High Yield Pediatric Anesthesia Review Flashcards
1
Q
What is unique with the pediatric CO?
A
Heart rate dependent CO
2
Q
Chest wall compliance in pediatric?
A
Greater chest wall compliance
3
Q
What is the body water content in pediatric
A
Higher Total body water content
4
Q
In pediatric patient ratio of BSA to body weight
A
Increase BSA to body weight
5
Q
Nasal passages of the pediatric is
A
Narrower
6
Q
Risk of morbidity in pediatric anesthesia is
A
INVERSELY Proportional to age
7
Q
Lung volume changes in pediatric
A
Reduce FRC, reduced lung compliance
8
Q
HR, BP and RR in the pediatric patients
A
Increase HR
REDUCED BP
Increased RR
9
Q
How is the LV in the pediatric patient?
A
Noncompliant LV
10
Q
Resistance to airflow is greater or lower in the pediatric patient?
A
Greater
11
Q
Epiglottis in the pediatric patients
A
Longer
12
Q
Head and tongue in the pediatric patients?
A
Larger head and tongue
13
Q
Cannulation of IV in the pediatric patients is
A
Difficult for both venous and arterial
14
Q
Larynx in the pediatric patients 2 characteristics?
A
Anterior and cephalad
15
Q
Trachea and neck of the pediatric patients
A
Shorter trachea and neck
16
Q
Protein binding for pediatric patients
A
Decreased protein binding for drug binding in blood
17
Q
Induction and recovery in the pediatric patients?
A
More rapid induction and recovery from inhaled anesthetics.
18
Q
MAC in pediatric patients is
A
Increased
19
Q
Volume of distribution for water soluble drugs in pediatric patients?
A
RELATIVELY LARGER VOLUME OF DISTRIBUTION for water soluble drugs
20
Q
NMJ for Pediatric patients
A
Immature NMJ
21
Q
Hepatic bio-transformation for the pediatric patients?
A
Immature liver/hepatic biotransformation
22
Q
0-1 months is a
A
Neonate
23
Q
1-12 months is a
A
infant
24
Q
12-24 months is a
A
toddler
25
2 -12 years is a
Young children
26
Neonate and infants ventilate (more/less) efficiently and why?
Less efficiently and thats because their ribs are more horizontal and they have BIG ABDOMEN (protuberant )
27
Airways of pediatric are ________
fewer and smaller
28
Alveoli are ______ in pediatric leading to e ______Lung compliance; ______airway resistance and ______ WOB
Fewer; Reduced lung complaince,
| Increased airway resistance and increased WOB
29
Cartilaginous ribcage in pediatric does what to chest wall compliance ?
Increase chest wall compliance that promotes collapse during inspiration and a LOW RV at expiration.
30
LOW RV predispose what in pediatric patients?
Limited O2 reserve during apneic episodes
| Predispose them to hypoxemia and ATELECTASIS
31
2 things that can both cause depression in respiration in PEDIATRIC ?
Hypoxia and HYPERCAPNIA
32
RR is ______ in neonates and reach adult values by ______
INCREASED
| ADOLESCENT (it decreases)
33
2 VALUES that remains constant THROUGHOUT DEVELOPMENT?
TV and DEAD space per KG
34
GLOTTIS for Neonates and infants is at
C4
35
Narrowest point of the airway in children younger than 5
Cricoid cartilate
36
Narrowest point of the airway in ADULTS
Glottis
37
CO is very sensitive to changes in ______for the pediatric patient?
HR
38
3 major things that can trigger bradycardia and profound reduction in CO?
Activation of PNS
Anesthetic overdose
Hypoxia
39
Bradycardia in the pediatric patients lead to
Hypotension
Asystole
Intraoperative death.
40
2 immature in the infants causing more prone to adverse events
SNS and baroreceptor reflexes are immature.
41
PEDIATRIC RESPONSE To exogenous catecholamies
Blunted response to exogenous catecholamines.
42
Pediatric heart and VA
Immature heart more sensitive to depression by VA and to opioid-induced bradycardia.
43
VASCULAR TREE is less able to ______In pediatric patients
Less able to respond to hypovolemia with compensatory vasoconstriction.
44
Intravascular volume depletion in neonates and infants may manifest as
Hypotension without tachycardia.
45
Normal BP for 12 months old`
95/65
46
Normal BP for 3yo
100/70
47
Normal BP for 12 years
110/60
48
Neonate BP
65/40
49
RR normal in neonate
40
50
RR normal in 12 months old
30
51
RR normal in 3 years old
25
52
Pediatric kidney function approaches to normal by
6 months to as late as 2 years old
53
Premature neonates renal problems include
```
decrease CrCl
Impaired sodium retention
Impaired glucose excretion
Impaired bicarb reabsorption
Reducing dilution and concentrating ability
```
54
Neonates and GI problems
Increase incidence of GERD
55
Neonate conjugation
Liver conjugates drugs and other molecules.
56
What predispose neonates to hypoglycemia?
They have REDUCED glycogen stores.
57
Neonates are more predisposed to hypoglycemia because they have a reduced glycogen stores, what can offset this tendency?
Their IMPAIRED GLUCOSE EXCRETION
58
What are the neonates at the greatest risk for HYPOGLYCeMIA>?
PREMATURE
Small for gestational age
Receiving hyperalimentation
Born to mothers with diabetes.
59
Pediatric pt weight calculation based on age
(Agex2) + 9
60
Neonates TBW vs ADULT
70-75% vs 50-60%
61
Vd for most IV drugs for neonates, infants and young children is
DISPROPORTIONATELY GREATER
62
What prolongs drug duration of action for neonates? 2 examples
Decreased muscle mass prolongs some drugs duration of action by delaying redistribution to muscle.
Fentany, THIOPENTAL
63
Neonate, infants and young children have a _________ alveolar ventilation and ________ FRC compared with aldults
Greater ; reduced
64
Minute Ventilation-to-FRC ratio in children?
GREATER
65
The greater minute ventilation to FRC ratio in children leads to what kind of changes?
Greater blood flow to vessel-rich organ contributes to a rapid increase in ALVEOLAR ANESTHETIC CONCENTRATION and SPEED INHALATION INDUCTION
66
What is responsible for the rapid increase in alveolar anesthetic concentration and speed of induction seen in PEDIATRIC patients?
The Greater Minute ventilation to FRC ratio is responsible .
67
MAC of halogenated agents adults vs neonate
Greater in infants than adults.
68
BP sensitivity and VA in neonates
Neonates and infants are more sensitive to volatile agents because of immature compensatory mechanisms and GREATER sensitivity of the neonate and infant myocardium to myocardial depressants.
69
Emergence delirium is faster after use of
Sevoflurane
70
Some clinicians switch to ISOFLURANE after induction with SEVOFLURANE, why?
Agitation and delirium upon emergence seen with sevoflurane.
71
Preferred agent for inhaled induction in pediatric anesthesia
Sevoflurane
72
Why do children require larger doses of propofol?
Because of a larger volume of distribution compared with adults.
73
Propofol elimination half life and plasma clerance for children?
Shorter elimination half life , HIGHER Plasma clearance.
74
Propofol in critically ill patients?
Propofol is not recommended for prolonged sedation in critically ill patients because of an association with GREATER mortality than other agents.
75
What is more common in children than adults with propofol>
PROPOFOL infusion syndrome
76
PROPOFOL INFUSION SYNDROME symptoms ae
```
Rhabdomyolysis
Metabolic acidosis
Hemodynamic instability
Hepatomegaly
Multiorgan failure.
```
77
Morphine sulfate , particularly in repeated doses in neonates?
Use in caution because HEPATIC conjugation is reduced and renal clearance of morphine metabolites is decreased.
78
Clearance of opioids in children
Sufentanil, Alfentanil, remifentanil, and fentanyl clerance may be greater in children
79
Ketamine and neonates
Higher doses than adults
80
Midazolam clearance and neonates
Reduces in neonates compared with older children.
81
Onset of Muscle relaxants in pediatric patients
Faster onset because of SHORTER circulation times.
82
Fastest onset MR for both adults and children
Succinylcholine 1-1.5mg/kg
83
Infants and doses of succinylcholine
Require larger doses of succinylcholine -3 mg/kg because of the LARGER VOLUME OF DISTRIBUTION.
84
Exclusion of succinylcholine and possibly cisatracurium, infants require
Significant smaller muscle relaxant doses than older children.
85
Rapid intubation can be achieved with a dose that _____the ED95
Twice
86
Why do you see a variable response to ND MR with neonates?
Because of an immature NMJ, tending to increase sensitivity (not yet proven) and a LARGE Extracellular compartment reducing drug concentration.
87
Duration of action of NDNMB in pediatric is _____Why>
Prolonged; because of immature neonatal hepatic function.
88
Infant ED 95 for succinylcholine (mg/kg)
0.7
89
Infant ED95 for cisatracurium
0.05
90
Infant ED95 for rocuronium
0.25
91
Infant ED95 for vecuronium
0.05
92
Pancuronium infant ED 95
0.07
93
Pancuronium child ED95
0.09
94
Child ED95 for vecuronium
0.08
95
Child ED95 For Rocuronium
0.4
96
When a child experiences cardiac arrest after succinylcholine administration, Immediate treatment for ____should be instituted
Hyperkalemia
97
Succinylcholine and children
Succinylcholine routinely avoided
98
Why is succinylcholine avoided in children?
Because of undiagnosed muscular dystrophy
99
Children getting succinylcholine should
Children may have profound bradycardia, and sinus node arrest after the first dose of succinylcholine without atropine pre-treatment.
100
Indications for succinylcholine in a child is only if
Full stomach and laryngospasm that does not respond to PPV
101
Succinylcholine may be used for rapid muscle relaxation before IV access,(with inhaled inudction in patients with full stomachs") IM dose is
4-6 mg/kg
102
Atropine dosing for administering IM succinylcholine ____why?
0.02 mg/kg ; to reduce the likelihood of bradycardia.
103
Drug of choice for routine intubation in the pediatric patients and why?
rocuronium 0.6 mg/kg; because it has the fastest onset of NDNMB agents.
104
Larger doses of rocuronium and implications
Larger doses of rocuronium 0.9-1.2 mg/kg may be used for RSI but a prolonged duration (up to 90 min) may follow.
105
What is the only NMBA that has been adequately studied for IM administration
Rocuronium 1- 1.5 mg/kg requires 3-4 min to onset
106
Young infants, particularly in short procedures, because these drugs consistently display short to intermediate duration , NMB agents
Atracurium and Cisatracurium
107
Peri-operative Risk of cardiac arrest for pediatric is
1.4 in 10000
108
Peri-operative Risk of cardiac arrest for pediatric, OVERALL mortality is
26%
109
33% of pediatric patients who had a cardiac arrest had ASA PS
1-2
110
Greatest risk of anesthesia-related arrests ____% Who is at the greatest risk?
Infants 55%
| younger than 1 month greatest risk
111
Most cardiac arrest with pediatric occurred during
Induction of anesthesia
112
3 things that preceded arrests with Pediatric patients?
Bradycardia
Hypotension
Low SPO2
113
Most common mechanism of cardiac arrest in pediatric is
Drug (medication) related
114
When a CV mechanism could be identified in pediatric patients , it was most often related to
Hemorrhage
Transfusion
Inappropriate fluid therapy.
115
Respiratory mechanism for pediatric included : (leading to adverse outcomes)
1. Laryngospasm
2. Airway obstruction
3. Difficult intubation
116
Equipment-related mechanism with pediatric most common
Attempt with CVC insertion including pneumo, hemothorax, and cardiac tamponade.
117
What place a child at an increased risk for perioperative PULMONARY complications
A viral infection 2- 4 weeks before GA.
118
Pulmonary complications common with pediatric
Wheezing
Laryngospasm
Hypoxemia
Atelectasis
119
Murmur in children and implications
Innocent murmurs may occur in about 30% of normal children.
120
Pediatric are more prone to
Dehydration
121
Breast milk up to ___before induction
4h
122
Light meal up to ___before induction
6-8h
123
Clear fluid up to ___before induction
2-3h
124
Children with uncontrollable separation anxiety, should be given a sedative such as
midazolam 0.3-0.5 mg/kg
125
Maximum midazolam for pediatric
15 mg
126
Preferred midazolam route for pediatric is
Oral
127
What is given orally,IM OR rectally to decrease the likelihood of bradycardia during induction?
Atropine , 0.05mg/kg rectally or IM, orally
128
Give atropine when?
During induction, or shortly after
129
Provide an inexpensive means to monitoring heart rate , heart sounds and airway patency
PRECORDIAL STETHOSCOPE
130
Neonate, where should the Pulse oximeter probe be placed
RIGHT HAND or EARLOBE to measure preductal oxygen saturation
131
FLOW THROUGH analyzers are usually
Less accurate in patients weighing less than 10 kg
132
CO2 and pediatric patients
Inspired CO2 can appear falsely elevated, and the expired CO2 can be falsely low.
133
Temperature monitoring and pediatric patients
Greater risk for malignant hyperthermia and intraoperative hypothermia and hyperthermia
134
Risk of hypothermia is prevented how in the pediatric patients?
Maintain a warm OR environment 26C or higher, warming and humidifying inspired gases, using a warm blanket and warming lights, and warming all IV fluids.
135
Best arterial cannulation for neonates and why?
RIGHT RADIAL artery , because its preductal location mirrors the OXYGEN CONTENT of the carotid and retinal arteries
136
Critically ill neonates may retain an
Umbilication artery catheter
137
What is an important indicator of the adequacy of intravascular volume and CO? In pediatrics
Urine output
138
What pediatric population is more prone to Hypoglycemia?
Premature
SMALL FOR Gestational age
Neonates receiving hyperalimentation
Mother with diabetes
139
GA is usually induced by what ways in pediatric?
IV or inhalational
140
IM ketamine and pediatric
Reserved for combative children
141
Preferred when the patient comes to the OR (Pediatric)
IV induction
142
When is awake/sedated awake intubation with topical anesthesia indicated ?
Emergency procedures in neonates and small infant and they are critically ill or a potential difficult airway is present.
143
IV induction sequence for pediatric
Same, propofol, NDNMB (if giving succinylcholine, ATROPINE MUST BE GIVEN)
144
Inhlational induction -->Explain steps
If without IV, mixture of N2O (70%) and O2 (30%). Sevoflurane can be added to the anesthetic gas mixture in 0.5% increments. After adequate depth of anesthesia, an IV Line is placed and a muscle relaxant is administered to facilitate intubation. Pts typically pass through an excitement stage during which any stimulation can induce LARYNGOSPASM> Steady application of 10 cm of PEEP will usually overcome laryngospasm.
145
Inhalation induction what can overcome laryngospasm?
10cm of PEEP
