Prodigy- Peds Flashcards
Whos got the longer epiglottis, kids or adults
kids
pediatric airway differences compared to the adult
-trachea (longer/shorter)
-epiglottis (longer/shorter)
-tongue relatively (larger/smaller)
-larynx more (cephalad/caudad)
-narrowest part?
shorter trachea
longer epiglottis
tongue larger
larynx more cephalad
narrowest part = cricoid ring (fixed) [dynamic = vocal cords] [vocal cords is narrowest in adult]
Level of the larynex in the infant vs adult
infant C3-C4
adult C4-C6
premie
T/F: the most common significant airway problem in the pediatric patients is airway obstruction due to laryngomalacia
True
softening of the laryngeal tissues
- upper airway tends to collapse during inspriation
- *PPV
- this typically resolves on its own as the kid grows up
Young child alveolar ventilation to FRC ratio
what is in in older children/adults
cause?
significance?
5:1
1.5:1
higher o2 consumption
results in faster deoxygenation
What is cardiac output most depdenent on in pediatric patients and why?
HR bc they have a decreased ability to increase their stroke volume
what is hypotension ina child with a normal heart rate usually indiciated of?
how should it be treated?
hypovolemia
fluids
PR interval in infants
0.10
Failure of the V1-V4 T waves to invert by week one of age can indicate what?
RV hypertrophy
- the RV is predominate in intrauterine development resulting in a right axis at birth.
6 variables that contribute to the rate of FA/FI rise (wash-in)
- inspired concentration of gas (%)
- alveolar ventilation
- FRC
- CO
- Solubility of the gas
- alveolar to venous partial pressure gradient of the anesthetic
washin is quicker in infants due to higher alveolar ventilation to frc watio (5:1) + greater distibution of CO to VRG
If an increased in CO in adults slows the rate of rise of FA/FI, why does an increase in cardiac output speed the rate of FA/FI in infants?
induction dose in infants compared to children
likely related to differences in blood distribution
-VRG comprises a greater proportion of body mass (18% compared to only 8% in adults) - so more blood from CO goes to VRG
infants 2.5-3mg/kg
kids 2-2.5mg/kg
Most common IV induction agent in pediatrics
propofol
Sux IV doses in:
neonates, infants, teens
IM dose - onset/doa
neonates = 3-4mg/kg
infants = 2mg/kg
teens = 1mg/kg
IM 4mg/kg onset 1-2 mins, doa 20 mins
Do neonates exhibit increased or decreased sensitivity to NDMRs?
why or why not
do you need more or less?
increased sensitivity to NDMRs
- the immature NMJ remains open longer, allowing more sodium into cell
however, you dont need more because neonates and infants have a larger relative ECF volume , increasing the colume of distribution for NMBs which are highly ionized and water soluable
T/F- the most widely used perioperative opioids in kids is fentanyl
is it water/lipid soluble and what does it bind to?
true
highly lipid solubalbe and
primarily bound to alpha-1 acid glycoprotein
dose of intranasal fentanyl
1-2mcg/kg
T/f- midazolam is water soluble prior to injection
true!
once its exposed to physiologic pH the imadazoel ring closes and it becomes lipid soluble
oral dose of midazolam in pediatric population
intranasal and intramsucular doses of midaz
IV dose and possible side effect
0.25-0.75mg/kg **(0.5mg/kg) **
0.1-0.2mg/kg
0.05-0.15 ( 0.1mg/kg) - can produce myoclonus that may look like siezure activity
oral dose of precedex in kids & it’s onset
nasal dose - onset
IV infusion
2-4mcg/kg - 30-60 mins
1-2mcg/kg - 60 mins
1mcg/kg over 10 mins followed by infusion of 0.3-0.7mcg/kg/hr
T/F- if bradycardia occurs from precedex, it should be treated with glycopyrrolate
FALSE
*can result in significant hypertension!
How long does acetaminophen provide analgesia for?
PO dose and onset; rectal dose and onset
IV dose and frequency
about 4 hours
PO 10-15mg/kg 10-15mins; Rectal 30-40mg/kg 1-2hrs
15mg/kg q6 hours
Simplify:
15mg/kg PO & IV; double for rectal 30mg/kg
Onset:
10-20mins PO
1-2hrs rectal
max dose of acetaminophen should not exceed what in a 24hr period
100mg/kg
In the US, etomidate is only approved for use in children older than what age?
10yo
can result in a drenal suppression for up to 24 hrs following short infusions and single doses
What IV induction agent is associated with nightmares
Ketamine
What is the only induction agent that can be used for IM injection
why wouldnt you want to give it to everyone? (3)
Ketamine
slower onset, painful, and potential for abcess formation
T/F- if achild has had a hospitalization for asthma, than their degree of asthema should be considered severe
True
T/F- even if they are not exhibiting any symptoms, children with a history of mild to moderate asthema should be administered a bronchodilator preoperatively
True
what do you need to ask if a kid has a history of asthma (4)
- what age did it start
- have they ever been hospitalized - when
- current treatment regiment
- current state of symptom control
Muscular dystrophy is a (dominant/recessive) trait that appears between what ages
symptoms
sex-linked recessive trait in males
2-5yo
painless, progressive muscle degeneration
In all muscular dystrophy there is a symmetric/assymetiric atrophy of skeletmal muscle, however, there is no denervation of skeletal tissue - what does this mean?
symmetric atrophy of skeletal muscle tissue
-intanct innervation to the msucle tissue means sensation and reflexes will be intact
kids with myopathies often exhibit proximal or distal limb weakness
proximal
+ptosis, facial weakness, resp muscle weakness, cardiomypathy (central to peripheral it seems)
most common inhertied muscular dystrophy
problem with depolarizers or non?
myotonic dystrophy
both but sensitivity to sux
-think nerves are intact, but muscle tissue atrophies so the post synaptic receptors are going to proliferate
What is Duchenne’s muscular dystrophy?
Onset?
What leads to EKG changes and what are they? (3- ones a rhythm and two very specific changes in certain leads)
An X-linked recessive disorder resulting from a near complete absences of dystrophin
onset 2-yo
degeneration of mycoardial cells (short PR, tall R waves in V1, deep Q waves in limb leads, and sinus tach)
Duchennes EKG changes (4)
Short PR
Tall R in V1
Deep Q in Limb leads
Sinus tach
*absence of dystrophyin
What is Becker muscular dystrophy?
a milder form of duschenes wit han onset that is usually when they are older than 10 (second decade of life)
reduced levels of dystrophin
What is Emery-Dreifuss syndrome and what is the primary concern
what do you need pre-op?
a milder form of muscular dystrophy
-primary concern = cardiac conduction defects resulting in syncope
preop echo and ekg
Is the incidence of OSA in kids greater in boys or girls?
equal incidence between both
gold standard for diagnosising OSA
polysomnography
what should you be thinking if you have a kid with OSA
to use alternative pain mangemenet stratgeis like NSAIDS, local, regional, ketamine, and alpha-2 agonists
*opioids may compound issue
What is postconceptual age
gestational age + postnatal age
what should be considered for any infant born between 37 weeks or less than 60 weeks post conceptual age for any surgical procedure
avoid opioids and give IV caffine 10mg/kg to reduce risk of apnea
the most common surgical procedure in former premature infants is what
what kind of anesthetic should you use
hernia repair
spinal or caudal
What % of severely obese pediatric patients will exhibit insulin resistance and metabolic syndrome?
50%
(20% GERD, and nonalcoholic fatty liver disease)
how should the bed be psotioned during preoxygenation and airway mangement of the obese pediatric patient
hob raised at least 25 degrees so the tragus is above the level of the sternum
pedaitric drug dosing:
drugs for TBW (5)
IBW (2)
LBW (2)
TBW: AF SSS Alfent, Fent, Sufent, sux, suga
IBW: morphine and NDMRS
LBW: prop and remi
IBW for kids less than 8= 2x age + 9
IBW for kids older than 8 = 3 x age
LBW = IBW + 1/3 (TBW- IBW)
ridiculous- adult LBW is IBW x 1.3 - think im sticking with that one
until you’ve reached a threshold at which you will adminsiter blood products, the traditional protocol is to administer how much of a balanced salt solution IV for each 1ml of blood loss
3cc
so 10cc blood loss =30 cc volume
MABL =
EBV x (hct - minimum Hct/hct)
third space loses for:
minor surgery
moderate surgery
major surgery
minor = 1-2ml/kg/hr
moderate = 2-5ml/kg/hr
major = 6-10ml/kg/hr
maintenance fluid requirement for a ptient who weighs 5kg
5 x 4 = 20ml/hr
4-2-1 rule
first 10 kg x 4mls/hr
10-20kg = 40 + 2ml/kg for every kg over 10
>20kg = 60ml + 1ml/kg for every kg > 20kg
maintenance fluid requirment for kid who weighs 15kg
10 x 4 = 40ml/hr +
5 x 2= 10ml/hr
=
50ml/hr
4-2-1 rule
first 10 kg x 4mls/hr
10-20kg = 40 + 2ml/kg for every kg over 10
>20kg = 60ml + 1ml/kg for every kg > 20kg
adding 40mls to weight in kg works for kids weighing over what?
20kg
Performing a deep extubation in kids generally requires an anesthetic level of what?
1.5-2x MAC
Highest incidence of respiratory complications postop is most common in kids under what age?
1yo
incidence of vomitting is most likely to occur in kids over what age?
> 8yo
first step in treating layngospasm
removing the offending cause - suction airway
then jaw thrust/postive pressure with 100% o2
difference between inspiratory stridor and expiratory stridor (causes)
inspiratory stridor results from upper airway obstruction
expiratory stridor results in lower airway obstruction
most common caues of desaturation in pacu in an otherwise healthy kid are what 2 things
airway obstruction and hypoventilation
t/f emergence delirium is more common with sevo in the pediatric population
true followed by des than iso
how long does postop delerium usually last
what can you give if inclined to not just let them ride it out
10-15 mins
propofol, midaz, ketamine, opioids, dexmedetomidine
highest incidence of NV (age range/sex)
dosing of decadron/zofran
females between 10-16yo
decadron 0.1mg/kg , zofran 0.05mg/kg - can reduce incidience as much as 80%
NMBs are not routinely used in kids except for in what 2 instances
laproscopic surgery or RSI
Compared to the adult, the neonatal
A. cardiac output is much less relative to body weight
B. myocardium is more sensitive to norepinephrine
C. myocardium is more sensitive to dopamine
D. baseline heart rate is lower
B
What is an appropriate rectal dose of acetaminophen for a pediatric patient for postoperative analgesia?
A. 1-2 mg/kg
B. 100 mg/kg
C. 20-30 mg/kg
D. 10-15 mg/kg
C
the age of:
A. 11-15 years
B. 25-30 years
C. 16-20 years
D. 5-10 years
not D…maybe A
Which of the following would be an acceptable intravenous induction dose of ketamine in a healthy 35 kg pediatric patient?
A. 25 mg
B. 75 mg
C. 125 mg
D. 175 mg
B
(2mg/kg)
In 2013, the FDA issued a black box warning against the use of codeine for postoperative pain for children undergoing _____.
A. inguinal hernia repair
B. tonsillectomy and adenoidectomy
C. strabismus surgery
D. laparoscopic surgery
B
Which of the following routes of administration of midazolam would be least recommended for a five year-old patient?
A. Rectal
B. Oral
C. Intramuscular
D. Intranasal
Not A, maybe C
Ideally, anesthesia should not be performed on children for _____ week(s) following an upper respiratory tract infection (URTI).
A. two
B. eight
C. four
D. one
Not A, maybe C
Meperidine is only recommended for the treatment of
A. shivering
B. increased intracranial pressure
C. seizures
D. postoperative pain in pediatrics
A
Which abnormality is associated with micrognathia and downward displacement of the tongue?
A. Down syndrome
B. Crouzon disease
C. Pierre-Robin syndrome
D. Apert syndrome
C
Administration of a large dose of which of the following drugs would be most likely to produce seizures in a pediatric patient?
A. Propofol
B. Flumazenil
C. Succinylcholine
D. Thiopental
B
In former premature infants, the incidence of apnea increases with decreased postconceptual age and
A. hyperkalemia
B. anemia
C. hypocalcemia
D. thrombocytosis
B
Caudal anesthesia would be a useful anesthetic adjunct in all of the following pediatric surgeries except:
A. Omphalocele repair
B. Clubfoot repair
C. Inguinal herniorrhaphy
D. Circumcision
A
Approximately how long will a dose of intravenous acetaminophen provide analgesia?
A. 2 hours
B. 8 hours
C. 4 hours
D. 30 minutes
C
Infants who were born before 37 weeks gestation and are less than 60 weeks postconceptual age require postanesthesia respiratory monitoring for apnea following
A. tonsillectomy and adenoidectomy
B. intracranial surgery
C. abdominal surgery
D. all surgical procedures
D
You are applying EMLA cream to a pediatric patient prior to placement of an intravenous line. What layer of skin is the primary determining factor in the speed of onset?
A. stratume lucidum
B. stratum cirrus
C. stratum basale
D. stratum corneum
D
What is the primary anesthetic concern for patients with Emery-Dreifuss syndrome?
A. dry eyes and corneal abrasion
B. aspiration
C. renal failure
D. cardiac conduction defects
D
Essential supplies that should be available when transporting a pediatric patient to recovery following a deep extubation include
A. fentanyl and midazolam
B. a laryngoscope and 7.0 ETT
C. a supraglottic airway and a defibrillator
D. oxygen and a self-inflating manual resuscitator
D
What is the ideal body weight in kilograms for a ten year-old child?
A. 20
B. 30
C. 45
D. 60
B
Which of the following is NOT associated with Duchenne muscular dystrophy?
A. Loss of reflexes
B. Symmetric skeletal muscle wasting
C. Mitral regurgitation
D. Recurrent pneumonia
A
The potency of rocuronium is inversely related to
A. alpha-1 acid glycoprotein levels
B. hemoglobin level
C. age
D. intracranial pressure
C
What is the most common significant airway problem in pediatric anesthesia?
A. bilateral recurrent laryngeal nerve palsy
B. tracheoesophageal fistula
C. subglottic stenosis
D. laryngomalacia
D
softening of the laryngeal muscles - makes them collapse during inspiration
After extubating a pediatric patient, the oxygen saturation begins dropping, you are unable to ventilate by mask, and there is no end-tidal CO2 waveform. You should first
A. perform compressions
B. turn on sevoflurane
C. apply positive airway pressure
D. turn on nitrous oxide
C
