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The BIG Test > Peds > Flashcards

Peds Flashcards

1
Q

Definitions
Neonates
Infants
Children

A

Neonates: 1-30 days
Infants: 1-12 mo
Children: 1-12 yrs

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2
Q

CO of neonates and infants is dependent on…

A

HR

*Since SV is relatively fixed by a noncompliant and poorly developed LV

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3
Q 
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
A 
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
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4
Q

Describe infant airway concerns.

A 
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
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5
Q

List pharmacologic differences in infant.

A 
Immature hepatic biotransformation 
Immature NMJ 
Decreased protein binding
Rapid induction and recovery
Increased MAC
Large Vd for water soluble drugs
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6
Q

What is the narrowest point of the airway in children younger than 5 years old?

A

Cricoid cartilage

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7
Q

GREATER THAN 2 yrs, ETT size formula…

A

(Age/4) + 4

*This will tell you uncuffed size - subtract 0.5 for cuffed size

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8
Q

Calculate ETT length at mouth.

A

(10+age)/2

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9
Q

What explains the following: you will have a more rapid induction with inhaled anesthetics in neonates?

A

Decreased FRC
Increased RR
Increased VA

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10
Q

What explains the following: neonates are prone to atelectasis and hypoxia during anesthesia?

A

Decreased FRC

Increased CV

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11
Q

Neonates rely on what muscles for breathing?

A

Diaphragmatic breathers
Intercostal muscles are underdeveloped
Diaphragm is high
Chest cavity is small

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12
Q

Normal HR ranges for preterm to 5 years.

A 
Preterm: 120-180
Term: 100-180
1 yr: 100-140
3 yr: 85-115
5 yr: 80-100
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13
Q

Normal BP ranges for preterm to 5 years.

A 
Preterm: 45-60/30
Term: 55-70/40
1 yr: 70-100/60
3 yr: 75-110/70
5 yr: 80-120/70
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14
Q 
Estimated BV 
Preterm
Infant
Toddler
Child
Adult (male)
Adult (female)
A

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

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15
Q

How do you calculate ABL?

A

EBV x (Hct – lowest/Hct)

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16
Q

How do you determine the hourly fluid maintenance for a child?

A

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

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17
Q

Is fetal circulation parallel or series circulation?

A

Parallel

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18
Q

Total body water (% TBW)
Preterm
Term
6-12 mo

A

Preterm: 90%
Term: 80%
6-12 mo: 60%
*The increase is seen in the EXTRACELLULAR compartment

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19
Q

Why are infants of diabetic mothers prone to hypoglycemia?

A

Infant will produce insulin in response to maternal BS
When cord is clamped - no more glucose from mom
Infant has stored insulin

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20
Q

Define prematurity.

A

Birth b4 37 weeks gestation

< 2500 gm

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21
Q

Define for small for gestation age.

A

Full or preterm

Age-adjusted weight < 5th %tile

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22
Q

Post-conceptual age =

A

Gestational age + post-maternal age

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23
Q

What are you main concerns for a premature infant?

A

Airway control
Fluid management
Temp regulation
Retinopathy of prematurity (retrolental fibroplasia)

*Fentanyl favored over volatile anesthetics

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24
Q

Less than how many weeks post-conceptual age have the greatest risk of experiencing post-anesthetic complications?

A

< 60 weeks post-conceptual age

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25
Q

What is a congenital diaphragmatic hernia usually associated with?

A

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)

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26
Q

Congenital diaphragmatic hernia: gut herniates into thorax via…
What is the most common? Why?

A 
Anterior foramen of Morgagni 
R posterolateral foramen of Bochdalek
L posterolateral foramen of Bochdalek* 
(70-90%) 
*L. side foramen closes after the R
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27
Q

The baby has a congenital diaphragmatic hernia. Would you expect the 1 min APGAR score to be depressed?

A

NO, may be normal owing to oxygenation of fetal blood by the placenta

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28
Q

What are hallmark signs of congenital diaphragmatic hernia?

A

Profound arterial hypoxia - R to L shunt
Barrel-shaped chest
Scaphoid abdomen

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29
Q

What are the management goals of an infant with congenital diaphragmatic hernia?

A 
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
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30
Q

What side pneumo is a concern in the setting of a congenital diaphragmatic hernia?

A

R. sided pneumo

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31
Q 
Incidence 
Congenital diaphragmatic hernia
Tracheoesophageal fistula 
Gastroschisis
Intestinal Malrotation and Volvulus
A 
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
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32
Q

What is the most common variation TEF?

A

Esophagus ends in a blind pouch
Lower esophagus that connects to the posterior wall of the trachea (just above the carina)
85%
Type IIIB

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33
Q

What will you see with a TEF? What happens with breathing? What happens with feeding?

A

Gastric distension w/ respirations

Feeding leads to 3 C’s: choking, coughing, cyanosis…HYPOXIA + BRADYCARDIA…pneumonia

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34
Q

What is VACTERL syndrome?

A 
Vertebral defect
Anal defect 
Cardiac anomalies
TEF
Esophageal atresia
Renal dysplasia 
Limb anomalies
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35
Q

Anesthesia Concerns for TEF.

A

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

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36
Q

What is the principle cause of death associated with a TEF?

A

Pulmonary complications

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37
Q

Describe pyloric stenosis.

A

Common cause of gastric outlet obstruction

Idiopathic hypertrophy of the circular smooth muscle of the pylorus

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38
Q

What are the s/s of pyloric stenosis?

A

Non-bilious projectile vomiting at 2-5 weeks of age
Olive-like mass palpated in the epigastrium
Starvation
Jaundice

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39
Q

What is the most common metabolic presentation of pyloric stenosis?

A

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

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40
Q

Anesthetic Concerns for Pyloric Stenosis.

A

Avoid pulmonary aspiration
Empty stomach b4 surgery
Apnea monitoring for 12 hrs post-op

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41
Q

What may occur 2-3 hrs after surgical correction of pyloric stenosis (besides possible apnea)?

A

HYPOcalcemia

D/t inadequate liver glycogen stores

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42
Q

Acute Epiglottitis

A 
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
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43
Q

Laryngotracheal Bronchitis

A 
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 Epi
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44
Q

What will a child with acute epiglottitis look like?

A 
Sitting forward and upright
Chin up 
Mouth open 
Drooling 
Tachypnea 
Lethargic 
Cyanotic 
*Acidotic, elevated CO2, dehydrated
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45
Q

Anesthetic Concerns for Acute Epiglottitis.

A 
Requires immediate intubation 
Sedate in sitting up position 
NO MR 
Small tube with leak 
Fluids 
Antibiotics - Ampicillin
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46
Q

Anesthetic Concerns for Laryngotracheal Bronchitis.

A 
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
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47
Q

Omphalocele

A 
Base of umbilicus 
W/in umbilical cord 
SAC is the amnion 
MULTIPLE anomalies - cardiac eval prior to surgery 
Occurs at 5-10 weeks gestation
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48
Q

Gastroschisis

A 
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
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49
Q

What do high alpha-fetoprotein levels in mom indicate?

A

Diagnostic for omphalocele

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50
Q

Anesthetic Concerns for Ompahlocele and Gastroschisis.

A 
Decompress stomach 
NO N2O 
May need MR to replace bowel in abd cavity - staged closure 
Monitor BS 
Hydrate (8-16 mL/kg/hr)
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51
Q

Prone Belly Syndrome Anesthesia

A 
Risk of aspiration 
Thin, weak abdominal wall 
Cannot cough well 
Awake intubation 
NO MR 
Renal involvement
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52
Q

Intestinal Malrotation and Volvulus

A

Abnormal rotation of the midgut around the mesentery

Present with s/s of bowel obstruction: bilious vomiting, abd tenderness and distention, *Metabolic acidosis

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53
Q

What is the most serious complication of intestinal malrotation and volvulus?

A

Midgut volvulus
Rapid compromise of intestinal blood supply
*This is a TRUE surgical emergency
(1/3 occur during the 1st week of life)

54
Q

Anesthetic Concerns for Intestinal Malrotation and Volvulus

A 
Decompress the stomach
High risk for aspiration 
Awake intubation
Antibiotics 
F&amp;E replacement
55
Q

Patients with volvulus are…

A 
HYPOvolemic - aggressive fluids, blood 
ACIDotic - NaBicarb 
Poor candidates for GA - use ketamine and opioid-based anesthesia 
Risk for bowel compartment syndrome 
25% mortality rate
56
Q

Bowel compartment syndrome results in…

A

Impaired ventilation
Decreased VR
Renal compromise
Requires several surgeries

57
Q

Which one is more severe: Pierre-Robin or Treacher-Collins Syndrome?

A

Treacher-Collins Syndrome

58
Q

Anesthetic Concerns
Trisomy 21 Syndrome
Down’s Syndrome
Extra chromosome 21

A

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

59
Q

Cystic Fibrosis

A 
Hereditary
Exocrine glands 
Pulmonary and GI systems 
Thick, viscous secretions 
Decreased ciliary activity 
Pneumonia, wheezing, bronchiectasis 
Malabsorption syndrome - F&amp;E disturbances
60
Q 
Explain what happens to the following with cystic fibrosis. 
RV
Airway resistance
Vital capacity
Expiratory flow rate
A

RV - increased
Airway resistance - increased

Vital capacity - decreased
Expiratory flow rate - decreased

61
Q

Scoliosis

Pre-op orders

A

Pre-op: PFTs, ABGs, ECG

62
Q

T&A
Increased risk for what?
Postpone surgery if?
Other considerations.

A 
Risk of perioperative airway problems 
Postpone if active infection or clotting dysfunction 
Anticholinergic to decrease secretions
Treat for PONV
*If bleeding, RSI + NG tube
63
Q

What are common causes of otitis media?

A

Hemophilus influenzae
Stretococcus
Pneumococcus
Mycoplasma pneumoniae

64
Q

Dantrolene

A

2 mg/kg
Q5-10 min
Max: 10 mg/kg

65
Q

Treatment of MH

A 
Turn off agents 
Hyperventilate with 100% O2 
Dantrolene 
Active cooling - 15 mL/kg of iced saline 
Give NaBicarb
Maintain UO (hydration, mannitol, lasix)
66
Q

1 min APGAR score correlates with…

A

Survival

67
Q

5 min APGAR score is related to…

A

Neurologic outcome

68
Q

What is the most common cause of neonatal depression?

A

Intrauterine asphyxia
Respiratory resuscitation
*Don’t suction > 3x

69
Q

What should you do?
APGAR score 0-2
APGAR score 3-4
APGAR score 5-7

A

APGAR score 0-2: intubate + compressions
APGAR score 3-4: assist ventilation (40/min)
APGAR score 5-7: stimulation, blow by

70
Q

Indications for PPV in Neonate

A

Apnea
HR < 100
Persistent central cyanosis on 100% O2 by mask

71
Q

Initial breaths may require peak pressures of up to ___cm water, but NOT to exceed ___ cm water subsequently.

A

40

30

72
Q

If the HR is < ___ bpm, intubate.

If the HR does not improve to > 80 bpm, then ______.

A

60

Start compressions

73
Q

How do you verify correct ETT size in a neonate?

A

Small tube leak with 20 cm water pressure

74
Q

Cardiac compression at a rate of ____/min and at a depth of _____ inches.

A

100 (30:2 if single, 15:2 if multiple)

1.5 inches/4 cm

75
Q

True or False.

Neonatal BP generally correlates with intravascular volume.

A

TRUE

1-2 kg: BP 50/25
> 3 kg: BP 70/40

76
Q

Pediatric Epinephrine Dose

A
  1. 01-0.03 mg/kg
  2. 1-0.3 mL/kg of 1:10,000
    * Give if asystole or HR < 80
77
Q

Pediatric Atropine Dose

A

0.03 mg/kg

78
Q

Pediatric Calcium Dose

A

30 mg/kg

*Mag toxicity

79
Q

Pediatric Naloxone Dose

A

0.01-0.02 mg/kg

80
Q

Pediatric Glucose Dose

A

4 mL/kg of a 10% solution

81
Q

LMA size formula

A

kg / 20 + 1 (round to nearest 0.5)

  1. 5: 20-30 kg
    3: 30-60 kg
    4: 60-80 kg
    5: > 80 kg
82
Q

ETT size for < 2 years

A

Preterm: 2.5
Term infant: 3
3-12 mo: 3.5
2: 4

83
Q

A child unexpectedly has cardiac arrest after Sux administration. How would you treat this patient?

A

Hyperkalemia

84
Q

The hallmark of intravascular fluid depletion in neonates and infants is…

A

Hypotension w/o tachycardia

85
Q

The major cause of perioperative morbidity and mortality in pediatric patients is?

A

Hypoxia from inadequate ventilation

86
Q

The pediatric patient’s major mechanism for heat production is?

A

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

87
Q

Which inhalational agent has the same MAC for neonates and infants?

A

Sevo

88
Q

You pediatric patient has had a recent viral infection. What time should pass before GA and ETT would be considered reasonable?

A

2-4 weeks

89
Q

Surfactant appears initially b/t…

A

23-24 weeks

90
Q

Why do newborns not tolerate large volumes of water and salts?

A

B/c of low GFR and decreased tubular concentrating ability

91
Q

When is the cytochrome P450 enzyme system fully functional?

A

1 mo

92
Q

In newborns, the closing capacity > FRC. What does this mean?

A

Some airways close during the expiratory phase of normal tidal breathing

93
Q

What should you set the TV on the vent for a neonate?

A

6-8 mL/kg

*Same as an adult

94
Q

What is the minute volume per kg for the neonate?

A

250 mL/kg

MV = TV x RR

95
Q

Physiological anemia of the neonate.

A

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

96
Q

Physiological anemia of the preterm neonate.

A

Decrease in Hgb levels is GREATER and EARLIER

4-8 weeks: Hgb 8

97
Q

Normal Hgb in the newborn and the pediatric patient.

A

Newborn: Hgb > 13

> 3 mo: Hgb > 10

98
Q

Pediatric fluid replacement for blood loss is best determined by which method of monitoring?

A

Hct

99
Q

At what age is BMR normally the highest?

A

B/t 6-12 mo

100
Q

What is the best way to maintain an infant’s body heat?

A

Maintain high ambient temp
Increase OR temp
*Premature - 26 deg C

101
Q

At what rate do infants consume O2?

A

7 mL/kg/min

*2x that of the adult

102
Q

Where should BP monitoring occur in the neonate with preductal coarctation of the aorta?

A

R. radial aline

103
Q

What causes the closure of the foramen ovale?

A

Decrease in PVR and increased pulmonary flow

Increased pressure in the LA

104
Q

What causes the closure of the ductus arteriosus (PA and aorta)?

A

Increased PaO2

Reduction in circulating prostaglandins

105
Q

What if the pediatric patient has a systolic and diastolic murmur?

A

PDA

L to R shunt

106
Q

Identify the best site to obtain ABGs from the neonate.

A

Radial artery

Reflects preductal oxygenation, which better reflects cerebral oxygenation

107
Q

What are the 4 primary precipitating factors in persistent fetal circulation?

A
  1. Hypoxemia
  2. Acidosis
  3. Pneumonia
  4. Hypothermia
    * Increased PVR, R to L shunting
108
Q

What is Eisenmenger’s pathology?

A

VSD + pulmonary HTN

R to L shunt

109
Q

What can worsen a R to L shunt?

A

Increase in PVR OR a decrease in SVR

Acidosis, hypercarbia, hypotension, volatile agents, histamine

110
Q

List 4 CHD involved with tetralogy of Fallot.

A
  1. VSD
  2. RV outflow tract obstruction (pulmonary stenosis)
  3. RVH
  4. Overriding aorta
111
Q

R to L shunt
Slow or accelerate…
Inhalation induction
IV induction

A

Inhalation induction - slow

IV induction - accelerate

112
Q

L to R shunt
Slow or accelerate…
Inhalation induction
IV induction

A

Inhalation induction - accelerate

IV induction - slow

113
Q

Name 4 conditions in which the patient presents with a large tongue.

A
  1. Down’s
  2. Pierre Robin
  3. Acromegaly
  4. Hypothyroidism
    * NOT Treacher Collins
114
Q

Name 3 conditions in which the patient presents with mandibular hypoplasia.

A
  1. Pierre Robin
  2. Treacher Collins
  3. Goldenhar
115
Q

Pierre Robin is a combo of what 3 things?

A
  1. Cleft palate
  2. Micrognathia
  3. Glossoptosis
116
Q

What is the most common of the mandibulofacial dystoses?

A

Treacher-Collins

117
Q

What is the most common CHD?

A

VSD

118
Q

What syndrome has an associated cleft palate?

A

Treacher-Collins

119
Q

Your patient has spina bifida. What is your primary concern?

A

Latex allergy

120
Q

What is the most frequent pediatric surgical emergency?

A

Foreign body aspiration

121
Q

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

A contralateral (usually R-sided) pneumo

122
Q

What acid-base disturbance will be seen with significant loss of bile vomitus?

A

Metabolic acidosis

123
Q

Is pyloric stenosis a medical emergency or a surgical emergency?

A

Medical

Surgery should be postponed for 24-48 hrs until F&E are corrected

124
Q

What is the average blood lost during a tonsillectomy?

A

4 mL/kg

5-10% of blood volume

125
Q

Kernicterus

A

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

126
Q

NPO Guidelines

A

Clear fluids: 2 hrs
Breast milk: 4 hrs
Formula or light meal: 6 hrs
Solid meal: 8 hrs

127
Q

How is the length of the ETT from the mouth determined?

A

(10 + age)/2

128
Q

Retinopathy of Prematurity

A

Inversely proportional to birth weight
Associated with oxygen exposure (>40%), apnea, blood transfusion, sepsis, fluctuating levels of CO2
Negligible after 44 weeks post-conception

129
Q

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?

A

Decreased O2 sat

130
Q

How do infants react to hypoxia?

A

Bradycardia

131
Q

What PaO2 is desirable when ventilating a premature infant for surgery?

A

60-80 mmHg

The BIG Test (21 decks)

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