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Prodigy Quick Review > Pediatric Pharmacology > Flashcards

Pediatric Pharmacology Flashcards

1
Q

How does protein binding compare between

pediatric and adult patients?

A

Protein binding is decreased in preterm and term infants, but is
similar between children and adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 84.

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2
Q

How does the volume of distribution for water-soluble

drugs compare between pediatric and adult patients?

A

Infants (both preterm and term) have a higher proportion of
water compared to their body mass. As a result, the volume of
distribution for water-soluble drugs is greater. Because of this,
they often require a higher loading dose of water-soluble drugs
such as digoxin, succinylcholine, and some antibiotics.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 85.

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3
Q

How does the responsiveness to dopamine compare

between term neonates and adult patients?

A

Term neonates exhibit decreased cardiovascular
responsiveness to many drugs. The dose required to increase
blood pressure and urine output in neonates may be as high as
50 mcg/kg/min. This dose would produce such severe
vasoconstriction in adults that it could cause injury to the patient.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 85.

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4
Q

How does the proportion of body fat and muscle
mass compare between pediatric patients and
adults?

A

Children and adolescents have fat and muscle masses
comparable to that of adults, but term and preterm neonates
have a decreased proportion of both.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 85.

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5
Q

How does the metabolism of morphine differ in

neonates compared to children and adults. Why?

A

Term and preterm infants cannot metabolize morphine as
effectively as children and adults. Neonates have a limited
ability to perform glucuronidation. Because morphine
undergoes glucuronidation, the active form of the drug will be
present in the circulatory system for a longer period of time.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 88-89.

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6
Q

Renal excretion of drugs is less effective in neonates

than in older children and adults. Why is this?

A

Neonates have incomplete glomerular development, a low
perfusion pressure, and an inadequate osmotic concentration to
exert a normal countercurrent effect.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 90.

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7
Q

What is the appropriate dose for oral ketamine in

pediatric patients?

A

5-6 mg/kg is the appropriate dose for orally administered
ketamine in patients from 1 to 6 years of age.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1225.

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8
Q

What is the caution regarding the use of intranasal

ketamine?

A

Ketamine has been shown to enter the central nervous system
directly when given via the intranasal route because it can track
along neurovascular tissues in the nasal mucosa. The
preservative in ketamine is neurotoxic and the possibility of
CNS toxicity exists with the administration of intranasal
ketamine.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 118.

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9
Q

How does premedication of pediatric patients with

ketamine affect the incidence of emergence delirium?

A

Premedication with ketamine has been shown to reduce the
incidence of emergence delirium in pediatric patients.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 118.

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10
Q

How does the bioavailability of intramuscular
ketamine compare between adults and pediatric
patients?

A

The bioavailability of ketamine is high in adults (93%), but is
even higher in children.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 117.

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11
Q

What is the IM induction dose of ketamine?

A

5-10 mg/kg
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 118.

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12
Q

What is the IV induction dose of ketamine?

A

1-3 mg/kg
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 118.

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13
Q

What drugs and foods can interfere with the

metabolism of midazolam?

A

Drugs that interfere with the cytochrome pathway that
metabolizes midazolam (CYP 4503A 4) include grapefruit juice,
erythromycin, calcium channel blockers, and protease
inhibitors. The concomitant administration of these agents can
potentially prolong the elimination half-life of midazolam.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 142.

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14
Q

Is midazolam effective as an induction agent for

pediatric patients?

A

No. Studies have demonstrated that doses as high as 1 mg/kg
IV do not reliably produce unconsciousness in pediatric patients.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 142.

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15
Q

You administer an intramuscular dose of midazolam
to a pediatric patient without an IV who cannot
cooperate to take PO midazolam. How long should
you wait before considering a supplemental dose?

A

The onset time of IM midazolam is 3-5 minutes and the time to
peak effect is 10-20 minutes. You should wait at least 20
minutes before considering giving a supplemental dose of
midazolam.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 142.

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16
Q

You administer midazolam rapidly via the IV route to
a pediatric patient. The patient begins to exhibit
seizure-like activity. What do you ascertain is the
likely cause of this?

A

Rapid IV or nasal administration of midazolam can produce
myoclonus that may have the appearance of seizure-like activity.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 141.

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17
Q

What factors can prolong the half-life of midazolam

in pediatric patients?

A

The elimination half-life of midazolam can be prolonged in
hypovolemia and in those receiving vasopressors. It is also
prolonged by any conditions that reduce hepatic blood flow
(such as cardiac surgery using bypass).
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 141.

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18
Q

By what routes may midazolam be administered in

pediatric patients? Which is least recommended?

A

Midazolam can be administered oraly, rectally, nasally,
intravenously, or intramuscularly. The IM route is not
recommended because of pain and the risk of a sterile abscess.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1230

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19
Q

How does the use of preoperative ketamine affect
the incidence of postoperative nausea and vomiting
in the pediatric patient?

A

The use of ketamine increases the incidence of postoperative
nausea and vomiting in pediatric patients.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1225.

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20
Q

What food allergies should be explored further in a
pediatric patient prior to the administration of
Diprivan? Why?

A

Soybeans and eggs, because Diprivan is formulated with 1%
propofol, 10% soybean oil, and 1.25% egg yolk phosphatide,
glycerol, EDTA, and sodium hydroxide.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 114.

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21
Q

What is the appropriate intravenous dose of

flumazenil in pediatric patients?

A

10 mcg/kg. The rectal dose is 50 mcg/kg.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 148.

22
Q

A pediatric patient is exhibiting oversedation from
midazolam. How can you reverse the effects of this
drug in this patient?

A

Flumazenil can be used to antagonize benzodiazepines in
pediatric patients. It should be noted that the short half-life of
flumazenil has been associated with re-sedation in children
ages one to five. Larger doses of flumazenil have been
associated with seizures in pediatric patients.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 148.

23
Q

You have administered 10 mg of midazolam PO to a
pediatric patient who weighs 44 lbs. Thirty minutes
later, the patient appears completely unaffected by
the drug. Was the first dose appropriate? If not,
how should you proceed?

A

The normal dose for PO midazolam in pediatric patients is 0.5
mg/kg. 10 mg is an appropriate dose for this patient. About
14% of all pediatric patients will not respond to this dose and a
higher total dose of 0.75 mg/kg may be required.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1240.

24
Q

What is the dose for intranasal midazolam in

pediatric patients?

A

0.2-0.3 mg/kg
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1230.

25
Q

By what age would the clearance of morphine in

pediatric patients be equal to that of adults?

A

By 6-12 months of age, the clearance of morphine is equal to
that of adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 130.

26
Q

What are the advantages of premedication with

ketamine over midazolam in children?

A

Ketamine is capable of producing both hypnosis and pain relief
and may reduce intraoperative opioid requirements.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1225.

27
Q

Is the volume of distribution of propofol larger in

children or adults?

A

The volume of distribution of propofol is larger in children than
adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 114.

28
Q

How does the clearance of propofol compare

between children and adults?

A

The clearance of propofol in children is similar to that of adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 114.

29
Q

How does the dose of propofol sufficient to abolish
the eyelash reflex differ between pediatric patients
and adult patients? In what age-group is the
required dose of propofol the highest?

A

In general, the dose of propofol required to abolish the eyelash
reflex increases as age decreases. The dose is highest
between the ages of 1 and 6 months.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 114.

30
Q

How does propofol affect the systolic blood pressure

in pediatric patients?

A

Induction doses of propofol decrease the arterial pressure by
15% in children which is equivalent to that seen in adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 115.

31
Q

What is the induction dose of propofol in children

younger than 2 years of age? Over 2 years of age?

A

The induction dose of propofol in infants between 1-6 months of
age is 3 mg/kg. For children 1-12 years old, it is 1.3-1.6 mg/kg.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1224.

32
Q

What age children metabolize thiopental the

fastest? How does this affect the duration of action?

A

Children between the ages of 5 and 13 months metabolize
thiopental twice as fast as adults. The duration of action,
however, is not changed significantly because it is still
dependent primarily upon redistribution rather than metabolism.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 114.

33
Q

Under what circumstances would thiopental be used

as a high-dose infusion in pediatric patients?

A

Thiopental can be infused at a rate of 2 mg/kg/hour in pediatric
patients in the treatment of intracranial hypertension.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 114.

34
Q

Can etomidate be used safely in children?

A

Yes, etomidate is often used to facilitate intubation in critically ill
children as it affords a great deal of hemodynamic instability.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 119.

35
Q

In what condition is ketamine contraindicated in

pediatric patients?

A

Because ketamine can produce increases in intracranial
pressure via cerebral vasodilation, it is contraindicated in
pediatric patients with intracranial hypertension.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 124.

36
Q

What is Propofol Infusion Syndrome (PRIS)?

A

Propofol Infusion Syndrome occurs in infants and children on
prolonged propofol infusions and has resulted in five pediatric
deaths. It is marked by the onset of lipemia, hyperkalemia, and
rhabdomyolysis that can convert into refractory cardiac collapse.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 116.

37
Q

In what pediatric patients is succinylcholine

contraindicated?

A

Succinylcholine is contraindicated in patients with malignant
hyperthermia, muscular dystrophy, recent burn injury, spinal
cord transection, and prolonged immobilization. Its use in
children is relatively contraindicated by the Food and Drug
Administration because of the risk of unidentified
contraindications.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1227.

38
Q

What is the IM dose of succinylcholine required to

produce intubating conditions?

A

When IV administration is not possible, succinylcholine may be
administered intramuscularly at a dose of 4 mg/kg in pediatric
patients to produce intubating conditions.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1226.

39
Q

What is the IV dose of succinylcholine to produce

intubating conditions in pediatric patients?

A

A dose of 3-4 mg/kg of succinylcholine in neonates, 2 mg/kg in
small children, and 1 mg/kg in adolescents can produce
satisfactory intubating conditions in pediatric patients in about
60 seconds.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1226.

40
Q

What infusion dose of propofol is required to produce

general anesthesia in pediatric patients?

A

250 mcg/kg/min is sufficient in the pediatric population to
produce general anesthesia for painless medical or radiolologic
procedures, but the dose may have to be increased to prevent
movement.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1224.

41
Q

You must administer a dose of succinylcholine
intramuscularly because no intravenous access is
available. What is the time to onset of an
intramuscular dose of succinylcholine?

A

Paralysis will occur in 3-4 minutes after an IM dose of
succinylcholine.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 122.

42
Q

What is the intravenous dose of cisatracurium for
intubation in pediatric patients and what is the onset
of the typical dose?

A

The dose is 0.08 mg/kg which will produce intubating conditions
in about two-and-a-half minutes.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 125.

43
Q

How does the volume of distribution and total body
clearance of cisatracurium differ in pediatric patients
compared to adults?

A

The volume of distribution and the total body clearance are both
significantly greater in pediatric patients, which accounts for the
faster recovery in children.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 125.

44
Q

How does the sensitivity to vecuronium in pediatric

patients compare to that of adult patients?

A

Pediatric patients are much more sensitive to the effects of
vecuronium than adults. Patients under the age of one year are
the most sensitive. By the time the patient reaches
adolescence, the dosage is the same as for adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 125.

45
Q

How does the sensitivity to vecuronium in pediatric

patients compare to that of adult patients?

A

Pediatric patients are much more sensitive to the effects of
vecuronium than adults. Patients under the age of one year are
the most sensitive. By the time the patient reaches
adolescence, the dosage is the same as for adults.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 125.

46
Q

Is the duration of action of rocuronium prolonged in

pediatric patients with renal failure?

A

No. Although the duration of action of rocuronium can be
prolonged in adults with renal failure, the same does not appear
to be true in patients over the age of one year.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 126.

47
Q

What are the cardiac changes seen with the
administration of intubating doses of rocuronium in
pediatric patients?

A

The heart rate increases by about 15 beats per minute when
rocuronium 0.6 mg/kg is administered to pediatric patients.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 126

48
Q

What is the normal intubating dose of pancuronium

in pediatric patients?

A

0.1 mg/kg will produce conditions satisfactory for tracheal
intubation in 70-90% of pediatric patients within 2.5 minutes.
Increasing the dose to 0.15 mg/kg will shorten the time to 80
seconds.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 127.

49
Q

What are the advantages to the use of pancuronium

in pediatric patients?

A

Pancuronium exerts a vagolytic effect which conveniently
counteracts the vagotonic properties of opioids, making the
combination of the two advantageous for pediatric patients
undergoing cardiac or other high-risk procedures.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 127.

50
Q

A pediatric patient received an intubating dose of
rocuronium 45 minutes ago. The nerve stimulator
indicates sustained tetany and the patient is
breathing on his own. Is it recommended to reverse
the muscle relaxant or should you avoid this in
pediatric patients? Explain.

A

Even when the clinical signs of recovery from neuromuscular
blockade are present and the nerve stimulator assessment
exhibits signs of recovery, the recommendation is to antagonize
the muscle relaxation in pediatric patients. Oxygen
consumption is higher in pediatric patients than in adults. As a
result, even a slight decrease in respiratory muscle strength can
result in hypoxemia and hypercapnia.
Cote CJ, Lerman J, & Anderson BJ. A Practice of Anesthesia
for Infants and Children. 5th Ed. Philadelphia: Elsevier
Saunders; 2013: 127.

51
Q

What are the potential side effects of succinylcholine

administration in pediatric patients?

A

Because succinylcholine mimics the effects of acetylcholine, it
can stimulate parasympathetic ganglia or even directly stimulate
muscarinic receptors in the heart resulting in bradycardia.
Myalgia is common following the administration of
succinylcholine in pediatric patients, as is myoglobinemia, which
may occur in 20% of children who receive succinylcholine.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1185.

52
Q

Is MAC higher in pediatric patients or adult patients?

A

MAC is higher in pediatric patients, for example, for sevoflurane
it is approximately 3.3% in neonates and 3.2% in infants 1-6
months of age. For children 6-12 months of age it is constant at
2.4%.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1222

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