Peds (Blue stuff only) Flashcards
How old is Premature?
Less than 37 weeks gestation or less than 2,500 g
How old is a Neonate?
0-1 month
How old is an infant?
1 month - 1 year
How old is a Toddler?
1 year - 3 years
How old is a Small Child?
4-6 years
How old is a Big child?
6-12 years
How old is an Adolescent?
13-18 years
What is the difference between a pediatric and adult airway?
-Cartilage isn’t calcified = easier to collapse w/loss of muscle tone
-Large tongue & occiput (difficult to achieve sniffing position)
-Larynx is higher than in adults (C2-C4 compared to C3-C6). More cephalad = difficult DL
-Epiglottis is Omega-Shaped and stiff
-Narrowest point of the airway = cricoid cartilage (adults is vc).
What are the differences in pediatric respiratory physiology?
-Airway resistance is greater due to smaller diameter
-Inc WOB
-Immature CNS: Apnea/irregular breathing patterns are normal
-Use smaller cuffs to avoid swelling/pressure (can have glottic narrowing simply because of prolonged intubation)
-Chest wall is very compliant (ribs not calcified yet)
-Alveolar compliance is low (limited O2 reserve - important during induction)
-Smaller residual lung volumes
-High risk of apnea in the preterm neonate <60 wks PCA
-Increased O2 consumption compared to adults
Infants < ____ weeks PCA should be monitored with a min of pulse ox overnight after general and neuraxial anesthesia.
-Due to high risk of apnea.
-Big concern with preemies.
< 60 weeks Post-Conceptual Age (PCA)
What type of muscle fibers are the diaphragm and intercostals in peds? Why is this important?
-They are type 2 fibers: built for short bursts of activity and fatigue rapidly.
-Don’t mature until 2 years of age
-Any factor that increases WOB leads to early fatigue of the respiratory system
What are considerations regarding a patient with Trisomy 21?
-Atlanto - occipital instability (underdeveloped ligaments - be gentle with head positioning)
-Chronic URIs (inc airway reactivity)
-Large tongue
-Small oral cavity
What are the differences with the pediatric Cardiovascular physiology?
-O2 consumption is 2x that of adults (7 mL/kg/min vs 3.5 mL/kg/min)
-CO is HR dependent (hypoxemia may precipitate bradycardia -very bad in peds)
-Vagal stimulation = marked bradycardia (can pretreat with anticholinergic like glyco or atropine)
-Increases susceptibility to myocardial depression by inhaled drugs (due to calcium channel blocking activity)
What is unique about Fetal Hemoglobin?
It has a higher affinity for O2 than adult hgb.
-Compensatory mechanism for low PaO2 in fetal circulation (fetus was getting O2 from mom via placenta)
-Fetal Hgb shifts curve to the left with a lower P50
-Increased 2,3 DPG corrects this by shifting it to the right.
-Support neonatal Hgb levels to avoid tissue hypoxia
-Levels stabilize at 2-3 months old
What are the differences with pediatric fluid/electrolyte balances?
-Larger total body water percentage (TBW is 75-80% compared to adults at 60%)
-Newborn ECF is 40% of their body weight
-Neonates are unable to conserve Na
What is the Estimated Blood Volume range for a Premature infant?
90-100 mL/kg
What is the Estimated Blood Volume range for a newborn (term)? (0 - 30 days)
80-90 mL/kg
What is the Estimated Blood Volume range for an infant? (30 days - 2 years)
75-80 mL/kg
What is the Estimated Blood Volume range for a School aged Child? (3-18 years)
75 mL/kg
What is the Estimated Blood Volume range for an Adult?
65-70 mL/kg
How do pediatrics perform thermoregulation?
-Thermoregulation is compromised because of a lack of the ability to shiver.
-They metabolize brown fat, cry, and move their extremities.
-Lose heat rapidly through conduction, radiation, and convection
What are the differences in the pediatric nervous system?
-Spinal cord ends at L3 instead of L1.
-Fontanelles are not fused (monitor for volume status)
-Blood brain barrier is incomplete.
-Myelination begins during the fetal period and extends progressively. It does not reach maturity until the age of 2-3.
What happens with peds because the BB Barrier is incomplete?
This is an important consideration in drugs that may not cross the blood brain barrier in adults, but will in pediatrics.
How many mg/kg/min of glucose does an infant require?
3-4 mg/kg/min
How many mg/kg/min of glucose does a neonate require?
5-6 mg/kg/min
How do you calculate the hourly glucose replacement for a 2 kg neonate?
2 kg neonate requires 5 mg/kg/min equals 10 mg/min= 600mg/hr
-D5% = 50 mg of dextrose per 1 mL
600mg/hr / 50mg/mL = 12mL/hr
What is unique about Pediatric Pharmacokinetics?
-Increased total body water affects the volume of distribution of drugs as compared to adults
-CNS effects of opioids and barbiturates may be prolonged because of the immature blood-brain barrier.
-Very sensitive to opioid respiratory depression (even more so if <60 wks PCA)
MAC is higher in infants from ____ to ____ months, peaking at ____ months.
MAC is higher in infants from one to six months, peaking at 3 months.
-Due to immature BB Barrier
-At around 6 months, it comes back down and starts to represent adult-ish values.
-Has a second increase in puberty (but not as much).
What is important to know regarding Succinylcholine in peds?
-Larger volume of distribution requires more per KG in children than adults
-Often avoided unless clinically indicated for a rapid sequence induction because of reported cases of unanticipated cardiac arrest (Dystrophy can precipitate untreatable hyperkalemia)
What is the weight based fluid calculation rule?
4 mL/kg for the first 10 kg
2 mL/kg for 10 - 20 kg
1 mL/kg for any remaining kgs over 20 kg
How much fluid replacement does a kid need who is 30 kg?
70 mL/hr of maintenance fluids
What is the fluid replacement for third spacing for Minor Surgery?
2-4 mL/kg/hr
Ex: Herniorrhaphy, clubfoot
What is the fluid replacement for third spacing for Moderate Surgery?
4-8 mL/kg/hr
Ex: Pyloromyotomy
What is the fluid replacement for third spacing for Major Surgery?
8-10 mL/kg/hr
Ex: Bowel resection, NEC
What is the equation for Allowable Blood Loss?
EBV x (Starting Hct - Target Hct) / Starting Hct
What is usually the lowest allowable Hgb/Hct for peds?
Hct of 30% or Hgb of 10, but should be patient specific
What is the initial fluid bolus rate for mild to moderate hypotension?
10-20 mL/kg of 5% Albumin or LR
Abstain for __ hours after a Heavy Meal before any anesthetic (fatty foods)
8 hours
Abstain for __ hours after a Light Meal before any anesthetic (toast and clears)
6 hours
Abstain for __ hours after Formula/Non-human milk before any anesthetic
6 hours
Abstain for __ hours after breast milk before any anesthetic
4 hours
Abstain for __ hours after Clear Liquids before any anesthetic
2 hours
What is the formula for estimating weight in kg based on age?
(Age x 2) + 9
-For ages 2-9 years
What is the ETT size (uncuffed) for a Preemie (<2.5 kg)?
2.5 to 3.0
What is the ETT size (uncuffed) for a Term Newborn?
3 to 3.5
What is the ETT size (uncuffed) for an Infant (3 months - 1 year)?
3.5 to 4
What is the ETT size (uncuffed) for a 2 year old?
4.5 (4 cuffed)
How do you determine the size of a CUFFED ETT for a patient aged > 1?
Reduce size by 0.5 mm.
How do you estimate ETT size for patient aged > 4 years old?
(age / 4) + 4
-Uncuffed tube size
What is the formula for estimating ETT depth (Age > 4 years old)?
3 times the ETT size or Age + 10 cm
What are the doses of Epinephrine for peds emergency?
-Epi 1 mcg/mL if less than 10 kg
-Vasopressor Dose: 2-10 mcg/kg
-Arrest Dose: 30 mcg/kg
What are the doses of Atropine for peds emergency?
0.02 - 0.04 mg/kg IM
0.02 mg/kg IV
What are the doses of Succinylcholine for peds emergency?
4 mg/kg IM
2 mg/kg IV
How do you prep your emergency drugs (in general) for peds cases)
-If the calculated weight-based doses involve giving less than ONE milliliter of a drug, the drug should be drawn up in a TB syringe.
-These drugs should be available with 21 gauge needles(**) on the syringe in case they have to be given IM prior to establishing IV access or in the event that IV access is lost
Describe the process of a basic Inhalation Induction.
1) Patient enters room. Place pulse ox
2) Child breathes in via mask 70% Nitrous and 30% O2
3) Gradually increase Sevo up to 8%
4) Patient is less responsive, lay flat and apply precordial, NIBP, and ECG
5) Other team member looks for IV while you manage airway
6) Shut off Nitrous, go to 100% O2, and decrease Sevo to 4-6%
7) Once IV established, give Fentanyl & Propofol
8) Establish airway, confirm bilat breath sounds
-Want a leak at ETT/glottic opening at 20 cmH2O (concern for causing pressure)
9) Tape ETT, listen again
