Peds Flashcards
Explain why a child desaturates quicker
Increased O2 consumption
Slightly deceased FRC due to collapse of chest wall
Unable to maintain a negative intrathoracic pressure
Increased work of breathing due weak intercostal muscles (no slow twitch fibers)
Explain the differences of a pediatric airway
Large occiput Higher larynx More anterior airway Large tongue Omega shaped, epiglottis Smaller and fewer airways - increased airway resistance
What is different about the CV system in peds?
Stroke volume is fixed, they are heart rate dependent
They have immature SNS so less responsive to catecholamines and may have hypotension without tachycardia
Why do kids have a faster inhalational induction?
They have a higher alveolar ventilation
Decreased FRC
And higher blood flow to organs
Lower blood/tissue solubility
Why do kids require larger doses of propofol?
Larger volume of distribution
Shorter elimination half life
Increased plasma clearance
Why are babies prone to hypoglycemia?
Decreased glycogen stores
What are the kidney function differences in children versus adults?
Decreased ability to concentrate the urine –> prone to dehydration
Decreased GFR
Approaches normal around 6 months - 2 years old
What are the pharmokinetics of NMBs in neonates?
Faster onset due to shorter circulation times Large ECF (larger Vd) Unpredictable response due to immature NMJ and hepatocytes
Why wouldn’t you use succinylcholine in a child?
Risk of hyperkalemic cardiac arrest (especially if undiagnosed neuromuscular disorder)
Precipitation of MH
A peds patient is crashing and you have no access. What do you do?
IO 18 G to the tibia
You have a neonate who needs an emergency ex lap, what will you do to optimize respiratory support in the OR?
Take out HME (decrease dead space)
Don’t let peak pressures rise above 15-18
How do you manage laryngospasm in a peds patient?
100% oxygen (turn off nitro) Deepen anesthetic Jaw thrust Positive pressure at 20 cm H2O IM rocuronium Lidocaine 1-1.5 mg/kg Atropine 0.02 mg/kg IM for hypoxia induced bradycardia 100 Mcg/kg epi down tube
Patient has a barking cough in PACU, what are you concern about? How do you manage? What could you do to prevent this.
Post-extubation croup from glottic or tracheal edema
Racemic epinephrine
0.5mg/kg of dexamethasone
A peds case is getting a circumcision, how much volume do you give in the caudal?
0.5 ml/kg or 1.25 mg/kg
Neonates comes in with a volvulus, what’s your anesthetic plan?
Pass OG/NG before induction
RSI with rocuronium and ketamine for induction
Judicious opioid use (fentanyl 1 Mcg/kg) for pain control, use ketamine as well
Maintenance with sevoflurane
NG tube after induction
Fluid resuscitation- 6 ml/kg/hr
What are the anesthetic considerations of a congenital diaphragmatic hernia?
Pulmonary hypertension
Pulmonary hypoplasia
Increased airway reactivity and resistance
Intestinal malrotation - aspiration, dehydration
Hypotension due to IVC compression after repair
Contralateral PTX
Other associated defects: ASD, coarctation, ToF, VSD, hydrocephalus
What is your anesthetic plan for congenital diaphragmatic hernia?
Start sedation with precedex, give glycopyrrolate as antisialoge, will also help against hypoxia induced bradycardia. Use ketamine to maintain pressure and airway reflexes.
Place NGT
Preoxygenation
Awake intubation sitting up - need to avoid PPV due to risk of barotrauma, contralateral PTX, gastric distention.
Induce : RSI
Keep spontaneously breathing on sevoflurane thru case
Maintain PaO2 between 90-100%
Allow permissive hypercapnea
Keep peak pressures less than 30, PIP < 25
How much fluid do you resuscitate with for third space losses in a big surgery?
6-10 ml/kg/hr
What is the anesthetic plan for TE fistula?
Central line in case they get into great vessels
arterial line do to surgical compression of heart/vessels + may have to one lung ventilate
Precordial stethoscope to detect obstruction of bronchus
Fogarty catheter for one lung ventilation
Awake intubation sitting up
RSI with inhalational
ETT tip distal to fistula and proximal to carina if possible. If this is not possible, intermittent gastrostomy venting
What are the anesthetic concerns in TE fistula?
Aspiration
PNA –> airway reactivity, sepsis, decreased compliance
Ventilation
Cardiac abnormalities
What monitors do you want for CDH or TEF?
Central line - for resuscitation, CVP and right heart function monitoring
Arterial line - for blood gas, but also because of surgical compression of heart/vessels
Precordial stethoscope for PTX, obstruction of bronchus
Pre and postductal pulse oximeters
Fiber optic near for tube checks
Esophageal or rectal temp probe
What is the anesthetic plan for pyloric stenosis?
Make sure patient is adequately resuscitated. Often have hypochloremic hyponatremic metabolic alkalosis from vomiting (BMP for electrolytes: Na > 130, chloride > 105, K > 3.0, bicarbonate < 30)
Pass NGT before induction. 2-3 X
RSI -
How will you resuscitate a newborn with pyloric stenosis and hypochloremic hyponatremic metabolic alkalosis?
NaCl with dextrose until Chloride is over 105 or urine chloride is greater than 20
Add K to solution with UOP is 1-2 ml/kg
How much dexmedetomidine can you use for pre med?
0.5-1 Mcg/kg IV
1-2 Mcg/kg intranasal
If you have no IV, what are your premed options?
IM Ketamine 2-5 mg/kg - onset 3-5 minutes, duration - 40
Intranasal dexmed 1-2 Mcg/ kg
Oral midazolam: onset 15 minutes, peak at 45, duration 2 hours
Oral fentanyl: 10 Mcg/kg
Intranasal fentanyl: 1-2 Mcg/kg
What do right to left shunts do to rate of inhalational induction?
Increases the speed of induction
Increased rate of rise of FA/Fi
What are the anesthetic considerations for BPD.
Increased airway resistance
Decreased compliance
V/Q mismatch, so low PaO2
Increased pulmonary infections
*** use nasal CPAP for recruitment!
What are anesthetic considerations for a Downs patient?
Difficult airway: Large tongue Cervical stenosis and A-A subluxation! - get X-rays to assess Obesity/OSA Sub glottic narrowing Redundant tissue --> obstruction
Difficult IV access: hypotonia and obesity, looser skin, more subq fat, and medialization of veins
Cardiac abnormalities: endocarditis cushion defects, ASD, VSD, profound bradycardia, pulmonary hypertension
GI: duodenal atresia and reflux
What are the anesthetic considerations for neuromuscular disorders?
Aspiration risk due to decreases airway reflexes, increased oral secretions
Body positioning - IV access
Resistant to NMBs (lack of functioning NMJ)
Decreased MAC and increased opioid sensitivity
Increased hypothermia
Increased blood loss, factor deficiency, TCP
Your peds patient is cold. What are you going to do?
Increase room temp Convective forced air Polymeric fabric blankets Heat lamp Heated water mattresses Plastic sheets around the head Warm IV fluids
Your peds patient bronchospasms - what do you do?
100% oxygen PPV Albuterol IV atropine 0.02mg/kg Suction Epinephrine 1 Mcg/kg
What are the anesthetic goals in noncyanotic heart lesions?
Balance of pulmonary VR and systemic VR
What are the risk factors for postoperative sleep apnea in children?
Obesity Less than 3 years old Obstruction on induction URI within last 4 weeks Nasal/craniofacial disorder Severe OSA Cor pulmonale HTN
A patient is in pain in PACU after T/A, how will you treat?
1st line: Tylenol
2nd line: oxycodone, morphine, ibuprofen
BLACKBOX on codeine
What are the anesthetic goals of congenital emphysema?
Avoiding hyperinflation of regions of the lung
Maintain spontaneous ventilation, avoid PPV, no N2O
What peds syndrome have AA Subluxation risk?
Morquio
Goldenhar
Downs
(Achondroplasia)
What peds syndrome requires awake intubation?
Pierre robin
Place nasal airway–> video laryngoscopy
Other features: posterior displacement of tongue
Opioid sensitivity
Cleft palate
Micrognathia
What are the airway concerns with MPS disorders?
Upper airway obstruction due to enlarged tongue and tissue
Difficult visibility due to lymphoid tissue infiltration
Thick secretions
Describe the circulation in a hypolplastic left heart
Systemic blood reaches RA and mixes with oxygenated blood from LA thru an ASD –> RV
2 pathways:
1. Goes to the lungs via the pulm. A
2. Goes thru the PDA retrograde flow to system
What are the anesthetic goals with hypo plastic LH?
Balance of circulation
Need to avoid an increase in pulmonary flow (keep FiO2 low, maintain preload, decrease minute ventilation and increase PaCO2 - remember PaCO2 of 28-32 causes pulmonary vasodilation)
What are the vasopressor said of choice in hypolplastic LH?
Milrinone
Phenylephrine
Phenoxybenzamine
Explain Fontan circulation, what are the anesthetic goals?
Patient now has 1 main ventricle (aorta connected to the RV)
Systemic circulation drains passively into the pulmonary artery
Pulmonary veins empty into LA
LV ejects into tricuspid to aorta
Anesthetic goals: maintain preload! Decrease PVR, maintain forward flow!
What is the initial resuscitation for a dehydrated peds patient?
20 ml/kg bolus with salt solution
10 ml/kg with albumin
What are signs of severe dehydration in a peds case?
Sucked fontanelle Dry mucous membranes UOP < 0.5 ml/kg/hr Urine specific gravity > 1.030 Weight loss of > 15%
What are the implications of an endocarditis cushion defect?
Incomplete walls
Incomplete valves
Conduction defects
What are the implications of an unrepaired endocardial cushiono defect?
Paradoxical embolization
VAE
Use a bubble trap!
How would you treat postop pain in an ENT case that you masked the whole case with no IV?
Rectal Tylenol
IM ketorolac
Intranasal fentanyl or precedex
Doing an ear tube case without an IV, patient’s heart rate drops to 4 what do you do?
Start CPR Call for help IM atropine (0.2 mg) IM epinephrine (100 Mcg) Turn off gas 100% Fi O2 Epi down ETT
How much blood would you transfuse in a neonate?
10-15 ml/kg
What is the transfusion threshold for infants with severe cadrdiopulmonary disease or neonates?
Hct less that 40-45%
What is the transfusion threshold for infants with moderate cardiopulmonary disease on CPAP or supplements O2 or major surgery?
Hct 30-35
What if the patient has stable anemia or unexplained breathing disorder? What is the transfusion threshold?
Hct 20-30
Can you give neonates “old blood”?
As long as it is within the licensed dating period it is ok to give. You do not have to use fresh blood
What is the treatment for acute chest syndrome ?
Exchange transfusion
What are the transfusion guidelines for sickle cell ?
Transfuse to maintain a HbS level below 30%, Hgb > 9 g/dl
This prevents stroke in children
What should you do if the baby’s heart rate is less than 100?
Give positive pressure ventilation
Suction
What do you do if a baby’s heart rate drops below 60?
Start chest compressions at 120 bpm
BMV with PPV
Epinephrine 10-30 Mcg/kg, 100 Mcg/kg if down ETT
Volume resuscitation of 10 ml/kg over 5-10 minutes
What is the controlled RSI technique for emergent intubation in peds?
gentle BMV with PIP less than 10-12
No cricoid pressure
O.6-0.7 mg/kg of rocuronium
In patients with pyloric stenosis, or undergoing other quick surgeries, what dose of roc can you use for intubation?
0.3-0.45 mg/kg
How will you treat postoperative pain from pyloric stenosis?
Avoid opioid due to postop apnea risk
rectal APAP and local infiltration
Could consider caudal block (1.25 ml/kg of ropi)
Give your differential for listlessness in a child
Fever Dehydration Homeopathic herbal therapy Metastatic disease to the brain (increased ICP) Seizure Anemia (bleeding) Cardiogenic shock Leukemia - immunosuppressive --> infection, bleeding,
What is an acceptable hematocrit in children?
21-26
What is different about placing a central line in a child?
More likely to pull them out!
Femoral lines are worse because of mobility issues and higher risk of thrombosis
Use Broviac catheter for cosmetics, less chance of dislodge, and less care
How would you sedate a child in the ICU.
- Benzodiazepine
Don’t use etomidate due to adrenal suppression
Don’t use propofol due to infusion syndrome
What foreign bodies are most dangerous to the lung?
Batteries –> leak acid
Oily nuts –> induce inflammation
Vegetables –> expand over time
What kind of supportive care of a kid with foreign body aspiration?
Make them calm! Supplemental O2 NPO status Beta agonists Steroids Antibiotics
What’s the oral dose of midazolam for a child 18 months - 3 years old?
0.75 mg-1mg/kg
What’s the oral dose of midazolam for a kid 3-6 years old?
0.6-0.75mg/kg
What’s the oral dose of midazolam for kids 6-10 years old?
0.5mg/kg
What’s the oral dose of midazolam for kids over 10?
0.3 mg/kg
How would you handle a complete airway obstruction on induction in a child with a foreign body?
Rapid intubation
Push foreign body down a bronchus and assume 1 lung ventilation
What is the preferred method of induction and intubation in setting of a foreign body?
Inhalational induction
Maintaining spontaneous ventilation with a ventilating bronchoscope
Emerge with mask because less stimulation of the airway
What are the expected postop complications after foreign body removal?
Vocal cord edema and stridor due to bronchoscope
Increased secretions
Bronchospasm
Consider deep extubation
What are the risk factors for postop apnea?
Post conception age 50-60 weeks (less than 44 need continuous O2 monitoring) Small for gestational age Anemia (<30%) Neuro abnormalities Sepsis
What are the critical things to know about a NICU stay?
Apnea episodes
Intubations and lengths of intubations
Methods of intubation
How long they were in NICU
How can you decrease the risk of postop apnea?
Wait to do surgery at least 6 months from last apnea episode
Regional anesthesia without sedation
IV aminophylline and caffeine 10mg/kg
What is primary apnea?
Apnea after initial attempts to restore breathing like stimulation
What is secondary apnea?
Apnea that occurs with continued oxygen deprivation
What does the Apgar score include?
Heart rate Respiratory effort Reflex irritability Muscle tone Color
Describe the normal closure of a PDA
Increase in arterial oxygen and decrease in pulmonary vascular resistance with initiation of ventilation reverses the shunt and exposes the PDA to high oxygen levels
Decreased prostaglandin circulation with placental separation causes closure of PDA within 2-4 days
What are predisposing factors to a PDA?
Prematurity RDS Hypoxia Acidosis Excessive fluid therapy
What is RDS from?
Insufficient surfactant –> widespread atelectasis –> intrapulmonary shunting –> hypoxia and acidosis
What are the side effects of indimethacin?
TCP
Hyponatremia
Reduced renal, cerebral and mesenteric blood flow
Ibuprofen is used in low birth weight neonates because same efficacy and less side effects
What are the potential complications you should anticipate for a neonate?
Hypothermia Retinopathy Postop apnea Hypoglycemia IVH
What monitors do you want for a closure of a PDA or other congenital heart cases?
Blood pressure on right arm (may clamp left subclavian if they tear the PDA)
Pulse of on right hand and lower limb for preductal and postductal pressure - can provide info about shunting (lower postductal oxygenation) and guide surgeon to ligate the right thing
What would you see on your pulse oximetry if the surgeon lighted the aorta in a PDA case?
Loss of the post ductal (lower extremity) waveform
What would you see on your monitors if the surgeon lighted the pulmonary artery in a PDA case?
Decrease in both pre and post ductal oximetry and decrease in ETCO2
How do you reduce the risk of retinopathy of the newborn?
Decrease FiO2 to maintain a PaO2 of 60-80 or oxygen saturation of 87-94%.
What are the RFs for retinopathy of a newborn?
Prematurity (especially < 32 weeks) Low birth weight (<1500 g) RDS/hypoxia/mechanical ventilation Acidosis Cyanosis CHD Fluctuations in CO2 and O2 Bright light Maternal diabetes, use of antihistamines within 2 weeks of birth Hyperglycemia Steroids IVH
How can lowering oxygen saturation help in a patient with L–> R shunt?
Increased hypoxia pulmonary vasoconstriction and thereby increasing pulmonary pressures and decreasing the shunt, so less pulmonary congestion and volume overload of the heart
How do you estimate blood loss for a neonate?
Weigh the sponges and laps
What’s the average blood volume of a premature neonate?
100 ml/kg
What’s the average blood volume of a neonate?
90 ml/kg
During dissection of a PDA, oxygen saturation drops and so does heart rate, what is this likely from?
Traction on the lung increasing pulm pressures and therefor R–> L shunting
Hand bag patient on 100% FiO2
Check other pressures and vitals
Talk to surgeon
Administration 0.01-0.02mg/kg for hypoxia induced Brady
What is neutral temperature?
Ambient temp at which oxygen consumption is minimized
What is the neutral temperature for a preterm neonate?
34 C
What is the neutral temperature for a term neonate?
32 C
What is the neutral temp for adults?
28 C
What happens with hypothermia in a neonate?
Increased oxygen and glucose utilization –> acidosis secondary to metabolism of brown fat into ketones
Increased PVR
Respiratory depression
Describe no shivering thermogenesis
Metabolize brown fat due to norepinephrine
Works by uncoupling oxidative phosphorylation producing heat instead of ATP
Inhibited by beta blockade and volatile anesthetic
How do you maintain normothermia in a neonate in the OR?
Maintain OR temp between 26-30 degrees C Heat lamps Forced air warmers Warm IVF Heat gases, humidify Polymeric fabric Water mattress Wrap plastic around the head
What’s on the differential for neonatal seizure?
Intracranial hemorrhage Cerebral edema Hypoglycemia Hypocalcemia Hypomagnesemia TORCH infection Sepsis
How would you eval for atlantoaxial subluxation?
Look at old ACRs
Neck X-rays for > 4-5 mm anterior atlantodental interval
Perform H& P assessing for myelopathy symptoms
If myelopathy –> delay case for X-rays and get neurosurgical consult
What airway equipment would you want for a Down’s syndrome patient?
Multiple different ETT with smaller diameters for sub glottic stenosis
Difficult mask - oral and nasal airways
What are the risk factors of emergence delirium?
Preop anxiety Young age (1-5 years old) Post op pain Less soluble volatile agents (servo and des) Underlying patient temperament Type of surgery: abdominal Prolonged surgery
How would you manage emergence delirium?
Call for help Secure arms to keep from dislodging IVs and ETT Attempt to reassure Quiet environment Sedation Pain control Check Foley, palate, US For retention Check vital signs
How would you prevent emergence delirium?
Preop reassurance
Preop medication (not midazolam)
Ensure pain control
How would you manage a TEF?
Avoid PPV
Allow spontaneous ventilation if possible
Call surgeon gastrostomy tube
Suction secretions
Consider ETT
Intermittent gastrostomy venting with minimal PPV
What are the concerns about prematurity?
RDS Necrotizing enterocolitis BPD Apneic spells Retinopathy IVH Reduced renal and hepatic function Impaired glucose regulation Increased sensitivity to hypothermia
What are the congenital abnormalities associated with TEF?
VACTERL Vertebral defects Anal atresia Cardiac abnormalities (ASD, VSD, coarc, ToF) TEF Renal dysplasia Limb anomalies
How would you evaluate a TEF patient preoperatively?
Assess volume status Assess pulmonary status : tachypnea, tachycardia, intercostal retractions, cyanosis CXR and ABG Echo Renal US spine films
What monitors would you want for a TEF case?
Arterial line for monitoring gasses and hemodynamics due to risk of instability from surgical manipulation of the lung, trachea, heart and great vessels
Precordial stethoscope in left axilla for monitoring of the heart and ventilation, over stomach to monitor for ventilation into the stomach
Place gastrostomy tube to water suction
Where would you place an arterial line in a neonate for TEF repair?
Umbilical artery or femoral artery
How would you induce a TEF patient?
Head up
Suction esophageal pouch, gastrostomy vent and suction
Topicalization of airway
Give atropine to avoid vagal response to laryngoscopy
Inhalational versus RSI
How would you ensure correct positioning of an ETT?
Advance ETT to right main stem, then pull back until bubbling in gastrostomy vent, then advance just until bubbling goes away,
Check bilateral breath sounds
What do you do if you continually ventilate the stomach in TEF?
Pass a fogarty catheter retrograde through the stomach to occlude the tracheal orifice
What is on the differential for hypoxia in a TEF repair?
Migration of tube into right mainstream or fistula
Surgical retraction of lung, trachea
Gastric distention causing worsening atelectasis
Bronchospasm
Pneumothorax
ETT clog or kink
At what rate would you give maintenance fluids?
4 ml/kg/hr
At what would you replace insensible losses?
6 ml/kg/h
What level of glucose is considered hypoglycemia in a neonate?
<40 Sx: Jitteriness Seizures Lethargy Temp instability Apnea
What is considered normothermia?
36.5-37.5
Why are neonates prone to hypothermia?
Due to thin skin
Large body surface area to mass ratio
Lower subcutaneous fat
Brown fat metabolism
What are the effects of hypothermia?
Delayed awakening Apnea Hypoventilation Increased PVR increased L-->R cardiac shunting due to above Decreased drug metabolism Coagulopathy Poor wound healing Metabolic acidosis (from brown fat metabolism)
What are the long term complications associated with TEF?
Anastomotic leak Strictures GERD Tracheomalacia Recurrent fistula Dysphagia Recurrent aspiration Barrett's Pneumonia Bronchitis Sepsis
What is the differential diagnosis for a child with fever, drooling, stridor and intercostal retractions?
Epiglottis Foreign body Pharyngitis Pharyngeal abscess Laryngotracheobronchitis Severe tonsillitis
What is a normal heart rate for a kid less than 1 year old?
100-190
What is a normal heart rate for a toddler 1-2 years old?
98-140
What is a normal heart rate for a preschooler 3-5 years old?
80-120
What is a normal heart rate for a kid 6-11 years old?
75-118
What’s a normal BP of a neonate less than 1 gram?
39-59/16-36
What is a normal BP for a neonate at 96 hours of life?
67-84/35-53
What’s a normal BP for an infant 1 month to 1 year old?
72-104/37-56
What are the contraindications to ECMO?
Gestational age less than 34 weeks Weight less than 2 grams ICH Mor than 1 week of aggressive respiratory therapy Congenital heart disease
Where does the umbilical vein central line go?
Catheter tip at the junction of the right atrium and IVC
What are the complications associate with umbilical vein catheterization?
Infection Thrombosis of portal and mesenteric veins Portal cirrhosis Endocarditis Cardiac tamponade Liver abscess Hemorrhage Sub capsular hematoma
Where would you place an umbilical artery catheter?
Thru iliohypogastric artery into the descending aorta to the level of T7-9
What is the pathophysiology of retinopathy of the newborn
Oxygen toxicity causes vasoconstriction and obliteration of retinal vessels in infants less than 44 weeks of GA
Patient with congenital diaphragmatic hernia is hypotensive after returning abdominal contents, what do you do?
Alert the surgeon Apply 100% FiO2 and hand ventilate Auscultate to rule out PTX and endobronchial intubation Check tube position Check ECG for arrythmia Check surgical field for bleeding Decrease volatile Ask surgeon to relieve the pressure if everything else is ruled out Increase preload with fluid
What is osteogenesis imperfecta?
Connective tissue disorder involving abnormal Type I collagen resulting in blue sclera, brittle bones, scoliosis, AA instability, CV defects (septal defect, aortic dilation/dissection), macroglossia’ short neck, kyphoscoliosis, restrictive lung disease, metabolic acidosis
Why is hydration an important initial step in correcting metabolic alkalosis associated with pyloric stenosis?
Because after a while the kidney start to hold onto sodium which also results in reabsorption of bicarbonate and worsening of metabolic alkalosis
Metabolic alkalosis leads to leftward shift of oxyhemoglobin curve, seizures, decreased ionized calcium, arrythmia,
What is a circle system?
Provides more effective preservation of heat and humidification
Reduces waste of anesthetic agents
Reduces OR pollution
Reduces dead space
Has unidirectional valves and CO2 absorber that increase resistance –> use pressure control and limit peak pressure to prevent delivery of excess tidal volume and increased work of breathing
What are the risk factors for post extubation croup?
Oversized ETT Age 1-4 years old Surgery duration > 1 hour Head neck surgery Volume overload Repositioning Traumatic intubation or multiple attempts Coexisting respiratory infection Previous history
What is Beckwith-Wiedemann syndrome?
Macrosomia Macroglossia Omphalocele Hypoglycemia Polycythemia
What monitors would you require for a neonatal surgery?
Standard ASA monitors Temperature probe Arterial line to assess acid-base status Peripheral nerve stimulator Pulse oximetry on RUE and LE Precordial stethoscope?
How would evaluate a child going for tonsillectomy preoperatively?
Airway exam
Lung auscultation
Look at sleep study
EKG or Echo searching for signs of RHF and pulmonary HTN
CXR to look for cardiomegaly or lower airway disease
How would you evaluate a patient with a possible bleeding disorder?
Get a coag profile
Consult hematology
Consider getting vWF activity, factor VIII and IX activity levels
How would you prepare a patient with hemophilia for surgery?
Give virally inactivated factor VIII concentrate to help prevent bleeding by raising his factor VIII levels above 30%
Goal is to raise to 75-100%
Consider desmopressin for increased release of vWF and factor VIII
What are the considerations for a post-tonsillectomy bleed?
Hypovolemia
Hemoconcentration 2/2 deceased fluid intake
Eval for signs of significant bleeding: tachycardia, hypotension, sweating, increased cap refill time, restlessness, pallor, excessive swallowing
Need large bore IV access
Type and cross for 2 units
How would you induce and intubate a patient who is actively vomiting blood?
Obtain IV access
Continue volume resuscitation thru large bore IVs
Have surgeon place a pharyngeal pack and transport to OR with supplemental oxygen and standard ASA monitors
Place patient with head down and in lateral position to allow drainage of blood from the mouth
Pre-oxygenate
Place patient supine and do RSI with sux, etomidate/ketamine and atropine
Insert OG to empty stomach full of blood
What is the pediatric stress dose steroid recommendations?
Minor surgery: hydrocortisone 25 mg
Moderate surgery: 50 mg
Major : 25 mg IV q6h and wean over 1-3 days
How would you extubate a patient after tonsillar bleed?
Empty stomach with an OG tubs
Position the patient laterally
Gently suction oropharnyx
Give bronchodilator and IV lidocaine to blunt airway irritation
Extubate awake with protective airway reflexes
How do you reduce PONV.
Adequate hydration Empty stomach with OG tube Utilize propofol on induction Dexamethasone intraoperative Give Zofran Minimize opioids
How long should you monitor factor levels after surgery in hemophilia patients?
For 2 weeks
Maintain levels above 75% in first 48 hours
30-50% until 10 days
What are the bleeding risk time frames for tonsillectomy?
75% within first 6 hours
25% within first 24
Secondary bleeding risk decreases after 10 days
What is the lowest normal heart rate for a kid less than 2 years old ?
100 bpm
What is the normal heart rate of a child over 3 years old to 11?
80-120
What is the upper heart rate for a 1-2 year old?
140
What is the upper limit of heart for a neonate?
190-205
What is the normal RR of a baby less than 1 year old?
30-53
What is the normal RR of a 1-2 year old?
22-37
What is the normal respiratory rate of 3-11 year old?
Up to 25-28
What is hypotension for a neonate at 1 g and 12 hours of life?
Less than 40 SBP
What is hypotension for a neonate at 12 hours?
Less than 50
What is hypotension of a neonate (less than 1 month old)?
Less than 60
What is hypotension for a less than 1 year old?
SBP < 70
What is the equation for hypotension above 1 year old to 11 years old?
Less than 70 + age X 2
How do you do jet ventilation in a pediatric patient?
Pressure of 5-10 psig
Inspiratory time of less than 1 second
What are the complications with jet ventilation?
PTX, pneumomediastinum, pericardium, peritoneum
Inadequate gas exchange, hypercarbia
Aspiration
Subq emphysema
During jet ventilation, the patient desaturates, what’s the differential? What would you do?
Ensure proper position of the ventilator and ventilate with 100%
Auscultate the chest
Intubate the patient if continued desaturation
Administer beta agonist Suction PPV to recruit Rule out PTX Deepen anesthetic
How long would you keep a patient intubated after airway fire?
Minimum of 24 hours
Give steroids, humidified oxygen, and monitor
Get serial CXR
When would you consider it safe to extubate someone after airway fire?
When the patient demonstrated adequate oxygenation and ventilation with minimal ventilation support, no evidence of ALI on CXR, no evidence of airway edema on bronchoscopy and passes airway leak test 24 hours after airway fire
How would you treat a Tet spell?
Increase SVR - give bolus and phenylephrine
CORRECT PVR - hypoxia, hypercarbia, acidosis
If infundibular spasm - give ketamine (increase anesthetic depth and maintain SVR) and esmolol
What is the ideal induction choice for someone with ToF and why
IV induction because with R–>L shunt, the speed is increased and you will have less drop in SVR, can control it more
Inhalational induction will be slowed with R to L shunt
What are the features of ToF?
RVOT obstruction
RVH
Overriding aorta
VSD
What are the signs and symptoms of propofol infusion syndrome?
Refractory bradycardia Metaboli acidosis Rhabdomyolysis Lipemia Hyperkalemia Hepatomegaly Fatty liver Renal failure Cardiomyopathy
What are sign is of child abuse?
Retinal hemorrhage Fractures of different ages Bruises in shapes of object Genital bruises Delayed medical care Poor hygiene, low weight and height
What are the concerns about an open EVD and the bag falling to the floor?
Sudden loss of CSF causing collapse of ventricles, rupture of veins and herniation
What are the risks of proceeding with a case when a child has a URI?
Increased risk of perioperative respiratory complications such as laryngospasm, bronchspasm, desaturation
Risk is higher in patients with severe symptoms (fever > 38.5, malaise, mucopurulent secretions, productive cough)
How long would you delay surgery if the patient has a URI and has only mild symptoms?
2-4 weeks
Mild symptoms include: sneezing, nasal congestion, nonproductive cough
When could you proceed if they had a URI ?
If they had only mild symptoms, no other risk factors and we’re not going to require ETT placement
Why wait 4-6 weeks for surgery in the setting of URI symptoms?
To await decrease of airway reactivity
How would you decrease the risk of airway complication when a patient returns after having URI?
Use an LMA
Administer preop atropine or glyco to decrease airway reactivity and bradycardia
Why would you not use succinylcholine in a strabismus surgery?
May interfere with the forced duction test
How would you treat bradycardia during strabismus surgery?
Tell the surgeon to stop manipulation
Hand ventilation with 100% FiO2
Analyze EKG
Auscultate the chest and ensure proper position of ETT
Administer atropine
Ask surgeon to locally infiltrate rectus muscles
You are called to PACU because a patient is tachycardic, what would you do?
Analyze patient’s hemodynamic stability - cycle BP, analyze EKG, provide oxygen, Auscultate chest, assess volume status
Look at records, meds given
Get ABG/ CXR
Give a fluid bolus
What would you do if a child went into SVT in the PACU?
Determine stable or unstable
Apply oxygen and monitors
Establish IV access
If Stable, do vagal maneuvers or ice to the face
If not, give 0.1 mg/kg of adenosine, subsequent dosing would be 0.2 and then 0.4
What is the dosing of synchronized cardioversion for pediatric SVT?
0.5 J/ kg up to 2J/kg
What is a Mapleson D circuit?
Has FGF at patient end
Relief valve proximal to the bag
If FGF > minute ventilation, no rebreathing
What is a Jackson-Rees modification?
Mapleson F
Low resistance, low deadspace
