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6903 - Special Populations > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

NPO guidelines: solids, formula, breast milk, clears

A

solids: 6h
formula: 6h
breast milk: 4h
clears: 2h

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2
Q

IV Versed dosing

A
  1. 05-0.1 mg/kg

* 1 year old = 1 mg; 2 year old = 2 mg

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3
Q

PO Versed dosing

A
  1. 5-1 mg/kg given 20-30 minutes before case
    - max dose 20 mg

*under 6 months = none, over 12 years = preop IV

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4
Q

EMLA Cream

A
  • lidocaine and prilocaine topical cream
  • cannot be applied to broken/open skin
  • cannot be used on infants or patients less than 10 kg
  • need to wait at least 15 min, ideally 45-60 min, max effect 2-3 hours
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5
Q

Pain Ease

A
  • instant topical anesthetic skin refrigerant
  • created cooling effect by evaporation that decreases the nerve conduction velocity of C and A-delta fibers
  • spray for 4-10 seconds at 3-7 inches until skin blanches
  • lasts 60 seconds
  • do not need to re-prep with alcohol
  • can be used on open skin
  • approved for children over 3
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6
Q

J-Tip

A
  • expensive

- injects local surrounding the puncture site

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7
Q

best site for airway monitoring with precordial?

A

-suprasternal notch

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8
Q

best site for breath sounds and heart tones with precordial?

A

-apex of heart: 5th left intercostal space at the midclavicular line just below the nipple

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9
Q

ETT sizing

A
  • (age/4) + 4
  • similar to size of child’s pinky
  • decrease 0.5 size for cuffed
  • uncuffed or microcuff for <6 y
  • depth 3x tube size
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10
Q

IV Drips - specifics for ages

A
  • <2y = buretrol
  • <12y = microdripper

-<6m = dextrose infusion

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11
Q

Emergency Drugs (5)

A
  • sux = 4-6 mg/kg on IM needle
  • atropine = 0.02 mg/kg on IM needle
  • phenylephrine
  • ephedrine
  • epinephrine
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12
Q

Pediatric Dosing: rectal acetaminophen

A

30-40 mg/kg rectal

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13
Q

Pediatric Dosing: Toradol

A

0.5 mg/kg IV or IM

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14
Q

Pediatric Dosing: Fentanyl

A

0.5-1 mcg/kg IV

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15
Q

Pediatric Dosing: Morphine

A

0.1 mg/kg IV

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16
Q

Pediatric Dosing: hydromorphone

A

10 mcg/kg IV

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17
Q

Pediatric Dosing: IV acetaminophen

A
  • <2 y = 10 mg/kg (not FDA approved)

- <12 y = 15 mg/kg

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18
Q

Pediatric Upper Airway

A
  • large occiput
  • large tongue
  • narrow nasal passages (choanal atresia, NG)
  • nasal breathers until 5 months
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19
Q

Pediatric Larnyx

A
  • larynx: anterior, cephalad (C3=preterm, C4=newborn, C5=age 6, C5-6= adult)
  • epiglottis omega shaped, short, stubby
  • cone shaped, cricoid is narrowest point until 10 y
  • short trachea
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20
Q

Pediatric Breathing

A
  • alveoli small and limited number until 8 y
  • decreased lung compliance, less surfactant in premature infants
  • increased work of breathing
  • increased metabolic rate/oxygen consumption, 7 cc/kg/min
  • hypoxic/hypercapnic respiratory drives not well developed
  • decreased FRC
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21
Q

Pediatric Breathing Muscles

A
  • diaphragm easily fatigued
  • intercostal muscles immature and weak
  • lack of type 1 muscle fibers (resistant to fatigue), similar percentage to adult at 2 y
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22
Q

Risk factors & Intervention for apnea or bradycardia following general anesthesia

A
  • Risk: premature, anemia, hypothermia, CNS disease, sepsis, hypoglycemia, metabolic disease
  • need 23 hour admission for apnea and hr monitoring
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23
Q

Persistent Pulmonary Hypertension Cause, Treatment, Goals

A

Cause: pulmonary circulation extremely sensitive to oxygen, pH, NO, prostaglandins

Treatment: high-frequency ventilation, ECMO, surfactant, NO, prostanoid

Goal: PaO2 50-70, PaCO2 50-55

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24
Q

In utero - circulation

A
  • ductus venous: closes with umbilical clamping
  • foramen ovale: closes at birth
  • ductus arteriosus: closes first 4 days of life
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25
Q

Pediatric Circulation

A
  • stroke volume fixed, changes dependent on heart rate

- less compliant ventricles

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26
Q

Pediatric Parasympathetic/Sympathetic Nervous System

A
  • sympathetic immature compared to parasympathetic: poor response to inotropic support for first 3 months
  • baroreceptors immature until 8y
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27
Q

Pediatric Kidneys

A
  • decreased GFR and RBF
  • inability to concentrate or dilute urine
  • decreased Na excretion
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28
Q

Fetal Hemoglobin

A
  • high affinity for oxygen (left shift)

- physiological anemia until teens when HbF is replaced by HbA

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29
Q

Pediatric Liver

A
  • immature until after 1 y
  • decreased albumin
  • enzymes mature over months to years; glucuronidation by 6 mo
  • minimal glycogen stores
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30
Q

Pediatric Hypoglycemia, treat less than ___

A

45

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31
Q

Pediatric Thermoregulation

A
  • increased heat loss: thin skin, low fat content, high surface area/weight ratio
  • no shivering first three months, temperature regulated by brown fat
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32
Q

Total Body Water %

A
  • preterm=80%

- >12 mo=60%

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33
Q

Fluid Resuscitation for hypotension in infant and child

A
  • infant=10 cc/kg

- child=20 cc/kg

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34
Q

Electrolyte differences

A
  • increased K in first 2 days of life

- decreased Ca in premature and infants

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35
Q

Estimated Blood Volume

A
  • preterm= 90 mL/kg
  • newborn= 80mL/kg
  • 3 mo-3 y= 75mL/kg
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36
Q

Hgb will increase by ____ g/dL with ____ mL/kg packed cells

A

Hgb will increase by 1 g/dL with 4 mL/kg packed cells

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37
Q

Pediatric platelet transfusion

A

10-15 mL/kg

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38
Q

Pediatric cryoprecipitate

A

1 unit/10 kg

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39
Q

Pediatric calcium gluconate

A

7.5-15 mg/kg

40
Q

Emergence delirium: most vulnerable and treatments

A

most vulnerable:
-sevoflurane, 2-5y

treatments:
-precedex 0.3 mg/kg, Propofol 1 mg/kg, fentanyl 1 mcg/kg

41
Q

leak test for ETT pressure

A

20-30 cm H20

42
Q

Delay surgery for ____ for upper respiratory infection

A

4 weeks

43
Q

Pediatric Ventilator Settings

A
  • RR=20
  • TV=6-8 mL/kg
  • PS=15-18 cm H20
  • PEEP=3-5 cm
44
Q

Dantrolene dosing

A
  • 2.5 mg/kg IV q5min

- max=10 mg/kg

45
Q

Pediatric Induction Sequence

A
  1. SpO2 monitor
  2. nitrous 70% (>3 years)
  3. sevo 8% (don’t turn nitrous off until IV is in)
  4. IV when past stage 2 (don’t place oral airway until IV is in)

*additional monitors when asleep unless concerns

46
Q

Urologic surgery: circumcision

A
  • regional: penile or caudal block

- postoperative fever common in children with phimosis (foreskin can’t be retracted)

47
Q

Urologic surgery: hypospadias repair

A
  • incorrect position of the penile meatus

- penile block is lower 1/3, caudal if closer

48
Q

Urologic surgery: orchidopexy

A
  • undescended testicles

- regional: caudal or local block with LMA or ETT

49
Q

Urologic surgery: ureteral reimplantation

A
  • incompetence where distal ureter implants at the bladder resulting in retrograde urine flow
  • long term effects: HTN, pyelonephritis, renal failure
  • regional: caudal or epidural catheter with LMA or ETT
  • sufficient fluid to avoid stasis in the bladder
50
Q

Urologic surgery: pyeloplasty

A
  • repair contortion at the ureteropelvic junction
  • minimal EBL, but 5-7 mL/kg/hr insensible fluid loss
  • epidural or intrathecal morphine for long term pain control
51
Q

Urologic surgery: Wilms’ tumor

A
  • advanced: tumor spreads to lungs, liver, inferior vena cava, and aorta
  • von Willebrand’s disease in some children
  • potential for large abdominal mass
52
Q

Urologic surgery: testicular torsion repair

A
  • surgical emergency
  • consider prokinetic to help facilitate gastric emptying and RSI
  • adolescents: spinal with sedation
53
Q

caudal block

A

-more difficult after age 12, not used in a child that can walk

54
Q

Dental surgery: nasal intubation

A
  • ETT 1/2 size smaller than oral
  • lubrication and afrin to dilate the airways
  • warm ETT in saline

*don’t use phenylephrine solutions in pediatric patients

55
Q

Oculo-cardiac Reflex

A

-occurs when traction placed on extraocular muscle

  1. tell the surgeon to release pressure on the eye
  2. administer glycopyrrolate or atropine
56
Q

factors increasing IOP (10)

A
  • coughing, bucking
  • vomiting
  • succinylcholine
  • ketamine
  • laryngoscopy
  • hypoxia, hypercarbia
  • external pressure on eye
  • HTN
  • contraction of extraocular muscles
  • eyelid closure
57
Q

factors decreasing IOP (9)

A
  • IV lidocaine
  • sedatives/GA agents
  • hypothermia
  • retrobulbar block
  • head up position
  • diuretics
  • SBP<85 mmHg
  • hypocarbia
  • deep inspiration
58
Q

Abdominal surgery: anesthesia considerations

A
  • anticipate RSI
  • do not give prokinetic agents
  • gastric decompression with OG or NG
59
Q

ENT surgery: myringotomy and tube placement

A
  • short <10 min
  • PO anti-anxiety, mask with sevo, no IV
  • intranasal fentanyl, rectal Tylenol
60
Q

ENT surgery: tympanoplasty, tympanomastoidectomy

A
  • general with facial nerve monitoring

- N/V a major concern

61
Q

ENT surgery: nose cautery

A
  • 10-15 minutes

- either mask and remove or LMA/ETT if expected to bleed

62
Q

ENT surgery: nasal fracture reduction

A
  • ETT or LMA to prevent blood in airway

- throat pack ** remove before extubation

63
Q

ENT surgery: tonsillectomy and adenoidectomy

A
  • **PONV prophylaxis
  • motionless patient
  • smooth emergence: soft bite block, deep extubation
  • cuffed oral RAE
64
Q

ENT surgery: bleeding tonsil

A
  • primary= 24 hours
  • secondary= 5-14 days
  • IV in pre-op
  • surgeon present at induction; RSI
65
Q

Congenital dysplasia of the hip: SPICA cast

A
  • GA

- towel between hip and belly to ensure adequate room for abdominal breathing

66
Q

Scoliosis Repair

A
  • PFTs: >80, >60 with reactive airway disease
  • severely affected may need cardiac testing and consult
  • full neuro monitoring
  • spinal cord vulnerable to ischemia when surgeon is straightening the spine: maintain MAP >70 mmHg, Hgb > 9 g/dL
67
Q

Scoliosis Repair: steps with loss of MEP or 50% decrease in SSEP

A
  • STOP
  • increase MAP to 90 mmHg
  • last instrumentation is reversed
  • steroids: 30 mg/kg methyl prednisone bolus, 5.4 mg/kg/hr for 24 hr
  • MRI
68
Q

diseases associated with difficult airway

A
  • trisomy 21
  • hurlers
  • epidermolysis bullosa simplex
  • treacher-collins syndrome
  • pierre robin
  • Emmanuel syndrome
69
Q

trisomy 21 anesthesia concerns

A
  • large tongue
  • atlantoaxial instability
  • cardiac defects: complete common atrioventricular canal
70
Q

hurlers syndrome anesthesia concerns

A
  • metabolic disease, unable to break down long sugar molecules (glycosaminoglycans)
  • joint disease; stiffness, abnormal bones in spine
  • deafness
  • heart valve problems
  • thick, coarse facial features with low nasal bridge
71
Q

treacher-collins syndrome anesthesia concerns

A
  • hypoplasia of maxilla and mandible; difficult to intubate and ventilate
  • failure of brachial arch to develop
72
Q

epidermolysis bullosa anesthesia concerns

A
  • skin cleavage at dermal-epidermal junction
  • chronic malnutrition
  • possible airway scarring and lesions, use smaller ETT
73
Q

pierre robin sequence anesthesia concerns

A
  • improves with age
  • cleft soft palate
  • jaw is small and far back, receding chin-weak muscle tone
  • glossoptosis: airway obstruction caused by backwards displacement of tongue base)
74
Q

emanual syndrome anesthesia concerns

A
  • neuromuscular blockade wears off in reverse order

- place on stomach after extubation

75
Q

laryngospasm risk preoperative risk factors

A
  • second hand smoke
  • URI
  • GERD
  • mechanical irritants
76
Q

laryngospasm risk intraoperative risk factors

A
  • excitement phase of inhalation induction
  • intubation/extubation during light anesthesia
  • upper airway surgical procedures
77
Q

pyloric stenosis anesthesia considerations

A
  • replace fluid/electrolyte deficit first
  • OG prior to induction: tilt baby from side to side to ensure emptying
  • RSI
78
Q

omphalocele and gastroschisis anesthesia considerations

A
  • visceral organs fail to move from the yolk sac back into the abdominal cavity
  • pulse oximeter on lower extremity to identify if there is a compromise to lower extremity perfusion
79
Q

atresia

A

absence of a normal opening, failure or a structure to be tubular

80
Q

VACTERL syndrome

A
  • infants with tracheoesophageal fistula or esophageal atresia
  • vertebral anomalies
  • anal atresia
  • cardiac
  • tracheoesophageal fistula
  • renal malformations
  • limb malformations
81
Q

tracheoesophageal fistula or esophageal atresia anesthesia considerations

A
  • RSI with ETT; turn bevel of ETT anteriorly to allow the posterior surface of the ETT to occlude the fistula
  • maintain in semi-recumbent position until induction
82
Q

congenital diaphragmatic hernia anesthesia considerations

A
  • defect of diaphragm that allows abdominal contents into thoracic cavity
  • decreased lung volumes, increased pulmonary artery pressures (right to left shunting)
  • stabilize pulmonary HTN
  • RSI
  • avoid nitrous oxide
  • preductal (right upper) and postductal (lower extremity) pulse oximetry monitor
83
Q

neonatal hydrocephalus anesthesia considerations

A
  • RSI

- oxygen sats 95-97 to avoid retinopathy of prematuria

84
Q

neonatal myelomeningocele

A
  • spinal bifida: urgent repair within 24 hours of life
  • donut ring on bed for myelomeningocele to rest in during induction
  • avoid muscle relaxants
  • at risk for latex sensitivity
85
Q

right-to-left shunts are _____?

name 6

A

cyanotic; low PaO2

  • hypoplastic left heart syndrome
  • pulmonary stenosis
  • transposition of the great arteries
  • tetralogy of fallot
  • tricuspid atresia
  • pulmonary atresia with intact ventricular septum
86
Q

left-to-right shunts are _____?

name 6

A

acyanotic; decreased tissue perfusion

  • ventricular septal defect
  • atrial septal defect
  • aortic stenosis
  • coarctation of the aorta
  • persistent ductus arteriosus
  • complete common AV canal
87
Q

3 steps to cardiac lesions

A
  1. determine if blood blow is obstructed in any part of the heart
  2. determine is blood is being shunted from one side to the other
  3. determine is there is a volume load or pressure load on the heart (right=dilate, left=hypertrophy)
88
Q

ventricular septal defect anesthesia considerations

A
  • untreated will result in CHF

- myocardial dysfunction, arrhythmias, RBBB

89
Q

patent ductus arteriosus anesthesia considerations

A

-indomethacin (ibuprofen in preterm) triggers the PDA to constrict and close

90
Q

coarctation of the aorta anesthesia considerations

A
  • obstruction of the aorta, resulting in increased left ventricular afterload
  • diagnosed by murmur, HTN in upper extremities, decreased femoral pulses
  • rely on open PDA, kept open with PGE1
91
Q

hypoplastic left heart syndrome anesthesia considerations

A

-systemic flow is completely dependent on patent PDA

92
Q

tetralogy of fallot defects (4)

A
  • anterior malalignment VSD
  • right ventricular outflow obstruction
  • right ventricular hypertrophy
  • large ascending aorta
93
Q

tetralogy of fallot “tet” spells

A
  • sudden episode of cyanosis due to infundibular spasm

- decrease PVR, increase SVR: knee to chest maneuver, phenylephrine

94
Q

tetralogy of fallot postoperatively

A
  • residual pulmonary insufficiency
  • RBBB
  • ventricular arrhythmias
95
Q

transposition of the great arteries anesthesia considerations

A
  • PGE1 to keep ductus open; emergent balloon atrial septostomy
  • atrial and ventricular tachyarrhythmias
96
Q

tricuspid valve atresia anesthesia considerations

A
  • hypoplasia or absence of the right ventricle
  • common to also have pulmonary stenosis
  • PGE1 to keep ductus open; emergent balloon atrial septostomy
97
Q

causes of patent ductus arteriosus

A
  • low O2 level
  • high CO2 level
  • acidosis
  • persistent pulmonary HTN

6903 - Special Populations (16 decks)

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