Pediatric Assessment

Questions and Answers

What is a significant consequence of the immature blood-brain barrier (BBB) in an infant?

Easier crossing of drugs allows for higher concentrations in the brain and quicker onset

Why do infants have a greater sensitivity to changes in cerebral blood volume?

Due to their underdeveloped cerebral autoregulation.

What is the primary reason for the open cranial sutures in an infant? (select 2)

To allow for cerebral blood volume changes due to undeveloped autoregulation.

What information can an anesthesia provider gather from the assessment of an infant's fontanelles?

The infant's hydration status and potential for increased ICP. Signup and view all the answers

Why do infants have a fixed stroke volume (SV)?

Due to their underdeveloped cardiac contractile elements making them dependent on free ionized calcium for contractility . Signup and view all the answers

How do infants increase their cardiac output?

By increasing their heart rate. Signup and view all the answers

What is a consequence of an infant's blunted response to catecholamines and decreased catecholamine stores?

Volume expansion, calcium, and epinephrine may be better options to treat hypotension Signup and view all the answers

What is the term for the areas where open sutures converge in an infant?

Fontanelles. Signup and view all the answers

What is a potential reason why catecholamines may be less effective in treating hypotension in infants?

Immaturity of their vasoactive receptors Signup and view all the answers

Why is volume expansion important in treating hypotensive infants?

To compensate for their decreased stores Signup and view all the answers

What is an advantage of using epinephrine over atropine in treating hypotension in infants?

Epinephrine has inotropic and chronotropic properties Signup and view all the answers

What is a consideration when planning for airway management and intubation of an infant?

The airway is easier to obstruct with minimal pressure on the submental space Signup and view all the answers

Why is a shoulder roll useful during intubation of an infant?

To align the laryngoscopic axes and is preferred over the sniffing position Signup and view all the answers

Why is it wise to use an uncuffed ETT when intubating an infant?

Cuffed ETTs are associated with increased airway resistance and tracheal damage Signup and view all the answers

What is the primary reason why neonatal patients are more dependent on heart rate for cardiac output?

Fixed stroke volume Signup and view all the answers

What is the primary reason why neonatal patients are obligate nose breathers?

Nasal breathing helps maintain a more consistent airflow pattern and reduces the risk of aspiration during feeding and breathing Signup and view all the answers

What is the primary reason why neonatal patients have a higher respiratory rate?

They have a higher oxygen consumption and therefore higher metabolic rate Signup and view all the answers

What is the significance of type II pneumocytes and surfactant in neonatal patients?

They are responsible for improving lung compliance Signup and view all the answers

What is the main reason why the cricoid cartilage is a significant concern in pediatric airway management?

It is the narrowest part of the airway and is non-expandable. Signup and view all the answers

What is the primary mechanism by which providers can compensate for the decreased functional residual capacity (FRC) of pediatric pts?

Positive pressure ventilation. Signup and view all the answers

What is the main concern regarding pain management in neonates?

Risk of intraventricular hemorrhage Signup and view all the answers

What is the primary reason for the increased volume of distribution (Vd) of certain drugs in neonates?

Increased lipid solubility - longer duration of action Signup and view all the answers

What is the primary stimulus for the Hering-Breuer reflex?

Stretching of the lungs leading to an end of inhalation and protecting lungs from over inflation Signup and view all the answers

What is the consequence of the drastic decrease in glycogen stores in the first 3 weeks of life in neonates?

Impaired ability to be NPO Signup and view all the answers

At what age is normal kidney function typically present in neonates?

6 months Signup and view all the answers

What is a characteristic of the pediatric nervous system?

Incomplete development at birth, with maturation continuing until the end of the first year. Signup and view all the answers

What is the primary mechanism of thermogenesis in neonates?

Brown fat metabolism Signup and view all the answers

What is the primary factor limiting exhalation in pediatric patients?

Adductor muscles of the larynx. Signup and view all the answers

When do anterior and posterior fontanelles typically close?

Anterior: 2 years, Posterior: 4 months Signup and view all the answers

Why is epinephrine preferred over atropine in pediatric anesthesia?

Epinephrine is an adrenergic agonist while atropine works by blocking vagal tone Signup and view all the answers

What is different between the cardiovascular system of adults and neonates?

Non-compliant left ventricle (LV) - increases in afterload, can cause a reduction in cardiac output (CO) Signup and view all the answers

Blood volume in mL/kg

90-100 = premature neonate 80-90 = neonate 75-80 = 3 months-3years 65-70 = <6 years Signup and view all the answers

What is the cause of physiologic anemia of infancy, which peaks at 3-4 months of age?

Decreased erythropoiesis and decreased life span of RBCs Signup and view all the answers

What is the significance of fetal hemoglobin in cardiovascular function?

It has a higher affinity for oxygen which allows the fetus to receive oxygen more efficiently Signup and view all the answers

What is unique about the larynx of neonates?

It is situated cephalad and anterior, pointing to the nasopharynx Signup and view all the answers

Why is the risk of mainstem intubation higher in pediatrics?

Pediatrics have a short trachea and bronchus Signup and view all the answers

In pediatrics, the subglottic is __ shaped

Funnel Signup and view all the answers

In pediatrics, the vocal cords have an ___ slant

downward slant from posterior to anterior Signup and view all the answers

What anatomic features result in decreased FRC in pediatrics? (select 2)

Horizontal ribs minimizing intercostal assistance with chest expansion, Signup and view all the answers

What is the response to decreased PaO2 in pediatrics?

Initial increased respiratory rate then decrease in respiratory rate once fatigued - inability to compensate Signup and view all the answers

What reflex causes periodic breathing and pauses lasting up to 10 seconds?

Hering-Breuer reflex Signup and view all the answers

Why are depolarizing neuromuscular blockers (NMB) avoided in neonates?

Immature NMJ increases sensitivity to depolarizing NMB Signup and view all the answers

What is the difference in the location of the conus medullaris and dural sac between adults and pediatric patients?

Adult conus medullaris ends at L1 and dural sac ends at S1, Pediatric conus medullaris ends at L3 and dural sac ends at S3 Signup and view all the answers

What is the implication of decreased protein binding in pediatrics?

Increased free drug concentrations leading to increased potency Signup and view all the answers

What is the expected effect of drugs with a high volume of distribution?

All of the above Signup and view all the answers

What factors contribute to a neonate's inability to regulate body temperature?

All of the above Signup and view all the answers

What factors influence the rapid induction and recovery from anesthetics in neonates?

Lack of accumulation in adipose tissues - drug can affect target tissues Signup and view all the answers

What is unique about the volume of distribution (Vd) for water-soluble drugs in pediatrics?

It is larger due to a higher percentage of body water in infants. Signup and view all the answers

What is an expected finding in a patient less than 6 months old?

Minimal separation anxiety Signup and view all the answers

Birth weight

LBW = 2500g VLBW = 1500g ELBW = <1000g LGA = >90% Signup and view all the answers

SGA < 10%

True Signup and view all the answers

What are the metabolic contributors of apnea in the premature infant?

All of the above Signup and view all the answers

What type of volatile anesthetics should be used to prevent apnea of prematurity?

Less soluble Signup and view all the answers

What is the result of an undeveloped respiratory system in premature infants?

Both A and B Signup and view all the answers

In pediatric patients within 2-4 weeks of a URI, which of the following complications are more likely to occur?

Increased risk of laryngospasm, wheezing, hypoxemia, and atelectasis Signup and view all the answers

When a pediatric patient presents with a URI, what can you do to prevent adverse reactions?

All of the above Signup and view all the answers

What is a simple way to avoid bronchospasm prior to induction?

Cough and deep breathe Signup and view all the answers

What factors result in a higher risk of aspiration for children?

Lowered competence of LES and lower pH in stomach Signup and view all the answers

What is the premedication of choice in pediatrics for anxiolysis?

Versed Signup and view all the answers

At what cervical level are the vocal cords located in pediatrics?

C3 to C4 Signup and view all the answers

What is the relationship between age and closing volume in infants?

Inversely proportional Signup and view all the answers

How does closing volume affect tidal volume?

The collapsed airways trapping air in lungs, decreasing the tidal volume Signup and view all the answers

What is the normal tidal volume and respiratory rate of infants?

6-8 ml/kg and 25-50 Signup and view all the answers

What will increase peripheral vascular resistance in pediatrics?

All of the above Signup and view all the answers

What will decrease pulmonary vascular resistance (PVR) in pediatrics?

all of the above Signup and view all the answers

What external feature is associated with mandibular hypoplasia?

Microtia Signup and view all the answers

Why are NPAs typically avoided in pediatrics?

To prevent trauma and bleeding from hypertrophied adenoids Signup and view all the answers

What can result from an air leak not being present?

Ischemic damage to the tracheal mucosa Signup and view all the answers

What are the preferred ventilator settings for pediatrics?

PCV at physiologic PEEP 4-5 Signup and view all the answers

What are the advantages of awake extubation?

Protected airway during stage 2 anesthesia Signup and view all the answers

What are the advantages of deep extubation in infants? (Select 2)

Removal of ET before stage 2 resulting in smoother emergence Signup and view all the answers

What is the treatment for laryngospasm?

A combination of PPV, jaw thrust, and NMB Signup and view all the answers

What is the presenting symptom of choanal atresia?

Cyanosis at rest, relieved by crying or insertion of an oral airway Signup and view all the answers

Children with Down Syndrome frequently need _____than anticipated ETTs

smaller Signup and view all the answers

ETT cuffed Age/4+3.5 ETT uncuffed Age/4+4

True Signup and view all the answers

Study Notes

Anesthesia in Infants

The blood-brain barrier (BBB) is immature in infants, allowing drugs to cross more easily and resulting in higher concentrations of drugs in the brain, leading to a faster onset and higher levels of the drug.
This immaturity affects the anesthetic plan for infants, requiring consideration of the potential for higher drug concentrations in the brain.

Cerebral Blood Volume and ICP

Infants have an underdeveloped central nervous system (CNS) and lack cerebral autoregulation, making them sensitive to changes in cerebral blood volume.
An increase in cerebral blood volume results in a rapid rise in intracranial pressure (ICP) in infants.

Cranial Sutures and Fontanelles

The cranial sutures are open in infants to allow for rapid growth and to accommodate increased cerebral blood volume without increasing ICP.
The anterior fontanelle closes by 2 years, and the posterior fontanelle closes by 4 months.
Fontanelles can be used to assess hydration status and increased ICP in infants; sunken fontanelles indicate dehydration, and bulging fontanelles indicate increased ICP.

Cardiovascular System

Infants have a fixed stroke volume (SV) due to immature cardiac contractile elements, which are dependent on free ionized calcium for contractility.
Infants increase their cardiac output by increasing their heart rate (HR).
Infants have blunted responses to catecholamines and decreased catecholamine stores, which affects the treatment of hypotension.
When treating hypotension, volume expansion is important, and calcium may be effective in treating infants not responsive to fluid bolus.
Epinephrine is a better choice than atropine due to its inotropic and chronotropic properties.

Airway Management

The larynx of an infant is higher and more superior, situated around the C3-4.
The epiglottis is stiff and floppy, and the tongue is large.
These anatomical features make airway management and intubation more challenging in infants.
It is easier to obstruct the airway of infants with minimal pressure on the submental space.
Placing an infant in the sniffing position worsens the laryngoscopic view due to the position of the larynx.
A shoulder roll is better used to align the laryngoscopic axes.
An uncuffed endotracheal tube (ETT) may be preferred due to the risk of increased airway resistance and tracheal damage from inflated cuffs.

Pediatric Patients

Pediatric patients have increased minimum alveolar concentration (MAC), rapid induction and recovery.
They have larger volumes of distribution for water-soluble drugs.

Neonatal Cardiovascular Characteristics

Immature myocardium and noncompliant left ventricle result in increased afterload and reduced cardiac output.
Fixed stroke volume and HR-dependent cardiac output.
Faster HR.
Epinephrine is better than atropine for bradycardia due to blunted responses to exogenous catecholamines.
Ensure adequate volume and avoid hypotension.
Underdeveloped baroreceptor reflex and parasympathetic innervation.
Fetal hemoglobin is predominant, with higher affinity for oxygen and physiologic anemia of infancy.

Neonatal Respiratory Characteristics

Type II pneumocytes and surfactant develop at 22-26 weeks and peak at 35-36 weeks.
Lack of surfactant leads to stiff, noncompliant lungs, severe atelectasis, V/Q mismatch, hypoxia, and hypercarbia.
Infant's metabolic rate and oxygen consumption are twice that of adults.
Increased resistance to airflow.
Obligate nose breathers.
Respiratory rate (RR) is 37 in healthy newborn babies, with smaller babies having to work harder to breathe.

Vent Settings

Low flow trigger to avoid exhaustion.
Avoid using volume control (VC) mode to prevent lung damage.

Neonatal Airway Anatomy

Large occiput and large tongue.
Short, small, stiff epiglottis.
Larynx is small, more cephalad, and anterior, pointing towards the nasopharynx.
Subglottic region is smaller than the glottis opening.
Cricoid cartilage is the narrowest part of the airway.

Pediatric Breathing Mechanics

Decreased functional residual capacity (FRC) due to underdeveloped muscles and skeletal structure.
Horizontal ribs resulting in minimal assistance with chest expansion for inspiration.
Exhalation limited by adductor muscles of the larynx.
Flat diaphragm, like COPD patients, requiring more effort to breathe.
Diaphragm composed mainly of fast-fatiguing fibers.
Must assess for increased respiratory effort and intervene to maintain oxygenation and prevent fatigue.

Overcoming Decreased FRC

Positive pressure can help overcome decreased FRC.

Breathing Control

Breathing controlled by PaO2, PaCo2, and pH.
Initial response to decreased PaO2 is an increase in ventilatory response, followed by a decrease in ventilatory response due to impaired ability to compensate and rapid fatigue.
Hering-Breuer reflex can cause pauses in breathing up to 10 seconds.

Pediatric Nervous System

CNS development is incomplete at birth and continues until the end of the first year of life.
Changes in cerebral blood flow, cerebral blood volume, and ICP greatly affect each other.
Autoregulation is easily impaired, and caregivers should monitor cerebral perfusion pressure (CPP).
Immature blood-brain barrier and neuromuscular junction.
CNS is vulnerable to trauma, hypoxia, hypoglycemia, and ischemia.

Pain

Lack of cerebral vascular autoregulation makes pain management challenging in neonates.
Recommended to limit infusions and doses of analgesics and use multimodal methods.

Liver of Neonates

Immature hepatic biotransformation, impaired metabolism, and decreased protein binding.
Increases in lipid solubility increase the volume of distribution, leading to longer duration of action.
Highly protein-bound and highly lipid-soluble drugs may leave more drug to target tissues specifically.

Kidneys of Neonates

Normal kidney function is not present until 6 months, and kidney function may not be fully mature until age 2.

Thermoregulation

Neonates lack the ability to regulate body temperature due to large surface area, lack of subcutaneous tissue, and inability to shiver.
Brown fat metabolism allows for non-shivering thermogenesis.
Hypothermia can be caused by various factors, including environmental temperature, cold surfaces, and inadequate clothing.

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Description

This quiz covers the effects of an immature blood-brain barrier and lack of cerebral autoregulation on anesthesia in infants. It discusses how these factors impact the administration of drugs and changes in cerebral blood volume.