Mod V: Peds Pre-op Part 2

Question 1

_{Psychological Preparation}

Peds are similar to adults from a physiologic standpoint. They are a whole different story when it comes to their psychological preparation. What’s a major psychological feature that distinguishes peds from adults?

Answer 1

Separation anxiety

How many of you have ever tried reasoning with an infant, toddler, or child!!!

Question 2

_{Psychological Preparation}

Sources of child & family stress/anxiety that you must recognize include:

Answer 2

Fear of separation

Fear of the unkown

^{Painful procedures - Survival}

Strange surroundings

You must take care of the parents as much as the child

Question 3

_{Psychological Preparation}

Which strategies can you use to reduce preoperative stress/anxiety?

Answer 3

Discuss anesthetic risk, plan, recovery, postop pain management, and discharge

Be simple and honest

Tell ‘em just what’s gonna happen in a supportive, positive way

Make positive suggestion

^{(“this BP cuff is gonne hug your arm”, “Im gonna put some stickers on your chest”, “you are gonna get a liitle sleepy”, “you gonna smell some fruity anesthetic candy air”}

Modify strategu according to age

Allow parental presence during induction for selected cases

Use pharmacological intervention as indicated

Question 4

_{Psychological Preparation}

T/F: In an effort to reduce anxiety, it is appropriate to allow parental presence during induction for selected cases

Answer 4

True

Question 5

_{Premedication}

What’s are the goals of premedication in pediatric anesthesia?

Answer 5

Reduce anxiety for Both child/parent

^{If child isn’t crying/screaming…parents more calm….child more calm!}

Provide sedation

Facilitate induction

Reduce airway secretions

Block vagal responses

Supplement anesthesia

Decreased gastric volume/acidity

Question 6

_{Premedication}

Why is premedictaion not required fo infants < 10mos

Answer 6

Tolerate short periods of separation

Only premedicate for co-existing disease

Question 7

_{Premedication}

D/t significant Separation anxiety, for which age range is premedication required?

Answer 7

10mos – 5 yrs

Question 8

_{Premedication}

Premedication with harmacological agents is often required for Older children. However they can also benefit from alternatives such as:

Answer 8

Information/reassurance

Parental presence in OR

Question 9

_{Antianxiety/Sedation}

Which doses of Midazolam may delay discharge for as long as (30”)?

Answer 9

Doses > 0.75 mg/kg

Question 10

_{Antianxiety/Sedation}

What’s the Peak sedation time for Midazolam?

Answer 10

30”

Question 11

_{Antianxiety/Sedation}

How often is administration of Midazolam is a/w peaceful separation?

Answer 11

85% of the time

Question 12

_{Antianxiety/Sedation}

What’s the Oral dose of Midazolam?

Answer 12

Midazolam

0.5-1.0 mg/kg

up to max 10 mg

Question 13

_{Antianxiety/Sedation}

How long after administration of 0.5 mg/kg of Midazolam is Antegrade amnesia noted?

Answer 13

Antegrade amnesia after 10”

Question 14

_{Antianxiety/Sedation}

How long after administration of 0.5 mg/kg of Midazolam is Significant anxiolysis noted?

Answer 14

Significant anxiolysis by 15”

Question 15

_{Antianxiety/Sedation}

Which substances can Midazolam be mixed with for oral administration?

Answer 15

Grape concentrate/Tylenol syrup/Motrin suspension

Beware: total volume > 0.4-0.5 ml/kg

Parent administer for better acceptance

Question 16

_{Antianxiety/Sedation}

Besides the oral route, what are other routes of administration of Midazolam?

Answer 16

Nasal - Rectal - IM

_{Less common routes}

Question 17

_{Antianxiety/Sedation}

Nasal dose of Midazolam - Time to Peak serum level - Nasal dose that may delay extubation - Nasal dose that does not delay recovery

Answer 17

Midazolam

Nasal dose: 0.2-0.6 mg/kg

Time to Peak serum level: 10”

Nasal dose that may delay extubation: 0.6 mg/kg

Nasal dose that does not delay recovery: 0.2 mg/kg

Question 18

_{Antianxiety/Sedation}

Rectal dose of Midazolam - Time to some effect - Time to Peak effect:

Answer 18

Midazolam

Rectal dose: 0.35 - 1.0 mg/kg

Time to some effect: 10”

Time to Peak effect: 20-30”

Question 19

_{Antianxiety/Sedation}

IM dose of Midazolam - Time to onset - Reserve for which type of pts?

Answer 19

Midazolam

IM dose: 0.3 mg/kg

Time to onset: 5-10”

Reserve for uncooperative child

Question 20

_{Antianxiety/Sedation}

Agent that provide sedation and analgesia, has no CV or resp depression, but will increase oral secretions, and is reserved for uncooperative child:

Answer 20

Ketamine

This is a dissociative anesthetic

Question 21

_{Antianxiety/Sedation}

What are the different routes of administration of Ketamine?

Answer 21

PO - IM - Dart

Question 22

_{Antianxiety/Sedation -Ketamine}

Oral dose - Time to Peak onset - rate of successful separation - Discharge concern w/ Ketamine:

Answer 22

Ketamine

PO dose: 6-10 mg/kg

Time to Peak onset: 20”

Rate of successful separation: 75%

May prolong time to discharge!!!

Question 23

_{Antianxiety/Sedation}

IM sedation dose of Ketamine - IM sedation dose of Ketamine that does not delay discharge

Answer 23

Ketamine

IM sedation dose: 2-4 mg/kg

2 mg/kg does not delay discharge

Question 24

_{Antianxiety/Sedation}

IM dose of Ketamine for induction of GA

Answer 24

Ketamine

IM induction of GA: 6-10 mg/kg

Question 25

_{Antianxiety/Sedation} Benefits of combining Ketamine + Midazolam

Answer 25

_Ketamine_ (4 mg/kg) + _Midazolam_ (0.4 mg/kg PO) =\> 100% **successful separation** =\> 85% **easy mask induction**

Question 26

_{Antianxiety/Sedation} Which drug would you administer to decrease secretions caused by Ketamine?

Answer 26

**Glycopyrrolate**

Question 27

_{Antianxiety/Sedation} Why has it become less common to give _Fentanyl_ in the Oral transmucosal (“lollipop”) form (15-20 mcg/kg)?

Answer 27

Inc **gastric volume** - Inc **PONV** **Pruritus** - _Hypoventilation_

Question 28

_{Antianxiety/Sedation} What's the Rectal dose of Methohexital? *How is it administered?*

Answer 28

**_Methohexital_** Rectal dose: **20-30 mg**/kg *10% solution warm tap H20*

Question 29

_{Pre-op Antianxiety/Sedation} Benefits of _Methohexital_ in the management of peds pre-op anxiety:

Answer 29

85% very **peaceful separation** Time to Onset: 10” **Rectal induction of GA** Duration of action: *45-90”*

Question 30

_{Pre-op Antianxiety/Sedation} Which drug can be given rectally for pediatric induction of General Anesthesia?

Answer 30

**Methohexital** Rectal dose: **20-30 mg**/kg

Question 31

_{Anticholinergics} What's the purpose of using Anticholinergics drugs in peds?

Answer 31

**Preempt bradycardia** a/w Airway manipulation Succinylcholine administration Halothane **Antisialagogue** d/t Oral procedures (Tonsillectomy & Adenoidectomy - FOI - Cleft lip) Ketamine secretions

Question 32

_{Anticholinergic - Atropine} Typical dose & Minimum dose of Atropine:

Answer 32

**_Atropine_** Dose: **0.01 - 0.02 mg**/kg Minimum dose **0.1mg**

Question 33

_{Anticholinergic - Atropine} Risk associated with giving less than minimum dose of Atropine:

Answer 33

**Paradoxical Bradycardia**

Question 34

_{Anticholinergic - Atropine} What is the recommended method of administration of Atropine in Peds? * A. IM dose as premed* * B. IV dose at time of induction*

Answer 34

*A. IM dose as premed* ***B. IV dose at time of induction*** IM not recommended as premed but rather IV at time of induction

Question 35

_{Anticholinergic - Atropine} Which drug is Atropine commonly administered with during induction of anesthesia in peds?

Answer 35

**Succinylcholine**

Question 36

_{Anticholinergic - Glycopyrrolate} IV & IM doses of Glycopyrrolate:

Answer 36

_Glycopyrrolate_ IV dose: **5-10 mcg**/kg IV IM dose: **10 mcg**/kg IM

Question 37

_{Anticholinergics} Which Anticholinergics drug takes longer to work? * A. Glycopyrrolate* * B. Atropine*

Answer 37

***A. Glycopyrrolate*** *B. Atropine*

Question 38

_{Anticholinergics} Which Anticholinergics drug is Better for drying of secretions? * A. Glycopyrrolate* * B. Atropine*

Answer 38

***A. Glycopyrrolate*** *B. Atropine*

Question 39

_{Aspiration Precautions} Which Drugs are used for Aspiration Precautions in peds

Answer 39

**Cimetidine**: 5mg/kg p.o. ^{1 hour preop} **Ranitidine**: 2.5mg/kg p.o. ^{1 hour preop} **Metoclopramide**: 0.2 mg/kg p.o. or IV ^{30 min to 1 hour preop} **Bicitra** (Na citrate and citric acid): 10-30 ml ^{Immediate preop (neutralizing buffer for aspiration pneumonitis)} _{However, it is important to note that these drugs are not commonly used in peds You will typically see zofran (>2 yo) & Decadron given for PONV If serious aspiration concerns however such as in pyloric stenosis for example, any or all of the above will be considered}

Question 40

_{Aspiration Precautions} Aspiration Precautions dose of _Cimetidine_ - *Best time to give*:

Answer 40

**_Cimetidine_** Dose: **5mg**/kg PO *1 hour preop*

Question 41

_{Aspiration Precautions} Aspiration Precautions dose of _Ranitidine_ - Best time to give:

Answer 41

**_Ranitidine_** Dose: **2.5mg**/kg PO *1 hour preop*

Question 42

_{Aspiration Precautions} Aspiration Precautions dose of _Metoclopramide_ - *Best time to give*:

Answer 42

_Metoclopramide_ Dose: **0.2 mg/**kg PO or IV *30 min to 1 hour preop*

Question 43

_{Aspiration Precautions} Aspiration Precautions dose of _Bicitra_ (Na citrate and citric acid) - Best time to give:

Answer 43

_Bicitra (Na citrate and citric acid)_ Dose: **10-30 mL** *Immediate preop* ^{(neutralizing buffer for aspiration pneumonitis)}

Question 44

_{Aspiration Precautions} It's important to note that Cimetidine, Ranitidine, Metoclopramide & Bacitra are not commonly used in peds. In reality, which drugs will typically be adminsitered to prevent PONV

Answer 44

**Zofran** (\>2 yo) & **Decadron**

Question 45

_{Aspiration Precautions} Which drugs will typically be adminsitered if serious aspiration concerns exist, such as in pyloric stenosis?

Answer 45

Any or all of the Aspiration Precautions drugs will be considered _{(Cimetidine, Ranitidine & Bacitra + Zofran & Decadron)}