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Peds-Dr. Sames > TEST 3 > Flashcards

TEST 3 Flashcards

1
Q

Children exhibit different pharmacokinetics from adults because of their (4) reasons

A

Lower protein binding (more free drug = greater effect)

Larger volume of distribution (Vd) “jellyfish” (required larger loading dose of water soluble meds to achieve clinical effect)

Smaller proportion of fat and muscle stores (less redistribution into muscle/fat mass = large initial blood concentration)

Immature renal and hepatic function (less metabolism and elimination)

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2
Q

(MM) What drugs will have a LARGER volume of Vd in the infant compared with the adult?

What drugs will have a SMALLER volume of Vd in the infant compared with the adult?

A

Water soluble drugs = LARGER Vd

Lipid soluble drugs = SMALLER Vd

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3
Q

Along with the factors and individual differences in drug metabolic enzymes in children, a drug’s metabolism may be ____ and/or ______ elimination.

In some cases, it may ______ metabolism.

A

Reduced

Delay

Increase

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4
Q

Pharmacokinetics in children, some medications may displace bilirubin from its ____ ____ ____ and possible predispose an infant to ____.

A

Protein binding sites

Kernicterus

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5
Q

Pharmacokinetics: it is important to carefully ____ of all medications that are administered to ____ and ____ infants to the desired response.

A

Titrate doses

Preterm and term

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6
Q

There are (2) reasons why neonates require a ____ dose of succinylcholine compared with the adult. Neonates have a ____ Vd for succinylcholine than adults.

A

Higher

Larger

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7
Q

___ -____% of body weight of neonate is extracellular fluid (ECF) whereas in the adult ECF is only ____-____ of the body weight.

A

40-50%

20-25%

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8
Q

_____ distributes in the ECF volume-so more drug is needed on a per kg basis.

A

Succinylcholine

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9
Q

The neuromuscular junctions in neonates are ____ (less sensitive or more resistant to its neuromuscular effects), so more SUX is needed to compete with ACh at the NMJ.

A

Immature

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10
Q

Neonates require ____ as much succinylcholine on a body weight basis than older children or adults.

A

TWICE

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11
Q

The neonate has a ____ sensitivity to nondepolarizing NMB agents than the adult and would require a ____ amount of the drug.

A

GREATER

Smaller amount

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12
Q

Nondepolarizing NMBs acts as a ____ ACh antagonists at the ____ neonatal NMJ.

A

Competitive

Immature

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13
Q

Neonates/infants have a ____ Vd for muscle relaxants and would require a ___ amount of the drug.

A

greater Vd

Greater amount of the drug

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14
Q

The ____ Vd (normally requiring a greater amount of drug) is offset by the ____ sensitivity of nondepolarizing muscle relaxants at the NMJ.

A

Increased

Increased

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15
Q

Neonates, infants, children require the ___ dose of nondepolarizing neuromuscular relaxants as adults on a weight basis.

A

Same

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16
Q

CNS effects: Lab data have demonstration that the ____ (lethal dose in 50%) for many medications to be significantly less in the neonatal animals than ___ animals.

A

LD 50

Adult

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17
Q

CNS effects: the sensitivity of human neonates to most the sedatives, hypnotics, narcotics is clinically well known and may be in part related to ____ or ___ for some medications

A

Increased brain permeability

immature BBB

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18
Q

___ ____ in infants may make it easier for drugs that are not particular lipid soluble to enter the brain at a greater rate than if the BBB were intact.

A

Incomplete myelination

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19
Q

Volatile concentration INCREASES more rapidly in alveoli in children than adults. That results from (3) things

A

High level of alveolar ventilation (Va) in relation to FRC)

Higher proportion of vessel-rich tissues that rapidly equilibrate with blood vessels

Lower blood-gas partition coefficients of volatile anesthetics in infants

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20
Q

Excretion/recovery of inhaled anesthetics is also ___ in children than adults.

Quick __ -> Quick ___.

A

Faster

Quick on -> Quick Off

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21
Q

What kind of a drug is toradol?

A

NSAID with potent analgesic properties

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22
Q

What age can you start using ketorlac?

A

Age of 2

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23
Q

What can toradol be used as?

A

An adjuvant to opioid analgesia to reduce potential respiratory depression/ PONV or for treatment of mild to moderate pain

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24
Q

What patients should you use ketorlac with caution in?

A

Patients with renal problems, reduced renal blood flow and in asthmatic patients (allergic reactions to NSAIDS)

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25
Q

Why does ketorlac have potential for post op bleeding?

A

Inhibition of platelet function through inhibition of cyclooxygenase

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26
Q

Compared to Asa, ketorlac’s platelet inhibition is _____________ and is gone when ______________________ .

A

Platelet inhibition is reversible and is gone when the drug has been excreted

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27
Q

Should you ask the surgeon before you give ketorlac?

A

Yes ask if there is any contraindication because the increased risk of bleeding.

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28
Q

How should ketorlac be drawn up?

A

In a TB syringe be careful to not overdose

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29
Q

What is the concentration of ketorlac?

A

1mL/30 mg

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30
Q

If drawing up in TB syringe each increment = how many mg?

A

Each increment = 3 mg

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31
Q

IV dose of ketorlac?

A

0.5mg/kg IV

Max 30 mg

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32
Q

IM dose of ketorlac?

A

0.5-1mg/kg

Max 30 mg

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33
Q

What is the dose of narcan?

A

0.001 mg/kg

1mcg/kg

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34
Q

What kind of drug is narcan?

A

Pure opioid antagonist and is rapidly effective in reversing opioid induced side effects.

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35
Q

What side effects of opioids does narcan reverse?

A 
Respiratory depression
N/V
pruritus
urinary retention 
constipation
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36
Q

What is the concentration of narcan in the vial?

A

0.4mg/ml

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37
Q

How do you dilute narcan?

A

Dilute 1 ml: 0.4mg/ml in 9 mL NS; will make it 40 mcg\ml

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38
Q

With Narcan, Respiratory depression may be reversed with as little as ________ mcg/kg although larger doses (up to _______ mcg/kg) may be required

A

1-10

Up to 100

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39
Q

Why do we use small doses of narcan?

A

To reverse the respiratory depression without reversing the analgesic effects

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40
Q

Why can resedation occur after giving narcan?

A

The elimination HL of narcan is shorter than the HL of most opioids

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41
Q

What should you do if resedation occurs after narcan?

A

Repeat the same dose IM and monitor closely

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42
Q

What are the major side effects of narcan?

A 
Hypertension
Cardiac arrhythmias (including v fib) 
Pulmonary edema (non cardiogenic)
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43
Q

What kind of a drug is flumazenil (Romazicon)?

A

GABA receptor competitive antagonist that reverses the effects of benzodiazepines

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44
Q

Does flumazenil work on opiods?

A

No

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45
Q

What is the concentration of flumazenil?

What is the dose of flumazenil?

A

1mg/10mL

0.01mg/kg or 10 mcg/kg

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46
Q

What are the adverse affects with flumazenil?

A 
N/V
Blurred vision
Sweating
Anxiety 
emotional liability
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47
Q

Because elimination HL of flumazenil is _____________ than the HL of most benzodiazepines, ____________ can occur.

A

Shorter

Resedation

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48
Q

What should you do if resedation occurs after flumazenil administration?

A

Repeat the dose and monitor closely

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49
Q

Dose of roc for RSI?

A

0.6-1.2 mg/kg

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50
Q

Rocuronium induction IV dose?

A

0.45-0.6mg/kg

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51
Q

Cisatracurium dose?

A

0.1-0.2 mg/kg

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52
Q

Pancuronium dose?

A

0.1mg/kg

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53
Q

Is rocuronium long/intermediate acting? Is it a non depolarizer/depolarizer?

A

Intermediate acting

Non depolarizer

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54
Q

Does rocuronium have cardiovascular or histamine release?

A

No rocuronium is without cardiovascular and histamine effects and similar to vecuronium

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55
Q

What is the dose of rocuronium?

A
  1. 6 mg/kg (good intubating dose)

1. 2 mg/kg for RSI

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56
Q

How is rocuronium eliminated?

A

Eliminated by the liver; only 10% is excreted by the kidneys

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57
Q

Neonates appears to be more sensitive to Roc than older infants? T/F?

A

True

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58
Q

What is the DOA of rocuronium?

A

90 minutes after 0.6 mg/kg

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59
Q

What kind of drug is cisatracurium?

A

Intermediate non depolarizer

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60
Q

What hemodynamic affects does cisatracurium have?

A

Minimal histamine release; stable hemodynamics

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61
Q

What is the intubating dose of cisatracurium?

What is the duration of action

A

0.1-0.2 Mg/kg

DOA 35 minutes

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62
Q

The duration of action of nimbex is unaffected by renal or hepatic failure and is therefore drug of choice for renal or hepatic patients? T/F?

A

True

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63
Q

How is nimbex eliminated?

A

Hoffman elimination and ester hydrolysis

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64
Q

Vecuronium is a depolarizing NMB agent. T/F?

A

False; non depolarizer

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65
Q

How long is the duration of action of vecuronium in children and small infants?

A

35-45 min in children

60-70 min in small infants

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66
Q

Does vecuronium have cardiovascular side effects?

A

No and metabolites seem not to have CNS effects

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67
Q

How is vecuronium metabolized?

A

By the liver and excreted in bile

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68
Q

What can prolong the action of non depolarizer NMB?

A

Tobramycin, neomycin, gentamicin, and hypothermia

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69
Q

What is the dose of vecuronium?

A

0.1mg/kg

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70
Q

What drug class is pancuronium (Pavulon)?

A

Longer acting non depolarizer NMB agent and is preferred when increased HR and BP is desired

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71
Q

What surgery is pancuronium desired, and why?

A

Pancuronium

Because HR and BP increased is desired

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72
Q

What can pancuronium cause in pre term infants?

A

Sustained tachycardia

HTN

Increased plasma epinephrine level

Some concern of increased risk of intracerebral hemorrhage

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73
Q

What is the dose of pancuronium?

A

0.1mg/kg

Each following dose should only be 10-20% initial dose

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74
Q

How is Panc excreted in the kidneys?

A

In the kidneys; prolonged NMB with renal impairment may occur

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75
Q

Dexamethasone dose for antiemetic?

A

0.1mg/kg Max 10 mg

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76
Q

Dexamethasone dose for airway?

A

0.5mg/kg max 10 mg

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77
Q

Why should NDMB always be reversed?

What 3 things can happen if patient is not reversed?

A

Because residual muscle paralysis will impair respiration and may result in hypoxemia, hypercapnia and acidosis.

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78
Q

What patients can inhibit the antagonism of NDMB?

A

Hypothermia can inhibit antagonism making neostigmine not fully effective

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79
Q

What antibiotics can prolong effect of NDMB?

A

Neomycin
Gentamicin
Tobramucin

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80
Q

In neonates and infants it is very easy to judge if twitches are present. T/F?

A

False; it is difficult

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81
Q

What are some clinical signs that patient/child is reversed?

A

Ability to flex hips/arms
Lift legs
Return of abdominal muscle tone

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82
Q

What is the dose of neostigmine?

What is the dose of glycopyrrolate?

A

0.07 mg/kg

10 mcg/kg

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83
Q

What drugs does sugammadex reverse?

A

Roc or vec

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84
Q

What is the recommended dose of sugammadex after 2 twitches have returned?

A

2mg/kg

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85
Q

What is the recommended dose of sugammadex after 1-2 post tetanic twitch revocery (no response to TOF)

A

4mg/kg

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86
Q

Can you use sugammadex for RSI dose of roc or vec?

A

No! ROC reversal only

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87
Q

For RSI- ROC reversal _________ mg/kg if there is a clinical need to reverse NM blockade soon ( approx. _____ minutes) after single dose of ___________ mg/kg of ROC.

A

16 mg/kg
3 minutes
1.2

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88
Q

What cardiac affects have been seen after administration of bridion/sugammadex?

A

Cardiac arrest and marked bradycardia

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89
Q

What drug does sugammadex compete with and patient education is very important?

A

Hormonal contraceptives, female patients who have received sugammadex during GETA are not protected for 7 days and can become pregnant

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90
Q

Does atropine of glycopyrrolate have more CNS effect?

A

Atropine crosses BBB; glycopyrrolate has minimal CNS effect

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91
Q

What drugs are used to offset the muscarinic effects of neostigmine for reversal of NDMB?

A

Glycopyrrolate

Atropine

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92
Q

Atropine and glycopyrrolate are used to treat bradycardia with oculocardiac reflex and dry up secretions (drooling with ketamine). T/F?

A

True

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93
Q

What drug should be used cautiously in Down syndrome because narrow angle glaucoma?

A

Atropine may worsen glaucoma and needs to be administered cautiously

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94
Q

What are the 3 5 HT3 (serotonin) receptor antagonists?

A

Odansetron (zofran)
Granisetron (kytril)
Dolasetron (anzemet)

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95
Q

Odansetron is used for prophylaxis and treatment of PONV and to reduce the severity of established N/V. T/F

A

True

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96
Q

What is the dose of odansetron?

A

0.1 mg/kg up to 4mg

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97
Q

How can odansetron be given?

A

IV, IM or orally

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98
Q

What can improve the efficacy of preventing PONV if given together?

A

Odansetron and dexamethasone

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99
Q

Children less than _______ months of age don’t require antiemetics in general (exceptions could be: pt is 1.5 yrs and had an emetogenic surgery (eyes, ears, T&A, abdominal)

A

24

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100
Q

When should you give the anti emetic dose of dexamethasone?

A

Early and give zofran before then end of the case

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101
Q

When should you avoid dexamethasone?

A

Patients who are newly diagnosed with leukemia/lymphoma and other hematologic malignancy

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102
Q

What is acute tumor lysis syndrome?

A

Occurs when rapidly dividing large volume tumors (i.e highly aggressive lymphomas and acute leukemia) are treated with cytotoxic agents inducing cell death of malignant tissues

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103
Q

Acute tumor lysis syndrome is characterized by what?

A

The rapid development of hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia and lactic acid may terminate in renal failure in a patient who may have a hematologic malignancy

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104
Q

It is okay to give dexamethasone to a patient with acute tumor lysis. T/F?

A

False it is like pouring oil on fire

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105
Q

What are amides degraded by?

A

Cytochrome p450

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106
Q

What are amides?

A

Lidocaine, mepivacaine, bupivicaine, levobupivacaine, ropivacaine, etidocaine

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107
Q

How are esters broken down?

A

By hydrolyzed by plasma cholinesterases

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108
Q

What are the esters?

A

Procaine
2 chloroprocaine
Tetracaine

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109
Q

Max dose of bupivacaine with epi

A

2.5mg/kg (max 175 mg)

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110
Q

Max dose of bupivacaine with epi PF caudal?

A

2.5 mg/kg

Max 175

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111
Q

What is the max dose of lidocaine without epi infiltration

A

4.5 mg/kg

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112
Q

What is the max dose of ropivacaine?

A

2.0 mg/kg

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113
Q

With 0.25% Bupivacaine with epi = 2.5 mg/mL -> give 1mL/kg

A

.

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114
Q

With 0.2% ropivacaine = 2mg/ml -> give 1mL/kg

A

.

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115
Q

What is epinephrine (adrenaline) IV used to treat?

A

Cardiac arrest
Hypotension
Heart failure

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116
Q

Dose and how often should you dose epi?

A

10 mcg/kg Q 3-5 minutes

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117
Q

Infusion dose of epi?

A

0.01- 1 mcg/kg/min

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118
Q

Dose of epinephrine to treat bronchospasm

A

1-2 mcg/kg IV to treat bronchospasm

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119
Q

___ speeds up induction and emergence (second gas effect). ___ might be a cause analgesia for ____.

A

Nitrous Oxide

Nitrous Oxide

Difficult IV sticks

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120
Q

Any gas-filled cavities within the body are vulnerable for expansion if nitrous oxide is administer including (5) things.

A

Obstructed Bowel

Pneumothorax

Cuff of ETT

LMA

Bubble veins

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121
Q

Theoretically, ___ __ should be avoided during laparoscopic surgery to avoid expanding ____ ___ that reach the venous circulation.

A

Nitrous oxide

CO2 bubbles

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122
Q

The appropriate concentration of oxygen to be delivered for each anesthetic should be carefully titrated to an _____ ______. Oxygen is often liberally administered in ___ of patient’s metabolic needs.

A

Individual’s needs

Excess

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123
Q

____ is considered one of many factors causing retinopathy of prematurity (ROP) in infants weighing less than 1500 gm or less than 28 wks gestation.

A

Hyperoxia

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124
Q

It is recommend to ___ __ with O2 to maintain SpO2 of 90-95% (even during transport of premature neonates)

A

blend air

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125
Q

However, while avoiding hyperoxia, one must never lose sight of the importance of avoiding _____.

A

Hypoxemia

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126
Q

____ is life-threatening whereas hyperoxia is not.

A

Hypoxemia

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127
Q

One cannot be ___ if ROP occur, provided a reasonable and safe approach to ___ administration and ventilation has been made.

A

Faulted

Oxygen

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128
Q

Check for a ____ ____ ___ before you give any medication to a girl who has reached 12 years of age or younger than 12 years if patients is post menses.

A

Negative Pregnancy Test

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129
Q

____ is NOT appropriate for inhalation induction due to its pungent odor which ______ airway reflexes and causes what three things.

A

Isoflurante

Irritate

Laryngospasm

Breath-holding

Coughing

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130
Q

Isoflurane is a profound ____ depressant. Rapid increase in ISO concentration decrease what 3 things especially in hypovolemia.

A

respiratory depressant

Decreased BP, HR, RR (especially in hypovolemia)

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131
Q

ISO (like DES) reacts with desiccated ___ ___ or ___ to release carbon monoxide into breathing circuit

A

Soda Lime

Baralyme

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132
Q

_____ has a very low blood solubility and the CV effects are similar to ISO.

A

Desflurane

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133
Q

Like ISO, ____ is not suited for inhalation induction, because of its very ___ odor and is irritant to the airway, and causing what (3) things

A

Desflurane

Pungent

Laryngospasm

Coughing

Breath-holding

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134
Q

Emergence from DES is very ___ and may result in ___, particularly if ___ is present.

A

Rapid

Delirium

Pain

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135
Q

DES interacts with desiccated ____ ___ or ____ and may produce potentially toxic concentration of ____ ___.

A

Soda Lime

Baralyme

Carbon Monoxide

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136
Q

____ is excellent for inhalation induction, has somewhat ____ odor and does NOT cause ____ irritation.

A

SEVO

Pleasant

Airway

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137
Q

With SEVO, CV and respiratory effects are similar to ____.

A

ISO

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138
Q

Emergence from SEVO is ___ and ___. Risk of emergence delirium is ___ if pain is not well controlled and high levels of ___ were given throughout the case.

A

Smooth and Rapid

Increased

SEVO

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139
Q

What is a dissociated state of consciousness which children are inconsolable, irritable, uncompromising, and/or uncooperative?

A

Emergence Delirium

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140
Q

During emergence delirium, many of the children ___ to recognize and respond ____ to their parents.

A

Fail

Appropriately

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141
Q

Incidence of emergence delirium (ED) after inhalation anesthesia in children ranges from ___ -____% (similar prevalence with SEVO, DES, ISO and less with HALO)

A

2-80%

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142
Q

The highest incidence of emergence delirium occurs in children __-__ years of age.

A

1-5 years

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143
Q

Appropriate ___ ___ often attenuates emergence delirium.

A

Pain relief

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144
Q

____ is hydrolyzed in the presence of soda lime/Baralyme to a potentially nephrotoxic Compound A.

A

SEVO

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145
Q

Studies with ___ suggests that SEVO may be administered in a closed circuit for up to ____ MAC-hrs before nephrotoxicity is a serious risk. Keep flow at ____ L/min.

A

Primates

25 MAC-hrs

2 L/min

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146
Q

All ___ ___ ___ and ___ trigger MH reactions in susceptible adults and children.

A

Potent anesthetic volatiles

Succinylcholine

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147
Q

In 1993, the FDA issued a __ __ warning against the routine use of SUX in children and adolescents except for ____ ____ ____.

A

“Black box” warning

Emergency airway management

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148
Q

Sux black box warning was based on several case reports of ____ and primarily in children with undiagnosed ___.

A

Hyperkalemic cardiac arrests

Undiagnosed Ducchenne muscular dystrophy

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149
Q

Hyperkalemia cardiac arrests and children with undiagnosed duchenne muscular dystrophy has a staggering mortality rate of ___%.

A

55%

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150
Q

Sux hyperkalemic cardiac arrest occur in what type of population?

A

Male children 8 years and younger

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151
Q

The use of succinylcholine should be reserved for ___ ___ or instance where immediate securing of the airway is necessary like in these (4) circumstance.

A

Emergency intubation

Larygospasm

Difficult airway

Full stomach

Intramuscular route when a suitable vein is inaccessible

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152
Q

In the presence of hypoxemia with partial or complete upper-airway obstruction. Give _____ IV Sux or ____ IM Sux.

And apply what?

A

0.1-1 mg/kg IV Sucs

4 mg/kg IM Sucs

Positive pressure ventilation

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153
Q

Sux is infrequently associated with an increase in ____ ___ tone “trismus” and is considered a trigger for _____.

A

Masseter muscle tone

MH

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154
Q

What circumstances do you avoid Succinylcholine?

A

Avoid SUX in eye trauma: Increase IOP (intraocular pressure)

Avoid SUX in children with burns (burns older >24 hrs)

massive trauma

major neurologic disease (neuromuscular disease)

renal failure compounded by neuropathy

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155
Q

With succinylcholine, Serum K+ concentration increases ___ mEq/L or less after IV Sux in normal children, however, life-threatening K+ can occur after __ single dose.

A

1 meq/L

1 single dose

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156
Q

Single dose of SUX can occasionally cause ___ and ___ in children.

A

Bradycardia

Asystole

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157
Q

What do you give prior to administering Sux?

A

Atropine IV 10-20 mcg/kg

Atropine IM 20-40 mcg/kg

Minimum of 100 mcg Atropine

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158
Q

Propofol is a short-acting ____, with a _____ recovery; however longer exposure to propofol might prolong ___ due to redistribution in fat cells.

A

Hypnotic

Pleasant recovery

Emergence

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159
Q

Propofol induction dose for GETA: ____ mg/kg, short period of ___ and slight decrease in ____.

A

2-4 mg/kg

APNEA

BP

160
Q

Propofol is painful on injection; therefore you must do what (2) things?

A

1% Lidocaine (1 mg/kg)

Inject slowly for induction

161
Q

Extreme caution regarding _____ with propofol is required. Wipe with ____ pads and cover with ______. Avoid Propofol induction through ____ lines= increased infection/occlusion.

A

ASEPSIS

Alcohol pads and

Cover with stopcock

PICC

162
Q

Propofol infusion is ____. Consider TIVA for pts with h/o severe _____.

A

Antiemetic

PONV

163
Q

Propofol infusion rates are greater in _____ than in ____. Titrate to ___ and surgical stimulation. Be cautious in combination with ____ and ____.

A

Children than adults

RR

Narcotics and anxiolytics

164
Q

MRI/CT/PET scan/Radiation Tx with no surgical stimulation and only Propofol dose

A

150-250 mcg/kg/min

165
Q

Propofol infusion dose only no other sedative for endoscopy/colonoscopy/bronchoscope

A

350-450 mcg/kg/min

166
Q

Other than propofol, what induction drug has an onset of anesthesia that is rapid smooth; usually accompanied by a brief episode of apnea with minimal CV changes?

A

Thiopental

167
Q

What is the induction dose for Thiopental?

A

4-6 mg/kg

168
Q

_____ are especially sensitive to barbiturates due to ___ ___ ___ of the drug in the serum (3-4 mg/kg)

A

Neonates

Reduced protein binding

169
Q

With thiopental, IV induction should NOT be used when there is a potential airway problem. True or False.

A

True

170
Q

Barbiturates are contraindicated in patient with ____

A

Porphyria

171
Q

What is porphyria?

A

An enzyme deficiency in heme production

172
Q

Barbiturates should be administered with extreme care in patients who are ___ and ___.

A

Hypovolemic

Limited cardiac reserve

173
Q

Thiopental reduces what two pressure and is therefore useful these two surgeries?

A

IOP and ICP

Neurosurgical and ocular procedures

174
Q

What is a phencyclidine derivative that produces profound analgesia, unconsciousness, cataleptic state and amnesia?

A

Ketamine

175
Q

Ketamine increases what (3) things. Ketamine causes minimal ___ __ if given alone and in adequate doses.

A

Increases HR, MAP, CO

Respiratory obstruction

176
Q

With ketamine, ____ with increased risk of laryngospasm, give an antisialagogue.

A

Hypersalivation

177
Q

Ketamine also increases ____ and ____ which is not desired in neuro cases.

A

CBF/ICP

cerebral metabolic rate

178
Q

Ketamine Increase IOP and nystagmus movement so therefore it is not desired for?

A

Eye surgery

179
Q

Ketamine has a high incidence of ___ __ (hallucination- bad dreams - frank psychosis). Give ___ intra-op, prior to administer.

A

Emergence phenomena

Midazolam

180
Q

Ketamine works well for what kind of children population?

A

Mentally retarted teenagers who are uncooperative with IV placement or inhalation induction

181
Q

What class drug is Dexmedetomidine (Precedex)?

A

Selective alpha 2 agonist

182
Q

What (4) things does Precedex do?

A

Decreases sympathetic tone

Attenuates stress response to anesthesia and surgery

Causes sedation and analgesia

Used as adjunction during regional anesthesia

183
Q

Dexmedetomidine is ___ -___ x more alpha specific than Clonidine.

A

8-10 x

184
Q

What is the loading dose for Precedex?

A

0.5-1 mcg/kg (over 10-20 minutes to attenuate hypotension

185
Q

What is the continuous infusion dose for Precedex?

A

0.2-1 mcg/kg/HOUR

Titrate to desired sedation level

186
Q

Etomidate is ___ -based hypnotic induction agent. Like propofol, it is ___ with administration.

A

Steroid

Painful

187
Q

Etomidate is mostly avoided by of what two reasons?

A

Risk of anaphylactic reactions

Suppression of adrenal function

188
Q

With etomidate, inhibition of steroid synthesis can occur after a ____.

A

Single dose

189
Q

When is etomidate useful?

And what is the induction dose?

A

Children with head injury and unstable CV status (cardiomyopathy)

0.3 mg/kg IV

190
Q

Sufentanil induction dose

A

1-10 mcg/kg

191
Q

Remifentanil IV GTT dose

A

0.05-2 mcg/kg/min

192
Q

What is the most commonly used opioid during GETA in infants and children?

A

Fentanyl

193
Q

Clearance of fentanyl in pre-term infants is extremely variable due to what 3 factors?

A

Reduced elimination HL due to decreased hepatic blood flow

Reduced hepatic function

Age dependent changes in Vd

194
Q

What is the usual initial dose of Fentanyl and titrate to what?

A

1-2 mcg/kg

titrate to RR

195
Q

Fentanyl is highly ____ and crosses ____ rapidly.

A

Lipid-soluble

BBB

196
Q

What is commonly used opioid when prolonged analgesia is required?

A

Hydromorphone (dilaudid)

197
Q

Dilaudid is ___ -____ X more potent than IV morphine.

A

5 - 7.5x

198
Q

How should you dilute Dilaudid in children?

A

Dilute 1 mg into a 10 ml syringe (add 9 ml of NS)-> 100 mcg/ml

199
Q

What is the initial and titration dose of Dilaudid?

A

10 mcg/kg- initial dose

5-10 mcg/kg through the case.

200
Q

With Dilaudid, It is BEST if the child is spontaneously breathing with LMA or ETT, titrate to age-appropriate RR. True or False

A

True

201
Q

What are the (3) side effects of Dilaudid?

A

Sedation

N/V

Respiratory depression

202
Q

When is dilaudid NOT appropriate?

A

For infants and small children up to age 2 years for same day surgery with discharge to home

203
Q

____ provides excellent post-op analgesia, however, neonates and infants are more sensitive to ventilatory depressant effects due to ____ permeability of BBB and less predictable clearance.

A

Morphine

Increased

204
Q

Morphine IM/IV dose

A

0.1 mg/kg

205
Q

(3) adverse effects of Morphine due to histamine release

A

Histamine release causes

Hypotension

Sedation

PONV

206
Q

Unlike Dilaudid, morphine is appropriate for infants and small children up to age of 2 years for same day surgery with discharge to home. True or False

A

FALSE. It causes respiratory depression/apnea and needs close observation

207
Q

What drug has an extremely high margin of safety and is more protein-bound and has a short elimination HL?

A

Sufentanil

208
Q

Since sufentanil blocks some stress responses, it is used for what kind of surgery?

A

Cardiac surgery

Administered in high doses for cardiac surgery in infants.

Produces CV stability with minimal depression of ventricular function

209
Q

Sufentanil IV dose

A

1-10 mcg/kg bolus

210
Q

Sufentanil infusion during GETA

A

0.1-1.5 mcg/kg/HOUR

211
Q

Adverse effect of Sufentanil?

A

Resp depression/apnea

CHEST WALL RIGIDITY

212
Q

Along with Dilaudid, morphine, it is NOT appropriate for infants and small children for same-day surgery with discharge to home. True or False

A

True

213
Q

What 3 medications is not allowed for children under 2 years old having same day surgery?

A

Dilaudid

Morphine

Sufentanil

214
Q

What is an ultra-short synthetic opioid with a 3-10 minute elimination half life? Independent of dose or duration of infusion or age of pt.

A

Remifentanyl (Ultiva)

215
Q

How is Remifentanyl eliminated

‘

A

Tissue esterase hydrolysis

216
Q

Continuous infusion dose of Remi (as an adjunct to GETA)

A

0.05-2.0 mcg/kg/MIN

217
Q

After bolus administration of Remifentanyl, what can potentially happen?

A

Severe bradycardia

Hypotension

Remi should only be administered only by continuous infusion

218
Q

(4) Adverse effects of Remifentanyl

A

Apnea

Bradycardia

Chest wall rigidity

Vomiting

219
Q

What syndrome entails chronic infusion of fentanyl and can cause tolerance and signs of dependence?

A

Neonatal Abstinence Syndrome.

220
Q

With neonatal abstinence syndrome, children require what?

A

Large doses to prevent response to surgical stimuli -> Use other anesthetic or analgesic drugs

221
Q

What are (7) signs of withdrawal with Neonatal Abstinence Syndrome?

A

Crying

Hyperactivity

Fever

Tremors

Poor feeding and sleeping

Extreme cases, vomiting and convulsion

222
Q

To prevent Neonatal Abstinence Syndrome, all long term infusion of fentanyl should be ____ slowly over days.

A

Tapered

223
Q

What are the (2) primary indications of methadone in children?

A

To wean from long-term opioid infusions to prevent withdrawal

To provide analgesia when other opioids have failed or have been associated with intolerable side effects

224
Q

Methadone is ___-___ protein bound and is a ___ ___ __ and is the main determinant of free factor of Methadone.

A

60-90% protein bound

Alpha 1-acid glycoproteins

225
Q

In children, Methadone has large ____, high plasma clearance and long _____.

A

large Vd

Long Half life

226
Q

Midazolam IV dosse

A

0.05- 0.1 mg/kg

227
Q

In children, midazolam has been shown to produce ____ and ____ sedation.

A

Tranquil and calm

228
Q

Midazolam properties (3)

A

Reduces separation anxiety

Facilitates induction of anesthesia

Enhances ANTEgrade amnesia

229
Q

Oral midazolam tastes ____ but provides adequate effect after ___ -___ minutes.

A

Bitter

10-15 minutes

230
Q

What (2) things can Midazolam do? (Respiratory wise)

A

Depress ventilatory response (Monitor respiratory depression) Especially when given in combo with other meds such as opioids)

Increases upper airway obstruction especially in children with OSA

231
Q

What drug is an analgesic and antipyretic drug WITHOUT anti-inflammatory actions?

A

Acetaminophen

232
Q

Tylenol does NOT metabolize well by infants and children of all ages. True or False.

A

False. Metabolizes early

233
Q

What is a useful as an analgesic for mild pain and opioid-sparing adjunct for severe pain?

A

Acetaminophen

234
Q

PO dose of Tylenol

A

10-15 mg/kg

235
Q

PR dose of Tylenol

A

30-40 mg/kg (loading dose)

236
Q

IV Tylenol dose <50 kg

How long should you infuse it for? And how often?

A

15 mg/kg IV Q6H for at least 15 minute

Do not exceed 750 mg/dose or 3.75 g/day

237
Q

IV dose Tylenol for > 50 kg

A

1000 mg IV Q6H (not to exceed 4 g/day)

238
Q

With Tylenol, what can occur with overdose and particularly at risk in the seriously ill child?

A

Hepatic Failure

239
Q

The fetal formation of the diaphragm is completed during what weeks?

A

7th - 10th week of gestation

240
Q

What congenital emergency is occurring when intrusion of abdominal viscera (including intestines, stomach, liver, spleen) into the thoracic cavity?

A

Congenital Diaphragmatic Hernia

241
Q

What are 90% of congenital diaphragmatic hernia?

A

Posterolateral Bochdalek-type.

80% left side Bochdalek-type CDH

242
Q

9% of congenital diaphragmatic hernia are what type?

A

Anterior Margagni-type

243
Q

What type of congenital diaphragmatic hernia occurs less than 1% of the time and is often fatal?

A

Bilateral hernia

244
Q

What is the incidence of congentinal diaphragmatic hernia?

A

1:2000-5000 live births

245
Q

What is the hallmark of congenital diaphragmatic hernia (CDH)?

A

Abnormal compression of pulmonary structure and cardiopulmonary sequelae

246
Q

In CDH, lung growth is severely retarded in what (6) ways?

A

Underdeveloped proximal airway division and supporting pulmonary vasculature

Fewer functional alveolar units and grossly diminished surface area for effective gas exchange

Deficiency of surfactant

Alveolar instability

Atelectasis

Intra-pulmonary shunting of deoxygenated blood

247
Q

How is CDH diagnosed antenatal?

A

Via level 2 sonography in a tertiary care center

248
Q

CDH often manifest as? In a neonate?

A

Severe respiratory distress in the neonate

249
Q

Severe respiratory distress occurs in CDH because of what (2) reasons?

A

Lung hypoplasia and

Inadeqyate pulmonary gas exchange

250
Q

What two S/S occurs in CDH?

A

Scaphoid abdomen

Bowel sounds in the lung field

251
Q

What CDH is the less severe respiratory compromise but with symptom of bowel obstruction?

A

Morgagni-type CDH

252
Q

With CDH, at birth, what is is the utmost priority?

A

DEFINITIVE airway

253
Q

At birth with CDH, Avoid ___ ___ with potential gastric insufflation.

A

Mask ventilation

254
Q

At birth, CDH patients should be intubated and mechanically ventilation with rapid low ____ and limited __ __ __ to reduce risk of barotrauma/right sided pneumothorax.

A

LOW tidal volume

Limited peak inspiratory pressures

255
Q

At birth with CDH, decompression of intestinal contents via ____.

A

NGT

256
Q

What (6) tests/considerations should you have prior to taking care of CDH patient?

A

Chest X-ray

ABGs

Echo

Cranial ultrasound

IV access

A-line

257
Q

Why is a cranial ultrasound ordered with CDH?

A

To rule out intraventricular hemorrhage (IVH)

258
Q

With CDH, what is contraindicated if IVH is present due to the need of systemic heparinization?

A

ECMO

259
Q

With CDH, the current practice is, surgical repair is IMMEDIATE/DELAYED.

A

Delayed (until the neonate is optimized)

260
Q

What (7) supportive care during surgery with CDH?

A

NICU ventilator/HFOV (high frequency oscillatory ventilation)

Serial ABGs

High dose opioid

Low dose volatile

Avoid N2O

Inhaled NO

ECMO?

261
Q

Overall survival for neonates with CDH has remained ___. Survivors often have a number of ___ ___ afterwards.

A

Unchanged

Medical issues

262
Q

What congenital emergency has an olive-shaped mass and occurs more in males (1:500 life births)?

A

Hypertrophied pyloric stenosis

263
Q

What relieves the obstruction of hypertrophied pyloric stenosis?

A

Surgical pyloro-myo-tomy

264
Q

Pyloric stenosis usually manifests with 2nd-6th week of life with __ __.

A

Nonbilirous vomiting

265
Q

With protracted vomiting in hypertrophied pyloric stenosis, infants may became what (3) things?

A

Hypokalemic

Hypochloremic

Alkalotic

266
Q

In hypertrophied pyloric stenosis, renal response to vomiting is two fold. What are those two responses?

A

Serum pH is initially defended by excretion of alkaline urine with Na+ and K+ loss

With depletion of electrolytes, the kidneys secrete acidic urine (paradoxical acidosis), which further increases metabolic alkalosis

267
Q

With hypertrophied pyloric stenosis, hypocalcemia is associated with?

A

Hyponatremia

268
Q

In hypertrophied pyloric stenosis, further fluid loss, prerenal azotemia may foreshadow what (2) things?

A

Hypovolemic shock

Metabolic acidosis

269
Q

Pyloric stenosis is a ___ emergency and NOT __ emergency.

A

Medical emergency

Not a surgical emergency

270
Q

Before pyloric stenosis, patient comes to the OR, they need to be __ __ stabilized and ___ within normal limits.

A

Intravascular volume

Electrolyte

271
Q

Infants with pyloric stenosis are considered “full stomach” and therefore require what (2) things?

A

IV access

RSI with cricoid pressure held in place until airway is secured

272
Q

With pyloric stenosis, before RSI, what should you give and do?

A

Give 100 mcg of atropine

Suction thoroughly with large-bore OGT the gastric contents (right and left lateral/supine)

273
Q

While suctioning in pyloric stenosis, the patient is ASLEEP. True or false

A

False.

Awake and gags and cries during suctioning

274
Q

While suctioning the patient with pyloric stenosis, allow the patient to do what in between?

A

Catch a breath

275
Q

With hypertrophied pyloric stenosis, pt should be what prior to extubation?

A

Fully awake (like every RSI patient)

276
Q

Due to ___ ___, pyloric stenosis patients have often a sluggish “breathing drive.”

A

Metabolic alkalosis

277
Q

With hypertrophied pyloric stenosis, local infiltration of the incision site with long acting LA usually provides complete analgesia; no fentanyl is generally given. True/False

A

True

278
Q

With pyloric stenosis, patients post op usually have numerous complications. True or False

A

False.

Mostly uncomplicated

279
Q

Necrotizing enterocolitis (NEC) is NOT an anomaly but an ___ found mostly in __ __.

A

Illness

Preterm infants

280
Q

With Necrotizing enterocolitis, infants often have bowel ___ and ___ from either the bowel or liver.

A

Perforation

Hemorrhage

281
Q

With NEC, premature infants can develop __ ___ and requires vasopressor support and enormous volume requirements.

A

Severe hypotension

282
Q

Infants of NEC will generally require transfusion of large amounts of blood products due to what (2) things?

A

Hemorrhage

Dissemated intravascular coagulopathy (DIC)

283
Q

NEC infants may appear very toxic with __ and __ abdomen and metabolic and ___ abnormalities (coagulopathy, DIC)

A

Distended and tender abdomen

Metabolic and hematologic abnormalities

284
Q

With NEC, X-rays usually suggest?

A

An ileus with edematous bowel and later demonstrate gas in the intestinal wall and biliary tract

285
Q

With NEC, what is gas in the intestinal wall called?

A

Pneumatosis intestinalis

286
Q

With NEC, “free gas” in the intestine occurs after?

A

perforation

287
Q

Morbidity associated with NEC include (3) things

A

Short bowel syndrome

Sepsis

Adhesions associated with bowel obstruction

288
Q

Associated condition/risk factors for NEC include? (9)

A

Birth asphyxia

Hypotension

RDS (respiratory distress syndrome)

PDA

Recurrent apnea

Intestinal ischemia

Umbilical vessel cannulation

Systemic infections

Early feedings

289
Q

What disease occurs when intestines are COVERED with amnion?

A

Omphalocele

290
Q

Where is the omphalocele defect?

A

At the BASE of the umbilicus

291
Q

What disease process occurs when intestines are NOT covered and exposed to hypothermia, infection and dehydration?

A

Gastroschisis

292
Q

Where is the defect in gastroschisis?

A

Periumbilical

293
Q

With omphalocele, failure of the __ to migrate from the yolk sac into the abdomen during 5th-10th week gestation?

A

Gut

294
Q

With omphalocele, when does the defect occur? And how often?

A

Earlier

And in 1:6000 births

295
Q

___ develops as a result of occlusion of the omphalomesenteric artery during 12-18th week of gestation.

A

Gastroschisis

296
Q

When does gastroschisis occurs and how often?

A

Later with less problems

Occurs 1: 15,000 live births

297
Q

What is O-B-B-B memory bridge?

A

O = omphalocele

B = base of umbilicus

B = bag (sac)

B = “bad news” - other anomalies

298
Q

Omphalocele is associated with genetic, cardiac, urologic and metabolic abnormalities, what (4) are they?

A

Trisomy 21

Beckwith-Widemann S

Congenital heart disease

Extrophy of the bladder

299
Q

Gastroschisis is NOT associated with other congenital anomalies, but may exhibit (2)?

A

Malrotation of GI tract

or intestinal atresia (atresia = absence of normal opening)

300
Q

In gastroschisis, the herniated viscera and intestines are exposed to (4) things?

A

Gut inflammation

Edema

Dilation

Functionally abnormal bowel

301
Q

With omphalocele and gastroschisis, immediately after birth, the exposed lesions are covered with?

A

Sterile, saline-soaked dressings

Or

Plastic silo to reduce the risk of hypothermia, infection and fluid loss

302
Q

With omphalocele and gastroschisis, fluid resuscitation with __ and/or 5%__ and decompression via __ are initiated.

A

Crystalloids and/or 5% Albumin

OGT

303
Q

With omphalocele and gastroschisis, what (4) things should you do?

A

Suction OGT

Perform RSI

Give paralytics and observe for markedly increase intra-abdominal pressure

Increase pulmonary pressure (PIP) during the reduction of the eviscerated organs and bowel

304
Q

With omphalocele and gastroschisis, complete reduction is NOT possible due to (3) things?

A

Severely compromised ventilation

Compromised organ perfusion

A staged reduction with silo pouch is performed

305
Q

What disease process is occurring where the esophagus ends in a blind pouch (atresia) and is associated with TEF?

A

Esophageal atresia

306
Q

What is TEF?

A

Tracheo-esophageal fistula

307
Q

Approximately 85% of esophageal atresia with TEF consists of (2) things

A

Dilated promixal esophageal pouch

Fistula between distal trachea and esophagus (left)

308
Q

Esophageal atresia ALONE is more common that TEF alone. True or False

A

False

Second most common

309
Q

Neonates with TEF alone often present with __ as the initial manifestation?

A

Pneumonia

310
Q

What type of esophageal atresia with TEF occurs 85.8% of the time?

A

Type C= 85.8%

Type A = 7.8%

Type B = 0.8%

Type D = 1.4%

Type E = 4.2%

311
Q

Specific cause for esophageal atresia with TEF is unknown. True or False

A

True

312
Q

How often does esophageal atresia with TEF occurs?

A

1: 3,000 births

313
Q

Affected neonates of esophageal atresia with TEF present with?

A

Excessive oral secretions

314
Q

Feeding leads to what (3) things with esophageal atresia with TEF?

A

Choking

Coughing

Cyanosis (hypoxia and bradycardia)

315
Q

How is diagnosis confirmed with esophageal atresia with TEF?

A

By the inability to pass a rigid orogastric tube into the stomach

Or

Radioactive dye in the esophageal pouch

316
Q

With esophageal atresia with TEF, before surgery and inuduction, you must do what?

A

Suction upper esophageal pouch via existing OGT

317
Q

With esophageal atresia with TEF, surgeons might decide to do a staged repair of EA with TEF, by placing first a __ __ to vent the stomach and __ __ __ for parenteral nutrients (which would give the premature neonate some time to grow)

A

Gastrostomy tube

Central venous line

318
Q

With esophageal atresia with TEF, often is a __ induction and ___ ventilation is used until the trachea is secured, particularly if rigid bronchoscope is used by the surgeon to determine the position of the tracheal fistula

A

IV induction

Spontaneous ventilation

319
Q

What kind of ventilation should you avoid with esophageal atresia with TEF prior to induction?

A

Positive pressure ventilation to prevent gastric inflation

320
Q

What is the process of proper ETT placement with esophageal atresia with TEF?

A

1) right mainstem ETT
2) Auscultate while carefully withdrawing the ETT until bilateral sounds are heard

Tip of the ETT is just ABOVE the carina and usually below the fistula

321
Q

How should you verify the proper placement of ETT with esophageal atresia with TEF?

A

Fiberoptic

322
Q

With esophageal atresia with TEF, careful securing of ETT is important. If the ETT is not in the proper place, what can’t be guaranteed?

A

Adequate pulmonary ventilation

323
Q

With esophageal atresia with TEF, pre-term infants have POOR compliant lungs and occasionally require?

A

Positive pressure ventilation

324
Q

If you encounter desaturation with esophageal with TEF, where is Ventilation occurring?

A

Through the fistula due to “path of least resistance” which may occur

325
Q

Infants with esophageal atresia with TEF usually do not have other congenital anomalies. True or False.

A

False, they do often have.

326
Q

What type of anesthetic should you consider with a patient with esophageal atresia with TEF?

A

Thoracic epidural

327
Q

What do you need to avoid after repair of esophageal atresia with TEF?

A

Avoid instrumentation of esophagus or extension of head = INCREASED risk of repair rupture

328
Q

EARLY/LATE extubation is desired, because it prevents prolonged pressure of ETT on the suture line.

A

Early

329
Q

Infants with esophageal atresia with TEF have a LOW/HIGH proportion of requiring intubation.

A

HIGH

330
Q

Esophageal atresia with TEF are associated with what other congenital abnormalities (VACTERL)?

A

Vertebral abnormalities

Anus (imperforated)

Congenital heart disease

TEF

Radial aplasia/Renal abnormalities

Limb abnormalities

331
Q

What is a LIFE-THREATENING infection that usually affection children age 1-7 years?

A

Epiglottitis

332
Q

What is the common pathogen of epiglottitis?

A

Haemophilus influenzae

333
Q

What other pathogens May contribute to epiglottitis?

A

Streptococcus

Staphalococcus

Candida

Other fungal pathogens

334
Q

Due to the rapid onset and progression of epiglottitis, it requires?

A

Urgent diagnosis and treatment

335
Q

What is epiglottitis?

A

Upper airway obstruction with INSPIRATORY stridor, tachypnea, and retraction

336
Q

With epiglottitis, progressive swelling leads to trapdoor-like occlusion of the __ __.

A

Glottis opening

337
Q

With epiglottitis, pt sits in __ position and demonstrates what (4) manifestations?

A

Tripod position

Drooling

Difficulty swallowing

High fever (>39 C)

Lethargy

338
Q

A child with airway obstruction from epiglottitis and severe distress is immediately moved to?

A

The OR

339
Q

Who should be ready for a child with epiglottitis?

A

ENT/surgical team available for rigid bronchoscopy/tracheostomy/cricothyrotomy

340
Q

Avoid inspection of epiglottitis in ___ because it can cause dynamic airway collapse.

A

The ED

341
Q

What does an enlarged epiglottis look like in an X-ray?

A

Thumb sign

342
Q

When DLing a patient with epiglottitis, the vallecula is obliterated by the swollen lingual tissue, so where should to place the tip of the blade?

A

Still into the vallecula and life the base of the tongue. DO NOT TOUCH THE EPIGLOTTIS DIRECTLY

343
Q

With epiglottitis, downsize the ETT by ___ mm because it lessens the risk of pressure necrosis on the mucosa.

A

0.5 mm

344
Q

After securing the airway with epiglottitis, you should obtain?

A

Throat and blood cultures

345
Q

After the culture, you should give appropriate antibiotics and give what kind of dose of dexamethasone?

A

“Airway dose” Usually 0.5mg/kg (max 10 mg)

346
Q

After securing the airway with epiglottitis, keep the child sedated and allow the child to breathe spontaneously and transport to ICU. True or False

A

True

347
Q

When should you consider extubating a patient with epiglottitis?

A

Extubation after 24-96 hours after supraepiglottic and periepiglottic swelling is reduced

348
Q

What (2) requirements are needed to extubate a patient with epiglottitis? Where should the extubation preferably done?

A

Leak around ETT and show signs of swallowing

In the OR

349
Q

What refers to an infection of the UPPER airway, generally in children, that obstructs breathing a causes a characteristic SEAL-LIKE BARKING cough?

A

Croup (laryngotracheobronchitis)

350
Q

What two signs are seen with croup?

A

Steeple

Or Pencil sign of the proximal trachea (narrow airway between swollen tissue)

351
Q

The cough and other symptoms of croup are the result of inflammation of what (3) areas??

A

Vocal cords/larynx

Trachea

Bronchi

352
Q

When a cough forces air through the narrowed passage, the swollen vocal cord is similar to seal barking. Likewise, taking a breath often produces a high-pitched whistling sound called?

A

Stridor

353
Q

What population of pediatrics does croup occur in?

A

Children age 6 mos- 6 years

354
Q

The cause of croup is often? And onset is?

A

Viral

Onset is insidious with low-grade fevere

355
Q

With croup, inhalation of nebulized __ ___ with 02 mask/cool humidity are used and often relieves airway obstruction/

A

Racemic epinephrine

356
Q

What is the dose of nebulized racemic epinephrine? And how often can you repeat?

A

0.25-0.5 ml of 2.25% epi mixed with 3 ml NS

Repeated treatment (1-4 hrs apart) are often necessary after relief and rebound airway obstruction

357
Q

With croup, if the airway obstruction become severe, the child is treated like a pt with _____

A

Epiglottitis -> quick transport to OR for intubation with surgical team/rigid bronchoscope/tracheostomy available

358
Q

For croup, the length of the intubation, steroid and follow-up are similar to epiglottitis patients. True or False.

A

True

359
Q

When a child arrives at the ED with presumptive foreign body (FB) aspiration require __ __.

A

IMMEDIATE assessment

360
Q

With foreign body aspiration, a history of what should you be suspicious about?

A

Chocking and cyanosis while eating (peanuts or popcorn)

361
Q

A wheezing child may NOT be an “asthmatic”, but may be due to PARTIAL/COMPLETE airway occlusion from a FB.

A

Partial

362
Q

___ may be misinterpreted as a state of emotional upset when it is due to seriously underlying HYPOXEMIA.

A

Agitation

363
Q

If a child is severely distressed because of partial occlusion of the airway, prepare for an immediate ___ for removal of FB.

A

Trip to the OR

364
Q

If a child is stable with FB, __ of the airway may be helpful in identifying and localizing the FB.

A

X-ray

365
Q

What is a great concern with FB when it comes to assisted ventilation

A

The possibility of forcing the FB dismally with assisted ventilation

366
Q

With FB, what is the induction process?

A

Keep the pt spontaneously breathing

Spray the vocal cords with 2-4% lidocaine (5 mg/kg) max before laryngoscopy

367
Q

During the removal of the FB, pt should be ___ anesthetized to prevent the possibility of dropping the FB in the proximal airway.

A

deeply

368
Q

What is possible after the removal of FB and careful assessment during emergence and in PACU is advised?

A

Residual airway edema

369
Q

What medication should you give a patient with FB?

A

“Airway dose” 0.5 mg/kg dexamethasone IV (max 10 mg)

370
Q

What is a developmental defect of the CNS in which a hernial sac (containing a portion of the spinal cord, meninges, and CSF) protrudes through a congenital cleft in the vertebral column?

A

Spina bifida = myelomeningocele

371
Q

What is the cause of spina bifida (myelomeningocele)?

A

Primarily a failure of neural tube to close during embryonic development

372
Q

How often does spina bifida occur?

A

1: 4000 infants

373
Q

What kind of spina bifida occurs when skin and soft tissues cover the defect?

A

Spina bifida occulta

374
Q

What spina bifida lesions where the defect communicates with the the outside?

A

Meningocele or myelomeningocele

375
Q

What is a profusion of the meninges filled with CSF through a gap in the spine?

A

Meningocele

376
Q

What type of spina bifida contains a portion of the spinal cord, its meninges, CSF that do not function below the level of the lesion (including no pain sensation)?

What is myelo?

A

Myelomeningocele

Myelo-nerve roots

377
Q

What (4) things are usually associated with spina bifida?

A

Varying degrees of paralysis of lower extremities

Musculoskeletal defects such as clubfoot flexion and joint deformities or hip dysphasia

Anal and bladder sphincter dysfunction, that can lead to GU disorders (neurogenic bowel and bladder)

Latex prophylaxis (avoiding all latex material) is recommended for prevention of latex allergy and anaphylaxis d/t subsequent surgical procedures and urinary catheterizations

378
Q

What is frequently related to the Arnold-Chiari malformation?

A

Hydrocephalus

379
Q

__ is the most common anomaly associated with myelomeningocele and occurs in approximately 90% of the cases in which the spinal lesion is located in the lumbosacral region.

A

Hydrocephalus

380
Q

___ is a neurological disorder where part of the brain, cerebellum (or more specifically the cerebellar tonsils), descends out of the skull into the spinal area (AKA hindbrain herniation)

A

Chiari Malformation Type I (CM)

381
Q

Chiari Malformation Type I (CM) results in __ parts of the brain and spinal cord, and disrupts the normal flow of __ and intensifies ___.

A

Compression of brain and spinal cord

Normal flow of CSF

Intensifies hydrocephalus

382
Q

With spina bifida, the potential for infection of the CNS dictates EARLY/LATE closure of the sac within __ -__ hours of life.

A

EARLY

12-24 hours

383
Q

What are some anesthesia consideration with spina bifida?

A

Special positioning and cushioning during induction and surgery (bc possibly lateral position during intubation)

384
Q

Post-op, patients with spina bifida are extubated and emerged in the supine position. True or false.

A

False. Intubated in the prone position

385
Q

What is Arnold-Chiari malformation?

A

A malformation consisting of an elongated cerebellar vermis that herniated through the foramen magnum and also compresses the brain

386
Q

What (2) thingsc can you see with chiari malformation?

A

Obliteration of cisterna magna

Downward displacement and hypoplasia of cerebellum

387
Q

What are the (4) symptoms of Arnold-Chiari malformation?

A

Difficulty swallow get

Recurrent aspiration

Stridor

Possible apneic episodes

388
Q

Clindamycin IV dose

A

10 mg/kg

389
Q

Gentamicin IV dose

Give over?

A

2.5 mg/kg

Give over 30 min via alaris pump

390
Q

Ampicillin IV (general)

A

50 mg/kg

391
Q

Vancomycin IV

Give over?

Bag concentration?

A

15 mg/kg

Give over an hr via alaris pump

500 mg/100 ml NS

392
Q

Zosyn is a mixture of what two drugs?

A

Piperacillin

Tazobactam

393
Q

Zosyn dose

Concentration per ml, and bag concentration for >30 kg

A
  1. 5 ml/kg

3. 375 mg/50 ml or 67.5 mg/ml

394
Q

What two drugs make up Unasyn?

A

Ampicillin

Sulbactam

395
Q

Dose of unasyn?

Bag concentration? ML concentration for someone >40 kg?

A

2.6 ml/kg

1500 mg/50 ml or 30 mg/ml

396
Q

Cefepime dose?

Cefepime concentration of bag?

A

50 mg/kg

1000 mg/50 ml NS

Peds-Dr. Sames (10 decks)

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