PEDS Exam 3 Flashcards
(181 cards)
1
Q
Oxygenated blood from placenta enters through the?
A
umbilical vein
2
Q
Most of the blood bypass fetal liver via the?
A
ductus venosus
3
Q
Most of the blood bypass fetal liver via the ductus venosus and mix with deoxygenated blood in?
A
inferior vena cava
4
Q
What does the foramen ovale do?
A
shunts blood from right atrium (increased pressure) directly into left atrium (decreased pressure).
5
Q
Why is blood shunted away from the fetal lungs?
A
increased resistance in the lungs
6
Q
What does the ductus arteriosus do?
A
connects pulmonary artery directly to the aorta.
7
Q
How does deoxygenated blood return to the placenta?
A
via the umbilical arteries
8
Q
Preductal vs post ductal?
A
Preductal is the blood before the hole of the ductus arteriosus and post ductal is after. Preductal is oxygenated and post ductal is low oxygen blood.
9
Q
Which childhood issue below is improved with aerosolized racemic epinephrine?
croup, epiglottitis, tracheitis?
A
croup
10
Q
thumbprint sign on lateral neck film describes?
A
epiglottitis
11
Q
subglottic narrowing describes?
A
tracheitis
also croup if steeple sign is present in AP neck films
12
Q
what causes epiglottitis?
A
Haemophilus influenzae B
13
Q
what causes croup?
A
Parainfluenza virus
14
Q
what causes tracheitis?
A
Staphylococcus aureus
15
Q
high grade fever, inspiratory strider, cyanosis and drooling, what is most likely being described?
A
acute epiglottitis
16
Q
what do you want to avoid doing if a kid is suspected or confirmed to have epiglottitis?
A
avoid laryngoscopy unless in the OR ready to intubate with a physician present who can take over if need be and also be ready to trach.
17
Q
how will you induce a child with acute epiglottis?
A
inhalation induction in sitting position, use smaller tube size.
18
Q
treatments for acute epiglottitis?
A
ET and antibiotics are life-saving
Ampicillin
Vaccination
19
Q
Does laryngotracheal bronchitis require intubation?
A
usually no
20
Q
low grade fever, barking cough, 4 month old what is described?
A
laryngotracheal bronchitis
21
Q
treatment for laryngotracheal bronchitis?
A
Oxygen and mist therapy
Nebulized epi
IV dex
Intubate if signs of respiratory depression appear
22
Q
if blood enters the right ventricle, where does it go from there?
A
into the pulmonary artery but bc the pulmonary resistance is so high it is then shunted through the ductus arteriosus and into the aorta
23
Q
how many umbilical arteries exist? What is the function?
A
2, return deoxygenated blood from fetal internal iliac arteries to placenta
24
Q
How many umbilical veins exist? what is the function?
A
1, supplies oxygenated blood from placenta to fetus
25
Blood in the umbilical vein is how much saturated with oxygen?
80%
26
The umbilical arteries have high or low O2 saturation?
low
27
Name the three important shunts that are present in the fetal circulation?
ductus venosus
foramen ovale
ductus arteriosus
28
how does the ductus venosus work?
Blood entering the fetus through umbilical vein is conducted via the ductus venosus into IVC to bypass the liver
29
How does the foramen ovale work?
Most oxygenated blood reaching the heart via the IVC is diverted through foramen ovale and pumped out the aorta to head and body
30
How does the ductus arteriosus work?
Deoxygenated blood from the SVC is expelled into the pulmonary artery and ductus arteriosus to the lower body of the fetus
31
explain what occurs at birth and with the first breath to change the fetal circulation?
at birth the infant takes a deep breath and this decreases resistance in pulmonary vasculature causing an increase in left atrial pressure vs right atrial pressure, formen ovale closes.
increased oxygen from respiration and decrease in prostaglandins due to placental separation causes closure of ductus arteriosus.
32
once the formen ovale closes what is it called?
fossa ovalis
33
What helps close the PDA?
INDOMETHACIN
34
What keeps the PDA open?
Prostaglandins E1 and E2
35
What is the PaCO2 and PaO2 of fetal blood?
```
PaCO2 = 48 mmHg
PaO2 = 30 mmHg (+10 increase if mother is on 100% O2)
```
36
When does the ductus arteriosus close?
2-3 weeks
37
when does the foramen ovale close?
takes months to close
38
**What occurs if the fetus has hypoxia or acidosis in the first few days?
ultimately pulmonary hypertension
| NEEDS MORE DETAILS
39
List the three cyanotic defects?
They all start with a T
Tetrology of Fallot
Transpostion of great vessel
Truncus
40
Acyanotic defects are?
```
VSD
ASD
PDA
Pulmonary stenosis
Aortic stenosis
Coarctation of aorta
Atrioventricular septal defect
```
41
What types of shunts always results in a decrease in arterial PO2 bc of admixture of venous blood with arterial blood?
right to left shunts
42
How can you estimate the magnitude of the right to left shunt?
the patient breathes 100% O2 and measuring the degree of dilution of oxygenated arterial blood by non-oxygenated shunted (venous) blood
43
what type of shunt is more common and why?
left to right shunts, bc pressures are higher on the left side of the heart
44
what percentage of the cardiac output normally bypasses the lungs resulting in a physiologic shunt?
2%
45
In certain cardiac abnormalities what percentage of blood may bypass the lungs?
up to 50%
46
what type of shunt is TOF?
?
47
What is Eisenmenger's syndrome?
When a left to right shunt becomes so bad that it reverses into a right to left shunt due to an increase in pulmonary hypertension.
48
What type of shunt does NOT result in decrease in arterial PO2?
left to right shunt. Instead PO2 will be elevated on the right side of the heart because there has been admixture of arterial blood with venous blood. (left side of the heart mixing blood with the right means more oxygen in the right side)
49
What type of shunts result in blue babies?
R to L shunts
50
What type of shunts result in blue kids?
L to R shunts
51
early cyanosis is what type of shunt?
right to left
52
late cyanosis is what type of shunt?
left to right
53
examples of right to left shunts also known as early cyanosis or blue babies
1. Tetralogy of Fallot (MCC of early cyanosis)
2. Transposition of great vessels
3. Truncus arteriosus
54
examples of left to right shunts also known as late cyanosis or blue kids?
1. VSD (MC congenital cardiac anomaly)
2. ASD
3. PDA (close with indomethacin)
55
most common types of left to right shunt?
VSD then ASD then PDA
56
late cyanosis due to a left to right shunt reversing into a right to left shunt will have what two symptoms?
clubbing and polycythemia
57
What is occurring with an atrial septal defect?
LA shunts blood into the RA which increases work on the right side of the heart leading the RVH. (right ventricle is receiving more blood and working harder)
58
what would you want to avoid with ASD?
avoid increases in SVR because this may worsen the L to R shunting
59
is childhood ASD symptomatic or no symptoms?
no symptoms
60
Complications of ASD?
Pulmonary HTN if age greater than 20 years.
Eisenmenger disease
61
What is the most common congenital heart disease?
VSD
62
VSD, how does this shunt start and how does it usually end up?
starts as a left to right shunt but with increased pulmonary resistance it turns into a right to left shunt and now the patient becomes cyanotic.
63
pulmonary resistance increases what 3 things?
hypoxia, hypercarbia, and hypothermia.
64
small VSD have no symptoms but large defects can cause what?
Pulmonary HTN
Growth failure
CHF
Infection
65
Physical findings with VSD?
Midsystolic harsh blowing murmur
66
What is coarctation of aorta?
Mechanical obstruction ‘kink’ between proximal and distal aorta, usually after the origin of left subclavian artery
67
Does coarctation of aorta cause increase or decrease in LV afterload?
increase
68
male to female ratio with coarctation of aorta
2:1
69
physical findings with coarctation of arota?
Weak or absent femoral pulse. Always compare radial and femoral pulse
Upper extremity hypertension; lower extremity hypotension
Cold extremities, claudication with exercise, leg fatigue
Rib notching, “3” sign
70
with coarctation of aorta are most patients symptomatic or asymptomatic?
most are asymptomatic, ten percent can have CHF in infancy
71
What are the four treatments for coarctation of aorta ?
Resection
Patch
End to end repair
Balloon
72
if a patient has VSD what should you avoid during repair?
Arrhythmia
RV dysfunction
Pulmonary vascular obstructive disease
Paradoxical embolus
73
EKG of a person with coarctation of aorta?
normal or LVH
74
what is a patent ductus arteriosus?
persistence of connection between pulmonary artery and aorta.
75
patent ductus arteriosus would cause what kind of shunt?
left to right shunt
76
what is the issue with a patent ductus arteriosus?
blood flow from aorta to pulmonary artery.
additional blood is re oxygenated in the lungs and returns to the LA and LV leading to increased work load and causing LVH
77
what type of murmur is present with PDA
Continuous murmur "machinery"
78
if you have a small defect with PDA you have no symptoms but if you have a large defect then what symptoms will a person have?
CHF
delayed growth
infections
79
Treatment for PDA
surgical ligation
| COX-1,COX-2 inhibtors and indomethacin “medical ligation"
80
** preductal and postductal anatomical locations and difference
3%
81
What four abnormalities are present in TOF
Narrowing of pulmonary valve
thickening of wall of right ventricle
displacement of aorta over ventricular septal defect
ventricular septal defect
82
TOF results in what type of oxygenation to the body?
insufficiently oxygenated blood pumped to the body
83
Pulmonary blood flow is decreased, the RV is hypertrophied, and deoxygenated blood enters the aorta.
What does this describe?
TOF
84
Boot shaped heart happens with what CHD?
TOF
85
MC congenital heart dz causing cyanosis?
TOF
86
Four features of TOF?
Pulmonary stenosis – RV outflow obstruction
Overriding aorta (aorta comes out both from left ventricle and right ventricle ( BIG AORTA)
Large VSD
Right ventricular hypertrophy
87
Right ventricular outflow obstruction (pulmonary stenosis) plus VSD results in ?
ejection of mixed blood into the aorta
88
clinical presentation of TOF?
CYANOSIS
Squatting
Dyspnea
Hypercyanotic and hypoxic spells (TET spells)
89
what does squatting with TOF do?
A position that increases systemic vascular resistance and aortic pressure, which decreases right-to-left ventricular shunting and thus increases arterial O2 saturation.
90
during feeding or crying a babies PO2 can drop to below 50, what is this known as?
TET spells, will be unresponsive to supplemental oxygen
91
physical examination of a person with TOF will reveal?
RV heave
| harsh systolic ejection murmur
92
what does squatting do for a TOF pt?
tries to decrease the shunt so lungs can get more blood
93
what do you see when the kid has a TET spell?
hands and feet can turn blue as well as lips and places on face.
94
Conditions that increase right to left shunt
increased pulmonary vascular resistance or decreased SVR
acidosis
hypercarbia
hypotension
95
Treatment for TOF kid?
For symptomatic patient , PGE1 infusion
For TET spells, knee-chest positioning, calming, O2, and vasoconstrictors
96
Surgery options for TOF
Blalock-Taussing shunt; connects subclavian artery to pulmonary artery
Closing VSD
Resecting obstruction
97
Anesthetic management of TOF kid?
maintain intravascular volume and SVR
avoid increases in pulmonary vascular resistance (N2O)
Ketamine is used bc it maintains or increases SVR and therefore does not aggravate R to L shunt
VA and histamine releasing drugs decrease SVR and increase the shunt
Phenylephrine increases SVR and decreases shunt
98
**Why do you want to keep the duct open in TOF or create a ductus?
by connecting subclavian artery and pulmonary artery leads to more blood to lungs as less blood is going because of pulmonary stenosis
99
What is Tricuspid atresia?
Missing Tricuspid valve
Blood can flow out of right atrium only via PFO or ASD
PDA is necessary for blood to flow from LV into pulmonary circulation
100
What is needed for survival with Tricuspid atresia?
PGE1 is needed for survival
101
Treatment of Tricuspid atresia?
Septostomy
B.T. shunt
Fontan procedure
-Anastomosis of right atrium with right pulmonary artery
Glen shunt
-SVC to pulmonary artery
Heart transplant
102
What is shown on EKG with Truncus arteriosus
biventricular hypertrophy
103
what is truncus arteriosus
Conotruncal separation does not occur, one trunk
104
when pulmonary resistance falls with truncus arteriosus what occurs
increased flow to the lungs leading to CHF, tachypnea
105
What is the treatment for Truncus arteriosus?
surgery, close VSD with trunk in LV, connect RV and pulmonary artery
106
What is transposition of Great Vessels ?
Right ventricle is connected to aorta and LV is connected to pulmonary artery
107
What must someone with TGV have to survive?
mixing of blood, thus they must have an ASD, VSD, PDA
| they must also have PGE1 infusion
108
On chest X ray what shape will the heart of someone with TGV have?
egg shaped heart
109
what is the surgery for TGV?
atrial septostomy if no connection, whole atrial switch in neonatal period
110
**TAPVR, what is it?
Pulmonary veins lead to RA instead of going to left atrium, even the coronary sinus go to the RA.
111
snowman shaped heart indicates what CHD?
TAPVR
112
What is hypoplastic left heart syndrome?
Hypoplasia of left ventricle, mitral valve and ascending aorta
mixing of pulmonary and systemic blood in single ventricle
113
if you have an increase or decrease in pulmonary vascular resistance with Hypoplastic LH syndrome what will happen?
cardiovascular collapse
114
systemic flow is depended on PDA in hypoplastic left heart syndrome, what keeps the duct open?
PG-E1 infusion to keep the duct open
115
prematurity is defined as birth before how many weeks and what weight?
37 weeks and less than 1000 g
116
prematurity complication can include?
```
Hyaline membrane disease
Apneic spells
Bronchopulmonary dysplasia
Respiratory distress syndrome
PDA
Retinopathy
```
117
Anesthetic considerations with premature babies?
Avoid excessive inspired O2
| Risk of post-anesthetic apnea
118
Congenital diaphragmatic hernia, what is it?
gut herniates into thorax through hole in diaphragm
119
what issue can a congenital diaphragmatic hernia cause?
hypoxia due to right to left shunt, resulting from persistent fetal circulation
Scaphoid abdomen
Bowel sound in chest
Pulmonary hypoplasia & hypertension
Severe retractions
120
Treatment for Congenital diaphragmatic hernia
```
Stabilization
Postductal PCO2 < 65mmHg and preductal O2 saturation >85%
ECMO is useful
Surgical decompression
Intrauterine surgery
```
121
Anesthetic considerations for congenital diaphragmatic hernia?
```
NG tube
Avoid high pressure PPV
Pre-oxygenation
decreased conc. of VA, muscle relaxant
Nitrous oxide (N2O) is contraindicated
High risk of pneumothorax, avoid barotrauma
-Chest tube
```
122
Most common type of tracheoesophageal fistula?
Type IIIB is most common
123
What is tracheoesophageal fistula? How do you know a child may have it?
Esophagus is a blind pouch attached by a fistula to the trachea.
Presents with increased oral secretions and respiratory distress.
cyanosis, chocking, and coughing with feedings - 3c's
124
Other defects may be present, what is VATER syndrome?
```
Vertebral defect
Anal atresia
TE fistula
Esophageal atresia
Radial dysplasia
```
125
if you put an NG tube down a kid with TF what will it show?
NG tube coiled in esophagus
126
TF is associated with what amount of fluid in utero?
polyhydramnios
127
what is oligohydramnios?
not enough amniotic fluid
128
What is a MUST to be performed for babies born with TF
surgical repair is a must, high risk aspiration
129
Anesthesia considerations with Tracheoesophageal Fistula ?
Need frequent suction due to increased secretion
avoid PPV
awake intubation
130
What is pyloric stenosis ?
Hypertrophy of pyloric smooth muscles
131
palpable olive shaped mass describes?
pyloric stenosis
132
pyloric stenosis causes?
projectile vomiting leading to metabolic alk. and shock
133
the vomiting causes a loss of what electrolytes?
sodium, potassium, hydrogen, chloride
134
what is paradoxic aciduria
trading off sodium with hydrogen
135
when is pyloric stenosis noticed?
present in the first two weeks to four months
136
what do you see on a barium study?
string sign
137
Treatment for pyloric stenosis?
Correct dehydration
NaCl and K+ supplement
Avoid Ringers lactate as lactate is metabolized to bicarb by liver
Surgical correction
138
Anesthetic consideration for pyloric stenosis?
```
Fix fluid and lytes first
Suction
High risk of aspiration
High risk of respiratory depression due to prolonged alkalosis
Awake intubation and rapid induction
Urinary output 1-2 ml/kg/hour
```
139
soar throat that leads to dysphagia that leads to obstruction describes?
acute epiglottitis
140
Tell me what you know about acute epiglottitis ?
```
Haemophilus influenzae type B
Edema of supraglottic structures
2-6 year of age
High grade fever
Inspiratory stridor
Tachypnea
SOB
Cyanosis
Drooling
Respiratory acidosis
```
141
Treatment for acute epiglottitis?
ET and antibiotics are life-saving
Ampicillin
Vaccination
142
Anesthetic considerations for acute epiglottitis?
```
Lateral neck X-ray to determine extent of obstruction
Prepare for tracheostomy
Avoid laryngoscopy
Inhalation induction in sitting position
Intubation with smaller size tubes
```
143
what size ETT do you want to use with acute epiglottitis and what type of induction do you want to perform?
smaller size ETT and inhalation
| inhalation induction in sitting position
144
symptoms of laryngotracheal bronchitis?
Low grade fever
Less air way obstruction than with AE
Barking cough
145
what age group does laryngotracheal bronchitis typically effect?
3 months to 3 years
146
treatment for laryngotracheal bronchitis?
oxygen and mist therapy
nebulized epi
IV dex
intubate if signs of resp. depression appear
147
does racemic epinephrine help croup, epiglottitis, or tracheitis?
it only helps improve the strider of croup
148
how long does it take croup to develop?
2-3 days
149
how long does it take epiglottitis to develop?
rapid onset over hours
150
how long does it take tracheitis to develop?
gradual onset
151
Pierre-Robin Syndrome /Treacher-Collins Syndrome how are they for intubations and what intubation or extubation technique will you want to use?
very difficult intubation
| use awake techniques
152
characteristics of pierre robin syndrome?
Cleft palate
| Small face and glottis
153
Treacher collins syndrome characteristics
Small lower jaw
Absent or malformed ear
More severe than Pierre-Robins
154
Congenital defects in abdominal wall leads to what?
external herniation of viscera
155
how common is omphalocele and how common is gastroschisis?
Omphalocele 1:5000
| Gastroschisis 1:15000
156
omphalocele vs gastroschisis, what are the differences? ( sac and anomalies)
omphalocele have a hernia sac and is associated with other congenital anomalies such as Down's syndrome.
gastroschisis does not have a hernia sac and is not associated with other congenital anomalies.
157
Persistence of herniation of abdominal contents into umbilical cord, covered with peritoneum describes what congenital issue?
omphalocele
158
Failure of lateral body folds to fuse leads to an extrusion of abdominal contents through abdominal folds what congenital issue is described?
Gastroschisis
159
increased maternal alpha fetoprotein is associated with omphalocele or gastroschisis?
omphalocele
160
Anesthetic considerations for omphalocele and gastroschisis?
NG decompression
Awake intubation
Nitrous oxide (N2O) is contraindicated ; avoid further distension
Muscle relaxation for reduction
161
omphalocele and gastroschisis staged closure surgery requires intragastric pressure to be? peak pressures to be? and end tidal CO2 to be?
Intragastric pressure > 20 cm H2O
Peak inspiratory pressure > 35 cm H2O
End-tidal CO2 > 50 mmHg
162
what will you replace third space lost with for omphalocele or gastroschisis ?
salt solution and five percent albumin
163
how long will babies with omphalocele and gastroschisis stay intubated after surgery?
1-2 days post op
164
What is Intestinal Malrotation and Volvulus ?
Abnormal rotation of the midgut around mesentery (SMA)
165
what are the symptoms of intestinal malrotation and volvulus?
symptoms of acute or chronic bowel obstruction
166
midgut volvulus can cut the blood supply and cause?
infarction
167
midgut volvulus, is it a surgical emergency?
yes
168
tell me some signs of midgut volvulus?
bilious vomiting
Progressive abdominal distension and tenderness
Metabolic acidosis
Bloody diarrhea is indicative of infarction
169
Anesthetic consideration for intestinal malrotation and volvulus twist...
Preop stabilization, NG, fluid/lyte balance, antibiotics
Rush to OR
Preoxygenation , awake intubation, rapid induction
170
bowl compartment syndrome may develop from intestinal malrotation and volvulus, which can cause?
impaired ventilation
obstruct venous return
impair renal functions
high mortality
171
Patients with volvus?
```
Hypovolumia
Poor tolerance to GA
Ketamine may be agent of choice
Fluid rescusitation
Blood products
```
172
what is intussusception?
telescoping of a segment of bowl into itself
173
what is the MC kind of bowel obstruction in first 2 years of life?
Intussusception
174
Risk factors that increase having intussusception?
Meckel’s diverticulum, intestinal lymphoma, viral infection
175
History and physical of a patient with intussusception may reveal?
Abrupt onset of abdominal pain in a health child
Colicky pain, vomiting, blood in stool “ current jelly stool”
Pallor , sweating
“Sausage-shape abdominal mass”
176
treatment of intussusception would include?
Correct fluid and electrolyte
Air contrast enema is diagnostic and curative
Surgical resection
177
cystic fibrosis, what is it and what does it cause?
Hereditary disease of exocrine glands of lungs and G.I.T
Most common recessive disorder in Caucasians [defective CFRT gene on chromosome 7]
Result from a defect in Cl- channels that is caused by mutation
Thick and sticky mucus builds up in lungs and intestine forming cysts.
Inability to clear secretions leading to bronchiectasis
Is associated with a deficiency of pancreatic enzymes resulting in malabsorption and steatorrhea
178
Clinical presentation of Cystic fibrosis
increased RV, increased airway resistance, decreased VC, decreased expiratory flow rate
Recurrent resp. infections , pneumonias
Fat malabsorption leading to deficiency of A,D,E, K
Fluid and electrolyte imbalance due to malabsorption
Failure to thrive
Death in early adulthood
179
How do you diagnose cystic fibrosis?
sweat chloride test is very increased
180
```
anesthetic considerations with cystic fibrosis?
what drugs are controversial?
what type of induction?
type of anesthesia for intubation?
ect.
```
Anticholinergic drugs are controversial
Prolong inhalation induction
Deep anesthesia for intubation
Avoid hyperventilation; may shallow postop respiration
Respiratory therapy
-Bronchodilators, incentive spirometry, postural drainage and proper antibiotics
181
Scoliosis what is it and what all will it affect in a person ?
Lateral curvature of vertebra and deformity of rib cage
Affect cardiac and respiratory functions
Hypoxia due to V/Q mismatch
Restrictive disease with low lung volume
decreased chest compliance
increased PCO2 in severe disease
Pulmonary hypertension due to increased pulmonary vascular resistance leading to RVH
