Mod V: Peds Induction Flashcards by Olivier Mba

_{Peds Induction & Emergence}

What’s the most commonly used induction technique in peds

Inhalational Induction

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_{Peds Induction & Emergence}

What’s is the only time we sway away from Inhalational Induction Techniques in peds

When RSI is indicated

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_{Peds Induction & Emergence - Inhalational Induction}

The “Excitement stage” or stage 2 of anesthsia is usually encountered during Inhalational Induction. What are S/s of stage 2 anesthesia?

Disconjugated guaze

Irregular breathing patterns

Increased HR

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_{Peds Induction & Emergence - Inhalational Induction}

“Excitement stage” encountered - What are signs of stage 3 of anesthesia?

…

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_{Peds Induction & Emergence - Inhalational Induction}

“Excitement stage” encountered - Minimize OR noise and activity, why?

Unlike when doing IV induction where they go through the stages of anesthesia quickly, you get to watch go through these stages more slowly

This can set them up for laryngospasm in stage 2

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_{Peds Induction & Emergence - Inhalational Induction}

What can we do that may increase acceptance of the mask?

Painting mask with flavor extracts

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_{Peds Induction & Emergence - Inhalational Induction}

Why is Parental presence questionable?

May make the situation worse for the child

Possible risk of parent’s reaction to child being induced

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_{Peds Induction & Emergence - Inhalational Induction}

What’s the Backup induction plan for a pt that becomes frightened, combative, uncooperative?

IM induction

This induction technique tends to be reserved for MR pts

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_{Peds Induction & Emergence - Inhalational Induction}

Inhalation induction technique in which the mask is held near face, but not touching

Steal Technique

Appropriate for Children 8 mos. to 5 y/o who are premedicated

Low flow rates of O2/N20 begun (1 to 3 L/min)

Add Sevoflurane or Halothane, gradually increasing concentration in 0.5% increments

Apply mask when lid reflex disappears

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_{Peds Induction & Emergence - Inhalational Induction}

What is one concern with the Steal Technique?

Everyone around, including the anesthetist is exposed to inhalation agents

This has been documented to be a problem for everyone in the room

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_{Peds Induction & Emergence - Inhalational Induction}

Inhalational Induction technique w/ Mixture of volatile anesthetic with N2O, and Child takes deep breath (vital capacity) of room air, blows all out (forced expiration), holds breath. Then you Place mask on face, Child takes deep inspiration of anesthetic mixture and holds breath….repeat for 4-5 breaths

“Single Breath” Induction

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_{Peds Induction & Emergence - Inhalational Induction}

How do you pre fill circuit with mixture of volatile anesthetic with N2O for “Single Breath” Induction?

Pre fill circuit with

70% N2O,

30% O2 &

7-8% Sevoflurane

This is done By Occluding end of circuit with plug or another reservoir bag

Leave pop-off valve open to minimize non scavenged spillage

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_{Peds Induction & Emergence - Inhalational Induction}

How is lost of consciousness achieved w/ “Single Breath” Induction?

LOC can be achieved with a single VC breath

However, most will be anesthetized in 60 sec’s.

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_{Peds Induction & Emergence - Inhalational Induction}

“Single Breath” Induction is the most popular induction technique in peds. What are its benefits?

A frigthenned pt will be crying most likely

As they exhale while crying and are getting ready to take another breath, place the mask quickly on their face

So when they take that next deep breath, they usually become anesthetized with that one single breath

This allows them to do go to sleep cooperatively

Be aware that even the most cooperative pt may become uncooperative once you place the mask on their face

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_{Peds Induction & Emergence - Inhalational Induction}

How can you use the reservoir bag visual cue to induce a pediatric pt?

Ask them to “blow up the balloon”

This will make them take big VT breaths b/c they are trying to “pop” the balloon

As they keep doing that, they will get deeper and deeper in their sedation

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_{Peds Induction & Emergence - Inhalational Induction}

Inhalational Induction in which the child is shown how to breathe through face mask, and N2O/O2 is given, followed by gradual addition of volatile anesthetics (sevoflurane/halothane):

“Slow” Inhalation Induction

Used with Cooperative toddlers and older children

Engage child in story incorporating breathing instructions (blow up balloon)

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_{Peds Induction & Emergence - Inhalational Induction}

T/F: Inhalational Induction techniques are by far the most used induction techniques in anesthesia, even for pt that can tolerate an IV

True

However, Other Induction Techniques and Pediatric Considerations are available

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_{Peds Induction & Emergence}

Intramuscular Induction are not favored. For which pts are they indicated for?

Extremely uncooperative or

Mentally retarded (MR) child

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_{Peds Induction & Emergence - Intramuscular Induction}

Ketamine “Dart” is often used for IM induction. What’s pharmacological composition of a Ketamine “Dart”?

Ketamine (4-8 mg/kg IM)

^{which takes effect in 3-5 mins}

Atropine (0.02 mg/kg IM) or glycopyrrolate (0.01 mg/kg IM)

^{should be mixed to prevent excessive salivation}

Midazolam (0.2 – 0.5 mg IM)

^{also to decrease incidence of emergence delirium}

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_{Peds Induction & Emergence - Intramuscular Induction}

How is Ketamine “Dart” administered?

Rapidly inject pt w/ Dart by surprise

They are usually asleep w/in 3-5 min

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_{Peds Induction & Emergence - Intravenous Induction}

What’s the difference btw Intravenous Induction in peds vs adults

Similar, but you need an IV access

Which is often difficult in peds

_{Peds Induction & Emergence - Intravenous Induction}

What can you do to facilitate obtaining an IV access in peds?

Local anesthesia before IV placement

EMLA (2.5% lidocaine & 2.5% prilocaine)

LMX (4% lidocaine)

Apply 45 min prior to start

_{Peds Induction & Emergence - Intravenous Induction}

T/F: Older children (> 8 years of age) often prefer intravenous Induction over mask induction

False

Older children would let you start an IV

But would still prefer inhalation induction over IV induction

_{Peds Induction & Emergence}

How do we treat Children with “Full Stomachs”?

Same principles apply to pediatrics as for adults plus

RSI with CCP

_{Peds Induction & Emergence - RSI for “Full Stomachs”} Which other drug may be given IV to prevent bradycardia, especially if succinylcholine will be given

Atropine

_{Peds Induction & Emergence - RSI for “Full Stomachs”} Peds require larger doses of IV induction agents. What are peds RSI doses for STP, Propofol, Succinylcholine

_STP_: **5 to 6 mg**/kg _Propofol_: **3 to 4 mg**/kg _Succinylcholine_: **1 to 2 mg**/kg IV *children* - **3 mg**/kg *neonates* **4-6 mg**/kg IM in *infants*

_{Peds Induction & Emergence - RSI for “Full Stomachs”} Decompress stomachs before induction if:

**Gastric distention** present (pyloric stenosis, etc) This is done while the pt is still awake Drop OGT if pyloric stenosis or severe Gastric distention Ranitidine (2-4 mg/kg) can be given

_{Peds Induction & Emergence - RSI for “Full Stomachs”} Which drug must be avoided if if gastric outlet or bowel obstruction present?

**Metoclopramide** Could cause the bowel to push against and obstruction and potentially cause a rupture or burst

_{Peds Induction & Emergence - RSI for “Full Stomachs”} Which type of ET tube (cuffed vs uncuffed) should you use if “Full Stomachs”?

**Cuffed** tube

_{Peds Induction & Emergence - RSI} What's the agent of choice for RSI in peds?

**Succinylcholine** Although we try to avoid Succinylcholine at all cost!!!

_{Peds Induction & Emergence} Hypoxemia that occurs within 30-45 sec's of induction, even after preoxygenation is known as:

**Apneic Infant During Induction**

_{Peds Induction & Emergence} D/t risk of Apneic Infant During Induction, you must cease intubation attempts immediately with onset of which symptoms?

**Bradycardia - Cyanosis** **Desaturation**

_{Peds Induction & Emergence} How do you treat Apneic Infant During Induction?

Administer **100% O2** _until oxygen saturation improves_ These pts do not have a lot of O2 reserves _Preoxygenation too much is rather useless!!!!_

_{Peds Induction & Emergence} Rigidity of jaw muscles that develops after administration of succinylcholine is known as:

**Masseter Muscle Rigidity**

_{Peds Induction & Emergence} Co-administration of which two drugs increases incidence of Masseter Muscle Rigidity?

Succinylcholine + **Halothane**

_{Peds Induction & Emergence} What are Manifestations of Masseter Muscle Rigidity?

Difficulty in **opening mouth**, d/t Slight increase in **masseter muscle resistance** Apparent active **tetany**

_{Peds Induction & Emergence - Masseter Muscle Rigidity} T/F: Administration of additional sux results in relaxation of masseter muscles

**False** Administration of additional sux does not result in relaxation of masseter muscles

_{Peds Induction & Emergence - Masseter Muscle Rigidity} T/F: During MMR other skeletal muscles are rigid as well

**False** Other skeletal muscles are relaxed during MMR

_{Peds Induction & Emergence - Masseter Muscle Rigidity} How long can MMR last? and why?

MMR may last as long as **30 mins** MMR persists until **neuromuscular function** begins to r_eturn in peripheral muscles_

_{Peds Induction & Emergence - Masseter Muscle Rigidity} How long may Myalgia/weakness a/w MMR persist?

**36hrs** following episode

_{Peds Induction & Emergence - Masseter Muscle Rigidity} Elevation of which lab values may follow within 24hrs of an MMR episode?

**CK** and **Myoglobinuria**

_{Peds Induction & Emergence - Masseter Muscle Rigidity} Differential diagnosis of MMR include susceptibility to which lifethreatening condition?

**Malignant Hyperthermia** (MH)

_{Peds Induction & Emergence - Masseter Muscle Rigidity} T/F: 50% of patients who experience MMR are also susceptible to MH

**True** ## Footnote

_{Peds Induction & Emergence - Masseter Muscle Rigidity} MMR that is accompanied by rigidity of muscles other than masseter muscles, including for example chest/limb rigidity is more likely:

**MH**

_{Peds Induction & Emergence - Masseter Muscle Rigidity} MMR in which Peripheral nerve stimulator shows flaccid paralysis is more likely:

MMR (confirmed)

_{Peds Induction & Emergence - Masseter Muscle Rigidity} Other events that mimic masseter spasm:

**Inadequate dose of succinylcholine** _Inadequate time for onset of action of SUX_ **Temporomandibular joint dysfunction** _Myotonic syndrome_

_{Peds Induction & Emergence - Masseter Muscle Rigidity} How is MMR managed?

Maintain **PPV with bag/mask** until muscles relax **Intubate** trachea when feasible Observe pt carefully for **signs of MH**

_{Peds Induction & Emergence - Masseter Muscle Rigidity} During an MMR episode, you must observe pt carefully for signs of MH - What are the signs of MH?

**Skeletal muscle rigidity** _Increased CO2 production/O2 consumption_ **Metabolic acidosis** _Tachycardia/arrhythmia’s_ **Increased body temperature** _Myoglobinuria_

_{Peds Induction & Emergence - Masseter Muscle Rigidity} If MH is developing or strongly suspected, what must you do?

Declare **MH emergency!!!** REVIEW MH

_{Peds Induction & Emergence - Masseter Muscle Rigidity} If MMR is confirmed, do you continue surgery or not?

**You do not continue the surgery,** usually... They will go for _further workup_ just to be sure, because there is a high association btw MMR and MH