Anesthesia for Pediatric Surgical Procedures

Question 1

What is the most common elbow fracture in children?

Answer 1

suprachondlylar fractures of the humerus, results from falling with an outstretched hand and extended elbow

Question 2

What are some complications from orthopedic limb fractures?

Answer 2

compartment syndrome
nerve palsies
late deformities

Question 3

What are some anesthesia considerations for a humerus fracture?

Answer 3

• Supine with table turned 90 degrees
• GETA
• Assess NPO status and full stomach precautions requiring an IV and RSI
• 30-60 minutes for pinning
• 30-90 minutes for open reduction
• Timing of emergence if cast or splint is placed after closing

Question 4

When is surgical treatment recommended for spinal curvature?

Answer 4

curves >45 degrees while still growing, or are continuing to progress greater than 45 degrees when growth stopped

Question 5

What is the goal of surgical treatment with posterior spine instrumentation?

Answer 5

prevent curve progression and to obtain some curve corection

Question 6

What are some anesthetic considerations for posterior spine instrumentation?

Answer 6

prone position
6+ hours
potential for significant blood loss (hypotensive technique on dissection, use of TXA, cell saver, autologous blood and hemodilution techniques)
intraoperative neurological monitoring with possible wake-up test
step down or ICU post-op

Question 7

What are some preop considerations for spine instrumentation?

Answer 7

• standard pediatric pre-op evaluation
• Starting CBC, coags, BMP, Hcg in females
• Comorbidities
• T&C/set up 2 PRBCs
• Discuss with team nerve monitoring goals and use of paralytics
• May prepare patient and family for puffy face from prone position

Question 8

What is the Cobb angle?

Answer 8

degree of lateral curvature, can indicate impaired respiratory function

Question 9

If the VC

Answer 9

Adequate despite restrictive pattern

Question 10

If the VC

Answer 10

postop ventilation may be required due to restrictive disease

Question 11

What things will you need to set up a case for a posterior spinal instrumentation?

Answer 11

• cell saver, fluid warmer, blood tubing
• Aline, lidco, PIVx2 (consider central line if difficult access)
• Prepare for prone position
• Eye lubricant with eye tape of choice
• Soft bite block
• Standard airway, induction meds, BIS, emergency meds, OG
• Ensure room temperature is increased prior to bringing patient to OR

Question 12

What do you need 4 syringe channels for during a posterior spinal instrumentation and fusion?

Answer 12

Fentanyl infusion 0.5-2 mcg/kg/hr
Ketamine 0.5 mg/kg bolus, 2 mcg/kg/min up to 2 mg/kg or 200 mg total
TXA bolus (after induction) 10 mg/kg (up to 1,000 mg) IV over 30 minutes
Precedex 0.2-0.3 mcg/kg/hr

Question 13

What do you need 4 fluid channels for during a posterior spinal instrumentation?

Answer 13

MIV

Propofol infusion

Question 14

What do you need to avoid if you are monitoring MEP during a posterior spinal instrumentaiton?

Answer 14

volatiles and paralytics

Question 15

Will precedex affect MEP/SSEPs?

Answer 15

Not in low doses, but may in high doses, better to keep

Question 16

What are some complications of posterior spinal instrumentation?

Answer 16

• spinal cord ischemia
• massive blood loss
• embolism
• accidental extubation
• corneal abrasion
• visual loss
• neurological sequel with loss of SSEPs or MEPs

Question 17

What should you do if you lose evoked potentials?

Answer 17

• notify surgeon
• turn off inhalation agent/N2O and switch to propofol/ketamine infusion
• turn off or reverse NMB
• increase perfusion pressure (MAP>70 mmHg) using ephedrine (0.2-0.3 mg/kg IV) and/or phenylephrine (1-10 mcg/kg IV)
• Check Hgb; transfuse RBC (10-15 mL/kg IV)
• ensure normocarbia; increase I:E ratio, decrease PEEP
• ensure normothermia
• consider wake up test
• consider high-dose steroid for spinal cord injury

Question 18

What are postop considerations for posterior spinal instrumentation?

Answer 18

• plan for extubation if possible
• CXR may be done at end of procedure with patient supine on bed
• pain score 7-9 –> hydromorphone PCA
• ICU or step down
• LOS 2-6 days

Question 19

What is the suggested max intra-abdominal pressure for general abdominal cases?

Answer 19

10-12 mmHg

Question 20

What are some contraindications for caudal anesthesia?

Answer 20

infection around the site, coagulopathy, anatomic abnormalities, parental refusal

Question 21

What are the caudal landmarks?

Answer 21

sacral hiatus, 2 PSIS

Question 22

What is the caudal dosing for genital and anal surgery?

Answer 22

0.5-0.75 mL/kg

Question 23

What is the caudal dosing for lower abdomen?

Answer 23

1 mL/kg

Question 24

What is the caudal dosing for abdominal incision?

Answer 24

1-1.25 mL/kg

Question 25

What is the intravascular caudal test dose for epinephrine?

Answer 25

0.5 mcg/kg

Question 26

What is the dose for clonidine for caudal anesthesia?

Answer 26

1-2 mcg/kg

Question 27

When is the cleft lip usually repaired?

Answer 27

10-12 weeks

Question 28

When is a cleft palate usually repaired?

Answer 28

12-18 months

Question 29

What kind of induction and ETT do you use for a cleft palate/lip repair?

Answer 29

routine induction

oral RAE with flexible connector

Question 30

What are some anesthetic considerations for cleft palate/lip repair?

Answer 30

• airway can be difficult
• mouth gag - reassess breath sounds once positioned
• no air bubbles
• coagulopathy may cause significant bleeding, blood loss usually insignificant but occasionally may require transfusion
• LA with epinephrine reduces blood loss and provides some analgesia
• protect eyes
• secretions and blood–clear airway on emergence
• possibility of airway and tongue edema
• extubate once return of protective airway reflexes
• protect surgical site from child’s manipulation

Question 31

What are some considerations for admission after a T&A?

Answer 31

-

Question 32

What does the 2011 Evidence Based Clinical Practice Guideline for optimization of peri-operative management suggest for T&As?

Answer 32

• Strong recommendation for single, intraoperative IV dexamethasone 0.5 mg/kg
• Strong recommendation against routine administration of perioperative antibiotics
• Recommendation to advocate for pain management but avoid ketorolac and codeine

Question 33

What is the “pediatric position” for emergence after a T&A?

Answer 33

patient on one side with head slightly down - allows blood to drain away from vocal cords

Question 34

Why should you be cautious with administering opioids for a restless child after a T&A?

Answer 34

may indicate airway compromise or hypoxia