Pediatric Anesthesia Lesson 12 PDF

[Basics of Pediatric Anesthesia] - Standard monitors - **Precordial stethoscope and SPO2 are required for induction!** - EKG and NIBP can wait until after induction - Appropriately sized ambu bag and circuit - IV kit = 20, 22, 24 angiocaths - Preop IV = Mr.Freeze, EMLA kit...

[Basics of Pediatric Anesthesia] - Standard monitors - **Precordial stethoscope and SPO2 are required for induction!** - EKG and NIBP can wait until after induction - Appropriately sized ambu bag and circuit - IV kit = 20, 22, 24 angiocaths - Preop IV = Mr.Freeze, EMLA kit - IV fluids =4/2/1 - Average weight in kg = age in yearsx2+10 = 90^th^ percentile - Emergency medications - Atropine (0.2mg/kg) - Epi (10mcg/kg) - Succinylcholine (2mg/kg IV; 4mg/kg IM) - Preop evaluation - Ask about length of pregnancy - If premature, ask about IVH and assisted ventilation - Family hx of anesthesia problems - Sickle cell or trait - GERD - Recent colds -- URI = more reactive airway for 6 weeks - NPO guidelines - Clear liquid 2 hours - Breast milk 4 hours - Formula 6 hours - Solids 8 hours - Premedication - Can make emergence slow - IM, IN, PO ketamine, fentanyl, versed - Induction - Inhalation - N2O 70%, O2 30% - If able, try stun dose of N2O prior to sevo - Gradual or full blast of sevo - IV - Combined inhalation and IV - Small gauge has increased discomfort with propofol -- consider 0.5 mg/kg lidocaine mixed with propofol - Benefit of spontaneous ventilation on inhalation agent = autoregulation - Too deep -- pt will breathe slower and take in less volatile - Too light -- pt will breathe quicker and take in more volatile - Bronchospasm - Common causes = RAD, mainstem ETT, mechanical obstruction e.g. kinked ETT - Can happen at any time during the case - Symptoms = difficulty or inability to ventilate even with ETT in place, high peak pressures, desaturation, could have low or even no ETCO2 , may have no breath sounds and very little chest rise - Treatment = 100% FiO2, deepen anesthetic, beta agonists, epi, terbutaline, ketamine, aminophylline, lidocaine, corticosteroid - Maintenance - Greatest risk of emergence delirium with sevo - Induction with sevo but you can change to another volatile - Desflurane keeps HR a little higher which can be a good thing in pediatric patients because their CO is HR dependent - Narcotics - Fentanyl - Morphine - Non-narcotic - Tylenol (PR, IV) - Toradol - If patient is bucking, what is the first thing you do? Pop them off the ventilator. Then deepen anesthetic to effect - Retinopathy of prematurity - ROP risk high \3 YO - TAPS block - Pyloromyotomy - Hypertrophy of muscle fibers of the pyloric sphincter results in gastric outlet obstruction characterized by a olive shaped palpable mass in abdomen - Not a surgical emergency but is a medical one due to need to correct fluid and electrolyte imbalance - These patients have dehydrated hyperchloremic metabolic alkalosis from vomiting - Alkalosis results in compensatory hypoventilation to increase CO2 - High pH suppresses the central respiratory centers in the medulla leading to inappropriate respiratory response to CO2 levels when they do rise - Patient population = usually several weeks old and are relatively healthy sans projectile vomiting from gastric outlet obstruction, occurs in boys\>girls - Positioning = supine and pt may be turned 90 degrees away - Usually a laparoscopic case - Anesthetic implications - Empty stomach with pt awake - RSI - Awake extubation - Complications - Delayed emergence - Postoperative respiratory depression - Both complications are the result of preop alkalosis on the pH of CSF - Broviac and Mediport - Patient population = those that require frequent or long-term IV access - Broviac done under fluoroscopy and is similar to central line placement - Maintenance - Not very painful so ½ dose of narcotic is usually sufficient - Ectopy while surgeon is threading catheter - Special considerations - Sickle cell - Need warm room because cold temperatures can cause increased sickling of RBCs - Preinduction EKG - Core temp monitors - Acute chest syndrome = vaso-occlusive crisis of the pulmonary vasculature - Cancer - Family interaction - Immunocompromised - Adjunct procedures while pt is already in OR and sedated e.g. bone marrow biopsy, LP - Circumcision - Usually done a day or two after birth - Simplest anesthetic technique is the subcutaneous ring block (using LA with NO EPI) at the base of the penis - No epi in LA for fingers, toes, penis, and nose - Complications = hematoma and penis ischemia - Circumcision later in life are normally done under GA - Penile ring block can provide postop analgesia - UTIs more common in uncircumcised men - Nissen Fundoplication - Used to treat GERD - Fundus of stomach is wrapped around a 3-4 cm segment of the lower esophagus to provide reinforcement - Procedure = laparoscopic vs open -- usually laparoscopic - RSI due to GERD sx - Caution with bougie due to esophageal perforation risk - Strabismus = deviation of one eye relative to the visual axis of another - Esophoria = one eye pointed inward - Exophoria = one eye pointed outward - Esotropia = inward deviation of both eyes - Surgery = repositioning of extraocular muscles - High incidence of PONV so treat with IVF or Zofran - Oculocardiac reflex/5 and dime/trigeminovagal reflex = bradycardia with pressure applied to eye