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Advanced Principles A (Spring 2024) > Test 4: Pediatric Anesthesia Pt. 2 (Andy's Cards) > Flashcards

Test 4: Pediatric Anesthesia Pt. 2 (Andy's Cards) Flashcards

1
Q

Pediatric PO and IV dose of Versed

A
  • PO: 0.3-0.75 mg/kg up to 15 mg
  • IV: 0.025-0.05 mg/kg
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2
Q

Pediatric IV dose of Fentanyl

A
  • 2-10 mcg/kg
  • Cardiac Cases: 50 mcg/kg
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3
Q

Pediatric IV and IM dose of Atropine

A
  • IV: 0.01 mg/kg
  • IM: 0.02 mg/kg
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4
Q

Pediatric IV dose of Lidocaine

A
  • 1mg/kg
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5
Q

Pediatric IV dose of Glycopyrrolate.

A
  • 5-10 mcg/kg
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6
Q

Pediatric IV dose of Propofol
Pediatric infusion dose of Propofol

A
  • 2-3 mg/kg
  • 50-200 mcg/kg/min
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7
Q

Pediatric IV and IM dose of Succinylcholine

A
  • IV: 2 mg/kg
  • IM: 4 mg/kg
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8
Q

What are the five main causes of pediatric airway management difficulties?

A
  • Inflammatory
  • Congenital
  • Iatrogenic (caused by us)
  • Neoplastic
  • Trauma
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9
Q

What is Croup?

A

A cause of airway obstruction that occurs d/t a viral etiology with swelling and inflammation of the subglottic area of the trachea.

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10
Q

Croup most commonly occurs in children between what ages?

A

6 months to 3 years

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11
Q

What are the symptoms of Croup?

A
  • URI symptoms that progress from stridor to hoarseness
  • “Barky Cough”, they sound like a seal
  • Low-grade fever (100 - 100.4 F)
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12
Q

Medical treatment for Croup

A
  • Comfort position, sitting upright and slightly bending forward
  • Humidified O2
  • Racemic epinephrine nebulized aerosol
  • May consider steroids
  • Intubation is rare
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13
Q

What causes Epiglottitis?

A

Haemophilus Influenza type B

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14
Q

Epiglottis most commonly occurs in children between what age?

A

1-7 years old

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15
Q

Pediatric presentation of Epiglottitis?

A
  • Sitting position, slumped over, drooling
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16
Q

Medical approach and treatment of Epiglottitis

A
  • Establish an artificial airway, using ETT one size smaller, mask induction with Sevo.
  • Fluids and Humidification
  • Racemic Epinephrine
  • Steroids
  • Time
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17
Q

Besides Croup and Epiglottitis, what are other inflammatory causes of difficult pediatric airways?

A
  • Retropharyngeal Abscess (usually from dental procedures)
  • Bronchiolitis
  • Asthma
  • Pneumonia
  • Foreign Body Aspiration
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18
Q

What are the congenital causes of difficult pediatric airways?

A
  • Syndrome of craniofacial abnormalities
  • Downs Syndrome
  • Beckwith-Weideman Syndrome
  • Goldenhar Syndrome
  • Pierre Robin sequence
  • Juvenile RA
  • Congenital neck masses
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19
Q

Anesthesia considerations for Downs Syndrome patients

A
  • Large tongue
  • a small mouth
  • Atlantoaxial instability
  • Inhalation induction bradyarrhythmias
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20
Q

What are iatrogenic causes of airway management difficulties in pediatrics?

A
  • Post-intubation croup
  • Laryngospasm
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21
Q

What is the most frequent postop airway problem?

A

Laryngospasm

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22
Q

What is Laryngospasm?

A
  • Reflex, involuntary closure of larynx caused by irritation
  • Irritation is from the stimulation of the vocal cords during light anesthesia
  • Laryngospasm can occur from the lack of full restoration of the normal glottic reflexes
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23
Q

What is the treatment for laryngospasm?

A
  • 100% O2
  • PEEP (APL) to 60-80 cm; this will hold cords open and help separate tissue
  • Open mouth and subluxate the mandible
  • IV lidocaine to control ventilation (1-2 mg/kg, onset 2 mins)
  • IV Succinylcholine will affect laryngeal nerves first (5-20 secs)
  • Intubate
  • Emergency cricothyroidotomy (last result)
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24
Q

What are examples of extrathoracic upper airway obstruction?

A
  • Foreign body
  • Epiglotottitis
  • Laryngospasm
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25
Q

What are examples of intrathoracic lower airway obstruction?

A
  • Asthma
  • Bronchiolitis
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26
Q

What is the first stage of laryngospasm?

A

Collapse of the supraglottic tissue onto itself

Therefore, during induction and emergence keep the larynx stretch. Positive pressure.

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27
Q

What are the early signs of laryngospasm?

A
  • Stridulous or “crowing” noise
  • Tracheal tugging (retraction)
  • Increase breathing efforts
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28
Q

What are the latent signs of laryngospasm?

A
  • Suprasternal, subcostal, and intercostal chest retraction
  • Paradoxical movement of chest and abdomen
  • Minimal or no movement of ventilation
  • Minimal or no anesthesia bag movement
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29
Q

Complication of laryngospasm

A
  • Hypoxemia
  • Cardiac arrest
  • Neg Pressure Pulmonary Edema (more often seen in adults than peds)
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30
Q

Patient risk factors for laryngospasm

A
  • Age
  • Smoking adults or passive smoking in pediatric patients (incidence ↑ 10x)
  • Recent or ongoing URI (incidence ↑ 2-5 x)
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31
Q

Anesthesia risk factors for laryngospasm

A
  • Inadequate depth of anesthesia (deep > light)
  • Vocal cord irritation
  • Experience level of anesthesia provider
  • Choice of VA (Desflurane ↑ incidence in peds)
  • Choice of airway device
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32
Q

Surgery-related risk factors for laryngospasm

A
  • Risk increased in Adenotonsillectomy
  • Upper airway procedures, bronchoscopy
  • Foreign body aspiration
  • Urgent vs. elective procedures
  • Appendectomy, hypospadias repair
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33
Q

Prevention of Laryngospasm during induction

A
  • Ensure adequate depth of anesthesia before airway manipulation or instrumentation
  • Consider an anticholinergic as an antisialagogue
  • Use of a short-term muscle relaxant for intubation
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34
Q

What can be done to prevent laryngospasm in a patient without a secured airway?

A
  • Maintain an adequate depth of anesthesia
  • Avoid Desflurane in pediatric patients
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35
Q

Prevention of Laryngospasm during emergence

A
  • Timing of airway removal/ deep extubation
  • Propofol 0.5 mg/kg
  • Lidocaine 1.5-2.9 mg/kg
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36
Q

What is “Anti-laryngospasm Spot” (Larson’s point)?

A
  • Group of nerves behind the earlobe but in front of the mastoid.
  • When firm pressure is applied, this may resolve the spasm quickly
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37
Q

What can help assess the degree of airway obstruction d/t neoplastic causes?

A

CT/MRI

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38
Q

Anesthesia consideration for traumatic causes of difficult airway

A
  • Always suspect spine precaution until confirmed clear by CT
  • Even after clearance, maintain neck stability.
  • Delayed extubation should be considered
  • Improve your skills with a Glidescope BEFORE you need it for trauma!
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39
Q

At what age is foreign body aspiration common?

A

2-4 years old

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40
Q

Male to Female ratio of foreign body aspiration

A

2:1

41
Q

Treatment of foreign body aspiration

A
  • Usually removed with a rigid bronchoscopy
  • May require post-op steroids
42
Q

MAC of Sevo for 0-1 month

A

3.3%

43
Q

MAC of Sevo for 1-5 month

A

3%

44
Q

MAC of Sevo for 6 months-3 years

A

2.8%

45
Q

MAC of Sevo for 3-12 years

A

2.5%

46
Q

Advantages of Sevo (long list)

A
  • Lower blood solubility
  • Faster induction time
  • Less myocardial depressant
  • No significant change in BP
  • Less extensively metabolized
  • Less hypercarbia
  • Pleasant smell
  • Less airway irritation
  • Significant faster recovery time
  • Better patient acceptance with single breath technique
  • No repeated use complications
47
Q

Disdvantages of Sevo

A
  • Excitement between 2-4min (placeboflurane)
  • Fluoride ion production
  • Compound A with low gas flows
  • N2O only decreases MAC 24%
  • Confusion and agitation during emergence
  • Increased cost
48
Q

Biotransformation of Sevoflurane in the human liver is ____% (range)

A

3-5%

49
Q

Metabolism of Sevoflurane in vivo produces ___________

A

Inorganic fluorides

50
Q

What is pyloric stenosis (Infantile Hypertrophic Pyloric Stenosis/ Gastric Outlet Obstruction)?

A
  • Narrowing of the pylorus, the lower part of the stomach, through which food and other stomach contents pass to enter the duodenum.
  • When an infant has pyloric stenosis, the muscles in the pylorus have become enlarged to the point where gastric emptying is prevented
51
Q

What are the causes of Pyloric Stenosis?

A
  • Multifactorial. Some researchers believe that maternal hormones could be a contributing cause.
  • May be that the thickening of the muscle is the stomach’s response to some type of allergic reaction in the body.
  • Infants may lack receptors in the pyloric muscle that detect nitric oxide, a chemical in the body that tells the pylorus muscle to relax → leading to hypertrophy
52
Q

What’s the occurrence of pyloric stenosis?

A

3 out of 1000 babies in the US

53
Q

Pyloric stenosis is about ___ times more likely to occur in firstborn male infants.

A

4x

54
Q

Pyloric Stenosis has also been shown to run in families - if a parent had pyloric stenosis, then an infant has up to a ____% risk of developing the condition.

A

20%

55
Q

Pyloric stenosis occurs more commonly in _______ infants (race) than in babies of other ethnic backgrounds

A

Caucasian

56
Q

Pyloric stenosis-affected infants are more likely to have blood type ___ or ___.

A

B, O

57
Q

Most infants who develop pyloric stenosis are usually between ____ weeks and ____ months of age

A

2 weeks and 2 months

58
Q

Symptoms of pyloric stenosis usually appear during or after the _____ week of life.

A

third

59
Q

The most common cause of intestinal obstruction during infancy.

A

Pyloric Stenosis

60
Q

The first symptom of pyloric stenosis.

A
  • Projectile vomiting
  • The breast milk or formula is ejected forcefully from the mouth in an arc, sometimes over a distance of several feet
  • The vomitus will not contain bile
61
Q

Inflammation in the digestive tract that may be caused by viral or bacterial infection will usually also have diarrhea with loose, watery, or sometimes bloody stools.

A

Gastroenteritis

62
Q

Pyloric Stenosis Diagnosis and Considerations

A
  • Usually are 3-6 weeks old
  • Diagnosed with barium swallow or ultrasound
  • Should always be considered a full stomach!
  • Infant will need to have IV access, prior to coming to the OR
  • Need to correct electrolyte depletion and dehydration
  • Usually have a (hypochloremic) metabolic alkalosis
63
Q

Anesthesia Management of a Pyloromyotomy

A
  • Keep room warm-78-80 degrees
  • Is the IV patent? -Give atropine watch for increased heart rate
  • Monitors- ECG and SaO2
  • 10-12 Fr. Salem sump, reinsert 4-5 times and change the infant’s position to decompress the stomach
  • Propofol/Sux/Tube- Do not delay intubation -stylet the ET Tube
  • RSI- Cricoid pressure! (gentle)
  • NO NARCOTICS!
  • Slow emergence is normal for this age/ They will move everything but their diaphragm
64
Q

Pediatric cardiac output is derived from what factors?

A
  • Volume
  • Heart Rate

Starling’s Law is not a factor in cardiac output in pediatrics until they are 5-6 years old

65
Q

Anesthesia Management of a Laparoscopic Pyloromyotomy

A
  • Desflurane inhalation maintenance with controlled ventilation, AFTER THE AIRWAY IS SECURED!
  • Utilizing higher concentrations (6-9%) of Des. allows for adequate depth of anesthesia and surgical relaxation. (Reflex tachycardia is a good thing.)
  • Placement of a 12 Fr. Salem sump
  • Hemostat and a Toomey syringe to inflate the stomach to check for pyloric perforation.
  • NO NARCS
  • Repeated doses of Succinylcholine is not recommended
  • Small dose of a Non-depolarizing muscle relaxant is an option.
  • Small dose of Propofol may provide enough additional relaxation
  • At the end of the case, turn down/off the Desflurane and allow the ETCO2 to rise to allow for spontaneous ventilation.
  • AWAKE EMERGENCE and EXTUBATION since they are still considered a full stomach
66
Q

Anesthesia Considerations of Pyloric Stenosis

A
  • This is considered an urgent case, but not an critical emergency procedure
  • Assess level of electrolyte disturbance and correct dehydration and metabolic alkalosis
  • Local injection by surgeon should provide adequate post op pain control
  • No Narcotics!
  • Always considered a full stomach! Before, during and after the case
67
Q

What is the IV fluid of choice for pediatric patients?

A

Lactated Ringers (closest composition to extracellular fluid)

68
Q

How many mls of crystalloid should be administered for every 1ml of blood loss?

A

The 3:1 rule is a fluid resuscitation guideline that states that for every 1 mL of blood loss, 3 mL of crystalloid fluid should be used.

69
Q

Why do neonates (less than 3 or 4 months) need fluids with dextrose?

A

Neonates have low glycogen stores and cannot break down triglycerides and convert them to usable energy. Therefore, fluids with dextrose (D5, D10) are needed for these patients.

70
Q

How will you make D2.5 from D50?

A

Mix 2.5 mL of D50 with 47.5 mL of LR.

71
Q

How will you make D10 from D50?

A

Mix 10 mL of D50 with 40 mL of LR.

72
Q

How will you make D7.5 from D50?

A

Mix 7.5 mL of D50 with 42.5 mL of LR

73
Q

How do you calculate fluid deficit?

A
  • 4-2-1 rule
  • 4 mL/kg for the first 10 kg
  • 2 mL/kg for the second 10 kg
  • 1 mL/kg for the rest of the weight
74
Q

Generally, for short pediatric cases, what is the rate of fluid replacement?

A

10-20 mL/kg

75
Q

Total blood volume for a preemie

A

100 mL/kg

76
Q

Total blood volume for a neonate

A

90 mL/kg

77
Q

Total blood volume for an infant

A

80 mL/kg

78
Q

Total blood volume for a child

A

70 mL/kg

79
Q

The formula for calculating the max allowable blood loss

A

[EBV x (pt Hct - 25)] / pt Hct

80
Q

What is the max allowable blood loss for an 8 kg infant if Hct is 36?

A

EBV = 8 kg x 80 mL/kg = 640

Blood Loss = [EBV x (pt Hct - 25)] / pt Hct

[640 x (36-25)]/36 = 195

Max allowable blood loss is 195 mL

81
Q

24 kg child, NPO for 6 hours.
What will be the fluid deficit?

A

Use 4-2-1 rule.
4 mL/kg x 10 kg = 40 mL
2 mL/kg x 10 kg = 20 mL
1 mL/ kg x 4 kg = 4 mL

64 mL/hour x 6 hours = 384 mL

82
Q

How do you make 5% albumin if you only have a 25% albumin bottle?

A
  • Get 100 mL NS bag
  • Take 20 mL NS out of the bag
  • Replace with 20 mL of 25% albumin.
83
Q

Estimate of Minimum SBP for 0-1 month

A

60 mmHg

84
Q

Estimate of Minimum SBP for 1 month to 1 year

A

70 mmHg

85
Q

Estimate of Minimum SBP for 1-10 years of age

A

70 mmHg + (2 x age in years)

86
Q

Estimate of Minimum SBP >10 years in age

A

90 mmHg

87
Q

Estimate of HR in Infant.

A

85-220 bpm

88
Q

What HR should SVT be suspected in an infant?

A

> 220 bpm

89
Q

Estimate HR of a child

A

60-180 bpm

90
Q

What HR should SVT be suspected in a child?

A

> 180 bpm

91
Q

Estimate of RR in Children

A

20-60 breaths per minute

(Note WOB, effort, mechanics, assess sounds, skin tone, pulse ox)

92
Q

What is the number one cause of bradycardia in a child?

A

Hypoxemia

93
Q

What is a BMT?

A
  • Bilateral Myringotomy and Tubes, used to treat otitis media.
  • A surgeon inserts the tubes to ventilate (let air into) the area behind the eardrum and to keep the pressure equalized to atmospheric pressure in the middle ear.
94
Q

Anesthesia techniques for BMT

A
  • Inhalation induction with Sevo or Halo
  • Spontaneous ventilation, mask maintenance
  • Keep nitrous on to help separate drum from middle ear
  • Turn head to the side and keep head still
  • Hard to chart and provide airway at the same time
95
Q

Anesthesia techniques for Tonsils and Adenoids

A
  • Inhalation induction, deep intubation
  • Use a drying agent (robinul)
  • IM narcotics
  • Zofran and Decadron
  • FiO2 < 30 w/ air
  • Deep extubation
96
Q

What are the 3 criteria for deep extubation

A
  • Hemostasis
  • Good PACU staff
  • Airway expert available to go PACU if needed
97
Q

In regards to pediatrics w/ URI when should surgery be postpone?

A
  • Active infection w/ high fever, purulent nasal drainage, purulent cough
  • Cancel the procedure, post-pone for 2 weeks
98
Q

What are major considerations for eye muscle surgeries?

A
  • Malignant Hyperthermia caution
  • N/V
  • Oculocardiac reflex
  • Intubate/Extubate deep with Oral Rae
  • Bradycardia and Apnea periods are not uncommon with eye surgery
99
Q

Which drug class can’t be given for a pylormyotomy?

A

Narcotics

Advanced Principles A (Spring 2024) (11 decks)

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