Exam 4: Key Terms Flashcards
1
Q
What is the incidence of gastroschisis in United States?
A
1:15,000
2
Q
If the patient is presenting for surgery on an omphalocele or Gastroschisis and is hypovolemic what type of intubation must be done?
A
Awake
RSI after IV atropine and O2
3
Q
At what pressure is and ETT leak acceptable for a patient with an omphalocele or gastroschisis?
A
30-40 cmH2O
Higher than normal because of increased intra-abdominal pressures
4
Q
What are some important considerations during induction for a patient with TEF?
A
Head up position to minimize aspiration
NG in esophagus to suction continuously
Awake intubation if hemodynamics unstable
RSI if stable
5
Q
What neonatal surgical emergency requires an awake intubation and avoiding use of a mask?
A
Congenital diaphragmatic hernia
- Patient only has one good lung and you fear a pneumothorax on the good side
** Dr Pae said this was not a surgical emergency cause you are no longer correcting lung problem. I know this is a key term but this is what he said this year not sure who taught it last year
6
Q
What are some important considerations during induction for a patient with a nasal encephalocele?
A
Positioning important
Awake intubation
7
Q
What is true of the patient’s ventilatory status during induction for a cystic hygroma?
A
Maintain spontaneous ventilation
8
Q
What are some potential benefits for pediatric premedication?
A
Calms Better acceptance of mask induction Less anxiety from parental separation Calms parents Diminishes postop behavior changes
9
Q
What are the main electrolyte imbalances seen with pyloric stenosis?
A
Hypokalemia
Hypochloremic metabolic alkalosis
10
Q
What happens to sodium levels during pyloric stenosis?
A
Relatively unchanged
-Body will defend volume before pH and thus saves sodium to retain water
11
Q
What is true of the relationship between post op apnea risk and post conceptual age (PCA)?
A
Inversely proportinal
12
Q
Which preoperative lab values are important to consider when worried about the risk of postoperative apnea?
A
Hct (and K+)
13
Q
Which routine labs are taken on healthy children preoperatively?
A
None
14
Q
Which labs are almost always taken for a tonsillectomy and adenoidectomy?
A
Coags preoperatively
15
Q
What are the signs and symptoms of pyloric stenosis?
A
Recurrent vomiting Malnutrition/dehydration Palpable "Olive" in the epigastrum Visible peristalsis Bradypnea Jaundice (5-10%) Acidic urine
16
Q
What are the two main types of apnea?
A
Central: No airflow at nares and no muscular activity (no effort)
Obstructive: Muscular effort without nasal airflow (trying, but can’t)
17
Q
What will cause a flattening of the CO2 response curve?
A
Prematurity
Younger postnatal age
Pre-terms with apnea vs without
Hypoxia
18
Q
What is the incidence of apnea of prematurity in infants less than 30 weeks gestation?
A
80%
19
Q
What are the contributing factors for AOP?
A
CNS disease
Systemic illness
Thermal/metabolic disturbances
Airway anomalies
20
Q
What effects do halogenated anesthetics have on muscle tone and FRC?
A
Decreased muscle tone of airway, Chestwall and diaphragm
Reduced FRC
21
Q
What effects do halogenated agents have on the CO2 response curve and ventilatory response to hypoxia?
A
Dose-dependent decrease in slope and right shift of CO2 response curve
Depressed ventilatory response to hypoxia
22
Q
What are the elective surgery recommendations based on post conceptual age?
A
Delay elective surgery beyond 46 weeks PCA
23
Q
Pyloric stenosis is considered what type of emergency?
A
Medical, not surgical
24
Q
What must be normalized before performing surgery on pyloric stenosis?
A
Adequate rehydration Normal electrolytes (Cl >90; HCO3 <30)
25
How does alveolar ventilation of children compared to that of adults?
2x
| 6cc/kg for Peds
26
How does the O2 dissociation curve of neonate s compare to adults?
Left shifted
27
Why do pediatric respiratory muscles fatigue more easily than adults?
Fewer Type 1 fibers
28
When should elective surgery be canceled in a patient with URI?
Purulent rhinitis
Fever (>38.3)
Elevated WBC with bands
Infiltrate by CXR
29
What percent of US children have asthma?
5-10%
30
How does asthma affect ASA status?
Asthma = automatic II
Asthma + daily meds = ASA III
Asthma + steroids = ASA IV
31
What are the characteristics of Bronchopulmonary displasia?
```
Increased airway resistance
Poor long compliance
VQ mismatch
Hypoxemia/O2 desaturation
Increased work of breathing
Chronic wheezing
```
32
For the preterm infant, how is the risk of postoperative apnea related to PCA?
Inversely proportional
33
What are the recommendations for surgery as related to PCA?
Surgery if >52 weeks PCA
| Monitor in hospital if <52 weeks PCA
34
How is PCA calculated?
Age since birth - weeks premature
35
What are the recommendations for children with murmurs and preoperative evaluation?
Healthy child w/ Grade I-II / VI SEM & no symptoms = no work up
Grade III + or symptomatic = preoperative ECHO
36
What is the recommended preoperative Hct level for patients with sickle cell?
Transfuse to Hct of 30% with PRBCs
| Not all may require
37
What are the fasting guidelines (in hours) for solids/milk for 36 mos of age?
< 6 mos = 4 hrs
6-36 mos = 6 hrs
> 36 mos = 8 hrs
38
What are the fasting guidelines for clear liquids for infants < 6 mos, 6-36 mos, > 36 mos of age?
< 6 mos = 2 hrs
6-36 mos = 3 hrs
> 36 mos = 3 hrs
39
What are the preoperative anxiety predictors?
```
>12 months of age
Parental anxiety
Temperament
Social adaptability
Lack of premed
```
40
What is the pediatric preop dose of midazolam?
0.5-0.7 mg/kg oral
41
What is the pediatric dose of fentanyl?
10-15 mcg/kg
42
What is the oral pediatric dose of ketamine?
6-9 mg/kg
43
What percentage of all pediatric surgery in the US is ambulatory?
75%
44
How of patients selected for ambulatory surgery?
General medical condition
Nature and extent of surgery
Degree of postoperative care required
45
Why is sevoflurane the most popular inhalational technique?
Least irritating to airway
| Desflurane = more laryngospasm and emergence excitement
46
What are the doses for pediatric acetaminophen?
```
PO = 20 mg/kg
PR = 40 mg/kg
```
47
What's the pediatric dose for IV toradol?
0.5 mg/kg
48
What is the rule for who can receive a caudal block?
Children < 7 & < 30 kg
49
What are the minimum discharge criteria for children?
```
Stable VS (w/in 20% baseline)
No respiratory distress
Age appropriate ambulation
No N/V
Intact pharyngeal reflexes
Age appropriate LOC
```
50
What procedures are associated with PONV?
T & A, ENT, Ears, Eyes, laparoscopic
51
Which drugs have been implicated in anesthetic neurotoxicity?
Ones the work on GABA and NMDA receptors
52
Is there a correlation between # surgeries and learning disabilities?
> 3 surgeries before age 2 = increased incidence of learning disabilities
53
What are the important anesthetic considerations relating to pyloric stenosis?
Aspiration risk
Dehydration
Metabolic derangements
54
List some of the main differences between omphalocele and gastroschisis
OMPHALOCELE: 1:6000; 2:1 (M:F); 30% mortality; midline to umbilicus; larger; associated with other congenital abnormalities; sac protects bowel from amniotic fluid
GSTROSCHISIS: 1:15000; 1:1 (M:F); 15% mortality; Right of umbilicus; smaller; not associated with other abnormalities; exposed to amniotic fluid
55
What electrolyte disturbances are common with omphalocele and gastroschisis?
Hypoglycemia and hypocalcemia
56
Where should the IV be placed for an omphalocele or gastroschisis?
Upper extremity
57
What is true of intra-abdominal pressure in omphalocele and gastroschisis?
Is increased and must be monitored
58
What are some important things to remember for intraop management of omphalocele and gastroschisis?
Warm OR (80*)
Check glucose, Ca, ABG
SaO2 94-97 (term); SaO2 90-94 (preterm)
Hct > 30%
59
What are the risks associated with primary closure of an omphalocele or gastroschisis?
Increased intra-abdominal pressure
Respiratory, renal, circulatory, GI dysfunction
Cyanotic legs, hypotension, poor venous return
60
What are the risks associated with secondary closure of an omphalocele or gastroschisis?
Infection!
| Less compromise to other organs
61
What is the most common cause of neonatal GI obstruction?
Hirschprung's disease
62
What are the treatment options for Hirschprung's?
"Leveling" colostomy
Definitive = abdominoperineal resection with colon pull-through (when child reaches 10 kg)
63
90% of TEFs are what?
Esophageal atresia with distal fistula
64
What are the associated abnormalities with TEF?
```
Vertebral
Anal
Congenital heart disease
TEF
EA
Renal or Radius anomalies
Limb abnormalities
```
65
How does TEF usually present?
Polyhydramnios
Excessive oral secretions
Cyanosis with feedings
EA with air in stomach = TEF
66
What are the two main postoperative risks associated with TEF?
Aspiration and respiratory infections
67
What is necrotizing enterocolitis (NEC)?
Ischemic condition of GI tract of multifactorial etiology
68
What percentage of NEC patients are premature?
> 90%
69
What are the signs and symptoms of NEC?
```
Abdominal distension/discoloration
Vomiting
Bloody stools
Temperature instability
Shock (due to sepsis and 3rd space losses)
DIC/Thrombocytopenia
```
70
What are the important metabolic preoperative considerations for NEC patients?
Hypoglycemia
Hypocalcemia
Severe acidosis (secondary to ischemia)
71
How is bicarbonate replacement managed?
HCO3 deficit = BD x wt x 0.3
Give half of calculated deficit SLOWLY
72
What is important to remember when considering a NEC patient's fluid status?
Will need aggressive fluid resuscitation (150cc/kg)
However, this may cause IVH
73
What are some postoperative considerations for a NEC patient?
Remain intubated (PPV)
Persistent 3rd space loss
Increased intra-abdominal pressure
Max. Muscle relaxation
25% mortality due to sepsis, gangrenous bowel, resp. failure, IVH, PDA, refractory met. acidosis
74
What is congenital diaphragmatic hernia?
At 4-9 weeks gestation the pleuroperitoneal membrane separates the two cavities. INCOMPLETE CLOSURE of membrane allows bowel herniate into chest when gut returns from yolk sac to the abdomen at 9 weeks gestation
75
How does CDH impact development?
Has severe impact on lung development (particularly on one side)
-aka pulmonary hypoplasia
76
Where do most CDHs occur?
80% Foramen of Bochdalek (posterolateral)
| L:R 5:1
77
What is often the cause of death with CDH?
Progressive hypoxemia, resp. failure, pulmonary HTN
78
The compression of abdominal contents in the chest causes what pathophysiological changes?
```
50% reduction in alveoli
Bronchial arrest @ 11-13wks
Mediastinal shift
Hypoplastic pulm. artery
Pulmonary HTN
```
79
100% of CDH patients have what GI anomaly?
Malrotation of bowel
80
What is the first line of treatment for CDH?
NOT surgical emergency
-medically stabilized
OR
-ECMO
81
What are the important criteria to remember during induction of a child with CDH?
Precordial on side opposite of defect
Awake intubation
NO mask ventilation
-want to avoid PTX on one good side
82
What must be maintained postop for a CDH patient in terms of respiratory status?
Respiratory alkalosis and PPV (determined by lung dz and intra-ab. pressure)
Minimal suctioning
83
What are some potential complications associated with CDH?
Contralateral PTX - do not attempt to expand lungs
Hypothermia
Metabolic acidosis
Persistent pulmonary HTN
84
What is the prognosis for CDH?
90% mortality (resp. distress in 1st hour)
80% mortality (contralateral PTX)
50% mortality (resp. distress 1st 6 hours)
85
What are the indications for ECMO?
Reversible resp. failure
| Meconium aspiration, CDH, drowning, infection, asthma
86
What are the entry criteria for ECMO?
> 34 wk gestation
> 2 kg
Reversible lung dz
80% predicted mortality
87
What are the exclusion criteria for ECMO?
> grade II IVH
| Other life threatening anomalies
88
What is myelodysplasia?
Abnormal fusion of neural groove in first month gestation leaving some portion of brain or cord exposed
89
Where are myelodysplasias most often found?
75% lumbosacral
90
What is the mortality rate associated with myelodysplasias and what is generally the cause of death?
17.6%
| Morbidity: risk of infection secondary to exposed elements
91
What type of myelodysplasia requires an awake intubation?
Nasal encephalocele
92
What is a cystic hygroma?
Large lymphatic malformation
| 10-15% extend to mediastinum
93
What is important to remember about cystic hygromas?
May involve tongue, great vessels, brachioplexus, facial, vagus, phrenic, & hypoglossal nerves
- Airway compromise (+/- difficult intubation)
- Infection
- Bleeding
94
What is true of induction for cystic hygroma patients?
IV atropine before laryngoscopy
| Maintain spontaneous ventilation
95
For almost all neonatal surgical emergencies what must be true of the operating room?
Keep it warm
96
What are some drugs that negatively affect lower esophageal sphincter (LES) tone?
```
Inhalational anesthetics
Opioids
Anticholinergics
Propofol
Beta blockers
Glucagon
Thiopental
```
97
What are some drugs that increase lower esophageal sphincter (LES) tone?
```
Anti-cholinesterase
Cholinergics
Acetylcholine
Metoclopramide
Serotonin
Metoprolol
```
98
What two factors put the patient at high risk for aspiration pneumonitis?
Volume > 25 mL
| pH < 2.5
99
What are some complications associated with diverticulitis?
Bleeding, abscess, perforation, peritonitis, fistula, obstruction
100
The GI tract handles how much fluid and secretions per day? How much of that is not absorbed?
9L/day
| 100 mL not absorbed
101
What is the normal pH of gastric fluid?
1-3.5
102
What effects do sympathetic and parasympathetic stimulation have on GI motility?
Parasympathetic stimulation = Increases motility
| Sympathetic stimulation = Decreases motility
103
Which structure is responsible for preventing aspiration of gastric contents into the lungs and the swallowing of air?
(UES) Upper esophageal sphincter
104
What effect do most anesthetic agents have on UES? What is the exception?
Decrease
Ketamine increases
105
What is the resting pressure for the lower esophageal sphincter (LES)? At what pressure does it become problematic?
```
Resting = 15-30mmHg
Problem = 10 mmHg
```
106
Define barrier pressure
Difference between gastric pressure and LES pressure
107
What is the name of the condition in which regular reflux of stomach acid irritates the esophagus, which leads to histological changes of the esophageal lining?
Barrett's Esophagus
108
Which condition requires an RSI because the LES does not relax properly?
Achalasia
109
What are esophageal varices? What is generally the cause?
Esophageal varices = Dilated veins in the distal esophagus (@ risk for serious bleed)
Cause = portal hypertension
110
What is the treatment for portal hypertension?
Transjugular intrahepatic portosystemic shunt (TIPS)
111
What GI medical emergency leads to sepsis and has the best outcome with early diagnosis (w/in 12 hrs)?
Upper GI perforation
112
What stomach disorder is commonly seen in conjunction with poorly controlled diabetes?
Gastroparesis = Delayed gastric emptying
113
Gastritis is commonly associated with what bacterial infection?
Heliobactor pylori
114
What are the five sections of the stomach?
```
Cardia
Fundus
Body
Antrum
Pylorus
```
115
What is the function of the stomach?
Responsible for food storage and initial digestion
| NOT Nutrient absorption
116
What is responsible for the primary innervation of the stomach?
Vagus nerve
117
What is the treatment for GERD and hiatal hernia?
Nissen fundoplication
118
Intra-abdominal pressure in excess of what decreases venous return?
>15 mmHg
119
What causes shoulder pain following laparoscopic surgery?
Referred pain from stimulation to the phrenic nerve
120
Where does most digestion and absorption occur?
Small intestine
121
How much time does the body produce per day?
1-2L/day
122
Which autoimmune disorder destroys the villi in the small intestine and cause a reaction to eating gluten?
Celiac disease
123
What are the two main inflammatory bowel diseases?
Crohn's disease
| Ulcerative colitis
124
How much bile is stored in the gallbladder?
50 mL
125
What are some causes of pancreatitis?
Alcohol abuse, blockage, trauma, autoimmune, hyperparathyroid, cystic fibrosis
Propofol can cause at high doses
126
What is the most common cause of emergency abdominal surgery?
Appendicitis
127
What is ERCP?
Endoscopic retrograde cholangiopancreatography
| -View the entrance of the common bile duct
128
Where are water and electrolytes absorbed?
Large intestine
129
How do gastric secretions compare to colonic secretions?
```
Gastric = very acidic
Colon = alkaline
```
130
What is the most common manifestation of carcinoid syndrome?
60% Carcinoid heart disease
-Right-sided involvement (tricuspid regurgitation and pulmonary valve involvement)
131
What is octreotide?
Somatostatin infusion
132
What are the four life-threatening causes of agitation during a MAC case?
Hypoxemia
Hypoventilation
Local toxicity
Cerebral hypoperfusion
133
Why might glycopyrrolate be given in conjunction with ketamine?
Glycopyrrolate controls the excessive secretions caused by ketamine
134
Why might glucagon be given for a GI case?
Glucagon relaxes the sphincter of Oddi
135
What does methylnaltrexone do?
Reverses bowel immobility from narcotics (used in ICU)
136
Be able to trace the flow of food from the time it enters the mouth to leaving the body
Mouth-esophagus-stomach-duodenum-jejunum-ileum-cecum-ascending colon-transverse colon-descending colon-sigmoid colon-rectum
137
The appendix lies in closest proximity to what GI structure?
Cecum
138
Where does the pancreas reside?
Immediately below the stomach and next to the duodenum
139
What is the name for the connection between the common bile duct and pancreatic duct? Where does it lie?
Sphincter of Oddi
| Connects to duodenum
140
The common bile duct is made up of what two smaller ducts?
Hepatic duct
| Cystic duct
141
For gastric bypass surgery, what portion of the GI tract is bypassed?
The jejunum connects directly to the esophagus bypassing the stomach and duodenum
142
What is part of the GI anatomy is manipulated during a nissen fundopliation?
The fundus of the stomach is wrapped around the lower esophagus
143
What is the Zenker's diverticulum?
Diverticulum of the mucosas of the pharynx just above the cricopharyngeal muscle (above UES)
144
What effects do sympathetic and parasympathetic stimulation have on GI motility?
Parasympathetic stimulation = Increases motility
| Sympathetic stimulation = Decreases motility
145
Which structure is responsible for preventing aspiration of gastric contents into the lungs and the swallowing of air?
(UES) Upper esophageal sphincter
146
What effect do most anesthetic agents have on UES? What is the exception?
Decrease
Ketamine increases
147
What is the resting pressure for the lower esophageal sphincter (LES)? At what pressure does it become problematic?
```
Resting = 15-30mmHg
Problem = 10 mmHg
```
148
Define barrier pressure
Difference between gastric pressure and LES pressure
149
What is the name of the condition in which regular reflux of stomach acid irritates the esophagus, which leads to histological changes of the esophageal lining?
Barrett's Esophagus
150
Which condition requires an RSI because the LES does not relax properly?
Achalasia
151
What are esophageal varices? What is generally the cause?
Esophageal varices = Dilated veins in the distal esophagus (@ risk for serious bleed)
Cause = portal hypertension
152
What is the treatment for portal hypertension?
Transjugular intrahepatic portosystemic shunt (TIPS)
153
What GI medical emergency leads to sepsis and has the best outcome with early diagnosis (w/in 12 hrs)?
Upper GI perforation
154
What stomach disorder is commonly seen in conjunction with poorly controlled diabetes?
Gastroparesis = Delayed gastric emptying
155
Gastritis is commonly associated with what bacterial infection?
Heliobactor pylori
156
What are the five sections of the stomach?
```
Cardia
Fundus
Body
Antrum
Pylorus
```
157
What is the function of the stomach?
Responsible for food storage and initial digestion
| NOT Nutrient absorption
158
What is responsible for the primary innervation of the stomach?
Vagus nerve
159
What is the treatment for GERD and hiatal hernia?
Nissen fundoplication
160
Intra-abdominal pressure in excess of what decreases venous return?
>15 mmHg
161
What causes shoulder pain following laparoscopic surgery?
Referred pain from stimulation to the phrenic nerve
162
Where does most digestion and absorption occur?
Small intestine
163
How much time does the body produce per day?
1-2L/day
164
Which autoimmune disorder destroys the villi in the small intestine and cause a reaction to eating gluten?
Celiac disease
165
What are the two main inflammatory bowel diseases?
Crohn's disease
| Ulcerative colitis
166
How much bile is stored in the gallbladder?
50 mL
167
What are some causes of pancreatitis?
Alcohol abuse, blockage, trauma, autoimmune, hyperparathyroid, cystic fibrosis
Propofol can cause at high doses
168
What is the most common cause of emergency abdominal surgery?
Appendicitis
169
What is ERCP?
Endoscopic retrograde cholangiopancreatography
| -View the entrance of the common bile duct
170
Where are water and electrolytes absorbed?
Large intestine
171
How do gastric secretions compare to colonic secretions?
```
Gastric = very acidic
Colon = alkaline
```
172
What is the most common manifestation of carcinoid syndrome?
60% Carcinoid heart disease
-Right-sided involvement (tricuspid regurgitation and pulmonary valve involvement)
173
What is octreotide?
Somatostatin infusion
174
What are the four life-threatening causes of agitation during a MAC case?
Hypoxemia
Hypoventilation
Local toxicity
Cerebral hypoperfusion
175
Why might glycopyrrolate be given in conjunction with ketamine?
Glycopyrrolate controls the excessive secretions caused by ketamine
176
Why might glucagon be given for a GI case?
Glucagon relaxes the sphincter of Oddi
177
What does methylnaltrexone do?
Reverses bowel immobility from narcotics (used in ICU)
178
Be able to trace the flow of food from the time it enters the mouth to leaving the body
Mouth-esophagus-stomach-duodenum-jejunum-ileum-cecum-ascending colon-transverse colon-descending colon-sigmoid colon-rectum
179
The appendix lies in closest proximity to what GI structure?
Cecum
180
Where does the pancreas reside?
Immediately below the stomach and next to the duodenum
181
What is the name for the connection between the common bile duct and pancreatic duct? Where does it lie?
Sphincter of Oddi
| Connects to duodenum
182
The common bile duct is made up of what two smaller ducts?
Hepatic duct
| Cystic duct
183
For gastric bypass surgery, what portion of the GI tract is bypassed?
The jejunum connects directly to the esophagus bypassing the stomach and duodenum
184
What is part of the GI anatomy is manipulated during a nissen fundopliation?
The fundus of the stomach is wrapped around the lower esophagus
185
What is the Zenker's diverticulum?
Diverticulum of the mucosas of the pharynx just above the cricopharyngeal muscle (above UES)
186
What procedure (generally performed under MAC) is used to view the upper GI tract? Lower GI tract?
```
Upper = (EGD) Esophagogastroduodenoscopy
Lower = Colonoscopy
```
187
What per engage of a term newborn's total body weight consists of water?
75%
188
What procedure (generally performed under MAC) is used to view the upper GI tract? Lower GI tract?
```
Upper = (EGD) Esophagogastroduodenoscopy
Lower = Colonoscopy
```
