Paediatric Anaesthesia Flashcards by Iseoluwa Ojo

The provision of safe anaesthesia for the paediatric patient requires a clear understanding of the ________,________,__________ and __________ differences children and adults.

psychological, anatomic, physiological and pharmacologic

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Span from Newborn to adolescent

Neonates –__________ of life. May be preterm
Infants – ______ to _________
Preschool -__-____yrs
Schoolage – ___-____ yrs

first 28 days

1 month to 1 year

1-5

5-12

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Neonates further classified as
 Full term
Pre-term <____wks
 Extreme preterm <____ wks
 Post-term >____ wks
 Low Birth Weight < ____g
 Extremely Low Birth Weight <______g

2500

1000

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Postconceptual age = ______ + _______

GA + PNA

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Anatomical differences

Anatomy of airway predisposes to obstruction and difficult intubation.
- ________ head, ________ neck, ________ neck muscles, ___ AP diameter→ difficult positioning.
- ________ nares → easily obstructed e.g ________ - ________ tongue readily obstructs ________ → obligate _____________
- Anterior, high larynx C___- C___
- (short or long?), ___-shaped epiglottis at _____ angle

large ; short ;underdev

↑; Small ;catarrah

large ;oropharynx ; nasal breathers

C2- C4

long ; U ; 450

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Pediatric

_______ shaped larynx with ______ as the narrowest part
The ________ is narrowest part in adults

Funnel; cricoid

glottis

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(Anterior or Posterior?) , (low or high?) larynx C___- C__ (C__- C__ in adults)

(Short or Long?), _____ epiglottis

Soft tracheal cartilages

Thin lining of airway which easily gets damaged.

Anterior ; Hugh

C2- C4

C5- C6

Long; floppy

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Paeds

(Vertical or Horizontal?) ribs with loss of ____________ movt does not contribute to resp mechanics→ _________ breathers

Large liver pushes up and flattens diaphragm → ________ tidal volume

____________ intercostal muscles

___________________ of bronchi -___0

Horizontal ; bucket-handle

diaphragmatic ; fixed

Poorly developed

Equal bifurcation

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Anatomical differences

CNS
Spinal cord terminates at _______
Dural sac terminates at _____ in neonates

CVS
_____ veins, extensive _________→ ________ cannulation

L3/L4

Tiny; subcut fat

difficult

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Physiological differences

Few alveoli → _______

↓FRC, closing volume encroaches on FRC
→ easily ________ with ____

↑alveolar ventilation will req ↑ ________________ 6-8ml/kg/min to meet demands
Response to hypercapnia and hypoxaemia →____________

Surfactant produced at ____wks GA

V/Q mismatch

hypoxic with apnoea

O2 consumption

respiratory depression

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Physiological Cardiovascular

Easily reverts to _______ circulation

↑ cardiac output ←↑_____ reqs ↑ ________

↓ myocardial contractile tissue→ less able to ↑ ___________. Thus Cardiac output is _________ dependent

Normal heart rate – _____-_____ bts/min (neonates)
Predominant _______ innervation of heart ↓ ____- activity → _______ and _______

foetal ; BMR ; perfusion

stroke volume ; heart rate

130 -160

parasym ; sym

low BP ; PVR

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Haematological

Blood volume

– preterm ____-____ mls/kg
- neonate – ____mls/kg
- infant - ____mls/kg
- child - ___mls/kg

Hb ____ – ___ g/dl at birth
- ‘physiological anaemia’

Hb____ predominant till ________ . ↓2,3 DPG, Lt shift of ODC

preterm 95 -100 mls/kg
- neonate – 90mls/kg
- infant - 85mls/kg
- child - 80mls/kg
Hb 18 – 21 g/dl at birth

HbF predominant till 6 months

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Pardiatric Neonate

(Mature or Immature?) CNS

___________ myelination →_____ conduction time but _______ interneuron distance for impulse to travel

Blood-brain barrier is (more or less?) permeable

Impaired autoregulation → intraventricular hmg

Immature

Incomplete; slower

shorter; more

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Paeds Temperature Control

High ______ area : _______ ratio → _____ loose heat esp from _______

Immature __________ centre
Lack of ___________
Unable to ________

Cutaneous vessels do not _________
Non-shivering thermogenesis → hypoxia, acidosis, hypoglycaemia
Thermoneutral temperature (____oC prems, ____oC neonates)

body surface area : body weight

rapidly ; head

thermoregulatory ; subcutaneous fat

shiver ; vasoconstrict

34oC ; 32oC

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Paeds Renal /Fluid Balance/ Hepatic

TBW = _____% of body wt
↑ ECF (75%) →↑__________ of drugs
→ more accessible to _______

________ renal function, therefore unable to
handle large fluid or Na loads.
Limited ____________________ → easily become hypoglycaemic

volume of distribution; fluid losses

Immature; carbohydrate stores

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Paeds pharmacology

↑ cardiac output → faster ____________

↑ ECF → ↑__________________ of highly
ionised drugs e.g muscle relaxants

Immature liver enzymes → ↓ _______________ especially __________

Immature renal fxn → ↓_____________

MAC – ___es with ____ing age till ____/12 (except _____)

↑ sensitivity to induction agents – immature ________

MR - ↑sensitivity, but ↑ vol of distr → dose

circulation time

vol of distribution ; drug metabolism

morphine; drug excretion

↑; ↑; 6; Sevo; BBB

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Most anatomical and physiological differences approach adult characteristics by age _________ yrs.

8 – 10

Neonatal surgery and anaesthesia should be performed in specialized centres

T/F

In paeds, ______ metabolic rate & ______ resp physiology make desaturation and hypoxia more likely

They are (more or less?) able to tolerate changes in temp, glucose homeostasis

Higher; immature

Less

Pre-op assessment

Should include meeting with _______
PCA – problems of prematurity
Newborn -Congenital abnormalities, metab disturbances
Presch/ sch age – URTI, enlarged adenoids, tonsils
Immunisation
PMH – Asthma, SCD General exam
Investigate all heart murmurs

parents

Formula to estimate weight from age

0-12 month
1-5 years
6-12 year

(0.5 x months )+4

(2 x years )+8

(3 x years )+7

Preperation & premedication

Allay anxiety in parents/patient
familiarisation tour of hospital and equipments
Crossmatch blood
_________ or __________ for venepuncture

Preop fasting guidelines- avoid prolonged fast
- clear fluid –____ hrs
- breast milk –___hrs
- formula milk / solid food–____ hrs

EMLA or ametop cream

2; 4 ; 6

Suitability for Daycase
Very (good or bad?) candidates for day case surgery
Selection criteria as for adults

Good

Suitability for Daycase

Exclusion includes –
- Former preterm PCA <_____ weeks
- Undiagnosed ________
-_________ dx
- Sleep apnoea

cardiac murmur

Sickle cell

The child with RTI Children prone to URTI. Many are benign and non-infectious Important to identify those with significant RTI → _______,________,________ Severe if –________ cough, _______ nasal discharge, fever malaise,_________ , ↑ _______ Postpone till _____ wks after resolution of URTI or _____ weeks after LRTI. Caution in infants

laryngospasm, brochospasm, atelectasis. productive; purulent; bronchospasm; WCC 2; 4

Conduct of Anaesthesia ________ anaesthesia ± _______ technique __________ as sole anaes techniq is contraindicated in paeds. Exception –______ anaes for prems -___________ for moribund patients

General regional Regional spinal; local infiltration

Induction Calculate drug doses, blood volume and fluid req before anaesthesia ? Parental presence ________ techniques ? Anticholinergic –______,________ Inhalational -_______ or ———— IV induction – ________,_________, or ________ IM –________ especially for difficult venous access Rectal – _________,__________. Irreg absorp

Distraction atropine, glycopyrrolate halothane or sevoflurane propofol, thiopentone or ketamine ketamine thiopentone, methohexitone

Airway mx Airway complications are common Head tilt, chin-lift, jaw thurst Position – ______,______ Intubation – _______,_________ blade - deep inhalational, relaxant Tube

neutral, sniffing curved, straight

Airway management – size =___________ - length = _______________ - non-cuffed if age < ____ yrs -tube mandatory in newborn -#3, 3.5 #2.5 (prems)

– size = (age/4) + 4 - length = age/2 + 12 (or 15) - non-cuffed if age < 8 yrs -tube mandatory in newborn -#3, 3.5 #2.5 (prems)

Airway LMA- size ___-___ Meticulous attention to fixing of tube

1-3

Ventilation Spontaneous ventilation IPPV -–__________ tube with audible____ to prevent ______________ (<10 yrs)

uncuffed; leak subglottic stenosis

Ventilation Equipment -________________ face masks - reduced _________ and good anatomical fit -___________ breathing system – up to ___kg -_________ system - ____ kg -_______ circuit -_____kg

Rendell-Baker-Soucek dead space Mapleson F ; 25 Paed circle; >5 Bain’s; >25

Maintenance Relaxants –_________ _-__mg/kg - NDMR - ↑ ________ Inhalational + N2O/ Air + O2 TIVA –_______ (> ___yrs), _______

Suxamethonium; 1-2 sensitivity Propofol; 3 ; ketamine

Monitoring ________/______ stethoscope BP, ECG, pulse oximetry, capnography Temp, bld loss, U/O Constant _____

Precordial / oeso observation

Analgesia in paeds Should not _____________ Combine regional / local with GA to ↓ need for __________ Fentanyl 1-2mcg/kg, morphine 0.1mg/kg, pethidine 1mg/kg Caution with _________ in infants < ___________ LAA – cau block

depress resp sys peri-op opioids NSAIDS; 6 mths

Temperature control Compromise between thermo-neutral temp (____prem, ____ neonates, ___ adolescent) and comfortable ambient temp (____o C) ↑ ambient temp Wrap esp _______, radiant heater, warming blanket Warm fluids and blood Humidify gases

34; 33; 30; 25 head

Reversal Reverse NMB – __________ + __________ / __________ Pharyngeal toileting Extubate neonates that are __________, _______thermic, _______glycaemic, _______tensive and breathing __________ Awake / deep extubation.

neostigmine + atropine / glyco fully awake normothermic normoglycaemic normotensive spontaneously

Regional Anaesthesia Not used as sole anaesthetic tech in children <____ yrs. _____ /______ – pre-terms and ex-prems

12 Spinal; caudal

Regional anaesthesia Spinal/caudal – ________ and ________ - ↓ incidence of _________,————- - less ____________ to _____________

pre-terms and ex-prems post-op apnoea, bradycardia disruptive to feeding regimen

POST-OPERATIVE Positioning – airway patency, prevent _______ Supplementary oxygen till ___________ Keep warm Monitoring Fluid therapy Post-op __________ – Pain scores -PCA(>____yrs) or NCA Commence oral feeds as soon as possible

aspiration; fully awake analgesia 5

Postoperative Analgesia Analgesia – Opioids – morphine, pentazocine - NSAIDS – only >________ - Paracetamol – IV, oral, rectal - PCA, NCA Regional anaesthesia, nerve blocks, local infiltration May require anti-emetics – ondansetron, dexamethasone

6 months