Anesthetics for Common Pediatric Procedures

Question 1

explanation of tonsillectomy and adenoidectomy procedure (T&A)

Answer 1

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

Question 2

explanation of bilateral myringotomy and tympanoplasty procedure

Answer 2

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

Question 3

indications for tonsillectomy: most common

Answer 3

OSA (80%), infection (20%)

Question 4

considerations for admission post tonsillectomy

Answer 4

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

Question 5

tonsillectomy 2011 evidence based clinical practice guideline for optimization of perioperative management includes

Answer 5

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.

Question 6

why avoid codeine in pedes?

Answer 6

substantial genetic variation in metabolism (CYP450 and CYP2D6) of codeine into morphine, causing cases of breathing problems

Question 7

T&A induction considerations

Answer 7

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

Question 8

T&A table turned

Answer 8

45-90 degrees

Question 9

T&A mouth gag

Answer 9

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)

Question 10

T&A analgesic management can include

Answer 10

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?

Question 11

cold steel tonsillectomy method

Answer 11

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.

Question 12

electro dissection tonsillectomy method

Answer 12

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

Question 13

microdebrider tonsillectomy method

Answer 13

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.

Question 14

coblation-cold ablation tonsillectomy method

Answer 14

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.

Question 15

radio frequency tonsillectomy method

Answer 15

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

Question 16

laser tonsillectomy method

Answer 16

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.

Question 17

T&A emergence considerations

Answer 17

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

Question 18

T&A and EBL

Answer 18

may be difficult to assess due to occult pooling in stomach

Question 19

bleeding tonsils: emergency

Answer 19

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

Question 20

BMT indications

Answer 20

chronic otitis media, can lead to hearing loss and formation of cholesteatoma

Question 21

BMT procedure considerations

Answer 21

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

Question 22

myelodisplasia aka spina bifida definition

Answer 22

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

Question 23

meningocele definition

Answer 23

only contains meninges

Question 24

myelominingocele definition

Answer 24

contains meninges and neural elements

Question 25

hydrocephalus definition

Answer 25

condition in which excess CSF builds up within the fluid containing cavities or ventricles of the brain.

Question 26

myelodisplasia neurosurgery: commonality, what else is present, timeline for repair

Answer 26

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

Question 27

myelodisplasia defect risk factors and where its most commonly located

Answer 27

risk factors: folate deficiency, chromosomal abnormalities | most common in lumbosacral region

Question 28

if hydrocephalus is also present with myelodisplasia, what may need to happen?

Answer 28

VP shunt will be necessary if arnold chiari malformation is present (hindbrain displaced downward into the foramen magnum, resulting in hydrocephalus)

Question 29

anesthesia for myelodisplasia repair: preoperatively

Answer 29

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

Question 30

anesthesia for myelodisplasia repair: induction and intraoperative considerations (what are they prone to? OR environmental consideration?)

Answer 30

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

Question 31

anesthesia for myelodisplasia repair: postoperative

Answer 31

goal is to extubatne | assess need for postop apnea monitoring

Question 32

what may be the cause of hydrocephalus

Answer 32

congenital defect like arnold chiari aqueduct stenosis) or by acquired disease (trauma, infection, tumor)

Question 33

ventriculoscopy for hydrocephalus neurosurgery

Answer 33

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

Question 34

ventriculo-peritoneal (VP) shunt for hydrocephalus neurosurgery placement

Answer 34

lateral ventricle to peritoneum is most common placement and allows room for growth

Question 35

ventriculo-atrial (VA) shunt for hydrocephalus neurosurgery placement

Answer 35

lateral ventricle to right atrium

Question 36

endoscopic third ventriculostomy (ETV) for hydrocephalus neurosurgery placement

Answer 36

burr hole created in floor of the 3rd ventricle allowing CSF to flow directly into the basal cisterns

Question 37

incision and positioning for hydrocephalus neurosurgery

Answer 37

incision is small, frontal or partietal to occipital. | position is supine with head turned and table 90-180 degrees.

Question 38

anesthesia for creation of CSF shunts: preoperatively

Answer 38

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

Question 39

anesthesia for creation of CSF shunts: induction

Answer 39

``` standard monitors propofol, fentanyl, rocuronium isoflurane or sevoflurrane GETA protect and pad eyes abx: cefazolin 30mg/kg IV ```

Question 40

anesthesia for creation of CSF shunts: maintenance

Answer 40

hyperventilation is undesirable because it may make cannulation fo the ventricle more difficult maintain paralysis or propofol bolus when tunneling

Question 41

what to be cautious of for specifically VA shunts:

Answer 41

caution of air embolism/PPV while vein is open

Question 42

anesthesia for creation of CSF shunts: emergence

Answer 42

reversal of paralytic antiemetics extubate fully awake to permit for rapid neurological assessment

Question 43

anesthesia for creation of CSF shunts: postoperative disposition

Answer 43

floor, step down, or ICU

Question 44

humerus fracture and 3 types

Answer 44

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

Question 45

scoliosis etiology can be either (2)

Answer 45

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)

Question 46

which elbow fracture in children is most common

Answer 46

supracondylar fractures of the humerus. results from falling with outstretched hand and extended elbow

Question 47

complications of supracondylar fractures of the humerus include

Answer 47

compartment syndrome nerve palsies late deformities

Question 48

anesthesia for humerus fracture: positioning, type of anesthetic, assessment considerations, emergence considerations

Answer 48

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

Question 49

anesthesia for humerus fracture: estimated length of surgery

Answer 49

30-60 minutes for pinning | 30-90 minutes for open reduction

Question 50

posterior spinal instrumentation: when is surgical treatment recommended?

Answer 50

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

Question 51

posterior spinal fusion for scoliosis goal of surgical treatment is two fold

Answer 51

1. prevent curve progression | 2. obtain curve correction

Question 52

describe posterior spinal fusion procedure for scoliosis

Answer 52

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

Question 53

LOS for postop posterior spinal fusion patients for scoliosis treatment and floor disposition type

Answer 53

3-6 days, step down or ICU postop.

Question 54

posterior spinal fusion positioning, duration, monitoring

Answer 54

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

Question 55

posterior spinal fusion for scoliosis and blood loss

Answer 55

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.

Question 56

posterior spinal fusion for scoliosis: preoperative

Answer 56

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

Question 57

restrictive vital capacity % and implications

Answer 57

<70% predicted respiratory reserve is adequate | <40% predicted postop ventilation may be required

Question 58

neuromuscular scoliosis and respiratory function/succinylcholine

Answer 58

with neuromuscular etiology, may be more sensitive to requiring postoperative ventilation related to muscle weakness succinylcholine may cause severe rhabdomyolysis with hyperkalemia

Question 59

posterior spinal fusion for scoliosis: case set up

Answer 59

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

Question 60

evoked potential monitoring and dexmedetomidine/opioids

Answer 60

compatible with MEP, SSEP, EMG monitoring. low dose dex does not effect MEP's/SSEP's but may in high doses. keep

Question 61

evoked potential monitoring and N2O/inhalationals

Answer 61

avoid for MEP, SSEP, EMG

Question 62

evoked potential monitoring and ketamine

Answer 62

enhances SSEP and MEP amplitude, if ketamine is given as a bolus our discontinued as an infusion IOM team should be informed

Question 63

evoked potential monitoring and propofol

Answer 63

in high doses (>130-150mcg/kg/min) will increase latency and decrease amplitude of EP's

Question 64

complications of posterior spinal fusion for scoliosis

Answer 64

``` spinal cord ischemia massive blood loss embolism accidental extubation corneal abrasion visual loss neurological sequela with loss of SSEP/MEP ```

Question 65

posterior spinal fusion for scoliosis postoperative considerations

Answer 65

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

Question 66

explanation of nissan laparoscopic fundoplication

Answer 66

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

Question 67

explanation of infantile hypertrophic pyloric stenosis

Answer 67

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

Question 68

when is a nissan fundoplication indicated for children

Answer 68

gastric reflux that failed medical management

Question 69

nissen fundoplication anesthetic and surgical technique

Answer 69

GETT, often laparoscopic

Question 70

nissen fundoplication and blood loss, fluid shifts, pain

Answer 70

not associated with large blood loss, fluid shifts, or pain

Question 71

nissen fundoplication intraoperative consideration to ensure no leaks in anastomosis

Answer 71

positioning of bougie within esophagus and insufflation via gastric tube to ensure no leaks

Question 72

when is hypertrophic pyloric stenosis usually diagnosed

Answer 72

2-12 weeks of life

Question 73

what is the clinical presentation of hypertrophic pyloric stenosis

Answer 73

postprandial projectile emesis, palpable pylorus, visible peristaltic waves

Question 74

what is the surgical correction for hypertrophic pyloric stenosis

Answer 74

pylorotomy

Question 75

how quickly does this hypertrophic pyloric stenosis surgery need to occur

Answer 75

semi elective to urgent, must be medically managed first due to their dehydration, electrolyte, and acid base derangements.

Question 76

symptoms of pyloric stenosis and subsequent metabolic derangement

Answer 76

persistent vomiting depletes Na/K/Cl- and H+ ions causing hypochloremic metabolic alkalosis

Question 77

how do the kidneys attempt to compensate for hyperchloremic metabolic alkalosis related to symptoms of pyloric stenosis

Answer 77

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

Question 78

anesthesia for pyloric stenosis

Answer 78

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

Question 79

definition of circumcision procedure

Answer 79

most common procedure. foreskin is opened, adhesions are removed, forerskin is separated from glans

Question 80

explanation of hypospadias procedure

Answer 80

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)

Question 81

circumcision population age, type of anesthesia, length of curgery

Answer 81

neonates to adults local, regional, or GA (grown man cant watch this ish) approx 1 hour to cutting foreskin cauterizing, suturing edges

Question 82

circumcision indications

Answer 82

phimosis, recurrent balantis, parental preference

Question 83

most common complication of circumision

Answer 83

bleeding

Question 84

hypospadias length of surgery and anesthetic technique

Answer 84

1-4hours or + | GA-LMA or ETT. regional is controversial (concern for venous pooling and poor outcomes)

Question 85

how a cleft palate occurs and where it can be located

Answer 85

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

Question 86

cleft palate and lip stages of repair

Answer 86

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

Question 87

cleft palate is associated with

Answer 87

difficulty feeding, malnutrition, speech development and congenital heart defects.

Question 88

cleft palate induction

Answer 88

routine

Question 89

cleft palate airway considerations

Answer 89

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

Question 90

cleft palate anesthetic considerations: coagulopathy and how to reduce blood loss

Answer 90

may cause significant bleeding. blood loss usually insignificant but occasionally may require transfusion LA with epinephrine reduces blood loss and provides some analgesia