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Preterm infant Flashcards

1
Q

Definitions:

  1. Neonate is first how many days after birth?
  2. Gestational age is the time elapsed between the first day of the last normal what and the day of what? (MP, B)
  3. Chronological age is the time elapsed after what? (B)
  4. Post-Conceptual Age is the sum what of what 2 ages?
A
  1. 28 days
  2. menstrual period, birth
  3. birth
  4. gestational and chronologic
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2
Q

Definitions:
1. Preterm is birth before how many gestational weeks?
2. “Preemies” should have what 2 ages
to help identify where infant is their maturation of their physiologic processes?

A
  1. 37

2. gestational and chronologic age

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3
Q

Classified Weight:

  1. Low Birth Weight is < how many grams?
  2. Very Low Birth Weight is < how many grams?
  3. Extremely Low Birth Weight is < how many grams?
A
  1. 2500 grams
  2. 1500 grams
  3. 1000 grams
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4
Q

Classified age:

  1. Mod to Late prematurity is what week range?
  2. Very Premature is what week range?
  3. Extremely Premature is what week range?
A
  1. 32 to < 37
  2. 28 to < 32
  3. < 28
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5
Q

Small airways:

  1. Increase in resistance to what? (A)
  2. Resistance to airflow is inversely proportional to the radius of the lumen to the what power for laminar flow to the what power for turbulent flow?
  3. Turbulent flow is from what to what bronchial division?
  4. Laminar flow is beyond what bronchial division?
  5. does the ETT increase or decrease resistance and work of breathing?
  6. does adding anesthesia increase or decrease WOB?
  7. anesthesia causes a loss in muscle toning creating a partial what? (O)
A
  1. airway
  2. 4th, 5th
  3. mouth to 4th bronchial division
  4. 5th
  5. increase
  6. increase
  7. obstruction
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6
Q

Subglottic Stenosis

  1. is the narrowing of airway below what? (VC)
  2. what are 3 causes? (PI, C, TFE)
  3. does this necessitate a smaller than normal ETT?
  4. how much smaller?
A
  1. vocal cords
  2. prolonged intubation, congenital, trauma from ETT
  3. yes
  4. 0.5
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7
Q

Tracheal Stenosis

  1. is the narrowing of trachea below what and above what? (VC, C)
  2. what are 4 causes? (PI, PT, C, T)
  3. may not need a smaller ETT because the stenosis is what to ETT? (D)
  4. will there still be an increased resistance and WOB?
  5. may there be trouble ventilating because of increased resistance?
A
  1. vocal cords, carina
  2. prolonged intubation, prolonged tracheostomy, congenital, trauma
  3. distal
  4. yes
  5. yes
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8
Q

Tracheobronchomalacia

  1. does the airway collapse during inhalation or exhalation?
  2. what are 2 things to stent open the airway? (C, P)
  3. is a higher PEEP usually is needed?
  4. Mechanical ventilation is better than spontaneous ventilation because it will help do what to the airways and decrease what 2 things? (SO; F, W)
  5. Should you use larger or smaller I:E ratios to prevent air trapping and hyperinflation?
A
  1. exhalation
  2. CPAP, PEEP
  3. yes
  4. stent open; fatigue, work of breathing
  5. smaller
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9
Q

Respiratory: High Metabolic Rate

  1. neonates have an increased in what 2 things? (AV, OC)
  2. what is average neonate alveolar ventilation ml/kg/min?
  3. what is average adult alveolar ventilation ml/kg/min?
  4. what is average neonate oxygen consumption ml/kg/min?
  5. what is average adult oxygen consumption ml/kg/min?
  6. what can be difficult to maintain normal d/t a neonates alveolar ventilation? (E)
  7. is the premature oxygen consumption higher or lower than neonates?
  8. do neonates have a rapid decrease in PaO2?
A
  1. alveolar ventilation, oxygen consumption
  2. 130 ml/kg/min
  3. 60 ml/kg/min
  4. 5-8 ml/kg/min
  5. 2-3 ml/kg/min
  6. ETCO2
  7. higher
  8. yes
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10
Q

Lungs: Pulmonary Gas Exchange

  1. lungs are immature in what 2 things? (S, F)
  2. Alveoli are what 3 things? (T, FF, SD)
  3. do alveoli require greater or lesser pressure to expand?
  4. production of what by type 2 alveolar pneumocytes is inadequate? (S)
  5. what gestational week range does surfactant production start?
  6. surfactant remains inadequate until what week?
  7. preemies are born with what syndrome? (RDS)
A
  1. structure, function
  2. thick, fluid filled, surfactant deficient
  3. greater
  4. surfactant
  5. 23-24 weeks
  6. 36 weeks
  7. respiratory distress syndrome
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11
Q

Immature lungs lead to Respiratory Distress Syndrome (RDS)

  1. decreases in what 2 things (LV, C)?
  2. increase intrapulmonary shunting leads to what mismatch and increases the risk of what? (VP, H)
  3. what are 3 clinical signs? (G, NF, CR)
  4. anesthesia decrease lung volumes even more which leads to increase in what mismatch and an increase risk of what? (VP, H)
A
  1. lung volume, compliance
  2. VP, hypoxia
  3. grunting, nasal flaring, chest retractions
  4. VP, hypoxia
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12
Q

Pulmonary Gas Exchange and Atelectasis

  1. Large abdomen pushes diaphragm cephalad causes disruption in what and places the what capacity within the expiratory reserve volume? (GE, CC)
  2. Closing capacity is the volume in the lungs at which the smallest airways do what? (C)
  3. expiratory reserve volume is the amount of air exhaled during what type of exhale? (F)
  4. do alveoli close quicker in premature infants?
  5. what other 3 things can increase abd pressure resulting in the closing capacity to be within the ERV? (OM, SP, SR)
A
  1. gas exchange closing capacity
  2. collapse
  3. forced
  4. yes
  5. overzealous masking, surgical procedure, surgical retraction
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13
Q
  1. anatomic forces that disrupt gas exchange result in what 2 things? (A, IS)
  2. what are 4 strategies to help improve a disrupted gas exchange? (MV, P, ES, CSA)
A
  1. atelectasis, intrapulmonary shunting

2. mechanical ventilation, PEEP, empty stomach, change surgical position

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14
Q

Mechanical lung injury:

  1. this can be caused by increased what volumes and frequent collapsing and reopening of what? (EILV, A)
  2. are micropreemies more susceptible to mechanical lung injuries?
  3. not having enough what contributes this micropreemies being more susceptible to mechanical lung injuries? (S)
  4. to prevent lung injuries we use what range of tidal volumes (ml/kg), greater what, sufficient what and permissive what? (RR, P, H)
  5. what is the permissive range we allow?
A
  1. end-inspiratory lung volume, atelectasis
  2. yes
  3. surfactant
  4. 4-6 ml/kg, RR, PEEP, hypercapnia
  5. 45-55 mmHg
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15
Q

Bronchopulmonary Dysplasia (BPD)

  1. defined as the need for supplemental oxygen at what postnatal days?
  2. In BPD, high levels of what and what type of ventilation disrupts maturation of alveoli in preemies? (O, M)
  3. at what weeks gestation does alveolarization begin?
  4. are alveoli larger or smaller and more or fewer?
  5. do alveoli have an increased or decreased SA which increases or decreases O2 requirements?
A
  1. 28 days
  2. oxygen, mechanical
  3. 36 weeks
  4. larger, fewer
  5. decreased SA, increases
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16
Q

Bronchopulmonary Dysplasia (BPD)

  1. severity is based on what 2 things? (F, P)
  2. greater risk for perioperative what? (C)
  3. goal is SpO2 in what % range and PaO2 in what mmHg range?
A
  1. FiO2, PPV
  2. complications
  3. 90-94%, 50-55 mmHg
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17
Q

How do we prevent BPD?

  1. what is one thing we can give mom and baby? (AC)
  2. what is one type of therapy? (EST)
  3. early and aggressive use of what to prevent ETT?
  4. what 2 type of meds can we give? (D, B)
A
  1. antenatal corticosteroids
  2. exogenous surfactant therapy
  3. CPAP
  4. diuretics, bronchodilators
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18
Q

Hyperoxia
1. what 2 prematurity-related diseases are associated with hyperoxia? (R, B)
2. Oxygen toxicity from hyperoxia leads
to the formation of reactive oxygen what that impair intracellular macromolecules and lead to cell what? (I, D)
3. formation of oxygen free radicals promotes an extensive inflammatory response, leading to what damage and cell what? (T, D)
4. Oxygen-induced vascular endothelial growth factor (VEGF) signals disturbances associated with abnormal what, which it may be detected in what 2 diseases? (A; R, B)
5. oxygen supplementation strategy: recent evidence suggest a graded approach according to what age, meaning increasing O2 saturation targets with increasing what? (G, A)

A
  1. retinopathy of prematurity, bronchopulmonary dysplasia
  2. intermediaries, death
  3. tissue damage, cell death
  4. angiogenesis; retinopathy of prematurity, bronchopulmonary dysplasia
  5. gestational age, age
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19
Q

Respiratory control:

  1. premature infants have what type of ventilatory response to hypoxia? (B)
  2. Initially ventilation increases or decreases but after several minutes they do what and then what ensues? (D,A)
  3. Ventilatory response to what is decreased in micropreemie and what further blunts this response? (C,H)
  4. does anesthesia increase or decrease the ventilatory responses to hypoxia and hypercapnia?
A
  1. biphasic
  2. increases, decrease, apnea
  3. CO2, hypoxia
  4. decrease
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20
Q

Apnea of Prematurity

  1. occurs commonly in micropreemies and increases or decreases with post-conceptual age?
  2. is it centrally, obstructively or both?
  3. central apnea is caused by a decrease in output from where? (RC)
  4. this decreased output is exacerbated by what 3 things? (H, H, H)
  5. obstructive apnea occurs because of the incoordination of what muscle? (P)
  6. is this incoordination made better or worse by anesthesia?
A
  1. decreases
  2. both
  3. respiratory center
  4. hypothermia, hypoglycemia, hypocalcemia
  5. pharyngeal muscle
  6. worse
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21
Q

Postoperative Apnea

  1. the incidence of this depends on what 3 things? (PCA, A, ToS)
  2. which of these is the most significant risk factor?
  3. occurs in what % of micropreemies?
  4. increased risk what hct is < what %?
  5. is it more common after major procedures like laparotomies or peripheral surgical procedures like inguinal hernia repairs?
  6. usually how many hours after emergence and can be up to how many hours?
  7. defined as apnea greater than how many seconds or brief apnea with HR less than or equal to how many beats?
A
  1. post-conceptual age, anemia, type of surgery
  2. post-conceptual age
  3. 50%
  4. < 30%
  5. after major
  6. 1 hour, 48 hours
  7. > 15 sec, less than or equal to 80
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22
Q

Postoperative Apnea: intraop prevention strategies

  1. Avoid what type of drugs? (N)
  2. prevent what 2 things? (H, A)
  3. can it occur with regional anesthesia?
  4. what 2 methylxanthines can be give to help prevent? (C, T)
  5. why is caffeine preferred over theophylline?
  6. what is the mg/kg IV dose of caffeine?
  7. caffeine increases the respiratory centers sensitization to what? (H)
A
  1. narcotics
  2. hypovolemia, anemia
  3. yes
  4. caffeine, theophylline
  5. longer half-life
  6. 10 mg/kg
  7. hypercarbia
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23
Q

Fetal circulation:

  1. oxygenated blood from placenta travels via the what vein through the ductus venosus in the what to the what and into which atrium?
  2. Oxygenated blood from the IVC preferentially enters the which ventricle then goes to which artery?
  3. oxygen rich blood supplies the what prior to mixing with the oxygen poor blood coming through the what?
  4. Deoxygenated blood from the superior vena cava enters which ventricle and is pumped to the which artery?
  5. It then passes through the what to meet the oxygenated blood in the aorta? (DA)
A
  1. umbilical vein, liver, inferior vena cava, right atrium
  2. left ventricle, aorta
  3. brain, ductus arteriosus
  4. right ventricle pulmonary artery
  5. ductus arteriosus
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24
Q

Fetal Circulation to Neonatal Circulation: With first breath…

  1. lungs do what? (E)
  2. O2 tension increases or decreases?
  3. pulmonary vascular resistance increases or decreases?
  4. blood flows to where? (L)
  5. does SVR increase or decrease with cord clamping?
A
  1. expand
  2. increases
  3. decreases
  4. lungs
  5. increase
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25
Fetal Circulation to Neonatal Circulation: 1. ductus arteriosus functionally closes what hour range after birth and anatomically closes what week range after birth? 2. increase in what tension and loss of what from the placenta is thought to close the ductus arteriosus? 3. any factors that increase what may revert back to fetal circulation? (P) 4. what are 4 things that can increase PVR? (H, H, H, A) 5. what shunt do these cause?
1. 12-24 hours; 2-3 weeks 2. O2 tension, prostaglandins 3. pulmonary vascular resistance 4. hypoxia, hypercarbia, acidosis, hypothermia 5. right to left
26
Failure of Patent ductus arteriosus closure: 1. 1 in how many thousands of full term births? 2. what % of extremely low-birth-weight infants? 3. immature smooth muscle cells fail to do what? (C) 4. immature lungs can't metabolize what? (P)
1. 1/2000 2. 60% 3. constrict 4. prostaglandins
27
PDA left to right shunt: 1. increase or decrease in SVR and increase or decrease in PVR at birth causes this? 2. results in excess BF to where as well as what 2 types of failure? 3. does the pulse pressure widen or narrow? 4. is there a risk for coronary ischemia? 5. what is restricted and what type of meds are given to offload lungs? (F, D)
1. increase, decrease 2. lungs; congestive heart failure, respiratory failure 3. widen 4. yes 5. fluids, diuretics
28
PDA right to left shunt: 1. occurs in neonates with persistent what and what syndrome? 2. this type of shunt results in what? (C) 3. flow ends up going out what and not to where?
1. persistent pulmonary hypertension, respiratory distress syndrome 2. cyanosis 3. patent ductus arteriosus, lungs
29
PDA and NSAIDs: 1. what 2 NSAIDs are given? (I, I) 2. these meds inhibit the production of what by decrease the activity of cyclooxygenase? 3. what % closure rate?
1. ibuprofen, indomethacin 2. prostaglandins 3. 80%
30
what 6 things increase pulmonary vascular resistance? (H, H, A, A, P, P)
1. hypercarbia 2. hypoxia 3. acidosis 4. atelectasis 5. PPV 6. PEEP
31
what 4 things decrease pulmonary vascular resistance? (N, O, A, H)
1. nitric oxide 2. oxygen 3. alkalosis 4. hypocarbia
32
Persistent Pulmonary Hypertension (PPHN) 1. occurs in how many births out of 1000? 2. PPHN is diagnosed when what-to-what shunting of blood occurs through a PDA and/or PFO in the absence of what disease? 3. this shunt occurs because what vascular resistance fails to decrease at birth? (PVR) 4. is the etiology understood? 5. Suspected in hypoxic neonates with no increase in preductal or postductal O2 sat despite being on vent and high FiO2? 6. what limb/limbs for preductal? 7. what limb/limbs for postductal?
1. 2/1000 births 2. right to left shunt; congenital heart disease 3. pulmonary vascular resistance 4. no 5. postductal 6. R arm 7. L arm and either leg
33
Persistent Pulmonary Hypertension (PPHN) 1. Greater preductal saturation or post ductal saturation supports diagnosis because all the oxygenated blood is going through PDA? 2. timely diagnosis and treatment is imperative to prevent what 4 things? (ND, CP, D, B) 3. do Premature infants tend to have worse outcomes requiring Extracorporeal membrane oxygenation (ECMO) compared to term infants?
1. preductal saturation 2. neurodevelopmental delay, cerebral palsy, deafness, blindness 3. yes
34
Persistent Pulmonary Hypertension Treatment: 1. maintain what pressure adequately? (SBP) 2. optimize lung management by preventing what? (O) 3. avoid what which will increase PVR? (A) 4. maximize the delivery of what? (O) 5. what invasive technique? (E) 6. inhaled what med? (N)
1. systemic blood pressure 2. overdistention 3. acidosis 4. oxygen 5. ECMO 6. nitric oxide
35
Pulm HTN and iNO 1. selectively what vasodilator by diffusing into what type of muscle and increasing what which causes vascular relaxation? (P, SM, cG) 2. iNO decreases what 2 things and increases what thing? (P, RtLS; SO) 3. does iNO decrease the need for ECMO? 4. do all infants respond to iNO? 5. what is the initial dose of iNO in ppm?
1. pulmonary vasodilator, smooth muscle, cGMP 2. PVR, R to L shunt; systemic O2 3. yes 4. no 5. 20 ppm
36
Pulmonary HTN and iNO 1. iNO oxidizes hemoglobin into what making it something to monitor? (M) 2. slowly wean iNO to avoid rebound what? (PH) 3. what med type can be added during weaning? (PI) 4. name 2 of these meds (S, M) 5. both of these meds increase what leading to smooth muscle vascular relaxation? (cG) 6. is sildenafil PDE 3 or PDE 5? 7. is milrinone PDE 3 or PDE 5?
1. methemoglobin 2. pulmonary htn 3. phosphodiesterase inhibitors 4. sildenafil, milrinone 5. cGMP 6. PDE 5 7. PDE 3
37
Cardiovascular: 1. fetal hearts have more what type of tissue? (C) 2. are the contractile elements more or less organized? 3. increased or decreased dependents on extracellular Ca? 4. high or low resting HR? 5. frank-starling more or less flat because of decreased ventricular compliance?
1. connective tissue 2. less 3. increased 4. high 5. more flat
38
Cardiovascular: 1. more or less sensitive to catecholamines? 2. Greater or lesser blood volume per kilogram but larger or smaller absolute blood volume? 3. Small amount of EBL can cause what 3 things? (H, H, S) 4. is autoregulation developed or not well developed? 5. May the HR not increase in response to hypovolemia? 6. can perfusion to brain decrease with very little EBL? 7. are micropreemies more prone to C/V collapse during anesthesia and surgery?
1. less sensitive 2. greater volume per kg; smaller absolute 3. hypovolemia, hypotension, shock 4. not well developed 5. yes 6. yes 7. yes
39
Immature Brain 1. is CNS fully developed at birth? 2. what week range does preoligodendrocytes and astrocytes multiply and cortical and subcortical structures develop? 3. During this week range, what white matter is most susceptible to injury? (P) 4. this white matter is termed watershed region because it is susceptible to poor what? (P) 5. this white matter is susceptible to injury when what is decreased and during what other states? (DCO, H, H, H) 6. is a baby born at 30 weeks still susceptible to these injuries?
1. no 2. 24-27 weeks 3. periventricular 4. perfusion 5. decreased cardiac output, hypotension, hypoxemia, hypercarbia 6. yes
40
Pain perception 1. First trimester: withdrawal reflex to what type of stimuli? (N) 2. Second trimester: transmission of what type of stimuli? (N) 3. Third trimester: pathways between what and what cortex are functional? (T, SC) 4. should we still treat pain in micropreemies?
1. non-noxious stimuli 2. noxious 3. thalamus, somatosensory cortex 4. yes
41
Glucose and brain 1. do neonates require a lot of glucose? 2. in regards to ischemic events, is hyperglycemia protective or harmful in neonates? 3. can mild hypoglycemia cause brain damage in preterm infants? 4. Micropreemie is more or less at risk because they have more or less glucose stores and consume more or less glucose? 5. Mild or moderate hyperglycemia during surgery is best managed by reducing the rate of infusion of and not administering what? (DCS, I)
1. yes 2. protective 3. yes 4. more, less, more 5. dextrose-containing solution, insulin
42
Complications of prematurity: 1. what are 5 long term disabilities? (CP, CD, BA, HI, VI) 2. ELBW only what % were normal developed at age 5 and what % were exhibited major disabilities? 3. Most common abnormality is problems in the periventricular cerebral white matter seen on what scan? 4. on the scan, Increased water content, and delayed white matter maturation suggest what type of injury? (IR)
1. cerebral palsy, cognitive deficits, behavioral abnormalities, hearing impairments, visual impairments 2. 25%, 20% 3. MRI 4. ischemia-reperfusion
43
Intraventricular Hemorrhage (IVH) 1. one in how many micropreemies have IVH? 2. associations between IVH and fluctuations in what? 3. what scan is used to determine severity?
1. 1/3 2. BP 3. ultrasound
44
IVH grading: 1. Grade 1- hemorrhage limited to what matrix? (G) 2. Grade 2- extending into the what system? (V) 3. Grade 3- extending into the ventricular system with dilation of what? (V) 4. Grade 4- extending into brain what? (P) 5. Long term neurocognitive sequelae associated with what grades?
1. germinal matrix 2. ventricular system 3. ventricles 4. parenchyma 5. grade 3 and 4
45
Intraventricular Hemorrhage (IVH) 1. what are 5 early onset (first day of life) risk factors? (FD, VD, RAS, MS, SH, MV) 2. what are 7 last onset (days to weeks) risk factors? (RDS, S, P, H, A, SH, V) 3. what 2 things can be given to decrease severity or incidence of IVH? (AG, I)
1. fetal distress, vaginal delivery, reduced apgar scores, metabolic acidosis, hypercapnia, mechanical ventilation 2. respiratory distress syndrome, seizures, pneumothoraces, hypoxemia, acidosis, severe hypercarbia, vasopressors 3. antenatal glucocorticoids, indomethacin
46
Temperature Regulation 1. what % of heat loss is radiation? 2. what % of heat loss is convection? 3. what % of heat loss is evaporation? 4. what % of heat loss is conduction? 5. micropreemies lose more heat from convection because they have no what for insulation? (F) 6. evaporation loss is more in micropreemies because they have less what? (K)
1. 39% 2. 34% 3. 24% 4. 3% 5. fat 6. keratin
47
Temperature Regulation 1. neonates use nonshivering thermogenesis which relies on what fat? (BF) 2. what week range does this fat develop? 3. keep skin moist or dry? 4. monitor temp so baby doesn't become what? (O)
1. brown fat 2. 26-30 weeks 3. dry 4. overheated
48
Immature renal function: 1. full term infant has GFR of what % of adults? 2. more or less nephrons and larger or smaller glomerular size? 3. at what age is GFR normal?
1. 30% 2. less nephrons, smaller glomerular size 3. 1 year
49
Preterm infant renal function: 1. what electrolyte is increased the first days of life? 2. higher or lower creatinine clearance compared with full term neonates? 3. prolonged or shorter drug excretion by the kidneys? 4. what 3 meds can be prolonged because of renal impairment? (P, G, N) 5. VLBW infants are at risk for what electrolyte abnormality? (H) 6. one and how many are at this risk?
1. potassium 2. lower 3. prolonged 4. penicillins, gentamicin, neuromuscular blocking drugs 5. hyponatremia 6. 1/3
50
Immature Renal function: 1. do Neonates and preemies have greater or lesser body water content than infants? 2. The smaller the PCA of neonate, the greater or lesser the percent of water present? 3. Because the volume of distribution of drugs confined to the extracellular fluid is increased, the initial doses of some medications (e.g., NMBDs, aminoglycosides) may be greater or lesser on a weight basis in neonates than adults? 4. In contrast, because of immaturity of renal function, the interval between doses of these drugs must be increased or decreased?
1. greater 2. greater 3. greater 4. increased
51
calcium homeostasis: 1. Term neonates benefit from maternal transfer of calcium in what trimester which helps bridge them to managing their own calcium homeostasis by the what day of life? 2. Premature infants do not benefit from this maternal transfer and are at risk for what? (H) 3. Hypocalcemia risk factors: limited what?, impaired secretion and response to what, increased what levels, and increased what losses? (OI, P, C, U) 4. what % of critically ill neonates have hypocalcemia?
1. third trimester, third day of life 2. hypocalcemia 3. oral intake, PTH, calcitonin, urinary 4. 40%
52
hypocalcemia definition: 1. Total serum calcium < what mg/dl full term? 2. Total serum calcium < what mg/dl in premature infants? 3. Ionized Ca2+ < what mg/dl (both term and preterm)? 4. what are 5 clinical manifestations of hypocalcemia? (NI, T, PQ, DCC, FoDGS)
1. 8 mg/dl 2. 7 mg/dl 3. 4 mg/dl 4. neuromuscular irritability, tachycardia, prolonged QT, decreased cardiac contractility, feature of digeorge syndrome
53
treating symptomatic hypocalcemia: 1. what mg/kg of calcium gluconate? 2. what mg/kg of calcium chloride over 10 min? 3. Check what level as well because if it is low then calcium can not be corrected
1. 90 mg/kg 2. 30 mg/kg 3. magnesium
54
Glucose Homeostasis 1. during 3rd trimester, glycogen stores in what 5 areas? (S, C, K, I, B) 2. At birth glucose drops to what mg/dl then stabilizes by 12 hours to > what mg/dl? 3. Premature infants are more prone to hypoglycemia requiring what mg/kg/min of glucose infusion? 4. Premature infants are more prone to hypoglycemia because they have reduced stores of what 2 things, have immature whats and increased what? (G, A; IRM, IED) 5. Full term infants are prone to hypoglycemia when they have been excessively what, are what for gestational age, and are infants of what mothers? (F, S, D) 6. full term infants require glucose infusion of what mg/kg/min to prevent hypoglycemia?
1. skeletal, cardiac, kidney, instestin, brain 2. 30 mg/dl, > 45 mg/dl 3. 8-10 mg/kg/min 4. glycogen, adipose, immature regulatory mechanisms, increased energy demands 5. excessive fasting, small for gestational age, diabetic mothers 6. 5-8 mg/kg/min
55
Hypoglycemia treatment: 1. what ml/kg of D25W? 2. what ml/kg of D10W? 3. along with those, increase what glucose infusion? (B) 4. over what minute range should these be given over? 5. never bolus a hypertonic glucose solution (greater than 5%) because it increases the risk of what? 6. in practice, we run what solution at half maintenance? 7. replace fluid deficits with solution free of what?
1. 1-2 ml/kg 2. 2.5-5 ml/kg 3. basal 4. 10-15 min 5. IVH 6. D5LR 7. glucose
56
GI function 1. Anatomic structures of GI tract are formed in what trimester but functional maturation does not occur until later in gestation and continues after birth? 2. motility increases at what range of weeks gestation? 3. Full term passes meconium in how many hours; in premature babies, it can be days 4. Decreased gastric motility increases time for colonization of what? (HB) 5. neonates have delayed what? (GE) 6. neonates have GERD because of incompetent what sphincter? (LE)
1. 2nd 2. 29-32 weeks 3. 24 hours 4. harmful bacteria 5. gastric emptying 6. lower esophageal sphincter
57
Necrotizing Enterocolitis (NEC) 1. what % of preemies get this? 2. Risk factors that put preemies at risk: increased time for what growth, decreased bactericidal what 2 secretions, and immature GI what? (B; G,P; D) 3. can early feeding help?
1. 10% 2. bacterial, gastric and pancreatic, defenses 3. yes
58
Hepatic Function 1. is immature hepatic metabolism seen in neonates and particularly in premature infants? 2. Slow drug metabolism because of immature whats, reduction of hepatic what, and low hepatic what? (E, P, P) 3. should careful titration be used? 4. should drugs not metabolized by the liver be used?
1. yes 2. enzymes, proteins, perfusion 3. yes 4. yes
59
premature infant hepatic function: 1. decreased synthesis of what leads to an increased or decreased unbound form of drug? (A) 2. Increased or decreased concentration of unbound bilirubin putting preemies at risk for what? (K) 3. can highly protein bound drugs displace bilirubin and increase the risk of the above disease? 4. can spontaneous liver hemorrhage occur because of its immaturity?
1. albumin, increased 2. increased, kernicterus 3. yes 4. yes
60
Hematologic Function 1. Full term neonates have average Hb of what g/dl? 2. physiologic anemia of the newborn at 8-12 weeks where what Hb falls and what levels rise? (F, E) 3. premature infants have decreased Hb depending on what age? 4. full term infants Hb at 8-12 weeks is what g/dl 5. premature infants Hb at 8-12 weeks is what g/dl? 6. fetal Hb is produced during what 2 trimesters? 7. The leftward shift of the oxygen-Hb dissociation curve resulting from the decreased affinity of Hgb-F for what, which is also more pronounced in the premature infant, further contributing to the anemia? (D)
1. 16.8 g/dl 2. fetal, erythropoietin 3. gestational 4. 11 g/dl 5. 9.4 g/dl 6. 2nd and 3rd 7. 2,3 diphosphoglycerate
61
Hematologic Function 1. Thrombocytopenia (plt <150,000/mm3) occurs in as many as what % of micropreemies? 2. Fragile what and decreased what coagulation factors increase preemies risk of bleeding? (C, VKD)
1. 70% | 2. capillaries, vitamin K dependent
62
Inhalational Anesthetics 1. which VA causes airway irritability and is not recommended for pts with BPD? 2. do all VAs cause decreases in BP? 3. Premature infants may be more susceptible to the what effects of inhalational anesthetics because inhalational anesthetics block the what channels, and the neonatal heart depends on the plasma ionized what electrolyte for contractility to a greater extent than do the hearts of older children? (C, C, C)
1. desflurane 2. yes 3. cardiodepressant, calcium, calcium
63
Reasons why N2O is not used: 1. usually given with what % of FiO2, which is not good for neonates who need O2 supplementation? 2. because of its blood gas solubility, it enters what cavities? (AF) 3. therefore it is not recommended for what 3 conditions? (NEC, BO, P) 4. N2O shows no antinociceptive effects in neonatal what? (R)
1. 30% 2. air-filled 3. necrotizing enterocolitis, bowel obstruction, pneumothorax 4. rates
64
Fentanyl: 1. produces what and what but not what 2 what? (A, S; U, A) 2. Large dose of fentanyl (30 mcg/kg) and roc used for what procedure because this combo it provides what? (PL; HS) 3. increased or decreased clearance in premature infants means elimination ½ life prolonged or shortened? 4. the above is because of an increased what, immature what enzyme and increased what pressure resulting in low flow to what organ? (VD, C, A, L) 5. post op apnea and slow recovery could require what for days? (MV)
1. analgesia, sedation; unconsciousness, amnesia 2. PDA ligation, hemodynamic stability 3. decreased, prolonged 4. volume of distribution, CPY450 3A4, abdominal, liver 5. mechanical ventilation
65
Morphine: 1. Elimination ½ life markedly prolonged or shortened? 2. Prefer fentanyl in premature infants because it has more what? (HS)
1. prolonged | 2. hemodynamic stability
66
Remifentanil: 1. has it been used in micropreemies with good hemodynamic stability? 2. what minute range for elimination half life in adult and infants? 3. Careful of what and you need a continuous what for constant rate of administration? (D, C)
1. yes 2. 3-4 minutes 3. dilution, carrier
67
Ketamine: 1. provides what are the 3 advantages of ketamine and it has little depression of what function? (A, A, U; C) 2. Depresses what 2 reflexes, which predispose to neonates to what 3 things? (V, AR; O, A, GA) 3. is an ETT recommended for surgical procedures with ketamine? 4. do brief procedures with ketamine need an ETT?
1. analgesia, amnesia, unconsciousness; C/V 2. ventilatory, airway; obstruction, apnea, gastric aspiration 3. yes 4. no
68
Propofol 1. use with caution because what and low what output have been associated with boluses of 1-3 mg/kg IV. (H, CO) 2. The mechanism underlying these responses remains unclear, although systemic what and acute pulmonary what with reversion to persistent what circulation remains a strong possibility. (V, H, F) 3. what range of propofol gtt with supplemental fentanyl can be used for micropreemies? 4. prolonged recovery d/t decreased what and decreased what 2 things to which to redistribute propofol to? (C, F, M) 5. in the PICU, propofol infusions have been implicated in unexpected deaths, called what syndrome? (PIS)
1. hypotension, cardiac output 2. vasodilation, hypertension, fetal 3. 50-200 mcg/kg/min 4. clearance, fat, muscle 5. propofol infusion syndrome
69
Midazolam: 1. can it be used as the sole anesthetic? 2. what other drug should it be combined with? 3. Micropreemies have markedly increased or decreased clearance, even more with what dysfunction (L) 4. Can cause what in premature infants? (H)
1. no 2. fentanyl 3. increased, liver 4. hypotension
70
Regional Anesthetics: 1. avoids what 2 things seen with IV or gas? (S, A) 2. is there enough data to say it is superior to IV or gas? 3. because infants have a lower lying conus medullaris, what 2 interspaces should an LP be done? 4. Larger or smaller doses of local anesthetics per kg are required? 5. Longer or shorter duration of LA?
1. sedation, apnea 2. no 3. L4-L5, L5-S1 4. larger 5. shorter
71
Neonates and Local anesthetics: 1. Larger or smaller volume of distribution of CSF? 2. Larger or smaller surface area of spinal cord and roots? 3. Increased or decreased cardiac output to spinal cord? 4. what 3 things are faster in neonates making duration? (DD, DU, EFC)
1. larger 2. larger 3. increased 4. drug distribution, drug uptake, elimination from CSF
72
does slightly less than 1 hour of sevo alter neurodevelopmental outcomes at age 2 years compared with awake regional anesthesia?
no
73
PDA Ligation: 1. is indomethacin less likely to close PDA in micropremie? 2. PDA can cause a left to right shunt resulting in severe pulmonary what and what 2 types of failure? (O, C, R) 3. In the setting of persistent pulmonary HTN the PDA will shunt where to where and can cause what? (C) 4. Performed via a left or right thoracotomy with manual lung retraction? 5. what 2 arteries lie in proximity to the PDA making PRBCs a necessity?
1. yes 2. overcirculation, congestive heart failure, respiratory failure 3. right to left, cyanosis 4. left 5. aorta, pulmonary artery
74
PDA ligation: 1. need for higher FiO2 d/t what? (LP) 2. are they often on the vent and requiring higher settings? 3. usually dry because of aggressive diuresis for pulm congestion, so a fluid bolus of what mL/kg can be given prior to induction? 4. fentanyl what range of mcg/kg and what other med type? 5. Post-op if hypotensive give what as first line and then consider an infusion of what med? (F, D) 6. BP cuff on what arm? 7. pulse ox on what arm and where else? 8. what is also being continuously monitored?
1. lateral position 2. yes 3. 10 mL/kg 4. 5-7 mcg/kg, NDMR 5. fluids, dopamine 6. right arm 7. right arm, lower extremity 8. ETCO2
75
PDA ligation: 1. avoid increases in what blood flow? (P) 2. what are 3 complications? (B, P, RNL) 3. Loss of lower extremity pulse ox indicates ligation of what artery? 4. Loss of both extremity pulse ox and EtCo2 decrease indicates ligation of what artery? 5. after successful ligation, what is gone and what increase? (M, D)
1. pulmonary 2. bleeding, pneumo, RLN nerve ligation 3. aorta 4. pulmonary artery 5. murmur, diastolic BP
76
Inguinal Hernia Repair 1. Surgical emergency if what? (I) 2. treat these like full what? (S) 3. non-incarcerated, what 2 techniques can be used? (G, R) 4. for general, maintain peak pressure less than how many cmH2O? 5. for pain management with general, what LA is used and what oral med is given? (R, A) 6. what caffeine mg/kg can be given to prevent post-op apnea?
1. incarcerated 2. stomach 3. general, regional 4. < 20 cmH2O 5. 0.2% ropivacaine with epi; acetaminophen 6. 10 mg/kg
77
Inguinal Hernia Repair 1. Regional only for patients with severe what? (B) 2. spinal with hyperbaric what LA or isobaric what LA 1-2 hours of surgical anesthesia (T, B) 3. what mg/kg for this spinal? 4. epidural is what % bupivacaine with epi and what mL/kg? 5. what gauge needle for caudals?
1. bronchopulmonary dysplasia 2. tetracaine, bupivacaine 3. 1 mg/kg 4. 0.375%, 0.75 mL/hr 5. 22 gauge
78
Eye surgery: 1. treat oculocardiac reflex with what mg/kg of atropine and asking the surgeon to stop what? (R) 2. use what ETT if intubating?
1. 0.01 mg/kg; retracting | 2. oral RAE
79
MRI: 1. < how many week post conception try swaddle and sweet - ez 2. for what week range do you give oral chloral hydrate? 3. what mg/kg of oral chloral hydrate what range of min prior to procedure which should give how many hours of sedation?
1. < 30 weeks 2. 30-70 weeks 3. 75 mg/kg, 30-60 min, 2 hours
80
Tracheoesophageal fistula/esophageal atresia (TEF/EA) 1. presentation includes excess oral what, regurgitation of what and resp distress made worse with what? (S, F, F) 2. recurrent PNA with what type? 3. which type is most common? 4. what % of cases is this type? 5. diagnosed with inability to pass a ridged OGT into where as well as radiographic studies? (S)
1. secretions, feedings, feedings 2. type H 3. type C 4. 80% 5. stomach
81
Esophageal Atresia and Tracheoesophageal Fistula Associated Abnormalities: what are the 6 abnormalities? (VA, IA, CHD, TF, RA, LA)
1. Vertebral anomalies 2. Imperforate Anus 3. congenital heart disease 4. Tracheoesophageal fistula 5. Renal abnormalities 6. Limb abnormalities
82
Tracheoesophageal fistula (TEF) surgical repair: 1. what is performed immediately before surgical repair to confirm fistula position and to occlude fistula with Fogarty balloon? (B) 2. positioning is LLD through a right sided what? (T)
1. bronchoscopy | 2. thoracotomy
83
Esophageal Atresia (EA) surgical repair: 1. definition: upper esophagus ends and does not connect with what and what? (LE, S) 2. Immediate primary repair = single layer end to end what? (PA) 3. if there is a substantial gap between esophageal pouches, a G tube is placed and we wait for grown of what pouch? (UEP)
1. lower esophagus, stomach 2. primary anastomosis 3. upper esophageal pouch
84
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) Induction: 1. pt at increased risk of what? (A) 2. suction out what pouch? (PEP) 3. Inhalation induction +/- muscle relaxation with what type of PPV? (G) 4. PPV should be < what cmH2O range? 5. Rigid bronch performed with ventilating bronchoscope and ETT inserted under visualization to ensure tip of ETT is placed above the what but distal to the what? (C, F) 6. If bronch not performed, intentional place ETT where and slowly withdrawal until breath sounds are heard on which side?
1. aspiration 2. proximal esophageal pouch 3. gentle PPV 4. 10-15 cm H2O 5. carina, fistula 6. right mainstem, left side
85
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) maintenance: 1. what technique using inhaled agents and opioids? (B) 2. avoid what gas? 3. avoid what 2 gas states? (H, H) 4. this gas states can be caused by what 4 things? (LR, KE, SOE, ME) 5. Blood loss is usually minimal, but maintain hct > what?
1. balanced 2. N2O 3. hypoxia, hypercarbia 4. lung retraction, kinked ETT, secretions occluding ETT, malpositioned ETT 5. > 35%
86
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) emergence: 1. are these pts intubated post-op? 2. avoid excessive neck extension or flexion?
1. yes | 2. flexion
87
Congenital Diaphragmatic Hernia (CDH) 1. Anatomic defect in the diaphragm that permits the intrusion of what contents into the thoracic cavity (A) 2. Diaphragm completes formation in what range of weeks of gestation? 3. a prenatal 20 week diagnosis can be made using what scan? 4. This scan can detect can detect an intrathoracic gastric what, mediastinal what away from the herniation site, and what other thing? (B, S, P) 5. what hernia type is most likely to have concurrent defects? (B)
1. abdominal 2. 7-10 weeks 3. ultrasound 4. bubble, shift, polyhydramnios 5. bochdalek
88
Congenital Diaphragmatic Hernia (CDH) incidence percent of these: 1. Posterior Bochdalek-type hernia 2. Anterior Morgagni-type hernia 3. Bilateral 4. bilateral is often what? (F)
1. 90% 2. 9% 3. < 1% 4. fatal
89
Bochdalek type hernias as more likely to have concurrent defects: 1. what % range have heart defects? 2. what % range have chromosomal anomalies? 3. what 2 systems have malformations?
1. 20-40% 2. 5-15% 3. GI/GU
90
Congenital Diaphragmatic Hernia (CDH) Presentation: 1. severe resp distress with a what to what shunt? 2. decreased pulmonary blood flow resulting in life threatening what, lung what and inadequate what exchange? (H, H, PG) 3. concave or convex abd? 4. what type shaped thorax? (B) 5. abd contents in chest on what scan? 6. what other 3 signs? (T, T, C)
1. right to left 2. hypoxemia, lung hypoplasia, pulmonary gas exchange 3. concave 4. barrel shaped 5. x-ray 6. tachycardia, tachypnea, cyanosis
91
Congenital Diaphragmatic Hernia (CDH) Initial Management: 1. improve what 2 things? (O, V) 2. avoid what ventilation to avoid gastric what? 3. ventilation strategy that allows for low what and limits what pressures to decrease barotrauma 4. before intubation, place what to decompress stomach?
1. oxygenation, ventilation 2. mask, insufflation 3. tidal volumes, peak 4. NGT
92
Congenital Diaphragmatic Hernia (CDH) Initial Management: 1. is it common to stabilize these pts in the ICU prior to OR? 2. decrease PVR using what inhaled med and what other thing? (N, S) 3. may ECMO be instituted?
1. yes 2. iNO, sedation 3. yes
93
Congenital Diaphragmatic Hernia (CDH): 1. what type of precautions for intubation? (FS) 2. should you aspirate stomach contents prior to induction? 3. should N2O be avoided? 4. Combined technique with hi or low dose inhaled agent and high or low dose opioid? 5. do these pts remain intubated and sedated and transported to NICU?
1. full stomach 2. yes 3. yes 4. low dose inhaled, high dose opioid 5. yes
94
GI pathology: 1. GI emergencies consist of what lesions, compromised intestinal what supply or both? (O, B) 2. Infants with obstructive lesions should be considered to have a full what which increases the risk of aspiration? (S) 3. During induction RSI should follow suctioning of what contents? (G) 4. what gas should be avoided to minimize intestinal distention? 5. Desaturation after a brief period of apnea during an RSI occurs more rapidly in neonates than in older infants, which is why emphasizing the importance of what and the rapid establishment of a what? (P, A) 6. Unless life-threatening compromise of organ blood flow occurs, these lesions do not require immediate surgical correction, and the priority is to correct any what derangements and establish what before surgery? (M, E)
1. obstructive lesions, blood supply 2. stomach 3. gastric 4. N2O 5. preoxygenation, airway 6. metabolic, euvolemia
95
Hypertrophic Pyloric Stenosis: 1. presents what week range of life? 2. what is being vomited and how? (NBV, P) 3. one in how many hundred? 4. male or female more frequent? 5. diagnosis by what scan? 6. what shaped mass palpated between midline and right or left upper quadrant of abdomen? (O)
1. 2-6 weeks 2. non-bilious vomiting 3. 1:500 4. male 5. ultrasound 6. olive, right
96
Hypertrophic Pyloric Stenosis: 1. is it a surgical emergency? 2. ensure UO is what range per mL/kg/hr? 3. ensure K is > what? 4. ensure Na is > what? 5. ensure Cl is > what? 6. she said never take a pt to OR with Cl < what? 7. dehydration and vomiting leads to contraction acidosis or alkalosis? 8. hypokalemia secondary to metabolic what and losses from what organ? 9. hypovolemia may progress to what shock and cause hemoconcentration or hemodilution?
1. no 2. 1-2 mL/kg/hr 3. 3.0 4. 130 5. 85 6. 100 7. alkalosis 8. alkalosis, kidney 9. hypovolemic, hemoconcentration
97
Hypertrophic Pyloric Stenosis Surgical Repair: 1. what is operating time range in minutes? 2. can it be done via minimal laparotomy or laparoscopically? 3. Induction steps: pre-oxygenate, suction what 3 ways with a large bore OGT?, pre-oxygenate again and then what induction technique? 4. baby will be mad with suctioning and do what quickly, so be ready with what med? (D, A)
1. 30-60 minutes 2. yes 3. left, right, supine; RSI 4. desaturate, atropine
98
Hypertrophic Pyloric Stenosis maintenance: 1. what 2 drug types? (IA, N) 2. minimal to no what type of drug? 3. consider rectal what med? (T)
1. inhaled agents, NDMR 2. opioids 3. tylenol
99
Hypertrophic Pyloric Stenosis emergence: 1. extubate when full what? (A) 2. postop what monitoring should be done? (A)
1. awake | 2. apnea
100
Necrotizing Enterocolitis (NEC) 1. Surgical emergency if what? (P) 2. Incidence is what % range in infants <1500g with mortality of what % range? 3. Pathogenesis is no completely understood, but intestinal what, inflammation of bowel what, alterations in normal intestinal flora secondary to what, gastric what and what type of CO states are key factors? (I, M, A, A, LCOS) 4. what are 4 early signs? (FI, IWOB, L, TI) 5. what are 6 later signs? (H, AD, A, T, C, MOF) 6. what are 3 radiographic findings of this? (PI, AiBT, FAiA)
1. perforated 2. 5-15%, 10-30% 3. ischemia, mucosa, antibiotics, alkalinity, low CO states 4. feeding intolerance, increased WOB, lethargy, temperature instability 5. hypotension, abdominal distention, apnea, thrombocytopenia, coagulopathy, multisystem organ failure 6. pneumatosis intestinalis, air in biliary tract, free air in abdomen
101
what is pneumatosis intestinalis?
air in the intestinal wall
102
Necrotizing Enterocolitis (NEC) surgery indications: 1. presence of what? (P) 2. Continued clinical what despite medical management? (D)
1. perforation | 2. deterioration
103
Necrotizing Enterocolitis (NEC) preop: 1. prepare for what 6 states? (H, CF, RF, CLS, D, H) 2. should you have an NGT and foley? 3. should you have 2 IVs and an art line? 4. should you weigh the need for central access for vasopressor infusions and time to acquire it?
1. hypovolemia, c/v failure, resp failure, capillary leak syndrome, DIC, hypoglycemia 2. yes 3. yes 4. yes
104
Necrotizing Enterocolitis (NEC) intra-op: 1. Maintenance at what ml/kg/hr + third space loss at what ml/kg/hr + replacement of what loss? (B) 2. Replace blood loss with PRBCs and FFP to maintain hgb > what mg/dl and PT/PTT within normal range 3. Administer platelets to keep platelets > what /mm? 4. what maintenance anesthetic technique is the first line as these infants are usually volume depleted and do not tolerate anesthetic meds well? (VA) 5. If hypotension occurs, what range of mL/kg of fluid should be given? 6. after that consider a gtt of what med, giving what electrolyte and stress dose of what? (D, C, G) 7. should blood products be available in the OR?
1. 4 ml/kg/hr, 10 ml/kg/hr, blood loss 2. > 10 mg/dl 3. 100,000 4. Opioid/muscle relaxant technique 5. 10-20 mL/kg 6. dopamine gtt, calcium, and stress dose glucocorticoids 7. yes
105
``` Necrotizing Enterocolitis (NEC) post-op: ventilated to NICU with sedation of fentanyl gtt of what mcg/kg/hr range? ```
1-3 mcg/kg/hr
106
Omphalocele and Gastroschisis are defects in the abd wall that result in impaired what to the herniated intestines and organs? (BS)
blood supply
107
Omphalocele: 1. incidence: one in how many thousands of live births? 2. etiology: failure of gut migration into where? (A) 3. is a sac present or absent? 4. herniated viscera: bowel and liver or just bowel? 5. location: periumbilical or within the umbilical cord? 6. common (50%) or uncommon (<10%)? 7. what are 3 associated anomalies? (BWS, CHD, BE) 8. prognostic factors include associated anomalies including what 2 areas? (C, A) 9. is it an urgent surgery?
1. 1:6,000 2. abdomen 3. present 4. bowel and liver 5. within the umbilical cord 6. common 50% 7. beckwith-wiedemann syndrome, congenital heart disease, bladder exstrophy 8. cardiac, airway 9. no
108
Gastroschisis: 1. incidence: one in how many thousands of live births? 2. etiology: occlusion of what artery? (O) 3. is a sac present or absent? 4. herniated viscera: bowel and liver or just bowel? 5. location: periumbilical or within the umbilical cord? 6. common (50%) or uncommon (<10%)? 7. associated anomalies include what 4 conditions of the exposed gut? (I, E, D, F) 8. prognostic factors include condition of the what? (B) 9. is it an urgent surgery?
1. 1: 15,000 2. omphalomesenteric artery 3. absent 4. bowel only 5. periumbilical 6. uncommon < 10% 7. inflammation, edema, dilation, foreshortened 8. bowel 9. yes
109
Anesthetic Management of Gastroschisis and Omphalocele include: 1. Volume what? (R) 2. preventing what? (H) 3. empty content from where? (S) 4. what 2 types of intubation? 5. muscle relaxation to facilitate reduction of what? (B) 6. After closure marked increase or decrease in abdominal pressure? 7. decreased what 2 things after abdominal closure? (OP, VR) 8. may abdominal closure decrease organ perfusion and alter drug metabolism? 9. Venous return from the lower body may be reduced resulting in lower extremity what and what? (C, C) 10. cyanosis may result in a re-opening of what? (SS) 11. decrease UO may result from renal what? (C) 12. If complete reduction is not possible, a staged reduction is carried out using what pouch? (S)
1. resuscitation 2. hypothermia 3. stomach 4. RSI vs awake intubation 5. bowel 6. increase 7. organ perfusion, ventilatory reserve 8. yes 9. congestion, cyanosis 10. surgical site 11. congestion 12. Silon pouch
110
no narcotics in pyloric stenosis pts because what is metabolically deranged? (C)
CSF

Peds (9 decks)

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