Pediatrics Flashcards

Question

What are some best practices for temperature monitoring in pediatrics?

Answer 1

* **Essential for all pediatric cases** * **Mid-esophageal placed probe**- best core temp! * can also be used as stethoscope * Axillary temp: **Advantage** - if properly positioned: * proximity to deltopectoral group improves recognition of elevated temp in MH * NO FOREHEAD TEMP- not advised * 10 MH episodes occurred that were unrecognized with forehead temp (Barash) * **Hypothermia:** consequences → * _delayed emergence- metabolism of drugs slower_ * reduced degradation of drugs * increased infection * **Hyperthermia:** MH? → primary presentation not always fever (1^st see ETCO2) * **Stop VA, high flow on, switch to TIVA, evaluate (stop anesthetic d/t Ca dysregulation getting worse)**

Answer 2

* **Total body water is highest** in premature infants & decreases with age * Larger SA per Kg * Metabolism correlates to O2 consumption, CO2 production CO, alveolar vent * **Better to look at Body SA (BSA**) rather than wt (better measure of metabolism) * Infants: ECF \> ICF * Adults: ECF \< ICF * Infants: don’t have ICF reserve → cant pull from when dehydrated (??) * Childhood: ICF proportion increases → reserve for dehydration * Electrolytes: * Same as adult → but know: * Issues w/ Na levels * K slightly higher 1^st 1-2 days

Answer 3

* Water soluble drugs have a larger volume of distribution (have higher TBW) * **Need a larger initial dose** (Sch; abx- higher dosing of water soluble drugs) * **Delay excretion** – from larger volume of distribution * **Acidic** drugs tend to bind mainly to **albumin** (e.g., _diazepam, barbiturates)_ * plasma protein binding of many drugs is decreased in the neonate relative to the adult in part because of reduced total protein and albumin concentrations. * **Basic** drugs bind to **globulins, lipoproteins, and glycoproteins.** (e.g._, amide local anesthetic agents)_ * **Half-life of medications in \>2 years of age is shorter** than adults or equivalent due to significant CO to liver & kidneys * More fentanyl/propofol mg/kg * **Pharmacokinetics in children varies with body composition, renal and hepatic function, and with altered protein binding** * Neonates have less fat & muscle * Drugs that depend on redistribution to fat for termination of action will have **prolonged effects (fentanyl; propofol)** * Protein binding: **\< 6 months** old have **reduced albumin & alpha-1 acid glycoprotein (AAG)** * higher free-fraction of protein bound drugs → **higher risk of toxicity!!** * Free fraction of **lidocaine** will be higher in the very young! **“In general, most medications will have a prolonged elimination half-life in preterm and term infants, a shortened half-life in children older than 2 years of age up to the early teenage years, and a lengthening of half-life in those approaching adulthood.”** **– patient to patient variability \*\*\***

Answer 4

* Preterm/infants: prolonged elimination half-life * \>2 yo to early teenage yrs: shorted half-life * Adulthood: lengthened half-life

Answer 5

Fetal Hgb: * Lower P50 (19 mmHg vs. adult normal of 26 mmHg) → left shift = Holds onto O2! * Low levels of 2,3 diphosphoglycerate * This lower P 50 allows the fetus to load more oxygen at low placental oxygen tension, but it makes unloading oxygen in tissues more difficult. * **3- 6 months after birth** → fetal hemoglobin has been replaced with adult hemoglobin. * **Tolerate Anemia more poorly bc left shift** * **Blood products helpful d/t having adult Hgb that allows released O2 to tissues** * **Target hct in neonates is higher** * Hct minimum 40% (instead of 30%) * Why?: bc * L shift * **Tx: _4-5 ml/kg_** of transfused PRBC’s **increase hgb ~1g/dL** * Order blood based on body weight * Ex: 15 kg pt = 75 ml blood

Answer 6

* Physiologic Natar: lowest point of anemia as fetal Hgb being replaced (PERIOD OF TRANSITION) * **Physiologic anemia at 2-3 months of age→ l**ower threshold to give blood products (low P50 & physiologic anemia)

Answer 7

* **_Maximum allowable blood loss calculation:_** * **_MABL_**= EBV x (starting HCT- target HCT)/ starting HCT * variables: EBV, patient starting hct (est by chart w/o labs), minimum allowable hct * \*gives threshold when need to start giving blood * Threshold varies (ex: ~30%) * Ex: \< 3 mo → higher threshold d/t physiologic anemia & low P50 * **Initial blood loss replaced at 3:1 with crystalloid** * Transfusion threshold: somewhere around hct ~24- 30%; minimal target hct should be _discussed based on individual child_ * consider blood sooner in the following: (higher tx threshold) * preterm infants * term newborns * children with cyanotic congenital heart disease * children with respiratory failure in need of high oxygen-carrying capacity * **young infants** (\< 3 months) may need a **higher transfusion threshold** due to left shift & physiologic anemia * **incidence of apnea is high in neonates and preterm infants who have hematocrit values \< 30%**

Answer 8

* Once MABL is approaching, if blood loss is expected to continue then blood will be given * always use a blood warmer * Calculation of blood to be transfused: _(desired hct - current hct) x EBV_ hct of PRBC’s (which is 60%) * \> 1 blood volume replaced → **FFP will be needed** * Watch for **ionized hypocalcemia** & resultant _CV depression (esp w/ rapid infusion of FFP_) * Reasons for it being risk: * Ca stores already low in neonates * FFP has highest concentration of citrate * **neonates & children with liver failure are at pronounced risk** * **Platelets**: need for replacement depends on starting platelet count- clinical oozing on the field is the typical indicator * Starting normal platelet count usually does not need platelets **UNTIL EBL \> 2 blood volumes**

Answer 9

* At birth, **vitamin K-dependent** coag factors are **low ( 2,7, 9,10)** * reach adult levles by 6 months age * **fibrinogen** polymerization does not reach its full capacity during first few postnatal months * **leads to prolonged thrombin time** * **PLT** number at birth **comparable** to adults * however, PLT **function** **impaired** in early life * **Postnatal** period represents **hypercoaguable** state * d/t inhibitor of coagulation decreased by 30% to 50% in newborn * Antithrombin III and protein S levels reach maturity by 3 months of age * protein C and plasminogen levels reach adult levels after 6 months of life * **higher risk for thrombotic complications in neonates and infants.**

Answer 10

* Components of fluid replacement: * 1. Fasting (NPO) deficit (maintenance rate x hours NPO for deficit) * *don't always replace NPO def in healthy child for elective procedure* * 2. Baseline maintenance fluid requirement- using LR (balanced salt solution- not dextrose unless risk pop) in most cases (4:2:1) * 3. Replacement of blood loss- hourly * (3:1 crystalloid replacement until MABL reached then 1:1 colloid (blood) * 4. Evaporative losses (based on invasiveness of surgery) * Now believe holliday segar not necessary * *Miller refers to using holiday segar for infnats \<6 months. \>6months 10-40mL/kg over 1-4 hours appropraite for NPO and replacement.*

Answer 11

* LR is typically used for maintenance in healthy children * \< 6 mo’s & in others at risk for hypoglycemia: glucose containing IVF may be needed in infants * Ex: D51/2 * **Minimize potential for error**: smaller IV bags (250/500 ml bag); buretrols * **Eliminate all air from IV line** * Volume of air and rate of entrainment leads to VAE * If PFO opens because of surgical stress, air will go straight up to brain * Recognize dehydration in infants: the best measure of deficit is **weight** * **Mild****:** ~50ml/kg deficit dry mouth, poor skin turgor * **Moderate**: ~100ml/kg mild sx plus deficit sunken fontanel, oliguria, tachycardia * **Severe****:** ~150 ml/kg moderate sx plus sunken eyes, hypotension, & anuria * Pulse pressure really useful, respiration,

Answer 12

* Routine use of glucose-containing IVF in the perioperative setting in children is **NOT recommended** * Exception: Children at high risk of hypoglycemia- **can use D5 1/2NS @ maintenance rates** * Don’t use for BL or evaporative loss replacement (must use balanced Na solution) * **Continuous TPN:** * must **NOT** suddenly stop * consider leaving on at a reduced rate * some providers may use D10 to bridge- monitor glucose!! * Children with mitochondrial disease will definitely need glucose containing replacement fluid Miller says cut the TPN rate by one third and leave running

Answer 13

Uptake (Wash-in) more rapid in children for several reasons: * increased respiratory rate * increased cardiac index\<\< *this is somewhat contradicted in Miller? Miller says uptake is dependent on CO. We learned before increase CO= slower onset?* * larger proportion of blood to VRG (heart, brain, GI, kidneys, endocrine) * Reduced tissue/blood and blood/gas solubility in infants * Increased Alveolar ventilation to FRC ratio * Infants: 5:1 * Adults: 1.5:1 * **_\*Increased risk of anesthetic overdose in infants/ toddlers_** * Faster equilibration to what set on dial (*from co-exist lecture last semester)* * **Determinants of “wash in” of VA → FRC, inspired concentration, alveolar ventilation** * Wash in is inversely related to solubility= lower solubility→ higher wash in * Less is binding to tissue, less dissolved in blood * **Removal → CO, solubility, alveolar-venous partial pressure** * **18% BF to VRG in infants as opposed to only 8% in adults**

Answer 14

* Sevoflurane: * Neonates: 3.3% * Infants (1-6 mo): 3.2% * Children (\> 6 mo): 2.5% * Desflurane: * Neonates: 9.2% * Infants (1-6 mo): 9.4 * Infants (6-12 mo): 9.9% * 1-3 yo: 8.7% * 5-12 yo: 8% * **All VA: MAC increases until 2 to 3 months of age** (max: 1 to 2 years old) and steadily declines with age thereafter * Sevo (Exception): MAC remains constant in neonates and infants up to 6 months * MAC up to 6 months is ~3.2% * MAC 6 months to 12 years is constant at 2.4% (decrease)

Answer 15

No, children have higher BIS for a specific fraction of MAC c/t adults

Answer 16

* Increase hypotension incidence in neonates & infants upon inhalational induction * **More rapid uptake** can unmask negative inotropic effects of the volatiles in infants Agents and use: * **Sevoflurane** – primary agent for inhalational induction * Well tolerated by mask * No irritation of airway (least pungency) * Potent bronchodilator * Halothane * low pungency * no longer used in US * bradycardia at induction (higher solubility- slower onset, phase 2, laryngospasms) * most dangerous → MAC multiples if turned all the way up, go up to 5.7x MAC (risk of overdose) * Desflurane – limited use * Pungent! * Leads to: Breath holding, coughing, salivation, laryngospasm * Low solubility → can use for maintenance for long sx/obese children * Faster wake up

Answer 17

* Respiratory: same as adults: * **Dose related respiratory depression** * decrease response to CO2 & hypoxia * As concentration increases, apnea ensues * CV: * **dose dependent depression** * Myocardial depression may be exaggerated in neonates d/t: * immaturity of sarcoplasmic reticulum → more susceptible to calcium-channel blocking effects of volatile anesthetics * Delicate balance of achieving adequate depth at induction & avoiding cardiovascular depression * **all can cause prolonged QT** * Sevo usually maintains or increases HR during induction * **halothane** has **greatest depression of contractility** → induction arrests! Over pressuring during induction and had negative inotropic affect * Halothane: high lipid solubility; slow onset & offset; low pungency; no longer used in US * Halothane hepatitis- antibody reaction; repeated exposure * Isoflurane: * limited utility for induction due to noxious smell * increased risk of laryngospasm/ coughing * confers more cardiac stability (as in adults) * Emergence delirium is commonly associated with all inhaled agents (sevo\>des\>halothane) * Halothane less likely bc comes off slower

Answer 18

* **Neonates:** Immature BBB & decreased metabolism can increase sensitivity * increased permeability of BBB makes more sensitive **Older** children & adolescents generally require **increased doses** of induction agents compared to adults * Dosing: * **Propofol** (Diprivan): have extra available * \< 2 yo: 2.9 mg/kg * 6-12 yo: 2.2 mg/kg * **Ketamine**: * 2 mg/kg IV * 4-8 mg/kg IM (plus atropine 0.02 mg/kg IM/IV → for hypersalivation) * **Etomidate**: * 0.25-0.3 mg/kg * **Thiopental** sodium (Pentothal): * neonates (\< 1 month): 3 to 4 mg/kg * infants (1 m–1 yr): 7 to 8 mg/kg * Children: 5-6 mg/kg * **Methohexital**: ECT therapy * 2 mg/kg IV or 15-25 mg/kg of a 1% or 20-30 mg/kg of a 10% solution PR

Answer 19

* Most commonly used IV induction agent in children * Greater Vd than adults * More rapid redistribution * Pain of injection can be reduced with a mini Bier block with 0.5-1 mg/kg of Lidocaine for 60 seconds (BP cuff) * Antiemetic properties * TIVA- lower rate of PONV/emergence delirium * **Propofol infusion syndrome**: long term infusions in ICU avoided in infants & children (acidosis); still appropriate for TIVA case * Egg/soy: only avoid if documented anaphylaxis with eggs

Answer 20

* can be used IM, IN, PO, IV → hemodynamic compromised pts * Induction with ketamine preferred in * severe hypovolemia, * cyanotic heart disease, * septic shock, & induction for mediastinal mass (need spontaneous ventilation) * Increased secretions (premedicate w/ anticholinergic) * Ex: atropine * Emergence irritation * reduced with co-administration w/ Midazolam * waking up in a dark/quiet room

Answer 21

* only approved for use in age \>10 yo in U.S (0.2-0.3 mg/kg IV) * Pain on injection * Adrenal suppression concern

Answer 22

most widely used anxiolytic pre-op * Oral dosing: * dose _increases_ in younger patients * poor oral bioavailability * bitter taste * **allow 10-15 minutes** * ORAL dosing: dose decreases w/ age * 18 mo-3yo: 0.75-1 mg/kg * 3-6 yo: 0.6-0.75 mg/kg * 6-10 yo: 0.5 mg/kg 6-10 yo * IV: 0.1-0.2 mg/kg (immediate onset) * Intranasal: 0.3 mg/kg * **MAX DOSING: 15 mg** * Reversal: * flumazenil 0.01mg/kg IV * Hepatic metabolism (CYP 3A4) & renal excretion

Answer 23

* Severe cognitive/ behaviorally challenged older children → **_IM_** administered preop \*\* preferred * IM dose: 4-5 mg/kg * Onset: 3-5 minutes * Duration: 30-40 minute duration * Oral onset: 15-20 min

Answer 24

* hypotension with loading doses * bradycardia with high dose infusion * (note biphasic response with transient hypertension initially) → then hypotension * will not be adequate as a sole anesthetic but can be helpful as adjunct * opioid sparing effects * Uses: * useful in awake FOB * radiological procedures * reduction of emergence delirium * Dosing: * IV: * initial dose: 0.7-1.0 μg/kg administered over 10 minutes * → followed by infusion: 0.5-1 μg/kg/hr * Intranasal: 80% bioavailability!! great premed!! But takes long to peak * Dose: 1-2 mcg/kg * Peak: 30-40 min (long time)

Answer 25

* **Variety of choices:** onset, potency, duration, & metabolism are factors just like in adults * Also consider previous exposure to opioids (tolerance), severity of pain, & other multi-modal strategies * **Morphine:** * active metabolite (morphine-3- glucuronide) * → cause prolonged respiratory depressant effects in neonates and preterm and critically ill infants * Dosing: 50-100 mcg/kg (IV) per single dose * **Dilaudid dosing**: 10-20 mcg/kg (IV) per single dose * **Fentanyl:** most widely used opioid intra-op in children * stable CV profile * Caution: chest wall rigidity * Dosing variability * ~ 0.5-1 mcg/kg range * Work up to 1-3 mcg/kg range (IV) per single dose & titrated for effect * *Safely go up to 10 mcg/kg depending on sx* * **Remifentanil:** * excellent for neonates * great choice in renal/hepatic failure/immaturity (due to metabolism via esterases → mature system in neonate) * predictable eliminiation * Caution: * bolus injections can cause significant bradycardia/hypotension * must have plan for analgesia once infusion discontinued * Dose: 0.05-0.1 mcg/kg/min * **Demerol:** * Admin for shivering in small doses (0.25-0.5 mg/kg) * Metabolite: normeperidine * **Codeine:** * historically very commonly prescribed postop * withdrawn from many markets due to respiratory events * SNP’s in ultra-rapid metabolizers confer risk of OD (CYP affected)→ **BLACK BOX warning** * Slow metabolizers- placebo

Answer 26

* Acetaminophen: * PO 10-15 mg/kg * IV: 15 mg/kg q 6 hours (10-15 min onset) * rectal absorption: SLOW (1-2 hours) * Ketorolac: * Dose: 0.5 mg/kg IV * Ask surgeon before administration * CAUTION: * Severe asthma → caution all NSAIDs * Nasal polyps, eczema, and asthma → tend to have NSAID allergies

Answer 27

* NMJ not fully mature until ~2 months of age * Infants: may be more sensitive to NDNMB but also have larger VD → so dose/kg is usually the same as adults * **EXCEPTION: Rocuronium**- dose is lower in infants * ex: infants 0.3 mg/kg * ex: children: 0.6 mg/kg * RSI: same * **Always use nerve stimulator** **→** **response is highly variable (neonates not have normal resp to NS)** * **Use small doses** * **Reassess frequently** * May see prolonged duration of action due to immature renal/ hepatic elimination

Answer 28

* Higher Sch doses needed in neonates & infants due to larger VD * \< 1yo: (2-3mg/kg) * Older → dose gets smaller Sch is limited to RSI and emergency tx of laryngospasm in Peds * Cardiac sinus arrest may follow 1^st dose of succs → more common after repeated bolus admins in any age * **Co-administer w/ vagolytic drug** **(atropine)** should probably be intravenously administered just before the first dose of succinylcholine in all children, including teenagers * unless a contraindication to tachycardia (e.g., a cardiomyopathy) exists * **RISKs:** * Bradycardia * Hyperkalemia * masseter spasm * MH in children w/ undiagnosed myopathies

Answer 29

* Routine reversal for TOFR \< 0.9 * Neostigmine: dose for infants & children 30-40% lower than adults * Dose: 0.02-0.04 mcg/kg * co-administered with anticholinergic * Sugammadex: not FDA approved in peds * Dose: 2 mg/kg * Always reverse peds pts!

Answer 30

* Cardiac output and local blood flow: 2-3x greater in infants than in adults * → so systemic LA absorption is increased (higher chance of LA toxicity) * Epinephrine is effective in slowing systemic uptake * Very Low Plasma concentration of AAG at birth (0.2 to 0.3 g/L) and does not reach adult levels (0.7 to 1.0 g/L) before 1 year of age * Free fraction of all local anesthetics is increased in infants Maximum doses of all amino-amides must be reduced (KNOW DOSES!) → think about cumulative amount going to give

Answer 31

* Age related increase in HR that declines with age * systolic lower in ped young patient and BP gradually increases * RR much higher in preterm neonate/infant c/t adult pt * shortcut for BP? * **2-10 yo -** SBP: minimum SBP → **70 + (age x 2)** Ex: 5 yo → 70 +5 x 2 = SBP 80 **\>10 yo: SBP 90** **\< 1 yo: SBP 70**

Answer 32

* Preschool age: distraction & premedication * Offer flavoring for the oxygen mask if available * Pre-operative preparation with OR equipment (see the mask, pick a flavor, etc.); child life specialists can assist * Distractions: music/ singing, story telling, jokes, guided imagery; “changing the flavor” of the mask * **Avoid** bright lights, loud voices, & lots of extra personnel in the room * Consider parental presence (especially in ages 1-6); **_parents must be educated on what to expect at induction (irritation)_****_→_**parent leave room once child lost**conciousness** * **9-10 mo range- consider midaz 10-15 prior** * **Toddler** * **Child- play games**

Answer 33

* Standard adult history and physical exam must be adapted; some topics that require further emphasis in children * Birth history; prematurity * Neurologic development- appropriate for chronological age? psychological issues? * Airway anomalies, surgical history, previous intubations, and general medical health (heart, lung, endocrine, renal disorders) * AW exam: * Indicators for Difficult AW: * check for facial dysmorphias * signs of stridor, dysphonia, swallowing disorders, difficulty in breathing, difficulty in speaking, and hoarseness * Genetic or dysmorphic syndrome? * Potential for anomalies in the cervical spine (eg, Down syndrome) or craniofacial dysmorphia * Down syndrome- atlantoaxial subluxation at C1-C2 level * Family history: fevers or troubles waking up? MH, PD * (1) malignant hyperthermia (MH) * (2) pseudocholinesterase deficiency * (3) postoperative nausea and vomiting * (4) congenital myopathies * (5) bleeding (brushing teeth) * No laboratory work is indicated for healthy children undergoing a procedure with minimal blood loss anticipated * Routine pregnancy testing: controversial; parents may decline; history alone can be unreliable * Have waver ready * Midaz- iatrogenic effect * Higher risk for latex allergy in certain pediatric populations: * Ex: spina bifida, myelodysplasia, urinary tract malformations; multiple previous surgeries

Answer 34

* Mandibular protrusion * mallampati * movement of atlantooccipital join * reduced mandibular space * increase tongue thickness * age \<1 yo * ASA II-IV * Obesity * maxillofacial and cardiac sx

Answer 35

* Frequent upper respiratory infections (URIs)? * Risk for post op resp complications/laryngospasm * Up to 6 weeks after URI * History of wheezing? History of noisy breathing? Hospitalizations? History of intubations? * History of eczema/skin allergy/atopy? → likely to have bronchospasms/AW issures * In daycare? Immunization status? Smokers in the house? → prone to reactive AW dx * Infant: Frequent vomiting after feeds/“choking” episodes? → reflux * Child: Frequent tonsillitis? Ear infections? Snoring?

Answer 36

Any family history of CHD/chromosomal abnormalities, sudden/premature death; maternal illness/infections (both chronic and during pregnancy); maternal medications/drug use * **Infant:** **look for clues on undiagnosed congenital heart defect** → * Any problems with poor feeding, sweating (especially on the forehead) during feeding, poor weight gain, FTT, decreased activity level * Symptoms of CHD often occur with feeding because of increased oxygen consumption and the need for greater cardiac output. * Need further testing * Babies with cyanotic heart disease turn dark blue or ruddy in color when crying because of prolonged expiratory phase and resulting increase in right-to-left shunting. * Hypercyanotic spells are often associated with extreme irritability and rapid, deep, and sometimes labored respirations. * **Older child/ adolescent:** * Any inability to keep up with the activity level of peers, need for frequent periods of rest, anorexia, cough, wheezing, rales, chest pain, leg cramps, syncope, light-headedness, palpitations; any history of drug use; any family history of sudden death, syncope, or arrhythmias * Any changes in color or cyanosis when crying? → undiag congenital heart defect

Answer 37

* 25% of all children younger than 5 years in the United States come from racial or ethnic minority backgrounds * Do not assume (based on language or ethnicity) to know the ideas or beliefs of a family * Understand the family hierarchy- who are the decision makers? Who answers questions? * Make every effort to use, pronounce, and record names correctly- important expression of respect * Try to learn a few words or phrases in the foreign languages you commonly encounter- this goes a long way with a child * Do not ask a parent to sign a consent that is not in their native language without full access to interpretation * *_allow extra time and do not rush the consent process_* * Talking with interpreters (best practices): Always look at the parent and child (not at the interpreter); speak slowly; in short sentences; in a normal tone of voice; allow enough time for the interpreter to translate; encourage questions; * **_Be very cautious of false fluency_** – may pretend to understand fully if only understand partially * **Interpreter vs. translator**: * **Translator**: deals only in words. * **\*Interpreter:** understands and communicates the meaning of looks, gestures, customs, traditions, and health practices in both directions between families and caregivers. * **Alternative medicine:** do not approach this with skepticism or bias but certainly ask about herbal & natural remedies & ask if they are working

Answer 38

* Always talk through your assessment; children like to know what to expect; get on the child’s eye level; stay calm * Airway: inspect face (include profile view), mouth opening, tongue mobility (“stick out tongue”), neck extension, loose teeth\* * Assess respirations in position of comfort (moms arms), look for flaring, retractions * Auscultate heart and lungs * Rales or wheeze? request a cough and listen again (just stuff in upper airway) * Murmur detected? * Further investigate- cyanosis, syncope, arrhythmias, tachycardia, poor feeding, activity tolerance * Innocent murmurs: up to 50% of normal children (especially age 2 to 6) → typically systolic murmurs * Soft, short, systolic ejection murmurs → accentuated by stress, anemia, fever * **Investigate:** **_Diastolic murmurs &/or symptomatic murmurs, new ones (esp. associated with poor feeding/FTT)_** * **Harsh, radiating loudly, systolic or diastolic murmur →** **investigate (most diastolic not ok)** * **Get echo!** * Palpate liver if any reason to suspect fluid overload: * Normal liver: 1-2 cm below intercostal margin * Sticking lower- fluid overload\*\* * **Hepatomegaly** **→** **sign of RV failure** * Cyanosis in the infant: Arterial desaturation or central cyanosis is best detected in the perioral area, the mucous membranes of the mouth, lips, and gums. * Central cyanosis should be distinguished from peripheral cyanosis * Central cyanosis: concerning * Peripheral: occur in a cold environment, and acrocyanosis, which in newborns is due to sluggish circulation in the fingers and toes

Answer 39

* **Somatic pain:** conveyed in part by _unmyelinated C fibers (“slow”)_ * leads to protective reflexes → autonomic reactions, muscle contraction, and rigidity (spastic) * _C fibers are fully functional from early fetal life onward_ * Connections between C fibers and dorsal horn neurons are not mature before the second week of postnatal life but nociceptive stimulations transmitted to the dorsal horn by C fibers elicit **long-lasting responses** * → Neonates have an exaggerated response to nociceptive stimuli * profound and prolonged response * With large amounts of pain- can make abnormal pathways that make more sensitive and lifelong * **Inhibitory control pathways are immature at birth and develop over the first 2 weeks** * Painful procedures during the neonatal period modify subsequent pain responses in infancy and childhood * With large amounts of pain- can make abnormal pathways that make more sensitive and lifelong * **Pre-emptive analgesia** **→** leads to a reduction in the magnitude of long-term changes in pain behaviors * Must use a pain scale appropriate to the developmental level of the child (\< 3 yo usually unable to self-report) * Procedural pain in infants and young children: common use of FLACC scale * FLACC- face, legs, activity, cry, consolability * (preverbal use) - \< 3 yo usually unable to self-report

Answer 40

* 2006 ASA guidelines * Clear liquids: Include only fluids without pulp, clear tea, or coffee without milk products * Gum chewing: * **70% increase in gastric fluid volume in the first 15 minutes after initiating** gum chewing, mostly saliva * most providers will proceed as long as gum is spit out (not swallowed)

Answer 41

* Always have a range of sizes of airway equipment (face masks, OPA’s, ETT’s, LMA’s, blades) * Need size up and size down from anticipated size * Straight blades are most commonly preferred in infants due to anatomical differences (get both out) * Appropriate size LMA should always be available even if intubation is planned in case of unanticipated difficult airway * Ensure appropriate sized BP cuff and pulse oximeter is present & functional * Calculate drug doses, allowable blood loss, & fluid requirements * Have primed bag of IV fluid ready and all supplies to start & _secure_ IV set up & accessible * Prepare a pediatric circuit/bag * 0.5, 1, 2 L bag → use peds circuit if \< 5-8 yo * If can pull TV \> than volume of bag → negative pressure in system (switch over to bigger bag) * Preset vent settings appropriate for size (& program in weight to anesthesia machine if applicable) * Pressure control better * Volume control- TV/kg can be calculated * Appropriate sized mask- injury, eyes, bad seal, VAGAL response! * **Emergency drugs for every pediatric case:** * **Sch & Atropine** **+ IM needle**: Weight appropriate doses with a small gauge needle appropriate for **IM injection** * Laryngospasm, take on every transport * **Propofol syringe** – have backup * facilitate intubation, break laryngospasm, increase depth of anesthesia quickly * **Epi diluted to 10mcg/ml**: not always drawn up but definitely consider drawing up in a sick patient/ complex case (cardiac arrythmias→ bradycardia not responsive to O2—ex: O2 typically primary tx ) * **Comes 100 mcg/ml** → need to dilute down to 10 mcg/ml * Plan for age appropriate distractions: have flavors for masks; consider parental presence if facility allows (cover supplies to hide anxiety) * Warm the room

Answer 42

* Often needed at the age ~10 months when separation anxiety becomes an issue * Be aware of secretions from crying → laryngospasm risk * Oral versed most common- SEE DOSING * Severe distress/ need for profound sedation * may combine medications (ketamine, atropine, versed combo PO) * may use IM route if uncooperative with PO sedation * Intranasal route is sometimes used but can really burn & make child more agitated * Intranasal dex (good bioavail) → alternative to intranasal midaz (burns)

Answer 43

* **Sniffing position is critical – no hyperextend neck** * **Tongue bigger/oral AW smaller** **→** prone to obstruct * **Align oral, pharyngeal, laryngeal axis – slightly displace mandible forward/neutral** * **Put little pillow behind to put nose to ceiling** * **Shoulder roll** * Avoid pressure on the soft tissue in the submental triangle – might cause obstruction * Jaw thrust * Low threshold for 2-person ventilation

Answer 44

* Common to use Jackson-Rees for transport ventilation (Mapelson F)\*\* * Low resistance and dead space * Pop-off valve * added to endo of reservoir to provide assisted ventilation * Should be open for spontaneous ventilation * Requires relatively high FGF (2-3 x’s minute ventilation) * Keep pop-off open for spontaneous ventilation → adds extra resistance (don’t want) * Mapleson A best for spontaneuous, D best for controlled breathing

Answer 45

* Stay flexible! All monitors may not go on before induction (*try for pulse ox*); child may be afraid of mask * Stay calm! Be warm and reassuring * **Inhalational induction is most common** * **Particular attention should be paid to frequent monitoring of blood pressure and heart rate during induction** * **Inhalational arrest high risk, get BP on ASAP when started gas** * Premedication: * \< 9-10 months: usually no premedication required * 1-3 yo: separation anxiety usually worst → plan to do premed (oral midaz/nasal dex) * Allow them to have pacifier * Alternative is pre-op IV with standard induction: topical anesthetics can be used for IV starts; EMLA cream onset is 45-60 minutes * Ex: \< 8 yo → no IV preop * IM Ketamine is rarely used for inductions in larger cognitively impaired/ extremely uncooperative children

Answer 46

Inhalational induction is common: seated or supine position One approach: * Higher flows with 70% N2O and 30% O2 (7L N2O and 3L O2) * Fully open APL * Allow a few breaths of N2O mixture and then incrementally turn on Sevo to 8% (some providers turn up sevo to 8% without using incremental technique after a few breaths of N2O- especially if crying) * Turn off N2O to provide 100% O2 * Assist spontaneous ventilation PRN- **caution about high inspired volatile agent with assisted or controlled ventilation (keep spontaneously breathing!)** * **Decrease inspired anesthetic if need to ventilate** * *****do not want to get to this point!* * Obtain IV * Once IV is in, induction proceeds- give some propofol, narcotic, +/- NMB, etc at this point and then proceed with airway management appropriate for case (LMA, ETT) * NOTE: intubation is often completed without NMB’s * Be sure to turn down Sevo to normal MAC range for the child; watch VS closely during induction

Answer 47

* Same principle as adults to prevent aspiration * Cricoid pressure in infants/ children is **+/-** (Barash says no) → increased likelihood of obstructing an infants airway with little proven benefit * Note that children will have rapid desaturation with hypoxia (limited reserve) and often hard to preoxygenate an uncooperative child * Equipment: ETT (pre-stylet) age calculated plus 0.5 smaller & 0.5 larger; laryngoscope (working), _suction immediately available at HOB_, functioning IV, pre-drawn drugs * Propofol 2-4 mg/kg (stable) vs. ketamine 1-2 mg/kg or etomidate 0.2-0.3 mg/kg (unstable) * *plus* Sch 2 mg/kg **(premed with Atropine 0.02 mg/kg)** * consider Rocuronium 1.2 mg/kg if Sch contraindicated (45 to 75 minute duration) * **Calcium (IV) should be immediately available in the event Sch leads to unanticipated hyperkalemia w/ ventricular arrhythmias** * **Succs used in DAW patient** **→** **have Ca available** the younger the pediatric patient, the less reserve they have

Answer 48

* Mask management is more critical skill in peds airway * Always have ranges of ETT sizes * (0.5 smaller than calculated & 0.5 larger) * Short trachea favors right mainstem intubation * Breath sounds are often referred → bilateral chest rise and fall/w/ sounds * **Common formula over 2 yo** * **_(Age + 16)/4_** * Cuffed tubes: reduce size by 0.5 mm * Cuffed tubes are fine as long as cuff pressures are monitored * Rough estimate of depth is 3x ID * Ex: using 4 tube → depth should be 12 cm * A leak should be maintained around cuff regardless @ 20-30 cmH20 (not want pressure on trachea) * If turn APL to 20, should hear leak * If leak at 10- will be polluting OR and wont get TV

Answer 49

* Used during routine surgeries & as a rescue device for failed intubation * Low failure rate for insertion (\< 1%) * Contraindicated in children with risk of pulmonary aspiration * **Other specific pediatric _contraindications:_** * mediastinal masses * children requiring high peak airway pressures to ventilate * tracheomalacia * very limited mouth opening

Answer 50

* Have LMA out & ready for back up * may use LMA as conduit for FOB Sample plan: known difficult airway plan for nasal intubation with FOB → MAINTAIN SV!!! No apnea!! * Apply standard ASA monitors; inhalational induction with sevoflurane, and maintain spontaneous ventilation (may require an oral airway) * Obtain intravascular access if not previously obtained. * Administer: * glycopyrrolate (5 mcg/kg) * propofol as needed to deepen anesthetic (larger doses may cause apnea) → don’t induce apnea * Prepare nasal cavity with oxymetazoline → reduce bleeding * Size both nostrils with a nasal pharyngeal airway (NPA). Keep the NPA in the smallest nostril and attach endotracheal tube connector to the end of the NPA. The patient can now entrain air : oxygen and sevoflurane during spontaneous ventilation. * Place a fiberoptic scope with a previously loaded nasal RAE endotracheal tube through the opposite nostril. Suction should be attached to the suction port. * Visualize the glottic opening. Spray the vocal cords with lidocaine (use 2% if over age 2 years, 4% if over age 8 years). Enter the trachea, and spray the trachea. * Lubricate the endotracheal tube and slowly pass through the nose into the trachea. Downsize the endotracheal tube by 0.5. Apply slow, steady pressure. * Place endotracheal tube connector from the NPA onto the ETT and confirm end-tidal CO2

Answer 51

* 6 to 8 mL/kg is typical * Sustained plateau airway pressures **\> 35 cm H2O** can lead to barotrauma: * Pneumothorax * Pneumomediastinum * subcutaneous emphysema * Lung protective strategies apply * Pressure control ventilation is proffered * Peak inspiratory pressure: 15-18 cmH2O * Titrate as needed * Resistance in circle system: unidirectional valves, kinking of ETT, CO2 absorbent, humidity and moisture exchanger * Issue with infant: sometimes need less valves, less resistance → use Mapleson circuit to limit resistance

Answer 52

* 95% of subglottic stenosis is acquired from excessive cuff pressures * Postintubation injury is the most common cause of acquired subglottic stenosis * **Risk factors associated with acquired SGS:** * trauma during intubation * ETT movement during intubation * Prematurity * presence of infection at the time of intubation * Avoid oversized ETT’s\* * Feels tight → exchange to smaller * Cuff pressures must be monitored throughout long cases/ extended intubations * **maintained at a level below 20-30 cm H2O (should hear leak**) * N2O use → can cause cuff to expand * \< 10 cm → pollutes OR * Microcuff tubes- cause less trauma to airway

Answer 53

* More frequent in infants; risk decreases with increasing age * Reflex closure of false & true vocal cords * **Sx**: stridor, retractions, flailing of lower ribs; “rocking horse” chest wall movement; stridor will be absent with complete closure “silent inspiratory effort” **(NO FOGGING OF MASK)** * Can lead to profound bradycardia & desaturation if unrelieved * **Risks:** 1. recent URI (w/in 3 wks), 2. secondhand smoke, 3. stimulation while “light,” 4. secretions in airway (CRYING, BLOOD IN AW) * **Treatment:** **Continuous positive airway pressure**,100% oxygen, jaw thrust at condyles of mandible (Larson’s Maneuver)- anterior displacement, suction secretions/ blood etc., deepen anesthesia (propofol) * Unresolved? * Atropine & Sch- if no IV access then give IM * Severe Laryngospasm/Bit through ETT: → lead to **negative pressure pulmonary edema** especially in healthy, muscular adolescents- may have to remain intubated for 12-24 hours & may need furosemide (flash pulmonary edema)

Answer 54

**THINK VENTILATION & OXYGENATION** * Infants: \<100 bpm * 1-5 yo: \<80 bpm * \>5 yo: \< 60 bpm * If O2 and vent don’t help → chest compressions! * Causes: * **Hypoxia** → leading cause of bradycardia in children (and asystole) * **Single dose Sch** * other causes: vagal stimulation, increased ICP, meds (Sch), CHD, hypothermia, air emboli, tension pneumothorax * **Treat cause:** **think oxygenation and ventilation first!! Then…** * → Atropine if vagal origin 0.02 mg/kg IV * Epinephrine if decompensated 10 mcg/kg * if HR \<60 with s/s of poor perfusion, call for help and start chest compressions Meds bradycardia: clonidine, beta blockers, Sevo esp in downs syndrome, propofol infusion syndrome, some eye drops, Sch without atropine The most frequently encountered arrhythmia in pediatric populations is hypoxia-induced bradycardia that can lead to asystole, if not appropriately handled. Ventricular fibrillation is extremely rare in infants and children.

Answer 55

* Neuromuscular function- check & reverse if appropriate * Different techniques for extubation; always prioritize patient safety * light anesthesia is the most common cause of laryngospasm * **Awake extubation**: must be awake & purposeful; laryngospasms happen when patients are extubated in the early & second phase, “if in doubt…don’t take it out!” * **3 phases waking up:** * **early phase-** coughing intermittently, gagging, struggling, moving nonpurposefully * **second phase-** apnea, agitation, straining, breathholding, RR not regular * **third (final) phase-** regular respiratory rate, purposeful movement, coughing, opening eyes spontaneously **_→ extubation now appropriate_**

Answer 56

* **Deep Extubation**: * Sevo **_increased_** to 1.5-2 MAC for at least 10 minutes * ensure no response (cough, breath holding) to suctioning or tube movement; & ensure regular respirations * place oral AW and allow them to breathe off gas or assist them * No deep extubate: DAW or aspiration risk * Transport in lateral decubitus position “recovery position” * Tx w/ O2 * PACU complications in ~5% of children: * vomiting 77% (more common in \>8 yo), airway compromise 22% (more common in \<1 yo); CV compromise is \<1%

Answer 57

* Caudal anesthesia * lower abdominal & LE surgery in \< 5-6 years of age (\> 6 yo- doesn’t work as well) * single shot block with LA will last 4-6 hours * done following GA induction in lateral position * type of epidural block sacral-coccygeal ligament- easier accessed in this age group bc fusion not finished (easy) * Epidural & spinal anesthesia are also used in children but are most frequently completed under general anesthesia * technique is similar to the adult patient * spinal anesthesia is technically difficult in neonates and infants; the overall failure rate ranges from 10% to 25%. * Regional nerve blocks usually done following induction of general anesthesia- ultrasound is very helpful since no patient feedback is available

Answer 58

* (1) severe coagulation disorders (hemophilia, DIC) * (2) severe infection such as septicemia or meningitis * (3) hydrocephaly and intracranial tumoral process * (4) true allergy to local anesthetics * (5) certain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesions that can be acutely aggravated by a block procedure * (6) uncorrected hypovolemia * (7) cutaneous or subcutaneous lesions, whatever their nature (infection, angioma, dystrophic or tumoral, tattoo) at the contemplated site of puncture * **Parental refusal is a non-medical absolute contraindication**

Answer 59

* The most commonly used technique of epidural blockade in children * Simple technique; low complication rate * Anatomy of the sacral hiatus: * a U -shaped or V -shaped aperture resulting from the lack of dorsal fusion of the fifth and often fourth sacral vertebral arches * limited laterally by two palpable bony structures, the sacral cornua * covered by the sacrococcygeal membrane (sacral continuation of the ligamenta flava) * 25-mm needles are long enough to reach the sacral epidural space and short enough to prevent inadvertent dural puncture in most patients * Contraindications: * major malformations of the sacrum (myelomeningocele, open spina bifida) * meningitis * intracranial hypertension. * Rare: unrecognized dural puncture can lead to cardiovascular collapse or respiratory arrest * Position: lateral or prone position with the legs flexed in the “frog” position * Single shot or placement of epidural catheter can be threaded to 2-3 cm (same as regular epidural block) * Upper limit of dosing: * **1 ml/kg (1.25 ml/kg can lead to block above T4)→ resp consequences!**

Answer 60

* Increased risk in certain surgeries: hernia; orchidopexy; T&A; strabismus; middle ear; laparoscopic * Strabismus sx pt- higher risk of MH (high risk of concurrent myopathies) (MD) * Prevention: * Hydration * multi-modal analgesia (opioid sparing- use less) * Peak incidence in females age 10-16 * Typical 2-3 agent strategy for prevention in at-risk (decreases risk by 80%): * **Ondansetron 0.05-0.15 mg/kg IV** (note risk in undiagnosed long QT syndrome) * **Dexamethasone 0.0625-1 mg/kg IV**

Answer 61

* Agitation & inconsolability unrelated to pain * **Peaks in age 2-6 yo** * Most common after Sevo (then Desflurane); less common with TIVA * Usually self-limiting (lasts ~ 10-20 minutes) * Tx: * Small dose of fentanyl clonidine, or propofol * Patient self-harm can be an issue (thrashing, etc.) * *need to go through and rule out hypoxemia/metabolic derangements* * *agitation may be due to pain, cold, full bladder, presence of casts, fear, anxiety, or having tantrum*

Answer 62

* varying degrees * Risks: aspiration, feeding difficulty; frequent otitis * \*\*Aspirations precautions * *not alway difficult airway, just take aspiration precautions*

Answer 63

* mandibular hypoplasia- tongue displaced posteriorly causing obstruction * **Universally difficult airway**: * **Pierre-Robin:** intubating conditions improve with age * **Treacher Collins**: becomes more difficult to intubate with age * Hemifacial microsomia (**Goldenhar**) * **→** **Very difficult mask ventilation** **&** **intubation**: * preserve spontaneous ventilation during induction * fiberoptic should be at the bedside (backup equip and support)

Answer 64

* Apert Syndrome * Crouzon Syndrome * Difficult Mask ventilation but may not be as difficult to intubate → must avoid eye injuries (protruding eyes are a feature)

Answer 65

* Life threatening **_bacterial_** infection of the epiglottis, aryepiglottic folds, arytenoids, & sometimes the uvula * **s/s:** high fever, severe sore throat, drooling, ill appearing, tripod positioning * **Rapid deterioration** may occur * **Common Age: 2-6 yo\*\*** * **Tx: antibiotics, securing AW!!** * Technique: * Calm, sitting inhalational induction, maintain SV\*\* * **Do not manipulate the airway without a backup for surgical airway in place** * Do not agitate the child (hold down for IV start; separate from parents)

Answer 66

**Croup= (Laryngotracheobronchitis)- LTB** * Viral infection of the subglottic structures; **more gradual onset** * **S/S:** barky or seal-like cough along with hoarse voice and inspiratory stridor * Technique: * Most cases resolve with simple management * Tx: humidified air or oxygen, steroids * \<10% require hospitalization

Answer 67

* **Both epiglottitis and croup have** **supraglottic swelling** * really nothing else in common * epiglottitis 2-6 yo * stirdoe uncommon * thumb sign * abx * need sx availability of airway, get airway secured * LTB \<2 yo * stridor common * steeple sign (subglottic narrowing) * use things to decrease swelling but typically don't need to intubate.

Answer 68

* most common airway problem in infants & children * Immature cartilage of the supraglottic larynx leads to symptoms * slowly resolves by **12–18 mo** * self-limiting & resolves w/ age * Symptoms: **Inspiratory stridor** w/ activity/feeding that IMPROVES when the child is calm * can lead to airway collapse

Answer 69

* Weakened/ “floppy” trachea that leads to symptoms * Symptoms: * Harsh noise/stridor on **expiration** caused by airway collapse * Onset: early neonatal period * Dx: bronchoscopy

Answer 70

* Optimize patients preoperatively * Pre-op review: ever been hospitalized for asthma? intubated? ER visits (last 6 mo)? age of onset? treatments used (today)? need for steroids? * Assessment: * Auscultate for wheezing * **Cancel elective cases for ACTIVE wheezing!** * Technique: * Admin pre-op bronchodilators in mild/moderate asthma even if not wheezing * Avoid intubation where facemask or LMA can be used (think sx type and aspiration risk) * Have bronchodilators present in OR * Refractory asthma (not moving air) → admin IV epi w/ refractory bronchospasms bc inhaled bronchodilators cant pass

Answer 71

* Prolonged upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep * altered response to CO2 * Anesthesia concerns: * opioid sensitivity * post-op respiratory complications * post-op admission for monitoring depending on results of sleep study * **Primary cause** of OSA in children: **large tonsils & adenoids** **→** **T&A sx most likely for OSA** * Other: craniofacial abnormalities, neuromuscular disorders, obesity **Assessment of risk factors:** * loud snoring, witnessed apnea, nocturnal enuresis, ADHD, behavioral problems, inattention at school; increased risk in African American * Daytime somnolence is not a common feature of OSA in children (opposite than adult pts) * AHI score- apnea-hypopnea index (**AHI**) * *graded by # of apnea and hypopneic episodes during 1 hour obs* * *Mild \>5 but \<15/hour* * *moderate 15-30/hr* * *severe \>30/hour*

Answer 72

* **Intermittent hypoxia** **→** **may lead to remodeling** * Consequences: pulmonary hypertension & right heart failure (cor pulmonale) * Preop: Echocardiography recommended when severe OSA suspected to have CV involvement * **Red flags:** * systemic hypertension * right ventricular dysfunction (s/s: peripheral edema, hepatic enlargement (below 1-2 cm costal margins), elevated liver enzymes) * frequent severe desaturations (\<70%)

Answer 73

* **CONSIDER NON-OPIOID ALTERNATIVES:** * local anesthetics * tylenol * ketorolac * ketamine * dexmedetomidine * **When opioid is given: REDUCE DOSE! (usually by 1/2)** * **Admin in small doses and assess for response** * High risk patient? * Safest route: Admit for postoperative monitoring even if no sleep study has confirmed diagnosis * Council family members about transporting child home → watch for obstruction

Answer 74

* Most common co-morbidity in children presenting for surgery * Increased risk complications/ bronchospasm at induction/emergence * Laryngospasm, bronchospasm, excess secretions * The most common perioperative respiratory adverse events (PRAEs) associated with URI are: * \*\*laryngospasm, bronchospasm, breath holding, atelectasis, arterial oxygen desaturation, bacterial pneumonia, and unplanned hospital admission * **Caution but proceed**: clinically look OK * clear runny nose * no fever * playful * clear lungs * **Cancel:** * purulent nasal discharge * fever * lethargy- ill looking * persistent cough, wheezing/ rales * previous preemie * \<1 yo * **Consider waiting at least 2 weeks for elective surgery** * Complications can persist up to **6-8 weeks**

Answer 75

* Airway manipulation (ETT) increases the risk of bronchospasm * Techniques: * ensure deep plane of anesthesia before manipulate AW * (risk of airway reflex response: face mask \< LMA \< ETT) * Avoid intubation if case can be done with less invasive airway (mask case; LMA) * Add propofol/local anesthetic * Considerations: * Tx for bronchospasm available @ bs * anticipate increased potential for laryngospasm * Most common perioperative respiratory adverse events associated w/ URI are: * laryngospasm * bronchopasm * breathholding * atelectasis * arterial oxygen desat * bacterial pna * unplanned hospital adm

Answer 76

* More frequent in infants * risk decreases with increasing age * **Reflex closure of false & true vocal cords** * **Afferent (sensory)** limb of reflex= internal branch of SLN (superior laryngeal nerve) * **Efferent (MOTOR)** limb of reflex is recurrent laryngeal nerve (affects all laryngeal muscles except cricothyroid) and external branch of SLN (affects cricothyroid) * Sx: stridor, retractions, flailing of lower ribs; “rocking horse” chest wall movement; stridor will be absent with complete closure “silent inspiratory effort” * Can lead to profound bradycardia & desaturation if unrelieved * Risks: * recent URI * secondhand smoke * stimulation while “light” * secretions in airway

Answer 77

* Treatment: * Continuous positive airway pressure * 100% oxygen * jaw thrust at condyles of mandible * suction secretions/ blood etc. * deepen anesthesia (propofol) * ask for help * Unresolved? * **Atropine & Sch- if no IV access then give IM** * Can lead to negative pressure pulmonary edema especially in healthy, muscular adolescents * May have to remain intubated for 12-24 hours & may need furosemide (0.5-1 mg/kg) * Self-limiting but can be severe

Answer 78

* One of the most commonly performed pediatric surgeries **Indications**: * recurrent infections * OSA * Most tonsillectomy patients have enlarged tonsils without other airway deformities * Must consider presence of sleep apnea * potential need for admission * use of multi-modal analgesia (reduce opioid doses) **Technique**: * LMA used by some but majority still intubate * RAE tube **Complications**: * **Post-op hemmorhage** * occurs in 0.1-3% of T&A * can be primary (day of surgery) or 7-10 days later * Consider: active bleeding in airway → * visualization difficult * full stomach- swallowing blood * RSI\*\* * hypovolemic shock potential

Answer 79

* Indications: one of the most common peds diseases in 1^st decade of life * Acute otitis media * Short outpatient procedure * 5-10 minutes of operating time for the experienced surgeon in uncomplicated patient **Anesthesia technique:** * Usually no premedication unless extremely apprehensive (may delay discharge) * Standard monitors * Inhalation induction is performed with a combination of sevoflurane and oxygen (with or without N2O); maintenance with mask is usually appropriate * Usually IV access is not necessary (other comorbidities may want IV) * May have co-existing tonsillar hypertrophy- airway obstruction is usually relieved by continuous positive pressure &/or oral airway * Rectal or PO acetaminophen or intranasal fentanyl can be used for pain control in the absence of an IV

Answer 80

* **Pectus carinatum:** abnormal **PROTRUSION** of xiphoid process and sternum * predominantly in males 4:1 * associated w/ other abnormalities: (affects w/ anesthetics) * scoliosis → restrictive lung dx * Marfan syndrome → vacular problems (at aortic root) & joint laxity * congenital heart disease * **Pectus excavatum:** abnormal **DEPRESSION** of sternum * many times medically insignificant- mostly cosmetic sx * if severe → may have restrictive lung dx

Answer 81

* most common birth defect * incidence: 1:25 live births * **L-to-R shunting:** * increases pulmonary BF → potentially decreases systemic blood flow * **R-to-L shunting:** * Blood bypasses pulm circulation → Deoxygenated BF into systemic circulation → causes reduced pulmonary blood flow and increased cyanosis * \*deoxygenation BF into periphery * PDA present * have pulse ox on RUE (preductal oxygenation) and any other extremity (postductal oxygenation) * Preductal: BF feeds head, neck, and RUE * Postductal: any other extremity

Answer 82

* Management is dependent on specific anatomy and physiology * Attempt to maintain pt baseline (same SpO2 and other vital signs) * **L-to-R shunts:** * Avoid increases in SVR and decreases in PVR (which will increase shunt) * Avoid negative inotropes * Avoid hypervolemia * Desaturation → Could be reversal of shunt * **Anesthetic considerations:** * **minimal impact on uptake of volatile anesthetics**

Answer 83

**R-to-L shunts:** * Maintain high SVR to decrease shunt: * Ex: Ketamine, phenylephrine * Avoid increased PVR * Minimize intrathoracic pressure * **Avoid air bubbles in IV** * **Anesthetic Considerations:** * decreased wash-in of VA * → IV supplementation may be required

Answer 84

* Most common cyanotic CHD * primary repair done at 3-12 months * Anatomy: * Right ventricular outflow (RVOT) obstruction * Infundibular narrowing, pulm stenosis, PA hypoplasia, pulm atresia * Ventricular septal defect (VSD): Large, unrestrictive * Overriding aorta * RV hypertrophy * **Tet spells**: (Left unrepaired) → cyanotic episodes!!! * Crying and agitation leading to tet spell leading to more hypoxemia, hypercarbia, acidosis (avoid) * Consequences: lead to RVH, RV failure, and death (50% in first year of life) * Increased R-to-L shunting caused by: * decreased SVR or * increased PVR * Avoid hypoxia, acidosis, high airway pressures, excitement, and agitation

Answer 85

* Can be associated with the later development of dysrhythmias (esp if approach was ventriculotomy → conduction system violated) * repaired single-ventricle physiology → high risk sudden death as a result of pathologic arrhythmias * any intraoperative arrhythmias must be reported to cardiologist → may require RF ablation * Children with a **single-ventricle physiology (Fontan)** require very specific anesthetic management: * well hydrated * avoid PEEP * avoid laparoscopic surgery (avoid intrathoracic/intraabdominal pressure) * **Williams syndrome** → high risk sudden death with anesthesia * Anatomy: aortic stenosis, abnormal coronary arteries, pulmonic stenosis * Former cardiac transplantation: * must rule out small vessel coronary artery disease

Answer 86

* Hgb SS homozygous: Hgb S permits deoxygenated Hgb molecules to polymerize into rigid insoluble fibers → resulting in sickled erythrocytes * Sickled erythrocytes = shortened life span → leading to **_chronic hemolysis and anemia_** **Complications**: * anemia, stroke, * **acute chest syndrome-** lead to sig pulm failure * A vascular occlusive crisis in the lungs leads to acute chest syndrome (ACS). ACS is leading cause of death and second most common complication in sickle cell disease. * , myonecrosis, CHF, MI, splenic sequestration, retinal hemorrhage, hematuria, ESRD, seizure, wound infection, UTI, and unexplained death

Answer 87

**AVOID:** * **Dehydration** * **Stasis** * **Hypoxia** * **Hypothermia** * **Acidemia** * **pain** ANY OF THESE LEADS TO → **Vaso-occlusive crises** * Vaso-occlusive crisis → lead to subsequent end-organ ischemia * Ex: Bone, chest, brain- may have significant sequelae from previous crises

Answer 88

**Pre-op:** * **warm, well-oxygenated, and hydrated!** * Thorough multi-system assessment * may have chronic pain, hx of stroke, pulmonary complications from infection or acute chest syndrome, anemia, infections, renal disease, AVN of hips * Consult hematologist preop: * Possible _preop transfusion to target hgb (10 g/dL)_ * ensure pre-op hydration- admit night before to hydrate * _IV access can be challenging_ Intra-op: * Maintain euvolemia & normothermia * avoid tourniquets Post-op: * Adequate IV hydration; early mobilization and incentive spirometry; supplemental O2; consider multimodal analgesia (many are opioid tolerant)

Answer 89

* One of the most common abdominal emergencies * most likely in teen years * \> 24 hrs delaying dx → increased risk perforation * s/s: classically RLQ pain * Risks of intraabdominal perforation: * Abscess * Ileus * sepsis **Considerations**: * Aspiration risks * active nausea and vomiting * tachycardia due to pain, dehydration, or sepsis **Management**: * Preop IV antibiotics w/ **gram negative** coverage * correct fluid deficits * use full stomach precautions – RSI * evacuate stomach with NG/ OG

Answer 90

Myopathies: need preop echo & ECG * **Duchenne muscular dystrophy-** x-linked * lack of dystrophin in skeletal & cardiac muscle * progressive cardiomyopathy adolescence * Becker muscular dystrophy- milder form of Duchenne * seen in 2nd decade of life * Emery Dreiffuss- may have concurrent heart block \*\*Careful w/ NMB and Succs!!! → why we avoid succs \< 8yo

Answer 91

* Childhood cancer → leading cause of disease related mortality Pediatric acute lymphoblastic leukemia (ALL): most common pediatric oncologic diagnosis * **Tumor lysis syndrome**: * metabolic crisis that often occurs when chemo started * Cause: acute lysis of a large number of tumor cells * **Classic triad**: * Hyperuricemia * Hyperkalemia * hyperphosphatemia * elevated phosphate causes hypocalcemia (Concerning: High K, Low Ca\*\*)

Answer 92

* Anesthesia is frequently needed for central line placement, lumbar punctures, bone marrow aspirates, etc. * Consider effects of cancer and its treatment: * **Anthracyclines** (doxorubicin, daunorubicin): cardiotoxicity * **Bleomycin, mitomycin**: pulmonary toxicity * Many other long term side effects and toxicities * \*\*be sure to complete a thorough multi-system evaluation, how long its been since tx

Answer 93

* Causes: lymphoma, teratoma, thymoma, thyroid tissue * Sx: vary based on size and location * **\*\*Stridor or SVC syndrome** * symptoms can progress rapidly especially in non-Hodgkins lymphomas → life-threatening AW obstruction

Answer 94

CAUTION: * Induction of GA → life threatening AW obstructions and CV collapse!! * Do NOT want to lose AW reflexes!!! * large masses may need radiation and steroids before anesthesia can be safely provided * IR for needle biopsy * **local** preferred if cooperative * **Technique:** * **Sit up** * **PRESERVE SPONTANEOUS BREATHING** * **Ketamine- light w/ anesthesia** * SVC syndrome: * will need IV in lower extremity * Preferred to keep patient in semi-sitting position * Severe obstruction may require repositioning prone or lateral * CV collapse may require cardiopulmonary bypass **(may have bypass on standby in large mediastinal mass)**

Answer 95

* 3rd copy of chromosome 21 * 1:1000 live births * increased incidence in moms over 35 * **Physical exam findings**: Midface hypoplasia, brachycephaly, epicanthal folds, simian crease, downward medial slant of eyes, high-arched palate, glossoproptosis, and murmur (DAW) * May require surgery for tympanostomy, strabismus, CHD repair, duodenal/esophageal atresia, marrow aspiration/biopsy, cervical spine fusion * Considerations: * \*\*5-fold risk **of bradycardia** during Sevo induction (first 6 minutes) in children with Downs (Barash) * Difficult intubating d/t macroglossia & glossoproptosis * Difficult masking d/t midface hypoplasia * Chart → * Keep neck neutral (d/t subluxation of C1/2)

Answer 96

* Airway * Have variety of devices available (e.g., oral and nasal airways, laryngeal mask, glidescope, fiberoptic) to manage airway obstruction. * Avoid neck extension during laryngoscopy if possible. * Smaller endotracheal tube may be necessary for narrowed subglottic space. * Vascular Access * Meticulously avoid injected air due to likelihood of CHD * Anticipated Problems/Concerns * **Bradycardia** with inhalational induction (sevo) * Resistance to separation from caregiver

Answer 97

* VACTERL: vertebral anomalies, anal atresia, congenital heart disease, tracheoesophageal fistula, esophageal atresia, and renal and radial dysplasia, limb defects * CHARGE: coloboma, heart defects, choanal atresia, retardation of growth and development, genitourinary problems, and ear abnormalities * CATCH 22: cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcemia * chromosome 22q11.2 deletion syndrome

Answer 98

* Blood relative or muscle biopsy * **Technique:** * **First case of the day** * Remove vaporizers from machine * flush per manufacturer guidelines (w/ charcoal filter) * Use trigger-free anesthetic: propofol, opioids, BZD’s, NDNMB’s, N2O, regional * **Mandatory Monitoring:** * EtCO2\* * increased etCO2 earliest indicator * temp monitoring\* * MH-susceptible children can have outpatient procedures as long as trigger-free anesthetic is used \* (no Succs or VA)

Answer 99

* Definitions for obesity in children are based on BMI * obesity = BMI \>95th percentile * morbid obesity= BMI \>99th percentile * IBW calculation for children: * **\< 8 years: 2 x Age (years) + 9** * **\>8 years: 3 x Age in years** * LBW calculation**= IBW + 1/3(TBW-IBW)**

Answer 100

* Consequences: * Restrictive pulmonary pattern * Increased O2 consumption * decreased chest wall compliance * FRC * vital capacity * CV effects: * Htn * LVH * premature atherosclerosis * Insulin resistance is common

Answer 101

* Drug dosing is complex (see chart)\*\* * Ex: Induction * TBW: succs, sugammadex * Technique: * **Airway:** * position HOB 25 degrees * plan for possible difficult mask ventilation * note rapid desaturation * Consider Desflurane for maintenance (least fat soluble) if airway reactivity is not a concern

Answer 102

* Look at post-conceptual age * Gestational age + postnatal age * Ex: born at 28 weeks and now 12 weeks old= 40 weeks postconceptual age * Former preemies will require post-op admission if \< 60 weeks postconceptual age- ***regardless of type of surgery*** * **Admission d/t Risk of post-op apnea & desaturations** * Discharge: **\>12 hours apnea free** * Techniques: * Opioids avoided/used sparingly in this pop * LA- great alternative

Pediatrics Flashcards

(128 cards)