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Flashcards in Pediatric Disorders and Problems Deck (33)
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What are the common Craniofacial anomalies?

  • Cleft lip/palate- varying degrees
    • aspiration risk
    • feeding difficulty
    • frequent otitis
  • Mandibular hypoplasia- tongue displaced posteriorly causing obstruction--always a difficult airway! 
    • ***very difficult to BMV, always maintain spont vent!
    • Pierre robin- small and posterior mandible, airway obstruction, cleft palate (far left pic)
    • Treacher-Collins- (far right pic)
      • normal mental development, no disability
      • defective ossification of the bone
      • small/absent cheek bones
      • normal size nose
      • eat tabs, receding chin
  • Midface hypoplasia
    • Apert syndrome, Crouzon syndrome (middle pic)
    • BMV difficult d/t location of eyes


What is epiglottitis?

  • Epiglottitis- life threatening bacterial infection of the epiglottis, aryepiglottic folds, arytenoids and sometimes uvula
  • Symptoms
    • high fever
    • severe sore throat
    • drooling
    • ill appearing
  • Rapid deterioration may occur;
    • DO NOT aggitate the child!
    • DO NOT  manipulate the airway!
    • DO a calm, sitting inhalational induction


What is Croup (Laryngotracheobronchitis)?

  • Viral infection of the subglottic structures
  • more gradual onset
  • barky or seal-like cough with hoarse voice and inspiratory stridor
  • Most cases resolve with simple management including humidified air or oxygen
  • Use ETT 1/2 size smaller if require intubation


Epiglottitis Vs Laryngotracheobronchitis



What is Laryngomalacia?


  • Laryngomalacia- immature cartilage of the supraglottic larynx leads to symptoms.  Slowly resolves by 12-18 mo.  
    • Symptoms: Insp stridor with activity or feeding that resolves when child is calm
    • Most common airway problem in infants and children
  • Tracheomalaci- weakened or "floppy" trachea
    • Symptoms: harsh noise/stridor on expiration caused by airway collapse
      • onset in early neonatal period
      • diagnosed by bronchoscopy


How should an asthmatic pt be treated?

  • Optimize the asthmatic pt preoperatively
  • Pre-op review:
    • previous hospitalization?
    • intubated?
    • ER visit?
    • age on onset?
    • treatments? steroids?
  • Assess carefully for wheezing: defer if surgery is elective and pt is wheezing
  • Give pre-op bronchodilators even if not wheezing
  • Avoid intubation if face mask or LMA can be used
  • Consider ketamine



Primary cause in Children?

Assessment/risk factors?


  • Primary cause in children is large tonsils and adenoids
    • also craniofacial abnormalities, neuromuscular disorders, obesity
  • Aassessment of risk factors:
    • loud snoring
    • witnessed apnea
    • nocturnal enuresis
    • ADHD
    • behavioral problems
    • increased in african american
    • daytime somnolence is NOT a feature in children



anesthesia concerns?

  • Anesthesia concerns:
    • opioid sensitivity- reduce dose by 1/2!
    • post-op resp complications
    • post-op admission for monitoring
  • Intermittent hypoxia can lead to PHTN and right heart failure
    • ECHO recommended in child with severe OSA
    • Red flags:
      • systemic HTN
      • right ventricular dysfunction (peripheral edema, hepatic enlargement, elevated liver enzymes)
      • frequent, severe desats (<70%)



Who needs post-op observation?

Classification (mild, mod, severe)

  • Post-op observation
    • <3 yo
    • craniofacial abnormalities
    • parents can't keep an eye on them
    • live far from hospital
    • obese
  • Classification:
    • mild: 1-5 apneic episodes/hr
    • moderate: 5-10 apneic episodes/hr
    • Severe: >10 apneic episodes/hr



Why is it a concern? 

When can you proceed?

  • Most common comorbidity in children presenting for surgery
  • Concern:  increased risk for complications (bronchospasm and laryngospasm)
    • Avoid airway manipulation (ETT) if possible.  Use LMA or mask
  • Use caution, but may proceed with:
    • clear runny nose
    • no fever
    • playful
    • clear lungs
  • Cancel if:
    • purulent nasal discharge
    • fever
    • lethargy
    • persistent cough
    • wheezing/rales
    • previous premie
    • <1 yo




preferred airway


  • Indicated for recurrent infections and OSA
    • many pts have large tonsils but otherwise normal airways
    • consider they might have OSA
  • Preferred airway: usually ETT, some use LMA (choice is surgeons)
  • Risks:
    • post-op hemmorhage (0.1-0.3%); can be day of surgery or 7-10 days later
    • Active bleeding will make visualization more difficult, full stomach, potential for hypovolemic shock


Myringotomy and Tympanostomy tubes anesthetic procedure

  • Usually a short outpatient procedure
  • 5-10 minutes of operating time
  • Technique:
    • usually no premed req unless extremely apprehensive
    • ASA monitors
    • inhalation induction (Sevo, O2, +/- Nitrous)
    • maintenace phase with mask ok
    • IV access usually not necessary
  • Acute otitis media is one of most common diseases in first decade of life
  • Pt may have co-existing tonsillar hypertrophy- usually relieved with positive pressure or OA
  • Pain: 
    • rectal/PO tylenol
    • intranasal fentanyl


What is Pectus excavatum?


  • Pectus carinatum- abnormal protrusion of the xiphoid process and sternum
    • predominantely males 4:1
    • can be associated with: scoliosis, marfan, and CHD
  • Pectus excavatum- abnormal depression of the sternum
    • usually medically insignificant


What is Tetralogy of Fallot?

When is it repaired?

  • Most common cyanotic CHD
  • Anatomy:
    • RVOT obstruction
    • infundibular narrowing
    • pulmonary stenosis
    • PA hypoplasia
    • pulmonary atresia
    • VSD (large, unrestrictive)
    • Overriding aorta
    • RV hypertrophy
  • Left unrepaired, tet spells can lead to RVH, RV failure and death (50% in first year of life)


What is significant about caring for a pt with a previously repaired CHD?

Key points for anesthetic for a single ventricle pt?

What is williams syndrome?

What should you check before anesthetizing a former cardiac transplant pt?

  • Can later develop dysrhythmias (esp if approach was ventriculotomy)
    • repaired single ventricles have high risk for sudden death as a result of pathologic arrhythmias
    • any intraop arrhythmias MUST be reported to cardilogist, may req RF ablation
  • Single ventricles: 
    • keep well hydrated
    • avoid PEEP
    • avoid laparoscopic surgery
  • Williams syndrome- aortic stenosis, abnormal coronary arteries, pulmonic stenosis
    • high risk for sudden death with anesthesia
  • Former cardiac transplants- rule out small vessel CAD first


Sickly cell:

Quick review




  • Hgb S allows deoxygenated Hgb to polymerize into rigid insoluble fibers, resulting in sickled erythrocytes
    • these have shortened life span, leading to hemolysis and anemia
  • Complications:
    • anemia
    • stroke
    • acute chest syndrome
    • myonecrosis
    • CHF
    • MI
    • splenic sequestration
    • retinal hemorrhage
    • hematuria
    • ESRD
    • sz
    • wound infection
    • UTI


Sickle Cell:

Things to avoid




  • Avoid:
    • dehydration
    • stasis
    • hypoxia
    • hypothermia
    • acidemia
    • pain
  • Pre-op: often admitted night before for IV fluids
    • warm
    • well oxygenated
    • hydrated
    • consult hematologist
    • may transfuse to target hgb of 10
  • Intra-op:
    • maintain euvolemia and normothermia
    • avoid tourniquets
  • Post-op
    • Adequate IV hydration
    • early mobilization
    • incentive spirometry
    • supplemental O2
    • consider multi-modal analgesia, many are tolerant to opioids





  • Most seen in teen years
  • Risks
    • increased perforation if dx delayed >24
    • abscess
    • ileus
    • sepsis
  • Considerations
    • aspiration (considered full stomack; RSI)
      • evacuate stomach with NG/OG
    • active N/V
    • tachycardia d/t pain
    • dehydration
    • sepsis
    • pre-op abx with gram negative coverage


What are the three myopathies and what is significant with each?

  • Get Pre-op ECHO and EKG!
  • Duchenne muscular dystrophy
    • X-linked
    • lack of dystrophin in skeletal and cardiac muscle
    • progressive cardiomyopathy at adolescence
  • Becker muscular dystrophy
    • milder form of Duchennes seen in 2nd decade of life
  • Emery Dreifuss
    • may have concurrent heart block


What is Tumor lysis syndrome?

What is anesthesia often needed for in pediatric pts with cancer?

What should you consider in pts getting treated for cancer?

  • Tumor lysis syndrome is a metabolic crisis that often occurs when chemo is started
    • caused by acute lysis of a large number of tumor cells
    • classic triad: hyperuricemia, hyperkalemia, hyperphosphatemia
      • elevated phosphate causes hypocalcemia
    • these pts require good fluid and electrolyte managment
  • Anesthesia needed for:
    • central line placement
    • lumbar punctures
    • bone marrow aspirates
  • Chemo effects:
    • Anthracyclines (doxorubicin, daunorubicin): cardiotoxicity
    • Bleomycin: pulmonary toxicity


Mediastinal mass:



What is concerning about these?

  • Causes:
    • lymphoma
    • teratoma
    • thymoma
    • thyroid tissue
  • Symptoms:  varies based on size and location
    • stridor
    • SVC syndrome
    • symptoms can progress rapidly esp in non-hodgkins lymphomas
  • Life threatening airway obstructions and CV collapse can occur with induction of GA
  • Pts may be receiving radiation and steroids


What are some treatment considerations for pts with a mediastinal mass?

  • May go to IR for needle biopsy and local ispreferred if cooperative
  • SVC syndrome will need IV in lower extremity
  • Preferred to keep pt in semi sitting position
  • Severe obstruction may require repositioning prone or lateral
  • CV collapse may require cardiopulmonary bypass
    • may have bypass on standby for large mass




Physical exam findings

common surgeries

  • 3rd copy of chromosome 21
  • 1:1,000 live births, increased incidence in moms >35 years
  • Physical findings:
    • midface hypoplasia
    • brachycephaly
    • epicanthal folds
    • simian crease
    • downward medial slant of eyes
    • high-arched palate
    • glossoproptosis
    • murmur
  • Surgeries:
    • tympanostomy
    • strabismus (poor eye muscle control)
    • CHD repair
    • duodenal/esophageal atresia
    • marrow aspiration/biopsy
    • cervical spine fusion


What are downsyndrome pts at high risk for?

Five-fold risk of bradycardia during sevo induction (first 6 minutes) in children with downs


Table of physical exam findings in down syndrome pts






Anesthesia considerations for down syndrome pts

  • Airway:
    • have a variety of devices available to manage obstruction (oral/nasal airways, LMA, glidescope, fiberoptic)
    • avoid neck extension during laryngoscopy (atlanto axial instability
    • smaller ETT may be necessary for narrowed subglottic space
  • Vascular access
    • meticulously avoid IV air d/t possible CHD
  • Anticpate problems:
    • Bradycardia with inhalation induction
    • Resistance to separation from caregiver


What is associated with VACTERL syndrome?



    • vertebral anomalies
    • anal atresia
    • CHD
    • tracheoesophageal fistula
    • esophageal atresia
    • renal and radial dysplasia
    • limb defects


What is associated with CHARGE syndrome?

    • coloboma (a hole in one of the structures of the eye)
    • heart defects
    • choanal atresia
    • retardation of growth and dev
    • genitourinary problems
    • ear abnormalities


What is associated with CATCH 22 syndrome?

  • CATCH 22

    • cardiac defects

    • abnormal face

    • thymic hypoplasia

    • cleft palate

    • hypocalcemia


Table to remember which syndromes have these traits:

Large tongue

small/underdeveloped mandible

cervical spine anomaly