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
