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165 Cards in this Set
- Front
- Back
When does Pyloric Stenosis present and how do you diagnose it |
Presents 2-8 weeks of life Palpation of an olive-sized mass int he upper aspect of the abdomen. Verified with upper GI series with Barium w/ x-ray |
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Clinical Presentation of Pyloric Stenosis |
Low Na, K, and Cl, Metabolic Alkalosis. If Severe Metabolic Acidosis |
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Pyloric Stenosis Tx is it a medical or surgical emergency |
Medical you give IV fluids D5.22NSS w/40KCl for 12-48 hours. |
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Pyloric Stenosis Anesthetic Management what do you do and whats your biggest concern |
Aspiration of Gastric Fluid primary concern so you do a True RSI. Suction at least 3 times prior to inducing. CO2 response curve changed don't over hyperventilate. |
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Congenital Hip biggest concern |
Greatest concern is lose of airway due to positioning |
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Congenital Club Foot what does it look like |
pointed downward and rotated inward. |
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What does osteogenesis effect |
defect of collagen production resulting in abnormal bones, ligaments, teeth, and sclera |
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Osteogenesis what's your biggest concern and whats the clinical presentation |
Positioning - big risk for fractures Hyper-metabolic, Bowing of long bones and kyphoscoliosis, platelet abnormalities, Otosclerosis, and deafness. |
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What is the only patient that you don't aggressively heat |
Osteogenesis |
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Cerebral Palsy clinical presentation |
MR, seizure, vison, speech, hearing, behavior, cognition issues. skeletal muscle spasticity and contractures. |
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Phenobarbital issue |
Hepatic microsomal enzyme inducer- need more meds. |
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Dantrolene |
Skeletal muscle relaxant - inhibits Ca++ release from SR |
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Baclofen |
Skeletal muscle relaxant - inhibits excitatory neurotransmitters |
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Fractures and Kids induction |
RSI if trauma.
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Scoliosis 4 issues |
1.Decrease lung volumes FEV1, FVC, VC 2.Decrease Chest wall compliance 3.V/Q mismatch leading to chronic hypoxemia 4.Increase in PVR, pulmonary HTN leading to RV Failure |
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Prone Positioning effects |
Compression of lungs Increase Intra abd pressure Compression of IVC Epidural Vein engorement, increase bleeding Decrease venous return and decrease cardiac output |
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Scoliosis surgical consideration (blood loss) |
25ml/kg blood loss. |
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Meingocele clinical presentation |
Neural function intact Spinal Cord is tethered by sacral nerve roots If unprepared - Ortho/Urologic issues |
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Myelomeningocele clinical presentation |
Varying degree of sensory and motor issues Dilation of upper urinary tract Spasticity Scoliosis |
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Anesthetic Management of Cele |
Repair first day of life! Keep pressure off sac- lateral position for repair. |
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Pierre Robin Structural anomalies |
Micrognathia (small chin), Glossoptosis, and Cleft Palate |
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Treachear Collins Associated defects |
Most common Mandibulofacial syndrome Ear tags and auditory canal and ossicular chain issues Cleft Congenital HD |
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Goldenhar |
Unilateral mandibular hypolasia eye, ear, vertebral abnormalities on the affected side |
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Cleft Lip and Palate implications 4 |
Problem swallowing, risk for aspiration, URI/otitis media increase, and poor nutrition and anemia. |
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Primary reason for correction of Cleft lip/palate is |
Speech |
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Special Gag with Cleft Lip/Palate repair At risk for what during surgery and what type of care after |
Dingman Gag placement or manipulation can lead to partial or complete obstruction.
Unrecognized blood loss no throat pack .. ICU after 24 hours observation for airway |
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Duchennes what is it and first clinical manifestations |
Painless degeneration and atrophy of skeletal muscles. Progressive and symmetric skeletal muscle weakness and wasting. Sensation and reflex remain intact Pelvis affected first- gait issues. |
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Duchennes Cardiac/Pulmo Dysfunction |
ECG changes - Tall R Wave in V1 and Deep Q waves in limb leads, short PR, ST
Mitral Regurg Recurrent PNA |
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Anesthetic Implications with Duchennes |
Delayed Gastric emptying - risk for aspiration Myocardial dysfunction Increase skeletal muscle cell permeability Decrease pulmonary reserve, retention of secretions |
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Congenital Diaphragmatic hernia what is it and what prenatal history do they have |
Defect in diaphragm that allows herniations of abd organs into the thoracic cavity Prenatal Hx of Polyhydramnios. |
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Congenital Diaphragmatic hernia common common issues 3 |
Bilateral Lung Hypoplasia Pulm HTN Left Ventricular Dysfunction |
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Classic Triad of CDH |
Dyspnea Cyanosis and Dextrocardia |
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How do you treat these patients |
24-48 hours of medical management Mech vent- low pressures, keep alkalotic - low TV, with high RR |
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Preoperative Management what do you have to prevent |
Hypothermia |
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What fluid do we use in children and what do we need to do to maintain homeostasis |
Need 100 ml for every 100 calories , 3Na, 2K, and 5 Glucose D5.22 - Maintenance fluid |
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Treatment for High K+ |
ECG Hyperventilation Sodium Bicarb CaCl Glucose and insulin |
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EBV in children Premature to over 6 years |
Premature 90-100 ml/kg Term 80-90 3mon-3year 75-80 3year to 6 year- 70-75 6 year and older65-70 |
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Lowest acceptable Hct in neonate Calculate EBL |
35% EBV x(starting Hct- acceptable Hct/ Average Hct) |
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Newborn thermoregulation limited because |
Small Size Increased surface area to volume ratio Increased Thermal Conductance They are homothermic |
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Major source of heat loss is |
Radiation |
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How do newborns maintain heat |
Non Shivering Thermogenesis - Brown Fat metabolism |
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Anesthetic Management of Hypothermia - how will it effect us |
Decrease MAC inhaled agents, increase tissue solubility, and decrease requirement of NDNM's, prolong duration |
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Signs of Compromise in neonatal resuscitation |
Cyanosis - in blood Bradycardia- insufficient delivery of oxygen to the heart muscle or brainstem |
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Initial things to check when a baby is born |
Term Gestation Crying or Breathing Good Muscle tone |
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What week baby do you apply a plastic wrap or bag to prevent heat loss w/o drying |
28 weeks or less
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What to do if the HR is below 100 |
PPV ventilation |
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Target Preductal SpO2 after birth by minutes |
1 min=60 2 min 65-70 3 min 70-75 4 min 75-80 5 min 80-85 10 min 85-95 |
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Bag mask ventilation what type of pressure do you give on the first breath |
30-40 cm then 15-20 succeeding breaths OG tube if bagging for longer than 2 minutes |
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Primary sign of effective ventilation is |
Increasing Heart Rate |
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When do you do chest compression |
HR less than 60 after PPV ventilation for 30 seconds |
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Tube size in neonate |
2.5 mm less than 28 weeks 3.0 mm if 28-34 weeks 3.5 mm if 34 or greater |
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Depth of ETT for 1kg,2kg,3kg, and 4 kg baby |
1kg = 7cm 2kg = 8cm 3kg = 9cm 4kg = 10cm |
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Depth of Chest compression and what is the compression to vent ratio How long until you D/C efforts |
1/2 to 3/4 inch. 3:1 compression to vent ratio 10 minutes |
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Epi Dose and when to give |
HR less than 60 IV: 1;10,000 concentration and give rapidly 0.1-0.3 ml/kg -umbilical vein ETT- 0.5-1.0 ml/kg - not as effective |
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Volume expanders dose |
10ml/kg over 5-10 minutes |
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Meconium suctioning when to do it |
Depressed respirations, decreased muscle tone, and HR less than 100. Mouth then nose |
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Resp anatomy of infants |
Large head, short neck, and large tongue Epiglottis - longer, narrower, and more acute angle |
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When do children get their teeth and when do they lose their teeth |
get 6 months lose 6-8 years |
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Narrowest part of airway of infant |
cricoid ring |
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When intubating a child what do you need to have |
Shoulder roll- life the thorax |
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Length of trachea in neonates and children up to one year of age |
5-9 cm |
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Infants are nasal breathers until when? Overcoming the resistance in nares compared to adults and infants.. where is the major source of resistance for infants |
infants nasal breathers 3-5 months Infants 25% adults 60% nares resistance Major resistance for infants - lower airways |
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ETT sizing |
Age + 16/ 4 |
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Air leak in infant should be what |
15-25 cm H2O |
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Stimulation of what nerve is common in laryngospasm |
Superior |
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Tx for Laryngospasm |
Remove stimuli or debris Deepen anesthetic 100% O2 with PPV (30-40) manual forward displacement of the mandible SCh and Atropine |
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Post intubation Laryngeal edema what age and whats the treatment |
age 1-4 Tx Humidification of inspired gases. then aerosolized racemic epi 0.5 2.25% in 2-3 ml saline |
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Epiglottis cause? what Age? symptoms? |
Causes - Haemophilus influenzae B Age 3-6 years Systemic septicemic- Rapid symptoms less than 24 hours, High Fever 39, and dysphagia, dysphonia, drooling, inspiratory stridor, distress
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Epiglottis Anesthetic implications and tx |
Urgent intubation under GA- don't overstimulate the child - keep calm. Try and maintain spont vent. smaller ett (0.5-1). |
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Epiglottis Extubation Criteria |
When Temp and WBC fall Audible leak around tube Extubation in OR after direct scope to check swelling |
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CROUP Etiology? Age? Patho? Symptoms? |
Etiology - parainfluenzae virus type 1&2, influenzae A, Resp syncitial virus. Age- 2 years or younger Patho - mucosal and submucosal edema within the cricoid ring Symptoms - Gradual onset 24-72 hours. URI progressing to barking cough, low grade fever <39 |
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Tx of Croup |
O2 with cool mist Racemic epi aerosolized, steroids, antipyretics, and intubation (rare) |
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Foreign Body Aspiration most common area? |
Right Mainstem |
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Tonsillectomy and Adenoidectomy Common bleeding times.. how to treat these patients |
Early - within 6 hours Secondary peak 7 days RSI for anesthesia. |
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Chonal Atresia Bilateral vs Unilateral |
Bilateral - surgical correction immediately Unilateral - dont notice until intractable unilateral nasal drainage |
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Caudal block for what |
T10 below for Post op Pain |
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Hepatic Degradation of amide LA's reduced until |
3-6 month of age. |
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Narrow therapeutic window in infants for LA why |
Increased free LA levels
Increased elimination half life of LA Larger weight scaled doses required to achieve the same level. |
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Caudal Block Placed where |
Sacrococcygeal ligament you located sacral hiatus between the sacral cornua. Palpate cephalad from coccyx |
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Bupi and Ropi dosing how long will block last |
Bupi 0.25 1cc/kg for T10 block- 5 hour block Rop 0.2 2.5 ml/kg is a safe and effective dose for bolus injection |
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Duramorph in Caudal duration and dose |
Duration - 8-12 hours of analgesia- watch for resp depression 24 hours, sedation pruritus, N/V, urinary retention
Dose 30mcg/kg |
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Clonidine duration and effect |
May increase block 1.5 to 2 x's For children older than 1 Dose 1-3 mcg/kg - 30 mcg max Increase sedation and hypotension |
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From caudal who doesn't get spinal headaches |
6 year old or less |
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Best way to prevent caudal intravascular injection |
Test dose - 3ml of epi 0.5 mcg/kg- if intravascular will see Twave up and HR up Wide QRS and arrhythmias with last in children |
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First fetal system to achieve functional state and by what week |
Cardiac by 8th week - malformation during this time is irreversible |
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Neonates are what dependent |
Heart Dependent - can't change SV |
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What is the only drug that can fix contractility in neonate |
Calcium |
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Response to Catecholamines in infants |
Diminished response - infants are PNS driven. |
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Down Syndrome characteristics |
Subglottic Stenosis Narrow nasopharynx Large tonsils and Adenoids Large Tongue Mid face hypoplasia Pharyngeal hypotonia |
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Down syndrome Anesthetic implications |
Avoid heavy sedation. choose smaller ETT. Maintain head and neck in neutral position poor AO |
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Premature Infant, Neonate, and Infant - what weeks define them |
Premature infant born <37 weeks Neonate 0-4weeks of life Infant 4 weeks to 12 months of age |
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When does Pharmacologic Maturation occur |
3-6 months of age. |
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Drug absorption... differences in neonates |
No structural differences, but pH (less acidic), gastric emptying and gastric transit time slower. |
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Infants and proteins difference |
Infants have less proteins and decrease affinity of proteins for drugs in the neonate - |
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What is the Nadir of Hgb |
period of anemia following birth 3-6 months. state with hgb 18-19 go down to 10-11. |
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Why do neonates require higher per kg dose of drugs to reach desired effect |
Larger volume of distribution. |
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What is most important to determining mature of drug metabolism - age related |
Postnatal age - not gestational. Degree to metabolism drugs |
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Drug Metabolism Hepatic are they present at birth? when do they develop |
Hepatic enzyme are incompletely developed at birth. Phase 1 & 2 develop within a few days. Conjugation developed by 3 months. |
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Kidney excretion become normal by what age |
3 months |
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Why is the uptake of inhaled anesthetics quicker in infants? what age has the highest MAC |
Infants have more rapid alveolar ventilation 6 months highest MAC |
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Uptake and shunting effects of L to R vs R to L |
L to R - uptake faster R to L - uptake slower. |
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Induction method in kids |
O2 at 2L . N20 at 4L Sevo at 8% until deep enough for IV start. |
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Midazolam dosing |
oral 0.5-1mg/kg- onset 15-30 minutes Intranasal - 0.2-0.3 mk/kg 1min onset with 10 min peak IV - 0.1 mg/kg |
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Propofol dosing |
ED infants 3.0 mg/kg ED older children 2.4 mg/kg |
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Ketamine dosing and side effects |
Ketamine 2 mg/kg IV and 6 mg/kg for IM given for pain - skin, muscle, and bone - not viscera cause increase salivation - give with antisialoguge should be given with benzo - reduce delirium |
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MSO4 dosing and neonates effect |
MSO4- 0.05-0.1 mg/kg doing Neonates long elimination and half life. |
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Dosing for fentanyl and who has a longer half life Remifentanil any differences |
Dosing 1-5mcg/kg Half life prolonged in premature infants - 6-32 hours. No differences in Reminfentanil in adults or nenonates |
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Atropine vs Glyco |
Atropine 10mcg/kg - crosses BBB, profound cardiac - less antisialagogue Glyco - 10mcg/kg - moderate cardiac more antisalagouge |
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SCh dosing? Give with what med? when do we give SCh? |
SCh 2.2 mg/kg - cholinesterase activity reduced infants up to 3 months Give with Atropine RSI and Laryngospasm (0.3mg/kg) we give SCh |
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SCh contraindicated in? |
Paraplegia, Muscular Dystrophies, Stroke, Myotonia, Burns, MH |
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Neostigmine vs Edrophonium |
Neo- dose 35-70 mcg/kg more potent than edro need 2/4 twitches Edro- 0.5-1.0mg/kg - more rapid onset. need 3/4 twitches. |
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LA toxicity first sign and dosing for Lid/Bup/Rop? what dose of epi can we give |
LA toxicity- dysrhythmias or CV collapse first sign Lid 5mg/kg (7mg/kg w/epi) Bupi - 2.5mg/kg Rop 0.5-1mg/kg Epi 2-3mcg/kg/dose |
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Dexmedetomidine dosing and effects |
Dex- alpha 2 receptor 0.25 -1.0 mcg/kg bolus or 0.2-1 mcg/kg/hr
does not cause resp depression, but causes a initial increase in B/P followed by low b/p and brady
sedative, analgesic, and sympatholytic effects. |
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TEF what is it and whats the most common |
Condition characterized by esophageal atresia with or without communication between the esophagus and and trachea Most common is C |
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TEF most common initial symptom and how to diagnosis |
TED - inability to manage oral secretions -choking on first feed Diagnosis - inability to pass suction catheter or OG tube into stomach... Chest x-ray confirm pouch |
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Preoperative prep things to consider |
NPO, HOB elevated 30 degree - prone/lateral Esophageal pump to CLWS gastrostomy to decompress stomach 12lead and echo mandatory .. AVOID N2O |
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TEF goal for ETT position |
above the carnia below the fistula. R maindtem intubation, withdraw the ETT until breath sounds are confirmed in L axilla. |
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Emergence goal with TEF |
extubate at the end of surgery prevent manipulation of anastomosis. - no extension of head or suctioning past esophageal anastomosis. |
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TEF long term complications |
esophageal stricture, tracheomalacia, GERD |
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GastRoschisis |
Vascular event causes defect to the anterior abd wall to the right of the umbilical cord; no effect to umbilical cord. - less common No Sac- 2-5 cm Bowel is matted, thickened, covered with inflammatory coating. involves only small/large intestines - isolated lesion |
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Omphalocele |
Central Defect involving the umbilical cord Abdominal contents - within a sac- stomach, large/small intestines, liver. Fascial defect >4cm incidence with other anomalies Beckwith-Wiedemann syndrome, Reiger syndrome, Prune belly syndrome |
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Negative impact of closure of abdominal defects |
Impairs diaphragmatic excursion- inadequate ventilation impedes venous return-hypotension aortocaval compression- bowel ischemia, decreased CO |
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Unsafe for primary close if these 4 things occur in abdominal defects |
CVP change of 4 greater than baseline ETCO2 greater than 50 Peak inspiratory pressure greater than 35 Intragastric pressure > 20 |
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Preoperative consideration (fluids) - stomach/heat |
Massive fluid loss - give 2-4 times maintenance rate. Prevent aspiration Maintain normothermia - exposed viscera. |
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Monitors with abdominal defect |
2 pulse ox preductal and post ductal 2 large IV above diaphragm |
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Postop considerations with Abdominal defect |
Mechanical Vent - 24-48hours after surgery. - better resp compliance. |
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Fetal lung development significance of 16 weeks, 24weeks, and 28 weeks. |
16- significant compromise if defects occurs before 16 weeks 24- life possible with mechanical ventilation 28 - unsupported ventilation possible |
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Adaption of breathing occurs with what |
clamping of the umbilical cord and increasing O2 tensions from air breathing |
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The primary event of the Respiratory system transition is ? What pressure must the infant generate to inflate the lungs? |
Initiation of Ventilation Infant must generate negative pressure -70 to inflate the lungs. |
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With Onset of ventilation whats happens with PBF and PVR |
PVR decreases and PBF increases- changes in PO2, PCO2, and pH are responsible for decrease in PVR. |
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why don't infants lungs collapse and what must we do with mechanical ventilation |
High closing volume - then they terminate there expiatory phase of breathing before reaching true FRC which results in intrinsic PEEP. Neonate w/ anesthesia give 5 of PEEP |
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Control of Ventilation whats wrong with Resp Control |
doesn't develop fully until 3-4 weeks. Chemoreceptor present. Newborns respond to hypercarbia but slope is decreased. |
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Ductus Venosus |
Umbilical vein goes to the ductus venous and diverts approx 50% of blood to liver and 50% to IVC then the RA --- (Parallel) |
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Foramen Ovale |
Preferential streaming causes O2 blood to be directed to Foramen Ovale which connects the right and left atrium. |
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Ductus Arteriosus |
RV output is delivered across the ductus arteriosus and connects the PA to the descending aorta - feeds lower body(PO2 22) |
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Transition fetus to neonate PVR, SVR, PBF, FO, Ductus Arteriosus |
Fetus - high PVR, low SVR &PBF, FO and Ductus Arteriosus open Neonate - PVR low, high SVR & PBF, FO and Ductus Arteriosus closed |
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Persistent Pulmonary HTN caused by what 2 things. - Signs and Symptoms |
Hypoxia and Acidosis Cyanosis, Tachypnea, Acidosis, and Right to Left shunt. |
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PPHN treatment |
Hyperventilation- maintain alkalosis
Pulmonary vasodilators Minimal handling Avoid stress ADEQUATE VENTILATION AND OXYGENATION IS KEY. |
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Renal System in fetal kidney |
low renal blood flow and low GFR. - changes in newborn- increase in systemic arterial pressure, renal vascular resistance down and increase in size in function.- 34 weeks all nephrons are developed. |
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Neonates are what when it comes to sodium |
Obligate sodium lose - excrete sodium even when depleted. - immature neonatal tubules reasoning not aldosterone. |
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Maintenance fluid for Neonate |
D5 .22NS |
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Best way to maintain temperature in infant
|
Warming the room 80-85 degrees. |
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Heat production in infant is achieved by |
Nonshivering thermogenesis - metabolism of brown fat. |
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Pulmonary blood flow increase vs decrease (shunting) |
Increase - volume or pressure overload to the pulmonary circulation VSD, ASD, PDA, AVC, Truncus Decrease- resulting in a relative inability to oxygenated blood (HSLS, TOF, Tricuspid Atresia) |
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Shunt Formula
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QP/QS = Sat(aorta)- Sat (SVC) / Sat (pulm venous) - Sat PA Want 1:1 ratio... ASD we would get 2:1 |
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CHD 4 main problems |
Chronic Hypoxemia CHF Arrhythmias Pulmonary Disease |
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Chronic Hypoxemia blood and growth |
Polycythemia - stroke, Abnormal hemostasis. Growth 1/3 metabolism devoted to growth |
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CHF common with |
VSD - increase pulmonary blood flow Obstructive- AS |
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Ohm's Law |
Q (blood flow) = P Pressure drop across vascular bed/ R Resistance in vascular bed |
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Poiseuille law |
small radius higher resistance less blood flow |
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ASD Key facts |
>8mm likely require intervention Left to Right shunt Ostium Secudum - most common. Curable lesion |
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Atrioventricular Canal Defects |
Need early surgical intervention - Shunting mass amount. CHF quickly. Total mixing |
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VSD |
Most common shunt. Left to Right. Left Atrium hypertrophy not RV |
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Tetralogy of Fallot |
Pulm Stenosis, VSD, Overriding Aorta, RVH Right to Left Shunt Needs preload |
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What causes a TET spell and how do u tx it |
Hypercyanotic episode. increased right to left shunting from decreased systemic blood pressure and increased RVOT. tx- Increase Intravascular load, 100% FiO2, phenylephrine, Beta Block, Narcotics, |
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Total Anomalous Pulmonary Venous Return |
Left to Right Shunt. Obstructed TAPVR immediately surgery Blood never goes to left side of the heart - need an VSD or PDA |
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Transposition of Great Arteries |
Right Ventricle connected to Aorta Left Ventricle connected to Pulmonary Artery Incompatible with life unless you have an ASD/PDA* |
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Truncus Arteriosus |
Septation between the aorta and pulmonary artery 4-5 weeks after conception Need VSD* Need to treat damage is irreversible |
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PDA Patent Ductus Arteriosus |
Fetus Right to left Neonate Lef to right. Closes first 72 hours of life. Large PDA steal from systemic circulation lowering diastolic b/p putting coronary circulation at risk. Endocarditis mandates PDA closure. |
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Coarctation of the Aorta |
Narrowing of the Aorta - Increased After on the systemic ventricle The after load results in LVH HTN proximal to the coarctation and hypotension distal to the coarctation. Tx HTN |
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Hypoplastic Left Heart Syndrome |
LV is nonfunctional. Need PDA - pulmonary venous return must be routed to the RA through an ASD where it mixes with systemic venous return. Need atrial mixing; 1:1 close. |
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Single Ventricle Physiology Oxygen issues |
Want O2 75 to 85 Above 85 your PVR decreases and blood overloads pulmonary system and decreased systemic blood pressure Below 75- PVR increases and blood goes to systemic circulation but unoxygenated. |
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Hypoplastic left heart syndrome tx |
Transplant or 3 step process 1. at birth, 2. 3-4 months, 3. - 2 years of age. |
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Fontan Anesthetic considerations |
CVP = Pulmonary Venous Pressure- dictates pulmonary blood flow. - AVOID hypoxemia, acidosis. - Prevent PVR increase. |
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Antibiotic prophylaxis |
Give to Artificial valve, Tx, or hx endocarditis Dental procedures, Resp procedures, Infected tissue. |