Pediatric Preanesthetic Eval, Premed, Induction Flashcards by Brooke Harris

pediatric age that tolerates separation and inhalation and induction well

infants 6-10 months

(no predmed needed)

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postop behaviors seen in children 6 months-6 years

postop nightmares, eating disturbances, bedwetting

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what med reduces instance of postop nightmares, bedwetting, and eating disturbances in kirs 6 mo-6 years old?

midazolam

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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

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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

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special considerations for kids with home monitoring/oxygen use

higher risk for postop obstruction, need overnight monitoring

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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

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pediatric complications of smoking exposure

increased risk of asthma, ear infections, eczema, hay fever, dental caries

increased airway complications during induction & emergence

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why are clear liquids encouraged 2-3 hours preop?

less hypotension/ bradycardia
helps with motility
clear liquid ½ life is 15 minutes

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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

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fasting guidelines for formula, milk, and solids

6 hours

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preop fasting guidelines for gum/candy

none after midnight - increases gastric secretions

(but also maybe no evidence that this is true)

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fasting goals - pH and volume

pH > 2.5

volume < 0.4 mL/kg

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fasting goals - pH and volume

pH > 2.5

volume < 0.4 mL/kg

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pts at increased risk of hypoglycemia

FTT
debilitated
receiving high glucose solutions preop

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concerns of a preop URI

2-7x increased risk of respiratory complications (especially if < 1 year old)

bronchospasm, laryngospasm
hypoxemia
atelectasis
croup, stridor

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when should surgery be postponed because of a URI?

s/s lower respiratory involvement
purulent rhinorrhea
acute onset (vs. chronic)
< 1 year old
fever

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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

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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

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difference in allergic rhinitis and URI

rhinitis has clear nasal drainage, no fever, and statistically not the same risks as URI

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most recommended preop Hct

exceptions to this

> 25%

if between 2-4 months old or chronic renal dailure, lower value acceptable

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how does chronic anemia affect the oxyhgb dissociation curve?

increased 2,3-DPG
increased O2 extraction
increased CO

RIGHT SHIFT

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should you transfuse preop to get a Hct of 30?

no - unnecessary risk of blood-borne disease transmission

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when should you consider postponing surgery with a fever

with symptoms of acute onset - rhinitis, sore throat, earache, dehydration

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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\*

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