Lumbar and thoracic epidural in Pediatrics-Technical aspect

The midline approach is most commonly used.

The ligamentum flavum is considerably thinner and less dense in infants than in older children and adults. This makes recognition of engagement in the ligament more difficult and requires both extra care and slower, more deliberate passage of the needle to avoid subarachnoid puncture.

The angle of approach to the epidural space is slightly more perpendicular to the plane of the back than in older children and adults, owing to the orientation of the spinous processes in infants and small children.

The loss of resistance technique should be used, but only with saline, not air. There are several reports of venous air embolism in infants and children when air was used to test for loss of resistance

Use a short (5 cm) 18-gauge Tuohy needle and a 20- or 21-gauge catheter in infants and children.

Epidural kits specifically for infants and children are available

Maximum of 0.4 mg/kg/hr of bupivacaine after the initial block is established, with this dose reduced by 30% for infants younger than 6 months of age.

practice of anesthesia for infants and children-page 879

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The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

sedationstation

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