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Coexisting > Peds 1&2 > Flashcards

Peds 1&2 Flashcards

1
Q

Neonate

A

Birth to 30 days

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2
Q

Post-gestational age (PGA) calculation

A

Post-gestational age (PGA) =

(# wks gestation @ birth) + (current age in wks)

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3
Q

Pre-term

A

< 37 weeks

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4
Q

What is considered low birth weight?

A

< 2500 grams

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5
Q

Extremely low gestational age (ELGAN):

A
  • 23-27 weeks gestation
  • all organs immature
  • most vulnerable peds pt
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6
Q

Most vulnerable peds pt

A

Extremely low gestational age (ELGAN):

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7
Q

ALL pre-terms have potential for:

A
  • Respiratory distress
  • Apnea
  • Hypoglycemia
  • Electrolyte disturbances (▼Mg++, Ca++)
  • Infection
  • Hyperbilirubinemia
  • Polycythemia
  • Thrombocytopenia
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8
Q

Former premature infants up to ____ PGA are at increased r/f _____ and _____, requiring post-op monitoring & admission.

A

Former premature infants up to 60 weeks PGA are at ↑ r/f postop apnea and bradycardia, requiring postop monitoring & admission

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9
Q

Primary changes that occur at birth:

A
  • Placenta is no longer primary source for oxygenated blood
  • Ductus venosus closes
  • Ductus arteriosus closes (d/t increased PaO2)
  • Foramen ovale closes (functional closure—could reopen bc not anatomically closed yet)
  • PVR ↓
  • SVR ↑
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10
Q

Changes at Birth: Transitional circulation

A
  • Occurs at birth for 1st several weeks
  • Hypoxia, hypercapnia, or hypothermia can lead to…
    • ↑ PA pressure
    • reversal of flow through foramen ovale
    • re-opening of ductus arteriosus
    • shunting
  • This hypoxia is difficult to correct
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11
Q

Fetal Circulation = ____PVR and ____SVR

A

High PVR

Low SVR

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12
Q

Cardiovascular System: Newborn heart

A
  • Structurally immature
  • Fewer myofibrils
  • Sarcoplasmic reticulum immature
  • Cardiac Ca++ stores reduced
    • ​greater dependency on serum ionized Ca++
      • particularly vulnerable to effects of citrated blood products
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13
Q

Minimal intrauterine pulmonary blood flow =

A

only ~ 10% of the cardiac output

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14
Q

Newborn heart ventricles are _______(more/less) compliant.

A

less

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15
Q

What is cardiac output dependent upon in the neonate?

A

CO is HR-dependent

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16
Q

Baroreceptor reflex immature in neonate, so…

A

inability to substantially compensate for

hypotension w/ reflex tachycardia

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17
Q

Neonatal heart has ______ dominance and the ____ is immature.

A

Neonatal heart has PSNS dominance; SNS is immature. Therefore, there is tendency of bradycardia w/ suctioning & DL

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18
Q

Resting CO in neonate at birth

A

~400 mL/kg/min

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19
Q

Resting CO in infant

A

200 mL/kg/min

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20
Q

Resting CO in adolescent

A

100 mL/kg/min

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21
Q

The neonatal myocardium is not as compliant compared to an older child. What does this mean?

A
  • Increased preload does not increase SV to same degree
    • Hypovolemia and bradycardia produce dramatic ↓in CO that threaten organ perfusion
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22
Q

What is the preferred treatment of bradycardia and ↓ CO in peds pts and why?

A

Epinephrine (rather than atropine)

increases contractility & HR

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23
Q

What is the leading cause of bradycardia in children?

A

Hypoxia

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24
Q

Minimum SBP (without anesthesia) for neonate

A

70

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25
Q

Minimum SBP (without anesthesia) 2-10 yrs old

A

Minimum SBP (without anesthesia) 2-10 yrs old =

70 + age (in yrs) X 2

ex: 5 yr old = 70 + (5x2) = 80 SBP

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26
Q

Minimum SBP (without anesthesia) > 10 years old

A

90

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27
Q

Neonate Pulmonary System

A
  • 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)
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28
Q

Neonate vs Adult

Oxygen consumption

A

Neonate: 6 mL/kg/min

Adult: 3.5 mL/kg/min

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29
Q

Neonate vs Adult

Alveolar Ventilation

A

Neonate: 130 mL/kg/min

Adult: 60 mL/kg/min

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30
Q

Neonate vs Adult

Respiratory Rate

A

Neonate: 35 bpm

Adult: 15 bpm

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31
Q

Neonate vs Adult

Tidal Volume

A

Neonate: 6 mL/kg

Adult: 6 mL/kg

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32
Q

Infant Airway

A
  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)
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33
Q

Gas Flow

A
  • Young children have elevated 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.
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34
Q

O2 consumption & CBF in brain of children compared to adults

A

O2 consumption & CBF in brain of children is

~50% greater

than adults

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35
Q

Myelinization & synaptic connections not complete until what age?

A

Myelinization & synaptic connections not complete until

age 3-4 yrs

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36
Q

Rapid growth of brain in first…

A

…2 yrs of life

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37
Q

When do the fontanels close?

A

Anterior fontanel closed by 18 months

Posterior fontanel closed by ~2 months

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38
Q

Which type of muscle fibers are not mature in the infant?

A
  • type 1 muscle fibers not mature
    • (slow twitch fibers that are resistant to fatigue)
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39
Q

Anesthesia-Induced Developmental Neurotoxicity:

our knowledge is still growing in this area

A
  • 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
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40
Q

Pain: Somatic pain

A
  • 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 2nd wk life but nociceptive stimulations transmitted to dorsal horn by C fibers elicit long-lasting responses
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41
Q

What kind of response do neonates have to nociceptive stimuli and why?

A
  • Neonates have exaggerated response to nociceptive stimuli
  • Inhibitory control pathways immature at birth & develop over first 2 wks
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42
Q

Pain: Painful Procedures

A
  • 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
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43
Q

Neuraxial Considerations

A
  • 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 terminates 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
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44
Q

Renal

A
  • GFR impaired at birth but improves throughout 1st yr
    • Greatest impairment first 4 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!!!!​
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45
Q

Liver: Enzyme systems

A
  • 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
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46
Q

Liver: glycogen stores

A

Minimal glycogen stores = prone to hypoglycemia

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47
Q

Liver: Proteins

A
  • Lower levels of albumin/other proteins for drug binding in newborns = larger proportion of unbound drug circulating
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48
Q

Liver: Clotting Factors

A
  • 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
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49
Q

GI

A
  • 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
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50
Q

Specific GI differences between adults and children

A
  • 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.
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51
Q

Thermoregulation

A
  • 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
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52
Q

Factors of Thermoregulation

A
  • 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
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53
Q

What is the most effective strategy to minimize heat loss in surgery in children >1 hr?

A

Forced air warmers:

most effective strategy to minimize heat loss

in surgery in children > 1 hr

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54
Q

Temp Monitoring

A
  • Essential for all peds cases
  • Hypothermia:
    • delayed emergence
    • reduced degradation of drugs
    • increased infection
  • Hyperthermia: MH?
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55
Q

What is the best temp monitoring in children?

A

Core temp best measure:

mid-esophageal probe

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56
Q

Advantage to axillary temp monitoring

A

Advantage to axillary temp if properly positioned:

proximity to deltopectoral group

improves recognition of elevated temp in MH

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57
Q

Forehead temp monitoring

A

Forehead temp:

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

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58
Q

Body Composition: TBW

A

TBW is highest in premature infants

&

decreases w/ age

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59
Q

Half life of meds compared to children and adults

A

Half-life of meds in >2 yrs old is

shorter or equivalent to adults

d/t significant CO to liver & kidneys

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60
Q

Protein binding and drugs in neonates

A
  • 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
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61
Q

Neonates have less fat & muscle. What effect does this have on meds?

A

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

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62
Q

Body Composition: Water soluble drugs

A
  • Water soluble drugs have larger Vd
    • Need larger initial dose (Sch; abx)
    • Larger Vd can delay excretion
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63
Q

Hematocrit & Blood Volume

A
  • 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
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64
Q

____ of transfused PRBC’s increase _____ about ______

A

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

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65
Q

Max Allowable Blood Loss (MABL)

A
  • Max allowable blood loss calculation
    • Variables:
      • EBV
      • patient starting hct
      • minimum allowable hct
    • MABL = EBV X [(starting hct - target hct)/ starting hct]
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66
Q

Components of Fluid Replacement

A
  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
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67
Q

Fluid Replacement

Holliday-Segar formula

A
  • 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
68
Q

HOLLIDAY-SEGAR: New Trends

A
  • 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
69
Q

Fluid Replacement

A
  • 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
70
Q

Fluid Replacement: TPN

A
  • 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
71
Q

Recognizing dehydraton in infants

A
  • 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
72
Q

Intraoperative Fluid Management

A
  • 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.
73
Q

Postop Fluid Management

A
  • 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.
74
Q

Glucose/Hypoglycemia

A
  • 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
75
Q

“In general, most meds will have ___ E½t in preterm and term infants, a ____ E½t in children > 2 years up to early teenage years, and a _____ of E½t in those approaching adulthood.”

A

“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.”

76
Q

Inhaled Anesthetics:

Uptake is more rapid in children for several reasons…

A
  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
77
Q

MAC of VA’s

A
  • 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%
78
Q

What is the primary agent used for inhalational induction?

A
  • 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
79
Q

Table 7.4. Determinants of the Rapid Wash-in of Inhalational Agents in Infants Compared With Adults

A
  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
80
Q

Inhaled Anesthetic Effects:

Respiratory

A
  • Respiratory: same as adults:
    • overall ↓MV
      • ↓TV w/ ↑RR
    • Depressed response to CO2 & hypoxia
    • As concentration ↑, apnea ensues
81
Q

Inhaled Anesthetic Effects:

CV

A
  • Dose dependent depression
  • Halothane has greatest depression of contractility
  • Sevo usually maintains or increases HR during induction
  • All can cause prolonged QT
82
Q

Inhaled Anesthetic Effects:

Liver

A

Halothane hepatitis:

antibody reaction; repeated exposure

83
Q

Induction Agents (overall)

A
  • Neonates: Immature BBB & decreased metabolism can increase sensitivity
  • Older children & adolescents generally require increased doses of induction agents compared to adults
84
Q

Induction Agents:

Propofol

A
  • 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
85
Q

Induction Agents:

Ketamine

A
  • 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
86
Q

Induction Agents:

Etomidate

A

Etomidate:

only approved for use in age >10 yo in US;

0.2-0.3 mg/kg IV

87
Q

Induction Agents:

Thiopental

A

Thiopental:

no longer available in US;

3-5 mg/kg IV

88
Q

Sedatives:

Midazolam

A
  • 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
89
Q

Sedatives:

Ketamine

A
  • 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
90
Q

Sedatives:

Dexmedetomidine

A
  • 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
91
Q

Opioids (in general)

A
  • 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
92
Q

Opioids:

Fentanyl

A
  • Most widely used opioid intra-op in children
  • Dosing typically in range of 1-3 mcg/kg (IV) per single dose & titrated for effect
93
Q

Opioids:

Remifentanil

A

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

94
Q

Opioids:

Demerol

A

Primarily given for shivering in small doses

95
Q

Opioids:

Codeine

A
  • Historically very commonly prescribed postop
  • Withdrawn from markets d/t respiratory events
    • SNP’s in ultra-rapid metabolizers confer r/f OD
96
Q

Non-opioids:

Acetaminophen

A
  • 10-15 mg/kg PO
  • 15 mg/kg IV q6hrs (10-15 min onset)
  • Rectal absorption is slow (1-2 hrs)
97
Q

Non-opioids:

Ketorolac

A
  • Typical dose IV 0.5 mg/kg
  • Ask surgeon before giving
  • Caution w/ all NSAIDS in severe asthma
98
Q

Muscle Relaxants

A
  • 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
99
Q

Succinylcholine

A
  • 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)
100
Q

Local Anesthetics

A
  • 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 clearance 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.​
101
Q

Local Anesthetics

Max Doses (bolus and infusion)

Lidocaine

A

Lidocaine

Bolus Dose = 4 mg/kg

Infusion = 0.8 mg/kg/hr

102
Q

Local Anesthetics

Max Doses (bolus)

Lidocaine with Epinephrine

A

Lidocaine with Epinephrine

Bolus dose: 7 mg/kg

103
Q

Local Anesthetics

Max Doses (bolus and infusion)

Ropivacaine

A

Ropivicaine

Bolus: 3 or 2.5 mg/kg

Infusion: 0.3 mg/kg/hr

104
Q

Local Anesthetics

Max Doses (bolus and infusion)

Bupivacaine

A

Bupivacaine

Bolus: 2.5 mg/kg

Infusion: 0.2 mg/kg/hr

105
Q

Local Anesthetics

Max Doses (bolus and infusion)

Chloroprocaine

A

Chloroprocaine

Bolus: 12 mg/kg

Infusion: 12 mg/kg/hr

106
Q

RR Range:

Preterm neonate

A

40-70

107
Q

RR Range:

0-12 months

A

24-55

108
Q

RR Range:

1-5 years

A

20-30

109
Q

RR Range:

5-9 years

A

18-25

110
Q

RR Range:

9-12 years

A

16-22

111
Q

RR Range:

12 years and older

A

12-20

112
Q

Developmental Considerations

A
  • 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
113
Q

Preoperative Evaluation

A
  • 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
114
Q

Airway History

A
  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?
115
Q

Airway History

Presence of URI could indicate what?

A
  • Presence of URI = predisposition to
    • Coughing
    • Laryngospasm
    • Bronchospasm
    • Desat during anesthesia
    • Postintubation subglottic edema
    • Postop desat
116
Q

Airway History

Snoring or noisy breathing could indicate what?

A
  • Snoring or noisy breathing could indicate:
    • Adenoidal hypertrophy
    • Upper airway obstruction
    • OSA
    • Pulm HTN
117
Q

Airway History

Presence/nature of cough could indicate what?

A
  • Presence/nature of cough could indicate:
    • “Croupy” cough may indicate:
      • subglottic stenosis
      • previous tracheoesophageal fistula repair
    • Productive cough may indicate:
      • bronchitis
      • pneumonia
118
Q

Airway History

Past episodes of croup could indicate what?

A
  • Postintubation croup
  • Subglottic stenosis
119
Q

Airway History

Inspiratory stridor, usually high pitched, could indicate what?

A
  • Inspiratory stridor, usually high pitched could indicate:
    • Subglottic narrowing
    • Laryngomalacia
    • Macroglossia
    • Laryngeal web
    • Extrathoracic foreign body
    • Extrathoracic tracheal compression
120
Q

Airway History

Hoarse voice could indicate what?

A
  • laryngitis
  • vocal cord palsy
  • papillomatosis
  • granuloma
121
Q

Airway History

Asthma and bronchodilator therapy could indicate what?

A

Bronchospasm

122
Q

Airway History

Repeated pneumonias could indicate what?

A
  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
123
Q

Airway History

Previous anesthetic problems, particularly related to airway, could indicate what?

A
  • difficult intubation
  • difficult mask ventilation
  • failed or problematic extubation
124
Q

Airway History

Atopy, allergy could indicate what?

A
  • increased airway reactivity/resistance
  • increased propensity to desat
125
Q

Airway Assessment

History of a congenital syndrome could indicate…

A

Many are associated w/ DA management

126
Q

Airway Assessment

Parents smoke in the house could indicate…

A

increased airway reactivity

127
Q

History:

Resp focus

A
  • 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?
128
Q

History:

CV focus

A
  • 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?
129
Q

Physical Exam

A
  • 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
130
Q

Fasting Guidelines

A
  • 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
131
Q

Room Setup

A
  • 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
132
Q

Premedication

A
  • 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
133
Q

Mask Ventilation

A
  • Sniffing position is critical
  • Avoid pressure on soft tissue in submental triangle
  • Jaw thrust
  • Low threshold for 2-person ventilation
134
Q

Induction

A
  • 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
135
Q

Inhalation Induction

A
  • 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
136
Q

RSI in Children

A
  • 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
137
Q

Airway Management

A
  • 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
138
Q

Where should the ETT be located on CXR?

A

Midway b/t cords and carina

139
Q

LMA use

A
  • Used during routine surgeries & as a rescue device for failed intubation
    • Low failure rate for insertion (< 1%)
140
Q

LMA Contraindications

A
  • 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
141
Q

Laryngeal Mask Sizes and Weights

A
  • 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
142
Q

ETT Size, cuff pressure monitoring

A
  • 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
143
Q

Risk factors associated w/ acquired SGS:

A
  • Risk factors associated w/ acquired SGS:
    • Trauma during intubation
    • ETT movement during intubation
    • Prematurity
    • Presence of infection at time of intubation
144
Q

Ventilation

A
  • 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
145
Q

Laryngospasm

A
  • More frequent in infants; risk decreases w/ increasing age
  • Reflex closure of false & true vocal cords
146
Q

Symptoms of laryngospasm

A
  • 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
147
Q

Laryngospasm risks

A
  • Recent URI
  • secondhand smoke
  • stimulation while “light”
  • secretions in airway
148
Q

Laryngospasm treatment

A
  • 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
149
Q

What is the leading cause of bradycardia in children?

A

Hypoxia

150
Q

“Other” causes of bradycardia in children

A
  • 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
151
Q

Bradycardia in infants

A

< 100 bpm

152
Q

Bradycardia in 1-5 yo

A

< 80 bpm

153
Q

Bradycardia in >5 yo

A

< 60 bpm

154
Q

Treatment for bradycardia in children

A
  • Treat cause: think oxygenation and ventilation first!
  • Atropine if vagal origin 0.02 mg/kg IV
  • Epinephrine if decompensated 10 mcg/kg
155
Q

3 phases of emergence

A
  • 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
156
Q

Position of transport/recovery

A
  • Transport in lateral decubitus position “recovery position”
157
Q

Emergence

PACU complications

A
  • 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%
158
Q

Emergence

A
  • 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
159
Q

Regional Anesthesia

A
  • 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
160
Q

Increased risk of PONV in children in certain surgeries:

A
  • Hernia
  • Orchidopexy
  • T&A
  • Strabismus
  • Middle ear
  • Laparoscopic
161
Q

Prevention of PONV in children

A
  • 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
162
Q

Population of children w/ peak incidence of PONV

A

Females

Age 10-16

163
Q

Emergence Delirium

A
  • 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
164
Q

Factors that affect incidence of emergence delirium:

A
  • young age
  • previous surgery
  • type of procedure
  • type of anesthetic
  • level of preop anxiety is predictive
165
Q

What age does emergence delirium peak?

A

Age 2-6 years

166
Q

Emergence delirium is most common with what?

A

Most common after Sevo (then Des)

167
Q

How long does emergence delirium last?

A
  • Usually lasts ~ 10-15 min
    • Protect from self-harm

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