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EDRA > 6.2 Paediatrics > Flashcards

6.2 Paediatrics Flashcards

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1
Q

Regional anaesthesia

A

Regional anaesthesia in children
is usually done under
general anaesthesia or sedation.

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2
Q

In neonates

Metabolism and effect

A

In neonates,

the liver enzymes
and metabolic processes are immature,

hence there is 
less metabolism of 
local anaesthetics and 
greater chances of 
toxicity as compared to adults.
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3
Q

A1 acid glyco levels

effects

A

In neonates,
α1 acid glycoprotein levels
are 20%–40% of adult levels,

hence higher plasma levels
of unbound free drug
contributes to toxicity as well

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4
Q

When does conjugation of LA reach adult level

A

Around 3 months of age,

the conjugation of
local anaesthetics reaches
adult value,

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5
Q

When does clearance reach adult level

A

whereas full maturation
and clearance equivalent to adults
occur by around 8 months.

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6
Q

is there diff in plasma concentrations when LA injected

A

In children, there may be

higher vascular absorption of
local anaesthetics and

higher plasma concentration.

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7
Q

Is the paediatric nerve equally sensitive to LA

A

As myelination is incomplete up to
the age of 12 years,

local anaesthetic can penetrate
better in the nerves.

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8
Q

Is the mg/kg dose the same vs adults

A

Because of
greater sensitivity and
potential for toxicity,

the dose of local anaesthetic in
children (mg/kg) is less than adults.

Because of loose fascial layers,
volume of LA is a key factor
for spread than dose.

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9
Q

Ester local anaesthetics metabolism

vs amide

why diff

A

Ester local anaesthetics

do not depend on liver
for their metabolism

and have more rapid clearance
than amide local anaesthetics in neonates.

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10
Q

Ester LA and neonates dose

why

A

However, because of

low levels of plasma
cholinesterases in neonates,
ester local anaesthetics
should be used with caution.

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11
Q

Local anaesthetics with their recommended doses

Lignocaine

A

Lignocaine 7 mg/kg (with adrenaline)

5 mg/kg (without adrenaline

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12
Q

Bupivacaine/ropivacaine/levo-bupivacaine dose

A

Bupivacaine/ropivacaine/ 2–4 mg/kg

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13
Q

Procaine

A

Procaine 10 mg/kg

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14
Q

2-Chloroprocaine dose

A

2-Chloroprocaine 20 mg/kg

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15
Q

Bupivicaine and neonates

A

There is
greater risk of toxicity
with bupivacaine in neonates
than adults because of:

1
Liver enzymes being immature –
less metabolism of bupivacaine.

2
Low levels of alpha-1 glycoprotein –
higher free fraction of
bupivacaine.

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16
Q

Early signs of LAST in paeds

A

Regional blocks are usually done
under sedation in paediatric patients.

Therefore, the central nervous system 
signs of local anaesthetic toxicity are
usually masked and the
first sign usually detected is 
cardiorespiratory arrest.
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17
Q

Some anatomical facts in neonates and children

Spinal cord terminates

reaches adult level

A

Spinal cord terminates at L3

and reaches adult level of
L1 by 1 year of age.

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18
Q

Dural sac

neonates ends @

reaches adult level by

A

Dural sac ends at S4 in neonates

and reaches adult level S2 by 1 year of age.

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19
Q

sacrum formed by

A

Sacrum is formed by fusion of sacral vertebrae by 8 years of age.

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20
Q

Tuffier’s line neonates

what level @1

A

Tuffier’s line passes through L5/S1
junction in neonates

and lies at L4/L5 by 1 year.

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21
Q

Epidural space found how estmiation

A

Epidural space may be found at 1 mm/kg body weight.

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22
Q

Are epidural contents the same

A

There is easy passage of catheter in
epidural space, as epidural fat is
less densely packed than adults.

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23
Q

what does spread of LA correlate well with

A

Spread of local anaesthetic correlates
better with body weight than
age in paediatric patients.

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24
Q

Optimum doses for caudal block in children are

A

Optimum doses for caudal block in children are:

0.2% ropivacine 1 mL/kg

or

0.125%–0.175% bupivacaine 1 mL/kg

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25
Epidural opiods in DOSA
Epidural opioids are avoided in day-case surgery because of side effects like nausea, vomiting, respiratory depression and urinary retention.
26
Local anaesthetic adjuvants for epidural in children | most common
most common adjuvant used is epinephrine
27
Epidural opioids dosa? s/e
Avoided in day-case surgeries Side effects like nausea, vomiting, respiratory depression and urinary retention
28
adjuvants for epidural Clonidine dose s/e
Clonidine 1–5 mcg/kg Side effects: hypotension and sedation Ventilatory response to increasing levels of carbon dioxide is blunted
29
adjuvants for epidural Ketamine dose solution safety? s/e
Ketamine 0.25–0.5 mg/kg Preservative-free solution must be used Its safety for epidural use is not established There are few animal studies suggesting neurotoxicity Side effects: psychomimetic effects
30
adjuvants for epidural Midazolam dose solution safety
Midazolam 0.05 mg/kg Preservative-free solution must be used Its safety for epidural use is not established
31
adjuvants for epidural Neostigmine dose solution safety s/e
Neostigmine 2 mcg/kg Preservative-free solution must be used Its safety for epidural use is not established Side effects: nausea and vomiting
32
complication of epidural block predominant organism colonising epidural catheter
predominant organism colonising epidural catheter is | Staphylococcus epidermidis.
33
The treatment of post-dural puncture headache in children involves
The treatment of post-dural puncture headache in children involves 1 bed rest, sedation and 2 analgesics like non-steroidal antiinflammatory drugs. 3 Blood patch may be used if medications fail.
34
EBP in paeds dose
The optimum dose of blood for | blood patch is 0.3 mL/kg.
35
cardiac instability and epidural
Unlike adults, use of epidural in children is cardiostable and presence of hypotension may indicate intrathecal location of catheter or local anaesthetic toxicity.
36
How are test doses monitored in paeds epidurals
Test dose must always be used for epidural catheter, with continuous ECG monitoring for T-wave changes.
37
Confirmation of epidural catheter position can be done with
1 Ultrasonography: 2 Epidural ECG: 3 Electrical stimulation test (Tsui test)
38
Ultrasonography
aids in identifying relevant anatomic structures and placement of epidural catheter. It is reliable only in children aged < 6 months, as calcification of vertebral bodies prevents visualisation after this age.
39
Epidural ECG what changes
Epidural ECG: T-wave changes help in identifying intravascular location of catheter. It may not identify intrathecal placement.
40
Epidural ECG Electrode connected to catheter
``` The right-arm electrode is connected to the epidural catheter, and epidural ECG is compared with standard reference ECG. ```
41
QRS amplitude | Epidural ECG
The amplitude of QRS complex in ECG obtained from epidural catheter increases as the tip reaches thoracic region, where it is comparable to the reference ECG.
42
Epidural ECG can it be used to confirm placement
It can be used to confirm placement of epidural catheter after neuromuscular blockers have been given or local anaesthesia given in epidural space.
43
Electrical stimulation test (Tsui test) cathode to anode to
Electrical stimulation test (Tsui test): cathode attached to epidural catheter while the anode is attached to skin.
44
Electrical stimulation test (Tsui test) Change after LA if correct
Within the epidural space, after correct placement of local anaesthetic, there would be increase in the current threshold current required to produce the motor response.
45
Electrical stimulation test (Tsui test) No change after dose not useful when
No change in threshold current indicates intravascular placement of catheter. It is not useful if neuromuscular blockers have been administered or local anaesthetics given in epidural space.
46
Nerve stimulators for epidural stim what current same as peripheral?
Nerve stimulators used for epidural stimulation test must be able to deliver a current up to 10 mA. As the nerve stimulators used for peripheral nerve blocks usually deliver a current up to 5 mA, they are unsuitable.
47
What element can be added to stim catheter to help Nerve stimulators used for epidural stimulation
Epidural-stimulating catheter containing metal element helps in proper electrical conduction and decreases the resistance to flow of the current.
48
Stylet epidural catheter use? Nerve stimulators used for epidural stimulation
The epidural catheter with stylet protects the tip and helps in easy threading of the catheter
49
Stylet ends how far from tip what shape does that produce Nerve stimulators used for epidural stimulation
The stylet ends 10 mm proximal to tip, forming a J shape during insertion.
50
Where is ground electrode placed Nerve stimulators used for epidural stimulation why
The ground electrode must be placed on upper limb and lower limb for lumbar and thoracic epidural catheter, respectively, to avoid any error from direct muscular stimulation by the electrical current
51
Caudal block needles with stylet
Caudal block can be done with ``` needles with stylet, as they provide good tactile sensation and prevent contamination of epidural space with skin tags ```
52
Caudal block IV cannulae
Intravenous cannula can be used, as they aid to detect placement in the blood vessel or bone.
53
Caudal block position
Caudal block can be performed in prone (adults) or lateral decubitus position (children)
54
How to identify sacral hiatus margins
Proper identification of sacral hiatus is done by drawing a line between the two posterior superior iliac spines. This line forms the base of an equilateral triangle whose apex is formed by the sacral hiatus
55
The needle angle for the skin puncture change after what is punctured Caudal block
The needle for the skin puncture must be angulated at an angle of 70°– 80° and the angle must be decreased to 20°–30° once the sacrococcygeal ligament is punctured.
56
Cannula over needle technique aids how
For caudal block, the cannula-over-needle technique aids in proper identification of the caudal space. The cannula slides off easily in the caudal space if the needle is in the right location.
57
Cannula over needle technique helps also ID what decreases risk of
It also helps in identifying needle placement in the bone or blood vessel. It decreases the risk of intrathecal placement.
58
epidural block in paediatric skin to epidural space distance in children vs adults
skin to epidural space distance in children | is less than in adults
59
skin to epidural space distance in neonates | mean
mean distance in neonates is around 1 cm.
60
Puncturing lig flavum vs adults
There is less tactile sensation on puncturing the ligamentum flavum as compared to adults
61
is hypotension common in epdural block
Sympathetic blockade is well tolerated in the paediatric population, and presence of hypotension must prompt suspicion of intravascular or intrathecal placement.
62
distance of the epidural space from skin may be dependen
distance of the epidural space from skin may be dependent on age and body weight of the child.
63
Tip of epidural catheter location
tip of the catheter must be at the surgical site, as the distance in children between adjacent vertebrae is very small
64
Threading the catheter into a | thoracic location from a lumbar insertion site
Because of formation of lumbar curvatur as the child grows, threading the catheter into a thoracic location from a lumbar insertion site becomes difficult
65
Approach for thoracic epidurals
Thoracic epidural block is done via median approach in children, compared with paramedian approach in adults.
66
CSF volume infants v adults
Cerebrospinal fluid volume in infants is 4 mL/kg, whereas in adults it is 2 mL/kg. in neonates in mL/kg is larger than adults
67
Duration of spinal in paeds vs adults dose block duration increases with
duration of spinal anaesthesia is shorter than for adults and they require higher dose of local anaesthetic. Duration of block increases with age.
68
Spinal positioning in paeds vs adults why
For proper positioning in sitting position, neck flexion, required in adults, must be avoided in infants. Neck flexion may compromise the airway in infants and is not very helpful for spinal anesthesia.
69
Hypobaric soln and infants
Hypobaric solutions are not routinely used in infants
70
What scale can be used to assess block <2yo
Bromage scale can be used to assess spinal block in children under 2 years of age
71
Modified Bromage score
1 Complete block (unable to move feet or knees) 2 Almost complete block (able to move feet only) 3 Partial block (just able to move knees) 4 Detectable weakness of hip flexion while supine (full flexion of knees) 5 No detectable weakness of hip flexion while supine 6 Able to perform partial knee bend
72
PDPH kids v adults
In children, | the incidence of PDPH is less than for adults.
73
Sympathetic block HD changes
Sympathetic blockade is better tolerated in infants, and changes in heart rate and blood pressure are rare.
74
Preloading in infants
Preloading is rarely required in infants prior to spinal blockade
75
Is spinal in prem a relative C/I
Spinal anaesthesia is preferred in preterm infants, as it reduces but does not eliminate the risk of post-operative apnea
76
Spinal anaesthesia and post op apnoea in prem eliminated
reduces but | does not eliminate the risk of post-operative apnea
77
Relative contraindications to spinal anaesthesia in paeds
Relative contraindications to spinal anaesthesia include coagulation abnormalities, local infection, raised intracranial pressure, degenerative neurological disease, refusal by parents and presence of ventriculoperitoneal shunts.
78
Scalene approach in paeds
Parascalene approach is preferred over interscalene in children to reduce risk of complications
79
In parascalene approach whats blocked
In parascalene approach, roots and trunks of brachial plexus are blocked.
80
Needle approach | In parascalene approach
The needle is inserted at the junction of upper two thirds and lower one third of an imaginary line drawn from C6 to the midpoint of clavicle.
81
Commonest BP block approach in paeds
Axillary block is the most common approach to brachial plexus block in the paediatric population
82
change in complication in paeds given performed under GA
Despite performance of blocks under general anaesthetic, the incidence of complications is not increased

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