Peds

Question 1

What is the appropriate technique for fluid resuscitation in a 7kg 5MO?

Answer 1

In states of acidosis, the excess hydrogen ions displace calcium bound by albumin and thus ionized levels of calcium increase. This process is reversed in the setting of alkalosis and should be considered before administering sodium bicarbonate to a patient with pre-existing hypocalcemia.

Question 2

When should dextrose containing fluids be given?

Answer 2

Child <3months, Surgery >3 hours, or other comorbidities

Question 3

PONV risks for Peds?

Answer 3

1) Duration of surgery > 30 minutes 2) Age > 3 years 3) History of PONV in the patient, parent, or sibling 4) Strabismus surgery

Question 4

Frequent blood transfusions for patients with beta-thalassemia would result in what possibly? what anesthetic concerns do you have?

Answer 4

Cardiomyopathy from repeated transfusions 2/2 iron overload and hemosiderosis Thalassemias are a hemolytic anemia Anesthetic considerations for these patients include: Preoperative hemoglobin levels Provision of leukocyte-reduced blood transfusions Cardiac, endocrine, hepatic assessments Bony deformities that may render the airway more difficult Fragile demineralized extremities that may render positioning challenging Post-splenectomy hypertension Thromboembolism prophylaxis and treatment

Question 5

fetal vascular accident affecting the first and second branchial arches. As such, it is a unilateral or asymmetric condition affecting the facial bones and muscles (micrognathia, cleft palate, abnormal tongue, hemivertebrae), eyes (microphthalmia, coloboma, etc), and ears (microtia, hearing loss). Anomalies of other systems are possible (e.g., tracheoesophageal fistula, renal agenesis, ventricular septal defect, hydrocephalus). Laryngoscopy is difficult but supraglottic airways have been repeatedly proven successful.

Answer 5

Goldenhar Syndrome

Question 6

consists of craniosynostosis (premature cranial suture ossification), hypertelorism (increased distance between the orbits), shallow orbits causing ocular proptosis, maxillary hypoplasia, and parrot-like beaked nose. Depending on the specific mutation, patients may or may not have acanthosis nigricans. Unlike Goldenhar/Pierre Robin/Treacher Collins patients, …. patients do not have mandibular hypoplasia/micrognathia. In fact, the maxillary hypoplasia with normal size mandible creates a relative prognathism. The main airway difficulties are difficult mask fitting and upper airway obstruction, whereas intubation is not as difficult unless neck mobility is decreased (cervical spine fusion may coexist).

Answer 6

Crouzon Syndrome

Question 7

tosomal recessive disorder due to an abnormality in alpha-L-iduronidase, which leads to intellectual disability, short stature, and multiorgan involvement secondary to mucopolysaccharide deposition. Treatment with recombinant human alpha-L-iduronidase or bone marrow transplantation can ameliorate the course of the disease. Anesthetic considerations are mostly those of airway management, complicated by abnormal facies, abundant secretions, large tongue, and short neck. The epiglottis may be higher in the neck and potentially displaced downward by insertion of an oral airway.

Answer 7

Hurler Syndrome

Question 8

micrognathia, glossoptosis, and cleft palate. Often an isolated finding, it can also occur in the context of multiple malformations. Unlike Goldenhar syndrome, … sequence is bilateral, and typically does not involve the eyes and ears. Patients with this sequence may require prone positioning or a tongue-lip stitch for spontaneous ventilation.

Answer 8

Pierre Robin

Question 9

syndrome consists of malar hypoplasia, downslanting palpebral fissures, colobomas of the lower eyelid, external ear abnormalities often involving hearing loss, and mandibular and pharyngeal hypoplasia. These patients are considerably more dysmorphic than Robin or Goldenhar patients, but their intelligence is normal, so they should be addressed as appropriate for age (other than speaking louder if they are hard of hearing).

Answer 9

Treacher Collins

Question 10

What are the 5 congenital abnormalities that I need to know for difficult airway in the pediatric patients?

Answer 10

Five congenital anomalies are specifically mentioned in the ABA Content Outline in relation to the difficult airway. Four of these can be grouped together as having mandibular (Goldenhar, Robin, Treacher Collins) or maxillary (Crouzon) hypoplasia with normal intelligence. The other is Hurler, which for airway purposes can be remembered because it shares certain traits with the much more common Down syndrome, namely short neck, large tongue, large adenoids, obstructive sleep apnea, small trachea, and potential atlantoaxial instability. All 5 anomalies are associated with obstructive sleep apnea, and supraglottic airway devices (e.g., laryngeal mask airway) have been reported to be useful in all of them. Robin sequence is the only anomaly that becomes easier to intubate with age, whereas Treacher Collins, Goldenhar, and Hurler reportedly become progressively more difficult. Crouzon syndrome becomes more difficult to intubate as a consequence of maxillary advancement surgery (distraction osteotomy is commonly performed in these patients).

Question 11

when does separation anxiety begin? How would you dose preoperative midazolam orally?

Answer 11

6-8 months. 0.5-0.75mg/kg

Question 12

what opioid is contraindicated post tonsillectomy?

Answer 12

Codeine because it is metabolized into morphine (active form) via cyto 2D6. Rapid metabolizers can have respiratory depression

Question 13

What is the estimated allowable blood loss equation?

Answer 13

MABL = EBV x (patient’s starting HCT – minimum acceptable HCT) /patient’s starting HCT

Question 14

what neurologic abnormalities are associated with myelomenigocele? what toxins are associated with its formation?

Answer 14

Myelomeningocele is the most severe of the spina bifida defects. It is associated with Arnold-Chiari malformations and the patient may require VPS placement later in life for hydrocephalus Even after repair, no neuraxial anesthesia MMC occurs in the 3rd week of development Toxins associated with MMC formation include: Calcium-channel blockers Carbamazepine Cytochalasins Hyperthermia Valproic acid

Question 15

Infant has hypothermia..what is the worst thing that happens to him/her? how does this happen?

Answer 15

Metabolic acidosis -nonshivering thermogenesis of brown fat (4-10% of fat stores in neonate and is high in mitochondria) (disappears around 3-6months after birth)…hypothermia causes norepinephrine release which binds to brown fat via CAMP causing breakdown of triglycerides by using O2 and glucose causing heat production. Ketones and water are byproducts.

Question 16

what should be the initial bolus be for a kid that needs resucitation? 12kg kid?

Answer 16

20ml/kg up to 30ml/kg of 0.9% NS. NO additives

Question 17

what are the common side effects of PRIS?

Answer 17

metabolic acidosis, rhabdomyolysis, hyperkalemia, hepatomegaly, renal failure, hyperlipidemia, arrhythmia, and cardiac failure maximum dose of propofol is 4mg/kg/hr

Question 18

The evaporative water loss per kg is _____ proportional to age

Answer 18

inversely 2/2 increased ratio of body surface area to Total body weight kids have a higher total body water content for size compared to adults

Question 19

is myelinization of the nerves in children advanced or delayed?

Answer 19

delayed. Means easier blocking but shorter duration.

Question 20

what causes gastroschisis ?

Answer 20

Occlusion of the omphalomesenteric artery (this is not associated without omphaloceles)

Question 21

explain the difference between adult and pediatric larynx?

Answer 21

relatively larger tongue of an infant, a more cephalad larynx, angled vocal cords and an omega shaped epiglottis. The infant’s epiglottis is narrower, omega-shaped, and angled away from the axis of the trachea.

Question 22

Tell me some of the key differences between adult and pediatric airways/respiratory system?

Answer 22

Infants have a larger occiput, obligate nose breathers despite smaller nasal passages, large tongues, longer epiglottis, shorter trachea, and a more cephalic larynx (C4) compared to adults (C6) alveolar ventilation and oxygenation is much higher in children (ml/kg/min) –>leads to a more rapid inhalation induction (Oxygen consumption is much higher in infants (approximately 7-9 mL/kg/min) compared to adults (3 mL/kg/min) ) tidal volumes are similar per ratio for adults and children infants have fewer alveoli and less elastin meaning LESS compliant lungs. chest is MORE compliant chest (less recoil) Decreased lung compliance makes inhalation more difficult and increased chest wall compliance adds work to exhalation. This combination promotes greater chest wall collapse, decreased residual volume, and therefore, decreased functional residual capacity (FRC) and greater atelectasis. In addition, infants also have poorly developed intercostal muscles and a diaphragm with a higher percentage of type 2, fast-twitch fibers that fatigue more easily. Altogether, this results in a relatively increased work of breathing compared to the adult patient.

Question 23

what kind of kids are more likely to have preoperative anxiety?

Answer 23

Younger children (i.e., preschool age), children with higher cognitive function, children with shy or withdrawn personalities, and children with anxious parents are all likely to have increased perioperative anxiety when they present for surgery.

Question 24

Is roc more or less potent in children? Succinylcholine?

Answer 24

Neostigmine and rocuronium are more potent in children, and therefore the dose of rocuronium in neonates and infants should be reduced due to immature receptors. The dose of cisatracurium and succinylcholine in children may be increased compared with adults due to an increased volume of distribution.

Question 25

Tell me about osteogenesis imperfecta?

Answer 25

is an inherited disorder of connective tissue that results in grossly abnormal collagen structure and formation, specifically, type I collagen. 4 types of OI, Type 3 is most severe Osteogenesis imperfecta (OI) is associated with normal to above average intelligence. OI is associated with brittle bones that are vulnerable to fracture, joint laxity, joint subluxation, blue-tinted sclera, hearing loss, restrictive lung physiology, cardiovascular anomalies (i.e. valvular heart disease, aortic aneurysms), and there is increased risk of bleeding due to collagen and platelet dysfunction. These patients can be difficult to intubate and backup airway equipment should always be readily available

Question 26

what is the Cobb angle? what angle indicates need for surgery?

Answer 26

Cobb angle is defined as the angle formed by the intersection of a line drawn parallel to the superior surface of the most proximal maximally tilted vertebra and a line drawn parallel to the inferior surface of the most distal maximally tilted vertebra. A Cobb angle of 10º or more defines scoliosis. In general, Cobb angles less than 30º will not continue to progress after the skeleton has matured. Bracing, and other non-surgical techniques, can assist with straightening the spine during development. A Cobb angle alone is not typically an indication for surgery, though angles >40-50º may require surgery to correct the curve. A Cobb angle >40° is indication for surgical intervention due to the severity and eventual worsening of pulmonary complications.

Question 27

who is at increased risk for postoperative apneic event? what is post conceptual age?

Answer 27

The most conservative approach is monitoring all infants younger than 60 weeks postconceptual age for 24 hours following surgery. Infants are at a higher risk for perioperative apnea if they have multiple congenital anomalies, a history of apnea or bradycardia, and chronic lung disease. Other contributing factors include hypothermia and anemia. Infants are at a higher risk for perioperative apnea if they have multiple congenital anomalies, a history of apnea or bradycardia, and chronic lung disease. Other contributing factors include hypothermia and anemia.

Question 28

what is the onset and duration of intranasal fentanyl?

Answer 28

and works rapidly with a 7-8 minute onset and a 1-2 hour duration

Question 29

when does physiologic anemia of infancy occurs? when is adult levels reached?

Answer 29

2-3 months of gestational age. nadir of 10 adult levels reached at 2 years preterm infants have a drop earlier

Question 30

what is the current fluid replacement strategy for the pediatric patient?

Answer 30

It is now recommended to use a simpler, more accurate method of fluid management. The current recommendation for fluid management in infants and children is to administer 20 to 40 mL/kg of a balanced salt solution (e.g. Lactated Ringer solution) during the course of the anesthetic.

Question 31

Tell me a little about MH?

Answer 31

Malignant Hyperthermia (MH) is a life-threatening condition caused by an induced hypermetabolic state of skeletal muscle. Susceptibility to MH is typically genetic and follows an autosomal dominant inheritance pattern with variable penetrance. Mutations lead to abnormally configured ryanodine calcium channels in the skeletal muscle sarcoplasmic reticulum. When activated by certain triggers (volatile anesthetics, succinylcholine), the mutated calcium channels change into a configuration that remains stuck open, resulting in excess myoplasmic calcium. This calcium ion load leads to excess oxygen consumption and ATP utilization which in turn leads to increased CO2 production, ATP depletion, and lactate production. If left uncontrolled, MH can lead to rhabdomyolysis and myonecrosis, renal failure, hyperkalemia, arrhythmias, DIC, and ultimately death.

Question 32

what is preoperative anxiety associated with?

Answer 32

When unmanaged, anxiety is associated with increased autonomic fluctuations, increased anesthetic requirement, increased postoperative nausea/vomiting risk, increased postoperative pain, increased hospital length of stay, and increased healthcare cost. Another concern is parent satisfaction as well as the possibility of psychological trauma from going to the operating room and how this can affect the patient’s mental health long-term.

Question 33

Marfan patients have both ____ and ____ pulmonary effects.

Answer 33

Obstructive and restrictive Marfans is autosomal dominant mainly. Occasionally sporadic.

Question 34

What is the most common cardiac defect associated with omphaloceles?

Answer 34

septal defect (particularly vsd) Other notable associations with omphalocele include Beckwith-Wiedemann (macrosomia, macroglossia, hemihypertrophy), trisomy 13, and trisomy 18

Question 35

The American Academy of Pediatrics, along with the American Academy of Pediatric Dentistry, publish guidelines for monitoring and management of sedation in pediatric patients. Vital signs during a moderate sedation case of a pediatric patient must be recorded at least how frequently?

Answer 35

10minutes deep sedation and general anesthesia require every 5 minutes

Question 36

what’s the common cause for epiglottis?

Answer 36

h influenza

Question 37

A 13-year-old, previously healthy boy presents with 3 days of fever, sore throat, trismus, and difficulty swallowing. what’s the cause?

Answer 37

most common is peritonsillar abscess caused by Group A, beta-hemolytic Streptococcus

Question 38

what are the requirements for pediatric outpatient surgery?

Answer 38

• No violation of a major body cavity - Generally, surgery is limited to less than 2 hours duration - Pain must be minimal to moderate and easily managed in the PACU with oral medications or nerve block - There must be no major blood loss or major physiological perturbation - Patient must be able to take oral nutrition/liquid immediately postoperatively - There must be no postoperative monitoring which cannot be completed by the parents or in the home environmen

Question 39

A 1-hour-old neonate born at 32 weeks gestational age is presenting with tachypnea, increased breathing effort, and cyanosis. The neonate is diagnosed with neonatal respiratory distress syndrome. Which of the following describes the correct management of neonatal respiratory distress syndrome?

Answer 39

Administration of surfactant within 2 hours postpartum to a neonate with neonatal respiratory distress syndrome (NRDS) is associated with improvement in oxygenation. This is due to the reduction in alveolar surface tension from surfactant molecules, thus preventing alveoli from collapsing.

Question 40

what makes surfactant?

Answer 40

alveolar type II pneumocytes

Question 41

yes this is in the Peds section…what are the zones of the MRI?

Answer 41

There are four MRI safety zones. Zone IV is the MR scanner room, zone III is the area surrounding the MR scanner room that requires screening and may be subject to magnetic forces (control room), zone II is the interface between the general public and the restricted zone III (the dressing/holding room), and zone I is all areas freely accessible to the general public.

Question 42

what is the most common adverse event during pediatric sedation?

Answer 42

hypoxia

Question 43

what are some factors that increase risks of adverse events in pediatric moderate sedation?

Answer 43

Several factors can contribute to adverse events in pediatric sedation cases, including factors related to the patient (ASA physical status, obstructive sleep apnea), procedure (endoscopy, bronchoscopy), and setting (non-hospital setting).

Question 44

gastroschisis vs omphalocele

Answer 44

Gastroschisis is typically an isolated lesion, involves exposed bowel without an enclosed covering through an abdominal wall defect to the right of the umbilicus. Since the bowel lacks a protective sac, gastroschisis has a higher incidence of heat loss, rapid dehydration, infection, and postoperative bowel hypomotility than omphalocele. Omphalocele is a central defect of the umbilical ring. The defect is typically larger than with gastroschisis and therefore additional organs (such as the stomach and liver) are often involved. The abdominal contents are covered by the umbilical sac. Omphalocele is often associated with other physical and chromosomal anomalies.

Question 45

what volatile anesthetic is most likely to cause emergence delirium?

Answer 45

sevoflurane isoflurane causes less than desflurane

Question 46

what are risk factors for bronchopulmonary dysplasia?

Answer 46

prematurity hyaline membrane disease (or respiratory distress syndrome) exposure to high FIO2 high airway pressures (mechanical ventilatioN) infections BPD is a chronic lung disease often found in preterm infants with underdeveloped lungs who are exposed to mechanical ventilation, high oxygen concentrations, or infection. These patients can develop interstitial fibrosis, emphysema, reactive airway disease, and eventually pulmonary hypertension and right heart failure. This ventilation and perfusion mismatch can result in hypoxemia and hypercarbia. Treatment goals include providing respiratory support while minimizing inspired oxygen concentrations and mean airway pressures, reducing fluid in the lungs (diuretics), supporting cardiac contractility (inotropes), and optimizing caloric intake to accommodate increased work of breathing. Preventative measures include avoiding the initial trauma of mechanical ventilation with exogenous surfactant, HFOV, and antenatal steroids.

Question 47

how much fluid should a 6kg kid get in first hour of surgery that has been npo for 4 hours?

Answer 47

The approach to intravenous fluid therapy in children must consider their high metabolic demands and high ratio of body surface area to weight. Hourly fluid requirements are calculated using the 4-2-1 rule. So, 4 mL/kg for children up to 10 kg, an additional 2 mL/kg for each kilogram between 10-20 kg, and an additional 1 mL/kg for each kilogram above 20 kg. Thus, a 6 kg infant would require (6 * 4 =) 24 mL/hr for maintenance. Fasting fluid deficits are calculated by multiplying the hourly maintenance rate by the number of hours fasting. So for this patient who has been NPO for 4 hours, his deficit would be (24 mL/hr * 4 hr =) 96 mL. Half of the deficit (48 mL) is replaced in the first hour and 25% (24 mL) in each of the next 2 hours. Thus, in the first intraoperative hour, the patient should receive 48 mL (NPO fluid deficit) + 24 mL (maintenance) = 72 mL.

Question 48

what are blood volumes of kids?

Answer 48

Question 50

what is the equation to calculate how much blood a person should receive?

Answer 50

The volume of pRBC to be transfused = [(Desired HCT - Present HCT) * EBV] / HCT of pRBCs]

It is important to note that a standard unit of pRBC’s will have a hematocrit of around 60%. Thus, in this case, the desired HCT was 20%, the present HCT at the time transfusion was started was around 15%, and their EBV was 200 mL. Given these factors, the volume of pRBC’s that need to be transfused in this patient is around 15 mL.

Question 51

what is the most sensitive way to detect venous air embolism during pediatric craniotomy?

Answer 51

Precordial doppler ultrasound

1) TEE (adults) or precordial Doppler ultrasound (infants/children), 2) EtCO2/EtN2/PAP, 3) cardiac output/CVP, 4) SpO2/BP/ECG changes. Echocardiography and Doppler ultrasound are sensitive enough to potentially detect VAE even before physiologic changes can occur.

Question 52

what is laryngotracheobronchitis?

Answer 52

Croup caused by

signs and symptoms include low-grade fever, inspiratory stridor, hoarseness, and a “barking” cough

steeple sign