Pediatric Lecture 1 Flashcards
Preterm
Before 37 weeks, post conceptual age
Newborn
First 24 hours
Neonate
First 30 days
Infant
1 month to a year
Children
1 to 12 years
Adaptation to extrauterine life
- Gas exchange(O2 andCO2) function transferred from placenta to lungs
- SBP falls initially, then increases progressively c/age
• Subcutaneous/muscle tissue develop during_______
third trimester
Organogenesis =
first 8 wks (try not do anesthesia during that time)
• Premature =
weigh < 2,500g
- Growing:
* Birth weight doubles by________, triples by_____
6 months; 1 yr
• Post-term neonate defined as being born
42 weeks gestation
• Length doubled by what age
4 years of age
• Preterm neonate =
born before 37 weeks gestation
• Estimation: Wt (kg) =
if >8
Wt (kg) = 2 × Age (years) + 9
• > 8yr = age (yr) x 3
Neonatal Circulation
First _____
• PVR experiences Major ___ to low “adult” levels during _____days
During the 1st wk of life, PVR___________
There is_______or pulmonary vasculature
There is __________+_________
↓ Pulmonary vascular disease (PVR)
decline ; 2-3 days
• During 1st wk of life, PVR decreases further
• 2° remodeling of pulmonary vasculature
• Thinning of vascular smooth muscle
+ recruitment of new vessels
Neonatal Circulation. What are the 2 crucial events for transition
↓PVR,↑SVR (closes FO, reverses
ductus arteriosus shunt)
Cardiovascular Physiology : Resting CO is
and because of a fixed SV there is
Resting CO maxed out Fixed SV - Decreased myocardial function - Increase Number of myocytes - More mitochondria needed for growth - Less organized -Stiff Heart - Limited functional reserve
Elaborate on Immature SNS
what is it driven by?
Left ventricle is
Driven by the parasympathetic
Left ventricle is noncompliant poorly developed
During the first 3 months
Unable to respond to stress with inotropic support
Limited ability to increase CO even with limited stress
Atropine vs Glycopyrrolate
Debatable,which intervention is more effective
LV has limited contractile reserve: There is a\_\_\_\_\_\_\_\_\_ in the number of alpha receptors There is \_\_\_\_\_\_\_\_\_of catecholamines \_\_\_\_\_\_\_\_\_Recruitable SV Immature\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ventricular compliance
↓ # alpha receptors • ↑catecholamines • Limited recruitable SV • Immature Ca2+ transport system ↓ ventricular compliance
Which receptors are better developed_______. Therefore use to maintain BP
Beta; beta agonists
Pediatrics They are prone to \_\_\_\_\_\_\_\_\_ Unable to \_\_\_\_\_\_\_\_ Use caution with \_\_\_\_\_\_\_ Cardiac output is
Bradycardia
Handle pressure or volume problems
Intraoperative fluids
Rate dependent
Mean Heart rate for premature
120-170
Mean HR for 0-3 months
100-150
Mean HR for 3-6 months
90-120
Mean HR for 6-12 months
80-120
Mean HR for 1-3 years
70-110
Mean HR for 3-6 years
65-110
Mean HR for 6-12 years
60-95
Mean HR for >12 years
55-85
Premature BP
SBP 55-75 / 35-45
0-3 months BP
SBP 65-85/45-55
3-6months BP
SBP 70-90/50-65
6-12 months BP
SBP 80-100/55-65
Pulmonary Physiology
_______Chest wall compliance(3)
Increased chest wall compliance
- underdeveloped intercostal muscles
- small chest cavity
- High diaphragm
Airway and alveoli develop until age?
age 8
Role of surfactant
Preemies and maternal diabetes=
Get rid of alveoli wall tension
Decreased production of surfactant
Pulmonary changes at birth
As the chest passes through the birth canal , the lungs are compressed –> Subsequent recoil of chest wall produces passive inspiration of air into the lungs
What establishes lung volume during fetal vaginal delivery?
It is required to_________
________ pressure is __________ and is for_________(in lung)
Fluid compressed from fetal lung during vaginal delivery = establishes lung volume
expand alveoli
• Negative inspiratory pressure (40-80 cm H2O)
Lung expansion
LA Place \_\_\_\_\_\_\_Required to keep bubble inflated Pt = If fluid lining of alveoli were purely interstitial fluid =
Pressure (Pt) required to keep a “bubble” inflated
= surface tension (T) at interface divided by the
radius of the bubble
• Pt = 2T/r
• If fluid lining of alveoli were purely interstitial
fluid = very high transmural pressure required
Ventilation
There is switching from________filled to______Filled
Normal ventilatory pattern TV within
Fluid; air
5-10 ins
TV is
Increased RR
mirrors______
There is _______metabolic demands
6-8 ml/kg
40-60, unable to increase TV
Increase in oxygen consumption
Ratio of MV to FRC
2-3x adults
Rapid induction or emergence
Because or ration of MV to FRC
Laryngeal location adult vs child
Adult C3-C6
Neonate C2-C4
Narrowest location of airway: adult vs child
Glottis
Narrowest location of airway: adult vs child
Glottis(cricoid?)
Right Mainstem Bronchus
Adult:more vertical
Child: less vertical
Tongue of the child
Larger in proportion to mouth
Epiglottis child
U shaped, Flappier bigger than adult
Lungs in child
less capacity
Trachea in child
Narrow and less rigidity in child
Most common Airway obstruction
Large tongue
Babies are __________
Obligate nose Breathers
PVR formula
PVR = 80 ( MPAP-PAWP)/CO
Normal PVR
<250 dynes
Child has ________Vocal cords
Anterior slanting vocal cords
Child has ______Occiput because of
large; High glottis
Major changes after birth
PVR low SVR HIGH (closes foramen ovale, reverses ductus arteriosus)
Muscle fibers Type 1
Slow twitch, high oxidation
Muscle fibers Type 1__________for ________Activity
Slow twitch, high oxidation
sustained active
Muscle fibers Type 2 _________For_________activity
Fast twitch, low oxidation
Immediate, short activity
In the diaphragm type 1 muscles aren’t
Matured until 8 months
In the Ribcage type 1 muscles aren’t
Mature at 2 months
Neonates have limited _______because they cannot
Functional reserve; increase CO
What closes shunt
the increase in SVR
PEEP does what
Suck airways closed
Pliable rib cage
High closing volume
Look for retractions
Apply peep at
5-8cm H2O
As far as renal physiology, neonates are obligates_______why? two reasons
daily requirements?
sodium losers
-because of immature tubular cells,
-They lose 20-25 mEq Na in urine, vs adult losing 5-10 mEq Na in urine
3-5 mEq/kg
Axis of deviation (left for adult), right for child why?
Right atrium , SA node more likely to go left because of large ventricule
Electricity goes through thick muscle
Hematology BV depends on
When cord was clamped
BV in premies ______Than neonates, why?
BV in premies greater (90/105mL/kg) than in full-tern
neonates because of increased plasma volume
- Capillary sampling vs venipuncture
- Term infants normally experience____Hgb during 9-12th wk, then ↑
- ____erythropoiesis,______ lifespan of RBC
- Normal physiologic adjustment to extrauterine life
- O2 delivery not compromised
- Why?
Normal Hgb 14-20
decrease
Decrease
Decrease
Increase 2,3 DPG (tells body to deliver O2)
CADET
Neonates have______Vagal reflex
strong
Hematopoiesis =
occurs in liver until 6 wks, then bone marrow
•_________ first 24 hr
• ___________end of first wk of life (neutrophils =
lymphocytes)
21,000/mm3
12,000/mm3
• Through 4 yo what is the predominant WBC??
After 4 years old, what is the predominant WBC?
lymphocyte predominant cell
Infants,____________ associated with mechanical
ventilation
Thrombocytopenia
Vit K dependent factors @________ of adult values at birth because of ________
20-60% • Immature liver
What is the most common cause of metabolic problems
in the newborn?
hyperinsulinemia MOST COMMON Persistent hyperinsulinemic hypoglycemia of infant Sepsis Hypothyroid Inborn errors of metabolism Intrauterine growth retardation Hypoxia Large for gestation Maternal infection
Hyperalimentation
Balance risk of
Hypoglycemia(dextrose in IVF)
keep tube feeding running and TPN
Augmentation of ischemic injury
Physiology Jaundice of the neonate High albumin due to by 12 weeks gluconeogenesis 15 weeks glyconenolysis Protein clotting factors are \_\_\_\_\_\_\_
Hyperalbuminemia secondary to
-increase bilirubin load (transition of Hgb-F to Hgb-A)
- Poor hepatic conjugation (decrease production of UDP-Glucuronyl transferase)
More proteins acidotic
Neonate pancreas
Placenta is _______To 2 hormones
- Placenta impermeable to insulin and glucagon = baby is on their own!
- Fetal pancreas begins secreting insulin week 11
• Fetal pancreas begins secreting insulin
week 11
• Maternal hyperglycemia leads to
hypertrophy/plasia fetal islets of Langerhans
• ↑insulin in fetus
→ alters lipid metab. → macrosomia (big baby)
Babies prone to__________ after being born
rapid hypoglycemia
- Abnormal glucose concentrations:
- _________in first 3 hrs of birth
- _________between 3-24hrs birth
- __________after 24 hrs
< 35 mg/dL
< 40 mg/dL
<45 mg/dL
Glucose > 150 mg/dL
• Stressed neonates, receiving glucose in IVF during
elective surgery
Peristalsis begins at _____(wk)
13 wks gestation
Duodenal motility marked maturation Which week?
@ 29-32 wks
Limits tolerance of enteral feeding before
29-30 wks gestation
Meconium contained in GI tract before birth
Usually passed a few hours after birth, almost always within 48 hrs
Temperature regulation
Most heat lost where?
Neonate have _____occiput
large surface area
most heat is lost in head
Large
Unable to generate _______Of heat
they have poor _____
Large amounts of heat
Non-shivering THERMOGENESIS
Insulation
Central Chemoreceptors
hypoxia depressed hypercapnic ventilatory response
Heat production
By fatty acid metabolism
26-30 weeks
2-6% weight
Barotrauma and volutrauma
when over ventilating (VOLUTRAUMA more dangerous)
______Fat in heat production
Formed_______
located in 2 locations
Brown
26-32
scapula , sternum
VO2 HIgh in child
Double as fast consumption of O2
FRC to body weight
Decrease ; FRC keeps airway open
Closing volume
Point where alveoli start to collapse
STAY ABOVE
TLC
160
Temperature Regulation in OR
Adequate ambient temperature
Preterm_____C
Full term_____C
Adult______C
Use
34 C 32 C 28 C Bear huggers Fluid warmers
FRC = Closing volume
Airway compromise start
The CNS is anatomically ________and functionally _________
complete at birth,
Functionally immature
CNS myelination done at _____years
7 years
2 growth spurts of CNS
15-20 weeks
20weeks to 2 years
CNS develops in
Cephalocaudal direction
Mental development depends on
maturation of CNS
Law of laplace
Tell us how things stay open
Transmural pressure required to maintain balloon inflated
BBB allows passage
selective passage of glucose, organic acids and amino acids.
BBB is damaged by
Hypoxemia/ ischemia–> Edema
Fluid maintenance
4-2-1
NPO deficit 1/2 first hour
1/4 2nd and 3rd hours
Traction of small airways keep alveoli open
more than surfactant
Surfactant are like
Detergents
EBV Premies newborn 3months to 1 year >1 year Adult
100 ml/kg 90 ml/kg 80 ml/kg 70-75 ml/kg 65-75ml/kg
Minute ventilation
TV (small in child) x RR
RR increase better to increase minute ventilation
VS RR
30-60
VS HR
110-160
Bronchial tree
week16
BP 1-2 kg
50/25mmhg
BP >3kg
65/40mmhg
Meconium Aspiration Syndrome
Meconium stained fluid indicative of fetal hypoxia
Not related to meconium present during delivery
Tx–> Conservative, suction until clear, NOT MORE THAN 3 times
Supine neonates
FRC small, less outward pressure of chest, more elastic recoil
COPD of neonates
Bronchopulmonary dysplasia
Disease of prematurity
________lung changes as bronchopulmonary dysplasia
Cystic
Treatment of bronchopulmonary dysplasia
Inhales anesthetics
Diuretics
Mechanical ventilation
Necrotizing Enterocolitis
Disorder of intestinal mucosa
Abdominal distention, Blood diarrhea, acidosis , Apnea
–>Septic Shock
Vocal cords of child
more anterior airway, (the smaller chin)
Intraventricular hemorrhage
Increased risk if
Grade 1-2?
Grade 3&$
premie with a history of stroke within several day s or birth
<30 weeks
Small amount of bleeding NO LONG TERM PROBLEMS
Severe bleeding ; blood presses on brain tissue, clots block CSF.
When is surgery safe?
Medically optimization (Medical vs surgical emergencies)
3 common concerns
Post op apnea
Post op bradycardia
Gestational and post conceptual age
Post conceptual age(PCA)
Gestational age+ Post maternal age
PCA <60 weeks
Have highest risk for post-anesthetic complications
PCA 46-60 weeks
Include full-term neonate less than 2 months
monitor for 24 hours post-op
Intubated child give _____
Masked child give
give PEEP
positive pressure
Nephrogenesis
Tubular
36weeks, adult 2 years old
Fetus 2 things: related to acid base balance
mild respiratory acidosis, kidney tend to crease more bicarb
more endogenous acid production with kids
Kids are more ______than adults
acidic
Parasympathetic nerves rises
3,7,9,10
Vit K dependent factors
2,7,9,10
PHHI
Hyperglycemic and hypoglycemic
Myelination happens from
Cephalocaudal :top to bottom(move arms freely before legs)
kg +______
40ml/hr for hourly maintenance.
Too much oxygen leads to the production of
free radicals
Anesthesia shouldn’t be given to __________(higher risk for apnea)
less than 2 months
