Pedi 2

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CateQ
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266682
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Pedi 2
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2014-03-16 21:21:24
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Anesthesia
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pedi 2
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  1. Preoperative assessment of pedi patient
    Medical History

    1. Gestational age and weight

    • 2. Events during labor and delivery,
    • including APGAR scores

    3. Neonatal illnesses and hospitalizations

    • 4. Congenital anatomic and metabolic
    • anomalies or syndromes

    • 5. Previous surgeries and problems with
    • anesthetics

    6. Family history of anesthetic problems

    7. Recent URI, croup or asthmatic episodes
  2. Physical Examination:
    1. General appearance including alertness, color, congenital anomalies, head size.

    2. Vital signs, height, weight

    3. Presence of loose teeth

    4. Respiratory system examination for signs of URI, asthma

    • §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. 

    5. Cardiovascular system examination for presence of murmurs and vascular access

    6. Neurological examination
  3. Respiratory system examination for signs of URI, asthma
    Children with viral rhinitis (runny nose) may undergo anesthesia under selected circumstances

    • anesthesia with URI
    • pretreat with atropine-muscarinic blockade
    • avoid laryngoscopy
    • use warm humidified air


    • §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, non acute, non purulent URI are mild and easily treatable.
  4. miller fasting guidelines
  5. breast milk and formula fasting guidelines
    breast milk is a solid but for kids >6 mod its 4 hours for kids older than 6 mos-3 years its 6 hours

    older than 3 its a meal

    formula is a solid
  6. 5 Dimensions of physical harm
    fear of pain, mutilation, death

    fear of separation of parents

    fear of unknown, don't know how to act in hospital

    • loss of control autonomy and confidence
    • witnessing parents anxiety or experiencing anxiety

    touching private parts

    the overall negative surgical experience, make a child scared
  7. child related factors for stress during surgery
    Child related:

    1-5 yo

    Bad previous experiences

    Shy and inhibited children

    Lack of development maturity and social adaptability

    High cognitive levels

    Isolated
  8. parent related factors for a negative surgical experience
    High trait, anxiety

    Divorced- fragmented families

    Multiple surgical procedures
  9. environmentally related factors for a negative surgical experience
    Sensory overload

    Conflicting messages

    Operating room
  10. prep anxiety and post op sleep disturbances
    • up to 75% of children have prep anxiety
    • up to 14 days postop increased sleep disturbances
    • behavior problems up to 6 months
  11. older children (>7 years)- what puts them at risk of prep anxiety
    • shy or inhited
    • anxious parents
    • previous upsetting surgical experience
    • do not have siblings
    • no preschool
    • greater risk of prep anxiety
  12. preparing for induction
    Identify developmental milestones

    Prepare parents and family prior to OR visit or prior to entering OR.

    • Consider parental presence with, without,  or
    • versus sedation.

    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. teenagers are most afraid of being exposed 

    EMLA cream prior to IV
  13. school age children psychology to be sensitive to
    • crisis of autonomy and self control
    • creative imagination
    • do not give too much detail about surgery 
    • pre operational thinkers very literal, be careful with similes and metaphors
    • Bodily integrity and need reassurance
    • Do best when given explanations
  14. infants 1-3 psychology
    • safety and trust
    • too young to understand explanations
    • increased risk of sleep disturbances 
    • comforted by favorite toy-transitional objects
  15. Preoperative sedation how do you decide whether or not to do it?  Age groups?
    Infants< 6 months: keep warm, cuddle, use pacifier.

    Children at 6 to 9 months develop separation anxiety.

    • Assess those children ( toddlers to teenagers who may benefit from pharmacological
    • intervention or non pharmacological intervention.

    • Effective,therapeutic communication is paramount.
    •  
    • ALL COMMUNICATION WITH CHILDREN SHOULD BE THERAPEUTIC.

    Parental Presence may be effective or counterproductive.
  16. Contraindications to preop sedation
    • altered mental status(acute)
    • elevated ICP
    • difficult airway
    • hypovolemia
    • respiratory dysfunction.
  17. Primary Goal of prep sedation
    Primary Goal is smooth separation from parents and ease the induction of anesthesia.
  18. Communicating with Pediatric patients
    Do not be condescending

    Don’t tell them they’re silly or childish.

    Don’t laugh at children unless you’re CERTAIN they’re deliberately trying to be funny.

    No teasing (long term care patients with frequent surgeries may be exception).

    SOTO VOCE

    Speak at eye level

    Speak in terms they can understand

    DO not discuss their illness in front of them without including them.

    You don’t always have to make eye contact.  (They’re listening despite what you may think).
  19. Midazolam dose
    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.
  20. methohexital dose
    Methohexital 20-30 mg/kg PR ( onset 5 mins. Unpredictable, duration 2 hours).
  21. fentanyl lollipop
    intranasal dose
    Fentanyl lollipop 10-15 mcg/kg ( onset 5-20 mins.) intranasal 2mcg/kg
  22. Ketamine dose
    Ketamine 4-10mg/kg IM; 8mg/kg PO; 1-2 mg/kg IV (onset of IM=1 min.  Use with midazolam and glycopyrolate.
  23. common adjuncts to sedation

    atropine
    metoclopramide
    ranitidine
    Common Adjuncts

    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)
  24. Preparing for induction equipment
    IV pumps for Neonates, Buritrols for infants, minidrips for children < 3 yrs with 250 cc bags.  REMOVE ALL AIR BUBBLES.

    ETT and suction catheter size (see next slide)

    • ET diameter = 
    • (16 + age in years)/4. for an uncured tube

    • ET length at lip in cm =12 + Age/2  or 
    • Age + 10.
  25. Laryngoscope sizes for
    preterm, neonate
    neonate to age 1.5 years
    Age 3 and older
    Age 1.5 to 4
    Age 3-6
    Laryngoscope Blade Age  

    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
  26. how do you figure out the size of an ETT?  ET length at lip
    ET diameter = (16 + age in years)/4. for an uncuffed tube









    • Tube sizes - modified Cole formula for uncuffed ETT (age [y]/4 + 4 mm ID) and
    • chosen one-half size less for cuffed ETT.

    ET length at lip in cm =12 + Age/2  or  Age + 10.
  27. ETT: Cuffed Vs. Uncuffed?
    Cuffs increase the risk of airway mucosal injury;

    Cuffs are not necessary because appropriately sized uncuffed tubes seal well at the cricoid ring

    • Adding a cuff necessitates a smaller tube, which increases airway resistance and work
    • of breathing
  28. Inhalational techniques: for children
    Slow inhalational induction-cooperative children.  slowly turn up the agent.  hold mask and move with child

    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.
  29. induction techniques
    Most common technique for children. (steal induction)

    Excitement stage

    1 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.

    Slow inhalational induction.

    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.

    could do IM ketamine

    IV induction.—Higher metabolic activity vs. immature hepatic function.

    • Increased dose of propofol in
    • infants and young children due to larger ECW and distribution.
  30. IV induction- child specific
    IV induction.—Higher metabolic activity vs. immature hepatic function.Increased dose of propofol ininfants and young children due to larger ECW and distribution.

    pretreat with atropine if succs needs to be used
  31. why do kids have faster inhalation induction? what drugs should always be available?
    ALWAYS HAVE SUCCS, ATROPINE(0.02mgs/kg), EPI (0.01MCG/KG) DRAW UP

    • kids have a lower FRC with higher alveolar ventilation
    • higher blood flow to vessel rich groups
    • FA/FI is higher-rapid rise
  32. what is the narrowest part of a pedi airway
    cricoid
  33. what should your tube leak be in a pedi patient
    Ensure slight tube leak (10-25 cm H2O)
  34. one a pediatric airway is established its safe as long as you tape it well until patient is extubated T/F?
    FALSE

    On infants and small children: extubation is possible with just extension of head.

    Neck flexion may cause R main stem intubation.
  35. Emergence delirium/agitation
    • Described as: 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.
  36. emergence delerium statistics
    • Reported in up to 5% of adult case but can be as high as 15 -50% in children (one study
    • reported 80%)
  37. causes of emergence delirium
    Rapid emergence

    Anesthetic choice- volatiles are implicated but so is prop

    Pain - can use

    • Toradol 1 mg/kg,
    • intranasal fentanyl 2 mcg/kg,
    • fentanyl IV2.5 mcgs/kg
    • Clonidine 3 mcg/kg,
    • dexmetatomindine.

    Surgical type– (Tonsils, thyroid, middle ear)

    Age (2-5)

    Preoperative anxiety

    • Temperament
    • some reports cited up to two days of regressive behavior
    • perceptual disturbances
    • psychomotor agitation

    age is easily confused with less able to cope

    impulsive, less adaptable, not social-high risk
  38. IV Fluids-Maintenance Rate:
    IV Fluids-Maintenance Rate:

    a.First 10 kg = 100cc/kg/day = 4 cc/kg/hr

    b.Second 10 kg = 50 cc/kg/day = 2 cc/kg/hr

    c. Each subsequent 1 kg > 20 kg = 20 cc/kg/day = 1 cc/kg/hr

    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.
  39. estimation of blood volume
    Estimation of Blood Volume:

    Premature Infants =  100 ml/kg

    Term Newborn =  95 ml/kg

    1 year age = 75 ml/kg

    3 years age=adult 70 ml/kg

    Adult female = 65 ml/ kg

    Adult male = 70 ml/kg
  40. blood product replacement
    Blood Product Replacement

    10 cc/kg packed RBC will raise HCT 3-4%

     10-20 cc/kg FFP if bleeding isacute; 1 ml of   FFP

    • contains 1 unit of coagulation
    • factor activity.

    • 1 unit/kg of Factor VIII will
    • raise plasma level by 2%

    •  1 unit of platelets contains at
    • least 5.5 x 10 platelets  in 50 to 70 ml
    • of plasma; 1 unit/10kg or 20 ml/kg
  41. Intraoperative fluid management
    Management of blood loss
    Estimated Allowable Blood Loss

    • EABL=
    • EBV x Starting hematocrit –Target hematocrit

    Starting hematocrit

    Example:

    •   3 year old male child weighs 15 kg; starting
    • HCT of 38% with Target or allowable HCT 25%.

    •  EABL=(15x70)x(3825)/(38=1050x13/38=360ml
    • (est.)

    Estimating volume of blood transfusion needed:

    • ([Desired HCT – Present HCT] x EBV )/
    • Hematocrit of PRBCs (60-80%)

    • 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.

    • Estimate ABL based on child’s
    • health history.

    Always use blood warmers.
  42. Children younger than ______ are particularly vulnerable to adverse events in the perioperative period.
    one
  43. open system
    • T piece-
    • high flows of anesthesia and fresh gas that exceed minute ventilation of the patient, no rebreathing, no resistance no valves.  lots of waste.  lists of heat and moisture system
  44. closed system
    plastic bag filled with sevo, some resistance, no fresh gas, lots of rebreathing.  very efficient, very conservation
  45. ideal pediatric circuit
    ideal

    • 1.)prevent rebreathing of Co2
    • 2.)low resistance to breathing
    • 3.)light weight
    • 4.)unidirectional valves or high gas flows
    • 5.) conserve heat and moisture as much as possible

    our tradition pedi semi closed systems with a CO2 absorber is adequate for most children
  46. Disadvantages  of semi closed circuits with small infants
    Disadvantages with small infants

    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
  47. Mapleson D
    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)
  48. Reservoir bags
    Reservoir bag volume should accommodate child’s Vital Capacity

    • nGuidelines:
    • 500 ml bag for newborns, 1000ml bag for 1-3 years, 2000 ml bag for children
    • older than 3

    •  Most infants and children can use the
    • semi-closed system with absorber
  49. mapleson D
    mapleson D systems are recommended for children under 10 Kg, more sensitive to change in gas flows
  50. Tonsillectomy and Adenoidectomy
    Hypertrophy of adenoidal and Tonsillar tissue

    One of the most common pediatric surgical procedures.

    • Hyperplasia may lead to FTT, speech disorders, olbigate mouth breathing, sleep
    • disturbances, orofacial abnormalities with a narrowing of the upper airways, and dental abnormalities.

    Assess for severity of sleep apnea.  Obstruction at the base of the soft palate.

    • OSA pedi patients are prone to rapid
    • desaturation during induction.  Must be
    • deep for induction.

    May require 24 hour admission.

    •  Long standing OSA can lead to cor pulmonale, pulmonary hypertension, and
    • ventricular failure.

    • Pediatric OSA patients are also sensitive to the respiratory depressant effects of
    • narcotics and standard weight based doses for narcotics may exceed what is safe
    • to administer to the patients. particularly morphine.

    Postoperative bleeding is a serious risk.  Pt. my need to be brought back to OR.  RSI.
  51. how much blood does a child usually lose during tonsillectomy
    4ml/kg of blood loss during a tonsillectomy
  52. Tonsillectomy and Adenoidectomy

    Preoperative Assessment
    BMI

    Hx of URI

    Use of medications: antihistamines, antibiotics

    Physical examination

    • Mouth breathing,  audible respirations,
    • nasal speech

    Chest retractions

    Facial features.

    Swallowing difficulties

    OSA symptoms

    Speech difficulties and evidence of hearing impairment.

    History of previous surgeries and hospitalizations resulting from URIs
  53. Tonsillectomy and Adenoidectomy

    anesthetic management
    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.

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