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Peds > Common Pediatric Surgeries -GI > Flashcards

Common Pediatric Surgeries -GI Flashcards

1
Q

What is Gastroschisis?

A

-Defect of the anterior abdominal wall of the right of the umbilical cord

-no sac- bowel is exposed to the intrauterine environment

-bowel is matted, thickened and covered w an inflammatory coating

-malabsorption issues

-results in peritonitis, extracellular fluid loss, significant heat loss

-fascial defect in 2-5 cm

-usually involves only large and small intestines

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2
Q

What is Gastroschisis a result of?

A

A vascular event resulting from an abnormality of a right omphalomesenteric artery or right umbilical vein

results in ischemia to the right paraumbilical area and dysplastic abdominal wall growth

Weakened area ruptures as abdominal organs grow

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3
Q

What are the risk factors for gastroschisis?

A

young maternal age, exposure to tobacco and alcohol during development

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4
Q

What are the risk factors for gastroschisis?

A

young maternal age, exposure to tobacco and alcohol during development

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5
Q

How is gastroschisis diagnosed?

A

before birth via ultrasound- associated w increased maternal serum alpha fetoprotein

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6
Q

What is Omphalocele?

A

Central defect of umbilical ring/base of umbilical cord

Abdominal contents are within a sac

umbillical cord embedded in sac

fascical defect >4cm

Sac contains stomach, large and small intestine, liver (30-50%)

(less than 4cm- considered umbilical hernia)

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7
Q

What is the embryology or omphalocele?

A

week 7-12: midgut herniated into umbilical cord

Week 12: abdominal cavity is large enough, gut re-enters abdomen.

  • failure of gut to return to abdominal cavity
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8
Q

What anomalies is gastroschisis associated with?

A
  • isolated lesion
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9
Q

What associated anomalies is omphalocele with?

A

50-70% incidence of other anomalies
20-30% chromosomal abnormalities
Beckwith- Wiedemann syndrome, Reiger syndrome, Prune belly syndrome
Trisomy 13, 15, 18, 21
Cardiac 20%

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10
Q

What symptoms/anomalies does Beckwith-Wiedemann Syndrome come with?

A

-omphalocele
-visceromegaly
-macroglossia
-mild microcephaly
-hypogycemia

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11
Q

What symptoms/anomalies does Beckwith-Wiedemann Syndrome come with?

A

-omphalocele
-visceromegaly
-macroglossia
-mild microcephaly
-hypogycemia

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12
Q

What is the surgical management for these pts?

A

-replacing the viscera and repairing the defect
-Primary vs. Staged repair w silo/mesh chimney
-staged- organs gradually returned to the abdominal cavity over 3-14 days

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13
Q

What are the factors that determine surgical management?

A
  • size of the defect
    -development of the abdominal wall
    -presence of anomalies
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14
Q

What are the negative effects of tight abdominal closure?

A

-impairs diaphragmatic excursion- inadequate ventilation, increased airway pressure

  • impedes venous return- profound HoTN

-aortocaval compression -bowel ischemia, decreased CO, renal and hepatic dysfunction

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15
Q

What are the negative effects of tight abdominal closure?

A

-impairs diaphragmatic excursion- inadequate ventilation, increased airway pressure

  • impedes venous return- profound HoTN

-aortocaval compression -bowel ischemia, decreased CO, renal and hepatic dysfunction

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16
Q

What is considered unsafe for primary closure?

A

Intragastric pressure >20 mmHg
Change in CVP > 4mmHg above baseline
ETCO2 >50 mmHg
Peak inspiratory pressure > 35 cm h2o

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17
Q

What is considered unsafe for primary closure?

A

Intragastric pressure >20 mmHg
Change in CVP > 4mmHg above baseline
ETCO2 >50 mmHg
Peak inspiratory pressure > 35 cm h2o

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18
Q

What is the reasoning for massive fluid losses?

A

Peritonitis, edema, ischemia, protein loss, third space loss, which results in dehydration metabolic acidosis, hypovolemic shock

19
Q

How should you fluid resuscitate?

A

Maintenance fluid: D5 or D10 in 0.2NS

replacement fluid: isotonic at 2-4 times maintenance rate

NS or LR as replacement (8-15 ml/kg/hr)

20
Q

What should UOP be maintained at?

A

1-2ml/kg/hr

21
Q

How should you maintain normothermia

A

prevent heat loss from exposed viscera

  • cover abdominal contents w warm, saline-soaked gauze
    -cover w plastic bowel bag
22
Q

Where should the two pulse ox monitors be placed?

A

pre-ductal (right arm)

Post ductal (left foot)

23
Q

What gas should be avoided?

A

Nitrous oxide - bowel distention

24
Q

what should spo2 and pao2 be maintained at?

A

spo2: 95-97%

pao2: 50-70mmhg

25
Q

What should be done to prevent hypothermia?

A

room temp 80 degrees
bair hugger
fluid warmer
plastic wrap for extremities, head, and leave hat on

26
Q

What should be done to prevent hypothermia?

A

room temp 80 degrees
bair hugger
fluid warmer
plastic wrap for extremities, head, and leave hat on

27
Q

What factors will determine extubation?

A

size of pt/prematurity
associated anomalies
size defect
type of repair
intraop events
hemodynamic status

28
Q

What factors will determine extubation?

A

size of pt/prematurity
associated anomalies
size defect
type of repair
intraop events
hemodynamic status

29
Q

What is the post-op management for these cases?

A

-mechanical ventilation for 24-48 hrs
-fluid requirements closely monitored
-circulatory compromise- cyanotic lower limbs, bowel ischemia
-prolonged post-op ileus- TPN required for days to weeks
-prevent infection

29
Q

What is the post-op management for these cases?

A

-mechanical ventilation for 24-48 hrs
-fluid requirements closely monitored
-circulatory compromise- cyanotic lower limbs, bowel ischemia
-prolonged post-op ileus- TPN required for days to weeks
-prevent infection

30
Q

What are some post-op complications?

A

-pneumonia
-necrotizing enterocolitis (NEC)
-renal insufficiency
-abdominal wall breakdown
-GERD

31
Q

What is a congenital diaphragmatic hernia (CDH)?

A

-defect in the diaphragm that allows herniation of abdominal organs into the thoracic cavity

32
Q

What are the associated anomalies of CDH?

A

prenatal hx of polyhydramnios

-malrotation of the gut
-CV
-CNS, GI, GU

33
Q

What are the associated anomalies of CDH?

A

prenatal hx of polyhydramnios

-malrotation of the gut
-CV
-CNS, GI, GU

34
Q

What are the classifications of CDH?

A

Posterolateral (80-90%)
left (75%)
paraesophageal 15-20%
anteromedial 2%

35
Q

What are the complications of CDH?

A

-bilateral lung hypoplasia
-pulm HTN and arteriolar reactivity
-Left ventricular dysfunction

36
Q

What is the pathophysiology of CDH?

A

Abdominal viscera occupies the left thoracic cavity and interferes w the development of the lung resulting in pulm hypoplasia

Herniation of abdominal contents shifts mediastinum to the right resulting in compression and hypoplasia of the contralateral lung

Structural abnormalities of pulm vasculature resulting in chronic lung disease
-Small number of airways
-Simple arterial branching pattern
-Increased smooth muscle mass in resistance vessels
-Left ventricular abnormalities

37
Q

What is the pathophysiology of CDH?

A

Abdominal viscera occupies the left thoracic cavity and interferes w the development of the lung resulting in pulm hypoplasia

Herniation of abdominal contents shifts mediastinum to the right resulting in compression and hypoplasia of the contralateral lung

Structural abnormalities of pulm vasculature resulting in chronic lung disease
-Small number of airways
-Simple arterial branching pattern
-Increased smooth muscle mass in resistance vessels
-Left ventricular abnormalities

38
Q

What is the clinical presentation of CDH?

A

-Symptoms appear within mins to hrs.

classic triad:
- dyspnea
-cyanosis
-apparent dextrocardia

physical exam reveals:
-bulding chest and scaphoid abdomen
-decreased breath sounds
-distant or right displaced heart sounds
-bowel sounds in chest
-CXR bowel loops in the chest and mediastinal shift

Dextrocardia- heart points to the right instead of the left

39
Q

What are the medical management goals of CDH?

A

medical stabilization for 24-48 hrs before surgery

-maximize arterial oxygenation:
- intubation
-mechanical ventilation - low inflating pressures (<20-30cm h2o)
- maintain muscle relaxation
-improve pulm perfusion
-correct acidosis
-prevent hypothermia
-prevent pain

40
Q

When can surgery occur for CDH?

A

when BP normal and stable for 24 hrs
preductal sat >85 (preferably 90-95%) w fio2 less than 50%
lactate < 3
UOP 1-2ml/kg/hr

41
Q

How can you improve pulm perfusion in CDH?

A

hyperventialtion (paco2 25-30 mmhg)
fentanyl infusion
minimal handling
nitric oxide
ECMO

early intubation and decompression of stomach is critical

42
Q

What are the complications of ECMO?

A

-Bleeding at cannulation sites
-intracranial hemorrhage
-sepsis
-HTN
-brain death

43
Q

What is the criteria for ECMO?

A

More than 2kgs
gestation >35 weeks

Peds (5 decks)

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