Lecture 3 (Part 2)-Peds Ortho Surgeries

Question 1

Congenital dislocation of the hip—cause = prolonged displacement of the fetal ___ head from the acetabulum, resulting in posterior dislocation during hip flexion

Answer 1

Fetal femoral head

Question 2

Severity of congenital dislocation of the hip ranges from joint ___ to ___ displacement

Answer 2

Joint laxity to irreducible displacement

Question 3

Treatment of congenital dislocation of hip = ___ harness; fluoroscopy guided closed reduction and ___ casting

Answer 3

Pavlick harness; spica casting

Question 4

Congenital dislocation of hip is common in ___ deliveries

Answer 4

Breech

Question 5

Congenital dislocation of hip could lead to degenerative hip ___ if missed

Answer 5

Arthritis

Question 6

Sign of congenital dislocation of hip = ___ click as the femoral head moves in and out of the acetabulum

Answer 6

Ortolani click

Question 7

Pavlick harness prevents ___ and ___ of hip joint while allowing some slight movement in the “safe zone”

Answer 7

Prevents extension and adduction of hip joint

Question 8

Anesthetic management for congenital hip dislocation—greatest concern = loss of ___ because patient will be lifted from the OR table to the spica casting frame and then back to the OR table

Answer 8

Airway

Question 9

Anesthetic management for congenital hip dislocation—___ anesthetic maintained via mask, LMA, ETT; patient must be kept ___ (stage ___) so that manipulation does not produce ___

Answer 9

Inhalation anesthetic; patient must be kept deep (stage III) so that manipulation does not produce laryngospasm

Question 10

Congenital hip dislocation—make sure airway device is ___ so that it does not become dislodged during position changes; disconnect ___ during position changes; d/c ___ prior to circuit disconnect

Answer 10

Make sure airway device is secured so that it does not become dislodged during position changes; disconnect circuit during position changes; d/c nitrous prior to circuit disconnect

Question 11

What condition is this describing?—structural deformity—shortened medial tendons of the lower leg, shortened Achilles’ tendon; foot pointed downward, rotated inward

Answer 11

Congenital clubfoot

Question 12

Congenital clubfoot = foot pointed ___, rotated ___

Answer 12

Foot pointed downward, rotated inward

Question 13

Treatment of congenital clubfoot = manipulation and casting done at ___-___ months of age

Answer 13

Manipulation and casting done at 3-6 months of age

Question 14

Anesthetic management for congenital clubfoot = general + regional—___ anesthetic and then one shot caudal with ___—provides analgesia for ___-___ hours, ___ (increases/decreases) inhaled anesthetic requirement

Answer 14

General + regional—inhaled anesthetic and then one shot caudal with bupivicaine 0.25% 1 ml/kg—provides analgesia for 4-6 hours, decreases inhaled anesthetic requirement

Question 15

Congenital clubfoot—can use ___ instead of caudal

Answer 15

IV opioids

Fentanyl 2-5 mcg/kg

Mag sulfate 0.1 mg/kg

Question 16

Patients with congenital clubfoot have immense post-op pain—consider consulting pain team for epidural catheter—T/F?

Answer 16

True

Question 17

Anesthetic management for congenital clubfoot—___ are utilized; stabilization of ___, continuous monitoring of breath sounds; positioning and padding of ___ extremities (position can sometimes be prone); intraoperative ___ monitoring and use of ___ containing solution (procedure can take 4 hours if bilateral); temperature ___

Answer 17

Tourniquets are utilized; stabilization of ETT, continuous monitoring of breath sounds; positioning and padding of upper extremities; intraoperative glucose monitoring and use of glucose containing solution; temperature conservation

Question 18

Congenital clubfoot surgery is usually done at ___-___ months

Answer 18

3-6 months

Question 19

What condition is this describing?—defect of collagen production, resulting in abnormal bones, ligaments, teeth, and sclera; patients suffer fractures after innocuous [unharmful] contact or trauma

Answer 19

Osteogenesis imperfecta

Question 20

In osteogenesis imperfecta, ___ in the bone don’t work well

Answer 20

Fibroblasts

Question 21

OI clinical presentation—___ of long bones and kypho___; oto___ and deafness; ___metabolic (not MH); ___ abnormalities and decreased Factor ___ levels in 30%

Answer 21

Bowing of long bones and kyphoscoliosis; otosclerosis and deafness; Hypermetabolic (not MH); platelet abnormalities and decreased factor VIII levels in 30%

Question 22

OI—the normal excessive prevention of hypothermia should be tempered because these patients have a Hypermetabolic state and their temps may rise easily (can be mistaken for MH but is just a Hypermetabolic state)—T/F?

Answer 22

True

Question 23

Bleeding d/t platelet/factor VIII abnormalities is rare in those with osteogenesis imperfecta—T/F?

Answer 23

True even though 30% of patients with OI have these abnormalities

Question 24

OI anesthetic management—gentle manipulation of the C-spine and airway is vital—patients will have atlantooccipital ___; cervical and mandibular fractures occur ___; airway cartilages and teeth are easily ___

Answer 24

Patients will have atlantooccipital instability; cervical and mandibular fractures occur easily; airway cartilages and teeth are easily damaged

Question 25

OI anesthetic management—normal airway = routine ___ or ___ induction and intubation

Answer 25

Routine inhalation or IV induction and intubation

Question 26

OI anesthetic management—difficult airway = ___ intubation

Answer 26

Awake fiber optic

Question 27

OI anesthetic management—give muscle relaxants only after adequate ___ is established

Answer 27

Adequate mask ventilation

Question 28

Analgesia for OI =

Answer 28

IV opioids Fentanyl 2-5 mcg/kg Mag sulfate 0.1 mg/kg

Question 29

OI—applying a tourniquet cannot cause a fracture—T/F?

Answer 29

False—tourniquet application can cause fractures in patients with OI

Question 30

OI—consider using a ___ laryngoscope to decrease the need for excessive extension of neck

Answer 30

Video laryngoscope

Question 31

OI—consider ___ for pain management

Answer 31

Peripheral nerve blocks

Question 32

OI anesthetic management—pay meticulous attention to ___ and ___ of the extremities; avoid aggressive ___ measures and anti-___ (because these patients are Hypermetabolic); ___ are utilized; ___-induced fasciculations can cause fractures

Answer 32

Pay meticulous attention to positioning and padding of the extremities; avoid aggressive heat conservation measures and anti-muscarinics; tourniquets are utilized; succinylcholine-induced fasciculations can cause fractures

Question 33

What disorder is this describing?—static encephalopathy, or any non progressive central motor deficit related to hypoxic or anoxic cerebral damage in the perinatal period; etiology = prematurity, birth trauma, hypoglycemia, intrauterine and neonatal infections, congenital vascular malformations

Answer 33

Cerebral palsy

Question 34

CP clinical presentation—associated with mental ___; ___ disorders; abnormalities of vision, speech, hearing, behavior, and cognition

Answer 34

Associated with mental retardation; seizure disorders; abnormalities of vision, speech, hearing, behavior, and cognition

Question 35

CP clinical presentation—skeletal muscle ___ and ___tures; impairment of ___ and ___ reflexes, leading to ___ and ___; poor dental ___

Answer 35

Skeletal muscle spasticity and contracture; impairment of laryngeal and pharyngeal reflexes, leading to GERD, and aspiration; poor dental hygiene

Question 36

CP—all anesthetic techniques and agents have been used safely in patients with CP—T/F?

Answer 36

True

Question 37

Moderate to severe CP airway management should involve intubation r/t predisposition to ___

Answer 37

Predisposition to aspiration

Question 38

CP—need for premedication is individually based—midazolam or ketamine dosing =

Answer 38

Intranasal versed 0.2-0.3 mg/kg Intramuscular ketamine 5-10 mg/kg

Question 39

CP—succs does not produce an exaggerated K+ release—T/F?

Answer 39

True

Question 40

CP patients’ response to NDNMBs is normal—T/F?

Answer 40

True

Question 41

CP—opioids are appropriate but can lead to impaired ___ or impaired airway ___

Answer 41

Impaired alertness or impaired airway reflexes

Question 42

CP—caudal block ___ (increases/decreases) inhaled anesthetic requirement and provides post-op ___

Answer 42

Decreases inhaled anesthetic requirement and provides post-op analgesia

Question 43

Children with CP tend to have a ___ (lower/higher) MAC than children without it

Answer 43

Lower MAC (need less agent, may require less propofol)

Question 44

CP—post-op ___ control is imperative

Answer 44

Post-op pain control is imperative—CP patients often cannot express their pain, parents can be helpful in determining if pain is present

Question 45

CP drug interactions—patients with seizure disorder—phenobarbital, phenytoin, carbamazepine should be taken ___ and including ___ of the procedure

Answer 45

Should be taken up to and including the day of the procedure

Question 46

CP drug interactions—phenobarbital is a hepatic microsomal enzyme ___

Answer 46

Inducer—patients may need higher doses of other medications because meds are metabolized faster

Question 47

CP drug interactions—___ or ___ may be used to treat spasticity

Answer 47

Dantrolene or baclofen may be used to treat spasticity

Question 48

CP/dantrolene—direct acting skeletal muscle relaxant, inhibits ___ release from the sarcoplasmic reticulum

Answer 48

Inhibits Ca release

Question 49

CP/baclofen—skeletal muscle relaxant, inhibits ___ neurotransmitters

Answer 49

Inhibits excitatory neurotransmitters

Question 50

Spasticity in CP thought to be caused by inadequate release of the GABA inhibitor ___ acid in the dorsal horn of the spinal cord, resulting in excess excitatory ___ on alpha motor neurons that produce simultaneous contraction of agonist/antagonist muscle groups; treat with ___ or ___

Answer 50

Inadequate release of the GABA inhibitor aminobenzoic acid in the dorsal horn of the spinal cord, resulting in excess excitatory glutamate on alpha motor neurons that produce simultaneous contraction of agonist/antagonist muscle groups; treat with dantrolene or baclofen

Question 51

Surgical treatment of skeletal muscle spasticity in CP = ___

Answer 51

Rhizotomy—cutting of nerve roots in the spinal cord; procedure effectively relieves chronic back pain and muscle spasms

Question 52

___ are common in the pediatric population r/t trauma

Answer 52

Fractures

Question 53

Child sustaining blunt force trauma must be evaluated for injury to ___ and other organ systems

Answer 53

C-spine

Question 54

Most common pediatric fracture = ___ fracture

Answer 54

Elbow fracture from monkey bar falls

Question 55

Anesthetic considerations for fractures—___ and endotracheal intubation indicated in patients coming from ED for ___/___ repair

Answer 55

RSI and endotracheal intubation indicated in patients coming from ED for urgent/emergent repair

Question 56

Urgent/emergent surgical repair = ___ compromise, ___ hematoma, ___tension

Answer 56

Vascular compromise, large hematoma, hypotension

Question 57

In acute fractures, often peripheral blocks are not used so ___ injury is more easily detected

Answer 57

Nerve

Question 58

Myelodysplasia = congenital failure of the ___ or ___ end of the neural tube to close, resulting in: ___ bifida, ___cele, ___cele

Answer 58

Congenital failure of the middle or caudal end of the neural tube to close, resulting in: spina bifida, meningocele, myelomeningocele

Question 59

What is this condition?—malformation of one or more vertebrae; it is sometimes called “closed”; in most cases, causes no problems; nerves escape between malformation of vertebrae

Answer 59

Spina bifida occulta

Question 60

What is this condition?—the meninges protrude with sac present filled with spinal fluid

Answer 60

Meningocele

Question 61

What is this condition?—the nerves of the spinal cord are present in the protruding sac; most severe of the myelodysplasias

Answer 61

Myelomeningocele

Question 62

Meningocele clinical presentation—neural function is ___; spinal cord is tethered (tied up, chained) by ___ nerve roots; if unrepaired, results in ___ and/or ___ symptoms

Answer 62

Neural function is intact; spinal cord is trapped by sacral nerve roots; if unrepaired, results in orthopedic and/or urologic symptoms

Question 63

Myelomeningocele clinical presentation—varying degrees of ___ and ___ deficits; dilation of ___ urinary tract; spasticity; scoliosis

Answer 63

Varying degrees of sensory and motor deficits; dilation of upper urinary tract; spasticity; scoliosis

Question 64

Myelodysplasia anesthetic management—surgical repair on the ___ day of life; lack of ___ covering defect makes patient prone to ___ and ___

Answer 64

Surgical repair on the first day of life; lack of skin covering defect makes patient prone to infection and sepsis

Question 65

Myelodysplasia anesthetic management—___ induction with standard agents

Answer 65

Routine induction

Question 66

Myelodysplasia anesthetic management—endotracheal intubation in the ___ position or ___ supported on towel rolls or a donut to avoid putting pressure on the sac

Answer 66

Endotracheal intubation in the lateral decubitus position or supine supported on towel rolls or a donut to avoid putting pressure on the sac

Question 67

Myelodysplasia anesthetic management—use of neurometric monitoring, so avoid ___ initially

Answer 67

Nondepolarizing NMBs

Question 68

Myelodysplasia anesthetic management—careful pre-op assessment of intravascular volume d/t potential for ___volemia from seepage of fluid from sac

Answer 68

Potential for hypovolemia

Question 69

Myelodysplasia anesthetic management—aggressive ___ conservation measures; blood loss typically not ___

Answer 69

Aggressive temperature conservation measures; blood loss typically not extensive

Question 70

Scoliosis = lateral and rotational deformity of the ___ spine, accompanied by deformity of the ___

Answer 70

Thoracolumbar spine, accompanied by deformity of the ribcage

Question 71

80% of scoliosis cases are ___ and coincide with periods of rapid ___

Answer 71

Idiopathic and coincide with periods of rapid growth

Question 72

Infantile scoliosis < ___ years

Answer 72

< 3 years

Question 73

Juvenile scoliosis = ___-___ years

Answer 73

3-10

Question 74

Adolescent scoliosis > ___ years

Answer 74

> 10 years

Question 75

Scoliosis physiologic derangements—___ (increased/decreased) lung volumes; ___ (increased/decreased) chest wall compliance; ___ mismatch, leading to chronic ___emia; ___ (increased/decreased) PVR, pulmonary ___tension leading to ___ failure

Answer 75

Decreased lung volumes; decreased chest wall compliance; V/Q mismatch, leading to chronic hypoxemia; increased PVR, pulmonary hypertension leading to RV failure

Question 76

Scoliosis anesthetic monitoring—routine monitors, SSEPs to assess ___ column function

Answer 76

Dorsal (sensory) column

Question 77

Scoliosis surgical positioning = ___

Answer 77

Prone

Question 78

Scoliosis + prone position = compression of ___; ___ (increased/decreased) intraabdominal pressure; ___ of IVC; epidural vein ___, increased bleeding; ___ (increased/decreased) venous return, ___ (increased/decreased) cardiac output

Answer 78

Compression of lungs; increased intraabdominal pressure; compression of IVC; epidural vein engorgement, increased bleeding; decreased venous return, decreased cardiac output

Question 79

Scoliosis—patient transfer is coordinated by the ___; ___ circuit and all monitors; meticulous attention to supporting the head and extremities; ___ all pressure points; special attention to protecting the ___ in prone position!

Answer 79

Patient transfer is coordinated by the anesthetist; disconnect circuit and all monitors; meticulous attention to supporting the head and extremities; pad all pressure points; special attention to protecting the eyes in prone position

Question 80

Scoliosis—pre-medication appropriate, except with coexisting respiratory ___osis and ___ (increased/decreased) pulmonary vascular resistance

Answer 80

Except with coexisting respiratory acidosis and increased pulmonary vascular resistance

Question 81

Use ___ dose inhaled agent for scoliosis patients

Answer 81

Low dose

Question 82

Scoliosis—fentanyl ___ mcg/kg load, then infusion at ___-___ mcg/kg/hr

Answer 82

10-15 mcg/kg load, then infusion at 2-4 mcg/kg/hr

Question 83

Scoliosis—mag sulfate ___ mg/kg load, then ___ mg/kg every 4 hours

Answer 83

0.2mg/kg load, then 0.1 mg/kg every 4 hours

Question 84

Scoliosis—remifentanil ___-___ mcg/kg/min

Answer 84

0.2-0.5 mcg/kg/min

Question 85

Scoliosis—precedex ___-___ mcg/kg/min

Answer 85

0.2-0.4 mcg/kg/min

Question 86

Scoliosis—inspired concentration of inhaled agent kept at ___-___ MAC so as not to impair ___

Answer 86

0.5-1.0 MAC so as not to impair SSEPs

Question 87

Scoliosis—blood loss often exceeds ___ ml/kg

Answer 87

25 ml/kg

Question 88

Scoliosis—TXA use— ___ mg/kg load, then ___ mg/kg/hr

Answer 88

30 mg/kg load, then 10 mg/kg/hr

Question 89

Scoliosis—deliberate ___tension during case; hourly measurement of ___; aggressive temperature ___ measures; consider medical causes of bleeding after loss of ___ blood volume—dilutional ___cytopenia, decreased factors ___ and ___; ___ products will be used

Answer 89

Deliberate hypotension during case; hourly measurement of H&H; aggressive temperature conservation measures; consider medical causes of bleeding after loss of one blood volume—dilutional thrombocytopenia, decreased factors V and VIII; banked products will be used

Question 90

Scoliosis post-op management—problems = ___ ventilation, ___volemia, ___, ___ (think GI issue r/t opioids), ___ (endocrine issue)

Answer 90

Mechanical ventilation, hypovolemia, pain, ileus, SIADH

Question 91

Scoliosis—occasionally, patient needs to remain intubated if pre-op ___ is present

Answer 91

Lung disease

Question 92

Scoliosis—post-op pain is very amenable to ___, so ___ is appropriate for pain control

Answer 92

Very amenable to opioids, so PCA is appropriate for pain control

Question 93

Scoliosis—consider IV ___ or IV ___ for pain control in addition to PCA

Answer 93

IV Tylenol or IV toradol

Question 94

Scoliosis/SIADH manifests as ___natremia, ___osmolality, ___ (increased/decreased) urine output, ___ (increased/decreased) urine osmolality

Answer 94

Hyponatremia, hypoosmolality, decreased urine output, increased urine osmolality