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Pharm Final review > peds week 2 pharm > Flashcards

peds week 2 pharm Flashcards

1
Q

When does pharmacologic maturation occur?

A

between 3-6 months of age

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2
Q

Drug Absorption

A

There is no structural difference between infants, children, and adults that affect GI absorption of drugs

There are differences in the neonate related to pH (less acidic), gastric emptying and gastric transit time (markedly slower)

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3
Q

Protein binding in neonates

A

The neonate has a qualitative and quantitative reduction in protein binding

There is a decrease in the number of plasma proteins and a decrease in the affinity of proteins for drugs in the neonate

This contributes to the apparent larger volume of distribution in comparison to adult proportions

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4
Q

Do neonates have less protein binding and a larger volume of distribution that adults?

A

Yes..

Neonates and infants have larger distribution of volumes for water-soluble drugs and smaller distribution volumes for lipophilic drugs due to higher percentage of total body water

Plasma protein binding of drugs decreases the apparent volume of distribution, and tissue binding increases the apparent volume of distribution.

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5
Q

the physiologic nadir of hemoglobin

A

Infants go through a period of anemia following birth (3- 6 months) with the destruction of fetal hemoglobin and the concurrent but slow production of RBC’s

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6
Q

Total body water, extracellular fluid and blood volume are relatively _____ when comparing the neonate with the child or adult on a per kg scale

A

Larger

This initial larger volume of distribution may explain why the neonate requires higher per kg dose of drugs to reach the desired effect

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7
Q

the neonate requires_____ per kg dose of drugs to reach the desired effect

A

higher

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8
Q

The infant’s brain receives a _____ proportion of cardiac output (in comparison to the adult) and the resultant brain concentration of many drugs is ______ in the infant than in the adult

A

large, higher

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9
Q

Post conceptual age –

A

weeks of age at birth + weeks of age since birth

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10
Q

Drug metabolism

A

The ability to metabolize drugs develops to the same degree in the same time period after birth in the premature infant and the full term infant

Postnatal age (not gestational age) is more important in determining maturity of drug metabolism

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11
Q

Hepatic enzyme systems are ______ developed or absent at birth

Phase I &II processes are ____ but ____ within a few days after birth

Conjugation reactions are developed by ___ months

A

Hepatic enzyme systems are incompletely developed or absent at birth

Phase I &II processes are limited but develop within a few days after birth

Conjugation reactions are developed by 3 months

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12
Q

The ultimate elimination of most drugs or their metabolites is by

A

renal excretion

Clearance of most drugs reaches adult values by 3 months of age

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13
Q

Is the uptake of inhaled anesthetics more rapid in infants and small children than in adults?

A

Yes, uptake is more rapid

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14
Q

Va / FRC

A

Va / FRC
5:1 in infants
1.4:1 in adults

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15
Q

True/False: Distribution of cardiac output is higher to the vessel-rich group (the brain) vs. adults

A

True

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16
Q

Effects of Shunting R>L

A

Slows uptake of agent
TOF, TGA, TA, TAPVR
Partial pressure of agent increases more slowly

Over-pressuring can be dangerous

Slow on means slow off!

Overpressuring can be dangerous because if you get significant cardiovascular depression from anesthetic overdose, it can be equally difficult to decrease the anesthetic concentration

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17
Q

Effects of Shunting L>R

A

Uptake is faster

ASD, VSD, PDA, BT Shunt
Increase depends on size of shunt

Large (>80%) more rapid increase in agent partial pressure

Small (<50%) change is negligible

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18
Q

There is an _____ relationship between MAC of inhalation agents and age

A

There is an inverse relationship between MAC of inhalation agents and age

MAC increases the first month of life

MAC starts to decrease after 6 months of life

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19
Q

True/False: In the first week of life, the neonate’s response to pain is diminished

A

True

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20
Q

Incidence of bradycardia, hypotension, and cardiac arrest during induction is ______ in infants than in adults

A

Greater

This is due to the increased amount of agent administered and increased sensitivity of the cardiovascular system

21
Q

The baroreceptor reflexes of the neonate and premature infant are _____

A

limited

22
Q

Halothane ______ the myocardium in direct proportion to depth of anesthesia and acts as ____ _____ _____

A

depresses, calcium channel blocker

23
Q

Isoflurane has a direct ____ ____ _____

A

negative inotropic effect

Not used for inhalation induction due to pungent smell and airway irritation

24
Q

Sevoflurane

A

Less soluble agent with more rapid wash in than halothane or isoflurane

Maintains cardiovascular homeostasis and produces fewer dysrhythmias than halothane or isoflurane

25
Q

What does adding N20 to sevo do?

A

decreases the MAC of sevoflurane proportionately in adults

The addition of 60% N2O decreases the MAC of sevoflurane in children 1-3 years old by only 25%

26
Q

Desflurane

A

Not used as an induction agent because of the high incidence of severe laryngospasm in infants and children

Cardiac stability is maintained but SVR is decreased

High incidence of emergence delirium in pediatric population

27
Q

Pediatric MAC values

A

Halothane 0.87
Isoflurane 1.6
Desflurane 9.2
Sevoflurane 3.3

28
Q

Why inhalation induction?

A

Infants and children are often uncooperative with IV starts

Increased minute ventilation and small body mass makes inhalation inductions safer and faster in children

Stage II is limited therefore decreasing chances of laryngospasm during induction

29
Q

How to do the inhalation method

A

O2/N20 at 2L/4L
Sevoflurane at 8% until patient is deep enough for IV start*

This produces rapid stun effect for an anxious or uncooperative child but must be followed with continued administration of IV agent or inhalation anesthetic

Pay close attention to heart rate – always in tune with the rate on the pulse ox, need to decrease agent once maximal point in reached to prevent bradycardia and cardiovascular effects

30
Q

Midazolam

A

~ 9 months and older

IV: 0.1 mg/kg

31
Q

Propofol

A

Induction dose from 2-5 mg/kg

ED50 infants: 3.0 mg/kg
ED50 older children: 2.4mg/kg

32
Q

Ketamine

A

IV: 2mg/kg
IM: 3-6mg/kg

Has potent analgesic properties for skin, muscle and bone (not for viscera)

Causes increased salivation (give with antisialogogue)

Causes hallucinations as well and should be co-administered with a benzodiazepine (i.e. Midazolam)

33
Q

Narcotics

Fentanyl

A

Neonates have an increased sensitivity to narcotics

Dose: 1-5 mcg/kg

34
Q

Anticholinergic Agents

A

Primary purpose in pediatrics is to protect against cholinergic challenge (prevent bradycardia)

Another purpose is to inhibit secretions

35
Q

Treu/False: Neonates are born with a fully developed parasympathetic nervous system

Sympathetic nervous system does not fully develop until 3-6 months of age

A

True

36
Q

Atropine

A

Dose: 10-20 mcg/kg

Glycopyrrolate: 10-20 mcg/kg

37
Q

Succinylcholine

A

Metabolized by plasma cholinesterase

Dose: Infant 2.2 mg/kg (the ED 95 required to give 95%
blockade)

May produce profound and sustained bradycardia in the infant and small child

Doses are usually preceded by atropine

Because of the potential for life threatening side effects, Succinylcholine use is usually restricted to emergencies in the pediatric population (ie. RSI or Laryngospasm)

38
Q

Due to its large K+ release, Succinylcholine is contraindicated in:

A

Neurologic conditions: paraplegia & stroke
Muscular Dystrophies- Duchenne’s
Myotonia
Burns
Malignant hyperthermia

39
Q

Laryngospasm dose of succs

A

0.3-0.5 mg/kg range IV and 4 mg/kg IM

40
Q

Rocuronium

A

Similar dose to adult

41
Q

Neostigmine

A

Dose: 35-70 mcg/kg

More potent as an anticholinesterase than Edrophonium but slower onset of action

42
Q

Edrophonium

A

Dose: 0.5-1.0 mg/kg

Has more rapid onset of action than neostigmine
Must have minimum of ¾ twitches, more appropriately 4/4 with little fade, to be able use as a reversal

43
Q

Children are ___ more resistant to LA toxicity than adults!

A

NOT

44
Q

The first signs of LA toxicity in infants and children may be:

A

dysrhythmias or cardiovascular collapse

45
Q

Max local doses of lido, bupivcacaine, ropivacaine

A

lido: 5 mg/kg
bupiv: 2.5 mg/kg
ropiv: 0.5-1 ml/lg

46
Q

Precedex for SVT

A

2 mcg/kg rapid bolus and followed with an infusion

47
Q

Precedex

A

Initial increase in BP with rapid administration
Hypotension and bradycardia occur
Dose:
Bolus 0.25-1 mcg/kg
Infusion 0.2-1 mcg/kg/hr

Has sedative, analgesic, and sympatholytic effects
Reduces IV and inhalation anesthetic requirements
Decreases post operative analgesic requirements

48
Q

Tranexamic Acid

A

Antifibrinolytic

Reversibly blocks the lysine binding site on plasminogen, preventing binding to fibrin and conversion to active plasmin

Also improves hemostasis by preventing plasmin-induced platelet activation

Anti-inflammatory properties

Tranexamic acid is 10 times more potent as an inhibitor of fibrinolysis than Aminocaproic Acid

Dose
Loading dose at CHP: 30 mg/kg
Infusion dose at CHP: 10 mg/kg/hr

Pharm Final review (24 decks)

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