Week 6: Preoperative preparation and Monitoring Flashcards
Preoperative Fasting Recommendations in Infants and Children
Clear liquids
Breast milk
Infant formula
Solids (fatty or fried foods)
- 2 hours
- 4 hours
- 6 hours
- 8 hours
Chewing gum, what is the concern?
- Gum will increase
______ and ______ (mostly from swallowing saliva). - Elective surgery can _______ as long as gum is spit out.
- Elective surgery should be _______ if the child swallows gum.
- Aspirated gum, at body temperature, is difficult to remove from the bronchus or trachea.
- gastric pH and volumes
- proceed
- cancelled
T/F:
Children can never be trusted to fast. During examination of the airway, look for candy, gum or food in the child’s mouth.
True
Most ASA 1 or 2 pediatric patients who aspirate _______ gastric contents have minimal to no sequelae.
If clinical signs of sequelae from an aspiration occur, they will be apparent within _______ hours.
clear; 2
Preoperative assessment
Body piercings- remove them
Primary and secondary smoking- vaping is not harmless
In order to reduce the incidence of postoperative pulmonary complications, really should stop smoking ___-____ weeks prior to surgery.
6-8
Psychological preparation of children for surgery
0–6 months
- Maximum stress for parent
- Minimum stress for infants, have not yet developed stranger anxiety
Psychological preparation of children for surgery
6 months–4 years
- Maximum fear of separation
- Not able to understand processes and explanations
- Significant postoperative emotional upset and behavior regression is possible
- Begin to have magical thinking
- Cognitive development and increased temper tantrums
Psychological preparation of children for surgery
4–8 years
- Begins to understand processes and explanations
- Fear of separation remains
- Concerned about body integrity and fear of mutilation
Psychological preparation of children for surgery
8 years–adolescence
- Tolerate separation well
- Understands processes and explanations
- May interpret everything literally
- May fear waking up during surgery or not waking up at all
Psychological preparation of children for surgery
Adolescence
- Independent
- Issues regarding self-esteem and body image
- Developing sexual characteristics and fear loss of dignity
- Fear of unknown
Psychological Aspects
- A child’s ______ and/or________ is the most important determinant of persistent behavioral disturbances.
- The type and complexity of the surgical procedure is also a factor.
- The postoperative course should be considered.
- The frequency of surgeries should be considered.
- Children respond positively to an honest description of exactly what they can anticipate and have some control over their situation.
- age
- cognitive development
Psychological Aspects
- Meeting with the patient and the parents requires complete explanations and good communication skills in order to diffuse fear of the unknown.
- Decide if the parent will or will not be present at induction. It is important to set limits as occasionally a parent may demand total control of the situation.
- Certified Child Life Specialists (CCLS) hold bachelor or master degrees in _________ and _________.
child psychology or child life development
Table 4.2 possible anesthetic implications
- History of squatting
- Jaundice
- Frequency
- SCD
- Loose or carious teeth
- TOF
- Drug metabolism/ hypoglycemia
- UTI, DM, Hypercalcemia
- Hydration and possible transfusion
- Aspiration of loose teeth; bacterial endocarditis
The child with seasonal or viral rhinitis, who does not have a ________ or ___________ may proceed with surgery on a case-by-case basis.
Most common allergies
fever or lower respiratory symptoms,
The risk of perioperative respiratory complications is increased; however, it may be difficult to find a disease-free window.
Penicillin and Latex
Involvement of minors in medical decision making Table 5.1
Decision making and techniques
- < 6yr
Involvement of minors in medical decision making Table 5.1
Decision making and techniques
- 6 - 12 y/o
Involvement of minors in medical decision making Table 5.1
Decision making and techniques
- 13 - 18
Involvement of minors in medical decision making Table 5.1
Decision making and techniques
- mature minor
Involvement of minors in medical decision making Table 5.1
Decision making and techniques
- Emancipated minor
Why premedicate?
- To allay anxiety
- Block autonomic (vagal) reflexes
- Reduce airway secretions
- Produce amnesia
- Aspiration prophylaxis
- Facilitate induction
- Analgesia
Premedication: Barbiturates
- Methohexital
- Thiopental
- Rectal: 20- 40 mg/kg (10% solution)
- IM: 10 mg/kg (5%)
- 20 - 40 mg/kg (10% solution)
Premedication: Benzos
Diazepam
Lorazepam
Oral: 0.1-0.5
Rectal: 1
mg/kg
PO: 0.025-0.05
Premedication: Benzos
Midozalam
Rectal: 0.5-1
Oral: 0.25-0.75
Nasal:0.2
IM: 0.1-0.15
mg/kg
Premedication: Phencyclidine
Ketamine
Rectal: 6-10
IM:2-10
Oral: 3-6
Nasal: 3
mg/kg
Premedication:
Clonidine
PO:0.004mg/kg
Premedication:Opioids
Morphine
Meperidine
- IM:0.1-0.2
- IM:1-2
mg/kg
Premedication: Opioids
Fentanyl
Sufentanil
Oral: 0.010 - 0.015 mg/kg (10-15mcg/kg)
Nasal: 0.001-0.002 mg/kg (1-2mcg/kg)
Nasal: 0.001 - 0.003 mg/kg (1-3mcg/kg)
Table 4.4 dose and max
- ampicillin-sulbactam
- ampicillin
- 50 mg/kg (max 3g)
- 50mg/kg (max 2g)
Table 4.4 dose and max
- Cefazolin
- ceftriaxone
- 30mg/kg (max 2g; 3g if >120kg)
- 50-75 mg/kg (2g)
Table 4.4 dose and max
- clindamycin
- Levofloxacin
- 10 mg/kg (900 mg)
- 10 mg/kg (500 mg)
Table 4.4 dose and max
Zosyn
Infants 2-9 months : 80mg/kg
Children >9months and <40kg: 100mg/kg
Max 3.3375 g
Table 4.4 dose and max
Vancomycin
15 mg/kg (15mg/kg)
Aspiration prophylaxis
- Bicitra
- Reglan IV
- Cimetidine
- Ranitidine (IV,PO)
- Famotidine (PO/IV)
- 30ml (0.5-1 ml/kg up to 30 ml)
- 0.1 mg/kg
- 5-10 mg/kg
- 2 mg/kg
- 0.5 mg/kg (not to exceed 40mg/day)
Table 4.10 Differential diagnosis of a child with a runny nose
Noninfectious causes
- Allergic rhinitis: seasonal, perennial,
clear nasal discharge; no fever - Vasomotor rhinitis: emotional (crying); temperature changes
Table 4.10 Differential diagnosis of a child with a runny nose
Infectious causes:
- Viral infections
- Viral exanthems
- Acute bacterial infections
Viral infections
- Nasopharyngitis (common cold)
- Flu syndrome (upper and lower respiratory tract)
- Laryngotracheal bronchitis (infectous croup)
Viral exanthems (diffuse rash)
- Measles
- Chicken pox
Acute bacterial infections
- Acute epiglottis
- Meningitis
- Streptococcal tonsillitis
Table 4.11 upper respiratory tract infection
Consider cancellation if
- Parents confirm symptoms: fever, malaise, cough, poor appetite, just developed symptoms last night.
- Lethargic; ill-appearing
- Purulent nasal discharge
- Wheezing, rales that DO NOT clear
- child <1 year, former premie
- Other factors: history of reactive airway disease, major operation, ETT required.
- Fever >38.5C
- Inpatient procedure that may result in exposure of immunocompromised children to viral/bacterial infection.
Table 4.11 upper respiratory tract infection
Proceed with caution if…
- child has “just a runny nose,” no other symptoms, “much better”
- Active and happy child
- Clear rhinorrhea
- Clear lungs and symptoms have leveled off or have improved
- Older child
- Social issues: hardship for parents to be away from work, insurance will run out
- No fever
- Outpatient procedure that will not expose immunocompromised children to possible infectious agent.
Table 4.13: Induction and maintenance dose based on
- Thiopental
- Propofol
- Synthetic opioids (Fentanyl, Sufentanil, Alfentanil)
- Morphine
- Remifentanil
- Nondepolarizing NMBAs
- Sux
- Sugammadex
- LBW (no infusion)
- LBW / TBW
- TBW / LBW
- IBW / IBW
- LBW / LBW
- IBW / IBW
- TBW
- TBW
The child with OSA (central, obstructive, or mixed).
Caution with opioids and premedication.
Sleep studies and postoperative admissions. Nocturnal desaturations <85% will increase sensitivity to __________.
opioids
Table 4.15 Clinical S/S suggesting OSA
- Predisposing physical characteristics
- > / 95th percentile for age and gender
- Craniofacial abnormalities affecting the airway (Ex: Down syndrome)
- Anatomic nasal obstruction
- Tonsils nearly touching or touching in the midline (kissing tonsils)
Table 4.15 Clinical S/S suggesting OSA
- Hx. of apperant airway obsturction during sleep
2 or more of the following present
1 if patient sleep is not observed by another person
- snoring (loud enough to be heard through a close door)
- Frequent snoring
- Observed pauses in breathing during sleep
- Awakened from sleep with choking sensation
- Frequent arousal from sleep
- intermittent vocalizations during sleep
- Parental report: restless sleep, difficulty breathing, or struggling respiratory efforts during sleep
- Child with night terrors
- Child sleeps in unusual positions
- Child with new-onset of enuresis
Table 4.15 Clinical S/S suggesting OSA
- somnolence
1 of the following
- frequent daytime somnolence or fatigue despite adequate “sleep”
- falls asleep easily in a nonstimulating environment (watching tv, reading, riding in, or driving a car) despire adequate “sleep”
- parent or teacher reports child appears sleepy during the day, easily distracted, overly aggressive, or difficult concentrating
- child often difficult to arouse at usual awakening time
Table 4.15 Determination of Severity
a.
- If a child has signs or symptoms in ________ or more of the above categories, there is a significant probability that he or she has OSA.
- The severity of OSA may be determined by _________.
- If a sleep study is not available, such patients should be treated as though they have _________ sleep apnea unless one or more of the signs of symptoms above is severely abnormal (e.g., _______________,___________,___________), in which cases patients should be treated as though they have severe sleep apnea.
b. If a sleep study has been done, the result should be used to determine the perioperative anesthetic management of a child. (Review the polysomnogram for evidence of nocturnal desaturations <85%, which increases sensitivity to opioids).
- two
- sleep study
- moderate
- weight ≥95th percentile for age and gender
- respiratory pauses that are frightening to the observer,
- child regularly falls asleep within minutes after being left unstimulated without another explanation.
Table 4.15 Pediatric AHI
Severity of OSA
None
Mild OSA
Moderate OSA
Severe OSA
Sleep laboratories differ in their criteria for detecting episodes of apnea and hypoxemia, the Task Force recommends that the sleep laboratory’s assessment (none, mild, moderate, or severe) take precedence over the actual apnea- hypopnea index (AHI, the number of episodes of sleep-disordered breathing per hour). If the overall severity is not indicated, it may be determined by using the following table:
Pediatric AHI
0
1-5
6-10
>10
Special concerns
- Preterm infants are prone to apnea with anemia ( Hct<_______%)
- Admit and monitor all former preterm infants who are less than _______ weeks post conception age.
- If a full-term infant demonstrates any abnormality of respiration after anesthesia, admit overnight for apnea monitoring.
- 30%
- 60
Special concerns
- Bronchopulmonary dysplasia (mild, moderate or severe)
- Seizure disorder (______ medications)
- Sickle cell disease (ensure adequate ______ and ________)
- continue
- hydration and oxygenation
Points to keep in mind during airway positioning of an infant:
- They have a large ______.
- Supine = ________.
- The ________ position is generally not recommended.
- Shoulder roll helpful (careful: _________ will worsen view upon laryngoscopy)
They have :
5. _______ neck with _______range of motion.
6. _______ tongue which lies closer to the ________
7. The larynx is more ____________ as compared to an adult (C4)
- Occiput
- Flexed
- sniffing
- hyperextension
- short, reduced
- Large; palate
- cephalad (C2 - C3)
Inhalation with sevoflurane
- Traditional mask induction with nitrous oxide in oxygen (___:____) for __-___minutes.
- Then introduce Sevoflurane (incrementally or in a single step)
Modified single breath induction works best in older children.
- Prime the circuit with _____% nitrous oxide and ______% sevoflurane. Instruct the child to maximally exhale then take a deep breath once face mask is placed, hold it, then breathe normally.
- 2:1; 1-2
- 70; 8
Delivering CPAP
- CPAP is routinely implemented during the induction phase, especially with:
- Pressure at ___-____ cm H2O is usually effective in keeping the airway from collapsing
- Use care and recall the opening pressure of the lower esophageal sphincter (LES) may be as low as 20 cm H2O - the risk of gastric insufflation exists.
- CPAP is primarily effective for ________ obstructions. It may not be effective for tumors or scar tissue of the airway.
- infants and small children
- 5 to 10
- soft-tissue
Oral airways:
- Oral airways are responsible for up to 55% of anesthesia-related dental complications
- Use caution in the ____-____ year old age group with loose teeth
- Insertion of the airway with a tongue depressor displaces the tongue to the floor of the mouth decreasing the incidence of damage to the __________
- A soft oral airway should not put pressure on the lateral aspect of the tongue = __________ injury
- 5-10
- hard palate
- hypoglossal nerve
Nasopharyngeal Airway
- Correct size measurement: from the auditory meatus to the tip of the nose
- If too long = __________
- If too short = _________
- Potential of traumatic injury to turbinates or adenoids (_____ to ____year olds)
- Potential risk of traumatic injury in children with bleeding disorders or facial abnormalities
- risk of laryngospasm
- risk of upper airway obstruction
- 2-6
Induction, maintenance & recovery
- Leave the sevoflurane at _______% (unless you detect hemodynamic instability (i.e., HR begins to decrease [Stage 2 to Stage 3]).
- Another anesthesia provider or RN will obtain intravenous access.
- Once intravenous access is obtained, discontinue the ____________ and de-nitrogenate with 100% oxygen before manipulating the airway.
- 8
- nitrous oxide
IV induction agents doses:
Thiopental
Methohexital
Propofol
Etomidate
Ketamine
- 5 - 8 mg/kg
- 1 - 2.5 mg/kg
- 2.5 - 3.5 mg/kg
- 0.2 - 0.3 mg/kg
- 1 - 2 mg/kg
Regional anesthesia and local anesthesia
- Play a major role by manipulating the sympathetic system and its pathways.
- Reduced incidence of nausea and vomiting.
- Earlier ambulation and discharge.
- In adults, avoidance of general anesthesia and airway management;
- In pediatrics, regional anesthesia is performed ________ the child is induced via inhalational induction or intravenous induction.
after
Complications in the PACU
- Laryngospasm
- Postoperative stridor
- Emergence agitation or delirium
- Shivering and rigidity
- Nausea and vomiting
- Pain
Hypothermia, usually defined as a body temperature less than ______°C, occurs frequently during anesthesia and surgery.
Unintentional perioperative hypothermia is more common in patients at the extremes of age, and in those undergoing abdominal surgery or procedures of long duration, especially with cold ambient operating room temperatures; it will occur in nearly every such patient unless steps are taken to prevent this complication.
- 36;
-
Infants and children lose heat through four mechanisms:
- Radiation (39%)
- Convection (“wind chill factor” secondary to air turnover of laminar flow in the OR ~20 cm/sec) (34%)
- Evaporation (perspiration, open wounds)(24%)
- Conduction (foam pad on OR table) (3%)
Temperature homeostasis:
- After delivery, the relatively low ambient environmental temperature and evaporation of the residual amniotic fluid from the skin combine to *increase _______ from the newborn infant.
- In addition to these environmental challenges, the newborn is intrinsically disadvantaged as compared to the adult by virtue of the:
- heat loss
- High surface area-to-mass ratio.
Thermoregulation:
- Hypothermia ________ metabolicoxygen requirements and can be protective during cerebral or cardiac ischemia.
- but, unintended perioperative hypothermia has been associated with an increased mortality rate.
reduces
Temperature homeostasis:
- Heat production, relative to body weight, must be greater in the newborn to maintain a normal body temperature to overcome this relative increase in _________.
- Heat production postnatally is the result of _________ and ______________.
- surface area.
- shivering and nonshivering thermogenesis
- In adults, heat production from shivering thermogenesis contributes significantly to maintenance of body temperature under conditions of cold stress.
- In general, _________ thermogenesis is thought to be more important than shivering thermogenesis soon after birth.
nonshivering
Temperature homeostasis:
- ____________ tissue is responsible for the generation of heat associated with nonshivering thermogenesis.
- it can be found in a variety of locations within the body, _________, ________,_______, and ____________ are major sites of brown fat storage.
- Brown adipose
- Upper back
- Neck,
- Mediastinum
- Perinephric areas
Brown adipose tissue is present in the adult, but it is relatively more abundant in the __________.
The degree to which brown fat supplies significant amounts of heat in the premature infant is less clear than it is in the term newborn.
- newborn
- In the normal, unanesthetized patient the _________ maintains core body temperature within very narrow tolerances, termed the “_______” range, with the threshold for sweating and vasodilation at one extreme and the threshold for vasoconstriction and shivering at the other.
- Anesthetics inhibit central thermoregulation by interfering with these hypothalamic reflex responses.
- Postoperative hypothermia should be treated with a forced-air warming device, if available; alternately (but less satisfactorily) warming lights or heating blankets can be used to restore body temperature to normal.
hypothalamus; interthreshold
Hypothermia can present as: (6)
- Metabolic acidosis
- Bradycardia
- Respiratory depression
- Hypoglycemia
- Coagulation disorders
- Impaired drug metabolism
Mapleson System
Mapleson ________ is frequently used for transport and preferable to an Ambu. The patient can breathe _______ and _______ is easily provided.
D
- spontaneously; PEEP
Mechanical Ventilation
The goal in pediatrics is to use minimal ________ to deliver the prescribed volumes.
If the circuit size is changed or a corrugated circuit’s length is altered, the compliance factor is inaccurate and the ventilator will deliver an innacurate _______ _______.
- pressure
- tidal volume
Pulse oximetry pleth is reflective of
Perfusion,
Pulsus parodoxus,
Vasoconstriction
Near-infrared spectroscopy (NIRS)
measures regional tissue oxygenation
Weigh surgical sponges to estimate EBL (1gm weight is equivalent to ______ml blood)
Monitor NMB (difficult in infants; flexion of the ________ is a clinical sign of recovery from NMB)
- 1 ml
- hips
Table 4.18
Symptoms and Signs of Heart Disease
- Feeding difficulties: disinterest, fatigue, diaphoresis, tachypnea, dypsnea
- Poor exercise tolerance
- Tachypnea
- Dyspnea
- Grunting
- Nasal flaring
- Intercostal, suprasternal, or subcostal retractions
- Frequent respiratory tract infections: a result of compression of airways by plethoric vessels leading to statis of secretion and atelectasis.
- Central cyanosis (involving warm mucous membranes: tongue and buccal mucosa) or poor capillary refill
- absent or abnormal peripheral pulses
