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N935 Advanced Pathophysiology II > Anesthesia Considerations for Premie, Neonate, and Peds > Flashcards

Anesthesia Considerations for Premie, Neonate, and Peds Flashcards

1
Q

special anesthesia considerations for kids

A
  • infection risk
  • IVH
  • apnea risk
  • temperature control
  • ventilation/oxygenation
  • saturation goals 90-94%
  • glucose, fluid and lyte management
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2
Q

MAC

A

inhaled anesthetic depth at which 50% of patients respond to painful stimulus with movement

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3
Q

MAC in prematurity

A
  • varies with age and espeically in premies and critically ill infants
  • more susceptible to cardio-depressant effects of inhalational anesthetics
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4
Q

fetal hemoglobin

A
  • main oxygen transport moelecule in utero and persists to 6 months of age
  • functionally able to bind oxygen with greater affinity than adult hemoglobin
  • results in leftward shift of oxy-hgb dissociation curve
  • concentration of HbF in utero is 50% greater than that of the mother
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5
Q

physiologic anemia in the newborn

A
  • healthy term infants, fetal hemoglobin concentration falls during the 9th and 12th weeks
  • due to decrease in erythropoiesis and shorter RBC lifespan
  • premies have slightly lower hgb levels at brith
  • nadir lower and reached earlier around 4-8 weeks
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6
Q

nadir of hgb in term infants

A

10-11 g/dL

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7
Q

nadir of Hgb in premies

A

7-9 g/dL

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8
Q

when does Hgb stabilize

A

3rd month of life at around 11-12 g/dL

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9
Q

PDA ligation

A
  • PDA may incur significant L to R shunting –> excess pulmonary blood flow –> CHF –> resp failure
  • pulm HTN or RDS of infant may cause R to L shunting –> cyanosis
  • surgical therapy = left thoracotomy, retraction of L lung
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10
Q

PDA medical therapy

A
  • admin of COX inhibitor

- indomethacin or ibuprofen

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11
Q

preop for PDA ligation

A
  • assess art pressure, HR, ABG, vent settings, and FiO2
  • severe bleeding may occur quickly due to the close proximity to aorta and pulmonary artery –> HAVE PRBCs ready to go!!
  • ABX (risk for endocarditis)
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12
Q

introp management of PDA ligation

A
  • BP monitoring (R arm = cerebral perfusion)
  • pulse ox on R arm and lower extremity (to monitor pre and post ductal sats)
  • ETCO2 monitoring
  • ETT minimal leak because surgical retraction of lung may mean increased inspiratory pressure and inspired oxygen
  • opioids, amnestic and muscle relaxation
  • intercostal nerve block by surgeon at completion of surgery
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13
Q

complications of PDA ligation

A
  • inadvertent ligation/lac of aorta or pulmonary artery
  • aortic clamp = loss of signal to lower extremity pulse ox
  • pulm artery clamp = decrease oxygen sat to both extremities and end tidal CO2
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14
Q

what happens if PDA ligation is successful?

A
  • increased arterial diastolic and mean pressure

- PDA murmur disappears

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15
Q

NEC (necrotizing enterocolitis)

A
  • illness most often found in LBW with mortality of 50%
  • 85% cases infants <1500g
  • morbidity with NEC = short gut, sepsis, adhesions
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16
Q

NEC cause

A
  • uncertain and mutlifactoral

- result = intestinal mucosa injury secondary to ischemia and ulceration of bowel

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17
Q

early signs of NEC

A
  • abdominal distention
  • bloody diarrhea
  • temperature instability
  • lethargy
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18
Q

what is indication of urgent/emergent surgery for NEC?

A
  • bowel perf and free air in the abdominal cavity

- need to resect the dead bowel

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19
Q

NEC presentation

A
  • metabolic and hematologic abnormalities
  • hyperkalemia
  • hyponatremia
  • metabolic acidosis
  • hyper or hypoglycemia
  • coagulopathy/DIC
  • anemia
  • intubated, unstable, NGT/OGT
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20
Q

surgical management of NEC

A
  • EMERGENCY
  • intestine can no longer hold waste, so bacteria may pass into bloodstream –> sepsis
  • involves initial primary peritoneal drainage or laparotomy with resection of necrotic bowel
  • primary peritoneal drainage = smaller incision, fewer anesthetic requirements, done at bedside
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21
Q

anesthetic management of NEC

A
  • aspiration risk –> RSI or awake intubation
  • inhalation agents poorly tolerated due to low BP; narcotic technique with muscle relaxation for hemodynamic instability
  • avoid N2O
  • vascular access (at least 2)
  • vasopressor infusions (dopa and epi) for maintenance of renal perfusion and CO
  • large fluid loss and blood loss
  • transfusion in neonates per kg
  • correct electrolytes and glucose
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22
Q

PRBCs for kiddos

A

10-15 mL/kg

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23
Q

FFP for kiddos

A

10-15 mL/kg

24
Q

allowable blood loss formula

A

ABL = [EBV x (starting Hct - allowable Hct)]/starting Hct

25
Q

inguinal hernia repair

A
  • common in premies
  • complications = incarcerated bowel, intestinal obstruction, gonadal infarction, infection, hematoma, recurrent hernias
  • general and/or regional
  • LMA if defect is small
  • ETT for large defect
26
Q

Eye surgery for ROP

A

-treated with cryotherapy, laser photocoagulation, slceral buckling surgery and/or vitrectomy

27
Q

diode laser photocoagulation for ROP

A
  • for moderate ROP, maybe bedside
  • 10-30 min treatments in series every few weeks
  • topical anesthesia alone, IV sedation, or GA
28
Q

cryotherapy for ROP

A
  • applies a freezing probe to the avascular retina in the OR
  • requires GA
  • often between 32 and 42 weeks PCA
29
Q

slceral buckling and vitrectomy

A
  • less frequently used with better screening and earlier treatment, performed for severe ROP with retinal detachment in the OR
  • requires GA
  • child is often older 6 months to 1 year
30
Q

anesthesia for radiologic imaging

A
  • MRI replacing US and CT for assessment of IVH due to lack of radiation exposure and is able to identify congenital lesions, vascular malformations and ischemic injury
  • requires immobility
  • anesthesia ranges from oral meds, sedation to general
  • off site anesthesia considerations along with MRI compatible monitoring
  • monitoring for post-op apnea considerations
31
Q

CDH

A
  • congenital diaphragmatic hernia
  • diaphragm normally completes formation during 7th-10th week
  • anatomic defects permit intrusion of abdominal contents into thoracic cavity
32
Q

early CDH

A
  • abdominal mass inhibits normal cardiopulmonary growth
  • severity of lung hypoplasia - associated with severe morbidity and mortality - negatively correlates with gestational age at the time the hernia occurred
33
Q

late CDH

A
  • occurs near or even after delivery

- associated with mature, well developed lungs and minimal problems with ventilation

34
Q

bochdalek type hernia

A
  • 95% of CDH

- more likely to have concurrent birth defects including CHD and chromosomal abnormalities

35
Q

hallmark signs of CDH

A
  • hypoxia
  • scaphoid abdomen
  • evidence of bowel in thorax
36
Q

why is CDH potentially lethal?

A
  • pulmonary HTN
  • pulmonary hypoplasia
  • associated cardiac or congenital defects
37
Q

CDH surgical approach

A
  • surgery = standard of care in 1980s
  • subcostal incision or thoracic laparoscopic
  • recurrent defect may be approached through the abdomen and minimally invasive
  • primary closure vs synthetic patch
  • surgery may be delayed until cardiorespiratory and medically stabilized
  • may occur before, after or during ECMO
  • surgery transiently worsens pulm HTN and may cause persistent fetal circulation
  • CDH outcomes function of the underlying pulm hypoplasia and pulm HTN
38
Q

anesthetic management of CDH repair

A
  • initial management includes definitive airway control and optimization of oxygenation and ventilation
  • avoid mask ventilation to limit gastric insufflation
  • supine or lateral
  • pre and post ductal sat monitoring
  • reactive pulmonary vasculature
  • PIV x2, +/- CVC, aline (serial ABGs)
  • EBL 5-10 mL/kg
  • paralysis, narcotics, limited inhalation agent
  • limited inspired O2, avoid N2O
  • supportive care during transport may be challenging
39
Q

omphalocele & gastroschisis

A
  • external herniation of abdominal contents through an anterior abdominal wall defect
  • may present with impaired blood supply to herniated organs, intestinal obstruction, and major intravascular fluid deficits
  • ultrasound confirms presence
  • large defects = C-section
40
Q

gastroschisis

A
  • intestines outside the abdomen through a hole in the abdomen
  • just right of the umbilical cord
  • exstrophy of belly/viscera through an abdominal wall gap
  • results of occlusion of the omphalomesenteric artery during gestation
  • 1 in 15,000 births
  • not usually associated with other congential abnormalities
  • herniated viscera are exposed to air after delivery resulting is worsening inflammation, edema, dilation with abnormal bowel function
41
Q

omphalocele

A
  • the intestines, liver, and other organs remain outside the abdomen in a sac
  • usually right by the umbilical ring
  • result of failure of the gut to migrate from the yolk sac into the abdomen
  • 1 in 6000 births
  • associated genetic, cardiac, urologic and metabolic abnormalities
  • viscera emerge from the umbilicus and are covered with a membranous sac
42
Q

management for gastroschisis and omphalocele

A
  • maintenance of perfusion and reduction of fluid loss
  • closure of abdomen is goal, however often delayed to avoid exposing the viscera to excessive pressure
  • high intra-abdominal pressure may result in cardiorespiratory failure, renal failure, decreased hepatic function, ischemic bowel and death
  • pressures > 20 mmHg poorly tolerated
  • silo = temporary housing for bowel
43
Q

anesthetic considerations for gastroschisis and omphalocele

A
  • assess for associated anomalies
  • increased IAP; gastric tube inserted to decompress stomach
  • severe electrolyte disturbances, monitor blood glucose
  • rehydrate (gastroschisis lose more fluid than omphalocele)
  • prevent hypothermia
  • aspiration risk maybe RSI, avoid N2O
  • risk for infection
44
Q

postoperative considerations for gastroschisis and omphalocele

A
  • assess ability to extubate
  • continue gastric suction until bowel function recovers
  • continue IV fluids and glucose
  • may require IV alimentation (weeks to months)
  • often remain intubated with IV sedation, paralytics and opioids until clinical status stabilizes
45
Q

criteria for aborting primary closure

A
  • intragastric pressure > 20 mmHg
  • intravesical pressure > 20 mmHg
  • end-tidal carbon dioxide 50 mmHg or higher
  • max ventilatory pressure of 35 cmH2O or greater
46
Q

TEF

A
  • tracheoesophageal fistula
  • 1 in 3500 live births
  • due to incomplete separation of the trachea and esophagus that begins during the 4th-5th week gestation
  • survival >95%
  • risks = pneumonia, poor nutrition, gastric distention (impairs ventilation)
47
Q

S/S used to diagnose esophageal atresia with or without TEF

A
  • excessive secretions
  • coughing
  • choking after first feeding
  • recurrent pneumonias
  • OG cannot be passed into the stomach
48
Q

surgical repair of EA and TEF

A
  • ligation of fistula and anastomosis of esophagus
  • urgent but not emergent
  • +/- G tube
  • ligation of fistula
  • anastomoese of esophagus atretic segments
  • left lateral decubitus and R thoractomy (so effectively 1 lung ventilation due to the retractor)
49
Q

how many types of TEF/EA are there?

A

5

vary by the location of the fistula

50
Q

what is the most common type of TEF/EA?

A

EA with distal TEF

type C/IIIB

51
Q

TEF and anesthesia

A
  • challenging airway - consider fiberoptic and awake intubation (minimizes gastric distention, allows precise placement of ETT cuff)
  • inhalation induction, avoid PPV, maintain spontaneous ventilation
  • RSI
  • confirm ETT placement
  • crucial to place ETT between fistula and carina (distal to fistula; some will R mainstem and slowly withdraw until BBSE)
52
Q

monitoring and hemodynamics for TEF

A
  • left lateral position
  • standard monitors
  • a line for Q1H abgs
  • L sided precordial to assess for tube migration
  • minimal blood loss, BUT surgical site is close to some pretty big vessels!
  • glucose infusion and monitoring
53
Q

maintenance of anesthesia for TEF

A
  • combination of inhaled and opioids
  • avoid N2O
  • muscle relaxation
  • large surgical surface area (at risk for hypothermia)
  • surgical traction may compromise lung, great vessels, trachea, heart and vagus nerve
54
Q

TEF post op

A
  • early extubation because prevents prolonged pressure of ETT on surgical site
  • may also remain intubated but again this could cause excessive pressure on new anastomosis and reintubation could be traumatic
55
Q

potential TEF complications

A
  • RLN injury
  • overlook additional fistulas
  • recurrent fistulas can complicate recovery
56
Q

early TEF complications

A
  • anastomosis leak and strictures
  • GERD
  • feeding aversions
  • esophageal dysmotility
57
Q

long-term TEF complications

A
  • strictures
  • pulmonary disease
  • tracheomalacia

N935 Advanced Pathophysiology II (16 decks)

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