Pediatric dz (exam 3 Massey) Flashcards
The perioperative period is stressful and anxiety-provoking for the child and family; many parents express more concern about ?
the risks of anesthesia than those of the surgery.
What age group in relation to anxiety is described below?
o Maximum stress for parent
o Minimum stress for infants—not old enough to be frightened of strangers
0-6 months
What age group has anxiety related to:
o Maximum fear of separation
o Not able to understand processes and explanations
o Significant postoperative emotional upset and behavior regression
o Begins to have magical thinking
o Cognitive development and increased temper tantrums
6 months to 4 years
How do you evaluate a pediatric pt. and family to know if they can or should not be present for induction or procedure?
Each child and family must be evaluated individually; what is good for one child and family may not be good for the next.
What age specific anxiety group is:
Beginning to understand processes and explanations.
fear of separation remains.
Concerned about body integrity.
4-8 year olds
What age group: Tolerates separation well Understands processes and explanations May interpret everything literally May fear waking up during surgery or not waking up at all
8 years to adolescence
what age group:
Independent
Issues regarding self-esteem and body image
Developing sexual characteristics and fear loss of dignity
Fear of unknown
Adolescence
Croup is indicative of?
subglottic narrowing
anesthetic implication of cyanosis?
right to left shunt!
if a child has a history of squatting then what does that mean?
tetralogy of fallot
What are the major objectives of pre-anesthetic medications?
o (1) allay anxiety
o (2) block autonomic (vagal) reflexes
o (3) reduce airway secretions
o (4) produce amnesia
o (5) provide prophylaxis against pulmonary aspiration of gastric contents
o (6) facilitate the induction of anesthesia
o (7) if necessary, provide analgesia.
What is one of the major things that premedication does for a pediatric patient’s stress response? (prevents)
decrease the stress response to anesthesia and prevent cardiac arrhythmias.
Factors to consider when selecting a drug or a combination of drugs for premedication include?
o the child’s age,
o ideal body weight,
o drug history, and allergic status;
o underlying medical or surgical conditions and how they might affect the response to premedication or how the premedication might alter anesthetic induction;
o parent and child expectations;
o the child’s emotional maturity, personality, anxiety level, cooperation, and physiologic and psychological status
What is the dose (premedication) of ketamine for pediatrics: Nasal Oral IM Rectal
nasal = 3mg/kg Oral = 3-6mg/kg IM = 2-10mg/kg Rectal = 6-10mg/kg
What is the dose (premedication) of lorazepam for pediatrics:
Oral
oral = 0.025-0.05mg/kg
Diazepam dose for premed. pediatric:
oral
rectal
oral = 0.1-0.5mg/kg Rectal = 1mg/kg
Midazolam premed. for pediatric patients: Nasal Oral IM Rectal
nasal = 0.2mg/kg oral = 0.25-0.75mg/kg IM = 0.1-0.15mg/kg Rectal = 0.5-1mg/kg
What is special about nasal administration of benzodiazepine medication?
Use preservative free for nasal administration due to fears of neurotoxicity
What antiholinergic’s cross the blood brain barrier and what s/s show due to this?
Atropine and Scopolamine.
may cause CNS excitation manifested as agitation, confusion, restlessness, ataxia, hallucinations, slurred speech, and memory loss if given in excessive doses.
Dose for atropine and scopolamine?
atropine = 0.01 to 0.02mg/kg
scopolamine = 0.005 to 0.010mg/kg
Which anticholinergic is more commonly used and why?
atropine, it blocks the vagus more effectively than scopolamine.
which anticholinergic is a better sedative, antisialagogue, and amnestic?
Scopolamine
Tell me about infants/pediatrics and HR and when to give WHAT medication related to this?
Infants who are at risk for or show early evidence of a slowing of the heart rate should receive the atropine before the heart rate actually decreases to ensure a prompt onset of effect to maintain cardiac output.
Which anticholinergic does not cross the BBB?
Glycopyrrolate
twice as potent as atropine in decreasing the volume of oral secretions, and it’s duration of effect is three times greater, what drug?
Glycopyrrolate
Dose of glyco?
0.01mg/kg
When will you actually use glyco?
to limit sialorrhea associated with ketamine
not just for normal pediatric secretions bc dry mouth is significantly dis-comfortable for peds.
Traditional mask induction for a child is what mixture of N20 to O2?
Then what do you introduce after max affect?
2:1
Then introduce sevo at 8%
Sevo considerations for a child if breathing on their own compared to controlled ventilation?
sevo is kept at 8% if child is breathing on their own (the body will adjust breathing rate as needed) but if controlled ventilation is started then Sevo should be decreased to avoid overdose.
Ideally all children should beath 100% oxygen before IV induction, if the face mask is met with resistance then what should you do?
hold the Y- connector of the circuit between your fingers over or near the child’s face.
IV induction drugs and doses (mg/kg): Etomidate Ketamine Methohexital Propofol Thiopental
Etomidate = 0.2-0.3 Ketamine = 1-2 Methohexital = 1-2.5 Propofol = 2.5-3.5 Thiopental = 5-8
Airway obstruction during anesthesia or loss of consciousness appears to be most frequently related to WHAT rather than WHAT?
loss of muscle tone in the pharyngeal and laryngeal structures rather than apposition of the tongue to the posterior pharyngeal wall.
If you place a child in “sniffing” position it will improve WHAT but not WHAT?
it will improve hypopharyngeal airway patency but DOES NOT NECESSARILY CHANGE THE POSITION OF THE TONGUE.
What is the most effective maneuver to improve airway patency and ventilation in children undergoing adenotonsillectomy.
Jaw Thrust
What position do you want an infant in for induction?
seated NOT laying or supine.
The progressive loss of tone with deepening anesthesia results in progressive airway obstruction primarily at the level of?
the soft palate and the epiglottis.
Important (but not the only) factor associated with laryngospasm?
Age: greater in infants than older children and adults, decreased risk with increasing age.
If laryngospasm occurs you will first use positive pressure ventilation with 100% oxygen and jaw thrust maneuver, if this fails what medication intervention will you do next?
In this order: Give IV or IM atropine (0.02mg/kg)
IV propofol (1mg/kg)
IV or IM sux (1-2mg/kg IV or 4 - 5 mg/kg IM)
What type of tubing for fluids should be used for kids?
You want to use buretrol IV tubing for fluids being given to kids 8 and under (to prevent giving too much fluid by accident).
(<1 y.o = 250ml, young children = 500ml, over 8 you can use macro or micro drip and 1,000ml bag)
Initial blood loss should be replaced with?
balanced salt solution at a rate of 3mL of solution for every 1 mL of blood loss. (3:1)
What is the smallest gauge IV you can infuse blood through rapidly?
22-gauge
how to calculate maintenance rate of fluids?
4-2-1 rule
4 ml/kg/hr for first 10 kg
2ml/kg/hr for second 10 kg (11-20 kg)
1ml/kg/hr for each kilogram > 20 kg
NPO deficit- how to calculate?
maint. rate (hourly requirement) x NPO hours.
replace 50% in first hour and 25% in 2nd and 3rd hour.
In order to deep extubate a child what depth of inhaled anesthetic do you want?
at least 1.5-2 x MAC
Optimal position for transfer of a child after surgery would be what position?
lateral decubitus position known as the recovery position
What does/can sevo and desflurane cause for a child during emergence?
emergence agitation also known as emergence delirium.
Tell me the details of Emergence delirium? % age anesthetic types lasts termination
a prevalence of 20% to 80%
has a peak incidence in children (of both sexes) at 2 to 6 years of age
is more common after certain anesthetics (sevoflurane ∼ desflurane ∼ isoflurane > halothane ∼ TIVA)
lasts 10 to 15 minutes, and is terminated either spontaneously or after an IV dose of propofol, midazolam, clonidine, dexmedetomidine, ketamine, opioids, or a host of other medications
The larynx in the pediatric neck?
The larynx has a higher position in the neck
narrowest portion of the larynx in the pediatric patient?
Cricoid cartilage (in adults it is the vocal cords)
Full- term neonates and their requirement for volatile anesthetics?
Full-term neonates require lower concentrations of volatile anesthetics than do infants 1 to 6 months of age
Neonate and infant requirements for sux is WHAT compared to older children?
WHY?
Neonates and infants require more succinylcholine on a per-kilogram basis than do older children to produce similar degrees of neuromuscular blockade because of the increased Extracellular Fluid volume and larger volume distribution characteristic of this age group.
Most practitioners limit the use of Sux to what kind of cases for those under ten? (2 types)
RSI
treatment of laryngospasm
What two physiological things could increase the sensitivity of neonates to the effects of hypnotics.
An immature BBB
decreased ability to metabolize drugs
Protein binding of drugs in infants? What will this cause?
Protein binding of many drugs is decreased in infants, which can result in high circulating concentrations of unbound and pharmacologically active drugs.
(the unbound drug is the pharmacologically active drug!)
Preterm infant with RDS who does not respond to CPAP therapy, what do you do?
If CPAP therapy fails, the newborn is intubated and surfactant administered
Preterm infant with RDS, what do you want your Hct to be and what do you want in relation to hydration status?
Hct keep near 40% to optimize systemic oxygen delivery.
Excessive hydration should be avoided; so use colloids over crystalloids
What size tube should you use in children with a history of mechanical ventilation and why?
an endotracheal tube one to one half size smaller than that predicted for age should be used because subglottic stenosis may be present
What is the diff. between laryngomalacia & bronchomalacia?
Bronchomalacia is seen in infants who have had a prolonged stay in the neonatal intensive care unit (NCU)
Laryngomalacia is a congenital or acquired condition of excessive flaccidity of the laryngeal structures, especially the epiglottis and arytenoids
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease of infancy. Is the choice of drugs for anesthesia or management of the airway more important?
management of the airway is more important than the choice of drugs for anesthesia
In newborns with BPD airway hyperreactivity is likely thus what kind of anesthesia should be in place before airway instrumentation?
deep plane of anesthesia
Most common metabolic problem occurring in newborn infants?
Hypoglycemia
What is a prudent level to keep all newborns glucose levels at or above?
40mg/dL
If an infant is symptomatic of hypoglycemia WITHOUT seizures what will you give them?
IV bolus 2mL/kg (200mg/kg) of 10% dextrose
If an infant is experiencing convulsions with hypoglycemia what will you give?
IV bolus of 4mL/kg of 10% dextrose is indicated.
What neonates are at higher risk of hypoglycemia intraoperatively?
less than 48 hours old
premature
small for gestational age
those born to diabetic mothers
What glucose blood level do you not want a newborn to go above?
Serum glucose concentrations in excess of 125 mg/dL can result in osmotic diuresis from glucosuria with subsequent dehydration as well as further release of insulin leading to rebound hypoglycemia
Clinical manifestations of hypocalcemia of the newborn?
irritability, jitteriness, seizures, and lethargy
ionized calcium levels in the newborn compared to total calcium levels when the newborn is hypocalcemic?
ionized calcium is decreased even as total calcium remains within normal limits.
If a newborn has hypotension WITHOUT an obvious cause what should you do?
give IV calcium
Giving IV calcium can cause what problem? Thus how should you administer calcium IV?
Cases of bradycardia and even asystole have been seen with rapid intravenous administration of calcium
Intravenous calcium should be given over 5 to 10 minutes with electrocardiographic monitoring
Apnea of prematurity (AOP) what is the drug therapy?
Methylxanthines are used which includes aminophylline, caffeine, and caffeine citrate
An infant with Congenital diaphragmatic hernia (CDH) can have profound hypoxemia, which reflects?
right to left shunting through the ductus arteriosus
CDH, how will you intubate?
preoxygenate
awake or RSI
Should you employ venous access in the lower extremity on a newborn with CDH?
No, venous access should be avoided in the lower extremities bc venous return may be impaired as a result of compression of the IVC following reduction of the hernia
