Pediatric Surgery - Module 1 Flashcards
(150 cards)
1
Q
What four emergency drugs must always be pre‑drawn on a pediatric anesthesia machine tray?
A
Succinylcholine, atropine, lidocaine, epinephrine
2
Q
Standard IV dose of succinylcholine to break laryngospasm in children?
A
2 mg kg⁻¹ IV (4 mg kg⁻¹ IM if no IV)
3
Q
Atropine dose that accompanies succinylcholine in infants and children?
A
0.02 mg kg⁻¹, minimum 0.1 mg
4
Q
First three non‑drug steps when laryngospasm occurs under anesthesia?
A
100 % oxygen, stop stimulation, jaw‑thrust with sniffing position
5
Q
Preferred volatile agent for a child with reactive airways?
A
Sevoflurane (desflurane can increase resistance)
6
Q
Two capnography changes that suggest intra‑op bronchospasm?
A
Slow phase‑III upslope and rising ETCO₂ despite ventilation
7
Q
Epinephrine IV dose range for intractable bronchospasm?
A
0.05–0.5 µg kg⁻¹ every minute as needed
8
Q
Define post‑extubation croup risk leak test.
A
No leak with cuff pressure >25 cm H₂O increases risk
9
Q
Therapeutic nebulized mixture for post‑extubation croup?
A
0.5 mL of 2.25 % racemic epinephrine nebulized
10
Q
Intravenous steroid dose for croup management?
A
Dexamethasone 0.5 mg kg⁻¹ IV
11
Q
Which congenital defect herniates abdominal organs into the thorax?
A
Congenital diaphragmatic hernia (CDH)
12
Q
Most common CDH location?
A
Left posterolateral Bochdalek foramen
13
Q
Why avoid mask PPV in CDH before intubation?
A
It inflates stomach and further compresses lungs
14
Q
Primary ventilatory strategy to stabilize severe CDH pre‑op?
A
High‑frequency oscillatory ventilation with low tidal volumes
15
Q
Induction drug and dose recommended for CDH surgery?
A
Fentanyl 50 µg kg⁻¹ IV
16
Q
Paralytic dose of rocuronium for rapid paralysis in CDH?
A
1.2 mg kg⁻¹
17
Q
Key ventilatory goal during gastroschisis closure?
A
Keep peak inspiratory pressure <25 cm H₂O
18
Q
Describe difference between gastroschisis and omphalocele.
A
Gastroschisis: bowel exposed right of umbilicus, no sac; Omphalocele: midline herniation covered by sac
19
Q
Electrolyte goals before pyloric stenosis repair (Na, K, Cl)?
A
Na >130 mEq/L, K >3 mEq/L, Cl >85 mEq/L
20
Q
Why avoid opioids during pyloromyotomy?
A
Opioids cause postoperative apnea in metabolically alkalotic infants
21
Q
Preferred induction sequence for pyloric stenosis (drug mnemonic TALLS)?
A
Towels (position), Atropine, Lidocaine, Lidocaine??, Succinylcholine
22
Q
Typical apnea monitoring duration after pyloromyotomy?
A
24 hours with cardiorespiratory monitor
23
Q
Three classic signs of tracheoesophageal fistula at first feed?
A
Choking, coughing, cyanosis
24
Q
TEF: Where should ETT tip be placed relative to fistula and carina?
A
Below the fistula but above the carina
25
Ventilatory approach during TEF repair thoracoscopy?
Spontaneous or gentle PPV with low pressures; low‑flow CO₂ insufflation allowed
26
Define VACTERL association.
Vertebral, Anal, Cardiac, Tracheoesophageal fistula, Renal, Limb anomalies
27
What airway region collapses most in infants causing obstruction?
Hypopharynx at level of epiglottis due to tone loss
28
Two non‑pharmacologic labor‑pain modalities highlighted (but in peds context as teaching)?
Hydrotherapy and TENS/acupuncture
29
Equation demonstrating airway resistance relation in croup slide?
Resistance inversely proportional to radius⁵
30
Which volatile agent increases airway resistance in children and should be avoided?
Desflurane
31
Give bronchodilator induction agents of choice for asthmatic child.
Ketamine or propofol with sevoflurane maintenance
32
List three risk factors for post‑extubation croup besides tube size.
Age 1‑4 years, surgery >1 hr, repeated or traumatic intubation
33
What is the racemic epinephrine concentration used for croup?
0.0225
34
Which muscle relaxant alternative can be used instead of roc in CDH?
Cisatracurium 2 mg kg⁻¹
35
Essential equipment addition on prep tray for peds airways?
Appropriate size oral airway, two blade sizes, styleted ETT
36
Inline nebulizer setup purpose during bronchospasm treatment?
Deliver beta‑agonist without breaking circuit
37
Why is CPAP applied early in partial laryngospasm?
Helps stent open vocal cords and wash out negative pressure
38
Initial FiO₂ and adjustments during bronchospasm?
Start 100 % O₂, maintain high FiO₂ while adjusting I:E ratio
39
Drug class to avoid in pyloric infants due to risk of apnea?
Opioids
40
Purpose of NG tube before CDH induction?
Decompress stomach, prevent further lung compression
41
Contraindicated gas in bowel‑containing defects?
Nitrous oxide
42
Primary cause of mortality after CDH repair?
Persistent pulmonary hypertension
43
Two intra‑op ventilator adjustments for bronchospasm management?
Decrease PEEP, increase expiratory time (I:E 1:3 or 1:4)
44
Micro‑cuff ETT advantage listed in croup slide?
High volume/low pressure cuff placed distally provides uniform seal
45
Explain Poiseuille’s law relevance to pediatric airway slides.
Small decreases in radius dramatically increase resistance (r⁴)
46
At what age are children at highest risk for post‑extubation croup?
1–4 years old
47
Head position recommended during TEF post‑repair ventilation?
Neutral head to avoid tension on anastomosis
48
What ventilatory change indicates excessive insufflation pressure in thoracoscopic CDH?
Sudden rise in ETCO₂ and decreased lung compliance
49
Name the sedative that doubles as bronchodilator and analgesic.
Ketamine
50
First anesthetic step when bronchospasm detected (before drugs)?
Remove the surgical stimulus if possible
51
In CDH, why is permissive hypercapnia often tolerated?
To avoid high ventilatory pressures that worsen barotrauma
52
Recommended warming device for pediatric abdominal wall defect cases?
Forced‑air Bair‑hugger blanket covering extremities
53
Why are infants with omphalocele at risk for cardiac anomalies?
Omphaloceles often accompany midline congenital defects incl. heart
54
Explain why IV induction is preferred for TEF intubation.
Quicker, more stable, allows controlled conditions without PPV
55
Key fluid strategy for gastroschisis patient before OR?
Dextrose‑containing crystalloids to replace losses and prevent hypoglycemia
56
Which monitoring line is mandatory for CDH repairs?
Arterial line for blood gases and blood pressure monitoring
57
Sign that intra‑op bronchospasm is resolving on capnograph?
Phase‑III slope becomes steeper (normal) and ETCO₂ decreases
58
Drug used prophylactically in subglottic croup risk patients?
Dexamethasone 0.5 mg kg⁻¹ IV at induction
59
Which congenital defect repair may require staged silo placement?
Gastroschisis with large viscera to avoid abdominal compartment syndrome
60
Why maintain spontaneous breathing during early TEF laryngoscopy?
Avoid PPV which can insufflate stomach via fistula causing airway compromise
61
Baseline ventilatory setting recommendation for CDH high‑frequency
Mean airway pressure low, small tidal volumes, high rate (e.g., 10 Hz)
62
Common age for pyloric stenosis presentation?
2–8 weeks old
63
Which metabolic state is typical in pyloric stenosis?
Hypochloremic, hypokalemic metabolic alkalosis
64
Why must succinylcholine be followed by atropine in infants?
Prevent profound bradycardia from vagal response
65
One sign of bronchospasm on ventilator pressure graph besides PIP rise?
Saw‑tooth oscillations or concave pressure curve
66
Treatment algorithm order for laryngospasm (mnemonic STOP MAIDS)?
Suction, Tilt head, Oxygen, Pressure (PPV), Medicate (Atropine, Induction agent, Depolarizer succs)
67
Describe Arnold–Chiari malformation relevance (preview for later modules).
Brainstem herniation can affect airway and respiratory control, caution with neck positioning
68
Why avoid CPAP in initial CDH stabilization?
CPAP can insufflate bowel in chest increasing lung compression
69
Preferred anesthetic maintenance for gastroschisis repair?
Opioid‑based with relaxed muscles, minimal volatile to maintain low pressures
70
Essential vitals to document after racemic epinephrine administration?
Heart rate and stridor resolution as epinephrine can cause tachycardia
71
What does a concave abdomen in newborn suggest?
Possible congenital diaphragmatic hernia
72
Three signs of bronchospasm aside from wheeze.
Increased PIP, slow ETCO₂ upslope, hypoxemia
73
Fluid loss rate assumption for exposed viscera in gastroschisis?
Up to 2–3 times maintenance fluid requirement
74
Goal hemoglobin before major neonatal surgery like CDH?
14–16 g dL⁻¹ to optimize oxygen delivery
75
Why keep omphalocele sac moist pre‑op?
Prevent heat and fluid loss and protect bowel
76
Key monitoring parameter during pediatric thoracoscopic CO₂ insufflation?
End‑tidal CO₂ to detect hypercarbia
77
Define Morgagni hernia vs Bochdalek.
Morgagni anterior parasternal, Bochdalek posterolateral
78
Primary ventilatory danger with large omphalocele reduction?
Increased intra‑abdominal pressure reducing venous return and ventilation
79
Explain why inline nebulizer needed for beta‑agonist under anesthesia.
Allows continuous delivery without breaking circuit causing aerosolized leaks
80
What suction setting for TEF proximal pouch?
Continuous low suction to prevent aspiration
81
Drug regimen to break severe bronchospasm besides epi.
IV steroids like methylprednisolone
82
Describe ‘airway donut’ positioning tool purpose.
Stabilizes infant head to maintain neutral airway during surgery
83
Why video laryngoscope blade size important in infants?
Helps accommodate large occiput and small mouth opening
84
Standard maintenance fluid for neonate under 10 kg.
D5 1/4 NS at 4 mL kg⁻¹ hr⁻¹ (4‑2‑1 rule)
85
Pediatric pain scale appropriate for <3 years.
FLACC scale
86
Why metabolic alkalosis predisposes pyloric infants to apnea post‑op.
CSF pH moves alkaline suppressing respiratory drive
87
Significance of persistent pulmonary hypertension in CDH.
Leads to right‑to‑left shunt and hypoxemia requiring vasodilators
88
Which inhaled anesthetic should be minimized in CDH.
Nitrous oxide (contraindicated)
89
Indication for ECMO in CDH according to slide.
PaO₂ <50 mmHg on 100 % FiO₂
90
Two conditions often associated with omphalocele.
Congenital heart disease, chromosomal anomalies (trisomy 13/18)
91
Define ‘silent chest’ in laryngospasm context.
No breath sounds or ETCO₂ despite respiratory effort
92
Why use micro‑cuff tubes in pediatrics per lecture.
Uniform seal with lower mucosal pressure lowering risk of croup
93
Describe leaks acceptable for uncuffed tube size check.
Air leak at 20–25 cm H₂O under positive pressure
94
Which sedative both bronchodilates and causes analgesia.
Ketamine
95
Goal urine output intra‑op neonate.
1 mL kg⁻¹ hr⁻¹
96
Why scoliosis surgery preview noted for later modules relevant here.
Potential respiratory compromise, large blood loss, wake‑up tests
97
Explain reason ventilatory pressures should be carefully managed in TEF post‑repair.
High pressures may disrupt suture line and cause leak
98
Which beta‑agonist delivered via inline neb for bronchospasm.
Albuterol 2.5 mg nebulized
99
What is the ETCO₂ waveform artifact typical in bronchospasm.
Prolonged phase‑III with shark‑fin shape
100
Preventive measure for TEF gastric distention pre‑op.
Keep stomach decompressed with OG tube
101
Why infants are more prone to airway collapse during anesthesia.
More compliant trachea and bronchi with smaller diameter airways
102
List initial anesthetic agents avoided in CDH due to pulmonary HTN risk.
Nitrous oxide, high doses of volatile agents
103
Drug and dose to reverse opioid respiratory depression.
Naloxone 0.01 mg kg⁻¹ IV
104
Describe fluid warmer importance per equipment list.
Prevents hypothermia and rapid infusion of warm fluids reduces heat loss
105
What does polyhydramnios suggest prenatally for TEF.
Possible esophageal atresia/fistula
106
Primary cause of elevated PIP after closure of abdominal wall defect.
Reduced compliance from increased intra‑abdominal pressure
107
Why atropine minimum dose is 0.1 mg.
Avoid paradoxical bradycardia from low dose
108
Explain importance of heat loss prevention in gastroschisis.
Exposed viscera evaporates fluid and drops temperature quickly
109
Which anesthetic gas increases airway resistance and is avoided.
Desflurane
110
Parameter to monitor to avoid air trapping in bronchospasm.
I:E ratio and auto‑PEEP on ventilator
111
Summary goal when treating pediatric airway events per slide.
Early recognition, remove stimulus, deepen anesthesia, apply appropriate drugs
112
Incidence of congenital diaphragmatic hernia (CDH) in live births?
≈ 1 in 2 000 live births
113
Most common CDH type and laterality?
Posterolateral Bochdalek defect—90 % of cases, 80–85 % occur on the left side
114
Percentage of CDH infants with additional congenital heart disease?
About 20–40 % have a concomitant CHD
115
ECMO trigger value noted for severe CDH hypoxemia?
PaO₂ < 50 mm Hg despite 100 % FiO₂
116
Incidence of gastroschisis?
≈ 1 in 2 000 live births
117
Underlying embryologic cause of gastroschisis given in the slide?
Occlusion of the omphalomesenteric artery during gestation
118
Incidence of omphalocele and a key association?
≈ 1 in 5 000; frequently associated with genetic and cardiac anomalies
119
Incidence of pyloric stenosis and gender predilection?
1 in 500 live births; first‑born males affected 4 : 1 over females
120
Classic acid–base picture in pyloric stenosis before resuscitation?
Hypochloremic, hypokalemic metabolic alkalosis
121
Criteria indicating readiness for pyloromyotomy after resuscitation?
Na > 130 mEq/L, K > 3 mEq/L, Cl > 85 mEq/L, good skin turgor, UOP > 1 mL kg⁻¹ h⁻¹
122
Incidence of tracheoesophageal fistula (TEF)?
≈ 1 in 3 000 births
123
Most common anatomic pattern of TEF with esophageal atresia?
Proximal EA with distal TEF (≈ 80‑85 % cases)
124
Typical location of the fistula relative to the carina?
1–2 tracheal rings above the carina
125
Mnemonic for TEF presentation at first feed?
3 C’s – Choking, Coughing, Cyanosis
126
VACTERL components to screen for in TEF infants?
Vertebral, Anal, Cardiac, Tracheoesophageal, Renal, Limb anomalies
127
Risk factors for post‑extubation croup besides tight tube leak?
Age 1‑4 yr, surgery >1 h, non‑supine positioning, repeated/traumatic intubation, prior croup history
128
Key bedside sign cluster of unrepaired CDH after birth?
Respiratory distress, concave (scaphoid) abdomen, absent breath sounds on affected side
129
Peak intragastric pressure threshold after wall‑defect closure that signals ischemia risk?
> 20 mm Hg measured via gastric tube
130
Why staged silo reduction may be chosen for gastroschisis?
Allows gradual accommodation of viscera to avoid high intra‑abdominal pressures and ventilatory compromise
131
Primary pulmonary hypertension pathway contributor in CDH pathophysiology?
Decreased cross‑sectional pulmonary vasculature increases pulmonary vascular resistance
132
ECMO initiation criterion noted for severe CDH hypoxemia?
PaO₂ < 50 mm Hg despite 100 % FiO₂
133
Rare anterior CDH variant and its incidence?
Morgagni defect – ~2 % of CDH cases
134
Typical fistula location in TEF with esophageal atresia?
1‑2 tracheal rings above the carina
135
Gestational timing error causing TEF formation?
Failure of trachea–foregut separation in weeks 4‑5 of gestation
136
Intra‑op position for TEF thoracotomy and why?
Left lateral decubitus for right thoracotomy to avoid the aortic arch
137
Pre‑surgical airway prep goal for TEF?
Place suction catheter in proximal pouch with continuous low suction
138
Ventilation advice before TEF repair to avoid gastric distention?
Avoid mask PPV; keep infant spontaneously breathing or use gentle pressures <15 cm H₂O
139
Post‑repair ventilation tweak requested by many surgeons?
Maintain postoperative intubation for 1–3 days to protect anastomosis and allow suctioning
140
Head positioning requirement after TEF anastomosis?
Keep head in neutral alignment to prevent tension on suture line
141
Reason to place an NGT before CDH induction?
Decompress stomach to reduce further lung compression
142
Contraindicated airway support mode in initial CDH resuscitation?
CPAP — can insufflate bowel and worsen pulmonary compression
143
High‑frequency oscillator ventilation rationale in CDH management?
Delivers very small tidal volumes at high rates, minimizing barotrauma while improving oxygenation
144
Infant abdominal wall too small after viscera reduction—device used?
Silo pouch to gradually return bowel as abdomen grows
145
Bronchospasm intra‑op IV steroid option?
Methylprednisolone 1–2 mg kg⁻¹ IV
146
Inline nebulizer advantage highlighted in slides?
Allows β‑agonist delivery without circuit disconnection, preventing loss of PEEP
147
Croup airway resistance relation per Poiseuille’s law?
Resistance increases with radius to the −5 power, so minor edema greatly raises resistance
148
Risk factor cluster for bronchospasm spelled out on slide?
Recent symptoms, uncontrolled asthma, recent hospital treatments, active limitations
149
Primary ventilator change post‑TEF repair to re‑expand alveoli?
Increase I:E ratio (longer expiratory time)
150
Chest tube placement advice before CDH surgery?
Insert contralateral chest tube first if pneumothorax present
