ITE Peds 2 Flashcards
Pt with Tetralogy of fallot becomes hypoxic and cyanotic during inhalational induction. What is the likely cause and treatment?
Tet spell
- d/t R to L shunting
- d/t increased and worsening PVR and blood is shunted through VSD
Phenylephrine
- increase SVR -> increases pulmonary blood flow -> decreases R to L shunt -> improves end organ perfusion pressures
- Reflex bradycardia reduces hypercontractility and limits RVOT
4 cardiac lesions of TOF
- VSD
- Overriding aorta (aorta sits on top of VSD)
- Infundibular pulmonic stenosis
- RVH -> RVOT
Isoproterenol is a ______. and causes cardiac muscle _____, and vascular smooth muscle ______
nonselective beta-agonist
- cardiac m contraction
- sm relaxation
*worsens TET spell
Milrinone is a ______. Causes cardiac muscle _____ and vascular smooth muscle ____
phosphodiesterase type 3 inhibitor
- cardiac m contraction
- sm relaxation and decreases SVR.
*worsens TET spell
Goals of anesthetic management of TOF (3)
- maintaining SVR
- reducing HR and contractility
- ensuring adequate oxygenation and normocarbia
Management of post op obstructions in pts following cleft palate and lip repairs
positional changes
- proning
Avoid nasal or oral airways - damage the surgical repair
Which pain medication is NOT recommended for children following T&A?
Codeine
- shown to inc pain post op
- FDA black box warning in children following T&A if they are rapid metabolizers
Codeine is and inactive medication that becomes ____ after CYP __ metabolism. It has a wide polymorphism in metabolic pathway (some metabolize it rapidly, and others do not metabolize it at all)
morphine
CYP 2D6
Why are pain control response more predictable with morphine and oxycodone vs codeine?
Morphine and oxy are active and do not require metabolism for activation
Codeine is inactive and requires CYP2D6 metabolism
Why is pulmonary edema a possible complication of post-tonsillectomy procedures?
Airway obstruction is relieved by tonsillectomy ->
increase negative inspiratory pressure ->
Increases pulmonary venous return and blood volume
Cardiomyopathy from repeated transfusions is most likely found in pts d/t ____ and _____
iron overload and hemosiderosis
Thalassemias are a variety of hemolytic anemia disorders in which the ratio of ____ to ____ units is unequal.
alpha to beta globin units
A pt with longstanding ostium primum defect (ASD) presents with dyspnea, SOB at baseline, and dec exercise tolerance indicates that the pt has _____, and is at risk for arrhhythmias.
pulmonary HTN
Permissive hypercapnia is not ideal for pts with pulmonary HTN bc it ______
increases pulmonary vascular resistance and worsens pulm HTN
Benzodiazepines act (Centrally/Peripherally) to potentiate GABA, which activates chloride channels and hyperpolarize the membranes, thus having muscle-relaxing properties
centrally
GABA is an (excitatory/inhibitory) neurotransmitter that controls the state of chloride ion channels
inhibitory
Infants have a more (cephalad/caudad) larynx than adults at C __ level
cephalad, C3,4
as the infant grows, the neck lengthens and moves caudal C5,6
How do the vocal cords differ in infants vs adults?
Adults
- perpendicular vocal cords to trachea
Infants
- angled vocal cords
- anterior insertion is lower than posterior insertion
Why is nitrous oxide contraindicated in pts with air filled cavities like emphysema?
Nitrous oxide is poorly dissolved in blood and will ppt out into air filled cavities and expand the cavity
Induction of anesthesia for pts with congenital emphysema includes _______ and ______
spontaneous ventilation
minimal peak inspiratory pressure
*Avoid nitrous oxide
Myelination of nerve fibers in the pediatric population is (accelerated/delayed) compared to adults, which leads to faster onset time and shortened duration.
delayed
- easier intraneural penetration of LA
(higher/lower) cognitive function in children leads to increased preoperative anxiety
higher
Pts with myelomeningocele often have associated ____ defects.
Neuraxial anesthesia is contraindicated d/t potential _____ and _____.
arnold-chiari malformation 80%
herniation of cerebellar tonsils and hydrocephalus
Neural tube defects include (3), in order of worsening severity
- spina bifida occulta
- meningocele
- myelomeningocele
NTD occurs during the ___ week of embryonic development, during neural tube pore closure, prevention with _____ supplementation is important.
3rd
- before most women realize they are pregnant
Folate
Hypothermia in neonates and infants if left uncorrected, can result in ______, from nonshivering thermogenesis and metabolism of brown fat.
metabolic acidosis
How does metabolic acidosis arise in infants after prolonged hypothermia?
Skin and core temp difference ->
Hypothalamus stimulates release of norepi ->
Norepi binds receptors on brown fat cells ->
Activates breakdown of fatty acids ->
Consumes oxygen and glucose ->
Promotes ketone production ->
metabolic acidosis
Examples of Active humidifiers
Nebulizers
Vaporizers
Maximum allowable blood loss equation
EBV x (pt starting Hct - min acceptable hct) / Pt’s starting Hct
What is the minimum acceptable hct lvl in children?
20%
Neonatal myasthenia gravis usually resolves w/in ___ weeks, after maternal antibodies (anti-AChR) that were transferred across the placenta are metabolized
2-4 weeks
Neonatal myasthenia gravis (decreased muscle tone, feeding/respiratory difficulties) occurs in __% of babies born to mother with myasthenia gravis
20%
Treatment of neonatal myasthenia gravis
Same as adult MG
- anticholinesterases or acetylcholinesterase inhibitors
Pts with myasthenia gravis response to succinylcholine and nondepolarizing NMB agents
resistance to succinylcholine
sensitivity to nondepolarizing NMB agents
Marfan syndrome can have (obstructive/restrictive) pulmonary defects
both
obstructive
- pneumothorax
- emphysema
restrictive
- pes excavatum: restrictive lung disease
- kyphoscoliosis
Hydralazine is an arteriolar (vasodilator/vasoconstrictor) and can cause significant reflex tachycardia
vasodilator
Nitric oxide, epoprostenol, and sildenafil have all been shown to (increase/reduce) pulmonary HTN in children
reduce
Sildenafil is a _____, and can help with pulmonary vasodilation cause by endogenous nitric oxide
PDE5 inhibitor
Pt with TOF becomes hypotensive after induction, how does applying pressure to abdomen help combat decreased systemic vascular resistance?
During induction, the pt has worsening R to L shunt.
Applying pressure increases preload and increases afterload and improves shunt conditions
*shoulda induced with ketamine, not propofol
Nitrous oxide causes an (increase/decrease) in pulmonary vascular resistance. In pts with VSD, this causes a _ to _ shunt
increase
R to L
What does VACTERL stand for?
congenital anomalies
Vertebral defects Anal atresia Tracheoesophageal fistula with Esophageal atresia Radial dysplasia Limb abnormalities
Most common type of tracheoesophageal fistula
type IIIb
- upper esophagus ends in blind pouch
- lower esophagus connects to trachea
Down syndrome abnormalities of concern to anesthesiologists (6)
- short neck
- atlantooccipital instability
- irregular dentition
- mental retardation
- hypotonia
- large tongue
- 40% congenital heart disease
Down syndrome abnormalities of concern to anesthesiologists (6)
- short neck
- atlantooccipital instability
- irregular dentition
- mental retardation
- hypotonia
- large tongue
