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Summer 2020 - Advanced Anesthesia - Pediatrics > Pediatric Pharmacology & Trauma - Quiz 4 > Flashcards

Pediatric Pharmacology & Trauma - Quiz 4 Flashcards

1
Q

How is Drug Absorption in the Neonate different from Infants, Children, & Adults?

A

Less Acidic pH

Slower Gastric Emptying & Transit

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2
Q

What influences IV Drug Distribution?

A

Protein Binding

RBC Binding

Tissue Volumes, Solubility, & Blood Flow

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3
Q

What are the characteristics of Protein Binding in the Neonate?

A

Less Plasma Proteins & Less Protein Affinity = Larger Volume Distribution

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4
Q

What is the Physiologic Nadir of Hemoglobin?

A

When infants have anemia 3-6 months after birth where fetal Hgb is eliminated & a slow production of RBCs begin

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5
Q

Why might the Neonate need more Higher per kg drug doses than the Child or Adult?

A

Neonates have more tissue volume –>

Total Body Water

ECF

Blood Volume

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6
Q

Why are many drug concentrations higher in the Infant’s Brain than the Adult’s Brain?

A

Immature BBB = Easier Lipid Drug Diffusion

Rate of Entry = Blood FLow

Infant Brain gets a lot of Cardiac Ouput

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7
Q

How does the Neonate’s smaller Muscle Mass & Fat stores affect drug distribution?

A

Less Uptake to Inactive Sites & Higher Plasma Volumes of the Drug

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8
Q

Why is Postnatal age more important in regards to the Ability to Metabolize Drugs?

A

Drug metabolism develops to the same degree in the same time period after birth

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9
Q

What are some examples of R>L Shunt?

A

Tetralogy of Fallot

Transposition of Great Arteries

Tricuspid Atresia

Total Anomalous Pulm. Venous Return

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10
Q

At what age does the Renal Clearance of drugs reach Adult Values?

A

3 Months of Age

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11
Q

Since Tidal Volume is constant througout life, what Respiratory aspect contributes to Infants having a more rapid Uptake of Inhaled Anesthetics?

A

Infants have higher Alveolar Ventilation in relation to FRC of 5:1 versus 1.4:1 for Adults

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12
Q

Which Inhaled Anesthetics have more effect on Shunting?

A

Insoluble Agents - Sevo & N2O

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13
Q

How does R>L Shunting affect Inhaled Anesthetic Uptake?

A

Slow On & Slow Off

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14
Q

How does L>R Shunting affect Inhaled Anesthetic Uptake?

A

Depends on Shunt Size

Small (<50%) = No change

Large (>80%) = Faster Uptake

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15
Q

What are some examples of L>R Shunts?

A

Atrial Septal Defect

Ventricular Septal Defect

Patent Ductus Arteriosus

Blalock-Taussig

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16
Q

What is the relationship b/t MAC and Age?

A

MAC increases the 1st month of life, then starts to decrease after 6 months of life

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17
Q

How does the Neonate’s response to pain develop?

A

Reponse to pain diminshed in first week of life & matures rapidly in first few months

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18
Q

Why do Infants have Bradycardia, Hypotension, and Cardiac Arrest more than Adults during Induction?

A

Increased CV Sensitivity

Over-Pressuring of Gas

Limited Baroreceptor Reflex (Gas worsens this)

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19
Q

What are the CV affects of Halothane?

A

Dose-Dependent Cardiac Depression

↓PVR

Act as CC-Blocker

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20
Q

What are the initial signs of Halothane Overdose?

A

Bradycardia

Hypotension

Muffled Heart Tones

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21
Q

What are the CV Effects of Isoflurane?

A

Direct Negative Inotrope
(but less than Halothane)

↓↓↓PVR

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22
Q

Why isn’t Isoflurane used for Inhaled Induction?

A

Pungent Smell & Airway Irritation

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23
Q

Why might Sevo be used rather than Isoflurane or Halothane?

A

Less Soluble –> Rapid Wash In

&

More CV Stable w/ less Dysrhythmias

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24
Q

How does adding N2O to Sevo affect the MAC in Adults vs Kids 1-3 years old?

A

Adults: N2O decreases MAC Proportionately

Kids (1-3): N2O decreases MAC by only 25%

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25
Q

Why is Desflurane not used for Kids?

A

Pungent

Airway Irritant

↑Laryngospasm Risk

Emergence Delirium

CV Stable, but ↓SVR

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26
Q

What is the Inhaled Induction Method w/ Sevo?

A
  • Start w/ O2/N2O @ 2L/4L
  • Then Sevo @ 8% until Deep enough for IV
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27
Q

When does separation anxiety begin, warranting the use of Pre-Op Versed?

A

> 9 months

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28
Q

What is the pediatric dose for Oral Versed?

A

0.5 - 1 mg/kg

15-30 min. Onset

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29
Q

What is the pediatric dose for Intranasal Versed?

A

0.2 - 0.3 mg/kg

Onset: 1 min

Peak @ 10 min.

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30
Q

What is the pediatric dose for IV Versed?

A

0.1 mg/kg

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31
Q

What is dose of Thiopental for Neonates?

A

3 mg/kg

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32
Q

What is Thiopental dose for Infants & Children?

A

5 - 7 mg/kg

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33
Q

What is the Thiopental dose for Adults?

A

3 -5 mg/kg up to 10 mg/kg d/t rapid redistribution

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34
Q

What is the ED50 for Propofol in Infants?

A

3 mg/kg

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35
Q

What is the ED50 of Propofol for Older Children?

A

2.4 mg/kg

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36
Q

What is the Pediatric dose for IV Ketamine?

A

2 mg/kg

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37
Q

What is the Pediatric dose for IM Ketamine?

A

3-6 mg/kg

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38
Q

Ketamine has potent analgesic properties for skin, muscle, and bone, but NOT for what?

A

Viscera

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39
Q

What should be given along with Ketamine for its side effects?

A

Antisialogogue - for increased salivation

&

Versed - for hallucinations

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40
Q

How do Neonates respond to Narcotics?

A

More Sensitive

More Toxic

Respiratory Depression

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41
Q

What is the Pediatric dose for Morphine?

A

0.05 - 0.1 mg/kg

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42
Q

Morphine has a longer half life in Neonates, what is the Elimination half-life?

A

Up to 14 hours

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43
Q

How much Protein Binding of Morphine is there in the Neonate vs. the Adult?

A

Neonate: 18-22%

Adult: 30-35%

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44
Q

What is the Pediatric dose for Fentanyl?

A

1 - 5 mcg/kg

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45
Q

What is the concern when giving Fentanyl to Premature Infants?

A

Clearance is Markedly Reduced

(Up to 32 Hour Half-Life)

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46
Q

What is the Pediatric Infusion Dose for Remifentanil?

A

0.02 - 2 mcg/kg/min

Onset: 1 min

Half-Life: 9 min

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47
Q

Why is a Bolus IV Dose of Remifentanil rarely used?

A

Profound Bradycardia & Asystole

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48
Q

Why are Anticholinergics used in the Pediatric Population?

A

Protect Against Cholinergic Challenge - Prevent Bradycardia

Inhibit Secretions

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49
Q

Why is Bradycardia such a big concern in the Pediatric Population?

A

Neonates are born w/ a fully developed PNS

The SNS does NOT fully develop until 3-6 months of age

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50
Q

What is the Pediatric dose for Atropine?

A

10 - 20 mcg/kg

Onset: 1 min

Duration: 30 - 60 min

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51
Q

What is the main reason why Atropine is used in Pediatrics?

A

Prevent Bradycardia > Antisiologogue effects

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52
Q

Does Atropine cross the Blood Brain Barrier?

A

Yes

53
Q

What is the Pediatric Dose for Glycopyrrolate?

A

10 - 20 mcg/kg

Onset: 2-3 min

Duration 30 - 60 min

54
Q

What is the Induction Infant Dose for Succinylcholine?

A

2.2 mg/kg

55
Q

What is usually given before Sux administration in Pediatrics?

A

Atropine - to contest profound bradycardia from Sux

56
Q

What are the age related differences that change the dosing of Sux?

A

Cholinesterase Activity

Receptor Sensitivity

Volume of Distribution

57
Q

When is Sux contraindicated because of its large potassium release?

A

Neuro Conditions

Muscular Dystrophies

Myotonia

Burns

MH

58
Q

What is the Pediatric Induction dose of Rocuronium?

A
  • 0.6 mg/kg
  • Onset: 1.5 min
  • Duration:
    • Infants < 10 months: 45 min
    • Kids 1-5 yrs.: 25 min
59
Q

What is the Pediatric Cisatracurium Dose?

A

0.1 - 0.2 mg/kg

Onset: Dose-Dependent 2-3 min

Duration 30-45 min

60
Q

How do Neostigmine & Edrophonium work?

A

Inhibits acetylcholinesterase, increasing ACh which competes w/ NDNMB

61
Q

What is the Pediatric Neostigmine Dose?

A

35 - 70 mcg/kg

Given w/ Atropine & Robinul

Must have 2/4 twitches for it to work

62
Q

How does Neostigmine compare to Edrophonium?

A

Neostigmine is more potent, but slower onset

63
Q

What is the Pediatric Dose for Edrophonium?

A

0.5 - 1 mg/kg

Given w/ Atropine

Must have at least 3/4 twitches for it to work

64
Q

What is the Sugammadex dose?

A

2 mg/kg - Shallow Block after T2

4mg/kg - Deep Block w/ 1-2 Post-Tetanic

65
Q

What are the first signs of LA Toxicity in Infants & Children?

A

Dysrhythmias or CV Collapse

66
Q

What are the common Local Anesthetics used in Pediatrics?

A

Lidocaine

Bupivacine

Ropivacaine

For Caudal Blocks & Local/Intra-Tracheal Infiltration

67
Q

What is the Max Lidocaine Dose w/ & w/o Epi

A

W/O Epi: 5 mg/kg

W/ Epi: 7 mg/kg

68
Q

What is the Max dose for Bupivacaine?

A

2.5 mg/kg

69
Q

What is the Max dose for Ropivacaine?

A

0.5 - 1 mL/kg

(2.5 mg/kg)

70
Q

What is the Max dose for Epinephrine?

A

2 - 3 mcg/kg/dose

Can re-dose after 30 min

71
Q

Other than its sedative and analgesic effects, what drug can also be used to treat SVT?

A

Precedex

72
Q

What is the dose for Precedex?

A

Bolus: 0.25 - 1 mcg/kg

Infusion: 0.2 - 1 mcg/kg/hr

73
Q

What is Tranexamic Acid?

A

Antifibrinolytic - Blocks Lysin Binding site and prevents Plasminogen converting to Plasmin

&

Anti-Inflammatory

74
Q

How does TXA compare to Amicar?

A

TXA is 10x more potent

75
Q

What is the dose for TXA?

A

Loading: 30 mg/kg

Infusion: 10 mg/kg/hr

76
Q

What are the Primary Causes of Pediatric Death or Long Term Disability?

A

Traumatic Brain Injury - 70%

Thoracic Injury - 20%

Abd. Injury - 10%

77
Q

What are the Categories of Pediatric Trauma?

A

Blunt - 90%

Penetrating - 10%

Burns

78
Q

What is included in the Primary Survey?

A
  • Airway
  • Breathing
  • Circulation
  • Disability - Assess Neuro
  • Expose - Remove clothes for visual exam
79
Q

What is included in the Secondary Survey?

A

Head to Toe

History

Labs

Imaging

80
Q

The pediatric Larynx & Glottic Opening is more _____ compared to adults

A

The pediatric Larynx & Glottic Opening is more CEPHALAD compared to adults

81
Q

Due to their big head & lack of neck muscles, what should be placed on a child who comes in as a trauma?

A

Head & Neck Protection - C-Collar

Assume C-Spine Injury

82
Q

How should Intubation be done w/ a C-Spine Injury?

A

Avoid Head & Chin Maneuvers

Use MILS

Direct Laryngoscopy w/ RSI

Video Assist

83
Q

What should be avoided whenever there is a Head Injury or Basilar Skull Fracture?

A

Nasal Instrumentation

84
Q

What are signs & symptoms of a Basilar Skull Fracture?

A

Rhinorrhea

Otorrhea

PeriOrbital Ecchymosis

85
Q

What does Crepitus indicate & how should this patient be intubated?

A

Tracheal/Bronchial Interruption

Use Awake Fiberoptic Intubation

86
Q

For a Difficult Airway in Pediatric Trauma, what meds should and should NOT be given?

A

Propofol

Remifentanil

Inhaled Induction w/ Spont. Ventilation

Avoid NMBs until Airway Secured

87
Q

What is an early sign of Shock?

A

Tachycardia - can be an early sign of Hypovolemia & Hemorrhagic shock

88
Q

How much total blood volume can be loss before there is ever any sign of hypotension?

A

Late Sign

25 - 35% of Total Blood Volume

or

~ 20 mL/kg

89
Q

Other than Tachycardia, what are other signs of Shock & Inadequate Peripheral Perfusion?

A

Delayed Cap. Refill

Weak Pulses

Mottling

Cyanosis

Impaired LOC

90
Q

In the setting of Shock, what does Bradycardia indicate?

A

Hypoxemia

Impending Arrest

↑ICP

91
Q

What are signs & symptoms of a <20% Pediatric Blood Loss?

A

Tachycardia

Weak Pulses

Cool Touch

↓Urine Output w/ ↑Specific Gravity

Irritable

92
Q

What are signs & symptoms of a 25% Pediatric Blood Loss?

A

Same as w/ < 20%, but with

Cold Extremities

Cyanosis/Mottling

Confusion

Lethargy

93
Q

What are signs & symptoms of a 40% Pediatric Blood Loss?

A

Frank Hypotension

Bradycardia

Pale

No Urine Output

Comatose

94
Q

What is the initial Fluid Bolus for Pediatric Volume Resuscitation?

A

20 mL/kg of Warmed LR or NS

95
Q

What is the next course of action for Pediatric Volume Resuscitation if the initial fluid bolus produces a transient or no response?

A

20 mL/kg Second Bolus of Warmed LR or NS

Give Third Bolus if needed

96
Q

How much Blood should be given for Pediatric Volume Resuscitation?

A

10 mL/kg

97
Q

What might causes Persistent Shock even after Volume Resuscitation?

A

Long Bone & Pelvic Fractures

Pericardial Effusion & Tamponade

Tension Pneumo

Intra-Abd. Injuries

Intracranial Bleed

98
Q

In Infants, what factor might cause Significant Unrecognized Blood Loss related to Intracranial Hemorrhage?

A

Expandable Fontanelle

99
Q

Why are “FAST” Sonograms less valuable for smaller patients?

A

Less Free Fluid

100
Q

What are the Primary & Secondary Neuro Surveys?

A

Primary - AVPU - Alert, Voice, Pain, Unresponsive

Secondary - GCS - Intubate if < 8

101
Q

What are the different types of Facial Trauma?

A

Soft Tissue - Most common, falls

Dental

Facial Fractures - Least Common

102
Q

What is the most common type of Facial Fracture?

A

Nasal > Mandibular > Maxillary

103
Q

Sometimes there are Oral Lacerations & Impalement, what should be done before the object is removed?

A

Angiogram

104
Q

Why are Pediatric Chest Injuries potentially Life Threatening?

A

Impairs Breathing & Circulation

Monitor or Place Thoracotomy Tube

105
Q

What are signs & symptoms of a Tension Pneumo?

A

↓Breath Sounds & Lung Compliance

Tracheal Deviation

Hypotension

↑PAP

106
Q

How is a Tension Pneumo treated?

A

Needle Decompression @ 2nd ICS, Midclavicular

107
Q

What causes an Open Pneumo?

A

Chest Wall Defect that equalizes pressures of the Pleural Space w/ Outside Environment

108
Q

How is an Open Pneumo treated?

A

Cover w/ Occlusive Dressing + Tape on 3 Sides

109
Q

What is the most common type of Abdominal Injuries?

A

Blunt Trauma - cause of 10% Trauma Deaths - treated w/ Medical Management rarely needing Surgery

110
Q

What is almost always associated w/ Multi-System Trauma?

A

Traumatic Brain Injury

111
Q

Why are Traumatic Brain Injuries the leading cause of Pediatric Death?

A

Big Head

Weak Neck

Thin Cranial Bones

Less Myelinated Nerve Tissue

112
Q

What are the Phases of Traumatic Brain Injury?

A

Primary Injury

Secondary Injury - Cerebral & Systemic Response

113
Q

What is the Goal in regards to Traumatic Brain Injuries?

A

Minimize Secondary Injury

114
Q

Where is the Cervical Mobility in Children vs Adults?

A

Children: C2-3

Adults: C5-7

115
Q

What characteristic of the Pediatric Spine decreases the incidence of Fractures?

A

Ligamentous Laxity

116
Q

What are the Mechanisms of Lawnmower Injuries?

A

Lower Mower Stability

Blade Contact

Mower Layout, Function, & Controls

Running/Backing Over

117
Q

What type of Skeletal Injuries include Vascular Involvement?

A

Supracondylar Distal Humerus Fracture

Distal Femur

Proximal Tibia

Displaced Pelvic Fracture

Knee Dislocation

118
Q

Which Induction Med is Neuro Protective and is a Profound Vasodilator?

A

Propofol

119
Q

Which Induction Med has Hemodynamic Stability, Neuro Protective, and Suppresses the Adrenal Response?

A

Etomidate

120
Q

What are the effects of using Ketamine for Induction?

A

Sympathetic Outflow

↑CBF

Marked Hypotension

Not Neuro Protective

121
Q

How much Allowable Blood Loss can be replaced w/ only cystalloids?

A

Up 40% ABL, except for pts w/ certain pre-existing conditions

122
Q

What should be given along with PRBCs?

A

Calcium - citrate binds to calcium & inactivates it

123
Q

When is FFP indicated?

A

Abnormal PT/PTT to replace Factors 2, 5, 8, 9, 10, 11, & AntiThrombi 3

&

For kids who received > 1 PRBC

124
Q

How long does it take to thaw FFP and How long is it good for?

A

45 min to Thaw, Good for 24 hrs.

125
Q

What is the Initial Pediatric dose for FFP?

A

10 - 15 mL/kg

126
Q

Platelets are usually required _____ FFP

A

Platelets are usually required BEFORE FFP

127
Q

How much will the Platelet count rise w/ 0.1 units/kg?

A

20,000

128
Q

True or False: Platelets should be Refrigerated.

A

FALSE

Summer 2020 - Advanced Anesthesia - Pediatrics (6 decks)

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