Pediatrics Flashcards
When should Ketamine not be used in congenital heart disease?
Ketamine should be avoided, however, in patients with systemic outflow tract obstructive lesions due to the increase in tachycardia and systemic vascular resistance.
Why are opiates beneficial in a patient with congenital heart disease?
(Explain the physiological reasons behind this)
The synthetic opioid technique reduces spikes in pulmonary vascular resistance and systemic vascular resistance from light anesthesia and painful stimuli, reducing the afterload on each ventricle.
What are the expected s/s of pyloric stenosis patient 3 weeks after symptoms?
Na?
K?
Cl?
pH?
The classic laboratory findings in patients with protracted pyloric stenosis are hyponatremia, hypokalemia, and hypochloremic metabolic alkalosis (Bicarbonate will be high)
What is the difference in etiology. Location, associated conditions of gastrochesis vs. omphalocele?
Etiology
Omphalocele - Lack of midgut migration from yolk sac
into the abdomen
- Within cord
Beckwith-Wiedemann syndrome
Trisomies 13, 18, and 21
Malrotation of GI tract
Bladder exstrophy
Gastrochesis Abnormal development of right omphalomesenteric
artery or umbilical vein with ischemia to right
paraumbi
- Out of cord (periumbilical)
Congenital heart disease Intestinal atresia
Malrotation of GI tract
Prematurity
What cardiac defects are associated with Down Syndrome?
Endocardial cushion defects AKA AV canal defects cause a mixing of blood and left to right shunting of blood because of associated ventricular septal defects.
Endocardial cushion defects account for approximately 3% of all congenital heart defects, with over 50% of the patients having trisomy 21.
Trisomy 21 is associated with newborn hypotonia, macroglossia, and subglottic stenosis. As children age, atlanto-axial instability needs to be considered as well as OSA.
What major anesthetic implication is associated with Klippel-Feil Syndrome?
Klippel-Feil syndrome is a congenital fusion of the cervical spine.
Patients with Klippel-Feil often have low hairlines and limited neck motion.
What are the currrent guidelines for children with RF for post-operative apnea?
Recommendations (Depends on if they have apnea or not)
- Proceed with an elective outpatient procedure include waiting until 44-60 weeks post-conceptual age (PCA) if the infant has never experienced apnea or bradycardia (exact time is institution specific).
Infants with a history of apnea and bradycardia are at increased risk for postoperative apnea, so it is recommended to proceed with elective outpatient surgery after a six month interval free from apnea and bradycardia.
If these criteria are not met, the infant should be monitored postoperatively for 12-24 hours or a regional anesthetic technique without sedation should be considered.
Which is more effective for kids, parental support or midazolam?
The use of oral midazolam alone is significantly more effective than parental presence for induction of anesthesia (PPIA) alone in reducing a child’s anxiety and increasing compliance with anesthesia.
What are the four main factors promote faster inhalational induction in infants and children compared to adults by allowing a more rapid rise in FA:FI?
Four main factors promote faster inhalational induction in infants and children compared to adults by allowing a more rapid rise in FA:FI:
- *1. Increased minute ventilation relative to FRC (most important)**
2. Increased blood flow to vessel-rich organs (less muscle mass than adults)
3. Decreased blood:gas partition coefficients
4. Decreased tissue:blood partition coefficients
What are the risk factors for post-operative apnea?
What is the one protective characterstic of post-operative apnea?
Risk factors for postoperative apnea include:
General anesthesia
Regional anesthesia with IV sedation
History of prematurity
PCA < 60 weeks (especially < 42-44 weeks)
History of apnea
Anemia (Hct of 25-30%), especially in premature
Protective:
Being small for gestational age (<10th percentile) has been found to be somewhat protective against postoperative apnea.
What is the singlemost effective medication for preventing PONV in pediatrics?
Ondansetron is the most efficacious pharmacotherapy to prevent PONV in pediatric patients.
What is the dose of propofol used in PONV prophylaxis in kids and adults?
Sub-hypnotic doses of propofol may also be beneficial to treat and prevent PONV
Use of propofol infusions decreases the incidence of PONV.
Doses studied include a 1 mg/kg bolus followed by an infusion of 20 mcg/kg/min.
Adult doses of propofol for PONV treatment have a similar infusion rate with a lower initial bolus rate.
Pediatric Doses:
Ondansetron?
Dexamethasone?
Droperidol?
Dexamethasone - 0.15 mg/kg
Droperidol - 10-15 mcg/kg
Ondansetron - 0.1-0.15 mg/kg
What is the airway management for a pediatric patient with epiglottitis that requires intubation?
Sitting Position (Avoid airway obstruction)’
Inhalation Anesthetic with Sevoflurane (Bronchodilation)
- Do not use Desflurane (Laryngospasm)*
- Do not use Nitrous Oxide*
- Avoided because it reduces the amount of oxygen available.*
- Additionally, if FBO were suspected then nitrous oxide could lead to a ball-valve phenomenon and risk overinflation of a lung (e.g. pneumothorax).*
- Do not use Paralytics*
- Neuromuscular blockers are contraindicated in this scenario in order to maintain spontaneous ventilation and avoid airway obstruction*
Maintaining continuous positive airway pressure (CPAP) during inhalational ventilation is useful in a child with acute epiglottitis as it prevents inspiratory collapse of the laryngeal airway.
Obtain IV Access after induction
Cuffed endotracheal tube should have an inner diameter that is 1-2 mm smaller than what would typically be expected due to anticipated upper airway edema.
