Pediatrics Flashcards
How do you dose epinephrine & fluids during resuscitation?
Epi = .01 mg/kg IV = 10 mcg/kg
= .1 mg/kg IT
Fluids = 10 mL/kg over 10 minutes
Normal VS for pediatric patients
Newborn = HR 140, BP 70/40, RR 40 - 60
1 yo = 120 …. 95/60 …. 40
3 yo = 100 ….. 100/65 ….. 30
12 y/o = 80 ….. 110/70 ….. 20
Why is the neonate’s Mve > the adult
Neonate increases RR more than Tv because it is metabolically more efficient
-Higher metabolic rate (6 mL/kg/m)
-Smaller FRC
-Increased alveolar ventilation (130 mL/kg/m)
What is the primary determinant of BP in the neonate?
HR
BP = HR x SV x SVR
Neonatal myocardium lacks the contractile elements to significantly adjust contractility. Also, the Frank-Starling relationship is underdeveloped.
Describe the autonomic influence on the newborns heart
PSNS dominates
Laryngoscopy, hypoxia = bradycardia
Additionally, the baroreceptor reflex is poorly developed, so the reflex fails to increase HR in the setting of hypovolemia.
Laryngeal position in adults vs infants
Adults = C5
Infants = C4
Premature infant = C3
Right mainstem bronchus in adults vs infants
Adults = 25 degree angle (left is 45)
Infants = 55 degree angle
O2 consumption, alveolar ventilation neonates vs adults
6 mL/kg/m - 3 mL/kg/m
130 mL/kg/m - 70 mL/kg/m
Fast vs slow twitch muscle fibers in the neonatal diaphragm
Neonates have more fast twitch (Type II) fibers than slow twitch (Type I).
Type I are for endurance. Adults have 45%. Neonates have 25%. Preemies have 1 - 10%.
FRC, VC, TLC, RV, CC in neonate vs adult
FRC, VC, TLC are decreased
RV and CC are increased
ABG from delivery to 1st 24 hours
Mom = 7.4 / 30 / 90
Umbi Vein = 7.35 / 40 / 30
Umbi Artery = 7.3 / 50 / 20
10 = 7.2 / 50 / 50
1 hour = 7.3 / 30 / 60 (oxygen)
24 hours = 7.35 / 30 / 70
P50 of fetal hemoglobin
19 (mom = 26.5)
When does respiratory control mature
42 - 44 weeks
before maturation = hypoxemia = bradycardia
Why does Hgb F have a higher affinity for oxygen
It does not have 2,3, DPG because it contains 2 alpha and 2 gamma chains. ONly beta will bind to 2,3,DPG.
2,3,DPG causes a right shift.
When do you transfuse FFP in the neonate
Coagulopathy with increased PT and PTT
Transfused 1 blood volume
Emergent reversal of warfarin
When is platelet transfusion indicated in the neonate? What is the dose?
< 50 k
5 mL/kg if apheresis (6 - 8 pooled)
1 pack (10 k)
1 pack will increase your plt by 50.
Normal H&H at birth, 3 months, 6 - 12 mo
Birth = 14 - 20
3 months = 10 - 14
6 - 12 months = 11 - 15
Adult Female = 12 - 16
Adult Male = 14 - 18
Normal EBV in neonate, term, infant, child
100 mL/kg
90 mL/kg
80 mL/kg
70 mL/kg
When do GFR and renal tubular function achieve full maturation?
GFR - 8 - 24 months
—>before, they do a bad job of conserving water or getting rid of LOTS of water
Renal tubular function = 2 years old
–>first few days of life, the neonate is an obligate sodium loser. after that, they can retain sodium better than they can excrete it. also has a tendency to lose glucose to the urine
Distribution of body water in preemie, neonate, child, adult
TBW preemie = 85 % * ECF 60 % * ICF 25%
TBW neonate = 70% * ECF 40% * ICF 35%
TBW child & adult = 60% * ECF 20% * ICF 40%
CO in the newborn
200 mL/kg/m
faster drug delivery
Plasma protein binding in the neonate
Before 6 months there is less albumin and alpha 1 glycoprotein. Thus, there is an increased free fraction of highly bound protein drugs.
MAC in kiddos
Premature = lesss than neonate
Neonate (0 - 30 days) = less than infant
Infant 1 - 6 mo = more than adult
Infant 2 - 3 mo = (HIGHEST)
mac requirement pattern for sevoflurane is different
0 days - 6 months = 3.2%
6 months - 12 years = 2.5%
Succinylcholine dosing in the neonate
IM - 5 mg/kg (fastest onset is submental)
IV - 2 mg/kg due to a higher ECF (Vd is larger)
*in kiddos < 5 y.o., large concern for bradycardia (esp. after 2nd dose)
How do you dose non-depolarizing neuromuscular blockers in the neonate? Why?
Same as with adults. There is a larger ECF. However, there is an increased sensitivity at the NMJ. So it’s net even
What other neuromuscular blocker can you give IM?
rocuronium
< 1 y.o. = 1 mg/kg
> 1 y.o. = 1.8 mg/kg
Name the 5 types of tracheoesophageal atresia. Which is most common?
Type A - two blind pouches
Type B - opposite of C
Type C (most common) the upper esophagus = blind pouch, with the lower esophagus communicating with trachea
Type D - two communicating esophaguses
Type E - one communicating esophagus
VACTERL
vertebral anomalies
anal imperforate
cardiac
tracheoesophageal fistula
esophageal atresia
renal dysplasia
limb anomalies
How to induce patient undergoing type C TEF repair
-head up, frequent suctioning
-awake intubating or inhalation induction with SV
-avoid PPV
-if there is a g-tube, open it to air
-ETT placed below fistula, above carina
what test can be done to assess fetal lung maturity in utero?
amniocentesis to assess the ratio of lecithin to sphingomyelin (L/S ratio)
L/S > 2 = adequate lung development
< 2 = increased risk of RDS
Difference btw pre&post ductal values is indicative of:
pulmonary hypertension
right to left cardiac shunt
return to fetal circulation via PDA
patient has a hernia at the foramen of bochdalek .. which congenital condition does this patient have?
diaphragmatic hernia
Foramen of Bochdalek = left lateral. It is the most common site for herniation.
Other sites = foramen of Morgangi and paraesophageal
What s/s suggest a CDH?
Scaphoid abdomen + RDS
Discuss ventilatory management of CDH patient
pulmonary hypoplasia (both or one lung)
-PIP < 25
-Permissive hypercapnia is better than barotrauma
-Avoid hypoxia, acidosis, hypothermia
-Pulse ox on LE can warn of increased intra-abd. pressure s/p abdominal closure
How and when does pyloric stenosis present?
When the hypertrophy of the pyloric muscle creates a mechanical obstruction at the gastric outlet (between stomach and duodenum). An olive shaped mass is palpated just below the xiphoid mass.
-non-bilious projectile vomit
-2 - 12 weeks of life
-more common in males
Describe pathophys of pyloric stenosis
Vomiting = hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis
Lungs compensate w/respiratory acidosis. Kidneys compensate by excreting bicarbonate
Why does paradoxical acidifcation of the urine occur with pyloric sstenosis?
as dehydration continues, aldosterone increases. to maintain electroneutrality, the kidneys lose hydrogen to the urine.
if dehydration is not corrected, it will lead to impaired tissue perfusion and metabolic acidosis. (LATE SIGN)
Postop concerns for pyloric sstenosis
postoperative apnea is common d/t CSF pH remaining alkalotic even after serum acid-base status normalizes.
NEC most common locations
-terminal ileum and proximal colon
ROP - what is it?
Vasculogenesis occurs 16 and 44 weeks post conception. the process begins at the macula and continues outwards towards the edges of the developing retina over time.
-Phase 1 = inhibited growth of retinal vessels
-Phase 2 = overgrowth of abnormal vessels with fibrous bands that extend to the vitreous gel which can precipitate retinal detachment
only medications that are ‘safe’ in neonates
fentanyl
opioids
Name, location, function of the 3 fetal shunts
Ductus venosus = highly oxygenated blood bypasses the liver (UVC -> IVC)
Foramen ovale = highly oxygenated blood bypasses lungs, goes to brain
Ductus arteriosus = poorly oxygenated blood enters aorta from PA
When does each shunt close? What is the adult remnant of each?
Foramen ovale - closes when SVR > PVR functionally. Anatomically, closes in 3 days. Remnant = fossa ovalis
Ductus arteriosus - closes when PaO2 rises and prostaglandins lower). Anatomically closes in a few weeks. Remmant = ligamentum arteriosum
Ductus venosus - closes with umbilical cord clamping. remnant = ligamentum venosus
Discuss the circulatory changes that occur during the transition to extrauterine life.
First breath = increased PaO2, drop in CO2, drop in PVR
-umbilical cord clamping = increased SVR
-drop in PVR, increase in SVR, LA > RA pressures = PFO closure
-drop in PVR reverses blood through the ductus arteriosus = exposes DA to oxygen - it closes
-Drop in circulating PGE1 (released from placenta) = DA closure
What drugs can be used to close the ductus arteriosus?
indomethacin closes. prostaglandins keep it open.
name the 5 cyanotic shunts
TOF
Transposition of the great arteries
Truncus arteriosus
Tricuspid valve abnormality - ebstein’s
Total anomalous pulmonary venous connection
HD goals for a right-to-left shunt
Keep PVR low
Maintain SVR
name the 4 acyanotic shunts
VSD (most common)
ASD
Coarc
PDA
HD goals for a left-to-right shunt
Keep SVR low
Maintain PVR
how do intracardiac shunts affect an inhalation or IV induction
right to left = slowed inhalational induction, quicker IV induction
left to right = neglible
what are the 4 defects associated with tetralogy of fallot?
-RVOTO
-RVH
-VSD
-Overriding aorta
how does a tet spell present?
-stimulus = increased sympathetic activity
-increased myocardial contractility leads to the spasm of infra-valvular region of the RVOT = rt > lt shunt
-response = hyperventilation & squatting (increased RV preload, SVR, and flow through RVOT)
HD goals for TOF
-avoid vasodilation
-maintain contractility and heart rate (avoid ephedrine)
-increase preload
what is the most common congenital anomaly in infants? how about adults?
vsd (kids)
bicuspid aortic valve (adults)
what is coarctation of the aorta? which syndrome is highly associated with this anomaly?
-narrowing of the thoracic aorta in the vicinity of the ductus arteriosus. typically occurs just before (infantile) or after the DA (dx as an adult)
**Turner syndrome is highly associated with coarctation of the aorta.
Discuss Ebstein’s anomaly
-congenital defect of tricuspid valve (ASD or PFO also). there is a downward displacement of the tricuspid valve and atrialization of the right ventricle (d/t ASD or PFO)
-severe TR
-SVT, RVF
discuss anesthetic management of the patient who has previously undergone fontan
-patient has a single ventricle that pumps blood into the systemic circulation
-no ventricle to pump blood into pulmonary ciculation
-blood flow to lungs is depedent on negative intrathoracic pressure, PPV avoided. Preload dependent patient
what is truncus arteriosus?
-single artery that gives rise to the pulmonary, systemic, and coronary circulations. no specific pathway for blood to enter pulmonary circulation before being pumped into systemic circulation.
-typically, a VSD
-decreasing PVR or increasing pulmonary blood flow steals blood form the systemic and coronary circulations.
discuss the typical ages affected and speed of onset for epiglottitis and croup
-Epiglottitis - quick onset (bacterial), age 2 - 5
-Croup (viral) - slow onset, age < 2
what organism causes epiglottitis
H influenza
Streptococci Group A
Pneumococci
Staphylococci
what organisms cause croup (laryngotracheobronchitis)
h. parainfluenzae
RSV
influenza A & B
contrast the regions affected by epiglottitis and laryngotracheobronchitis
epiglottitis = supraglottic (thumb sign)
laryngotracheobronchitis = laryngel structures (subglottic) = steeple sign
discuss clinical presentation and treatment of epiglotittis
four D’s = drooling, dyspnea, dysphonia, dysphagia
tripod position, high fever
treatment: oxygen, intubate with ENT present, antibiotics
–SV induction with CPAP
Discuss clinical presentation and treatment of croup
inspiratory stridor, barking cough
treatment: racemic epinephrine, oxygen, humidifed air, fluids, steroids
what age is at highest risk for postintubation laryngeal edema? what about congenital dx?
< 4 years old
T21
what is the treatment for postintubation laryngeal edema
racemic epinephrine 2.25%
-2.5 mL of NS
0 - 20 kg = 0.52 mL
20 - 40 = 0.5 mL
> 40 = 0.75 mL
other treatment = decadron 0.5 mg/kg, heliox, humidified o2
how many hours should the patient be monitored after racemic epinephrine is administered
4 hours
describe the presentation of the child who presents with foreign body aspiration
cough
wheezing
decreased breath sounds on the right
supraglottic = stridor
subglottic = wheezing
big tongue
beckwith syndrome
T21
small chin
pierre robin
goldenhaur
treacher collins
cru du chat
c-spine instability
klippel-feil
trisomy 21
goldenhar
describe the airway in the trisomy 21 patient
-small mouth, large tongue
-c-spine unstable
-subglottic stenosis
-recurrent pulmonary infections
-midface hypoplasia
-narrow & high palate
-OSA
CHARGE
colboma
heart defect
choanal atresia
restricted growth
gu problems
ear problems
CATCH 22
digeorge!
Cardiac defect
Abnormal face
Thymus hypoplasia
Cleft palate
Hypocalcemia
what is the most common coagulation disorder for patients undergoing T&A
von willibrand dx
patients who receive DDAAVP are at risk for hyponatremia, decrease IVF by half
what is the most common indication for T&A in kids
nocturnal upper airway obstruction
kids with OSA are at risk for
longer emergence
give less opioids
higher incidence of oxygen requirement
admit for 23 hours!!!!!
discuss primary vs. secondary bleeding with tonsils
primary = within 24 hours. 75% are within the first 6 hours.
secondary = 5 - 10 days after tonsillectomy when the eschar contracts
