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326 Cards in this Set
- Front
- Back
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The functional part of the placenta is the
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chorionic villus
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fetal blood flow is separated from the maternal blood flow in the placenta by..
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a thin layer of cells known as the syncitial trophocytes
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3 substances that pass through the syncitial trophocytes.
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02
C02 non-ionized small particles |
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fetal circulation is characterized by [2]
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high PVR (uninflated atelectatic lungs and HPV)
low systemic circulatory resistance (high flow and low impedance of the placental vessels) |
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_____blood travels down the fetal Aorta and through the ___ arriving in the placenta via ____.
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fetal deoxygenated blood
internal illiac arteries paired umbilical arteries |
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the umbilical arteries divide, forming the __, __ and __ of the ___.
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arterioles, capillaries and venules of the intervillous placental space
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oxygenated blood is delivered to the fetus via...
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a single umbilical vein
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2 extra cardiac shunts
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DA, DV
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1 intracardiac shunt
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FO
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the oxygenated blood bypasses the lungs by flowing through _____ forming a parallel circulation.
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2 extracardiac and 1 intracardiac shunts
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The __ routes oxygenated blood away from the sinusoids of the liver.
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ductus venosus
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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
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eustatian valve
foramen ovale |
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Blood entering the pulmonary artery from the right ventricle flows to the aorta via the ___.
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ductus arteriosus
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only __% of the combined ventricular output flows through the pulmonary circulation
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5-10%
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The ___ circulation is established at the time of birth
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transitional
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at birth,with cessation of placental blood flow, aortic pressure ___
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increases
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clamping of the umbilical vein causes..
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a doubling of SVR
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at birth, PVR ____'s with lung expansion and increasing Pa02 produces __, resulting a further decrease of PVR
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decreases
vasodilation |
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at birth, decreases in RAP with accompanying increases in LAP cause...
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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) |
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The foramen ovale ussually closes with in...
Approx __% of adults have an undetected PFO> |
2-3 months
25% |
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In utero, ___ maintain the patency of the ductus arteriosus
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prostaglandins
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the ductus arteriosus closes because..
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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 |
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___ 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 |
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Persistant Pulmonary hypertension of the Newborn (PPHN) is manifested by..
AKA.. |
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 |
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Persistant Pulmonary hypertension of the Newborn (PPHN) is common in...
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preterm infants and infants with metabolic derangements (asphyxia, sepsis, meconium aspiration, congenital diaphramatic hernia)
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Primary precipitating factors in Persistant Pulmonary hypertension of the Newborn (PPHN)
[4] |
hypoxemia
acidosis pneumonia hypothermia |
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3 interventions that will attenuate [decrease] the increase in PVR with Persistant Pulmonary hypertension of the Newborn (PPHN)
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oxygenation
avoidance of acidosis maintenance of normothermia |
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Persistant Pulmonary hypertension of the Newborn (PPHN) can lead to...
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cor pulmonale
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Persistant Pulmonary hypertension of the Newborn (PPHN) treatment
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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 |
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The ventricles of the newborn are...
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eqaul in size ans shape and posses a low contractile mass
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__ is the DOC for pediatric bradycardia and decreased CO.
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Epinephrine
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marked changes in the newborn HR and rhthym occur secondary to changes in______.
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autonomic tone
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In utero, autonomic control of HR occurs via the _____; however _____ control of the HR takes over shortly after birth.
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parasympathetic system before birth
sympathetic after birth |
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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) |
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newborn HR...
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120 first day increasing to 160 at 1 month, then steadily decreasing to 75 at adolescece.
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BP at birth...
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BP increases immediately, rising to a mean of 70-75 within the first 48 hours.
BP is lower in preterm infant |
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The infants HR will ____ with a concurrent ___ in ___.P.
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HR will decrease with a concurrent increase in BP
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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.... |
60
70 70+ twice the age in years |
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average HR, SBP, DBP for ages
neonate 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 |
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After birth, 02 delivery to the tissues is assured despite high levels of FhGb because...
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increased concentrations fo 2,3 DPG that shift the oxyhemoglobin dissociation curve to the right
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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. |
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an eleveated hemoglobin (_____) inhibits_____
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14-20g/100ml
erythropoesis |
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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) |
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Newborns should receive __ prophylaxix.
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VIT K
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VITAMIN K dependent clotting factors [4]
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2,7,9,10
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Vit K levels in the newborn are ___ of adult levels
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20-50%
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Maternal ingestion of ___may precipitate development of a coagulopaty.
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wafarin
isonazide |
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EBL estimates by age
premature 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 |
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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 __.
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higher
child C2-C4 adult C3-C6 age 6 |
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The epiglottis is a child is __ and __.
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U shaped and stiff
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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 |
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The __ and __ make mask ventilation more difficult than in the adult.
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anterior position of the larynx and the large tongue
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The placement of a rolled towel under the ____ aids in the visual alignment of the ___ axes during laryngoscopy.
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shoulders
oral, pharyngeal and laryngeal axes |
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The prolonged use of cuffed ET tubes may produce __ leading to __ and __.
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mucosal damage
edema formation airway obstruction |
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According to Poiselle's law, increases in airway radius decrease the airway's resistance by a factor of __.
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4
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The newborn is an __ breather
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obligate nose breather
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what is failure of the development of the opening between the nasal cavity and the nasopharynx?
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choanal atresia
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In a pediatric patient, the mainstem bronchus branches from mainline at a __ angle. In the adult, the angles are...
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55 degree in
adult is l-45, right 25 |
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Surfactant productin begins during the __ week of gestation and reaches satisfactory levels at __ weeks.
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30th
35th |
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congenital diaphragmatic hernia creates a __ lung
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hypoplastic
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airway resistance is __ in children compared to adults, this is because..
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greater resistance due to smaller caliber
airway resistance dramatically decreases after the age of 5 |
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according to Poiseuille's law, airway resistance is ____ proportional to the __th power of the ___ of the airway during laminar flow.
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inversely proportional
4th radius |
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airway resistance dramatically ___ after the 5th year of age.
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decreases
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The newborn's chest wall is very pliable because it lacks ___ and because the skeletal structure is primarily composed of __.
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developed musculature
cartilage |
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The ribs of the newborn are ___, providing __ assistance in the expansion of the chest wall with inspiration.
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horizontal
minimal assistance |
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paradoxical chest movement may occur in the premature infant because..
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of a more pliable chest wall
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In normal newborns, the PIP;s are set to..
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24-25 cm h20
NORMAL INFANTS 20-24 |
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at birth, FRC is __ that of an adult.
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one half
but this difference dissapears in the first few days of life |
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The infant's metabolic rate and o2 consumption are ___ compared the adult?
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twice
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__ and __ cause a rapid decrease in oxygen saturation when ventilation is interupted.
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low FRC
high o2 demand |
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in the newborn ___ produces a mismatching of ventilation and perfusion
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airway closure
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The volume of poorly ventilated alveoli that contributes to intra-pulmonary shunting is lesser/greater in the neonate compared to the adult.
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greater
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A rapid development of cyanosis in the newborn can result from...
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increased pulmonary vascular resistance that produces a left to right shunt through the PFO and the PDA
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The neonates control of ventilation is dependent on ___ sensed via the ___ chemoreceptors.
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pa02
peripheral |
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high Pao2 ___ respirations in the newborn, whereas low Pa02 ___respiration.
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high P02 depresses
low po2 stimulates ALTHOUGH hypoxia ultimately produces ventilatory depression |
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Periodic breathing occurs more often in the ___ and during ___.
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premature infant
REM sleep |
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Apnea is uncommon/common in the premature infant.
__ and __ can follow apneic epsidodes |
common
bradycardia and cardiac arrest |
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The suspected causes of apnea in the premature infant includes...
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immature responses of the respiratory control center to hypercarbia or hypoxic stimuli and respiratory fatigue
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Infants that have experienced ____ are at higher risk of having bradycaric/apneic episodes during general anesthesia.
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bradycaric/apneic episodes
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The __ and __ reflexes are clinical demonstratons of the immaturity of the CNS at birth.
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Moro
grasp |
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myelination of the CNS is not complete until age__/
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3
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The __ can be used as an indicator of fluid volume status in the newborn.
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fullness of the fontanelle
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The spinal cord ends at __ in pediatric patients.
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L3
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THE BBB IS __ IN INfants
BBB disruption occurs following... |
incomplete
traumatic head injury subaracdhnoid or intracerebral hemmorage cerebral ischemia |
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the fragility of the cerebral vessels predispose preterm and low birth weight infants to___ which can be precipitated by...[6]
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intracranial hemmorage
hypoxia hypercaribia hyperglycemia hypoglycemia hypernatremioa and wide swings in arterial or venous pressure |
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adult strength sodium bicarbonate should not be administered to neonates because...
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the IV administration of hypertonic solutions may damage the fragile cerebral vessels leading to a hemmorage
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the newborn has an adult complement of renal ___
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nephrons, although they are immature in function
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in the neonate, GFR is __% of adult GFR.
GFR reaches adult levels by age--- |
15=30%
mature at 6-12 months |
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The low GFR in the newborn is the result of...
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lower systemic arterial pressure
increased renal vascular resistance decreased permeability of the glomerular capillaries |
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infants are unable to tolerate fluid overload because of ---
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a decreased GFR
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renal function is __% at the end of the first month.
adult function reached at .. |
70%
age 1 |
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The ability of the kidney's tubules to concentrate or dilute the urine does not mature until age...
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2-3 years
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Infants are obligate sodium excreters because..
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of their inability to conserve sodium
the renin-angiotensin-aldosterone system is functional but the tubules do not respond |
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the newborn has an _____ response to increasing plasma glucose concentrations because...
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osmotic diuresis
tubules inability to resorb glucose |
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albumin production does not begin until...
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3-4 months gestation
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concentration of clotting factors in the premature infact and newborn is ____.
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low
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preterm and SGA infants should be monitored for development of ____ because...
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hypoglycemia
smaller glycogen stores |
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Enterohepatic circulation of bilirubin is increased because
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of the depressed activity of glucuronyl transferrase that is required for hepatic conjugation
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kernicterus is..
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encephalopathy from high bilirubin
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___ regulate conductive, convective and radiant heat loss.
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cutaneous blood vessels
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heat loss is precipitated through an increase in..
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rate and depth of respiration
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skeletal muscles participate in heat production through ___, whereas the simpathetic stimulation of brown fat metabolism (aka_____) increases heat by 100% in neonates
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shivering thermogenesis
non-shivering thermogenesis |
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premature infants lack ____ which predisposes them to hypothermia
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browm fat
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heat production follows an increase in the basal metabolic rate stimulated through the release of ____
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anterior pituitary hormones
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during GA, the __ input continues, but the ____ responses are diminished
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afferent continues
effector organ responses are diminished |
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heat loss in the OR occurs as a result of...[4]
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internal redistribution of heat
reduced metabolism and heat production increased heat loss to the environment effects of anesthetic agents on thermoregulatory control |
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heat loss in infants occurs more rapidly because of __ and __.
They also have __skin and __ SQ tissue |
limited heat production (NST)
larger BSA thin less |
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perioperative hypothermia, contributing causes..[5]
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cold OR
cold IV fluids cold irrigation cool gases insesible losses from open cavities anesthetic induced vasodilation |
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____ is the infant's defense against hypothermia
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NST (brown fat metabolism)
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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 |
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____ loss is responsible for the majority of heat loss
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radiant
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radiant heat loss is..
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the transfer of heat from one objerct to another, the rate of whiuch is dependent on the temperature gradient betwee the objects
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conductive heat loss is...
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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!! |
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Convective heat loss is...
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the transfer of heat by air currents
preheat room to 26C wet diapers are bad |
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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% |
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fat is __% at birth, reaching __ at 1 year
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12% at birth
30% at 12 months |
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protien binding is ___ in newborns
albumin is responsible for the binding of ____ compounds. |
less
acidic |
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___ is responsible for the binding of basic compounds.
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AAG....alpha-1 acid glycoprotien
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Both albumin and AAG concentrations are __ at birth.
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low at birth, but reach adult levels by infancy
therefore all drugs are less bound and more available |
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Phase 2 reactions transform the the metabolic product into a___
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water soluble compund, facilitating excretion within the bile or urine
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phase __ reactions are inadeqate at birth.
the neonate lacks the capacity to efficiently conjugate ___ and metabolize ___/ |
phase 2
bilirubin tylenol chlorophenicol sulfonamides drug elimination 1/2 times are increased |
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many drug elimination 1/2 times are increased in the newborn. these include..[5]
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bupivicaine
mepivicaine indomethacin meperidine dilantin |
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the plasma drug concentration with PO/rectal administration is dependent on...[3]
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molecular weight
degree of ionization lipid solubility |
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PO
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 |
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gastric ph of the neonate at birth
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6-7
although it decreases to 1-3 within 24 hours |
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gastric emptying is slowed in the newborn but reaches adult levels in __
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6 months
gastric emptying affects peak drug concentrations |
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the ___ vein empties into the portal system.
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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 |
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high doses of acetominophen may deplete ____ , increasing the accumulation of the intermediate metaboite which can cause liver necrosis
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glutathione
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rectal tylenol pediatric doses
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10-15mg/kg Q 4hrs (no more than 25-30 mg/kg per dose)
mAX OF 60-65 MG/KG/DAY |
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nasal midazolam dose
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0.2 mg/kg atomized
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drugs that may be administered by inhalation...[4]
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water soluble
atropine fentanyl lidocaine morphine only 5-10% of the dose will reach systemic circulation |
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factors that affect inhalation anesthetic uptake [4]
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CO
Blood;gas partition coefficient alveolar ventilation inhaled anesthetic concentration |
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pediatric patients have a greater Ve because..[2]
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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. |
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The percentage of blood flow to the vessel rich organs is __ in the infant and the blood-gas partition coefficients are ___.
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higher blood flow to organs
lower partition coefficients |
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alveolar concentration rise ___ in infants than adults
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more rapidly
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inhalational induction is _____ in pediatric patients and is accompanied by a higher incidence of _____ than in adults.
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more rapid
myocardial depression |
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with halothane, ____ may occur with inadequate depths of anesthesia and with hypercarbia.
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ventricular dysrhythmias
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The MAC for halothane in o2 for neonates and infants is ..
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.87% neonates
1.2% infants |
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Isoflourane in infants can produce significant decreases in..
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HR, BP and MAP which are not corrected with prior atropine administration
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the MAC for isoflurane in neonate, children and infants is..
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1.6%
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dramatic increases in Desflurane concentration may produce __ and __.
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hypertension and tachycardia
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the MAC for desflurane in neonates, infants and children is...
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neonates 9.2
infants 9 children 6-10 |
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sevoflourane in excess of 6% has caused ____ in animals.
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seizures
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unpremedicated children may experience _____ with sevo
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emnergence dilirium and agitation
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with high concentrations of SEVO, ____ may occur.
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apnea
sevo depresses respirations to a greater degree than halothane |
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Sevoflurane drawbacks..[3]
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compound A with C02 abdsorbants
increased serum flouride levels emergence dilirum/agitation |
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infants and children have a higher/lower proportion of CO delivered to vasular rich tissues.
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higher
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IV drugs administered to pediatric neonates may have a prolonged duration of action because...
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of decreased percentages of muscle and fat.
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The CNS effects of opioids and barbiturates may also be prolonged because of...
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the imaturity of the BBB.
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Increased doses of thiopental, propofol, and ketamine are required because of..
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a greater volume of distribution secondary to increased body water.
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induction DOC for stabismus repair? why?
|
propofol..antiemetic effects
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propofol induction doses
lidocaine to add? |
Infants 2.5-3mg/kg
children 2-2.5mg/k 0.2mg/kg |
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______ may induce seizure activity in children with temporal lobe epilepsy
|
methohexital
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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? |
ionized
low lipophilicity (they are water soluble) difficult to cross the BBB. ECF compartment |
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The ECF compartment is larger/smaller in the neonate and infant compared the child and adult?
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larger
|
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What 2 differences in infants affect the pharmacologic properties of neuromuscular blockers?
|
INCREASED ECF
ongoing maturation of neonatal skeletal muscle and aCh receptors |
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The presynaptic release of ACH IS _____ in the neonate compared to the adult
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slower
|
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succinylcholine S/A's [6]
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increased intragastric pressure
increased intraoccular pressure increased intracranial pressure cardiac dysrhtmias myalgias myoglobinemia |
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succinylcholine is composed of..
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2 acetylcholine molecules united by an ester bond.
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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. |
bradycardia
junctional rhythms unifocal PVC's VF atropine 0.2mg/kg |
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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 |
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_____ is common after succinylcholine administration.
This is hypothesized to be because of _____. |
myalgia
prostaglandins IV ASA decreases mYALGIA |
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Sux is a __ trigger.
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MH 1:15000
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__ is a foreboding sign of MH.
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masseter muscle rigidity.
this can occur as a result of inadequate sux IV doses in children |
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the signs of ___ should be sought in the child experiencing masseter muscle rigidity.
|
MH
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signs of MH.[4]
|
masseter muscle rigidity
increased end tidal CO2 increased skin temp other skeletal muscle rigidity |
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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 |
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succinylcholine ED95 dose for
neonates infants children adults |
neonates 620mcg/kg
infants 729mcg/kg children 423mcg/kg adults 290mcg/kg |
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IM succinylcholine may be used with a dose of...
what must be added to the syringe? |
3-4mg/kg
atropine 0.02mg/kg |
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boys younger than age 8 with undiagnosed ____ may experience hyperkalemia and subsequent cardac arrest after sux admin.
|
Duchenne's muscular dystrophy
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succinylcholine should/should not be routinely employed for airwaqy management in children younger than ____ years.
|
should not
younger than 8 years |
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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 |
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The selection of a nondepolarizer should take into consideration..[3]
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desired degree and duration
the immaturity of organ systems associated side affects |
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interpatient variablity in response to nondepolarizers is greatest in..
|
neonates and children
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Mivacurium is a __acting nondepolarizer that is metabolized by ___.
|
short acting
plasma cholinesterase at a rate 70-88 percent that of sux |
|
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mivacurium ED95
infants children adults 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) |
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Atracurium is a __acting nondepolarizer that is metabolized by..
|
intermediate
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 mg.kg |
|
|
__ 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,
|
vecuronium
vec stimulates histamine release |
|
|
Rocuronium is an __ acting NMB with an onset 0f ____ with an intubating dose of __.
maintenance dose? infusion rate? |
intermediate
60-90 onset 0.6 mg/kg maint-0.075-0.125 mg/kg infusion 0.004- 0.016mg/kg/min |
|
|
IM dose rocuronium?
duration? |
1000-1800mcg/kg 2.5-3 minutes onset
60 minutes or greater |
|
|
residual neuromuscular blockade places the pediatric patient at risk for ....[2]
|
hypoventilation
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 MIF>-25 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 PRESERVATIVE FREE!! |
|
|
The oral airway should be inserted with the aid of a
|
tongue blade
NO ROTATION 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?
|
NO
|
|
|
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 -LMA/ETT -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.
|
greater
You want less compliance in a pediatric circuit to allow delivery of accurate tidal volumes |
|
|
The ideal pediatric breathing circuit should be...[7]
|
-lightweight
-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.
|
D
|
|
|
The Mapleson ___ was modified by Jackson-Reese with the addition of a reservoir bag with an adjustable valve at the end of the bag.
|
F
|
|
|
The Mapleson ____ has been described as the breathing circuit that nearly meets the ideal requirements for the pediatric patient.
|
F
|
|
|
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. |
2-3X
20 kg (not economical) |
|
|
The Bain circuit is a ___ modification of the ___.
RECOMMENDED FGF's for the Bain are... |
coaxial
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.
|
5-9
|
|
|
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...
|
CHF
|
|
|
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.
|
greater
|
|
|
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...
|
SIGNIFICANT MORTALITY
|
|
|
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
laryngospasm cardiac arrest bronchospasm hypotension apnea |
|
|
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 -GERD -GI obstruction -morbid obesity -CRF -DM |
|
|
the risk of pulmonary aspiration in the pediatric patient...
|
1:10,000
|
|
|
Mendelson's syndrome requires a vol of greater than ___ and a pH less than __.
|
0.4ml/kg
2.5 |
|
|
metaclopramide dose..
|
0.1mg/kg
|
|
|
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 formula 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]
|
cough
pharyngitis tonsillitis croup |
|
|
The child with active or resoving URI has ____ airway reactivity, a propensity for developing __ and ___, and the potential to experience ___.
|
increased
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. |
rhinitis
COLOR and duration of nasal discharge |
|
|
purulent nasal discharge is associated with ___ [3] and is indicative of a...
|
pharyngitis
cough fever 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] |
cough
pharyngitis wheezing 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.
|
croup
hypoxemia brochospasm |
|
|
A WBC of ___ suggests the presence of infection and surgery should be cancelled.
|
12-15000
|
|
|
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]
example? |
asymptomatic
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
dental T&A bronchosopy cystoscopy gall ballder vaginal procedures uretheral procedures GI/respiratory mucosa |
|
|
common childhood diseases that may have an accomanying rash..
|
measles
rubella 5th's disease RF scarlet fever |
|
|
Chicken pox..aka?
when? cx surg if? |
Varicella
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]
|
anemia
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.
|
inversely
50 |
|
|
can apnea occur with regional anesthesia?
|
YES
|
|
|
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.
|
hypoxemia
brady/apnea |
|
|
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.
|
individualized
|
|
|
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..
|
intra-nasal
IV IM PO transmucosal |
|
|
IM midazolam dose...
onset? |
0.07-0.1 mg/kg
onset 30-60 minutes LEAST DESIRABLE route |
|
|
IV midazolam dose...
onset? |
0.023-0.05 mg/kg
1-2 min |
|
|
intranasal midazolam dose?
onset? |
0.2mg/kg
2-10 minutes kids don't like |
|
|
PO midazolam dose?
onset? |
0.25-0.5 MG/KG
|
|
|
Rectal midazolam dose?
|
0.5-1mg/kg
|
|
|
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 infant child |
neonate 24g
infant 22g child 20g |
|
|
preferred sites for PIV?
UE/LE |
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...
|
20-22g
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
hx GERD |
|
|
CAUTIOUS use of nitrous with..[2]
|
GERD
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
|
vasodilation
myocardial depression |
|
|
surgical stress ____ blood glucose levels.
|
increase
|
|
|
hyperglycemia will act osmotically to _____ renal losses of free water.
|
INCREASE
|
|
|
morphine and halothane have been shown to increase the release of ___.
|
ADH
|
|
|
Total body water of the premie is as high as __% of total body weight, whereas the infant is __% and the adult is __%.
|
80%
70-75% 55-60% |
|
|
the most direct and widely accepted method for determining IVF requirements is based on.....
|
body weight
|
|
|
pediatric fluid requirement formula....
|
4-2-1
4-first 10kg 2-next 10-20 1-after 20 |
|
|
peds 3rd space losses...
|
3-4
5-6 7-10 use LR, NS or plasmalyte |
|
|
there is evidence ot suggest a worsening of neurologic outcome in the presence of ____glycemia.
|
hyperglycemia
|
|
|
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 ___.
|
130-155
280-310 |
|
|
renal tubular function develops after the ___ week of gestation.
The nephrons mature by the __ week. at term, GFR is.. adult at... |
34th
36th 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-LR
<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.
|
1gm=1cc
|
|
|
moderate to severe decreases in intravascular volume produce...[7]
|
tachcardia
hypotension narrowed pulse pressure low UOP decreased CVP pallor 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...
|
30
|
|
|
blood loss is replaced by...
|
3ml of crystalloid for each 1ml blood loss
|
|
|
ABL equation.
|
ABL=EBVx(Ho-Hl)/Ha
Ha=average |
|
|
blood loss that is less than the calculated ABL may be replaced with...
|
COLLOID 1:1
|
|
|
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
|
