Pediatric Flashcards
How do you figure out EBV:
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
Causes of post intubation croup: how long do they need to be watched? How do mike symptoms get treated?
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
Is there decreased croup with cuffed or uncuffed tunes?
Decreased with cuffed
Respiratory compromise in patients after tonsillectomy can happen. What are risk factors?
Preemie, age less than 3, neuromuscular disorders, uri within 4 weeks of surgery, obstruction on inhalational induction
What is the first line treatment in infants with apnea? After that?
Tactile stimulation. After that-then bag mask ventilation
When does surfactant start forming? What is BPD?
24-38 weeks. BPD is oxygen dependency for more than 28 days after birth and an abnormal chest radiograph
A baby is a preemie if what!
If they’re born before 37 weeks
What does VACTERL stand for?
Vertebral defects
Anal atresia
Cardiac defects
Tracheoesophageal fistul, renal abnormalities, limb abnormalities
Can you use caudal Anesthesia for repair of an imprrforae anus?
Yes, but Rene eat that these kids can have vertebral defects, so they’ll need an MRI firmest. Defects are contraindications
An infant with TEF and Esophageal atresia May have:
May have coarctation of the aorta
How does thermogenesis in the infant happen?
Bybcatabolism of brown fat. Not adipose-it’s in the vertebral and neck area.
Why does heat loss happen at a slower rate in the infant compared with adult. Greatest loss of heat? What can hypothermia cause?
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.
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?
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.
Do infants rely on cardiac accelerators for heart rate?
Infants do not rely on the cardiac accelerating fibers for a resting heart rate and therefore do not develop bradycardia with spinal anesthesia.
Spinal cord and dural sac in infants vs children
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.
Can adults get bradycardia during spinal anesthesia?
ONly if T1-T4 is blocked which is not good.
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?
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
Order of repair for HLHS?
Norwood, Glenn, Fontan
Pyloric stenosis abnormalities: Potassium? Bicarb? Chloride? Metabolic state?
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.
EBV and age chart
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
Bradycardia is common after induction in which pediatric patient population?
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.
Expect what when dealing with patient’s with Down syndrome?
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.
In infants and children under 5 years, the first sign of a high or total spinal is ____
When would you use a caudal anesthetic?
Apnea
It is best suited for procedures at or below a T10 dermatomal level (e.g. lower abdominal, urologic, and lower extremity procedures).
Dural sac in newborns ends at
S3
Site of injection for Caudal Anesthesia
S4-S5
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.
What is myotonic dystrophy?
Myotonic dystrophy is a progressive genetic condition with associated muscle weakness and myotonia, along with contractures of the muscles
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.
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.
Appropriate amount of oral midazolam in a child:
An appropriate preoperative dose of oral midazolam is approximately 0.5 mg/kg in pediatric patients.
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.
Infant formula NPO guideline:
6 hours!!!!!
If it’s not breast milk-so any other kind of milk, or formula, the NPO time is:
6 hours!!!!!!
What is the MOST common congenital abnormality recognized at birth?
Perimembranous (upper) ventricular septal defect
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.
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.
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.
Adults have a lower blood gas solubikity than kids T/F:
FalseInfants have a lower blood gas solubility than adults
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
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.
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
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.
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.
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.
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)
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
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.
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.
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).
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.
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.
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
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%.
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
