Peds2 Pediatric Anesthesia & Pain Management – Flashcards
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In the sniffing position the neck & head are
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Neck: flexed Head: extended
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What age group would it be best to place a blanket roll under the shoulders in order to align the 3 axis for proper sniffing position
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Less than 2 years [PALS] (maybe up to 5) (large occiput causes babies to otherwise be overly sniffed)
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What age group would it be best to place a blanket roll under the neck as they are already aligned to the 3 axis of proper sniffing position (under neck to simply keep head from rolling side-to-side)
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Children 6-11
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What age groups would it be best to place a blanket roll or pillow under the head in order to align the 3 axis for proper sniffing position
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Teenagers and adults
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Sodde's Law of Anesthesia
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"The laryngoscope light stays on until the blade is down the patient's throat" (keep 2 laryngoscopes available in case failure)
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How would you place an ET tube with a single vocal cord distance marker near the end?
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Line at the vocal cords (just barely hidden by vocal cords)
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How would you place an ET tube with two vocal cord distance marker lines near the end?
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Vocal cords between the two sets of lines
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How would you place an ET tube with three vocal cord distance marker lines near the end?
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Vocal cords at the second set of lines
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How would you place an ET tube that was all black at the end?
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All of the black goes past the vocal cords with the cords at the line between black ; not black
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*!* How long is the average newborn trachea from vocal cords to carina ; compare to adult
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Neonate: 5 cm Adult: 8-13 cm (If you look at neonatal ETT you'll notice it is 2.5 cm from vocal cord line marker to end. This is 1/2 total trachea length)
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*!* ETT internal diameter formula for peds older than 2 yrs (up to ~12 yrs old?)
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(a 5 yr old takes a 5 50% of the time)
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*!* Depth of ETT insertion (at the teeth) formula for peds
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(Use the vocal cord marker, then note the line marker at teeth is a better method)
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*!* ETT insertion (at the gums) formula for premature
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(# kg + 6) = # cm
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When to use cuffed vs uncuffed ETT for peds
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A low pressure, high volume cuff "generally" indicated for children older than 8-10. Otherwise uncuffed for younger.
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What is very important in regards to children with cervical spine abnomoralities?
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Don't cause a C-spine injury! Control the C-spine -hold at the neck when moving pt (not head) -don't try to make the neck fit the laryngoscope rather modify the technique to the anatomy of the neck (hold true for all pts)
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Anesthesia considerations for Down's syndrome (x4)
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-Macroglossia (large tongue) -C-spine instability (atlantoaxial subluxation in ~20%) -Congenital subglottic stenosis (web below vocal cords causes stenosis) -Congenital AV canal defects
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What is an AV canal defect?
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Atrio-ventricular septal defect (ASD, VSD, or both)
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Term for undersized jaw
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Micrognathia
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The most common anatomical cause of a difficult intubation
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Micrognathia (undersized jaw/chin)
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Fetal origination of the mandible
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1st branchial arch
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Anesthesia concern for preauricular skin tags or abnormally developed external ears
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Potentially difficult intubation (possible sign of congenital disorder)
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What to expect when attempting to intubate a micrognathic patient (x2) ; what improves these problems
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-Tongue ; soft tissue will not be easily displaced during laryngoscopy as it is not pulled forward in the normal developmental fasion. -Mouth unable to open as easily or widely These tend to improve with age.
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A very rare disease characterized by the complete absence of the mandible and other structures derived from the first branchial arch.
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Bilateral 1st arch syndrome
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2 similar but less severe (; more common) conditions to bilateral 1st arch syndrome
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-Treacher Collins syndrome -Pierre Robin syndrome
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Syndrome characterized by underdeveloped cheek ; jaw, down slanting eyes, ; ear deformities
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Treacher Collins Syndrome
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Syndrome characterized by hemicraniofacial ; vertebral defects related to the abnomal development of the 1st ; 2nd branchial arches
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Goldenhar's Syndrome
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Goldenhar's Syndrome major systems affected (x5)
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-Facial ; airway defects -Vertebral defects -Congenital heart disease -Pulmonary defects -Renal defects
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Airway issues with Goldenhar's syndrome (x5)
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-Retrognathia (recessed jaw) -Micrognathia (underdeveloped jaw) -Mandibular hypoplasia (undersized jaw) -Palatal defects -Vertebral anomalies
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Airway-related characteristics of Pierre-robin syndrome (x4)
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-Micrognathia (small lower jaw) -Glossoptosis (tongue tends to ball at back of the mouth & falls toward back of throat) -Breathing problems -Cleft palate may or may not be present
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Term for when the tongue tends to ball at back of the mouth & falls toward back of throat
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Glossoptosis
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NPO guidelines for Neonate / Pediatrics
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Fatty or fried: 8 hrs Light meal: 6 hrs Non-human milk: 6 hrs Infant formula: 6 hrs Breast milk: 4 hrs Clear liquids: 2 hrs (If they are sick they may need more time d/t delayed gastric emptying)
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Helpful tip for working with pediatrics
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Try to give them control (pick flavor, toy, etc.)
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Neonatal Preop anticholinergic doses (x2)
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Glycopyrolate: 0.01 mg/kg Atropine: 0.02 mg/kg
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How to reduce risk for bradycardia with laryngoscopy of neonate
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Give Anticholinergic
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Concern for laryngoscopy on a neonate
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Bradycardia (very developed parasympathetic & little sympathetic)
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Pediatric midazolam (Versed) dose
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0.5 mg/kg PO
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Which is most common induction method for pediatrics
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Inhalation (IV, IM, rectal are possible but only for select & uncommon cases)
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The "gold standard" monitor for pediatrics
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Precordial stethoscope
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Steps for induction of pediatric pts (x11) (inhalation technique)
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-Plan ahead & discuss with all involved -Premedicate -Comfort (parent?, warm, designated talker, min distractions) -Monitors (pulse ox, precordial) -Operator at head, assistant at chest -Mask (not touching face) with 50/50 N?O/O?, increase to 70/30 -Mask to face & Sevoflurane 2% every 3 breaths -Prevent airway obstruction (PEEP if needed) -Place IV -Guarantee airway before paralytics (if using) -Airway (as needed)
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MAC (%) is greatest for what age
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6 months
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Drinking / Voiding for pediatric patients
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Not mandatory
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Rule of thumb for effect of PRBCs on Hct
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1 mL/kg of PRBCs will ? Hct by 1.5%
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Steriochemistry of Hgb S (sickle) vs normal Hgb
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Hgb S: Valine substituted for glutamic acid at position 6 of the ?-chain of hemoglobin
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Until what age do false negatives occur when testing for sickle cell?
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Until 6 months (otherwise false negative d/t presence of fetal hemoglobin)
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Define Acute chest syndrome
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-Sickle cells occlude pulmonary vasculature causing ?PO? which leads to further sickling & more obstuction (a life-threatening emergency)
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Blood products for sickle-cell patients
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Conservative transfusion regimen (don't transfuse if Hgb greater than 10)
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Precautions for sickle cell patients in the OR (x5)
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-Prevent hypoxia -Prevent hypothermia -Adequate hydration -Aseptic technique (prone to infection) -Manage pain (sickling is painful)
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Most common cause of death in pediatrics
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Trauma #1 type is head trauma (greater than the next 5 causes combined)
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Most common cause of death by disease in pediatrics
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Cancer
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Most common type of cancer in pediatrics
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Leukemia
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Most common type of solid tumor in pediatrics
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Brain tumor
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Risk for intraventricular hemorrhage (IVH) among premature newborns (x2)
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500-750 grams: 60-70% risk IVH 1000-1500 grams: 10-20% risk IVH
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Location of brain tumors in pediatrics vs adults
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Peds: 2/3 are infratentorial (posterior fossa) Adults: 2/3 are supratentorial
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Most common type of supratentorial tumor in pediatric patients
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Craniopharyngioma
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Posterior fossa tumors in peds (x3)
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-Astrocytoma (32%) -Medulloblastoma (32%) -Brainstem gliomas (20%)
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A malformation that can accompany myelomeningocele and other neural tube disorders where the cerebellum and medulla oblongata protrude into the spinal cord
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Arnold-Chiari Malformation (ACM)
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*!* What type of Arnold-Chiari Malformation (ACM) is associated with myelomeningocele
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Type 2 (Difficult to distinguish from Dandy-Walker syndrome)
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Treatment for Arnold-Chiari Malformation (ACM)
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Surgery - posterior fossa decompression, cervical laminectomy
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Caution for Arnold-Chiari Malformation (ACM) (x2)
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-BEWARE flexion/extension of the neck may transect the spinal cord -Risk for post-op airway dysfunction (CN10)
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Malformation caused by cystic expansion of the 4th ventricle (90% occurance of hydrocephalus)
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Dandy-Walker Malformation
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Treatment for Dandy-Walker malformation
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Surgery to shunt ventricles ; cyst
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Condition where the caudal spinal cord attaches to the bottom of the vertebral column
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Tethered cord
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How to calculate a morphine dose for an infant 2-12 months ; why this won't work if less than 2 months
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-Using the same mg/kg dose as an adult -Cytochrome P-450 system too immature at birth but reaches adult level at 2 months
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Pharmacokinetics of morphine for newborn & infant less than 2 months (x3)
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-20% protein bound in infant vs 30% in adult -t 1/2 is 2x longer in newborns -BBB immature & more permeable to morphine
