Common Pediatric Procedures Flashcards
Tonsillectomy and Adenoidectomy
- chronic inflammation and hypertrophy of lymphoid tissue in the pharynx may necessitate surgery to relieve obstruction or to remove the focus of infection
- 3rd most common surgical procedure
- can be inpatient or outpatient
tonsillitis
- caused by strep or viral agents
- symptoms = inflammation and swelling of the tonsils, sometimes severe enough to cause respiratory obstruction
indications for tonsillectomy
- OSA is most common indication
- chronic recurrent tonsillitis
- hypertrophic tonsillitis with OSA
- unilateral hypertrophic tonsil
considerations for admission post T&A
- < 3 years old
- abnormal bleeding tendencies
- significant OSA
- airway abnormalities
- other systemic diseases
- those living an excessive distance
tonsillectomy periop management
- IV dexamethasone 0.5 mg/kg
- no abx admin
- good pain management but no codeine and maybe no ketorolac (talk to surgeon)
- standard induction with oral RAE tape in middle; can also use LMA
- table turned 45-90 degrees
- mouth gag -require adequate depth of anesthesia, ensure tube patentcy/placement after gag placed
- throat pack
- muscle relaxants OK, but often quick operation
why no codeine in kids?
genetic variation in activity of CYP450 enzyme CUP2D6 which metabolizes codeine into morphine (active metabolite)
analgesic management for T&A
- fentanyl 1-2 mcg/kg; 10-15 mg/kg IV
- dexmethasone 0.5-1 mg/kg; zofran 0.1 mg/kg
- precedex 0.1-0.5 mcg/kg IV
- consider toradol/ibuprofen admin post-resection
cold steel tonsillectomy method
- stainless steel scissors and scalpels, toothed forceps and herd’s dissector/retractor used to dissect whole tonsil tissue from its capsule
- exposes underlying constrictor muscles and hence more PAIN and more chances of hemorrhage
electro dissection tonsillectomy method
- monopolar or bipolar dissection of whole tonsil
- heat of cautery induces hemostasis
- lateral thermal damage = PAIN
microdebrider tonsillectomy method
- soft tissue shaver
- 90-95% tonsillar tissue removed (so it can grow back)
- associated with less M&M (less blood loss, less pain)
coblation tonsillectomy method
- cold ablation
- energy used in a plasma field to break the molecular bonds to excise or dissolve the soft tissue at a temperature of 40-70 degrees
- provides dissection, cautery, suction and hemostasis in the same machine
radiofrequency tonsillectomy method
- mono polar radio frequency used to remove tonsil
- cost-effective, easy to use, and time saving
laser tonsillectomy method
- CO2 laser and KTP lasers can be used
- less bleeding, less pain, discomfort and is a day procedure
- more secondary hemorrhage and post op pain noted with this method
T&A emergence
- high risk of laryngospasm, aspiration, airway reactivity (need OGT to empty stomach and reduce risk of emesis)
- considerations for deep vs awake extubation
- coughing can increase bleeding, use of careful soft-suction
- recovery position
- be cautious to admin opioids for a restless child as it may indicate airway compromise or hypoxia
recovery position for T&A
-on one side with head slightly down, allows blood to drain away from vocal cords
highest incidence of bleeding for T&A methods
cold steel
the bleeding tonsil… what to do!?
- bleeding may be occult (swallowed) and is emergency
- post-tonsillectomy bleeding may require surgery
- ensure adequate IV access
- hypovolemia requiring vigorous resuscitation
- potential for hemodynamic instability on induction
- H&H, T&C, coags
- considered full stomach –> RSI
- potential for difficulty obtaining secure airway (swelling)
- OGT to empty stomach
primary hemorrhage
occurs within 24 hours
0.2-2.2%
secondary hemorrhage
occurs > 24 hours (up to 5-10 days after)
0.1-3%
myringotomy and tympanostomy (BMT)
- myringotomy = creates opening in tympanic membrane through which fluid can drain
- tympanostomy = placement of ventilation tube with lumen; alleviates pressure from middle ear and serves as stent allowing continued drainage until tubes naturally extruded in 6 months to a year
- indicated in chronic otitis media
BMT anesthetic considerations
- often have URI
- short operative time
- oral midaz may outlast procedure (consider not giving)
- often mask-only anesthetic
- IV placed if another procedure is also being done
- D/c sevo during second side
myelodysplasia (spina bifida)
-failure of neural tube to close resulting in herniation of the spinal cord and meninges through a defect
-most common CNS defect that occurs during first month of gestation
most common in lumbosacral region
-hydrocephalus often present and may need VP shunt
-URGENT repair required within 24-48 hrs due to risk of infection or worsening cord function
meningocele
only contains meninges
myelomeningocele
contains meninges and neural elements
hydrocephalus
- excess CSF builds up in ventricles
- “water on the brain” from Greek words
- may be caused by congenital defect (Chiari or aqueduct stenosis) OR by acquired disease (trauma, infection, tumor)
preop anesthesia considerations for myelodysplasia repair
- assess level of lesion and degree of deficit
- review of systems and rule out additional congenital anomalies
- CBC, T&S
intraop anesthesia considerations for myelodysplasia repair
- routine monitors, may use IONM (avoid muscle relaxation if MEPs)
- positioning - supine, lateral, prone for procedure
- induce with inhaled or IV
- potential for blood loss if large defect
- prone to hypothermia
- latex free environment
postop anesthesia considerations for myelodysplasia repair
- goal = extubate
- assess the need for postop apnea monitoring
ventriculoscopy
use of fiber optic scope through cranial burr holes to visualize lateral, third, and occasional fourth ventricle; alternative may be placed under US guidance
VP shunt
- ventriculo-peritoneal shunt
- lateral ventricle to peritoneum
- most common type of shunt and allows room for growth
VA shunt
- ventriculo-atrial shunt
- lateral ventricle to right atrium
- abdominal pathology use this
ETV
- endoscopic third ventriculostomy
- burr hole created in the floor of the 3rd ventricle allowing CSF to flow directly into the basal cisterns
neurosurgery for hydrocephalus anesthesia implications
- incision is small frontal or parietal-occipital
- position is supine with head turned
- table 90-180 degrees
CSF shunt preop anesthesia considerations
- assess baseline neuro stats and ICP
- avoid premeds if ICP increased
- assess for vomiting history and dehydration
- routine H&P
- if child has had previous shunt revisions, review old records
- IV x1-2
CSF shunt induction considerations
- standard monitors
- prop, fent, roc
- iso or sevo
- GETA
- protect and pad eyes
- abx = ancef 30 mg/kg IV
CSF shunt maintenance considerations
- hyperventilation is undesirable because it may make cannulation of the ventricle more difficult
- maintain paralysis or propofol bolus when tunneling
- VA shunts - be caution of air embolism/PPV while the vein is open
CSF shunt emergence considerations
- reversal of paralytic
- antiemetics
- extubate
- fully awake to permit for rapid neuro assessment
humerus fracture
- long bone of upper arm
- 3 types of fractures depending on the location
- proximal = break in upper part of humerus near shoulder
- mid-shaft = break in middle par to humerus
- distal = break near elbow; usually part of a more complex elbow injury and sometimes involves loose bone fragments
scoliosis
-sideways curvature of spine
idiopathic scoliosis
no definite cause and most common form of the condition; mainly affects adolescent girls
neuromuscular scoliosis
caused by conditions of muscle weakness or spasticity (such as CP, muscular dystrophy, and SCI) and associated with greater bladder loss
supracondylar fracture of humerus
- most common elbow fracture in children
- results from falling with an outstretched hand and extended elbow
- complications include - compartment syndrome, nerve palsies and late deformities
anesthesia for humerus fracture
- supine with table turned 90
- GETA
- assess NPO status and full stomach precautions requiring IV and RSI
- 30-60 min for pinning
- 30-90 min for open reduction
- timing of emergence if cast or splint is placed after closing
posterior spinal instrumentation
- surgical treatment is recommended for patients whose curves are greater than 45 degrees while still growing or are continuing to progress greater than 45 degrees when growth stopped
- the goal is to prevent curve progression and obtain some curve correction
- surgical team utilizes metal implants that are attached to spine and then connected to a single or two rods
- posterior or anterior approach
- following surgical treatment, no external bracing or casts are used
- hospital stay between 3-6 days
- prone
- surgical time = 6+ hours
- significant blood loss potential
- intraop neuro monitoring used
- stepdown or ICU post op
posterior spinal instrumentation preop anesthesia considerations
- standard peds preop eval
- starting CBC, coags, BMP, and HCG in females
- 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
respiratory anesthesia implications with posterior spinal instrumentation
- cobb angle - degree will determine amount of impairment of respiratory function
- restrictive lung disease = decreased TLC + decreased VC
- VC <40% may mean post op ventilation
- patients with neuromuscular scoliosis may be more sensitive and require postop ventilation secondary to muscle weakness
posterior spinal instrumentation case set up
- cell saver, fluid warmer, and blood tubing
- a line and PIVx2
- prepare for prone position with superman arms on spine table
- consider EKG placement, prone pillow, and underbody bair hugger
- eye lube, eye tape, bilateral soft bite blocks
- standard airway, induction meds, BIS, cerebral oximetry, emergency meds, OGT
- increase room temp
evoked potential monitoring
- dex opioids are ok
- N2O and inhalation agents avoided
- ketamine enhances SSEPs and MEPs amplitude; if given inform IOM team
- propofol in high doses increases latency and decreases amplitude of EPs
complications of posterior spinal instrumentation
- spinal cord ischemia
- massive blood loss
- embolism
- accidental extubation
- corneal abrasion
- visual loss
- neurological sequele with loss of SSEPs and/or MEPs
postop anesthetic implications of posterior spinal instrumentation
- plan for extubation if possible
- CXR may be obtained at end of procedure prior to exubation
- pain score 7-9 = hydromorphone PCA
- ICU or step down
- LOS 3-6 days
Nissen
laparoscopic nissen fundoplication is minimally invasive procedure which is done to restore the function of the LES by wrapping the stomach around the esophagus
infantile hypertrophic pyloric stenosis
- thickening or swelling of pylorus 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
- diagnosed between 2-12 weeks of life
- clinical presentation = postprandial projectile emesis, palpable pylorus, visible parastaltic waves
- surgical correction = pyloromyotomy
Nissen anesthetic implications
- gastric reflux and failed medical management
- involves mobilizing muscles around esophagus at level of LES
- GA-ETT
- often laparoscopic
- not associated with large blood loss, fluid shifts, or pain
- positioning of bougie within the eophagus and insufflation via gastric tube to ensure no leaks at the anastomosis
pyloric stenosis results in what acid/base disturbance?
hypochloremic metabolic alkaosis
anesthesia for pyloric stenosis
- prior to induction suction stomach with OGT and tilt baby in various directions to remove all contents
- HIGH risk for aspiration
- RSI, cricoid, prop, succ/roc
- cuffed ETT
- quick procedure (20 min)
- extubate AWAKE
circumcision
- removal of foreskin from human penis
- most common procedure
hypospadias
- condition in which the opening of the urethra is on the underside of the penis instead of at 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 anesthesia considerations
- neonates to adults
- local, regional, GA
- indications = phimosis, recurrent balanitis, parental preference
- approximately 1 hour, involves cutting foreskin and cauterizing/suturing skin edges
- most common complication is bleeding
hypospadias anesthesia considerations
- 1:250 live male births
- 1-4 hours
- GA LMA or ETT
- regional controversial (concern for venous pooling and poor outcomes)
caudal anesthesia benefits
- intra and postop analgesia
- reduction in systemic opioid requirements and side effects
- reduction in anesthesia requirements
procedures that could utilize caudal
- circ
- inguinal herniorrhaphy
- hypospadias
- anal surgery
- clubfoot repair
- other subumbilical procedures
contraindications for caudal
- infection around site
- coagulopathy
- anatomic abnormalities
- parental refusal
cleft palate
- cleft = opening or space
- all different and can occur at different places
- human development –> L and R sides of face fuse near midline; cleft occurs when this fusion doesnt occur properly
- some genetic but also environmental factors
- cause not entirely clear but may have associated syndrome with anesthesia implications
cleft lip and palate surgery
- may be repaired in stages
- lip usually at 10-12 weeks
- palate at 12-18 months
- alveolar bone graft
- pharyngoplasty at 5-15 years
- associated symptoms = difficulty feeding, malnutrition, speech development and congenital heart defects
- routine induction
- oral RAE with flexible connector
cleft lip and palate anesthesia implications
- airway may be difficult (w or without syndrome)
- mouth gag (so reassess breath sounds)
- no air bubbles
- coagulopathy may cause significant bleeding
- LA with EPI reduces blood loss and provides some analgesia
- protect eyes
- secretions and blood, clear airway on emergence
- possibility of airway and tongue edema
- extubate once return of protective airway reflexes
- no-nos after surgery to protect surgical site from child’s manipulation
