Paediatric anaesthesia Flashcards
1
Q
Preterm
A
< 37 weeks post conceptual age
2
Q
Low birth weight
A
Less than 2.5kg
3
Q
Very low birth weight
A
Less than 1.5kg
4
Q
Extremely low birth weight
A
Less than 1Kg
5
Q
Infant
A
1 month - 1 year
6
Q
Which studies are the neonatal survival rates derived from?
A
EPICure and EPICure 2 Studies
7
Q
What is the morbidity and mortality for < 23 weeks
A
Negligible survival. Appropriate to not attempt resuscitation as standard.
8
Q
What is the morbidity and mortality for 23 - 23+6?
A
80% mortality 54% survivors have moderate to severe disability Reasonable to not attempt resuscitation but decision made with family
9
Q
What is the morbidity and mortality for 24 - 24+6?
A
66% Mortality Half remaining have moderate to severe disability Resuscitation is generally considered appropriate unless there are other antenatally diagnosed conditions that would further impair survival
10
Q
What is the morbidity and mortality for > 25 weeks?
A
33% Mortality Resuscitate as standard
11
Q
When does surfactant secretion begin?
A
24-26th week
12
Q
When does alveolar development begin?
A
From 32nd week
13
Q
What are the cut off ages for 24 hour postoperative apnoea monitoring in neonates?
A
Up to 60th PC week if born preterm Up to 44th PC week if born term
14
Q
How commonly is a patent ductus arteriosus seen in preterm neonates?
A
Up to 50% of extreme preterms
15
Q
Describe the physiological complications of a PDA
A
Excessive pulmonary blood flow Low systemic pressures Myocardial failure Inability to wean from mechanical ventilation Sequela of low DBP e.g. NEC
16
Q
List cardiorespiratory complications of ex-premature neonates
A
Bronchopulmonary dysplasia Tracheomalacia (from long term ETT placement) Subpglottic stenosis Persistent pulmonary hypertension of the newborn (PPHN)
17
Q
Neonate
A
Less than 1 month
18
Q
Paediatric defibrillation energy
A
4 J/Kg
19
Q
Paediatric cardiac arrest adrenaline dose
A
10 mcg/kg
20
Q
Infant estimated weight
A
(0.5 X Months) + 4 in Kg
21
Q
Child weight estimate
A
weight in kg = 2 x (age in years + 4)
e.g. a 5 y/o = 18 Kg
22
Q
Uncuffed tube size
A
(Age / 4) + 4
23
Q
Cuffed tube size
A
(Age / 4) + 3.5
24
Q
Oral ETT length
A
(Age / 2) + 12
25
Nasal ETT length
(Age / 2) + 15
26
LMA size for less than 5 Kg
1
27
LMA size for 5 - 10 Kg
1.5
28
LMA size for 10 - 20 Kg
2
29
LMA size for 20 - 30 Kg
2.5
30
LMA size for 30 - 50 Kg
3
31
Normal obs for infant
RR 30 - 40 HR 110 - 160 SBP 70 - 90
32
Normal obs for child 1 - 3
* RR 25 - 35
* HR 100 - 150
* SBP 80 - 95
33
Normal obs for child 3 - 6
* RR 25 - 30
* HR 95 - 140
* SBP 80 - 100
34
Normal obs for child 6 - 13
* RR 20 - 25
* HR 80 - 120
* SBP 90 - 110
35
Normal obs for child 13 - 17
* RR 15 - 20
* HR 60 - 100
* SBP 100 - 120
36
Propofol dose
1 - 4 mg/kg
37
Thiopentone dose
4 - 6 mg/kg
38
Ketamine dose
2 mg/kg
39
Fentanyl dose
1 - 2 mcg/kg
40
Morphine dose
0.1 mg/kg
41
Alfentanyl dose
30 - 50 mcg/kg
42
Paracetamol dose
15 mg/kg
43
Ibuprofen dose
5 mg/kg
44
Codeine dose
1 mg/kg
45
Atracurium dose
0.5 mg/kg
46
Rocuronium dose
1 mg/kg
47
Suzamethonium dose
2 mg/kg
48
Ondansetron dose
0.1 mg/kg
49
Dexamethasone dose
0.1 mg/kg
50
Neostigmine / Glycopyrrolate dose
1 amp per 50 kg
51
Sugammadex dose
16 mg / kg immediate reversal
52
Atropine dose
20 mcg/kg
53
Adrenaline dose
10 mcg/kg
54
Phenylephrine dose
1 mcg/kg
55
Amiodarone dose
5 mg/kg
56
Naloxone dose
100 mcg/kg (2mg in older than 5)
57
Tranexaminc acid dose
15 mg/kg (max 1 g)
58
Co-amoxiclav dose
30 mg/kg
59
Cefuroxime dose
20 mg/kg
60
Metronidazole dose
7.5 mg/kg
61
Flucloxacillin dose
25 mg/kg
62
Gentamicin dose
1 - 2 mg/kg
63
Diclofenac dose
1 mg/kg
64
Midazolam dose
0.1 mcg/kg
65
Oromorph dose
200 - 400 mcg/kg
66
Adenosine dose
100 mcg/kg then double (max 12g)
67
Noradrenaline infusion
0.01 - 0.5 mcg/kg/min (start at 0.1)
68
Adrenaline infusion
0.01 - 0/5 mcg/kg/min (start at 0.1)
69
Morphine infusion
10 - 40 mcg/kg/hour (start at 20)
70
Midazolam infusion
0.1 mg/kg/min
71
Calculate SBP based on age
80 + (Age X 2)
72
Define status epilepticus
Seizures lasting \>30 mins or 2 or more seizures without recovery
73
First line seizure management
Lorazepam 0.1 mg/kg IV Diazepam 0.5 mg/kg PR
74
Second line seizure management
Phenytoin 15-20 mg/kg over 20 mins Phenobarbital 20 mg/kg if on phenytoin already
75
Third line seizure management
GA Thio 4-5 mg/kg Midaz 0.1 mg/kg
76
Common pitfalls in paediatric sedation
Inexperience Too much sedation (verbal endpoints different) Too little sedation Poor timing Non-fasting Dose errors Hyperactive delirium (e.g. katamine)
77
Cause of cleft palate
Defective palatal growth and fusion in 1st trimester
78
Incidence of pyloric stenosis
1:3-400 live births
79
Pyloric stenosis male:female
85% Male
80
Metabolic resuscitation goals for pyloric stenosis prior to theatre
Cl greater than 90 HCO3 = 24 Na = 135
81
O2 consumption differences (Adult and Paed)
Paediatric: 6-8 ml/kg/min Adult: 4ml/kg/min
82
Closing volume of lung
Within tidal breathing
83
Level of the larynx
C4
84
Narrowest part of paediatric airway
Cricoid ring
85
Define laryngospasm
A variable upper airway obstruction secondary to partial or complete ADduction of the vocal cords. Due to a primitive reflex to protect the airway from aspiration. Large -ve pressures can cause pulmonary oedema
86
Patient risk factors for laryngospasm
* Increased secretions
* Anxiety (i.e. increased sympathetic stimulation)
* Younger age
* URTI
* GORD
* Asthma
* Smoking
* Obseity / OSA
87
Anaesthetic risk factors for laryngospasm
* LMA use
* Light planes of anaesthesia
* Desflurane / Isoflurane
* Airway manipulation
* Inexperience of anaesthetist
88
Surgical risk factors for laryngospasm
* ENT surgery
* Blood in airway
* Poor surgical timing - pain at light plane
* Hypospadias repair
89
Treatment of laryngospasm
* Remove trigger
* Ensuring a clear larynx
* Open airway
* CPAP with 100% oxygen
* Consider propfol 0.5mg/kg bolus
* Consider suxamethonium 0.1-2 mg/kg
90
Methods to prevent laryngospasm
* Clear communication on surgery start
* Avoid moving in light planes
* Meticulus suctioning
* Pharmacological
* Mg 15 mg/kg
* Lidocaine 1.5 mg/kg IV
* Lidocaine 4% spray to cords
* Atropine premed - presumably to dry secretions
91
What is "viral croup?"
* Laryngotracheobronchitis
* Responsible for 80% of acute stridor in children
* Usually 2° to parainfluenza, influenza A or B, respiratory syncytial virus or rhinovirus.
92
Assessment priorites when returning to theatre with a bleeding tonsil
* Evaluate blood loss (usually underestimated)
* Ensure IV access
* Send blood for x-match
* Resuscitate
* Review anaesthetic chart
* Airway
* Dentition / Loose teeth
* Review pt haemodynamics: Cap refil, UO, HR, RR, differential temperature
* Recent food
* Stridor or breathing difficulty
* Recent opiod analgesia
93
Perioperative priorities when returning to theatre with a bleeding tonsil
* Equipment
* Selection of laryngoscope blades
* Smaller than expected tracheal tubes
* 2 suction catheters
* Induced once the child is haemodynamically stable
* PreO2 and RSI with slight head-down positioning
* Consider left lateral if bleeding is excessive
* Fluid resuscitation and transfusion continue intraoperatively as necessary
* Following haemostasis, a large-bore OG to emply stomach
* Extubate the child fully awake in the recovery position
* After operation, monitor closely for any recurrence of bleeding.
94
Methods to decrease PONV in bleeding tonsils
* OG/NG and thorough suctioning
* Suctioning of blood from pharynx
* Dual antiemetics
* 0.15 mg/kg IV Dex
* 0.1 mg/kg IV ondansetron
* Reduce BMV (stomach insuflation)
* Recude opiate analgesia (LA by surgeons)
95
What are the clinical features of viral croup?
* Barking cough
* Low-grade fever
* Inspiratory stridor
* Increased respiratory effort:
* Fatigue
* Hypoxia
* Hypercarbia
96
Give an example Croup Scoring system and appropraite actions.
* Breath sounds: Normal, Harsh, Delayed
* Stridor: None, Inspiratory, Biphasic
* Cough: None, Horse, Bark
* Recession/Flaring: None, Flaring, Subcostal
* Cyanosis: None, in air, in 40% O2
Score 0, 1, 2 in each category
* 0-3 Mild
* 4-6 Moderate - transfer to HDU
* \> 7 Severe - consider intubation
97
Treatment options for Viral Croup
* Humifified oxygen
* Steroids
* Dexamethasone 0.6 mg/kg IV/PO or
* Beclomethasone 2 mg NEB
* Nebulised Adrenaline
* 0.5ml of 1/1000 (500mcg) diluted to 5 ml
* Repeated 30-60 minutes as needed
* Heliox
98
Describe the proceedure for intubation for a child with Viral Croup
* Escort child to theatres
* Minimal monitoring so as to not upset child
* Inhalational induction with sevoflurane in 100% O2
* Maintain SV, apply CPAP via mapleson-F
* Establish IV acces ASAP following induction
* Intubate once pupils are small and central
* Oral intubation preferred (quicker)
* Be prepared with a number of smaller uncuffed tubes
* Consider exchange for nasal ETT once stable
* Maintain sedation
* Secure lines (consider arm splint)
* Extubate once a leak is demonstrated
99
What is epiglotitis?
a life-threatening emergency caused by **bacterial infection** of the epiglottis, aryepiglottis, and arytenoids. Typically caused by Haemophilus influenzae type b (Hib), beta-haemolytic streptococci, staphylococci, or pneumococci. Vaccination against Hib has greatly reduced its incidence. Regardless, 10% of those with Hib epiglotitis had the vaccine.
100
How can you clinically distinguish epiglotitis and croup?
Epiglottitis Differentiating Characteristics
* More Toxic appearance
* Slightly older children (2–6 yrs)
* Abrupt onset:
* high fever
* sore throat
* dysphagia
* stridor
* drooling
* Speech muffled/lost
* **Absence of cough**
* Classically forward sitting, open mouth with **drooling**
* Unlikely to be relieved by adrenaline nebs
101
Describe the proceedure for intubation for a child with Epiglotitis
* Escort child to theatres
* Minimal monitoring so as to not upset child
* Inhalational induction with sevoflurane in 100% O2
* Maintain SV, apply CPAP via mapleson-F
* **Have ENT standing by for immediate surgical airway**
* Establish IV acces ASAP following induction
* Intubate once pupils are small and central
* Oral intubation preferred (quicker)
* Be prepared with a number of smaller uncuffed tubes
* Consider exchange for nasal ETT once stable
* Maintain sedation
* Secure lines (consider arm splint)
* Extubate once a leak is demonstrated
102
What technique can you employ if you cannot visualise the airway during epiglotitis intubation?
* Compress the chest slightly but suddenly
* Bubbles appear at the laryngeal inlet
* Intubate at the bubbles
103
What is an appropriate dose of antibiotics for epiglotitis?
* extended spectrum cephalosporin
* e.g. ceftriaxone 80 mg/kg/day max 4 g/day
104
What is bacterial tracheitis?
An uncommon bacterial infection of the trachea. Most commonly 2° to: Staphylococcus aureus, Haemophilus influenzae, streptococci or Neisseria spp. Since the Hib vaccine, this has taken over as the leading cause of infective upper airway obstruction in children.
105
What are the clinical features of bacterial tracheitis?
* Midway between viral croup and bacterial epiglotitis
* URTI 48 hours preceeding
* Sudden deterioration in condition (8-10 hrs)
* High fever
* Respiratory distress
* Copious purulent secretions
* No dysphasia or drooling
* Child can usually lie flat
106
You are about to intubate a case of bacterial tracheitis. Any extra proceedures necessary?
* Inhalation induction and set up as for epiglotitis
* Bronchoscope ready to remove pus/debris from airway proior to intubation
* In extremis, intubation must go first, but immediate bronchoscopy and a tube change is very likely
107
Antibiotic treatment in bacterial tracheitis?
* Ceftriaxone
* Consider vancomycin if MRSA suspected
108
Describe the proceedure for administering caudal anaesthesia.
* SLIMRAG
* Left lateral position, knees drawn up to the chest
* Landmarks:
* Equilateral triangle formed between two posterior superior iliac spines and the cornua
* Hiatus palbable between cornua
* Needle introduced slightly cranial through the hiatus
* A click is felt as the needle pierces the sacrococcygeal membrane
* Aspirate to confirm the absence of blood/cerebrospinal fluid
* Inject local anaesthetic while feeling for inadvertent subcutaneous injection
109
What is the armitage dosing guide for caudal anaesthesia?
* 0.5 ml/kg, 0.25% bupivacaine (sacro-lumbar block)
* 1 ml/kg, 0.25% bupivacaine (upper abdominal block)
* 1.2 ml/kg, 0.25% bupivacaine (mid-thoracic block)
110
A rough rule to work out a childs SBP
systolic blood pressure = (age in years x 2) + 80.
111
Calculate a childs blood volume
* 80 ml/kg up to 2 years
* 70 ml/kg thereafter
112
Adrenaline in anaphylaxis dose
* \>12 years - 500 mcg IM
* 6-12 years - 300 mcg IM
* \<6 years - 150 mcg IM
* Can use IV at doses of 1mcg/kg, but IM is the resus council recommended route
113
Cause, incidence, gender distribution and presentation of cleft palate?
* Environmental/genetic factors
* early failure of fusion of embryoinic palate
* Typically 1st trimester
* 1 in 1000 LB
* Male preponderance
* Left preponderance
114
Cleft lip/palate disease assocations
* Pierre Roban
* Treacher Collins
* Downs
* EtoH fetal syndrome
115
What is the incidence of MH in children?
1 in 15,000
116
Why are neonates prone to respiratory fatigue?
disproportionately fewer Type 1 (oxidative) slow muscle fibres in the diaphragm
