Mod V: Peds Pre-op Part 2 Flashcards
Psychological Preparation
Peds are similar to adults from a physiologic standpoint. They are a whole different story when it comes to their psychological preparation. What’s a major psychological feature that distinguishes peds from adults?
Separation anxiety
How many of you have ever tried reasoning with an infant, toddler, or child!!!
Psychological Preparation
Sources of child & family stress/anxiety that you must recognize include:
Fear of separation
Fear of the unkown
Painful procedures - Survival
Strange surroundings
You must take care of the parents as much as the child
Psychological Preparation
Which strategies can you use to reduce preoperative stress/anxiety?
Discuss anesthetic risk, plan, recovery, postop pain management, and discharge
Be simple and honest
Tell ‘em just what’s gonna happen in a supportive, positive way
Make positive suggestion
(“this BP cuff is gonne hug your arm”, “Im gonna put some stickers on your chest”, “you are gonna get a liitle sleepy”, “you gonna smell some fruity anesthetic candy air”
Modify strategu according to age
Allow parental presence during induction for selected cases
Use pharmacological intervention as indicated
Psychological Preparation
T/F: In an effort to reduce anxiety, it is appropriate to allow parental presence during induction for selected cases
True
Premedication
What’s are the goals of premedication in pediatric anesthesia?
Reduce anxiety for Both child/parent
If child isn’t crying/screaming…parents more calm….child more calm!
Provide sedation
Facilitate induction
Reduce airway secretions
Block vagal responses
Supplement anesthesia
Decreased gastric volume/acidity
Premedication
Why is premedictaion not required fo infants < 10mos
Tolerate short periods of separation
Only premedicate for co-existing disease
Premedication
D/t significant Separation anxiety, for which age range is premedication required?
10mos – 5 yrs
Premedication
Premedication with harmacological agents is often required for Older children. However they can also benefit from alternatives such as:
Information/reassurance
Parental presence in OR
Antianxiety/Sedation
Which doses of Midazolam may delay discharge for as long as (30”)?
Doses > 0.75 mg/kg
Antianxiety/Sedation
What’s the Peak sedation time for Midazolam?
30”
Antianxiety/Sedation
How often is administration of Midazolam is a/w peaceful separation?
85% of the time
Antianxiety/Sedation
What’s the Oral dose of Midazolam?
Midazolam
0.5-1.0 mg/kg
up to max 10 mg
Antianxiety/Sedation
How long after administration of 0.5 mg/kg of Midazolam is Antegrade amnesia noted?
Antegrade amnesia after 10”
Antianxiety/Sedation
How long after administration of 0.5 mg/kg of Midazolam is Significant anxiolysis noted?
Significant anxiolysis by 15”
Antianxiety/Sedation
Which substances can Midazolam be mixed with for oral administration?
Grape concentrate/Tylenol syrup/Motrin suspension
Beware: total volume > 0.4-0.5 ml/kg
Parent administer for better acceptance
Antianxiety/Sedation
Besides the oral route, what are other routes of administration of Midazolam?
Nasal - Rectal - IM
Less common routes
Antianxiety/Sedation
Nasal dose of Midazolam - Time to Peak serum level - Nasal dose that may delay extubation - Nasal dose that does not delay recovery
Midazolam
Nasal dose: 0.2-0.6 mg/kg
Time to Peak serum level: 10”
Nasal dose that may delay extubation: 0.6 mg/kg
Nasal dose that does not delay recovery: 0.2 mg/kg
Antianxiety/Sedation
Rectal dose of Midazolam - Time to some effect - Time to Peak effect:
Midazolam
Rectal dose: 0.35 - 1.0 mg/kg
Time to some effect: 10”
Time to Peak effect: 20-30”
Antianxiety/Sedation
IM dose of Midazolam - Time to onset - Reserve for which type of pts?
Midazolam
IM dose: 0.3 mg/kg
Time to onset: 5-10”
Reserve for uncooperative child
Antianxiety/Sedation
Agent that provide sedation and analgesia, has no CV or resp depression, but will increase oral secretions, and is reserved for uncooperative child:
Ketamine
This is a dissociative anesthetic
Antianxiety/Sedation
What are the different routes of administration of Ketamine?
PO - IM - Dart
Antianxiety/Sedation -Ketamine
Oral dose - Time to Peak onset - rate of successful separation - Discharge concern w/ Ketamine:
Ketamine
PO dose: 6-10 mg/kg
Time to Peak onset: 20”
Rate of successful separation: 75%
May prolong time to discharge!!!
Antianxiety/Sedation
IM sedation dose of Ketamine - IM sedation dose of Ketamine that does not delay discharge
Ketamine
IM sedation dose: 2-4 mg/kg
2 mg/kg does not delay discharge
Antianxiety/Sedation
IM dose of Ketamine for induction of GA
Ketamine
IM induction of GA: 6-10 mg/kg
Antianxiety/Sedation
Benefits of combining Ketamine + Midazolam
Ketamine (4 mg/kg) + Midazolam (0.4 mg/kg PO)
=> 100% successful separation
=> 85% easy mask induction
Antianxiety/Sedation
Which drug would you administer to decrease secretions caused by Ketamine?
Glycopyrrolate
Antianxiety/Sedation
Why has it become less common to give Fentanyl in the Oral transmucosal (“lollipop”) form (15-20 mcg/kg)?
Inc gastric volume - Inc PONV
Pruritus - Hypoventilation
Antianxiety/Sedation
What’s the Rectal dose of Methohexital? How is it administered?
Methohexital
Rectal dose: 20-30 mg/kg
10% solution warm tap H20
Pre-op Antianxiety/Sedation
Benefits of Methohexital in the management of peds pre-op anxiety:
85% very peaceful separation
Time to Onset: 10”
Rectal induction of GA
Duration of action: 45-90”
Pre-op Antianxiety/Sedation
Which drug can be given rectally for pediatric induction of General Anesthesia?
Methohexital
Rectal dose: 20-30 mg/kg
Anticholinergics
What’s the purpose of using Anticholinergics drugs in peds?
Preempt bradycardia a/w
Airway manipulation
Succinylcholine administration
Halothane
Antisialagogue d/t
Oral procedures
(Tonsillectomy & Adenoidectomy - FOI - Cleft lip)
Ketamine secretions
Anticholinergic - Atropine
Typical dose & Minimum dose of Atropine:
Atropine
Dose: 0.01 - 0.02 mg/kg
Minimum dose 0.1mg
Anticholinergic - Atropine
Risk associated with giving less than minimum dose of Atropine:
Paradoxical Bradycardia
Anticholinergic - Atropine
What is the recommended method of administration of Atropine in Peds?
- A. IM dose as premed*
- B. IV dose at time of induction*
A. IM dose as premed
B. IV dose at time of induction
IM not recommended as premed but rather IV at time of induction
Anticholinergic - Atropine
Which drug is Atropine commonly administered with during induction of anesthesia in peds?
Succinylcholine
Anticholinergic - Glycopyrrolate
IV & IM doses of Glycopyrrolate:
Glycopyrrolate
IV dose: 5-10 mcg/kg IV
IM dose: 10 mcg/kg IM
Anticholinergics
Which Anticholinergics drug takes longer to work?
- A. Glycopyrrolate*
- B. Atropine*
A. Glycopyrrolate
B. Atropine
Anticholinergics
Which Anticholinergics drug is Better for drying of secretions?
- A. Glycopyrrolate*
- B. Atropine*
A. Glycopyrrolate
B. Atropine
Aspiration Precautions
Which Drugs are used for Aspiration Precautions in peds
Cimetidine: 5mg/kg p.o.
1 hour preop
Ranitidine: 2.5mg/kg p.o.
1 hour preop
Metoclopramide: 0.2 mg/kg p.o. or IV
30 min to 1 hour preop
Bicitra (Na citrate and citric acid): 10-30 ml
Immediate preop (neutralizing buffer for aspiration pneumonitis)
However, it is important to note that these drugs are not commonly used in peds
You will typically see <strong>zofran</strong> (>2 yo) & <strong>Decadron</strong> given for PONV
If serious aspiration concerns however such as in pyloric stenosis for example, any or all of the above will be considered
Aspiration Precautions
Aspiration Precautions dose of Cimetidine - Best time to give:
Cimetidine
Dose: 5mg/kg PO
1 hour preop
Aspiration Precautions
Aspiration Precautions dose of Ranitidine - Best time to give:
Ranitidine
Dose: 2.5mg/kg PO
1 hour preop
Aspiration Precautions
Aspiration Precautions dose of Metoclopramide - Best time to give:
Metoclopramide
Dose: 0.2 mg/kg PO or IV
30 min to 1 hour preop
Aspiration Precautions
Aspiration Precautions dose of Bicitra (Na citrate and citric acid) - Best time to give:
Bicitra (Na citrate and citric acid)
Dose: 10-30 mL
Immediate preop
<em>(neutralizing buffer for aspiration pneumonitis)</em>
Aspiration Precautions
It’s important to note that Cimetidine, Ranitidine, Metoclopramide & Bacitra are not commonly used in peds. In reality, which drugs will typically be adminsitered to prevent PONV
Zofran (>2 yo) & Decadron
Aspiration Precautions
Which drugs will typically be adminsitered if serious aspiration concerns exist, such as in pyloric stenosis?
Any or all of the Aspiration Precautions drugs will be considered
(Cimetidine, Ranitidine & Bacitra + Zofran & Decadron)
