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AP: Summer Exam 3 > Pediatric Pearls > Flashcards

Pediatric Pearls Flashcards

1
Q

Why are pediatric pts temperature regulation different? (4)

A

Low body fat content
Thin skin
Increased BSA
Neonates unable to shiver

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2
Q

What is the typical pattern of hypothermia during anesthesia for pediatric pts?

A

Loss from core to periphery
Heat loss to the environment

Note: Phase C indicates rewarming.

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3
Q

Almost ALL of pediatric codes are ______ in origin.

A

respiratory

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4
Q

What % of pediatric cardiopulmonary arrest are primarily due to respiratory distress and occur at < ___ y/o?

A

80%

1

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5
Q

What are statistics to heed by ASAs 1990 closed claim project? (4)

A
  • Respiratory events were the largest class of injury
  • More common in children
  • 92% of claims occurred between 1975-1985
  • Brain damage and death in 85% cases but improved with pulse ox and CO2 monitoring
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6
Q

What are anatomical differences in the pediatric airway? (5)

A
  • Large head, tongue, tonsils, and adenoids
  • Anterior, cephalad larynx
  • Long, floppy epiglottis
  • Funnel-shaped larynx
  • Loose teeth (5-8 y/o)
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7
Q

When does obligate nasal breathing subside?

A

3-5 months

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8
Q

Where are the vocal cords located in an:

premature infant
infant
adult

A

middle of C3

C3-C4

C4-5

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9
Q

What are the consequences of a pediatric pts larger tongue? (3)

A

Airway obstructed easily
Difficult to visualize
Miller blade preferred

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10
Q

What is different in an infants vocal cords?

What is the consequence of blindly placing ETT during nasal intubation?

A

More angled attachment to trachea than adults VC that are more perpendicular.

ETT easily lodges into anterior commisure.

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11
Q

What is the difference in the epiglottis in infants vs. adults? (2)

A

More omega shaped
More angled away from axis of trachea

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12
Q

What are common MAC and Miller blades in peds?

A

MAC

  • 1
  • 2
  • 2 1/2
  • 3

Miller

  • 0,0 (premature newborn)
  • 0
  • 1
  • 1 1/2
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13
Q

How do you size the diameter of an endotracheal tube?

A

4 + age/4

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14
Q

Where do you tape the tube?

A

12 + age/2

Note: More importantly listen for bilateral breath sounds and tape tube well since slight movement can be devastating.

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15
Q

What is the most you can inflate the cuff in a peds tube?

A

1 - 1.5 cc

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16
Q

Traditionally, uncuffed ET recommended in children < ____ y/o to prevent post-extubation ______ and ________.

A

8

stridor

subglottic stenosis

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17
Q

What is the argument againsted CUFFED ETT? (4)

A

Smaller size increases a/w resistance
Increased work of breathing
Poorly designed for pediatric patients
Need to keep cuff pressure < 25 cm H2O

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18
Q

What are the arguments against UNCUFFED ETT? (4)

A
  • More tube changes during long-term intubation
  • Leak of anesthetic agent to environment
  • More FGF > 2L/min required
  • Higher risk for aspiration
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19
Q

What is the effect of edema?

A

If radius is halved, resistance increases 16x.

Note: Poiseuille’s law

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20
Q

For short cases when ETT size > ____, choice of cuff vs. uncuffed probably does not matter.

A

4.0

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21
Q

In what cases is a cuffed ETT preferred? (3)

A

Increased risk of aspiration (bowel obstruction)

Low lung compliance (ARDS, pneumoperitoneum, CO2 insufflation, CABG)

Precise control of ventilation (increased intracranial pressure, single ventricle)

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22
Q

What are the complications of endotracheal intubation? (2)

A

Stridor –Postintubation croup (Occurs in <10%)

Subglottic stenosis (laryngotracheal )(Occurs 90% of prolonged intubations)

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23
Q

What are the risk factors for postintubation croup (aka stridor)? (6)

A

Large ETT
Change in pt position intraop
Multiple attempts at intubation
Pts < 4 y/o
Surgery > 1 hour
Coughing on ETT

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24
Q

Ischemic injury caused by lateral wall pressure of larynx leads to what? (3)

A

Edema

Necrosis

Ulceration of mucosa

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25
Q

What are respiratory development considerations in pediatric pts? (4)

A

Weak intercostals/diaphragmatic muscles –> less efficient ventilation

Incomplete alveolar maturation

Increased chest wall compliance –> less efficient ventilation

Limited O2 reserve during apnea

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26
Q

What is the FRC in pediatric patients?

A

28-30 cc/kg

Note: Infants also have increased O2 demand and metabolism leading to faster desaturation.

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27
Q

What is the oxygen consumption of an infant vs. an adult?

A

Infant: 6 ml/kg/min

Adult: 3.5 ml/kg/min

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28
Q

Greater O2 consumption in infants leads to what?

A

increased inspiratory rate

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29
Q

How does the FRC of an awake infant compared to an adult?

A

Both are similar when normalized to body weight.

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30
Q

The ratio of alveolar minute ventilation to FRC is _____ in infants.

A

doubled

Thus, with hypoxia, apnea, or GA in an infant the FRC is diminished quickly.

31
Q

Chemoreceptors are developed in the term newborn thus hypercarbia will stimulate ventilation. True or false?

A

True

32
Q

Infants fatigue faster because they have fewer Type ___ muscle fibers.

A

I

Note: Type I slow twitch fibers are more efficient as using oxygen for fueling the muscles.

33
Q

Until age 2-3 weeks, hypoxemia causes a _______ increase in ventilation followed by a _______ depression.

A

transient

sustained

Note: By after 3 weeks after birth, hypoxemia induces sustained hyperventilation.

34
Q

Newborns respond to hypercapnia by increasing ventilation but _____ than older infants.

A

less

The CO2 response curve increases with gestational age.

35
Q

What are important points during the airway evaluation and medical history for a pediatric pt? (8)

A

URI
Snoring / noisy breathing
Allergies
Asthma
Cigarette smoke exposure
Productive cough–may indicate bronchitis, pneumonia
Pneumonia–indicates GERD, immune suppression
Previous problems with anesthesia

36
Q

What are signs of impending respiratory failure? (12)

A

Increased work of breathing
Tachypnea/tachycardia
Nasal flaring
Grunting
Wheezing
Stridor
Agitation or altered consciousness
Retraction of muscles / use of accessory
Irregular breathing or apnea
Diaphoresis
Inability to lie down
Head bobbing

37
Q

Immature myocardium at birth results in: (4)

A

Fewer organized myocytes
Less contractile tissue
Less compliant ventricles
Neonates are HEART RATE DEPENDENT!!!

38
Q

The _____ allows blood to bypass the lungs by connecting the _____ to the descending aorta.

A

ductus arteriosus

pulmonary artery

39
Q

What is the Hb of:

adult
neonate
3 month infant

A

Adult: 12-17 g/dL

Neonate: 15-20 g/dL

3 month old: 11-12 g/dL (“physiologic anemia”)

Note: Adult lab values depicted.

40
Q

What is the blood volume of:

premature infant
full-term neonate
12 month old infant

A

Premature: 90 - 100 ml/kg

Full-term: 80 - 90 ml/kg

12 month: 75 - 80 ml/kg

41
Q

What is normal respiratory rate for:

neonate
12 months
3 years
12 years

A
  • 40
  • 30
  • 25
  • 20
42
Q

What is normal heart rate for:

neonate
12 months
3 years
12 years

A
  • 140
  • 120
  • 100
  • 80
43
Q

What is normal BP for:

neonate
12 months
3 years
12 years

A

65/40

95/65

100/70

110/60

44
Q

What is the dose of atropine for peds?

What is the minimum PALS dose?

A

IV: 0.01 - 0.02 mg/kg

0.1 mg

45
Q

What is the dose of succinylcholine for peds?

A

IV: 2mg/kg (same as adults)

IM: 4mg/kg (for inhalational induction)

46
Q

What is the dose for versed in peds?

A

PO: 0.5 mg/kg

IV: 0.1 mg/kg

47
Q

What is the dose of rocuronium in peds?

A

IV: 0.6 - 1.2 mg/kg (same as adults)

48
Q

What is the dose of fentanyl for peds?

A

IV: 1-2 mcg/kg

49
Q

What is the dose of Zofran for peds?

A

IV: 0.1 mg/kg

50
Q

What is the dose of Ancef in peds?

A

IV: 25 - 50 mg/kg

51
Q

What are the fasting guidelines for solids/milk and clear liquids:

  • *< 6** months
  • *6-36** months
  • *> 36** months
A

4 / 2 hours

6 / 2-3 hours

8 / 2-3 hours

52
Q

How do you perform an inhalational induction?

A

Nitrous, O2, Sevo

4 good breaths

53
Q

What are the risks of an inhalational induction? (2)

A

Airway not protected!

No IV!

54
Q

What are the sequence of events in an inhalational induction? (4)

A

Mask induction

Stage 2 completes

Place IV

Then intubate

55
Q

What are the MAC requirements of isoflurane for peds?

A

Premature: 1.4

Neonates: 1.6

1-6 months: 1.8

6-12 months: 1.6

56
Q

What is a good starting point for ventilation settings?

A

Pressure support

Pinspired = 15 cmH2O

57
Q

What should consider when using fentanyl? (2)

A

Much less needed!

Dilute to 10 mcg/ml or place in tb syringe

58
Q

When is the rule of thumb in age for caudal blocks? (2)

A

Age < 7

OR

Weight < 30 kg

59
Q

How are caudal blocks performed? (3)

When are caudal blocks used?

What should you be careful of?

A
  • Sacral hiatus
  • Volume based, not concentration based
  • 0.05 kg/dermatome

GU and anal cases

Produces weak legs so be careful.

60
Q

How are caudal blocks inserted?

A

Place pt in lateral position

Place in sacral hiatus–dimpled area

61
Q

What is the proper way to extubate deep? (8)

A
  • Spontaneous ventilation
  • 100% O2
  • 1.5- 2 MAC
  • Deflate cuff
  • Cuff leak test
  • Suction
  • Oral airway
  • Pull tube
62
Q

What commonly occurs to pediatric patients upon extubation?

A

LARYNGOSPASM

Usually occurs in PACU.

63
Q

The incidence of laryngospasm is significant in the ___-___ age group.

A

0 - 9 y/o

64
Q

Most cardiac arrests in children occur during _____.

Name the most common mechanisms of arrest from greatest to least.

A

INDUCTION

Cardiovascular > medication > respiratory > equipment

65
Q

What are the signs of cardiac arrest? (3)

A

BRADYCARDIA

HYPOTENSION

DECREASING SATURATIONS

66
Q

Infants ____ y/o accounted for 55% of all arrests.

What are the predictors of mortality? (2)

A

< 1 y/o

ASA 3-5
Emergency status

67
Q

What are issues relating to prematurity? (3)

A

Pulmonary issues

Apnea

Retinopathy

68
Q

When is extrauterine life possible?

What is full-term?

A

~24 - 25 weeks of gestation

40 weeks

69
Q

When do the lungs develop in the fetus?

Premature infants are prone to ______ because of insufficient surfactant.

A

> 35 weeks gestation

RDS

70
Q

What are the intra-op concerns with asthma ped pts? (2)

A

Tracheal intubation more likely to produce adverse event

Steroids may help

71
Q

What is trisomy 21?

What are physical attributess of trisomy 21? (7)

A

Down’s syndrome

  • Short neck
  • Microcephaly
  • Large tongue
  • Flattened nose
  • Congenital heart disease
  • Subglottic stenosis
  • Tracheoesophageal fistula
72
Q

What increases sickling of cells in sickle cell disease? (4)

A
  • HYPOthermia
  • Hypoxemia
  • Dehydration
  • Stress

Note: During surgery keep them warm, well-hydrated, and treat pain aggressively.

73
Q

What is of greatest concern perioperatively in sickle cell disease?

A

ACUTE CRISIS

AP: Summer Exam 3 (7 decks)

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