Peds Flashcards

Question

oxygen consumption: neonate and adult

Answer 1

* neonate: 6 ml/kg/min * adult: 3.5 ml/kg/min

Answer 2

* neonate: 130 ml/kg/min * adult: 60 ml/kg/min

Answer 3

* neonate: 35 bpm * adult: 15 bpm

Answer 4

* neonate: 6 ml/kg * adult: 6 ml/kg \*\*note tidal volume is consistent across age\*\*

Answer 5

* 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)

Answer 6

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

Answer 7

* child: 5.5 ml/100 g/min * adult: 3.5 ml/100 g/min

Answer 8

* child: 70-110 ml/min/100 g * adult 50 ml/min/100 g

Answer 9

* 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.

Answer 10

* 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

Answer 11

~ 2 months

Answer 12

* 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

Answer 13

* 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

Answer 14

* 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

Answer 15

* faces * legs * activity * cry * consolability

Answer 16

* 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

Answer 17

* 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

Answer 18

* 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

Answer 19

* 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

Answer 20

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%)

Answer 21

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)

Answer 22

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

Answer 23

* lower levels of albumin/other proteins for drug binding in newborns * LARGER PORTION OF UNBOUND DRUG CIRCULATING

Answer 24

* minimal glycogen stores - PRONE TO HYPOGLYCEMIA

Answer 25

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.

Answer 26

4-5 months of age \*\*high incidence of refulx especially in preterm infants\*\*

Answer 27

* 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

Answer 28

* 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

Answer 29

* 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

Answer 30

* 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

Answer 31

* alter non shivering thermogenesis

Answer 32

* 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\*\*

Answer 33

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

Answer 34

* 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)

Answer 35

* 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)

Answer 36

* \< 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

Answer 37

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

Answer 38

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

Answer 39

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)\*\*

Answer 40

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

Answer 41

* 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.

Answer 42

increased; immaturity

Answer 43

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)

Answer 44

dilutional coagulopathy

Answer 45

* 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

Answer 46

* 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.

Answer 47

* smaller IV bags * buretrols * eliminate all air from IV line

Answer 48

* infants \< 6 months * at risk for hypoglycemia * children with mitochondrial disease \*\*only D₅1/2NS for maintenance rates!!, LR for the rest\*\*

Answer 49

* 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

Answer 50

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

Answer 51

* 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.

Answer 52

"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\*\*

Answer 53

inversely I.e. lower solulbility = higher wash in

Answer 54

* delivery to lungs * inspired concentration * alveolar ventilation * FRC * removal from lungs * CO * solubility * alvoelar to venous partial pressure gradient

Answer 55

* SEVO * MAC up to 6 months is ~3.2% * MAC 6 mo to 12 years is constant at 2.4%

Answer 56

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.

Answer 57

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

Answer 58

* 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

Answer 59

* antibody reaction * most frequently seen with repeated exposure

Answer 60

* immature BBB * decreased metabolism

Answer 61

* 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

Answer 62

* 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

Answer 63

* approved for use in age \> 10 yo in US * 0.2 - 0.3 mg/kg IV

Answer 64

* no longer available in US * dose: 3 - 5 mg/kg IV

Answer 65

* 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

Answer 66

* 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)

Answer 67

* 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

Answer 68

* 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

Answer 69

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

Answer 70

* primarily given for shivering in small doses * maintains RR * has an active metabolite and unwanted SE

Answer 71

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

Answer 72

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

Answer 73

* 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

Answer 74

* 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\*\***_

Answer 75

* 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

Answer 76

* cisatracurium/atracurium * hoffman elimination * TEMP AND PH DEPENDENT

Answer 77

* **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

Answer 78

* 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

Answer 79

* 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

Answer 80

* lidocaine w/o epi: 4 mg/kg * lidocaine w/ epi: 7 mg/kg

Answer 81

* 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\*\*\*\*\*\*

Answer 82

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

Answer 83

* parental anxiety may be extreme

Answer 84

* 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.

Answer 85

* loss of control * let them pick arm for BP cuff or anything you can let them control

Answer 86

* preschool age: concrete thoughts * school age: desire to meet adult's expectations

Answer 87

* 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

Answer 88

* spina bifida * myelodysplasia * urinary tract malformations * multiple previous surgeries

Answer 89

* 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

Answer 90

* 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

Answer 91

* predisposition to coughing, laryngospasm, bronchospasm, and desaturation during anesthesia or to postintubation subglottic edema or postoperative desaturation

Answer 92

* adenoidal hypertrophy, upper airway obstruction, obstructive sleep apnea, pulmonary hypertension

Answer 93

* “croupy” cough may indicate subglottic stenosis or previous tracheoesophageal fistula repair; productive cough may indicate bronchitis or pneumonia

Answer 94

* postintubation croup * subglottic stenosis

Answer 95

* subglottic narrowing; laryngomalacia, macroglossia, laryngeal web, extrathoracic foreign body or extrathoracic tracheal compression

Answer 96

* laryngitis * vocal cord palsy * papillomatosis * granuloma

Answer 97

* bronchospasm

Answer 98

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

Answer 99

* difficult intubation, difficulty with mask ventilation, failed or problematic extubation

Answer 100

* increased airway reactivity/resistance, increased propensity to desaturation

Answer 101

* many are associated with DA management

Answer 102

* increased AW reactivity

Answer 103

* 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

Answer 104

* 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

Answer 105

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

Answer 106

* 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

Answer 107

* 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

Answer 108

* 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

Answer 109

* 10 months * separation anxiety becomes an issue

Answer 110

* 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)

Answer 111

* 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

Answer 112

* onset: 45 - 60 minutes * topical anesthetic that can be used for IV starts in pre op

Answer 113

* 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

Answer 114

* 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

Answer 115

* 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

Answer 116

* 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

Answer 117

* (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

Answer 118

* 3.5 * very prone to kinking and obstruction - really watch any weight on tube and vigilantly monitor PIP

Answer 119

* ID x 3 * tube should be midway between cords and carina on chest xray

Answer 120

* at risk for pulmonary aspiration * mediastinal mass * requires high peak airway pressures to ventilate * tracheomalacia * very limited mouth opening

Answer 121

* postintubation injury * 95% of subglottic stenosis is acquired

Answer 122

* 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

Answer 123

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

Answer 124

* barotrauma * pneumothorax * pneumomediastinum * subcutaneous emphysema

Answer 125

* reflex closure of false & true vocal cords * more frequent in infants, risk decreases with increasing age

Answer 126

* recent URI * secondhand smoke * stimulation while "light" * secretions in AW

Answer 127

* 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\*\*\***

Answer 128

* **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!

Answer 129

* **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

Answer 130

* infants: \< 100 bpm * 1 - 5 yo: 80 bpm * \> 5 yo: \< 60 bpm with s/s of poor perfusion

Answer 131

* **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

Answer 132

* 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_**

Answer 133

* 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”

Answer 134

* ~5% * vomiting 77% (more common in \>8 yo) * AW compromise 22% (more common in \< 1 yo) * CV compromise is \< 1%

Answer 135

* 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

Answer 136

* Yes, but are most frequently completed under GA * technique is similar ot the adult patient

Answer 137

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

Answer 138

* 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

Answer 139

* phenomenon characterized by nonpurposeful restlessness and agitation, thrashing, crying or moaning, and disorientation

Answer 140

* 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

Answer 141

* 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