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Advanced Principles II > Pediatric Anesthesia > Flashcards

Pediatric Anesthesia Flashcards

1
Q

When does organogenesis of the fetus take place?

A

In the first eight weeks

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2
Q

When does fetal organ function develop?

A

During the second trimester

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3
Q

When does the fetus begin to gain weight?

A

During the third trimester

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4
Q

When do genetic malformations occur in the developing fetus?

A

They can occur at any time during the pregnancy

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5
Q

What type of circulation occurs in the fetus?

A

Serial circulation

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6
Q

Where is oxygenated blood directed in fetal circulation?

A

Placenta –> umbilical vein –> ductus venosus into IVC –> RA–> foramen ovale –> LA –> LV –> Ascending aorta to brain

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7
Q

Where is deoxygenated blood directed in fetal circulation?

A

SVC –> RA –> RV –> pulmonary artery –> PDA –> Aorta where blood is directed to the lower body

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8
Q

What physiological changes occur when the infant breaths for the first time?

A

Decreased pulmonary vascular resistance
PVR decreases increased blood flow to the lungs
LA pressures increase which closes the foramen ovale

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9
Q

What physiological processes occur when the placenta is clamped from the newborn?

A

Increased SVR and decreased IVC blood flow and RA pressure

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10
Q

What causes the ductus arteriosus to close?

A

Increased SVR and aortic pressure above pulmonary pressure reverse blood flow through DA
Decreased prostaglandins from additional O2 concentration

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11
Q

When should permanent closure of the PDA occur?

A

Usually completed within 5-7 days but may persist until three weeks

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12
Q

What is the difference between a functional and anatomical closure of the PDA?

A 
Functional = immediate
Anatomical = 2-3 weeks
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13
Q

What features cause the change of fetal circulation to adult like circulation?

A

The placenta is removed, lungs expand, pulmonary VR decreases, SVR increases, blood oxygenated through the lungs, portal BP falls, DA, PDA and DV close

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14
Q

What term is used to describe the critical period when an infant can readily revert from adult circulation to fetal type circulation?

A

Transitional circulation

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15
Q

What can cause transitional circulation to occur?

A 
Hypoxia (increases pulmonary VR and can cause PDA to reopen)
Acidosis
Hypothermia
CHD
Infection
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16
Q

What can occur if the PFO is reopened?

A

R –> L shunt leading to hypoxemia

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17
Q

What can occur if the PDA is reopened?

A

L –> R shunt leading to pulmonary overload

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18
Q

How much of the infants myocardium is non contractile?

A

60% compared to adults is 30%

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19
Q

What is the significance of the large amount of non contractile myocardium of an infant?

A

Stroke volume is fixed, non compliant and poorly developed left ventricle

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20
Q

What factor determines CO of an infant?

A

Heart rate since stroke volume is fixed

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21
Q

What is the hallmark sign of hypovolemia in an infant?

A

HoTN without tachycardia

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22
Q

What factors can cause bradycardia in an infant?

A

Hypoxia
Vagal stimulation (DL)
Volatiles

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23
Q

What should be considered the first cause of bradycardia in an infant?

A

Hypoxia, however consider anticholinergics if bradycardia is severe and symptomatic

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24
Q

What is a good rule of thumb in calculating a SBP and DBP in a pediatric patient?

A 
SBP = (age x 3) + 90
DBP = (age x 1.5) +50
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25
Q

Why isn’t extrauterine life not possible until after 24-25 weeks gestation?

A

Lung maturation occurs much later in fetal development

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26
Q

When does surfactant production begin to occur in the fetus and what type of cells produce it?

A

22 weeks surfactant production begins from the type II pneumocytes

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27
Q

What is the function of surfactant?

A

Alveolar lining layer that stabilizes the alveoli, preventing their collapse on expiration

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28
Q

Why might infants delivers via c-section have more residual fluid in the lungs compared to vaginal deliveries?

A

During vaginal delivery approximately 90mL of fluid is forced from the lungs via the vaginal squeeze

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29
Q

Why do infants tire quickly from respiration thus leading t apnea?

A

They have a low number of type I muscle fibers which are marathon muscles

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30
Q

When are type I muscle fibers developed in the pediatric patient?

A

At least 6-8 months of age

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31
Q

What cause diaphragmatic breathing in children?

A

Their chest wall is more horizontal and pliable, minimal vertical movement causes decreased room for lung expansion

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32
Q

What is the oxygen consumption requirement of a child compared to an adult?

A

O2 consumption is 2-3x higher in a child compared to an adult

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33
Q

Why do children have increased resistance to air flow?

A

Smaller diameter of the airways

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34
Q

How is FRC different in pediatric patients?

A

It is decreased and the closing capacity is increased

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35
Q

How does CO2 production vary between pediatric and adults?

A

Peds 6mL/kh
Adults 3mL/kg
Its doubled in the pediatric patient

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36
Q

Why are pediatric patients more sensitive to drugs that affect the CNS?

A

The BBB is immature, rendering the developing brain more vulnerable to drugs or toxins

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37
Q

How is autoregulation impacted in a sick neonate?

A

It is impaired and therefore dependent on pressure for blood flow

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38
Q

Why are pre term neonates at risk for intraventricular hemorrhage?

A

They have very fragile cerebral vessels

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39
Q

What factors predispose a pre term neonate to IVH?

A

Hypoxia, hypercarbia, hypernatremia, fluctuations in pressure, low HCT, over transfusion and rapid administration of hypertonic fluids

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40
Q

What causes retinopathy of prematurity?

A

Hyperoxgenation, maintain sats 90-95% to avoid giving too much O2

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41
Q

What is retinopathy of prematurity?

A

The arrest of normal retinal vascular development in exchange for retinal vessel proliferation

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42
Q

What are the consequences of retinopathy of prematurity?

A

Fibrous tissue formation and retinal detachment

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43
Q

What does the terms periodic breathing indicate in an infants?

A

Rapid ventilation with periods of 5-10 second apnea occurs in preterm infants and some full term infants

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44
Q

When should periodic breathing cease in an infant?

A

44-46 weeks post conceptual age

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45
Q

What is considered apnea in an infant?

A

No breathing for greater than 20-30 seconds

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46
Q

What symptoms can accompany apnea in an infant?

A

Bradycardia less than 80bpm

Desaturations

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47
Q

What pediatric age group is most likely to experience post op apnea?

A

Preterm infants up to 60 weeks post conceptual age

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48
Q

What pharmacologic intervention could help to prevent apnea in the infant?

A

Caffeine 10mg/kg (preservative free)

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49
Q

How long does an infant have fetal hemoglobin?

A

In utero and persists until roughly six months of age

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50
Q

What is the difference between adult hemoglobin and fetal hemoglobin?

A

Fetal hemoglobin can binds to oxygen with a greater affinity which allows the mothers oxygen to be delivered across the placenta

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51
Q

How is the oxyhemoglobin dissociation curve affected by fetal hemoglobin?

A

Causes a leftward shift

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52
Q

What is the P50 of fetal hemoglobin?

A

19 compared to adult Hgb 26

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53
Q

What causes physiologic anemia in the infant?

A

Fetal Hgb synthesis deactivated and adult Hgb synthesis activated, Hgb levels begin to decline around week three

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54
Q

What is usually the goal Hct in an infant?

A

30%

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55
Q

Why pediatric patients have a increased risk for heat loss?

A

Larger surface area
Thin skin
Lower fat content

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56
Q

What are the four routes of heat loss?

A

Radiation (39%)
Evaporation (24%)
Convection (34%)
Conduction (4%)

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57
Q

How does hypothermia affect the pediatric patient?

A 
Delayed awakening from anesthesia
Cardiac instability
Respiratory depression
Increased PVR
Altered drug response
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58
Q

Why is shivering severely limited in premature infants?

A

Small amount of brown fat stores

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59
Q

When does normal kidney function occur in the pediatric patient?

A

Not present until greater than six months of age

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60
Q

How did the kidneys function in utero?

A

Passive, reduced GFR and RBF

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61
Q

When are infants able to concentrate urine?

A

At about one month old

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62
Q

When is phase II metabolism (making drugs more water soluble) functional?

A

At about 1 year old

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63
Q

Why do pediatric patients have a greater level of unbound drug?

A

Limited ability to handle large protein loads and have low albumin

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64
Q

Why are neonates predisposed to hypoglycemia?

A

Neonates have very low glycogen stores

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65
Q

At what level are pediatric patients considered to be hypoglycemic?

A

At less than 40mg/dL

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66
Q

What can be done to avoid hypoglycemia in a neonate required to be NPO?

A

Maintained on IV dextrose infusions when NPO

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67
Q

How is calcium homeostasis maintained after birth?

A

Reliance on calcium reserves however, parathyroid function is not fully established and vitamin D stores may be inadequate

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68
Q

How should hypocalcemia be treated in the neonate?

A

SLOW infusion of calcium chloride or calcium gluconate

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69
Q

Why do pediatric patients have a larger volume of distribution for water soluble drugs?

A

They have greater total body water content

Less muscle mass and fat

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70
Q

How can weight of a child generally be estimated?

A

(Age x 2) + 9 OR

if they are less than 1 (mos/2) + 4

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71
Q

What are common water soluble dugs we use in anesthesia that would require a larger dose in the pediatric population?

A

Succinylcholine
Bupivicaine
most Antibiotics

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72
Q

At what age does the BBB begin to mature?

A

By the age of 2

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73
Q

What type of drugs do pediatrics have a decreased volume of distribution to?

A

Fat soluble drugs due to decreased fat and muscle mass (fentanyl & thiopental)

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74
Q

How is does onset of volatile anesthetics change in the pediatric population?

A

Inhaled anesthetic concentration in the alveoli increases more rapidly with decreasing age (infants > children > adults)

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75
Q

What factors contribute to the rapid rise of volatile anesthetics in pediatrics?

A

Increased RR (high minute ventilation)
Decreased FRC
Increased cardiac index, high blood flow to vessel rich organs

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76
Q

Why are blood pressures in pediatric patents so sensitive to volatile anesthetics?

A

Lack compensatory mechanisms
Immature myocardium
Reduced calcium stores

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77
Q

In what way does MAC change with age?

A

Infants have higher MACs than older children and adults

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78
Q

What is the blood gas partition coefficient and MAC of N2O?

A

B/G: 0.47

MAC: 104%

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79
Q

What types of cases is N2O contraindicated?

A

Pneumothorax, NEC, and bowel obstruction

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80
Q

What gas law explains the second gas effect?

A

Daltons Law of partial pressure

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81
Q

What is the volatile agent of choice in pediatrics?

A

Sevoflurane because it is less pungent and less irritating to the airways

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82
Q

What is the blood gas partition coefficient and MAC of Sevo?

A

B/G: 0.68

MAC: 2%

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83
Q

What can occur if low flows are used with Sevo?

A

CO2 absorbers containing barium hydroxide or soda lime can increase the production of Compound A

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84
Q

What is the B/G coefficient of Isoflurane and its MAC?

A

B/G: 1.4

MAC: 1%

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85
Q

What is the B/G coefficient and MAC of Desflurane?

A

B/G: 0.42

MAC: 6%

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86
Q

Why is it controversial to use Desflurane with a LMA?

A

There is a high probability of laryngospasm

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87
Q

What is the IV induction dose of Propofol in the pediatric patient?

A

2.5-3mg/kg IV

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88
Q

At what dose of Propofol infusion does nerve monitoring become an issue?

A

Greater than 120-130mcg/kg/min

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89
Q

What are the doses of Ketamine used in the pediatric population?

A

1-2mg/kg IV Induction

2-5mg/kg IM sedation

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90
Q

What medication should always be given with ketamine in pediatric patients?

A

Glycopyrrolate 0.01mg/kg IV to prevent excessive secretions

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91
Q

Why isn’t Etomidate widely used in peds?

A 
Pain on injection
Anaphylactoid reactions
Suppression of adrenal function
Myoclonus
Laryngospasm
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92
Q

What dose of Morphine is typically used in peds?

A

0.025-0.05mg/kg

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93
Q

Why do some providers prefer not to use Morphine in peds?

A

Histamine Release, Hepatic conjugation is reduced and Renal clearance is decreased

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94
Q

What is the dose of Hydromorphone in peds?

A

5-10mcg/kg IV

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95
Q

What is the dose of Fentanyl given to peds?

A

0.5-1mcg/kg

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96
Q

What is the pediatric dose of Naloxone?

A

0.5-1mcg/kg

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97
Q

What is the dose of Midazolam given to a pediatric patient for premedication?

A

0.5mg/kg PO

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98
Q

What is the IV dosing of Midazolam for pediatric patients/

A

0.05mg/kg IV

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99
Q

What is the pediatric dose of Flumazenil?

A

2-20mcg/kg IV

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100
Q

What is the dose of Clonidine given to pediatric patients for premedication?

A

4mcg/kg PO

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101
Q

How much Clonidine can be added to a block in a pediatric patient for prolonged effects?

A

1-2mcg/kg

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102
Q

Why is Dexmedetomidine preferred for sedation in pediatric patients compared to Clonidine?

A

It is eight times more specific for the Alpha 2 adrenergic Receptor than Clonidine

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103
Q

Why must Dexmedetomidine be administered slowly when given IV?

A

It can cause bradycardia

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104
Q

What is the dose of Dexmedetomidine for pediatric patents?

A
  1. 25-1mcg/kg IV OR

0. 2-2mcg/kg/min for continuous drip

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105
Q

How is the onset of muscle relaxants different in the pediatric population?

A

All relaxants have a shorter onset because of shorter circulation times

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106
Q

Why is it difficult to assess the effects of relaxants with a PNS in peds?

A

Electrodes may over lap or be too close

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107
Q

What is the dose of Succinylcholine in the pediatric population?

A

2mg/kg IV

4mg/kg IM

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108
Q

What is the IV dose of succinylcholine in a pediatric patient who has laryngospasmed?

A

0.25-0.5mg/kg

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109
Q

Why might pediatric patients have increased sensitivity to non-depolarizing NMBA?

A

Immaturity of the neuromuscular junction and increased exntrajunctional receptors

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110
Q

Why cant cisatracurium be given IM like all the other muscle relaxants?

A

Undergoes Hoffman Elimination

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111
Q

What is the dose of Toradol in pediatric patients?

A

0.5mg/kg IV, should not be given to patients less than two years old

112
Q

What type of procedures is Toradol contraindicated in?

A

ENT and some orthopedic procedures

113
Q

What should be given to pediatric patients if hypoglycemia occurs?

A

10% Dextrose 1-2mL/kg

114
Q

Why should D50 never be given to pediatric patients?

A

Vessel necrosis and High osmolarity can cause cerebral edema

115
Q

How should D50 be diluted to get a concentration of D10?

A

D50 = 50g/100mL = 0.5g/mL
Take 1mL of D50 and dilute it into 4mL of sterile water
Final concentration 0.1g/mL –> D10

116
Q

What is the code dose of Epinephrine for pediatrics?

A

10mcg/kg

117
Q

How do we calculate maintenance IVF rate in the pediatric patient?

A

4mL/kg for the first 10kg
2mL/kg for the next 10kg
60mL + 1mL/kg after 20kg

118
Q

How should NPO deficit be replaced?

A

NPO hours times maintenance
50% given in first hour
25% given second hour
25% given third hour

119
Q

How much fluid should be given to a pediatric patient prior to induction?

A

10-20mL/kg bolus

120
Q

What is a risk factor for pediatrics receiving 5% dextrose in 0.45% NS for maintenance?

A

Risk for hypoglycemia

121
Q

Why is it so important not to overload the pediatric patient with fluid?

A

The kidneys are unable to excrete large amounts of excess water or electrolytes
The volume in the extracellular fluid space is larger than adults

122
Q

What should always be used when transfusing a pediatric patient with RBCs?

A

Filter and Warmer

123
Q

How do you calculate the max allowable blood loss?

A

[EBV x (starting Hct - target Hct)] /starting Hct

124
Q

How do you calculate the volume of PRCs transfused to a pediatric patient?

A

[(desired Hct-present Hct) x EBV] / Hct of PRC which is about 60%

125
Q

When is fresh frozen plasma given to a pediatric patient?

A

To replenish clotting factors lost during massive transfusion often when EBL exceeds 1-1.5 the EBV

126
Q

What should be used when administrating FFP to a pediatric patient?

A

Filter and Warmer

127
Q

At what point will we transfuse a pediatric patient with platelets when ITP or chemo has been used?

A

Tolerate platelet counts as low as 15,000mm3

128
Q

At what point will we transfuse a pediatric patient whose platelet count is decreased because of dilution?

A

Generally require transfusion when the count is less than 50,000mm3

129
Q

What devices should be used when transfusing platelets to a pediatric patient?

A

Filter only warmer will cause the platelets to stick together

130
Q

What electrolyte is often depleted after major transfusions?

A

Calcium binds to citrate preservative

131
Q

What are often indications that the patient may be hypocalcemic after transfusion?

A

Cardiac depression with hypotension

132
Q

What blood products contain calcium citrate?

A

PRBC and FFP

133
Q

What can be done to blood products to prevent graft versus host disease in cancer and immunocompromised patients?

A

Irradiated blood products

134
Q

What infection can be avoided by filtering blood products?

A

CMV infection

135
Q

What can be done to blood products to prevent life threatening allergic reactions to blood products?

A

Washing products

136
Q

What is the dose of calcium that should be given if hyperkalemia results from massive blood product transfusion?

A

Calcium Gluconate 30-100mg/kg (max 3g)

Calcium Chloride 10-20mg/kg (max 1g)

137
Q

What is the dose of bicarb that should be given if hyperkalemia results from massive blood product transfusion?

A

1mEq/kg IV

138
Q

What is the dose of glucose and insulin that should be given if hyperkalemia results from massive blood product transfusion?

A

Dextrose 1-2g/kg (use 10 or 25%)

Insulin 0.1 units/kg

139
Q

What is the dose of Kayexalate that should be given if hyperkalemia results from massive blood product transfusion?

A

1-2g/kg via NG tube or PR

140
Q

What can be done to help with hyperkalemia if the patient is mechanically ventilated?

A

Hyperventilate the patient

141
Q

What inhaled medication can help in lowering K in a hyperkalemic crisis?

A

Albuterol (beta agonist)

142
Q

What is the most common indication for a T&A in North America?

A

OSA

143
Q

What would make you admit a patient who had a T&A?

A 
Less than 3 y/o
Abnormal bleeding tendencies
Significant OSA
Airway abnormalities
Systemic disease
Live an excessive distance
144
Q

What are strong recommendation post T&A?

A

Single dose of decahedron 0.5mg/kg
No antibiotics
Pain Management

145
Q

What pain medications should be avoided with T&A procedure?

A

Avoid codeine (active metabolite morphine) and ketorolac (increased hemorrhage rate)

146
Q

Why must patients be at an adequate level of anesthesia before incision?

A

Mouth gag is extremely stimulating

147
Q

Why might breath sound be lost after placement of a out gag?

A

Can dislodge ETT

148
Q

What may be a major cause of nausea in patients after a T&A?

A

Swallowing lots of blood, ensure to suction GI contents prior to extubation

149
Q

What is the pediatric position after extubation?

A

On one side with the head slightly down, allows contents to drain away from the vocal cords

150
Q

What is considered a primary hemorrhage post T&A?

A

Occurs within 24hrs of surgery

151
Q

What is considered a secondary hemorrhage post T&A?

A

Occurs after 24hrs (5-10days)

152
Q

Why is a myringotomy and tympanstomy usually preformed?

A

To alleviate pressure from the middle ear

153
Q

What kind of anesthetic can be preformed with BMT?

A

Mask anesthetic, d/c Sevo when working on second ear

154
Q

What is the most common CNS defect that occurs during the first month of gestation?

A

Mylomeningocele (spine bifida)

155
Q

What is the difference between meningocele and myelomeningocele?

A

Meningocele only contains meninges

Myelomeningocele contains meninges and neural elements

156
Q

Where is the most common place for a mylomeningocele to occur?

A

In the lumbarscral region

157
Q

Why is a mylomeningocele considered an emergency case?

A

Risk of infection or worsening cord function

158
Q

Why would a VA shunt revision be done compared to a VP shunt?

A

If there was infection or pathology in the abdomen

159
Q

What is a major benefit to using a VP shunt versus a VA shunt?

A

It allows room for growth

160
Q

What should be avoided in placements of CSF shunts if the ICP is elevated?

A

Avoid premeds if ICP is increased

161
Q

What anesthetic intervention can cause difficulty when cannulating the ventricle for a VP shunt?

A

Hyperventilation

162
Q

What is important to do when the surgeon is tunneling for a VP shunt?

A

Maintain paralysis, extremely stimulating

163
Q

What are the most common elbow fractures in children?

A

Supracondylar fractures of the humerus

164
Q

What are complications associated with a humerus fracture in kids?

A 
Compartment syndrome (NO regional)
Nerve palsies
Late deformities
165
Q

When is surgical intervention required in patients with scoliosis?

A

Patients whose curves are greater than 45 degrees while still growing or are continuing to progress greater than 45 degrees when growth has stopped

166
Q

What interventions can be done to decrease the amount of blood loss in a spinal instrumentation?

A

HoTN technique on dissection (maintain 20% baseline)

Use of TXA, cell saver and autologous blood

167
Q

In patients with scoliosis, what can impair respiratory function?

A

Cobb Angle which is the degree of lateral curvature

168
Q

What type of restrictive respiratory pattern is usually seen with scoliosis?

A

Decreased TLC and VC

169
Q

What drug affects the amplitude of both SSEPs and MEPs?

A

Ketamine

170
Q

What dose of dexmedetomidine will not interfere with MEPs and SSEPs?

A

Less than 0.3mcg/kg/hr

171
Q

After an X-ray is completed with spinal surgery, what should be done prior to extubation?

A

Ensure the surgeon has seen the X-ray prior to extubation in the case that he may have to reenter

172
Q

What is the suggested intraabdominal pressure for a pediatric patient?

A

10-12mmhg

173
Q

What surgical intervention can be done when medical management of reflux has failed?

A

Abdominal Nissen

174
Q

What is a nissen procedure?

A

Mobilizing the muscles around the esophagus at the level os the LES

175
Q

What are indications for a circumcision?

A

Phimosis, recurrent balanitis and parental preference

176
Q

What are the landmarks for caudal anesthesia?

A

Sacral Hiatus and two PSIS

177
Q

How are caudal blocks dosed for dental and anal surgery?

A

0.5-0.75mL/kg (sacral)

178
Q

How are caudal blocks dosed for lower abdominal and extremity procedures?

A

1mL/kg (sacral up to low thorax)

179
Q

How are caudal blocks dosed for abdominal procedures?

A

1-1.25mL/kg (sacral up to mid thorax)

180
Q

How much epinephrine should be added to a caudal block?

A

0.5mcg/kg

181
Q

How much clonidine should be added to a caudal block in order to increase its duration?

A

1-2mcg/kg

182
Q

What problems are often associated with cleft lip and cleft palate in the pediatric patient?

A

Difficulty feeding
Malnutrition
Speech development
Congenital heart defects

183
Q

How does an IO needle function?

A

The needle is injected through the bone’s hard cortex and into the soft marrow interior which allows immediate access to the vascular system

184
Q

Where is the most common site to place an IO in a pediatric patient?

A

Antero-medial aspect of the upper tibia

185
Q

What is the preferred induction agent in peds with hypovolemia?

A

Ketamine 1-2mg/kg IV

186
Q

In an airway emergency, how might the provider secure the airway?

A

Awake fiberoptic
Awake Tracheostomy
Blind nasal

187
Q

What is a Laryngospasm?

A

Involuntary spasm of the laryngeal musculature caused by stimulation of the superior laryngeal nerve

188
Q

What are preoperative factors that can contribute to the cause of a laryngospasm?

A 
Exposure to second hand smoke
Concurrent or recent URI
Reactive airway disease 
GERD
Irritants such as secretions
189
Q

What are intraoperative factors that can contribute to the cause of a laryngospasm?

A

Excitement phase of inhalation induction
Tracheal intubation/extubation during light anesthesia
Upper airway surgical procedures (T&A)

190
Q

What time is laryngospasm most common in the child?

A

During induction, but can occur at any time

191
Q

What are clinical signs of a laryngospasm?

A

High pitch inspiratory stridor
Progress to silence
Suprasternal and supraclavicular retractions
Paradoxical chest movement
Desaturation –> bradycardia –> asystole

192
Q

How should a laryngospasm be treated?

A

Remove any precipitating factors
Positive pressure with 100% FiO2
Jaw thrust
Deepen the anesthetic

193
Q

What are the IV and IM doses of succinylcholine in the pediatric patient experiencing a laryngospasm?

A

0.5-1mg/kg IV

4mg/kg IM

194
Q

What dose of Propofol should be given if a pediatric patient is experiencing a laryngospasm?

A

Propofol 1-2mg/kg

195
Q

What dose of Lidocaine should be given if a pediatric patient is experiencing a laryngospasm?

A

1-1.5mg/kg

196
Q

What dose of Atropine should be given with Succinylcholine if a pediatric patient is experiencing a laryngospasm?

A

0.02mg/kg

197
Q

What is postintubation croup?

A

Subglottic edema

198
Q

When would the provider start to see symptoms postintubation croup?

A

Usually symptomatic within the first hour after extubation with maximum edema usually occurring at 4hrs after extubation and resolving by 24hrs

199
Q

What are clinical manifestations of postintubation croup?

A 
Braking 
Stridor
Retractions
Hypoxemia
Mental status changes
200
Q

What are the main causes of postintubation croup?

A 
Traumatic or repeated intubations
Tight fitting ETT
Prolonged intubations
Surgery of head/neck
Coughing or bucking on the tube
201
Q

How is post intubation croup treated?

A

Humidified oxygen by mask, can add recemic epinephrine
Consider decadron
May keep over night for observation

202
Q

What dose of decahedron should be given for postintubation croup?

A

0.5mg/kg

203
Q

What dose of recemic epi should be given to a patient with post intubation croup?

A

0.25-0.5mL of 2.25% solution in 3mL of NS administer via nebulization facemask

204
Q

What is acute epiglottitis?

A

An inflammation of the supraglottic structures that can occur at any age

205
Q

What pathogen most commonly causes acute epiglottitis?

A

Haemophilus influenza type B

206
Q

What are the most common clinical manifestations of patients with acute epiglottitis?

A

Rapid onset over 24hrs
Sitting forward, leaning forward, drooling and tri pod position
Sore throat, fever, muffled voice and dysphagia

207
Q

What is seen on an X-ray in a patient with acute epiglottitis?

A

Thumb sign, epiglottis swollen and looks like a thumb

208
Q

Why is the population shifting from peds to adult patients in acute epiglottitis?

A

Due to the Hib vaccine

209
Q

What are two common diagnoses that can be falsely diagnosed when acute epiglottitis is present?

A

Croup and Foreign body in the airway

210
Q

Why shouldn’t an airway assessment be performed on a patient with suspected acute epiglottitis?

A

Potential for irrevocable loss of the airway

211
Q

How should an airway be established in patients with suspected acute epiglottitis?

A

Strict monitoring conditions in the operating room, while maintaining spontaneous ventilation
Readiness of a team capable of performing an immediate tracheostomy

212
Q

What are ideal intubation conditions in patients with acute epiglottitis?

A

Inhalation induction or IV induction sitting with spontaneous respirations, avoid muscle relaxants
Fiberoptic nasal or rigid bronchoscopy using ETT with reduced diameter

213
Q

What symptoms are associated with aspiration of a foreign body?

A 
Respiratory distress
Cough
Stridor
Drooling 
Aphonia
214
Q

What symptoms are associated with unwitnessed foreign body in the airway?

A

Fever
Chest pain
New onset of asthma

215
Q

What are items commonly aspirated into the right side of the bronchus compared to the left side?

A

The angle is less on the right (20-30 degree) compared to the left (40-50 degree)

216
Q

Why do you want to keep the child spontaneously breathing if there is a foreign body aspiration?

A

Could push the object further into the lungs

217
Q

What should be done if complete airway obstruction occurs?

A

Requires CPR and ECMO

218
Q

What type of anesthesia should be done for a foreign body aspiration?

A

TIVA with propofol, preceded, ketamine or remifentanyl

219
Q

What additional drugs can be given for a foreign body aspiration?

A

Glycopyrrolate reduction of vagal tone and antisialagogue
Corticosteroids
Recempic epi

220
Q

What are the clinical manifestation of MH?

A

Increased ETCO2
Increased HR and RR
Muscle rididity

221
Q

What is a late sign of MH?

A

Rapid rise in temperature

222
Q

What is the dose of dantrolene?

A

2.5mg/kg

223
Q

What dose of bicarb can be given for acidotic patients with MH?

A

1-2mEq/kg, maintain pH >7.2

224
Q

How is hyperkalemia treated in MH?

A

CaCl 10mg/kg or Ca gluconate 30mg/kg

Regular insulin 0.1u/kg and 1mL/kg D50

225
Q

How is dantrolene mixed?

A

20mg vial mixed with 60mL sterile water

226
Q

How does dantrolene treat MH?

A

A postsynaptic muscle relaxant that lessens excitation contraction coupling in muscle cells
Inhibits calcium ion release from the SR stores by antagonizing the ryanodine receptors

227
Q

What characterized emergence delirium?

A

Postoperative phenomenon of aberrant cognitive and psychomotor behavior

228
Q

What are clinical manifestation of emergence delirium?

A

Disorientation
Non purposeful movements
Failure to establish eye contact
Inconsolable

229
Q

What population is most at risk for emergence delirium?

A

Children younger than six
Prep anxiety
Rapid emergence from GA

230
Q

What is the most common cause of bradycardia in the pediatric population?

A

Hypoxemia until proven otherwise

231
Q

What are other causes of bradycardia in peds?

A

Vagal reflexes

Excessive potent anesthetic agent

232
Q

What is the treatment for bradycardia in pediatric patients?

A

Administer 100% O2
Stop procedure
IV atropine 0.02mg/kg, if unresponsive 2-10mcg/kg of epinephrine

233
Q

When should compressions be initiated in pediatric patients with bradycardia?

A

HR less than 60bpm, infants HR less than 80bpm

234
Q

What is the appropriate amount of joules a pediatric patient should be shocked with during resuscitation?

A

2-4j/kg

235
Q

What is the dose of amiodarone for a pediatric patient?

A

5mg/kg bolus may repeat x2

236
Q

What age group is not usually upset by separation from parents prior to surgery?

A

0-6mos old

237
Q

What age group is less upset by separation from parents but asks a lot of questions and would like choices?

A

School aged children

238
Q

What age group experiences separation anxiety prior to surgery?

A

6months-4yrs old

239
Q

What age group fears the process of narcosis and loss of control they also value modesty?

A

Adolescents

240
Q

What are NPO guidelines for children?

A

Clear liquids 2hrs
Breast milk 4hrs
Formula 6hrs
Solid food 8hrs

241
Q

How frequently is a heart murmur detected in pediatric patients?

A

Detected up to 50% of pediatric patients

242
Q

When is it necessary for a heart murmur to be investigated?

A

Difficulty feeding, SOB
Poor exercise tolerance
Family history CHD
Cyanotic episodes

243
Q

What labs are indicated prior to surgery for the pediatric population?

A

Often unnecessary

May consider HH on neonates especially in prematurity

244
Q

When is it contraindicated to do a mask induction in a pediatric patient?

A

Full stomach
Difficult airway
Cardiac instability

245
Q

What types of conditions seen in pediatric patients may indicate a potential unstable cervical spine?

A

Down syndrome or Marfans syndrome

246
Q

How much of a IVF bolus is given with pediatric inductions?

A

10-20mL/kg

247
Q

At what point would you switch from using a pediatric circuit to an adult circuit?

A

25-30kg and up use an adult circuit

248
Q

What contributes to easy airway obstruction of the infants airway?

A

The tongue is relatively large in proportion to the rest of the oral cavity

249
Q

Where is the larynx in the pediatric patient compared to the adult patient?

A

C3-4 compared to C4-5 and seems more anterior

250
Q

How does the epiglottis of a child differ from an adult?

A

The epiglottis is narrower, omega shaped and angled away from the axis of the trachea
Often obstructs the view of the vocal cords and is more difficult to lift

251
Q

Why might the ETT be more difficult to advance through the cords compared to an adult?

A

Vocal cords have a lower attachment anteriorly, the tip of the ETT can get held up at the anterior portion of the folds

252
Q

What is the narrowest portion of the child’s larynx?

A

Cricoid cartilage until about age 8

253
Q

What can occur if the ETT fits too tightly at the cricoid cartilage?

A

It compresses the tracheal mucosa at this level may cause edema and result in post extubation croup

254
Q

Why do pediatric patients have an increased oxygen requirement?

A

2-3x higher than adults because of increased metabolic rate

255
Q

How does pulmonary physiology differ in the pediatric patent?

A

Decreased FRC and Increased closing capacity

Trachea, larynx and bronchi are highly compliant

256
Q

Why do pediatric patients belly breathe?

A

Chest wall is more horizontal and pliable which allows for minimal vertical movement

257
Q

What is used to align the OLP axes in pediatric patients?

A

Shoulder roll

258
Q

What is the most common error in mask ventilating a pediatric patient?

A

Compressing the submental triangle below mandibular ridge

259
Q

How should we size an oral airway?

A

Lips to the angle of the mandible

260
Q

How should we size a nasopharyngeal airway?

A

The tip of the nose to the tragus of the ear

261
Q

Why are NPAs often avoided in pediatric patients?

A

To prevent trauma and bleeding from hypertrophied adenoids

262
Q

What is the formula for the depth insertion of an ETT?

A

10 for newborns
11 for 1y/o
12 for 2y/o
Greater than 2y/o tube size times three

263
Q

What intervention has shifted the thought away from kids under eight should receive uncuffed ETTs?

A

The replacement of high pressure low volume cuffs with low pressure, high volume cuffs

264
Q

When should the provider change to a smaller tube after a leak check?

A

If there is no air leak around the tube below 20-25cm H2O the ETT should be changed to the next half size smaller

265
Q

What is the perfusion pressure of the tracheal mucosa?

A

30-40cmH2O, if ETT exerts more pressure than the perfusion pressure ischemia may occur

266
Q

What air leak is associated with risk for aspiration?

A

Less than 18cmH2O

267
Q

What is typically the cause of laryngotracheal (subglottic) stenosis?

A

Ischemic injury of lateral wall pressure from the ETT

268
Q

When does granulation begin to form after tracheal ischemia has occurred?

A

Within 48hrs resulting in narrowing of the airways

269
Q

When are infants able to convert to oral breathing?

A

By 5 months of age

270
Q

How should the cuff of an ETT be inflated for the pediatric patient?

A

Leak check with 20cmH2O

271
Q

Why should cuff pressure be checked more frequently in cases using N2O?

A

N2O can diffuse into the cuff causing an increase in pressure

272
Q

How can you judge an awake child or infant?

A

Eye opening
Moves all limbs
Can pull legs to chest
Regular respirations after stimulation

273
Q

What are two primary factors of low or no cardiac output?

A

Loss of pulse oximeter and inability to measure blood pressure

274
Q

What may be happening if the pulse oximeter is still picking up but the BP won’t pick up?

A

Likely hypovolemia or anesthetic overdose

275
Q

What is the gold standard for confirming successful endotracheal intubation?

A

Capnography

276
Q

What can cause changes on the wave of the capnograph?

A

Bronchospasm
Endobronchial intubation
Kinked ETT
Low pulmonary blood flow

277
Q

What can be a problem with capnography in small children?

A

Inaccuracy of recording especially with high fresh gas flow rates

Advanced Principles II (8 decks)

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