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nura 620 anesthesia and coexisting conditions > Peds > Flashcards

Peds Flashcards

1
Q

How to calculate Postgestational age (PGA).

A

(# weeks gestation @ birth) + (current age in weeks)

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2
Q

Former Premature infants up to 60 weeks PGA are at an increased risk for?

A

post operative apana and bradycardia, requiring postoperative monitoring and admission

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3
Q

Which peds patient is in the most vulnerable peds population?

A

Extrememly low gestational age (ELGAN): 23-27 weeks gestation – all organs immature

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4
Q

low birth weight

A

<2500 grams

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5
Q

ALL pre terms have potential for:

A
  • respiratory distress
  • apnea
  • hypoglycemia
  • electrolyte disturbances (dec Mg, Ca)
  • infection
  • hyperbilirubinemia
  • polycythemia
  • thrombocytopenia
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6
Q

Fetal circulation has ____ pulmonary vascular resistance and ____ systemic vascular resistance.

A

high; low

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7
Q

At birth, explain the primary changes that occur in circulation

A
  • ductus venosus closes, ductus arteriosus closes (due to increased PaO2)
  • pulmonary vascular resistance decreases
  • pulmonary vascular resistance increases
  • foramen ovale closes
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8
Q

Explain the significance of only a “functional closure” of the foramen ovale and ductus arteriosus at birth.

A

Because they are only “funcitonally closed” and not “anatomically closed”, this means they can reopen.

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9
Q

For the first several weeks, the infant is undergoing transitional ciruclation. List events that can lead to increases in pulmonary artery pressures and subsequent implications.

A
  • hypoxia, hypercapnia, hypothermia can lead to increased PAP
  • this can lead to reversal of flow through foramen ovale, re opening of ductus arteriosus & shunting
  • **this hypoxia is difficult to correct**
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10
Q

Structural differences of the newborn heart and subsequuent implications.

A
  • structurally IMMATURE
  • fewer myofibrils
  • sarcoplasmic reticulum immature
  • cardiac calcium stores are reduced – GREATER DEPENDENCY ON SERUM IONIZED CA++
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11
Q

Explain compliance of the newborn heart and subsequent implications.

A
  • because the cells are immature, ventricules are less compliant (don’t get as much stretch) – CO IS HR DEPENDENT!
  • consider frank starling curve – in a child, don’t have the ability to increase their compliance and stroke volume is “RELATIVELY” fixed – fluid CAN make a difference, but you only have a small window in which fluid will make a difference.
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12
Q

Discuss the baroreceptor reflex in the neonate and subsequent implications

A
  • inability to substantially compensate for hypotension with reflex tachycardia
  • keep in mind that hypotension for a child is a very late sign of hemodynamic compromise!!
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13
Q

Appropriate BP calculations for a child NOT under anesthesia (discussed in class)

A
  • min. SBP for a neonate without anesthesia: 70 mmHg
  • min. SBP for ages 2 - 10: 70 mmHg + age x 2 (I.e. 5 year old – 70 + (5x2) = 80 mmHg)
  • >10 years old: min SBP 90 mmHg
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14
Q

Leading cause of bradycardia in children.

A

Hypoxia (99.9% of the time)

**so anytime you see a child’s HR drop, you should first think about oxygenation and ventilation!!** – open the airway, clear an obstruction, and give 100% oxygen

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15
Q

Autonomic nervous system in the neonatal heart: tend to have ____________ dominance; SNS is _________.

A

parasympathetic dominanace; SNS is immature

**tendency to have bradycardia with suctionaling and laryngoscopy**

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16
Q

Resting CO: neonate @ birth

A

~400 ml/kg/min

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17
Q

Resting CO: infant

A

200 ml/kg/min

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18
Q

Resting CO: adolescent

A

100 ml/kg/min

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19
Q

General overview of CV considerations

A
  • dependence on ionized calcium: particularly vulnerable to effects of citrated blood products
  • neonatal myocardium is not as compliant compared to an older child: increased preload does increase SV to the same degree
    • hypovolemia and bradycardia produce dramatic decreses in CO that threaten organ perfusion
  • Epinephrine rather than atropine increases contractility AND HR: preferred treatment of bradycardia and decreased CO
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20
Q

Pulmonary system: alveoli increase in number & size up until age ___.

A

8

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21
Q

Pulmonary system: why do infants have increased airway resistance?

A

small airway diameter

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22
Q

Discuss chest wall compliance, airway complicance, muscle fiber maturity, and subsequent implications.

A
  • highly compliant airway & chest wall - MORE COLLAPSBILE – will see retactions under distress
  • eartly fatigue and diphragmatic & intercostal muscles until age 2 (type 1 muscle fibers (slow twitch) not mature)
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23
Q

O2 consumption is _____ the adult with increased alveolar ventilation.

A

2 - 3 x’s

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24
Q

What is an anatomical difference of the right mainstem bronchus and important implications.

A
  • ANGULATION of right mainstem bronchus – more likely to cause right mainstem intubation
  • So anytime you have a position change, turning, or head movement with a pediatric patient, recheck tube position
  • **in a neonate, flexing the head can push the tube into right mainstem intubation and extenstion can extubate!!**
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25
Q

oxygen consumption: neonate and adult

A
  • neonate: 6 ml/kg/min
  • adult: 3.5 ml/kg/min
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26
Q

alveolar ventilation: neonate and adult

A
  • neonate: 130 ml/kg/min
  • adult: 60 ml/kg/min
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27
Q

respiratory rate: neonate and adult

A
  • neonate: 35 bpm
  • adult: 15 bpm
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28
Q

tidal volume: neonate and adult

A
  • neonate: 6 ml/kg
  • adult: 6 ml/kg

**note tidal volume is consistent across age**

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29
Q

List anatomical differences of the infant airway.

A
  • larger tongue in a smaller submental space - HARDER TO GET A VIEW
  • high larynx (C2 to C4) - more “anterior view”
  • omega shaped epiglottic - narrower; more difficult to lift - CLASSICALLY, USE MILLER BLADE
  • angled vocal cords (slant caudally)
  • funnel shpaed larynx with narrowest region @ cricoid ring
    • okay to use cuffed ETT as long as monitoring pressures
    • size down 1/2 size when using cuffed ETT
  • obligate nasal breathers
  • large occiputs – the “sniffing” position is favored for axis alignment - but NOT hyperextended
  • edentulous - be sure to assess for presence of natal teeth (these would be easy to dislodge
  • short trachea (4-5 cm)
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30
Q

Anatomical differences in the infant airway (APEX chart)

A
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31
Q

Gas flow: turbuelent airflow is present up to the ___ bronchial division; a 50% reduction in radius increased the pressure ___ fold. What does this mean for AW management?

A

5th; 32

  • Very prone to respiratory distress with any upper AW irritation and swelling – GIVE STEROIDS LIBERALLY WITH AW EDEMA – also, keep in mind that steroids do not have a quick onset so give steroids early on.
    • also, consider the what is causing the AW swelling - maybe consider racemic epinephrine vs albuterol - goal is not bronchodilation, but a reduction in swelling
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32
Q

Child O2 brain consumption vs adult.

A
  • child: 5.5 ml/100 g/min
  • adult: 3.5 ml/100 g/min
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33
Q

Child CBF vs adult

A
  • child: 70-110 ml/min/100 g
  • adult 50 ml/min/100 g
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34
Q

Discuss Anesthesia Induced Developmental Neurotoxicity

A
  • knowledge is still growing in this area
  • increased and accelerated neuroapoptosis with virutally all anesthetics (IV and VA)
  • single exposures of short duration are usually of no consequence
  • repeated &/or prolonged exposures at a young age (< 3 - 4 years (when synaptogenesis is still taking place)) may be associated with later behavioral & learning difficulties - we dont have conclusive evidence
  • current thought is to delay non urgent and elective surgeries until age < 3 - 4 years.
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35
Q

The nervous system is _______ complete at birth, but _______ immature.

A
  • anatomically; functionally
  • myelinization & synaptic connections NOT complete until age 3-4 years (7 years of age per cote) – rapid growth of brain in first 2 years of life
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36
Q

Anterior fontanel closed by ______.

A

18 months

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37
Q

Posterior fontanel closed by ______.

A

~ 2 months

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38
Q

Discuss fontanel assessment and importance.

A
  • can help you determine hydration status, or information about hydrocephalus
  • important to assess appropriate fontanel opening/closure at certain ages (I.e. if 6 month old baby has synostosis of cranial vault, would notify surgery team and likely cancel surgery for further assessment) – imporant for brain to have room for growth up until typical fontanel closure timelines
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39
Q

Discuss somatic pain in the neonate.

How is the pain conveyed?

Are fibers mature?

Do neonates have suppresses or exaggerated response to nociceptive stimuli?

A
  • somatic pain: conveyed in part by unmyelinated C fibers (“slow”)
  • leads to protective relfexes such as autonomic reactions, muscle contraction, and rigidity
  • C fibers are fully functional from early fetal life onward
  • connections between C fibers and dorsal horn neurons are not mature before the second week of postnatal life but nociceptive stimualtions transmitted to the dorsal hortn by C fibers elicit long lasting responses
    • probably as a result of extensive depolarization to the prodcution of large amounts of substance
  • inhibitor control pathways are immature at birth and develop over the first 2 weeks
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40
Q

Explain the importance of pre remptive analgesia in the neonatal period.

A
  • painful procedures during the neonatal period modify subsequent pain responses in infancy and childhood
  • pre emptive analagesia leads to a reduction in the magnitude of long term changes in pain behaviors
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41
Q

What does FLACC stand for?

A
  • faces
  • legs
  • activity
  • cry
  • consolability
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42
Q

General neuraxial considerations for the neonate: spinal curvature and timing of neuraxial

A
  • lack of a lumbar lordosis compared to older children predisposes the infant to high spinal blockade with changes in positioning
  • generally do neuraxial anesthesia AFTER GA, unlike in adults
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43
Q

Neuraxial considerations: discuss landmark differences of the conus medullaris, dural sac, and intercristal line.

A
  • conus medullaris ends at approximately L1 in adults (migrates to L1-L2 by age 3)
  • ends at L2 - L3 in neonates (level L3 @ birth)
  • in infants, the line across the top of both iliac crests (the intercristal line) crosses the vertebral column at L4-L5 or L5-S1 interspace, well below the termination of the spinal cord
  • dural sac in neonates and infants also terminates in a more caudad location compared ot adults, usually at about the level of S3 compared to the adult level of S1
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44
Q

Describe the functionality of GFR in the neonate and timeline of full maturation. What does this mean for your anesthetic?

A
  • GFR is significantly impaired at birth but improves throughout 1st year
    • greatest impairment is in 1st 4 weeks of life
    • renal maturation will be delayed further with prematruity
  • half life of medicacations excreted by glomerular filtration are prolonged in the very young

****GFR immaturity is important in drug selection for drugs that rely on renal clearance**** – remifentanil is a good choice for immature GFR because plasma esterases are fully functional in the neonate

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45
Q

Decribe ther functionality of renal tubular concentrating abilities and timeline for full maturity. What does this mean for your anesthetic?

A
  • renal tubular concentrating abilities do not achieve full capcity until ~2 years
  • very premature infants easily bcome hyponatremic because of reduces proximal tubular reabsorption of sodium and water and reduced receptors for hormones that influence tubular sodium transport
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46
Q

Liver: enzyme systems are still developing up until ___ year/years of age.

A

1

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47
Q

Liver: Phase I cyp 450 system is ____% of adult values at birth.

A

50%

(phase 1 reactions are responsible for the majority of drug metabolism in the liver via the CYP 450 enzyme systems (3A4 ~50% of drugs & 2D6 10 - 20%)

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48
Q

Liver: Phase II (conjugation reactions) are _________ in neonates. What does this mean for your anesthetic?

A

impaired

(phase II - conjugation reaction makes drugs more water soluble to facilitate renal excretion)

  • long half life of BZD and morphine
  • decreased bilirubin breakdown due to reduction in glucuronyl transferase (leading to jaundice) – glucuronyl transferase also needed for metabolism of tylenol (can easily develop acetaminophen poisoning)
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49
Q

Liver: hepatic synthesis of clotting factors reach adult levels within _____ week/weeks of birth.

A

one week

  • at birth, vitamin K dependent factors (I.e. II, VII, IX, and X) are 20 to 60% of adult values
  • in preterm infants, the values are even less
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50
Q

Liver: Discuss albumin levels/protein levels in the neonate and subusequent anesthetic implications.

A
  • lower levels of albumin/other proteins for drug binding in newborns
  • LARGER PORTION OF UNBOUND DRUG CIRCULATING
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51
Q

Liver: discuss glycogen stores in the neonate and subsequent implications.

A
  • minimal glycogen stores - PRONE TO HYPOGLYCEMIA
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52
Q

GI: Important pearl to note about poor feeding/FTT in the infant.

A

Poor feeding equates to poor aerobic activity in infant. An infant that cannot feed well is equivalent to an adult that can’t walk out to their mailbox.

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53
Q

GI: coordination of swallowing with respiration is not mature until ________ months of age. What does this mean for the neonate?

A

4-5 months of age

**high incidence of refulx especially in preterm infants**

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54
Q

Compare and contrast the GI tracts of children and adults.

A
  • gastric juices are less acidic (more neutral) up to ~3 yrs
  • absorption of oral meds is generally slower compred to adults
  • GI tract is generally slower in children compred to adults.
  • adults have a larger GI tract, faster emptying time, and more protein transporters, which all cause an increase in absorption compared with children
  • children have differences in gastric pH, emptying time, intestinal transit, immaturity of secretions, and activity of both bile and pancreatic fluids
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55
Q

Thermoregulation: list 4 ways you can lose heat and give an example of each.

A
  • conduction (3%) - IV fluid
  • evaporation (24%) - mask ventilation with gases from machine
  • convection (34%) - air stream across exposed skin
  • radiation (39%) - putting off body heat out into the environment
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56
Q

Explain difficulties of thermoregulation in neonate.

A
  • large surface area to body wt
  • lack of SQ tissue as an insulator
  • inability to shiver: metabolize brown fat to increase heat production; can lead ot metabolic acidosis & increased O2 consumption
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57
Q

List mechanisms to actively warm.

A
  • warm the OR
  • use a warming mattress
  • use incubators (when kid in NICU/PICU)
  • cover with blankets
  • head coverings (up to 60% of heat loss)
  • transport in isolette
  • humidy gases (HME exchanger?)
  • use plastic wrap on the skin
  • warm prep & irrigation solutions
  • change wet diapers
  • remove wet clothing
  • forced air warmers - MOST EFFECTIVE STRATEGY TO MINIMIZE HEAT LOSS IN SURGERY IN CHILDREN > 1 HR
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58
Q

How do anesthetics alter thermogenesis in the neonate?

A
  • alter non shivering thermogenesis
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59
Q

List mechanisms for appropriate temp monitoring in pediatric cases.

A
  • core temp best measure; mid esophageal probe placed
  • advantage to axillary temp if properly positioned: proximity to deltopectoral group improves recognition of elevated temp in MH
  • 10 MH episodes occurred that were unrecognized with forehead temp

**TEMP MONITORING ESSENTAIL FOR ALL PEDS CASES**

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60
Q

Discuss problems associated with hypothermia and hyperthemia.

A
  • HYPOTHERMIA
    • delayed emergence
    • reduced degradation od drugs
    • increased infection
    • decreased perfusion to new anastamoses/wounds
  • HYPERTHERMIA
    • suspect MH until proven otherwise
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61
Q

Discuss body composition of the neonate compared to adults. What does this mean for Vd, dosing, and excretion of drugs

A
  • TBW is highest in premature infants & decreases with age
  • water soluble drugs have a larger Vd
    • need a larger initial dose of succ and dose/kg of abx
    • larger Vd can delay excretion
  • half life of meicatiosn in >2 years of age is hsorter than adults or equivalent due to significant CO to liver & kidneys (remember GFR is mature at this point)
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62
Q

Discuss body composition (fat + muscle) and associated drug effects.

A
  • neonates hae less fat & muscle
  • drugs that depend on redistribution to fat for termination of action will have prolonged effects (I.e. propofol, more dependent on this factor with infusion vs one time dose)
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63
Q

Discuss protein binding in the neonate and associated effect of drugs.

A
  • < 6 mo old have reduced albumin & alpha 1 glycoprotein
    • higher free fraction of protein bound drugs
    • free fraction of lidcoaine will be higher in the very young
    • acidic drugs (diazepam, barbs) tend to bind mainly to albumin
    • basic drugs (amide local anesthetic agents) bind to globulins, lipoproteins, and glycoproteins
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64
Q

At what age do infants have a physiologic anemia. Why?

A

2 - 3 months of age - fetal hemoglobin is being replaced with adult hemoglobin from 3-6 months – happens gradually over time

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65
Q

How do we dose 1 unit of PRBCs inthe infant? What increase do we expect to see in both hgb and hct?

A

5 ml/kg to increase hgb 1 g/dL and hct about 3%

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66
Q

Calculation: maximum allowable blood loss calculation

A

MABL = EBV x (starting hct - target hct (lowest hct you’ll allow))/starting hct

**remember, we don’t reach MABL before we start thinking about blood (have to think about rate of blood loss, how easy of a time the surgeon is having a gaining hemostatic control, the trajectory of future blood loss in the case)**

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67
Q

Transfusion threshold for neonates.

A

40% instead of 30% related to L shift, decreased CV reserve, higher CBF, increased O2 consumption

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68
Q

In which neonatal populations do we consider blood sooner and why?

A
  • preterm infants
  • term newborns
  • children with cyanotic congenital heart disease
  • those with respiratory failure in need of high O2 carrying capacity

Carry an increased risk for post operative apnea and respiratory complications when anemic – not even entirely sure why.

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69
Q

Normal hgb/hct values (chart)

A
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70
Q

Estimated blood volume – EBV cc/kg (chart)

A
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71
Q

Neonates have _______ susceptibility to infection: related in part to _______ of leukocytes.

A

increased; immaturity

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72
Q

Describe the components of CLASSIC fluid replacement.

A
  1. fasting (NPO) deficit (maintenance rate x hours of NPO for deficit)
  2. baseline maintenance fluid requirement - using LR in most cases (4, 2, 1)
  3. replacement of blood loss - (3:1 crystalloid replacement; 1:1 blood or colloid replacement)
  4. evaporative losses - (based on invasiveness of sx)
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73
Q

Fluid replacment of 75-100 ml/kg may encounter _____________.

A

dilutional coagulopathy

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74
Q

Describe how to calculate fluid repalcement using the Holliday - Segar formula: 4:2:1. (chart)

A
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75
Q

Describe the new trends of intra operative fluid management.

A
  • new guidelines are recognizing the impact of ADH secretion on fluid status
  • simple stategy for healthy children undergoing elective sx
    • administrations of 20-40 ml/kg of crystalloid (balanced salt solution) over the duration of the case
      • takes into account maintenance fluid as well as NPO deficit
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76
Q

Describe the new trends for fluid managment in the post operative period.

A
  • new 2 - 1 - .5 rule applies (2 ml/kg for the first 10 kg, 1 ml/kg for 10-20 kg, and 0.5 mlg/kg for each kg above 20 kg in weight)
  • this therapy now recognizes the common dysregulation of ADH seretion after sx and prevents hyponatremia
  • If NO oral intake after 12 hours, then D5 0.45% saline should be given using the 4 - 2 - 1 rule.
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77
Q

Fluid Replacement: how can you minimize potential for error?

A
  • smaller IV bags
  • buretrols
  • eliminate all air from IV line
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78
Q

Which pt populations may require glucose contian IVF?

A
  • infants < 6 months
  • at risk for hypoglycemia
  • children with mitochondrial disease

**only D51/2NS for maintenance rates!!, LR for the rest**

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79
Q

How do manage TPN rates regarding fluid managment?

A
  • TPN should not be stopped suddenly
    • circulating insulin levels have acclimated to this basal infusion of glucose & hypoglycemia will be problematic
  • either continued in OR or ramped down & bridged with glucose containing IVF (ok to stop lipids)
    • deduct this from hourly maintenance calculated rate
    • some do cut back to 1/3 or 1/2 due to the increase in glucose released d/t surgical stress - if you choose to do this then be sure to monitor glucose
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80
Q

What is the best way to measure dehydration/fluid deficit in infants? List the effects at mild, moderate and severe dehydration.

A

WEIGHT

  • mild - 50 ml/kg deficit
    • dry mouth, poor skin turgor
  • moderate - 100 ml/kg
    • mild sx plus suken fontanel, oliguria, tachycardia
  • severe - 150 ml/kg
    • moderate sx plus sunken eyes, hypotension & anuria
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81
Q

Questions to consider with intra operative fluid managment.

A
  • Is the HR persistently increased or does It vary with surgical stimulation?
  • Is the pulse pressure narrow or more ominously, is teh BP reduced for age?
  • Does It vary with positive pressure breaths?
  • Are the extremities warm?
  • Is capillary refill brisk?
  • What is the u/o?
  • Are these variables changing?
  • What is the rate of change?

WHEN HYPOVOLEMIA IS SUSECTED, OBSERVING THE RESPONSE TO A 10 - 20 ML/KG BOLUS OF ISOTONIC CRYSTALLOID OR COLLOID MAY TEST THE HYPOTHESIS.

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82
Q

General medication considerations for pediatrics (quote)

A

“In general, most medications will have a prolonged E1/2 life in preterm and term infants, a shortened E1/2 life in children older than 2 years of age up to the early teenage years, and a lengthening of half life in those approaching adulthood”

**There are so many factors interplaying with the PK/PD in neonates - this leads to a lot of pt to pt variability with drug admnistration**

83
Q

Inhaled Anesthetics: Why is uptake more rapid in peds? (chart)

A
84
Q

“Wash in” is ________ related to solubility.

A

inversely

I.e. lower solulbility = higher wash in

85
Q

List determinants of “wash in” related to “delivery to lungs” and “removal from lungs:

A
  • delivery to lungs
    • inspired concentration
    • alveolar ventilation
    • FRC
  • removal from lungs
    • CO
    • solubility
    • alvoelar to venous partial pressure gradient
86
Q

Discuss MAC variation with age and with sevo (chart).

A
  • SEVO
    • MAC up to 6 months is ~3.2%
    • MAC 6 mo to 12 years is constant at 2.4%
87
Q

Which VA is the primary induction agent used for inhalational induction? Why?

A

sevoflurane - low pungency

Desflurane is limited by pungency; however, you can switch to desflurance after induction. It is just not appropriate to use in a light plane of anesthesia as It can cause laryngospasm, bronchospasm. But desflurane, like iso and sevo, is also a bronchodilator.

88
Q

IA effects: respiratory

A
  • same as adults!
  • overall decrease in MV
    • decreased TV with increase RR
    • depressed response to CO2 & hypoxia
      • as concentration increases, apnea ensues
89
Q

IA effects: CV

A
  • dose dependent depression
  • sevo usuallly maintains or increases HR during induction
  • all can cause prolonged QT
  • halothane has greatest depression of contractility
  • increased incidence of hypotension in neonates & infants upon inhalational induction
    • more rapid uptake can unmask negative inotropic effects of the volatiles in infants
90
Q

IA: halothane hepatitis

A
  • antibody reaction
  • most frequently seen with repeated exposure
91
Q

IA: advantages and disadvantages (chart)

A
92
Q

Older children & adolescents generally require ______ doses of induction agents compred to adults.

A

increased

93
Q

List 2 factors that increase sensitivity of neonates to induction agents.

A
  • immature BBB
  • decreased metabolism
94
Q

Induction agents: propofol. Use + considerations.

A
  • most ocmmonly used IV induction agent in children
  • pain of injection can be reduced with a mini bier block with 0.5 - 1 mg/kg of lidocaine for 60 sec (aka too much trouble)
    • so pts that already have an IV can sill experience distress if doing IV induction with prop
  • antiemetic properties
  • propfol infusion syndrome: long term infusions in ICU avoided in infants & children; still appropriate for TIVA
  • egg/soy: only avoid if documented anaphylaxis with eggs
95
Q

Induction agents, KETAMINE: Use in specific populations + considerations with emergence.

A
  • can be used IM, IN, PO, IV
  • ketamine inductions preferred in
    • cyanotic heart disease
    • septic shock
    • induction for mediastinal mass (do not want to take away spontaneous ventilation and risk tracheal collapse on induction)
  • emergence irritation can be reduced with co admin w/ midazolam & waking up in a dark, quiet room
96
Q

Indution agents, ETOMIDATE: approved use + dose

A
  • approved for use in age > 10 yo in US
  • 0.2 - 0.3 mg/kg IV
97
Q

Induction agents, THIOPENTAL: use + dose

A
  • no longer available in US
  • dose: 3 - 5 mg/kg IV
98
Q

Sedatives, MIDAZOLAM: oral dosing considerations, reversal, metabolism, excretion

A
  • most widely used anxiolytic pre op
  • oral dosing: doses INCREASES in younger patients
    • poor bioavailability
    • bitter taste
    • allow 10 - 15 minutes
  • Reversal: flumazenil, 0.01 mg/kg IV
  • Hepatic metabolism (CYP 3A4)
  • Renal Excretion
99
Q

Sedatives, KETAMINE: IM use, considerations, onset & duration

A
  • severe cognitive/behaviorally challenged older children may have to be given IM ketamine for sedation in pre op (2 - 5 mg/kg)
    • give with antisialagogue - lots of secretions
  • onset: 3 - 5 min
  • duration: 30 - 40 min (usually able to start IV)
100
Q

Sedatives, DEX: Use, dosing concerns/considerations

A
  • useful in awake FOB, radiological procedures & reduction of emergence delirium
  • will not be adequate as a sole anesthetic but can be helpful as adjunct
  • hypotension with loading doses
  • bradycardia with high dose infusion
101
Q

Opioids, FENTANYL: use + dosing

A
  • most widely used opioid intra op in children
  • typically 1 - 3 mcg/kg IV per single dose & titrated for effect
    • common to start with 1 mcg/kg and titrate from there
102
Q

Opioids, REMIFENTANIL: use

A
  • excellent for neonates due to immaturity of renal/hepatic metabolism/excretion
  • great for procedures that are painful during procedure, but not painful after
103
Q

Opioids, DEMEROL: use

A
  • primarily given for shivering in small doses
  • maintains RR
  • has an active metabolite and unwanted SE
104
Q

Opiods, CODEINE: historical use, reason for withdrawal from many markets

A
  • historically very commonly prescribed postop
  • withdrawn from many markets due to respiratory events
  • SNPs in ultra rapid metabolizers confer risk of OD
105
Q

Non opiods, TYLENOL: dosing

A
  • PO: 10 - 15 mg/kg
  • IV: 15 mg/kg IV q6h (10 - 15 min onset)
  • rectal absorption is slow (1 - 2 hrs)
106
Q

Non opioids, KETOROLAC: dosing + considerations

A
  • typical dose: 0.5 mg/kg IV
  • ask surgeon before administration
  • caution with all NSAIDs in severe asthma
  • NSAIDs work very well for bone pain
107
Q

NMJ is not fully mature until _____ of age.

A

~2 months

108
Q

Muscle relaxants: general dosing considerations for infants.

A
  • may be more sensitive to NDNMB but also have larger Vd so dose/kg is usually the same as adults
  • EXCEPTION - rocuronium
    • dose is lower in infants

_**ALWAYS USE A NERVE STIMULATOR, RESPONSE IS HIGHLY VARIABLE**_

109
Q

Muscle relaxants: reversal agent considerations + dosing.

A
  • routine reversal for TOFR < 0.9; ALWAYS REVERSE
  • dose of neostigmine in infants & children is 30 - 40% lower than adults
    • 0.02 - 0.04 mcg/kg coadministered with anticholinergic
110
Q

Which muscle relaxants are particularly useful in newborns and children with immature or abnormal hepatic or renal function? Why?

A
  • cisatracurium/atracurium
    • hoffman elimination
      • TEMP AND PH DEPENDENT
111
Q

SUCCINYLCHOLINE: limited uses in peds, IM/IV dosing, coadministration, risks

A
  • Sch is limited to RSI and emergency tx of laryngospasm in peds
  • higher doses are needed In neonates & infnats dues to larger Vd
    • IV: 3 mg/kg
    • IM: 4 mg/kg - paralyzes within 1 -2 min; duration may be up to 20 min
  • When given, concurrent atropine is a routine practice in order to prevent bradycardia/asystole with single dose admin
    • Atropine dose: 0.02 mg/kg
  • Risk of bradycaria, hyperkalemia, masseter spasm (potential heralding sign of MH)
    • risk with potential undiagnosed myopathes or MH in children
112
Q

How do CO and local blood flow affect systemic LA in the infant? What is an effect medication that alters uptake?

A
  • CO and local blood flow are 2 to 3 times greater in infants than in aduls so systemic LA absorption is increased
  • Epinephrine is effecting in slowing systemic uptake
113
Q

How does the level of protein in the infant affect protein binding of LA?

A
  • Plasma concentration of AAG is very low at birth (0.2 to 0.3 g/L) and does not reach adul levels (0.7 to 1.0 g/L before 1 year of age
  • free fraction of all LA is increased in infants
    • maximum doses of all amino amides must be reduced
  • nonionized LA cross almost freely the capillary wall close to the injection site
114
Q

MAX DOSE of lidocaine w/o epi and lidocaine w/ epi

A
  • lidocaine w/o epi: 4 mg/kg
  • lidocaine w/ epi: 7 mg/kg
115
Q

Discuss metabolism of LA in the neonate.

A
  • LA are metabolized by CYP450
  • CYP3A4 metabolizes lidocaine and bupivacaine
  • CYP1A2 metabolizes ropivacaine
  • These hepatic microsomal enzymatic systems are immature at birth and, as a result, hepatic clearance of amide anesthetics is delayed in children
  • levels of plasma esterases that metabolize ester LA are also lower infants; however, the delay in metabolism is not significant

*****CONSIDER IMMATURE METABOLISM AND ALTERED METABOLISM IN ANY PATIENT WHEN REDOSING WITH CONSIDERATION GIVEN TO MAX DOSES******

116
Q

MAX DOSE of chloroprocaine

A

12 mg/kg

117
Q

MAX DOSE of ropivacaine

A

3 mg/kg (sometimes cited as 2.5 mg/kg)

118
Q

MAX DOSE of bupivacaine

A

2.5 mg/kg

119
Q

Normal HR range: neonate (< 30 days)

A
  • 120-160
120
Q

Normal HR range: 1 - 6 months

A

110-140

121
Q

Normal HR range: 6 - 12 months

A

100 - 140

122
Q

Normal HR range: 1 - 2 years

A

90-130

123
Q

Normal HR range: 3 - 5 years

A

80-120

124
Q

Normal HR range: 6 - 8 years

A

75 - 115

125
Q

Normal HR range: 9 - 12 years

A

70 - 110

126
Q

Normal HR range: 13 - 16 years

A

60 - 110

127
Q

Normal HR range: > 16 years

A

60 - 100

128
Q

Expected range of RR: preterm neonate

A

40 - 70

129
Q

Expected range of RR: 0 - 12 months

A

24 - 55

130
Q

Expected range of RR: 1 - 5 years

A

20 - 30

131
Q

Expected range of RR: 5 - 9 years

A

18 - 25

132
Q

Expected range of RR: 9 - 12 years

A

16 - 22

133
Q

Expected range of RR: 12 years and older

A

12 - 20

134
Q

Psychological assessment in the neonate (0-30 days of life) and anesthesia plan considerations.

A
  • parental anxiety may be extreme
135
Q

Psychological assessment in the infant (1 - 12 months) and anesthesia plan considerations.

A
  • separation anxiety begins @ 8 - 10 months
  • really no need for pre med or parental presence before that age
  • just be warm, soothing, keep infant warm, etc.
136
Q

Psychological assessment in the toddler (1 - 3 years) and anesthesia plan considerations.

A
  • loss of control
  • let them pick arm for BP cuff or anything you can let them control
137
Q

Psychological assessment in the child (4 - 12 years) and anesthesia plan considerations.

A
  • preschool age: concrete thoughts
  • school age: desire to meet adult’s expectations
138
Q

Psychological assessment in the teenager or adolescent (13 - 19 years) and anesthesia plan considerations.

A
  • fears death
  • hides emotions
  • tend to be stoic, but remember they are just as scared
  • modesty tends to be an issue so reassurance that we maintain their modesty while they’re asleep
139
Q

Which populations are at higher risk for latex allergy in certain pediatric populations?

A
  • spina bifida
  • myelodysplasia
  • urinary tract malformations
  • multiple previous surgeries
140
Q

List components of the pre operative evaluation.

A
  • standard adult hx and physical exam must be adapted; some topics that require further emphasis in children
  • birth hx; prematurity
  • neurological development - appropraite for chronological age? psychological issues?
  • AW anomalies, surgial hx, previous intubations, and general medical health (heart, lung, endocrine, renal)
  • genetic or dysmorphic syndrome?
    • potential for anomalies in the cervical spine (eg. down syndrome) or craniofacial dysmorphia
  • family hx
    • MH
    • pseudocholinesterase deficiency
    • post op N/V
    • congenital myopathies
    • bleeding
141
Q

Is lab work and pregnancy testing routine in the pediatric population?

A
  • no lab work is indicated for healthy children undergoing a procedure with minimal blood loss anticipated
  • routine pregnancy testing: controversial; parents may decline; hx alone can be unreliable
142
Q

Airway History, What are our concerns with: presence of URI?

A
  • predisposition to coughing, laryngospasm, bronchospasm, and desaturation during anesthesia or to postintubation subglottic edema or postoperative desaturation
143
Q

Airway History, What are our concerns with snoring or noisy breathing?

A
  • adenoidal hypertrophy, upper airway obstruction, obstructive sleep apnea, pulmonary hypertension
144
Q

Airway History, What are our concerns with presence and nature of cough?

A
  • “croupy” cough may indicate subglottic stenosis or previous tracheoesophageal fistula repair; productive cough may indicate bronchitis or pneumonia
145
Q

Airway History, What are our concerns with past episodes of croup?

A
  • postintubation croup
  • subglottic stenosis
146
Q

Airway History, What are our concerns with inspiratory stridor, usually high pitched?

A
  • subglottic narrowing; laryngomalacia, macroglossia, laryngeal web, extrathoracic foreign body or extrathoracic tracheal compression
147
Q

Airway History, What are our concerns with hoarse voice?

A
  • laryngitis
  • vocal cord palsy
  • papillomatosis
  • granuloma
148
Q

Airway History, What are our concerns with asthma and bronchodilator therapy?

A
  • bronchospasm
149
Q

Airway History, What are our concerns with repeated PNAs?

A
  • incompetent larynx with aspiration, gastroesophageal reflux, cystic fibrosis, bronchiectasis, residual tracheoesophageal fistula, pulmonary sequestration, immune suppression, congenital heart disease
150
Q

Airway History, What are our concerns with previous anesthetic problems, particularly related to the AW?

A
  • difficult intubation, difficulty with mask ventilation, failed or problematic extubation
151
Q

Airway History, What are our concerns with atopy, allergy?

A
  • increased airway reactivity/resistance, increased propensity to desaturation
152
Q

Airway History, What are our concerns with hx of congenital syndrome?

A
  • many are associated with DA management
153
Q

Airway History, What are our concerns with parents that smoke in the house?

A
  • increased AW reactivity
154
Q

Airway History, What are our concerns with suspicion of a c spine anomaly?

A
155
Q

Discuss the assessment of a mumur in a child.

A
  • innocent murmurs are found in up to 50% of normal children (especially age 2 to 6)
    • these ares systolic ejection murmurs & are accentuated by stress, anemia, fever
  • diastolic murmurs &/or symptomatic murmurs need investigation
    • cyanosis, syncome, arrhythmias, tachycardia, poor feeding, poor activity tolerance
156
Q

Cyanosis in the infant is best detected where?

A
  • arterial desaturation or central cyanosis is best detected in the perioral area
    • mucous membranes of the mouth, lips, and gums
  • central cyanosis should be distinguished from peripheral cyanosis, which can occur in a cold environment, and acrocyanosis, which in newborns is due to sluggish circulation in the fingers and toes
157
Q

How do you palpate the liver in a child? Why do we do this?

A
  • 1 to 2 cm below costal margin
  • palpate if any reason to suspect fluid overload
  • hepatomegaly is a sign of RV failure
158
Q

List appropriate fasting guidelines.

What does clear liquids encompass?

What are the guidelines for gum chewing?

A
  • Clear liquids: include only fluids without pulp, clear tea or coffee w/o milk products
  • gum chewing: 70% increase in gastric fluid volume in the first 15 minutes after initiating gum chewing; mostly saliva, most providers will proceed as along as gum is spit out (not swallowed) - must cancel case if swallowed
159
Q

Discuss room set up

A
  • Always have a range of sizes of airway equipment (face masks, OPA’s, ETT’s, LMA’s, blades)
    • Straight blades are most commonly preferred in infants due to anatomical differences
    • Appropriate size LMA should always be available even if intubation is planned in case of unanticipated difficult airway
  • Ensure appropriate sized bp cuff and pulse oximeter is present & functional
  • Calculate drug doses, allowable blood loss, & fluid requirements
  • Have primed bag of IV fluid ready and all supplies to start & secure IV set up & accessible
  • Prepare a pediatric circuit/ bag; Preset vent settings appropriate for size (& program in weight to anesthesia machine if applicable)
  • Emergency drugs for every pediatric case:
    • Weight appropriate doses of Sch & Atropine with a small gauge needle appropriate for IM injection
      • laryngospasm
    • Syringe of propofol
      • facilitate intubation, break laryngospasm, increase depth of anesthesia quickly
    • Epi diluted to 10mcg/ml: not always drawn up but definitely consider drawing up in a sick patient/ complex case
  • Plan for age appropriate distractions: have flavors for masks; consider parental presence if facility allows
  • Warm the room
  • precordial ear piece if using
160
Q

How do babies with cyanoitic heart disease present when crying? Why?

A
  • turn dark blue or rudy in color when crying because of prolonged expiratory phase and resulting increase in right to left shunting
  • hypercyanotic spells are often associated with extreme irritability and rapid, deep, and sometimes labored respirations
161
Q

Premedication is often need at ~ ____ months of age. Why?

A
  • 10 months
  • separation anxiety becomes an issue
162
Q

How do we administer versed as a premed to a child?

A
  • oral versed MOST COMMON
  • severe distress/need for profound sedation
    • may combine medications (ketamine, atropine, versed combo PO)
    • may use IM route if uncooperative with PO sedation
  • intranasal route is sometimes used but can really burn & make child more agitated (not preferred)
163
Q

Pearls for mask ventilation of the child.

A
  • sniffing position is CRITICAL
  • avoid pressure on the soft tissue in the submental triangle
    • can push tongue up into the oropharynx and occlude AW
  • jaw thrust
  • low threshold for 2 person ventilation
164
Q

EMLA cream: use + onset

A
  • onset: 45 - 60 minutes
  • topical anesthetic that can be used for IV starts in pre op
165
Q

Why is It safest to maintain spontaneous ventilation of the child for induction?

A
  • taking over ventilation will increase the risk of anesthetic oversodse
    • a negative feedback loop exists where when anesthetic depth increases, ventilation decreases
  • the combo of high inspired concentrations of an IA and controlled ventilation have contributed to cardiac arrests
  • high inspired concentrations of an IA should be avoided until IV access is established
166
Q

Inhalational induction process.

A
  • Inhalational induction is common: seated or supine position
  • One approach:
    • Higher flows with 70% N2O and 30% O2
    • Fully open APL
    • Allow a few breaths of N2O mixture and then incrementally turn on Sevo to 8% (some providers turn up sevo to 8% without using incremental technique after a few breaths of N2O- especially if crying)
    • Turn off N2O to provide 100% O2
    • Assist spontaneous ventilation PRN- caution about high inspired volatile agent with assisted or controlled ventilation
    • Obtain IV
    • Once IV is in, induction proceeds- give some propofol, narcotic, +/- NMB, etc at this point and then proceed with airway management appropriate for case (LMA, ETT); NOTE: intubation is often completed without NMB’s
    • Be sure to turn down Sevo to normal MAC range for the child; watch VS closely during induction
    • can allow pacifier for comfort during induction & remove when pt loses consciousness
167
Q

RSI process in children

A
168
Q

Are bilateral breath sounds good verification of ETT placement. Why or why not? What are some additional measures of appropraite tube placement?

A
  • No, breath sounds are often referred
    • bilateral breath sounds, but high peak pressures - suspect R mainstem intubation
  • use bilateral chest rise, normal peak pressures, ETCO2
  • bronchospasm post induction - may suspect ETT is too close to carina and may need to pull back
169
Q

Describe tracheal anatomy of the infant and subsequent anesthetic implications.

A
  • short trachea, distance from cords to carina is very short
    • favors a right mainstem intubation
    • must be attentive to:
      • neck extension - extubation
      • neck flexion - righ mainstem
170
Q

Common formula for ETT size over 2 yo.

How do you decide cuffed vs uncuffed and how do you assess appropriate leak?

A
  • (Age + 16)/4
  • cuffed tubes are fine as long as cuff pressures are monitored (use ID 0.5 mm smaller tube)
  • leak maintained around cuff @ 20 - 30 cm H20
    • < 20 - contamination of OR
    • > 30 - too much pressure on trachea
171
Q

We try and avoid an ETT smaller than ____. Why?

A
  • 3.5
    • very prone to kinking and obstruction - really watch any weight on tube and vigilantly monitor PIP
172
Q

How do you measure appropriate depth of an ETT?

A
  • ID x 3
  • tube should be midway between cords and carina on chest xray
173
Q

Cuffed/uncuffed ETT sizing by age (chart)

A
174
Q

Appropriate LMA size for < or = to 5 kg

A

1

175
Q

Appropriate LMA size for 5 - 10 kg

A

1.5

176
Q

Appropriate LMA size for 10 - 20 kg

A

2

177
Q

Appropriate LMA size for 20 - 30 kg

A

2.5

178
Q

Appropriate LMA size for 30 - 50 kg

A

3

179
Q

Appropriate LMA size for 50 - 70 kg

A

4

180
Q

Appropriate LMA size for 70 - 100 kg

A

5

181
Q

Appropriate LMA size for > 100 kg

A

6

182
Q

Contraindications for LMA in pediatric population

A
  • at risk for pulmonary aspiration
  • mediastinal mass
  • requires high peak airway pressures to ventilate
  • tracheomalacia
  • very limited mouth opening
183
Q

Most common cause of acquired subglottic stenosis.

A
  • postintubation injury
  • 95% of subglottic stenosis is acquired
184
Q

Risk factors associated with acquired subglottic stenosis and assoicated interventions

A
  • trauma during intubation
  • ETT movement during intubation
  • prematurity
  • presence of infection at time of intubation
  • oversized ETT
  • use appropriate sized ETT
  • be gentle with AW
  • monitor and maintain cuff pressures 20 - 30 cm H2O
  • use microcuff tube
185
Q

Describe appropriate ventilation strategies: TV, vent mode

A
  • 6 to 8 ml/kg is typical
  • lung protective strategies
    • PC vith volume guarantee is most common
    • just keep an eye on TV
186
Q

Sustained plateau AW pressures > 35 cm H2O can lead to?

A
  • barotrauma
    • pneumothorax
    • pneumomediastinum
    • subcutaneous emphysema
187
Q

What is laryngospasm & what is the frequency in kids?

A
  • reflex closure of false & true vocal cords
  • more frequent in infants, risk decreases with increasing age
188
Q

Risks for laryngospasm in the pediatric pt

A
  • recent URI
  • secondhand smoke
  • stimulation while “light”
  • secretions in AW
189
Q

S/S of laryngospasm in the pediatric pt

A
  • stridor
  • retractions
  • flailing of lower ribs
  • “rocking horse” chest wall movement
  • stridor will be absent wiht complete closure - “silent inspiratory effort”
  • can lead to negative pressure pulmonary edema especially in healthy, muscular adolscnts - may have to remain intubated for 12 - 24 hrs & may need furosemide

***can lead to profound bradycardia and desaturation if unrelieved***

190
Q

Treatment of laryngospasm in the pediatric pt.

A
  • Continuous positive airway pressure
  • 100% fiO2
  • jaw thrust at condyles of mandible
  • suction secretions/blood, etc.
  • deepen anesthesia (propofol)
  • if unresolved
    • atropine & succ - if no IV access then give IM!
191
Q

List all possible causes of bradycardia in children.

A
  • HYPOXIA - leading cause
  • vagal stimulation
  • increased ICP
  • CHD (congenital heart disease)
  • hypothermia
  • air emboli
  • tension pneumothorax
  • single dose succinylcholine w/o atropine
  • clonidine
  • beta blockers
  • sevo especially in downs syndrome
  • propofol infusion syndrome
  • some eye drops
192
Q

Bradycardia parameters by age

A
  • infants: < 100 bpm
  • 1 - 5 yo: 80 bpm
  • > 5 yo: < 60 bpm with s/s of poor perfusion
193
Q

Treatment of bradycardia in the pediatric pt

A
  • Treat cause! - think oxygenation and ventilation first!
  • 100% fiO2
  • open the AW - suction any secretions
  • ventilate
  • Drugs
    • atropine if vagal origin: 0.02 mg/kg IV
    • epinephrine if decompensated 10 mcg/kg + CPR
194
Q

Emergence: Awake Extubation

A
  • ALWAYS reverse if NMB given
  • patient safety first priority - if risk for aspiration - have to do an awake extubation
  • must be awake & purposeful; laryngospasms happen when patients are extubated in the early & second phase, “if in doubt…don’t take it out!”
  • 3 phases:
    • early phase- coughing intermittently, gagging, struggling, moving nonpurposefully
    • second phase- apnea, agitation, straining, breathholding
    • third (final) phase- regular respiratory rate, purposeful movement, coughing, opening eyes spontaneously- extubation now appropriate
195
Q

Emergence: Deep extubation

A
  • Do if not at risk for aspiration, pt easy airway, or didn’t have to do an RSI to begin with
  • Sevo increased to 1.5-2 MAC for at least 10 minutes
  • ensure no response (cough, breath holding) to suctioning or tube movement; & ensure regular respirations
  • Transport in lateral decubitus position “recovery position”
196
Q

PACU complications in ~___% of children: list the incidence of each.

A
  • ~5%
  • vomiting 77% (more common in >8 yo)
  • AW compromise 22% (more common in < 1 yo)
  • CV compromise is < 1%
197
Q

What is caudal anesthesia?

Types of sx and up to what age?

How is It completed?

A
  • lower abdominal and LE surgery in < 5 - 6 yrs of age
  • single shot block with LA will last 4 - 6 hrs
  • done following GA induction in lateral position
198
Q

Do we do spinal and epidural anesthesia in peds?

A
  • Yes, but are most frequently completed under GA
  • technique is similar ot the adult patient
199
Q

PONV in children: increased risk @ which age and which types of surgeries?

A
  • peak incidence in females age 10 - 16
  • surgeries
    • hernia
    • ochidopexy (testicles)
    • T&A (tonsils & adenoids)
    • strabismus (lazy eye sx)
    • middle ear
    • laparoscopic
200
Q

PONV in children: prevention inlcuding medications

A
  • hydration
  • multimodal analgesia (opioid sparing)
  • typical 2 agent strategy for prevention in @ risk (decreases risk by 80%)
    • ondansetron: 0.05 - 0.15 mg/kg IV
      • note risk in undiagnosed long QT syndrome
    • dexamethasone: 0.0625 - 1 mg/kg IV
      • OG says she gives about 8 - 10 mg in 10 yo
201
Q

How do we characterize emergence delirium?

A
  • phenomenon characterized by nonpurposeful restlessness and agitation, thrashing, crying or moaning, and disorientation
202
Q

What is the incidence of emergence delirium in peds and what are contributing factors?

A
  • Incidence
    • 18% of all children undergoing sx and anesthesia
    • peaks in 2 - 6 yo
  • Factors
    • young age
    • previous sx
    • type of procedure
    • type of anestethic
      • most common after sevo (then desflurane)
    • level of preoperative anxiety is predictive
203
Q

About how long does emergence delirium last and how should we manage It?

A
  • usually lasts ~10 - 15 minutes (self limiting)
  • protect from self harm
    • wrap IVs
    • pad side rails (bumper pads)
    • protect surgical incision
    • keep bed in low position
    • watch their eyes when they’re thrashing around

nura 620 anesthesia and coexisting conditions (7 decks)

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