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Advanced Principles 2 > Pediatric preoperative evaluation, set-up, and anesthetic induction techniques > Flashcards

Pediatric preoperative evaluation, set-up, and anesthetic induction techniques Flashcards

1
Q

________ have the highest rate of adverse events (even more so than adults)

A

infants <1 month old

bradycardia, respiratory complications, cardiac arrest, medication related, equipment related

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2
Q

Bradycardia is secondary to

A

hypoxia & high inhalation anesthetic concentration

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3
Q

Describe psychological preparation.

A

preoperative prep is very important
some centers may have a child-life specialist, videos, hospital tours, etc.
basic objective is to explain to the child & parents in respectful simple, understandable, and reassuring terms
bond with the child- key for decreasing parental anxiety too

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4
Q

Psychological aspects for age 0-6 months include

A

not usually upset by separation from parents; prolong separation may impair parent-child bonding

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5
Q

Psychological aspects for ages 6 months to 4 years include

A

separation anxiety, fear of hospitalization. may show regressive behavior

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6
Q

Psychological aspects for school-age children include

A

less upset by separation from parents, asks questions, involved, wants choices, more concerned with surgical procedure and its possible affects on body image

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7
Q

Psychological aspects for adolescents include

A

fear the process of narcosis, the loss of control, waking up during surgery, and pain of surgery; value modesty; HcG testing in females

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8
Q

Psychological aspects for parents include

A

provide explanation of what to expect

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9
Q

Describe important considerations for adolescents

A

transitioning from childhood illness to adulthood
mental health
confidentiality
assent vs. consent- blood transfusion, epidural for childbirth, abortion, gender affirmation
HcG testing- aprepitant & sugammadex considerations
experimentation with alcohol, marijuana, amphetamines, narcotics, vaping

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10
Q

Parental presence at induction is based upon

A

the age of the child & if it provides added benefit

is important to prepare the parent of what to expcet

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11
Q

Parental presence may not be appropriate in certain circumstances including:

A

adequate preoperative sedation
the parent’s level of anxiety
language barrier
emergency/RSI cases
anticipated difficult airway or an unstable patient
pregnant mother (due to nitrous oxide exposure)

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12
Q

The interview and physical exam should include

A 
sources of information include the EMR, parents, and the child
NPO status
current weight
auscultation of lungs and heart
evaluation of the airway, inquire about loose teeth
PMH/previous anesthetics/MH
recent URI's or fevers
cigarette exposure in the home
possibility of pregnancy
allergies & current medications
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13
Q

NPO guidelines include

A

clear liquids: 2 hours
breast milk: 4 hours
formula, non-human milk, light meal: 6 hours
fatty foods: 8 hours

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14
Q

Review of the child’s history for age should include

A

gestational, conceptional, birth history, maternal pregnancy history

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15
Q

Review of the child’s history for CNS should include

A

seizures, hydrocephalus, neuromuscular disorders, head trauma, autism

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16
Q

Review of the child’s CV history includes

A

murmur, cyanosis, dyspnea, sweating, hypertension, exercise tolerance, congenital heart defects, indications for subacute bacterial endocarditis

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17
Q

Review of the child’s respiratory history includes

A

prematurity, respiratory distress syndrome, apnea, recent upper respiratory infection (URI), cough, croup, asthma, cystic fibrosis, need for preop-oxygen therapy

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18
Q

Review of the child’s gastrointestinal history includes

A

NPO status

reflux, vomiting, diarrhea, liver

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19
Q

Review of the child’s GU system includes

A

renal failure, bladder surgery

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20
Q

Review of the child’s endocrine system includes

A

DM, thyroid, pituitary, adrenal, steroid therapy

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21
Q

Review of the child’s hematology system includes

A

anemia, bruising, bleeding, sickle cell

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22
Q

Review of the child’s immunology system includes

A

allergies, immunocompromised

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23
Q

Preop lab considerations:

A

often unnecessary for most healthy children
consider if labs are needed while awake or could wait until the patient is under GA
consider glucose in prolonged fasting & metabolic disorders
consider pregnancy testing in females

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24
Q

Consider a hemoglobin on

A

neonates, premature infants, cardiopulmonary disease, known hematologic dysfunction, and anticipated major blood loss during the surgical procedure

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25
For the child with an URI, it may be
a simple common viral infection or may be a symptom of a much more serious illness
26
Irritable airways are at increased risk for
laryngospasms, bronchospasm, post-intubation croup, atelectasis, pneumonia, and desaturations
27
For the child with an URI, consider
LMA over ETT if appropriate; tricky b/c not a secure airway
28
For patients with URI, consider
rescheduling elective surgery 2-4 weeks for URIs, and 6-8 weeks for LRI
29
Some reasons to postpone surgery include
elective, febrile, elevated WBC, productive/purulent sputum, getting worse, acutely ill, malaise, tachypnea, wheezing
30
Anesthesia with an URI, present an increased risk of complications with GA including
need for ETT asthma, reactive airway, etc. tracheal mucociliary flow & pulmonary bactericidal activity is decreased by general anesthesia PPV may help spread the infection from upper to lower airways
31
Management of anesthesia with an URI includes
adequate hydration, & oxygenation reduce secretions, limit airway manipulation bronchodilators (beta 2 agonists) for wheezing anticholinergics (inhibits cholinegic-mediated bronchospasm) muscle relaxants for laryngospasm
32
Children ages 2-6 commonly have a functional
systolic "Still's" murmur a heart murmur is detected in up to 50% of pediatric patients innocent or pathologic
33
A cardiologist may need to evaluate previously undiagnosed murmurs prior to induction of anesthesia such as in patients with:
difficulty feeding, SOB poor exercise tolerance, can't match peers family history of CHD cyanotic episodes abnormal peripheral pulses unequal blood pressures in upper vs. lower extremities (coarctation)
34
Infants younger than <6-12 months
usually separate from parents without the need for premedication
35
Oral premedication may
prolong time to discharge
36
Midazolam is most commonly used premed & dose is
0.5 mg/kg PO (usual max is 20 mg)*** 15 to 30 min prior to induction
37
Special considerations with oral premedication include
careful sedating a child with congenital heart disease, increased ICP, OSA, sepsis, trauma, or suspected difficult airway
38
Nasal premedications & dosages include
midazolam 0.2 mg/kg nasal ketamine 3 mg/kg nasal dexmedetomidine 1-2 mcg/kg nasal
39
Set up & monitoring should include
blood pressure (appropriate size cuff) ECG- often 3 lead (5 lead for cardiac patients) pulse oximetry (weight-based probe): purple <3 kg or >40 kg; orange 3-20 kgs capnography temperature neuromuscular function shoulder roll
40
Describe normal vital signs for a premature baby.
HR 120-170 BP 55-75/35-45 MAP 40-55
41
Describe normal vital signs for 0-3 months old.
HR 100-150 BP 65-85/45-55 MAP 52-65
42
Describe normal vital signs for 3-6 months old.
HR 90-120 BP 70-90/50-65 MAP 57-73
43
Describe normal vital signs for 6-12 months.
80-120 BP 80-100/55-65 MAP 63-77
44
Describe normal vital signs for 1-3 yrs.
HR 70-110 BP 90-105/55-70 MAP 67-82
45
Preparation for induction of anesthesia includes.
warm the operating room & ensure warming devices are functioning pre-induction checklist of equipment, suction, emergency airway devices, ventilator default, and monitoring settings, etc. consider a chair or stool if the parent is present to help avoid fainting epsiodes ensure a quiet, calm OR
46
A variety of induction techniques exist and should be based upon
past medical & surgical history child's developmental level ability to cooperate previous experiences
47
LMA size 1 is appropriate for
neonates/infants up to 5 kg
48
LMA size 1.5 is appropriate for
infants 5-10 kg
49
LMA size 2 is appropriate for
infants/children 10-20 kg
50
LMA size 2.5 is appropriate for
Children 20-30 kg
51
LMA size 3 is appropriate for
30-50 kg
52
Laryngoscopy includes use of straight blade in
children <1 year
53
Describe considerations for laryngoscopy.
ensure head is correctly positioned and supported- shoulder roll, caution in patients with potential unstable cervical spine (e.g., down syndrome, trauma) examine for loose teeth- if they are removed, should return to parents
54
Describe the approximate depth calculation of peds ETT tubes
<3 kg: 1-2-3 kg or 7-8-9 cm at lips | >3 kg: ID x 3
55
Emergency medication set up of atropine includes
0.4 mg/mL <10 kgs- place in 1 mL syringe >10 kgs- place in 3 mLs syringe
56
Emergency medication set up of succinylcholine includes
3 mL syringe 20 mg/mL IM needle (22 ga)
57
Caution with using flush syringes as these may result in
syringe swaps & inadvertent administrations***
58
Pediatric breathing circuits are needed because
small enough for sensitivity to small tidal volume big enough to give a vital capacity breath neonatal- ask anesthesia tech for neonate circuit peds circuit 1L bag <30 kgs
59
In children <2 years old, may not administer ______ for nasal intubations to avoid______
afrin; hypertension
60
The most common method of inducing anesthesia in children is
inhalation induction with sevoflurane being the age of choice
61
Additional considerations for inhalation induction include
pacifiers are okay to leave in, may need a larger mask okay to have the child lay down, sit up, or sit in someone's lap may use N2O & O2 for 1-2 minutes and then use sevoflurane at 6-8% after GA is induced, the sevoflurane should be reduce to around 4-5% to prevent overdose & assisted ventilation may be necessary IV is placed following stage 2 and prior to instrumentation of the airway
62
Mask induction aids & distraction techniques include
``` scented masks bubbles playing video games or watching a movie use of the elbow without a mask and tenting with the hand music jokes steal induction in an asleep child single-breath inhalation ```
63
IV induction of anesthesia is the
most reliable & rapid | necessary when inhalation induction is contraindicated (i.e. difficult airway, full stomach, cardiac instability)
64
The main disadvantage of IV induction of anesthesia is that
starting an IV can be painful and threatening to a child and therefore is usually reserved for older children (>8) may place IV under N2O in older children topical anesthetics (EMLA, ethyl-chloride spray)
65
Ideally all children should be ________ before intravenous induction, but this is not always possible
pre-oxygenated with 100% oxygen
66
IV access should be obtained if
the patient is at risk for aspiration requiring a RSI anticipated difficult airway potential cardiac instability
67
When obtaining IV access in pediatric patients for induction,
consider use of a topical anesthetic cream keep the equipment from the child's view if especially fearful be deliberate in insertion, flash may be slower than expected be cautious of all potential air bubbles
68
It is preferable to avoid _____ injections in children
IM
69
IM induction may be indicated in
uncooperative children who refuse other routes of sedation -commonly utilized is concentrated IM ketamine where large volume will necessitate multiple injections development of laryngospasm during inhalation induction -if IV access is not present, succinylcholine & atropine can be given IM or sublingually
70
With mask anesthesia, avoid
applying pressure over the soft tissue of the chin & neck during mask anesthesia precordial stethoscope can be helpful to monitor breath sounds
71
Sites for peripheral IVs include
``` back of hands feet-including top, sides, & saphenous inside wrist avoid AC Iv's if possible b/c difficult to tell if it gets infiltrated EJ/scalp veins ```
72
By far the two most commonly accessed veins are:
superficial dorsal hand veins | saphenous vein
73
Describe IV size for neonates, infants, & children.
neonates: 24 gauge infants 24-22 gauge children 22-20 gauge
74
Bolus for pediatrics is
10-20 mL/kg
75
Use of ________ for IV fluid administration in peds <30 kg
metered chamber buretol ***** close roller-clamp between IV bag & chamber expel any air
76
Describe the use of arterial lines for children
may use an IV catheter rather a premade arterial line device 22g >2 years old 24g for <2 years old
77
Wires for Seldinger's technique include
"Baby wire" is 0.012 in & often used with 24 g. IVs
78
Describe benefits of caudal anesthesia
intraoperative & postoperative analgesia reduction in systemic opioid requirements & side effects reduction in anesthesia requirements
79
Procedures in which caudal anesthesia may be used include
circumcision, inguinal herniorrhaphy, hypospadias, anal surgery, clubfoot repair, other sub-umiblical procedures
80
Contraindications to caudal anesthesia include
infection around the site coagulopathy anatomic abnormalities like sacral dimple parental refusal
81
Caudal landmarks include
sacral hiatus | 2 PSIS
82
Describe caudal dosing for genital & anal surgery:
0.5-0.75 mL/kg
83
Describe caudal dosing for lower abdomen, extremity:
1 mL/kg
84
Describe caudal dosing for abdominal incision
1-1.25 mL/kg
85
Using clonidine in caudal anesthesia may lead to
increase in duration of 2-3 hours increased sedation scores, potential for hypotension & respiratory depression in some infants (avoid dexmedetomidine if clonidine is placed in the caudal)
86
Traveling post anesthesia considerations include:
appropriately sized ambu bag oxygen source: blow=by vs. facemask vs. nasal cannula monitoring (pulse ox only, vs. ECG and/or BP) emergency meds (atropine, succinylcholine, epinephrine) pain medications treatment for emergence delirium (e.g. dexmedetomidine, propofol, fentanyl) lateral position
87
Handover report for PACU should include
name, age, weight, & allergies PMH, operation/procedure airway, IVs, medications, fluids

Advanced Principles 2 (42 decks)

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