Pediatric Pre-operative Evaluation, Set-up and anesthetic induction Flashcards
What pediatric population has the highest rate of adverse events?
infants
List possible adverse events
bradycardia s/c to hypoxia and high VA concentrations
respiratory complications (bronchospasm, laryngospasm, apnea)
cardiac arrest (8/10 from hyperkalemia d/t transfusion)
medication related
equipment related (CVC insertion, pnemothorax, hemothorax)
What is the age of a newborn?
1-28 days
What is the age of an infant?
less then 1 year
what is the age of a small child?
2-5 years
What is the age of school aged children?
6-14 years
What ages are adolescents?
> 14 years- 18 years
Describe the stage of development for a 0-6month old
not usually upset by separation from parents
prolong separation may impair parent-child bonding
Describe the psychological aspect between 6 months and 4 years
separation anxiety, fear of hospitalization, may show regressive behavior
Describe the psychological aspect of school aged children
less upset by separation from parents
asks questions involved
wants choices, more concerned with surgical procedure and its possible affects on body image
Describe the psychological aspect of adolescents
fear the process of narcosis, the loss of control, walking up during surgery, and pain of surgery, value modesty, HCG testing in females
Describe the psychological aspect of parents
provide explanation of what to expect
What are two drugs where HCG testing in adolescents needs to be recongized?
aprepitant (4 weeks)
sugammedex (2 weeks)
When is it not approprirate to bring the parent back for inductions?
adeqaute preoperative sedation
the parent’s level of anxiety
language barrier
emergency RSI cases
anticipated difficult airway or unstable patient
pregnant mother (due to N20)
What are important aspects of the pre-op interview?
sources of information
NPO status
current weight
ausculation of the lungs and heart
evaluation of the airway, inquire about loose teeth
PMH, previous anesthetics, MH
recent URIs or fevers
cigaretter exposure in the home
possibility of pregnancy
allergies and current medications
What are the NPO guidelines?
clears- 2 hours
breast milk 4 hours
formula, non human milk, light meal 6 hours
fatty food 8 hours
Important history questions regarding patients age
gestational, conceptulal, birth history, maternnal pregnancy history
Important history questions regarding patients CNS
seizures, hydrocephalus, neuromuscular disorders, head trauma, autism
Important history questions regarding patients CV
murmur, cyanosis, dyspnea, sweating, hypertension, exercise tolerance, congential heart defects, indications for subacute bacterial endocarditis
Important history questions regarding patients respiratory status
prematurity, respiratory distress syndrome, apnea, recent respiratory infection (URI), cough, croup, asthma, cystic fibrosis, need for pre-op oxygen therapy
Important history questions regarding patients GI
NPO status
reflux
vomiting
diarrhea
liver
Important history questions regarding patients GU
renal failure, bladder surgery
Important history questions regarding patients endocrine
diabetes, thyroid, pituitary, adrenal steroid therapy
Important history questions regarding patients Hematology
anemia, bruising, bleeding, sickle cell
Important history questions regarding patients immunology
allergies, immunocompromised
Consider collecting a hemoglobin on
neonates, premature infants, cardiopulmonary disease, known hematologic dysfunction, and anticipated blood loss during the surgical procedure
What are irritable airways at an increased risk for?
laryngospams, bronchospasms, post-intubation croup, ateletasis, pneumonia, and desaturations
What should be considered in an child with an URI
LMA over an ETT
What are reasons to postpone surgery?
elective, febrile, elevated WBC, productive and purulent sputum, getting worse, acutely ill, malaise, tachypnea, wheezing
What are the increased risk of an URI with GA?
need for ETT
asthma reactive airway
tracheal mucocillary flow and pulmonary bactercidal activity is decreased by general anesthesia
PPV may help spread the infection from upper to lower airways
How do you manage anesthesia with a URI
adequate hydration, oxygenation
reduce secretions, limit airway manipulation
bronchodilators (beta 2 for wheezing)
anticholinergics (prevents bronchospasm)
muscle relaxants for laryngospasm
When does a cardiologist need to evaluate a murmur prior to induction of anesthesia?
difficult feeding, SOB, poor exercise tolerance, can’t match peers, family history of CHD, cyanotic episodes, abnormal peripheral pulses, unequal blood pressures in upper and lower extremities
What the max dose of PO versed?
20mg
What are the special considerations for premedication?
careful sedating a child with congenital heart disease, increase ICP, OSA, sepsis, trauma or suspected difficult airway
What do you need for set up in pediatrics?
blood pressure cuff
ECG (5 lead for cards)
pulse oximeter
capnography
temperature
neuromuscular function
shoulder roll
What is the normal VSS for premature baby?
HR
SBP/DBP
MAP
120-170
55-75
35-45
40-55
What is the normal VSS for 0-3month?
HR
SBP/DBP
MAP
100-150
65-85
45-55
52-65
What is the normal VSS for 3-6 months?
HR
SBP/DBP
MAP
90-120
80-100
55-65
63-77
What is the normal VSS for 1-3 years?
HR
SBP/DBP
MAP
70-110
90-105
55-70
67-82
How do you prepare for an induction?
warm the operating room and check warming devices
pre-induction checklist of equipment, suction, emergecny airway devices, ventilator default and monitoring setting
consider a chair or stool
ensure a quiet calm operating room environment
a variety of induction techniques exist
(technique utilized will depend on several factor including the past medical and surgical history, the child’s developmental level, ability to cooperate and previous experiences
When do you commonly use a straight blade?
< 1 year
What is the appropriate ETT size for a premature child?
2-2.5 uncuffed
what is the appropriate ETT size for a term infant?
3
What is the appropriate ETT size for a 3-9 month old
3-3.5
What is the appropriate ETT for 9-18 months
3.5-4
What is the appropriate ETT for 18-36
4-4.5
What is the appropriate ETT for > 36 months
(age/4) + 3.5 = cuffed size
What is the depth calculation
< 3 kg 1-2-3kg= 7-8-9 cm at lips
> 3kg ID x3
What is require at Duke for set up?
atropine
succinylcholine
epi 100mcg/ml and 10mcg/ml if under 10kg 1mg/ml
propofol
muscle relaxant
analgesic
lidocaine
flush syringes
masks x2, oral airways x2 temp probe blade x2 warmer og/ng
peds anesthesia circuit <30kg
fluids
What gauge is an IM needle?
22g
What size syringe does succinylcholine go into ?
3ml syringe
What should sevoflurane be reduced after general anesthesia is induced?
4-5%
When do you place the IV on inhalation induction?
following stage 2 prior to manipulation of the airway
consider 100% during IV placement
What is the most reliable and rapid method of induction?
IV induction
WHen is an inhalation induction contraindicated?
difficult airway, full stomach, cardiac instability
Can you place an IV during N20?
yes
When do you obtain an IV?
patient is at risk for aspiration requiring an RSI, an anticipated difficult airway, or those potential cardiac instability, an IV should be placed prior to induction
What is the max recommended volume in an infant vastus lateralis?
0.5ml
What is the max recommended volume in a toddler’s deltoid
0.5ml
what is the max recommended volume in a toddler’s vastus lateralis?
0.5-1ml
what is the max recommended volume in a pre-school age vastus lateralis?
1ml
what is the max recommended volume in a school age vastus lateralis?
1.5ml-2ml
What is the max recommended volume in a pre-school age deltoid
0.5ml
What is the max recommended volume in a school age deltoid
0.5-1ml
Where are common IV placement sites?
back of hands, feet (including top, sides and saphenous, inside wrist, avoid AC IVs if possible
EJ scalp veins
What are the two most accessed veins?
superficial dorsal hand veins off the basilic vein
saphenous vein at the ankle
What size catheter is needed for an arterial line?
22g >2 years
24g <2 yrs
What are the baby wires?
wires to float in an arterial line
baby wire is 0.12in, used in 24g IV
0.15ins as well
What are the benefits of caudal anesthesia?
intraoperative and postoperative anesthesia
reduction in systemic opioid requirements and side effects
reduction in anesthesia requirements
What procedures is caudal anesthesia beneficial?
circumcision
inguinal hernia
hypospadias
anal surgery
clubfoot repair
other sub umbilical procedures
When is caudal anesthesia contraindicated?
infection, patient refusal, coagulopathy, anatomic abnormalities
What are the caudal landmarks?
sacral hiatus and 2 PSIS
What is caudal dosing for genital and anal surgery?
0.5-0.75ml/kg
What is caudal dosing for lower abdomen and extremitiy?
1ml/kg
What is caudal dosing for abdominal incision
1-1.25ml/kg
What is needed for pediatric post-anesthesia care?
appropriate ambu bag
oxygen source
monitoring
emergency medications
pain medications
treatment for emergence delirium
lateral position
