peds pharm Flashcards
1
Q
infants have an increased proportion of water leading to an increase in ______ of _______
A
volume of distribution
2
Q
increase volume of distribution requires an increased _______ _____
A
loading dose
3
Q
net result (bc infants are MORE sensitive):
[Drug dosing]
A
loading dose/kg usually the same as for older children and adults
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
5
Q
key to safe drug dosing:
A
titrate to effect (you can always give more but you cant take it back!)
6
Q
liver metabolism is ______ in neonates
A
decreased
7
Q
diseases such as CF and celiac’s can cause a decrease in ________
A
P-450
8
Q
elim 1/2 life is _____ in infants
A
increased
9
Q
there are many P-450 substrates from genetics/ethnic differences that are ______ _____ in drug metabolism
A
clinically significant
10
Q
Phase I - P-450 is reduced in infants causing decreased ______ and prolonged _______
A
clearance
half-life
11
Q
Phase II - synthetic or conjugating reactions convert _______ to ________ for renal excretions
A
lipophilics to hydrophilics
12
Q
Phase II reactions are limited in infants leading to increased _____ of ______
A
risk of toxicity
13
Q
neonatal RBF is ____ of CO
A
6%
14
Q
adult RBF is _______ of CO
A
15-25%
15
Q
neonates have ____, _______ tubules
A
small, undeveloped
16
Q
_______ is not as useful an indicator of renal fxn as in adults (but commonly used to monitor drugs)
A
creatinine
17
Q
______ ______ MUST BE CONSIDERED WHEN DOSING INFANTS
A
RENAL FUNCTION
18
Q
paradigm shift
A
we must protect children FROM research to we must protect children THROUGH research
19
Q
current legislation requires ____ _____ to be done
[Ethics and Meds Drug Research]
A
pediatric trials
20
Q
provide additional 6 months of _____ _____ for pediatric exclusivity
A
patent time
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
22
Q
despite labeling, we are within _____ and _____ rights to use these drugs
A
medical and legal
23
Q
unapproved does NOT mean ______, ______, _______, or ________
A
improper, illegal, investigational, or experimental
24
Q
therapeutic decision must always rely on the ______ _______ _______ and the importance of the benefit for the individual patient
A
best available evidence
25
neurons are genetically programmed to ______ ______ if they fail to make synaptic connections on time
commit suicide
26
this ______ is normal and necessary
apoptosis
27
anesthetics disrupt _________ ________ (birth - 4 years)
developmental synaptogenesis
28
this anesthesia induced neuroapoptosis causes two things
1. abnormal apoptic death of good neurons
2. inhibited apoptic death of weaker neurons
29
receptors involved:
y-aminobutyric acid (GABAa)
N-methyl-D-aspartate (NMDA) glutamate
30
Drugs causing AIN
NMDA antagonists - ketamine, N2O, ETOH
GABA agonists - benzos, inhalation agents, propofol
31
_____ studies have proven this but _____ trials are minimal and indicating it may be clinically insignificant
[Ethics and Meds Drug Research]
animal
human
32
2016 FDA warning
brain development may be affected with lengthy procedures in children < 3 years and pregnant women in the 3rd trimester. (lengthy = > 3 hrs of exposure)
33
recent human studies show that a single, short procedure is _____ to cause negative effects
unlikely
but further research is needed
34
wash-in is more rapid in neonates bc (3)
1. higher alveolar ventilation to FRC ratio
2. lower tissue/blood solubility
3. lower blood/gas solubility
35
LD 50 much ______ in neonates
lower
36
________ blood brain barrier and/or ________ myelination
immature
incomplete
37
caution with centrally acting meds in children _____
< 1 year
38
EXTREME caution in ______ post-conceptual age
< 48 weeks
39
use low dose and weigh _____/_____
risks/benefits
40
vigilant monitoring _______
required
41
volatiles increase _______ and decrease ________
CBF
CMRO2
42
current evidence shows that _____ and ______ are best for neuroanesthesia in children ____ MAC and mild ________
iso and sevo
< 1 MAC
mild hyperventilation
43
BIS monitoring
not reliable in children
(adult goal BIS < 60)
44
volatiles cause dose dependent CV depression by: (4)
1. depressing contractility
2. altering conduction
3. vascular dilation
4. altering PNS, SNS, and reflex responses
45
volatiles overall have a ______ margin of safety in children
decreased
46
_____ used, but mostly for CV sx
TEE
47
neonates compensate _______
poorly
48
generally, 1 MAC causes _____ drop in SBP in children
30%
EXTREMELY IMPORTANT
49
______ tolerated much better than halothane
sevo
50
halothane slows HR leading to ______ rhythm, ________, and then asystole
junctional rhythm
bradycardia
51
hypercapnia with halothane causes
ventricular ectopy
52
halothane sensitizes myocardium to _______, especially with ______ anesthesia
catecholamines
light anesthesia
53
inhalation agents cause dose-dependent ________ _______
respiratory depression
54
may see paradoxical "rocking horse" pattern where _____ falls, infant ______, and _____ must be considered
FRC
fatigues
EEP
55
the death spiral
spontaneous ventilation decreases to apnea, then hypoxia and bradycardia ensue
56
volatiles affect renal fxn by affecting (4)
1. CV
2. autonomic
3. neuroendocrine
4. metabolic processes
57
interferes with P-450 leading to _______ ________ leading to potential renal toxicity
inorganic fluoride
58
there were past concerns specific to sevo but currently there is
no higher risk than other volatiles
59
sevo + CO2 absorbent can produce
compound A
60
hepatic metabolism reaches adult levels by
2 years old
61
all volatiles can cause post-op ______ dysfunction and failure in adults and children
liver
62
1 peds death d/t ______ _____
halothane hepatitis
63
many drugs induce _____ ______
hepatic enzymes
64
halothane risks still being debated but do we care?
we dont use halothane anymore
65
_______ and ______ are airway irritants
iso and des
66
______ and _______ good for inhalation induction
halothane and sevo
67
_____ + ______ common BUT many clinicians now use ______
sevo + 50-70% N2O
100% O2
68
wake up time follows
wash out order
69
switching to less solubles, data shows
no difference
70
biggest emergence factors (2)
1. not reducing/discontinuing agent in a timely manner
2. other factors equal, increased anesthesia time increasing wake-up time
71
no difference in _______ or ________ between agents
[emergence]
laryngospasm or vomiting
72
emergence delirium is a true phenomenon and symptoms include:
disorientation, inconsolable, irrational, non-purposeful actions, and staring
73
emergence delirium is worse with _______ and _______ than with ______
sevo and des
isoflurane
74
emergence delirium usually in kids less than _______ and lasts _______
< 6 years old
10-20 minutes
75
strategies to help with emergence delirium
- regional
- opioids
- dex
- prop
-ketamine
- midazolam
76
N2O - beware of ___-______ ______
air-filled cavities
77
N2O known to increase risk of ______
PONV
78
with LOW volatile or TIVA, N2O can help _____ _______/________
avoid recall/awareness
79
pulmonary toxicity is _____ ______
well documented - use a BLENDER
80
rapid redistribution
VRG (vital organs) to muscles to VPG (bone, fat)
81
redistribution is primary determinant of ______ of _______
duration of action
82
_____ and ____-____ barrier maturation big factors in neonates
body and blood-brain barrier
83
smaller doses of propofol
create good intubating conditions after inhalation induction
84
_____ ______ _______ seen in children after prolonged sedation
propofol infusion syndrome
85
ketamine pre-op routes
oral, nasal, rectal
86
ketamine maintains
spontaneous ventilation
87
ketamine is good for children with hypovolemia (trauma), and cyanotic (R to L) shunts since ______ maintained
SVR
88
ketamine relaxes ______ ____ _____
bronchiolar smooth muscle (good for asthma and wheezing)
89
neonates tolerate ketamine _____ _____
very well
90
etomidate is good for peds with _____ and _____ compromise d/t low risk of CV effects
TBIs and CV compromise (hypovolemia, cardiomyopathy)
91
with etomidate, consider ______ ______ coverage, especially for critically ill children
steroid stress coverage
92
80% of children < 10 years old will have bradycardia after ______. pretreat with vagolytic
sux
93
children are _____ susceptible
MH
94
_________ - esp with burns, immobility, chronic infection, upper/lower motor neuron disease, crush injuries, neuromuscular disorders
hyperkalemia
95
sux - ________ not seen with infants
fasciculations
96
best RSI alternative to sux
high dose roc with sugammadex available
97
atracurium - for intubation, ________. 2 minutes and duration aprox 20 mins
2-3x ED95 (0.5 mg/kg)
98
atracurium - children require ______ and _______ than adults
more mg per kg
faster
99
atracurium - good for hepatic or liver dysfunction but __________ can be elevated in children with hepatic impairments
laudanosine
100
cisatracurium - _____ recovery in children d/t larger Vd
faster
101
vecuronium - NO _____ effects
CV
102
vecuronium major disadvantage
metabolized by liver (caution with increased LFTs)
103
rocuronium - neonates more sensitive with marked variability in ______ of _____
duration of action (d/t reduced clearance and P-450 substrates)
104
roc can be given _____ (_____) but intubating conditions may take up to 4 mins
IM (1.8mg/kg)
105
pancuronium has known ______ effects
vagolytic (known tachycardic response)
106
pancuronium is common for ______ surgery and in high risk infants/neonates
cardiac
107
panc frequently used in ______ _______ for mech ventilation
neonatal ICUs
108
panc has very ________ recovery in neonates, infants, and young children compared to vec and roc
predictable
109
even slight residual blockade can result in _____
hypercarbia
110
observe pre-op clinical conditions and aim for _____ _____ _______ at emergence
back to baseline
111
when antagonizing MRs, asses for:
facial nerve, hip/arm flexing, lift, abdominal muscle tone
112
______ infants before attempting reversal
warm
113
with neostigmine, give anticholinergic and wait for
increase in HR
114
HUGE implications for peds RSIs
sugammedex
- more peds trials needed, approved for > 2 years with ongoing studies for < 2 years
115
morphine is frequently used post-op in children and has _____ _______ in children, especially infants
rapid clearance
116
morphine bigger respiratory depressant than ________ or _______
meperidine or fentanyl
117
with opioids neonatal brain has _____ uptake of adults d/t immature BBB
3x
118
caution with opioids in children ______
< 1 year old
119
meperidine decreases
shivering
120
in neonates, meperidine varies ___-____ hrs whereas children it varies only ___+/-____
3.3 - 60 hours
3 +/- 0.5 hours
121
meperidine repeated doses result in _______ which can lead to seizures
normeperidine
122
many peds centers have removed ______ from their formularies
meperidine
123
______ is the most common opioid for peds GA
fentanyl (bc CV stable)
124
fent - ______ doses tolerated well by preemies and neonates
HUGE
125
fent - pharm dynamics are variable so ____ _____ ______
TITRATE TO EFFECT
126
fent + midazolam can cause profound _____ _____ especially in neonates
decreased BP
127
fent - increased vagal tone leads to decreased HR which decreases ______ ______ in neonates
cardiac output
128
nasal fent is used for GA with
no IV
129
used fentanyl patches contain _____ amounts of drug if patch is ingested
lethal
130
methadone best use for children
prevention of withdrawal symptoms when weaning from opioid infusions
131
methadone has _______ _______ in children
elimination variability
132
when sux should be avoided, _____ with _______ is good for intubating conditions
remi and prop
133
ketorolac is an NSAID with analgesia similar to low-dose morphine without the _____ ______
respiratory depression
134
ketorolac for peds is used as an _____/______ to opioids
adjunct/alternative
135
ketorolac is known to cause post - ______ ______
T&A bleeding
136
most common benzo for peds
midazolam
137
midazolam - caution when used with ______
opioid
138
midazolam - caution with _____ and _____ patients
OSA (resp depression) and neuro (VP shunt dysfunction)
139
ondansetron is good for peds undergoing
strabismus repair and ENT sx
140
dexmedetomidine is GREAT for _______ with good spontaneous ventilation, _____ tolerance when weaning from vent, _____ sparing, and emergence delirium
sedation
ETT
opioid
141
atropine common in neonates/infants to ______ _______, prevent or treat ________, pre-treat sux, and block _______ reflex
decrease secretions
bradycardia
oculocardiac reflex
142
atropine can be given ___/___. Given ____ before inhalation induction in infants < 6 months old, infrequent now with sevo though
IV/IM
IM
143
atropine crosses
BBB
144
glyco has minimal _____ _______
BBB penetration
145
any child treated with ______ needs close monitoring to observe for reoccurrence of resp depression
narcan
146
neonates and children often need large doses of narcan but _____, ______, and ______ ______ may result
HTN
dysrhythmias
pulm edema
147
flumazenil has a _____ 1/2 life so children must be monitored
brief
148
in peds, flumazenil is commonly used during _______ after pre-op midazolam has been given
emergence
