Exam IV: Anesthesia for Neonates and Infants Flashcards
1
Q
preterm definition
A
< 37 weeks gestation
2
Q
low birth weight def:
A
<2500 gram (5.5 lb)
3
Q
very low birth weight def:
A
<1500 gram (3.3 lb)
4
Q
extremely low birth weight def:
A
<1000 gram (2.2 lb)
5
Q
Premie Respiratory Physiology
Small airways predispose to _______
A
obstruction
6
Q
Premie Respiratory Physiology
Surfactant production incomplete until ____ ____ gestation
A
36 weeks
7
Q
Premie Respiratory Physiology
Low surfactant leads to increased _____ _____ _____
A
alveolar surface tension
8
Q
Premie Respiratory Physiology
O2 toxicity and barotrauma causes ________ ______ (____)
A
bronchopulmonary dysplasia (BPD)
9
Q
Apnea
Common in premies, decreases with advancing ____-_____ ____
A
post-conceptual age
10
Q
Apnea
Central: Failure to breathe (usually _____)
A
neuro
11
Q
Apnea
Obstructive: Inability to maintain a _____ _____
A
patent airway - some have a mix of both central and obstructive
12
Q
Apnea
_____ increases the incidence of apnea
A
Anesthesia
13
Q
Apnea
Incidence of apnea significantly decreases at ____ ____ _______ age
A
55 weeks postconceptual
14
Q
Apnea
Incidence depends on (3 things)
A
postconceptual age, HCT & surgical procedure
15
Q
Apnea
Most significant risk factor:
A
Postconceptual age
16
Q
Apnea
Usually begins within the 1st post-op hour and risk continues for ____ ____
A
48 hrs
17
Q
Apnea
Studies show apnea can occur after _____ alone
A
regional
18
Q
Premie CV Physiology
Cardiac output dependent on heart rate (_______ can be LETHAL)
A
bradycardia
19
Q
Premie CV Physiology
Small absolute blood volume so _____ & ______ occur quickly
A
hypovolemia & hypotension
20
Q
Premie CV Physiology
poorly developed ______
A
autoregulation
21
Q
Premie CV Physiology
Many have a ____ _____ _____ (___) causing pulmonary hypertension and CHF
A
patent ductus arteriosus (PDA)
22
Q
Premie Neuro Physiology
- Pain receptors begin developing at ____ _____ gestation
- Controversy: When does pain perception and memory begin?
- Current practice: Anesthesia and analgesia with post-op pain management - regardless of _____ ____
A
19 weeks
gestational age
23
Q
neuro phys:
- ______ _____ (___) huge problem in premies
- Grade I – IV
- Grade IV causes severe long-term neuro consequences (CP, development delays, neurologic devastation)
- Many risk factors (fetal distress, low APGARs, acidosis, hypercapnia, +pressure ventilation, vasopressors, rapid changes in cerebral blood flow)
A
Intraventricular hemorrhage (IVH)
24
Q
Temp Regulation
Premie method of heat production:
A
Non-shivering thermogenesis
25
Temp Regulation
Dependent on brown fat stores (____ in premies)
low
26
Temp Regulation
Lots of warming techniques:
Lights, fluid warmers, plastic, low flows, warm OR
27
Temp Regulation
Most effective means of warming:
Forced Hot Air Warming
28
Metabolic Physiology
- Decrease renal fx due to less nephrons and smaller glomerular size
- Hypo______ common
- Immature hepatic fx can affect drug metabolism
- At risk for _____ _____ _____
- Thrombocytopenia common (sepsis, DIC, NEC)
natremia
spontaneous liver hemorrhage
29
Glucose Requirements
At risk for hypoglycemia due to ↓ _____ & ____ ____
At risk for hyperglycemia due to combo of ↓ insulin production and glucose infusions
Glucose infusions via pumps with monitoring of blood glucose levels should _____ _____
glycogen and body fat
continue intraoperatively
30
General and regional techniques used
Generals done with inhaled and IV agents
Current trend: Low volatile with opioids or regional when possible
Common in neonates:
High dose opioid with relaxant and post-op ventilation (promotes hemodynamic stability)
31
venous access is
a MAJOR PROBLEM r/t small vessels, dehydration, 3rd space losses, over-used thrombotic veins
32
where to go?
UACs, UVC, scalp, peripheral, CVLs, and PICCs
33
may need
surgically placed lines
34
Routine monitoring:
EKG, precordial or esophageal stethoscope, non-invasive BP, temp, SaO2 & EtCO2
35
May need _____ line (UAC, radial, posterior tibial, dorsalis pedis) and _____
arterial
foley
36
Preductal SaO2: ____ hand
Right
37
_____ductal SaO2: Any other extremity (Historically useful to trend shunting)
Post
38
Prevention:
- Heat the room, the OR table, fluids, circuit
- If staff is not sweating (especially the surgeon), the OR is probably too cold
- LABS, LABS, LABS
- Blood availability
- NICU vent settings
- Access (may need CVL consult)
- Fluids & pumps
- Informed consent
39
Neonatal Airway Procedures (5)
- Choanal Atresia & Stenosis
- Laryngeal Webs
- Subglottic Stenosis
- Tracheoesophageal Fistula (TEF)
- Congenital Diaphragmatic Hernia (CDH)
40
Choanal Atresia
- Failure of nasopharyngeal bone to regress during development leading to ______ or _____ obstruction
- May be part of “CHARGE” syndrome
- Coloboma, H____ _____, Atresia of choana, Retarded growth, Genital & Ear anomalies
unilateral or bilateral
Heart dz
41
Laryngeal Webs
Fibrous membrane obstructs airway leading to respiratory distress
Complete obstruction is delivery room emergency
Tx with ETT, cricothyrotomy* or tracheostomy
Electively, _____ ____ without ENT available for emergent tracheostomy
NEVER PROCEED
*extremely difficult in infants & neonates – rarely (if ever) used
42
Subglottic Stenosis
Severity dependent on degree of narrowing
______ than ______ ETT needed
Smaller than expected
43
Subglottic Stenosis
Remember ______ _____ – Small ↓ in airway diameter = large ↑ in airway resistance
Definitive repair: Laryngeal tracheal reconstruction (LTR)
Poiseuille’s law
44
TE Fistula
Frequently with VACTERL (formerly VATERs) syndrome
Vertebral anomalies, imperforate Anus, C_____ _____ _____, TE fistula, Renal anomalies, Limb anomalies
congenital heart disease
45
TE fistula
Most common: Blind esophageal pouch - distal end to trachea just above carina
Many get _____ _____ for venting pre-op
gastrostomy tube
46
TE fistula
Correct ETT placement crucial: Below _____, above _____ (confirm with FOB)
fistula
carina
47
Congenital Diaphragmatic Hernia
Failure of diaphragmatic fusion causing abdominal contents inside thoracic cavity
_____ _____!!! (Inability to oxygenate with mediastinal shift)
HUGE EMERGENCY
48
Congenital Diaphragmatic Hernia
_____ diagnosis greatly improves outcome
Prenatal
49
Congenital Diaphragmatic Hernia
EXIT (EX utero Intrapartum Treatment)
Alternative ventilation techniques (_______, ______)
oscillators, HFJV
50
Congenital Diaphragmatic Hernia
Pulmonary _______ - prostaglandins, nitrates, NO (nitric oxide)
vasodilators
51
Congenital Diaphragmatic Hernia
- ______ (ExtraCorporeal Membrane Oxygenation)
- WHEN STABLE, surgical repair (often in NICU)
ECMO
52
Anesthesia and CDH Repair
Infant may come to OR with nonconventional vent (_____, _____) needs, ____ system or _____
HFJV, oscillator
NO
ECMO
53
Anesthesia and CDH Repair
- Often done in NICU
- Medical treatments (prostaglandins) cause hypotension and bleeding
- _____ causes anticoagulation and platelet dysfunction
- Inadvertent ECMO decannulation leading to _____ _____
ECMO
RAPID exsanguination
54
Anesthesia and CDH Repair
****Required high PIPs lead to potential ______
PTXs
55
Intestinal Obstructions
Associated with _______ _______(ie, meconium ileus/CF, duodenal atresia/trisomy 21)
other anomalies
56
Intestinal Obstructions
Abdominal distension with major ____ _____, _____, ______ imbalance
3rd spacing, vomiting, electrolyte imbalance
57
Intestinal Obstructions
Sepsis, relative _______, anemia, hemodynamically ______, pressors
hypovolemia
unstable
58
Intestinal Obstructions
Prone to hypo_____, hypo_____, hyper______
Prone to hypothermia, hypoglycemia, hyperglycemia
59
Intestinal Obstructions
Need _____
RSI
60
Intestinal Obstructions
NO _____
nitrous
61
Intestinal Obstructions
probably post-op ______
ventilation
62
Pyloric Stenosis
_____ - _____ week of life, full term, OTW healthy, at home.
2nd – 6th
63
Pyloric Stenosis
Non-bilious, ______ vomiting
projectile
64
Pyloric Stenosis
_____ emergency, NOT _____
Medical
surgical
65
Pyloric Stenosis
Hypo______, hypo______, metabolic alkalosis (due to vomiting) must be corrected pre-op
hypokalemic
hypochloremic
66
Pyloric Stenosis
Clear stomach with _____ _____ lavage before a true RSI
warmed NS
67
Imperforate Anus
______ to _____ meconium in 1st 48 hours
Failure to pass
68
Imperforate Anus
Common with ______ syndrome
VACTERL
69
Imperforate Anus
should have _____ eval with ECHO preop
CV
70
Imperforate Anus
many require _____ before definitive repair, consider ____
ostomy
RSI
71
NEC (necrotizing enterocolitis)
Sick, SICK, SICK
_____ ______ leads to shunting away from gut causing necrotic bowel/perforation/sepsis
Perinatal hypoxia
72
NEC (necrotizing enterocolitis)
Acidotic, hypotensive, anemic, coag dysfunction, huge _____ _____ loss and anemia leading to huge fluid and _____ _____ needs
3rd space
blood product
73
NEC (necrotizing enterocolitis)
commonly on ______, consider _____
pressors
RSI
74
NEC (necrotizing enterocolitis)
NO N2O, high _____, relaxant, volatile agent?
opioid
75
Omphalocele and Gastroschisis
____ _____ outside abdominal wall
GI organs
76
Omphalocele and Gastroschisis
huge ____ _____ loss, often treated with _____ pre-op
3rd space
silo
77
Omphalocele and Gastroschisis
__________ associated with other anomalies
Omphalocele
78
Omphalocele and Gastroschisis
Primary closure leads to need for _____ _____
Consider post-op ventilation
higher PIPs
79
Volvulus
Incomplete migration or malrotation of _____ from _____ _____ into abdomen
intestines
yolk sac
80
Volvulus
Emergent if _______ is suspected
strangulation
81
Volvulus
Hypo_____, hypo_____, electrolyte imbalance
No N2O, RSI
hypotensive
hypovolemic
82
_____ _____ - most common neonatal colonic obstruction
Hirschsprung Dz
83
Hirschsprung Dz
Absence of _______ _______ cells leading to a non-peristaltic segment
parasympathetic ganglion
84
Hirschsprung Dz
Often get _____ before definitive repair
ostomy
85
Hirschsprung Dz
Intra-op _____ ______ to find functional ganglia, "____ ____" for definitive repair
sequential testing
"pull through"
86
Hirschsprung Dz
No _____, no _____ due to nerve monitoring
N2O
relaxant
87
Hirschsprung Dz
good drug choices:
low volaitles and remifent
88
hernias - common in _____ infants, can be emergent if ______
preterm
incarcerated
89
hernia - must be admitted for apnea monitoring if ______ _____ post conceptual age
<55 weeks
90
Consider the following: Ex 28 wk premie, now 5 months old, admitted for out-patient hernia repair. Can he go home???
no
28+20=48 weeks
91
PDA Ligation
A patent ductus arteriosus (PDA) is _____ in _____ infants
common in preterm
92
PDA Ligation
___ to ___ shunting (non-cyanotic) causes CHF and respiratory failure
L to R
93
PDA Ligation
With _____ _____ _____ of the newborn (PPHN), R>L shunting (cyanotic) can occur
persistent pulmonary hypertension
94
PDA Ligation
Because of proximity to vessels, massive sudden _____ ____ can occur
blood loss
95
PDA ligation
Consider ______ and ______ monitoring
pre-ductal and post-ductal
96
PDA ligation
Open thoracotomy or _____
VATS
97
PDA ligation
High _____, _____, _______ ventilation is technique of choice
opioid, relaxant, post-op
98
Other Common Neonatal Procedures
- VP (ventriculo-peritoneal) shunts, EVDs (external ventricular devices) and sub-galeal shunts for IVH/hydrocephalus
- CVLs for long-term TPN, meds or access
- LASER for retinopathy of prematurity (ROP)
- Bronchoscopies, esophagoscopies
- Tracheostomies
- Fundoplication and/or gastrostomy tubes
