Mod V: Peds Induction Flashcards
Peds Induction & Emergence
What’s the most commonly used induction technique in peds
Inhalational Induction
Peds Induction & Emergence
What’s is the only time we sway away from Inhalational Induction Techniques in peds
When RSI is indicated
Peds Induction & Emergence - Inhalational Induction
The “Excitement stage” or stage 2 of anesthsia is usually encountered during Inhalational Induction. What are S/s of stage 2 anesthesia?
Disconjugated guaze
Irregular breathing patterns
Increased HR
Peds Induction & Emergence - Inhalational Induction
“Excitement stage” encountered - What are signs of stage 3 of anesthesia?
…
Peds Induction & Emergence - Inhalational Induction
“Excitement stage” encountered - Minimize OR noise and activity, why?
Unlike when doing IV induction where they go through the stages of anesthesia quickly, you get to watch go through these stages more slowly
This can set them up for laryngospasm in stage 2
Peds Induction & Emergence - Inhalational Induction
What can we do that may increase acceptance of the mask?
Painting mask with flavor extracts
Peds Induction & Emergence - Inhalational Induction
Why is Parental presence questionable?
May make the situation worse for the child
Possible risk of parent’s reaction to child being induced
Peds Induction & Emergence - Inhalational Induction
What’s the Backup induction plan for a pt that becomes frightened, combative, uncooperative?
IM induction
This induction technique tends to be reserved for MR pts
Peds Induction & Emergence - Inhalational Induction
Inhalation induction technique in which the mask is held near face, but not touching
Steal Technique
Appropriate for Children 8 mos. to 5 y/o who are premedicated
Low flow rates of O2/N20 begun (1 to 3 L/min)
Add Sevoflurane or Halothane, gradually increasing concentration in 0.5% increments
Apply mask when lid reflex disappears
Peds Induction & Emergence - Inhalational Induction
What is one concern with the Steal Technique?
Everyone around, including the anesthetist is exposed to inhalation agents
This has been documented to be a problem for everyone in the room
Peds Induction & Emergence - Inhalational Induction
Inhalational Induction technique w/ Mixture of volatile anesthetic with N2O, and Child takes deep breath (vital capacity) of room air, blows all out (forced expiration), holds breath. Then you Place mask on face, Child takes deep inspiration of anesthetic mixture and holds breath….repeat for 4-5 breaths
“Single Breath” Induction
Peds Induction & Emergence - Inhalational Induction
How do you pre fill circuit with mixture of volatile anesthetic with N2O for “Single Breath” Induction?
Pre fill circuit with
70% N2O,
30% O2 &
7-8% Sevoflurane
This is done By Occluding end of circuit with plug or another reservoir bag
Leave pop-off valve open to minimize non scavenged spillage
Peds Induction & Emergence - Inhalational Induction
How is lost of consciousness achieved w/ “Single Breath” Induction?
LOC can be achieved with a single VC breath
However, most will be anesthetized in 60 sec’s.
Peds Induction & Emergence - Inhalational Induction
“Single Breath” Induction is the most popular induction technique in peds. What are its benefits?
A frigthenned pt will be crying most likely
As they exhale while crying and are getting ready to take another breath, place the mask quickly on their face
So when they take that next deep breath, they usually become anesthetized with that one single breath
This allows them to do go to sleep cooperatively
Be aware that even the most cooperative pt may become uncooperative once you place the mask on their face
Peds Induction & Emergence - Inhalational Induction
How can you use the reservoir bag visual cue to induce a pediatric pt?
Ask them to “blow up the balloon”
This will make them take big VT breaths b/c they are trying to “pop” the balloon
As they keep doing that, they will get deeper and deeper in their sedation
Peds Induction & Emergence - Inhalational Induction
Inhalational Induction in which the child is shown how to breathe through face mask, and N2O/O2 is given, followed by gradual addition of volatile anesthetics (sevoflurane/halothane):
“Slow” Inhalation Induction
Used with Cooperative toddlers and older children
Engage child in story incorporating breathing instructions (blow up balloon)
Peds Induction & Emergence - Inhalational Induction
T/F: Inhalational Induction techniques are by far the most used induction techniques in anesthesia, even for pt that can tolerate an IV
True
However, Other Induction Techniques and Pediatric Considerations are available
Peds Induction & Emergence
Intramuscular Induction are not favored. For which pts are they indicated for?
Extremely uncooperative or
Mentally retarded (MR) child
Peds Induction & Emergence - Intramuscular Induction
Ketamine “Dart” is often used for IM induction. What’s pharmacological composition of a Ketamine “Dart”?
Ketamine (4-8 mg/kg IM)
which takes effect in 3-5 mins
Atropine (0.02 mg/kg IM) or glycopyrrolate (0.01 mg/kg IM)
should be mixed to prevent excessive salivation
Midazolam (0.2 – 0.5 mg IM)
also to decrease incidence of emergence delirium
Peds Induction & Emergence - Intramuscular Induction
How is Ketamine “Dart” administered?
Rapidly inject pt w/ Dart by surprise
They are usually asleep w/in 3-5 min
Peds Induction & Emergence - Intravenous Induction
What’s the difference btw Intravenous Induction in peds vs adults
Similar, but you need an IV access
Which is often difficult in peds
Peds Induction & Emergence - Intravenous Induction
What can you do to facilitate obtaining an IV access in peds?
Local anesthesia before IV placement
EMLA (2.5% lidocaine & 2.5% prilocaine)
LMX (4% lidocaine)
Apply 45 min prior to start
Peds Induction & Emergence - Intravenous Induction
T/F: Older children (> 8 years of age) often prefer intravenous Induction over mask induction
False
Older children would let you start an IV
But would still prefer inhalation induction over IV induction
Peds Induction & Emergence
How do we treat Children with “Full Stomachs”?
Same principles apply to pediatrics as for adults plus
RSI with CCP
Peds Induction & Emergence - RSI for “Full Stomachs”
Which other drug may be given IV to prevent bradycardia, especially if succinylcholine will be given
Atropine
Peds Induction & Emergence - RSI for “Full Stomachs”
Peds require larger doses of IV induction agents. What are peds RSI doses for STP, Propofol, Succinylcholine
STP: 5 to 6 mg/kg
Propofol: 3 to 4 mg/kg
Succinylcholine:
1 to 2 mg/kg IV children - 3 mg/kg neonates
4-6 mg/kg IM in infants
Peds Induction & Emergence - RSI for “Full Stomachs”
Decompress stomachs before induction if:
Gastric distention present (pyloric stenosis, etc)
This is done while the pt is still awake
Drop OGT if pyloric stenosis or severe Gastric distention
Ranitidine (2-4 mg/kg) can be given
Peds Induction & Emergence - RSI for “Full Stomachs”
Which drug must be avoided if if gastric outlet or bowel obstruction present?
Metoclopramide
Could cause the bowel to push against and obstruction and potentially cause a rupture or burst
Peds Induction & Emergence - RSI for “Full Stomachs”
Which type of ET tube (cuffed vs uncuffed) should you use if “Full Stomachs”?
Cuffed tube
Peds Induction & Emergence - RSI
What’s the agent of choice for RSI in peds?
Succinylcholine
Although we try to avoid Succinylcholine at all cost!!!
Peds Induction & Emergence
Hypoxemia that occurs within 30-45 sec’s of induction, even after preoxygenation is known as:
Apneic Infant During Induction
Peds Induction & Emergence
D/t risk of Apneic Infant During Induction, you must cease intubation attempts immediately with onset of which symptoms?
Bradycardia - Cyanosis
Desaturation
Peds Induction & Emergence
How do you treat Apneic Infant During Induction?
Administer 100% O2 until oxygen saturation improves
These pts do not have a lot of O2 reserves
Preoxygenation too much is rather useless!!!!
Peds Induction & Emergence
Rigidity of jaw muscles that develops after administration of succinylcholine is known as:
Masseter Muscle Rigidity
Peds Induction & Emergence
Co-administration of which two drugs increases incidence of Masseter Muscle Rigidity?
Succinylcholine + Halothane
Peds Induction & Emergence
What are Manifestations of Masseter Muscle Rigidity?
Difficulty in opening mouth, d/t
Slight increase in masseter muscle resistance
Apparent active tetany
Peds Induction & Emergence - Masseter Muscle Rigidity
T/F: Administration of additional sux results in relaxation of masseter muscles
False
Administration of additional sux does not result in relaxation of masseter muscles
Peds Induction & Emergence - Masseter Muscle Rigidity
T/F: During MMR other skeletal muscles are rigid as well
False
Other skeletal muscles are relaxed during MMR
Peds Induction & Emergence - Masseter Muscle Rigidity
How long can MMR last? and why?
MMR may last as long as 30 mins
MMR persists until neuromuscular function begins to r_eturn in peripheral muscles_
Peds Induction & Emergence - Masseter Muscle Rigidity
How long may Myalgia/weakness a/w MMR persist?
36hrs following episode
Peds Induction & Emergence - Masseter Muscle Rigidity
Elevation of which lab values may follow within 24hrs of an MMR episode?
CK and Myoglobinuria
Peds Induction & Emergence - Masseter Muscle Rigidity
Differential diagnosis of MMR include susceptibility to which lifethreatening condition?
Malignant Hyperthermia (MH)
Peds Induction & Emergence - Masseter Muscle Rigidity
T/F: 50% of patients who experience MMR are also susceptible to MH
True
Peds Induction & Emergence - Masseter Muscle Rigidity
MMR that is accompanied by rigidity of muscles other than masseter muscles, including for example chest/limb rigidity is more likely:
MH
Peds Induction & Emergence - Masseter Muscle Rigidity
MMR in which Peripheral nerve stimulator shows flaccid paralysis is more likely:
MMR (confirmed)
Peds Induction & Emergence - Masseter Muscle Rigidity
Other events that mimic masseter spasm:
Inadequate dose of succinylcholine
Inadequate time for onset of action of SUX
Temporomandibular joint dysfunction
Myotonic syndrome
Peds Induction & Emergence - Masseter Muscle Rigidity
How is MMR managed?
Maintain PPV with bag/mask until muscles relax
Intubate trachea when feasible
Observe pt carefully for signs of MH
Peds Induction & Emergence - Masseter Muscle Rigidity
During an MMR episode, you must observe pt carefully for signs of MH - What are the signs of MH?
Skeletal muscle rigidity
Increased CO2 production/O2 consumption
Metabolic acidosis
Tachycardia/arrhythmia’s
Increased body temperature
Myoglobinuria
Peds Induction & Emergence - Masseter Muscle Rigidity
If MH is developing or strongly suspected, what must you do?
Declare MH emergency!!!
REVIEW MH
Peds Induction & Emergence - Masseter Muscle Rigidity
If MMR is confirmed, do you continue surgery or not?
You do not continue the surgery, usually…
They will go for further workup just to be sure, because there is a high association btw MMR and MH
