Pediatric Pearls Flashcards
Why are pediatric pts temperature regulation different? (4)
Low body fat content
Thin skin
Increased BSA
Neonates unable to shiver
What is the typical pattern of hypothermia during anesthesia for pediatric pts?
Loss from core to periphery
Heat loss to the environment
Note: Phase C indicates rewarming.
Almost ALL of pediatric codes are ______ in origin.
respiratory
What % of pediatric cardiopulmonary arrest are primarily due to respiratory distress and occur at < ___ y/o?
80%
1
What are statistics to heed by ASAs 1990 closed claim project? (4)
- 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
What are anatomical differences in the pediatric airway? (5)
- Large head, tongue, tonsils, and adenoids
- Anterior, cephalad larynx
- Long, floppy epiglottis
- Funnel-shaped larynx
- Loose teeth (5-8 y/o)
When does obligate nasal breathing subside?
3-5 months
Where are the vocal cords located in an:
premature infant
infant
adult
middle of C3
C3-C4
C4-5
What are the consequences of a pediatric pts larger tongue? (3)
Airway obstructed easily
Difficult to visualize
Miller blade preferred
What is different in an infants vocal cords?
What is the consequence of blindly placing ETT during nasal intubation?
More angled attachment to trachea than adults VC that are more perpendicular.
ETT easily lodges into anterior commisure.
What is the difference in the epiglottis in infants vs. adults? (2)
More omega shaped
More angled away from axis of trachea
What are common MAC and Miller blades in peds?
MAC
- 1
- 2
- 2 1/2
- 3
Miller
- 0,0 (premature newborn)
- 0
- 1
- 1 1/2
How do you size the diameter of an endotracheal tube?
4 + age/4
Where do you tape the tube?
12 + age/2
Note: More importantly listen for bilateral breath sounds and tape tube well since slight movement can be devastating.
What is the most you can inflate the cuff in a peds tube?
1 - 1.5 cc
Traditionally, uncuffed ET recommended in children < ____ y/o to prevent post-extubation ______ and ________.
8
stridor
subglottic stenosis
What is the argument againsted CUFFED ETT? (4)
Smaller size increases a/w resistance
Increased work of breathing
Poorly designed for pediatric patients
Need to keep cuff pressure < 25 cm H2O
What are the arguments against UNCUFFED ETT? (4)
- More tube changes during long-term intubation
- Leak of anesthetic agent to environment
- More FGF > 2L/min required
- Higher risk for aspiration
What is the effect of edema?
If radius is halved, resistance increases 16x.
Note: Poiseuille’s law
For short cases when ETT size > ____, choice of cuff vs. uncuffed probably does not matter.
4.0
In what cases is a cuffed ETT preferred? (3)
Increased risk of aspiration (bowel obstruction)
Low lung compliance (ARDS, pneumoperitoneum, CO2 insufflation, CABG)
Precise control of ventilation (increased intracranial pressure, single ventricle)
What are the complications of endotracheal intubation? (2)
Stridor –Postintubation croup (Occurs in <10%)
Subglottic stenosis (laryngotracheal )(Occurs 90% of prolonged intubations)
What are the risk factors for postintubation croup (aka stridor)? (6)
Large ETT
Change in pt position intraop
Multiple attempts at intubation
Pts < 4 y/o
Surgery > 1 hour
Coughing on ETT
Ischemic injury caused by lateral wall pressure of larynx leads to what? (3)
Edema
Necrosis
Ulceration of mucosa
What are respiratory development considerations in pediatric pts? (4)
Weak intercostals/diaphragmatic muscles –> less efficient ventilation
Incomplete alveolar maturation
Increased chest wall compliance –> less efficient ventilation
Limited O2 reserve during apnea
What is the FRC in pediatric patients?
28-30 cc/kg
Note: Infants also have increased O2 demand and metabolism leading to faster desaturation.
What is the oxygen consumption of an infant vs. an adult?
Infant: 6 ml/kg/min
Adult: 3.5 ml/kg/min
Greater O2 consumption in infants leads to what?
increased inspiratory rate
How does the FRC of an awake infant compared to an adult?
Both are similar when normalized to body weight.
The ratio of alveolar minute ventilation to FRC is _____ in infants.
doubled
Thus, with hypoxia, apnea, or GA in an infant the FRC is diminished quickly.
Chemoreceptors are developed in the term newborn thus hypercarbia will stimulate ventilation. True or false?
True
Infants fatigue faster because they have fewer Type ___ muscle fibers.
I
Note: Type I slow twitch fibers are more efficient as using oxygen for fueling the muscles.
Until age 2-3 weeks, hypoxemia causes a _______ increase in ventilation followed by a _______ depression.
transient
sustained
Note: By after 3 weeks after birth, hypoxemia induces sustained hyperventilation.
Newborns respond to hypercapnia by increasing ventilation but _____ than older infants.
less
The CO2 response curve increases with gestational age.
What are important points during the airway evaluation and medical history for a pediatric pt? (8)
URI
Snoring / noisy breathing
Allergies
Asthma
Cigarette smoke exposure
Productive cough–may indicate bronchitis, pneumonia
Pneumonia–indicates GERD, immune suppression
Previous problems with anesthesia
What are signs of impending respiratory failure? (12)
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
Immature myocardium at birth results in: (4)
Fewer organized myocytes
Less contractile tissue
Less compliant ventricles
Neonates are HEART RATE DEPENDENT!!!
The _____ allows blood to bypass the lungs by connecting the _____ to the descending aorta.
ductus arteriosus
pulmonary artery
What is the Hb of:
adult
neonate
3 month infant
Adult: 12-17 g/dL
Neonate: 15-20 g/dL
3 month old: 11-12 g/dL (“physiologic anemia”)
Note: Adult lab values depicted.
What is the blood volume of:
premature infant
full-term neonate
12 month old infant
Premature: 90 - 100 ml/kg
Full-term: 80 - 90 ml/kg
12 month: 75 - 80 ml/kg
What is normal respiratory rate for:
neonate
12 months
3 years
12 years
- 40
- 30
- 25
- 20
What is normal heart rate for:
neonate
12 months
3 years
12 years
- 140
- 120
- 100
- 80
What is normal BP for:
neonate
12 months
3 years
12 years
65/40
95/65
100/70
110/60
What is the dose of atropine for peds?
What is the minimum PALS dose?
IV: 0.01 - 0.02 mg/kg
0.1 mg
What is the dose of succinylcholine for peds?
IV: 2mg/kg (same as adults)
IM: 4mg/kg (for inhalational induction)
What is the dose for versed in peds?
PO: 0.5 mg/kg
IV: 0.1 mg/kg
What is the dose of rocuronium in peds?
IV: 0.6 - 1.2 mg/kg (same as adults)
What is the dose of fentanyl for peds?
IV: 1-2 mcg/kg
What is the dose of Zofran for peds?
IV: 0.1 mg/kg
What is the dose of Ancef in peds?
IV: 25 - 50 mg/kg
What are the fasting guidelines for solids/milk and clear liquids:
- *< 6** months
- *6-36** months
- *> 36** months
4 / 2 hours
6 / 2-3 hours
8 / 2-3 hours
How do you perform an inhalational induction?
Nitrous, O2, Sevo
4 good breaths
What are the risks of an inhalational induction? (2)
Airway not protected!
No IV!
What are the sequence of events in an inhalational induction? (4)
Mask induction
Stage 2 completes
Place IV
Then intubate
What are the MAC requirements of isoflurane for peds?
Premature: 1.4
Neonates: 1.6
1-6 months: 1.8
6-12 months: 1.6
What is a good starting point for ventilation settings?
Pressure support
Pinspired = 15 cmH2O
What should consider when using fentanyl? (2)
Much less needed!
Dilute to 10 mcg/ml or place in tb syringe
When is the rule of thumb in age for caudal blocks? (2)
Age < 7
OR
Weight < 30 kg
How are caudal blocks performed? (3)
When are caudal blocks used?
What should you be careful of?
- Sacral hiatus
- Volume based, not concentration based
- 0.05 kg/dermatome
GU and anal cases
Produces weak legs so be careful.
How are caudal blocks inserted?
Place pt in lateral position
Place in sacral hiatus–dimpled area
What is the proper way to extubate deep? (8)
- Spontaneous ventilation
- 100% O2
- 1.5- 2 MAC
- Deflate cuff
- Cuff leak test
- Suction
- Oral airway
- Pull tube
What commonly occurs to pediatric patients upon extubation?
LARYNGOSPASM
Usually occurs in PACU.
The incidence of laryngospasm is significant in the ___-___ age group.
0 - 9 y/o
Most cardiac arrests in children occur during _____.
Name the most common mechanisms of arrest from greatest to least.
INDUCTION
Cardiovascular > medication > respiratory > equipment
What are the signs of cardiac arrest? (3)
BRADYCARDIA
HYPOTENSION
DECREASING SATURATIONS
Infants ____ y/o accounted for 55% of all arrests.
What are the predictors of mortality? (2)
< 1 y/o
ASA 3-5
Emergency status
What are issues relating to prematurity? (3)
Pulmonary issues
Apnea
Retinopathy
When is extrauterine life possible?
What is full-term?
~24 - 25 weeks of gestation
40 weeks
When do the lungs develop in the fetus?
Premature infants are prone to ______ because of insufficient surfactant.
> 35 weeks gestation
RDS
What are the intra-op concerns with asthma ped pts? (2)
Tracheal intubation more likely to produce adverse event
Steroids may help
What is trisomy 21?
What are physical attributess of trisomy 21? (7)
Down’s syndrome
- Short neck
- Microcephaly
- Large tongue
- Flattened nose
- Congenital heart disease
- Subglottic stenosis
- Tracheoesophageal fistula
What increases sickling of cells in sickle cell disease? (4)
- HYPOthermia
- Hypoxemia
- Dehydration
- Stress
Note: During surgery keep them warm, well-hydrated, and treat pain aggressively.
What is of greatest concern perioperatively in sickle cell disease?
ACUTE CRISIS
