TEST 3 Flashcards
Children exhibit different pharmacokinetics from adults because of their (4) reasons
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)
(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?
Water soluble drugs = LARGER Vd
Lipid soluble drugs = SMALLER Vd
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.
Reduced
Delay
Increase
Pharmacokinetics in children, some medications may displace bilirubin from its ____ ____ ____ and possible predispose an infant to ____.
Protein binding sites
Kernicterus
Pharmacokinetics: it is important to carefully ____ of all medications that are administered to ____ and ____ infants to the desired response.
Titrate doses
Preterm and term
There are (2) reasons why neonates require a ____ dose of succinylcholine compared with the adult. Neonates have a ____ Vd for succinylcholine than adults.
Higher
Larger
___ -____% of body weight of neonate is extracellular fluid (ECF) whereas in the adult ECF is only ____-____ of the body weight.
40-50%
20-25%
_____ distributes in the ECF volume-so more drug is needed on a per kg basis.
Succinylcholine
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.
Immature
Neonates require ____ as much succinylcholine on a body weight basis than older children or adults.
TWICE
The neonate has a ____ sensitivity to nondepolarizing NMB agents than the adult and would require a ____ amount of the drug.
GREATER
Smaller amount
Nondepolarizing NMBs acts as a ____ ACh antagonists at the ____ neonatal NMJ.
Competitive
Immature
Neonates/infants have a ____ Vd for muscle relaxants and would require a ___ amount of the drug.
greater Vd
Greater amount of the drug
The ____ Vd (normally requiring a greater amount of drug) is offset by the ____ sensitivity of nondepolarizing muscle relaxants at the NMJ.
Increased
Increased
Neonates, infants, children require the ___ dose of nondepolarizing neuromuscular relaxants as adults on a weight basis.
Same
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.
LD 50
Adult
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
Increased brain permeability
immature BBB
___ ____ 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.
Incomplete myelination
Volatile concentration INCREASES more rapidly in alveoli in children than adults. That results from (3) things
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
Excretion/recovery of inhaled anesthetics is also ___ in children than adults.
Quick __ -> Quick ___.
Faster
Quick on -> Quick Off
What kind of a drug is toradol?
NSAID with potent analgesic properties
What age can you start using ketorlac?
Age of 2
What can toradol be used as?
An adjuvant to opioid analgesia to reduce potential respiratory depression/ PONV or for treatment of mild to moderate pain
What patients should you use ketorlac with caution in?
Patients with renal problems, reduced renal blood flow and in asthmatic patients (allergic reactions to NSAIDS)
Why does ketorlac have potential for post op bleeding?
Inhibition of platelet function through inhibition of cyclooxygenase
Compared to Asa, ketorlac’s platelet inhibition is _____________ and is gone when ______________________ .
Platelet inhibition is reversible and is gone when the drug has been excreted
Should you ask the surgeon before you give ketorlac?
Yes ask if there is any contraindication because the increased risk of bleeding.
How should ketorlac be drawn up?
In a TB syringe be careful to not overdose
What is the concentration of ketorlac?
1mL/30 mg
If drawing up in TB syringe each increment = how many mg?
Each increment = 3 mg
IV dose of ketorlac?
0.5mg/kg IV
Max 30 mg
IM dose of ketorlac?
0.5-1mg/kg
Max 30 mg
What is the dose of narcan?
0.001 mg/kg
1mcg/kg
What kind of drug is narcan?
Pure opioid antagonist and is rapidly effective in reversing opioid induced side effects.
What side effects of opioids does narcan reverse?
Respiratory depression N/V pruritus urinary retention constipation
What is the concentration of narcan in the vial?
0.4mg/ml
How do you dilute narcan?
Dilute 1 ml: 0.4mg/ml in 9 mL NS; will make it 40 mcg\ml
With Narcan, Respiratory depression may be reversed with as little as ________ mcg/kg although larger doses (up to _______ mcg/kg) may be required
1-10
Up to 100
Why do we use small doses of narcan?
To reverse the respiratory depression without reversing the analgesic effects
Why can resedation occur after giving narcan?
The elimination HL of narcan is shorter than the HL of most opioids
What should you do if resedation occurs after narcan?
Repeat the same dose IM and monitor closely
What are the major side effects of narcan?
Hypertension Cardiac arrhythmias (including v fib) Pulmonary edema (non cardiogenic)
What kind of a drug is flumazenil (Romazicon)?
GABA receptor competitive antagonist that reverses the effects of benzodiazepines
Does flumazenil work on opiods?
No
What is the concentration of flumazenil?
What is the dose of flumazenil?
1mg/10mL
0.01mg/kg or 10 mcg/kg
What are the adverse affects with flumazenil?
N/V Blurred vision Sweating Anxiety emotional liability
Because elimination HL of flumazenil is _____________ than the HL of most benzodiazepines, ____________ can occur.
Shorter
Resedation
What should you do if resedation occurs after flumazenil administration?
Repeat the dose and monitor closely
Dose of roc for RSI?
0.6-1.2 mg/kg
Rocuronium induction IV dose?
0.45-0.6mg/kg
Cisatracurium dose?
0.1-0.2 mg/kg
Pancuronium dose?
0.1mg/kg
Is rocuronium long/intermediate acting? Is it a non depolarizer/depolarizer?
Intermediate acting
Non depolarizer
Does rocuronium have cardiovascular or histamine release?
No rocuronium is without cardiovascular and histamine effects and similar to vecuronium
What is the dose of rocuronium?
- 6 mg/kg (good intubating dose)
1. 2 mg/kg for RSI
How is rocuronium eliminated?
Eliminated by the liver; only 10% is excreted by the kidneys
Neonates appears to be more sensitive to Roc than older infants? T/F?
True
What is the DOA of rocuronium?
90 minutes after 0.6 mg/kg
What kind of drug is cisatracurium?
Intermediate non depolarizer
What hemodynamic affects does cisatracurium have?
Minimal histamine release; stable hemodynamics
What is the intubating dose of cisatracurium?
What is the duration of action
0.1-0.2 Mg/kg
DOA 35 minutes
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?
True
How is nimbex eliminated?
Hoffman elimination and ester hydrolysis
Vecuronium is a depolarizing NMB agent. T/F?
False; non depolarizer
How long is the duration of action of vecuronium in children and small infants?
35-45 min in children
60-70 min in small infants
Does vecuronium have cardiovascular side effects?
No and metabolites seem not to have CNS effects
How is vecuronium metabolized?
By the liver and excreted in bile
What can prolong the action of non depolarizer NMB?
Tobramycin, neomycin, gentamicin, and hypothermia
What is the dose of vecuronium?
0.1mg/kg
What drug class is pancuronium (Pavulon)?
Longer acting non depolarizer NMB agent and is preferred when increased HR and BP is desired
What surgery is pancuronium desired, and why?
Pancuronium
Because HR and BP increased is desired
What can pancuronium cause in pre term infants?
Sustained tachycardia
HTN
Increased plasma epinephrine level
Some concern of increased risk of intracerebral hemorrhage
What is the dose of pancuronium?
0.1mg/kg
Each following dose should only be 10-20% initial dose
How is Panc excreted in the kidneys?
In the kidneys; prolonged NMB with renal impairment may occur
Dexamethasone dose for antiemetic?
0.1mg/kg Max 10 mg
Dexamethasone dose for airway?
0.5mg/kg max 10 mg
Why should NDMB always be reversed?
What 3 things can happen if patient is not reversed?
Because residual muscle paralysis will impair respiration and may result in hypoxemia, hypercapnia and acidosis.
What patients can inhibit the antagonism of NDMB?
Hypothermia can inhibit antagonism making neostigmine not fully effective
What antibiotics can prolong effect of NDMB?
Neomycin
Gentamicin
Tobramucin
In neonates and infants it is very easy to judge if twitches are present. T/F?
False; it is difficult
What are some clinical signs that patient/child is reversed?
Ability to flex hips/arms
Lift legs
Return of abdominal muscle tone
What is the dose of neostigmine?
What is the dose of glycopyrrolate?
0.07 mg/kg
10 mcg/kg
What drugs does sugammadex reverse?
Roc or vec
What is the recommended dose of sugammadex after 2 twitches have returned?
2mg/kg
What is the recommended dose of sugammadex after 1-2 post tetanic twitch revocery (no response to TOF)
4mg/kg
Can you use sugammadex for RSI dose of roc or vec?
No! ROC reversal only
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.
16 mg/kg
3 minutes
1.2
What cardiac affects have been seen after administration of bridion/sugammadex?
Cardiac arrest and marked bradycardia
What drug does sugammadex compete with and patient education is very important?
Hormonal contraceptives, female patients who have received sugammadex during GETA are not protected for 7 days and can become pregnant
Does atropine of glycopyrrolate have more CNS effect?
Atropine crosses BBB; glycopyrrolate has minimal CNS effect
What drugs are used to offset the muscarinic effects of neostigmine for reversal of NDMB?
Glycopyrrolate
Atropine
Atropine and glycopyrrolate are used to treat bradycardia with oculocardiac reflex and dry up secretions (drooling with ketamine). T/F?
True
What drug should be used cautiously in Down syndrome because narrow angle glaucoma?
Atropine may worsen glaucoma and needs to be administered cautiously
What are the 3 5 HT3 (serotonin) receptor antagonists?
Odansetron (zofran)
Granisetron (kytril)
Dolasetron (anzemet)
Odansetron is used for prophylaxis and treatment of PONV and to reduce the severity of established N/V. T/F
True
What is the dose of odansetron?
0.1 mg/kg up to 4mg
How can odansetron be given?
IV, IM or orally
What can improve the efficacy of preventing PONV if given together?
Odansetron and dexamethasone
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)
24
When should you give the anti emetic dose of dexamethasone?
Early and give zofran before then end of the case
When should you avoid dexamethasone?
Patients who are newly diagnosed with leukemia/lymphoma and other hematologic malignancy
What is acute tumor lysis syndrome?
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
Acute tumor lysis syndrome is characterized by what?
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
It is okay to give dexamethasone to a patient with acute tumor lysis. T/F?
False it is like pouring oil on fire
What are amides degraded by?
Cytochrome p450
What are amides?
Lidocaine, mepivacaine, bupivicaine, levobupivacaine, ropivacaine, etidocaine
How are esters broken down?
By hydrolyzed by plasma cholinesterases
What are the esters?
Procaine
2 chloroprocaine
Tetracaine
Max dose of bupivacaine with epi
2.5mg/kg (max 175 mg)
Max dose of bupivacaine with epi PF caudal?
2.5 mg/kg
Max 175
What is the max dose of lidocaine without epi infiltration
4.5 mg/kg
What is the max dose of ropivacaine?
2.0 mg/kg
With 0.25% Bupivacaine with epi = 2.5 mg/mL -> give 1mL/kg
.
With 0.2% ropivacaine = 2mg/ml -> give 1mL/kg
.
What is epinephrine (adrenaline) IV used to treat?
Cardiac arrest
Hypotension
Heart failure
Dose and how often should you dose epi?
10 mcg/kg Q 3-5 minutes
Infusion dose of epi?
0.01- 1 mcg/kg/min
Dose of epinephrine to treat bronchospasm
1-2 mcg/kg IV to treat bronchospasm
___ speeds up induction and emergence (second gas effect). ___ might be a cause analgesia for ____.
Nitrous Oxide
Nitrous Oxide
Difficult IV sticks
Any gas-filled cavities within the body are vulnerable for expansion if nitrous oxide is administer including (5) things.
Obstructed Bowel
Pneumothorax
Cuff of ETT
LMA
Bubble veins
Theoretically, ___ __ should be avoided during laparoscopic surgery to avoid expanding ____ ___ that reach the venous circulation.
Nitrous oxide
CO2 bubbles
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.
Individual’s needs
Excess
____ is considered one of many factors causing retinopathy of prematurity (ROP) in infants weighing less than 1500 gm or less than 28 wks gestation.
Hyperoxia
It is recommend to ___ __ with O2 to maintain SpO2 of 90-95% (even during transport of premature neonates)
blend air
However, while avoiding hyperoxia, one must never lose sight of the importance of avoiding _____.
Hypoxemia
____ is life-threatening whereas hyperoxia is not.
Hypoxemia
One cannot be ___ if ROP occur, provided a reasonable and safe approach to ___ administration and ventilation has been made.
Faulted
Oxygen
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.
Negative Pregnancy Test
____ is NOT appropriate for inhalation induction due to its pungent odor which ______ airway reflexes and causes what three things.
Isoflurante
Irritate
Laryngospasm
Breath-holding
Coughing
Isoflurane is a profound ____ depressant. Rapid increase in ISO concentration decrease what 3 things especially in hypovolemia.
respiratory depressant
Decreased BP, HR, RR (especially in hypovolemia)
ISO (like DES) reacts with desiccated ___ ___ or ___ to release carbon monoxide into breathing circuit
Soda Lime
Baralyme
_____ has a very low blood solubility and the CV effects are similar to ISO.
Desflurane
Like ISO, ____ is not suited for inhalation induction, because of its very ___ odor and is irritant to the airway, and causing what (3) things
Desflurane
Pungent
Laryngospasm
Coughing
Breath-holding
Emergence from DES is very ___ and may result in ___, particularly if ___ is present.
Rapid
Delirium
Pain
DES interacts with desiccated ____ ___ or ____ and may produce potentially toxic concentration of ____ ___.
Soda Lime
Baralyme
Carbon Monoxide
____ is excellent for inhalation induction, has somewhat ____ odor and does NOT cause ____ irritation.
SEVO
Pleasant
Airway
With SEVO, CV and respiratory effects are similar to ____.
ISO
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.
Smooth and Rapid
Increased
SEVO
What is a dissociated state of consciousness which children are inconsolable, irritable, uncompromising, and/or uncooperative?
Emergence Delirium
During emergence delirium, many of the children ___ to recognize and respond ____ to their parents.
Fail
Appropriately
Incidence of emergence delirium (ED) after inhalation anesthesia in children ranges from ___ -____% (similar prevalence with SEVO, DES, ISO and less with HALO)
2-80%
The highest incidence of emergence delirium occurs in children __-__ years of age.
1-5 years
Appropriate ___ ___ often attenuates emergence delirium.
Pain relief
____ is hydrolyzed in the presence of soda lime/Baralyme to a potentially nephrotoxic Compound A.
SEVO
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.
Primates
25 MAC-hrs
2 L/min
All ___ ___ ___ and ___ trigger MH reactions in susceptible adults and children.
Potent anesthetic volatiles
Succinylcholine
In 1993, the FDA issued a __ __ warning against the routine use of SUX in children and adolescents except for ____ ____ ____.
“Black box” warning
Emergency airway management
Sux black box warning was based on several case reports of ____ and primarily in children with undiagnosed ___.
Hyperkalemic cardiac arrests
Undiagnosed Ducchenne muscular dystrophy
Hyperkalemia cardiac arrests and children with undiagnosed duchenne muscular dystrophy has a staggering mortality rate of ___%.
55%
Sux hyperkalemic cardiac arrest occur in what type of population?
Male children 8 years and younger
The use of succinylcholine should be reserved for ___ ___ or instance where immediate securing of the airway is necessary like in these (4) circumstance.
Emergency intubation
Larygospasm
Difficult airway
Full stomach
Intramuscular route when a suitable vein is inaccessible
In the presence of hypoxemia with partial or complete upper-airway obstruction. Give _____ IV Sux or ____ IM Sux.
And apply what?
0.1-1 mg/kg IV Sucs
4 mg/kg IM Sucs
Positive pressure ventilation
Sux is infrequently associated with an increase in ____ ___ tone “trismus” and is considered a trigger for _____.
Masseter muscle tone
MH
What circumstances do you avoid Succinylcholine?
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
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.
1 meq/L
1 single dose
Single dose of SUX can occasionally cause ___ and ___ in children.
Bradycardia
Asystole
What do you give prior to administering Sux?
Atropine IV 10-20 mcg/kg
Atropine IM 20-40 mcg/kg
Minimum of 100 mcg Atropine
Propofol is a short-acting ____, with a _____ recovery; however longer exposure to propofol might prolong ___ due to redistribution in fat cells.
Hypnotic
Pleasant recovery
Emergence
Propofol induction dose for GETA: ____ mg/kg, short period of ___ and slight decrease in ____.
2-4 mg/kg
APNEA
BP
Propofol is painful on injection; therefore you must do what (2) things?
1% Lidocaine (1 mg/kg)
Inject slowly for induction
Extreme caution regarding _____ with propofol is required. Wipe with ____ pads and cover with ______. Avoid Propofol induction through ____ lines= increased infection/occlusion.
ASEPSIS
Alcohol pads and
Cover with stopcock
PICC
Propofol infusion is ____. Consider TIVA for pts with h/o severe _____.
Antiemetic
PONV
Propofol infusion rates are greater in _____ than in ____. Titrate to ___ and surgical stimulation. Be cautious in combination with ____ and ____.
Children than adults
RR
Narcotics and anxiolytics
MRI/CT/PET scan/Radiation Tx with no surgical stimulation and only Propofol dose
150-250 mcg/kg/min
Propofol infusion dose only no other sedative for endoscopy/colonoscopy/bronchoscope
350-450 mcg/kg/min
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?
Thiopental
What is the induction dose for Thiopental?
4-6 mg/kg
_____ are especially sensitive to barbiturates due to ___ ___ ___ of the drug in the serum (3-4 mg/kg)
Neonates
Reduced protein binding
With thiopental, IV induction should NOT be used when there is a potential airway problem. True or False.
True
Barbiturates are contraindicated in patient with ____
Porphyria
What is porphyria?
An enzyme deficiency in heme production
Barbiturates should be administered with extreme care in patients who are ___ and ___.
Hypovolemic
Limited cardiac reserve
Thiopental reduces what two pressure and is therefore useful these two surgeries?
IOP and ICP
Neurosurgical and ocular procedures
What is a phencyclidine derivative that produces profound analgesia, unconsciousness, cataleptic state and amnesia?
Ketamine
Ketamine increases what (3) things. Ketamine causes minimal ___ __ if given alone and in adequate doses.
Increases HR, MAP, CO
Respiratory obstruction
With ketamine, ____ with increased risk of laryngospasm, give an antisialagogue.
Hypersalivation
Ketamine also increases ____ and ____ which is not desired in neuro cases.
CBF/ICP
cerebral metabolic rate
Ketamine Increase IOP and nystagmus movement so therefore it is not desired for?
Eye surgery
Ketamine has a high incidence of ___ __ (hallucination- bad dreams - frank psychosis). Give ___ intra-op, prior to administer.
Emergence phenomena
Midazolam
Ketamine works well for what kind of children population?
Mentally retarted teenagers who are uncooperative with IV placement or inhalation induction
What class drug is Dexmedetomidine (Precedex)?
Selective alpha 2 agonist
What (4) things does Precedex do?
Decreases sympathetic tone
Attenuates stress response to anesthesia and surgery
Causes sedation and analgesia
Used as adjunction during regional anesthesia
Dexmedetomidine is ___ -___ x more alpha specific than Clonidine.
8-10 x
What is the loading dose for Precedex?
0.5-1 mcg/kg (over 10-20 minutes to attenuate hypotension
What is the continuous infusion dose for Precedex?
0.2-1 mcg/kg/HOUR
Titrate to desired sedation level
Etomidate is ___ -based hypnotic induction agent. Like propofol, it is ___ with administration.
Steroid
Painful
Etomidate is mostly avoided by of what two reasons?
Risk of anaphylactic reactions
Suppression of adrenal function
With etomidate, inhibition of steroid synthesis can occur after a ____.
Single dose
When is etomidate useful?
And what is the induction dose?
Children with head injury and unstable CV status (cardiomyopathy)
0.3 mg/kg IV
Sufentanil induction dose
1-10 mcg/kg
Remifentanil IV GTT dose
0.05-2 mcg/kg/min
What is the most commonly used opioid during GETA in infants and children?
Fentanyl
Clearance of fentanyl in pre-term infants is extremely variable due to what 3 factors?
Reduced elimination HL due to decreased hepatic blood flow
Reduced hepatic function
Age dependent changes in Vd
What is the usual initial dose of Fentanyl and titrate to what?
1-2 mcg/kg
titrate to RR
Fentanyl is highly ____ and crosses ____ rapidly.
Lipid-soluble
BBB
What is commonly used opioid when prolonged analgesia is required?
Hydromorphone (dilaudid)
Dilaudid is ___ -____ X more potent than IV morphine.
5 - 7.5x
How should you dilute Dilaudid in children?
Dilute 1 mg into a 10 ml syringe (add 9 ml of NS)-> 100 mcg/ml
What is the initial and titration dose of Dilaudid?
10 mcg/kg- initial dose
5-10 mcg/kg through the case.
With Dilaudid, It is BEST if the child is spontaneously breathing with LMA or ETT, titrate to age-appropriate RR. True or False
True
What are the (3) side effects of Dilaudid?
Sedation
N/V
Respiratory depression
When is dilaudid NOT appropriate?
For infants and small children up to age 2 years for same day surgery with discharge to home
____ 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.
Morphine
Increased
Morphine IM/IV dose
0.1 mg/kg
(3) adverse effects of Morphine due to histamine release
Histamine release causes
Hypotension
Sedation
PONV
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
FALSE. It causes respiratory depression/apnea and needs close observation
What drug has an extremely high margin of safety and is more protein-bound and has a short elimination HL?
Sufentanil
Since sufentanil blocks some stress responses, it is used for what kind of surgery?
Cardiac surgery
Administered in high doses for cardiac surgery in infants.
Produces CV stability with minimal depression of ventricular function
Sufentanil IV dose
1-10 mcg/kg bolus
Sufentanil infusion during GETA
0.1-1.5 mcg/kg/HOUR
Adverse effect of Sufentanil?
Resp depression/apnea
CHEST WALL RIGIDITY
Along with Dilaudid, morphine, it is NOT appropriate for infants and small children for same-day surgery with discharge to home. True or False
True
What 3 medications is not allowed for children under 2 years old having same day surgery?
Dilaudid
Morphine
Sufentanil
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.
Remifentanyl (Ultiva)
How is Remifentanyl eliminated
‘
Tissue esterase hydrolysis
Continuous infusion dose of Remi (as an adjunct to GETA)
0.05-2.0 mcg/kg/MIN
After bolus administration of Remifentanyl, what can potentially happen?
Severe bradycardia
Hypotension
Remi should only be administered only by continuous infusion
(4) Adverse effects of Remifentanyl
Apnea
Bradycardia
Chest wall rigidity
Vomiting
What syndrome entails chronic infusion of fentanyl and can cause tolerance and signs of dependence?
Neonatal Abstinence Syndrome.
With neonatal abstinence syndrome, children require what?
Large doses to prevent response to surgical stimuli -> Use other anesthetic or analgesic drugs
What are (7) signs of withdrawal with Neonatal Abstinence Syndrome?
Crying
Hyperactivity
Fever
Tremors
Poor feeding and sleeping
Extreme cases, vomiting and convulsion
To prevent Neonatal Abstinence Syndrome, all long term infusion of fentanyl should be ____ slowly over days.
Tapered
What are the (2) primary indications of methadone in children?
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
Methadone is ___-___ protein bound and is a ___ ___ __ and is the main determinant of free factor of Methadone.
60-90% protein bound
Alpha 1-acid glycoproteins
In children, Methadone has large ____, high plasma clearance and long _____.
large Vd
Long Half life
Midazolam IV dosse
0.05- 0.1 mg/kg
In children, midazolam has been shown to produce ____ and ____ sedation.
Tranquil and calm
Midazolam properties (3)
Reduces separation anxiety
Facilitates induction of anesthesia
Enhances ANTEgrade amnesia
Oral midazolam tastes ____ but provides adequate effect after ___ -___ minutes.
Bitter
10-15 minutes
What (2) things can Midazolam do? (Respiratory wise)
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
What drug is an analgesic and antipyretic drug WITHOUT anti-inflammatory actions?
Acetaminophen
Tylenol does NOT metabolize well by infants and children of all ages. True or False.
False. Metabolizes early
What is a useful as an analgesic for mild pain and opioid-sparing adjunct for severe pain?
Acetaminophen
PO dose of Tylenol
10-15 mg/kg
PR dose of Tylenol
30-40 mg/kg (loading dose)
IV Tylenol dose <50 kg
How long should you infuse it for? And how often?
15 mg/kg IV Q6H for at least 15 minute
Do not exceed 750 mg/dose or 3.75 g/day
IV dose Tylenol for > 50 kg
1000 mg IV Q6H (not to exceed 4 g/day)
With Tylenol, what can occur with overdose and particularly at risk in the seriously ill child?
Hepatic Failure
The fetal formation of the diaphragm is completed during what weeks?
7th - 10th week of gestation
What congenital emergency is occurring when intrusion of abdominal viscera (including intestines, stomach, liver, spleen) into the thoracic cavity?
Congenital Diaphragmatic Hernia
What are 90% of congenital diaphragmatic hernia?
Posterolateral Bochdalek-type.
80% left side Bochdalek-type CDH
9% of congenital diaphragmatic hernia are what type?
Anterior Margagni-type
What type of congenital diaphragmatic hernia occurs less than 1% of the time and is often fatal?
Bilateral hernia
What is the incidence of congentinal diaphragmatic hernia?
1:2000-5000 live births
What is the hallmark of congenital diaphragmatic hernia (CDH)?
Abnormal compression of pulmonary structure and cardiopulmonary sequelae
In CDH, lung growth is severely retarded in what (6) ways?
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
How is CDH diagnosed antenatal?
Via level 2 sonography in a tertiary care center
CDH often manifest as? In a neonate?
Severe respiratory distress in the neonate
Severe respiratory distress occurs in CDH because of what (2) reasons?
Lung hypoplasia and
Inadeqyate pulmonary gas exchange
What two S/S occurs in CDH?
Scaphoid abdomen
Bowel sounds in the lung field
What CDH is the less severe respiratory compromise but with symptom of bowel obstruction?
Morgagni-type CDH
With CDH, at birth, what is is the utmost priority?
DEFINITIVE airway
At birth with CDH, Avoid ___ ___ with potential gastric insufflation.
Mask ventilation
At birth, CDH patients should be intubated and mechanically ventilation with rapid low ____ and limited __ __ __ to reduce risk of barotrauma/right sided pneumothorax.
LOW tidal volume
Limited peak inspiratory pressures
At birth with CDH, decompression of intestinal contents via ____.
NGT
What (6) tests/considerations should you have prior to taking care of CDH patient?
Chest X-ray
ABGs
Echo
Cranial ultrasound
IV access
A-line
Why is a cranial ultrasound ordered with CDH?
To rule out intraventricular hemorrhage (IVH)
With CDH, what is contraindicated if IVH is present due to the need of systemic heparinization?
ECMO
With CDH, the current practice is, surgical repair is IMMEDIATE/DELAYED.
Delayed (until the neonate is optimized)
What (7) supportive care during surgery with CDH?
NICU ventilator/HFOV (high frequency oscillatory ventilation)
Serial ABGs
High dose opioid
Low dose volatile
Avoid N2O
Inhaled NO
ECMO?
Overall survival for neonates with CDH has remained ___. Survivors often have a number of ___ ___ afterwards.
Unchanged
Medical issues
What congenital emergency has an olive-shaped mass and occurs more in males (1:500 life births)?
Hypertrophied pyloric stenosis
What relieves the obstruction of hypertrophied pyloric stenosis?
Surgical pyloro-myo-tomy
Pyloric stenosis usually manifests with 2nd-6th week of life with __ __.
Nonbilirous vomiting
With protracted vomiting in hypertrophied pyloric stenosis, infants may became what (3) things?
Hypokalemic
Hypochloremic
Alkalotic
In hypertrophied pyloric stenosis, renal response to vomiting is two fold. What are those two responses?
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
With hypertrophied pyloric stenosis, hypocalcemia is associated with?
Hyponatremia
In hypertrophied pyloric stenosis, further fluid loss, prerenal azotemia may foreshadow what (2) things?
Hypovolemic shock
Metabolic acidosis
Pyloric stenosis is a ___ emergency and NOT __ emergency.
Medical emergency
Not a surgical emergency
Before pyloric stenosis, patient comes to the OR, they need to be __ __ stabilized and ___ within normal limits.
Intravascular volume
Electrolyte
Infants with pyloric stenosis are considered “full stomach” and therefore require what (2) things?
IV access
RSI with cricoid pressure held in place until airway is secured
With pyloric stenosis, before RSI, what should you give and do?
Give 100 mcg of atropine
Suction thoroughly with large-bore OGT the gastric contents (right and left lateral/supine)
While suctioning in pyloric stenosis, the patient is ASLEEP. True or false
False.
Awake and gags and cries during suctioning
While suctioning the patient with pyloric stenosis, allow the patient to do what in between?
Catch a breath
With hypertrophied pyloric stenosis, pt should be what prior to extubation?
Fully awake (like every RSI patient)
Due to ___ ___, pyloric stenosis patients have often a sluggish “breathing drive.”
Metabolic alkalosis
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
True
With pyloric stenosis, patients post op usually have numerous complications. True or False
False.
Mostly uncomplicated
Necrotizing enterocolitis (NEC) is NOT an anomaly but an ___ found mostly in __ __.
Illness
Preterm infants
With Necrotizing enterocolitis, infants often have bowel ___ and ___ from either the bowel or liver.
Perforation
Hemorrhage
With NEC, premature infants can develop __ ___ and requires vasopressor support and enormous volume requirements.
Severe hypotension
Infants of NEC will generally require transfusion of large amounts of blood products due to what (2) things?
Hemorrhage
Dissemated intravascular coagulopathy (DIC)
NEC infants may appear very toxic with __ and __ abdomen and metabolic and ___ abnormalities (coagulopathy, DIC)
Distended and tender abdomen
Metabolic and hematologic abnormalities
With NEC, X-rays usually suggest?
An ileus with edematous bowel and later demonstrate gas in the intestinal wall and biliary tract
With NEC, what is gas in the intestinal wall called?
Pneumatosis intestinalis
With NEC, “free gas” in the intestine occurs after?
perforation
Morbidity associated with NEC include (3) things
Short bowel syndrome
Sepsis
Adhesions associated with bowel obstruction
Associated condition/risk factors for NEC include? (9)
Birth asphyxia
Hypotension
RDS (respiratory distress syndrome)
PDA
Recurrent apnea
Intestinal ischemia
Umbilical vessel cannulation
Systemic infections
Early feedings
What disease occurs when intestines are COVERED with amnion?
Omphalocele
Where is the omphalocele defect?
At the BASE of the umbilicus
What disease process occurs when intestines are NOT covered and exposed to hypothermia, infection and dehydration?
Gastroschisis
Where is the defect in gastroschisis?
Periumbilical
With omphalocele, failure of the __ to migrate from the yolk sac into the abdomen during 5th-10th week gestation?
Gut
With omphalocele, when does the defect occur? And how often?
Earlier
And in 1:6000 births
___ develops as a result of occlusion of the omphalomesenteric artery during 12-18th week of gestation.
Gastroschisis
When does gastroschisis occurs and how often?
Later with less problems
Occurs 1: 15,000 live births
What is O-B-B-B memory bridge?
O = omphalocele
B = base of umbilicus
B = bag (sac)
B = “bad news” - other anomalies
Omphalocele is associated with genetic, cardiac, urologic and metabolic abnormalities, what (4) are they?
Trisomy 21
Beckwith-Widemann S
Congenital heart disease
Extrophy of the bladder
Gastroschisis is NOT associated with other congenital anomalies, but may exhibit (2)?
Malrotation of GI tract
or intestinal atresia (atresia = absence of normal opening)
In gastroschisis, the herniated viscera and intestines are exposed to (4) things?
Gut inflammation
Edema
Dilation
Functionally abnormal bowel
With omphalocele and gastroschisis, immediately after birth, the exposed lesions are covered with?
Sterile, saline-soaked dressings
Or
Plastic silo to reduce the risk of hypothermia, infection and fluid loss
With omphalocele and gastroschisis, fluid resuscitation with __ and/or 5%__ and decompression via __ are initiated.
Crystalloids and/or 5% Albumin
OGT
With omphalocele and gastroschisis, what (4) things should you do?
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
With omphalocele and gastroschisis, complete reduction is NOT possible due to (3) things?
Severely compromised ventilation
Compromised organ perfusion
A staged reduction with silo pouch is performed
What disease process is occurring where the esophagus ends in a blind pouch (atresia) and is associated with TEF?
Esophageal atresia
What is TEF?
Tracheo-esophageal fistula
Approximately 85% of esophageal atresia with TEF consists of (2) things
Dilated promixal esophageal pouch
Fistula between distal trachea and esophagus (left)
Esophageal atresia ALONE is more common that TEF alone. True or False
False
Second most common
Neonates with TEF alone often present with __ as the initial manifestation?
Pneumonia
What type of esophageal atresia with TEF occurs 85.8% of the time?
Type C= 85.8%
Type A = 7.8%
Type B = 0.8%
Type D = 1.4%
Type E = 4.2%
Specific cause for esophageal atresia with TEF is unknown. True or False
True
How often does esophageal atresia with TEF occurs?
1: 3,000 births
Affected neonates of esophageal atresia with TEF present with?
Excessive oral secretions
Feeding leads to what (3) things with esophageal atresia with TEF?
Choking
Coughing
Cyanosis (hypoxia and bradycardia)
How is diagnosis confirmed with esophageal atresia with TEF?
By the inability to pass a rigid orogastric tube into the stomach
Or
Radioactive dye in the esophageal pouch
With esophageal atresia with TEF, before surgery and inuduction, you must do what?
Suction upper esophageal pouch via existing OGT
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)
Gastrostomy tube
Central venous line
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
IV induction
Spontaneous ventilation
What kind of ventilation should you avoid with esophageal atresia with TEF prior to induction?
Positive pressure ventilation to prevent gastric inflation
What is the process of proper ETT placement with esophageal atresia with TEF?
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
How should you verify the proper placement of ETT with esophageal atresia with TEF?
Fiberoptic
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?
Adequate pulmonary ventilation
With esophageal atresia with TEF, pre-term infants have POOR compliant lungs and occasionally require?
Positive pressure ventilation
If you encounter desaturation with esophageal with TEF, where is Ventilation occurring?
Through the fistula due to “path of least resistance” which may occur
Infants with esophageal atresia with TEF usually do not have other congenital anomalies. True or False.
False, they do often have.
What type of anesthetic should you consider with a patient with esophageal atresia with TEF?
Thoracic epidural
What do you need to avoid after repair of esophageal atresia with TEF?
Avoid instrumentation of esophagus or extension of head = INCREASED risk of repair rupture
EARLY/LATE extubation is desired, because it prevents prolonged pressure of ETT on the suture line.
Early
Infants with esophageal atresia with TEF have a LOW/HIGH proportion of requiring intubation.
HIGH
Esophageal atresia with TEF are associated with what other congenital abnormalities (VACTERL)?
Vertebral abnormalities
Anus (imperforated)
Congenital heart disease
TEF
Radial aplasia/Renal abnormalities
Limb abnormalities
What is a LIFE-THREATENING infection that usually affection children age 1-7 years?
Epiglottitis
What is the common pathogen of epiglottitis?
Haemophilus influenzae
What other pathogens May contribute to epiglottitis?
Streptococcus
Staphalococcus
Candida
Other fungal pathogens
Due to the rapid onset and progression of epiglottitis, it requires?
Urgent diagnosis and treatment
What is epiglottitis?
Upper airway obstruction with INSPIRATORY stridor, tachypnea, and retraction
With epiglottitis, progressive swelling leads to trapdoor-like occlusion of the __ __.
Glottis opening
With epiglottitis, pt sits in __ position and demonstrates what (4) manifestations?
Tripod position
Drooling
Difficulty swallowing
High fever (>39 C)
Lethargy
A child with airway obstruction from epiglottitis and severe distress is immediately moved to?
The OR
Who should be ready for a child with epiglottitis?
ENT/surgical team available for rigid bronchoscopy/tracheostomy/cricothyrotomy
Avoid inspection of epiglottitis in ___ because it can cause dynamic airway collapse.
The ED
What does an enlarged epiglottis look like in an X-ray?
Thumb sign
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?
Still into the vallecula and life the base of the tongue. DO NOT TOUCH THE EPIGLOTTIS DIRECTLY
With epiglottitis, downsize the ETT by ___ mm because it lessens the risk of pressure necrosis on the mucosa.
0.5 mm
After securing the airway with epiglottitis, you should obtain?
Throat and blood cultures
After the culture, you should give appropriate antibiotics and give what kind of dose of dexamethasone?
“Airway dose” Usually 0.5mg/kg (max 10 mg)
After securing the airway with epiglottitis, keep the child sedated and allow the child to breathe spontaneously and transport to ICU. True or False
True
When should you consider extubating a patient with epiglottitis?
Extubation after 24-96 hours after supraepiglottic and periepiglottic swelling is reduced
What (2) requirements are needed to extubate a patient with epiglottitis? Where should the extubation preferably done?
Leak around ETT and show signs of swallowing
In the OR
What refers to an infection of the UPPER airway, generally in children, that obstructs breathing a causes a characteristic SEAL-LIKE BARKING cough?
Croup (laryngotracheobronchitis)
What two signs are seen with croup?
Steeple
Or Pencil sign of the proximal trachea (narrow airway between swollen tissue)
The cough and other symptoms of croup are the result of inflammation of what (3) areas??
Vocal cords/larynx
Trachea
Bronchi
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?
Stridor
What population of pediatrics does croup occur in?
Children age 6 mos- 6 years
The cause of croup is often? And onset is?
Viral
Onset is insidious with low-grade fevere
With croup, inhalation of nebulized __ ___ with 02 mask/cool humidity are used and often relieves airway obstruction/
Racemic epinephrine
What is the dose of nebulized racemic epinephrine? And how often can you repeat?
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
With croup, if the airway obstruction become severe, the child is treated like a pt with _____
Epiglottitis -> quick transport to OR for intubation with surgical team/rigid bronchoscope/tracheostomy available
For croup, the length of the intubation, steroid and follow-up are similar to epiglottitis patients. True or False.
True
When a child arrives at the ED with presumptive foreign body (FB) aspiration require __ __.
IMMEDIATE assessment
With foreign body aspiration, a history of what should you be suspicious about?
Chocking and cyanosis while eating (peanuts or popcorn)
A wheezing child may NOT be an “asthmatic”, but may be due to PARTIAL/COMPLETE airway occlusion from a FB.
Partial
___ may be misinterpreted as a state of emotional upset when it is due to seriously underlying HYPOXEMIA.
Agitation
If a child is severely distressed because of partial occlusion of the airway, prepare for an immediate ___ for removal of FB.
Trip to the OR
If a child is stable with FB, __ of the airway may be helpful in identifying and localizing the FB.
X-ray
What is a great concern with FB when it comes to assisted ventilation
The possibility of forcing the FB dismally with assisted ventilation
With FB, what is the induction process?
Keep the pt spontaneously breathing
Spray the vocal cords with 2-4% lidocaine (5 mg/kg) max before laryngoscopy
During the removal of the FB, pt should be ___ anesthetized to prevent the possibility of dropping the FB in the proximal airway.
deeply
What is possible after the removal of FB and careful assessment during emergence and in PACU is advised?
Residual airway edema
What medication should you give a patient with FB?
“Airway dose” 0.5 mg/kg dexamethasone IV (max 10 mg)
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?
Spina bifida = myelomeningocele
What is the cause of spina bifida (myelomeningocele)?
Primarily a failure of neural tube to close during embryonic development
How often does spina bifida occur?
1: 4000 infants
What kind of spina bifida occurs when skin and soft tissues cover the defect?
Spina bifida occulta
What spina bifida lesions where the defect communicates with the the outside?
Meningocele or myelomeningocele
What is a profusion of the meninges filled with CSF through a gap in the spine?
Meningocele
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?
Myelomeningocele
Myelo-nerve roots
What (4) things are usually associated with spina bifida?
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
What is frequently related to the Arnold-Chiari malformation?
Hydrocephalus
__ 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.
Hydrocephalus
___ 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)
Chiari Malformation Type I (CM)
Chiari Malformation Type I (CM) results in __ parts of the brain and spinal cord, and disrupts the normal flow of __ and intensifies ___.
Compression of brain and spinal cord
Normal flow of CSF
Intensifies hydrocephalus
With spina bifida, the potential for infection of the CNS dictates EARLY/LATE closure of the sac within __ -__ hours of life.
EARLY
12-24 hours
What are some anesthesia consideration with spina bifida?
Special positioning and cushioning during induction and surgery (bc possibly lateral position during intubation)
Post-op, patients with spina bifida are extubated and emerged in the supine position. True or false.
False. Intubated in the prone position
What is Arnold-Chiari malformation?
A malformation consisting of an elongated cerebellar vermis that herniated through the foramen magnum and also compresses the brain
What (2) thingsc can you see with chiari malformation?
Obliteration of cisterna magna
Downward displacement and hypoplasia of cerebellum
What are the (4) symptoms of Arnold-Chiari malformation?
Difficulty swallow get
Recurrent aspiration
Stridor
Possible apneic episodes
Clindamycin IV dose
10 mg/kg
Gentamicin IV dose
Give over?
2.5 mg/kg
Give over 30 min via alaris pump
Ampicillin IV (general)
50 mg/kg
Vancomycin IV
Give over?
Bag concentration?
15 mg/kg
Give over an hr via alaris pump
500 mg/100 ml NS
Zosyn is a mixture of what two drugs?
Piperacillin
Tazobactam
Zosyn dose
Concentration per ml, and bag concentration for >30 kg
- 5 ml/kg
3. 375 mg/50 ml or 67.5 mg/ml
What two drugs make up Unasyn?
Ampicillin
Sulbactam
Dose of unasyn?
Bag concentration? ML concentration for someone >40 kg?
2.6 ml/kg
1500 mg/50 ml or 30 mg/ml
Cefepime dose?
Cefepime concentration of bag?
50 mg/kg
1000 mg/50 ml NS
