Pediatric/Neonate Flashcards

Question

Ketamine use in peds as sedatives?

Answer 1

* Severe cognitive/ behaviorally challenged older children → **_IM_** administered preop \*\* preferred * IM dose: 4-5 mg/kg * Onset: 3-5 minutes * Duration: 30-40 minute duration * Oral onset: 15-20 min

Answer 2

* hypotension with loading doses * bradycardia with high dose infusion * (note biphasic response with transient hypertension initially) → then hypotension * will not be adequate as a sole anesthetic but can be helpful as adjunct * opioid sparing effects * Uses: * useful in awake FOB * radiological procedures * reduction of emergence delirium * Dosing: * IV: * initial dose: 0.7-1.0 μg/kg administered over 10 minutes * → followed by infusion: 0.5-1 μg/kg/hr * Intranasal: 80% bioavailability!! great premed!! But takes long to peak * Dose: 1-2 mcg/kg * Peak: 30-40 min (long time)

Answer 3

* **Variety of choices:** onset, potency, duration, & metabolism are factors just like in adults * Also consider previous exposure to opioids (tolerance), severity of pain, & other multi-modal strategies * **Morphine:** * active metabolite (morphine-3- glucuronide) * → cause prolonged respiratory depressant effects in neonates and preterm and critically ill infants * Dosing: 50-100 mcg/kg (IV) per single dose * **Dilaudid dosing**: 10-20 mcg/kg (IV) per single dose * **Fentanyl:** most widely used opioid intra-op in children * stable CV profile * Caution: chest wall rigidity * Dosing variability * ~ 0.5-1 mcg/kg range * Work up to 1-3 mcg/kg range (IV) per single dose & titrated for effect * *Safely go up to 10 mcg/kg depending on sx* * **Remifentanil:** * excellent for neonates * great choice in renal/hepatic failure/immaturity (due to metabolism via esterases → mature system in neonate) * predictable eliminiation * Caution: * bolus injections can cause significant bradycardia/hypotension * must have plan for analgesia once infusion discontinued * Dose: 0.05-0.1 mcg/kg/min * **Demerol:** * Admin for shivering in small doses (0.25-0.5 mg/kg) * Metabolite: normeperidine * **Codeine:** * historically very commonly prescribed postop * withdrawn from many markets due to respiratory events * SNP’s in ultra-rapid metabolizers confer risk of OD (CYP affected)→ **BLACK BOX warning** * Slow metabolizers- placebo

Answer 4

* Acetaminophen: * PO 10-15 mg/kg * IV: 15 mg/kg q 6 hours (10-15 min onset) * rectal absorption: SLOW (1-2 hours) * Ketorolac: * Dose: 0.5 mg/kg IV * Ask surgeon before administration * CAUTION: * Severe asthma → caution all NSAIDs * Nasal polyps, eczema, and asthma → tend to have NSAID allergies

Answer 5

* NMJ not fully mature until ~2 months of age * Infants: may be **more sensitive** to **NDNMB** but also have larger VD → so dose/kg is usually the same as adults * **EXCEPTION: Rocuronium**- dose is **lower** in infants * ex: infants 0.3 mg/kg * ex: children: 0.6 mg/kg * RSI: same * Considerations: * * **Always use nerve stimulator** **→** **response is _highly variable_ (neonates not have normal resp to NS)** * **Use small doses** * **Reassess frequently** * May see a **prolonged** duration of action due to immature renal/ hepatic elimination **Use of succinhylcholine:** * Higher Sch doses needed in neonates & infants due to larger VD * \< 1yo: (2-3mg/kg) * Older → dose gets smaller * **Sch is limited to RSI and emergency tx of laryngospasm in Peds** * Cardiac **sinus arres**t may follow 1st dose of succs → more common after repeated bolus admins in any age * **Co-administer w/ vagolytic drug (atropine) s**hould probably be intravenously administered just before the first dose of succinylcholine in all children, including teenagers * unless a contraindication to **tachycardia** (e.g., a cardiomyopathy) exists * _**RISKs\*\*\***_: * Bradycardia * Hyperkalemia * masseter spasm * MH in children w/ undiagnosed myopathies

Answer 6

* Routine reversal for TOFR \< 0.9 * Neostigmine: dose for infants & children 30-40% lower than adults * Dose: 0.02-0.04 mcg/kg * co-administered with anticholinergic * glycopyrrolate 0.01mg/kg * atropine 0.02mg/kg * Sugammadex: not FDA approved in peds * Dose: 2 mg/kg * Always reverse peds pts!

Answer 7

* Cardiac output and local blood flow: 2-3x greater in infants than in adults * → so systemic LA absorption is increased (higher chance of LA toxicity) * Epinephrine is effective in slowing systemic uptake * Very Low Plasma concentration of AAG at birth (0.2 to 0.3 g/L) and does not reach adult levels (0.7 to 1.0 g/L) before 1 year of age * Free fraction of all local anesthetics is increased in infants Maximum doses of all amino-amides must be reduced (KNOW DOSES!) → think about cumulative amount going to give Extra key points about LA: * Nonionized LA cross almost freely the capillary wall close to injection site * rbc storage * In neonates, high HCT values (exceed 70%) and enlargement of erythrocytes cause entrapement of LA and lower peak plasma concentrations after a single injection, but increases secondary release. which increases half life of LA * in infants: a physiologic anemia reduces RBC storage of LA and protects against systemic toxicity. * LA are metabolized by CYP45, CYP3A4 metabolizes lido and bupi. cyp1a2 metabolizes ropi. these hepatic systems are immature at birth

Answer 8

* Standard adult history and physical exam must be adapted; some topics that require further emphasis in children * Birth history; prematurity * Neurologic development- appropriate for chronological age? psychological issues? * Airway anomalies, surgical history, previous intubations, and general medical health (heart, lung, endocrine, renal disorders) * AW exam: * Indicators for Difficult AW: * check for facial dysmorphias * signs of stridor, dysphonia, swallowing disorders, difficulty in breathing, difficulty in speaking, and hoarseness * Genetic or dysmorphic syndrome? * Potential for anomalies in the cervical spine (eg, Down syndrome) or craniofacial dysmorphia * Down syndrome- atlantoaxial subluxation at C1-C2 level * Family history: fevers or troubles waking up? MH, PD * (1) malignant hyperthermia (MH) * (2) pseudocholinesterase deficiency * (3) postoperative nausea and vomiting * (4) congenital myopathies * (5) bleeding (brushing teeth) * No laboratory work is indicated for healthy children undergoing a procedure with minimal blood loss anticipated * Routine pregnancy testing: controversial; parents may decline; history alone can be unreliable * Have waver ready * Midaz- iatrogenic effect * Higher risk for latex allergy in certain pediatric populations: * Ex: spina bifida, myelodysplasia, urinary tract malformations; multiple previous surgeries

Answer 9

* Mandibular protrusion * mallampati * movement of atlantooccipital join * reduced mandibular space * increase tongue thickness * age \<1 yo * ASA II-IV * Obesity * maxillofacial and cardiac sx

Answer 10

* Frequent upper respiratory infections (URIs)? * Risk for post op resp complications/laryngospasm * Up to 6 weeks after URI * History of wheezing? History of noisy breathing? Hospitalizations? History of intubations? * History of eczema/skin allergy/atopy? → likely to have bronchospasms/AW issures * In daycare? Immunization status? Smokers in the house? → prone to reactive AW dx * Infant: Frequent vomiting after feeds/“choking” episodes? → reflux * Child: Frequent tonsillitis? Ear infections? Snoring? Airway history * Presence of URI- risk of larynospasm * Snoring or noisy breathing * Presence and nature of cough * Past episodes of croup * Inspiratory stridor, usually high pitched * Hoarse voice * Asthma and bronchodilator therapy * Repeated pneumonias * Previous anesthetic problems, particularly related to the airway * Atopy, allergy * History of a congenital syndrome * **Parents smoke in the house? Increase risk of laryngospasm** * Suspicion of a C-spine anomaly? * down syndrome, klippel-feil, goldenhar * fracture/sbuluxation/neck burn * RA

Answer 11

Any family history of CHD/chromosomal abnormalities, sudden/premature death; maternal illness/infections (both chronic and during pregnancy); maternal medications/drug use * **Infant:** **look for clues on undiagnosed congenital heart defect** → * Any problems with poor feeding, sweating (especially on the forehead) during feeding, poor weight gain, FTT, decreased activity level * Symptoms of CHD often occur with feeding because of increased oxygen consumption and the need for greater cardiac output. * Need further testing * Babies with cyanotic heart disease turn dark blue or ruddy in color when crying because of prolonged expiratory phase and resulting increase in right-to-left shunting. * Hypercyanotic spells are often associated with extreme irritability and rapid, deep, and sometimes labored respirations. * **Older child/ adolescent:** * Any inability to keep up with the activity level of peers, need for frequent periods of rest, anorexia, cough, wheezing, rales, chest pain, leg cramps, syncope, light-headedness, palpitations; any history of drug use; any family history of sudden death, syncope, or arrhythmias * Any changes in color or cyanosis when crying? → undiag congenital heart defect

Answer 12

* Have LMA out & ready for back up * may use LMA as conduit for FOB Sample plan: known difficult airway plan for nasal intubation with FOB → MAINTAIN SV!!! No apnea!! * Apply standard ASA monitors; inhalational induction with sevoflurane, and maintain spontaneous ventilation (may require an oral airway) * Obtain intravascular access if not previously obtained. * Administer: * glycopyrrolate (5 mcg/kg) * propofol as needed to deepen anesthetic (larger doses may cause apnea) → don’t induce apnea * Prepare nasal cavity with oxymetazoline → reduce bleeding * Size both nostrils with a nasal pharyngeal airway (NPA). Keep the NPA in the smallest nostril and attach endotracheal tube connector to the end of the NPA. The patient can now entrain air : oxygen and sevoflurane during spontaneous ventilation. * Place a fiberoptic scope with a previously loaded nasal RAE endotracheal tube through the opposite nostril. Suction should be attached to the suction port. * Visualize the glottic opening. Spray the vocal cords with lidocaine (use 2% if over age 2 years, 4% if over age 8 years). Enter the trachea, and spray the trachea. * Lubricate the endotracheal tube and slowly pass through the nose into the trachea. Downsize the endotracheal tube by 0.5. Apply slow, steady pressure. * Place endotracheal tube connector from the NPA onto the ETT and confirm end-tidal CO2

Answer 13

* 6 to 8 mL/kg is typical * Sustained plateau airway pressures **\> 35 cm H2O** can lead to barotrauma: * Pneumothorax * Pneumomediastinum * subcutaneous emphysema * Lung protective strategies apply * Pressure control ventilation is proffered * Peak inspiratory pressure: 15-18 cmH2O * Titrate as needed * Resistance in circle system: unidirectional valves, kinking of ETT, CO2 absorbent, humidity and moisture exchanger * Issue with infant: sometimes need less valves, less resistance → use Mapleson circuit to limit resistance

Answer 14

* More frequent in infants; risk decreases with increasing age * Reflex closure of false & true vocal cords * afferent limb- internal branch of SLN * Efferent limb- recurrent larngeal nerve (innervates all laryngeal muscles except cricothyroid) and External branch SLN (cricotyhroid muscle) * **Sx**: stridor, retractions, flailing of lower ribs; “rocking horse” chest wall movement; stridor will be absent with complete closure “silent inspiratory effort” **(NO FOGGING OF MASK)** * Can lead to profound bradycardia & desaturation if unrelieved * **Risks:** 1. recent URI (w/in 3 wks), 2. secondhand smoke, 3. stimulation while “light,” 4. secretions in airway (CRYING, BLOOD IN AW) * **Treatment:** **Continuous positive airway pressure**,100% oxygen, jaw thrust at condyles of mandible (Larson’s Maneuver)- anterior displacement, suction secretions/ blood etc., deepen anesthesia (propofol) * Unresolved? * Atropine & Sch- if no IV access then give IM * Severe Laryngospasm/Bit through ETT: → lead to **negative pressure pulmonary edema** especially in healthy, muscular adolescents- may have to remain intubated for 12-24 hours & may need furosemide (flash pulmonary edema)

Answer 15

**THINK VENTILATION & OXYGENATION** * Infants: \<100 bpm * 1-5 yo: \<80 bpm * \>5 yo: \< 60 bpm * If O2 and vent don’t help → chest compressions! * Causes: * **Hypoxia** → leading cause of bradycardia in children (and asystole) * **Single dose Sch** * other causes: vagal stimulation, increased ICP, meds (Sch), CHD, hypothermia, air emboli, tension pneumothorax * **Treat cause:** **think oxygenation and ventilation first!! Then…** * → Atropine if vagal origin 0.02 mg/kg IV * Epinephrine if decompensated 10 mcg/kg * if HR \<60 with s/s of poor perfusion, call for help and start chest compressions Meds bradycardia: clonidine, beta blockers, Sevo esp in downs syndrome, propofol infusion syndrome, some eye drops, Sch without atropine The most frequently encountered arrhythmia in pediatric populations is hypoxia-induced bradycardia that can lead to asystole, if not appropriately handled. Ventricular fibrillation is extremely rare in infants and children.

Answer 16

* Neuromuscular function- check & reverse if appropriate * Different techniques for extubation; always prioritize patient safety * light anesthesia is the most common cause of laryngospasm * **Awake extubation**: must be awake & purposeful; laryngospasms happen when patients are extubated in the early & second phase, “if in doubt…don’t take it out!” * **3 phases waking up:** * **early phase-** coughing intermittently, gagging, struggling, moving nonpurposefully * **second phase-** apnea, agitation, straining, breathholding, RR not regular * **third (final) phase-** regular respiratory rate, purposeful movement, coughing, opening eyes spontaneously **_→ extubation now appropriate_**

Answer 17

* **Deep Extubation**: * Sevo **_increased_** to 1.5-2 MAC for at least 10 minutes * ensure no response (cough, breath holding) to suctioning or tube movement; & ensure regular respirations * place oral AW and allow them to breathe off gas or assist them * No deep extubate: DAW or aspiration risk * Transport in lateral decubitus position “recovery position” * Tx w/ O2 * PACU complications in ~5% of children: * vomiting 77% (more common in \>8 yo), airway compromise 22% (more common in \<1 yo); CV compromise is \<1%

Answer 18

* (1) severe coagulation disorders (hemophilia, DIC) * (2) severe infection such as septicemia or meningitis * (3) hydrocephaly and intracranial tumoral process * (4) true allergy to local anesthetics * (5) certain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesions that can be acutely aggravated by a block procedure * (6) uncorrected hypovolemia * (7) cutaneous or subcutaneous lesions, whatever their nature (infection, angioma, dystrophic or tumoral, tattoo) at the contemplated site of puncture * **Parental refusal is a non-medical absolute contraindication**

Answer 19

* The most commonly used technique of epidural blockade in children * Simple technique; low complication rate * Anatomy of the sacral hiatus: * a U -shaped or V -shaped aperture resulting from the lack of dorsal fusion of the fifth and often fourth sacral vertebral arches * limited laterally by two palpable bony structures, the sacral cornua * covered by the sacrococcygeal membrane (sacral continuation of the ligamenta flava) * 25-mm needles are long enough to reach the sacral epidural space and short enough to prevent inadvertent dural puncture in most patients * Contraindications: * major malformations of the sacrum (myelomeningocele, open spina bifida) * meningitis * intracranial hypertension. * Rare: unrecognized dural puncture can lead to cardiovascular collapse or respiratory arrest * Position: lateral or prone position with the legs flexed in the “frog” position * Single shot or placement of epidural catheter can be threaded to 2-3 cm (same as regular epidural block) * Upper limit of dosing: * **1 ml/kg (1.25 ml/kg can lead to block above T4)→ resp consequences!**

Answer 20

* Increased risk in certain surgeries: hernia; orchidopexy; T&A; strabismus; middle ear; laparoscopic * Strabismus sx pt- higher risk of MH (high risk of concurrent myopathies) (MD) * Prevention: * Hydration * multi-modal analgesia (opioid sparing- use less) * Peak incidence in females age 10-16 * Typical 2-3 agent strategy for prevention in at-risk (decreases risk by 80%): * **Ondansetron 0.05-0.15 mg/kg IV** (note risk in undiagnosed long QT syndrome) * **Dexamethasone 0.0625-1 mg/kg IV**

Answer 21

* Agitation & inconsolability unrelated to pain * **Peaks in age 2-6 yo** * Most common after Sevo (then Desflurane); less common with TIVA * Usually self-limiting (lasts ~ 10-20 minutes) * Tx: * Small dose of fentanyl clonidine, or propofol * Patient self-harm can be an issue (thrashing, etc.) * *need to go through and rule out hypoxemia/metabolic derangements* * *agitation may be due to pain, cold, full bladder, presence of casts, fear, anxiety, or having tantrum*

Answer 22

* **Both epiglottitis and croup have** **supraglottic swelling** * really nothing else in common * epiglottitis **2-6 yo** * stirdor **uncommon** * **thumb** sign on CXR * abx * need sx availability of airway, get airway secured * **Epiglotittis review** * Life threatening **_bacterial_** infection of the epiglottis, aryepiglottic folds, arytenoids, & sometimes the uvulas/s: high fever, severe sore throat, drooling, ill appearing, tripod positioning * **Rapid deterioration** may occur * **Tx**: antibiotics, securing AW!! * **Technique**: * Calm, sitting inhalational induction, maintain SV\*\* * Do not manipulate the airway without a backup for surgical airway in place * Do not agitate the child (hold down for IV start; separate from parents) * LTB (aka croup) \<2 yo * stridor **common** * **steeple sign (**subglottic narrowing) on CXR * use things to **decrease swelling but typically don't need to intubate.** * **Croup= (Laryngotracheobronchitis)- LTB review** * **Viral** infection of the subglottic structures; more gradual onset * S/S: **barky or seal-like coug**h along with hoarse voice and inspiratory stridor * Technique:Most cases resolve with **simple management** * Tx: **humidified** air or oxygen, steroids * \<10% require hospitalization

Answer 23

Both can lead to airway collapse Laryngomalacia * most common airway problem in infants & children * Immature cartilage of the supraglottic larynx leads to symptoms * slowly resolves by 12–18 mo * self-limiting & resolves w/ age * Symptoms: **_Inspiratory_ stridor w/ activity/feeding that IMPROV**ES when the child is **calm** Tracheomalacia * Weakened/ “floppy” trachea that leads to symptoms * Symptoms: * Harsh noise/stridor on **expiration** caused by airway collapse * Onset: early neonatal period * Dx: bronchoscopy

Answer 24

* Optimize patients preoperatively * Pre-op review: ever been hospitalized for asthma? intubated? ER visits (last 6 mo)? age of onset? treatments used (today)? need for steroids? * Assessment: * Auscultate for wheezing * **Cancel elective cases for ACTIVE wheezing!** * Technique: * Admin pre-op bronchodilators in mild/moderate asthma even if not wheezing * Avoid intubation where facemask or LMA can be used (think sx type and aspiration risk) * Have bronchodilators present in OR * Refractory asthma (not moving air) → admin IV epi w/ refractory bronchospasms bc inhaled bronchodilators cant pass

Answer 25

* Prolonged upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep * altered response to CO2 * **Anesthesia concerns**: * **opioid sensitivity** * CONSIDER NON-OPIOID ALTERNATIVES: * local anesthetics * tylenol * ketorolac * ketamine * dexmedetomidine * When opioid is given: **REDUCE DOSE! (usually by 1/2)** * Admin in small doses and assess for response * **post-op respiratory complications** * post-op admission for monitoring depending on results of sleep study * High risk patient? * Safest route: Admit for postoperative monitoring even if no sleep study has confirmed diagnosis * Council family members about transporting child home → watch for obstruction * **Primary cause** of OSA in children: **large tonsils & adenoids** **→** **T&A sx most likely for OSA** * Other: craniofacial abnormalities, neuromuscular disorders, obesity **Assessment of risk factors:** * loud snoring, witnessed apnea, nocturnal enuresis, **ADHD**, behavioral problems, inattention at school; increased risk in African American * Daytime somnolence is **not** a common feature of OSA in children (opposite than adult pts) * AHI score- apnea-hypopnea index (**AHI**) * *graded by # of apnea and hypopneic episodes during 1 hour obs* * *Mild \>5 but \<15/hour* * *moderate 15-30/hr* * *severe \>30/hour* BIG concern with OSA in peditrics: * **Intermittent hypoxia** → may lead to remodeling * Consequences: pulmonary hypertension & right heart failure (cor pulmonale) * Preop: Echocardiography recommended when severe OSA suspected to have CV involvement * **Red flags:** * systemic hypertension * right ventricular dysfunction (s/s: peripheral edema, hepatic enlargement (below 1-2 cm costal margins), elevated liver enzymes) * frequent severe desaturations (\<70%)

Answer 26

* Most common co-morbidity in children presenting for surgery * Increased risk complications/ bronchospasm at induction/emergence * Laryngospasm, bronchospasm, excess secretions * The most common perioperative respiratory adverse events (PRAEs) associated with URI are: * \*\*laryngospasm, bronchospasm, breath holding, atelectasis, arterial oxygen desaturation, bacterial pneumonia, and unplanned hospital admission * **Caution but proceed**: clinically look OK * clear runny nose * no fever * playful * clear lungs * **Cancel:** * purulent nasal discharge * fever * lethargy- ill looking * persistent cough, wheezing/ rales * previous preemie * \<1 yo * **Consider waiting at least 2 weeks for elective surgery** * Complications can persist up to **6-8 weeks**

Answer 27

* Airway manipulation (ETT) increases the risk of bronchospasm * Techniques: * ensure deep plane of anesthesia before manipulate AW * (risk of airway reflex response: face mask \< LMA \< ETT) * Avoid intubation if case can be done with less invasive airway (mask case; LMA) * Add propofol/local anesthetic * Considerations: * Tx for bronchospasm available @ bs * anticipate increased potential for laryngospasm * Most common perioperative respiratory adverse events associated w/ URI are: * laryngospasm * bronchopasm * breathholding * atelectasis * arterial oxygen desat * bacterial pna * unplanned hospital adm

Answer 28

* One of the most commonly performed pediatric surgeries **Indications**: * recurrent infections * OSA * Most tonsillectomy patients have enlarged tonsils without other airway deformities * Must consider presence of sleep apnea * potential need for admission * use of multi-modal analgesia (reduce opioid doses) **Technique**: * LMA used by some but majority still intubate * RAE tube **Complications**: * **Post-op hemmorhage** * occurs in 0.1-3% of T&A * can be primary (day of surgery) or 7-10 days later * Consider: active bleeding in airway → * visualization difficult * full stomach- swallowing blood * RSI\*\* * hypovolemic shock potential

Answer 29

* most common birth defect * incidence: 1:25 live births * **L-to-R shunting:** * increases pulmonary BF → potentially decreases systemic blood flow * **R-to-L shunting:** * Blood bypasses pulm circulation → Deoxygenated BF into systemic circulation → causes reduced pulmonary blood flow and increased cyanosis * \*deoxygenation BF into periphery * PDA present * have pulse ox on RUE (preductal oxygenation) and any other extremity (postductal oxygenation) * Preductal: BF feeds head, neck, and RUE * Postductal: any other extremity

Answer 30

* Management is dependent on specific anatomy and physiology * Attempt to maintain pt baseline (same SpO2 and other vital signs) * **L-to-R shunts:** * Avoid increases in SVR and decreases in PVR (which will increase shunt) * Avoid negative inotropes * Avoid hypervolemia * Desaturation → Could be reversal of shunt * **Anesthetic considerations:** * **minimal impact on uptake of volatile anesthetics**

Answer 31

**R-to-L shunts:** * Maintain high SVR to decrease shunt: * Ex: Ketamine, phenylephrine * Avoid increased PVR * Minimize intrathoracic pressure * **Avoid air bubbles in IV** * **Anesthetic Considerations:** * decreased wash-in of VA * → IV supplementation may be required

Answer 32

* Most common cyanotic CHD * primary repair done at 3-12 months * Anatomy: * Right ventricular outflow (RVOT) obstruction * Infundibular narrowing, pulm stenosis, PA hypoplasia, pulm atresia * Ventricular septal defect (VSD): Large, unrestrictive * Overriding aorta * RV hypertrophy * **Tet spells**: (Left unrepaired) → cyanotic episodes!!! * Crying and agitation leading to tet spell leading to more hypoxemia, hypercarbia, acidosis (avoid) * Consequences: lead to RVH, RV failure, and death (50% in first year of life) * Increased R-to-L shunting caused by: * decreased SVR or * increased PVR * Avoid hypoxia, acidosis, high airway pressures, excitement, and agitation

Answer 33

* Can be associated with the later development of dysrhythmias (esp if approach was ventriculotomy → conduction system violated) * repaired single-ventricle physiology → high risk sudden death as a result of pathologic arrhythmias * any intraoperative arrhythmias must be reported to cardiologist → may require RF ablation * Children with a **single-ventricle physiology (Fontan)** require very specific anesthetic management: * well hydrated * avoid PEEP * avoid laparoscopic surgery (avoid intrathoracic/intraabdominal pressure) * **Williams syndrome** → high risk sudden death with anesthesia * Anatomy: aortic stenosis, abnormal coronary arteries, pulmonic stenosis * Former cardiac transplantation: * must rule out small vessel coronary artery disease

Answer 34

* Hgb SS homozygous: Hgb S permits deoxygenated Hgb molecules to polymerize into rigid insoluble fibers → resulting in sickled erythrocytes * Sickled erythrocytes = shortened life span → leading to **_chronic hemolysis and anemia_** **Complications**: * anemia, stroke, * **acute chest syndrome-** lead to sig pulm failure * A vascular occlusive crisis in the lungs leads to acute chest syndrome (ACS). ACS is leading cause of death and second most common complication in sickle cell disease. * , myonecrosis, CHF, MI, splenic sequestration, retinal hemorrhage, hematuria, ESRD, seizure, wound infection, UTI, and unexplained death

Answer 35

**AVOID:** * **Dehydration** * **Stasis** * **Hypoxia** * **Hypothermia** * **Acidemia** * **pain** ANY OF THESE LEADS TO → **Vaso-occlusive crises** * Vaso-occlusive crisis → lead to subsequent end-organ ischemia * Ex: Bone, chest, brain- may have significant sequelae from previous crises

Answer 36

**Pre-op:** * **warm, well-oxygenated, and hydrated!** * Thorough multi-system assessment * may have chronic pain, hx of stroke, pulmonary complications from infection or acute chest syndrome, anemia, infections, renal disease, AVN of hips * Consult hematologist preop: * Possible _preop transfusion to target hgb (10 g/dL)_ * ensure pre-op hydration- admit night before to hydrate * _IV access can be challenging_ Intra-op: * Maintain euvolemia & normothermia * avoid tourniquets Post-op: * Adequate IV hydration; early mobilization and incentive spirometry; supplemental O2; consider multimodal analgesia (many are opioid tolerant)

Answer 37

* Blood relative or muscle biopsy * **Technique:** * **First case of the day** * Remove vaporizers from machine * flush per manufacturer guidelines (w/ charcoal filter) * Use trigger-free anesthetic: propofol, opioids, BZD’s, NDNMB’s, N2O, regional * **Mandatory Monitoring:** * EtCO2\* * increased etCO2 earliest indicator * temp monitoring\* * MH-susceptible children can have outpatient procedures as long as trigger-free anesthetic is used \* (no Succs or VA)

Answer 38

* Definitions for obesity in children are based on BMI * obesity = BMI \>95th percentile * morbid obesity= BMI \>99th percentile * IBW calculation for children: * **\< 8 years: 2 x Age (years) + 9** * **\>8 years: 3 x Age in years** * LBW calculation**= IBW + 1/3(TBW-IBW)**

Answer 39

* Consequences: * Restrictive pulmonary pattern * Increased O2 consumption * decreased chest wall compliance * FRC * vital capacity * CV effects: * Htn * LVH * premature atherosclerosis * Insulin resistance is common

Answer 40

* Drug dosing is complex (see chart)\*\* * Ex: Induction * TBW: succs, sugammadex * Technique: * **Airway:** * position HOB 25 degrees * plan for possible difficult mask ventilation * note rapid desaturation * Consider Desflurane for maintenance (least fat soluble) if airway reactivity is not a concern

Answer 41

* Lung development **begins in utero** at approximately **4 weeks’** gestation but lungs are functionally immature until nearing term * **occurs in five stages:** * embryonic, * pseudoglandular, * canalicular, * saccular, and * alveolar * growth of the pulmonary parenchyma and surfactant system occurs during the **_saccular phase occurring from week 24 through week_** **40** (36 weeks: magic # for surfactant) * maturation & expansion of alveoli occur during the alveolar period which begins near term & continues to mature through childhood * *24 mil alveoli at birht, 300 mil by age 8* * *surfactant can be adminitered via ETT in premie infant* * Alveoli must transition from **fluid filled** state to **air-filled** (gas exchanging) parenchyma

Answer 42

Respiratory system newborn variations: * Diaphragm is **flatter**; * **more** **compliant** **chest** with cartilaginous ribs; * **poorly** **compliant** **lungs**; may see paradoxical breathing; * *paradoxical breathing= inward movement of chest during inspiration* * predominantly **nose** breathers until **4 weeks of age**; * chest circumference very close in size to head circumference at birth

Answer 43

Also called **Persistent Pulmonary Hypertension of the Newborn** * PA pressures abnormally **elevated** causing the **ductus arteriosus & foramen ovale** to **remain** **open (or re-open)**: * leads to hypoxia due to **_R to L shunting_** * **Hypoxia & acidosis** with concurrent inflammatory mediators are **primary causes** * **Precipitating conditions:** * severe birth asphyxia, * meconium aspiration, * sepsis, * congenital diaphragmatic hernia, * mom’s use of NSAIDS, * idiopathic * Response to treatment is **unpredicatable** * Initial tx: **provide optimal oxygenation** * ****(PaO2 60-100, * correct stressors like hypoglycemia or polycythemia * Other tx: surfactant, **inhaled nitric oxide**, HFOV, ECMO * *inhaled nitric oxide only FDA approved treatment*

Answer 44

* **Period of vulnerability:** * **Hypoxia (acidosis)** * **Hypercapnia (acidosis)** * **Hypothermia** * **Infection** * **Prematurity** * Preterm infants: ductus arteriosus may remain open for several weeks & can cause hemodynamic instability 1. tx: prostaglandin inhibitor (indomethacin) 2. surgical ligation * ex: if see sudden hypoxia \< 10 days old → suspect flip flow circulation occurring * tx: hyperventilate & hyperoxygenate – difficult to correct * Phenomenon leads to sudden increases in pulmonary artery pressure and shunting of blood past the lungs through a patent foramen ovale or the ductus arteriosus, which may reopen, particularly during th**e first 10 days of life**

Answer 45

APGAR scoring: * five signs measured/observed in neonates **1 minute & 5 minute**s after delivery * **PREDICTIVE** on neonatal **distress** and **need for intervention** * Components: * **Most important:** * heart rate * HR \< 100 bpm: signifies arterial hypoxemia * quality of respiratory effort * **Least informative:** * color – * healthy neonates have acrocyanosis @ 1 min from cold ambient temps (peripheral vasoconstriction) * Persistent cyanosis- acidosis and pulm vasoconstriction most likely causes * Scores 3–7: **Mild to moderately depressed function** * may respond to oxygen administration by face mask * with or without positive pressure ventilation * Score _\<_ 3: **CONCERN** * consult NRP algorithm Score 0-10

Answer 46

Initial actions for newborn in distress: * Clear infant airway * Warm/dry them * Stimulate * Position- sniffing * Evaluate: HR, respirations, color * Ex: labored breathing and persistent cyanosis- suction * HR \< 100 bpm- assist w/ PPV * HR \< 60: intubate, PPV, chest compressions * O2 & chest compressions not effective → IV Epi

Answer 47

* assess mucous membranes; * look at tongue size/ mobility- look at frenulum of tongue (impact feeding); * *a short tight lingual fenulum attached to inferior tip of tongue may impede movement of tongue and breastfeeding* * evaluate chin (retrognathia?- diff intubate); * nasal patency/ discharge; * intact hard and soft palate?; * presence of natal teeth (\< 1 mo old- fall out easily)? * *teeth that erupt in first month of life, typically central incisors* * *similar to normal teeth but lack developed root system and may fall out* * *no indication for removal unless concern for aspiration or interference with feeding* * unrestricted neck movement * congenital torticollis- means that a baby is born with an odd position of the neck. The odd position is because of a tight, short neck muscle

Answer 48

* assess for tachypnea, flaring grunting, retractions * respirations may be “regularly irregular” with pauses (**pauses should not last \>20 seconds)** * Periodic breathing: more common in infants, particularly preterm infants; probably due to inadequate development of the medullary respiratory centers * Assess length of pause * assess clavicles * Clavicular fractures are a common birth injury occurring in 0.2%–3.5% of births. Usually left untreated * assess upper & lower extremity pulses 1. risk of CHD- impact perfusion to extremities * Murmurs common in newborns 1. Systolic murmur- *not as concerning* 2. Diastolic murmur – concerning!! * PDA: murmur best heard along the left lower sternal border

Answer 49

* Neuro assessment: * Posture, * muscle tone, * movement, * seizure activity; * head control, * quality of cry; * response to light and sound; * fontanelles (Anterior and posterior) * Back: Spinal contour; presence of cysts, sinuses, dimples, tufts of hair * ·Musculoskeletal: * Normal: Inward flexion resting position of upper and lower extremities * Abnormal: rigidity or extension *

Answer 50

* Larger volume of distribution: increased dose for water soluble meds * Ex: AntiX and Succs * Decreased protein binding: increased free fraction of primarily protein bound drugs * Ex: More drug available to exert effects * Decreased body fat percentage: higher levels of drugs that are primarily redistributed to muscle and fat * Less redistribution that takes place * Immature renal and hepatic function

Answer 51

* Versed and opioids combined in neonates can lead to severe hypotension- titrate carefully * Propofol: variability in elimination in neonates and preterm infants * may see longer elimination times * Morphine clearance directly correlated with gestational age * r/t immaturity of kidneys * → reduce frequency of admission * Remifentanyl has similar PK to older children making it a reliable choice for an intraoperative opioid * Independent of liver/kidneys * Sch dose increased * **DOSE: 3 mg/kg** * **Pretreatment: w/ atropine** * NDNMB: * have significant variability and unpredictability in this population- titrate carefully * Will always need reversal in neonates\*\* * Vecuronium: considered a “long acting” NDNMB in infants \<1 yo due to liver immaturity * Cisatracurium produces reliable recovery due to Hoffman elimination * TEMP & PH MUST BE NORMAL * laudanosine → can decrease seizure threshold * Lidocaine has a longer half life and volume of distribution in the neonate

Answer 52

* Historic tx: ETT immediately after delivery with suctioning of meconium from newborn’s airways * Roughly 10% of newborns have meconium staining- routinely intubating all leads to complications of advanced airway in many who do not need it. * **Currently tx:** more conservative * NRP guidelines updated (2010): do NOT recommend routine oropharyngeal/nasopharyngeal suctioning with either **clear** or **meconium-stained amniotic fluid** * Endotracheal **suctioning** IS indicated for **nonvigorous** meconium-stained newborns * Recommendation: meconium present → * Tx: * 1^st: orally suction * vigorous & crying- no further action. * If still depressed: * intubate & suction * If vigorous → pull the tube and reintubate (don’t want merconium in tube) * If not → keep tube → move to PPV. **Recommendation**: meconium present- 1st orally suction, if vigorous and crying- no further action. If still depressed then intubate and suction- if then vigorous, pull the tube and reintubate. If not- keep tube and move to PPV.

Answer 53

* Primary Cause: Lack of surfactant * decreased number of branching airways and alveoli * atelectasis * impaired gas exchange * hypoxemia * poor lung compliance & propensity for alveolar collapse * Incidence inversely proportional to gestational age & birth weight (\< 36 wks → more likely to have RDS b/c less surfactant in alveoli) * S/S: * Tachypnea * Tachycardia * Cyanosis * Grunting * Retractions * flaring * Tx: surfactant (delivered via ETT)Anesthesia: Limit hypoxemia while avoiding hyperoxia * follow ABG’s * Consequences: * Long term: bronchopulmonary dysplasia * Surfactant **initially appears at 23 to 24 weeks** and increases in concentration during the last **10 weeks.** * Surfactant is released into the alveoli at about **36 weeks’ gestation,** thus making normal extrauterine life possible.

Answer 54

* Abnormal embryogenesis (formation) of neuroectodermal cell linen → obstructing nasal passage * functional atresia may also occur resulting from obstruction (blood, mucus, or meconium) * ~90%: bony * 10% : membranous **Considerations**: * Nasal obstruction should be suspected when good breathing efforts but in whom air entry is absent * Recall- infants are obligate nasal breathers 1. 40% of term infants can convert to oral breathing if nasal airway is obstructed (60% cant) 2. 5 mo- Almost all infants can easily convert to oral breathing *

Answer 55

s/s: * cyanosis (develops if these infants are forced to breathe with their mouths closed) * Respiratory distress at birth * worsen w/ feeding * Improve w/ crying (bc breathing out mouth) * Airway obstruction * stridor * paradoxical cyanosis (normally, newborns turn pink when crying as they begin to breathe through their open mouth). * 1/2 of children with choanal atresia have other congenital issues -- *also look for ear defomiries. can be s/s of other congenital syndromes* * **CHARGE** association: * Coloboma- eye deformity * heart disease * atresia [choanal] * retarded growth * genital abnormalities * ear deformity * Unilateral atresia: rarely a surgical emergency, * often intervention can be delayed. * **Dx**: Unilateral or bilateral choanal stenosis * based on inability to pass a small catheter through each nare * **Tx**: * Congenital choanal atresia requires surgical treatment during the neonatal period * Use of an oral airway may be necessary until surgical correction can be accomplished * Functional choanal atresia is treated by nasal suctioning

Answer 56

* Herniation of abdominal viscera through a defect in diaphragm * Locations of Herniations: 1. Foramen of Bochdalek (on the left side): most common site 2. Anterior foramen of Morgagni herniation: occurs in only 2%. * **Consequences**: Lungs are underdeveloped d/t compression in utero * Alveolar & Vascular hypoplasia * **S/S:** * Severe respiratory distress at birth * Cyanosis * scaphoid abdomen (collapsed abdomen) * Chest x-ray: abdominal contents in thorax * Associated anomalies (40%-50% pts) 1. CNS- meningomyelocele 2. CHD- most common * Initial treatment in delivery room: * avoid aggressive mask ventilation * urgent intubation * decompress stomach * maintenance of PaCO2 \<40 * optimal oxygenation * **Problems**: must avoid **iatrogenic volutrauma** (over ventilating)!!! * **High risk pneumothorax** on the side opposite the hernia if attempts are made to expand the **ipsilateral lung** * **Hypoxemia** secondary to **pulmonary hypoplasia & pulmonary hypertension** * **Hypotension** d/t **overdistention** of **stomach** & mechanical kinking of great vessels

Answer 57

* Tx: * Supportive care rather than immediate surgery after birth: ECMO, HFOV, & nitric oxide (manage PHTN) * Management: * awake intubation without positive pressure ventilation * adequate IV access * a-line * opioids * muscle relaxation * maintain optimal oxygenation (PaO2 \>100) * ventilation * avoid nitrous oxide (d/t bowel distention) * anticipate ICU postop

Answer 58

* Inversely proportional to gestational age * Immaturity of the respiratory control centers of the brainstem → decreased sensitivity to elevations in CO2 * Both central apnea & obstructive apnea * Dx: * apneic periods \>15-20 seconds * apnea with HR \< 80-100 * apnea with desaturation * Tx: * Methylxanthines- primary tx * Others: * aminophylline * caffeine

Answer 59

* The most common problem in newborns & young infants * Patho: * Early in gestation, the fetal liver begins to store glycogen while a continuous supply of glucose is delivered by transplacental transfer from the mother. * In the third trimester, glycogen stores begin to develop in fetal skeletal and cardiac muscle, as well as in the kidneys, intestines, and brain. (but still immature) * Birth → neonatal glucose concentrations decrease rapidly to 30 mg/dL w/in 1st 1-2 hrs * → stimulates glycogenolysis & gluconeogenesis * → glucose flux usually stabilizes at values \> 45 mg/dL by 12 hours post birth

Answer 60

* **S/s:** * Hypotension * Tremors * Seizures * can be masked by anesthesia * Other sx: respiratory distress, apnea, cyanosis, high-pitched cry, irritability, limpness, lethargy, eye-rolling, poor feeding, temperature instability, and sweating * **Highest risk:** Infants with intrauterine growth restriction; diabetic mothers; severe intrauterine fetal distress * Premature infants: * prone to hypoglycemia owing to immature glucoregulatory mechanisms, * reduced levels of glycogen storage, * increased energy demands, * limited adipose stores (reduced free fatty acids and ketones available as alternative sources of energy) * Also at risk: Full-term infants who have been excessively fasted, small-for-gestational-age (SGA) infants, and infants of diabetic mothers

Answer 61

* **Full term neonates:** 1. **\< 40 mg/dL glucose [] during 1^st 24 hours after birth** 2. **\< 60 mg/dL at 36 hours** * **Premature infants:** 1. **\< 45 mg/dL at 1^st 24 hrs** 2. **\< 50 mg/dL \> 24 hrs after birth** * Prevention: * 1^st 48 hours MIVF: * contains 10% glucose in 0.2% saline with 20 mmol/L K * \> 48 hours: * 5% glucose supplementation is usually okay * preterm infants will have increased requirement

Answer 62

* Acute dose: bolus 0.25 - 0.5 g/kg (1–2 mL/kg of **D25 W** or 2.5–5 mL/kg of **D10 W**) 1. → then increase glucose in MIVF (to prevent stimulation of insulin production) * A **single bolus** of **glucose** without **subsequent** **infusion** can **stimulate** **insulin** production with consequent return to the hypoglycemic state * All other fluids (e.g., to replace third-space losses, blood loss, and fluid deficits) should be glucose-free to avoid **hyperglycemia** * Check blood sugar frequently * TPN- do not stop suddenly without bridging with a glucose containing fluid

Answer 63

* 3 forms of Ca in body: * 1. Protein bound * 2. Chelated to bicarb, phos, and citrate * 3. Free or Ionized- physiologically active component * Not always clear relationship b/t total serum Ca and iCa (correlation is poor with hypoalbuminemia or acid-base disturbances, as seen in premature and critically ill neonates) * Hypocalcemia: * iCa: \< 1 mmol (in both premature and neonate pop) * Hypocalcemia is defined as a **total** serum calcium concentration less than **8 mg/dL** (**2 mmol/L**) in **full-term infants** and less than **7 mg/dL (1.75 mmol/L) i**n **premature** infants. **An iCa 2+ less than 4 mg/dL (1 mmol/L**) defines hypocalcemia in both populations. * At birth → abrupt loss of maternal calcium * by 3^rd day of life, serum calcium concentrations in the full-term neonate to return to normal * Infants who are born prematurely do not benefit from the transfer of maternal calcium * Hypocalcemia present in nearly 40% of critically ill neonates * Causes: PTH insufficiency, inadequate calcium supplementation, and altered calcium metabolism caused by transfusion with citrated blood products, bicarbonate administration, or diuretics (e.g., furosemide) * Hypocalcemia s/s: * asymptomatic or… * nonspecific symptoms such as neuromuscular irritability (myoclonic jerks, exaggerated startle, or seizures), tachycardia, prolonged QT interval, and decreased cardiac contractility

Answer 64

* Tx: * Slow IV infusion over 5-10 min w/ → (2 txs) * **1. 90 mg/kg calcium gluconate** * May be given IV but is vesicant!! (tissue necrosis and subcutaneous calcification deposits with extravasation) * **2. 30 mg/kg calcium chloride** * Infused through central line\*\* * **Monitor for bradycardia!!!** (seen with rapid increases in the serum concentration of calcium) * Consider need for Magnesium supplementation as well

Answer 65

* Hernial protrusion of a part of the meninges and **spinal cord** through a defect in the vertebral column * To protect the defect, it is placed on a “**doughnut**” and towels are placed under the head * Anesthesia: * Plan for **positioning** for intubation to **protect defect** * Anticipate larger **insensible losses** – membranous sac * High possibility of hydrocephalus * Possibility of **cranial nerve (vocal cord) palsy** leading to respiratory distress/ stridor * Potential for brainstem **herniation** * Higher incidence of **latex allergy:** 1. always use latex precautions * Meningomyelocele usually have an **_Arnold-Chiari malformatio_**_n_ and may have **stridor from vocal cord paralysis** * caudal displacement of the medulla * treatment: 1. relief of the hydrocephalus 2. possible cervical decompression of the herniation 3. tracheotomy and long-term mechanical ventilation may be required (if VC paralysis)

Answer 66

* The **inability to swallow amniotic fluid** in utero results in **polyhydramnios** * Five plus different configurations * esophageal communication with trachea causes aspiration pneumonitis * Suspect in polyhydramnios * **Esophageal atresia**: the esophagus ends in a blind pouch * **s/s:** Copious amounts of oropharyngeal secretions are usually present * **Diagnostic** test: inability to pass a suction catheter into the stomach * Suspect other anomalies: * VATER association ( V , vertebral; A , anal; TE , tracheoesophageal; R , renal) or * VACTERL association (VATER and C , cardiac; and L , limb). * Echocardiogram advised before anesthesia Prematurity and polyhydramnios are associated with TEF. The inability to swallow amniotic fluid in utero results in polyhydramnios

Answer 67

* **Classification by Gross** * **Type C is the most common (~ 85% of TEFs)** A—Esophageal atresia without fistula B—Esophageal atresia with communication of the upper esophageal segment to the trachea C—Esophageal atresia with communication of the lower esophageal segment to the trachea D—Esophageal atresia with both upper and lower esophageal segments communicating with the trachea E—No esophageal atresia but TEF F—Esophageal stenosis without fistula

Answer 68

* Anticipate presence of aspiration pneumonia * may have to receive treatment before stable for surgery * g-tube may be placed for nutrition * Airway management: * withhold feedings * place soft suction in esophagus to drain saliva * position prone in a head-up position * Plan: 1. awake intubation with sedation (fentanyl/ versed/ topicalization) 2. Intentional right mainstem then back out to Bil BS → hope is that ETT is past fistula * **ETT placement is CRITICAL**- it is possible to ventilate one lung, both lungs, and/or the fistula depending on tube placement with 1-2 mm movement * Ventilation: 1. **spontaneous assisted ventilation** → best to avoid stomach over distention until the fistula is ligated or g-tube placed * SpO2 placement should be pre-ductal and post-ductal * Consider left precordial stethoscope (under left axilla) * continuously monitor for endobronchial intubation * May require postoperative ventilation but may trial extubation depending in surgeon preference * Postoperative pain may be managed with a caudal catheter Miller suggestion: 0.5 to 1 μg/kg of fentanyl and 25 to 50 μg/kg of midazolam and topicalizes the tongue, larynx, and vocal cords with no more than 5 mg/kg of lidocaine (1.0%) Stomach can rupture if large volumes of air are being instilled with positive pressure ventilation

Answer 69

* Major defects in the closure of the abdominal wall that result in exposure of viscera * **omphalocele:** covered by peritoneum * **typically ass.** w/ anomalies (very sick) * **W/in umbilical cord** * **gastroschisis**: not covered by peritoneum * not ass. w/ anomalies * **periumbilical** * Complications: * severe dehydration and massive fluid loss from the exposed visceral surfaces * heat loss * complex surgical closure * High association with prematurity and other congenital defects * cardiac abnormalities common (omphalocele ∼20%)

Answer 70

* ECHO before anesthesia * Anticipate need for postop ventilation * May be a staged repair 1. Early repair: reduces the potential for infection and compromise of bowel function; minimizes fluid & heat loss * Must optimize fluid and electrolyte balance before surgery * Obtain good IV access 1. anticipate need for TPN postop- central line placement * Expect invasive monitoring if associated cardiac defect is present * Expect liberal use of muscle relaxants for closure of the defect * Anticipate hypotension secondary to tension on a major organ (liver) or caval compression (tight space fitting everything) * Increased abdominal pressure after a tight closure 1. Impairs ventilation 2. Risk of **abdominal compartment syndrome** → may alter hepatic/ renal function & metabolism * Omphalocele has association with Beckwith-Wiedemann syndrome * → profound hypoglycemia, hyperviscosity syndrome, congenital heart disease, and associated visceromegaly

Answer 71

* The **absence** of **parasympathetic** ganglion cells in the large intestine- a **nonperistaltic** segment in gut of variable length, a **tonically contracted anorectal sphincter, and delayed passage of meconium** * Functional obstruction occurs at the level of the affected segment * ~ **60**% of patients will have an **associated anomaly**. * S/S: * consistent with bowel obstruction * bilious vomiting * abdominal distention * Left untreated it can lead to **toxic megacolon** * Tx: * volume replacement * vasopressor support * Surgical repair * varies: anorectal myomectomy, mucosal resections, diverting colostomies, and transanal pull-throughs

Answer 72

* Lower GI obstruction usually develops 1-7 days after birth * Ex: Imperforate anus, duodenal atresia, jejunoileal atresia, intussusception, malrotation, volvulus, choledocal cyst, meconium ileus * **S/s:** Vomiting secondary to obstruction → fluid shifts * Increased intra-abdominal pressure can lead to respiratory compromise * **Management**: * Optimize pre-op: 1. Na+ 130mEq/L 2. UOP 1-2 ml/kg/hr * **Anesthesia**: * fluid and electrolyte resuscitation * full stomach precautions (awake intubation or RSI) * N2O avoided * adequate muscle relaxation req * consider remifentanil infusion if planning to extubate → indep of renal/liver for metabolism * Look for other congenital anomalies: * association w/ trisomy 21, cystic fibrosis, imperforate anus, or renal abnormalities

Answer 73

* Not a surgical emergency, correct metabolic derangement before surgery * normally revealed in the first 3 to 6 weeks of life * have severe projectile vomiting * **Considerations**: ALL electrolytes/fluids SHOULD BE CORRECTED * full stomach * metabolic alkalosis with hypochloremia and hypokalemia * sodium deficits * severe dehydration * **Management**: * NGT BEFORE induction: suction stomach in the supine and the right and left lateral positions * Awake intubation or RSI w/ cricoid pressure after → * atropine (0.02 mg/kg) * propofol (3 mg/kg) * succinylcholine (2 mg/kg) administration

Answer 74

Necrotizing enterocolitis * Typically affects **premature infants** but may be seen in term newborns * Patho: immature intestine has **decreased absorptive ability** leading to **stasis** 1. the stasis promotes bacterial proliferation and sepsis; * **ischemia and infection c**an lead to intestinal **necrosis** and **perforation** * Medical management: * NPO * Antibiotics * OG tube * F&E * hemodynamic support * Unresponsive to medical management: **Ex lap** * **_Extremely ill patient_** 1. **RSI** with cardiac stable agent (ketamine) 2. caution with Sch if hyperkalemic from dead bowel * 25-50% mortality * Maintenance: 1. avoid nitrous oxide 2. very judicious with inhalational agent if unstable (use opioids as primary anesthetic) low VA 3. Anticipate need for blood products; expect massive fluid losses 4. Anticipate postoperative continuation of intubation and ventilation

Answer 75

* Neonatal (term and preterm) response to muscle relaxants _varies greatly from patient to patient_ * **Best practice: titrate to response** * Dose: 1. reduce 30%-50% trach intubation dose w/ potent inhaled agent * atracurium/ cisatracurium: advantage is Hoffman elimination since renal/ hepatic are immature * vecuronium: **very prolonged duration** in newborns (approaching pancuronium) 1. good b/c no histamine

Answer 76

* Landmarks: * Coccyx * the two sacral cornua * posterior superior iliac spines * The sacral cornua are identified. * A styletted needle is introduced into the caudal space through the sacral hiatus. * A “pop” is felt as the sacrococcygeal ligament is accessed. After aspiration, 0.8 to 1 mL/kg of local anesthetic solution is injected. * Most common: 0.125% bupivacaine, 0.25% bupivacaine, or 0.2% ropivacaine. Epinephrine, 1:200,000, is added for recognition intravascular injection * This provides analgesia for hernia repair, circumcisions, and lower abdominal surgeries * Analgesia lasts 6-8 hours

Answer 77

* Always have a range of sizes of airway equipment (face masks, OPA’s, ETT’s, LMA’s, blades) * Need size up and size down from anticipated size * Straight blades are most commonly preferred in infants due to anatomical differences (get both out) * Appropriate size LMA should always be available even if intubation is planned in case of unanticipated difficult airway * Ensure appropriate sized BP cuff and pulse oximeter is present & functional * Calculate drug doses, allowable blood loss, & fluid requirements * Have primed bag of IV fluid ready and all supplies to start & _secure_ IV set up & accessible * Prepare a pediatric circuit/bag * 0.5, 1, 2 L bag → use peds circuit if \< 5-8 yo * If can pull TV \> than volume of bag → negative pressure in system (switch over to bigger bag) * Preset vent settings appropriate for size (& program in weight to anesthesia machine if applicable) * Pressure control better * Volume control- TV/kg can be calculated * Appropriate sized mask- injury, eyes, bad seal, VAGAL response! * **Emergency drugs for every pediatric case:** * **Sch & Atropine** **+ IM needle**: Weight appropriate doses with a small gauge needle appropriate for **IM injection** * Laryngospasm, take on every transport * **Propofol syringe** – have backup * facilitate intubation, break laryngospasm, increase depth of anesthesia quickly * **Epi diluted to 10mcg/ml**: not always drawn up but definitely consider drawing up in a sick patient/ complex case (cardiac arrythmias→ bradycardia not responsive to O2—ex: O2 typically primary tx ) * **Comes 100 mcg/ml** → need to dilute down to 10 mcg/ml * Plan for age appropriate distractions: have flavors for masks; consider parental presence if facility allows (cover supplies to hide anxiety) * Warm the room

Answer 78

* **Sniffing position is critical – no hyperextend neck** * **Tongue bigger/oral AW smaller** **→** prone to obstruct * **Align oral, pharyngeal, laryngeal axis – slightly displace mandible forward/neutral** * **Put little pillow behind to put nose to ceiling** * **Shoulder roll** * Avoid pressure on the soft tissue in the submental triangle – might cause obstruction * Jaw thrust * Low threshold for 2-person ventilation

Answer 79

Inhalational induction is common: seated or supine position One approach: * Higher flows with 70% N2O and 30% O2 (7L N2O and 3L O2) * Fully open APL * Allow a few breaths of N2O mixture and then incrementally turn on Sevo to 8% (some providers turn up sevo to 8% without using incremental technique after a few breaths of N2O- especially if crying) * Turn off N2O to provide 100% O2 * Assist spontaneous ventilation PRN- **caution about high inspired volatile agent with assisted or controlled ventilation (keep spontaneously breathing!)** * **Decrease inspired anesthetic if need to ventilate** * *****do not want to get to this point!* * Obtain IV * Once IV is in, induction proceeds- give some propofol, narcotic, +/- NMB, etc at this point and then proceed with airway management appropriate for case (LMA, ETT) * NOTE: intubation is often completed without NMB’s * Be sure to turn down Sevo to normal MAC range for the child; watch VS closely during induction

Answer 80

* Same principle as adults to prevent aspiration * Cricoid pressure in infants/ children is **+/-** (Barash says no) → increased likelihood of obstructing an infants airway with little proven benefit * Note that children will have rapid desaturation with hypoxia (limited reserve) and often hard to preoxygenate an uncooperative child * Equipment: ETT (pre-stylet) age calculated plus 0.5 smaller & 0.5 larger; laryngoscope (working), _suction immediately available at HOB_, functioning IV, pre-drawn drugs * Propofol 2-4 mg/kg (stable) vs. ketamine 1-2 mg/kg or etomidate 0.2-0.3 mg/kg (unstable) * *plus* Sch 2 mg/kg **(premed with Atropine 0.02 mg/kg)** * consider Rocuronium 1.2 mg/kg if Sch contraindicated (45 to 75 minute duration) * **Calcium (IV) should be immediately available in the event Sch leads to unanticipated hyperkalemia w/ ventricular arrhythmias** * **Succs used in DAW patient** **→** **have Ca available** the younger the pediatric patient, the less reserve they have

Answer 81

* Mask management is more critical skill in peds airway * Always have ranges of ETT sizes * (0.5 smaller than calculated & 0.5 larger) * Short trachea favors right mainstem intubation * Breath sounds are often referred → bilateral chest rise and fall/w/ sounds * **Common formula over 2 yo** * **_(Age + 16)/4_** * Cuffed tubes: reduce size by 0.5 mm * Cuffed tubes are fine as long as cuff pressures are monitored * Rough estimate of depth is 3x ID * Ex: using 4 tube → depth should be 12 cm * A leak should be maintained around cuff regardless @ 20-30 cmH20 (not want pressure on trachea) * If turn APL to 20, should hear leak * If leak at 10- will be polluting OR and wont get TV

Answer 82

* One of the most common abdominal emergencies * most likely in teen years * \> 24 hrs delaying dx → increased risk perforation * s/s: classically RLQ pain * Risks of intraabdominal perforation: * Abscess * Ileus * sepsis **Considerations**: * Aspiration risks * active nausea and vomiting * tachycardia due to pain, dehydration, or sepsis **Management**: * Preop IV antibiotics w/ **gram negative** coverage * correct fluid deficits * use full stomach precautions – RSI * evacuate stomach with NG/ OG

Answer 83

* 3rd copy of chromosome 21 * 1:1000 live births * increased incidence in moms over 35 * **Physical exam findings**: Midface hypoplasia, brachycephaly, epicanthal folds, simian crease, downward medial slant of eyes, high-arched palate, glossoproptosis, and murmur (DAW) * May require surgery for tympanostomy, strabismus, CHD repair, duodenal/esophageal atresia, marrow aspiration/biopsy, cervical spine fusion * Considerations: * \*\*5-fold risk **of bradycardia** during Sevo induction (first 6 minutes) in children with Downs (Barash) * Difficult intubating d/t macroglossia & glossoproptosis * Difficult masking d/t midface hypoplasia * Chart → * Keep neck neutral (d/t subluxation of C1/2)

Answer 84

* Airway * Have variety of devices available (e.g., oral and nasal airways, laryngeal mask, glidescope, fiberoptic) to manage airway obstruction. * Avoid neck extension during laryngoscopy if possible. * Smaller endotracheal tube may be necessary for narrowed subglottic space. * Vascular Access * Meticulously avoid injected air due to likelihood of CHD * Anticipated Problems/Concerns * **Bradycardia** with inhalational induction (sevo) * Resistance to separation from caregiver