Peds Flashcards
Definitions
Neonates
Infants
Children
Neonates: 1-30 days
Infants: 1-12 mo
Children: 1-12 yrs
CO of neonates and infants is dependent on…
HR
*Since SV is relatively fixed by a noncompliant and poorly developed LV
Compare neonate vs. adult. Infant has a... HR BP RR TV Lung compliance Chest wall compliance FRC CV RV VA TLC Ratio of body surface area to body wt Total body water content
Faster HR Lower BP Faster RR (40 vs. 10) Decreased TV (6 vs. 7 mL/kg) Lower lung compliance Greater chest wall compliance Lower FRC (30 vs. 34 mL/kg) Increased CV Increased RV (20 vs. 17 mL/kg) Higher VA (100 vs. 60 mL/kg/min) Decreased TLC (60 vs. 80 mL/kg) Higher ratio of body surface area to body wt Higher total body water content
Describe infant airway concerns.
Large head Large tongue ANTERIOR and CEPHALAD larynx Long epiglottis Slanting vocal cords Narrow cricoid ring - subglottic Short trachea Short neck Prominent tonsils and adenoids Narrow nasal passages (resistance x12) *Infants are obligate nose breathers
List pharmacologic differences in infant.
Immature hepatic biotransformation Immature NMJ Decreased protein binding Rapid induction and recovery Increased MAC Large Vd for water soluble drugs
What is the narrowest point of the airway in children younger than 5 years old?
Cricoid cartilage
GREATER THAN 2 yrs, ETT size formula…
(Age/4) + 4
*This will tell you uncuffed size - subtract 0.5 for cuffed size
Calculate ETT length at mouth.
(10+age)/2
What explains the following: you will have a more rapid induction with inhaled anesthetics in neonates?
Decreased FRC
Increased RR
Increased VA
What explains the following: neonates are prone to atelectasis and hypoxia during anesthesia?
Decreased FRC
Increased CV
Neonates rely on what muscles for breathing?
Diaphragmatic breathers
Intercostal muscles are underdeveloped
Diaphragm is high
Chest cavity is small
Normal HR ranges for preterm to 5 years.
Preterm: 120-180 Term: 100-180 1 yr: 100-140 3 yr: 85-115 5 yr: 80-100
Normal BP ranges for preterm to 5 years.
Preterm: 45-60/30 Term: 55-70/40 1 yr: 70-100/60 3 yr: 75-110/70 5 yr: 80-120/70
Estimated BV Preterm Infant Toddler Child Adult (male) Adult (female)
Preterm: 90 mL/kg
Infant: 80 mL/kg
Toddler: 75 mL/kg
Child: 72 mL/kg
Adult (male): 70 mL/kg
Adult (female): 65 mL/kg
How do you calculate ABL?
EBV x (Hct – lowest/Hct)
How do you determine the hourly fluid maintenance for a child?
4-2-1 Rule
4 mL/kg for 1st 10 kg
2 mL/kg for 10-20 kg
1 mL/kg for each kg > 20 kg
Is fetal circulation parallel or series circulation?
Parallel
Total body water (% TBW)
Preterm
Term
6-12 mo
Preterm: 90%
Term: 80%
6-12 mo: 60%
*The increase is seen in the EXTRACELLULAR compartment
Why are infants of diabetic mothers prone to hypoglycemia?
Infant will produce insulin in response to maternal BS
When cord is clamped - no more glucose from mom
Infant has stored insulin
Define prematurity.
Birth b4 37 weeks gestation
< 2500 gm
Define for small for gestation age.
Full or preterm
Age-adjusted weight < 5th %tile
Post-conceptual age =
Gestational age + post-maternal age
What are you main concerns for a premature infant?
Airway control
Fluid management
Temp regulation
Retinopathy of prematurity (retrolental fibroplasia)
*Fentanyl favored over volatile anesthetics
Less than how many weeks post-conceptual age have the greatest risk of experiencing post-anesthetic complications?
< 60 weeks post-conceptual age
What is a congenital diaphragmatic hernia usually associated with?
Pulmonary hypoplasia
Caused by in utero compression of the developing lungs by the herniated viscera
*Occurs at 5- 10 weeks of fetal life
(high incidence of CHD and intestinal malrotation)
Congenital diaphragmatic hernia: gut herniates into thorax via…
What is the most common? Why?
Anterior foramen of Morgagni R posterolateral foramen of Bochdalek L posterolateral foramen of Bochdalek* (70-90%) *L. side foramen closes after the R
The baby has a congenital diaphragmatic hernia. Would you expect the 1 min APGAR score to be depressed?
NO, may be normal owing to oxygenation of fetal blood by the placenta
What are hallmark signs of congenital diaphragmatic hernia?
Profound arterial hypoxia - R to L shunt
Barrel-shaped chest
Scaphoid abdomen
What are the management goals of an infant with congenital diaphragmatic hernia?
Pulse ox - place preductal on RUE and postductal on LLE Maintain preductal sat > 85% Peak inspiratory pressure < 25 cm H2O Pressure limited modes of ventilation Allow mod hypercapnia (PCO2 45-55 mmHg) Decompress stomach Avoid venous access in LE Avoid N2O and halogenated agents Paralysis with narcotics *NO for persistent pul HTN does NOT work
What side pneumo is a concern in the setting of a congenital diaphragmatic hernia?
R. sided pneumo
Incidence Congenital diaphragmatic hernia Tracheoesophageal fistula Gastroschisis Intestinal Malrotation and Volvulus
Congenital diaphragmatic hernia: 1:5,000 Tracheoesophageal fistula: 1:3,000 Omphalocele: 1:5,000 Gastroschisis: 1:15,000 Intestinal Malrotation and Volvulus: 1:500
What is the most common variation TEF?
Esophagus ends in a blind pouch
Lower esophagus that connects to the posterior wall of the trachea (just above the carina)
85%
Type IIIB
What will you see with a TEF? What happens with breathing? What happens with feeding?
Gastric distension w/ respirations
Feeding leads to 3 C’s: choking, coughing, cyanosis…HYPOXIA + BRADYCARDIA…pneumonia
What is VACTERL syndrome?
Vertebral defect Anal defect Cardiac anomalies TEF Esophageal atresia Renal dysplasia Limb anomalies
Anesthesia Concerns for TEF.
Frequent suctioning - copious pharyngeal secretions
NO PPV prior to intubation
Head up position
Awake intubation w/o MR
Dehydrated and malnourished
Do NOT extend neck or instrument esophagus
What is the principle cause of death associated with a TEF?
Pulmonary complications
Describe pyloric stenosis.
Common cause of gastric outlet obstruction
Idiopathic hypertrophy of the circular smooth muscle of the pylorus
What are the s/s of pyloric stenosis?
Non-bilious projectile vomiting at 2-5 weeks of age
Olive-like mass palpated in the epigastrium
Starvation
Jaundice
What is the most common metabolic presentation of pyloric stenosis?
HYPOkalemic, HYPOchloremic primary METABOLIC ALKALOSIS with
secondary RESPIRATORY ACIDOSIS
(Kidneys compensate by excreting NaBicarb in urine)
Severe dehydration d/t persistant vomiting may lead to metabolic acidosis with compensatory hyperventilation
(Kidneys must conserve sodium even at the expense of H ion excretion)
* HYDRATION status is CRUCIAL to METABOLIC status
Anesthetic Concerns for Pyloric Stenosis.
Avoid pulmonary aspiration
Empty stomach b4 surgery
Apnea monitoring for 12 hrs post-op
What may occur 2-3 hrs after surgical correction of pyloric stenosis (besides possible apnea)?
HYPOcalcemia
D/t inadequate liver glycogen stores
Acute Epiglottitis
2-7 yrs HIGH fever (> 39 C) SUPRAglottic edema Difficulty swallowing INSPIRATORY stridor 5% of children with stridor Neutrophilia Haemophilus INFLUENZA type B Tx - Ampicillin
Laryngotracheal Bronchitis
6 mo - 6 years
LOW fever
SUBglottic edema
Less airway obsturction
CROUPY cough ("barking")
80% of children with stridor
SLOW onset
Common cold - VIRAL
Tx - cool humidity, oxygen, racemic EpiWhat will a child with acute epiglottitis look like?
Sitting forward and upright Chin up Mouth open Drooling Tachypnea Lethargic Cyanotic *Acidotic, elevated CO2, dehydrated
Anesthetic Concerns for Acute Epiglottitis.
Requires immediate intubation Sedate in sitting up position NO MR Small tube with leak Fluids Antibiotics - Ampicillin
Anesthetic Concerns for Laryngotracheal Bronchitis.
Only intubate if increased PaCO2 Cool humidity, oxygen 2.25% Epi 0.5-1 mL in 2-3 mL normal saline - 0.05 mL/kg - 0.5 mL/kg Repeat in 20 min Repeat Q2-4 hrs
Omphalocele
Base of umbilicus W/in umbilical cord SAC is the amnion MULTIPLE anomalies - cardiac eval prior to surgery Occurs at 5-10 weeks gestation
Gastroschisis
Lateral to umbilicus Periumbilical NO SAC or amnion *Prevent hypothermia, dehydration, and infection Requires URGENT repair NO other anomalies Occurs at 12-18 weeks gestation
What do high alpha-fetoprotein levels in mom indicate?
Diagnostic for omphalocele
Anesthetic Concerns for Ompahlocele and Gastroschisis.
Decompress stomach NO N2O May need MR to replace bowel in abd cavity - staged closure Monitor BS Hydrate (8-16 mL/kg/hr)
Prone Belly Syndrome Anesthesia
Risk of aspiration Thin, weak abdominal wall Cannot cough well Awake intubation NO MR Renal involvement
Intestinal Malrotation and Volvulus
Abnormal rotation of the midgut around the mesentery
Present with s/s of bowel obstruction: bilious vomiting, abd tenderness and distention, *Metabolic acidosis
What is the most serious complication of intestinal malrotation and volvulus?
Midgut volvulus
Rapid compromise of intestinal blood supply
*This is a TRUE surgical emergency
(1/3 occur during the 1st week of life)
Anesthetic Concerns for Intestinal Malrotation and Volvulus
Decompress the stomach High risk for aspiration Awake intubation Antibiotics F&E replacement
Patients with volvulus are…
HYPOvolemic - aggressive fluids, blood ACIDotic - NaBicarb Poor candidates for GA - use ketamine and opioid-based anesthesia Risk for bowel compartment syndrome 25% mortality rate
Bowel compartment syndrome results in…
Impaired ventilation
Decreased VR
Renal compromise
Requires several surgeries
Which one is more severe: Pierre-Robin or Treacher-Collins Syndrome?
Treacher-Collins Syndrome
Anesthetic Concerns
Trisomy 21 Syndrome
Down’s Syndrome
Extra chromosome 21
Difficult airway
Small ETT
Atlanto-occipital dislocation d/t congenital laxity of the ligaments
Avoid air bubbles in IV (possible R to L shunt)
Post-op apnea and stridor is common
Cystic Fibrosis
Hereditary Exocrine glands Pulmonary and GI systems Thick, viscous secretions Decreased ciliary activity Pneumonia, wheezing, bronchiectasis Malabsorption syndrome - F&E disturbances
Explain what happens to the following with cystic fibrosis. RV Airway resistance Vital capacity Expiratory flow rate
RV - increased
Airway resistance - increased
Vital capacity - decreased
Expiratory flow rate - decreased
Scoliosis
Pre-op orders
Pre-op: PFTs, ABGs, ECG
T&A
Increased risk for what?
Postpone surgery if?
Other considerations.
Risk of perioperative airway problems Postpone if active infection or clotting dysfunction Anticholinergic to decrease secretions Treat for PONV *If bleeding, RSI + NG tube
What are common causes of otitis media?
Hemophilus influenzae
Stretococcus
Pneumococcus
Mycoplasma pneumoniae
Dantrolene
2 mg/kg
Q5-10 min
Max: 10 mg/kg
Treatment of MH
Turn off agents Hyperventilate with 100% O2 Dantrolene Active cooling - 15 mL/kg of iced saline Give NaBicarb Maintain UO (hydration, mannitol, lasix)
1 min APGAR score correlates with…
Survival
5 min APGAR score is related to…
Neurologic outcome
What is the most common cause of neonatal depression?
Intrauterine asphyxia
Respiratory resuscitation
*Don’t suction > 3x
What should you do?
APGAR score 0-2
APGAR score 3-4
APGAR score 5-7
APGAR score 0-2: intubate + compressions
APGAR score 3-4: assist ventilation (40/min)
APGAR score 5-7: stimulation, blow by
Indications for PPV in Neonate
Apnea
HR < 100
Persistent central cyanosis on 100% O2 by mask
Initial breaths may require peak pressures of up to ___cm water, but NOT to exceed ___ cm water subsequently.
40
30
If the HR is < ___ bpm, intubate.
If the HR does not improve to > 80 bpm, then ______.
60
Start compressions
How do you verify correct ETT size in a neonate?
Small tube leak with 20 cm water pressure
Cardiac compression at a rate of ____/min and at a depth of _____ inches.
100 (30:2 if single, 15:2 if multiple)
1.5 inches/4 cm
True or False.
Neonatal BP generally correlates with intravascular volume.
TRUE
1-2 kg: BP 50/25
> 3 kg: BP 70/40
Pediatric Epinephrine Dose
- 01-0.03 mg/kg
- 1-0.3 mL/kg of 1:10,000
* Give if asystole or HR < 80
Pediatric Atropine Dose
0.03 mg/kg
Pediatric Calcium Dose
30 mg/kg
*Mag toxicity
Pediatric Naloxone Dose
0.01-0.02 mg/kg
Pediatric Glucose Dose
4 mL/kg of a 10% solution
LMA size formula
kg / 20 + 1 (round to nearest 0.5)
- 5: 20-30 kg
3: 30-60 kg
4: 60-80 kg
5: > 80 kg
ETT size for < 2 years
Preterm: 2.5
Term infant: 3
3-12 mo: 3.5
2: 4
A child unexpectedly has cardiac arrest after Sux administration. How would you treat this patient?
Hyperkalemia
The hallmark of intravascular fluid depletion in neonates and infants is…
Hypotension w/o tachycardia
The major cause of perioperative morbidity and mortality in pediatric patients is?
Hypoxia from inadequate ventilation
The pediatric patient’s major mechanism for heat production is?
Non-shivering thermogenesis by metabolism of brown fat
Cold stress - increase NE production - metabolism of brown fat - increase body heat
Persists up to the age of 2
*Controlled by autonomic NS
Which inhalational agent has the same MAC for neonates and infants?
Sevo
You pediatric patient has had a recent viral infection. What time should pass before GA and ETT would be considered reasonable?
2-4 weeks
Surfactant appears initially b/t…
23-24 weeks
Why do newborns not tolerate large volumes of water and salts?
B/c of low GFR and decreased tubular concentrating ability
When is the cytochrome P450 enzyme system fully functional?
1 mo
In newborns, the closing capacity > FRC. What does this mean?
Some airways close during the expiratory phase of normal tidal breathing
What should you set the TV on the vent for a neonate?
6-8 mL/kg
*Same as an adult
What is the minute volume per kg for the neonate?
250 mL/kg
MV = TV x RR
Physiological anemia of the neonate.
Full-term newborn: Hgb 14-20
“Bottoms out” during the 9th to 12th week - Hgb 10-11, Hct 33%
3 mo/12 weeks: Hgb 11.5 until the age of 2
Physiological anemia of the preterm neonate.
Decrease in Hgb levels is GREATER and EARLIER
4-8 weeks: Hgb 8
Normal Hgb in the newborn and the pediatric patient.
Newborn: Hgb > 13
> 3 mo: Hgb > 10
Pediatric fluid replacement for blood loss is best determined by which method of monitoring?
Hct
At what age is BMR normally the highest?
B/t 6-12 mo
What is the best way to maintain an infant’s body heat?
Maintain high ambient temp
Increase OR temp
*Premature - 26 deg C
At what rate do infants consume O2?
7 mL/kg/min
*2x that of the adult
Where should BP monitoring occur in the neonate with preductal coarctation of the aorta?
R. radial aline
What causes the closure of the foramen ovale?
Decrease in PVR and increased pulmonary flow
Increased pressure in the LA
What causes the closure of the ductus arteriosus (PA and aorta)?
Increased PaO2
Reduction in circulating prostaglandins
What if the pediatric patient has a systolic and diastolic murmur?
PDA
L to R shunt
Identify the best site to obtain ABGs from the neonate.
Radial artery
Reflects preductal oxygenation, which better reflects cerebral oxygenation
What are the 4 primary precipitating factors in persistent fetal circulation?
- Hypoxemia
- Acidosis
- Pneumonia
- Hypothermia
* Increased PVR, R to L shunting
What is Eisenmenger’s pathology?
VSD + pulmonary HTN
R to L shunt
What can worsen a R to L shunt?
Increase in PVR OR a decrease in SVR
Acidosis, hypercarbia, hypotension, volatile agents, histamine
List 4 CHD involved with tetralogy of Fallot.
- VSD
- RV outflow tract obstruction (pulmonary stenosis)
- RVH
- Overriding aorta
R to L shunt
Slow or accelerate…
Inhalation induction
IV induction
Inhalation induction - slow
IV induction - accelerate
L to R shunt
Slow or accelerate…
Inhalation induction
IV induction
Inhalation induction - accelerate
IV induction - slow
Name 4 conditions in which the patient presents with a large tongue.
- Down’s
- Pierre Robin
- Acromegaly
- Hypothyroidism
* NOT Treacher Collins
Name 3 conditions in which the patient presents with mandibular hypoplasia.
- Pierre Robin
- Treacher Collins
- Goldenhar
Pierre Robin is a combo of what 3 things?
- Cleft palate
- Micrognathia
- Glossoptosis
What is the most common of the mandibulofacial dystoses?
Treacher-Collins
What is the most common CHD?
VSD
What syndrome has an associated cleft palate?
Treacher-Collins
Your patient has spina bifida. What is your primary concern?
Latex allergy
What is the most frequent pediatric surgical emergency?
Foreign body aspiration
What might be signaled by a sudden fall in lung compliance (increased peak inspiratory pressure), blood pressure, or oxygenation during repair of a congenital diaphragmatic hernia?
A contralateral (usually R-sided) pneumo
What acid-base disturbance will be seen with significant loss of bile vomitus?
Metabolic acidosis
Is pyloric stenosis a medical emergency or a surgical emergency?
Medical
Surgery should be postponed for 24-48 hrs until F&E are corrected
What is the average blood lost during a tonsillectomy?
4 mL/kg
5-10% of blood volume
Kernicterus
Bilirubin encephalopathy
Toxic effects of unconjugated bilirubin
Crosses the immature BBB of a neonate
Drugs that compete for albumin binding sites may increase the risk: furosemide, sulfa, diazepam
NPO Guidelines
Clear fluids: 2 hrs
Breast milk: 4 hrs
Formula or light meal: 6 hrs
Solid meal: 8 hrs
How is the length of the ETT from the mouth determined?
(10 + age)/2
Retinopathy of Prematurity
Inversely proportional to birth weight
Associated with oxygen exposure (>40%), apnea, blood transfusion, sepsis, fluctuating levels of CO2
Negligible after 44 weeks post-conception
With an immature SNS, the CV parameters are remarkably stable in the neonate with a high or total spinal. What sign would indicated a high or total spinal?
Decreased O2 sat
How do infants react to hypoxia?
Bradycardia
What PaO2 is desirable when ventilating a premature infant for surgery?
60-80 mmHg
