Peds exam 3

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  1. Myringotomy
    creation of an opening thru which fluid can drain to reduce serous otitis media which is common in young children
  2. Cholesteatoma
    skin growth that occurs in an abnormal location, the middle ear behind the eardrum. It is usually due to repeated infection which causes an ingrowth of the skin of the eardrum
  3. Tympanic membrane
    separates middle from outer ear
  4. PE tube
    ventilation tube placed in hole created by myringotomy, serves as a stent for the ostium
  5. Patients with what condition have a high incidence of middle ear disease, needing PE tubes?
    Cleft palate

    Due to the associated abnormalities of the cartilage and muscles surrounding the eustachian tubes.
  6. When is emergence delirium risk the highest?
    In cases where sevoflurane is used alone and not in conjunction with a narcotic
  7. Acetaminophen oral
    10-20 mg/kg
  8. acetaminophen rectal
    30-40 mg/kg

    • onset 60-90 minutes
    • peak 2-3 hours
  9. What nerve is of major concern during tympanoplasty and mastoid surgery?
    Facial nerve

    Must avoid muscle relaxants to allow for nerve monitoring
  10. What nerve runs along the vestibular cochlear nerve?
    the facial nerve
  11. What level of the spinal cord are at risk for subluxation due to the laxity of the ligaments?
  12. 15 to 30% of these children have atlantoaxial instability
    Down syndrome or achondroplasia
  13. What is the most important anesthetic consideration for middle ear or mastoid surgery?

    airway must be absolutely secure
  14. Max does of epinephrine
    10 mcg/kg
  15. Why would you want to do a light anesthetic on cochlear implants?
    B/c the surgeon needs to be able to test the stapedius reflex
  16. What has to happen for the ossicular chain to stiffen?
    The stapedius stiffens the ossicular chain by pulling the stapes of the middle ear away from the oval window of the cochlea and the tensor tympani muscle stiffens the ossicular chain by loading the eardrum when it pulls the malleus in toward the middle ear
  17. How do inhalational anesthetics affect the stapedius reflex threshold?
    Increasing the concentration increases the reflex threshold, making it more difficult to test to see if it's working
  18. What is the major concern for endoscopic sinus surgery?

    They will vomit blood on emergency if there's a lot of bleeding.

    • Throat pack- document it to remember to take it out
    • Use a cuffed tube
    • suck stomach out before waking up
    • Surgeon may use: oxymetazoline, phenylephrine, cocaine, or dexamethasone

    Wake up quick to reduce aspiration chance
  19. Children who require endoscopic sinus surgery frequently have these conditions
    • Asthma
    • Cystic Fibrosis
  20. What might tonsillar hyperplasia lead to?
    • Chronic airway obstruction resulting in:
    • OSA
    • CO2 retention
    • Cor Pulmonale
    • Faliure to thrive
    • swallowing disorders
    • speech abnormalities
  21. Recite the four goals for adentonsillectomy
    • 1. provide smooth atraumatic induction
    • 2. provide surgeon with optimal operation conditions
    • 3. establish IV access for volume expansion and meds
    • 4. provide rapid emergence so child is awake and able to protect recently instrumented airway
  22. What pressure for leak is the best for adenotonsillectomy?
    20 cm H2O
  23. What are the complications that can occur with LA infiltration into the tonsillar fossa?
    • Intracranial hemorrhage,
    • bulbar paralysis,
    • deep cervical abscess
    • cervical osteomyelitis
    • medullopontine infarct
    • cardiac arrest
  24. Choanal atresia or stenosis
    narrowing of the nasopharynx

    may present as cyanosis at rest that resolves with crying or placement of an oral airway
  25. VATER syndrome
    • Vertebral abnormalities
    • imperforate Anus
    • Tracheoesophageal fistula
    • Radial aplasia
    • Renal abnormalities

    esophaleal atresia and tracheosophageal fistula associated
  26. What is the most common form of tracheoesophageal fistula?
    esophagus ends in a blind pouch with the distal end of the esophagus connected to the trachea just above the carina
  27. Foramen of Bochdalek
    herniation site of abdominal organs into the thorax

    toward dorsal side

    where 90% of the herinations in the diaphragm occur
  28. How should a patient with congenital diaphragm herniation be positioned?
    affected side down to decrease weight on mediastinum and heart

    rapid low TV to avoid barotrauma and potential for pneumothorax
  29. What is the use of NO in pediatrics?
    Nitric Oxide is a specific vasodilator of the pulmonary vascular bed
  30. What is the main cause of Congenital diaphragm herniation mortality?
    Pulmonary deterioration

    Hypercarbia after surgery indicates ventilation is not occurring and there is a 90% mortality rate when this occurs
  31. Pyloric stenosis
    olive sized mass in pyloric region

    non-bilious vomitus= no duodenal contents b/c the stenosis

    alkaline urine initially, then becomes acidotic contributing to the metabolic alkalosis
  32. Which would you rather be? Acidotic or alkalotic?
    • acidosis is better because the tissues still get oxygen b/c of the right shift of the oxyhemoglobin dissociation curve.
    • Left shift (alkalotic) makes the HGB hold onto the oxygen more, so the tissues don't get the oxygen b/c the HGB is hogging it
  33. How may pyloric stenosis patients present?


  34. What other conditions are duodenal and ileal obstructions associated with?
    trisomy 21

    • VSD
    • ASD
    • atrioventricular canal
  35. What kind of vomit can you expect to see with duodenal atresia?
    bilious vomit

    double-bubble sign formed by air contrast of the dilated stomach and proximal duodenum
  36. Incarcerated hernia


    3-5% of term infants, and 30% of premies
  37. Necrotizing enterocolitis
    5-15% in infants under 1500 grams

    stop feeding, decompress abdomen, ABX, dopamine in increase CO and improve intestinal perfusion

    • Avoid inhalational agents
    • Awake intubation
  38. oompalocele and gastroschisis
    defect in abdominal wall

    herniated viscera are covered with a membrane sac

    oompalocele are in a sac

    SaO2 in lower extremities may differ from upper extremities
  39. hemodynamic changes at birth
    Right Ventricle
  40.  Decreased afterload
    • decreased pulmonary vascular
    • resistance
    • Ductal closure
    • Decreased volume load
    • Eliminated umbilical vein
    • return
    • Output diminishes 25%
  41. Hemodynamic changes at birth
    left ventricle
    • Increased afterload
    • placenta eliminated
    • ductal closure
    • increased volume load
    • increased pulmonary venous
    • return
    • output increases nearly 25%
    • Transient left to right shunt
    • at ductus
  42. What are the three fetal
    Ductus arteriosus

    Ductus venosus

    foramen ovale
  43. Ductus arteriosus closure facts
    closed in 58% of neonates by day 2, and 98% by day 4

    • Initial closure functional due to pressure differences and increased oxygen
    • concentration. Reduction of circulating prostaglandins with placental
    • detachment
  44. In what percentage of adults does the foramen ovale remain patent?
  45. Does the fetal heart have more or less optimal contractile components than the adult heart?
    • Less!
    • Fetal-30%
    • Adult-60%

    The Frank-Starling Law doesn't work as well in fetal cardiac systems
  46. When I say t-tubule and sarcoplasm reticulum, you say

    Blood products contain citrate, which chelates with circulating calcium thus reducing available Ca for myocyte use
  47. How can neonates modify their CO to adjust for their high metabolic rate?
    Stroke volume and heart rate can be altered

    These components are supercharged just to be normal
  48. Is the SNS or PNS more developed in neonates?
    The PNS is more developed

    Thus, sux and DL can cause marked responses to vagal stimuli
  49. Why would acidosis prolong transitional circulation?
    Acidotic patients are ususally having trouble with systemic vascular resistance so the right side pressure is greater than the left side pressure, leading to right to left shunt

    Acidosis potentiates a production of natural NO, which creates a state of hypotension due to vasodilation
  50. Conditions prolonging transitional circulation
    • prematurity
    • pulmonary disease
    • hypoxemia
    • hypercarbia
    • congenital heart disease
    • sepsis
    • acidosis
    • hypothermia
    • high altitude
    • prolonged stress
  51. What three means do congenital heart malformations incur pathophysiological cost?
    • Volume loads
    • Pressure loads
    • Hypoxemia
  52. Structural defects that promote left ventricular flow to the pulmonary circulation trigger:
    • Increased adrenal catecholamine output
    • increased renin and angiotension production
    • expanded intravascular volume
    • constriction of noncritical vascular beds to compensate for the lost systemic flow by increasing total left ventricular output

    These manifestations are also seen in massive hemorrhage...
  53. Left to right shunts impose an ????????? volume load on the heart
  54. Which septal defect is the worse one? Atrial or ventricular?
  55. Signs and symptoms of congestive heart failure in infants:
    • Tachypnea
    • grunting respirations
    • nasal flaring
    • chest retractions
    • poor feeding
    • poor growth
    • hepatosplenomeagly
    • diaphoresis
  56. In children with CHD in which volume is the issue, what is the implication of anesthetic agents?
    These infants demonstrate greater vulnerability to the myocardial depressant effects
  57. WHAT causes increased pressure load to a neonatal heart?
    • Obstruction in the outflow tract,
    • semilunar valve, and or great artery
  58. what can cause volume load problems in neonatal hearts?
    Intra-atrial and ventricular septal defects
  59. What two distinct pathophysiologic mechanisms cause systemic hypoxemia?
    right to left shunt

    pulmonary venous return
  60. Tetralogy of fallot
    • Narrow pulmonary artery
    • Aorta is overriding the VSD 
    • intra-ventricular septal defect
    • right ventricular hypertrophy

    Is a right to left shunt lesion
  61. Dopamine
    Alpha, Beta, dopaminergic receptors

    Directly stimulates cardiac beta-1 receptors and provokes release of norepinephrine from cardiac sympathetic nerve terminals
  62. Why won't neonates respond to ephedrine?
    Because their sympathetic system is too immature to adequately respond
  63. Dobutamine
    structural analogue of isoproternol

    may be a better choice in CHF and cardiogenic shock b/c the actions of dobutamine do not depend on endogenous catecholamine stores
  64. Dobutamine provides
    relatively selective beta agonism
  65. Isoproterenol
    pure, non-selective B-adrenergeic agonist

    More beta-1 than beta-2

    • Good for heart transplants
    • Increases HR and contractility and causes vasodilation in mesenteric, renal, and skeletal muscle tissue beds
  66. Epinephrine
    alpha, beta1, beta2 adrenergic agonist effects

    Larger doses causes alpha induced vasoconstriction

    is direct, does not depend on catecholamine stores
  67. Phenylephrine
    pure alpha adrenergic agonist

    goal is peripheral vasoconstriction

    Can cause compensatory decrease in HR (Bainbridge reflex)
  68. Propranolol dose
    0.05-0.2 mg/kg slowly

    Non-selective beta blocker

    SE: bradycardia, hypotension, worsening of myocardial pump function, AV block, bronchospasm, depression, fatigue
  69. Labetalol dose
    0.1-0.4 mg/kg/dose    

    0.25-1.0mg/kg/hr infusion

    repeat dose q 5-10 minutes
  70. Esmolol dose
    100-500 mcg/kg loading dose over 5 minutes

    50-250 mcg/kg/min infusion

    metabolism by plasma and RBC cell esterases
  71. Nitroprusside dose
    0.5 to 1 mcg/kg/min infusion with max of 6-10 mcg/kg/min

    arterial and venous vasodilator
  72. What is the metabolite of nitroprusside infusion?
    Sodium thiocyanate

    can occur when nitroprusside at >4mcg/kg/min and or used > 2-3 days
  73. What is the antidote for cyanide poisoning?
    Amyl nitrate followed up with methylene blue

    Methylene blue b/c of the methemoglobinemia induced by the amyl nitrate
  74. Nitroglycerin infusion rate
    0.5-1 mcg/kg/min

    predominantly venous dilation

    Used for cooling and rewarming after bypass
  75. At what levels may the dural sac extend to in infants?
    S3 or S4
  76. What is the major complication for caudal anesthetics?
  77. Doses for caudal blockade
    0.5 ml/kg for lower extremity or perineal surgery

    0.75 ml/kg for T-10 level

    1ml/kg for lower thoracic level
  78. Addition of preservative free MSO4 to caudal block for 18-24 hour postop pain relief in the following doses:
    Perineal surgery: 50mcg/kg

    Mid abdominal incision: 60 mcg/kg

    Sternotomy: 70mcg/kg
  79. Why might clonidine be beneficial to add into the caudal block mix?
    • Less respiratory depression
    • Less N/V
    • Less itching
    • Similar/prolonged analgesia vs. morphine
  80. How is correct placement confirmed for caudal blocks?
    • ease of injection
    • negative aspiration
    • radiographic imaging
    • nerve stim. thru catheter
  81. What percentage of children with congenital heart disease have surgery within their first year of life?

    25% have surgery within the first month
  82. WHat are the goals for preanesthetic visit for CHD patients?
    • 1. medical assessment
    • 2. administering premedication
    • 3. providing information
    • 4. creating a relationship with the child and family
    • 5. formulating an anesthetic plan
  83. What is the most common
    premedication used for heart children?

    0.5-1 mg/kg
  84. How do children with cyanotic
    heart defects compensate for chronic hypoxia?
    • Increased erythropoesis
    • increased circulating blood
    • volume
    • vasodilation
    • metabolic adjustment of 2,3
    • DPG
  85. At what HCT does surgical
    hemostasis becomes a problem

    • Excessive viscosity impairs microvascular perfusion & outweighs the
    • advantages of increased oxygen carrying capacity
  86. Dependent shunt
    those in which size and direction of shunting thru abnormal cardiac communications depend on the relationship between pulmonary vascular resistance and systemic vascular resistance and are thus variable
  87. Obligatory shunt
    those in which shunting is relatively independent of the relationship between pulmonary vascular resistance and systemic vascular resistance
  88. Name 5 types of dependent shunts
    • PDA
    • simple atrial septal defect
    • simple ventricular septal defect
    • aortopulmonary windows
    • other systemic to pulmonary shunts, like Blalock-Tassig
  89. Name several types of obligatory shunts
    • common AV canal defects
    • systemic arteries and veins (AV fistula)
    • tricuspid or mitral atresia
    • aortic or pulmonary atresia

    Obligatory shunts must have another dependent shunt at another level
  90. When the pressure differential on two sides of a dependent shunt becomes very great, it takes on the characteristics of an ??????? shunt
  91. Restrictive shunts
    communications are small, the size of the defect itself limits shunting and considerations of relative PVR and SVR become correspondingly smaller in determining the amount of shunting
  92. Why is hemostasis impaired in the neonate?
    Vitamin K-dependent coagulation factors are only 40-66% of normal values
  93. When introducing the volume of the primer for cardiac bypass, what values are notably affected?
    Fibrinogen is decreased by 50%

    Platelet count decreased to 30% of pre-bypass levels
  94. What is the dose of platelets?
  95. What does cryopricipate provide?
    Factor 8

    von Willebrand factor

    Factor 13
  96. Of these three choices, which 2 are best to administer to neonates?

    Platelets, cryo, or FFP
    Platelets and cryoprecipitate
  97. What are the 3 identified antifibrinolytics used in pediatric cardiac surgery?
    • EACA- e-aminocaproic acid
    • TA- tranexamic acid
    • aprotinin
  98. What benefits does ultrafiltration provide during and after cardiac bypass?
    • increasing the HCT
    • concentrating the clotting factors and platelets
    • increasing blood pressure and reducing pulmonary vascular resistance
    • removing inflammatory mediators
  99. What dose DDAVP do
    increases plasma levels of factor 8 and von Willebrand factor

    Dose is 0.3 mg/kg
  100. When might EtCO2 monitoring be off?
    When  cyanotic lesions cause V:Q mismatching
  101. Of the following three sites, which most truly matches the brain temperature?
    1. Tympanic membrane
    2. esophagus
    3. rectum
    The esophagus

    tympanic membrane and rectal sites overestimate the temp. of the brain
  102. Children with what kind of shunt will experience slower induction with inhalational anesthetics?
    cyanotic right to left shunts with reduced pulmonary blood flow
  103. What two factors are related to myocardial damage during by-pass?
    Duration of the aortic cross clamp

    effectiveness of the myocardial protection
  104. What two drugs are used during cardiac surgery to control blood pressure?
    Phenylepherine to increase

    Phentolamine to decrease
  105. What should the ACT be after giving heparin and before going on bypass?
    At least 3 times the baseline

  106. What is the dose of heparin for cardiac bypass?
    400 units/kg
  107. Will Sevoflurane exacerbate the shunt between the right and left sides of the heart thru an ASD or VSD when given in standard concentrations in 100% oxygen?
  108. Why should nitrous oxide be avoided in children with CHD?
    Because the risk of enlarging intravascular air emboli and the potential to increase PVR
  109. WHat are the doses for ketamine?
    • IV 1-2 mg/kg
    • IM 5-10 mg/kg
  110. What three manifestations of ketamine use might not be that desirable in cardiac kiddos?
    increases in BP, HR, and CO
  111. When should propofol be avoided?
    in those patients with a fixed cardiac output such as severe aortic or mitral stenosis b/c it might cause severe hypotension
  112. What is the order of preference of induction techniques, starting with the most preferred?
    • 1. IV
    • 2. INH
    • 3. IM
    • 4. intranasal, rectal, and SQ

    IV has the greatest margin of safety
  113. What is the most common septal defect?
    ventricular wall defect
  114. Name 5 Left to right shunt types
    • 1. ASD
    • 2. VSD
    • 3. PDA
    • 4. endocardial cusion
    • 5. aortopulmonary window
  115. What is the equation to figure SVR?
    SVR= (MAP-CVP) / CO
  116. In left to right shunts, what relationship between PVR and SVR increases PBF?
    SVR > PVR = increased PBF= pulmonary congestion=CHF

    when the PVR > SVR, a right to left shunt develops and Eisenmenger's syndrome results
  117. What is the goal for Left to Right shunts?
    Decrease SVR and Increase PVR to decrease the L to R shunt

    • How?
    • positive pressure ventilation and Peep Increases PVR
    • Inhalational agents decrease SVR

    Remember ketamine increases SVR
  118. Name 4 right to left shunts
    • 1. tetralogy of Fallot
    • 2. Pulmonary atresia
    • 3. tricuspid atresia
    • 4. Ebstein's anomaly

    Right to left shunts involve pulmonary vascular resistance that is greater than systemic vascular resistance, which results in decreased pulmonary blood flow and hypoxemia and cyanosis

    Blue Babies
  119. What are the goals for right to left shunts?
    Increase Pulmonary blood flow by decreasing pulmonary vascular resistance and increasing systemic vascular resistance
  120. What is the most common right to left shunt?
  121. Tet spells
    acute cyanosis and hyperventilation

    factors such as decreased BP and SVR should be avoided to not have tet spell under GA
  122. What do you do for a tet spell?
    • Knees to chest
    • increase blood volume
    • increase inspired oxygen concentrations
    • increase SVR with neosynephrine
    • lower PIP
    • increase level of sedation
    • Beta-adrenergic blockade
  123. What are complex shunts?
    they produce both cyanosis and CHF

    continuous mixing of venous and arterial blood: SaO2 will be about 70-80%
  124. Name several types of complex shunts
    • truncus arteriosus
    • transposition of the great vessels
    • double outlet right ventricle
    • hypoplastic left heart syndrome
    • total anomalous pulmonary venous return
  125. What is the procedure that is the first stage for hypoplastic left heart repair?
    The norwood procedure
  126. What procedure is used to correct transposition of the great vessels defect?
    Jantene Procedure
  127. Obstructive lesions
    either valvular stenosis or vascular bands

    decreased perfusion and pressure overload of corresponding ventricle
  128. Name some types of obstructive lesions
    • aortic stenosis
    • mitral stenosis
    • pulmonic stenosis
    • coarctation of the aorta
    • interrupted aortic arch
Card Set:
Peds exam 3
2014-11-29 21:15:13
Pediatric Anesthesia

ENT, Cardiac, GI, regional
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