Regional

Question 1

what anesthetic agents can cause neuroapoptosis?

Answer 1

• GABA_A agonists (propofol, benzos, volatile agents)
• NMDA antagonists (ketamine, N₂O

Question 2

what age kids are at risk of neuroapoptosis?

what increases the risk?

Answer 2

• kids < 3 yrs (occurs in utero during 3rd trimester too)
• increased risk with anesthesia time > 3 hrs and repeated exposure

Question 3

why is use of neuraxial and regional techniques growing?

Answer 3

to avoid GA

Question 4

T/F: regional techniques are safe and effective for intra-op and post-op analgesia in infants, children, but not in pre-term neonates

Answer 4

false - safe for infants, children, and neonates

Question 5

advantages for using regional/spinals in peds

Answer 5

• opioid related adverse effects avoided
• promotes spontaneous ventilation and earlier extubation
• reduces risk of post-op apnea and respiratory dysfunction in high-risk infants
• airway instrumentation can be avoided
• enhances hemodynamic stability

Question 6

advantage of continuous epidural analgesia in peds

Answer 6

• decreases time to extubation
• promotes return of bowel function
• decreases metabolic stress response
• may decrease postoperative sedation needs
• promotes shorter ICU length of stay

Question 7

little fact: when combined with GA, regionals decrease intra-op volatiles, opioids and neuromuscular blocking agents

(reduces risk of negative cognitive outcomes)

Answer 7

yay

Question 8

indications for spinals (5)

Answer 8

• lower abdominal procedures (urologic and hernias)
• lower extremity orthopedics
• omphalocele
• exploratory laparotomy
• myelomeningocele

Question 9

T/F: there are frequent complications with spinal use in peds, mainly being permanent neurologic injury or death

Answer 9

false

“Complications infrequent; no reports of permanent neurological injury or death in children”

Question 10

what can be added to a spinal to double the duration?

Answer 10

clonidine

Question 11

complex procedures often benefit from a spinal combined with what other technique?

Answer 11

caudal catheter

Question 12

agents commonly used for sedation with spinals?

Answer 12

precedex - infusion

fentanyl, midazolam - boluses

Question 13

difference in conus medullaris in peds vs adults?

when is it the same as adults?

Answer 13

conus medullaris more caudal in neonates and infants (L3)

reaches adult level at 1 y/o

Question 14

level of lumbar puncture in peds vs adults?

why?

Answer 14

at L4-L5 or L5-S1 to avoid spinal cord trauma

Question 15

what approach to a spinal is preferred in peds?

Answer 15

midline

Question 16

difference in sacrum in peds vs adults

Answer 16

• sacrum more narrow and flat
• access to subarachnoid space from caudal canal more direct (dural puncture more likely)

Question 17

differnce in ligamentum flavum in peds vs adults?

consideration?

Answer 17

less dense in peds

harder to feel loss of resistance

Question 18

duration of spinal in peds vs adults?

why the difference?

Answer 18

• peds have shorter block duration
• due to faster CSF turnover rate

Question 19

in a pediatric patient, how much space is between the skin and the subarachnoid space?

Answer 19

1.5 cm

Question 20

T/F: a spinal eliminates the incidence of post-op apnea in former premies

Answer 20

false - decreases but does not eliminate

Question 21

what agent when given in addition to a spinal causes more apnea than a GA?

Answer 21

ketamine

Question 22

what is deafferentation?

Answer 22

sedation due to decreased sensory input to RAS from periphery

(can be advantage or disadvantage of SAB)

Question 23

what specific pediatric population is the most common to use spinal techniques on?

Answer 23

infants

uncommon past infancy

Question 24

what age group is the most hemodynamically stable after a spinal or epidural anesthetic?

Answer 24

infants - more stable than older kids or adults

~and more responsive to hemodynamic meds vs those ppl too

Question 25

who has a bigger impact on their respiratory function with a spinal - infants or children? why?

Answer 25

infants - they rely more on diaphragm for their tidal volume but most compensate and tolerate well

Question 26

common technique for spinals in peds

Answer 26

* usually sitting position * 1% lidocaine * midline insertion at L4-L5 or L5-S1 (lower than adults) * must remain horizontal to avoid high spinal - no leg raises, toe touches, somersaults, etc. * avoid sedation if possible - esp ketamine

Question 27

complications of SAB

Answer 27

* total spinal - apnea, bradycardia * post-dural puncture headache * spinal cord trauma * epidermoid tumors

Question 28

what usually causes epidermoid tumors?

Answer 28

when needle used without the stylet

Question 29

effects of prolonged amide infusions in infants and young children

Answer 29

* variable pharmacokinetics * increased risk of LAST

Question 30

which LA is starting to have a resurgence for epidural anesthesia? how is it metabolized?

Answer 30

2-chloroprocaine metabolized by plasma esterases in seconds to minutes

Question 31

\*theoretically can epidurals in peds be the sole anesthetic?

Answer 31

yes - but usually combined with GA

Question 32

most common regional technique in children — in some places

Answer 32

caudals

Question 33

are caudal blocks used ase the sole anesthetic?

Answer 33

nope, always used with GA

Question 34

landmarks for a caudal block

Answer 34

* posterior iliac spine * sacral cornu

Question 35

T/F: a caudal block requires sterile technique

Answer 35

false - aseptic\*

Question 36

is a caudal block a type of spinal or type of epidural?

Answer 36

epidural

Question 37

technique for a caudal block

Answer 37

1. after induction, turn lateral or prone 2. palpate landmarks 3. insert small gauge needle, angiocath, or Crawford needle at 45°angle 4. after “pop”, drop to angle parallel to back and advance into caudal canal 5. for continuous, insert catheter 6. test dose while watching EKG & BP 7. inject local over approx. 2 minutes - injection should be easy 8. watch for sub-cu infiltration

Question 38

how long to inject local over for a caudal block

Answer 38

over 2 minutes

Question 39

for a continuous caudal epidural, how far does the catheter need to be advanced?

Answer 39

mid-level of surgical incision

Question 40

fun facts on back side :)

Answer 40

* some ppl use ultrasound to confirm catheter placement of caudal epidural catheter * these need “meticulous dressing for catheter placement”

Question 41

the dose needed for a caudal block depends on what two factors?

Answer 41

* desired dermatome level * volume **_not_** concentration

Question 42

common volume per kg and drug given for a T4-T6 sensory caudal block

Answer 42

0.5-1 mL/kg of 0.2% ropivacaine (or can use 0.25% bupivacaine but its more toxic) ~~idk if saying we won't dose on exam was we don't need to know them, or if we just wont have to calculate

Question 43

what is a common drug to administer with a caudal block to prolong the block? what dose of this drug is associated with increased apnea?

Answer 43

common: clonidine 1 mcg/kg 2 mcg/kg increases apnea ~~idk if saying we won't dose on exam was we don't need to know them, or if we just wont have to calculate

Question 44

dose that can be used for post-op pain control with a caudal epidural catheter? considerations if little babe?

Answer 44

max: 0.4 mg/kg/hr (of what? unclear) if \< 6 months reduce by 30% ~~idk if saying we won't dose on exam was we don't need to know them, or if we just wont have to calculate

Question 45

contraindications to a caudal block

Answer 45

* parents refuse consent * surgeon preference * allergy to local anesthetics * skin infection/diaper rash in sacral area * VP shunt in place * history of spinal abnormality or surgery (relative) * sacral “dimple” (relative)

Question 46

when we look at our little baby patient's booty, we see a cute lil booty dimple. what can this indicate? is this an absolute contraindication to a caudal block?

Answer 46

* can indicate spinal structures behind due to some malformation * only a relative contraindication, not absolute

Question 47

post caudal complications which is most common?

Answer 47

* most common: catheter displacement/malfunction * IV or IO injection → CV arrest * epidural abscess (emergent) * meningitis * epidural hematoma * urinary retention * neuronal injury (rare)

Question 48

what are some common fascial blocked used as an adjunct to GA? \*ones that we would do

Answer 48

* TAP block * quadratus lumborum block (QLB) * serratus anterior plane block (SAPB) * erector spinae block (ESB)

Question 49

what are some common blocks done by the surgeon as an adjunct to GA?

Answer 49

* rectus sheath * inguinal * penile * intercostal * paravertebral

Question 50

is it safe to administer regional to an anesthetized child?

Answer 50

yep here's some obvious reasons why: * maintains stillness * avoids uncooperative and distressed patient * immobility helps avoid accidental needle displacement/puncture of vital structures negative - any advantages of patient feedback are lost with children who are unable to communicate usefully