Pediatric Flashcards
1
Q
How do you figure out EBV:
A
In peds, blood volume is inversely proportional to age. Child 1-12 years has blood volume of 70-75 mL per kg. Take those mL and multiply by kg
2
Q
Causes of post intubation croup: how long do they need to be watched? How do mike symptoms get treated?
A
Subglottic injury and edema due to traumatic intubation, oversized ETT, overinflated cuff,l. They need to be watched for at least 4-5 (if treated with epi) hours . Mild treated with a must, severe with racemic epinephrine
3
Q
Is there decreased croup with cuffed or uncuffed tunes?
A
Decreased with cuffed
4
Q
Respiratory compromise in patients after tonsillectomy can happen. What are risk factors?
A
Preemie, age less than 3, neuromuscular disorders, uri within 4 weeks of surgery, obstruction on inhalational induction
5
Q
What is the first line treatment in infants with apnea? After that?
A
Tactile stimulation. After that-then bag mask ventilation
6
Q
When does surfactant start forming? What is BPD?
A
24-38 weeks. BPD is oxygen dependency for more than 28 days after birth and an abnormal chest radiograph
7
Q
A baby is a preemie if what!
A
If they’re born before 37 weeks
8
Q
What does VACTERL stand for?
A
Vertebral defects
Anal atresia
Cardiac defects
Tracheoesophageal fistul, renal abnormalities, limb abnormalities
9
Q
Can you use caudal Anesthesia for repair of an imprrforae anus?
A
Yes, but Rene eat that these kids can have vertebral defects, so they’ll need an MRI firmest. Defects are contraindications
10
Q
An infant with TEF and Esophageal atresia May have:
A
May have coarctation of the aorta
11
Q
How does thermogenesis in the infant happen?
A
Bybcatabolism of brown fat. Not adipose-it’s in the vertebral and neck area.
12
Q
Why does heat loss happen at a slower rate in the infant compared with adult. Greatest loss of heat? What can hypothermia cause?
A
KIM that heat loss occurs immediately and in the infant they have smaller peripheral body compartment, and that leads to heat more slowly being lost from the core. They have a larger BSA to volume ratio. Radiation counts for greatest loss of heat. Can cause oil HTn, if bad enough, then right to keftvshubt, lactic acidosis, NE secretion, worsening hypoxia.
13
Q
T/F:CSF volume is higher on a mL/kg basis in children compared to adults
And also, is the volueme of bupivicaine need to be higher or lower in infants?
PDPH higher or lower occurence in peds?
A
True
And the volume needs to be more due to their increased CSF
The increased CSF means less Postdural puncture headache. PDPH is unlikely in children under 8.
14
Q
Do infants rely on cardiac accelerators for heart rate?
A
Infants do not rely on the cardiac accelerating fibers for a resting heart rate and therefore do not develop bradycardia with spinal anesthesia.
15
Q
Spinal cord and dural sac in infants vs children
A
Termination of the spinal cord occurs at the L3 level in infants. The dural sac extends to about S3 in an infant and the spinal cord ends at L3. The spinal cord and dural sac withdraw upwards with age. In adulthood, the spinal cord terminates at L1 in a majority of patients.
16
Q
Can adults get bradycardia during spinal anesthesia?
A
ONly if T1-T4 is blocked which is not good.
17
Q
What is HLHS-what’s the anatomy? What is needed for sustaining stuff? and what should you not give? Give me a basic rundown:
That being said, what will decreasing minute ventilation do to this whole scenario?
A
hypoplastic left ventricle and can also have a hypoplastic left atrium with mitral stenosis. HLHS patients are dependent upon the patent ductus arteriosus for systemic blood flow from the right ventricle through the pulmonary arteryenous admixture is a fundamental characteristic of single ventricle physiology and thus arterial oxygen saturation (SaO2) will be decreased at baseline with goal SpO2 of approximately 85%.KIM that basically, you need to have a balance of PVR and Systemic BP. if PVR decreases and pulmonary blood flow increases, then the systemic pressure will decrease.
The goal is to make sure that Pulmonary blood flow and systemic flow is in balance. Increasing SVR, increases pulmonary blood flow=bad as that will decrease systemic perfusion. no phenylephrine. KIM that doing certain things will increase pulm blood flow and thus decrease systemic perfusion-increasing the FiO2 (decreases HPV)
Decreasing minute ventilation will increase the PaCO2, and thereby cause HPV and then will decrease pulmonary blood flow and increase systemic flow
18
Q
Order of repair for HLHS?
A
Norwood, Glenn, Fontan
19
Q
Pyloric stenosis abnormalities: Potassium? Bicarb? Chloride? Metabolic state?
A
hypokalemic, hypochloremic metabolic alkalosis. This is often accompanied by a compensatory respiratory acidosis. Bicarbonate produced in the pancreas is exchanged in the stomach by chloride ions. Chloride-rich gastric fluids are lost in pyloric stenosis, and serum bicarbonate levels are elevated due to increased gastrointestinal absorption. Hypokalemia occurs through gastric losses, secretion of aldosterone, and H+/K+ exchange within the kidneys.
20
Q
EBV and age chart
A
Age Group Blood Volume Premature infant 90-105 mL/kg Full-term newborn 80-90 mL/kg Infant 3-12 months 70-80 mL/kg Child 1-12 years 70-75 mL/kg Adult male 65-70 mL/kg Adult female 60-65 mL/kg
21
Q
Bradycardia is common after induction in which pediatric patient population?
A
In patients with Down Syndromeradycardia is common after inhalational induction and patients with Down syndrome often have altered responses to atropine including paradoxical bradycardia or profound tachycardia.
22
Q
Expect what when dealing with patient’s with Down syndrome?
A
Notably, the anesthetic provider should be prepared to manage atlantoaxial instability (AAI), macroglossia, OSA, subglottic stenosis, congenital heart defects, extremes of cardiac chronotropy, and intestinal malformations which may promote aspiration. Atlantoaxial instability (AAI) is another key feature of the disease.
23
Q
In infants and children under 5 years, the first sign of a high or total spinal is ____
When would you use a caudal anesthetic?
A
Apnea
It is best suited for procedures at or below a T10 dermatomal level (e.g. lower abdominal, urologic, and lower extremity procedures).
24
Q
Dural sac in newborns ends at
A
S3
25
Site of injection for Caudal Anesthesia
S4-S5
26
Spinal Anesthesia in kids vs adults-response, and why it's not the same.
The usual hemodynamic changes caused by sympathetic blockade from high or total spinal anesthesia in adults (hypotension and bradycardia, sometimes with an initial transient tachycardia) are generally not seen in infants and children. This difference has been attributed to the relative immaturity of the sympathetic nervous system (SNS) in children and especially infants. Since infants and children have low baseline SNS function, a sympathectomy from a high spinal causes little change in blood pressure or heart rate. In addition, there is a smaller relative blood volume in the lower extremities in young children and so venous pooling following spinal anesthesia causes less hemodynamic change. The SNS matures by approximately age 7-8 years and an adult-like response to spinal anesthesia may be observed at this time.
27
What is myotonic dystrophy?
Myotonic dystrophy is a progressive genetic condition with associated muscle weakness and myotonia, along with contractures of the muscles
28
What can you expect in patients with myotonic dystrophy ? What type of inheritance pattern?
cardiomyopathies, are at increased risk for aspiration, and can develop upper airway obstruction from pharyngeal muscle weakness. Shivering caused by hypothermia can precipitate myotonias. Autosomal dominant inheritance.
29
In myotonic dystrophy, can you give fluids with K+? What about neostigmine? What about Sux?
Give fluids with little to no potassium due todevelop hyperkalemia following severe myotonia as a result of muscle damage and rhabdomyolysis.
Neostigmine:Neostigmine inhibits acetylcholinesterase, thereby increasing acetylcholine at the neuromuscular junction. This increase in acetylcholine causes increased muscle activation and has been associated with myotonias.Succinylcholine causes muscle activation and fasciculation, which in a patient with myotonic dystrophy is very likely to cause severe myotonias. Myotonias severe enough to interfere with ventilation have been documented.
30
Appropriate amount of oral midazolam in a child:
An appropriate preoperative dose of oral midazolam is approximately 0.5 mg/kg in pediatric patients.
31
Preemie lung problems due to decreased surfactant (doesn't start getting made until 32 weeks)
n the premature lung with inadequate surfactant activity, the resultant higher surface tension leads to instability of the lung at end-expiration, low lung volume, and decreased compliance. In premature infants, surfactant deficiency is the primary cause of RDS because the loss of surfactant leads to an increase in the amount of pressure needed to open alveoli. Alveolar instability at low volume results in alveolar collapse and diffuse atelectasis as well as decreased compliance.
32
Infant formula NPO guideline:
6 hours!!!!!
33
If it's not breast milk-so any other kind of milk, or formula, the NPO time is:
6 hours!!!!!!
34
What is the MOST common congenital abnormality recognized at birth?
Perimembranous (upper) ventricular septal defect
35
MCC cardiac valve abnormality:
Bicuspid aortic valvehis lesion occurs when two of the aortic valve leaflets fuse during fetal development. This is the most common cardiac valvular anomaly and males are four times as likely to have a bicuspid aortic valve as females. Aortic regurgitation is a common consequence as is the development of aortic stenosis which typically occurs in the 4th and 5th decade. Bicuspid aortic valves are associated with aortic root post stenotic dilatation and a very high rate of aortic valve endocarditis.
36
Why is a volatile anesthetic inhalational induction more rapid in infants?
Infants have a greater fraction of cardiac output that is distributed to vessel-rich organs. This higher percentage of cardiac output is an important determinant in the induction of anesthesia. Compared to adults, induction of anesthesia occurs quicker in infants because of a higher cardiac output to the vessel-rich organ group.
37
FRC in kids vs adults? What about neonates?
Children have a similar FRC as adults on a per kilogram basis. Neonates have a smaller FRC, but this is typically only for the first few days of life.
38
Adults have a lower blood gas solubikity than kids T/F:
FalseInfants have a lower blood gas solubility than adults
39
Beckwith widemann syndrome: what do they have? what can increase your chances of getting it?
Visceromegaly-which causes hypoglycemia, macroglossia (making them a difficult intbation), overgrowth of soft tissues
40
Trisomy 21:
Down syndrome, also known as trisomy 21, is the most common chromosomal abnormality. The incidence of trisomy 21 is roughly 1 in 1000 children. At birth trisomy 21 is associated with low muscle tone, cardiac defects (especially endocardial cushion defects), and a large tongue. As these children age, they often develop physical features such as a flat nose, angled eyes, and a simian crease. Additionally, these patients may have an unstable atlantoaxial joint.
41
VATER syndrome:
VATER association is a collection of characteristics that can be found together. VATER or VACTERL are acronyms standing for: V- vertebral, A- anal imperforate, TE- tracheoesophageal fistula, R – renal abnormalities, C – congenital cardiac condition, L – limb abnormality. The VATER association characteristics should be looked for in any patient displaying even one of the anomalies. The association of these characteristics is because these structures form around the same time in utero
42
William's syndrome:
Think Will Ferrell-Williams syndrome is a congenital disorder caused by a deletion on chromosome 7. These patients are often described as “elf-like in appearance” are not large in size. They also may develop a supravalvular aortic stenosis, which can affect an anesthetic induction. If a patient is dehydrated and then, systemic vascular resistance falls, fatal myocardial ischemia can develop.
43
Sux and strabismus repair:
| kids with strabismus and increase in risk of:
Children with strabismus who receive succinylcholine for general anesthesia are 4 times more likely to experience MMR.ONV and bradycardia are common side effects of pediatric strabismus surgery, with or without the use of succinylcholine for muscle relaxation. PONV may occur in over 80% of untreated cases, but is unrelated to succinylcholine.
44
why no sux in kids?
Succinylcholine is relatively contraindicated for use in children out of concerns for a hyperkalemic response in patients with undiagnosed myopathies.
45
A 46-week-old infant is undergoing laparoscopic repair of an inguinal hernia under general anesthesia. Following intubation with an uncuffed endotracheal tube, a leak pressure of 42 cm H2O is measured. What next?
If the leak pressure of an uncuffed endotracheal tube (ETT) is > 40 cm H2O, it should be replaced with a smaller endotracheal tube. It should be replaced with a smaller ETT (0.5-1 mm size down)
46
What is theThe optimal leak pressure of an uncuffed ETT in pediatric patients?
Low leak pressure?
what happens if its too high?
is between 20-30 cm H2OA leak pressure < 10-20 cm H2O may indicate an inadequate seal and may result in an increased risk of aspiration, difficulty providing positive pressure ventilation, and/or inaccurate EtCO2 monitoring. A leak pressure > 30-40 cm H2O places the patient at risk for a range of complications due to tracheal ischemia
47
Tetrology of Fallot-what is it?
The associated defects include VSD, overriding aorta, infundibular pulmonic stenosis, and RVH. The goals of anesthetic management include maintaining SVR, reducing heart rate and contractility, and ensuring adequate oxygenation and normocarbia. Phenylephrine is the drug of choice for preserving SVR. The modified Blalock-Taussig shunt allows deoxygenated blood to enter the pulmonary tree via the subclavian artery. This is a temporizing procedure and is reversed upon complete surgical repair.
48
How can you increase SVR?
SVR can be increased by flexing the legs or by compressing the abdominal aorta directly. Children will squat during a hypercyanotic spell to increase their SVR and cause a decrease in the right-to-left shunt. Flexing the legs can also be used during induction of anesthesia for these patients.
49
What happens during a TET spell? and why is phenylephrine helpful during a tet spell?
During a “Tet” spell, increased pulmonary vascular resistance (PVR) shunts blood through the ventricular septal defect (VSD) and into systemic circulation. This occurs because systemic vascular resistance is less than PVR and blood flows via the path of least resistance. In addition to increasing PBF by increasing SVR, phenylephrine also serves to improve end-organ perfusion pressures and the reflex bradycardia reduces hypercontractility thus limiting the incidence of infundibular spasm of the right ventricular outflow tract (RVOT).
50
What is Klippel Feil syndrome?
Klippel-Feil syndrome is a congenital condition most often associated with fusion of the cervical spine.
Patients with Klippel-Feil are often difficult to intubate because of the fusion and decreased neck mobility. Patients with Klippel-Feil are often described as having a short neck with a low hairline. Additionally, most may have associated scoliosis, strabismus, or scapular defects. Heart and other spinal conditions are more likely to occur in these patients as well.
51
pierre robin syndrome-what do they have, what are associated syndromes?
Micrognathia in the neonate is associated with Pierre Robin sequence. Pierre Robin sequence is associated with micrognathia, macroglossia, and severe upper airway obstruction. There are a few other conditions which are associated with Pierre Robin such as fetal alcohol syndrome, Treacher Collins, and velocardiofacial syndrome.
52
Tell me about how you would induce a patient with congenital emphysema
Induction of anesthesia for a patient with congenital emphysema includes maintenance of spontaneous ventilation with minimal peak inspiratory pressure. Nitrous oxide should be avoided
53
Are APGAR scoes good at predicting long term success?
| and if the HR is below 100-then ___ and ____ simultaneously:
noAccording to the AHA CPR guidelines of 2010, if the infant has continued apnea, cyanosis, bradycardia (pulse < 100 beats/min), and poor muscle tone during the first minute of life, then positive pressure ventilation with room air in a full-term newborn should be initiated. Pulse oximetry should be placed simultaneously and oxygen may be titrated into an air/oxygen mixture to achieve SpO2 >90%.
54
When does separation anxiety begin? if giving midaz, how much do you give?
6-8 monthsOral midazolam in doses 0.5-0.75 mg/kg is the most commonly used agent. Both the dose and length of time after premedication determine success of anxiolysis, with at least 10 minutes required before any discernible benefit is demonstrated
55
Initial resuscitation in pediatric patients with severe dehydration begins with
What about solutions with dextrose? what about K?
20 mL/kg bolus of an isotonic salt solution, usually 0.9% sodium chloride (B), Ringer’s lactate, or Plasmalyte. This clinical scenario may be common with pyloric stenosis.
olutions containing dextrose (C,D,E) are considered maintenance fluids and should be administered after initial resuscitation is completed. Potassium (E) should not be administered until adequate urine output (≥0.5-1 mL/kg/hr) has been established in order to prevent life-threatening hyperkalemia.
56
Why do kids NOT get codeine?
Codeine has not been shown to increase pain control over acetaminophen following tonsillectomy. Additionally, in 2013 the FDA placed a black box warning on codeine stating that it is contraindicated in all children following tonsillectomy. The reason for the warning is because codeine has been associated with several pediatric deaths following tonsillectomy.
57
who else shouldnt have codeine and why?
Inhibitors of CYP 2D6 include quinidine and serotonin specific reuptake inhibitors (SSRIs) such as fluoxetine. Therefore, codeine is not an ideal opioid for patients who are taking SSRIs.
58
Pulmonary edema after tonsillectomy?
Pulmonary edema can occur when airway obstruction is relieved by tonsillectomy. It has been suggested that increased negative inspiratory pressure consequent to airway obstruction increases venous return and pulmonary blood volume.
59
Anesthetic mgmt of CDH:
Key points to anesthetic management of newborns undergoing CDH repair include allowing permissive hypercapnia while avoiding: hypothermia, venous access in the lower extremities, and nitrous oxide
NB: CDH is left sided and female
Anesthetic management involves avoiding the catastrophic persistent pulmonary hypertension by maintaining adequate arterial oxygenation, treating pain, maintaining acid-base balance, and improving pulmonary blood flow. In addition, while transient pulmonary vasodilation may occur with respiratory alkalosis, it is much more important to avoid large tidal volumes in an attempt to maintain normocapnia and instead tolerate some degree of hypercapnia (C). This avoids volutrauma leading to secondary lung injury which will increase inflammatory mediators and lead to pulmonary vasoconstriction.
60
CDH and hypothermia, nitrous and vascular access
Newborns with CDH are more prone than healthy newborns to the risks of hypothermia and avoidance of this complication (D) is important to prevent increased oxygen consumption, which can lead to hypoxemia, acidosis, and subsequent pulmonary vasoconstriction. Vascular access in the lower extremities should be avoided (B) because the inferior vena cava may become compressed after the reduction of the hernia. This may also decrease the cardiac preload and cardiac output. The administration of nitrous oxide can be deleterious (A) as it can diffuse into the viscera residing within the thoracic field and cause further lung compression. Additionally, infants with CDH often require high inspired oxygen concentrations and may not tolerate the lower FiO2 with nitrous oxide use
61
hyopplastic left heart syndrome; pathophys, what is it associated with?
what is essential for their survival? how do the coronaries get perfused? look at the photo
Blood flow and physiology of HLHS. Systemic venous blood (blue arrows) enters the right atrium and mixes with oxygenated blood which passes from the left atrium to the right atrium via an ASD. This blood then enters the right ventricle, traverses the pulmonic valve, enters the pulmonary artery and then takes two paths: 1) to the lungs for further oxygenation via the pulmonary arteries, or 2) to the systemic circulation through a PDA. Systemic blood flow is, therefore, dependent on a PDA. This semi-oxygenated blood (purple arrows) provides retrograde blood flow to coronary (A) circulation
In HLHS, the left ventricle is significantly hypoplastic and essentially nonfunctional. Associated lesions include ASDs, severely stenotic or atretic mitral and aortic valves, patent ductus arteriosus (PDA), and a hypoplastic ascending aorta.
62
Risk factors for post-operative apnea:____ what's protective?
Risk factors for postoperative apnea include use of general anesthesia or regional anesthesia with IV sedation, a history of prematurity, PCA < 60 weeks (especially < 42-44 weeks), a history of apnea, and anemia. Being small for gestational age has been found to be somewhat protective against postoperative apnea.
63
How long should a patient stay after post-op apnea?
Infants with a history of apnea and bradycardia are at increased risk for postoperative apnea, so it is recommended to proceed with elective outpatient surgery after a six month interval free from apnea and bradycardia. If these criteria are not met, the infant should be monitored postoperatively for 12-24 hours or a regional anesthetic technique without sedation should be considered.
64
URIs pose what risks for surgery:
Children with URIs are at increased risk for perioperative pulmonary complications including coughing, laryngospasm, bronchospasm, transient periods of hypoxia, croup, and pneumonia. However, long-term outcome studies do not show any significant difference in long-term sequelae in pediatric patients with or without URIs.
truly elective and active URIs should be canceled
65
T/F:Apneic oxygenation is less effective in children with URIs.
TRUE: Apneic oxygenation is less effective in children with URIs.
66
LMA vs ETT in URI
The use of endotracheal tubes seems to cause more stimulation to the inflamed airways and therefore carries more pulmonary risks than LMA in this setting.
67
Induction in epiglottitis:
Safe airway management of acute epiglottitis is founded on inhalational induction in the sitting position with maintenance of CPAP during spontaneous ventilation to prevent inspiratory laryngeal airway collapse or irritation.
Acute epiglottitis is a form of variable extrathoracic obstruction, depicted as inspiratory compromise on the pulmonary flow-volume loop.
68
Dosing of caudal blocks in infants? you need more lA?
Dosing of single-shot caudal epidural blocks in infants and young children is done on a ml/kg basis. Using 0.5 mL/kg of local anesthetic will cover the sacral dermatomes, 1 mL/kg will cover up to the low thoracic dermatomes, and 1.25 mL/kg will cover up to the mid thoracic dermatomes
audal epidural blocks are effective for surgeries involving the lower abdomen and lower extremities, i.e. procedures in areas innervated by low thoracic, lumbar, and/or sacral nerve roots.Unlike in adults, these large volumes can be safely injected into the caudal epidural space. This is possible because the space is loosely packed and higher volumes of local anesthetic are needed to spread to and reach the desired nerve roots/dermatomes.
69
where does the dural sac and spinal cord stop in kids?
In newborns, the dural sac typically ends at S3 and the conus medullaris at L3. In adults, the dural sac typically ends at S1-S2 and the conus medullaris at L1-L2.
70
What is the first step in pulmonary atresia?
A modified Blalock-Taussig (BT) shunt is the first stage in correction of pulmonary atresia
A modified Blalock-Taussig (BT) shunt is the first stage in correction of pulmonary atresia #18 on test on 6/26/19
71
Is midaz better than mom?
Benefits of PPIA include a decreased need for premedication, decreased anxiety in the child, and increased anesthetic compliance. However, PPIA is less effective than premedication alone in reducing anxiety and increasing compliance in pediatric patients.
72
Duchenne's muscular dystrophy-how is it inherited?
sex linked-affects the dystrophin gene
73
MCC of death in Duchenne's:
The most common causes of death in patients with DMD are congestive heart failure or aspiration pneumonia.
74
stuff that can happen in duchennes with anesthesia
When under general anesthesia, these patients are at increased risk for dysrhythmias because of changes in the sympathetic and parasympathetic balance.Dysrhythmias occur because of fibrosis in the cardiac conduction system and as a result of cardiomyopathies occurring with DMD.
Answer B: Hyperkalemia may result in patients with DMD who have been given succinylcholine.Rhabdomyolysis can occur in patients with DMD who receive volatile anesthetics. Volatile anesthetics disrupt cellular structure and patients with DMD are more susceptible. This cellular disruption causes a rise in intracellular calcium and cell death. Rhabdomyolysis causes an increase in creatinine kinase (CK) which has been mistaken for malignant hyperthermia.
75
vecuronium metabolism in neonates
Hepatic metabolism in neonates is usually decreased leading to an increased duration of action of hepatically metabolized drugs such as vecuronium and rocuronium.
76
ECF and TBW in neonates:
nfants and small children have larger extracellular fluid volumes by percentage of TBW and therefore require larger weight-based dosing of muscle relaxants.
77
Propofol is avoided in patients with what type of disease?
Mitochondrial disease
78
why is nitrous oxide avoided when possible in patients with MTHFR mutations
Nitrous oxide directly inhibits methionine synthetase.When this pathway is inhibited homocysteine levels rise.Elevated homocysteine increases incidence of thrombosis and adverse coronary events.
MTHFR deficiency causes a problem in one limb of folate and homocysteine metabolism. Nitrous oxide can inhibit the path at another location and further increase homocysteine levels
79
PGe1 is great-why? what bad stuff can happen?
PGE1 is used to maintain patency or reopen the ductus arteriosus in "ductal dependent lesions" to improve blood flow to the lungs or systemic circulation depending on the nature of the congenital lesion. Side effects include apnea, hypotension, fevers, and CNS irritability
80
Which one is covered? gastroschesis or omphalocele?
Omphalocele os covered-gastroschesis is not.The lack of an enclosing membrane around exposed bowel with gastroschisis (abdominal wall defect-to the right of the umbilical cord) results in a higher incidence of heat loss, dehydration, and infection compared to omphalocele
Gastroschisis is more rare and also is usually alone while omphalocele is not.
81
Gastroschis vs omphalocele in terms of risk factors
Gastroschisis is associated with young maternal age (20 years or less) and maternal exposure to cigarette smoking, illicit drugs, and certain over-the-counter medications (e.g. acetaminophen, aspirin, and pseudoephedrine). Omphalocele tends to be associated with advanced maternal age.
82
The Pentalogy of Cantrell includes:
1) Omphalocele
2) Ectopia cordis (heart partially or completely outside thorax)
3) Ventricular septal defect or ventricular diverticula
4) Sternal cleft
5) Anterior diaphragmatic hernia
83
Pierre robin and aspiration risk:
| considerations for induction with this:
These patients frequently have gastroesophageal reflux from esophageal dysmotility and are aspiration risks, therefore evaluation preoperatively by speech pathology with a swallow study is indicated.ierre Robin Sequence is comprised of airway obstruction, glossoptosis, and micrognathia and is associated with difficult intubation. Airway management focuses on maintenance of spontaneous ventilation, availability of alternate airway devices, and consideration for having an otolaryngologist present
84
Hypothermia and fetal circulation:
Hypothermia is commonly associated with reversion to fetal circulation in the newborn. Newborns are at high risk for developing hypothermia, which has several potentially devastating complications. Hypothermia is associated with metabolic acidosis. Acidosis increases pulmonary vascular resistance and decreases systemic resistance. This increases flow across the foramen ovale and ductus arteriosus, maintaining fetal circulation
85
acidosis and fetal circulation:
Acidosis (maternal and fetal) can cause reversion to fetal circulation after birth. Respiratory acidosis causes an increase in PaCO2, which inhibits ductus arteriosus closure. Acidosis causes an increase in pulmonary vascular resistance and a decrease in systemic vascular resistance. This change in vascular resistances causes shunting (right to left) to occur across the foramen ovale. Shunting from the right atrium to left atrium and shunting from the pulmonary artery to the aorta is consistent with fetal circulation.
86
Hypoxemia and fetal circulation; what is the most important stimuli for PDA closure?
Hypoxemia (maternal and fetal) causes persistent fetal circulation. Hypoxemia is a potent stimulus for pulmonary vasoconstriction, which increases pulmonary artery pressures. This increase in pressure causes shunting to occur across the foramen ovale (right to left), which is not mechanically closed until several months after birth. Additionally, arterial oxygen concentration is the most potent stimuli for ductus arteriosus closure. Hypoxemia also causes a shift from aerobic to anaerobic metabolism. Anaerobic metabolism causes a metabolic acidosis, which further increases pulmonary resistance and decreases systemic resistance
87
Maternal NSAID use and ductus closure
Maternal NSAID use is associated with premature ductal closure and not persistent fetal circulation.
88
Why do infants have increased work of breathing compared to adults?
Respiration is less efficient in infants and the work of breathing can be as much as three times higher than adults. The airway of infants is highly compliant and poorly supported by the surrounding structures. The chest wall is also highly compliant, therefore the ribs provide little support for the lungs; that is negative intrathoracic pressure is poorly maintained. This means that functional airway closure accompanies each breath. The pliable rib cage gives less mechanical support than in the older child or adult, leading to significant retractions with less efficient gas exchange and functional airway closure, thus increasing the work of breathing.
89
How are the diameters of infant airways compared to adults? Type 1 diaphragm fibers?
The smaller diameter of infant airways relative to adults causes increased resistance to airflow. This is explained by the Poiseuille law, in which resistance is inversely proportional to the radius raised to the fourth power assuming laminar flow. Until the age of 2, infants’ diaphragms have a much smaller proportion of fatigue-resistant type I (slow twitch) muscle fibers. Therefore, infant diaphragmatic and intercostal muscles tire more quickly, as compared to adults, and additional muscle groups need to be recruited.
90
O2 consumption is increased in infants-what does the body do to help with that?
Oxygen consumption per kilogram is 2-3 times higher in infants as compared to adults (6-7 mL/kg vs. 2-3 mL/kg). To meet this increased need, minute ventilation is accordingly increased.
91
Mgmt strategy of choice in CDH
Gentle ventilation" with permissive hypercapnia using a low tidal volume strategy, PIP < 25 cm H20, and FiO2 + PEEP adjustment to maintain preductal SpO2 of 90-95% has been shown to decrease mortality in patients with congenital diaphragmatic hernia (CDH) and is the management strategy of choice.
92
hypothermia and acidosis:
ypothermia is associated with metabolic acidosis. Acidosis increases pulmonary vascular resistance and decreases systemic resistance.
93
In CDH:If sudden hypotension or hypoxia ensues, determination of the cause must be sought promptly, with two being the most common: would you use this intervention all the time?
Preductal sat goa for CDH:
One is contralateral pneumothorax, treated with chest tube or needle thoracostomy, and the other is worsened pulmonary hypertension, which should be treated with nitric oxide (NO). KIM-you wont use NO at jump-only if in a last resort situation.
90-95%
94
Whatare the primary triggers for nonshivering thermogenesis in neonates and infants?
Norepinephrine (B), glucocorticoids, and thyroxine
95
4 mechanisms of heat generation, and which ones are neonates less proficient in?
Humans generate heat through four mechanisms: voluntary muscle activity, shivering, dietary thermogenesis, and nonshivering thermogenesis. Each of these mechanisms works by increasing metabolic rate since heat is a byproduct of cellular metabolism. In neonates and infants, the ability to generate heat through voluntary muscle activity is limited. In addition, neonates generally do not shiver and if they do, its contribution to heat production is limited. The importance of shivering grows with increasing age. Dietary thermogenesis plays a more important role with protein and amino acid metabolism stimulating significant thermogenesis.
96
Which method of heat generation is best for neonates? what is released that helps them with this? where does it occur? tell me about tht environment and its innervation?
Of the four mechanisms for heat generation, nonshivering thermogenesis plays the most important role in neonates and infants with its importance thereafter decreasing with age. Nonshivering thermogenesis is metabolic heat production (above basal metabolic rate) not produced from muscle activity. It primarily occurs in brown fat which is able to uncouple oxidative phosphorylation at the mitochondrial level, resulting in heat generation instead of ATP production. Nonshivering thermogenesis can effectively double metabolic heat production in neonates and infants.
Compared to normal adipose tissue, brown fat is highly vascularized and has significant β-sympathetic innervation. Cold stress causes sympathetic nervous system stimulation which leads to norepinephrine (B) release which then triggers increased lipase activity in brown fat. Lipase causes hydroxylation of triglycerides and the release of free fatty acids which are then used as substrates for metabolism and uncoupled oxidative phosphorylation, yielding heat. Significant cold stress can cause up to 25% of cardiac output to be delivered to brown fat which results in direct warming of blood. Glucocorticoids and thyroxine have also been shown to trigger nonshivering thermogenesis.
97
What role does epi,blood glucose, and free fatty acids play in non-shivering thermogenesis?
epinephrine, blood glucose levels, and circulating levels of free fatty acids, none of these are triggers for nonshivering thermogenesis
98
What inhibits non-shivering thermogenesis?
t is inhibited by inhalational anesthetics and β-blockers.
99
One of the first signs of a total spinal anesthetic in a neonate is:
apnea or respiratory depression which will likely necessitate intubation for controlled ventilation
100
Order of things to happen in an adult high spinal:
In adults, the first signs and symptoms of high or total spinal anesthesia are dyspnea (primarily due to the inability to feel chest wall movement during respiration) and difficulty speaking or swallowing (due to pharyngeal and laryngeal muscle weakness). Shortly thereafter, cardiovascular signs manifest including hypotension and tachycardia (a brief initial reflex from hypotension) which progresses to bradycardia (as the T1-T4 cardiac accelerator fibers are anesthetized). This can then progress to respiratory depression/failure and loss of consciousness due to brain stem involvement and cerebral hypoperfusion.
101
infant high spinal-is there hypotension? is there tachycardia?
Unlike adults who first present with subjective symptoms and cardiovascular signs, total spinal anesthesia in neonates presents with respiratory depression, which is typically seen as a decrease in oxygen saturation and apnea. Treatment is supportive and usually only involves intubation for controlled ventilation (C) until adequate spontaneous ventilation returns. However, failure to ensure adequate oxygenation can lead to hypoxic cardiac arrest (D).
The sympathetic blockade seen in adults is not typically seen in children less than 5-8 years old, especially in neonates and infants. This is most likely due to the immaturity of the sympathetic nervous system (SNS) and already predominant parasympathetic tone in children. Studies have shown that blockade even at levels of T3 in children under five years old results in few hemodynamic consequences. In addition, infants without fluid preloading tolerate total spinal anesthesia with few autonomic changes.
Occasionally, bradycardia (B) may be a later sign of total spinal anesthesia either due to decreased sympathetic input to the heart, or as a result of respiratory depression and hypoxia. Tachycardia does not typically occur (A).
Hypotension is unusual, again due to reduced SNS activity, but also since there is less venous pooling in neonates and infants due to a smaller relative volume of blood in their lower extremities.
102
Eoiglottitis- what does it look like? who gets it? which imaging sign do they have? anesthesia?
Epiglottitis is considered an airway emergency usually caused by Haemophilus influenzae type B (A) in the 2-5-year-old population and rarely in adults. Due to current vaccination standards, the occurrence is rare in the U.S. and is usually limited to immigrants.
Common clinical signs and symptoms of epiglottitis include: drooling, stridor, difficulty swallowing, “toxic” appearance, high fever, and the inability to lay supine without developing respiratory distress. Neck x-ray will reveal a “thumb” sign that represents the swollen epiglottis along with significant edema in the prevertebral region.NO attempts at stimulation or suction should be performed. Emergent intubation in the OR should be of highest priority, ideally with ENT present for possible emergent tracheostomy. Keep them breathing spontaneously, do not make them sit supine
103
What is croup? signs? imaging? causative agent?
Laryngotracheobronchitis is usually caused by a viral pathogen, namely parainfluenza virus. The symptoms usually are preceded by a viral prodrome, low-grade fever, and a barking cough. Drooling and severe toxic appearance are rare. A radiograph would display a “steeple” sign showing mucosal edema only. Treatment includes cool mist, inhaled racemic epinephrine, and sometimes steroids. Intubation is rarely needed.
104
When are patients ready go back for surgery for pyloric stenosis?
Patients with pyloric stenosis often develop a hyponatremic hypokalemic hypochloremic metabolic alkalosis. Normalization of chloride is probably the best indicator that metabolic alkalosis has resolved in these patients
105
Highest MAC value for infants:
The highest MAC values are for infants 3-6 months of age
106
How does cardiac output affect inhalational induction time, and is that affected by age?
If a patient has an increased CO, which inhalationals are most affected by it?
Is CO higher in children?
Who has a faster inhalational induction-children or adults?
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Regardless of age, a decreased cardiac output (CO) will decrease induction time by inhalational anesthesia by allowing FA:FI to rise faster. This may also place low CO patients at risk of overdose. As CO increases, so does the uptake of inhaled anesthetic. This phenomenon is more pronounced with soluble anesthetics such as halothane and isoflurane, less with agents such as nitrous oxide and desflurane which have lower blood:gas coefficients. There is a relative increase in CO in the pediatric population which slightly offsets the other factors which lead to a faster rise in FA:FI in children.
Kids have a faster inhalational induction
#2 on peds test from 4/3
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107
Adults do have higher blood:gas partition coefficients compared to infants and children. (t/F)
TRUE. Again, this means that inhalational agents are more soluble in blood in adults which leads to a slower rise in the FA:FI and a slower induction due to the increased uptake of volatile anesthetic into the blood stream.
108
Who has lower tissue: blood coefficients-adults or children? What does this even mean?
In addition, infants and children have decreased tissue:blood coefficients, further promoting the equilibration of alveolar to inspired anesthetic gas concentrations and increasing the rate of rise of FA:FI.
Sevo is less soluble in infants,rising Fa:Fi, and increasing speed of induction
109
Note, “gas concentrations” may also be called
Note, “gas concentrations” may also be called “partial pressures” or “anesthetic gas partial pressures.”
110
Infants and children have faster inhalation inductions primarily because
they have increased minute ventilation relative to functional residual capacity. This creates a faster rise in FA:FI and therefore a quicker induction.
111
Even though there is VACTERL, if a patient has a tracheoesophageal fistula, then they most commonly have which of the rest of VACTERL?
Congenital heart defects
112
All patients with TEF should undergo a
Echo
113
Cause behind tracheoesophageal fistulas?
Tracheoesophageal fistulas are the result of a midline defect during development of the fetus
114
Why is it that compared to an adolescent, a preterm infant is more responsive to atropine?
The autonomic nervous system of newborns is not mature. It is characterized by low catecholamine stores and poor responsiveness to exogenous catecholamines. Conversely, the parasympathetic nervous system is intact in newborns and predominates. For this reason, bradycardia or hypotension in neonates is typically very responsive to atropine, a muscarinic acetylcholine receptor blocker.
115
Neonates and fluid-does increased preload help them with hypotension?
Their cardiac output is relatively insensitive to increased preload as their stroke volume is relatively static. Heart rate in neonates, however, is highly variable and is the major determinant of cardiac output.
116
Is midazolam one of those CYP 450 things
yeah. Concurrent use of antacids and/or grapefruit juice can increase the onset time and bioavailability of midazolam by inhibiting the cytochrome P450 enzyme system.
117
Midazolam bioavailability among routes of administration (greatest to least):
intravenous > intramuscular > intranasal > rectal > oral.
118
Dehydration chart photo
okay
119
Fluid replacement strategy during a case (not anything carazy-just fluids)
20-40 mL/kg of a balanced salt solution (LR)
120
Amount of D5 1/2 NS to give after you've given ns to resuscitate
This infant is volume depleted with poor urine output in the setting of pyloric stenosis and therefore volume resuscitation with normal saline and initiation of D5 1/2 NS at 1.5 times maintenance fluid(20-40 mL/kg) is the most appropriate initial medical therapy.
121
Newborns and PTX
| How do you treat it?
While the incidence of a pneumothorax (PTX) in all vaginal deliveries is 1%, a newborn with a birth complicated by meconium has a 10% chance of developing a PTX.
Clinically, a PTX appears as poor hemithorax excursion, hyperinflation, and possible muffled heart sounds. In a neonate, a 22-gauge blunt needle or angiocatheter may be inserted in the ipsilateral second intercostal space at the midclavicular line to emergently relieve the PTX. A pediatric sized thoracostomy tube can then be inserted, secured in place, and connected to a suction or water seal device.
122
So, are you suctioning meconium or no?
So, i guess if it's causing respiratory distress, but if not-leave it alone because they're not down for routine suctioning.
123
TEF: What type is most common? explain it.
| Characteristic diagnostic test for TEF:
There are five different variations of congenital TEF, the most common being type C (occurs about 84% of the time). In type C, the proximal esophagus ends in a blind pouch, while the distal esophagus is connected to the trachea through a fistula. Acquired TEF can occur with malignancy, trauma, foreign body, and inflammatory processes.
A characteristic diagnostic test is the inability to pass a nasogastric tube into the stomach, and a large leak onthe ventilator (expiratory volume lower than inspiratory volume on the ventilator)
124
Mgmt of TEF:
Management of tracheoesophageal fistula includes intubation while maintaining spontaneous ventilation, advancing the tracheal tube beyond the fistula, and positioning the bevel of the tube anteriorly. If the fistula is at or distal to the carina, consider one-lung ventilation.
125
Goldenhar syndrome-major problem in anesthesia and other stuff they have
Goldenhar syndrome is a rare genetic disorder that has varying implications on anesthesia care. The most important consideration is airway management as there is potential for difficult mask ventilation and difficult laryngoscopic visualization.
Cervical subluxation
congenital cardiac defects
micronagthia
126
Patients with a hx of apnea, how long before they should have surgery:
If an infant has a history of apnea and bradycardia, it is advocated that there should be a six-month interval free from any events prior to proceeding with elective outpatient surgery.
127
What is periodic breathing? Is it normal or naw?
Note, periodic breathing is regular breathing interrupted by short pauses or apnea lasting 5-10 seconds without cyanosis or bradycardia. This is a normal variant and may be present in both full term and preterm neonates.
128
What do they say as far as infants who are preemies for surgery even if they've never had apnea?
Premature infants are at risk for postoperative apnea following general anesthesia (GA) or sedation with regional anesthesia. Current recommendations to proceed with an elective outpatient procedure include waiting until 44-60 weeks postconceptual age (PCA) if the infant has NEVER experienced apnea or bradycardia.
129
T/F: Factors that increase FA relative to FI increase the rate of induction of anesthesia.
TRUE
130
Things that make children more anxious during the perioperative period.
Younger children (preschool age), higher cognitive function, shy or withdrawn personalities, and children with anxious parents are all likely to have increased perioperative anxiety when they present for surgery.
131
Postconceptual age of ___ correlates to <1% risk of postoperative apnea
Postconceptual age of 56 weeks correlates to <1% risk of postoperative apnea
132
Biggest risk of post-operative apnea:
Prematurity is the strongest risk factor for postoperative apnea. The younger the patient, the more likely they are to develop postoperative apnea. Infants are higher risk if they also have multiple congenital anomalies, history of apnea or bradycardia, and chronic lung disease. Other contributing factors include hypothermia and anemia
133
Peds patients lose heat more quickly than adults. Why?
Pediatric patients have increased body surface areas relative to their total body volume leading to increased heat loss. In addition, they have less subcutaneous fat and thinner skin as compared to adults. Neonates are largely dependent on nonshivering thermogenesis via the metabolism of brown fat, which uncouples oxidative phosphorylation in the mitochondria to generate heat.
134
______ are the most effective way to treat intraoperative hypothermia in a pediatric patient
Forced air warming blankets are the most effective way to treat intraoperative hypothermia in a pediatric patient
135
As for risk of post operative apnea, we know regional and general are both risks for apnea, but is one better?
Neuraxial anesthesia
136
Formula for maximum allowable blood loss
Look at chart with EBV
Do this: Mabl for 8 kg 6 month old
MABL = EBV x (patient’s starting HCT – minimum acceptable HCT) /patient’s starting HCT
Okay
MABL = [(8 kg x 75 ml/kg) x (40% - 20%)] / (40%)
137
Pediatric endotracheal tube formula:
A conservative estimate of A-a gradient can be calculated with the same equation as pediatric endotracheal tube size: (Age / 4) + 4.
