FINAL 1 Flashcards by Timothy Harris

Ex-Premature infants are infants born:

<37 weeks gestation and <60 weeks postconceptional age.

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These premature infants will need _____ hours post-op monitoring for apnea and desaturation

12-24

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3 Factors that Increase the risk of postop apnea

<60 weeks post-conceptual age
Anemia (Hgb < 12)
Secondary Diagnoses (like intraventricular hemorrhage)

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Do you want to give opioids to ex-premature infants?

nope

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Caffeine ____mg/kg IV given intraoperatively can reduce the frequency of apnea

10mg/kg

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These infants at risk of post-op apnea can be discharged _____ hours after free from apnea

12 hours

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Does reginal anesthesia increase risk of post-op apnea?

No- so, they will not require extended monitoring, only ones under sedation or GA.

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Abnormality of Tricuspid Valve where septal and often posterior leaflets are displaced into the RV

Ebstein’s Anomaly

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Ebstein’s Anomaly (if occurs in isolation) is considered what type of lesion?

Acyanotic. But most will have a ASD or PFO and blood will be shunted R to L, causing cyanosis.

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Ebsteins Anomaly can have ____ outflow tract obstruction

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Ebstein’s Anomaly- Tricuspid valve is usually _____ but may be _____

Regurgitant, Stenotic.

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Result of Ebstein’s Anomaly

RA is Dilated and RV is atrialized with reduced RV cavity

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Sx of Ebstein’s Anomaly in Neonates:

Presents as systemic venous congestion and cyanosis which worsens AFTER ductus arteriosus closes, which leads to decreased pulmonary blood flow

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Ebstein’s Anomaly- Anterior valve leaflet is ____ and ___-like, with chordal attachments to the ____ free wall

elongated, sail-like.

Chordal attachments to RV free wall

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Older children are diagnosed with Ebsteins Anomaly bc/ ________ is found

incidental murmur

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Adolescents and adults with Ebsteins Anomaly will have

SVT causing CHF, worsening cyanosis and occasional syncope.

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Patients with Ebsteins Anomaly are at risk for (4 items)

Paradoxical Embolization
Brain Abscess
CHF
Sudden Death

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Classic Signs/Sx of Ebstein’s Anomaly

Cyanosis-depends on degree of R-L shunt
Systolic Murmur- (Left Lower Sternal Border)
Hepatomegaly (d/t hepatic congestion from CHF)
ECG=Tall, broad P waves, possible 1st degree AVB
PST and VT
20% have W-P-W
Echo=Cardiomegaly, R heart can compress lungs and become “restrictive” heart disease.

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Treatment for Ebsteins’s Anomaly

Controversial- may do tricuspid valve repair, Fontan procedure or transplant.

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Treatment of EA in older patients

Prevent associated complication like infective endocarditis, CHF and SVT.
Repair or replace the tricuspid valve and repair the ASD

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Complications of EA repair

3rd degree AVB
SVT
Residual Tricuspid Regurg
Prosthetic Valve Dysfunction

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EA- may be a _____ effect of IV anesthetics

delayed. d/t pooling and dilution of blood in the RA

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3 Major Hazards with anesthetic management of EA.

Depressed RV function and forward flow
Hypoxia d/t increased R-L shunt
SVTs

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Anesthetic goals with EA management (ventilation and cardiac)

Minimize mechanical and metabolic affects of ventilation

Maintain RV contractility

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What is the most common chromosomal disorder?

Down Syndrome (Trisomy 21)

3 most common cardiac anomalies with Down Syndrome

Complete AV canal defect VSD ASD (Others include TOF and PDA)

All of the cardiac anomalies with Down Syndrome have the propensity for

increased pulmonary blood flow (Pulm. HTN)

1 of the most common clinical features with DS

Hypotonia (weak muscle tone) can affect patency of airway.

Issues with DS that adds to risk of upper aw obstruction

Large Tongue Short Neck Crowded Midface Laryngomalcia (congenital softening of the tissues of the larynx, above the vocal cords).

DS Pts have increased incidence of subglottic and tracheal ______. So ETT size may need to be ____

Stenosis | Smaller

DS Pts need cervical xrays to assess_____

Ligamentous Laxity of Atlantoaxial Joint (Atlanto-Axial Instability)

DS: Postpone the case I atlantodens interval is _____ on cervical x-ray

>5mm

Normal Alantodens interval for Adult and Child

Adult < 3mm | Child<4.5mm (<5mm on next slide)

DS: Keep head and neck in _____ position

neutral

What do you know about C1?

"Atlas" Ring shaped Does not have a body

What do you know about C2?

"Axis" | Has fused remnants of the atlas body called the "Odontoid Process" or "Dens"

What is the Alantodens interval (ADI)?

Distance between the odontoid process and the posterior order of the anterior arch of the atlas.

``` Downs Syndrome Chart ____ birth weight _____ stature Congenital ____ Disease _____ susceptibility to pulmonary HTN ______ Sensitivity High arched narrow _____ _____glossia _____gnathia Subglottic _____ Postextubation _____ Upper airway _______- Sleep Apnea ```

``` Low birth weight Short stature Congenital Heart Disease Increased susceptibility to pulmonary HTN Atropine Sensitivity High arched narrow palate Macroglossia Micrognathia Subglottic Stenosis Postextubation stridor Upper airway obstruction- Sleep Apnea ```

``` More DS Chart Dental ________ ________ obstruction Gastroesophageal ____ H_______ Disease Mental _______ Ep_____y St______s _____tonia ______extensibility or flexibility D______ pelvis Alantoaxial ________ Neonatal poly______ Low circulating levels of ___________ Hypothyroidism ```

``` Dental Abnormalities Duodenal obstruction Gastroesophageal reflux Hirschprung Disease Mental Retardation Epilepsy Strabismus Hypotonia Hyperextensibility or flexibility Dysplastic pelvis Alantoaxial subluxation Neonatal polycythemia Low circulating levels of catecholamine Hypothyroidism ```

In utero, abdomen swells with fluid and is resorbed by birth leaving wrinkled abdomen.

Prune Belly Syndrome

Prune belly associated with _____hydramnios and urethral ________

Oligohydramnios | Urethral Obstruction

Prune Belly Syndrome occurs mostly with ______(m/f?)

Males

Is Prune Belly associated with other defects?

Yes 50% Orthopedic involvement 30% GI involvement 10% Congenital Heart Disease and Chromosomal defects

Describe patho of Prune Belly Syndrome as it leads to aspiration pneumonia.

Abdominal overdistention in utero leads to Weak rectus abdominis which interferes with infants ability to EXHALE FORCEFULLY. Leading to inability to cough and clear secretions, leading to Aspiration Pneumonia

What is a frequent GI problem with Prune Belly Syndrome.

Constipation. Will often need stool softeners.

Prune Belly associated with Trisomy ____, and contradictory to previous knowledge, is now associated with 60-80% _____(m/f?)

18 | Females

Discuss the 3 types of Prune Belly Syndrome Classifications

Type 1: Severe Renal Disease, or pulmonary hypoplasia or both. Incompatible with survival Type 2 Neonatal Emergencies with severe uropathy and UTI. Requires multiple surgeries Type 3 Minimal problems as newborn Pro to infections in later childhood

Which type of PBS is associated with neonatal emergencies with severe uropathy and UTI. Will required several surgeries

Type 2

Which type of PBS is associated with minimal problems as a newborn but prone to infections later in childhood

Type 3

Which type of PBS is associated with severe renal disease, or pulmonary hypoplasia or both and incompatible with survival?

Type 1

``` Anesthetic management of PBS Avoid preop ________ Use H2 _______ and sodium ______ _____ intubation or ___ Avoid ______ relaxants Minimal ______ Avoid drugs requiring _____ excretion Controlled _______ Maintenance - inhalation or IV ______ extubation Reginal anesthesia may be ______ ```

``` Avoid preop sedation Use H2 antagonist and sodium citrate Awake intubation or RSI Avoid muscle relaxants Minimal opioids Avoid drugs requiring renal excretion Controlled ventilation Maintenance - inhalation or IV Awake extubation Reginal anesthesia may be preferred ```

Pierre Robin is characterized by (3 things (R.A.G))

Retrognathia (posterior position of the mandible) Airway Obstruction Glossoptosis (tongue falling to back of throat)

Sequence (not syndrome) of fixed fetal position in the uterus inhibiting mandibular growth leading to small mandible and subsequent airway obstruction.

Pierre Robin

Pierre Robin is often associated with ______ syndrome

Stickler

Stickler syndrome characteristics (3 things)

Micrognathia Poor Vision Collagen disorder with hyperflexible Joints

PR also associated with

velocardiofacial syndrome fetal alcohol syndrome bilateral hemifacial microsomia

PR will always have some sort of ______ obstruction and may need to have _____ or _____ position to relieve.

airway | lateral or prone position

PR often have _____ and ______ difficulties (GI)

reflux and feeding difficulties

Surgical management options for Pierre-Robin (3 options)

Tongue-lip adhesion Mandibular distraction Tracheostomy

Tongue Lip adhesion involves

Suturing the inferior portion of the tongue to the lower lip. Relieves AW obstruction and improves feeding. Will need several days postop ventilation. Left intact until child is about a year old

Mandibular distraction is performed in infants ____ months old

< 6

Tracheostomy for PR takes an average of ____ years for decannulation

Pierre Robin are usually difficult mask ventilation and intubation. What techniques should you be prepared to employ? (4)

LMA Nasal Intubation Video Laryngoscopy Suture (o-silk) placed at base of tongue to displace tongue anteriorly

Tongue-lip adhesion or mandibular distraction will require _____ intubation, _____induction with ____ventilation.

nasal inhalation spontaneous

Tongue-lip adhesion will require postop_____, then to ICU, but extubate back in the _____

ventilation | OR- so that you can readily reintubate if needed

Mandibular distraction will have difficulty with ______ ventilation because of the distractors

mask- distractors prevent effective mask ventilation

Cleft lip is usually repaired at age_____ | Cleft palate is usually repaired at age ____

3-6 months | 9-18 months

Technique used to repair hard/soft palates. Usually done before _____ year old

Palatoplasty | 1 year old

Technique used to repair/treat incompetent velopharyngeal sphincter that allows inappropriate nasal air to escape during speech. Done between ___ and ____ years of age

Pharyngoplasty | 5-15 years of age

Clefting AW management is usually straightforward. | Factors that predict difficult laryngoscopic view (2)

Blilateral Clefts | Retronathia

GA with clefting- remain ______ breathing until trachea is secure

spontaneous

Beware using _____ in patients with cleft repair because potential for disruption of repair.

LMA

This type of ETT is preferred for patients with a cleft.

Oral RAE

Due to the fixed length of the Oral RAE, there is an increased risk of _________ intubation

mainstem

For Palate surgery keep MAP ________

50-60 to reduce risk of bleeding

Palate surgery- surgeon infiltrates palate with epinephrine. What is a safemaximal dose?

10mcg/kg for infiltration

Palate correction surgery is long so

positioning and padding is critical. | Protect infant's chest and extremities

Main concern postop for palate repair? | Confirm removal of _____

Postop airway obstruction | Throat pack

Palate repair has risk for tongue, palate and pharyngeal ______. If this occurs, best to:

edema | reintubate and mechanically ventilate for a few days until edema subsides

Rectal dose of Acetaminophen

20-40mg/kg initially | followed by 20mg/kg Q6H

Oral dose of Acetaminophen

10-15mg/kg Q 4-6 hours

Morphine dose IV

0.02mg/kg IV q 3-4 hours

Reginal technique used for cleft palate repair pain control. What nerve does this block and what sensory does this nerve provide?

Bilateral Infraorbital nerve block Maxillary division of trigeminal nerve that exits infraorbital foramen and supplies sensory to the upper lip, choana, maxillary sinus and part of the nasal septum

Craniofacial defect characterized by poorly developed supraorbital ridges, aplastic/hypoplastic zygomas, ear deformities, hearing loss, cleft palate (in 1/3), mandibular and midface hypoplasia

Treacher Collins Syndrome

Another name for Treacher Collins Syndrome

Mandibulofacial dysostosis

TC is associated with mutation on chromosome ____

AW is always a concern with TC and obstruction depends on (3 things)

Degree of Maxillary and mandibular hypoplasia Choanal Atresia Glossoptosis

TC: trach may be needed for those at risk for

OSA and SIDS

TC may be difficult to mask or intubate. | Techniques used for success?

Bullard Laryngoscopy LMA Glidescope Sedation and fiberoptic intubation

TC- make sure you protect the patient's ____

Eyes- d/t zygomatic hypoplasia

TC can be accompanied by congenital cardiac defects so

use antibiotic prophylaxis to prevent subacute endocarditis.

FINAL 1 Flashcards

(91 cards)