Anesthetics for Common Pediatric Procedures Flashcards
explanation of tonsillectomy and adenoidectomy procedure (T&A)
chronic inflammation and hypertrophy of lymphoid tissue in the pharynx may necessitate surgery to relieve obstruction or to remove the focus of infection
explanation of bilateral myringotomy and tympanoplasty procedure
myringotomy creates an opening in tympanic membrane through which fluid can drain
placement of ventilation tube (tympanoplasty) with lumen is frequently also performed.
alleviates pressure from middle ear and serves as a stent allowing continued drainage until tubes are naturally extruded in 6 months to a year
indications for tonsillectomy: most common
OSA (80%), infection (20%)
considerations for admission post tonsillectomy
<3 years old abnormal bleeding tendencies significant OSA airway abnormalities other systemic diseases those living in excessive distance
tonsillectomy 2011 evidence based clinical practice guideline for optimization of perioperative management includes
strong recommendation for single intraoperative IV dexamethasone .5mg/kg
strong recommendation against routine administration of perioperative antibiotics
recommendation to advocate for pain management however avoid codeine and ketorlac.
why avoid codeine in pedes?
substantial genetic variation in metabolism (CYP450 and CYP2D6) of codeine into morphine, causing cases of breathing problems
T&A induction considerations
standard with oral RAE or reinforced ETT. cuffed with 20cmH2O aw pressure. LMA possible. secure midline
muscle relaxants ok but often a relatively quick operation
T&A table turned
45-90 degrees
T&A mouth gag
requires adequate depth of anesthesia
reevaluate airway after placement to ensure no dislodgment of ETT or LMA
throat pack
(metal thing that holds mouth open)
T&A analgesic management can include
fentanyl 1-2mcg/kg IV tylenol 10-15mg/kg IV dexamethasone .5-1mg.kg zofran .1mg/kg dexmedetomidine .1-.5mcg/kg IV consider ketorlac/ibuprufen administration post resection?
cold steel tonsillectomy method
stainless steel scissors and scalpels, toothed forceps and herds dissector/retractor are used to dissect the whole tonsil tissue from its capsule. exposes underlying constrictor muscle and hence more pain and more chance of hemorrhage!!! old school method not used much anymore.
electro dissection tonsillectomy method
mono polar or bipolar dissection of whole tonsil. head of cautery can reach 300-400 degrees to induce hemostasis, causes more lateral thermal damage and hence more pain and discomfort in the postoperative period.
kinetic energy heats intracellular and extracellular fluids and ruptures localized tissue
microdebrider tonsillectomy method
soft tissue shaver. 90-95% of tonsilar tissue is removed. natural, biological dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. associated with less M&M than the other techniques. less blood loss, less pain.
coblation-cold ablation tonsillectomy method
introduced in 1998, energy is used in plasma field to break molecular bonds to excise or dissolve soft tissue at at a temperature of 40-70 degrees celsius and hence maintain integrity of the surrounding tissue. provides dissection, cautery, suction, and hemostasis in the same machine. it is quick, precise, and a smooth procedure.
radio frequency tonsillectomy method
cost effective, easy to use, time saving alternative to laser tonsillectomy. mono polar radio frequency energy is transferred by inserting probe into tonsil tissue in three or four sittings. ultimately produce scarring of tonsil tissue and thus reduce the size
laser tonsillectomy method
CO2 laser and KTP lasers can be used. less bleeding, less pain, discomfort, and is a day procedure. but more secondary hemorrhage and post operative pain have been noted with laser.
T&A emergence considerations
high risk fo laryngospasm, aspiration, and airway reactivity.
OG to empty stomach reduces incidence of emesis.
consideration for deep v awake extubation
coughing 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
be cautious to administer opioids for a restless child as it may indicate airway compromise or hypoxia
T&A and EBL
may be difficult to assess due to occult pooling in stomach
bleeding tonsils: emergency
ensure adequate IV access (PIVx2, IO)
hypovolemia requiring vigorous resuscitation
potential for hemodynamic instability on induction
H&H, T&C, coagulation studies
RSI based on full stomach, try to adequately preoxygenate. propofol or ketamine followed by 2mg/kg succinylcholine IV
potentially difficult AW securing
OG to empty stomach
BMT indications
chronic otitis media, can lead to hearing loss and formation of cholesteatoma
BMT procedure considerations
kids often have URI
short OR time, PO midazolam may outlast procedure
consider PR acute
often mask only anesthetic
IV placed if another procedure is being done like a cleft palate repair
d/c sevoflurane during 2nd side
myelodisplasia aka spina bifida definition
failure of neural tube to close resulting in herniation of the spinal cord and meninges through a defect
meningocele definition
only contains meninges
myelominingocele definition
contains meninges and neural elements
hydrocephalus definition
condition in which excess CSF builds up within the fluid containing cavities or ventricles of the brain.
myelodisplasia neurosurgery: commonality, what else is present, timeline for repair
most common CNS defect that occurs during the first month of gestation.
hydrocephalus is also present and paralysis may occur below lesion
urgent repair required within 24-48 hours due to risk of infection or worsening cord function
myelodisplasia defect risk factors and where its most commonly located
risk factors: folate deficiency, chromosomal abnormalities
most common in lumbosacral region
if hydrocephalus is also present with myelodisplasia, what may need to happen?
VP shunt will be necessary if arnold chiari malformation is present (hindbrain displaced downward into the foramen magnum, resulting in hydrocephalus)
anesthesia for myelodisplasia repair: preoperatively
assess level of lesion and degree of deficit
review systems and rule out additional congenital anomalies
CBC, T&S
anesthesia for myelodisplasia repair: induction and intraoperative considerations
(what are they prone to? OR environmental consideration?)
routine monitors, may use intraoperative nerve monitoring (avoid muscle relaxation if motor evoked potential monitoring is utilized)
positioning: supine with sterile donut, lateral if large defect, prone for procedure
induce with inhalation or IV
potential for blood loss if it is large deficit
prone to hypothermia
latex free environment
anesthesia for myelodisplasia repair: postoperative
goal is to extubatne
assess need for postop apnea monitoring
what may be the cause of hydrocephalus
congenital defect like arnold chiari aqueduct stenosis) or by acquired disease (trauma, infection, tumor)
ventriculoscopy for hydrocephalus neurosurgery
use of fiber optic scope through cranial burrr holes to visualize lateral, third, and occasional fourth ventricle. alternatively, shunts may be positioned under ultrasound guidance
ventriculo-peritoneal (VP) shunt for hydrocephalus neurosurgery placement
lateral ventricle to peritoneum is most common placement and allows room for growth
ventriculo-atrial (VA) shunt for hydrocephalus neurosurgery placement
lateral ventricle to right atrium
endoscopic third ventriculostomy (ETV) for hydrocephalus neurosurgery placement
burr hole created in floor of the 3rd ventricle allowing CSF to flow directly into the basal cisterns
incision and positioning for hydrocephalus neurosurgery
incision is small, frontal or partietal to occipital.
position is supine with head turned and table 90-180 degrees.
anesthesia for creation of CSF shunts: preoperatively
assess baseline neurological status and ICP
avoid premeds if ICP is increased
assess for vomiting history and dehydration
routine H&P
if the child has had repeated shunt revisions, review previous anesthesia records for any problems with airway or IV access
IVx1-2
anesthesia for creation of CSF shunts: induction
standard monitors propofol, fentanyl, rocuronium isoflurane or sevoflurrane GETA protect and pad eyes abx: cefazolin 30mg/kg IV
anesthesia for creation of CSF shunts: maintenance
hyperventilation is undesirable because it may make cannulation fo the ventricle more difficult
maintain paralysis or propofol bolus when tunneling
what to be cautious of for specifically VA shunts:
caution of air embolism/PPV while vein is open
anesthesia for creation of CSF shunts: emergence
reversal of paralytic
antiemetics
extubate
fully awake to permit for rapid neurological assessment
anesthesia for creation of CSF shunts: postoperative disposition
floor, step down, or ICU
humerus fracture and 3 types
long bone of upper arm
proximal: break in upper part of humerus near shoulder
mid shaft: break in middle
distal: occurs near elbow. usually a part of a more complex elbow injury and sometimes involves loose bone fragments
scoliosis etiology can be either (2)
idiopathic (most common, mainly affects adolescent girls)
neuromuscular (conditions of muscle weakness or spasticity is cause such as CP, MD, SCI. associated with greater blood loss)
which elbow fracture in children is most common
supracondylar fractures of the humerus. results from falling with outstretched hand and extended elbow
complications of supracondylar fractures of the humerus include
compartment syndrome
nerve palsies
late deformities
anesthesia for humerus fracture: positioning, type of anesthetic, assessment considerations, emergence considerations
supine with table turned 90 degrees
GETA
assess NPO status and full stomach precautious requiring IV and RSI
timing of emergence if cast or splint is placed after closing
anesthesia for humerus fracture: estimated length of surgery
30-60 minutes for pinning
30-90 minutes for open reduction
posterior spinal instrumentation: when is surgical treatment recommended?
when curves are greater than 45 degrees while still growing or are continuing to progress greater than 45 degrees when growth stopped
posterior spinal fusion for scoliosis goal of surgical treatment is two fold
- prevent curve progression
2. obtain curve correction
describe posterior spinal fusion procedure for scoliosis
utilizes metal implants that are attached to the spine, and then connected to a single rod or two rods. posterior versus anterior approach (may require one lung ventilation). no external braces or casts are utilized
LOS for postop posterior spinal fusion patients for scoliosis treatment and floor disposition type
3-6 days, step down or ICU postop.
posterior spinal fusion positioning, duration, monitoring
positioning: prone. extra care in positioning ett. tongue and eye protection.
6+ hour surgery
intraoperative neuro monitoring may be utilized with possible wake up test
posterior spinal fusion for scoliosis and blood loss
potential for significant blood loss. can utilize hypotensive technique on dissection (while still maintaining within 2-% of baseline). can use TXA, cell saver, autologous blood and hemp dilution techniques.
posterior spinal fusion for scoliosis: preoperative
standard pediatric preoperative evaluation
starting CBC, coagulation, BMP, HCG in female patients
comorrbidities
T&C, set up 2 PRBC’s and cell saver
discuss with the team the nerve monitoring goals and use of paralytics
prepare patient and family for puffy face after prone position
restrictive vital capacity % and implications
<70% predicted respiratory reserve is adequate
<40% predicted postop ventilation may be required
neuromuscular scoliosis and respiratory function/succinylcholine
with neuromuscular etiology, may be more sensitive to requiring postoperative ventilation related to muscle weakness
succinylcholine may cause severe rhabdomyolysis with hyperkalemia
posterior spinal fusion for scoliosis: case set up
cell saver, fluid warmer, blood tubing
aline, PIVx2, consider CVC if difficult access
prepare for prone position with superman arms
spinal underbody bair hugger
eye lubricant with tape, soft bite blocks
standard AW, induction meds, BIS, cerebral oximeter, emergency meds and OG
ensure room temperature is increased prior to bringing patient into OR
evoked potential monitoring and dexmedetomidine/opioids
compatible with MEP, SSEP, EMG monitoring. low dose dex does not effect MEP’s/SSEP’s but may in high doses. keep
evoked potential monitoring and N2O/inhalationals
avoid for MEP, SSEP, EMG
evoked potential monitoring and ketamine
enhances SSEP and MEP amplitude, if ketamine is given as a bolus our discontinued as an infusion IOM team should be informed
evoked potential monitoring and propofol
in high doses (>130-150mcg/kg/min) will increase latency and decrease amplitude of EP’s
complications of posterior spinal fusion for scoliosis
spinal cord ischemia massive blood loss embolism accidental extubation corneal abrasion visual loss neurological sequela with loss of SSEP/MEP
posterior spinal fusion for scoliosis postoperative considerations
plan for extubation if possible
CXR may be obtained at end of procedure with patient supine on inpatient bed. ensure that surgeon has reviewed CXR prior to extubation
pain score 7-9: hydromorphone PCA
explanation of nissan laparoscopic fundoplication
minimally invasive procedure which is done to restore the function of the lower esophageal sphincter (valve between esophagus and stomach) by wrapping stomach around esophagus
-involves mobilizing muscles around esophagus at the level of LES
explanation of infantile hypertrophic pyloric stenosis
thickening or swelling of pylorus-muscle between stomach and intestines-that causes severe and forceful vomiting in the first few months of life. enlargement of the pylorus causes a narrowing (stenosis) of the opening from the stomach to the intestines which blocks stomach contents from moving into the intestine
-palpable obstructive lesion, olive shaped enlargement of pylorus
when is a nissan fundoplication indicated for children
gastric reflux that failed medical management
nissen fundoplication anesthetic and surgical technique
GETT, often laparoscopic
nissen fundoplication and blood loss, fluid shifts, pain
not associated with large blood loss, fluid shifts, or pain
nissen fundoplication intraoperative consideration to ensure no leaks in anastomosis
positioning of bougie within esophagus and insufflation via gastric tube to ensure no leaks
when is hypertrophic pyloric stenosis usually diagnosed
2-12 weeks of life
what is the clinical presentation of hypertrophic pyloric stenosis
postprandial projectile emesis, palpable pylorus, visible peristaltic waves
what is the surgical correction for hypertrophic pyloric stenosis
pylorotomy
how quickly does this hypertrophic pyloric stenosis surgery need to occur
semi elective to urgent, must be medically managed first due to their dehydration, electrolyte, and acid base derangements.
symptoms of pyloric stenosis and subsequent metabolic derangement
persistent vomiting depletes Na/K/Cl- and H+ ions causing hypochloremic metabolic alkalosis
how do the kidneys attempt to compensate for hyperchloremic metabolic alkalosis related to symptoms of pyloric stenosis
kidneys attempt to compensate by excreting sodium bicarbonate
hyponatremia/dehydration worsen, and kidneys attempt to conserve sodium at the expense of hydrogen
because lactate is metabolized to bicarbonate, LR should be avoided
anesthesia for pyloric stenosis
prior to induction, must suction stomach with OG. (tilt baby in various directions to remove all contents)
RSI with cricoid pressure, propofol, succ/roc
cuffed ETT
quick procedure
extubate awake
definition of circumcision procedure
most common procedure. foreskin is opened, adhesions are removed, forerskin is separated from glans
explanation of hypospadias procedure
condition in which the opening of the urethra is on the underside of the penis instead of the tip
location of the opening can vary and can be anywhere from underneath the tip of the penis (more common) to the base of the penis (less common)
circumcision population age, type of anesthesia, length of curgery
neonates to adults
local, regional, or GA (grown man cant watch this ish)
approx 1 hour to cutting foreskin cauterizing, suturing edges
circumcision indications
phimosis, recurrent balantis, parental preference
most common complication of circumision
bleeding
hypospadias length of surgery and anesthetic technique
1-4hours or +
GA-LMA or ETT. regional is controversial (concern for venous pooling and poor outcomes)
how a cleft palate occurs and where it can be located
can occur at one of more different places on face such as lips, palate, or gum ridge (alveolus)
right and left sides of face fuse near midline. cleft results when fusion does not properly occur
cleft palate and lip stages of repair
cleft lip usually 10-12 weeks
cleft palate 12-18 months
alveolar bone graft
pharyngoplasty 5-15 years
cleft palate is associated with
difficulty feeding, malnutrition, speech development and congenital heart defects.
cleft palate induction
routine
cleft palate airway considerations
oral RAE with flexible connector
AW can be difficult with or without syndrome
mouth gag-reassess breath sounds once positioned
no air bubbles
possible AW and tongue edema
extubate once return of protective aw reflexes
protect eyes
secretions and blood-clear airway on emergence
cleft palate anesthetic considerations: coagulopathy and how to reduce blood loss
may cause significant bleeding. blood loss usually insignificant but occasionally may require transfusion
LA with epinephrine reduces blood loss and provides some analgesia
