Pediatrics Part 2 Flashcards
what should be included on preoperative evaluations of the pediatric population
all illnesses review of organ systems previous hospitalization childhood syndromes medication list herbal remedies allergies (abx, latex)
herbal remedies are associated with what?
CV instability
coagulation disturbances
prolonged anesthesia
immunosuppression
common uses for Echinacea
prophylaxis and treatment of virla, bacterial and fungal infection
pharmacologic effects: stimulation of the immune system, long term use may be immunosuppressive
potential perioperative complications with Echinacea
reduced effectiveness of immunosuppressants
potential for wound infection
hepatoxicity
common use for ginseng
used to protect the body against stress and restore homeostasis; pharmacologic effects: possible potentiation of y-aminobutyric acid (GABA) transmission
potential perioperative complications with ginseng
potentiates sedative effects of anesthetic agents. possible withdrawal syndrome after sudden abstinence; kava-induced hepatoxocity
common use of garlic
antihypertensive, lipid lowering agent, anti-thrombus forming; pharmacologic effects: inhibits platelet aggregation (partially irreversibly) in a dose dependent manner. lowers serum lipid and cholesterol levels.
potential perioperative complications with garlic
may potentiate other platelet inhibitors, concerns for perioperative bleeding.
common use for st. johns wort (goat weed, amber, hard hay)
treatment of depression and anxiety; pharmacologic effects potentiation of GABA neurotransmission
potential perioperative complications with st. johns wort
potentiates sedative effects of anesthetic agents. withdrawal-type syndrome with sudden abstinence.
when should herbal remedies be discontinued?
2 weeks prior to surgery
active or resolving URI results in what potential complications?
increased airway reactivity
risk of atelectasis
mucus plugging
postop hypoxemia
if procedure is emergent and patient has active URI, what is the appropriate course of action?
must proceed
if procedure is elective and non urgent, what would alert you to the need to postpone for 4-6 weeks?
fever >38.4 C malaise productive cough wheezing rhonchi
if patient displays mild symptoms such as nonproductive cough, sneezing, nasal congestion what is the appropriate course of action?
proceed if regional or GA with mask; if requires ETT, wait 2-4 weeks
what should be evaluated preop for URI patients
hydration status
airway humidification
drugs like anticholinergic and beta agonists (helps airway secretions and hyperreactivity)
proceed with caution in these situations
child just has runny nose or is ‘much better’
active and happy child
clear rhinorrhea
clear lungs and symptoms that have leveled off
older child
hardship for parents to be away from work or insurnace will run out
no fever
outpatietn procedure that wont expose child to infectious agent
consider cancellation in these situations
parents confirm symtoms: fever, malaise, cough, poor appetitite, new symptoms
lethargic or ill appearing
purulent nasal discharge
wheezing, rales that don’t clear
<1 yr or ex premie
history or reactive airway disease, major operation, oett required
fever >38.5 C
inpatient procedure that exposese child to infection
are routine Hgb and UA indicated for most elective procedures?
no
when should Hgb levels be obtained?
procedures with potential for blood loss
specific risk factors for hemoglobinopathy
formerly preterm infants
<6mo of age
when should coags be obtained
major reconstructive surgeries
T&A
are routine CXRs necessary?
no
is pregnancy testing necessary?
yes; all those of childbearing age
what are some pharmacokinetic/dynamic considerationsf or the pediatric population?
TBW composition immaturity of metabolic degradation pathways reduced protein binding immaturity of BBB greater blood flow to vessel rich organs reductions in GFR smaller FRC increased MV immature receptor responses
muscle mass % for preterm infant
15
muscle mass % for full term infant
20
muscle mass % for adult
50
fat % for preterm infant
3
fat % for full term infant
12
fat % for adult
18
TBW for preterm infant
90%
TBW for full term infant
80%
TBW for adult
60%
extracellular fluid for preterm infant
50%
extracellular fluid for full term infant
40%
extracellular fluid for adult
20%
intracellular fluid for preterm infant
40%
intracellular fluid for full term infant
40%
intracellular fluid for adult
40%
administered drug/plasma concentration
volume of distribution
lower plasma concentrations (dilute) of water soluble drugs occurs due to what?
larger ECF and greater TBW
is a higher or lower dose required for water soluble drugs?
higher
higher plasma concentrations for lipid soluble drugs occurs due to what?
decreased fat and muscle
what occurs with reduced plasma proteins (infant)
more free drug
when do proteins reach adult equivilence?
5-6 mo
when are proteins fully funcitonal?
1 year
phase I of drug metabolism includes what?
3 enzyme reactions catalyzed by P450 system; oxidative, reduction, and hydrolysis
what is the result of phase I metabolism?
water-soluble metabolic product
phase II drug metabolism consists of what process?
conjugation (immature at birth)
what does conjugation do?
couples drug with substratefor excretion
enzyme systems are present at birth but activity is reduced, this does what to drug elimination half lives
increases
major objectives of premedication in the pediatric population
allay anxiety block autonomic (vagal) reflexes reduce airway secretions produce amnesia provide prophylaxis against pulmonary aspiration of gastric contents facilitate induction of anesthesia provide analgesia if needed
what should be considered when selecting a drug for premedication?
childs age ideal body weight drug history allergic status underlying conditions parent and child expectations child psychological status route; oral, intranasal, parenteral, rectal
rectal dose of methohexital
20-40 mg/kg
IM dose of methohexital
10mg/kg
rectal thiopental dose
20-40 mg/kg
oral dose of diazepam
0.1-0.5mg/kg
rectal dose of midazolam
1 mg/kg
oral dose of midazolam
0.25-0.75 mg/kg
nasal dose of midazolam
0.2 mg/kg
IM dose of midazolam
0.1-0.15 mg/kg
oral dose of lorazepam
0.025-0.05 mg/kg
oral ketamine dose
3-6 mg/kg
nasal dose of ketamine
3 mg/kg
rectal dose of ketamine
6-10 mg/kg
IM dose of ketamine
2-10mg/kg
oral dose of clonidine
0.004 mg/kg
oral dose of fentanyl
0.010-0.015 mg/kg (10-15 mcg/kg)
IM dose of morphine
0.1-0.2 mg/kg
IM dose of meperidine
1-2 mg/kg
nasal dose of sufenta
1-3mcg/kg
nasal dose of fentanyl
1-2 mcg/kg
midazolam half life
2 hrs - short acting
advantageof midazolam
rapid uptake and elimination
peak plasma concentration for midazolam
10 minutes after intranasal
16 minutes for rectal
53 inutes for oral
IV dose of midazolam
0.025-0.1 mg/kg
younger child may require higher or lower doses of midazolam?
higher
IV dose of morphine for preop pain
0.05-0.1 mg/kg
oral dose of fentanyl for premedication
10-15 mcg/kg (onset 10 minutes)
intranasal dose of fentanyl usually given when?
after induction
intranasal dose of sufentanil for premed
1.5-3 mcg/kg
ketamine does what
dissociation of cortex from limbic system
preserves upper airway and respiratory drive
disadvantage of ketamine
sialorrhea
nystagmus
psychological reactions (consider use of midazolam and glyco)
use of anticholinergics
prevent bradycardia
minimize autonomic vagal effects
reduce secretions
side effects of anticholinergics
dry mouth, skin erythema, tachycardia, hyperthermia
which anticholinergics cross the BBB?
atropine and scopolamine
which anticholinergic does not cross the BBB
glycopyrrolate
dose of atropine
0.01-0.02 mg/kg
glyco dose
0.01 mg/kg
are the doses of acetaminophen used in anesthesia toxic?
rarely
dose for acetaminophen for myringotomies
10-15 mg/kg
dose of acetaminophen for T&A
preop 40 mg/kg + 20 mg rectally in 2 hrs
total 24 hr dose not >100mg/kg
ofirmev dose for >13 year old or >50kg
1000 mg q 6 hrs or 650 mg q 4hrs
2 yo or < 50 kg
15 mg/kg q 6 hrs or 12.5 mg q 4 hrs
