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Special Population-RCM > Pediatric > Flashcards

Pediatric Flashcards

1
Q

What guides the selection of pediatric anesthesia airway equipment?

A
  • Child’s age
  • Weight
  • Medical history
  • Proposed surgical procedure.
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2
Q

What are examples of essential pediatric airway equipment?

A
  • Various sizes of anesthesia masks
  • Oral and nasal airways
  • LMAs
  • laryngoscope blades
  • ETTs, and ETT stylets
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3
Q

How is the trachea most easily exposed in older children (≥6 years) for tracheal intubation?

A
  • By placing a folded blanket or pillow beneath the occiput of the head (5 to 10 cm elevation)
  • Displacing the cervical spine anteriorly.
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4
Q

What position is typically used to achieve the optimal airway alignment in older children during tracheal intubation?

A
  • The classic “sniffing” position
  • Achieved by extending the head at the atlantooccipital joint.
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5
Q

How is the head positioned for tracheal intubation in infants and younger children?

A
  • Head extension at the atlantooccipital joint alone, without elevating the head
  • As the large occiput proportionally displaces the cervical spine anteriorly.
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6
Q

What technique is recommended to facilitate tracheal intubation in neonates?

A
  • Holding the patient’s shoulders flat on the operating room table with the head slightly extended
  • Or placing a rolled towel under the shoulders to facilitate intubation.
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7
Q

When might placing a rolled towel under the shoulders of neonates be disadvantageous?

A
  • When intubating standing up
  • Advantageous if seated.
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8
Q

What formulas can be used to estimate the internal diameter of an endotracheal tube?

A
  • (16 + age in years)/4
  • (Age in years/4) + 4
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9
Q

What formulas can be used to estimate the length required for an orotracheal tube?

A
  • Height (in cm)/10 + 5
  • Weight (in kg)/5 + 12
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10
Q

How far should the endotracheal tube be advanced from the alveolar ridge during intubation?

A

3 times the internal diameter

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11
Q

What is the formula to calculate the distance to advance the endotracheal tube based on age?

A

(Age in years/2) + 12

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12
Q

What are two common airway complications in pediatric patients?

A

Laryngospasm and bronchospasm.

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13
Q

What is the function of the larynx in protecting the lungs?

A
  • Protects the lungs from aspiration of foreign material
  • Facilitated by the glottic closure reflex.
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14
Q

What triggers laryngospasm?

A

Noxious stimuli of the superior laryngeal nerve.

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15
Q

What are potential complications of laryngospasm?

A
  • Complete airway obstruction
  • Gastric aspiration
  • Postobstruction pulmonary edema
  • Cardiac arrest
  • Death
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16
Q

What is bronchospasm?

A

Increased airway resistance caused by smooth muscle contraction.

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17
Q

How does bronchospasm typically resolve?

A

Spontaneously or with pharmacologic intervention.

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18
Q

What physical sign may manifest with bronchospasm?

A

Audible wheeze.

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19
Q

How might bronchospasm be detected on the ETCO2 waveform?

A
  • Prominent slope on the expiratory portion
  • Indicative of prolonged expiration.
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20
Q

What are physical signs associated with bronchospasm?

A
  • Hypoxemia
  • Hypercarbia
  • Wheezing
  • Increased peak airway pressures
  • Difficulty ventilating
  • Chest retraction
  • Altered ETCO2 waveform
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21
Q

What is the initial intervention when ventilation is compromised due to bronchospasm?

A

Administering 100% oxygen.

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22
Q

What may be heard upon auscultation of the lungs in a patient experiencing bronchospasm?

A

Wheezing.

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23
Q

What action should be taken if bronchospasm is severe?

A

Inform the surgeon to stop the surgery.

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24
Q

How can the anesthetic depth be managed in bronchospasm?

A
  • Assess and deepen anesthesia as needed
  • Manually ventilate the patient
  • Administer a bronchodilator like albuterol via ETT
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25
Q

What is the recommended treatment for life-threatening bronchospasm emergencies?

A
  • Dilute a 1-mg vial of epinephrine in a 10-mL syringe
  • Give 1 to 2 mL (100–200 mcg) IV push in increments
  • Max dose: 0.5 mg of 1: 1000 solution
  • Corticosteroids may also be given
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26
Q

Are corticosteroids immediately effective in acute airway emergencies?

A

No, they are not immediately effective due to their prolonged onset of action.

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27
Q

What should be avoided if there are indications of a potentially difficult airway?

A

Neuromuscular blocking agents.

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28
Q

What equipment should be prepared for managing a difficult airway?

A
  • Variety of laryngoscope blades
  • ETTs
  • Oropharyngeal airways
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29
Q

What are the different induction options to plan for in a difficult airway scenario?

A
  • Awake fiberoptic
  • Sedation with anesthetizing spray
  • Inhalation induction
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30
Q

What should be administered after achieving a deep plane of anesthesia?

A

100% oxygen.

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31
Q

How can oral secretions be decreased in a difficult airway situation?

A

Atropine or glycopyrrolate.

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32
Q

How should respirations be maintained in a difficult airway scenario?

A

Always maintain spontaneous respirations.

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33
Q

What technique can facilitate glottis visualization during intubation?

A

External manipulation of the trachea.

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34
Q

What adjunct airway equipment should be used or available for difficult airway management?

A
  • Videolaryngoscopy
  • Fast-track LMA
  • Blind nasal intubation
  • Light wand
  • Cricothyrotomy.
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35
Q

What approach should be followed in managing a difficult airway?

A

Follow the standardized difficult airway algorithm.

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36
Q

What is the approach to the end of surgery in pediatric patients, similar to adults?

A

Return of spontaneous breathing and weaning of anesthetic agents.

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37
Q

Why is it important to have airway equipment readily available after extubation?

A

In case of the need to reestablish a patent airway.

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38
Q

When do critical airway events tend to occur more often in pediatric patients?

A

During emergence and extubation rather than induction and intubation.

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39
Q

What factors influence the decision between deep versus awake extubation in pediatric patients?

A

Patient’s medical history and type of surgical procedure.

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40
Q

When is awake extubation recommended in pediatric patients?

A

In children with a history of difficult airway and full stomach.

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41
Q

When is deep extubation preferred in pediatric patients?

A

In children with reactive airway and when postsurgical coughing and bucking should be avoided.

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42
Q

How do pediatric intravascular and extracellular fluid compartments compare to adults’?

A

They are relatively larger in pediatric patients.

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43
Q

Why are hepatic biotransformation pathways immature in neonates and young infants?

A

Due to developmental immaturity.

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44
Q

What effect does immature hepatic function have on drug metabolism in pediatric patients?

A

It may result in altered drug metabolism and clearance.

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45
Q

How does protein binding typically differ in pediatric patients compared to adults?

A

Protein binding is decreased in pediatric patients.

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46
Q

How does metabolic rate in infants compare to adults?

A

Metabolic rate is higher in infants.

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47
Q

What accounts for the higher total body water in infants compared to adults?

A
  • Higher fat content and smaller muscle mass
  • Leading to proportionately higher total body water.
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48
Q

Why might pediatric patients require increased loading doses of water-soluble drugs?

A
  • Due to their larger extracellular fluid compartment
  • Higher total body water
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49
Q

Why are increased doses of ketamine required in pediatric patients?

A

Because of their greater volume of distribution and higher metabolic rate.

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50
Q

How do dose requirements for propofol differ between infants and children?

A
  • Infants require higher doses (2.5-3.0 mg/kg)
  • Compared to children (2.0-2.5 mg/kg).
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51
Q

What contributes to faster emergence from propofol anesthesia in children?

A

Shorter elimination half-lives and higher plasma clearance.

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52
Q

What is propofol infusion syndrome (PIS) and when does it occur?

A
  • It occurs when propofol is given at doses > 4mg/kg per hr.
  • for > 48 hrs, inhibiting mitochondrial function and uncoupling oxidative phosphorylation.
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53
Q

What are the symptoms and complications of propofol infusion syndrome (PIS)?

A
  • Severe lactic acidosis
  • Hypertriglyceridemia
  • Fever
  • Hepatomegaly
  • Dysrhythmias
  • Rhabdomyolysis
  • Heart failure
54
Q

Why do infants and children require increased amounts of inhalation agents compared to adults?

A

Due to their increased basal metabolic rate.

55
Q

Why is inhalation induction more rapid in pediatric patients?

A
  • Due to their higher minute ventilation
  • Lower functional residual capacity
  • Higher blood flow to vessel-rich organs
56
Q

When are MAC requirements highest for inhalation agents in pediatric patients?

A

At six months, except for sevoflurane, which are highest at birth and decrease with age.

57
Q

What is emergence delirium, and how does it manifest in pediatric patients?

A
  • Altered behavior postoperatively
  • Restlessness
  • Crying
  • Moaning
  • Incoherence
  • Disorientation
58
Q

What is the incidence range of emergence delirium in pediatric patients?

A

10% to 80%.

59
Q

Which medications have a prophylactic effect in preventing and treating emergence delirium in pediatric patients?

A
  • Propofol
  • Fentanyl
  • Dexmedetomidine
  • Preoperative analgesia
60
Q

Why do muscle relaxants generally have shorter onset times in pediatric patients compared to adults?

A

Due to their shorter circulation times.

61
Q

Why do infants require higher doses of succinylcholine compared to adults?

A

Because of their larger volume of distribution.

62
Q

How do neonates and young infants’ sensitivity to nondepolarizing relaxants compare to their volume of distribution?

A
  • They are more sensitive due to immature neuromuscular junctions
  • But this effect tends to cancel out because of their large volume of distribution.
63
Q

What tends to be the duration of nondepolarizing relaxants in pediatric patients compared to adults?

A

Slightly longer.

64
Q

Where should neuromuscular function be assessed after providing neuromuscular blockade?

A

At the adductor pollicis muscle in the forearm.

65
Q

Why is residual neuromuscular blockade concerning in infants and children?

A

It places them at risk of hypoventilation and the inability to maintain a patent airway.

66
Q

How is residual neuromuscular blockade detected in pediatric patients?

A

Integration of clinical criteria and assessment via a peripheral nerve stimulator.

67
Q

What are conventional doses of anticholinesterase inhibitors for antagonizing nondepolarizing neuromuscular blockade?

A
  • Neostigmine (50-60 mcg/kg)
  • Edrophonium (500-1000 mcg/kg)

With appropriate doses of:

  • Atropine (0.02 mg/kg)
  • Glycopyrrolate (0.2 mg for each 1 mg of neostigmine).
68
Q

Why might anesthesia providers administer an anticholinergic drug prior to an anticholinesterase drug?

A

To prevent bradycardia, a consequence of administering an anticholinesterase drug.

69
Q

Is sugammadex FDA approved for use in pediatric patients?

A
  • No, it is not FDA approved for patients younger than 18 years old
  • But research suggests it is well tolerated in pediatric patients.
70
Q

What are the three enzymatic reactions involved in Phase I drug metabolism?

A
  1. Oxidation
  2. Reduction
  3. Hydrolysis catalyzed by the cytochrome P-450 (CYP450) enzyme system.
71
Q

Which enzyme systems are capable of hydrolyzing various pharmacologic agents?

A
  • Enzyme systems within red blood cells
  • Plasma
  • Other extrahepatic tissues.
72
Q

What types of reactions do Phase I metabolism reactions introduce?

A

They introduce polar hydroxyl, amino, sulfhydryl, or carboxyl groups.

73
Q

What is the main function of Phase II drug metabolism reactions?

A
  • Conjugation or synthesis
  • Which facilitate excretion
74
Q

Why do newborns lack efficient bilirubin conjugation capacity?

A

Due to decreased glucuronyl transferase activity.

75
Q

Why is the rate of absorption of orally administered drugs slower in pediatric patients?

A
  • Due to delayed gastric emptying time
  • Which reaches adult range by 6 months of age
76
Q

How does rectal drug absorption differ based on the location of administration?

A

Medications applied in the upper third of the rectum undergo first-pass metabolism due to drainage into the portal system.

77
Q

What are the recommended IV acetaminophen dosages for pediatric patients?

A
  • For patients 2 years or older weighing <50 kg: 15 mg/kg every 6 hours or 12.5 mg/kg every 4 hours. Do not exceed 75mg/kg per day
  • For patients 13 years and older weighing >50 kg: 1000 mg every 6 hours or 650 mg every 4 hours.
  • Daily max dose of APAP 4000mg/day

High doses of acetaminophen may deplete glutathione, increasing the accumulation of Nacetyl-pbenzoquinone
imine, which is thought to be responsible for acetaminophen-induced liver necrosis.

78
Q

What is the maximum daily dose of acetaminophen (APAP)?

A

4000 mg.

79
Q

What risk is associated with high doses of acetaminophen?

A
  • High doses may deplete glutathione, leading to the accumulation of N-acetyl-p-benzoquinone
  • Which can cause acetaminophen-induced liver necrosis.
80
Q

Where is preoperative assessment typically completed?

A

In the preoperative anesthesia clinic or in the patient’s hospital room.

81
Q

Why should acutely ill patients be assessed in the preoperative area?

A

To optimize chronic diseases and create an individualized anesthetic plan.

82
Q

How can reviewing the medical record aid in preoperative assessment?

A

It can answer many questions before approaching the patient/parents for information.

83
Q

Why is understanding congenital history important in preoperative preparation?

A

It aids in developing a tailored plan of care.

84
Q

What information can previous anesthetic records provide?

A

Insights into previous anesthetic experiences and implications.

85
Q

What is the key factor in preventing post-intubation laryngeal edema?

A

Maintaining an air leak < 25 cm H2O.

86
Q

When using a cuffed endotracheal tube, how should cuff pressure be monitored?

A

Intermittently using a manometer.

87
Q

What are the risk factors for post-intubation laryngeal edema?

A
  • Using an ETT that is too large
  • Age < 4
  • High cuff pressure
  • Trauma from intubation attempts
  • Prolonged intubation
88
Q

What are the common treatments for post-intubation laryngeal edema?

A
  • Cool and humidified oxygen
  • Dexamethasone
  • Racemic epinephrine (dose based on patient’s weight)
89
Q

Why are children with an active or recent upper respiratory tract infection at increased risk of pulmonary complications?

A

Due to potential airway irritation and inflammation.

90
Q

How long should a procedure be postponed after the onset of symptoms in a child with a URI?

A

2 - 4 weeks.

91
Q

What are reasons to cancel a procedure in a child with a recent URI?

A
  • Purulent nasal discharge
  • Temperature > 38.0°C
  • Lethargy
  • Persistent cough
  • Poor appetite
  • Wheezing and rales that don’t clear with a cough
92
Q

How can the risk of post-intubation croup be reduced in a child with a recent URI?

A

Administering dexamethasone at 0.25 - 0.5 mg/kg.

93
Q

Which volatile agent is preferred in a child with a recent URI?

A

Sevoflurane.

94
Q

Is pretreatment with an inhaled bronchodilator or glycopyrrolate recommended for children with a recent URI?

A

No, it does not provide clear benefits.

95
Q

What is the classic triad of symptoms seen in over 60% of children with foreign body aspiration?

A
  • Cough
  • Wheezing
  • Decreased breath sounds on the affected side (usually the right).
96
Q

What respiratory sound is associated with supraglottic obstruction?

A

Stridor.

97
Q

What respiratory sound is associated with subglottic obstruction?

A

Wheezing.

98
Q

What is considered the “gold standard” procedure for retrieving a foreign body from the airway?

A

Rigid bronchoscopy.

99
Q

What is the recommended induction method for anesthesia in cases of foreign body aspiration?

A

Sevoflurane induction with spontaneous ventilation.

100
Q

Why is positive pressure ventilation avoided during anesthesia for foreign body aspiration?

A
  • It can push the foreign body deeper into the bronchial tree
  • Or cause it to move distally if the patient coughs or bucks.
101
Q

Which maintenance technique is considered optimal for anesthesia during foreign body retrieval?

A

Total intravenous anesthesia (TIVA).

102
Q

What are some airway-specific risks associated with cleft lip and palate?

A
  • Airway obstruction
  • Difficult laryngoscopy
  • Difficult mask ventilation
  • Aspiration
103
Q

How can the Dingman-Dott mouth retractor increase the risk of post-extubation airway obstruction?

A

It can reduce venous drainage and cause tongue engorgement.

104
Q

What is a common issue related to feeding in infants with cleft lip and palate?

A

Failure to thrive due to inability to generate negative pressure required for sucking.

105
Q

At what age is cleft lip repair typically performed?

A

Around 1 month of age.

106
Q

At what age is cleft palate repair typically performed?

A

Around 12 months of age.

107
Q

What is the most common chromosomal disorder associated with trisomy 21?

A

Down syndrome.

108
Q

Why are patients with Down syndrome at an increased risk for difficult ventilation and intubation?

A
  • Due to anatomical features
  • Small mouth
  • Large tongue
  • Narrow palate with high arch
  • Midface hypoplasia
109
Q

What are some other concerns associated with Down syndrome?

A
  • Co-existing congenital heart disease
  • Low muscle tone
  • GERD
  • Obstructive sleep apnea
  • Intellectual disability
110
Q

What specific anatomical abnormality puts patients with Down syndrome at risk for atlantoaxial instability?

A

Abnormal development of the atlantoaxial joint.

111
Q

What is a potential complication related to subglottic stenosis in Down syndrome?

A

Increased risk of airway obstruction.

112
Q

What does the VACTERL association consist of?

A
  • Vertebral defects
  • Imperforated anus
  • Cardiac anomalies
  • Tracheoesophageal fistula
  • Esophageal atresia
  • Renal dysplasia
  • Limb anomalies.
113
Q

What are the components of the CHARGE association?

A
  • Coloboma
  • Heart defects
  • Choanal atresia
  • Restriction of growth and development
  • Genitourinary problems
  • Ear anomalies
114
Q

What are the features of CATCH 22 syndrome (DiGeorge syndrome)?

A
  • Cardiac defects
  • Abnormal face
  • Thymic hypoplasia
  • Cleft palate
  • Hypocalcemia
  • 22q11.2 gene deletion (the cause of the syndrome)
115
Q

What are the indications for tonsillectomy and adenoidectomy in children?

A
  • Nocturnal upper airway obstruction
  • Chronic and/or recurrent infections
116
Q

What is the most common cause of obstructive sleep apnea (OSA) in children?

A

Adenotonsillar hypertrophy.

117
Q

What is the most common coagulation disorder in patients undergoing adenotonsillectomy?

A

Von Willebrand disease.

118
Q

How does dexamethasone benefit patients undergoing adenotonsillectomy?

A
  • It may reduce postoperative airway swelling
  • Reduces Pain
  • Reduces Postoperative nausea and vomiting (PONV)
119
Q

What precautions should be taken to prevent airway fire during adenotonsillectomy?

A
  • Maintain a low FiO2 (≤ 40%)
  • Avoid nitrous oxide (N2O), as it supports combustion.
120
Q

Why should children with OSA undergoing adenotonsillectomy be admitted to the hospital for monitoring?

A

They should be monitored for airway obstruction for 23 hours postoperatively.

121
Q

What should be done in the event of post-tonsillectomy bleeding?

A
  • It is a surgical emergency requiring volume resuscitation
  • Rapid sequence intubation to prevent aspiration.
122
Q

What is crucial to monitor in the postoperative care of pediatric patients, particularly in the PACU?

A

Oxygenation.

123
Q

What are some factors that may contribute to postoperative hypoxia in pediatric patients?

A
  • Postextubation croup
  • Laryngospasm
  • airway obstruction
  • Obstructive sleep apnea
  • Apnea of prematurity
124
Q

How can airway obstruction in pediatric patients be managed in the postoperative period?

A

Repositioning the patient’s head and ensuring adequate oral suctioning.

125
Q

Fluid management Tables

A
126
Q

Fluid management Formulas

A
127
Q

Medical Hx Review Table

A
128
Q

Preop Lab Table

A
129
Q

Preanesthetic Drugs: Midazolam

A
130
Q

Epiglottitis vs Croup

A
131
Q

Epiglottitis vs Croup Patho

A
132
Q

Conditions associated with difficult airway

A

Special Population-RCM (8 decks)

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