Peds Flashcards
When does renal tubular function equal that of an adult?
Renal tubular function achieves full concentrating ability at ~2 years old
What three kidney values are lower in neonates than adults?
GFR
Renal perfusion pressure
Diluting/concentrating ability
When does GFR improve to adult levels in the neonate?
GFR improves in the first few weeks of life, but isn’t fully mature until 8-24 months of life
Describe cyanotic shunt HD goals:
Maintain SVR
Decrease PVR
Increase preload
Maintain HR and contractility
Describe cyanotic shunt hd goals:
Avoid increased SVR
Avoid decreased PVR
Right to left shunt examples:
Tetralogy of Fallot
Truncus arteriosus
Transposition of the great vessels
Tricuspid displacement (Ebstein’s anomaly)
Epiglottitis vs Laryngotracheobronchitis: Organism
Bacterial vs viral
Epiglottis vs Laryngotracheobronchitis: Age
2-6 yrs vs < 2 yrs
Epiglottis vs Laryngotracheobronchitis: Onset
Rapid (<24 hours) vs Gradual (24-72 hours)
Epiglottis vs Laryngotracheobronchitis: Region affected
Supraglottic: epiglottis, vallecula, arytenoids, aryepiglottic folds
Laryngeal structures below vocal folds
Epiglottis vs Laryngotracheobronchitis: Neck X-ray
Swollen epiglottis (Thumb sign) with lateral X-ray
Subglottic narrowing (Steeple sign) with frontal X-ray
Epiglottis vs Laryngotracheobronchitis: Clinical Presentation
High grade fever
Tripod assisted breathing
4 D’s: drooling, dyspnea, dysphagia, dysphonia
Low-grade fever
Barking cough
Vocal hoarseness
Inspiratory stridor
Retractions (suprasternal, substernal, intercostal)
Epiglottis vs Laryngotracheobronchitis: Treatment
Oxygen
Urgent airway management: tracheal intubation or tracheostomy
Abx if bacterial
Induction with spontaneous respirations (CPAP 10-15 cmH2O to prevent airway collapse)
ENT MUST BE PRESENT
Oxygen
Racemic epinephrine
Corticosteroids
Humidification
Fluids
Intubation rarely required
Racemic epinephrine dosing
0-20 kg = 0.25 mL of 2.25% racemic epi in 2.5 mL of NS
20-40 kg = 0.5 mL of 2.25% racemic epi in 2..5 mL of NS
> 40 kg = 0.75 mL of 2.25% racemic epi in 2.5 mL of NS
Treatment for postintubation croup:
Racemic epi
Cool and humidified O2
Dexamethasone 0.25-0.5 mg/kg IV (max effect 4-6 hours)
Heliox - increased laminar flow
Is not infectious so abx not indicated
Airway risks in peds with URI:
increased airway reactivity (bronchospasm)
laryngospasm
mucous plugging in airway
atelectasis
desaturation events
postoperative hypoxemia
When to postpone elective surgery due to URI:
purulent nasal drainage
fever >38C or 100.4F
lethargic
persistent cough
poor appetite
wheezing and rales that don’t clear with cough
child <1 year or previous premie
When to proceed with elective surgery despite URI:
clear rhinorrhea
no fever
active
appears happy
clear lungs
older child
How long should you wait to anesthetize a child after URI?
2-4 post onset of symptoms
but
pulmonary complications can persist for up to 6-8 weeks
What medication can help prevent post-intubation croup?
Dexamethasone 0.25 - 0.5 mg/kg IV
Foreign body aspiration classic triad:
cough
wheezing
decreased breath sounds on affected side (usually the right)
What do you hear with supraglottic obstruction?
stridor
What do you hear with subglottic obstruction?
wheezing
Pneumonic for large tongue
Big Tongue
Beckwith sydrome
Trisomy 21
Pneumonic for small/underdeveloped mandible
Please Get That Chin
Pierre Robin
Goldenhar
Treacher Collins
Cri du Chat
Pneumonic for cervical spine anomaly
Kids Try Gold
Klippel-Feil
Trisomy 21
Goldenhar
What characteristics contribute to the difficult airway of a Down Syndrome patient?
small mouth
large tongue
high arched and narrow palate
mid face hypoplasia
AO instability (C1 & C2 subluxation/avoid neck flexion)
subglottic stenosis (increased risk postintubation croup->use smaller ETT)
OSA
chronic pulmonary infection
What CV affects accompany Down Syndrome?
AV septal defect (most common)
VSD (second most common)
bradycardia during sevo induction (tx=anticholinergic + increase sevo carefully)
low levels of circulating catecholamines
VACTERL association
Vertebral defects
imperforated Anus
Cardiac anomalies
Tracheoesophageal fistula
Esophageal atresia
Renal dysplasia
Limb anomalies
CHARGE association
Coloboma
Heart defects
choAnal Atresia
Restricted growth and development
GU problems
Ear anomalies
CATCH 22 syndrome
Cardiac defects
Abnormal face
Thymus hypoplasia
Cleft palate
Hypocalcemia (due to hypoparathyroidism)
22q11.2 gene deletion
When do post-tonsil bleeds usually occur?
Within the first 24 hours, usually within 6 hours
When does post-tonsil bleeding usually occur in the healing stage and why?
5-10 postop when the scar (eschar) covering the tonsil bed contracts (secondary bleeding)
What are dizziness and orthostatic hotn in a post-tonsil
What are orthostatic hotn and dizziness indicative of in a post-tonsil bleed?
> /= 20% loss of circulating volume
give ongoing volume resuscitation before induction
What position should you place a post-tonsil bleed in and why?
left-lateral, head down to drain blood away from the airway
Describe METs
Bedside tool to assess functional reserve and measure perioperative risk.
1 MET = O2 consumption of 3.5 mL O2/kg/min
What two questions can you ask to determine proceeding with surgery without cardiac workup?
Can you walk up a flight of stairs without stopping?
Are you able to walk four blocks without stopping?
What does 1 METs mean? What activities correlate?
Poor functional capacity
Self-care activities
Working at a computer
Walking 2 blocks slowly
What does 4 METs indicate? What activities correlate?
Good functional capacity
Climbing a flight of stairs without stopping
Walking up a hill (>1-2 blocks)
Light housework
Raking leaves
Gardening
What does 10 METs correlate to? What activities does it include?
Outstanding functional capacity
Strenuous sports (running, swimming, basketball)
For every MET a patient can achieve, mortality decreases by what percentage?
11%
What volumes and capacities increase in the elderly?
RV
FRC
CC
What volumes and capacities decrease in the elderly?
ERV
VC
What volumes and capacities remain unchanged in the elderly?
TLC
What renal function remains the same in the elderly?
Serum creatinine
decreased GFR but also decreased muscle mass (less Cr produced) = no change
What is the most sensitive indicator of renal function and drug clearance in the elderly?
Creatine clearance
When does GFR decrease age wise and by how much?
Decreases 1 mL/min/year after age 40
How much does MAC decrease in the adult?
6% every decade after age 40
Why does perioperative hepatic function decrease?
Result from decreased liver blood flow and decreased liver mass
NOT due to impaired hepatocellular function (remains unchanged)
Does alpha 1-acid glycoprotein production increase or decrease? What does that mean for drug reservoir?
Increases. Increased reservoir for basic drugs
Does pseudocholinesterase increase or decrease in the elderly? What does this do to succinylcholine and ester LAs?
It decrease, leading to an increase in succinylcholine and ester LAs (more so in men than women)
The aging process does not meaningfully affect which three processes:
Systolic function
Total lung capacity
Hepatocellular function
Loss of lung elastic recoil in the elderly lead to what lung volume/capacity changes?
Increased dead space
Increased A-a gradient
Increased V/Q mismatch
Decreased alveolar surface area
Decreased PaO2
