Pediatrics Flashcards
1
Q
NPO guidelines: solids, formula, breast milk, clears
A
solids: 6h
formula: 6h
breast milk: 4h
clears: 2h
2
Q
IV Versed dosing
A
- 05-0.1 mg/kg
* 1 year old = 1 mg; 2 year old = 2 mg
3
Q
PO Versed dosing
A
- 5-1 mg/kg given 20-30 minutes before case
- max dose 20 mg
*under 6 months = none, over 12 years = preop IV
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
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
6
Q
J-Tip
A
- expensive
- injects local surrounding the puncture site
7
Q
best site for airway monitoring with precordial?
A
-suprasternal notch
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
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
10
Q
IV Drips - specifics for ages
A
- <2y = buretrol
- <12y = microdripper
-<6m = dextrose infusion
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
12
Q
Pediatric Dosing: rectal acetaminophen
A
30-40 mg/kg rectal
13
Q
Pediatric Dosing: Toradol
A
0.5 mg/kg IV or IM
14
Q
Pediatric Dosing: Fentanyl
A
0.5-1 mcg/kg IV
15
Q
Pediatric Dosing: Morphine
A
0.1 mg/kg IV
16
Q
Pediatric Dosing: hydromorphone
A
10 mcg/kg IV
17
Q
Pediatric Dosing: IV acetaminophen
A
- <2 y = 10 mg/kg (not FDA approved)
- <12 y = 15 mg/kg
18
Q
Pediatric Upper Airway
A
- large occiput
- large tongue
- narrow nasal passages (choanal atresia, NG)
- nasal breathers until 5 months
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
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
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
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
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
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
25
Pediatric Circulation
- stroke volume fixed, changes dependent on heart rate
| - less compliant ventricles
26
Pediatric Parasympathetic/Sympathetic Nervous System
- sympathetic immature compared to parasympathetic: poor response to inotropic support for first 3 months
- baroreceptors immature until 8y
27
Pediatric Kidneys
- decreased GFR and RBF
- inability to concentrate or dilute urine
- decreased Na excretion
28
Fetal Hemoglobin
- high affinity for oxygen (left shift)
| - physiological anemia until teens when HbF is replaced by HbA
29
Pediatric Liver
- immature until after 1 y
- decreased albumin
- enzymes mature over months to years; glucuronidation by 6 mo
- minimal glycogen stores
30
Pediatric Hypoglycemia, treat less than ___
45
31
Pediatric Thermoregulation
- increased heat loss: thin skin, low fat content, high surface area/weight ratio
- no shivering first three months, temperature regulated by brown fat
32
Total Body Water %
- preterm=80%
| - >12 mo=60%
33
Fluid Resuscitation for hypotension in infant and child
- infant=10 cc/kg
| - child=20 cc/kg
34
Electrolyte differences
- increased K in first 2 days of life
| - decreased Ca in premature and infants
35
Estimated Blood Volume
- preterm= 90 mL/kg
- newborn= 80mL/kg
- 3 mo-3 y= 75mL/kg
36
Hgb will increase by ____ g/dL with ____ mL/kg packed cells
Hgb will increase by 1 g/dL with 4 mL/kg packed cells
37
Pediatric platelet transfusion
10-15 mL/kg
38
Pediatric cryoprecipitate
1 unit/10 kg
39
Pediatric calcium gluconate
7.5-15 mg/kg
40
Emergence delirium: most vulnerable and treatments
most vulnerable:
-sevoflurane, 2-5y
treatments:
-precedex 0.3 mg/kg, Propofol 1 mg/kg, fentanyl 1 mcg/kg
41
leak test for ETT pressure
20-30 cm H20
42
Delay surgery for ____ for upper respiratory infection
4 weeks
43
Pediatric Ventilator Settings
- RR=20
- TV=6-8 mL/kg
- PS=15-18 cm H20
- PEEP=3-5 cm
44
Dantrolene dosing
- 2.5 mg/kg IV q5min
| - max=10 mg/kg
45
Pediatric Induction Sequence
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
Urologic surgery: circumcision
- regional: penile or caudal block
| - postoperative fever common in children with phimosis (foreskin can't be retracted)
47
Urologic surgery: hypospadias repair
- incorrect position of the penile meatus
| - penile block is lower 1/3, caudal if closer
48
Urologic surgery: orchidopexy
- undescended testicles
| - regional: caudal or local block with LMA or ETT
49
Urologic surgery: ureteral reimplantation
- 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
Urologic surgery: pyeloplasty
- 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
Urologic surgery: Wilms' tumor
- advanced: tumor spreads to lungs, liver, inferior vena cava, and aorta
- von Willebrand's disease in some children
- potential for large abdominal mass
52
Urologic surgery: testicular torsion repair
- surgical emergency
- consider prokinetic to help facilitate gastric emptying and RSI
- adolescents: spinal with sedation
53
caudal block
-more difficult after age 12, not used in a child that can walk
54
Dental surgery: nasal intubation
- 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
Oculo-cardiac Reflex
-occurs when traction placed on extraocular muscle
1. tell the surgeon to release pressure on the eye
2. administer glycopyrrolate or atropine
56
factors increasing IOP (10)
- coughing, bucking
- vomiting
- succinylcholine
- ketamine
- laryngoscopy
- hypoxia, hypercarbia
- external pressure on eye
- HTN
- contraction of extraocular muscles
- eyelid closure
57
factors decreasing IOP (9)
- IV lidocaine
- sedatives/GA agents
- hypothermia
- retrobulbar block
- head up position
- diuretics
- SBP<85 mmHg
- hypocarbia
- deep inspiration
58
Abdominal surgery: anesthesia considerations
- anticipate RSI
- do not give prokinetic agents
- gastric decompression with OG or NG
59
ENT surgery: myringotomy and tube placement
- short <10 min
- PO anti-anxiety, mask with sevo, no IV
- intranasal fentanyl, rectal Tylenol
60
ENT surgery: tympanoplasty, tympanomastoidectomy
- general with facial nerve monitoring
| - N/V a major concern
61
ENT surgery: nose cautery
- 10-15 minutes
| - either mask and remove or LMA/ETT if expected to bleed
62
ENT surgery: nasal fracture reduction
- ETT or LMA to prevent blood in airway
| - throat pack ** remove before extubation
63
ENT surgery: tonsillectomy and adenoidectomy
- **PONV prophylaxis
- motionless patient
- smooth emergence: soft bite block, deep extubation
- cuffed oral RAE
64
ENT surgery: bleeding tonsil
- primary= 24 hours
- secondary= 5-14 days
- IV in pre-op
- surgeon present at induction; RSI
65
Congenital dysplasia of the hip: SPICA cast
- GA
| - towel between hip and belly to ensure adequate room for abdominal breathing
66
Scoliosis Repair
- 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
Scoliosis Repair: steps with loss of MEP or 50% decrease in SSEP
- 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
diseases associated with difficult airway
- trisomy 21
- hurlers
- epidermolysis bullosa simplex
- treacher-collins syndrome
- pierre robin
- Emmanuel syndrome
69
trisomy 21 anesthesia concerns
- large tongue
- atlantoaxial instability
- cardiac defects: complete common atrioventricular canal
70
hurlers syndrome anesthesia concerns
- 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
treacher-collins syndrome anesthesia concerns
- hypoplasia of maxilla and mandible; difficult to intubate and ventilate
- failure of brachial arch to develop
72
epidermolysis bullosa anesthesia concerns
- skin cleavage at dermal-epidermal junction
- chronic malnutrition
- possible airway scarring and lesions, use smaller ETT
73
pierre robin sequence anesthesia concerns
- 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
emanual syndrome anesthesia concerns
- neuromuscular blockade wears off in reverse order
| - place on stomach after extubation
75
laryngospasm risk preoperative risk factors
- second hand smoke
- URI
- GERD
- mechanical irritants
76
laryngospasm risk intraoperative risk factors
- excitement phase of inhalation induction
- intubation/extubation during light anesthesia
- upper airway surgical procedures
77
pyloric stenosis anesthesia considerations
- replace fluid/electrolyte deficit first
- OG prior to induction: tilt baby from side to side to ensure emptying
- RSI
78
omphalocele and gastroschisis anesthesia considerations
- 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
atresia
absence of a normal opening, failure or a structure to be tubular
80
VACTERL syndrome
- infants with tracheoesophageal fistula or esophageal atresia
- vertebral anomalies
- anal atresia
- cardiac
- tracheoesophageal fistula
- renal malformations
- limb malformations
81
tracheoesophageal fistula or esophageal atresia anesthesia considerations
- 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
congenital diaphragmatic hernia anesthesia considerations
- 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
neonatal hydrocephalus anesthesia considerations
- RSI
| - oxygen sats 95-97 to avoid retinopathy of prematuria
84
neonatal myelomeningocele
- 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
right-to-left shunts are _____?
name 6
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
left-to-right shunts are _____?
name 6
acyanotic; decreased tissue perfusion
- ventricular septal defect
- atrial septal defect
- aortic stenosis
- coarctation of the aorta
- persistent ductus arteriosus
- complete common AV canal
87
3 steps to cardiac lesions
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
ventricular septal defect anesthesia considerations
- untreated will result in CHF
| - myocardial dysfunction, arrhythmias, RBBB
89
patent ductus arteriosus anesthesia considerations
-indomethacin (ibuprofen in preterm) triggers the PDA to constrict and close
90
coarctation of the aorta anesthesia considerations
- 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
hypoplastic left heart syndrome anesthesia considerations
-systemic flow is completely dependent on patent PDA
92
tetralogy of fallot defects (4)
- anterior malalignment VSD
- right ventricular outflow obstruction
- right ventricular hypertrophy
- large ascending aorta
93
tetralogy of fallot "tet" spells
- sudden episode of cyanosis due to infundibular spasm
| - decrease PVR, increase SVR: knee to chest maneuver, phenylephrine
94
tetralogy of fallot postoperatively
- residual pulmonary insufficiency
- RBBB
- ventricular arrhythmias
95
transposition of the great arteries anesthesia considerations
- PGE1 to keep ductus open; emergent balloon atrial septostomy
- atrial and ventricular tachyarrhythmias
96
tricuspid valve atresia anesthesia considerations
- hypoplasia or absence of the right ventricle
- common to also have pulmonary stenosis
- PGE1 to keep ductus open; emergent balloon atrial septostomy
97
causes of patent ductus arteriosus
- low O2 level
- high CO2 level
- acidosis
- persistent pulmonary HTN
