Exam 1: Pediatric Anesthesia pt 2 (pg 18-40)

Question 1

What Transesophageal Fistula (TEF) are A, C, and E?

Answer 1

• A: esophageal atresia (5-8%)
• C: proximal pouch and distal fistula (most common type)
• E: H type- very rare and occasionally detected later in life with recurrent pneumonias

pg 18

Question 2

TEF occurs in 1/3,000 births, 80-85% of these infants have esophagetal atresia with?

Answer 2

with a distal esophageal pouch and a proximal TEF (Type C)

pg 19

Question 3

TEF is usually located where in relation to the carina?

Answer 3

1-2 rings above the carina

pg 19

Question 4

true or false: TEF occurs more in males.

Answer 4

FALSE: TEF is equal in males/females and all races

pg 19

Question 5

When does TEF occur gestationally?

Answer 5

• Weeks 4-5
• d/t error is seperation of trachea from floor of foregut

pg 19

Question 6

TEF is often associated with VACTERL. What does this acronym stand for?

Answer 6

• Vertebral anomalies
• Anus imperforate
• Congenital heart disease
• TracheoEsophageal fistula
• Renal abnormalities
• Limb abnormalities

pg 19

Question 7

How is TEF diagnosed prenatally?

Answer 7

• Polyhydramnios
• Absent/small gastric bubble
• blind ending upper pouch in fetal neck

pg 20

Question 8

What signs/symptoms cause concern for TEF postnatally?

Answer 8

• excessive salivation,
• choking
• coughing
• regurgitation at the first feeding leading to cyanosis,
• respiratory distress causing a distended abdomen from the stomach filling with air when the baby cries

pg 20

The 3 C’s

• Choking
• Coughing
• Cyanosis

Question 9

How is TEF confirmed post-birth?

Answer 9

• Inability to pass NG tube into stomach more than 7cm.
• o Dilated proximal esophagus with air in conjunction with air in the distal stomach on Xray, CT, or direct visualization via bronchoscopy/endoscopy

pg 20/21

Question 10

The following image is likely for what?

Answer 10

TEF
* TEF with esophageal atresia
* Feeding tube coiled in esophageal pouch (yellow)
* Large volume of gas in abdomen (orange)

pg 21

Question 11

why should the proximal pouch tube be secured and placed to continous suction before surgery?

Answer 11

suction lessens risk of aspiration

pg 22

Question 12

What anesthetic airway maneuvers should be avoided prior to surgery for TEF?

Answer 12

• Mask ventilation
• Tracheal intubation

Likely to exacerbate distention.

pg 22

Question 13

how would you stabilize infant prior to TEF surgery?

Answer 13

• get IV access
• correct e-lyte imbalances
• type and cross for blood
• evaluate other possible anomalies such as VACTERL

pg 22

Question 14

How is TEF surgically repaired?

Answer 14

• open via toractomy
• frequently done now via thorascopic approach

pg 22

Question 15

What positioning is common for TEF and why?

Answer 15

Left Lateral Decubitus

Right thoracotomy approach that helps avoid the aortic arch.

pg 22

Question 16

is single lung ventilation required for TEF procedure?

Answer 16

• no
• low flow/ low pressure CO2 can be used to collapse the right lung for exposure

pg 22

Question 17

What can help the surgeon identify the proximal pouch?

Answer 17

naso-esophageal tube

pg 22

Question 18

Steps for surgical repair for TEF

Answer 18

• Fistula is ligated 1st to prevent further air entrapment in the stomach
• Primary “end to end” anastomosis of the esophagus follows the ligation

pg 23

Question 19

Why do you want to keep the infant spontaneously breathing during TEF procedure?

Answer 19

to avoid PPV and achieve awake intubation (can be traumatic and difficult to achieve without a crying infant further adding more air to the stomach)

pg 23

Question 20

What type of induction should be perfromed for pts undergoing TEF procedure?

Answer 20

• IV induction is quicker, more stable, and the use of muscle relaxants can optimize intubating conditions

pg 23

Question 21

Where should the ETT tip be placed in TEF patients?

Answer 21

Inbetween the fistual and carina

pg 23

o Purposeful R stem intubation and then slowly withdraw ETT while auscultating the L chest until BBS are heard.
o Verify with fiberoptic scope and guide ETT into correct placement if needed

Question 22

Gentle mask ventilation with high peak pressures should be used on induced TEF patients. T/F?

Answer 22

False. Ensure peak pressures are low

pg 23

Question 23

TEF Anesthetic considerations

Answer 23

• Frequent ETT suctioning may be required
• After surgical correction ventilation with increased I:E time to re-expand alveoli
• Early extubation can help alleviated pressure on suture lines. However, many surgeons request post-op intubation for days to help prevent pneumonia, atelectasis, or emergent reintubation, & perforation of suture lines
• An in aitu ETT allows suctioning and lung expansion
• Maintain head in neutral position, preventing pulling on surgical esophageal anastomosis
• An epidural catheter from the caudal space or an intrapleural catheter can be left in place for post-op analgesia

pg 24

Question 24

What newborn condition is often diagnosed between 2 - 8 weeks of age with non-bilious projectile vomiting?

Answer 24

Pyloric stenosis

pg 25

• occurs in 1/500 live births
• more frequent in 1st born males (4:1)

Question 25

What is pyloric stenosis?

Answer 25

Hypertrophy/Hyperplasia of muscular layer of pylorus resulting in gastric outlet obstruction. | pg 25

Question 26

What acid-base imbalance is typical for pyloric stenosis?

Answer 26

Metabolic alkalosis with hypokalemia & hypochloremia *(however chronic vomitting and severe cases can lead to metabolic acidosis)* | pg 26

Question 27

Why does metabolic alkalosis occur with pyloric stenosis?

Answer 27

* Kidney excretion of HCO₃⁻ in attempt to maintain a normal blood pH * kidneys excrete H+ and then K⁺ to maintain euvolemia and retain sodium. | pg 26 ## Footnote * Renal response: conserve water and retain Na ions through upregulation of aldosterone. And which H and K ions (which are already in short supply from vomiting) are excreted in urine in exchange for Na. * Can lead to paroxysmal aciduria despite presence of metabolic alkalosis

Question 28

hypertrophied pylorus muscle is described as?

Answer 28

an olived shaped mass in the RUQ | pg 25 lecture

Question 29

how does pyloric stenosis present clinically?

Answer 29

* Projectile, non-bilious vomiting * Immediate postprandial vomiting * Infant is hungry between feedings (hungry vomiter) * On US: Target or donut sign | pg 25 lecture

Question 30

Is pyloric stenosis a medical emergency typically?

Answer 30

No. 24-48 hours are typically taken to correct electrolyte imbalances | pg 26

Question 31

what IVF are infants with pyloric stenosis started on for maintenance and electrolyte balance?

Answer 31

D5NS with 20mEq/L of K (10-20mL/kg/hr) | pg 26

Question 32

When are infants with pyloric stenosis ready for surgey?

Answer 32

* Good skin turgor * Adequate UOP (1-2mL/kg/hr) * Na > 130mEq/L * K> 3.0 mEq/L * Cl> 85 mEq/L * Assess adequate hydration through fontanel assessment | pg 26

Question 33

how is pyloric stenosis diagnosed?

Answer 33

Commonly via US and rarely with barium swallow and XRAY | pg 27

Question 34

infants today are diagnosed quickly with pyloric stenosis, what is effect of this?

Answer 34

less likely to see severe fluid and e-lyte imbalances as in the past | pg 27

Question 35

The "donut" sign is typical for what condition?

Answer 35

Pyloric stenosis | pg 27

Question 36

what is a pyloromyotomy and how is it done?

Answer 36

* pyloric stenosis repai * Most commonly done open or laparoscopic | pg 28

Question 37

how is open pyloromyotomy done?

Answer 37

open is done via periumbilical incision | pg 28/29

Question 38

what are the benefits of laparoscopic pyloromyotomy?

Answer 38

reduced hospital stay, quicker return to oral feeding, preferred cosmetically | pg 28/30

Question 39

How should an infant with pyloric stenosis be induced?

Answer 39

* preoxygenate with 100% O2 * RSI s/t gastric outlet obstruction * Then suction right, center, then left | pg 31

Question 40

What supplies should you have for pyloric stenosis induction?

Answer 40

* towels * large red rubber catheter | pg 31

Question 41

Set up for pyloric stenosis repair

Answer 41

* Styletted ETT * Mil 1 * small handle * Oral airway * mask * red rubber catheter * prop * TB syringe of succs * TB syringe lidocaine * atropine * Tylenol suppository | pg 31

Question 42

What narcotics are typically used for pyloric stenosis?

Answer 42

Trick question. **No Narcotics**! | pg 32

Question 43

What is the pediatric dose of lidocaine for induction?

Answer 43

Lidocaine 1-2 mg/kg | pg 32

Question 44

What is the pediatric dose of atropine for induction?

Answer 44

Atropine 0.2 mg/kg | pg 32 ## Footnote reduces vagal bradycardia that occurs during induction with suctioning and induced vomiting with red rubber catheter

Question 45

What is the pediatric dose of propofol for induction?

Answer 45

2-4 mg/kg | pg 32

Question 46

What is the pediatric dose of succinylcholine for induction?

Answer 46

2mg/kg | pg 32

Question 47

What is the pediatric dose for rectal tylenol?

Answer 47

30-40 mg/kg | pg 32

Question 48

Why would you want to avoid using opioids intraop for pyloric stenosis repairs?

Answer 48

* Quick surgery (< 30min) * Minimal post-op pain and local is given in field at surgical sites | pg 32

Question 49

What type of fluids are used for hydrating infants post-operative for pyloromyomectomy (until adequate oral intake occurs)?

Answer 49

Dextrose containing fluids (for calories & glucose). | pg 32

Question 50

Preop alkalosis of pyloric stenosis pt's leads to post-op apnea, why?

Answer 50

The body’s response to alkalosis is hypoventilation and increased PCO2 so you will see some respiratory acidosis | pg 32 lecture

Question 51

Pyloric stenosis repair necessitates an ____ extubation.

Answer 51

awake b/c considered full stomach and post op respiratory depression is common (apnea monitor for the 1st 24hrs post op) | pg 33

Question 52

What do you want to monitor post op pyloric stenosis repair?

Answer 52

hypoglycemia | pg 33

Question 53

What can be used in small doses after pyloric stenosis repair?

Answer 53

morphine 0.02-0.03 mg/kg | pg 33

Question 54

What condition occurs in 1/2000 births which is a reult of occlusion of the omphalomesenteric artery during gestation and not associated with other congenital anomalies?

Answer 54

Gastroschisis | pg 33/34

Question 55

Where are the herniated viscera typically located in gastroschisis patients?

Answer 55

Typically to the **right** of the umbilicus. | pg 34

Question 56

Why are babies with gastroschisis a high risk for infection and fluid loss?

Answer 56

Functionally abnormal dilated and foreshortened bowel because they are exposed to amniotic fluid in utero and air after delivery which results in inflammation and edema | pg 34

Question 57

What condition occurs in 1/5000 births, where there is failure of the gut to migrate from the yolk sac into the abdomen during gestation

Answer 57

Omphalocele | pg 33/35

Question 58

omphalocele is associated with what abnormalaties?

Answer 58

* genetic * cardiac * urologic * metabolic abnormalities | pg 35

Question 59

where does the omphalocele emerge from?

Answer 59

Emerges from umbilicus and covered in membranous sac | pg 35

Question 60

Between gastroschisis and omphalocele, which one is the bowl morpholgically and usually functions normally?

Answer 60

omphalocele | pg 35

Question 61

Gastroschisis vs Omphalocele: * cause: * location of defect: * associated with:

Answer 61

| pg 36

Question 62

An easy way to remeber ompalocele vs gastroschisis

Answer 62

| pg 36

Question 63

How do we manage both ompalocele and gastroschisis?

Answer 63

* Aimed at maintaining perfusion to the viscera and reducing fluid loss * Cover mucosal surfaces with sterile saline soaked dressings * A plastic wrap is placed over the herniated viscera to decrease evaporative loss and prevent heat loss and hypothermia (much more pronounced with gastroschisis) * Complete surgical reduction or staged reduction with a silastic pouch * The pouch size is reduced slowly allowing gradual accommodation of the abdominal contents into the abdominal cavity without compromising ventilation or organ perfusion. * Usually reduced over a weeks time | pg 38

Question 64

Managment of Gastroschisis & Omphalocele: * Continued volume resuscitation: ____ * Measures to prevent ____ * Intragastric tube can measure pressure that exceeds ____mmHg after primary closure which can cause abdominal ischemia and can result in a surgical emergency * Bowel can become edematous and renal congestion can result in? * ____ and ____ discrepancies from upper and lower extremities * Decreased ____, ____, and ____

Answer 64

Managment of Gastroschisis & Omphalocele: * Continued volume resuscitation: **dextrose IVF** * Measures to prevent **hypothermia** * Intragastric tube can measure pressure that exceeds **20**mmHg after primary closure which can cause abdominal ischemia and can result in a surgical emergency * Bowel can become edematous and renal congestion can result in **decreased urine output, lower extremity congestion, and cyanosis from impeded venous return** * **BP and pulse ox** discrepancies from upper and lower extremities * Decreased **diaphragm function, bilateral lower lobe atelectasis, and respiratory failure** | pg 39 ## Footnote sry, im tired and cant be bothered trying to figure out how to seperate these into smaller FC. feel free to change. -bri

Question 65

Anestheitc Managment of Gastroschisis & Omphalocele: * Warm the room, have what available? * Aspirate the in situ gastric tube- place to suction prior to ____ and place to ____ throughout the case * Preoxygenate with 100% O2 as tolerated * RSI with cricoid pressure * Maintain with O2 and air * No ____ * ____ and ____ for surgical repair

Answer 65

* Warm the room, have **underbody bear hugger, lights, hat, in-line humidifier** * Aspirate the in situ gastric tube- place to suction prior to **intubation** and place to **continuous gravity drainage** throughout the case * Preoxygenate with 100% O2 as tolerated * RSI with cricoid pressure * Maintain with O2 and air * No **N2O** * **Narcotics and muscle relaxation** for surgical repair | pg 39

Question 66

Anestheitc Managment of Gastroschisis & Omphalocele: * Preoperative ____ should be maintained throughout surgery and postoperatively * Monitor Peak Airway Pressure & maintain < ____ mmHg during primary closure * Watch for____ * What may be required during surgery? * ____ intubation and controlled ventilation

Answer 66

* Preoperative **dextrose IVF** should be maintained throughout surgery and postoperatively * Monitor Peak Airway Pressure & maintain **< 25mmHg** during primary closure * Watch for **hypotension** (increased abdominal P can decreased venous return) * Pulse ox on upper and lower extremity to watch venous return from the lower extremity * **Rehydration with crystalloid and colloid** may be required during surgery * **Post operative** intubation and controlled ventilation | pg 40