Pediatric Anesthesia Quiz #5 Flashcards
(128 cards)
1
Q
What is the most prominent muscurinic action of a bolus of succinylcholine in the pediatric patient? How can this action be prevented?
A
Bradycardia, develops in response to succinylcholine; for this reason, atropine should be administered prior to succinylcholine.
2
Q
A 2 year-old develops laryngospasm postoperatively and becomes bradycardia. Should atropine be given prior, concurrently, or after succinylcholine? Explain your answer.
A
- If continuous positive pressure of 10-15 cmH20 does not break the laryngospasm, then atropine 0.02 mg/kg followed by succinylcholine(1mg/kg IV or 4 mg/kg IM) is needed.
- Succinylcholine mimics the effects of acetylcholine at cardiac muscurinic receptors, which ca precipitate more severe bradycardia, junctional rhythms or sinus arrest.
3
Q
How much non depolarizing muscle relaxant does a pediatric patient require compared with adults on a weight basis? Succinylcholine?
A
- Neonates, infants and children require the same dose of non depolarizing neuromuscular relaxants as adults.
- Neonates require twice as much succinylcholine on a body weight basis than older children or adults
4
Q
Given that the infant has a greater sensitivity to non depolarizing neuromuscular relaxants than the adult(because the NMJ of the neonate is immature), why is the dose administered on a weight basis the same for infants and adults?
A
- Infants have a greater volume of distribution for muscle relaxants.
- The increased volume of distribution, normally requiring a greater amount of drug, is offset by the increased sensitivity of NDMR at the NMJ.
- Thus, the infant dose of the non-depolarizer is the same as the adult dose on a weight basis.
5
Q
State two reasons why neonates require more succinylcholine on a mg/kg basis than adults?
A
- Neonates have a larger volume of distribution for succinylcholine than adults.
- 40-50% of body weight of neonate is extracellular fluid(ECF) whereas in the adult ECF is only 20-25% of the body weight.
- Succinylcholine distributes in the extracellular volume so more drug is needed on a per kg basis.
- Also, the NMJ is immature(less sensitive) in the neonate, so more drug is needed on this basis.
6
Q
Deine ED90. State if the ED90 for succinylcholine is increased, decreased or unchanged in the neonate compared with the adult, and indicate what this means?
A
- ED90 is the dose of drug that is effective in 90% of the population.
- The ED90 for succinylcholine is increased in the neonate compared with the adult.
- An increased ED90 means that a larger dose of succinylcholine must be given to the neonate to achieve adequate paralysis.
7
Q
As you know, neonates require a higher dose of succinylcholine compared with the adult. This due to both an immature neuromuscular junction and greater body water content per unit weight. How would the ED95 for succinylcholine compare between a neonate and an adult-the same, higher, or lower?
A
- The ED95 of succinylcholine for the neonate would be greater than that for the adult.
- Specifically, for succinylcholine the ED95=620 mcg/kg for the neonate and the ED95=290 mcg/kg for the adult.
- This simply states the need for a greater dosing of succinylcholine in the neonate compared with the adult.
8
Q
Compare the actions of vecuronium(Norcuron) in the infant and the adult with respect to potency, onset, duration of action and recovery.
A
- Vecuronium(Norcuron) has similar potency in infants and adults.
- Onset is more rapid in infants, duration of action is long in infants and recovery is slower in infants compared to adults.
9
Q
An infant has a life-threatening succinylcholine-induced hyperkalemia: what is the definitive treatment?
A
- The definitive treatment of succinylcholine-induced hyperkalemia is IV calcium(10mg/kg calcium chloride or 30 mg/kg calcium gluconate or more).
- This restores the gap between the resting membrane potential of the cardiac cells and the threshold potential for depolarization.
- Repeated doses of calcium must be administered together with cardiopulmonary resuscitation, epinephrine, sodium bicarbonate, glucose and insulin, and hyperventilation until the arrhythmia abate.
10
Q
Describe the 4 steps to treating hyperkalemia in the neonate.
A
- Emergent treatment of hyperkalemia in the neonate centers around antagonizing the cardiac effects of excess potassium-administer calcium as calcium chloride(0.1-0.3 ml/kg of 10% solution) or calcium gluconate(0.3-1.0 ml/kg 10% solution) over 3-5 minutes.
- Return potassium to the intracellular space by correcting acidosis through administration of sodium bicarbonate, mild hyperventilation, and a B-agonist.
- Maintain potassium in the intracellular space by glucose + insulin infusion, 0.5-1.0 g/kg glucose with 0.1 U/kg insulin over 30-60 minutes.
- Remove whole-body potassium burned by Kayexalate or dialysis and correct the underlying etiology.
11
Q
How does an infant’s quantity of plasma proteins, body fat and muscle differ from the adult?
A
- Plasma proteins, body fat and muscle are reduced in the infant compared with the adult.
- Decreased plasma proteins mean more free drug is available to produce clinical effects.
- A lower dose of drug may be indicated.
12
Q
Of the following drugs administered to the pediatric patient for sedation, which will have the shortest duration of action: ketamine(rectal or IM), chloral hydrate(PO), methohexital(rectal) or propofol(IV)?
A
- Propofol has the shortest duration of action because it is administered IV.
- The duration of action of a bolus of propofol is 5-10 minutes.
- Ketamine has a duration of 12-25 minutes when administered rectally or IM.
- Midazolam has a duration of 30-90 minutes when administered rectally.
- Chloral hydrate, the most commonly used hypnotic for monitored conscious sedation by non anesthetics, has a duration of 30-60 minutes(PO).
- Note: IV thiopental has a duration of 5-15 minutes, which is similar to the duration of propofol.
13
Q
Compare the onset and duration of IV morphine in the neonate with the onset and duration of IV morphine in the adult.
A
- The onset of action of morphine is faster in the neonate compared with the adult, possibly because of greater penetration of morphine through the blood-brain-barrier and greater sensitivity of the respiratory centers to morphine.
- The duration of action of morphine will be longer in the neonate because, during the first month, metabolism of morphine by the immature cytochrome P450 system is reduced.
14
Q
Compare the duration of action of IV morphine in the infant and child with the onset and duration of IV morphine in the adult.
A
-The duration of action of morphine is shorter in the infant and child because, after the first month, metabolism of morphine by the mature cytochrome P450 system is increased as a result of greater hepatic blood flow.
15
Q
State 3 reasons why the uptake of anesthetic drugs is typically faster in children than in adults.
A
- The child’s higher alveolar ventilation per weight accounts largely for this effect.
- Increased cardiac output with greater distribution to the vessel-rich groups combined with lower muscle mass allows more of the agent to concentrate in vital organs, especially the brain.
- Anesthetic agents appear to be less blood soluble in children than in adults, that is, the agents work faster in children than adults.
16
Q
Give the two most important reasons why children are induced faster than adults with inhalational agents.
A
-Children have a smaller functional residual capacity per unit of body wight and greater blood flow to the brain.
17
Q
Nitrous oxide(N20) should be avoided in what pediatric procedures?
A
- Diaphragmatic hernia
- Bowel obstruction
- Pneumoencephalography
- Tympanoplasty
- Congenital emphysema
- Lung cysts
- Pneumothorax
- Necrotizing enterocolitis
- Patent ductus arteriosus(PDA)
- Omphalocele repair
18
Q
What is the most common type of delirium in children?
A
- In children, emergence delirium is more common.
- Emergence delirium occurs within minutes of regaining consciousness.
19
Q
The first maladaptive behavioral change in children that may be evident after surgery is emergence delirium. What its the incidence of emergence delirium in children. Briefly characterize emergence delirium.
A
- Emergence delirium has been reported in up to 18% of children undergoing surgery.
- Non-purposeful restlessness and agitation, thrashing, crying or moaning, and disorientation lasting about 45 minutes characterize emergence delirium.
- Fortunately, emergence delirium appears to be self-limiting.
20
Q
Which fluid is most appropriate for a normal 6-month-old patient requiring surgery?
A
- For short procedures, D5LR is appropriate.
- For long procedures, lactated Ringer’s is appropriate with separate D5W or D10W at a rate of 4-6 ml/kg after blood glucose levels are checked
***note from Katrin: never have glucose and electrolyte-containing fluids as a “free-flowing” IV fluid-have these fluids on infusion pump only!!!
21
Q
What is the best criteria for determine premedication dosages in kids?
A
-Body weight of child
22
Q
The child becomes unruly and combative in the preoperative period. What agents are appropriate in this situation? Specify the dose and routes of administration of each agent on the list.
- Methohexital
- Ketamine
- Midazolam
- Scopolamine
A
- Methohexital(10% solution): 25-30 mg/kg rectally, produces sleep in 8-10 minutes if the child weighs less than 20 kg.
- Ketamine: up to 10mg/kg IM, 10mg/kg rectally, 6-10mg/kg orally, 3-6mg/kg intranasally.
- Midazolam: 0.025-0.05mg/kg IM, 0.5-0.7mg/kg orally, 0.75-1.0mg/kg rectally, 0.2mg/kg intranasally.
- Scopolamine: 0.1mg IM for 6-12 months; 0.15mg for 1-5 year old.
23
Q
What is the most commonly used analgesic for pediatric outpatients?
A
- Acetaminophen is the most commonly used mild analgesic for pediatric outpatients.
- The initial dose is often administered rectally(up to 45 mg/kg) prior to awakening from anesthesia.
- Supplemental doses are then given orally(10 mg/kg every 4 hours or 20 mg/kg every 6 hours) to maintain adequate blood levels and effective analgesia.
24
Q
What is the dosage of IV Propofol and the dosage of a Propofol gatt?
A
- 2-4 mg/kg
- 25-400 mcg/kg/min
25
What is the dosage of Pentothal IV?
4-6 mg/kg
26
What is the IV dose of Etomidate?
0.3 mg/kg
27
What is the IV, IM and PO dosages for Ketamine?
- IV: 1-2 mg/kg
- IM: -7 mg/kg
- PO: 3-6 mg/kg
28
What is the loading dose of Dexmedetomidine(>20min) and what is the maintenance IV drip dose of Dexmedetomidine?
- 0.5-1 mcg/kg
| - 0.2-1 mcg/kg/HR(notice per HR!!!)
29
Propofol is a short-acting ___, with pleasant recovery, however, longer exposure to propofol might prolong emergence due to _________________.
- hypnotic
| - redistribution in the fat cells
30
Why is aseptic technique especially critical in regards to Propofol?
Bacteria loves the emulsions found in propofol. Avoid propofol induction through PICC lines secondary to increased risk of infection and occlusion of the line.
31
Propofol infusion is a great ____. Consider TIVA for patients with a history of severe ____.
- antiemetic
| - PONV
32
What is the dosage of a propofol drip used as the sole anesthetic for a MRI/CT/PET?
-150-250 mcg/kg/min(cause its not very stimulating)
33
What is the dosage of a propofol drip used as the sole anesthetic for a endoscopy/colonoscopy/bronchoscopy?
-350-400 mcg/kg/min(cause its very stimulating)
34
Neonates are especially sensitive to barbiturates(Thiopental for example) due the __________ of the drug in the serum. IV induction should not be used when there is a potential airway problem.
-reduced protein binding
35
Barbiturates are contraindicated in patients with ____, and they should be administered with extreme care in patients who may be _____ and those with __________.
- porphyria
- hypovolemic
- limited cardiac reserve
36
What types of procedures is Thiopental especially useful in and why?
- neurosurgical and ocular procedures
| - it reduces IOP and ICP
37
Ketamine increases ___, ____ and ____. Ketamine causes minimal respiratory obstruction if given alone and in adequate doses. What is a major side affect of Ketamine administration and what can be given to offset it?
- HR, MAP, CO
| - hyper salivation, an antisialoagogue
38
Is Ketamine indicated for Neuro and Eye cases? Why or why not?
- no
| - increases CBF/ICP/IOP/nystagmus movement
39
What can be administered with ketamine to decrease the incidence of hallucinations and emergence deliriums that accompanies it?
midazolam intra-op
40
Dexmedetomidine is ______ x more specific than Clonidine.
8-10 xs
41
Etomidate is a _______ hypnotic induction agent that can be _____ like propofol. It is mostly avoided because of risk of ___ reactions and ___________. It is very useful in children with ____ injuries and those with an unstable _______ status, such as ____.
- steroid based
- painful IV
- anaphylactoid reactions
- suppression of adrenal functions
- cardiovascular
- cardiomyopathy
42
The induction dose of fentanyl in children is?
1-2 mcg/kg
43
The dose of Hydromorphone is?
10-20 cg/kg
44
The dose of morphine sulfate is?
0.1 mg/kg
45
The induction dose of Sufentanil is?
1-10 mcg/kg
46
The dose of a Remifentanil IV drip is?
0.05-2 mcg/kg/min
47
The clearance of Fentanyl in preterm infants is extremely variable due to(3)?
- reduced elimination HL due to decreased hepatic BF
- reduced hepatic function
- age dependent changes in Vd
48
***TEST QUESTION***
| What are two hallmark characteristics of Fentanyl that affects the way it impacts the pediatric patient?
- its highly lipid soluble
| - it crosses the BBB rapidly
49
0.1 ml of Fentanyl = how many mcg?
5 mcg
50
When is Hydromorphone commonly used in the pediatric population and how does it compare to morphine?
- it is commonly used when prolonged analgesia is required
| - it is 5-7.4 times more potent than IV morphine
51
How is hydromorphone diluted to make it more user friendly in the pediatric population?
1 mg dilaudid is mixed in a 10 ml syringe with NS(9ml NS + 1 mg dilaudid) = 100 mcg/ml
52
What is the dosages of dilaudid given in a pediatric case?
10 mcg/kg initially then 5-10 mcg/kg throughout the case
53
What are the side effects of dilaudid and in what patients is it not appropriate?
- SE: sedation, N/V and respiratory depression
- requires close observation, NOT APPROPRIATE for infants and small children for same-day surgery with discharge to home
*Best is child is spontaneously breathing with LMA or ETT, titrate to age-appropriate RR*
54
Morphine provides excellent post-op analgesia, however, neonates and infants are more sensitive to ___ ____ ___ due to these two reasons. These are the adverse effects of morphine:
- ventilatory depressant effects
- increased permeability of BBB & less predictable clearance of morphine
- histamine release causing hypotension, respiratory depression/apnea, sedation, PONV
55
Sufentanil is has an extremely high margin of safety. What are its characteristics in regards to protein-binding and elimination?
-it is highly protein bound(92%) and has a shorter elimination HL
56
What are some adverse SE of Sufentanil?
Resp depression/apnea/chest wall rigidity
57
What is the HL of Remifentanil, and how is it eliminated?
- Ultra-short acting synthetic opioid: 3-10 minutes elimination HL, independent of dose or duration of infusion or age of patient.
- It is eliminated via tissue esterase hydrolysis.
*so it can be used in any patient because it does not require the kidneys for elimination*
58
What may occur after bolus administration of Remifentanil and what are adverse effects of Remi in general?
- Remi should be administered only by continuous infusion:0.05-2.0 mcg/kg/MIN. Severe bradycardia and hypotension may occur after bolus administration.
- Apnea, bradycardia, chest wall rigidity and vomiting
59
Signs of withdrawal secondary to neonatal abstinence syndrome are?
- crying, hyperactivity, fever, tremors, poor feeding and sleeping...in extreme cases, vomiting and convulsions
* all long-term infusions should be tapered slowly over days*
60
What is the primary indication for methadone in children?
is to wean from long-term opioid infusions to prevent withdrawal and to provide analgesia when other opioids have failed or have been associated with intolerable SE.
61
In children, what are the characteristics of Methadone in regards to volume of distribution, plasma clearance and HL? How protein bound is Methadone, and what is the main determinant of it's free factor?
- large volume of distribution, high plasma clearance and long HL
- 60-90% protein bound and a1-acid glycoprotein is the main determinant of the free factor of Methadone.
62
What is the PO and the IV dose of Midazolam?
- IV: 0.05-0.1mg/kg
| - PO: 0.5-0.7 mg/kg(with a max of 20mg)
63
What is the PO and rectal dose of Acetaminophen?
- PO: 10-15 mg/kg/dose q6hrs
| - Rectal: 30-40 mg/kg PR x 1 loading
64
What is the IV and IM dose of Ketorolac?
- IV:0.5 mg/kg(max 30 mg)
| - IM:0.5-1 mg/kg(max 30 mg)
65
In children, midazolam has been shown to produce tranquil and calm sedation, reduces separation anxiety, facilitates induction of anesthesia and enhances _____ amnesia.
Oral Midazolam tastes bitter but provides adequate effect after _____ minutes.
- antegrade
| - 10-15 minutes
66
Acetaminophen has analgesic and antipyretic properties without ______ action. Doses should not exceed ___?
-anti-inflammatory actions
-90 mg/kg/24 hrs
Hepatic failure may occur with OD and is a particular risk in the seriously ill child.
67
In what two types of patients should the use of Ketorolac be especially cautious?
- renal patient as Ketorolac reduces RBF
| - asthmatic patient(allergic reaction to NSAIDS---->prostaglandins)
68
A major concern with Ketorolac is the inhibition of _____ and ______ and potential post-op bleeding. Compared with Aspirin, Ketorolac's platelet inhibition is _____ and is gone when ______. What type of pediatric surgery should Ketorolac ABSOLUTELY not be given in?
- platelet function and cyclooxyrgenase
- reversible
- the drug has been excreted
- T&A
69
What type of syringe should be used to administer Ketorolac to a child?
TB
70
What is the dosage of Naloxone(Narcan), why types of patients is it useful in, and how should it be diluted?
- 0.001 mg/kg = 1 mcg/kg
- effective in reversing opioid-inducing SE including res depression, N/V, pruritus, urinary retention and constipation.
- A vial contains 0.4 mg/ml ---> dilute in 9 ml NS to get 40 mcg/ml
* Resp depression may be reversed with as little as 1-10 mcg/kg, although larger doses(up to 100 mcg/kg) may be required*
71
Because elimination HL of Naloxone is shorter than the HL of most opioids, ___ can occur ___> consider __________ and monitor closely. What are some SE of Naloxone?
- resedation
- repeating the dose
- HTN, cardiac arrhythmias, pulm edema
* repeated small doses reverse the resp depression w/o reversing the analgesic effects*
72
What is Flumazenil used for? What is its mechanism of action? What is the dose?
Flumazenil is a specific GABA receptor competitive antagonist that reverses the effects of benzodiazepines.
* It does not reverse the effects of opioids*
0. 01 mg/kg = 10 mcg/kg
73
What are the adverse effects of Flumazenil? Because elimination HL of Flumazenil is shorter than the HL of most Benzos, _____ can occur ---> consider ________ and monitoring closely.
- N/V, blurred vision, sweating, anxiety and emotional liability
- resedation
- repeating the dose of Flumazenil
74
What is the IV dose of Succinylcholine in the pediatric patient?
1.5-2 mg/kg
75
What is the IV dose for RSI of Rocuronium? What is the induction dose of Rocuronium?
- 0.6-1.2 mg/kg
| - 0.45-0.6 mg/kg
76
What is the IV dose of Vecuronium, Cisatracurium and Pancuronium?
- 0.1 mg/kg
- 0.1-0.2 mg/kg
- 0.1 mg/kg
77
What are the characteristics of Rocuronium in regards to onset of action, SE, elimination and sensitivity(DOA)?
- intermediate NDNMB with the fastest onset of action
- devoid of CV/histamine effects similar to Vec
- eliminated by the liver, only 10% are excreted by the kidneys
- Neonates appear to be more sensitive to Roc than older infants with a DOA of 90 minutes after 0.6 mg/kg.
78
What are the characteristics of Vecuronium in regards to DOA, SE, and how it is metabolized.
- 35 to 45 minutes in children, but longer in small infants(70 minutes)
- no CV SE and metabolites seem not have have CNS effects.
- Vecuronium is primarily metabolized by the liver and excreted in bile.
79
When NDNMB are given in conjunction with _____ there DOA may be prolonged.
antibiotics such as tobramycin, neomycin, gentamicin and hypothermia
80
What are the characteristics of Cisatracurium(Nimbex) in regards to SE, DOA and how is it eliminated?
- stable hemodynamics and minimal histamine release
- 35 minutes
- Elimination via Hoffman elimination and ester hydrolysis_> the duration of action is unaffected by renal or hepatic failure and is therefore the drug of choice for renal or hepatic failure patients.
81
What are the characteristics of Pancuronium(Pavulon) in regards to when it is preferred, how affects pre-term infants and how it is eliminated?
- longer acting NDNMB is preferred when increased HR and BP is desired(cardiac surgery)
- In preterm infants, Panc causes a sustained tachycardia, HTN and increased plasma epinephrine level. There is some concern of increased risk of intracerebral hemorrhage.
- Pavulon is excreted via the kidneys, prolonged NMB with renal impairment may occur.
*each following dose should only be 10-20% of initial dose*
82
What is the pediatric dose of Glycopyrrolate IV?
10 mcg/kg
83
What is the IV pediatric dose of Atropine?
10-20 mcg/kg(min 100 mcg)
84
What is the pediatric Neostigmine dose?
0.07 mg/kg(with a max of 5mg)
85
What is the antiemetic IV dose of Dexamethasone and what is the airway IV dose of Dexamethasone?
- antiemetic 0.1 mg/kg(max 10 mg)
| - airway 0.5 mg/kg(max 10 mg)
86
What is the dose IV of Ondansetron?
0.1 mg/kg(max usually 4 mg)
87
In neonates and infants it is difficult to judge if twitches are preset...what clinical signs should be observed:
ability to flex hips/arms, lift legs, return of abdominal muscle tone.
*Neostigmine should be mixed with 10 mcg/kg Glycopyrrolate.
88
How doe Atropine and Glycopyrrolate affect the CNS and why?
-Atropine crosses readily the BBB and has some central sedative effect. However Glycopyrrolate has minimal CNS effect.
89
What are Atropine and Glycopyrrolate used for in the pediatric population?
-both are used to off-set muscurinic effects of neostigmine for reversal of NDMB, to treat bradycardia with oculocardiac reflex and to dry up sections(drooling with Ketamine)
90
Explain the caution that should be observed when administering atropine to a Down syndrome child.
Some Down syndrome children may have narrow-angle glaucoma so atropine must be administered cautiously because it might worsen the glaucoma.
91
Why should Dexamethasone never be given intra-op to a cancer patient?
due to tumor lysis syndrome
92
How are Amides degraded? And how to tell Amides from Esters.
- Amides are degraded in the liver by Cytochrome P450
| - Amides have 2 i's in them
93
How are Esters degraded?
-Esters are primarily hydrolyzed by plasma cholinesterase's (have only 1 i)
94
What is the dose of Bupivacaine with Epi and what is its max dose?
- 2.5 mg/kg
- Max dose 175 mg
Bupivacaine comes 0.25% so its 2.5 mg/kg so if you have a 10 kg kid the dose would be 10ml
95
What is the dose of Lidocaine with Epi?
4.5 mg/kg
96
What is the dose of Ropivacaine?
2.0 mg/kg
Ropivacaine is 0.2% so its 2 mg/kg--->give 1 ml/kg
97
Epinephrine(Adrenalin) IV to treat cardiac arrest, hypotension and heart failure. What is the dosage? What is the infusion dose? and how is it diluted to treat bronchospasm?
- give 10 mcg/kg Q3-5 min
- infusion 0.01 - 1 mcg/kg/MIN
- Epinephrine(diluted to 10 mcg/ml) give small amounts in 1-2 mcg/kg IV to treat bronchospasm
98
What is the dosages of nebulized Racemic Epi?
-if child 2 years old give 0.5 of 2.25% solution mixed in 3 ml NS solution.
99
What are the dosages of Cefazolin, Clindamycin and Gentamicin IV? What is important to remember about how to administer Gentamicin?
- Cef 25 mg/kg
- Clinda 10 mg/kg
- Gent 2 mg/kg--->remember to infuse Gentamicin over > 30 minutes via Alaris pump!!
100
What are the urology and general doses of Ampicillin? What is the dosages for Vancomycin and how should it be administered?
- Amp(Urology) 20 mg/kg
- Amp(General) 25-50 mg/kg
- Vanc 15 mg/kg(20 mg/kg Neuro)--->remember to infuse Vanc over 1 hour via Alaris pump!!!
101
What is the dosage of Zosyvn and in what concentration does it come in?
- dose 1.3 ml/kg(***notice its ml/kg***)
| - concentration 67.5 mg/ml
102
Calculate the Zosyvn dose in ml and mg for a 2 y/o appendicitis patients that weighs 18.3 kg
- dose 1.3 ml/kg--->23.8 ml
- infuse 23.8 ml via Alaris pump over > 30 minutes
- concentration is 67.5 mg/ml --->1606.5 mg is what would be charted
103
What is the dosage of Unasyn and what is the concentration?
- 1.3 ml/kg
| - 30 mg/ml
104
Calculate your patients Unasyn dose in ml and mg: 3 y/o exploratory laparotomy patient weights 22.3 kg.
-administer 29 ml over > 30 minutes ---> chart 870 mg(concentration 30 mg/ml)
105
What is the dosages of Cefepime and concentration?
- If your patient is 30 mg/kg
- If your patient is > 14 days old ---> 50 mg/kg
- Cefepime's concentration is 20 mg/ml
106
Your 17 day old craniotomy patient weights 3.1 kg...what is the dose?
-155 mg ----> so infuse 7.75 ml over > 30 minutes
107
What is the dosages of Vancomycin and its concentration?
- Vancomycin is 15mg/kg with a max dose of 1500 mg
- Vancomycin(neurology) dose is 20 mg/kg with a max dose of 1500 mg
- Vancomycin's concentration is 5 mg/ml
108
Calculate the dosage in a 17 day old craniotomy patient that weighs 3.1 kg.
-62 mg ----> 12.4 mls over 1 hour!!!!!
109
The fetal formation of the diaphragm is completed during which fetal weeks?
7-10th fetal weeks
110
90% Diaphragmatic hernias are this type, 9% are this type and the remaining 1% are this type?
-90% posterolateral Bchdalek-type hernia(80% are left sided)
-9% anterior Morgagni-type
-
111
What are the hallmark features of Congenital Diaphragmatic Hernia?
Abnormal compression of pulmonary structures is the hallmark of CDH and its cardiopulmonary sequelae. Lung growth is severely retarded.
- under developed proximal airway divisions and supporting pulmonary arterial vasculature
- fewer functional alveolar units and grossly diminished surface area for effective gas exchange
- deficiency of surfactant
- alveolar instability
- atelectasis
- intrapulmonary shunting of deoxygenated blood
112
Clinically how does a CDH usually manifest itself?
CDH most often manifests as severe respiratory distress in the neonate, a direct consequence of lung hypoplasia and inadequate pulmonary gas exchange.
- "Scaphoid abdomen" and bowel sounds in the lung field
- Morgagni-type CDH: less severe respiratory compromise but with symptoms of bowel obstruction.
113
How should CDH be treated at birth?
- definitive airway control is a priority(avoid mask ventilation with potential gastric insufflation), intubation and mechanical ventilation(with rapid low Vt and limited PIPs to reduce risk of barotrauma/right-sided pneumothorax)
- decompression of intestinal contents via NGT
- Chest X-ray, ABGs, Echo, Cranial U/S(to rule out IVH), IV access, A-line, ECMO
Currently, surgical repair is delayed until the neonate has been optimized
114
How is CDH infants surgically managed from the CRNA point of view?
-Supportive care during surgery(NICU ventilator/HFOV, ABGs, high-dose opioid, low dose volatile, avoid N2O, inhaled NO, ECMO?
115
In the patient with congenital diaphragmatic hernia whittling is usually involved?
- Herniation on the left side through the foramen of Bochdalek in 80% of congenital diaphragmatic hernias
- Hence, the left lung is involved
116
Is the infant with a diaphragmatic hernia with bowels extending into the chest an emergency? List seven anesthetic considerations for managing an infant with a diaphragmatic hernia with bowels extending into the chest.
- This is an emergency
- Anesthetic considerations for managing this patient include:
- place an NGT
- do not apply positive ventilation via mask, intubate with controlled ventilation, do not use N2O, monitor PaCO2 and SaO2 and use 100% O2
- Give muscle relaxants and opioids after the chest is opened
117
During the intraoperative period of a congenital diaphragmatic hernia repair, the SaO2 suddenly falls to 65% and heart rate decreases to 50 bpm. What is the likely cause and what should be done?
- Any sudden deterioration in lung compliance, HR, oxygen saturation, or BP suggests a tension pneumothorax on the contralateral side
- Absent or diminished breath sounds confirmed the diagnosis of pneumothorax, and the chest type should be inserted immediately
118
What is Hypertrophied Pyloric Stenosis, and what surgical procedure repairs it?
- Hypertrophy of the muscular layer of the pylorus(olive shaped mass); more males(1:500 live births)
- Surgical pyloro-myo-tomy relieved the obstruction
119
When does Pyloric stenosis usually manifest itself, and what three laboratory findings are secondary to its protracted vomiting?
- Pyloric stenosis usually manifests with 2nd to 6th week of life with non-bilirous vomiting.
- With protracted vomiting these infants may become hypokalemic, hypochloremic and alkalotic.
120
What is the renal response to Pyloric stenosis?
- Renal response to the vomiting caused by Pyloric stenosis is two-fold:
1. serum pH initially is defended by excretion of alkaline urine with Na+ and K+ loss.
2. with depletion of electrolytes, the kidneys secrete acid urine(paradoxic acidosis), which further increases metabolic alkalosis.
121
Hypocalcemia may be associated with _____. With further fluid loss preener azotemia may foreshadow ___ ____ and _____.
- hyponatremia
| - hypovolemic shock and metabolic acidosis
122
Is Pyloric stenosis a surgical emergency?
No it is a medical emergency, but not a surgical emergency.
123
What should be done pre-op to prepare for the surgery, and what type of induction are they??
- Before coming to the OR patient should have their intravascular volume stabilized and electrolytes within normal limits.
- RSI--->100 mcg of atropine should be given and they should be suctioned thoroughly with a large-bore OGT left, right and lateral before intubation.
124
How should emergence be handled in the Pyloric stenosis patient?
- patient should be fully awake prior to extubation
- due to metabolic alkalosis, pyloric stenosis patients often have a sluggish "breathing drive"--->remember elevated CO2 stimulates breathing
- LA at the incision site withholding-acting LA generally provides complete analgesia-no fentanyl is generally given.
125
What acid-base disturbance will be seen with significant loss of bile vomitus?
-significant loss of bile vomitus will result in metabolic acidosis.
Katrin's comment: True-significant loss of bile vomitus will result in metabolic acidosis, however loss of gastric acid and the kidney's response of excreting acid urine can also cause metabolic alkalosis.
*on the test it can be both acidosis and alkalosis*
126
What serum sodium, potassium and chloride concentrations and what urine output are needed before surgery in the patient with pyloric stenosis?
```
-electrolytes need to be:
Na+ > 130 mEq/L
K+ > 3 mEq/L
Cl- > 85 mEq/L
UOP of at least 1-2 ml/kg/hr
```
127
How might you intubate the Pyloric stenosis patient?
-RSI with cricoid pressure
128
The newborn has undergone a pyloromyotomy. What might you be concerned about in the postoperative period?
-Neonates who have undergone pyloromyotomy may be at increased risk for respiratory depression and hypoventilation in the recovery room because of persistent metabolic or cerebrospinal fluid alkalosis.
