Pediatric Anesthesia Week 5 Flash Cards
What is the administration dose of Propofol IV? IV infusion?
- 2 to 4 mg/kg IV
- 25 to 400 mcg/kg/MINUTE
What is the administration dose of Pentothal IV?
4 to 6 mg/kg IV
What is the administration dose of Etomidate IV?
0.3 mg/kg IV
What is the administration dose of Ketamine IV?
1 to 2 mg/kg IV
What is the administration dose of Ketamine IM?
3 to 7 mg/kg IM
What is the administration dose of Ketamine PO?
3 to 6 mg/kg PO
What is the Dexmedetomidine loading dose for > 20 min?
0.5 to 1 mcg/kg
What is the Dexmedetomidine IV infusion rate?
0.2 to 1 mcg/kg/HOUR
What do you want to administer prior to administration of Propofol? How do you want to administer Propofol? Why?
- Lidocaine 1% at 1 mg/kg
- Slowly as it is painful
What should you use caution with in using Propfol? Through what type of IV access do you want to avoid? Why?
- Use aseptic technique
- Avoid PICC LINES
- Increased risk of INFECTION and OCCLUSION
Why would Propofol infusion (TIVA) be considered for patients with a history of severe PONV?
Propofol is an anti-emetic
In which population are infusion rates of Propofol greater, Pediatrics or Adults?
Pediatrics
What would be a usual infusion rate of Propofol for a MRI/CT/PET scan?
150 to 250 mcg/kg/min
What would be a usual infusion rate of Propofol for a radiation treatment with no surgical stimulation?
150 to 250 mcg/kg/min
** What would be a usual infusion rate of Propofol for an Endoscopy/Colonoscopy/Bronchoscopy?
350 to 400 mcg/kg/min
This induction agent’s onset is rapid & smooth, usually accompanied by a brief episode of apnea with minimal cardiovascular changes
Thiopental
What is the induction dose of Thiopental?
4 to 6 mg/kg IV
In which population of patients are especially sensitive to barbiturates, such as Thiopental? Why? What dose should you use?
- Neonates
- Due to the REDUCED PROTEIN BINDING of the drug in serum
- 3 to 4 mg/kg
When is Thiopental contraindicated for IV induction? When are barbiturates contraindicated?
- When there is a potential airway problem
- Patients with Porphyria (enzyme deficiency in heme production)
When should barbiturates used with extreme caution?
- Patients who may be HYPOVOLEMIC
- Patients with LIMITED CARDIAC RESERVE
When are barbiturates the best choice for induction agent? Why?
- Useful for NEUROSURGICAL and OCULAR procedures
- Barbiturates like Thiopental REDUCE INTRAOCULAR and INTRACRANIAL pressure
This induction agent is a short-acting hypnotic, with pleasant recovery, but with long exposure may prolong emergence due to its redistribution in fat cells
Propofol
This induction agent is a Phencyclidine derivative which produces profound analgesia, unconsciousness, cataleptic state and amnesia
Ketamine
How does Ketamine effect cardiovascular hemodynamics?
INCREASES:
- Heart Rate
- MAP
- Cardiac Output
Ketamine, if given alone and in adequate doses can cause…?
Minimal RESPIRATORY OBSTRUCTION
What medications would you want to pretreat with prior to administering Ketamine to pediatrics and why?
- Glycopyrrolate (anti-sialagogue) and Midazolam
- Causes HYPERSALIVATION increasing risk for laryngospasm and EMERGENCE PHENOMENA
When is Ketamine NOT the best choice for induction agent? Why?
- NOT recommended for NEURO or OCULAR procedures
- Increases CEREBRAL BLOOD FLOW, ICP, IOP, and causes nystagmus
What is the IV dose for Ketamine?
1 to 2 mg/kg for anesthesia
What is the IM dose for Ketamine?
3 to 7 mg/kg for anesthesia
What is the PO dose for Ketamine?
3 to 6 mg/kg for anesthesia
When is Ketamine IM route the best?
For uncooperative patients during IV placement or inhalation induction
This induction agent is a selective A2 agonist that decreases sympathetic tone, attenuates stress responses to anesthesia and surgery, causes sedation and analgesia, and is also used as adjuncts during regional anesthesia
Dexmedetomidine (Precedex)
What is the loading dose of Dexmedetomidine? What is the continuous infusion rate?
- 0.5 to 1 mcg/kg (over 10 to 20 minutes to attenuate hypotension
- 0.2 to 1 mcg/kg/HOUR. Titrate to effect
This induction agent is a STEROID-BASED hypnotic with a painful IV administration
Etomindate
Etomidate is usually avoided because of what 2 risks?
- Risk of anaphylactoid reaction
- Suppression of adrenal function
When is Etomidate very useful in pediatrics?
- Children with head injury
- Children with an unstable cardiovascular status (cardiomyopathy)
What is the induction dose of Etomidate?
0.3 mg/kg IV
What is the induction dose of Fentanyl?
1 to 2 mcg/kg IV
What is the dose for Hydromorphone?
10 to 20 mcg/kg
What is the induction dose for Sufentanil?
1 to 10 mcg/kg
What is the infusion rate for Remifentanil?
0.05 to 2 mcg/kg/MIN
Which population are more sensitive to Morphine’s ventilatory depressent effects? Why?
- Neonates & Infants
- Due to increased permeability of BBB and less predictable clearance of morphine
What is the IV/IM dose of Morphine?
0.1 mg/kg
What are some of Morphine’s adverse effects?
- HISTAMINE RELEASE
- Hypotension
- Respiratory depression/apnea
- Sedation
- PONV
What is the most commonly use opioid during GETA in infants and children?
Fentanyl
Why is clearance of fentanyl in preterm infants extremely variable?
Due to reduced elimination half life from
- Decreased hepatic blood flow
- Reduced hepatic function
- Age-dependent changes in Vd
What is the initial dose for Fentanyl?
1 to 2 mcg/kg and titrate to effect
What 2 factors make Fentanyl so effective?
- Highly lipid-soluble
- Crosses the BBB rapidly
Chronic infusion of fentanyl can cause …?
Tolerance and signs of dependence
What are signs of withdrawal from opioids in infants?
- Crying
- Hyperactivity
- Fever
- Tremors
- Poor feeding and sleeping
- Extreme cases: Vomiting and Convulsions
This opioid is commonly used when prolonged analgesia is required
Hydromorphone (Dilaudid)
How do you dilute Hydromorphone?
1 mg into a 10 mL syringe (add 9 mL of NS) = 100 mcg/mL
How much of an initial dose would you give with Hydromorphone?
10 mcg/kg and titrate with 5 to 10 mcg/kg as needed
True or False: Dilaudid is best used if a child is spontaneously breathing with an LMA or ETT
True
What are some side effects of Hydromorphone? When is Hydromorphone not appropriate to use?
- Sedation
- N/V
- Respiratory depression
- For infants and small children scheduled for same-day surgery with the intent to discharge home
This opioid has an extremely high margin of safety, it is also more protein-bound at 92% (vs 84%), and has a shorter elimination half life
Sufentanil
Why is Sufentanil a great choice with cardiac surgery in infants?
- Appears to block some of the stress response to cardiac surgery
- At high doses, produces good cardiovascular stability with minimal depression of ventricular function
What is the IV bolus dose for Sufentanil?
1 to 10 mcg/kg IV BOLUS
What is the infusion rate during GETA for Sufentanil?
0.1 to 1.5 mcg/kg/HOUR
What are some of the adverse effects of Sufentanil?
- Respiratory depression/apnea
- Chest wall rigidity
This opioid is an ultra-short acting synthetic opioid with a short half life that is independent of dose or duration of infusion or age of patient
Remifentanyl (Ultiva)
What is the half life of Remifentanyl? How is it eliminated?
- 3 to 10 minutes
- Tissue esterase hydrolysis
How should Remifentanyl be administered? At what dose?
- Continuous infusion
- 0.05 to 2.0 mcg/kg/MINUTE (as adjunct to GETA)
What are some adverse effects with Remifentanyl?
- Severe bradycardia
- Hypotension
- Apnea
- Chest wall rigidity
- Vomiting
Which is the only opioid that can be administered to any age group since it is metabolized via tissue esterase hydrolysis?
Remifentanyl
This medication is used in children to wean from long-term opioid infusions to prevent withdrawal and to provide analgesia when other opioids have failed or have been associated with intolerable side effects
Methadone
How much of Methadone is protein-bound? What is the main determinant of the free factor Methadone?
- 60 to 90%
- Alpha-1 acid glycoprotein
How does Methadone in children differ in adults?
- Large volume of distribution
- High plasma clearance
- Long half life
What is the PO dose for Midazolam?
0.5 to 0.7 mg/kg PO (max of 20 mg)
Why is Midazolam PO not a great choice with children? How long does it take to take effect?
- It has a bitter taste
- 10 to 15 minutes
What is the IV dose for Midazolam?
0.05 to 0.1 mg/kg IV
What is the PO dose for Acetaminophen?
10 to 15 mg/kg/dose every 6 hours
What is the PR dose for Acetaminophen?
30 to 40 mg/kg PR x1 loading dose
What is the IM dose for Ketorolac?
0.5 to 1 mg/kg IM (max of 30 mg)
What is the IV dose for Ketorolac?
0.5 mg/kg IV (max of 30 mg)
This drug has been shown to produce tranquil and calm sedation, reduces separation anxiety, and facilitates induction of anesthesia and enhances ANTEgrade amnesia
Midazolam (Versed)
What are some adverse effects of Midazolam?
- Depresses ventilatory response
- Increase upper airway obstruction
What is the max dose of Acetaminophen? What are they at risk for?
- 90 mg/kg/24 HOURS
- Hepatic failure
This is an NSAID with very potent analgesic properties used in children as an adjuvant to opioid analgesia to reduce potential respiratory depression/ PONV or for treatment of mild-moderate pain
Ketorolac (Toradol)
Which population of patient would you exercise caution in using Ketorolac?
- Renal patients
- Asthmatic patients
What medication is used to reverse an opioid overdose? What dose? What is the normal concentration?
- Naloxone (Narcan)
- 10 mcg/kg
- 0.4 mg/mL vial
What medication is used to reverse a benzodiazapine overdose? What dose?
- Flumazenil (Romazicon)
- 10 mcg/kg
What are the adverse effects of Flumazenil?
- N/V
- Blurred vision
- Sweating
- Anxiety
- Emotionally labile
What is the IV dose of Succinylcholine?
1.5 to 2 mg/kg
What is the RSI IV dose of Rocuronium?
0.6 to 1.2 mg/kg
What is the IV dose of Rocuronium? What kind of NMB is it?
- 0.45 to 0.6 mg/kg
- Intermediate non-depolarizer with fastest onset of action
What is the IV dose of Vecuronium?
0.1 mg/kg
What is the IV dose of Cisatracurium? What kind of NMB is it?
- 0.1 to 0.2 mg/kg
- Intermediate non-depolarizer with stable hemodynamics and minimal histamine release
What is the IV dose of Pancuronium? What kind of NMB is it? How is it redosed?
- 0.1 mg/kg
- Longer acting non-depolarizer, preferred when increased HR and BP is desired (cardiac surgery)
- Following doses should be only 10 to 20 % of initial dose
What medications can prolong non-depolarizing NMB’s? What else can prolong NDNMB’s?
Antibiotics, such as:
- Tobramycin
- Neomycin
- Gentamycin
- Hypothermia
What can Pancuronium cause in preterm infants?
- Sustained tachycardia
- HTN
- Increased plasma epinephrine level
- Increased risk of intracerebral hemorrhage
What is the IV dose of Glycopyrrolate?
10 mcg/kg
What is the IV dose of Atropine?
10 to 20 mcg/kg (MINIMUM 100 mcg)
What is the IV dose of Neostigmine?
0.07 mg/kg (MAX 5 mg)
What is the IV antiemetic dose of Dexamethasone?
0.1 mg/kg (MAX 10 mg)
What is the IV airway dose of Dexamethasone?
0.5 mg/kg (MAX 10 mg)
What is the IV dose of Zofran?
0.1 mg/kg (Usually max 4 mg)
What is the most prominent muscurinic action of a bolus of succinylcholine in the pediatric patient? How can this action be prevented?
- BRADYCARDIA develops in response to succinylcholine
- Atropine (10 to 20 mcg/kg) should be administered to pretreat
How much non-depolarizing muscle relaxant does a pediatric patient require compared with adults on a weight basis? Succinylcholine?
- Neonates, infants, and children require the same dose of non-depolarizing neuromuscular relaxants as adults
- Neonates require twice as much Succinylcholine on a body weight basis than older children or adults
Infants have a greater sensitivity to NDNMB’s than the adult, why?
Because of the neuromuscular junction of a neonate is inmature
Why is the dose administered on a weight basis the same for infants and adults?
- Infants have greater Vd for muscle relaxants
- Increased sensitivity of NDNMB’s at the neuromuscular junction which offsets the increased Vd
Give 2 reasons why neonates require more Succinylcholine on a mg/kg bases than that of adults?
- Larger Vd for Succinylcholine
2. 40 to 50% of a neonate’s body weight is EXTRACELLULAR fluid (where as an adult ECF is only 20 to 25%)
Compare the actions of Vecuronium (Norcuron) in the infant and the adult with respect to potency, onset, duration of action, and recovery
- Vecuronium has similar potency in infants and adults
- Onset is more rapid in infants, duration of action is longer in infants, and recovery is slower in infants than compared to adults
How does an infant’s quantity of plasma proteins, body fat, and muscle differ from the adult?
- They are reduced in the infant when compared to an adult
- Decreased plasma protein mean more free drug is available to produce clinical effects
- A lower dose of drug maybe indicated
A 2 year-old develops laryngospasm postoperatively and becomes bradycardic. What medication would you use if no IV was available?
- Atropine 20 to 40 mcg/kg IM
- Succinylcholine 4 mg/kg IM
Why do you give Atropine prior to giving Succinylcholine?
Succinylcholine mimics the effects of acetylcholine at the cardiac muscurinic receptors, which can precipitate more severe bradycardia, junctional rhythms, and even sinus arrest
What 2 drugs for sedation have the shortest duration of action, ideal for sedation in a pediatric patient?
- Propofol (5 to 15 minutes)
- Thiopental IV (5 to 15 minutes)
Give 3 reasons why the uptake of anesthetic drugs is typically faster in children than in adults?
- Child’s higher alveolar ventilation per weight
- Increased cardiac output with greater distribution to the vessel-rich groups combined with lower muscle mass
- Anesthetic agents appear to be less blood soluble in children than in adults, that is, the agents work faster in children than in adults
Which fluid is most appropriate for a normal 6 month-old patient requiring surgery?
- For short procedures, D5LR is appropriate
- For long procedures, LR is appropriate with separate D5W or D10W at a rate of 4 to 6 ml/kg after blood glucose levels are checked.
- INFUSION PUMPS ONLY*
Which agents are appropriate should a child become unruly and combative during the preoperative period?
- Methohexital 25 to 30 mg/kg rectally
- Ketamine up to 10 mg/kg IM
- Midazolam 0.025 to 0.05 mg/kg IM, 0.5 to 0.7 mg/kg PO
- Scopolamine 0.1 mg IM (< 1 year), 0.15 mg (1 to 5 years)
What are the 4 steps in treating hyperkalemia in a neonate?
- Administer Calcium Chloride at 0.1 to 0.3 mL/kg of 10% solution or Calcium Gluconate at 0.3 to 1.0 mL/kg over 3 to 5 minutes
- Administer Sodium Bicarb, mild hyperventilation, and a beta agonist
- Administer an insulin and glucose infusion at 0.5 to 1.0 G/kg of glucose and 0.1 U/kg over 30 to 60 minutes
- Give Kayexalate or place on dialysis
What 2 electrolyte abnormalities will be seen with projectile vomitting?
Hypokalemia and Hypochloremia
What are 6 primary considerations for the pediatric patient with hypertrophic pyloric stenosis?
- Postpone surgery until volume and electrolyte deficiencies have been corrected
- Must be normovolemic and correct the metabolic alkalosis
- DO NOT USE LR as it is metabolized to bicarbonate
- Stomach should be empty
- High risk of aspiration during induction
- Risk for postoperative respiratory depression
Neonates who are post phyloromyotomy are at risk for? Why?
- Risk for respiratory depression and hypoventilation
- Due to persistant metabolic or CSF alkalosis
What 4 actions should be taken to manage a patient with pyloric stenosis?
- Empty the stomach
- RSI
- Perform awake intubation
- Perform awake extubation
Is pyloric stenosis a medical or a surgical emergency?
- Pyloric stenosis is a MEDICAL, not surgical, emergency
- Surgery should be postponed for 24 to 48 hours until fluid and electrolyte abnormalities are corrected
What happens to the OHDC in patients with pyloric stenosis? Why?
- Shift to the LEFT
- Due to metabolic alkalosis s/t vomitting
What should Na, K, Cl, and UOP be prior to proceeding with surgery?
Na > 130 mEq/L
K > 3 mEq/L
Cl > 85 mEq/L
UOP of AT LEAST 1 to 2 mL/kg/hr
What acid-base disturbance will be seen with significant loss of bile vomitus?
Significant loss of bile vomitus will result in metabolic acidosis (bilious vs non-bilious)
What class of drugs do you want to avoid in surgeries for pyloric stenosis? Why?
- Opioids
- Because due to their metabolic alkalotic state, they often have sluggish “breathing drive” already
List 7 anesthetic considerations for managing an infant with a diaphragmatic hernia with bowels extending into the chest?
- This is an emergency
1. Place NG tube
2. DO NOT apply POSITIVE VENTILATION via mask
3. Intubate with CONTROLLED VENTILATION
4. NO N2O
5. Monitor PaCO2 and SaO2
6. Use 100 % FiO2
7. Give MUSCLE RELAXANTS and OPIOID after the chest is open
What is the max peak inspiratory pressure for a patient who has a diaphragmatic hernia? Why?
- PIP should be LESS THAN 30 cmH20
- Pneumothorax of the contralateral (usually RIGHT) lung can occur if PIP is too high
Which lung is usually involved in a patient with a congenital diaphragmatic hernia?
Usually LEFT LUNG through the FORAMEN of BOCHDALEK in 80% of patients
List 4 anesthesia considerations for a patient with congential diaphragmatic hernia
- Use Ketamine 0.5 to 1.0 mg/kg OR Fentanyl 1 to 3 mcg/kg
- Avoid N2O
- Avoid barotrauma PIP < 30 cmH20
- Anticipate postoperative ventilator support
