Pediatric Anesthesia Exam 2

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nikistivers
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286048
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Pediatric Anesthesia Exam 2
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2014-11-29 16:18:45
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Pediatric anesthesia
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Rest of pharmacology, pediatric airway
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  1. Benadryl
    1.25 mg/kg PO

    Lasts 3-6 hours
  2. Tagamet is not useful if given ___ hours before surgery
    4 hours.  Needs one hour to take effect. Tagamet induces the CYP 450 enzyme
  3. Reglan dose
    0.15 mg/kg

    induces gastric emptying by antagonizing dopamine.

    directly works on chemoreceptor trigger zone for antiemetic effect
  4. Zofran dose
    100-150 mcg/kg q 6 hours
  5. Zofran class and advantages
    Class- serotonergic antagonist (5HT3)

    Advantages- prevents N/V and decreases severity of existing N/V
  6. Atropine dose
    0.02 mg/kg
  7. Scopolamine dose
    0.01 mg/kg
  8. Robinol dose
    0.01 mg/kg
  9. Which two of the following drugs are tertiary amides?

    Scoplamine, atropine, robinol, aspirin
    Scop and atropine. They can cross the BBB.
  10. IM dose of Succinylcholine
    3mg/kg in infants

    1.5-2 mg/kg in children
  11. Which anticholinergic is the most effective antisialogogue?
    Scopolamine
  12. What do you do if your patient goes into cardiac arrest from hyperkalemia?
    • 1. hyperventilate
    • 2. give 2-4 mg/kg calcium choloride
    • 3. give dextrose 0.5 g/kg with insulin 0.1 unit/kg
    • 4. give kayexelate 1-2 grams/kg
  13. Nimbex dose
    0.1 mg/kg

    shorter acting in peds than in adutls
  14. nimbex mode of elimination
    hoffmann

    pH and temp dependent
  15. Vec and Roc mode of elimination
    hepatic and renal
  16. Vecuronium dose
    < 1 year= 0.07 to 0.1 mg/kg

    children= 0.1 mg/kg

    considered long acting in peds
  17. rocuronium dose
    0.6 mg/kg

    1.2 mg/kg for RSI
  18. Pancuronium dose
    0.1 mg/kg

    Used for cardiac surgery for HR support
  19. What are children more susceptible to with inadequate NMB reversal?
    Hypoxemia and CO2 retention
  20. Which muscle is the best indicator of diaphragm function when considering reversal?
    adductor pollicis. It is more sensitive to NMB than the diaphragm, so if the adductor pollicis shows a TOF of 4, we can be confident that the diaphragm is functional. The diaphragm is one of the last muscles to be affected by NMB and one of the first to come back.
  21. What is the principle factor in determining lung compliance?
    Volume
  22. When I say compliance, you say
    collapsible.

    Volume increases throughout childhood, and is the principle determining factor for compliance
  23. The highest negative pressure generated for a neonate is
    70 cm H2O.

    Adults is 100 cm H2O
  24. Law of LaPlace
    Pressure= tension/resistance

    Neonates cannot suck in big volumes of air b/c their airways collapse b/c of the relatively increased tension
  25. Functional residual capacity
    The volume of air that remains in the lungs at the end of each normal expiration
  26. Laryngeal braking
    The FRC of an infant is set by an automatic stopping of exhalation at a long volume in excess of the relaxation volume. They have a prolonged expiration constant.
  27. Specific airway resistance
    the reciprocal of resistance (1/R)

    smaller airways=higher resistance

    is higher in preterm infants and decreases thru the 1st 5 years of life
  28. At what age do the number of alveoli increase exponentially?
    5 years old.

    Significantly decreased resistance.
  29. PaO2
    peripheral chemoreceptors in carotid and aortic bodies
  30. PaCO2 and pH
    central chemoreceptors in the medulla oblongata
  31. Tracheal compliance in newborns is ____ that of adults
    Twice.

    Importance in possibility of tracheal collapse during inspiration and expiration
  32. What neural circuit group in the ventrolateral medulla are thought to be the respiratory rhythm center generators?
    pre-Botzinger complex and retrotrapezoid nucleus/parafacial respiratory group
  33. when does the vast majority of alveolar formation occur?
    after birth
  34. How many terminal sacs does the neonatal lung have at birth typically?
    10-20 milling terminal air sacs
  35. Changes in what elicits an acute decrease in pulmonary blood flow?
    • PO2
    • PCO2
    • pH
  36. Describe the pressure changes that causes functional closure of the left to right one-way flap valve across the foramen ovale?
    • increased left atrial pressure
    • decreased right atrial pressure
  37. List four respiratory issues that are especially important to the pediatric popluation
    • 1. upper respiratory tract infections
    • 2. Reactive airway disease/asthma
    • 3. Ventilatory problems relating to prematurity
    • 4. Congenital diesases
  38. Name four interventions that may relieve laryngospasm
    • 1. jaw thrust
    • 2. positive pressure
    • 3. IV lidocaine
    • 4. IV succinylcholine (this WILL work)
  39. Where is the smallest part of the pediatric trachea?
    Often times it is below the cords b/c the pediatric trachea tends to taper in diameter

    (the underdeveloped cricoid cartilage)
  40. What cervical level does the pediatric larynx lie?
    C 3- C 4
  41. Glottic opening in a preterm infant is at what cervical level?
    C3
  42. Glottic opening in a full term infant is at what level?
    C4
  43. Glottic opening in an adult is at what cervical level?
    C5
  44. Factors that make pediatric airways different from adults include?
    • Relatively larger tounge
    • angled vocal cords
    • differently shaped epiglottis (ohmega)
    • funnel shaped larynx
  45. What are the age parameters for uncuffed ETT use?
    < 8 years old

    A tight fitting ETT may cause edema and trouble upon extubation
  46. Poisueille's Law
    If radius is halved, resistance increases 16 times

    • Normal infant tracheal radius is 4 mm
    • Adults is 8 mm

    Infants have 16 times the resistance to air movement than adults to start with. Edema and secretions are not tolerated well.
  47. The high larynx position and position of the tongue
    results in poor coordination between the respiratory efforts and oropharyngeal motor/sensory input that is immature
  48. Presence of Upper respiratory infection may preclude:
    • Laryngospasm
    • bronchospasm
    • post-intubation subglottic edema
    • desaturation
  49. Snoring or noisy breathing indicates:
    upper airway obstruction or OSA
  50. inspiratory stridor may be heard with:
    • subglottic narrowing
    • laryngomalacia
    • macroglossia
    • laryngeal web
    • extrathoracic foreign body
    • extra thoracic tracheal comression
  51. hoarse voice may indicate:
    • laryngitis
    • vocal cord palsy
    • papillomatosis
    • granuloma

    Treat with bronchodilator
  52. Repeated pneumonias indicate
    • incompetent larynx (aspiration)
    • GERD
    • cyctic fibrosis
    • bronchiectasis
    • TE fistula
    • immune supression
    • congenital heart disease
  53. Expiratory sound is
    wheezing

    may indicate lower airway disease
  54. What is the biggest mistake committed by SRNAs in pediatric airway maintence?
    Improper mask technique. Obstruction by improper placement of hand around soft tissue below jawline.

    KEEP YOUR HAND ON THE BAG
  55. Why should you consider avoiding nasal trumpets in children?
    Hypertrophied adenoid trauma can lead to significant bleeding
  56. What is an appropriate intervention to make during the alignment phase in preparation for endotracheal intubation?
    infants and children < 6 years old benefit from no placement of a pillow or sheet beneath the occiput for best visualization because they have proportionally bigger heads than persons > 6 years old
  57. What can you do to treat post-extubation croup?
    humidified mist and racemic epinephrine
  58. ETT size for neonate to 6 months
    3 to 3.5
  59. ETT size for 6 months to 1 year old
    3.5 to 4.0
  60. ETT size for 1-2 years
    4.0-5.0
  61. ETT size for > 2 years old
    age in years + 16  divided by 4
  62. What is the peak inspiratory pressure for an appropriate leak with proper ett size
    20-35 cm H2O PIP
  63. What is the cause 90% of the time for laryngotracheal subglottic stenosis?
    endotracheal intubation, especially for a long time
  64. Name three advantages for use of LMA
    • 1. no increase in IOP
    • 2. allows for oxygenation & ventilation
    • 3. can use in asthma patients

    LMA is like swallowing a mask. It does nothing for laryngospasm
  65. Ideal LMA cuff position
    • Superior- base of tongue
    • Lateral - piriform recess
    • Inferior- upper esophageal sphincter
  66. LMA size for neonate/infant up to 5 kg
    1
  67. LMA size for infants 5-10 kg
    1.5
  68. LMA size for infants/children 10-20 kg
    2
  69. LMA size for children /small adults 30-50 kg
    3
  70. LMA size for adolescents/adults 50-70 kg
    4
  71. LMA size for large adolescents/adults 70-100 kg
    5
  72. LMA size for children 20-30 kg
    2.5
  73. Name contraindications for LMA use
    • diabetes
    • trauma
    • decreased peristalsis
    • pharyngeal pathology
    • pharyngeal obstruction
    • restrictive airway disease requiring high pressures to ventilate
    • any surgical procedure other than supine
    • anticipated surgical time > 2 hours
  74. Ketamine IV dose
    0.25-0.5 mg/kg q 2 minutes, titrate to effect
  75. When I say ketamine, you think
    • Dissociative
    • NMDA receptors
    • maintains spontaneous breathing
  76. What can you give with ketamine to decrease the psychomimetic emergence reactions?
    anticholinergic (robinol or scop) + benzodiazepine (versed)
  77. Lidocaine dose
    5mg/kg
  78. Why do we not use cetacaine in patients less than 40 kg?
    Because it's associated with methhemogobinemia and is difficult to titrate
  79. Methemoglobinemia
    disorder characterized by the presence of a higher than normal level of methemoglobin (metHb, i.e., ferric [Fe3+] rather than ferrous [Fe2+] haemoglobin) in the blood. Methemoglobin is a form of hemoglobin that contains ferric [Fe3+] iron and has a decreased ability to bind oxygen. However, the ferric iron has an increased affinity for bound oxygen.[1] The binding of oxygen to methemoglobin results in an increased affinity of oxygen to the three other heme sites (that are still ferrous) within the same tetrameric hemoglobin unit. This leads to an overall reduced ability of the red blood cell to release oxygen to tissues, with the associated oxygen–hemoglobin dissociation curve therefore shifted to the left. When methemoglobin concentration is elevated in red blood cells, tissue hypoxia can occur.
  80. Criteria for extubation:
    • Pt must be fully awake
    • Have adequate ventilatory effort
    • Be fully reversed
  81. What can you give if airway edema is suspected?
    decadron 0.5 mg/kg IV
  82. What can you do if you can't ventilate and suspect a subglottic or glottic obstruction?
    Percutaneous Needle Cricothyrotomy
  83. Herring-Breuer Reflex
    Vagal response with alveoli overinflation
  84. Term infant Hgb, HCT, WBC, PT/INR
    16.8 g/dL, 55 %, 18000 mmcubed, 13 seconds
  85. One year old HGB, HCt, WBC, PT/INR
    12 g/dL, 36 %, 10,000 mm cubed, 11 seconds
  86. What risks are magnified in the setting of operative blood loss and anemia?
    • Hypovolemia
    • Hypotension
    • Acidosis
    • postoperative apnea
  87. When to transfuse FFP
    • Documented congenital or acquired coagulationfactor deficiency where a specific factor is unavailable
    • Acquired coagulopathy secondary to massive transfusion
    • Immediate reversal of warfarinDIC, TTP
  88. When to transfuse Cryoprecipitate
    • Anticipated bleeding in von Willebrand disease unresponsive to DDAVP
    • Acquired hypofibrinogemia associated with massive transfusion
  89. Clinical signs of hemolytic anemia
    • anemia
    • splenomegaly
    • jaundice
  90. Subdivisions of hemolytic anemia's
    • 1. RBC membrane defects (ex. hereditary spherocytosis)
    • 2. enzymatic defects (ex. G6PD deficiency)
    • 3. qualitative and quantitative defects (ex. sickle cell and thalassemia)
  91. What is the most common cause of inherited chronic hemolysis in North America and northern Europe
    Hereditary Spherocytosis

    • 1-2: 5,000
    • Often familial
  92. Classic triad of symptoms with hereditary spherocytosis
    • Anemia
    • Splenomegaly
    • jaundice

    Diagnosis from RBC smear and central pallor of RBC spherocytes
  93. Gold standard of hereditary spherocytosis diagnosis
    Osmotic fragility test



    produces age-related results and must be preformed by experienced lab technicians
  94. When I say protein, you say
    Colloid osmotic pressure


    • Albumin- large protein
    • Hetastarch- large carbohydrate
  95. G6PD deficiency diagnosis
    • Heinz bodies
    • normocytic anemia

    Presenting signs= anemia and jaundice
  96. What other conditions do G6PD emulate?
    • anemia of infancy
    • chronic hemolytic anemia
  97. G6PD
    hemolysis in the presence of various oxidative stressors
  98. Serum Osmolality
    280-300 mOmol/L
  99. WHY do premies have lower plasma oncotic pressure?
    immature liver development
  100. With increased sodium and water,
    blood volume increases
  101. with sodium and water excretion,
    blood volume decreases
  102. What primarily regulates serum osmolality?
    • ADH
    • Thirst
    • Renal concentrating ability
  103. What part of the hypothalamus releases ADH to be carried to the neurohypophysis for release?
    supraoptic and paraventricular nuclei
  104. Angiotension II supports BP by: (3 ways)
    • 1. Direct vasoconstriction
    • 2. increased sodium and water retention (decreased GFR)
    • 3. Stimulation of aldosterone secretion
  105. At what week gestation does renal development begin?
    5 weeks

    The total # of nephrons are present at 38 weeks, and renal blood flow is 1/3 of normal
  106. At birth, newborns have limited urine concentrating ability. What is the urine osmolality in a newborn?
    Half that of an adult (1300-1400)

    700-800 mOsm/kg
  107. At year one, what are the GFR and renal blood flow compared to an adults'?
    1/2
  108. Why is hyponatremia common in the neonate?
    With excess sodium loss in the urine, maintenance requirements for sodium are greater.
  109. Why are fluid requirements high in the neonate?
    • Neonates require:
    • Large volumes of urine to excrete high solute concentrations
    • High surface area to volume ratio
    • High evaporative loss
  110. What is the best measure of blood volume?
    Lean body mass
  111. Name the circulating blood volume ratios for premies, < 6 months, 6mo-2 years, and 2-12 years:
    90ml/kg, 80 ml/kg, 75ml/kg, 72 ml/kg

    90, 80, 75, 72
  112. intracellular or extracellular water % is higher in the infant and child than the adult?
    Extracellular is higher in kiddos
  113. Why do children need to fast before surgery?
    To minimize gastric contents and thus decrease risk of aspiration

    The period of vulnerability is longer with inhalataional induction than IV, but is not absent with IV induction
  114. How long before surgery can clear liquids be given to children?
    2-3 hours.

    This has been shown to stimulate peristalsis and reduce gastric volume and acidity.
  115. What parameters can you assess when determining fluid volume status?
    • HR
    • Capillary refill
    • Blood pressure
    • CVP
    • SVR
    • Oxygen saturation pleth variation
    • Urine Output
  116. Minimal insensible (incisional) loss
    3-5 ml/kg
  117. Moderate insensible (incisional) loss
    5-10 ml/kg
  118. Large insensible (incisional) loss
    8-20 ml/kg
  119. What glucose level must be maintained to avoid neurological injury?
    > 45 mg/dL
  120. Signs and symptoms of hypoglycemia
    • jitteriness
    • lethargy
    • temperature instability
    • convulsions
  121. What do you give for hypoglycemia that cannot be treated orally?
    2-4 ml/kg D10W followed by 4-6 ml/kg/min with BG checks q 30 minutes
  122. When would you want an IV before induction?
    GERD, trauma, full stomach, anticipated difficult airway
  123. Which are better for rapid infusion? Longer or shorter catheters?
    Shorter because longer increases resistance to flow
  124. Complications of IO placement
    • compartment syndrome
    • damage to growth plates
    • catheter is more easily dislodged
    • onset of drugs is unpredictible
  125. Why are isotonic fluids preferred for intraop administration?
    • Most intraop losses are isotonic
    • Hypotonic soln may decrease serum osmolality and cause electrolyte imbalance and fluid shifts
    • Plasma volume expansion is necessary b/c loss of vascular tone d/t anesthesia
    • Increases in ADH result in H2O retention in excess of sodium retention= dilutional hyponatremia
  126. What can occur if you give 3% HTS too fast?
    central pontine myelonlysis
  127. S/S of dehydration
    slow cap refill, poor skin elasticity, absent tears with crying, sunken anterior fontanelle, irritability, dry mucous membranes
  128. Dehydration correction emergent phase
    20-30 ml/kg isotonic crystalloid/colloid bolus
  129. Dehydration correction repletion phase 1
    25-50 ml/kg over 6-8 hours
  130. Dehydration correction repletion phase 2
    remainder of deficit of 24-48 hours
  131. What dictates the treatment for hypernatremia?
    neurologic status determines treatment
  132. What may accompany acute hypernatremia?
    hypoglycemia
  133. What should you watch for during treatment for hypernatremia?
    apnea, seizures, and CVR compromise
  134. What can you give if acute hyperkalemia manifests in the OR?
    Calcium Chloride- it antagonizes the cardiac effects.
  135. At what level do we consider K to be low?
    2.5 mEq/L
  136. SIADH
    urinary dilution with plasma hypo-osmolality

    Too much ADH

    • hyponatremia <135 mEq/l
    • serum osmolality , 280 mOmol/l
    • urine osmolality   > 100mOmol/l
  137. How do we treat SIADH
    • free water restriction
    • Sodium replacement
  138. Diabetes Insipidus
    decreased secretion of OR renal insensitivity to ADH

    Too little ADH

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