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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
Q

For the child with an URI, it may be

A

a simple common viral infection or may be a symptom of a much more serious illness

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26
Q

Irritable airways are at increased risk for

A

laryngospasms, bronchospasm, post-intubation croup, atelectasis, pneumonia, and desaturations

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27
Q

For the child with an URI, consider

A

LMA over ETT if appropriate; tricky b/c not a secure airway

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28
Q

For patients with URI, consider

A

rescheduling elective surgery 2-4 weeks for URIs, and 6-8 weeks for LRI

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29
Q

Some reasons to postpone surgery include

A

elective, febrile, elevated WBC, productive/purulent sputum, getting worse, acutely ill, malaise, tachypnea, wheezing

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30
Q

Anesthesia with an URI, present an increased risk of complications with GA including

A

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

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31
Q

Management of anesthesia with an URI includes

A

adequate hydration, & oxygenation
reduce secretions, limit airway manipulation
bronchodilators (beta 2 agonists) for wheezing
anticholinergics (inhibits cholinegic-mediated bronchospasm)
muscle relaxants for laryngospasm

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32
Q

Children ages 2-6 commonly have a functional

A

systolic “Still’s” murmur
a heart murmur is detected in up to 50% of pediatric patients
innocent or pathologic

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33
Q

A cardiologist may need to evaluate previously undiagnosed murmurs prior to induction of anesthesia such as in patients with:

A

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)

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34
Q

Infants younger than <6-12 months

A

usually separate from parents without the need for premedication

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35
Q

Oral premedication may

A

prolong time to discharge

36
Q

Midazolam is most commonly used premed & dose is

A

0.5 mg/kg PO (usual max is 20 mg)*** 15 to 30 min prior to induction

37
Q

Special considerations with oral premedication include

A

careful sedating a child with congenital heart disease, increased ICP, OSA, sepsis, trauma, or suspected difficult airway

38
Q

Nasal premedications & dosages include

A

midazolam 0.2 mg/kg nasal
ketamine 3 mg/kg nasal
dexmedetomidine 1-2 mcg/kg nasal

39
Q

Set up & monitoring should include

A

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
Q

Describe normal vital signs for a premature baby.

A

HR 120-170
BP 55-75/35-45
MAP 40-55

41
Q

Describe normal vital signs for 0-3 months old.

A

HR 100-150
BP 65-85/45-55
MAP 52-65

42
Q

Describe normal vital signs for 3-6 months old.

A

HR 90-120
BP 70-90/50-65
MAP 57-73

43
Q

Describe normal vital signs for 6-12 months.

A

80-120
BP 80-100/55-65
MAP 63-77

44
Q

Describe normal vital signs for 1-3 yrs.

A

HR 70-110
BP 90-105/55-70
MAP 67-82

45
Q

Preparation for induction of anesthesia includes.

A

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
Q

A variety of induction techniques exist and should be based upon

A

past medical & surgical history
child’s developmental level
ability to cooperate
previous experiences

47
Q

LMA size 1 is appropriate for

A

neonates/infants up to 5 kg

48
Q

LMA size 1.5 is appropriate for

A

infants 5-10 kg

49
Q

LMA size 2 is appropriate for

A

infants/children 10-20 kg

50
Q

LMA size 2.5 is appropriate for

A

Children 20-30 kg

51
Q

LMA size 3 is appropriate for

A

30-50 kg

52
Q

Laryngoscopy includes use of straight blade in

A

children <1 year

53
Q

Describe considerations for laryngoscopy.

A

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
Q

Describe the approximate depth calculation of peds ETT tubes

A

<3 kg: 1-2-3 kg or 7-8-9 cm at lips

>3 kg: ID x 3

55
Q

Emergency medication set up of atropine includes

A

0.4 mg/mL
<10 kgs- place in 1 mL syringe
>10 kgs- place in 3 mLs syringe

56
Q

Emergency medication set up of succinylcholine includes

A

3 mL syringe
20 mg/mL
IM needle (22 ga)

57
Q

Caution with using flush syringes as these may result in

A

syringe swaps & inadvertent administrations***

58
Q

Pediatric breathing circuits are needed because

A

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
Q

In children <2 years old, may not administer ______ for nasal intubations to avoid______

A

afrin; hypertension

60
Q

The most common method of inducing anesthesia in children is

A

inhalation induction with sevoflurane being the age of choice

61
Q

Additional considerations for inhalation induction include

A

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
Q

Mask induction aids & distraction techniques include

A 
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
Q

IV induction of anesthesia is the

A

most reliable & rapid

necessary when inhalation induction is contraindicated (i.e. difficult airway, full stomach, cardiac instability)

64
Q

The main disadvantage of IV induction of anesthesia is that

A

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
Q

Ideally all children should be ________ before intravenous induction, but this is not always possible

A

pre-oxygenated with 100% oxygen

66
Q

IV access should be obtained if

A

the patient is at risk for aspiration requiring a RSI
anticipated difficult airway
potential cardiac instability

67
Q

When obtaining IV access in pediatric patients for induction,

A

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
Q

It is preferable to avoid _____ injections in children

A

IM

69
Q

IM induction may be indicated in

A

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
Q

With mask anesthesia, avoid

A

applying pressure over the soft tissue of the chin & neck during mask anesthesia
precordial stethoscope can be helpful to monitor breath sounds

71
Q

Sites for peripheral IVs include

A 
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
Q

By far the two most commonly accessed veins are:

A

superficial dorsal hand veins

saphenous vein

73
Q

Describe IV size for neonates, infants, & children.

A

neonates: 24 gauge
infants 24-22 gauge
children 22-20 gauge

74
Q

Bolus for pediatrics is

A

10-20 mL/kg

75
Q

Use of ________ for IV fluid administration in peds <30 kg

A

metered chamber buretol
***** close roller-clamp between IV bag & chamber
expel any air

76
Q

Describe the use of arterial lines for children

A

may use an IV catheter rather a premade arterial line device
22g >2 years old
24g for <2 years old

77
Q

Wires for Seldinger’s technique include

A

“Baby wire” is 0.012 in & often used with 24 g. IVs

78
Q

Describe benefits of caudal anesthesia

A

intraoperative & postoperative analgesia
reduction in systemic opioid requirements & side effects
reduction in anesthesia requirements

79
Q

Procedures in which caudal anesthesia may be used include

A

circumcision, inguinal herniorrhaphy, hypospadias, anal surgery, clubfoot repair, other sub-umiblical procedures

80
Q

Contraindications to caudal anesthesia include

A

infection around the site
coagulopathy
anatomic abnormalities like sacral dimple
parental refusal

81
Q

Caudal landmarks include

A

sacral hiatus

2 PSIS

82
Q

Describe caudal dosing for genital & anal surgery:

A

0.5-0.75 mL/kg

83
Q

Describe caudal dosing for lower abdomen, extremity:

A

1 mL/kg

84
Q

Describe caudal dosing for abdominal incision

A

1-1.25 mL/kg

85
Q

Using clonidine in caudal anesthesia may lead to

A

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
Q

Traveling post anesthesia considerations include:

A

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
Q

Handover report for PACU should include

A

name, age, weight, & allergies
PMH, operation/procedure
airway, IVs, medications, fluids

Advanced Principles 2 (42 decks)

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