PEDS surg. procedures 4/16+

Question 0

peds ENT:
bilateral myringotomy tubes (BMT):
1. what type of anesthesia?
2. what is a side effect of gas case?
3. what can be used for pain?

Answer 0

1. usually mask GA with no IV
2. may have emergence delirium (especially if no narcotic used)
3. can use IM fentanyl or torodol also intranasal fentanyl

Question 1

ENT cases

1. what is the dose of fentanyl?
2. what is the dose of morphine?
3. what is the dose of decadron?

Answer 1

1. fentanyl 1-2 mcg/kg
2. morphine 0.1 mg/kg
3. decadron 0.25-0.5 mg/kg (closer to 0.5 mg/kg)

Question 2

ENT: T&A-

1. what type of induction?
2. what type tube?
3. narcotics used?
4. how long of a case?

Answer 2

1. inhalation induction
2. RAE tube is usually used (some doctors like a straight tube)
3. morphine 0.1 mg/kg or fentanyl 1-2 mcg/kg
4. these can be very fast cases

Question 3

ENT: T&A
maintainance:
1. what can interfere with your ETT airway?
2. how will you manage this patient? keep them breathing or paralyze?
3. what medication will you be giving to these cases in a higher than usual dose?

Answer 3

1. mouth gag or shoulder roll can cause displacement or disconnect of ETT
2. patient may breathe spontaneously as long as they are deep; no need to paralyze
3. high dose decadron (0.25-0.5 mg/kg)

Question 4

ENT: T&A-

1. Emergence (deep or awake)?
2. do you use antiemetics?

Answer 4

1. most do children deep, though awake is the recommended way
2. antiemetics may mask the feeling of nausea from swallowed blood

Question 5

Peds ENT: T&A-

complications: post obstructive negative pressure pulmonary edema:

Answer 5

1. post obstructive negative pressure pulmonary edema: caused by negative intrathoracic pressure, hypoxia and resultant massive sympathetic discharge
   - this leads to an increase in venous return to the right heart, increasing pulmonary blood volume and microvascular pressure
   - this results in rapid trasudation of fluid and lymph into alveoli
   - presentation and treatment same in adults and children

Question 6

ENT: complications-
Bleeding tonsil:
1. considered what for intubation?
2. what should you have sooooo available?
3. what might the hydration status of this patient be?
4. if you have to re-intubate, how can you see?

Answer 6

1. full stomach; RSI intubation
2. have suction ready
3. severely dehydrated
4. sometimes you can’t; follow the bubbles

Question 7

ENT: 
Laryngoscopy, bronchoscopy:
1. indications:
2. what are the airway issues?
3. be ready for what...?
4. the MD may want to do an awake...?
5. local anesthesia via what device?
6. words of advice: "stay \_\_\_\_"

Answer 7

ENT:
Laryngoscopy, bronchoscopy:
1. indications: for evaluation of airway obstruction or stridor
2. what are the airway issues? shared airway with physician, table turned 90 degrees.
3. be ready to take over airway.
4. the MD may want to do an awake look
5. local anesthesia via what device? LTA
6. stay organized and know where everything is on your table.

Question 8

Ear, Nose and Throat
Laryngoscopy, bronchoscopy
1. what is the best way to manage the airway? what else can be used?
2. how would you start the case?
3. what do you do with your breathing circuit?
4. what should you have handy (just in case)
5. what might you hear post extubation? how do you treat it?

Answer 8

Ear, Nose and Throat
Laryngoscopy, bronchoscopy
1. Spontaneously breathing patient is usually desired
may use LMA for flexible bronchoscopy
2. Start as mask GA, titrate in propofol as needed
3. Connect circuit to rigid bronchoscope
 Can use jet ventilation if patient is not spontaneously breathing
4. Have multiple size ETT’s available in case, pt. may require smaller size
5. May have post extubation stridor,
 Tx with racemic epi and or decadron as needed

Question 9

Tympanoplasty & Mastoidectomy

1. what type induction?
2. what dont you want to use for maintainance? what about muscle relaxants? why?
3. what will be the table positioning?
4. these patients are high risk for what condition? what must you do? what reginem would you give?
5. what type of emergence? why?

Answer 9

Tympanoplasty & Mastoidectomy
1. Standard induction
2. Maintenance: No N2O for tympanoplasty
 Usually no muscle relaxants for mastoidectomy
 Surgeon may monitor facial nerve
3. Table turned 90-180 degrees
4. PONV risk; Aggressive PONV prophylaxis
 give dramamine pre op, decadron, and zofran intra-op (save reglan for post op)
5. Emergence= Deep
 Avoid straining or coughing that could blow tympanic graft

Question 10

 General Surgery
Hernia Repair
1. What hernias are usually for children?
2. what type of anesthesia plan?
3. If using GA, what can you use?
4. if doing caudal anesthesia, what should be limited?

Answer 10

General Surgery
Hernia Repair 
1. Usually umbilical or inguinal
2. GA with caudal or SAB
3. If GA, may use LMA, muscle relaxation not usually required 
4. Limit narcotic if caudal

Question 11

General Surgery
 Appendectomy
1. what will the patient definately need?
2. appendectomies are considered what? therefore intubation sequence should include…?
3. what do you need for this procedure (“glue”)
4. patient should be extubated in what manner?

Answer 11

General Surgery
  Appendectomy
       
Preop IV and antibiotics 
2. Full stomach; RSI with sux (after versed and 10% zem priming dose).
3. Muscle relaxation required, 
4. Awake extubation

Question 12

General Surgery
Broviac/port placement/PICC
1. what pre-op tests?
2. what type of induction?
3. what type of sedation with older children?

Answer 12

General Surgery
Broviac/port placement/PICC
     
1. May need CBC if oncology patient
2. Mask or IV induction
3. May be able to do deep sedation with older children, or use LMA

Question 13

Pediatric General Surgery
  Circumcision
1. anesthesia type
2. what type of block is performed? what should you do?
3. what type of local?

Answer 13

Pediatric General Surgery
Circumcision
  
1. Usually GA with LMA and caudal block.
2. Surgeon may perform penile block if no caudal; Limit narcotic
3. local WITHOUT epi

Question 14

Frenulectomy:
 how quick of a case?
 any IV?
 how do you give pain meds?

Answer 14

Frenulectomy
 Quick mask case,
 usually no IV
 IM fentanyl

Question 15

General Surgery
Colostomy, bowel resection
1. Induction:
2. what's one of the most important aspects of child surgery? how is this accomplished?
3. what is one of the biggest things that must be monitored in child surgery?
 what fluid is used for replacement?
 how many lines will you need?
 can you free flow your IV?
 how can you determine EBL

Answer 15

General Surgery
Colostomy, bowel resection
1. Induction
 May be inhalation or IV
 Fentanyl 1-2 mcg/kg to start (?up to 5 mcg/kg) for case Maintenance
2. Keep patient warm
 Bair hugger
 Fluid warmer
3. Keep up with fluid and blood losses
 Use LR for replacement
 Use 2 lines, one for maintenance and one for 3rd space and blood losses
 Pumps are helpful in determining fluids delivered, necessary with infants (unless using buretrol)
 EBL: May need to weigh sponges (1 gram sponge weight=1cc blood)

Question 16

ORIF

 what anesthetic considerations?

Answer 16

ORIF

 Standard

Question 17

Plastic Surgery
Cleft Lip and Palate Surgery
1. what age are these patients usually?
2. induction; what type? 
3. d/t nature of surgery, what issues might one run into?
4. how is this issue remidied
5. what type of ETT tube?

Answer 17

Plastic Surgery
Cleft Lip and Palate Surgery
1. Cleft palate repair at 1-5 years, cleft lip as early as 1 week
2. Inhalation induction
3. Cleft palate can be associated with craniofacial defects
4. FOB (fiber optic bronchoscope) if difficult airway suspected
5. RAE tube

Question 18

Plastic Surgery
Cleft Lip and Palate Surgery: Maintenance
1. how will the table be positioned?
 what will you need on your tube?
2. what other items will be needed?
3. will you anesthetize with gas only or will you use MRs?

Answer 18

Plastic Surgery
Cleft Lip and Palate Surgery: Maintenance 
1. Table turned 90-180 degrees 
  Long circuit
2. Mouth gag and throat pack 
3. gas +/- muscle relaxation

Question 19

Plastic Surgery
Cleft Lip and Palate Surgery: Emergence
1. What do you want for emergence?
2. do you put an oral airway in automatically?
3. what should come out before extubation?

Answer 19

Plastic Surgery
Cleft Lip and Palate Surgery: Emergence
1. Smooth wake up
2. No oral airway, usually no nasal airway
 Communicate with surgeon on nasal airway use (sometimes you can use a soft bite block)
  If nasal airway, use unaffected nares (Cleft lip repair usually affects one side of nose )
3. Ensure throat pack removed


Question 20

Opthamology
Strabismus Repair
1. induction type:
2. what is a side effect of eye repair?
 what might be given pre-emptively for this
3. what type tube?
4. what is table position? 
5. what medication should not be given to strabismus kid?

Answer 20

Opthamology
Strabismus Repair
1. Standard induction
2. bradycardia d/t stimulation of occulocardiac reflex
 May give Atropine or Glycopyrrolate if not given preop
3. tube type:Oral RAE
4. Table turned 90-180 degrees
5. no sux d/t Muscular Dystrophy risk with strabismus

Question 21

Opthamology
Strabismus Repair:  Maintenance
1. how is patient maintained?
2. what can cause bradycardia?
3. how does this occur?  what are manifestations?
4. what is the treatment?

Answer 21

Opthamology
Strabismus Repair: Maintenance
1. +/- muscle relaxant
2. Oculocardiac reflex
3. Triggered by pressure, pain or traction on ocular structures
 Bradycardia, junctional rhythm, ventricular arrythmias, asystole
4. Treatment
 Alert surgeon, discontinue stimulus
 Ensure adequate depth of anesthesia Atropine for persistent bradycardia Surgeon may infiltrate local

Question 22

Opthamology
Strabismus Repair: Emergence
1. common post complaint?
2. how do you avert this situation medicinally?
3. what should be done before emergence to prevent PONV?
4. what type of extubation?

Answer 22

Opthamology
Strabismus Repair: Emergence
1. PONV common
2. Aggressive PONV prophylaxis:
Reglan, 
 ondansetron,  
decadron 
3. Suction stomach while deep
4. deep extubation

Question 23

Opthamology
Nasolacrimal duct probing: 
1. indications
2. anesthesia considerations?
3. airway if table is turned?
 if not?

Answer 23

Opthamology
Nasolacrimal duct probing 
1. for blocked tearducts
2. Standard anesthetic considerations
3. LMA
 mask

Question 24

``` Oral Surgery: Tooth extraction 1. what may be an issue with this patient?  this may cause a challenge with what? 2. what type of airway?  what should you always do? ```

Answer 24

``` Oral Surgery: Tooth extraction 1. Patients may be mentally disabled  Induction may be challenging 2. usually a Nasal RAE tube,  ask surgeon first though ```

Question 25

Out of Operating Room Procedures: | Where might these take place (5 places)?

Answer 25

``` Out of Operating Room Procedures 1. Endoscopy  EGD  Colonoscopy  Rectal Biopsy 2. CT Scan 3. MRI 4. EEG 5. Interventional Radiology (PICC line) ```

Question 26

``` Out of Operating Room Procedures: Endoscopy EGD &Colonoscopy 1. what is the best way to manage the patient during this procedure? 2. Induction for:  child under 5 y/o:  age 5-9:  older child: 3. advantages of this technique: ```

Answer 26

Out of Operating Room Procedures: Endoscopy EGD &Colonoscopy 1. Let patients breathe spontaneously throughout 2. induction: Under age 5, usually GA with ETT, Mask induction, once intubated may d/c agent and titrate propofol age 5-9 may be mask induction, then O2 by nasal cannula or blow-by: d/c agent and titrate propofol Older patients with IV can usually be done with deep sedation 3. advantages of this technique:  Less nausea and emergence delirium  Quicker discharge

Question 27

Out of Operating Room Procedur: Endoscopy Rectal Biopsy -- type of anesthesia:

Answer 27

Out of Operating Room Procedur: Endoscopy Rectal Biopsy --Often times no anesthesia is required (If anesthesia is desired by endoscopist, mask GA)

Question 28

EEG: | --What type of anesthesia?

Answer 28

EEG | --Usually light GA with LMA (propofol sedation)

Question 29

Out of Operating Room Procedures: CT Scan | -- Anesthesia type?

Answer 29

Out of Operating Room Procedures: CT Scan | --GA or sedation, depending on patient (Infants & cooperative patients may be able to go without anesthesia)

Question 30

Out of Operating Room Procedures: MRI 1. anesthesia type (allow for what)? 2. remember you are in MRI so... no___ in the MRI?

Answer 30

Out of Operating Room Procedures: MRI 1. GA for pediatrics with ETT/ LMA Standard induction without narcotic (Allow spontaneous respirations) 2. (No precordial in MRI)

Question 31

Out of Operating Room Procedures: Recovery- 1. what should you bring with you to PACU? 2. what other "monitor" should be on the patient during transport?

Answer 31

Out of Operating Room Procedures: Recovery- 1. Bring monitors (including pulse ox), mask & O2 to travel long distance to PACU 2. Use precordial during transport