Week 5 - Basics of Pediatric Anesthesia Flashcards
Why is weight important during the Pre-anesthetic evaluation in pediatrics?
- Weight and age are extremely important for selection of appropriately sized equipment (ETT/IV/Laryngoscope)
- Drug dosages are weight based (difference in a few kg is a big deal)
- Is the weight appropriate for the child’s age?
What are some tips on how to complete a pre-anesthetic evaluation in pediatrics?
- Get down to their level
- Smile and be friendly
- Acknowledge parents and child
- Spend time bonding
- Mom/Dad/Guardian comfort can foster the child’s comfort
- Find something that may interest them (characters, games, iPhone, sports, school, friends, etc)
What issues are associated with Prematurity?
- Retinopathy of Prematurity (ROP)
- Apnea
- Bronchopulmonary dysplasia (BPD)
- Intraventricular Hemorrhage (IVH)
- Necrotizing Enterocolitis (NEC)
- Patent Ductus Arteriosus (PDA)
When does respiratory control mature in infants?
Not until 42-44 week post-gestational age
-before this hypoxemia will depress ventilation and after it will stimulate ventilation
At what age is over night admission for apnea monitoring required?
Generally 44 weeks without risk factors and 60 weeks post-conceptual age with risk factors
-treat with caffeine 10mg/kg
What is included in the review of systems in pediatrics?
- Assess growth and development (ask about pregnancy and birth course)
- Neurologic (any known issues?)
- Gastrointestinal (reflux - infant excessively “pukey”?)
- Hepatic/Renal (focused review… either we know due to previous hx or reason for current visit) – think bilirubin and competition for plasma proteins
- Respiratory (cough, fever, wheezing, runny nose? work of breathing)
- Cardiac (able to play hard w/o turning blue? any known hx?)
- Airway Assessment (ask parent about teeth)
What is a child at increased risk for during anesthesia if they had a recent URI?
Bronchospasm, Laryngospasm, and Arterial Desaturation
- if URI in the last 4-6 weeks… generally cancel case
- often proceed if minimal symptoms and minor/non-invasive surgery
*take care to optimize situation, minimal stimulation/airway manipulation, keep deep, LMA vs ETT, deep extubation, albuterol
What are signs of a lower respiratory tract infection in children?
- Active wheezing on auscultation
- Coughing up mucus/phlegm of varying colors
- Shortness of breath, tracheal tugging, increased work of breathing
- Fever, malaise, decreased activity level
- Recent pneumonias
What should you administer pre-op if a child is recovering from respiratory illness or mild symptoms?
Nebulizer
Glycopyrrolate for secretions
Keep the child calm – midazolam?
*have diluted epinephrine ready for bronchospasm (ketamine, magnesium, decadron)
At what age does separation anxiety begin?
generally around 8-9 months
What medications are typically used as premedication in pediatrics?
Oral Midazolam: 0.5-0.75 mg/kg (20mg max) – onset 10-15 min, may last 1-2 hours
Intranasal Midazolam: 0.2-0.6 mg/kg – onset 20-30 seconds (BURNS)
Intranasal Precedex: 2-4 mcg/kg – onset ~30 min
IM Ketamine: 4 mg/kg – onset within minutes, profound sedation quickly w/ combative pts (last resort)
*increased salivation - add 10-20 mcg/kg glycopyrrolate
How should you set up your room for a pediatric case?
- Pre-warming: large body surface area to weight ratio causes dramatic heat loss (room temp 72 minimum, infant radiant warmer)
- IV fluids in room (no bubble no trouble!)
- Shoulder Roll (w/ head roll)
- Standard Monitors (pulse ox, 3 lead EKG, appropriate size BP cuff)
Why should you use two pulse oximetry monitors in neonates?
the ductus arteriosus can reopen
- R Hand = pre-ductal
- L Hand/Bilateral Feet = post-ductal
*if the number is very different between the two then it is a clue that the ductus reopened
What are machine setup considerations for a pediatric case?
ALWAYS check ventilator setting before induction
Change alarm parameters
Set NIBP to cycle 1-3 minutes
Turn pulse ox volume up so it is easily audible
How should you prepare the airway supplies for a pediatric case?
Size and age appropriate airway supplies:
- Bag: 500cc/1L/2L
- Circuit sizes
- Mask size
- Oral airway
- ETT tubes (microcuff preferred)
- Laryngoscope blades
- LMA
*prepare multiple sizes of everything
What is the equation of ETT sizing in pediatrics?
Age/4 + 4
*uncuffed – for cuffed minus 0.5 size
What is the emergency drug dosing for Atropine, Succinylcholine, Epinephrine, and Ephedrine?
Atropine: 0.01 mg/kg IV and 0.02 mg/kg IM
SUX: 1-2 mg/kg IV and 4 mg/kg IM (up to 5 mg/kg in neonates)
Epi: 0.5-1 mcg/kg for hypotension/bradycardia and 10 mcg/kg for code
Ephedrine: dilute and titrate for hypotension 1-2.5 mg per dose
What are induction considerations for a pediatric case?
- Apply as many monitors as possible (pulse ox first, can wait on cycling BP until child is asleep)
- Inhalation vs IV (determined by child age and ability to place IV pre-op)
- Sevo with or without N2O (avoid N2O w/ neonates and small infants)
- Increase Sevo slowly in cooperative child (increase in 2% increments – if uncooperative/combative, Sevo 8%)
- Apply remaining monitors/cycle BP once child is asleep
What are some considerations of stage 2 anesthesia in pediatrics?
- Prolonged time in stage 2 w/ inhalation induction (tachycardia/tachypnea, deconjugate eyes)
- Avoid stimulation to child during this time — No IV (wait until stage 2 passes), prone to laryngospasm (treat w/ positive pressure, “laryngospasm notch”, IM/SL SUX
- Watch for Sevo overdose (bradycardia) – don’t take over breathing until IV is in place and running
When should IV induction be done in a pediatric case?
- If you are able to place pre-op IV
- Chronic uncontrolled GERD
- Full Stomach
- Pyloric Stenosis
*place EMLA/LMX cream on child in preop to facilitate IV placement
What are the anesthetic maintenance doses for Propofol infusion, Remifentanil infusion, Fentanyl boluses, and Rocuronium?
Propofol: 100-500 mcg/kg/min
Remifentanil: 0.1-0.4 mcg/kg/min
Fentanyl: 0.5-1 mcg/kg
Rocuronium: 0.5 mg/kg (as needed for surgical exposure)
What should the ventilator settings be for a pediatric case?
- Pressure Control or Volume Control (PCV minimizes chance of over inflation and barotrauma)
- RR increases with decreasing age – titrate to appropriate ETCO2
- Tidal Volume: 5-8 cc/kg (possibly up to 8-10 cc/kg)
- Change I:E ratio to 1:1.5 (if needed) to promote larger tidal volumes without changing PIP
- PEEP as needed – start at 3-5
- Utilize minimal FiO2 to reduce change of O2 toxicity, atelectasis, and free radical creation (30-40%)
What are the typical fluids used in pediatrics?
LR and Plasmalyte are common
*NS can have too high sodium load for neonates to tolerate
How do you dose maintenance fluids in pediatrics?
4-2-1 Rule
- 4mL for first 10kg
- 2mL for next 10kg
- 1mL for rest of pt’s weight
- If on maintenance IV from PICU/NICU/Floor usually leave running
- Assess fluid status before induction (irritability, fontanels, mucus membranes, cap refill, Hct, specific gravity)
What is the doses of a Crystalloid bolus, Albumin, and Blood products in pediatrics?
Crystalloid Bolus: 10-20 mL/kg
Albumin: 5-10 mL/kg
Blood Products: 10-20 mL/kg
*1:1 with blood loss in some cases
What do you treat suspected hypotension in pediatrics with first?
Fluids!
-hypotension = late finding and ominous sign (they maintain normotension until 35% of blood volume is lost)
What are signs of hypovolemia in pediatrics?
Hypotension (late finding)
Tachycardia (sensitive but not specific)
Decreased Urine Output
Weak pulses, cyanosis, pale/cool skin
*check infant’s fontanels and cap refill
What are considerations during emergence for a pediatric case?
- Deep vs Awake Extubation — awake in small babies, deep must have easy airway (place oral airway and minimize stimulation)
- Always suction stomach and oral cavity prior to extubation — test for airway reactivity/stimulation
- Spontaneous Respirations w. adequate TV and ETCO2 levels
- Assess infants/neonates awake level – grimace, attempting to cry
- Long acting narcotic and adjuncts administered
- Once extubated assure adequate ventilation
- Swaddle infants/neonates for comfort
- Take mask and ambu bag with to PACU – quick transport to PACU
What is the treatment for laryngospasm and bronchospasm in pediatrics?
Laryngospasm: positive pressure, deepening with propofol, succinylcholine is last choice
Bronchospasm: positive pressure, deepening with propofol
- Epi 1 mcg/kg
- Ketamine 0.5-1 mg/kg
- Magnesium Sulfate 25-50 mg/kg
- Decadron may be as high as 0.6 mg/kg
What is a reliable indicator of risk for Emergence Delirium in pediatrics? How do you prevent it?
Preop disposition of the child – how the kid got to sleep is an indication of how they may awaken
Prevention with Dexmedetomidine 0.25-1 mcg/kg bolus and 0.5-1 mcg/kg/min infusion if needed
*Most frequent incidence after Sevo administration
What are typical PACU orders for pediatrics?
- IVF at maintenance rate
- Narcotics (morphine or hydromorphone)
- Ondansetron in OR (generally no Phenergan in young kids)
- PRN albuterol and racemic epi if post extubation inspiratory stridor
- Pedialyte when child is awake and patent airway
- Parents to PACU as soon as child is stable
