Peds 1&2 Flashcards

Question

Minimum SBP (without anesthesia) 2-10 yrs old

Answer 1

Minimum SBP (without anesthesia) 2-10 yrs old = **70 + age (in yrs) X 2** ex: 5 yr old = 70 + (5x2) = 80 SBP

Answer 2

* **Alveoli ↑** in number & size up until 8 yo * _Infants_: **small airway** diameter = **↑ resistance** * Highly **compliant** airway & chest wall *(more collapsible lungs; see retractions and flaring in distress)* * **Early fatigue** of diaphragmatic & intercostal muscles until age 2 (**type 1 muscle fibers** *(slow twitch fibers that are resistant to fatigue)* **not mature**) * **O₂ consumption** is 2-3 x’s the adult w/ **increased alveolar ventilation** * **Angulation of R mainstem** bronchus *(more susceptible to R mainstem intubation)*

Answer 3

Neonate: 6 mL/kg/min Adult: 3.5 mL/kg/min

Answer 4

Neonate: 130 mL/kg/min Adult: 60 mL/kg/min

Answer 5

Neonate: 35 bpm Adult: 15 bpm

Answer 6

Neonate: 6 mL/kg Adult: 6 mL/kg

Answer 7

1. **Larger tongue** in smaller submental space *(less space to get a view)* 2. **Edentulous** 3. Obligate **nasal** breathers 4. **Higher larynx** (C2 to C4) *(more anterior view)* 5. **Funnel shaped** larynx with **narrowest region @ cricoid** ring 6. **Omega shaped epiglottis** = narrower; more difficult to lift 7. **Angled** vocal cords (slant caudally) *(more anterior view)* 8. **Large occiputs** & **“sniffing” position** favored for axis alignment 9. **Short trachea** (4-5 cm) *(head manipulation can lead to inadvertent R mainstem or extubation)*

Answer 8

* Young children have e**levated airway resistance** at baseline * Diameter of small airways does not significantly increase until approx 5 yo * Turbulent airflow is present to 5th bronchial division * 50% ↓ in radius = ↑ pressure 32X * Very prone to **respiratory distress** w/ any upper airway irritation or swelling * Resistance _inversely_ proportional to **radius⁴ for laminar** flow and **radius⁵ for turbulent** flow.

Answer 9

O₂ consumption & CBF in brain of children is **~50% greater** than adults

Answer 10

Myelinization & synaptic connections not complete until ## Footnote **age 3-4 yrs**

Answer 11

...**2 yrs** of life

Answer 12

**Anterior fontanel** closed by **18** months **Posterior fontanel** closed by **~2** months

Answer 13

* type 1 muscle fibers not mature * (slow twitch fibers that are resistant to fatigue)

Answer 14

* Increased and accelerated neuroapoptosis w/ virtually all anesthetics * **Single exposures of short duration** are usually of no consequence * Repeated &/or prolonged exposures at a young age (\< 3-4 yrs) ***may be*** associated w/ later behavioral & learning difficulties- _we do not have conclusive evidence_

Answer 15

* _Somatic pain_: conveyed by **unmyelinated C fibers** (slow) * Leads to protective reflexes such as autonomic reactions, muscle contraction, and rigidity * **C fibers fully functional from early fetal life onward** * **Connections** b/t C fibers and dorsal horn neurons **_not_ mature** before 2^nd wk life *but* **nociceptive stimulations** transmitted to dorsal horn by C fibers **elicit long-lasting responses**

Answer 16

* Neonates have **exaggerated response** to nociceptive stimuli * **Inhibitory control pathways immature** at birth & develop over first 2 wks

Answer 17

* Painful procedures during neonatal period **modify subsequent pain responses** in infancy and childhood * **Pre-emptive analgesia** leads to reduction in magnitude of long-term changes in pain behaviors * Use **pain scale appropriate** to developmental level of child (\< 3 yo usually unable to self-report) * Procedural pain in infants and young children: common use of **FLACC** scale

Answer 18

* **Conus medullaris** ends at ~ L1 in adults and **L2–L3** in neonates & infants. * *Conus medullaris is at L3 at birth & migrates to L1-L2 by 3 yrs* * In infants, line across iliac crests (**intercristal line**) crosses vert. column at **L4–L5 or L5–S1 interspace**, well below termination of spinal cord * **Dural sac** in neonates and infants t**erminates in more caudad location** compared to adults = **S3** compared to adult S1 * _Infants_: _lack lumbar lordosis_ compared to older children predisposes infant to **high spinal blockade w/ changes in positioning**

Answer 19

* **GFR impaired** at birth but improves throughout 1^st yr * Greatest impairment first4 wks of life * Renal maturation delayed further w/ prematurity * Renal **tubular concentrating** abilities do not achieve full capacity until **~2 yrs** * *Very premature infants easily become _hyponatremic_ bc of reduced proximal tubular reabsorption of Na+ & H₂O and reduced receptors for hormones that influence tubular Na+ transport. As many as 1/3 of ELBW neonates develop hyponatremia.* * **Half-life of meds** excreted by glomerular filtration are **_prolonged_ in very young** * In contrast, during **childhood, renal clearance rate may *_increase_*** to levels higher than adult clearance rates!!!!

Answer 20

* Enzyme systems still developing up until 1 yr of age * _Phase I_ CYP450 system is 50% of adult values at birth * _Phase II_ (conjugation reactions) are impaired in _neonates_ * **Long E½t of benzos and morphine** * Decreased bilirubin breakdown d/t **reduction in glucuronyl tranferase** (leading to jaundice) * *glucuronyl transferase also needed for metabolism of Tylenol*

Answer 21

Minimal glycogen stores = prone to **hypoglycemia**

Answer 22

* **Lower levels of albumin**/other proteins for drug binding in newborns = **larger proportion of unbound drug** circulating

Answer 23

* Hepatic synthesis of clotting factors reach adult levels w/in **1 wk** of birth * At birth, **vitamin K–dependent factors** (2, 7, 9, 10) are 20-60% of adult values * In preterm infants, values even less

Answer 24

* Coordination of swallowing w/ respiration not mature until 4-5 months old = high incidence **reflux**, especially in pre-terms * Gastric juices **less acidic** (more neutral) up to ~3 yrs old * Generally **slower absorption** of oral meds compared to adults * **GI tract is generally slower** in children than adults

Answer 25

* Children have differences in: * gastric pH * emptying time * intestinal transit * immaturity of secretions * activity of both bile and pancreatic fluids * Adults have a larger GI tract, faster gastric emptying time, and more protein transporters, which all cause an increase in absorption compared to children.

Answer 26

* **Large surface area to body weight** * **Lack of subq tissue** as an insulator * Inability to shiver: **metabolize brown fat** to **↑** heat production → can lead to **met acid & ↑ O₂ consumption**

Answer 27

* _Factors_: cold OR, anesthetic-induced vasodilation, room-temp IV fluids, evaporative heat loss from surgical site, cool irrigating solutions on field, cool/dry anesthetic gases * Active warming is critical: * Warm OR; use warming mattress; incubators; cover w/ blankets; head coverings (up to 60% of heat loss); transport in isolette; humidify gases; use plastic wrap on the skin; warm prep & irrigation solutions; change wet diapers & remove wet clothing * **Anesthetics alter non-shivering thermogenesis in neonates**

Answer 28

**Forced air warmers:** ## Footnote most effective strategy to minimize heat loss in surgery in children \> 1 hr

Answer 29

* Essential for all peds cases * **Hypothermia:** * **delayed emergence** * reduced degradation of drugs * increased infection * Hyperthermia: MH?

Answer 30

Core temp best measure: ## Footnote **mid-esophageal probe**

Answer 31

_Advantage to axillary temp if properly positioned:_ **proximity to deltopectoral group** improves recognition of elevated temp in MH

Answer 32

Forehead temp: **not advised**; 10 MH episodes occurred that were unrecognized w/ forehead temp *(Barash)*

Answer 33

TBW is **highest in premature infants** & **decreases w/ age**

Answer 34

Half-life of meds in **\>2 yrs** old is **_shorter or equivalent_** to adults d/t significant **CO to liver & kidneys**

Answer 35

* Protein binding: **\< 6 months** have decreased albumin & alpha-1 acid glycoprotein (AAG) * **Higher free-fraction** of protein bound drugs * **Free fraction of _lidocaine_ will be higher** in very young

Answer 36

Drugs that **depend on redistribution to fat for termination** of action will have **prolonged effects**

Answer 37

* Water soluble drugs have **larger Vd** * Need **larger initial** dose (Sch; abx) * Larger Vd can **delay excretion**

Answer 38

* **Lower P50 of fetal hgb**: L shift (19 mmHg vs. adult normal of 26 mmHg) * **Target hct in neonates higher** d/t L shift & decreased CV reserve (minimum hct 40% instead of 30%) * Neonatal polycythemia (central hct \> 65%) occurs in 3-5% of full-term neonates * Neonates have increased **r/f bacterial infection** d/t **immaturity of leukocyte function** * **Physiologic anemia 2-3 months old**

Answer 39

**4-5 mL/kg** of transfused PRBC’s _increase_ **hgb ~ 1 g/dL**

Answer 40

* _Max allowable blood loss calculation_ * **Variables**: * EBV * patient starting hct * minimum allowable hct * MABL = EBV X [(starting hct - target hct)/ starting hct]

Answer 41

1. **Fasting (NPO) deficit:** (maintenance rate x hrs NPO for deficit) 2. **Baseline maintenance** fluid requirement: _LR_ most cases 3. **Replacement of blood loss**: 3:1 crystalloid replacement 4. **Evaporative loss**: based on _invasiveness_ of surgery

Answer 42

* 4:2:1: * \< 10 kg: **4** mL/kg * 11-20kg: 40 mL + next 10 kg @ **2** mL/kg * \> 20 kg: 60 mL + anything over 20 kg @ **1** mL/kg

Answer 43

* Rather than 4-2-1, new guidelines recognize impact of **ADH secretion** on fluid status * _Healthy children undergoing elective surgery_ * **Administer 20-40 mL/kg of crystalloid (balanced salt solution) over duration of case** * Takes into account maintenance fluid & NPO deficit * *and then still replace blood loss at 3:1* * *Be familiar w/ both*

Answer 44

* **LR** typically used for maintenance in healthy children * **Glucose containing IVF** may be needed in infants \< 6 mo’s & in others at r/f hypoglycemia * **Minimize potential for error**: smaller IV bags; buretrols * **Eliminate all air from IV line**

Answer 45

* **Do NOT stop TPN suddenly**; either continue in OR or ramp down & bridged w/ glucose-containing IVF (ok to stop lipids)- deduct this from hourly maintenance calculated rate * *Never abruptly d/c TPN- circulating insulin levels have acclimated to this basal infusion of glucose and hypoglycemia will be problematic. Some do cut back to 1/3 to 1/2 d/t increase in glucose release d/t surgical stress- if you choose to do this then be sure to monitor glucose*

Answer 46

* Recognize dehydration in infants: **best measure of deficit is weight** * _Mild_: ~ 50 mL/kg deficit-- dry mouth, poor skin turgor * _Moderate_: ~ 100 mL/kg-- mild sx + deficit sunken fontanel, oliguria, tachycardia * _Severe_: ~ 150 mL/kg-- moderate sx + sunken eyes, hypotension, & anuria

Answer 47

* **_Requires knowledge of age-related norms for HR and BP_** * **HR persistently increased**, or **vary** w/ surgical stim? * **Pulse pressure narrow**, or, more ominously, is **BP reduced for age**? * Does it **vary w/ positive-pressure breaths**? * **Warm** **extremities**? * **Cap refill** brisk? * What is **UOP**? * Are these variables changing? * What is the rate of the change? * **When hypovolemia is suspected, observing response to a 10-to20-mL/kg bolus of isotonic crystalloid or colloid may test the hypothesis.**

Answer 48

* Isotonic crystalloid (LR) at ½ rate described in original 4-2-1 fluid regimen (ex: 2:1:0.5) * If NO oral intake after 6-12 hrs, initiate standard maintenance fluid therapy (4-2-1) w/ hypotonic saline (0.45% saline) +/- glucose to avoid hypernatremia and fluid overload from prolonged administration of isotonic solutions.

Answer 49

* Routine use of glucose-containing IVF periop in children is **not recommended** * _Exception_: Children at high **r/f hypoglycemia**-- can use **D5½NS** @ **maintenance rates** * Continuous TPN: must not suddenly stop * Children w/ mitochondrial dz will definitely **need glucose** containing replacement fluid

Answer 50

“In general, most meds will have _prolonged E½t_ **in preterm and term infants**, a _shortened E½t_ in **children \> 2 yrs up to early teenage** yrs, and a _lengthening of E½t_ in those approaching **adulthood**.”

Answer 51

1. **↑ RR & CI** 2. larger proportion of blood to **VRG** (heart, brain, GI, kidneys, endocrine) 3. **↓ tissue and blood solubility** in infants * Alveolar vent to FRC ratio is 5:1 in infants vs 1.5 :1 in adults * **↑ r/f anesthetic overdose in infants/ toddlers** * ↑ incidence of **hypotension** in neonates & infants upon inhalational induction. * More rapid uptake can unmask negative inotropic effects of volatiles in infant

Answer 52

* MAC of VA’s (other than Sevo) ↑ until 2–3 months old and steadily declines w/ age thereafter * **_Sevo_**: Exception = MAC remains constant in neonates & infants up to 6 months * MAC up to 6 months is ~3.2% * MAC 6 mo – 12 yrs is constant at 2.4%

Answer 53

* **Sevoflurane** is primary agent used for inhalational induction * Halothane also has low pungency but no longer used in US * **halothane** frequently caused **bradycardia** at induction * Use of _desflurane_ for induction limited by **pungency**

Answer 54

1. Greater ratio of alveolar ventilation to FRC 2. Greater fraction of CO distributed to the VRG 3. Reduced tissue/blood solubility 4. Reduced blood/gas solubility

Answer 55

* Respiratory: same as adults: * overall **↓MV** * **↓TV w/ ↑RR** * **Depressed response** to CO2 & hypoxia * As concentration ↑, **apnea** ensues

Answer 56

* **Dose dependent depression** * _Halothane_ has greatest depression of contractility * _Sevo_ usually maintains or increases HR during induction * All can cause **prolonged QT**

Answer 57

**Halothane hepatitis**: antibody reaction; repeated exposure

Answer 58

* Neonates: Immature BBB & decreased metabolism can increase sensitivity * Older children & adolescents generally require **increased doses** of induction agents compared to adults

Answer 59

* _Propofol_ * **Most commonly used** IV induction agent in children * **Pain** of injection can be reduced with a **mini Bier block**: * **0.5-1 mg/kg of Lidocaine for 60 sec** * **Antiemetic** properties * Propofol infusion syndrome: long term infusions in ICU avoided in infants & children; still appropriate for TIVA * Egg/soy: only avoid if **documented anaphylaxis w/ eggs**

Answer 60

* Ketamine: can be used IM, IN, PO, IV * Induction w/ ketamine preferred in **cyanotic heart** dz, **septic shock**, & induction for **mediastinal mass** (need spontaneous ventilation) * Emergence irritation can be reduced w/ co-admini w/ midazolam & waking up in a dark, quiet room

Answer 61

Etomidate: only approved for use in **age \>10** yo in US; **0.2-0.3 mg/kg** IV

Answer 62

Thiopental: **no longer available in US**; **3-5 mg/kg** IV

Answer 63

* Midazolam: most widely used anxiolytic pre-op * Oral dosing: dose **_increases_ in younger** pts; poor oral bioavailability; bitter taste; allow 10-15 min * Reversal: **flumazenil 0.01 mg/kg** IV * **Hepatic metabolism** (CYP 3A4) & renal excretion

Answer 64

* Ketamine * Severe cognitive/ behaviorally challenged older children may have to be given **IM Ketamine** for sedation in preop (**2-5 mg/kg**) * **Onset will be 3-5 min w/ 30-40 min DOA**

Answer 65

* _Dexmedetomidine_ * **Hypotension** w/ loading doses; **bradycardia** w/ high dose infusion * Not adequate as sole anesthetic but can be helpful as adjunct * Useful in awake FOB, radiological procedures, & reduction of emergence delirium

Answer 66

* Variety of choices: onset, potency, duration, & metabolism are factors just like in adults * Also consider previous exposure to opioids (tolerance), severity of pain, & other multi-modal strategies

Answer 67

* Most widely used opioid intra-op in children * Dosing typically in range of **1-3 mcg/kg** (IV) per single dose & titrated for effect

Answer 68

Excellent for neonates d/t **immaturity** of renal/ hepatic metabolism/excretion

Answer 69

Primarily given for **shivering in small doses**

Answer 70

* Historically very commonly prescribed postop * Withdrawn from markets d/t respiratory events * **SNP’s in ultra-rapid metabolizers** confer **r/f OD**

Answer 71

* 10-15 mg/kg PO * 15 mg/kg IV q6hrs (10-15 min onset) * Rectal absorption is slow (1-2 hrs)

Answer 72

* Typical dose IV **0.5 mg/kg** * Ask surgeon before giving * Caution w/ all NSAIDS in severe asthma

Answer 73

* NMJ not fully mature until ~2 months of age * _Infants_: may be **more sensitive to NDNMB** but also have **larger VD** so dose/kg is usually same as adults * _Exception:_ **Rocuronium- dose is lower** in infants * Always use nerve stimulator, response highly variable * May see **prolonged duration of action** d/t immature renal/hepatic elimination * Routine reversal for TOFR \<0.9 * Infants & children, **neostigmine dose is 30-40% lower than adults (0.02-0.04 mcg/kg)** co-administered w/ anticholinergic

Answer 74

* Higher Sch doses needed in in neonates & infants d/t larger VD (3mg/kg) * Sch IM 4mg/kg paralyzes w/in 1-2 min * duration may be up to 20 min * **_Sch is limited to RSI and emergency tx of laryngospasm in Peds_** * When given, concurrent atropine (0.02 mg/kg) administration is routine practice *to prevent bradycardia and asystole (even with single dose administration)* * R/f bradycardia; hyperkalemia; masseter spasm; MH in children w/ undiagnosed myopathies * Atracurium/ Cisatracurium: particularly useful in newborns and children w/ immature or abnormal hepatic or renal function (Hofman elimination...pH/temp dependent)

Answer 75

* CO and local blood flow are 2-3X greater in infants than adults so **systemic LA absorption is ↑** * Epinephrine is effective in slowing systemic uptake * Plasma concentration of AAG is very low at birth (0.2 to 0.3 g/L) and does not reach adult levels (0.7 to 1.0 g/L) before 1 yo * Free fraction of all LA’s is ↑ in infants * **Max doses** of all **amino-amides must be reduced** * *LA’s are metabolized by CYP450.* * *CYP3A4 metabolizes lidocaine and bupivacaine.* * *CYP1A2 metabolizes ropivaciane.* * *These hepatic microsomal enzymatic systems are **immature** at birth and, as a result, hepatic c**learance of amide anesthetics** is **delayed** in children.* * *Levels of plasma esterases that metabolize ester LA’s are also lower in infants; however, delay in metabolism is not significant.*

Answer 76

Lidocaine Bolus Dose = 4 mg/kg Infusion = 0.8 mg/kg/hr

Answer 77

Lidocaine with Epinephrine Bolus dose: 7 mg/kg

Answer 78

Ropivicaine Bolus: 3 or 2.5 mg/kg Infusion: 0.3 mg/kg/hr

Answer 79

Bupivacaine Bolus: 2.5 mg/kg Infusion: 0.2 mg/kg/hr

Answer 80

Chloroprocaine Bolus: 12 mg/kg Infusion: 12 mg/kg/hr

Answer 81

* Preschool age: distraction & premedication * Offer flavoring for the O2 mask if available * Pre-op prep w/ OR equipment (see the mask, pick a flavor, etc.); child life specialists can assist * Distractions: music/ singing, story telling, jokes, guided imagery; “changing flavor” of mask * **Avoid** bright lights, loud voices, & lots of extra personnel in room * Consider parental presence (especially in ages 1-6); **_parents must be educated on what to expect at induction_**

Answer 82

* Standard adult **history and physical exam** must be adapted; some topics that require further emphasis in children * **Birth history**; prematurity * **Neuro** development: appropriate for chronological age? psychological issues? * **Airway** anomalies, surgical history, previous intubations, and general medical health (heart, lung, endocrine, renal disorders) * Genetic or dysmorphic syndrome? * Potential for anomalies in the **cervical spine** (eg, Down syndrome) or craniofacial dysmorphia * _Family history_: 1. MH 2. pseudocholinesterase deficiency 3. PONV 4. congenital myopathies 5. bleeding * **No lab work** indicated for healthy children undergoing procedure w/ minimal blood loss anticipated * Routine **pregnancy testing** controversial; parents may decline; history alone can be unreliable * Higher r/f **latex allergy** in certain peds populations: spina bifida, myelodysplasia, urinary tract malformations; multiple previous surgeries

Answer 83

1. Presence of **URI** 2. **Snoring** or noisy breathing 3. Presence and nature of **cough** 4. Past episodes of **croup** 5. **Inspiratory stridor**, usually high pitched 6. **Hoarse** voice 7. **Asthma** and bronchodilator therapy 8. Repeated pneumonias 9. Previous anesthetic problems, particularly related to the airway 10. Atopy, allergy 11. History of a congenital syndrome 12. Parents smoke in the house? 13. Suspicion of a C-spine anomaly?

Answer 84

* Presence of URI = predisposition to * Coughing * Laryngospasm * Bronchospasm * Desat during anesthesia * Postintubation subglottic edema * Postop desat

Answer 85

* Snoring or noisy breathing could indicate: * Adenoidal hypertrophy * Upper airway obstruction * OSA * Pulm HTN

Answer 86

* _Presence/nature of cough_ could indicate: * **“Croupy” cough** may indicate: * subglottic stenosis * previous tracheoesophageal fistula repair * **Productive cough** may indicate: * bronchitis * pneumonia

Answer 87

* Postintubation croup * Subglottic stenosis

Answer 88

* Inspiratory stridor, usually high pitched could indicate: * Subglottic narrowing * Laryngomalacia * Macroglossia * Laryngeal web * Extrathoracic foreign body * Extrathoracic tracheal compression

Answer 89

* laryngitis * vocal cord palsy * papillomatosis * granuloma

Answer 90

Bronchospasm

Answer 91

1. incompetent larynx with aspiration 2. gastroesophageal reflux 3. cystic fibrosis 4. bronchiectasis 5. residual tracheoesophageal fistula 6. pulmonary sequestration 7. immune suppression 8. congenital heart disease

Answer 92

* difficult intubation * difficult mask ventilation * failed or problematic extubation

Answer 93

* increased airway reactivity/resistance * increased propensity to desat

Answer 94

Many are associated w/ DA management

Answer 95

increased airway reactivity

Answer 96

* Resp focus: * Frequent URIs? * History of wheezing? * History of noisy breathing? * Hospitalizations? * History of intubations? * History of eczema/skin allergy? * In daycare? * Immunization status? * Smokers in the house? * Infant: Frequent vomiting after feeds/“choking” episodes? * Child: Frequent tonsillitis? Ear infections? Snoring?

Answer 97

* CV focus: * Any family history of * CHD/chromosomal abnormalities * Sudden/premature death * Maternal illness/infections (both chronic and during pregnancy) * Maternal medications/drug use * _Infant_: Any problems with poor feeding, sweating (especially on the forehead) during feeding, poor weight gain, FTT, decreased activity level * _Older child/ adolescent_: Any inability to keep up with the activity level of peers, need for frequent periods of rest, anorexia, cough, wheezing, rales, chest pain, leg cramps, syncope, light-headedness, palpitations; any history of drug use; any family history of sudden death, syncope, or arrhythmias * Any changes in color or cyanosis when crying?

Answer 98

* Always talk through assessment; children like to know what to expect; get on their eye level; stay calm * _Airway_: inspect face (include profile view), mouth opening, tongue mobility (“stick out tongue”), neck extension, loose teeth * Assess respirations in position of comfort (moms arms), look for flaring, retractions * Auscultate heart and lungs * Rales or wheeze? request a cough and listen again * Murmur detected? further investigate- cyanosis, syncope, arrhythmias, tachycardia, poor feeding, activity tolerance * Innocent murmurs are found in up to 50% of normal children (especially age 2 to 6)- these are systolic ejection murmurs & are accentuated by stress, anemia, fever * Diastolic murmurs &/or symptomatic murmurs need investigation * Palpate liver if any reason to suspect fluid overload: Normal liver is 1-2 cm below costal margin * Hepatomegaly is a sign of RV failure * Cyanosis in infant: Arterial desaturation or central cyanosis is best detected in perioral area, the mucous membranes of mouth, lips, and gums. * Central cyanosis should be distinguished from peripheral cyanosis, which can occur in a cold environment, and acrocyanosis, which in newborns is d/t sluggish circulation in fingers and toes

Answer 99

* Clear liquids: Include only fluids w/out pulp, clear tea, or coffee w/out milk products * Gum chewing: 70% ↑ in gastric fluid volume in first 15 min after initiating gum chewing, mostly saliva; most providers will proceed as long as gum is spit out (not swallowed) * Clear liquids 2 hrs * Breast milk 4 hrs * Infant formula 6 hrs * Solids (fatty/fried food) 8 hrs

Answer 100

* Range of sizes of airway equipment (face masks, OPA’s, ETT’s, LMA’s, blades) * Appropriate size LMA should always be available even if intubation is planned in case of unanticipated difficult airway * _Straight blades_ most commonly preferred in infants d/t anatomical differences * Appropriate sized **BP cuff and pulse ox** is present & functional * Calculate drug doses, allowable blood loss, & fluid requirements * Have **primed bag of IV fluid** ready and all supplies to start & secure IV set up & accessible * Prepare **pediatric circuit/** bag; Preset **vent settings** appropriate for size (& program in weight to anesthesia machine if applicable) * Emergency drugs for every pediatric case: * Weight appropriate doses of **Sch & Atropine** w/ a small gauge needle appropriate for IM injection * Laryngospasm * Syringe of **propofol** * Facilitate intubation, break laryngospasm, increase depth of anesthesia quickly * **Epi** diluted to 10 mcg/ml: not always drawn up but definitely consider drawing up in sick pt/ complex case * Plan for **age appropriate distractions**: have flavors for masks; consider parental presence if facility allows * **Warm** room

Answer 101

* Often needed at age **~10 months** when **separation anxiety** becomes an issue * **Oral versed** most common- SEE DOSING * Severe distress/ need for profound sedation * May combine meds (ketamine, atropine, versed combo PO) * May use **IM route** if uncooperative w/ PO sedation * Intranasal route is sometimes used but can really burn & make child more agitated

Answer 102

* Sniffing position is critical * Avoid pressure on soft tissue in submental triangle * Jaw thrust * Low threshold for 2-person ventilation

Answer 103

* Stay flexible! All monitors may not go on before induction (try for pulse ox); child may be afraid of mask * Stay calm! Be warm and reassuring * **Inhalational induction most common** * **\*\*Frequent monitoring of BP and HR during induction** * \< 10 months: usually no premed required * Alternative is pre-op IV w/ standard induction: topical anesthetics can be used for IV starts; EMLA cream onset is 45-60 min * IM Ketamine rarely used for inductions in larger cognitively impaired/ extremely uncooperative children * *It is safest to maintain spontaneous ventilation for induction; taking over ventilation will increase risk of anesthetic overdose*

Answer 104

* Inhalational induction is common: seated or supine position * One approach: * Higher flows with 70% N2O and 30% O2 * Fully open APL * Allow few breaths of N₂O mix and then incrementally turn on Sevo to 8% (some providers turn up sevo to 8% w/out using incremental technique after few breaths of N2O- especially if crying) * Turn off N₂O to provide 100% O2 * Assist spontaneous ventilation **PRN-** caution about high inspired VA w/ assisted or controlled ventilation * Obtain IV * Once IV in, induction proceeds- give some propofol, narcotic, +/- NMB, etc at this point and then proceed w/ airway management appropriate for case (LMA, ETT); NOTE: intubation is often completed w/out NMB’s * Be sure to turn down Sevo to normal MAC range for child; watch VS closely during induction

Answer 105

* Same principle as adults to prevent aspiration * Cricoid pressure in infants/ children is +/- (Barash says no); increased likelihood of obstructing an infants airway w/ little proven benefit * Note that children will have rapid desat w/ hypoxia (limited reserve) * _Equipment_: ETT (pre-stylet) age calculated plus 0.5 smaller & 0.5 larger; laryngoscope (working), sxn immediately available at HOB, functioning IV, pre-drawn drugs * **Propofol 2-4 mg/kg** (stable) vs. **ketamine 1-2 mg/kg** or **etomidate 0.2-0.3 mg/kg** (unstable) * *plus* **Sch 2mg/kg (premed w/ Atropine 0.02 mg/kg)** * Consider Rocuronium 1.2 mg/kg if Sch contraindicated (45 to 75 min duration) * **Calcium (IV)** should be immediately available in the event Sch leads to unanticipated hyperkalemia w/ ventricular arrhythmias

Answer 106

* Always have ranges of ETT sizes (0.5 smaller than calculated & 0.5 larger) * Short trachea favors **right mainstem intubation** * Breath sounds often referred * Common formula over 2 yo * (Age + 16) / 4 * Cuffed tubes are fine as long as cuff pressures are monitored- use ID 0.5 mm smaller tube * Rough estimate of depth is 3x ID * A leak should be maintained around cuff regardless @ 20-30 cm H20

Answer 107

Midway b/t cords and carina

Answer 108

* Used during routine surgeries & as a rescue device for failed intubation * Low failure rate for insertion (\< 1%)

Answer 109

* Contraindicated in children w/ **r/f pulmonary aspiration** * Other **specific pediatric contraindications**: * Mediastinal masses * Children requiring high peak airway pressures to ventilate * Tracheomalacia * Very limited mouth opening

Answer 110

* 1: _\<_ 5 kg * 1.5: 5-10 kg * 2: 10-20 kg * 2.5: 20-30 kg * 3: 30-50 kg * 4: 50-70 kg * 5: 70-100 kg * 6: \>100 kg

Answer 111

* 95% of subglottic stenosis is acquired * Post-intubation injury most common cause of **acquired subglottic stenosis** * Avoid oversized ETT’s * Cuff pressures must be monitored throughout long cases/ extended intubations * Maintained at a level below 20-30 cm H2O

Answer 112

* Risk factors associated w/ acquired SGS: * Trauma during intubation * ETT movement during intubation * Prematurity * Presence of infection at time of intubation

Answer 113

* 6 to 8 mL/kg is typical * Sustained plateau airway pressures **\> 35 cm H2O can lead to barotrauma**: * PTX * pneumomediastinum * subq emphysema * Lung protective strategies apply

Answer 114

* More frequent in infants; risk decreases w/ increasing age * Reflex closure of false & true vocal cords

Answer 115

* Stridor * Retractions * Flailing of lower ribs * “Rocking horse” chest wall movement * Stridor will be absent with complete closure = “silent inspiratory effort” * Can lead to profound bradycardia & desat if unrelieved

Answer 116

* Recent URI * secondhand smoke * stimulation while “light” * secretions in airway

Answer 117

* **Continuous positive airway pressure** * 100% O2 * jaw thrust at mandibular condyles * sxn secretions * Deepen anesthesia (propofol) * Unresolved? * Atropine & Sch- if no IV access then give IM * Can lead to negative pressure pulmonary edema especially in healthy, muscular adolescents- may have to remain intubated for 12-24 hrs & may need furosemide

Answer 118

* Vagal stimulation * Increased ICP * CHD * Hypothermia * Air emboli * Tension PTX * Meds * single dose Sch * *clonidine, beta blockers, Sevo esp in downs syndrome, propofol infusion syndrome, some eye drops*

Answer 119

\< 100 bpm

Answer 120

* Treat cause: think oxygenation and ventilation first! * **Atropine** if vagal origin **0.02 mg/kg** IV * **Epinephrine** if decompensated **10 mcg/kg**

Answer 121

* 3 phases: * **Early phase**: coughing intermittently, gagging, struggling, moving nonpurposefully * **2nd phase**: apnea, agitation, straining, breathholding * **3rd (final) phase**: regular RR, purposeful movement, coughing, eyes open spontaneously- extubation now appropriate

Answer 122

* Transport in lateral decubitus position “recovery position”

Answer 123

* PACU complications in ~5% of children: * **Vomiting** 77% (more common in \> 8 yo) * **Airway compromise** 22% (more common in \< 1 yo) * **CV compromise** is \< 1%

Answer 124

* Neuromuscular function: check & reverse if appropriate * Different techniques for extubation: always prioritize patient **safety** * **Awake extubation**: must be awake & purposeful; laryngospasms happen when pts are extubated in early & 2nd phase, “if in doubt…don’t take it out!” * **Deep extubation**: Sevo _increased_ to 1.5-2 MAC for at least 10 min * Ensure no response (cough, breath holding) to suctioning or tube movement & ensure regular respirations

Answer 125

* **Caudal anesthesia** * Lower abdominal & LE surgery in \<5-6 yrs of age * Single shot block w/ LA will last 4-6 hrs * Done following GA induction in lateral position * Epidural & spinal anesthesia also used in children but are most frequently completed under **general anesthesia** * Technique similar to adult

Answer 126

* Hernia * Orchidopexy * T&A * Strabismus * Middle ear * Laparoscopic

Answer 127

* **Prevention**: hydration, multi-modal analgesia (opioid sparing) * Typical 2 agent strategy for prevention in at-risk (decreases risk by 80%): * **Ondansetron 0.05-0.15 mg/kg** IV (note risk in undiagnosed long QT syndrome) * **Dexamethasone 0.0625-1 mg/kg** IV

Answer 128

Females Age 10-16

Answer 129

* Phenomenon characterized by **non-purposeful restlessness** and agitation, **thrashing, crying** or moaning, and **disorientation** * 18% of all children undergoing surgery and anesthesia develop emergence delirium

Answer 130

* young age * previous surgery * type of procedure * type of anesthetic * level of preop anxiety is predictive

Answer 131

Age 2-6 years

Answer 132

Most common after Sevo (then Des)

Answer 133

* Usually lasts ~ **10-15 min** * Protect from self-harm