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Advanced Principles 2 > Pharmacology pediatric anesthesia > Flashcards

Pharmacology pediatric anesthesia Flashcards

1
Q

There is a large volume of distribution for

A

water soluble medications (higher TBW)

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2
Q

______ Vd of fat-soluble drugs occurs in pediatrics

A

decreased

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3
Q

Children have altered and reduced

A

protein binding- increases free fraction of medications

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4
Q

Children have an immature

A

blood brain barrier

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5
Q

Children have longer

A

half-lives (secondary to immature hepatic/renal function)

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6
Q

Pediatric dosing is typically based on a

A

per kilogram recommendation

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7
Q

Weight can be roughly estimated by the following:

A

50th percentile weight (kg)= (Age x2) + 9

<1: age (mo)/2+ 4

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8
Q

Regarding volume of distribution, neonates have a

A

proportionately higher total water content 70-75% (adult is 50-60%)
reduced % of fat
reduced amounts of lean muscle mass
-these differences result in a ECF volume of distribution proportionately HIGHER than that of an adult

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9
Q

There is an increased Vd of ________

A

water-soluble drugs (related to higher total water content)

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10
Q

The increased Vd of water-soluble drugs is due to

A
  • larger initial doses of water-soluble drugs are required
  • potentially delayed excretion
  • succinylcholine, bupivacaine, many antibiotics
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11
Q

There is a decreased Vd of

A

fat soluble drugs (related to decreased fat & muscle mass)

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12
Q

With fat-soluble drugs, there is an

A

increased duration of action because there is less tissue mass into which the drug can distribute
-thiopental, fentanyl

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13
Q

Decreased Vd of fat soluble drugs is improved by age 2 related to

A

improved BBB

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14
Q

Membrane permeability is ______ in the newborn

A

HIGH

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15
Q

There is reduced total

A

serum protein concentrations

leading to more of the administered drug free in the plasma to exert a clinical effect (e.g. lidocaine & alfentanil)

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16
Q

In regards to protein binding, _______ may be needed for drugs such as barbiturates and local anesthetics

A

reduced dosing

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17
Q

Hepatic enzymes usually convert medications from a

A

less polar state (lipid soluble) to a more polar, water-soluble compound
in general this ability is reduced in neonates

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18
Q

The ability to metabolize a conjugate medication improves with

A

age with both increased enzyme activity and increased delivery of drugs to the liver

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19
Q

_________ have a prolonged elimination half-life in neonates

A

aminoglycosides & cephalosporins

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20
Q

_______ develops rapidly in first few months of life

A

GFR & tubular function

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21
Q

Renal function is______

A

less efficient than in adults

-incomplete glomerular development, low perfusion pressure, and inadequate osmotic load

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22
Q

The concentration of inhaled anesthetics in the alveoli

A

increase more rapidly with decreasing age: infants>children>adults

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23
Q

In pediatrics, the inhalation induction is

A

more rapid

overdose occurs quickly and is leading cause of serious complications

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24
Q

Excretion and recovery of inhaled anesthetics is

A

more rapid

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25
Q

Determinates of the wash-in of inhalational agents includes

A

inspired concentration
alveolar ventilation
functional residual capacity
cardiac output
solubility- wash-in is inversely related to the blood solubility
alveolar to venous partial pressure gradient

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26
Q

In regards to inhalational anesthetics, the pediatric population has:

A

increased respiratory rate (higher minute ventilation)
decreased FRC
increased cardiac output distribution to vessel-rich groups*****

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27
Q

It is popular to use

A

N2O to allow for 2nd gas effect that will speed induction further

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28
Q

Possible explanations for the increased induction speed include

A 
cerebral maturation
age-related differences in blood-gas partition coefficients
state of hydration/dehydration
type of anesthesia circuit
vaporizer design
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29
Q

Faster induction + immature cardiac development equals

A

INCREASED risk of overdose

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30
Q

Blood pressure is VERY sensitive to volatiles because

A
  • lack compensatory mechanisms
  • immature myocardium
  • reduced calcium stores
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31
Q

MAC changes with age:

A

infants have a higher MAC than noted in older children or adults
peaks around 3 months of age

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32
Q

Inhalation anesthetics potentiate the actions of

A

NDMRS

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33
Q

Describe the stages of anesthesia:

A

Stage I: disorientation
Stage II: excitement or delirium
Stage III: surgical anesthesia; plane III: this was the desired plane for surgery when muscle relaxants were not used
Stage IV: overdose

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34
Q

Nitrous oxide is commonly used in pediatrics to

A

facilitate inhalation induction

  • enhances the rate of uptake of inhaled anesthetics into the alveoli (2nd gas effect)
  • analgesia and amnesia during maintenance
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35
Q

The blood/gas partition coefficient and MAC of nitrous oxide is

A

0.47

104%

36
Q

Nitrous oxide is contraindicated in

A

pneumothorax, necrotizing enterocolitis, bowel obstructions, etc.
may contribute to PONV

37
Q

N2O doubles the size of a pneumothorax in

A

12 minutes

38
Q

The 2nd gas effect relates to

A

Dalton’s law of partial pressure

39
Q

The agent of choice for inhalation inductions is

A

sevoflurane

least irritating to the airway of the inhaled anesthetics

40
Q

The blood gas solubility of sevoflurane is

A

0.68

41
Q

The following can increase the production of Compound A:

A

high temperature as mixtures
low fresh gas flow rates <2L/min
use of Co2 absorbers containing barium hydroxide or soda lime

42
Q

With sevoflurane there is a

A

dose related depression in RR & TV

43
Q

The blood gas coefficient of isoflurane is

A

1.43

44
Q

Pertinent info regarding isoflurane includes

A

slower & more pungent (major disadvantage)
appropriate to use in pediatrics, especially after inhalation induction
potentiates NDMR to a greater extent than sevoflurane or desflurane
least costly inhalation agent

45
Q

The blood gas coefficient of desflurane is

A

0.42

46
Q

Pertinent info regarding desflurane includes

A 
most pungent, causes airway irritation
(50% incidence of laryngospasm if used during induction)
better use is maintenance
use with LMA is controversial
emergence is rapid
47
Q

Propofol is _____ liphophilic and distributes rapidly from plasma to peripheral tissues

A

highly

48
Q

Propofol requires _______ induction doses related to increased volume of distribution

A

larger

49
Q

The elimination half time of propofol is

A

shorter due to higher rates of plasma clearance

50
Q

Common IV induction for propofol is

A

1-3 mg/kg

  • pain on injection
  • associated with reduced PONV
51
Q

TIVA infusion of propofol is

A

25 mcg-200 mcg/kg/min

-intraoperative nerve monitoring: <120-130 mcg/kg/min.

52
Q

Propofol may produce

A

profound hypotension in critically ill infants**

53
Q

Ketamine causes a

A

dissociation of the cerebral cortex

analgesic & amnestic- commonly used in burns/dressing changes

54
Q

Side effects of ketamine include

A

secretions, vomiting, & hallucinations

-consider supplementing with glycopyrrolate 0.01 mg/kg IV to prevent excessive secretions

55
Q

Ketamine preserves

A

spontaneous respirations and aids to maintain a patent airway, however apnea & laryngospasm may still occur

56
Q

Ketamine dosages include

A

oral: 6-10 mg/kg
sedation IM: 2-5 mg/kg
IV induction: 1-2 mg/kg
IM induction: 5-10 mg/kg

57
Q

Etomidate is not widely used in children because of

A

pain on injection, myoclonus, anaphylactoid reactions, and suppression of adrenal function

58
Q

Etomidate is a

A

hypnotic steroid-based induction agent

59
Q

Dose of etomidate is

A

0.2-0.3 mg/kg

60
Q

Main advantage & disadvantage of etomidate includes:

A

advantage: CV stability in hypovolemic patients
disadvantage: adrenocortical suppression not well tolerated in critically ill children

61
Q

With opioids in pediatrics there are

A

more potent effects

  • considered to be a result of an immature blood brain barrier
  • increased sensitivity of the respiratory centers
62
Q

Describe the dose and use of morphine

A

dose 0.025-0.05 mg/kg IV
histamine release
hepatic conjugation is reduced
renal clearance is decreased

63
Q

Fentanyl has a ______ duration of action

A

increased duration of action in high doses related to decreased fat/muscle
neonates & preterm infants may metabolize fentanyl more slowly

64
Q

Describe the IV dose of fentanyl

A
  1. 25-1 mcg/kg IV

0. 5-2 mcg/kg/hr infusion

65
Q

With hydromorphone, patients with compromised renal function are at risk for

A

metabolite accumulation & neuroexcitatory symptoms (tremor, agitation, cognitive dysfunction)

66
Q

Naloxone may be used to

A

antagonize opioids

dose for reversal of opioid-induced respiratory depression is 0.25-0.5 mcg/kg, repeated doses until effect

67
Q

Describe midazolam doses:

A
  1. 5 mg/kg PO (onset 20 minutes)
  2. 2-0.3 mg/kg intranasal
  3. 05 mg/kg IV (onset 5 minutes)
68
Q

Clonidine may be administered as an

A

oral premed at 4 mcg/kg (60-90 min onset)

may cause residual sedation postop

69
Q

Dexmedetomidine is useful for

A

sedation without respiratory depression

IV 0.25-1 mcg/kg over 10-15 minutes***

70
Q

Neonates have a _______ sensitivity to NMBDs

A

increased

  • reduction in release of acetylcholine and reduced muscle mass
  • fetal receptors have a greater opening time, allowing more sodium to enter the cell
71
Q

All muscle relaxants have a _____ onset

A

shorter onset because of faster circulation times

-may be difficult to monitor effects of relaxants with a peripheral nerve stimulator

72
Q

Describe the dose of succinylcholine for infants

A

infants require larger doses because of the increased ECF volume of distribution

73
Q

With succinylcholine, pediatrics are at increased risk for:

A 
cardiac arrhythmias
hyperkalemia
rhabdomyolysis
myoglobinuria
masseter muscle spasm
malignant hyperthermia
74
Q

If cardiac arrest occurs after succinylcholine administration, treat for

A

hyperkalemia*******

75
Q

______ should be given to prevent bradycardia

A

atropine 0.02 mg/kg IV/IM

76
Q

Non-depolarizing muscle relaxants have a much greater

A

variability with dose & response

  • immaturity of the nmj and increased extra-junctional receptors may result in increased sensitivity to drugs
  • immaturity of the hepatic system may result in prolonged duration of action required for the liver to metabolize
77
Q

For urgent or emergent reversal of large doses of rocuronium, the mean time to neuromuscular recovery is significantly faster with

A

sugammedex compared to spontaneous recovery with succinylcholine

78
Q

Caution with ketorolac is used in

A

impaired renal, increased risk of bleeding, impaired bone healing
may be reserved for children >1 year

79
Q

Neonates have very low

A

glycogen stores & are prone to hypoglycemia during NPO & stress (such as periods of illness & surgery)

80
Q

symptoms of hypoglycemia include

A

jitteriness, convulsions, and apnea

81
Q

Acute hypoglycemia management includes

A

10% dextrose 1-2 mL/kg
never administer bolus of D50% due to risk of vessel necrosis and higher osmolarity
maintenance on supplemental IV dextrose infusions
minimize preoperative fasting

82
Q

D50% is equal to

A

50 grams of dextrose per 100 mLs= 0.5 grams/mL

83
Q

To dilute D50% to D10% for PIV administration:

A

take 1 mL of D50% dilute into total of 5 mLs–> 0.1 gram/mL or D10%

84
Q

Describe epinephrine dose for resuscitation:

A

1 mcg/kg to treat hypotension IV; 10 mcg/kg for cardiac arrest repeated q3-5 as needed

85
Q

Describe atropine dose for resuscitation:

A

20 mcg/kg IV (for symptomatic bradycardia). max dose: 1 mg for child & 2 mg for adolescent

Advanced Principles 2 (42 decks)

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