Peds pt 2 Flashcards
1
Q
What increases the risk of neonatal intracerebral hemorrhage
A
htn, immature cerebral autoregulation, fragile cerebral vasculature
2
Q
Normal ICP
A
2-4 mmhg
3
Q
Cushing response in peds
A
absent cushing response
4
Q
Where does the spinal cord end in peds
A
L3 and is normal by age 8
5
Q
Consider sinus brady____ until proven otherwise
A
hypoxia
6
Q
CO is derived form ___ and ____
A
HR and volume
7
Q
Explain peds being HR dependent
A
-Peds don’t have the startlings law; the ability to increase force of contraction to maintain CO.
-The under developed myocardium/ immature contractile elements = decreased contractility
- Poorly compliant ventricles; can’t increase contractility to overcome elevated afterload.
- with increased SVR in an underdeveloped heart it cant compensate for the increased pumping needs/ increased workload
- maximum contracltity in neonates because of increased beta stimulation and thyroid hormone
- have a higher resting tesion but develop less stress during transition
8
Q
What is the primary determinant of SBP
A
HR
9
Q
In the setting of hypovolemia + bradycardia what is the medication of choice
A
epi because it augments contractility
10
Q
Which vasopressor should be avoided in peds
A
Phenylephrine because the HR needs to be able to adjust to the increased SVR
11
Q
How does the ventricle eventually become more compliant
A
SVR increases with age -> LV pumps against higher SVR -> develops stronger contractile elevments= better adjust contractlity
12
Q
Normal CO
A
200 ml/kg/min
13
Q
Normal SVR in peds
A
Low
14
Q
Explain where the PFO is
A
R to left atrium. R-> left shunt.
15
Q
How does the PFO close
A
when blood returns to the heart from the pulmonary veins increases the pressure in the LA and above that of the RA -> closure.
16
Q
When is PFO usually closed
A
closes between 3 months - 1 year. 10-30% of ppl have a PFO.
17
Q
Risk of PFO
A
Venous air embolism.
18
Q
PDA location
A
Between the pulm artery and the aorta.
19
Q
When does the PDA close
A
10-15 hrs of life and anatomical closure takes place in 4-6 weeks.
20
Q
Premature Ductus arteriosus closure causes
A
NSAIDs, preterm bitht, inc PAP, dec PBF.
21
Q
During stress / hypoxia what changes does the heart make
A
hypoxemia, hypercarbia, and acidosis the heart reverts back to utilizing the vessels; R->L shunting, arterial hypoxia- > further increases PVR -> worsening shunting and persistent pulm htn.
Parasymathatic nervous system -> hypotension
22
Q
Baroreceptors in neonates
A
baroreceptor reflex is poorly developed in neonates = reflex fails to increase the HR in the setting of hypovolemia.
23
Q
Stroke volume in neonates
A
static/ doesn’t move
24
Q
peds and the BBB
A
immature, allows the passage of drugs that would otherwise not be able to enter the brain -> higher sensitivity to sedative- hypnotics.
25
Exogenous catecholamines in neonates
they are less effective because they have a higher endogenous catecholamine level.
26
Herring–Breuer inflation reflex
over lung inflation -> stimulate stretch receptors -> vagal afferents in apenustic center -> inhibition of apneustic center -> inhibits inspiration -> prolonged expiration.
27
FRC in children
FRC is lower in children 30 ml/ kg vs adults 34 ml/kg,
28
Chest wall vs lung compliance in peds
highly compliant thoracic wall and poorly compliant lung tissue
29
Peds accommodation for air trapping from compliant airways
sustained tonic activity of inspiratory muscle, narrowing of the glottis during expiration, shorter expiratory time w. Faster RR = end-expiratory pressure
30
Risks with increased closing capacity in neonates
less outward recoil, lungs have a tendency to collapse (increased closing capacity)-. vq mismatch, increased A-a gradient and risk of hypoxemia.
31
Peds dead space
2 ml/kg
32
Why are peds nose breathers?
up to 5 months of age. convert to oral breathing w/ nasal obstruction. Becuase they have long epiglotis and absence of paranasal sinus -> decrease riststance in the nasal passages.
33
Peds O2 consumption vs adults
6ml/kg/min (double that of adults=3.5ml/kg/min) -> inc CO2 production = inc RR/MV. Newborn = 9 ml/kg/min
Managed by inc RR not VT
VT remains normal
34
normal neonate alveolar ventilation
130 ml/kg/min
because increased O2 consumption and decreased SA = increased need for alveolar ventilation
35
normal VT peds
6-8 ml/kg
36
How is surfactant produced
starting at 20 weeks gestation from type 2 pneumocytes
surfactant lowers the air liquid interfacial tension and reduces the opening pressure necessary to aerate the alveoli and prevent alveolar collapse.
usually adequate in neonates borns after 35 weeks.
37
What is inspiration dependent on
diaphragmatic descent
because intercostal muscles are poorly developed and less effective as accessory muscles
38
Muscle type on the diaphragm peds
they have more type 2 muscle fibers (fast twitch/ short bursts of heavy workload/ tire easily) and less type 1 (slow twitch/ endurance/ resistance to fatigue/ 25% vs adults usually have 55%)
39
How to detect R-> L shunting
-Preductal and postductal oxygen saturation by simultaneous use of two pulse oximeters, RUL (preductal) and and lower limb (postductal).
-Preductal arterial saturation of at least more than 3% above the postductal saturation = R-> L shunting.
-This results in decreased oxygen delivery to peripheral tissue and hypoxia and slows uptake of volatiles-> prolonged inhalation induction
40
Neonates respiratory control
ventilatory response to hypoxia/ hypercarbia is impaired. takes weeks to develop
41
Fetal hbg structure
2 alpha and 2 gamma subunits
increased affinity for O2
adult hbg 2 alpha and 2 beta
42
Binding site for DPG on hbg
beta chain of adult hbg
43
Life span of fetal hbg
70-90 days
44
lifespan of adult hbg
120 days
45
HBF relationship to 23DPG
they won't bind -> L shift in oxyhb curve/ higher affinity for O2
46
HBF P50
19 mmhg vs adults 26.5
47
When will there be physiologic anemia from the transition of HBF to HBA
9-12 weeks.
48
CO2 set point for spont ventilation
50-55 mmhg
49
Role and number of umbilical artery
return of deoxygenated blood form the fetus to the placenta
2 arteries
50
Role and number of umbilical vein
take blood from the placenta to the fetus
1 vein
51
Ductus venosus role
connects from the umbilical vein to the inferior vena cava and bypasses the liver
52
Portal vein role
where blood enters the umbilical vein and joints the deoxygenated blood coming form the lower half of the body
53
Risks associated with passive transfusion
hypocalcemia (binding of calcium by citrate), metabolic acidosis/ or metabolic alkalosis (due to citrate metabolism to bicarbonate in the liver), and hyperkalemia (due to administration of older blood), hypothermia (transfusion of cold blood). Hyperglycemia (due to dextrose additive to stored blood)
54
Transfusion threshold for < 4 months
< 4 months old = transfuse at 12 g/dL w/ severe cardiopulmonary dz
Transfusion trigger < 10 g/dL in children w/ major surgery or with moderate cardiopulmonary dz.
55
dose for transfusion
10-15 ml/kg
10 ml/kg will rase hbg 1-2 g/dl
56
Threshold for transfusion > 4 months old
Transfuse if hbg < 6g/dL
or if
Intraoperative blood loss > 15% blood volume
57
Tranfusion dose for platelets
Dose 5 ml/kg or If pooled 1 pack/10 kg
One pooled plat will increase plat by 10-50 /L
Maintain platelet > 50,000
58
Peds dont have teeth if they are _____
< 6 months
59
peds laryxn positioning
superior/cephalad/ rostral
not anterior
60
Cervical positioning of larynx
Full term = C3-4 (apex info)
Infants = C1-2 (dr ernst info)
Adults - C4-6 (achieved at 5-6 yo)
61
vocal cord attachment in peds
Vocal cords are attached LOWER anteriorly than posteriorly = ETT gets caught on the anterior commissure (anterior slant)
62
Bronchi takeoff in peds
Both bonchi take off at 55 degrees on both sides from the midline. Risk of R or L mainstem up to age 3. (adult R mainstem = 25 degrees, L = 45)
63
Normal infant larynx radius
Normal infant larynx = 4 mm vs adults 8 mm (consider pousielles Law Resistance = 8x viscosity x length / pie radius to the 4th )
64
Parasympathetic nervous system in children
more developed/ prevalent than SNS
Stress in adults = sns stim
Stress in baby = psns stim -> bradycardia w/ hypoxia/hypotension
65
When is the SNS developed
4-6 months
66
Areas of resistance in the small airway
bronchi because of small diameter of airways and greater compliance of the trachea and bronchi -> obstuctuion
trachea in infants is short and narrow and more compliant because of the presence of immature cartilage
67
Child's airway flow
turbulent flow
68
Premies skin
Thin keratin layer -> increased evalopartive loss
69
forms of heat loss
conduction
convection
radiation
evaporation
70
What is the major mechanism of heat loss
radiation
71
what is conducting heat loss
contacting cold objects
72
what is convection heat loss
air moving over and around the body
uncovered head = 60% of heat loss
73
what is radiation heat loss
warm air from the body that is trying to warm the cooler environment.
74
What is evaporation heat loss
skin and lungs. each gm of water evaporation carries -.58 kcal.
75
Consequences of heat loss
decreased metabolism/ drug distribution -> narcotize, paralyse, slow wake-up
blood coagulopathy is slowed -> bleeding risk
Shivering -> imparied wound healing
cardiac arrhythmias
76
Explain brown fat metabolism with shivering
Increase brown fat metabolism -> lipase release that splits trig into glycerol and fatty acids = increase heat/ NE production -> VC -> increase PA pressure -> R to L shunt thru PFO & ductus arteriosus -> hypoxemia. (also hard to place IV)
77
neonates and bilirubin
decreased glucouronic transferase; enzyme that breaks down bilirubin -> increased bilirubin levels
The neonate cannot conjugate bilirubin due to a reduction in glucosyl transferase -> this is the same enzyme that metabolizes acetaminophen.
78
Neonates and glucose stores
Neonates still need glucose because they have low glycogen stores and impaired gluconeogenesis and depend on carbohydrates and free fatty acids for fuel. (D5, D7.5, D10)
79
what things depress cyp3A4
Grapefruit juice, ccb, erythromycin, protease inhibitors, depress cyp3A4 activity
80
what things induce cpy3A4
Anticonvulsants, rifampin, st johns wort, glucocorticoids, and barbiturates induce cyp 3A4
81
peds and total body water
Higher TBW required higher doses of water-soluble drugs to achieve a given plasma concentration (NMBD)
82
peds and plasma proteins
With lower concentration of plasma proteins, (albumin and alpha 1 acid glycoproteins) there will be an increasing free fraction of highly protein-bound drugs (before 6 months of age = increased risk of toxicity. )
83
peds and drug biotransformation
Drug biotransformation reactions are underdeveloped in the first month of life. Adult values are reached by 1 year of age.
84
Peds and the ability to concentrate urine
Can't concentrate urine (don't conserve water) but they are unable to excrete large volumes of water so they don't do well with fluid overload either
85
how do neonates lose most of their body water
through evaporation
86
At what age does GFR match adults
age 2
GFR improves in the first few weeks of life but does not reach adult levels until 8-24 months
The renal tubular function continues to improve after birth and does not achieve full concentrating ability until 2 years of age.
* know which meds are renal excreted/ active metabolites.
87
term for babys first 28 days of life
neonate
88
term for baby between 29 days and 1 year
infant
89
age to sedate for separation anxiety
6 months - 6 years
90
anatomy to measure for selecting oral airway size
earlobe/ corner of mandible to the corner of the lip
91
miller # 0 age range
large neonates to 4 yrs
92
miller #1 age range
4 yrs to 7 yrs
93
miller #2 age range
age 8 and up
94
ETT depth formula
(age / 2) + 12
(kg/5) + 12
3 x size of ett
95
checking for a cuff leak
check between 20-30 cmh20.
leak < 20 = cant deliver 20 cmh20 of pressure and cuff is too small / PPV wont work so replace with larger tube
no leak @ 20cm h20 = risk of periglottic edema -> post op croup; replace with smaller tube.
96
Ped surgeries that use an oral rae
T&A and eye surgeries
97
What site of temp monitoring reflects for temp
Axilla if placed in proximity to the brachial artery and is the best option for MH.
runs a degree centigrade less
98
Circuit dead space sections
ETT, elbow, etco2 adapters, first 12- 20 inches of the circuit, HME/ NOSE
99
How to do an inhalation induction
Hold head in right hand and mask in left
Open APL
N2O 70% and .5 % sevo every 3-4 breaths
LOC -> assist ventilation + CPAP 5-8 cm
Pt crying? Single breath, prime with 70% N2O and 8% sevo -> 1-2 cries -> LOC
Always have prop drawn up and ready
TV and RR to judge depth
Best to use without IV narcotics
Mask case? Keep deep
100
When is an IV armboard placed
at the end of the surgery
101
Other term for cricoid pressure and amount of pressure
Selicks maneuver; 30-40 newtons (3-4 kg of force) intraluminal pressure of 50 cmh20 in the upper esophagus
102
Neonates IV size
24 gauge
103
Neonate extubation criteria
Grimacing, elbow or hip flexion, knees to chest
Neonates won't have a head lift
TOF > 90% = full recovery
MIF < -25cmH2O predicts adequate recovery from nmbd
104
what are caudal blocks used for
Used for procedures that require blockage of lower thoracic, lumbar and sacral nerves (T10-S5)
Can be used to block upper thoracic incisional pain
Used for circumcision
105
Medication used for caudal block
0.1-0.25% bupivicaine with epi
0.1 % can have 4-6 hrs of analgesia with minimal motor blockade
Max dose of 0.25% with epi is 2-3 mg/kg w/ a concentration of 25 mg/ml
Decrease dose by 30% in patients less than 6 months
Dose formulas
0.75-1 ml/kg of bupiv = reach T10
0.05ml/kg/dermatome to blockade
Morphine 0.02-0.05 mg/kg = 8-24 hr analgesia
Fentanyl 1-2 mcg/kg w/ LA
106
Caudal block anatomy
The hiatus extends from the sacral cornu to the fused arch of the 4th sacral vertebra
Locate the posterior superior iliac spine and find the equilateral triangle to the sacral hiatus. Once the hiatus is found then palpate between the sacral cornu
107
Technique for caudal block
Needle inserted at 45 degrees caudal and advanced till loss of resistance is felt.
Advance the cannula, remove needle and observe for blood. Aspiration confirms negative pressure = no blood or CSF
Do test dose
Insert dose = no subq distension and plunger should be easy to push
108
Complications from a caudal block
Intravascular or intraosseous injection, hematoma, infection
Epidural injection -> rapid rise in blood levels and toxic reaction
109
Versed doses in peds; oral, rectal, nasal, IV, IM
Oral = 0.5 mg/kg 20-30 min before induction
Rectal = 0.2-0.5 mg/kg works in 5-10 min
Nasal = 0.2 mg/kg works in 5 min
IV; 0.025-0.1 mg/kg
IM; 0.1-0.2 mg/kg
110
oral, rectal and nasal verssed can cause____
hiccups
111
half life of versed
2 hrs
112
Ketamine doses; oral, rectal, intranasal, IM, IV
Oral = 5 mg/kg
Rectal = 6-10 mg/kg
Intranasal = 3 mg/kg
IM 2 mg/kg (calming) 4-5 mg/kg (sedating)
IV 1-2 mg/kg
113
Ketamine side effects
Nystagmus, inc secretions, PONV, hallucinations, nightmares, delirium. (administer versed to attenuate but remember the combination prolongs stays)
Give atropine/ glycopyrrolate with it
114
Fent doses; oral, IV, maint boluses, intranasal, suckers
Oral = 10-15 mcg/kg
IV; 1-2 mcg/kg, maint boluses 0.25-0.5 mcg/kg
Intranasal; 1-2 mcg/kg (5 mcg/ nare)
Suckers= 100-400 mcg
115
morphine doses IM and IV
IM; 0.1-0.2 mg/kg
IV; 0.05-0.1 mg/kg (0.02-0.03mg/kg)
116
neonates and morphine
Neonates are sensitive to the resp depressant effect of morphine
117
Meperidine IM doses
IM; 1-2 mg/kg
118
Meperidine side effects
CNS excitation; sx, tremors, muscle twitches
consider active metabolite normeperidine
Repeat doses not recommended
Given for postoperative shivering
119
Sufent dose intranasal
Nasal 1.5-3 mcg/kg
120
sufent potency
10 x more potent than fentanyl
Decreased chest wall compliance after nasal dose
121
Tramadol doses oral and IV
Oral; 1.5 mg/kg
IV; 1.5 mg/kg
122
Tramadol MOA
Weak mu opioid R, inhibit NE reuptake and stimulation of serotonin release.
Analgesia for 6-9 hrs
123
Codein and peds
NO ANALGESIC BENEFIT IV BECAUSE 5-10% of CHILDREN DONT HAVE CYP 2D6 ENZYMES TO CONVERT TO MORPHINE
Oral; 0.5-1.5 mg/kg
Onset 20 min peak 1-2 hr
124
Prop doses
2-4 mg/kg
50-200 mcg/kg/min
125
Etomidate doses
0.2-0.3 mg/kg
Myoclonic activity
Suppress adrenal steroid synthesis
126
Lidocaine doses
1-2 mg/kg IV/ETT
127
Roc doses
0.3-0.6 mg/kg
128
Vec doses
0.1mg/kg
129
When might a stress dose steroid be necessary
Those taking chronic corticosteroids (lupus, Crohns, asthma, acute lymphocytic leukemia) -> depressed HPA axis
130
Normal stress dose steroid
Hydrocortisone 1-2 mg/kg IM or IV is equivalent to dexamethasone 0.05-0.1 mg/kg (repeat q 6 hr for up to 72 hrs)
131
MAC in peds for neonates, premature, infants 1-2 months and infants 2-3 months
Neonate 0-30 days; MAC is lower than the infant
Premature; MAC is lower than the neonate
Infant 1-2 months; MAC is higher than the adult
Infant 2-3 months; MAC peaks at its highest level
132
Sevo MAC peds
MAC 0-1 month = 3.3%
MAC 1-5 month = 3%
MAC 6 month- 3 yrs = 2.8%
MAC 3-12 yr = 2.5%
133
SEVO blood gas coefficient
0.69
134
SEVO vapor pressure
157 torr
135
Des mac
6.6%
136
DEs vapor pressure
669
137
Des B;G
0.42
138
ISO B;G
1.46
139
ISO vapor pressure
238
140
ISO mac
1.17
141
Tylenol doses rectal and PO
rectal 10-40mg/kg.
PO 10-15 mg.
142
Tylenol and neonates
Safe to use in neonates because the immature hepatic enzyme system in neonates produces less toxic metabolites than in older children
143
rectal tylenol peak time
Rectal peaks in 60-180 min
144
Ibuprophen rectal doses
40 mg/kg/day for up to 3 days
145
Toradol dose
0.5 mg/kg- 1 mg/kg max dose 15 mg
146
Zofran dose
0.1 mg/kg
147
decadron dose
0.5-1 mg/kg
148
cefazolin dose
25-40 mg/kg
149
Neostigmine dose
0.05-0.07 mg/kg; peak in 10 min
150
Succinylcholine doses IV and IM
2mg/kg IV 4 mg/kg IM
151
Succinylcholine in peds consideration
Consider the hyperkalemia undiagnosed muscular dystrophy in children under 8yo. IV calcium is the first-line treatment.
Less than 5 yo -> bradycardia/ asystole. (pretreat with atropine 0.02 mg/kg)
The increased dose requirement of succinylcholine in younger
patients is thought to result from its rapid distribution into an
enlarged volume of extracellular fluid rather than an altered
response to the action of the drug at postjunctional AChRs. The
fact that expressing the dose of succinylcholine in mg m22
abolishes the differences in dose requirements between the age
groups supports this suggestion, as extracellular fluid volume and
surface area bear a close relationship throughout life
152
IM roc dose
IM; 1 mg/kg in children < 1 yo and 1.8 mg/kg in children > 1 yo. Onset - 3-4 min
153
Atropine doses IV and IM
0.02 mg/kg IV and IM
20 mcg/kg
154
Baby Atropine
1 ml syringe of 0.1mg/ml
155
Side effects of atropine
Crosses BBB -> cns excitation, agitation restlessness, hallucinations, slurred speech
156
Epi doses
0.01 mg/kg, or 5-10 mcg/kg-> 10 mcg/ml
157
Glycopyrrolate dose
10 mcg/kg- 20 mcg/kg
158
calcium gluconate dose
50 mg/kg
159
Calcium chloride dose
20 mg/kg
160
EBV neonates < 37 weeks
100-90 ml/kg
161
Term neonates EBV
80-90 ml/kg
162
Infant EBV
70-80 ml/kg
163
child EBV
70-75 ml/kg
164
TBW adult
60%
165
TBW baby
75-85%
166
increased ECF volume significance
Increase ECF volume = increase volume of distribution = increase dosages (ie suc (DOA is similar)
167
ABL formula
MABL = EBV x (hct in - hct final) / hct in
168
NPO times
Clear liquids ---- 2 hours
Breast milk ---- 4 hours
Infant formula-- 6 hours
Non-human milk 6 hours
Light meal ------ 6 hours
Meal with fat---- 8 hours
169
age based NPO times
< 6 mo = solids = 4 hrs
6-36 months = solids = 6 hrs
> 36 months - solids= 8 hr
170
NPO replacement
4 ml for the first 10 kg, 2 ml for the next 10 kg, 1 ml/kg over 20 kg,
½ in first hour, ¼ in 2nd hour, ¼ in 3rd hour
0-10 kg -> Start with 4 ml/kg/hr
10-20 kg -> 2 ml/kg/hr to previous total
> 20 kg -> 2 ml/kg/hr to previous total
171
3rd space calculation
Replace whats lost in the 3rd spacing and evaporation
Minimal surgical time = 3-4 ml/kg/hr
Moderate surgical trauma= 5-6 ml/kg/hr
Major surgical trauma= 7-10 ml/kg/ hr
172
blood loss ratios
Replace crystalloid at 3:1
Colloid at 1:1
Blood at 1:1
173
Albumin max dose
5% max dose = 20 ml/kg
25% can cause too high of colloid osmotic pressure/ fluid shifts
174
Treatment for croup
steroids, humidified O2, racemic epi neb aerosols
175
Epiglottitis induction
mask induction with parents in the room
Size down ETT 1 size.
176
Down syndrome and anesthesia
Downs syndrome (trisomy 21); large tongue, small mouth, atlantoaxial instability (prone to bradyarrhythmias with inhalation induction)
177
laryngospasm is what type of maneuver
Inspiratory effort that longitudinally separates the vocal cords from the vestibular folds. Intrinsic and extrinsic muscles do not contract
The Vaslava maneuver causes glottic closure during expiration.
The upper part of the larynx is partially open -> high-pitched inspiratory stridor “mouse squeak”.
The thyroartentoid and the thyrohyoid don't contract
178
causes of laryngospasm
light anesthesia, stimulation, secretions. Stimulated during light anesthesia
179
Treatment for laryngospasm
100% O2
Stop stimulation and call for help if it worsens.
Sniffing position.
Deepen anesthetic; PROP, inc flows/ crank sevo
Peep 60-80cmh20 (increases the transverse dimension of the airway
Visualize obstruction if unable to rule out cause
Ant & upward displacement of mandible/ open mouth
Larsons maneuver
IV lidocaine 1-2 mg/kg (1-2 min onset)
IV succ 1mg//kg, IM succ 4 mg/kg
Neg pressure pulm edema can occur (treat with ventilation)
Emergency perc circ if all else fails (fingernails to feel)
180
Early and late signs of laryngospasm
Early signs; stridulous/ crowing noise, tracheal tugging, Increased effort
Latent signs; chest retractions, paradoxical movement, no movement of ventilator/ bag movement.
181
Bronchospasms s/s
Polyphonic expiratory wheeze -> prolonged expiration
Executive expiration with increased respiratory effort
Increased peak airway pressures
Increase alpha angle of ETCO2 waveform; “sharkfin”
Increased ETCO2, decreased SPO2
182
Tx for bronchospasm
ketamine/ propofol on induction. Sevo or iso are preferred. Avoid Des.
100% O2, deepen anesthetic. Avoid tracheal and vocal cord stim
Inhalation beta agonist; albuterol, xopenex. Give with inspiration
decreases PEEP and increases I;E ratio time to minimize air trapping.
IV steroids/ EPi
Epi; 0.05-0.5 mcg/kg given every minute
183
How does decreasing peep help with bronchospasms
Decreasing Peep decreases Autopeep by decreasing the work of breathing from the diaphragm and decreasing the pressure gradient required to overcome auto-Peep.
184
treatment/ prevention of post intubation croup
acepic or nebulized epi. Dexamethasone 0.5 mg/kg, microcuff; high volume, Low pressure elliptical balloon more distally, no murphy eye, provides uniform surface contact
Age 1-4 = increased incidence (1%)- increased subglottic airway growth
Intubations > 1 hr
Previous croup increases the chances
185
recent URI follow up questions
How long?
Clear discharge? Mild cough, no fever = okay to proceed.
Need ear tubes? Don't instrument airway and do ear tubes w/ in 2-3 days.
Surgery should be postponed on pts with an active infection/ fever, purulent discharge or purulent cough
Postpone for 2 weeks after resolution of symptoms
TIVA?
186
Explain CP
Group of nonprogressive motor impairment syndromes due to lesions or anomalies of the brain that is more a symptom complex than a disease.
MRI to diagnose
Spastic = lesion in the cerebrum
Can have baclofen pump
VP shunt possible
Epilepsy occurs in 30% of children with CP
Continue anticonvulsant therapy
Latex allergy is common (spina bifida or congenital urologic abnormalities)
187
Explain retinopathy of prematurity
Arrest of normal retinal vascular development in exchange for neovascularization and fibrous tissue formation of the retina and vitreous humor
Common cause of vision loss in childhood
Retina continues to mature until 42-44 weeks gestation
Hyperoxia results in abnormal vessel growth and worsening of blindness
Avoid nitrous
5 stages
188
What age is apnea of prematurity a concern
Respiratory control matures at 42-44 weeks post-conceptional age
Before maturation; hypoxemia depresses ventilation
After maturation; hypoxemia stimulates ventilation
Infants less than 60 weeks post-conceptual age should be admitted for 24 hr observation with an apnea monitor
Former preterm infants less than 44 wells postconceptual age risks; subglottic stenosis, perioperative respiratory complications, apnea
Pt with anemia hct < 30 are prone to apnea incidences
189
apnea of prematurity diagnosis and treatment
Apnea spells lasting 20 seconds resulting in bradycardia and cyanosis
Are they taking caffeine or aminophylline (risk of toxicity)?
Prophylactic caffeine to prevent postoperative apnea after general anesthesia
Methylxanthines; Caffeine 10mg/kg half life 5 hrs . Theophylline (8mg/kg).
May needs CPAP or even mechanical vent
For GA use short acting anesthetics (sevo/ des) and opioids (fent/ sufent).
190
What is pyloric stenosis
Infantile hypertrophic pyloric stenosis/ gastric outlet obstruction
Narrowing/enlargement of the pylorus = no gastric emptying
lack receptors that detect NO.
191
age pyloric stenosis is usually diagnosed
2 weeks- 2 months of age (3rd week of life) diagnosis
192
s/s of pysloric stenosis
Projectile Vomiting = first sign. No bile contents are present
Postprandial vomiting ; baby is hungry
Gastroenteritis = inflammation of the digestive tract
Dx; barium swallow/ultrasound (target or donut sign)
193
Pyloric stenosis anesthesia considerations
Full Stomach -> RSI
IV access prior to OR
Correct electrolyte depletion and dehydration
Hypochloremic, hypokalemia metabolic alkalosis
Loss of water and choride and hydrogen ions -> dehydration
Hypercarbia so resp can correct it
Severe cases can lead to metabolic acidosis
Kidneys excrete HCO3 to maintain normal pH, the kidneys excrete hydrogen and potassium to maintain euvolemia and retain Na+
Can lead to paroxysmal polyuria
Preoperative alkalosis can lead to hypoventilation/ increase PCO2 (Apnea monitor or first 24 hrs postoperatively)
Awake extubation
Watch glucose
Give atropine and watch for increase HR to ensure IV is in
RSI; PROP/ SUX/ TUBE + criciod pressure
NO NARCOTICS (impairs spont ventilation)
10-12 Fr Salem sump reinsert (red rubber catheter) 4-5 times and change the infant's position (awake)
Desflurane after airway secured ( strong depth of anesthesia.) reflex tachycardia. (6-9% = surgical relaxation)
Correct electrolytes, give fluid bolus = good CO.
Dextrose fluid and electrolyte balance
IV fluid is usually D5NS w/ 20 meq/ L of K @10-20 ml/kg/hr till electrolytes are normal
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Criteria for surgery with pyloric stenosis
Ready for surgery when; adequate UOP (1-2 ml/kg/hr), Na+ > 130, potassium > 3.0, Cl > 85 meq/L, assess fontanel
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Treatment for pyloric stenosis
pyloromyotomy
Laparoscopic (3 ports) or open
Open via a periumbilical incision
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Treatment for hypoglycemia
Less than 72 hrs old; hypoglycemia with glucose < 30-40 mg/dl
> 72 hrs hypoglycemia with glucose < 40
GA can mask signs of hypoglycemia
Tx; 10% dextrose (2ml/kg), sz? = 4 ml/kg. After bolus do gtt @ 8 ml/kg/min and titrate to glucose > 40 mg/dl
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Latex allergy considerations
Susceptible; spina bifida, meningocele paraplegics, OR techs, high allergic types, frequency surgical pts, urinary tract anomalies (require frequent catheterization)
Also allergies to bananas, chestnuts, avocados, kiwi, pineapple
IgE-mediated allergic reaction -> anaphylaxis
Can they blow a balloon? When they go to the dentist does the tongue swell when plastic is in the mouth?
Epi, steroids, h 1 and H2 blockers
Use narcotics, muscle relaxants, and low-agent concentrations
