Peds Anesthesia Flashcards
(57 cards)
1
Q
adverse events in infants <1 getting anesthesia
A
- bradycardia secondary to hypoxia and high inhalation anesthetic concentration
- respiratory complications like bronchospasm, laryngospasm, apnea
- cardiac arrest (8 out of 10 result from hyperkalemia following transfusion)
- medication related
- equipment related (CVC placement)
2
Q
psychological preparation for kids
A
- IMPORTANT
- may have child-life, videos, tours etc
- basic objective = explain to child and parents in respectful, simple, understandable and reassuring terms
- bond with child to reduce their anxiety as well as their parents
3
Q
0-6 months psychological aspect
A
not usually upset by separation from parents, prolonged separation may impair parent-child bonding
4
Q
6 months-4 years psychological aspect
A
separation anxiety, fear of hospitalization; may show regressive behavior
5
Q
School age children psychological aspect
A
less upset by separation from parents, asks questions, involved, wants choices, more concerned with surgical procedures and its possible effects on body image
6
Q
adolescents psychological aspect
A
fear of the process of narcosis, loss of control, waking up during surgery, and pain of surgery; value modesty; HCG test in females
7
Q
parents psychological aspect
A
provide an explanation of what to expect
8
Q
parental presence on induction not appropriate when…
A
- adequate preop sedation
- parent’s level of anxiety
- language barrier
- emergency/RSI cases
- anticipated difficult airway or unstable patient
- pregnant mother (due to N2O exposure)
9
Q
interview and physical exam peds
A
- sources of information include the EMR, parents, and the child
- NPO status
- current weight
- auscultate heart and lungs
- evaluation of the airway, inquire about loose teeth
- PMH/previous anesthetics/MH
- recent URIs or fevers
- cigarette exposure in the home
- possibility of pregnancy
- allergies and current meds
10
Q
preop lab considerations for peds
A
- often not necessary
- consider if the labs could wait until they are under anesthesia
- Hgb on certain patients
- glucose in prolonged fasting and metabolic disorder
- pregnancy test in females
11
Q
patient who may need Hgb
A
- neonate
- premie
- cardiopulmonary disease
- known heme dysfunction
- anticipated major blood loss during procedure
12
Q
child with URI
A
- may be simple infection or much more serious
- LMA over ETT if appropriate
- consider rescheduling surgery for 2-4 weeks or 6-8 weeks if lower resp tract
13
Q
URI is more irritable and at increased risk for
A
- laryngospasm
- bronchospasm
- post-intubation croup
- atelectasis
- pneumonia
- desats
14
Q
reasons to post-pone surgery for URI
A
- elective
- febrile
- elevated WBC
- productive/purulent sputum
- getting worse
- acutely ill
- malaise
- tachypnea
- wheezing
15
Q
anesthetic management with URI
A
- adequate hydration and oxygenation
- reduce secretions
- limit airway manipulation
- bronchodilators (beta-2-agonists) for wheezing
- anticholinergics (inhibits cholinergic mediated bronchospasm)
- muscle relaxants for laryngospasm
16
Q
what symptoms combined with a murmur might mean something more
A
- difficulty feeding, SOB
- poor exercise tolerance, can’t match peers
- family history of CHD
- cyanotic episodes
- abnormal peripheral pulses
- unequal blood pressures in upper vs lower extremities
17
Q
oral premedication
A
- individualize (not everyone needs it esp <6-12 months because they don’t get separation anxiety)
- may prolong time to discharge
- midaz 0.5 mg/kg PO max 20 mg
- careful sedating child with congenital heart defect, increased ICP, OSA, sepsis, trauma, or suspected difficult airway
18
Q
nasal premeds
A
- midaz 0.2 mg/kg
- ketamine 3 mg/kg
- precedex 1-2 mcg/kg
19
Q
set-up and monitoring
A
- BP cuff (appropriate size)
- ECG (often 3 lead, but 5 for cardiac patients)
- pulse ox
- capnography
- temperature
- neuromuscular function
- temperature
20
Q
prep for induction of anesthesia in peds
A
- warm room
- pre induction checklist
- chair or stool if parent is present
- ensure quiet, calm OR
- variety of techniques exist
21
Q
set up of peds case
A
- mask x2-3 (one bigger/one smaller)
- ETT x3 (onse size above and below)
- blades (several)
- appropriately sized breathing circuit, BP cuff, ECG, SpO2
- appropriate syringe sizes for weight based dosing
- IM needles (for succ and atropine)
- warming devices
- shoulder roll
- sevo in line and filled
- IV set ups
- soft ETT suction appropriate for ETT size
- appropriate sized OGT
22
Q
LMA size 1
A
neonate/infant up to 5 kg
max cuff volume 4 mL
23
Q
LMA size 1.5
A
infant 5-10 kg
cuff volume 7 mL
24
Q
LMA size 2
A
infants/children 10-20 kg
cuff volume 10 mL
25
LMA size 2.5
children 20-30 kg
| cuff volume 14 mL
26
LMA size 3
children 30-50 kg
| cuff volume 20 mL
27
LMA size 4
adults 50-70 kg
| cuff volume 30 mL
28
premie ETT size
2-2.5 mm uncuffed
29
term infant ETT size
3 mm
30
3-9 months ETT size
3-3.5 mm
31
9-18 months ETT size
3.5-4 mm
32
18-36 months ETT size
4-4.5 mm
33
>36 months ETT size
age/4 + 3.5 = cuffed size
34
ETT depth calculation < 3 kg
1-2-3 kg --> 7-8-9 cm depth at lips
35
ETT depth calculation > 3 kg
internal diameter of ETT (ID) x 3
36
emergency meds for peds case
- atropine --> 0.4 mg/mL [<10 kg place in 1 cc syringe; > 10 kg place in 3 cc syringe]; with 22G IM needle
- succ - 20 mg/mL in 3 cc syringe; 22G IM needle
- epi - 100 mcg/mL (abboject), 10 mcg/mL, 1 mcg/mL (for neonates)
37
pediatric breathing circuits
- small enough for sensitivity to small tidal volume
- big enough to give a vital capacity breath
- neonatal circuit
- peds circuit 1 L bag < 30 kg
- adult circult 3 L bag > 30 kg
38
inhalation induction
- most common method of inducing anesthesia in kids
- sevo = agent of choice
- paci OK to leave in
- OK to have child lay down, sit up, or sit in someones lap
- mask gently placed over child's face, with admin of N2O and O2 for 1-2 minutes, sevo introduced and rapidly increased to 6-8%
- after GA induced, sevo should be decreased to around 4-5% to prevent OD
- IV then placed following stage 2 and prior to instrumentation of airway; consider 100% FiO2 during IV (ie d/c the nitrous)
39
mask induction aids and distraction techniques
- scented mask
- bubble
- playing video games or watching a movie
- use of elbow without a mask and tenting with the hand
- music
- jokes
- steal induction in asleep child
- single-breath induction
40
IV induction for peds
- most reliable and rapid
- main disadvantage is starting IV can be painful and traumatic for child (reserved for age 8 or older)
- necessary when inhalation induction is contraindicated
- may place IV under N2O
- topical anesthetic (EMLA, or spray)
- ideally all children preoxygenated with 100% oxygen before IV induction, but this is not always possible
41
when to do IV induction
- at risk for aspiration requiring RSI (full stomach)
- anticipated difficult airway
- potential cardiac instability
42
intramuscular induction
- preferred that all IM injections are avoided in kids
- may be indicated in uncooperative children who refuse other routes of sedation
- also may need rescue meds if patient develops laryngospasm during inhalation induction
43
infant IM max recommended volume
- deltoid - not recommended
| - vastus lateralis - 0.5 mL
44
toddler IM max recommended volume
- deltoid - 0.5 mL
| - vastus lateralis - 0.5-1 mL
45
preschool age IM max recommended volume
- deltoid - 0.5 mL
| - vastus lateralis - 1 mL
46
school age IM max recommended volume
- deltoid - 0.5-1 mL
| - vastus lateralis - 1.5-2 mL
47
mask anesthesia
- always have age and size appropriate equipment for intubation/LMA placement
- appropriately sized mask
- oral airways and tongue blade
- avoid applying pressure over soft tissue of the chin and neck during mask anesthesia
- monitor breath sounds, ETCO2, movement of reservoir bag
- precordial!!!!
48
two most commonly used veins for IVs in kiddos
- superficial dorsal hand veins off the basilic vein
| - saphenous vein at the ankle
49
IV catheter sizes for art lines
- 22g for > 2 years
| - 24g for < 2 years
50
caudal anesthesia
-caudal space, continuous caudal catheters
51
benefits of caudal
- intraop and postop analgesia
- reduction in systemic opioid requirements and side effects
- reduction in anesthesia requirements
52
procedures that could use a caudal
- circumcision
- inguinal hernia repair
- hypospadias
- anal surgery
- clubfoot repair
- other sub umbilical procedures
53
contraindications to caudal
- infection around the site
- coagulopathy
- anatomic abnormalities
- parental refusal
54
caudal landmarks
- sacral hiatus
| - 2 posterior superior iliac spine (PSIS)
55
caudal dosing
- genital and anal surgery = 0.5-0.75 mL/kg
- lower abdomen, extremity = 1 mL/kg
- abdominal incision = 1-1.25 mL/kg
56
caudal additives
- epi --> intravascular test dose 0.5 mcg/kg; increase duration; theoretical neurologic complications
- clonidine --> 1-2 mcg/kg; increase DOS
- narcotics
57
things to bring when taking peds patient to PACU
- appropriately sized ambu bag
- oxygen source
- monitoring (pulse ox, ECG, BP)
- emergency meds (at the least atropine, succ, epi)
- pain meds
- treatment for emergence delirium (precedex, propofol, fentanyl)
- lateral position
