Lecture 3 (Part 1)-Peds GI Surgeries

Question 1

What are two types of abdominal wall defects in peds?

Answer 1

• Gastrochisis

- Omphalocele

Question 2

What is the following describing?—defect of the anterior abdominal wall to the right of the umbilical cord; no sac, bowel is exposed to the intrauterine environment; bowel is matted, thickened, covered with an inflammatory coating

Answer 2

Gastroschisis

Question 3

Newborns with gastroschisis have ___ issues

Answer 3

Malabsorption

Question 4

Gastroschisis results in ___itis, ___cellular fluid loss, significant ___ loss

Answer 4

Peritonitis, extracellular fluid loss, significant heat loss

Question 5

Fascial defect in gastroschisis is ___-___ cm

Answer 5

2-5 cm

Question 6

Umbilical cord in gastroschisis is normal—T/F?

Answer 6

True

Question 7

Gastroschisis usually involves ___ and ___

Answer 7

Large and small intestines

Question 8

Gastroschisis is a ___ event, resulting from an abnormality of ___ (right/left) omphalomesenteric artery or ___ (right/left) umbilical vein

Answer 8

Vascular event, right omphalomesenteric artery or right umbilical vein

Question 9

Gastroschisis results in ischemia to ___ (right/left) periumbilical area and dysplastic abdominal wall growth

Answer 9

Right

Question 10

In gastroschisis, weakened area ___ as abdominal organs grow

Answer 10

Ruptures

Question 11

Gastroschisis results from a ___ (increased/decreased) blood supply during development

Answer 11

Decreased blood supply

Question 12

Risk factors for gastroschisis = ___ maternal age, exposure to ___ and ___ during development

Answer 12

Young maternal age, exposure to tobacco and alcohol during development

Question 13

Diagnosis of gastroschisis is done ___ birth via ___

Answer 13

Before birth via ultrasound

Question 14

Omphalocele is more associated with increased maternal serum alpha fetoprotein than is gastroschisis—T/F?

Answer 14

False—gastroschisis has a higher incidence in mothers with increased maternal serum alpha fetoprotein

Question 15

What is this describing?—central defect of umbilical ring/base of umbilical cord; abdominal contents are within a sac; umbilical cord embedded in a sac

Answer 15

Omphalocele

C in Omphalocele = central defect

Question 16

Fascial defect in Omphalocele is > ___ cm

Answer 16

> 4 cm

Question 17

Omphalocele—sac contains ___, ___ and ___, ___ (30-50%)

Answer 17

Stomach, large and small intestine, liver

Question 18

Omphalocele—if fascial defect is < 4 cm, then it is considered ___

Answer 18

Umbilical hernia

Question 19

Omphalocele results from a failure of ___

Answer 19

The gut to return to abdominal cavity

Question 20

Embryology of Omphalocele—weeks ___: midgut herniates into umbilical cord

Answer 20

7-12

Question 21

Embryology of Omphalocele—week ___, abdominal cavity is large enough and gut re-enters the abdomen

Answer 21

12…in Omphalocele, the gut does NOT return back into the abdominal cavity

Question 22

Which has associated anomalies—gastroschisis or Omphalocele?

Answer 22

Omphalocele

Question 23

Gastroschisis or omphalocele—isolated lesion

Answer 23

Gastroschisis

Question 24

Gastroschisis or omphalocele—associated anomalies common

Answer 24

Omphalocele

Question 25

Gastroschisis or omphalocele—central defect

Answer 25

Omphalocele

Question 26

Gastroschisis or omphalocele—lateral defect

Answer 26

Gastroschisis

Question 27

Gastroschisis or omphalocele—umbilical cord within defect

Answer 27

Omphalocele

Question 28

Gastroschisis or omphalocele—umbilical cord normal

Answer 28

Gastroschisis

Question 29

Gastroschisis or omphalocele—bowel exposed, thickened, edematous

Answer 29

Gastroschisis

Question 30

Gastroschisis or omphalocele—sac covers organs, bowl normal

Answer 30

Omphalocele

Question 31

Which is more common—gastroschisis or omphalocele?

Answer 31

Omphalocele = 1:4,000-7,000

Gastroschisis = 1:10,000

Question 32

Surgical management of omphalocele—in some cases with very large omphalocele in which the organs are so large they will not fit into the abdominal cavity, a “paint and wait” method is done. Eventually, skin will grow over the sac and after the baby grows, the surgeon can discuss a procedure to finish closing what remains—T/F?

Answer 32

True

Question 33

If primary closure is to be done for omphalocele, the peritoneal cavity must be able to accommodate abdominal viscera without compromising ___ and ___

Answer 33

Ventilation and circulation

Question 34

Negative effects of tight abdominal closure—impairs diaphragmatic excursion, resulting in inadequate ___ and ___ (increased/decreased) airway pressure

Answer 34

Inadequate ventilation and increased airway pressure

Question 35

Negative effects of tight abdominal closure—impaired ___ return, leading to profound ___tension

Answer 35

Impaired venous return, leading to profound hypotension

Question 36

Negative effects of tight abdominal closure—aortocaval compression, leading to bowel ___, ___ (increased/decreased) CO, and renal and hepatic dysfunction

Answer 36

Bowel ischemia, decreased CO

Question 37

If tight abdominal closure is done, ___ syndrome can occur

Answer 37

Abdominal compartment syndrome

Question 38

Abdominal wall defects—unsafe for primary closure = intragastric pressure > ___ mm Hg

Answer 38

> 20 mm Hg

Question 39

Abdominal wall defects—unsafe for primary closure = change in CVP > ___ mm Hg above baseline

Answer 39

CVP > 4 mm Hg

Question 40

Abdominal wall defects—unsafe for primary closure = ETCO2 > ___ mm Hg

Answer 40

ETCO2 > 50 mm Hg

Question 41

Abdominal wall defects—unsafe for primary closure = peak inspiratory pressure > ___ cm H2O

Answer 41

PIP > 35 cm H2O

Question 42

Abdominal wall defects—CVP change > 4 mm Hg above baseline can indicate reductions in ___ and ___

Answer 42

Venous return and cardiac index

Question 43

Abdominal wall defects pre-op—fluid resuscitation—maintenance fluid = __ or ___ in 0.2 NS

Answer 43

D5 or D10 in 0.2 NS

Question 44

Abdominal wall defects pre-op—replacement fluid—___ solution at ___-___ times maintenance rate

Answer 44

Isotonic solution (NS or LR) at 2-4 times maintenance rate (8-15 cc/kg/hr)

Question 45

Abdominal wall defects pre-op—urine output goal ___-___ cc/kg/hr

Answer 45

1-2 cc/kg/hr

Question 46

Abdominal wall defects pre-op—monitor ___ose, ___lytes, ___ status

Answer 46

Glucose, electrolytes, acid/base status

Question 47

Abdominal wall defects pre-op—maintain ___thermia and prevent ___ from exposed viscera; cover abdominal contents with ___ gauze and ___ bag

Answer 47

Maintain normothermia and prevent heat loss from exposed viscera; cover abdominal contents with warm, saline soaked gauze and plastic bowel bag

Question 48

Abdominal wall defects—a lot of heat loss can happen through wet gauze dressing, so plastic bowel bag is imperative to prevent heat loss—T/F?

Answer 48

True

Question 49

Abdominal wall defects pre-op—treat sepsis with ___

Answer 49

Broad spectrum antibiotics

Question 50

Abdominal wall defects—prevent aspiration by ___

Answer 50

Decompressing the stomach with orogastric tube

Question 51

Anesthetic management of abdominal wall defects—ASA standard monitors; ___ pulse oximeters—right ___ (pre-ductal) and left ___ (post-ducal); ___ large bore IVs above diaphragm; ___ line if hemodynamically unstable; foley; monitor airway ___; CVP to assess changes in blood ___, magnitude of visceral compression

Answer 51

2 pulse oximeters—right arm (pre-ducal) and left foot (post-ducal); 2 large bore IVs above diaphragm; arterial line if HD unstable; foley; monitor airway pressures; CVP to assess changes in blood volume, magnitude of visceral compression

Question 52

Abdominal wall defects—avoid ___ because it can cause bowel distention

Answer 52

Nitrous oxide

Question 53

Abdominal wall defects—set FiO2 to maintain SPO2 ___-___%, PaO2 ___-___ mm Hg

Answer 53

Sat 95-97%, PaO2 50-70 mm Hg

Question 54

Abdominal wall defects—maintenance fluid = ___

Answer 54

D5.2 NS

Question 55

Abdominal wall defects—replacement fluid = ___ at ___-___ ml/kg/hr

Answer 55

Isotonic fluid at 8-15 ml/kg/hr

Replace third space losses with this*

Question 56

Abdominal wall defects—replace blood loss with ___ PRBCs

Answer 56

Washed PRBCs (decreased K in washed)

Question 57

Abdominal wall defects—maintain normothermia; room temp ___ degrees

Answer 57

80 degrees

Question 58

NICU often prefers to receive patient ___ post-op because they can more easily control pain and ensure baby maintains adequate ventilation support while receiving narcotics

Answer 58

Intubated post-op

Question 59

Post-op abdominal wall defects—___ required for days to weeks d/t prolonged postoperative ileus

Answer 59

TPN

Question 60

Postoperative complications after abdominal wall repair—___onia, ___ (NEC), ___ insufficiency, ___ breakdown, ___ reflux

Answer 60

Pneumonia, necrotizing enterocolitis, renal insufficiency, abdominal wall breakdown, gastroesophageal reflux

Question 61

What is this describing?—defect in the diaphragm that allows herniation of abdominal organs into the thoracic cavity

Answer 61

Congenital diaphragmatic hernia

Question 62

Congenital diaphragmatic hernia usually occurs if there is a prenatal history of ___

Answer 62

Polyhydramnios

Question 63

(3) CDH Classifications:

Answer 63

• Posterolateral (80-90%, left 75%)
• Anteromedial (2%)
• Paraesophageal (15-20%)

Question 64

Which CDH classification occurs most commonly?

Answer 64

Posterolateral—80-90%, left 75%

Question 65

CDH complications—bilateral lung ___plasia; pulmonary ___tension and arteriolar ___; ___ ventricular dysfunction

Answer 65

Bilateral lung hypoplasia; pulmonary hypertension and arteriolar reactivity; left ventricular dysfunction

Question 66

CDH—the degree of pulmonary hypoplasia and hypertension is predictive of mortality and long-term sequelae—T/F?

Answer 66

True

Question 67

Pathophysiology of CDH—abdominal viscera (midgut, stomach, parts of descending colon, L kidney, L lobe of liver) occupy the ___ thoracic cavity and interfere with the development of the lung, resulting in pulmonary hypoplasia

Answer 67

Left thoracic cavity

Question 68

Patho of CDH—herniation of abdominal contents shifts mediastinum to the ___, resulting in ___ and ___plasia of the contralateral lung

Answer 68

Shifts mediastinum to the right, resulting in compression and hypoplasia of the contralateral lung

Question 69

Patho of CDH—CDH causes structural abnormalities of pulmonary vasculature, which results in ___ lung disease—___ number of airways; simple arterial branching pattern; ___ (increased/decreased) smooth muscle mass in resistance vessels; left ventricular abnormalities

Answer 69

Chronic lung disease—small number of airways; simple arterial branching pattern; increased smooth muscle mass in resistance vessels; left ventricular abnormalities

Question 70

CDH—compressed lungs leads to hindered development of ___

Answer 70

Hindered development of alveoli—there are less of them overall

Question 71

CDH—smaller alveolar gas exchange ___

Answer 71

Surface area

Question 72

CDH—___ is usually the problem d/t rising ___; ___ is okay

Answer 72

Ventilation is usually the problem d/t rising CO2; oxygenation is okay

Question 73

Clinical presentation of CDH—symptoms appear within ___ to ___

Answer 73

Minutes to hours

Question 74

CDH classic triad of symptoms =

Answer 74

• Dyspnea
• Cyanosis
• Apparent dextrocardia (heart points to the right instead of left)

Question 75

CDH physical exam—___ chest and ___ abdomen; ___ (increased/decreased) breath sounds; ___ or ___ (right/left) displaced heart sounds; ___ sounds in the chest; chest x-ray shows ___ loops in the chest and ___ shift

Answer 75

Bulging chest and scaphoid abdomen; decreased breath sounds; distant or left displaced heart sounds; bowel sounds in the chest; chest x-ray shows bowel loops in the chest and mediastinal shift

Question 76

Key to survival of CDH = ___ diagnosis which can allow the birth to occur in a center with a high level NICU and experienced surgeons

Answer 76

Prenatal diagnosis—can see bowel in the thoracic cavity on ultrasound

Question 77

Old school of thought—CDH was considered a neonatal surgical emergency; surgical repair was performed immediately; goal was ___ventilation with ___% O2 to produce pulmonary vaso___ with ___oxia and respiratory ___osis

Answer 77

Goal was hyperventilation with 100% O2 to produce pulmonary vasodilation with hyperoxia and respiratory alkalosis

Question 78

Result of former CDH interventions was repeated over distention of the lung tissue and damage to the alveolar and capillary membranes; net effect of hyperventilation/oxygenation was an ___ response that caused the release of vasoactive mediators, worsening pulmonary vaso___ and pulmonary ___tension

Answer 78

Inflammatory response that caused the release of vasoactive mediators, worsening pulmonary vasoconstriction and pulmonary hypertension

Question 79

Goals of medical management of CDH—current wisdom is that these patients benefit from 24-48 hours of medical stabilization prior to surgery—T/F?

Answer 79

True

Question 80

4 goals of medical management for CDH—maximize arterial ___; correct ___osis; prevent ___thermia; and prevent ___

Answer 80

Maximize arterial oxygenation; correct acidosis; prevent hypothermia; and prevent pain!

Question 81

CDH maximize arterial oxygenation—intubation; mechanical ventilation with low inflating pressures (< ___-___ cm H2O); maintain muscle ___

Answer 81

Inflating pressures < 20-30 cm H2O; maintain muscle relaxation

Question 82

CDH surgery can occur when ___ is normal for age and stable for 24 hours; pre-ductal sat > ___ (preferably ___ to ___) with FiO2 less than ___; no ___osis; lactate < ___; urine output ___-___ ml/kg/hr

Answer 82

When BP is normal for age and stable for 24 hours; pre-ductal sat > 85 (preferably 90 to 95) with FiO2 less than 0.5; no acidosis; lactate < 3; urine output 1-2 ml/kg/hr

Question 83

CDH intubation diminishes the danger of ___

Answer 83

Pneumothorax

Question 84

CDH intubation—minimize ___trauma/___trauma from positive pressure ventilation, thereby minimizing further lung damage

Answer 84

Minimize barotrauma/volutrauma

Question 85

CDH—bag mask ventilation has the potential to create distention of the stomach and intestines, resulting in ___ (increased/decreased) chest compliance

Answer 85

Decreased chest compliance

Question 86

CDH—important to improve pulmonary perfusion—___ventilation (maintain PaCO2 ___-___ mm Hg); ___ infusion to maintain sedation and limit spikes in PVR from irritability; minimal handling

Answer 86

Hyperventilation (maintain PaCO2 25-30 mm Hg); fentanyl infusion

Question 87

CDH—use ___ because it allows for vascular smooth muscle relaxation and decreases PVR

Answer 87

Nitric oxide

Question 88

ECMO for CDH—blood removed via ___ cannula, passed through membrane oxygenator, returned via ___ cannula; common sites for cannulation = ___ and ___

Answer 88

Blood removed via venous cannula, passed through membrane oxygenator, returned via arterial cannula; common sites for cannulation = IJ and common carotid

Question 89

CDH—since spontaneous ventilatory efforts are usually inadequate, early ___ and ___ of the stomach are critical initial steps to prevent further distention of abdominal organs and pulmonary compression by abdominal viscera

Answer 89

Early intubation and decompression of the stomach

Question 90

CDH—unless right to left shunting has occurred, permissive ___capnea should occur to PaCO2 of ___-___, helping to provide less aggressive ventilatory support resulting in secondary lung injury

Answer 90

Permissive hypercapnea should occur to PaCO2 55-60

Question 91

Complications of ECMO—___ at cannulation sites; ___ hemorrhage; ___sis; ___tension; ___ death

Answer 91

Bleeding at cannulation sites; intracranial hemorrhage; sepsis; hypertension; brain death

Question 92

Criteria for ECMO—weight more than ___ kg; gestation > ___ weeks

Answer 92

Weight more than 2.0 kg; gestation > 35 weeks

Question 93

CDH preoperative prep—IV access in ___ extremities (because vena cava is sometimes compressed after reduction of hernia); prevent ___thermia

Answer 93

IV access in upper extremities; prevent hypothermia

Question 94

CDH preoperative management—___ support; meticulous management of ___ and ___; hemodynamic monitoring

Answer 94

Ventilatory support; meticulous management of fluids and nutrition; hemodynamic monitoring

Question 95

CDH preoperative management—often there is a ___ period followed by rapid ___

Answer 95

Honeymoon period followed by rapid deterioration—mild ventilatory/hemodynamic support, then quickly deteriorate requiring NO or ECMO—unexplained reasons

Question 96

CDH signs of deterioration—___ (increased/decreased) intraabdominal pressure; ___ (increased/decreased) perfusion of the viscera and periphery; ___ (increased/decreased) diaphragmatic excursion; ___ pulmonary compliance

Answer 96

Increased intraabdominal pressure; decreased perfusion of the viscera and periphery; decreased diaphragmatic excursion; worsening pulmonary compliance

Question 97

CDH anesthetic management—ASA standard monitors; arterial line; foley; precordial stethoscope at ___ axilla; ___ to decompress stomach; IV access; core temp management to prevent ___thermia

Answer 97

Precordial stethoscope at right axilla; NGT to decompress stomach; IV access; core temp management to prevent hypothermia

Question 98

CDH induction—___ intubation; ___ induction; avoid ___ ventilation or ___ pressure ventilation before intubation

Answer 98

Awake intubation; rapid sequence induction; avoid mask ventilation or positive pressure ventilation before intubation

Question 99

CDH anesthetic maintenance—avoid ___ because it increases oxygen concentration required and can expand viscera and cause further compression of the lungs

Answer 99

Nitrous oxide

Question 100

CDH anesthetic maintenance—TIVA can be done with ___ infusion and muscle relaxation

Answer 100

Remifentanil infusion

Question 101

CDH anesthetic maintenance—inhaled agents can be used, but will ___ (increase/decrease) PVR; ___ decreases more than PVR, which could cause right to left shunting

Answer 101

Decrease PVR; SVR decreases more than PVR, which could cause right to left shunting

Question 102

What may be the best anesthetic maintenance for CDH?

Answer 102

Narcotics and muscle relaxants

Question 103

CDH anesthetic maintenance—avoid ___ia and ___osis, which ___ (increase/decrease) PVR and cause R to L shunting

Answer 103

Hypoxia and acidosis, which increase PVR and cause R to L shunting

Question 104

CDH—hypothermia ___ (increases/decreases) PVR, which increases R to L shunting through PDA or patent foramen ovale; also increases oxygen consumption

Answer 104

Increases PVR

Question 105

CDH—have ___ and ___ in the room

Answer 105

Nitrous oxide and ECMO

Question 106

CDH surgical complications—___emia; pulmonary ___plasia; pulmonary ___tension; respiratory ___ from distention of stomach, ___ intraabdominal pressure; contralateral ___; ___ compression; ___tension

Answer 106

Hypoxemia; pulmonary hypoplasia; pulmonary hypertension; respiratory compromise from distention of stomach, increased intraabdominal pressure; contralateral pneumothorax; IVC compression; hypotension

Question 107

CDH—during surgery, if hemodynamics/ventilatory status quickly deteriorates, must be able to differentiate between ___ crisis or ___

Answer 107

Pulmonary hypertensive crisis or pneumothorax

Pulmonary HTN = nitrous + hyperventilate

Pneumothorax = needle decompression + chest tube placement

Question 108

CDH outcomes—pulmonary = the first year post-op consists of multiple respiratory ___; need for ___, inhaled ___; however, by childhood and late adolescence, survivors achieve near normal lung ___ and ___ with minimal obstructive or restrictive lung disease/without pulmonary HTN

Answer 108

The first year post-op consists of multiple respiratory infections; need for bronchodilators, inhaled steroids; however, by childhood and late adolescence, survivors achieve near normal lung volumes and mechanics with minimal obstructive or restrictive lung disease/without pulmonary HTN

Question 109

CDH outcomes—MSK = mild ___ abnormalities can be noted—pectus ___ or ___ can be noted in 7-9%

Answer 109

Mild chest abnormalities can be noted—pectus excavatum or scoliosis can be noted in 7-9%

Question 110

CDH outcomes—GI dysfunction = GERD, can later do ___ fundoplication; bowel ___ or ___ (d/t lack of fixation to abdominal cavity)

Answer 110

GERD, can later do nissen fundoplication; bowel obstruction or malrotation (d/t lack of fixation to abdominal wall)

Question 111

CDH outcomes—neuro = cerebral ___regulation is affected d/t pulmonary ___tension and hemodynamic instability; ultimately leads to cognitive issues d/t lack of ___

Answer 111

Cerebral autoregulation is affected d/t pulmonary hypertension and hemodynamic instability; ultimately leads to cognitive issues d/t lack of perfusion

Question 112

Pyloric stenosis occurs in 1 in ___ live births; occurs 4 times more often in ___

Answer 112

Occurs in 1 in 500 live births; occurs 4 times more often in males

Question 113

Pyloric stenosis is ___, not congenital; occurs more often if ___

Answer 113

Acquired; occurs more often if a parent had the same condition

Question 114

Patho of pyloric stenosis = gross thickening of the circular smooth muscle of the ___; results in gradual ___ of the gastric outlet; causes ___, ___, nonbilious vomiting

Answer 114

Gross thickening of the circular smooth muscle of the pylorus; results in gradual obstruction of the gastric outlet; causes forceful, projectile, nonbilious vomiting

Question 115

What disease is this characteristic of?—vomiting “across the room and hitting the wall”

Answer 115

Pyloric stenosis

Question 116

Pyloric stenosis typically presents between ___-___ weeks of life; most commonly ___ weeks and ___ kg

Answer 116

2-8 weeks of life; most commonly 4 weeks and 4 kg

Question 117

Pyloric stenosis diagnosis = palpation of ___-sized mass in the ___ aspect of the abdomen; verified by upper GI series with ___, ___, or abdominal ___

Answer 117

Palpation of olive-sized mass in the upper aspect of the abdomen; verified by upper GI series with barium, x-ray, or abdominal ultrasound

Question 118

Pyloric stenosis clinical presentation—persistent vomiting results in the loss of ___ gastric juices rich in ___, ___, and to a lesser degree ___ ions

Answer 118

Persistent vomiting results in the loss of acidic gastric juices rich in hydrogen, chloride, and to a lesser degree sodium ions

Question 119

Pyloric stenosis—vomitus does not contain the ___ secretions of the duodenum

Answer 119

Vomitus does not contain the alkaline secretions of the duodenum

Question 120

Pyloric stenosis—kidneys begin secreting ___ ions in exchange for hydrogen in an attempt to maintain normal arterial pH

Answer 120

Potassium ions

Question 121

Pyloric stenosis—patient develops a ___ ___osis— decreased ___ and ___

Answer 121

Metabolic alkalosis—decreased Na and Cl

Question 122

Pyloric stenosis—after vomiting, patient is ___

Answer 122

Hungry again

Question 123

The result of pyloric stenosis is a ___ infant with a ___natremic, ___kalemic, ___chloremic metabolic ___osis

Answer 123

Dehydrated infant with a hyponatremic, hypokalemic, hypochloremic metabolic alkalosis

Question 124

Severe cases of pyloric stenosis can manifest as a metabolic ___osis, secondary to severe ___ and ___perfusion

Answer 124

Metabolic acidosis secondary to severe dehydration and hypoperfusion

Question 125

Pyloric stenosis is a ___ emergency, NOT a ___ emergency!

Answer 125

Medical emergency…NOT a surgical emergency!

Question 126

Initial treatment of pyloric stenosis is aimed at correcting the ___ and ___ disturbances; administration of IV fluid containing ___, ___, and ___

Answer 126

Correcting the fluid and electrolyte disturbances; administration of IV fluid containing Na, KCl, and glucose—D5 0.45% NSS with KCl meq/L for 12-48 hours

Question 127

What is the primary concern of pyloric stenosis?

Answer 127

Aspiration of gastric fluid

Question 128

Pyloric stenosis induction—IV in place; O2 by mask, atropine 10-20 mcg/kg; ___ stomach with large bore (14 Fr) catheter at least ___ times; give O2 inbetween; ___ induction—propofol, succs (roc), styletted ETT, do NOT ___

Answer 128

IV in place; O2 by mask, atropine 10-20 mcg/kg; suction stomach with large bore (14 Fr) catheter at least 3 times; give O2 inbetween; rapid sequence induction—propofol, succs (roc), styletted ETT, do NOT ventilate

Question 129

Pyloric stenosis maintenance—O2, ___, low dose ___ agent; “short-acting” ___ muscle relaxant; no ___; ___ anesthetic at the surgical site

Answer 129

O2, N2O, low dose inhalation agent; “short-acting” non-depolarizing muscle relaxant; no narcotics; local anesthetic at the surgical site—bupivicaine 0.25%

Question 130

Pyloric stenosis emergence—patients are prone to post-operative respiratory ___ related to preexisting central ___osis; patient must be fully ___ and demonstrating acceptable patterns of ___ before extubation—adequate ___ volume, movement of extremities, protective reflexes intact, absence of breath ___ and ___

Answer 130

Patients are prone to post-operative respiratory alkalosis related to preexisting central alkalosis (because body will want to hold onto CO2 to normalize pH); patient must be fully awake and demonstrating acceptable patterns of ventilation before extubation—adequate tidal volume, movement of extremities, protective reflexes intact, absence of breath holding and apnea

Question 131

Pyloric stenosis—the alkalosis can reset the respiratory drive, and the CO2 may need to be in the ___ in order for the baby to breathe

Answer 131

CO2 may need to be in the 40s

Question 132

Pyloric stenosis—why don’t we use narcotics for these patients? What can be used alternatively?

Answer 132

Narcotics can cause gastroparesis, slow the gut; consider IV or rectal Tylenol

Question 133

What condition is this describing?—condition characterized by esophageal atresia with or without a communication (fistula) between the esophagus and trachea; it is the most common esophageal anomaly, 1:3,000-4,500 live births

Answer 133

Tracheoesophageal fistula

Question 134

Tracheoesophageal fistula is common with ___ and ___

Answer 134

Prematurity (20-40%) and polyhydramnios (60%)

Question 135

TEF—associated anomalies occur in ___-___% of patients

Answer 135

20-50% of patients

Question 136

TEF survival rate is > ___%

Answer 136

> 90%

Question 137

Types of TEF; most common?

Answer 137

Types A-E; C is most common

Question 138

What type of TEF often escapes diagnosis until later in life when recurrent pneumonias occur?

Answer 138

Type E

Question 139

TEF clinical presentation—inability to manage ___ secretions; excessive ___; ___ on first feed; ___ing; ___nosis; ___ation; gastric ___; ___monia

Answer 139

Inability to manage oral secretions; excessive salivation; choking on first feed; coughing; cyanosis; aspiration; gastric distention; pneumonia

Question 140

Gastric distention is very common with type ___ TEF

Answer 140

Type C TEF—because the lower esophagus connects to the trachea

Question 141

If TEF is not diagnosed prenatally, it is usually diagnosed ___

Answer 141

In the first few hours after birth

Question 142

TEF diagnosis—inability to pass ___ catheter or ___ tube into the stomach; chest x-ray confirming position of catheter in ___ pouch, ___ in the stomach and intestines

Answer 142

Inability to pass suction catheter or orogastric tube into the stomach; chest x-ray confirming position of catheter in esophageal pouch, air in stomach and intestines

Question 143

TEF associated anomalies—incidence 35-65%, VATER or VACTERL

Answer 143

V = vertebral anomalies
A = anorectal anomalies
C = cardiac anomalies, 20-25%
T = TEF
E = esophageal atresia
R = renal anomalies
L = limb anomalies

Question 144

TEF surgical repair—identification and ligation of the fistula; esophageal repair—primary or staged using stomach or intestine; placement of feeding ___ and ___ tube

Answer 144

Placement of feeding gastrostomy and chest tube

Question 145

TEF preop preparation—minimize ___ complications—keep patient ___; HOB elevated ___, consider ___ or ___ position; esophageal ___ to low continuous suction

Answer 145

Minimize pulmonary complications—keep patient NPO; HOB elevated 30 degrees, consider prone or lateral position; esophageal sump to low continuous suction

Question 146

TEF preop preparation—___ x-ray, ___ x-ray, ___ ultrasound; 12 lead ECG, echocardiogram—___; central IV access for ___; medical stabilization—treat ___monia and optimize volume and acid/base status

Answer 146

Chest x-ray, abdominal x-ray, renal ultrasound; 12 lead ECG, echocardiogram—mandatory; central IV access for TPN; medical stabilization—treat pneumonia and optimize volume and acid/base status

Question 147

TEF anesthetic management—priorities = ___ation, ___ation, securing the ___, prevention of ___

Answer 147

Oxygenation, ventilation, securing the airway, prevention of aspiration

Question 148

TEF anesthetic management—monitors = ASA standard, precordial stethoscope over ___ chest, ___ line

Answer 148

ASA standard, precordial stethoscope over left chest, arterial line

Question 149

TEF—precordial stethoscope can allow breath to breath monitoring to determine ventilation of ___ lung

Answer 149

Dependent lung

Question 150

TEF induction—concerns are ___, gastric ___, respiratory ___

Answer 150

Aspiration, gastric distention, respiratory compromise

Question 151

TEF induction for unstable infants—consider ___ insertion and ___ intubation—this allows ETT positioning without ___ ventilation

Answer 151

Consider gastrostomy insertion and awake intubation—this allows ETT positioning without positive pressure ventilation

Question 152

TEF induction for stable infants—___ induction with spontaneous ventilation vs. ___ induction; avoid or minimize ___ ventilation—___ tidal volumes, ___ peak inspiratory pressures

Answer 152

Inhalation induction with spontaneous ventilation vs. IV induction; avoid or minimize positive pressure ventilation—small tidal volumes, low peak inspiratory pressures

Question 153

TEF—surgery may begin with ___ to evaluate where the lesion is—keep patient ___ ventilating during this

Answer 153

Surgery may begin with rigid Bronchoscopy to evaluate where the lesion is—keep patient spontaneously ventilating during this

Question 154

TEF—surgeon should be available because in an emergency, gastric ___ may need to occur via insertion of transcutaneous needle or catheter

Answer 154

Gastric decompression

Question 155

TEF—assessment of ETT position—goal = above the ___, below the ___

Answer 155

Above the carina, below the fistula

Question 156

TEF technique for intubation = ___ intubation; withdraw ETT until breath sounds are confirmed at the ___

Answer 156

Right mainstem intubation; withdraw ETT until breath sounds are confirmed at the left axilla

Question 157

TEF anesthetic management—minimize gastric ___; avoid or minimize ___ ventilation—small ___ volumes, low ___ pressures

Answer 157

Minimize gastric distention; avoid or minimize positive pressure ventilation—small tidal volumes, low peak inspiratory pressures

Question 158

Anesthetic maintenance for TEF—___ position for R thoracotomy

Answer 158

Left lateral decubitus position for R thoracotomy

Question 159

Anesthetic maintenance for TEF—after ligation of fistula, ___ relaxation and controlled ___; use ___ agent and ___ to maintain anesthesia; avoid ___

Answer 159

After ligation of fistula, muscle relaxation and controlled ventilation; use inhalation agent and opioids to maintain anesthesia; avoid nitrous oxide

Question 160

TEF intraoperative complications—___ intubation; intubation of ___; ___ of ETT from secretions, blood, infectious material; obstruction/compression of ___ or ___ by surgeon; atelectasis, lung retraction; ___thermia; ___glycemia; resumption of ___ circulation—___ shunting

Answer 160

Right mainstem intubation; intubation of fistula; obstruction of ETT from secretions, blood, infectious material; obstruction/compression of trachea or bronchus by surgeon; atelectasis, lung retraction; hypothermia; hypoglycemia; resumption of fetal circulation—R to L shunting

Question 161

TEF emergence—goal is ___ at the end of surgery to prevent manipulation of anastamosis from ETT; patient must be able to maintain airway ___ because reintubation could damage repair; consider that the patient may have tracheo___ or tracheal ___

Answer 161

Goal is extubation at the end of surgery to prevent manipulation of anastamosis from ETT; patient must be able to maintain airway patency because reintubation could damage repair; consider that the patient may have tracheomalacia or tracheal collapse

Question 162

TEF—sometimes exubation is not possible d/t issues with ___ control and ___ complications—sometimes safer to leave patient intubated to allow them more time to heal

Answer 162

D/t issues with pain control and pulmonary complications

Question 163

TEF post-op—___ should be avoided if possible during first several days post-op

Answer 163

Bag valve mask

Question 164

TEF postop—no ___ of the head because it puts tension on the anastomosis; no ___ suctioning beyond the level of the esophageal anastomosis

Answer 164

No extension of the head; no esophageal suctioning

Question 165

Long-term complications from TEF = esophageal ___, tracheo___, gastroesophageal ___

Answer 165

Esophageal stricture; tracheomalacia; gastroesophageal reflux

Question 166

Esophageal strictures post-TEF may require serial ___

Answer 166

Dilations

Question 167

Tracheomalacia post-TEF usually occurs in the ___ one third of the trachea just above the fistula; other respiratory issues = chronic ___, ___, exercise ___

Answer 167

Usually occurs in the lower one third of the trachea just above the fistula; other respiratory issues = chronic cough, wheezing, exercise intolerance

Question 168

GERD occurs in ___ to ___% of patients with TEF

Answer 168

40 to 65%