Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/165

Click to flip

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

Clinical Presentation of Pyloric Stenosis

Low Na, K, and Cl, Metabolic Alkalosis.




If Severe Metabolic Acidosis

Pyloric Stenosis Tx is it a medical or surgical emergency

Medical you give IV fluids D5.22NSS w/40KCl for 12-48 hours.

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.

Congenital Hip biggest concern

Greatest concern is lose of airway due to positioning

Congenital Club Foot what does it look like

pointed downward and rotated inward.

What does osteogenesis effect

defect of collagen production resulting in abnormal bones, ligaments, teeth, and sclera

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.






What is the only patient that you don't aggressively heat

Osteogenesis

Cerebral Palsy clinical presentation

MR, seizure, vison, speech, hearing, behavior, cognition issues.


skeletal muscle spasticity and contractures.

Phenobarbital issue

Hepatic microsomal enzyme inducer- need more meds.

Dantrolene

Skeletal muscle relaxant - inhibits Ca++ release from SR

Baclofen

Skeletal muscle relaxant - inhibits excitatory neurotransmitters

Fractures and Kids induction

RSI if trauma.


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

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

Scoliosis surgical consideration (blood loss)

25ml/kg blood loss.

Meingocele clinical presentation

Neural function intact


Spinal Cord is tethered by sacral nerve roots


If unprepared - Ortho/Urologic issues

Myelomeningocele clinical presentation

Varying degree of sensory and motor issues


Dilation of upper urinary tract


Spasticity


Scoliosis

Anesthetic Management of Cele

Repair first day of life!


Keep pressure off sac- lateral position for repair.

Pierre Robin Structural anomalies

Micrognathia (small chin), Glossoptosis, and Cleft Palate

Treachear Collins Associated defects


Most common Mandibulofacial syndrome


Ear tags and auditory canal and ossicular chain issues


Cleft


Congenital HD

Goldenhar

Unilateral mandibular hypolasia


eye, ear, vertebral abnormalities on the affected side

Cleft Lip and Palate implications 4

Problem swallowing, risk for aspiration, URI/otitis media increase, and poor nutrition and anemia.

Primary reason for correction of Cleft lip/palate is

Speech

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



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.

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


Anesthetic Implications with Duchennes

Delayed Gastric emptying - risk for aspiration


Myocardial dysfunction


Increase skeletal muscle cell permeability


Decrease pulmonary reserve, retention of secretions

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.

Congenital Diaphragmatic hernia common common issues 3

Bilateral Lung Hypoplasia


Pulm HTN


Left Ventricular Dysfunction

Classic Triad of CDH

Dyspnea Cyanosis and Dextrocardia

How do you treat these patients

24-48 hours of medical management


Mech vent- low pressures, keep alkalotic - low TV, with high RR

Preoperative Management what do you have to prevent

Hypothermia

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

Treatment for High K+

ECG


Hyperventilation


Sodium Bicarb


CaCl


Glucose and insulin

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

Lowest acceptable Hct in neonate


Calculate EBL

35%




EBV x(starting Hct- acceptable Hct/ Average Hct)

Newborn thermoregulation limited because

Small Size


Increased surface area to volume ratio


Increased Thermal Conductance




They are homothermic

Major source of heat loss is

Radiation

How do newborns maintain heat

Non Shivering Thermogenesis - Brown Fat metabolism

Anesthetic Management of Hypothermia - how will it effect us

Decrease MAC inhaled agents, increase tissue solubility, and decrease requirement of NDNM's, prolong duration

Signs of Compromise in neonatal resuscitation

Cyanosis - in blood




Bradycardia- insufficient delivery of oxygen to the heart muscle or brainstem

Initial things to check when a baby is born

Term Gestation


Crying or Breathing


Good Muscle tone

What week baby do you apply a plastic wrap or bag to prevent heat loss w/o drying

28 weeks or less

What to do if the HR is below 100

PPV ventilation

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

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

Primary sign of effective ventilation is

Increasing Heart Rate

When do you do chest compression

HR less than 60 after PPV ventilation for 30 seconds

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

Depth of ETT for 1kg,2kg,3kg, and 4 kg baby

1kg = 7cm


2kg = 8cm


3kg = 9cm


4kg = 10cm

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

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



Volume expanders dose

10ml/kg over 5-10 minutes

Meconium suctioning when to do it

Depressed respirations, decreased muscle tone, and HR less than 100.


Mouth then nose

Resp anatomy of infants

Large head, short neck, and large tongue




Epiglottis - longer, narrower, and more acute angle

When do children get their teeth and when do they lose their teeth

get 6 months


lose 6-8 years

Narrowest part of airway of infant

cricoid ring

When intubating a child what do you need to have

Shoulder roll- life the thorax

Length of trachea in neonates and children up to one year of age

5-9 cm

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

ETT sizing

Age + 16/ 4

Air leak in infant should be what

15-25 cm H2O

Stimulation of what nerve is common in laryngospasm

Superior

Tx for Laryngospasm

Remove stimuli or debris


Deepen anesthetic


100% O2 with PPV (30-40)


manual forward displacement of the mandible


SCh and Atropine

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

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



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).

Epiglottis Extubation Criteria

When Temp and WBC fall


Audible leak around tube


Extubation in OR after direct scope to check swelling

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

Tx of Croup

O2 with cool mist


Racemic epi aerosolized, steroids, antipyretics, and intubation (rare)

Foreign Body Aspiration most common area?

Right Mainstem

Tonsillectomy and Adenoidectomy Common bleeding times.. how to treat these patients

Early - within 6 hours


Secondary peak 7 days


RSI for anesthesia.

Chonal Atresia Bilateral vs Unilateral

Bilateral - surgical correction immediately


Unilateral - dont notice until intractable unilateral nasal drainage

Caudal block for what

T10 below for Post op Pain

Hepatic Degradation of amide LA's reduced until

3-6 month of age.

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.



Caudal Block Placed where

Sacrococcygeal ligament




you located sacral hiatus between the sacral cornua. Palpate cephalad from coccyx

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

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


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

From caudal who doesn't get spinal headaches

6 year old or less

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

First fetal system to achieve functional state and by what week

Cardiac by 8th week - malformation during this time is irreversible

Neonates are what dependent

Heart Dependent - can't change SV

What is the only drug that can fix contractility in neonate

Calcium

Response to Catecholamines in infants

Diminished response - infants are PNS driven.

Down Syndrome characteristics

Subglottic Stenosis


Narrow nasopharynx


Large tonsils and Adenoids


Large Tongue


Mid face hypoplasia


Pharyngeal hypotonia

Down syndrome Anesthetic implications

Avoid heavy sedation. choose smaller ETT. Maintain head and neck in neutral position poor AO

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

When does Pharmacologic Maturation occur

3-6 months of age.

Drug absorption... differences in neonates

No structural differences, but pH (less acidic), gastric emptying and gastric transit time slower.

Infants and proteins difference

Infants have less proteins and decrease affinity of proteins for drugs in the neonate -

What is the Nadir of Hgb

period of anemia following birth 3-6 months. state with hgb 18-19 go down to 10-11.

Why do neonates require higher per kg dose of drugs to reach desired effect

Larger volume of distribution.

What is most important to determining mature of drug metabolism - age related

Postnatal age - not gestational. Degree to metabolism drugs

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.

Kidney excretion become normal by what age

3 months

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

Uptake and shunting effects of L to R vs R to L

L to R - uptake faster




R to L - uptake slower.

Induction method in kids

O2 at 2L . N20 at 4L


Sevo at 8% until deep enough for IV start.

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

Propofol dosing

ED infants 3.0 mg/kg


ED older children 2.4 mg/kg

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

MSO4 dosing and neonates effect

MSO4- 0.05-0.1 mg/kg doing




Neonates long elimination and half life.

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

Atropine vs Glyco

Atropine 10mcg/kg - crosses BBB, profound cardiac - less antisialagogue




Glyco - 10mcg/kg - moderate cardiac more antisalagouge

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

SCh contraindicated in?

Paraplegia, Muscular Dystrophies, Stroke, Myotonia, Burns, MH

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.

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

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.

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

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

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

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.

Emergence goal with TEF

extubate at the end of surgery prevent manipulation of anastomosis. - no extension of head or suctioning past esophageal anastomosis.

TEF long term complications

esophageal stricture, tracheomalacia, GERD

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

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

Negative impact of closure of abdominal defects

Impairs diaphragmatic excursion- inadequate ventilation


impedes venous return-hypotension


aortocaval compression- bowel ischemia, decreased CO

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

Preoperative consideration (fluids) - stomach/heat

Massive fluid loss - give 2-4 times maintenance rate.


Prevent aspiration


Maintain normothermia - exposed viscera.

Monitors with abdominal defect

2 pulse ox preductal and post ductal


2 large IV above diaphragm

Postop considerations with Abdominal defect

Mechanical Vent - 24-48hours after surgery. - better resp compliance.

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

Adaption of breathing occurs with what

clamping of the umbilical cord and increasing O2 tensions from air breathing

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.

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.

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



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.

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)

Foramen Ovale

Preferential streaming causes O2 blood to be directed to Foramen Ovale which connects the right and left atrium.

Ductus Arteriosus

RV output is delivered across the ductus arteriosus and connects the PA to the descending aorta - feeds lower body(PO2 22)

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

Persistent Pulmonary HTN caused by what 2 things. - Signs and Symptoms

Hypoxia and Acidosis




Cyanosis, Tachypnea, Acidosis, and Right to Left shunt.

PPHN treatment

Hyperventilation- maintain alkalosis

Pulmonary vasodilators


Minimal handling


Avoid stress


ADEQUATE VENTILATION AND OXYGENATION IS KEY.


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.

Neonates are what when it comes to sodium

Obligate sodium lose - excrete sodium even when depleted. - immature neonatal tubules reasoning not aldosterone.

Maintenance fluid for Neonate

D5 .22NS

Best way to maintain temperature in infant

Warming the room 80-85 degrees.

Heat production in infant is achieved by

Nonshivering thermogenesis - metabolism of brown fat.

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)

Shunt Formula

QP/QS = Sat(aorta)- Sat (SVC) / Sat (pulm venous) - Sat PA




Want 1:1 ratio... ASD we would get 2:1

CHD 4 main problems

Chronic Hypoxemia


CHF


Arrhythmias


Pulmonary Disease

Chronic Hypoxemia blood and growth

Polycythemia - stroke, Abnormal hemostasis.




Growth 1/3 metabolism devoted to growth





CHF common with

VSD - increase pulmonary blood flow




Obstructive- AS

Ohm's Law

Q (blood flow) = P Pressure drop across vascular bed/ R Resistance in vascular bed

Poiseuille law

small radius higher resistance less blood flow



ASD Key facts

>8mm likely require intervention


Left to Right shunt


Ostium Secudum - most common.


Curable lesion

Atrioventricular Canal Defects

Need early surgical intervention - Shunting mass amount. CHF quickly. Total mixing

VSD

Most common shunt. Left to Right.


Left Atrium hypertrophy not RV

Tetralogy of Fallot

Pulm Stenosis, VSD, Overriding Aorta, RVH


Right to Left Shunt


Needs preload

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,

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

Transposition of Great Arteries

Right Ventricle connected to Aorta


Left Ventricle connected to Pulmonary Artery




Incompatible with life unless you have an ASD/PDA*

Truncus Arteriosus

Septation between the aorta and pulmonary artery 4-5 weeks after conception


Need VSD*


Need to treat damage is irreversible

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.

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

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.

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.

Hypoplastic left heart syndrome tx

Transplant or 3 step process 1. at birth, 2. 3-4 months, 3. - 2 years of age.

Fontan Anesthetic considerations

CVP = Pulmonary Venous Pressure- dictates pulmonary blood flow. - AVOID hypoxemia, acidosis. - Prevent PVR increase.

Antibiotic prophylaxis

Give to Artificial valve, Tx, or hx endocarditis


Dental procedures, Resp procedures, Infected tissue.