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NUNA 692 Principles III > Exam IV: Anesthesia for Neonates and Infants > Flashcards

Exam IV: Anesthesia for Neonates and Infants Flashcards

1
Q

preterm definition

A

< 37 weeks gestation

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2
Q

low birth weight def:

A

<2500 gram (5.5 lb)

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3
Q

very low birth weight def:

A

<1500 gram (3.3 lb)

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4
Q

extremely low birth weight def:

A

<1000 gram (2.2 lb)

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5
Q

Premie Respiratory Physiology

Small airways predispose to _______

A

obstruction

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6
Q

Premie Respiratory Physiology

Surfactant production incomplete until ____ ____ gestation

A

36 weeks

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7
Q

Premie Respiratory Physiology

Low surfactant leads to increased _____ _____ _____

A

alveolar surface tension

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8
Q

Premie Respiratory Physiology

O2 toxicity and barotrauma causes ________ ______ (____)

A

bronchopulmonary dysplasia (BPD)

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9
Q

Apnea

Common in premies, decreases with advancing ____-_____ ____

A

post-conceptual age

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10
Q

Apnea

Central: Failure to breathe (usually _____)

A

neuro

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11
Q

Apnea

Obstructive: Inability to maintain a _____ _____

A

patent airway - some have a mix of both central and obstructive

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12
Q

Apnea

_____ increases the incidence of apnea

A

Anesthesia

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13
Q

Apnea

Incidence of apnea significantly decreases at ____ ____ _______ age

A

55 weeks postconceptual

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14
Q

Apnea

Incidence depends on (3 things)

A

postconceptual age, HCT & surgical procedure

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15
Q

Apnea

Most significant risk factor:

A

Postconceptual age

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16
Q

Apnea

Usually begins within the 1st post-op hour and risk continues for ____ ____

A

48 hrs

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17
Q

Apnea

Studies show apnea can occur after _____ alone

A

regional

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18
Q

Premie CV Physiology

Cardiac output dependent on heart rate (_______ can be LETHAL)

A

bradycardia

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19
Q

Premie CV Physiology

Small absolute blood volume so _____ & ______ occur quickly

A

hypovolemia & hypotension

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20
Q

Premie CV Physiology

poorly developed ______

A

autoregulation

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21
Q

Premie CV Physiology

Many have a ____ _____ _____ (___) causing pulmonary hypertension and CHF

A

patent ductus arteriosus (PDA)

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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

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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)

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24
Q

Temp Regulation

Premie method of heat production:

A

Non-shivering thermogenesis

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25
Q

Temp Regulation

Dependent on brown fat stores (____ in premies)

A

low

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26
Q

Temp Regulation

Lots of warming techniques:

A

Lights, fluid warmers, plastic, low flows, warm OR

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27
Q

Temp Regulation

Most effective means of warming:

A

Forced Hot Air Warming

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28
Q

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)
A

natremia
spontaneous liver hemorrhage

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29
Q

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 _____ _____

A

glycogen and body fat
continue intraoperatively

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30
Q

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:

A

High dose opioid with relaxant and post-op ventilation (promotes hemodynamic stability)

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31
Q

venous access is

A

a MAJOR PROBLEM r/t small vessels, dehydration, 3rd space losses, over-used thrombotic veins

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32
Q

where to go?

A

UACs, UVC, scalp, peripheral, CVLs, and PICCs

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33
Q

may need

A

surgically placed lines

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34
Q

Routine monitoring:

A

EKG, precordial or esophageal stethoscope, non-invasive BP, temp, SaO2 & EtCO2

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35
Q

May need _____ line (UAC, radial, posterior tibial, dorsalis pedis) and _____

A

arterial
foley

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36
Q

Preductal SaO2: ____ hand

A

Right

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37
Q

_____ductal SaO2: Any other extremity (Historically useful to trend shunting)

A

Post

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38
Q

Prevention:

A
  • 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
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39
Q

Neonatal Airway Procedures (5)

A
  • Choanal Atresia & Stenosis
  • Laryngeal Webs
  • Subglottic Stenosis
  • Tracheoesophageal Fistula (TEF)
  • Congenital Diaphragmatic Hernia (CDH)
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40
Q

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
A

unilateral or bilateral
Heart dz

41
Q

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

A

NEVER PROCEED

*extremely difficult in infants & neonates – rarely (if ever) used

42
Q

Subglottic Stenosis

Severity dependent on degree of narrowing
______ than ______ ETT needed

A

Smaller than expected

43
Q

Subglottic Stenosis

Remember ______ _____ – Small ↓ in airway diameter = large ↑ in airway resistance
Definitive repair: Laryngeal tracheal reconstruction (LTR)

A

Poiseuille’s law

44
Q

TE Fistula

Frequently with VACTERL (formerly VATERs) syndrome
Vertebral anomalies, imperforate Anus, C_____ _____ _____, TE fistula, Renal anomalies, Limb anomalies

A

congenital heart disease

45
Q

TE fistula

Most common: Blind esophageal pouch - distal end to trachea just above carina
Many get _____ _____ for venting pre-op

A

gastrostomy tube

46
Q

TE fistula

Correct ETT placement crucial: Below _____, above _____ (confirm with FOB)

A

fistula
carina

47
Q

Congenital Diaphragmatic Hernia

Failure of diaphragmatic fusion causing abdominal contents inside thoracic cavity
_____ _____!!! (Inability to oxygenate with mediastinal shift)

A

HUGE EMERGENCY

48
Q

Congenital Diaphragmatic Hernia

_____ diagnosis greatly improves outcome

49
Q

Congenital Diaphragmatic Hernia

EXIT (EX utero Intrapartum Treatment)
Alternative ventilation techniques (_______, ______)

A

oscillators, HFJV

50
Q

Congenital Diaphragmatic Hernia

Pulmonary _______ - prostaglandins, nitrates, NO (nitric oxide)

A

vasodilators

51
Q

Congenital Diaphragmatic Hernia

  • ______ (ExtraCorporeal Membrane Oxygenation)
  • WHEN STABLE, surgical repair (often in NICU)
52
Q

Anesthesia and CDH Repair

Infant may come to OR with nonconventional vent (_____, _____) needs, ____ system or _____

A

HFJV, oscillator
NO
ECMO

53
Q

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 _____ _____
A

ECMO
RAPID exsanguination

54
Q

Anesthesia and CDH Repair

**Required high PIPs lead to potential ______

55
Q

Intestinal Obstructions

Associated with _______ _______(ie, meconium ileus/CF, duodenal atresia/trisomy 21)

A

other anomalies

56
Q

Intestinal Obstructions

Abdominal distension with major ____ _____, _____, ______ imbalance

A

3rd spacing, vomiting, electrolyte imbalance

57
Q

Intestinal Obstructions

Sepsis, relative _______, anemia, hemodynamically ______, pressors

A

hypovolemia
unstable

58
Q

Intestinal Obstructions

Prone to hypo_____, hypo_____, hyper______

A

Prone to hypothermia, hypoglycemia, hyperglycemia

59
Q

Intestinal Obstructions

Need _____

60
Q

Intestinal Obstructions

NO _____

61
Q

Intestinal Obstructions

probably post-op ______

A

ventilation

62
Q

Pyloric Stenosis

_____ - _____ week of life, full term, OTW healthy, at home.

A

2nd – 6th

63
Q

Pyloric Stenosis

Non-bilious, ______ vomiting

A

projectile

64
Q

Pyloric Stenosis

_____ emergency, NOT _____

A

Medical
surgical

65
Q

Pyloric Stenosis

Hypo______, hypo______, metabolic alkalosis (due to vomiting) must be corrected pre-op

A

hypokalemic
hypochloremic

66
Q

Pyloric Stenosis

Clear stomach with _____ _____ lavage before a true RSI

67
Q

Imperforate Anus

______ to _____ meconium in 1st 48 hours

A

Failure to pass

68
Q

Imperforate Anus

Common with ______ syndrome

69
Q

Imperforate Anus

should have _____ eval with ECHO preop

70
Q

Imperforate Anus

many require _____ before definitive repair, consider ____

71
Q

NEC (necrotizing enterocolitis)

Sick, SICK, SICK
_____ ______ leads to shunting away from gut causing necrotic bowel/perforation/sepsis

A

Perinatal hypoxia

72
Q

NEC (necrotizing enterocolitis)

Acidotic, hypotensive, anemic, coag dysfunction, huge _____ _____ loss and anemia leading to huge fluid and _____ _____ needs

A

3rd space
blood product

73
Q

NEC (necrotizing enterocolitis)

commonly on ______, consider _____

A

pressors
RSI

74
Q

NEC (necrotizing enterocolitis)

NO N2O, high _____, relaxant, volatile agent?

75
Q

Omphaloceleand Gastroschisis

____ _____ outside abdominal wall

76
Q

Omphaloceleand Gastroschisis

huge ____ _____ loss, often treated with _____ pre-op

A

3rd space
silo

77
Q

Omphalocele and Gastroschisis

__________ associated with other anomalies

A

Omphalocele

78
Q

Omphalocele and Gastroschisis

Primary closure leads to need for _____ _____
Consider post-op ventilation

A

higher PIPs

79
Q

Volvulus

Incomplete migration or malrotation of _____ from _____ _____ into abdomen

A

intestines
yolk sac

80
Q

Volvulus

Emergent if _______ is suspected

A

strangulation

81
Q

Volvulus

Hypo_____, hypo_____, electrolyte imbalance
No N2O, RSI

A

hypotensive
hypovolemic

82
Q

_____ _____ - most common neonatal colonic obstruction

A

Hirschsprung Dz

83
Q

Hirschsprung Dz

Absence of _______ _______ cells leading to a non-peristaltic segment

A

parasympathetic ganglion

84
Q

Hirschsprung Dz

Often get _____ before definitive repair

85
Q

Hirschsprung Dz

Intra-op _____ ______ to find functional ganglia, “____ ____” for definitive repair

A

sequential testing
“pull through”

86
Q

Hirschsprung Dz

No _____, no _____ due to nerve monitoring

A

N2O
relaxant

87
Q

Hirschsprung Dz

good drug choices:

A

low volaitles and remifent

88
Q

hernias - common in _____ infants, can be emergent if ______

A

preterm
incarcerated

89
Q

hernia - must be admitted for apnea monitoring if ______ _____ post conceptual age

90
Q

Consider the following: Ex 28 wk premie, now 5 months old, admitted for out-patient hernia repair. Can he go home???

A

no

28+20=48 weeks

91
Q

PDA Ligation

A patent ductus arteriosus (PDA) is _____ in _____ infants

A

common in preterm

92
Q

PDA Ligation

___ to ___ shunting (non-cyanotic) causes CHF and respiratory failure

93
Q

PDA Ligation

With _____ _____ _____ of the newborn (PPHN), R>L shunting (cyanotic) can occur

A

persistent pulmonary hypertension

94
Q

PDA Ligation

Because of proximity to vessels, massive sudden _____ ____ can occur

A

blood loss

95
Q

PDA ligation

Consider ______ and ______ monitoring

A

pre-ductal and post-ductal

96
Q

PDA ligation

Open thoracotomy or _____

97
Q

PDA ligation

High _____, _____, _______ ventilation is technique of choice

A

opioid, relaxant, post-op

98
Q

Other Common Neonatal Procedures

A
  • 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

NUNA 692 Principles III (20 decks)

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