Lifespan Flashcards
ABG changes in pregnancy
Ph same, 02 inc, co2 and bicarb decrease
Changes in preg: oxy hgb dissoc curve
Right shift to give 02 to fetus
Clotting changes in pregnancy
Mom makes more clot but breaks it down faster. Inc factors 1,7,8,9,10,12. Dec c+s. Inc fibrin breakdown. Dec 11,13.
Uterine blood flow: ml/min, %CO, dependent on what
700, 10. Map/co/vasc resistance, not autoregulated
Uterine blood flow calc
Uterine artery pressure-uterine venous pressure / uterine vascular resistance
Drug traits that favor placental transfer
Low molecular weight, high lipid solubility, unionized, nonpolar
Drugs w significant placental transfer
Local anesthetics, iv anes, vas, opioids, benzos, atropine, BBs, mag
Drugs w no placental transfer
Nmbs, glyco, heparin, insulin
Cause of early, variable, and late decals
Early= head comp. variable= umbilical cord comp. late= maternal acidosis and preeclampsia
Things that reduce fetal hr variability
Cns depressant drugs, hypoxemia, fetal sleep, acidosis, anencephaly, cardiac anomalies
Mnemonic for fetal decels
Veal chop
Tier 2 and 3 for fhr
2= bradycardia or tachy. Some variability. Variable decels. 3= Brady, no baseline variability, late and variable, sinusoidal pattern
Side effects of mag
Pulm edema, hypotension, skel muscle weakness, inc potency nmbs, cns dep, reduced fx of ephedrine and phenylephrine
Tx for too much mag
Calcium, diuretics
SE of oxytocin
H20 retention, low na, low bp, tachycardia (reflex), coronary vasoconstriction
Methergine: s/e if given iv
Vasoconstriction, high bp, cerebral hemorrhage
Hemabate: second or third line, dose, se
Third. 250 mcg. Nvd, low or high bp
Ketorolac implication in preg
Nsaids contraindicated after 3rd trimester, can close ductus arteriosus
Best trimester for pregnant pt non emergent surgery
Second
When pregnant woman needs aspiration prophylaxis. When drugs need to be given
Beyond 14 weeks gestation. Bicitra 30 min preop and ranitidine 1 hr before
Differences b/w gest htn, preeclampsia, and eclampsia.
All occur after 20 weeks. Gest htn just htn. Pree= +proteinura and edema. Eclampsia= +seizures
Pt w preeclampsia develops what in abnormal amounts, overall effect
More thromboxane than prostacyclin. Vasoconstriction, inc plt agg, reduced placental bf
Diff b/w mild and severe preeclampsia: SBP, DBP, urine diff
Severe= >160/110. Inc proteinura and less 24 hr urine total than 500
Diff b/w mild and severe preeclampsia: edema, others
Severe has pulm edema, both have generalized. Severe: cyanosis, h/a, visual impairment, belly pain, hellp syndrome, less plt, impaired fetal growth
Preeclampsia: exag response to which drugs, implication of mag to consider
Sympathomimetics, methergine, and nmbs. Mag inc risk of postpartum hemorrhage
Anes implic of maternal cocaine abuse
Acute intox inc mac, chronic abuse dec mac. Tx htn with vasodilators, bb may cause heart failure. Low bp may not respond to ephedrine. May have low plt, check before neuraxial
What happens in 3 placental implantation disorders
Accreta attaches to surface, Increta invades myometrium, percreta extends beyond uterus
Diff b/w placenta Previa and placental abruption
Previa= lower uterine segment, painless bleed. Abruption: separates from wall before delivery, risk of amniotic fluid emb/dic
Uterine atony is increased by what
Mu;ltiparity, multiple gestation, polyhydramnios, oxytocin infusion for awhile before delivery
Normal vs newborn
70/40, 140, 40-60 rr
Normal vs 1 year old
95/60, 120, rr 40
Normal vs 3 year old
100/65, 100, rr 30
What hypotension is in: newborn, 1 year old, if older than 1
Newborn <60. 1 y/o <70. >1=
Infant: breathing pattern, tongue, neck length, epiglottis shape
Pref nose breather, large tongue, shorter neck, epiglottis= u or omega, stiffer, longer
Infant: VC position, larynx location
VC slanted anterior, larynx c3-4
When peds have adult numbers of alveoli
8-10 years old
Neonate: 02 consump, avl vent, tv
6 ml/kg/min, 130ml/kg/min, 6 ml/kg (same as adult tv)
Neonatal diaphragm muscle type compared to adult
Less type 1 muscle fibers. Type 1= more resistant to fatigue
Pts at risk for apnea after surgery. Treatment
<60 weeks post conceptual age, should be monitored for 24 hrs after. Tx= caffeine or theophylline
Neonate compared to adult: FRC, VC, tlc, RV, cc, tv
Tv same. FRC, VC, and tlc decreased. RV and cc are higher than adult
Umbilical vein: ph, 02, co2. Umbilical art: ph, 02, co2
Vein (placenta to fetus) 7.3, 30, 40. Artery (fetus to placenta) 7.3, 20, 50.
Newborn abg after delivery: 10 min, 1 hr, 24 hr
10 min: 7.2, o2 50, co2 50. 1 hr: 7.35, 02 60, co2 30. 24 hr: 7.35, 02 70, co2 30.
When respiratory control matures in newborn (to hypoxemia). What happens before v after
44 weeks post conceptual age. Before= hypoxemia depresses vent. After= hypoxemia stim vent
Fetal hgb: p50, what it does to curve
- Shifts curve left to hold onto 02
When hgb f replaced by hgb a in baby
6 months
Hgb at: birth, 3 months, 6 months
17 at birth. 3= 10. 6=same as adult, 26.5
Transfusion trigger for rbcs if less than 4 months old
<13 if severe cardiopulm disease. <10 if major surgery or moderate cardiopulm disease
Rbc transfusion dose in <4 month old, how much it raises hgb
10-15 cc/kg. 1-2 g/dl
Ffp dose in peds
10-20 ml/kg
Plt transfusion in peds: when indicated, dose if apheresis, dose if pooled plt
<50k. Apheresis= 5 ml/kg. Pooled= 1 pack per 10kg
Neonates: how they handle water and sodium
Poor conservation of water and unable to excrete large volumes of water, and high insensible losses. Obligate na loser first few days of life
When gfr matures in peds, when renal tubular func can fully concentrate
8-24 months gfr. 2 years
When hypoglycemia signs appear in newborns. Treatment
<40 mg/dl if awake. 2 ml/kg 10% dextrose, 4 ml/kg if seizures. D10 gtt 8 mg/kg/min to maintain
How CO, VD, and PB changes in neonate affect drugs in them
CO inc (inc delivery and clearance), larger TBW so need higher dose of h20 sol, less albumin/a1glycoprotein if <6 month old= higher risk toxicity of Pb drugs
How fat content, hepatic metab, and renal clearance changes affect neonate w drugs
Lower fat content, longer doa if require fat for redistribution. Underdeveloped liver until 1 year old. Dec renal clearance until 2 years old
How MAC is diff in 1-6 months, 2-3 months, neonate, and premie
1-6 higher than adult. 2-3 highest level. 0-30 days lower than infant. Premie= lower than neonate
Mac for sevo if 0-6 months, 6months-12 years
0-6 higher. To 12 years lower than 0-6 but still higher than adult
Sux in peds: dose for neonates/infants, dose if older kid. When and how much atropine to give
5 mg/kg. 4 mg/kg. 0.02mg/kg if less than 5 years, definitely if second dose
Roc in peds: SE in peds, Im dose <1 year >1 year. Onset
Mild inc in hr. 1 mg/kg, 1.8 mg/kg. 3-4 min
Vec diff in peds
Longer doa
VACTERL association of TEF in peds
Congenital anomalies. Vertebral defects, Imperforated anus, cardiac anomalies, TEF, esophageal atresia, renal dysplasia, limb anomalies
Risk factors for RDS in peds
Low birth weight, low GA, 02 toxicity, barotrauma from PPV, ETT, maternal dm
Lecithin to sphingomyelin ratio: ratio when adequate
> 2 = nml lung development
RDS pts: where preductal pulse ox and postductal pulse ox shout led be placed. What diffference in the two could mean. Where to put a line
Pre= right upper arm. Post= lower extrem. Diff= pulm htn, right to left shunt, return to fetal circ via pda. Preductal a line
Omphalocele: organ involvement, covering, incidence, coex disease, surgery urgency
Bowel +/- liver. Covering present. More common. Trisomy 21, cardiac defects, beckwith syndrome. Less urgent
Gastroschisis: organ involve, covering, incidence, coex disease, surgery urgency
Bowel, no covering, less common. Prematurity, more urgent
Pyloric stenosis: lyte and ph changes from vomiting
Low na/k/cl. Metabolic alkalosis.
Pyloric stenosis: which way curve shifts, how kidney responds. Late complication
Left, less tissue 02 release. Bicarb excretion. Aldosterone release, na and h20 retained. Metabolic acidosis from lactate release
Pyloric stenosis: intraop fluids. Postop what is common and why
20 ml/kg 0.9% ns, 1.5x maintenance rate of d5 0.45% ns. Postop apnea from csf remaining alkalotic
To prevent retinal complic from 02, what spo2 should be maintained between until what age
85-93 up to 44 week post conception
Where to monitor 02 sat of retinal vessels
Pre ductal spo2
Drugs associated with apoptosis, how
IAs, nitrous, prop, ketamine, etomidate, barbs, benzos. Antagonizing or stimulating nmda receptor
Drugs that arent associated with apoptosis
Opioids, precedex, xenon
What kernicterus is, what leads to it
Fetal encephalopathy caused by anything that increases bilirubin
Risk factors for kernicterus
Premature, low plasma protein conc, acidosis
Epiglottitis: mechanism, age, onset
Bacterial, 2-6 years old, <24 hr
Laryngotracheobronchitis (croup): mechanism, age, onset
Viral or rarely bacterial, <2 yr old, 24-72 hours
Epiglottitis: area affected, ____ sign, presentation
Supraglottic area, thumb sign. High fever, tripod Ig, drooling, dysphoria, dyspnea, dysphagia
Croup: region affected, ___ sign, presentation
Laryngeal, steeple. Mild fever, stridor, barking cough
Treatment epiglottitis
02, emergency a/w mgmt, abx, cpap, induc w spont breathing, ent surgeon needs to be present, icu after sx
Treatment croup
02, racemic epi, steroids, humidification, fluids, rarely needs intubation
Dose of racemic epi for postintubation croup
0.5 ml of a 2.25% sol
Risk factors post ett croup
<4 years old, ett to large or cuff col to high, several attempts, prolonged intubation, coughing, head or neck surgery, history of croup, trisomy 21
Supraglottic obstruc leads to ____, infraglottic obstruc leads to ____
Stridor. Wheeze
Pierre robin anomalies
Small mandible, tongue falls back, cleft palate
Treacher Collins anomalies
Small mouth and mandible, nasal airway blockers, ocular
Trisomy 21 anomalies
Small mouth large tongue atlantoaxial instab, small subglottic diameter
Klippel feil change
Fusion of cervical vertebrae
Goldenhaur and beckwith anomalies
Gold= small mandible and cervical spine abn. Beck= large tongue
Cri du chat abn
Small mandible, laryngomalacia, stridor
1st and 2nd most common cardiac abn in downs
1st is atrioventricular septal defect 2nd is VSd
Anes consid in downs
Difficult ett (small mouth, big tongue, arched palate, atlantoaxial instab), c1/2 sublux (dont flex neck, get X-ray if 3-5 years old), need smaller ett, osa, chronic pulm infec, Brady common w induc. Epilepsy, gerd, flexible joints
What is charge association
Coloboma (hole in eye), heart defects, Chantal atresia, retardation of growth, gu problems, ear anomalies
What is catch 22 syndrome, other names
Cardiac defects, abn face, thymic hypoplasia, cleft palate, hypocalcemia, 22q11.2 gene deletion. Also called DI George
DI George syndrome: electrolyte consid, if ___ absent at high risk of infec. Transfusion consid
Low ca (albumin, hypervent, and blood products may worsen this). Thymus. Leukocyte depleted irradiated blood is best
What is 1 met
3.5 ml/kg/min
What activities are equal to 1 what
Self care, work at computer, slowly walking 2 blocks
What activities = 4 mets
Climbing a flight of stairs, 1-2 blocks uphill, light housework, raking leaves, gardening
Which respiratory traits increase in elderly
Min vent, lung compliance, dead space, v/w mismatch, a-a gradient,
Which resp traits decrease in elderly
Lung elasticity, pa02, lung recoil, chest wall compliance, response to inc co2/dec02
Lung volumes that increase in elderly
FRC, cc, RV
Hemodynamics in elderly: values that inc, dec, or stay same
Inc: BP, PP. Dec: diastolic func, SV, HR, CO. Same: SBP
ANS changes in elderly
Inc sns tone, dec pns tone, dec response to catecholamines. Dec baroreceptor response, inc syncope/ortho hypo
How mac changes in elderly
Dec 6% each decade after 40
How neuraxial is diff in elderly (sensitivity to LA and intrathecal and epidural anes, response to epi, etc)
Inc sensitivity to all 3.dec number of nerves and diameter. Dec csf vol= greater la spread (need to dec dose). Dec response to epi test dose
Kidney changes in elderly: renal bf, serum creat, renal , mass, creat clearance
Serum creat same. Gfr dec, renal bf dec 10% per decade, renal mass dec, dec creat clearance (best indicator of func).
Kidney in elderly: gfr, response to acid load, aldosterone, adh
Gfr dec 1 ml/min/year after 40. Inc risk overload. Dec response to acid load, dec aldosterone (inc risk dehydration), dec response to adh
Liver in elderly: mass, bf, periop function
Dec mass (less enzyme made), dec bf (less toxin delivered per time), dec func bc bf/mass not bc of hepatocellular func
Diff and implication in elderly: a1 glycoprotein, albumin produc, psuchocholinesterase
Inc a1 (inc reservoir for basic drugs), dec albumin (dec reservoir for acidic rx), dec pseudocholinesterase (inc doa sux and ester las)
Diff and implic in elderly: phase 1 rxn, phase 2 rxn, first pass metab
Dec phase 1, no change 2, dec first pass.
Diff in elderly: lipophilic and hydrophilic drug response
Inc body fat= inc vd for lipophilic drugs, may inc DOA. Dec lean muscle mass= less body water= smaller vd hydrophilic. Higher conc per dose
Change in elderly: protein binding and recovery from VAs
Inc free frac acidic drugs, dec free frac basic drugs, dec rate of recovery (inc fat and dec hepatic metab and dec gas exchange)
Drugs w poor placental transfer tend to be what and example
Highly ionized. Sux, ndmrs, heparin, glyco, insulin
Drugs w inc placental transfer tend to be what and ex
Lipophilic. Benzos, opioids, VAs, IV anesthetics, LAs, BBs, atropine
Maternal and fetal SE from B2 agonist therapy
Mom: inc bg, dec K, inc HR. Baby: low bg after delivery, inc hr
Fetal bradycardia is most common in which kind of neuraxial/block
Paracervical block
Best time to do elective sx on preg pt
Second trimester
4 abn associated with tet of fallot
VSd, aorta overrides PA, RV outflow tract obstruct, RV hypertrophy
Youngest age acceptable for same day sx
60 weeks
What heat transfer is ex of: covering head w plastic, incubator, foam pad on or table, humidifying gas
Radiation, convection, conduction, evaporation
Which subunits are on a fetal nicotinic receptor
Gamma, delta, beta, 2 alpha
What age does closing capacity exceed FRC when supine
45 years old
Causes of post op delirium
Pneumonic= delirium. Drug use, lyte abn, lack of drug (withdrawal), infec (uti), reduced sensory input, IC dysfunc, urine ret/fecal impac, myo event and male gender
Drug to give when Parkinson’s pt dhowing inc DA fitting in PACU
Benadryl
Where are ductus venosus And arteriosus
Venousus= b/w umb vein and ivc. Arteriosus= b/w pa and proximal descending aorta
How PVR and SVR different in fetal circ
PVR high and SVR low (unlike adults)
When foramen ovale closes
When lap > rap, umbilical cord clamp. Officially over 3 days
Ductus arteriosus: purpose, when it closes
Shunt blood from pulm trunk to aorta. SVR > PVR (inc pa02 dec prostaglandin). Several weeks
Ductus venosus: purpose, when it closes
Allows umb blood to bypass liver, closes w umbilical cord clamping
3 things we can effect that increase PVR
Light aneasthesia, tburg, and hypercarbia
Factors that inc PVR
High co2, low 02, acidosis, collapsed alveoli, tburg, low temp, inc sns, light anes, pain
Factors that decrease PVR
Hypocarbia, adequate 02, alkalosis, hemodilution, vasodilators, nitric
Factors that inc SVR
Pressers, fluid bolus, inc sns, pain, anxiety
Factors that decrease SVR
IAs, prop, dec SNS, histamine, anaphylaxis, hemodilution, sepsis
Which shunts cause cyanosis, examples
R to L. 5 Ts: tet, TGA, tricuspid valve abn, truncus arteriosus, total anomalous pulm venous connection
Right to left shunt effect on inhalation and iv inductions
IA: slower induc, rate of rise slower (blood bypassing lungs), more profound if less sol (des and n20). IV: faster onset, rx enters systemic circ faster
Left to right shunt: examples
VSd, asd, pda, coarctation of aorta
L to right shunt: patho and goals
Dec CO and BP. Inc pulm bf (pulm htn). Goal: avoid inc SVR, avoid dec PVR, dec fio2 and hypoventilation
Eisenmengers syndrome occurs when
When L to R shunt pt gets pulm htn, causes flow reversal and cyanosis
Tet of fallot defects
Vsd, aorta overrides RV and lv, pulm stenosis, RV hypertrophy
Tet of fallot goals
Minimize r to l shunt by inc SVR dec PVR maintaining contractility and hr, inc preload
Tet of fallot: things and drugs to avoid
Vasodilation (want to inc SVR), high co2/acidosis and low 02 (want to dec PVR), sns stim/ephedrine/dobutamine/epi (want to maintain hr)
Tet of fallot: good drugs
Phenylephrine, nitric, esmolol, crystalloid, albumin
Tet of fallot: best induc agent, avoid drugs that do what, ekg
Ketamine. Avoid histamine releasers. Right axis deviation
Most common pediatric vs adult congenital cardiac anomaly
Ped= VSD. Adult= bicuspid aortic valve
Where coarctation of aorta occurs
Narrowing of thoracic aorta before or after ductus arteriosus. Rarely prox to L subclavian
Which coarctation of aorta more common in neonate v adult
Neonate= preductal, adult=postductal
Coarctation of aorta: patho, what can cause hemodynamic collapse
Inc LV afterload, SBP elev in upper extrem and dec in Lower extrem. PDA closure
