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d. principles exam 4 2013 > Peds anesthesia 1 > Flashcards

Peds anesthesia 1 Flashcards

0
Q

inserting the ETT:

  1. what is a rule of thumb for depth of insertion?
  2. what is a more quantitative way to ensure proper placement?
  3. where above the carina would this be?
A
  1. 3x the size of the tube (i.e. 5 cm=15cm deep).
  2. look for a double black line at the vocal cords
  3. 2 cm above carina
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1
Q
  1. what is the formula for ET tubes for a peds patient?
  2. what size tube for a:
    - –1 yr old:
    - –2 yt old:
    - –3 yr old:
  3. what is a good way to estimate?
  4. what should always be done post intubation?
A
  1. age/4=X then X+4 OR age +16/4 (1+16=17/4=4.25
  2. tube sizes
    - –1 yr old: (1/4=.25+4)=4.25 (4)
    - –2 yr old: (2/4=.5+4)=4.5
    - –3 yr old: (3/4=.75+4)=4.75 (4.5-5)
  3. use their pinkie finger as a guidelins
  4.  Confirm by auscultation
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2
Q 
VS: by Morgan & Mikhail
what are normal pediatric vital signs?
-------------------RR----HR----SBP/DBP
1. Neonate: 
2. 1 year 
3. 3 years
4. 12 years
A
  • —————RR–HR—SBP/DBP
    1. Neonate: 40, 140+, 65/40
    2. 1 year : 30, 120, 95/65
    3. 3 years: 25, 100, 100/70
    4. 12 years: 20, 80, 110/60
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3
Q

pediatric fluid administration:
Composition of Fluids Glucose or not?
1. what can glucose in the IV lead to (potentially)?
2. what are infants and children at risk for?
 why?

A

Composition of Fluids :Glucose or not?
1. Greater hypoxic brain damage has been found in relation to high blood glucose levels
2. Infants and children are believed by some to have ↑ risk of hypoglycemia
d/t long NPO time and diminished glycogen stores

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4
Q

 Cortisol levels
1. What is the variation called that show changes in cortisol levels?
 What is the variation?
2. When is it better for a child to be NPO?
3. Why not put glucose IV on children that are NPO overnight?
4. what if your patient comes to you on a dextrose IV?
 or on TPN?

A

 Cortisol levels
1. “DIURNAL” variation;
cortisol level (and glucose) is higher in AM than PM
2. Children NPO overnight have a higher blood glucose than those NPO throughout the day
3. hyperglycemia is due to the stress response; glucose IV will only exaggerate this
4. Keep the dextrose running but at maintainance rate and add LR for replacement fluid
 cut TPN in half and add LR

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5
Q
  1. how often is a periopertive child found to be hypoglycemic?
  2. What are the exceptions?
  3. what should done with these children’s IV fluids with dextrose?
     why?
A
  1. Recent studies have shown that perioperative hypoglycemia is RARE in most children. The majority of children can be given dextrose free maintenance fluids.
  2. Exceptions
     Neonates less than 48 hours old
     Neonates in whom a pre-operative glucose infusion is interrupted
     Children below the 3rd percentile in weight
  3. These groups of children should be maintained on dextrose infusions without prolonged interruption.
     these children are at high risk for hypoglycemia.
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6
Q

Composition of Fluids  Lactated Ringers
1. When can you use ____ alone for OR cases?
2. what if you have a really long case and have only dextrose that cannot be interrupted, what should you consider?
3. dextrose containing IVs should be on what?
4. what type of fluid is added for replacement?
 for what purpose?

A

Composition of Fluids  Lactated Ringers
1. Short cases with minimal fluid replacement requirements
2. Longer cases and cases in which current glucose infusion should not be interrupted may consider 2 different fluids
3. Dextrose containing fluids on pump for maintenance fluids only
4. LR for replacement of:
NPO deficit,
3rd space losses and
replacement of blood loss,
to prevent HYPERglycemia

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7
Q

what are maintainance fluids based on?

A

Maintenance fluid volume requirements:
 Daily fluid requirements are based on metabolic demand (high in pediatrics),
 the high ratio of BSA to weight

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8
Q 
pediatric fluid requirements:
  0 – 10 kg 
  11 – 20 kg 
  > 20 kg 
  what about >~ 50 kg?
A 
pediatric fluid requirements:
  0 – 10 kg (4ml/kg)
  11 – 20 kg (40ml + 2ml/kg)
  > 20 kg (60ml + 1ml/kg)
  ??
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9
Q

Pediatric Fluid Administration: NPO Deficit

  1. what is the formula for fluid replacements (___x__)?
  2. In what increments is it replaced?
  3. why might you not be able to replace all of the NPO deficet?
  4. what can you do if the child is undergoing a minor procedure and hasn’t made up his NPO deficet?
  5. avoid what with fluid replacement?
A

Pediatric Fluid Administration: NPO Deficit
 Maintenance fluids x hours NPO
 Replace 1⁄2 deficit in 1st hour, 1⁄4 deficit per hour over next 2 hours (or 1/2, 1/4, 1/4)
 Realize that many cases are so short there is not enough time to replace NPO deficit
4. Patient’s undergoing minor procedures who can tolerate PO fluids post op can make up some or all of their own deficit by drinking
5. Avoid fluid overload

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10
Q

-how much of a fluid bolus is given for short procedures such as circumcision

A

10 ml/kg as a bolus

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11
Q

Surgical/third space losses what are the losses for each procedure type: Give examples:

  • —————–loss rate/hr——examples of procedures:
    1. very minor:
    2. minor:
    3. moderate:
    4. major:
    5. massive:
A

Surgical/third space losses

  1. Very minor 0-2 ml/kg/hr  BMT(tubes), frenulectomy
  2. Minor 2-4 ml/kg/hr  Hernia
  3. Moderate 4-6 ml/kg/hr  ENT, laparoscopic
  4. Major 6-10 ml/kg/hr  Bowel, open intra-abdominal
  5. Massive 10-20 ml/kg/hr  Craniofacial, spinal fusion
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12
Q

Replacement of blood loss
1. what is the replacement ratio with crystaloids?
2. what is replacement ratio with colloids or blood?
3. what colloids would you use?
 what colloid would you not want to use?
4. what should you calculate?

A

Replacement of blood loss
1. 3:1 replacement with crystalloids
2. 1:1 replacement with colloids or blood
3. Colloid: 5 % Albumin
 do not use hespan on pediatric patients
4. Calculate MABL (maximal allowable blood loss)

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13
Q

Putting it all together:
1. what are all the factores that are replaced during a surgery?
2. Example: solve for fluid replacement for a:
6 month baby for bowel resection, 7kg, NPO 8 hours
 1st hour:
 2nd hour:
 3rd hour:
 4th hour:

A

Putting it all together
1. NPO deficit + hourly maintenance fluid + surgical/third space
losses + blood loss  Example:
 6 month baby for bowel resection, 7kg, NPO 8 hours
A-LOSS: for bowel resection=6-10cc/hr =8cc/hr x 7kg=(56cc)
B-NPO: for 6 month old= 7kg x 4cc/hr (maint) x 8 hours npo=224ml 224/2=112; 112/2=56» (112cc; 56cc; 56cc)
C-MAINTAINANCE: for 7kg= 7kg x 4cc= (28cc)

 1st hour: 56 + 112 + 28 = 196ml
 2nd hour: 56 + 56 + 28 = 140 ml
 3rd hour: 56 + 56 + 28 = 140 ml
 4th hour: 56 + 28 = 84 ml

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14
Q

RECAP: figure out the SURGICAL LOSS for this patient:

 6 month baby for bowel resection, 7kg, NPO 8 hours

A

 6 month baby for bowel resection, 7kg, NPO 8 hours

SURGICAL LOSS: for bowel resection=6-10cc/hr =8cc/hr x 7kg=(56cc)

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15
Q

RECAP: figure out the MAINTAINANCE for this patient:

 6 month baby for bowel resection, 7kg, NPO 8 hours

A

- 6 month baby for bowel resection, 7kg, NPO 8 hours

MAINTAINANCE: for 7kg= 7kg x 4cc= (28cc)

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16
Q

-RECAP: figure out the NPO DEFICET for this patient:

 6 month baby for bowel resection, 7kg, NPO 8 hours

A

 6 month baby for bowel resection, 7kg, NPO 8 hours

NPO: for 6 month old= 7kg x 4cc/hr (maint) x 8 hours npo=224ml 224/2=112; 112/2=56» (112cc; 56cc; 56cc)

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17
Q 
Blood Products; Replacement rates: 
when replacing blood products, how much do you replace per Kg?
1. Red blood cells (PRBC’s):
2.  FFP:
3.  Platelets:
4.  Cryoprecipitate:
A

Blood Products; Replacement rates:

  1. Red blood cells (PRBC’s)= 10-20 ml/kg
  2. FFP= 10-15 ml/kg
  3. Platelets= 1 unit/10kg (0.1 unit/kg)
  4. Cryoprecipitate= 0.1 units/kg (up to 3 units)
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18
Q
  1. what are the 5 major S/S of symptomatic hypovolemia in pediatrics?
  2. what symptom has an audio/visual sign that somthing is wrong?
  3. what symptom is a sign that if you see it, you have “dropped the ball”?
  4. what is the difference in BP symptoms between pediatrics and adults with loss of volume?
  5. How much of a bolus of LR should be given?
  6. what else can you give?
A 
1. Symptomatic Hypovolemia (s/s)
  ↓ urine output
  Tachycardia
  Mottled skin
  Cold extremities
  Hypotension
2.  cool extremities: Has your pulse-ox stopped picking up??
3.  Hypotension is a late sign
4.  Peds differs from adults in that they may maintain BP until >25% reduction in volume status (thats why BP is a late sign).
5.  Bolusing Crystalloids 
  5-20 ml/kg LR (start at 5 ml and work up unless really symptomatic)
6.  Bolus of Colloids (bolus 5% albumin)
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19
Q 
NPO Guideline:  Fasting time
1.  < 6 months
  Milk and solids: 
  Clear liquids: 
  Breast milk: 
2.  6 months – 3 years
  Milk and solids: 
  Clear liquids: 
3.   > 3 years
  Milk and solids: 
  Clear liquids:
A 
NPO Guideline:  Fasting time
1.  < 6 months
  Milk and solids: 4 hours
  Clear liquids: 2 hours
  Breast milk: 3-4 hours
2.  6 months – 3 years
  Milk and solids: 6 hours
  Clear liquids: 2 hours
3.   > 3 years
  Milk and solids: 8 hours
  Clear liquids: 2 hours
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20
Q

room set up:

  1. first thing in the morning for pediatric cases; do what to the room?
  2. what should be on the table and on?
  3. Peds set up: what should you have different sizes of (2 things)?
A

Room set up
1. Warm the room!! (Turn thermostat up in early AM)
2. Bair hugger on OR table and turned on for appropriate cases
3.Peds set up
 Different mask sizes
 ETT’s: 3 sizes…the one you plan to use, one size up and one size down (by half sizes)

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21
Q

cuffed or uncuffed tubes: 4 arguements for uncuffed tubes:

A

Traditional thoughts on benefits of uncuffed ETT’s
a Pediatric funnel shaped trachea
b Cricoid cartilage is the narrowest portion of airway up to age eight, therefore negating need for cuffed tubes
c Cuffs may cause subglottic stenosis
d Allows for larger diameter ETT therefore decreasing airway resistance

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22
Q

cuffed tubes: 6 arguements for the use of cuffed tubes in children:

A

Consider using cuffed instead of uncuffed
a Improved volumes
b Less risk of airway fire
c Less leakage of inhaled agent into OR
d Less incidence of reintubation due to too large of a leak (ETT too small)
e Less ETT movement during head and neck manipulation (more stablilty)
f Subglottic stenosis has been found NOT to be a factor in patients with cuffed tubes for short term intubation

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23
Q

Room set up:

  1. what cart should be in the room?
  2. what 2 “monitors” should be ready to go?
  3. what airway equipment should be ready?
  4. this “roll” positioning equipment for what age range?
A

Getting Ready: Room set up
1. Peds cart
2. 2 monitors
 Precordial: have this ready with the sticker on
 Temperature monitor: forehead sticker or esophageal available
3. airway equipment:
 Laryngoscope, blades, Different airway sizes available
 Masks and filters
 Stylet available (usually not necessary, but have one available)
4. positioning equipment
 Shoulder roll if < 12-18 months (Positioning is important!!)

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24
Q

room set up: peds cart:

-what should be sitting on top of it (2 things)

A

 LMA

 Appropriate size suction catheters for ETT

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25
Q

peds cart:

what iv and drug supplies should be on top:

A 
  Syringes for drugs
  IV supplies
  20, 22, 24 gauge IV catheters 
  Tape
  Alcohol and gauze
26
Q

Peds cart: what fluid equipment should be ready?

A

 Fluids Primed for each patient
 Under 1 year, prime with buretrol if available
 >1 through 8 years, prime with microdrip tubing
 Over age 8, use macrodrip tubing

27
Q

peds cart:

  1. what should you know?
  2. what should be drawn up and what should be on the syringe?
A
  1. What should you know?
     Know your mg or mcg/kg doses!
     Be sure you know how much drug is in 0.1 ml of TB syringe
  2. what should be drawn up:
     Induction drug of choice
     Narcotic of choice
     Succinylcholine and Atropine drawn up WITH NEEDLES.
     Decadron, Zofran, etc
  3. Extra syringes in appropriate sizes (mostly TB stringes for patients < 1 y/o)
28
Q

room set up:
1. gas machine: what do you have to change?
2. monitor machine: what pediatric specific monitoring devices do you need? If its a long case what can you put on the toe?
3. circuit changes–When to change to peds circuit?
4. machine bags: what sizes for what age?
(These are guidelines only and vary by practitioner and personal preference)

A 
  Room set up 
1. Gas Machine:
  Change to pediatric or infant mode
2. monitor machine:
  Peds BP cuff
  Peds pulse ox (Usually only if < 6 mo or long case, the adult one can be placed right over the big toe) 
3. Circuit
  peds circuit for\_\_\_\_
  Peds spirometry sensor
4. Bags (size based on age)
  0.5 L (under 6 mo)
  1 L (6mo-3 years)
  2 L (3-10 years)
29
Q

preopertively: why consider developmental stage in pre-op?
1. 0-8 (to 10) months: who is the stress on? do you need premedication?
2. 8 (to10)months to 4 yrs old: what fears in this age? will you need premedication?

A
  1. 0 – 8-10 months
     Minimal stress for infant, maximal stress for parents
     Premedication usually not necessary
  2. 8-10 mo – 4 years
     Fear of separation
     Usually need premedication unless parental presence is permitted on induction
30
Q

developmental age and pre-op:
4-6 yr old:
1. what can they understand?
2. what 2 things do they need (the second only if parents are not permitted in the OR?
3. what extra thing can you do if the child fears the mask?

A

4-6years
1. Understand
 simple explanations
2. they need:
 Need reassurance
 May need premedication unless parental presence is permitted during induction
 can take the mask to the child if they fear it; tell them it wont hurt them

31
Q 
developmental stage and pre-op:
6-12 yrs old:
1. do well with:
2. explaining is good because they...?
3. what are their fears (2 things)?
4. how can you alleviate these fears?
A

 6 – 12 years
1. do what well:
 Separate well from parents (usually)
2. need explaining d/t:
 Better understanding of explanations
3. fears:
 May fear not waking up
 Fear of the IV
4. what can be done to aleviate these fears:
 Over age 8, may have IV placed in preop, depends on the child  +/- premedication (oral versed)
 tell them they will be breathing happy gas

32
Q

teenagers:

  1. what are their needs:
  2. what are their fears?
  3. what can be done to alleviate them?
A 
Teenagers:
1. needs:
  Need information and reassurance
2. fears:
  Fear of losing control
  Fear of the IV
3. how to alleviate:
  let them choose to have IV placed post gas (if possible)
33
Q

special circumstances:

  1. special populations to be aware of (4) at least, and what should you know?
  2. what should you do to make things to smoother?
A 
1. Consider special circumstances
  Developmentally disabled
  Developmental delays
  Autism (dont like eye contact)
  Multiple anesthetic history (may have developed preferences (i.e. bubble gum mask)
2. what can we do:
  Take cues from patients and parents 
  get a detailed History
  May enlist parental help
34
Q

pre op interview:

  1. interview whom?
  2. what are history details that you need?
A

Preoperatively: Preoperative Interview
1. interview whom?
 Interview parents, include the child if appropriate
2. details of interview:
a. NPO status
b. Allergies
c. Birth history
 Prematurity or complications
 Prolonged hospitalization after birth?
 Required ventilator or oxygen?
d. Anesthetic history, INCLUDING FAMILY anesthetic history
e. Recent colds, URI, fever
f. Elaborate on any positive medical history
 Asthma
 Heart murmur (was it innocent)

35
Q

Preopertive interview:

  1. what MUST be done prior to going back to OR:
  2. If mask induction, parents and children are usually comforted by the fact that there will…
A

Preoperative interview:
1. what MUST be done prior to going back:
 Confirm parent’s understanding/statement of procedure
 Explain what to expect
2. If mask induction, parents and children are usually comforted by the fact that there will…
 be no “poke’s” while awake

36
Q

preop interview: explain what to expect:
Toddlers and young children:
1. what can you do to make them feel at ease?
2. what dont you want to do (remembering that they are toddlers)?
3. tips to help bond with the child (and parent):

A

Toddlers and young children
1. what can you do to make them feel at ease?
 “make friends”, give them a mask and ambu bag to try out
 Follow their lead, if they don’t want any part of you, leave them alone after quick physical exam and just speak to parents
2. what dont you want to do (remembering that they are toddlers)?
 Be careful not to give more information than they can handle
3. 3 tips to help bond with the child:
 Get a feel for this and don’t overwhelm them, exude confidence!

37
Q

Preoperative interview :Explain what to expect

  1. infants and small toddlers: you should do what for parents?
  2. doing what can help put the parents minds at ease?
A
  1. infants and small toddlers: you should do what for parents?
     For infants and small toddlers (mostly non-verbal) explain to parents that they may seem “out of sorts” during recovery
  2. doing what can help put the parents minds at ease?
     Assure parents pain medicine will be given
38
Q

Preoperative Interview; Explain what to expect

  1. what should you explain to patient and parents?
  2. bring what with you?
  3. If child is crying or protesting, what should you do?
A
  1. explain:
     how you will take them to OR ( Carry, wagon, wheelchair)
  2. bring what with you:
     Bring security items( Blankets, pacifier, stuffed animals)
  3. If child is crying or protesting
     go quickly
39
Q

Preoperative physical assessment:

  1. what does the physical assessment entail?
  2. what should you always do regarding heart and lungs?
A
  1. physical assessment:
    a. Overall appearance
    b. Physically or mentally delayed?
    c. Healthy vs. sick “looking”
    d. Airway
    e. Teeth
     Presence of, loose teeth
     Tell toddlers and preschoolers you want to count their teeth
    f. Heart and lungs
  2. what should you always do regarding heart and lungs?
     Listen!!
40
Q

Induction

  1. Now that we’re in the room, what do we do?
  2. If crying or combative?
A
  1. Now that we’re in the room, what do we do?
     Place monitors if pt allows (definately put on precordial 1st)
     Start BP cuff (after pt asleep)
     Speak quietly to pt, chaos and loud voices are scary!
     Remind OR staff to speak quietly as well
  2. If crying or combative?
     get started without monitors (just put on pulse ox)
     get OR nurse and anesthesiologist to assist with remaining monitors
41
Q

induction: what if the patient has a full stomach?

A

IV induction: Full stomach
 RSI with cricoid pressure
 Technique same as in adults
Induction

42
Q

induction: -Inhalation Induction
1. Infant and uncooperative patient?
2. what is done with circuit before putting it on uncoopertive patient?

A

-Inhalation Induction
1. Infant and uncooperative patient?
 use 70% N2O (2L O2 + 6L N2O) + 8% Sevoflurane
2. what is done with circuit?
 Prime circuit before placing mask, pop-off open

43
Q

induction: -Inhalation Induction
1. what 2 things are imperitive with mask induction?
2. what dont you want to do until patient is asleep?
3. mask fit is hard, but what dont you want to do?
4. what should be handy?

A

-Inhalation Induction
1. what 2 things are imperitive with mask induction?
 Proper hand position on mask
 Ensure tight mask seal; nice fit
2. what dont you want to do until patient is asleep?
 Be sure not to stimulate pt with jaw lift before sleepy
3. mask fit is hard, but what dont you want to do?
 Be sure not to obstruct the airway by pushing on soft tissue under chin
4. what should be handy?
 Have tongue blade and airway within reach

44
Q

induction: Inhalation induction: Cooperative older toddler/school age child: More options;
1. what “gradual method” can be done to get the patient asleep?
2. whats a game you can play to get them to sleep?
3. what is the single breath technique?

A

Inhalation induction: Cooperative older toddler/school age child
1. More options; what can be done to get the patient asleep?
 Gradual induction starting with 70% N2O, once pt sleepy, dial
in sevoflurane incrementally
2. whats a game you can play to get them to sleep?
 Play game asking child to blow up the balloon, showing them the bag and giving lots of encouragment
3. what is the single breath technique?
 Single breath technique with 70% N2O + 8% Sevoflurane; have them inhale and hold; they will go to sleep.

45
Q

 Inhalation induction

  1. Once pt asleep and not fighting,
  2. best way to ventilate these patients?
  3. use your HEARING during these cases; how?
A

 Inhalation induction
1. Once pt asleep and not fighting,
 gently assist respirations as needed
2. best way to ventilate these patients?
 maintain spontaneous respirations (less risk of anesthetic overdose)
3. use your HEARING during these cases; how?
 Listen to pulse ox for desaturation and through precordial for obstruction

46
Q

Inhalation Induction

  1. Oral airway: when? why?
  2. what can Placing airway too soon cause?
  3. what is the Goal of mask induction?
  4. If you are masking the patient, who is gonna start the IV?
A

Inhalation Induction
1. Oral airway: when? why?
 Place airway once deep enough (only if needed)
2. what can Placing airway too soon cause?
 may cause laryngospasm
3. what is the Goal of mask induction?
 to get patient either deep enough for start of procedure
(BMT) or for IV placement
4. If you are masking the patient, who is gonna start the IV?
 MDA usually places IV while CRNA continues with inhalation induction and prepares for intubation

47
Q
  1. what are the pitfalls to mask induction?

2. how can you tell the difference between breath holding and laryngospasm?

A
  1. what are the pitfalls to mask induction?
     Breath holding
     Laryngospasm
     Anesthetic overdose
  2. difference between laryngospasm and breath holding:
     during breath holding the chest WILL NOT be moving
48
Q

Pitflls: complete laryngospasm:

  1. what will be seen? why?
  2. initial treatment for laryngospasm (2 things)?
  3. if still no response and patient is desaturating?
  4. how successful is propofol in breaking laryngospasm?
A

laryngospasm
1. what will be seen?
 “rocking boat” movement between chest and abdomen (there is respiratory effort but no air movement)
2. treatment for laryngospasm:
 turn up the gas to get them deeper
 turn up the APL valve; flutter the bag
3. if still no response and patient is desaturating:
 turn up the APL valve apply >~20 chH20 (may need alot of peep) continuous positive pressure via mask
 Propofol (??5-10 mg) if IV placed
 IM/IV succinylcholine if pt continues to desaturate or becomes bradycardic and spasm does not break (you may want to give some atropine10-20 mcg/kg (min 0.1 mg)prior to sux (which can further cause bradycardia)).
4. how successful is prop?
 99% successful

49
Q

Induction: Pitfalls
Breath holding
1. why should you not attempt to assist respirations
2. what should you do, even if the patient turns blue?
3. why is it important that you be able to distinguish between breath-holding and laryngospasm?

A

Induction: Pitfalls
Breath holding
1. why should you not attempt to assist respirations
May cause laryngospasm
2. what should you do, even if the patient turns blue?
 Be patient
3. why is it important that you be able to distinguish between breath-holding and laryngospasm?
 cause you are going to be standing there waiting and if it is a laryngospasm, you have wasted precious time

50
Q

Pitfalls Partial laryngospasm
Stridor:
what is the treatment?

A 
Pitfalls Partial laryngospasm
Stridor:
what is the treatment:
  Give gentle positive pressure
  PEEP on the bag
  Deepen patient
51
Q
  1. Once IV is placed successfully, preoxygenate patient by:
  2. then get ready for :
  3. what should be right next to you?
A

 discontinuing N2O
 intubation or LMA insertion
 suction: Be sure is available and on!!!

52
Q

Intubation: Infants

  1. they have big heads, how do you get them into sniffing position?
  2. what is different about their larynx?
  3. what wont you usually use in peds, but should have it near?
  4. blade of choice for infants:
A 
Intubation: Infants
1. they have big heads, how do you get them into sniffing position?
  Use shoulder roll 
2. what is different about their larynx?
  More anterior larynx
3. what wont you usually use in peds, but should have it near?
  Have stylet available 
4. blade of choice for infants:
  Miller 0 or 1 blade

Induction

53
Q

Toddlers

  1. how hard to intubate?
  2. blade of choice for toddlers?
A 
Toddlers
1. how hard to intubate?
  Usually easy laryngoscopy
2. blade of choice for toddlers?
  Miller 2, WIS 1 or MAC 2 blade
54
Q

-School Age

blade of choice:

A

School Age
blade of choice:
 Miller 2, WIS 2 or MAC 2-3

55
Q

Pitfalls: Anesthetic overdose

  1. Once patient is deep enough for IV placement and respiratory effort is minimal, what can you do?
  2. best anesthesia plan for this patient?
  3. use your hearing for what?
A
  1. once patient deep…
     may ↓ agent
  2. best anesthesia plan for this patient:
     Maintain spontaneous respirations
  3. use your hearing:
     Listen to pulse oximetry for heart rate, pt may exhibit bradycardia and hypotension with excessive depth of anesthesia
56
Q
  1. during insertion of ETT, make sure that the tube doesnt…?
  2. how do you guage Depth of insertion?
  3. what should you always do post intubation?
  4. why important in pediatrics to check both sides?
A

Intubation
1. during insertion
 Watch closely during insertion, ETT should not “drag” on
cords
2. Depth of insertion
 Double black line on ETT at level of vocal cords
3. what should you always do?
 Auscultate both sides
4. why important in pediatrics to check both sides?
 ETT can slip down either side in neonates & small infants

57
Q

Intubation: Assessing for correct tube size
– what is a Leak test: what type leak is normal?
what denotes too large or too small of a tube?

A

Intubation: Assessing for correct tube size
– what is a Leak test?
 Patient should have audible leak at 20 cm H2O, but not much
less than that
 Large leak at < 20 cm H2O means ETT is too small
 No leak at 20-30 cm H2O means ETT is too large

58
Q
  1. what should be done after patient or table repositioning?
  2. what should you Consider changing after patient is intubated?
  3. why change?
  4. What will some institutions give at this time to assist with post op pain control?
  5. why should you tell pacu about the tylenol?
A
  1. what should be done after patient or table repositioning?
     Re-check proper ETT placement
  2. what should you Consider changing after patient is intubated?
     from Sevoflurane to Desflurane or Isoflurane
  3. why change?
     to ↓ incidence of emergence delirium caused by sevoflurane (Practitioner preference)
  4. What will some institutions give at this time to assist with post op pain control?
     Acetaminophen suppository 15 mg/kg
  5. why should you tell pacu about the tylenol?
     so pt does not receive Tylenol with codeine too soon and receive Tylenol overdose
59
Q

Volume control

  1. why not so good for neonates and infants?
  2. for whom is volume control better for?
  3. what should you ensure regarding rate on the vent?
A

Volume control
1. why not so good for neonates and infants?
 Can be a difficult mode for very small volumes (neonate &
infant) because it can be an inaccurate and unreliable delivery of volume
2. for whom is volume control better for?
 Good for older babies and children
3. what should you ensure regarding rate on the vent?
 Provide appropriate RR for age

60
Q

Pressure control

  1. is this a good mode for neonates etc.?
  2. what settings should you use (PIP, RR)?
  3. what is the best way to guage adequacy of ventilation?
A

Pressure control
1. is this a good mode for neonates etc.?
 Excellent mode for neonates and infants
2. what settings should you use?
 Start with PIP 15 and assess chest expansion,
 Adjust PIP to proper chest expansion and Vt
 Provide appropriate RR for age
3. what is the best way to guage adequacy of ventilation?
 chest expansion

61
Q

Emergence delirium

  1. what is it?
  2. how to treat it (what are the best meds)?
A
  1. what is Emergence delirium
     Patients inconsolable, thrashing
  2. how to treat it?
     Narcotic has been shown to be more effective than benzodiazepines (0.05-1 mcg/kg fentanyl or 0.025-0.1 mg/kg morphine)
     Dexmedetomidine 0.1-0.3 mcg/kg IV slowly
62
Q

stridor:

  1. what do you do first?
  2. what might be the cause; what might you see?
  3. what is the treatment?
A

Stridor
1. what to do first:
 Assess patient
2. what could be the cause?
 Secretions, airway obstruction or stridor?
 Respiratory distress or retractions present?
3. what might be required?
 May require assistance, reintubation
 Provide humidified oxygen
 Decadron 0.25-1 mg/kg
 Racemic Epinephrine: 0.25-0.5ml 2.25% solution nebulized in 2.5ml NS

63
Q

Pain

  1. good rule of thumb with narcotics:
  2. Morphine: dose?
  3. Fentanyl: dose?
  4. Toradol: dose?
A 
Pain
1. good rule of thumb with narcotics:
  Start small, you can always give more
2.  Morphine
  0.05 - 0.1mg/kg
3.  Fentanyl
  0.5-1mcg/kg
4.  Toradol
  0.5 mg/kg

d. principles exam 4 2013 (7 decks)

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