Pediatric Assessment
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Questions and Answers

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

  • It reduces the risk of anesthetic toxicity.
  • It prevents the crossing of anesthetic drugs into the brain.
  • Easier crossing of drugs allows for higher concentrations in the brain and quicker onset (correct)
  • It leads to a slower onset of anesthetic drugs in the brain.

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

  • Due to their mature blood-brain barrier.
  • Due to their increased cardiac output.
  • Due to their underdeveloped cerebral autoregulation. (correct)
  • Due to their developed 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. (correct)
  • To reduce the risk of intracranial hypertension.
  • To facilitate the rapid growth of the brain in utero. (correct)
  • To improve the development of cerebral autoregulation.

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

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

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

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

    How do infants increase their cardiac output?

    <p>By increasing their heart rate.</p> Signup and view all the answers

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

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

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

    <p>Fontanelles.</p> Signup and view all the answers

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

    <p>Immaturity of their vasoactive receptors</p> Signup and view all the answers

    Why is volume expansion important in treating hypotensive infants?

    <p>To compensate for their decreased stores</p> Signup and view all the answers

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

    <p>Epinephrine has inotropic and chronotropic properties</p> Signup and view all the answers

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

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

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

    <p>To align the laryngoscopic axes and is preferred over the sniffing position</p> Signup and view all the answers

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

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

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

    <p>Fixed stroke volume</p> Signup and view all the answers

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

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

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

    <p>They have a higher oxygen consumption and therefore higher metabolic rate</p> Signup and view all the answers

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

    <p>They are responsible for improving lung compliance</p> Signup and view all the answers

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

    <p>It is the narrowest part of the airway and is non-expandable.</p> 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?

    <p>Positive pressure ventilation.</p> Signup and view all the answers

    What is the main concern regarding pain management in neonates?

    <p>Risk of intraventricular hemorrhage</p> Signup and view all the answers

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

    <p>Increased lipid solubility - longer duration of action</p> Signup and view all the answers

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

    <p>Stretching of the lungs leading to an end of inhalation and protecting lungs from over inflation</p> 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?

    <p>Impaired ability to be NPO</p> Signup and view all the answers

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

    <p>6 months</p> Signup and view all the answers

    What is a characteristic of the pediatric nervous system?

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

    What is the primary mechanism of thermogenesis in neonates?

    <p>Brown fat metabolism</p> Signup and view all the answers

    What is the primary factor limiting exhalation in pediatric patients?

    <p>Adductor muscles of the larynx.</p> Signup and view all the answers

    When do anterior and posterior fontanelles typically close?

    <p>Anterior: 2 years, Posterior: 4 months</p> Signup and view all the answers

    Why is epinephrine preferred over atropine in pediatric anesthesia?

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

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

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

    Blood volume in mL/kg

    <p>90-100 = premature neonate 80-90 = neonate 75-80 = 3 months-3years 65-70 = &lt;6 years</p> Signup and view all the answers

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

    <p>Decreased erythropoiesis and decreased life span of RBCs</p> Signup and view all the answers

    What is the significance of fetal hemoglobin in cardiovascular function?

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

    What is unique about the larynx of neonates?

    <p>It is situated cephalad and anterior, pointing to the nasopharynx</p> Signup and view all the answers

    Why is the risk of mainstem intubation higher in pediatrics?

    <p>Pediatrics have a short trachea and bronchus</p> Signup and view all the answers

    In pediatrics, the subglottic is __ shaped

    <p>Funnel</p> Signup and view all the answers

    In pediatrics, the vocal cords have an ___ slant

    <p>downward slant from posterior to anterior</p> Signup and view all the answers

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

    <p>Horizontal ribs minimizing intercostal assistance with chest expansion,</p> Signup and view all the answers

    What is the response to decreased PaO2 in pediatrics?

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

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

    <p>Hering-Breuer reflex</p> Signup and view all the answers

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

    <p>Immature NMJ increases sensitivity to depolarizing NMB</p> 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?

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

    What is the implication of decreased protein binding in pediatrics?

    <p>Increased free drug concentrations leading to increased potency</p> Signup and view all the answers

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

    <p>All of the above</p> Signup and view all the answers

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

    <p>All of the above</p> Signup and view all the answers

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

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

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

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

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

    <p>Minimal separation anxiety</p> Signup and view all the answers

    Birth weight

    <p>LBW = 2500g VLBW = 1500g ELBW = &lt;1000g LGA = &gt;90%</p> Signup and view all the answers

    SGA < 10%

    <p>True</p> Signup and view all the answers

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

    <p>All of the above</p> Signup and view all the answers

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

    <p>Less soluble</p> Signup and view all the answers

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

    <p>Both A and B</p> 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?

    <p>Increased risk of laryngospasm, wheezing, hypoxemia, and atelectasis</p> Signup and view all the answers

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

    <p>All of the above</p> Signup and view all the answers

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

    <p>Cough and deep breathe</p> Signup and view all the answers

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

    <p>Lowered competence of LES and lower pH in stomach</p> Signup and view all the answers

    What is the premedication of choice in pediatrics for anxiolysis?

    <p>Versed</p> Signup and view all the answers

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

    <p>C3 to C4</p> Signup and view all the answers

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

    <p>Inversely proportional</p> Signup and view all the answers

    How does closing volume affect tidal volume?

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

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

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

    What will increase peripheral vascular resistance in pediatrics?

    <p>All of the above</p> Signup and view all the answers

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

    <p>all of the above</p> Signup and view all the answers

    What external feature is associated with mandibular hypoplasia?

    <p>Microtia</p> Signup and view all the answers

    Why are NPAs typically avoided in pediatrics?

    <p>To prevent trauma and bleeding from hypertrophied adenoids</p> Signup and view all the answers

    What can result from an air leak not being present?

    <p>Ischemic damage to the tracheal mucosa</p> Signup and view all the answers

    What are the preferred ventilator settings for pediatrics?

    <p>PCV at physiologic PEEP 4-5</p> Signup and view all the answers

    What are the advantages of awake extubation?

    <p>Protected airway during stage 2 anesthesia</p> Signup and view all the answers

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

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

    What is the treatment for laryngospasm?

    <p>A combination of PPV, jaw thrust, and NMB</p> Signup and view all the answers

    What is the presenting symptom of choanal atresia?

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

    Children with Down Syndrome frequently need _____than anticipated ETTs

    <p>smaller</p> Signup and view all the answers

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

    <p>True</p> 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.

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