Unit 4 Flashcards
(246 cards)
1
Q
At what age are you physiologically “similar” to an adult?
A
8 years old
not on slide, mentioned during lecture
2
Q
What weight constitutes low birth weight?
A
< 2500 g
3
Q
What weight constitutes very low birth weight
A
< 1500 g
4
Q
What weight constitutes extremely low birth weight?
A
< 1000 g
5
Q
What weight constitutes a micropremie?
A
< 750 g
6
Q
Why do stressors cause bradycardia in newborns?
A
Because the PNS is dominant, it will have the greater/exaggerated effect in response to stress, causing bradycardia
7
Q
What ion is vital for myocardial performance?
A
Ca
8
Q
What is the average HR, SBP and DBP of a neonate?
A
140, 70 - 75 and 40
9
Q
What is the average HR, SBP and DBP of a 12 month old?
A
120, 95 and 65
10
Q
What is the average HR, SBP and DBP of a of a 3 yr old?
A
100, 100 and 70
11
Q
What is the average HR, SBP and DBP of a 12 year old?
A
80, 110 and 60
12
Q
What constitutes hypotension in a neonate?
A
Less than 60 SBP
13
Q
What constitutes hypotension in a 1 - 12 month old?
A
Less than 70 SBP
14
Q
What constitutes hypotension in a children (ages 1 - 10 yr)?
A
< 70 SBP + (2 x age in years)
15
Q
What constitutes hypotension in a child older than 10?
A
Less than 90 SBP
16
Q
What is the HgB total at birth?
A
18 - 20 g/dL
17
Q
What is the estimated blood volume in a premie?
A
90 - 100 mL/kg
18
Q
What is the estimated blood volume in a newborn (less than 1 month)?
A
80 - 90 mL/kg
19
Q
What is the estimated blood volume in a infant (1 month - 3 yr)?
A
75 - 80 mL/kg
20
Q
What is the estimated blood volume in a child (older than 6)?
A
65 - 70 mL/kg
21
Q
What is the estimated blood volume in an adult?
A
65 - 70 ml/kg
22
Q
What is the P50 of HgB F?
A
19 mmHg
adult is ~26.5
23
Q
What is the difference between adult and fetal HgB in terms of their physical structure?
A
HgB A has 2 alpha chains and 2 beta chains
HgB F has 2 alpha chains and 2 gamma chains
24
Q
Why can’t fetal HgB bind DPG?
A
Because DPG only binds on beta chains, and fetal HgB doesn’t have beta chains
25
When does alveolar ductal development start?
24 weeks gestation
26
When does surfactant production/secretion begin?
22 - 26 weeks
27
At what age do alveoli stop growing?
~ 8 years old
28
Why do we delay birth (if possible) to 35 - 36 weeks?
Because this is when peak surfactant production occurs
29
Why are newborns susceptible to respiratory problem if their respiratory rate is elevated?
They have less type 1 muscle fibers (slow twitch that are resistant to fatigue)
30
How does a newborns diaphragm differ from an adult?
Newborns is more flat
31
Newborn MV is more dependent on what?
RR than Vt
*Opposite is true in adults, adults are more reliant on Vt*
32
T/F: FRC is increased in newborns
False
33
What lung volumes are increased in a neonate? Decreased?
Increased: CC and RV
Decreased: FRC, VC and TLC
34
How does the larynx position differ in a neonate?
It is more superior and cephalad, closer to C3/4
*In an adult, it is closer to C4/5*
35
What is the narrowest point in the airway in a child? Adult?
Child - cricoid cartilage
Adult - vocal cords
36
How does the anatomy of the airway differ in kids relative to adults?
Large tongue
Superior Larynx
Omega-shaped epiglottis
Vocal cords are angled
Short, funnel-shaped trachea
37
How do the mainstem bronchi differ in children?
They take off at an angle of 55 degrees (much more even/identical takeoff angles relative to each other)
*In adults, the right mainstem is closer to 25 degrees and the left is closer to 45 degrees*
38
Children are obligate what in terms of their respirations?
Obligate nasal breathers
39
The infant tracheal lumen is about half the size of the adult. How does the relate to airflow resistance?
It means they have exponentially much higher airway resistance, and also have much less "give" if airway edema occurs
40
How does the CNS differ in children?
Incomplete myelination
Immature NMJ
Most neurological growth and development occurs in utero
Rapid brain growth occurs after birth
BBB is immature until 1 year old
41
When does the BBB mature?
~ 1 year of age
42
When does most neurological growth/development occur?
In utero
43
Where do the conus medullaris and dural sac begin in children?
2 levels lower for both; so L3 and S3
*so adults would begin at L1 and S1*
44
T/F: the neonate brain lacks autoregulation
False: it is present, just not fully developed
*so meds/toxins can have an exaggerated effect, especially if the BBB isn't fully developed*
45
What conditions can make a young child susceptible to cerebral hemorrhage?
Can be caused by hypoxia, hypercarbia high/low glucose, hypernatremia and big swings in BP
46
When does GFT reach adult levels?
~ 6 - 12 months
47
How does the neonate renal system differ from adults?
Diminished ADH
Immature renal tubules
Meaning they do NOT tolerate fluid overload well
They are also obligate sodium excreters – include Na in their fluids
48
Why is it important to include sodium in any fluids given to neonates?
They are obligate Na excreters - so you must make sure to replenish excreted Na reserves
49
What is a premie GFR? Full term? 2 year old?
Premie - 0.55 ml/min/kg
Full term - 1.6
2 year old - 2 ml/min/kg
*not on slide, mentioned in lecture*
50
What is the fluid requirement for a neonate?
150 ml/kg/day
*fairly high d/t high rate of insensible loss*
51
How does the hepatic system differ in neonates?
Glycogen stores do not reach adult levels until 3 weeks old
Decreased liver function
Low albumin and AAG
Hyperbilirubinemia
Low levels of clotting factors
Require Vit K to prevent bleeding
52
What are the vitamin K dependent clotting factors?
2, 7, 9 and 10
53
The gastric pH is what at birth?
Alkalotic - decreases to normal by day 2
54
Why are neonate at higher risk of GERD?
Coordinating swallowing w/respiration does not fully mature until 4 - 5 months of age
55
If there are developmental problems that affect the GI system, at what timeframe would symptoms start to occur?
24 - 36 hours of life
56
Why is the rate of absorption of PO drugs slower in neonates?
Delayed gastric emptying
57
Why do infants lack the ability to effectively regulate body temp?
Large body surface area
Lack of subcutaneous tissue
Inability to shiver
58
What do neonates use to increase heat production?
NST - non-shivering thermogenesis. Stimulated by the SNS to enhance the metabolism of brown fat to increase heat production
59
Hypothermia can cause what in infants/neonates?
Hypothermia can lead to bradycardia, acidosis, and coagulopathies
60
What is the basic difference between convection and radiation in terms of heat loss?
Convection - loss of heat by the movement of air
Radiation - transfer of body heat to the cooler environment
*Radiation generally is the most significant loss of heat*
61
What are the basic pharmcokinetic factors that affect drugs we give to neonates/children?
Absorption and distribution are increased (Higher CO)
Decreased elimination (Immature metabolic pathways, Immature kidneys)
Metabolism (Underdeveloped CYP-450 pathway – generally mature at 3 months)
Immature BBB
62
When do the CYP-450 pathways generally mature?
Around 3 months
63
How do infant body compositions differ from adults?
Greater TBW with a larger ECF compartment and decreased ICF
*this means they have a larger Vd for water soluble drugs like neuromuscular blockers and lipid soluble drugs have a longer effect. This also leads to a higher concentration of protein bound drugs*
64
How are NCR (nicotinic cholinergic receptors) different in a neonate?
They remain open much longer, making them sensitive to NDMBs -> unpredictable effect
65
How do opioid receptors differ in neonates?
They have a change in number and affinity of the mu/kappa receptors -> this creates a variable occurrence in the chances of respiratory depression occurring
66
How do GABA receptors differ in a neonate?
They have 1/3 the total number of them -> making them sensitive to benzos
67
T/F: MAC is higher for a premie
False, it decreases for premies/neonate, then starts to increase for infants
68
What is the basic summary of considerations for pediatric pharmacology (slide 39)?
Differences in TBW composition
Immature metabolic degradation pathways
Reduced protein binding
Immature blood-brain-barrier
A greater proportion of blood flow to vessel-rich organs
Reduced glomerular filtration
Smaller FRC
Increased MV
Immature receptor responses
69
A R -> L shunt causes what change in gas uptake?
Slower uptake of gas
70
How does a L -> R shunt affect gas uptake?
Minimal change to uptake
71
T/F: inhalation agents have more CV side effects in neonates?
True
72
When do MAC requirements peak?
Infant age 2 - 3 months
73
What is the MAC for neonates?
3.3
74
What is the MAC for infants?
3.2
75
What is the MAC for children (older than 6 months)?
2.5
76
What is the preferred inhalation agent for neonates/children?
Sevo
77
T/F: the MAC of nitrous has been determined in children
False
78
Does nitrous in induction increase PONV risk in children?
No, but only if used during induction, if used throughout the case PONV risk does increase
79
Why do inhalation agents have such a profound/rapid on/off in neonates?
Decreased distribution of adipose tissue & decreased muscle mass affect the rate of equilibration among the alveoli, blood, & brain, or rather a greater% of blood flow goes to the vessel rich organs
80
What are the general considerations of IV anesthetics in pediatrics?
Higher CO to vessel-rich tissues
Prolonged DOA
Prolonged CNS side effects
81
What are 2 changes to propofol use to consider in pediatrics?
Require larger dosages d/t increase metabolism and greater Vd
Reduced clearance in preterm neonates
82
What is the ED 50 for propofol: 1 - 6 months, 1 - 12 yr old and 10 - 16 yr old?
1-6 M: 3 mg/kg (increased incidence of hypotension and other s/e)
1 - 12 Yr old: 1.3 - 1.6 mg/kg
10 - 16 yr old: 2.4 mg/kg
83
What is the induction dose of ketamine in pediatrics?
1 - 3 mg/kg
84
How does ketamine dosing change for children? Neonates?
Children: higher d/t increased clearance
Neonates: lower d/t decreased clearance
85
What is the induction dose of etomidate in children?
0.2 - 0.3 mg/kg
86
What is the primary concern of etomidate use in children?
Concerns regarding anaphylactoid reactions and adrenal suppression -> limited use in children
87
Precedex dose in children?
1 - 2 mcg/kg
Peak effect takes 30 - 40 minutes
88
Why is precedex useful in children?
Decreases incidence of emergence delirium/agitation
*Though high doses can prolong the recovery phase*
89
Morphine dose in pediatrics?
0.05 - 0.1 mg/kg
90
When does clearance of morphine reach adult levels?
6 - 12 months of age
*decrease dose in neonates*
91
What opioid has a black box warning against use in children after a tonsillectomy?
Codeine
92
Fentanyl dose in pediatrics?
0.5 - 2 mg/kg
*except in neonates, the dose increases to 3 mg/kg*
93
Why is the fentanyl dose higher for neonates?
They have a larger Vd
94
Why is fentanyl the most frequently used opioid in pediatrics?
Greater hemodynamic stability
Rapid onset
Short DOA
Clearance is reduced in preterm infants but greater than in adults in older infants and children
95
What opioid do neonates clear more rapidly than older children?
Remi
96
How do pediatric responses to NMBDs differ from adults?
Increased sensitivity
Increased Vd
Reduced clearance, immature NMJ, and increased sensitivity
NMBDs are highly ionized and not lipophilic
97
What paralytics do not have a change in sensitivity in pediatrics?
Sux
98
What is the infant dose of IV sux? Children?
Infant - 2 mg/kg
Children - 1 mg/kg
99
What is the IM dose of sux in neonates/infants? Older than 6 months?
N/I = 5 mg/kg
6 m = 4 mg/kg
100
Sux has a prolonged DOA in what age range?
Neonates
101
Bradycardia can occur with sux in what age range?
Less than 5 years old
102
Why are repeat doses of sux discouraged in pediatrics?
Cardiac arrest may follow the first dose, more common after repeated doses
103
Why are NDMR drugs used with extreme caution in peds?
Infants are more sensitive & responses vary
Initial doses are similar
Prolonged DOA
Choice of agent depends on side effects & duration of muscle relaxation required
104
What is the only NDMR that can be given IM?
Roc
105
Why is it difficult to assess recovery in neonates/infants?
TOF ratio >90% and MIF >-25 cm H2O
Facial grimacing, elbow and hip flexion, and bringing knees to the chest are subjective
106
What are the 2 anti-cholinesterase drugs used for reversal in peds (include dose range)?
Neostigmine 0.05-0.07 mg/kg
Edrophonium 0.5-1.0 mg/kg – very rare to use
107
Sugammadex has been approved for use in all ages in 2014, despite this, what age range do we still rarely use sugammadex in?
Kids less than 2 years old
108
What is the dose range for sugammadex in peds?
2 - 4 mg/kg
109
T/F: Routine labs, ECG, and CXR are not recommended for healthy children
True
110
At what age are children most likely to have parental separation anxiety?
Ages 1 - 3
111
Distraction works best for what age group?
Ages 1 - 3
112
Preop play works best for what age group?
Ages 3 - 6
113
What age group would likely want more explanation and want to actively participate in the preop process?
Ages 7 - 12
114
What age range would the parents experience the most stress?
Ages 0 - 6 months
115
What are some common predictors of difficult intubation in pediatrics?
Mandibular protrusion
Mallampati Classification
Movement of the atlantooccipital joint
Reduced mandibular space
Increased tongue thickness
Age < 1 year
ASA II-IV
Obesity
Maxillofacial & cardiac surgery
116
What 3 syndromes mentioned in lecture are common predictors of difficult airway?
Down syndrome, Treacher-Collins and Pierre-Robin
117
What airway implications are common to down syndrome?
Atlantooccipital abnormalities, small oral cavity and macroglossia
118
What airway implications are common to Treacher-Collins?
Micrognathia (undersized lower jaw), small oral opening and zygomatic hypoplasia (small chin)
119
What airway implications are common Pierre-Robin?
Micrognathia, glossoptosis (posterior displacement or retraction of the tongue), cleft palate, micrognathia (unilateral) and cervical dysfunction
120
Of the syndromes specifically mentioned in lecture, which one is characterized by unilateral micrognathia?
Pierre-Robin
121
What perioperative respiratory adverse events are associated with URI's?
Bronchospasm, laryngospasm, breath holding, atelectasis, arterial oxygen desaturation, bacterial pneumonia, postintubation croup, and unplanned hospital admission
122
What type of induction reduces the chances of PRAEs?
IV induction
123
How long after a URI is it recommended to wait before going under anesthesia?
2 weeks
124
For a URI, would s/sx would prompt you to cancel the case?
Purulent nasal drainage
Fever
Lethargic
Persistent cough
Poor appetite
Wheezing
Child < 1 or previous preemie
125
For a URI, what s/sx would warrant you to proceed with caution rather than cancel the case?
Runny nose
No fever
No changes in behavior
Clear lungs
Older child
126
What is the number 1 priority when selecting airway equipment for pediatrics?
Ensure appropriate sizes are available in the room
127
Per lecture, how do you measure an OPA in pediatrics?
Tip of the mouth to the edge of the mandible
128
What blade(s) are more commonly used in neonates/toddlers?
Miller/wis-Hipple blade
129
What formula (that I personally use in clincials) can help size a pediatric ETT?
Age in years / 4 + 4 for an uncuffed tube, subtract 0.5 for cuffed
130
In general, what size of tube would you use for ages 1 - 2?
3.5
131
In general, what size of tube would you use in a child less than 1 year of age?
3.0
132
Quick shortcut to determine the ideal length of insertion for a pediatric tube?
ID of ETT x 3
*so a 3.0 mm tube would have an ideal insertion depth of 9 cm*
133
What volume is a pediatric circuit bag?
1L
134
When setting up IV tubing for a pediatric, what safety check is paramount?
Ensuring there are no air bubbles
135
What special IV tubing is frequently used with neonates/small children?
A Burette set
136
What 4 non-intubation drugs are commonly used in pediatrics?
Ofirmev, dexamethasone, ondansetron, dexmedetomidine
137
What are the 4 essential drugs, and their dosages, to know for peds?
Epinephrine 0.01 mg/kg
Succinylcholine 2 mg/kg IV; 4 mg/kg IM
Atropine 0.02 mg/kg
Glycopyrrolate 0.01 mg/kg
138
What is the PO dose of versed?
0.25 - 1 mg/kg PO
139
What is the nasal dose of precedex?
1 - 2 mcg/kg
140
What is the IM dose of ketamine in peds?
5 - 10 mg/kg IM
141
If using nitrous for a mask induction, when do you stop it?
After LOC
*ensure you start 100% O2 and Sevo*
142
When is an IV induction indicated in peds?
Full stomach (RSI) or anticipated difficult intubation
143
List the steps of a mask induction
+/- PO Premed
Place monitors
Sevo +/- N2O
IV placement
Medications
Airway
144
List the steps of an IV induction for peds
+/- IV Premed
Place monitors
Preoxygenation
Medications
Airway
145
What patient position in peds can help relieve an upper airway obstruction
Lateral decubitus
146
What is the 4:2:1 rule?
4 ml/kg for first 10 kg of weight
2 ml/kg for the next 10 kg of weight
then 1 ml per kg of each additional kg of weight
*so a 35 kg patient would end up being 75 ml/hr*
147
What is one drawback to using the 4:2:1 rule in sick children?
It likely overestimates the fluid maintenance
148
What factors contribute to perioperative fluid losses?
Surgery dependent – Replace with 10-15 up to 50 ml/kg/hr
Environmental temperature
Cold, dry anesthetic gases
Neuroendocrine regulation affected by anesthetic agents
149
Over the first 3 hours, how would you replace the NPO fluid deficit?
1/2 the deficit in the first hour, then 1/4 the deficit in hours 2 and 3
150
What type of fluid do you avoid bolusing during surgery in peds?
Dextrose containing fluids
151
What dose of dextrose would you give for symptomatic hypoglycemia? If seizures are present?
2 ml/kg of 10% dextrose
4 ml/kg of 10% dextrose if seizures are present
152
What peds patients would you routinely consider needing glucose for?
Premature infants, infants of diabetic mothers, children with diabetes who have received a portion of daily insulin preoperatively, children who receive glucose-based parenteral nutrition
153
At what HCT does apnea occur more frequently in neonates/premies?
Less than 30
154
What is the allowable blood loss equation?
EBV x (Starting Hct – Target Hct)/Starting Hct
155
What is the ratio of crystalloid replacement for blood loss?
3:1
156
A 3 year old child weighs 15 kg, starting HCT is 38, desired is 25, what is the max allowable blood loss?
3 years old EBV is 70 - 75 ml/kg
(15 x 70) x (38 - 25) / 38 = 360 ml
157
What is the HCT of PRBCs?
~ 60%
158
How much would 4 ml/kg of PRBCs increase Hgb?
~ 1 g/dL
159
What are contraindications for outpatient peds surgery?
infants born premature < 35 weeks of gestation or those < 60 weeks of post-conceptual age
*high risk for post-op apnea, must stay overnight in hospital. The patient needs to be able to take PO meds without n/v prior to d/c*
160
Incidence of respiratory complications is related to what in peds?
The experience level of the anesthesia provider
161
What circuit must be used during transport to PACU?
A jackson-reese circuit
162
What treatment is used to stabilize the respiratory rhythm in peds (include doses)?
Caffeine 20 mg/kg followed by maintenance therapy of 5 mg/kg/day
163
What age should peds be admitted for 24 hour post-op monitoring?
Less than 60 weeks age
164
How does post-op delirium commonly manifest in peds?
Disorientation
Not responding to parents/staff
No eye contact
Inconsolable
165
Peds risk factors for emergence delirium?
Age 2-9
Surgery type
Anesthetic
Pre-existing ED
Anxiety and parental anxiety
Pain
166
What is the patient positioning for caudal anesthesia?
Lateral w/knees flexed
167
What landmarks should you palpate prior to sacral anesthesia?
The sacral cornu, visually identify the tip of the coccyx as well
168
What volume of anesthesia covers the T4 - 6 dermatomes in sacral anesthesia?
1.2 - 1.5 ml/kg
169
What are pre-op risk factors for laryngospasm?
2nd-hand smoke exposure, recent URI, GERD and mechanical irritants (oropharyngeal secretions)
170
What are intra-op risk factors for laryngospasm?
Excitement phase of inhalation induction, intubation/extubation w/light anesthesia, upper airway surgical procedures
171
Laryngospasm treatment?
100% O2
Apply pressure behind the mandible
Remove stimulus
Deepen anesthetic
Succinylcholine (with atropine or glycopyrrolate)
172
How does a bronchospasm change the ETCO2 waveform?
Creates a prominent slope on the expiratory portion of the waveform
173
Treatment of bronchospasm?
Remove stimulus, deepen anesthetic, increase FiO2
Decrease PEEP and increase expiratory time
Corticosteroids, albuterol, IV magnesium
Epi if resistant to treatment
174
What can increase airway edema, increasing the risk of croup?
Too large ETT
Multiple DL attempts
Surgical positioning
Surgical time
Upper airway infection
Coughing on ETT
175
What would you educate the parents on for a child that received racemic epi about discharge time?
Must be monitored for at least 4 hours
176
What syndromes are associated with a large tongue?
Beckwith syndrome and Trisomy 21 (down syndrome)
*Pneumonic: Big Tongue -> Beckwith and Trisomy 21*
177
What syndromes are associated with small/underdeveloped mandibles?
Please Get That Chin
Pierre Robin
Goldenhar
Treacher Collins
Cri du Chat
178
What syndromes are associated with c-spine anomalies?
Kids Try Gold
Klippel-Feil
Trisomy 21
Goldenhar
179
What is the peak age range for foreign body aspiration?
6 months to 3 yrs old
180
What breath sound is a hint that a foreign body obstruction is supraglottic?
Stridor
181
What breath sound is a hint that a foreign body obstruction is subglottic?
Wheezing
182
What type of anesthesia is ideal for a foreign body asipration?
TIVA
183
What is the clinical presentation for epiglottitis? Treatment?
Drooling, dyspnea, dysphonia, dysphagia, high fever
Tx: O2, Urgent airway mgmt. with ENT present, antibiotics
184
What is the clinical presentation for croup? Treatment?
Mild fever, inspiratory stridor, barking cough
Tx: Humidified O2, racemic epi, steroids, fluids
185
What region is affected during epiglottis? Croup?
E = supraglottic
C = laryngeal
186
What is the onset of epiglottis? Croup?
E = rapid
C = 24 - 72 hours
187
What organism is usually the cause of epiglottis? Croup?
E = bacterial
C = viral
188
What airway alterations are common to down syndrome?
Small mouth
Large tongue
Palate is narrow with a high arch
Atlantoaxial instability
Subglottic stenosis (generally size down ETT)
OSA
Chronic pulmonary infections
189
What are the common congenital heart defects in down syndrome?
Most common = AV septal defect
The second most common = VSD
Others: PDA and TOF
190
List each part of the CHARGE syndrome pneumonic
C - Coloboma (a hole in one of the eye structures)
H - Heart defects
A - Choanal atresia (back of nasal passage is obstructed)
R - Restriction of growth/development
G - GU problems
E - Ear anomalies
191
List each part of the Catch 22 pneumonic (DiGeorge syndrome)?
C- Cardiac
A- Abnormal face
T- Thymic hypoplasia
C- Cleft palate
H- Hypocalcemia (d/t hypoparathyroidism)
22- 22q11.2 gene deletion
192
What 2 interventions are common during surgery for DiGeorge patients?
Giving calcium and blood products need to be irradiated (d/t poorly functioning thymus)
193
What reflex is commonly encountered during strabismus surgery?
Oculocardiac (oculu-emetic) reflex
194
What is the first step in treating the oculocardiac reflex?
Stop the stimuli - subsequent stimuli generally do not have as severe responses
195
What cardiac outcomes occur during the oculocardiac reflex?
Bradycardia, AV block, ventricular ectopy, asystole
196
What causes retinopathy of prematurity?
Liberal oxygen use
197
What is the ideal SPO2 range when caring for a premie?
89 - 94%
198
Where do you measure a preductal sat?
On the right hand
199
What are the preop anesthetic considerations for an adenotonsillectomy?
Increased risk for OSA
Repeat infections/reactive airway
Airway assessment
Easy/frequent bruising, epistaxis, family h/o bleeding disorders?
200
What is the dose of decadron commonly used during a T&A?
0.5 mg/kg
201
What are the anesthetic complications to keep in mind for a T&A?
Bleeding
Primary: Within 6-24 hours postop
Secondary: 5-10 days after
Airway fire
Maintain low FiO2 < 30%
Avoid N2O
202
What position do you keep the patient in for intubation for a post tonsillar bleed?
Left lateral head down
203
How do you size your ETT during a post tonsillar bleed?
Half a size smaller
204
When does post-intubation croup generally occur?
30 - 60 minutes s/p extubation
205
Risk factors for croup?
Age < 4 years, ETT too large, ETT cuff volume too high, multiple intubation attempts, prolonged intubation, coughing/bucking, head/neck surgery, head repositioning during surgery, h/o infectious/postintubation croup, trisomy 21, URI
206
How to prevent post intubation edema?
Maintain an air leak, less than 25 cm H2O
207
Treatment of post intubation laryngeal edema?
Racemic epi, cool/humidified O2, dexamethasone 0.5 mg/kg, heliox
208
What is the common anesthesia plan for cleft lip/palate?
Oral RAE tube common
Awake extubation
Analgesia: acetaminophen & opioids
Potential for postop obstruction
209
What are the common timeframes for cleft lip surgeries?
Primary cleft lip repaired ~ 3-6 months & primary cleft palate ~ 6-12 months
210
What patient populations most likely to be diagnosed with pyloric stenosis?
First born males
*usually diagnosed between 2 - 12 weeks of age*
211
What condition(s) have nonbilious emesis? Bilious emesis?
NE = pyloric stenosis
BE = necrotizing enterocolitis and midgut volvulus
212
What acid base disorder is common to pyloric stenosis?
Hypochloremic, hypokalemic metabolic alkalosis
213
What is the difference between an omphalocele and gastroschisis?
Both have organs/systems outside of the body cavity, but gastro does not have a membrane surrounding the protruding organs/systems
214
Which condition requires more urgent treatment, omphalocele or gastroschisis?
Gastro
215
Which condition requires a cardiac workup prior to treatment, omphalocele or gastroschisis?
Omphalocele
216
Anesthetic considerations for Omphalocele and Gastroschisis?
Adequate IV access essential
Avoid N2O
Colloid administration likely
Muscle relaxation used
A-line – help guide fluid replacement, allows for frequent blood work
Pulse ox on lower extremity
217
What are general concerns in patients with Omphalocele and Gastroschisis?
Severe dehydration
Massive fluid loss from exposed viscera & internal third spacing of fluid d/t bowel obstruction
Hypothermia
Potential for sepsis
Associated anomalies
Increased intraabdominal pressure
Postoperative ventilation requirements
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What is the common etiology of Necrotizing Enterocolitis (NEC)?
Secondary to bowel ischemia & immaturity, probable bacterial invasion, and premature oral feeding
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What lab values would you expect in NEC?
Hyperkalemia, hyponatremia, metabolic acidosis, hyperglycemia, hypoglycemia, DIC in severe cases
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How is NEC diagnosed?
Via imaging
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Common s/sx of NEC?
Increased gastric residuals with feedings
Abdominal distention
Bilious vomiting
Lethargy
Occult/gross rectal bleeding
Fever
Hypothermia
Oliguira
Jaundice
Apnea/bradycardia
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Initial treatment of NEC?
Ensuring oxygenation
Manage hypovolemia and acidosis
Withhold enteral feeding
NG decompression
Abx
*followed by Ex-lap with resection of dead bowel, colostomy, and peritoneal lavage*
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Anesthetic management of NEC?
Frequently septic, already intubated on arrival to OR
Bedside ex-lap may be performed in NICU
Avoid N2O
Cautious with VA -> can cause vasodilation/hypotension
May need inotropic support
Assess hydration status
Early colloid administration
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What is the surgical intervention for midgut volvulus?
Ladd procedure
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When is malrotation a medical emergency?
When the intestine becomes twisted & ischemic it is a volvulus -> emergent procedure
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What side of the body do congenital diaphragmatic hernia generally herniate through?
The left side
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What do congenital diaphragmatic hernias generally herniate through?
The foramen of Bochdalek
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How do congenital diaphragmatic hernia increase the R -> L shunt?
Thickening of arteriolar smooth muscle extending to the capillary level -> increased PAP -> R-to-L shunt
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Common s/sx of a congenital diaphragmatic hernia at birth?
Dyspnea
Tachypnea
Cyanosis
Absence of breath sounds on the affected side
Severe retractions
Scaphoid abdomen
Barrel chest
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A congenital diaphragmatic hernia can be treated intrauterine with the goal of accomplishing what?
Reversing the pulmonary hypoplasia
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Median age of congenital diaphragmatic hernia surgery?
~4 days old
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Ventilation strategy for a congenital diaphragmatic hernia?
Permissive hypercarbia with high-frequency, oscillatory ventilation
Avoid inflating the stomach with air
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What patient factors can increase PVR?
Hypoxia, hypothermia, acidosis
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Goal PIP during congenital diaphragmatic hernia?
Less than 25 - 30 cm H2O
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What type of Tracheoesophageal Fistula and Esophageal Atresia is most common?
Type C
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What are the prenatal s/sx of Tracheoesophageal Fistula and Esophageal Atresia?
Polyhydramnios, stomach bubble on u/s
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How do you diagnose Tracheoesophageal Fistula and Esophageal Atresia?
Cannot pass OGT into stomach immediately after birth, coughing/choking after first feeding, recurrent PNA with feedings
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How do you minimize pulmonary complications of TEF (tracheoesophageal fistula) and EA (esophageal atresia)?
d/c oral feedings
Place balloon-tipped catheter to suction nasopharyngeal secretions that accumulate in the blind esophageal pouch
Semi recumbent position
Gastrostomy tube
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What is the anesthetic induction technique for TEF (tracheoesophageal fistula) and EA (esophageal atresia)?
Head up position, frequent suctioning
Awake intubation, inhalational induction & maintenance of SV
May have difficulty ventilating lungs
May perform bronchoscopy after induction
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How do you position the airway in TEF (tracheoesophageal fistula) and EA (esophageal atresia) if the patient needs to remain intubated?
Position 1 cm away from the fistula repair line
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Why is surgery to fix an imperforate anus more urgent in males?
In female neonates – common presence of rectovaginal fistula, the procedure can be delayed a few weeks
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S/sx of increased ICP in neonatal hydrocephalus?
bulging anterior fontanelle, irritability, somnolence, vomiting, LOC, &/or CV collapse
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Anesthetic technique for neonatal hydrocephalus?
RSI
Goal – extubate at the end of the procedure
Inhalational agents – cause cerebral vascular dilation at > 1 MAC & can increase ICP
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What is the most common CNS defect that occurs during the 1st month of gestation?
Myelomeningocele
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What is a Myelomeningocele?
Failure of the neural tube to close -> herniation of the spinal cord and meninges through a defect in the spinal column and back
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What is the common cause of a myelomeningocele?
Low folic acid intake
