperative induction, what is ALWAYS the first monitor placed?

A

Pulse oximeter, then EKG, then BP

103
Q

Where is the pediatric larynx located?

A

C3-C4

104
Q

What is the narrowest portion of the pediatric airway?

A

Cricoid cartilage - airway is funnel-shaped

105
Q

Length of trachea up to 1 year of age is??? What does this mean for ETT tube?

A

5-9 cm - DO NOT BURY ETT tube

106
Q

What parameters are unsafe for primary closure of gastroschisis or omphalocele?

A

Intragastric pressures > 20 mmHg; Chang in CVP > 4 mmHg; EtCO2 > 50 mmHg; or PIP > 35 mmHg

107
Q

What does a pt with scoliosis > 25 degrees require?

A

An echo to check for cardiac involvement?

108
Q

What does a pt with scoliosis > 40 degrees require?

A

Surgical intervention

109
Q

What does a pt with scoliosis > 65 degrees indicate?

A

Restrictive lung disease

110
Q

How do you calculate ETT for peds? How do you know proper size once intubated?

A

(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
Q

What is the dose of succinylcholine for laryngospasm?

A

Succs concentration is 20 mg/ml
4 mg/kg IM
0.4 mg/kg IV

112
Q

Why is IV induction advantageous for children?

A

Children go to sleep without going through stage 2 —> Decreased r/o laryngospasm

113
Q

What is the most common reason for bradycardia in a child?

A

Hypoxia

114
Q

What are the NPO guidelines for pediatrics?

A

2 hours clears
4 hours breast milk
6 hours formula
8 hours solid food

115
Q

What can cold stress lead to respiratory wise for infants?

A

Decreased surfactant —> alveoli collapse —> reopening of fetal circulation

116
Q

In a pediatric trauma, what is tachycardia an early sign of?

A

CV compromise and impending shock - generally indicates at least 10% loss of circulating blood volume

117
Q

Hypotension in a child should be recognized as a??

A

LATE sign of hypovolemia & hemorrhage

118
Q

Hypotension in a pediatric trauma indicates what % loss of blood volume?

A

25% ~ 20 ml/kg

119
Q

Brady cardia in a pediatric trauma indcates?

A

40% loss f blood volume — hypoxemia & impending arrest or increased ICP

120
Q

What is included in primary survey of pediatric trauma?

A

ABCDE’s - Airway; Breathing; Circulation/CPR; Disability; Expose

121
Q

What is the #1 cause of death in those 1-19 years of age?

A

Trauma

122
Q

What kind of children is codeine essentially inactive? What is the other end of the spectrum?

A

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
Q

What is different about infant breathing until about 3 to 5 months of age?

A

Obligate nasal breathers

124
Q

Any time you are incubating a pt with concern for obstructed airway (foreign object, eppiglottitis) what special consideration should be taken?

A

Make sure they maintain spontaneous respirations

125
Q

What is the peak day for delayed post-tonsillectomy bleeding?

A

Day 7

Pediatric Anesthesia (1 decks)

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