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Peds Flashcards

1
Q

How to reduce PONV

A
  1. adequate IV hydration
  2. prop, avoid volatile, min opioids
  3. antiemetic: zofran, dex
  4. decompress stomach-avoid gastric distention
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2
Q

pediatric airway differences

How does it alter management

A
  1. large head and tongue:shoulder roll instead of head elevation (occiput)
  2. more cephalad larynx (C4 vs C6), cricoid narrowest part, long stiff epiglottis: -, straight blade (epiglottis), more inclined to use cricoid (anterior airway),
  3. nasal passage and airway smaller ( increases in resistance with edema and secretions):watch out for airway obstruction w anesthesia
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3
Q

why are peds pt prone to hypoxia on induction

Why is inhalational induction faster

A

higher O2 conumption, and smaller FRC

higher MV: FRC ratio

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4
Q

why is respiration less efficient

A
  1. ribs are cartilagenous & pliant ribs predisposing to chest wall collapse, ribs angled horizontally and do not lift up to expand chest
  2. diaphragm less fatigue resistant type 1 fibers
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5
Q

How is fetal circulation unique

how does this change at birth

A
  1. PVR elevated due to collpased unoxygenated lungs
  2. SVR low 2/2 low resistance placenta
  3. 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

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6
Q

How is neonatal CV system different from adult? 6

A
  1. 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. 2/2 ventricular noncompliance: less able to handle increase preload, less capable of increasing contractility in response to afterload, more ventricular interdependence
  3. less responsive to catecholamines
  4. SNS less developed predisposing to bradycardia
  5. autonomic reflexes blunted
  6. prediposed to PHTN
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7
Q

Why is neonatal NS different (3)

A
  1. more sensitive to anethetics: less protein binding, increased perm BBB, decreased drug elim (, increased sensitivity to drugs
  2. less autoregulation of CBF
  3. NMJ is immature–>increased sensitivity to NMB
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8
Q

EBV

A

premature 100cc/kg

FT neonate 90

Pregnant 90ml/kg

infant 80

70 child

60 adult

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9
Q

Anatomical considerations for spinal of caudal?

A

L3 (cord) S3(caudal sac)

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10
Q

Hematologic considerations of newborn

A

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

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11
Q

What are the functional limitations of a immature kidney

A

low GFR (unable to handle large fluid load)

immature tubular fxn (concentrating, retention NA, resorption glucose, ability to acidify urine

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12
Q

What is considered hypoglycemia in a newborn

why are premature infants prone to glucosuria

A

<30 in newborn <45 after 24 hrs

in infants less than 34 weeks there can be reduced tubular absoption of glucose

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13
Q

Why are pediatric pts predisposed to hypothermia

how do they generate heat in response to cold stress, when less effective

A

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

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14
Q

Newborn struggling on delivery. ddx

A

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)

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15
Q

NALS

A
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16
Q

Signs res distress

A

apnea

noisy breathing (stridor dyspena

tachypnea, use of acessory muscles, nasal flaring

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17
Q

cold

A

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

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18
Q

When acceptable to remove LMA prior to emergence

A

no obstructive sleep apnea, obesity, difficult airway, aspiration risk

otherwise remove when child regains consciousness (opens eyes to command)

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19
Q

signs of post tonsilectomy hemorrhage

consistent with blood loss in excess of 20%

A

orthostatic hypotension, tachycardia, dizziness,

excessive swallowing

increased capillary refill time, pallor, sweating, restlessness

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20
Q

opioids and children undergoing TA

A

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

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21
Q

posttonsillectomy bleeding

A

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

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22
Q

when to cancel for respiratory infection

risks

when does airway reactivity resolve

A

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

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23
Q

MH dx

at risk pts

suscpetibility

ABG

A

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

24
Q

MH tx

A
  • 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
25
Q

What causes dudctus arterrosis closure

causes of persistent PDA

drugs tx to close, SE

A
  • 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
26
Q

What is RDS

signs

dx

prevention

RF

long term consequences

A
  • 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
27
Q

What is EIsenmengers

A
  • Pulmonary vascular overload, irreversible pHTN,RHF, reversal of shunt (RL=Eisenmengers)
28
Q

Risks of prematurity and low birth weight

A
  • 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)
29
Q

Potential PDA closure complications

A
  • 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)
30
Q

How are pre and post dutal readings helpful

A
  • 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)
31
Q

Goals to avoid ROP

RF

A

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
32
Q

How to maintain normothermia in neonate in OR

A

-ensure ambient temp in OR at least 26-30

infrared heating lamps

forced air warmers

warmed IV fluids

heated transport incubator

Heat moister exxchanger

33
Q

When is vascularization of retina complete and ROP less of a risk

Goals O2 sat Pa02

pathophys

A

44 wks PCA

87-94%, 50-80mmHg

High O2 leads to vasoconstricton and obliteration of retinal vessels, relative hypoxia results in abnormal neovasculariztion

34
Q

neonatal seziure ddx

A

IVH, cerebral edema

hypoxia hypercarbia

hypogycemia, hypomag, hypocalcemia

TORCH (toxo, rubella, CMV, herpes), sepsis

35
Q

unable to open pts mouth during induction ddx

A

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

36
Q

How to prepare Machine for pt who once had MH

A

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

37
Q

signs sx pyloric stenosis, metabolic derrangements

when would the kid be optimied for surgey

Why alkalosis

A

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

38
Q

How to access neonate volume status

A

sunken fontelles, skin turgur, capillary refill,

HR, BP mental status

freq./volume of wet diapers

39
Q

Why in inhalational induction faster in neonate

A

higher MV:FRC ratio

increased blood flow to vessel rich organs

40
Q

Concerns for anesthesia w premature neonates

RF for post op apnea, decreaserisk

A

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

41
Q

Downs features

A
  • 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
42
Q

how to get IV in uncooperative child

A

EMLA (lido + prilocaine) + ketamine IM (3mg/kg) + inhaled dex+nitrous +inhalational induction

43
Q

features of CDH

A

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

44
Q

CHD initial tx

A
  • 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

45
Q

Initial management of TEF

Goal

Types

A

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

46
Q

congenital abnormalities associated w TEF

A

VACTERL

vertebral, anal atresia cardiac, TE, renal, radial, limb

cardiac 20% corartation of aorta, Atrial or ventricular septal defects, TOF

47
Q

adequate leak for cuff ETT

reason

A

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
48
Q

ddx for inspiratory stridor

RF for post intubation croup

tx

A

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

49
Q

post op complications/lon terms TEF repair

A

anastamotic leak

tracheal/esophageal stricture, fistula

GERD, dysphagia, esophageal dysmotility, aspiration

50
Q

what is cob angle

what is abnormal, when is surgery considered, pulm dysfunction, and pHTN (rest and exercise)

A

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

51
Q

omphalocele vs gastrochesis

omhalocele associated conditions

features of beckwith wiedamenn

A

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)

52
Q

causes of difference between pre and post ductal pulse ox

A

inflated R sided BP cuff

compression (abdominal distention)

R–>L shunt via PDA

coartation of aorta

53
Q

When to do a staged closure for omphalocele

A

intragastric or intravesticular pressure >20

PIP>35

ETC02 >50

54
Q

How to eval AO instability in Downs

A

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

55
Q

WHy no awake IV or fiberoptic in epiglottits

A

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

56
Q

child comes in w suspected aspiration but it can also be

when can u consider waiting for imaging

issues w PPV

A

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

57
Q

Item lodged in carina cant ventilat, what do u do

A

ask surgeon to remove

have surgeon move it distally to allow OLV

move pt into lateral/prone

try to advance ETT beyond obstruction

CBP

AW (15 decks)

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