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NUNA 692 Principles III > peds pharm > Flashcards

peds pharm Flashcards

1
Q

infants have an increased proportion of water leading to an increase in ______ of _______

A

volume of distribution

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2
Q

increase volume of distribution requires an increased _______ _____

A

loading dose

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3
Q

net result (bc infants are MORE sensitive):

[Drug dosing]

A

loading dose/kg usually the same as for older children and adults

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4
Q

decreased muscle mass causes meds that are dependent on redistribution to have increased initial ______ and increased sustained ______

A

peak
concentration
ex: muscle relaxants

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5
Q

key to safe drug dosing:

A

titrate to effect (you can always give more but you cant take it back!)

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6
Q

liver metabolism is ______ in neonates

A

decreased

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7
Q

diseases such as CF and celiac’s can cause a decrease in ________

A

P-450

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8
Q

elim 1/2 life is _____ in infants

A

increased

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9
Q

there are many P-450 substrates from genetics/ethnic differences that are ______ _____ in drug metabolism

A

clinically significant

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10
Q

Phase I - P-450 is reduced in infants causing decreased ______ and prolonged _______

A

clearance
half-life

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11
Q

Phase II - synthetic or conjugating reactions convert _______ to ________ for renal excretions

A

lipophilics to hydrophilics

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12
Q

Phase II reactions are limited in infants leading to increased _____ of ______

A

risk of toxicity

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13
Q

neonatal RBF is ____ of CO

A

6%

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14
Q

adult RBF is _______ of CO

A

15-25%

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15
Q

neonates have ____, _______ tubules

A

small, undeveloped

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16
Q

_______ is not as useful an indicator of renal fxn as in adults (but commonly used to monitor drugs)

A

creatinine

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17
Q

______ ______ MUST BE CONSIDERED WHEN DOSING INFANTS

A

RENAL FUNCTION

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18
Q

paradigm shift

A

we must protect children FROM research to we must protect children THROUGH research

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19
Q

current legislation requires ____ _____ to be done

[Ethics and Meds Drug Research]

A

pediatric trials

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20
Q

provide additional 6 months of _____ _____ for pediatric exclusivity

A

patent time

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21
Q

since 1998, _____ peds clinical drug trials and over ______ failed to show efficacy in children, and over _____ drug label updates specific to children

A

1000
25%
700

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22
Q

despite labeling, we are within _____ and _____ rights to use these drugs

A

medical and legal

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23
Q

unapproved does NOT mean ______, ______, _______, or ________

A

improper, illegal, investigational, or experimental

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24
Q

therapeutic decision must always rely on the ______ _______ _______ and the importance of the benefit for the individual patient

A

best available evidence

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25
Q

neurons are genetically programmed to ______ ______ if they fail to make synaptic connections on time

A

commit suicide

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26
Q

this ______ is normal and necessary

A

apoptosis

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27
Q

anesthetics disrupt _________ ________ (birth - 4 years)

A

developmental synaptogenesis

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28
Q

this anesthesia induced neuroapoptosis causes two things

A
  1. abnormal apoptic death of good neurons
  2. inhibited apoptic death of weaker neurons
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29
Q

receptors involved:

A

y-aminobutyric acid (GABAa)
N-methyl-D-aspartate (NMDA) glutamate

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30
Q

Drugs causing AIN

A

NMDA antagonists - ketamine, N2O, ETOH
GABA agonists - benzos, inhalation agents, propofol

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31
Q

_____ studies have proven this but _____ trials are minimal and indicating it may be clinically insignificant
[Ethics and Meds Drug Research]

A

animal
human

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32
Q

2016 FDA warning

A

brain development may be affected with lengthy procedures in children < 3 years and pregnant women in the 3rd trimester. (lengthy = > 3 hrs of exposure)

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33
Q

recent human studies show that a single, short procedure is _____ to cause negative effects

A

unlikely
but further research is needed

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34
Q

wash-in is more rapid in neonates bc (3)

A
  1. higher alveolar ventilation to FRC ratio
  2. lower tissue/blood solubility
  3. lower blood/gas solubility
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35
Q

LD 50 much ______ in neonates

A

lower

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36
Q

________ blood brain barrier and/or ________ myelination

A

immature
incomplete

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37
Q

caution with centrally acting meds in children _____

A

< 1 year

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38
Q

EXTREME caution in ______ post-conceptual age

A

< 48 weeks

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39
Q

use low dose and weigh _____/_____

A

risks/benefits

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40
Q

vigilant monitoring _______

A

required

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41
Q

volatiles increase _______ and decrease ________

A

CBF
CMRO2

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42
Q

current evidence shows that _____ and ______ are best for neuroanesthesia in children ____ MAC and mild ________

A

iso and sevo
< 1 MAC
mild hyperventilation

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43
Q

BIS monitoring

A

not reliable in children
(adult goal BIS < 60)

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44
Q

volatiles cause dose dependent CV depression by: (4)

A
  1. depressing contractility
  2. altering conduction
  3. vascular dilation
  4. altering PNS, SNS, and reflex responses
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45
Q

volatiles overall have a ______ margin of safety in children

A

decreased

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46
Q

_____ used, but mostly for CV sx

A

TEE

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47
Q

neonates compensate _______

A

poorly

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48
Q

generally, 1 MAC causes _____ drop in SBP in children

A

30%
EXTREMELY IMPORTANT

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49
Q

______ tolerated much better than halothane

A

sevo

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50
Q

halothane slows HR leading to ______ rhythm, ________, and then asystole

A

junctional rhythm
bradycardia

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51
Q

hypercapnia with halothane causes

A

ventricular ectopy

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52
Q

halothane sensitizes myocardium to _______, especially with ______ anesthesia

A

catecholamines
light anesthesia

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53
Q

inhalation agents cause dose-dependent ________ _______

A

respiratory depression

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54
Q

may see paradoxical “rocking horse” pattern where _____ falls, infant ______, and _____ must be considered

A

FRC
fatigues
EEP

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55
Q

the death spiral

A

spontaneous ventilation decreases to apnea, then hypoxia and bradycardia ensue

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56
Q

volatiles affect renal fxn by affecting (4)

A
  1. CV
  2. autonomic
  3. neuroendocrine
  4. metabolic processes
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57
Q

interferes with P-450 leading to _______ ________ leading to potential renal toxicity

A

inorganic fluoride

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58
Q

there were past concerns specific to sevo but currently there is

A

no higher risk than other volatiles

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59
Q

sevo + CO2 absorbent can produce

A

compound A

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60
Q

hepatic metabolism reaches adult levels by

A

2 years old

61
Q

all volatiles can cause post-op ______ dysfunction and failure in adults and children

62
Q

1 peds death d/t ______ _____

A

halothane hepatitis

63
Q

many drugs induce _____ ______

A

hepatic enzymes

64
Q

halothane risks still being debated but do we care?

A

we dont use halothane anymore

65
Q

_______ and ______ are airway irritants

A

iso and des

66
Q

______ and _______ good for inhalation induction

A

halothane and sevo

67
Q

_____ + ______ common BUT many clinicians now use ______

A

sevo + 50-70% N2O
100% O2

68
Q

wake up time follows

A

wash out order

69
Q

switching to less solubles, data shows

A

no difference

70
Q

biggest emergence factors (2)

A
  1. not reducing/discontinuing agent in a timely manner
  2. other factors equal, increased anesthesia time increasing wake-up time
71
Q

no difference in _______ or ________ between agents

[emergence]

A

laryngospasm or vomiting

72
Q

emergence delirium is a true phenomenon and symptoms include:

A

disorientation, inconsolable, irrational, non-purposeful actions, and staring

73
Q

emergence delirium is worse with _______ and _______ than with ______

A

sevo and des
isoflurane

74
Q

emergence delirium usually in kids less than _______ and lasts _______

A

< 6 years old
10-20 minutes

75
Q

strategies to help with emergence delirium

A
  • regional
  • opioids
  • dex
  • prop
    -ketamine
  • midazolam
76
Q

N2O - beware of ___-______ ______

A

air-filled cavities

77
Q

N2O known to increase risk of ______

78
Q

with LOW volatile or TIVA, N2O can help _____ _______/________

A

avoid recall/awareness

79
Q

pulmonary toxicity is _____ ______

A

well documented - use a BLENDER

80
Q

rapid redistribution

A

VRG (vital organs) to muscles to VPG (bone, fat)

81
Q

redistribution is primary determinant of ______ of _______

A

duration of action

82
Q

_____ and ____-____ barrier maturation big factors in neonates

A

body and blood-brain barrier

83
Q

smaller doses of propofol

A

create good intubating conditions after inhalation induction

84
Q

_____ ______ _______ seen in children after prolonged sedation

A

propofol infusion syndrome

85
Q

ketamine pre-op routes

A

oral, nasal, rectal

86
Q

ketamine maintains

A

spontaneous ventilation

87
Q

ketamine is good for children with hypovolemia (trauma), and cyanotic (R to L) shunts since ______ maintained

88
Q

ketamine relaxes ______ ____ _____

A

bronchiolar smooth muscle (good for asthma and wheezing)

89
Q

neonates tolerate ketamine _____ _____

90
Q

etomidate is good for peds with _____ and _____ compromise d/t low risk of CV effects

A

TBIs and CV compromise (hypovolemia, cardiomyopathy)

91
Q

with etomidate, consider ______ ______ coverage, especially for critically ill children

A

steroid stress coverage

92
Q

80% of children < 10 years old will have bradycardia after ______. pretreat with vagolytic

93
Q

children are _____ susceptible

94
Q

_________ - esp with burns, immobility, chronic infection, upper/lower motor neuron disease, crush injuries, neuromuscular disorders

A

hyperkalemia

95
Q

sux - ________ not seen with infants

A

fasciculations

96
Q

best RSI alternative to sux

A

high dose roc with sugammadex available

97
Q

atracurium - for intubation, ________. 2 minutes and duration aprox 20 mins

A

2-3x ED95 (0.5 mg/kg)

98
Q

atracurium - children require ______ and _______ than adults

A

more mg per kg
faster

99
Q

atracurium - good for hepatic or liver dysfunction but __________ can be elevated in children with hepatic impairments

A

laudanosine

100
Q

cisatracurium - _____ recovery in children d/t larger Vd

101
Q

vecuronium - NO _____ effects

102
Q

vecuronium major disadvantage

A

metabolized by liver (caution with increased LFTs)

103
Q

rocuronium - neonates more sensitive with marked variability in ______ of _____

A

duration of action (d/t reduced clearance and P-450 substrates)

104
Q

roc can be given _____ (_____) but intubating conditions may take up to 4 mins

A

IM (1.8mg/kg)

105
Q

pancuronium has known ______ effects

A

vagolytic (known tachycardic response)

106
Q

pancuronium is common for ______ surgery and in high risk infants/neonates

107
Q

panc frequently used in ______ _______ for mech ventilation

A

neonatal ICUs

108
Q

panc has very ________ recovery in neonates, infants, and young children compared to vec and roc

A

predictable

109
Q

even slight residual blockade can result in _____

A

hypercarbia

110
Q

observe pre-op clinical conditions and aim for _____ _____ _______ at emergence

A

back to baseline

111
Q

when antagonizing MRs, asses for:

A

facial nerve, hip/arm flexing, lift, abdominal muscle tone

112
Q

______ infants before attempting reversal

113
Q

with neostigmine, give anticholinergic and wait for

A

increase in HR

114
Q

HUGE implications for peds RSIs

A

sugammedex

  • more peds trials needed, approved for > 2 years with ongoing studies for < 2 years
115
Q

morphine is frequently used post-op in children and has _____ _______ in children, especially infants

A

rapid clearance

116
Q

morphine bigger respiratory depressant than ________ or _______

A

meperidine or fentanyl

117
Q

with opioids neonatal brain has _____ uptake of adults d/t immature BBB

118
Q

caution with opioids in children ______

A

< 1 year old

119
Q

meperidine decreases

120
Q

in neonates, meperidine varies ___-____ hrs whereas children it varies only ___+/-____

A

3.3 - 60 hours
3 +/- 0.5 hours

121
Q

meperidine repeated doses result in _______ which can lead to seizures

A

normeperidine

122
Q

many peds centers have removed ______ from their formularies

A

meperidine

123
Q

______ is the most common opioid for peds GA

A

fentanyl (bc CV stable)

124
Q

fent - ______ doses tolerated well by preemies and neonates

125
Q

fent - pharm dynamics are variable so ____ _____ ______

A

TITRATE TO EFFECT

126
Q

fent + midazolam can cause profound _____ _____ especially in neonates

A

decreased BP

127
Q

fent - increased vagal tone leads to decreased HR which decreases ______ ______ in neonates

A

cardiac output

128
Q

nasal fent is used for GA with

129
Q

used fentanyl patches contain _____ amounts of drug if patch is ingested

130
Q

methadone best use for children

A

prevention of withdrawal symptoms when weaning from opioid infusions

131
Q

methadone has _______ _______ in children

A

elimination variability

132
Q

when sux should be avoided, _____ with _______ is good for intubating conditions

A

remi and prop

133
Q

ketorolac is an NSAID with analgesia similar to low-dose morphine without the _____ ______

A

respiratory depression

134
Q

ketorolac for peds is used as an _____/______ to opioids

A

adjunct/alternative

135
Q

ketorolac is known to cause post - ______ ______

A

T&A bleeding

136
Q

most common benzo for peds

137
Q

midazolam - caution when used with ______

138
Q

midazolam - caution with _____ and _____ patients

A

OSA (resp depression) and neuro (VP shunt dysfunction)

139
Q

ondansetron is good for peds undergoing

A

strabismus repair and ENT sx

140
Q

dexmedetomidine is GREAT for _______ with good spontaneous ventilation, _____ tolerance when weaning from vent, _____ sparing, and emergence delirium

A

sedation
ETT
opioid

141
Q

atropine common in neonates/infants to ______ _______, prevent or treat ________, pre-treat sux, and block _______ reflex

A

decrease secretions
bradycardia
oculocardiac reflex

142
Q

atropine can be given ___/___. Given ____ before inhalation induction in infants < 6 months old, infrequent now with sevo though

143
Q

atropine crosses

144
Q

glyco has minimal _____ _______

A

BBB penetration

145
Q

any child treated with ______ needs close monitoring to observe for reoccurrence of resp depression

146
Q

neonates and children often need large doses of narcan but _____, ______, and ______ ______ may result

A

HTN
dysrhythmias
pulm edema

147
Q

flumazenil has a _____ 1/2 life so children must be monitored

148
Q

in peds, flumazenil is commonly used during _______ after pre-op midazolam has been given

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