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Pediatric Anesthesia > Exam3:abd/GU surgery, neuro, ENT/opthalmic surgery, geriatric > Flashcards

Exam3:abd/GU surgery, neuro, ENT/opthalmic surgery, geriatric Flashcards

1
Q

what are omphalocele and gastroschisis associated with

A

latex allergy from expose to products

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2
Q

which has a present sac holding abd contents omphalocele or gastroschisis

A

omphalocele

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3
Q

omphalocele vs gastroschisis

A
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4
Q

which occurs R of the umbilical cord gastroschisis or omphalocele

A

gastroschisis

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5
Q

which comes out of umbilical cord area gastroschisis or omphalocele

A

OMPHALACELE

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6
Q

what kind of evaluation do we need for surgery with omphalacele

A

cardiac

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7
Q

what is omphalocele associated with

A

*Trisomy 21,
Diaphragmatic hernia,
cardiac/bowel malformation
*Beckwith-Wiedemann syndrome

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8
Q

T/F use N2O on gastroschisis or omphalocele

A

false

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9
Q

anesthetic managmet of gastroschisis or omphalocele

A

*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

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10
Q

what do we do before induction for gastroschisis or omphalocele

A

NGT to decompress stomach

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11
Q

what kind of induction for gastroschisis or omphalocele

A

RSI or awake

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12
Q

what two complication would make us delay closure for gastroschisis or omphalocele

A

PIP> 25-30 or high intragastric pressure

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13
Q

what lab do we monitor intraop for gastroschisis or omphalocele

A

glucose

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14
Q

what do we aggressively hydrate gastroschisis or omphalocele with

A

BSS and 5% albumin

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15
Q

what are s/s of diphragmatic hernia after birth

A

*dyspnea,
tachypnea,
cyanosis,
absence of breath sounds on the affected side,
severe retractions
scaphoid abdomen
barrel chest

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16
Q

what is treatment for diaphragmatic hernia

A

surgical correction around day 4 when neonate is stabilized

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17
Q

anesthetic managment of diaphragmatic hernia

A

*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)

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18
Q

what are tracheoesophageal fistula and esophageal atreasia associate with (VACTERL)

A
  • Vertebral anomalies
  • Anal atresia (imperforate anus)
  • Cardiac anomalies
  • Tracheoesophageal fistula and esophageal atresia
  • Renal anomalies
  • Limb malformation
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19
Q

what are s/s tracheoesophageal fistula and esophageal atreasia

A

*choking on first feeding,
inability to place NGT,
excessive secretions,
respiratory distress with feedings

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20
Q

how do we intubate Tracheoesophageal Fistula and Esophageal Atresia

A

awake

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21
Q

what SpO2 monitors do we place for Tracheoesophageal Fistula and Esophageal Atresia

A

pre and post ductal

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22
Q

how do we place ETT in Tracheoesophageal Fistula and Esophageal Atresia

A

R main stem then pull back until BBS, keep bevel anterior

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23
Q

what procedures do we do with Tracheoesophageal Fistula and Esophageal Atresia

A

bronchoscopy
art line

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24
Q

after Tracheoesophageal Fistula and Esophageal Atresia are corrected what is an important anesthetic managment

A

recruit alveoli

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25
Q

when do we extubate Tracheoesophageal Fistula and Esophageal Atresia

A

early

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26
Q

what population has necrotizing enterocolitis

A

premature

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27
Q

what are s/s necrotizig enterocolitis

A
  • 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
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28
Q

what are labs in necrotizing enterocolitis

A

hyperkalemia,
hyponatremia,
metabolic acidosis,
hyperglycemia,
hypoglycemia, and,
in the most serious cases, signs of disseminated intravascular coagulation.

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29
Q

what does imaging show us in necrotizing enterocolitis

A

Dilated intestinal loops,
pneumatosis intestinalis,
portal vein air,
ascites,
pneumoperitoneum.

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30
Q

anesthetic managment of necrotizing enterocolitis

A

*Narcotic + muscle relaxant
*Avoid volatiles
*Inotropes: Dopamine
*Large volume replacement
*Blood products: FFP, PLT, blood
*Warmed OR and warmed fluids
*Post-Op ventilation

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31
Q

what is an olive shaped enlargement of the pylorus muscle

A

pyloric stenosis

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32
Q

what are s/s pyloric stenosis

A

*Nonbilious postprandial emesis that becomes more projectile with time,
a palpable pylorus,
visible peristaltic waves

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33
Q

what is anesthetic managment of pyloric stenosis

A

*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

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34
Q

when do hernias become emergencies

A

when they are incarcerated, leads to bowel death and sepsis

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35
Q

what kind of block can we do for inguinal hernia

A

caudal

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36
Q

what kind of induction do we do for inguinal hernia

A

RSI

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37
Q

how happens if bowel obstruction is left untreated

A

bowel death and sepsis

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38
Q

what is anesthesia for bowel obstruction

A

awake intubation or RSI

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39
Q

what is tx for status epilepticus

A

lorazepam 0.1 mg/kg push over 2 minutes q10
diazepam 0.5/kg

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40
Q

what is a dysraphism (imcomplete fusion) of the head

A

encephalocele

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41
Q

what is a dysraphism (incomplete fusion) of the spine

A

meningocele

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42
Q

what vitamin helps prevent neural tube defects

A

folic acid/folate

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43
Q

what is NTHFR

A

folate deficiency

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44
Q

know the different pictures

A

spina bifida pictures

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45
Q

what do we avoid in chiari malformation

A

increased ICP (they are herniated)

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46
Q

what is the most common cause of hydrocephalus

A

tumors causing obstruction
(less common is overproduction of CSF)

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47
Q

what is an overproduction or impaired drainange of CSF from brain

A

hydrocephalus

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48
Q

what are s/s hydrocephalus

A

HA, vomiting, ataxia, seizures

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49
Q

what anesthetic drug do we avoid in myasthemia gravis

A

muscle relaxers

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50
Q

what muscle relaxer do patients with myotonic dystrophy have an increased sensitivity to

A

anectine

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51
Q

what are anesthetic concerns of myotonic dystrophy

A

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

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52
Q

what anesthetic technique do we avoid in cerebral palsy

A

regional

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53
Q

what is the hypothesis about intracranial contents

A

monroe kellie
CSF
blood
brain

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54
Q

what is CPP formula

A

CPP= MAP-CVP

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55
Q

where is CSF made

A

choriod plexus in two lateral ventricles and 3 and 4th ventricles

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56
Q

where is CSF reabsorbed

A

arachnoid villi

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57
Q

what happens if ICP> CPP

A

ischemia

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58
Q

what range of MAP is CBF autoregulated

A

50-150 mmHg

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59
Q

what is anesthetic management for increased ICP

A

*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

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60
Q

what anesthetic drug can increase ICP

A

ketamine

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61
Q

what drugs can mess with neuro exam

A

versed

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62
Q

how can we decrease ICP

A

*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

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63
Q

what is risk of opening cranial vault

A

VAE

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64
Q

what is treatment for VAE

A

*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

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65
Q

T/F burn injuries have declined over the past two decades

A

true

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66
Q

what home device is used more to help prevent burns?

A

smoke detectors

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67
Q

what is a major cause of death in burn patients

A

multiple organ failure and infection

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68
Q

what is the largest organ in the body

A

skin

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69
Q

what are two important functions of skin

A

-important sensory organ
-barrier to protect against pathogens

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70
Q

what percentage of burn injuries occur on 17 years of age

A

35%

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71
Q

what kind of injuries are predominant in small children

A

scald injuries

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72
Q

what are sources of chemical burns for children

A

household chemicals and/or cleaning products

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73
Q

what is the 2nd leading cause of accidental death among children ages 1-4

A

fires and burns

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74
Q

what is one of the most common injuries resulting from abuse amongst children

A

scald burns

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75
Q

what kind of burn often accompanies thermal burns

A

inhalation burns

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76
Q

when we have thermal burns what should we suspect until aggressively ruled out

A

inhalation burns

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77
Q

what temp of dry air leads to inhalation burn

A

300* C

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78
Q

what temp of steam leads to inhalation burn

A

100* C

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79
Q

what does brief exposure of the epiglottis or larynx to 300c dry or 100c steam lead to

A

massive edema and rapid airway obstruction

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80
Q

what are warning signs of respiratory injury

A

hoarseness
sore throat
dysphagia
hemoptysis
tachypnea
use of accessory muscles
wheezing
carbonaceous sputum production
elevated carbon monoxide levels
singed facial and nose hair

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81
Q

all burn patient must be considered at risk of ______ compromise

A

respiratory

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82
Q

with all burns we must aggressively rule out

A

upper airway injury

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83
Q

what is the best way to determine if their is upper airway injury from burn

A

direct visualization from laryngoscope or FOB

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84
Q

what is first treatment of upper airway burn injury

A

early ET intubation

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85
Q

what is timeline for giving succs for burns

A

safe before 24 hrs, unsafe after 24 hrs

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86
Q

when can we use succs again in burn patient

A

until complete wound closure has occurred and the patient is gaining weight

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87
Q

what is the safest way to secure airway with abnormal airways or upper airway obstruction

A

patient awake

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88
Q

what drugs do we use with caution in abnormal airways or upper airway obstruction

A

sedatives and narcotics

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89
Q

what drug is beneficial for sedation with abnormal airways or upper airway obstruction

A

Precedex

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90
Q

what VS do we watch with precedex

A

BP

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91
Q

what are methods to secure airway in abnormal airways or upper airway obstruction

A

glidescope
McGrath
FOB
direct laryngoscopy
LMA
blind nasal intubation
bullard laryngoscope

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92
Q

if upper airway is badly damaged and endotracheal intubation is not possible how do we secure airway

A

direct surgical approach
-needle cric
-surgical cric
-tracheostomy

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93
Q

when do we remove ETT

A

until laryngeal edema has subsided

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94
Q

what is presentation of carbon monoxide poisoning

A

cherry red appearance
pulse oximeter reads false high
ABG show normal PaO2 which does not correlated SaO2

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95
Q

how does pulse oximeter read with carboxyhemoglobin

A

false high (85%?)

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96
Q

how does 100% O2 affect CO half life

A

shortens it from 4 hrs to 40 minutes

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97
Q

when is fluid loss greatest from burn

A

within the first 12 hours

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98
Q

when does fluid loss from burns stabilize

A

after 24 hours

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99
Q

what is parkland formula for fluid replacement

A

4mL x kg (body weight) x % of total burned surface area
first half over 8 hours, 2nd half over next 16 hours

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100
Q

What is the Brooke Formula for burn resuscitation?

A

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

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101
Q

what is the minimum urinary output in burn patients for children weighing less than 30 kg

A

1 ml/kg/hr

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102
Q

what phase is burn victim in after initial 48 hours

A

hypermetabolic hyperhemodynamic phase

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103
Q

what is manifestation of hypermetabolic phase

A

hyperthermia
tachypnea
tachycardia
increases serum catecholamine levels
increased oxygen consumption
increased catabolism
incresed BMR

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104
Q

how long does hypermetabolic phase last

A

several weeks until wound healing is well underway

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105
Q

what are the 4 patho effects of burns

A

hypothermia
hypovolemia
infection
trauma to other structures

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106
Q

what is goal of surgical debridement and grafting

A

rapidly restore skin integrity after the burn

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107
Q

what is common approach to skin grafting

A

-initial waiting period of fluid resuscitation and stabilization
-excision and grafting of the wound

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108
Q

what is goal of wound excision

A

control infection and remove sloughing burn eschar

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109
Q

when do we stop wound excision

A

after 2-3 hours
when patient temp decreases to 35c or less
blood loss of 10 u PRBCs

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110
Q

a full burn removal can loose _______ blood volumes

A

2-3

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111
Q

what is a consideration of debridement with sedation

A

very painful

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112
Q

what are anesthetic considerations for the burn patient

A

-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

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113
Q

what are parts of preop eval for burns

A

-complete medical hx
-laboratory studies
-brief physical exams
-lung auscultation
-assessment of chest compliance
-inspection of neck and oral cavity for intubation

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114
Q

what burn details do we include in history

A

time elapsed
type of burn

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115
Q

what kind of burns are most common in children

A

thermal burns
flame and scald

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116
Q

what do we ask about with any kind of burn

A

inhalation injury

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117
Q

what type of burn has more damage than can be observed

A

electrical

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118
Q

what injuries are often associated with burns

A

C spine injuries
fractures

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119
Q

what other burn information do we get preop for burns

A

-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

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120
Q

what state are burn patients in

A

shock…

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121
Q

when do we stop orojejunal or nasojejunal intake prior to sedation or induction

A

4 hours before

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122
Q

what can we use to monitor residuals from intake

A

NGT

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123
Q

what are components of physical exam for burns

A

examine airway
hoarseness and wheezing
carbonaceous sputum
extent and depth of burns
IV access sites

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124
Q

what temp should OR be for burn patients

A

97F or 37C

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125
Q

what can use use to help warm burn patients

A

multi-blankets
reflective warming blankets
radiant warmers
fluid/blood warmers
forced air warmers
sterile wrapping

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126
Q

what is O2 status of burn patients? what % O2 do we give

A

hypoxemic
give 100% O2

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127
Q

what kid of ETT do we use for burn patients

A

cuffed

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128
Q

is oral or nasal intubation better tolerated for long term

A

nasal

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129
Q

how do we secure ETT in burn

A

sutured to nasal septum
wired to maxilla

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130
Q

what do we place in burn patient to prevent aspiration

A

NG tube (post injury ileus)

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131
Q

what do we do since ECG leads are difficult to place/secure in burns

A

staple the leads or use needle electrodes

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132
Q

where do we place blood pressure cuffs on burn patients

A

unaffected limb or non surgical site

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133
Q

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

A line

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134
Q

what are alternative pulse ox sites

A

nose
ear
cheek

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135
Q

what can give false reading of pulse ox

A

carboxyhemoglobin

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136
Q

T/F DC preexisting lines such as aline, CVP, PA in OR

A

false

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137
Q

what is an alternative infusion route for burns if IV is not accessible

A

IO

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138
Q

what kind of temp monitor do we use in burns

A

esophageal stethoscope

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139
Q

who monitors VS during burn transport to and from OR

A

CRNA

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140
Q

what are some transport considerations for burn patients

A

multiple infusions
VS monitoring
portable Oxygen
intubated
consider comfort and privacy
admine amnestic and analgesic drugs
secure ETT

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141
Q

what is blood loss per cm2 on skin excised for skin graft

A

1-4ml

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142
Q

what guides our decision to replace blood

A

UO
HCT
hemodynamic parameters

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143
Q

what can we do as a local soak to provide hemostasis

A

epinephrine soaks

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144
Q

how do we titrate anesthetics in burns to prevent hypotension

A

slowly

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145
Q

what can we give to derease anxiety in stable patients

A

benzo or narcotic

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146
Q

what are psych complications burn patients often experience

A

anxiety
depression
pain

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147
Q

where do we sometimes induce burn patients

A

on pts bed then move to OR table

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148
Q

what kind of anesthesia can we use for burn trauma limited to a small area or extremity to provide prolonged postop analgesia

A

regional

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149
Q

when do we avoid regional anesthesia

A

on burned tissues
severe hypovolemia
coagulopathy
cardiorespiratory instability
extent of surgical field including donor site

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150
Q

what kind of neuraxial can we do on children for lower extremity burns

A

caudal injection

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151
Q

T/F standard induction drugs are all acceptable to use in burns

A

true

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152
Q

when do we limit use of propofol

A

hypotension
sepsis
during initial resuscitation

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153
Q

what sedative maintains hemodynamics and has less resp depression than barbiturates

A

etomidate

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154
Q

what does repeated doses of etomidate lead to

A

adrenocortical suppression

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155
Q

what anesthetic drug offers stable hemodynamics and analgesia

A

ketamine

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156
Q

what is a good drug for sedation during dressing changes

A

ketamine

157
Q

what happens with ketamine and repeated dosages

A

tolerance

158
Q

how do we minimize hallucinogenic episodes with ketamine

A

benzos in small doses

159
Q

what drug class do we give to decrease secretions

A

anticholinergics

160
Q

how do we induce pediatric patients

A

inhalation induction

161
Q

what happens with narcotics and repeated burn procedures

A

tolerance development, will need more drugs with subsequent procedures

162
Q

what is a good narcotic for dressing changes

A

remifentanyl

163
Q

what pain med do we use cautiously in burns

A

NSAIDS

164
Q

what is a good method of narcotic delivery in burns

A

PCA

165
Q

what anesthetic gas is good for dressing changes

A

N2O

166
Q

what is timeframe for avoiding succs in burns

A

24 hours to 1.5 years after thermal injury

167
Q

when do burn patients develop resistance to NDMR

A

1 week post burn

168
Q

how do dose NDMRs for patients with burns >20%

A

increased dose 2-5x

169
Q

what is the phase after burn is “healed”

A

reconstructive phase

170
Q

what are considerations during the reconstructive phase of a burn

A

visible scars remain
physical and occupational therapy
prevent contractures and deformity
reconstructive procedures
psychological issues
burn camps

171
Q

what age does accidental ingestion of toxic substances usually occur

A

often in adolescents but also in toddlers

172
Q

what do we look for in systemic toxicity from poisoning/overdose

A

airway protection
local skin and mucosal damage

173
Q

what do we do to precent aspiration in poisoning/overdose

A

intubate if needed

174
Q

what do corrosive materials cause

A

burn to GI tract, edema of airway

175
Q

T/F induce vomiting in ingestion of corrosive substances

A

false

176
Q

what do we do when assessing poisoning/overdose

A

gather as much hx of event as possible
urine and serum drug screen

177
Q

what is a geriatric patient

A

> 65

178
Q

what saying do we follow for geriatrics

A

start low and go slow

179
Q

what drug class do we avoid in geriatrics during induction (and throughout case)

A

narcotics

180
Q

what can we replace narcotics with for pain in geriatrics

A

tylenol and ibuprofen

181
Q

what are the 4 main factors of surgical risk for geriatrics

A

age
patients status/co-existing disease
elective or emergent surgery
type of procedure

182
Q

what is anesthesia implication of myocardial hypertrophy

A

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

183
Q

what are anesthetic implications of Reduced B receptor responsiveness

A

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

184
Q

what are anesthetic implications of conductive system abnormalities

A

Severe bradycardia with potent opioids;
decreased CO from decrease in end-diastolic volume

185
Q

what are anesthetic implications of stff arteries

A

Labile BP;
diastolic dysfunction;
sensitive to volume status

186
Q

what are anesthetic implications of stiff ceins

A

Changes in blood volume cause exaggerated changes in cardiac filling

187
Q

what is the most common complication and the leading cause of death in the postop period

A

myocardial infarction

188
Q

what are parts of the periop cardiac risk calculator

A

surgical procedure
functional status
creatinine level
ASA classification
age

189
Q

what are the 6 variables of the revised cardiac risk index

A

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

190
Q

what does the revised cardiac risk index predict

A

30 day risk of death, MI, or cardiac arrest

191
Q

how much is each point on revised cardiac risk index increase risk by

A

each item is 15%

192
Q

what is a MET

A

metabolic equivalent
the amount of energy it cost to complete a task

193
Q

1 MET = _______ ml/kg/min O2

A

3.5

194
Q

MET score

A
195
Q

what is met score for watching tv

A

1

196
Q

what is met score for gardening

A

2

197
Q

what is met score for getting dressed

A

2-3

198
Q

what is met score for housework

A

3-4

199
Q

what is met score for taking a shower

A

3-4

200
Q

what is met score for brisk walking

A

3.3 met

201
Q

what is met score for golfing

A

4-5 met

202
Q

what is met score for strenuous hiking

A

6-7 met

203
Q

what is met score for swimming

A

9-10 met

204
Q

know this image

A
205
Q

how is chest wall compliance in geriatrics

A

decreased

206
Q

how is alveloar surface area in geriatric

A

decreased, so decreased gas exchange

207
Q

how is PO2 in geriatrics

A

lower

208
Q

how is TV in geriatrics

A

same

209
Q

how is Residual volume in geriatrics

A

increased

210
Q

how is ERV in geriatrics

A

less

211
Q

how is IRV i geriatrics

A

less

212
Q

how is FRC in geriatrics

A

increased

213
Q

how is VC in geriatrics

A

decreased

214
Q

what are some surgical related factors that lead to postop pulmonary complications

A
  • Prolonged operation (> 3 hours)
  • Surgical site
  • Emergency operation
  • General anesthesia
  • Perioperative transfusion
  • Residual neuromuscular blockade after an operation
215
Q

what are some patient related factors that lead to postop pulmonary complications

A
  • 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)
216
Q

what fluid can we give to older patients who are dehydrated

A

albumin

217
Q

what 4 risks does a decrease in renal function lead to

A

1.Fluid overload
2.Accumulation of drugs excreted by kidneys
3.Decreased drug elimination
4. Electrolyte imbalances (cardiac arrhythmias

218
Q

the decline of what two systems lead to prolonged action of drugs in oldies

A

kidneys and liver

219
Q

what do we keep blood sugar under for surgery

A

<150

220
Q

hypothermia lasts (longer/shorter) in oldies

A

longer

221
Q

why do old people get cold

A

less body mass
thin dermis
reduced BMR
higher surface area

222
Q

what temp do old people shiver

A

35 C
95 F

223
Q

how do old people handle CNS effects of anesthesia

A

increased confusion, can last days

224
Q

what drugs cause more confusion in older adults

A

benzos
versed
scopalamine
benadryl
ketamine
atropine
reglan

225
Q

how is baroreceptor response in neuraxial for oldies

A

impaired baroreceptor response leads to severe hypotension

226
Q

T/F regional is the best option for older adults

A

False

227
Q

how is dose for oldies in spinal and epidural

A

decreased

228
Q

what kind of herbals cause bleeding

A

g ones like garlic…

229
Q

what narcotic do we avoid in elderly

A

demerol 2/2 toxic metabolite

230
Q

some polypharmacy considerations

A

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

231
Q

how is mac affected by age

A

MAC decreases with increasing age

232
Q

how is VD in oldies

A

increased

233
Q

what patients are we cautious on anectine

A

immobile patient, may be at more risk of hyperkalemia

234
Q

how doe propofol affect oldies

A

Hypotension; prolonged recovery; increased brain sensitivity

235
Q

who do we adjust prop dose for oldies

A

decrease by 50% (1-1.5 mg/kg)

236
Q

how does etomidate affect older adult

A

Increased brain sensitivity; greater hemodynamic stability

237
Q

how do we adjust etomidate dose for oldies

A

decrease by 50%

238
Q

how do opioid affect oldies

A

Increased brain sensitivity; profound physiologic effects; slower onset and delayed recovery; consider route of metabolism and metabolites; avoid meperidine

239
Q

how do we adjust opioid dose for oldies

A

decrease by 50%

240
Q

how does midazolam affect oldies

A

Increased brain sensitivity; avoid per Beers Criteria

241
Q

how do we adjust midazolam for oldies

A

decrease by 75%

242
Q

T/F decrease our dose of MR in elderly

A

F, keep it the same

243
Q

what is haldol dose for oldies

A

1-2 mg
.25-.5 q2

244
Q

what are risk factors for posop cognitive dysfunction

A
  • 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
245
Q

occulodexter is the ______ eye

A

right

246
Q

oculosinister is the ____ eye

A

left

247
Q

oculi uteque is ________ eye

A

both eyes

248
Q

what is normal IOP

A

10-20

249
Q

what drugs increase IOP

A

ketamine
succs

250
Q

what nerves are involved in the oculocardiac reflex

A

trigeminal
vagal

251
Q

what is most common sign of oculocardiac reflex

A

sinus brady

252
Q

what is the afferent oculocardiacs nerve

A

trigeminal (5)

253
Q

what is the efferent occulocardiac nerve

A

vagus (10)

254
Q

what conditions can trigger the ocular cardiac reflex

A

traction on extraocular muscles
direct pressure on globe
ocular trauma
retrobulbar block

255
Q

what is a complicaiton of a continous increase in IOP

A

blindness

256
Q

what is first action to fix oculocardiac reflex

A

ask surgeon to stop

257
Q

what medication do we give to treat brady from oculocardiac reflex

A

atropine 0.01-0.02 mg/kg IC

258
Q

what is affect of robinol and atropine on IOP

A

increase it

259
Q

what is deviation of one eye relative to the visual axis of the other eye

A

strabismus

260
Q

what is the tendency of one eye to turn inward

A

esophoria

261
Q

what is the tendency of one eye to turn outward

A

exophoria

262
Q

what is the inward deviation of both eyes “crossed eyes”

A

esotropia

263
Q

when does visual maturation occus

A

age 5

264
Q

when should strabismus surgery be completed

A

early childhood

265
Q

what anesthetic complication is linked to strabismus

A

MH

266
Q

how do extubate in strabismus

A

deep

267
Q

what do want to avoid in strabismus sx

A

coughing and bucking

268
Q

what complication has a high incidence in strabismus surgery

A

NV

269
Q

what is surgical correction for strabismus

A

repositioning of extra occular muscles

270
Q

what anomalies are associated with glaucoma

A

sturge-weber syndrome
craniofacial abnormalities

271
Q

what is congenital glaucoma caused by

A

inadequate outflow of aqueous humor

272
Q

what procedure is for glaucoma

A

goniotomy- facilitates drainage of aqueous humor through normal channels

273
Q

what causes retinopathy of prematurity

A

abnormal proliferation of vascular tissue

274
Q

when does temporal retina reach maturation

A

44 weeks post conception

275
Q

where does ROP most commonly occur

A

temporal retina

276
Q

what population does ROP most commonly occur in

A

LBW infants

277
Q

infants weighing __________ have an 80% chance of developing ROP

A

<1000g

278
Q

premature neonates requiring ________ have an increase risk of ROP

A

O2 therapy

279
Q

what is treatment of ROP aimed at

A

preventing progression and repair of existing retinal defects

280
Q

what procedure is indicated for a posterior retinal detachment

A

scleral bulking procedure

281
Q

if neovascularization has progressed into the vitreous, what may be performed

A

vitrectomy

282
Q

what is the condition of bone blocking nasal passage

A

choanal atresia

283
Q

T/F patients with choanal atresia can breath nasaly

A

no

284
Q

what do we do for chaonal atresia to maintain oral airflow

A

oral airway

285
Q

what is CHARGE syndrome

A

colobomas
heart abnormalities
choanal atresia
growth or mental retardation
genitourinary anomalies
ear abnormalities

286
Q

when does bilateral choanal atresia need to be fixed

A

first few days of life

287
Q

when does unilateral choanal atresia need to be fixed

A

school age

288
Q

what is bilateral choanal atresia associated with

A

crouzon syndrome
CHARGE syndrome

289
Q

T/F crying is a major issue in choanal atresia

A

F, promotes mouth breathing which is good

290
Q

what is important in managing choanal atresia

A

maintain oral airway

291
Q

what are s/s choanal atresia

A

stridor
paroxysmal cyanosis
pink when crying

292
Q

T/F you can delay unilateral choanal atresia sx

A

T, can be when school aged

293
Q

what are indications for PE tubes (myringotomy and tympanostomy tubes)

A

chronic otitis media
RAOME
acute otitis media
unresponsive to treatment with toxicity signs

294
Q

what other symptoms to PE tube patients usually have

A

URI
fever

295
Q

what are risk factors for needing ear tubes

A

daycare
siblings
suboptimal breastfeeding
ill health in pregnancy
cleft pallate

296
Q

what to PE tubes allow

A

fluid to drain from ear

297
Q

how are ear tubes removed

A

usually fall out on their own

298
Q

what can chronic otitis media lead to

A

hearing loss

299
Q

what are symptoms of otitis media

A

HA
earaches

300
Q

T/F cancel PE cases for URI

A

false

301
Q

how long do tube cases take

A

5 minutes

302
Q

what is common anesthetic for tubes

A

maybe preop anxiolytic
inhalational induction with sevo 8%
N2O 70/30
no IV
spontaneous ventilation
maybe oral airway

303
Q

when do we start ear tube surgery

A

until out of stage 2 and loss of lid reflex

304
Q

what is common pain/anesthetic meds for tube cases

A

rectal APAP 30 mg/kg
intranasal precedex (1-4 mcg/kg)
intranasal fentanyl (1-2 mcg/kg)

305
Q

why does ear tube patient need to be deep

A

movement can cause damage to ear
if stage two can cause laryngospasm

306
Q

what is important for masking ear tube patients

A

keep tight seal so patient doesn’t get light on anesthesia

307
Q

what is the repair of reconstruction of tympanic membrane with or without grafting

A

tympanoplasty

308
Q

what are indications for tympanoplasty and mastoidectomy

A

tympanic perforation
removal adhesions
improve hearing
removal of cholesteatoma

309
Q

what is a mastoidectomy

A

expose and remove infected mastoid air cells within the mastoid process

310
Q

what anesthetic do we avoid in tympanoplasty and mastoidectom

A

nitrous oxide N2O

311
Q

what is anesthetic management for tympanoplasty and mastoidectomy

A

IV or inhalation induction
ET tube
LTA
deep gas

312
Q

what do we avoid in tympanoplasty and mastoidectomy to decrease bleeding

A

hypercarbia, HTN

313
Q

what meds do we give intympanoplasty and mastoidectomy for PONV prevention

A

zofran
decadron
propofol TIVA

314
Q

what is positioning to watch for in tympanoplasty and mastoidectomy

A

watch neck position to avoid damage
bed is turned 90 -180*

315
Q

what do you watch when changing patients position

A

airway

ETT

circuit

ETCO2

IV

316
Q

do you use NMB for tympanoplasty and mastoidectomy

A

short-acting or none at all to allow monitoring of CN7 (communicate with surgeon)

317
Q

when do we use an IV for tympanoplasty and mastoidectomy

A

> 100 lbs OR
10 year olds

318
Q

what are ways to blunt airway response in tympanoplasty and mastoidectomy since you are not paralyzed

A

LTA
deep with gas
bump with propofol
alter triggers on vent (low trigger)
drop CO2 (increase RR)

319
Q

what are indication for tonsillectomy and adenoidectomy

A

recurrent infections and OSA

320
Q

what can hyperplasia of tonsils and adenoids lead to

A

CO2 retention
cor pulmonale
FTT

321
Q

characteristics of OSA

A
322
Q

what are risk factors of OSA

A

trecher collins
goldenhars aperts
arnold-chiari
achondroplasia
obesity
CP
trisomy 21

323
Q

what kind of OSAS require tonsillectomy

A

lymphoid hypertrophy

324
Q

what are the three forms of TA surgery

A

snare
cold or hot knife
cautery

325
Q

what is benefit and risk of cautery for TA

A

less bleeding, but is more painful

326
Q

what do we do for O2 concentration and cautery

A

turn down O2 2/2 fire risk

327
Q

what can bleeding from TA surgery leed to

A

vomiting from blood in stomach, so use OG to suction stomach after case, give antiemetics

328
Q

what is biggest concern of TA surgery

A

rebleeding

329
Q

T/F TA surgeries often have URi

A

true

330
Q

how long is a TA surgery

A

15 min

331
Q

what is steps of TA surgery

A

inhalation induction
place IV
IV induction

332
Q

what are meds for TA surgery induction

A

sevo 8% and N2O 70/30

333
Q

what kind of intubation do we do for TA surgery

A

atraumatic
videoscope

334
Q

how do we place ETT for TA surgery

A

taped down center of mouth to chin

335
Q

T/F use ibuprofen and toradol for TA surgery

A

false
avoid due to bleeding

336
Q

what are positioning techniques for TA sx

A

remove pillow and place towel for head turban

337
Q

what are some meds for TA surgery

A

IV APAP 15 mg/kg
IV fentanyl/precedex
Decadron
zofran

338
Q

what are adverse affects of Local with EPI in TA surgery

A

tachycardia
HTN
abscess formation
medullopntine infarct
bulbar paralysis

339
Q

what do we do prior to emergence to decrease NV after TA

A

OGT to suction stomach of blood (gently suction)

340
Q

T/F TA surgery has a high incidence of laryngospasm

A

true

341
Q

where does rebleeding usually occur after TA

A

PACU or after discharge

342
Q

what bleeds after TA

A

Internal and EXTERNAL carotid artery branches

343
Q

what do we avoid food wise after TA

A

red drinks or food

344
Q

what can high BP lead to after TA

A

bleeding, so give labetalol or carcoti at end of case, or bump with propofol

345
Q

what kind of induction do we do for FESS

A

IV or inhalation

346
Q

what kind of ETT do we use for FESS

A

RAE ETT

347
Q

what is a common complication of FESS? how do we intervenese

A

Bleeding
use throat pack
nose pack
vasoconstrictors

348
Q

what is th surgical debridement of sinus cavity

A

FESS
Functional Endoscopic Sinus Surgery

349
Q

what are indications for FESS

A

deviated septum
turbinates?

350
Q

what are useful anesthethetic adjuvants for FESS

A

precedex
fentanyl
tylenol

351
Q

what is benefit of precedex

A

proved sedation and decreases BP

352
Q

what are S/S foreign body aspiration

A

coughing
dyspnea
stridor
cyanosis

353
Q

when foreign body is located in the ___________ you are more likely to have wheezing, coughing, dyspnea, air trapping, and chronic infection

A

bronchus

354
Q

what kind of induction do we do for foreign body aspiration

A

inhalational with sevo and O2
or TIVA?

355
Q

what are important parts of anesthetic plan for foreign body aspiration

A

maintain spontaneous ventilation
local anesthetic at vocal cords and trachea

356
Q

what do we do to remove foreign body aspiration

A

rigid bronchoscope

357
Q

what kind of foreign body aspiration is an emergency

A

button batteries

358
Q

what are s/s epiglottitis

A

looks ill
febrile
drooling
severe sore throat
sits up while leaning forward to promote patent airway

359
Q

what is radiographic sign of epiglottitis

A

thumb sign

360
Q
A

thumb sign

361
Q
A

epiglottitis

362
Q

what causes epiglottitis

A

Haemophilus influenzae type B
Group A beta-hemolytic streptococci

363
Q

croup vs epiglottitis

A
364
Q

where does croup occur (subglottic, supraglottic)

A

subglottic

365
Q

where does epiglottitis occur (subglottic, supraglottic)

A

supraglottic

366
Q

what age does croup occur at

A

<3 years

367
Q

what age does epiglottitis occur at

A

3-6 years

368
Q

is croup bacterial or viral

A

viral

369
Q

is epiglottitis bacterial or viral

A

bacterial

370
Q

what are s/s croup

A

barking cough
hoarse voice
recumbent position
rapid RR
non-tender larynx
high fever
steeple sign on AP radiograph

371
Q

what are S/S epiglottitis

A

drooling
marked dysphagia
tripod sitting position
normal RR
normal larynx
low grade fever
thumb sign on radiograph

372
Q

T/F airway support is need in croup

A

F, only in <3%

373
Q

T/F airway support is needed in epiglottitis

A

T, always indicated

374
Q

Do we use narcs or muscle relaxers in epiglottitis

A

no

375
Q

what tools do we have for epiglottitis intubation

A

glidescope
blades
different size tubes
FOB
tracheostomy kit

376
Q

how do we transport epiglottitis

A

face mask and pulse ox

377
Q

how do we induce epiglottitis

A

sevo and oxygen induction, maintain spontaneous breathing

378
Q

what airway support do we use for epiglottitis

A

CPAP 10-15 mmHg

379
Q

what size/type of tube do we use for epiglottitis

A

cuffed tube 1-2 sizes smaller than normal

380
Q

what is a rare condition that causes tissue to partially or completely obstruct the glottic opening

A

laryngeal web

381
Q

what can be required in laryngeal web

A

can cause resp distress requiring an emergency airway

382
Q

subglottic stenosis grades

A
383
Q

what is subglottic stenosis 0-50%

A

grade 1

384
Q

what is subglottic stenosis 51-70%

A

grade 2

385
Q

what is subglottic stenosis 71-99%

A

grade 3

386
Q

what is subglottic stenosis 100%

A

grade

387
Q

what is treatment for subglottic stenosis

A

airway dilation

388
Q

what size ett do we use for subglottic stenosis

A

smaller ETT

389
Q

subglottic stenosis vs normal

A

Pediatric Anesthesia (5 decks)

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