Pediatrics Flashcards
Pediatric definitions
Neonate: birth to 1 month
Infant: 1 month to 1 year
Toddler: 1 year to 2 years
Young children 2 to 12 years
Pedi respiratory anatomy differences
6
- Larger occiput
- Larger tongue
- Narrower nasal passage
- larynx is more anterior and cephalad
- Longer epiglottis
- shorter neck and trachea
What is the most narrow point in the pedi respiratory tract?
cricoid cartilage
Respiratory Characteristics for Pedis
SWARRRRMIIING
- Short Trachea and neck
- Weaker diaphragm muscles
- Anterior/Cephalad Larynx
- Relatively longer epiglottis
- Relatively larger head / tongue
- Reduced lung compliance
- Reduced FRC
- More prominent tonsils and adenoids
- Increased RR
- Increased chest wall compliance
- Increased O2 consumption 6-8 mL/kg/min
- Narrow nasal passage
- Greater resistance to airflow
Do pedis have an increased work of breathing?
Yes
What is not fully functional in the pediatric population?
Hypoxic and hypercapnic ventilatory drives
Pediatric cardiovascular characteristics
PHIRRN
- Potential difficulty with venous and arterial cannulation
- Heart rate dependent CO
- Increased HR
- Reduced BP
- Residual fetal circulation issues
- Non-compliant LV
What are residual fetal circulation issues?
PFO
Patent ductus arterious
Is the myocardium more or less sensitive to depressant effects of anesthetics?
More
What is a concern about pediatric volume changes?
possible without accompanying HR changes
Is hypothermia or hypertherma a larger issues in the pediatric populaiton?
Hypothermia
Why is hypotherma a larger issue in pedis?
Larger body surface area
Thin skin
Low fat
What is the Mosteller formula for?
BSA calculations
What is the mosteller formula?
The SQRT of Height x Weight / 3600
BSA = m^2, Height in cm, Weight in kg
What are the three types of fat?
- White
- Brown
- Beige
What is white fat?
Most common, around organs
What is brown fat?
Energy storage
burnt to generate heat
What is beige fat?
Combination of white and brown fat
How do neonates stay warm?
brown fat metabolism
this process is inhbited by anesthetics
Pediatric renal function
- Slightly reduced
- Normal by 6 months
Can be delayed up to 2 years
Pediatric GI function
Podssible increased GERD due to pyloric stenosis
Pediatric Hepatic function
Decreased phase 2 metabolism
Reduced glycogen storage leads to possible hypoglycemia
Pediatric Drug Dosing Guide / Characteristics
WADIIF
- Weight based still used secondary to familiarity
- Adjusments based on BSA rather than mass
- Decreased protein drug binding
- Increased circulation times
- Immature biotransformation pathways
- Fluid compartment changes
5oth percentile weight formula
(Age x 2) + 9 = (kg)
Who has more total water: Adult or neonate?
Neonate
(Gradually decreased with age)
What does more TBW do to drugs?
Increased Vd
What does an increased Vd mean for drugs?
More drug leaves plasma and enteres intersticial space
Higher drug dosing needed
Drug clearance is slower due to lower metabolism
We get a fast emergence with Sevo and Des in pediatrics, what is something we need to watch out for becuae of this?
Incerased post-op delirium
What does halothane do to the myocardium?
Sensitizes it to catecholamines, so go slow
Do pedis need a higher or lower MAC?
Higher
Is respiratory depression more or less pronounced in pediatrics?
More
Nonvolatile Anesthetics in pediatrics: Propofol
- Shorter eliminaiton half-life
- Higher plasma clearance
- propofil infusion syndrom more comin in critically ill kids
- Accumulates more than opiods, verses, or precedex
Nonvolatile Anesthetics in pediatrics: Opiods
- More pronounced effect in neonates
- Remi has increased clearance rate
Nonvolatile Anesthetics in pediatrics: Versed
Fastest clearance of all benzos
Nonvolatile Anesthetics in pediatrics: Precedex
Intranasal: 1-2 mcg/kg
Up to 0.5 mcg/kg IV (watch bradycardia)
Paradoxycal effects: Versed
Can be mitigated by flumazenil or precedex
Muscle relaxers: Non-Depole
- Infants require lower doses
- use twitch monitor
- Roc: 1-1.5 mg/kg IM
Muscle relaxers: Depole
- Infants require larger doeses
- Succs: 2-3 mg/kg IV
- Succs: 4-6 mg/kg IM
- Give atropine with Succs everytime (0.1mg/kg IV or 0.02 mg/kg IM)
What are the more pronounced sympoms from Succs in pediatrics?
HARMMM
- Hyperkalemia
- Arrhythmias
- Rhabdomyolysis
- Myoglobinemia
- Masseter spasm
- MH
NPO guidelines for healthy kids
- Clear fluids up to 2 hours prior
- Breast milk / formula up to 4 hours prior
- Light meal up to 6 hours prior
Pre-OP medications
Versed
Ketamine
Dexmedetomidine
Fentanyl Lollipos
Versed/Ketamine Combo
Pre-OP Dosing: Versed alone
0.25 mg/kg IM
0.25-0.7 mg/kg PO (20mg MAX)
20-45 min onset
Pre-OP Dosing: Ketamine alone
4-6 mg/kg IM
Give with Atropine 0.02mg/kg IM
Pre-OP Dosing: Dexmedetomidine
- 1-2 mcg/kg intranasal
Pre-OP Dosing: : Fentanyl Lollipops
5-15 mcg /kg
Color coded doses
Pre-OP Dosing: Versed/Ketamine Combo
Versed: 0.1-0.15 mg/kg IM
Ketamine: 2-3 mg/kg IM
Mask induction
No IV, kids scared of needles
Rapid Induction Speed
N2O has no odor or irritation
Sevo least offensive (good smelling stuff is added)
Two types of mask inductions?
Smooth (Normal)
Steal (aggresive child)
Smooth mask induction
70/30 N2O/O2 mixture
Slowly add Sevo
~4% ET Sevo to get through stage 2
Place IV after asleep
Steal mask Induction
- Occlude mask and a slightly closed APL valve
- High flow O2, N2O, and 8% Sevo
- Get help holding child and place mask over face
- If kid hold breath, great!
- Keep maks on airway as much as possible
- Careful of Sevo overdose
IV cannulation after asleep: common locations
- Saphenous
- AC
- Hand
- Wrist
IO access
- 16 or 18g IO needle with different lenghs and bevels
- limited to no more than 24 hours
- avoid epiphyseal plates
IO access contraindications
PROOF-BC
- Previous IO attempts (48 hours)
- Recent orthopedic procedure
- Osteogenesis imperfecta
- Osteoporossis
- Fracture
- Burns
- Cellulitis / infection
IO access locations
PDS-HD
- Proximal Tibia
- Distal Tibia
- Sterum
- Humerus
- Distal Femur
IO access: Sterum
- Not apporved for pediatrics < 12yr old
- Not great for compressions
- 1cm caudal to sternal notch
- Midline
IO access: Humerus
- Internally rotate humerus
- Hand placed on abdomen
- palpate the surgical neck and insert needle 2 cm cephalad into greater tubercle
- 45° angle
Bullshit Humerus IO insertion flowchart
Step 1-9
- Place patients hand over abdomen (elbow adducted and humerus internally rotated)
- Place your palm on patients shoulder anteriorly, should feel like a ball (push deeply in obese patients)
- Place ulnar aspect of one hand vertivally over axilla
- Place ulnar aspect of opposite hand along midline of upper arm
- Place thumbs together over the arm, this identifies the vertical line of insertion on the proximal humerus
- Palpate deeply as you go up the humerus to the surgical neck (golfball meets tee)
- Insertion site is on most promnent aspect of greater tubercle 1-2cm above surgical neck
- Clean with chloraprep, aim needle 45°, push tip through skin unti it hits bone, 5mm stil above skin, drill until pop
- Hold hub and pull driver off, twist stylet counter clockwise, needle firmly in bone, place stabilizing dressing over hub, attach primed tubing, aspirate
IO access: Distal Femur
- Leg straight and centered in anterior plane
- 1 cm proximal to patella
- 1-2 cm medially
IO access: Proximal Tibia
1-2 cm inferior and medial to the tibial tuberosity
(flat of the tibia)
IO access: Distal Tibia
- 2 cm proximal to the medial malleolus
(flat of the tibia)
IO access: Epiphyseal plates
drilling into these may cause growth development issues later in life
Endotracheal Tube Medications
NAVEL
- Naloxone
- Atropine
- Vasopressin
- Epi
- Lido
2-2.5 times normal dose and dilute with 5-10 mL of N/S
Pediatric Intubation tips
- Use ramping, large occiput
- watch for prominent tonsillar tissue
- miller blade preferred
- cricoid is narrow so watch out for causing trauam to it with ETT
Pediatic tube choices: Sizing
No uncuffed beyond 4.0
Size: Age + 4 / 4
Depth: Age +12 / 2
Uncuffed tube leak test
15-25 cm H20
Pediatric cases: ventilator
Smaller reservoir bags (0.5 L)
smaller circuits for reduced dead space
older machines have inaccurate pedi volumes
Buretrol: indications and concerns
Limits margin of error
caution with air bubbles in pedi cases
4:2:1 rule
Circulating blood volumes
- Preterm neonate: 100mL/kg
- Full term neonate: 85-90mL/kg
- Infants: 80mL/kg
Blood transfusing dosages
- Platlets: 10-15 mL/kg
- FFP: 10-15 mL/kg
- Cryoprecipitate: 1 unit/10 kg
Caudal anesthesia
- for below the umbilicus
- lateral
- prone jackknife
Caudal anesthesia contraindications
Infection
coaguloapathy
anatomic abnormalities
Caudal block: what ligament do we go through?
sacrococcygeal ligament
Caudal dosing
2 mg/kg of 0.25% Marcaine with Epi
Pedi laryngospasm treatment
PPV
jaw Thrust
Propofol
Lido 1-1.5 mg/kg
Muscle relaxer
What is the rescue position and why do we use it?
Lay on side, top leg out and head back
helps with secrections
Recovery breathing treatments
- Decadron (takes longer)
- Inhaled racemic Epi
Epi: 0.25-0.5mL of a 2.25% solution in 2.5 mL N/S
Hypothermia issues
LIPIDIC-APP
Left Shift Hemoglobin-oxygen sat curve (O2 doesn’t leave)
Increased Renal dysfunction
Platelet dysfunction
Increased infection risk
Decreased drug metabolism
Increased cortisol levels
Coagulopathy
-
Arrhythmias
Protein catabolism
Poor wound healing
Emergence Delirium: Risk Factors
SPPPEC-M
- Sevo / Des
- Preschool age
- Pre-OP anxiety
- Parental anxiety
- ENT procedure
- Child temperment
- Male
Emergence Delirium: Tips
- Reduciton in volatile agents help
- Precedex helps smooth wakeups
- Single use of propofol near end of procedure
- Parental help
Precedex dosing for kids
0.2-0.5 mcg/kg
