Week 10

Question 1

Ch 26 Anesthesia for Neurosurgery

• Neurophysiologic monitoring & effects of surgical brainstem manipulation
• Encephaloceles and myelodysplasia
• Chiari malformations
• Hydrocephalus
• NCraniosynostosis
• Epilepsy
• Venous air embolism

Answer 1

Review in Book

Question 2

• _______(a) matter injury is a major cause of persistent brain injury in small preterm infants.
  o This may occur as a result of IVH or as a consequence of prematurity, hypoxia, ischemia, and _______(1).
  o _______(2) therapy may reduce the incidence of severe IVH.
• IVH (grades 1 – IV) can occur during the first few days of life.
  o IVH is the leading cause of morbidity and mortality in small, preterm infants.
  o Predisposing factors to IVH include:
  ■ _______(3), _______(4), _______(5) (3 hyps)
  ■ fluctuations in arterial or venous pressure, low hematocrit, overtransfusion,
  ■ rapid administration of _______(6) solutions (i.e., _______(7)).
• Avoid procedures that increase ICP, blood pressure and anterior fontanelle pressure such as “_______(b)” intubations and aggressive _______(c) of the ETT.
• Analgesia and anesthesia should be provided during surgery and painful procedures
  o Consider comfort measures to _______(8) _______(9).
• Consider _______(d) glucose (i.e., “Sweet-Ease”) in the infant population.

Answer 2

Answers:
1. inflammation
2. Indomethacin (NSAID)
3. hypoxia
4. hypercarbia
5. hypernatremia
6. hypertonic
7. sodium bicarbonate
8. minimize
9. stress
a. Periventricular white
b. awake
c. suctioning
d. 24%

Question 3

Cerebrospinal fluid (CSF) and hydrocephalus
- CSF, which occupies the cerebral ventricles and the subarachnoid spaces surrounding the brain and spinal cord, is formed by the _______(1) in the temporal horns of the lateral ventricles, the posterior portion of the third ventricle, and the roof of the fourth ventricle.
o Meningeal and ependymal vessels and blood vessels of the brain and spinal cord also contribute small amounts of CSF.

• The choroid plexuses are cauliflower-like structures consisting of blood vessels covered by thin epithelium through which CSF continuously exudes.
  o In the adult, the rate of secretion is ~_______(2) mL/day.
  ▪ About ~_______(3) mL circulating at any given time.
• In the adult, CSF is formed at ~_______(4) mL/Hr.
  o _______(5) are similar for babies
• CSF flow is initiated by pulsation in the choroid plexus.
  o From the lateral ventricles, CSF passes into the third ventricle via the foramen of Monro and along the aqueduct of Sylvius into the fourth ventricle, with each ventricle contributing more fluid by secretion from its choroid plexus.
  o CSF then flows through the two lateral foramina of Luschka and the midline foramen of Magendie into the cisterna magna and throughout the subarachnoid spaces.
  o CSF is reabsorbed into the blood by _______(a) filtration through the _______(6), which project from the subarachnoid space into the venous sinuses.
• Goals of anesthesia for neurosurgery are neuroprotective.
  o Avoid cerebral _______(7)
  o Avoid cerebral _______(8)
  o Avoid cerebral _______(9)
  o Avoid cerebral _______(10)
  o Avoid _______(11)

Answer 3

Answers:
1. choroid plexus
2. 500
3. 150
4. 20
5. Proportions
6. arachnoid villi
7. edema
8. hypoxia
9. hypoperfusion
10. hypermetabolism
11. neuronal membrane damage
a. hydrostatic

Question 4

**Review Table 26.1 below Neurophysiologic Effects of Common Anesthetic Agents

**Review Table 26.2 Maneuvers of Neuroprotection

Table 26.2: Maneuvers of Neuroprotection
- Goals: table 26.2 maneuvers of neuroprotection
- Avoid cerebral _______(1)
- Avoid cerebral _______(2)
- Avoid cerebral _______(3)
- Avoid cerebral _______(4)
- Avoid _______(5)

Maneuvers: table 26.2 maneuvers of neuroprotection
- Head of bed at _______(6) degrees in midline:
o Increases cerebral venous drainage while maintaining CPP
- Corticosteroids:
o May improve outcomes in spinal cord injury.
o Decrease vasogenic cerebral edema in children with tumors.
o Stabilize neuronal membranes. Free-radical scavengers
- Controlled ventilation:
o Maintaining PaCO2 at normal to slightly low levels prevents both cerebral vasodilation and increased ICP.
- Muscle paralysis:
o Avoids coughing, straining, child movement, and other causes of increased ICP

Answer 4

Answers:
1. edema
2. hypoxia
3. hypoperfusion
4. hypermetabolism
5. neuronal membrane damage
6. 30

Question 5

Maneuvers for Neuroprotection

• Ventricular drainage: Decreases ICP.
• Antihypertensives:
  o Prevent further cerebral edema, ischemia, and cerebral hemorrhage.
  o Severe _______(1) can significantly decrease CPP.
• Anticonvulsants: Prevent seizure activity and increased ICP
• Hypothermia: Decreases _______(a) consumption
• Barbiturate coma: Membrane-stabilizing agents. ______(b) CBF and CMRO2.
• General principles of intraoperative management
  o Increased ICP
  ■ PaCO2; volatile anesthetics; induction/emergence
  o Risk for bleeding
  ■ Adequate IV access, Type & Cross with blood available in the OR
  ■ Consider monitoring CVP and/or arterial line
• General principles of intraoperative management
  o Difficult airway
  ■ Have difficult airway cart in the room; have additional experienced staff on hand; have multiple back up plans in accordance with the difficult airway algorithm
  o Risk for VAE
  o Possible CVL to aspirate air
  ■ _______(2) (millwheel murmur)
  ■ You need to aspirate the air very _______(3)

Answer 5

Answers:
1. hypotension
2. Precordial doppler
3. quickly
a. CMRO2 and CMRglu
b. Decreases

Question 6

Maneuvers for Neuroprotection

• Ask the surgeon if nerve monitoring is planned before choosing to use a NMB. Surgeon may need to identify nerve roots before patient is paralyzed.
• Do you need to use a paralytic?
  o Low dose Rocuronium (_______(a) mg/kg) may be used to facilitate endotracheal intubation.
  o Nowadays, with _______(1), you don’t necessarily need to do low dose anymore
• In infants and children, _______(2) or _______(3) may be given before intubation to prevent reflex bradycardia and to decrease secretions.
• Special Pediatric Neurosurgical Conditions
  o Encephalocele
  o Myelodysplasia
  o Chiari malformations
  o Tumors
  o Hydrocephalus
  o Craniosynostosis
  o Epilepsy
  o Vascular malformations

Answer 6

Answers:
1. Sugammadex
2. atropine
3. glycopyrrolate
a. 0.3

Question 7

Myelodysplasias
- Neural tube defect causing defective development of any part of the spinal cord
- Results from failure of the neural tube to fuse during early fetal development (during the first _______(1) weeks of gestation).
- Much less common now thanks to prenatal vitamins and PO _______(2)

Encephalocele
- Encephalocele: a protrusion of the _______(3) and _______(4) through a defect in the skull, resulting in a _______(a)-like structure.
- Typically diagnosed in-utero via _______(5)
- Most occur in the _______(6) area; however, it may also occur in the frontal, parietal, and nasopharyngeal regions.

Answer 7

Answers:
1. four
2. Folate
3. brain
4. meninges
5. ultrasound
6. occipital
a. sac

Question 8

Encephalocele Repair Procedure
- Most often repaired through _______(1): The dura is opened, the sac is removed, the dura is closed, and the skull is closed with bone or artificial plate applied to repair the skull defect.
- Encephalocele protrusion in the nasopharynx is repaired _______(2) by visualization of the defect, a layered repair using bone or cartilage, followed by a free mucosal graft.
- Craniofacial surgery is performed for protrusions in the skull (nose, sinuses, forehead) affecting the _______(3) and _______(4).

Answer 8

Answers:
1. craniotomy
2. endoscopically (FESS)
3. cribriform plate
4. nasal defect

Question 9

Myelomeningocele Repair Procedure
- The defect is dissected and layers are separated and repaired.
- The edges of the spinal cord are mobilized from the adjacent epithelium and overlapped to form a closed tube.
- The dura is dissected from the fascia and closed over the spinal cord.
o The lamina defect is _______(1).
o The lamina defect may be addressed when the child is _______(2) if kyphosis or vertebral angulation develops.
- An attempt is made to separate and repair the lumbosacral fascia.
- Finally, the subcutaneous tissue and skin layers are arranged and closed.
o For more severe cases, _______(3) may be used to cover the spinal defect.

Answer 9

Answers:
1. not reconstructed
2. older
3. skin or muscle flaps

Question 10

Neurosurgical Procedures

Considerations
- Maintain “defect” covered with sterile dressing
- Positioning for induction and intubation may be challenging:
o Place the meningomyelocele or encephalocele inside a doughnut pillow or in between rolls to prevent pressure injuries.
■ May need additional padding for shoulder and head.
o Alternatively, place patient in the _______(1) position with an assistant applying forward pressure from the back of the head and backward pressure on the shoulders to prevent neck extension.
o Goal: Avoid _______(2) on the defect, and also optimize the airway
o Likely to use the _______(3)

• Position for surgery: _______(4)
• Body temperature maintenance may be challenging:
  o Pre-warm OR to 24°C (75°F)- often hotter than that
  o Avoid unnecessary exposure of body parts
  o Warm all fluids; warm and humidify all gases
  o Use infrared heating lamp (during induction and emergence)
  o Warm skin preparation solutions to _______(5)
  o Use warm incubator postoperatively.
• Blood loss may be significant: Have cross-matched blood available
• Only use _______(6) free equipment/supplies

Answer 10

Answers:
1. left lateral decubitus
2. direct pressure
3. videoscope
4. prone
5. 40°C
6. latex

Question 11

Neurosurgery

Anesthesia
- Maintenance
o Muscle relaxation as needed and allowed by surgeon.
o Controlled ventilation to maintain EtCO2 _______(1).
o Check positioning, padding, and ETT placement after every position change and periodically.
o Maintain body temperature and hemodynamic stability
o Monitor & maintain fluid balance carefully.
o _______(a) blood pressure and _______(2) can be used as guide for replacement as accurate measurement of blood loss may be difficult.

• Emergence:
  o patients almost always remain intubated for the first _______(3) hours.
• Arnold-Chiari Malformation
  o an anatomic anomaly of the cerebellum, brainstem and craniocervical junction.
  o Results in a downward displacement of the cerebellum through the foramen magnum into the spinal canal.

Answer 11

Answers:
1. 35-40
2. HCT
3. 24
a. Arterial systolic

Question 12

Table 26.3: Types of Chiari Malformation
- Type I:
- _______(a) displacement of cerebellar _______(1) below the plane of the _______(2)
- Type II (Arnold-Chiari; associated with myelomeningocele):
- ______(a) displacement of the cerebellar _______(3), _______(4), and _______(b) brainstem below the plane of the foramen magnum
- Dysplastic brainstem with characteristic kink, elongation of the fourth ventricle, beaking of the quadrigeminal plate, hypoplastic tentorium with small posterior fossa, polymicrogyria, enlargement of the massa intermedia
- Type III:
- Caudal displacement of the cerebellum and brainstem into a _______(5) meningocele
- Type IV:
- Cerebellar _______(6)

Answer 12

Answers:
1. tonsils
2. foramen magnum
3. vermis
4. fourth ventricle
5. high cervical
6. hypoplasia
a. Caudal
b. lower

Question 13

Patients with Arnold Chiari malformations may present with
- Difficulty Swallowing
- Recurrent _______(1)
- Stridor
- Apneic episodes
- _______(2) or absent gag reflex - Can’t protect their own airways
- Elevated ICP
- Pain (mainly _______(3) and _______(4) headaches)
- Tongue _______(5)

Abnormal control of ventilation
- Stridor → may _______(6) preoperatively
- May not improve immediately postoperatively
- Possible postoperative apnea

Recurrent aspiration
- Impaired pulmonary function → difficult _______(7) possible

Patient positioned prone with neck flexed
- _______(8) tube may be used; less likely to kink
o tape is unlikely to be loosened by saliva

Increased ICP may be present resulting in N/V, electrolyte disturbances
Blood loss may be rapid, massive and difficult to measure accurately requiring invasive monitoring, IV access, have blood products available
Intraoperative neurophysiologic studies or cortical ______(a) may be necessary; high concentrations of inhalational agents may interfere with the recording; consider _______(9)

Answer 13

Answers:
1. aspiration
2. Depressed
3. neck
4. occipital
5. atrophy
6. intubate
7. ventilation
8. Nasotracheal
9. TIVA
a. SSEPs

Question 14

Arnold-Chiari Considerations

Prone position
- Consider a _______(1) tube in small children à secure appropriately
- Prone on a frame or pins or bolsters with, _______(2) head-up tilt
- Monitor vital signs carefully during manipulation in the region of the brain stem

Sitting position
- Concern for air embolism → use precordial _______(3) probe and capnograph;
■ place _______(4) line to aspirate air in case of embolism and to guide fluid therapy
o Zero arterial transducer at level of the _______(5) and CVP transducer at level of the _______(6)
o CV stability → Lower limbs bandaged to promote venous return

Procedure may be performed in prone or _______(7) position.
- Head placed in _______(a) fixation: NOT Babies
- Midline incision made and dissection is carried down to the skull and the posterior arch of _______(8)
- Paramedian burr holes are placed to aid in the _______(9) craniectomy.

Answer 14

Answers:
1. nasotracheal
2. 15°
3. Doppler
4. CVP
5. ear
6. heart
7. seated
8. C1
9. suboccipital
a. Mayfield pin

Question 15

Arnold-Chiari Considerations

Full recovery from anesthesia for extubation
- Gauge your anesthetic so the surgeon can do a neuro exam shortly after extubation
- Smooth extubation
o IV Lidocaine 1.5 mg/kg

If the patient is unresponsive, or shows signs of respiratory depression, then the patient should remain intubated.
- Preserve Optimal Intracranial Conditions
o Blood Pressure (_______(1) – _______(2) = _______(3))
o Support Cerebral Autoregulation
o Fluid Status
o Routine Monitoring of Neurologic Signs
o Anticonvulsants

Alterations in Neuro-Hormonal Regulatory Systems (i.e., ADH)
Bleeding, Infection
Local anesthesia (_______(4))
- Postoperative Analgesia

Answer 15

Answers:
1. MAP
2. ICP
3. CPP
4. 0.25% bupivacaine with 1:200.000 epinephrine 0.5ml/kg

Question 16

Neurosurgery: Tumors
- Clinical presentation:
o Visual impairment
o Endocrine deficits
o Growth hormone, gonadotropins, ACTH, TSH, ADH
- Tumor infiltration into hypothalamus:
o Leads to disturbances of memory, attention, impulse control, motivation, socialization

• _______(1) have been shown to increase intra- and post- operative morbidity rates
• Children were found to be more likely to present with _______(2)
  o reflecting the increased incidence of increased intracranial pressure and hydrocephalus in this patient population.

Answer 16

Answers:
1. Diabetes insipidus, hypoadrenalism and hypothyroidism
2. headache, nausea/vomiting, and papilledema (swelling of the optic nerve)

Question 17

Neurosurgery Tumors

Endocrine Disturbances
- _______(a) thirst or urination
- Unusual sleepiness or change in energy level
- Unusual changes in personality or behavior
- Short stature, slow growth, or delayed puberty
- _______(1) 5 senses?
- Obesity

Increased ICP
- Headaches including _______(2) that goes away after vomiting
- Vision changes
- Nausea and vomiting
- Loss of balance or trouble walking
- Increased head size

Steroid therapy may be warranted as part of the anesthetic care plan
- _______(3) therapy may begin preoperatively

Agents to help decrease ICP:
- _______(4)
- _______(5)
- _______(6)
- _______(7)

Avoid the following:
- Agents that may increase ICP:
■ SCh. _______(8), etc.
- Overstimulation
■ Prolonged laryngoscopy
■ Noisy environment
- _______(9)Breathing?
■ It is more difficult for the surgeon to confirm that the entire tumor has been removed.

Answer 17

Answers:
1. Hearing loss
2. morning headache or headache
3. Corticosteroid
4. Mannitol
5. 3% saline
6. Propofol
7. Isoflurane
8. Ketamine
9. Hyperventilation
a. Increased

Question 18

Neurosurgery Tumors

What to look for:
- Monitors
- Positioning
- Blood loss

How to be ready
- Standard monitors plus:
o A-line
o _______(1)
o Urine output
o ± _______(2)

Long surgery
- Positioning
■ Semi-sitting (possible a.)
- Pressure points
- Table turned 180°

Minimal blood loss unless there is accidental perforation of internal carotid or cavernous sinus

Answer 18

Answers:
1. CVP
2. Doppler
a. VAE

Question 19

Neurosurtgery Tumors

Review Figure 26.6 for relative sensitivities of air embolism monitoring modalities.

What to Look For:
- Diabetes insipidus
- Optimal neurosurgical conditions

How to be ready
- Fluid replacement
o Rapid correction - seizures, coma, cerebral edema
o Serial serum _______(1) should be checked
o Vasopressin (_______(2) U/kg/hour)

• Blood pressure control
  o High blood pressure
  ■ Leads to higher _______(3)
  o Low blood pressure
  ■ Leads to _______(4)
• Increased _______(5) may occur and/or be severe
  o Avoid use of _______(6)
  o Vomiting may ensue d/t increased ICP → check _______(7) preoperatively
  o Acute symptoms of increased ICP demand immediate _______(8)
  o Doll’s Eyes: Clear appearance of ICP
• _______(9) extubation (to permit rapid neurologic assessment)
• Large and secure IV access
• Latex precautions

Answer 19

Answers:
1. osmolalities
2. 0.001-0.01
3. ICP
4. ischemia
5. ICP
6. succinylcholine and/or ketamine
7. electrolytes
8. surgery
9. Awake

Question 20

Hydrocephalus
- an abnormal accumulation of CSF within the cranium that may either be obstructive or non-obstructive.
- _______(1) hydrocephalus is caused by a blockage in the flow of CSF.
- Considered ‘_______(2)’ when the fluid’s pathway proximal to the subarachnoid space is obstructed
o as in aqueduct _______(3).
- Non-obstructive hydrocephalus, or “communicating,” occurs when the CSF pathway into the subarachnoid space is _______(4), such as may occur after chronic _______(5).
o Caused by a reduction in the volume of brain substance, with secondary dilation of the ventricles
■ and/or an overproduction of CSF as in _______(6)
■ and/or _______(7) reabsorption of CSF due to scarring.

• Hydrocephalus is often managed surgically with placement of a shunt.
  o Hydrocephalus shunting involves the implantation of two catheters and a flow control valve system to drain the excess accumulation of cerebrospinal fluid (CSF) from the brain’s ventricles (or the lumbar subarachnoid space) to another part of the body where it can be absorbed (the _______(8) or the right atrium).

Answer 20

Answers:
1. Obstructive
2. non-communicating
3. stenosis or Arnold-Chiari
4. open
5. arachnoiditis
6. choroid plexus papilloma
7. reduced
8. peritoneum

Question 21

Hydrocephalus

Considerations
- Blood loss usually minimal but have a large bore IV ready
- Inject local anesthetic to block _______(1) nerve for frontal shunt or to block _______(2) nerve for posterior shunts.
- The use of LA _______(3) but does not eliminate the postoperative pain medication requirements.
- The part of the surgery that is most stimulating is the _______(4) process used to place the distal catheter.
- Discontinue inhalational agents before the end of surgery so child is completely _______(5) before leaving OR to facilitate neurologic evaluation.

Craniosynostosis
- the premature _______(6) of cranial sutures occurring within the first _______(7) months of life.
■ The early fusion prevents normal skull expansion and results in facial deformities.
■ Compression and increased ICP can lead to neurologic damage if not repaired.

Answer 21

Answers:
1. supraorbital
2. posterior auricular
3. reduces
4. tunnelling
5. awake and responsive
6. fusion
7. 20

Question 22

Blood Loss During Repair of Craniosynostosis

Type of suture being repaired | Typical blood loss, % of blood volume
— | —
Sagittal | a.
Unicoronal |b.
Metopic | c.
Bicoronal | d.

• Males are affected _______(1) times more frequently than females.
• Although the exact _______(2) is unknown, it has been linked to alterations in the _______(3) signaling pathways during fetal development.

Answer 22

Answers:
a. 24 ± 15
b. 21 ± 12
c. 42 ± 12
d. 65 ± 35
1. two
2. cause
3. cytokine

Question 23

Scaphocephaly
- the most common form of craniosynostosis and is caused by the fusion of the _______(1) suture resulting in elongation in the _______(2) direction.

Brachycephaly/Plagiocephaly
- the next most common form and results from the fusion of the _______(3) suture causing an expansion in the _______(4) directions
- Half of these children also have _______(5) delays.

• Non-syndromic craniosynostosis has no identifiable genetic cause and is classified as simple, involving only one suture, or compound, involving two or more sutures.
• Syndromic craniosynostosis is associated with genetic abnormalities and is most commonly seen in _______(6) and _______(7) syndrome.
  o It has been linked to alterations in _______(8) signaling pathways.

Answer 23

Answers:
1. sagittal
2. anteroposterior
3. coronal
4. lateral
5. developmental
6. Apert
7. Crouzon
8. fibroblastic growth factor

Question 24

Craniosyntosis

History/physical exam
- Patient age, body weight (<_____(4) kg) are associated with increased blood loss
- length of time to surgery increases the risk of associated neurological issues
- Associated neurological issues (>_______(5) suture involvement = increased ICP; possible developmental problems; potential for _______(1) atrophy)

It is common for these patients to have other congenital disorders such as difficult airways, cardiac defects, and cleft palates.

Airway assessment
- Potential for difficult airway (may have associated craniofacial conditions)
- _______(2) syndrome (beaked nose, hypoplastic maxilla = difficult mask ventilation and risk for airway obstruction)
- _______(3) syndrome (hypoplastic maxilla, fusion of cervical vertebrae, narrow/fused trachea = difficult mask ventilation and breathing issues/airway obstruction)

Answer 24

Answers:
1. optic
2. Crouzon
3. Apert
4. 5
5. 1

Crow’s Nose for beaked (Crouze)
Atlas for Apert (cervical fusion)

Question 25

Craniosyntosis Procedures

Premedication
- Administer cautiously in patients with:
■ Increased ICP
● Ventilatory depression = hypercapnia
● May mask postoperative neurological issues
■ Airway malformations/difficult airway

Two common surgical techniques
- _______(1) craniotomies: faster surgical time but used only for minor suture fusions.
- _______(2) Reconstruction: longer OR times and possible MASSIVE blood loss
■ It is an open procedure that involves removing bone flaps, outfracturing skull bone and modifying edges to remold the cranium with absorbable plates and screws.
■ _______(3) is desirable for the Total Calvarial Technique due to possible blood loss and changes in hemodynamics (Placement can be difficult in children)
● Blood loss results from the cutting of fresh bone ends.
■ Have blood available in the OR.

Answer 25

Answers:
1. Strip
2. Total Calvarial
3. A-line

Question 26

Craniosyntosis Surgeries

PACU → PICU → Pediatric Unit → Home
- Extent of the surgery will determine need for controlled ventilation, control of ICP, pain & replacement of blood loss
- Close monitoring of brain function in addition to standard monitoring

Facial edema - may be upsetting to parents
- Cerebral edema
■ Drain(-s) may be needed, placed under scalp
■ Diuretics may be given (_______(1) / _______(2))
■ Head of bed elevation _______(3)

Control of ICP
- Avoid straining, crying, coughing, hypoventilation,hypoxemia

Pain
- Relatively low pain scores
- Helmet
■ Protection and/or remodeling
■ Worn for several months and refitted as needed for progress

Answer 26

Answers:
1. Mannitol
2. Furosemide
3. 15°

Question 27

Epilepsy
- ______(a) is designed to prevent seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve.
o These pulses are supplied by a device similar to a pacemaker.

Vascular Malformations
- An AVM, or arterio-venous malformation, occurs when an artery abnormally connects to a vein without capillaries to _______(1) blood flow.
- An aneurysm of the _______(2) is an arterio-venous malformation involving the vein of _______(3);
● Without capillaries, blood is shunted directly into the vein at a high output.
→ This increases the workload of the heart.
● If left untreated, VOGM often results in abnormal brain development, mental retardation, _______(4), seizures, paralysis, learning difficulties, _______(5), and ultimately cardiac failure and death.

Answer 27

Answers:
1. slow
2. Vein of Galen
3. Galen
4. strokes
5. hydrocephalus
a. Vagus nerve stimulation (VNS)

Question 28

Vascular Malformations

Symptoms include _______(a) cardiac output, severe congestive heart failure, ______(b), seizures, headaches, prominent veins of the _______(1), _______(2) under the eyes, failure to thrive
- Older children reveal developmental delay, _______(3) and _______(4) (bulging eyes)
- Diagnosis is generally made by _______(5) in the _______(6) trimester (Prenatally)

Staged closed embolization of the vessels is currently the _______(7) treatment.
o This procedure is done in a neuroradiology suite and involves threading a catheter to the site of the AVM with the aid of _______(8) followed by embolization.
o Following embolization, surgical removal of the AVM is possible.

Mortality rate is high (in neonates)
o Uncontrollable bleeding
o Intraoperative cardiac arrest from either hypotension prior to clipping of the aneurysm or _______(9) SVR after clipping of the aneurysm
o Renal Failure or volume overload may develop from the use of _______(10) to identify the AVM

Topics Covered
Thoracoscopy
Thoracotomy
Lobectomy
Pneumonectomy
General Thoracic surgery
Tracheal stenosis (acquired or congenital)
Fiberoptic, or rigid bronchoscopy
Pulmonary sequestrations
Cystic adenomatoid malformations
Congenital lobar enphysema
Chest wall issues
TEF/EA
Congenital Diaphragmatic hernia
Anterior spinal fusions
Thymectomy
Mediastinal tumors
Lung Biopsy
Lung tumors

Table 13-1 → Thoracoscopic Procedures in Infants and Children:
Diagnostic inspection
Lung biopsy
Lobectomy
Sequestration resection
Cyst excision
Lung decortication
Foregut duplication resection
Thymectomy
Patent ductus arteriosus ligation
Thoracic duct ligation
Esophageal atresia repair
Sympathectomy
Aortopexy
Mediastinal mass excision
Anterior spinal fusion

Table 13-2. → Advantages of Thoracoscopic versus Open-Chest Surgery:
Improved surgical visualization
Decreased pain
Decreased surgical stress
Decreased ileus/earlier return to feeds
Quicker return to normal activity (parents and child)
Shorter hospitalization
Fewer long-term complications
Cosmetically superior

Answer 28

Answers:
1. face
2. dark circles
3. nosebleeds
4. proptosis
5. ultrasound
6. 3rd
7. safest
8. contrast
9. elevated
10. contrast dye
a. high
b. hydrocephalus

Question 29

Techniques for one-lung ventilation in pediatric patients

• Use of Single-lumen Endotracheal tube (intentional main-stem bronchus intubation)
• Use of Balloon – Tipped Bronchial Blockers
• Use of Univent tube (Conventional ETT with second lumen containing small blocker catheter)
• Traditional double lumen tube- usually only used in older big kids

Chest Wall Deformities
- Pectus Excavatum (_______(1) chest) or Latin for Hallowed Chest
o Congenital abnormality of sternum, ribs, and costal cartilages
o Possible Marfan’s
o Possible CHD
- Pectus Carination (_______(2) Chest)

Answer 29

Answers:
1. funnel
2. Pigeon

Question 30

Pectus Carinatum (pigeon chest)

Surgery for Pectus Excavatum
- Chest x-ray (heart displaced to _______(1) and compressed)
- PFT’s ( Normal to reduced _______(2) & _______(3), in severe cases, may demonstrate a V/Q mismatch)
- ECG ( arrhythmias, _______(4) axis deviation)

• Echocardiogram (increased incidence of _______(5))
• Labs (blood loss) and ABGs
• Exercise tolerance

Answer 30

Answers:
1. left
2. FVC
3. TLC
4. right
5. MVP

Question 31

Surgical issues with Chest Procedures
- Blood loss minimal to massive
- Pneumothorax
- Flail chest
- Post-operative atelectasis
- Pain management requires a _______(1) or _______(2) epidural.

Congenital Lobar Emphysema
- Abnormally _______(3) lobe that communicates with the bronchial tree
- _______(4) distension of a lobe with air trapping and compressive changes in remainder of the lung
- Approximately _______(a)% have associated anomalies
- Emergency lobectomy may be required
o Volatile agents, spontaneous ventilation and no _______(5)

Answer 31

Answers:
1. thoracic
2. lumbar
3. emphysematous
4. Over
5. nitrous
a. 10

Question 32

Congenital Cystic Adenomatoid Malformation
- A cystic, solid, or mixed intrapulmonary mass that _______(1) with the normal tracheobronchial tree (page 782)

Pulmonary Sequestration
- It is a portion of non functioning lung tissue that does not contain bronchial connection.

Ch 29 Anesthesia for General Abdominal and Urologic Surgery

Inguinal herniorrhaphy and umbilical herniorrhaphy
Orchiopexy
Surgery for pyloric stenosis
Wilms Tumor procedure
Neuroblastoma procedures
Fundoplication (anti-gastroesophageal reflux) procedures
Hirshsprung’s disease procedures
Intussusception repair
Anesthesia for General Abdominal and Urologic Surgery
Chapter 29 summarizes the anesthetic considerations of the most common general abdominal and urologic procedures performed.
For the most part, anesthetic considerations for pediatric patients are similar to those of adult patients (RSI and aspiration, NG tube placement, fluid balance, sepsis, compartment syndrome)

Answer 32

Answers
1. communicates

Question 33

Inguinal herniorrhaphy and umbilical herniorrhaphy
- _______(1) is the most common surgical problem of childhood.
o It results from a small sac that comes through the inguinal ring that is normally open during fetal life and closes around the time of birth.
- This sac then makes a pathway for abdominal organs to come through the inguinal ring into the groin.
o In boys, the organ is usually a loop of bowel and, in girls, it may be bowel or an ovary.
- In boys and girls, the hernia first appears as a bulge in the groin, and may appear and disappear, or may be present all the time.
- It will usually “pop out” when the child _______(a).
- If only fluid comes through the inguinal ring into the sac, the defect is called a _______(2).
- Orchidopexy
- Cryptorchidism (undescended testicles) may include inguinal hernia
- Higher incidence of prematurity, _______(3) syndrome, _______(4) and _______(5) syndromes.

Answer 33

Answers:
1. Inguinal hernia
2. hydrocele
3. Prune-Belly
4. Noonan’s
5. Prader-Willi
a. cries or strains

Question 34

Pyloric stenosis
- A common surgical problem of infancy and may occur in up to 1 in 500 births.
- _______(a) are more commonly affected – _______(b) week of life
- It is defined as _______(1) of the muscle of the pyloric sphincter which causes obstruction and persistent vomiting.
- It is a medical emergency; not a surgical emergency.
o Therefore, _______(2) need to be normalized prior to surgery
- Infant is usually _______(c) weeks of age
- Presents with _______(3) vomiting and intolerance of feedings
- Surgical correction involves _______(4) to relieve the stricture

Answer 34

Answers:
1. hypertrophy
2. electrolytes
3. nonbilious projectile explosive
4. pyloromyotomy
a. First born males
b. 2nd to 6th
c. 2-6

Question 35

Pyloric Stenosis

Laboratory Findings

• Early
  o _______(1)K?
  o _______(2)CL?
  o Metabolic ____a.1(mild)
  o ___a. Urine
  o Normal ____b. e-?
• Late
  o _______(3)K?
  o _______(4)Cl?
  o Metabolic alkalosis (severe)
  o ____c. Urine
  o _______(5)Na?
  o _______(6)Ca?
• Very Late
  o Severe Dehydration
  o Hypovolemic Shock
  o Metabolic _______(7)

Answer 35

Answers:
1. Hypokalemia
2. Hypochloremia
a.1 alkalosis
a. Alkaline
b. Na+
3. Hypokalemia
4. Hypochloremia
c. Acidic
5. Hyponatremia
6. Hypocalcemia
7. Acidosis

Question 36

Pyloric Stenosis

• a. Cl?
• b. K?
• Metabolic ___c.
• Dehydration

Preoperative requirements include:
- Hydration normal
- Urine output assessed
- Biochemistry should be:
■ pH _______(1)
■ Na >_______(2)
■ Cl > _______(3)
■ K > _______(4)
■ Bicarbonate < _______(5) mmol/L

Surgical intervention = _______(6)
- A medical emergency but not a surgical emergency.
o Great T/F!
- Rehydrated, electrolyte balanced
- Orogastric suctioning
- Awake and rapid sequence induction
o RSI d/t projectile vomiting!
- Emergence: extubate only when fully awake with intact protective airway reflexes
- Be very judicious with opioids (if administered at all)

Answer 36

Answers:
a. Hypochloremia
b.Hypokalemia
c. Alkalosis
1. 7.3 - 7.5
2. 132
3. 90
4. 3.2
5. 30
6. Pyloromyotomy

Question 37

Wilms Tumor or Nephroblastoma (congenital embryonal neoplasm)
- Most common childhood renal tumor
- Incidence about 1 in 15, 000 births
- Diagnosed between age of _______(1) months and _______(2) years (peak age is _______(3) years)
- Genetic mutation that affects cell growth in the a.
- Congenital Associations with Wilms’ tumor (relisted to reconfirm)
- WAGR Syndrome
o Wilms’ Tumor → 33% CHANCE OF DEVELOPMENT!
o b. (absent iris)
o Genital anomalies
o Mental Retardation

• Denys-Drash Syndrome
  
  • Gonadal dysgenesis
  • Nephropathy → renal failure
• Beckwith-Wiedemann Syndrome

Presenting signs include:
- Increasing abdominal _______(4) with palpable abdominal mass (85%)
- Abdominal pain
- _______(5) (60%)
- Fever
- _______(6) (10-25%)
- Anemia
- Acquired _______(7) disease

Answer 37

1. 6
2. 5
3. 1-3
   a.kidney
   b.aniridia
4. girth
5. Hypertension
6. Hematuria
7. Von Willebrand’s

Question 38

Wilms Tumor Staging Table

Stage | Description
— | —
I | Tumor limited to the a.__ and excised
II | Tumor extending beyond the kidneys but b.___ excised
III | Residual nonhematogenous tumor confined to the c.____
IV | Hematogenous metastases, d.____ involvement
V | e._____ renal involvement at diagnosis

Treatment
- Radical f.____ of the involved kidney
- Chemotherapy (g.____)
- Radiotherapy

Anesthetic issues:
- Renal function
- Chemotherapy/radiation
- Abdominal distention
- Blood loss
- Hemodynamic stability
- Pain management

• Anti-gastroesophageal reflux procedures or fundoplication procedures
• Surgery for biliary atresia
• Hepatic tumor procedures
• Hirschsprung’s disease procedures
• Appendicitis
• Intussusception repair
• Omphalocele and Gastroschisis

Esophageal Atresia and Tracheoesophageal Fistula
- The incidence of TEF is approximately 1 in 2500-3000 live births with more than 85% are associated with _______(1).
- Prenatal diagnosis: _______(2) and _______(3) (44%) predictive
- Clinical signs 1st oral feedings, _______(4)
- More _______(5); 20-30% of infants are premature
- Cardiac (29%), GI (14%), GU (14%), musculoskeletal (10%) or craniofacial anomalies
- CHD: most common is _______(6), also PDA, TOF, ASD, AV canal, coarctation of aorta and right sided aortic arch

Answer 38

Answers:
a. kidney
b. completely
c. abdomen
d. Lymph node
e. Bilateral
f. nephrectomy
g. Vincristine, actinomycin and doxorubicin

1. esophageal atresia (EA)
2. polyhydramnios
3. ultrasound
4. OG tube
5. male
6. VSD

drugs think DAV!

Question 39

Esophageal Atresia and Tracheoesophageal Fistula

Pre Op concerns?
- Airway management
- Aspiration
- Co-existing diseases – review workup
- Ligation of TEF is _______(1) although not _______(2) (unless _______(3) insufficiency)
- Avoid _______(4)
- _______(5) positioning (GI reflux)
- Intermittent suctioning of _______(6)
- Antibiotics as indicated

Surgical technique
- Right thoracotomy or thoracoscopy using postero-lateral extrapleural approach
- One-lung ventilation
- More like the “_______(7) the lung to the side” and compress it

• Fistula ligated and the esophagus is primarily anastomosed
• Precordial stethoscope placed _______(8) axilla (right thoracotomy)
• Pre-ductal and post-ductal pulse _______(9)

Answer 39

Answers:
1. urgent
2. emergent
3. respiratory
4. feeding
5. Upright
6. upper pouch
7. push
8. left
9. oximetry

Question 40

Postoperative - Esophageal Atresia and Tracheoesophageal Fistula

• Tracheal Extubation
  
  • _______(a) (as high as 75%) - subglottic obstruction?
  • _______(b) injury - nerve?
  • _______(c) paresis - structure?
  • Laparoscopic techniques allow earlier extubation & discharge from ICU
• Postoperative apnea
• Pain management – caudal techniques or opioid infusions

Gastroschisis vs Omphalocele

Gastroschisis:
- Incidence: 1: 3000. Maternal age is often <_______(1) years.
- Location of defect: Herniation of abdominal contents from a defect lateral to the umbilicus (usually _______(2)).
- Covering sac: _______(3)
- Condition of bowel: Bowel wall may be _______(4), with a fibrin ‘peel’ due to exposure to amniotic fluid.
- May involve stomach, bladder, uterus, rarely liver.

Exomphalos (Omphalocele):
- Incidence: 1: 5000. Maternal age is often >_______(5) years.
- Location of defect: Herniation of abdominal contents through the extra embryonal part of the umbilical cord.
- Covering sac: _______(6)
- Condition of bowel: May be minor herniation into umbilical cord, a small 5-8 cm defect (exomphalos minor) or a large defect, including liver, with poorly developed abdominal and thoracic cavities and pulmonary _______(7)(exomphalos major).

Answer 40

Answers:
1. 20
2. right-sided
3. Absent
4. thickened
5. 40
6. Present
7. hypoplasia
a. Tracheomalacia
b. RLN
c. Vocal cord

Question 41

TABLE 37.6 BELOW
Comparison of Omphalocele and Gastroschisis: TABLE 37.6
- Cause:
- Omphalocele: Failure of gut migration from _______(1) into abdomen.
- Gastroschisis: Occlusion of _______(2) artery.
- Location:
- Omphalocele: Within the _______(3).
- Gastroschisis: _______(4).
- Associated lesions:
- Omphalocele:
- Beckwith-Wiedemann syndrome (_________(5), gigantism, _________(6), hyperviscosity).
- Congenital heart disease.
- Exstrophy of bladder.
- Gastroschisis:
- Exposed gut ________(7)
- Edema
- Dilation
- foreshortened.

Answer 41

Answers:
1. yolk sac
2. omphalomesenteric
3. umbilical cord
4. Periumbilical
5. macroglossia
6. hypoglycemia
7. inflammation

Question 42

VATER/VACTERL
VATER Syndrome
- Vertebral _______(a)
- Anal _______(1)
- Tracheoesophageal fistula
- Esophageal atresia
- Renal defects/radial abnormalities

VACTERL
VACTERL ASSOCIATION
- Vertebral
- A imperforate _______(2)
- Cardiac
- TEF
- Esophageal _______(3)
- Renal
- L _______(b) Limb aplasia

Congenital Diaphragmatic Hernia
- Incidence is 1-2 in 2500 births
- Herniation of abdominal contents into the _______(4) at 8 weeks gestation with resultant _______(c) lung hypoplasia
- 90% are _______(d)hernia (foramen) (75%) on _______(5) side

Answer 42

Answers:
A. Defects
1. atresia
2. anus
3. fistula
b. Radial
4. thorax
C. ipsilateral
5. left
d. Bochdalek’s

Question 43

Congenital Diaphragmatic Hernia

Pathology
- Vary degrees of bilateral lung _______(1)
- Pulmonary _______(2) and arteriolar reactivity
- Congenital anomalies
- Significant morbidity and mortality

Pulmonary Pathology
- Pulmonary Hypoplasia → normal ratio of airways & alveoli but there is a decrease in _______(3) which results in a _______(4) total lung mass.
- Pulmonary Vascular Abnormalities → decrease in pulmonary _______(5) size, decreased arterial _______(a), muscular hypertrophy of the _______(b) muscle in small diameter vessels.
- Persistent Pulmonary Hypertension → elevated _______(6) resulting from pulmonary hypoplasia and vascular abnormalities (_________(7)) and constriction of normal vessels (reversible).

Answer 43

Answers:
1. hypoplasia
2. hypertension
3. number
4. decreased
5. artery
6. pulmonary vascular resistance
7. irreversible
a. branching
b. media, & smooth

Question 44

Antenatal Diagnosis - Congenital Diaphragmatic Hernia
- Prenatal _______(1)
- 30% of cases of CDH are associated with _______(2)
- Males _______(3) to 1 over females
- High incidence of other chromosomal abnormalities and other genetically determined disorders

Congenital Anomalies Associated with CDH
System - Associated Anomalies
Cardiovascular:
- _______(4), VSD, PDA, Tetralogy of Fallot (15%)
CNS:
- Hydrocephalus, _______(5)
Gastrointestinal:
- _______(6), malrotation of gut (40%)
GU:
- _______(7) - penile opening?

Answer 44

Answers:
1. ultrasound
2. polyhydramnios
3. 2 to 1
4. ASD
5. myelomeningocele
6. Duodenal bands
7. Hypospadias

Question 45

Urologic Surgery
- Cystoscopy
- _______(1)
- Ureteral reimplantation
- Prune Belly syndrome
- Bladder exstrophy
- Hypospadias repair
- Testicular torsion repair
- _______(2)

Special Conditions to Consider During Preoperative Examination
- _______(3)
- Hypertension
- _______(4) medications
- Infection or Sepsis
- PONV
- Laparoscopic procedures

Circumcision
- Performed in neonates, infants, children and adults under local, regional (penile ring block) or general anesthesia
- Indications:
- _______(5) – the foreskin cannot be retracted over the glans penis
- Recurrent _______(6) – a skin condition causing swelling and redness
- Parental preference
- Procedure lasts less than one hour
- Complications include bleeding and pain

Answer 45

Answers:
1. Circumcision
2. Pyeloplasty
3. Reduced renal function
4. Corticosteroid
5. Phimosis
6. balanitis

Question 46

Ureteral Reimplantation
- Surgical correction for _______(1) (VUR)
(i.e., reverse flow)
- Anesthesia issues
- Length of surgery: _______(2)
- Bladder spasms

Prune-Belly Syndrome or Triad Syndrome or Eagle-Barrett Syndrome
- It is caused by _______(3) of the abdominal musculature, which results in a thin walled, protruding abdomen
- _______(4)
- Cryptorchidism: (undescended testes) like andrew

Answer 46

Answers:
1. vesicoureteral reflux
2. Very lengthy procedure
3. agenesis
4. Distal urinary tract obstruction

Question 47

Prune-Belly Syndrome
- Bladder wall _______(1)
- _______(a) distension
- _______(a) muscle loss
- Renal dysplasia
- _______(2)
- Lower limb abnormalities

• Orthopedic - _______(3) & scoliosis 50%
• GI - malrotation & volvulus – 30%
• CHD (_______(4) & VSD) – 10%
• Trisomy b. (Edward’s)
• Trisomy c. (Down)

Answer 47

Answers:
1. atrophy
2. Cryptorchidism
3. hip dislocation
4. TOF (Tetralogy of Fallot)
a. Abdominal
b. 18
c. 21

Its toF VS the D

Belly
B-bladder atrophy
E- tiology (Trisonomy 18 and 21)
L- Lower Limb Abnormality (most likely hip dislocatin or scoliosis)
L- Loss of muscle (abdominal)
Y-Yurination issues ( renal dysplasia and cryptochoridism)

Question 48

Bladder Exstrophy

1. Infraumbilical mesoderm fills in all of the _______(1) membrane except the urogenital floor.
   a. Genital _______(2) fuse.
2. This leads to:
   a. Failure of infraumbilical mesoderm to invade _______(3) membrane.
3. The outcomes of this failure are:
   a. Breakdown of cloacal membrane, exposing posterior wall of bladder.
   b. Incomplete fusion of genital tubercles often with _______(4).
   c. Separated pubic rami, short lower abdominal wall, +/- inguinal herniae.

Bladder Exstrophy
- Typically a lengthy procedure
- EBL can be excessive; 2 PIV and/or CVL
- Due to evaporative losses and third-space fluid loss can experience _______(5) fluid shifts.

Answer 48

Answers:
1. cloacal
2. tubercles
3. cloacal
4. epispadias
5. large

Question 49

Hypospadias repair
- Congenital defect of abnormal positioning of the urethral _______(1).
- Urethra opens along the undersurface of the penis anywhere from just proximal to the glans to the scrotum.
- It is often associated with a _______(2) (head of the penis curves downward or upward)
- Not usually associated with other congenital defects
- Surgery last from _______(3)
- Procedure can be simple OR _______(4);
communication with surgeon is required to determine appropriate anesthetic plan
- More extensive procedures usually require GETA, possibly an overnight hospital stay, and a pain management plan.

Answer 49

Answers:
1. meatus
2. chordee
3. 1-4 hours
4. highly complex

Question 50

Testicular Torsion repair
- Acute scrotal pain resulting from twisting of the _______(1) cord with vascular compromise of the testicle
- May be associated with _______(2)
- Ischemia occurs in _______(3) hours

Pyeloplasty
- Procedure to repair ureteropelvic junction obstruction, the most common cause of congenital ___a.
- Anesthesia issues
- Positioning (_______(4))
- Open or laparoscopic
- Postoperative pain management
- Fluid resuscitation

Answer 50

Answers:
1. spermatic
2. incarcerated hernia
3. 6-8
a. hydronephrosis
4. prone/Jack-knife or lateral