MODIFIERS Flashcards
MODIFIER: Neonate
PATHOLOGY
- Resp (RDS, Mec, diaphragm hernia, CF)
- Birth trauma (HIE, PTx, IVH)
- NEC, jaundice
- Congenital HD
- Hypoglyc
- NAI
- Inborn errors
AIRWAY & RESP
- Large occiput (towel behind)
- Soft, small calibre airways
- Larger tongue
- Anterior larynx
- Large, floppy epiglottis (Miller blade)
- Vagal ++ (bradycardia prone)
- Conical airways (narrowest at cricoid- uncuffed ETT)
- Compliant chest wall
-Obligate nasal breathers
-Diaphragm-reliant
-Low sats + cyanosis normal for first 10 mins
–> SpO2 60s at delivery. Should be 90% by 10mins.
- Inflation breath crucial to transition
- Higher metabolic rate = shorter safe apnoea time
- RSI
–> No ketamine <6mo
–> Higher dose sux (2-3mg/kg)
–> Atropine ready
–> Miller 00 prem, 0 term
–> Uncuffed, size = gestation/10, depth = weight +6/ 3x ETT size
NEURO
- Larger heads prone to injury
- Thin, soft cranial bones
- Open fontanelles (USS)
- No BBB
CVS
- Larger surface area (more fluid requirement)
- Small total blood vol
- Reliant on tachycardia to increase CO
- Access: umbi line (til day 10), scalp
- CPR:
–> Initiate only after 30sec optimal PPV trial
–> Indication PR 60
–> 3:1
–> RR 40-60
–> No amiodarone, no DCR
GI
- Immature LOS tone (regurg/ asp)
GU
- Inability to concentrate urine (dehydration)
- Higher UO 1-2.ml/kg/hr
METABOLIC
- Poor temp regulation
- Prone to hypoglycaemia
SOCIAL/OTHER
- Guardianship
- Managing parents
- NAI
MODIFIER: Paeds
PATHOLOGY
- Infective
- CHD
AIRWAY & RESP
- Large occiput (towel behind)
- Neutral position
- Soft, small calibre airways
- Larger tongue
- Anterior larynx
- Large, floppy epiglottis (Miller blade to age 2)
- Vagal ++ (bradycardia prone)
- Conical airways (narrowest at cricoid- uncuffed ETT to age 10)
- Compliant chest wall
-Obligate nasal breathers to 12mo
-Diaphragm-reliant
-Higher metabolic rate = shorter safe apnoea time
- RSI
–> No ketamine <6mo
–> Higher dose sux (2-3mg/kg) until 12mo
–> Atropine ready
–> Blade size 1 at 1, 2 at 2, 3 at Gr 3, 4 at 14
–> ETT size = age/4+4, depth = triple ETT or age/2+ 12, uncuffed until age 10
NEURO
- Larger heads prone to injury
- Thin, soft cranial bones
- Open fontanelles (USS)
–> Post until 3mo, Ant until 18mo
- No BBB until 3 months
CVS
- Larger surface area (more fluid requirement)
- Small total blood vol
- Reliant on tachycardia to increase CO
- CPR:
–> Palm
–> 15:1, Rate 100-120
–> AP pads, 4J/kg
GI
- Immature LOS tone (regurg/ asp)
GU
- Inability to concentrate urine (dehydration)
- Higher UO 1-2.ml/kg/hr
METABOLIC
- Poor temp regulation
- Prone to hypoglycaemia
SOCIAL/OTHER
- Guardianship
- Managing parents
- NAI
MODIFIER: Obstetrics
See card in ‘Obstetrics’ folder
MODIFIER: Elderly
NEURO
- Atrophy, prone to trauma/ bleed
- Delirium
- Poor history
- Altered perception of symptoms
- Reduced thirst (dehydration prone)
AIRWAY & RESP
- C spine immobility/ AA instability
- Adentulous/ poorer BVM fit
- Prone to aspiration
- Reduced compliance
- Less alveoli/ gas exchange surface
- Aa gradient increases with age
- Reduced FVC, FEV1
- Reduced O2 consump
RSI
- GOC
- Mouth opening: dentures out
- Neck limitaiton: Ramp, BURP, videoscope
- Optimise preox (short apnoea time). Use NIV if CCF/COPD.
- Optimise preload (atrial kick dependent)- fill.
- Attenuated dosing, longer dosing intervals.
- Avoid bagging (prone asp)
CVS
- Reduced vascular compliance
- Reduced cardio/vascular responsiveness
–> To adrenergics: vasoplegia
–> To baroreceptors
- Less ability to increase CO/ inotropy
- Increased reliance on ‘atrial kick’
- Preload dependent
GI
- May not guard
GU
- Renal dysfunction
MSK
- Falls, unstable
- Prone to resp fatigue
- OP and fractures
- Thin skin (tears, infection)
METABOLIC
- Impaired thermoregulation
- Prone hypoglycaemia
- Reduced immunity + blunted response
–> No SIRS
–> No inflamm markers
- Altered pharmacokinetics:
–> Lower lean body mass, less adipose
–> Slower hepatic blood flow
–> Less p450 activity
–> Less GI motility (PO meds)
–> Renal dysfunction
SOCIAL/ OTHER
- Capacity/ consent
- GOC/ futility
- Elder abuse
- Aids (hearing, visual, mobility)
MODIFIER: Obese
AIRWAY & RESP
- Soft tissue +, obstruction
–> Poorer view
–> BVM/ LMA/ cric/ ETT all higher failure rate
- Reduced head extension
- May decompensate if flat
- Prone to aspiration
- Reduced compliance
- Dependent atelectasis
–> Hypercarbia
–> Reduced FRC
–> Dead space +, VQ mismatch
–> Infection - Baseline hypoventilation, hypercarbia
- Shorter safe apnoea time
- Respiratory muscle fatigue
- RSI:
–> Ramp
–> Preox ++ (may require BVM with PEEP, or NIV
–> Ket + roc on IDW
–> Higher PEEP
CVS
- Cor pulmonale
- LVH
- L lateral tilt (aortocaval compression)
GI
- NASH
- Harder to elicit clinical signs
-
GU
METABOLIC
- Polycythaemia
- Double VTE risk
- Altered pharmacokinetics:
–> **Opioid/ anaesthetic drugs should be IBW*
–>
SOCIAL/ OTHER
- Special equipment
- ?fit in scanner
- Less reliable clinical examination
- Procedures difficult
- Bias
PHYSIOLOGICAL optimisations pre-intubation:
O2:
- Positioning
- Preoxygenate with augmented BVM or NIV
- Delayed sequence
- Apnoeic oxygenation
- Bag through induction
BP:
- Fill
- Pressor infusion (eg. Norad)
- Push dose/ rescue pressor
- Optimise pump: inotrope, pacing
- HD neutral induction/sedation (Ket, fent)
- Modest Vt (preload)
Acidosis:
–> Apnoea kills in metabolic acidosis! (cut off compensation)
- Optimise perfusion (above)
- Bag through induction
- NaBic if severe (worsen intracell)
- Match the pre-tube RR
- Consider awake intubation
