Peds Flashcards by Joshua Hall

When does renal tubular function equal that of an adult?

Renal tubular function achieves full concentrating ability at ~2 years old

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What three kidney values are lower in neonates than adults?

GFR
Renal perfusion pressure
Diluting/concentrating ability

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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

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Describe cyanotic shunt HD goals:

Maintain SVR
Decrease PVR
Increase preload
Maintain HR and contractility

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Describe cyanotic shunt hd goals:

Avoid increased SVR
Avoid decreased PVR

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Right to left shunt examples:

Tetralogy of Fallot
Truncus arteriosus
Transposition of the great vessels
Tricuspid displacement (Ebstein’s anomaly)

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Epiglottitis vs Laryngotracheobronchitis: Organism

Bacterial vs viral

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Epiglottis vs Laryngotracheobronchitis: Age

2-6 yrs vs < 2 yrs

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Epiglottis vs Laryngotracheobronchitis: Onset

Rapid (<24 hours) vs Gradual (24-72 hours)

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Epiglottis vs Laryngotracheobronchitis: Region affected

Supraglottic: epiglottis, vallecula, arytenoids, aryepiglottic folds

Laryngeal structures below vocal folds

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Epiglottis vs Laryngotracheobronchitis: Neck X-ray

Swollen epiglottis (Thumb sign) with lateral X-ray

Subglottic narrowing (Steeple sign) with frontal X-ray

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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)

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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

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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

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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

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Airway risks in peds with URI:

increased airway reactivity (bronchospasm)
laryngospasm
mucous plugging in airway
atelectasis
desaturation events
postoperative hypoxemia

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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

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When to proceed with elective surgery despite URI:

clear rhinorrhea
no fever
active
appears happy
clear lungs
older child

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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

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What medication can help prevent post-intubation croup?

Dexamethasone 0.25 - 0.5 mg/kg IV

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Foreign body aspiration classic triad:

cough
wheezing
decreased breath sounds on affected side (usually the right)

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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