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Test 4 Flashcards

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1
Q

Difference between apnea-hypopnea index of adults and peds

A

Peds require much less apnea episodes for diagnosis and increased severity

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2
Q

4 ways to actively cool the patient during acute MH episode

A

Lavage OG, bladder, open cavities

Administer cooled IV saline

Surface cooling

CPB in severe cases

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3
Q

Elements of syndrome similar to MH

Cocaine intoxication

A

Fever

Rigidity

Rhabdomyolysis

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4
Q

Type of craniosynostosis characterized by premature fusion of cranial sutures

A

Type 1

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5
Q

Why is tracheostomy often required for Pierre Robin Sequence

A

Glossoptosis (tongue further back in mouth)

Partial/complete obstruction

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6
Q

Causes of Goldenhar Syndrome

A

Vascular accident in the fetus

Blood supply cur off and clots in area of those tissues develop into the structures of the ear and lower jaw

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7
Q

Is suspicion of MH greater in adults or children

A

Children

1: 10,000 peds
1: 50,000 adults

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8
Q

Anesthetic agents absolutely contraindicated in patients with family history of MH

A

All volatiles

Succinylcholine

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9
Q

Adapter from what size ETT will fit an IV catheter to attach to a breathing circuit

A

3.0 ETT

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10
Q

Why is prilocaine unsuitable for neonates

A

Metabolism to O-toulidine leading to methemoglobinemia

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11
Q

Definition of MH

A

Life-threatening clinical syndrome of hyper metabolism involving skeletal muscle

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12
Q

How long does it take for activated charcoal filter to reduce exposure to volatiles once applied to circuit

A

<90 seconds

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13
Q

Type of cerebral palsy

Tense, contracted muscles

A

Spastic CP

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14
Q

Next treatment steps

A

Administer dantrolene sodium (Ryanodex)

Activated charcoal filters on circuit

TIVA

Hyperventilate

Aggressive IV hydration

Actively cool patient

Aline, central line, foley

Send labs

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15
Q

Drug of choice for MH

A

Ryanodex

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16
Q

MOA of cystic fibrosis

A

Mutant CFTR channel does not move chloride ions causing sticky mucus to build up

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17
Q

3 syndromes associated with Craniosynostosis

A

Apert

Pfieffer

Crouzon

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18
Q

Components of Elma cream

A

Prilocaine

Lidocaine

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19
Q

Why is the half life of ester LAs prolonged in infants

A

Decreased plasma cholinesterase activity

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20
Q

Adults insulin and dextrose dose for hyperkalemia

A

Regular insulin 10 units

50 ml D50

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21
Q

Intubation with Down’s syndrome kid

A

Avoid excessive flexion, rotation, or neck extension

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22
Q

Iced saline dosage for MH

A

10ml/kg every 10 minutes for 30 minutes

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23
Q

Development and intelligence in Treacher Collins

A

Normal development and intelligence

Need early hearing and speech interventions

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24
Q

Which drugs should be avoided in patient with family hx of MH

A

Succinylcholine and volatiles

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25
How fast may temperature increase during MH episode
1-2 degrees Celsius every 5 minutes
26
Sown slanting eyes Lower jaw small and receding Macrostomia Microtia Coloboma
Treacher Collins Syndrome
27
Type of craniosynostosis Cloverleaf shape of skull Hampers normal brain growth Mental retardation
Type 2
28
High incidence of MH in what areas of US
Wisconsin Nebraska West Virginia Michigan
29
Most cases of cerebral palsy are related to what risk factor
Antenatal - prematurity and LBW - intrauterine infections - multiple gestation - pregnancy complications 70-80%
30
Induction of post tonsillectomy bleed patient
RSI
31
Cormack and Lehane laryngoscopic grading system Visualization of just soft palate
Grade IV
32
Neonates do not metabolize which LA
Mepivacaine
33
OSA MOA
Partial or complete collapse of upper airway
34
Skull deformities (premature closure of cranial sutures) Eyes abnormally far apart Fusing or webbing of digits and other abnormalities
Craniosynostosis
35
Unilateral or bilateral underdevelopment of mandible, microtia, reduction in size and flattening of maxilla
Goldenhar Syndrome
36
Max recommended dosage and duration 2-Chloroprocaine
Max 20 mg/kg 30-60 minutes
37
Elements of syndrome similar to MH Serotonergic toxicity is associated with what
SSRI
38
Decrease in airflow lasting > 10 seconds with 30% 02 reduction in airflow and at least 4% desaturation from baseline
Hypoapnea
39
Summation of number of obstructive apnea and hypopnea events
Apnea hypopnea index
40
Children scheduled for T&A have high incidence of
Airway reactivity Laryngospasm
41
Primary triggers for MH
Succinylcholine All volatile agents
42
Down syndrome are at increased risk of
Post intubation stridor Hypothyroidism Atlanto-occipital instability
43
Force diuresis with prevention of ARF with MH want UOP of what
2ml/kg/hr
44
Narrowing of upper airway and indication of impending upper airway closure
Flow limitation
45
Major advantage of electrocautery with adenotonsillectomy
Reduction in intraop blood loss And post op primary and secondary hemorrhage
46
Analgesia from Bupivacaine can last how long in peds
Up to 4 hours Less in small infants
47
Initial steps in treating MH
Call for help DC triggering agent Hyperventilate with 100% O2 Notify surgeon, anesthesia team, nursing Ask for MH cart
48
Why might 2.5mg/kg dantrolene be administered to a patient preoperatively
To prevent, prophylactically an episode of MH
49
Single palmar crease
Simian crease
50
Max recommended dosage and duration Procaine
Max 10 mg/kg 60-90 minutes
51
Type of cerebral palsy Poor sense of balance, often causing falls and stumbles
Ataxic CP
52
Uncontrolled and excessive release of Ca in skeletal muscles leads to
Overwhelms the bodies capacity to supply O2 (HYPOXIA) Elevates CO2 (high ETCO2) Excessive heat production (INCREASED TEMP) Circulatory arrest and death
53
To prevent PONV in child with T&A with OSA
Suction stomach Hydrate well IV airway Decadron dose Zofran
54
3 major features result from Klippel-Feil Syndrome
Short neck Limited ROM in neck Low hairline at back of head ***most have 1 or 2 of these***
55
Simian crease associated with what
Downs Fetal alcohol syndrome Aarskog syndrome
56
Autosomal recessive disorder Disruption of electrolyte transport in epithelial cells
Cystic fibrosis
57
Small mouth Hypoplastic mandible Protruding tongue Possible difficult intubation Atlanto-occipital instability
Downs Syndrome. Trisomy 21
58
Syndromes that share elements of MH
Hyperthyroidism Sepsis Pheochromocytoma Metastatic carcinoid Cocaine intoxication Heat stroke Masseter spasm Neuroleptic malignant syndrome Serotonergic toxicity
59
Supportive therapy for MH
Correct acidosis and hyperkalemia Send labs Monitor for rhabdo, arrhythmia, ARF Prepare for transport to ICU
60
Cormack and Lehane laryngoscopic grading system Visualizaiton of posterior area of cords
Grade II
61
3 concerns related to anesthetizing a downs patient
Possible difficult intubation (large tongue, short neck, small mouth, subglottic stenosis) Atlanto-occipital dislocation Congenital heart disease
62
Conditions where normal tissue in or around the eye (iris, retina, choroid, optic disc) is missing from birth
Coloboma
63
In event of PVC, dysrhythmia, or cardiac arrest with MH assume what
Hyperkalemia
64
Regional anesthesia and pulmonary function in kids having thoracic or upper abdominal procedures
Improves pulmonary function
65
Anesthesia considerations with cystic fibrosis
Anxiolytics Hydrate Nebulized saline pre and post op Humidified circuit High PIP expected Suction ETT under deep GETA AVOID GLYCOPYROLLATE Reverse isolation
66
Late signs of MH
Truncal and/or masseter rigidity Hyperkalemia Arrhythmia Myoglobinuria (coke colored urine) Rhabdomyolysis (increased CPK) Coagulopathy (DIC) MOSF Death
67
You continue giving ryanodex at what dose how often
1mg/kg every 4-8 hours for 24-48 hours
68
Which LA not metabolized in neonates
Mepivacaine
69
Secondary post tonsillectomy bleeding occurs when
5-10 days after T&A Eschar covering tonsillar bed retracts
70
Correction of hyperkalemia Peds
Regular insulin 0.1 unit/kg IV and D50 0.5gm/kg CaCl 10 mg/kg Ca gluconate 30mg/kg Albuterol, kayexelate, dialysis, ECMO
71
Underdevelopment or absence of cheekbones and side wall and floor of eye socket
Macrostomia
72
Primary post tonsillectomy bleeding occurs when
W/i first 24 hours
73
Avoid what drugs with ryanodex. Why
Calcium channel blocking agents Life threatening hyperkalemia may result
74
Children with long standing OSA show what anatomic changes in heart? Can be caused by what?
PA HTN and RVH Can be caused by hypertrophied tonsils
75
Cessation of airflow lasting <10seconds
Apnea
76
Hepatic metabolism of prilocaine makes what
O-toulidine
77
7 early signs of MH
Tachycardia Hypertension Tachycardia Increased ETCO2 Increased O2 consumption Increased temperature 1-2 degrees every 5 minutes Metabolic and respiratory acidosis
78
Who is susceptible to MH
Autosomal dominant trait Ryanodine receptor 1 gene mutation
79
Ester LA half life in infants
Prolonged
80
If you dont have a 3.0 ETT adapter how to you ventilate with cricothyrotomy with needle
3ml syringe attatched to IV catheter Insert 8.0 ETT into syringe barrel Attach to breathing circuit
81
Max recommended dosage and duration Tetracaine
Max 1.5 mg/kg 3-10 hours
82
Patients classified as +3 or greater are at increased risk of what
Developing airway obstruction during anesthetic induction
83
Dose of LA for peds should be based on
Age Physical status Area to be anesthetized Weight by lean body mass
84
Type of cerebral palsy Constant, uncontrolled motion of head, limbs, and eyes
Athetoid CP
85
Major disadvantage of electrocautery with adenotonsillectomy
Greater pain Poor PO intake post-op
86
Amide LA metabolism
Degraded by cytochrome P450
87
Patient with MH crisis has PVCs. What is antiarrythmic drug of choice
Procainamide 15mg/kg IV Or lidocaine
88
At what age is chest palate usually repaired
12-18 months of age
89
T&A performed for what reason
Chronic or recurrent tonsillitis and obstructive adenotonsillar hyperplasia
90
Term to describe group of chronic conditions affecting body movement and muscle coordination
Cerebral palsy
91
Diagnostic test for MH How is it done Is it sensitive
Halothane caffeine contracture test Skeletal muscle biopsy placed in halothane Sustained contraction of muscle is diagnostic Not very sensitive and many false positives
92
Preparations f Ryanodex
Dilute with 5 ml sterile water 250 mg/vial
93
11 clinical manifestations of MH
``` Hypercarbia Tachycardia Tachypnea Hyperthermia Hypertension Cardiac dysrhythmias Acidosis (metabolic) Hyperkalemia Skeletal muscle rigidity Myoglobinuria Hypoxemia ```
94
Earliest sign of rhabdo is
Myoglobinuria/myoglobinemia
95
Type of craniosynostosis Similar to type 2 but cloverleaf skull not present
Type 3
96
Most common form of sleep-disordered breathing
Obstructive sleep apnea
97
Chronic airway obstruction with tonsilar hyperplasia results in
OSA CO2 retention Cor pulmonale Failure to thrive Swallowing disorders Speech abnormalities
98
Type 1 craniosynostosis Other abnormalities Intelligence Survival rate
Recessed cheekbones, finger and toe abnormalities Normal intelligence Significant survival rate
99
Methods to correct acidosis
Hyperventilate Sodium bicarb 8.4%. 1-2 mEq/kg
100
Metabolisms of prilocaine
Hepatic metabolism of prilocaine can lead to methemoglobinemia
101
Children of what gender and with what conditions are more susceptible to MH
69% male Some form of muscular dystrophy or strabismus
102
Tonsilar hyperplasia may lead to what
Chronic airway obstruction
103
How to prevent ARF with MH
IV fluids Force diuresis Bicarb infusion if CPK or K rise
104
How long do MH patients need to be observed in ICU
36 hours
105
Reduced risks of cardiac and neurologic toxicities compared with bupivacaine
Ropivacaine
106
Bone disorder characterized by abnormal fusion of 2 or more cervical vertebrae present from birth
Klippel-Feil Syndrome
107
VACTERL (VATER) syndrome
Vertebral anomalies Anal or intestinal atresia Cardiac anomalies TEF Renal malformations Limb defects
108
Post tonsillectomy bleeding is a
Surgical emergency
109
Max recommended dosage and duration Ropivacaine
2 mg/kg 2-4 hours
110
Children with severe OSA produce what response to opioids
Exaggerated respiratory depression to smaller doses of opioids
111
OSA pt having T&A discharge criteria
With OSA stay overnight with pulse ox and apnea monitor Non OSA stay 6-8 hours for observation
112
Woman in labor is ID as behind susceptible to MH. What anesthetic techniques are acceptable
Epidural without dantrolene pretreatment for routine labor If GETA give dantrolene prophylactically and use non triggering agents
113
Elements of syndrome similar to MH Pheochromocytoma
Difference is marked BP swings
114
Type of cerebral palsy Uncontrollable shaking, interfering with coordination
Tremors CP
115
A patient has just experienced masseter muscle rigidity from succinylcholine. What lab may confirm the diagnosis
Elevated CPK >20,000
116
regional anesthesia considerations in jaundiced neonate
Bilirubin may further reduce potential for protein binding Extends half life of LA
117
Syndromes predicting difficult intubation
Pierre Robin Sequence Treacher Collins Goldenhar Beckwith-Wiedemann Kippel Fiel Apert, Pfieffer, Crouzon
118
When using bipolar electrocautery during adenotonsillectomy
Keep Fi02 low High risk of airway fire
119
Is halothane caffeine contracture test a good diagnostic test for MH Why
No because too many false positives
120
MH episode may not occur with every exposure to trigger agent. Clinical manifestations may depend on (3)
Genetic predisposition Dose of trigger agents Duration of exposure
121
Which more serious primary or secondary post tonsillectomy bleed
Primary more serious More brisk and more profuse
122
Earliest sign of MH
Increased ETCO2
123
Doses of amides should be decreased by how much in infants < 6 months old
Decrease by 30%
124
Cormack and Lehane laryngoscopic grading system Visualization of just epiglottis
Grade III
125
VATER Syndrome growth and development
Small stature Normal development Normal intelligence
126
What size IV catheter for percutaneous cricothyrotomy
12-14 G
127
Once the initial episode of MH is controlled the patient remains at risk for what 5 complications
Reoccurrence DIC Myoglobinuric renal failure Skeletal muscle weakness Electrolyte abnormalities
128
Extubation of T&A
Fully awake Suction stomach and pharynx Have nasal airway in place
129
Cause of cerebral palsy
Damage to one or more specific areas of brain Usually during fetal development
130
Macroglossia Visceromegaly Omphacele
Beckwith-Wiedemann Syndrome
131
Myringotomy and ventilating tube insertion anesthetic plan
GETA Sevo inhalation induction No IV Mask ventilation Intranasal fentanyl
132
Children with cardiac valvular disease and tonsilar hyperplasia
Risk for endocarditis due to recurrent strep bacteremia secondary to infected tonsils
133
Ester LA metabolism
Hydrolyzed by plasma cholinesterases
134
During preop you discover positive family history for MH. What 6 steps should be taken
- standard premeds. Low normal HR - remove vaporizers, change absorbent, Flush 02 at 10l/min for >10 minutes - measure ETCO2 - core body temp measurement - Aline and central line - observe closely in postop period
135
Rapid breakdown of muscle tissue
Rhabdomyolysis
136
Child undergoing surgery with halothane develops tachycardia, increased temperature, and skeletal muscle rigidity. What is drug of choice?
Dantrolene 2.5 mg/kg
137
What syndrome can mimic MH
Neuroleptic malignant syndrome But develops over 24-72 hours
138
Type of cerebral palsy Tight muscles that resist effort to make them move
Rigidity CP
139
Elements of syndrome similar to MH Metastatic carcinoid
Flushing Diarrhea Hypotension
140
MH Uncontrolled and excessive Ca release in skeletal muscles can lead to
Sustained muscle contraction Drastic and uncontrolled increase in oxidative metabolism in skeletal muscle
141
At what body temperature should cooling of MH patient be stopped? Why?
38 degrees Celsius To prevent deleterious effects of hypothermia
142
Max recommended dosage and duration Mepivacaine
7mg/kg 2-4 hours
143
Max recommended dosage and duration Bupivacaine
Max 2.5 mg/kg 3-10 hours
144
Pt with OSA and emergence
Episodes of hypoxia and hypercapnia during sleep impair arousal mechanism at emergence
145
Dantrolene sodium drug class
Ryanodine receptor 1 antagonist
146
Cormack and Lehane laryngoscopic grading system Visualization of complete laryngeal opening
Grade I
147
In almost all cases when do first manifestations of MH occur
In the OR
148
Recommended ester for neonatal regional anesthesia and epidural
2,3 Chloroprocaine (1.5%)
149
Most common type of CP
Spastic
150
Dantrolene MOA
Blocks ryanodine receptors and inhibits abnormal Ca release from SR
151
Increased incidence of intra-abdominal tumors with this syndrome
Beckwith-Widemann Syndrome
152
Block locations with highest to lowest vascular uptake
ICE Block Intercostal Caudal Epidural Block- peripheral nerve blocks
153
What causes time between loss of airway and resultant hypoxemia causing neurologic injury to be significantly diminished in children
Increased metabolic rate Decreased FRC
154
Structural until of myofibril in muscle
Sarcomere
155
Elements of syndrome similar to MH Sepsi
Early normal ABG Late metabolic acidosis
156
Hypoglycemia with visceromegaly
Increased insulin secretion
157
Patients treated with what drugs are susceptible to neuroleptic malignant syndrome
Antipsychotic agents Reflects dopamine depletion in CNS
158
Functions as storage area and release area for calcium in cardiac and skeletal muscle
Sarcoplasmic Reticulum (SR)
159
Intranasal fentanyl dose for myringotomy tube insertions
1-2 mcg/kg
160
Power house of cell
Mitochondrion
161
Hallmarks of cystic fibrosis
Elevated sweat chloride Viscous mucus production Lung disease Intestinal obstruction Pancreatic insufficiency Biliary cirrhosis
162
In person susceptible to MH what gene abnormality present
Ryanodine receptor gene 1 (RyR1)
163
Desaturation of 10kg infant from sat 90% to 0% takes how long
4 minutes Vs 10 minutes in 70kg adult
164
Duration of action of LA is dependent on
Concentration Total dose Site of administration Childs age
165
8 actions for initial management of MH
DC volatile and succinylcholine Hyperventilate Dantrolene Treat acidosis with bicarb Lower body temp Activated charcoal filters, new circuit, new absorbent Monitor capnography and ABG Treat hyperkalemia and dysrhythmia
166
Cleft soft palate (no cleft lip) Micrognathia/retrognathia Glossoptosis
Pierre Robin Sequence
167
Elements of syndrome similar to MH Hyperthyroidism
Minimal ABG CPK abnormalities
168
How do pharmacokinetics of LA differ in children
Rapid absorption Tissue blood flow higher Epidural space has less fat to buffer LA Larger volume of distribution
169
Ryanodex dosage
2.5 mg/kg Repeat as needed up to max of 10 mg/kg
170
Earliest sign of rhabdo
Myoglobin blood test CPK may not rise for several hours
171
How and where does dantrolene work
Acts at ryanodine receptor to decrease calcium level in skeletal muscle by decreasing calcium from SR Skeletal muscle relaxes when Ca supply to contractile proteins impaired
172
Underdeveloped malformed ears
Microtia
173
Bupivacaine dos for peripheral nerve blocks
0.25%
174
Rhabdomyolysis can result in
Damage to kidneys DIC
175
Spontaneous or controlled ventilation in difficult airway
Spontaneous until secure
176
Max recommended dosage and duration Lidocaine
4.5mg/kg 90-200 minutes
177
Does a history of uneventful anesthesia with MH triggering agents rule out susceptibility to MH
NO

Pediatrics (6 decks)

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