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Pediatrics - Preop Planning Flashcards

1
Q

What should we discuss about the patient’s preoperative history? (4)
What are the two most important?

A
  1. Pre-existing medical conditions
  2. Past anesthetic history
    * 3. Current medication/allergies
    * 4. Family history
    * = most important
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2
Q

What is the most common complication during a peds induction?

A

AW obstruction with no IV access (inhalational induction)

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3
Q

What two diseases are characterized by small mandibular size and limited mouth opening?

A

Pierre Robin and Treacher Collins

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4
Q

What airway anatomy complication do you have to consider in Down’s patients?

A

Atlanto-occiptal instability

Limited range of motion of the mandible

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5
Q

How is the pediatric trachea different from an adult’s?

A

Tracheal cartilages are not fully developed so the trachea is more compliant; also smaller

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6
Q

What two pediatric diseases result in a partially closed airway?

A

Laryngomalacia

Tracheomalacia

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7
Q

How is the pediatric glottis different from an adult’s?

A

Anterior and cephalad

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8
Q

At what cervical level are the vocal cords of a neonate?

A

C3

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9
Q

At what cervical level are the vocal cords in a child?

A

C3-C4

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10
Q

At what cervical level are the vocal cords in an adult?

A

C4-C5

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11
Q

What structures in the pediatric airway are enlarged?

A

Head, tongue, and adenoids

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12
Q

How is the pediatric epiglottis different from an adult’s?

A

Long, narrow

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13
Q

What is the narrowest part of the pediatric airway?

A

Cricoid cartilage

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14
Q

What do Type 1 fibers in respiratory muscles do?

A

Function in endurance

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15
Q

Pediatrics have ____ Type 1 muscle fibers than adults. Why is this significant?

A

Fewer (20% of adults)

They will work very hard against an obstructed airway but only for a short time before they fatigue and cannot breathe.

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16
Q

How are the pediatric ribs different from an adult’s?

A

Horizontal and not well attached to the sternum or vertebral column

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17
Q

How are the pediatric vocal cords different from an adult’s?

A

Cords slant downward and anterior

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18
Q

What is the pediatric O2 consumption compared to adult O2 consumption?
What is the pediatric CO2 production compared to adult CO2 production?

A

Increased

Increased

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19
Q

Alveolar ventilation is ___ of adults’. What variable is changed?

A

Two times that of adults. RR is increased. TV is the same per kg as adults’.

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20
Q

What does pediatric ventilation depend on?

A

Diaphragm

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21
Q

Where is the greatest resistance in the pediatric airway?

A

Nares

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22
Q

The O2 dissociation curve is shifted which direction in neonates? What does this mean?

A

Shifted to the left. Hemoglobin F has a greater ability to bind to O2 and hold onto it (P50=19 vs 27 in adult)

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23
Q

How does the FRC of pediatrics compare to that of adults?

A

FRC is the same. FRC = 28-30 cc/kg
BUT a 2 kg baby only has 60 cc in their FRC whereas an adult has 1.5 L so a pediatric patient will desaturate very quickly

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24
Q

What are 3 important questions to ask in the preop pulmonary physical exam?

A
  1. Recent URI?
  2. Asthma?
  3. Former preterm infant?
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25
Q

When should elective surgery be cancelled?

A
  1. Purulent rhinitis
  2. Fever > 38.3 degrees C
  3. Elevated WBC with bands (immature WBCs)
  4. Infiltrate by CXR
    * Look for lower respiratory disease: bronchitis or pneumonia.
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26
Q

How many URIs does the average child have per year?

A

8

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27
Q

What % of US children have asthma?

A

5-10%

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28
Q
  1. If a child is diagnosed with asthma, into which ASA class does that automatically put them?
  2. If child is on daily asthma medication?
  3. If child is on steroids for asthma?
A
  1. Dx = ASA 2
  2. Daily meds = ASA 3
  3. Steroids = ASA 4
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29
Q

What should we do for an asthma pt? (3)

A
  1. Optimize medications
  2. Ensure no concurrent respiratory illness
  3. Ensure patient compliance with meds 24-48 hours prep
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30
Q

What is defined as a preterm infant?

A

Any child born before 37 weeks gestation

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31
Q

If child was a premie, what age can the child have elective surgery and go home same day?

A

52 weeks PGA (post gestiational age)

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32
Q

What age does postop apnea begin to decline?

A

45 weeks PGA

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33
Q

What do you always want to know about a preterm infant?

A

Room Air sat

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34
Q

Premies younger than 52 weeks PGA must stay how long in hospital and must be monitored for what?

A

Minimum 12 hours
Checking : Desaturation
Bradycardia
Apnea

35
Q

What membrane is affected with bronchopulmonary dysplasia? What are the characteristics of BPD? (6)

A

Hyaline Membrane Disease

  1. Increased airway resistance
  2. Poor lung compliance
  3. VQ mismatch
  4. Hypoxemia/O2 desaturation
  5. Tachypnea/increased work of breathing
  6. Chronic wheezing despite maximum medical tx
36
Q

What should we do for bronchopulmonary dysplasia pts prep?

A
  1. Optimize medications

2. Ensure no concurrent illness

37
Q

What is PCA?

A

Post-conceptual age

38
Q

When is anemia especially a problem for the preterm infant?

A

When they experienced placenta previa or placenta abruption

39
Q

What is the hematocrit of healthy, full-term babies? What is the hematocrit of anemic premies?

A

Healthy: 50-60
Anemic: 27-28

40
Q

Premies are at greater risk for what 2 complications?

A

GERD

Aspiration pneumonitis

41
Q

What grade murmurs do not require a workup?

A

Grades I and II and asymptomatic

42
Q

What grade murmurs do require a workup and ECHO?

A

Grades III and greater OR if there are any symptoms

43
Q

What grade murmur can you hear without the stethoscope on the chest?

44
Q

What are the guidelines for sickle cell disease pts?

A
  1. Get a baseline H/H
  2. Transfuse to Hct 30% with PRBCs preop
  3. Always have blood available in OR
45
Q

What are fasting guidelines for < 6 months?

A

4 hrs for solids, milk, and formula

2 hrs for clear liquids

46
Q

What are fasting guidelines for 6-36 months?

A

6 hrs for solids, milk, and formula

3 hrs for clear liquids

47
Q

What are fasting guidelines for > 36 months?

A

8 hrs for solids, milk, and formula

3 hrs for clear liquids

48
Q

What is Pedialyte considered to be for fasting guidelines?

A

Clear liquid

49
Q

At what age should we start giving premed Versed?

A

> 12 months (do not use Versed before 12 months of age

50
Q

What are the benefits of premed?

A
  1. Calms child and parents
  2. Better acceptance of mask induction
  3. Diminishes postop behavioral changes
  4. Fewer tears & secretions = dec risk of laryngospasm during induction
51
Q

What is normal dose of premed Versed?

A

Midazolam 0.5-0.7 mg/kg orally, max 15-20 mg

0.2 mg/kg nasally

52
Q

What hypnotic agent can be used as a premed?

A

Ketamine 6-9 mg/kg orally

53
Q

What premed is given rectally?

A

Methohexital (Brevital) 10%, 25 mg/kg

very unpredictable though–based on feces presence/absence

54
Q

What is an opioid premed?

A

Transmucosal fentanyl 10-15 mcg/kg (intranasal or lollipop)

55
Q

On a healthy child, what labs should be done in preop?

56
Q

If moderate blood loss is expected, what labs should be done preop?

A

Baseline H/H

57
Q

What type of surgery is the exception to the guidelines for preop labs?

A

ENT, especially tonsillectomy bc of hemophilia dx

58
Q

What % of ped surgeries are ambulatory?

59
Q

What anesthetic agent is most often used and why?

A

Sevoflurane bc it causes the least airway irritation

60
Q

Which anesthetic prolongs emergence?

61
Q

Which anesthetic causes more laryngospasm, coughing, and emergence excitement?

A

Desflurane (petechiae from coughing so hard)

62
Q

Do all cases require IV access?

A

No, ear tubes, for example, are only 5 minute procedures so no need

63
Q

Forced drinking for hydration in PACU causes what?

A

Increased incidence of PONV (23% compared to 14% for elective drinkers)

64
Q

For ped pain management, what medications are preferred and why?

A

NSAIDs preferred over opioids (minimize use of opioids if at all possible)

65
Q

What is dose of Ibuprofen orally?

A

5 mg/kg PO

66
Q

What is dose of IM & IV ketorolac?

A

IM: 1 mg/kg
IV: 0.5 mg/kg
*Be careful giving to tonsillectomy pts –> increased bleeding

67
Q

What can surgeons do to help with pain management?

A

Local anesthetic wound infiltration

68
Q

What is most common regional technique performed in peds? Advantages and disadvantages?

A

Caudal block
Easy, good landmarks, predictable
Occasional motor block in older pts

69
Q

Onset and duration of caudal block

A

10-12 min

4-6 hrs

70
Q

On what pts do we perform caudal blocks? (age and weight)

A

< 7 years of age

< 30 kg

71
Q

What is a TAP block? What are three most common performed?

A

Transverse abdominis plane block

Ilioinguinal, iliohypogastric, and penile

72
Q

Which procedures/factors have the highest incidence of PONV?

A 
ENT, esp middle ear
Laparoscopic
Eye
Family hx
Motion sickness
73
Q

What is the dosage of Zofran?

A

0.1 mg/kg up to max 4 mg

74
Q

What is dose of Reglan?

A

0.15 mg/kg IV

75
Q

What is dose of promethazine?

A

0.5 mg/kg IV/PR

76
Q

What is dose of decadron?

A

0.33 mg/kg

77
Q

What is the recommendation for prevention of PONV in peds?

A

2 drug therapy

78
Q

What is one of only drugs that has not shown neural toxicity?

A

Dexmedetomidine

79
Q

Flick’s study showed that infants who had 3 or more surgeries before age 2 had what?

A

3x incidence of learning disabilities

80
Q

What has been proven to be neuroprotective?

A

Lithium, single dose

81
Q

What other agents are possibly neuroprotective? (studies still ongoing)

A

Dexmedetomidine
tPA (tissue plasminogen activator)
Plasmin
Erythropoietin

82
Q

What study used healthy children undergoing a single anesthetic and a single procedure comparing Sevo to regional anesthesia for hernia repairs?

83
Q

What study used sibling pairs undergoing a single anesthetic for hernia repairs?

A

PANDA study (Pediatric Anesthesia Neurodevelopment Assessment Study)

AP Summer (24 decks)

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