KN Part 2 Flashcards
9; 21-39
T/F:
prophylactic antibiotics are not required for Adenoidectomy
True
the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) no longer recommends prophylactic antibiotics
Who should get prophylactic antibiotics before Adenoidectomy
cardiac lesions
may be at risk for endocarditis caused by recurrent streptococcal bacteremia secondary to infected tonsils and will require prophylactic antibiotics
the major indications for Adenoidectomy
- Chronic or recurrent tonsillitis
- obstructive adenotonsillar hyperplasia
Adenoidectomy
Surgical treatment is required when tonsillitis is so severe that…
- recurs despite adequate medical therapy
- associated with peritonsillar abscess
- when acute or chronic airway obstruction compromise breathing
chronic tonsillitis S/S (3)
- halitosis
- persistent pharyngitis
- cervical adenitis
Tonsillar hyperplasia is a risk for chronic airway obstruction, which can lead to…
- OSA
- failure to thrive
- swallowing disorders
- speech abnormalities
- pulmonary hypertension
- right-sided heart failure
- eventually cor pulmonale
How does Tonsillar hyperplasia cause pulmonary hypertension, right ventricular hypertrophy & cor pulmonale?
chronic hypoxemia & hypercarbia
Indications for Adenotonsillectomy
T/F:
People usually have their adenoids and tonsills removed at the same time.
True
Indications for adenoidectomy alone
- chronic or recurrent purulent adenoiditis
- recurrent otitis media with effusion secondary to adenoidal hyperplasia,
- chronic sinusitis
Advanced adenoidal hyperplasia may lead to
- nasopharyngeal obstruction
- obligate mouth breathing
- poor feeding resulting in failure to thrive
- speech disorders
- sleep-disordered breathing (SDB)
adenoid facies or long face syndrome
Long-standing nasal obstruction ➔ orofacial abnormalities with a narrowing of the upper airway and dental abnormalities
Tonsil/Adenoids
Electrocautery dissection method
less intraoperative blood loss & postop hemorrhage
but
more pain and poor postop oral intake
Adenoids/tonsils
Complications by age group
- >10 years more commonly have a secondary hemorrhage
- younger more commonly have both poor oral intake and respiratory complications.
- Most children under 3 have airway problems after adenotonsillectomy for obstructive breathing
Complications of adenotonsillectomy (rare)
- uvular amputation & edema
- velopharyngeal insufficiency
- nasopharyngeal stenosis
- atlantoaxial subluxation (neck pain and torticollis)
- mandibular subluxation and condylar fracture
- cervical adenitis & osteomyelitis
- bleeding, burns, and airway fires account for over one-third of malpractice claims associated with this procedure.
- throat pain, otalgia, emesis, poor oral intake, and dehydration are common morbidities.
The single most important task for adenotonsillectomy preop eval:
distinguish OSAS from isolated obstructive breathing (e.g., primary snoring) and chronic infectious tonsillitis
because the former children are at greater risk for developing severe perioperative respiratory adverse events (PRAEs), possibly including death, after adenotonsillectomy
most severe form of OSAS will result in….
- pulmonary & systemic HTN
- cor pulmonale, ventricular hypertrophy,
- metabolic syndrome
- neurocognitive dysfunction
- life-threatening nocturnal hypoxemia
unexpected deaths after adenotonsillectomy from ____________ after discharge from a monitored setting, including to home
presumed sleep apnea
SDB
(abnormal breathing patterns during sleep)
- obstructive breathing
- snoring
- paradoxical chest motion
- increased respiratory effort
- apneas
- hypopneas leading to hypercarbia, and desaturation followed by arousal
T/F:
Adenotonsillectomy can be the initial treatment for OSAS
True
adenotonsillectomy is often the initial treatment
T/F:
anticipate disease with multiple organ system involvement in children undergoing adenotonsillectomy
True
URIs are frequent in children undergoing adenotonsillectomy. Why is this important?
Higher risk respiratory compromise & hemorrhage
Increases risk of postop adenotonsillectomy hemorrhage
- URIs
- Obese
- SDB
- > 10 years more commonly have a secondary hemorrhage
- aspirin, NSAIDs, and valproic acid
aspirin, NSAIDs, and ___ increase risk of bleeding
valproic acid
Airway exam:
tonsilar size
T/F:
Cor pulmnale can occur with SDB in addition to OSA.
True
T/F:
Preop coags should done routinely before adenotonsillectomy.
False
no evidence that routine preop coags are beneficial unless they are indicated by history or the presence of a disorder of hemostasis
The anesthetic goals for adenotonsillectomy (4)
- smooth, atraumatic induction
- provide the surgeon with optimal operating conditions
- IV access for volume expansion & meds as indicated
- rapid emergence (awake & can protect a recently instrumented airway)
Can you pre-medicate a child with OSA?
Yes, with caution
short-acting, reversible drugs & pulse ox
adenotonsillectomy
possible anesthesia methods
- Inhalational, TIVA, ETT or LMA, spont. or controlled ventilation
- Sevoflurane = smooth induction
- Maintenance w/ desflurane (with ETT) = rapid emergence & recovery
Children who are scheduled for adenotonsillectomy have a greater risk of …
airway reactivity and laryngospasm than those undergoing non-airway surgery
Benefits of cuffed ETT during adenotonsillectomy (3)
- Prevent air leak & the bubbling of gas in secretions and blood that can interfere with surgery
- Minimize pollution
- May decrease the risk of an airway fire w/ electrocautery
LMA for
adenotonsillectomy
use one w/ flexible spiral, metallic reinforced shaft; less postop stridor & laryngospasm
T/F:
Emptying the stomach with an OGT reduces PONV incidence after adenotonsillectomy
FALSE
it does NOT
lateral “recovery” or “tonsil” position
- head slightly down; blood & secretions pool in the dependent cheek and drain out
- remain in the tonsil position postoperatively
- increases both the cross-sectional area & total volume of the upper airway
Can you do a deep extubation after adenotonsillectomy?
- Deep extubation can be done with Precedex
- similar rates of respiratory events
(Other card suggest fully awake exTT is priority)
Significant pain and severe functional limitations for up to ___ after adenotonsillectomy
7 days
Using local in the tonsillar fossa
-limitations
-complications
Only brief pain relief
Life-threatening complications:
- intracranial hemorrhage
- bulbar paralysis
- deep cervical abscess
- cervical osteomyelitis
- medullopontine infarct
- cardiac arrest
adenotonsillectomy
Pain Mgmt
- Dexmedetomidine (2 µg/kg IV over 5 to 10 minutes followed by 0.7 µg/kg per hour)
- Dexamethasone (0.3–1 mg/kg)
- NSAIDS: may use tordaol AFTER hemostasis achieved; avoid ibuprofen in children taking aspirin (postop bleeding)
- Oxycodone may be used in older children
- Codeine is no longer indicated
minimum morphine-sparing dose of decadron for adenotonsillectomy
0.5 mg/kg
may precipitate acute tumor lysis syndrome
Dexamethasone
adenotonsillectomy & codeine
FDA mandate: all codeine-containing products have a warning of risk after tonsillectomy or adenoidectomy
AND
contraindicated under 18 yrs undergoing tonsillectomy
adenotonsillectomy
common comorbid conditions post-op
Emesis and poor oral intake
adenotonsilectomy
How to control PONV
- Propofol, zofran, (5HT3) antagonist , dexamethasone
- A single intraop dose of dexamethasone reduces emesis during the first 24 hours
- no post-op fluids until the child asks
- Rehydrate during anesthesia (20 - 25ml/kg LR or NS)
Induction for adenotonsillectomy:
CPAP
- pneumatic splint increases caliber & longitudinal tension on the pharyngeal airway ➔ less collapsible & higher lung volumes.
- 5 - 10 cm H2O ➔ increases dimension of the pharyngeal airway dramatically
consider IV access before induction
How much CPAP will increase the dimension of the pharyngeal airway dramatically ?
5-10 cm H2O
When to admit overnight after tonsil/adenoid removal
T/F:
Repeated middle ear infections may be improved by an adenoidectomy
True
the most common indication for T&A
Obstructive sleep apnea
adenotonsillectomy
How to position for induction
Inhalational induction
Supine position, shoulder roll, head extended
“Field avoidance” in adenotons.
(table turned 90 degrees)
with the surgeon at head of the table
EBL during adenotonsillectomy
varies widely from 10 - 200 ml, so monitor carefully
adenotonsillectomy
There is a high risk for laryngospasm secondary to …
upper respiratory infection
(URI)
Throat pack
in adenoid/tonsils, may be placed in the posterior of the pharynx to limit blood draining into the stomach
The surgeon is placing/manipulating the throat pack. You should monitor for…
ETT compression or accidental extubation
adenoids/tonsils
Patients with Down syndrome may need to be evaluated for possible…
atlantoaxial subluxation, as the neck is typically extended
Emergence Delirium
altered state of consciousness that may occur as a child awakens or emerges from general anesthesia
manifests as:
- disorientation
- hyperactive behavior
- hypersensitivity in the immediate postoperative period
T/F:
most cases of ED are self-limited and resolves on its own.
True
Medicating emergence delirium
- Dexmedetomidine (0.3-0.5 mcg/kg slow bolus)
- Propofol (0.5-1 mg/kg)
- Opioids (fentanyl 1-2 mcg/kg)
effects of ED may cause these behavioral changes even after discharge…
- general anxiety
- separation anxiety
- sleep anxiety
- bed wetting
- eating disturbances
- aggression
Which has less occurences of ED? TIVA or inhalationals?
TIVA
TIVA has been shown to be effective in reducing ED when compared to the use of volatile anesthetics.
non-pharm. methods to prevent ED
- Parental presence during induction
- Virtual tours prior to surgery
- Video distraction/tablet-based interactions during mask induction
Drugs shown to help reduce the incidence of ED
- opioids (i.e., fentanyl, remifentanil, and sufentanil),
- propofol,
- dexmedetomidine, clonidine,
- ketamine
Does preop Versed reduce ED?
mixed data
it reduces pre-op anxiety which is linked to reduced incidence of ED
Timeframe for ED
Typically occurs soon after emergence from general anesthesia but can be delayed up to 45 minutes
ED usually presents as
- agitation
- nonpurposeful movement (kick, pull, and flail)
- lack of eye contact & self-awareness
- thrashing, disorientation, crying, and screaming
The differential diagnosis of ED
(1) pain
(2) Hypoxia
(3) Hypo or hypercarbia
(4) Hypoglycemia
(5) Hypotension
(6) Increased intracranial pressure
Risk factors for ED
- age: preschool (2-6)
- ear, nose, throat, eye
- sevo, des (less-soluble inhalationals)
- negative interactions/coping
- preop anxiety in the child & parents
- h/o anxiety, temperment disorders
- preop mental state
Order of the anesthestics most likely to be a/w ED
T/F:
The duration and depth of anesthesia does not affect occurrence of ED.
True
T/F:
There is a clear correlation between male gender and ED.
False
inconclusive but may still be seen as a risk factor
score >10: waarants intervention
Factors that do not predispose a child to delirium
- rapid emergence from anesthesia
- a greater depth of anesthesia
- preoperative anxiety (controversial)
T/F:
Emergence delirium usually lasts < 15-20 minutes and resolves spontaneously if the children are left undisturbed or they are held by their parents and will not recur.
True
T/F:
Orienting the child to their parents, familiar objects, or surroundings can help manage ED.
False
they cannot recognize parents, familiar objects, or surroundings
inconsolable!
talks irrationally during early emergence from anesthesia.
Emergence delirium occurs ___ % more often in children than in adults, esp 2-6 years of age
30–50%
proposed mechanism of emergence delirium
- possible source: frontal lobe EEG and in the locus coeruleus
- CNS metabolites in the parietal cortex
- lactic acid and other metabolites after sevoflurane
> 10 or 12 = ED
8 in PICU = predicts ED
Intervene if >10
ED prevention
doses
Steeple sign represents
croup
Steeple sign
appearance on XR
blurred tracheal air shadow on lateral neck films, and symmetric narrowing of the subglottic air shadow
“church steeple” or “sharpened pencil” sign on anteroposterior films
Beware of neck XR obtained from the ____ angle. These show normal supraglottic structures and epiglottic shadow even if croup is present!
lateral neck radiographs
“church steeple” or “sharpened pencil” sign on anteroposterior films
Advantages of thoracoscopy (compared with thoracotomy):
- smaller chest incisions – minimal musculoskeletal changes
- reduced postoperative pain
- more rapid postoperative recovery
Size Telescopes for use in infants
1.2-4.0 mm in diameter
Endoscopes
vs
Digital cameras
Endoscopes: pass thru needle & trocar system and digital video signals can be electronically modified to yield sharp, detailed, color images with a minimum light intensity.
Digital cameras: maintain an image in an upright orientation regardless of how the telescope is rotated
T/F:
Thoracoscopy requires one-lung ventilation.
False
can be performed while both lungs are being ventilated using CO2 insufflation and placement of a retractor to displace lung tissue in the operative field.
SLV is extremely desirable during thoracoscopy because
lung deflation improves visualization of thoracic contents and may reduce lung injury caused by the use of retractors
The smallest of telescopes
use fiberoptics and are < 2 mm in diameter
Thorascopic vs Open-chest Surgery
(Pros)
Neurosurgery anesthetic goals
- If intracranial HTN, primary goals during induction are to minimize severe increases in ICP and decreases in blood pressure.
- avoid the ICP increasing effects of hypoxemia, hypercarbia, and coughing
atropine or glycopyrrolate may be given before ETT to prevent reflex bradycardia and to decrease secretions. How much glyco would you give?
Glycopyrrolate: 0.005–0.01 mg/kg
T/F:
You can treat bradycardia from precedex with glyco 5mcg/kg.
False
severe persistent hypertension
Why is neostigmine less desirable than atropine & glyco?
comparitvely delayed elimination (renal)
muscarinic effects (bradycardia, secretions, bronchospasm may theoretically occur postoperatively after antagonism)
Best combo to reverse paralytic after tonsillectomy
atropine and neostigmine
less PONV than glycopyrrolate and neostigmine
The surgeon is complaining secretions are obsucring his view through the bronchoscope. You reach for….
An antisialagogue (atropine or glycopyrrolate)
Which drug combo can reduce secretions while also reducing mucosal swelling from repeated intubations?
An antisialagogue, such as glycopyrrolate, with dexamethasone
(0.5 mg/kg [max 10–20 mg])
Prophylaxis for trigeminovagal (oculocardiac) reflex from Retrobulbar block
atropine (20 µg/kg)
or
glycopyrrolate (10-20 µg/kg)
on induction or early thereafter
T/F:
A retrobulbar block will completely prevent the OCR response to further surgical stimulation or manipulation
False
it may not in some cases
T/F:
Atropine and glycopyrrolate prevent bradycardia from the trigeminovagal reflex from occurring, thus they are given on induction.
False!!!!
DO NOT PREVENT
decrease the severity and duration
anticholinergics cause pupillary dilatation, which doesn’t bother the ophthalmologist, but they may…
slightly increase the IOP
oculocardiac reflex
-NT involved
-pathway
The neurotransmitter from the vagus nerve to the sinoatrial node is acetylcholine
(reflex is blocked by antimuscarinic pharmacologic agents (i.e. atropine and glycopyrrolate)
T/F:
If OCR is anticipated, prophylactic prevention with IV neostigmine may be warranted
False!
IV atropine or glycopyrrolate
must use antimuscarinic
Oculocardiac reflex
-prophylactic dose
-refractory dose
induction:
atropine (20 µg/kg) or glycopyrrolate (10-20 µg/kg)
atropine (10–20 µg/kg) or glycopyrrolate (5–10 µg/kg).
Uses for atropine and glyco
- if OCR expected
- before succs to help prevent bradycardia
- with ketamine to decrease secretions
glyco & atropine dosing
RSI trauma
Most frequent congenital craniofacial malformation
Cleft palate
Cleft palate affects (males/females) more
males
T/F:
Clef palate may environmental causes
True
genetic and environmental
How does Cleft palate start?
defect in palatal growth during 1st trimester
Cleft palate repair steps
(allows for tissue maturation)
- Primary cleft LIP repair: 2-3 months
- Primary cleft PALATE repair: 6-10 months
- Palatal revision and alveolar bone grafts: 10 years
- Rhinoplasty and maxillary osteotomy complete repair: 17-20 years
T/F:
Micrognathia (no chin) is an independent predictor of difficult airway
True
risk decreases with increased age; worst at < 6 months
When is micrognathia worst?
< 6 months
difficult airway risk decreases with increased age
Pre-op assessment
Which congenital malformations are a/w Cleft palate? (2)
- mandibular hypoplasia (Pierre Robin Syndrome [PRS])
- restricted neck movement (Klippel-Feil Syndrome)
Features of mandibular hypoplasia
(Pierre Robin Syndrome [PRS])
- micrognathia
- glossoptosis (caudally displaced tongue)
- respiratory distress 24-48 hr after birth
Syndromes commonly associated with cleft lip & palate (8)
- PRS
- Down syndrome
- Klippel-Feil syndrome
- Treacher collins syndrome
- Velocardiofacial syndrome
- Fetal alcohol syndrome
- Nager syndrome
- Goldenhar syndrome
Cleft palate repair
Rule of ten
- Hgb 10
- At least 10 weeks old
- At least 10 lbs
Cleft palate repair
Airway considerations
- Wide cleft palate = more difficult DL
- Best to use a straight blade via right paraglossal approach (displace tongue to the left)
Sometimes, tongue may be sutured to mandible or lower lip to preclude airway obstruction in infants with PRS
Ideal route to secure airway in cleft palate repair
intubate with oral RAE
Anesthetic mgmt for cleft palate
- Inhalational or IV
- Short acting opioids (fentanyl 1-2 mcg/kg)
- Infraorbital nerve blocks (improved satisfaction, decreased emergence agitation, decreased opioid & antiemetic need)
- IV acetaminophen better than rectal for pain
Which supplemental airway is good for postop cleft palate repair? Why?
nasal trumpet (placed by surgeon)
- Kids are often nose breathers & pharyngeal space is reduced after repair
- Also permits airway suctioning without damaging repair
cleft palate repair
Interventions by surgeon that require our attention
- Surgeons may move head a lot
- Epi used by surgeons → consider systemic absorption
- pharyngeal packs OUT before extubation
cleft palate:
most common complications
and what that means for us
bleeding and swelling → AIRWAY OBSTRUCTION
During a cleft palate repair, a mouth gag is in place for over 2-3 hours. What is your concern?
Acute airway obstruction from lingual swelling
Decadron (0.5 mg/kg) may help with airway edema
What % of cleft palate repair patients experience OSA?
10
Aside from bleeding, swelling and airway obstruction, what are other complications associated with cleft palate repair? (4)
- late postop airway edema,
- subcutaneous emphysema,
- oxyhemoglobin desaturation,
- bronchospasm, laryngospasm
Cleft palate repair patients should be monitored for upper airway obstruction for how long?
48 hours
Pediatric shock
Most commonly cause
hypovolemia in trauma patients
Can also be cardiogenic shock (rare) if chest trauma or preexisting CV disease
Pediatric shock
Main goal
PERFUSION
T/F:
When in shock, kids will likely compensate better than adults
True
In trauma, we want 2 large bore IVs. Where do we want them?
Abdominal trauma: IVs in upper extremities
Chest trauma: upper and lower extremities (just in case major vessel is injured)
Bolus for shock if hypotensive
20 ml/kg of isotonic crystalloids (LR or NS)
Repeat boluses to stabilize BP
Shock
When should we consider PRBC? How much do we give?
If >40-60 ml/kg fluid bolus fails to fix hypotension give PRBCs 10 ml/kg
IV attempts have failed. An IO can be placed where?
tibial tuberosity
Shock
Avoid glucose-containing solutions if hypoglycemia is not present due to…
potentially worsening neuro outcome
Primary and Secondary Survery
Fluid Bolus algorithm
Airway mgmt in trauma without head injury
GI Foreign body most commonly occurs in which kids
toddlers 1-3 yo
Choking while eating or playing
___% of foreign bodies lodge in right mainstem bronchus
95
T/F:
Esophageal foreign bodies do not cause airway obstruction
FALSE
may compress the trachea
partial vs complete
obstruction
S/S
Partial: coughing, wheezing, drooling, stridor, respiratory distress
Complete: hypoxia, cardiorespiratory compromise, aphonia
Tracheal foreign body signs and symptoms
brassy cough, abnormal voice, bidirectional stridor
If bronchus is completely obstructed, what will be seen on CXR?
distal hyperinflation from air trapping
Pneumonia is an (early/late) sign of a foreign body and typically occurs on the (left/right) side.
late; right
Why are Unroasted peanuts especially dangerous
Oils induce inflammatory response (pneumonitis) → extremely inflamed airway
Small button sized batteries should be urgently removed because…
potential for extensive local damage
4 types of obstruction
- Check valve: can inhale; not exhale
- Ball valve: can exhale; not inhale
- By-pass valve: partial obstruction of both inhalation & exhalation
- Stop valve: total blockage
A foreign body should always be considered (2)
full stomach and potential difficult airway
for foreign bodies, have this med ready in addition to anticholinergics to reduce secretions
metoclopramide (0.15 mg/kg)
Foreign body
Anesthesia management options
- Controlled ventilation or spontaneous respirations
- 100% oxygen with sevo (least irritating)
- Prop TIVA
- Topical lidocaine (3-4 mg/kg)
Cerebral blood flow
All potent inhalational anesthetics…
decrease cerebral vascular resistance
(cerebral vasodilation → increased CBF)
Order of increase in CBF
halothane > enflurane ~ des > iso > sevo
IAs & velocity
- CBF velocity increases with halothane and des
- Sevo does not increase CBF velocity
preferred VAs for neuroanesthesia
Sevo & Iso
at small MAC (< 1) and with mild hyperventilation
Order of increase in CBF: halothane > enflurane ~ des > iso > sevo
CMRO2 is greater in children than in adults. How much is it?
> 3.5-4.5 mL O2/100 g/min
GA reduces CMRO2 by how much?
50%
Most IV drugs decrease ICP due to….
a decrease in CMRO2 and CBF
Most inhalational agents uncouple…
- CBF and CMRO2 (increased CBF and decreased CMRO2)
- Dose dependent increase in CBF to CMRO2 ratio
greatest depression of CMRO2
Iso
Anesthetics that decrease ICP & CMRO2 and maintain CPP are desired. Which are drug increases CMRO2?
ketamine
T/F:
Moderate hypothermia may be useful in neurosurgery.
True
may decrease CMRO2
Congenital diaphragmatic hernia (CDH)
- part of the fetal diaphragm doesnt develop & abdominal contents enter the thorax, interfering with normal lung growth
- life-threatening
how common is Congenital diaphragmatic hernia (CHD)
1 in 2000 live births.
The most common type of CDH occurs at
Congenital diaphragmatic hernia (CHD)
posterolateral foramen of Bochdalek (90%)
largest & greatest degree of pulmonary hypoplasia.
CDH occurs 5X more frequently on the (left/right) side
left
Neonates with the Bochdalek hernia are more likely to have other birth defects such as
- 20-40% frequency of congenital heart defects
- a 5-15% frequency of chromosomal abnormalities
foramen of Bochdalek
80-90% of diaphragmatic defects, a portion of the posterior diaphragm fails to close, (80-85% of cases on the left side), forming a triangular defect
most common type of CDH occurs at the posterolateral foramen of Bochdalek (90%) and is also the largest and is associated with the greatest degree of pulmonary hypoplasia.
Hernias through the foramen of Bochdalek occurring early in fetal life usually cause respiratory failure immediately after birth due to…
pulmonary hypoplasia
Foramen of bochdalek
CDH Signs and Symptoms
- Tachypnea
- scaphoid abdomen
- absent breath sounds on affected side
CXR: bowel in the left hemithorax, with deviation of the heart and mediastinum to the right and compression of the right lung.
CDH interventions for significant respiratory distress
- AVOID mask ventilation
- immediate ETT
Why should you not bag-mask ventilate a Congenital diaphragmatic hernia (Foramen of bochdalek) patient in significant respiratory distress?
it can distend the thoracic gut postnatally & further compresses the inflated lungs, rendering ventilation and oxygenation more difficult
congenital diaphragmatic hernia causes what type of shunt
pulmonary hypertension with right-to-left shunting
congenital diaphragmatic hernia:
type of ventilation recommended
High-frequency oscillatory ventilation
congenital diaphragmatic hernia:
meds used to increase oxygenation
Pulmonary vasodilators
Tolazoline, prostacyclin, dipyridamole, and nitric oxide
congenital diaphragmatic hernia
used to maintain a PDA and reduce RV afterload
Prostaglandin E1
If patient has CDH and pulmonary vasodilators, PGE1, and high-frequency oscillatory ventilation have failed. What next?
ECMO initiated early to avoid progressive lung injury
Surgical correction via a subcostal incision with ipsilateral chest tube placement may be performed before, during, or immediately after ECMO.
congenital diaphragmatic hernia may benefits from (hypo/hyper)ventilation
Hyperventilation
to induce a respiratory alkalosis and 100% oxygen may be administered to decrease pulmonary vascular resistance.
congenital diaphragmatic hernia
Anesthetic goal
minimize sympathetic discharge
Most complications in children with URIS are related to the presence of
secretions and heightened airway reactivity
Heightened airway activity in patients with URIs may persist for
up to 6 weeks
following the infection
a URI patient should be transported to PACU in ___ position
recovery
algorithm for URI & proceeding/delaying surgery
Most clinicians wait …. after the URI has resolved to do surgery
2-4 weeks
4-2-1 rule
Laryngospasm in cryptorchidism and inguinal hernia
requires GA (mask, LMA, ETT) + pain mgmt
When the surgeon pulls on the foreskin, hernia sac, or testis during surgery, laryngospasm may occur if the depth of anesthesia is inadequate.
Of the currently available inhalational agents, ___ provides a smooth induction of anesthesia
sevoflurane
Maintenance of anesthesia with ___ (for those whose airway is secured with an ETT) provides rapid emergence and recovery
desflurane
If laryngospasm develops during induction
bolus of propofol (1–2 mg/kg IV) should be promptly administered
induction
__ may be given IV or IM before bradycardia occurs
Atropine (20 μg/kg)
How to break laryngospasm if an IV catheter has not been placed
IM succinylcholine or rocuronium
RDI
RDI > 20 events per hour: a/w breath-holding on induction
RDI > 30: a/w laryngospasm and desaturation during emergence
Upper endoscopies have the inherent risk of
apnea, laryngospasm, bronchospasm, and airway obstruction
Using an LMA instead of an ETT in the presence of a URI may reduce…
mild bronchospasm, laryngospasm, breath-holding, and O2 desaturation
⭐️
Pediatric Comorbidities considered “high risk” for office-based procedures
- OSA
- Uncontrolled asthma or URI
- Neurologic and neuromuscular disorders
- Complex congenital heart disease
- Sickle cell disease
- Increased BMI
Acute Pain Management
- Regional: surgical anesthesia or post-operative pain management
- Tylenol: 15 mg/kg (oral)
- Ibuprofen: 10 mg/kg (oral)
- Demerol: ONLY for shivering
T/F:
Demerol is only used for shivering because it can cause seizures.
False
its metabolite, Normeperidine can cause seizures
Discharge Criteria for Outpatient Setting
- CV function & airway patent
- Arousable, protective reflexes
- Child talk & sit up (if age approp)
- Young or disabled child: responsiveness as close as possible to baseline
- Adequate hydration
- If full gait not returned, parents can carry their child (inform of risk of injury if not properly supervised)
- Pain controlled on PO medications
- Oral hydration without PONV
Sudden onset bradycardia, until proven otherwise, is due to
hypoxemia
Other than hypoxemia, what can cause bradycardia?
vagal response, meds, increased ICP, high spinal
bradycardia mgmt
treat underlying cause
- O2 & ventilate if necessary
- If HR not improved: Atropine (0.02 mg/kg)
- If not improved 30 seconds after, give epinephrine (2-10 mcg/kg)
- symptomatic bradycardia: immediately give epinephrine – if no response, start chest compressions
T/F:
Coughing, vomiting, hypoxia usually results in tachycardia.
False
in kids, bradycardia
Hemodynamically significant bradycardia can be treated & prevented with prophylactic anticholinergic. What meds/doses?
- Atropine: 10-20 mcg/kg (IV or IM)
- Glyco: 5-10 mcg/kg
Topical phenylephrine
most common for dilation of eyes – can cause severe HTN & reflex bradycardia
Pilocarpine
cholinergic agonist, improves aqueous humor flow,
if absorbed can acutely cause bradycardia
T/F:
Use caution with Vagal nerve stimulators, as sudden bradycardia is likely.
False
Stimulation may affect vocal cord function, but sudden bradycardia is uncommon
Cardiovascular effects of Steep reverse trendelenburg (2)
transient hypotension & bradycardia
reversed with fluids & atropine
This agent used for induction may make Down syndrome kids bradycardic
sevo induction
Trisomy-21 kids (with or without hypothyroidism)
T/F:
MRI uses radiation.
False
Which O2 tank can be taken into MRI
3AL (aluminum)
MRI “safe” vs “conditional”
safe: “not posing any known hazard in any MR environment”
conditional: may or may not be safe depending on the specific conditions that are present
Which devices/implants must be evaluted for MRI safety?
- Stainless steel/surgical steel may have translational or rotational forces
- Intracranial aneurysm clips can potentially move & dislodge
- Stents, implants, shrapnel, prosthetic limbs, intraorbital metal, some permanent makeup/tattoos
- Pacers: Vfib, rapid atrial pacing, asynchronous pacing, inhibition of pacing output, movement of device
MRI & the ETT
- Switch to cuffed tube before scan
- Small-diameter cuffed (Bivona) are MRI conditional – acceptable for use, but pilot balloon needs to be taped out of the way
Magnetic field strength
0.5-3 T (tesla)
___ objects can be attracted to MRI and cause serious injury and death
Ferromagnetic
T/F:
The MRI magnet is never off.
True!
The magnets are never off, even at night
Where is MRI Power drawn from?
supercooled helium that must be vented (“quenched”) to shut down the magnet
Quenching the magnet will super cool the MRI room (frost bite risk) and O2 displacement
Pediatric temperature changes in MRI
can increase core body temp by 0.5° C during MRI of < 1hr in a 1.5-T
MRI needs cold environment & humidity to function, but generates radiofrequency radiation that gets absorbed by child & can offset heat lost to the environment
Specific absorption rate (SAR)
FDA allowable limit
0.4 watts/kg
Gadolinium
used for contrast in MRI
advanced kidney failure: only use if absolutely necessary & do dialysis right after
Performing anesthesia with a Non-MRI compatible machine
- Machine outside the MRI suite
- GETA or LMA: induce outside the scanner room
- 30 ft airway circuit threaded through wall of scanner to child
- IV sedation/anesthesia using MRI compatible pump or extension tubing
- If compatible ETCO2 monitor not available, CO2 monitor outside room can be used
- AMBU bag or Mapleson circuit always inside MRI suite and connected to O2 within the scanner room
- The only part of the laryngoscope that is not MRI-safe is the battery (can replace with a lithium battery)
Propofol vs. Precedex for MRI
Propofol is a better choice when used alone or in combo with other agents (usually 200-250 mcg/kg/min)
Infants & cognitive dysfunction may need to increase rate by 20-50% or add remi
Potential Difficulties in MRI
- Malfunction of anesthesia equipment
- Malfunction of monitoring
- Anesthesia equipment causing interference with image quality
- High-velocity ferromagnetic projectile from loose object
- Disruption of electronic devices, credit cards
Monitoring Failure in MRI
- ECG: T waves & ST altered and qualitative info lacks during scanning; use MRI leds
- Pulse Ox: use fiberoptic connection to prevent burn
- Capnography: long tubing = delayed measurements
- Temperature: filtered cable
- Precordial Stethoscope: Long tubing, sounds obscured by scanner
- O2 analyzer: Non-magnetic lithium battery is required – shortened battery life
The single most important task during the preoperative evaluation of the child for adenotonsillectomy
- distinguish the child with OSAS from the child with isolated obstructive breathing (e.g., primary snoring) and chronic infectious tonsillitis
- because the children with OSAS are at greater risk for→developing severe perioperative respiratory adverse events (PRAEs), possibly including death
preop eval of
Neuromuscular scoliosis
look at PFTs, echo
(dilated cardiomyopathy, tachycardia)
preop eval of Cleft lip/palate
Additional abnormalities like mandibular hypoplasia (Pierre Robin)
Restricted neck movement (Klippel-Feil)
General pre-op lab/imaging eval
- labs, imaging
- urinalysis
- sickle cell testing
- heart murmurs, cardiac consults
- URI details
& any other pertinent info to your case
