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Flashcards in Neonatal 2 Deck (26)
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1

What is choanal atresia?

Tx?

  • blockage at the back of the nasal passage by bone or soft tissue
  • Usually associated with other congenital issues
  • Unilateral or bilateral diagnosed based on the inability to pass a small catheter through each nare
  • Surgical tx required during neonatal period
  • Oral airway may be necessary until surgery

2

What is a congenital diaphragmatic hernia?

Sx

initial tx

  • Herniation of the abdominal viscera through a defect in the diaphragm
    • usually on the left via foramen Bochdalek
  • Sx:
    • severe resp distress at birth
    • cyanosis
    • scaphoid abdomen (guts are up in lungs)
    • can be seen on x-Ray
  • Initial treatment in delivery room:
    • avoid aggressive mask ventilation
    • urgent intubation
    • decompress stomach
    • maintain PaCO2 < 40 and optimal oxygenation

3

What must be avoided in a pt with a congenital diaphragmatic hernia?

Plan of care?

 

  • Must avoid iatrogenic volutrauma (over ventilating)!
    • high risk pneumothorax on side opposite of hernia if attempts are made to expand the ipsilateral lung
    • hypoxemia secondary to pulmonary hypoplasia and pulmonary hypertension
    • hypotension d/t overdistention of stomack and mechanical kinking of great vessels
  • Trend is supportive care instead of immediate surgery
    • ECMO
    • HFOV
    • Nitric oxide

4

Anesthetic management of diaphragmatic hernia

  • Awake intubation without positive pressure ventilation
  • adequate IV access
  • a-line 
  • opioids
  • muscle relaxation
  • maintain optimal oxygenation PaO2 >100 and ventilation
  • avoid nitrous
  • anticipate ICU postop

5

What causes apnea of prematurity?

How is it diagnosed?

treatment?

  • Immaturity of the respiratory control centers of the brainstem
    • decreased sensitivity to elevations in CO2
    • both central apnea and obstructive apnea
    • inversely proportional to gestational age
  • Dx
    • apneic periods >15-20 seconds
    • apnea with HR <80-100
    • apnea with desaturation
  • Methylxanthines are primary treatment
    • aminophylline
    • caffeine

6

Neonatal hypoglycemia:

Sx

Who is at highest risk?

  • Sx- can be masked by anesthesia
    • hypotension
    • tremors
    • sz
    • resp distress/apnea, cyanosis
    • high pitched cry
    • irritability
    • limpness
    • lethargy
    • eye rolling
    • poor feeding
    • temp instability
    • sweating
  • Highest risk:
    • infants with intrauterine growth restriction*
    • diabetic mothers*
    • severe intrauterine fetal distress*
    • excessively fasted full-term infants
    • SGA
    • infants of diabetic mothers

7

What is considered hypoglycemia?

Full term neonates?

Premature infants?

  • Full term neonates: <40 mg/dL during first 24 hours after birth 
    • <60 mg/dL at 36 hours
  • Premature infants: <45 mg/dL during first 24 hour
    • later than 24 hrs <50 mg/dL

8

How is neonatal hypoglycemia prevented?

  • 1st 48 hours IV maintenace fluid should contain 10% glucose in 0.2% saline with 22 mmol/L K
  • After 48 hrs: 5% glucose
    • pre-terms will have increased requiremnt

9

How is hypoglycemia treated?

  • bolus of 0.25 to 0.6 g/kg
    • 1-2 ml/kg of D25 W 
    • 2.5-5 ml/kg of D10 W
  • After bolus start infusion
    • bolus will stimulate insulin production and pt will return to hypoglycemic state
  • glucose should be in MAINTENANCE FLUID ONLY
  • check bs frequently

10

Hypocalcemia:

Who is affected?

Causes

  • At birth there is abrupt loss of maternal Ca
    • by third day of life Ca levels return to normal in full-term neonate
    • premies don't benefit from the transfer of maternal calcium
  • Hypocalcemia in nearly 40% of critically ill neonates
  • Causes:
    • PTH insufficiency
    • inadequate Ca supplementation
    • altered calcium metabolism caused by citrated products
    • bicarb administration
    • diuretics (furosemide)

11

Hypocalcemia symptoms

  • may be asymptomatic
  • neuromuscular irritability (myoclonic jerks, exaggerated startle, sz)
  • tachycardia
  • prolonged QT interval
  • decreased cardiac contractility

12

Hypocalcemia treatment

 

  • 90 mg/kg calcium gluconate or 30 mg/kg calcium chloride by slow IV infusion over 5-10 min
    • while monitoring for bradycardia
  • Calcium gluconate is vesicant, can go through IV but watch closely! 
    • causes necrosis and subcutaneous calcification
  • Calcium chloride must go through central line
  • Consider need for Mg supplementation as well!

13

Which CHD present as CHF?

What are CHF symptoms in newborn?

  • CHDs
    • VSD
    • PDA
    • critical aortic stenosis
    • coarctation of the aorta
  • Newborn CHF symptoms
    • poor feeding
    • irritability
    • sweating
    • tachycardia
    • tachypnea
    • decreased peripheral pulses
    • poor cutaneous perfusion
    • hepatomegaly

14

Which CHDs present as cyanotic?

  • Tetralogy of Fallot
  • transposition of the great arteries
  • hypoplastic left heart syndrome

15

What is meningomyelocele?

Anesthesia considerations?

  • hernial protrusion of a part of the meninges and spinal cord through a defect in the vertebral column
    • These pts often have chiary malformation (caudal displacement of medulla)
  • Anesthesia considerations:
    • protect defect with positioning (difficult during intubation)
    • anticipate larger insensible losses
    • high possibility of hydrocephalus, esp after surgical repair
    • possibility of CN palsy affecting vocal cord and causing resp distress/stridor
    • potential for brainstem herniation
    • higher incidence of latex allergy
    • No NMB d/t neuromonitoring

16

What is an arnold chiari malformation?

How is it treated?

  • Caudal displacement of the medulla
    • often seen with meningomyelocele
  • Treatement:
    • relief of hydrocephalus and possible cervical decompression of herniation
    • trach and long-term ventilation may be required

17

What is esophageal atresia?

How is it diagnosed?

  • Esophagus doesnt form correctly and communicates with the trachea causing aspiration peumonitis
    • esophagus ends in a blind pouch
  • suspect this with polyhydramnios
  • diagnosed by inability to pass a suction catheter into the stomach
  • Suspect other anomolies (VATER, VACTERL)
  • GET ECHO before anesthesia

18

What are the different types of TEFs?

(pic)

19

Airway management with esophageal atresia

  • anticipate pt to have aspiration pna- may require g-but before esophageal surgery
  • Airway management:
    • hold feedings
    • place soft suction in the esophagus to drain saliva
    • position prone in a head-up position
    • plan for awake intubation with sedation
    • intentionally right mainstem then back out to BBS
      • ideally you want end of ETT bast fistula but above bifurcation

20

How do you want to ventilate a pt with esophageal atresia?

How might you manage post-op pain?

  • spontaneous assisted ventilation is best to avoid stomach over distention until the fistula is ligated or g-tube is placed
  • watch preductal and post ductal SpO2
  • Consider left precordial stethescope under left axilla to continuously monitor for r mainstem intubation
  • May require post-op ventilation
  • post op pain may be managed with caudal catheter

21

What is an omphalocele?

Gastroschesis?

What complications can occur?

  • They are major defects in the closure of the abdominal wall that result in exposure of viscera
  • omphalocele is covered by peritoneium
    • comon to have cardiac abnormalities as well
  • gastorschesis is not covered by peritoneum
  • Complications:
    • severe dehydration
    • massive fluid loss
    • heat loss
    • complex surgical closure (staged)
  • Get echo before anesthesia
  • anticipate post-op ventilation

22

Omphalocele/gastroschisis repair anesthetic considerations

  • Early repair reduces the potential for infection and compromis of bowel function, minimizes fluid and heat loss
  • must optimize fluid and electrolyte balance before surgery
  • obtain good IV access
  • anticipate need for TPN postop
  • expect invasive monitoring if cardiac defect is present
  • expect to need lots of muscle relaxant to close the defect
  • anticipate hypotension secondary to tension on liver or caval compression
  • increased abdominal pressure after closure impairs ventilation
  • risk of abdominal compartment syndrome

23

Omphalocele is associated with what syndrome?

 

  • Beckwith-Wiedemann syndrome
    • profound hypoglycemia
    • hyperviscosity syndrome
    • congenital heart disease
    • visceromegaly

24

What is different between omphalocele and gastroschisis?

(table)

25

What is Hirschsprung?

symptoms?

What happens if not treated?

surgical repair?

  • Hirschsprungs is the absence of parasympathetic ganglion cells in the large intestine.  A segment of colon has no paristalsis, delays passage of meconium
    • functional obstruction at level of affected segment
  • Sx consistent with bowel obstruction: bilious vomiting and abdominal distention
  • Can lead to toxic megacolon- this will requie volume replacement and vasopressor support
  • Surgical repairs vary:
    • anorectal myomectomy
    • mucosal resections
    • diverting colostomies
    • transanal pull-throughs

26