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Flashcards in Exam 4: Key Terms Deck (188):
1

What is the incidence of gastroschisis in United States?

1:15,000

2

If the patient is presenting for surgery on an omphalocele or Gastroschisis and is hypovolemic what type of intubation must be done?

Awake
RSI after IV atropine and O2

3

At what pressure is and ETT leak acceptable for a patient with an omphalocele or gastroschisis?

30-40 cmH2O
(Higher than normal because of increased intra-abdominal pressures)

4

What are some important considerations during induction for a patient with TEF?

Head up position to minimize aspiration
NG in esophagus to suction continuously
Awake intubation if hemodynamics unstable
RSI if stable

5

What neonatal surgical emergency requires an awake intubation and avoiding use of a mask?

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

What are some important considerations during induction for a patient with a nasal encephalocele?

Positioning important
Awake intubation

7

What is true of the patient's ventilatory status during induction for a cystic hygroma?

Maintain spontaneous ventilation

8

What are some potential benefits for pediatric premedication?

Calms
Better acceptance of mask induction
Less anxiety from parental separation
Calms parents
Diminishes postop behavior changes

9

What are the main electrolyte imbalances seen with pyloric stenosis?

Hypokalemia
Hypochloremic metabolic alkalosis

10

What happens to sodium levels during pyloric stenosis?

Relatively unchanged
-Body will defend volume before pH and thus saves sodium to retain water

11

What is true of the relationship between post op apnea risk and post conceptual age (PCA)?

Inversely proportinal

12

Which preoperative lab values are important to consider when worried about the risk of postoperative apnea?

Hct (and K+)

13

Which routine labs are taken on healthy children preoperatively?

None

14

Which labs are almost always taken for a tonsillectomy and adenoidectomy?

Coags preoperatively

15

What are the signs and symptoms of pyloric stenosis?

Recurrent vomiting
Malnutrition/dehydration
Palpable "Olive" in the epigastrum
Visible peristalsis
Bradypnea
Jaundice (5-10%)
Acidic urine

16

What are the two main types of apnea?

Central: No airflow at nares and no muscular activity (no effort)
Obstructive: Muscular effort without nasal airflow (trying, but can't)

17

What will cause a flattening of the CO2 response curve?

Prematurity
Younger postnatal age
Pre-terms with apnea vs without
Hypoxia

18

What is the incidence of apnea of prematurity in infants less than 30 weeks gestation?

80%

19

What are the contributing factors for AOP?

CNS disease
Systemic illness
Thermal/metabolic disturbances
Airway anomalies

20

What effects do halogenated anesthetics have on muscle tone and FRC?

Decreased muscle tone of airway, Chestwall and diaphragm
Reduced FRC

21

What effects do halogenated agents have on the CO2 response curve and ventilatory response to hypoxia?

Dose-dependent decrease in slope and right shift of CO2 response curve
Depressed ventilatory response to hypoxia

22

What are the elective surgery recommendations based on post conceptual age?

Delay elective surgery beyond 46 weeks PCA

23

Pyloric stenosis is considered what type of emergency?

Medical, not surgical

24

What must be normalized before performing surgery on pyloric stenosis?

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