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SNRAObPedGer > PEDIATRIC ANESTHESIA > Flashcards

PEDIATRIC ANESTHESIA Flashcards

1
Q

Pediatric patients have_______Which ____Vd of _____medications
meaning required___________
• Neonates require even more, but are also_________

A 
Increased total body water:
• ↑Volume of distribution of water-soluble
medications
Larger initial dose
more sensitive to effects
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2
Q

Less muscle/fat →

• Slow redistribution of the drug into muscle will

A
  • longer clinical drugs effect

- increase duration of clinical effect (opioids, barbiturates)

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3
Q

Mean cerebral blood flow peaks

A

at 3-8 years

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4
Q

Proportionally

A

↓CBF in neonates

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5
Q

• Highly lipophilic drugs used for anesthetic induction

A

rapidly achieve equilibrium with brain tissue

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6
Q

• Reduced cerebral perfusion means that onset time after IV induction is_________

A

slower in neonates that in early childhood

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7
Q

Offset time is also delayed why?

A

because redistribution to the well perfused and deep, under perfused tissues is less

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8
Q

Offset time to reach brain then

A

back to body

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9
Q

Acidic drugs: (2) (BAD)

• Acidic drugs mainly bind to________

A

diazepam, barbiturates

-albumin

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10
Q
  • Basic drugs: __________ and _________
  • Basic drugs bind to
  • Mainly bound to __________= ↓premies/infants, adult levels by 6 mo
A

amide local anesthetics, alfentanil
globulins, lipoproteins, and glycoproteins
α1-acid glycoprotein (AAG) =

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11
Q

MAC

A

minimum alveolar concentration

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12
Q

Plasma protein binding ↓in neonates = _____and____ why?

A

more free medication –>↑pharmacological effect

↓total protein + albumin

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13
Q

Significantly affects highly protein bound drugs

A

• Phenytoin, salicylate, bupivacaine, barbiturates, antibiotics, theophylline, diazepam

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14
Q

Minimum Alveolar Concentration (MAC)

A
  • Highest at 6 months

* Higher in children compared to adults

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15
Q

Why MAC higher

A

May relate to
maturational changes in cerebral blood flow (CBF) γaminobutyric acid (GABA) class A receptor numbers
or developmental shifts in regulation of CHLORIDE transporters

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16
Q

Chloride ions

A

hyperpolarizes cells

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17
Q

“wash-in” aka “FA/FI” aka “induction” aka

A

GO TO SLEEP!

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18
Q

Determined by 6 factors: FA/FI –> IAF/CSA

A
  1. Inspired concentration
  2. Alveolar ventilation
  3. Functional residual capacity (you want ideallow)
  4. Cardiac output
  5. Solubility (ideal low)
  6. Alveolar to venous partial-pressure gradient (ideal high)
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19
Q

FA/FI means

A

Fractional alveolar to fractional inspired partial pressures

How much in alveoli from how much was given

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20
Q

What’s in alveoli is whats in the

A

BRAIN

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21
Q

FA/FI best if it’s

A

1

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22
Q

Factors 1-3 determine

A

delivery of anesthetic to lungs

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23
Q

Factors 4-6 determine

A

determine rate of removal (uptake) from lungs

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24
Q

Low FRC

A

Desaturation

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25
Q

From alveoli to ______Eventually because of pressure gradient difference

A

blood

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26
Q

Ratio of alveolar ventilation (Va)

A

to FRC is the primary determinant of delivery of inhaled anesthetics to lungs
• Affects more soluble agents greatly because they are easily stolen out of the lungs

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27
Q

Greater Va/FRC =

A

more rapid equilibration

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28
Q

memorize slide

A

8

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29
Q

About ____ to get to brain

A

12 minutes

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30
Q

BP every

A

3-5 minutes

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31
Q

Normally, rate of rise in FA/FI is

• Mostly affects more

A

inversely related to changes in CO

soluble agents

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32
Q

• Less anesthesia leeched from lungs in

A

↓CO states

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33
Q

Opposite in pediatrics is with CO

A

OPPOSITE in pediatrics
• ↑CO speeds up FA/FI
• More CO distributed to vessel-rich group (VRG)
• Brain, heart, kidney, splanchnic organs, endocrine glands
Partial pressures of anesthetics in the VRG equilibrate with those in the alveoli more rapidly in neonates than in
adults

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34
Q

Isoflurane

A

Does not go to brain as quickly

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35
Q

As you go up FA/FI

A

more insoluble

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36
Q

Anesthetic gases are less soluble in neonates in general due to (3)

A
  • ↑water content
  • ↓protein/lipid concentration
  • Reduces time for equilibration
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37
Q

For older people, VA induction with mask if CO is lower than normal

A

they go to sleep faster

less anesthesia leeched from lungs

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38
Q

The opposite in pediatric, proportion of blood that gets to the brain is

A

WAY MORE THAN ADULT

SLEEP FASTER

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39
Q

Solubility for gas (VA) is

A

NOT GOOD

IT IS SLOW

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40
Q
  • Wash-out follows

* Exact opposite of

A

exponential decay

wash-in curves

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41
Q
  • Washout similar in

* More rapid in

A

children and adults

neonates and infants

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42
Q

Cardiovascular

A

• Both directly and indirectly depressed

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43
Q

Affect Directly CV by

A
  • Ca2+ channel blockade, altering conduction system, dilating peripheral vasculature
  • ↓ Ca2+ flux
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44
Q

AFFect Indirectly CV by

A
  • Affecting balance of ANS and neurohumoral, renal, or reflex responses
  • All inhalational anesthetics modestly depress systolic BP in children
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45
Q

Down syndrome patients have increased risk of

A

bradycardia during induction

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46
Q

Sevoflurane can cause

A

bradycardia during induction

Junctional rhythm

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47
Q

HR normally unaffected by desflurane unless inspired concentration↑ suddenly
• Attenuated by________ administration

A

opioid administration

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48
Q

VOLATILE ANESTHETICS: Isoflurane:

LPC

A

☺ Less myocardial depression than Halothane
☺ Preservation of heart rate
☺ CMRO2 reduction rate (brain requiring less O2)

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49
Q

It is a PULMONARY IRRITANT

A

DESFLURANE (NOT USE IN KIDS OR WITH MASK)

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50
Q

Desflurane (2) major (IC) think DIC

A

☺ Increased incidence of coughing, laryngospasm,
secretions
☺ Concern of hypertension and tachycardia from
sympathetic activation

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51
Q

CONTRAINDICATED FOR ASTHMA

A

DESFLURANE

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52
Q

VOLATILE ANESTHETICS: SEVOFLURANE (LCM)

A

Sevoflurane
☺ Less pungent than Isoflurane
☺ Concern of compound A (nephrotoxicity) (for rats
☺ Most suitable for induction

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53
Q

Sevo usually run at

A

2L/min

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54
Q

ONLY FDA approved for INHALATIONAL Induction

A

SEVOFLURANE

55
Q

Underlying pulmonary conditions

A

Do not use desflurane

56
Q

Remember: About MAC and neonates and premies

A

MAC for potent volatile anesthetics
is increased in neonates, but may be lower for
sicker neonates and premies

57
Q

* MATHmust know Induction drugs:
Methohexital dose is ? Rectal dose is? when can you use it ?
Long acting vs short acting
Advantage of methohexital (1)

A

Methohexital 1-2 mg/kg IV ☺20-30 mg/kg per rectum(can be used when propofol not available)
• Short acting barbiturate
• Minimal CV effects

58
Q

Side effects and Contraindications for METHOHEXITAL
BAEH
Contraindication to Methohexital?

A 
☺ Side effects:
burning
hiccup
apnea
extrapyramidal syndrome
☺ Contraindication: temporal lobe epilepsy
59
Q

Propofol
Causes CHLORIDE SHIFT
Made from

A

GABA agonist
• Made from 1% propofol, soybean oil, egg yolk
phosphatide (ovolecithin), glycerol,** EDTA (BURNS!),
NaOH (buffer)

60
Q

Propofol dose until (6 years of age)

A

☺ 3 mg/kg i.v. (until 6 years of age)

61
Q

Propofol pain on injection use what?

A

☺ Pain on injection - 0.2 mg/kg Lidocaine i.v

62
Q

Ketamine dose ______IV, PR orally

A

1mg/kg IV

☺6-10 mg/kg PR, orally

63
Q

Ketamine works on _____receptor

A

• N-methyl-D-aspartate (NMDA) receptor

64
Q

• Duration of KETAMINE if single IV bolus =

A

5-8 minutes

65
Q

Advantages of Ketamine

A

• No upper airway obstruction but can still cause

hypoventilation (high doses)

66
Q

**Contraindications of KETAMINE (COIS)

A

Increased ICP
Open globe injury
Seizure hx (cerebral excitation)
Can’t be used for EEG

67
Q

Ketamine leads to (salivation )

A

☺ Increased SALIVATION (laryngospasm!) → antisialagogue

68
Q

KETAMINE will do what to IOP

A

Increase

69
Q

Etomidate dose pediatric

A

0.2 - 0.3 mg/kg IV

70
Q

ETOMIDATE has_______

A

propylene glycol ; so it burns on injection

71
Q

ETOMIDATE children needs?
ADvantages?
Disadvantage?

A

Like propofol, children need higher bolus
• Cardiac stable, less apnea than propofol, quickly redistributes
• Burns on injection (propylene glycol)

72
Q

Diazepam pediatric dose

A

☺ 0.1-0.3 mg/kg orally

73
Q

***Diazepam half life

A

***80 hours

74
Q

**Diazepam contraindicated

A

***infants less than 6 months

75
Q

Only FDA benzo approved in neonates

A

Midazolam

76
Q

Midazolam dose

IV, intranasal, IM, oral , rectal

A 
☺ 0.1mg/kg IV (
☺ 0.2 mg/kg intranasal (2 nose)
☺ 0.1-0.15 mg/kg IM
☺ 0.5mg/kg orally 
☺ 0.5-1mg/kg rectal (large dose)
77
Q

Side effects of each route

Most common is

A 
Oral - slow onset (most common)
IM – pain
Rectal - uncomfortable, defecation, burn
Nasal -irritating
Sublingual -bad taste
78
Q

Roles on

A

Role when awake separation of child from
parent before induction is planned.
2. Its success may be judged by the peacefulness of
the separation.
3. Large volume of literature indicates lack of
clearly ideal technique

79
Q 
Versed PO:
• Bioavailability =
• Peak serum levels after\_\_\_\_\_\_
• Peak sedation by about\_\_\_\_\_\_\_
• 85% peaceful separation
• Mix with
A

up to 12 mg max.
30%
about 45 minutes
30 minutes

Grape concentrate or acetaminophen
(Tylenol) syrup or elixir or Motrin Suspension (10
mg/kg of the 2% suspension)

80
Q

Possible concern with versed

Nasal dose

A

animal studies reveal neurotoxicity after topical application.
0.2mg/kg, peak 10 minutes, higher doses may delay intubation

81
Q

Methohexital (Brevital) rectal dose is _______as ____% solution in __________

• 85%__________________
induction of GA (very peaceful separation)
**Sleep duration:*

A

**Rectal 25 to 30 mg/kg as 10% solution in warm
tap water
sleeping within 10 minutes = rectal
about 45 to 90 minutes

82
Q 
Ketamine PO:\_\_\_\_\_\_\_\_\_
• May slightly prolong time to discharge after a
short case
• IM:\_\_\_\_\_\_\_\_\_\_ sedation;
• 2 mg/kg did not delay recovery
• 10 mg/kg:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
A

6 to 10 mg/kg
3 to 4 mg/kg

as effective as Midazolam 1 mg/kg but
some delay in recovery may be expected

83
Q

Ketamine• = __________IM induction of general

anesthesia

A

6 to 10 mg/kg

84
Q

Midazolam + Ketamine:

DOSE

A

• PO 0.4 mg/kg + 4 mg/kg respectively

100% successful separation

85
Q

Ketamine + Propofol in the same syringe

A

KETAFOL (50mg of ketamine in 50 mg of propofol)

86
Q

Consider medication

Fentanyl Lollipo consideration

A

Glycopyrollate (ENT, airway surgery )

Can increase volume of gastric contents

87
Q

EMLA cream:

A

Eutectic mixture of Lidocaine and Prilocaine.

88
Q

MORPHINE
Water soluble? or lipid soluble?
Who does if affect more and why?
rectal administation =______–>______

A 
Morphine 0.05-0.2 mg/kg
☺Water soluble = slow CNS 
☺Neonates affected more → immature BBB
☺Rectal administration = delayed absorption → resp.
arrest
89
Q 
MEPERIDINE dose
only indicated for\_\_\_\_\_\_\_\_\_
\_\_\_\_\_Route not recommended
\_\_\_\_\_\_Vd= \_\_\_\_\_\_\_Resp depression
Long infusion leads to \_\_\_\_\_\_\_\_\_---> \_\_\_\_\_\_\_-->
A

Meperidine 1-2 mg/kg
☺Only indicated for anti-shivering, NOT analgesia
☺Rectal route not recommended
☺Larger Vd = less respiratory depression
☺ Long infusions → normeperidine → seizures

90
Q

Fentanyl dose
Lipid or water soluble?
CV response?
Synergistic with what medication>?

A

–>1 mcg/kg
☺Lipid soluble, small molecules → efficient BBB
penetration and redistribution
☺Stable cardiovascular response
☺Synergistic with midazolam
☺Fast administration → chest wall + glottic rigidity
☺Can ↑vagal tone → bradycardia

91
Q

Fentanyl too fast you can get

A

CHEST WALL and GLOTTIC RIGIDITY

92
Q

Alfentanyl and Sufentanyl:

A

☺ More rapid clearance than adults
* Can cause parasympathetic response –>
bradycardia, hypotension**

93
Q

Volume of distribution make succinylcholine

A

HIGHER DOSES in pediatric

More water

94
Q

Succinylcholine dose _______
Laryngospasm breaking dose__________IV IM
GIVE WITH IT__________ or prior
Potential side effects:

A 
☺ 1-2 mg/kg IV; 4.0 mg/kg IM
☺Laryngospasm breaking dose = 0.1mg/kg IV,
4mg/kg IM
☺ Consider Atropine 10-15 mcg/kg given prior SUX
☺ Potential side effects:
Rhabdomyolysis
Hyperkalemia
Masseter spasm
MH
95
Q

Know ROC

A

0.1

96
Q 
Benzylisoquinoline: Atra and cisa 
Atra dose?
Metabolism?
Intubation condition in \_\_\_\_\_minuts
Lasts \_\_\_\_\_\_mins
A
  • Atracurium 0.5 mg/kg IV
  • Hofmann elimination, ester hydrolysis
  • Intubation conditions in 2-3 minutes
  • Lasts 30 minutes
97
Q

Cisatracurium
Dose
Daughter of __________
Same ______except____

A 
0.15 mg/kg IV
• Daughter of atracurium
• Same elimination except NO ester hydrolysis
• Same duration
• Onset ↑with ↑ dose
98
Q

Atracurium may give some

A

Airway issues

99
Q

Potentiation of NMB with anesthesia gases in descending order:

A

DO NOT NEED TO MEMORIZE,
• isoflurane, desflurane, sevoflurane > nitrous oxide
• Per Barash: des > sevo > iso > N2O

100
Q

Hoffman ALKALOSIS

A

Favor elimination

101
Q

Hoffman acidosis

A

Less elimination

102
Q

Aminosteroids

A

• Vecuronium

Rocuronium

103
Q 
Vecuronium dose is \_\_\_\_\_\_\_
CV effects
Intubating conditions in \_\_\_\_\_\_
Metabolized \_\_\_\_\_\_, excreted \_\_\_\_\_\_\_
Who is sensitive?
A 
0.1 mg/kg
No adverse CV effects
• Intubating conditions in 3-5 min
• Metabolized by liver and excreted via bile
• Infants significantly sensitive
104
Q

Rocuronium dose?
compared to vec is ________? intubating conditions?
with HR?

A

0.6-1.2 mg/kg, 1.8mg/kg IM
• Faster acting than vecuronium, 0.5-1.5 min for intubating conditions depending on dose
• Transient ↑HR seen with higher doses

105
Q

Reversal agents: Peds at high risk of

• Monitor

A

resp. failure w/residual NMB

- TOF at adductor pollicis

106
Q

Clinical signs of NMB antagonism in infants:

A

Flex hips/arms, lift legs, return of abdominal muscle tone, inspiratory force of -25 cm H2O or greater (more negative)

107
Q

• Hypothermia

A

potentiates NMB (makes muscle slower)

108
Q

Potentiated by NMB

• Potentiated by magnesium

A

antibiotics: aminoglycoside derivatives (gentamicin, tobramycin, and neomycin) = greatest effect
Magnesium and HYPOCALCEMIA

109
Q

Rule of 6

A

twitch and cc of neogstimine
4/4 twitch 6-4= 2 cc
1/4 twitch 6-1= 5 cc
*****CAN’T GO OVEr 5

110
Q 
Anticholinesterases
• Neostigmine dose\_\_\_\_\_\_\_\_
• Require \_\_\_\_\_\_\_\_\_\_\_than adults
• Doses >\_\_\_\_\_\_\_\_\_
• Co-administer with\_\_\_\_\_\_\_\_\_
A

0.020-0.025 mg/kg
0.1mg/kg can cause paradoxical weakness from ↑Ach at NMJ
smaller dose
glycopyrrolate 0.005-0.01 mg/kg

111
Q 
Sugammadex dose is 
Class
Roc vs Vec encapsulates better
Safe in peds?
Worry about?
A

Sugammadex 2 mg/kg (moderate block; reversed in 1.2 min)
• Cyclic oligosaccharide
• Encapsulates rocuronium best, vecuronium less
• Studies have concluded safe to use for peds
• Worry about allergic/anaphylactic reactions
MAY GET BRADYCARDIA

112
Q

FASTING Clear liquids -
☺ If infants are breast fed -
☺ For older patients =
☺ Be aware of

A

2-3 h before the procedure
4 h before the procedure
the adults rule
dehydration

113
Q 
Inhalational induction:
After induction -->
Use suggestions in older child -->
What protects against anesthetic OD-->
In a case of difficult airway --> \_\_\_\_\_\_\_\_\_
A

Younger than 12 months
☺ After the induction, place the intravenous catheter
☺ Use suggestions in older child (pilot’s mask)
☺Spontaneous ventilation protects against anesthetic
overdose
☺ In a case of difficult airway - Fiberoptic intubation

114
Q

What agents used for RECTAL INDUCTION

A 
☺ Methohexital (KeMidMethoThi)
☺ Thiopental
☺ Ketamine
☺ Midazolam
☺ Technique no more intimidating than rectal
temperature measurement
☺ Usual time of onset ~ 10-15 min
115
Q

Usual time of onset of RECTAL INDUCTION

A

10-15 min

116
Q

IM induction
Most common used is ______
Disadvantage is _______
ADvantage ______

A

☺ Most common used Ketamine
☺ Disadvantage painful needle insertion
☺ Advantage: reliability

117
Q 
IV induction 
The most \_\_\_\_\_\_ and \_\_\_\_\_\_\_Technique
Disadvantage is \_\_\_\_\_\_\_\_\_\_
if patient is older \_\_\_\_\_\_\_
If you insert the IV line" 
3 things you should do?
A

☺ The most reliable and rapid technique
☺ Disadvantage - starting intravenous line
☺ If patient is older ask the patient
☺ If you insert IV line:
I. Do not allow the patient to see it
II. Use EMLA cream
III. If use local - ask the patient if there is any sensation on puncture

118
Q

Patient with a FULL STOMACH
RSI with ________using _______
Tell the patient that will feel ________
Be aware of ________which leads to _______
What should you administer before Succinylcholine and why ?
Use _________dose ________
Use Succinylcholine dose _________

A

☺ RSI with ODL using cricoid pressure
☺ Tell the patient that will feel “touching on the neck”
☺ Be aware of Increased VO2 (desaturation)
☺ 0.02 mg/kg of Atropine administer before SUX to
avoid bradycardia (usually after 2nd dose)
☺ Use Rocuronium 1.2 mg/kg
☺ Use Succinylcholine 1-2 mg/kg  if really need
short duration (difficult airway)

119
Q

Premature infant -
Full-term infant -
3-12 month old child -
1 year and older child -

A

100 ml/kg
90 ml/kg
80 ml/kg
70 ml/kg

120
Q

MABL

A

EBV (Starting Hct - TARGET hct)/ Starting Hct

121
Q 
Packed Red Blood Cells:
☺ Child usually tolerates Hct\_\_\_\_\_\_\_ ~
☺ If the child is 
-
-
-
☺ No one formula permits a definitive decision
☺ Replace\_\_\_\_\_\_\_\_blood with \_\_\_\_\_Of L 
☺ Be aware of blood disorders (sickle cell disease)
A 
20 in mature children
Premature,
- Cyanotic congenital disease
- Decreased  O2 carrying capacity
Hct ~ 30

1ml blood with 3 ml of LR

122
Q

What is a late sign of decreased O2 carrying capacity

A

☺ Lactic acidosis

123
Q

Bleeding and FFP rule of thumb

A

☺ A patient should be never given FFP to replace bleeding that is surgical in nature

124
Q

Blood transfusion : If transfused faster than________ severe______May occur

A

1.0 ml/kg/min ionized hypocalcemia may occur

125
Q

BLood transfusion Ionized hypocalcemia can occur in neonates frequently why?

A

because of decreased ability to mobilize Ca++ and metabolize citrate

126
Q

Monitoring the Pediatric Patients:

A 
☺ Must be consistent with the severity of the
underlying medical condition
☺ Minimal monitoring:
I. ASA monitors
II. ***Precordial stethoscope***
III. Anesthetic agent analyzer
127
Q

Special Monitoring the Pediatric
Patients:
☺ Intraarterial catheter - most common _______
☺ Pulmonary artery catheters are indicated or not? why?
☺ In a case of severe multisystem organ failure
What might be helpful ?
☺_____________atheters are valuable in ICU patients
☺ In a case of rapid fluid replacement ______________might be very useful
☺__________________________
or umbilical vein may be life-saving

A

☺ Intraarterial catheter - most common radial
☺ Pulmonary artery catheters are rarely indicated
because equalization of the pressure right/left heart
☺ In a case of severe multisystem organ failure
insertion of PAC might be particularly useful
☺ Multilumen catheters are valuable in ICU patients
☺ In a case of rapid fluid replacement peripheral
venous catheter might be very useful
☺ Short-term cannulation of femoral/brachiocephalic
or umbilical vein may be life-saving

128
Q

How do nonrebreathing circuits work?

A

• Expiration →exhaled gas pushed down expiatory
limb and collects in reservoir bag and opens
expiratory valve (“pop-off, APL”)
• All NRB are convenient, light weight, and easily
scavenged

129
Q

Recommended circuit in children is the
Use of _______is recommended in children < ___-kg
3 reasons?

A

☺Use of Mapleson D system is recommended in
children < 10 kg
• More sensitive to changes in gas flow
• More sensitive to humidification
• Actual delivered volume is greater than other systems

130
Q 
Mapleson D is 
\_\_\_\_\_\_\_\_ circuit
\_\_\_\_\_\_\_\_\_\_
FGF tubing directed within the \_\_\_\_\_\_\_limb
FGF enters \_\_\_\_\_\_\_\_\_
Adds more \_\_\_\_+\_\_\_\_\_\_
A
  • Bain circuit
  • “coaxial” Mapleson D circuit
  • FGF tubing directed within the inspiratory limb
  • FGF enters circuit near mask
  • Adds more heat + humidity
131
Q 
Anesthesia Circuits: Non-Rebreathing 
Speeds-up rate of \_\_\_\_\_\_\_\_\_\_\_\_\_
•\_\_\_\_\_\_\_And \_\_\_\_\_\_\_\_\_\_ are less
(small circuit volume)
• No \_\_\_\_\_\_\_\_\_\_\_\_r = rebreathing highly dependent
on \_\_\_\_\_\_\_\_
• Minimum FGF \_\_\_\_\_\_\_\_\_\_\_
A 
All lack unidirectional valves
• Minimal work of breathing
Speeds-up rate of inhalational induction
• Compression and compliance volumes are less
(small circuit volume)
• No CO2 scrubber = rebreathing highly dependent
on FGF
• Minimum FGF 5L/min (or 2-3 x MV)
132
Q

Sugammadex only work for

A

ROCURONIUM > VECURONIUM

NOT for atracurium or cisatracurium

133
Q

Gases have

A

MUSCULAR RELAXANT PROPERTIES

134
Q

REDUCE doses of volatiles anesthetics because they also have muscular relaxant properties

A

KNOW SLIDE 38

SNRAObPedGer (25 decks)

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