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Pediatric Anesthesia - Wolfe > Pediatric Anesthesia > Flashcards

Pediatric Anesthesia Flashcards

1
Q

Is pyloric stenosis considered an emergency?

A

Yes

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2
Q

prior to 37 weeks gestational age

A

pre-term

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3
Q

1-28 days of life

A

neonate

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4
Q

28 days to 1 year

A

infant

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5
Q

> 1 year

A

child

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6
Q

most significant part of transition occurs within the first ___ to ____ hours after birth

A

24 to 72

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7
Q

________ changes occur in all organ systems

A

adaptive

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8
Q

Adaptive changes (4)

A

establish FRC, convert circulation, recover from birth asphyxia, maintain ccore temperature

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9
Q

During fetal respiration, gas exchange occurs in the ______. 02 transport is accomplished by fetal hemoglobin which totals ____ to ___%.

A

placenta / 70 - 90%

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10
Q

Fetal Hgb shifts the oxyhemoglobin dissociation curve to the ______.

A

Left / increased 02 loading in the lungs/placenta, decreased 02 unloading at tissues

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11
Q

02 unloading adequate for fetus becomes insufficient after _______

A

birth

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12
Q

Hgb of full term neonate

A

18-20 g/dL

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13
Q

Lowest acceptable hemoglobin on a child under the age of 1 is what?

A

10

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14
Q

Fetal lung at 4 weeks

A

primitive lung buds develop from foregut

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15
Q

fetal lung at 16 weeks

A

branching of bronchial tree complete to 28 divisions, no further formation of cartilaginous airways

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16
Q

Fetal lung at 24 weeks

A

primitive alveoli (saccules) and type II cells present; surfactant detectable; survival possible with artifical ventilation

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17
Q

From a respiratory standpoint, at what fetal age is it viable

A

24 weeks

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18
Q

Fetal lung 28-30 weeks

A

capillary network surrounds saccules; unsupported survival

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19
Q

Fetal lung 36-40 weeks

A

true alveoli present, roughly 20 million at birth

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20
Q

Birth - 3 months

A

Pa02 rises as R to L mechanical shunts close

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21
Q

Birth - 6 yrs

A

rapid increase in alveoli and have 350 million by age 6

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22
Q

Fetus makes respiratory movments in utero called _____ ______ in utero

A

guppy breathing

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23
Q

Guppy breathing isFrom 30 weeks gestation, present 30% of the time at a rate of _____ breaths/min and responds to ______ ______

A

60 breaths/min / Chemical stimuli

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24
Q

Guppy breathing serves as ______ _______ to ensure that respiratory system is developed and ready at birth

A

prenatal practice

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25
Q

Proven in fetal lambs that denervation of the diaphragm leads to lung _______

A

hypoplasia

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26
Q

Traditional view of adapation of breathing

A

hypoxemia, hypercarbia and acidosis of birth asphyxia stimulates chemoreceptors that produce gasping followed by rhythmic breathing

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27
Q

Fetal lamb studies have shown that total devervation of carotid, aortic and peripheral chemoreceptors does not alter fetal breathing or initiation of _______ at birth

A

ventilation

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28
Q

Looks at normal blood gas values in smith anesthesia

A

page 27

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29
Q

Current view of adaptation of breathing- rhythmic breathing occurs with clamping of the umbilical cord and increasing 02 tensions from ___ _____

A

air breathing

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30
Q

Respiratory system transition – The primary event of the respiratory system transition is _____ ____ _____

A

initiation of ventilation

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31
Q

Initiation of ventilation changes the alveoli from a fluid-filled to an ___ _____ state

A

air-filled

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32
Q

Large surface tension forces are overcome by the small radius of the curvature of the diaphragm. Infant must generate a high negative presesure of ____ to inflate the lungs

A

(-70 cmH20)

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33
Q

Respiratory System Transition - With the onset of ventilation, pulmonary vascular resistance decreases dramatically and the pulmonary blood flow increases allowing ___ ______ to occur

A

gas exchange

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34
Q

Respiratory System Transition - Changes in P02, PC02, and pH are responsible for the decreases in ______

A

PVR

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35
Q

Respiratory System Transition - Increase in P02, decrease in C02 and decrease in ______

A

PVR

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36
Q

With nenonates, ______ is your best friend

A

PEEP

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37
Q

FRC of approximately __ to ___ ml/kg is established to act as a buffer against cyclical alterations in P02 and PC02 between breaths

A

25-30 ml/kg

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38
Q

Neonate and infant lungs prone to collapse due to

A

weak elastic recoil, weak intercostal muscles, intrathoracic airways collapse during exhalation

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39
Q

High closing volume encroaches upon FRC - small airway closure begins at volumes at or above _____ leading to lung collapse and ___ _____

A

FRC / VQ mismatch

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40
Q

Why don’t infants have lung collapse all of the time? Infants terminate the expiratory phase of breathing before reaching true ____ which results in ______ _______ and higher FRC. When anesthetized however, this protective mechanism is ________. The opposing tonic state of the intercostal muscles is overridden and atelectasis occurs. The moral of this story – PEEP of 5 cmH20 can help maintain FRC/lung inflation in the neonate during anesthesia.

A

FRC / intrinsic PEEP / abolished

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41
Q

The very first attempt to compensate is ________ and is usually the first sign of ______ ______

A

tachypnea / respiratory distress

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42
Q

Respiratory control is poorly developed in neonates. The system is normal by __ to ___ weeks of age, but likely remains immature for some time, especially in pre-term babies

A

3 to 4 weeks

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43
Q

________ control is present at birth so can respond to hypercarbia

A

chemoreceptor

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44
Q

If under 60 days of gestational age, will stay ________

A

overnight

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45
Q

Newborns respond to hypercarbia by increasing _________, but the slope of the response curve is decreased

A

ventilation

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46
Q

Hypoxia depresses the neonate’s response to _____

A

C02

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47
Q

Response to hypoxia is _______ - initial hypernea followed by depression of respiration in about ____ min

A

biphasic / 2 min

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48
Q

Initial hyperpneic response is abolished by ______ and low levels of _____ ______

A

hypothermia and anesthetic gases

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49
Q

______ is a common response and real danger, especially in pre-term infants

A

apnea

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50
Q

By 3 weeks, hypoxia produces sustained ________

A

hyperventilation

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51
Q

Apnea of infancy are respiratory pauses exceeding _____ sec or those accompanied by _______ or ______

A

20 sec / bradycardia / cyanosis

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52
Q

Hypoxia causes profound _______ in babies

A

BRADYCARDIA

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53
Q

Ventilate the baby. The number one reason you get into trouble with kids is not _______ for them

A

breathing

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54
Q

Contributing factors for apnea of infancy

A

increased work of breathing = FATIGUE

55
Q

Apnea of infancy factors - Very _______ upper airway structures and ribcage which tend to collapse during inspiration, inefficient diaphragmatic _______, and 25% of muscles fibers in diaphragm are Type I fatigue-resistant work horse fibers whereas it’s _____% in adults

A

compliant / contraction / 55%

56
Q

Apnea of infancy factors - Increased 02 consumption at ___ ml/kg, decreased FRC, and _______ closing volume

A

6 ml/kg | increased

57
Q

Once hypoxia ensues, these factors will result in abnormal breathing patterns and ______ much more quickly than in the older child or adult

A

apnea

58
Q

How do fetal needs differ from those of the newborn

A

gas exchange occurs in the placenta AND lungs required only nutrient flow of 5-10% of cardiac output

59
Q

Fetal intracardiac and extracardiac shunts exist to minimized blood flow to the _____ while maximizing flow/02 delivery to _______ _____

A

lungs / organ systems

60
Q

Ducuts Venosus, foramen ovale, ducuts arteriosus

A

look into these further

61
Q

PVR drops at _____

A

birth

62
Q

Fetal Circulation - _________ blood travels the descending aorta to the umbilical arteries to the placenta (very low resistance to flow). Oxygenated blood returns via the _______ ________ (P02 35 mmHg). Ducuts venosus diverts approx 50% of blood away from the ________ into the _______ then to the ______.

A

deoxygenated / umbilical veins / liver / IVC / RA

63
Q

Fetal circulation - Preferential streaming causes 02 rich blood to be directed across the _____ _____ which connects the right and left ________. 02 rich blood fed to the ______and ejected into the aorta, thereby feeding the coronary and cerebral circulations.

A

foramen ovale / atrium / LV

64
Q

Fetal Circulation - SVC and hepatic flow delivered to the _____. Pulmonary vasuclar resistance is _______. RV output is delivered across the ______ ________ which connects the _____ to the descending aorta. Blood entering the descending aorta returns to the _________ and feeds the lower body (P02 22mmHg)

A

RV / HIGH / ductus arteriosus / PA / placenta

65
Q

Watch Dr. Najeeb

A

slide 31

66
Q

Transitional circulation

A

umbilical cord is cut: increased SVR, reversal of shunts, onset of breathing decreases PVR and you have reversal of shunts

67
Q

At birth, placental vessels are clamped and _______ increases dramatically

A

SVR

68
Q

Initiation of ventilation increases ________ and _______ P02 which _______ pulmonary vasculature – this results in _____ decreases dramatically and pulmonary blood flow increases by ______%

A

arterial and alveolar / dilates / PVR / 450%

69
Q

Transitional circulation - LA pressure increases and ____ pressure decreases. The _____ _______ will close (25-30% of adults have PFO)

A

RA / Foramen ovale

70
Q

Transitional circulation - ductus arteriosus constricts within several minutes due to increased ____ and decreased circulating _________. Physiologic closure in ____ to _____ hrs and anatomic closures in 2-3 weeks.

A

P02 / prostaglandins / 10-15 hrs

71
Q

Ductus venosus closes and becomes ______ over time

A

fibrous

72
Q

The ______ ______, _____ _____ and _____ ______ are the shunts needed for effective fetal circulation that must close after birth to allow effect newborn circulation.

A

foramen ovale / ductus arteriosus / ductus venosus

73
Q

At birth increased SVR and decreased PVR causes flow through the FO and DA to become ___ to ____, shunts _____ and circulation becomes more like that of an adult

A

left to right / close

74
Q

In utero - PVR is ____ and SVR is _____

A

high / low

75
Q

Born - SVR is _____ and PVR is _______ and shunts _____

A

high / low / close

76
Q

Persistant Pulmonary Hypertension of the Newborn (PPHN) is persistance of fetal shunting beyond the normal transition period in the absence of structural ____ _____

A

heart defect

77
Q

Because shunts are not anatomically closed immediately after birth, certain clinical conditions may contribute to either the persistance of OR a return to _____ _____

A

fetal circulation

78
Q

Etiology of PPHN

A

hypoxia and acidosis

79
Q

Consequences of PPHN

A

increased PVR, pulm HTN, decreased PBF, RAP > LAP, increased ductal flow

80
Q

Can the consequnces of PPHN open the foramen ovale?

A

YES

81
Q

Signs and symptoms of PPHN

A

marked cyanosis, tachypnea, acidosis, right to left shunt across FO and DA = marked cyanosis

82
Q

Right to left shunt =

A

cyanotic shunt

83
Q

PPHN - before anatomic closure of the fetal shunts, transient right to left shunting may occur in normal neonates during coughing, bucking, or straining during anesthetic __________ or __________

A

induction or emergence

84
Q

PPHN treatment

A

hyperventilation (maintain alkalosis), Pulmonary vasodilators (prostaglandin), minimal handling, avoidance of stress

85
Q

What is key with PPHN treatment

A

adequate ventilation and oxygenation

86
Q

With PPHN you do not want them to get ____ or ____

A

cold or acidosis

87
Q

Amniotic fluid is important for normal development of the ___ ______ and acts as a shock absorber for the fetus

A

fetal lung

88
Q

The fetal kidney has ____ renal blood flow and _____ GFR

A

low / low

89
Q

The fetal kidney has low renal blood flow and low GFR due to structurally immature - small sized ______, low systemic ______ _____, high renal ______ ______ and low permability of ________ capillaries

A

glomeruli / arterial pressure / vascular resistance / glomerular

90
Q

Transitional changes to the renal system in the newborn - Systemic arterial pressure ______, renal vascular resistance _______ and increase in size and function occur through _______

A

increases / decreases / maturity

91
Q

Renal system - Renal function at the time of birth and in the first few weeks of life depends upon ____ _______ age as well as the extent of transition. By _____ weeks all nephrons are developed, so premature babies have incomplete renal development.

A

post conceptual / 34 weeks

92
Q

In a pre-term baby we talk about ____ ______ age

A

post conceptual

93
Q

In the first several days of life in the full term infant there is a diminished ability to concentrate _______ resulting from the low _____ at birth. This is partially due to inadequte _______

A

urine / GFR / sodium

94
Q

Urine osmolality at birth

A

700-800 mOsm/L

95
Q

Urine creatinine at birth

A

0.8-1.2 g/dL

96
Q

Inadequate sodium conservation - Neonates have a normal renin-angiotensin-aldosterone system and _________ fascilitates reabsorption of NA in the distal tubule. Immature neonatal tubules do not completely reabsorb ____ under the stimulus of aldosterone

A

aldosterone / NA

97
Q

The neonate will excrete ______ even in the presence of a severe ____ deficit

A

Na / Na

98
Q

The neonate is considered an _______ _____ _____

A

obligate sodium loser

99
Q

Neonates can conserve filtered Na the first week at ___% and 2nd week ____%

A

70% / 84%

100
Q

Urine Na neonate

A

20-25 mEq/L

101
Q

The renin-angiotensin-aldosterone system is the primary ________ mechanism for the reabsorption of the Na and H20 losses of plasma, blood, GI tract fluid and third space fluid during ______

A

compensatory / surgery

102
Q

IV fluid must contain ______. Why? Neonates cannot completely conserve Na, so a baby will continue to produce dilute urine to the point of dehydration without adequate fluid replacement.

A

Na

103
Q

All neonates they will run a background infusion of ____

A

D5

104
Q

Increased renal blood flow and decreased Renal vascular resistance result in rapid improvement in renal function within the first ___ to ___ days of life. This is reflected in the increased ability of the infant to _____ ____ with time.

A

3 to 4 / concentrate urine

105
Q

Glucose needs of the neonate is addressed by having maintenance fluid of _______

A

D5 .2NS

106
Q

In the face of ongoing surgical blood loss, neonates and infants will require red cell replacement _______

A

sooner

107
Q

Higher Hgb/Hct because of high 02 demand with limited ability to increase ____ _____

A

cardiac output

108
Q

lowest acceptable Hct

A

35%

109
Q

_______ blood volume per unit weight

A

increased

110
Q

_______ cardiac output per unit weight

A

increased

111
Q

term baby blood volume

A

90 ml/kg

112
Q

pre-term baby blood volume

A

100 ml/kg

113
Q

Are infants homeotherms?

A

yes

114
Q

ability of infants to thermoregulate is significantly _____ and easily ______

A

limited / overwhelmed

115
Q

Homeostasis is accomplished by balancing

A

heat production with heat loss

116
Q

The neonate’s limited thermal range is a function of their (what 3 things)

A

small size, increased surface area to volume ration, increased thermal conductance

117
Q

Heat loss occurs in two stages: Transfer of heat from body core to ____ ______ AND dissipation of heat from the skin surface to the ______

A

skin surface / environment

118
Q

Both stages of heat loss are governed by the laws of _____, ______, ______ and ______

A

conduction, convection, radiation, evaporation

119
Q

Temperature in the OR should be

A

80 degrees

120
Q

Factors that control conductive loss in infants are _______ ______ flow and ________ - the amount of subcutaneous tissue.

A

cutaneous blood / insulation

121
Q

Prevention of conductive losses

A

warm blankets, heating mattress, and bair hugger

122
Q

Factors that control convetion losses (3)

A

air temp, air velocity, volume of air flow

123
Q

Prevention of convection losses

A

keep OR at 80 degrees and reduce air movment across body surface

124
Q

Factors that control radiation heat losses

A

temperature gradient b/t skoin and surrounding surfaces and total radiating surface of the infant

125
Q

Prevention of readiation losses

A

keep OR warm, radiant lamps (french fry lights)

126
Q

Factors that control evaporation losses from skin and respiratory system

A

relative humidity and minute ventilation

127
Q

Prevention of evaporation losses

A

cover exposed body cavities, heat and humidify inspired gases

128
Q

Heat production is achieved by

A

voluntary muscles activity, involuntary muscle activity and NON-SHIVERING THERMOGENESIS

129
Q

Major component of thermal regulation in the neonate

A

non-shivering thermogenesis

130
Q

Non- shivering thermogenesis is achieved by metabolism of _____ ______. This develops in the fetus between ___ and ____ weeks gestation and comprises 2-6% of the neonat’s total body weight.

A

brown fat / 26-30 weeks

131
Q

Brown fat is located in the _______, b/t the scapulae, around the adrenals and in the ________

A

mediastinum /axilla

132
Q

Brown fat has an ________ vascular supply and rich innervation of the ______

A

abundant / SNS

133
Q

Non-shivering thermogenesis occurs with ____ ____, is mediated by the ______, and the heat produced is a product of ____ _____ metabolism

A

cold stress / SNS / fatty acid

Pediatric Anesthesia - Wolfe (1 decks)

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