Measuring the crown to rump length (most accurate)

Calculating mothers last menstrual period (inaccurate)

Dubowitz scoring system (neurological and external physical criteria)

Weight below 10th percentile at gestational age

(affected by intrapartum factors)

Large Gestational Age (LGA)

What does this result from?

Wt above 90th percentile at gestational age

result from organolmegally and increase in deposition of SQ fat 2ndry to increase in fetal insulin

Respiratory distress syndrome (RDS)

Apnea

Perinatal Depression

 Intrauterine Malnutrition

Hypoglycemia

Hypocalcemia

Polycythemia

Hypothermia (O2 consumption)

Congential Anomalies

 Maternal Drug Addiction

Fetal Alcohol Syndrome

RDS

 Hypoglycemia

 Hypocalcemia

 Hypomagnesemia

Hyperbilirubinemia

Birth Trauma

Hyperbilirubinemia

Hypoglycemia

First Trimester (____ weeks)

 ____ ____ phase in development

_______growth

eight weeks

Most important phase in development

Embryonic growth

*all baby's organs formed by end of 1st trimester

Third trimester:

fetal ______, which includes what 3 things?

Fetal growth

Wt gain

Subcutaneous tissue

Development of muscle mass

In the 1st trimester, where is the heart found? Where does it migrate to?

During the 3rd week, what do the heart tubes connect with?

heart found vertically in pharyngeal region

later migrates to the thorax

3rd wk: heart tubes connect with the arterial and venous system

 How do the lung buds appear at 26 (2 wks) days of gestation?

What occurs in the lung buds at day 52 (7wks) of gestation?

appear as diverticulum of the embryonic foregut:

Primordial trachea

bronchial tree

epithelial lining of lungs

alveoli

day 52:

segmental bronchi

diaphragm is complete

Glandular Stage (7-16 wks)

Canalicular Stage (16-24 wks)

Terminal Saccules/Alveolar Stage (24 wks - term)

Develop mainly after birth

increase in number and size until chest cavity stops growing

When do the pulmonary vessels develop?

Arterial smooth muscle formation lags, it follows the dev. of the ______ and is complete in _____.

They accompany the pattern of the bronchial tree at 16th week

arterial smooth muscle follows dev. of alveoli

Complete in adolescence

Surface of the lung develops gas exchanging ability

Surfactant production in Type II pneumocytes

Surfactant increases in the amniotic fluid

The CV system in utero is predominantly under control of ______ NS.

After birth it's under control of ______ NS.

Parasympathetic NS in utero

SNS after birth

What is the mean HR from:

newborn -24 hrs

 24hrs to 1 month

1 mo - adolescence

newborn -24 hrs: 120 bpm

24hrs to 1 month: increase to 160 bpm

1 mo - adolescence: gradual decrease from 160-75 bpm

The newborn myocardium is _______.

This results in _______ stroke vol.

Cardiac output is dependent on ___.

What effects do the following have:

atropine

epi

calcium chloride

immature

decreased

HR

(dependent on muscle itself; no Frank Starling Mechanism with these little guys)

atropine: increase HR

epi: increases contractibility/HR

CaCl: increases contractibility

What is the mean systemic blood pressure for:

 the newborn to 12 hrs

12 hrs-4 days

4 days-6 wks

6 wks-1 yr

1 yr-6 yr

6 yr-adulthood

the newborn to 12 hrs: 65

12 hrs-4 days: 75

4 days-6 wks: 95

6 wks-1 yr: little change

1 yr-6 yr: very slight increase

6 yr-adulthood: gradual rise

T/F: The renal system is active in utero

What contributes a large amount to amniotic fluid vol?

 GFR at birth...

T

production of urine

15-30% normal adult function

GFR

5-10 days after birth

What is the clinical relevance of hepatic immaturity at birth? Why?

When does it improve?

When does it reach maturity?

Inability to metabolize proteins and drugs

neonates have an immature phase I (cytochrome dependent) rxns--oxidation, reduction & hydrolysis not fully developed

Improves after first week

can take up to 3 full months to reach maturity

II

VII

IX

X

At birth, what level are the vitamin K factors at?

What is needed?

When does the infant reach adult levels of coagulation factors?

The system shifts from the _____ to the ____ _____. Production of ______ types of blood cells.

20-60% of adult values

Prophylactic Vitamin K needed

after 1st few weeks

 liver to bone marrow

 all

Has a higher affinity for O2 than adult

Facilitates O2 uptake as fetal blood circulates

Allows the fetus to exist in a relatively low PaO2 environment as compared to adults

What does head circumference reflect?

Large head circumference suggests...

Small head circumference suggests what? What is the name for this?

Reflects the growth of brain & intracranial vol

Hydrocephalus

Abnormal brain growth

(Craniosynostosis--cranium fuses faster than norm)

Infant head circumference growth:

9 mos (compared to adult)

1 yr

2 yrs

over next 10 yrs

9 mos: 50% of adult size

1 yr: grow up to 10 cm

2 yrs: grow another 2.5 cm (75% adult size)

Over next 10 yrs: 2.5-3 cm

When does the anterior fontanelle close?

What does it indicate if the anterior fontanelle is sunken?

If it is bulging?

9 - 18 mths

sunken: late sign of dehydration

bulging: ICP, hydrocephalus, infection, hemorrhage, increased Pa CO2

When do permanent teeth appear?

In what amount of time?

6 years

shedding of deciduous teeth

Permanent teeth come in over next 6-8 years

5-10 years old

don't want them to aspirate these!

When do infants begin to display separation anxiety?

What is the major goal of the preoperative visit aside from the assessment?

Infants have anxiety d/t separation, why do adolescent normally have anxiety?

4-6 mths

Relieve stress and anxiety for the pt AND parents

40-60% experience anxiety

Loss of control

Oligohydramnios

Polyhydramnios

renal anomalis

tracheal esophageal fistual

Meconium stained = risk for ?

Mom with preeclampsia = risk for _____ w/ infant?

Diabetes in mom = risk for?

interstitial pneumonitis

Neonatal neutropena and thrombocytopenia

hypoglycemia

If a child is on asthma medications we should be on guard for...

A reactive airway

When should herbal remedies be d/c'd before surgery?

What is the problem with Chinese herbal remedies?

2 weeks

Twice as likely to develop hypokalemia and impaired hemostasis

Garlic

Ginseng

Ginkgo Biloba

All increase risk of bleeding

St John's wort most commonly interacts with ____ and ___ _____.

Potent _____ of CYP 450 & P-glycoprotein.

What problems can herbal remedies cause? (4)

St John's wort most commonly interacts with anesthetics and drug metabolism.

Potent inducer of CYP 450 & P-glycoprotein.

CV instability

coagulation disturbances

immunosuppression

prolong anesthesia

In the preop history, it is important to thoroughly review CV system.

What can the following findings be signs of:

murmur

cyanosis

history of squatting

rheumatic fever

diaphoresis with feeds

heart surgery

HTN

murmur: septal defects--avoid air bubbles!

cyanosis: rt to left shunt

history of squatting: TOF

rheumatic fever: valvular hrt disease

(might want to give prophylactic ABX)

diaphoresis with feeds:  CHF

heart surgery:  HLHS

(hypoplastic left heart syndrome--3 stages of surg)

HTN:  COA, renal disease

What should we look for if pts have the following CNS problems?

seizures

hydrocephalus

head injury

cerebral tumor

swallowing incoordination

neuromuscular disease

cerebral palsy

meningomyelocele

What meds should be avoided?

seizures: meds, serum levels, seizure precautions

hydrocephalus: possible ICP

head injury: eleveated ICP

cerebral tumor: chemo, ICP

swallowing incoordination: aspiration, GERD

neuromuscular disease: paralytic sensitivity, MH

cerebral palsy: aspiration, positioning, infections

meningomyelocele: hydrocephalus, renal dysfcns, latex sensitivity (home catheterization)

ketamine, methohexital, enflurane, sux

With the endocrine sys, what assessments relate to the following?

Diabetes mellitus

thyroid disease (__ can interfere w/ intubation)

pituitary disease

adrenal disease

hypoglycemia

Diabetes mellitus: insulin req, insulin pump, glucose level

thyroid disease: med status, airway (nodule can interfere with intubation)

pituitary disease: adrenal insufficiency

adrenal disease: corticosteroid therapy, DI

hypoglycemia: hyopglycemia/glucose level

The CV system is predominantely under control of ______ NS in utero.

After birth it's under control of ______ NS

Parasympathetic

sympathetic

What do we look for regarding GI/hepatic system?

GERD

Growth failure

 Vomiting/diarrhea

liver recipient

liver disease/jaundice

GERD: apsiration, reactive airway

Growth failure: anemia

Vomiting/diarrhea: electrolytes, dehydration

liver recipient: drug metab, immunosupression

liver disease/jaundice: drug metab, hypoglycemia

What should we look for regarding the genitourinary system?

Renal  failure

frequency

bladder exstrophy

HCG piercings

latex/sensitive/allergy

Renal failure: anemia, electrolyte status (K+), vol status, dialsysis schedule

frequency: recurrent infections, hypercalcemia, DI

bladder exstrophy: suggestive of latex allergy

HCG test: follow hospital policy

(start ~10yrs) 

piercings: liability/risk--remove

latex/sensitive/allergy: latex free equipment

What do we look for regarding resp system?

preterm

resp distress syndrome

recent upper resp infection (avoid surgery till?)

bronchitis

croup

asthma/RAD

cystic fibrosis

snoring

preterm: peri/post op apnea

resp distress syndrome: gestational age at birth, residual chronic resp distress, impaired gas exchange, anemia

recent upper resp infection: acute infection, lower resp infection, wheezing, rales, postpone surgery for 2 weeks

bronchitis: reactive airway, possible bronchospasm

croup: subglottic stenosis, avoid intubation

asthma/RAD: reactive airway, status, medicine, neb trtmts, steroids

cystic fibrosis: present pulmonary fcn, acute infection, anesthesia plan

snoring: reactive airway, obstructive airway, OSAS, hypoxia

What do we look for regarding hematologic system?

anemia

bruising/free bleeding

sickle cell disease

anemia: transfusion requirement

bruising/free bleeding: coagulopathy, thrombocytopenia, lab work-up

sickle cell disease: trait vs disease, anemia, transfusion, hydration, oxygenation, warmth devices, limit tourniquet use

*Sickle cell trait (also known as being a carrier) occurs when a person has one gene for sickle hemoglobin and one gene for normal hemoglobin

Muscular dystrophy:

history of MH

hyperthermia

hypotonia

special PACU protocol

possible post-op admission

avoid MR if possible

risk of hyperkalemia

What do we look for regarding growth and dvpt?

Milestones relative to age

delays:

learning

sensory

motor

speech

ambulation

What can a high arch of the palate indicate ?

Mask induction might be difficult in which kind of pts?

Standardized tonsillar size:

0

+1

+2

+3

+4

0: (in fossa)

+1:  <25%

+2: 25%-50%

+3: 50-75%

+4>75%

NPO schedules:

clears

breast milk

formula, milk and solid food

Be specific when telling parents what the child can have; give some examples of clear liquid.

clears:  2 hours

breast milk:  4 hours

formula, milk and solid food: 6-8 hrs

apple juice, water, pedialyte ---NO grape per lec

peritoneal --- cant get fistula till adult

peds still receive hemodialysis--maybe thru a dialysis catheter?....oh yeah lol it was late when I wrote that =-)

What should you do if the pt recently has had croup?

Pts with cystic fibrosis have a large _____ d/t lots of secretions and thus you should consider doing a ____ anesthetic.

OSAS in kids is also associated with ______.

Avoid intubation b/c pt will have subglottic stenosis

Use LMA or mask

VQ

TIVA

obesity

Down syndrome children are often mouth breathers d/t?

Remember that tons of secretions may trigger ______ during which stage of anesthesia skipped with adults?

H&H ratio of ____ is kind of the limit as to when you need to give blood or postpone the surgery with kids per lec.

swollen adnoids

laryngospasms

Stage 2

10:30

Family Hx

Premedical Hx

Surgical Hx

Medications/Herbs

Allergies

Mallampati Classifications:

Class I

Class II

Class III

Class IV

Class I - tonsilar pillars, hard & soft palate, uvula

Class II - tonsilar pillars, hard & soft palate, but tip of uvula is hidden by base of tongue

Class III - only hard & soft palate, no uvula

Class IV - only hard palate