Pediatric Lecture 2

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cmatthews
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265817
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Pediatric Lecture 2
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2014-03-12 19:02:38
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BC CRNA Adv Priniciples Pediatric Lecture
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March 10 lecture
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  1. What are the anesthesia considerations for ENT surgery?
    • Caution sedation
    • Assess for difficult airway and mask
    • Consult with surgeon and family
    • Smooth, deep induction (communicate effectiveness of ventilation)
    • Minimize narcotics and optimize non narcotic pain management
    • Discuss emergence with surgeon (effective communication with OR personnel).
    • Awake vs deep extubation.
    • Strict monitoring while transporting and reporting to PACU
  2. What are the anesthetic considerations for a T & A?
    • Calm controlled induction (caution with preoperative medications)
    • Assess ability to ventilate. May need to reposition or utilize another provider.
    • Gentle, deep intubation.
    • Prevent bleeding. (4ml/kg)
    • Maintain correct level of anesthetic depth and prepare for incision.
    • Actively communicate with surgeon and plan for emergence.
    • Recognize proper emergence criteria:Establish plan for deep vs. awake extubation.
    • Post operative pain may be severe after tonsillectomy (laser or electrocautery).
    • Steroids have been found to be efficacious in decreasing pain from swelling.
    • Local infiltration is more beneficial for blood loss reduction rather than pain reduction
  3. What are the disadvantages with small infants and a semi closed circuit?
    • Increased resistance with spontaneous breathing (inspiratory and expiratory valves)
    • Large volume of absorber system acts as a reservoir for anesthetic agents
    • Large compression volume of tubing
  4. What type of breathing circuit is used for small infants?
    • Nonrebreathing, open circuit (Mapelson D or Bain)
    • Rebreathing is prevented with high flows (2-2.5 x MV)
    • Useful for very small infants to breath spontaneously. (Capnography essential)
  5. Reservoir bag volume should accommodate child’s Vital Capacity. What are the guidelines for bag sizes?
    • 500 ml bag for newborns
    • 1000ml bag for 1-3 years
    • 2000 ml bag for children older than 3
  6. What are our concerns with URI in pediatrics?
    • Children with URI, particularly less than 1 year of age, have an increased risk of respiratory related adverse events intraoperatively and postoperatively
    • Symptomatic infants with URI have a decreased time to desaturation during apnea.
    • Endotracheal intubation seems to be a major risk factor for hypoxemia, bronchospasm, and atelectasis in children with URI.
    • Temporary airway hyperreactivity may exist for 6 weeks after a viral infection. Most complications seen in older children (> 1 year of age), with mild, nonacute, nonpurulent URI are mild and easily treatable.
  7. What are the NPO guidelines for breastmilk?
    BM is a solid but for kids younger than 6M it’s 4 hours, for those older than 6M to 3yr, it’s 6hr and then it’s 8 hours.
  8. How do you prepare each age for induction ?
    • Infant < 6months rarely need sedation
    • Separation anxiety for children 1-3 years old. (stormy inductions)
    • Incorporate play or active participation with preschool age children (3-6y). (Mastery and participation)
    • Encouraging, supportive, complementary, positive comments with school age child.
    • Protection from harm and embarrassment in older children.
  9. What are some contraindications for pre-op sedation?
    altered mental status (acute), elevated ICP, difficult airway, hypovolemia, or respiratory dysfunction.
  10. What is the dosing for pre-op sedation Midazolam?
    • 0.5-1 mg/kg po not to exceed 20 mg( peak effect in 30 minutes)
    • 0.1- 0.3 mg/kg IM not to exceed 10mg.
  11. What is the dosing for pre-op sedation for Methohexital?
    Methohexital 20-30 mg/kg PR ( onset 5 mins. Unpredictable, duration 2 hours).
  12. What is the dosing for Fentanyl (pre-op sedation)?
    • Fentanyl lollipop 10-15 mcg/kg ( onset 5-20 mins.)
    • Intranasal 2mcg/kg
  13. What is the dosing for Ketamine  (pre-op sedation)?
    • Ketamine 4-10mg/kg IM; 8mg/kg PO; 1-2 mg/kg IV (onset of IM=1 min.  
    • Use with midazolam and glycopyrolate
  14. What are the common adjunts for pre-op sedation in pediatrics?
    • Atropine: 0.02mg/kg IM/PO; 0.01mg/kg IV (onset 2 mins)
    • Metaclopramide: 0.1mg/kg po ( onset 1 hour)
    • Ranitidine: 2 mg/kg PO, 0.5-1 mg/kg IV (onset 30 mins)
  15. What are the special IVF requirements in pediatrics?
    Iv pumps for Neonates, Buritrols for infants, minidrips for children < 3 yrs with 250 cc bags. REMOVE ALL AIR BUBBLES
  16. What are the ET measurements we need to know?
    • ETT and suction catheter size (see next slide)
    • ET diameter = {16 + age (years)}/4.
    • ET length at lip in cm =12 + Age/2 or Age + 10.
  17. What are the laryngoscope sizes for pediatrics?
    • Miller 0: Preterm, Neonate
    • Miller 1: Neonate to age 1.5 years
    • Miller 2: Age 3 and older
    • Wis-Hippel: 1.5 Age 1.5 to 4
    • Macintosh 2: Age 3-6
  18. What are the sizes and cuff volumes for LMA?
    • Size 1.0: Neonate/Infants ? 5kg; 4ml
    • Size 1.5: Infants 5 – 10 kg; 7ml
    • Size 2.0: Infants/children 10 – 20 kg; 10ml
    • Size 2.5: Children 20 – 30 kg; 14ml
    • Size 3.0: Children/Small adult > 30 kg; 20ml
    • Size 4.0: Normal/Large adolescent/adult; 30ml
    • Size 5.0: Large adolescent/adult; 40ml
  19. What is the single breath induction?
    • Single VC breath of 8% Sevo with 70% N2O.
    • Occlude circuit and fill with Agent, open APL.
    • Flavor mask, stickers, or color mask (keep child engaged)
    • Child takes a deep breath, blows it out, then holds his/her breath.
    • Place mask, and let breath mixture.
    • Hold breath again and repeat while keeping mask against child’s face
  20. What is the slow inhalation technique induction?
    • Most common technique for children. (steal induction)
    • Excitement stage1 to 3 L/min of O2 and N2O with volatile gradually increased in 0.5% increments.
    • Initially, mask does not touch face until lid reflex disappears.
  21. Why is an inhalation induction so fast in kids?
    Fast inhalation in kids because lower FRC, higher alveoli ventilation, and higher blood flow to VRG. Rapid rise in FA/FI
  22. What is the leak we want??
    Ensure slight tube leak (10-25 cm H2O)
  23. What is emergence delirium or agitation?
    • A dissociative state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolable crying, moaning, kicking, or thrashing.
    • Typically lasts 5-15 mins post op and is self limiting.
    • Reported in up to 5% of adult case but can be as high as 15 -50% in children (one study reported 80%)
  24. What are the causes for emergence delirium?
    • Rapid emergence
    • Anesthetic choice
    • Pain
    • Surgical type– (Tonsils, thyroid, middle ear)Age (2-5)
    • Preoperative anxiety
    • Temperament
  25. What can we give for pain to prevent emergence delirium?
    • Toradol 1 mg/kg
    • Intranasal fentanyl 2 mcg/kg
    • IV fentanyl 2.5 mcgs/kg
    • Clonidine 3 mcg/kg
    • Dexmetatomindine.
  26. How long does emergence delirium or agitation last in pediatric patients?
    typically lasts 5-15min post-op and is self limiting
  27. What is the O2 consumption in newborn, children, and adults
    • 5-8 cc/kg/min in newborn
    • 4-6 cc/kg/min in children
    • 3-5 cc/kg/min in adults
  28. When would we use LR and when would we use D5?
    • Use LR for fluid replacement in healthy child.
    • Use 5% dextrose for premature, septic, infants of diabetic mothers and those receiving TPN. Measure blood glucose closely.
  29. What are the estimate blood volumes for each age/sex
    • Premature Infants = 100 ml/kg
    • Term Newborn = 95 ml/kg
    • 1 year age = 75 ml/kg
    • 3 years age to adult 70 ml/kg
    • Adult female = 65 ml/ kg
    • Adult male = 70 ml/kg
  30. 10 cc/kg packed RBC will raise HCT __-___%
    3-4%
  31. when would we give FFP and how much would we give?
    10-20 cc/kg FFP if bleeding is acute
  32. What does 1ml of FFP contain?
    1 ml of FFP contains1 unit of coagulation factor activity
  33. 1 unit/kg of Factor VIII will raise plasma level by __%
    2%
  34. 1 unit of platelets contains how many platelets (and in how much plasma)?
    1 unit of platelets contains at least 5.5 x 10 platelets in 50 to 70 ml of plasma
  35. How would we dose platelets?
    1 unit/10kg or 20 ml/kg
  36. If EBL is 1/3 of allowable blood loss, what should we replace it with? What if it's more than allowable blood loss?
    • If EBL is 1/3 of ABL, replace with LR. If greater than 1/3, consider replacement with 5% Albumin.
    • If EBL > ABL, Use PRBC with colloid. Platelets and FFP should be guided by blood tests.

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