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Peds Pharmacology Flashcards

1
Q

less than what % of drugs used on neonates are FDA approved?

A

5%

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2
Q

what are the only 3 drugs approved for use on neonates? (R,R,S)

A
  1. remifentanil
  2. rocuronium
  3. sevoflurane
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3
Q

body composition:

  1. does total body water increase or decrease with age?
  2. does fat increase or decrease with age?
  3. does muscle increase or decrease with age?
A
  1. decrease
  2. increase
  3. increase
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4
Q

what is it called when the amount of drug removed from the body equals the amount of the dose?

A

steady state

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5
Q

body water composition:

  1. do infants have most of their total body water intracellular or extracellular?
  2. because of their body water composition, what puts infants at risk for dehydration?
A
  1. extracellular

2. unable to mobilize water from cells because don’t have much water in there

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6
Q

what 3 things make up total drug effect? (TBW, ME, PB)

A
  1. total body water
  2. maturational effects
  3. protein binding
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7
Q

protein binding:

  1. does protein binding increase or decrease with age?
  2. does the amount of free drug increase or decrease with age?
A
  1. increase

2. decrease

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8
Q

protein binding:

  1. does albumin concentration increase or decrease with age?
  2. do acidic or basic drugs bind to albumin?
  3. does alpha-1 acid glycoprotein increase or decrease with age?
  4. at birth alpha-1 acid glycoprotein is what % amount of adults?
  5. do acidic or basic drugs bind to alpha-1 acid glycoprotein?
A
  1. increase
  2. acidic
  3. increase
  4. 50%
  5. basic
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9
Q

what type of meds are an example of a basic drug?

A

amide local anesthetics

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10
Q

what 1 drug and 1 drug type are acidic? (D, B)

A
  1. diazepam

2. barbiturates

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11
Q

does the liver make meds more or less polar?

A

more polar

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12
Q

half-life is confounded by what 2 things? (C, V)

A
  1. clearance

2. volume

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13
Q

half-lives of meds:

  1. in one word, describe them in neonates? (P)
  2. do they increase or decrease in children 4-10 years old?
  3. at what age period do they reach adult values? (A)
A
  1. prolonged
  2. decrease
  3. adolescents
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14
Q

do half-lives increase or decrease with age?

A

decrease

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15
Q

biotransformation/metabolism are affected by what 3 things? (E, IE, M)

A
  1. enzyme
  2. induction exposure
  3. medications
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16
Q

Phase 1 reactions:

  1. what are 3 reactions in phase 1? (H, O, R)
  2. what group of enzymes provides the majority of phase 1 drug metabolism?
  3. in this phase, a parent drugs is converted into a more polar active metabolite by inserting a what on it? (PFG)
A
  1. hydrolysis, oxidation, reduction
  2. cytochrome P-450
  3. polar functional group
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17
Q

phase 2 reactions:

  1. what are 3 reactions in phase 2? (G, A, S)
  2. in this phase, a parent drug is converted to a more polar inactive metabolite by conjugation of what to functional groups? (S)
  3. used to facilitate elimination via what organ?
  4. what are 3 enzymes in this phase? (UD, S, NA)
A
  1. glucuronidation, acetylation, sulfation reactions
  2. subgroups
  3. kidney
  4. uridine diphosphoglucuronosyltransferase, sulfotransferase, N-acetyltransferase 2
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18
Q

fetal hepatic metabolism:

  1. starts as early as what range of weeks gestation?
  2. liver enzyme activity is what % range of an adult?
A
  1. 9-22 weeks gestation

2. 2-36%

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19
Q

neonate hepatic metabolism:

  1. is metabolism overall increased or decreased in neonates?
  2. as hepatic blood flow increases as the infant matures, does metabolism increase or decrease?
  3. does an open or closed PDA effect drug delivery to metabolizing organs?
A
  1. decrease
  2. increase
  3. yes
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20
Q

CYP-450:

  1. these enzymes are increase or decreased in neonates, which increases or decreases clearance and increases or decreases half-lives of meds?
  2. what CYP-450 enzyme is the most important because it has the broadest range of drgs it metabolizes and compromises the majority of the enzymes in the adult liver?
  3. this enzyme approaches adult levels by what post-natal month range?
A
  1. decreased, decreases, increases
  2. CYP3A
  3. 6-12 months
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21
Q

what 7 meds are metabolized by phase 1? (A,C,C,L,M,N,O)

A
  1. acetaminophen
  2. caffeine
  3. codeine
  4. lidocaine
  5. midazolam
  6. nicotine
  7. omeprazole
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22
Q

what 4 meds are metabolized by phase 2? (A,C,L,M)

A
  1. acetaminophen
  2. caffeine
  3. lorazepam
  4. morphine
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23
Q

what 3 things combine to decrease renal excretion in peds? (IGD, LPP, IOL)

A
  1. incomplete glomerular development
  2. lower perfusion pressure
  3. inadequate osmotic load
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24
Q

renal excretion:

  1. normal renal clearance by what months?
  2. fully mature by what age in years?
A
  1. 4 months

2. 2 years

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25
Q

renal drugs:

  1. what 2 abx have an increased half-life in peds because they are primarily excreted by the kidneys? (A, C)
  2. what LA can build up in peds and cause seizures d/t decrease renal excretion?
A
  1. aminoglycosides, cephalosporin

2. bupivacaine

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26
Q

pharmacokinetics are referred to the changes in what within what over time?

A

changes in drug concentrations within the body

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27
Q

first order kinetics:

  1. constant what is removed per time?
  2. is more drug removed at a higher concentration?
A
  1. fraction

2. yes

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28
Q

does a portion of enzymes needs to be free in order for first order kinetics to work?

A

yes

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29
Q

zero order kinetics:

  1. constant what is removed per time?
  2. why is it also referred to as saturation kinetics?
  3. what 3 drugs are eliminated by these kinetics at therapeutic doses in neonates? (C,D,F)
A
  1. amount
  2. because this type of kinetics occurs when the enzymes are saturated
  3. caffeine, diazepam, furosemide
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30
Q

what is context-sensitive half-life?

A

the amount of time required for the plasma drug concentration to decrease by 50% after infusion termination

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31
Q

half-life:

  1. how many half lives does it take to reach steady state equilibrium?
  2. when are loading doses used?
A
  1. 5

2. when the time to reach a constant concentration is excessive (3-5 half-lives)

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32
Q

Body composition:

  1. do infants have a greater Vd for fat-soluble or water-soluble meds?
  2. because of this, do they need an increased or decreased loading dose based on body weight to get target concentrations?
  3. do term neonates need a greater or lesser loading dose for some meds than older children?
  4. do neonates tend to be sensitive to the respiratory, neuro, and circulatory effects of many meds, and therefore more responsive to effects at a reduced blood concentration compared to children and adults?
A
  1. water-soluble
  2. increased
  3. greater
  4. yes
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33
Q

at what age range does cerebral blood flow peak in children at 70 mL/min per 100 g?

34
Q

is IV induction slower in neonates or young children?

35
Q

adult enteral absorption rates may not be reached until what month range?

A

6-8 months

36
Q

Wash-in:

  1. wash-in is the ratio of what 2 partial pressures?
  2. what are 6 factors that determine wash-in? (IC, AV, FRC, CO, S, A:VPPG)
  3. do infants and children have a faster or slower wash-in compared to adults?
A
  1. ratio of alveolar partial pressure to inspired anesthetic partial pressure (FA/Fi)
  2. inspired concentration, alveolar ventilation, functional residual capacity, cardiac output, solubility, alveolar:venous PP gradient
  3. faster
37
Q

what are the 4 reasons why infants have a faster wash-in?

  1. what 2 solubilities are reduced?
  2. greater fraction of CO to what group?
  3. what pulmonary ratio is increased?
A
  1. tissue/blood, blood/gas
  2. vessel-rich
  3. alveolar ventilation to FRC
38
Q

what ratio is the main determinant of rate of delivery of anesthetic to lungs?

A

alveolar ventilation to FRC

39
Q

what is the VA/FRC in:

  1. neonates
  2. adults
A
  1. 5:1

2. 1.5:1

40
Q

wash-in and cardiac output:

  1. in neonates, does an increased CO increase or decrease FA/Fi?
  2. why does it happen like this?
A
  1. increase

2. because of the preferential CO to vessel-rich group, the blood that returns to the lungs has a higher PP of VA

41
Q

blood/gas solubility is decreased in neonates:

  1. what 2 things in blood are decreased in neonates that causes this decrease?
  2. what % decrease in blood/gas solubility is halothane and isoflurane in neonates?
A
  1. cholesterol, protein

2. 18%

42
Q

tissue/gas solubility is decreased in neonates:

  1. what % decrease in tissue/gas solubility is halothane and isoflurane in neonates?
  2. one reason for this is the greater amount of what content in neonates?
  3. 2 other reasons for this is the decreased amount of what content in neonates?
A
  1. 50%
  2. water content
  3. lipids, proteins
43
Q

can anesthetic depth be adjusted faster with a more soluble or less soluble anesthetic?

A

less soluble

44
Q

do the age related changes that affect blood/gas and tissue/gas solubilities apply to sevoflurane?

45
Q

what is neonate MAC for these:

  1. halothane
  2. isoflurane
  3. sevoflurane
A
  1. 0.87
  2. 1.6
  3. 3.2
46
Q

do more soluble or less soluble gases have a greater effect by the second gas effect?

A

more soluble

47
Q

the concentration effect (second gas effect) of N2O depends on both a what effect and an increase in what ventilation which results in an increase uptake of N2O? (C, A)

A

concentrating effect, alveolar ventilation

48
Q

what partial pressure gradient determines the amount of uptake of inhaled VA into the blood?

A

alveolar to venous PP gradient

49
Q

as the PP of venous VA increases, does the uptake of VA increase or decrease?

50
Q

left-to-right and right-to-left shunts:

  1. which one does not affect FA/Fi assuming CO is unchanged?
  2. which bypass acts as a intrapulmonary or intracardiac shunt?
  3. which one markedly delays FA/Fi?
A
  1. left-to-right
  2. right-to-left
  3. right-to-left
51
Q

in a right-to-left shunt, are more soluble or less soluble gases delayed more?

A

less soluble

52
Q

does it matter if the right-to-left shunt is intracardiac or intrapulmonary?

53
Q

what effect occurs when the blood from the right-to-left shunt mixes with blood in the pulmonary vein? (D)

A

dilutional effect

54
Q

by the right-to-left shunting blood mixing with the blood in the pulmonary vein, does the PP of VA increase or decrease?

55
Q

what is the order of VA blood solubility from least to most? (6 VAs)

A

N2O, Des, Sevo, Iso, Enflu, Halo

56
Q

name a case where a steady state and depth of anesthetic would be hindered from a strictly inhalational perspective? (BFFB)

A

bronchoscopy for foreign body

57
Q

what is the best method to develop an adequate depth of anesthesia for a bronchoscopy for foreign body with an infant who has a right-to-left shunt?

58
Q

what VA might undergo metabolism and thus have its wash-out curve look a little different than just being the inverse of the wash-in curve?

59
Q

does the wash out emergence curve follow the inverse of the wash-in curve?

60
Q

do more soluble or less soluble VAs wash-out faster?

A

less soluble

61
Q

what is the classic stimulus for MAC in humans?

A

skin incision

62
Q

do we know why these changes in MAC with age occurs?

63
Q

Sevo MACs:

  1. full-term neonates
  2. 1-6 months
  3. 6 months to 10 years
A
  1. 3.3%
  2. 3.2%
  3. 2.5%
64
Q

Isoflurane MACs:

  1. neonates
  2. 1-6 months
  3. 3-5 years
  4. 10 years
A
  1. 1.6%
  2. 1.87%
  3. 1.6%
  4. 1.4%
65
Q

Desflurane MACs:

  1. neonates
  2. 6-12 months
  3. 1-3 years
  4. 10 years
A
  1. 9.2%
  2. 9.9%
  3. 8.5%
  4. 8.5%
66
Q

at what age do the MACs of these VAs peak?

  1. sevo
  2. iso
  3. des
A
  1. neonates
  2. 1-6 months
  3. 6-12 months
67
Q

emergence delirium:

  1. greatest in what year range?
  2. which VA is it not similar in?
  3. is it increased or decreased in the presence of adjuvant meds (e.g. opioids)?
  4. increased or decreased in the presence of pain?
A
  1. 1-5 years
  2. halothane
  3. decreased
  4. increased
68
Q

Succs black box warning:

  1. what type disorder can be undiagnosed that can cause cardiac arrest in peds?
  2. succs can cause cardiac arrest in peds from what? (HR)
A
  1. muscle disorder

2. hyperkalemic rhabdomyolysis

69
Q

what med can be used instead of succs for an emergence intubation?

A

rocuronium

70
Q

if peds pt arrests after succs, what should be assumed is the cause?

A

hyperkalemia

71
Q

Succs:

  1. are infants more or less resistant than children?
  2. the cause of this is the rapid distribution of succs into large volume of what fluid in infants?
  3. put the speed of onset in order for these routes of administration: IM, IV, lingual
  4. what gauge needle should be used for lingual administration?
A
  1. more
  2. extracellular fluid
  3. IV, lingual, IM
  4. 25 gauge
72
Q

Succs:

  1. succs can cause what heart rhythm and should also given with what?
  2. avoid in what 5 peds populations? (MD, PUMNL, B, H, PB)
  3. does succs increase potassium in cerebral palsy?
  4. why does or doesn’t it in cerebral palsy?
A
  1. bradycardia, atropine
  2. muscular dystrophy, postnatal upper motor neuron lesions, burns, hyperkalemia, prolonged bedrest
  3. no
  4. because CP is developed prenatally, thus no upregulat of the extrajunctional receptors
73
Q

Non depolarizers:

  1. in general are the doses lower for infants than children?
  2. can 1.2 mg/kg of roc be used instead of succs for rapid intubation?
  3. if using 0.3 mg/kg of roc for intubation, how many minutes do you wait?
A
  1. yes
  2. yes
  3. 3 minutes
74
Q

Succs dose (mg/kg)

  1. infants
  2. children (range)
A
  1. 3 mg/kg

2. 1.5-2 mg/kg

75
Q

rocuronium (mg/kg)

  1. infants (range)
  2. children (range)
A
  1. 0.25-0.5 mg/kg

2. 0.6-1.2 mg/kg

76
Q

vecuronium (mg/kg):

  1. infants (range)
  2. children
A
  1. 0.07-0.1 mg/kg

2. 0.1 mg/kg

77
Q

are children easier to intubate without paralytic compared to adults?

78
Q

why do sick children need paralytics for intubation?

A

because they don’t handle deep anesthesia as well

79
Q

what is the most frequently used opioid in postop pain in children?

80
Q

to produce apnea for short procedures consider deepening them with what and ventilating them how?

A

propofol, hyperventilating

Peds (9 decks)

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