Pediatrics Flashcards
Define the oculocardiac reflex. What are the nerves involved? How do you treat it?
Decrease in heart rate of 10% following pressure on the globe or manipulation of the eye muscles.
Afferent limb: ophthalmic division of the Trigeminal nerve, efferent: Vagus nerve
Treatment: ask surgeon to stop stimulus, make sure patient is deep enough, turn up FiO2, if bradycardia doesn’t resolve, consider atropine 20mcg/kg
What are the blood volumes assigned to each age group?
Adult female: 60-75 ml/kg Adult male: 65-70 ml/kg Child 1-12 years: 70-75 Child 3-12 months: 70-80 Full term newborn: 80-90 Pre-mature: 90-100
What is the anesthetic management of CDH?
- pre-ductal sats 90-95
2. PIP < 25, with low TV
For pediatric heart cases, what two types of medications should you be careful about mixing, and why?
- opiods and benzos
- These kids have decreased CP reserve due to heart defects. Anything that would cause vasodilation will worsen perfusion to the rest of the body
What are the side effects of PGE1?
apnea, bradycardia, fever, flushing, gastric outlet obstruction, and CNS irritability
What is the difference in codeine and morphine metabolism in neonates and school aged children?
Neonates: Decreased CYP2D6 activity, so less codeine is converted to morphine, therefore they are less sensitive
Morphine: two other enzymes that convert opioids to inactive metabolites and morphine to its two metabolites are low at birth, leading to increased sensitivity of the drug in neonates
What is the main way that babies keep warm? What factors increase this heat production? What inhibits heat production?
- non shivering thermogenesis: breakdown of brown fat into TG
- NE, thyroxine, glucocorticoids
- inhaled anesthetics and B blockers
How would you describe the trend of DM 1 and 2 in children? increasing? or decreasing?
Both are increasing
What abnormalities are associated with Trisomy 21?
- heart defects: AVSD > VSD > TOF > PDA
- Duodenal atresia
- Pulmonary HTN
- Difficult IV access, difficult airway
- Subglottic stenosis
What causes persistent fetal circulation?
Increased pulmonary pressures (I.e. hypoxia, acidosis, and hypothermia
What are the criteria for starting a newborn on PPV? When do you start CPR?
- persistent cyanosis, HR < 100
2. HR < 60
How do you treat mild post-intubation croup vs. moderate to severe?
- mild: cold, humidified air
2. mod-severe: racemic epinephrine and monitoring for at least 4 hours following extubation
What is the first surgical correction step for pulmonary atresia?
- BT shunt placement: This is a shunt between the R subclavian artery and the pulmonary artery. Therefore blood goes from the aorta –> R subclavian –> pulmonary artery –> lungs
“what will not flow will not grow”
What are the optimal leak pressures for a cuffed vs. uncuffed tube?
- Cuffed: 20 cm H20
- Uncuffed: 20-30 cm H20
- if the leak pressure is >20-30 then the cuff is TOO BIG
What agent should be avoided in patients with the MHTFR mutation?
N20
How do you induce a patient with congenital emphysema? What should you avoid?
- use spontaneous ventilation with minimal PIP
2. avoid n20
What are the early signs of MH?
- masseter muscle spasm
- Increased EtCO2
- Hyperthermia
- Tachycardia
- Tachypnea
What are the symptoms of propofol infusion syndrome? What is the one organ NOT effected?
- Cardiac abnormalities
- Renal failure (hyperkalemia, rhabdo)
- Liver problems
- metabolic acidosis
BUT pulmonary edema is NOT see
What does VACTERL stand for?
- vertebral
- Anal atresia
- cardiac
- TEF
- Renal
- limb
True or false: high cognitive ability is associated with increased risk for peri-operative anxiety
true
What is the youngest age of a child that would benefit from midazolam? Why?
9 months. That’s when separation anxiety begins
Define Klippel-Feil syndrome
congenital fusion of the cervical spine
What are the risk factors for post op apnea in kiddos?
- prematurity
- anemia
- GA or local w/ sedation
- hx of apnea
Why do infants have an increased WOB?
- Highly compliant chest wall and poorly supported airway structures leads to functional airway closure with each breath
- increased metabolic demand
- smaller diameter of airways = increased R
What is the first sign of total spine anesthesia in a neonate?
- respiratory distress and apnea
2. hemodynamic changes and autonomic effects are minimal
In comparing gastroschisis and omphalocele:
- which is more common?
- which is associated with chromosomal abnormalities?
- which has an encasing?
- which is associated with increased rates of infection and heat loss?
- Omphalocele
- Omphalocele
- Omphalocele
- Gastroschisis
What is the most efficacious treatment of PONV in kiddos?
Zofran, NOT the use of propofol
What are the risk factors for PONV in kids?
- Older than 3
- Surgery > 30 minutes
- strabismus surgery
- FMH of PONV
Explain the factors that lead to a faster induction of anesthetic in kids.
- Greater MV compared to FRC (most important)
- Greater blood flow to vessel rich organs in kids (i.e. the brain)
- Kids have lower blood:gas partition coefficients
- Gas is LESS soluble in tissue, meaning that there is an increase in blood concentration of gas and therefore an increase in speed of induction
What drug is specifically CI following tonsillectomy and why?
Codeine. Some kids are rapid metabolizers, while others are not! That means that you cannot predict the anesthetic effect, whereas you can predict the effect of morphine since it is not a pro-drug.
REMEMBER: codeine ..> morphine via CYP2D6
What are the metabolic derangements seen in pyloric stenosis? What is the most reliable indicator of readiness for surgery?
- metabolic alkalosis, with an compensation of resp acidosis
- Hypochloremia –> most reliable indicator
- Hypokalemia (though 1/3 are hyperkalemic)
- Hyponatremia
What is the most effective way to warm a child in the OR?
Forced Air heating blankets
Describe the differences between mild, moderate, and severe dehydration in regards to:
- weight loss
- fluid deficit
- skin turgor
- fontanelle
- eyes
- urine
- urine specific gravity
Weight loss (%) 5 10 15
Fluid deficit (mL/kg) 50 100 150
Skin turgor Normal Decreased Greatly decreased
Anterior fontanel Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Mucous membranes Moist Dry Very Dry
Urine flow (mL/kg/hr) < 2 < 1 < 0.5
Urine specific gravity < 1.020 1.020-1.030 > 1.030
What is the initial fluid bolus used in a kid with severe dehydration?
20 ml/kg of NS
How does the weight based dosing in kids change in comparison to adults?
- increased weight based dosing due to larger Vd, larger ECF compartment compared to TBW
When should intrathecal bupivicaine be discontinued in neonates? What should be used for long term infusions instead?
After 48 hours, this is due to increase risk for toxicity 2/2 decreased protein binding. Use lidocaine instead! You can measure it’s serum levels
What agents can help decrease post op myalgias following succinylcholine administration?
- Lidocaine
- Mg
- NDMB (roc)
- NSAIDs
Patients with strabismus are MORE susceptible to what as a result of succinylcholine administration compared to the general pediatric surgical population?
Masseter muscle spasm
Describe the facial features seen with Crouzon syndrome
- early fusion of cranial sutures
Describe Pierre Robin sequence
Micrognathia, large tongue, u shaped cleft palate
What does the pneumonic ASk for a CD stand for?
Mapleson A: spontaneous ventilation
Mapleson D: controlled ventilation
Rank the bioavailability of midazolam from most to least
IV > IM > Intranasal > rectal > oral
