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Peds Anesthesia: Beyond the Introduction
Notes
73
Nursing
Graduate
04/06/2015

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Term
Newborn is defined as
Definition
1-28 days
Term
Infants are defined as
Definition
up to end of first year
Term
Infant's larynx is at
Definition
C3/C4
Term
Adult larynx is at
Definition
C5/C6
Term
THE NARROWEST OPENING OF THE INFANT/SMALL CHILD LARYNX IS THE _____ ______ WHICH IS A _____ _____
Definition
CRICOID CARTILAGE, COMPLETE RING
Term
Children less than 2 years of age should be placed into a _____ head position, with a _____ _____ _____
Definition
neutral head position, with a towel below the shoulders
Term
In a child greater than 2 years of age, the ________ _______ makes for optimal alignment of the airway just as in the adult, with a towel under ___ ____
Definition
sniffing position, with a towel under the head
Term
The distance from the vocal cords to the carina is ____ in the infant.
Definition
4 cm
Term
The adult has a right bronchus angle of about ___ degrees where the left has an angle of _____ degrees
Definition
25, 40-60
Term
Anatomical airway differences between kids and adults
Definition
Obligate nose breathers
Small nares
Large head/occiput
Small mouth opening and chin
Large tonsils and adenoids
Short neck and trachea
Larynx is more cephalad/superior
Narrowest portion of airway = cricoid cartilage
Cords attach lower anteriorly (on a slant)
Main stem bronchi leave at 55 degree angle
Term
Size Calculation
Definition
(Age + 16) / 4
Term
Depth Calculation
Definition
(Age/2) + 12
Term
Average depth of ETTs for infants under one year
Definition
Newborn = 10cm, 6months-1year = 11-12 cm
Term
Premie under 1000gms ETT size
Definition
2.5 ETT
Term
Premie 1000-2500 gms ETT size
Definition
3.0 ETT
Term
Premie >2500gms
Definition
3.5 ETT
Term
Premie depth calculation
Definition
7cm + 1cm x(each kg above 1 kg) (max 10cm)
Term
LMA (0-5kg)
Definition
1
Term
LMA (5-10kg)
Definition
1.5
Term
LMA (10-20kg)
Definition
2
Term
LMA (20-30kg)
Definition
2.5
Term
LMA (30-50 kg)
Definition
3.0
Term
Hypertrophic Pyloric Stenosis symptoms
Definition
manifests within the 2nd to 6th week of life as nonbilous, projectile vomiting about 30 minutes after feedings
Term
Hypertrophic Pyloric Stenosis feels like...
Definition
an olive shaped mass between the midline and right upper quadrant
Term
Chronic vomiting in HPS causes
Definition
metabolic alkalosis, hypokalemia and hypochloremia
Term
HPS causes paradoxical aciduria because...
Definition
Due to Na loss the kindeys start to conserve Na and spit out hydrogen ions
Term
pyloromyotomy may indicate a ___________emergency, but ____ _ _______ emergency
Definition
MEDICAL, NEVER a surgical
Term
Pyloromyotomy can be dangerous if you don't do what preop?
Definition
Hydration and electrolyte correction, can take 24-48 hours in severe cases
Term
IVF of choice for pyloromyotomy
Definition
D5.45NS or D5.9NS
Term
Preop optimizatoin goals for pyloromyotomy
Definition
, the Sodium should be >130mEq; Potassium >3mEq; Chloride>85 mEq; urine output should be 1-2 ml/kg/hr.
Term
Major concern in pyloromyotomy
Definition
aspiration
Term
Pyloromyotomy induction
Definition
OGT
RSIV or awake intubation
Term
Pyloromyotomy postop major concern
Definition
respiratory depression and hypoventilation is an increased risk in this population. The increased risk comes from persistent metabolic alkalosis or CSF alkalosis (central chemoreceptors are bathed in CSF. Alkolotic CSF makes the brain want to decrease respirations whick drives up CO2).
Term
should you use narcotics in pyloromyotomy
Definition
wouldnt be a great idea due to resp depression and quick speed of cases
Term
nissen fundoplication
Definition
decompress stomach with OGT,
Use esophageal dilator,
sometimes OG must come out for dilator
Term
Intussusception feels like and looks like what foods?
Definition
feels like a distinct “sausage” mass in the abdomen

bloody, maroon stools (look like currant jelly)
Term
Is intussusception an emergecny?
Definition
Yes, Intussusception creates a real potential for dead bowel if not relieved in a timely manner, and therefore is an emergency

Do RSIV, watch electrolytes, and fluid status
Term
20-30% of children with duodenal atresia also have
Definition
trisomy 21
Term
Meconium ileus occurs in 10-15% of infants with
Definition
cystic fibrosis
Term
Duodenal and Ileal Obstruction anesthetic considerations
Definition
massive fluid and electrolyte shifts,
OG or NG,
AVOID nitrous!
hemodynamically unstable so Consider TIVA,
RSIV induction,
NDMRs are required for abdominal relaxation and manipulation.
Term
omphalocele
Definition
herniation of abdominal contents at the umbilicus, covered by a thin membrane, includes the umbilical cord in the herniation
Term
imperforate anus
Definition
surgery in 2-3 days of life
Term
omphalocele incidence
Definition
is 1 in 6,000 births
Term
_____ _____syndrome is often associated with an omphalocele
Definition
Beckwith-Wiedomann
Term
Beckwith-Wiedomann symptoms
Definition
macroglossi (large tongue), visaromegaly (large organs) and hypoglycemia (due to islet hyperplasia and hyperinsulinism).
Term
Gastroschisis
Definition
gastroschisis (images on the right) is a full thickness abdominal wall defect usually to the right of the normal umbilical cord
Term
True or false: kids with gastrochisis typically have other anomalies
Definition
False
Term
True or false: kids with omphalocele typically have other anomalies
Definition
True, they can have GI, cardiovascular, GU and CNS anomolies and beckwith-weidoman syndrome
Term
Anesthetic considerations for gastrochisis and omphalocele
Definition
1 Maintain body heat and fluid balance!
more an issue for gastroschisis
2 Watch for major fluid shifts with exposed bowel!
3 These kids need to be intubated and paralyzed.
4 continue mechanical ventilation
5 RSIV induction or awake intubation
6 No nitrous!
7 Full paralysis
Term
Duchenne MD
Definition
most common form of MD and one of the most severe

Duchenne MD occurs more frequently in males (1:3,300).

abnormality of dystrophine.
Term
Is duchenne MD associated with MH
Definition
NOpe!
Term
In duchenne MD what muscle is often effected?
Definition
Heart (70% of cases)
Term
Anesthesia Considerations:Muscular Dystrophy
Definition
1 Aspiration risk
2 no succs
3 NDMRs are OK
4 Post operative ventilation
5 use a 5 lead ECG
6 Kyphosis is the most common reason for surgery
Term
Cerebral Palsy occurs from lack of O2 to cerebellum at what time?
Definition
during pregnancy (75%), during childbirth (5%), or after birth up to about age three (15%).
Term
Considerations for CP
Definition
-Aspiration risk, full stomach
-positioning challenges
-NO SUCCS
-Unable to shiver, susceptible to hypothermia
-Slow emergence
-high rate of POPCs
Term
Cystic Fibrosis considerations
Definition
-fat soluble vitamin deficiencies
-may have meconium ileus as newborns
-many lung issues
Term
CF anesthetic considerations
Definition
-Prolonged induction/emergence
-CPT preop is good
-No to aggresive narcotic use
-No nitrous
-Ketamine is bad d/t incresed secretions
-Glyco is controversial
-Intubate DEEP
-Suction during case and before extubation
-Regional is preferred
Term
Juvenile RA
Definition
-Airwaydifficult (stiff neck and larynx)
-MAS (macrophage activation syndrome)
-Avoid NSAID triggers for MAS
Term
Turner syndrome characteristics
Definition
Short stature
Webbed neck
Small mandible
Coarctation of aorta
Diabetes
Thyroid conditions
Lymphedema
Term
Turner syndrome key points
Definition
1) difficult intubation
2) HTN d/t coarctation of aorta (avoid sympathomimetics, ketamine)
3) endocrine involvement, renal, thyroid, diabetes
4) check for any other cardiac anomalies
Term
Klinefelter syndrome characteristics
Definition
1. mental disabilities
2. Scoliosis
3. Microcephally
4. Aggressive behavior
5. Congenital heart disease
6. Most frequently – infertility
7. Gynecomastia, which can develop into breast cancer
Term
Cri-du-chat
Definition
Difficult intubation

Characteristics:
Microcephaly
Micrognathia
Often have CHD
Hypotonia
Laryngomalacia
Term
The most important anesthetic consideration for trisomy 21
Definition
instability of the neck
Term
CHD associated with trisomy 21
Definition
VSD, PDA, tetralogy of fallot
Term
What about Volatile anesthetics for trisomy 21?
Definition
You need less volatile anesthetic
Term
What about muscle relaxants for trisomy 21?
Definition
decreased dose, they are sensitive to these drugs
Term
Piere Robin Syndrom
Definition
Micrognathia, horseshoe cleft, downwardly displaced tongue

Aiwary challenge

never on backs
Term
Crouzon anesthetic considerations
Definition
Anesthesia considerations: 1. Difficult intubation
2. Upper airway obstruction
3. Increased ICP
4. Strabismus is associated with MH!
5. Cardiac conditions should be ruled out
6. Careful eye care!
Term
Osteogenesis imperfecta anesthetic implications
Definition
Transferring patient to/from OR bed and positioning obviously require EXTREME care!
BP cuff can/will break bones – change settings to inflate as low as possilbe if monitor allows
Teeth are very fragile!
Old and new fractures should be documented
Avoid succs….the associated fasciculations can cause fractures!
Body temperature often elevates with general anesthesia…which is NOT usually associated with MH
Term
Is osteogensis imperfecta associated with MH?
Definition
No, they have a rise in temp with GA but it is not usually associated with MH
Term
Is freeman-sheldon syndrome associated with MH?
Definition
YES!!!
Term
Scleroderma anesthetic implications
Definition
Anesthetic implications:
Difficult intubation – tightening of skin around mouth, small mouth opening, stiff/rigid larynx and neck. Skin tears easily with rough intubations.
May have pulmonary functions testing to determine degree of pulmonary involvement
Renal and hepatic function may change some of your dosing/drug choices
Vitamin K malabsorption leads to a vitamin K dependent factor deficiency and a tendency to bleed
RSIV induction
Wean and extubate fully awake
If hypertension exists, remember the patient may by hypovolemic preoperatively. Be prepared (as you always should be) to treat both hyper and hypotension.
Term
Mitochondrial disorder considerations
Definition
-No IVFs with lactate
-IVF with glucose is good
-minimize NPO time
-Minimize stressors like pain hypo-hyperthermia
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