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Pediatrics > Test 3 > Flashcards

Test 3 Flashcards

1
Q

Children have _____ protein binding compared to adults

A

Lower

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2
Q

Pediatrics have ______ volume of distribution

Results in what adjustment to water soluble drugs

A

Larger Vd

Larger loading dose of water soluble

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3
Q

4 ways children pharmacokinetics differ from adults

A
  • lower protein binding
  • larger volume of distribution
  • smaller proportion of fat and muscle
  • immature renal and hepatic function
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4
Q

Lipid soluble drugs have ______ volume of distribution in infant compared with adult

A

Smaller

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5
Q

What drugs have larger volume of distribution in infant compared with adult?

What have smaller Vd?

A

Larger Vd- water soluble drugs

Smaller Vd- lipid soluble

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6
Q

Some medications may displace bilirubin from protein binding site predisposing infant to

A

Kernicterus

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7
Q

2 reasons why neonate require a higher dose of succinylcholine compared to adults

A

Larger volume of distribution

NM junction in neonates are immature (more resistant)

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8
Q

Neonates require how much succinylcholine on body weight basis than older children/adults

A

Twice as much

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9
Q

Neonates and nondepolarizing NMB

A

Neonates are more sensitive to NDNMR

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10
Q

Mechanism of neonates requiring same dose of nondepolarizers as adults on weight basis

A
  • greater sensitivity
  • greater Vd

Balances out

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11
Q

Sensitivity of human neonates to most sedatives, hypnotics, and narcotics is partly related to

A

Increased brain permeability

Immature BBB

Also incomplete myelination

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12
Q

Incomplete myelination in infants results in

A

Easier for drugs that are not lipid soluble to enter brain at greater rate than if BBB intact

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13
Q

3 reasons volatile concentration increases more rapidly in alveoli in children than adults

A
  • high level alveolar ventilation in relation to FRC
  • higher proportion of vessel-rich tissues that rapidly equilibrate with blood levels
  • lower BGP of volatile in infants
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14
Q

Excretion/recovery of inhaled anesthetics is ______ in children than adults

A

Faster

Quick on- Quick off

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15
Q

Why should N20 be avoided in laparoscopic surgery?

A

Avoid expanding CO2 bubbles that reach venous circulation

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16
Q

To speed up induction and emergence with volatiles do what

A

N20

Second gas effect

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17
Q

Examples of gas filled cavities within the body that are vulnerable for expansion if N20 is used (5)

A

Bowel obstruction

Pneumothorax

Cuff of ETT

LMA

Bubbles in veins

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18
Q

Factor identified in causing retinopathy of prematurity

A

Hyperoxia

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19
Q

Retinopathy of prematurity occurs in infants weighing ______

Or __________ weeks gestation

A

Less than 1500gm

Less than 28 weeks gestation

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20
Q

It is recommended to blend air with 02 to maintain sat _______

A

90-95%

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21
Q

However while avoiding hyperoxia, one must not lose sight of importance of _____________

A

Avoiding hypoxemia

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22
Q

Check for negative Hcg before any medication to girl who has reached

A

12 years of age

Or younger if post-menses

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23
Q

Why isoflurane not appropriate for inhalation induction

A

Pungent odor

Irritates airway reflexes (causes laryngospasm, breath-holding, coughing, etc)

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24
Q

Rapid increase of Iso concentration effects on CV profile

A

Decreased BP, HR, RR

Especially with hypovolemia

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25
Q

Iso and des react with desiccated soda lime or baralyme to release

A

Carbon monoxide into breathing circuit

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26
Q

Why Desflurane not suitable for inhalation induction

A

Very pungent odor

Irritant to airway

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27
Q

Emergence from des

A

Very rapid

May cause delirium if pain present especially

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28
Q

Risk of emergence delirium is increased when

A

If pain not well controlled

High levels of sevo given throughout the case

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29
Q

Dissociated state of consciousness in which children are inconsolable, irritable, uncompromising, and/or uncooperative

A

Emergence delirium

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30
Q

Highest incidence of emergence delirium occurs in children of what age

A

1-5 years of age

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31
Q

Appropriate________ often attenuated emergence delerium

A

Pain relief

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32
Q

Sevo hydrolyzed to _______ in presence of soda lime/baralyme

A

Compound A (potentially nephrotoxic)

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33
Q

Triggers for malignant hyperthermia

A

All potent volatile anesthetics

Succinylcholine

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34
Q

Why did FDA issue black box warning against routine use of succinylcholine in children

A

Several case reports of

  • hyperkalemic cardiac arrest

Esp in children with undiagnosed duchenne muscular dystrophy

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35
Q

Duchenne muscular dystrophy more common in

A

Male children under 8 years old

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36
Q

Use of succinylcholine in peds should be reserved for

A

Emergency intubation

Laryngospasm

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37
Q

When to avoid succinylcholine in children

A
  • eye trauma (increases IOP)
  • burns
  • massive trauma
  • major neurologic disease
  • renal failure compounded by neuropathy
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38
Q

Single dose of succinylcholine can cause _____ in children

Prevention

A

Bradycardia and asystole

Tx. Atropine 10-20mcg/kg IV or 20-40mcg/kg IM before succ

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39
Q

Infusion rate for propofol in children compared to adults

A

Higher in children

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40
Q

Neonates are __________ sensitive to barbiturates due to

A

More sensitive

Reduced protein binding

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41
Q

Contraindicated in patients with porphyria

A

Barbiturates

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42
Q

Barbiturates should be administered with extreme care in patients which are

A

Hypovolemic

Limited cardiac reserve

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43
Q

Reduces IOP and ICP

A

Thiopental

Good for neurosurgical and ocular procedures

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44
Q

Hypersalivation with ketamine increases risk of

A

Laryngospasm

Give antisialagogue

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45
Q

Why ketamine not used for neuro or eye cases

A

Increases CBF, ICP, CMRO2, IOP, nystagmus movement

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46
Q

Ketamine has high incidence of emergence phenomena (hallucinations, bad dreams, frank psychosis)

How do you prevent

A

Midazolam intraop

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47
Q

Dexmedetomidine is selective A2 agonist

Why good for sg

A

Decreases sympathetic tone

Attenuates stress response to anesthesia and surgery

Causes sedation and analgesia

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48
Q

Steroid based hypnotic induction agent

A

Etomidate

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49
Q

Why Etomidate mostly avoided

A
  • risk of anaphylactoid reaction
  • suppression of adrenal function
  • inhibition of steroid synthesis
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50
Q

Patient population Etomidate is useful

A

Head injury

Unstable CV status (cardiomyopathy)

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51
Q

Fentanyl is ______ lipid soluble

Effect on BBB

A

Highly lipid soluble

Crosses BBB rapidly

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52
Q

Dilaudid peds prep and administration

A

Dilute 1 mg in 10ml syringe (100mcg/ml)

Initial dose 10mcg/kg
Titrated 5-10mcg/kg during case

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53
Q

Hydromorphone is not appropriate for

A

Infants and children <2 yo

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54
Q

Morphine and neonates and infants

A

Ventilatory depressant effects more in neonates and infants

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55
Q

Ventilatory depressant effect of morphine on neonates and infants due to

A

Increased permeability of BBB

Less predictable clearance of morphine

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56
Q

Adverse effects of morphine

A

Histamine release causes hypotension, sedation, PONV

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57
Q

Sufentanil not appropriate for

A

Infants and small children for same day surgery with planned discharge home

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58
Q

Adverse effects of sufentanil

A

Respiratory depression

Chest wall rigidity

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59
Q

Remi should be continuous infusion only

If bolus see

A

Severe bradycardia and hypotension

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60
Q

S/S widrawal

A

Crying

Hyperactivity

Fever

Tremors

Poor feeding

Poor sleeping

Extreme cases:vomiting and convulsions

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61
Q

Primary indication for methadone in children

A

Wean from long-term opioid infusions

Prevent withdrawal

Provide analgesia when other opioids have failed

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62
Q

Methadone protein binding

Main determinant of free factor of methadone

A

60-90%

Alpha 1- acid glycoprotein

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63
Q

Methadone in children

A

Large Vd

High plasma clearance

Long half life

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64
Q

Midazolam enhances what type of amnesia

A

Antegrade

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65
Q

Analgesic and antipyretic drug without anti-inflammatory actions

A

Acetaminophen

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66
Q

NSAID with very potent analgesic properties

A

Ketorolac

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67
Q

Ketorolac avoided in

A

Children <2

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68
Q

Caution with toradol in what patients

A

Renal (reduced renal BF)

Asthmatics (allergic reaction)

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69
Q

Major concern with toradol

A

Inhibition of platelet function through inhibition of cyclooxygenase

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70
Q

Difference in ASA and Toradol on platelet inhibition

A

Toradol platelet inhibition is reversible

Gone when drug excreted

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71
Q

Toradol in TB syringe

Each ml has ______mg

A

3MG

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72
Q

Narcan prep

A

Dilute a vial (0.4mg/ml) in 10cc syringe

40mcg/ml

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73
Q

Side effects of Narcan

A

Systemic HTN

Cardiac arrhythmia (VF)

Noncardiogenic pulmonary edema

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74
Q

Specific GABA receptor competitive antagonist

A

Flumazenil

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75
Q

Flumazenil reverses effects of

A

Benzodiazepines

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76
Q

Which more sensitive to Roc neonates or infants

A

Neonates

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77
Q

Elimination of Cisatracurium

A

Hoffman elimination and ester hydrolysis

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78
Q

Nondepolarizer NMB are prolonged with

A

Tobramycin

Neomycin

Gentamicin

Hypothermia

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79
Q

Because some Down syndrome children have ________ administer atropine cautiously

A

Narrow angle glaucoma

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80
Q

Used for prophylaxis and treatment of PONC and reduce severity of established NV

A

Zofran

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81
Q

Children < ______ dont require antiemetic in general

A

24 months of age

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82
Q

Avoid dexamethasone in patients with

A

Newly diagnosed leukemia/lymphoma

Hematologic malignancy

83
Q

LA

Amides degredation

A

In liver by cytochrome P450

84
Q

LA esters degredation

A

Hydrolyzed by plasma cholinesterases

85
Q

Epi prep and admin for bronchospasm

A

Dilute to 10mcg/ml

1-2mcg/kg IV

86
Q

Nebulized racemic epi dose

<2

> 2

A

<2- 0.25ml 2.25% in 3ml NS

> 2- 0.5ml of 2.25% in 3 ml NS

87
Q

Zosyn bag concentration

3.375mg/50ml

88
Q

What is the most prominent muscarinic action of bolus of succinylcholine in pediatric patient?

How to prevent?

A

Bradycardia

Atropine before succinylcholine

89
Q

2 year old develops laryngospasm postop and becomes bradycardic. Should atropine be given prior, concurrently, or after succinylcholine

A

Atropine then succ

Succ can precipitate more bradycardia, junction alone rhythm, arrest

90
Q

How much NDNMB does beds patient require compared to adult on weight basis?

Succinylcholine

A

NDNMB- same dose

Succinylcholine- twice as much in neonates

91
Q

Infant has greater sensitivity to NDNMB than adult why dose the same as adult?

A

Greater Vd balances out increased sensitivity

92
Q

2 reasons neonates require more succinylcholine on mg/kg basis than adults

A

Larger Vd

NM junction immature (less sensitive)

93
Q

Define ED90. Is EF90 for succinylcholine increased, decreased, or unchanged in neonate compared with adult. Interpretation

A
  • ED90- dose of drug effective in 90% of population
  • ED90 for succinylcholine increased in neonates than adults
  • larger dose given to neonate for adequate paralysis
94
Q

How would ED95 for succinylcholine compare between neonate and adult?

A

Neonate ED95 would be greater

95
Q

4 reasons neonates and infants are more resistant to succinylcholine than older children and adults

A
  • faster clearance
  • larger Vd
  • shorter onset time
  • ED95 2-2.5 times greater than adult
96
Q

Compare action of Vec in infant and adult. Potency, onset, duration, and recovery

A

Similar potently

More rapid onset

Longer duration of action

Recovery slower

97
Q

Definitive treatment for succinylcholine induced hyperkalemia

A

IV calcium
- calcium chloride 10mg/kg

  • calcium gluconate 30mg/kg
98
Q

How does calcium work for hyperkalemia treatment

A

Restores gap between RMP and TP of cardiac cells

99
Q

4 steps to treat hyperkalemia in neonate

A

Calcium chloride/gluconate

Hyperventilation, sodium bicarb, beta agonist

Insulin/glucose infusion

Kayexalate or dialysis

100
Q

How does infant quantity of plasma proteins, body fat, and muscle differ from adult

A

Reduced in infant

Decreased plasma proteins = more free drug to produce clinical effects

May need lower dose

101
Q

3 reasons why uptake of anesthetic drugs typically faster in children than adults

A
  • higher alveolar ventilation per weight
  • increased cardiac output with greater distribution to vessel rich group w/ lower muscle mass = more agent conentration in vital organs (brain)
  • less blood soluble in children (work faster)
102
Q

2 most important reasons why children induced faster than adults with inhalation agents

A

Smaller FRC per unit of body weight

Greater blood flow to brain

103
Q

N20 should be avoided in which pediatric procedures

A

Diaphragmatic hernia

Bowel obstruction

Pneumoencephalography

Tympanoplasty

Congenial emphysema

Lung cyst

Pneumothorax

Necrotizing enterocolitis

PDA

Omphalocele repair

104
Q

Most common type of delirium in children

A

Emergence delirium

Occurs within minutes of regaining consciousness

105
Q

Don’t give ______ to patient having T&A

106
Q

Fetal formation of diaphragm completed during

A

7-10th week gestation

107
Q

Congenital diaphragmatic hernia is result of

A

Intrusion of abdominal viscera into thoracic cavity

108
Q

Majority of congenital diaphragmatic hernias are which type

A

90% posterolateral Bockdalek-type hernia

109
Q

Hallmark of congenital diaphragmatic hernia and cardiopulmonary sequelae is

A

Abnormal compression of pulmonary structures

110
Q

Result of congenital diaphragmatic hernia is

A

Lung growth is severely retarded

Underdeveloped proximal airway divisions and supporting PA vasculature

Fewer fx alveolar units

Deficiency of surfactant

Alveolar instability

Atelectasis

Intrapulmonary shunting of deoxygenated blood

111
Q

Congenital diaphragmatic hernia often manifests as severe respiratory distress in neonate. A direct consequence of

A

Lung hypoplasia

Inadequate pulmonary gas exchange

112
Q

Priority at birth with congenital diaphragmatic hernia is

A

Airway control

113
Q

Airway control and management with congenital diaphragmatic hernia includes

A

Avoid mask ventilation

Rapid low TV

Limited PIP

114
Q

When is surgical diaphragmatic hernia repair performed

A

Delayed until neonate optimized

115
Q

Treatment for hypertrophied pyloric stenosis

A

Surgical pylori-myo-tomy

116
Q

When does hypertrophied pyloric stenosis manifests when with what symptoms

A

2nd to 6th week of life

Nonbilirous vomiting

117
Q

With protracted vomiting these infants may become

A

Hypokalemic

Hypochloremic

Alkalotic

118
Q

Renal response to vomiting

A

Serum pH initially normalized by excretion of alkaline urine with Na and K loss

After lytes depleted kidneys excrete acidic rinse further increasing metabolic alkalosis

119
Q

With further fluid loss prerenal azotemia may foreshadow _____ and _____

A

Hypovolemic shock

Metabolic acidosis

120
Q

Before pyloric stenosis patient comes to OR needs what

A

Intravascular volume stabilized

Electrolytes WNL

121
Q

Induction of pyloric stenosis patient

A

Treated as full stomach

Before RSI 100mcg Atropinie and suction with OGT in different positions

RSI with cricoid pressure

122
Q

Emergence/extubation of pyloric stenosis patient

A

Fully awake

May have sluggish breathing drive

123
Q

Pyloric stenosis patients often have sluggish “breathing drive” due to what

A

Metabolic alkalosis

124
Q

Necrotizing entercolitis is not an anomaly but a _____ found in _____

A

Illness found in mainly preterm infants

125
Q

Systemic effects on necrotizing entercolitis

A

Severe hypotension

Hemorrhage

DIC

126
Q

XRay with necrotizing entercolitis

A

Initially suggests lleus

After perforation will show “free air” in intestine

127
Q

Mobility associated with NEC includes

A

Short bowl syndrome

Sepsis

Adhesions ass with bowel obstruction

128
Q

Omphacele

Intestines are

Defect is where

A

Intestines are COVERED with amnion

Defect at base of umbilicus

129
Q

Gastroschisis

Intestines are

Defect is

A

Intestines are NOT COVERED (exposed to hypothermia, infection, dehydration)

Defect is periumbilical

130
Q

Failure of gut to migrate from yolk sac into the abdomen during 5th-10th week gestation

131
Q

Develops as a result of occlusion of omphalomesenteric artery during 12-18th week gestation

A

Gastroschisis

132
Q

Which is later defect with less problems

A

Gastroschisis

133
Q

Which is earlier defect associated with additional abnormalities

134
Q

Omphalocele is associated with

A

Genetic, cardiac, urology, and metabolic abnormalities

135
Q

Esophagus ends in blind pouch and associated with tracheoesophageal fistula

A

Esophageal atresia

136
Q

Most common form of esophageal atresia

A

Dilated proximal esophageal pouch

Fistula between distal trachea and esophagus

137
Q

Second most common esophageal atresia consists of

A

Esophageal atresia alone

138
Q

Neonates with tracheoesophageal fistula alone often present with what as initial manifestation

139
Q

Neonates affected with esophageal atresia with TEF present with

A

Excessive oral secretions

140
Q

Feeding of neonates with esophageal atresia with TEF leads to

A

Choking

Coughing

Cyanosis

  • hypoxia and bradycardia-
141
Q

Induction of pt with esophageal atresia with TEF

A

Avoid positive pressure ventilation prior to induction

Fiberoptic intubation- right mainstem and withdraw tube slowly until bilat breath sounds but below the fistula

142
Q

ETT tip in esophageal atresia with TEF

A

Just above carina and below the fistula

143
Q

After repair of esophageal atresia with TEF avoid

A

instrumentation of esophagus and extension of head

*increased risk of repair rupture

144
Q

Esophageal atresia often associated with other congenital abnormalities

In particular VATER syndrome (parts)

A

Vertebral abnormalities

Imperforated anus

CHD

TEF

Radial aphasia/renal abnormalities

Limb abnormalities

145
Q

Epiglottitis is ______ usually affecting children of what age

A

Life threatening infection

1-7 years old

146
Q

S/S epiglottitis

A

Upper airway obstruction with INSPIRATORY STRIDOR, tachypnea, retraction

147
Q

On XRay, pt with epiglottitis have what sign

A

Thumb sign of epiglottis

148
Q

Avoid inspection of epiglottis in ED. Intubation of pt with epiglottitis

A

DL with tip of blade in vallecula

Do not directly touch epiglottis

Downsize ETT by 0.5mm

Airway dose of IV dexamethasone 0.5mg/kg

149
Q

When do you extubate with epiglottitis

A

After 24-96 hours

Confirm lead amount ETT, signs of swallowing

Preferably done in OR

150
Q

Laryngotracheobronchitis aka

151
Q

Croup is

A

Infection of upper airway

152
Q

Characteristic of croup

A

Seal-like barking cough

153
Q

XRay with croup shows

A

Steeple or pencil sign of proximal trachea

154
Q

Croup occurs mostly in children of what age

Cause

Onset

A

6mo-6yo

Viral cause

Onset insidious with low grade fever

155
Q

Initial treatment of croup

A

Inhalation of racemic epi nebulizer with O2 and cool humidity

156
Q

A history of ______ must arouse suspicion for foreign body aspiration

A

Choking and cyanosis while eating

157
Q

Myelomeningocele aka

A

Spina bifida

158
Q

Protrusion of meninges filled with CSF through a gap in the spine

A

Meningocele

159
Q

Protrusion containing portion of spinal cord, meninges, and CSF with no function below level of lesion

A

Myelomeningocele

160
Q

Spina bifida usually accompanies by

A

Varying degree of paralysis of lower extremities

Musculoskeletal defects

Anal and bladder sphincter dysfunction

Latex prophylaxis

161
Q

Hydrocephalus with myelomeningocele is frequently related to the _____

Most common anomaly associated with spina bifida

A

Arnold-chiari malformation

162
Q

Chiari malformation type 1

A

Neurologic disorder where brain, cerebellar tonsils descend out of skull into spinal area

Aka hindbrain herniation

163
Q

Anesthesia considerations with spina bifida

A

Potential for infection of CNS dictates early closure (first 12-24 hours of life)

Special positioning during induction and surgery (lateral induction)

Post op remains intubated and prone

164
Q

What is Arnold-Chiari malformation?

A

Malformation consisting of elongated cerebellar vermis that herniated through foramen magnum and compresses brain stem

165
Q

4 symptoms of Arnold-Chiari malformation

A

Difficulty swallowing

Recurrent aspiration

Stridor

Possibly apneic episodes

166
Q

In patient with congenital diaphragmatic hernia, which lung usually involved?

A

Left side through foramen of Bochdalek

80% of cases

LEFT LUNG

167
Q

Is infant with diaphragmatic hernia with bowel extending into chest and emergency?

A

Yes. It is an emergency

168
Q

7 anesthetic considerations for managing infant with diaphragmatic hernia with bowels extending into chest

A

Place NGT

No positive pressure ventilation with mask

Intubate with controlled ventilation

No N20

Monitor PaCO2 and SaO2

100% O2

Give relaxants and opioids after chest opened

169
Q

During intraoperative period of congenital diaphragmatic hernia repair, SaO2 suddenly falls to 65% and HR decreased to 50 bpm. What is like cause and what should be done?

A

Any sudden deterioration in lung compliance, HR, sat, or BP suggests TENSION PNEUMOTHORAX on contralateral side

Confirmed with absent or diminished breath sounds

Insert chest tube immediately

170
Q

What serum sodium, potassium, and chloride concentrations and what UOP needed before surgery in patient with pyloric stenosis?

A

Na >130 mEq/L

K >3 MEq/L

Cl > 85 mEq/L

UOP 1-2 ml/kg/hr

171
Q

Is pyloric stenosis a medical or surgical emergency?

A

Medical but not surgical emergency

Surgery postponed 24-48 hours until fluid and electrolyte abnormalities corrected

172
Q

The newborn has undergone a pyloromyotomy. What might you be concerned about in postoperative period?

A

Increased risk for respiratory depression and hypoventilation in PACU due to persistent metabolic or CSF fluid alkalosis

173
Q

What PIP should be used with patient who has a diaphragmatic hernia? Why?

A

PIP < 30 cm H20

Pneumothorax of contralateral (usually right) lung if PIP too high

174
Q

What might be signaled by sudden fall in lung compliance ( increased PIP), BP, or oxygenation during repair of congenital diaphragmatic hernia?

A

Contralateral (usually right sided) pneumothorax

175
Q

What acid-base and electrolyte abnormalities develop in the patient with pyloric stenosis?

A

Metabolic alkalosis

Hypochloremic

Hypokalemic

Hyponatremic

dehydrated with hypokalemia, hypochloremic alkalosis

176
Q

Neonate is diagnosed with pyloric stenosis presents with NA of 120, CL or 84, RR 16. What is appropriate course of action for this patient?

A

Moderately severe electrolyte abnormalities.

Give D51/2NS with 20-40mEq K at rate of 10ml/kg/hr

Avoid LR- metabolized to bicarbonate

177
Q

What happens to oxyhemoglobin dissociation cure in pyloric stenosis? Why?

A

Shifts to left

Metabolic alkalosis secondary to vomiting

178
Q

How is infant with pyloric stenosis prepared for surgery?

A

Stop oral intake

Metabolically reconstitute with IV Na, Cl, K, glucose

Correct in 12-24 hours

Surgery postponed 24-48 hours

179
Q

What is major concern for inducing and infant scheduled for pyloromyotomy? What do you need to do before inducing a patient with pyloric stenosis?

A

Pulmonary aspiration is major concern during induction

Empty stomach as much as possible with large bore catheter prior to induction

180
Q

What are 6 primary considerations for pediatric patient with hypertrophic pyloric stenosis?

A

Postpone sg until lytes corrected

Correct volume deficit and metabolic alkalosis with NaCl solution with K

Do not use LR

Empty stomach before sg

High risk of aspiration with induction

Anticipate postop respiratory depression r/t CSF alkalosis

181
Q

What 2 electrolyte abnormalities seen with projectile vomiting

A

Hypokalemia

Hypochloremia

182
Q

Gastroschisis

Location

Hernial sac

Associated congenital anomalies

A

Lateral to umbilicus

Hernial sac absent

No associated congenital anomalies

183
Q

Omphalocele

Location

Hernial sac

Associated congenital anomalies

A

Located at base of umbilicus

Hernial sac present

Associated congenital anomalies (downs, cardiac anomalies, diaphragmatic hernia, bladder anomalies)

184
Q

Perioperative management of gastroschisis and omphacele center around what 3 preventative measures?

A

Prevent:

Hypothermia

Dehydration

Infection

185
Q

In which disorder (gastroschisis or omphalocele) are hypothermia, dehydration, and infection most serious? Why?

A

Gastroschisis because hernial sac is absent

186
Q

Where is fistula usually locked in patient with TEF (tracheoesophageal fistula)?

A

90% lower segment of esophagus inserts just above carina on posterior wall of trachea

187
Q

Where is proper placement of ETT in patient with TEF? Procedure for intubating patient with TEF

A

Tip just distal to TEF (bw carina and fistula)

Enter until mainstem, withdraw slowly until bilateral breath sounds present

188
Q

Key to successful anesthetic management of neonate with TEF is correct positions of ERR. What is important consideration for intubating the infant with a TEF? What intubation techniques are appropriate?

A

Avoid positive pressure ventilation.

Use inhalation induction followed by topical application of lidocaine while infant spontaneously breathing

Or

IV or inhalation induction and intubate with paralysis. (May lead to distinction of fistula and stomach after onset of positive pressure ventilation)

189
Q

What is tracheomalacia? What patients are at risk for developing tracheomalacia

A

Tracheobroncomalacia

Softening of tracheal tissue, esp cartilaginous rings

Often associated with TEF or extrensic compression by vascular anomalies or mediastinal masses

May be associated with hyperthyroidism

190
Q

What is etiology of epiglottitis

A

Due to life-threatening infection by Haemophilus influenza type B bacteria

191
Q

9 S/S of epiglottitis

A

Upper airway obstruction

Inspiratory stridor

Chest retractions

Tachypnea

Cyanosis

Drooling

Difficulty swallowing

Insists on sitting and is restless

192
Q

Children of what age get epiglottitis

A

1-7 years old

Occurs with greater frequency in children less than 3 years of age

193
Q

Where is optimal hospital location for intubation of patient with epiglottitis? Why?

A

Intubation in OR

Total obstruction of airway could occur at any moment

An attempt to visualize the epiglottis should not be taken until child is in the OR where intubation of trachea and possible emergency tracheostomy should be performed

194
Q

How is GETA induced in child with acute epiglottitis?

A

Parents should be present until airway secure

Quiet OR, monitors applied at least pulse ox

100%O2/Sevo with pt in sitting position

Start IV, give fluids and atropine.

Orally intubate

NO MUSCLE RELAXANTS

Avoid touching epiglottis with blade

Bronchoscope if needed

Tracheostomy performed if all fail

195
Q

What induction agent and what endotracheal tube size should be used in patient with epiglottitis?

A

Inhalation induction followed by intubation with ETT 1/2 to 1 size smaller than usual

196
Q

How long might one expect the ETT to be left in place in patient with epiglottitis? What is one signal suggesting it is time for extubation?

A

ETT left for 24-96 hours

Air leak appears around ETT signals possibility of extubation

197
Q

Where and when should patient with epiglottitis be extubated?

A

Extubation performed only in OR after DL confirmed resolution of swelling of epiglottitis

198
Q

What is usual cause of croup (laryngotracheobronchitis)?

199
Q

3 treatments for postintubation laryngeal edema (post intubation croup)

A

Aimed at reduction in airway edema

Cool, humidified O2 with face tent

Aerosolized racemic epi

IV dexamethasone (4-6 hours to manifest)

200
Q

What is pathogenesis of post-intubation croup? 6 risk factors for post-intubation croup?

A

Due to glottis or tracheal edema

Associated with:

  • early childhood (<14yo)
  • repeated intubation attempts
  • large ETT
  • prolonged surgery
  • head and neck procedures
  • excessive movement of ETT
201
Q

Appropriate treatment for post-intubation croup?

A

Inhalation of nebulized racemic epinephrine

IV dexamethasone

202
Q

What causes myelomeningocele? Difference between meningocele and meningomyocele?

A
  • caused from failure of neural tube to close in fetus during development. Results in spina bifida

Meningocele is a sac containing only meninges

Meningomyocele is sac present containing meninges and neural elements

203
Q

7 year old patient with spina bifida comes to OR for VP shunt. What is primary concern?

A
  • high probability of latex allergy, may trigger anaphylactic reaction in OR
  • 18-34% of spina bifida patients have a latex allergy
  • most children with intraoperative anaphylaxis had spina bifida
204
Q

Which type of shock is most frequent in pediatric patient?

A

Hypovolemic shock

  • often due to blood loss from trauma
  • children may lost 1/4 of blood volume without significant CV changes in supine position
  • hypovolemic shock due to plasma loss can be seen with burns and peritonitis and may be a component of septic shock

Pediatrics (6 decks)

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