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Peds > Difficult airway- congenital abnormalites > Flashcards

Difficult airway- congenital abnormalites Flashcards

1
Q

What level is the larynx in the infant?

A

C3-C4

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2
Q

Where is the larynx in the adult?

A

C5-C6

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3
Q

infants are obligate nasal breathers until around when?

A

5 months

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4
Q

What are the features of the pediatric airway?

A

-large epiglottis
-short trachea and neck
-prominent adenoids and tonsils
-rigid cricoid ring is functionally the narrowest portion of the larynx

-tongue is larger in proportion to mouth
-pharynx is smaller
-epiglottis is larger and floppier
-larynx is more anterior and superior
-trachea is narrow and less rigid

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5
Q

What physiologic lung values are increased in the neonate/infant/ped?

A

Increased O2 consumption (6 vs 3)

increased alveolar ventilation (130 vs 60)

Increased Co2 production (6 vs 3)

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6
Q

What physiologic lung values are decreased?

A

Vital capacity (35 vs 70)

FRC (25 vs 40)

PaO2 (65-85 vs 85-95)

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7
Q

What are peds prone to when apneic?

A

atelectasis and hypoxemia

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8
Q

During apnea, how does paco2 rise?

A

6 mmHg during the first minutes, the 3-4mmHg each min after

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9
Q

What percentage of type 1 slow twitch muscle fibers in the diaphragm does the ped have?

A

25%
-promotes chest wall collapse during inspiration and low residual lung volumes during expiration

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10
Q

What respiratory drives are not well developed in the ped?

A

hypercapnic and hypoxic

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11
Q

Which conditions have a large tongue?

A

-Beckwith syndrome
-Trisomy 21

“Big tongue”

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12
Q

Which conditions have a small mandible (micrognathia/mandibular hypoplasia)

A

-Pierre Robin
-Goldenhar
-Treacher Collins
-Cri du chat

“Please Get That Chin”

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13
Q

Which conditions have spine anomalies?

A

Klippel-Feil
Trisomy 21
Goldenhar

“Kids Try Gold”

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14
Q

The larger the tongue the more likely the ______

A

obstruction

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15
Q

What does an anterior larynx mean?

A

Larynx sits high under the base of the tongue: no space to displace the tongue; the larynx will remain anterior

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16
Q

What does the TMJ do?

A

opens the upper airway and translocates the lower jaw forward.

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17
Q

What are some syndromes with soft tissue abnormalities?

A

Freeman-Sheldon syndrome
Beckwith- Wiedeman Syndrome
Down syndrome
Sturge Weber
Dwarfism

-limits movement of the airways
-affects mouth opening

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18
Q

What are some syndromes with craniosynostosis?

A

Apert syndrome
Crouzon syndrome
Pfeiffer syndrome

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19
Q

What are the features of Crouzon disease?

A

-Hypertelorism (increased distance btwn eyes)

-craniostenosis

-shallow orbits

-proptosis (abnormal protrusion of eyes)

-midface hypoplasia

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20
Q

What are the features of Apert disease

A

-Hypertelorism (increased distance btwn eyes)

-craniostenosis

-shallow orbits

-proptosis (abnormal protrusion of eyes)

-midface hypoplasia

-Syndactyly of extremities (webbing)

-cardiac and renal problems: dydronephrosis/polycystic kidney disease

-possible esophageal atresia

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21
Q

What are the anesthesia implications for craniosynosis?

A

OSA- may require trach
-need smaller ETT
-Difficult mask
-don’t close mouth or will obstruct
-topical lidocaine before oral airway
-ETT not difficult unless neck mobility issues

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22
Q

With what cleft abnormality will you see obstruction?

A

Cleft palate

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23
Q

What are the features of bilateral clefts?

A

Premaxilla angled anteriorly (makes blade insertion difficult)

If younger than 6 months- intubation won’t be as difficult

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24
Q

What are other associated diseases with cleft lip and palate?

A

-associated w congenital heart disease
-pulm aspiration
- anemia (d/t poor nutrition)

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25
Q

What is usually placed pre-op for a cleft palate and lip?

A

Tongue stitch before waking up bc correction can narrow the airway making it more likely for the tongue to obstruct the airway

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26
Q

What meds should be used for cleft lip and palate?

A

non-respiratory depressants

-tylenol
-dexmedetomidine
-ketorolac

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27
Q

What age are cleft lips corrected?

A

3 months

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28
Q

What age are cleft palates repaired?

A

6 months

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29
Q

What happens in micrognathia?

A

Glossoptosis (downward displacement or retraction of the tongue)

resp obstruction

usually isolated but can be a part of stickler syndrome or velocardial syndrome

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30
Q

Describe Pierre Robin Sequence

A

Resp compromise:

-hypoxia
-arrest
-pulm HTN
-failure to thrive

-25% have feeding problems

-rapid facial growth btwn 3-12 months

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31
Q

What can be done at birth to relive obstruction for Pierre robin?

A

place oral airway and place prone

extreme cases: tracheostomy

32
Q

What are the intraoperative considerations for Pierre robins?

A

do not give muscle relaxants while attempting intubation

keep pt breathing

-fiberoptic

33
Q

What is the OMENS classification?

A

-orbital distortion
-mandibular hypolasia
-ear anomaly
-nerve involvement
-soft tissue deficiency

34
Q

What happens in hemifacial microsomia?

A
  • varying degree of mandibular hypoplasia

-auricular abnormalities

-overlying soft tissue loss

-facial nerve weakness

-unilateral defects in 90% of cases

normally right sided

Variant of Goldenhar syndrome

35
Q

Mandibular abnormalities: Pruzansky classifies 3 types:

A
  1. Mild hypoplasia of the ramus with little abnormality of the mandibular body
  2. Mandible has a small condylar head and ramus. Condyle is flat, glenoid fossa is poorly developed or absent, infratemporal surface assumes a flat contour
  3. Mandible abnormality
    TMJ joint fails to form
    Ramus may exist as a thin bony lamina or may be completely absent
    the degree of mandibular hypoplasia is associated with increased difficulty of ET intubation
36
Q

What is Goldenhar syndrome?

A

associated w abnormality on chromosome 5p15

defect in development of the 1st and 2nd branchial arches

Main feature: macrostomia (failure of fusion of maxillary and mandibular process

  • vertebral abnormalities
    -limited neck extension
    -10% cardiac defects w outflow tract/septum issues
    -hydrocephalus
    -TEF

if abnormality is bilateral- similar to Pierre robin

37
Q

What is Treacher Collin syndrome?

A

Disorder or the 1st and 2nd pharyngeal arches

-autosomal dominant mandibularfacial dysostosis (development of the bone)

hypoplasia of maxillary, zygomatic, and mandibular

  • -laterally sloping palpebral fissures
    -notched lower eyelids
    -coloboma of eye (lens, retina, iris)
    -small mouth
    -high arched palate
    -hearing loss (atresia of auditiory canal)
    -absence of the medial lower eyelashes

secondary problems: cleft palate, velopharyngeal incompetence

38
Q

Anesthetic considerations for treacher collins syndrome:

A

mask ventilation and intubation difficult

keep pt spontaneously breathing
sedated fiberoptic intubation
LMA or fiberoptic
Trach

39
Q

Craniofacial abnormality management

A

sevo
prop
ketamine
precedex
nebulized lido
alfentanil

nasal trumpet or nasal ray to deliver volatile anesthetics

40
Q

What are the noncraniofacial abnormalities?

A

Mucopolysaccharidoses

Beckwith-Wiedemann

Down syndrome

41
Q

What is Mucopolysaccharidoses

A

Lysosomal storage disorder: deficiency in the enzymes required for the stepwise breakdown of glycosaminoglycans (GAGs)

Components of ground substance of bone and cartilage, lubricant for joint fluid, and the surface coating that initially binds growth factors to cells

42
Q

How does Mucopolysaccharidoses affect the airway?

A

Airways: infiltration of GAG deposits leads to tongue enlargement, thickening and redundancy of the soft-tissue mucosa of the oropharynx, and blockage of nasal passages

Progressive airway obstruction leads to severe respiratory compromise

Mask ventilation and tracheal intubation become impossible

43
Q

What are the features of MPS 1: Hurler syndrome?

A

Appear normal at birth

During first year: course facial features, wide nasal bridge, flattened midface

Hepatosplenomegaly, umbilical or inguinal hernias

Skeletal abnormalities: dysostosis multiplex

Typically present at 6 months to 2 yrs. with developmental delay, recurrent respiratory infections with chronic nasal discharge
Rapidly enlarging head size, heart failure, hernias, lower spine deformities

Age:2-3: joint stiffness and contractures, multiword sentences and walking: declines

44
Q

MPS 1: Hurler syndrome continued

A

High pressure communicating hydrocephalus

Craniosynostosis

Loss of vision: corneal clouding early on

Soft tissue thickening of the nose and pharynx, storage within the tonsils, adenoids, and abnormalities in tracheal cartilage cause progressive airway obstruction and sleep apnea

Sleep apnea: hypoxemia at night, pulmonary HTN, cor pulmonale

Cardiac abnormalities: age 5
Cardiomyopathy, endocardial fibroelastosis, valvular regurgitation

Abnormal storage of GAG in coronary vessels cause narrowing

Odontoid Dysplasia and anterior C1-C2 subluxation: can cause cord compression and sudden death.

45
Q

What is the management for MPS?

A

FIRST CHOICE: AWAKE FOI

Preop evaluation of upper airway, lungs, cervical spine, heart, and neurologic evaluation

Periop morbidity and mortality most often related to difficult airway management and tracheal intubation

Awake FOI first choice

Spontaneous ventilating FOI

Be aware of co-existing cardiac and liver disease and choose drugs accordingly

Cautious use of narcotics as depressant effects could worsen pre-existing restrictive/obstructive ventilation defects

Delayed awakening in Hunter’s Syndrome has been described

46
Q

What is Beckwith-Wiedemann syndrome

A

Omphalocele, macroglossia, gigantism

Hyperplasia of the kidneys and pancreas

prone to hypoglycemia**

Hepatosplenomegaly

Eventration of diaphragm (higher than usual in anatomic position)

Large protuberant tongue: can lead to airway obstruction

microcephaly, macroglossia, umbilical hernia

47
Q

Management of Beckwith-Wiedemann syndrome:

A

-keep spontaneously breathing

-mask difficult d/t large tongue

-have someone gold tongue

-immediate post op s/p partial glossectomy- tongue may be bigger

-Keep pt intubated nasally

48
Q

Down syndrome

A

Smaller than normal for age

Craniofacial: microbrachycephaly (small head)
Short neck, oblique palpebral fissure

Epicanthal folds, Brushfield’s spots (small white or greyish/brown spots on the periphery of the iris)

Small low set ears

Macroglossia

Microdontia with fused teeth

Mandibular hypoplasia

Narrow nasopharynx with hypertrophic lymphatic tissue: tonsils and adenoids

Generalized hypotonia

pulm HTN

atlantoaxial instability

subglottic stenosis

Smaller ETT

49
Q

Most common heart abnormalities in down syndrome

A

Atrioventricular septal defect

VSD

TOF

PDA

strong underlying vagal tone: bradycardia common during induction

50
Q

What is Klippel-Feil syndrome?

A

Severe limitation of flexion/extension of the neck as a result of fusion of cervical vertebrae and atlanto-occipital abnormalities

Spinal canal stenosis

Scoliosis

Easy mask ventilation usually
Intubation very difficult due to l
imitation of neck movement

Care must be taken in manipulation of neck as neurological injury can occur

FOI vs LMA

51
Q

What syndromes had the highest rate of tracheotomy?

A

Crouzon
Apert
Pfeiffer

Next highest: Treacher Collins

52
Q

what reduced risk of tracheotomy?

A

cleft palate

53
Q

CAEC 8:

A

ett 3.5-4.5

54
Q

CAEC 11:

A

ett 5.0-6.0

55
Q

CAEC 14:

A

ett 6.5-7.0

56
Q

indications for spinal anesthesia

A

hernia repair
orchiopexy
hypospadias
circumcision
exploratory lap
muscle biopsy
LE surgery

57
Q

Where is the infant clonus medularis located?

A

L3

58
Q

Where is the infant dural sac located?

A

S3

59
Q

What is the volume of csf in neonates?

A

> 10mL/kg

60
Q

what is the volume of csf in infants?

A

4mL/kg (<15kg)

61
Q

what is the volume of csf in children?

A

3mL/kg

62
Q

What is the volume of csf in adults and adolescents?

A

1.5-2ml/Kg

63
Q

What size needle do you use for an infant and neonate spinal?

A

1.5 inch

64
Q

Where should the spinal needle be placed?

A

L4-L5 interspace (iliac crests)

65
Q

what is the most commonly used regional block in pediatric anesthesia?

A

caudal block

-lower extremities, lower abdomen, lower thoracic dermatomes

66
Q

what are contraindications to a caudal block?

A

pilonidal cyst
abnormal superficial landmarks
myelomeningocele
hydrocephalus or intracranial htn
neuropathies
parental nonconsent

67
Q

caudal anatomy: sacral hiatus

A

Results from the lack of dorsal fusion of the 5th and often 4th sacral vertebral arches

V-shaped aperture

Limited laterally the sacral cornua

Covered by the sacrococcygeal membrane (sacral continuation of the ligamenta flava)

68
Q

in a caudal block where is the needle placed?

A

sacral canal

22G/20G angio-catheter or tuohy needle

69
Q

what is the positioning for a caudal block?

A

lateral- into fetal position

prone

70
Q

sacral level

A

0.5-0.75 mL/kg

71
Q

Lumbar level

A

1-1.2 ml/kg

72
Q

low thoracic

A

1.2-1.5ml/kg

73
Q

max volume/max dose

A

25ml / 3mg/kg

74
Q

toxicity treatment

A

20% intralipid

bolus 1.5 ml/kg repeat 1-2 times if needed

infusion 0.25ml/kg/min for 30-60 mins

75
Q

what are signs of intravascular injection?

A

HR increase of 10 bpm
BP increase of 15 mm Hg
T wave ampitude increase of >25% of baseline or bradycardia are all signs of intravascular injection.

Children are at an increased risk because of increased C.O. and increased systemic uptake of the agent.

76
Q

signs of neurotoxicity

A

Neurotoxicity: HA, somnolence, vertigo, perioral or lingual parathesias, tremors, twitching, shivering or convulsions.

77
Q

signs of cardiac toxicity

A

Cardiac toxicity: LA prevents the fast inward sodium channels in the myocardium from opening.
Dysrhythmias, conduction block, widening QRS, torsades de pointes, VT, or cardiovascular collapse

Peds (5 decks)

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