Exam IV: Common Post Anesthesia Complications in Children Flashcards
Laryngospasm
Any _____ patient
Any _____
Induction or emergence
_____ or _____ extubation
May have no precipitating cause
pediatric
technique
Deep or awake
Laryngospasm
Most common culprit: ___________________
Secretions and/or stimulation during Stage 2
What can we do to prevent laryngospasms during intubation? (2)
- Do not rush, especially with no muscle relaxant (MR).
- Before repeated laryngoscopy with no MR, re-dose propofol or mask ventilate with high-percent sevo.
What can we do to prevent laryngospasms during extubation? (5)
- Suction oropharynx before extubation.
- Extubate end-inspiration or with positive pressure.
- Extubating awake? Make sure they are AWAKE.
- Extubating deep? Keep them DEEP.
- Immediately upon extubation, apply PEEP until air movement is confirmed.
Laryngospasm Treatment:
100% O2 with ____ _____
+ pressure
Laryngospasm Treatment:
______ 0.5-1mg/kg
Lidocaine
Laryngospasm Treatment:
Succinylcholine (__-__ ___) with _____ (0.1mg) in young children
0.5-1 mg/kg
atropine
Laryngospasm Treatment:
I_____
Intubate
Laryngospasm Treatment:
BEWARE of post-obstructive _____ _____ ______ edema
negative pressure pulmonary edema (especially in muscular, adolescent males)
“If the laryngeal nerve becomes _____ enough, a laryngospasm will break.”
hypoxic
But until then… What about hypoxia in infants?
Hypoxia causes bradycardia which causes ______ and eventually _____
Must treat decreasing heart rate quickly!
dysrhythmias
arrest
Succinylcholine leads to _______
Many advocate _____ with sux, but that practice is being questioned.
bradycardia
atropine
Consider quick, aggressive treatment for those at high risk of _____ _____ _____ edema.
negative pressure pulmonary
Bronchospasm
Increased risk with hx of ____ _____ disease
reactive airway
Bronchospasm
Usually during _____, before extubation
emergence
Bronchospasm
May require extremely ___ ___ (uncuffed ETT?)
high PIP
Bronchospasm
Treatment: ____ ____
β2 agonist (albuterol) aerosol
Bronchospasm
If severe: ______ (____/___ ___)
Epinephrine (10 mcg/kg IV)
Bronchospasm
If severe and extubated: _____
Reintubate
About Epinephrine…
Your patient weighs 10 kg
You want to give 10 mcg/kg
10 mcg x 10 kg = 100 mcg
How many mcg/mL in this Epi jet?
Answer: 100 mcg/mL
SO – For every 10 kg, give 1 mL of 1:10,000 Epi
Airway Obstruction
- Sedation due to _____, _____, _____ anesthesia
- ______ neuromuscular blockade
- Positioning
- Sleep apnea
- Laryngospasm
- Laryngeal ____
- Secretions
- Wound hematoma
- Vocal cord _____
opioids, midazolam, general anesthesia
Residual
edema
paralysis
A/W obstruction symptoms
- Desaturation
- Stridor
- Paradoxical breathing
- Inspiratory retractions
A/W obstruction interventions
Stimulation
Chin lift, jaw thrust*
Oral or nasal airway
Repositioning
Suctioning
CPAP, PEEP
Antagonists
Intubation
PONV - determine _____ if possible
cause
(Opioids, ileus, gastric distension, pain, blood in stomach, vagal stimulation, motion, increased ICP)
PONV - continue _____
IVF
PONV - most effective prophylaxis
Hydration + 5-HT3 antagonist + dexamethasone
PONV - most effective rescue
5-HT3 antagonist, Phenergan, Non-opioid analgesics
Aspiration Prevention:
Suction after _____ and before extubation
induction
Aspiration Prevention:
Minimal ____ with LMAs and masks
PIPs
Aspiration Prevention:
Extubate with ____ ____ intact
airway reflexes
Aspiration Prevention:
_____ position postoperatively
Recovery
Aspiration Prevention:
Medical _____
prophylaxis
If aspiration suspected…
Baseline CXR and ABG
CXR re-evaluation at 4 hours
No change = _____ _____ _____
Probably no aspiration
Mild aspiration: _____ and _____ _____
O2 and chest PT
Major aspiration: _____, _____ ventilation, ____ may be required
Intubation, mechanical ventilation, ICU may be required.
Pulm edema causes: (2)
- Fluid overload (especially with poor CV reserve)
- Post-obstructive negative pressure incident
Pulm edema treatment: (4)
Health pt should _____ within a few hours
- O2
- Diuretics
- Admit until resolved
- Reintubate if severe
resolve
Hemodynamic Instability
______: Uncommon in peds except with congenital heart disease or hypovolemia
Hypotension
Hemodynamic Instability Treatment:
- IV fluid boluses (crystalloid or colloid) if Hct stable
- PRBCs may be indicated.
- Recombinant Factor VII (Novo 7®)
Return to OR?
Hemodynamic Instability
Hypertension usually due to ____
pain.
____ overload can cause HTN.
Fluid
Hemodynamic Stability
Bradycardia (significant?)
Tachycardia (significant?)
Other dysrhythmias are _____.
rare
Hypothermia
Defined:
Defined: Core temp < 36˚C (96.8˚F)
Hypothermia Risks
Delayed ____ _____ and awakening
Wound infection and delayed healing
_____ crisis
drug metabolism
Sickling
Hypothermia
Temp ≥ ____: CMS quality indicator for pay for performance incentives
36
Hypothermia warming methods
- FORCED WARM AIR
- HMEs
- Fluid warmers
- Wrapping (especially the head)
- Make the surgeon sweat
Emergence Delirium
Delirium vs. ____ vs. Hungry vs. Wanting Mama…
Pain
Emergence Delirium
Studies after MRI show its a ____ _____
true phenomenon
Emergence Delirium
_____, _____, _____
disoriented, inconsolable, irrational
Emergence Delirium
Worse with ____flurane and ____flurane than with ____flurane
sevo
des
iso
Emergence Delirium
Usually < ____ years old
6
Emergence Delirium
Usually __-__ minutes
5-15
Emergence Delirium - strategies
- Regional
- Opioids
- Dexmedetomidine
- Propofol
- Ketamine
- Flumazenil
Stridor (Croup) Laryngeal edema due to:
- Traumatic or repeated laryngoscopy
- Poorly fitted ETT (cuffed or uncuffed)
- ETT cuff pressure
- Prolonged intubation
- Head and neck procedures
- Intraoperative positioning
- Upper respiratory infection
- Coughing
Stridor treatment
- Humidified O2
- IV dexamethasone
- Racemic epinephrine aerosol
Severe stridor, they need _____
reintubation
If stridor unresolved, _____ for _____ and obs
admit for treatment
Laryngeal Edema leads to _____ _____
Subglottic Stenosis
Pressure at the cricoid ring causes reduced blood flow and edema which leads to ulcerated mucosa developing _____ and leaving _____ ____
collagen
fibrous scar
Scar contracts causing permanent subglottic stenosis and significant ____ _____
airway narrowing
Laryngeal tracheal reconstruction (LTR) with cartilage grafting is the _____ _____
definitive treatment.
Post-op Evaluation
Time of evaluation varies according to ____ _____.
hospital policy
Post-op Evaluation
CMS states all post-op notes must be documented before discharge by an (3)
anesthesiologist, CRNA or anesthesia resident.
Post-op Evaluation
_____ VS, O2 requirements, level of consciousness, pain, nausea/vomiting, sore throat, intake.
Evaluate
Post-op Evaluation
Report and/or treat possible _____ and follow-up.
complications
