Exam 4: Key Terms Flashcards
What is the incidence of gastroschisis in United States?
1:15,000
If the patient is presenting for surgery on an omphalocele or Gastroschisis and is hypovolemic what type of intubation must be done?
Awake
RSI after IV atropine and O2
At what pressure is and ETT leak acceptable for a patient with an omphalocele or gastroschisis?
30-40 cmH2O
Higher than normal because of increased intra-abdominal pressures
What are some important considerations during induction for a patient with TEF?
Head up position to minimize aspiration
NG in esophagus to suction continuously
Awake intubation if hemodynamics unstable
RSI if stable
What neonatal surgical emergency requires an awake intubation and avoiding use of a mask?
Congenital diaphragmatic hernia
- Patient only has one good lung and you fear a pneumothorax on the good side
** Dr Pae said this was not a surgical emergency cause you are no longer correcting lung problem. I know this is a key term but this is what he said this year not sure who taught it last year
What are some important considerations during induction for a patient with a nasal encephalocele?
Positioning important
Awake intubation
What is true of the patient’s ventilatory status during induction for a cystic hygroma?
Maintain spontaneous ventilation
What are some potential benefits for pediatric premedication?
Calms Better acceptance of mask induction Less anxiety from parental separation Calms parents Diminishes postop behavior changes
What are the main electrolyte imbalances seen with pyloric stenosis?
Hypokalemia
Hypochloremic metabolic alkalosis
What happens to sodium levels during pyloric stenosis?
Relatively unchanged
-Body will defend volume before pH and thus saves sodium to retain water
What is true of the relationship between post op apnea risk and post conceptual age (PCA)?
Inversely proportinal
Which preoperative lab values are important to consider when worried about the risk of postoperative apnea?
Hct (and K+)
Which routine labs are taken on healthy children preoperatively?
None
Which labs are almost always taken for a tonsillectomy and adenoidectomy?
Coags preoperatively
What are the signs and symptoms of pyloric stenosis?
Recurrent vomiting Malnutrition/dehydration Palpable "Olive" in the epigastrum Visible peristalsis Bradypnea Jaundice (5-10%) Acidic urine
What are the two main types of apnea?
Central: No airflow at nares and no muscular activity (no effort)
Obstructive: Muscular effort without nasal airflow (trying, but can’t)
What will cause a flattening of the CO2 response curve?
Prematurity
Younger postnatal age
Pre-terms with apnea vs without
Hypoxia
What is the incidence of apnea of prematurity in infants less than 30 weeks gestation?
80%
What are the contributing factors for AOP?
CNS disease
Systemic illness
Thermal/metabolic disturbances
Airway anomalies
What effects do halogenated anesthetics have on muscle tone and FRC?
Decreased muscle tone of airway, Chestwall and diaphragm
Reduced FRC
What effects do halogenated agents have on the CO2 response curve and ventilatory response to hypoxia?
Dose-dependent decrease in slope and right shift of CO2 response curve
Depressed ventilatory response to hypoxia
What are the elective surgery recommendations based on post conceptual age?
Delay elective surgery beyond 46 weeks PCA
Pyloric stenosis is considered what type of emergency?
Medical, not surgical
What must be normalized before performing surgery on pyloric stenosis?
Adequate rehydration Normal electrolytes (Cl >90; HCO3 <30)
How does alveolar ventilation of children compared to that of adults?
2x
6cc/kg for Peds
How does the O2 dissociation curve of neonate s compare to adults?
Left shifted
Why do pediatric respiratory muscles fatigue more easily than adults?
Fewer Type 1 fibers
When should elective surgery be canceled in a patient with URI?
Purulent rhinitis
Fever (>38.3)
Elevated WBC with bands
Infiltrate by CXR
What percent of US children have asthma?
5-10%
How does asthma affect ASA status?
Asthma = automatic II
Asthma + daily meds = ASA III
Asthma + steroids = ASA IV
What are the characteristics of Bronchopulmonary displasia?
Increased airway resistance Poor long compliance VQ mismatch Hypoxemia/O2 desaturation Increased work of breathing Chronic wheezing
For the preterm infant, how is the risk of postoperative apnea related to PCA?
Inversely proportional
What are the recommendations for surgery as related to PCA?
Surgery if >52 weeks PCA
Monitor in hospital if <52 weeks PCA
How is PCA calculated?
Age since birth - weeks premature
What are the recommendations for children with murmurs and preoperative evaluation?
Healthy child w/ Grade I-II / VI SEM & no symptoms = no work up
Grade III + or symptomatic = preoperative ECHO
What is the recommended preoperative Hct level for patients with sickle cell?
Transfuse to Hct of 30% with PRBCs
Not all may require
What are the fasting guidelines (in hours) for solids/milk for 36 mos of age?
< 6 mos = 4 hrs
6-36 mos = 6 hrs
> 36 mos = 8 hrs
What are the fasting guidelines for clear liquids for infants < 6 mos, 6-36 mos, > 36 mos of age?
< 6 mos = 2 hrs
6-36 mos = 3 hrs
> 36 mos = 3 hrs
What are the preoperative anxiety predictors?
>12 months of age Parental anxiety Temperament Social adaptability Lack of premed
What is the pediatric preop dose of midazolam?
0.5-0.7 mg/kg oral
What is the pediatric dose of fentanyl?
10-15 mcg/kg
What is the oral pediatric dose of ketamine?
6-9 mg/kg
What percentage of all pediatric surgery in the US is ambulatory?
75%
How of patients selected for ambulatory surgery?
General medical condition
Nature and extent of surgery
Degree of postoperative care required
Why is sevoflurane the most popular inhalational technique?
Least irritating to airway
Desflurane = more laryngospasm and emergence excitement
What are the doses for pediatric acetaminophen?
PO = 20 mg/kg PR = 40 mg/kg
What’s the pediatric dose for IV toradol?
0.5 mg/kg
What is the rule for who can receive a caudal block?
Children < 7 & < 30 kg
What are the minimum discharge criteria for children?
Stable VS (w/in 20% baseline) No respiratory distress Age appropriate ambulation No N/V Intact pharyngeal reflexes Age appropriate LOC
What procedures are associated with PONV?
T & A, ENT, Ears, Eyes, laparoscopic
Which drugs have been implicated in anesthetic neurotoxicity?
Ones the work on GABA and NMDA receptors
Is there a correlation between # surgeries and learning disabilities?
> 3 surgeries before age 2 = increased incidence of learning disabilities
What are the important anesthetic considerations relating to pyloric stenosis?
Aspiration risk
Dehydration
Metabolic derangements
List some of the main differences between omphalocele and gastroschisis
OMPHALOCELE: 1:6000; 2:1 (M:F); 30% mortality; midline to umbilicus; larger; associated with other congenital abnormalities; sac protects bowel from amniotic fluid
GSTROSCHISIS: 1:15000; 1:1 (M:F); 15% mortality; Right of umbilicus; smaller; not associated with other abnormalities; exposed to amniotic fluid
What electrolyte disturbances are common with omphalocele and gastroschisis?
Hypoglycemia and hypocalcemia
Where should the IV be placed for an omphalocele or gastroschisis?
Upper extremity
What is true of intra-abdominal pressure in omphalocele and gastroschisis?
Is increased and must be monitored
What are some important things to remember for intraop management of omphalocele and gastroschisis?
Warm OR (80*)
Check glucose, Ca, ABG
SaO2 94-97 (term); SaO2 90-94 (preterm)
Hct > 30%
What are the risks associated with primary closure of an omphalocele or gastroschisis?
Increased intra-abdominal pressure
Respiratory, renal, circulatory, GI dysfunction
Cyanotic legs, hypotension, poor venous return
What are the risks associated with secondary closure of an omphalocele or gastroschisis?
Infection!
Less compromise to other organs
What is the most common cause of neonatal GI obstruction?
Hirschprung’s disease
What are the treatment options for Hirschprung’s?
“Leveling” colostomy
Definitive = abdominoperineal resection with colon pull-through (when child reaches 10 kg)
90% of TEFs are what?
Esophageal atresia with distal fistula
What are the associated abnormalities with TEF?
Vertebral Anal Congenital heart disease TEF EA Renal or Radius anomalies Limb abnormalities
How does TEF usually present?
Polyhydramnios
Excessive oral secretions
Cyanosis with feedings
EA with air in stomach = TEF
What are the two main postoperative risks associated with TEF?
Aspiration and respiratory infections
What is necrotizing enterocolitis (NEC)?
Ischemic condition of GI tract of multifactorial etiology
What percentage of NEC patients are premature?
> 90%
What are the signs and symptoms of NEC?
Abdominal distension/discoloration Vomiting Bloody stools Temperature instability Shock (due to sepsis and 3rd space losses) DIC/Thrombocytopenia
What are the important metabolic preoperative considerations for NEC patients?
Hypoglycemia
Hypocalcemia
Severe acidosis (secondary to ischemia)
How is bicarbonate replacement managed?
HCO3 deficit = BD x wt x 0.3
Give half of calculated deficit SLOWLY
What is important to remember when considering a NEC patient’s fluid status?
Will need aggressive fluid resuscitation (150cc/kg)
However, this may cause IVH
What are some postoperative considerations for a NEC patient?
Remain intubated (PPV)
Persistent 3rd space loss
Increased intra-abdominal pressure
Max. Muscle relaxation
25% mortality due to sepsis, gangrenous bowel, resp. failure, IVH, PDA, refractory met. acidosis
What is congenital diaphragmatic hernia?
At 4-9 weeks gestation the pleuroperitoneal membrane separates the two cavities. INCOMPLETE CLOSURE of membrane allows bowel herniate into chest when gut returns from yolk sac to the abdomen at 9 weeks gestation
How does CDH impact development?
Has severe impact on lung development (particularly on one side)
-aka pulmonary hypoplasia
Where do most CDHs occur?
80% Foramen of Bochdalek (posterolateral)
L:R 5:1
What is often the cause of death with CDH?
Progressive hypoxemia, resp. failure, pulmonary HTN
The compression of abdominal contents in the chest causes what pathophysiological changes?
50% reduction in alveoli Bronchial arrest @ 11-13wks Mediastinal shift Hypoplastic pulm. artery Pulmonary HTN
100% of CDH patients have what GI anomaly?
Malrotation of bowel
What is the first line of treatment for CDH?
NOT surgical emergency
-medically stabilized
OR
-ECMO
What are the important criteria to remember during induction of a child with CDH?
Precordial on side opposite of defect
Awake intubation
NO mask ventilation
-want to avoid PTX on one good side
What must be maintained postop for a CDH patient in terms of respiratory status?
Respiratory alkalosis and PPV (determined by lung dz and intra-ab. pressure)
Minimal suctioning
What are some potential complications associated with CDH?
Contralateral PTX - do not attempt to expand lungs
Hypothermia
Metabolic acidosis
Persistent pulmonary HTN
What is the prognosis for CDH?
90% mortality (resp. distress in 1st hour)
80% mortality (contralateral PTX)
50% mortality (resp. distress 1st 6 hours)
What are the indications for ECMO?
Reversible resp. failure
Meconium aspiration, CDH, drowning, infection, asthma
What are the entry criteria for ECMO?
> 34 wk gestation
2 kg
Reversible lung dz
80% predicted mortality
What are the exclusion criteria for ECMO?
> grade II IVH
Other life threatening anomalies
What is myelodysplasia?
Abnormal fusion of neural groove in first month gestation leaving some portion of brain or cord exposed
Where are myelodysplasias most often found?
75% lumbosacral
What is the mortality rate associated with myelodysplasias and what is generally the cause of death?
17.6%
Morbidity: risk of infection secondary to exposed elements
What type of myelodysplasia requires an awake intubation?
Nasal encephalocele
What is a cystic hygroma?
Large lymphatic malformation
10-15% extend to mediastinum
What is important to remember about cystic hygromas?
May involve tongue, great vessels, brachioplexus, facial, vagus, phrenic, & hypoglossal nerves
- Airway compromise (+/- difficult intubation)
- Infection
- Bleeding
What is true of induction for cystic hygroma patients?
IV atropine before laryngoscopy
Maintain spontaneous ventilation
For almost all neonatal surgical emergencies what must be true of the operating room?
Keep it warm
What are some drugs that negatively affect lower esophageal sphincter (LES) tone?
Inhalational anesthetics Opioids Anticholinergics Propofol Beta blockers Glucagon Thiopental
What are some drugs that increase lower esophageal sphincter (LES) tone?
Anti-cholinesterase Cholinergics Acetylcholine Metoclopramide Serotonin Metoprolol
What two factors put the patient at high risk for aspiration pneumonitis?
Volume > 25 mL
pH < 2.5
What are some complications associated with diverticulitis?
Bleeding, abscess, perforation, peritonitis, fistula, obstruction
The GI tract handles how much fluid and secretions per day? How much of that is not absorbed?
9L/day
100 mL not absorbed
What is the normal pH of gastric fluid?
1-3.5
What effects do sympathetic and parasympathetic stimulation have on GI motility?
Parasympathetic stimulation = Increases motility
Sympathetic stimulation = Decreases motility
Which structure is responsible for preventing aspiration of gastric contents into the lungs and the swallowing of air?
(UES) Upper esophageal sphincter
What effect do most anesthetic agents have on UES? What is the exception?
Decrease
Ketamine increases
What is the resting pressure for the lower esophageal sphincter (LES)? At what pressure does it become problematic?
Resting = 15-30mmHg Problem = 10 mmHg
Define barrier pressure
Difference between gastric pressure and LES pressure
What is the name of the condition in which regular reflux of stomach acid irritates the esophagus, which leads to histological changes of the esophageal lining?
Barrett’s Esophagus
Which condition requires an RSI because the LES does not relax properly?
Achalasia
What are esophageal varices? What is generally the cause?
Esophageal varices = Dilated veins in the distal esophagus (@ risk for serious bleed)
Cause = portal hypertension
What is the treatment for portal hypertension?
Transjugular intrahepatic portosystemic shunt (TIPS)
What GI medical emergency leads to sepsis and has the best outcome with early diagnosis (w/in 12 hrs)?
Upper GI perforation
What stomach disorder is commonly seen in conjunction with poorly controlled diabetes?
Gastroparesis = Delayed gastric emptying
Gastritis is commonly associated with what bacterial infection?
Heliobactor pylori
What are the five sections of the stomach?
Cardia Fundus Body Antrum Pylorus
What is the function of the stomach?
Responsible for food storage and initial digestion
NOT Nutrient absorption
What is responsible for the primary innervation of the stomach?
Vagus nerve
What is the treatment for GERD and hiatal hernia?
Nissen fundoplication
Intra-abdominal pressure in excess of what decreases venous return?
> 15 mmHg
What causes shoulder pain following laparoscopic surgery?
Referred pain from stimulation to the phrenic nerve
Where does most digestion and absorption occur?
Small intestine
How much time does the body produce per day?
1-2L/day
Which autoimmune disorder destroys the villi in the small intestine and cause a reaction to eating gluten?
Celiac disease
What are the two main inflammatory bowel diseases?
Crohn’s disease
Ulcerative colitis
How much bile is stored in the gallbladder?
50 mL
What are some causes of pancreatitis?
Alcohol abuse, blockage, trauma, autoimmune, hyperparathyroid, cystic fibrosis
Propofol can cause at high doses
What is the most common cause of emergency abdominal surgery?
Appendicitis
What is ERCP?
Endoscopic retrograde cholangiopancreatography
-View the entrance of the common bile duct
Where are water and electrolytes absorbed?
Large intestine
How do gastric secretions compare to colonic secretions?
Gastric = very acidic Colon = alkaline
What is the most common manifestation of carcinoid syndrome?
60% Carcinoid heart disease
-Right-sided involvement (tricuspid regurgitation and pulmonary valve involvement)
What is octreotide?
Somatostatin infusion
What are the four life-threatening causes of agitation during a MAC case?
Hypoxemia
Hypoventilation
Local toxicity
Cerebral hypoperfusion
Why might glycopyrrolate be given in conjunction with ketamine?
Glycopyrrolate controls the excessive secretions caused by ketamine
Why might glucagon be given for a GI case?
Glucagon relaxes the sphincter of Oddi
What does methylnaltrexone do?
Reverses bowel immobility from narcotics (used in ICU)
Be able to trace the flow of food from the time it enters the mouth to leaving the body
Mouth-esophagus-stomach-duodenum-jejunum-ileum-cecum-ascending colon-transverse colon-descending colon-sigmoid colon-rectum
The appendix lies in closest proximity to what GI structure?
Cecum
Where does the pancreas reside?
Immediately below the stomach and next to the duodenum
What is the name for the connection between the common bile duct and pancreatic duct? Where does it lie?
Sphincter of Oddi
Connects to duodenum
The common bile duct is made up of what two smaller ducts?
Hepatic duct
Cystic duct
For gastric bypass surgery, what portion of the GI tract is bypassed?
The jejunum connects directly to the esophagus bypassing the stomach and duodenum
What is part of the GI anatomy is manipulated during a nissen fundopliation?
The fundus of the stomach is wrapped around the lower esophagus
What is the Zenker’s diverticulum?
Diverticulum of the mucosas of the pharynx just above the cricopharyngeal muscle (above UES)
What effects do sympathetic and parasympathetic stimulation have on GI motility?
Parasympathetic stimulation = Increases motility
Sympathetic stimulation = Decreases motility
Which structure is responsible for preventing aspiration of gastric contents into the lungs and the swallowing of air?
(UES) Upper esophageal sphincter
What effect do most anesthetic agents have on UES? What is the exception?
Decrease
Ketamine increases
What is the resting pressure for the lower esophageal sphincter (LES)? At what pressure does it become problematic?
Resting = 15-30mmHg Problem = 10 mmHg
Define barrier pressure
Difference between gastric pressure and LES pressure
What is the name of the condition in which regular reflux of stomach acid irritates the esophagus, which leads to histological changes of the esophageal lining?
Barrett’s Esophagus
Which condition requires an RSI because the LES does not relax properly?
Achalasia
What are esophageal varices? What is generally the cause?
Esophageal varices = Dilated veins in the distal esophagus (@ risk for serious bleed)
Cause = portal hypertension
What is the treatment for portal hypertension?
Transjugular intrahepatic portosystemic shunt (TIPS)
What GI medical emergency leads to sepsis and has the best outcome with early diagnosis (w/in 12 hrs)?
Upper GI perforation
What stomach disorder is commonly seen in conjunction with poorly controlled diabetes?
Gastroparesis = Delayed gastric emptying
Gastritis is commonly associated with what bacterial infection?
Heliobactor pylori
What are the five sections of the stomach?
Cardia Fundus Body Antrum Pylorus
What is the function of the stomach?
Responsible for food storage and initial digestion
NOT Nutrient absorption
What is responsible for the primary innervation of the stomach?
Vagus nerve
What is the treatment for GERD and hiatal hernia?
Nissen fundoplication
Intra-abdominal pressure in excess of what decreases venous return?
> 15 mmHg
What causes shoulder pain following laparoscopic surgery?
Referred pain from stimulation to the phrenic nerve
Where does most digestion and absorption occur?
Small intestine
How much time does the body produce per day?
1-2L/day
Which autoimmune disorder destroys the villi in the small intestine and cause a reaction to eating gluten?
Celiac disease
What are the two main inflammatory bowel diseases?
Crohn’s disease
Ulcerative colitis
How much bile is stored in the gallbladder?
50 mL
What are some causes of pancreatitis?
Alcohol abuse, blockage, trauma, autoimmune, hyperparathyroid, cystic fibrosis
Propofol can cause at high doses
What is the most common cause of emergency abdominal surgery?
Appendicitis
What is ERCP?
Endoscopic retrograde cholangiopancreatography
-View the entrance of the common bile duct
Where are water and electrolytes absorbed?
Large intestine
How do gastric secretions compare to colonic secretions?
Gastric = very acidic Colon = alkaline
What is the most common manifestation of carcinoid syndrome?
60% Carcinoid heart disease
-Right-sided involvement (tricuspid regurgitation and pulmonary valve involvement)
What is octreotide?
Somatostatin infusion
What are the four life-threatening causes of agitation during a MAC case?
Hypoxemia
Hypoventilation
Local toxicity
Cerebral hypoperfusion
Why might glycopyrrolate be given in conjunction with ketamine?
Glycopyrrolate controls the excessive secretions caused by ketamine
Why might glucagon be given for a GI case?
Glucagon relaxes the sphincter of Oddi
What does methylnaltrexone do?
Reverses bowel immobility from narcotics (used in ICU)
Be able to trace the flow of food from the time it enters the mouth to leaving the body
Mouth-esophagus-stomach-duodenum-jejunum-ileum-cecum-ascending colon-transverse colon-descending colon-sigmoid colon-rectum
The appendix lies in closest proximity to what GI structure?
Cecum
Where does the pancreas reside?
Immediately below the stomach and next to the duodenum
What is the name for the connection between the common bile duct and pancreatic duct? Where does it lie?
Sphincter of Oddi
Connects to duodenum
The common bile duct is made up of what two smaller ducts?
Hepatic duct
Cystic duct
For gastric bypass surgery, what portion of the GI tract is bypassed?
The jejunum connects directly to the esophagus bypassing the stomach and duodenum
What is part of the GI anatomy is manipulated during a nissen fundopliation?
The fundus of the stomach is wrapped around the lower esophagus
What is the Zenker’s diverticulum?
Diverticulum of the mucosas of the pharynx just above the cricopharyngeal muscle (above UES)
What procedure (generally performed under MAC) is used to view the upper GI tract? Lower GI tract?
Upper = (EGD) Esophagogastroduodenoscopy Lower = Colonoscopy
What per engage of a term newborn’s total body weight consists of water?
75%
What procedure (generally performed under MAC) is used to view the upper GI tract? Lower GI tract?
Upper = (EGD) Esophagogastroduodenoscopy Lower = Colonoscopy
