Term
| What age range delineates a neonate, infant and child? |
|
Definition
*0-28 days old Neonate
*1-12 months Infant
*1year- puberty Child |
|
|
Term
Due to disproportionate weight to length, it is more accurate to use ________ when calculating basal fluids, nutritional needs, and drug dosages.
(usually seen in heart room or NICU) |
|
Definition
|
|
Term
| Due to a large head and a short fat neck, infants are more prone to __________ airway obstruction. What is the biggest airway problem in a child, however? |
|
Definition
|
|
Term
| How does the brain develop throughout infancy? |
|
Definition
*Relatively large at birth
*Size doubles by 6 months
*Triples by 1 year |
|
|
Term
| How is the blood brain barrier different in infancy? |
|
Definition
|
|
Term
| How long after birth are the brain stem and cortex? |
|
Definition
| *Cells are fully developed by 1 year |
|
|
Term
| How long does myelination continue after birth? |
|
Definition
|
|
Term
| How is an infant metabolic rate compare to that of an adult? |
|
Definition
| *Rate is double that of an adult |
|
|
Term
| Where does the spinal cord extend to at birth? |
|
Definition
|
|
Term
| At what age does the spinal cord move to L1-L2? |
|
Definition
|
|
Term
| Which part of the autonomic nervous system is fully functional at birth? |
|
Definition
| *The parasymptathetic nervous system |
|
|
Term
| How long does it take for the sympathetic system to develop in an infant? |
|
Definition
|
|
Term
| Are baroreflexes fully functional at birth? |
|
Definition
|
|
Term
| How long does it take for pain pathways to be fully functional in the infant? |
|
Definition
| *Pain pathways are fully functional at birth |
|
|
Term
| When do sensory fibers form connections to the dorsal horn? When does cutaneous and mucous sensation begin? |
|
Definition
*6th week of gestation for sensory
*7-20th week gestation for mucous and cutaneous sensation |
|
|
Term
| Nutrition has a direct effect on _______ development |
|
Definition
|
|
Term
| Which reflex can be activated by stimulation of receptors on face, nose, upper airway, chemical stimuli, water, foreign bodies and noxious gas in the pediatric patient? |
|
Definition
|
|
Term
| At what time does the posterior fontanelle close? |
|
Definition
|
|
Term
| At what time does the anterior fontanelle close? |
|
Definition
| *around 10-16 months of age |
|
|
Term
| What are three terms to describe a fontanelle? |
|
Definition
|
|
Term
| When is the heart fully developed? |
|
Definition
|
|
Term
| What cardiac problems are rare in children? |
|
Definition
*Coronary artery disease
*Life-threatening arrhythmias |
|
|
Term
| What is the first major organ perfused in the fetus? |
|
Definition
|
|
Term
| How does half of the blood bypass the liver? |
|
Definition
| *The ductus venosus (Connects IVC to SVC) |
|
|
Term
| Trace oxygenated blood in the fetal circulation |
|
Definition
| *From mother--> umbilical vein--> Ductus venosus--> inferior vena cava--> RA --> PFO --> LA --> LV--> Aorta |
|
|
Term
| Where does deoxygenated blood flow in? |
|
Definition
| *Blood in the head is drained by the superior vena cava-> RA--> Deoxy mixes with oxy from IVC--> RV --> Pulmonary trunk --> pulmonary artery --> lungs or ductus arteriorsus--> Aorta |
|
|
Term
| What are the 4 fetal shunts? |
|
Definition
*Ductus venosus (connects umbilical vein to IVC bypassing liver)
*Foramen Ovale (connects RA-LA)
*Ductus arteriosis (Connects Pulmonary trunk to aorta)
*RV 66% or cardiac output, LV 34% of cardiac output |
|
|
Term
| Why does only a small amount of blood enter the pulmonary circuit in a fetus? |
|
Definition
| *Due to the lungs being collapsed, and their blood vessels have a high resistance to flow |
|
|
Term
| How does most of the blood in the pulmonary artery bypass the lungs? |
|
Definition
| *Enters the ductus arteriosus and into the aortic arch |
|
|
Term
| What is the PaO2 in a fetus? |
|
Definition
|
|
Term
| List what factors make an efficient method of oxygen removal in a fetus? |
|
Definition
*High HgbF (Fetal hemoglobin)
*Decreased 2,3 DPG
*O2 sat of 80%
*Leftward shift in the O2 curve with P50 of 18-20mmHg
|
|
|
Term
| How long does HgbF persist in an infant? |
|
Definition
| *Until 3 months of age until the hgb is the lowest |
|
|
Term
| At what age is the hemoglobin the lowest in an infant. What is this period called? |
|
Definition
*3 months
*Called physiologic anemia or nadir |
|
|
Term
| Describe the transitional circulation changes at birth |
|
Definition
*Placental flow ceases doubling the SVR
*Lungs expand with air
*PVR decreases
*PaO2 rises causing decreased PVR
*Relaxation or dilation of the pulmonary vasomotor tone |
|
|
Term
| How is the foramen ovale functionally closed shortly after birth? |
|
Definition
| *As PVR decreases, blood flows to the lungs and pulmonary veins causing the left atrium volume and pressure to increase. It increases above the right atrium closing the foramen ovale |
|
|
Term
| How is flow reversed in the ductus arteriosus after birth? |
|
Definition
*Removing the placenta (ie a low resistance vascular bed) from circulation causes an increases in SVR (along with decreased PVR), which increases aortic pressure above the pulmonary artery reversing flow through the ductus arteriosus.
*Increased O2 tension causes the muscular wall to constrict |
|
|
Term
| How long does it take flow through ductus arteriosus to be insignificant? When does permanent closure occur? |
|
Definition
*Flow is insignificant by 15 hours
*Permanent closure is 5-7 days |
|
|
Term
| How is persistent pulmonary hypertension (PPHN) treated in the neonate? |
|
Definition
*May need supplemental O2
*May need OET
*Paralysis
*Inhalation of NO (dilates blood vessels in lungs)
*ECMO (Extracorporeal Membrane Oxygenation) |
|
|
Term
| What is a persistent fetal circulation precipitated by? |
|
Definition
| *Precipitated by increase in pulmonary vasoconstriction |
|
|
Term
| What are possible causes of the ductus arteriosus to remain open? |
|
Definition
*Hypercarbia
*Hypoxia
*Acidosis
*If RAP>LAP the foramen ovale will stay open |
|
|
Term
| What determines CO in the infant and why? |
|
Definition
| *Ventricles are less compliant therefore stroke volume is limited making CO Heart rate dependent |
|
|
Term
| __________ leads to marked reduction in CO. |
|
Definition
|
|
Term
| At birth the ________________ nervous system is underdeveloped and the ______________ nervous system is dominant. |
|
Definition
*Sympathetic
*Parasympathetic |
|
|
Term
| Why is cardiac output increased 30-60% in neonates? |
|
Definition
| *To meet the high metabolic demands of O2 consumption. |
|
|
Term
| How many ml/kg/min of oxygen does the neonate consume? |
|
Definition
|
|
Term
| How many mL/kg/min of oxygen does the infant-5 year old consume? |
|
Definition
|
|
Term
| How many mL/kg/min of O2 do adults consume? |
|
Definition
|
|
Term
| Due to the large head, short neck, and large tongue infants are ______________ breathers. |
|
Definition
|
|
Term
| Where is the larynx located in an infant? |
|
Definition
| *Cephalad C2-C3 and anterior |
|
|
Term
| Where is the airway the narrowest in the infant? |
|
Definition
|
|
Term
| The epiglottis in an infant is ___________________. |
|
Definition
| *Long and stiff, U shaped |
|
|
Term
| What is the length of the trachea in an infant? |
|
Definition
|
|
Term
| Why can both left and right mainstem intubations easily occur in the child under 3? |
|
Definition
| *Because the lungs bifurcate at 55 degree angles until about age 3. |
|
|
Term
| What does the size and shape of the epiglottis in an infant enable it to do? |
|
Definition
| *Allows eating and breathing simultaneously |
|
|
Term
| What type of ventilation pattern do infants do and why? |
|
Definition
| *Diaphragmatic due to horizontal rib position |
|
|
Term
| What type of muscle cells dominate the diaphragm? |
|
Definition
*Type II muscle cells
*Fast twitch, low oxidative, short activity, easily fatigued (75% of diaphragm) |
|
|
Term
| Type I muscle cells are deficient in infants, when do they exhibit similar amounts in adults? |
|
Definition
*At age 2 the amount of Type 1 muscles cells are similar in amount to adults
*Type i muscle cells are slow twitch, high oxidative, fatigue resistant |
|
|
Term
| What cells produce surfactant? |
|
Definition
|
|
Term
| When does surfactant production begin? |
|
Definition
|
|
Term
| When does surfactant production peak? |
|
Definition
|
|
Term
|
Definition
| *Helps provide stability to alveolar tissues and prevents lung collapse |
|
|
Term
| Why is alveolar ventilation doubled in an infants and children when compared to adults? |
|
Definition
*High metabolic rate
*Higher O2 consumption of infant and children
*Smaller lung volumes than adults |
|
|
Term
| How do infants respond to CO2 and O2 levels? |
|
Definition
*Respond normally to increased CO2 when awake but fatigue easily
*100% O2 decreases ventilation |
|
|
Term
| Why is FRC lower in infants? |
|
Definition
| *Chest compliance is very high providing a weak force to maintain FRC. |
|
|
Term
| What are normal PIPs for infants? |
|
Definition
|
|
Term
| What should the anesthetized childs Vt be? |
|
Definition
| *10-15mL/kg, just like the adult |
|
|
Term
| Is total airway resistance high or low in the child? |
|
Definition
| *High due to small nasal passages, diameter of small airways, and total lung volumes |
|
|
Term
| Why should PEEP be used during mechanical ventilation in infants? |
|
Definition
*Should be used especially in those <8 months
*Prevent atelectasis
*More prone d/t marked reduction of compliance under GA and paralysis |
|
|
Term
| Why is spontaneous ventilation decreased under anesthesia in the infant? |
|
Definition
| *Due to inhibition of the chemoreceptor and loss of movement of intercostal muscles. |
|
|
Term
| Why does FRC even further decrease under anesthesia? |
|
Definition
| *D/t elevation of the diaphragm and loss of chest wall stability. |
|
|
Term
| True or False: Laryngospasm happens less frequently in children. |
|
Definition
|
|
Term
| Patients between 1 to 3 months have a ________X higher incidence of laryngospasm. |
|
Definition
*3
*5-1000 patients who have laryngospasm will have cardiac arrest
*Is it complete or incomplete |
|
|
Term
| What is the treatment for laryngospasm? |
|
Definition
*100% O2 by facemask with a tight seal and positive pressure
*Deepen the anesthesia
*Give propofol
*Succinylchoine |
|
|
Term
| What is the Succinylcholine dose for a laryngospasm? |
|
Definition
*1-2mg/kg IV, onset 1min (IV), duration 4-6 (IV)
*Alt: 2.5-4mg/kg IM, onset 2-3min (IM), duration: 10-30min (IM) (Ultrashort acting)
*25-50% of intubating dose IV or IM with Atropine if SPO2 falls to unacceptable levels. |
|
|
Term
| Where should emergency IM meds be given? |
|
Definition
| *In the deltoid, closest to the heart |
|
|
Term
| Is the liver fully functional at birth? |
|
Definition
| *The liver enzyme system is immature resulting in inability to conjugate some drugs |
|
|
Term
| What is physiologic jaundice? |
|
Definition
| *Uncongugated hyperbilirubinemia during the first week of life is secondary to increased bilirubin load, limited hepatic cell uptake of bilirubin and deficient hepatic conjugation to the water soluble glucuronide. |
|
|
Term
| What is different about plasma proteins in infants, what are the effects? |
|
Definition
*Plasma proteins necessary for binding drugs are lower in infants resulting in greater amounts of free drug.
|
|
|
Term
| What is the primary catecholamine released in the infant? What is anatomically different about the adrenal glands in an infant? |
|
Definition
*Norepinephrine
*Adrenal glands are enlarged
|
|
|
Term
| When does gastric pH in the infant reach that of an adult? |
|
Definition
|
|
Term
| Why is GERD more common in the infant? |
|
Definition
| *Inability to coordinate breathing and swallowing until about 4-5 months of age. |
|
|
Term
| How much of metabolic heat loss is through the skin surface? |
|
Definition
*90% d/t very large surface area
*10% is from respiratory system |
|
|
Term
| How do infants regulate their temperature due to an immature regulating system and inability to shiver? |
|
Definition
| *Nonshivering thermogenesis |
|
|
Term
| What is nonshivering thermogenesis? |
|
Definition
| *How infants maintain their temperature |
|
|
Term
| How does nonshivering thermogenesis work? |
|
Definition
*Brown fat located around the scapula, mediastium, kidneys and adrenals.
*The fat is "brown" due to the dense mitochondria
*Innervated by alpha adrenergic nerves
*Initiated by norepinephrine
*Allows infants to double their heat productions
*Perisists until 2 years of age
*Present in infants as small as 1500 grams ~ 24-28 weeks |
|
|
Term
| What are the for top modes of heat transfer? |
|
Definition
*Radiation
*Conduction
*Convection
*Evaporation |
|
|
Term
| List ways to keep a baby warm in the operating room. |
|
Definition
*Warm the room!
*Bair Hugger
*Warm fluids
*HME
*"French Fry Lights"
*Plastic bags
*Hats
*Warmer |
|
|
Term
| When does redistribution hypothermia occur intra op? Where are temps taken in the OR? |
|
Definition
*2-3 hours intraop
*Normally do axillary temps d/t chance of low temps peripherally. |
|
|
Term
| What are diseases/myopathies that are often associated with Malignant Hyperthermia? |
|
Definition
*Myotonia Congenita
*Evans Syndrome
*Duchenne muscular dystrophy
*Strabismus or ptosis surgery patients
*Central core disease |
|
|
Term
| Are kidneys fully mature at birth? |
|
Definition
|
|
Term
| What is GFR at birth compared to adults? |
|
Definition
| *GFR is decreaseddue to high renal vascular resistance. |
|
|
Term
| When does GFR reach adult maturity in the infant? |
|
Definition
| *Over the first 3 months, GFR doubles and reaches adult maturity by 1-2 years |
|
|
Term
| To what level is sodium excreted and urine concentrated in infants? |
|
Definition
*Sodium excretion is decreased
*Ability to concentrate urine is limited |
|
|
Term
| How is hydration measured in the infant? |
|
Definition
*Can be measured by HR, MAP, Capillary filling time, urine output, temperature of extremities.
*Dehydration is detrimental to the newborn |
|
|
Term
What are the percentages of TBW in the:
-Preterm infant
-Infant
-Child
-Adult |
|
Definition
*Preterm infant: 80-90%
*Infant: 75%
*Child: 65-70%
*Adult: 55-60% |
|
|
Term
| What S/S in infant indicate TBW <5% volume loss? |
|
Definition
*Dry mouth
*Malaise
*Decreased U/O
*Hx of N/V/D
*Normal BP
*Cap refill <2 sec |
|
|
Term
| What S&S are associated with TBW loss of 5-10%. |
|
Definition
*Lethargy
*loss of appetite
*Thick mucous
*Dry mucous membranes
*Sunken eyes and fontanelles
*Tachycardia
*3 second cap refil
*Normal BP |
|
|
Term
| What S&S are associated with >10% TBW volume loss in the infant? |
|
Definition
*Mottled cool skin
*cap refill >3 seconds
*anuria
*BP <60 mmHg
|
|
|
Term
| What S&S are associated with 20% TBW volume loss in the infant? |
|
Definition
*Coma
*DIC
*Very high mortality |
|
|
Term
| Preterm, Term, and infants (7-8mo) all have a larger % of ECF than ICF in comparison to adults. What pharmacological significance does this have? |
|
Definition
| *There is an increase in volume in distribution |
|
|
Term
What are the Ml/kg of EBV for:
-Premature newborn
-full term newborn
-Age 3 months to 3 years
-Age 3-6 years
-Age <6 years |
|
Definition
*Premature: 90-100mL/kg
*Full term: 80-90mL/kg
*Age 3 months to 3 years: 75-80mL/kg
*Age 3-6 years: 70-75mL/kg
*Age <6 years: 65-70mL/kg |
|
|
Term
| What is a rule of thumb for what MAP should be in infants? |
|
Definition
| *MAP should be gestational age in infants |
|
|
Term
| What formula is used for pediatric fluid requirements? |
|
Definition
*The 4-2-1 formula
*<10kg 4mL/kg/hr
*10-20kg 2mL/kg/hr (for each add kg) +40cc
*>20kg 1mL/kg/hr (for each add. kg) +60cc |
|
|
Term
| What is the NPO deficit for a child? |
|
Definition
| *Using the hourly maintenance fluid rate multiplied by the number of hours the child is NPO |
|
|
Term
| How is fluid replaced intraop in the Pediatric patient? |
|
Definition
*Replace one half of the deficit the first intraoperative hour
*Give 25% of NPO deficit in the 2nd intraoperative hour
*Give last 25% of NPO deficit in the 3rd intraoperative hour |
|
|
Term
| What are the guidelines of fluid replacement for the pediatric patient for third space losses (surgical/exposure loss)? |
|
Definition
*Insensible loss= 1-2ml/kg/hr (Hernias)
*Minimal=3-8ml/kg/hr(Fractures, elbows)
*Major=8-10ml/kg/hr(abdominal, head trauma) |
|
|
Term
| What formulas can be used for Allowable blood loss? |
|
Definition
*ABL= EBV x (Ho-HL)/(Ha)
-EBV=estimated blood loss
-Ho= original hematocrit
-HL=Lowest hematocrit
-Ha=hematocrit average
ex. 8kg, 10 month old, EBV=80mL/kg (80x8=640mL)
Ho=35%
HL=25%
640x (35-25)/(35+25)/2=213mL |
|
|
Term
| What can result in hypokalemia in an infant? What is the treatment? |
|
Definition
*Alkalosis
*Insulin
*Beta-adrenergic durgs
*Poor nutrition
**Replace K at 0.25mEQ/kg/hr
|
|
|
Term
| What can cause Hyperkalemia in an infant? |
|
Definition
*Decrease in u/o
*Sch
*Digitalis
*Acidosis
*burns
*Crushing or Ischemic injuries
*Addison's Disease
*Irradiated blood (3wks of storage of PRBCs increases the K to 22mEQ/L)
**Treatment: Hyperventilate, CaCl, NaHCO3, glucose & insulin together, Peritoneal dialysis or hemodialysis |
|
|
Term
| What can result in hyponatremia in an infant? What is the treatment? |
|
Definition
*Drug induced (NSAIDS, Morphine, Remifentanyl)
*Dilutional and 3rd space losses
*Endocrine
*SIADH
*Head injury
*Renal Disease
*N/V/D
**Causes a shift from ECF to ICF resulting in cerebral edema <115 treat |
|
|
Term
| What can cause hypernatremia in an infant? |
|
Definition
*Water loss and NaHCO3
*endocrine disorders
*Cusings
*lithium
*Amphotericin B |
|
|
Term
| What can cause hypocalcemia in an infant? Treatment? |
|
Definition
*From blood administration, the most citrate is in FFP
*DeGeorge's Syndrome (born w/o thymus)
**10mg/kg CaCl |
|
|
Term
| What can cause hypochloremia in an infant? Treatment? |
|
Definition
*N/V/D
*Pyloric stenosis
*Long term diuretic therapy
**Treat underlying etiology!
Cl should be >90mEQ/L before surgery |
|
|
Term
| What type of fluid replacement stays in the intravascular compartment longer but can cause allergic response? Which specific agent is avoided in children? |
|
Definition
*Colloids
*Hespan is NOT used in children d/t higher chance of reaction
*only 5% albumin |
|
|
Term
| What children are glucose solutions used in? |
|
Definition
*Historically used
*Use glucose if:
-Child is <3mo
-Child is <3kg
-sick
-FTT
-preterm infants with documented hypoglycemia <40
The maximum renal tubular clearance for glucose is low in healthy children. |
|
|
Term
| What should be given to replace minimal blood loss (20%). |
|
Definition
|
|
Term
| What should be given to replace moderate blood loss (20-30%) |
|
Definition
| *Colloid 1:1 (5% albumin) |
|
|
Term
| What should be given to replace major blood loss (30-50%)? |
|
Definition
|
|
Term
| What should be given for massive blood loss (50-60%)? |
|
Definition
*Call for help
*PRBC
*FFP
*Plt |
|
|
Term
| What should be given for blood loss >66%? |
|
Definition
*Call for help and pray
*PRBC
*FFP
*PLT
*Cryo |
|
|
Term
| How much will 1cc/kg of PRBCs raise Hct? 10cc/kg? |
|
Definition
*1cc/kg= increase in Hct by 1%
*10cc/kg= increase in Hct by 10% |
|
|
Term
| How much FFP should be given if used? |
|
Definition
|
|
Term
| What is the "dose" for platelets? How much will this raise the Plt count? |
|
Definition
*1u/15kg or 0.2u/kg
*Will increase by 100,000 |
|
|
Term
| What is the "dose" of Cryo? How much will this increase the fibrinogen? |
|
Definition
*1u/10kg
*Will increase fibrinogen by 50mg/dL |
|
|
