Mod IV: Peds Opioids, Neuromuscular Blocking Agents - Anticholinergics - Benzodiazepines

Question 1

_{Opiods - Key Points}

Opiods are a/w Increased central respiratory depression, particularly in what age group?

Answer 1

Neonates and infants < 6mos

Question 2

_{Opiods - Key Points}

Opiods are a/w Increased central respiratory depression, particularly in Neonates and infants < 6mos. Which opioid is most responsible for this?

Answer 2

MSO4 > fentanyl, sufenta, alfentanil, & remifentanil

Question 3

_{Opiods - Key Points}

What are other negative effects o opioid use in neonates and infants < 6mos?

Answer 3

Increase incidence PONV

Upper airway obstruction in susceptible patients

Chest wall rigidity is not uncommon in this population

Question 4

_{Opiods - Key Points}

What’s The most frequently used narcotic in children for postop pain control

Answer 4

Morphine

Question 5

_{Opiods - Morphine}

Use Morphine cautiously in neonates and infants, why?

Answer 5

Reduced hepatic conjugation

Decreased renal clearance of morphine metabolite

Infants have immature BBB, crosses over more than adults

Question 6

_{Opiods - Morphine}

IV Dose of Morphine is:

Answer 6

0.1 to 0.2 mg/kg

Question 7

_{Opiods - Morphine}

T/F: Morphine May be given rectally in peds

Answer 7

True

Question 8

_{Opiods - Morphine}

How does Ventilatory depression as a result of Morphine administration manifest?

Answer 8

Decreased VT and Rate

Question 9

_Opiods

What’s the most popular anesthesia adjuvant for all age groups?

Answer 9

Fentanyl

Question 10

_{Opiods - Fentanyl}

How can Fentanyl be administered in peds?

Answer 10

IV, IM, Oral, or Transmucosal

Question 11

_{Opiods - Fentanyl}

Which factors results in prolongation of effect of fentanyl?

Answer 11

Anything decreasing hepatic blood flow

Hypothermia

Question 12

_{Opiods - Fentanyl}

T/F: Respiratory depressant effect of Fentanyl outlasts analgesia

Answer 12

True

Pt will become free from analgesic effect of Fentanyl but still have some respiratory depression

Question 13

_{Opiods - Fentanyl}

Bradycardia with large doses of Fentanyl is secondary to:

Answer 13

Near complete ablation of sympathetics

(more cardiac than vascular)

Significant negative effect on peds CO since it is so dependent on HR

Question 14

_Opiods

Which opioid, although not used frequently, Possess the most favorable profile

Answer 14

Remifentanil

Easily titratable

Question 15

_{Opiods - Remifentanil}

How is Remifentanil metabolized?

Answer 15

Tissue and plasma esterases

Question 16

_{Opiods - Remifentanil}

How quickly do Remifentanil Effects dissipate after discontinuing infusion?

Answer 16

Effects dissipate within 5 – 10 mins of discontinuing infusion

Question 17

_{Opioids - Remifentanil}

T/F: Remifentanil is associated with decreased incidence of postoperative apnea in premature infant and neonate

Answer 17

True

Question 18

_{Opioids - Remifentanil}

Both bolus and continuous infusion doses of Remifentanil are higher in infants and young children; why?

Answer 18

Larger Vd

Increased elimination clearance

Question 19

_{Opioids - Remifentanil}

Bolus and continuous infusion doses of Remifentanil:

Answer 19

Remifentanil

1-2ug/kg bolus followed by

continuous infusion at 0.5ug/kg/min and TTE

Question 20

_Opioids

Opioid that is less commonly used, but that is less potent, more protein bound, and allows for rapid awakening

Answer 20

Alfentanil

Question 21

_{Opioids - Alfentanil}

Incidence of postoperative nausea and vomiting w/ Alfentanil

Answer 21

30% to 50%

Question 22

_{Opioids - Alfentanil}

DOA of Alfentanil in hepatic disease (or preterm)

Answer 22

Prolonged action

Question 23

_Opioids

Most potent synthetic narcotic:

Answer 23

Sufentanil

Question 24

_{Opioids - Sufentanil}

Bolus doses of Sufentanil can cause

Answer 24

Bradycardia/Asystole

Question 25

_{Opioids - Sufentanil} Dose and administration of Sufentanil:

Answer 25

**Sufentanil** 0.1**ug**/kg then TTE Dilute 50 ug/ml to 5 ug/ml

Question 26

_{Opioids - Sufentanil} T/F: Sufentanil can be used intranasal for preop

Answer 26

**True** But watch your patient really closely after the dose

Question 27

_{Neuromuscular Blocking Agents} Muscle relaxant are less commonly used during induction in peds compare to adults. Why is that?

Answer 27

Many children have LMA or ET tube placed after receiving inhalation agents and placement of an IV access, and administration of various combinations of Propofol, opioids, and Lidocaine

Question 28

_{Neuromuscular Blocking Agents} Which Neuromuscular Blocking Agent remains the fastest acting with shortest duration of action of any muscle relaxant?

Answer 28

**Succinylcholine**

Question 29

_{Neuromuscular Blocking Agents - Succinylcholine} Dose requirements for Succinylcholine higher in infants, neonates, and young children. What's the infants & neonates dose?

Answer 29

**3 mg**/kg IV

Question 30

_{Neuromuscular Blocking Agents - Succinylcholine} Dose requirements for Succinylcholine higher in infants, neonates, and young children. What's the young children dose?

Answer 30

**2 mg**/kg IV

Question 31

_{Neuromuscular Blocking Agents - Succinylcholine} How could you administer Succinylcholine in emergency when IV access is not available?

Answer 31

Can be given IM in emergencies when IV access not available

Question 32

_{Neuromuscular Blocking Agents - Succinylcholine} What's the IM dose of Succinylcholine when given in emergency d/t IV access not being available?

Answer 32

**4-6mg**/kg IM

Question 33

_{Neuromuscular Blocking Agents - Succinylcholine} What's the Onset time and duration of Succinylcholine when given in emergency d/t IV access not being available?

Answer 33

Onset time **3-4mins** with Duration approx. **20mins**

Question 34

_{Neuromuscular Blocking Agents - Succinylcholine} What are Adverse effects/complications a/w administration of Succinylcholine?

Answer 34

Profound Bradycardia/junctional arrhythmias/sinus node arrest ^{(after 1st dose without pretreatment with atropine) Must always administer atropine 0.02 mg/kg (minimum dose 0.1 mg) prior to administering succinylcholine in pediatric patients} Hyperkalemia ^{Life-threatening arrhythmias (wide complex tachycardia, ventricular fibrillation, asystole Muscle atrophy (Duchenne Muscular dystrophy) Up-regulation of extra-junctional acetylcholine receptors (Burns)} Rhabdomyolysis leading to myoglobinuria Muscle masseter spasm ^{May represent a normal response, especially if succinylcholine is under dosed Harbinger of MH (50% of those who develop severe MMR test positive for MH)} Malignant hyperthermia Increased IOP, ICP, and intragastric pressure Fasciculations/postoperative myalgia ^{Uncommon in children < 8yrs of age}

Question 35

_{Neuromuscular Blocking Agents - Succinylcholine} Must always administer atropine 0.02 mg/kg (minimum dose 0.1 mg) prior to administering succinylcholine in pediatric patients; why?

Answer 35

Profound Bradycardia/junctional arrhythmias/sinus node arrest after 1st dose without pretreatment with atropine

Question 36

_{Neuromuscular Blocking Agents - Succinylcholine} Hyperkalemia a/w administration Succinylcholine can cause/or be the result of:

Answer 36

Life-threatening arrhythmias ^{(wide complex tachycardia, ventricular fibrillation, asystole)} Muscle atrophy ^{(Duchenne Muscular dystrophy)} Up-regulation of extra-junctional acetylcholine receptors ^(Burns)

Question 37

_{Neuromuscular Blocking Agents - Succinylcholine} What's the Treatment for Hyperkalemia a/w administration of Succinylcholine?

Answer 37

_CaCl_ **5-10 mg**/kg IV

Question 38

_{Neuromuscular Blocking Agents - Succinylcholine} Muscle masseter spasm (Masseter Muscle Rigidity) may represent a normal response, especially if:

Answer 38

Succinylcholine is **under dosed**

Question 39

_{Neuromuscular Blocking Agents - Succinylcholine} What percentage of pts who develop severe MMR test positive for MH?

Answer 39

**50%**

Question 40

_{Neuromuscular Blocking Agents - Succinylcholine} T/F: Fasciculations/postoperative myalgia following administration of Succinylcholine is common in children \< 8yrs of age

Answer 40

**False** _Fasciculations/postoperative myalgia_ following administration of Succinylcholine is **uncommon i**n children **\< 8yrs of age**

Question 41

_{Neuromuscular Blocking Agents - Succinylcholine} According to the FDA “Black Box” warning, “Succinylcholine in children should be reserved for which types of procedures?

Answer 41

Emergency intubations, or Instances where immediate securing of the airway is necessary

Question 42

_{Neuromuscular Blocking Agents - Succinylcholine} Accepted indications for Succinylcholine use in peds are:

Answer 42

RSI with full stomach Laryngospasm Difficult airway

Question 43

_{Neuromuscular Blocking Agents - Succinylcholine} T/F: Despite drawbacks to use in children, succinylcholine retains its place as agent of choice for RSI and life-threatening airway obstruction

Answer 43

**True**

Question 44

_{Neuromuscular Blocking Agents - Succinylcholine} 11 Side Effects of Succinylcholine

Answer 44

Inc. ICP Inc. IOP Inc. IGP Trismus Cardiac dysrhythmias Hyperkalemia Myalgia Rhabdomyolysis Myoglobinemia Inc. O2 consumption & Inc. CO2 production Release of catecholamines

Question 45

_{Neuromuscular Blocking Agents - NDMRs} Why are dosage and response to NDMRs variable in peds?

Answer 45

**Larger Vd** =\> increases bolus dose required to achieve desired affect **Increase sensitivity (immature NMJ)** =\> decrease dosage requirement **Immature hepatic function** prolongs duration action for drugs that depend primarily on hepatic metabolism **^{Pancuronium, vecuronium, & rocuronium}**

Question 46

_{Neuromuscular Blocking Agents - NDMRs} Recommended doses of NDMRs agents are identical on a weight basis for neonates, infants, children and adults. How does their DOA compare to that of adults

Answer 46

Slightly longer

Question 47

_{Considerations when selecting a NDMR - Possible side effects} Which NDMR has desirable vagolytic properties?

Answer 47

**Pancuronium**

Question 48

_{Considerations when selecting a NDMR - Possible side effects} Which NDMRs are a/w Histamine release?

Answer 48

Mivacurium Atracurium

Question 49

_{Considerations when selecting a NDMR - Route of metabolism/excretion} How are Amino steroid (vecuronium, pancuronium, Rocuronium) metabolized?

Answer 49

**Liver** to _inactive products_ This is the reason why their duration of action is unpredictable

Question 50

_{Considerations when selecting a NDMR - Route of metabolism/excretion} How are Benzylisoquinoliniums (cisatracurium, atracurium, mivacurium) metabolized?

Answer 50

**Hoffmann's elimination** Results in Predictable duration of action

Question 51

_{Neuromuscular Blocking Agents - NDMRs} Which is considered the drug of choice for _routine intubation_ (Not RSI) in the pediatric patient?

Answer 51

**Rocuronium**

Question 52

_{Neuromuscular Blocking Agents - NDMRs} Fastest onset of nondepolarizing muscle relaxants

Answer 52

**Rocuronium**

Question 53

_{Neuromuscular Blocking Agents - NDMRs} What are effects of Higher dosages (0.9-1.2 mg/kg IV) of Rocuronium

Answer 53

Produces **onset** of action within *_90secs_* Expect prolonged **duration of action** *_(90mins)_*

Question 54

_{Neuromuscular Blocking Agents - NDMRs} What's the only NDMR that can be given IM?

Answer 54

**Rocuronium** **1.0- 1.5 mg**/kg IM Requires 3-4mins for onset Deltoid injection

Question 55

_{Anticholinergics} T/F: Anticholinergics are very important in the pediatric practice

Answer 55

True

Question 56

_{Anticholinergics - Atropine} Dose and route of administration of Atropine:

Answer 56

**_Atropine_** **0.02 mg**/kg oral, rectal, IM, IV

Question 57

_{Anticholinergics - Atropine} Effects of Atropine

Answer 57

Decreases LES tone in infants

Question 58

_{Anticholinergics - Atropine} How is Atropine prepared?

Answer 58

Emergency syringe Succinylcholine + atropine with IM needle available for laryngospasm/bradycardia

Question 59

_{Anticholinergics} T/F: Glycopyrrolate has slower onset but longer action compared to Atropine

Answer 59

True

Question 60

_{Anticholinergics} What's the administration dose of Glycopyrrolate?

Answer 60

**_Glycopyrrolate_** 0.01 **mg**/kg

Question 61

_{Anticholinergics} When is Glycopyrrolate often used in peds?

Answer 61

For **Airway** procedures such tonsillectomy or For **Dental** procedures

Question 62

_{Benzodiazepines - Midazolam} What's a common indication for Midazolam in Peds?

Answer 62

Separation anxiety

Question 63

_{Benzodiazepines - Midazolam} How is Midazolam typically administered in peds and why?

Answer 63

Oral Lack of IV access

Question 64

_{Benzodiazepines - Midazolam} What's the typical dose of Midazolam?

Answer 64

_Midazolam_ **0.5-1.0 mg**/kg PO up to max 10 mg

Question 65

_{Benzodiazepines - Midazolam} What are effects of 0.5 mg/kg dose of Midazolam in peds?

Answer 65

**Anterograde amnesia** after 10” Significant **anxiolysis** by 15”

Question 66

_{Benzodiazepines - Midazolam} What's a potentially undesirable effect of a \> 0.75 mg/kg dose of Midazolam?

Answer 66

May delay **discharge** (30”)

Question 67

_{Benzodiazepines - Midazolam} Which factor is important to consider when timing administration of Midazolam to alleviate separation anxiety?

Answer 67

**Peak sedation 30”** Do not attempt separation from family just 5 min for example after administration Allow 10 -15 min for effect Realize that time for peak sedation is 30 min Parent administer for better acceptance For peds under 16 mo old, you may forgo the Midazolam

Question 68

_{Benzodiazepines - Midazolam} What percentage of pre-op anxiety treated w/ Midazolam result in peaceful separation

Answer 68

85%

Question 69

_{Benzodiazepines - Midazolam} What can you mix w/ Midazolam to increase acceptance?

Answer 69

Grape concentrate Tylenol syrup Motrin suspension

Question 70

_{Benzodiazepines - Midazolam} What's a concern w/ mixing Midazolam with other solutions to increase acceptance?

Answer 70

NPO status Beware: total volume \> _0.4-0.5 ml_/kg (NPO)