Pediatric Disorders and Problems Flashcards by Maggie McDonell

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

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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

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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

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Epiglottitis Vs Laryngotracheobronchitis

(table)

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What is Laryngomalacia?

Tracheomalacia?

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

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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

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OSA:

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

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OSA:

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%)

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OSA:

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

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URI:

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

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Tonsillectomy:

indications

preferred airway

risks

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

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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

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What is Pectus excavatum?

Carinatum?

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

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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)

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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

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Sickly cell:

Quick review

Complications

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

pre-op

Intra-op

post-op

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

Appendicitis

Risks

considerations

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:

causes

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
PRESERVE SPONTANEOUS BREATHING
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

Downsyndrome:

incidence

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 HEENT CV ENDO IMMUNE/ONC MS

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?

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

What is associated with CHARGE syndrome?

* CHARGE * 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

Anesthetic considerations for a pt who is susceptible to MH

* A pt with a family history of MH or a + muscle biopsy test * First case of the day * remove vaporizes from the machine, flush machine per manufacturer guidelines * Use trigger-free anesthetic: * propofol * opioids * BZDs * NDMB * N2O * regional * Monitor ETCO2, temp * Susceptible children can have outpatient procedures as long as trigger-free anesthetic is used

Childhood obesity: definitions IBW calculation for children LBW calc

* Definition for obesity in children based on BMI * Obesity = BMI \> 95th percentile * morbid obesity = BMI \> 99th percentile * IBW calc: * \<8 yo: 2 x Age (years) + 9 * \>8 yo: 3 x age in years

What are the physiological changes seen in obese children?

* Pulm * Restrictive pulmonary pattern * decreased chest wall compliance * decreased FRC and VC * CV * HTN * LVH * premature atherosclerosis * Insulin resistance