Anesthesia for Pediatric Surgical Procedures Flashcards
What is the most common elbow fracture in children?
suprachondlylar fractures of the humerus, results from falling with an outstretched hand and extended elbow
What are some complications from orthopedic limb fractures?
compartment syndrome
nerve palsies
late deformities
What are some anesthesia considerations for a humerus fracture?
- 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
When is surgical treatment recommended for spinal curvature?
curves >45 degrees while still growing, or are continuing to progress greater than 45 degrees when growth stopped
What is the goal of surgical treatment with posterior spine instrumentation?
prevent curve progression and to obtain some curve corection
What are some anesthetic considerations for posterior spine instrumentation?
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
What are some preop considerations for spine instrumentation?
- 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
What is the Cobb angle?
degree of lateral curvature, can indicate impaired respiratory function
If the VC
Adequate despite restrictive pattern
If the VC
postop ventilation may be required due to restrictive disease
What things will you need to set up a case for a posterior spinal instrumentation?
- 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
What do you need 4 syringe channels for during a posterior spinal instrumentation and fusion?
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
What do you need 4 fluid channels for during a posterior spinal instrumentation?
MIV
Propofol infusion
What do you need to avoid if you are monitoring MEP during a posterior spinal instrumentaiton?
volatiles and paralytics
Will precedex affect MEP/SSEPs?
Not in low doses, but may in high doses, better to keep
What are some complications of posterior spinal instrumentation?
- spinal cord ischemia
- massive blood loss
- embolism
- accidental extubation
- corneal abrasion
- visual loss
- neurological sequel with loss of SSEPs or MEPs
What should you do if you lose evoked potentials?
- 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
What are postop considerations for posterior spinal instrumentation?
- 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
What is the suggested max intra-abdominal pressure for general abdominal cases?
10-12 mmHg
What are some contraindications for caudal anesthesia?
infection around the site, coagulopathy, anatomic abnormalities, parental refusal
What are the caudal landmarks?
sacral hiatus, 2 PSIS
What is the caudal dosing for genital and anal surgery?
0.5-0.75 mL/kg
What is the caudal dosing for lower abdomen?
1 mL/kg
What is the caudal dosing for abdominal incision?
1-1.25 mL/kg
What is the intravascular caudal test dose for epinephrine?
0.5 mcg/kg
What is the dose for clonidine for caudal anesthesia?
1-2 mcg/kg
When is the cleft lip usually repaired?
10-12 weeks
When is a cleft palate usually repaired?
12-18 months
What kind of induction and ETT do you use for a cleft palate/lip repair?
routine induction
oral RAE with flexible connector
What are some anesthetic considerations for cleft palate/lip repair?
- 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
What are some considerations for admission after a T&A?
-
What does the 2011 Evidence Based Clinical Practice Guideline for optimization of peri-operative management suggest for T&As?
- 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
What is the “pediatric position” for emergence after a T&A?
patient on one side with head slightly down - allows blood to drain away from vocal cords
Why should you be cautious with administering opioids for a restless child after a T&A?
may indicate airway compromise or hypoxia
