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Anesthesia > Pediatric Anesthesia > Flashcards

Pediatric Anesthesia Flashcards

1
Q

Why are neonates/preterm infants at increased anesthetic risk?

A
  1. pulmonary factors
  2. cardiovascular factors
  3. thermoregulation factors
  4. pharmacologic factors
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2
Q

What are the pulmonary factors affecting neonates?

A
  1. anatomic differences
  2. lower FRC, VC is 1/2 and RR is 2x that of adults
  3. higher O2 consumption
  4. rightward shift of CO2 response curve
  5. agents have more profound effects on ventilation & oxygenation
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3
Q

What are the cardiovascular factors affecting neonates?

A
  1. ventricles are non-compliant; increasing contractility does not increase CO
  2. CO is HR-dependent
  3. parasympathetic system is more active – more prone to bradycardia
  4. agents have more profound myocardial depressant effects
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4
Q

What are the thermoregulation factors affecting neonates?

A
  1. poor central thermoregulation
  2. little muscle mass –> cannot shiver effectively
  3. non-shivering thermogenesis –> uses brown fat; inefficient (consumes more O2)
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5
Q

What are the pharmacologic factors affecting neonates?

A
  1. larger volume of distribution
  2. less protein-binding affinity
  3. immature kidneys and liver
  4. larger initial dose but slower clearance
  5. more rapid uptake of volatile agents
  6. lower MAC
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6
Q

Why are neonates/preterm infants at high risk of regurgitation/reflux?

A

Incompetent LES, slow gastric emptying time

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7
Q

What are the 2 most common causes of morbidity in the neonatal period?

A

Apnea
Bradycardia

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8
Q

Why is apnea dangerous?

A

Chemoreceptors are not very sensitive to hypercarbia and hypoxia. Apnea lasting >15 seconds may lead to bradycardia and worsen hypoxia.

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9
Q

What are the mechanisms of heat loss?

A

Radiation, conduction, evaporation, convection

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10
Q

In what order do the mechanisms contribute from greatest to lowest heat loss?

A
  1. Radiation
  2. Convection
  3. Evaporation
  4. Conduction
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11
Q

How to minimize heat loss?

A
  1. Warm room at least 1 hour prior (>24C)
  2. Use warming blanket & lights, head cover
  3. Cover exposed skin with plastic
  4. Use forced-air warming devices
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12
Q

What are common intraoperative problems?

A
  1. hypoxia
  2. bradycardia
  3. hypothermia
  4. hypotension
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13
Q

What are the usual causes of bradycardia in neonates?

A

hypoxia
vagal stimulation - laryngoscopy
volatile anesthetics, succinylcholine

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14
Q

What is the usual cause of sudden intraoperative hypoxia in neonates?

A

dislodged/displaced ETT OR pressure on chest/abdomen during surgical manipulation

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15
Q

Up to what age do you expect postoperative apnea?

A

60 weeks post-conceptual age (PCA), even with minor surgery.

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16
Q

What are the most common neonatal surgeries?

A

TEF/EA
Gastroschisis
Omphalocele
Congenital Diaphragmatic Hernia
Patent Ductus Arteriosus
Pyloric Stenosis
Intestinal Obstruction

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17
Q

What other preparations be done in anesthetizing a neonate?

A
  • Multiple sizes of airway (both smaller and larger) ready
  • Compute for MF, EBV, and ABL
  • Use a Buretrol or Soluset
  • Consider using a precordial stet
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18
Q

Is surgical repair of pyloric stenosis emergent?

A

No. Make sure to correct fluid and electrolyte imbalances before proceeding with surgery.

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19
Q

What are the metabolic disturbances present in pyloric stenosis?

A

Dehydration
Hypochloremia
Metabolic alkalosis

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20
Q

How to induce a neonate with congenital diaphragmatic hernia (CDH)?

A

Awake intubation
Mask ventilation is CONTRAINDICATED (because it can cause visceral distention and worsen oxygenation)
Decompress the stomach with OGT/NGT

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21
Q

What are the ventilation strategies for CDH?

A

Low pressures (<25 cmH2O) - to prevent barotrauma
Permissive hypercapnia (45-60 mmHg) - secondary to lower TV
Pre-ductal 85-95%, post-ductal >70% - to avoid O2 toxicity

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22
Q

Is surgical repair of CDH emergent?

A

No. Severity of pulmonary hypertension depends on underlying lung hypoplasia.

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23
Q

What are other congenital anomalies that may present with TEF?

A

VATER/VACTERL:
Vertebral
Anus (imperforate)
Cardiac
Renal
Limb

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24
Q

What other anomalies may present with omphalocele?

A

cardiac, urologic, and metabolic

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25
Q

What other anomalies may present with gastroschisis?

A

usually none

26
Q

Which surgeries usually necessitate delayed extubation?

A

CDH
Repair of gastroschisis/omphalocele

27
Q

Describe the baroreceptor reflex in a child.

A

Infants have an immature baroreceptor reflex –> cannot effectively compensate for hypotension by increasing HR

28
Q

What are the anatomic differences between adult and pediatric airways?

A
  1. obligate nose breather - easily blocked by secretions
  2. large tongue - obstruction, difficult laryngoscopy
  3. large occiput - sniffing position is achieved by placing a shoulder roll
  4. anterior larynx & vocal cords slant anteriorly - difficult intubation
  5. larynx & trachea are funnel-shaped - vocal cords are the narrowest portion
29
Q

What are the differences between adult and pediatric pulmonary mechanics?

A
  1. ↓ pulmonary compliance – prone to airway collapse
  2. ↑ airway resistance d/t small airways – ↑ work of breathing
    Prone to diseases affecting small airways
  3. ↓ TLC, ↑ RR and O2 consumption - more rapid desaturation
  4. ↑ closing volume – ↑ dead space
  5. horizontal ribs, pliable ribs and cartilage – inefficient chest wall mechanics
  6. Less type 1 high-oxidative muscle – fatigue more easily
30
Q

How to induce anesthesia in children?

A

INHALATIONAL
and
INTRAVENOUS

31
Q

How to do inhalational induction?

A

70% N2O + 30% O2 for 1 minute > > add sevoflurane

32
Q

How to do inhalational in an uncooperative child?

A

RAPID induction:
Hold the kid down
Use 70% NO + 30% O2 + 8% sevoflurane
Place mask against the child’s face
Decrease sevoflurane once induced

33
Q

How to induce a sleeping child?

A

STEAL induction:
Hold the mask near the face while gradually increasing sevoflurane

34
Q

What are the common induction meds and doses?

A

Propofol 2-3 mg/kg IV
Etomidate 0.2-0.3 mg/kg IV
Ketamine 1-3 mg/kg IV or 2-5mg/kg IM

35
Q

What is EMLA?

A

Eutectic Mixture of Local Anesthetics: 2.5% lidocaine + 2.5 % prilocaine
Apply at least 60 minutes prior to use

36
Q

What happens in left-to-right shunting?

A

right-sided & pulmonary circulation volume overload > ↓ pulmonary compliance & congestive heart failure

37
Q

What happens in right-to-left shunting?

A

hypoxemia, LV overload

38
Q

Which type of shunt causes cyanosis?

A

right-to-left is cyanotic

left-to-right is acyanotic

39
Q

How does a left-to-right shunt affect induction?

A

INHALATIONAL: minimally affected
INTRAVENOUS: prolonged onset

40
Q

How does a right-to-left shunt affect induction?

A

INHALATIONAL: delayed uptake
INTRAVENOUS: shorter onset

41
Q

What other considerations are necessary for a child with CHD?

A

Maintain PVR
Avoid air bubbles
Prophylactic antibiotics to prevent IE

42
Q

What are conditions/drugs that increase left-to-right shunt?

A

low HCT
↑ SVR, ↓ PVR
hyperventilation
hypothermia
isoflurane

43
Q

What are conditions/drugs that increase right-to-left shunt?

A

↑ PVR, ↓ SVR
hypoxia
hypercarbia
N2O, ketamine

44
Q

What is the effect of pulmonary vascular resistance on intracardiac shunting?

A

Left-to-Right:
↑ PVR - reversal of blood flow
↓ PVR - pulmonary edema

Right-to-Left:
↑ PVR - worsen oxygenation
↓ PVR - improve hemodynamics

45
Q

What are the 4 lesions in TOF?

A
  1. pulmonary artery atresia/stenosis (right ventricular outflow tract) obstruction
  2. overriding aorta
  3. VSD
  4. right ventricular hypertrophy
46
Q

How to manage a tet spell?

A
  • maintain airway
  • volume infusion
  • increase depth of anesthesia
    decrease surgical stimulation
  • beta-blocker to control HR
  • phenylephrine to ↑ SVR
47
Q

How to estimate ETT size?

A

Cole formula:
Uncuffed = (age/4)+4
Cuffed = (age/4)+3

Insert ETT ~3x the internal diameter

48
Q

Can cuffed ETT be used in < 8yo?

A

Yes, advantages include:
- lower number of intubation attempts
- decreased air leak
- allow use of lower FGF

49
Q

What is the effect of age on MAC?

A

1-6months: highest MAC - least potent

children > adults
premature & neonates < children

50
Q

How to compute for the maintenance fluid?

A

Use the 4-2-1 rule (Holliday-Segar)

51
Q

What is the estimated blood volume in children?

A

neonates ~90ml/kg
1 y/o ~80ml/kg
>1 y/o ~70ml/kg

52
Q

How to compute for the allowable blood loss?

A

[EBV x (actual hct - lowest acceptable hct)] / average hct

53
Q

What is the most common type of regional anesthesia done in children?

A

Caudal block
- bupivacaine 0.125 - 0.25%
- ropivacaine 0.2%

54
Q

What is the dose for caudal block?

A

Depending on level of block
- sacral/lumbar: 0.5ml/kg
- lumbar/thoracic: 1ml/kg
- upper thoracic: 1.2ml/kg

55
Q

What are common postoperative concerns/complications?

A

PONV
Laryngospasm, stridor
Emergence agitation

56
Q

What are the risk factors for PONV in children?

A

Age > 6yo
Procedure > 20min
Eye & inner ear surgeries
Tonsillectomy/adenoidectomy
History of motion sickness
Preop nausea/anxiety
Use of opioid, nitrous oxide

57
Q

How to manage PONV in children?

A

Limiting oral intake
IV hydration
Prophylaxis if high-risk (ondansetron, dexamethasone, metoclopramide)

58
Q

Differentiate laryngospasm from stridor

A

Laryngospasm is the transient, reversible spasm of the vocal cords
Stridor - high-pitched sound usually occurring at inspiration; may be associated with laryngospasm

59
Q

How to manage laryngospasm?

A

ASK FOR HELP
Jaw thrust, establish airway
Suction secretions
CPAP + 100% O2
May give propofol or NMB as necessary

60
Q

Which agents are associated with emergence agitation?

A

Sevoflurane, desflurane (shorter-acting volatile agents)
Ketamine

61
Q

What is the general guideline on children with URTI for an elective procedure?

A

Postpone 4-6weeks
- risk for adverse respiratory events is 9-11x

62
Q

How to minimize adverse respiratory events in a child with ‘mild’ URTI?

A

Minimize airway manipulation: mask > LMA > > ETT
Anticholinergics to decrease secretions
Beta-agonist to decrease airway reactivity

Anesthesia (8 decks)

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