*Fullterm vs. premature

*Respiratory problems at birth

*Any other birth complications (On O2, ventilator, subglottic stenosis)

*Apena monitor at home

*How long in NICU

*Given Nephrotoxic Abx

*Feeding Problems

*Hitting the developmental milestones?

*Weight proportional to height

*Snoring when sleeping

*Walking (if regresses back to crawling think MD)

*Breath holding spells

*Childhood Obesity

*Adolescent pregnancy

*Allergic Rhinitis

*Vasomotor Rhinitis-crying

*Prodromal stages of systemic viral illness (Varicella, rubeola influenza)

*Prodromal stages of bacterial illness (epiglottitis, adenotonsilitis)

*Sinusitis

*Increased nasal secretions---> Laryngospasm

*Increased lower airway secretions--> Atelectasis/Pneumonia

*Increased airway edema and inflammation--> Postintubation croup

*Increased tachykinins--> Airway reactivity

*Decreased Muscarinic respiratory function-->Airway reactivity

*How often does the child have asthma attacks?

*What precipitates attacks?

*Is the child on chronic medication? (How often, what kind, Oral or inhaled)

*Has the child taken corticosteroids in the last six months? Ever? Oral or Inhaled?

*Intal

*Mast Cell Stabilizer

*Singular

*Leukotriene Inhibitor

*5mg/kg IV load over 15 minutes then 0.5-1.2mg/kg/h

*Watch for toxicity

*Not a first line drug

*Also used in apnea of prematurity

*Rheumatoid Arthritis

*Ulcerative Colitis

*Asthma

*Transplant

*Sickle Cell Disease

*MS

*Give stress dose d/t suppression of hypothalamic-Pituitary Axis & ceasing of production of endogenous steroids

*Innocent murmur or significant lesion

*Risk of paradoxical embolism

*Dyspnea, tachypnea, sweating

*HTN

*Needs for prophylactic Abx

*Hemoconcentration

*Previous heart surgery

*Cardiac workup/old records

*Seizures

*Hydrocephalus- need prophylactic Abx

*Meningomyelocele/tethered cord

*Head Injury

*Cerebral Tumors- most are benign

*Latex Allergy

*Renal Infections

*Impaired Renal function

*Difficulty positioning d/t contractures

*Cerebral Palsy

*Muscular Dystrophy

*Down's Syndrome

*C1-C2 instability

*Should have films on hand to confirm or deny.  If films are not available or done, do not hyperextend neck, or put pillow under shoulders.

*30% subsides after 18 months

*30% persists beyond 4 years

*5% experience esophageal stricture

*5% die of complications

*Evidence of aspiration pneumonia

*Reactive airways

*Bronchospasm

*Recent PO intake?

*risk of regurgitation

*Need for IV anti-emetics

*Children with Neural tube defects

*Patients with a history of Atopy (allergy to nuts, strawberries, avacado, bananas anything coming from rubber tree). 

*Health Care Workers

*Hypotension

*Rash

*Tachycardia

*Bronchospasm

*Hypoxemia

*Flushing

What are some to look for in the H&P that may suggest a difficult airway?

*Abnormal face and ears (low set=downs)

*Loose teeth around age 5-6

*Cleft lip and palate, syndromes

*Cervical range of motion - know if Chiari defect is present

*Labs

*Vital Signs

*Malampatti class typically isn't done

*2 hours Clear liquids

*4 hours breast milk

*6 hours formula

*8 hours solids

*PO 0.5mg/kg (max dose 20mg) Give 20 minutes prior to arriving in OR.

*IV- 0.05-0.1mg/kg (2-4mg)

*IV:1-2mg/kg 

*IM: 5-8mg/kg

*Glycopyrrolate

*The location of the fresh gas flows

*Overflow valve

*Reservoir bag

*The volume of the reservoir tube must be greater than the patient's tidal volume otherwise expired gas will enter the bag and contaminate the inspired gas.

*Fresh gas flow must exceed minute ventilation by 50%.

*Unlike the T-piece and Bain, the efficiency of the circuit is unaffected by the respiratory pattern.

*Inexpensive

*Provides the advantages of a non-rebreathing ciruit with reasonable economy of gas use

*The position of the valve closes to the patient's head may be inconvenient for orofacial surgery

*Difficult to perform intermittent positive pressure ventilation effectively.

*Fresh gas flow enters near the patient end and the overflow valve is located near the reservoir bag

*During controlled ventilation the overflow valve is partially closed

*During spontaneous ventilation the overflow valve is open

*The Pethick test

*Functions in the same way as the T-piece, except that the tube supplying fresh gas to the patient is located inside the reservoir tube.

*Inspiration: The patient inspires fresh gas from the outer reservoir tube

*Expiration: The patient expires into the reservoir tube.  Although fresh gas is still flowing into the system at this time, it is wated as it contaminated by expired gas.

*Expiratory pause: Fresh gas from the inner tube washes the expired gas out of the reservoir tube, filling it with fresh gas for the next inspiration.

*Similar considerations apply as for the t-piece

*The Bain is more efficient at eliminating exhaled gas, since the fresh gas is directed down the endotracheal tube, which reduces dead space

*Compact and inexpensive

*Low dead-space

*Low resistance to breathing

*Facilitates scavenging of waste gases

*High fresh gas flow requirement in larger kids

*If the inner tube becomes disconnected or breaks, the entire breathing tube becomes dead-space, leading to severe alveolar hypoventilation.

*High gas flow rates, if the oxygen flush valve is used, may cause lung barotrauma

*Inspiration: The patient inspires fresh gas form the reservoir tube

*Expiration: The patient expires into the reservoir tube.  Although fresh gas is still flowing into the system at this time, it is wasted as it is contaminated by expired gas.

*Expiratory pause:Fresh gas washes the expired gas out of the reservoir tube, filling it with fresh gas for the next inspiration

*The volume of the reservoir tube must be greater than the patient's tidal volume, otherwise the inspired gas will be contaminated by the surrounding air.

*Requires 1.5-2 times the minute ventilation to prevent rebreathing of gases 

*Intermittent positive pressure ventilation may be performed by intermittently occluding the end of the reservoir tube.

*Compact

*Inexpensive

*No valves

*Low dead-space

*Low resistance to breathing

*The bag may get twisted and impede breathing

*High gas flow requirement

*Malnutrition decreases CO2 production 

*Parenteral nutrition increases CO2 production by as much as 70%

*Equipment

*Fresh gas flows

*Minute ventilation

*Valves

*ETT connectors

*The change in atmospheric pressure during inspiration and expiration

*Compliance volume is the distensibility (stretch) of the equipment

*Ayre's T-Piece no valves

*Mapleson Systems with overflow popoff valves

*Should minimize deadspace- use smallest mask you can manage

*Be nonthreatening

*Wide range of different blades: Flagg, Wis, Wis-Hipple, Macintosh

*Miller 2 for ages 2-99

*1kg= 7cm

*2kg=8cm

*3kg=9cm

*4kg=10cm

*3x ID(mm) of ETT

*Length (cm)= age(in years)/2+12

In general, a 3.0 ETT in a neonate can be secured at...

1yr old....

2 yr old....

*9cm at 3mo

*10cm at 1yr

*12cm at 2yrs

*Uncuffed: (age/4)+4

*Cuffed: (age/4)+3

*Airway lesions

*Mandibular hypoplasia

*During RSI

*A buretrol to prevent fluid overload- 100mL in buretrol to prevent overload after induction

*If inpatient, fluid should be on pump

*Radiation 39%

*Convection 34%

*Evaporation 24%

*Conduction 3%

*Warm the room

*Newborns and infants have a large surface to volume ratio thus radiant heat loss in proportionately greater the smaller the infants

*Warming devices

*Room temperature

*Radiant heat lamps

*Protective coverings

*Bair Huggers

*Fluid Warmers

*Plastic

*Heated Circuits

*HME

*"You"

*Brutane or bear hug avialable

*Pulse ox

*Precordial

*BP, Temp (usually axillary), EKG

*Oxygen analyzer

*Capnography, dopplar

*Needle: 2-3cm, 23-25g or a 22g angiocatheter

*Positioning: Fetal lateral sims

*Needle placement:

-The needle should be at 120 degrees.  The characteristic "pop" confirms penetration of the sacrococcygeal ligament (Bring needle down to 90 degrees)

-The needle should then be depressed toward the skin to align the needle approximately in the long axis of the canal. Leave in angiocatheter

-Injection should be after negative aspiration, (lack of blood or CSF) and ffel no resistance. NO SQ bulge should be felt

*An inherited autosomal recessive disorder

*Has a high incidence in ethnic groups exposed to malaria

*Hemolytic anemia

*Hemolytic thalassemia

*With deoxygenation a gel forms at the point of contact between alpha and beta chains causing the hgb to line up and distort the membrane.

*SCD is a group of disorders with HbS

*Hb SS (SCD) 

*Hb SA (SC trait)

*Hb S-Thalassemia

*Hypovolemia, Hypoxemia, Hypothermia

*RBCs sickle at PO2 of 15mmHg

*Vasoocclusive crisis

*Sequestration crisis

*Aplastic crisis

*Prevention

*Gene Manipulation

*Transfusion: Simple vs. exchange

*Bone marrow transplant

*Hydroxyurea- study drug

*Hgb S must be below 40% of Hgb and must be seen by the SCD hematology clinic people prior to surgery.

*They may need blood transfusion to raise their hemoglobin to 10gm/dL

*Keep them warm
*Normocapnic

*Well Hydrated

*Avoid hypotension

*OXYGEN

*Children with HB SC are very vulnerable to the effects of Hypoxemia!

*It is an autosomal dominant Inheritance

*In humans not a single disease but a syndrome