Peds Pharm Flashcards
Vd of water soluble drugs
High dt high TBW
Ie succinylcholine, antibiotics, bupivacaine
Vd of fat soluble drugs
Low ; increased ruation of action b/c less tissue mass
Ie fentanyl, thiopental
Protein binding
Altered and lowered
increases free fraction of medications
50th percentile formula
Age x 2 … + 9
< 1 year old = mo/2 + 4
Neonatal total water content
70-75%
What contributes to a high ECF Vd
High TBW
low fat %
Reduced lean muscle mass
Vd water soluble drugs admin
Higher initial dose
Delayed excretion
At what age does the BBB improve
age 2
protein binding
reduced total protein resulting in more of the administered drug to be free in the plasma
lidocaine, alfentanil
dosing for barbiturates and LA
reduced dosing
renal function (3)
incomplete glomerular development
low perfusion presesure
inadequate osmotic load
aminoglycosides + cephalosporins
prolonged elimination 1/2 life in neonates
inhalational agents
more rapid induction
more rapid excretion
more rapid overdose occurrence
determinates of wash-in of inhalations
- inhaled concentration
- FRC
- CO
- alveolar ventilation
- solubility
- alveolar to venous partial pressure gradient
wash in is inversely related to
blood solubility
peds population and respiratory characteristics (3)
- increased RR
- increased blood flow to vessel rich groups
- decreased FRC
other explanations for rapid inhalational induction
- cerebral maturation
- age related differences in blood-gas coefficients
- state of hydration/dehydration
- type of anesthesia circuit
- vaporizer design
why is BP sensitive to volatiles?
lack of compensation
immature myocardium
reduced calcium stores
Sevoflurane MAC values
neonate: 3.2
infant: 3.2
children: 2.5
isoflurane MAC values
neonate: 1.6
infant: 1.8
small child: 1.4
desflurane MAC values
neonate: 9.2
infants: 10
small children: 8.2
stage I
induction of GA to LOC
‘stage of analgesia’
stage II
‘stage of excitement
LOC to the onset of automatic breathing
no eyelash reflex
stage III
‘state of surgical anesthesia’
onset of automatic respiration to respiratory paralysis
stage III plane I
automatic respiration to the cessation of eyeball movements
- eyelid reflex lost
- swallowing reflex disappears
- lots of eyeball movement
- corneal reflex lost @ end
stage III plane II
cessation of eyeball movements to the beginning of IC muscle paralysis
-laryngeal reflex lost
stage III plane III
from beginning to complete IC paralysis
- diaphragmatic respiration persists
- pupils dilated
- no light reflex
stage III plane IV
complete IC paralysis to diaphragmatic paralysis
stage IV
anesthetic overdose causing medullary paralysis and vasomotor collapse
nitrous
analgesia + amnesia b/g: 0.47 MAC: 104% ADR: PONV c/i: pneumo/NEC/bowel obstructions
dalton’s law of partial pressure
PT = P1 + P2 + P3
sevoflurane
least irritating to the airways
b/g: 0.68
what contributes to compound A
high temperature
low FGF
CO2 absorbers w/barium hydroxide or soda lime
isoflurane
b/g: 1.43
potentiates NDMR to a greater extent than sevo/des
least costly !!
good for neuro cases/sz risk
desflurane
b/g: 0.42
laryngospasm @ 50% if used during induction
c/i with LMA
rapid emergence
propofol
require larger induction dose r/t increased Vd
elimination 1/2 life is shorter
high rates of plasma clearance
IONM prop dose
< 120 - 130 mcg/kg/m
ketamine used since
1964
ketamine dosing
oral: 6 - 10 mg/kg IM sedation: 2 - 5 mg/kg IM induction: 5 - 10 mg/kg IV pain: 0.5 mg/kg or 4 mcg/kg/m IV induction: 1 - 2 mg/kg
ketamine ADR:
vomit
secretion - consider glyco 0.01 mg/kg
hallucinate
ketamine and respiratory considerations
preserves spontaneous respirations but apnea and laryngospasm can still occur
rapid IV dose may produce respiratory depression
BRONCHODILATION
etomidate
not used lots in kids
-pain on injection, myoclonus, anaphylactoid reactions, adrenal suppression
etomidate & rr
dose dependent reduction
opioids
MORE POTENT
morphine
0.025 - 0.05 mg/kg IV
histamine release
hepatic conjugation & renal excretion decreased
fentanyl
increased DOA (> 30 - 60 m) immediate onset, but maximal analgesia will occur in several minutes
fentanyl dependence
may occur by 7 days
fentanyl dosing
- 25 - 1 mcg/kg IV
0. 5 - 2 mcg/kg/hr gtt
hydromorphone
semi-synthetic opioid agonist, derivative of morphine. 5x the potency
onset: 5m
DOA: 2 - 3h
hydromorphone & renal considerations
metabolite accumulation & neuroexcitatory symptoms
tremor - agitation - cognitive dysfunction
naloxone
reduces resp. depression, n/v, pruritis & urinary retention
0.25 - 0.5 mcg/kg
MAX = 2 MG
naloxone onset
30s - 1 m
1/2 life - 1.5 - 3 hours
naloxone ADR:
systemic HTN
arrhythmia
pul. edema
midaz history
1976 first came into use !!
midaz dosing
PO 0.5 mg/kg - 20m onset
0.2 - -.3 mg/kg IN
0.05 mg/kg IV 5 m onset
PICU sedation 0.4 - 2 mcg/kg/m
DOA 1 - 6 hours
flumazenil
onset 5 - 10m
10 mcg/kg IV
1/2 life 1 hour
clonidine MOA
pre-synaptic alpha agonist. binding decreases calcium levels, thus inhibiting release of NE
clonidine dosing
PO 4 mcg/kg (60 - 90 m onset)
adjunct to regional: 1 - 2 mcg/kg epidural/caudal (prolongs analgesia by 3h)
clonidine adr
residual sedation postop
hypotension and bradycardia
dexmedetomidine
8x more specific for a2adrenergic receptor
anxiolysissedationanalgesia
sedation w/o reespiratory depression
precedex dosing
PO 1 mcg/kg (45 m onset)
IN 1 mcg/kg
IV 0.25 - 1 mcg/kg over 15m
gtt: 0.2 - 2 mcg/kg/h (great for spine)
neonates + nmbds
increased sensitivity d/t
- reduction in Ach release, reduced muscle mass
- fetal receptors have greater opening time, allowing more sodium to enter cell
nmbd onset
shorter (up to 50%) d/t faster circ times
cis dosing
0.15 mg/kg IV
vec dosing
0.1 mg/kg
reversals for nmbds
glyco 0.01 mg/kg + neostigmine 0.05 mg/kg
sugammadex 2 - 4 mg/kg IV
sux
larger dose d/t increased ECF volume of distribution
fastest onset
recovery is the same as adult
sux + peds risks
arrhythmias hypeerK rabdo myoglobinuria masseter muscle spasm MH
sux + atropine
@ 0.02 mg/kg IV/IM to prevent bradycardia
sux dosing
IV < 10 kg = 2mg/kg
> 10 kg = 1 - 2 mg/kg
IM = 4 mg/kg
Laryngospasm = 0.5 mg/kg
NDMR
non-depolarizing has much greater variability with dose and response d/t immature NMJ and increased extrajunctional receptors (all leading to increased sensitivity to drugs)
roc RSI dose
can be intubated in 45s, but DOA is 60 - 90 m (ugh)
low dose roc
0.3 mg/kg
can intubate in 3 m
roc
can cause pain on injection…
when did sugammadex get approved
2015
sugammadex MOA
cyclodextrin is rigid, ring-shaped composed of sugar unit. outside is hydrophilic (which makes the molecule water-soluble)
the hole is hydrophobic, which allows lipophilic molecules to enter this cavity creating a water-soluble complex
ketorolac
0.5 mg/kg
e 1/2: 4 hours
caution: impaired renal, bleeding, impaired bone healing, kids < 1 year
glucose homeostasis
low glycogen stores –> prone to hypoglycemia during NPO/stress
good news: impaired glucose excretion by kidney beeaanssss
hypoglycemia s/s
jittery, convulsions, apnea
hypoglycemia management
D10% 1 - 2 mL/kg
how do you dilute D50
2 mL into 8 mL
what does D50% mean
50 grams of dextrose per 100 mL
0.5 grams/mL
epinephrine hypotension
1mcg/kg
epi cardiac arrest
10 mcg/kg q 3 - 5 m
atropine
0.02 mg/kg for bradycardia
max = 1 mg (child)
2 mg for adult
adenosine
100 mcg/kg
max 6 mg
200 mcg/kg
max 12 mg
