Pediatric Pearls Flashcards by Cindy Ehret

Why are pediatric pts temperature regulation different? (4)

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

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

Almost ALL of pediatric codes are ______ in origin.

respiratory

How well did you know this?

Not at all

Perfectly

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

80%

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

When does obligate nasal breathing subside?

3-5 months

How well did you know this?

Not at all

Perfectly

Where are the vocal cords located in an:

premature infant
infant
adult

middle of C3

C3-C4

C4-5

How well did you know this?

Not at all

Perfectly

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

Airway obstructed easily
Difficult to visualize
Miller blade preferred

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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

More omega shaped
More angled away from axis of trachea

How well did you know this?

Not at all

Perfectly

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 well did you know this?

Not at all

Perfectly

How do you size the diameter of an endotracheal tube?

4 + age/4

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

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

1 - 1.5 cc

How well did you know this?

Not at all

Perfectly

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

stridor

subglottic stenosis

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is the effect of edema?

If radius is halved, resistance increases 16x.

Note: Poiseuille’s law

How well did you know this?

Not at all

Perfectly

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

4.0

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

What are the complications of endotracheal intubation? (2)

Stridor –Postintubation croup (Occurs in

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

Edema

Necrosis

Ulceration of mucosa

How well did you know this?

Not at all

Perfectly

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 ## Footnote 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 ## Footnote 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 ## Footnote 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 P_inspired = 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