Paediatrics Flashcards
Preterm
< 37 weeks post conceptual age
Low birth weight
Less than 2.5kg
Very low birth weight
Less than 1.5kg
Extremely low birth weight
Less than 1Kg
Infant
1 month - 1 year
Which studies are the neonatal survival rates derived from?
EPICure and EPICure 2 Studies
What is the morbidity and mortality for < 23 weeks
Negligible survival. Appropriate to not attempt resuscitation as standard.
What is the morbidity and mortality for 23 - 23+6?
80% mortality
54% survivors have moderate to severe disability
Reasonable to not attempt resuscitation but decision made with family
What is the morbidity and mortality for 24 - 24+6?
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
What is the morbidity and mortality for > 25 weeks?
33% Mortality
Resuscitate as standard
When does surfactant secretion begin?
24-26th week
When does alveolar development begin?
From 32nd week
What are the cut off ages for 24 hour postoperative apnoea monitoring in neonates?
Up to 60th PC week if born preterm
Up to 44th PC week if born term
How commonly is a patent ductus arteriosus seen in preterm neonates?
Up to 50% of extreme preterms
Describe the physiological complications of a PDA
Excessive pulmonary blood flow
Low systemic pressures
Myocardial failure
Inability to wean from mechanical ventilation
Sequela of low DBP e.g. NEC
List cardiorespiratory complications of ex-premature neonates
Bronchopulmonary dysplasia
Tracheomalacia (from long term ETT placement)
Subpglottic stenosis
Persistent pulmonary hypertension of the newborn (PPHN)
Neonate
Less than 1 month (44 weeks PCA)
Paediatric defibrillation energy
4 J/Kg
Paediatric cardiac arrest adrenaline dose
10 mcg/kg (20 mcg/kg neonate)
Infant estimated weight
(Months/2) + 4 in Kg
Child weight estimate
Weight in kg = 2 x (age in years + 4)
OR new Luscombe (age x 3) + 4
Uncuffed tube size
Age/4 + 4
Cuffed tube size
Age/4 + 3.5
Oral ETT length
Age/2 + 12
Nasal ETT length
Age/2 + 15
LMA size for less than 5 Kg
1
LMA size for 5 - 10 Kg
1.5
LMA size for 10 - 20 Kg
2
LMA size for 20 - 30 Kg
2.5
LMA size for 30 - 50 Kg
3
Normal obs for infant
RR 30 - 40
HR 110 - 160
SBP 70 - 90
Normal obs for child 1 - 3
RR 25 - 35
HR 100 - 150
SBP 80 - 90
Normal obs for child 3 - 6
RR 25 - 30
HR 95 - 140
SBP 80 - 100
Normal obs for child 6 - 13
RR 20 - 25
HR 80 - 120
SBP 90 - 110
Normal obs for child 13 - 17
RR 15 - 20
HR 60 - 100
SBP 100 - 120
Propofol dose
1 - 4 mg/kg
Thiopentone dose
4 - 7 mg/kg
Ketamine dose
2 mg/kg IV
10mg/kg IM
Fentanyl dose
1 - 2 mcg/kg
Morphine dose
0.1 mg/kg
Alfentanil dose
30 - 50 mcg/kg
Paracetamol dose
PO: 15 mg/kg (neonate 20mg/kg)
IV:
Neonate 32 weeks-term: 7.5mg/kg every 8h
Neonate + child up to 10kg: 10mg/kg every 4-6h, max 30mg/kg
Child 10-50kg: 15mg/kg every 4-6h, max 60mg/kg
Child 50kg+: 1g every 4-6h, max 4g
Ibuprofen dose
5 mg/kg
Codeine dose
Under 12: avoid
Over 12: 1 mg/kg (30-60mg)
Atracurium dose
0.3-0.6 mg/kg
(0.3-0.5 mg/kg neonates)
Rocuronium dose
1 mg/kg
Suxamethonium dose
Neonate + infant: 2mg/kg
Child + adult: 1mg/kg
IM: 4mg/kg
Ondansetron dose
0.1 mg/kg
Dexamethasone dose
0.1 mg/kg
Neostigmine (2.5mg/ml) / Glycopyrrolate (0.5mg/ml) dose
0.02 mL/kg
max 2ml
1 amp per 50 kg
Sugammadex dose
16 mg/kg immediate
4 mg/kg - TOF 1-2
2 mg/kg - TOF 2-4
Atropine dose
20 mcg/kg
Adrenaline dose
10 mcg/kg (0.1ml/kg of 1:10,000)
Neonate: 20mcg/kg (0.2ml/kg of 1:10,000)
Anaphylaxis: IV 0.01ml/kg of 1:10,000
IM use 1:1000
Up to 6 months - 100-150 mcg
6 months-6 years: 150mcg
6 years-12 years: 300mcg
12 years-adult: 500mcg
Phenylephrine dose
1 mcg/kg
Amiodarone dose
5 mg/kg
Naloxone dose
100 mcg/kg (2mg in older than 5)
Tranexamic acid dose
15 mg/kg (max 1 g)
Co-amoxiclav dose
30 mg/kg
Cefuroxime dose
20 mg/kg
Metronidazole dose
7.5 mg/kg
Flucloxacillin dose
25 mg/kg
Gentamicin dose
1 - 2 mg/kg
Diclofenac dose
1 mg/kg
Midazolam dose
0.1 mg/kg
Oramorph dose
0.1-0.2mg/kg
Adenosine dose
100 mcg/kg then double (until max 12g reached)
Noradrenaline infusion
0.01 - 0.5 mcg/kg/min (start at 0.1)
Adrenaline infusion
0.01 - 0.5 mcg/kg/min (start at 0.1)
Morphine infusion
10 - 40 mcg/kg/hour (start at 20)
Midazolam infusion
0.1 mg/kg/min
Calculate SBP based on age
80 + (Age x 2)
Define status epilepticus
Seizures lasting >5 mins or 2 or more seizures without recovery
First line seizure management
2x benzo doses:
Lorazepam 0.1 mg/kg IV
Diazepam 0.5 mg/kg PR
Midazolam 0.5mg/kg buccal
Second line seizure management
Phenytoin 20 mg/kg (rate 50mg/min)
Sodium valproate 40 mg/kg
Levetiracetam 60mg/kg
Third line seizure management
Another second line agent
Fourth line seizure management
Phenobarbital 15 mg/kg
GA - propofol/thio/midaz
Common pitfalls in paediatric sedation (7)
Inexperience
Too much sedation (verbal endpoints different)
Too little sedation
Poor timing
Non-fasting
Dose errors
Hyperactive delirium (e.g. katamine)
What causes cleft palate
Defective palatal growth and fusion in 1st trimester
Incidence of pyloric stenosis
1:3-400 live births
4:1 male:female (85% male)
What is pyloric stenosis?
Congenital hypertrophy of the pylorus muscle causing obstruction of gastric emptying
This results in projectile non-bilious vomiting after feeds, usually at 1 month of age
Electrolytes in pyloric stenosis?
Py lo ric stenosis - low K⁺ low Cl⁻ low Na⁺ metabolic alkalosis
Metabolic resuscitation goals for pyloric stenosis prior to theatre
Cl⁻ >100
HCO₃⁻ <28
Physiology of low potassium in pyloric stenosis (3)
- GI loss - vomiting leads to loss of water, sodium, potassium + hydrochloric acid → hypokalaemia, hypochloraemic metabolic acidosis
- Intracellular movement - buffering of intravascular alkalosis by movement of H⁺ out of cells in exchange for K⁺ into cells
- Renal loss - initially alkaline urine → hypovolaemia triggers aldosterone → retains sodium in exchange for urinary potassium loss + hydrogen in an attempt to restore blood volume - eventually acidic urine
O₂consumption at rest (adult vs paed)
Adult 2-3 ml/kg/min
Paeds 6-8 ml/kg/min
Closing volume of lung in paediatric patients
Within tidal breathing
Level of the larynx
Neonate: C3-4
Child: C3-5
Adult: C5-6
Narrowest part of paediatric airway
Cricoid ring (subglottic) - vs adults which is vocal cords
Define laryngospasm
Upper airway obstruction secondary to partial or complete adduction of the vocal cords
Due to a primitive reflex to protect the airway from aspiration
Patient risk factors for laryngospasm
Increased secretions
Anxiety (i.e. increased sympathetic stimulation)
Younger age
URTI
GORD
Asthma
Smoking
Obesity / OSA
Anaesthetic risk factors for laryngospasm
LMA use
Light planes of anaesthesia
Desflurane / Isoflurane
Airway manipulation
Inexperience of anaesthetist
Surgical risk factors for laryngospasm
ENT surgery
Blood in airway
Poor surgical timing - pain at light plane
Hypospadias repair
Treatment of laryngospasm
Remove trigger
Ensuring a clear larynx
Open airway
CPAP with 100% oxygen
Consider propofol 0.5mg/kg bolus
Consider suxamethonium 0.1-2 mg/kg
Methods to prevent laryngospasm
Clear communication on surgery start
Avoid moving in light planes
Meticulous suctioning
Pharmacological:
Mg²⁺ 15 mg/kg
Lidocaine 1.5 mg/kg IV
Lidocaine 4% spray to cords
Atropine premed - presumably to dry secretions
What is viral croup?
Laryngotracheobronchitis
Responsible for 80% of acute stridor in children
Usually 2° to parainfluenza, can also be 2° to influenza A/B, RSV, rhinovirus.
Assessment priorities 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: CRT, UO, HR, RR, temperature
Recent food
Stridor or breathing difficulty
Recent opioid analgesia
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
PreO2and 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.
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 insufflation)
Reduce opiate analgesia (LA by surgeons)
What are the clinical features of viral croup? (4)
Barking cough
Low-grade fever
Inspiratory stridor
Increased respiratory effort:
- Fatigue
- Hypoxia
- Hypercarbia
Give an example of a croup scoring system and appropriate actions
Westley Croup Score:
Method of assessing the severity of croup in children
Comprises assessment of:
Chest wall retractions (0-3 points)
Stridor (0-2 points)
Cyanosis (0-5 points)
Level of consciousness (0-5 points)
What is heard on auscultation (0-2 points)
Treatment options for viral croup
Humidified 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
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 access 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
What is epiglotitis?
A life-threatening emergency caused bybacterial infectionof 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 epiglottitis had the vaccine.
How can you clinically distinguish epiglotitis and croup?
Epiglottitis:
More toxic appearance
Slightly older children (2–6 yrs)
Abrupt onset of: high fever, sore throat, dysphagia, stridor, drooling
Speech muffled/lost
Absence of cough
Classically forward sitting, open mouth withdrooling
Unlikely to be relieved by adrenaline nebs
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 access 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
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
What is an appropriate dose of antibiotics for epiglotitis?
Extended spectrum cephalosporin
e.g. ceftriaxone 80 mg/kg/day max 4 g/day
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.
What are the clinical features of bacterial tracheitis?
Midway between viral croup and bacterial epiglottitis
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
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
Antibiotic treatment in bacterial tracheitis?
Ceftriaxone
Consider vancomycin if MRSA suspected
Describe the proceedure for administering caudal anaesthesia.
CAMDEN
Left lateral position, knees drawn up to the chest
Landmarks:
Equilateral triangle formed between two posterior superior iliac spines and the sacral hiatus
Sacral hiatus palpable between between cornua
Needle (20-22g cannula) introduced slightly cranial (45°) through the hiatus
A pop is felt as the needle pierces the sacrococcygeal membrane
Aspirate to confirm the absence of blood/CSF
Inject local anaesthetic while feeling for inadvertent subcutaneous injection
Calculate a childs blood volume
Preterm: 90-100 ml/kg
Neonate-3 months: 80-90 ml/kg
3 months+: 70 ml/kg
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
Incidence, gender distribution and presentation of cleft palate?
1 in 1000 LB
Male preponderance
Left preponderance
Environmental/genetic factors
Typically 1st trimester
Presentation:
Visible defect
Difficulty latching while feeding
Respiratory distress and reflux during feeding
Speech problems, such as a nasal sound or difficulty being understood
Ear infections, which can lead to hearing loss if left untreated
Dental problems, such as cavities, missing teeth, or malformed teeth
Cleft lip/palate disease associations
Pierre Robin
Treacher Collins
Downs
EtoH fetal syndrome
What is the incidence of MH in children?
Why are neonates prone to respiratory fatigue?
Disproportionately fewer Type 1 (oxidative) slow muscle fibres in the diaphragm
