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Advanced Principles A (Spring 2025) Grayson's Cards > Exam 4: Pediatric Anesthesia 3 (Becky M.) > Flashcards

Exam 4: Pediatric Anesthesia 3 (Becky M.) Flashcards

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1
Q

Laryngospasm is a hyperresponsive ________ ________ d/t noxious stimuli of the ________ ________ nerve.

A

glottic closure reflex

superior laryngeal nerve

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2
Q

What 3 major complications can laryngospasm lead to?

A
  1. complete obstruction
  2. aspiration
  3. negative pressure pulmonary edema
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3
Q

4 reasons why laryngospasm is more common in pedi pts:

A
  1. mask induction
  2. no NMBD
  3. reactive airways/frequent URI
  4. ENT surgery
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4
Q

4 pre-op risk factors for laryngospasm:

A
  1. secondhand smoke exposure
  2. recent resp tract infection
  3. GERD
  4. mechanical irritants - secretions
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5
Q

3 intra-op risk factors for laryngospasm:

A
  1. excitement phase (stage 2) inhalational induction
  2. tracheal intubation/extubation during light anesthesia
  3. Upper airway surgery
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6
Q

7 Preventative measures for laryngospasm

A
  1. avoid noxious stimuli during light anesthesia
  2. good depth of anesthesia beofre airway instrumentation
  3. topical lidocaine
  4. IV lidocaine prior to extubation
  5. suction prior to extubation
  6. extubate awake or deep enough
  7. 100% FiO2 3-5 min prior
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7
Q

Laryngospasm treatment

A
  1. 100% FiO2
  2. positive pressure
  3. Call for help
  4. laryngeal notch pressure
  5. remove stimulus
  6. deepen anesthetic
  7. Succ IV or IM
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8
Q

Laryngospasm Tx

Propofol dose

A

0.5-2 mg/kg

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9
Q

Laryngospasm Tx

Succinylcholine dose:

A

IV: 0.25-0.5mg/kg (up to 2mg/kg)
IM: 3-4mg/kg

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10
Q

What is bronchospasm?

A
  • disorder of smooth muscle
  • increase in airway resistance
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11
Q

Risk Factors of bronchospasm ( 5)

A
  1. asthma
  2. URI
  3. Hx of allergies & anaphylaxis
  4. foreign body ingestion
  5. pts w/ pulmonary edema
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12
Q

Characteristics of Bronchospasm (5)

A
  1. expiratory wheeze
  2. prolonged expiration
  3. increased airway pressures
  4. upslope in CO2 waveform
  5. Hypoxia

↑ ETCO2, ↓ SPO2

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13
Q

Bronchospasm Tx:

A
  1. remove stimulus
  2. deepen anesthetic
  3. 100% FiO2
  4. ↑ expiratory time ↓ PEEP to minimize air trapping
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14
Q

Meds that Tx Bronchospasm

A
  1. Corticosteroids
  2. Albuterol (beta agonist)
  3. IV Mg for persistent bronchospasm
  4. Epi 5-10 mcg/kg
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15
Q

What causes post-intubation/extubation croup?

A

Edema
* large ETT
* multiple DL attempts
* surgical positioning/timing
* age
* URI
* coughing on ETT

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16
Q

Sxms of Post-intubation/extubation croup:

A
  1. barking cough
  2. hoarseness
  3. inspiratory stridor
  4. ↑ WOB
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17
Q

Tx for post-intubation/extubation croup:

A
  1. steroids (IV/nebulized)
  2. Racemic Epi 2.25% (0.05mL/kg)
  3. Supplemental O2 - cool & humidified
  4. Heliox
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18
Q

What is the corticosteroid & dose given for post-intubation/extubation croup?

A

0.05 mg/kg Decadron

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19
Q

When can rebound swelling happen after racemic epi?

A

4 hours

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20
Q

Prevention for post-intubation/extubation croup:

A
  • ensure ETT has a leak < 25cmH2O
  • don’t immediately inflate after intubation
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21
Q

When does post-intubation croup usually present?

A

30-60 min after extubation

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22
Q

Risk Factors for post-intubation laryngeal edema (aka croup)

A
  1. age < 4 yrs old
  2. large ETT, or high cuff volume
  3. multiple intubation attempts
  4. prolonged intubation
  5. coughing/bucking
  6. head/neck surgery
  7. Hx of infection/post intubation croup
  8. Trisomy 21
  9. URI
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23
Q

What 4 Pt histories indicate difficult airway?

A
  1. previous difficult airway
  2. snoring/difficulty breathing w/ feeding
  3. resp infections or croup
  4. syndromes
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24
Q

Difficult Airway - Syndromes

Small Underdeveloped Mandible - Please Get That Chin

A
  1. Pierre Robin
  2. Goldenhar
  3. Treacher Collins
  4. Cri du Chat

videoscope/fiberoptic

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24
# Syndromes - Difficult airway **B**ig **T**ongue
**difficult mask ventilation** * Beckwith Wiedemann * Trisomy 21 (down syndrome) | *oral airway helpful*
25
# Diffiuclt Airway - Syndromes Cervical Spinal Anomaly - **K**ids **T**ry **G**old
**atlanto-axial instability** 1. Klippel-Fell 2. Trisomy 21 3. Goldenhar | *videoscope/fiberoptic*
26
What things should we do with any indication of a difficult airway?
1. No NMBD 2. mutiple sizes of airway equipment 3. different induction option plans 4. 100% FiO2 5. IV access 6. maintain SV 7. external manipulation of trachea 8. LMA & adjuncts 9. difficult airway algorithm!
27
If a foreign body goes into the airway where does it usually go?
R mainstem bronchus - air trapping
28
s/s of foreign body aspiration supraglottic: subglottic:
* cough, stridor, wheeze, decreased breath sounds * Supraglottic: stridor * subglottic: wheezing
29
Do we want PPV or SV when retrieving a foreign body?
SV * PPV pushes the foreign body deeper
30
Anesthetic Considerations in foreign body retrieval
1. may need higher FGF & VA to maintain depth 2. consider TIVA w/ low narcotic 3. prevent coughing/bucking 4. topical lidocaine
31
Foreign body aspirations are high risk for ________, ________, and ________.
Laryngospasm, bronchospasm, post-intubation croup
32
Button battery aspiration creates an ________ environment and leads to ________ ________.
Alkaline (pH 12-13) tissue necrosis (w/i 15 min)
33
If a button battery is in the esophagus what can it erode through?
* trachea * major hemorrhage b/c esophageal vasculature is eroded
34
If a button battery is in the trachea what can it erode through?
spinal cord
35
Who are high-risk patients when a button battery is aspirated?
1. < 5 yr old 2. battery > 20mm 3. prior bleed 4. negative pole or narrow side faces posterior 5. impacted @ level of aorta
36
**Epiglottitis** * organism: * age: * onset: * region affected: * clinical presentation: * Tx:
* bacterial * 2-6 yr old * rapid onset * supraglottic * drooling, dyspnea, tripod, dysphonia, dysphagia, high fever * Tx: O2, urgent aw management, ENT present, Abx
37
**Croup** * organism: * age: * onset: * region affected: * clinical presentation: * Tx:
* usually viral * < 2 yr old * Onset 24-72 hr * laryngeal * s/s: mild fever, inspiratory stridor, barking cough * Tx: humidifed O2, racemic epi, steroids, fluids
38
What special pedi population has developmental delay in socialization & communication skills?
Autism
39
What procedures are commonly done for autism pts?
dental, EUA
40
What are Autistic kids sensitive to?
1. light 2. sound 3. touch 4. pain
41
Autism - anesthetic considerations
1. pre-med 2. +/- parental presence 3. reunite w/ parents in PACU ASAP
42
What airway alterations are present w/ Trisomy 21?
**difficult ventilation/intubation** * small smouth * large tongue * palate narrow - high arch * atlantoaxial instability * subglottic stenosis/tracheal stenosis * OSA * large T & A * chronic pulmonary infections
43
What is the most common congenital heart defect/disease associated w/ Trisomy 21?
* AV septal defect * 2nd: VSD * also, PDA, TOF
44
What adverse cardiac event can happen in inhalational induction in kids w/ Trisomy 21? What should we do?
Bradycardia * slow induction * atropine 0.02 mg/kg * glyco 0.01mg/kg
45
What are 8 other considerations/anomalies w/ Trisomy 21?
1. intellectual disabilities 2. strabismus 3. hypotonia 4. hyperflexible joints 5. GERD 6. Epilepsy 7. Thyroid dz 8. increased incidence of leukemia
46
What is VATER/VACTERL?
**usually 3 of these anomalies** 1. **V**ertebral anomalies - most common 2. **A**nal atresia 3. **C** ardiovascular anomalies 4. **T**racheoesophageal fistula - most common 5. **E**sophageal atresia 6. **R**enal and/or radial anomalies 7. **L**imb defects
47
What is CHARGE Syndrome?
1. **C**oloboma (hole in an eye structure) 2. **H**eart defects 3. **A** - Choanal atresia (nasal passage obstruction) 4. **R**estriction of growth & development 5. **G**enitourinary problems 6. **E**ar Anomalies | *sxms worsen overtime*
48
What procedures will we see CHARGE pts for?
GI/GU
49
What is DiGeorge or CATCH22?
* **C**ardiac - most common * **A**bnormal face (small ears/hooded eyes) * **T**hymic hypoplasia * **C**left lip/palate * **H**ypocalcemia (hypoparathyroidism) * **22 - 22q11.2 gene deletion**
50
Why do CATCH 22 pts need irradiated blood?
Absent thymus - risk of infection
51
When would we forgo nasal intubation for dental procedures?
* difficult airway * bleeding disorder (can cause adenoids to bleed)
52
Type of induction & anesthetic for dental procedures:
* Inhalation - IV placed * GETA w/ nasal RAE tube
53
# Dental procedures What is equipment/meds are needed for nasal intubation?
* Oxymetazoline nasal spray (afrin) * Nasal RAE, Magill Forceps, red rubber or NPA
54
What does strabismus repair fix? Anesthetic Technique?
* corrects misalignment of the extra-ocular muscles & re-establishes the visual axis * GA w/ LMA or ETT (inhalation induction)
55
What reflex should we anticipate being activated w/ strabismus repair?
Oculocardiac - pulling on eye muscles
56
# Strabismus repair S/S of oculocardiac reflex
* bradycardia * AV block * ventricular ectopy * asystole
57
# Strabismus Repair Managment of oculocardiac reflex
* ask surgeon to stop pulling on muscle * glyco 0.01 mg/kg
58
What are risk factors for retinopathy of prematurity?
* prematurity < 30 weeks * Birth weight < 1000g * oxygen toxicity
59
# Retinopathy of Prematurity how does high PaO2 lead to retinopathy of prematurity?
causes abnormal vascular growth
60
# Retinopathy of Prematurity When is retinal maturation complete? What should SpO2 be maintained at in preemies?
44 weeks post conception * SpO2 89-94%
61
Does post-ductal or pre-ductal O2 better correlate with/ O2 sat of retinal vessels?
Pre-ductal * measure pre-ductal on R hand (PDA) w/ structurally normal heart
62
# Retinopathy of Prematurity What does surgery aim to do?
stop abnormal growth of blood vessels in the baby's eye
63
What are causes of OSA in children?
1. tonsillary hypertrophy 2. obesity 3. neuromuscular d/o 4. craniofacial abnormalities
64
What are 3 precautions to take in children w/ OSA?
1. caution w/ pre-med 2. careful titration of opioids 3. may need extended observation post-op
65
What are 3 indications for adenotonsillectomy?
1. obstruction (sleep apnea) 2. infection 3. mass/lesion
66
# T & A What are 2 risks w/ T&A that we need to assess pre-op?
* reactive airway - OSA/infections * bleeding - easy bruising/epistaxis
67
# T & A Anesthetic Management
* ETT - oral RAE * inhalation induction * smooth induction & emergence!! * analgesics & anti-emetics
68
# T & A Deep or awake extubation?
Deep * increased risk of laryngospasm * suction well (OGT)
69
# T & A - anesthetic management What analgesics are helpful?
* opioids * acetaminophen * NSAIDs - controversial (bleeding) * Dexmedetomidine
70
# T & A Complications When does primary bleeding happen? secondary bleeding?
primary: within 6-24hrs secondary: 5-10days after
71
# T & A complications What 2 things should we do to prevent **airway fire?**
* FiO2 < 30% * avoid N2O
72
# T & A How do we need to manage a post-tonsillar bleed?
1. RSI - full stomach 2. volume resuscitation 3. pre-oxygenate L lateral head up 4. ETT 1/2 size smaller 5. extubate awake
73
What is a cleft lip/palate?
Defect in palatal growth in 1st trimester of pregnancy
74
# Cleft lip/palate When is primary cleft lip repaired? Primary cleft palate?
Cleft lip: ~ 3-6 mos Cleft palate: ~ 6-12 mos
75
What 3 syndromes are commonly associated w/ cleft lip/palate?
1. Pierre Robin 2. Trisomy 21 3. Fetal alcohol syndrome
76
# Cleft lip/palate Anesthesia management ETT: extubation: analgesia:
* oral RAE - stitched in place * awake extubation - NO OPA * analgesia: tylenol and opioids
77
What is pyloric stenosis?
**medical emergency** * olive-shaped obstructive lesion (can feel it just below the xiphoid process)
78
Who is pyloric stenosis more common in & when is it commonly diagnosed?
* first born males * Dx 2-12 weeks of age
79
s/s of pyloric stenosis:
1. **nonbilious** postprandial emesis (projectile food vomitng) 2. palpable pylorys 3. visibile peristaltic waves
80
Tx of pyloric stenosis
Pyloroymyotomy - laparoscopic
81
What 3 big things need to be corrected pre-op w/ pyloric stenosis?
1. correct hypovolemia 2. correct acid/base disorders 3. correct electrolyte abnormalities
82
What acid/base disorders and electrolyte abnormalities are present w/ pyloric stenosis?
1. hypochloremic, hypokalemic metabolic alkalosis 2. hyponatremia
83
What type of induction should be done w/ pyloric stenosis?
* modified RSI w/ Roc * saline irrigation and suction stomach first!!
84
Type of emergence/extubation for pyloric stenosis
* awake * concern for post-op apnea & weakness ( < 2 weeks old)
85
Who is inguinal hernia prevalent in? What are the main concerns?
pre-term neonate * small bowel incarceration * ipsilateral testicular injury
86
Anesthetic technique for inguinal hernia
* spinal/caudal w/ GETA * Inhalational or IV * LMA or ETT d/o surgical technique
87
What is a post-op concern w/ inguinal hernia repair in the neonate?
* post-op apnea
88
what is a defect in the abdominal wall (occuring in gestation) when the visceral organs fail to move from the yolk sac back into the abdominal cavity?
**omphalocele:** thin membrane **Gastroschisis:** does not have a membrane
89
What 6 anomalies are associated w/ omphalocele & gastroschisis?
1. **cardiac** 2. **GU** 3. metabolic 4. malrotation 5. meckel diverticulum 6. intestinal atresia | **also Beckwith Weidemann**
90
# Omphalocele & Gastroschisis Which is dehydration more common with?
Gastroschisis * massive fluid loss - exposed viscera & 3rd spacing
91
# Omphalocele & Gastroschisis Anesthetic concerns:
* hypothermia * sepsis * anomalies * increased intra-abdominal pressure * **may need post-op ventilation**
92
# Omphalocele & Gastroschisis Anesthetic Considerations
* 2 IVs * avoid N2O * muscle relaxation * art line * pulse-ox on lower & upper extremity - ensures good perfusion to lower while closing

Advanced Principles A (Spring 2025) Grayson's Cards (17 decks)

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