Exam 1: Pediatric Anesthesia pt 1 (pg 1-18) Flashcards by brianna jester

What medications is included in a pediatric anesthesia setup?

succinylcholine
atropine (x2- 10 mL and baby atropine 1mL syringe =0.1mg/mL)
lidocaine (20mg/ml)
epinephrine (10mcg/ml)
flush syringes
IM needles

pg 2

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What supplies should be included in pediatric setup?

tray with oral airway
handle
blade
ETT +/- stylet
ekg
mask
temperature monitor device
suction
bair hugger
lights
positioning equipmnet
IV kit

pg 3

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why are infants and children more prone to airway collapse?

the trachea and bronchi are very compliant

pg 3

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resistance is inversely related to?

the airway radius to the 5th power

pg 3

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In infants where is most of the resistance?
Why?

most of the resistance is in small airways and bronchi b/c of the relatively smaller diameter of airways and greater compliance of the trachea and bronchi

pg 3

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why is airway obstruction very common during pediatric anesthesia?

d/t loss of muscle tone in pharyngeal and laryngeal structures
most pronounced at the hypopharynx at the level of the epiglottis

pg3

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Resistance is inversely related to airway radius to the ____ power.

4th

Poiseuille’s Law

pg 4

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what type of flow is poiseuilles law for?

laminar flow

pg 4

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Why does the text say resistance is inversely related to the airway radius to the 5th power?

d/t Cote which describes a childs airway (crying or in distress) as turbulent flow

pg 4

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laryngospasms differ from voluntary laryngeal closure, how?

intrinsic and extrinisc muscles do not contract

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Laryngospasm occurs during inspiratory or expiratory effort?

Inspiratory which longitudinally separates the vocal from vestibular folds

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what are causes of laryngospasms?

light anesthesia
stimulation
secretions

pg 4 lecture

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what is an example of glottic closure during expiration?

valsalva

pg 4 lecture

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what is happening in a mild laryngospasm?

upper portion of larynx is partially open –> high pitched inspiratory stridor

pg 4 lecture

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What is the treatment for laryngospasms?

administer 100% O2
stop stimulation
call for help
sniffingposition, jaw thrust and chin lift improve airway patency and ventilation
deepen anesthetic (IV 1st, then VA)
CPAP/IPPV
may need to visualize the airway to rule out obstruction
trat persistent laryngospasm with succs and atropine

pg 5

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What is the dose of succs to treat laryngospasm?

IV 2mg/kg
IM 3 mg/kg

pg 5 lecture

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What is an intraoperative bronchospasm?

loss of muscle tone with induction of anesthesia that significantly increases the work of breathing

pg 5

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What questions would you want to ask that are r/t intraoperative bronchospasms?

asthma history? (mild uncontrolled or severe but well controlled?)
recent symptoms
limitiations
recent use of meds
recent in hosptial tx associated with preoperative bronchospasm

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What is intraoperative bronchospasm characterized by?

polyphonic expiratory wheeze
prolonged expiration
active expiration w/ increased respiratory effort
increase peak airway pressures
Slow up slope of etCO2 waveform (shark fin appearance)
Increased etCO2
Decreased SpO2

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The following EtCO₂ waveform in a pediatric patient would be suggestive of what?

Bronchospasm

pg 6

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What is the treatment for a bronchospasm?

IV ketamine (bronchodilator) or propofol induction and sevoflurane or isoflurane are preferred
Administer 100% O2
Deepen anesthetic (IV first then inhaled)
Avoidance of tracheal and vocal cord stimulation are ideal
- LMA is less stimulating so may be a better option for some

pg 7

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What is the intra op treatment for bronchospasm?

remove stimulus
deepen anesthesia
inhaled beta agonists
increasing FiO2
decreasing PEEP
increasing I:E time to minimize air trapping

pg 7

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Why should desflurane be avoided in children?

Desflurane can increase airway resistance in children and should be avoided

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What does increasing I:E ratio mean?

increases exhlation, decreases inspiratory time

pg 7

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if youre unable to break the bronchospasm with traditional tx, what should you consider?

IV steroids and/or epinephrine | pg 7

What is the pediatric dose of epinephrine for bronchospasm?

0.05 - 0.5 mcg/kg q1min as needed | pg 7

What are examples of short acting inhaled beta agonist and how do you administer?

* Albuterol/Xopenex * given during inspiration and delivered in-line when on the vent. | pg 8

How would you set up this inline neb setup?

| pg 9

Optimal jaw thrust is one of the most effective techniques in relieving ____ ____ ____ during general anesthesia in infants and small children

upper airway obstruction | extra video

The following symptoms are associated with what type of spasm?

Laryngospasm | pg 9

The following symptoms are associated with what type of spasm?

Bronchospasm | pg 9

differences between laryngospasm vs bronchospasm

| pg 9

Inflammation & edema related to compression of the tracheal mucosa is refered to as?

Post-extubation Croup | pg 10

What causes post-extubation croup?

* reduction in the luminal diameter and increasing the resistance * ex: Airway resistance inversely r/t to radius to the 5th power * 2mm decrease- that is a 32-fold increase in airway resistance (2^5) | pg 10

post-extubation croup can occur in 1% of children, what are the risk factors?

* Larger ETT size than airway (no leak >25cm H2O) * Changes in position during surgery other than supine * repeated attempts at intubation or traumatic intubation * Patients age 1-4 at higher risk * Subglottic area = narrowest place in pediatric pt * Length of surgery >1hr * Previous croup history | pg 10

What are the treatment options for croup?

* Nebulized epi (racemic epi) * 1hr acute PACU stay * Dexamethasone 0.5mg/kg | pg 11

how do you prevent croup?

* Micro-cuff ETT used (high volume/low pressure) * elliptical balloon placed more distally (allows for reduction of pressure on criocid ring and adjacent tissue) * no murphy eye * provides uniform surface contact | pg 11

What is the pediatric dexamethasone dosage for croup?

0.5 mg/kg | pg 11

____ is caused by failure of the complete closure of the pleural and peritoneal canals.

Congenital diaphragmatic hernia (CDH) | pg 12

CDH results in herniation of abdominal organs into the thorax which inhibits what?

* Inhibits normal lung growth (division of airways, formation of pulmonary vasculature leading to decreased bronchi and alveoli) | pg 12

What are the pulmonary consequences of CDH (Congenital Diaphragmatic Hernia) d/t decreased surface area for gas exchange ?

- ↑ PVR - Pulm HTN | pg 12

what lung is affected more with CDH?

Ipsilateral lung is usually the one affected but contralateral lung can be as well | pg 12

The most common form of CDH occurs at the left posterolateral _____ ____ _______.

Foramen of Bochdalek | pg 12

Foramen of Bochdalek CDH is the largest type and is associated with the greatest degree of pulmonary ________.

hypoplasia | pg 12

infants with CDS are more likely to have other birth defects such as?

* congential heart defects (20-40%) * chromosomal abnormalities (5-15%) | pg 12

90% of CDH occurs at the postlateral foramen of bochdalek, what are 2 other forms of CDH?

- Morgagni (anteromedial) (2%) - esophageal hiatus | pg 12

CDH is assosicate with?

* GU * GI malformations * chromosomal abnormalities like trisomy 13, trisomy 18, tetrasomy, and 12p mosaicism | pg 12

how is CDH prenatally diagnosed?

* Most made prenatally via ultrasound * Polyhydramnios * Intrathoracic gastric bubble * Mediastinal shift away from herniation site | pg 13

How is CDH diagnosed antenatal?

* Antenatal diagnosis via abdominal chest Xray showing intestinal loops and/or abdominal organs in the thorax and ipsilateral lung compression | pg 13

Which lung will be compressed in left posterolateral CDH?

Left lung (ipsilateral to the CDH) | pg 14

What are s/s of CDH?

* Respiratory distress * Tachycardia/tachypnea * Cyanosis (R->L shunt contributes to severe hypoxemia) * Concave abdomen * Barrel chest * Absent breath sounds on affected side | pg 15

CDH treatment once aimed at emergent surgical correction, but now focuses on stabilizing medically and optimize infat prior to surgery, how?

* improve pHTN and decreased PVR * 100% FiO2 and hyperventilate * High frequency oscillatory ventilation- small frequent Vt, limited PAP, and avoid CPAP * Vasodilator therapy to improve oxygenation (inhaled NO) * Prostaglandin E1 to maintain the PDA and reduce R ventricular afterload * ECMO used in severe cases of lung hypoplasia and pulmonary HTN (institute ECMO if PaO2< 50mmHg with 1.0 FiO2) | pg 15

What is the major cause of mortality in infants undergoing CDH repair without ECMO?

Pulmonary HTN | pg 16

How is CDH repaired surgically?

* Open surgical procedure with transabdominal approach and primary closure * Thorascopic repair is done in infants that are medically stable | pg 16/17

Why might there be a decrease in pulmonary compliance in infants undergoing CDH repain

the infant’s abdomen is too small to accommodate the replacement of all the bowels and results in dramatic decrease in pulmonary compliance | pg 16

If an infant's stomach is too small to hold herniated abdominal contents from a CDH, what can be used to hold viscera outside of the body and slowly introduce it into the abdomen over time?

Silo Pouch | pg 16

When would a chest tube be placed for CDH repair?

Chest tube may be placed on contralateral side before surgery if pneumothorax exists | pg 17

Is single lung ventilation necessary for CDH repair?

Not necessarily. Low flow, low pressure CO₂ insufflation on the ipsilateral lung can aid in returning abdominal viscera back where it needs to go. | pg 17

What position is the infant placed in for CDH repair?

The infant is placed in the lateral decubitus position with upper arm positioned for field avoidance | pg 17

For CDH anesthesia how do we avoid volutrauma (oscillator ventilation)?

* with controlled ventilation ( low VT, reduced peak airway pressure, no CPAP) | pg 17

Elevated _______ should be avoided in CDH surgeries.

PVR | pg 17

What are some common causes of elevated PVR?

- Hypoxemia - Acidosis - Hypothermia - Hypercarbia | pg 17

What are some commonly used methods to avoid increased PVR in CDH patients?

- Hyperventilation - Narcotics (SNS blunting) | pg 17

what should be placed before inducation for pts with CDH?

NGT to decrease likelkihood of air entering the stomach | pg 17

What VAA should be avoided in CDH management?

N₂O | pg 18

What induction sequence should be used for pts undergoing CDH repair?

* Fentanyl induction 50mcg/kg * Muscle paralysis * rocuronium 1.2mg/kg or * Cisatracurium 2mg/kg, * sevoflurane as tolerated | pg 18

What is postop plan for pts undergoing CDH repair?

Patients return to ICU intubated and muscle relaxant should be maintained | pg 18

Exam 1: Pediatric Anesthesia pt 1 (pg 1-18) Flashcards

(67 cards)