What pts are more likely to brady with loss of airway, code, & experience an adverse cardiopulmonary event d/t the great physiologic diffence to adults?
(decreased physiologic reserves)
! Define the following by dates:
-preterm: less than 37 wks gestation
-term: 37-42 wks gestation
-post-dates: greater than 42 wks gestation
-neonate: 1st month of life
-infant: 1st year
-child: 1 to 12 years
What is the most important differing physiological system in pediatric pts vs adults?
How does it differ? (x3)
-2x oxygen consumption (6mL/kg)
-TV is same per weight as adult
-so RR is double (24-30/min vs 10-12 in adults)
What is the oxygen consumption per weight of pediatric pts?
How does this compare to adults?
The Foramen Ovale typically closes between ___ & ___ (age)
What % of adults have a PFO?
3 months to 1 yr
20-30% of adults have PFO
The ligamentum arteriousum connects the ___ to the ___ distal to the ___
left subclavian artery
The ductus arteriosus typically closes at 10-15 hrs of life with anatomic closure at 4-6 weeks. What is the most common cause for this to reopen during this time?
! Where would you measure a preductal blood gas?
A difference of ___ mmHg between these two would indicate ____.
-preductal: R radial
-postductal: umbilical, posterior tibial, dorsalis pedis
-difference of 20 mmHg indicates persistant fetal circulation
! Explain why the following will lead to persistant fetal circulation:
increased pulmonary vascular resistance
labetalol + neonate =
can kill them
(kids are very HR dependent with a "floppy" hypoplastic heart that has little ability to compensate for decreased HR by increasing contractility)
What is most important to preventing anesthetic overdose in neonates?
(muffled heart tones = cardiovascular depression from anesthesia overdose)
What is the best way to detect hypotension in neonates?
(muffled heart tones = cardiovascular depression from anesthesia overdose)
Describe why neonates have such an elevated HR.
How does volume loss correlate to effect on BP?
neonates dependent on HR to maintain BP
(little sympathetic development so less vasoconstriction with hypovolemia/hemorrhage, CO reliant on HR not contractility)
10% volume loss = 15-30%
Total body water is __% of body weight in neonates vs ___% in adults
By __ to __ months it is close to adult values
40% in neonates
20% in adults
GFR in neonates is greately ___
It ___ __x by 5 weeks of age
How is clearance of renally excreted drugs affected by neonates?
Why is fluid management in neonates difficult? (x2)
-obligate sodium losers = unable to conserve volume
-decreased GFR = tend to excrete volume slowly (easy to volume overload)
Fetal hemoglobin is ___-shifted on the oxy-hgb dissociation curve
Fetal Hgb has an ____ affinity for oxygen
The P₅₀ of fetal hgb is ___ mmHg vs 27 mmHg in adults
At ___ months the oxy-hgb dissociation curve approximates adults
What compensates for physiologic anemia in neonates (d/t transition from fetal hemoglobin to adult hemoglobin occuring at 2-3 months)?
How would you interpret a hct of 30% in a neonate?
increased RBC concentration
may be better to maintain a Hct of 40% in neonates
Describe the mechanism neonates can use to generate heat
What stimulates this mechanism?
Brown fat can be metabolized
Describe anesthetic requirements of neonates & infants.
-MAC is 25% less in neonates than infants (less mature nervous system)
-MAC increases until peak at 3 months then decreases with increasing age
What 2 things occur at 3 months
-MAC requirements at their highest
-physiologic anemia from hgbF loss & transition to adult hgb
Why not use succs in neonates?
When might be the only time for using succs?
If you did use succs you would give ____ (higher/lower) doses
Give ___ (higher/lower) doses of nondepolarizers
-incidence of MH & myoglobinuria (undiagnosed MD, etc.)
-use if RSI to rescue from laryngospasm, etc.
-higher (they require more presumably d/t differences in ECF volumumes)
-lower (they are more sensitive to nondepolarizers)
-NM junction not mature until 2 months & fewer ACh receptors
Why is a precordial stethoscope so important when using volatile anesthetics in pediatrics?
inotropic depressing effects of inhaled anesthetics greatly enhanced
What may need to be altered when measuring EtCO₂in neonates?
may need to use mainstream analyzer (side stream would suck more out of circuit than what is going into the pt)
Hyaline membrane disease is a form of ___ syndrome
respiratory distress syndrome
Respiratory distress syndrome, describe the following intraop considerations:
-keep PaO₂near preoperative levels (shunting d/t alveolar collapse from lack of surfactant)
-more prone to pneumothorax d/t unstable alveoli & increased surface tension (think of law of laplace & 1 bubble emptying into another)
-maintain hct near 40 to optimize O₂delivery
-tend to be hypotensive but avoid excess fluid which can open PDA leading to more hypoxia
____ is a chronic pulmonary disorder that afflicts children with a history of RDS. (prognosis is good if they survive beyond the 1st year)
It is characterized by:
-___ airway reactivity
-___ airway resistance
-___ pulmonary compliance
-oxygen consumption is ____ 25%
-↑ airway reactivity
-↑ airway resistance
-↓ pulmonary compliance
-oxygen consumption is ↑ 25%
What is most important when performing anesthesia on an infant with history of broncho-pulmonary dysplasia?
airway management is most important
(reactive airway- ensure good anesthetic level before airway manipulation)
Pulmonary dysfunction is most prominent ____ with broncho-pulmonary dysfunction
during 1st year of life
(BPD occurs 2ndary to neonatal RDS)
! What are the 4 types of intracranial hemorrhage?
What is the most important & most frequent type?
-periventricular-intraventricular (most important, most common)
! Periventricular - Intraventricular hemmorrhage occurs ___% in neonates less than ___ wks gestational age
less than 35 wks
(prematurity is the most important risk factor)
Discuss intraop BP, PaO₂&PaCO₂management for a periventricular-intraventricular hemmorhage in a neonate
-A birth weight less than ___ is more prone to retinopathy of prematurity (retrolental fibroplasia)
-What should you keep PaO₂below to avoid this?
-hyperoxia causes retinal vasoconstriction & new retinal arteries form (vasculogenic process) that disturb retinal development
Pt has hx of prematurity, what is important information to illicit? (x2)
How might postop monitoring need to be adjusted?
Risk is decreased beyond ___ weeks postconception
-RDS at birth? apnea spells at home?
-monitor at least 12 hours (not candidate for outpatient)
Kernicterus is caused by toxic effects of ___ bilirubin
(liver unable to conjugate large amt at birth from fetal hgb breakdown)
What are the clinical features of kernicterus?
What are the parameters for hypoglycemia in neonates? (x3)
Why is there a difference?
Why should hypoglycemia be treated immediately?
Why should you avoid hyperglycemia?
What hyperglycemic glucose level should be avoided?
-preterm: less than 25 mg/dL
-neonates less than 3 days old: less than 35 mg/dL
-neonates more than 3 days old: less than 45 mg/dL
-neonates have a poorly developed system for maintaining adequate serum glucose
-can cause brain dmg
-hyperglycemia may cause osmotic diuresis & dehydration
-greater than 125 mg/dL
Hypocalcemia is Ca less than ___ mEq/L or an ionized Ca less than ___ mEq/L
__to__ mg of calcium ____ for each mL of blood given should be used to prevent hypocalcemia in neonates
1-2 mg calcium gluconate (not Cl for neonates)
Citrate from blood transfusions causes ___-calcemia
! What is the most common location of congenital diaphragmatic hernia? (name)
Left chest, foramen of Bochdalek
What alters the severity of congenital diaphragmatic hernia?
timing of herniation (early = more hypoplastic lung & poss. hypoplastic LV)
Positive pressure ventilation should not exceed ___ cmH2O with congenital diaphragmatic hernia
Do you paralyze for intubation with congenital diaphragmatic hernia?
no- awake intubation
Where should an art-line be placed for a congenital diaphragmatic hernia neonate?
R radial or temporal artery
(preductal to monitor oxygenation to the brain)
Why avoid nitrous with a neonate & congenital diaphragmatic hernia repair? (x2)
-increases pulmonary HTN
-may cause distention of GI
! What is the most common tracheoesophageal fistula?
Type C (blind upper esophageal pouch with distal esophagus fistula to the trachea)
What are the commonly associated congenital defects with tracheoesophageal fistula?
How does the ETT need to be placed for TE fistula?
above carina but below fistula (or else air leak into stomach)
Which abdominal wall defect has a hernial sac present?
(gastroschesis - no sac)
! What are the congenital anomalies associated with Beckwith-Wideman syndrome? (x4)
Incidence of preterm is higher with oomphalocele or gastroschisis?
What is the preop volume replacement for gastroschesis/oomphalocele?
___% of this volume should be of protein-containing solutions, why?
25% (otherwise oncotic issues & 3rd spacing)
! Management of anesthesia for abdominal wall defects in neonates:
-monitoring temp is important d/t____
-narcotics or volatiles are ____
-why monitor airway pressures?
-art line ____
-evaporative heat loss
-narcotics / volatiles allowed
-tight closure may necessitate postop vent
-recommended art line (avoid hypotension)
______ disease is an absence of ganglion cells in the rectum.
What does this cause?
How is it repaired?
-ganglion cells dilate bowel by producing NO & cause peristalsis so HD = tight bowel & obstruction
-repaired by bringing ganglionated bowl down to the anus
What electrolyte & pH abnormalities occur with pyloric stenosis? (x3)
-metabolic alkalosis (acidosis may occur if prolonged & depletion of bicarb occurs?)
(vomitting depletes H+ & the kidneys exchange H+ ions for K so less K reabsorption if less H+ secretion)
Greatest risk for necrotizing enterocolitis is for neonates born at ___ weeks or less than ___ g
less than 32 weeks or less than 1500g (primarily associated with preterm neonates)
____ occurs often with RDS neonates that require mechanical ventilation & appears on XRay as bowel gas penetration into the submucosal regions
____ often requires a near-total pancreatectomy and is the most common cause of recurrent hypoglycemia in neonates.
____ is a rare cause of respiratory distress in neonates where distended lobes compress normal lung parenchyma impairing venous return & causing arterial hypoxemia, tachycardia, tachypnea, cyanosis, & wheezing
-How is this treated?
-What is very important in regards to the method of induction?
-What agent should be avoided?
-maintain spontaneous breathing, do an inhalational induction (PPV can cause cardiac arrest)
-avoid nitrous (can cause further distention)
What is the most common symptom of cerebral palsy?
They also have varying degrees of ___ & ___
What type of surgeries do they have? (x2)
What is an induction concern?
-skeletal muscle spasticity
-muscle retardation & speech defects
-orthopedic & dental restoration
-GE reflux common (aspiration)
What type of anesthesia is almost always required for cerebral palsy pts?
What will be expected on emergence?
What does this necessitate?
-GERD & aspiration risk
-teeth issues often
-delayed emergence d/t cerebral damage
-make sure fully awake before extubation
____ causes hydrocephalus by obstructing the 4th ventricle
____ is caused by basilar subarachnoid paths being underdeveloped (cerebellum often protrudes into the spinal canal)
Which type is associated wtih myelomeningocele?
Low or high ___ will alter anesthetic plan with hydrocephalus.
-low = standard induction
-high = induce with care & maintain MAP (CPP = MAP - CVP or ICP whichever higher), avoid succs
! Failure of the neural crest to close can result in what 3 conditions? What are the differences between these?
Spina bifida - defect of the vertebral arches
Meningocele - sac containing meninges
Myelomeningocele - Sac contiaining meninges & neural elements
What NMBs would you use for a meningomyelocele repair?
What is an important allergy consideration?
succs ok but avoid nondepolarizers
-surgeon will want to test nerve function intraop & postop
-latex allergy incidence increased
What congenital disorder is associated with latex allergies (often anaphylactic)?
____ is premature closure of cranial sutures
The most common sutures involved are the ___
What is a big concern for craniectomy repair for craniostenosis?
What perop consideration relates to this?
art line a must
What is Lennox-gastaut syndrome?
severe epileptic encephalopathy (usually leads to mental retardation) (5% of childhood epilepsy)
Tuberous sclerosis is associated with ____
Preop anesthesia concerns with seizures
-get good hx from family (meds, last med taken, last seizure)
-make sure if any levels need drawn that they are before the procedure
What is the single transverse palmar crease common to Down Syndrome pts called?
What are the 4 parts of tetraology of Fallot?
pulm outflow obstruction
What are 4 considerations with Down Syndrome pts?
-airway (large tongue, difficult airway)
-neck (20% atlantoaxial instability)
-heart (40% incidence of TOF, ASD/VSD, or other congenital heart defects)
-pulmonary (pulm HTN & pneumonia)
What preop drugs would be given for down syndrome pt? (x2)
-anticholinergics (decrease secretions)
-oral midazolam common, ketamine IM for stubborn pts
____ is a congenital progressive disease of supportive tissue in the nervous system
____ spots are common
cafe au lait
Why is anemia common with cleft lip & cleft palate?
secondary to poor feeding
A ___ & ___ are done to repair cleft lip/cleft palate
What is the timing for these?
cheiloplasty (lip reduction)
palatoplasty (reconstruct palate) - usually delayed until 18 months
What are 4 mandibular hypoplastic syndromes?
Which is unilateral?
Goldenhar Syndrome (unilateral)
____ is an increased distance between the eyes (associated with many craniofacial abnormalities including Crouzon's & Apert syndromes)
! What is the bacteria associated with acute epiglotittis?
Describe the intubation process for acute epiglottitis
What about the extubation process?
-ENT surgeon in the OR room
-nasal intubation under direct vision
-to ICU until fever, inflammation, infection resolve
-direct vision under anesthesia to ensure resolution
epiglotittis occurs ____ where laryngotracheobronchitis (croup) occurs over ___
rapidly (less than 24 hrs)
gradual onset (24-72 hrs)
____ is a viral infection of the upper airways
What is characteristic of this disease?
-cough is brassy or barking in quality, low-grade fever, runny nose
Postintubation laryngeal edema can be prevented by allowing air leaks at ___ cmH2O
What can be used to treat this?
aerosolized racemic epinephrine & humidification
____ is the most common benign laryngeal tumor of childhood. Usually regresses at puberty. Airway management varies greatly between cases depending on the severity with awake intubation for severe cases.
____ results from aspirating secretions containing bacteria, may require surgical excision if not responsive to abx
____ may be used to prevent seeding other lung with pus
____ occurs in 2 forms: asphyxiating thoracic dystrophy (neonatal form) & diffuse interstitial fibrosis of the kidneys (child form)
-What is a trademark symptom to both?
-deformed thoracic cage
The gene on chromosome __ that is responsible for the ____ receptor is culprit in malignant hyperthermia
How long after exposure to a triggering agent might MH manifest?
____ has decreased mortality from 70% to 5%
What dose is administered?
may be 10 min, may be hours
2-3 mg/kg IV repeated every 3-5 min until 10 mg/kg given
What are the treatments (besides dantrolene) for MH? (x6)
-immediate termination of anesthetic
-prompt conclusion of surgery
-treak hyperK as needed
-hydration & maintenance of urine output
70% of pts with MH will have increased levels of ___ at rest
Exposure to ____ & ___ of a muscle biopsy sample can diagnose MH although it is assocated with a high level of false positives
What drug is good to use in the case of MH?
How to prepare the anesthesia machine for a pt with MH? (x3)
flush with 100% O2 for 5-20 min
fresh CO2 absorber
____ is an inherited disorder that causes dysfunction of the autonomic nervous system & 50% die by age 4 d/t respiratory complications (hypoxia w/o autonomic respiratory response)
-sudden changes in BP
-baroreceptor reflex disrupted so that HR changes disconnected from BP
-temp control erratic
-no pain response
(Shy-Drager syndrome similar but does not have systemic HTN like Riley-Day)
___ are tumors that occur anywhere along the sympathetic ganglion chain
60-70% occur in the adrenal medulla & retroperitoneal area
____ are the most common malignant renal tumors in children
How is BP altered?
-Systemic HTN so severe may cause encephalopathy or seizures
-Hypokalemia 2ndary to hyperaldosteronism
Why would you place central line in upper extremeties & avoid lower extremity central line for a nephroblastoma?
IVC may need to be clamped
Describe superior mediastinal syndrome
a mediastinal lymph node may compress the superior vena cava & trachea (an oncological emergency)
What happens to CO with major burn injuries in the initial & later phases?
-initially profound myocardial depression d/t circulating myocardial depressant factore
-after 24 hours system becomes hyperdynamic (CO to 2x normal)
What is the best treatment of carbon monoxide poisioning?
(decreases half-life of carboxyhemoglobin from 4-6 hrs to 40-80 min)
Describe metabolism in burn pts
increases in porportion to the extent of the burn injury (can more than double)
(TPN may be needed to meet this increased metabolism)