Pediatric Preanesthetic Eval, Premed, Induction Flashcards
pediatric age that tolerates separation and inhalation and induction well
infants 6-10 months
(no predmed needed)
postop behaviors seen in children 6 months-6 years
postop nightmares, eating disturbances, bedwetting
what med reduces instance of postop nightmares, bedwetting, and eating disturbances in kirs 6 mo-6 years old?
midazolam
how does a previous surgery impact a 2-6 year old’s response to subsequent surgeries?
evidence says previous surgery helps with preop anxiety, but according to Lisa this doesn’t always translate to practice
why might sedation make preop experience worse in children > 6 years
may interfere with ability to cooperate and worsen overall expereince
adolescents - want to be in control, may dislike sedation
special considerations for kids with home monitoring/oxygen use
higher risk for postop obstruction, need overnight monitoring
family history we want to know about for a peds pt
- SIDS in family
- hx prolonged paralysis, MH
- genetic defects
- sickle cell, CF, MD, bleeding tendencies
- allergic reactions
- drug addiction
pediatric complications of smoking exposure
increased risk of asthma, ear infections, eczema, hay fever, dental caries
increased airway complications during induction & emergence
why are clear liquids encouraged 2-3 hours preop?
- less hypotension/ bradycardia
- helps with motility
- clear liquid ½ life is 15 minutes
can babies have breast milk 2 hours preop?
if not, how long do they have to wait?
no - increased lipid content causes delayed emptying
wait 4 hours
fasting guidelines for formula, milk, and solids
6 hours
preop fasting guidelines for gum/candy
none after midnight - increases gastric secretions
(but also maybe no evidence that this is true)
fasting goals - pH and volume
pH > 2.5
volume < 0.4 mL/kg
fasting goals - pH and volume
pH > 2.5
volume < 0.4 mL/kg
pts at increased risk of hypoglycemia
- FTT
- debilitated
- receiving high glucose solutions preop
concerns of a preop URI
2-7x increased risk of respiratory complications (especially if < 1 year old)
- bronchospasm, laryngospasm
- hypoxemia
- atelectasis
- croup, stridor
when should surgery be postponed because of a URI?
- s/s lower respiratory involvement
- purulent rhinorrhea
- acute onset (vs. chronic)
- < 1 year old
- fever
if you cancel a case because of URI, when should it be rescheduled for?
bronchial reactivity can last 7 weeks - but practically, delay 2 weeks and surgery is ok as long as the kid is getting better
is it safe to anesthetize a mild URI for a short procedure without intubation?
yes - increased spasms and desats but no worse than without URI, no increased morbidity
difference in allergic rhinitis and URI
rhinitis has clear nasal drainage, no fever, and statistically not the same risks as URI
most recommended preop Hct
exceptions to this
> 25%
if between 2-4 months old or chronic renal dailure, lower value acceptable
how does chronic anemia affect the oxyhgb dissociation curve?
- increased 2,3-DPG
- increased O2 extraction
- increased CO
RIGHT SHIFT
should you transfuse preop to get a Hct of 30?
no - unnecessary risk of blood-borne disease transmission
when should you consider postponing surgery with a fever
with symptoms of acute onset - rhinitis, sore throat, earache, dehydration
interventions for pt with a slight fever and is asymptomatic
procede with anesthesia
reduce fever to decrease O2 demand (tylenol, motrin)
how do inhalation agents affect fever
blunt febrile response
(whatever that means)
when should preop sickle cell screening be done
if results unknown and HbSC in family, unknown status with low hct
what test is done to determine severity of HbSC if preop screen is positive
hemoglobin electrophoresis
preop considerations for sickle cell patients
should be admitted overnight for IVF, potential transfusion prior to surgery
transfusion goal for sickle cell pt
up to hgb 10/hct 30
T/F - a sickle cell screen can be positive with sickle cell trait
true - hemoglobin electrophoresis determines severity of screen positive
useful preop meds for kids with developmental delays
PO or IM “cocktail” of ketamine and glycopyrrolate
PO or nasal versed
preop considerations for diabetic kiddos
- consult endocrinology for intraop blood sugar plan
- schedule for first case of day
- common: preop IV access, 5% glucose MIVF, ½ usual insulin dose
anesthesia considerations for kids with seizure disorders
- anesthesia may alter seizure threshold and increase activity post-op
- some drugs induce seizures
- some seizure meds interact with anesthetics (CYP interactions)
what should you do with TPN during surgery?
do not abruptly stop
decrease rate by ⅓ to ½
monitor glucose and electrolytes periop
important history for pts with asthma
- ER visits & hospitalizations
- home meds and last doses
- exacerbation triggers
- steroid use
- last wheezing
meds kids with asthma should take the morning of surgery
bronchodilators (albuterol)
airway considerations for pts with asthma
consider avoiding intubation or extubate while deep
LMA preferred if appropriate
you go to preop to see a kid with asthma and he’s just wheezing away. can you go ahead with the surgery
nah, postopone
(((((unless this is his baseline after all the meds in the world))))
not that you’re ever going to check a preop ABG for routine surgery on an asthmatic, but if you did and the PaCO2 was > 45, what does that mean
increased risk for postop resp failure
what is BPD?
chronic lung disease related to prolonged mechanical ventilation, barotrauma, or O2 toxicity
usually former preemie or other special lil creature like swinderella
respiratory changes in BPD pts
- decreased FRC
- prone to airway obstruction
- hypoxic with stimulation (picture princess glitter sparkles turning purple just bc she could)
s/s BPD
tachypnea
dyspnea
reactive airway
o2 dependence
why might you need to get preop labs on BPD pts?
may be on diuretics
what inhaled anesthetic should be avoid in BPD pts and why?
N2O - chronic air trapping
*avoid hyperventilation almost always* but why especially in BPD pts
they’re chronically hypercarbic
they’re basically babies with COPD
why might BPD babies need a smaller ETT?
may have subglottic stenosis, often undiagnosed
if a kid shows up for a T&A and has a murmur that hasn’t been evaluated, what should you do?
what about if the pediatrician has evaluated and determined it to be innocent?
delay (elective) procedures until after CV consult
if the pediatrician says its innocent - proceed
what is the only certain way to r/o a structural defect assoc. with a murmur
ECHO
pts at risk for latex allergies
- neural tube defects
- frequent urine cath
- hx multiple surgeries
- tropical fruit allergies
what is the most common cause of intraop anaphylaxis in peds?
latex allergy
T/F - H2 blockers and steroids reliably prevent anaphylaxis assoc. with latex allergy
false
best prevention for anaphylactic reaction from latex allergy
latex free environment
considerations for drawing up meds in pts with latex allergies
some meds have latex in the vial - single vial puncture is safest
fun fact: apparently in Alabama, biologic dad can’t consent for the baby if he isn’t married to mom
seems a little effed up to me
dose for versed as a premed
0.3-0.5 mg/kg PO 20-30 min prior
max dose 15 mg
how long does sedation from PO versed last
about an hour
if the procedure is longer than ___ minutes, preop versed doesn’t affect recovery or discharge times
10 minutes
dose of ketamine as a premed
how long before amnesia and analgesia seen
3-5 mg/kg IM
amnesia/analgesia in 5 minutes
what meds should be given after preop ketamine to prevent:
- nightmares
- secretions
nightmares - versed
secretions - anticholinergic
minimal dose of atropine
0.1 mg/kg (except preemies)
tylenol dose
10-20 mg/kg PO
precordial stethoscope placement
4-5th ICS
L sternal border
steps for inhalation induction
- pop-off open
- high flows (8-10 L/min) via mask
- 100% O2 (or N2O and > 30% O2)
- begin with sevo at 2%, increase gradually (every 3-4 breaths) to 8%
how long is high sevo (8%) with spontaneous ventilation maintained for inhalation induction?
until IV access obtained
respiratory interventions for inhalation induction as pt gets deeper
PEEP and/or oral airway for upper airway obstruction
how many people are required to be in the OR for an inhalation induction?
2
at least 1 anesthesia provider
T/F - intubating a pediatric patient requires NMBs
false - vocal cords have to be relaxed but can be done with volatiles, propofol, narcotics
propofol dosage healthy children can tolerate
4-5 mg/kg
negative effects of increasing the sevo concentration too rapidly during inhalation induction
- irritates airway, causes coughing
- hemodynamic effects
negative effects of increasing sevo too slowly during inhalation induction
- prolonged induction, including excitation period
- increased risk of airway obstruction, laryngospasm, vomiting
why is inhalation induction considered higher risk than IV induction?
drags through stage 2 vs. IV induction, which quickly goes grom stage 1 to 3
higher risk for laryngospasm
*during inhalation induction, keep them spontaneously breathing until the IV is placed*
:)
*during inhalation induction, keep them spontaneously breathing until the IV is placed*
:)
interventions with vital sign deterioration during inhalation induction
decrease or D/C anesthetic concentration
100% O2
treat bradycardia STAT
how to treat bradycardia in a bebe with and without an IV
atropine
if no IV: IM atropine, dilute epi via ETT
how to manage airway obstruction during inhalation induction
- tight mask fit and seal
- jaw thrust, oral/nasal airway
- slightly close pop-off to generate 5-10 cm PEEP
- after IV: positive pressure, lidocaine, propofol, succs, etc.
what is modified single breath induction?
inhale and fully hold, exhale and fully hold, apply mask with max concentration (8% sevo), take a deep breath and hold, then breathe normally
what is required for modified single-breath induction to work?
- child’s cooperation
- coach and practice before induction
- circuit priming (high flow/8% sevo)
which is faster - traditionl inhalation induction or modifed single-breath technique?
modifed single breath 3x faster than traditional inhalation induction
common induction technique for MH susceptible or RSI kids
use 50% N2O/O2 mix
start IV, proceed with IV induction
why is use of N2O not indicated for induction of a pt with a full stomach?
N2O causes N/V
modified RSI
use of positive pressure ventilation with low PIPs to prevent desat before intubation
