Pediatric Anesthesia Week 1 Flash Cards Preview

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Flashcards in Pediatric Anesthesia Week 1 Flash Cards Deck (100):

What is the pediatric dose of:
Midazolam PO

0.5-0.7 mg/kg PO (max: 20mg)


What is the pediatric dose of:
Cefazolin IV

25 mg/kg


What is the pediatric dose of:
Succinylcholine IV

1.5-2.0 mg/kg


What is the pediatric dose of:
Atropine IV (How much in mcg?)

0.01-0.02 mg/kg (no < than 0.1mg)

(10-20 mcg/kg IV)


What is the pediatric dose of:
Atropine IM?

20-40 mcg/kg IM


What is the pediatric dose of:
Propofol IV

2-4 mg/kg IV


What is the pediatric dose of:
Vecuronium IV

0.1 mg/kg


What is the pediatric dose of:
Fentanyl IV (induction dose)

1-2 mcg/kg


What is the pediatric dose of:
Hydromorphone IV

10-20 mcg/kg IV


What is the pediatric dose of:
Neostigmine IV

0.07 mg/kg IV (with a max dose of: 5 mg)


What is the pediatric dose of:
Glycopyrrolate IV (how much in mcg?)

0.01 mg/kg IV (10 mcg/kg IV)


What is the pediatric dose of:
Ondansetron IV

0.1 mg/kg


What is the formula to estimate proper ETT size?
Uncuffed? Cuffed?

((age) + 16) / 4 = ETT size uncuffed (decrease size by 0.5 if cuffed)


A pediatric patient is 23 kg,
what estimated size LMA would you use?

Between 20-30 kg: Size 2.5 LMA


A pediatric patient is 14 kg,
what estimated size LMA would you use?

Between 10-20 kg: Size 2 LMA


A pediatric patient is 9 kg,
what estimated size LMA would you use?

Between 5-10 kg: Size 1.5 LMA


A pediatric patient is 34 kg,
what estimated size LMA would you use?

Between 30-50 kg: Size 3 LMA


A pediatric patient is 3000 g,
what estimated size LMA would you use?

<5 kg: Size 1 LMA


A pediatric patient is 54 kg,
what estimated size LMA would you use?

Between 50-70 kg: Size 4 LMA


What influences place pediatric patients at higher risk for perioperative anxiety?

Parental characteristics
- Anxious parents
- Parents who use avoidance coping mechanisms
- Separated or divorced parents


What does PPIA stand for?
What is it used for?

Parental Presence of Induction of Anesthesia (PPIA)
Allows parents to be present during induction allowing pediatric patients to be calm on induction.


What are the most common medications for perioperative anxiety?
What are the normal dosages?

Transmucosal fentanyl (nasal spray)
Dexmedetomidine (Precedex)


What are some strategies to minimize perioperative anxiety in a pediatric patient?

Build rapport:
- Maintain eye contact
- Interact with patient
- Spend time with patient


What is important for the anesthesia provider to remember with pediatric patients?

They are not "little adults":
Physiologic differences related to general metabolism and to immature function of the various organs (i.e heart, lungs, liver, kidneys, CNS, etc.)


When is an neonate considered premature?

If they are born BEFORE 38 weeks AND weigh LESS THAN 2500g (2.5kg)


When is an neonate considered pre-term?

If they were born before 37 weeks of gestation


When is an neonate considered full-term?

If they were born between 37 and 42 weeks of gestation


When is an neonate considered post-term?

If they were born after 42 COMPLETED weeks of gestation


In what FIVE ways is a premature neonate different from a full-term neonate?

When compared to a full-term neonate, a premature infant is less able to:
- suck - maintain body temperature
- swallow - sustain ventilation
- eat


A pediatric patient is considered a NEONATE if they are:

Less than 30 days of age


A pediatric patient is considered an INFANT if they are:

1 to 12 months of age


A pediatric patient is considered a CHILD if they are:

1 to 12 years of age


A pediatric patient is considered an ADOLECENT if they are:

13 to 19 years of age


In terms of birth weight, what is considered a "Micropremie"?

Weighing LESS THAN 750 gm


In terms of birth weight, what is considered Extremely Low Birth Weight?

Less than 1 kg


In terms of birth weight, what is considered Very Low Birth Weight (VLBW)?

Less than 1.5 kg (1500g)


In terms of birth weight, what is considered a Low Birth Weight (LBW)?

Less than 2.5 kg (2500g)


What two factors play an important role in normal growth of a neonate?

Duration of gestation AND weight


What factors may affect the DURATION OF GESTATION and WEIGHT of neonate leading to abnormal growth?

- Inadequate maternal nutrition (malnutrition, placental insufficiency)
- Maternal disease (PIH, gestational diabetes, collagen disorders, etc.)
- Maternal toxins (drugs, alcohol, tobacco, etc.)
- Fetal infections (Rubella, Syphillis, Toxoplasmosis, CMV, etc.)
- Genetic abnormalities (Trisomy 21, 18, & 13)
- Fetal congenital malformations


What is the most commonly used form of measurement of growth in pediatric patients?

Weight (more sensitive index of well-being, illness, or poor nutrition than length or head circumference)


What is "failure to thrive" indicative of?

A serious underlying disorder may be present


What is a full-term neonates airway like?

- Short neck
- Chin that often meets the chest at the level of the 2nd rib
* Tracheostomies' they are often buried under the chin, unless the neck is extended with a roll


How do neonates/infants typically react to General Anesthesia (GETA)? Why?

They are more prone to upper airway obstruction because of the upper airway muscles, that normally support the airway patency, are disproportionally sensitive to the depressant effect of GETA resulting in pharyngeal airway collapse and thus, obstruction.


What are some of the major differences between neonatal and adult airway?

- TONGUE is disproportionally large to the rest of the oral cavity increasing risk of obstruction
- LARYNX is more CEPHALAD (C2-C3) vs adult (C4-C5) and funnel shaped; making a straight blade (Miller/ Wis-Hipple) easier for visualization of the vocal chords than a curved blade
- EPIGLOTTIS is more narrow, shorter, and angled towards trachea (more difficult to displace)
- VOCAL CHORDS are more angled increasing difficulty


How many PRIMARY teeth are there? When do they begin to erupt? When do they begin to shed?

- 20 primary teeth
- 1st year of life
- Between 6 to 12 years of age
* a thorough pre-op of children to note loose teeth which may be dislodged during airway management


How many permanent teeth are there? When do they begin to erupt? What considerations are there?

- 32 permanent teeth
- At the time primary teeth are shed
- Examine braces, loose, or damaged teeth


What are some considerations in neonates when conducting mask ventilation?

Unintentional jaw pressure from neck flexion, submental pressure, or mandibular pressure during facemask application are associated with airway obstruction


Many infants have some degree of this, that renders the supraglottic structured prone to collapse during inspiration.



What is a common error when mask ventilation a neonate/infant?

Applying the facemask too low over the nose, compressing the nasal passages


What technique can be applied to improve upper airway obstruction in a neonate/infant?

Chin lift, jaw thrust with application of CPAP


How much CPAP pressure can be applied to improve upper airway obstruction in a pediatric patient?

5-15 cm of H2O pressure at the APL valve
*Use caution as CPAP can unintentionally inflate the stomach


How can a "chin-lift" maneuver on a pediatric patient improve upper airway obstruction?

It will extend the head at the atlantooccipital joint stretching and straightening the airway decreasing soft tissue obtruction


During neonatal resuscitation, positive pressure ventilation and mask are being conducted, when is endotracheal intubation indicated?

If there is no immediate ( < 30 seconds) improvement in the clinical condition of the neonate


When should IMMEDIATE endotracheal intubation be considered during neonatal resuscitation?

For situations in which bag and mask ventilation is likely going to be ineffective such as:
- Extreme prematurity with low pulmonary compliance secondary to surfactant deficiency
- Large bilateral pleural effusions
- Congenital Diaphragmatic Hernias


When is an oral airway considered "Too Large"?

The tip lines up posterior to the angle of the mandible and obstructs the glottic opening by pushing down on the epiglottis


When is an oral airway considered "Too Small"?

When the tip lines up well above angle of the mandible, kinking the tongue and obstructing the airway


How should a nasal airway be inserted in a pediatric patient?

Very carefully...
- Lubricated
- Inserted in a posterocaudad direction along the floor of the nasal cavity


When should nasal airway/trumpets be avoided in pediatric patients?

Pediatric patients with:
- Coagulopathy
- Thrombocytopenia
- Suspicion of a traumatic basilar skull fracture
- Cancer patient
* Okay for T&A patients, upon ENT request


How does an LMA compare to an ET tube with pediatrics patients?

- Associated with less laryngeal stimulation
- Decrease incidence of airway complications in children with upper respiratory tract infections


Peak inspiratory pressures should not exceed _____cmH2O to prevent gastric insufflation



When is an LMA not indicated for use?

Children at risk for pulmonary aspiration of gastric contents


At what depth do you place an ET tube in newborn? 1 year old? 2 year old?

- Newborn 10 cm
- 1 year old 11 cm
- 2 year old 12 cm


What size ET tube for a full-term neonate?
At what depth?

- Uncuffed 3.0 to 3.5
- Newborn is 10 cm


What size ET tube for a pre-term less than 2 kg?
At what depth?

- Uncuffed 2.5
- 7 to 9 cm


What size ET tube for a pre-term less than 1 kg?
At what depth?

- Uncuffed 2.0
- 6 cm


What size ET tube for a 1 year old?
At what depth?

- Uncuffed 3.5 to 4.0 or cuffed 3.0 to 3.5
- 11 cm


What size ET tube for a 6 year old?
At what depth?

- ((age) + 16) / 4 = 22/4= cuffed 5.0 or 5.5
- 14 to 15 cm


What is the narrowest portion of the airway in an pediatric larynx (2 months to 13 years of age)? What is the shape?

- The glottis and immediate subglottic area
- Funneled-shaped and exaggerated


How do you prepare for a nasal intubation on a pediatric patient?

- Administer a topical vasoconstrictor (Oxymetazolin 0.05%) bilaterally after induction
- Pre-softened nasal RAE ET tube
- Lubricated nasal trumpet
- Antibiotic endocarditis prophylaxis in susceptible children


What is physiologically occurring during a full laryngospasm?
Partial laryngospasm?
What are some differential diagnosis?

- Reflex closure of the upper airway (glottic musculature spasm). Stimulation of the AFFERENT fibers contained in the INTERNAL branch of the SUPERIOR LARYNGEAL NERVE (SLN)
- Inspiratory stridor
- Bronchospasm or Supraglottic obstruction


What is the best volatile to use to decrease the risk of laryngospasm?



What anesthesia techniques can be done to decrease the risk of a laryngospasm?

- Deepen anesthesia during airway manipulation and IV placement
- Awake vs. deep extubation
- Positive inflation of lungs during extubation
- Reduce secretion with small doses of Glycopyrrolate (dose?)


How do you treat a laryngospasm in a pediatric patient?

- Identify and remove stimuli
- Apply "jaw thrust" (pressure to the "laryngospasm notch") just behind the earlobe
- Insert oral/nasal airway
- Apply PPV with 100% O2, deepen anesthesia with Sevoflurane or
- Propofol 0.5 mg/kg IV
- Succinylcholine 0.1 mg/kg IV or up to 4 mg/kg IM
(with Atropine 10 to 20 mcg/kg IV (>100 mcg) or 20 to 40 mcg/kg IM)
- Rocuronium IM (dose?)
- Continue to mask ventilate or intubate
- Monitor for gastric distention or post-obstructive negative pressure pulmonary edema


What is the limit of viability in a fetus for respiratory development?
Which cells produce surfactant?
When does it increase?

- Around the 23rd to 24th week of gestation, when the lungs develop a gas-exchange surface and surfactant production begins
- Type II Pneumocytes
- Production/concentration increases in the last 10 weeks gestation of life


What is the Lecithin-Sphingomyelin Ratio (L/S Ratio)?

A clinically useful indicator or measurement of lung-maturity (from 30 to 36 weeks of gestation, surfactant secretion concentration increases in the amniotic fluid)


Blood shunt through what two structures in the neonate with persistent fetal circulation?

Blood shunt through the Ductus Arteriosus and the Foramen Ovale


How does a fetus (fetal circulation) transition to air breathing (neonatal circulation)?

The increase afterload forces closure of the "flap-valve" mechanism of the Foramen Ovale and reverses the direction of the shunt through the Ductus Arteriosus.


What can delay the transition from fetal to neonatal circulation?

Increased PVR in response to HYPOXIA or ACIDOSIS may precipitate the reversal to RIGHT-to-LEFT shunting leading to CYANOSIS

*Until the fetal shunts close anatomically the pattern of circulation is unstable


What are the mechanics of breathing in a neonate?

- Ribcage is cartilaginous and the thorax is too compliant to resist inward recoil of the lungs
- Chest wall is easily deformed, moving inward on inspiration
- Inspiration occurs almost entirely as a result of diaphragmatic descent


What is "Periodic Breathing" in a neonate?
What is it related to?

- Recurrent pauses in ventilation lasting no more than 5 to 10 seconds w/ alternating bursts of respiratory activity
- Gestational age and sleep state (REM)


What is "Apnea of Prematurity" in a neonate?

- A life threatening condition (25% of pre-term neonates, most premature)
- Episodes of apnea that involve desaturation arterial oxygen, bradycardia, loss of muscle tone
- May be terminated by tactile stimulation, but may require resuscitation


Which neonates are at greatest risk for post-operative apnea?

Those who are/or have:
- Premature
- Congenital anomalies
- History of apnea and bradycardia
- Chronic lung disease


What agent may be given prophylactically to reduce the incidence of post-operative apnea?

Caffeine, a CNS stimulant, with a loading dose of 10 mg/kg of caffeine base, obtained from 20 mg of caffeine citrate.

*Do not administer caffeine and then discharge the patient assuming it will prevent apnea


How do neonates respond to hypoxemia?
How do you treat it?

- Pulmonary and systemic vasoconstriction
- Bradycardia
- Decreased cardiac output (CO)
*100% O2 and administer Atropine (dose?)


What is an appropriate SaO2 and PaO2 for a premature infant during anesthesia?

SaO2 of 90 to 95%
PaO2 of 60 to 80 mmHg (AAP & ACOG says 50 to 80 mmHg)


What is "postconceptual age (PCA)"?
What is the relationship between PCA and the risk of postanesthetic respiratory depression?

- PCA= The sum of gestational age and chronologic age
- The risk of postanesthetic respiratory depression is inversely related to the postconceptual age (PCA)


When can a premature infant be discharged from the PACU?
When do they have to be admitted for monitoring?

- A PCA of 55 to 60 weeks who are not anemic and not experiencing apnea be observed for an extended period of time and if stable may discharge
- A PCA of < 55 weeks who are anemic ( Hct < 30%) and experiencing apnea may be admitted for monitoring


How many days postgestation is it safe for surgery in a full-term infant?
How many weeks PCA for a pre-term infant?

- 15th through 56th day for a full-term
- AT LEAST 60 weeks postconception (PCA) for a pre-term


Would a formerly premature infant be a candidate for outpatient surgery?

No. < 46 weeks postconceptual age (PCA) even healthy have an increase risk for postanesthetic apnea and bradycardia
They should have a minimum of 24 hours post op cardiorespiratory monitoring


Fetal circulation involve __ umbilical vein(s) carrying _______ blood ____ mom and __ umbilical artery(ies) carrying _______ blood _____ mom.

- 1
- Oxygenated
- From
- 2
- Deoxygenated
- To


In fetal circulation, Ductus _______ bypasses the ______, while the Ductus _______ bypasses the _______.

- Arteriosus (along with the Foramen Ovale)
- Lungs
- Venosus
- Liver


In a neonate, the Autonomic Nervous System is predominantly ______. Stroke volume is _______, which is why _______ determines cardiac output.

- Parasympathetic
- Fixed
- Heart rate


List two ways the physiology of the cardiovascular system of the neonate differs from an adult

- CO is HR dependent (as stroke volume (SV) is fixed)
- Left ventricle compliance is decreased


What is a normal heart rate for a term neonate?

120-180 BPM


What is the estimated blood volume (EBV) of a:
Pre-term neonate?

90-100 ml/kg


What is the estimated blood volume (EBV) of a:
Full-term neonate?

80- 90 ml/kg


What is the estimated blood volume (EBV) of an:
Infant (3 months to 1 year)?

70- 80 ml/kg


What is the estimated blood volume (EBV) of a:
School-aged child (< 12 years)

70 ml/kg


What is the estimated blood volume (EBV) of a:

65- 70 ml/kg


What is the estimated blood volume (EBV) of an:
Obese child

60- 65 ml/kg