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Pediatric Anesthesia > Pediatric Anesthesia Pearls > Flashcards

Pediatric Anesthesia Pearls Flashcards

1
Q

Cardiac Output is dependent on what in the pediatric patient?

A

HR dependent

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2
Q

What happens to the FRC in pediatrics?

A

Reduced FRC bc of reduced lung compliance & an increased chest wall compliance which yields a low residual volume at expiration. Can lead to rapid desaturation during apnea. Can lead to atelectasis & hypoxemia

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3
Q

Describe the left ventricle on pediatrics.

A

Non-compliant left ventricle leading to a FIXED stroke volume. CO extremely dependent on HR

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4
Q

What are the 6 main pharamacological differences in pediatrics to adults.

A
  1. Immature hepatic biotransformation
  2. Decreased blood protein for drug binding
  3. More rapid rise in FA/Fi = more rapid inhalational induction & emergence
  4. Increased MAC
  5. Large Vd for H2O Soluble Meds
  6. Immature NMJ
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5
Q

Larynx is more cephalad in pediatrics placing the glottis at what level?

A

C4

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6
Q

Obligatory nose breathers up to what age?

A

5 mo

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7
Q

What is the narrowest part of the pediatric airway up to age 5?

A

Cricoid Cartilage

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8
Q

Pediatrics can become bradycardic quickly for many causes. List some

A

Anesthesia, hypoxia, vagal, increased sensitivity to volatile agents & bradycardia

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9
Q

How to neonates attempt to regulate temperature?

A

Heat production is metabolized by brown fat. Neonates CANNOT shiver.

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10
Q

How do volatile agents affect temperature regulation in neonates?

A

Can inhibit thermogenesis from brown fat

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11
Q

Name some effects heat loss/ hypothermia have on peds

A

Can delay wake ups d/t decreased conduction velocity of the CNS, can cause cardiac irritability, respiratory depression, increased pulmonary vascular resistance, and alter response to medications

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12
Q

What nerve is responsible for inducing laryngospasm?

A

SUPERIOR laryngeal nerve (SLN)

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13
Q

IM SUX dose to treat laryngospasm

A

4-6 mg/kg

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14
Q

IV SUX dose to treat laryngsopasm

A

20mg IVP or 0.5-1 mg/kg

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15
Q

What breathing system is most efficient for spontaneous breathing in pediatrics & why?

A

Mapelson A because FGF can = minute ventilation thereby preventing rebreathing

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16
Q

In controlled ventilation, what does the minute ventilation need to be in a Mapleson A to prevent rebreathing?

A

3x

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17
Q

How does a Mapleson A turn into a Mapleson D?

A

Take the APL valve which is closest to the patient in Mapleson A, and move the APL valve toward the reservoir bag

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18
Q

What is the difference between a Mapleson D & a bain circuit?

A

Bain circuit is a mapelson D but has corrugated tubing for heat conservation. Caution, it can kink.

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19
Q

What position do you place pediatric patients in for transport & PACU?

A

Recovery position

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20
Q

What ages is postop croup most common?

A

1-4 yo

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21
Q

What are 2 meds you can give to help with postop croup?

A

Decadron 0.25-0.5 mg/kg
Racemic EPI 0.25

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22
Q

What does capillary refill provide us in the pediatric patient?

A

Estimate of cardiac output & intravascular volume

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23
Q

At what age is the pediatric HR the highest average?

A

8-30 days

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24
Q

What does the anacrotic limb of an A-line waveform tell us?

A

The rate of increase in pressure which relates to myocardial contractility. (More upright = increased contractility)

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25
Q

What does the Area Under the Curve of an A-line waveform tell us?

A

Pulse pressure & Stroke Volume

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26
Q

What does systolic time of an A-line waveform tell us?

A

Myocardial O2 consumption

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27
Q

What does diastolic time of an A-line waveform tell us?

A

Myocardial O2 supply

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28
Q

What does a short systolic time indicate?

A

Hypovolemia & high SVR

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29
Q

Marked respiratory swing in A-line indicates?

A

Hypovolemia, pericardial effusion + high intra-thoracic pressure (constricting heart), airway obstruction

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30
Q

What does a slow systolic time indicate?

A

Poor myocardial contractility

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31
Q

What percent of CO is renal blood flow (RBF)

A

25%

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32
Q

At what age is renal blood flow 1/2 that of an adult?

A

6mo-1yr

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33
Q

At what age is renal blood flow comparable/normal to adults?

A

3 yo

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34
Q

At what systolic BP are the kidneys autoregulated at?

A

80-180 mmHg systolic

35
Q

What does nitric oxide work on in the kidneys and how?

A

Renal vascular tone with natural vasodilating effects

36
Q

What structure in the kidneys slowly filtrates albumin?

A

Lamina rara interna

37
Q

What structure of the kidneys slowly filters lactoperoxidase?

A

Lamina rara externa

38
Q

What is GFR driven by?

A

Hydrostatic pressures

39
Q

What is the largest site of the nephron for absorption?

A

PCT

40
Q

What is the major function of the PCT of the nephron?

A

Sodium reabsorption

41
Q

What percent of GFR is responsible for absorption in the PCT?

A

~50-60%

42
Q

What major metabolic components play a major role of the PCT?

A

Na/K Pump & ATP & ANG II

43
Q

Where is filtered sodium reabsorbed in the nephron?

A

Loop of Henle
Ascending & Descending

44
Q

Where is passive solute & H20 reabsorbed in the nephron?

A

Descending Limb of LOH

45
Q

Where is Na & Cl reabsorbed in excess of H2O in the nephron?

A

Thick Ascending Limb of LOH

46
Q

What creates the countercurrent mutliplier mechanism of the nephron/renal system?

A

Tubular fluid leaving LOH is HYPOtonic (100-200 mOsm/L) + the interstitium is HYPERtonic

47
Q

What components make up the countercurrent multiplier mechanism of the renal system?

A

LOH, cortical collecting tubules, medullary collecting tubes, respective capillaries

48
Q

Where does Na reabsorption occur against a steep gradient? What is this related to?

A

DCT & Aldosterone

49
Q

Where are K & H ions secreted in the nephron?

A

DCT

50
Q

Where in the nephron is Bicarbonate formed?

A

DCT

51
Q

Where in the nephron are acidic components converted to urine?

A

DCT

52
Q

What stimulates the release & increase in Renin?

A

Decreased intravascular volume

53
Q

Functions of Angiotensin II

A
  1. Increases sympathetic tone which increases HR, peripheral vascular resistance, and BP
  2. Increase/stimulates release of Aldosterone. Increases distal Na reabsorption (DCT), decreases urinary Na excretion, increases IV volume
  3. Increases proximal Na reabsorption at the PCT.
  4. Increases glomerular Efferent arteriolar resistance which increases the filtration fraction and increases Na reabsorption at the PCT.
  5. Increases thirst sensation and thus water consumption
  6. Increases cardiac contractility
54
Q

What pediatric body compartment contains the most water?

A

Muscle @ ~75%

55
Q

What fluid accounts for the majority of total body water (TBW)? & what percent? What percent accounts for total body weight?

A
  1. Intracellular fluid (ICF) @ 2/3 of TBW
  2. 30-40% of total body weight
56
Q

What electrolytes are most abundant of the intracellular fluid?

A

Potassium, Phosphate, Magnesium

57
Q

What makes up 1/3 of total body water and what does it contain?

A

Extracellular fluid (ECF). Plasma accounts for 10%.
Blood cells, PLTs, proteins

58
Q

What is the estimated blood volume (EBV) of an infant?

A

80 mL/kg

59
Q

What age range do pediatrics have maximal concentration ability (mOsm/kg) of the nephron and the same as an adult level?

A

1-3 yo

60
Q

When is the nephron fully matured in the pediatric population?

A

By 36 weeks gestation

61
Q

What contributes to the decreased ability to concentrate urine in infants?

A

Immature PCT & DCT
Slow response to mineralcorticoids

62
Q

What are 2 fluid therapy concepts related to low birth weights?

A

Large heat loss & large insensible losses

63
Q

What fluid concept contributes to rapid dehydration of pediatrics even though they do not manifest quickly?

A

Pediatric total body water is greater than their total body weight (higher ratio)

64
Q

What intravenous fluid should be considered in pediatric patients for early caloric supplementation?

A

D5W

65
Q

What is the blood replacement ratio in peds?

A

1:1

66
Q

What is the crystalloid replacement ratio in peds?

A

3:1

67
Q

Treatment of hyponatremia in peds? Restrictions & goals of raising Na concentrations?

A

3% NaCl
1. Only raise Na concentrations by 1 mEq/L/hr
2. Can be raised by 4-8 mEq/L if seizing
3. GOAL: 15-20 mEq/L in 48 hours

68
Q

Ramifications of correcting hyponatremia too rapidly (5)

A
  1. Demyelinating lesions of pons (central pontine myelinolysis)
  2. Pulmonary Edema
  3. Hypokalemia bc increased Na and K is inverse
  4. Hyperchloremic metabolic acidosis (hydrogen ions)
  5. Transient hypotension bleeding (r/t prolonged PT & PTT)
69
Q

What 2 components drive Central Diabetes Insipidus?

A

Hypothalamus or Pituitary

70
Q

Polyuria w/ urine osmo < plasma osmo

A

Central DI

71
Q

Diagnosis of central DI

A

Increase in urine osmo after administration of ADH

72
Q

What are 2 medications & their doses used to treat Central DI?

A
  1. SQ or IM Vasopressin (5-10 units, q4-6hr)
  2. IN DDAVP (10-40 mcg/day) & has long duration (12-24h)
73
Q

Medications that could result in Nephrogenic DI in pediatric patients?

A

Amphotericin, lithium, mannitol, ifosfamide, demeclocycline

74
Q

Hallmark of nephrogenic diabetes insipidus?

A

Kidneys fail to respond to ADH

75
Q

What is the primary cation in ICF making up 90%? How does it play in gradients?

A

Potassium. Gradient essential to maintain transmembrane potential

76
Q

Where is 85% of potassium reabsorbed in the nephron?

A

PCT & Thick limb of LOH (where lasix works)

77
Q

What are the “7 L’s (low) that are S/S of hypokalemia?

A
  1. Lethargic
  2. Low, shallow respirations… failure
  3. Lethal cardiac dysrhythmias (ST depression, shallow T wave, projecting U-wave)
  4. Lots of urine
  5. Leg cramps
  6. Limp muscles
  7. Low BP
78
Q

What does the acronym “DITCH” stand for in hypokalemia because your body is trying to DITCH potassium?

A
  1. Drugs: loop diuretics, laxatives, glucocorticoids/hydrocortisone
  2. Inadequate consumption of K
  3. Too much water intake
  4. Cushing’s syndrome (causes kidneys to excrete K)
  5. Heavy fluid loss (NGT, V/D, wound drainage)
79
Q

What are the 3 mechanism action names of the 3 classes of drugs for hyperkalemia treatment?

A

Membrane stabilizers, shifters, excreters

80
Q

What are membrane stabilizers used in the treatment of hyperkalemia?

A

Calcium gluconate
Hypertonic Saline 3%

81
Q

What are shifters used in treatment of hyperkalemia?

A

Short acting insulin (regular/humalin or novalin)
Albuterol

82
Q

What are excreters used in the treatment of hyperkalemia?

A

Furosemide
Sodium Bicarbonate
Sodium Polystyrene Sulfonate

83
Q

Which diuretic has the longest duration of action, where does it work, what is the MOA?

A

Spironolactone (Aldactone), DCT & collecting duct, competitive inhibitor of aldosterone

84
Q

What is the MOA of furosemide?

A

Inhibits chloride reabsorption

Pediatric Anesthesia (2 decks)

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