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
