1
Q
Premature.
A
<37w of gestational
2
Q
Neonate
A
first 28 days of extrauterine life (0-1m)
3
Q
Infant
A
29 days - 1 year
4
Q
Todler
A
2-3 years
5
Q
Preschool
A
3-6 years
6
Q
school age
A
6-12
7
Q
adolescent/teen
A
12-20
8
Q
child has hx of squatting
A
TOF = Cyanosis = R to L shunt
9
Q
Hypertension in child
A
coarctation of aorta
10
Q
heart murmur in child
A
septal defect, avoid air bubbles in IV
11
Q
child has hx of rheumatic fever
A
valvular heart disease
12
Q
child with hx of neuromuscular disease
A
MH, or Muscular dystrophy
13
Q
full term neonate is
A
> 37weeks (between 37-42 weeks of gestation)
14
Q
what is low birth weight? very low, extremely low?
A
LBW: <2500g
VBW: <1500g
ELBW: <1000g
15
Q
A child with URIs, when to postpone?
A
if children has a cough or pharyngitis with fever and wheezing.
- fever of 38C or higher
- Delay 4-6 weeks if severe, 2-4w if minor
- Highest risk for URIs is within first 2 weeks of symptoms.
16
Q
NPO for breast milk guideline?
A
4 hours fast
17
Q
Infant formulas guidline fasting
A
6 hours
18
Q
PEDS Alveolar ventilation to FRC RATIO compared to adults?
A
- Children desaturate faster because their small FRC provides little oxygen reserve, and their high alveolar ventilation quickly uses up or washes out that reserve (VA:FRC = 5:1). In adults, a larger FRC (VA:FRC = 1.5:1) provides a greater buffer, delaying desaturation.
19
Q
RESP of peds compared to adult
A
- greater oxygen consumed
- increased lung compliance of rib cage (floppy chest wall, lack support)
- reduced compliance of lungs (lack of elastin)
- Less type 1 muscle fibers (slow twitch, high endurance) in diaphragm > prone to atelactasis.
20
Q
First choice tx for apnea of prematurity?
A
Caffeine (prophylactic, 10mgkg/IV)
21
Q
Neuro Oxygen consumption in peds compared to adults
A
CMRO2 5.5 mL/100g/min
compared to
3.5 mL/100g/min in adults
21
Q
sign of hypovolemia in peds
A
hypotension with normal or increased HR
22
Q
Cerebral Blood Flow in peds vs adults
A
peds: 70-110 mL/min/100g
adults: 45-60 mL /100g/ min
23
Q
Is sniffing position a good idea during induction for kids?
A
No avoid sniffing position > sniffing place glottic opening more anterior. Also infant has a larger occiput
put shoulder roll under
24
Infant/peds breathing pattern naturally?
nose breather up to 5 months of age
25
Bilateral choanal atresia becomes emergent if
infant unable to mouth breathe
bilateral choanal atresia emergent surgery is required for child to breathe
26
Tongue size of peds
large tongue relative to oral volume
> easier to obstruct upper airway, harder to displace during laryngoscopy
26
Neck length in peds?
SHORTER than adults
27
Epiglottis compared to adult
Peds:
U or omega shape, stiffer and longer > more difficult to displace during laryngoscopy
Adults: leaf or c shape, floppier, shorter
28
laryngeal position in peds vs adults
peds: C3-C4 (this allow spontaneous ventilation while feeding).
- Larynx is more superior/cephalad but not anterior.
- Achieve adults position at 5-6 years old
Adults: C5-C6
29
Narrowest point of airway in peds vs adults
cricoid ring in peds
glottis (vocal cords) in adults
30
Vocal cords in peds vs adults
peds: concave
adults convex
31
what is poiseuille's, how is it related to peds airway?
Radius to the fourth power for laminar flow
> small changes in radius (funnel cricoid/subglottic airway shape in peds) > significantly increase resistance to airflow.
32
Subglottic airway shape in peds vs adult
peds: funnel
adults: cylinder
33
Resistance to ETT insertion beyond vocal cords in peds is because?
CRICOID RING
34
Right mainstem bronchus in peds vs adult
Peds: Less verticle (55 degree off the midline)
adults: more verticle (25 degree off the midline)
35
Why neonate cannot regulate temp?
Lack of subQ tissue
Large surface area to body weight ratio
Minimal ability to shiver
SNS enhances the metabolism of brown fat to increase heat production =non-shivering thermogenesis (NST)
36
Non shivering thermogensis causes what? and its consequences
NST causes heat production, but byproducts are acidic (acetone, acetoacetic acid, and beta-hydroxybutyric acid). These can cause
metabolic acidosis and then lead to bradycardia and cardiac arrest in neonates
37
What is brown fat?
Highly specialized tissue- dense with mitochondria
o Heat produced as a byproduct of fatty acid metabolism
o Comprises 2-6% of infants body mass
o Found in 6 locations
▪ Between scapulae
▪ Around blood vessels of the neck
▪ The axillae
▪ Mediastinum
▪ Around internal mammary vessels
▪ Around adrenal glands
38
What is conductive heat loss, how to minimize?
Conductive heat loss is DIRECT TRANSFER by contact (neonate to OR table)
> wrap in warm blanket
> Warmed irrigating solution
> Underbody warming (bair hugger)
> Wrap head with stockinet or cap
> preheat OR to 26 degree C (78.8F)
39
what is Radiant heat loss? how to minimize?
Emission of electromagnetic radiation
> radiant heat lamp (increase temp of air b/w neonate and lamps)
*It is INEFFECTIVE during surgical procedure
40
Why is neonate head should be covered?
decrease conductive heat loss because blood flow to neonate’s head is higher.
Neonate’s head may account for 60% of total heat loss during perioperative period
41
What is evaporation heat loss?
loss of heat by evaporation of water
Humidify inspired gases
Decreases insensible respiratory tract evaporative loss. This requires special
monitoring to avoid overheating patient
42
What is convection heat loss?
Moving air removes radiated heat.
43
Formulation to calculated CUFF ETT and depth insertion in peds of <2 years old
(AGE in years / 4) + 3
age/2 + 12
44
Formulation to calculated CUFF ETT and depth insertion in peds of >2 years old
(AGE in years / 4) + 3.5
Depth: age/2 +12
45
LMA size for neonate?
1
46
LMA size for 6m - 1 year
1.5
47
LMA size for 2-10 year old
2-2.5
48
depth at gums of ETT for term neonate?
9-10 cm (should not be >10cm)
49
depth at gum of ETT for pre term
7-8 cm
50
Induction dose of propofol?
2-3 mg/kg IV
51
Ketamine doses for peds IV and IM
IV 1-2 mg/kg
IM 4-6 mg/kg
52
Rocuronium dose in peds
0.6-1 mg/kg IV
RSI is 1.2 mg
53
Succinylcholine IV and IM dose peds
RSI 2 mg/kg
IM: 4mg/kg
54
Atropine dose IV , IM in peds
0.02 mg/kg IV, IM
55
epinephrine dose IV , IM in peds; how to dilute epi?
0.01 mg/kg IV IM;
- Take 1 mL (100mg) of a 1 mg vial and dilute into a 10 mL syringe
- This gives 100mcg/10 mL (10mcg/mL)
- These can be used as IV push for emergencies (such as bronchospasm) (dose: 10mcg/kg)
Max dose 0.5 mg
56
Glycopyrrolate IV dose
0.01 mg IV
57
gas of choice for peds?
Sevo
58
Vital sign
Age HR SBP DBP RR
Premature 110-170 55-75 35-45 40-70
0-3 months 110-170 65-85 45-55 35-55
3-6 months 110-160 70-90 50-65 30-45
6-12 months 90-160 80-100 55-65 22-38
1-3 years 80-150 90-105 55-70 22-30
3-6 years 70-120 95-110 60-75 20-24
6-12 years 60-110 100-120 60-75 16-22
> 12 years 60-100 110-135 65-85 12-20
59
what is different about SEVO MAC in peds?
MAC of sevoflurane is higher in neonates and infants → decreases after 6 months of age (3% -> 2.5%)
● Highest amount of sevoflurane required for neonates and goes down with age
▪ Other inhalation agents (Iso and Des): MAC increases with age from neonatal period to 6 months and then decreases with increasing age
* Neonates have a lower MAC, infants have the highest MAC (in other agents)
60
Why is MAC higher is peds than adult?
Peds has HIGHER minute ventilation > rapid inhalation uptake
61
Using isoflurane in children can cause
decrease HR, BP, MAP in infants due to adverse respiratory events compared to sevo
62
Using Des in children can cause
sympathetic stimulation (tachy and HTN)
63
how to calculate minute ventilation of peds?
MV = TV x RR
64
What is ped TV?
5-7 mL/kg
65
What is Mapleson A and how to calculate FGF
Mapleson A (best for spontaneous):
Spontaneous ventilation: FGF ≈ 1 × MV (often quoted as equal to MV)
Controlled ventilation: inefficient → FGF high (≈ 3× MV or more)
66
What is Mapleson D (Bain) and how to calculate FGF
Mapleson D / Bain (best for controlled ventilation):
Controlled ventilation: FGF ≈ 1–1.5 × MV (efficient)
Spontaneous: FGF ≈ 2–3 × MV
67
What is Mapleson E (Jackson Rees)
Mapleson E / Jackson-Rees
Spontaneous ventilation: FGF ≈ 2–3 × MV
E (T-piece)
68
Incomplete laryngospasm peds:
incomplete closure of the vocal cords → air can still move
Grunting or audible inspiratory and expiratory phonation heard on a precordial stethoscope then tracheal tug and thoracoabdominal
asynchrony
Stridor, suprasternal and supraclavicular retraction, paradoxical chest movements
69
Complete airway obstruction/laryngospasm
no inspiratory and expiratory sounds, and unable to deliver positive pressure ventilation
70
Treatment for incomplete airway obstruction
First: discontinue noxious stimuli (stop procedures or movements/suction)
Second: Increase anesthetic depth by inhalation or IV propofol
Third: gentle positive pressure ventilation w/ 100% oxygen with concurrent airway opening maneuvers (slight head extension, chin lift,
jaw thrust)
Continuous positive pressure of 15-20 cm H2O
If ineffective: call for help, repeat propofol dose and administer succinylcholine 1-2 mg/kg IV or 4-5 mg/kg IM
71
Treatment for complete airway obstruction
Arterial oxygenation saturation may decrease with accompanying bradycardia
o Administer succinylcholine
▪ IM: 4 mg/kg in the deltoid if no IV access
▪ Administer atropine if need be
o Apply firm and direct bilateral pressure toward the skull to displace anteriorly
72
Why masking can be difficult in peds?
large tongue and stick to palate
73
Metabolic rate and Oxygen Consumption in peds vs adults?
twice as much
74
Signs of upper airway obstruction in peds:
Thoracoabdominal asynchrony: contraction of the chest with abdominal expansion
* Can occur during induction as the soft tissues collapse and after ETT extubation
* May appear without traditional sounds of upper airway obstruction(snoring) like it would with an adult
75
Fetal circulation:
1. Placenta (Gas Exchange)
o Oxygenated blood comes from the placenta → into the umbilical vein .
2. Bypassing the Liver
o Most blood bypasses the liver via the ductus venosus (DV)
→ enters the IVC .
o IVC blood has PaO₂ ~26–28 mmHg.
3. Entering the Right Atrium (RA)
o Oxygenated blood from the IVC enters the RA.
o Guided by the eustachian valve toward the atrial septum.
4. Foramen Ovale (FO) Shunt
o Blood crosses the FO → left atrium → left ventricle → ascending aorta.
o This sends the highest oxygenated blood to the head, brain, and coronary arteries.
5. Blood Returning from Head/Upper Body
o Deoxygenated blood from the SVC (PaO₂ ~12–14 mmHg) enters the RA → RV → pulmonary artery.
6. Bypassing the Lungs
o Because lungs have high PVR, most blood shunts across the ductus arteriosus (DA) → descending aorta.
o Only 5–10% of cardiac output flows through the fetal
lungs.
7. Supplying the Lower Body
o Mixed, less oxygenated blood flows through the descending aorta → abdominal organs → lower extremities .
8. Return to Placenta
o Blood continues into the iliac arteries → umbilical arteries → placenta .
o Here it unloads CO₂ and picks up O₂/nutrients again.
76
Transitional changes during circulation changes. Explain the hemodynamic shift changes:
Placenta removed → aortic pressure rises (SVR)
* Umbilical vein clamped → no more placental blood supply
* Umbilical arteries clamped → systemic vascular resistance (SVR) doubles
* (first breathe) Lung expansion + ↑ PaO₂ → pulmonary vasodilation → pulmonary
vascular resistance (PVR) falls
77
What happens when Foramen Ovale closes?
↓ RA pressure + ↑ LA pressure → blood flow reverses across FO
==> causes FO to functionally closes
o Can reopen if RA > LA pressure (e.g., pulmonary HTN, CDH, neonatal distress)
o Permanent/anatomic closure: within 2–3 months (but up to 25% of adults have probe-patent FO)
* Bubble precautions: always important in neonates with IV fluids/meds (can
cause paradoxical air emboli - if bubbles gets to Left side of heart and travels to brain)
78
what happens when ductus arteriosus closes?
The closure is Driven by ↑ SVR + ↓ PVR
* Prostaglandins (from placenta) normally keep DA open → after birth, prostaglandin supply falls
==> causes Functional closure (muscle constriction/thrombosis): 1–8 days
* Anatomic closure (fibrosis): 1–4 months
79
Persistent PDA (patent DA) causes
L->R shunt needs
pharmacologic/surgical/interventional closure
also will produces a continuous systolic and diastolic murmurs
80
Which congenital heart defects requires PDA patency?
hypoplastic left heart, interrupted aortic arch) → prostaglandin infusion may be needed to open DA until surgery
81
What happen when Ductus Venous closes?
DV continues to receive portal venous blood initially
* Mechanism not fully known, but its muscular wall constricts in 1–3 hours after birth
Blood then rerouted into the liver → portal venous pressure rises
82
In neonatal which one is a fixed values (SV, CO, HR)? and meaning
SV is fixed
> CO depends on HR
83
Is peds primarily parasympathetic or sympathetic controlled?
parasympathetic
84
which Hgb does peds has? oxyHgb curve?
Neonate has HgbF
Higher affinity for O2 > shift curve LEFT
(Left = love)
85
Hepatic of neonate
Neonate: Lower plasma concentrations of albumin → increased levels of free drug
▪ Reaches adult levels at 1 year
86
Neonate affinity to DMR and NDMR
The NMJ: Ach receptor has a greater affinity for depolarizing agents and a lower affinity for nondepolarizing muscle relaxants
→ use TOF
▪ Diaphragm is more response to NDMRs than peripheral musculature
87
TBW of neonates
Higher percentage of TBW = large volume of distribution → need more NDMRs and depolarizing muscle relaxants
88
Fontanelles in neonates:
Anterior: closes at 2 years, used to assess increased ICP and dehydration
Posterior: closes at 4 months
89
blood brain barriers in neonates:
BBB is underdeveloped; the brain contains highest fat concentration → more fat soluble drugs are stored
90
What is an ideal pediatric breathing circuit?
A. Lightweight
B. Minimize dead space
C. Provide low compressible volume
D. Provide low resistance
E. Providing humidification and warming of inspired gas
F. Permits the collection and scavenging of exhaled anesthetic gases.
91
what is cyanotic defects?
Right to Left Shunt (blood gets shunt to Left side and bypass pulmonary circulation (unable to pick up O2) > enters systemic circulation).
92
What are the disease that cause R-L Shunt?
Tetralogy of Fallot (TOF)
Eisenmenger Syndrome
Ebstein Anomaly
93
What are the 5 Ts of R to L shunt
Tetralogy of Fallow (most common)
Transposition of the great arteries
Tricuspid Valve Abnormality (Ebstein’s Anomaly)
Truncus Arteriosus
Total Anomalous Pulmonary Venous Connection
94
TOF is what?
1 Right Ventricular Outflow Tract Obstruction
2 Right Ventricular Hypertrophy due to high-pressure load from the RV obstruction
3 Ventricular Septal Defect
4 Overriding Aorta that receives blood from BOTH ventricles
Biggest problem here is: RVOT > Deoxygen blood shunted thru VSD and into aorta.
95
What precipitated TET spell and its patho
Precipitated by: increased Sympathetic Activity (crying, agitation, pain, defecation, fright or trauma)
Increases myocardial contractility > cause spasm of infra-valvular region of RVOT
Increased in resistance at the RVOT > blood will flow through ventricular septal defect
Results in increased right to left shunting → Hypoxemia
96
Sign of a TET Spell?
Hyperventilate
Hypoxemia
Squatting position
97
How squatting position helps these child during TET spell?
Increase intra-abdominal pressure to compress abdominal arteries.
> Increase RV Preload
> Increase SVR
> More blood goes thru RVOT obstruction
> Restore pulmonary blood flow
> Improves Oxygenation
98
If TET spell occurs peri-op, what to do?
Treat w/ 100% FiO2
Gives Fluid to expand
Intra-vascular volume
Increase SVR with Phenylephrine to augment PVR to SVR ratio
Reduce SNS stimulation to improve dynamic RVOT obstruction
Do this by: deepen anesthesia, beta-blockade w/short acting agent (ESMOLOL)
Avoid inotropes > can worsen RVOT obstruction
Avoid excessive airway pressure
Place the infant in knee to chest position to mimic squatting.
99
effects of R-L cyanotic shunt on inhalation induction
Shunted blood does not go to lungs. So, blood doesn’t take volatile anesthetic
Shunted blood dilutes content of volatile anesthetic in left heart and decreases volatile anesthetic and partial pressure in arterial circulation
Rate of rise of FA/FI decreases ⟶SLOWER ONSET slower induction
Difference is seen greatly with less soluble agents such as N2O and desflurane.
Less of an issue with isoflurane (more soluble agents)
100
Effects of R-L cyanotic shunt on Intravenous Induction
drugs reach vessel rich organs faster, leading to FASTER ONSET
101
What is acyanotic defects?
Left to Right Shunt
L-R shunt causes Oxygenated blood to return directly to lungs instead of pump out systemically
Ex: VSD, PDA, Atrial septal defect, Coarctation of Aorta
102
Effect on inhalation induction of acyanotic shunt
None
103
Effect on intravenous induction of acyanotic shunt
prolonged
104
The increased in pulmonary blood flow of acyanotic shunt can leads to?
Volume OverLoad in both ventricles leading to BIVETRICULAR FAILURE
Ventricular hypertrophy
Decreased lung compliance
Increased airway resistance
Pulmonary HTN
105
what to avoid if child has L to Right shunt?
Avoid increased SVR
Avoid decreased in PVR
(High FiO2, Hypocapnia, Vasodilators, Alkalosis ==> can decrease PVR)
L-R shunt --> more blood volume to pulmonary --> hence if we decrease PVR > even more blood enters.
106
How to improve Right to Left shunt hemodynamically?
Decrease PVR
( hyperoxia, high FiO2, Hyperventilation)
R-L shunt > less blood going into pulmonary > hence we need to decrease PVR so more blood can goes their to oxygenate
107
what is coarctation of aorta?
congenital narrowing of aorta
108
what is pulmonary HTN of new born?
sustained elevation of PVR
> Decreased lungs perfusion
> R to L shunt of blood through DA and FO
109
Ductus Arteriosus is?
by pass from Pulmonary artery > directly to > Aorta (Deoxy blood > Systemic)
110
Treatment for Pulmonary Hypertension
Selective pulmonary vasodilation
nitric oxide, epoprostenol, sildenafil/tadalafil, phosphodiesterase 3 inhibitor,
endolhein receptor antagonist bosentan, and prostanoids such as prostacyclin, iloprost, or treprostinil.
* Optimal lung inflation
* Correct and avoid
acidosis and hypoxemia
● Maintain normal Hct
111
What increases PVR?
Hypercapnia, hypoxemia, acidosis, hypothermia, high PEEP, high PIP, unpalliated pain w/ sympathetic
stimulation, vasoactive medications that affect PVR (neo)
112
why a higher dose of propofol is needed in neonate?
2-2.5 mg/kg
increased metabolic rate and a greater Vd
113
Right-to-left shunts: more difficult to maintain depth of anesthesia. what should we do?
supplemental IV anesthetic
114
Pharmacokinetics consideration for neonate
1. absorption and distribution is INCREASED (due to increased CO)
2. Decrease Albumin/Protein concentration
--> increased free drug levels
3. Immature BBB
4. Elimination is decrease due to immature metabolic pathways
115
what is resting CO of Neonate at birth?
400 mL/kg/min
116
biggest risk when administer blood to neonates
Hyperkalemia (can cause cardiac arrest)
117
Neonates spinal cord/conus medullaris terminates at?
L2 and L3
118
Neonates spinal cord/conus medullaris terminates reaching adult level at?
1 year old
adult level L1
119
Dural Sac of peds extends from
extends from S3-S4
120
Dural Sac of peds reach adult level at?
S1 adult position
until 1y.o
121
Volume of CSF in peds is ____ compared to adult. they are:
TWICE of adults
4ml/kg in peds
vs
2ml/kg in adults
122
Why does higher dose requirement and shorter duration of analgesia for spinal in peds?
PEDS Volume of CSF is TWICE of the adult (4 mL/kg vs 2 mL/kg)
→ This dilutes the local anesthetics injected
123
High level of block T2-T4 can cause?
intercostal muscle weakness > requires dependence on diaphragmatic movement for tidal breathing > but Vt and RR may not be affected.
124
Why is LA (Amide) metabolized more slowly in neonates
AMIDE LA metabolized via liver enyzmes
Neonate has immature hepatic degradation
> slower metabolize
125
Why is ESTER LA metabolized more slowly in neonates?
hydrolysis via plasma cholinesterase > decreased in neonate
126
Metbolism and elimination of LAs is
Prolonged in neonates
127
If doing a SPINAL in neonate, where to puncture?
LUMBAR puncture > L3, L4 or L4, L5 interspace
because neonate spinal cord ends at L3.
128
Which needle is inserted? for spinal anesthesia?
1.5 inch 22gauge needle
129
How to know when spinal needle in ligamentum flavum and in subarachnoid space?
Resistance can be felt as the needle enters ligamentum flavum and POP occurs when needle enters Subarachnoid Space.
130
what is SPINAL DOSAGE for Spinal anesthesia in neonates?
0.14 mL/kg of Bupivacaine 0.5%
0.5% bupivacaine = 5mg/mL
131
Which epidural is mostly used in peds anesthesia?
caudal epidurals
(used for sacral, lumbar, lower thoracic dermatomes)
Can also be used as adjunct to general anesthesia or solely for post-op pain analgesia.
Placed after induction with ultrasound.
132
which position to placed child in when giving epidural caudal?
lateral position with knee flexes
133
Landmarks for epidural
Tip of coccyx to fix midline
Sacral cornu on either side of sacral hiatus
⇒ these form > points of an equilateral triangle with the tip resting of sacral hiatus.
134
needle size for epidural caudal in peds? and how to insert?
22 gauge
bevel up at 45 degree
135
When does the LOSS of RESISTANCE is felt during epidural caudal in peds?
When sacrococcygeal membrane is punctured
e. Distinctive LOSS of RESISTANCE is felt
136
After the Loss of resistance is felt, do what next in epidural caudal?
f. Angle of needle is reduced and advanced CEPHALAD
g. Saline should be used with the LOR technique (air can cause intravascular air embolism and permanent spinal cord injury)
h. After aspiration, NO CSF or BLOOD > LAs can be injected.
137
What determines the height of the block in epidural caudal anesthesia peds?
volume of LAs
Volume of 1.2-1.5 mL/kg provide anesthesia to T4-T6 dermatones.
1 mL/lg is usually used for lower procedures.
NO MORE THAN 2.5 mg/kg
138
contraindications of epidurals?
systemic or localized (at the site) infection,
concurrent anticoagulation or coagulopathy,
central
nervous system pathology or neurologic deficits,
previous spinal surgery
139
Pyloric Stenosis is what? need what?
Obstructive lesion caused by an olive-shaped enlargement of the pylorus
Surgical procedure: pyloromyotomy → done laparoscopically to relieve gastric outlet obstruction
considered medical emergency
140
S/S of pyloric stenosis in peds?
postprandial emesis that becomes projective, palpable pylorus, visible peristaltic waves
141
Anesthesia consideration for pyloric stenosis
Correct hypovolemia before anesthesia
Correct acid base disorders and electrolyte abnormalities before anesthesia
Difficulty with feeding and regurgitation > optimize fluid and electrolyte imbalance is essential in pre-op
Hypochloremic, Hypokalemia, Metabolic Alkalosis > common
Must ensure normalized lab, hydration status before bring in OR
142
Before induction for a child with pyloric stenosis, what to do?
All quadrants of neonate stomach are SUCTIONED via multiorifice Orogastric Tube
Placing Orogastric tube and suction the neonate in supine, right lateral, left lateral position
Some will irrigate stomach via orogastric tube with warm NS until the aspirate is CLEAR and Minimal
These infants are high risk for gastric aspiration
143
Induction for pyloric stenosis is going to be
RSI
144
anesthesia for inguinal hernia in peds
May cause incarceration of the small bowel causing colon ischemia and tissue death
o Can injure the ipsilateral testicle
* Can be open or laparoscopic
* Contralateral side is explored to rule out another defect
* Can be done under a caudal block while they are awake
* Inhalation or IV induction with ETT or LMA
145
Congenital diaphragmatic
hernia is what?
Defect in the diaphragm allows extrusion of the abdominal contents into the thoracic cavity
● Prevent normal lung growth → mainly the ipsilateral lung but contralateral can be affected too
▪ Reduced size of the bronchi, less bronchial branching, decreased alveolar surface area,
abnormal pulmonary vasculature
poor pulmonary vascular development, increase PVR, pulmonary HTN, Impaired Airway development, airway reactivity
146
Congenital diaphragmatic
hernia anesthesia consideration
Maintain PIP at less than 25-30 cm H2O
* Administer an anticholinergic (atropine 0.02 mg/kg) IV prior to induction
● Gentle ventilation to avoid inflation of the stomach: decreases pulmonary compliance, increases passive gastric
regurgitation
* Post-op ventilation goal: arterial oxygenation >150 mm Hg
Keep PIP < 25-30 cm H2O to minimize barotrauma and pneumothorax in GOOD lung
Avoid increases in PVR (hypoxia, acidosis, hypothermia)
One-lung ventilation of the BETTER lung > maybe needed due to pulmonary hypoplasia of affected lung
Abdominal Closure may increase PIP > surgeon can create a temporary Ventral hernia > to decrease abdominal pressure.
147
Most common site of herniation in Congenital Diaphragmatic Hernia and other sites.
Foramen of Bochdalek (usually on left site)
Other sites of herniation?
Forament of Morgagni and around the esophagus
148
Sign of Congenital Diaphragmatic Hernia
Sunken in (Scaphoid) Abdomen; Barrel chest, Cardiac Displacement, Fluid Filled GI segments in the thorax.
149
Congenital Diagphragmatic hernia cause what to PVR?
high PVR, this can cause:
⇒ R to L shunting through the DUCTUS ARTERIOSUS
→ lead to hypoxemia, cyanosis, further increases of PVR
150
For congenital diaphragmatic hernia, where to monitor for SpO2 in peds?
Use Right UPPER extremity (right hand) to monitor pre-ductal SpO2 and BP
Preductal SpO2 should be > 90%
151
Where is preductal sites in peds?
Preductal Sites: The right hand or wrist is a
common preductal site.
Blood before it passes the ductus arteriosus → represents blood going to the brain and heart
152
where is postductal site in peds?
Postductal Sites: Either foot or the left hand are common postductal sites.
Blood after it mixes with blood from the ductus arteriosus → represents systemic (lower body) oxygenation
153
what is Tracheoesophageal fistula
Suspected by the presence of polyhydramnios and stomach bubble on ultrasound
* Esophageal Atresia with distal fistula is the most common
o Esophagus ends in a blind pouch, and the distal esophagus forms a fistula with the trachea, usually
above the carina
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how to dx Tracheoesophageal fistula?
Dx: immediately after birth when OG cannot be passed, coughing and choking after first feeding, or recurrent
pneumonia associated with feedings
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Preop for Tracheoesophageal fistula?
o ECHO to exclude cardiac defects and right-sided aortic arch
o Minimize pulmonary complication by:
> Stopping oral feedings,
> keep infant in semirecumbent position to prevent aspiration, > place a gastrostomy tube
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Where to pulse ox monitor for Tracheoesophageal fistula? surgery?
Preductal and postductal oximeter to assess shunting that may occur
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how to verify ETT placement in Tracheoesophageal fistula?
Intubate right main-stem and pull back until lung sounds are heard on the left
Place gastrostomy in water → bubbles = fistula is being ventilated
▪ Turn ETT anteriorly to occlude the fistula
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Patent ductus arteriosus causes
PDA causes left-to-right shunting causing pulmonary over circulation and symptoms of CHF
acyanotic
After birth: PVR drops (lungs expand, oxygen levels rise).
SVR increases (placenta is clamped off).
The pressure gradient reverses: now aortic pressure > pulmonary artery pressure. (this causes L-R shunt if PDA occurs)
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What can changes drastically after surgery of PDA
Consider BP changes after closure, especially diastolic and pulse pressure
Postligation cardiac syndrome (PLCS): systemic hypotension w/ poor cardiac output, increased PA pressure
▪ Occurs 2 hours after up to 24 hours
Prone to diastolic dysfunction which may be worsened after closure and cause pulmonary venous congestion
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How to prevent PLCS after PDA sx
Pretreated with steroids
▪ Tx: hemodynamics w/ fluid, milrinone and/or epi, mechanical ventilation
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what is myelomingocele
Form of spina bifida
* Failure of the neural tube to close causing herniation of the spinal cord and meninges through defect in the
spinal column and back
● Meningocele: contains only meninges
* Surgical repair is completed within the first 24 hours of life
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What does myelomingocele pt can have?
Arnold-Chiari malformation, which is the result of the hindbrain displacing downward into the foramen
magnum, leading to hydrocephalus > need a VP shunt
There are significant neuro deficits below the level of lesion → evaluate
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what are pt with myelomingocele at risk for?
Prone to hypothermia→ keep OR at least 27 degrees before procedure
o Utilize radiant heat lamps
o Humidify anesthetic gases
* Increased risk for latex allergy → AVOID LATEX
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Key difference b/w Omphalocele and gastrochisis
Omphalocele:
+ midline > include umbilicus
+ Has a membrane
+ Bowel and liver herniate
+ Common anomalies
+ More in term newborns.
poor outcome
Gastrochisis:
+ more common in preterm newborn
+ No covering membrane
+ right of umbilicus
+ only bowel herniated
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where to place pulse ox on omphalocele and gastrochisis pt?
Pulse is placed on LOWER EXTREMITY will indicate whether there is compromise in perfusion to the lower extremities due to obstruction of venous return.
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Why post-op ventilation is mandatory in omphalocele and gastrochisis?
requiring continued use of paralytics and sedation with an opioid infusion until stabilized and abdominal closure can be accomplished
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How to decrease Emergence delirium?
Begin in preop, treat anxiety, provide distraction, prepare for what to expect.
Minimize sevo, use propofol based TIVA for maintenance;
intra-op dexmedetomidine
0.5 mcg/mL of Precedex in 2-7 years old undergoing tonsillectomy with Sevo
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tx for bradycardia in kids
TX: atropine (0.02 mg/kgIV) Epi (0.01 mg/kg)
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What can cause bradycardia during induction
Common cause: hypoxia and medications
● succinylcholine, dex, sevo (especially in kids with trisomy 21), halothane
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Extubation criteria:
return of spontaneous breathing and weaning of anesthetic agents is needed
● For kids under 7 years: w/o a difficult airway
o Conjugate gaze
o Facial grimace
o Eye opening
o Purposeful movement
o TV >5 mL/kg
o Child should show facial grimacing, spontaneous eye opening, and purposeful movement
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when to do a deep extubation in kids?
for kids with reactive airway and when postsurgical coughing and bucking should avoided
o Pros:
▪ Less likely to experience HTN, tachycardia, increased ICP → decreases risk of postop bleeding
o Done after oropharynx suctioning
o Depth of anesthesia is checked with maneuvers such as: jaw thrust or deep suctioning → no patient stimulation should occur
o Be aware of level of PACU care
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Contraindications of deep extubation.
Inadequate training of PACU staff, copious secretions or bleeding, high risk for pulmonary aspiration, difficult airway, OSA, significant airway obstruction
during induction
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Optimal position for transport from OR to PACU
The lateral decubitus position aka the “recovery position” is optimal for transport → child has neck extended and mouth opened so secretions can fall
on mattress instead
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stridor in post op cause and treatment
laryngeal edema
Occurs 30 min after tracheal extubation
o Risk factors: use of a larger ETT, prolonged intubation, hx of multiple intubations or attempts
* Tx: humidified oxygen, nebulized racemic epi, IV corticosteroids
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Sign and symptoms of negative pressure pulmonary edema?
s/s: hypoxia, course breath sounds, pink frothy sputum within an hour of event
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risk for vomitting after surgery?
Risk factors:
▪ Age >3
▪ History of PONV or family hx
▪ Postpubertal female
▪ Intraop:
* 1. strabismus surgery
2. adenotonsillectomy
3. otoplasty
4. surgery greater than or equal to 30 minutes 5. volatile anesthetic use, and
* 6. anticholinesterase administration
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NA3
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