Anesthetics for common pediatric procedures

Question 1

Otorhinolaryngology is a

Answer 1

surgical subspecialty that deals with the surgical and medical management of conditions of the head & neck

Question 2

Tonsillectomy and adenoidectomy may be required due to

Answer 2

chronic inflammation and hypertrophy of lymphoid tissue in the pharynx may necessitate surgery to relieve obstruction or to remove the focus of infection

Question 3

Bilateral myringotomy and tympanostomy is when

Answer 3

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

Question 4

The main symptoms of tonsillitis are

Answer 4

inflammation and swelling of the tonsils, sometimes severe enough to cause respiratory obstruction

Question 5

The most common indication for T&A in North America is

Answer 5

OSA
may lead to chronic airway obstruction, carbon dioxide retention, cor pulmonale, failure to thrive, and speech abnormalities

Question 6

Considerations for admission for tonsillectomy include

Answer 6

<3 years old
abnormal bleeding tendencies 
significant OSA
airway abnormalities
other systemic diseases
those living an excessive distance

Question 7

Guideline for optimization of perioperative management includes:

Answer 7

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

Question 8

Why is codeine avoided in pediatrics?

Answer 8

active metabolite is morphine which causes sustained respiratory issues

Question 9

Describe standard induction for T&A.

Answer 9

Oral RAE (may consider reinforced)- cuffed ETT with 20 cmH2O airway pressure
LMA
secure midline
Table turned 45-90 degrees

Question 10

Describe the use of a mouth gag in T&A.

Answer 10

requires adequate depth of anesthesia
reevaluate airway after placement to ensure no dislodgement of ETT or LMA
throat pack

Question 11

Describe analgesic management for T&A.

Answer 11

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

Question 12

Describe the cold steel method

Answer 12

more pain and increased chance of hemorrhage

Question 13

Electro-dissection uses

Answer 13

heat of cautery

causes more lateral thermal damage and hence more pain in the postop period

Question 14

Describe the use of the microdebrider

Answer 14

associated with less M&M than other techniques due to less blood loss & less pain

Question 15

Describe the use of coblation.

Answer 15

provides dissection, cautery, suction, and hemostasis in the same machine

Question 16

Be cautious to administer opioids for a restless child as it may indicate

Answer 16

airway compromise or hypoxia

Question 17

Describe T&A emergence.

Answer 17

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

Question 18

Complaints of _____ especially in the setting of potent antiemetic therapy should raise a suspicion of tonsil/adenoidal bleed

Answer 18

abdominal pain

Question 19

EBL for T&As may be

Answer 19

difficult to assess due to occult pooling in the stomach

Question 20

For the bleeding tonsil,

Answer 20

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

Question 21

Describe primary vs. secondary hemorrhage for the bleeding tonsil

Answer 21

0. 2-2.2% “primary hemorrhage” occurs within 24 hours

0. 1%-3% “secondary hemorrhage” occurs >24 hours (5-10 days)

Question 22

Chronic otitis media is common in young children ad can lead to

Answer 22

hearing loss and formation of cholesteatoma

Question 23

Describe considerations for myringotomy & tympanostomy.

Answer 23

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

Question 24

Spina bifida is the

Answer 24

Failure of the neural tube to close resulting in herniation of the spinal cord and meninges through a defect

Question 25

Meningocele

Answer 25

only contains meninges

Question 26

Myelomeningocele

Answer 26

contain meninges & neural elements

Question 27

Hydrocephalus is a

Answer 27

condition in which excess cerebrospinal fluid (CSF) builds up within the fluid-containing cavities or ventricles of the brain

Question 28

The most common CNS defect that occurs during the first month of gestation is

Answer 28

myelodysplasia

Question 29

Risk factors for myelodysplasia include

Answer 29

folate deficiency & chromosomal abnormalities

Question 30

Myelodysplasia occurs most frequently in the

Answer 30

lumbosacral region

Question 31

Myelodysplasia is considered an

Answer 31

urgent repair required within 24-48 hours due to risk of infection or worsening cord function

Question 32

_______ is often present with myelodysplasia

Answer 32

hydrocephalus; and paralysis may occur below the lesion

Question 33

Preoperative considerations for the myelodysplasia repair includes

Answer 33

assess level of lesion and degree of deficit review of systems & rule out additional congenital anomalies CBC, T&S

Question 34

Intraoperative considerations for the myelodysplasia repair includes

Answer 34

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

Question 35

Postoperative considerations for the myelodysplasia repair includes

Answer 35

goal is to extubate | assess the need for postoperative apnea monitoring

Question 36

Hydrocephalus may be caused by

Answer 36

a congenital defect (Arnold-Chiari, aqueduct stenosis) or by acquired disease (trauma, infection, tumor)

Question 37

Shunts can be

Answer 37

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

Question 38

Neurosurgery hydrocephalus positioning is

Answer 38

position is supine with head turned, table 90-180 degrees | incision is small frontal or parietal-occipital

Question 39

Preoperative considerations for CSF shunt creation includes

Answer 39

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

Question 40

Induction considerations for CSF shunt creation includes

Answer 40

``` standard monitors propofol, fentanyl, rocuronium isoflurane or sevoflurane GETA protect & pad eyes antibiotics: cefazolin 30 mg/kg IV ```

Question 41

Maintenance anesthesia for VP shunt includes

Answer 41

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

Question 42

Describe emergence anesthesia for VP shunts.

Answer 42

``` reversal of paralytic antiemetics extubate fully awake to permit for rapid neurological assessment postop- floor, step-down, or ICu ```

Question 43

The three types of humerus fractures include

Answer 43

proximal- break in the upper part near the shoulder mid-shaft- break in the middle distal- near the elbow

Question 44

Describe neuromuscular versus idiopathic scoliosis.

Answer 44

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

Question 45

_______ are the most common elbow fracture in children

Answer 45

supracondylar fractures | -results from falling with an outstretched hand & extended elbow

Question 46

Complications of limb fractures include

Answer 46

compartment syndrome nerve palsies late deformities

Question 47

Anesthesia for humerus fracture includes

Answer 47

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

Question 48

Posterior spinal instrumentation is recommended for patients whose curves are

Answer 48

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

Question 49

The goal of surgical treatment for posterior spinal instrumentation is

Answer 49

prevent curve progression | obtain some curve correction

Question 50

The hospital stay for posterior spinal instrumentation is

Answer 50

generally between 3 and 6 days

Question 51

Describe positioning indications for posterior spinal instrumentation.

Answer 51

prone position | -extra care in securing the ETT, tongue & eye protection

Question 52

There is a potential for ______ in posterior spinal instrumentation.

Answer 52

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

Question 53

Preoperative considerations for posterior spinal instrumentation include

Answer 53

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

Question 54

Patients with neuromuscular scoliosis may be

Answer 54

more sensitive & require postop ventilation secondary to muscle weakness***** -succinylcholine may cause severe rhabdomyolysis with hyperkalemia

Question 55

Case set up for posterior spinal instrumentation includes

Answer 55

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

Question 56

Describe the how medications affect evoked potential monitoring.

Answer 56

dexmedetomidine & opioids are compatible N2O & inhalation agents are avoided ketamine enhances amplitude propofol decreases amplitude

Question 57

Complications of posterior spinal instrumentation includes

Answer 57

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

Question 58

Postoperative considerations for posterior spinal instrumentation include

Answer 58

``` 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 ```

Question 59

Laparoscopic nissen fundoplication is a minimally invasive procedure which is done to restore

Answer 59

the function of the lower esophageal sphincter by wrapping the stomach around the esophagus

Question 60

Infantile hypertrophic pyloric stenosis is the

Answer 60

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

Question 61

Describe the anesthetic considerations for a issen.

Answer 61

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

Question 62

Hypertrophic pyloric stenosis is a

Answer 62

palpable obstructive lesion- "olive shaped" enlargement of pylorus usually diagnosed between 2-12 weeks of life

Question 63

Clinical presentation of hypertrophic pyloric stenosis is

Answer 63

postprandial projectile emesis, palpable pylorus, visible peristaltic waves

Question 64

Surgery for hypertrophic pyloric stenosis is

Answer 64

"semi-elective"- urgent but must be medically managed first | dehydration, electrolytes, and acid-base

Question 65

Persistent vomiting from pyloric stenosis leads to

Answer 65

depletion of sodium, potassium, chloride & hydrogen ions causing hypochloremic metabolic alkalosis***

Question 66

The body responds to hypochloremic metabolic alkalosis by

Answer 66

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

Question 67

Anesthesia for pyloric stenosis includes

Answer 67

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

Question 68

Hypospadias is a condition in whcih

Answer 68

the opening of the urethra is on the underside of the penis instead of at the tip

Question 69

Considerations for circumcision include

Answer 69

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

Question 70

Hypospadias considerations include

Answer 70

1-4 hours+ GA- LMA or ETT regional is controversial due to concerns for venous pooling and poor outcomes

Question 71

Benefits of caudal anesthesia include

Answer 71

intraoperative & postop analgesia reduction in systemic opioid requirements & side effects reduction in anesthesia requirements

Question 72

Procedures in which caudal anesthesia is used includes

Answer 72

``` circumcision inguinal herniorrhaphy hypospadias anal surgery clubfoot repair other subumbilical procedures ```

Question 73

Contraindications to caudal anesthesia includes

Answer 73

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

Question 74

A cleft refers to

Answer 74

an opening or space; can occur in the lips, palate or gum ridge

Question 75

Cleft palate & lip may be repaired in

Answer 75

stages - cleft lip usually at 10-12 weeks - cleft palate 12-18 months - alveolar bone graft - pharyngoplasty 5-15 years

Question 76

Cleft palates may result in

Answer 76

difficulty feeding, malnutrition, speech development, & congenital heart defects

Question 77

Anesthetic considerations for cleft palates include

Answer 77

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"