Exam 4: Pediatric Anesthesia 2 (Becky M.) Flashcards by Autumn Walker

Pre-op Anxiety

What age is less prone to peri-op anxiety & parental separation?

< 9 mos

1-3 yrs most prone

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Pre-op Anxiety

Interventions for anxiety b/o age:
1-3 yrs old:
3-6 yrs old:
7-12 yrs old:

1-3: distraction
3-6: pre-op play
7-12: explain more, actively participate

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Physical Exam

What are some physical anomalies that can indicate a difficult airway?

size/shape of head
mandible size/shape
maxilla size/shape

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Physical Exam

What is the list of predictors of difficult airway in children? (9)

Mandibular Protrusion
Mallampati Classification
Movement of the atlanto-occipital joint
reduced mandibular space
Increased tongue thickness
Age < 1 yr
ASA II-IV
Obesity
Maxillofacial & Cardiac surgery

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Syndromes w/ difficult airway

Pierre-Robin Sequence (4)

micrognathia (small lower jaw)
glossoptosis (tongue rests more backwards and downwards)
cleft palate
cervical dysfunction

small chin, difficult to intubate

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Syndromes - difficult airway

Treacher Collins Syndrome (3)

micrognathia
small oral opening
zygomatic hypoplasia (underdevelopment of zygomatic bone)

small chin, difficult to intubate

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Syndromes - difficult airway

Apert Syndrome (4)

limited cervical motion
macroglossia
micrognathia
midface hypoplasia

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Syndromes - difficult airway

Hunter & Hurler Syndrome (2)

cervical dysfunction
macroglossia

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Syndromes - difficult airway

Beckwith-Wiedemann Syndrome (1)

macroglossia

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Syndromes - difficult airway

Freeman-Sheldon Syndrome (3)

Circumoral fibrosis
microstomia (small mouth opening)
limited cervical motion

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Syndromes - difficult airway

Down Syndrome/Trisomy 21 (3)

atlantooccipital abnormalities
small oral cavity
macroglossia

difficult masking, x-ray for neck clearance

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Syndromes - difficult airway

Klippel-Feil Syndrome (1)

cervical fusion

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Syndromes - difficult airway

Hallerman-Streiff Syndrome (1)

Microstomia

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Syndromes - difficult airway

Arthrogyroposis (1)

cervical dysfunction

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Syndromes - difficult airway

Cri-du-chat Syndrome (2)

Micrognathia
Laryngomalacia (soft and floppy supraglottic larynx)

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Syndromes - difficult airway

Edwards Syndrome (1)

micrognathia

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Syndromes - difficult airway

Fibrodysplasia Ossificans Progressiva (1)

limited cervical motion

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URi

What are 8 common perioperative respiratory adverse events? (PRAE)

bronchospasm
laryngospasm
breath holding
atelectasis
arterial oxygen desaturation
bacterial pneumonia
post-intubation croup
unplanned hospital admission

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URI

What things can decrease the risk of PRAE?

IV induction vs. inhalation induction
LMA vs. ETT

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URI

How long can bronchial hyperreactivity persist for?

Up to 6 weeks

recommendations to wait 2 weeks after sxms

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URI

What sxms indicate we can proceed w/ surgery?

runny nose
no fever
no changes in behavior
clear lungs
older child

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URI

What sxms indicate we should cancel the case?

purulent nasal drainage
fever
lethargic
persistent cough
poor appetite
wheezing
child < 1 or previous preemie

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NPO time clear liquids

2 hours

pedialyte/apple juice

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NPO time breast milk

4 hours

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NPO time infant formula, nonhuman milk, light meal

6 hours

NPO time regular meal (fatty foods)

8 hours

What do we want the mask to cover on a pedi pt?

* cover nose & mouth w/o occluding * not protruding into eyes

How do we determine correct sizing for an **oral airway?**

* tip of the mouth to edge of mandible

What can happen w/ an oral airway that is **too small?**

* it can press on the tongue = occlusion of lingual vein = swollen tongue

What can happen w/ an oral airway that is **too big?**

* protrude out of the mouth = masking difficult * can cover epiglottis & make airway obstruction worse

What pt population is a nasal airway a good option for? How do we measure for an NPA?

* the in b/w stage (choking on OPA) * tip of nose - edge of mandible | **won't help if tongue is obstructing**

What is the formula to determine the ID of an ETT?

* (16 + age in yrs)/4 * (age in yrs/4) + 4 | *formulas are for uncuffed; **subtract 0.5 for cuffed***

What is the average tube ID for a 1-2 yr old?

3.5mm

What is the average tube ID for a **neonate >/= 3kg & infants < / = 1yr**

3.0mm

What are the height/weight based formulas to calculate the length for orotracheal tube placement?

* height(cm)/10 + 5 * weight (kg)/5 +12

What is the age related formula for length of an orotracheal tube placement?

(age in yrs/2) + 12

What is the formula for length of orotracheal tube using the ID of the ETT?

ID of ETT x 3

Pre-term * tube size: * Laryngoscope size: * distance:

* 2.5 uncuffed * 0 * 6-7 cm

Full term * tube size: * laryngoscope size: * distance:

* 3.0-3.5 uncuffed * 0-1 * 8-10cm

3 months - 1 year * Tube size: * Laryngoscope size: * Distance:

* 3.5-4.0 cuffed * 1 * 11cm

2 years * Tube size: * Laryngoscope size: * Distance:

* 4.5-5.0 cuffed * 1-1.5 * 12cm

6 years * Tube size: * Laryngoscope size: * Distance:

* 5.0-5.5 cuffed * 1.5-2 * 15cm

10 years * Tube size: * Laryngoscope size: * Distance:

* 6.0-6.5 cuffed * 2-3 * 17cm

18 years * Tube size: * Laryngoscope size: * Distance:

* 7.0-8.0 cuffed * 3 * 19cm

LMA Size 1 * Pt weight: * Volume:

* < 5 kg * 4mL

LMA Size 1.5 * Pt weight: * volume:

* 5-10 kg * 7mL

LMA size 2 * Pt weight: * Volume:

* 10-20kg * up to 10mL

LMA size 2.5 * Pt weight: * Volume:

* 20-30kg * up to 14mL

LMA size 3 * Pt weight: * Volume:

* 30-50kg * up to 20mL

LMA size 4 * Pt weight: * Volume:

* 50-70kg * up to 30mL

LMA Size 5 * Pt weight: * Volume:

* 70-100kg * up to 40mL

What are 2 types of IV tubing we can use in peds?

* buratrol: prevents overhydrating (10-20mL/kg in buratrol) * microdrip tubing

How can we dilute fentanyl in peds cases?

* 100mcg/2mL in 10mL syringe = 10mcg/mL

What is the emergency dose of **epinephrine?**

0.01mg/kg

What is the emergency dose of **succinylcholine?**

2mg/kg IV or 4mg/kg IM

What is the emergency dose of **atropine?**

0.02mg/kg

What is the dose of **glycopyrrolate?**

0.01mg/kg

What is standard monitoring equipment for peds cases?

1. 3 lead EKG (5 if cardiax Hx) 2. NIBP cuff 3. 2 SpO2 probes 4. temp probe | **adjust monitor settings**

What is the Versed pre-med dose? Onset?

* 0.25-1mg/kg PO **(0.5mg/kg most common)** * onset ~20 min

What is the pre-med dose of Precedex?

1-2mcg/kg intranasal

Ketamine pre-med dose

5-10 mg/kg IM

When would we want to do an IV induction in kids?

1. full stomach RSI 2. known difficult airway (may still be able to do inhalation if easy ventilation)

What is the appropriate N2O:O2 mix for teens?

50:50

When should we turn N2O off in an inhalation induction?

After stage 2!! | *want 100% FiO2*

What is the NMBD of choice in RSI in kids?

**Still succinylcholine**

# Airway management Why are kids prone to upper airway collapse?

Their anatomy * big tongue * big tonsils/adenoids * occiput - flex forward * cephalad larynx

# Airway management What does thoracoabdominal asynchrony indicate in kids?

airway obstruction | *using abodminals more than chest*

What 8 things can we do to relieve airway obstruction in kids?

1. head extension 2. chin lift 3. jaw thrust 4. mouth opening 5. CPAP 6. lateral decubitus position 7. OPA/NPA 8. deepen anesthetic

What is the optimal positioning for ventilation/induction a pedi pt?

* flat on the bed = obstruction * head rest/shoulder roll = useful

How should the hand be held when single-hand masking?

C/E formation * hand on mandibular body - avoid submental area * avoid soft tissue of neck!

What are 3 major goals to peri-op fluid management?

1. meet maintenance requirements 2. replace pre-op NPO deficit 3. compensate for ongoing loss peri-op | **don't over or under hydrate**

What is the 4, 2, 1 rule

* 1st 10 kg = 4mL/kg * 2nd 10 kg = 2mL/kg * Remaining kg = 1mL/kg | **overestimates for sick children**

What are 4 things that impact periop fluid loss?

1. surgical losses 2. environmental temperature 3. cold, dry anethetic gases 4. neuroendocrine regulation affeted by anesthetic agents

How do we calculate pre-op fluid deficit? How do we replace it intra-op?

4, 2, 1 rule x NPO hours * 1/2 1st hour * 1/4 2nd hour * 1/4 3rd hour | **avoid giving > 20mL/kg/hr**

What age is dextrose containing fluids adminsitered?

< 6 mos old | *use w/ buratrol*

What fluids do we give for symptomatic hypoglycemia?

IV 10% Dextrose 2mL/kg

What fluids do we give when seizures from hypoglycemia are present?

* IV 10% dextrose @ 4mL/kg

What are examples of cases we should consider glucose admin?

1. premature infants 2. infants of diabetic moms 3. children w/ DM who got a portion of daily insulin pre-op 4. children who receive glucose based parenteral nutrition

What is the EBV for a premature infant?

90-100mL/kg

What is the EBV for a full-term newborn?

80-90mL/kg

What is the EBV 3mos-3yrs?

75-80mL/kg

What is the EBV for children 3-6 yrs?

70-75mL/kg

What is the EBV for children > 6 yrs?

65-70mL/kg

At what Hct may neonates & premature infants experience a ↑ in apnea?

Hct < 30% | *congenital heart disease may need a ↑ Hct*

What is the formula for MABL (minimal allowable blood loss)?

EBV x (starting Hct - Target Hct) / starting Hct

What is the MABL for a 3yr old weighing 15kg, starting Hct 38%, target Hct 28%?

1. 15kg x 70mL = 1,050mL EBV 2. 1,050mL x (38-25)/38 3. 1,050mL x 13/38 4. 13,650/38 5. 359.2mL = MABL

What is the formula for **volume of PRBCs** to admin?

Volume of PRBCs = (desired Hct - current Hct) x EBV/Hct of PRBCs | **Hct of PRBCs = 60%**

How much will 4mL/kg of PRBCs raise the Hgb?

1g/dL

How much blood will we give to a 3.5 kg baby, current Hct 20, desired Hct 20?

1. EBV = 3.5kg x 80mL = 280mL 2. (25-20) x 280mL/60 3. 5 x 280 = 1,400 4. 1,400/60 = 23.3 mL of blood

What are 2 contraindications to outpatient anesthesia?

1. premature < 35 weeks 2. 60 weeks post-conceptual age | **risk for post-op apnea**

What are contributing factors to peri-op hypothermia in kids? ICEICA

I - inspiration of cool/dry anesthetic gases C - cool irrigating solutions E - evaporative heat loss I - infusion of room temp IVF C - cold OR A - anesthetic induced vasodilation

What are the most common causes of cardiac origin cardiac arrest in children?

1. Hypovolemia 2. Hyperkalemia 3. Myocardial Ischemia 4. sudden arrhythmias

What are 4 common causes of respiratory-related cardiac arrests?

Laryngospasm Bronchospasm Inadequate oxygenation Difficult intubation

What oxygen delivery device should we use when transporting kids to PACU?

Jackson-Rees

Premature infants have an impaired ventilatory response to ________ & ________, leading to ________ ________.

Hypoxia & hypercarbia post-op apnea

What are physiologic contributors to AOP (apnea of prematurity)?

1. inadequate development of respiratory centers 2. incomplete myelination of CNS 3. incomplete CV development = altered responses to stress

What are metabolic contributors to AOP?

1. hypothermia 2. hypoglycemia 3. hypocalcemia 4. acidosis 5. resp. instability

What are anesthetic contributors to AOP?

1. residual anesthetics 2. opioids 3. muscle relaxants 4. sedatives 5. prolonged intubation/ventilation

What 2 things may a premature infant be on to stabilize the resp. rhythm?

1. Caffeine (20 mg/kg - 5mg/kg/day maint) 2. CPAP

What is are 2 anesthetic techniques for neonates having episodes of As & Bs?

* apnea & bradycardia * non-opioid medications * spinal/caudal

What is the incidence of ED in pedi population?

10-80%

What is ED?

Emergence delirium * altered behavior in PACU * restlessness * crying * moaning * incoherence * disorientation

What are some potential causes of agitation/ED?

1. pain 2. cold 3. full bladder 4. fear/anxiety 5. parental separation

What are 4 ways delirium presents in peds?

1. disorientation 2. don't respond to parents/staff 3. no eye contact 4. inconsolable

6 risk factors for ED:

1. age 2-9 2. ENT surgery 3. VA vs. TIVA 4. pre-existing ED 5. anxiety 6. pain

4 treatments for ED

1. tx pain 2. Dexmedetomidine: alpha 2 agonist 3. propofol 4. time

Where does the spinal cord end in newborns?

L3 | *after 1yr old = L1*

Where does the dural sac end in newborns?

S3-S4 | *S1 after 1yr old*

What is the CSF volume in neonates/infants? Adults?

* neonate/infant: 4mL/kg * Adult: 2mL/kg | **need higher dose of LA, have shorter DOA**

What are 3 ex. surgeries where caudal is used?

1. inguinal hernia 2. circumscision 3. orchiopexy

What is the position for caudal anesthesia?

* lateral * knees flexed * chin tilted down

Anatomical landmarks for caudal:

* tip of cocyx to find midline * sacral cornu on sides of sacral hiatus * equiliateral triangle (divot) - where we want to go

What volume of LA in a caudal will provide analgesia to T4-T6 dermatome?

1.2-1.5mL/kg

What is the max concentration of LA that should be used in caudal?

2.5 mg/kg

Exam 4: Pediatric Anesthesia 2 (Becky M.) Flashcards

(114 cards)