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Advanced Principles II > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

Neonatal period:

age

PGA calculation

What is considered low birth rate?

Extremely low gestational age?

A
  • Neonate is birth to 30 days old
  • PGA =(# weeks gestation at birth) + (current age in weeks)
    • post-op admission for pts <60 weeks PGA
  • Pre-term <37 weeks
  • Low birth rate <2500 grams
  • ELGAN = 23-27 weeks
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2
Q

All pre-term patients have potential for what problems?

(8)

A
  • respiratory distress
  • apnea
  • hypoglycemia
  • electrolyte disturbances (low mg and Ca)
  • infection
  • hyperbilirubinemia
  • polycythemia
  • thrombocytopenia
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3
Q

What are the risks for babies of normal gestation?

postmature?

former premature up to 60 weeks PGA?

A
  • Normal gestation: 37-40 weeks
    • congenital anomalies
    • viral infections
    • perinatal depression
    • fetal alcohol
    • thrombocytopenia
  • Postmature: >42 weeks (the above risks +…)
    • meconium aspiration
    • birth trauma if LGA
    • hypoglycemia (esp if mother is diabetic)
    • hyperbilirubinemia
  • Up to 60 weeks PGA
    • post-op apnea and bradycardia (often require 12 hour admission)
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4
Q

Describe fetal circulation

A
  • oxygenated blood leaves placenta via umbilical vein
  • blood bypasses the liver via the ductus venosus to go straight to the IVC
  • Portion of this blood “Jet streams” straight across Right atrium through Foramen ovale into left atrium to then be pumped through ventricle and aorta
  • *Remaining blood goes normal route to right ventricle and PA. High pulmonary vascular resistance forces most of this blood through the Ductus arteriosus from PA to Aorta
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5
Q

What are the primary changes that occur to fetal circulation at birth?

(6)

A
  • ductus venosus closes
  • blood is now oxygenated via lungs
  • ductus arteriosus closes (d/t increased arterial O2 concentration)
  • pulmonary vascular resistance decreases
  • peripheral vascular resistance increases
  • foramen ovale closes
    • true closure is weeks later and 25-30% of adults have patent foramen ovale
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6
Q

What is transitional circulation and what causes it?

How can it be prevented?

A
  • occurs at birth and first several weeks of life
  • hypoxia, hypercapnia, or hypothermia can lead to increased pulmonary artery pressure, reversal of flow through the foramen ovale, re-opening of ductus arteriosus and shunting
    • hypoxia is #1 cause
  • Prevention with optimal oxygenation, correct acidosis, keep pt warm
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7
Q

How does the neonatal cardiovascular system differ?

A
  • Heart:
    • structurally immature
    • fewer myofibrils
    • sarcoplasmic reticulum immature
    • cardiac calcium stores reduced
  • Ventricles less compliant
    • CO is HR dependent
    • increased preload does not increase SV as much as in an older child
  • Baroreceptor reflex immature in the neonate causing inability to compensate for hypotension with reflex tachycardia
  • Parasympathetic dominance- tendency to brady
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8
Q

What is the resting CO for a neonate at birth?

infant?

adolescent?

A
  • neonate at birth: 400 ml/kg/min
  • infant: 200 ml/kg/min
  • adolescent:100 ml/kg/min
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9
Q

Neonates are vulnerable to problems caused by citrated blood products because __________.

__________ is the preferred treatment of badycardia and decreased cardiac output in pediatric patients.

A

they are dependent on ionized calcium

Epi

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10
Q

How does the neonatal pulmonary system differ?

A
  • Fewer and smaller alveoli- they increase in number and size up until 8 yo
  • Infants have a small airway diameter and increased resistance
  • Highly compliant airway and chest wall - easy to see retractions
  • Closing capacity is greater than FRC in very young and very old
    • airway closure can occure before end exhalation–leads to shunting and dead space
  • Early fatigue and diaphragmatic and intercostal muscles until age 2 b/c type 1 muscle fibers are not mature
    • neonates have 10%, 2 yr and greater have 55%
  • O2 consumption is 2-3x an adult
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11
Q

Describe the airway anatomy of an infant

(10)

A
  • larger tongue in smaller submental space
  • higher larynx (C2-C4)
  • short stubby (omega shaped) epiglottis
  • angles vocal cords (caudal slant)
  • funnel shaped larynx with narrowest region @ cricoid ring
  • obligate nasal breathers
  • large occiputs that affect sniffing position (use shoulder roll)
  • edentulous
  • short trachea (4-5 cm)
  • angulation of right mainstem bronchus
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12
Q

Airway differences comparing infant to adult

(table)

A
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13
Q

Compare between an adult and neonate: (table)

Oxygen consumption

alveolar ventilation

respiratory rate

TV

A
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14
Q

How does the pediatric airway affect gas flow?

A 50% reduction in radius increases the pressure ___-fold

A
  • young children have elevated airway resistance at baseline
    • swelling can have huge impact by increasing resistance
  • Turbulant airflow is present to 5th bronchial division
  • 32-fold
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15
Q

How does the pediatric neurological system differ?

O2 consumption

CBF

growth

other things…

A
  • Oxygen consumption and CBF is about 50% greatr in children than adults
    • adults: 3.5 ml blood flow/100 g brain mass
    • neonates: 5.5 ml/100g
  • Myelinization and synaptic connections not complete until age 3-4 years
  • Rapid brain growth in first 2 years
  • Conus medullaris at L3 at birth, migrates to L1 or L2 by 3 yo
  • Fontanels: anterior closed by 18 months, posterior closed by 2 mo
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16
Q

What does recent research say about anesthesia-induced developmental neurotoxicity?

A
  • Increased and accelerated neuroapoptosis occurs with virtually all anesthetics
  • Single exposures of short duration are usually of no consequence
  • Repeated and/or prolonged exposures at a young age (<3-4 years) may be associated with later behavioral and learning difficulties
  • ***evidence is inconclusive
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17
Q

What are differences you should consider with neuraxial in pediatrics?

A
  • The conus medullaris ends at L1 in adults and at the L2-L3 in neonates and infants
  • Iliac crest is even with L4-L5 or L5-S1 interspace (similar to adults) so it is still well below the conus medullaris
  • Dural sac terminates more caudally (S3) in neonates and infants than in adults (S1)
  • Infants have less lumbar lordosis leading to increased risk of high spinal with changes in positioning
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18
Q

How does the renal system change from infancy through childhood?

A
  • GFR is signifincantly impaired at birth but improves throughout the 1st year
    • premature infants will take longer to reach renal maturation
  • Renal tubular concentrating abilities do not achieve full capacity until about 2 yr
  • Half-life of medications excreted by glomerular filtration are prolonged in the very young
  • During childhood, renal clearance rate may be higher than adult clearance rates
    • drug half life is shorter that adults for kids >2yr
19
Q

How is liver function different in pediatrics?

A
  • Enzyme systems are still developing up until 1 yr
  • At birth Phase I Cytochrome P450 system is 50% of adult values and Phase II (conjugation reactions) are impaired in neonates
    • Causes longer half life on BZD and morphine
    • deceased bilrubin breakdown d/t reduction in glucuronyl transferase (also affects tylenol metabolism)
  • Hepatic synthesis of clotting factors reach adult levels withing one week of birth
  • Lower levels of albumin and other proteins for drug binding in newborns–> causes larger proportion of unbound drug and increased effects
  • Minimal glycogen stores- prone to hypoglycemia
20
Q

How does the GI system differ in pediatrics?

A
  • Coordination of swallowing with respiration is not mature until 4-5 months of age
    • causes high incidence of reflux
  • Gastric juices are less acidic up to about 3 years
  • Absorption of oral medications is slower compared to adults
  • GI tract is slower (slower emptying time)
21
Q

What is the significance of thermoregulation in pediatric patients?

< 3 months old?

factors that contribute?

A
  • They have large body surface area to weight ratio
  • lack subq tissue for an insulator
  • < 3 months:
    • inability to shiver
    • metabolize brown fat to increase heat production
    • can lead to metabolic acidosis and increased O2 consumption
  • Factors that contribute:
    • cold OR
    • anesthetic-induced vasodilation
    • room temp IV fluids
    • evaporative heat loss from surgical site
    • cold irrigating solutions
    • cold anesthetic gases
22
Q

What are the ways heat is lost in the OR?

(pic)

A
  1. conduction
  2. evaporation
  3. convection
  4. radiation
23
Q

How can you actively warm a pediatric patient?

A
  • warming mattress
  • incubator
  • cover with blankets
  • head coverings
  • transport in isolette
  • humidify gases
  • use plastic wrap on the skin
  • warm prep and irrigation solutions
  • change wet diapers and remove wet clothing
  • Forced air warming **most effective strategy for childre >1 yr**
24
Q

How should you monitor temp?

How should you not?

What are some problems that hypothermia can cause?

A
  • Core temp is best (esophageal)
  • Axillary temp can recognize MH earlier
  • NO Forehead temp! 10 MH episodes unrecognized w/forehead temp
  • Hypothermia:
    • delayed emergence
    • reduced degradation of drugs
    • increased infection
25
Q

How does body composition vary over the age spectrum?

(table)

*know trends, not actual numbers

A
26
Q

How does the difference in body composition affect anesthesia?

A
  • Higher total body water:
    • Water sluble drugs have a larger volume of distribution
      • need a larger initial dose (sch, abx)
      • larger distribution can delay excretion
  • Neonates have less fat and muscle
    • drugs that depend on redistribution to fat for termination of action will have prolonged effects
  • Protein binding: <6 mo have less albumin and alpha-1 acid glycoprotein (AAG)
    • higher free-fraction of protein bound drugs
    • free fraction of local anesthetics will be higher (bind to AAG)
27
Q

In general, most medications will have a _______ elimination half-life in pre-term and term infants, a _______ half-life in children older than 2 yrs up to early teen years, and a ________ of half-life in those approaching adulthood.

A

In general, most medications will have a prolonged elimination half-life in pre-term and term infants, a shortened half-life in children older than 2 yrs up to early teen years, and a lengthening of half-life in those approaching adulthood.

28
Q

How do you calculate maximum allowable blood loss (MABL)?

A
29
Q

How does fetal hgb differ from adult hgb?

Target hct for neonates?

A
  • Fetal Hgb has a lower P50 at 19 mmhg compared to 26 mmHg in adults
    • LEFT shift
  • Target HCT is higher in neonates d/t L shift and decreased CV reserve
    • minimum HCT of 40% instead of 30%
30
Q

What is the expected hgb and hct for: (table)

newborn

3 mo***

6-12 mo

adult female

adult male

A

*** physiologic anemia at 2-3 mo

31
Q

__-__ ml/kg of PRBC will increase hgb about ____g/dL

EBV table

premature neonate

term neonate

infant

>1 yr

A

4-5 ml/kg of PRBC will increase hgb about 1g/dL

32
Q

How is blood administration done for pediatrics?

ratio

threshold

When would you consider blood sooner?

A
  • Blood loss replaced at 3:1 with crystalloid
  • Threshold: 24-30%, determined on individual basis
    • infants <3 mo may have higher threshold d/t left shift and physiologic anemia
  • Consider blood sooner when:
    • preterm infants
    • term newborns
    • cyanotic congenital heart disease
    • respiratory failure needing higher O2 carrying capacity
  • **Incidence of apnea is high in neonates and preterm infants who have hct <30
33
Q

When do you transfuse FFP?

What do you need to watch for with FFP?

When do you replace platelets?

How do you calculate how much blood should be transfused?

A
  • FFP if > one blood volume is being replaced
  • FFP has the highest levels of citrate, so need to watch for ionized hypocalcemia and CV depression
    • especially in neonates and children with liver failure
  • Platelets replacement depends on starting plt cound and if there is oozing on the field
    • a child with a nml plt count usually does not need plt until EBL is > 2 blood volumes
34
Q

What kind of fluid is used in children?

What are signs of dehydration in children?

A
  • LR for maintenancy in healthy children
    • glucose containing IVF may be needed in infants < 6 mo or other risk of hypoglycemia (mitochondrial disease)
    • use smaller bags or buretrol
    • eliminate ALL air from line
  • TPN should not be stopped suddenly, either continue in OR or ramp it down and bridge with glucose containing fluid
  • Signs of dehydration:
    • mild: (~50 ml/kg deficit) dry mouth, poor skin turgur
    • moderate (~100ml/kg): mild sx plus sunkin fontanel, oliguria, tachycardia
    • severe (~150 ml/kg): mod sx plus sunken eyes, hypotension, and anuria
35
Q

How do pediatrics differ regarding inhaled anesthetics?

A
  • uptake is more rapid d/t:
    • increased RR and cardiac index
    • large proportion of blood to VRG (heart, brain, GI, kidneys, endocrine)
    • reduced tissue and blood solubility in infants
  • alveolar ventilation to FRC ratio is 5:1 in infants vs 1.5:1 in adults
  • Increased incidence of hypotension in neonates and infants
  • Increased risk of anesthetic overdose in infants/toddlers
    • when HR starts to go down, turn down the gas!
  • MACS are generally higher in children
36
Q

What is the inhaled agent of choice for pediatrics and why?

Why not the others?

A
  • Sevo
    • not very pungeant, does not irritate the airway
  • Halothane was good as well but is no longer available; caused bradycardia
  • Desflurane is too pungeant, can cause coughing, laryngospasm, salivation
    • lower solubility makes it useful for maintenance during long procedures or obese children
37
Q

Effects of volatile agents on…

respiratory

CV

emergence delirium

A
  • Resp: all volatiles cause dose related resp depression and depressed response to CO2 and hypoxia
    • apnea worsens with higher concentration
  • CV: dose dep depression
    • sevo usually maintains or increases HR during induction
    • all cause prolonged QT
    • halothane has greatest depression of contractility
    • myocardial depression may be exaggerated in deonates
  • Emergence delirium associated with all VA
    • sevo > des > halothane
38
Q

How is dosing of induction agents for pediatrics done?

A
  • Neonates have immature BBB and slower metabolism so they require lower doses
  • Older children and adolescents require higher doses
  • Propofol
    • 3 mg/kg for infants <2yr
    • 2.5 mg/kg for children 6-12 years
  • Ketamine
    • 2 mg/kg IV or 4-8 mg/kg IM
    • plus atropine 0.02 mg/kg IM/IV (for secretions)
  • Etomidate (not FDA approved < 12yr)
    • 0.25-0.3 mg/kg
  • Thiopental
    • neonates 3-4 mg/kg
    • infants 7-8 mg/kg
    • children 5-6 mg/kg​
39
Q

Sedatives:

midaz oral dosing (18 mo-3 yr, 3-6 yr, and 6-10 yr)

Ketamine dart dose

A
  • Oral midaz dosing- increases in younger pts; poor oral bioavailability and bitter taste
    • 18 mo-3 yr: 0.75-1 mg/kg
    • 3-6 yr: 0.6-0.75 mg/kg
    • 6-10yr: 0.5 mg/kg
  • Ketamine dart:
    • 2-5 mg/kg
    • onset 3-5 min and duration 30-40 min
40
Q

Opioid dosing in peds:

morphine

dilaudid

fentanyl

remi

demeral

codeine

A
  • Morphine: 50-100 mcg/kg
  • Dilaudid: 10-20 mcg/kg
  • Fentanyl: 0.5-3 mcg/kg
  • Remi: 0.05-0.1 mcg/kg/min
  • Demerol: 0.25-0.5 mg/kg
  • Codeine: no longer prescribed as often d/t ultra rapid metabolizers having increased risk of OD–>BLACK BOX
41
Q

Non opioid pain dosing in pediatrics:

acetaminophen

ketorolac

A
  • Acetaminophen
    • PO: 10-15 mg/kg
    • IV: 15 mg/kg q 6 hours (10 min onset)
  • Ketorolac
    • 0.5 mg/kg
    • **Caution with all NSAIDS in severe asthma
42
Q

How are muscle relaxants different in peds?

A
  • NMJ not fully mature until about 2 mo
    • infants more sensitive to NDMB but have larger VD, so dose ends up the same as adults (except ROC)
    • Roc dose is 0.3 mg/kg
  • May see prolonged DOA d/t immature kidney and liver
  • Higher sch dose needed in neonateds d/t larger VD
    • Sch only used in RSI or laryngospasm (bradycardia, hyperkalemia, MH)
  • Neostigmine dose 40% lower than adult (0.2-0.4 mcg/kg
43
Q

How are LA different for pediatrics?

A
  • LA absorption increased d/t increased CO and local blood flow (2-3x greater in infants than adults)
  • Epi can still slow down uptake
  • Plasma AAG is low at birth and does not reach adult levels before 1 yr
    • Free fraction of all LA is increased in infants

Advanced Principles II (20 decks)

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