FINAL 1 Flashcards
Ex-Premature infants are infants born:
<37 weeks gestation and <60 weeks postconceptional age.
These premature infants will need _____ hours post-op monitoring for apnea and desaturation
12-24
3 Factors that Increase the risk of postop apnea
<60 weeks post-conceptual age
Anemia (Hgb < 12)
Secondary Diagnoses (like intraventricular hemorrhage)
Do you want to give opioids to ex-premature infants?
nope
Caffeine ____mg/kg IV given intraoperatively can reduce the frequency of apnea
10mg/kg
These infants at risk of post-op apnea can be discharged _____ hours after free from apnea
12 hours
Does reginal anesthesia increase risk of post-op apnea?
No- so, they will not require extended monitoring, only ones under sedation or GA.
Abnormality of Tricuspid Valve where septal and often posterior leaflets are displaced into the RV
Ebstein’s Anomaly
Ebstein’s Anomaly (if occurs in isolation) is considered what type of lesion?
Acyanotic. But most will have a ASD or PFO and blood will be shunted R to L, causing cyanosis.
Ebsteins Anomaly can have ____ outflow tract obstruction
RV
Ebstein’s Anomaly- Tricuspid valve is usually _____ but may be _____
Regurgitant, Stenotic.
Result of Ebstein’s Anomaly
RA is Dilated and RV is atrialized with reduced RV cavity
Sx of Ebstein’s Anomaly in Neonates:
Presents as systemic venous congestion and cyanosis which worsens AFTER ductus arteriosus closes, which leads to decreased pulmonary blood flow
Ebstein’s Anomaly- Anterior valve leaflet is ____ and ___-like, with chordal attachments to the ____ free wall
elongated, sail-like.
Chordal attachments to RV free wall
Older children are diagnosed with Ebsteins Anomaly bc/ ________ is found
incidental murmur
Adolescents and adults with Ebsteins Anomaly will have
SVT causing CHF, worsening cyanosis and occasional syncope.
Patients with Ebsteins Anomaly are at risk for (4 items)
Paradoxical Embolization
Brain Abscess
CHF
Sudden Death
Classic Signs/Sx of Ebstein’s Anomaly
Cyanosis-depends on degree of R-L shunt
Systolic Murmur- (Left Lower Sternal Border)
Hepatomegaly (d/t hepatic congestion from CHF)
ECG=Tall, broad P waves, possible 1st degree AVB
PST and VT
20% have W-P-W
Echo=Cardiomegaly, R heart can compress lungs and become “restrictive” heart disease.
Treatment for Ebsteins’s Anomaly
Controversial- may do tricuspid valve repair, Fontan procedure or transplant.
Treatment of EA in older patients
Prevent associated complication like infective endocarditis, CHF and SVT.
Repair or replace the tricuspid valve and repair the ASD
Complications of EA repair
3rd degree AVB
SVT
Residual Tricuspid Regurg
Prosthetic Valve Dysfunction
EA- may be a _____ effect of IV anesthetics
delayed. d/t pooling and dilution of blood in the RA
3 Major Hazards with anesthetic management of EA.
Depressed RV function and forward flow
Hypoxia d/t increased R-L shunt
SVTs
Anesthetic goals with EA management (ventilation and cardiac)
Minimize mechanical and metabolic affects of ventilation
Maintain RV contractility
What is the most common chromosomal disorder?
Down Syndrome (Trisomy 21)
3 most common cardiac anomalies with Down Syndrome
Complete AV canal defect
VSD
ASD
(Others include TOF and PDA)
All of the cardiac anomalies with Down Syndrome have the propensity for
increased pulmonary blood flow (Pulm. HTN)
1 of the most common clinical features with DS
Hypotonia (weak muscle tone) can affect patency of airway.
Issues with DS that adds to risk of upper aw obstruction
Large Tongue
Short Neck
Crowded Midface
Laryngomalcia (congenital softening of the tissues of the larynx, above the vocal cords).
DS Pts have increased incidence of subglottic and tracheal ______. So ETT size may need to be ____
Stenosis
Smaller
DS Pts need cervical xrays to assess_____
Ligamentous Laxity of Atlantoaxial Joint (Atlanto-Axial Instability)
DS: Postpone the case I atlantodens interval is _____ on cervical x-ray
> 5mm
Normal Alantodens interval for Adult and Child
Adult < 3mm
Child<4.5mm (<5mm on next slide)
DS: Keep head and neck in _____ position
neutral
What do you know about C1?
“Atlas”
Ring shaped
Does not have a body
What do you know about C2?
“Axis”
Has fused remnants of the atlas body called the “Odontoid Process” or “Dens”
What is the Alantodens interval (ADI)?
Distance between the odontoid process and the posterior order of the anterior arch of the atlas.
Downs Syndrome Chart \_\_\_\_ birth weight \_\_\_\_\_ stature Congenital \_\_\_\_ Disease \_\_\_\_\_ susceptibility to pulmonary HTN \_\_\_\_\_\_ Sensitivity High arched narrow \_\_\_\_\_ \_\_\_\_\_glossia \_\_\_\_\_gnathia Subglottic \_\_\_\_\_ Postextubation \_\_\_\_\_ Upper airway \_\_\_\_\_\_\_- Sleep Apnea
Low birth weight Short stature Congenital Heart Disease Increased susceptibility to pulmonary HTN Atropine Sensitivity High arched narrow palate Macroglossia Micrognathia Subglottic Stenosis Postextubation stridor Upper airway obstruction- Sleep Apnea
More DS Chart Dental \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_ obstruction Gastroesophageal \_\_\_\_ H\_\_\_\_\_\_\_ Disease Mental \_\_\_\_\_\_\_ Ep\_\_\_\_\_y St\_\_\_\_\_\_s \_\_\_\_\_tonia \_\_\_\_\_\_extensibility or flexibility D\_\_\_\_\_\_ pelvis Alantoaxial \_\_\_\_\_\_\_\_ Neonatal poly\_\_\_\_\_\_ Low circulating levels of \_\_\_\_\_\_\_\_\_\_\_ Hypothyroidism
Dental Abnormalities Duodenal obstruction Gastroesophageal reflux Hirschprung Disease Mental Retardation Epilepsy Strabismus Hypotonia Hyperextensibility or flexibility Dysplastic pelvis Alantoaxial subluxation Neonatal polycythemia Low circulating levels of catecholamine Hypothyroidism
In utero, abdomen swells with fluid and is resorbed by birth leaving wrinkled abdomen.
Prune Belly Syndrome
Prune belly associated with _____hydramnios and urethral ________
Oligohydramnios
Urethral Obstruction
Prune Belly Syndrome occurs mostly with ______(m/f?)
Males
Is Prune Belly associated with other defects?
Yes
50% Orthopedic involvement
30% GI involvement
10% Congenital Heart Disease and Chromosomal defects
Describe patho of Prune Belly Syndrome as it leads to aspiration pneumonia.
Abdominal overdistention in utero leads to
Weak rectus abdominis which interferes with infants ability to EXHALE FORCEFULLY. Leading to
inability to cough and clear secretions, leading to
Aspiration Pneumonia
What is a frequent GI problem with Prune Belly Syndrome.
Constipation. Will often need stool softeners.
Prune Belly associated with Trisomy ____, and contradictory to previous knowledge, is now associated with 60-80% _____(m/f?)
18
Females
Discuss the 3 types of Prune Belly Syndrome Classifications
Type 1: Severe Renal Disease, or pulmonary hypoplasia or both. Incompatible with survival
Type 2 Neonatal Emergencies with severe uropathy and UTI. Requires multiple surgeries
Type 3 Minimal problems as newborn
Pro to infections in later childhood
Which type of PBS is associated with neonatal emergencies with severe uropathy and UTI. Will required several surgeries
Type 2
Which type of PBS is associated with minimal problems as a newborn but prone to infections later in childhood
Type 3
Which type of PBS is associated with severe renal disease, or pulmonary hypoplasia or both and incompatible with survival?
Type 1
Anesthetic management of PBS Avoid preop \_\_\_\_\_\_\_\_ Use H2 \_\_\_\_\_\_\_ and sodium \_\_\_\_\_\_ \_\_\_\_\_ intubation or \_\_\_ Avoid \_\_\_\_\_\_ relaxants Minimal \_\_\_\_\_\_ Avoid drugs requiring \_\_\_\_\_ excretion Controlled \_\_\_\_\_\_\_ Maintenance - inhalation or IV \_\_\_\_\_\_ extubation Reginal anesthesia may be \_\_\_\_\_\_
Avoid preop sedation Use H2 antagonist and sodium citrate Awake intubation or RSI Avoid muscle relaxants Minimal opioids Avoid drugs requiring renal excretion Controlled ventilation Maintenance - inhalation or IV Awake extubation Reginal anesthesia may be preferred
Pierre Robin is characterized by (3 things (R.A.G))
Retrognathia (posterior position of the mandible)
Airway Obstruction
Glossoptosis (tongue falling to back of throat)
Sequence (not syndrome) of fixed fetal position in the uterus inhibiting mandibular growth leading to small mandible and subsequent airway obstruction.
Pierre Robin
Pierre Robin is often associated with ______ syndrome
Stickler
Stickler syndrome characteristics (3 things)
Micrognathia
Poor Vision
Collagen disorder with hyperflexible Joints
PR also associated with
velocardiofacial syndrome
fetal alcohol syndrome
bilateral hemifacial microsomia
PR will always have some sort of ______ obstruction and may need to have _____ or _____ position to relieve.
airway
lateral or prone position
PR often have _____ and ______ difficulties (GI)
reflux and feeding difficulties
Surgical management options for Pierre-Robin (3 options)
Tongue-lip adhesion
Mandibular distraction
Tracheostomy
Tongue Lip adhesion involves
Suturing the inferior portion of the tongue to the lower lip. Relieves AW obstruction and improves feeding. Will need several days postop ventilation. Left intact until child is about a year old
Mandibular distraction is performed in infants ____ months old
< 6
Tracheostomy for PR takes an average of ____ years for decannulation
3
Pierre Robin are usually difficult mask ventilation and intubation. What techniques should you be prepared to employ? (4)
LMA
Nasal Intubation
Video Laryngoscopy
Suture (o-silk) placed at base of tongue to displace tongue anteriorly
Tongue-lip adhesion or mandibular distraction will require _____ intubation, _____induction with ____ventilation.
nasal
inhalation
spontaneous
Tongue-lip adhesion will require postop_____, then to ICU, but extubate back in the _____
ventilation
OR- so that you can readily reintubate if needed
Mandibular distraction will have difficulty with ______ ventilation because of the distractors
mask- distractors prevent effective mask ventilation
Cleft lip is usually repaired at age_____
Cleft palate is usually repaired at age ____
3-6 months
9-18 months
Technique used to repair hard/soft palates. Usually done before _____ year old
Palatoplasty
1 year old
Technique used to repair/treat incompetent velopharyngeal sphincter that allows inappropriate nasal air to escape during speech. Done between ___ and ____ years of age
Pharyngoplasty
5-15 years of age
Clefting AW management is usually straightforward.
Factors that predict difficult laryngoscopic view (2)
Blilateral Clefts
Retronathia
GA with clefting- remain ______ breathing until trachea is secure
spontaneous
Beware using _____ in patients with cleft repair because potential for disruption of repair.
LMA
This type of ETT is preferred for patients with a cleft.
Oral RAE
Due to the fixed length of the Oral RAE, there is an increased risk of _________ intubation
mainstem
For Palate surgery keep MAP ________
50-60 to reduce risk of bleeding
Palate surgery- surgeon infiltrates palate with epinephrine. What is a safemaximal dose?
10mcg/kg for infiltration
Palate correction surgery is long so
positioning and padding is critical.
Protect infant’s chest and extremities
Main concern postop for palate repair?
Confirm removal of _____
Postop airway obstruction
Throat pack
Palate repair has risk for tongue, palate and pharyngeal ______. If this occurs, best to:
edema
reintubate and mechanically ventilate for a few days until edema subsides
Rectal dose of Acetaminophen
20-40mg/kg initially
followed by 20mg/kg Q6H
Oral dose of Acetaminophen
10-15mg/kg Q 4-6 hours
Morphine dose IV
0.02mg/kg IV q 3-4 hours
Reginal technique used for cleft palate repair pain control. What nerve does this block and what sensory does this nerve provide?
Bilateral Infraorbital nerve block
Maxillary division of trigeminal nerve that exits infraorbital foramen and supplies sensory to the upper lip, choana, maxillary sinus and part of the nasal septum
Craniofacial defect characterized by poorly developed supraorbital ridges, aplastic/hypoplastic zygomas, ear deformities, hearing loss, cleft palate (in 1/3), mandibular and midface hypoplasia
Treacher Collins Syndrome
Another name for Treacher Collins Syndrome
Mandibulofacial dysostosis
TC is associated with mutation on chromosome ____
5
AW is always a concern with TC and obstruction depends on (3 things)
Degree of Maxillary and mandibular hypoplasia
Choanal Atresia
Glossoptosis
TC: trach may be needed for those at risk for
OSA and SIDS
TC may be difficult to mask or intubate.
Techniques used for success?
Bullard Laryngoscopy
LMA
Glidescope
Sedation and fiberoptic intubation
TC- make sure you protect the patient’s ____
Eyes- d/t zygomatic hypoplasia
TC can be accompanied by congenital cardiac defects so
use antibiotic prophylaxis to prevent subacute endocarditis.
