Pediatric Lecture 1 Flashcards
1
Q
Preterm
A
Before 37 weeks, post conceptual age
2
Q
Newborn
A
First 24 hours
3
Q
Neonate
A
First 30 days
4
Q
Infant
A
1 month to a year
5
Q
Children
A
1 to 12 years
6
Q
Adaptation to extrauterine life
A
- Gas exchange(O2 andCO2) function transferred from placenta to lungs
- SBP falls initially, then increases progressively c/age
7
Q
• Subcutaneous/muscle tissue develop during_______
A
third trimester
8
Q
Organogenesis =
A
first 8 wks (try not do anesthesia during that time)
9
Q
• Premature =
A
weigh < 2,500g
10
Q
- Growing:
* Birth weight doubles by________, triples by_____
A
6 months; 1 yr
11
Q
• Post-term neonate defined as being born
A
42 weeks gestation
12
Q
• Length doubled by what age
A
4 years of age
13
Q
• Preterm neonate =
A
born before 37 weeks gestation
14
Q
• Estimation: Wt (kg) =
if >8
A
Wt (kg) = 2 × Age (years) + 9
• > 8yr = age (yr) x 3
15
Q
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 __________+_________
A
↓ 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
16
Q
Neonatal Circulation. What are the 2 crucial events for transition
A
↓PVR,↑SVR (closes FO, reverses
ductus arteriosus shunt)
17
Q
Cardiovascular Physiology : Resting CO is
and because of a fixed SV there is
A
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
18
Q
Elaborate on Immature SNS
what is it driven by?
Left ventricle is
A
Driven by the parasympathetic
Left ventricle is noncompliant poorly developed
19
Q
During the first 3 months
A
Unable to respond to stress with inotropic support
Limited ability to increase CO even with limited stress
20
Q
Atropine vs Glycopyrrolate
A
Debatable,which intervention is more effective
21
Q
LV has limited contractile reserve: There is a\_\_\_\_\_\_\_\_\_ in the number of alpha receptors There is \_\_\_\_\_\_\_\_\_of catecholamines \_\_\_\_\_\_\_\_\_Recruitable SV Immature\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ventricular compliance
A
↓ # alpha receptors • ↑catecholamines • Limited recruitable SV • Immature Ca2+ transport system ↓ ventricular compliance
22
Q
Which receptors are better developed_______. Therefore use to maintain BP
A
Beta; beta agonists
23
Q
Pediatrics They are prone to \_\_\_\_\_\_\_\_\_ Unable to \_\_\_\_\_\_\_\_ Use caution with \_\_\_\_\_\_\_ Cardiac output is
A
Bradycardia
Handle pressure or volume problems
Intraoperative fluids
Rate dependent
24
Q
Mean Heart rate for premature
A
120-170
25
Mean HR for 0-3 months
100-150
26
Mean HR for 3-6 months
90-120
27
Mean HR for 6-12 months
80-120
28
Mean HR for 1-3 years
70-110
29
Mean HR for 3-6 years
65-110
30
Mean HR for 6-12 years
60-95
31
Mean HR for >12 years
55-85
32
Premature BP
SBP 55-75 / 35-45
33
0-3 months BP
SBP 65-85/45-55
34
3-6months BP
SBP 70-90/50-65
35
6-12 months BP
SBP 80-100/55-65
36
Pulmonary Physiology
| _______Chest wall compliance(3)
Increased chest wall compliance
- underdeveloped intercostal muscles
- small chest cavity
- High diaphragm
37
Airway and alveoli develop until age?
age 8
38
Role of surfactant
| Preemies and maternal diabetes=
Get rid of alveoli wall tension
| Decreased production of surfactant
39
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
40
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
41
```
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
42
Ventilation
There is switching from________filled to______Filled
Normal ventilatory pattern TV within
Fluid; air
| 5-10 ins
43
TV is
Increased RR
mirrors______
There is _______metabolic demands
6-8 ml/kg
40-60, unable to increase TV
Increase in oxygen consumption
44
Ratio of MV to FRC
2-3x adults
45
Rapid induction or emergence
Because or ration of MV to FRC
46
Laryngeal location adult vs child
Adult C3-C6
| Neonate C2-C4
47
Narrowest location of airway: adult vs child
Glottis
48
Narrowest location of airway: adult vs child
Glottis(cricoid?)
49
Right Mainstem Bronchus
Adult:more vertical
Child: less vertical
50
Tongue of the child
Larger in proportion to mouth
51
Epiglottis child
U shaped, Flappier bigger than adult
52
Lungs in child
less capacity
53
Trachea in child
Narrow and less rigidity in child
54
Most common Airway obstruction
Large tongue
55
Babies are __________
Obligate nose Breathers
56
PVR formula
PVR = 80 ( MPAP-PAWP)/CO
57
Normal PVR
<250 dynes
58
Child has ________Vocal cords
Anterior slanting vocal cords
59
Child has ______Occiput because of
large; High glottis
60
Major changes after birth
```
PVR low
SVR HIGH (closes foramen ovale, reverses ductus arteriosus)
```
61
Muscle fibers Type 1
Slow twitch, high oxidation
62
Muscle fibers Type 1__________for ________Activity
Slow twitch, high oxidation
| sustained active
63
Muscle fibers Type 2 _________For_________activity
Fast twitch, low oxidation
| Immediate, short activity
64
In the diaphragm type 1 muscles aren't
Matured until 8 months
65
In the Ribcage type 1 muscles aren't
Mature at 2 months
66
Neonates have limited _______because they cannot
Functional reserve; increase CO
67
What closes shunt
the increase in SVR
68
PEEP does what
Suck airways closed
Pliable rib cage
High closing volume
Look for retractions
69
Apply peep at
5-8cm H2O
70
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
71
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
72
Hematology BV depends on
When cord was clamped
73
BV in premies ______Than neonates, why?
BV in premies greater (90/105mL/kg) than in full-tern
| neonates because of increased plasma volume
74
* 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
75
Neonates have______Vagal reflex
strong
76
Hematopoiesis =
occurs in liver until 6 wks, then bone marrow
77
•_________ first 24 hr
• ___________end of first wk of life (neutrophils =
lymphocytes)
21,000/mm3
| 12,000/mm3
78
• Through 4 yo what is the predominant WBC??
| After 4 years old, what is the predominant WBC?
lymphocyte predominant cell
79
Infants,____________ associated with mechanical
| ventilation
Thrombocytopenia
80
Vit K dependent factors @________ of adult values at birth because of ________
20-60% • Immature liver
81
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
```
82
Hyperalimentation
| Balance risk of
Hypoglycemia(dextrose in IVF)
keep tube feeding running and TPN
Augmentation of ischemic injury
83
```
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
84
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
85
• Fetal pancreas begins secreting insulin
week 11
86
• Maternal hyperglycemia leads to
hypertrophy/plasia fetal islets of Langerhans
87
• ↑insulin in fetus
→ alters lipid metab. → macrosomia (big baby)
88
Babies prone to__________ after being born
rapid hypoglycemia
89
* 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
90
Glucose > 150 mg/dL
• Stressed neonates, receiving glucose in IVF during
| elective surgery
91
Peristalsis begins at _____(wk)
13 wks gestation
92
Duodenal motility marked maturation Which week?
@ 29-32 wks
93
Limits tolerance of enteral feeding before
29-30 wks gestation
94
Meconium contained in GI tract before birth
Usually passed a few hours after birth, almost always within 48 hrs
95
Temperature regulation
Most heat lost where?
Neonate have _____occiput
large surface area
most heat is lost in head
Large
96
Unable to generate _______Of heat
| they have poor _____
Large amounts of heat
Non-shivering THERMOGENESIS
Insulation
97
Central Chemoreceptors
hypoxia depressed hypercapnic ventilatory response
98
Heat production
By fatty acid metabolism
26-30 weeks
2-6% weight
99
Barotrauma and volutrauma
when over ventilating (VOLUTRAUMA more dangerous)
100
______Fat in heat production
Formed_______
located in 2 locations
Brown
26-32
scapula , sternum
101
VO2 HIgh in child
Double as fast consumption of O2
102
FRC to body weight
Decrease ; FRC keeps airway open
103
Closing volume
Point where alveoli start to collapse
| STAY ABOVE
104
TLC
160
105
Temperature Regulation in OR
Adequate ambient temperature
106
Preterm_____C
Full term_____C
Adult______C
Use
```
34 C
32 C
28 C
Bear huggers
Fluid warmers
```
107
FRC = Closing volume
Airway compromise start
108
The CNS is anatomically ________and functionally _________
complete at birth,
| Functionally immature
109
CNS myelination done at _____years
7 years
110
2 growth spurts of CNS
15-20 weeks
| 20weeks to 2 years
111
CNS develops in
Cephalocaudal direction
112
Mental development depends on
maturation of CNS
113
Law of laplace
Tell us how things stay open
| Transmural pressure required to maintain balloon inflated
114
BBB allows passage
selective passage of glucose, organic acids and amino acids.
115
BBB is damaged by
Hypoxemia/ ischemia--> Edema
116
Fluid maintenance
4-2-1
NPO deficit 1/2 first hour
1/4 2nd and 3rd hours
117
Traction of small airways keep alveoli open
more than surfactant
118
Surfactant are like
Detergents
119
```
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
```
120
Minute ventilation
TV (small in child) x RR
| RR increase better to increase minute ventilation
121
VS RR
30-60
122
VS HR
110-160
123
Bronchial tree
week16
124
BP 1-2 kg
50/25mmhg
125
BP >3kg
65/40mmhg
126
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
127
Supine neonates
FRC small, less outward pressure of chest, more elastic recoil
128
COPD of neonates
Bronchopulmonary dysplasia
| Disease of prematurity
129
________lung changes as bronchopulmonary dysplasia
Cystic
130
Treatment of bronchopulmonary dysplasia
Inhales anesthetics
Diuretics
Mechanical ventilation
131
Necrotizing Enterocolitis
Disorder of intestinal mucosa
Abdominal distention, Blood diarrhea, acidosis , Apnea
-->Septic Shock
132
Vocal cords of child
more anterior airway, (the smaller chin)
133
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.
134
When is surgery safe?
Medically optimization (Medical vs surgical emergencies)
3 common concerns
Post op apnea
Post op bradycardia
Gestational and post conceptual age
135
Post conceptual age(PCA)
Gestational age+ Post maternal age
136
PCA <60 weeks
Have highest risk for post-anesthetic complications
137
PCA 46-60 weeks
Include full-term neonate less than 2 months
| monitor for 24 hours post-op
138
Intubated child give _____
| Masked child give
give PEEP
| positive pressure
139
Nephrogenesis
| Tubular
36weeks, adult 2 years old
140
Fetus 2 things: related to acid base balance
mild respiratory acidosis, kidney tend to crease more bicarb
| more endogenous acid production with kids
141
Kids are more ______than adults
acidic
142
Parasympathetic nerves rises
3,7,9,10
143
Vit K dependent factors
2,7,9,10
144
PHHI
Hyperglycemic and hypoglycemic
145
Myelination happens from
Cephalocaudal :top to bottom(move arms freely before legs)
146
kg +______
40ml/hr for hourly maintenance.
147
Too much oxygen leads to the production of
free radicals
148
Anesthesia shouldn't be given to __________(higher risk for apnea)
less than 2 months
