Pediatric Anesthesia Quiz #6 Flashcards
(140 cards)
1
Q
What type of procedure is a Myringotomy and Ventilating tube insertion, and what type of anesthetic does it require?
A
-Myringotomy is the surgical drainage of accumulated fluid in the middle ear. -Ventilating tubes are often placed in the tympanic membrane as stents which allows for continued drainage of the middle ear.
-very brief procedure, requiring GETA with SEVO inhalation induction, mask ventilation with or without oral airway and usually no iv catheter placement -Intranasal Fentanyl 1‐2 mcg/kg -IM Ketorolac 0.5‐1 mg/kg
2
Q
What condition would require a Adenotonsillectomy?
A
Chronic or recurrent tonsillitis and obstructive adenotonsillar hyperplasia are the major indications for surgical removal of tonsils and adenoids.
3
Q
What could be some side effects to having tonsillar hyperplasia?
A
Tonsillar hyperplasia may lead to chronic airway obstruction, resulting in sleep apnea, carbon dioxide retention, cor pulmonale, failure to thrive,
swallowing disorders, and speech abnormalities.
Children with cardiac valvular disease may be at risk for endocarditis d/t recurrent streptococcal bacteremia
secondary to infected tonsils.
4
Q
Describe a Adenotonsillectomy.
A
Surgical techniques for adenotonsillectomy vary and include guillotine and snare technique, cold and hot knife dissection, suction, ultrasound coblation, and unipolar
and bipolar electrocautery techniques.
5
Q
What are the advantages and risk of using electrocautery intraop.
A
A major advantage of electrocautery dissection is a reduction in the incidence of intraoperative blood loss as well as post‐op primary and secondary hemorrhage.
A major disadvantage is greater pain and poor oral intake post‐operatively.
Keep FiO2 low – risk of airway fire!!!
6
Q
What is the mortality rate and the morbidities associated with Adenotonsillectomy?
A
Mortality associated with adenotonsillectomy is estimated to be 1: 16,000 to 1: 35,000 procedures – wow!
Common morbidities include throat pain, otalgia, poor oral intake, dehydration, obstructive breathing (3y and younger) and post‐op bleeding (> 10y).
7
Q
Children who are scheduled for T&A have a high incidence of ___ ___ and ___.
A
- airway reactivity
- laryngospasm
8
Q
What is the standardized system for evaluation of tonsillar size?
A
0-sugically removed tonsils 1-tonsils hidden within tonsil pillars 2-tonsils extending to the pillars 3-tonsils are beyond the pillars 4-tonsils extend to midline
Pts classified as +3 or greater, having more than 50% of
the pharyngeal area occupied by hypertrophied tonsils, are at increased risk of developing airway obstruction during anesthetic induction.
9
Q
Adenotonsillectomy for a child with OSA: What do patients with OSA experience?
A
-Patients with OSA experience apnea, hypopnea and
flow limitations:
-Apnea –cessation of airflow lasting ≥ 10 seconds
-Hypopnea – a decrease in airflow lasting ≥ 10 seconds
with a 30% O2 reduction in airflow and with at least a
4% O2 desaturation from baseline.
-Flow limitation – narrowing of the upper airway and an
indication of an impeding upper airway closure
OSA is the most common form of sleep‐disordered
breathing (SDB)
A partial or complete collapse of the upper airway
that causes muscles controlling the soft palate and tongue to relax
10
Q
What is the Apnea Hypopnea Index(AHI) and describe the grading system associated with it.
A
-The AHI (Apnea Hypopnea Index) is the
summation of the number of obstructive apnea
and hypopnea events
-Apnea‐Hypopnea Index (AHI) is the standard measure of OSA during a sleep‐study.
-Measured as total events per hour of sleep
Check out the differences between AHI of
Adults and Pediatrics!!!
Severity of OSA: Adult AHI Pediatric AHI None 0‐5 0 Mild OSA 6‐20 1‐5 Moderate OSA 21‐40 6‐10 Severe OSA >40 >10
11
Q
Describe the anesthetic plan for a Adenotonsillectomy in the pediatric patient with OSA.
A
If OSA‐pt is getting a pre‐med -> observe closely
and monitor with pulse oximetry.
Titrate analgesia (fentanyl ) carefully to the RR –
have pt spontaneously breathing throughout the
procedure!
Remember: Children with severe OSA may
produce an exaggerated resp. depression to
smaller doses of opioids than children without
OSA.
Pts with OSA experience recurrent episodes of
hypoxia and hypercapnia during sleep, which
impairs the arousal mechanism at emergence
from anesthesia.
12
Q
Describe the extubation and discharge of a pediatric Adenotonsillectomy that has OSA.
A
Fully awake extubation after T&A of OSA pt!!!
Suction stomach and pharynx, have nasal airway
in place, titrate carefully more analgesia after
extubation.
To prevent PONV, suction stomach, hydrate well,
give IV “airway”‐dose of Dexamethasone 0.5
mg/kg (max. 10 mg) and 0.1 mg/kg of IV
ondansetron (max. 4 mg).
Discharge policy for ambulatory T&A: OSA pts will
stay over night with pulse oximetry/ apnea
monitor
Otherwise healthy, non‐OSA pt will probably stay
6‐8 hrs for observation.
13
Q
What are the characteristics of a Post-Tonsillecetomy Bleed?
A
POST‐TONSILLECTOMY BLEEDING IS A SURGICAL
EMERGENCY.
This can be primary (within first 24 hrs after
T&A) or
secondary (5‐10 days after T&A, when the
eschar covering the tonsillar bed retracts).
Primary bleed is more serious, more brisk &
profuse.
Consider the circumstances: you might deal with
anxious parents, an upset surgeon, and a
frightened anemic, hypovolemic child with a
stomach full of blood and potentially no IV
catheter.
14
Q
What should be the anesthetic plan for a Post-Tonsillectomy Bleed?
A
Assess the child for dizziness, orthostatic
hypotension and estimated amount of hematemesis.
Place iv catheter, draw lab samples and Type &
Cross and rehydrate pt well before entering the
OR.
Vigorous fluid resuscitation with crystalloids
(repeated boluses of 20ml/kg of balanced salt
solution) and/or colloids to improve CO and
hemodynamic stability before RSI.
RSI with Succinylcholine or Rocuronium, cricoid
pressure, suction catheter and styletted cuffed
ETT, …
After airway is secured, place OGT and suction
stomach – consider large blood clots are often
too large to be suctioned.
Surgeon will find and repair the bleeding vessel
which is generally not very painful.
GIVE IV “AIRWAY”‐DOSE OF DEXAMETHASONE 0.5
MG/KG (MAX. 10 MG) AND 0.1 MG/KG OF IV
ONDANSETRON (MAX. 4 MG).
Awake extubation and close observation
15
Q
Children with long-standing obstructive sleep apnea(caused by hypertrophied tonsils, for example) show what anatomic changes in the heart?
A
-In children with long-standing hypoxemia and hypercarbia, pulmonary artery hypertension and RV hypertrophy develop.
16
Q
What is the average amount of blood lost(in ml/kg) during an tonsillectomy?
A
- During tonsillectomy, blood loss averages 4 ml/kg and must be carefully monitored.
- In terms of percentage, Gregory states that 5-10% blood volume may be lost during a tonsillectomy
17
Q
What are the three complications of tonsil and adenoid surgery?
A
- bleeding
- laryngospasm
- emesis
18
Q
Should extubation be performed while the patient is awake or asleep after a tonsillectomy? Why?
A
An awake extubation is preferred by most anesthetist because risk of aspiration is reduced.
19
Q
What actions are taken if the tonsillectomy patient begins bleeding? What are the major consideration
A
- Initial attempts to control bleeding may be made using pharyngeal packs and cautery.
- If the patient needs to be taken to the OR, intravascular volume must first be restored, and the patient must be considered to have a full stomach because large quantities of blood can be swallowed.
20
Q
What is the problem with an Inguinal hernia and when is it considered an emergency?
A
In an inguinal hernia, a loop of bowel protrudes beyond the internal ring, causing a bulge in the inguinal region or scrotum.
If no bowel ischemia is suspected, elective surgery can
be scheduled.
If strangled bowel is suspected, surgical emergency with full stomach is required.
Regional block (penile block or single shot caudal anesthesia)
21
Q
What nerves are blocked for repair of an inguinal hernia?
A
The ilioinguinal and iliohypogastric nerves are blocked for inguinal hernia repair.
22
Q
What pediatric syndromes are considered difficult airway/intubation?
A
Pierre Robin Sequence Treacher Collins Syndrome Goldenhar Syndrome Beckwith‐Wiedemann Syndrome Klippel‐Feil Syndrome Apert Syndrome, Pfeiffer Syndrome, Crouzon Syndrome
23
Q
What are the characteristics of Pierre Robin Syndrome?
A
-DIFFICULT INTUBATION
-Cleft soft palate ( no cleft lip)—>difficulty with “breath‐suckswallow” pattern, choking and failure to thrive
Micrognathia / retrognathia —>difficult intubation
-Glossoptosis = the tongue being placed further back in the mouth —> partial/complete obstruction of airway and tracheostomy is often required
24
Q
What is Pierre Robin Syndrome? What are the concerns and how should this patient be managed? What intubation technique should be used?
A
- Pierre Robin syndrome is a combination of a cleft palate, migrognathia(small lower jaw with receding chin), glossoptosis(downward retraction or displacement of the tongue).
- Respiratory obstruction may occur(the tongue may cause total airway obstruction) and can lead to cor pulmonate; maintain airway by placing prone on the frame; may require tongue suture, intubation, or tracheostomy.
25
What are the characteristics of Treacher-Collins Syndrome?
-DIFFICULT INTUBATION
-down‐slanting eyes
-notched lower eyelids
-underdevelopment or absence of cheekbones and
the side wall and floor of the eye socket
-lower jaw is often small and receding
-underdeveloped, malformed and/or prominent ears
-Most children with Treacher Collins have normal development and intelligence; however, it is important
that there be early hearing tests & speech interventions.
26
What types of operations may a patient with Treacher Collins require?
These TCS patients may require extensive bony and soft tissue reconstruction over multiple procedures, including orbital and zygomatic reconstruction before age
10, external ear reconstruction, and mandibular advancement as teenagers when bony growth is
complete.
27
Describe the suggested tracheal intubation technique for a patient with Treacher Collins syndrome?
- Treacher Collins syndrome is the most common of the mandibulofacial distress, a group of syndromes that feature mandibular hypoplasia.
- In addition, up to 30% of Treacher Collins patients have an associated cleft palate. An awake tracheal intubation(oral or nasal) with aid of a fiberoptic laryngoscope after adequate topical anesthesia is recommended.
- Miller advocates: (1) topicalization with 1% lidocaine, (2) LMA insertion, followed by (3) fiberoptic intubation through the LMA. Also consider fiberoptic tracheal intubation after inhalational induction.
28
Treacher Collins syndrome is associated with cleft palate, as you know, indicating a difficult airway. What congenital heart disease is associated with Treacher-Collins syndrome?
- Treacher Collins syndrome is frequently accompanied by congenital heart disease, most prominently VSD.
- Concept: ventricular septal defect(VSD) is the most commonly occurring congenital heart disease, therefore VSD is frequently associated with many other congenital anomalies.
29
In addition to cleft palate and VSD, what other conditions are associated with Treacher-Collins syndrome? Is a macroglossia(large tongue) associated with Treacher Collins syndrome?
- Treacher Collins syndrome is associated with cleft palate(30%), VSD, malaria hypoplasia, colhbomas(notching of the lower eyelids), macrostomia(large mouth), malocclusion, and a small oral cavity.
- Treacher Collins syndrome is not associated with macroglossia(large tongue) or mental retardation.
30
What are the characteristics and possible causes of Goldenhar Syndrome?
-DIFFICULT INTUBATION
• Unilateral or bilateral underdevelopment of the
mandible, microtia (small ears), reduction in size and
flattening of the maxilla (upper jaw)
• Causes of Goldenhar Syndrome: thought to be a vascular accident in the fetus. This accident causes the blood supply to be cut off and production of blood clots in the area of those tissues which will develop into the
structures of the ear and lower jaw.
31
Mandibular hypoplasia is associated with what three congenital diseases? Should these patients generally be intubated awake or asleep?
- Patients with Pierre Robin syndrome, Treacher Collins syndrome and Goldenhar syndrome have mandibular hypoplasia and may be difficult to intubate
- These patients are more often intubated after induction of anesthesia with volatile anesthetics.
- While awake intubation can sometimes be accomplished, awake intubation of these patients may produce severe trauma to the upper airway and does not eliminate the risk of pulmonary aspiration.
32
What are the characteristics of Beckwith-Wiedemann Syndrome?
-DIFFICULT INTUBATION
Macroglossia (relatively improves with growth; may require partial glossectomy) --->Difficult intubation
Chronic airway obstruction may predispose to cor pulmonale
Hypoglycemia from increased insulin secretion
Visceromegaly: Large heart, visceromegaly (nephromegaly, hepatomegaly, splenomegaly,
pancreatomegaly)
Omphalocele, increased incidence of intra‐abdominal tumors
33
What are the characteristics of Klippel-Feil Syndrome?
-DIFFICULT INTUBATION
Klippel‐Feil syndrome is a bone disorder characterized by the abnormal joining (fusion) of two or more cervical vertebrae, which is present from birth.
Three major features result from this abnormality:
- -->a short neck,
- -->a limited range of motion in the neck,
- -->a low hairline at the back of the head.
Most affected people have one or two of these characteristic features
34
What three syndromes are associated with Craniosynostois, and what are the major characteristics of these syndromes?
- Apert Syndrome
- Pfeiffer Syndrome
- Crouzon Syndrome
- Major characteristics of syndromic craniosynostosis include:
- -->Skull deformities (premature closing of the cranial sutures
- -->Eyes abnormally far apart
- -->Fusing or webbing of the digits and other abnormalities.
Long‐term, life limiting or life threatening consequences may result from these abnormalities.
35
What are the clinical characteristics of Pierre-Robin Sequence?
-Micrognathia, cleft palate, glossoptosis(posterior displacement of tongue)
36
What are the clinical characteristics of Treacher-Collins Syndrome?
-Hypoplasia of maxilla and mandible, variable eye and ear deformities
37
What are the clinical characteristics of Hemifacial microsomia(i.e. Goldenhar's)?
-Unilateral/bilateral mandibular hypoplasia, variable microphthalmia, microtia, macrostomia(wide mouth)
38
What are the clinical characteristics of Beckwith-Wiedemann syndrome?
-Macroglossia, Visceromegaly/organomegaly, omphalocele, hypoglycemia
39
What are the clinical characteristics of Klippel-Feil syndrome?
-cervical vertebral fusion
40
What are the clinical characteristics of Apert Syndrome, Pfeiffer Syndrome and Crouzon Syndrome?
-Craniosynostosis
41
Difficult Pediatric Airway
It is important to recognize circumstances that may cause airway obstruction or difficult laryngoscopy.
Conditions that predispose to airway problems may be due to congenital or neoplastic disorders, inflammation
(___ ___), trauma (___, ___, ___ ___ ___) or metabolic disorders (___).
- rheumatoid arthritis
- fractures, subluxation, neck burn contracture
- mucopolysaccharidosis
42
What is Mucopolysaccharidosis?
-Mucopolysaccharidosis are a group of metabolic disorders caused by the absence or malfunctioning of lysosomal enzymes needed to break down molecules called glycosaminoglycans(long chains of sugar carbohydrates) in each of our cells that help build bone, cartilage, tendons, corneas, skin and connective
tissue.
43
Describe the laryngoscopical grading system of Cormack and Lehane:(grades I-IV)
Grade I = visualization of the complete laryngeal
opening
Grade II = visualization of just the posterior area
Grade III = visualization of just the epiglottis
Grade IV = visualization of just the soft palate
44
What is the preferred technique when dealing with an difficult airway?
-Preferred technique is when the patient is
either awake but sedated or spontanenously
breathing under GETA with adequate
oxygenation while the airway is evaluated.
-Combi of Benzos & Opioids (Versed &
Fentanyl) or Ketamine & Versed & Glyco or
-SEVO and spray VC with Lidocaine (max. 5mg/kg) – KEEP THE PATIENT SPONTANEOUSLY BREATHING!!!
45
In the event of an unexpected difficult intubation, what is the differences between infants and adults regarding hypoxia?
-Although it is a rare occasion, the practitioner
should be prepared for life‐threatening event.
-Because infants have an increased metabolic rate
and decreased FRC, the time between the loss of
the airway and resultant hypoxemia with
potential secondary neurologic injury is
significantly diminished compared to adults.
-DESATURATION OF 10 KG INFANTS FROM SPO2 90 ‐ 0% WITHIN 4 MINUTES VERSUS 10 MINUTES IN HEALTHY 70KG ADULT.
46
Describe the process of performing an emergency cricothyrotomy.
-Extend the head in the midline with a rolled towel or folded sheet beneath the shoulders; standing to the left of the child, stabilize trachea with the right
hand
-The cricothyroid membrane is located with the index fingertip of the left hand between the thyroid and cricoid cartilages{This space is so narrow (1 mm) in an infant that only a fingernail can discern it. The trachea is then stabilized between the middle finger and thumb of the left hand while the fingernail of the index finger marks the cricothyroid membrane.}
-A large intravenous catheter (12to 14 gauge) is then inserted through the cricothyroid membrane (C), and air is aspirated.
-The catheter is advanced into the trachea through the
membrane, and the needle is discarded; an intraluminal
position is reconfirmed by attaching a 3‐mL syringe
and aspirating for air.
-An adapter from a 3.0 ETT can be attached to any intravenous catheter. Ventilation is accomplished by attaching to a breathing circuit.
IF YOU DON’T HAVE A 3.0 ETT ADAPTER:
An alternative would be to leave the barrel of the 3‐
mL syringe attached to the intravenous catheter,
insert an 8.0 ETT adapter to the syringe barrel, and
then attach to the breathing circuit.
47
Describe the characteristics of Trisomy 21/Down Syndrome:
Small mouth, hypoplastic mandible, protruding tongue may be difficult intubation
Mental retardation
50% have cardiac issues: VSD, ASD, Tetrology of Fallot,…
Hypotonia (floppy‐ ”Downs’s dance!”)
Increased risk of bradycardia on induction
Atlanto‐occipital instability –avoid
hyperextension!
Increased risk of post‐intubation stridor
Increased risk of hypothyroidism, acute
leukemias, …
48
Describe the risk of Atlanta-Occipital Instability in the Down Syndrome patient:
Down syndrome patient needs MRI/CT evaluation of their cervical and temporomandibular anatomy
d/t the unique risk of atlantooccipital instability if neck pain or neurological symptoms exist (e.g.,
abnormal gait, incr. clumsiness, complaints of numbness/
tingling/weakness of an extremities, etc.)
Avoid excessive flexion, rotation, or neck extension during any manipulation of the neck or airway
during mask ventilation or intubation.
HAVE THE RADIOLOGIST/SURGEON HYPEREXTEND HEAD IF IT REQUIRES IT AND DOCUMENT THAT IS WAS PERFORMED BY THE MD.
49
What is a simian crease?
A simian crease is a single palmar crease as compared to two creases in a normal palm. Simian crease occurs in
about 1 out of 30 normal people, but is also frequently
associated with other conditions such as Down Syndrome, Aarskog syndrome or fetal alcohol syndrome.
50
What are three major concerns related to anesthetizing the Down's(trisomy 21) patient?
- Intubation may be difficult owing to the large tongue, short neck, small mouth, and subglottic stenosis(select ETT one size smaller than anticipated)
- Neck flexion during laryngoscopy and intubation may result in atlanto-occipital(cervical spine) dislocation because of congenitally weak ligaments(consider getting cervical-spine films);
- Congenital heart disease is present in 40% of patients(anesthesia compatible with the patient's congenital heart defects should be delivered).
51
What are four pathophysiological features associated with Down syndrome, inanition to difficult airway, atlanto-occipital instability and congenital heart defect?
- Pathophysiological features of Down syndrome also include:
- -->Irregular dentition
- -->Mental retardation
- -->Hypotonia
- -->Tracheoesophageal fistula
- -->Chronic pulmonary infections
- -->Seizures
52
What may be the most important considerations for anesthetizing the Down's patient?
- Intubation of the trachea is generally not too difficult to accomplish.
- Hence, the most important consideration may be the atlanto-occipital(cervical spine) instability.
53
What are the 6 anomalies associated with VACTERL(VATER) Syndrome?
```
V = vertebral anomalies
A = anal or intestinal atresia
C = cardiac anomalies
T E = tracheo‐esophageal fistula
R = renal malformations
L = limb defects
```
Babies who have been diagnosed as having VACTERL association usually have at least three or more of these individual anomalies.
The TE fistula is often accepted as essential for the diagnosis.
54
What are the characteristics of Vertebral anomalies associated with VACTERL Syndrome?
Vertebral anomalies, or defects of the spinal
column, usually consist of small (hypoplastic)
vertebrae or hemivertebra where only one half
of the bone is formed. Risk of scoliosis.
55
What are the characteristics of Congenital heart disease associated with VACTERL Syndrome?
Congenital heart disease (up to 75 percent)‐
most common heart defects seen with VACTERL
association are VSD, ASD and Tetrology of Fallot
56
What are the characteristics of Renal/kidney defects associated with VACTERL Syndrome?
Renal / kidney defects (50%) ‐ these defects can
be severe with incomplete formation of one or
both kidneys or urologic abnormalities.
57
What are the characteristics of Limb defects associated with VACTERL Syndrome?
Limb defects, including absent or displaced
| thumbs, extra digits (polydactyly), fusion of digits (syndactyly) and forearm defects.
58
What are the characteristics of Growth associated with VACTERL Syndrome?
Growth – small stature, difficulty gaining
weight, but normal development and normal
intelligence.
59
What are the pathophysiology behind Cystic Fibrosis?
Autosomal recessive disorder (requires the presence of two copies of a gene mutation in order to express observable phenotype)
Disruption of electrolyte transport in epithelial
cells in sweat ducts, airway, pancreatic duct,
intestine, biliary tree elevated sweat chloride
conc. (test for diagnosis), viscous mucus
production, lung disease, intestinal obstruction,
pancreatic insufficiency, biliary cirrhosis.
-Normal CFTR Channel--->moves chloride ions to the outside of the cell
-Mutant CFTR Channel--->does not move chloride ions, causing sticky mucus to build up on the outside of the cell.
CFTR channel = Cystic fibrosis transmembrane
conductance regulator
60
What are the characteristics of Cystic Fibrosis?
-Lung disease (most common) – mucus plugging d/t
impaired ciliary clearance, chronic infection,
inflammation, bronchial hyperactivity, increased
airway resistance.
ADDITIONAL PROBLEMS WITH CF:
--->malnutrition with increased caloric demand
d/t severe lung disease,
--->diabetes (pancreatic insufficiency),
--->coagulopathy (hepatic dysfunction),
--->end‐stage cor pulmonale (organ
transplantation needed).
--->CF children require multiple surgeries in their
life: e.g.,nasal polypectomy, ENT surgery, central line placement, bronchoscopy/lavage, EGD & colonoscopy, GI surgeries, cholecystectomy, tx of recurrent pneumothorax, organ transplantation, …
61
What are the anesthetic considerations of Cystic Fibrosis?
Anxiolytics (CF patients are emotionally vulnerable!)
Hydrate well
Give nebulized saline Tx before and after surgery
Circuit humidifier, optimize ventilation with FiO2
Expect high airway pressure (be careful with
barotrauma/ pneumothorax)
Suction ETT under deep anesthesia
Complete reversal of neuromuscular blockade
but avoid extra glycopyrrolate (prevent antisialagogue)
Reverse isolation – keep our germs away from
the CF patients
62
What is Cerebral Palsy(CP)?
Cerebral palsy is a term used to describe a group
of chronic conditions affecting body movement
and muscle coordination.
It is caused by damage to one or more specific
areas of the brain, usually occurring during fetal
development; before, during, or shortly after
birth; or during infancy.
Thus, these disorders are not caused by problems in the muscles or nerves. Instead, faulty development or
damage to motor areas in the brain disrupt the brain's ability to adequately control movement and
posture.
This is a group of disorders that are often accompanied by disturbances of sensation, cognition, communication,
perception, behavior and a seizure disorder or mental impairment.
63
What are the risk factors associated with Antenatal CP and what percentage of CP does it make up?
Antenatal:
- prematurity and low birth weight
- intrauterine infections
- multiple gestation
- pregnancy complications
- 70-80% of CP
64
What are the risk factors associated with Perinatal CP and what percentage of CP does it make up?
- birth asphyxia
- complicated labor and delivery
- 10% of CP
65
What are the risk factors associated with Postnatal CP and what percentage of CP does it make up?
- non accidental injury
- head trauma
- meningitis/encephalitis
- cardio-pulmonary arrest
- didn't state the % but if Antenatal is 70-80% and Perinatal is 10%...well you do the math
66
What are the types of Cerebral Palsy and what is associated with each of them?(Athetoid, Spastic, Ataxic, Tremors, Rigidity)
Athetoid: constant, uncontrolled motion of head, limbs and eyes.
Spastic: tense, contracted muscles(most common type of CP)
Ataxic: poor sense of balance; often causing falls and stumbles
Rigidity: tight muscles that resist effort to make them move
Tremors: uncontrollable shaking, interfering with coordination
67
What are the characteristics of fetal alcohol syndrome?
Signs of fetal alcohol syndrome may include:
-Distinctive facial features, including small eyes, an
exceptionally thin upper lip, a short, upturned nose and a
smooth skin surface between the nose and upper lip
-Heart defects (ASD, VSD)
-Slow physical growth pre‐and postnatally
-Small head circumference and brain size (microcephaly)
-Mental retardation and delayed development
- Learning disorders, poor coordination, sleep
problems
-Abnormal behavior, such as a short attention
span, hyperactivity, poor impulse control, extreme nervousness and anxiety
-Vision difficulties or hearing problems
-Deformities of joints, limbs and fingers
68
What 9 cardiovascular signs indicate fetal cocaine toxicity in the newborn of a cocaine-adddicted mother?
- arterial hypoxemia
- increased BP
- increased HR
- increased cerebral blood flow
- reduced cardiac output
- reduced stroke volume
- right ventricular conduction delay
- RV hypertrophy
- ST segment and T wave changes
69
At what age is cleft palate usually repaired?
Cleft palate repair is usually undertaken when the infant is 12-18 months old, but sometimes younger.
70
What is the concern with an infant who has a cleft palate?
In infants with a large cavernous defect of the palate, intubation of the trachea becomes difficult if the blade slips into the cleft and cannot be adequately manipulated.
71
What incubating technique would you use on a child with a cleft palate?
- Insert a small piece of sponge or dental roll to fill the gap of the cleft and thus reduce the likelihood of the blade lodging in the gap.
- Tape the ETT to the lower lip in the midline
- Use a preformed RAE tube to reduce the chance of tracheal tube occlusion by the palate retractor during palatoplasty.
72
Name four conditions in which the patient presents with a large tongue? What is the concern if the patient has a large tongue?
- Down's syndrome
- Pierre Robin syndrome
- Acromegaly
- Hypothyroidism
--->Patients with large tongues are prone to respiratory obstruction.
73
What are the characteristics associated with Necrotizing Enterocolitis?
-Necrotizing enterocolitis (NEC) is not an anomaly
but an illness found mostly in preterm infants.
-Necrotizing enterocolitis with segment of dead bowel.
These infants often have bowel perforation and
hemorrhage from bowel and/or liver.
-They can have severe hypotension requiring vasopressor
support and enormous volume requirements.
-Moreover, because of hemorrhage and disseminated
intravascular coagulopathy, these infants will generally
require transfusions of large amounts of blood products.
74
How do infants with Necrotizing Enterocolitis present?
-NEC infants may appear very toxic with distended and tender abdomen and metabolic and hematologic abnormalities (coagulopathy, DIC).
-X‐Rays suggest initially an ileus with edematous bowel and later demonstrate gas in the intestinal wall (pneumatosis intestinalis) and biliary tract “free gas” in
the intestine after perforation.
75
What is the morbidity and associated risk factors seen with Necrotizing Enterocolitis?
Morbidity associated with NEC includes short bowel syndrome, sepsis, and adhesions associated with bowel obstruction.
Associated conditions/ risk factors include birth
asphyxia, hypotension, RDS (resp.distress syndrome), PDA, recurrent apnea, intestinal ischemia, umbilical vessel cannulation, systemic infections, and early feedings.
76
What is the difference between an Omphalocele and Gastroschisis?
OMPHALOCELE:
Intestines are covered with the amnion.
Defect is at the base of the umbilicus.
GASTROSCHISIS:
Intestines are not covered and exposed to
hypothermia, infection and dehydration.
Defect is periumbilical.
77
What is the difference between an Omphalocele and Gastroschisis in regards to when the defect develops and how often it is seen in live births?
```
OMPHALOCELE:
Failure of the gut to migrate from the yolk sac into the abdomen during 5th‐10th wk gestation.
Earlier defect associated with additional abnomalities
Occurs 1:6,000 births
O‐B‐B‐B memory bridge
O = Omphalocele
B = Base of umbilicus
B = Bag (sac)
B = “Bad news”‐ other anomalies
```
GASTROSCHISIS:
Develops as a result of occlusion of the omphalomesenteric artery during 12th‐18th wk gestation
later with less problems
Occurs 1:15,000 births
78
What is the difference between an Omphalocele and Gastroschisis in association with other birth defects and abnormalities?
```
OMPHALOCELE:
Associated with genetic, cardiac, urologic and metabolic abnormalities:
‐Trisomy 21
‐Beckwith‐Wiedemann S.
‐Congenital heart disease
‐Extrophy of the bladder
```
GASTROSCHISIS:
Not associated with other congenital anomalies; may
exhibit malrotation of GI tract, or intestinal atresia
(atresia = absence of a normal opening).
The herniated viscera and intestines are exposed to
gut inflammation, edema, dilation and functionally
abnormal bowel
79
How are Omphalocele and Gastroschisis treated upon presentation at birth?
-Usually born via C-section
-Immediately after birth the exposed lesions are
covered with sterile, saline‐soaked dressings or
with a plastic silo to reduce the risk of hypothermia,
infection and fluid loss.
-Fluid resuscitation with cystalloids and/or 5%
Albumin and decompression via OGT are initiated.
- In the OR: suction OGT, perform RSI, give paralytics
and observe for markedly increased intraabdominal
pressure and eventually pulmonary pressure (↑PIP) during the reduction of the eviscerated organs and bowel.
-If complete reduction is not possible due to severely
compromised ventilation and organ perfusion, a staged
reduction with the Silo pouch is performed.
80
What are the characteristics of Esophageal Atresia
| with Tracheoesophageal Fistula?
-two problems
The most common form (approximately 85%)
consists of a dilated proximal esophageal pouch
and a fistula between the distal trachea and
esophagus (left).
81
What are the characteristics of Esophageal Atresia alone/
| Tracheoesophageal Fistula alone?
-The second most common form consists of esophageal
atresia alone.
- Neonates with TEF alone often present with pneumonia
as the initial manifestation.
82
What are the 5 types of TEF and the percentage occurrence of each?
- EA with distal TEF(87%)
- Isolated EA(8%)
- Isolated TEF(4%)
- EA with proximal TEF(1%)
- EA with double TEF(1%)
83
What is the specific cause of Esophageal Atresia with Tracheoesophageal Fistula and how often does it occur. How do these infants present, and how is it diagnosed?
Specific cause for EA with TEF is unknown
1: 3,000 births
Affected neonates usually present with excessive oral secretions. Feeding leads to choking, coughing, and cyanosis (hypoxia & bradycardia).
Diagnosis is confirmed by the inability to pass a rigid orogastric tube into the stomach or radioactive dye in the esophageal pouch.
84
What is the anesthetic plan for patients that present with Esophageal Atresia and Tracheoesophageal Fistula?
- Before surgery/ induction, suction upper esophageal pouch via existing OGT.
-Surgeons might decide to do a staged repair of EA with TEF by placing first a gastrostomy tube to vent the stomach and a central venous line for parenteral nutrition –that would give the premature neonate some
time to grow.
-Intubation for TEF repair: often iv induction and spontaneous ventilation is used until the trachea is
secured, particularly if rigid bronchoscopy is used by the
surgeon to determine the position of the tracheal fistula.
-Avoid positive pressure ventilation prior to induction to
prevent gastric inflation.
-For proper ETT placement, right mainstem the ETT,
auscultate while carefully withdrawing the ETT until
bilateral breath sounds are heard tip of ETT is just
above the carina and usually below the fistula (fiberoptic
will verify the placement)
-Carefully secure the ETT in place! If ETT is withdrawn to
the position of the fistula opening, adequate pulmonary
ventilation cannot be guaranteed.
-Preterm infants with poorly compliant lungs
occasionally require positive pressure ventilation, and
ventilation through the fistula is the “path of least
resistance” – you may encounter desaturations.
Additionally, these infants have often other congenital
anomalies.
-Consider thoracic epidural.
-Avoid instrumentation of esophagus or extension of
head after repair – increased risk of repair rupture.
-Early extubation is desired, because it prevents
prolonged pressure of ETT on the suture line; however,
a high proportion of these infants require reintubation.
85
What other anomalies is Esophageal atresia with TEF associated with?
```
Esophageal atresia with TEF are often associated with other congenital abnormalities, in particular the VACTERL (VATER) syndrome:
Vertebral abnormalities
Anus (imperforated)
Congenital heart disease
TEF
Radial aplasia/Renal abnormalities and
Limb abnormalities
```
86
What is epiglottitis and what pathogen causes it?
Epiglottitis is a life threatening infection that usually affects children age 1‐7 years.
Common pathogen: Haemophilus influenzae, but
also Streptococcus, Staphalococcus, Candida,
other fungal pathogens.
The rapid onset & progression of the disease requires urgent diagnosis & treatment
87
What is the characteristics of Epiglottitis?
-Upper airway obstruction with inspiratory stridor, tachypnea and retraction.
-Epiglottitis ‐progressive swelling leads to
trapdoor‐like occlusion of the glottic opening
-Pt sits in tripod position, demonstrates drooling and difficulty swallowing. High fever (>39°C), lethargy, …
88
What is the anesthetic plan associated with epiglottitis?
-A child with airway obstruction from epiglottitis and severe distress is immediately moved to the OR --->
Have surgical team available for rigid bronchoscopy/ tracheostomy/cricothyrotomy.
-Avoid inspection of epiglottis in the ED--->can cause dynamic airway collapse!
-DL: Although the vallecula is obliterated by the swollen lingual tissue, try to place the tip of the blade into the vallecula and lift the base of the tongue, without directly touching the epiglottis.
-Downsize the ETT by 0.5 mm it lessens the risk of pressure necrosis on the mucosa.
-After securing the airway, obtain throat & blood cultures, give appropriate antibiotics, 0.5 mg/kg IV dexamethasone (max.10mg), keep child sedated but allow child to breathe
spontaneously, and transport to ICU.
-Extubation after 24‐96 hrs after supraepiglottic and periepiglottic swelling is reduced, leak around ETT is present and pt shows signs of swallowing. Extubation
preferably done in OR.
89
How is general anesthesia induced in the child with acute epiglottitis?
- parents should be present until the airway is secured.
- the OR should be quiet. Monitors should be applied as tolerated, especially the pulse oximeter.
- Initiate induction with 100% O2/Halothane or O2/Sevoflurane with the patient in the sitting position
- Start an IV, give fluids and atropine and orally intubate.
- Do not use muscle relaxants
- Avoid touching the epiglottis with the laryngoscope blade--->go in the vallecula.
- If oral intubation fails, try with a bronchoscope.
- If that fails, then a tracheostomy is performed.
90
What is Laryngotracheobronchitis, what causes it and in what age does it most commonly occur and what clinical signs?
Laryngotracheobronchitis = Croup
-Croup refers to an infection of the upper airway, generally in children, which obstructs breathing and causes a characteristic seal‐like barking cough.
-Note the steeple or pencil sign of the proximal trachea
(narrow airway between swollen tissue) evident on this
anteroposterior film.
-The cough and other symptoms of croup are the
result of inflammation around the vocal cords/larynx, trachea and bronchi.
-When a cough forces air through this narrowed
passage, the swollen vocal cords produce a noise
similar to a seal barking. Likewise, taking a breath
often produces a high‐pitched whistling sound
(stridor).
-It occurs mostly in children age 6 months to 6 years,
the cause is usually viral and the onset is insidious
with low‐grade fever.
91
How is laryngotracheobronchitis treated?
At first, inhalation of nebulized racemic epinephrine
(0.25‐0.5 ml of 2.25% Epi mixed with 3 ml NS) with O2
mask/ cool humidity are used and often relieve the
airway obstruction. Repeated Tx (1‐4 hrs apart) are
often necessary after relief & rebound airway
obstruction.
If the airway obstruction becomes severe, the child
is treated like one with epiglottitis quick transport to OR for intubation with surgical team rigid
bronchoscope/tracheostomy, etc. available.
The length of intubation, steroid, and follow‐up are similar with epiglottitis patients.
92
How does a child with a foreign body aspiration present, and what is the treatment?
A child that arrives at the ED with presumptive foreign body (FB) aspiration requires immediate assessment. A history of choking and cyanosis while eating (peanuts or popcorn) must arouse strongest suspicion of FB aspiration.
A wheezing child may not be an “asthmatic” but may be due to partial airway occlusion from a FB.
Agitation may be misinterpreted as a state of emotional upset when it is due to serious underlying hypoxemia
If the child is severely distressed because of
partial occlusion of the airway, prepare for
an immediate trip to the OR for removal of
FB.
If child is stable, X‐Ray of the airway may be helpful in identifying and localizing the FB.
93
What is the anesthetic plan for the pediatric patient with a foreign body aspiration?
The possibility of forcing the FB distally in the
airway with assisted ventilation is of great concern --->during induction keep pt spontaneously breathing and spray the VC with 2‐4% lidocaine (5mg/kg max.) before
laryngoscopy.
During the removal of the FB, the pt should be
deeply anesthetized (no coughing or moving!) to
prevent the possibility of dropping the FB in the
proximal airway.
Residual airway edema is possible after the removal of FB, and careful assessment during emergence and in PACU is advised.
Give 0.5 mg/kg dexamethasone IV (max.10mg)
94
What causes Spina Bifida, what is Spina Bifida and how many infants are affected by Spina Bifida?
SPINA BIFIDA = MYELOMENINGOCELE
Myelomeningocele is a developmental defect of the CNS in which a hernial sac [containing a portion of the spinal
cord, its meninges, and CSF] protrudes through a congenital cleft in the vertebral column.
The condition is caused primarily by failure of the neural tube to close during embryonic development.
Myelomeningocele may affect as many as 1 out of every 4000 infants.
95
Discuss the different types of Spina Bifida...as related to their specific abnormalities.
Spina bifida occulta refers to spina bifida that occurs when skin and soft tissues cover the defect. "tuff of hair"
Meningocele or myelomeningocele are lesions where the defect communicates with the outside.
Meningocele is a protrusion of the meninges filled with CSF through a gap in the spine.
Myelomeningocele contains a portion of the spinal cord (myelo =nerve roots), its meninges, and CFS that do not function below the level of the lesion (including no pain
sensation)
96
What conditions normally accompany Spina bifida?
varying degrees of paralysis of the lower
extremities; by musculoskeletal defects such as clubfoot,
flexion and joint deformities, or hip dysplasia;
and
by anal and bladder sphincter dysfunction, which can lead to serious genitourinary disorders (neurogenic bowel and bladder).
Latex prophylaxis (avoiding all latex materials) is recommended for prevention of latex allergy and anaphylaxis d/t subsequent surgical procedures and urinary catheterizations
Hydrocephalus, frequently related to the Arnold‐Chiari malformation, is the most common anomaly associated with myelomeningocele and occurs in approximately 90% of the cases in which the spinal lesion is located in the
lumbosacral region.
Chiari Malformation Type I (CM) is a neurological disorder where part of the brain, the cerebellum (or more specifically the cerebellar tonsils), descends out of
the skull into the spinal area (AKA hindbrain herniation).
This results in compression of parts of the brain and spinal cord, and disrupts the normal flow of CSF which intensifies hydrocephalus.
97
What are the anesthesia considerations for Spina bifida?
ANESTHESIA CONSIDERATIONS WITH SPINA
BIFIDA:
The potential for infection of the CNS dictates early closure of the sac within the first 12‐24 hours of life.
Special positioning and cushioning during anesthesia induction and surgery (possibly lateral position during
intubation!)
Post‐op: pt remains intubated in prone position
98
What is Arnold-Chiara malformation? What are 4 symptoms of Arnold-Chiara malformation?
- Arnold-Chiari malformation is a malformation consisting of an elongated cerebellar vermis that herniates through the foramen magnum and also compresses the brain stem.
- Symptoms of Arnold-Chiara malformation are:
* difficulty swallowing
* recurrent aspiration
* stridor
* possibly apneic episodes
99
A seven-year old patient with spina bifida comes to the OR for a ventricular-peritoneal shut. What is the primary concern?
- The major concern for this patient is the high probability of latex allergy, which may trigger an anaphylactic episode in the OR.
- While the incidence of latex allergy among medical personnel is 6-7%, 18-34% of spina bifida patients have a latex allergy
- Most children who have had intraoperative anaphylaxis had spina bifida.
100
What is Prune Belly Syndrome?
Prune belly syndrome is also known as
triad syndrome. It is characterized by a triad of
abnormalities that include:
Absence or severe weakness of abdominal muscles
Undescended testicles
An abnormal, expanded bladder and problems in
the upper urinary tract, which may include the
bladder, ureters, and kidneys
Because the urinary tract is involved, children with
prune belly syndrome are usually unable to
completely empty their bladders and have serious
bladder, ureter, and kidney problems.
There may be underdeveloped muscles of the
abdomen preventing a child from sitting upright or
walking.
101
List three congenital anomalies associated with prune-belly syndrome?
- Cryptorchidism(undescended testicle)
- Club foot
- Genitourinary tract abnormality
--->Tip: even though the syndrome is called prune-belly, there are no associated gastrointestinal anomalies, not withstanding the underdevelopment of the abdominal musculature.
102
List four anesthesia considerations for the patient with congenital diaphragmatic hernia?
- Use Ketamine 0.5-1.0 mg/kg or Fentanyl 1-3 mcg/kg
- Avoid nitrous oxide
- After the repair, attempt gently to re-expand the lungs under direct vision using pressures no greater than 30 cm H2O
- Anticipate the need for postoperative support of ventilation.
103
What peak inspiratory pressure should be used with a patient who has a diaphragmatic hernia, why?
- Peak inspiratory pressure should be less than 30 cmH20
| - Pneumothorax of the contralateral(usually right) lung occur if peak inspiratory pressure is too high.
104
What might be signaled by a sudden fall in lung compliance(reflected by an increased peak inspiratory pressure), BP, or oxygenation during repair of a congenital diaphragmatic hernia?
-A contralateral(usually right sided) pneumothorax should be suspected.
105
What acid-base and electrolyte abnormalities develop int he patient with pyloric stenosis?
- As a result of persistent vomiting, the infant becomes alkalotic(metabolic alkalosis), hypochloremic, hypokalemic, and possibly hyponatermic.
- The infant is dehydrated with a hypokalemic, hypochloremic alkalosis.
106
A neonate diagnosed with pyloric stenosis presents with a Na+ of 120 mEq/L, CL of 84 mEq/L, and a RR of 16. What is the appropriate course of action for this patient?
- Pyloric stenosis is characterized by persistent vomiting which depletes Na+, K+, CL, and H+ ions, causing hypochloremic metabolic alkalosis.
- In this particular presentation the disturbances are moderately severe and the patient should be given IV D5 1/2 NS with 20-40 mEq/L K+ administered at a rate of 10ml/kg/hr.
- Avoid lactated Ringer's solution, because lactate is metabolized to bicarbonate.
107
What happens to the oxyhemoglobin dissociation curve in pyloric stenosis? Why?
-The oxyhemoglobin dissociation curve shifts to the left because of metabolic alkalosis secondary to vomiting.
108
Is pyloric stenosis a medical or surgical emergency?
- Pyloric stenosis is a medical, but not a surgical, emergency.
- Surgery should be postponed for 24-48 hours until fluid and electrolyte abnormalities are corrected.
109
How is the infant with pyloric stenosis prepared for surgery?
- The emergent therapy for pyloric stenosis is to stop oral intake(stop formula feeding or breast feeding) and metabolically reconstitute the child with intravenous sodium, chloride, potassium, and glucose(dextrose).
- The metabolic abnormalities can be corrected in 12-24 hours by IV therapy.
- Surgery should be postponed for 24-48 hours.
110
What concentrations of sodium chloride(saline), potassium, and glucose are used to prepare the infant with pyloric stenosis for surgery?
- The dehydration and hyponatremia can be corrected with IV saline(0.45 - 0.9%).
- When urine output is restored, potassium(usually 40 mEq/L) must be added to this correct the hypokalemia.
- Maintenance fluid should be added to this regimen, and for this purpose 5% dextrose in 0.225% saline is usually adequate.
111
What is the major concern for inducing an infant who is scheduled for a pyloromyotomy? what do you need to do before inducing a patient with pyloric stenosis?
- Pulmonary aspiration is the major concern during induction.
- The stomach is emptied as much as possible with a large-bore catheter prior to induction.
112
In addition to emptying the stomach, list three actions that should be taken to manage a patient with pyloric stenosis?
- In addition to emptying the stomach:
* Use RSI
* Perform awake intubation
* Extubate awake
113
What are six primary considerations for the pediatric patient with hypertrophic pyloric stenosis?
1. Postpone surgery until volume and electrolyte deficiencies have been corrected
2. Correction of the volume deficit and metabolic alkalosis requires hydration with sodium chloride solution supplemented with potassium
3. Do not use LR because lactate is metabolized to bicarbonate, which would aggravate the metabolic alkalosis
4. The stomach should be emptied prior to surgery
5. There is a high risk of aspiration during induction
6. Postoperative respiratory depression secondary to cerebrospinal fluid alkalosis should be anticipated.
114
What two electrolyte abnormalities will be seen with projectile vomiting?
- Hypokalemia
| - Hypochloremia
115
Compare gastroschisis and omphalocele with regard to location, hernial sac, and associated congenital anomalies?
- GASTROSCHISIS:
* location is lateral to umbilicus
* hernial sac is absent
* associated congenital anomalies are absent
- OMPHALOCELE:
* location is at the base of the umbilicus
* hernial sac is present
* associated congenital anomalies are present and include trisomy 21(Down's syndrome), cardiac anomalies, diaphragmatic hernia and bladder anomalies.
116
Perioperative management of gastroschisis and omphalocele centers around what 3 preventative measures?
1. hypothermia
2. dehydration
3. infection
117
In which disorder, gastroschisis or omphalocele, are hypothermia, dehydration, and infection most serious? Why?
-These problems are more serious in gastroschisis because the hernial sac is absent.
118
Where is the fistula usually located in a patient with a trachea-esophageal fistula(TEF)?
-In 90% of tracheal-esophageal fistulas, the lower segment of the esophagus inserts just above the carina onto the posterior wall of the trachea
119
Where is the proper placement of the ETT in a patient with tracheal-esophageal fistula? Describe the procedure for intubating the patient with a TEF?
- The time of the ETT can be placed just distal to the TEF(between the fistula and the carina)
- The ETT can be inserted until it enters one or the other mainstem bronchi
- Look for unilateral expansion of the chest and the unilateral breath sounds
- The ETT is then slowly withdrawn until bilateral breath sounds are present.
120
The key to successful anesthetic management of the neonate with TEF is correct positioning of the ETT. What is the important consideration for intubating the infant with a TEF? What intubation techniques are appropriate?
- An important issue is to avoid positive pressure ventilation, with will distend the stomach, thereby increasing the risk for relax and ventilatory compromise. There are two approaches to tracheal intubation after induction of anesthesia:
* One is to use inhalation induction, followed by topical application of lidocaine and intubation while the infant is breathing spontaneously.
* The other technique is to use an IV or inhalation induction and intubate the trachea with muscle paralysis. This latter technique may lead to distention of the fistula and stomach after onset of positive pressure ventilation.
121
What is tracheomalacia(also known as tracheobronchomalacia)? What patients are at risk for developing tracheomalacia?
- "Malacia" means abnormal softening of tissue, therefore tracheomalacia would be softening of the tracheal tissue, especially the cartilaginous rings.
- Tracheomalacia is sometimes seen in neonates/infants, often in association with esophageal atresia(TEF), or with extrinsic compression by vascular anomalies or mediastinal masses.
- Tracheomalacia may also be associated with hyperthyroidism.
122
What is the anesthetic concern for the patient with tracheomalacia?
- Airway obstruction, possibly requiring urgent intubation, is a great concern for the patient with tracheomalacia.
- Airway obstruction fue to tracheomalacia may be intra-throacic or extra-throacic; flow-volume loops will differentiate between intra-and extra-throacic obstruction.
123
What is the etiology of epiglottitis?
-Epiglottitis is due to life-threathening infection by Haemophilus influenza type B bacteria
124
List nine signs and symptoms of epiglottitis.
1. upper airway obstruction
2. inspiratory stridor
3. chest retractions
4. tachypnea
5. cyanosis
6. drooling
7. difficulty of swallowing
8. the child also insists on sitting
9. the child is restless
125
Children of what ages get epiglottitis?
- Affected children are usually 1-7 years old
| - Epiglottitis occurs with greater frequency in children less than 3 years of age.
126
Where is the optimal hospital location for intubation of a patient with epiglottitis? Why?
- Intubation should occur in the operating room
- Total obstruction of the airway could occur at any moment
- An attempt to visualize the epiglottis should not be taken until the child is in the OR where intubation of the trachea and possible emergency tracheostomy should be preformed.
127
What induction agent and what endotracheal tube size should be used in the patient with epiglottitis?
-An inhalation induction is followed by intubation with an ETT 1/2 to 1 size smaller than usual.
128
How long might one expect the ETT to be left in place in the patient with epiglottitis? What is one signal suggesting it is time for extubation?
- The ETT is left in place for 24-96 hours
- At this time an air leak usually appears around the ETT(because swelling has gone down) signaling the possibility of extubation.
129
Where and when should the patient with epiglottitis be extubated?
-Extubation of the trachea is performed in the OR only after direct laryngoscope has confirmed resolution of the swelling of the epiglottis.
130
In what position would you induce the patient with epiglottitis?
-A parent should hold the child on his/her lap, and after mask induction of the child is placed supine with the head slightly up.
131
What is the usual cause of croup)Laryngotracheobronchitis)?
The cause is usually viral
132
List three treatments for post-intubation laryngeal edema(post-intubation "croup")
1. Treatment of post-intubation laryngeal edema("croup") is aimed at reduction of airway edema. Mild cases often improve with cool, humidified mist and oxygen therapy, ideally administered by a face tent.
2. More severe cases require hourly administration of aerosolized racemic epinephrine(0.25-0.5 ml of 2.25% epinephrine mixed in 3 ml of saline).
3. Intravenous dexamethasone(0.25-0.5 mg/kg) may prevent the edema, but the effect takes up to 4-6 hours to manifest.
133
Identify 10 factors associated with post-intubation laryngeal edema("croup").
1. Age younger than 4 years
2. Tight-fitting ETT, no audible leak at 15-25 cm H2O
3. Traumatic or repeated intubation
4. Prolonged intubation
5. High-pressure, low-volume cuff
6. Patient "bucking" or coughing during intubation
7. Head repositioning while intubated
8. History of infectious or post-intubation croup
9. Neck/airway surgery
10. Upper respiratory infection
11. Trisomy 21
134
What is the pathogenesis of post-intubation croup? Identify 6 risk factors for post-intubation croup.
- Post-intubaiton croup is due to glottic or tracheal edema.
- Post-intubation croupis associated with:
* early childhood(age 14 years)
* repeated intubation attempts
* large ETT
* prolonged surgery
* head and neck procedures
* excessive movement of the ETT
135
What is the most frequent pediatric surgical emergency?
-Foreign body aspiration into the airway or esophagus is the most frequent pediatric surgical emergency.
136
List 7 anomalies often co-existent with myelomeningocele.
1. club foot
2. hydrocephalus
3. dislocation of hips
4. extrophy of bladder
5. prolapsed uterus
6. Klippel-Feil syndrome
7. Congenital cardiac defects
137
What causes myelomeningocele? What is the difference between a meningocele and meningomyelocele?
- Myelomeningocele is caused from failure of the neural tube to close in the fetus during development.
- Failure of the caudal end to close results in spina bifida.
- A sac is present which contains meninges and neural elements
- A meningocele is a sac containing only meninges.
138
What are the concerns for anesthetizing the newborn with myelomeningocele?
- The patient may not be able to lay supine for intubation due to possible sac disruption.
- The awake lateral decubitus position may be necessary.
139
Which type of shock is most frequent in the pediatric patient?
- Hypovolemic shock, often due to blood loss from trauma, is the most common cause of shock in children.
- Appreciate that the compensatory mechanisms(vasoconstriction and tachycardia) in children are very efficient at maintaining perfusion; children may lose as much as 1/4 of their blood volume without significant cardiovascular changes in the supine position.
- Hypovolemic shock due to plasma loss can be seen with burns and peritonitis, and may be a component of septic shock.
140
What is the best fluid replacement for the pediatric patient in hypovolemic shock?
- Crystalloid solutions(i.e.;Lactated Ringer's solution) are effective in the initial treatment of hypovolemic shock in pediatric patients.
- Crystalloids administered early in the management of hypovolemic shock will prevent renal failure and also prevent renal collapse.
- If indicated, blood should be transfused as soon as crossmatching has been done.
