*Less than 37 weeks

*2.5-3.5kg at birth

*31-36 Weeks

*2.5kg

*22-30 weeks

*Intracranial hemorrhage

*Sepsis

*Respiratory Distress

*Lack the ability to maintain body temperature *Sucking

*Swallow

*Eat

*Sustain life

*Stress leads to anaerobic metabolism and metabolic acidosis

*Causes include: 

-Antepartum hemorrhage

-intrauterine infection

-breech delivery

-RDS

*Respiratory distress occurs 3x more often with C/S than vaginal delivery

*90% of babies 900-1000g survive

*70% of babies <750g survive

*Survival rate is related to surfactant and steroid use

*Brown fat develops at 26-30

*Increases in mass 3-6 weeks after birth

*Hypoglycemic infants

*CNS damaged infants 

What is bronchopulmonary dysplasia (BPD)?

*Maldistribution of ventilation and perfusion

*Hypercarbia

*Hypoxemia

*Prolonged ventilation

*Fluid overload

*Infections

*Premature lungs

*barotrauma

*O2 toxicity

*often associated with PDA

*Pulmonary air leak

*PEEP

*Diuretics

*PaO2 50-70mmHg

*Albuterol

*Ventilate with room air

*Keeps SpO2 87-92%

Solumedrol 

*limit fluids

*Premature infants prone to apnea do not breath under anesthesia and must be ventilated beginning with induction

*Preterm infants need 12 hours of apnea free discharge home 46-50 weeks PGA

*Hgb should be kept at 10-15g

*A hgb of 14-15 is more likely to prevent apnea 

*Retinopathy of Prematurity (Retrolental Fibroplasia)

-Retinal damage due to prematurity

-Require multiple OR visits for EUA and for phototherapy

*Occurs d/t small infants being exposed to O2, their small vessels in their eyes bleed & scar, eventually detaching the retina.

*More apt d/t premature neurovascular bed and fluctuations in BP

*Poor outcomes associated with Grade III and IV, which almost always require VP shunts

*Perforated bowel due to infection and decreased perfusion

*It is an emergency case: laparotomy

*Can have massive blood loss

*Difficulty maintaining normothermia

*PDA causes pulmonary congestion d/t a left to right shunt

*Require increased ventilatory support

*LV failure--> CHF

*Treatment with Indomethocin before surgical repair

*Can cause renal and PLT dysfunction

*Dopamine may be necessary until correction of PDA to improve CO

*Left thoracotomy for closure

A PFO is a common lesion of prematurity, what can t

his cause and how is it treated?

*Can cause primary pulmonary HTN

*Reduce PVR

*Deair all IV lines

*Adequate oxygenation is necessary to maintain PVR

*Pulmonary vasodilators include O2, tolazoline, PGE1, NO, ECMO

*Pregnancy problems

*Drug use with pregnancy

-look for in baby: agitation, tremors, poor feeding

-barbiturates: seizures

-diazepam and methadone: symptoms take 5-10 days to show

-Cocaine: pulmonary hypertension, prematurity, bowel perforation

*ASA and Tylenol-Pulmonary HTN, persistent fetal circulation

*Asphyxia at birth- effects may still be present and autoregulation of cerebral blood flow may be absent

*Shoulder Dystocia- sudden increases in blood pressure may cause ICH.

*VS (MAP~ gestational age up to 41 weeks)

*Respiratory status- on the vent?

*Fluids, IV, Feedings- PICC, use 1cc syringes for flushes

*Weight- is current less than birth weight?

*U/O

*Medications

*Presence of PDA

*Presence of PFO

*Electrolyte abnormalities not uncommon

*Clotting factors will be abnormal

*Thrombocytopenia (<10,000) will not transfuse unless surgery is planned

*Term infant- <30

*Preterm infant- <20

*Renal immaturity

*increased dose = increased interval

*Initial doses of some medication are higher to achieve therapeutic blood concentrations

*Prolonged excretion of penicillin, gentamycin, pavulon

*Preductal- on right hand

*Postductal- on left food or left hand

*EtCO2

*PaCO2

*Will require less than full term infants but don't give too little, patient could get an intracranial hemorrhage

*Inhaled anesthetics causes more hypotension in preterm neonates.

*Have 5% albumin available for volume

*You may need PRBC's if low Hct

*Use room air when possible 

*If using an umbilical catheter- is it above the diaphragm or below?

*Preterm infants <44 weeks gestation will develop post op apnea 

*Patients should be monitored for 24 hours post op

*Less than 50 weeks PGA (Post Gestational Age) not considered outpatient candidates

*Transfer patient in an isolette

1.Position neck roll

2. Open airway

3. Suction if necessary

4. Mask with mouth open watch that tongue is not occluding

5. If heart rate>100 continue ventilation

6. If heart rate <100 start CPR and reposition airway/mask

7. If HR below 80 continue PPV and do chest compressions

-1 finger breadth below nipple line, using 2 fingers

-1/2 to 3/4 compression depth

-Accompanied by ventilations, ratio is 3:1 or 90 compressions to ventilations in 1 minute.

8. Give Epi (0.1-0.3mL/kg of a 1:10,000 solution- every 3-5 minutes as necessary)

9. If prolonged arrest give NaHCO3

10. If suspicion of acute blood loss or signs of hypovolemia give blood or volume expander

*Prolonged bag and mask ventilation

*Bag and mask is ineffective

*2.0 ETT & 5-6 french suction catheter

*2.5 ETT

* 6 French suction catheter

*3-3.5 ETT

*8 French suction catheter

*3.5-4.0 ETT 

*8 French suction catheter

*6+weight (kg)

*Ex: Neonate weight 500g=0.5kg

0.5+6=6.5cm

*Protein binding is less

*RBC binding

*Tissue Volumes

*solubility is more because of larger ECF and blood flow to the tissues

*Uptake is higher- the breathe faster

*Higher alveolar ventilation 

*low FRC higher CO to vessel rich groups

*Rapid lung wash in/wash out

*Different muscle composition

*Lower plasma albumin

*Low alpha acid glycoprotein

*Large volume of distribution

*TBW increased

*ECF increased

*Brain flow increased

*Fat is decreased

*Muscle is decreased

*Brain volume is increased

*Brain flow is increaed

*Splanchnic volume is increased

*Renal flow is decreased

*Muscle volume is decreased

*Muscle flow is decreased

*Preterm infants have posttetanic exhaustion 

*Diaphragm and intercostals innervated mostly by type II fast twitch fibers that fatigue easily

*Rate of synaptic transmission is slower due to the immature myelination

Infant Adult

Gamma subunit           Epsilon Subunit

Junctional and extrajunc.       Localized to end plate

Unstable half-life 24h Shorter opening time

Long open time 2-10x>

Agonists dep. easier    Agonists dep. less easy

*high renal vascular resistance for 1-3 days after birth

*At 9 months 80-90% of GFR is complete

*Proximal tubule is functioning around 4-5 months

*Lower FRC

*Higher respiratory rate

*Infant- 25 minutes

*Child- 30 minutes

*Adults- 60 minutes

*Blood gas solubility changes over development

*Body composition is low muscle and fat

*Alveolar ventilation is high

*CO/CI is high

*FRC is low

*Lung wash in is rapid

When does MAC peak?

*At 3 months of age

*The smaller the child the more rapid the uptake into the alveoli, high concentrations may cause hypotension in infants and young children. (Esp. those with cerebral palsy)

*Sensitizes the myocardium to catecholamines

*Very cardiac depressive

*Should not be used in patients with elevated ICP

*Halothane Hepatitis happens LESS frequently in children than adults

*High blood gas solubility 2.4

*SLOW inhalation induction 5-6 minutes

*NO

*Very pungent odor, not used for IH induction

*Less cardiac depression than with halothane

*Less irritating to airways

*Fast IH induction secondary to low blood gas solubility (0.69).  

*May see tonic/clonic movements with induction.

*Can cause post operative agitation 

*Very expensive

*Great for short cases and mask cases

*No.

*May still have emergence agitation (can be slightly prevented by giving opioids to provide adequate analgesia during recovery from anesthesia)

*Not used at CHM except in idiopathic spinal fusions

*Tympanoplasty cases, bowel cases, eye muscle surgery cases or cases where N/V are frequent

*"Brute force"- a 4 point restraint system to keep the patient and staff safe if necessary

*Use as a last resort

*Baroreceptor response depressed (a decrease in BP without a decrease in HR)

*Incomplete adrenergic penetration of myocardium

*Dose dependent depression of the myocardium

*Increased brain blood flow

*Immature BBB

*Decreased metabolism of barbiturates
*Increase in volume of distribution

In children benzodiazapines have ______ respiratory depression and ________ amnesia

*Mild

*antegrade

*Adrenal insufficiency

*Epilepsy

*Acute porphyria

*Children <2

*Opioids

*Unless they are staying on the ventilator

*Crosses the BBB, highly lipophilic, higher T1/2 life

*MUST give atropine with it!

*Higher dose requirement d/t increased TBW, ECF, and volume of distribution

*Fasiculations are absent in children <3 years old d/t immature NMJ

*Diaphragm is paralyzed at the same time as the peripheral muscles

*Rapid onset and recovery

*Watch for patients with high K, high IOP or high ICP

*Phase II block on second dose 

*MH precautions- secondary to muscular dystrophy

*Cardiovascular effects: Bradycardia, asystole, hyperkalemia

*Due to poorly developed musculature, immature NMJ, lean muscle mass

*Can be potentiated by aminoglycosides (ie. Gent)

*Pancuronium: may be preferred for CV support in preterm infants and cardiac babies

*Vecuronium: long acting in children up to 2 years of age

*Cisatricurium: especially for renal patients

*Rocuronium: for RSI

*Onset is much quicker than adults, same duration.

*Consider using atropine with neostigmine to reverse preterm infants or failure to thrive infants.

*Safe dose: 10mcg/mL

*in LA 5mcg/mL can be added to decrease peak concentration by 30-40%.  It also increases duration in infants and children 4-6 years old.

*Epinephrine

*For tabletop setup:

<20kg dilute to 10mcg/mL

<5kg dilute to 1mcg/mL