Anesthetics for common pediatric procedures Flashcards
Otorhinolaryngology is a
surgical subspecialty that deals with the surgical and medical management of conditions of the head & neck
Tonsillectomy and adenoidectomy may be required due to
chronic inflammation and hypertrophy of lymphoid tissue in the pharynx may necessitate surgery to relieve obstruction or to remove the focus of infection
Bilateral myringotomy and tympanostomy is when
myringotomy creates an opening in the tympanic membrane through which fluid can drain
placement of a ventilation tube (tympanostomy) with a lumen is frequently also performed
-this alleviates pressure from the middle ear and serves as a stent following continued drainage until the tubes are naturally extruded in 6 months to a year
The main symptoms of tonsillitis are
inflammation and swelling of the tonsils, sometimes severe enough to cause respiratory obstruction
The most common indication for T&A in North America is
OSA
may lead to chronic airway obstruction, carbon dioxide retention, cor pulmonale, failure to thrive, and speech abnormalities
Considerations for admission for tonsillectomy include
<3 years old abnormal bleeding tendencies significant OSA airway abnormalities other systemic diseases those living an excessive distance
Guideline for optimization of perioperative management includes:
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 hover: avoid codeine**, may avoid ketorolac d/t hemorrhage
Why is codeine avoided in pediatrics?
active metabolite is morphine which causes sustained respiratory issues
Describe standard induction for T&A.
Oral RAE (may consider reinforced)- cuffed ETT with 20 cmH2O airway pressure
LMA
secure midline
Table turned 45-90 degrees
Describe the use of a mouth gag in T&A.
requires adequate depth of anesthesia
reevaluate airway after placement to ensure no dislodgement of ETT or LMA
throat pack
Describe analgesic management for T&A.
muscle relaxants okay- but often a relative quick operation
fentanyl 1-2 mcg/kg; IV tylenol 10-15 mg/kg
dexamethasone 0.5-1 mg/kg; zofran 0.1 mg/kg
dexmedetomidine 0.1-0.5 mcg/kg IV
Describe the cold steel method
more pain and increased chance of hemorrhage
Electro-dissection uses
heat of cautery
causes more lateral thermal damage and hence more pain in the postop period
Describe the use of the microdebrider
associated with less M&M than other techniques due to less blood loss & less pain
Describe the use of coblation.
provides dissection, cautery, suction, and hemostasis in the same machine
Be cautious to administer opioids for a restless child as it may indicate
airway compromise or hypoxia
Describe T&A emergence.
high risk of laryngospasm, aspiration, and airway reactivity- OG to empty the stomach reduces incidence of emesis
considerations for deep vs. awake extubation (ability to protect airway)
cough can increase bleeding, use of careful soft-suction
“recovery position”- on one side with head slightly down- allows blood to drain away from vocal cords
Complaints of _____ especially in the setting of potent antiemetic therapy should raise a suspicion of tonsil/adenoidal bleed
abdominal pain
EBL for T&As may be
difficult to assess due to occult pooling in the stomach
For the bleeding tonsil,
bleeding may be occult (swallowed) and is an emergency
Ensure adequate IV access** (PIVx2), IO
H&H, T&C*, coag studies
considered a full-stomach emergency requiring RSI
-adequate preoxygenation
-propofol or ketamine followed by succinylcholine 2 mg/kg IV
potential for difficulty obtaining secure airway
OG to empty stomach
Hypovolemia requiring vigorous resuscitation
potential for hemodynamic instability on induction
Describe primary vs. secondary hemorrhage for the bleeding tonsil
- 2-2.2% “primary hemorrhage” occurs within 24 hours
0. 1%-3% “secondary hemorrhage” occurs >24 hours (5-10 days)
Chronic otitis media is common in young children ad can lead to
hearing loss and formation of cholesteatoma
Describe considerations for myringotomy & tympanostomy.
often have URI
short operative time
PO midazolam may outlast procedure/ consider PO acetaminophen
often mask-only anesthetic
IV placed if another procedure is also being done
D/C sevoflurane during 2nd side
Spina bifida is the
Failure of the neural tube to close resulting in herniation of the spinal cord and meninges through a defect
Meningocele
only contains meninges
Myelomeningocele
contain meninges & neural elements
Hydrocephalus is a
condition in which excess cerebrospinal fluid (CSF) builds up within the fluid-containing cavities or ventricles of the brain
The most common CNS defect that occurs during the first month of gestation is
myelodysplasia
Risk factors for myelodysplasia include
folate deficiency & chromosomal abnormalities
Myelodysplasia occurs most frequently in the
lumbosacral region
Myelodysplasia is considered an
urgent repair required within 24-48 hours due to risk of infection or worsening cord function
_______ is often present with myelodysplasia
hydrocephalus; and paralysis may occur below the lesion
Preoperative considerations for the myelodysplasia repair includes
assess level of lesion and degree of deficit
review of systems & rule out additional congenital anomalies
CBC, T&S
Intraoperative considerations for the myelodysplasia repair includes
routine monitors, may use intraoperative nerve monitoring
induce with inhalation or IV
potential for blood loss if it is large defect
prone to hypothermia
latex free environment
positioning-
supine & intubate on “sterile donut” ring
lateral- induce & intubate if large defect
prone for the surgical procedure
Postoperative considerations for the myelodysplasia repair includes
goal is to extubate
assess the need for postoperative apnea monitoring
Hydrocephalus may be caused by
a congenital defect (Arnold-Chiari, aqueduct stenosis) or by acquired disease (trauma, infection, tumor)
Shunts can be
ventriculoscopy- cranial burr holes
VP shunt- lateral ventricle to peritoneum
Ventriculo-atrial shunt- typically d/t abdominal pathology
Third ventriculostomy- burr hole in 3rd ventricle
Neurosurgery hydrocephalus positioning is
position is supine with head turned, table 90-180 degrees
incision is small frontal or parietal-occipital
Preoperative considerations for CSF shunt creation includes
assess baseline neurological status & ICP
avoid premeds if ICP is increased
assess for vomiting history & dehydration
routine H&P
if the child has had repeated shunt revisions- review previous anesthesia records for any problems with airway or IV access
IV x 1-2
Induction considerations for CSF shunt creation includes
standard monitors propofol, fentanyl, rocuronium isoflurane or sevoflurane GETA protect & pad eyes antibiotics: cefazolin 30 mg/kg IV
Maintenance anesthesia for VP shunt includes
hyperventilation is undesirable because it may make cannulation of the ventricle more difficult
maintain paralysis or propofol bolus when tunneling
VA shunts: be cautious of air embolism/PPV while the vein is open
Describe emergence anesthesia for VP shunts.
reversal of paralytic antiemetics extubate fully awake to permit for rapid neurological assessment postop- floor, step-down, or ICu
The three types of humerus fractures include
proximal- break in the upper part near the shoulder
mid-shaft- break in the middle
distal- near the elbow
Describe neuromuscular versus idiopathic scoliosis.
idiopathic (no definite cause) most common form of the condition, and it mainly affects adolescent girls
neuromuscular is caused by conditions of muscle weakness or spasticity (such as cerebral palsy, muscular dystrophy, and spinal cord injury) and is associated with greater blood loss
_______ are the most common elbow fracture in children
supracondylar fractures
-results from falling with an outstretched hand & extended elbow
Complications of limb fractures include
compartment syndrome
nerve palsies
late deformities
Anesthesia for humerus fracture includes
supine with table turned 90
GETA
assess NPO status & full stomach*** precautions requiring an IV & RSI
30-60 minutes for pinning
30-90 minutes for open reduction
timing of emergence if cast or splint is placed after closing
Posterior spinal instrumentation is recommended for patients whose curves are
greater than 45 degrees while still growing or are continuing to progress greater than 45 degrees when growth stopped
The goal of surgical treatment for posterior spinal instrumentation is
prevent curve progression
obtain some curve correction
The hospital stay for posterior spinal instrumentation is
generally between 3 and 6 days
Describe positioning indications for posterior spinal instrumentation.
prone position
-extra care in securing the ETT, tongue & eye protection
There is a potential for ______ in posterior spinal instrumentation.
significant blood loss
- hypotensive technique on dissection- careful to maintain within 20% baseline
- use of TXA, cell saver, autologous blood & hemo-dilution techniques may be used
Preoperative considerations for posterior spinal instrumentation include
standard pediatric preop evaluation
starting CBC, coagulation, BMP, HCG in female patients
comorbidities
T&C/set-up 2 PRBCs, cell-saver
discuss with the team the nerve monitoring goals and use of paralytics
prepare the patient and family for puffy face from prone position
Patients with neuromuscular scoliosis may be
more sensitive & require postop ventilation secondary to muscle weakness*****
-succinylcholine may cause severe rhabdomyolysis with hyperkalemia
Case set up for posterior spinal instrumentation includes
cell saver, fluid warmer, & blood tubing
aline & PIV x 2 (consider central line if difficult access)
prepare for prone position with superman arms on spine table- consider EKG placement posteriorly, prone pillow, spinal underbody bair hugger
eye lubricant with eye tape of choice, bilateral soft bite blocks
standard airway, induction meds, BIS, cerebral ox, emergency meds & OG
ensure room temp is increased prior to bringing patient into OR
Describe the how medications affect evoked potential monitoring.
dexmedetomidine & opioids are compatible
N2O & inhalation agents are avoided
ketamine enhances amplitude
propofol decreases amplitude
Complications of posterior spinal instrumentation includes
spinal cord ischemia massive blood loss embolism accidental extubation corneal abrasion visual loss neurological sequel with loss of SSEPs or MEPs
Postoperative considerations for posterior spinal instrumentation include
plan for extubation if possible chest XR may be obtained at end- ensure that surgeon has reviewed XR prior to extubation Pain score 7-9--> hydromorphone PCA ICU or step down LOS 2-6 days
Laparoscopic nissen fundoplication is a minimally invasive procedure which is done to restore
the function of the lower esophageal sphincter by wrapping the stomach around the esophagus
Infantile hypertrophic pyloric stenosis is the
thickening or swelling of the pylorus that causes severe and forceful vomiting in the first few months of life
blocks stomach contents from moving into the intestine
Describe the anesthetic considerations for a issen.
GA/ETT
often laparoscopic- insufflation
not associated with large blood loss, fluids shifts, or pain
positioning of the bougie within the esophagus and insufflation via the gastric tube to ensure no leaks at the anastomosis
Hypertrophic pyloric stenosis is a
palpable obstructive lesion- “olive shaped” enlargement of pylorus
usually diagnosed between 2-12 weeks of life
Clinical presentation of hypertrophic pyloric stenosis is
postprandial projectile emesis, palpable pylorus, visible peristaltic waves
Surgery for hypertrophic pyloric stenosis is
“semi-elective”- urgent but must be medically managed first
dehydration, electrolytes, and acid-base
Persistent vomiting from pyloric stenosis leads to
depletion of sodium, potassium, chloride & hydrogen ions causing
hypochloremic metabolic alkalosis***
The body responds to hypochloremic metabolic alkalosis by
kidneys attempt to compensate by excreting sodium bicrab
hyponatremia/dehydration worse, & kidneys attempt to conserve sodium at the expense of hydrogen
because lactate is metabolized to bicarbonate, LR should be avoided
Anesthesia for pyloric stenosis includes
prior to induction- MUST suction stomach with OG- tilt the baby in various directions to remove all contents
High aspiration risk: RSI with cricoid pressure pre-oxygenate–> propofol–> succinylcholine/rocuronium
cuffed ETT
quick procedure
extubate awake
Hypospadias is a condition in whcih
the opening of the urethra is on the underside of the penis instead of at the tip
Considerations for circumcision include
neonates to adults
local, regional, GA
indications: phimosis, recurrent balanitis, parental preference
approx 1 hour, involves cutting the foreskin & cauterizing & suturing the skin edges
most common complication is bleeding
Hypospadias considerations include
1-4 hours+
GA- LMA or ETT
regional is controversial due to concerns for venous pooling and poor outcomes
Benefits of caudal anesthesia include
intraoperative & postop analgesia
reduction in systemic opioid requirements & side effects
reduction in anesthesia requirements
Procedures in which caudal anesthesia is used includes
circumcision inguinal herniorrhaphy hypospadias anal surgery clubfoot repair other subumbilical procedures
Contraindications to caudal anesthesia includes
infection around the site, coagulopathy, anatomic abnormalities, parental refusal
A cleft refers to
an opening or space; can occur in the lips, palate or gum ridge
Cleft palate & lip may be repaired in
stages
- cleft lip usually at 10-12 weeks
- cleft palate 12-18 months
- alveolar bone graft
- pharyngoplasty 5-15 years
Cleft palates may result in
difficulty feeding, malnutrition, speech development, & congenital heart defects
Anesthetic considerations for cleft palates include
routine induction
oral RAE with flexible connector
airway can be difficult
mouth gag- reassess breath sounds once positioned
no air bubbles
coagulopathy may cause signficant bleeding. blood loss is usually insignificant
LA with epi reduces blood loss and provides some analgesia
protect eyes
secretions and blood - clear airway on emergence
possibility of airway & tongue edema
extubate once return of protective airway reflexes
protect surgical site from child’s manipulation- “no-no’s”
