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Pediatric Anesthesia Flashcards

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1
Q

Why are neonates/preterm infants at increased anesthetic risk?

A
  1. pulmonary factors
  2. cardiovascular factors
  3. thermoregulation factors
  4. pharmacologic factors
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2
Q

What are the pulmonary factors affecting neonates?

A
  1. anatomic differences
  2. lower FRC, VC is 1/2 and RR is 2x that of adults
  3. higher O2 consumption
  4. rightward shift of CO2 response curve
  5. agents have more profound effects on ventilation & oxygenation
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3
Q

What are the cardiovascular factors affecting neonates?

A
  1. ventricles are non-compliant; increasing contractility does not increase CO
  2. CO is HR-dependent
  3. parasympathetic system is more active – more prone to bradycardia
  4. agents have more profound myocardial depressant effects
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4
Q

What are the thermoregulation factors affecting neonates?

A
  1. poor central thermoregulation
  2. little muscle mass –> cannot shiver effectively
  3. non-shivering thermogenesis –> uses brown fat; inefficient (consumes more O2)
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5
Q

What are the pharmacologic factors affecting neonates?

A
  1. larger volume of distribution
  2. less protein-binding affinity
  3. immature kidneys and liver
  4. larger initial dose but slower clearance
  5. more rapid uptake of volatile agents
  6. lower MAC
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6
Q

Why are neonates/preterm infants at high risk of regurgitation/reflux?

A

Incompetent LES, slow gastric emptying time

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7
Q

What are the 2 most common causes of morbidity in the neonatal period?

A

Apnea
Bradycardia

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8
Q

Why is apnea dangerous?

A

Chemoreceptors are not very sensitive to hypercarbia and hypoxia. Apnea lasting >15 seconds may lead to bradycardia and worsen hypoxia.

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9
Q

What are the mechanisms of heat loss?

A

Radiation, conduction, evaporation, convection

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10
Q

In what order do the mechanisms contribute from greatest to lowest heat loss?

A
  1. Radiation
  2. Convection
  3. Evaporation
  4. Conduction
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11
Q

How to minimize heat loss?

A
  1. Warm room at least 1 hour prior (>24C)
  2. Use warming blanket & lights, head cover
  3. Cover exposed skin with plastic
  4. Use forced-air warming devices
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12
Q

What are common intraoperative problems?

A
  1. hypoxia
  2. bradycardia
  3. hypothermia
  4. hypotension
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13
Q

What are the usual causes of bradycardia in neonates?

A

hypoxia
vagal stimulation - laryngoscopy
volatile anesthetics, succinylcholine

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14
Q

What is the usual cause of sudden intraoperative hypoxia in neonates?

A

dislodged/displaced ETT OR pressure on chest/abdomen during surgical manipulation

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15
Q

Up to what age do you expect postoperative apnea?

A

60 weeks post-conceptual age (PCA), even with minor surgery.

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16
Q

What are the most common neonatal surgeries?

A

TEF/EA
Gastroschisis
Omphalocele
Congenital Diaphragmatic Hernia
Patent Ductus Arteriosus
Pyloric Stenosis
Intestinal Obstruction

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17
Q

What other preparations be done in anesthetizing a neonate?

A
  • Multiple sizes of airway (both smaller and larger) ready
  • Compute for MF, EBV, and ABL
  • Use a Buretrol or Soluset
  • Consider using a precordial stet
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18
Q

Is surgical repair of pyloric stenosis emergent?

A

No. Make sure to correct fluid and electrolyte imbalances before proceeding with surgery.

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19
Q

What are the metabolic disturbances present in pyloric stenosis?

A

Dehydration
Hypochloremia
Metabolic alkalosis

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20
Q

How to induce a neonate with congenital diaphragmatic hernia (CDH)?

A

Awake intubation
Mask ventilation is CONTRAINDICATED (because it can cause visceral distention and worsen oxygenation)
Decompress the stomach with OGT/NGT

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21
Q

What are the ventilation strategies for CDH?

A

Low pressures (<25 cmH2O) - to prevent barotrauma
Permissive hypercapnia (45-60 mmHg) - secondary to lower TV
Pre-ductal 85-95%, post-ductal >70% - to avoid O2 toxicity

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22
Q

Is surgical repair of CDH emergent?

A

No. Severity of pulmonary hypertension depends on underlying lung hypoplasia.

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23
Q

What are other congenital anomalies that may present with TEF?

A

VATER/VACTERL:
Vertebral
Anus (imperforate)
Cardiac
Renal
Limb

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24
Q

What other anomalies may present with omphalocele?

A

cardiac, urologic, and metabolic

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25
What other anomalies may present with gastroschisis?
usually none
26
Which surgeries usually necessitate delayed extubation?
CDH Repair of gastroschisis/omphalocele
27
Describe the baroreceptor reflex in a child.
Infants have an immature baroreceptor reflex --> cannot effectively compensate for hypotension by increasing HR
28
What are the anatomic differences between adult and pediatric airways?
1. obligate nose breather - easily blocked by secretions 2. large tongue - obstruction, difficult laryngoscopy 3. large occiput - sniffing position is achieved by placing a shoulder roll 4. anterior larynx & vocal cords slant anteriorly - difficult intubation 5. larynx & trachea are funnel-shaped - vocal cords are the narrowest portion
29
What are the differences between adult and pediatric pulmonary mechanics?
1. ↓ pulmonary compliance -- prone to airway collapse 2. ↑ airway resistance d/t small airways -- ↑ work of breathing Prone to diseases affecting small airways 3. ↓ TLC, ↑ RR and O2 consumption - more rapid desaturation 4. ↑ closing volume -- ↑ dead space 5. horizontal ribs, pliable ribs and cartilage -- inefficient chest wall mechanics 6. Less type 1 high-oxidative muscle -- fatigue more easily
30
How to induce anesthesia in children?
INHALATIONAL and INTRAVENOUS
31
How to do inhalational induction?
70% N2O + 30% O2 for 1 minute > > add sevoflurane
32
How to do inhalational in an uncooperative child?
RAPID induction: Hold the kid down Use 70% NO + 30% O2 + 8% sevoflurane Place mask against the child's face Decrease sevoflurane once induced
33
How to induce a sleeping child?
STEAL induction: Hold the mask near the face while gradually increasing sevoflurane
34
What are the common induction meds and doses?
Propofol 2-3 mg/kg IV Etomidate 0.2-0.3 mg/kg IV Ketamine 1-3 mg/kg IV or 2-5mg/kg IM
35
What is EMLA?
Eutectic Mixture of Local Anesthetics: 2.5% lidocaine + 2.5 % prilocaine Apply at least 60 minutes prior to use
36
What happens in left-to-right shunting?
right-sided & pulmonary circulation volume overload > ↓ pulmonary compliance & congestive heart failure
37
What happens in right-to-left shunting?
hypoxemia, LV overload
38
Which type of shunt causes cyanosis?
right-to-left is cyanotic left-to-right is acyanotic
39
How does a left-to-right shunt affect induction?
INHALATIONAL: minimally affected INTRAVENOUS: prolonged onset
40
How does a right-to-left shunt affect induction?
INHALATIONAL: delayed uptake INTRAVENOUS: shorter onset
41
What other considerations are necessary for a child with CHD?
Maintain PVR Avoid air bubbles Prophylactic antibiotics to prevent IE
42
What are conditions/drugs that increase left-to-right shunt?
low HCT ↑ SVR, ↓ PVR hyperventilation hypothermia isoflurane
43
What are conditions/drugs that increase right-to-left shunt?
↑ PVR, ↓ SVR hypoxia hypercarbia N2O, ketamine
44
What is the effect of pulmonary vascular resistance on intracardiac shunting?
Left-to-Right: ↑ PVR - reversal of blood flow ↓ PVR - pulmonary edema Right-to-Left: ↑ PVR - worsen oxygenation ↓ PVR - improve hemodynamics
45
What are the 4 lesions in TOF?
1. pulmonary artery atresia/stenosis (right ventricular outflow tract) obstruction 2. overriding aorta 3. VSD 4. right ventricular hypertrophy
46
How to manage a tet spell?
- maintain airway - volume infusion - increase depth of anesthesia decrease surgical stimulation - beta-blocker to control HR - phenylephrine to ↑ SVR
47
How to estimate ETT size?
Cole formula: Uncuffed = (age/4)+4 Cuffed = (age/4)+3 Insert ETT ~3x the internal diameter
48
Can cuffed ETT be used in < 8yo?
Yes, advantages include: - lower number of intubation attempts - decreased air leak - allow use of lower FGF
49
What is the effect of age on MAC?
1-6months: highest MAC - least potent children > adults premature & neonates < children
50
How to compute for the maintenance fluid?
Use the 4-2-1 rule (Holliday-Segar)
51
What is the estimated blood volume in children?
neonates ~90ml/kg 1 y/o ~80ml/kg >1 y/o ~70ml/kg
52
How to compute for the allowable blood loss?
[EBV x (actual hct - lowest acceptable hct)] / average hct
53
What is the most common type of regional anesthesia done in children?
Caudal block - bupivacaine 0.125 - 0.25% - ropivacaine 0.2%
54
What is the dose for caudal block?
Depending on level of block - sacral/lumbar: 0.5ml/kg - lumbar/thoracic: 1ml/kg - upper thoracic: 1.2ml/kg
55
What are common postoperative concerns/complications?
PONV Laryngospasm, stridor Emergence agitation
56
What are the risk factors for PONV in children?
Age > 6yo Procedure > 20min Eye & inner ear surgeries Tonsillectomy/adenoidectomy History of motion sickness Preop nausea/anxiety Use of opioid, nitrous oxide
57
How to manage PONV in children?
Limiting oral intake IV hydration Prophylaxis if high-risk (ondansetron, dexamethasone, metoclopramide)
58
Differentiate laryngospasm from stridor
Laryngospasm is the transient, reversible spasm of the vocal cords Stridor - high-pitched sound usually occurring at inspiration; may be associated with laryngospasm
59
How to manage laryngospasm?
ASK FOR HELP Jaw thrust, establish airway Suction secretions CPAP + 100% O2 May give propofol or NMB as necessary
60
Which agents are associated with emergence agitation?
Sevoflurane, desflurane (shorter-acting volatile agents) Ketamine
61
What is the general guideline on children with URTI for an elective procedure?
Postpone 4-6weeks - risk for adverse respiratory events is 9-11x
62
How to minimize adverse respiratory events in a child with 'mild' URTI?
Minimize airway manipulation: mask > LMA > > ETT Anticholinergics to decrease secretions Beta-agonist to decrease airway reactivity

Anesthesia (8 decks)

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