Peds Flashcards
How to reduce PONV
- adequate IV hydration
- prop, avoid volatile, min opioids
- antiemetic: zofran, dex
- decompress stomach-avoid gastric distention
pediatric airway differences
How does it alter management
- large head and tongue:shoulder roll instead of head elevation (occiput)
- more cephalad larynx (C4 vs C6), cricoid narrowest part, long stiff epiglottis: -, straight blade (epiglottis), more inclined to use cricoid (anterior airway),
- nasal passage and airway smaller ( increases in resistance with edema and secretions):watch out for airway obstruction w anesthesia
why are peds pt prone to hypoxia on induction
Why is inhalational induction faster
higher O2 conumption, and smaller FRC
higher MV: FRC ratio
why is respiration less efficient
- ribs are cartilagenous & pliant ribs predisposing to chest wall collapse, ribs angled horizontally and do not lift up to expand chest
- diaphragm less fatigue resistant type 1 fibers
How is fetal circulation unique
how does this change at birth
- PVR elevated due to collpased unoxygenated lungs
- SVR low 2/2 low resistance placenta
- R–>L shunt across PFO and across PDA 2/2 high R sided pressures
birth:
expansion of lungs and increase O2–>PVR decreases
loss of placenta–>increase SVR
PFO closes due to increase L sided pressures; PDA closes due to increase Pa02 and loss of placental prostaglandins
How is neonatal CV system different from adult? 6
- fewer contractile proteins–>decreased compliance–>limiting SV and making CO more dependent on HR, less able to increase CO in repsonse to preload and afterload
- 2/2 ventricular noncompliance: less able to handle increase preload, less capable of increasing contractility in response to afterload, more ventricular interdependence
- less responsive to catecholamines
- SNS less developed predisposing to bradycardia
- autonomic reflexes blunted
- prediposed to PHTN
Why is neonatal NS different (3)
- more sensitive to anethetics: less protein binding, increased perm BBB, decreased drug elim (, increased sensitivity to drugs
- less autoregulation of CBF
- NMJ is immature–>increased sensitivity to NMB
EBV
premature 100cc/kg
FT neonate 90
Pregnant 90ml/kg
infant 80
70 child
60 adult
Anatomical considerations for spinal of caudal?
L3 (cord) S3(caudal sac)
Hematologic considerations of newborn
Hct 55 –>30 (6 months)
Hgb F 75%–>0 6months P50 21 vs 27
risk of def of vit K dependent factors 2,7,9,10
What are the functional limitations of a immature kidney
low GFR (unable to handle large fluid load)
immature tubular fxn (concentrating, retention NA, resorption glucose, ability to acidify urine
What is considered hypoglycemia in a newborn
why are premature infants prone to glucosuria
<30 in newborn <45 after 24 hrs
in infants less than 34 weeks there can be reduced tubular absoption of glucose
Why are pediatric pts predisposed to hypothermia
how do they generate heat in response to cold stress, when less effective
increased surface area/body mass , low fat content, thin skin
(radiation main, convection, conduction, evaporation)
-inefficient mech of heat production-nonshivering thermogenesis:hypothermia stimulates release of NE that triggers brown fat to underoes breakdown of TG into glycerol and FA into heat, (increases oxygen consumption
volatiles limit process, and less stores premature
Newborn struggling on delivery. ddx
neuro: anesthesia drugs, hypermag, hypoglycemia
cardiac: decreased uteroplacenta insufficiency
Pulm: TTN (retained lung fluid), meconium aspiration, persistant pulm HTN (decreased oxygen during/before birth, RDS (not fully developed lung), choanal atresia
congenital abnormality affecting airway (Pierre Robin, Beckwith Wiedemann)
NALS
Signs res distress
apnea
noisy breathing (stridor dyspena
tachypnea, use of acessory muscles, nasal flaring
cold
cough congestion runny nose sneezing,
wheezing rales
malise
purulent mucus
age onset, trigger events, allergies.
sx: cough sputum wheezing
current meds, anesthetic hx, asthma related hx
When acceptable to remove LMA prior to emergence
no obstructive sleep apnea, obesity, difficult airway, aspiration risk
otherwise remove when child regains consciousness (opens eyes to command)
signs of post tonsilectomy hemorrhage
consistent with blood loss in excess of 20%
orthostatic hypotension, tachycardia, dizziness,
excessive swallowing
increased capillary refill time, pallor, sweating, restlessness
opioids and children undergoing TA
children undegoing TA for OSA are more sensitive to opioids 2/2 to alterations int their mu R w repeated episodes of hypoxemia. utilize half the dose of opioid
-lowest effective dose for shortest period of time needed
posttonsillectomy bleeding
75% occur in first 6 hrs, with remainder in 24 hrs
primary bleeding: 1st 24 hrs-more serious than secondary bleeding
secondary bleeding: due to contraction of eschar covering tonsillar bed may occur up to 10 days
when to cancel for respiratory infection
risks
when does airway reactivity resolve
perioperative respiratory complications: bbroncospasm, larngospasm, desaturation
- delay 4-6 weeks if fever >38.5, malise, productive cough, mucopurulent sputum, pulm involement (wheezing)
- mild sx delay 2-4 weeks: sneezing nasal congestion, nonproductive cough +require ETT + additional RF (exposure to smoke, underlying pulm dz (asthma), surgery of airway, age < 1 year /premature
- proceed if mild sx and do no require ETT (mask, LMA, regional)
**resolution airway hyperreactivity may take 8 weeks
MH dx
at risk pts
suscpetibility
ABG
AD, kign denborough dz, central core dz
muscle biopsy halothane caffeine contracture test-the muscle of MH pt contracts and lower concentrations of caffeine and halothane (ost specific and most sensitive) at age 7
not diagnostic: genetic testing for ryanodine mutation
-increased PaCo2, decreased Pa02 (increased oxygen consumption), lactic acidosis
MH tx
- call for help.ICU 72 hrs
- admin drantrolene 2.5g/kg q5-10 min, infusion 1mg/kg q6h for 24-48 hrs
- hyperventilate pt w 100%
- active cooling: lavage-gastric bladder rectal, peritoneal lavage, CBP, ice packs over major arteries
- maintain UOP w lasix fluids, mannitol
- monitor K (dextrose insulin) calcium, ABG (acidosis-bicarb), serum CK, liver enzymes, coagulation
- monitor for DIC, myoglobinuric renal failure (ATN, obstructive nephropathy), recrudenscence
What causes dudctus arterrosis closure
causes of persistent PDA
drugs tx to close, SE
- Functional closure in 2-4 days:Increased oxygen levels (Pa02 and decrease PVR )and rapid decrease in prostaglandin E (from placenta)
- Anatomic closure over weeks due to fibrosis of ductus arteriosus (ligamentum arteriosus
NSAID exposure 32 weeks
- Predisposing factors:
- hypoxia acidosis, RDS
- prematurity: poorly muscular layer of ductus arteriosus less responsive to increased oxygen
- excessive fluid therapy
- Close: prostaglandin synthetase inhibitors (indomethacin, IBP)
- SE: hyponatremia, reduced renal, mesenteric, cerebral blood flow, thrombocytopenia
What is RDS
signs
dx
prevention
RF
long term consequences
- insufficient surfactant production (production inadequate before 35 weeks) that leads to widespread atelectasis, shunting, hypoxemia and met acidosis
- tachypnea tachycardia, nasal flaring, intercostal retractions, b/l rales, cyanosis
- CXR: b/l infiltrates and reduced lung volumes (atelectasis)
- steriods up till 37 weeks
- low gestation age, low birth weight, surgical delivery w/o labor, maternal diabetes
- broncopulm dysplasia
What is EIsenmengers
- Pulmonary vascular overload, irreversible pHTN,RHF, reversal of shunt (RL=Eisenmengers)
Risks of prematurity and low birth weight
- Neuro: IVH, hypothermia, retinopathy of prematurity
- Resp: post op apnea, RDS, PPHN
- GI: NEC, impaired liver fxn
- Renal: imapired renal fxn
- Endocrine: hypoglycemia (poor glycogen stores)
- Heme: anemia (transfuse 40-45 if severe cardiopul dz, 30-35 moderate, normal 20-25)
Potential PDA closure complications
- Neuro: recurrent laryngeal nerve injury (hoarseness), L phrenic nerve injury (diagrammatic paralysis)
- CV:
- massive blood loss,
- HTN (s/p ligation: BP increase 2/2 to elim of pulm runoff during diastole),
- reopening of ductus,
- HF (ischemia, increased afterload, R–>L shunting)
- Pulm: thoracic duct injury (chylothorax), hypoxemia (intrapulm/ extrapulm R shunt)
How are pre and post dutal readings helpful
- preductal (R) and postductal (LE) sat: increased rightL shunt (decrease postductal), ligation aorta (loss of postductal waveform), ligation PA (decrease pre and post ductal waveform)
Goals to avoid ROP
RF
Goal: Pa02 50-80; Sp02 87-94% (min anemia and oxygen consumption)
avoid fluctuations in Co2 or O2 levels, acidosis
avoid anemia, hypotension,
- Prematurity <32 weeks, LBW <.1kg, # days oxygen therapy
- IVH
- Cyanotic CHD, hypotension,
- Mechanical vent, RDS, Co2 and O2 fluctuations, hyperoxia,
- Sepsis, RBC transfusion, anemia
- Endocrine: CST, hyperglycemia, maternal diabetes
- Exposure to bright light, maternal antihistamine use w/I 2 weeks of delivery
How to maintain normothermia in neonate in OR
-ensure ambient temp in OR at least 26-30
infrared heating lamps
forced air warmers
warmed IV fluids
heated transport incubator
Heat moister exxchanger
When is vascularization of retina complete and ROP less of a risk
Goals O2 sat Pa02
pathophys
44 wks PCA
87-94%, 50-80mmHg
High O2 leads to vasoconstricton and obliteration of retinal vessels, relative hypoxia results in abnormal neovasculariztion
neonatal seziure ddx
IVH, cerebral edema
hypoxia hypercarbia
hypogycemia, hypomag, hypocalcemia
TORCH (toxo, rubella, CMV, herpes), sepsis
unable to open pts mouth during induction ddx
TMJ
masseter muscle rigidity: can result in MH or rhabdo, cancel and keep overnight
mytonic syndrome: avoid hypothermia, direct stimulation, hyperkalemia, succ, and neo, conduction, aspiration, risk
undx musclar dystorphy
How to prepare Machine for pt who once had MH
remove vaporizers/succ
flush machine 10L for at least 10 min
chage circuit, CO2 absorber and get charcalfilters
MH cart, code cart, make ICU aware
signs sx pyloric stenosis, metabolic derrangements
when would the kid be optimied for surgey
Why alkalosis
nonbilius vomiting, small abdominal mass,
hypokalemic hypochloremic, hyponatremic, met alkalosis
hydrated, good urine output and correction of metabolic derrangements (7.3-7.5, Na 130, K 3, Cl 85 bicarb <30
UOP 1-2cc/kg/hr
dehydration results in increased reabsoption of Na which results in reabs of bicarb and excretion of H
How to access neonate volume status
sunken fontelles, skin turgur, capillary refill,
HR, BP mental status
freq./volume of wet diapers
Why in inhalational induction faster in neonate
higher MV:FRC ratio
increased blood flow to vessel rich organs
Concerns for anesthesia w premature neonates
RF for post op apnea, decreaserisk
hypothermia
hypoglycemia
ROP
post op apnea: LGA, chronic lung dz, hx apnea and bradycardia, neurollogical ab,
PCA <50-60, anemia (iron supplmnatation)
reduce risk w caffeine
consider monitor for 24 hrs post op
SGA considered protective
Downs features
- Features
- Neuro: alanto axial instability: subluxation,
- Cardiac: bradycardia w/ sevo, 50% endocardial cushion defects (defects involving atrial, ventricular septum, and 1 or both AV valves), VSD, ASD, PDA, TOF
- Pulm: marcroglossia, micrognathia, subglottic stensosis, hypotonia and redundancy soft tissue, osa
- gi: duodenal atresia
how to get IV in uncooperative child
EMLA (lido + prilocaine) + ketamine IM (3mg/kg) + inhaled dex+nitrous +inhalational induction
features of CDH
decreased breath sounds of L, resp distress, and scaphoid abdomen
pulm: impaired lung maturation (decreased alveoli, decreased surfactant, abnormal pulm vascular-more reactive)–>imtrapulm shunting +pHTN
cards: pHTN impaired transition from fetal circ–>intracardiac shunting through PDA and PFO
hypoplastic lung causes intrapulm shunting and pHTN. The pHTN leads to extrapulm shunting
CHD initial tx
- 100% O2, intubate (awake or RSI) (msk ventilate–>air into stomach)
- NGT for stomach decompression
- ventilator: resolve hypoxia hypercarbia acidosis, while avoiding high airway pressures, (PTX on R side), low TV: goal preductal O2 sat >85% and PIP <30cm H20, permissive hypercapnia 45-55
- sedate w opioids benzos to min release catecholamines that increased PVR, normothermia
- pulm vasodilators: prostaglandin E, nitric oxide , surfactant, milirinone (RV failure) (goal is to medically manage pHTN before surgery to decrease R–> L shunt through PFO and PDA
agonists (prostacyclin, NO) or antagonists (endothelin)
- muscle relaxant to reduced V02
- serial ABG, CXR, echo (cardiac lesions)’
ECMO
Initial management of TEF
Goal
Types
intubate:
- awake: uncooperative, IVH
- inhalational: mainatin sponatneous vent
consider gastrotomy tube if significant gastric distention, ventilation did not improve, baby was unstable
avoid ETT and PPV to avoid gastric expansion
Fogartery catheter from gatrotomy to occlude esophagus from below if need PPV can keep losing ventilation through fistula
congenital abnormalities associated w TEF
VACTERL
vertebral, anal atresia cardiac, TE, renal, radial, limb
cardiac 20% corartation of aorta, Atrial or ventricular septal defects, TOF
adequate leak for cuff ETT
reason
20-25 cm H20
reduce change of post extubation croup
- pro; less need for repeated larngosopy to change tube, morerelibale delivery of airway pressures,less polution
con: smaller internal diameter-increased resistance
ddx for inspiratory stridor
RF for post intubation croup
tx
extrathoracic upper airway obstruction: epiglotittis, larngotracheobronchitis, larengyal foreign body, post intubation croup, asthma, anaphalaxsis
intubation: traumatic, prolongedm tight tube
head neck procedures, intraoperative postition changes, small larynx, coughing w tube in place
foreign body (airway/esophgael injury), croup, epiglotttis, reactive airway dz
steriods, racemic epi, humidified oxygen
post op complications/lon terms TEF repair
anastamotic leak
tracheal/esophageal stricture, fistula
GERD, dysphagia, esophageal dysmotility, aspiration
what is cob angle
what is abnormal, when is surgery considered, pulm dysfunction, and pHTN (rest and exercise)
measures severity of scoliosis
lines parallel to the upper border of most cranial tilted vertebrae and the lower border of the most caudal tilted vertebra, then erecting perpendiculars from these lines to cross each other, the angle between these perpendiculars being the ‘angle of curvature’
>10 abnormal, >40-50, >60-65 pulm dysfunction, pHTN >70 at exercise, .110 pHTN at rest
omphalocele vs gastrochesis
omhalocele associated conditions
features of beckwith wiedamenn
omphalocele-at umbilicus, gut fails to migrate into abdomen covering, congential defects,
gastrochesis-occlusion of imphalomesenteric artery–>defect in abdominal wall; risk hypovolemia/infection
trisomy 21, CDH, ettrophy of bladder, cardiac, beckwith-wiedemann syndrome (macroglossia, macrsomonia, midline wall defects, hypoglycemia)
causes of difference between pre and post ductal pulse ox
inflated R sided BP cuff
compression (abdominal distention)
R–>L shunt via PDA
coartation of aorta
When to do a staged closure for omphalocele
intragastric or intravesticular pressure >20
PIP>35
ETC02 >50
How to eval AO instability in Downs
look for prior imaging: subluxation: anterior atlamtodental interval (AADI)>4-5mm in lateral view, neural canal; width, atalanto axial instability
PE:
If signs consistent with cord compression/spine instabilitydelay case and have repeat cervical imagine and neuro surgical eval of cervical spine (motor/sensory pain changes w flexion/extension
No signs likely don’t need imagine but avoid excessive extension flexion rotation
WHy no awake IV or fiberoptic in epiglottits
placement of IV can trigger larngospasm
Any kind of upsetting manever (IV; separating family) can cause crying and potentially trigger resp distress and airway obstruction
child comes in w suspected aspiration but it can also be
when can u consider waiting for imaging
issues w PPV
foriegn body in lungs
asthma
anaphalaxis
croup/epiglottis
not concerned that aspirated object will swell, become firable or cause chemical irritation (chemical pneumonitis)
distal migration of object, worsening of hyperinflation/PTX
Item lodged in carina cant ventilat, what do u do
ask surgeon to remove
have surgeon move it distally to allow OLV
move pt into lateral/prone
try to advance ETT beyond obstruction
CBP
