Question Answer Considerations for the pediatric patient rolling to PACU keep warm, presentable (for the parents), bring with emergency equipment (just in case), Organized, side rails up, side-lying, airway cognizant, tonsil position ***At what point is it ok to leave the patient with PACU staff The CRNA must remain with the child until the patient is stable and the PACU team is comfortable and ready to assume the care of the child. sick ratio 1:1 routine ratio 1:2 rate of emergence is directly related to what? duration of anesthesia (with inhaled agents) T/F – midazolam appears to reduce postoperative agitation false – pull out extra midazolam remaining in the stomach prior to PACU Emergence delirium is especially prevalent in what ages? < 6yrs old How to treat emergence delirium low dose opioids, ketoralac, tylenol, time (the faster you emerge them, the higher the likelihood of emgergence delirium How would emergence delirium cost the facility more $ it may be a reason to delay discharge from the PACU Extubation should be followed immediately by ______ and the patient should not be transported until _____ O2, Sats sustained at >= 95% ***Most frequent and worrisome complication Respiratory insufficiency Most common respiratory events that occur in the PACU Hypoxemia, hypoventilation, upper airway obstruction conditions contributing to hypoxemia hypoventilation, diffusion hypoxia, upper airway obstruction, bronchospasm, aspiration of gastric contents, post-obstructive pulmonary edema, pneumothorax, atelectasis (basically anything that would block normal exchange) Minute volume equation MV = RR * Tv Hypoventilation leads to hypercarbia and alveolar collapse Ventilatory response to CO2 is _____ dependent age Differential diagnoses to hypoventilation muscle weakness, respiratory disturbance, upper airway obstruction, inadequate analgesia (breath holding) clinical hallmarks to airway obstruction O2 desaturation, inspiratory stridor, inspiratory retraction, paradoxical chest wall motion Initial intervention to airway obstruction improve airway patency If the initial intervention to airway obstruction fail (improving airway patency), what are you going to do? add O2, atropine + succinylcholine, reintubate Interventions for post-intubation croup humidified O2, nebulized racemic epi over 10 minutes ***Which postoperative patients would need to be MONITORED (in the hospital) former preterm infants that are < 55 weeks PCA, those who are anemic (hct<30%), and those with ongoing apnea. ***If an infant is deemed as high risk for post-operative apnea, what interventions can be done? prophylactic admin of caffeine (10mg/kg) ***Most common cause of bradycardia in infants and children hypoxemia unless proven otherwise! ***Bradycardia – what should be done In this order: O2 and ventillation, atropine (0,02 mg/kg), if no response – epinephrine (2 – 10 mcg/kg), then standard CPR postoperative Tachycardia may be due to hypoxemia, hypercapnia, hypovolemia, emergence delirium, anxiety, pain, sepsis (fever), hypervolemia, full bladder, previously unrecognized conduction abnormality Postoperative pain should be handled in what way multimodal Postoperative multimodal approach would likely include what? Acetaminophen: oral (15mg/kg) OR rectal (35-45 mg/kg preoperatively), ibuprofen (10mg/kg), ketoralac (0.2 – 0.5 mg/kg IV q 6 hrs) – all of which can drop opioid requirements by 25-30% ***which patients would likely be OBSERVED postoperatively for an extended period of time? former preterm infants 55-60 weeks PCA (anemia and apnea do not need to be present) Medicolegal: Make certain you adhere to “policy and procedures” written for individual institutions (if not it may be used against you) an unanticipated event happens: who should be informed the patient and in some cases, the family. Outcomes in general are to be shared with these problems during patient care that have the potential to cause an undesirable or unanticipated outcome Adverse event How old must a patient be to give consent 18 T/F – Consent means to agree to something after thoughtful consideration false (this is assent) Process that provides patients with sufficient information to make an informed choice regarding anesthesia consent A child with a hx of multiple surgeries may have suggestions that should be considered for the anesthetic TIVA indicated for what kinds of sx strabismus / eye sx, any child with high risk of PONV PACU: Increased emergence delirium with _____ (more/less) soluble inhalation agents less Pediatric patient is on doses of theophylline – would they take their morning dose? yes All patients < _____ (what age) need to be admitted for monitoring if receiving general anesthesia full term neonates less than 30 days of age Post conceptual age formula PCA = weeks of age at birth + weeks of age since birth. For example: 25 weeks at birth + 15 weeks since birth = 40 weeks PCA two biggest reasons for tachycardia in the peds patient anxiety and pain prolonged intubation is > ____ (how long) 2 hrs risk factors for post intubation stridor age < 4 years old, multiple attempts at intubation, prolonged intubation, head and neck sx, URI, coughing vigorously prior to intubation, airway trauma, inhalational injury, hx of asthma ways to treat post intubation stridor avoid agitation (crying), cool mist O2, inhaled racemic epinephrine, decadron, reintubation