Pediatrics Flashcards
Caudal blocks are basically just an?
epidural
what dermatmoes can be blocked with caudal?
sacral, lumbar, and lower thoracic dermatomes
caudal can deliver block up to what level?
T10
why do we not use caudal blocks in adults?
hard to identify sacral anatomy in adults.
lumbar epidural is easier to perform with the same results
What are the absolute contraindications to a caudal block?
spina bifida
meningomyelocele of the sacrum
meningitis
relative CI for caudal block
pilondial cyst
abnormal superficial landmarks
hydrocephalus
intracranial tumor
progressive degenerative neuropathy
advancing the needle beyond blank increases risk of dural puncture during caudal block
S2/S3
should you use air for LOR when doing caudal block? why or why not?
no, because of risk of an air embolism
what can you do while performing caudal block to rule out sub q infiiltration?
palpate the skin during injection
what concentration of epi would you use in a caudal block? what is the benefit of adding epi?
incrased DOA
use epi 1:200,000 (5mcg/ml)
why might you use clonidine in a caudal block? what is the dose?
it can provide equal analgesia to epidural opioids
clonidine 1mcg/ml
pediatric caudal dosing
sacral 0.5ml/kg
sacral to low thoracic 1ml/kg
sacral to mid thoracic 1.25ml/kg (miller says to avoid this dose range…)
what concentration LA should you use for caudal block?
any concentration is fine, just make sure total dose is < 2.5mg/kg
can use any concentration of Bupi, levobupi, or ropi
why should you select lower concentration LAs for pediatric caudal blocks?
caudal blocks are usually done with GA, so you only need analgesia from the block, not surgical anesthesia.
list some common cases when a caudal block would be useful
circumcision
hypospadias repair
Anal surgery
inguinal herniorrhaphy
low thoracic surgery
what is another name for epiglottitis?
supraglottitis
is epiglottitis bacterial or viral?
bacterial
in what ages to epigottitis usuallly occur?
2-6yrs
is epiglottitis rapid or slow onset?
rapid onset
what “sign” is present on x-ray in epiglottitis?
thumb sign
what are the presenting s/s of epiglottitis
high grade fever
4 Ds
drooling, dyspnea, dysphonia, dysphasia
main is the main treatment consideration for epiglottitis?
urgent airway mgmt
tracheal intubation or tracheostomy
abx if bacterial
how should you induce a patient with epiglottitis?
maintain spontaneous RR with CPAP 10-15 to prevent airway collapse and ENT surgeon must be present for induction
what is another name for laryngotracheobronchitis?
croup
is croup viral or bacterial?
viral
what age does larngotracheobronchitis usually occur?
<2yrs
larngotracheobronchitis affects which airway structures?
below the vocal cords
what “sign” is seen in croup on x-ray?
steeple sign indicative of sub glottic narrowing.
how does laryngotracheogronchitis present?
low grade fever
vocal horseness
inspiratory stridor
retractions
croup tx
racemic epi
corticosteroids
humidification
fluids
INTUBATION RARELY REQUIRED
what is another name for post intubation laryngeal edema?
post intubation croup
is what patient population is post intubation laryngeal edema most common?
small children (<4yrs most common)
what is the most common cause of post intubation croup?
ETT that is too large
what else an cause post intubation croup other than using an ETT that is too large?
rigid bronchoscopy, multiple intubation attempts, coughing > causes ETT to move up and down
what is tracheal perfusion pressure?
25cmH20
what are s/s of post intubation laryngeal edema?
hoarsness, barky cough, stridor
how soon does post intubation laryngeal edema occur after extubation?
usually within 30-60min
what is best tx for post intubation laryngeal edema?
racemic epi
best if driven by intermitent positive pressure ventilation or nebulization
how do you prepare racemic epi? what is the concentration of racemic epi? what is the dosing?
alwasy diluted in saline
racemic epi is 2.25%
always add to 2.5ml saline
0-20kg 0.25ml racemic epi
20-40kg 0.5ml racemic epi
>40kg 0.75ml racemic epi
other treatment options for post intubation laryngeal edema besides racemic epi
cool humidified O2
dexamethasone 0-.25-0.5mg/kg (max effect not for 4-6hrs though)
heliox to improve laminar flow
how long should you observe patient after giving racemic epi for post intubation laryngeal edema?
for at least 4 hours
are most upper respiratory infections bacterial or viral?
most are viral
recent URI increases risk of Pulmonary Complications. What are these complications?
bronchospasm
laryngospasm
mucus plug
atelectasis
desaturation
post op hypoxemia
proced with caution with what URI symptoms?
clear rhinorrhea
no fever
child appears happy
clear lungs
older child
consider cancelling case for URI when what symptoms are present?
purulent nasal discharge
fever >38C or 100.4F
child is lethargic
persistent cough
poor appetite
wheezing or rales that don’t clear with cough
child <1yr or previous preemie
most clinicians delays cases for how long after symptom onset for URI? How long does risk of pulm complications persist?
2-4 weeks. although risk of pulm complications can persist for 6-8weeks
ways to decrease risk of pulm complications with recent URI?
avoid ETT if possible
facemask >LMA»>ETT
if you must use ETT, size down
make sure they are deep before instrumenting airway
decadron 0.25-0.5mg/kf decrease risk of post intubation croup
does pretreatment with bronchodilator or glyclpyrrolate help in setting of recent URI?
No, there is no clear benfit.
with foreign body aspiration what percent of patients present with the classic triad?
60%
what is the classic triad of symptoms in foreign body aspiration?
cough
wheezing
decreased breath sounds on affected side (usually right side)
supraglottic airway obstruction causes?
stridor
subglottic airway obstruction causes?
wheezing
what are tx options for foreign body aspiration? what is the gold standar?
rigid bronchoscopy (gold Standard)
flexible bronchoscopy
thoracotoomy
what are the complications associated with rigid bronchoscopy
laryngospasm
bradycardia from scope insertion
post intubation croup
pneumothorax
why might a patient not immediatly improve after removal of an aspirated foreign body?
residual lung inflammation from the foreign body
which kind of induction is best for aspirated foreign body?
sevo induction that maintains spontaneous ventilation
why should you maintain sponatneous ventilation during case for foreign body aspiration?
this maintains laminar flow and decreases the risk of distal movement of the foreign body
what kind of ventilation should you avoid with foreign body aspiration?
positive pressure ventilation
what can you do with anesthesia circuit and rigid bronchoscope? what is the benfit?
you can connect the circuit to the rigid bronchoscope.
this will allow you to use the circuit to deliver O2 and inhaled anesthetic
also allows for ability to provide PPV if needed
what is significatn about the air leak that comes with ridig bronchoscope?
this will allow for room air entrainment which will dilute your VA concentration and you FiO2 concentration
why is TIVA proably best for aspirated foreign body case?
dont have to worry about delivering VA with the leak from rigid bronchoscope
PLUS propofol decreases airway reflexes
what is the risk of patieint coughing or bucking during case for aspirated foreign body?
this can cause the foreign body to move distally. This is not good!
Pediatric disorder associated with Big tounge
“Big Tongue”
beckwith syndrome
trisomy 21
pediatric disorders associated with small underdeveloped mandible
“Please Get That Chin”
pierre robin
goldenhar
treacher collins
Cri du chat
pediatric disorders associated with cervical spine anomonly
“Kids Try Gold”
kilpell-fiel
trisomy 21
goldenhar
Big things to know about Pierre Robin Dz
micrognathia
tongue that falls back and downwards (glossoptosis)
cleft palate
neonate often requires intubation
big things to know about Treacher collins
small mouth
micrognathia
nasal airway blockd by choanal atresia
occular and auricular anomalies
big 4 airway things to know about trisomy 21
small mouth
large tonge
atlanto-axial subluxation
subglottic stenosis
big thing to know about Klippel-Feil
congenital fusion of neck vertebrae > neck rigidity.
main things to know for Cri du chat
micrognathia
laryngomalacia
stridor
cleft lips / cleft palates are commonly associated with other ….
genetic disorders
airways risks associated with cleft lip or cleft palate
airway obstruction
difficult laryngoscopy
difficult mask ventilation
aspiration
what is dingman-dott retractor used for?
in cleft palate surgery
what is the risk associated with dingman-dott retractor?
can occlude venous drainage and cause tongue engorment which leads to risk of post extubation airway obstruction
other conisderation with cleft palate patient
often have failure to thrive
when is cleft lip typically fixed?
at 1 month
when is cleft palate usually fixed?
typically at 12 months
what happens genetically in trisomy 21?
there is a third copy of chromosome 21
what is the most common chromosomal disorder?
trisomy 21
what babies are at higher risk of developing trisomy 21?
babies of older moms
what organ systems does trisomy 21 affect?
nearly every organ system
how can heart be affected by trisomy 21?
co-existing congenital heart dz is common
what is the most common congenital heart defect associated with trisomy 21?
AV septal defect is the most common
what is the second most common heart defect associated with trisomy 21?
VSD is the 2nd most common
What should you think about when doing sevo mask induction on a patient with trisomy 21
sevo can cause bradycardia in trisomy 21, so go slow with up with the sevo.
anticholinergics are the tx for sevo induced bradycardia
trisomy 21 patients have low levels of ciruclating…
catecholamines
other conditions associated with Trisomy 21
intellectual disability
epilepsy
strabismus
low muscle tone
hyperflexible joints
GERD
thyroid dz
increased incidince of leukemia
