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Anesthesia Principles III
Pediatrics- History & Physical, Anesthesia Circuits, Airway, Caudals, SCD, MH
132
Medical
Graduate
07/18/2010

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Cards

Term
Below what age can an infant not be an outpatient?
Definition
*<46 weeks post-gestational age
Term
What are some questions to ask the parents about the Delivery/Neonatoal period?
Definition

*Fullterm vs. premature

*Respiratory problems at birth

*Any other birth complications (On O2, ventilator, subglottic stenosis)

*Apena monitor at home

*How long in NICU

*Given Nephrotoxic Abx

Term
What are some questions to ask parents about growth and development?
Definition

*Feeding Problems

*Hitting the developmental milestones?

*Weight proportional to height

*Snoring when sleeping

*Walking (if regresses back to crawling think MD)

*Breath holding spells

*Childhood Obesity

*Adolescent pregnancy

Term
What emotional maturity occurs age 0-6 months?
Definition
*Nothing
Term
What emotional maturity occurs 6 months- 4years?
Definition
*Separation anxiety
Term
What emotional maturity occurs 4-6 years?
Definition
*Separation, Body Integrity- shy and modest
Term
How many URI's do most children have per year?
Definition
*6-9
Term
What emotional maturity occurs at 6 yrs to adolescence?
Definition
Loss of Control 
Term
What are differential diagnoses for runny nose in peds?
Definition

*Allergic Rhinitis

*Vasomotor Rhinitis-crying

*Prodromal stages of systemic viral illness (Varicella, rubeola influenza)

*Prodromal stages of bacterial illness (epiglottitis, adenotonsilitis)

*Sinusitis

Term
What are Symptoms and effects of URI?
Definition

*Increased nasal secretions---> Laryngospasm

*Increased lower airway secretions--> Atelectasis/Pneumonia

*Increased airway edema and inflammation--> Postintubation croup

*Increased tachykinins--> Airway reactivity

*Decreased Muscarinic respiratory function-->Airway reactivity

Term
What is the mean duration of URIs?
Definition
*7-9 days 
Term
How long after URIs may reactive airways persist?
Definition
*6 weeks
Term
If there is evidence of acute infection or pyrexia, what should be given to offset postop croup if case is not cancelled?
Definition
*Decadron 0.5mg/kg
Term
What are some questions the anesthetist should ask parents of children with asthma attack?
Definition

*How often does the child have asthma attacks?

*What precipitates attacks?

*Is the child on chronic medication? (How often, what kind, Oral or inhaled)

*Has the child taken corticosteroids in the last six months? Ever? Oral or Inhaled?

Term
What is the mineralcorticoid given to peds with asthma? What is the dosing?
Definition
*Methylprednisolone (Solu-Medrol) 0.5-2mg/kg (1mg/kg) then q6 hours
Term
When do clinical effects of Methylprednisolone begin?
Definition
*1-3 hours and peak at 4-8 hours
Term
What glucocorticoid is used with asthma?
Definition
*Hydrocortisone (Solu-Cortef)
Term
What is the dose for albuterol?
Definition
*0.01mL/kg of 5% solution (0.5mL in 2.5mL NS)
Term
How much of Albuterol reaches end of ETT when given at connector?
Definition
*Only 2.5-12% 
Term
What is the dose of albuterol for peds <6 months?
Definition
*0.25 in 1.25mL NS
Term
What is Fluticasone?
Definition
*Flovent-Inhaled Steroid
Term
What is Cromolyn Sodium?
Definition

*Intal

*Mast Cell Stabilizer

Term
What is Montelukast?
Definition

*Singular

*Leukotriene Inhibitor

Term
What is the dosing for Aminophylline?
Definition

*5mg/kg IV load over 15 minutes then 0.5-1.2mg/kg/h

*Watch for toxicity

*Not a first line drug

*Also used in apnea of prematurity

Term
What type of patients may be taking steroids?  What should be given preop?
Definition

*Rheumatoid Arthritis

*Ulcerative Colitis

*Asthma

*Transplant

*Sickle Cell Disease

*MS

*Give stress dose d/t suppression of hypothalamic-Pituitary Axis & ceasing of production of endogenous steroids

Term
What are some questions the anesthetist should ask about a child with a CHD?
Definition

*Innocent murmur or significant lesion

*Risk of paradoxical embolism

*Dyspnea, tachypnea, sweating

*HTN

*Needs for prophylactic Abx

*Hemoconcentration

*Previous heart surgery

*Cardiac workup/old records

Term
What are common CNS problems in Peds?
Definition

*Seizures

*Hydrocephalus- need prophylactic Abx

*Meningomyelocele/tethered cord

*Head Injury

*Cerebral Tumors- most are benign

Term
What findings are usually associated with Meningomyelocele in peds?
Definition

*Latex Allergy

*Renal Infections

*Impaired Renal function

*Difficulty positioning d/t contractures

Term
What are common Musculoskeletal disorders in Peds?
Definition

*Cerebral Palsy

*Muscular Dystrophy

*Down's Syndrome

Term
What is Cerebral Palsy?
Definition
*Progressive Central motor deficit
Term
What do patients with Duchenne's Muscular Dystrophy have an increased risk of?
Definition
*Risk of MH
Term
What do 15% of Down's Syndrome children have?
Definition

*C1-C2 instability

*Should have films on hand to confirm or deny.  If films are not available or done, do not hyperextend neck, or put pillow under shoulders.

Term
What percent of GERD subsides by 18 months and what % persists beyond 4 years?
Definition

*30% subsides after 18 months

*30% persists beyond 4 years

*5% experience esophageal stricture

*5% die of complications

Term
What are some important considerations for the ped GERD patient?
Definition

*Evidence of aspiration pneumonia

*Reactive airways

*Bronchospasm

*Recent PO intake?

*risk of regurgitation

*Need for IV anti-emetics

Term
What may be compromised in the pediatric patient with vomiting/diarrhea?
Definition
*Nutritional and hydration status
Term
Which children are considered an at risk group for latex allergy?
Definition

*Children with Neural tube defects

*Patients with a history of Atopy (allergy to nuts, strawberries, avacado, bananas anything coming from rubber tree). 

*Health Care Workers

 

Term
Which type of Latex Allergy reaction is most worrisome?
Definition
*Type I IgE-mediated anaphylactic reaction
Term
What is the presentation for anaphylactic reaction?
Definition

*Hypotension

*Rash

*Tachycardia

*Bronchospasm

*Hypoxemia

*Flushing

Term

What are some to look for in the H&P that may suggest a difficult airway?

Definition

*Abnormal face and ears (low set=downs)

*Loose teeth around age 5-6

*Cleft lip and palate, syndromes

*Cervical range of motion - know if Chiari defect is present

*Labs

*Vital Signs

*Malampatti class typically isn't done

Term
What are the ASA NPO Guidelines?
Definition

*2 hours Clear liquids

*4 hours breast milk

*6 hours formula

*8 hours solids

Term
Why are younger children more at risk for hypoglycemia with NPO?
Definition
*The younger the child, the smaller the glycogen stores and the more likely an occurrence of hypoglycemia with prolonged intervals of fasting.
Term
What are the doses for PO and IV Midazolam in the Ped patient?
Definition

*PO 0.5mg/kg (max dose 20mg) Give 20 minutes prior to arriving in OR.

*IV- 0.05-0.1mg/kg (2-4mg)

Term
What is peds dose for IV thiopental?
Definition
**2-5mg/kg
Term
What is the dose for IV & IM ketamine in peds?  What additional adjunct should be given?
Definition

*IV:1-2mg/kg 

*IM: 5-8mg/kg

*Glycopyrrolate

Term
What should the anesthetist do if a tube becomes dislodged in the pediatric patient?
Definition
*Don't take it out, keep it in, continue to bag while plugging nose.
Term
Which Mapleson circuit does not have corrugated tubing?
Definition
*Mapleson C
Term
What type of pressure/volume do cuffed ETT have?
Definition
*Low volume, high pressure
Term
What are the three determinants that Mapleson circuits depend on?
Definition

*The location of the fresh gas flows

*Overflow valve

*Reservoir bag

Term
What happens to the valve on a Mapleson system upon inspiration?
Definition
*The valve closes and the patient inspires fresh gas from the reservoir tube
Term
What happens during expiration to the valve on a Mapleson bag?
Definition
*The patient expires into the reservoir tube.  Toward the end of expiration, the bag fills and positive pressure opens the valve, allowing expired gas to escape
Term
What does expiratory pause mean in relation to the Mapleson circuit?
Definition
*Fresh gas washes the expired gas out of the reservoir tube, filling it with fresh gas for the next inspiration.
Term
What are the operational requirements of a Mapleson system?
Definition

*The volume of the reservoir tube must be greater than the patient's tidal volume otherwise expired gas will enter the bag and contaminate the inspired gas.

*Fresh gas flow must exceed minute ventilation by 50%.

*Unlike the T-piece and Bain, the efficiency of the circuit is unaffected by the respiratory pattern.

Term
What are the advantages of the Mapleson A system?
Definition

*Inexpensive

*Provides the advantages of a non-rebreathing ciruit with reasonable economy of gas use

Term
What are the disadvantages of Mapleson A?
Definition

*The position of the valve closes to the patient's head may be inconvenient for orofacial surgery

*Difficult to perform intermittent positive pressure ventilation effectively.

Term
Describe the Mapleson D system
Definition

*Fresh gas flow enters near the patient end and the overflow valve is located near the reservoir bag

*During controlled ventilation the overflow valve is partially closed

*During spontaneous ventilation the overflow valve is open

Term
What is the Bain Circuit?
Definition
*A co-axial modification of the basic T-piece system, developed to facilitate scavenging of waste anesthetic gases.
Term
How does the Bain circuit differ from the Mapleson D?
Definition
*The Bain circuit has fresh gas flows placed coaxial with the expiratory limb
Term
How can one test a Bain circuit for an undetected leak in the inspiratory limb?
Definition

*The Pethick test

 

Term
How is the Pethick test performed?
Definition
*Placing the bag on the patient end and flushing the system with fresh gas should create the venture effect within the circuit causing the bag to collapse. It the bag inflates, you have a leak in the circuit.
Term
How does the Bain circuit function?
Definition

*Functions in the same way as the T-piece, except that the tube supplying fresh gas to the patient is located inside the reservoir tube.

*Inspiration: The patient inspires fresh gas from the outer reservoir tube

*Expiration: The patient expires into the reservoir tube.  Although fresh gas is still flowing into the system at this time, it is wated as it contaminated by expired gas.

*Expiratory pause: Fresh gas from the inner tube washes the expired gas out of the reservoir tube, filling it with fresh gas for the next inspiration.

Term
What are the operational requirements of a Bain circuit?
Definition

*Similar considerations apply as for the t-piece

*The Bain is more efficient at eliminating exhaled gas, since the fresh gas is directed down the endotracheal tube, which reduces dead space

Term
What are the advantages of a Bain circuit?
Definition

*Compact and inexpensive

*Low dead-space

*Low resistance to breathing

*Facilitates scavenging of waste gases

Term
What are the disadvantages of the Bain circuit?
Definition

*High fresh gas flow requirement in larger kids

*If the inner tube becomes disconnected or breaks, the entire breathing tube becomes dead-space, leading to severe alveolar hypoventilation.

*High gas flow rates, if the oxygen flush valve is used, may cause lung barotrauma

Term
What is the Ayre's T-Piece?
Definition
*It is the original Mapelson E system
Term
How does the Ayre's T-Piece function?
Definition

*Inspiration: The patient inspires fresh gas form the reservoir tube

*Expiration: The patient expires into the reservoir tube.  Although fresh gas is still flowing into the system at this time, it is wasted as it is contaminated by expired gas.

*Expiratory pause:Fresh gas washes the expired gas out of the reservoir tube, filling it with fresh gas for the next inspiration

Term
What are the operational requirements of the Ayre's T-Piece?
Definition

*The volume of the reservoir tube must be greater than the patient's tidal volume, otherwise the inspired gas will be contaminated by the surrounding air.

*Requires 1.5-2 times the minute ventilation to prevent rebreathing of gases 

*Intermittent positive pressure ventilation may be performed by intermittently occluding the end of the reservoir tube.

Term
What is the Jackson-Rees'?
Definition
*A modification of the Ayre's T-Piece (Sometimes known as the Mapleson F system) connects a bag to the expiratory limb of the circuit.  This allows respiratory movements to be more easily seen and permits intermittent positive ventilation if necessary.  The bag is, however, not essential to the functioning of the circuit.
Term
What are the advantages of the Jackson Rees' system?
Definition

*Compact

*Inexpensive

*No valves

*Low dead-space

*Low resistance to breathing

Term
What are the disadvantages of the Jackson Rees'?
Definition

*The bag may get twisted and impede breathing

*High gas flow requirement

Term
What type of breathing systems do most pediatric institutions use?
Definition
*Rebreathing Semi-Closed Circle Sytem
Term
How does CO2 production differ between adults and children?
Definition
*Infants CO2 production can almost double that of an adult
Term
How does temperature effect CO2 production?
Definition
*Changes up and down 7%/degree celcius
Term
How does nutrition affect CO2 production?
Definition

*Malnutrition decreases CO2 production 

*Parenteral nutrition increases CO2 production by as much as 70%

Term
How is dead space (rebreathing) adjusted?
Definition

*Equipment

*Fresh gas flows

*Minute ventilation

Term
What valves cause resistance in breathing systems?
Definition

*Valves

*ETT connectors

Term
What is compression volume?
Definition

*The change in atmospheric pressure during inspiration and expiration

*Compliance volume is the distensibility (stretch) of the equipment

 

Term
What valves are in the pediatric breathing systems?
Definition

*Ayre's T-Piece no valves

*Mapleson Systems with overflow popoff valves

Term
What are two important features of a facemask?
Definition

*Should minimize deadspace- use smallest mask you can manage

*Be nonthreatening

Term
Airways are not frequently used on induction in children because they are .......
Definition
*Obligate nose breathers
Term
What can happen if an oral airway is inserted when the child is too light?
Definition
*Laryngospasm
Term
What type of blade is preferred in infants and why?
Definition
*Straight blades d/t they displace the tongue and allow for better visualization of the larynx.
Term
What size blade for premature and neonate?
Definition
*Miller 0
Term
What size blade up to 2 years of age?
Definition
*Miller 1
Term
What size blade between 2-8 yrs of age?
Definition

*Wide range of different blades: Flagg, Wis, Wis-Hipple, Macintosh

*Miller 2 for ages 2-99

Term
What depth should the ETT be secured in a small neonate?
Definition

*1kg= 7cm

*2kg=8cm

*3kg=9cm

*4kg=10cm

Term
What formula can be used for depth of tube placement?
Definition

*3x ID(mm) of ETT

*Length (cm)= age(in years)/2+12

Term
What is the formula for depth of placement for nasal tubes?
Definition
*Length (cm)= 3xID(mm)+2
Term
What is the appropriate tube size for premature <1000g
Definition
*2
Term
What is the tube size for premature >1000g
Definition
*2.5
Term
What tube size in term neonate- 3months?
Definition
*3.0-3.5
Term
What size tube for age 3-9 months?
Definition
*3.5-4.0
Term
What size tube for 9-18 months?
Definition
4.0-4.5
Term
What size tube for >2 years?
Definition
*Age+16/4
Term

In general, a 3.0 ETT in a neonate can be secured at...

1yr old....

2 yr old....

Definition

*9cm at 3mo

*10cm at 1yr

*12cm at 2yrs

Term
At what pressure should an ETT have a leak at?
Definition
*20cm
Term
If there is no leak present above 20cmH2O, what risk does this increase?
Definition
*Post extubation stridor
Term
How many ETT should be on hand for induction?
Definition
*3 ETT a half size above and below size that is to be used
Term
What should the anesthetist be looking for "at the cords" when intubating peds?
Definition
*black area or lines "2 at the cords"
Term
How should ETT be secured after placement is confirmed in the ped patient?
Definition
*Disconnect the ETT from the breathing circuit to secure/tape ETT to prevent accidental extubation
Term
What are some calculations for cuffed and uncuffed tube sizes?
Definition

*Uncuffed: (age/4)+4

*Cuffed: (age/4)+3

Term
Since stylets are not always used in the peds population, which situations should they be used in?
Definition

*Airway lesions

*Mandibular hypoplasia

*During RSI

Term
What should be used for all infants and children unless they are inpatient?
Definition

*A buretrol to prevent fluid overload- 100mL in buretrol to prevent overload after induction

*If inpatient, fluid should be on pump

Term
What size IV is common in peds?
Definition
*22g, besure to examine IV tubing for air
Term
In what order largest to smallest does heat loss occur?
Definition

*Radiation 39%

*Convection 34%

*Evaporation 24%

*Conduction 3%

Term
What is the #1 way to prevent heat loss?
Definition

*Warm the room

*Newborns and infants have a large surface to volume ratio thus radiant heat loss in proportionately greater the smaller the infants

Term
List some ways to prevent heat loss.
Definition

*Warming devices

*Room temperature

*Radiant heat lamps

*Protective coverings

*Bair Huggers

*Fluid Warmers

*Plastic

*Heated Circuits

*HME

Term
What monitors/devices should be used in the pediatric patient?
Definition

*"You"

*Brutane or bear hug avialable

*Pulse ox

*Precordial

*BP, Temp (usually axillary), EKG

*Oxygen analyzer

*Capnography, dopplar

Term
What is the only monitoring device that MUST always be used in the ped patient?
Definition
*Oxygen analyzer
Term
What procedures are ideal for Caudal Epidural blockade?
Definition
*Perineal & Perianal procedures up to T10
Term
What amount and what agent should be used for caudal epidural anesthesia for circumcisions and low anal surgery (low sacral)
Definition
*Bupivacaine 0.25% 0.5-1mL/kg
Term
How much LA for blockage of lower thoracic nerves for CEB?
Definition
*1mL/kg
Term
How much LA for blockade of midthoracic nerves in CEB?
Definition
*1.25mL/kg
Term
________mL of LA are necessary to predictably provide a sensory level of T12 to T10 in the pediatric patient.
Definition
25-35mL
Term
What is the technique for a Caudal?
Definition

*Needle: 2-3cm, 23-25g or a 22g angiocatheter

*Positioning: Fetal lateral sims

*Needle placement:

-The needle should be at 120 degrees.  The characteristic "pop" confirms penetration of the sacrococcygeal ligament (Bring needle down to 90 degrees)

-The needle should then be depressed toward the skin to align the needle approximately in the long axis of the canal. Leave in angiocatheter

-Injection should be after negative aspiration, (lack of blood or CSF) and ffel no resistance. NO SQ bulge should be felt

Term
What is Sickle Cell Disease?
Definition

*An inherited autosomal recessive disorder

*Has a high incidence in ethnic groups exposed to malaria

Term
What blood disruptions does SCD cause?
Definition

*Hemolytic anemia

*Hemolytic thalassemia

Term
What type of hemoglobin is more prevalent in the pt with SCD?
Definition
*Hemoglobin S
Term
How is hemoglobin S formed?
Definition
*When valine is substituted for glutamic acid in the 6th position of the 2 beta polypeptide chains in the Hgb molecule
Term
What occurs with deoxygenation in the SCD patient's Hgb?
Definition

*With deoxygenation a gel forms at the point of contact between alpha and beta chains causing the hgb to line up and distort the membrane.

*SCD is a group of disorders with HbS

Term
What are the three most common types of SCD?
Definition

*Hb SS (SCD) 

*Hb SA (SC trait)

*Hb S-Thalassemia

Term
True or false: Severity of SCD is not linked to the amount of Hgb that is Hgb S.
Definition
False
Term
Hb SS is characterized by _____% of Hgb being Hgb S
Definition
*70-98%
Term
Hb SA is characterized by _____ of hgb being hgb S.
Definition
*10-50%
Term
Definitive diagnosis of SCD requires what?
Definition
*Plasmaphoresis
Term
What Stressors can cause sickling?
Definition

*Hypovolemia, Hypoxemia, Hypothermia

*RBCs sickle at PO2 of 15mmHg

Term
What crisises can occur with sickling?
Definition

*Vasoocclusive crisis

*Sequestration crisis

*Aplastic crisis

Term
What are some treatments for SCD?
Definition

*Prevention

*Gene Manipulation

*Transfusion: Simple vs. exchange

*Bone marrow transplant

*Hydroxyurea- study drug

Term
What are some preoperative considerations for the patient with SCD?
Definition

*Hgb S must be below 40% of Hgb and must be seen by the SCD hematology clinic people prior to surgery.

*They may need blood transfusion to raise their hemoglobin to 10gm/dL

Term
What are 4 important points for an anesthetist to focus on during anesthetic management of a pt with SCD?
Definition

*Keep them warm
*Normocapnic

*Well Hydrated

*Avoid hypotension

Term
What is the most important postop consideration for the pt with SCD?
Definition

*OXYGEN

*Children with HB SC are very vulnerable to the effects of Hypoxemia!

Term
How is Malignant Hyperthermia passed genetically?
Definition

*It is an autosomal dominant Inheritance

*In humans not a single disease but a syndrome

Term
How does MH manifest pathologically?
Definition
*Defects in the release and reuptake of calcium from the sarcoplasmic reticulum of the skeletal muscle.
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