Mod IV: Peds Opioids, Neuromuscular Blocking Agents - Anticholinergics - Benzodiazepines Flashcards
Opiods - Key Points
Opiods are a/w Increased central respiratory depression, particularly in what age group?
Neonates and infants < 6mos
Opiods - Key Points
Opiods are a/w Increased central respiratory depression, particularly in Neonates and infants < 6mos. Which opioid is most responsible for this?
MSO4 > fentanyl, sufenta, alfentanil, & remifentanil
Opiods - Key Points
What are other negative effects o opioid use in neonates and infants < 6mos?
Increase incidence PONV
Upper airway obstruction in susceptible patients
Chest wall rigidity is not uncommon in this population
Opiods - Key Points
What’s The most frequently used narcotic in children for postop pain control
Morphine
Opiods - Morphine
Use Morphine cautiously in neonates and infants, why?
Reduced hepatic conjugation
Decreased renal clearance of morphine metabolite
Infants have immature BBB, crosses over more than adults
Opiods - Morphine
IV Dose of Morphine is:
0.1 to 0.2 mg/kg
Opiods - Morphine
T/F: Morphine May be given rectally in peds
True
Opiods - Morphine
How does Ventilatory depression as a result of Morphine administration manifest?
Decreased VT and Rate
Opiods
What’s the most popular anesthesia adjuvant for all age groups?
Fentanyl
Opiods - Fentanyl
How can Fentanyl be administered in peds?
IV, IM, Oral, or Transmucosal
Opiods - Fentanyl
Which factors results in prolongation of effect of fentanyl?
Anything decreasing hepatic blood flow
Hypothermia
Opiods - Fentanyl
T/F: Respiratory depressant effect of Fentanyl outlasts analgesia
True
Pt will become free from analgesic effect of Fentanyl but still have some respiratory depression
Opiods - Fentanyl
Bradycardia with large doses of Fentanyl is secondary to:
Near complete ablation of sympathetics
(more cardiac than vascular)
Significant negative effect on peds CO since it is so dependent on HR
Opiods
Which opioid, although not used frequently, Possess the most favorable profile
Remifentanil
Easily titratable
Opiods - Remifentanil
How is Remifentanil metabolized?
Tissue and plasma esterases
Opiods - Remifentanil
How quickly do Remifentanil Effects dissipate after discontinuing infusion?
Effects dissipate within 5 – 10 mins of discontinuing infusion
Opioids - Remifentanil
T/F: Remifentanil is associated with decreased incidence of postoperative apnea in premature infant and neonate
True
Opioids - Remifentanil
Both bolus and continuous infusion doses of Remifentanil are higher in infants and young children; why?
Larger Vd
Increased elimination clearance
Opioids - Remifentanil
Bolus and continuous infusion doses of Remifentanil:
Remifentanil
1-2ug/kg bolus followed by
continuous infusion at 0.5ug/kg/min and TTE
Opioids
Opioid that is less commonly used, but that is less potent, more protein bound, and allows for rapid awakening
Alfentanil
Opioids - Alfentanil
Incidence of postoperative nausea and vomiting w/ Alfentanil
30% to 50%
Opioids - Alfentanil
DOA of Alfentanil in hepatic disease (or preterm)
Prolonged action
Opioids
Most potent synthetic narcotic:
Sufentanil
Opioids - Sufentanil
Bolus doses of Sufentanil can cause
Bradycardia/Asystole
Opioids - Sufentanil
Dose and administration of Sufentanil:
Sufentanil
0.1ug/kg then TTE
Dilute 50 ug/ml to 5 ug/ml
Opioids - Sufentanil
T/F: Sufentanil can be used intranasal for preop
True
But watch your patient really closely after the dose
Neuromuscular Blocking Agents
Muscle relaxant are less commonly used during induction in peds compare to adults. Why is that?
Many children have LMA or ET tube placed after receiving inhalation agents and placement of an IV access, and administration of various combinations of Propofol, opioids, and Lidocaine
Neuromuscular Blocking Agents
Which Neuromuscular Blocking Agent remains the fastest acting with shortest duration of action of any muscle relaxant?
Succinylcholine
Neuromuscular Blocking Agents - Succinylcholine
Dose requirements for Succinylcholine higher in infants, neonates, and young children. What’s the infants & neonates dose?
3 mg/kg IV
Neuromuscular Blocking Agents - Succinylcholine
Dose requirements for Succinylcholine higher in infants, neonates, and young children. What’s the young children dose?
2 mg/kg IV
Neuromuscular Blocking Agents - Succinylcholine
How could you administer Succinylcholine in emergency when IV access is not available?
Can be given IM in emergencies when IV access not available
Neuromuscular Blocking Agents - Succinylcholine
What’s the IM dose of Succinylcholine when given in emergency d/t IV access not being available?
4-6mg/kg IM
Neuromuscular Blocking Agents - Succinylcholine
What’s the Onset time and duration of Succinylcholine when given in emergency d/t IV access not being available?
Onset time 3-4mins with
Duration approx. 20mins
Neuromuscular Blocking Agents - Succinylcholine
What are Adverse effects/complications a/w administration of Succinylcholine?
Profound Bradycardia/junctional arrhythmias/sinus node arrest (after 1st dose without pretreatment with atropine)
Must always administer atropine 0.02 mg/kg (minimum dose 0.1 mg) prior to administering succinylcholine in pediatric patients
Hyperkalemia
Life-threatening arrhythmias (wide complex tachycardia, ventricular fibrillation, asystole
Muscle atrophy (Duchenne Muscular dystrophy)
Up-regulation of extra-junctional acetylcholine receptors (Burns)
Rhabdomyolysis leading to myoglobinuria
Muscle masseter spasm
May represent a normal response, especially if succinylcholine is under dosed
Harbinger of MH
(50% of those who develop severe MMR test positive for MH)
Malignant hyperthermia
Increased IOP, ICP, and intragastric pressure
Fasciculations/postoperative myalgia
Uncommon in children < 8yrs of age
Neuromuscular Blocking Agents - Succinylcholine
Must always administer atropine 0.02 mg/kg (minimum dose 0.1 mg) prior to administering succinylcholine in pediatric patients; why?
Profound Bradycardia/junctional arrhythmias/sinus node arrest after 1st dose without pretreatment with atropine
Neuromuscular Blocking Agents - Succinylcholine
Hyperkalemia a/w administration Succinylcholine can cause/or be the result of:
Life-threatening arrhythmias
(wide complex tachycardia, ventricular fibrillation, asystole)
Muscle atrophy
(Duchenne Muscular dystrophy)
Up-regulation of extra-junctional acetylcholine receptors
(Burns)
Neuromuscular Blocking Agents - Succinylcholine
What’s the Treatment for Hyperkalemia a/w administration of Succinylcholine?
CaCl 5-10 mg/kg IV
Neuromuscular Blocking Agents - Succinylcholine
Muscle masseter spasm (Masseter Muscle Rigidity) may represent a normal response, especially if:
Succinylcholine is under dosed
Neuromuscular Blocking Agents - Succinylcholine
What percentage of pts who develop severe MMR test positive for MH?
50%
Neuromuscular Blocking Agents - Succinylcholine
T/F: Fasciculations/postoperative myalgia following administration of Succinylcholine is common in children < 8yrs of age
False
Fasciculations/postoperative myalgia following administration of Succinylcholine is uncommon in children < 8yrs of age
Neuromuscular Blocking Agents - Succinylcholine
According to the FDA “Black Box” warning, “Succinylcholine in children should be reserved for which types of procedures?
Emergency intubations, or
Instances where immediate securing of the airway is necessary
Neuromuscular Blocking Agents - Succinylcholine
Accepted indications for Succinylcholine use in peds are:
RSI with full stomach
Laryngospasm
Difficult airway
Neuromuscular Blocking Agents - Succinylcholine
T/F: Despite drawbacks to use in children, succinylcholine retains its place as agent of choice for RSI and life-threatening airway obstruction
True
Neuromuscular Blocking Agents - Succinylcholine
11 Side Effects of Succinylcholine
Inc. ICP
Inc. IOP
Inc. IGP
Trismus
Cardiac dysrhythmias
Hyperkalemia
Myalgia
Rhabdomyolysis
Myoglobinemia
Inc. O2 consumption & Inc. CO2 production
Release of catecholamines
Neuromuscular Blocking Agents - NDMRs
Why are dosage and response to NDMRs variable in peds?
Larger Vd => increases bolus dose required to achieve desired affect
Increase sensitivity (immature NMJ) => decrease dosage requirement
Immature hepatic function prolongs duration action for drugs that depend primarily on hepatic metabolism
Pancuronium, vecuronium, & rocuronium
Neuromuscular Blocking Agents - NDMRs
Recommended doses of NDMRs agents are identical on a weight basis for neonates, infants, children and adults. How does their DOA compare to that of adults
Slightly longer
Considerations when selecting a NDMR - Possible side effects
Which NDMR has desirable vagolytic properties?
Pancuronium
Considerations when selecting a NDMR - Possible side effects
Which NDMRs are a/w Histamine release?
Mivacurium
Atracurium
Considerations when selecting a NDMR - Route of metabolism/excretion
How are Amino steroid (vecuronium, pancuronium, Rocuronium) metabolized?
Liver to inactive products
This is the reason why their duration of action is unpredictable
Considerations when selecting a NDMR - Route of metabolism/excretion
How are Benzylisoquinoliniums (cisatracurium, atracurium, mivacurium) metabolized?
Hoffmann’s elimination
Results in Predictable duration of action
Neuromuscular Blocking Agents - NDMRs
Which is considered the drug of choice for routine intubation (Not RSI) in the pediatric patient?
Rocuronium
Neuromuscular Blocking Agents - NDMRs
Fastest onset of nondepolarizing muscle relaxants
Rocuronium
Neuromuscular Blocking Agents - NDMRs
What are effects of Higher dosages (0.9-1.2 mg/kg IV) of Rocuronium
Produces onset of action within 90secs
Expect prolonged duration of action (90mins)
Neuromuscular Blocking Agents - NDMRs
What’s the only NDMR that can be given IM?
Rocuronium
1.0- 1.5 mg/kg IM
Requires 3-4mins for onset
Deltoid injection
Anticholinergics
T/F: Anticholinergics are very important in the pediatric practice
True
Anticholinergics - Atropine
Dose and route of administration of Atropine:
Atropine
0.02 mg/kg
oral, rectal, IM, IV
Anticholinergics - Atropine
Effects of Atropine
Decreases LES tone in infants
Anticholinergics - Atropine
How is Atropine prepared?
Emergency syringe
Succinylcholine + atropine with IM needle available for laryngospasm/bradycardia
Anticholinergics
T/F: Glycopyrrolate has slower onset but longer action compared to Atropine
True
Anticholinergics
What’s the administration dose of Glycopyrrolate?
Glycopyrrolate
0.01 mg/kg
Anticholinergics
When is Glycopyrrolate often used in peds?
For Airway procedures such tonsillectomy or
For Dental procedures
Benzodiazepines - Midazolam
What’s a common indication for Midazolam in Peds?
Separation anxiety
Benzodiazepines - Midazolam
How is Midazolam typically administered in peds and why?
Oral
Lack of IV access
Benzodiazepines - Midazolam
What’s the typical dose of Midazolam?
Midazolam
0.5-1.0 mg/kg PO
up to max 10 mg
Benzodiazepines - Midazolam
What are effects of 0.5 mg/kg dose of Midazolam in peds?
Anterograde amnesia after 10”
Significant anxiolysis by 15”
Benzodiazepines - Midazolam
What’s a potentially undesirable effect of a > 0.75 mg/kg dose of Midazolam?
May delay discharge (30”)
Benzodiazepines - Midazolam
Which factor is important to consider when timing administration of Midazolam to alleviate separation anxiety?
Peak sedation 30”
Do not attempt separation from family just 5 min for example after administration
Allow 10 -15 min for effect
Realize that time for peak sedation is 30 min
Parent administer for better acceptance
For peds under 16 mo old, you may forgo the Midazolam
Benzodiazepines - Midazolam
What percentage of pre-op anxiety treated w/ Midazolam result in peaceful separation
85%
Benzodiazepines - Midazolam
What can you mix w/ Midazolam to increase acceptance?
Grape concentrate
Tylenol syrup
Motrin suspension
Benzodiazepines - Midazolam
What’s a concern w/ mixing Midazolam with other solutions to increase acceptance?
NPO status
Beware: total volume > 0.4-0.5 ml/kg (NPO)
