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How can you calculate the low range of age appropriate SBP?

Age 2-10 years: 70 + (age * 2)


At what age do you usually need to pre-medicate with oral versed?

What are some noteable developmental ages? (table)







10 mo d/t separation anxiety.

**nasal versed can burn!


What should be emphasized in the pre-op evaluation?

  • birth history
  • neological development (appropriate for age?)
  • airway anomalies, previous intubations
  • Genetic or dysmorphic syndrome
  • routine pregnancy test age 10+
  • No laboratory workup for healthy kids with minimal blood loss surgery
  • Standard adult assessment


What patients are at higher risk for latex allergy?

  • spina bifida
  • myelodysplasia
  • urinary tract malformations
  • multiple previous surgeries


What should you ask during the respiratory focused portion of the Pre-op assessment?

  • Frequent URI?
  • Hx of wheezing?
  • Hx of noisy breathing?
  • Hospitalizations?
  • previous intubations?
  • Hx of eczema/skin allergy? 
  • In daycare? Immunization status?
  • Smokers in house?
  • Infant:  Frequent vomiting or choking with feeds?
  • Child? Frequent tonsillitis? ear infections? snoring?


What should you ask during the CV focus portion of the pre-op assessment?

  • Any family history of CHD or chromosoma abnormalities?
  • family hx of sudden/premature death
  • maternal illness or infections (both chronic or during pregnancy)
  • maternal medications/drug use
  • Infant: problems with poor feeding, sweating during feeding, poor weight gain, FTT (Red flag for undiagnosed cardiac problem)
  • Older child: Inability to keep up with activity level of peers, need frequent rest, anorexia, cough, wheezing, rales, chest pain


What should you do if you detect a murmur?

  • Investigate further: **Diastolic or symptomatic murmurs need further investigation
    • cyanosis
    • syncope
    • arrhythmias
    • tachy
    • poor feeding
    • activity intolerance
  • Innocent murmors are found in up to 50% of normal children (esp age 2-6)
    • these are systolic ejection murmurs and are accentuated by stress, anemia, fever


Where should you find the liver?

What would a bigger liver be indicative of?

  • Palpate liver 1-2 sm below costal margin
  • If larger, could be fluid overload or RV failure


How can you distinguish central cyanosis from peripheral cyanosis?

What is acrocyanosis?

  • arterial desaturation or central cyanosis is best detected in the perioral area, the mucous membranes of the mouth, lips and gums
  • Peripheral cyanosis can occur in a cold environment
  • Acrocyanosis is due to sluggish circulation in the fingers and toes


How is does pain work for neonates?

  • C fibers are fully functional from early fetal life
    • unmyelenated/slow for somatic pain
  • Connections btw C fibers and dorsal horn neurons are not mature before second week of postnatal life
    • nociceptive stim transmitted to dorsal horn by C fibers elicit long-lasting responses
    • neonates have an exaggerated response to stimuli
  • inhibitory control pathways are immature at birth and develop over first 2 weeks
  • **painful procedures during the neonatal period modify subsequent pain responses in infancy and childhood
    • pre-emptive analgesia can reduces this


What is the commonly used pain scale in infants and young children?

  • < 3 yo cannot self report
  • FLACC used
    • face
    • legs
    • activity
    • cry 
    • consolability


What are some key points to setting up a room for a pediatric case?

  • Always have a range of sizes of airway equipment
  • straight blades are commonly preferred d/t pediatric airway anatomy
  • Calculate drug doses, ABL, and fluid replacement
  • prepare a pediatric circuit and preset vent settings
  • Emergency drugs:
    • wt app sch and atropine with IM needle
    • syringe of propofol
    • epi diluted to 10 mcg/ml (for a sick pt)
  • warm the room


How is an inhalation induction done?

  • Pt can be seated or supine
  • Higher flows with 70% N2O and 30% O2
  • Fully open APL
  • allow a few breaths of N2O then incrementally turn Sevo up to 8%
  • Turn off N2O to provide 100% O2
  • Assist spontaneous ventilation prn
    • caution with high inspired volatile agent with assisted or controlled ventilation
    • if HR starts to lower, TURN DOWN GAS!
  • Obtain IV
  • Once IV is in, induction proceeds
    • propofol, narcotic, +/- NMB then proceed with airway management
  • Be sure to turn Sevo down to normal MAC for child


What should you consider for an RSI in children?

  • +/- cricoid pressure--may obstruct airway with little proven benefit
  • Need to have all equipment ready, including functioning IV
  • Drugs:
    • Propofol 2-4 mg/kg (stable)
    • Ketamine 1-2 mg/kg (unstable)
    • etomidate 0.2-0.3 mg/kg (unstable)
    • Sch 2 mg/kg IV, 4 mg/kg IM with atropine 0.02 mg/kg
    • Roc 1.2 mg/kg if sch is contraindicated (expect 45-75 min duration)
  • Calcium should be immediately available in the event sch leads to unanticipated hyperkalemia with ventricular arrhythmias


What is the formula for ETT in a pt >2 yo?

How do you calculate depth?

What should leak be at?

(16 + age) / 4

* subtract 0.5 if using a cuffed tube

Depth is tube size x 3

Leak should be at 20-30 cm H2O


Why might you want to use a cuffless tube for a pt who needs a size 3-4 ETT?

Because those tubes are so small they can be difficult to ventilate through so it isnt always worth having a cuff to make it even smaller.


What are the contraindications for LMA use in pediatrics?

  • Children at risk of pulmonary aspiration
  • mediastinal masses
  • children requiring high peak airway pressures to ventilate
  • tracheomalacia
  • limited mouth opening


What size LMA would you use for: (table)

<5 kg









What size ETT would you use for: (table)

preterm infant

term infant

1-6 mo

7-12 mo

1-2 years



How should you handle a pediatric intubation in a pt with a known difficult airway?

  • Plan for nasal intub
  • apply monitors, inhalation induction, obtain IV (maintain spontaneous ventilation)
  • Administer glyco (5 mcg/kg) and proporol prn to deepen
  • prepare nasal cavity with oxymetazoline
  • Put nasal airway in smallest nostril and attach ett connector
  • place fiberoptic scope with previously loaded nasal RAE ETT through the opposite nostril
  • visualize glottic opening, spray cords with lidocaine, enter trachea and spray trachea
  • lubricate the tube and slowly pass trhough the nose into trachea
  • confirm placement


Pediatric vent settings

  • 6-8 ml/kg
  • Sustained plateau pressure >35 can lead to barotrauma:
    • pneumothorax
    • pneumomediastinum
    • sub q enphysema
  • Use lung protective strategies


What causes subglottic stenosis?

How can it be avoided?

  • 95% of subglottic stenosis is acquired
    • usually postintubation injury
  • Risk factors:
    • trauma during intubation
    • ETT movement during intubation
    • prematurity
    • presence of infection at time of intubation
  • Avoid:
    • avoid oversize ETTs
    • monitor cuff pressures through long cases and extended intubations
      • maintain < 20-30 cm H2O






  • More frequent in infants and risk decreases with age
    • recent uri
    • secondhand smoke
    • stimulation while "light"
    • secretions in airway
  • Sx:
    • stridor- may be absent if completely closed
    • retractions
    • flailing of lower ribs (rocking horse chest movement)
  • Tx:
    • continuous postitve pressure
    • 100% O2
    • jaw thrust
    • suctions
    • deepen
    • atropine and Sch- IV or IM


What is considered bradycardia?


1-5 yo

>5 yo

What can cause bradycardia?


  • Bradycardia:
    • Infants: <100 BPM
    • 1-5 yo: <80 BPM
    • >5 yo: <60 BPM
  • Causes:
    • hypoxia (leading cause)
    • vagal stim
    • increased ICP
    • meds (Sch)
    • CHD
    • hypothermia
    • air emboli
    • tension pneumo
  • Treatment:
    • Treat the cause! 
      • think oxyganation and ventilation first!
    • Atropine if of vagal origination 0.02 mg/kg
    • Epi if decompensated 10 mcg/kg


What are the three phases seen in awake extubation?

  • Early phase:
    • coughing intermittently
    • gagging
    • struggling
    • moving non-purposefully
  • Second phase:
    • apnea
    • agitation
    • straining
    • breatholding
  • Third (final) phase
    • regular respiratory rate
    • purposeful movement
    • coughing
    • opening eyes spontaneously
    • extubation appropriate


How is a pediatric deep extubation done?

What are the common PACU complications seen in children?

  • Increase sevo to 1.5-2 MAC for at least 10 min
  • ensure no response (cough, breatholding) to sxn or tube movement
    • ensure regular respirations
  • Extubate
  • Transport in lateral decub recovery position
    • with Oxygen d/t minimal reserve
  • PACU complications: (~5% of children)
    • vomiting- more common >8 yo
    • airway compromise - more common < 1yo
    • CV compromise- least common


Caudal anesthesia





  • Used for lower abdominal or LE surgury in pts younger than 5 or 6 yo
  • single shot block will last 4-6 hours
  • Dose: 1 ml/kg will block all sacral and lumbar dermatomes
    • redose catheter at least one hour later with 1/2 the dose
  • Done following GA induction in lateral position or prone with frogged legs
    • using 25 mm needle
    • find sacral cornu and introduce needle into sacral hiatus at 60 degree angle
    • once pop is felt through sacrococcygeal membrane, lower angle and advance 2-3 mm further


Caudal anesthesia:


rare risk

  • Contraindications:
    • major malformations of the sacrum 
      • myelomeningocele
      • open spina bifida
    • meningitis
    • intracranial hypertension
  • Unrecognized dural puncture can lead to cardiovascular collaps or resp arrest (high spinal?)


Contraindications for pediatric neuraxial

  • parental refusal
  • severe coagulation disorders (hemophilia, DIC)
  • Severe infection
  • hydrocephaly and intracranial tumor
  • allergy to LA
  • certain chemotherapies
    • Cisplatin prone to induce subclinical neurologic lesions that can be acutely aggravated by a block procedure
  • uncorrected hypovolemia
  • cutaneous or subcutaneous lesions at the site of puncture
    • infection
    • angioma
    • dystrophic or tumor
    • tattoo
  • Open spina bifida (Spina Bifida occulta NOT a contraindication


What are some methods of Post-op pain control for a pediatric pt?

  • Regional options:
    • caudal anesthesia
    • caudal opioids
    • regional blocks
  • PCA pumps- usually not given a basal rate unless the pt is ventilated
    • child controlled
    • parent controlled
    • nurse-controlled