Ear Surgery 1. Otitis media, or inflammation of the ___________, is the most prevalent disease of childhood secondary to upper respiratory tract infections (URIs). 2. Eustachian tube obstruction results in negative middle ear pressures and can produce a sterile transudative middle ear effusion. Infants and young children have __________ eustachian tubes than older children, which makes them more susceptible to reflux of nasopharyngeal secretions into the middle ear space and the subsequent development of otitis media. 3. Eustachian tube dysfunction 4. Recurrent URI 5. Otitis media that is non-responsive to antibiotics may require ______________.

1. middle ear 2. shorter 5. bilateral myringotomy with placement of tubes (BMT).

Middle Ear Procedures __________ preservation (Avoid ________); nerve monitoring Control bleeding with the use of _________ solutions; elevate the head to improve venous draining and +/- _____________. Take steps to decrease PONV Avoid nitrous oxide because N2O diffuses into the middle ear more rapidly than nitrogen can leave and causes an increase in middle ear pressure, which may displace the graft or cause a tympanic membrane rupture.

Facial nerve (NMBs) epinephrine-containing; controlled hypotension

Functional Endoscopic Sinus Surgery (FESS) Treatment for ________________. Surgeon’s use of vasoconstrictors (i.e., epinephrine ____:_________ solution, maximum dose is _______________) Emergence:

chronic sinus disease 1:200,000, 10 mcg/kg awake extubation

Indications for T & A ______ and ________ in the pharynx, to relieve an airway obstruction or focus of infection. Repeated middle ear infections may be improved by ______________. ______________ is now the most common indication for T&A. Rarely, acute tonsillitis may lead to peritonsillar abscess or quinsy (quinsy = “to strangle”) tonsil.

Chronic inflammation and hypertrophy of lymphoid tissue adenoidectomy Obstructive sleep apnea Surgery often performed in ambulatory surgical unit (ASU) Special consideration required in selection of suitable children. Efficient follow-up service must be provided to deal with unexpected complications.

Indications for admission after T&A: Generally, age less than ______ years Abnormal __________ studies or a history of increased bleeding tendencies Evidence of __________. Systemic diseases presenting increased perioperative risk (congenital heart disease, endocrine or neuromuscular disease, chromosomal abnormalities, obesity) _____________ abnormalities including Down syndrome. History of a _____________.

3 coagulation obstructive sleep apnea (OSA) Craniofacial peritonsillar abscess

Post tonsillectomy bleeding Full stomach Dehydration OR preparation (cuffed ETT ___________ than usual) AIRWAY, AIRWAY, AIRWAY Surgery is typically quick and minimally painful. Plan accordingly. EXTUBATE ________. Tonsillectomy & Adenoidectomy postoperative complications

0.5mm smaller AWAKE Considered a full stomach (potential for aspiration) Be cautious when ordering opioids for a restless child as the restlessness may be an indication of hypoxia Abdominal pain (stomachache) after T & A are suggestive of swallowing blood from ongoing bleeding

Ludwig’s Angina An acute, life threatening cellulitis of the _____and______ spaces It spreads ________ Respiratory obstruction can occur due to fulminant edema of the mouth, tongue, neck and deep cervical fascia.

sublingual and submandibular rapidly

Epiglottitis Most common in children ___-____ years old but also occurs in infants or adults. It is accompanied by severe systemic illness with _______ AND ________. S/S included: In addition to the epiglottitis, all the supraglottic structures are swollen and inflamed, creating a potential obstruction.

3-7 pyrexia and leukocytosis - sore throat, - dysphagia, - drooling, - obstruction.

Epiglottitis Once intubated, place monitors Administer ____-____ ml/kg of crystalloid because the patient is most likely dehydrated Obtain blood cultures once airway is secured. _____________________ is the most common bacteria that causes epiglottitis. Due to HiB vaccine, increase in incidence caused by _________.

20 - 30 Haemophilus influenzae type B (HiB); Strep

Week 11 - ENT, Plastic, Orthopedic, Eye surgery Flashcards by Luisa Torres

Ear Surgery

Otitis media, or inflammation of the ___________, is the most prevalent disease of childhood secondary to upper respiratory tract infections (URIs).
Eustachian tube obstruction results in negative middle ear pressures and can produce a sterile transudative middle ear effusion.
Infants and young children have __________ eustachian tubes than older children, which makes them more susceptible to reflux of nasopharyngeal secretions into the middle ear space and the subsequent development of otitis media.
Eustachian tube dysfunction
Recurrent URI
Otitis media that is non-responsive to antibiotics may require ______________.

middle ear
shorter
bilateral myringotomy with placement of tubes (BMT).

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Bilateral Myringotomies and Tubes

Premedication?
Induction
IV?
Maintenance
Post-op analgesia?

usually versed, not on all patients
mask induction
## no IV
toradol, nasal fentanyl

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Middle Ear and Mastoid

Chronic otitis media may lead to complications which may entail more complex surgeries such as:

Mastoidectomy
Middle ear exploration
Tympanoplasty

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Middle Ear Procedures

__________ preservation (Avoid ________); nerve monitoring
Control bleeding with the use of _________ solutions; elevate the head to improve venous draining and +/- _____________.
Take steps to decrease PONV
Avoid nitrous oxide because N2O diffuses into the middle ear more rapidly than nitrogen can leave and causes an increase in middle ear pressure, which may displace the graft or cause a tympanic membrane rupture.

Facial nerve (NMBs)
epinephrine-containing; controlled hypotension

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Nasal Surgery

Generally associated with a pathophysiology such as:

Asthmatics
Cystic fibrosis
Chronic sinusitis
Congenital Disorders
Turbinate reduction

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Functional Endoscopic Sinus Surgery (FESS)

Treatment for ________________.
Surgeon’s use of vasoconstrictors (i.e., epinephrine ____:_________ solution, maximum dose is _______________)
Emergence:

chronic sinus disease
1:200,000, 10 mcg/kg
awake extubation

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T & A

The single most important task during the preoperative evaluation of the child for adenotonsillectomy is to distinguish the child with the __________ from the child with isolated obstructive breathing (e.g., primary snoring) and chronic infectious tonsillitis, because the former children are at greater risk for developing severe perioperative respiratory adverse events (PRAEs), possibly including death, after adenotonsillectomy.

OSAS

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Indications for T & A

______ and ________ in the pharynx, to relieve an airway obstruction or focus of infection.
Repeated middle ear infections may be improved by ______________.
______________ is now the most common indication for T&A.
Rarely, acute tonsillitis may lead to peritonsillar abscess or quinsy (quinsy = “to strangle”) tonsil.

Chronic inflammation and hypertrophy of lymphoid tissue
adenoidectomy
Obstructive sleep apnea

Surgery often performed in ambulatory surgical unit (ASU)
Special consideration required in selection of suitable children.
Efficient follow-up service must be provided to deal with unexpected complications.

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Indications for admission after T&A:

Generally, age less than ______ years
Abnormal __________ studies or a history of increased bleeding tendencies
Evidence of __________.
Systemic diseases presenting increased perioperative risk (congenital heart disease, endocrine or neuromuscular disease, chromosomal abnormalities, obesity)
_____________ abnormalities including Down syndrome.
History of a _____________.

3
coagulation
obstructive sleep apnea (OSA)
Craniofacial
peritonsillar abscess

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Tonsillectomy & Adenoidectomy

____________ induction
Supine position, shoulder roll, head extended,
Tracheal intubation; LMA use is increasing in popularity depending upon the surgeon
“Field avoidance” (table turned ____ degrees) with the surgeon at head of the table
EBL varies widely from ___ - ___ ml, so monitor carefully

Inhalational
90
10 - 200

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Tonsillectomy & Adenoidectomy

High risk for _________ secondary to upper respiratory infection and/or airway secretions.
Throat pack may be placed in the posterior of the pharynx to limit blood draining into the stomach.
Observe for compression of ETT or accidental extubation when throat pack is manipulated and/or if Dingman retractor is utilized.
Patients with Down syndrome may need to be evaluated for possible ________________, as the neck is typically extended.
Blood and secretions should be suctioned from the oropharynx and stomach following the completion of surgery to avoid PONV.
Verify removal of throat packs.
Extubating “awake” vs “deep”
Extubation under deep anesthesia decreases coughing. However, it requires vigilance to avoid airway obstruction and aspiration at emergence and during transport to PACU.

laryngospasm
atlantoaxial subluxation

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Clinical Presentation of OSA (12)

Young age (< 6yr )
Snoring during sleep
Failure to thrive
Recurrent URI
Craniofacial abnormalities
Cardiac arrhythmias
Apnea during sleep
Somnolence when awake
Developmental delay
Obesity
Behavioral problems
Cor Pulmonale

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Tonsillectomy & Adenoidectomy

___________ is common
Decrease the risk by withholding post-op fluids until the child requests them
Rehydrate during anesthesia (____-______ LR or NS)
Administration of dexamethasone and a (5HT3) antagonist.

PONV
20 - 25ml/kg

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Tonsillectomy & Adenoidectomy

Post-operative complications include bleeding leading to hypovolemia and airway obstruction
There are two vulnerable periods of potential bleeding including up to _________ hours after surgery (although the majority occur within _______ hours) and… the first post-operative week when the scab falls off ____-____ days later.

24
6
5-10

Between 1 - 3 % of patients who experience post-operative bleeding will return to the OR for surgery.
Respiratory obstruction from blood clots = hypoxia
Hypovolemia
Hypoxia + hypovolemia = cardiac arrest

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Post tonsillectomy bleeding

Full stomach
Dehydration
OR preparation (cuffed ETT ___________ than usual) AIRWAY, AIRWAY, AIRWAY
Surgery is typically quick and minimally painful. Plan accordingly.
EXTUBATE ________.

Tonsillectomy & Adenoidectomy postoperative complications

0.5mm smaller
AWAKE

Considered a full stomach (potential for aspiration)
Be cautious when ordering opioids for a restless child as the restlessness may be an indication of hypoxia
Abdominal pain (stomachache) after T & A are suggestive of swallowing blood from ongoing bleeding

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Ludwig’s Angina

An acute, life threatening cellulitis of the _____and______ spaces
It spreads ________
Respiratory obstruction can occur due to fulminant edema of the mouth, tongue, neck and deep cervical fascia.

sublingual and submandibular
rapidly

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Peritonsillar Abscess

Occurs in ______ or _______.
Infection originates in the _______ spreading to the __________ space between the tonsillar capsule and the superior constrictor muscle
Patients present with: (5)

older children or young adults
tonsil; peritonsillar

Fever,
Pharyngeal swelling,
Sore throat,
Difficulty in swallowing, and
Trismus that results from spasm of pterygoid muscles (moves jaw from side to side).

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Epiglottitis

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Croup

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Epiglottitis

Most common in children ___-____ years old but also occurs in infants or adults. It is accompanied by severe systemic illness with _______ AND ________.
S/S included:

In addition to the epiglottitis, all the supraglottic structures are swollen and inflamed, creating a potential obstruction.

3-7
pyrexia and leukocytosis

- sore throat,
- dysphagia,
- drooling,
- obstruction.

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Epiglottitis is associated with:

Drooling
Dysphagia
Dysphonia
Dyspnea
Dehydration

These children are septic with no cough and rapid onset.

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Epiglottitis

Avoid making child cry as he/she may become acutely obstructed. Parent may be present. No _________________.
Transfer the child to the OR ASAP. The OR should be prepared for emergency _________ and possible _________ (surgeon present, scrubbed, and ready to intervene if needed).
Child should remain ______ at all times. Do not examine airway in ED.

premedication
bronchoscopy; tracheotomy
sitting

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Epiglottitis

Remember the patient will most likely have a longer than normal induction time secondary to _______________.
If a PIV has been established, consider administering lidocaine 1 mg/kg IV to minimize the risk of coughing and laryngospasm.
Use a _________ than predicted ETT

smaller tidal volumes
smaller

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Epiglottitis

Once intubated, place monitors
Administer ____-____ ml/kg of crystalloid because the patient is most likely dehydrated
Obtain blood cultures once airway is secured.
_____________________ is the most common bacteria that causes epiglottitis. Due to HiB vaccine, increase in incidence caused by _________.

20 - 30
Haemophilus influenzae type B (HiB); Strep

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# Laryngotracheobronchitis LTB or “croup” * Most commonly caused by a _______ in children < _____ years. * An obstruction of the airway, below the epiglottis, characterized by a __________. * Principal symptom is _____________ caused by swelling of the loose tracheal mucosa at the level of the cricoid cartilage. * Symptoms are worse at _________.

* virus; 3 * barking cough * inspiratory stridor * night.

# Laryngotracheobronchitis (croup) * ________ ml of ________% Racemic Epinephrine in 2 - 3 ml of normal saline in nebulizer. * Be aware of the potential “______________,” requiring monitoring for ______ hours (per facility protocol) * Suitable pediatric face mask held comfortably around child’s face * Monitor the child for ______ or _________ requiring intervention

* 0.5; 2.25 * rebound affect; 4 * stridor or a barking cough

# Nasotracheal intubation If you must perform a nasotracheal intubation, remember the following: * The size of the endotracheal tube must be small enough to provide a leak at about ______ cm H2O PIP. * Constant respiratory care because the thick secretions and small ETT will lead to obstruction/blockage.

Tracheostomy may be necessary for certain cases:

* A child who cannot be intubated * A child who cannot be successfully extubated after standard time * Most common in infants, **< 1 year of age**, with a history of **congenital subglottic stenosis or a history of repeated croup**

# Endoscopy Issues Laryngoscopy, bronchoscopy, esophagoscopy Existing airway problem – complete airway obstruction Premedication? Spontaneous versus controlled-ventilation

* judicious w/ premedication

# Foreign Body Aspiration * Upper airway obstruction varies from a partial obstruction with ______,________,________, _______ and __________ to complete obstruction with _______ and __________compromise * Considered a “full stomach” * Potentially a difficult airway

* coughing, wheezing, drooling, stridor, and respiratory distress * hypoxia and cardiorespiratory

# Foreign Body Aspiration * **Dyspnea, Coughing, Wheezing and Decreased air entry** on the affected side are indicative of a ________. * **Dyspnea, Coughing, Stridor and Cyanosis** are more common with ____________. * **Aphonia** is of particular concern as it may indicate a ________________.

* bronchial aspiration * laryngeal or tracheal foreign body * total obstruction

# Foreign Body Aspiration * 95% foreign bodies lodge in right mainstem bronchus * History of choking while eating or playing * If the FB completely obstructs bronchus, then ______________ from air trapping can be seen on CXR * A late sign may present as __________.

* distal hyperinflation * pneumonia

1. ___________: air can be inhaled but not exhaled (i.e., ___________) 2. __________: air can be exhaled but not inhaled (i.e., ___________) 3. ___________: partial obstruction of both inhalation & exhalation 4. ____________: total blockage (i.e., ___________)

1. Check valve; emphysema 2. Ball valve; collapse of the bronchopulmonary segment 3. By-pass valve 4. Stop valve (airway collapse and consolidation).

# Cleft Lip and Cleft Palate * The most frequent congenital craniofacial malformations – 1 in 700 births in US (_____>______) * May be isolated, familial, or part of a syndrome – more than ________ syndromes are associated with cleft lip and palate; more with ________. * Primary cleft **lip** repair at _____-_____ months of age. * Primary cleft **palate** is done around ____-_____ months.

* Males > Females * 300; palate * 2- 3 * 6- 10

# Cleft Lip and Cleft Palate Cleft lip closure may be carried out early “Rule of ten” refers to:

Hb of 10, At least 10 weeks old, At least a weight of 10 lbs

# Cleft Lip and Cleft Palate * Early childhood lip & nose revisions * Palatal revision & alveolar bone grafts around ________ years of age. * Rhinoplasty & maxillary osteotomy complete repair around _____-______ years of age. * Some may need _______ to allow normal speech & to prevent nasal regurgitation.

* 10 * 17 - 20 * pharyngoplasty

# Anesthetic Issues: Cleft Lip and Cleft Palate * Induction – inhalational or Intravenous * Airway issues * Intubate with _________ * Movement of head * Epinephrine dose issues * Pharyngeal packs | Emergence: ## Footnote * Pharyngeal packs gone? Oral cavity dry? * Stomach emptied? Nasal airway? * Extubation only if patient is ** completely awake!** * Can they maintain own airway without intervention? * Restrain arms to prevent child from pulling at suture lines * Pain management

oral RAE

Partial list of syndromes and conditions commonly associated with craniofacial anomalies:

# Cleft Lip and Cleft Palate: Postoperative Concerns * The most common complications are bleeding and swelling (airway obstruction). * Airway edema (obligate mouth breathers) about 10% experience will experience:______ * Acute airway obstruction from lingual swelling, especially if mouth retractor is in place for more than _____-_____ hours.

* obstructive sleep apnea. * 2 to 3

1. _______________: repair to prevent permanent craniofacial deformity 2. May involve multiple surgical services, e.g., ENT, Plastics, Neuro, etc. 3. Severe forms associated with:

* Craniosynostosis ## Footnote Part of genetic syndromes Elevated ICP Neurologic deficits Ophthalmologic problems

Most common type of craniosynostosis (50%) Premature closure of sagittal suture

Scaphocephaly

(18%) results from **unilateral** synostosis of a coronal suture, producing a **unilateral “tilting”** forehead and orbital anomalies

(9%) results from **bilateral** coronal synostosis and causes a **broadened skull and midface hypoplasia** - Neurologic complications - Apert’s and Crouzon’s syndromes

(9%) is the result of premature closure of the **metopic** suture, resulting in a **triangular shaped head and hypotelorism**.

# Craniosynostosis: Anesthetic concerns * Comorbidities * Elevated ICP * Craniotomy and large scalp flaps will be associated large blood loss > ____ BV * (maintain hemoglobin > ______) * Increased incidence of VAE * Adequate IV access, +/- a-line * Airway management ## Footnote Surgical duration Orbit and face manipulation (_______) Emergence issues Postoperative airway problems ________ intubation

* 1 * 7.5 ## Footnote - OCR - Prolonged

Syndromes associated with cranyosystosis

# Upper extremity and hand surgery __________: another finger (usually the _______ finger) and is turned into a thumb by surgically moving the finger to where a thumb should be.

Pollicization; pointer

# Fractures * Consider NPO status for non planned cases. * Homeostasis is more complex b/o __________. * Risk of infection due to prior contamination (during the accident) and hardware implantation * Deep venous thrombosis and fat embolism incidence is _______ common in children. * Congenital, genetic and birth disorders (dysmorphic) ## Footnote * Trauma or accidents * Osteogenesis imperfecta (OI) * ORIF vs closed reduction

* smaller blood volume * not as ## Footnote * Trauma or accidents * Osteogenesis imperfecta (OI) * ORIF vs closed reduction

* is a condition of the hip joint where the head of the femur slips off of the neck. * Upon detection by clinical exam and x-ray, immediate bed rest , +/- traction, and surgery is required. * A surgical incision is made and a screw is inserted through the femoral head and the growth plate to prevent any further slip.

Slipped Capital Femoral Epiphysis (SCFE)

Used to treat Developmental Dislocation of the Hip (DDH) (i.e., congenital dislocation)

Pavlik harness or Wheaton Harness

# types of Spica cast placement

Bilateral long leg hip spica cast One and one-half hip spica cast Short leg spica cast

# Spica cast placement The patient is moved to a “spica table”. The patient must remain still and an _____ is typically indicated. Padding is used during the casting process to ensure room for abdominal expansion. A hole is cut out for elimination. ## Footnote Post-anesthesia recovery issues Emergence delirium Is it pain? Is the cast too tight? Excess swelling? Should we bi-valve the cast? PONV Distraction techniques (parents, fluid, food) Compartment syndrome

* ETT

# Tourniquets & Pain * Used to minimize EBL and improve visualization of the surgical field. * Complications: muscle, nerve, vascular damage; skin safety; altered temperature regulation * Typically, pressure is set _______ mmHg > SBP for a maximum of ____-____ hours. * After _____ minutes or so, evidence of TQ pain is expressed by increased HR and BP * Considerations in Sickle Cell Disease * Appropriate timing of antibiotic administration

* 50; 1.5-2 * 30

# Scoliosis * ______ curvature of the spine with rotation of vertebrae within the curve * Requires an ______ or _______ spinal fusion * May be _____,_____ or ________. * Early detection offers the best treatment options (PT, OT, Casting, Bracing, Surgery)

* Lateral * anterior or posterior * congenital, idiopathic, or neuromuscular

# Scoliosis: Congenital * Present at birth, caused by failure of the ________ to form normally * Child may also have ________, ________, or _________, which make the anesthetic plan more complex.

* vertebrae * urinary tract, cardiac or spinal cord problems

# Scoliosis: Idiopathic * Most commonly presents at age greater than _________ years of age * Cause is ___________ * Occurs seven times more frequently in __________ * **Curves may or may not progress during growth**

* 5 * unknown * girls

# Scoliosis: Neuromuscular * Caused by various disorders such as: (6) * Children may have **rapid and unpredictable deterioration** of the curve * Surgery typically results in :____________.

* Polio, * cerebral palsy, * spina bifida, * arthrogryposis, * neurofibromatosis and * muscular dystrophy * extensive EBL

# Scoliosis * Pre-operative preparation includes x-rays, EKG, +/- echocardiogram, +/- PFTs, * Labs include CBC, CMP, Coags, PFA and Type & Screen * A pre-surgical anesthesia evaluation is necessary to explain the anesthesia plan to the patient and the parents. * It is necessary to discuss the use of ____ and ________, positioning considerations and the evaluation of motor function in the OR. ## Footnote surgery consists of:

SSEPs and MEPS ## Footnote Harrington rods Distraction (expandable) rods Pedicle screws with or without rods Vertical expandable prosthetic titanium ribs (VEPTR)

# Scoliosis Spinal Cord Monitoring ## Footnote A typical anesthetic plan requires

“Wake-up” test (“Gold Standard”) Sematosensory Evoked Potentials (SSEPs) Motor Evoked Potentials (MEPs) Lower Extremity Motor Function evaluation ## Footnote 2 large bore IVs at least Arterial line for precise control of BP and sampling Prone position, two soft bite blocks 2nd to MEPs Precise control of neuromuscular blockade Maximize SSEP and MEP evaluation Consider TIVA Ability to quickly wake-up the patient for examination of motor function Post-operative pain management

# Scoliosis surgery * Minimize blood loss through precise control of MAP (hypotensive anesthesia MAP _____-______mmHg) * Positioning * Temperature regulation * Be prepared for massive blood loss (colloids, antifibrinolytics, cell saver, PRBC) * Be prepared for loss of evokes (i.e., Spinal Cord Protocol: increase ______ to perfuse cord, increase _______, ______ to decrease inflammation) * Once the dressings are on, the patient will be turned supine onto the hospital bed. * At this time, a thorough ______ _____ examination must occur. * If the awake patient passes the motor function examination, the trachea can be extubated. * Otherwise, the patient is returned to the prone position, GA is induced and exploration to identify and correct the problem causing spinal cord ischemia.

* 50-65 * BP, temperature, ? steroids * motor function

# Scoliosis: Assessing Motor Function * Assess the patient in a supine position. Compare the right and left sides. * Ask the patient to separate both legs to test for hip abduction. * Ask the patient to bring the legs back together to test for hip adduction. * Ask the patient to flex and extend the knee. If the patient is able to do this, apply resistance as these movements are repeated. * Test plantar flexion (____,_____) and dorsiflexion (_____) by having the patient push down against your hand with their foot and then pull up against your hand with their foot.

* L4, S1 * L5

# General Anesthesia for Eye Surgery GA is almost always required for this type of surgery due to children's immaturity and inability to remain still during these delicate procedures. During emergence avoid unnecessary sympathetic responses such as ____________ from straining, crying, coughing and bucking. ## Footnote Preoperative: * May give IV atropine or glycoyrrolate at induction. * Avoid pre-operative emotional stress such as crying evoked by (separation) anxiety * Parents and family are of great assistance in these scenarios.

increased intraocular pressure

# Ophthalmic Medication & Side Effects * Medications applied to the conjunctiva or injected into the eye have multiple systemic effects. * Phenylephrine & Epinephrine can cause _______ and ________.

hypertension and arrhythmias

# Ophthalmic Medication & Side Effects * Phenylephrine- avoid _______% eye drops contraindicated in children because it can cause cardiac arrest; (may use ______%) * Scopolamine eye drops can cause _______, ______, and ________. Treat adverse side effects with IV physostigmine.

* 10; 2.5 *excitation, disorientation and possible psychosis

# Eye Surgery * Children have increased sensitivity to ___________. * Monitor HR closely with manipulation of the eyes and extraocular muscles. * Ocular nerve is connected to the vagus nerve. Atropine (______-_____mg/kg) or glycopyrrolate can be given at induction to block OCR. * If atropine is contraindicated in a pediatric patient, note that a vagotonic response is more likely to be elicited from a ________________ versus gradually applied traction.

* oculocardiac reflex (OCR) * 0.01-0.02 * sudden aggressive pull

# Ophthalmic Reflexes: nerves involved 1. OCR (oculocardiac reflex) 2. ORR (oculorespiratory reflex) 3. OER (oculoemetic reflex) or oculogastric

1. Trigeminal nerve Vagus nerve 2. Trigeminal nerve 3. Vagus nerve

# Foreign Body/Trauma * Atropine causes a slight increase in _______ and is **not** contraindicated in children with _______. * IV succinylcholine causes a **transient** increase in _______. * An RSI dose of Rocuronium is preferred in pediatric patients with _________.. * Conservative pre-op sedation recommended for “full stomach” patients to prevent further risks of aspiration. ## Footnote * Ketamine was originally thought to substantially increase IOP but is now thought to have little effect on IOP. However, Ketamine causes ________, which is an undesired side effect during eye surgery. * If child is undergoing an elective surgery and is not a “full stomach”, an _________ is an option.

* IOP; glaucoma * IOP * penetrating eye trauma ## Footnote * nystagmus * LMA

# Anesthetic Considerations * Any increase in _________ during correction of a penetrating eye trauma can cause protrusion of eye contents. * Be careful with the use of a facemask, which can increase pressure on the eye globe increasing IOP. It also may be difficult to maintain a good seal with face mask ventilation when a child has an eye patch/eye dressing. * Be careful with O2 leaks from face masks and electrocautery near the eyes secondary to increased risk of surgical fires. * Avoid N20 * Respirations should be closely monitored. * * If a foreign body presents in the eye trauma, IV antibiotics will be prescribed immediately. Early IV access is critical. ## Footnote * IV lidocaine 1 - 1.5 mg/kg followed by propofol minimizes the increase in IOP precipitated by laryngoscopy * Also, IV lidocaine prior to extubation may blunt the cough reflex and avoid unnecessary increases in IOP. * Extubate the child fully ______ and in the ____ position to facilitate a smoother transition

* IOP ## Footnote *awake/ lateral

# Eye surgery: Post-Op Pain, Nausea & Vomiting * Acetaminophen suppository post-induction. * ___________ placed intraoperatively has great benefits postoperatively. * Topical local anesthetics such as ______ eye drops administered post-operatively. * PONV prophylaxis: consider propofol as your primary anesthetic and/or IV ondansetron, IV dexamethasone

* Retrobulbar block * tetracaine

# Retinopathy of Prematurity (ROP) * Is caused by: * It is the leading cause of ______ in preterm neonates, particularly those weighing less than _____ grams. * It was initially believed high FiO2 caused ROP. * Now it is believed to be a process of ______ and ________ **(stimulated by hypoxia)**.

* retinal vessel proliferation and retinal detachment. * blindness; 1500 * angiogenesis and vasculogenesis

# Retinopathy of Prematurity (ROP) * Exposure of the retina of the preterm neonate to ____________ levels **in excess** of the usual fetal levels interrupts normal vasculogenesis. * It is theorized that additional oxygen will not cause further damage. ## Footnote * Risk factors include :

* tissue oxygen ## Footnote Hypoxia, Hypercarbia or hypocarbia, Blood transfusions, Exposure to light, Recurrent apnea, and Sepsis.

# Retinopathy of Prematurity (ROP) * Monitor the SaO2 at a preductal site (_____OR ______) and maintain SaO2 ____% to ____%. * If high fractions of inspired oxygen are required, such as in a code situation, then do not be afraid to do what is necessary to take care of the patient.

* right hand or right earlobe; 90% to 95

# Retinopathy of Prematurity (ROP): Neonatal Screening * Screening process is recommended to begin at _____ weeks of gestation or _____ weeks of age, whichever is greater * Dilation of the pupils is accomplished with ______ and _____; indirect ophthalmoscopy is completed by an ophthalmologist. * Risk analysis is used to identify neonates that are at higher risk for unfavorable outcomes.

* 31; 4 *Phenylephrine and Tropicamide

# Retinopathy of Prematurity (ROP): Disease Classification & Progression Progression of the disease in five stages * Stage I = * Stage II = * Stage III = * Stage IV = * Stage V = ## Footnote Zones I - III determine area of damage.

* Stage I – mildly abnormal blood vessel growth * Stage II – moderately abnormal blood vessel growth * Stage III – Severely abnormal blood vessel growth * Stage IV –partially detached retina * Stage V – completely detached retina

# Retinopathy of Prematurity (ROP) * _______________ is currently the preferred method of treatment. * A diode laser is utilized to make small burns in the periphery of the retina preventing further growth of abnormal vessels. * Treatment can be accomplished with _________ or ________. Depending on age of the patient. Intraoperative: * No significant blood loss or surgical stress but case can be long in duration * Biggest challenges in these patients are due to size and prematurity (monitoring, vascular access, hypothermia) * Limited access to patient during procedure * Avoid N20 due to its potential to expand and increase IOP * Monitoring of **blood glucose** during long procedures * Smooth extubation without coughing or bring patient back to NICU intubated

* Retinal photocoagulation * deep sedation, or under general anesthesia

# Retinopathy of Prematurity (ROP): postoperative manafement. * Close monitoring postoperatively * Higher incidence of postop apnea due to prematurity; remaining intubated may be safest approach * Antibiotic drops are administered post-operatively to reduce risk of infection * Repeat examination should be completed within _____-_____ days * If regression is noted, re-treatment should occur within ____-____days

* 5-7 * 10-14

# Intraocular Surgery and EUA for Cataracts, Glaucoma and Tumors * Children undergoing surgery for cataract or glaucoma, treatment of detached retina or examination under anesthesia (EUA) for glaucoma or tumor often require _______. * Children do not tolerate sedation and local analgesia for the eye.

- General anesthesia.

# Eye Operations * Congenital cataracts: **lens opacity** present at birth and must be surgically removed. Associated with __________ and other chromosomal conditions. * Glaucoma: a _______ issue; several anomalies are in association, _______ measurements are taken before intubation.

* maternal rubella ## Footnote * Congenital; IOP

# Special Anesthesia Problems: eye surgery * The oculocardiac reflex (OCR) * Intraocular pressure may be affected by anesthesia drugs and techniques * Coughing and straining may elevate the intraocular pressure (induction and emergence from anesthesia should be as quiet and as smooth as possible) Pre-op: * Give adequate sedation to prevent coughing and straining * Explain to older children that their eye will probably be covered with an eye patch after surgery Periop: * Anesthesia induction should be as smooth as possible, by inhalation of ______ or __________ or intravenously with Propofol. * Current recommendations do not favor the administration of __________. * For brief EUA procedures, you may use a ________, but avoid pressure on the globe as it may increase IOP. * Otherwise, either deepen anesthesia using a single dose of Propofol (up to 3 – 5 mg/kg IV) or spray the larynx with lidocaine before intubating the trachea or inserting a well-lubricated LMA. * For prolonged surgeries, a nondepolarizing muscle relaxant may be administered.

Review - Sevoflurane and N2O - succinylcholine - facemask

# Perioperative Management cont. eye surgery * Maintain anesthesia with isoflurane, sevoflurane, or desflurane. * Allow spontaneous ventilation for brief ________ procedures, otherwise, control ventilation to prevent hypercapnia. * Alternatively, use a Propofol infusion to maintain anesthesia because it may be advantageous in reducing postoperative vomiting. * If sulfur hexafluride or air is to be injected, discontinue N2O early. * A retrobulbar block may help reduce postoperative pain. * Avoid coughing or straining on emergence * Suction pharynx, extubate trachea or remove LMA while child is deeply anesthetized * Administration of lidocaine 1 - 1.5 mg/kg IV prior to extubation * Re-apply facemask, support airway and administer O2 until child awakens

- EUA ## Footnote Ensure adequate sedation and analgesics are ordered Ensure an antiemetic as needed has been ordered

The most common eye surgery in children

Strabismus sx.

# Special Anesthesia Problems w/ strabismys sx. Oculocardiac reflex * Severe bradycardia/cardiac arrest can occur due to traction on extraocular muscles * Powerful in children * Atropine 0.02 mg/kg Oculogastric reflex * Vomiting after surgery is common * Also triggered by “____________” & ________. ## Footnote Post operative pain may be considerable in older children. Excessive sedation should be avoided in order to assess adjustable sutures post operatively. Consider ondansetron and dexamethasone.

pushing fluids; early ambulation

# Strabismys sx. preop: Do not give heavy sedation as the surgeon usually examines the child immediately before surgery. Effective premedication: * Versed (0.5-0.75 mg/kg PO, >____ yr old) * Clonidine (______ mcg/kg PO); give 60-90 min before surgery Consider IV Atropine on induction. ## Footnote Monitor for bradycardia; if it occurs, ask surgeon to discontinue traction, and administer IV atropine or glycopyrrolate. Alternatively, repeated gentle traction on the muscle may fatigue the reflex.

* 6; * 4

# Strabismys sx. post-op: * Postoperative analgesia should be provided * IV _______ decreases postoperative pain and is associated with less PONV * __________ eye drops and injections of bupivicaine or ropivicaine (by the surgeon) can also provide postoperative analgesia * Smooth removal of the LMA or ET tube should be considered as coughing or straining on emergence can cause a subconjuctival hemorrhage. * Deep extubation with airway support is common. * Provide analgesics and adequate hydration. * There is a high incidence of PONV with strabismus surgery!

* ketorolac * Tetracaine

* Rapidly developing cancer of the cells of the retina * The most common pediatric intraocular tumor * Prevalence: 1 in 15k-20k

Retinoblastoma

# Treatment for Retinoblastoma * _____________ (Lens-sparing radiation, photoradiation) * IV chemotherapy * Laser photocoagulation * Cryotherapy * In advanced cases, _________ (removal of the eye) may be needed

* Radiotherapy * enucleation

# Anesthesia for Radiotherapy Anesthesia Considerations: * Treatment may require daily, repeated _____________, where patients have to remain absolutely still * Challenge is to administer short-acting anesthetics and have the child return to normal activity and feeding as soon as possible * Retching and vomiting provoked by radiation present a potential challenge for proper radiotherapy and anesthesia management * Many children will have an indwelling venous port or PICC line for the duration of their radiation therapy treatments

* radiotherapy

# Anesthesia management for lens-sparing radiotherapy: Anesthesia time: < ______ minutes Various techniques may be used * Inhaled sevoflurane * IV propofol * LMA or nasal oxygen with capnometry * Avoids repeated risk of laryngeal trauma with endotracheal intubation * Maintain airway with careful positioning or with molded immobilization device.

* 20

Anesthesia management for photoradiation therapy: * Photoradiation uses a __________ to mark the tumor for argon laser therapy * Use of _______ in darkness * Side effects of HpD therapy include _____ and ______, when exposed to light * _________ is safe and reliable in the presence of HpD * Consider ↑ risk of PONV (chemotherapy and anesthesia)

* hematoporphyrin derivative (HpD) * General Anesthesia * skin pigmentation and burns * Pulse oximetry

Week 11 - ENT, Plastic, Orthopedic, Eye surgery Flashcards

(92 cards)