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Semester 6 TxWes > Unit 1 > Flashcards

Unit 1 Flashcards

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1
Q

What are the 4 meds you should have ready for peds cases?

A

Sux, atropine, lidocaine and epi

Along with flushes and IM needles

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2
Q

Airway obstruction in peds is most pronounced at what location?

A

The hypopharynx at the level of the epiglottis

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3
Q

Most of the airway resistance is where in peds?

A

In the small airways and bronchi

d/t the relatively smaller diameter of airways and greater compliance of the trachea and bronchi

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4
Q

Finish the phrase: Resistance is inversely related to the ____________________________

A

airway radius to the 5th power

Of note, Poiseuille’s law says it’s “resistance is inversely related to radius to the 4th power”, perhaps peds airways are an exception and are up to the 5th power rather than 4th?

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5
Q

Laryngospasms result from what kind of respiratory effort?

A

Inspiratory effort

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6
Q

3 common causes of laryngospasms in peds?

A

Light anesthesia, stimulation and secretions

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7
Q

What is your anesthetic of choice in laryngospasm?

A

Propofol first

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8
Q

What clinical findings can indicated an intraoperative bronchospasm?

A

Polyphonic expiratory wheeze
Prolonged expiration
Active expiration with increased respiratory effort
Increase peak airway pressures
Slow up slope of ETCO2 waveform
Increased ETCO2
Decreased SPO2

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9
Q

What characteristic ETCO2 waveform shape is indicative of bronchospasm?

A

Shark fin

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10
Q

Bronchospasm treatments?

A

Ketamine or propofol induction and Sevoflorane or Isoflorance are preferred

Desflurane can increase airway resistance in children and should be avoided

Administer 100% oxygen

Deepen anesthetic (IV first then increase inhaled anesthetic)

Avoidance of tracheal and vocal cord stimulation are ideal (LMA could be ideal)

Intra-op treatment includes remove stimulus, deepen anesthesia, inhaled beta agonists, increasing FiO2, decreasing PEEP and increasing I:E ratio to minimize air trapping

Consider IV steroids and/or epinephrine

Epinephrine at 0.05-0.5mcg/kg given every minute

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11
Q

What s/sx are indicative of a laryngospasm? Bronchospasm?

A

L: Inspiratory, stridor, retraction of intercostals at suprasternal notch, no change in expiration and fast onset cyanosis

B: Expiratory, wheeze and/or croup, accessory muscles of inspiration, prolonged expiration, cyanosis onset is slow

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12
Q

What 2 factors from croup contribute to the narrowing/increase in airway resistance?

A

Inflammation and edema related to compression of tracheal mucosa

Reduction in the luminal diameter and increasing the airway resistance

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13
Q

Risk factors for croup?

A

Larger ETT size than airway (no leak > 25cm H20)

Changes in position during surgery other than supine

Repeated attempts at intubation or traumatic intubation

Patients age 1-4 at higher risk

Length of surgery > 1 hour

Previous croup history

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14
Q

Croup treatment?

A

Treatment: nebulized Epinephrine (Racemic epi)
Dexamethasone 0.5mg/kg

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15
Q

What ETT can be used to help reduce croup risk?

A

Micro-cuff ETT used (high volume/low pressure) - elliptical balloon placed more distally, no Murphy eye, provides uniform surface contact

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16
Q

What lung is usually the most affected by CDH (congenital diaphragmatic hernia)?

A

The ipsilateral lung

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17
Q

What 2 pulmonary changes are common to CDH?

A

Increased PVR and primary pulmonary HTN

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18
Q

Where does the most common form of CDH herniate through?

A

The foramen of Bochdalek

This type is the largest type and associated with greatest amount of pulmonary hypoplasia

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19
Q

CDH is associated with what other abnormalities?

A

GU, GI malformations, and chromosomal abnormalities like trisomy 13, trisomy 18, tetrasomy, and 12p mosaicism

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20
Q

What is the 2nd most common area for CDH to herniate through?

A

Para-esophageal hernias

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21
Q

What ultrasound findings (prenatally) would indicate a CDH?

A

Findings of polyhydramnios, intrathoracic gastric bubble, and mediastinal shift away from herniation site

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22
Q

S/sx of CDH?

A

Respiratory distress
Tachycardia
Tachypnea
Cyanosis (R to L shunting contributes to severe hypoxemia)
Concave abdomen
Barrel chest
Absent breath sounds on the affected side

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23
Q

The goal is to medically stabilize the peds patient prior to CDH surgery. What would be some common goals/treatments?

A

Improve pulmonary hypertension and decrease PVR, vasodilator therapy (such as inhaled NO), give prostaglandins to maintain the PDA to reduce RV afterload and ECMO in severe cases

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24
Q

What lab findings would indicated severe lung hypoplasia and pulmonary HTN indicating the need for ECMO prior to CDH surgery?

A

PaO2 less than 50 mmHg on 100% FiO2

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25
Why do you avoid CPAP in CDH?
It can further entrain air in the stomach
26
What is the primary cause of morbidity/mortality in CDH?
Pulmonary HTN
27
What intervention would be used if you could not fit all the abdominal viscera into the abdominal compartment s/p CDH repair?
Place contents in a silo pouch and slowly replace them into the cavity
28
Where is a chest tube commonly placed (if needed) s/p CDH surgery?
The contralateral side
29
Patient position for CDH surgery?
Lateral decubitus w/upper arm positioned for field avoidance
30
Common goals for anesthesia for CDH surgery?
Avoiding volutrauma (oscillator ventilation) with controlled ventilation Avoid increased PVR (hypoxemia, acidosis, hypothermia, hypercarbia) To decrease PVR - hyperventilation, narcotics to blunt sympathetic discharge An NGT should be passed prior to induction if not already present to decrease likelihood of air entering the stomach Avoid nitrous, maintain paralysis Fentanyl induction 50mcg/kg, Rocuronium 1.2mg/kg or Cisatracurium 2mg/kg, Sevoflurane as tolerated Patients return to the ICU intubated and muscle relaxant should be maintained
31
If you are using an oscillator to ventilate during an CDH surgery, what should your anesthetic plan be?
A TIVA
32
Most common TEF (tracheoesophageal fistula)?
Type C
33
Where is a TEF commonly located?
1 - 2 tracheal rings above the carina
34
What is TEF commonly associated with?
VACTERL: Vertebral anomalies imperforate Anus Congenital heart disease TracheoEsophageal fistula Renal abnormalities Limb abnormalities
35
Prenatally what diagnoses a TEF?
Signs of polyhydramnios, small or absent gastric bubble, blind ending upper pouch in fetal neck
36
What are the postnatal s/sx of a TEF?
Excessive salivation, choking, coughing, regurgitation at the first feeding leading to cyanosis, and or respiratory distress and a distended abdomen from the stomach filling with air when the baby cries and inability to pass a nasogastric tube
37
What are the 3 C's of a TEF
Choking, coughing and cyanosis
38
What tests can officially diagnose a TEF
Confirmed with the inability to pass a nasogastric tube into the stomach more than about 7cm Dilated proximal esophagus with air in conjunction with air in the distal stomach on Xray, CT or direct visualization via bronchoscopy/endoscopy
39
What are 3 pre-surgical goals for a TEF surgery?
Proximal pouch tube should be secured and placed to continuous suction Mask ventilation and tracheal intubation avoided prior to surgery, can exacerbate gastric distention Focus is now on stabilization of infant prior to surgery
40
Patient position for TEF surgery
Left lateral decubitus
41
Why is left lateral decubitus the preferred position for TEF surgery
It allows for a right thoracotomy approach to help avoid the aortic arch
42
What are the common anesthetic considerations for a TEF?
Keep the infant spontaneously breathing to avoid positive pressure ventilation and achieve awake intubation (can be traumatic and difficult to achieve without a crying infant further adding more air to the stomach) IV induction is quicker, more stable, and the use of muscle relaxants can optimize intubating conditions Gentle mask ventilation with low peak pressure The tip of the ETT is placed above the carina but distal to the fistula (generally done by intentionally mainsteming, then slowly pulling it back)
43
Why can positive pressure ventilation create a vicious cycle in TEF surgery?
The + pressure increased abdominal pressure, which increases the chances of gastric contents spilling into the airway. Further + pressure further increases abdominal pressure which further increases gastric spillage risk
44
Describe how you would optimize tube position in TEF surgery
Intentionally right mainstem, then slowly retract tube until you either get bilateral breath sounds or you can identify both bronchi via fiber optic scope *the goal is to sit just distal to the carina, this way you are below the level of the TEF but high enough to ventilate both lungs*
45
Why do you increase I:E ratio after TEF surgery?
To help re-expand alveoli
46
Why do you commonly keep pts intubated s/p TEF surgery?
Many surgeons request post-op intubation for days to help prevent pneumonia, atelectasis, or emergent reintubation, & perforation of suture lines
47
What 2 regional catheters may help post-op analgesia in TEF surgery?
Caudal or intrapleural
48
When is pyloric stenosis commonly diagnosed?
Usually diagnosed between 2 and 8 weeks of age with non bilious projectile vomiting *more common in males than females, 4:1*
49
What acid/base imbalance is common to pyloric stenosis?
Hypokalemic/Hypochloremic metabolic alkalosis *though if severe enough can progress to metabolic acidosis d/t excretion of bicarb*
50
What clinical s/sx indicate pyloric stenosis?
Projectile non-bilious vomiting, immediate postprandial vomiting and infant is hungry in between feedings
51
What ultrasound finding is indicative of pyloric stenosis?
Target sign or donut sign
52
What findings indicate that an infant is now medically ready for pyloric stenosis surgery?
Good skin turgor, adequate UOP (1- 2mL/kg/hour) Sodium greater than 130mEq/L Potassium greater than 3.0 mEq/L Chloride greater than 85 mEq/L
53
What anesthesia considerations are common to pyloric stenosis surgery?
RSI secondary to gastric outlet obstruction Towels!! Large red rubber catheter Preoxygenate with 100% oxygen Suction (turned RIGHT, CENTER, LEFT)
54
What drugs (including dosages) are common to use in pyloric stenosis surgery?
Lidocaine 1-2mg/kg Atropine .02mg/kg Propofol 2-4mg/kg Succinylcholine 2mg/kg Tylenol 30-40mg/kg (given as rectal suppository) No Narcs!
55
What type of fluid is common to use in pyloric stenosis patients?
Dextrose containing fluids
56
What PACU considerations are common to pyloric stenosis patients?
Awake extubation Post-op respiratory depression is common Apnea monitor for the first 24 hours postoperatively Monitor for hypoglycemia Morphine can be used in PACU in small doses (0.02-0.03mg/kg) after extubation
57
What condition is more severe, gastroschisis or omphalocele?
Gastroschisis *no membrane, contents are open to air = massive fluid/heat loss*
58
Gastroschisis occurs because of what?
Occlusion of the omphalomesenteric artery during gestation
59
Which is associated with other congenital anomalies: Gastroschisis or Omphalocele
Omphalocele
60
What causes the bowels to be edematous and inflamed in gastroschisis?
Functionally abnormal dilated and foreshortened bowel because they are exposed to amniotic fluid in utero and air after delivery
61
What causes an Omphalocele?
Failure of the gut to migrate from the yolk sac into the abdomen during gestation
62
What congenital abnormalities are associated with Omphaloceles?
Associated with genetic, cardiac, urologic, and metabolic abnormalities
63
Where does Gastroschisis usually emerge from? Omphalocele?
G = periumbilical and usually to the right O = directly from the umbilicus
64
What interventions to manage both gastroschisis and omphalocele?
Aimed at maintaining perfusion to the viscera and reducing fluid loss Cover mucosal surfaces with sterile saline soaked dressings A plastic wrap is placed over the herniated viscera to decrease evaporative loss and prevent heat loss and hypothermia (much more pronounced with gastroschisis) Complete surgical reduction or staged reduction with a Silastic pouch The pouch size is reduced slowly allowing gradual accommodation of the abdominal contents into the abdominal cavity without comprising ventilation or organ perfusion Continued volume resuscitation Measures to prevent hypothermia Warm the room, have underbody bear hugger, lights, hat, in line humidifier Aspirate the in situ gastric tube Preoxygenate with 100% oxygen RSI with cricoid Maintain with oxygen & air No nitrous! Narcotics and muscle relaxation for surgical repair
65
An intragastric pressure of what indicated abdominal ischemia after closure of a gastroschisis or omphalocele?
Greater than 20 mmHg
66
Why should you use a BP cuff and pulse ox on both upper and lower extremities of peds s/p gastroschisis or omphalocele surgery?
If the bowel becomes edematous, it can increase renal congestion, lower UOP, increase BLE congestion which impedes venous return. Combined, this causes BP and pulse ox discrepancies from the BUE and BLE
67
What type of fluids should be used preop in Gastroschisis and Omphalocele surgery? Post-op?
Dextrose containing for both
68
What is the goal PAP in Gastroschisis and Omphalocele surgery?
Less than 25 mmHg *PAP = peak airway pressure*
69
What environmental causes are associated with neural tube defects?
Folate deficiency, maternal anti-epileptic drugs, retinoins (vitamin A drugs like accutane), and maternal diabetes
70
What is spina bifida?
Abnormal or incomplete formation of midline structures over the back Skin, bone, and neural elements can be involved individually or in combination of each other
71
T/F: Spina Bifida is always associated with brain anomalies
False
72
What are the common types of spina bifida?
Spina Bifida Occulta Spina Bifida Aperta/Cystica
73
What s/sx are common to spina bifida occulta?
Overlying skin appears normal and intact Hairy patch may be present Sacral dimple Lipoma Spinal cord can end lower than usual *Occulta means "hidden"*
74
What s/sx are common to spina bifida aperta?
Obvious lesion on the back (can be covered by meninges “meningocele” or uncovered “myelomeningocele”) Meningocele contains CSF without spinal tissue Myelomeningocele contains CSF and spinal nerves Can be diagnosed antenatally or at birth
75
What is the most common form of spinal dysraphism?
Spina bifida aperta
76
In spina bifida aperta, what is the difference between a meningocele and a myelomeningocele?
Meningocele = contains CSF but no spinal tissue Myelo = contains both CSF and spinal nerves
77
If considering neuraxial anesthesia in spina bifida occulta, what anatomic change in these patients should be considered?
The spinal cord ends in a lower position, around L3, so caudal blocks, in general, should be avoided or done with extreme caution
78
What secondary conditions are common to spina bifida aperta?
Hydrocephalus is usually present (80% develop) Type II Chiari (Arnold Chiari Malformation) is common Myelomeningocele sac contains nerve roots that do not function below the level of the lesion
79
The myelomeningocele r/t spina bifida aperta must be repaired ASAP, what complications/long term considerations are common?
CSF leaks or dural ruptures can occur Patients often develop hydrocephalus after surgical repair requiring VP shunt Long term complications can include paraparesis, neurogenic bowel or bladder, renal insufficiency, trophic limb changes, joint contractures, and scoliosis requiring surgical intervention
80
What are common considerations for spina bifida patients?
Assess pre-op motor and sensory defects Positioning for intubation and surgical procedure (may need support with foam donuts and towels to optimize) Preserve function and further injury Increased ICP a concern? May need to avoid NSAIDs if renal dysfunction No need to avoid Succs** Can be considerable blood loss Warming measures in place
81
What pt position is common in spina bifida surgery?
Prone w/chest and abdominal rolls, head turned to the side
82
What is an encephalocele?
A herniation of neural tissue and meninges out of the skull through deficient skin and bone The location can occur from occiput to frontal area
83
Anterior encephalocele is associated with what tissues? Posterior?
Anterior- can be associated with brain, orbits, and or pituitary gland Posteriorly- associated with cerebral or cerebellar tissue
84
Why are encephalocele's so devastating to patients?
They can exist intranasal and can be hard to detect, and are associated with high mortality and survivors have severe neuro developmental delay and hydrocephalus. Furthermore, surgical treatment is the ONLY option and frequently also require VP shunt placement
85
Common encephalocele anesthesia considerations?
Assess pre-op motor and sensory defects Positioning for intubation and surgical procedure (may need support with foam donuts and towels to optimize) Prone positioning depending on location Make sure your ETT is secured well Preserve function and prevent further injury Can be considerable blood loss (2 IVs for resuscitation) Warming measures in place
86
What is a chiari malformation?
Cerebellar herniation results when the cerebellar tonsils herniate through the foramen magnum from the posterior fossa to the cervical space Bony abnormality in the posterior fossa and upper cervical spine Often associated with myelomeningocele This leads to an obstruction of CSF flow and eventually hydrocephalus results
87
What is hydrocephalus?
A mismatch of CSF production and absorption that leads to an increased intracranial volume of CSF - commonly from an outflow obstruction or imbalance of absorption/production
88
A chiari can lead to chronic increase in ICP, chronic s/sx of ICP include:
Headache Irritability Vomiting
89
What is the only type of chiari malformation that can occur later in life (after age 12)?
Type I
90
Describe the physiological and important points of each chiari malformation
Type I: Caudal displacement of cerebellar tonsils below the foramen magnum, generally with mild s/sx (HA and/or neck pain) Type II: Caudal displacement of cerebellar vermis, fourth ventricle and lower brainstem. Usually coexists with myelodysplasia Vocal cord paralysis, stridor, resp distress, aspiration Type III: Caudal displacement of cerebellum and brainstem into a high cervical meningocele. Very rare, poor prognosis Type IV: Cerebellar hyoplasia. Considered as primary cerebellar agenesis
91
What type of chiari is very rare with a poor prognosis?
Type III
92
What is the only chiari not associated with caudal displacement of the cerebellum?
Type IV
93
What chiari has caudal displacement of cerebellum and brainstem into a high cervical meningocele?
Type III
94
What chiari includes herniation of the 4th ventricle?
Type II
95
Common s/sx of type II chiari?
Vocal cord paralysis with stridor Respiratory distress Apnea Abnormal swallowing Aspiration Opisthotonos – backward arching of back/spine Cranial nerve deficits
96
What is the surgery of choice to treat a chiari?
Usually a decompressive suboccipital craniectomy with cervical laminectomies
97
What is the common position for chiari surgery?
Repaired in posterior fossa craniotomy positioning Head placed in pins or placed on a padded horseshoe shaped frame
98
What are common anesthesia considerations to chiari surgery?
2 large IVs and arterial line Nasal intubation may be preferred for prone positioning Afrin to bilateral nares, nasal trumpet dilation, Magills for ETT advancement with DL OGT placed and left to gravity during case Eyes lubricated and clear Tegaderms placed over eyes Chest and pelvic rolls (ensure relief of pressure on abdominal contents and pressure on femoral nerves and genitalia) Use of a soft bite block (especially if cortical motor potentials are used) Avoid overhydration Maintain normothermia
99
What medication, especially if increased ICP is of concern, should be avoided in chiari surgery?
Ketamine *use hyperventilation to decrease ETCO2 and narcotics to blunt the response to DL*

Semester 6 TxWes (1 decks)

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