Neonatal Problems at Increased Incidence in a Preterm (<37 weeks) small for gestational age (SGA)
Respiratory distress syndrome
Apnea
Perinatal depression
Hypoglycemia
Polycythemia
Hypocalcemia
Hypomagnesemia
Hyperbilirubinemia
Viral infection
Thrombocytopenia
Congenital anomalies
Maternal drug addiction
Fetal alcohol syndrome
Neonatal Problems at Increased Incidence in a Preterm (<37 weeks) appropriate for gestational age (AGA)
Respiratory distress syndrome
Apnea
Hypoglycemia
Hypocalcemia
Hypomagnesemia
Hyperbilirubinemia
Neonatal Problems at Increased Incidence in a Preterm (<37 weeks) large for gestational age (LGA)
Respiratory distress syndrome
Hypoglycemia; infant of diabetic mother
Apnea
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Neonatal Problems at Increased Incidence in a Postmature (>42 weeks) small for gestational age (SGA)
Meconium aspiration syndrome
Congenital anomalies
Viral infection
Thrombocytopenia
Maternal drug addiction
Perinatal depression
Aspiration pneumonia
Hypoglycemia
Neonatal Problems at Increased Incidence in a Postmature (>42 weeks) large for gestational age (LGA)
Birth trauma
Hyperbilirubinemia
Hypoglycemia; infant of diabetic mother
The germinal stage starts with … and ends approximately … later with the … . One key feature of this period is the formation of the …
conception
two weeks
implantation of the embryo into the uterine wall
placenta
The embryonic stage comprises the period between the … weeks of pregnancy and is characterized by rapid cell proliferation, migration, and differentiation leading to the establishment of …
third and eighth
all major organs
The fetal stage lasts from … to … and is characterized by …
the 9th week of pregnancy
birth
the growth and functional differentiation of organs
Prematurity is stratified into …
mild preterm (32–37 weeks), very preterm (28–31 weeks), and extremely preterm (<28 weeks)
Normal birth weight at term ranges from …
Infants weighing less are classified as low birth weight (…), very low birth weight (…), and extremely low birth weight (…)
2500g to 4200g
<2500g
<1500g
<1000g
Describe the The Apgar Score
1) Appearance (skin color):
Cyanotic/pale all over: 0
Peripheral cyanosis only: 1
Pink: 2
2) Pulse (heart rate)
0: 0
<100: 1
>100: 2
3) Grimace (reflex irritability)
0: No response to stimulation
1: Grimace (facial movement)/weak cry when stimulated
2: Cry when stimulated
4) Activity (tone)
0: Floppy
1: Some flexion
2: Well flexed and resisting extension
5) Respiration
0: Apneic
1: Slow, regular breathing
2: Strong cry
… cause reversion to the fetal circulation and hemodynamic instability and progressive hypoxia
Hypoxia, hypercapnia, and changes in peripheral or pulmonary vascular resistance
Risk factors increasing persistent fetal circulation include …
prematurity, infection, acidosis, meconium aspiration, acidosis, hypothermia, and congenital heart disease.
In neonatal patients, myocardial calcium stores are … because of the …, leading to a greater dependence on … and probably increased susceptibility to myocardial depression by …
reduced
immaturity of the sarcoplasmic reticulum
exogenous (blood-ionized) calcium
volatile anesthetics that have calcium channel–blocking activity.
The lung bud rises from the … during the … and the gas-exchanging portions of the airway are formed during the … .
Alveolar ductal development starts at … while the septation of the air sacs begins around the … .
Alveoli then increase in number and size until the child is approximately … years old.
Further growth is exhibited as an increase in size of the alveoli and airways.
At term, complete development of surface-active proteins helps maintain patency of the airways. If a child is born prematurely and these proteins are insufficient, then respiratory failure (…) may follow.
foregut
first trimester
second trimester
24 weeks
36th gestational week
8 years old
respiratory distress syndrome
Respiration is less efficient in infants. The small diameter of the airways increases resistance to airflow. The neonatal and infant tracheobronchial tree and chest wall are … compliant, which can lead to airway … .
Thus, functional airway closure may accompany each breath. Dead space ventilation is proportionally like adults. However, oxygen consumption is … higher.
In preterm infants, the work of breathing is approximately … that in adults and can be significantly increased by cold stress (due to increased metabolic demand for oxygen) or any degree of airway obstruction.
Another important factor is the composition of the diaphragmatic and intercostal muscles. These muscles do not develop into … fibers until the child is approximately … . Because … fibers provide the ability to sustain repeated contractions, any factor that increases the work of breathing contributes to early fatigue of the respiratory muscles. This partially accounts for the infant’s rapid respiratory rate and their propensity to develop fatigue and apnea with airway obstruction
highly
obstruction and atelectasis
two to three times
three times
mature type I muscle
2 years old
type I muscle
Particularities of the pediatric airway
In relation to the oropharynx, the relatively large size of the infant’s tongue increases the likelihood of upper airway obstruction and technical difficulties during laryngoscopy.
The larynx is located more cephalad in the neck and the epiglottis is relatively short, omega shaped, and angled over the laryngeal inlet.
Finally, the infant larynx is funnel shaped, with the narrowest portion occurring at different levels depending on whether static or dynamic measurements were made.
Classic teaching has been that the adult larynx is cylindrical, and the infant larynx is funnel shaped. However, it is now known that the narrowest portion in 30% of adults is also in the subglottic region at the level of the cricoid cartilage
T or F
F
Classic teaching has been that the adult larynx is cylindrical, and the infant larynx is funnel shaped. However, it is now known that the narrowest portion in 70% of adults is also in the subglottic region at the level of the cricoid cartilage
Neonates and infants are considered as obligate nasal breathers and complete nasal obstruction result in apnea.
T or F
F
Neonates and infants are considered as obligate nasal breathers but revert to oral breathing in response to complete nasal obstruction. The prevalence of spontaneous oral breathing has been reported to be as high as 50% during sleep, and oral breathing could be consistently initiated in response to nasal obstruction
Glomerular Filtration Rate (mL/min/1.73m2 mean) by age
1 day:
2–8 days:
10–22 days:
37–95 days:
1–2 years:
1 day: 24 (3–38)
2–8 days: 38 (17–60)
10–22 days: 50 (32–68)
37–95 days: 58 (30–86)
1–2 years: 115 (95–135)
Renal function is diminished in neonates and even more in preterm infants because of …
Nearly complete maturation of glomerular filtration and tubular function occurs by approximately … after birth, although delayed in preterm infants.
Complete maturation of renal function occurs at approximately … of age.
Thus, the ability to excrete free water and solute loads may be impaired in neonates, and the half-life of medications excreted by means of glomerular filtration will be prolonged (e.g., antibiotics that therefore require longer intervals between doses in neonates)
relatively low perfusion pressures and immature glomerular and tubular function
20 weeks
2 years
The cytochrome P450 system and phase I drug metabolism of lipophilic compounds is …% of adult values at birth. CYP… (cytochrome P450, family …, subfamily …) is generally present at adult values at birth, whereas other cytochromes are absent or reduced.
Phase II reactions, which conjugate drugs able to facilitate renal excretion, are often impaired in neonates and result in … and long drug (and their active metabolites) half-lives. Some of these reactions do not achieve adult activity until after … of age.
50
3A
3
A
jaundice (decreased bilirubin breakdown)
1 year
A preterm infant’s liver has minimal … stores and is unable to manage large … loads. This accounts for the neonate’s tendency toward … and for the failure to gain weight when the diet contains too much …
Additionally, plasma levels of albumin and other proteins necessary for the binding of drugs are … in full-term newborns (and are even … in preterm infants)
glycogen
protein
hypoglycemia and acidemia
protein
lower
lower
The ability to coordinate swallowing with respiration does not fully mature until infants are … of age, thus resulting in a high incidence of …, particularly in preterm newborns.
4 to 5 months
gastroesophageal reflux
-
Cerebral Physiology and the Effects of Anesthetic Drugs36
-
Neuromuscular Physiology and Pharmacology31
-
Respiratory Physiology and Pathophysiology27
-
Cardiac Physiology26
-
Gastrointestinal Physiology and Pathophysiology14
-
Hepathic Physiology, Pathophysiology and Anestetic Considerations39
-
Renal Anatomy, Physiology, Pharmacology, and Evaluation of Function31
-
Basic Principles of Pharmacology34
-
Inhaled Anesthetics80
-
Preoperative Evaluation133
-
Airway Management in the Adult36
-
Patient Positioning and Associated Risks24
-
Inhaled Anesthetics: Delivery Systems45
-
Intravenous Anesthetics109
-
Opioids76
-
Pharmacology of Neuromuscular Blocking Drugs61
-
Local Anesthetics44
-
Spinal, Epidural and Caudal Anesthesia109
-
The Postanesthesia Care Unit47
-
Acute Postoperative Pain8
-
Cardiovascular Monitoring93
-
Neurophysiologic Monitoring52
-
Anesthesia for Vascular Surgery98
-
Anesthesia for Obstetrics114
-
Respiratory Monitoring73
-
Intravenous Drug Delivery Systems18
-
Peripheral Nerve Blocks and Ultrasound Guidance for Regional Anesthesia96
-
Perioperative Fluid and Electrolyte Therapy154
-
Perioperative Acid–Base Balance88
-
Patient Blood Management: Transfusion Therapy94
-
Patient Blood Management: Coagulation118
-
Pediatric Anesthesia38
-
Anesthesia and the Renal and Genitourinary Systems78
-
Anesthesia for Orthopedic Surgery52
-
Anesthesia for Bariatric Surgery41
-
Anesthesia for Abdominal Organ Transplantation42
-
Anesthesia for Robotic Surgery14
-
Anesthesia for Otolaryngologic and Head–Neck Surgery18
-
Anesthesia for Ophthalmic Surgery94
