Lecture 3 (Part 1)-Peds GI Surgeries Flashcards
What are two types of abdominal wall defects in peds?
- Gastrochisis
- Omphalocele
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
Gastroschisis
Newborns with gastroschisis have ___ issues
Malabsorption
Gastroschisis results in ___itis, ___cellular fluid loss, significant ___ loss
Peritonitis, extracellular fluid loss, significant heat loss
Fascial defect in gastroschisis is ___-___ cm
2-5 cm
Umbilical cord in gastroschisis is normal—T/F?
True
Gastroschisis usually involves ___ and ___
Large and small intestines
Gastroschisis is a ___ event, resulting from an abnormality of ___ (right/left) omphalomesenteric artery or ___ (right/left) umbilical vein
Vascular event, right omphalomesenteric artery or right umbilical vein
Gastroschisis results in ischemia to ___ (right/left) periumbilical area and dysplastic abdominal wall growth
Right
In gastroschisis, weakened area ___ as abdominal organs grow
Ruptures
Gastroschisis results from a ___ (increased/decreased) blood supply during development
Decreased blood supply
Risk factors for gastroschisis = ___ maternal age, exposure to ___ and ___ during development
Young maternal age, exposure to tobacco and alcohol during development
Diagnosis of gastroschisis is done ___ birth via ___
Before birth via ultrasound
Omphalocele is more associated with increased maternal serum alpha fetoprotein than is gastroschisis—T/F?
False—gastroschisis has a higher incidence in mothers with increased maternal serum alpha fetoprotein
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
Omphalocele
C in Omphalocele = central defect
Fascial defect in Omphalocele is > ___ cm
> 4 cm
Omphalocele—sac contains ___, ___ and ___, ___ (30-50%)
Stomach, large and small intestine, liver
Omphalocele—if fascial defect is < 4 cm, then it is considered ___
Umbilical hernia
Omphalocele results from a failure of ___
The gut to return to abdominal cavity
Embryology of Omphalocele—weeks ___: midgut herniates into umbilical cord
7-12
Embryology of Omphalocele—week ___, abdominal cavity is large enough and gut re-enters the abdomen
12…in Omphalocele, the gut does NOT return back into the abdominal cavity
Which has associated anomalies—gastroschisis or Omphalocele?
Omphalocele
Gastroschisis or omphalocele—isolated lesion
Gastroschisis
Gastroschisis or omphalocele—associated anomalies common
Omphalocele
Gastroschisis or omphalocele—central defect
Omphalocele
Gastroschisis or omphalocele—lateral defect
Gastroschisis
Gastroschisis or omphalocele—umbilical cord within defect
Omphalocele
Gastroschisis or omphalocele—umbilical cord normal
Gastroschisis
Gastroschisis or omphalocele—bowel exposed, thickened, edematous
Gastroschisis
Gastroschisis or omphalocele—sac covers organs, bowl normal
Omphalocele
Which is more common—gastroschisis or omphalocele?
Omphalocele = 1:4,000-7,000
Gastroschisis = 1:10,000
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?
True
If primary closure is to be done for omphalocele, the peritoneal cavity must be able to accommodate abdominal viscera without compromising ___ and ___
Ventilation and circulation
Negative effects of tight abdominal closure—impairs diaphragmatic excursion, resulting in inadequate ___ and ___ (increased/decreased) airway pressure
Inadequate ventilation and increased airway pressure
Negative effects of tight abdominal closure—impaired ___ return, leading to profound ___tension
Impaired venous return, leading to profound hypotension
Negative effects of tight abdominal closure—aortocaval compression, leading to bowel ___, ___ (increased/decreased) CO, and renal and hepatic dysfunction
Bowel ischemia, decreased CO
If tight abdominal closure is done, ___ syndrome can occur
Abdominal compartment syndrome
Abdominal wall defects—unsafe for primary closure = intragastric pressure > ___ mm Hg
> 20 mm Hg
Abdominal wall defects—unsafe for primary closure = change in CVP > ___ mm Hg above baseline
CVP > 4 mm Hg
Abdominal wall defects—unsafe for primary closure = ETCO2 > ___ mm Hg
ETCO2 > 50 mm Hg
Abdominal wall defects—unsafe for primary closure = peak inspiratory pressure > ___ cm H2O
PIP > 35 cm H2O
Abdominal wall defects—CVP change > 4 mm Hg above baseline can indicate reductions in ___ and ___
Venous return and cardiac index
Abdominal wall defects pre-op—fluid resuscitation—maintenance fluid = __ or ___ in 0.2 NS
D5 or D10 in 0.2 NS
Abdominal wall defects pre-op—replacement fluid—___ solution at ___-___ times maintenance rate
Isotonic solution (NS or LR) at 2-4 times maintenance rate (8-15 cc/kg/hr)
Abdominal wall defects pre-op—urine output goal ___-___ cc/kg/hr
1-2 cc/kg/hr
Abdominal wall defects pre-op—monitor ___ose, ___lytes, ___ status
Glucose, electrolytes, acid/base status
Abdominal wall defects pre-op—maintain ___thermia and prevent ___ from exposed viscera; cover abdominal contents with ___ gauze and ___ bag
Maintain normothermia and prevent heat loss from exposed viscera; cover abdominal contents with warm, saline soaked gauze and plastic bowel bag
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?
True
Abdominal wall defects pre-op—treat sepsis with ___
Broad spectrum antibiotics
Abdominal wall defects—prevent aspiration by ___
Decompressing the stomach with orogastric tube
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
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
Abdominal wall defects—avoid ___ because it can cause bowel distention
Nitrous oxide
Abdominal wall defects—set FiO2 to maintain SPO2 ___-___%, PaO2 ___-___ mm Hg
Sat 95-97%, PaO2 50-70 mm Hg
Abdominal wall defects—maintenance fluid = ___
D5.2 NS
Abdominal wall defects—replacement fluid = ___ at ___-___ ml/kg/hr
Isotonic fluid at 8-15 ml/kg/hr
Replace third space losses with this*
Abdominal wall defects—replace blood loss with ___ PRBCs
Washed PRBCs (decreased K in washed)
Abdominal wall defects—maintain normothermia; room temp ___ degrees
80 degrees
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
Intubated post-op
Post-op abdominal wall defects—___ required for days to weeks d/t prolonged postoperative ileus
TPN
Postoperative complications after abdominal wall repair—___onia, ___ (NEC), ___ insufficiency, ___ breakdown, ___ reflux
Pneumonia, necrotizing enterocolitis, renal insufficiency, abdominal wall breakdown, gastroesophageal reflux
What is this describing?—defect in the diaphragm that allows herniation of abdominal organs into the thoracic cavity
Congenital diaphragmatic hernia
Congenital diaphragmatic hernia usually occurs if there is a prenatal history of ___
Polyhydramnios
(3) CDH Classifications:
- Posterolateral (80-90%, left 75%)
- Anteromedial (2%)
- Paraesophageal (15-20%)
Which CDH classification occurs most commonly?
Posterolateral—80-90%, left 75%
CDH complications—bilateral lung ___plasia; pulmonary ___tension and arteriolar ___; ___ ventricular dysfunction
Bilateral lung hypoplasia; pulmonary hypertension and arteriolar reactivity; left ventricular dysfunction
CDH—the degree of pulmonary hypoplasia and hypertension is predictive of mortality and long-term sequelae—T/F?
True
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
Left thoracic cavity
Patho of CDH—herniation of abdominal contents shifts mediastinum to the ___, resulting in ___ and ___plasia of the contralateral lung
Shifts mediastinum to the right, resulting in compression and hypoplasia of the contralateral lung
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
Chronic lung disease—small number of airways; simple arterial branching pattern; increased smooth muscle mass in resistance vessels; left ventricular abnormalities
CDH—compressed lungs leads to hindered development of ___
Hindered development of alveoli—there are less of them overall
CDH—smaller alveolar gas exchange ___
Surface area
CDH—___ is usually the problem d/t rising ___; ___ is okay
Ventilation is usually the problem d/t rising CO2; oxygenation is okay
Clinical presentation of CDH—symptoms appear within ___ to ___
Minutes to hours
CDH classic triad of symptoms =
- Dyspnea
- Cyanosis
- Apparent dextrocardia (heart points to the right instead of left)
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
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
Key to survival of CDH = ___ diagnosis which can allow the birth to occur in a center with a high level NICU and experienced surgeons
Prenatal diagnosis—can see bowel in the thoracic cavity on ultrasound
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
Goal was hyperventilation with 100% O2 to produce pulmonary vasodilation with hyperoxia and respiratory alkalosis
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
Inflammatory response that caused the release of vasoactive mediators, worsening pulmonary vasoconstriction and pulmonary hypertension
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?
True
4 goals of medical management for CDH—maximize arterial ___; correct ___osis; prevent ___thermia; and prevent ___
Maximize arterial oxygenation; correct acidosis; prevent hypothermia; and prevent pain!
CDH maximize arterial oxygenation—intubation; mechanical ventilation with low inflating pressures (< ___-___ cm H2O); maintain muscle ___
Inflating pressures < 20-30 cm H2O; maintain muscle relaxation
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
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
CDH intubation diminishes the danger of ___
Pneumothorax
CDH intubation—minimize ___trauma/___trauma from positive pressure ventilation, thereby minimizing further lung damage
Minimize barotrauma/volutrauma
CDH—bag mask ventilation has the potential to create distention of the stomach and intestines, resulting in ___ (increased/decreased) chest compliance
Decreased chest compliance
CDH—important to improve pulmonary perfusion—___ventilation (maintain PaCO2 ___-___ mm Hg); ___ infusion to maintain sedation and limit spikes in PVR from irritability; minimal handling
Hyperventilation (maintain PaCO2 25-30 mm Hg); fentanyl infusion
CDH—use ___ because it allows for vascular smooth muscle relaxation and decreases PVR
Nitric oxide
ECMO for CDH—blood removed via ___ cannula, passed through membrane oxygenator, returned via ___ cannula; common sites for cannulation = ___ and ___
Blood removed via venous cannula, passed through membrane oxygenator, returned via arterial cannula; common sites for cannulation = IJ and common carotid
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
Early intubation and decompression of the stomach
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
Permissive hypercapnea should occur to PaCO2 55-60
Complications of ECMO—___ at cannulation sites; ___ hemorrhage; ___sis; ___tension; ___ death
Bleeding at cannulation sites; intracranial hemorrhage; sepsis; hypertension; brain death
Criteria for ECMO—weight more than ___ kg; gestation > ___ weeks
Weight more than 2.0 kg; gestation > 35 weeks
CDH preoperative prep—IV access in ___ extremities (because vena cava is sometimes compressed after reduction of hernia); prevent ___thermia
IV access in upper extremities; prevent hypothermia
CDH preoperative management—___ support; meticulous management of ___ and ___; hemodynamic monitoring
Ventilatory support; meticulous management of fluids and nutrition; hemodynamic monitoring
CDH preoperative management—often there is a ___ period followed by rapid ___
Honeymoon period followed by rapid deterioration—mild ventilatory/hemodynamic support, then quickly deteriorate requiring NO or ECMO—unexplained reasons
CDH signs of deterioration—___ (increased/decreased) intraabdominal pressure; ___ (increased/decreased) perfusion of the viscera and periphery; ___ (increased/decreased) diaphragmatic excursion; ___ pulmonary compliance
Increased intraabdominal pressure; decreased perfusion of the viscera and periphery; decreased diaphragmatic excursion; worsening pulmonary compliance
CDH anesthetic management—ASA standard monitors; arterial line; foley; precordial stethoscope at ___ axilla; ___ to decompress stomach; IV access; core temp management to prevent ___thermia
Precordial stethoscope at right axilla; NGT to decompress stomach; IV access; core temp management to prevent hypothermia
CDH induction—___ intubation; ___ induction; avoid ___ ventilation or ___ pressure ventilation before intubation
Awake intubation; rapid sequence induction; avoid mask ventilation or positive pressure ventilation before intubation
CDH anesthetic maintenance—avoid ___ because it increases oxygen concentration required and can expand viscera and cause further compression of the lungs
Nitrous oxide
CDH anesthetic maintenance—TIVA can be done with ___ infusion and muscle relaxation
Remifentanil infusion
CDH anesthetic maintenance—inhaled agents can be used, but will ___ (increase/decrease) PVR; ___ decreases more than PVR, which could cause right to left shunting
Decrease PVR; SVR decreases more than PVR, which could cause right to left shunting
What may be the best anesthetic maintenance for CDH?
Narcotics and muscle relaxants
CDH anesthetic maintenance—avoid ___ia and ___osis, which ___ (increase/decrease) PVR and cause R to L shunting
Hypoxia and acidosis, which increase PVR and cause R to L shunting
CDH—hypothermia ___ (increases/decreases) PVR, which increases R to L shunting through PDA or patent foramen ovale; also increases oxygen consumption
Increases PVR
CDH—have ___ and ___ in the room
Nitrous oxide and ECMO
CDH surgical complications—___emia; pulmonary ___plasia; pulmonary ___tension; respiratory ___ from distention of stomach, ___ intraabdominal pressure; contralateral ___; ___ compression; ___tension
Hypoxemia; pulmonary hypoplasia; pulmonary hypertension; respiratory compromise from distention of stomach, increased intraabdominal pressure; contralateral pneumothorax; IVC compression; hypotension
CDH—during surgery, if hemodynamics/ventilatory status quickly deteriorates, must be able to differentiate between ___ crisis or ___
Pulmonary hypertensive crisis or pneumothorax
Pulmonary HTN = nitrous + hyperventilate
Pneumothorax = needle decompression + chest tube placement
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
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
CDH outcomes—MSK = mild ___ abnormalities can be noted—pectus ___ or ___ can be noted in 7-9%
Mild chest abnormalities can be noted—pectus excavatum or scoliosis can be noted in 7-9%
CDH outcomes—GI dysfunction = GERD, can later do ___ fundoplication; bowel ___ or ___ (d/t lack of fixation to abdominal cavity)
GERD, can later do nissen fundoplication; bowel obstruction or malrotation (d/t lack of fixation to abdominal wall)
CDH outcomes—neuro = cerebral ___regulation is affected d/t pulmonary ___tension and hemodynamic instability; ultimately leads to cognitive issues d/t lack of ___
Cerebral autoregulation is affected d/t pulmonary hypertension and hemodynamic instability; ultimately leads to cognitive issues d/t lack of perfusion
Pyloric stenosis occurs in 1 in ___ live births; occurs 4 times more often in ___
Occurs in 1 in 500 live births; occurs 4 times more often in males
Pyloric stenosis is ___, not congenital; occurs more often if ___
Acquired; occurs more often if a parent had the same condition
Patho of pyloric stenosis = gross thickening of the circular smooth muscle of the ___; results in gradual ___ of the gastric outlet; causes ___, ___, nonbilious vomiting
Gross thickening of the circular smooth muscle of the pylorus; results in gradual obstruction of the gastric outlet; causes forceful, projectile, nonbilious vomiting
What disease is this characteristic of?—vomiting “across the room and hitting the wall”
Pyloric stenosis
Pyloric stenosis typically presents between ___-___ weeks of life; most commonly ___ weeks and ___ kg
2-8 weeks of life; most commonly 4 weeks and 4 kg
Pyloric stenosis diagnosis = palpation of ___-sized mass in the ___ aspect of the abdomen; verified by upper GI series with ___, ___, or abdominal ___
Palpation of olive-sized mass in the upper aspect of the abdomen; verified by upper GI series with barium, x-ray, or abdominal ultrasound
Pyloric stenosis clinical presentation—persistent vomiting results in the loss of ___ gastric juices rich in ___, ___, and to a lesser degree ___ ions
Persistent vomiting results in the loss of acidic gastric juices rich in hydrogen, chloride, and to a lesser degree sodium ions
Pyloric stenosis—vomitus does not contain the ___ secretions of the duodenum
Vomitus does not contain the alkaline secretions of the duodenum
Pyloric stenosis—kidneys begin secreting ___ ions in exchange for hydrogen in an attempt to maintain normal arterial pH
Potassium ions
Pyloric stenosis—patient develops a ___ ___osis— decreased ___ and ___
Metabolic alkalosis—decreased Na and Cl
Pyloric stenosis—after vomiting, patient is ___
Hungry again
The result of pyloric stenosis is a ___ infant with a ___natremic, ___kalemic, ___chloremic metabolic ___osis
Dehydrated infant with a hyponatremic, hypokalemic, hypochloremic metabolic alkalosis
Severe cases of pyloric stenosis can manifest as a metabolic ___osis, secondary to severe ___ and ___perfusion
Metabolic acidosis secondary to severe dehydration and hypoperfusion
Pyloric stenosis is a ___ emergency, NOT a ___ emergency!
Medical emergency…NOT a surgical emergency!
Initial treatment of pyloric stenosis is aimed at correcting the ___ and ___ disturbances; administration of IV fluid containing ___, ___, and ___
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
What is the primary concern of pyloric stenosis?
Aspiration of gastric fluid
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 ___
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
Pyloric stenosis maintenance—O2, ___, low dose ___ agent; “short-acting” ___ muscle relaxant; no ___; ___ anesthetic at the surgical site
O2, N2O, low dose inhalation agent; “short-acting” non-depolarizing muscle relaxant; no narcotics; local anesthetic at the surgical site—bupivicaine 0.25%
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 ___
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
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
CO2 may need to be in the 40s
Pyloric stenosis—why don’t we use narcotics for these patients? What can be used alternatively?
Narcotics can cause gastroparesis, slow the gut; consider IV or rectal Tylenol
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
Tracheoesophageal fistula
Tracheoesophageal fistula is common with ___ and ___
Prematurity (20-40%) and polyhydramnios (60%)
TEF—associated anomalies occur in ___-___% of patients
20-50% of patients
TEF survival rate is > ___%
> 90%
Types of TEF; most common?
Types A-E; C is most common
What type of TEF often escapes diagnosis until later in life when recurrent pneumonias occur?
Type E
TEF clinical presentation—inability to manage ___ secretions; excessive ___; ___ on first feed; ___ing; ___nosis; ___ation; gastric ___; ___monia
Inability to manage oral secretions; excessive salivation; choking on first feed; coughing; cyanosis; aspiration; gastric distention; pneumonia
Gastric distention is very common with type ___ TEF
Type C TEF—because the lower esophagus connects to the trachea
If TEF is not diagnosed prenatally, it is usually diagnosed ___
In the first few hours after birth
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
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
TEF associated anomalies—incidence 35-65%, VATER or VACTERL
V = vertebral anomalies A = anorectal anomalies C = cardiac anomalies, 20-25% T = TEF E = esophageal atresia R = renal anomalies L = limb anomalies
TEF surgical repair—identification and ligation of the fistula; esophageal repair—primary or staged using stomach or intestine; placement of feeding ___ and ___ tube
Placement of feeding gastrostomy and chest tube
TEF preop preparation—minimize ___ complications—keep patient ___; HOB elevated ___, consider ___ or ___ position; esophageal ___ to low continuous suction
Minimize pulmonary complications—keep patient NPO; HOB elevated 30 degrees, consider prone or lateral position; esophageal sump to low continuous suction
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
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
TEF anesthetic management—priorities = ___ation, ___ation, securing the ___, prevention of ___
Oxygenation, ventilation, securing the airway, prevention of aspiration
TEF anesthetic management—monitors = ASA standard, precordial stethoscope over ___ chest, ___ line
ASA standard, precordial stethoscope over left chest, arterial line
TEF—precordial stethoscope can allow breath to breath monitoring to determine ventilation of ___ lung
Dependent lung
TEF induction—concerns are ___, gastric ___, respiratory ___
Aspiration, gastric distention, respiratory compromise
TEF induction for unstable infants—consider ___ insertion and ___ intubation—this allows ETT positioning without ___ ventilation
Consider gastrostomy insertion and awake intubation—this allows ETT positioning without positive pressure ventilation
TEF induction for stable infants—___ induction with spontaneous ventilation vs. ___ induction; avoid or minimize ___ ventilation—___ tidal volumes, ___ peak inspiratory pressures
Inhalation induction with spontaneous ventilation vs. IV induction; avoid or minimize positive pressure ventilation—small tidal volumes, low peak inspiratory pressures
TEF—surgery may begin with ___ to evaluate where the lesion is—keep patient ___ ventilating during this
Surgery may begin with rigid Bronchoscopy to evaluate where the lesion is—keep patient spontaneously ventilating during this
TEF—surgeon should be available because in an emergency, gastric ___ may need to occur via insertion of transcutaneous needle or catheter
Gastric decompression
TEF—assessment of ETT position—goal = above the ___, below the ___
Above the carina, below the fistula
TEF technique for intubation = ___ intubation; withdraw ETT until breath sounds are confirmed at the ___
Right mainstem intubation; withdraw ETT until breath sounds are confirmed at the left axilla
TEF anesthetic management—minimize gastric ___; avoid or minimize ___ ventilation—small ___ volumes, low ___ pressures
Minimize gastric distention; avoid or minimize positive pressure ventilation—small tidal volumes, low peak inspiratory pressures
Anesthetic maintenance for TEF—___ position for R thoracotomy
Left lateral decubitus position for R thoracotomy
Anesthetic maintenance for TEF—after ligation of fistula, ___ relaxation and controlled ___; use ___ agent and ___ to maintain anesthesia; avoid ___
After ligation of fistula, muscle relaxation and controlled ventilation; use inhalation agent and opioids to maintain anesthesia; avoid nitrous oxide
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
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
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 ___
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
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
D/t issues with pain control and pulmonary complications
TEF post-op—___ should be avoided if possible during first several days post-op
Bag valve mask
TEF postop—no ___ of the head because it puts tension on the anastomosis; no ___ suctioning beyond the level of the esophageal anastomosis
No extension of the head; no esophageal suctioning
Long-term complications from TEF = esophageal ___, tracheo___, gastroesophageal ___
Esophageal stricture; tracheomalacia; gastroesophageal reflux
Esophageal strictures post-TEF may require serial ___
Dilations
Tracheomalacia post-TEF usually occurs in the ___ one third of the trachea just above the fistula; other respiratory issues = chronic ___, ___, exercise ___
Usually occurs in the lower one third of the trachea just above the fistula; other respiratory issues = chronic cough, wheezing, exercise intolerance
GERD occurs in ___ to ___% of patients with TEF
40 to 65%
