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326 Cards in this Set

  • Front
  • Back
The functional part of the placenta is the
chorionic villus
fetal blood flow is separated from the maternal blood flow in the placenta by..
a thin layer of cells known as the syncitial trophocytes
3 substances that pass through the syncitial trophocytes.
non-ionized small particles
fetal circulation is characterized by [2]
high PVR (uninflated atelectatic lungs and HPV)

low systemic circulatory resistance (high flow and low impedance of the placental vessels)
_____blood travels down the fetal Aorta and through the ___ arriving in the placenta via ____.
fetal deoxygenated blood

internal illiac arteries

paired umbilical arteries
the umbilical arteries divide, forming the __, __ and __ of the ___.
arterioles, capillaries and venules of the intervillous placental space
oxygenated blood is delivered to the fetus via...
a single umbilical vein
2 extra cardiac shunts
1 intracardiac shunt
the oxygenated blood bypasses the lungs by flowing through _____ forming a parallel circulation.
2 extracardiac and 1 intracardiac shunts
The __ routes oxygenated blood away from the sinusoids of the liver.
ductus venosus
The oxygenated blood in the inferior vena cava is directed by the __ valve toward the atrial septum and passes through the __ to enter the left side of the circulation
eustatian valve

foramen ovale
Blood entering the pulmonary artery from the right ventricle flows to the aorta via the ___.
ductus arteriosus
only __% of the combined ventricular output flows through the pulmonary circulation
The ___ circulation is established at the time of birth
at birth,with cessation of placental blood flow, aortic pressure ___
clamping of the umbilical vein causes..
a doubling of SVR
at birth, PVR ____'s with lung expansion and increasing Pa02 produces __, resulting a further decrease of PVR

at birth, decreases in RAP with accompanying increases in LAP cause...
a change in the direction of blood flow through the FO, resulting in closure of the FO as LAP increases

The FO may remain open if RAP>LAP (PH)
The foramen ovale ussually closes with in...

Approx __% of adults have an undetected PFO>
2-3 months

In utero, ___ maintain the patency of the ductus arteriosus
the ductus arteriosus closes because..
an increase in SVR and decrease in PVR

within a few hours of birth, the muscular wall of the DA constricts, preventing retrograde flow from the aorta into the PA.

The functional closure (thrombosis) occurs within 1-8 days

Anatomotic closure (fibrosis) requires 1-4 months

ductus closure may be influenced by increases in systemic Pa02 levels after birth
___ of portal blood flow enters the ductus venosus after interruption of umbilical vein blood flow.

The mechanism of DV closure is..
the majority

unknown, but the muscular wall of the DV begins to constrict 1-3 hours postnatally causing blood flow to be directed to the liver increasing portal venous pressures
Persistant Pulmonary hypertension of the Newborn (PPHN) is manifested by..

increases in PVR and accompanying PH, which produces a rigtht to left shunt across the FO and the DA, with resultant cyanosis.

persistant fetal circulation
Persistant Pulmonary hypertension of the Newborn (PPHN) is common in...
preterm infants and infants with metabolic derangements (asphyxia, sepsis, meconium aspiration, congenital diaphramatic hernia)
Primary precipitating factors in Persistant Pulmonary hypertension of the Newborn (PPHN)
3 interventions that will attenuate [decrease] the increase in PVR with Persistant Pulmonary hypertension of the Newborn (PPHN)
avoidance of acidosis
maintenance of normothermia
Persistant Pulmonary hypertension of the Newborn (PPHN) can lead to...
cor pulmonale
Persistant Pulmonary hypertension of the Newborn (PPHN) treatment
NO, a specific short acting pulmonary vasodilator, decreases PVR and provides antegrade flow through the DA while avoiding changes in SVR.

other vasodilators may decrease SVR which may worsen shunt.

ECMO for PPHN and severe respiratory dysfuntion
The ventricles of the newborn are...
eqaul in size ans shape and posses a low contractile mass
__ is the DOC for pediatric bradycardia and decreased CO.
marked changes in the newborn HR and rhthym occur secondary to changes in______.
autonomic tone
In utero, autonomic control of HR occurs via the _____; however _____ control of the HR takes over shortly after birth.
parasympathetic system before birth

sympathetic after birth
the initial axis deviation of the newborn is...

Other EKG findings...
to the right but shifts left with left ventricular maturation

evident P wave
PR<0.12 and increases until adolescence
upright T waves in chest leads (RV hypertrophy)
newborn HR...
120 first day increasing to 160 at 1 month, then steadily decreasing to 75 at adolescece.
BP at birth...
BP increases immediately, rising to a mean of 70-75 within the first 48 hours.

BP is lower in preterm infant
The infants HR will ____ with a concurrent ___ in ___.P.
HR will decrease with a concurrent increase in BP
hypotension in an anesthetized newborn is defined as a SBP of less than ___

in an anesthetized 1 year-old it is..

older than that, the rule is....


70+ twice the age in years
average HR, SBP, DBP for ages

12 month
3 year
12 year
neonate 140 65/40
12 month 120 95/65
3 year 100 100/70
12 year 80 110/60
After birth, 02 delivery to the tissues is assured despite high levels of FhGb because...
increased concentrations fo 2,3 DPG that shift the oxyhemoglobin dissociation curve to the right
the newborn's blood volume is dependent on..

average volume?
the time of cord clamping (transfusion from placenta)

89-90 ml/kg but may be as high as 100ml/kg in the premature

the intravascular volume decreases 25% in the immediate postnatal period with the loss of intravascular fluid.
an eleveated hemoglobin (_____) inhibits_____

Hemoglobin ____ shortly after birth

There may be a dramatic fall in Hgb because of..

this fall stops at ____ and there is no comprimise becasue..
begins to fall

insufficient iron stores

3 months

right shift of the curve (2,3 dpg)
Newborns should receive __ prophylaxix.
VITAMIN K dependent clotting factors [4]
Vit K levels in the newborn are ___ of adult levels
Maternal ingestion of ___may precipitate development of a coagulopaty.
EBL estimates by age

newborn (<1 month)
infants 3mo-3yr
children> 6yr
premature 90-100
newborn (<1 month) 80-90
infants 3mo-3yr 75-80
children> 6yr 65-70
The larynx is higher/lower in the neck of a child compared to an adult. It extends from __ to __. The adult extends from __ to __ and the adult level is achieved by age __.

child C2-C4

adult C3-C6

age 6
The epiglottis is a child is __ and __.
U shaped and stiff
The newborn tongue is __ and __ and is hard to manipulate because of _____.

In addition, a _____ is present in which to displace the tongue during laryngoscopy
large and hard to manipulate because of the position of the hyoid.

smaller submental space
The __ and __ make mask ventilation more difficult than in the adult.
anterior position of the larynx and the large tongue
The placement of a rolled towel under the ____ aids in the visual alignment of the ___ axes during laryngoscopy.

oral, pharyngeal and laryngeal axes
The prolonged use of cuffed ET tubes may produce __ leading to __ and __.
mucosal damage

edema formation

airway obstruction
According to Poiselle's law, increases in airway radius decrease the airway's resistance by a factor of __.
The newborn is an __ breather
obligate nose breather
what is failure of the development of the opening between the nasal cavity and the nasopharynx?
choanal atresia
In a pediatric patient, the mainstem bronchus branches from mainline at a __ angle. In the adult, the angles are...
55 degree in

adult is l-45, right 25
Surfactant productin begins during the __ week of gestation and reaches satisfactory levels at __ weeks.

congenital diaphragmatic hernia creates a __ lung
airway resistance is __ in children compared to adults, this is because..
greater resistance due to smaller caliber

airway resistance dramatically decreases after the age of 5
according to Poiseuille's law, airway resistance is ____ proportional to the __th power of the ___ of the airway during laminar flow.
inversely proportional


airway resistance dramatically ___ after the 5th year of age.
The newborn's chest wall is very pliable because it lacks ___ and because the skeletal structure is primarily composed of __.
developed musculature

The ribs of the newborn are ___, providing __ assistance in the expansion of the chest wall with inspiration.

minimal assistance
paradoxical chest movement may occur in the premature infant because..
of a more pliable chest wall
In normal newborns, the PIP;s are set to..
24-25 cm h20

at birth, FRC is __ that of an adult.
one half

but this difference dissapears in the first few days of life
The infant's metabolic rate and o2 consumption are ___ compared the adult?
__ and __ cause a rapid decrease in oxygen saturation when ventilation is interupted.
low FRC
high o2 demand
in the newborn ___ produces a mismatching of ventilation and perfusion
airway closure
The volume of poorly ventilated alveoli that contributes to intra-pulmonary shunting is lesser/greater in the neonate compared to the adult.
A rapid development of cyanosis in the newborn can result from...
increased pulmonary vascular resistance that produces a left to right shunt through the PFO and the PDA
The neonates control of ventilation is dependent on ___ sensed via the ___ chemoreceptors.

high Pao2 ___ respirations in the newborn, whereas low Pa02 ___respiration.
high P02 depresses

low po2 stimulates

ALTHOUGH hypoxia ultimately produces ventilatory depression
Periodic breathing occurs more often in the ___ and during ___.
premature infant

REM sleep
Apnea is uncommon/common in the premature infant.

__ and __ can follow apneic epsidodes

bradycardia and cardiac arrest
The suspected causes of apnea in the premature infant includes...
immature responses of the respiratory control center to hypercarbia or hypoxic stimuli and respiratory fatigue
Infants that have experienced ____ are at higher risk of having bradycaric/apneic episodes during general anesthesia.
bradycaric/apneic episodes
The __ and __ reflexes are clinical demonstratons of the immaturity of the CNS at birth.
myelination of the CNS is not complete until age__/
The __ can be used as an indicator of fluid volume status in the newborn.
fullness of the fontanelle
The spinal cord ends at __ in pediatric patients.
THE BBB IS __ IN INfants

BBB disruption occurs following...

traumatic head injury
subaracdhnoid or intracerebral hemmorage
cerebral ischemia
the fragility of the cerebral vessels predispose preterm and low birth weight infants to___ which can be precipitated by...[6]
intracranial hemmorage

and wide swings in arterial or venous pressure
adult strength sodium bicarbonate should not be administered to neonates because...
the IV administration of hypertonic solutions may damage the fragile cerebral vessels leading to a hemmorage
the newborn has an adult complement of renal ___
nephrons, although they are immature in function
in the neonate, GFR is __% of adult GFR.

GFR reaches adult levels by age---

mature at 6-12 months
The low GFR in the newborn is the result of...
lower systemic arterial pressure

increased renal vascular resistance

decreased permeability of the glomerular capillaries
infants are unable to tolerate fluid overload because of ---
a decreased GFR
renal function is __% at the end of the first month.

adult function reached at ..

age 1
The ability of the kidney's tubules to concentrate or dilute the urine does not mature until age...
2-3 years
Infants are obligate sodium excreters because..
of their inability to conserve sodium

the renin-angiotensin-aldosterone system is functional but the tubules do not respond
the newborn has an _____ response to increasing plasma glucose concentrations because...
osmotic diuresis

tubules inability to resorb glucose
albumin production does not begin until...
3-4 months gestation
concentration of clotting factors in the premature infact and newborn is ____.
preterm and SGA infants should be monitored for development of ____ because...

smaller glycogen stores
Enterohepatic circulation of bilirubin is increased because
of the depressed activity of glucuronyl transferrase that is required for hepatic conjugation
kernicterus is..
encephalopathy from high bilirubin
___ regulate conductive, convective and radiant heat loss.
cutaneous blood vessels
heat loss is precipitated through an increase in..
rate and depth of respiration
skeletal muscles participate in heat production through ___, whereas the simpathetic stimulation of brown fat metabolism (aka_____) increases heat by 100% in neonates
shivering thermogenesis

non-shivering thermogenesis
premature infants lack ____ which predisposes them to hypothermia
browm fat
heat production follows an increase in the basal metabolic rate stimulated through the release of ____
anterior pituitary hormones
during GA, the __ input continues, but the ____ responses are diminished
afferent continues

effector organ responses are diminished
heat loss in the OR occurs as a result of...[4]
internal redistribution of heat
reduced metabolism and heat production
increased heat loss to the environment
effects of anesthetic agents on thermoregulatory control
heat loss in infants occurs more rapidly because of __ and __.

They also have __skin and __ SQ tissue
limited heat production (NST)

larger BSA

perioperative hypothermia, contributing causes..[5]
cold OR
cold IV fluids
cold irrigation
cool gases
insesible losses from open cavities
anesthetic induced vasodilation
____ is the infant's defense against hypothermia
NST (brown fat metabolism)
brown fat stores contain a high density of __ in the ____.

hypothermia stimulates the release of ____
mitocondria in the scapulae, axilla and the mediastinum and surrounding the kidneys

norepinephrine which acts on brown fat to uncouple oxidative phosphorylation
____ loss is responsible for the majority of heat loss
radiant heat loss is..
the transfer of heat from one objerct to another, the rate of whiuch is dependent on the temperature gradient betwee the objects
conductive heat loss is...
the transfer of heat to the environment and is dependent on the temperature differences between the child and the environment

warm solutions
bair huggers
prewarming the room

the head 60% loss..cover it!!
Convective heat loss is...
the transfer of heat by air currents

preheat room to 26C

wet diapers are bad
infant vs adult TBW
infant vs adult ECF
infant vs adult ICF
TBW 80-90 vs 55-60%
ECF 50-60 vs 20%
ICF 60 vs 40%
fat is __% at birth, reaching __ at 1 year
12% at birth

30% at 12 months
protien binding is ___ in newborns

albumin is responsible for the binding of ____ compounds.

___ is responsible for the binding of basic compounds.
AAG....alpha-1 acid glycoprotien
Both albumin and AAG concentrations are __ at birth.
low at birth, but reach adult levels by infancy

therefore all drugs are less bound and more available
Phase 2 reactions transform the the metabolic product into a___
water soluble compund, facilitating excretion within the bile or urine
phase __ reactions are inadeqate at birth.

the neonate lacks the capacity to efficiently conjugate ___ and metabolize ___/
phase 2



drug elimination 1/2 times are increased
many drug elimination 1/2 times are increased in the newborn. these include..[5]
the plasma drug concentration with PO/rectal administration is dependent on...[3]
molecular weight
degree of ionization
lipid solubility

acidic drugs are _____ and are favorably absorbed in the low pH medium of the stomach.

basic drugs are more favorable absorbed in the----
acidic are non-ionized

alkaline environment of the small intesting
gastric ph of the neonate at birth

although it decreases to 1-3 within 24 hours
gastric emptying is slowed in the newborn but reaches adult levels in __
6 months

gastric emptying affects peak drug concentrations
the ___ vein empties into the portal system.
superior rectal vein (upper third of the rectum)

this results in lower concentrations because of first pass effect.

avoid upper third administration with opioids, midazolam and barbiturates
high doses of acetominophen may deplete ____ , increasing the accumulation of the intermediate metaboite which can cause liver necrosis
rectal tylenol pediatric doses
10-15mg/kg Q 4hrs (no more than 25-30 mg/kg per dose)

mAX OF 60-65 MG/KG/DAY
nasal midazolam dose
0.2 mg/kg atomized
drugs that may be administered by inhalation...[4]
water soluble


only 5-10% of the dose will reach systemic circulation
factors that affect inhalation anesthetic uptake [4]
Blood;gas partition coefficient
alveolar ventilation
inhaled anesthetic concentration
pediatric patients have a greater Ve because..[2]
of smaller FRC and a higher CO.

in addition, thier decreased distribution of adipose tissue and decreased muscle mass affect the rate of equlibration among the alveoli, blood and brain.
The percentage of blood flow to the vessel rich organs is __ in the infant and the blood-gas partition coefficients are ___.
higher blood flow to organs

lower partition coefficients
alveolar concentration rise ___ in infants than adults
more rapidly
inhalational induction is _____ in pediatric patients and is accompanied by a higher incidence of _____ than in adults.
more rapid

myocardial depression
with halothane, ____ may occur with inadequate depths of anesthesia and with hypercarbia.
ventricular dysrhythmias
The MAC for halothane in o2 for neonates and infants is ..
.87% neonates

1.2% infants
Isoflourane in infants can produce significant decreases in..
HR, BP and MAP which are not corrected with prior atropine administration
the MAC for isoflurane in neonate, children and infants is..
dramatic increases in Desflurane concentration may produce __ and __.
hypertension and tachycardia
the MAC for desflurane in neonates, infants and children is...
neonates 9.2
infants 9
children 6-10
sevoflourane in excess of 6% has caused ____ in animals.
unpremedicated children may experience _____ with sevo
emnergence dilirium and agitation
with high concentrations of SEVO, ____ may occur.

sevo depresses respirations to a greater degree than halothane
Sevoflurane drawbacks..[3]
compound A with C02 abdsorbants
increased serum flouride levels
emergence dilirum/agitation
infants and children have a higher/lower proportion of CO delivered to vasular rich tissues.
IV drugs administered to pediatric neonates may have a prolonged duration of action because...
of decreased percentages of muscle and fat.
The CNS effects of opioids and barbiturates may also be prolonged because of...
the imaturity of the BBB.
Increased doses of thiopental, propofol, and ketamine are required because of..
a greater volume of distribution secondary to increased body water.
induction DOC for stabismus repair? why?
propofol..antiemetic effects
propofol induction doses

lidocaine to add?
Infants 2.5-3mg/kg

children 2-2.5mg/k

______ may induce seizure activity in children with temporal lobe epilepsy
Neuromuscular drugs are highly ____ and have a _____ lipophilicity, which has what affect on thier ability to cross the BBB?

Where do these properties restrict their distribution to?

low lipophilicity
(they are water soluble)

difficult to cross the BBB.
ECF compartment
The ECF compartment is larger/smaller in the neonate and infant compared the child and adult?
What 2 differences in infants affect the pharmacologic properties of neuromuscular blockers?

ongoing maturation of neonatal skeletal muscle and aCh receptors
The presynaptic release of ACH IS _____ in the neonate compared to the adult
succinylcholine S/A's [6]
increased intragastric pressure
increased intraoccular pressure
increased intracranial pressure
cardiac dysrhtmias
succinylcholine is composed of..
2 acetylcholine molecules united by an ester bond.
stimulation of the parasympathetic ganglia or direct stimulation of cardiac muscarinic receptors by succinylcholine will produce...[4]

The prior administration of _______ will block the cardiac muscarinic receptors and minimize the cardiac effects.
junctional rhythms
unifocal PVC's

atropine 0.2mg/kg
Myeglobinemia may occur in ___% of children who receive ___ and in ___% of children who receive __ and __.

The prior administration of a small dose of _______ will modify the degree of myeglobinemia.
20% sux

40% halothane and sux

a non-ddepolarizer
_____ is common after succinylcholine administration.

This is hypothesized to be because of _____.


IV ASA decreases mYALGIA
Sux is a __ trigger.
MH 1:15000
__ is a foreboding sign of MH.
masseter muscle rigidity.

this can occur as a result of inadequate sux IV doses in children
the signs of ___ should be sought in the child experiencing masseter muscle rigidity.
signs of MH.[4]
masseter muscle rigidity
increased end tidal CO2
increased skin temp
other skeletal muscle rigidity
neonates are more/less resistant to the effects of succinylcholine than children or adults.

this is because...
more resistant

of the increased volume of distribution within the large extracellular compartment
succinylcholine ED95 dose for

neonates 620mcg/kg
infants 729mcg/kg
children 423mcg/kg
adults 290mcg/kg
IM succinylcholine may be used with a dose of...

what must be added to the syringe?

atropine 0.02mg/kg
boys younger than age 8 with undiagnosed ____ may experience hyperkalemia and subsequent cardac arrest after sux admin.
Duchenne's muscular dystrophy
succinylcholine should/should not be routinely employed for airwaqy management in children younger than ____ years.
should not

younger than 8 years
neonates are ____, infants are _____, and children are ___ to the effects of nondepolarizing neuronmuscular blocking drugs.
neonates are sensitive
infants are less sensitive
children are resistant

larger VD in infants and neonates
The selection of a nondepolarizer should take into consideration..[3]
desired degree and duration
the immaturity of organ systems
associated side affects
interpatient variablity in response to nondepolarizers is greatest in..
neonates and children
Mivacurium is a __acting nondepolarizer that is metabolized by ___.
short acting

plasma cholinesterase at a rate 70-88 percent that of sux
mivacurium ED95


an intubating dose of ____ will produce intubating conditions in 2-3 minutes with a duration of?

recovery time?
infants 85mcg/kg
children 89-103mcg/kg
adults 58-120mcg/kg

0.2mg/kg (200mcg/kg)
20 minutes

25% recovery-6min[infants] 10 minutes[children)
Atracurium is a __acting nondepolarizer that is metabolized by..

non-specific plasma esterases and hofmann elimination

same for cis-atracurium
unlike mivacurium, plasma choinesterase defeciency DOES NOT affect the metab/elimination for____.
atracurium, cis-atracurium
Atracurium intubating dose?
Cis-atracurium intbating dose?
atra 0.5mg/kg, maintenance 0.2-0.3 mg/kg

cis-atra 0.1mg/kg, maintenance 0.08-0.1
__ and __ may be the neuromuscular blocking drugs of choice in neonates and infants because...
sux, miv

these drugs are not dependent of mature organ systems for elimination
prolonged infusions of ___ in the ICU setting have been associated with prolonged paralysis,

vec stimulates histamine release
Rocuronium is an __ acting NMB with an onset 0f ____ with an intubating dose of __.

maintenance dose?
infusion rate?

60-90 onset

0.6 mg/kg

maint-0.075-0.125 mg/kg
infusion 0.004- 0.016mg/kg/min
IM dose rocuronium?

1000-1800mcg/kg 2.5-3 minutes onset

60 minutes or greater
residual neuromuscular blockade places the pediatric patient at risk for ....[2]

inability to protect the airway
conventional doses of anticholinesterase inhibitors for reversal....
neostigmine 0.4-0.7mg/kg
pyridostigmine 0.1-0.2mg/kg
edrophonium 0.5mg/kg

along with appropriate doses of atropine or glycopyrolate
clinical signs of adequate NMB reversal in the adult include..

in the neonate and infant...
5-sec head lift
bilateral sustained grip strength
ability to protrude the tongue
absence of discoordinate movements
return to normal TO4

spontaneous and sustained leg lift
spontaneous arm movement
normal T04
mif of -32 corresponds with leg lift
premature neonates have a reduced ability to metabolize the preservatives __ and __. These agents can produce __[3].

therefore __ must be used.
benzoyl alcohol and sodium benzoate

CNS toxicity, Sz'z and premanant brain damage

The oral airway should be inserted with the aid of a
tongue blade


nasals are uncommon
the approx size of ETT for children age 2 and older may be determined by...

the depth of ETT insertion from dental alveoli may be estimated by...
age + 16/4

1,2,3,4/7,8,9,10 rule
another method of estimating ETT insertion depth is...
diameter of tube x 3
Always have what sizes of ETT's at the bedside?
one above, one below and the estimated size
goal air leak with pos pressure?
15-20 cm/h20
The confirmation of breath sounds is done...
after intubation and repeated after taping of tube.
Use of a precordial stethoscope placed over the __ area of the chest will aid in the detection of ____ migration of the RAE tube.
left anterior

right bronchial
The distal end of the LMA cuff rests in the __ superior to the __.
inferior aspect of the hypopharynx

esophageal sphincter
is isolation of the esophageal sphincter guaranteed with an LMA?
what effects does nitrous oxide have on ETTs and LMAs?
cuff hyperinflation
LMA cuff pressure is adjusted to where there is a leak at....
15-26cm h20
The blending of air with oxygen decreases the Fi02 and may be desirable for [2]
laser surgery
to prevent retinopathy of the newborn in high risk premies
Nitrous should be avoided in infants with acute...
intraabdominal disease
advantages of the circle system [3]
conservation of inhalational agents
ability to retain both heat and humidity
ease of collecting and scavenging waste gases
components of the adult circle system [8]
-1 meter length of tubing with Y connector
-elbow or straight connector
-unidirectional respiratory valves
-reservoir bag
-c02 absorber
-port for FGF inflow
-pop-off valve that directs exhaled gases to the scavenging system
pediatric circle system differeces from adult [3]
smaller tubing
smaller c02 canisters
lower resistance valves
newly designed circle systems compare in performance with the _____ circuits that have comparable resistance and are acceptable for short periods of spontaneous ventilation in small infants.
Mapleson F
Compliance of a standard circle system is greater/lesser than a Mapleson F.

You want less compliance in a pediatric circuit to allow delivery of accurate tidal volumes
The ideal pediatric breathing circuit should be...[7]
-minimize dead space
-have a low resistance
-have a low compressible volume
-be adaptable for both spontaneous and controlled ventilation
-be capable of providing humidification and warming of inspired gases
-permit the collection and scavenging of exhaled anesthetic gases.
contemporary pediatric breathing circuits include...[3]
-the traditional circle system
-Mapleson D and F circuits
-Bain modification of Mapleson
Modification of the Ayer's T-peice has been classified as...
Mapleson A to E's
The Mapleson ____ contains an expiratory valve at the distal end of the expiratory limb.
The Mapleson ___ was modified by Jackson-Reese with the addition of a reservoir bag with an adjustable valve at the end of the bag.
The Mapleson ____ has been described as the breathing circuit that nearly meets the ideal requirements for the pediatric patient.
FGF's ____ times the patient's Ve are required to prevent rebreathing of exhaled gases with the Mapleson F circuit.

This limits the use of this circuit to __kg.

20 kg (not economical)
The Bain circuit is a ___ modification of the ___.

RECOMMENDED FGF's for the Bain are...

Mapleson D

200-300 ml/kg for spontanous
70-100 ml/kg for controlled
disadvantages of the Bain circuit[4]
___ is used to test the integrity of the inspiratory limb
-practitioner unfamiliarity
-misconnection of the adapter mounted to the anesthesia machine
-kinking of the inner insipratory limb
-integrity of the inner inspiratory limb must be maintained, otherwise inspired fresh gas will enter the expiratory limb, creating a large dead space

Pethick's maneuver
Pethick's maneuver is...
used to test the integrity of the inspiratory limb of the Bain circuit.

patient end is occluded, the reservoir is filled with the flush valve, keeping the flush open, the patient end is opened.

THe reservoir should collapse due to the Venturi effect if the insp. limb is intact.

if the reservoir inflates, the insp. limb is fractured.
The selected reservoir bag must be appropriate for the patient's size, i.e......

too small...
too large...
capable of containing a volume in excess of the patient's inspiratory capacity.

too small=increased resp. effort

too large=decreased ability to visually monitor ventilation
When using a Mapleson F or the Bain circuit, the variables that must be considered to determine PaC02 during controlled ventilation include...[4]
-the ratio of dead space to tidal volume Vd/Vt

- the FGF rate

-the child's Co2 production

-the alveolar to arterial C02 difference
When using a Mapleson F or Bain circuit, FGF rates need to be _____ for patients with decreased Ve.
increased or controlled
The review of the chart should focus on...[5]

The child should also be evaluated for proper__ and ___. Developmental delay may suggest...
-medical hx(begining with gestational hx)
-previous hospitalizations
-previous medical or surgical experiences
-the presence of chronic illness or infectious desease
-any family hx of anesthetic complications (atypical psuedocholinesterase)

growth and development as determined by a review of norms and percentages for age and gender.

a prenatal pathologic ocondition, the presence of a chronic illness, or the presence of a concurrent neurologic or neuromuscular disease.
it is important to examine the ____ for signs of redness when a cough or rhinorhea is present.
the throat
airway obstruction secondary to adenotonsillar hypertrophy may be uncovered through a history of...

these children may have....
snoring with sleep

obstructive sleep apnea and underlying pulmonary hypertension
CHILDREN between the ages of ___ and ___ should be evaluated for the presence of loose teeth these should be noted on the examination.
preoperative laboratory tests should be ordered based on...
abnormal findings from the medical history and physical exam
An 'adequate' hemoglobin concentration has been arbitrarily defined sa a Hgb of ___ or a Hct of __.
10 or 30
Children who benefit from preoperative Hgb testing include...[4]
premies less than 60 weeks post-conceptual age

children with concurrent cardiopulmonary disease

children with known hematologic disease (sickle cell)

children in whom major blood loss is anticipated.
Juandice-possible anesthetic implications [2]
altered drug metabolism

risk of hypoglycemia
adrenal insufficiency is a possible anesthetic implication of...
steroid therapy
croup carries a possible anesthetic implication of...
possible subglottic stenosis or anomaly
a hx of squatting is suggestive of...
tetralogy of fallot
diaphoresis with feedings is suggestive of...
frequency and nocturia are suggestive of...[2]
unrecognized diabetes or UTI
what lab test for CF patients...
blood glucose
what preop test for Down's syndrome patients....
cervical spine radiograph

r/o subluxation of atlantooccipital junction
Children's exhibited behavoir is age dependent and shaped by fears of...[4]
-parental separation
-postoperative pain
-the potential for disfigurment
-loss of control
children between the ages of __ and __ become distressed when separated from thier parents.
6mo-5 years
anesthetic morbidity and mortality is greater/less than in adults.
pediatric cardiac arrest is rarely a primary event, but follows the development of __ or __ that is either __ or __ in origin.
hypoxemia or acidosis

respiratory (failure to manage the airway)

circulatory (frank inhalational overdose)
Because HR is an essential determinant of CO in the infant, introoperative bradycardia precipitatied by high concentrations of inhalational agents or hypoxemia is associated with...
Children less than ____ age have the greatest risk of experiencing adverse events during the perioperative period and the greatest risk if intraoperative death.

These adverse events include...[5]
4 weeks

cardiac arrest
patients between the ages of __ and __ experience the fewest perioperative anesthetic complications.

Children between the ages of __ and __ have a greater incidence of intraoperative dysrhymias than adults
1 month and 12 years

1 and 5...6 and 10
____ and ___ are known consequences of GA.
gastric regurgitation and pulmonary aspiration
Pathologic conditions that increase the risk of pulmonary aspiration include...[7]
-known difficult airway
-impaired protective airway reflexes secondary to neurologic inury
-GI obstruction
-morbid obesity
the risk of pulmonary aspiration in the pediatric patient...
Mendelson's syndrome requires a vol of greater than ___ and a pH less than __.

metaclopramide dose..
preop acess to clear fluids __ hrs before induction has shown to have a minimal impact of resultant volume and ph.
2 hrs
NPO guidelines

clear liquids
breast milk
cow milk
light meal
clear liquids 2 hrs
breast milk 4 hrs
formula 6 hrs
cow milk 6 hrs
light meal 6 hrs
URI's are common in the pediatric age group, are seasonal and may be accompanied by...[4]
The child with active or resoving URI has ____ airway reactivity, a propensity for developing __ and ___, and the potential to experience ___.

atelectasis and mucus plugging

perioperative arterial hypexemia
bronchial reactivity may persist for ___ to ___ weeks after an URI.
6 to 8 weeks
healthy children who are presenting for tympanostomy tubes frequently have...

assessing the ___ will assist in deciding whether it is chronic or acute.

COLOR and duration of nasal discharge
purulent nasal discharge is associated with ___ [3] and is indicative of a...

bacterial or viral URI
children with chronic allergic rhinorrhea exhibited as clear nasal drainage without accompanying signs of illness are probably in satisfactorily condition for elective GA with no imposed increased risk.

The accompanying signs of illness are..[4]
associated fever
_______ typically accompanies viral or bacterial URI.

these are associated with...
lower RTI

a 5 fold increase in risk of layrngospasm and bronchospasm (10 fold)
there is an increase in the incidence of postintubation __, __, and __ in patient's with URI's.
A WBC of ___ suggests the presence of infection and surgery should be cancelled.
clearly, elective surgery should be postponed for children who have...
a cough and pharyngitis accompanied by fever and wheezing
decreases in HR or acute hypotension after induction will be poorly tolerated in patient's with...
aortic stenosis
Children with 'functional' murmurs are generally...[3]

no cyanosis
growing appropriately

Still's vibratory systolic murmur (common age 2-6)
surgical procedures that involve invasion of the _____ may produce transient bacteremia.

examples of procedures...
mucosal surfaces

gall ballder
vaginal procedures
uretheral procedures
GI/respiratory mucosa
common childhood diseases that may have an accomanying rash..
5th's disease

scarlet fever
Chicken pox..aka?


cx surg if?

January and May

exposed w/i 21 days with no signs
standard bacterial endocarditis prophylaxix?
amoxiciliin 50mg PO 1 hr before
no po, then 50mg IV 3o min before

PCN allergy..clinda, cephalexin, azithro, clrarithro
infants born before __ are considered premature.
37 weeks
Prematurity presents its own set of complications including...[5]
aspiration with feeding
intraventricular hemorrhage
periodic apnea wityh bradycardia
chronic resp dysfunction
postconceptual age is..

greatest surgical risk at...
gestational age plus postnatal age
less than 60 weeks postnatal age
premies have a significant risk of ___ and ___ in the first ___hrs after surgery.
apnea and bradycardia

24 hrs
the incidence of postop apnea is ____ proportional to the postconeptual age and is most frequent in infants of ____ weeks postconceptual age.

can apnea occur with regional anesthesia?
Premies with a hx of apnea are __ times as likely to develop postop apnea.
2 times
all premies less than ___ weeks postconceptual age shold be admitted with continuous monitoring for apnea and bradycarida for at least 24 hours. They should have no occurances for at least __hr before discharge
60 weeks

12 hours
elective surgical procedures should be deferred until at least __ weeks of postconceptual age.
44 weeks
prolonged periods of __ may be UNacompanied by ____ in healthy premature infants.

the ideal premedication should be...
dependable with a rapid and reliable onset/offset

should be devoid of S/A's
premedications must be ____ to account for diffrences in maturation and development and the child;s previous experiences.
the reliance on pre-meds should/should not be routine.
SHOULD NOT, it should be reserved for patient's who are extremely apprehensive
children older than __ may benefit from anxiolysis.
1 year
routes for midazolam..
IM midazolam dose...

0.07-0.1 mg/kg

onset 30-60 minutes

IV midazolam dose...

0.023-0.05 mg/kg

1-2 min
intranasal midazolam dose?


2-10 minutes

kids don't like
PO midazolam dose?

0.25-0.5 MG/KG
Rectal midazolam dose?
the essential monitoring modalities for inhalational induction include...[2]
precordial stethoscope

pulse oximetry
Inhalational induction sequence...
start at 70:30 mix then agent started at 0.5% with 0.5% increases every 4-5 breaths.

after LOC, DC nitrous, 100% 02, decrease sevo to 2-2.5%, assist ventilations.

place IV, then intubate.
PIV sizes..

neonate 24g
infant 22g
child 20g
preferred sites for PIV?

UE-non-dominant, dorsum of hand, AC fossa

LE-dorsum of foot, saphenous vein
the scalp veins should be reserved for...
fluid administration as the injection of alkaline drugs can lead to necrosis and sloughing
Deep saphenous vein approach...

medial malleoulus...move finger towards the anterior portion of the tibia.....extend foot, into the skin parralel to the tibia and pass SQ early into the saph vein.

use board to immobilize
IV induction of pediatric patients indicated if...[2]
full stomach

CAUTIOUS use of nitrous with..[2]
impaired swallowing
Immediately before laryngoscopy, DC the?
inhalational agent
EMLA cream must be applied ___ before attempts.
30-60 min
Rectal methohexital dose and notes...
25-30 mg/kg in 2% solution, onset 15 minutes

insert cath no more than 3cm

best distal(middle/inferior veins-- (no first pass effect)
IM induction agents/notes....
Ketamine 2-3mg/kg with midazolam

brevital 6 mg/kg onset in 5 min
inhalational agents produce vaso______ and some degree of myocardial _____ which leads to decreasing systemic BP and decreasing organ blood flow
myocardial depression
surgical stress ____ blood glucose levels.
hyperglycemia will act osmotically to _____ renal losses of free water.
morphine and halothane have been shown to increase the release of ___.
Total body water of the premie is as high as __% of total body weight, whereas the infant is __% and the adult is __%.


the most direct and widely accepted method for determining IVF requirements is based on.....
body weight
pediatric fluid requirement formula....

4-first 10kg
2-next 10-20
1-after 20
peds 3rd space losses...

use LR, NS or plasmalyte
there is evidence ot suggest a worsening of neurologic outcome in the presence of ____glycemia.
clincal circumstances in which hypoglycemia is likely to develop....[4]
-premie-less glycogen (D10.25NS)

-diabetic mothers

-diabetes with am insulin given

-glucose based parenteral nutrition
crystalloids move freely between which 2 compartments?
intravascular and interstitial.
an isotonic solution has a sodium of ____ and an osmolarity of ___.

renal tubular function develops after the ___ week of gestation.
The nephrons mature by the __ week.

at term, GFR is..

adult at...


GFR is 15-30% of adult

1 year
a newborn's inability to concentrate urine is due to ___ and leads to ....
inability to reabsorb sodium

large quantities of dilute urine
which is worse...

under or overestimation of fluid needs.
underestimation is worse
fluid for 6 month and older?

younger than 6 months?

replace preop deficit by...

<6 NS or D5.45NS

crystalloid 10ml/kg (for each 1% of dehydration)
THE INTRAVASCULAR VOLUME may be estimated by...

the estimated blood volume is calculated by..
mutiplying the child's weight by the EBV.

premie- 90-100ml/kg
newborn 80-90ml/kg
3 mo-3yr 75-80ml/kg
>6yr 65-70ml/kg
every __gm of weight is equal to __ml of blood loss.
moderate to severe decreases in intravascular volume produce...[7]
narrowed pulse pressure
low UOP
decreased CVP
slow cap refill
a sudden decrease in BP in neonates and infants with rate-dependant CO is indicative oif...
significant intravascular volume depletion
the incidence of apnea in neonates and infants is higher when the hgb is below...
blood loss is replaced by...
3ml of crystalloid for each 1ml blood loss
ABL equation.

blood loss that is less than the calculated ABL may be replaced with...
blood transfusion for neonate...
draw up through infusion tubing with syringe

less than 1 week old, irradiated

do not dilute
increased intra-abdominal pressure during laparoscopy can cause..[6]
bradycardia (from mesenteric and peritoneal stretching)
limited ventilatory reserve
decreased CO and preload
decreased intraabdominal orgaN BLOOD FLOW
alters acid base balance (decreased pH)
intercranial bleeding

possibly premed with atropine 20mcg/kg before insufflation
decreased preload in the infant can lead to...
a return of fetal circulation
acute gas emolization manifestation...
drastic drop in ETCO2
hypertrophic pyloric stenosis...
more in white males
1:1000 births

identified with onset of projectile vomiting at 2-4 weeks

NEVER an emergency

risk of barium regurg/aspiration
prolonged vomiting creates..

what IVF replacement?
hyperchloremic metabolic acidosis

give D5LR
infants may have a grater risk of amide local toxicity beacuse...
decreased levels of AAG