Pediatric Surgery - Module 2 Flashcards
(108 cards)
1
Q
Define scoliosis in terms of spinal curvature.
A
Lateral deviation of the normal vertical spine greater than 10 °
2
Q
Define kyphosis.
A
Posterior (convex) angulation of the spine—“humpback”
3
Q
Define lordosis.
A
Anterior (concave) angulation of the spine—“sway‑back”
4
Q
Cobb angle at which surgery is considered in children with progressive curves.
A
Greater than 40–50 °
5
Q
Most common method to measure scoliosis curvature.
A
Cobb method on anteroposterior radiograph
6
Q
Two primary versus secondary spinal curves distinction.
A
Primary curves are early thoracic/lumbar; secondary compensatory curves develop above/below to maintain alignment
7
Q
Incidence of congenital scoliosis hemivertebra associated anomalies.
A
25 % have urologic and 10 % have cardiac abnormalities
8
Q
Effectiveness of bracing/casting in congenital scoliosis.
A
Generally ineffective; surgical options required
9
Q
Age range and treatment trigger for infantile idiopathic scoliosis.
A
Birth to 3 y; brace when curve reaches 30 °
10
Q
Percentage of idiopathic scoliosis that is juvenile (4–10 y).
A
10–15 %
11
Q
Underlying neurologic condition present in 20 % of juvenile idiopathic cases.
A
Arnold‑Chiari malformation
12
Q
Pulmonary concern in adolescent idiopathic scoliosis despite curve severity.
A
May have disproportionate restrictive impairment on PFTs
13
Q
Definition of neuromuscular scoliosis.
A
Curvature caused by brain, spinal‑cord, or muscular disorders with progressive muscle weakness
14
Q
Intra‑operative neuromonitoring modalities standard for scoliosis surgery.
A
SSEP, MEP, and EMG (plus possible wake‑up test)
15
Q
Factors that can depress evoked‑potential signals.
A
Volatile anesthetics, hypercarbia, hypoxia, hypotension, hypothermia, muscle relaxants
16
Q
What causes reduced lung compliance in scoliosis?
A
Distortion of the vertebra and ribs
- convex side - the rib is pushed posteriorly and thoracic cage is narrowed (Near normal end-inspiration
- Concave side - rib is pushed laterally and anteriorly (near normal expiration but not end-inspiraton)
17
Q
Minimum vascular access recommended before spine fusion begins.
A
Two large‑bore PIVs; consider central line and arterial line
18
Q
Blood‑conservation strategies listed for scoliosis cases.
A
Predonation, cell‑saver use, tranexamic acid protocol
19
Q
Example pre‑op midazolam dose per protocol.
A
Versed 2 mg IV in pre‑op
20
Q
Fentanyl induction dose range for scoliosis fusion.
A
2–5 µg kg⁻¹ IV
21
Q
Alternative opioid and dose for induction per protocol.
A
Sufentanil 1 µg kg⁻¹ IV
22
Q
Ketamine induction adjunct (+/-) dose.
A
1 mg kg⁻¹ IV optional
23
Q
Methadone induction adjunct (+/-) dose?
A
0.1 mg/kg (Max 10 mg))
24
Q
Propofol induction dose after lidocaine.
A
2–4 mg kg⁻¹ IV
25
Tranexamic acid loading dose for idiopathic curves.
50 mg kg⁻¹ over 15–20 min before incision
26
Higher TXA loading dose suggested for neuromuscular curves.
100 mg kg⁻¹
27
TXA infusion rate for idiopathic scoliosis.
5 mg kg⁻¹ h⁻¹ until skin closure
28
TXA infusion rate for neuromuscular scoliosis.
10 mg kg⁻¹ h⁻¹
29
Inhalation agent guideline once TIVA infusions running.
Sevoflurane 2–3 % initially, then <0.5 MAC or off for TIVA
30
Propofol TIVA rate sequence during maintenance.
200 → 150 → 100 µg kg⁻¹ min⁻¹ titrated to BIS 55–60
31
Remifentanil infusion range and off time before wake‑up.
0.1–0.3 µg kg⁻¹ min⁻¹; discontinue 10–15 min before wake‑up
32
Sufentanil infusion range and off time.
0.1–0.4 µg kg⁻¹ h⁻¹; stop 60–90 min before closure
33
Ketamine analgesic infusion rate.
0.1–0.2 mg kg⁻¹ h⁻¹; discontinue 60–90 min before end
34
Lidocaine infusion range and toxicity threshold.
20–40 µg kg⁻¹ min⁻¹; check levels, toxicity >7 µg mL⁻¹
35
Dexmedetomidine infusion rate used without loading.
0.1 µg kg⁻¹ h⁻¹
36
Volatile and gas to avoid in scoliosis fusion.
Nitrous oxide should be avoided
37
Key positioning cautions for prone spine surgery.
Protect eyes and nose, use donut headrest, ensure arms padded; maintain visualization throughout case
38
Temperature management tools listed.
Forced‑air warmer on lower body ± under‑body blanket
39
Three blood‑pressure control infusions named for scoliosis cases.
- Phenylephrine
- Nicardipine (Cardene)
- Dopamine
40
Fetal incidence of neural tube defects per 10 000 pregnancies.
17 per 10 000 pregnancies
41
Live‑birth incidence of neural tube defects.
5.7–6.7 per 10 000
42
Percentage of neural tube defects linked to chromosomal abnormalities.
10%
43
Environmental factors contributing to neural tube defects.
Folate deficiency, maternal anti‑epileptic drugs, retinoids, maternal diabetes
44
What is Spina Bifida?
Abnormal or incomplete formation of midline structures over the back
- Skin, bone, or neural elements may be involved
- Can be associated with brain anomalies
- Not always detected at birth
45
Symptoms of Spina Bifida
- Neurological impairment
- Muscle weakness, at times involving paralysis
- Bowel and bladder problems
- Seizures, especially if child requires a shunt
- Orthopedic problems
46
Spina Bifida Occulta characteristics:
- Overlying skin appears normal and intact
- Hairy patch may be present
- Sacral dimple
- Lipoma
- Spinal cord can end lower than usual
47
Spina Bifida Aperta characteristics:
- Most common type of spinal dysraphism - 1/1000 live births
- Obvious lesion on the back
- Covered - meningocele
- Uncovered - myeolomeningocele
48
Difference between spina bifida occulta and aperta.
Occulta: no herniation, intact skin; Aperta: open defect with sac protrusion
49
What's the difference between meningocele and myelomeningocele
Meningocele: Covered (meninges) - CSF without spinal tissue
Myelomeningocele: Uncovered - CSF and spinal nerves
50
Common brain malformation associated with spina bifida aperta.
Chiari II malformation
51
Classic external sign of spina bifida occulta.
Lumbosacral hairy patch or sacral dimple
52
Rate of hydrocephalus development in spina bifida aperta.
Approximately 80 %
53
Common brain malformation associated with spina bifida aperta.
Chiari II malformation
54
In myelomeningocele, the nerve roots contained in the sac continue to function below the level of the lesion. T/F?
False
55
Timing goal for myelomeningocele repair after birth.
Within first hours to few days to prevent infection/trauma
56
Airway & positioning consideration for intubating infant with myelomeningocele.
Use donut/towels to avoid sac pressure; may need lateral intubation
57
Is succinylcholine contraindicated in spina bifida?
No—succinylcholine can be used
58
Intra‑op concerns for spina bifida repair.
- Assess baseline deficits
- Potential major blood loss
- Warming measures
59
Drug class to consider avoiding if renal dysfunction in spina bifida.
NSAIDs
60
What is encephalocele
Herniation of neural tissue and meninges out of the skull through deficient skin and bone
61
Two main encephalocele locations and associated tissues. Where's an additional location that may be difficult to detect?
- Anterior (may involve brain/orbits/pituitary)
- Posterior (cerebral/cerebellar)
- Intranasal
62
Primary anesthetic challenges in encephalocele repair.
- Assess baseline
- Positioning (often prone)
- Secure ETT
- Possible large blood loss - 2 IVs
- Temperature management
63
Pathophysiology hallmark of Chiari malformation. Often associated with which condition?
- Cerebellar tonsils herniate through foramen magnum causing CSF obstruction
- Myeolomeningocele
64
What characterizes each of the 4 types of Chiari malformations?
I - Caudal displacement of cerbellar tonils.
II - Caudal displacement of cerebellar vermis, 4th ventricle and lower brainstem
III - Caudal displacement of cerebellum and brainstem
IV - Cerebellar hyoplasia (incomplete development of the cerebellum.
65
Three common symptoms of elevated ICP in Chiari malformation.
- Headache
- Vomiting
- Irritability
66
Respiratory sign seen in infants with Arnold‑Chiari.
- Vocal cord paralysis with stridor
- Respiratory distress
- Apnea
- Aspiration
67
Other S/S that may be seen with Arnold Chiari malformation
- Abnormal swallowing
- Cranial nerve deficits
- Opisthonos (condition where the body arches back, specifically the back and neck d/t sustained muscle spasms)
68
Untreated severe scoliosis can lead to what long‑term pulmonary issue?
Restrictive lung disease with hypoxemia, hypercarbia, recurrent infections, pulmonary hypertension
69
Impact of scoliosis on neuraxial block placement.
Epidural/spinal may be technically difficult due to distorted landmarks
70
Besides anesthetics, name three physiologic factors that impair SSEP/MEP.
Hypotension, hypoxia, hypothermia
71
Maximum recommended TXA infusion dose for idiopathic scoliosis.
5 mg kg⁻¹ h⁻¹ until skin closure
72
Why are pumps emphasized in scoliosis setup slide?
Multiple simultaneous infusion requirements for TIVA, analgesia, TXA, antibiotics, and vasoactive agents
73
Recommended antibiotic prophylaxis timing for vancomycin in spine surgery.
Start infusion after induction as soon as lines are placed, before flip
74
Standard dexamethasone antiemetic dose in scoliosis protocol.
0.5 mg kg⁻¹ up to 8 mg IV
75
Optimal BIS target range during propofol TIVA.
55–60 or lower
76
Two reasons cell saver is helpful in pediatric spine fusion.
Reduces allogeneic transfusion need and limits anemia in long cases
77
Definition of hemivertebra.
Failure of one side of a vertebral body to form, producing wedge‑shaped vertebra and congenital scoliosis
78
Primary goal when using TXA in scoliosis surgery.
Minimize intra‑operative blood loss and transfusion requirements
79
Define neuromuscular scoliosis and two common underlying disorders.
Spinal curvature caused by neuromuscular weakness or imbalance; often associated with cerebral palsy and Duchenne muscular dystrophy
80
Pulmonary function test feature that predicts postoperative ventilation need in scoliosis.
Forced vital capacity (FVC) < 40 % predicted indicates high risk for postoperative ventilation
81
Hemoglobin target prior to long spinal fusion in adolescents.
≥ 10 g dL⁻¹ to maintain oxygen delivery and reduce transfusion triggers
82
Cell saver contraindication noted for spinal fusion cases.
Do not reinfuse cell‑saver blood if povidone‑iodine irrigation was used in the field
83
Dexamethasone antiemetic dose ceiling per protocol.
Maximum 8 mg IV
84
Preferred hypnotic dose adjustment when BIS < 40 during TIVA.
Decrease propofol infusion by 25–50 µg kg⁻¹ min⁻¹ increments until BIS 55–60
85
Neurophysiologic sign warranting immediate surgical pause.
MEP amplitude drop > 80 % from baseline
86
Initial treatment algorithm for lost MEP signals.
Increase MAP, raise Hb/O₂, correct temperature, decrease anesthetic depth, rule out surgical compression
87
Maximum lidocaine infusion plasma concentration before toxicity.
7 µg mL⁻¹
88
Typical intra‑op blood loss range for posterior spinal fusion in teenagers.
20–40 mL kg⁻¹
89
If rapid transfusion needed, what core temperature must be maintained?
Above 35 ° C to prevent coagulopathy
90
Reason nitrous oxide is avoided in scoliosis fusion.
Increases airspace pressure, expands embolism risk, and interferes with MEP/SSEP reliability
91
Standard ventilation strategy for prone adolescent with restrictive lungs.
Pressure‑controlled ventilation with Vt 6 mL kg⁻¹ and PEEP 5 cm H₂O
92
Why muscle relaxants are avoided after incision in fused spine cases.
MEP monitoring requires intact motor pathways; NMBs abolish responses
93
Scoliosis Cobb angle associated with decreased life expectancy if untreated.
> 100 ° can lead to cor pulmonale and reduced survival
94
Tranexamic acid maximum cumulative dose suggestion.
Do not exceed 100 mg kg⁻¹ total intra‑op in idiopathic curves
95
Blood pressure target during pedicle screw placement.
Maintain MAP 65–70 mm Hg for hemostasis while preserving cord perfusion
96
Postoperative analgesia method highlighted in protocol.
Intrathecal morphine 5 µg kg⁻¹ or wound catheter local anesthetic infusion
97
Criteria to resume normal diet after myelomeningocele repair.
Return of bowel sounds and no evidence of ileus—usually 24 h
98
Post‑repair spina bifida positioning precaution.
Keep infant prone until wound inspection confirms no CSF leak
99
What is the purpose of the intra‑operative wake‑up test in scoliosis fusion?
To verify intact motor pathways by having the patient move feet when MEP signals are equivocal
100
List five physiologic or anesthetic factors that can depress SSEP/MEP signals.
Volatile anesthetics, muscle relaxants, hypotension, hypothermia, hypoxia/hypercarbia
101
Why does the protocol slide say “Pumps, pumps—did I say pumps?” for spine cases?
Multiple simultaneous infusions (TIVA, remifentanil or sufentanil, TXA, vasoactive agents, antibiotics) require several programmable pumps
102
Most common congenital scoliosis defect and two surgical options.
Hemivertebra; treatment options include convex hemiepiphysiodesis or VEPTR / growing rods
103
Peri‑op complication risk after myelomeningocele repair that may need VP shunt.
Hydrocephalus developing post‑repair
104
What postoperative complication is common at the myelomeningocele repair site?
CSF leak or dural rupture
105
Typical position & fixation used for Chiari decompression surgery.
Prone or sitting posterior‑fossa craniotomy with the head secured in pins or padded horseshoe
106
Key respiratory impact of thoracic scoliosis on lung mechanics.
Restrictive defect with normal end‑expiration but impaired end‑inspiration due to rib distortion
107
Ventilator mode recommended initially for severe CDH stabilization.
High‑frequency oscillatory ventilation delivering very small tidal volumes
108
Which sedative‑analgesic infusion is stopped 10–15 min before wake‑up test?
Remifentanil at 0.1–0.3 µg kg⁻¹ min⁻¹
