Pediatrics Flashcards
NPO guidelines: solids, formula, breast milk, clears
solids: 6h
formula: 6h
breast milk: 4h
clears: 2h
IV Versed dosing
- 05-0.1 mg/kg
* 1 year old = 1 mg; 2 year old = 2 mg
PO Versed dosing
- 5-1 mg/kg given 20-30 minutes before case
- max dose 20 mg
*under 6 months = none, over 12 years = preop IV
EMLA Cream
- 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
Pain Ease
- 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
J-Tip
- expensive
- injects local surrounding the puncture site
best site for airway monitoring with precordial?
-suprasternal notch
best site for breath sounds and heart tones with precordial?
-apex of heart: 5th left intercostal space at the midclavicular line just below the nipple
ETT sizing
- (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
IV Drips - specifics for ages
- <2y = buretrol
- <12y = microdripper
-<6m = dextrose infusion
Emergency Drugs (5)
- sux = 4-6 mg/kg on IM needle
- atropine = 0.02 mg/kg on IM needle
- phenylephrine
- ephedrine
- epinephrine
Pediatric Dosing: rectal acetaminophen
30-40 mg/kg rectal
Pediatric Dosing: Toradol
0.5 mg/kg IV or IM
Pediatric Dosing: Fentanyl
0.5-1 mcg/kg IV
Pediatric Dosing: Morphine
0.1 mg/kg IV
Pediatric Dosing: hydromorphone
10 mcg/kg IV
Pediatric Dosing: IV acetaminophen
- <2 y = 10 mg/kg (not FDA approved)
- <12 y = 15 mg/kg
Pediatric Upper Airway
- large occiput
- large tongue
- narrow nasal passages (choanal atresia, NG)
- nasal breathers until 5 months
Pediatric Larnyx
- 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
Pediatric Breathing
- 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
Pediatric Breathing Muscles
- diaphragm easily fatigued
- intercostal muscles immature and weak
- lack of type 1 muscle fibers (resistant to fatigue), similar percentage to adult at 2 y
Risk factors & Intervention for apnea or bradycardia following general anesthesia
- Risk: premature, anemia, hypothermia, CNS disease, sepsis, hypoglycemia, metabolic disease
- need 23 hour admission for apnea and hr monitoring
Persistent Pulmonary Hypertension Cause, Treatment, Goals
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
In utero - circulation
- ductus venous: closes with umbilical clamping
- foramen ovale: closes at birth
- ductus arteriosus: closes first 4 days of life
Pediatric Circulation
- stroke volume fixed, changes dependent on heart rate
- less compliant ventricles
Pediatric Parasympathetic/Sympathetic Nervous System
- sympathetic immature compared to parasympathetic: poor response to inotropic support for first 3 months
- baroreceptors immature until 8y
Pediatric Kidneys
- decreased GFR and RBF
- inability to concentrate or dilute urine
- decreased Na excretion
Fetal Hemoglobin
- high affinity for oxygen (left shift)
- physiological anemia until teens when HbF is replaced by HbA
Pediatric Liver
- immature until after 1 y
- decreased albumin
- enzymes mature over months to years; glucuronidation by 6 mo
- minimal glycogen stores
Pediatric Hypoglycemia, treat less than ___
45
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
Total Body Water %
- preterm=80%
- >12 mo=60%
Fluid Resuscitation for hypotension in infant and child
- infant=10 cc/kg
- child=20 cc/kg
Electrolyte differences
- increased K in first 2 days of life
- decreased Ca in premature and infants
Estimated Blood Volume
- preterm= 90 mL/kg
- newborn= 80mL/kg
- 3 mo-3 y= 75mL/kg
Hgb will increase by ____ g/dL with ____ mL/kg packed cells
Hgb will increase by 1 g/dL with 4 mL/kg packed cells
Pediatric platelet transfusion
10-15 mL/kg
Pediatric cryoprecipitate
1 unit/10 kg
Pediatric calcium gluconate
7.5-15 mg/kg
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
leak test for ETT pressure
20-30 cm H20
Delay surgery for ____ for upper respiratory infection
4 weeks
Pediatric Ventilator Settings
- RR=20
- TV=6-8 mL/kg
- PS=15-18 cm H20
- PEEP=3-5 cm
Dantrolene dosing
- 2.5 mg/kg IV q5min
- max=10 mg/kg
Pediatric Induction Sequence
- SpO2 monitor
- nitrous 70% (>3 years)
- sevo 8% (don’t turn nitrous off until IV is in)
- IV when past stage 2 (don’t place oral airway until IV is in)
*additional monitors when asleep unless concerns
Urologic surgery: circumcision
- regional: penile or caudal block
- postoperative fever common in children with phimosis (foreskin can’t be retracted)
Urologic surgery: hypospadias repair
- incorrect position of the penile meatus
- penile block is lower 1/3, caudal if closer
Urologic surgery: orchidopexy
- undescended testicles
- regional: caudal or local block with LMA or ETT
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
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
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
Urologic surgery: testicular torsion repair
- surgical emergency
- consider prokinetic to help facilitate gastric emptying and RSI
- adolescents: spinal with sedation
caudal block
-more difficult after age 12, not used in a child that can walk
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
Oculo-cardiac Reflex
-occurs when traction placed on extraocular muscle
- tell the surgeon to release pressure on the eye
- administer glycopyrrolate or atropine
factors increasing IOP (10)
- coughing, bucking
- vomiting
- succinylcholine
- ketamine
- laryngoscopy
- hypoxia, hypercarbia
- external pressure on eye
- HTN
- contraction of extraocular muscles
- eyelid closure
factors decreasing IOP (9)
- IV lidocaine
- sedatives/GA agents
- hypothermia
- retrobulbar block
- head up position
- diuretics
- SBP<85 mmHg
- hypocarbia
- deep inspiration
Abdominal surgery: anesthesia considerations
- anticipate RSI
- do not give prokinetic agents
- gastric decompression with OG or NG
ENT surgery: myringotomy and tube placement
- short <10 min
- PO anti-anxiety, mask with sevo, no IV
- intranasal fentanyl, rectal Tylenol
ENT surgery: tympanoplasty, tympanomastoidectomy
- general with facial nerve monitoring
- N/V a major concern
ENT surgery: nose cautery
- 10-15 minutes
- either mask and remove or LMA/ETT if expected to bleed
ENT surgery: nasal fracture reduction
- ETT or LMA to prevent blood in airway
- throat pack ** remove before extubation
ENT surgery: tonsillectomy and adenoidectomy
- **PONV prophylaxis
- motionless patient
- smooth emergence: soft bite block, deep extubation
- cuffed oral RAE
ENT surgery: bleeding tonsil
- primary= 24 hours
- secondary= 5-14 days
- IV in pre-op
- surgeon present at induction; RSI
Congenital dysplasia of the hip: SPICA cast
- GA
- towel between hip and belly to ensure adequate room for abdominal breathing
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
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
diseases associated with difficult airway
- trisomy 21
- hurlers
- epidermolysis bullosa simplex
- treacher-collins syndrome
- pierre robin
- Emmanuel syndrome
trisomy 21 anesthesia concerns
- large tongue
- atlantoaxial instability
- cardiac defects: complete common atrioventricular canal
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
treacher-collins syndrome anesthesia concerns
- hypoplasia of maxilla and mandible; difficult to intubate and ventilate
- failure of brachial arch to develop
epidermolysis bullosa anesthesia concerns
- skin cleavage at dermal-epidermal junction
- chronic malnutrition
- possible airway scarring and lesions, use smaller ETT
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)
emanual syndrome anesthesia concerns
- neuromuscular blockade wears off in reverse order
- place on stomach after extubation
laryngospasm risk preoperative risk factors
- second hand smoke
- URI
- GERD
- mechanical irritants
laryngospasm risk intraoperative risk factors
- excitement phase of inhalation induction
- intubation/extubation during light anesthesia
- upper airway surgical procedures
pyloric stenosis anesthesia considerations
- replace fluid/electrolyte deficit first
- OG prior to induction: tilt baby from side to side to ensure emptying
- RSI
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
atresia
absence of a normal opening, failure or a structure to be tubular
VACTERL syndrome
- infants with tracheoesophageal fistula or esophageal atresia
- vertebral anomalies
- anal atresia
- cardiac
- tracheoesophageal fistula
- renal malformations
- limb malformations
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
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
neonatal hydrocephalus anesthesia considerations
- RSI
- oxygen sats 95-97 to avoid retinopathy of prematuria
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
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
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
3 steps to cardiac lesions
- determine if blood blow is obstructed in any part of the heart
- determine is blood is being shunted from one side to the other
- determine is there is a volume load or pressure load on the heart (right=dilate, left=hypertrophy)
ventricular septal defect anesthesia considerations
- untreated will result in CHF
- myocardial dysfunction, arrhythmias, RBBB
patent ductus arteriosus anesthesia considerations
-indomethacin (ibuprofen in preterm) triggers the PDA to constrict and close
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
hypoplastic left heart syndrome anesthesia considerations
-systemic flow is completely dependent on patent PDA
tetralogy of fallot defects (4)
- anterior malalignment VSD
- right ventricular outflow obstruction
- right ventricular hypertrophy
- large ascending aorta
tetralogy of fallot “tet” spells
- sudden episode of cyanosis due to infundibular spasm
- decrease PVR, increase SVR: knee to chest maneuver, phenylephrine
tetralogy of fallot postoperatively
- residual pulmonary insufficiency
- RBBB
- ventricular arrhythmias
transposition of the great arteries anesthesia considerations
- PGE1 to keep ductus open; emergent balloon atrial septostomy
- atrial and ventricular tachyarrhythmias
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
causes of patent ductus arteriosus
- low O2 level
- high CO2 level
- acidosis
- persistent pulmonary HTN
