Test 3 Flashcards
(204 cards)
1
Q
Children have _____ protein binding compared to adults
A
Lower
2
Q
Pediatrics have ______ volume of distribution
Results in what adjustment to water soluble drugs
A
Larger Vd
Larger loading dose of water soluble
3
Q
4 ways children pharmacokinetics differ from adults
A
- lower protein binding
- larger volume of distribution
- smaller proportion of fat and muscle
- immature renal and hepatic function
4
Q
Lipid soluble drugs have ______ volume of distribution in infant compared with adult
A
Smaller
5
Q
What drugs have larger volume of distribution in infant compared with adult?
What have smaller Vd?
A
Larger Vd- water soluble drugs
Smaller Vd- lipid soluble
6
Q
Some medications may displace bilirubin from protein binding site predisposing infant to
A
Kernicterus
7
Q
2 reasons why neonate require a higher dose of succinylcholine compared to adults
A
Larger volume of distribution
NM junction in neonates are immature (more resistant)
8
Q
Neonates require how much succinylcholine on body weight basis than older children/adults
A
Twice as much
9
Q
Neonates and nondepolarizing NMB
A
Neonates are more sensitive to NDNMR
10
Q
Mechanism of neonates requiring same dose of nondepolarizers as adults on weight basis
A
- greater sensitivity
- greater Vd
Balances out
11
Q
Sensitivity of human neonates to most sedatives, hypnotics, and narcotics is partly related to
A
Increased brain permeability
Immature BBB
Also incomplete myelination
12
Q
Incomplete myelination in infants results in
A
Easier for drugs that are not lipid soluble to enter brain at greater rate than if BBB intact
13
Q
3 reasons volatile concentration increases more rapidly in alveoli in children than adults
A
- high level alveolar ventilation in relation to FRC
- higher proportion of vessel-rich tissues that rapidly equilibrate with blood levels
- lower BGP of volatile in infants
14
Q
Excretion/recovery of inhaled anesthetics is ______ in children than adults
A
Faster
Quick on- Quick off
15
Q
Why should N20 be avoided in laparoscopic surgery?
A
Avoid expanding CO2 bubbles that reach venous circulation
16
Q
To speed up induction and emergence with volatiles do what
A
N20
Second gas effect
17
Q
Examples of gas filled cavities within the body that are vulnerable for expansion if N20 is used (5)
A
Bowel obstruction
Pneumothorax
Cuff of ETT
LMA
Bubbles in veins
18
Q
Factor identified in causing retinopathy of prematurity
A
Hyperoxia
19
Q
Retinopathy of prematurity occurs in infants weighing ______
Or __________ weeks gestation
A
Less than 1500gm
Less than 28 weeks gestation
20
Q
It is recommended to blend air with 02 to maintain sat _______
A
90-95%
21
Q
However while avoiding hyperoxia, one must not lose sight of importance of _____________
A
Avoiding hypoxemia
22
Q
Check for negative Hcg before any medication to girl who has reached
A
12 years of age
Or younger if post-menses
23
Q
Why isoflurane not appropriate for inhalation induction
A
Pungent odor
Irritates airway reflexes (causes laryngospasm, breath-holding, coughing, etc)
24
Q
Rapid increase of Iso concentration effects on CV profile
A
Decreased BP, HR, RR
Especially with hypovolemia
25
Iso and des react with desiccated soda lime or baralyme to release
Carbon monoxide into breathing circuit
26
Why Desflurane not suitable for inhalation induction
Very pungent odor
Irritant to airway
27
Emergence from des
Very rapid
May cause delirium if pain present especially
28
Risk of emergence delirium is increased when
If pain not well controlled
High levels of sevo given throughout the case
29
Dissociated state of consciousness in which children are inconsolable, irritable, uncompromising, and/or uncooperative
Emergence delirium
30
Highest incidence of emergence delirium occurs in children of what age
1-5 years of age
31
Appropriate________ often attenuated emergence delerium
Pain relief
32
Sevo hydrolyzed to _______ in presence of soda lime/baralyme
Compound A (potentially nephrotoxic)
33
Triggers for malignant hyperthermia
All potent volatile anesthetics
Succinylcholine
34
Why did FDA issue black box warning against routine use of succinylcholine in children
Several case reports of
- hyperkalemic cardiac arrest
Esp in children with undiagnosed duchenne muscular dystrophy
35
Duchenne muscular dystrophy more common in
Male children under 8 years old
36
Use of succinylcholine in peds should be reserved for
Emergency intubation
Laryngospasm
37
When to avoid succinylcholine in children
- eye trauma (increases IOP)
- burns
- massive trauma
- major neurologic disease
- renal failure compounded by neuropathy
38
Single dose of succinylcholine can cause _____ in children
Prevention
Bradycardia and asystole
Tx. Atropine 10-20mcg/kg IV or 20-40mcg/kg IM before succ
39
Infusion rate for propofol in children compared to adults
Higher in children
40
Neonates are __________ sensitive to barbiturates due to
More sensitive
Reduced protein binding
41
Contraindicated in patients with porphyria
Barbiturates
42
Barbiturates should be administered with extreme care in patients which are
Hypovolemic
Limited cardiac reserve
43
Reduces IOP and ICP
Thiopental
Good for neurosurgical and ocular procedures
44
Hypersalivation with ketamine increases risk of
Laryngospasm
Give antisialagogue
45
Why ketamine not used for neuro or eye cases
Increases CBF, ICP, CMRO2, IOP, nystagmus movement
46
Ketamine has high incidence of emergence phenomena (hallucinations, bad dreams, frank psychosis)
How do you prevent
Midazolam intraop
47
Dexmedetomidine is selective A2 agonist
Why good for sg
Decreases sympathetic tone
Attenuates stress response to anesthesia and surgery
Causes sedation and analgesia
48
Steroid based hypnotic induction agent
Etomidate
49
Why Etomidate mostly avoided
- risk of anaphylactoid reaction
- suppression of adrenal function
- inhibition of steroid synthesis
50
Patient population Etomidate is useful
Head injury
Unstable CV status (cardiomyopathy)
51
Fentanyl is ______ lipid soluble
Effect on BBB
Highly lipid soluble
Crosses BBB rapidly
52
Dilaudid peds prep and administration
Dilute 1 mg in 10ml syringe (100mcg/ml)
Initial dose 10mcg/kg
Titrated 5-10mcg/kg during case
53
Hydromorphone is not appropriate for
Infants and children <2 yo
54
Morphine and neonates and infants
Ventilatory depressant effects more in neonates and infants
55
Ventilatory depressant effect of morphine on neonates and infants due to
Increased permeability of BBB
Less predictable clearance of morphine
56
Adverse effects of morphine
Histamine release causes hypotension, sedation, PONV
57
Sufentanil not appropriate for
Infants and small children for same day surgery with planned discharge home
58
Adverse effects of sufentanil
Respiratory depression
Chest wall rigidity
59
Remi should be continuous infusion only
If bolus see
Severe bradycardia and hypotension
60
S/S widrawal
Crying
Hyperactivity
Fever
Tremors
Poor feeding
Poor sleeping
Extreme cases:vomiting and convulsions
61
Primary indication for methadone in children
Wean from long-term opioid infusions
Prevent withdrawal
Provide analgesia when other opioids have failed
62
Methadone protein binding
Main determinant of free factor of methadone
60-90%
Alpha 1- acid glycoprotein
63
Methadone in children
Large Vd
High plasma clearance
Long half life
64
Midazolam enhances what type of amnesia
Antegrade
65
Analgesic and antipyretic drug without anti-inflammatory actions
Acetaminophen
66
NSAID with very potent analgesic properties
Ketorolac
67
Ketorolac avoided in
Children <2
68
Caution with toradol in what patients
Renal (reduced renal BF)
Asthmatics (allergic reaction)
69
Major concern with toradol
Inhibition of platelet function through inhibition of cyclooxygenase
70
Difference in ASA and Toradol on platelet inhibition
Toradol platelet inhibition is reversible
Gone when drug excreted
71
Toradol in TB syringe
Each ml has ______mg
3MG
72
Narcan prep
Dilute a vial (0.4mg/ml) in 10cc syringe
40mcg/ml
73
Side effects of Narcan
Systemic HTN
Cardiac arrhythmia (VF)
Noncardiogenic pulmonary edema
74
Specific GABA receptor competitive antagonist
Flumazenil
75
Flumazenil reverses effects of
Benzodiazepines
76
Which more sensitive to Roc neonates or infants
Neonates
77
Elimination of Cisatracurium
Hoffman elimination and ester hydrolysis
78
Nondepolarizer NMB are prolonged with
Tobramycin
Neomycin
Gentamicin
Hypothermia
79
Because some Down syndrome children have ________ administer atropine cautiously
Narrow angle glaucoma
80
Used for prophylaxis and treatment of PONC and reduce severity of established NV
Zofran
81
Children < ______ dont require antiemetic in general
24 months of age
82
Avoid dexamethasone in patients with
Newly diagnosed leukemia/lymphoma
Hematologic malignancy
83
LA
Amides degredation
In liver by cytochrome P450
84
LA esters degredation
Hydrolyzed by plasma cholinesterases
85
Epi prep and admin for bronchospasm
Dilute to 10mcg/ml
1-2mcg/kg IV
86
Nebulized racemic epi dose
<2
>2
<2- 0.25ml 2.25% in 3ml NS
>2- 0.5ml of 2.25% in 3 ml NS
87
Zosyn bag concentration
3.375mg/50ml
67.5mg/ml
88
What is the most prominent muscarinic action of bolus of succinylcholine in pediatric patient?
How to prevent?
Bradycardia
Atropine before succinylcholine
89
2 year old develops laryngospasm postop and becomes bradycardic. Should atropine be given prior, concurrently, or after succinylcholine
Atropine then succ
Succ can precipitate more bradycardia, junction alone rhythm, arrest
90
How much NDNMB does beds patient require compared to adult on weight basis?
Succinylcholine
NDNMB- same dose
Succinylcholine- twice as much in neonates
91
Infant has greater sensitivity to NDNMB than adult why dose the same as adult?
Greater Vd balances out increased sensitivity
92
2 reasons neonates require more succinylcholine on mg/kg basis than adults
Larger Vd
NM junction immature (less sensitive)
93
Define ED90. Is EF90 for succinylcholine increased, decreased, or unchanged in neonate compared with adult. Interpretation
- ED90- dose of drug effective in 90% of population
- ED90 for succinylcholine increased in neonates than adults
- larger dose given to neonate for adequate paralysis
94
How would ED95 for succinylcholine compare between neonate and adult?
Neonate ED95 would be greater
95
4 reasons neonates and infants are more resistant to succinylcholine than older children and adults
- faster clearance
- larger Vd
- shorter onset time
- ED95 2-2.5 times greater than adult
96
Compare action of Vec in infant and adult. Potency, onset, duration, and recovery
Similar potently
More rapid onset
Longer duration of action
Recovery slower
97
Definitive treatment for succinylcholine induced hyperkalemia
IV calcium
- calcium chloride 10mg/kg
- calcium gluconate 30mg/kg
98
How does calcium work for hyperkalemia treatment
Restores gap between RMP and TP of cardiac cells
99
4 steps to treat hyperkalemia in neonate
Calcium chloride/gluconate
Hyperventilation, sodium bicarb, beta agonist
Insulin/glucose infusion
Kayexalate or dialysis
100
How does infant quantity of plasma proteins, body fat, and muscle differ from adult
Reduced in infant
Decreased plasma proteins = more free drug to produce clinical effects
May need lower dose
101
3 reasons why uptake of anesthetic drugs typically faster in children than adults
- higher alveolar ventilation per weight
- increased cardiac output with greater distribution to vessel rich group w/ lower muscle mass = more agent conentration in vital organs (brain)
- less blood soluble in children (work faster)
102
2 most important reasons why children induced faster than adults with inhalation agents
Smaller FRC per unit of body weight
Greater blood flow to brain
103
N20 should be avoided in which pediatric procedures
Diaphragmatic hernia
Bowel obstruction
Pneumoencephalography
Tympanoplasty
Congenial emphysema
Lung cyst
Pneumothorax
Necrotizing enterocolitis
PDA
Omphalocele repair
104
Most common type of delirium in children
Emergence delirium
Occurs within minutes of regaining consciousness
105
Don’t give ______ to patient having T&A
Toradol
106
Fetal formation of diaphragm completed during
7-10th week gestation
107
Congenital diaphragmatic hernia is result of
Intrusion of abdominal viscera into thoracic cavity
108
Majority of congenital diaphragmatic hernias are which type
90% posterolateral Bockdalek-type hernia
109
Hallmark of congenital diaphragmatic hernia and cardiopulmonary sequelae is
Abnormal compression of pulmonary structures
110
Result of congenital diaphragmatic hernia is
Lung growth is severely retarded
Underdeveloped proximal airway divisions and supporting PA vasculature
Fewer fx alveolar units
Deficiency of surfactant
Alveolar instability
Atelectasis
Intrapulmonary shunting of deoxygenated blood
111
Congenital diaphragmatic hernia often manifests as severe respiratory distress in neonate. A direct consequence of
Lung hypoplasia
Inadequate pulmonary gas exchange
112
Priority at birth with congenital diaphragmatic hernia is
Airway control
113
Airway control and management with congenital diaphragmatic hernia includes
Avoid mask ventilation
Rapid low TV
Limited PIP
114
When is surgical diaphragmatic hernia repair performed
Delayed until neonate optimized
115
Treatment for hypertrophied pyloric stenosis
Surgical pylori-myo-tomy
116
When does hypertrophied pyloric stenosis manifests when with what symptoms
2nd to 6th week of life
Nonbilirous vomiting
117
With protracted vomiting these infants may become
Hypokalemic
Hypochloremic
Alkalotic
118
Renal response to vomiting
Serum pH initially normalized by excretion of alkaline urine with Na and K loss
After lytes depleted kidneys excrete acidic rinse further increasing metabolic alkalosis
119
With further fluid loss prerenal azotemia may foreshadow _____ and _____
Hypovolemic shock
Metabolic acidosis
120
Before pyloric stenosis patient comes to OR needs what
Intravascular volume stabilized
Electrolytes WNL
121
Induction of pyloric stenosis patient
Treated as full stomach
Before RSI 100mcg Atropinie and suction with OGT in different positions
RSI with cricoid pressure
122
Emergence/extubation of pyloric stenosis patient
Fully awake
May have sluggish breathing drive
123
Pyloric stenosis patients often have sluggish “breathing drive” due to what
Metabolic alkalosis
124
Necrotizing entercolitis is not an anomaly but a _____ found in _____
Illness found in mainly preterm infants
125
Systemic effects on necrotizing entercolitis
Severe hypotension
Hemorrhage
DIC
126
XRay with necrotizing entercolitis
Initially suggests lleus
After perforation will show “free air” in intestine
127
Mobility associated with NEC includes
Short bowl syndrome
Sepsis
Adhesions ass with bowel obstruction
128
Omphacele
Intestines are
Defect is where
Intestines are COVERED with amnion
Defect at base of umbilicus
129
Gastroschisis
Intestines are
Defect is
Intestines are NOT COVERED (exposed to hypothermia, infection, dehydration)
Defect is periumbilical
130
Failure of gut to migrate from yolk sac into the abdomen during 5th-10th week gestation
Omphacele
131
Develops as a result of occlusion of omphalomesenteric artery during 12-18th week gestation
Gastroschisis
132
Which is later defect with less problems
Gastroschisis
133
Which is earlier defect associated with additional abnormalities
Omphacele
134
Omphalocele is associated with
Genetic, cardiac, urology, and metabolic abnormalities
135
Esophagus ends in blind pouch and associated with tracheoesophageal fistula
Esophageal atresia
136
Most common form of esophageal atresia
Dilated proximal esophageal pouch
Fistula between distal trachea and esophagus
137
Second most common esophageal atresia consists of
Esophageal atresia alone
138
Neonates with tracheoesophageal fistula alone often present with what as initial manifestation
Pneumonia
139
Neonates affected with esophageal atresia with TEF present with
Excessive oral secretions
140
Feeding of neonates with esophageal atresia with TEF leads to
Choking
Coughing
Cyanosis
- hypoxia and bradycardia-
141
Induction of pt with esophageal atresia with TEF
Avoid positive pressure ventilation prior to induction
Fiberoptic intubation- right mainstem and withdraw tube slowly until bilat breath sounds but below the fistula
142
ETT tip in esophageal atresia with TEF
Just above carina and below the fistula
143
After repair of esophageal atresia with TEF avoid
instrumentation of esophagus and extension of head
***increased risk of repair rupture**
144
Esophageal atresia often associated with other congenital abnormalities
In particular VATER syndrome (parts)
Vertebral abnormalities
Imperforated anus
CHD
TEF
Radial aphasia/renal abnormalities
Limb abnormalities
145
Epiglottitis is ______ usually affecting children of what age
Life threatening infection
1-7 years old
146
S/S epiglottitis
Upper airway obstruction with INSPIRATORY STRIDOR, tachypnea, retraction
147
On XRay, pt with epiglottitis have what sign
Thumb sign of epiglottis
148
Avoid inspection of epiglottis in ED. Intubation of pt with epiglottitis
DL with tip of blade in vallecula
Do not directly touch epiglottis
Downsize ETT by 0.5mm
Airway dose of IV dexamethasone 0.5mg/kg
149
When do you extubate with epiglottitis
After 24-96 hours
Confirm lead amount ETT, signs of swallowing
Preferably done in OR
150
Laryngotracheobronchitis aka
Croup
151
Croup is
Infection of upper airway
152
Characteristic of croup
Seal-like barking cough
153
XRay with croup shows
Steeple or pencil sign of proximal trachea
154
Croup occurs mostly in children of what age
Cause
Onset
6mo-6yo
Viral cause
Onset insidious with low grade fever
155
Initial treatment of croup
Inhalation of racemic epi nebulizer with O2 and cool humidity
156
A history of ______ must arouse suspicion for foreign body aspiration
Choking and cyanosis while eating
157
Myelomeningocele aka
Spina bifida
158
Protrusion of meninges filled with CSF through a gap in the spine
Meningocele
159
Protrusion containing portion of spinal cord, meninges, and CSF with no function below level of lesion
Myelomeningocele
160
Spina bifida usually accompanies by
Varying degree of paralysis of lower extremities
Musculoskeletal defects
Anal and bladder sphincter dysfunction
Latex prophylaxis
161
Hydrocephalus with myelomeningocele is frequently related to the _____
Most common anomaly associated with spina bifida
Arnold-chiari malformation
162
Chiari malformation type 1
Neurologic disorder where brain, cerebellar tonsils descend out of skull into spinal area
Aka hindbrain herniation
163
Anesthesia considerations with spina bifida
Potential for infection of CNS dictates early closure (first 12-24 hours of life)
Special positioning during induction and surgery (lateral induction)
Post op remains intubated and prone
164
What is Arnold-Chiari malformation?
Malformation consisting of elongated cerebellar vermis that herniated through foramen magnum and compresses brain stem
165
4 symptoms of Arnold-Chiari malformation
Difficulty swallowing
Recurrent aspiration
Stridor
Possibly apneic episodes
166
In patient with congenital diaphragmatic hernia, which lung usually involved?
Left side through foramen of Bochdalek
80% of cases
LEFT LUNG
167
Is infant with diaphragmatic hernia with bowel extending into chest and emergency?
Yes. It is an emergency
168
7 anesthetic considerations for managing infant with diaphragmatic hernia with bowels extending into chest
Place NGT
No positive pressure ventilation with mask
Intubate with controlled ventilation
No N20
Monitor PaCO2 and SaO2
100% O2
Give relaxants and opioids after chest opened
169
During intraoperative period of congenital diaphragmatic hernia repair, SaO2 suddenly falls to 65% and HR decreased to 50 bpm. What is like cause and what should be done?
Any sudden deterioration in lung compliance, HR, sat, or BP suggests TENSION PNEUMOTHORAX on contralateral side
Confirmed with absent or diminished breath sounds
Insert chest tube immediately
170
What serum sodium, potassium, and chloride concentrations and what UOP needed before surgery in patient with pyloric stenosis?
Na >130 mEq/L
K >3 MEq/L
Cl > 85 mEq/L
UOP 1-2 ml/kg/hr
171
Is pyloric stenosis a medical or surgical emergency?
Medical but not surgical emergency
Surgery postponed 24-48 hours until fluid and electrolyte abnormalities corrected
172
The newborn has undergone a pyloromyotomy. What might you be concerned about in postoperative period?
Increased risk for respiratory depression and hypoventilation in PACU due to persistent metabolic or CSF fluid alkalosis
173
What PIP should be used with patient who has a diaphragmatic hernia? Why?
PIP < 30 cm H20
Pneumothorax of contralateral (usually right) lung if PIP too high
174
What might be signaled by sudden fall in lung compliance ( increased PIP), BP, or oxygenation during repair of congenital diaphragmatic hernia?
Contralateral (usually right sided) pneumothorax
175
What acid-base and electrolyte abnormalities develop in the patient with pyloric stenosis?
Metabolic alkalosis
Hypochloremic
Hypokalemic
Hyponatremic
**dehydrated with hypokalemia, hypochloremic alkalosis**
176
Neonate is diagnosed with pyloric stenosis presents with NA of 120, CL or 84, RR 16. What is appropriate course of action for this patient?
Moderately severe electrolyte abnormalities.
Give D51/2NS with 20-40mEq K at rate of 10ml/kg/hr
Avoid LR- metabolized to bicarbonate
177
What happens to oxyhemoglobin dissociation cure in pyloric stenosis? Why?
Shifts to left
Metabolic alkalosis secondary to vomiting
178
How is infant with pyloric stenosis prepared for surgery?
Stop oral intake
Metabolically reconstitute with IV Na, Cl, K, glucose
Correct in 12-24 hours
Surgery postponed 24-48 hours
179
What is major concern for inducing and infant scheduled for pyloromyotomy? What do you need to do before inducing a patient with pyloric stenosis?
Pulmonary aspiration is major concern during induction
Empty stomach as much as possible with large bore catheter prior to induction
180
What are 6 primary considerations for pediatric patient with hypertrophic pyloric stenosis?
Postpone sg until lytes corrected
Correct volume deficit and metabolic alkalosis with NaCl solution with K
Do not use LR
Empty stomach before sg
High risk of aspiration with induction
Anticipate postop respiratory depression r/t CSF alkalosis
181
What 2 electrolyte abnormalities seen with projectile vomiting
Hypokalemia
Hypochloremia
182
Gastroschisis
Location
Hernial sac
Associated congenital anomalies
Lateral to umbilicus
Hernial sac absent
No associated congenital anomalies
183
Omphalocele
Location
Hernial sac
Associated congenital anomalies
Located at base of umbilicus
Hernial sac present
Associated congenital anomalies (downs, cardiac anomalies, diaphragmatic hernia, bladder anomalies)
184
Perioperative management of gastroschisis and omphacele center around what 3 preventative measures?
Prevent:
Hypothermia
Dehydration
Infection
185
In which disorder (gastroschisis or omphalocele) are hypothermia, dehydration, and infection most serious? Why?
Gastroschisis because hernial sac is absent
186
Where is fistula usually locked in patient with TEF (tracheoesophageal fistula)?
90% lower segment of esophagus inserts just above carina on posterior wall of trachea
187
Where is proper placement of ETT in patient with TEF? Procedure for intubating patient with TEF
Tip just distal to TEF (bw carina and fistula)
Enter until mainstem, withdraw slowly until bilateral breath sounds present
188
Key to successful anesthetic management of neonate with TEF is correct positions of ERR. What is important consideration for intubating the infant with a TEF? What intubation techniques are appropriate?
Avoid positive pressure ventilation.
Use inhalation induction followed by topical application of lidocaine while infant spontaneously breathing
Or
IV or inhalation induction and intubate with paralysis. (May lead to distinction of fistula and stomach after onset of positive pressure ventilation)
189
What is tracheomalacia? What patients are at risk for developing tracheomalacia
Tracheobroncomalacia
Softening of tracheal tissue, esp cartilaginous rings
Often associated with TEF or extrensic compression by vascular anomalies or mediastinal masses
May be associated with hyperthyroidism
190
What is etiology of epiglottitis
Due to life-threatening infection by Haemophilus influenza type B bacteria
191
9 S/S of epiglottitis
Upper airway obstruction
Inspiratory stridor
Chest retractions
Tachypnea
Cyanosis
Drooling
Difficulty swallowing
Insists on sitting and is restless
192
Children of what age get epiglottitis
1-7 years old
Occurs with greater frequency in children less than 3 years of age
193
Where is optimal hospital location for intubation of patient with epiglottitis? Why?
Intubation in OR
Total obstruction of airway could occur at any moment
An attempt to visualize the epiglottis should not be taken until child is in the OR where intubation of trachea and possible emergency tracheostomy should be performed
194
How is GETA induced in child with acute epiglottitis?
Parents should be present until airway secure
Quiet OR, monitors applied at least pulse ox
100%O2/Sevo with pt in sitting position
Start IV, give fluids and atropine.
Orally intubate
NO MUSCLE RELAXANTS
Avoid touching epiglottis with blade
Bronchoscope if needed
Tracheostomy performed if all fail
195
What induction agent and what endotracheal tube size should be used in patient with epiglottitis?
Inhalation induction followed by intubation with ETT 1/2 to 1 size smaller than usual
196
How long might one expect the ETT to be left in place in patient with epiglottitis? What is one signal suggesting it is time for extubation?
ETT left for 24-96 hours
Air leak appears around ETT signals possibility of extubation
197
Where and when should patient with epiglottitis be extubated?
Extubation performed only in OR after DL confirmed resolution of swelling of epiglottitis
198
What is usual cause of croup (laryngotracheobronchitis)?
Viral
199
3 treatments for postintubation laryngeal edema (post intubation croup)
Aimed at reduction in airway edema
Cool, humidified O2 with face tent
Aerosolized racemic epi
IV dexamethasone (4-6 hours to manifest)
200
What is pathogenesis of post-intubation croup? 6 risk factors for post-intubation croup?
Due to glottis or tracheal edema
Associated with:
- early childhood (<14yo)
- repeated intubation attempts
- large ETT
- prolonged surgery
- head and neck procedures
- excessive movement of ETT
201
Appropriate treatment for post-intubation croup?
Inhalation of nebulized racemic epinephrine
IV dexamethasone
202
What causes myelomeningocele? Difference between meningocele and meningomyocele?
- caused from failure of neural tube to close in fetus during development. Results in spina bifida
Meningocele is a sac containing only meninges
Meningomyocele is sac present containing meninges and neural elements
203
7 year old patient with spina bifida comes to OR for VP shunt. What is primary concern?
- high probability of latex allergy, may trigger anaphylactic reaction in OR
- 18-34% of spina bifida patients have a latex allergy
- most children with intraoperative anaphylaxis had spina bifida
204
Which type of shock is most frequent in pediatric patient?
Hypovolemic shock
- often due to blood loss from trauma
- children may lost 1/4 of blood volume without significant CV changes in supine position
- hypovolemic shock due to plasma loss can be seen with burns and peritonitis and may be a component of septic shock
