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N934: Advanced Principles of Anesthesia > Pediatric Pharmacology Principles > Flashcards

Pediatric Pharmacology Principles Flashcards

1
Q

What pharmacokinetic and pharmacodynamic priniciples are different in pediatrics then adults? (5)

A

large volume of distribution for water soluble medications (higher TBW)
decreased Vd of fat soluble drugs
Altered and reduced protein binding (increases free fraction of medications)
longer half lives (s/c to immature hepatic/renal function)
immature blood brain barrier

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2
Q

Describe the volume of distribution in neonates?

A

a proportionately higher total water content 70-75% (vs. adult is 50-60%)
-reduced % of fat
reduced amounts of lean muscle mass

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3
Q

What does the difference volume distribution in neonates vs adults result in?

A

ECF volume of distribution proportionately HIGHER than that of an adult
-potentially delayed excretion
-increased volume of distribution of water soluble drugs (related to higher total water content)
-HIGH membrane permeability in the newborn

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4
Q

What drugs are effected by the increased volume distribution in neonates?

A

antibiotics & succinylcholine

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5
Q

When administering water soluble drugs in neonates what is required of the dosing?

A

larger initial doses of water soluble drugs

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6
Q

What age does membrane permeability/ blood brain barrier improve?

A

age 2

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7
Q

Discuss protein binding in pediatrics

A

reduced total serum protein concentrations
more of the administered drug is free in the plasma to exert a clinical effect
reduced dosing may be needed for drugs

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8
Q

What drugs are effected by the protein binding changes in pediatrics?

A

lidocaine and alfentanil
barbiturates and local anesthetics

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9
Q

What is required of dosing in drugs that are protein bound? Drug examples?

A

reduced dosing may be needed
barbiturates and local anesthetics

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10
Q

In general what do hepatic enzymes do to metabolize medications?

A

convert medications from a lesser polar state (lipid soluble) to a more polar, water soluble compound

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11
Q

What is hepatic metabolism like in neonates?

A

reduced in neonates
reduced ability to break down medications from a lipid soluble state to a more polar water soluble compound for excretion

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12
Q

Describe the ability to metabolize a conjugate medication as a neonate ages

A

the ability to metabolize a conjugate medication improves with age with both increased enzyme activity and increased delivery of drugs to the liver

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13
Q

Describe renal function in pediatrics

A

renal function is less efficient than in adults
incomplete glomerular development
low perfusion pressure
inadequate osmotic load
GFR and tubular function develop rapidly in first few months of life

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14
Q

What drugs have a prolonged elimination half-life in neonates?

A

amnioglycosides and cephalosporins have a prolonged elimination half life in neonates

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15
Q

Describe the concentration of inhaled anesthetics in the alveoli in pediatrics

A

the concentration of inhaled anesthetics in the alveoli increase more rapidly with decreasing age
infants> children> adults

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16
Q

What is a serious complication of inhalation agents and pediatrics?

A

overdose can occur quickly

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17
Q

Describe the inhalation agent sequence in pediatrics

A

more rapid inhalation induction
excretion and recovery of inhaled anesthetics is more rapid

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18
Q

What are the determinates of the wash-in of inhalation agents

A

inspired concentration
alveolar ventilation
functional residual capacity
cardiac output
solubility
alveolar to venous partial pressure gradient

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19
Q

What is the relationship between solubility and wash-in of an inhalation agent?

A

wash-in is inversely related to the blood solubility

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20
Q

List the inhalation agents from lowest blood solubility to highest blood solubility

A

N20
desflurane
sevoflurane
isoflurane
halothane

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21
Q

Describe the physiological components that allow a faster wash in for pediatrics

A

increased respiratory rate
decreased FRC
increased cardiac output distribution to vessel rich groups

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22
Q

What do increased respiratory rate, decreased FRC and an increase in CO cause?

A

they result in a rapid RISE (wash in) in alveolar anesthetic concentration that rapidly equilibrates with blood concentrations

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23
Q

What does N20 allow for in inhalation inductions?

A

2nd gas effect will speed induction further

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24
Q

What are other possible explanations of wash in with pediatrics?

A

cerebral mutation
age related differences in blood-gas parition coefficients
state of hydration/dehydration
type of anesthesia circuit
vaporizer design

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25
Q

Why is there an increased risk of overdose with pediatric and inhalation agents?

A

faster induction + immature cardiac development

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26
Q

What is very sensitive to volatiles in pediatrics? Why?

A

blood pressure
lack compensatory mechanisms
immature myocardium
reduced calcium stores

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27
Q

How does MAC change with age?

A

infants have a higher MAC than noted in older children or adults

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28
Q

Describe the relationship of NDMRs and volatiles?

A

all potentiate the actions of NDMRs

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29
Q

What is MAC of sevo in an neonate?

A

3.2

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30
Q

What is the MAC of sevo in an infant?

A

3.2

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31
Q

WHat is the MAC of sevo in a child

A

2.5

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32
Q

What is the MAC of iso in a neonate?

A

1.6

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33
Q

What is the MAC of Iso in an infant?

A

1.8

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34
Q

What is the MAC of iso in a child?

A

1.4

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35
Q

What is the MAC of des in a neonate?

A

9.2

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36
Q

What is the MAC of des in an infant?

A

10

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37
Q

What is the MAC of des in an child?

A

8.2

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38
Q

What is the peak MAC age?

A

peaks around 3 months of age

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39
Q

What is stage 1 of anethesia?

A

stage of analgesia or disorientation
from beginning of induction of general anesthesia to loss of consciousness

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40
Q

What is stage 2 of anesthesia?

A

stage of excitement or delirium
from the loss of consciousness to onset of automatic breathing
eyelash reflex will disappear but other reflexes remain intact and coughing, vomiting and struggling may occur; respiration can be irregular with breath-holding

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41
Q

What is the first plane of stage 3?

A

From the onset of automatic respiration to cessation of eyeball movements
eyelid reflex is lost, swallowing reflex disappears, marked eyeball movement may occur but conjunctival reflex is lost at the bottom of the plane

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42
Q

What is the 3rd stage of anesthesia called?

A

surgical anesthesia
from onset of autonomic respiration to respiratory paralysis
Divided into 4 planes

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43
Q

What is the second plane during stage 3 of anesthesia?

A

from cessation of eyeball movements to beginning of paralysis of intercostal muscles
laryngeal reflex is lost although inflammation of the upper respiratory tract increases reflex irritability, corneal reflex disappears

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44
Q

What is the third plane of stage 3 anesthesia?

A

from beginning to completion of intercostal muscle paralysis
diaphragmatic respiration persists but there is progressive intercostal paralysis, pupils dilate and light reflex is abolished
laryngeal reflex lost in plane 2 can still be initiated by painful stimuli

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45
Q

What is the desired stage of anesthesia when muscle relaxation is not used?

A

stage 3 plane 3

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46
Q

What is plane 4 of stage 3 anesthesia?

A

from complete intercostal paralysis to diaphragmatic paralysis

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47
Q

What is stage 4 anesthesia?

A

anesthetic overdose causing medullary paralysis and vasomotor collapse

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48
Q

What is commonly used in pediatrics to inhalation induction? why?

A

nitrous oxide
enhances the rate of uptake into the alveoli (2nd gas effect)

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49
Q

What does nitrous oxide add during maintenance?

A

analgesia and amnesia during maintenance

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50
Q

What is nitrous oxide’s MAC and blood gas coefficient?

A

odorless, insoluble
blood gas coefficient 0.47
MAC 104%

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51
Q

What does the anesthetic implication of a low blood: gas coefficient ?

A

Nitrous is 0.47
Fi/FA therefore, its is not soluble into the blood and will cross the BBB quicker leading to a faster onset

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52
Q

When is nitrous oxide contraindicated?

A

pnemothorax, necrotizing entercolitis, bowel obstructions

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53
Q

How long does 70% N2o take to double the size of a pneumothorax?

A

12 minutes

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54
Q

What N2O cause?

A

PONV

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55
Q

What is the 2nd gas effect?

A

Dalton’s Law of Partial pressure
The total pressure of a gas is equal to the sum of the pressures of the individual gases in a mixture

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56
Q

Name the characteristics of Sevoflurane (5)

A

least irritating to the airway of VA
dose related depression in RR and TV
common to being with N2o then add sevoflurane in stepwise fashion
single vital capacity breath induction
high temperature gas mixtures, low fresh gas flow rates <2L/min and use of CO2 absorbers contain barium hydroxide or soda lime can increase the production of compound A

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57
Q

What is the BG coefficient of sevo?

A

0.68

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58
Q

What is the BG coefficient of isoflurane?

A

1.43

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59
Q

What are the characteristics of iso? (4)

A

slower and more pungent (major disadvantage)
appropriate to use in pediatrics, especially after inhalation induction
potentiates NDMRs to a greater extent than sevoflurane or desflurane
least costly inhalation agent

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60
Q

When would Iso be a good anesthetic for a case?

A

Possibly prevents seizures

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61
Q

What is the blood gas coefficient of desflurane?

A

smallest blood/gas coefficient
0.42

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62
Q

Describe characteristics of desflurane (4)

A

most pungent, causes airway irriation
(50% incidence of laryngospasm if used during induction)
better use is maintenance
use with LMA is controversial
emergence is rapid

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63
Q

Why does propofol require higher doses in children?

A

due to the increased volume of distribution

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64
Q

How is the half life of propofol in pediatrics compared to adults?

A

elimination 1/2 life is shorter

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65
Q

How is the plasma clearance of propofol in pediatrics compared to adults?

A

higher rates of plasma clearnance

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66
Q

Describe 2 characteristics of propofol

A

highly lipophilic and distributes rapidly from plasma to peripheral tissues

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67
Q

How long is propofol good for?

A

expires in 6hours

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68
Q

What is the dose of propofol for IV inductions in children?

A

1-3 mg/kg

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69
Q

What is the dose of propofol for TIVA infusion in children?

A

25mcg-200mcg/kg/min

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70
Q

At what does is intraoperative monitoring effected with propofol infusion?

A

<120-130mcg/kg/min

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71
Q

What is the mechanism of action of propofol?

A

presumed to exert its sedative hypnotic effects through an interaction with GABA, the principle inhibitory neurotransmitter in the CNS

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72
Q

How does propofol effect the CV system?

A

produces decrease in systemic vascular resistance and systolic BP
may produce profound hypotension in critically ill infants

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73
Q

What can propofol cause critically ill infants

A

may produce profound hypotension

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74
Q

What does propofol cause on injection?

A

pain

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75
Q

What does propofol help with?

A

decreases PONV

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76
Q

Describe propofol’s effect on the ventilation

A

produces dose-dependent depression of ventilation

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77
Q

What is the oral dose of ketamine?

A

6-10mg/kg

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78
Q

What is the IM induction dose of ketamine?

A

5-10mg/kg

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79
Q

WHat is the IM sedation dose of ketamine?

A

2-5mg/kg

80
Q

What is the IV induction dose of ketamine?

A

1-2 mg/kg

81
Q

WHat is the IV pain dose of ketamine?

A

0.5mg/kg bolus & 4mcg/kg/min infusion

82
Q

What does ketamine cause?

A

analgesic and amnestic

83
Q

How does ketamine work?

A

dissociation of the cerebral cortex
NMDA antagonist

84
Q

What are the side effects of ketamine?

A

secretions, vomiting, hallucinations

85
Q

What are the benefits of ketamine?

A

preserves spontaneous respirations and aids to maintain a patent airway

86
Q

What can still occur with ketamine despite its positive properties?

A

apnea and laryngospasm can occur

87
Q

What is the MOA of katemine

A

produces dissociative anesthesia
may resemble a cataleptic state
patients eyes may remain open with nystagmus gaze

88
Q

How does ketamine effect the CV system?

A

effects resemble sympathetic nervous system stimuation
increase BP, pulmonary pressures HR and CO

89
Q

How does ketamine effect the ventilatory system?

A

does not produce significant respiratory depression unless given by rapid IV dose
does produce bronchodilation and is useful in asthmatic patients

90
Q

What are side effects of etomidate?

A

pain on injection
myoclonus
anaphylactoid reactions
suppression of adrenal function

91
Q

What class is etomidate?

A

hypnotic steroid-based induction agent

92
Q

What is the dose of etomidate for pediatrics?

A

0.2-0.3mg/kg

93
Q

What is the main advantage of etomidate?

A

cardiovascular stability in hypovolemic patients

94
Q

What is the main disadvantage of etomidate?

A

adrenocortical suppression not well tolerated in critically ill children

95
Q

What is the MOA of etomidate?

A

presumed to produce CNS depression via an ability to enhance the inhibitory NT GABA

96
Q

How does etomidate effect the CV system?

A

produces minimal changes in heart rate and cardiac output

97
Q

How does etomidate effect the ventilation system?

A

produces dose-dependent depression of ventilation

98
Q

How do opioids affect pediatrics? why?

A

more potent effects
considered to be a result of an immature blood brain barrier
increased sensitivity to respiratory centers

99
Q

What is the dose of morphine?

A

0.025-0.05mg/kg IV

100
Q

What does morphine cause?

A

histamine release

101
Q

What is reduced with morphine metabolism in pediatrics?

A

hepatic conjugation is reduced
renal clearance is decreased

102
Q

Describe the DOA of fentanyl in pediatrics

A

increased duration of action in high doses related to decreased fat/muscle
30-60 minutes

103
Q

What class is fentanyl?

A

synthetic opioid agonist

104
Q

What is the MOA of fentanyl?

A

acts on steroeospecific opioid receptors in the CNS

105
Q

What are the effects of fentanyl?

A

used to produce analgesia and to blunt the circulatory response to direct laryngoscopy

106
Q

What is the onset of action of fentanyl?

A

almost immediate when drug given IV, however the maximal analgesic and respiratory depressant effect may not be noted for several minutes

107
Q

What is the dose of fentanyl?

A

0.25-1mcg/kg IV
0.5-2mcg/kg/hr gtt

108
Q

When can fentanyl dependence occur?

A

as little as 7 days

109
Q

Who may metabolize fentanyl more slowly?

A

neonates and preterms infants

110
Q

What class is hydromorphone?

A

semi synthetic opioid agonist
derivate of morphine

111
Q

How much more potent is hydromorphone then morphine?

A

5x more potent then morphine

112
Q

What routes are dilaudid administered?

A

IV and epidural

113
Q

What is the onset of dilaudid?

A

5 minutes

114
Q

What is the DOA of diluadid?

A

2-3 hours

115
Q

WHo is at risk for metabolite accumulation and neuroexcitatory symptoms?

A

patients with compromised renal function

116
Q

What are neuroexcitatory symptoms?

A

tremor, agitation, cognitive dysfunction

117
Q

What is naloxone?

A

antagonizes opioids

118
Q

What is the effect of naloxone?

A

reduces respiratory depression, N/V, puritus and urinary retention

119
Q

What is the dose for reversal of opioid induced respiratory depression?

A

0.25-0.5mcg/kg until doses reach effect
always titrate slowly

120
Q

what is the max dose of naloxone?

A

2mg

121
Q

What is the onset of naloxone?

A

rapid

122
Q

What is the elimination 1/2 life of naloxone?

A

1.5-3 hours

123
Q

What can a naxolone overdose cause?

A

systemic hypertension, cardiac arrhythmias, and pulmonary edema

124
Q

What is the DOA of midazolam?

A

1-6 hours

125
Q

What is the PO dose of midazolam as a pre-medications?

A

0.5mg/kg PO

126
Q

What is the onset of PO midazolam?

A

20 minutes

127
Q

What is the intranasal dose of midazolam?

A

0.2-0.3mg/kg

128
Q

What is the pre-medication IV dose of midazolam?

A

0.05mg/kg IV

129
Q

What the onset of IV premedication versed?

A

5 mintues

130
Q

What is the PICU sedation gtt of versed?

A

0.4-2mcg/kg/minute

131
Q

What is the MOA of clonidine?

A

pre-synaptic alpha agonist
binding decreases calcium levels thus inhibiting release of NE

132
Q

What is the oral premed dose of clonidine and OSA?

A

4mcg/kg
60-90min onset

133
Q

How can clonidine be used in addition to a pre-medication? Dosing?

A

adjunct to regional anesthesia
1-2mcg/kg epidural/caudal
prolongs analgesia by 3 hours

134
Q

What can clonidine cause?

A

residual sedation post-operatively

135
Q

What is the purpose of flumazenil?

A

reversal agent for benzodiazepine

136
Q

What is the MOA of flumazenil

A

GABA receptor antagonist

137
Q

What is the onset of flumazenil?

A

rapid onset of 5-10 minutes

138
Q

What is the IV dose of flumazenil?

A

10mcg/kg

139
Q

What is the elimination 1/2 life of flumazenil?

A

1 hour

140
Q

What is the MOA of dexmedetomidine?

A

8x more specific for alpha 2 adrenergic receptor then clonidine with anxiolytic, sedative and analgesic properties

141
Q

What is the benefit of precedex?

A

sedation without respiratory depression

142
Q

What is the elimination 1/2 life of precedex?

A

2 hours

143
Q

What is the oral dose of precedex?

A

1mcg/kg

144
Q

What is the intranasal dose of precedex?

A

1mcg/kg

145
Q

What is the IV dose of precedex?

A

0.25-1mcg/kg over 10-15 minutes

146
Q

What is the gtt rate for precedex?

A

0.2-2mcg/kg/hour

147
Q

What population has increased sensitivities to NMBD? why?

A

neonates
reduction in release of acetylcholine and reduced muscle mass
fetal receptors have a greater opening time, allowing more sodium to enter the cell

148
Q

What are characteristics of relaxants in pediatrics?

A

shorter onset (50%) because of faster circulation times

149
Q

What is the dose of roc?

A

0.6mg/kg (1.2mg/kg IV RSI)

150
Q

What is the dose of cisatricurium?

A

0.15mg/kg IV

151
Q

What is the dose of vecuronium?

A

0.1mg/kg IV

152
Q

What is the dose of glycopyrrolate IV?

A

0.01mg/kg

153
Q

WHat is the dose of neostigmine IV?

A

0.05mg/kg IV

154
Q

WHat is the dose of sugammadex IV?

A

2-4 mg/kg IV
16mg/kg IV for 1.2mg/kg roc dose

155
Q

What relaxant has the fastest onset of action?

A

succinycholine

156
Q

What is the recovery time of succinylcholine in pediatrics?

A

similar to adults

157
Q

Why is succinylcholine cautiously used in pediatrics?

A

cardiac arrhythmias
hyperkalemia
myoglobinuria
masster muscle spasm
malignant hyperthermia

158
Q

If cardiac arrest occurs after succinycholine administration what are you treating?

A

hyperkalemia

159
Q

WHat is the dose of atropine and why is it adminstered?

A

0.02mg/kg IV/IM to prevent bradycardia

160
Q

What is the IV intubation dose of succinylcholine?

A

<10kg 2mg/kg
>10kg 1-2mg/kg

161
Q

What is the IM dose of succinylcholine?

A

4mg/kg

162
Q

What is the IV dose of succinylcholine for a laryngospasm?

A

0.25-0.5mg/kg

163
Q

Describe the characteristics of non-depolarizing muscle relaxants in pediatrics (3)

A

much greater variability with dose and response
immaturity of the neuromuscular junction and increased extra-junctional receptors may result in increase sensitivity to drugs
immaturity of the hepatic system may result in prolonged duration of action required to the liver to metabolize (pancuronium, vecuronium, rocuronium)

164
Q

What class is rocuronium?

A

steroid based muscle relaxant

165
Q

What is the onset of an RSI dose of ROC?

A

45 seconds

166
Q

What is the disadvantage of an RSI dose of ROC?

A

60-90 minutes

167
Q

What is the low dose of roc?

A

0.3mg/kg
intubating conditions in 3 minutes

168
Q

What is the advantage of sugammadex compared to succinylcholine?

A

urgent or emergent reversal of large doses of rocuronium (1.2mg/kg) the mean time to neuromuscular recovery is significantly faster with sugammedex (16mg/kg) compared to spontaneous recovery with succinylcholine

169
Q

What class is ketorlac?

A

NSAID

170
Q

What is the dose of ketorlac?

A

0.5mg/kg

171
Q

What is the 1/2 life of ketorlac?

A

4 hours

172
Q

When do you use ketorlac cautiously?

A

impaired in renal, increased risk of bleeding, impaired bone healing

173
Q

Who should ketorlac be reserved for?

A

children> 1 year

174
Q

Describe neonate glucose homeostasis

A

neonates have low glycogen stores and are prone to hypoglycemia during NPO and stress (illness and surgery)
impaired glucose excretion by kidneys can work to offset these problems

175
Q

WHat are symptoms of hypoglycemia?

A

jitteriness, convulsions, apnea

176
Q

How do you manage acute hypoglycemia management?

A

10% dextrose 1-2ml/kg
never administer a bolus of D50 due to risk of vessel necrosis and high osmolarity
maintenance on supplemental IV dextrose infusions
minimize preoperative fasting

177
Q

Describe the grams of drug per 100mls of fluid: D50

A

D50%
50grams of dextrose per 100ml
0.5g/ml

178
Q

Describe the grams of drug per 100mls of fluid: D10

A

D10%
10grams in 100ml
0.1g or 10mg in each ml

179
Q

Describe the grams of drug per 100mls of fluid: D5

A

D5%
5g in 100ml
0.05g or 5mg in each ml

180
Q

Describe how to dilute D50 to D10 and D5 for PIV administration

A

take 1ml of D50% dilute into total of 5ml= 0.1g/ml or D10
take 1ml of D50% and dilute into 10ml=0.05g/ml or D5

181
Q

Epi Dose for Hypotension

A

1mcg/kg IV

182
Q

Epi dose of cardiac arrest

A

10mcg/kg IV q3-5 minutes

183
Q

Atropine IV dose for symptomatic bradycardia

A

20mcg/kg

184
Q

Max dose of atropine

A

1mg for child
2mg for adolescent

185
Q

What is the bicarbonate dose IV

A

1-2mEq/kq to be guide by blood analysis results

186
Q

What is the IV Calcium chloride dose?

A

10-20mg/kg IV
0.1-0.2mg/kg of a 10% solution

187
Q

What is the IV calcium gluconate dose?

A

30-60mg/kg IV (0.3-0.6mg/kg of a 10% solution)

188
Q

What is the dose of adenosine?

A

IV 100mcg/kg rapid IV push and flush

189
Q

What is the max dose of adenosine?

A

6mg

190
Q

What is the second dose of adenosine?

A

200mcg/kg
max 12mg

191
Q

What is the dose of IV lidocaine?

A

1mg/kg followed by 20-50mcg/kg/min gtt

192
Q

What is the dose of amiodarone?

A

5mg/kg IV
Max 300mg
Ventricular fibrillation/ ventricular tachycardia

193
Q

What is the dose of procainamide?

A

5-15mg IV
loading dose over 30-60minutes
then 20-80mcg/kg/min by infusion pump
EKG required

194
Q

What is the caution of procainamide?

A

hypotension and prolonged QT may occur

195
Q

What is the IV dose of magnesium?

A

25-50mcg/kg
max 2g for torsades de pointes

196
Q

What is the intranasal dose of ketamine?

A

3mg/kg nasal

N934: Advanced Principles of Anesthesia (16 decks)

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