Pediatrics

Question 1

what are apgar score categories?

Answer 1

Question 2

what is the first sign of high spinal in children <5?

Answer 2

apnea

Question 3

is a congenital condition associated with visceromegaly, which can cause hypoglycemia and abdominal wall defects in neonates. They develop larger tongues in relation to their mouths than other neonates, which can complicate intubation

Answer 3

Beckwith-Wiedemann

Question 4

known predictors of postop respiratory problems and OSA post adenotonsillectomy?

Answer 4

• Severe OSA on polysomnography
• History of prematurity (B)
• Age <3 years (A)
• Morbid obesity
• Mallampati score of 3-4
• Nasal pathology (e.g. deviated septum or enlarged turbinates)
• Neuromuscular disorders
• Craniofacial disorders and genetic disorders
• Enlarged lingual tonsils
• Upper respiratory infection (URI) within 4 weeks of surgery (D)
• Cor pulmonale
• Systemic hypertension
• Marked obstruction on inhalational induction (C)
• Disordered breathing in the PACU
• Difficulty breathing during sleep
• Growth impairment resulting from chronic obstructed breathing

Question 6

what are the determinants of pulmonary vascular resistance?

Answer 6

member that determinants of pulmonary vascular resistance include PAO2 (hypoxic pulmonary vasoconstriction), PaCO2, temperature, intrathoracic pressure, functional residual capacity, and use of direct vasodilators such as nitric oxide, nitroglycerin, and nitroprusside.

Question 7

what is the appropriate fluid replacvement for a surgery in kid?

Answer 7

20-40ml/kg over the anesthetic

Question 8

Children with strabismus who receive succinylcholine for general anesthesia are 4 times more likely to experience …….?

Answer 8

masseter muscle rigidity

Question 9

Most effective way to warm pediatric patient?

Answer 9

forced air blanket

Question 11

how does brown fat work?

Answer 11

Neonates are largely dependent on nonshivering thermogenesis via the metabolism of brown fat, which uncouples oxidative phosphorylation in the mitochondria to generate heat.

Question 12

what electrolyte normalicy would best illustrate a patient is a candidate for pylorotomy 2/2 pyloric stensosis?

what kind of metabolic derangement do these kids have?

Answer 12

Semi-normalization of chloride may be the most important and most relevant metabolic change suggesting surgical optimization

Patients with pyloric stenosis often develop a hyponatremic hypokalemic hypochloremic metabolic alkalosis. Normalization of chloride is probably the best indicator that metabolic alkalosis has resolved in these patients.

A bicarbonate level of 34 mmol/L (A) is elevated and suggests that the patient remains alkalotic. The bicarbonate level should be less than 30 mmol/L prior to surgery. The bicarbonate level is a good indicator of hydration status in patients with pyloric stenosis.

Question 13

What is the blood volumes of kids/adults?

Answer 13

Question 14

how does brown fat get activated?

Answer 14

Nonshivering thermogenesis is the metabolism of brown fat. Brown fat makes up 4-10% of fat stores in the neonate and is high in mitochondria. Brown fat can be found in a neonate from 26 weeks and up and disappears around 3-6 months after birth. When there is at least a 2° C (3.6° F) gradient between the skin and core temperature, the hypothalamus stimulates a release of norepinephrine into the blood stream.

The circulating norepinephrine binds to receptors on brown fat cells which, through cyclic adenosine monophosphate (cAMP), activate intracellular lipase and causes the breakdown of triglycerides. The breakdown of the fatty acids, which consumes oxygen and glucose, promotes the uncoupling of mitochondrial oxidative phosphorylation and thus causes the generation of heat. Ketones and water are byproducts of this process.

Ketone production leads to metabolic acidosis

Question 15

WHat are side effects of PGE1?

Answer 15

Bottom Line: PGE1 is used to maintain patency or reopen the ductus arteriosus in “ductal dependent lesions” to improve blood flow to the lungs or systemic circulation depending on the nature of the congenital lesion. Side effects include apnea, hypotension, fevers, and CNS irritability.

Question 16

dosing for caudals?

Answer 16

Dosing of single-shot caudal epidural blocks in infants and young children is done on a ml/kg basis. Using 0.5 mL/kg of local anesthetic will cover the sacral dermatomes, 1 mL/kg will cover up to the low thoracic dermatomes, and 1.25 mL/kg will cover up to the mid thoracic dermatomes.

Question 17

is gastroshisis associated with other abnormalities? how about omphaloceles?

Answer 17

Gastroschisis tends to be an isolated lesion (B) while omphalocele is often associated with other anomalies and/or chromosomal abnormalities including Beckwith-Wiedemann, Reiger, and prune belly syndromes and trisomy 13, 18, and 21.

Question 18

Omphalocele vs Gastroschisis?

Answer 18

Question 19

wht is the fluid replacement strategy for pyloric stenosis?

what are electrolyte goals?

Answer 19

This infant is volume depleted with poor urine output in the setting of pyloric stenosis and therefore volume resuscitation with normal saline and initiation of D5 1/2 NS at 1.5 times maintenance fluid is the most appropriate initial medical therapy.

Because of the acid-base, electrolyte, and volume derangement associated with pyloric stenosis, appropriate fluid therapy prior to surgical intervention is a must. Initial volume replacement with normal saline should be used with initiation of maintenance fluid containing glucose and no potassium should be used. Potassium can be added once adequate urine output (1-2 mL/kg/hr) is obtained. End points for resuscitation include sodium > 130 mEq/L, potassium > 3 mEq/L, chloride > 100 mEq/L, and bicarbonate < 30 mEq/L.

Question 20

what are postoperative risks with pyloric stenosis? why?

Answer 20

Postoperative apnea is a significant risk in patients with pyloric stenosis due to alterations in CSF pH and central chemoreceptor response to carbon dioxide, therefore the use of opioids and hyperventilation should be minimized.

Question 21

how does csf volume compare between adults and children?

Answer 21

Cerebrospinal fluid (CSF) volume is higher on a mL/kg basis in children than it is in adults.

Infants have a CSF volume of 4 mL/kg, children have a CSF volume of 3 mL/kg, and adults have a CSF volume of 1.5-2 mL/kg. Isobaric bupivacaine will provide appropriate anesthesia for just over an hour. A high CSF volume is why a larger dose of local anesthetic, on a mL/kg basis, is needed in infants. Additionally, the larger CSF volume may be one reason why children have lower rates of postdural puncture headache.

Question 22

what opioid is contraindicated after tonsillectomy?

Answer 22

codeine

Codeine is an inactive medication that becomes morphine after CYP 2D6 metabolism. There is a wide polymorphism in this metabolic pathway. Therefore, some people do not metabolize codeine into morphine (poor pain control) and others metabolize large amounts rapidly (morphine overdose). Several pediatric deaths have been attributed to codeine use in post tonsillectomy patients; likely these patients were rapid metabolizers. Inhibitors of CYP 2D6 include quinidine and serotonin specific reuptake inhibitors (SSRIs) such as fluoxetine. Therefore, codeine is not an ideal opioid for patients who are taking SSRIs.

Question 23

what causes epiglottis?

Answer 23

Acute epiglottitis is typically caused by Haemophilus influenza type B, Staphylococcus aureus, or group A beta-hemolytic Streptococci.

Question 24

what is the ventilatory strategy of congenital diaphragms?

Answer 24

“Gentle ventilation” with permissive hypercapnia using a low tidal volume strategy, PIP < 25 cm H20, and FiO2 + PEEP adjustment to maintain preductal SpO2 of 90-95% has been shown to decrease mortality in patients with congenital diaphragmatic hernia (CDH) and is the management strategy of choice.

Question 25

what triggers thermogenesis in infants?

Answer 25

norepi, thyroxine, and glucocorticoids

Question 26

what is klippel-fleil associated with?

Answer 26

Patients with Klippel-Feil are often difficult to intubate because of the fusion and decreased neck mobility. Patients with Klippel-Feil are often described as having a short neck with a low hairline. Additionally, most may have associated scoliosis, strabismus, or scapular defects. Heart and other spinal conditions are more likely to occur in these patients as well.

Question 27

signs of mild, moderate, and severe dehydration in children?

Answer 27

Question 28

goldenhar syndrome?

Answer 28

Goldenhar syndrome is a rare genetic disorder that occurs in 1:3000-5000 live births. Case reports in the anesthesia literature are few and there are no universally accepted features for the definition of the syndrome. The original description by Goldenhar included pre-auricular appendages, fistulae, and epibulbar dermoids. Certainly, this syndrome presents challenges to the anesthesia provider – specifically craniovertebral anomalies potentially presenting as a difficult to manage airway. This includes micrognathia, hypoplastic zygomatic arch, facial asymmetry, and facial hypoplasia. Most patients have moderate to severe congenital cardiac defects and respiratory problems. Most Goldenhar patients have normal intelligence, but approximately 5-15% have some degree of intellectual disability.

The conduct of anesthesia needs to include a thorough preoperative evaluation, specifically regarding the airway. Head and neck movement and mouth opening should be assessed. The provider should consider obtaining cervical spine radiographs because these patients are at risk for subluxation of C1-C2. The Schwartz hyoid maneuver has been useful in these patients and includes measuring the anterior-posterior distance from the middle of the inside of the mentum of the mandible to the hyoid bone. This gives an approximate idea for the potential space one will have during laryngoscopy; normal distance in infants is >1.5cm and in adults is >3cm (two fingers). If there is a decrease in this space, it should key the provider to potential difficulty.

Question 29

how does lung and chest wall compliance in kids compare to adults?

Answer 29

The newborn lung is less compliant compared to adults while the chest wall is relatively more compliant.

Question 30

anatomic airway differences between kids and adults?

Answer 30

Infants have a larger occiput, are obligate nose breathers despite having smaller nasal passages, have relatively larger tongues, longer epiglottis, shorter trachea, and a more cephalad larynx (C4) than adults (C6).

Question 31

what is myotonic dystrophy?

Answer 31

Myotonic dystrophy is a progressive genetic condition with associated muscle weakness and myotonia, along with contractures of the muscles. The condition is most often inherited in an autosomal dominant fashion caused by a trinucleotide repeat. These patients also develop cardiomyopathies, are at increased risk for aspiration, and can develop upper airway obstruction from pharyngeal muscle weakness. Shivering caused by hypothermia can precipitate myotonias. Additionally, there are several medications used in anesthesia which can precipitate myotonias as well.

Bottom Line: In patients with myotonic dystrophy, avoid succinylcholine, neostigmine, and potassium containing solutions.

Question 32

what alveolar pneumocytes produce surfactant and are responsible for replication?

Answer 32

type II