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
