pediatric pharmacology

Question 0

1. name the blood proteins:
2. blood proteins are found in ___ concentrations in neonates than adults:
3. what does the differene in blood proteins cause?
4. at what age does neonatal protein levels equal adult levels?

Answer 0

1. Albumin and Alpha-acid glycoprotein (AAG)
2. blood proteins found in smaller concentrations in neonates than adults
3. this causes increased amount of free (active) drug in neonate tissue
4. neonate levels reach adult levels at approx. 5 months of age

Question 1

how is protein binding of drugs altered in neonates?

Answer 1

substances commonly found in plasma of neonates decreases protein binding of drugs: i.e.

a. bilirubin
b. free fatty acids
c. maternal steroids

Question 2

1. volume of distribution is greater or lesser in neonates and children than adults?
2. there dose requirements will be higher or lower for water soluble drugs?
3. give examples of water soluble drugs:
4. neonates and children have a higher or lower body fat percentage?
5. this affects “what” medications in “what way”?

Answer 2

1. vD is greater in neonates and children d/t increased total body water.
2. will have decreased dose requirements for water soluble drugs
3. succinylcholin is water soluble, some antibiotics
4. neonates actually have a lower body fat %
5. drugs that depend on redistribution into fat for termination may have a longer duraton in neonates.

Question 3

1. what happens in phase I and phase II recations in neonates?
2. what may cause this change?
3. development of hepatic enzymes is a function of what stage of aging?
4. why do the enzymes take time to develop?
5. by what age dose the liver mature?

Answer 3

1. they are reduced
2. barbituates
3. function of postnatal age versus gestatonal age
4. the liver is not well perfused in utero d/t ductal shunting
5. mature by 1 year of age

Question 4

1. how much of the cardiac output does the kidney receive in adults vs. neonates
2. what is term infant GFR vs. preterm infant GFR?
3. by when will GFR increase?
4. immature renal function impedes what?

Answer 4

1. adults=20%; neonates=5-6%
2. —term infant GFR=40% of adult GFR;
   - —preterm infant GFR is 20-30% of adult GFR
3. GFR increases over 1st year of life
4. ability to remove drugs from its system that are dependent on excretion

Question 5

1. risk of what complication during inhaled induction of anesthesia is more comon in prenatals than children and adults?
2. in what population is the risk highest?
3. what is the cause?

Answer 5

1. higher risk of cardiovascular complications
2. <1 year
3. age related differences in uptake, anesthetic requirements and sensitivity of cardiovascular system

Question 6

inhaled anesthetics:

1. uptake speed of inhaled agents:
2. why?
3. what are the ratios of Fe:Fi of 1.0 in infants, childrena and adults?

Answer 6

1. faster in infants and small children
2. greater ratio of alveolar ventilation to functional residual capacity
3. Fe:Fi of 1.0–
   - —infants=25 min
   - —child=30 min
   - —adult=60 min

Question 7

1-what does overpressuring during inhalation cause in infants?
2-what must be done during inhalation inducton?
3-what are s/s of inhalation agent overdose in infants?

Answer 7

1-leads to high tissue concentrations early and causes cardiovascular depression
2-vigilant monitoring of blood pressure and heart rate
3-bradycardia and hypotension

Question 8

what is the difference between adult and infant MAC?

Answer 8

infant and neonate MAC is higher than adults.

Question 9

Isoflurane :

1. what is adult mac?
2. what is child mac?
3. how does its cardiac effects compare to Halothane?
4. why cant it be used for induction?

Answer 9

1. adult: 1.2
2. infant: 1.6
3. less myocardial depression but decreases SVR more
4. cant use for inhaled induction d/t pungent odor

Question 10

1. What is the effect does congenital heart disease (i.e. l=right to left or left to right shunt) have on uptake of inhaled anesthetics?
   - —A. right to left shunt:
   - —B. left to right shunt:
2. what does left to right shunt effects depend on? what is affected?

Answer 10

1. A. Right to left shunt
   - – Slower rise in blood concentration
   - – Slower inhalation induction
2. B. Left to right shunt
   - – Large shunts speed induction
   - – Small shunts have little effect
3. depends upon shunt size; affects FE:FI ratio

Question 11

Desflurane: 
1. what are the MACs for :
a.  Neonate = 
b.  Infant 1-6mo = 
c.  Infant >6mo = 
d.  Toddler = 
e.  Child = 
f.  Adult = 
2. not used for inhalation d/t:
3. why use it?

Answer 11

MAC
a.  Neonate = 9.16
b.  Infant 1-6mo = 9.4
c.  Infant >6mo = 9.9
d.  Toddler = 8.72
e.  Child = 8.0 – 8.3
f.  Adult = 6
2. Pungent odor, associated with coughing, laryngospasm
3. but good for maintenance of anesthesia

Question 12

sevoflurane:
1. MAC
  Neonate = 3
  Infant 1-6mo= 3.2
  Infant >6mo = 2.6
  Child 1 –12 = 2.5
  Adult = 2.5
  Elderly = 1.5
2. what is sevo ideal for?
3. why is it good for cardiac?
4. what should you avoid with sevo? why?
5. what is a side effect seen on emergence?

Answer 12

1. MAC
  Neonate = 3
  Infant 1-6mo= 3.2
  Infant >6mo = 2.6
  Child 1 –12 = 2.5
  Adult = 2.5
  Elderly = 1.5
2.   Ideal for inhalation induction
3.  Low incidence of myocardial depression even with overpressure
4.  Avoid low flows due to toxic renal metabolites, especially in neonates
5.  Emergence delirium

Question 13

IV induction agents:

1. what type of induction dose would a child need in comparison to an adult?
2. why?
3. If IV induction agent is planned following inhalation induction (preceeding intubation), what can you do with your induction dose?

Answer 13

Induction Agents
1.  Children usually require larger doses than adults to induce
anesthesia
2. -a  ↑ metabolic rate
-b  ↑ cerebral O2 consumption
-c  ↑ cerebral blood flow 
-d  ↑Vd
3.  dose may be decreased or omitted (pt is already asleep from agent)

Question 14

iv induction: peds:

1.  Propofol
   - —- Induction?
   - —- Sedation?
2.  Etomidate
   - —- Induction?

Answer 14

1.  Propofol
   - —- Induction 2-3 mg/kg IV
   - —- Sedation 60-300 mcg/kg/min
2.  Etomidate
   - —- Induction 0.2-0.3 mg/kg IV

Question 15

Induction agents: peds-
ketamine
1. Induction dose:
--IV:
--IM:
2. sedation doses:
--intermittened bolus:
--infusion (loading dose and drip):
3. what are side effects of ketamine?
4. how should you pre treat for these?

Answer 15

induction agents: peds-

1. Ketamine
   - - Induction
   - — IV 1-3 mg/kg
   - — IM 5-10 mg/kg
2. Sedation
   - — IV 0.5-1 mg/kg intermittent boluses or
   - — Loading dose= 1-2 mcg/kg, then infusion 15-75 mcg/kg/hr
3. drooling, halucinations, dissociative disorder
4. May consider Robinul 10 mcg/kg + Versed 0.1 mg/kg

Question 16

midazolam: pediatrics-
1. doses (IV, PO and onset):
2. uses:
3. what route is good for children that we dont always see?
4. side effects in regards to emergence?
5. at what age should children start getting versed? why?

Answer 16

midazolam: peds-
1.  IV: 0.1 mg/kg
- – PO:0.3-0.5mg/kg,upto15mg
- – Onset 10 minutes
2. Used for pediatric preoperative sedation
3. Intranasal: 0.2-0.3 mg/kg
4. May prolong emergence in short cases
5. Not usually necessary before age 10-12 months
- –No separation anxiety

Question 17

Dexmedetomidine: peds-

1. action:
2. pros (respiratory):
3. cons (contraindications):
4. Uses in pediatrics:

Answer 17

Dexmedetomidine

1. Selective alpha2-agonist with sedative and analgesic properties
2. Provides respiratory stability with no ventilatory depression
3. Contraindicated in patients with heart block or bradycardia
4. Uses in pediatrics
   -  Procedural sedation
   -  Supplement to GA
   -  Premedication (controversial)
   -  Emergence delirium
   -  Postoperative Shivering

Question 18

Dexmedetomidine: pediatrics-
1.Sedation or supplement to GA
  Load 
  Infusion 
2.Premedication
  dose & route?
  give how soon before procedure?
3. Emergence delirium 
  give how many minutes before end of procedure?

Answer 18

Dexmedetomidine: pediatrics-
1. Sedation or supplement to GA
  Load 1 mcg/kg IV (optional)
  Infusion 0.5 - 1 mcg/kg/hr
2. Premedication
  1-2 mcg/kg intranasal
  give 30-45 min prior to procedure
3. Emergence delirium 
  0.1-0.5 mcg/kg IV
  give 30 min prior to end of procedure
4. Post op shivering:
  0.1-0.5 mcg/kg IV

Question 19

Dexmedetomidine: pediatrics-
 brand name?
1. Avoid in patients with Hx of or visualized…:(2 things )
2. Use as premedication is considered what?
3. Indications for using etomidate as a pre medication:
4. what should you have on if giving dexmedetoidine pre-op?

Answer 19

Dexmedetomidine: pediatrics- 
  brand name:Precedex
1. Avoid in patients with:
  heart block, 
  bradycardia
2.   Use as premedication is considered off-label, use only in certain circumstances
3. Need for premedication but
  Allergy to midazolam
  Dysphoria with midazolam
  Short surgery with history of emergence delirium
4. Monitors should be on in preop

Question 20

Fentanyl: pediatrics-

1. dose for small, minimally invasive & shorter procedures
   (hernia) ?
2. dose for moderately-highly invasive procedures (bowel)?
3. dose for cardiac surgery?

Answer 20

Fentanyl: pediatrics-
1. dose for small, minimally invasive & shorter procedures
(hernia)
  1-2 mcg/kg 
2. dose for moderately-highly invasive procedures (bowel)
  5-10 mcg/kg and up 
3. dose for cardiac surgery
  50 mcg/kg

Question 21

opiods: fentanyl-pediatric-
1. doses: intranasal:
2. doses: continuous IV:
3. when should you turn off if planning to extubate?

Answer 21

Fentanyl

1. Intranasal1-2 mcg/kg
2. Continuous infusion 1-2 mcg/kg/hr
3. Turn off 1 hour prior to emergence if planning on extubating

Question 22

Opioids: Morphine Sulfate (PEDIATRICS)

1. dose:
2. what is different in neonates?
3. what should you do if planning to intubate?

Answer 22

Opioids: Morphine Sulfate

1. dose: 0.025-0.1 mg/kg
2. Prolonged clearance in neonates…
3. best to avoid giving morphine if planning on extubating

Question 23

Opioids: pediatric
 Demerol
1. How often used in children?
2. dose?
3. contraindications:
4. mostly used for:

Answer 23

Opioids: pediatric
 Demerol
1. Routine use in pediatrics uncommon
2. 0.25-0.5 mg/kg IV
3. Contraindicated in seizure disorder, renal failure
4.  Useful for post operative shivering

Question 24

``` Opioids I. Sufentanil a. Loading dose (what speed?): b. Infusion 2. Remifentanil a. Loading dose: b. Infusion dose? titrate to what? 3. Used for what? ```

Answer 24

``` Opioids I. Sufentanil a. Load slowly 0.2-1 mcg/kg b. Infusion .01-1 mcg/kg/hr 2. Remifentanil a. Load 0.5-1 mcg/kg (may omit load & use fentanyl on induction) b. Infusion 0.1-0.2 mcg/kg/min, titrate to BP, HR 3. Supplement to GA ```

Question 25

``` Succinylcholine(Depolarizing MR) doses: 1. Induction (route and onset): 2. Laryngospasm-  route 1 dose & duration:  route 2 dose: 3. what's the difference between adult and neonate doses? ```

Answer 25

``` Succinylcholine(Depolarizing MR) Doses: 1 Induction  IV 2mg/kg (onset within 1min) 2. Laryngospasm  IM 4 mg/kg (onset 1-2 min) ---- Duration for IM may last up to 20 minutes  IV 0.2 mg/kg 3. doses are higher in neonates d/t ↑ Vd ```

Question 26

Succinlycholine-Pediatrics: 1. what should you consider giving with succ in peds population? why? 2. what is s/e of sux is reduced in children? why? 3. what has been seen in children d/t what disorders? which is notorious for causing this?

Answer 26

1. Consider giving with Atropine 10-20 mcg/kg;  causes marked bradycardia 2. ↓fasiculationsinchildren  r/t↓musclemass 3. Cardiac arrest has been reported in children following succinylcholine administration with previously undiagnosed myopathies such as:  Duchenne’s muscular dystrophy

Question 27

``` Anticholinergics: Pediatrics- 1. Atropine: a. what is the dose? b. what is the minimal dose for pediatrics? c. what can low dose atropine cause in both peds and adults? d. how does this happen? 2. Glycopyrrolate: a. what is the dose? ```

Answer 27

1. Atropine a. 10-20 mcg/kg b. Minimum Atropine dose is 0.1 mg c. Low dose atropine can cause worsening of bradycardia (peds and adult pt’s) d. Due to central stimulation of vagal centers before the postganglionic block is complete 2. Glycopyrrolate  10 mcg/kg

Question 28

NDMRs in Pediatrics: 1. how does the dose differ between adults and peds? 2. how is this possible if children have an ↑Vd? 3. how does duration of action differ between adults and peds? 4. what should ALWAYS be used/done with any NDMR use?

Answer 28

1. It DOESN'T; Dose same on mg/kg basis as adults 2. children have an ↑ Vd, but also immature neuromuscluar junction (sensitive to NDMR). These balance each other and is why the dose is the same as adult dosing 3. Duration of action may be slightly longer in peds 4. Always use nerve stimulator with NDMR and titrate to effect

Question 29

what are the pediatric (and adult) doses for: 1. Vec 2. Pan 3. Cisatra 4. Roc

Answer 29

```  Vecuronium = 0.1 mg/kg  Pancuronium = 0.1mg/kg  Cisatracurium = 0.1-0.2 mg/kg  Rocuronium= 0.6-1.2 mg/kg child dose same as adult! ```