possible severe pain post-op- steroids may decrease pain from swelling
T or F, deep extubation is associated with fewer airway complications?
F, there's no difference
What type of airway circuits are commonly used for pedi?
Semi closed circuits, like normally used for adults
Disadvantages in using semi closed circuits with small infants
increased rx with spontaneous breathing (insp and exp valves)
large volume of absorber system acts as a reservoir for anesthetic agents
large compression volume of tubing
Reservoir bag volume for a child
Should accommodate child's VC
Newborn reservoir bag volume
500 ml
Child 1-3 yo reservoir bag volume
1L
Child > 3 yo reservoir bag volume
2L
Components of the ideal pedi breathing circuit
No CO2 rebreathing
Low rx to breathing
Lightweight
Unidirectional valves or high gas flows
Conserve heat and moisture as much as possible
The Mapleson D circuit is recommended for kids < ____ kg.
10 as it is more sensitive to gas change flows and humidification and actual volume delivered is greater than other circuits
Pedi pre-op assessment
Gestational age and weight- (L or R of normal)
Events during L+D, APGAR scores
Neonatal illness and hospitalizations
congenital anatomic and metabolic issues
prev surgeries / anes issues
family h/o anes issues
recent URI / croup / asthma
T or F, a child < 1 year old with a URI has an increased risk of respiratory related adverse events intra-op and post-op
T
Symptomatic infants with URI have an increased time to desat during apnea
F, decreased time to desat
Temporary airway hyper reactivity may exist for ____ after a viral infection
6 weeks
Most complications seen in older kids (> 1 y.o.) with mild, non acute, non purulent URI are mild and easily treatable, T or F?
T
Interventions for a child with non purulent rhinitis and URI
Pretreat with atropine for muscarinic blockade
Warm humidified air
Avoid DL if possible
Fasting guidelines
< 6 mo
milk and solids
4 hours
Fasting guidelines
< 6 mo
clear lix
2 hours
Fasting guidelines
6-36 mo
milk and solids
6 hrs
Fasting guidelines
6-36 mo
clear lix
3 hrs
Fasting guidelines
>36 mo
milk and solids
8 hours
Fasting guidelines
>36 mo
clear lix
3 mo
Formula is considered a liquid, T or F?
F, solid
What types of fears r/t surgery do grammar school kids typically have?
Fear of mutilation, blood, gore, death
Child related risk factors for post-op delirium
ages 1-5 years
bad previous experiences
shy and inhibited children
lack of development- maturity and social adaptability
high cognitive levels
isolated
Parent related risk factors for post-op delirium
anxiety, high strung
divorced
multiple surgical procedures
Environment related risk factors for post-op delirium
Sensory overload
Conflicting messages
OR
T or F, infants < 6 mo frequently need sedation
F, rarely require sedation
Strategy for participation with school age kids
games / participation
Mapleson D and Bain circuits are examples of _____ circuits
open
Mapleson D and Bain circuits are useful for small infants b/c ?
allows them to breath spontaneously with minimal rx
Separation anxiety occurs between what ages?
1-3 yo
Strategies for dealing with induction for a school age child
encouraging
supportive
complementary
positive comments
Teen concern with surgery
fear of embarrassment / being seen naked
Goal of pre-op sedation
smooth separation from parents and ease the induction of anesthesia
When does sep anx begin to develop
6-9 mo
Infants < 6 mo, how to ease transition into OR / induction
keep warm, cuddle, pacifier
Is it acceptable to give school age kids details about their surgeries?
Avoid too much detail as they are very literal thinkers
Avoid similes/ metaphors
contra-ind to pre-op sedation
altered mental status (acute- trauma)
elevated ICP
difficult airway (unless part of difficult airway strategy)
hypovolemia
respiratory dysfunction
Midaz pre-op sedation dose
PO
IM
max dose of each
PO 0.5-1 mg (peaks in 30 mins), max 20 mg
0.1-0.3 mg IM, max 10 mg
Fent pre-op sedation dose
10-15 mcg/ kg (onset 5-20 mins)
Intranasal 2 mcg /kg
Ketamine pre-op sedation dose
IM
PO
IV
IM 4-10 mg / kg
PO 8 mg / kg
IV 1-2 mg / kg
What meds should be given with pre-op ketamine
midaz and glyco
Atropine IM/ PO dose and IV dose
IM/ PO 0.02 mg/ kg
IV 0.01 mg/ kg (onset 2 mins)
What size bag of IVF should be used for kids < 3 yo
250 cc
Laryngoscope blade sizes:
preterm / neonate
neonate to age 1.5 years
age 1.5 - 4
age 3 and over
preterm / neonate Miller 0
neonate to age 1.5 years Miller 1
age 1.5 - 4 Wis-Hippel 1.5
> 3 yo Miller 2 or MAC 2
Formula to calculate ETT size
ETT diameter (uncuffed) = 16 + age (years) / 4
How should tube size derived from the formula be modified if a cuffed tube is desired?
Go down a half size
Formula to determine ETT length at lip in cm
age + 10
Adv to using a non cuffed ETT
Cuffs increase risk of airway mucosal injury
Cuffs unnecessary b/c appropriately sized uncuffed tubes seal well at cricoid ring
Adding a cuff necessitates a smaller tube, which increases airway rx and WOB
Describe how to perform a slow mask induction
Child selection- cooperative and will breathe when instructed
Give 70% N20 until child relaxes
Then increase sego by 1/2 % per breath
Describe how to perform a "single breath" mask induction
Child selection (ages 1-3 yo) or uncooperative child
Close APL
Sevo up to 8%, 70% N20
Obstruct circuit and fill with agent
Open APL
Have child breath agent
T or F, mask inductions are typically used for intubation?
F, for IV placement, then intubated is performed with IV agents
Pedi epi dose
0.01 mg/ kg
Pedi atropine dose
0.02 mg / kg
When masking a child CPAP of __ to __ cmH20 is desired.
10 to 15
What factors account for kids faster inhalation induction
Rapid rise in Fa/Fi
Lower FRC
Higher alveolar ventilation
Higher blood flow to VRG
T or F, a slight tube leak is desired?
T
What effects can head movement have on ETT position in infants and small children?
Head extension can cause extubation
Neck flexion may cause right main stem intubation
In general, kids <___ yo get (cuffed or uncuffed?) tubes?
8
uncuffed
Describe emergence delirium in pedi
Dissociative state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, inconsolable crying, moaning, kicking, thrashing