Peds week 2 Flashcards
When do deciduous teeth erupt?
At 6 months and begin shedding between 5-8 yrs.
Epiglottis is ______, ______, and at a more _____ angle from the trachea making it more difficult to lift
Epiglottis is narrower, longer, and at a more acute angle from the trachea making it more difficult to lift
The narrowest part of the pediatric airway is:
The cricoid cartilage. In adults it is at the vocal chords
The pediatric larynx is at:
C3-4
The adult larynx is at:
C4-5
What shape is the pediatric airway?
Funnel shaped
Length of the trachea (vocal cords to carina) in neonates and children up to one year of age is ___cm or ___
Length of the trachea (vocal cords to carina) in neonates and children up to one year of age is 5-9 cm or 2-2.5 inches
DO NOT ____ THE ETT once you go through the vocal cords
DO NOT BURY THE ETT once you go through the vocal cords
Do NOT overextend…keep the head ______
Do NOT overextend…keep the head parallel
The epiglottis is ____ shaped
omega
True/False: It is more difficult to lift an infants epiglottis with a laryngoscopic blade
True
A small decrease in airway size (edema from inflammation or trauma) results in what?
a large increase in resistance to flow
Infants are _____ ______ breathers until 3-5 months of age because?
Infants are obligate nasal breathers until 3-5 months of age because the major source of resistance to airflow is the lower airways
What can occlusion of the nares can cause?
complete airway obstruction
Overcoming the resistance of the nares accounts for only ___% of the work of breathing for infants as compared to ___% in adults
Overcoming the resistance of the nares accounts for only 25% of the work of breathing for infants as compared to 60% in adults
What kind of breathing do children under 6 months of age rely on?
diaphragmatic breathing
Thorax is weak and unstable
Diaphragm contains a smaller percentage of Type 1 (slow twitch, fatigue-resistant) muscle fibers
Ribcage/intercostal muscle contribution to ventilation is ___to___%
By 9 months of age, ribcage contribution increases to ___%
Ribcage/intercostal muscle contribution to ventilation is 20-40%
By 9 months of age, ribcage contribution increases to 50%
By 12 months of age, chest wall is stable and resists inward recoil of lungs
FRC is ____
FRC is small (not functional)
Infant respiratory rate is ____
30-50
Infants tidal volume is ___
7
Infants dead space is ____
Alveolar ventilation is _____
100-150
Functional residual capacity is ____
27-30
Oxygen consumption is ___
7-9
Anesthesia reduces FRC by causing ____ ____ ____ and impaired intercostal and diaphragm activity
peripheral airway collapse
ETT Size (mm ID) =
age in years +16 / 4
There should be an audible air leak around the tube at a pressure between ___-___ cm H20 (we typically go with 20 cm H2o)
There should be an audible air leak around the tube at a pressure between 15-25 cm H20 (we typically go with 20 cm H2o)
What is the biggest factor for post operative croup?
caused by excessive tube size
Is cuffed ETT is always a half size smaller?
Yep
Is percussion and auscultation is of limited usefulness in small children?
Yep. Limited usefulness
URI within the past 2-6 weeks =
significant risk of bronchospasm
Canceled Cases:
Wheezing
Green nasal drainage
Fever
Laryngospasm
Stimulation in stage 2
Sustained tight closure of the vocal cords during light planes of anesthesia (creates a state of central disinhibition)
Stimulation of the superior laryngeal nerve, not the recurrent laryngeal nerve
Contraction of the adductor muscles of the larynx (lateral cricoarytenoids, thyroarytenoids, and cricoarytenoids)
Causes of laryngospasm
Inhalation of volatile agents
Excessive secretions in the airway
Presence of URI (hyper-irritable)
Manipulation of the airway (intubation, extubation)
Stimulation of the visceral nerve endings in the pelvis, abdomen, and thorax
Treatment for laryngospasm
Remove irritating stimulus (suction)
Remove debris from airway
Deepen anesthesia as appropriate
100% O2 via tight fitting face mask
*Sustained positive airway pressure (30-40 cm H2O)
Manual forward displacement of the mandible
If airway maneuvers fail – atropine, succinylcholine, and consider intubation
Succinylcholine 0.4mg/kg IV
4mg/kg IM
Atropine 20mcg/kg IM/IV
Post Intubation Laryngeal Edema
Potential complication of intubation in all children but incidence is greatest in children ages 1-4
Causes of post-intubation laryngeal edema
Mechanical trauma to the airway during intubation
Placement of a tube that produces a tight fit (no leak up to 40 cm H2O)
Treatment for post intubation laryngeal edema
Humidification of inspired gases
Aerosolized racemic epinephrine 0.5ml of 2.25% solution in 2-3 ml saline –
vasoconstriction of capillaries in subglottic mucosa
Re-intubation
Tracheostomy
Epiglottitis
Rare cause of infectious upper airway obstruction in children
Etiology – haemophilus influenzae type B
Occurs in children 3-6 yrs.
Pathology – systemic septicemic process with local erythema and edema most marked in the epiglottis, aryepiglottic folds, and supraglottic connective tissue
Symptoms of epiglottitis
Rapid clinical progression of symptoms, <24 hrs.
Dysphagia, dysphonia, drooling, inspiratory stridor, distress
High fever, >39°C
Treatment for epiglottitis
O2
Urgent intubation of the trachea under general anesthesia – NEED to be in the OR
Antibiotics, antipyretics
Fluids
Anesthetic Management for epiglottitis
Transfer the child to the OR – do nothing to upset or agitate the child
Smooth, controlled inhalation induction with sevoflurane, child in a sitting position, CPAP applied to the circuit
Obtain IV access, administer atropine
Achieve Stage III, do no precipitate laryngospasm
ENT HAS TO BE PRESENT
Place the child supine, intubate the trachea with a small ETT a size and ½ smaller
MAINTAIN SPONTANEOUS VENTILATION
Through direct laryngoscopy by the ENT surgeon to confirm diagnosis
Anesthetic implications with epiglottitis
Expect a slow induction due to the partially obstructed airway
Inflammation of the airway may enhance irritability and increase the potential for coughing, breathholding, and laryngospam
CV depressant effects of inhalation agent magnified r/t hypovolemia
Rigid ventilating bronchoscope and surgical airway equipment must be available
With severe obstruction and mucosal swelling, identification of supraglottic structures may be difficult
May choose to replace oral tube with nasal tube intubated for 48-96 hrs.
Recovery of epiglottitis
Extubation considered when temp and white count fall
Resolution of the swelling signaled by audible leak around ETT
Extubation only after direct laryngoscopy in the OR under GA to confirm that swelling of epiglottis has resolved
How can you tell if epiglottitis swelling has resolved?
by audible leak around ETT
Laryngotracheobronchitis(croup, subglottic infection)
Accounts for 90% of infectious upper airway obstruction in children
Etiology – parainfluenzae virus type 1 and 2, influenzae A, respiratory syncytial virus
Occurs in children <2 years of age
Pathology – mucosal and submucosal edema within the circoid ring (decreased luminal size)
Laryngotracheobronchitis
Gradual onset and progression of symptoms, 24-72 hrs.
History of URI progressing to hoarse cry or barking cough
Low grade fever <39ºC
Treatment for laryngotracheobronchitis
O2 with cool aqueous mist
Aerosolized racemic epi (vasoconstriction of capillaries in subglottic mucosa, Beta adrenergic bronchodilatory effect) Albuterol
Corticosteroids. Stabilize cell membrane integrity, decrease release of inflammatory mediators
Antipyretics
Intubation of the trachea is RARE unless exhaustion occurs
Foreign Body Aspiration
Most frequent site is right mainstem
Cough, wheezing, decreased
air entry into affected lung, URI, pneumonia
Treatment of Foreign Body Aspiration
Laryngoscopic or endoscopic removal
Best to remove object within 24 hrs.
Risks of leaving the foreign object:
-Migration of the aspirated material
-Pneumonia
-Residual pulmonary disease
Anesthetic Management for airway obstruction
Induction technique will depend on severity of airway obstruction:
With airway obstruction, inhalation of volatile agent in O2 maintaining spontaneous ventilation
Without airway obstruction, IV induction with standard agents
After anesthetic management for airway obstruction continued..
Achieve Stage III of anesthesia, perform direct laryngoscopy for the purpose of anesthetizing the vocal cords to prevent laryngospasm – lidocaine 1% 1-2 mg/kg
With airway obstruction, avoid NDNMBs: Positive pressure ventilation may contribute to migration of the aspirated material
Narrow bronchoscope creates high resistance to gas flow
Typically there is a large gas leak around the bronchoscope
Anesthetic Management continued
Maintenance – O2, IH agent
Skeletal muscle paralysis may be required for removal if the aspirate object is too large to pass through the moving vocal cords – succs, cisatracurium
Emergence – pt. may or may not be intubated after removal of the foreign body
Post-op – aerosolized racemic epi, corticosteroids to reduce subglottic edema
Foreign body aspiration complications
Airway obstruction
Fragmentation of the foreign body
Arterial hypoxemia
Hypercarbia
Subglottic edema from trauma to the tracheobronchial tree – foreign body, instrumentation
Tonsillectomy and Adenoidectomy implications
Upper airway obstruction
Massive hypertrophy
Chronic upper respiratory infections
Obstructive sleep apnea
Anesthetic management for Tonsillectomy and Adenoidectomy
Pre-medication oral or intranasal midazolam
IH induction with sevoflurane
Intubation – deep (sevoflurane + propofol 1-2mg/kg) or with short acting NDNMB
Analgesia – MSO4 0.1mg/kg or Fentanyl 1-2mcg/kg (Obstructive sleep apnea cut meds to ½ dose)
Steroid –dexamethasone 0.3-1mg/kg
Emergence – extubate when child fully awake…don’t need to
Post-tonsillectomy Bleeding
Bleeding that continues or recurs after tonsillectomy and requires surgical intervention (packing or suturing)
Early: Incidence 0.2-2%
*Within first 24 hrs. 99% within first 6 hrs.
Secondary/Delayed
Incidence 0.1-3%
24 hrs. up to 2-3 wks. post-op, peak - day 7
Post-tonsillectomy Bleeding risk populations
Older pts.
Presence of inflammation, infection
Pre-op ingestion of ASA, NSAIDS – inhibition of platelet function
Coagulopathy
Patients that have had strep multiple times
Post-tonsillectomy Bleeding prevention
Careful dissection in tonsilar capsule
Meticulous hemostasis
Avoid surgery during/immediately after acute inflammation, infection
Avoid blind vigorous suctioning
Avoid use of NSAIDS
Post-tonsillectomy bleeding symptoms
Frequent swallowing
The kid will throw up blood
Tonsil bleed is an RSI
Need to know hemoglobin and urine specific gravity (how dehydrated) 1.010-1.015
Post-tonsillectomy Bleeding clinical presentation
Hypovolemia
Anemia
Agitation
Shock
Stomach full of blood
Active bleeding (poor visualization of glottis)
Post-tonsillectomy Bleeding preop evaluation
Assessment of volume status:
BP (orthostatic changes), HR, urine output, mucus membranes, skin turgor, sensorium
Labs, H/H, urine specific gravity/osmolality
E
stablish IV access-rehydration or transfusion must begin immediately
SEND for BLOOD
Post-tonsillectomy Bleeding management
2 Suctions AT THE HEAD OF THE BED!!! In case the one clots
Choanal Atresia
Occlusion of one or both posterior nares
Atresia is partially or totally bony in 90% of cases
Freq. association craniosynostosis
Since neonates are obligatory nose breathers, bilat. choanal atresia causes suffocation if the mouth is not kept open (oral airway or large rubber nipple secured in the mouth)
Unilateral atresia may go undiagnosed for months or years; is eventually diagnosed due to the presence of intractable unilateral nasal drainage
Surgical correction or tracheostomy must be performed within the first few days of life
Anesthetic Management of choanal atresia
Anesthetic Management of choanal atresia
Awake intubation with oral RAE tube
Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia
Emergence – wide awake for extubation
Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured
Stents are place – baby will transfer to ICU
IV Induction: Advantageous because…
Asleep without going through Stage 2
Risk of Laryngospasm very low
Stages chart
anatomical differences between pediatric and adult airways
Anesthetic Management of choanal atresia
Awake intubation with oral RAE tube
Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia
Emergence – wide awake for extubation
Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured
Stents are place – baby will transfer to ICU
Anesthetic Management of choanal atresia
Awake intubation with oral RAE tube
Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia
Emergence – wide awake for extubation
Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured
Stents are place – baby will transfer to ICU
Laryngospasm dose of succs
Succinylcholine 4mg/kg IM 0.4 mg/kg IV
Positive pressure 40 mm Hg – This is the reason you bring the mask and oral airway with every child –
and why you transport with O2 in the event of spasm
the kid has been oxygenated prior to event rather than starting at room air
Opioid doses for peds
½ the dose for fatigued children
½ the dose for children with OSA
Narcan o.5 mcg/kg
Anesthetic Management of choanal atresia
Awake intubation with oral RAE tube
Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia
Emergence – wide awake for extubation
Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured
Stents are place – baby will transfer to ICU
Nausea/Vomiting
Zofran 0.1-0.5mg/kg
Anesthetic Management of choanal atresia
Awake intubation with oral RAE tube
Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia
Emergence – wide awake for extubation
Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured
Stents are place – baby will transfer to ICU
