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238 Cards in this Set

  • Front
  • Back
In peds, cardiac output is primarily dependent on _____ secondary to nocompliant ventricles and fixed stroke volume, but _____ does have some role.
heart rate, contractility
What is drug of choice in peds for bradycardia and low output states?
epinephrine
What is pediatric CO?
180-240 mL/kg
compared to adult 70 ml/kg
Peds cannot tolerate _______ because they can't compensate for it. It should be immediately treated with ______.
bradycardia, epinephrine
What is used in peds for pretreatment to prevent bradycardia during NMB?
atropine
How do HR and BP change between neonates and age 12?
neonate- 140, 65/40
12 mo- 120, 95/65
3 yrs- 100, 100/70
12 yrs- 80, 110/60
What are the estimated blood volumes for premies and newborns <1 month?
preemie- 90-100 ml/kg
newborn- 80-90 ml/kg
What are the estimated blood volumes for infants 3 mo-3 yrs, and for children >6 yrs?
3 mo - 3 yrs: 75-80 ml/kg
>6 yrs- 65-70 ml/kg
Fetal Hgb decreases ____% after delivery.
25%
How does HCT change between full term, 3 months and 6 months old?
full term 55%
3 months 30%
6 months 35%
Newborn hematocrit reaches a low point at 3 months due to a decrease in _____, increase in ______, and short lifespan of newborn______.
decr erythropoiesis
incr plasma volume
short life newborn RBCs
Despite the lower HCT at 3 months of age, the delivery of O2 remains sufficient because of...
shift of oxyHgb curve to right and increase in 2,3 DPG
Why do newborns require Vitamin K prophylaxis?
Vit K - dependent clotting factors 2,7,9,10 are only 25-50% of adult levels -- Vit K given just after birth because not born w sufficient clotting factors
What is the main difference between adult and fetal circulation?
higher pulmonary vascular resistance in fetus than systemic vascular resistance -- no need to shunt blood through the lungs!
What are the 3 patent ducts in fetal life that are supposed to close after birth?
- ductus venosus in liver
- ductus arteriosus by aorta
- foramen ovale between atria
Why does the foramen ovale close at birth? When should it occur?
due to incr SVR and decr PVR at birth, occurs within 4-10 days (But remains patent in 50%of 5 yr olds and 25% of adults)
Ductus venosus closes by constriction due to ____.
incr O2 levels
The ductus arteriosus may remain open for ____ hours with permanent closure within ____ wks. Closure occurs in the presence of ...
10-15 hrs, 2-3 wks

closure ocurs with incr O2 levels, decr PGE levels, and normal acid-base balance
Air bubbles should be avoided at all costs in peds population because of the incr risk of...
persisting PFO beyond birth
What is persistent pulmonary HTN of the newborn? (PPHN)
- fetal circulation may return or persist, pulmonary vascular resistance remains higher than systemic vascular resistance
- manifested by incr PVR and pulm HTN --> R to L shunt across the PFO and ductus arteriosus resulting in cyanosis
What are the common causes of PPHN?
- preterm infants
- infants w metabolic conditions (asphyxia, sepsis, meconium aspiration, congenital diaphargmatic hernia)
How is PPHN treated?
treat underlying cause,

Nitric oxide (pulm vasodilator) and ECMO
What are the precipitating factors for PPHN?
hypoxemia, acidosis, hypothermia all worsen PPHN
Why is N20 undesirable in PPHN?
would incr pulm vascular resistance further
Respiratory maturation is ____ at birth.
incomplete
Surfactant production in fetal lung starts in the _____ week. Sufficient levels are not reached until the _____ Week.
30th wk, 35th wk
Initial negative thoracic pressures in the newborn are _____ at _____ cmH20.
higher, 40-60 cmH20
What is retinopathy of prematurity (ROP)?
retina underdeveloped until 36 wks, try to keep blood oxygenation below 95% saturation
The pulmonary system of infants features a lower ____, which limits O2 reserve. Infants desaturate ____ seconds after induction.
FRC, 20-30 sec
Infants have lower _____ and lower lung compliance, secondary to _____.
closing volumes,
small alveoli
Infants have _____ chest wall compliance due to ________ chest wall, rather than the fixed rib cage of an adult.
greater compliance, cartilaginous chest wall
How are infant O2 requirements different from adult?
O2 req. higher in infants, 6 ml/kg compared to 3 ml/kg in adults
How is CO2 production different in infants?
doubled
Why are O2 and CO2 higher in infants?
higher RR
Are TV and dead space different between infants and adults?
no- constant per kg
What is infant TV?
5-8 cc/kg
Alveolar ventilation is _____ in neonates to meet increased O2 demand (130 vs 60 ml/kg/min), which can be achieved by increasing ____.
doubled, respiratory rate
How does infant O2 consumption compare to adult?
doubled -- 6 ml/kg/min vs 3 ml/kg/min in adults
_____ and _____ depress respiration rather than stimulate it in newborns, unlike in adults. This is due to...
hypoxia and hypercarbia,

due to immaturity of CNS control of ventilation
Immaturity of infant respiratory muscles can cause fatigue, which leads to ____ and ______.
airway obstruction,
hypoxia
In what type of infants are apnea and bradycardia common?
premies, <60 wks postconception
anemia, sepsis, hypothermia, CNS disease, hypoglycemia
Apnea and bradycardia may occur in infancy due to immature responses to respiratory control center to ____ or ____ stimuli, or due to _____ fatigue.
- hypercarbic or hypoxic stimuli
- respiratory fatigue
Infants are at incr risk for bradycardia and apnea after being exposed to ___.
General anesthesia

risk of apnea/bradycardia is doubled after anesthetic
What is the suggested observation time for a child post op?
24 hrs postop, or 12 hrs postop if no documented apnea/bradycardia episodes
What are the causes of apnea in peds?
- thermal instability
- infection (neonatal sepsis, meningitis, necrotizing enterocolitis)
- drugs (maternal/fetal exchange)
- decr O2 delivery (hypoxemia, anemia, shock, L to R shunt due to PDA)
- premature age
- CNS problems (asphyxia/edema, hemorrhage, seizures, malformations)
- metabolic disorders: hypoglycemia (if <6 mo give dextrose soln in OR), hypocalcemia, hyponatremia, hypernatremia/dehydration, hyperammonemia
What are the differences between adult and peds airways?
- laryngeal location: C2-C4 in peds, C3-C6 in adults
- narrowest location: CRICOID IN PEDS up to 8 yrs, GLOTTIS IN ADULTS
- shape of epiglottis: u-shaped, narrow and long in peds; v-shaped in adults
- R main stem bronchus: less vertical to tracheal in peds, more vertical to trachea in adults
Why dont peds get a cuffed OETT?
cricoid is narrowest portion of airway in peds until age 8, no cuff because natural cuff occurs at cricoid area, cuffed tube would cause necrosis and damage

sometimes might have to use a cuffed tube in smaller kids for ENT procedures if too big or leak without it
What is the #1 reason for desaturation after intubation in peds?
R main stem bronchial intubation -- less vertical to trachea (always listen on L side first in peds, if no breath sounds then pull back)
Peds are obligate nose breathers until
3 months old
What is chonal atresia?
failure of development of opening between nasal cavity and nasopharynx, produces airway obstruction
Peds have a ___ tongue, making a ____ blade useful.
larger, macintosh
Peds have a _____ mandible and oral cavity.
smaller
It is important to watch for loose teeth in peds because
teeth are deciduous from 6 mo-6 yrs
What is the best larygoscope blade to use in peds < 1 yr?
straight miller blade
What law am i?
peds airway resistance is increased by small changes in diameter -- resistance to laminar flow varies inversely with radius to fourth power
poiseieulles law
In peds, a small amt of airway edema leads to marked increase in airway ____.
resistance
CNS is immature at birth, and myelination is not complete until ___, making proper _____ essential.
3 yrs, nutrition
How does the length of the spinal cord in the canal differ between birth and age 1?
birth at L3, 1 yr at L1
The pediatric CNS is more _____ than _____, which develops at 4-6 months, making peds more prone to bradycardia that should be pretreated with _____.
more parasympathetic than sympathetic,
atropine
The blood brain barrier is incomplete in the peds population, leading to easier disruption with ....
traumatic head injury, SAH, ICH, and cerebral ischemia
*more susceptible to injury*
What precipitates intracranial bleeding in peds?
hypoxia, hypercarbia, hyperglycemia, hypoglycemia, hypernatremia, and BP swings
Administration of _____ solutions can damage fragile pediatric cerebral vessels.
hypertonic
If pts have immature/incomplete/disorders of the blood brain barrier, it is important to use ____ the usual narcotic dose.
half
The NMJ is immature at bith and causes a decreased amount of _____ Activity until 2 months of age.
pseudocholinesterase
How is pediatric succinylcholine dose different than adult?
peds have larger volume of distribution, higher doses of succ required --> 2 mg/kg IV and 4 mg/kg IM
Why is the NDMR response variable in the immature NMJ of peds?
immature NMJ incr sensitivity whereas the ECF dilutes the cnocentration
Peds are obligate _____ excretors.
sodium
The kidneys are ___% mature by 1 month.
70
GFR in peds is decreased ____% of adult levels, which decreases their ability to ___ or _____ urine.
15-30% of adults,
concentrate or dilute urine
Renal clearance in peds is decreased due to decreased ____.
GFR
Premies do not tolerate ____ or ____ loads due to decreased GFR and decreased concentrating ability.
H20 or Na
The smaller the child, the more _____ you should be with fluid administration.
cautious
Giving a flush on a very small ped pt is actually giving a ____.
bolus
With volume overload, pediatric kidneys will....
shut down
Total body water, extracellular fluid, and intracellular fluid are all _____ in peds.
greater!
FYI:
premies have 80-90% TBW with 50-60% ECF and 60% ICF,
infants have 75/40/35%
children have 65-70/30/40%
adults have 55-60/20/40%
(Ratios are TBW/ECF/ICF)
Body water composition affects the volume of
drug distribution
Total protein decreased in the neonate and infant leads to
more free drug available -- dont bind as well, higher circulating active drug
Both albumin (binds acid drugs) and AAG (binds basic drugs) are ____ in the newborn.
decreased

check drug levels more in peds
In peds, _____ reactions in the liver are immature.
conjugation
What is caused by reduced enzyme activity (CYP450) in peds?
incr drug elimination half-lives

ex: bupivacaine 25 hrs, norm 12 hrs
What Non-depolarizing NMB is good in peds because it is a vagolytic that helps to maintain and increased HR?
pancuronium
Peds population has a greater _____ to weight ratio.
body surface area
In infants and children, skeletal muscles contribute to heat production by ______.
shivering thermogenesis
How do infants increase heat production?
nonshivering thermogenesis (incr heat production by 100%)

sympathetic stimulation of brown fat metabolism increases norepinephrine through release of anterior pituitary hormones after incr in BMR
Because premies lack ______, they are less able to maintain normothermia.
brown fat
Pts are transported from the NICU to the OR in..
their own isolettes -- prevents heat loss
What is the mnemonic for heat loss mechanisms?
RCECd
radiation, convection, evaporation, conduction
What kind of heat loss am I?
transfer of heat into the environment, responsible for the majority of heat loss, 40-60% is lost through head
radiation
How can heat loss be ameliorated in newborns?
cover head with cap, use warmed irrigation solns, warmed blankets, and forced air warmers
What kind of heat loss am i?
transfer of heat from one object to another (placing infant on cold table)
conduction

use warm blankets and radiant heat lamps
What type of heat loss am i?
moving air currents, OR air circulation is changed 6-12x/hr, air surrounding body is warmed and rises, being replaced by cooler ambient air
convection

raise room temp to 80-85 degrees, remove wet clothing and sheets
What kind of heat loss am I?
vaporization of fluid from body cavities and respiratory tract, sensible and insensible losses (Sweat through skin)
evaporation

humidify gases, warm blankets and irrigating solns
What are the fasting guidelines for Clears in peds?
2 hours
What are the fasting guidelines for breast milk in peds?
4 hours
What are the fasting guidelines for formula in peds?
6 hours
What are the fasting guidelines for solids in peds?
8 hours
MAC is ____ in neonates up to 1 month and premies.
lower
MAC increases ____ until 2-3 months and then declines to adult levels.
2-3 x
Peds have rapid induction and emergence due to .....
rapid uptake of gases-- higher RR, higher alveolar ventilation, low FRC, large vessel rich group with incr CO
In peds, myocardial depression can occur with ...
high concentrations of IAs
(high doses of sevo can cause decr HR and BP, seizures; halothane causes bradycardia)
In peds, IV anesthetics may have a prolonged duration of action because...
decr % of muscle and fat, and because of immature blood-brain barrier
Infants have an increased total body water, and may require ____ doses due to ____ volume of distribution.
higher, greater
In healthy children, IV induction has a _____ onset and requires ____ dosage.
slower, higher
What are the age-specific approaches for infancy?
- smile, soft gentle voice
- avoid abrupt/jerky mvmts
- separation anxiety develops 8-9 months (Before that time, no premed required, after assess need for premed)
What are the age speficif approaches for toddlers?
- assess child through play
- minimal physical contact initially
- use restraint when appropriate and request parents assistance
- praise for cooperative behavior
What are the age specific approaches for preschool age children?
- same as toddler, if shy allow to wear clothes into OR
- make up stories about procedure
What are the age specific approaches for school age children?
- cooperative in most situations
- explain purpose of equipment and teach
- allow to wear clothes into OR if requests
What are the considerations for use of acetaminophen in peds?
- safe admin at following doses: 10-15 mg/kg PO/PR q4-6hrs, insert PR after induction
- excessive dosages result in hepatic toxicity and death
- PO 30 mg/kg with induction
- PR 40 mg/kg
-IV Tylenol 15mg/kg over 15 mins
Common premedications in peds population
- zofran 0.1-0.15 mg/kg IV (no in prolong QT or severe HA)
- toradol 0.5 mg/kg (no higher due to liver compromise)
- fentanyl 1-2 mcg/kg IV
- ketamine 6 mg/kg + atropine 20 mcg/kg + versed 0.1 mg/kg IM (useful in short cases that dont require IV access and intubation)
In what type of peds case should ketamine be avoided?
eye cases- causes bad nystagmus
What are the induction IV anesthetic options in peds?
- propofol 2.5-3 mg/kg infants, 2-2.5 mg/kg child (Add lido 0.2 mg/kg to decr pain on injection)
- methohexital 10 mg/kg IM (20-30 mg/kg PR)
- ketamine 2-10 mg/kg IM (Give w benzos!)
What are the induction techniques for IA induction in peds?
- mask induction good for ifants <10-12 mo. bc dont have separation anxiety yet
- place mask w hand behind had and hold until kid falls asleep
- may become hyper before going to sleep (eye and breathing pattern changes)
- can hold end of circuit in cupped hand and incr concentration until LOC
- w older child: bring child into room w 1 parent, show mask, have child pick flavor, can have child blow bag up like a balloon, give O2/N2O mixture then slowly incr sevo by 0.5% increments every 3-4 breaths -- dont incr too fast bc may cause myocardial depression
Children may try to breath hold during induction, so it is important not to force giving a breath because it may induce...
cough and laryngospasm
What is the best way to break pediatric laryngospasm?
- positive pressure ventilation
It is important to watch _____ to make sure child is breath holding and the airway is not obstructed.
chest movement
What neurological complication may occur during induction that should be monitored for?
seizures
If giving 10 cm H20 pressure does not break laryngospasm, what is the next action?
administer rapid positive pressure breaths, give succinylcholine (IM 4-5 mg/kg)
How should a combative child be mask induced?
flood circuit w sevo and place on face, will induce w several breaths -- after asleep, insert IV and then intubate PRN
What crucial piece of anesthesia equipment should be used to help recognize laryngospasm?
precordial stethascope
What are the considerations for succinylcholine use in peds?
- use for true RSI
- watch for bradycardia
- trigger for MH
- 2 mg/kg IV or 4 mg/kg IM
*usually over 8y/o but it is still given younger
What are the considerations for using atracurium in peds?
- nonspecific esterases and hoffman elimination
- 0.5 mg/kg intubating and 0.2-0.3 mg/kg maintenance
What are the considerations for using cisatracurium in peds?
- hoffman elimination
- 0.1 mg/kg intubating, followed by 0.08-0.1 mg/kg maintenance
What are the considerations for vecuronium in peds?
0.1-0.15 mg/kg, more reliable than rocuronium
What are the considerations for using rocuronium in peds?
0.6 mg/kg intubating, 1.2 mg/kg RSI
Even with the return of TOF, reversal medications should be given to avoid risk of....
hypoventilation --> bradycardia --> arrest
What are the dosages for reversal meds in peds?
- neostigmine 0.04-0.07 mg/kg
- edrophonium 0.5 mg/kg
- pyridostigmine 0.1 mg/kg
What are the anticholinergics and dosages given in peds reversals?
- atropine 0.01-0.02 mg/kg
- glycopyrolate 0.01 mg/kg
In what order must NMB reversal agents be given?
ALWAYS GIVEN ANTICHOLINERGIC PRIOR TO ANTICHOLINESTERASE!
It is best to reverse peds NMB if less than ____ half lives have passed.
5
(Freedman does if they have gotten paralytics in last 4 hours)
It is advisable to use ____ masks in peds to decreased dead speace.
smallest possible
Oral airway tips should reach the angle of the mandible, because if it is too large....
it will occlude the airway, move tongue back

have estimated size, and bigger/smaller sizes immediately available
What is the LMA mask size, pt weight, and cuff volume for infants?
size 1: <5 kg, 2-4 mL
size 1.5: 5-10 kg, 5-10 mL
What is the LMA mask size, pt weight, and cuff volume for small children?
size 2: child, 10-20 kg, up to 10 mL
size 2.5: 20-30 kg, up to 15 mL
How do you estimate size and length of insertion for peds ETT placement?
> 2 yrs old, 4 + (age/4) OR (16+ age)/4

length of insertion: 3 x ETT size
The ETT should remain uncuffed to age ___ with a leak at _____ cmH20.
8, 15-25
Cuffs increase the outer diameter of OETT in peds by ___ mm.
0.5 mm
Options for laryngoscopic blades in peds?
- miller (commonly used for peds to improve the view that can become obstructed by large epiglottis)
- mac
- wis-hipple (longer miller)
- robert-shaw
Peds ETT are roughly the size of the child's..
pinky or nostril
What is the formula to estimate the weight of a child?
Age x 2 +9 = wt in kg
ex: age 4
4 x 2 + 9= 17kg
EKG and BP cuff should be placed after...
induction/LOC

(place pulse ox and precordial before induction)

*be sure to monitor temp in peds*
Foleys should be used to monitor urine output in larger cases, with a goal output of...
0.5-1 ml/kg/hr
What is the 4-2-1 rule for IVFs in peds?
maintenance fluid calculation

first 10 kg: 4 ml/kg/hr
10-20 kg: +2 ml/kg/hr
>20 kg: +1 ml/kg/hr

if > 40 kg, add 40 ml to weight in kg for maintenance
What is laryngotracheobronchitis?
croup
accounts for 80% of children w stridor <2 yrs old
viral etiology
gradual onset over 24-72 hrs
What are the s/s of laryngotracheobronchitis (croup)?
- inspiratory stridor
-croupy cough, seal-like
- rhinorrhea
- rarely fever
- cold symptoms
What is the treatment for laryngotracheobronchitis (croup)?
humidified O2
racemic epi nebs
fluids
steroids
rarely may need intubation
What is epiglottitis?
- age 2-6 yrs old, 5% of children w stridor
- bacterial etiology (H-flu B)
- rapid onset, <24 hrs
What are the s/s of epiglottitis?
- inspiratory stridor
- pharyngitis
- drooing
- fever > 39 C
- lethargic
- sitting/leaning forward
- tachypneic
- cyanosis
How is epiglottitis diagnosed?
xray shows lateral swollen epiglottis
What is the treatment for epiglottitis?
- blow by O2
- urgent intubation in controlled setting (OR)
- induction: let child position self, usually sitting forward w spontaneous respirations, use blow by O2/N20, person must be skilled at intubation (may only get 1 attempt), use ETT 1-2x smaller than calculated
- admit to PICU, give fluids, abx, steroids
- extubation: in OR after audible leak present, 2-3 days later usually
What is post-intubation laryngeal edema?
- 1-4 yrs old
- usually within 3 hrs after extubation
What causes post-intubation laryngeal edema?
- repeated airway manipulation
- tight-fitting ETT (Check for a leak, amt of pressure that alows air to go around tube, want it to be 15-25 when APL closed)
- position changes after intubation
- co-existing URI
- head and neck procedures
How is post-intubation laryngeal edema prevented?
- presence of leak at 15-25 cmH20
- minimize airway manipulation
How is post-intubation laryngeal edema treated?
- racemic epi nebs
- steroids
What is pierre robin syndrome?
- congenital, challenging anesthesia implications
- micrognathia (the smaler the kid, the easier they are to intubate, becomes more difficult as kid gets larger and chin less proportional)
- glossoptosis (posterior displacement of tongue)
- cleft palate
- associated cardiac anomalies
Pts with pierre robin syndrome may be presenting for what type of surgery? What are the anesthesia implications of this surgery?
cleft palate repair

may have to suture tongue down and forward to prevent airway obstruction
awake/difficult intubation (may proceed to tracheostomy quickly)
What allergy is commonly seen with bladder atrophy and spinal defect pts?
latex allergy common
What is klippel feil syndrome?
- congenital, challenging anesthesia implications
- short neck w fusion of 2+ cervical vertebrae
- c-spine immobility
- scoliosis (60%)
- spina bifida (45%) - high latex allergy
- central alveolar hypoventilation (35%)
- renal anomalies (35%)
- cardiac anomalies (VSD, AV)
- facial asymmetry
- cleft palate and vocal cord dysfunction
What are the anesthesia implications of klippel feil syndrome?
- plan for difficult/awake intubation
- maintain cervical allignment
- prone to bradycardia
- no air bubbles in line due to possible R to L shunt
What is treacher collins syndrome?
- congenital, DIFFICULT MASK FIT AND VENTILATION
- mandibulofacial dystosis
- obstructive apnea
- congenital heart defects
What is down syndrome?
- trisomy 21
- congenital, multiple anomalies (1:660 births, incidence incr w maternal age, most commonly seen congenital defect)
- flat face, oblique palpebral fissures, simian crease, mental retardation, dysplastic middle phalanx of 5th finger, fat pad at back of neck
- 20% have atlanto-occipital axis instability --> c1-c2 subluxation can lead to spinal cord injury (if not documented, assume that they do have it and maintain inline stabilization)
- upper airway chronically obstructed due to narrow nasopharynx, large tonsils, tongue hypertrophy
What are the associated congenital anomalies w down syndrome?
- 50% heart defects (tetralogy of fallot 8%)
- endocardial cushion defect most common
- cataracts, strabismus, otitis media
What are the anesthesia considerations for down syndrome pts?
- awake intubation and extubation (large tongue, mandibular hypoplasia, subglottic stenosis)
- use smaller than normal size ETT
- racemic epi nebs for edema if postop stridor/obstruction
- do not hyperextend neck - assume immobile unless documented stable neck status
- no air bubbles in IV due to possible R-L shunt
What is a tracheoesophageal fistula (TEF)?
- esophageal atresia and TEF commonly occur together in 1:4000 births, congenital
- occur from incomplete separation of lung bud from foregut during embryologic development
at corina, you can see R and L mainstem bronchi and tracheoesoph. fistula leading to GI tract
What are the anesthesia considerations for down syndrome pts?
- awake intubation and extubation (large tongue, mandibular hypoplasia, subglottic stenosis)
- use smaller than normal size ETT
- racemic epi nebs for edema if postop stridor/obstruction
- do not hyperextend neck - assume immobile unless documented stable neck status
- no air bubbles in IV due to possible R-L shunt
Of the 5 types of TEF, the most common is type ______, which involves a blind upper esophageal pouch and fistula connecting the _____ from the ____.
3B,
stomach from trachea
20% of pts with tracheoesophageal fistulas have coexisting diseases and cardiac anomalies, which may include....(VATER)
V- vertebral anomalies
A- anal anomalies
T- tracheoesophageal fistula
E- esophageal atresia
R- radial or renal anomalies
How is tracheoesophageal fistula diagnosed?
- cant pass catheter into stomach
- coughing, cyanosis w feeds
How is tracheoesophageal fistula surgically repaired?
- primary repair: ligation of fistula and esophageal anastomosis
- staged repair: gastrostomy with fistula diversion and latex repair of esophagus
How is tracheoesophageal fistula treated?
- decompress upper pouch before intubation
- place in sitting position before induction
- awake intubation: intubate w bevel of ETT facing posteriorly to avoid fistula intubation; deliberate R mainstem intubation initially performed, then retract ETT until equal bilateral breath sounds heard; tip of ETT should be above carina but below fistula; observe PIP vigilantly because tip of ETT may migrate
- position L lateral decub (place precordial in dependent axilla to detect mainstem intubation, avoid incr airway pressures that can cause gastric distension)
- awake extubation using narcotics
What are the postop complications associated with tracheoesophageal fistula?
GE reflux
aspiration
anastomosis leakage
tracheomalacia (Flaccid tracheal support cartilage, leads to airway collapse)
esophageal strictures
What is pyloric stenosis?
- thickening/narrowing of smooth muscles around pylorus with edema of surrounding mucosa
- pylorus = where stomach meets small intestines
- incidence 1:5000 births, familial
Is pyloric stenosis a surgical emergency or a medical emergency?
MEDICAL -- stabilize pt first
What is the presentation of pyloric stenosis?
- projectile vomiting 2-3 wks old after feeding
- olive size palpable mass
- electrolyte imbalances: HYPOKALEMIC, HYPOCHLOREMIC, METABOLIC ALKALOSIS W COMPENSATORY RESP ACIDOSIS (d/t dehydration)
How is pyloric stenosis treated?
- correct electrolyte imbalance (req. 12-24 hrs before OR, Na > 130, Cl <85, K >3, uop 1-2 ml/kg/hr)
- maint IVF D5 1/2 NS
- surgical correction when medically stable
-pyloromyotomy: spreads open the muscle around the pyloric valve of the stomach, 1 inch incision around belly button or on R side)
What are the anesthesia considerations for pyloric stenosis?
- awake intubation (full stomach
OR
RSI w propofol, fentanyl, lidocaine, rocuronium, atropine
- NGT to sxn
- emergence: fully awake w good efforts
What is gastroschisis?
- interruption of omphalomesenteric artery with dissolution of the layering of the abdominal wall
- defect of abdominal wall on R lateral aspect of umbilicus through which a variable amt of abdominal viscera protrudes
- NO SAC OR MEMBRANE COVERS DEFECT
- incidence 1:30,000 live births, no gender predominance
What are the characteristics of gastroschisis?
- no amnion covering
- R lateral position
- rarely has other anomlies
- incr incidence of preterm delivery
What is am omphalocele?
- failure of part or all of the intestines to return to abdominal cavity at approx 10 wks gestation
- herniation of intestine into base of umbilical cord
- AMNION-COVERED SAC CONTAINS EXPOSED VISCERA
- incidence 1:600-100k live births, male predominance
What are the characteristics of omphalocele?
- midline, contents covered w amnion
- 75% assoc. w anomalies (cardiac, trisomy 21, beckwith-weidemann syndrome (organomegaly, macroglossia, hypoglycemia), epigastric (cardiac and lung anomalies), hypogastric (extrophy of bladder and other GU disorders) )
What are the preop considerations for gastroschisis and omphalocele?
- prevent infection
- minimize heat/fluid loss
- cover exposed viscera w moist drsg and plastic bag to prevent evaporative fluid/heat loss
- NGT to prevent aspiration
- fluid resuscitation 6-12 ml/kg/hr (hypovolemia leads to hemoconcentration and metabolic acidosis, albumin given to replace lost plasma albumin and maintain colloid pressure, NaHCO3 given slowly PRN)
What are the induction considerations of gastroschisis and omphalocele?
- maintain upright position during intubation d/t aspiration risk
- gastric decompression before intubation
- awake intubation
What are the maintenance considerations of gastroschisis and omphalocele?
- narcotic or inhalation technique
- avoid N20 to prevent further bowel distension
- administer NDMR
- monitor airway pressure (inform surgeon if increasing, high PIP may be necessary bc of impaired diaphragmatic fcn and incr intraabdominal pressure)
- avoid heat loss
- generous fluids (incr third space loss)
- glucose infusion in presence of hypoglycemia (<40 mg/dl) -- infusion of D10W 2ml/kg bolus or 8-10 ml/kg/min, serial glucose measurements
What are the emergence considerations for gastroschisis and omphalocele?
- awake extubation (may req. postop ventilation 24-48 hrs)
- post op concerns: HTN due to incr abdominal pressure, extremity edema, high airway pressures, 3rd space fluids for 3-4 days
What is a congenital diaphragmatic hernia?
- incomplete closure of diaphragm causes herniation of bowel into thorax and leads to hypoplastic lung on affected side
What is a congenital diaphragmatic hernia?
- incomplete closure of diaphragm causes herniation of bowel into thorax and leads to hypoplastic lung on affected side
How does congenital diaphragmatic hernia present?
- scaphoid abdomen
- bowel sounds in chest (L side)
- barrel chest
- hypoxia, acidosis which leads to PFC due to incr PVR -- treat w ECMO or Nitric oxide to decr PVR until diaphragm can be repaired
What are the anesthesia implications of congenital diaphragmatic hernia?
- decompress stomach before intubation
- awake intubation (do not exceed 25 cmH20 PIP -- leads to tension pneumo in good lung)
What are the maintenance techniques for congenital diaphragmatic hernia?
- watch for incr PIP
- use RR 50-100 with low PIP to maintain MV
- standard montoring, a-line,foley
- avoid IV access in LE due to decr venous return if IVC compressed
Why shouldn't the anesthetist attempt to inflate the hypoplastic lung following diaphragmatic hernia repair?
may lead ot pneumo on contralateral side
In diaphragmatic hernia repairs, if abdominal closure is tight, you may see...
incr PIP,
decr FRC,
compression of IVC
What are the emergence considerations for diaphragmatic hernia?
- remains intubated post op
- poor prognosis, death d/t lung hypoplasia and PFC
PFC
persistent fetal circulation (patent ducts x3)
Why are tonsillectomy/adenoidectomies (T&A) done?
treatment for children and young adults with sleep apnea (measured w RDI -- resp distress index -- normal is <3) from hypertrophied tonsils and tissues

chronic airway obstruction leads to pulmonary HTN and cor pulmonale if left untreated
What labs should be done preop for T&A?
CBC, PT/PTT
What are the induction techniques for T&A?
- avoid sedatives/hypotics
- antisialagogue
- standard monitoring
- inhalation or IV
- oral RAE or reinforced ETT
What are the maintenance techniques for T&A?
generous fluid administration, EBL may be difficult to assess
What are the emergence techniques for T&A?
- gentle sxn
- N/V prophylaxis
- steroids
- fully awake for extubation (prone to laryngospasm)
- transport in tonsil position -- lateral, head down, so secretions will come up and avoid aspiration
What are the postop complications for T&A?
- postop bleeding: most common first 6 hrs postop OR 5 days postop (when eschar falls off)
- s/s: frequent swallowing, restless, pale, tachycardia, hypotension
If reoperation for T&A is needed, what are the anesthesia considerations?
- rehydrate first
- full stomach precautions for swallowed blood
- awake intubation or RSI
- ketamine d/t hypovolemia
- may need to use IO if stomach is full of blood and pt wont tolerate IV placement -- cant have mask induction
How do cleft lip/palate repairs present?
- incidence 1:1000 births
- presents w aspiration, rhinorrhea, growth retardation, cardiac anomalies
What are the major concerns with cleft lip/palate?
- difficulty feeding
- prone to aspiration
- prone to otitis media
When are cleft lips/palates repaired surgically?
- lips 2-3 months
- palates at 18 months
What are the anesthesia implications of cleft lip/palate repairs?
- depends on degree of airway obstruction
- if no other anomalies, IV induciton
- if pierre robin, awake intubation
- intubation may be difficult d/t blade falling in cleft
- airway obstruction may occur d/t relaxed pharyngeal muscles
- use regular OETT or oral RAE tube -- no nasal intubation bc interferes w surgery and may injure floor of nasal cavity
What are the postop complications associated with cleft repair?
- airway obstruction
- tongue/mucosa/subglottis
/flap edema
- posterior displacement of tongue
- prolonged bleeding
- blocked nasal passages
- decr anterior/posterior oropharyngeal distance leads to hypoxia/apnea (suture tongue and tape to cheek)
-prone to laryngospasm due to blood/secretions in airway
What causes strabismus?
weakened extraocular muscles -- most common peds ocular sx
What are the concerns in caring for a strabismus repair?
- oculocardiac reflex (5 and dime reflex -- 5th and 10th cranial nerve)
- mediated afferently by trigeminal nerve, efferently by vagus nerve --> bradycardia in response to traction on rectus muscle, especially medial
- direct pressure on globe, admin of retrobulbar block, ocular trauma, pain, manipulation, hypoxia, hypercarbia, retrobulbar hemorrhage
- high risk PONV w ENT pts (pretreat w droperidol after induction 0.075 mg/kg or decadron 0.2-0.4 mg/kg)
- risk for MH: avoid succ, triggers MH and causes bradycardia, interferes w forced duction test, increases incidence of myoglobinemia
What should you do if pt exhibits oculocardiac reflex?
- inform surgeon to stop
- incr depth of anesthesia
- HR should incr in approx 20 sec -- if doesnt incr, treat w atropine 0.007 mg/kg or glycopyrrolate 0.004-0.008 mg/kg
- fatigues w manipulation
Why is zofran contraindicated in strabismus repair PONV prophylaxis?
causes prolonged QT, severe headaches
What are the emergence techniques for strabismus repair?
- extubate deep or give lidocaine and narcotic to avoid bucking
- want smooth extubation of LMA or OETT
What is myelomeningocele?
associated w incr incidence of MH and latex allergy -- take all necessary precautions
What are the anesthesia implications for scoliosis?
- usually present for ortho sx (laminectomy, harrington rod placement)
- controlled hypotension (lower MAP to 65 in normotensive pts)
- anticipate extensive blood/fluid losses
- monitor spinal cord integrity (prep pt for this -- wake up tests vs SSEPs)
- consider risk of VAE
- position upper extrem to minimize stretch
- GA, fluid plan, pronation
- if prone, check for no pressure on eye (anemia and hypotension assoc w ischemic optic neuropathy - IOP)
- postop ventilation may be necessary if VC <40% predicted, hypoxemia, hypercapnia, pulm HTN
- if scoliosis d/t muscular dystrophy, predisposed to MH, cardiac dysrhythmias, and untoward effects of succ -- use non-triggering anesthetics!
What is the most common elective peds procedure?
inguinal hernia repair
What causes inguinal hernias?
persistence of all or part of the processus vaginalis
What is the major risk involved in inguinal hernia repair?
incarceration and strangulation of a loop of bowel within the hernia sac
What are the anesthesia techniques used in inguinal hernia repair?
- normal/healthy/outpt child: illio-inguinal block, caudal block numb from hips down, LMA/ETT
- if incarcerated, may need RSI with GETA, fluid replacement essential
Anatomy for caudal- Sacral hiatus bound posteriorly by _______, superiorly by _________ and fused arch of sacrum
sacrococcygeal ligament
sacral cornu
Caudal anesthesia- Needle can be misplaced into
bone marrow, subperiostium, sacral ligaments
Caudal anesthesia can as
and used for which procedures
Single-shot or continuous catheter technique
Useful for thoracic, abdominal, pelvic and orthopedic procedures
-epidural space easily accessed by this position=less risk of dural puncture
Insert pediatric ______ needle or 20/22G needle/angiocath through sacral hiatus midline at____ angle
After needle “pops” through _______ ligament, reduce angle of needle to _____ to skin and advance____ into caudal canal
Touhy/Crawford, 45*
sacrococcygeal, 30 degrees, 2-3mm
Caudal technique Position patient in either
prone, lateral, or knee-chest position
Test dose for caudal
Aspirate then give test dose of 0.1 ml/kg of Bupivacaine 0.25% with epinephrine 1:200,000

Make sure to keep palpating finger over sacrum during injection so that SQ injection can be immediately recognized with bleb raised under finger
Penile block is best for
last for_____
and works on which roots
Utilized for circumsion (best) and hypospadias repair

Provides postoperative analgesia for 3-6 hours
Roots from S2-S4 form paired penile nerves, located under symphysis pubis and run next to dorsal arteries and vein of penis deep to Buck’s fascia
Do use give epi with the penile block
NO
-used for circumcision and hypospadias repair
-provides analgesia for 3-6 hrs
-roots S2-S4 form paired penile nerves, located under symphysis pubis and run next to dorsal arteries and vein of penis deep to Buck's fascia (supply dorsal aspect of penis and foreskin)
Penile block technique
25 G needle inserted to left and right of dorsal penile vein at the 10:30 and 1:30 positions to a depth of 3-5 mm until Buck’s fascia pierced
Aspirate and Bupivacaine 0.25% WITHOUT EPINEPHRINE up to 2 mg/kg
Max dose:
1 ml in infant/small child
6 ml in larger child
Circumferentially inject base of penis superficial to Buck’s fascia
Avoids risk of distal ischemia
ring block
What kind of block provides analgesia over the inguinal region?
ilioinguinal/iliohypogastric block
ilioinguinal/iliohypogastric block is useful for postop analgesia after ______ for several hours.
inguinal herniorrhaphy
ilioinguinal/iliohypogastric block is ______ analgesia for manipulation of spermatic cord or testicle but will block incisional pain after these procedures
inadequate
When is the ilioinguinal/iliohypogastric block performed?
immediately after induction or after wound closure
For ilioinguinal/iliohypogastric block:
nerves run beneath internal oblique muscle medial to the ________?
anterosuperior iliac spine
-blocked by a fan shaped infiltration of the abdominal wall in region
What is the technique for a ilioinguinal/iliohypogastric block?
-22/25 G needle inserted 1-1.5 cm cephalad and 1-1.5 cm medial to anterior superior iliac spine
-2 distinct pops felt through the external oblique fascia and aponeurosis
-needle directed to ilium and half volume injected as needle withdrawn
-needle then redirected toward inguinal ligament and all but 0.5-1 ml injected
-remaining LA injected SQ to block iliohypogastric nerve
What LA can you use for a ilioinguinal/iliohypogastric block?
-bupivicaine 0.25% or 0.5% up to 2mg/kg
-large volumes of LA at higher concentrations have been known to cause prolonged motor blockade of femoral nerve
Infaorbital blocks are _____ mm below the infraorbital bone edge. This provides coverage from the lower eyelid to the ____>
-4-7mm
-lower eyelid to the upper lip
What are other blocks used in peds anesthesia?
-interscalene
-femoral
-TAP
-sciatic
-rectus sheath
For the pediatric cart set up; what does the mnemonic SOAP stand for?
S= Suction
O= Ocygen
A= Airway
P= Pharm
-note; have the sevo ready
For the pediatric cart set up: set up your airway...
-blades
-handles
-ETTS (uncuff=3, cuff=2)
-Stylettes
-Oral airways
-LMAs
-Masks
-Bags (<10kg use 1L bag)
For the pediatric cart set up: the extras...
-appropriately sized BP cuff and all monitoring equipment
-green face mask
-head ring
-tube tree
-shoulder roll
For the pediatric cart set up: IV set up...
-IV boat with IVs
-fluid buretrol vs regular tubing (10kg, 4yrs)
-Always best to be safe