Exam IV: Selected RA Topics for Infants/Children Flashcards by Linsley Lloyd

Q

1999: First reports from animal studies lead to growing concerns r/t anesthesia effects on the ____ ____.

A

developing brain

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Q

Many of our anesthetic agents ‘cause’ anesthesia induced neuroapoptosis. Including:

A

GABAA agonists (propofol, benzos, volatile agents)
NMDA antagonists (ketamine, N2O)
Children from birth to 3 years of age are possibly at risk, especially with anesthesia time > 3 hours and repeated exposures.

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Q

_____ & ______ techniques that allow for avoiding general anesthesia are growing.

A

Neuraxial and regional

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Q

Advantages of Regional Techniques in Children

Regional techniques: Safe and effective for intra-op and post-op analgesia in ____, _____ & _____ neonates.

A

infants, children and pre-term

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Q

Advantages of Regional Techniques in Children

Opioid related adverse effects avoided; promotes ______ ventilation and earlier _____.

A

spontaneous
extubation

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Q

Advantages of Regional Techniques in Children

Spinal
- Reduces risk of post-op apnea and respiratory dysfunction in _____ _____.
- Airway instrumentation can be _____.
- Enhances hemodynamic _____.

A

high-risk infants
avoided
stability

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Q

Advantages of Regional Techniques in Children

Continuous epidural analgesia
- Decreases time to extubation, promotes return of _____ function and decreases _____ _____ response.
- May decrease postoperative sedation needs leading to shorter ____ ____ of stay.

A

bowel
metabolic stress
ICU length

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Q

Advantages of Regional Techniques in Children

Combined with GA, regionals decrease intra-op _____, _____ and neuromuscular blocking agents (reduces risk of negative _____ outcomes).

A

volatiles
opioids
cognitive

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Q

Spinal Anesthesia

Indications:

A

Lower abdominal (urologic and hernias); lower extremity orthopedics; omphalocele, exploratory laparotomy; myelomeningocele

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Q

Spinal Anesthesia

Complications infrequent; no reports of permanent _____ ______ or _____ in children.

A

neurological injury or death

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Q

Spinal Anesthesia

Addition of _____ can double duration.

A

clonidine

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Q

Spinal Anesthesia

Can be combined with ____ ____ for complex procedures.

A

caudal catheter

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Q

Spinal Anesthesia

Continuous ______; fentanyl or midazolam boluses can be used for sedation.

A

dexmedetomidine

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Q

Subarachnoid Block

Anatomic & physiologic differences in children
- Conus medullaris (neonate & infant) more ____ (___); reaches adult level at around ____ ____

A

caudal (L3)
1 year

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Q

Subarachnoid Block

LP should be at ___-___ or ___-___ to avoid spinal cord trauma

A

L4-5 or L5-S1

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Q

Subarachnoid Block

_____ approach preferable

A

Midline

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Q

Subarachnoid Block

Sacrum more ____ and ____ making access to SA space from caudal canal more ____ (dural puncture more likely)

A

narrow and flat
direct

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Q

Subarachnoid Block

_____ _____ less dense

A

Ligamenta flava

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Q

Subarachnoid Block

CSF turnover rate much _____ (_____ block duration)

A

greater
shorter

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Q

Subarachnoid Block

Less than ____ ____ between skin and SA space

A

1.5 cm

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Q

Subarachnoid Block

Decreases incidence of post-op apnea in ____ ____

A

former premies

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Q

Subarachnoid Block

______ info has caused growing appeal for SABs in infants and young children

A

Neuroapoptosis

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Q

Subarachnoid Block

____ + _____ causes more apnea than GA

A

SAB + ketamine

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Q

Subarachnoid Block

Deafferentation: Sedation d/t decreased ____ ____ to RAS from periphery (can be advantage or disadvantage)

A

sensory input

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Subarachnoid Block For now, admission criteria same regardless of ____ ____

anesthetic technique

Peds SABs uncommon beyond _____

infancy

SAB Hemodynamics Infants: SABs and epidural blocks _____ stable than in older children and adults

more

SAB Hemodynamics Even with upper thoracic blocks, ____ ____

BP stable

SAB Hemodynamics High spinals cause bradycardia that responds ____ to anticholinergic

well

SAB Hemodynamics Infants rely more on ______ for TV, so respiratory fx is affected more than in children

diaphragm

SAB Hemodynamics Most compensate and tolerate _____

well

SAB Technique Usually sitting, local with ____ _____

1% lidocaine

SAB Technique Midline LP @ L4-5 or L5-S1 with ___ gauge or smaller, ____ inch spinal needle (several available in peds sizes)

22 1.5

SAB Technique After injection, MUST REMAIN ______ TO AVOID HIGH SPINAL (No ___ ____ - caution with grounding pad placement)

HORIZONTAL leg raise

SAB Technique Avoid sedation if possible, especially ______

ketamine

Post-SAB complications

1. Total spinal anesthesia - Apnea usually without hemodynamic events - Can cause profound bradycardia, but easily treated with anticholinergic 2. Post-dural puncture headache or back-ache (difficult to assess) 3. Spinal cord trauma (rare) 4. Epidermoid tumors (usually when needle without stylet used)

Epidural Anesthesia Historically, children at risk for ____ ____ ____ ____ (____). Per APSF, all due to high-dose bupivacaine infusions.

local anesthesia systemic toxicity (LAST).

Epidural Anesthesia Prolonged _____ infusions in infants and young children have variable pharmacokinetics and increased risk of LAST.

amide

Epidural Anesthesia Resurgence: _______ Metabolized by ____ ____; plasma half-life is seconds to minutes (amides can last for hours).

2-chloroprocaine plasma esterases

Epidural Anesthesia Can be ____ anesthetic or combined with ____.

sole GA

Caudal epidural anesthesia Most common regional technique in _____ (?)

children

Caudal epidural anesthesia Used in conjunction with ____

GA

Caudal epidural anesthesia - Technique (aseptic)

- After induction, turn lateral or prone. - Palpate posterior superior iliac spines/sacral cornu. - Insert small gauge needle (22 or 23), 22 gauge angiocath, or Crawford needle at 45°angle - After “pop”, drop to angle parallel to back and advance into caudal canal. - For continuous, insert catheter. - Test dose while watching EKG & BP. - Inject local over approx. 2 minutes.

Caudal epidural anesthesia Injection should be ____ ____.

very easy

Caudal epidural anesthesia Watch/palpate for ____ _____.

sub-cu infiltration

Caudal epidural anesthesia For continuous catheter placement, advance to _____ of surgical incision.

mid-level

Caudal epidural anesthesia Some use ultrasound catheter ______.

confirmation

Caudal epidural anesthesia Meticulous _____ for catheter placement

dressing

Caudal drugs Dose dependent on desired _____ _____ and _____ – not concentration.

dermatome level and VOLUME

Caudal drugs Generally: ____/____/dermatome

0.05 mL/kg

Caudal drugs Common method for T4-6 sensory block: 0.5 – 1.0 mL/kg of ____ ______ or _____ _____ (less toxic than Bupivicaine)

0.25% Bupivicaine 0.2% Ropivicaine

Caudal drugs Clonidine ___ _____ prolongs block (___ ____ causes increased incidence of apnea)

1 mcg/kg 2 mcg/kg

Caudal drugs Catheters can be used ______ (Max: 0.4 mg/kg/hr. Reduce by 30% for < 6 months old)

post-op

Caudal CIs: (7)

- Parents refuse consent - Surgeon preference - Allergy to local anesthetics - Skin infection/diaper rash in sacral area - VP shunt in place - History of spinal abnormality or surgery (relative) - Sacral “dimple” (relative)

Post-epidural (caudal) Complications Most common: Catheter _______ or _______

displacement or malfunction

Post-epidural (caudal) Complications _____ or ______ injection can lead to CV arrest

IV or intraosseous

Post-epidural (caudal) Complications Epidural abscess (_____) Meningitis

emergent

Post-epidural (caudal) Complications Epidural _______ (caution with thrombocytopenia, coagulopathy or pre-op anticoagulant therapy)

hematoma

Post-epidural (caudal) Complications Urinary ______ Neuronal injury (_____)

retention rare

Ultrasound Guided Fascial Blocks (4)

Transversus abdominis plane (TAP) block Quadratus lumborum block (QLB) Serratus anterior plane block (SAPB) Erector spinae block (ESB)

Misc Blocks done Mostly by surgeon (5)

- Rectus Sheath - Inguinal - Penile - Intercostal - Paravertebral

Controversy: Is it safe to administer ____ _____ to anesthetized children?

regional blocks

Long-standing peds anesthesia practice: Conduct regional anesthesia ____ anesthetized patient.

with

Maintains ______; avoids uncooperative and distressed patient.

stillness

______ helps avoid accidental needle displacement/puncture of vital structures.

Immobility

Any advantages of patient feedback are lost with children who are unable to _____ usefully.

communicate

American Society of Regional Anesthesia and Pain Medicine (2008): With the exception of _____ blocks, providing regionals in anesthetized children may have an acceptable risk-benefit profile.

interscalene