Mod V: Peds Induction

Question 1

_{Peds Induction & Emergence}

What’s the most commonly used induction technique in peds

Answer 1

Inhalational Induction

Question 2

_{Peds Induction & Emergence}

What’s is the only time we sway away from Inhalational Induction Techniques in peds

Answer 2

When RSI is indicated

Question 3

_{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?

Answer 3

Disconjugated guaze

Irregular breathing patterns

Increased HR

Question 4

_{Peds Induction & Emergence - Inhalational Induction}

“Excitement stage” encountered - What are signs of stage 3 of anesthesia?

Answer 4

…

Question 5

_{Peds Induction & Emergence - Inhalational Induction}

“Excitement stage” encountered - Minimize OR noise and activity, why?

Answer 5

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

Question 6

_{Peds Induction & Emergence - Inhalational Induction}

What can we do that may increase acceptance of the mask?

Answer 6

Painting mask with flavor extracts

Question 7

_{Peds Induction & Emergence - Inhalational Induction}

Why is Parental presence questionable?

Answer 7

May make the situation worse for the child

Possible risk of parent’s reaction to child being induced

Question 8

_{Peds Induction & Emergence - Inhalational Induction}

What’s the Backup induction plan for a pt that becomes frightened, combative, uncooperative?

Answer 8

IM induction

This induction technique tends to be reserved for MR pts

Question 9

_{Peds Induction & Emergence - Inhalational Induction}

Inhalation induction technique in which the mask is held near face, but not touching

Answer 9

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

Question 10

_{Peds Induction & Emergence - Inhalational Induction}

What is one concern with the Steal Technique?

Answer 10

Everyone around, including the anesthetist is exposed to inhalation agents

This has been documented to be a problem for everyone in the room

Question 11

_{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

Answer 11

“Single Breath” Induction

Question 12

_{Peds Induction & Emergence - Inhalational Induction}

How do you pre fill circuit with mixture of volatile anesthetic with N2O for “Single Breath” Induction?

Answer 12

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

Question 13

_{Peds Induction & Emergence - Inhalational Induction}

How is lost of consciousness achieved w/ “Single Breath” Induction?

Answer 13

LOC can be achieved with a single VC breath

However, most will be anesthetized in 60 sec’s.

Question 14

_{Peds Induction & Emergence - Inhalational Induction}

“Single Breath” Induction is the most popular induction technique in peds. What are its benefits?

Answer 14

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

Question 15

_{Peds Induction & Emergence - Inhalational Induction}

How can you use the reservoir bag visual cue to induce a pediatric pt?

Answer 15

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

Question 16

_{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):

Answer 16

“Slow” Inhalation Induction

Used with Cooperative toddlers and older children

Engage child in story incorporating breathing instructions (blow up balloon)

Question 17

_{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

Answer 17

True

However, Other Induction Techniques and Pediatric Considerations are available

Question 18

_{Peds Induction & Emergence}

Intramuscular Induction are not favored. For which pts are they indicated for?

Answer 18

Extremely uncooperative or

Mentally retarded (MR) child

Question 19

_{Peds Induction & Emergence - Intramuscular Induction}

Ketamine “Dart” is often used for IM induction. What’s pharmacological composition of a Ketamine “Dart”?

Answer 19

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}

Question 20

_{Peds Induction & Emergence - Intramuscular Induction}

How is Ketamine “Dart” administered?

Answer 20

Rapidly inject pt w/ Dart by surprise

They are usually asleep w/in 3-5 min

Question 21

_{Peds Induction & Emergence - Intravenous Induction}

What’s the difference btw Intravenous Induction in peds vs adults

Answer 21

Similar, but you need an IV access

Which is often difficult in peds

Question 22

_{Peds Induction & Emergence - Intravenous Induction}

What can you do to facilitate obtaining an IV access in peds?

Answer 22

Local anesthesia before IV placement

EMLA (2.5% lidocaine & 2.5% prilocaine)

LMX (4% lidocaine)

Apply 45 min prior to start

Question 23

_{Peds Induction & Emergence - Intravenous Induction}

T/F: Older children (> 8 years of age) often prefer intravenous Induction over mask induction

Answer 23

False

Older children would let you start an IV

But would still prefer inhalation induction over IV induction

Question 24

_{Peds Induction & Emergence}

How do we treat Children with “Full Stomachs”?

Answer 24

Same principles apply to pediatrics as for adults plus

RSI with CCP

Question 25

_{Peds Induction & Emergence - RSI for “Full Stomachs”}

Which other drug may be given IV to prevent bradycardia, especially if succinylcholine will be given

Answer 25

Atropine

Question 26

_{Peds Induction & Emergence - RSI for “Full Stomachs”}

Peds require larger doses of IV induction agents. What are peds RSI doses for STP, Propofol, Succinylcholine

Answer 26

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

Question 27

_{Peds Induction & Emergence - RSI for “Full Stomachs”}

Decompress stomachs before induction if:

Answer 27

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

Question 28

_{Peds Induction & Emergence - RSI for “Full Stomachs”}

Which drug must be avoided if if gastric outlet or bowel obstruction present?

Answer 28

Metoclopramide

Could cause the bowel to push against and obstruction and potentially cause a rupture or burst

Question 29

_{Peds Induction & Emergence - RSI for “Full Stomachs”}

Which type of ET tube (cuffed vs uncuffed) should you use if “Full Stomachs”?

Answer 29

Cuffed tube

Question 30

_{Peds Induction & Emergence - RSI}

What’s the agent of choice for RSI in peds?

Answer 30

Succinylcholine

Although we try to avoid Succinylcholine at all cost!!!

Question 31

_{Peds Induction & Emergence}

Hypoxemia that occurs within 30-45 sec’s of induction, even after preoxygenation is known as:

Answer 31

Apneic Infant During Induction

Question 32

_{Peds Induction & Emergence}

D/t risk of Apneic Infant During Induction, you must cease intubation attempts immediately with onset of which symptoms?

Answer 32

Bradycardia - Cyanosis

Desaturation

Question 33

_{Peds Induction & Emergence}

How do you treat Apneic Infant During Induction?

Answer 33

Administer 100% O2 until oxygen saturation improves

These pts do not have a lot of O2 reserves

Preoxygenation too much is rather useless!!!!

Question 34

_{Peds Induction & Emergence}

Rigidity of jaw muscles that develops after administration of succinylcholine is known as:

Answer 34

Masseter Muscle Rigidity

Question 35

_{Peds Induction & Emergence}

Co-administration of which two drugs increases incidence of Masseter Muscle Rigidity?

Answer 35

Succinylcholine + Halothane

Question 36

_{Peds Induction & Emergence}

What are Manifestations of Masseter Muscle Rigidity?

Answer 36

Difficulty in opening mouth, d/t

Slight increase in masseter muscle resistance

Apparent active tetany

Question 37

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

T/F: Administration of additional sux results in relaxation of masseter muscles

Answer 37

False

Administration of additional sux does not result in relaxation of masseter muscles

Question 38

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

T/F: During MMR other skeletal muscles are rigid as well

Answer 38

False

Other skeletal muscles are relaxed during MMR

Question 39

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

How long can MMR last? and why?

Answer 39

MMR may last as long as 30 mins

MMR persists until neuromuscular function begins to r_eturn in peripheral muscles_

Question 40

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

How long may Myalgia/weakness a/w MMR persist?

Answer 40

36hrs following episode

Question 41

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

Elevation of which lab values may follow within 24hrs of an MMR episode?

Answer 41

CK and Myoglobinuria

Question 42

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

Differential diagnosis of MMR include susceptibility to which lifethreatening condition?

Answer 42

Malignant Hyperthermia (MH)

Question 43

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

T/F: 50% of patients who experience MMR are also susceptible to MH

Answer 43

True

—

Question 44

_{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:

Answer 44

MH

Question 45

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

MMR in which Peripheral nerve stimulator shows flaccid paralysis is more likely:

Answer 45

MMR (confirmed)

Question 46

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

Other events that mimic masseter spasm:

Answer 46

Inadequate dose of succinylcholine

Inadequate time for onset of action of SUX

Temporomandibular joint dysfunction

Myotonic syndrome

Question 47

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

How is MMR managed?

Answer 47

Maintain PPV with bag/mask until muscles relax

Intubate trachea when feasible

Observe pt carefully for signs of MH

Question 48

_{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?

Answer 48

Skeletal muscle rigidity

Increased CO2 production/O2 consumption

Metabolic acidosis

Tachycardia/arrhythmia’s

Increased body temperature

Myoglobinuria

Question 49

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

If MH is developing or strongly suspected, what must you do?

Answer 49

Declare MH emergency!!!

REVIEW MH

Question 50

_{Peds Induction & Emergence - Masseter Muscle Rigidity}

If MMR is confirmed, do you continue surgery or not?

Answer 50

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