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What are the anesthesia considerations for ENT surgery?
- Caution sedation
- Assess for difficult airway and mask
- Consult with surgeon and family
- Smooth, deep induction (communicate effectiveness of ventilation)
- Minimize narcotics and optimize non narcotic pain management
- Discuss emergence with surgeon (effective communication with OR personnel).
- Awake vs deep extubation.
- Strict monitoring while transporting and reporting to PACU
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What are the anesthetic considerations for a T & A?
- Calm controlled induction (caution with preoperative medications)
- Assess ability to ventilate. May need to reposition or utilize another provider.
- Gentle, deep intubation.
- Prevent bleeding. (4ml/kg)
- Maintain correct level of anesthetic depth and prepare for incision.
- Actively communicate with surgeon and plan for emergence.
- Recognize proper emergence criteria:Establish plan for deep vs. awake extubation.
- Post operative pain may be severe after tonsillectomy (laser or electrocautery).
- Steroids have been found to be efficacious in decreasing pain from swelling.
- Local infiltration is more beneficial for blood loss reduction rather than pain reduction
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What are the disadvantages with small infants and a semi closed circuit?
- Increased resistance with spontaneous breathing (inspiratory and expiratory valves)
- Large volume of absorber system acts as a reservoir for anesthetic agents
- Large compression volume of tubing
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What type of breathing circuit is used for small infants?
- Nonrebreathing, open circuit (Mapelson D or Bain)
- Rebreathing is prevented with high flows (2-2.5 x MV)
- Useful for very small infants to breath spontaneously. (Capnography essential)
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Reservoir bag volume should accommodate child’s Vital Capacity. What are the guidelines for bag sizes?
- 500 ml bag for newborns
- 1000ml bag for 1-3 years
- 2000 ml bag for children older than 3
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What are our concerns with URI in pediatrics?
- Children with URI, particularly less than 1 year of age, have an increased risk of respiratory related adverse events intraoperatively and postoperatively
- Symptomatic infants with URI have a decreased time to desaturation during apnea.
- Endotracheal intubation seems to be a major risk factor for hypoxemia, bronchospasm, and atelectasis in children with URI.
- Temporary airway hyperreactivity may exist for 6 weeks after a viral infection. Most complications seen in older children (> 1 year of age), with mild, nonacute, nonpurulent URI are mild and easily treatable.
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What are the NPO guidelines for breastmilk?
BM is a solid but for kids younger than 6M it’s 4 hours, for those older than 6M to 3yr, it’s 6hr and then it’s 8 hours.
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How do you prepare each age for induction ?
- Infant < 6months rarely need sedation
- Separation anxiety for children 1-3 years old. (stormy inductions)
- Incorporate play or active participation with preschool age children (3-6y). (Mastery and participation)
- Encouraging, supportive, complementary, positive comments with school age child.
- Protection from harm and embarrassment in older children.
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What are some contraindications for pre-op sedation?
altered mental status (acute), elevated ICP, difficult airway, hypovolemia, or respiratory dysfunction.
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What is the dosing for pre-op sedation Midazolam?
- 0.5-1 mg/kg po not to exceed 20 mg( peak effect in 30 minutes)
- 0.1- 0.3 mg/kg IM not to exceed 10mg.
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What is the dosing for pre-op sedation for Methohexital?
Methohexital 20-30 mg/kg PR ( onset 5 mins. Unpredictable, duration 2 hours).
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What is the dosing for Fentanyl (pre-op sedation)?
- Fentanyl lollipop 10-15 mcg/kg ( onset 5-20 mins.)
- Intranasal 2mcg/kg
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What is the dosing for Ketamine (pre-op sedation)?
- Ketamine 4-10mg/kg IM; 8mg/kg PO; 1-2 mg/kg IV (onset of IM=1 min.
- Use with midazolam and glycopyrolate
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What are the common adjunts for pre-op sedation in pediatrics?
- Atropine: 0.02mg/kg IM/PO; 0.01mg/kg IV (onset 2 mins)
- Metaclopramide: 0.1mg/kg po ( onset 1 hour)
- Ranitidine: 2 mg/kg PO, 0.5-1 mg/kg IV (onset 30 mins)
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What are the special IVF requirements in pediatrics?
Iv pumps for Neonates, Buritrols for infants, minidrips for children < 3 yrs with 250 cc bags. REMOVE ALL AIR BUBBLES
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What are the ET measurements we need to know?
- ETT and suction catheter size (see next slide)
- ET diameter = {16 + age (years)}/4.
- ET length at lip in cm =12 + Age/2 or Age + 10.
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What are the laryngoscope sizes for pediatrics?
- Miller 0: Preterm, Neonate
- Miller 1: Neonate to age 1.5 years
- Miller 2: Age 3 and older
- Wis-Hippel: 1.5 Age 1.5 to 4
- Macintosh 2: Age 3-6
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What are the sizes and cuff volumes for LMA?
- Size 1.0: Neonate/Infants ? 5kg; 4ml
- Size 1.5: Infants 5 – 10 kg; 7ml
- Size 2.0: Infants/children 10 – 20 kg; 10ml
- Size 2.5: Children 20 – 30 kg; 14ml
- Size 3.0: Children/Small adult > 30 kg; 20ml
- Size 4.0: Normal/Large adolescent/adult; 30ml
- Size 5.0: Large adolescent/adult; 40ml
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What is the single breath induction?
- Single VC breath of 8% Sevo with 70% N2O.
- Occlude circuit and fill with Agent, open APL.
- Flavor mask, stickers, or color mask (keep child engaged)
- Child takes a deep breath, blows it out, then holds his/her breath.
- Place mask, and let breath mixture.
- Hold breath again and repeat while keeping mask against child’s face
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What is the slow inhalation technique induction?
- Most common technique for children. (steal induction)
- Excitement stage1 to 3 L/min of O2 and N2O with volatile gradually increased in 0.5% increments.
- Initially, mask does not touch face until lid reflex disappears.
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Why is an inhalation induction so fast in kids?
Fast inhalation in kids because lower FRC, higher alveoli ventilation, and higher blood flow to VRG. Rapid rise in FA/FI
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What is the leak we want??
Ensure slight tube leak (10-25 cm H2O)
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What is emergence delirium or agitation?
- A dissociative state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolable crying, moaning, kicking, or thrashing.
- Typically lasts 5-15 mins post op and is self limiting.
- Reported in up to 5% of adult case but can be as high as 15 -50% in children (one study reported 80%)
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What are the causes for emergence delirium?
- Rapid emergence
- Anesthetic choice
- Pain
- Surgical type– (Tonsils, thyroid, middle ear)Age (2-5)
- Preoperative anxiety
- Temperament
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What can we give for pain to prevent emergence delirium?
- Toradol 1 mg/kg
- Intranasal fentanyl 2 mcg/kg
- IV fentanyl 2.5 mcgs/kg
- Clonidine 3 mcg/kg
- Dexmetatomindine.
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How long does emergence delirium or agitation last in pediatric patients?
typically lasts 5-15min post-op and is self limiting
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What is the O2 consumption in newborn, children, and adults
- 5-8 cc/kg/min in newborn
- 4-6 cc/kg/min in children
- 3-5 cc/kg/min in adults
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When would we use LR and when would we use D5?
- Use LR for fluid replacement in healthy child.
- Use 5% dextrose for premature, septic, infants of diabetic mothers and those receiving TPN. Measure blood glucose closely.
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What are the estimate blood volumes for each age/sex
- Premature Infants = 100 ml/kg
- Term Newborn = 95 ml/kg
- 1 year age = 75 ml/kg
- 3 years age to adult 70 ml/kg
- Adult female = 65 ml/ kg
- Adult male = 70 ml/kg
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10 cc/kg packed RBC will raise HCT __-___%
3-4%
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when would we give FFP and how much would we give?
10-20 cc/kg FFP if bleeding is acute
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What does 1ml of FFP contain?
1 ml of FFP contains1 unit of coagulation factor activity
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1 unit/kg of Factor VIII will raise plasma level by __%
2%
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1 unit of platelets contains how many platelets (and in how much plasma)?
1 unit of platelets contains at least 5.5 x 10 platelets in 50 to 70 ml of plasma
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How would we dose platelets?
1 unit/10kg or 20 ml/kg
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If EBL is 1/3 of allowable blood loss, what should we replace it with? What if it's more than allowable blood loss?
- If EBL is 1/3 of ABL, replace with LR. If greater than 1/3, consider replacement with 5% Albumin.
- If EBL > ABL, Use PRBC with colloid. Platelets and FFP should be guided by blood tests.
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