Exam3:abd/GU surgery, neuro, ENT/opthalmic surgery, geriatric Flashcards
what are omphalocele and gastroschisis associated with
latex allergy from expose to products
which has a present sac holding abd contents omphalocele or gastroschisis
omphalocele
omphalocele vs gastroschisis
which occurs R of the umbilical cord gastroschisis or omphalocele
gastroschisis
which comes out of umbilical cord area gastroschisis or omphalocele
OMPHALACELE
what kind of evaluation do we need for surgery with omphalacele
cardiac
what is omphalocele associated with
*Trisomy 21,
Diaphragmatic hernia,
cardiac/bowel malformation
*Beckwith-Wiedemann syndrome
T/F use N2O on gastroschisis or omphalocele
false
anesthetic managmet of gastroschisis or omphalocele
*Decompress stomach with NG before induction
*RSI vs awake intubation
*No nitrous oxide
*Muscle relaxation
*Keep intubated 1 - 2 days
*If PIP > 25-30cmH20 or intragastric pressure high à delayed closure
*Monitor glucose
*May have compromised ventilation
*Aggressive hydrate w/ BSS and 5% albumin to replace 3rd space losses
*Warm OR
what do we do before induction for gastroschisis or omphalocele
NGT to decompress stomach
what kind of induction for gastroschisis or omphalocele
RSI or awake
what two complication would make us delay closure for gastroschisis or omphalocele
PIP> 25-30 or high intragastric pressure
what lab do we monitor intraop for gastroschisis or omphalocele
glucose
what do we aggressively hydrate gastroschisis or omphalocele with
BSS and 5% albumin
what are s/s of diphragmatic hernia after birth
*dyspnea,
tachypnea,
cyanosis,
absence of breath sounds on the affected side,
severe retractions
scaphoid abdomen
barrel chest
what is treatment for diaphragmatic hernia
surgical correction around day 4 when neonate is stabilized
anesthetic managment of diaphragmatic hernia
*Awake intubation vs RSI
*Anticholinergic to prevent bradycardia
*NG Tube
*Affected side down (decrease compression on heart/lung)
*High RR, low TV ventilation
*Need to reduce PVR (or prevent further increase)
*Monitor left-to-right shunt
*SpO2 probe on RUE (pre-ductal) and lower extremity (post-ductal)
what are tracheoesophageal fistula and esophageal atreasia associate with (VACTERL)
- Vertebral anomalies
- Anal atresia (imperforate anus)
- Cardiac anomalies
- Tracheoesophageal fistula and esophageal atresia
- Renal anomalies
- Limb malformation
what are s/s tracheoesophageal fistula and esophageal atreasia
*choking on first feeding,
inability to place NGT,
excessive secretions,
respiratory distress with feedings
how do we intubate Tracheoesophageal Fistula and Esophageal Atresia
awake
what SpO2 monitors do we place for Tracheoesophageal Fistula and Esophageal Atresia
pre and post ductal
how do we place ETT in Tracheoesophageal Fistula and Esophageal Atresia
R main stem then pull back until BBS, keep bevel anterior
what procedures do we do with Tracheoesophageal Fistula and Esophageal Atresia
bronchoscopy
art line
after Tracheoesophageal Fistula and Esophageal Atresia are corrected what is an important anesthetic managment
recruit alveoli
when do we extubate Tracheoesophageal Fistula and Esophageal Atresia
early
what population has necrotizing enterocolitis
premature
what are s/s necrotizig enterocolitis
- Increased gastric residuals with feeding
- Abdominal distention
- Bilious vomiting
- Lethargy
- Occult or gross rectal bleeding
- Fever
- Hypothermia
- Abdominal mass
- Oliguria
- Jaundice
- Apnea and bradycardia
- Fever
what are labs in necrotizing enterocolitis
hyperkalemia,
hyponatremia,
metabolic acidosis,
hyperglycemia,
hypoglycemia, and,
in the most serious cases, signs of disseminated intravascular coagulation.
what does imaging show us in necrotizing enterocolitis
Dilated intestinal loops,
pneumatosis intestinalis,
portal vein air,
ascites,
pneumoperitoneum.
anesthetic managment of necrotizing enterocolitis
*Narcotic + muscle relaxant
*Avoid volatiles
*Inotropes: Dopamine
*Large volume replacement
*Blood products: FFP, PLT, blood
*Warmed OR and warmed fluids
*Post-Op ventilation
what is an olive shaped enlargement of the pylorus muscle
pyloric stenosis
what are s/s pyloric stenosis
*Nonbilious postprandial emesis that becomes more projectile with time,
a palpable pylorus,
visible peristaltic waves
what is anesthetic managment of pyloric stenosis
*Correct hypovolemia, acidosis, and electrolyte disorders
*Place NG tube BEFORE induction and suction
*Awake intubation or RSI
*Awake extubation
Typically turned 90 on operating table
when do hernias become emergencies
when they are incarcerated, leads to bowel death and sepsis
what kind of block can we do for inguinal hernia
caudal
what kind of induction do we do for inguinal hernia
RSI
how happens if bowel obstruction is left untreated
bowel death and sepsis
what is anesthesia for bowel obstruction
awake intubation or RSI
what is tx for status epilepticus
lorazepam 0.1 mg/kg push over 2 minutes q10
diazepam 0.5/kg
what is a dysraphism (imcomplete fusion) of the head
encephalocele
what is a dysraphism (incomplete fusion) of the spine
meningocele
what vitamin helps prevent neural tube defects
folic acid/folate
what is NTHFR
folate deficiency
know the different pictures
spina bifida pictures
what do we avoid in chiari malformation
increased ICP (they are herniated)
what is the most common cause of hydrocephalus
tumors causing obstruction
(less common is overproduction of CSF)
what is an overproduction or impaired drainange of CSF from brain
hydrocephalus
what are s/s hydrocephalus
HA, vomiting, ataxia, seizures
what anesthetic drug do we avoid in myasthemia gravis
muscle relaxers
what muscle relaxer do patients with myotonic dystrophy have an increased sensitivity to
anectine
what are anesthetic concerns of myotonic dystrophy
1.Cardiomyopathy
2.Respiratory muscle weakness and sensitivity to respiratory depressants
3.Vulnerability to aspiration of gastric contents
4.Potential for abnormal responses to anesthetic drugs
what anesthetic technique do we avoid in cerebral palsy
regional
what is the hypothesis about intracranial contents
monroe kellie
CSF
blood
brain
what is CPP formula
CPP= MAP-CVP
where is CSF made
choriod plexus in two lateral ventricles and 3 and 4th ventricles
where is CSF reabsorbed
arachnoid villi
what happens if ICP> CPP
ischemia
what range of MAP is CBF autoregulated
50-150 mmHg
what is anesthetic management for increased ICP
*Induction goal for intracranial hypertension: AVOID INCREASE IN ICP
*Most anesthetic drugs decrease ICP, except ketamine
*Preoperative sedatives - Oral versed 0.5-1mg/kg
*Opioids, IV Lidocaine, Barbiturates
*Propofol (2 to 5 mg/kg) has similar effects on cerebral hemodynamics and maintains tight coupling of cerebral blood flow and cerebral metabolic rate
*RSI: rocuronium 1.2mg/kg
*Rapid intubation after full GA established and relaxation
*Avoid prolonged apnea
what anesthetic drug can increase ICP
ketamine
what drugs can mess with neuro exam
versed
how can we decrease ICP
*Hyperventilation
*Keep PaO2 > 100
*Use lowest possible ventilator pressures
*Maintain preintubation MAP
*Mannitol
*Adequate NMB - reduce tone, avoid coughing
*Lidocaine
*Sedation
*Check for venous occlusion
what is risk of opening cranial vault
VAE
what is treatment for VAE
*Flood surgical field with saline, jugular compression, bone wax, lower head, 100% O2, turn of nitrous, turn left lateral decubitus, central line to aspiration air, supportive measures
T/F burn injuries have declined over the past two decades
true
what home device is used more to help prevent burns?
smoke detectors
what is a major cause of death in burn patients
multiple organ failure and infection
what is the largest organ in the body
skin
what are two important functions of skin
-important sensory organ
-barrier to protect against pathogens
what percentage of burn injuries occur on 17 years of age
35%
what kind of injuries are predominant in small children
scald injuries
what are sources of chemical burns for children
household chemicals and/or cleaning products
what is the 2nd leading cause of accidental death among children ages 1-4
fires and burns
what is one of the most common injuries resulting from abuse amongst children
scald burns
what kind of burn often accompanies thermal burns
inhalation burns
when we have thermal burns what should we suspect until aggressively ruled out
inhalation burns
what temp of dry air leads to inhalation burn
300* C
what temp of steam leads to inhalation burn
100* C
what does brief exposure of the epiglottis or larynx to 300c dry or 100c steam lead to
massive edema and rapid airway obstruction
what are warning signs of respiratory injury
hoarseness
sore throat
dysphagia
hemoptysis
tachypnea
use of accessory muscles
wheezing
carbonaceous sputum production
elevated carbon monoxide levels
singed facial and nose hair
all burn patient must be considered at risk of ______ compromise
respiratory
with all burns we must aggressively rule out
upper airway injury
what is the best way to determine if their is upper airway injury from burn
direct visualization from laryngoscope or FOB
what is first treatment of upper airway burn injury
early ET intubation
what is timeline for giving succs for burns
safe before 24 hrs, unsafe after 24 hrs
when can we use succs again in burn patient
until complete wound closure has occurred and the patient is gaining weight
what is the safest way to secure airway with abnormal airways or upper airway obstruction
patient awake
what drugs do we use with caution in abnormal airways or upper airway obstruction
sedatives and narcotics
what drug is beneficial for sedation with abnormal airways or upper airway obstruction
Precedex
what VS do we watch with precedex
BP
what are methods to secure airway in abnormal airways or upper airway obstruction
glidescope
McGrath
FOB
direct laryngoscopy
LMA
blind nasal intubation
bullard laryngoscope
if upper airway is badly damaged and endotracheal intubation is not possible how do we secure airway
direct surgical approach
-needle cric
-surgical cric
-tracheostomy
when do we remove ETT
until laryngeal edema has subsided
what is presentation of carbon monoxide poisoning
cherry red appearance
pulse oximeter reads false high
ABG show normal PaO2 which does not correlated SaO2
how does pulse oximeter read with carboxyhemoglobin
false high (85%?)
how does 100% O2 affect CO half life
shortens it from 4 hrs to 40 minutes
when is fluid loss greatest from burn
within the first 12 hours
when does fluid loss from burns stabilize
after 24 hours
what is parkland formula for fluid replacement
4mL x kg (body weight) x % of total burned surface area
first half over 8 hours, 2nd half over next 16 hours
What is the Brooke Formula for burn resuscitation?
0.45mL x kg + 1.5 ml/kg colloid (body weight) x % of total burned surface area
first half over 8 hours, 2nd half over next 16 hours
what is the minimum urinary output in burn patients for children weighing less than 30 kg
1 ml/kg/hr
what phase is burn victim in after initial 48 hours
hypermetabolic hyperhemodynamic phase
what is manifestation of hypermetabolic phase
hyperthermia
tachypnea
tachycardia
increases serum catecholamine levels
increased oxygen consumption
increased catabolism
incresed BMR
how long does hypermetabolic phase last
several weeks until wound healing is well underway
what are the 4 patho effects of burns
hypothermia
hypovolemia
infection
trauma to other structures
what is goal of surgical debridement and grafting
rapidly restore skin integrity after the burn
what is common approach to skin grafting
-initial waiting period of fluid resuscitation and stabilization
-excision and grafting of the wound
what is goal of wound excision
control infection and remove sloughing burn eschar
when do we stop wound excision
after 2-3 hours
when patient temp decreases to 35c or less
blood loss of 10 u PRBCs
a full burn removal can loose _______ blood volumes
2-3
what is a consideration of debridement with sedation
very painful
what are anesthetic considerations for the burn patient
-warm up operating room
-check hgb hct, order blood
-have blood in room and checked
-have one blood warmer primed and ready
-if large burn have two blood warmers
-adequate IV access
-narcotics
-invasive line placement
what are parts of preop eval for burns
-complete medical hx
-laboratory studies
-brief physical exams
-lung auscultation
-assessment of chest compliance
-inspection of neck and oral cavity for intubation
what burn details do we include in history
time elapsed
type of burn
what kind of burns are most common in children
thermal burns
flame and scald
what do we ask about with any kind of burn
inhalation injury
what type of burn has more damage than can be observed
electrical
what injuries are often associated with burns
C spine injuries
fractures
what other burn information do we get preop for burns
-Underlying trauma
-Mechanism of burn
-Percentage of TBSA burned
-Location of burn sites
-Area and the amount that the surgeon intends to debride
-Whether the patient will be grafted during the perioperative course
what state are burn patients in
shock…
when do we stop orojejunal or nasojejunal intake prior to sedation or induction
4 hours before
what can we use to monitor residuals from intake
NGT
what are components of physical exam for burns
examine airway
hoarseness and wheezing
carbonaceous sputum
extent and depth of burns
IV access sites
what temp should OR be for burn patients
97F or 37C
what can use use to help warm burn patients
multi-blankets
reflective warming blankets
radiant warmers
fluid/blood warmers
forced air warmers
sterile wrapping
what is O2 status of burn patients? what % O2 do we give
hypoxemic
give 100% O2
what kid of ETT do we use for burn patients
cuffed
is oral or nasal intubation better tolerated for long term
nasal
how do we secure ETT in burn
sutured to nasal septum
wired to maxilla
what do we place in burn patient to prevent aspiration
NG tube (post injury ileus)
what do we do since ECG leads are difficult to place/secure in burns
staple the leads or use needle electrodes
where do we place blood pressure cuffs on burn patients
unaffected limb or non surgical site
what line/monitor do we place for extensive surgical debridement, or if expecting rapid blood losses, have a potential for hemodynamic swings, and intraoperative labs needed
A line
what are alternative pulse ox sites
nose
ear
cheek
what can give false reading of pulse ox
carboxyhemoglobin
T/F DC preexisting lines such as aline, CVP, PA in OR
false
what is an alternative infusion route for burns if IV is not accessible
IO
what kind of temp monitor do we use in burns
esophageal stethoscope
who monitors VS during burn transport to and from OR
CRNA
what are some transport considerations for burn patients
multiple infusions
VS monitoring
portable Oxygen
intubated
consider comfort and privacy
admine amnestic and analgesic drugs
secure ETT
what is blood loss per cm2 on skin excised for skin graft
1-4ml
what guides our decision to replace blood
UO
HCT
hemodynamic parameters
what can we do as a local soak to provide hemostasis
epinephrine soaks
how do we titrate anesthetics in burns to prevent hypotension
slowly
what can we give to derease anxiety in stable patients
benzo or narcotic
what are psych complications burn patients often experience
anxiety
depression
pain
where do we sometimes induce burn patients
on pts bed then move to OR table
what kind of anesthesia can we use for burn trauma limited to a small area or extremity to provide prolonged postop analgesia
regional
when do we avoid regional anesthesia
on burned tissues
severe hypovolemia
coagulopathy
cardiorespiratory instability
extent of surgical field including donor site
what kind of neuraxial can we do on children for lower extremity burns
caudal injection
T/F standard induction drugs are all acceptable to use in burns
true
when do we limit use of propofol
hypotension
sepsis
during initial resuscitation
what sedative maintains hemodynamics and has less resp depression than barbiturates
etomidate
what does repeated doses of etomidate lead to
adrenocortical suppression
what anesthetic drug offers stable hemodynamics and analgesia
ketamine
what is a good drug for sedation during dressing changes
ketamine
what happens with ketamine and repeated dosages
tolerance
how do we minimize hallucinogenic episodes with ketamine
benzos in small doses
what drug class do we give to decrease secretions
anticholinergics
how do we induce pediatric patients
inhalation induction
what happens with narcotics and repeated burn procedures
tolerance development, will need more drugs with subsequent procedures
what is a good narcotic for dressing changes
remifentanyl
what pain med do we use cautiously in burns
NSAIDS
what is a good method of narcotic delivery in burns
PCA
what anesthetic gas is good for dressing changes
N2O
what is timeframe for avoiding succs in burns
24 hours to 1.5 years after thermal injury
when do burn patients develop resistance to NDMR
1 week post burn
how do dose NDMRs for patients with burns >20%
increased dose 2-5x
what is the phase after burn is “healed”
reconstructive phase
what are considerations during the reconstructive phase of a burn
visible scars remain
physical and occupational therapy
prevent contractures and deformity
reconstructive procedures
psychological issues
burn camps
what age does accidental ingestion of toxic substances usually occur
often in adolescents but also in toddlers
what do we look for in systemic toxicity from poisoning/overdose
airway protection
local skin and mucosal damage
what do we do to precent aspiration in poisoning/overdose
intubate if needed
what do corrosive materials cause
burn to GI tract, edema of airway
T/F induce vomiting in ingestion of corrosive substances
false
what do we do when assessing poisoning/overdose
gather as much hx of event as possible
urine and serum drug screen
what is a geriatric patient
> 65
what saying do we follow for geriatrics
start low and go slow
what drug class do we avoid in geriatrics during induction (and throughout case)
narcotics
what can we replace narcotics with for pain in geriatrics
tylenol and ibuprofen
what are the 4 main factors of surgical risk for geriatrics
age
patients status/co-existing disease
elective or emergent surgery
type of procedure
what is anesthesia implication of myocardial hypertrophy
Failure to maintain preload leads to an exaggerated decrease in CO;
excessive volume more easily increases filling pressures to congestive failure levels;
dependence on sinus rhythm and low-normal HR
AKA be fluid conservative and keep NSR
what are anesthetic implications of Reduced B receptor responsiveness
Hypotension from anesthetic blunting of sympathetic tone;
altered reactivity to vasoactive drugs; increased dependence on Frank-Starling mechanism to maintain CO;
labile BP,
more hypotension
what are anesthetic implications of conductive system abnormalities
Severe bradycardia with potent opioids;
decreased CO from decrease in end-diastolic volume
what are anesthetic implications of stff arteries
Labile BP;
diastolic dysfunction;
sensitive to volume status
what are anesthetic implications of stiff ceins
Changes in blood volume cause exaggerated changes in cardiac filling
what is the most common complication and the leading cause of death in the postop period
myocardial infarction
what are parts of the periop cardiac risk calculator
surgical procedure
functional status
creatinine level
ASA classification
age
what are the 6 variables of the revised cardiac risk index
hx ischemic heart disease
hx of CHF
hx of cerebrovascular disease
hx of DM requiring preop insulin
CDK with creatinine >2
undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery
what does the revised cardiac risk index predict
30 day risk of death, MI, or cardiac arrest
how much is each point on revised cardiac risk index increase risk by
each item is 15%
what is a MET
metabolic equivalent
the amount of energy it cost to complete a task
1 MET = _______ ml/kg/min O2
3.5
MET score
what is met score for watching tv
1
what is met score for gardening
2
what is met score for getting dressed
2-3
what is met score for housework
3-4
what is met score for taking a shower
3-4
what is met score for brisk walking
3.3 met
what is met score for golfing
4-5 met
what is met score for strenuous hiking
6-7 met
what is met score for swimming
9-10 met
know this image
how is chest wall compliance in geriatrics
decreased
how is alveloar surface area in geriatric
decreased, so decreased gas exchange
how is PO2 in geriatrics
lower
how is TV in geriatrics
same
how is Residual volume in geriatrics
increased
how is ERV in geriatrics
less
how is IRV i geriatrics
less
how is FRC in geriatrics
increased
how is VC in geriatrics
decreased
what are some surgical related factors that lead to postop pulmonary complications
- Prolonged operation (> 3 hours)
- Surgical site
- Emergency operation
- General anesthesia
- Perioperative transfusion
- Residual neuromuscular blockade after an operation
what are some patient related factors that lead to postop pulmonary complications
- Age greater than 60 years
- Chronic obstructive pulmonary disease
- ASA class II or greater
- Functional dependence
- Congestive heart failure
- Obstructive sleep apnea
- Pulmonary hypertension
- Current cigarette use
- Impaired sensorium
- Preoperative sepsis
- Weight loss greater than 10% in 6 months
- Serum albumin level less than 3.5 mg/dL
- Blood urea nitrogen level greater than or equal to 7.5 mmol/L (≥ 21 mg/dL)
- Serum creatinine level greater than 133 mol/L (> 1.5 mg/dL)
what fluid can we give to older patients who are dehydrated
albumin
what 4 risks does a decrease in renal function lead to
1.Fluid overload
2.Accumulation of drugs excreted by kidneys
3.Decreased drug elimination
4. Electrolyte imbalances (cardiac arrhythmias
the decline of what two systems lead to prolonged action of drugs in oldies
kidneys and liver
what do we keep blood sugar under for surgery
<150
hypothermia lasts (longer/shorter) in oldies
longer
why do old people get cold
less body mass
thin dermis
reduced BMR
higher surface area
what temp do old people shiver
35 C
95 F
how do old people handle CNS effects of anesthesia
increased confusion, can last days
what drugs cause more confusion in older adults
benzos
versed
scopalamine
benadryl
ketamine
atropine
reglan
how is baroreceptor response in neuraxial for oldies
impaired baroreceptor response leads to severe hypotension
T/F regional is the best option for older adults
False
how is dose for oldies in spinal and epidural
decreased
what kind of herbals cause bleeding
g ones like garlic…
what narcotic do we avoid in elderly
demerol 2/2 toxic metabolite
some polypharmacy considerations
1.Discontinuing or substituting medications that have potential drug reactions with anesthesia
2.Discontinuing nonessential medications that increase surgical risk
3.Identifying medications that should be discontinued based on Beer’s Criteria
4.Continuing medications with withdrawal potential
5.Avoid starting new benzodiazepines and reducing the dose prescribed to patients at risk for POD
6.Avoid administering meperidine for analgesia
7.Using caution with antihistamines and medications with strong anticholinergic effects
8.Consider starting medications that decrease perioperative cardiovascular adverse events per ACC/AHA guidelines for β-blockers and statins
9.Adjusting dosing of medications that undergo renal excretion based on estimated GFR
how is mac affected by age
MAC decreases with increasing age
how is VD in oldies
increased
what patients are we cautious on anectine
immobile patient, may be at more risk of hyperkalemia
how doe propofol affect oldies
Hypotension; prolonged recovery; increased brain sensitivity
who do we adjust prop dose for oldies
decrease by 50% (1-1.5 mg/kg)
how does etomidate affect older adult
Increased brain sensitivity; greater hemodynamic stability
how do we adjust etomidate dose for oldies
decrease by 50%
how do opioid affect oldies
Increased brain sensitivity; profound physiologic effects; slower onset and delayed recovery; consider route of metabolism and metabolites; avoid meperidine
how do we adjust opioid dose for oldies
decrease by 50%
how does midazolam affect oldies
Increased brain sensitivity; avoid per Beers Criteria
how do we adjust midazolam for oldies
decrease by 75%
T/F decrease our dose of MR in elderly
F, keep it the same
what is haldol dose for oldies
1-2 mg
.25-.5 q2
what are risk factors for posop cognitive dysfunction
- Genetic disposition
- Lower educational level
- High alcohol intake or alcohol abuse
- Increasing age
- High ASA status
- Preexisting mild cognitive impairment
- History of cerebrovascular accident
- Major operations, redo operations
- Cardiac surgery
- Longer duration of surgery and anesthesia
- Intraoperative cerebral desaturation
- Postoperative delirium
- Postoperative infection
occulodexter is the ______ eye
right
oculosinister is the ____ eye
left
oculi uteque is ________ eye
both eyes
what is normal IOP
10-20
what drugs increase IOP
ketamine
succs
what nerves are involved in the oculocardiac reflex
trigeminal
vagal
what is most common sign of oculocardiac reflex
sinus brady
what is the afferent oculocardiacs nerve
trigeminal (5)
what is the efferent occulocardiac nerve
vagus (10)
what conditions can trigger the ocular cardiac reflex
traction on extraocular muscles
direct pressure on globe
ocular trauma
retrobulbar block
what is a complicaiton of a continous increase in IOP
blindness
what is first action to fix oculocardiac reflex
ask surgeon to stop
what medication do we give to treat brady from oculocardiac reflex
atropine 0.01-0.02 mg/kg IC
what is affect of robinol and atropine on IOP
increase it
what is deviation of one eye relative to the visual axis of the other eye
strabismus
what is the tendency of one eye to turn inward
esophoria
what is the tendency of one eye to turn outward
exophoria
what is the inward deviation of both eyes “crossed eyes”
esotropia
when does visual maturation occus
age 5
when should strabismus surgery be completed
early childhood
what anesthetic complication is linked to strabismus
MH
how do extubate in strabismus
deep
what do want to avoid in strabismus sx
coughing and bucking
what complication has a high incidence in strabismus surgery
NV
what is surgical correction for strabismus
repositioning of extra occular muscles
what anomalies are associated with glaucoma
sturge-weber syndrome
craniofacial abnormalities
what is congenital glaucoma caused by
inadequate outflow of aqueous humor
what procedure is for glaucoma
goniotomy- facilitates drainage of aqueous humor through normal channels
what causes retinopathy of prematurity
abnormal proliferation of vascular tissue
when does temporal retina reach maturation
44 weeks post conception
where does ROP most commonly occur
temporal retina
what population does ROP most commonly occur in
LBW infants
infants weighing __________ have an 80% chance of developing ROP
<1000g
premature neonates requiring ________ have an increase risk of ROP
O2 therapy
what is treatment of ROP aimed at
preventing progression and repair of existing retinal defects
what procedure is indicated for a posterior retinal detachment
scleral bulking procedure
if neovascularization has progressed into the vitreous, what may be performed
vitrectomy
what is the condition of bone blocking nasal passage
choanal atresia
T/F patients with choanal atresia can breath nasaly
no
what do we do for chaonal atresia to maintain oral airflow
oral airway
what is CHARGE syndrome
colobomas
heart abnormalities
choanal atresia
growth or mental retardation
genitourinary anomalies
ear abnormalities
when does bilateral choanal atresia need to be fixed
first few days of life
when does unilateral choanal atresia need to be fixed
school age
what is bilateral choanal atresia associated with
crouzon syndrome
CHARGE syndrome
T/F crying is a major issue in choanal atresia
F, promotes mouth breathing which is good
what is important in managing choanal atresia
maintain oral airway
what are s/s choanal atresia
stridor
paroxysmal cyanosis
pink when crying
T/F you can delay unilateral choanal atresia sx
T, can be when school aged
what are indications for PE tubes (myringotomy and tympanostomy tubes)
chronic otitis media
RAOME
acute otitis media
unresponsive to treatment with toxicity signs
what other symptoms to PE tube patients usually have
URI
fever
what are risk factors for needing ear tubes
daycare
siblings
suboptimal breastfeeding
ill health in pregnancy
cleft pallate
what to PE tubes allow
fluid to drain from ear
how are ear tubes removed
usually fall out on their own
what can chronic otitis media lead to
hearing loss
what are symptoms of otitis media
HA
earaches
T/F cancel PE cases for URI
false
how long do tube cases take
5 minutes
what is common anesthetic for tubes
maybe preop anxiolytic
inhalational induction with sevo 8%
N2O 70/30
no IV
spontaneous ventilation
maybe oral airway
when do we start ear tube surgery
until out of stage 2 and loss of lid reflex
what is common pain/anesthetic meds for tube cases
rectal APAP 30 mg/kg
intranasal precedex (1-4 mcg/kg)
intranasal fentanyl (1-2 mcg/kg)
why does ear tube patient need to be deep
movement can cause damage to ear
if stage two can cause laryngospasm
what is important for masking ear tube patients
keep tight seal so patient doesn’t get light on anesthesia
what is the repair of reconstruction of tympanic membrane with or without grafting
tympanoplasty
what are indications for tympanoplasty and mastoidectomy
tympanic perforation
removal adhesions
improve hearing
removal of cholesteatoma
what is a mastoidectomy
expose and remove infected mastoid air cells within the mastoid process
what anesthetic do we avoid in tympanoplasty and mastoidectom
nitrous oxide N2O
what is anesthetic management for tympanoplasty and mastoidectomy
IV or inhalation induction
ET tube
LTA
deep gas
what do we avoid in tympanoplasty and mastoidectomy to decrease bleeding
hypercarbia, HTN
what meds do we give intympanoplasty and mastoidectomy for PONV prevention
zofran
decadron
propofol TIVA
what is positioning to watch for in tympanoplasty and mastoidectomy
watch neck position to avoid damage
bed is turned 90 -180*
what do you watch when changing patients position
airway
ETT
circuit
ETCO2
IV
do you use NMB for tympanoplasty and mastoidectomy
short-acting or none at all to allow monitoring of CN7 (communicate with surgeon)
when do we use an IV for tympanoplasty and mastoidectomy
> 100 lbs OR
10 year olds
what are ways to blunt airway response in tympanoplasty and mastoidectomy since you are not paralyzed
LTA
deep with gas
bump with propofol
alter triggers on vent (low trigger)
drop CO2 (increase RR)
what are indication for tonsillectomy and adenoidectomy
recurrent infections and OSA
what can hyperplasia of tonsils and adenoids lead to
CO2 retention
cor pulmonale
FTT
characteristics of OSA
what are risk factors of OSA
trecher collins
goldenhars aperts
arnold-chiari
achondroplasia
obesity
CP
trisomy 21
what kind of OSAS require tonsillectomy
lymphoid hypertrophy
what are the three forms of TA surgery
snare
cold or hot knife
cautery
what is benefit and risk of cautery for TA
less bleeding, but is more painful
what do we do for O2 concentration and cautery
turn down O2 2/2 fire risk
what can bleeding from TA surgery leed to
vomiting from blood in stomach, so use OG to suction stomach after case, give antiemetics
what is biggest concern of TA surgery
rebleeding
T/F TA surgeries often have URi
true
how long is a TA surgery
15 min
what is steps of TA surgery
inhalation induction
place IV
IV induction
what are meds for TA surgery induction
sevo 8% and N2O 70/30
what kind of intubation do we do for TA surgery
atraumatic
videoscope
how do we place ETT for TA surgery
taped down center of mouth to chin
T/F use ibuprofen and toradol for TA surgery
false
avoid due to bleeding
what are positioning techniques for TA sx
remove pillow and place towel for head turban
what are some meds for TA surgery
IV APAP 15 mg/kg
IV fentanyl/precedex
Decadron
zofran
what are adverse affects of Local with EPI in TA surgery
tachycardia
HTN
abscess formation
medullopntine infarct
bulbar paralysis
what do we do prior to emergence to decrease NV after TA
OGT to suction stomach of blood (gently suction)
T/F TA surgery has a high incidence of laryngospasm
true
where does rebleeding usually occur after TA
PACU or after discharge
what bleeds after TA
Internal and EXTERNAL carotid artery branches
what do we avoid food wise after TA
red drinks or food
what can high BP lead to after TA
bleeding, so give labetalol or carcoti at end of case, or bump with propofol
what kind of induction do we do for FESS
IV or inhalation
what kind of ETT do we use for FESS
RAE ETT
what is a common complication of FESS? how do we intervenese
Bleeding
use throat pack
nose pack
vasoconstrictors
what is th surgical debridement of sinus cavity
FESS
Functional Endoscopic Sinus Surgery
what are indications for FESS
deviated septum
turbinates?
what are useful anesthethetic adjuvants for FESS
precedex
fentanyl
tylenol
what is benefit of precedex
proved sedation and decreases BP
what are S/S foreign body aspiration
coughing
dyspnea
stridor
cyanosis
when foreign body is located in the ___________ you are more likely to have wheezing, coughing, dyspnea, air trapping, and chronic infection
bronchus
what kind of induction do we do for foreign body aspiration
inhalational with sevo and O2
or TIVA?
what are important parts of anesthetic plan for foreign body aspiration
maintain spontaneous ventilation
local anesthetic at vocal cords and trachea
what do we do to remove foreign body aspiration
rigid bronchoscope
what kind of foreign body aspiration is an emergency
button batteries
what are s/s epiglottitis
looks ill
febrile
drooling
severe sore throat
sits up while leaning forward to promote patent airway
what is radiographic sign of epiglottitis
thumb sign
thumb sign
epiglottitis
what causes epiglottitis
Haemophilus influenzae type B
Group A beta-hemolytic streptococci
croup vs epiglottitis
where does croup occur (subglottic, supraglottic)
subglottic
where does epiglottitis occur (subglottic, supraglottic)
supraglottic
what age does croup occur at
<3 years
what age does epiglottitis occur at
3-6 years
is croup bacterial or viral
viral
is epiglottitis bacterial or viral
bacterial
what are s/s croup
barking cough
hoarse voice
recumbent position
rapid RR
non-tender larynx
high fever
steeple sign on AP radiograph
what are S/S epiglottitis
drooling
marked dysphagia
tripod sitting position
normal RR
normal larynx
low grade fever
thumb sign on radiograph
T/F airway support is need in croup
F, only in <3%
T/F airway support is needed in epiglottitis
T, always indicated
Do we use narcs or muscle relaxers in epiglottitis
no
what tools do we have for epiglottitis intubation
glidescope
blades
different size tubes
FOB
tracheostomy kit
how do we transport epiglottitis
face mask and pulse ox
how do we induce epiglottitis
sevo and oxygen induction, maintain spontaneous breathing
what airway support do we use for epiglottitis
CPAP 10-15 mmHg
what size/type of tube do we use for epiglottitis
cuffed tube 1-2 sizes smaller than normal
what is a rare condition that causes tissue to partially or completely obstruct the glottic opening
laryngeal web
what can be required in laryngeal web
can cause resp distress requiring an emergency airway
subglottic stenosis grades
what is subglottic stenosis 0-50%
grade 1
what is subglottic stenosis 51-70%
grade 2
what is subglottic stenosis 71-99%
grade 3
what is subglottic stenosis 100%
grade
what is treatment for subglottic stenosis
airway dilation
what size ett do we use for subglottic stenosis
smaller ETT
subglottic stenosis vs normal
