ITE Peds 1 Flashcards
Preterm Infants who ingest cow milk (not formula or breast) before the age of ____ are at increased risk of _____.
12 months
Iron deficiency anemia
*infants age 6 mo - 3 yrs have high iron requirements d/t increased growth
Progress for treatment of iron deficiency can be tracked with ______
reticulocyte count
If a pt has a patent ductus arteriosus (PDA) and low pulmonary vascular resistance, blood will preferentially travel to the ____, and overtime, result in ______
lungs
- large diastolic run off from aorta to pulmonary artery
Congestive heart failure
Blood enters the fetus via the ______, then passes ____, unless it bypasses it via the _____ to the IVC
single umbilical vein
through the liver
ductus venosus
In the fetus, pulmonary vascular resistance is (higher/lower) than systemic vascular resistance.
higher
- very small fraction of blood flow enters the pulmonary tree, and majority enters the aorta via ductus arteriosus
Both the ________ and _______ are present in the fetus to shunt blood systemically away from the pulmonary bed since the lungs serve no major function.
Ductus arteriosus (PDA) and foramen ovale
_____% of adults have a patent foramen ovale
25-30%
- Decrease in PVR
- Increase in SVR
- Increase in PaO2 > 50 mmHg
- Normocarbia
All result in (Opening/Closure) of the ductus arteriosus
Closure
- PaO2 >50 mmHg causes arterial sm of the ductus to contract)
Indomethacin is a ______ inhibitor and therefore inhibit prostaglandin synthesis.
nonselective cyclooxygenase (COX) inhibitor
In certain cyanotic heart lesions, ________ can help keep PDA open for survival and prevent hypoxemia
PGE1, alprostadil
Examples of cyanotic heart lesions leading to impaired pulmonary blood flow
- Pulmonary atresia
- Critical pulmonary stenosis
- Transposition of the great arteries
- Severe subpulmonic stenosis with VSD
- TOF
These are special and require__________
keep PDA open with PGE1 for survival and prevent hypoxemia
Congenital heart disease pearl:
What does not see flow, will not grow
- inadequate or absent blood flow = impaired growth of heart structures
Physiological anemia of the newborn typically occurs at age ____ at a value of ___ g/dL.
8-12 weeks of age
11 g/dL
Does not require treatment!
Anemia occuring at 4-8 weeks of age is most likely d/t _______
anemia of prematurity or hemolytic anemias
Anemia occuring at 12-16 weeks of age is most likely _______
not physiologic and needs to be further evaluated.
Spinal anesthesia (subsarachnoid space) in infants. - How is the onset of action and duration of action different?
More rapid onset
Shorter duration of action
d/t higher Cardiac output, highly vascular pia matter, and loose myelination that provides little barrier for drug diffusion across spinal cord
How does the intrathecal space and CSF pressure differ in infants vs adults?
narrower intrathecal space
decreased CSF pressure
Spinal cord infants terminate at ____ until 2 years of age
L3
How common is hypotension and bradycardia infants during spinal?
Rare
- d/t compensatory vagal responses
- Immature SNS
CSF volume in:
- Neonates
- Infants
- Children
- Adults
- Neonates: 10 mL/kg
- Infants: 4 mL/kg
- Children: 3 mL/kg
- Adults: 2 mL/kg
How does a high spinal manifest in infants?
Apnea
- lack of thoracic kyphosis leads to increased cephalad spread of LA
*NOT CV collapse
Estimated blood volume: Premature infant Full term newborn Infant (3-12mo) Child (1-12 yrs) Adult male Adult female
Premature infant: 100 ml/kg Full term newborn: 90 mL/kg Infant (3-12mo): 80 mL/kg Child (1-12 yrs): 75 mL/kg Adult male: 70 mL/kg Adult female: 65 mL/kg
Which congenital heart disorder is common in pts with pectus excavatum?
Mitral valve prolapse
- RV outflow tract obstruction
Most common side effect of succinylcholine in pediatric pt that it should be expected?
Bradycardia
- succ is 2 ACh molecules chemically linked, and can activate muscarinic receptors in sinus node
- pretreat with atropine (muscarinic antagonist) if pt < 1 y.o
K is expected to rise in serum by ___ mEq/dL after admin of Succinylcholine
- 5 mEq/dL
* K release can be profound (huge surge) if pt has dmged or denervated muscle fibers –> fatal arrhythmia
Cole formula for internal diameter of uncuffed ETT
(Age/4) + 4
Ideal local anesthetic for ureteral procedures should cover ____ somatic and visceral distributions
T10-L2
Epidurals usually have sacral sparing d/t:
- tendency of epidural boluses to travel upwards
- thicker nerve root sheaths
- larger diameters of sacral root fibers
_________ techniques are superior in achieving reduced bladder spasms and incisional pain control after open surgery for VUR
Caudal catheter
Approximately __% of omphaloceles are associated with congenital cardiac anomalies.
20%
Infants with cyanotic heart disease do not usually experience postnatal fall in hgb [ ] since _______
continued hypoxemia maintains erythropoiesis
The fetus uses ____ mL/kg/min of oxygen, compared to adult oxygen requirement of ____ mL/kg/min.
fetus: 8 mL/kg/min
adult: 3 mL/kg/min
The placenta uses __% of oxygen delivered to it, leaving __% of the oxygen to be transferred to the growing fetus
40%
60%
*the more the placenta consumes, the less the fetus gets
Fetal hgb has a greater oxygen affinity (Right/Left) shift than maternal hgb
Left shift
- hgb “sink” promotes transfer of oxygen
During alkalotic conditions, oxygen has a (greater/lesser) affinity for hgb
greater
*in the lung, oxygen binds to hgb with greater affinity
physiologic effect that describes hgb’s affinity for oxygen at different conditions
Bohr effect
Condition in the placenta where the maternal bohr effect and the fetal bohr effect occur in opposite binding conditions. Accounts for 2-8% of oxygen transfer across placenta
double bohr effect
- maternal side: hgb is in an acidic environment = promote oxygen offloading
- fetal side: hgb is in alkalotic state, promotes oxygen uptake
- Higher fetal hgb [ ]
- Bohr effect
- Double Bohr effect
- help promote oxygen transfer from ____ to ____
mother to fetus
Dosing for caudal epidural block using 0.2% ropivacaine is ___ mL/kg.
This will provide coverage from _____ to ____ dermatomes
1 mL/kg
- sacral to low thoracic dermatomes
- 5 mL/kg
- only cover sacral dermatomes - 25 mL/kg
- cover up to mid thoracic
4 T’s of a mediastinal mass
- Thymoma
- Teratoma (other germ cell tumors)
- Thyroid neoplasm
- Terrible Lymphoma
Which mediastinal mass is the most common anterior mediastinal mass in children?
thymomas
The ______ is the central space of the thoracic cavity located behind the sternum and between the two lungs and their respective pleura.
mediastinum
In newborns, the dural sac typically ends at __, and the conus medullaris at __
S3
L3
*adults its S1-2 and L1-2
How does increased intraabdominal pressure (ie: insufflation) affect a CSF shunt?
hinders output
What questions can the anesthesiologist ask to assess ventriculoperitoneal shunt function?
Nausea
Headache
blurred vision
How does increased intraabdominal pressure (ie: insufflation) affect a Cerebral venous return?
decreased
(True/False) males are at the same risk for PONV as females until puberty
true
- kids are also 2x more likely to develop PONV than adults
- increased risk of dehydration, postop bleeding, aspiration, wound dehiscence
What is the MOA of emend?
it is aprepitant, a NK-1 receptor antagonist w/ similar efficacy to zofran at preventing PONV, especially at 24-48 hours post op
Why is respiration less efficient in children when they have a more compliant chest wall than adults?
Highly compliant chest wall, but poorly supported by surrounding structures (ie pliable ribs).
Functional airway closure accompanies each breath, thus increasing work of breathing.
Why does the smaller diameter of infant airways relative to adults cause increased resistance to airflow?
Poiseuille (poi_se’) Law
- resistance is inversely proportiinal to radius raised to 4th power
_________ is also known as mandibulofacial dysostosis.
- Underdeveloped supraorbital ridges
- Hypoplastic zygomas
- Ear deformities
- Cleft palate
- Midface hypoplasia
- OSA
- Hearing loss (50%)
Treacher collins syndrome
(True/False) In Treacher collins syndrome, airway difficulty decreases with age
False. it Increases in difficulty!
- supraglottic devices as conduit for fiberoptic intubation successful
Apgar scores should not be used to ______ outcomes or direct termination of care. Lower Apgar scores are simply _____ with worse outcomes.
predict
correlated
If a newborn has a HR < 100 bpm and is not responding, add ______.
If HR is < 60 bpm, add _____
positive pressure ventilation
chest compressions in a 3:1 ratio
Why are neonates less SENSITIVE to codeine compaired to school-age children?
decreased CYP2D6
- *cytochrome that converts prodrug to morphine (active drug)
*effects of opioids in children are not by opioid receptors, but by drug metabolism
CYP2D6 is (High/Low) at birth and (Increases/Decreases) with age. Especially in the first 2 weeks.
low
increase
**cytochrome that converts prodrug to morphine (active drug)
CYP3A is (High/Low) at birth and (Increases/Decreases) with age. Especially in the first year of life.
This mechanism makes pts more susceptible to oversedation and respiratory depression.
Low
Increases
*cytochrome that converts opioids to inactive metabolites (fentanyl to norfentanyl, and tramadol to nortramadol)
UGT2B7 converts _____ to ______, which are then renally excreted. Levels are low after birth until 10 days of age.
morphine to metabolites (M3G and M6G)
- Reduce morphine by 50% to achieve same analgesic effect on kg/body weight
Neonates are more (sensitive/resistant) to hydrophilic opioids (morphine) d/t receptor immaturity and decreased excretion despite the increased volume of distribution.
Sensitive
- ASA 3 or >
- Age < 3 mo
- Airway related procedures (i.e bronch)
- mult drug combo
Are all risk factors for ______ during pediatric sedation
Laryngospasm
Heat loss during anesthesia is most likely ______. But heat loss through the breathing circuit is by _______
radiation ( pt and surrounding)
Evaporation (water to gas, hence the humidified air to minimize loss)
_____, _____, and _____ are the primary triggers for nonshivering thermogenesis in neonates and infants
Norepi, glucocorticoids, thyroxine
What type of shivering thermogenesis is most important in neonates and infants?
- Voluntary muscle
- Shivering
- Dietary thermogenesis
- Nonshivering thermogenesis
Nonshivering thermogenesis
- Major source of metabolic heat production, not produced from muscle activity
Down syndrome is associated with cervical (instability/rigidity)
Instability
50% of pts w/ Down syndrome have CV defects like ____
Endocardial cushion defect, ASD, VSD, TOF, PDA
- most to least common
Why are children with Down syndrome a challenge to intubate? (6)
- Fusion of teeth
- Cleft lip/palate
- Mandibular hypoplasia
- hypertrophic tonsillar tissue
- Cervical instability
- Subglottic stenosis
Klippel-Feil syndrome is associated with cervical (instability/rigidity)
rigidity
How common is bradycardia following admin of succinylcholine?
Common
- can pre-treat with atropine, but not recommended
MRI is located in zone ____
IV
Treatment of laryngospasm
- continuous positive airway pressure with 100% oxygen
- Deepen anesthetic with propofol
- Succinylcholine 1-2 mg/kg
- co-treatment with atropine to prevent bradycardia
Other methods succinylcholine can be administered
IM 5 mg/kg
Intralingual
Submental
Interosseous
How does rocuronium and neostigmine potency affect infants? How does it affect the dose?
potency is greater d/t immature receptors
- dose should be reduced for both
How does succinylcholine dose affect infants?
Infants are more resistant to it, bc they have a higher volume of distribution.
- Dose can be increased
Earliest sign of inadequate gas exchange in OR
loss of continuous waveform during ETCO2 capnography monitoring
Postop bowel hypomotility is more common in pts with (gastroschisis/omphalocele)
gastroschisis
*usually smaller than omphalocele
(gastroschisis/omphalocele) involves abd wall defect to the R of the umbilical cord
gastroschisis
Water soluble drugs (most abx) require (higher/lower) initial dose to achieve same clinical fx in neonates compared to children
higher
Lipid-soluble agents have (longer/shorter) DOA d/t decreased fat content of neonates
longer
- not rapidly redistributed into fatty compartments
Protein binding in neonates and infants are (increased/decreased) and require a LOWER dose of a highly protein bound drug to achieve similar fx
decreased
The HIGHER amt of total body water in neonates means that water-soluble drugs will require a (higher/lower) dose to achieve the same fx
higher
Why is venous access difficult in pts with down syndrome? (3)
- xerodermia
- atopic dermatitis
- obesity
3 conditions associated with atlantoaxial instability
- Down syndrome
- RA
- achrondroplasia
What happens if a loose tooth is accidently swallowed?
does not routinely need to be retrieved unless it is in the tracheobronchial tree
_____ has more emergence delirium than any other volatile anesthetic.
sevoflurane
- low blood:gas solubility
Desflurane comes in second
5 min myringotomy and tympanoplasty procedure. Best medication for post op analgesia?
Intranasal fentanyl
- works rapidly w/in 7-8 min
- 1-2 hour duration
- rapidly absorbed into bloodstream but quickly reaches steady therapeutic state
Maintenance fluid is using the 4-2-1 rule and the deficit is replaced as ________
half in the first hour and second half over the next 2 hours
Administration of ______ w/in __hrs postpartum to a neonate with NRDS is associated with improvement in oxygenation
surfactant, 2hrs
- can be administered endotracheal
in neonates with NRDS what do you titrate FiO2 to target SaO2 of __%.
90%
- (100% will increase risk for complications like bronchopulmonary dysplasia)
NRDS is self limited and typically improves by 3-4 days, treatment typically starts with CPAP and PEEP setting of ___ mmHg
3-8 mmHg
____ is a chronic lung disease often found in preterm infants w/ underdeveloped lungs who are exposed to mechanical ventilation, high oxygen [ ], or infection
bronchopulmonary dysplasia
risk factors for PONV in pediatric pts
- prolong surgery time >30 min
- age > 3 yrs
- h.o PONV
- strabismus surgery
children presenting for elective surgery with suspected URI should be rescheduled at least __ weeks later
4
Vital signs in a moderate sedation pediatric case must be recorded at least every _ min, and every _ min for deep sedation and GA
10 min
5 min
Osteogenesis imperfecta cognitive/intelligence level
normal
Osteogenesis imperfecta problems for anesthesiologists: respiratory problems meds other
- restrictive lung disease
- fasciculations from succinylcholine can cause bone fx
- hearing loss/deaf
Blood volume Preterm infant Full-term infant 3-12 mo infant > 1 y.o
Preterm infant: 100 mL/kg
Full-term infant: 90 mL/kg
3-12 mo infant: 80 mL/kg
> 1 y.o: 70 mL/kg
Who mandates each healthcare organization to approve a plan outlining the credentialing process for practitioners providing pediatric procedural sedation
The Joint Commission
All other societies can only provide guidelines, not mandates
Noonan syndrome is most commonly assoc w/ which congenital heart abnlty?
Pulmonary stenosis
Noonan syndrome is most commonly assoc w/ which congenital heart abnlty?
Pulmonary stenosis
Turner syndrome is most commonly assoc w/ which congenital heart abnlty?
bicuspid aortic valve
coarctation of aorta
What happens if sufficient air enters the pulmonary circulation during venous air embolism?
- Trigger bronchoconstriction (lead to shunting)
- Respiratory distress
- Increase dead space ventilation
What happens if sufficient air enters the L sided systemic circulation via R to L shunt during venous air embolism?
- cause MI
- arrhythmias
- cerebrovascular compromise
Why are children more likely to become symptomatic from a VAE?
smaller circulatory volume
smaller heart size easily overwhelmed by smaller volumes of entrained air
How effective is aspiration of air from a central line in a pt with a massive VAE?
rarely successful
- instead, flood the field with saline
- compress jugular veins
- increase PEEP (increases central venous pressure, make it more diff for air to enter vasculature)
______ presents with low grade fever, inspiratory stridor, hoarseness, “barking” cough, steeple sign
laryngotracheobronchitis
- croup
