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Pediatrics > Knowledge Navs Exam 2 > Flashcards

Knowledge Navs Exam 2 Flashcards

1
Q

Rhabdomyolysis has been reported after succinylcholine in children with ____________

A

Duchenne and Becker muscular dystrophy.

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2
Q

The dose response of rocuronium in children with Duchenne muscular dystrophy shows ____________

A

marked prolongation of both the onset and recovery times (two to three times normal).

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3
Q

NMBDs in children with severe pre-existing respiratory dysfunction

A

caution
even a small dose of a NMBD may cause profound muscle weakness and the need for ventilatory support.

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4
Q

Children with syndromes are relatively sensitive to NMBDs because ____________

A

Most are relatively sensitive to the NMBDs, particularly those with muscular dystrophy, because of muscle wasting.

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5
Q

NMBDs in children with burns

A

may require two to three times the usual IV dose of nondepolarizing relaxants.

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6
Q

what is the blood volume of a preterm infant

A

90-100 mL/kg

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7
Q

blood volume of a term neonae

A

80-90 mL/kg

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8
Q

blood volume of infant 3 months to 1 year

A

70-80 mL/kg

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9
Q

blood volume of older child

A

70 mL/kg

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10
Q

A healthy child readily tolerates a hematocrit well below ____________

A

30%

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11
Q

It is our practice not to transfuse otherwise healthy infants up to about 3 months old until their hematocrits have decreased to ____________ and hematocrits of older children have decreased to ____________ if there is little potential for postoperative bleeding.

A

25%; 20%

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12
Q

A unit of whole blood can provide …

A
  • 1 unit of PRBCs
  • 1 unit of whole blood–derived platelets
  • 1 unit of fresh frozen plasma (FFP)
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13
Q

Succinylcholine-induced muscle fasciculation is associated with (3)

A
  • mild hyperkalemia
  • increased intragastric and intraocular pressures
  • skeletal muscle pains
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14
Q

what effects of succinylcholine may occur in patients with neuromuscular disorders?

A

rhabdomyolysis and myoglobinemia

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15
Q

The serum potassium concentration increases ____________ after IV succinylcholine in normal children; this increase does not cause arrhythmias

A

1 mEq/L or less

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16
Q

Succinylcholine in children with burns

A

Succinylcholine can cause hyperkalemia in children with burns, which may cause a cardiac arrest.

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17
Q

smallest burn that has been associated with hyperkalemia

A

8%

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18
Q

the first 24 hours after a burn and succinylcholine

A

hyperkalemia after succinylcholine has not been reported in the first 24 hours after a burn

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19
Q

Hyperkalemia is thought to result from ____________ along the surface of the muscle membrane in the postburn phase.

A

the upregulation of acetylcholine receptors

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20
Q

succinylcholine IV dose for < 1 yr

A

2-3 mg/kg

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21
Q

succinylcholine IM dose for > 1 yr

A

4-5 mg/kg

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22
Q

For brief cases in which children are anesthetized with 8% inspired sevoflurane, 0.3 mg/kg rocuronium yields satisfactory intubating conditions within ____________

A

2 to 3 minutes.

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23
Q

0.3 mg/kg of Rocuronium can be antagonized within approximately ____________ of administration

A

20 minutes

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24
Q

PONV relation to age in children

A

PONV is inversely related to age in children

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25
Q

PONV ↑ or ↓ throughout childhood

A

↑

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26
Q

The incidence of PONV in children is greatest after what kind of surgeries?

A

tonsillectomy, strabismus repair, hernia repair, orchiopexy, microtia, and middle ear procedures

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27
Q

after puberty who experiences more PONV

A

girls experience much more than boys

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28
Q

The medical complications of PONV include…

A

pulmonary aspiration, dehydration, electrolyte imbalance, fatigue, wound disruption, and esophageal tears.

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29
Q

PONV can produce what kinds of effects in children

A

psychological effects that may produce anxiety in the children and parents and lead them to avoid further surgery.

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30
Q

The most effective prophylaxis strategy in children at moderate or high risk for PONV is to use combination therapy that includes …

A
  • hydration
  • a 5- HT3-receptor antagonist
  • a second drug such as dexamethasone
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31
Q

A dose of ____________ at the end of surgery effectively reduces emesis after strabismus surgery and tonsillectomy, although the magnitude of its effectiveness may be limited

A

0.15 mg/kg of metoclopramide

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32
Q

metoclopramide mechanism of action

A
  • The antiemetic properties result from its direct effects on the chemoreceptor trigger zone.
  • Gastric emptying is a result of the antagonism of the neurotransmitter dopamine, which stimulates gastric smooth muscle activity
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33
Q

Some studies report that ____________ is superior to metoclopramide (0.15 mg/kg) for the prophylactic control of postoperative vomiting in children undergoing tonsillectomy.

A

ondansetron (0.1 mg/kg)

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34
Q

Most pediatric anesthesiologists limit their routine of 5-HT3 antagonist use to …

A

children undergoing procedures known to have a substantial incidence of PONV, such as:
- strabismus repair
- tonsillectomy
- middle ear surgery
- to children with a known history of motion sickness or previous nausea and vomiting after surgery
The usual recommended dose is 100 to 150 μg/kg every 6 hours.

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35
Q

The usual recommended dose of ondansetron is ____________

A

100 to 150 μg/kg every 6 hours

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36
Q

A number of studies in children demonstrated that the antiemetic effect of drugs from this class can be improved if they are combined with ____________ or other anesthetic techniques known to reduce vomiting.

A

dexamethasone

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37
Q

Rapid administration of FFP is more likely to be associated with ____________ than the transfusion of components with smaller volumes of plasma (e.g., PRBCs).

A

citrate toxicity

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38
Q

what is initial dose of FFP in peds

A

10-15 mL/kg

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39
Q

T/F FFP contains functional platelets

A

false, no functional platelets, leukocytes, RBCs

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40
Q

midazolam IV dose in peds

A

0.05-0.15 mg/kg

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41
Q

____________ is the only benzodiazepine approved by the FDA for use in neonates, including preterms

A

midazolam

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42
Q

how is midazolam metabolized

A

hepatic hydroxylation (CYP3A4) ➔ excreted in urine

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43
Q

midazolam clearance in neonates

A

reduced

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44
Q

The suggested infusion rate of midazolam is ____________ for preterm infants younger than 32 weeks gestational age

A

0.5 μg/kg/min

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45
Q

The suggested infusion rate of midazolam is ____________ for infants infants greater than 32 weeks gestational age

A

1 μg/kg/min

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46
Q

prolonged admin of midazolam

A

tolerance, dependency, and benzodiazepine withdrawal

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47
Q

Accordingly, one must wait sufficient time between doses of midazolam ____________ to achieve the peak CNS effects before considering supplemental doses or other medications

A

(3–5 minutes)

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48
Q

diazepam dose

A

0.2-0.3 mg/kg

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49
Q

half life of diazepam

A

20-80 hours

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50
Q

metabolism of diazepam

A

demethylation by CYP 2C19

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51
Q

which benzodiazepine is painful when given IV or IM and what can you do to treat it?

A

diazepam, use lido!

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52
Q

diazepam in infants and neonates

A

Avoided in infants and neonates because of prolonged t ½ and metabolites

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53
Q

hypothermia in infants and coagulation

A
  • may worsen major blood loss and replacement
  • compromises platelet function & impairs coagulation cascade
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54
Q

hypothermia and oxygen consumption

A

may ↓ O2 consumption and demand ORRRRR increase consumption through shivering

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55
Q

hypothermia shift of oxygen-hemoglobin dissociation curve

A

left shift

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56
Q

in the presence of severe hypothermia (about 32°C) what may occur to cardiac rhythm

A

refractory ventricular tachycardia

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57
Q

only allowable method to give warmed blood

A

Blood warmer device

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58
Q

what happens to RBCs if they are overheated > 42º C

A

RBCs hemolyze

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59
Q

Ways to maintain thermal neutrality:

A
  • Warming blood and all other IV infusions with a high-capacity blood warmer
  • hot air warming blankets and - radiant warmers
  • plastic wrap around extremities
  • heated humidifier in the anesthesia circuit
  • covering the head
  • maintaining a warm to hot operating room
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60
Q

what does hypothermia do to most nondepolarizing muscle relaxants

A

potentiates them and delays elimination

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61
Q

How can shivering affect NMB?

A

Shivering increases oxygen consumption. If respiratory muscles cannot match this → hypoxemia and CO2 retention →acidosis → potentiates NMB.

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62
Q

the infant should be warmed if temperature is

A

< 35º C

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63
Q

mild to moderate hypothermia in infants

A

may cause apnea in infants, alter the pharmacokinetics of medications, decrease blood clotting and increase surgical site infections

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64
Q

how does MAC change with temperature

A

decreases MAC; in children 4 to 10 years, the MAC of isoflurane decreases 5% per degree Celsius

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65
Q

most common route of heat loss in infants

A

radiation (39%)

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66
Q

the transfer of energy through the generation of electromagnetic waves to solid surfaces such as cold walls

A

radiation

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67
Q

the transfer of energy from the child by the gas or liquid surrounding it. It can be passive, as in still air, or active when air flows past the infant

A

convection

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68
Q

the loss of heat as liquid is converted to gas. This is typically seen through perspiration but can also occur with major open wounds, and dissipation of cleansing preparation solutions

A

evaporation

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69
Q

the transfer of energy directly from one body to another and can occur in solids, liquids, and gases. Based on their material, objects are conductors (metals) or insulators (gases)

A

conduction

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70
Q

minimum acceptable Hct varies according to ____________

A

individual need

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71
Q

which populations often require a greater hematocrit

A

severe pulmonary disease or cyanotic congenital heart disease often require a greater hematocrit

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72
Q

preterm infant hematocrit requirement is higher bc…

A

prevent apnea, reduce cardiac and respiratory work, and possibly improve neurologic outcomes

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73
Q

healthy infant 3 months old transfusion threshold

A

Do not transfuse healthy infants up to about 3 months old until their hematocrits have decreased to 25%

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74
Q

MABL in Children

A
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75
Q

what medication is directly related to PONV in peds

A

the morphine dose

> 0.1 mg/kg correlates with a 50% or more incidence in vomiting

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76
Q

Latino children and morphine

A

Latino children 4x more pruritus and 7x more vomiting with similar morphine and morphine metabolite values.

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77
Q

ondansetron dose in children

A

100 to 150 µg/kg every 6 hours

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78
Q

risks of ondansetron

A

ventricular tachyarrhthmias (Torsades) if long QT syndrome, esp when using inhalationals (sevoflurane)

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79
Q

which agents are better for chemo induced N/V

A

Granisteron and tropisteron

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80
Q

metoclopramide effects

A

Gastric emptying: dopamine antagonism, which stimulates gastric smooth muscle activity

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81
Q

dose of metoclopramide

A

0.15 mg/kg at the end of strabismus and tonsillectomy surgery

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82
Q

Neurokinin 1 Antagonists mechanism of action

A
  • in the brainstem (area postrema and nucleus tractus solitarius)
  • receptor for substance P
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83
Q

procedures with high risk of PONV

A

strabismus repair, tonsillectomy, or middle ear surgery

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84
Q

upper airway obstruction not included

A
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85
Q

longitudinal stretch during inspiration

A

laryngospasm

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86
Q

Incidence of laryngospasm after maintenance of anesthesia with ____________ is significantly less than with ____________ .

A

propofol, sevoflurane

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87
Q

The effects of spraying the vocal cords with lidocaine on the incidence of laryngospasm and bronchospasm

A

effects are unclear

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88
Q

Prophylactic treatment with glycopyrrolate, ipratropium, or albuterol (does/ does not) affect the incidence of URI-related adverse events.

A

does not

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89
Q

Prophylactic ____________ reduced perioperative airway sequelae in children with URIs.

A

salbutamol

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90
Q

laryngospasm is accompanied by

A

an inspiratory effort, which longitudinally separates the vocal from the vestibular folds.

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91
Q

what is physiologically similar to involuntary laryngeal closure

A

Glottic closure during forced expiration (forced glottic closure or Valsalva maneuver)

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92
Q

hallmark high-pitched inspiratory stridor is caused by

A

the upper portion of the larynx to be partially open during mild laryngospasm

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93
Q

how to relieve laryngospasm

A

Anterior and upward displacement of the mandible (jaw thrust applied at the condyle of the ascending ramus of the mandible)

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94
Q

how does jaw thrust work

A

Longitudinally separates the base of the tongue, the epiglottis, and the aryepiglottic folds from the vocal cords.

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95
Q

predominantly inspiratory stridor suggests

A
  • an upper airway (extrathoracic) lesion: epiglottitis, croup, extrathoracic foreign body
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96
Q

both expiratory and inspiratory stridor suggests what kind of lesion

A

an intrathoracic lesion
- aspirated foreign body, vascular ring or large esophageal foreign body

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97
Q

expiratory stridor or prolonged expiratory phase can suggest

A

lower airway disease

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98
Q

RDS can cause (3)

A
  • Reduced lung volumes and lung compliance
  • Increased intrapulmonary shunting
  • Ventilation-perfusion mismatch
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99
Q

clinical manifestations of RDS

A
  • Grunting respirations
  • Nasal flaring
  • Chest retractions that develop shortly after birth
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100
Q

infant normal RR

A

30-53

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101
Q

1-3 y/o normal RR

A

22-37

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102
Q

4-5 y/o normal RR

A

20-28

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103
Q

6-12 y/o normal RR

A

18-25

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104
Q

13-18 y/o normal RR

A

12-20

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105
Q

The upper airway compromises…

A

the nasal cavities, oral cavity, pharynx, and larynx.

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106
Q

The mucosa that lines the upper airway is loose-fitting ____________

A

pseudostratified columnar epithelium

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107
Q

pressure on the mucosa may cause ____________

A

reactive edema that encroaches on the diameter of the lumen.

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108
Q

Because the subglottic region in the infant is smaller in the adult, the same degree of airway edema results in ____________

A

greater resistance in the infant.

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109
Q

Upper airway patency is maintained by

A

connective tissue and by sustained and cyclic contractions of the pharyngeal dilator muscles.

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110
Q

tongue in neonate

A

large in proportion to the rest of the oral cavity and more easily obstructs the airway, especially in the neonate.

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111
Q

larynx in infants

A

more cephalad at C3-4 (adults C4-5)

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112
Q

how many cartilages and bones in larynx

A

1 bone, 11 cartilages

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113
Q

The vocal cords are covered with ____________

A

stratified epithelium

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114
Q

branches of superior laryngeal nerve

A
  • internal branch → sensory innervation to the supraglottic region
  • external branch → motor innervation to the cricothyroid muscle
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115
Q

recurrent laryngeal nerve function

A

sensory innervation to the subglottic larynx and motor to all other laryngeal muscles.

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116
Q

____________ is the only laryngeal function that alters the cricothyroid angle.

A

phonation

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117
Q

Despite significant airway obstruction during inspiration, it may still be possible to ____________

A

phonate.

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118
Q

____________ is functionally the narrowest portion of the upper airway.

A

the cricoid cartilage

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119
Q

Growth of the subglottic airway occurs rapidly during

A

the first 2 years of life

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120
Q

Cricoid and thyroid cartilages reach adult proportions by ____________

A

10-12 years of age

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121
Q

The____________ is the only complete ring of cartilage in the laryngo tracheobronchial tree - nondistensible.

A

cricoid

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122
Q

how are vocal cords angled

A

Angled such that the anterior insertion is more caudad than the posterior insertion

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123
Q

where might the tip of the ETT be held up

A

at the anterior commissure of the vocal folds

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124
Q

infant epiglottis
shape & angle

A

narrow, omega shaped, and angled away from the axis of the trachea

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125
Q

why is the peds epiglottis shaped like that?

A

Shape allows the epiglottis to approach the uvula during infant breastfeeding - separating breath from fluid and allowing respiration at the same time as swallowing.

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126
Q

upper lip bite

A
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127
Q

focused airway exam

A
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128
Q

defibrillation pads placement for infants < 25 kg

A

pads placed on chest and back

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129
Q

defibrillation pads for kids > 25 kg

A

pads placed on R. and L. lateral chest

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130
Q

joules/kg of pediatric defibrillation

A

2 joules/kg

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131
Q

For V fib/Vtach defibrillation:

A

2 joules/kg ASYNCHRONOUS;
repeat up to 4 joules/kg

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132
Q

For SVT/Vtach cardioversion:

A

0.5 joules/kg SYNCHRONOUS;
repeat up to 2 joules/kg

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133
Q

crystalloid boluses

A

10-20 ml/kg (up to 3 boluses)

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134
Q

colloid bolus amount

A

20 mL/kg

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135
Q

RBC or FFP bolus amount

A

10-20 mL/kg

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136
Q

what is the apnea-hypopnea index (AHI)

A

Summation of the number of obstructive apnea and hypopnea events

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137
Q

obstructive sleep apnea syndrome

A

periodic cessation of air exchange with apnea episodes lasting longer than 10 sec and AHI indicating the total number of obstructive sleep episodes per hour of sleep is greater than 1

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138
Q

AHI 1-5

A

mild OSA

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139
Q

AHI 6-10

A

moderate OSA

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140
Q

AHI > 10

A

severe OSA

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141
Q

what is commonly given as a topical cream for transdermal local anesthetic

A

lidocaine and prilocaine

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142
Q

what might Eutectic Mixture of Local Anesthetics (EMLA) cause

A

may cause vasoconstriction and blanching, making placement of IV difficult

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143
Q

there is a high risk of ____________ with EMLA

A

methemoglobinemia

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144
Q

what is methemoglobinemia

A

hemoglobin is converted into methemoglobin; decreases available O2 carrying capacity and increases affinity of unaltered hemoglobin for O2, which further impairs O2 delivery

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145
Q

neonates have ↑ or ↓ methemoglobin reductase activity compared to older children and adults

A

reduced activity

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146
Q

atropine dose

A

0.02 mg/kg

younger than 6 months require larger doses to increase heart rate

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147
Q

what might atropine and scopolamine cause

A

decreased ability to sweat ➔ increase in temperature

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148
Q

Central sedative effects of both atropine and scopolamine are antagonized with ____________

A

physostigmine

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149
Q

atropine admin in T21 patients

A

may have narrow-angled glaucoma- caution with administration can worsen

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150
Q

scopolamine dose

A

0.01 mg/kg

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151
Q

uses of anticholinergics

A

diminish secretions preoperatively
block laryngeal and vagal reflexes
treat or prevent the bradycardia from succinylcholine,
treat the bradycardia of anesthetic-induced myocardial depression
muscarinic effects of neostigmine
oculocardiac reflex

152
Q

red vs infrared light

A

red- 660 nm
infrared- 930 nm

153
Q

do SCD and fetal hemoglobin impact pulse oximetry?

A

no

154
Q

If otherwise safe for the neonate; the oxygen saturation measured by pulse oximetry (SpO2) is between ____________ to minimize the risk of oxygen toxicity without increasing perioperative mortality.

A

91% and 95%

155
Q

when is a low FiO2 desirable

A

(1) congenital heart disease to reduce the oxygen saturation to balance the pulmonary and systemic blood flows
(2) airway surgery to reduce the risk of airway fires
(3) in infants and neonates to reduce the risk of retinopathy of prematurity

156
Q

inspiration ____________ venous return to the heart

A

increases

157
Q

exhalation ____________ venous return to the heart

A

decreases

158
Q

when is pulsus paradoxus more pronounced?

A

when there is a decrease in the central venous filling pressure (hypovolemia) or if there is a significant increase in the inspiratory force (upper airway obstruction)

159
Q

____________ is an algorithm used to predict patients whose cardiac output might benefit from fluid bolus

A

Pleth Variability Index (PVI)

160
Q

when is an uncuffed ETT used

A

patient less than 8

161
Q

when is cuffed ETT used

A

patient older than 8

162
Q

uncuffed ETT size

A

age/4 + 4

163
Q

cuffed ETT size

A

age/4 + 3 (or 3.5)

164
Q

children with down syndrome require a ____________ ETT

A

smaller diameter

165
Q

children with cardiac disease often require a ____________ ETT

A

larger size

166
Q

A sustained inflation pressure of ____________ should be applied to detect an audible or auscultated air leak over the glottis

A

20 to 25 cm H2O

167
Q

If no leak is detected, the ETT size is …

A

excessive and it should be exchanged for one with an ID 0.5 mm smaller

168
Q

distance for ETT insertion

A

size x 3

169
Q

1000 g ETT size

A

2.5

170
Q

1000-2500 g ETT size

A

3.0

171
Q

neonate to 6 month ETT size

A

3.0 - 3.5

172
Q

6 months - 1 year ETT size

A

3.5 to 4.0

173
Q

1 to 2 years ETT size

A

4.0 - 5.0

174
Q

who acts as the decision maker for children and legally can give conset

A

the parents

175
Q

age group consent vs permission

A
  • <6 years no decision-making capacity - best interest standards
  • 6-12 years developing- informed permission informed assent
  • 13-18 years mostly developed- informed permissions informed assent
  • Mature minors developed- informed consent
  • Emancipated minor developed- informed consent
176
Q

recommendations for risk communication to patients

A
177
Q

If an adolescent has a positive pregnancy test before anesthesia. Given the principles of confidentiality, it is ethically appropriate to inform ____________

A

only the adolescent.

178
Q

Necessary emergent care for minors who do not have a parent available to give legal consent should be ____________

A

provided regardless

179
Q

greatest risk age group for preop anxiety

A

ages 1-5

180
Q

____________ % of children develop fear and anxiety before surgery

A

40-60%

181
Q

signs of pre-op anxiety

A
  • scared or agitated, breathe deeply, tremble, stop talking or playing, and start to cry.
  • some may wet or soil themselves, display increased motor tone, and actively attempt to escape from medical personnel
182
Q

Children who are 6 years or older benefit from ____________ before the surgery

A

a prep program 5 days

183
Q

prep program had a negative impact for what age group

A

children less than 3

184
Q

ADVANCE Prep program

A
185
Q

Children with dynamic obstruction to the left or right ventricular outflow tracts often benefit from sedative premedication because ____________

A

crying and struggling during induction may worsen obstruction

186
Q

Premedication for infants younger than 6 months of age

A

is usually unnecessary

187
Q

onset of midazolam

A
188
Q

the only premedication approved for neonates

A

Midazolam

189
Q

midazolam provides ____ amnesia

A

anterograde

190
Q

Midazolam can cause respiratory depression and hypotension if given with

A

fentanyl

191
Q

Midazolam dosing

A
  • 0.1mg/kg IV
  • 0.5 -1.0 mg/kg PO Most commonly used
  • 0.2 mg/kg nasal
192
Q

T/F:
Versed causes pain on injection in pediatric patients.

A

False
water soluble

193
Q

Ketamine dosing
(mg/kg)
* oral
* rectal
* nasal
* IM

A
194
Q

BZD dosing (mg/kg)

A
195
Q

Clonidine dose

A

0.004 mg/kg PO

196
Q

You can give morphine IM at what dose

A

0.1-0.2 mg/kg

197
Q

Give demerol IM at what dose

A

1-2 mg/kg

198
Q

Fentanyl Oral and nasal dosing

A
199
Q

Barbiturates dosing (thiopental and methohexital in mg/kg)

A
200
Q

Basic vs acidic drugs and which plasma protein they bind to

A
  • Basic drugs (lidocaine or alfentanil) bind to plasma a1 acid glycoprotein (AAG)
  • Acidic drugs (diazepam, barbiturates) bind to albumin

“Basic girls like the Alpha guys”

201
Q

Neonates have (decreased/increased) protein binding, which means…

A

decreased

greater unbound drug ready for passive diffusion

202
Q

Neonates have factors that both decrease and increase medication levels bc…

A
  • reduced clearance = increased medication levels
  • increased Vd = decreased medication levels
203
Q

kernicterus from medications

A
  • Medications that compete with bilirubin to bind to albumin cause hyperbilirubinemia
  • Phenytoin, salicylate, caffeine, ceftriaxone, hypaque
204
Q

Likely to cause methemoglobinemia

A

EMLA

2.5% lidocaine and 2.5% prilocaine

205
Q

T/F:
Iodine antiseptics likely to cause hyperthyroidism

A

False
HYPOthyroidism

205
Q

T/F:
Neonates and infants have the same MAC requirements.

A

False
less in neonates than in infants

206
Q

The difference in the potency (or MAC) of inhalational anesthetics varies inversely with ____

A

lipid solubility

207
Q

What begins at approximately 0.6 MAC?

A

decrease in vascular resistance causes a reciprocal increase in CBF

208
Q

The speed of induction dependent on
(4)

A
  • potency/MAC of the agent
  • rate of increase of the inspired concentration
  • maximum inspired concentration
  • respiration
209
Q

Prop
pediatric maintenance infusion rate

A

200-250 mcg/kg/min

210
Q

An approrpiate way to warn about injection pain from propofol

A

“warmth” or “sunshine on your arm”

211
Q

Propofol induction dose

A

3-4 mg/kg

212
Q

Prop
distibution and Cl

A

Rapid re-distribution, hepatic and extrahepatic clearance (lung, kidney)

213
Q

Prop allergy is due to the

A

egg white protein

214
Q

T/F:
Prop has less emergence delirium than inhalations and less PONV

A

True

215
Q

To eliminate pain with propofol injection, pretreat with

A
  • IV lidocaine (0.5 mg/kg),
  • meperidine,
  • nitrous oxide,
  • metoprolol,
  • dexmedetomidine,
  • low dose ketamine or tramadol
216
Q

PRIS risk, infusion at rates greater than

A

5 mg/kg per hour

217
Q

The Propofol ED50 for loss of eyelash reflex

A
  • 1–6 months: 3 ± 0.2 mg/kg
  • 1–12: 1.3 - 1.6 mg/kg
  • 10–16: 2.4 ± 0.1 mg/kg
  • ED90-95 LOER for all ages is 50% to 75% > ED50.
  • no premedication: propofol (per kg) required for loss of the eyelash reflex is generally inversely r/t age
218
Q

Methohexital (brevital)
is a (short/long)-acting barbiturate

A

short

219
Q

Methohexital (brevital)
IV induction dose

A

1-2.5 mg/kg

220
Q

T/F:
Expect airway obstruction but not desaturation with Methohexital

A

False
Oxygen desaturation 4% of cases and can cause airway obstruction (reposition head)

221
Q

Methohexital (brevital)
SEs

A

Pain on injection
Hiccups
Seizure-like activity

222
Q

T/F
Methohexital can be given rectally as a premedication

A

True

223
Q

Methohexital Clearance

A

0.76 L/minute per 70 kg

224
Q

Thiopental
moA

A

Binds GABAA receptors to prolong chloride channel opening

225
Q

Thiopental CL

A

0.24 L/minute per 70 kg

(less than Brevital)

226
Q

Thiopental
IV induction dose

A

3-4 mg/kg

227
Q

Duration of effect depends primarily on redistribution rather than metabolism (10% per hour)

A

Thiopental

228
Q

Thiopental
effects on myocardium vs vasculature

A

Myocardial depressant & weak vasodilator (little direct effect on vascular smooth muscle tone)

229
Q

T/F:
Prop causes a greater hypotensive response than thiopental in neonates.

A

True
The hypotensive response in neonates given thiopental appears not as dramatic as propofol

230
Q

Ketamine
moA

A

NMDA receptor antagonist

231
Q

Ketamine induction doses

A

1 - 3 mg/kg IV
5-10 mg/kg IM

232
Q

Ketamine peak concentrations are reached within

A

10 minutes after 4 mg/kg

IM??

233
Q

Ketamine
desirable effects

A

Analgesic & amnestic, dissociative amnesia
Bronchodilator

234
Q

Ketamine
UNdesirable effects

A
  • Direct cardiac depressant
  • May precipitate seizures in susceptible children

Side effects: nystagmus, increased secretions, 30% increase in intraocular pressure, increased intracranial pressure (cerebral vasodilation) & CMRO2

235
Q

Do adults or peds get higher doses of Ketamine? Why?

A

Doses are typically larger in children due to greater clearance than in adults

236
Q

Ketamine CV effects and how to lessen them

A
  • increased HR & BP, little effect on pulmonary artery pressure
  • fewer cardiovascular effects with the dextro isomer
237
Q

Ketamine Cl

A
  • neonates is reduced (26 L/hour per 70 kg)
  • matures to reach adult rates
    (80 L/hour per 70 kg; that is, liver blood flow) within the first 6 months of life
238
Q

Why use ketamine IM?

A

combative larger children

239
Q

Etomidate
moA

A

Steroid-based hypnotic induction agent

240
Q

Etomidate
is metabolized by

A

hepatic esterases

241
Q

Etomidate
suppresses adrenal function for up to…

A

24 hours

242
Q

Etomidate dosing

A

0.2 - 0.3 mg/kg IV, typically 30% increase in dose in children due to increased volume of distribution

243
Q

T/F:
Etomidate is appropriate for head injuries

A

True
and CV unstable

244
Q

T/F:
Etomidate has no effect on hemodynamics

A

True

245
Q

Etomidate side effects

A
  • Emesis
  • Adrenal suppression
  • Pain on injection
246
Q

Neonates need (less/more) NMB.

A

less

increased sensitivity

247
Q

Why do neonates need less NMB?

A
  • Neuromuscular transmission is immature until 2 months old
  • Reduction in acetylcholine released
  • Reduced muscle mass
  • Reduced clearance
248
Q

The neonate’s diaphragm function may recover earlier than peripheral muscles bc…

A

Type 1 (slow twitch) diaphragm muscle fibers are most sensitive to NMBDs
BUT
preterm neonate has only ~10% type 1 fibers

249
Q

T/F:
Neonates and infants need lower doses of NMB than adults.

A

False
Neonates have increased sensitivity
Infants require larger doses than adults

250
Q

Why do infants need higher NMB dose than adults?

A

Larger volume of distribution due to greater total body water & extracellular fluid

251
Q

T/F:
Neonates have faster NMB onset due to greater cardiac output

A

True

252
Q

T/F:
Infants are more resistant to Suxx than adults

A

True

253
Q

How to dose atropine when giving Suxx

A

10-20 mcg/kg
every 5-10 minutes

254
Q

Suxx has rapid redistribution in

A

extracellular fluid volume

255
Q

Succinylcholine dose

A

infants: 3 mg/kg IV or 5 mg/kg IM

children 1.5- 2mg/kg IV or 4 mg/kg IM

Infants more resistant than adults

256
Q

T/F:
You will not see defasiculations from suxx in a toddler

A

False

1-3 years old can see fasciculations but don’t see them in infant

257
Q

Succinylcholine side effects

A
  • increased masseter muscle tone when given with halothane - masseter spasm potential sign of malignant hyperthermia
  • Arrhythmia - bradycardia due to choline metabolites; more likely with 2nd dose
  • Hyperkalemia - normal increase K+ ~1 mEq/L; higher in burns, motor neuron lesions & neuromuscular disease
  • Increased intraocular pressure
258
Q

How much does Suxx increase K?
What worsens this?

A

1 mEq/L

higher in burns, motor neuron lesions & neuromuscular disease

259
Q

What is plasma cholinesterase (pseudocholinesterase)

A

circulating glycoprotein that metabolizes succinylcholine into succinylmonocholine

260
Q
A
260
Q

Which conditions decrease and increase plasma cholinesterase activity

A

Decreases: severe liver disease, malnutrition, organophosphate poisoning, severe burns, renal failure, plasmapheresis, cyclophosphamide, echothiophate iodide, oral contraceptives

Increases: thyroid disease, obesity, nephrotic syndrome, cognitively challenged children

261
Q

Fastest onset of non-depolarizing relaxants

A

Roc

262
Q

Roc dose may need to be increased if

A

doing TIVA

263
Q

Which NMB?
Spontaneous degradation not dependent on plasma cholinesterase

A

Cisatracurium

264
Q

T/F:
Children recovery slower from cisatracurium than adults

A

False
Faster recovery in children due to greater volume of distribution & total body clearance

265
Q

T/F:
Vecuronium is metabolized by liver and excreted in urine

A

False
excreted in bile

this is correct for Roc

266
Q

Who is more sensitive to Vec?
infants or children?

A

infants <1

are more sensitive to vec compared to children

267
Q

T/F:
Vec has no CV effects

A

True

268
Q

Which NMB is not used in peds?

A

Pancuronium

Long-acting
> 50% excreted in urine unchanged, 10% in bile
Side effect: tachycardia - blocks presynaptic noradrenaline uptake

269
Q

NMBs by dose
infants and children

A
270
Q

MAC for neonates

A
271
Q

What determines Wash In of inhalation agents

A
272
Q

how does CO affect FA/FI

A

lower CO = more rapid increase FA/FI

273
Q

T/F:
The slower the FI of nitrous oxide the more rapid the increase FA/FI

A

False

faster

274
Q

T/F:
Neonates have more bradycardia and hypotension with increasing volatile anesthetics compared to adults

A

True

Immature sarcoplasmic reticulum in cardiac cells = poor Ca retention and release

275
Q

Premeds can be given for:
(6)

A
  • anxiety,
  • block vagal responses/reflexes,
  • reduce airway secretions,
  • amnesia,
  • GI prophylaxis,
  • facilitate induction and analgesia
276
Q

Premedicant drugs include:

A
  • Tranquilizers: Versed, diazepam, Lorazepam
  • BARBs
  • Nonbarbiturate sedatives:
  • Chloral hydrate and triclofos
  • morphine, fentanyl, sufenta, tramadol, butorphanol, codeine
  • Ketamine
  • A2 agonists (clonidine, precedex)
  • AntiACh
  • Topicals (EMLA, ELA Max, S-caine patch
  • Tylenol (2+Y)
  • corticosteroids
277
Q

major effect of tranquilizers is to allay anxiety but they also have the potential to

A

produce sedation

278
Q

Tranquilizers
This group of drugs includes:

A

Benzodiazepines (widely used in children)
Phenothiazines + Butyrophenones (infrequently used)

279
Q

T/F:
Benzodiazepines cause minimal drowsiness and cardiovascular or respiratory depression at low doses.

A

True

280
Q

most widely used premedication for children

A

Midaz

281
Q

major advantage of midazolam over other drugs in its class

A

rapid uptake and elimination

282
Q

Midazolam duration and half life

A
  • short-acting, water-soluble
  • elimination half-life of approximately 2 hour
283
Q

Versed routes

A

IV, IM, nasally, PO, rectally with min irritation
Bitter taste when given PO + nasally

284
Q

Versed dose

A

Most children are adequately sedated with:

  • 0.025 to 0.1 mg/kg IV
  • 0.1 to 0.2 mg/kg IM
  • 0.25 to 0.75 mg/kg orally
  • 0.2 mg/kg nasally
  • 0.1 mg/kg rectally
285
Q

T/F:
required dose of midazolam increases as age decreases in children

A

true

286
Q

CYP 450 Inducers
(↓ DOA Versed)

A
  • anticonvulsants (phenytoin and carbamazepine)
  • rifampin
  • St. John’s wort
  • glucocorticoids
  • barbiturates
287
Q

T/F:
PO Versed is effective in sedation but increases residual volume

A

False
effective and does NOT increase gastric pH or residual volume

288
Q

CYP 450 Inhibitors
(prolonged sedation w/ Versed)

A
  • grapefruit juice
  • erythromycin
  • protease inhibitors
  • calcium-channel blockers
289
Q

Increased postoperative sedation may be attributed to synergism between

A

propofol and midazolam on GABA receptors

290
Q

children can become agitated after giving midazolam by which route?
wyd?

A

oral

IV Ketamine (0.5 mg/kg) may reverse the agitation

291
Q

Nasal versed
- onset
- effectiveness

A
  • onset: anxiolysis + sedation within 10 mins
  • not well accepted because it causes irritation, discomfort + burning aftertaste
292
Q

T/F:
IV Versed can cause neurotixicity.

A

False
Nasal

Potential to cause neurotoxicity via the cribriform plate (use preservative free only)

293
Q

Diazepam should only be used for premedication of older children bc…

A

infants + premies immature hepatic function causes markedly prolonged elimination half life

294
Q

Diazepam
Active metabolite:

A
  • desmethyldiazepam
  • pharmacologic activity equal to diazepam with half life > 9 days
295
Q

Most effective routes for diazepam

A

IV
(followed by PO then rectal)

296
Q

T/F:
Like Versed, Diazepam can be given IM.

A

False

do not give Diazepam IM
pain + erratic absorption

297
Q

Lorazepam
dose

A

(0.05 mg/kg): PO, IV, or IM

298
Q

These BZDs are reserved primarily for older children

A

Diazepam
Lorazepam

299
Q

Why use Lorazepam instead of Diazepam?

A

Causes less tissue irritation + more reliable amnesia than diazepam
Inactive metabolites

300
Q

IV form of this BZD is avoided in neonates because it may be neurotoxic

A

Lorazepam

301
Q

Diazepam vs Lorazepam
onset
doA

A

Lorazepam is slower and longer

302
Q

advantages of barbiturates

A

minimal respiratory or cardiovascular depression, anticonvulsant effects, and a very low incidence of nausea and vomiting

303
Q

relatively short-acting barbiturates thiopental and methohexital may be given rectally as a

A

10% solution

304
Q

T/F:
Barbiturates are infrequently used for premedication

A

True

305
Q

How to give rectal thiopental or methohexital

A

30 mg/kg via a shortened suction catheter, which produces sleep in about two-thirds of the children within 15 minutes

10% solution

306
Q

What to monitor for when giving rectal thiopental or methohexital

A

sedation may be profound, resulting in airway obstruction and laryngospasm

always have: source of oxygen, suction, and a means for providing ventilatory support

307
Q

disadvantages of rectal methohexital

A
  • unpredictable systemic absorption
  • defecation
  • hiccups
308
Q

Children chronically treated with _____ are more resistant to the effects of rectally administered methohexital

A

phenobarbital or phenytoin

309
Q

Contraindications to methohexital

A
  • hypersensitivity
  • temporal lobe epilepsy
  • latent or overt porphyria

do NOT give rectal if rectal mucosal tears or hemorrhoids

310
Q

Nonbarbiturate sedatives

A
  • Chloral hydrate and triclofos
  • orally administered nonbarbiturate drugs used to sedate children
  • both are slow onset and relatively long acting
311
Q

Chloral hydrate
is rarely used bc…

A
  • unreliable
  • has a prolonged DOA
  • unpleasant taste
  • irritating to skin mucosa & GI tract
312
Q

Chloral hydrate use in ____ is not recommended because of impaired metabolism

A

neonates

313
Q

Opioids:
SEs

A

N/V, respiratory depression, sedation, + dysphoria

314
Q

All children that receive opioid premedication should be…

A

continuously observed + monitored with pulse ox

315
Q

Morphine IV dose

A

0.05 to 0.1 mg/kg

316
Q

Other than IV, what routes can we give Morphine?
Pros and cons

A

IM
Also effective when given PO

rectally not recommended because erratic absorption

317
Q

____ are more sensitive to the respiratory depressant effects of morphine (rarely used)

A

Neonates

318
Q

Fentanyl:
was introduced in a “lollipop” delivery system known as

A

oral transmucosal fentanyl citrate (OTFC)

no longer used for this

319
Q

T/F:
Fentanyl has a moderate incidence of PONV

A

False
HIGH

319
Q

Which opioid is Currently used to treat breakthrough cancer pain

A

Fentanyl

320
Q

How to utilize Fentanyl

A

administered nasally (1 to 2 µg/kg)

primarily after induction to provide analgesia in children without IV access

321
Q

Sufentanil is ___ times more potent than fentanyl

A

10

322
Q

Sufenta
administered nasally in a dose of

A

1.5 to 3 µg/kg

323
Q

Sufenta isnt a popular choice for premedication bc….

A

the adverse effects

more PONV and reduced chest wall compliance and prolonged hospital stay

324
Q

After giving this drug for premideication, children are usually calm and cooperative, and most separate from their parents with minimal distress

A

Sufenta

325
Q

Tramadol
moA

A

weak µ-opioid receptor agonist

analgesic effect is mediated via inhibition of norepinephrine reuptake and stimulation of serotonin release

326
Q

How does Tramadol affect breathing and bleeding?

A

devoid of action on platelets and does not depress respirations in the clinical dose range

327
Q

Tramadol
peak
doA
metab

A
  • Serum concentrations peak by 2 hours after oral dosing
  • analgesia for 6 to 9 hours.
  • metabolized by CYP2D6
328
Q

Butorphanol
moA

A

synthetic opioid agonist-antagonist with properties similar to those of morphine that can be administered nasally

329
Q

Butorphanol:
most frequent adverse effect

A

sedation that resolves approximately 1 hour after administration

330
Q

Tramadol
how much and when to give

A

dose of 0.025 mg/kg administered nasally immediately after the induction

331
Q

Opioids + Midazolam

A

more respiratory depression than opioids or midazolam alone

decrease dose of both

332
Q

Codeine is a prodrug that must undergo _____ in the liver to produce morphine to provide effective analgesia

A

O-demethylation

333
Q

oral codeine dose

A

0.5 to 1.5 mg/kg

334
Q

Codeine
onset
duration

A
  • onset within 20 minutes
  • peak effect between 1 and 2 hours
  • elimination half-life 2.5 to 3 hours.
335
Q

combination of codeine with acetaminophen is effective in relieving

A

mild to moderate pain

336
Q

Some children do not get analgesia from codeine. Why?

A

5% and 10% of children lack the cytochrome isoenzyme (CYP2D6) required for conversion

337
Q

A normal codeine dose in these children can be an overdose

A

obstructive sleep apnea
altered mu receptors and increased analgesia

338
Q

Ketamine
moA

A

Dissociates cortex from limbic system, producing sedation and analgesia
but preserves airway reflexes and respiratory drive
bronchodilation

339
Q

Ketamine uses

A

pre-med, opioid-sparing adjunct, in asthmatics

340
Q

Ketamine preserves airway reflexes and respiratory drive but what are the cons?

A
  • hallucinations, nightmares,
  • nystagmus,
  • sialorrhea,
  • increased PONV
  • high doses IM = more psychological effects
341
Q

You’re giving Versed to mitigate the negative psych effects on Ketamine. What should you consider?

A

versed mitigates this but prolongs recovery from anesthesia

342
Q

“Ketamine Dart”

A

high concentration Ketamine,
+/- versed,
+/- antisialagogue

343
Q

Ketamine with the addition of _____ is recommended to decrease sialorrhea

A

atropine or glycopyrrolate

344
Q

IM ketamine is an effective means of sedating which pts?

A

combative, apprehensive, or developmentally delayed children who are otherwise uncooperative and refuse oral medication

345
Q

Ketamine IM dose

A

IM: 2-5mg/kg, EA 3-5min

  • 2mg/kg, +/- 0.1-0.2mg/kg versed, for mask induction
  • 4-5mg/kg for induction dose if BP stability needed (CHD)
  • Up to 10mg/kg for up to 25 min need- most SE (good for burn pts)
346
Q

Ketamine PO dose

A

PO: 5-6mg/kg, EA 12 min

3mg/kg + 0.5mg/kg versed works better and did not prolong recovery in cases longer than 30min

347
Q

T/F:
Oral ketamine alone or in combination with oral midazolam is an effective premedication to alleviate the distress of invasive procedures

A

True

348
Q

Nasal ketamine dose, usage, onset

A

6 mg/kg

effective premedication
sedation developing by 20 to 40 minutes

349
Q

Rectal ketamine dose, absorption, & uses

A
  • 5 mg/kg
  • good anxiolysis and sedation within 30 minutes
  • but unreliable absorption
350
Q

Clonidine
moA

A

α2-agonist
dose-related sedation by its effect in the locus coeruleus

351
Q

T/F:
Clonidine attenuates the hemodynamic response to intubation

A

True
acts both centrally and peripherally to reduce blood pressure

352
Q

T/F:
Clonidine is devoid of respiratory depressant properties, even when administered in an overdose

A

True

353
Q

T/F:
Clonidine decreases MAC requirements but may prolong emergence.

A

False
does not prolong emergence

354
Q

T/F:
Oral clonidine 4 µg/kg reduces the incidence of vomiting after strabismus surgery

A

True!

355
Q

Oral clonidine offers sedation and analgesia but must be given _____ before induction

A

60 mins

impractical in busy outpatient setting

356
Q

Dexmedetomidine
moA

(not as common as clonidine)

A
  • Great affinity for alpha-2 receptors
  • produces sedation
  • reduces postop opioid requirements
  • useful as opioid sparing adjunct
  • improves separation anxiety
357
Q

T/F:
In contrast to clonidine, Precedex in higher doses can prolong emergence and recovery

A

True!

esp in combination with other sedating drugs

358
Q

Precedex
Beware of _____ with rapid dosing

A

bradycardia

359
Q

Precedex dosing

A
  • PO: 2-4mcg/kg, effective in 20-30min
  • IN: 2-3mcg/kg, effective in 30-45min
  • IV: up to 1-1.5mcg/kg over 10min, effective in ~15min
360
Q

Anticholinergics:
Uses

A
  • prevent bradycardia from agents (sux, halothane)
  • Block vagal reflexes from surgical stimulation (laryngoscopy, insufflation, strabismus repair)
  • Decrease secretions
361
Q

AntiACh SEs

A

tachycardia, dry mouth, impaired sweating

Scopolamine and atropine cross BBB- may cause agitation, confusion, restlessness, memory loss

362
Q

AntiACh
Safety in pediatrics

A

with neonates, have atropine ready
kids are HR dependent
0.01-0.02mg/kg

Glyco- consider thoughtfully d/t uncomfortable s/e of dry mouth
0.01mg/kg

363
Q

Atropine vs Glyco strength

A

Glyco is twice as potent at blocking secretions and lasts 3x longer

careful consideration when giving glyco

364
Q

Topical Anesthetics:
EMLA

A

Lidocaine & Prilocaine

Occlusive dressing for one hour
Can cause vasoconstriction and blanching- increased difficult IV

365
Q

ELA-Max

A

4% lido

Requires only 30min
Less vasoconstriction than EMLA

366
Q

S-caine patch

A

lido and tetracaine

Heat controlled patch for accelerated delivery- only 20min
Theoretically should dilate

367
Q

Acetaminophen
FDA approved for children….

A

2 years and older

368
Q

Tylenol dosing

A
  • PO: 10-15mg/kg

IV:

*2-12yrs: 15mg/kg q6hrs
* 1month- 2yrs: 12.5mg/kg q6hr or 10mg/kg q4h (max 50-60mg/kg/day)
* FT neonates up to 28days: 7.5mg/kg q6hr (max 30mg/kg/day

369
Q

Who should get Corticosteroids as premedication?

A

currently taking or who have discontinued chronic corticosteroid treatment in the last 6 mons

370
Q

Corticosteroids
usual recommended dose

A

hydrocortisone IM or IV: 1-2 mg/kg
or
equivalent of dexamethasone (0.05 to 0.1 mg/kg)

1 hour before induction or as soon as IV access is established

371
Q

How long do we wait between corticosteroid doses?

A

dose may be repeated every 6 hours for up to 72 hours

372
Q

GI drugs
dosing chart

A
373
Q

Only a single dose of ____ is recommended due to metabolites that can cause seizures

A

meperidine

374
Q

TABLE 4.4
Surgical Antibiotic Prophylaxis (Weight-Normalized)

A

Pediatrics (2 decks)

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