Peds 4

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  1. fetal circulation?
    • –Placenta – organ of respiration
    • –Umbilical Vein carries oxygenated blood (max PaO2 = 30-35mm) from the placenta to
    • The liver and via the Ductus Venosus to the IVC
    • –To the RA, oxygenated blood preferentially flows through the Foramen Ovale to the LA and LV
    • Into the ascending aorta to the carotid arteries (PaO2 is now about 26-28 mm)

    • –Deoxygenated blood from the SVC
    • flows to the RV and PA where high pressures limit flow to lungs to about 10%
    • The other 90% passes through the Ductus Arteriosus into the aorta
    • –Both paths send deoxygenated
    • blood through the aorta and Umbilical Arteries and back to the Placenta
  2. where does oxygentaed fetal blood come from?
    umbilical vein
  3. Factors that promote PFC?
    • •Prematurity
    • •Pulmonary Disease (pneumonia*)
    • •Hypoxia* & Hypercarbia
    • •Congenital Heart Disease
    • •Sepsis
    • •Acidosis*
    • •Hypothermia*
    • •High Altitude
    • •Prolonged Stress
  4. what changes fetal circulation to adult?
    • •Loss of tremendous blood flow
    • through the placenta
    • •SVR doubles at birth – increase in aortic pressure,
    • left atrial and left ventricular pressure
    • •Decrease in pulmonary vascular resistance (x 5) due to expansion of the lungs – oxygen initiated vasodilation takes place when aeration of the
    • lungs eliminates HPV
    • •Decrease in PA pressure, right atrial and right ventricular pressure
    • •Blood attempts to flow backward
    • through the foramen ovale from left atrium (higher
    • pressure) to right atrium (lower pressure) – small valve over the foramen ovale on the left side of the atrial septum closes over the opening preventing further flow through the foramen ovale (fibrous closure in a few months)

    • •Functional closure of the ductus arteriosus (DA)-
    • blood attempt to flow from aorta (higher pressure) to PA (lower pressure)
    • however the muscle wall of the DA constricts (initiated by ápaO2)
    • within 1-14 days and becomes fibrous by 4 months (structural closure)
  5. what are the cyanotic defects?
    • Tetralogy of Fallot
    • Transposition of great vessels
    • Truncus arteriosus
    • Tricuspid atresia
    • Total anomalous pulmonary venous return
    • HLH
    • Pulmonary stenosis
  6. what are the acyanotic defects?
    • Acyanotic defects (left-to-right shunt)
    • VSD
    • ASD
    • PDA
    • Pulmonary stenosis
    • Aortic stenosis
    • Coarctation of aorta
    • atrioventricularseptal defect
  7. explain functional closure of PDA?
    • blood attempts to flow from aorta (higher pressure) to PA (lower pressure) however the
    • muscle wall of the DA constricts (initiated by increased paO2) within 1-14
  8. when does structureal closure occur?
    DA becomes fibrous at 4 months (structural closure)
  9. what conditions increase persistent fetal circulation? where does shunting continue to occur?
    • Prematurity.
    • Any factor that increases PVR:
    • Pulmonary Disease (pneumonia*)
    • Hypoxia** & Hypercarbia, CHD, Sepsis
    • Acidosis* Hypothermia*High Altitude
    • Prolonged Stress

    shunting occurs through the foramen ovale and PDA
  10. what increases PVR?
    • •N20, Desflurane ≥ 1.6 MAC
    • Ketamine ???,
    • PPV, peep, high TV & PIP
    • Hypoxia, hypercapnia , acidosis & atelectasis
    • SNS stimulation, pain, light anesth
    • hypothermia
  11. what decreases PVR?
    • increased pO2, hypocarbia, alkalosis
    • Nitric Oxide
    • Prostacyclin and Prostaglandin (PGE1, also keeps
    • PDA open)
    • Propofol
    • Volatile inhalation agents (not N2O)
    • Spontaneous or HFJ vent
    • Surfactant
  12. what increases SVR? Decreases?
    • –Increased by
    • Pain, light anesthesia
    • SNS stimulation
    • Vaso-constricting drugs (phenylepherine)

    –Decreased by

    • •Volatile inhalation agents (not N2O)
    • Vasodilating drugs (nitroprusside)
    • Neuraxial regional anesthesia
    • Most IV anesthetics (except Ketamine and Etomidate)
    • Morphine (& all histamine releasers)
  13. what are the 2 negative consequences that result from pulmonary htn in newborn?
    2 big things (corpulmonale/reversal shunt)

    • 2 big negative consequences
    • RVH & CHF
  14. what 4 things make up TOF?
    • Ventricular septal defect (VSD)
    • Pulmonic stenosis
    • Dextroposition (right side) and overriding of
    • aorta
    • Right ventricular hypertrophy
  15. what is the treatment of a tet spell?
    • Prone
    • knee-chest position/squatting (­ SVR by kinking arteries)
    • supplemental O2
    • narcotic, propranolol, phenylephrine
  16. what are the signs & symptoms of a tet spell?
    • a)
    • Cyanosis
    • clubbing of the digits
    • normal pulses
    • systolic murmur
    • loud 2nd heart sound
    • boot-shaped heart (RVH)
    • diminished pul. vascular markings
    • right axis deviation
    • RVH
  17. what abx is given in CHD?
    amoxicillin 50mg/kg
  18. what 5 things prevent acyanotic changing to cyanotic shunt?
    • ­
    • increased PVR (hypoxia, hypercarbia, hypothermia, PNA, N2O, desflurane > 1.6 MAC, high
    • altitude)
  19. what causes IVH? what makes it worse?
    fragile vessels

    • what makes it worse
    • Prematurity
    • is the most important risk factor for intracranial hemorrhage

    • respiratory complications (RDS)
    • impaired autoregulation of CBF (rapid ­¯ CBF during induction & intubation)
    • ­increased CVP
    • immature cerebral blood vessels
    • bicarb administration (­ CO2 vasodilates & rapid infusion hyperosmolar
    • stressed neonates (arterial hypoxemia & hypercapnia)
  20. what monitoring do you need for a child with CHD?
    • •Appropriate monitoring: five-lead
    • EKG, 2 pulse oximeters, multiple site temperature
    • measurement, radial or femoral (>1y) Aline, CVP, ABGs, ionized Ca++, TEE
  21. what defects are linked to other comorbidities?
    • CHARGE with choanal atresia
    • Colobomas (hole in iris)
    • Heart abnormalities
    • Atresia (choanal)
    • Retardation
    • GU
    • anomalies
    • Ear abnormalities
  22. what is VACTERL?
    VACTERL with TEF (TEF type D most common)

    • TEF/EA occur together
    • vertebral anomalies
    • anus (imperforate)
    • cardiac anomalies
    • tracheoesophageal fistula or esophageal atresia;
    • renal anomalies;
    • limb anomalies
  23. what is diapghragmatic hernia linked to?
    • CV abnormalities 25%
    • Hypoplastic lung
    • Pul hypoplasia & pul HTN (medical
    • emergencies)
  24. what is omphalocele & gastrochisis associated with?
    • Oomphacele – cardiac defects, Beckwith
    • Weidermean & GI anomalies

    Gastrochisis - other congenital anomalies
  25. what is associated with prune belly syndrome?
    Undescended testicles

    Urinary tract anomalies
  26. what are the causes of NEC?
    • its not an anomaly, it is an illness
    • contributing factors:
    • Mucosal ischemia (secondary to splanchnic vasoconstriction, Bacterial invasion of immature bowel,Immature immune system, Early enteral
    • feeding, Umbilical vessel cannulation and
    • Cardiac or pulmonary disease
  27. what is the mortality of NEC? early signs? physical signs?
    • Mortality 10-30%
    • Early signs of NEC include
    • feeding problems, vomiting, jaundice, lethargy
    • bloody stools, fever, or hypothermia
    • The abdomen may be distended tender
  28. what are the significant abnormalities of electrolytes with NEC?
    Significant abnormalities of electrolytes (hyperglycemia, hyperkalemia) and coagulation (DIC, thrombocytopenia) & anemia may be present
  29. what drugs to use when you want to decrease PVR?
    • increased paO2, hypocarbia, alkalosis
    • Nitric Oxide
    • Prostacyclin and Prostaglandin (PGE1, also keeps
    • PDA open)
    • Propofol
    • Volatile inhalation agents (not N2O)
    • Spontaneous or HFJ vent
    • Surfactant
  30. Which sx for which congenitial condition its important to avoid pul HTN
    L to R shunt defects (acyanotic defects)
  31. what is the airway mgmt for TEF?
    • Awake or asleep intubation (IV* or inhalational induction)
    • Rotate the ETT during intubation so the bevel faces anteriorly to avoid fistula intubation
    • Deliberate RIGHT mainstem intubation then retract
    • ETT until equal BBS heard
    • Tip of the ETT is above carina but below the fistula
    • Choose the largest ETT possible for frequent suctioning
  32. what type of ETT should be used in the mgmt of TEF?
    • ETT should NOT have a Murphy eye so that the posterior wall of the tube will block the fistula opening
    • ETT should be cuffed and inflating the cuff will help to block the fistulous opening
  33. where do you tape precordial steth? what should be avoided?what gas should be avoided during TEF?
    • Tape precordial stethoscope
    • to the LEFT axilla –helps in diagnosis of ETT migration
    • Avoid increased­ airway pressures – will cause gastric distention, especially during induction.
    • N2O; avoid ­FiO2 (O2/AIR OK)
  34. what intraop mgmt is used for TEF?
    • Opioid anesthetic (fentanyl 10-25 mcg/kg)
    • low dose IA
    • Epidural (via caudal or thoracic)
    • Intercostal Nerve block for analgesia
  35. postop mgmt for TEF? complications post op?
    extubation in OR if stable, warm, awake & pain free

    • Complications
    • Aspiration,anastomosisleakage,tracheomalacia,
    • strictures, apnea, hypoventilation, metabolic acidosis, hypothermia,
  36. what is the AN mgmt of omphalocele and gastrochisis?
    • fluid & heat loss
    • prevent infection
    • cover viscera
    • IV access for fluids/abx
    • NGT/RSI after suctioning the stomach
    • GA
    • Epidural asleep
    • Muscle relaxation
    • NO N2O
    • aggressive fluid replacement (10 mL/kg/hr LR or 5% Albumin)
    • avoid effects of ­ increase abd. Pressure
  37. when is gastrochisis repair done? ompahlocele?
    repair is undertaken as soon as possible after birtrh while an unruptured imphalocele is repaired only after evaluation for other associated anomalies
  38. when is the mgmt for CDH?
    • Pulmonary HTN & hypoplasia are medical emergencies
    • CDH is managed medically
    • until respiratory & CV status is stabilized
    • then the surgery is scheduled within several days of birth (done 1st or 2nd day old)
  39. what is the induction for CDH repair?
    • Initial AIRWAY control is priority:
    • Awake intubation –(or RSI)
    • NGT to decompress stomach & intestines
    • Position infant with the affected side down for intubation (max ventilation of good lung)
    • Pneumothorax at anytime
    • Rapid, low TV ventilation (HFOV or low PIP/high RR PCV)

    Hypocarbia, narcotics, inhaled nitric oxide, ECMO

    AVOID hypoxemia and acidemia, all decrease PVR

    prevent pul HTN & R to L shunting
  40. what conditions are NICU babies predisposed to?
    • IRDS(hyaline membrane disease)
    • Apnea of prematurity
    • Hypoglycemia
    • Hypocalcemia
    • Hypomagnesemia
    • Hyponatremia
    • Hyperkalemia
    • Hyperbilirubinemia
    • Polycythemia
    • Thrombocytopenia
    • Congenital anomalies
    • Infections
    • Acidosis
  41. what lyte imbalances seen in prematurity?
    • hyperkalemia d/t immature distal tubule function and relative hypoaldosteronism
    • hypocalcemia caused by parathyroid hormone insufficiency and peripheral resistance to PTH, inadequate CA supplementation, altered distribution of calcium by transfusions, diuretics
    • hypoglycemia(decreased glycogen stores)
    • hypomag
  42. treatment for hypocalcemia?
    correct hypomag, 100mg/kg calcium gluc by slow IV infusion, maintenance CA++
  43. what is the etiology of ROP?

    1. Caused by alteration in development of retinal vasculature

    • 2. Arterial hyperoxia (PaO2 >80 mmHg) leads to retinal vasoconstriction disturbing normal retinal development
    • Retinal vasoconstriction, angiogenesis &
    • growth of vessels & scarring
    • When PaO2 returns to normal, abnormal vascularization of retina continues, scarring develops
  44. what is the normal PA02 at birth?
    Normal PaO2 @ birth = 60-80 mmHg
  45. what are the risk factors for ROP?
    • #1 is prematurity(< 44 wkspostconceptual age)
    • birth weight <1500 gm
  46. what should you do you do for IVH?
    • avoid factors that can precipitate hemorrhage; maintain BP within normal limits, avoid hypoxia, hypercapnia, avoid alteration in cerebral blood flow,
    • hyperventilation, vigilant monitoring
  47. which surgeries are dire emergencies vs stabilize first?
    • Choanal atresia (surgical emergency)
    • TEF (surgical emergency)
    • Gastrochisis (surgical emergency)
    • Imperforate anus (surgical emergency)

    • NEC (medical management first)
    • Oomphalacele (medical management)
    • CDH ( medical management first)
    • Pyloric stenosis(medical)
    • BPD (medical management first)
  48. AN mgmt for CDH?
    • Most pts arrive to OR intubated, sedated and
    • ventilate
    • Unintubated pts- NGT before induction
    • RSI or awake intubation
    • IV atropine 0 .02 mg/kg as premed before induction to avoid bradycardia
    • NO mask ventilation (stomach distention)
    • NO N2O
    • avoid worsening of pul. HTN (will ­ increase PVR and cause R toL cyanotic shunt)
    • High dose opiods (fentanyl 10-20 mcg/kg vs. normal
    • 1-2mcg/kg) if tolerated
  49. AN monitoring for CDH? positioing? chest tubes? extubation? paralysis? postop pain mgmt?
    • Vigilant monitoring: pre & post-ductal SpO2 (will reflect degree of shunting)right radial Aline CVP, Temprature (avoid hypothermia),ACTs if on ECMO, Frequent ABGs if on HFOV (end-tidal CO2 is hard to monitor), foley,
    • Position supine, transabdominal approach
    • After reduction of viscera from chest, the diaphragmatic defect is closed primarilyor with a prosthetic patch
    • Chest tubes are not used routinely
    • Muscle paralysis is maintained
    • Infants remain intubated postop and transported to NICU
    • Morphine IV infusion to avoid responses to stress
  50. what to avoid with CDH? vent mode?
    • Do not attempt to inflate hypoplastic lung after repair – may lead to tension pneumothorax on unaffected side (hypoplasia (not atelectasis) is
    • the problem)
    • Keep PIP < 25 cm H2O use pressure mode ventilation!!
  51. BPD AN mgmt?
    • Correct metabolic abnormalities due to chronic diuretic therapy
    • Optimize respiratory & CV status.
    • Pts may have a cardiomyopathy due to steroid
    • therapy (inflammatory component of BPD)
  52. Tx for BPD mgmt?
    • Vigilance with fluids
    • Diuretics (long term use = hypoKalemia, hypoChloremia, ­ serum bicarb)
    • NO N2O
    • bronchodilators, theophylline, caffeine, steroids
    • Anxiolysis for severe BPD (avoid BPD spell -
    • bronchospasm & cyanosis likely during phys. Stimulation
    • SPinal anesthesia
  53. AIrway mgmt for BPD?
    • increase Expiratory time, Avoid excessive PPV
    • chose LMA instead of ETT if possible

    deep extubation to avoid bronchospasm monitor for postop apnea.
  54. what factors predisposes preemie to hypoglycemia?
    • decrease glycogen stores = hypoglycemia
    • infant ­ increase BMR = use up glucose quickly
    • hepatic immaturity (where glycoNEOgenesis
    • occurs)
    • infants of maternal diabetics
  55. what causes anemia in newborns?
    • multiple blood draw), doesn’t’ cause disturbances in electrolytes, even though increase volume, baby cannot replace RBC's quickly= blood draws primarily effect ANEMIA
    • Also due to decrease EPO
    • decrease RBC lifespan

    Electrolyte disturbances will be due to immature production of electrolytes or problems with renal retention
  56. tx for meconium aspiration?
    • oropharyngeal suctioning
    • selective tracheal intubation & suctioning of meconium from the lungs (infants with Apgars <7),
    • chest physiotherapy
    • warmed humidified oxygen
    • Bronchial lavage is contraindicated (NO squirting saline down lungs)
  57. why are newborns more susceptible to sepsis?
    Leukocyte function is immature:pt prone to sepsis, bacterial infections
  58. what is normal preductal sp02? Pa02? safe inteaop pa02?
    • Normal SPO2 93-95% (preductal)
    • Normal PaO2 60-80 mmHg (> 80= retinal vasoconstriction in ROP)
    • Intra-op PaO2 < 150 safe
  59. complications of CDH?
    • Pneumothorax @ anytime(Sudden hypotension &
    • desaturation)
    • Hypoventilation
    • Hypothermia
    • Metabolic acidosis (toxin release from bowel)
    • increase PVR
    • CHF
  60. choanal atresia airway mgmt
    • CHARGE workup (25% have other congenital
    • anomalies)
    • Airway emergency – intubated in delivery room
    • right away
    • Arrive to surgery – what changes need to be made
    • Laser compatible ETT (Surgery involves LASER:
    • (malleable aluminum metal)PVC tubing if hit by laser will melt & burn

    • lowest possible FiO2 – compressed air instead; NO N2O
    • be aware of the hazard of airway fire
  61. when does surgactant production occur?
    • Begins @ 13 weeks (notes – first lecture)
    • Type II pneumocytes appear @ 22 weeks
    • Viability @ 24 weeks
    • Functional/ ”satisfactorily” @ 30-36 weeks
  62. what factors will cause persistent fetal circulation?
    • Shunting @ PFO/PDA
    • Things that ­ increase PVR will contribute to PFC
  63. which shunt has faster IV induction slower inhalation?
    R to left(cyanotic)
  64. which shunt has faster inhaled induction slower IV?
    Left to right (acyanotic)
  65. what drugs keep PDA open? closed?
    Prostacyclins(PGE1) keeps open 0.1mck/kg IV

    Cox inhibitors (indomethacin, ibuprofen) closes
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Peds 4
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