Peds Flashcards
(131 cards)
1
Q
Definitions
Neonates
Infants
Children
A
Neonates: 1-30 days
Infants: 1-12 mo
Children: 1-12 yrs
2
Q
CO of neonates and infants is dependent on…
A
HR
*Since SV is relatively fixed by a noncompliant and poorly developed LV
3
Q
Compare neonate vs. adult. Infant has a... HR BP RR TV Lung compliance Chest wall compliance FRC CV RV VA TLC Ratio of body surface area to body wt Total body water content
A
Faster HR Lower BP Faster RR (40 vs. 10) Decreased TV (6 vs. 7 mL/kg) Lower lung compliance Greater chest wall compliance Lower FRC (30 vs. 34 mL/kg) Increased CV Increased RV (20 vs. 17 mL/kg) Higher VA (100 vs. 60 mL/kg/min) Decreased TLC (60 vs. 80 mL/kg) Higher ratio of body surface area to body wt Higher total body water content
4
Q
Describe infant airway concerns.
A
Large head Large tongue ANTERIOR and CEPHALAD larynx Long epiglottis Slanting vocal cords Narrow cricoid ring - subglottic Short trachea Short neck Prominent tonsils and adenoids Narrow nasal passages (resistance x12) *Infants are obligate nose breathers
5
Q
List pharmacologic differences in infant.
A
Immature hepatic biotransformation Immature NMJ Decreased protein binding Rapid induction and recovery Increased MAC Large Vd for water soluble drugs
6
Q
What is the narrowest point of the airway in children younger than 5 years old?
A
Cricoid cartilage
7
Q
GREATER THAN 2 yrs, ETT size formula…
A
(Age/4) + 4
*This will tell you uncuffed size - subtract 0.5 for cuffed size
8
Q
Calculate ETT length at mouth.
A
(10+age)/2
9
Q
What explains the following: you will have a more rapid induction with inhaled anesthetics in neonates?
A
Decreased FRC
Increased RR
Increased VA
10
Q
What explains the following: neonates are prone to atelectasis and hypoxia during anesthesia?
A
Decreased FRC
Increased CV
11
Q
Neonates rely on what muscles for breathing?
A
Diaphragmatic breathers
Intercostal muscles are underdeveloped
Diaphragm is high
Chest cavity is small
12
Q
Normal HR ranges for preterm to 5 years.
A
Preterm: 120-180 Term: 100-180 1 yr: 100-140 3 yr: 85-115 5 yr: 80-100
13
Q
Normal BP ranges for preterm to 5 years.
A
Preterm: 45-60/30 Term: 55-70/40 1 yr: 70-100/60 3 yr: 75-110/70 5 yr: 80-120/70
14
Q
Estimated BV Preterm Infant Toddler Child Adult (male) Adult (female)
A
Preterm: 90 mL/kg
Infant: 80 mL/kg
Toddler: 75 mL/kg
Child: 72 mL/kg
Adult (male): 70 mL/kg
Adult (female): 65 mL/kg
15
Q
How do you calculate ABL?
A
EBV x (Hct – lowest/Hct)
16
Q
How do you determine the hourly fluid maintenance for a child?
A
4-2-1 Rule
4 mL/kg for 1st 10 kg
2 mL/kg for 10-20 kg
1 mL/kg for each kg > 20 kg
17
Q
Is fetal circulation parallel or series circulation?
A
Parallel
18
Q
Total body water (% TBW)
Preterm
Term
6-12 mo
A
Preterm: 90%
Term: 80%
6-12 mo: 60%
*The increase is seen in the EXTRACELLULAR compartment
19
Q
Why are infants of diabetic mothers prone to hypoglycemia?
A
Infant will produce insulin in response to maternal BS
When cord is clamped - no more glucose from mom
Infant has stored insulin
20
Q
Define prematurity.
A
Birth b4 37 weeks gestation
< 2500 gm
21
Q
Define for small for gestation age.
A
Full or preterm
Age-adjusted weight < 5th %tile
22
Q
Post-conceptual age =
A
Gestational age + post-maternal age
23
Q
What are you main concerns for a premature infant?
A
Airway control
Fluid management
Temp regulation
Retinopathy of prematurity (retrolental fibroplasia)
*Fentanyl favored over volatile anesthetics
24
Q
Less than how many weeks post-conceptual age have the greatest risk of experiencing post-anesthetic complications?
A
< 60 weeks post-conceptual age
25
What is a congenital diaphragmatic hernia usually associated with?
Pulmonary hypoplasia
Caused by in utero compression of the developing lungs by the herniated viscera
*Occurs at 5- 10 weeks of fetal life
(high incidence of CHD and intestinal malrotation)
26
Congenital diaphragmatic hernia: gut herniates into thorax via...
What is the most common? Why?
```
Anterior foramen of Morgagni
R posterolateral foramen of Bochdalek
L posterolateral foramen of Bochdalek*
(70-90%)
*L. side foramen closes after the R
```
27
The baby has a congenital diaphragmatic hernia. Would you expect the 1 min APGAR score to be depressed?
NO, may be normal owing to oxygenation of fetal blood by the placenta
28
What are hallmark signs of congenital diaphragmatic hernia?
Profound arterial hypoxia - R to L shunt
Barrel-shaped chest
Scaphoid abdomen
29
What are the management goals of an infant with congenital diaphragmatic hernia?
```
Pulse ox - place preductal on RUE and postductal on LLE
Maintain preductal sat > 85%
Peak inspiratory pressure < 25 cm H2O
Pressure limited modes of ventilation
Allow mod hypercapnia (PCO2 45-55 mmHg)
Decompress stomach
Avoid venous access in LE
Avoid N2O and halogenated agents
Paralysis with narcotics
*NO for persistent pul HTN does NOT work
```
30
What side pneumo is a concern in the setting of a congenital diaphragmatic hernia?
R. sided pneumo
31
```
Incidence
Congenital diaphragmatic hernia
Tracheoesophageal fistula
Gastroschisis
Intestinal Malrotation and Volvulus
```
```
Congenital diaphragmatic hernia: 1:5,000
Tracheoesophageal fistula: 1:3,000
Omphalocele: 1:5,000
Gastroschisis: 1:15,000
Intestinal Malrotation and Volvulus: 1:500
```
32
What is the most common variation TEF?
Esophagus ends in a blind pouch
Lower esophagus that connects to the posterior wall of the trachea (just above the carina)
85%
Type IIIB
33
What will you see with a TEF? What happens with breathing? What happens with feeding?
Gastric distension w/ respirations
| Feeding leads to 3 C's: choking, coughing, cyanosis...HYPOXIA + BRADYCARDIA...pneumonia
34
What is VACTERL syndrome?
```
Vertebral defect
Anal defect
Cardiac anomalies
TEF
Esophageal atresia
Renal dysplasia
Limb anomalies
```
35
Anesthesia Concerns for TEF.
Frequent suctioning - copious pharyngeal secretions
NO PPV prior to intubation
Head up position
Awake intubation w/o MR
Dehydrated and malnourished
Do NOT extend neck or instrument esophagus
36
What is the principle cause of death associated with a TEF?
Pulmonary complications
37
Describe pyloric stenosis.
Common cause of gastric outlet obstruction
| Idiopathic hypertrophy of the circular smooth muscle of the pylorus
38
What are the s/s of pyloric stenosis?
Non-bilious projectile vomiting at 2-5 weeks of age
Olive-like mass palpated in the epigastrium
Starvation
Jaundice
39
What is the most common metabolic presentation of pyloric stenosis?
HYPOkalemic, HYPOchloremic primary METABOLIC ALKALOSIS with
secondary RESPIRATORY ACIDOSIS
(Kidneys compensate by excreting NaBicarb in urine)
Severe dehydration d/t persistant vomiting may lead to metabolic acidosis with compensatory hyperventilation
(Kidneys must conserve sodium even at the expense of H ion excretion)
* HYDRATION status is CRUCIAL to METABOLIC status
40
Anesthetic Concerns for Pyloric Stenosis.
Avoid pulmonary aspiration
Empty stomach b4 surgery
Apnea monitoring for 12 hrs post-op
41
What may occur 2-3 hrs after surgical correction of pyloric stenosis (besides possible apnea)?
HYPOcalcemia
| D/t inadequate liver glycogen stores
42
Acute Epiglottitis
```
2-7 yrs
HIGH fever (> 39 C)
SUPRAglottic edema
Difficulty swallowing
INSPIRATORY stridor
5% of children with stridor
Neutrophilia
Haemophilus INFLUENZA type B
Tx - Ampicillin
```
43
Laryngotracheal Bronchitis
```
6 mo - 6 years
LOW fever
SUBglottic edema
Less airway obsturction
CROUPY cough ("barking")
80% of children with stridor
SLOW onset
Common cold - VIRAL
Tx - cool humidity, oxygen, racemic Epi
```
44
What will a child with acute epiglottitis look like?
```
Sitting forward and upright
Chin up
Mouth open
Drooling
Tachypnea
Lethargic
Cyanotic
*Acidotic, elevated CO2, dehydrated
```
45
Anesthetic Concerns for Acute Epiglottitis.
```
Requires immediate intubation
Sedate in sitting up position
NO MR
Small tube with leak
Fluids
Antibiotics - Ampicillin
```
46
Anesthetic Concerns for Laryngotracheal Bronchitis.
```
Only intubate if increased PaCO2
Cool humidity, oxygen
2.25% Epi 0.5-1 mL in 2-3 mL normal saline -
0.05 mL/kg - 0.5 mL/kg
Repeat in 20 min
Repeat Q2-4 hrs
```
47
Omphalocele
```
Base of umbilicus
W/in umbilical cord
SAC is the amnion
MULTIPLE anomalies - cardiac eval prior to surgery
Occurs at 5-10 weeks gestation
```
48
Gastroschisis
```
Lateral to umbilicus
Periumbilical
NO SAC or amnion
*Prevent hypothermia, dehydration, and infection
Requires URGENT repair
NO other anomalies
Occurs at 12-18 weeks gestation
```
49
What do high alpha-fetoprotein levels in mom indicate?
Diagnostic for omphalocele
50
Anesthetic Concerns for Ompahlocele and Gastroschisis.
```
Decompress stomach
NO N2O
May need MR to replace bowel in abd cavity - staged closure
Monitor BS
Hydrate (8-16 mL/kg/hr)
```
51
Prone Belly Syndrome Anesthesia
```
Risk of aspiration
Thin, weak abdominal wall
Cannot cough well
Awake intubation
NO MR
Renal involvement
```
52
Intestinal Malrotation and Volvulus
Abnormal rotation of the midgut around the mesentery
| Present with s/s of bowel obstruction: bilious vomiting, abd tenderness and distention, *Metabolic acidosis
53
What is the most serious complication of intestinal malrotation and volvulus?
Midgut volvulus
Rapid compromise of intestinal blood supply
*This is a TRUE surgical emergency
(1/3 occur during the 1st week of life)
54
Anesthetic Concerns for Intestinal Malrotation and Volvulus
```
Decompress the stomach
High risk for aspiration
Awake intubation
Antibiotics
F&E replacement
```
55
Patients with volvulus are...
```
HYPOvolemic - aggressive fluids, blood
ACIDotic - NaBicarb
Poor candidates for GA - use ketamine and opioid-based anesthesia
Risk for bowel compartment syndrome
25% mortality rate
```
56
Bowel compartment syndrome results in...
Impaired ventilation
Decreased VR
Renal compromise
Requires several surgeries
57
Which one is more severe: Pierre-Robin or Treacher-Collins Syndrome?
Treacher-Collins Syndrome
58
Anesthetic Concerns
Trisomy 21 Syndrome
Down's Syndrome
Extra chromosome 21
Difficult airway
Small ETT
Atlanto-occipital dislocation d/t congenital laxity of the ligaments
Avoid air bubbles in IV (possible R to L shunt)
Post-op apnea and stridor is common
59
Cystic Fibrosis
```
Hereditary
Exocrine glands
Pulmonary and GI systems
Thick, viscous secretions
Decreased ciliary activity
Pneumonia, wheezing, bronchiectasis
Malabsorption syndrome - F&E disturbances
```
60
```
Explain what happens to the following with cystic fibrosis.
RV
Airway resistance
Vital capacity
Expiratory flow rate
```
RV - increased
Airway resistance - increased
Vital capacity - decreased
Expiratory flow rate - decreased
61
Scoliosis
| Pre-op orders
Pre-op: PFTs, ABGs, ECG
62
T&A
Increased risk for what?
Postpone surgery if?
Other considerations.
```
Risk of perioperative airway problems
Postpone if active infection or clotting dysfunction
Anticholinergic to decrease secretions
Treat for PONV
*If bleeding, RSI + NG tube
```
63
What are common causes of otitis media?
Hemophilus influenzae
Stretococcus
Pneumococcus
Mycoplasma pneumoniae
64
Dantrolene
2 mg/kg
Q5-10 min
Max: 10 mg/kg
65
Treatment of MH
```
Turn off agents
Hyperventilate with 100% O2
Dantrolene
Active cooling - 15 mL/kg of iced saline
Give NaBicarb
Maintain UO (hydration, mannitol, lasix)
```
66
1 min APGAR score correlates with...
Survival
67
5 min APGAR score is related to...
Neurologic outcome
68
What is the most common cause of neonatal depression?
Intrauterine asphyxia
Respiratory resuscitation
*Don't suction > 3x
69
What should you do?
APGAR score 0-2
APGAR score 3-4
APGAR score 5-7
APGAR score 0-2: intubate + compressions
APGAR score 3-4: assist ventilation (40/min)
APGAR score 5-7: stimulation, blow by
70
Indications for PPV in Neonate
Apnea
HR < 100
Persistent central cyanosis on 100% O2 by mask
71
Initial breaths may require peak pressures of up to ___cm water, but NOT to exceed ___ cm water subsequently.
40
| 30
72
If the HR is < ___ bpm, intubate.
| If the HR does not improve to > 80 bpm, then ______.
60
| Start compressions
73
How do you verify correct ETT size in a neonate?
Small tube leak with 20 cm water pressure
74
Cardiac compression at a rate of ____/min and at a depth of _____ inches.
100 (30:2 if single, 15:2 if multiple)
| 1.5 inches/4 cm
75
True or False.
| Neonatal BP generally correlates with intravascular volume.
TRUE
1-2 kg: BP 50/25
> 3 kg: BP 70/40
76
Pediatric Epinephrine Dose
0. 01-0.03 mg/kg
0. 1-0.3 mL/kg of 1:10,000
* Give if asystole or HR < 80
77
Pediatric Atropine Dose
0.03 mg/kg
78
Pediatric Calcium Dose
30 mg/kg
| *Mag toxicity
79
Pediatric Naloxone Dose
0.01-0.02 mg/kg
80
Pediatric Glucose Dose
4 mL/kg of a 10% solution
81
LMA size formula
kg / 20 + 1 (round to nearest 0.5)
2. 5: 20-30 kg
3: 30-60 kg
4: 60-80 kg
5: > 80 kg
82
ETT size for < 2 years
Preterm: 2.5
Term infant: 3
3-12 mo: 3.5
2: 4
83
A child unexpectedly has cardiac arrest after Sux administration. How would you treat this patient?
Hyperkalemia
84
The hallmark of intravascular fluid depletion in neonates and infants is...
Hypotension w/o tachycardia
85
The major cause of perioperative morbidity and mortality in pediatric patients is?
Hypoxia from inadequate ventilation
86
The pediatric patient's major mechanism for heat production is?
Non-shivering thermogenesis by metabolism of brown fat
Cold stress - increase NE production - metabolism of brown fat - increase body heat
Persists up to the age of 2
*Controlled by autonomic NS
87
Which inhalational agent has the same MAC for neonates and infants?
Sevo
88
You pediatric patient has had a recent viral infection. What time should pass before GA and ETT would be considered reasonable?
2-4 weeks
89
Surfactant appears initially b/t...
23-24 weeks
90
Why do newborns not tolerate large volumes of water and salts?
B/c of low GFR and decreased tubular concentrating ability
91
When is the cytochrome P450 enzyme system fully functional?
1 mo
92
In newborns, the closing capacity > FRC. What does this mean?
Some airways close during the expiratory phase of normal tidal breathing
93
What should you set the TV on the vent for a neonate?
6-8 mL/kg
| *Same as an adult
94
What is the minute volume per kg for the neonate?
250 mL/kg
| MV = TV x RR
95
Physiological anemia of the neonate.
Full-term newborn: Hgb 14-20
"Bottoms out" during the 9th to 12th week - Hgb 10-11, Hct 33%
3 mo/12 weeks: Hgb 11.5 until the age of 2
96
Physiological anemia of the preterm neonate.
Decrease in Hgb levels is GREATER and EARLIER
| 4-8 weeks: Hgb 8
97
Normal Hgb in the newborn and the pediatric patient.
Newborn: Hgb > 13
| > 3 mo: Hgb > 10
98
Pediatric fluid replacement for blood loss is best determined by which method of monitoring?
Hct
99
At what age is BMR normally the highest?
B/t 6-12 mo
100
What is the best way to maintain an infant's body heat?
Maintain high ambient temp
Increase OR temp
*Premature - 26 deg C
101
At what rate do infants consume O2?
7 mL/kg/min
| *2x that of the adult
102
Where should BP monitoring occur in the neonate with preductal coarctation of the aorta?
R. radial aline
103
What causes the closure of the foramen ovale?
Decrease in PVR and increased pulmonary flow
| Increased pressure in the LA
104
What causes the closure of the ductus arteriosus (PA and aorta)?
Increased PaO2
| Reduction in circulating prostaglandins
105
What if the pediatric patient has a systolic and diastolic murmur?
PDA
| L to R shunt
106
Identify the best site to obtain ABGs from the neonate.
Radial artery
| Reflects preductal oxygenation, which better reflects cerebral oxygenation
107
What are the 4 primary precipitating factors in persistent fetal circulation?
1. Hypoxemia
2. Acidosis
3. Pneumonia
4. Hypothermia
* Increased PVR, R to L shunting
108
What is Eisenmenger's pathology?
VSD + pulmonary HTN
| R to L shunt
109
What can worsen a R to L shunt?
Increase in PVR OR a decrease in SVR
| Acidosis, hypercarbia, hypotension, volatile agents, histamine
110
List 4 CHD involved with tetralogy of Fallot.
1. VSD
2. RV outflow tract obstruction (pulmonary stenosis)
3. RVH
4. Overriding aorta
111
R to L shunt
Slow or accelerate...
Inhalation induction
IV induction
Inhalation induction - slow
| IV induction - accelerate
112
L to R shunt
Slow or accelerate...
Inhalation induction
IV induction
Inhalation induction - accelerate
| IV induction - slow
113
Name 4 conditions in which the patient presents with a large tongue.
1. Down's
2. Pierre Robin
3. Acromegaly
4. Hypothyroidism
* NOT Treacher Collins
114
Name 3 conditions in which the patient presents with mandibular hypoplasia.
1. Pierre Robin
2. Treacher Collins
3. Goldenhar
115
Pierre Robin is a combo of what 3 things?
1. Cleft palate
2. Micrognathia
3. Glossoptosis
116
What is the most common of the mandibulofacial dystoses?
Treacher-Collins
117
What is the most common CHD?
VSD
118
What syndrome has an associated cleft palate?
Treacher-Collins
119
Your patient has spina bifida. What is your primary concern?
Latex allergy
120
What is the most frequent pediatric surgical emergency?
Foreign body aspiration
121
What might be signaled by a sudden fall in lung compliance (increased peak inspiratory pressure), blood pressure, or oxygenation during repair of a congenital diaphragmatic hernia?
A contralateral (usually R-sided) pneumo
122
What acid-base disturbance will be seen with significant loss of bile vomitus?
Metabolic acidosis
123
Is pyloric stenosis a medical emergency or a surgical emergency?
Medical
| Surgery should be postponed for 24-48 hrs until F&E are corrected
124
What is the average blood lost during a tonsillectomy?
4 mL/kg
| 5-10% of blood volume
125
Kernicterus
Bilirubin encephalopathy
Toxic effects of unconjugated bilirubin
Crosses the immature BBB of a neonate
Drugs that compete for albumin binding sites may increase the risk: furosemide, sulfa, diazepam
126
NPO Guidelines
Clear fluids: 2 hrs
Breast milk: 4 hrs
Formula or light meal: 6 hrs
Solid meal: 8 hrs
127
How is the length of the ETT from the mouth determined?
(10 + age)/2
128
Retinopathy of Prematurity
Inversely proportional to birth weight
Associated with oxygen exposure (>40%), apnea, blood transfusion, sepsis, fluctuating levels of CO2
Negligible after 44 weeks post-conception
129
With an immature SNS, the CV parameters are remarkably stable in the neonate with a high or total spinal. What sign would indicated a high or total spinal?
Decreased O2 sat
130
How do infants react to hypoxia?
Bradycardia
131
What PaO2 is desirable when ventilating a premature infant for surgery?
60-80 mmHg
