Lecture 2-Perioperative Considerations In Pediatrics

Question 1

Literature has indicated that the most effective method for pediatric induction is PO ___ with ___ presence

Answer 1

PO versed with parental presence

Question 2

Once a ___, always a ___; respiratory effects will last into ___

Answer 2

Once a premie, always a premie; respiratory effects will last into adulthood

Question 3

Neuro history—history of seizures—increased risk of seizures with ___ (IH), but it is still the drug of choice for pediatric induction

Answer 3

Increased risk of seizures with sevo

Question 4

Neuro history—neuromuscular disorder (muscular dystrophy, myotonic dystrophy, cerebral palsy)—caution using ___ d/t increased risk of hyperkalemia

Answer 4

Succinylcholine

Question 5

Respiratory history—recent cough, cold, fever, pneumonia within the past ___ weeks—if yes, risk of ___/___ is very high

Answer 5

Recent cough, cold, fever, pneumonia within the past 6 weeks—if yes, risk of laryngospasm/bronchospasm is very high (because everything is inflamed)

Question 6

Mask induction—if kid is not crying, put ___ on first, then mask

Answer 6

Monitors on first, then mask

Question 7

Mask induction—if kid is screaming/crying, put on ___ first, then ___

Answer 7

Mask first, then monitors (they are going to rip off the monitors, so may as well wait until they are asleep before putting them on)

Question 8

First monitor is ALWAYS ___, then ___, ___

Answer 8

Pulse ox, then EKG, BP

Question 9

Anesthesia stages—stage 1 = ___; eyes ___

Answer 9

Awake; eyes midline

Question 10

Anesthesia stages—stage 2 = ___; eyes ___; HR goes ___ during this stage

Answer 10

Hyperexcitable; eyes divergent; HR goes through the roof during this stage

Question 11

Anesthesia stages—stage 3 = ___; eyes ___; good time to put in an ___

Answer 11

Asleep; eyes midline; good time to put in an IV

Question 12

Anesthesia stages—stage 4 = CV reflexes are ___; can be ___tensive, ___cardic; turn down ___ (especially in kids with ___); eyes ___

Answer 12

CV reflexes are anesthetized; can be hypotensive, bradycardic; turn down gas (especially in kids with Down Syndrome—as soon as HR goes down, cut down gas to half…these kids are at high risk for cardiac arrest during induction); eyes midline

Question 13

IV induction is advantageous in pediatric patients because kid goes to sleep without going through stage ___, so risk of ___ is very low

Answer 13

Stage 2, so risk of laryngospasm is very low

Question 14

Anatomical differences between pediatric and adult airways—pediatric airway = proportionally smaller ___; epiglottis is ___ (shorter/longer) and ___ (narrower/wider); head and occiput are proportionally ___ (smaller/larger); tongue is proportionally ___ (smaller/larger); neck is much ___ (shorter/longer); larynx is more ___ (anterior/posterior) and ___ (cephalad/caudal); adenoids are ___ (smaller/larger)

Answer 14

Proportionally smaller larynx; epiglottis is longer and narrower; head and occiput are proportionally larger; tongue is proportionally larger; neck is much shorter; larynx is more anterior and cephalad; adenoids are larger

Question 15

The narrowest portion of the pediatric airway is the ___

Answer 15

Cricoid cartilage (below the vocal cords)

Question 16

Narrowest portion of the adult airway is the ___

Answer 16

Vocal cords

Question 17

Risk of mainstem intubation is much ___ (higher/lower) in pediatrics d/t short trachea and bronchus

Answer 17

Higher

Question 18

If you are meeting resistance when inserting ETT in pediatric patient, you need to ___ the ETT

Answer 18

Downsize…do NOT force it!

Question 19

As soon as you see the ETT pass through the vocal cords in the pediatric patient, you should continue to advance the tube—T/F?

Answer 19

False—don’t bury the tube…as soon as you see the tube pass through the vocal cords, stop there and don’t continue to advance

Question 20

Kids are at highest risk of laryngospasm when going to sleep and when waking up during stage ___ of anesthesia

Answer 20

2

Question 21

If child is in stage 2 of anesthesia, do not ___ the child until they are awake

Answer 21

Do not stimulate the child until they are awake

I.e.: if child is extubated deep or LMA is removed deep and he is brought straight to PACU, he will go through stage 2 while in PACU…do not place monitors on the child in PACU when they are still in stage 2

Question 22

Medication treatment of laryngospasm = ___ + ___

Answer 22

Succinylcholine 0.4 mg/kg IV + atropine 20 mcg/kg IM

Question 23

If patient is experiencing laryngospasm during stage 2 of anesthesia and you don’t have your IV yet, how should you give medication?

Answer 23

Give meds IM—remember, don’t want to place an IV during stage 2 (hyperexcitable stage)

Question 24

Why do we give atropine with succinylcholine to break laryngospasm?

Answer 24

Because succs can cause profound bradycardia in children

Question 25

First line treatment of laryngospasm =

Answer 25

Positive pressure 40 mm Hg

Question 26

___ allows you to give positive pressure and feel the bag inflate/deflate as patient is spontaneously breathing once you break the laryngospasm (can’t feel the patient spontaneously breathing with regular ambu bag)

Answer 26

Mapelson D

Question 27

Always bring ___ to PACU in case child laryngospasms—that way, child has been oxygenated prior to the event rather than starting at room air

Answer 27

Oxygen tank

Question 28

Fatigue can account for ___ of the needed anesthetic in the OR and PACU—___ (increase/decrease) dosing of narcotics, sedatives, and anesthetic gases for fatigued children

Answer 28

1/3–decrease dosing

Question 29

Opioids—give ___ the dose for fatigued children

Answer 29

1/2

Question 30

Opioids—give ___ the dose for children with OSA

Answer 30

1/2

Question 31

Narcan dose in children—___ mcg/kg

Answer 31

0.5 mcg/kg

Question 32

Zofran dose peds—___-___ mg/kg; black box warning—risk of ___

Answer 32

0.1-0.5 mg/kg; black box warning—risk of prolonged QT

Question 33

Post-op—if you have adequately dosed child with pain meds and they are still fussy, what should you do?

Answer 33

Feed them! They may be fussy because they are hangry—sugar binky, sugar water, bottle, get mom for breastfeeding infants…food can replace the need for further medication