1
Q
Definitions of neonate, infant, and child
A
Neonate: Birth to 30 days
Infant: 1 month to 1 year
Child: 1 - 12 years
2
Q
Kids develop similar physiology to an adult by age
A
8 years
3
Q
Premature is considered
A
< 37 weeks
4
Q
Fetal transition to neonatal physiology takes place during the first ___-___ hours
A
24-72
5
Q
Ductus arteriosus closure
A
Anatomic closure: 2-6 weeks
High O2 can help it close
6
Q
Foramen ovale closure
A
Functionally: rapid closure
Anatomically: 3 months
(until three months deosygenation can cause a reversion back to fetal circualtion worsening the issue)
7
Q
CV differences in kids
A
- Noncompliant LV
- limited ability to handle increase in fluid volume
- Unable to increase SV
- Heart rate dependent
- only able to increase CO by increasing HR
- (this means that BP depends on HR as well)
- Limited catecholamine stores
- May give atropine prophylactically - Effect of ephedrine?
- Fetal circulation considerations
- Cold, hypoxia, and hypercarbia can re-open these shunts
- Higher metabolic O2 demand than adults
- because they are growing so rapidly!
8
Q
Pulmonary differences in kids
A
- Increased O2 consumption (5-9 ml/kg/min)
- TV and dead space same as adults
- dependent on rate for adequate MV for needed O2 demand
- Resp rate is 2-3x that of adults
- Increased chest wall compliance
- Decreased lung compliance**
- SMALL DIAMETER AIRWAYS = increased resistance to flow
- Hypoxia and hypercapnea will depress ventilation
- makes a prommble worse!!!!
- Decreased Type 1 muscle fibers in diaphram
- kid poops out quickly from high RR and poor lung compliance
- Fewer alveoli Smaller FRC****
9
Q
Unique airway differences in kids
A
- Narrow nasal passages (lean towards using oral airway)
- Obligate nasal breathing*****
- (until about 6 months, until then, make sure their nose is clear so they can breath!!!)
- Cricoid cartilage is narrowest portion of airway***
- Short neck, large head, large tongue
- Larynx is more cephalad (C4) and is funnel shaped
- Epiglottis is narrow and stubby
- VC attachment is angled anterior and caudad
- Smaller margin of error for R mainstem intubation
10
Q
How should infants be positioned for intubation?
A
Slighly neutral and flexed
- Towel roll under shoulders b/c their heads are fucking huge.
- This should align things properly
- Also, neck should be neutral or slightly flexed.
- Extreme flexion or extension will kink airway***
11
Q
Just 1mm of airway edema can decrease cross-sectional area by ___%
A
75%
12
Q
Fluid/Electrolyte differences in kids
A
- Higher total body water ECF = 40% of TBW in neonates and 20% of TBW in those over 2 years
- More ECF = more prone to dehydration
13
Q
Kidney function reaches normal by __ months
A
6 months
Until this time, every week counts for kidney development!!
Peaks at 2 years
14
Q
Hemoglobin levels in kids
A
- Hgb pre-term = 13-15 g/dL
- Hgb at birth = 18-20 g/dL
- Most is fetal Hgb = shift to the left! helps extract O2 from mom.
- Low Hgb levels bad in newborn d/t shift to the left.
- Hgb at 2 months = 10-12 g/dL
- Lower threshold for transfusion
- Hgb at 6-24 months = 12 g/dL
- Hgb at 2-6 years = 12.5 g/dL
- Hgb at 6-12 years = 13.5 g/dL
- In newborn blood loss >10-15% may not be tolerated Fetal Hgb
- Most kids though end up doing ok with low hgb.
- Always check with surgeon before giving blood to a kid.
15
Q
Hepatic and GI differences in kids
A
- Low hepatic blood flow in first months of life
- CYP450 maturity has huge variability
- Type 1 reactions mature faster than Type 2 (conjugation) = avoid drugs that undergo type 2
- Low glycogen stores (worry about hypoglycemia!)
- glucose in MAINTINENCE fluids
- Impaired conjugation = jaundice
- Poor coordination with breathing and swallowing until 4-5 months (reflux is common!)
- Low plasma albumin levels
16
Q
Kids can’t shiver until __ months
A
3 months
Until then, they rely on brown fat metabolism
Keeping kids warm is a huge priority**
17
Q
Thermoregulation
A
- Brown fat metabolism = high O2 consumption
- Thin skin
- Low fat content
- Large surface area
- Interventions: Warmed mattress, blankets, warm room, cover the head, humidify inspired gases, bair hugger
18
Q
General rules about kids and E1/2t of drugs
A
Infants: Prolonged E1/2t
Children 2-12: Shortened E1/2t
Reaching adulthood: Normal E1/2t
19
Q
Highes to lowest MAC requirements
A
- Infant (highest→but have a lower therepeutic index)
- Neonate Child Adult (lowest)
- Preemies tolerate IAs poorly.
- Use minimally or not at all.
20
Q
When is it appropriate to give sux to a kid?
A
- RSI and laryngospasm
- Must give with atropine!
- Avoid second dose if possible
- higher risk of bradycardia and arrest with second dose
- Roc can be risky b/c it has a longer DOA if you have difficulty securing the airway
- peds have lower FRC and higher O2 demand –> desat quickly)
21
Q
NDMR dosing is kids
A
- Kids have a higher Vd, but also immature NMJ.
- This results in NDMR dosing similar to adults.
- Neostigmine dosing is slightly lower though
- (0.02-0.05mg/kg)
- NMJ matures around 2 months.
22
Q
Why is adequate reversal critical in kids?
A
- Lower FRC and higher O2 demand
- need proper lung functioning
- Increased lung compliance
- MV dependent on RR
23
Q
How to determine if tube is the correct size in a kid
A
Check leak pressure If leak occurs at
24
Q
Reservoir bag size for peds
A
1-2L
25
MONITOR YOU MUST HAVE FOR PEDIATRIC CASES
* Precordial Stethoscope!!!
* Very sensitive to bronchospasm.
* Some places will send you home if you forget it at clinicals.
26
Pediatric ETT insertion depth
* 2cm below cords
* Often there will be black mark 2cm proximal to ETT tip. Place black mark at the cords for correct placement.
27
If cuffed ETT is used, cuff pressure should be kept below \_\_\_\_\_mmHg
25mmHg
28
Laryngoscope blade sizes
**Miller is more popular in peds because of their anatomy!**
* Miller 0 = neonates - 2 years
* Miller 1 = 2 - 6 years
* Miller 2 = \> 6 years
* Mac 1 = 2 - 6 years
* Mac 2 = \>6 years
29
Formula for ETT insertion distance **beyond 2 years**
**(Age/2) + 12**
30
Formula for **ETT** size **above 2 years**
**(Age + 16) / 4**
**or roughly tube size x 3**
31
LMA sizing
* **1** = up to 5 kg → cuff 4-6cc
* **1.5** = 5-10 kg → cuff 7-10 cc
* **2** = 10-20 kg → cuff 10-15 cc
* **2.5** =20-30 kg → cuff 14-20cc
* **3** = 30-50 kg → cuff 20-30cc
* **4** = 50-70kg → cuff 30-45 cc
32
Pro-tips for pediatric airway management
* Pillow under shoulders / occiput for neutral alignment
* Keep fingers off soft tissue during mask ventilation!!
* For all equipment, have one size larger and smaller than anticipated available
* Oral airways preferred to nasal
* (they have smaller nasal passages)
33
Air leak should be present after intubation
between \_\_-\_\_mmHg of pressure
20-30 mmHg
34
EBV for kids
* Preemie → (**90-100** mL/kg)
* Neonate → (**80-90** mL/kg)
* Infant → (**75-80** mL/kg)
* Child \> 6 → (**70** mL/kg)
35
Hct in young kids
* Hct of **55%** in neonates (but mostly HgbF)
* Falls to **30%** as it switches to HgbA.
* Settles to **35%** by about 6 months.
36
Formula for volume of PRBCs to transfuse
EBV x desired Hct x (current Hct / Hct of PRBCs)
37
Formula for dosing of platelets
0.1-0.3 units/kg
38
Fluids to use in kids
D5W for maintenance
(b/c risk of hypoglycemia)
NS for replacement of deficits and losses
39
Delivering fluid in kids
* 2 years → use 500cc bag with microdrip
* Kids are easily fluid overloaded.
* Have med port as close to the pt as possible
* Small air bubbles can be huge deal (
* as little as **0.1** cc can occlude an extremity)
40
URI in kids can result in increased airway irritability for up to ___ weeks
6 weeks
41
Kids and premedication
* 9 months = probs need it
* Role of parents is huge.
* They can come to the OR for induction.
42
Pediatric Induction Sequence
* Place monitors
* Mask with **70% N2O** and **30%** O2
* Add sevo (overpressure) until LOC occurs
* Have assistance start an **IV**
* Turn off N2O and give 100% O2 with sevo
* (pre-oxygenation).
* They should be breathing on their own.
* Once pre-oxygenation is done and IV is placed, give MNB.
* Once paralyzed, turn off agent and intubate.
* Start maintenance.
43
What is the true MAC of the patient?
* Expired agent concentration.
* NOT what you set the vaporizer to.
44
Post-op delirium is common with these agents
* Sevoflurane and desflurane.
* Ketamine
* Kids post-op will scream, be confused, and look like theyr'e in pain, but they will snap out of it.
* Sometimes versed pre-op can help with this.
* Can look concerning, but it's just something that happens in kids.
* Let parents know this.
45
Laryngospasm is more/less common in kids than adults. Also tx.
* More common.
* Anticipate that kids will have a laryngospasm.
* Treat with PPV and **0.5-1** mg/kg sux
46
Treatment of post-intubation croup
| (inflammation around the vocal cords)
* Decadron **0.25-0.5** mg/kg
* Racemic epinephrine
47
Caudal block
* Epidural block for kids 7.
* Short beveled needle 2-3cm into sacral canal.
* Dosing: High sacral block: **0.5** mL/kg
* High lumbar block: **1** mL/kg
* Mid thoracic block: **1.25** mL/kg
* Max volume of **20** mL\*\*\*
48
Considerations for preemies:
* Preemie = **\> 37** weeks
* Lack of surfactant can lead to IRDS
* Increased WOB
* Risk for post-op apnea and bradycardia
* Minimal glycogen stores → (hypoglycemia and acidosis risk)
* Unable to handle large loads of protein → (would fluid overload the kid who has non-compliant heart)
* Renal function
* Decreased GFR
* Impaired sodium retention
* Impaired glucose excretion
* Impaired bicarb reabsorption
* Difficult to dilute
* Do frequent electrolyte checks and be careful with fluid administration
* Higher total body water % → (think about H2O soluble drugs)
* Less body fat (less drug distributed into fat)
* Prolonged E1/2t → (immature liver and kidneys)
* Lower anesthetic requirement
* immature BBB and more sensitive to opioids
* Risk for reverting to fetal circulation\*\*\*\*\*\*
* Because the shunts were meant to be open at that age.
49
Considerations for trisomy 21
* Airway:
* Short neck
* Irregular dentition
* A-O instability (do radiographic eval)
* Large protruding tongue (difficult to ventilate)
* Subglottic stenosis (very narrow cricoid)
* Many have congenital cardiac abnormalities
