Test 4: Pediatric Anesthesia Pt. 3 Flashcards

Question

Anesthesia considerations for Downs Syndrome patients

Answer 1

* Large tongue * a small mouth * Atlantoaxial instability * Inhalation induction bradyarrhythmias

Answer 2

- no NMBDs - prepare difficult airway equipment - 100% FiO2 - IV access - use external manipulation of the trachea if possible *low threshold for progressing down the difficult airway algorithm quickly* ## Footnote Thrown in an LMA to ventilate if you need

Answer 3

* Foreign body * Epiglotottitis * Laryngospasm

Answer 4

* Asthma * Bronchiolitis

Answer 5

6 months - 3 years old

Answer 6

* Usually removed with a rigid bronchoscopy * May require post-op steroids * Consider TIVA b/c you may not get much gas when they are maipulating the airway

Answer 7

- Probably wont intubate with a rigid bronch - TIVA (can mask when rigid scope is in) - topical lidocaine to decrease bronchospasm/laryngospasm when the scope goes in - Want pt spontaneously breathing b/c PPV could push the FB farther down the bronchus

Answer 8

Epiglottitis is more emergent, while croup is urgent

Answer 9

- developmental delay in social and communication - changes in routine are difficult - sensative to sensory stimuli (light, sound etc) - preop is important (triggers and soothing things) - premedication is important +/- parental presence - reunite with parents in PACU asap

Answer 10

- most frequent chromosomal anomaly - risk for difficult **ventilation**/intubation - everything about this airway will scream obstruction (large tongue, OSA, subglottic stenosis, palate narrow etc) *air on the side of smaller ETT b/c of subglottic stenosis*

Answer 11

Trick question! - 40-50% have congenital heart disease - most common is AV septal defect - 2nd most common is VSD - additional: PDA, TOF (tet.) - brady is very common in inhalation induction (independent of a heart condition) *go very slow with inhalation induction* - they have low levels of circulating catecholemines ## Footnote have glyco (0.01mg/kg) and atropine (0.02mg/kg) ready!

Answer 12

- Likely have developmental delays (propbabily need to premedicate) - strabismus - hypotonia - hyperflexible joints - GERD common - epilepsy - thyroid disease - increased incidence of leukemia

Answer 13

**V**ertebral anomalies *most common* **a**nal atresia **c**ardiovascular anomalies **t**racheoesophageal fistula *most common* **e**sophageal atresia **r**enal and/or radial anomalies **l**imb defects exact cause is unknown (not hereditary)

Answer 14

**C**oloboma (hole in the eye structures) **h**eart defects **a** choanal atresia (back of nasal passage obstructed) **r**estruction of growth/development **g**enitourinary problems **e**ar anomalies

Answer 15

**C**ardiac **a**bnormal face **t**hymic hypoplasia (blood needs to be irriadiated b/c thymus isn't working) **c**left palate **h**ypocalcemia (d/t hypoparathyroid) **22**q11.2 gene deletion

Answer 16

- many pts need dental work under GA (they cant tolerate going to the dentist) - we share the airway - nasal intubation

Answer 17

- corrects extraocular muscles and re-establishes the visual axis - GA with LMA or ETT and inhalational induction - Anesthetic concerns: careful preop exam (underlying conditions?), **anticipate oculocardiac reflex**, PONV common

Answer 18

- happens b/c of Extraoccular muscles - causing pressure on the globe - Afferent pathway to ophthalmic branch CNV (trigeminal ganglion) stimulates Efferent pathway of vagus (cardiac depressor) - bradycardia, AV block, ventricular ectopy, asystole - **response decreases with repeated stimulation** *first treatment is ask the surgeon to stop*

Answer 19

- Higher PaO2 that can cause abnormal vascular growth - retinal maturation is complete at ~44 weeks - **if caring for preemies, maintain SpO2 at 89-94%** - risk factors: <30 weeks gestation, or <1000g birthweight - goal of surgery is to preserve the retina (uses laser or cryotherapy)

Answer 20

* Inhalation induction, deep intubation * Use a drying agent (robinul) * Opioids * Zofran and Decadron (0.5mg/kg for airway swelling) * Deep extubation (usually)

Answer 21

Bleeding - primary: within 6-24 hours postop - secondary: 5-10 days postop Airway fire - maintain low FiO2 <30% - avoid N2O

Answer 22

- emergency, considered full stomach - pre-oxygenate - RSI with cric pressure (difficult to do awake intubation with peds) - ETT 1/2 size smaller - lost lots of blood (IV, fluids and potentially blood) - antiemetics - OGT - extubate awake

Answer 23

- defect in palatal growth in the first trimester - primary lip repaired ~3-6 months - primary palate repaired ~6-12 months - syndromes commonly associated with cleft lip & palate

Answer 24

- GETA (oral rae) - awake extubation - acetaminophen and opioids - potential for postop obstruction

Answer 25

* Narrowing of the pylorus, the lower part of the stomach, through which food and other stomach contents pass to enter the duodenum. * When an infant has pyloric stenosis, the muscles in the pylorus have become enlarged to the point where gastric emptying is prevented * **olive shaped mass just below xiphoid process**

Answer 26

* Multifactorial. Some researchers believe that maternal hormones could be a contributing cause. * May be that the thickening of the muscle is the stomach's response to some type of allergic reaction in the body. * Infants may lack receptors in the pyloric muscle that detect nitric oxide, a chemical in the body that tells the pylorus muscle to relax → leading to hypertrophy

Answer 27

2 weeks and 12 weeks

Answer 28

* Projectile vomiting * The breast milk or formula is ejected forcefully from the mouth in an arc, sometimes over a distance of several feet * The vomitus will not contain bile

Answer 29

- assess acid/base balance (lots of vomiting) - correct hypovolemia and e-lyte abnormalities - neonate is considered a full stomach - before inducing anesthesia, suction stomach until clear - RSI - extubate awake - concern for postop apnea (these babies are very weak d/t lack of nutrition **avoid narcotics, just do rectal tylenol**

Answer 30

- prevalent in preterm neonates - concerns for small bowel incarceration and ipsilateral testicular injury - open or laparoscopic

Answer 31

- anesthesia technique (provider preferance) - spinal or caudal - inhalational or IV induction - LMA or ETT - concern for postop apnea

Answer 32

- defects in the abd wall that occur during gestation when the visceral organs fail to move from the yolk sack in the the abd cavity (outside of body) - usually have other issues too (cardiac, GU, metabolic, malrotation, Meckel diverticulum or intenstinal atresia) - Omphalocele outcomes are poor (covered by membrane) - Gastroschisis (not covered by memebrane) ## Footnote Beckwith-Wiedemann syndrome associated with these GI abnormaliites too

Answer 33

- **severe dehydration (more with gastro) and temp loss** - high risk for sepsis - other associated abnormalities - avoid increased IAB - postop vent requirements - lungs will be more squished when the GI is back in the body - less freedom of movement needs support

Answer 34

**NO N2O!** - air expands with N2O remember? - adequate IV access (x2) - prepare for colloid administration - yes NMBD (open abdomen) - a-line (guide fluid mangement) - pulse ox on UE and LE (monitor perfesion in both)

Answer 35

- intestinal inflammatory condition **emergency** - secondary to bowel ischemia and immaturity - probable bacterial invasion - delayed oral feeding - occurs usually in preterm babies with gestational age <32 weeks, weight <1500g *common to see in premies with PDA*

Answer 36

- hyperkalemia - hyponatremia - metabolic acidosis - hyper or hypo glycemia - DIC in severe cases

Answer 37

Imaging studies

Answer 38

- increased gastric residuals with feedings - ABD distension - bilious vomiting - lethargy - rectal bleeding - fever - hypothermia - oliguria - jaundice - apnea/bradycardia

Answer 39

- ensure adequate oxygenation - manage hypovolemia and acidosis - withhold enteral feeding - NG decompression - ABx Surgical intervention - ex-lap with dead bowel resection, colostomy or peritoneal lavage

Answer 40

- The intestine becomes twisted and ischemic = volvulus **emergent** - presentation 1st week of life - **bilious vomiting** Sugery = Ladd procedure

Answer 41

- fluid replacement - e-lyte management - full stomach - increased IAP = less FRC!! plus all the other GI considerations we have been talking about

Answer 42

Abdominal content protrude into thoracic cavity and act as a space occupying lesion - prevents normal lung growth (lung can be small) - 80% of these are on the L side

Answer 43

- dyspnea - tachycardia - cyanosis - absence of breath sounds on affected side - severe retractions - scaphoid abdomen - barrel chest Dx: with US prenatally

Answer 44

possibility for prenatal intrauterine surgical intervention (goal to revers pulmonary hypoplasia) - if born, median age of operation is ~4 days (may be done at bedside) - possibility for 1 lung ventilation - *no double lumen tube, R mainstam the tube*

Answer 45

- likely intubated already - consider atropine IV prior to induction - VAA and meds and guided by how unstable they are (likely need TIVA) - likely only need opioids and NMBD - vent strategies - premissive hypercarbia with high-frequency oscillatory ventilation - avoid inflating stomach with air - control PVR factors! - PIP should be maintained <25-30 cmH2O - postop goal to keep PaO2>150mmhg and slowly wean to lower O2 over 72 hours

Answer 46

Fistual to esophagus through trachea - cannot pass OGT into stomach immediately after birth - coughing/choking after first feeding *assume they have another congenital issue too*

Answer 47

- Preformed via R side thoracotomy - fistula ligated then anastomosis of the 2 ends are put together

Answer 48

- ECHO preop - minimize oral feedings - place balloon-tipped catheter to suctions nasopharyngeal secretions that accumulate in the esophageal pouch - gastrostomy tube - **maintain spont. breathing** - PPV will go into stomach - may need bronch after induction (ENT may place for you)

Answer 49

Diagnosed with neonate does not pass meconium within the first few days after birth - ranges from mild stenosis to complete anal atrasia **may be associated with VACTERL**

Answer 50

- in males: surgery is urgent to allow passage of meconium via colostomy - in females: common presence of rectovaginal fistula (so the procedure can be delayed a few weeks)

Answer 51

d/t obstruction of CSF flow leading to increased ICP - bluging anterior fontanelle, irritability, somnolence, vomiting, LOC and/or CV collapse - may need VP shunt *risk of delying surgery includes brain herniation*

Answer 52

- control ICP - RSI - goal to extubate at the end of procedure - VAAs cause cerebral vascular dilation at >1 MAC and can increase ICP

Answer 53

- form of spina bifida: most common CNS defect that occurs during the first month of gestation **decreased FA intake is the cause** - **failure of neural tube to close leads to herniation of the spinal cord and meninges through a defect in the spinal column and back** - most often in lubosacral - can be repaired in utero or in first 24 hours of life arnold-chiari malformation will require a VP shunt

Answer 54

* Volume * Heart Rate ## Footnote Starling's Law is not a factor in cardiac output in pediatrics until they are 5-6 years old

Answer 55

The 3:1 rule is a fluid resuscitation guideline that states that for every 1 mL of blood loss, 3 mL of crystalloid fluid should be used.

Answer 56

Neonates have low glycogen stores and cannot break down triglycerides and convert them to usable energy. Therefore, fluids with dextrose (D5, D10) are needed for these patients.

Answer 57

Mix 10 mL of D50 with 40 mL of LR.

Answer 58

[EBV x (pt Hct - allowed Hct)] / pt Hct

Answer 59

EBV = 8 kg x 80 mL/kg = 640 Blood Loss = [EBV x (pt Hct - 25)] / pt Hct [640 x (36-25)]/36 = 195 Max allowable blood loss is 195 mL

Answer 60

Use 4-2-1 rule. 4 mL/kg x 10 kg = 40 mL 2 mL/kg x 10 kg = 20 mL 1 mL/ kg x 4 kg = 4 mL 64 mL/hour x 6 hours = 384 mL

Answer 61

* Get 100 mL NS bag * Take 20 mL NS out of the bag * Replace with 20 mL of 25% albumin.

Answer 62

20-60 breaths per minute (Note WOB, effort, mechanics, assess sounds, skin tone, pulse ox)

Test 4: Pediatric Anesthesia Pt. 3 Flashcards

(92 cards)