Peds Flashcards
2 categories which have highest rate of adverse events during postoperative period
Neonates
Infants <12m
10x increased incidence of morbidity and mortality in neonates compared to older pediatric patients
Ductus Arteriosus connects
pulmonary artery to Aorta
Ductus venosus
Umbilical vein to IVC (bypassing liver)
Foramen Ovale
Right Atrium to Left ATrium
Umbilical arteries (2)
Umbilical vein (1)
Carries deoxygenated blood from fetus back to mother
carries oxygenated blood
Umbilical cord cut and clamped marks the start of ________ . The flow to the ______ is markedly reduced which causes its closure
↑ flow out LVOT, DA senses ↑ pO2, PGE from placenta ↓ & DA closes
transitional circulation
Ductus Venosus
Transitional circulation - System goes from ____PVR to ___ PVR and ___ SVR to ___ SVR
LOW PVR (↓ resistance) to ↑ PVR
High ↑ SVR to Low ↓SVR
Transitional Circulation - What happens in the Lungs?
Amniotic fluid replaced by air; (raising alveolar O2 tension) and fluid is resorbed.
Blood flow to the lungs increases
Hypoxic vasoconstriction in lungs reverses
Transitional Circulation - ↑ blood return to LA which ______
(↑ pressure) causing PFO to close
Hyperoxia and hormonal factors cause ____ to close
DA
Factors that increase PVR, may delay transition from fetal circucation AKA persistent fetal circulation.
Lung disease
pulmonary hypoplasia
Acidosis
Hypoxemia
PpHTN develops a. result of
BPD and Cardiac Disease
Persistant PHTN in the newborn is characterized by:
A sustained elevation of PVR
decreased perfusion to the lungs
DA and FO remain open
Continued R –> Shunt
R and L ventricular dysfunction with diminished CO
Managing PHTN
Nitric
HF ventilation (oscillation)
O2
Surfactant (pre-term)
Maintain Normal HCT - viscous blood triggers vasoconstriction
use of lung recruitment strategies, such as high-frequency ventilation and exogenous surfactant administration, is particularly important in infants with PPHN associated with parenchymal disease, but has limited impact in infants with primary vascular disease
Meds to treat PHTN
PDE-5 inhibitors
Sildenafil; Tadalafil
Meds to treat PHTN
Endothelin Receptor Antagonists:
Bosentan
Meds to treat PHTN :
Prostanoids
Prostacyclin, Treprostinil
when surgery is necessary, all neonates require
____or _____ anesthesia
General or Regional
Postop apnea is a common occurrence in young infants who are ________ and observation for______ is necessary
< 60 weeks’ post-conceptual age
24 hours
fetal circulatory system relies on the ______ for delivery of oxygen and transport of CO2.
The ________ is the functional unit of the placenta
placenta
chorionic villus
Fetal circulation is characterized by high pulmonary vascular resistance
and low systemic circulatory resistance
Uninflated atelectatic lungs and hypoxic vasoconstriction
high flow and low impedance of placental vessels
With the cessation of placental blood flow, aortic pressure ______. Clamping of the umbilical vein ______ SVR. PVR falls with lung expansion, and increasing
PaO2 produces _______ resulting in further decreases in PVR. These changes in systemic and pulmonary blood flow produce corresponding changes in intracardiac pressure.
_____ in RAP with accompanying increases in LAP change the direction of blood flow through the FO, resulting in the ______ of the FO. THE FO may reopen if RAP is > LAP (e.g., pulmonary hypertension),
INCREASES
DOUBLES
pulmonary vasodilation
Decreases, Increases ,
functional closure
Term used to describe permanent closure of the FO within 2-3 months
Anatomical closure
In utero, what maintains the patency of the DA?
prostaglandins
Within a few hours after birth, the muscular wall
of the DA constricts, preventing retrograde blood flow from the ______ into the _______ artery.
Functional closure of the DA aka _________ occurs within ______.
Anatomic closure aka -_________ requires _______
aorta, pulmonary
(thrombosis) , 1 to 8 days
(Fibrosis of the DA), 1 - 4 months
Closure of the DA is precipitated by the increase in SVR and decrease in PVR. Closure of the DA is also influenced by elevations in the systemic PaO2 that occur after birth.
Persistent fetal circulation is common in ______ and infants with ____________,
preterm infants & infants with metabolic derangements
examples of metabolic derrangements:
asphyxia, sepsis, meconium aspiration, CDH
Primary precipitating factors of PPHN
Hypoxemia, Acidosis, Pneumonia, and Hypothermia
Oxygenation, correcting acidosis, and maintenance of normothermia will attenuate the increase in PVR
Accordingly, the neonatal heart is _____ capable of generating a response to an increase in resistive load (increase in stroke volume) and is dependent on _______ for contractility.
Despite this immaturity, the neonatal heart is capable of limited increases in SV up to left atrial pressures of ________mm Hg when afterload remains low.
LESS
free ionized calcium
10-12
neonatal heart is operating near the _____of the Frank-Starling curve because there is
a _________
peak
- limited reserve to increases in both preload and afterload.
pediatric cardiac output is highly
dependent on ________.
Heart Rate
In the s/o bradycardia atropine may be less effective b/c marked increases in heart rate fail to a large extent to produce further increases in _______
This is the more important intervention:
CO
volume expansion (VE)
The combination of hypovolemia and bradycardia produce dramatic decreases in cardiac output that threaten organ perfusion. ________ rather than
atropine increases contractility and heart rate and is warranted for the treatment of bradycardia and decreased CO in pediatric patients.
EPI
The __________ is not completely developed,
limiting the neonate’s ability to compensate for hypotension with the reflex tachycardia as would be expected in the older child and adult
baroreceptor reflex
Autonomic innervation of the neonatal heart is predominantly controlled by the _______
This predominance produces bradycardia that may occur with minor clinical interventions such as
pharyngeal suctioning and laryngoscopy
parasympathetic nervous system.
The ECG axis of a neonate is shifted to the ____ but shifts to the ______ with maturation and accompanying hypertrophy of the left ventricle
Right
Left
Hypotension is defines as:
____ in term neonates
____ in infants 1-12mo
____ in children 1-10
____ in children >10
< 60 mm Hg in term neonates (0 to 28 days)
< 70 mm Hg in infants (1 month to 12 months)
< 70 mm Hg + (2 × age in years) in children 1-10 years
< 90 mm Hg in children >10 years of age
EBV
-Premature
-Newborn (less than 1 month of age)
-Infants 3 months to 3 years of age
-Children older than 6 years of age
-Adults
Premature - 90–100
Newborn (less than 1 month of age) - 80–90
Infants 3 months to 3 years of age - 75–80
Children older than 6 years of age - 65–70
Adults 65–70
Avg HR
Neonate
12 months
3 yr
12 yr
Avg Hr
140
120
100
80
Normal BPs
Neonate
12 months
3 yr
12 yr
70–75 / 40
95 / 65
100 / 70
110 / 60
A decrease in erythropoiesis and decreased life span of the newborn’s red blood cells (RBCs)
produces a progressive decrease in hemoglobin, which peaks approximately between _______
3 and 4 months of age.
The period of “physiologic anemia of infancy” does not compromise the oxygen delivery to tissues, because the oxyhemoglobin dissociation curve shifts to the _____ and RBC concentrations of 2,3-diphosphoglycerate increase
Right
Fetal hemoglobin is replaced by adult hemoglobin during the first _______ producing a rightward shift of the oxyhemoglobin dissociation curve as compared to the neonatal period.
3 to 6 months
Premature infants should receive _______ and ______ Prophylaxis because the concentration of vitamin K–dependent clotting factors _____________ are 20% to 50% of adult levels.
Premature infants have lower levels of vitamin K–dependent clotting factors.
iron and vitamin K prophylaxis,
II, VII, IX, and X
Maternally ingested drugs such as ________ may precipitate the development of a coagulopathy
warfarin and isoniazid
Newborn’s blood volume is dependent on the ________
Delaying umbilical cord clamping in premature infants for ______ stabilizes transitional circulation, decreases the need for inotropic medications and reduces
blood transfusions, necrotizing enterocolitis (NEC), and intraventricular hemorrhage.
time of cord clamping (transfusion from the placenta).
30 seconds
the process of alveolar formation is accelerated between ——– and increases to 200 to 300 million between 8 and 10 years of age
12 and 18 months postnatally
THSE are responsible for the production and secretion of surfactant, which begins between 22 and 26 weeks, and concentrations peak between 35 and 36 weeks’ gestation.
Type II pneumocytes
The treatment for infantile respiratory distress syndrome includes
synthetic surfactant,
continuous positive airway pressure (CPAP)
mechanical ventilation
Increases in PaO2 will _____ the ventilatory response in the newborn, whereas a decreased PaO2 will _____ the ventilatory
response.
depress
increase
THE larynx is located more cephalad and anterior, extending from C2 to C4
The anesthetic implication of the more cephalad location is that placing a neonate in the sniffing position for laryngoscopy and intubation will ________
move the larynx in an anterior direction, potentially increasing the difficulty of intubation
The placement of a rolled towel under the
shoulders aids in the visual alignment of which 3 axis’ during laryngoscopy?
oral, pharyngeal, and
laryngeal axes
Type 1 muscle Fibers are ______ muscle Fibers and are _______ fatigue. These fibers are essential for sustained ventilatory activity. Type 2 muscle fibers, also known as ______ muscle fibers, are fast twitch but ______
slow twitch , resistant to
fast twitch, fatigue rapidly
The reflex that causes respiratory depression and/or apnea in the newborn after stimulation of the carina and/or the SLN, following upper airway obstruction or following sustained lung inflation
Hering-Breuer reflex
airway resistance in the smaller airways is ______
increased in newborns
Lack of development of_______ may actually increase the intensity and duration of the painful stimulus. It has been suggested that newborn infants may develop prolonged responses to painful
procedures that far outlast the stimuli by hours or days. Procedures that are painful to infants include:
sensory pain fibers detected as early as
inhibitory pain tracts
Circumcision
Heel lancing
7 weeks
What are the 2 major fontanelles?
________ fontanelle closes by 2 years of age.
______ fontanelle closes at approximately 4 months. ________ fontanelle can be used to assess increased ICP (seen as ________ of the fontanelle, and also dehydration, seen as ________ fontanelle).
Anterior and Posterior
Anterior closes by 2
posterior by 4 months
anterior
bulging anterior
sunken anterior
The blood-brain barrier (BBB) is immature until approximately _______.
higher concentrations of medications and toxins that would be impermeable to the adult brain can result in ______ cerebral concentrations throughout infancy.
1 year
higher
Nerve cells within the spinal cord mature until
completion at 6 to 7 years of age.
. Being mindful
of this information is imperative to providing safe anesthesia during
placement of a spinal or caudal anesthetic. By age 8, the spinal cord
approximates the adult and ends at L1.33 Fig. 52.5 illustrates the comparison between the adult and infant spinal anatomy.
As the pediatric patient grows, the conus medularis and the dural sac migrates _______ Although the
exact vertebral level of these structures varies slightly, the conus medularis terminates between _______ in neonates. The dural sac ends between ________ until approximately 6 years of age
cephalad
conus medularis L2 and L3
dural sac S2 and S3
the neonate, there are _______stores of glycogen,
making hypoglycemia a major source of morbidity
decreeased
S&S of hypoglycemia in a neonate
apnea, hypotension, bradycardia, convulsions, and brain injury
CBF in the premature infant is and in older children approaches the adult level of 100 mL/100 g per minute.
40 mL/100g/minute,
Complete loss of cerebral autoregulation may occur with
hypoxia, severe, hypercapnia (> 80 mm Hg), BBB disruption after head trauma, SAH or intracerebral hemorrhage, or cerebral ischemia, or after the administration of high concentrations of potent inhalation anesthetics and vasodilators (nitroprusside).
Blood vessels are fragile ,predisposes neonates to _______
Intracranial hemorrhage may be precipitated by ____________________________
intravenous administration of _______ solutions may damage these fragile vessels.
concentrations of sodium bicarbonate that
would be administered to an adult _______ be administered to neonates.
ICH
hypoxia, hypercarbia, hyperglycemia, hypoglycemia,
hypernatremia, and wide swings in arterial or venous pressure
hypertonic
should not
If bradycardia occurs, the anesthetist should focus on ______ first as possible cause.
hypoxia
Epiglottis is ______
Arytenoids are _______
Subglottic region_______ glottis
Cartilages _______ forming a _______ shape
ETT may pass through glottis but _________
______ tongue – makes layrngoscopy and mask ventilation more difficult
Larynx is more _____
occiput is _______
Neck is ______
Epiglottis is short and small
Arytenoids are large
Subglottic region smaller than glottis
Cartilages telescope forming a conical shape
ETT may pass through glottis but may not be able to be advanced
Large tongue – makes layrgoscopy more difficult makes mask ventilation more difficult
Larynx is more anterior airway
Large occiput
shorter neck
risk of mainstem much ______in peds d/t short trachea and bronchus
higher
narrowest portion of airway is ________ which is below cords
cricoid cartilage
Respiratory
Pharmacologic
Neurogenic
Metabolic
Respiratory - (any cause resulting in hypoxia)
* Airway obstruction (laryngospasm, postextubation croup)
* Bronchospasm
* Pulmonary aspiration
* Inadequate oxygen delivery system
* Pneumothorax
Pharmacologic
* Inhalation anesthetics
* Succinylcholine
* Anticholinesterases
Neurogenic
* Celiac reflex
* Oculocardiac reflex
* SLNr/rRLN nerve stimulation (during intubation, airway manipulation)
Metabolic
* hypoglycemia
* Anemia
* Hypothermia
* Acidosis
Breathing in Neonate
FRC is
Diaphragm is ______ instead of dome shaped
______ breathing and _______common
Immature responses of resp control center to _______ or _________ stimuli and fatigue
↑Metabolic rate and O2 consumption + ↓FRC=________
Airway resistance is greatest in _______
Decreased
Flat
apnea and periodic breathing are common
hypercarbia
hypoxia
rapid desaturation
Neonates
NMJ immature
ACh receptors have __________ opening, causing muscles to be ________ depolarized
________for non depolarizing muscle relaxants
prolonged
more easily
greater affinity
Myelination not complete until age 3
Associated with which reflex?
Moro and Grasp reflex
Most significant neurologic growth & development occurs in _____
utero
Cerebral cortex and brainstem complete by
1 yr
myelination of nerve cell development complete at _____
Nerve cells in spinal column mature until _______
3 yr
7 yrs
risk of mainstem much ______ in peds d/t short trachea and bronchus
higher
Renal Function
GFR much _____ in preterm neonates compared to full term neonates
Unable to tolerate fluid overload
Able to excrete water and sodium but cannot conserve electrolytes as effectively - known as ______
renal function reaches adult levels by end of _______
lower
obligate sodium excreters
By end of year 1- renal function reaches adult levels
first year
High fluid requirement 2/2
____ metabolic rate
______ body composition of water
TBW ______ in neonate and babies
_____ insensible losses from Evaporation
ratio of : BSA : body-weight (4x higher)
skin immature
high
increased
high
high
High
Surge of +_______ at birth causes oliguria over the first few days.
ADH
This conditions is the result of RBC breakdown and
active suppression of enzymes needed in this process
immaturity of stage II metab (conjugation)
Treatment: phototherapy & exchange transfusion (rare)
Can cause encephalopathy (kernicterus)
Physiologic vs. pathologic
Hyperbilirubinemia
Metabolically driven mechanism to generate heat; does not involve musculature; SNS stimulation enhances metabolism of brown fat to increase heat production; Metabolic by products are also produced
Non-shivering thermogenesis (NST)
WHy cant neonates generate heat?
Large surface area
Lack of SQ tissues
Inability to shiver
Thermoregulatory response is inhibited by anesthetic agents Core body temp decreases between 1-3 degrees C
Heat loss occurs more rapidly in neonates because of
their increased body surface/body weight ratio. The skin (particularly of the premature neonate) is thinner and has less subcutaneous tissue,
increasing the rate of ______ heat loss
Hypothermia stimulates the release of NE which acts on brown fat to uncouple oxidative phosphorylation Heat production follows an increase in the basal metabolic rate stimulated through the release of anterior pituitary hormones. The result of NST is not only heat production but also the metabolic biproducts of brown fat metabolism namely acetone, acetoacetic and β-hydroxybutyric acid. Metabolic acidosis can rapidly lead to bradycardia, and cardiac arrest in a neonate.
evaporative heat loss
contributors to periop hypothermia
Cold OR
Vasodilation (anesthetic)
IV fluids
Evaporate heat loss from body
Irrigation solutions
Inspiration of cool anesthetic gases
CO2 from insufflation
Result of unstable respiratory rhythm
and immature/abnormal response of hypoxia & hypercarbia
Treated with: CPAP & caffeine 5 to 10 mg/kg.
Apnea of Prematurity (AOP)
Methylxanthines such as caffeine are presumed to work through blockade of adenosine receptors.
AOP typically resolves with maturation suggesting in
Increased myelination of the brainstem
General rules of anesthesia in premature infants
s.
GA
induction: sevo
Maintenene: des or sevo (sevo preferred)
Spinal or caudal anesthesia can also be performed.
Transversus abdominis plane (TAP) blocks can be used safely to decrease the incidence of postoperative pain and decrease the postoperative need for opioid
Non-opiod medications:: ketorolac and acetaminophen preferable to reduce the risk of perioperative complications related to inadequate ventilation
There is a risk of _________ in neonates after a TAP block.
LAST
Due to the decreased hepatic metabolism and renal excretion of IV medication in the neonate, the dose of LA administered must be calculated to avoid LAST
Extubate when the infant is _____, and shows adequate _______ effort, with vigorous purposeful movement.
All infants under _______ post-menstrual age (PMA) should be monitored postoperatively with an oxygen saturation monitor and an abdominal pressure transducer.
Infants over 62 weeks PMA with a significant history of apnea or respiratory disease also should be monitored.
Infants over 62 weeks’ PMA can be discharged following minor surgery after an appropriate period of recovery (minimum ______) if they are stable and otherwise healthy.
Higher-risk infants require _____ of monitoring
awake, respiratory
62 weeks
4hrs
24hrs
Abnormal growth of blood vessels in the retina
Can lead to blindness
Anesthetic Considerations:
O2 sats- 92-98%
Atropine (increase IOP)
Retinopathy of Prematurity
MAC is higher at birth than in adults and increases until peaking at _______. The values at 1 year of age are closer to the adult
Neonates have a somewhat lower MAC,
which peaks at approximately
3-6 months
30 days of age
SMART TOTS recommendations
Minimize duration of anesthesia
Use short acting drugs
Combine general anesthesia and multimodal pain therapy
clinical implication of a right-to-left intracardiac
shunt is that inhalation induction can require _____ prior to loss of consciousness.
In the presence of a left-to-right shunt, there is a _____ in inhalation anesthetic uptake
more time
minimal increase
IV anesthetic agents are readily taken up by tissues in vessel rich gourp and are subsequently redistributed to tissues less well perfused (muscle and fat).
IV administered drugs may have a ______ duration of
action in neonates and infants because of decreased % of muscle and fat.
The CNS effects of opioids may ______ because of the immaturity of the BBB.
_______ is well tolerated even in the most critical neonates. It is now understood that appropriate anesthetic drugs are necessary for neonatal procedures.
prolonged
also be prolonged
fentanyl
REVERSAL
Signs NMBA is wearing off:
Another measurement is the ability to generate a
maximum negative inspiratory force (MIF) > _____H2O. An MIF of at least___cm H2O has been found to correspond with leg lift, which is indicative of the adequacy of ventilatory reserve required before tracheal extubation.
Observing flexion of the elbows and hips,
knee to chest movements
Return of abdominal muscle tone,
presence of facial grimacing
MIF of > (- 25)
a MIF of (-32)
Neonates are capable of generating an MIF of −70 cm H2O with the firrst few breaths after
birth
If a peripheral nerve stimulator is used, the train-of-four should demonstrate the standard 90% recovery.
2 anticholinesterase drugs used for reversal of neuromuscular blockade are
neostigmine DOSE:
Edrophonium DOSE
Neostigmine is routinely administered as it is more potent and, and has a greater efficacy for inhibiting cholinesterase.
An anticholinergic agent should be given prior to the anticholinesterase in neonates to prevent cholinergic side effects such as______ and ______
Anticholinergics:
- atropine DOSE
- glycopyrrolate. DOSE:
neostigmine DOSE: (0.05–0.07 mg/kg)
Edrophonium DOSE (0.5–1.0 mg/kg).
-bradycardia and bronchopasm
- atropine DOSE (0.02 mg/kg)
- glycopyrrolate. DOSE: (0.01 mg/kg)
Due to similarities in time to onset and duration of action,
glycopyrrolate is usually combined with neostigmine
atropine usually combined with edrophonium.
Premature neonates have a reduced ability to metabolize the preservatives benzyl alcohol and sodium benzoate.
Numerous anesthetic and nonanesthetic medications contain preservatives such as benzyl alcohol.
This accumulation of benzoic acid can result in benzyl alcohol gasping syndrome, and can manifest as:
- gasping respirations
- metabolic acidosis
- multiple organ system failure.
These agents can produce severe CNS toxicity, seizures, and permanent brain damage.
The use of preservative-free drugs and solutions is essential when possible
Most newborns require 2–4 mg/kg per min of glucose .
* SGA/LGA infants may require greater than 15 mg/kg per min on days 1 to 3 of
life.
* Glucose tolerance may fluctuate significantly in very low- and extremely
low-birth-weight (VLBW and ELBW) infants.
Preterm and SGA neonates can have a glucose requirement of 8 to 10 mg/kg per min to prevent hypoglycemia.
Glucose as a D5 or D10 solution followed by a 10% to 15% dextrose solution can be titrated to maintain a serum glucose level greater than 40 mg/dL.
It is as important to avoid hyperglycemia,
which can result in intraventricular hemorrhage, osmotic diuresis, dehydration, and release of insulin, leading to hypoglycemia
Electrolyte abnormalities are often seen in preterm neonates.
Electrolyte abnormalities are often seen in preterm neonates.
Hypernatremia may result if water loss is greater than sodium depletion combined with abnormal renal tubular function. Hypokalemia can result from respiratory alkalosis or aggressive diuresis.
Hyperkalemia
can be caused by infusion of large amounts of potassium-containing fluids.
When saturated, every 4” x 4” surgical sponge= approximately _______ of blood loss
10 ml
ROS - cardiac ask about transplant and if yes, assume
fixed HR, insensitivity to anticholinergic drugs
laryngescope sizes
New born Miller 0
1 mo - 12 mo Miller 1 or Wis 1.5
12 mo - 3 yrs Wis 1.5 or Miller 2
3 yr - 12 yr Miller 2 or Mac 2
12 - 16 y Miller 2 or Mac 3
> 16 yrs. Miller 3 or Mac 4
Straight blade
Wide flat tip
18-24 months (usually preferred)
Wis 1.5 = between a Miller 1 and 2
Miller 1 (100mm) vs Miller 2 (152mm)
Wis Hipple
115mm in length
Video
CMAC Storz
Miller 0
Miller 1
McGrath
Mac 1
Mac 2
child with an active or resolving URI has increased airway reactivity, a propensity for the development of atelectasis and mucous plugging of the airways, and the potential to experience postoperative arterial hypoxemia In addition, bronchial reactivity may persist for 6 to 8 weeks after a viral lower respiratory tract infection
differentiate between a chronic allergic or an acute infectious presentation and to determine whether there is lower airway involvement
Elective surgery should be postponed for children who have a cough and pharyngitis accompanied by fever and wheezing.Children with a fever of 38.0°C and higher, malaise, wheezing, dyspnea, rhonchi, nasal congestion, and a productive cough are signs of an acute infection necessitating the postponement of surgery
However, for those patients who require ETT placement for anesthesia, especially children under 1 year of age, it is important to identify risk factors such as passive smoke exposure and underlying conditions (e.g., asthma, chronic lung disease) because these children may benefit from a slight delay of 2 to 4 weeks. Finally, those patients with resolving respiratory tract infections with severe symptoms or mild symptoms should have the same relative waiting periods fulfilled (i.e., 2 to 4 weeks after resolution of minor URI and 4 to 6 weeks after resolution of severe URI or LRI) to minimize the risks of proceeding with surgery
Midazolam is the most commonly used premedicant in the pediatric patient. $is short-acting, benzodiazepine produces amnesia and anxiolysis and in suffcient dosages may also produce sleep (hypnosis). Other medications that have been used with success include ketamine, clonidine, and pregabalin
PO Midazolam dose: _____
PO Ketamine dose: ____
Dexmedetomidine
-IV and IN
Midazolam (0.25-1mg/kg PO)
Ketamine (5-10mg/kg PO)
Dexmedetomidine
- 2mcg/kg IN
- 0.5mcg-1mcg/kg IV
(EMLA cream) is a combination of lidocaine (2.5%) and prilocaine (2.5%) that can be applied to the skin causing numbness to help facilitate IV catheter placement. $e medication should be applied well in advance (30 to 60 minutes) to achieve an adequate e!ect. Methemoglobinemia is a rare side e!ect that is associated with prilocaine toxicity.
“Ketamine-dart” 4-6mg/kg
Prepare parents for involuntary movements, nystagmus
Consider benzodiazepine
kids who arent cooperative
MaC
Sevo:
inductions
Iso:
Des:
Sevo 3%
not a potent airway irritant- used for inhalational
Depresses MV And at high doses RR and apnea will occur At high doses here is greater degree of inhibition of myocardial contractility and increased PVR
Iso: 1.6%
Des: 9%
Obstructive lesion characterized by “olive-shaped” enlargement of pylorus muscle
More common in males
Diagnosed between 2-12 weeks
Symptoms:
Nonbilious postprandial emesis-projectile
Palpable pylorus
Visible peristaltic waves
Procedure: pyloromyotomy
Considered medical emergency
Initial management – optimize!
Correct hypovolemia, acid-base imbalance & electrolytes
HYPOCHLOREMIC, HYPOKALEMIC METABOLIC ALKALOSIS
Anesthesia Management:
Prior to induction-suction to empty bellies – OGT thoruhg mouth or nose;
Pre-oxygenate, RSI
GETA required to protect airway CUFFED TUBES ONLY
Inhalational agents & IV agents
Laparoscopic procedure
pyloric stenosis
Prevalent in pre-term infants
Problem: possibility of incarceration of the small bowel in the defect
Colon ischemia and death
Injury to ipsilateral testicle
Procedure: open or laparoscopic
Bilateral sides examined
EVEN IF ONLY ON ONE SIDE, CONSENT IS FOR EXPLORATION OF BOTH SIDES.
Anesthetic is provider preference
Inhalation vs IV
Mask, LMA, ETT
+/- caudal – BEST FOR PAIN MANAGEMENT OF INGUIONAL HERNIA
ETT if laparoscopic approach
Post op apnea in neonates - may benefit from spinal
Inguinal herna
Pre-natal diagnosis – PICKED UP ON ECHO
Defect of the diaphragm that allows extrusion of the abdominal contents into the thoracic cavity
1:2500 live births
Herniated contents is space occupying and hinders normal lung growth and development
80% on left side
WHEN LUNG CAN’T DEVELOP PROPERLY Causes reduced bronchial size, less branching, decreased alveolar surface area and abnormal pulmonary vasculature
Results in increase pulmonary pressures AND THEY ARE AT RISK FOR PHTN
Neonate presents after birth with
dyspnea, tachypnea, cyanosis, absence of breath sounds on affected side and retractions
TEAM STANDING BY TO INTUBATE THEM
40-60% of neonates have other abnormalities (cardiac)
Historically considered emergent=> stabilization of pulmonary HTN IS NOW PRIORITIZATION
Ventilation strategies pre-operatively
Permissive hypercarbia – fetus’ are used to a lower PO2 levels
and even though CO2 vasoconstricts
HIGH FREQEUNCY OSCILLATING VENTILATION
Treatment options:
Prenatal intervention may be offered in predicted poor outcome patients
Laparotomy, thoracoscopic repair & laparoscopic approaches can be used
Anesthetic management
Most patients will come to OR intubated
RSI
Gentle ventilation (stomach insufflation)
N2O should be avoided (GI tissue expansion)
Arterial Line
Pre/Post ductal pulse ox (R-L shunt)
Limit conditions that will increase PVR
Post-op ventilation (48-72hrs)
CDH
