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Peds-Dr. Sames > Memory Master Test 3 > Flashcards

Memory Master Test 3 Flashcards

1
Q

What drugs will have a larger volume of distribution in the infant compared with the adult?
Smaller volume of distribution?

A

Larger = water-soluble will have larger volume of distribution in the infant

Smaller = lipid-soluble will have smaller volume of distribution in the infant

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2
Q

What is the most prominent muscurinic action of a bolus of succinylcholine in the pediatric patient?

How can this action be prevented?

A

Bradycardia develops in response to succinylcholine; so atropine should be administered prior to succinylcholine

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3
Q

A 2 yr old develops laryngospasm postop and becomes bradycardic. Should atropine be given prior? Concurrently? Or after succinylcholine?

A

If 10-15 cmH2O does not break the laryngospasm, then atropine 0.02 mg/kg followed by succinylcholine 0.1-1 mg/kg IV or 4 mg/kg IM

Succinylcholine mimics effect of acetylcholine at cardiac muscurinic receptors, which can cause severe bradycardia, junctional rhythms, or sinus arrest.

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4
Q

How much NDMR does a pediatric patient require compared with adults on a weight basis? And succinylcholine?

A

Neonates, infants, and children require the same dose of nondepolarizing neuromuscular relaxants as adults

Succinylcholine, neonates require 2x as much as older children or adults.

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5
Q

Given that an infant has greater sensitivity to NDMR than adults (due to immaturity of neuromuscular junction), why is the dose administered on a weight basis the same for infants and adults?

A

Infants have a greater volume of distribution for muscle relaxants.

The increased volume of distribution normally requiring a greater amount of drug is offset by the increased sensitivity of NDMR at neuromuscular junction so infant and adult dose are the same on a weight basis.

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6
Q

2 reasons why neonates require more succinylcholine on a mg/kg basis than adults

A
  1. Neonates have larger volume of distribution for succinylcholine than adults. Extracellular fluid (ECF) makes up 40-50% in neonate body weight and 20-25% of body weight in adults. Succinylcholine distributes to ECF so more drug is needed on a per kg basis.
  2. Neuromuscular junction is immature (less sensitive) in the neonate, so more drug is needed.
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7
Q

Define ED90. State if the ED90 for succinylcholine is increased, decreased, or unchanged in the neonate compared with the adult, and indicate what this means.

A

ED90 is the dose of drug that is effective in 90% of population.

ED90 for succinylcholine is increased in the neonate compared with adult.

An increased ED90 means that a larger dose of succinylcholine must be given to the neonate to achieve adequate paralysis

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8
Q

How would the ED95 for succinylcholine compare between neonate and adult- the same, higher, or lower?

A

ED95 of succinylcholine for the neonate would be HIGHER.

Specifically, sux ED95 = 620 mcg/kg for neonate and 290 mcg/kg for adult

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9
Q

Neonates and infants require about twice as much succinylcholine (mcg/kg) as older kids and adults. State 4 reasons why neonate and infants are more resistant to succinylcholine than older kids and adults.

A

Neonates and infants up to 2 yrs old are more resistant due to:

1) an ED95 of 625 and 729 mcg/kg (2-2.5x greater)
2) Faster clearance
3) Larger volumes of distribution
4) Shorter onset times

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10
Q

Compate Vecuronium in infant and adult in regards to potency, onset, duration of action, and recovery.

A

Vecuronium potency similar to infants and adults

Onset more rapid and duration longer and recovery slower in infants compared to adults.

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11
Q

An infant has life-threatening succinylcholine-induced hyperkalemia: what is the definitive treatment?

A

IV calcium (10mg/kg Calcium Chloride) or (30 mg/kg Calcium Gluconate)

This restores the gap between the resting membrane potential of the cardiac cells and the threshold potential for depolarization.

Repeated doses of calcium must be administered together with cardiopulmonary resuscitation, epinephrine, sodium bicarbonate, glucose and insulin, and hyperventilation until arrhythmia resolves.

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12
Q

Describe 4 steps to treating hyperkalemia in the neonate.

A

1) Calcium Chloride (0.1-0.3 mL/kg 10% solution) or Calcium Gluconate (0.3-1.0 mL/kg 10% solution) over 3-5 minutes.
2) Return K to intracellular space by correcting acidosis with Sodium BICARB, mild HYPERventilation, and BETA-AGONISTS
3) Maintain K in intracellular space with GLUCOSE (0.5-1.0 g/kg) and INSULIN (0.1 U/kg) infusion over 30-60 minutes.
4) Remove whole-body K burden with KAYEXALATE or DIALYSIS

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13
Q

How does an infant’s quantity of plasma proteins, body fat, and muscle differ from the adult?

A

Plasma proteins, body fat, and muscle are reduced in the infant compared with the adult.

Decreased plasma proteins mean more free drug is available to produce clinical effects.

A lower dose may be indicated.

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14
Q

State 3 reasons why the uptake of anesthetic drugs is typically faster in children than adults.

A

1) Children have higher alveolar ventilation per weight (accounts mostly for affect)
2) Increased CO with greater distribution to Vessel Rich Groups combined with lower muscle mass allows more of the agent to concentrate in vital organs, especially the brain
3) Anesthetic Agents appear less blood soluble in children than adults so they work faster.

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15
Q

Give the two most important reasons why children are induced faster than adults with inhalational agents.

A

1) Smaller FRC per body weight

2) Greater blood flow to the brain

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16
Q

Name 10 procedures where N2O should be avoided.

A
  1. Patent Ductus Arteriosus
  2. Pneumothorax
  3. Pneumoencephalography
  4. Lung cysts
  5. Omphalocele repair
  6. Necrotizing enterocolitis
  7. Bowel Obstruction
  8. Diaphragmatic hernia
  9. Tympanoplasty
  10. Congenital Emphysema
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17
Q

What is the most common type of delirium in children?

A

Emergence delirium.

Occurs within minutes of regaining consciousness

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18
Q

In the patient with congenital diaphragmatic hernia, what lung is usually involved?

A

Herniation on the left side through the foramen of Bochdalekin 80% of congenital diaphragmatic hernias hence the left lung is involved.

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19
Q

Is the infant with a diaphragmatic hernia with bowels extending into the chest an emergency?

A

Hell yeah.

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20
Q

List 7 anesthetic considerations for managing an infant with a diaphragmatic hernia with bowels extending into the chest..

A
  1. NG tube
  2. No + pressure via mask
  3. Intubate with controlled ventilation
  4. Monitor PaCO2 and SaO2
  5. Use 100% O2
  6. Use muscle relaxants and Opioids after the chest is opened.
  7. No N2O.
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21
Q

During the intraoperative period of a congenital diaphragmatic hernia repair, the SaO2 suddenly falls to 65% and heart rate decreases to 50 bpm. What is the likely cause and what should be done?

A

Any sudden deterioration in lung compliance, HR, oxygen saturation, or BP suggests a tension pneumothorax on the contralateralside.

Absent or diminished breath sounds confirmthe diagnosis of pneumothorax, and the chest tube should be inserted immediately.

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22
Q

What serum sodium, potassium, and chloride concentrations and what urine output are needed before surgery in the patient with pyloric stenosis?

A 
Na = >130 mEq/L
K = >3 mEq/L
Cl = >85 mEq/L
UOP = 1-2 mL/kg/hr minimum
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23
Q

Is pyloric stenosis a medical or surgical emergency?

A

Medical. Postpone surgery 24-48 hours until fluid and electrolyte abnormalities are corrected.

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24
Q

The newborn has undergone a pyloromyotomy. What might you be concerned about in the postoperative period?

A

Neonates who have undergone pyloromyotomy may be at increased risk for respiratory depression and hypoventilation in the recovery room because of persistent metabolic or cerebrospinal fluid alkalosis.

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25
Q

What peak inspiratory pressure should be used with a patient who has a diaphragmatic hernia? Why?

A

Peak Pressures should be <30 cm H2O

Pneumothorax of the contralateral (usually R side) lung can occur if peak inspiratory pressure is too high

26
Q

What might be signaled by a sudden fall in lung compliance (reflected by an increased peak inspiratory pressure), BP, or oxygenation during repair of a congenital diaphragmatic hernia?

A

A Contralateral (usually R side) pneumothorax should be suspected

27
Q

What acid-base and electrolyte abnormalities develop in the patient with pyloric stenosis?

A

As a result of persistent vomiting, the infant becomes alkalotic (Metabolic alkalosis), hypochloremic, hypokalemic, and possibly hyponatremic.

The infant is dehydrated with hypokalemic, hypochloremic alkalosis.

28
Q

A neonate diagnosed with pylori stenosis presents with
Na=120
Cl= 84
RR= 16
What is appropriate course of action for this patient?

A

Pyloric stenosis is characterized by persistent vomiting which depletes Na, K, Cl, and H ions, causing hypochloremic metabolic alkalosis.

In this presentation the disturbances are moderately severe and the patient should be given IV D5 1/2NS with 20-40mEq/L K administered at a rate of 10 mL/kg/hr.

AVOID LR because lactate metabolizes to bicarb

29
Q

What happens to the oxyhemoglobin dissociation curve in pyloric stenosis? Why?

A

Oxyhemoglobin dissociation curve shifts to the LEFT because of metabolic alkalosis secondary to vomiting.

30
Q

How is the infant with pyloric stenosis prepared for surgery?

A

The emergent therapy is to stop oral intake (NO formula or breast feeding)

Metabolically reconstitute the child with IV Na, Cl, K, and Dextrose.

Abnormalities can be corrected in 12-24hrs by IV therapy. Surgeryshould be postponed for 24-48 hrs.

31
Q

What is the major concern for inducing an infant who is scheduled for a pyloromyotomy?

What do you need to do before inducing this patient?

A

Pulmonary aspiration is the major concern during induction.

Stomach is emptied as much as possible with large bore catheter prior to induction.

32
Q

What are six primary considerations for the pediatric patient with hypertrophic pyloric stenosis?

A
  1. Postpone surgery until volume and electrolyte deficiencies have been corrected
  2. Correction of the volume deficit and metabolic alkalosis requires hydration with NaCl solution supplemented with K
  3. Do not use LR because lactate is metabolized to bicarb, (worse metabolic alkalosis)
  4. Stomach should be emptied prior to surgery
  5. High risk of aspiration during induction
  6. PostOP respiratory depression secondary to CSF alkalosis should be anticipated
33
Q

What two electrolyte abnormalities will be seen with projectile vomiting?

A

Hypokalemia and hypochloremia

34
Q

Compare gastroschisis and omphalocele with regard to location, hernial sac, and associated congenital anomalies?

A

Gastroschisis:

  1. Location lateral to umbilicus
  2. Hernial sac is absent
  3. Associated congenital anomalies are absent

Omphalocele:

  1. Location base of the umbilicus
  2. Hernial sac present
  3. Associated congenital anomalies include trisomy 21, cardiac, diaphragmatic hernia, and bladder anomalies.
35
Q

Perioperative management of gastroschisis and omphalocele centers around what three preventative measures?

A
  1. H -Prevent Hypothermia
  2. I -Prevent Infection
  3. D -Prevent Dehydration
36
Q

Which is worse? Gastroschisis or Omphalocele with hypothermia, infection, and dehydration? Why?

A

Gastroschisis because no hernial sac

37
Q

Where is the fistula usually located in a patient with trachea-esophageal fistula (TEF)?

A

90% of TEF the lower segments of the esophagus inserts just above the carina onto the posterior wall of the trachea.

38
Q

Where is the proper placement of the ETT in patient with TEF? Describe intubation with TEF.

A

Tip of the ETT placed just distal to the TEF between fistula and carina

1) ETT inserted until it enters one or the other mainstem bronchi
2) Look for unilateral expansion of the chest and unilateral breath sounds
3) ETT then slowly withdrawn until bilateral breath sounds are present

39
Q

The key to successful anesthetic management of the neonate with TEF is correct positioning of the ETT. What is the important consideration for intubating the infant with a TEF? What intubation techniques are appropriate?

A
  1. Avoid positive pressure ventilation. (It will distend stomach, increase reflux risk and ventilatory compromise)

2 approaches to intubation:

A) Inhalation induction, followed by topical application of lidocaine and intubation while the infant is breath spontaneously

B) IV or inhalation induction and intubate the trachea with paralytic. This may lead to distension of the fistula and stomach after onset of + pressure ventilation.

40
Q

What is tracheomlacia (or tracheobronchomalacia)? What patients are at risk for developing tracheomalacia?

A

Softening of the tracheal tissue (especially cartilaginous rings).

Tracheomalacia is seen in neonates/infants, often in association with esophageal atreasia (TEF) or with extrinsic compression by vascular anomalies or mediastinal masses.

It is associated with hyperthyroidism.

41
Q

What is the definition of malacia?

A

Abnormal softening of the tissue

42
Q

What is the etiology of epiglottitis?

A

Life-threatening infection by Haemophilus influenza type B bacteria

43
Q

9 Signs & Symptoms of epiglottitis

A

AIR RAID TC
A= Airway Closed
I= Increased Pulse
R= Restlessness

R= Retractions
A= Anxiety increased
I= Inspiratory stridor
D= Drooling
T= Tachypnea
C= Cyanosis
44
Q

Children of what ages get epiglottitis?

A

Usually 1-7 years old

Higher frequency in <3 years

45
Q

Where is the optimal hospital location for intubation of a patient with epiglottitis? Why?

A

OR because total obstruction can occur at anytime.

An attempt to visualize the epiglottis should not be taken until the child is in the OR where intubation of the trachea and possible emergency tracheostomy should be performed.

46
Q

How is general anesthesia induced in the child with acute epiglottitis?

A
  1. Parents present until secure airway
  2. Quiet OR. Apply monitors as tolerated (esp Pulse Ox)
  3. Initiate induction with 100% O2/Sevoflurane (or Halothane) with the patient in the sitting position.
  4. Start an IV, give fluids and atropine and orally intubate
  5. NO PARALYTICS
  6. Avoid touching the epiglottis with laryngoscope blade just go to vallecula
  7. If oral intubate fails use FOB
  8. If FOB fails then tracheostomy.
47
Q

What induction method and what ETT size should be used in the patient with Epiglottitis?

A

Inhalation induction and ETT -0.5 to -1 smaller than usual.

48
Q

How long will ETT be in place with epiglottitis?

A

24-96 hours

49
Q

When should you extubate someone with epiglottitis?

A

An air leak usually appears around ETT due to decrease in swelling which may allow extubation

50
Q

Where and when should the patient with epiglottitis be extubated?

A

Extubation of the trachea is performed in the OR only after DL has confirmed resolution of the swelling of the epiglottitis.

51
Q

What is usual cause of croup (laryngotracheobronchitis) ?

A

VIRAL

52
Q

What frequently precedes Croup?

A

Upper Respiratory Infections

53
Q

What are some symptoms of Croup?

A
  1. Occurs at night
  2. Restlessness and Retractions
  3. Barking cough, crowing sounds
  4. Slow onset and slight temp (102)
54
Q

List three treatments of postintubation laryngeal edema (postintubation “croup”)

A
  1. Mild cases= cool, humidified mist and O2 therapy (face tent usually)
  2. Hourly admin of aerosolized racemic epinephrine ( 0.25 - 0.5 mL of 2.25% epinephrine mixed with 3 mL of Saline). For severe cases.
  3. IV Dexamethasone (0.25 - 0.5 mg/kg) max 10mg… may prevent edema but takes up to 4-6 hours to manifest.
55
Q

What is pathogenesis of post-intubation croup?

A

Due to glottic or tracheal edema.

56
Q

6 risk factors for post-intubation croup.

A
  1. Early childhood (14 years)
  2. Repeated intubation attempts
  3. Large ETT
  4. Prolonged surgery
  5. Head/neck procedures
  6. Excessive movement of the ETT
57
Q

What is the appropriate treatment for post-intubation croup?

A

Post-intubation croup is treated with the inhalation of nebulized racemic epinephrine (0.25 - 0.5 mL of 2.25% in 3mL of NS)

IV dexamethasone (0.25 - 0.5 mg/kg) Max 10 mg may prevent edema.

58
Q

What causes myelomeningocele? What is the difference between meningocele and meningomyelocele?

A

Failure of neural tube to close in fetus during development.
Failure of caudal end to close results in spina bifida.

A sac is present which contains meninges and neural elements
A meningocele is a sac containing only meninges.

59
Q

A seven-year-old patient with spina bifida comes to the OR for a ventricular-peritoneal shunt. What is the primary concern?

A

The major concern for this patient is the high probability of latex allergy which can trigger an anaphylactic episode in the OR.

Most children who have had intraoperative anaphylaxis had spina bifida.

60
Q

Which type of shock is most frequent in the pediatric patient?

A

HYPOVOLEMIC shock often due to blood loss from trauma.

Appreciate compensatory mechanisms (vasoconstriction and tachycardia) in children are very efficient at maintaining perfusion; children may lose as much as 1/4 of blood volume without CV changes in supine position.

Hypovolemic shock due to plasma loss can be seen with burns peritonitis and may be a component of septic shock.

Peds-Dr. Sames (10 decks)

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