1
Q
What guides the selection of pediatric anesthesia airway equipment?
A
- Child’s age
- Weight
- Medical history
- Proposed surgical procedure.
2
Q
What are examples of essential pediatric airway equipment?
A
- Various sizes of anesthesia masks
- Oral and nasal airways
- LMAs
- laryngoscope blades
- ETTs, and ETT stylets
3
Q
How is the trachea most easily exposed in older children (≥6 years) for tracheal intubation?
A
- By placing a folded blanket or pillow beneath the occiput of the head (5 to 10 cm elevation)
- Displacing the cervical spine anteriorly.
4
Q
What position is typically used to achieve the optimal airway alignment in older children during tracheal intubation?
A
- The classic “sniffing” position
- Achieved by extending the head at the atlantooccipital joint.
5
Q
How is the head positioned for tracheal intubation in infants and younger children?
A
- Head extension at the atlantooccipital joint alone, without elevating the head
- As the large occiput proportionally displaces the cervical spine anteriorly.
6
Q
What technique is recommended to facilitate tracheal intubation in neonates?
A
- Holding the patient’s shoulders flat on the operating room table with the head slightly extended
- Or placing a rolled towel under the shoulders to facilitate intubation.
7
Q
When might placing a rolled towel under the shoulders of neonates be disadvantageous?
A
- When intubating standing up
- Advantageous if seated.
8
Q
What formulas can be used to estimate the internal diameter of an endotracheal tube?
A
- (16 + age in years)/4
- (Age in years/4) + 4
9
Q
What formulas can be used to estimate the length required for an orotracheal tube?
A
- Height (in cm)/10 + 5
- Weight (in kg)/5 + 12
10
Q
How far should the endotracheal tube be advanced from the alveolar ridge during intubation?
A
3 times the internal diameter
11
Q
What is the formula to calculate the distance to advance the endotracheal tube based on age?
A
(Age in years/2) + 12
12
Q
What are two common airway complications in pediatric patients?
A
Laryngospasm and bronchospasm.
13
Q
What is the function of the larynx in protecting the lungs?
A
- Protects the lungs from aspiration of foreign material
- Facilitated by the glottic closure reflex.
14
Q
What triggers laryngospasm?
A
Noxious stimuli of the superior laryngeal nerve.
15
Q
What are potential complications of laryngospasm?
A
- Complete airway obstruction
- Gastric aspiration
- Postobstruction pulmonary edema
- Cardiac arrest
- Death
16
Q
What is bronchospasm?
A
Increased airway resistance caused by smooth muscle contraction.
17
Q
How does bronchospasm typically resolve?
A
Spontaneously or with pharmacologic intervention.
18
Q
What physical sign may manifest with bronchospasm?
A
Audible wheeze.
19
Q
How might bronchospasm be detected on the ETCO2 waveform?
A
- Prominent slope on the expiratory portion
- Indicative of prolonged expiration.
20
Q
What are physical signs associated with bronchospasm?
A
- Hypoxemia
- Hypercarbia
- Wheezing
- Increased peak airway pressures
- Difficulty ventilating
- Chest retraction
- Altered ETCO2 waveform
21
Q
What is the initial intervention when ventilation is compromised due to bronchospasm?
A
Administering 100% oxygen.
22
Q
What may be heard upon auscultation of the lungs in a patient experiencing bronchospasm?
A
Wheezing.
23
Q
What action should be taken if bronchospasm is severe?
A
Inform the surgeon to stop the surgery.
24
Q
How can the anesthetic depth be managed in bronchospasm?
A
- Assess and deepen anesthesia as needed
- Manually ventilate the patient
- Administer a bronchodilator like albuterol via ETT
25
What is the recommended treatment for life-threatening bronchospasm emergencies?
* Dilute a 1-mg vial of epinephrine in a 10-mL syringe
* Give 1 to 2 mL (100–200 mcg) IV push in increments
* Max dose: 0.5 mg of 1: 1000 solution
* Corticosteroids may also be given
26
Are corticosteroids immediately effective in acute airway emergencies?
No, they are not immediately effective due to their prolonged onset of action.
27
What should be avoided if there are indications of a potentially difficult airway?
Neuromuscular blocking agents.
28
What equipment should be prepared for managing a difficult airway?
* Variety of laryngoscope blades
* ETTs
* Oropharyngeal airways
29
What are the different induction options to plan for in a difficult airway scenario?
* Awake fiberoptic
* Sedation with anesthetizing spray
* Inhalation induction
30
What should be administered after achieving a deep plane of anesthesia?
100% oxygen.
31
How can oral secretions be decreased in a difficult airway situation?
Atropine or glycopyrrolate.
32
How should respirations be maintained in a difficult airway scenario?
Always maintain spontaneous respirations.
33
What technique can facilitate glottis visualization during intubation?
External manipulation of the trachea.
34
What adjunct airway equipment should be used or available for difficult airway management?
* Videolaryngoscopy
* Fast-track LMA
* Blind nasal intubation
* Light wand
* Cricothyrotomy.
35
What approach should be followed in managing a difficult airway?
Follow the standardized difficult airway algorithm.
36
What is the approach to the end of surgery in pediatric patients, similar to adults?
Return of spontaneous breathing and weaning of anesthetic agents.
37
Why is it important to have airway equipment readily available after extubation?
In case of the need to reestablish a patent airway.
38
When do critical airway events tend to occur more often in pediatric patients?
During emergence and extubation rather than induction and intubation.
39
What factors influence the decision between deep versus awake extubation in pediatric patients?
Patient’s medical history and type of surgical procedure.
40
When is awake extubation recommended in pediatric patients?
In children with a history of difficult airway and full stomach.
41
When is deep extubation preferred in pediatric patients?
In children with reactive airway and when postsurgical coughing and bucking should be avoided.
42
How do pediatric intravascular and extracellular fluid compartments compare to adults'?
They are relatively larger in pediatric patients.
43
Why are hepatic biotransformation pathways immature in neonates and young infants?
Due to developmental immaturity.
44
What effect does immature hepatic function have on drug metabolism in pediatric patients?
It may result in altered drug metabolism and clearance.
45
How does protein binding typically differ in pediatric patients compared to adults?
Protein binding is decreased in pediatric patients.
46
How does metabolic rate in infants compare to adults?
Metabolic rate is higher in infants.
47
What accounts for the higher total body water in infants compared to adults?
* Higher fat content and smaller muscle mass
* Leading to proportionately higher total body water.
48
Why might pediatric patients require increased loading doses of water-soluble drugs?
* Due to their larger extracellular fluid compartment
* Higher total body water
49
Why are increased doses of ketamine required in pediatric patients?
Because of their greater volume of distribution and higher metabolic rate.
50
How do dose requirements for propofol differ between infants and children?
* Infants require higher doses (2.5-3.0 mg/kg)
* Compared to children (2.0-2.5 mg/kg).
51
What contributes to faster emergence from propofol anesthesia in children?
Shorter elimination half-lives and higher plasma clearance.
52
What is propofol infusion syndrome (PIS) and when does it occur?
* It occurs when propofol is given at doses > 4mg/kg per hr.
* for > 48 hrs, inhibiting mitochondrial function and uncoupling oxidative phosphorylation.
53
What are the symptoms and complications of propofol infusion syndrome (PIS)?
* Severe lactic acidosis
* Hypertriglyceridemia
* Fever
* Hepatomegaly
* Dysrhythmias
* Rhabdomyolysis
* Heart failure
54
Why do infants and children require increased amounts of inhalation agents compared to adults?
Due to their increased basal metabolic rate.
55
Why is inhalation induction more rapid in pediatric patients?
* Due to their higher minute ventilation
* Lower functional residual capacity
* Higher blood flow to vessel-rich organs
56
When are MAC requirements highest for inhalation agents in pediatric patients?
At six months, except for sevoflurane, which are highest at birth and decrease with age.
57
What is emergence delirium, and how does it manifest in pediatric patients?
* Altered behavior postoperatively
* Restlessness
* Crying
* Moaning
* Incoherence
* Disorientation
58
What is the incidence range of emergence delirium in pediatric patients?
10% to 80%.
59
Which medications have a prophylactic effect in preventing and treating emergence delirium in pediatric patients?
* Propofol
* Fentanyl
* Dexmedetomidine
* Preoperative analgesia
60
Why do muscle relaxants generally have shorter onset times in pediatric patients compared to adults?
Due to their shorter circulation times.
61
Why do infants require higher doses of succinylcholine compared to adults?
Because of their larger volume of distribution.
62
How do neonates and young infants' sensitivity to nondepolarizing relaxants compare to their volume of distribution?
* They are more sensitive due to immature neuromuscular junctions
* But this effect tends to cancel out because of their large volume of distribution.
63
What tends to be the duration of nondepolarizing relaxants in pediatric patients compared to adults?
Slightly longer.
64
Where should neuromuscular function be assessed after providing neuromuscular blockade?
At the adductor pollicis muscle in the forearm.
65
Why is residual neuromuscular blockade concerning in infants and children?
It places them at risk of hypoventilation and the inability to maintain a patent airway.
66
How is residual neuromuscular blockade detected in pediatric patients?
Integration of clinical criteria and assessment via a peripheral nerve stimulator.
67
What are conventional doses of anticholinesterase inhibitors for antagonizing nondepolarizing neuromuscular blockade?
* Neostigmine (50-60 mcg/kg)
* Edrophonium (500-1000 mcg/kg)
With appropriate doses of:
* Atropine (0.02 mg/kg)
* Glycopyrrolate (0.2 mg for each 1 mg of neostigmine).
68
Why might anesthesia providers administer an anticholinergic drug prior to an anticholinesterase drug?
To prevent bradycardia, a consequence of administering an anticholinesterase drug.
69
Is sugammadex FDA approved for use in pediatric patients?
* No, it is not FDA approved for patients younger than 18 years old
* But research suggests it is well tolerated in pediatric patients.
70
What are the three enzymatic reactions involved in Phase I drug metabolism?
1. Oxidation
2. Reduction
3. Hydrolysis catalyzed by the cytochrome P-450 (CYP450) enzyme system.
71
Which enzyme systems are capable of hydrolyzing various pharmacologic agents?
* Enzyme systems within red blood cells
* Plasma
* Other extrahepatic tissues.
72
What types of reactions do Phase I metabolism reactions introduce?
They introduce polar hydroxyl, amino, sulfhydryl, or carboxyl groups.
73
What is the main function of Phase II drug metabolism reactions?
* Conjugation or synthesis
* Which facilitate excretion
74
Why do newborns lack efficient bilirubin conjugation capacity?
Due to decreased glucuronyl transferase activity.
75
Why is the rate of absorption of orally administered drugs slower in pediatric patients?
* Due to delayed gastric emptying time
* Which reaches adult range by 6 months of age
76
How does rectal drug absorption differ based on the location of administration?
Medications applied in the upper third of the rectum undergo first-pass metabolism due to drainage into the portal system.
77
What are the recommended IV acetaminophen dosages for pediatric patients?
* For patients 2 years or older weighing <50 kg: 15 mg/kg every 6 hours or 12.5 mg/kg every 4 hours. Do not exceed 75mg/kg per day
* For patients 13 years and older weighing >50 kg: 1000 mg every 6 hours or 650 mg every 4 hours.
* Daily max dose of APAP 4000mg/day
## Footnote
High doses of acetaminophen may deplete glutathione, increasing the accumulation of Nacetyl-pbenzoquinone
imine, which is thought to be responsible for acetaminophen-induced liver necrosis.
78
What is the maximum daily dose of acetaminophen (APAP)?
4000 mg.
79
What risk is associated with high doses of acetaminophen?
* High doses may deplete glutathione, leading to the accumulation of N-acetyl-p-benzoquinone
* Which can cause acetaminophen-induced liver necrosis.
80
Where is preoperative assessment typically completed?
In the preoperative anesthesia clinic or in the patient’s hospital room.
81
Why should acutely ill patients be assessed in the preoperative area?
To optimize chronic diseases and create an individualized anesthetic plan.
82
How can reviewing the medical record aid in preoperative assessment?
It can answer many questions before approaching the patient/parents for information.
83
Why is understanding congenital history important in preoperative preparation?
It aids in developing a tailored plan of care.
84
What information can previous anesthetic records provide?
Insights into previous anesthetic experiences and implications.
85
What is the key factor in preventing post-intubation laryngeal edema?
Maintaining an air leak < 25 cm H2O.
86
When using a cuffed endotracheal tube, how should cuff pressure be monitored?
Intermittently using a manometer.
87
What are the risk factors for post-intubation laryngeal edema?
* Using an ETT that is too large
* Age < 4
* High cuff pressure
* Trauma from intubation attempts
* Prolonged intubation
88
What are the common treatments for post-intubation laryngeal edema?
* Cool and humidified oxygen
* Dexamethasone
* Racemic epinephrine (dose based on patient's weight)
89
Why are children with an active or recent upper respiratory tract infection at increased risk of pulmonary complications?
Due to potential airway irritation and inflammation.
90
How long should a procedure be postponed after the onset of symptoms in a child with a URI?
2 - 4 weeks.
91
What are reasons to cancel a procedure in a child with a recent URI?
* Purulent nasal discharge
* Temperature > 38.0°C
* Lethargy
* Persistent cough
* Poor appetite
* Wheezing and rales that don't clear with a cough
92
How can the risk of post-intubation croup be reduced in a child with a recent URI?
Administering dexamethasone at 0.25 - 0.5 mg/kg.
93
Which volatile agent is preferred in a child with a recent URI?
Sevoflurane.
94
Is pretreatment with an inhaled bronchodilator or glycopyrrolate recommended for children with a recent URI?
No, it does not provide clear benefits.
95
What is the classic triad of symptoms seen in over 60% of children with foreign body aspiration?
* Cough
* Wheezing
* Decreased breath sounds on the affected side (usually the right).
96
What respiratory sound is associated with supraglottic obstruction?
Stridor.
97
What respiratory sound is associated with subglottic obstruction?
Wheezing.
98
What is considered the "gold standard" procedure for retrieving a foreign body from the airway?
Rigid bronchoscopy.
99
What is the recommended induction method for anesthesia in cases of foreign body aspiration?
Sevoflurane induction with spontaneous ventilation.
100
Why is positive pressure ventilation avoided during anesthesia for foreign body aspiration?
* It can push the foreign body deeper into the bronchial tree
* Or cause it to move distally if the patient coughs or bucks.
101
Which maintenance technique is considered optimal for anesthesia during foreign body retrieval?
Total intravenous anesthesia (TIVA).
102
What are some airway-specific risks associated with cleft lip and palate?
* Airway obstruction
* Difficult laryngoscopy
* Difficult mask ventilation
* Aspiration
103
How can the Dingman-Dott mouth retractor increase the risk of post-extubation airway obstruction?
It can reduce venous drainage and cause tongue engorgement.
104
What is a common issue related to feeding in infants with cleft lip and palate?
Failure to thrive due to inability to generate negative pressure required for sucking.
105
At what age is cleft lip repair typically performed?
Around 1 month of age.
106
At what age is cleft palate repair typically performed?
Around 12 months of age.
107
What is the most common chromosomal disorder associated with trisomy 21?
Down syndrome.
108
Why are patients with Down syndrome at an increased risk for difficult ventilation and intubation?
* Due to anatomical features
* Small mouth
* Large tongue
* Narrow palate with high arch
* Midface hypoplasia
109
What are some other concerns associated with Down syndrome?
* Co-existing congenital heart disease
* Low muscle tone
* GERD
* Obstructive sleep apnea
* Intellectual disability
110
What specific anatomical abnormality puts patients with Down syndrome at risk for atlantoaxial instability?
Abnormal development of the atlantoaxial joint.
111
What is a potential complication related to subglottic stenosis in Down syndrome?
Increased risk of airway obstruction.
112
What does the VACTERL association consist of?
* Vertebral defects
* Imperforated anus
* Cardiac anomalies
* Tracheoesophageal fistula
* Esophageal atresia
* Renal dysplasia
* Limb anomalies.
113
What are the components of the CHARGE association?
* Coloboma
* Heart defects
* Choanal atresia
* Restriction of growth and development
* Genitourinary problems
* Ear anomalies
114
What are the features of CATCH 22 syndrome (DiGeorge syndrome)?
* Cardiac defects
* Abnormal face
* Thymic hypoplasia
* Cleft palate
* Hypocalcemia
* 22q11.2 gene deletion (the cause of the syndrome)
115
What are the indications for tonsillectomy and adenoidectomy in children?
* Nocturnal upper airway obstruction
* Chronic and/or recurrent infections
116
What is the most common cause of obstructive sleep apnea (OSA) in children?
Adenotonsillar hypertrophy.
117
What is the most common coagulation disorder in patients undergoing adenotonsillectomy?
Von Willebrand disease.
118
How does dexamethasone benefit patients undergoing adenotonsillectomy?
* It may reduce postoperative airway swelling
* Reduces Pain
* Reduces Postoperative nausea and vomiting (PONV)
119
What precautions should be taken to prevent airway fire during adenotonsillectomy?
* Maintain a low FiO2 (≤ 40%)
* Avoid nitrous oxide (N2O), as it supports combustion.
120
Why should children with OSA undergoing adenotonsillectomy be admitted to the hospital for monitoring?
They should be monitored for airway obstruction for 23 hours postoperatively.
121
What should be done in the event of post-tonsillectomy bleeding?
* It is a surgical emergency requiring volume resuscitation
* Rapid sequence intubation to prevent aspiration.
122
What is crucial to monitor in the postoperative care of pediatric patients, particularly in the PACU?
Oxygenation.
123
What are some factors that may contribute to postoperative hypoxia in pediatric patients?
* Postextubation croup
* Laryngospasm
* airway obstruction
* Obstructive sleep apnea
* Apnea of prematurity
124
How can airway obstruction in pediatric patients be managed in the postoperative period?
Repositioning the patient's head and ensuring adequate oral suctioning.
125
Fluid management Tables
126
Fluid management Formulas
127
Medical Hx Review Table
128
Preop Lab Table
129
Preanesthetic Drugs: Midazolam
130
Epiglottitis vs Croup
131
Epiglottitis vs Croup Patho
132
Conditions associated with difficult airway
