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Principles II Flashcards

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1
Q

Location of Glottis in neonates vs. adults

A

C3-C4

(adults have a lower glottis at C4-C5)

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2
Q

Describe the differences in Respiratory Systems of neonates

A
  • poor respiratory control
    • sensitive to respiratory depressant effects of opioids and inhalational agents
  • high risk of post-anesthetic apnea
    • 52-60 weeks post conceptual age
  • 2-3x O2 consumption
  • depressed CO2 response curve
  • decreased energy reserves
  • equivalent tidal volumes, but faster breathing
  • prone to atelectasis
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3
Q

Describe the differences in Cardiovascular System in Neonates

A
  • less compliant myocardium
  • HR dependent
  • immature SNS, so cardiac output can only increase by 30-40%
  • preload insensitive
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4
Q

Describe the differences in the Hepatic System of Neonates

A
  • functionally immature liver
    • reaches adult levels within 1st few months
  • longer half-life of drugs
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5
Q

Describe the differences in the Hematologic System of Neonates

A
  • HbF makes up 75% of total hemoglobin
  • Hemoglobin around 17 g/dL
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6
Q

How much blood loss can critically ill newborns take?

A

HCT > 35% or blood loss > 15%

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7
Q

Describe Heat Loss in Neonates

A
  • increased body surface to weight
  • non-shivering thermogenesis
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8
Q

Consequences of Hypothermia in Neonates

A
  • hyperviscosity
  • increased O2 consumption
  • lactic acidosis
  • depression of respiration, circulation, metabolism, and glucose levels
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9
Q

Ideally, how old should an infant be before surgery

A

greate than 60 weeks old if anemic and 50 weeks old if apenic

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10
Q

Size formula for Pediatric ETT

A

age/4 + 4

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11
Q

Pre-operative dose of Atropine prior to Sux

A

0.02 mg/kg

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12
Q

Dose of Succinylcholine in Pediatrics

A

2 mg/kg IV

or

4 mg/kg IM

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13
Q

Treatment for Post-Extubation Croup in Pediatrics

A

racemix Epi via nebulizer

(0.5 mL of 2% solution)

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14
Q

Treatment for Hypocalcemic Peds

A

1 - 2 mL/kg 10% calcium chloride

(or gluconate)

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15
Q

Treatment for Hypoglycemic Peds

A

250 - 500 mg/kg bolus of glucose (D25)

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16
Q

What may cause retinopathy of prematurity?

A

High O2 concentrations

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17
Q

Range of Hypoglcemia in Infants

A

< 30 mg/dL

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18
Q

Children with URI symptoms are at increased risk for ______ weeks after the onset of symptoms

  • laryngospasm, bronchospasm, desaturation
A

4 - 6 weeks

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19
Q

Pre-operative dose of Versed for Pediatrics

A

0.25 - 0.5 mg/kg

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20
Q

Normal Systolic Blood Pressure in Pediatrics

A
  • Newborn to 1 month
    • 60 mmHg
  • 1 month to 1 year
    • 70 mmHg
  • > 1 year
    • (age * 2) + 70mmHg
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21
Q

Typical/expected diastolic Blood pressure

(equation)

A

2/3 x SBP

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22
Q

Normal Pulse for Pediatrics

A
  • Newborn to 1 year
    • 140 bpm
  • 1 year to 4 years
    • 120 bpm
  • 4 years to 12 years
    • 100 bpm
  • > 12 years
    • 80 bpm
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23
Q

Normal Respiratory Rates for Pediatrics

A
  • Newborn to 1 year
    • 40
  • 1 to 4 years
    • 30
  • 4 to 12 years
    • 20
  • > 12 years
    • 15
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24
Q

Why does inhalational inductino occur faster in pediatric patients?

A

higher minute ventilation and small FRC

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25
Why do pediatric patients develop respiratory fatigue easily?
muscles of respiration poorly developed
26
Congenital Diaphragmatic Hernia (CDH)
hole in the diaphragm allows abdominal organs to move into the chest, which prevents the lungs from developing normally, resulting in pulmonary hypoplasia
27
What is the pulmonary problem in patients with CDH?
* compression of lungs leads to pulmonary hypoplasia * arterial hypoxemia occurs because of right-to-left shunt through ductus arteriosus * increased pulmonary vascular resistance
28
Which side does CDH usually occur?
Left | (75% of cases)
29
How is CDH usually diagnosed?
prior to birth by US chest X-ray shows loop of bowel in chest
30
How is an infant with CDH treated immediately after birth?
* decompression of stomach with OG/NG * supplemental oxygen * AVOID PEEP
31
Intubation in patient with CDH
awake intubation * do not let peak airway pressures exceed 25-40 cmH2O * too high of pressures will cause pneumothorax
32
What size ETT should be used for a full term baby?
3.0 - 3.5
33
Formula for ETT depth
age/2 + 12 or I.D. of ETT x 3
34
Which hand gives a pulse ox reading of **preductal** saturation?
right hand
35
Importance of avoiding hypothermia in CDH patients
hypothermia will increase PVR and increase right-to-left shunt, and increase O2 consumption and acidosis
36
What are the signs of a pneumothorax?
* decrease in lung compliance * deterioration of oxygenation and blood pressure
37
In CDH surgery, once the hernia is reduced, should attempts be made to inflate the hypoplastic lung?
No it is unlikely to expand and contralateral lung may be damaged by excessive positive pressure
38
Should glucose containing fluids be used to replace blood or for third–space losses?
No
39
Indications for CABG
* angina not controlled by medical treatment * unstable angina or episodes of myocardial ischemia * unacceptable angina, despite optimal therapy * prinzmetal angina with coronary artery obstruction * acute MI, intractable arrhytmias
40
How do you calculate left ventricular function?
* history of MI and angina * symptoms * dyspnea, nocturnal orthopnea, pitting edema * Cardiac catheterization, angiography, and ECHO
41
What are the (3) major determinants of myocardial O2 consumption?
* myocardial wall tension * contractility * heart rate
42
Determinants of Coronary Blood Flow
* aortic diastolic pressure * LVEDP * patency of coronary arteries * coronary vascular tone
43
Systemic Oxygen demand decreases \_\_\_\_% for every degree of temperature drop
9%
44
Normal Pulmonary Capillary Wedge Pressure
4 - 12 mmHg (more than 18 mmHg reflects heart failure)
45
Common complications of Swan-Ganz catheter
* infection * hematoma * air embolism * thrombosis * catheter shearing and embolization * arrhythmias * pulmonary infarction
46
Complications of Swan-Ganz catheter from Subclavian approach
* pneumothorax * hemothorax * hydrothorax
47
Diagnostic uses of TEE
* Monitoring left ventricular filling and ejection * Detection of hypokinesia, akinesia, and dyskinesia * Detection of air embolism * Detection of valvular regurgitation * Analysis of congenital cardiac lesions * Diagnosis of thoracic aorta pathology * Diagnosis of cardiac tumors * Detection of other cardiac lesions and cardiac tamponade
48
Cardiovascular effects of Volatile Agents
* depression of ventricular function * vasodilation * decreased CO and sympathetic tone
49
What should you do during sternal splitting?
stop ventilations and deflate lungs
50
Would you monitor pulmonary capillary wedge pressure continuously?
no may cause pulmonary infarction
51
What anticoagulant would you give before CPB?
**heparin** in doses of 300 U/kg * measure heparin activity with ACT
52
Heparin and ACT during CPB
* onset of ACT prolongation in radial artery occurs within 1 minute * obtain baseline prior to heparin * check ACT 3-5 minutes after heparin administration and then every 30-60 minutes * no less than 300sec during normothermia and 400sec during hypothermia
53
Cardioplegia
hypothermic and hyperkalemic solution * used to induce electromechanical dissociation * infused between clamp and aortic valve
54
What should you check if the patient will not wean from CPB?
* adequacy of repair * TEE * hemodynamic variables * institute pharmacologic therapy
55
Signs of Anaphylaxis
* hypoxemia * rash or hives * hypotension * tachycardia * broncospasm or wheezing * increased peak inspriatory pressure (PIP) * angioedema
56
Treatment for Anaphylaxis
* discontinue potential allergens and volatile agents * 100% O2 * IV fluid bolus and epinephrine * consider vasopressin * Treat symptoms with albuerol, Epi, H1 antagonist and H2 antagonist * consider intubation and IV access
57
Signs of Local Anesthetic Toxicity
* tinnitus or a metabolic taste * altered mental status * seizures * hypotension * bradycardia * ventricular arrhythmias * cardiovascular collapse
58
Treatment of Local Anesthetic Toxicity
* If pulseless, start CPR * stop local anesthetic and avoid vasopressin * call for intralipids * 1.5 mL/kg bolus of 20% intralipid IV
59
Signs of Myocardial Ischemia
* depression or elevation of ST segment * arrhythmias * regional wall motion abnormalities * chest pain in awake patient
60
Treatment for Myocardial Ischemia
* increase 100% O2 * treat hypotension (or hyper) * beta blocker
61
Where does an AAA usually occur
beween renal and mesenteric arteries
62
Normal intraocular pressure
10 - 20 mmHg
63
What type of drugs should you avoid in glaucoma patients?
anticholinergics
64
Phenylephrine in Ophthalmic surgery
dilates pupil
65
Epinephrine in Ophthalmic surgery
decreases aqueous secretions
66
Ecothiophate
long-acting topical anticholinesterase * needs to be off 2-3 weeks before surgery to allow plasma cholinesterase levels to return to normal
67
Acetazolamide in Ophthalmic surgery
diuretic used to lower IOP * can cause hypotension if given too quickly
68
Preoperative issues in patients undergoing Ophthalmic surgery
* claustrophobic * can they lie still on their backs * do they cough a lot?
69
Strabismus
"cross eyed" * imbalance of intraocular muscles * surgery has high incidence of nausea and vomiting * type of muscle disorder, so there may be a higher risk of MH
70
Pterygium
growth on surface of eye due to excess sun exposure
71
Ptosis
droopy eyelids
72
Orchiopexy
surgery to move an undescended testicle into the scrotum * may need general and regional * vagal response and nausea
73
Pectus Excavatum
congenital chest wall deformity that causes the chest to cave in * respiratory problems and cardiac compromise * restrictive lung disease
74
Mediastinal Mass Excision
* assess child's ability to breath * some may not be able to lay flat * CPB and rigid bronchoscopy available
75
Wilm's Tumor
Nephroblastoma * most common liver cancer of children
76
VP shunt
* increased ICP * high risk of latex allergy
77
Craniotomy
* children more likely to have infratentorial tumors * fine movement and balance * Risk of venous air embolism dur to beach chair position
78
Craniosynotosis
premature closure of a cranial suture * increases ICP * risk of blood loss and venous air embolism
79
NDMR in neonates
needs a higher dose inititally smaller redoses and less often
80
Total body of water in newborns
70-85%
81
Trends in body compartment volumes from neonate to adult
total body water - decrease intracellular fluid - same blood volume - decrease muscle mass - increase fat - increase
82
Why are neonates more susceptible to the cardiovascular effects of inhalational agents?
* hearts are more sensitive * rapid uptake and distribution * right-to-left shunt has a slower rate of rise in arterial contraction * MAC is lower in newborns than infants
83
Cardio differences in Neonates
less compliant, fixed stroke volume, HR dependent, decrease contractile mass, and decreased velocity
84
Atropine dose in neonates
0.03 - 0.05 mg/kg ## Footnote (compared to 0.01 in adults) **doses less than 0.1 mg may produce paradoxical bradycardia!**
85
Which narcotic will migrate more? Fentanyl or Morphine
Morphine it is more hydrophilic compared to Fentanyl which is lipophilic
86
Why is Pancuronium a good MR in children?
potent vagolytic can increase HR
87
Which type of local anesthetics are more preferable in neonates?
esters amides are metabolized in the liver, but their liver may not be well developed yet. Esters are metabolized by plasma esterases
88
Omphalocele
organs stick out through the belly button
89
organs stick out in a hole besides the belly button
gastroschisis
90
Pyloric Stenosis
narrowing of pyloris ## Footnote (stomach to duodenum) * presents 3-6 weeks of age * dehydrated and nutrient deprived * aspiration risk * Needs an OG/NG placed
91
TEF
Transesophageal Fistula
92
Transesophageal Fistula
blind esophageal pouch connecting it to the trachea
93
Meningomyelocele
"Spina Bifida" spinal canal and the backbone don't close before the baby is born, letting the spine and membranes protrude through the baby's back
94
PDA
Patent Ductus Arteriosus
95
Patent Ductus Arteriosus
large left-to-right shunt
96
Coronary Artery Disease
artherosclerosis of the blood vessels supplying the heart * leads to myocardial ischemia
97
Risk factors for CAD
* genetics * diet * environment * hypertension * smoking * diabetes
98
What part of the heart is most vulnerable to ischemia
left ventricular subendocardium
99
Drug of choice for coronary spasm
Nitroglycerin
100
Which venodilating drug decreases venous return and ventricular filling pressure?
Nitroglycerin
101
Which drug increases the MVO2 requirements due to increased coronary perfusion pressure?
Phenylephrine
102
Which CCB is good for SVT?
Verapamil
103
Normal Pulmonary Wedge Pressure
12
104
An ejection fraction \< ____ indcates myocardial dysfunction
0.4
105
"LAMPS" before CPB
* Laboratory * Anesthesia * Monitor * Patient * Support
106
(7) Components of CPB
* circuit * oxygenator * pump * heat exchanger * primer * anticoagulants * myocardial protection
107
In CPB, blood is drained from the ____ and returned to the \_\_\_\_
right atrium, ascending aorta
108
Two types of Oxygenators in CPB
bubble and membrane
109
3 types of CPB pumps
roller, centrifugal, and pulsatile
110
Hypothermia during CPB
10 - 15 oC
111
Systolic BP should be reduced to _____ before aortic cannulation to reduce risk of aortic dissection
80-100 mmHg
112
What is the most likely cause of neurologic injuryafter CPB
emboli with increased risk if hypotensive
113
Why should Versed be given before rewarming after CPB?
increased risk of awareness
114
Dose of Protamine on CPB?
1 mg/100 units heparin | (usually 3 mg/kg)
115
Risks of Protamine
hypotension and mast cell degraulation
116
Intra-Aortic Balloon Pump
deflates before systole to decrease afterload inflates during diastole to increase coronary blood flow
117
Manifestations of Cardiac Tamponade
* hypotension * equalization of diastolic filling pressures * fixed stroke volume * peripheral vasoconstriction * tachycardia * potential myocardial ischemia

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