Neonatal 2

Question 1

What is choanal atresia?

Tx?

Answer 1

• blockage at the back of the nasal passage by bone or soft tissue
• Usually associated with other congenital issues
• Unilateral or bilateral diagnosed based on the inability to pass a small catheter through each nare
• Surgical tx required during neonatal period
• Oral airway may be necessary until surgery

Question 2

What is a congenital diaphragmatic hernia?

Sx

initial tx

Answer 2

• Herniation of the abdominal viscera through a defect in the diaphragm
  
  • usually on the left via foramen Bochdalek
• Sx:
  
  • severe resp distress at birth
  • cyanosis
  • scaphoid abdomen (guts are up in lungs)
  • can be seen on x-Ray
• Initial treatment in delivery room:
  
  • avoid aggressive mask ventilation
  • urgent intubation
  • decompress stomach
  • maintain PaCO2 < 40 and optimal oxygenation

Question 3

What must be avoided in a pt with a congenital diaphragmatic hernia?

Plan of care?

Answer 3

• Must avoid iatrogenic volutrauma (over ventilating)!
  
  • high risk pneumothorax on side opposite of hernia if attempts are made to expand the ipsilateral lung
  • hypoxemia secondary to pulmonary hypoplasia and pulmonary hypertension
  • hypotension d/t overdistention of stomack and mechanical kinking of great vessels
• Trend is supportive care instead of immediate surgery
  
  • ECMO
  • HFOV
  • Nitric oxide

Question 4

Anesthetic management of diaphragmatic hernia

Answer 4

• Awake intubation without positive pressure ventilation
• adequate IV access
• a-line
• opioids
• muscle relaxation
• maintain optimal oxygenation PaO2 >100 and ventilation
• avoid nitrous
• anticipate ICU postop

Question 5

What causes apnea of prematurity?

How is it diagnosed?

treatment?

Answer 5

• Immaturity of the respiratory control centers of the brainstem
  
  • decreased sensitivity to elevations in CO2
  • both central apnea and obstructive apnea
  • inversely proportional to gestational age
• Dx
  
  • apneic periods >15-20 seconds
  • apnea with HR <80-100
  • apnea with desaturation
• Methylxanthines are primary treatment
  
  • aminophylline
  • caffeine

Question 6

Neonatal hypoglycemia:

Sx

Who is at highest risk?

Answer 6

• Sx- can be masked by anesthesia
  
  • hypotension
  • tremors
  • sz
  • resp distress/apnea, cyanosis
  • high pitched cry
  • irritability
  • limpness
  • lethargy
  • eye rolling
  • poor feeding
  • temp instability
  • sweating
• Highest risk:
  
  • infants with intrauterine growth restriction*
  • diabetic mothers*
  • severe intrauterine fetal distress*
  • excessively fasted full-term infants
  • SGA
  • infants of diabetic mothers

Question 7

What is considered hypoglycemia?

Full term neonates?

Premature infants?

Answer 7

• Full term neonates: <40 mg/dL during first 24 hours after birth
  
  • <60 mg/dL at 36 hours
• Premature infants: <45 mg/dL during first 24 hour
  
  • later than 24 hrs <50 mg/dL

Question 8

How is neonatal hypoglycemia prevented?

Answer 8

• 1st 48 hours IV maintenace fluid should contain 10% glucose in 0.2% saline with 22 mmol/L K
• After 48 hrs: 5% glucose
  
  • pre-terms will have increased requiremnt

Question 9

How is hypoglycemia treated?

Answer 9

• bolus of 0.25 to 0.6 g/kg
  
  • 1-2 ml/kg of D25 W
  • 2.5-5 ml/kg of D10 W
• After bolus start infusion
  
  • bolus will stimulate insulin production and pt will return to hypoglycemic state
• glucose should be in MAINTENANCE FLUID ONLY
• check bs frequently

Question 10

Hypocalcemia:

Who is affected?

Causes

Answer 10

• At birth there is abrupt loss of maternal Ca
  
  • by third day of life Ca levels return to normal in full-term neonate
  • premies don’t benefit from the transfer of maternal calcium
• Hypocalcemia in nearly 40% of critically ill neonates
• Causes:
  
  • PTH insufficiency
  • inadequate Ca supplementation
  • altered calcium metabolism caused by citrated products
  • bicarb administration
  • diuretics (furosemide)

Question 11

Hypocalcemia symptoms

Answer 11

• may be asymptomatic
• neuromuscular irritability (myoclonic jerks, exaggerated startle, sz)
• tachycardia
• prolonged QT interval
• decreased cardiac contractility

Question 12

Hypocalcemia treatment

Answer 12

• 90 mg/kg calcium gluconate or 30 mg/kg calcium chloride by slow IV infusion over 5-10 min
  
  • while monitoring for bradycardia
• Calcium gluconate is vesicant, can go through IV but watch closely!
  
  • causes necrosis and subcutaneous calcification
• Calcium chloride must go through central line
• Consider need for Mg supplementation as well!

Question 13

Which CHD present as CHF?

What are CHF symptoms in newborn?

Answer 13

• CHDs
  
  • VSD
  • PDA
  • critical aortic stenosis
  • coarctation of the aorta
• Newborn CHF symptoms
  
  • poor feeding
  • irritability
  • sweating
  • tachycardia
  • tachypnea
  • decreased peripheral pulses
  • poor cutaneous perfusion
  • hepatomegaly

Question 14

Which CHDs present as cyanotic?

Answer 14

• Tetralogy of Fallot
• transposition of the great arteries
• hypoplastic left heart syndrome

Question 15

What is meningomyelocele?

Anesthesia considerations?

Answer 15

• hernial protrusion of a part of the meninges and spinal cord through a defect in the vertebral column
  
  • These pts often have chiary malformation (caudal displacement of medulla)
• Anesthesia considerations:
  
  • protect defect with positioning (difficult during intubation)
  • anticipate larger insensible losses
  • high possibility of hydrocephalus, esp after surgical repair
  • possibility of CN palsy affecting vocal cord and causing resp distress/stridor
  • potential for brainstem herniation
  • higher incidence of latex allergy
  • No NMB d/t neuromonitoring

Question 16

What is an arnold chiari malformation?

How is it treated?

Answer 16

• Caudal displacement of the medulla
  
  • often seen with meningomyelocele
• Treatement:
  
  • relief of hydrocephalus and possible cervical decompression of herniation
  • trach and long-term ventilation may be required

Question 17

What is esophageal atresia?

How is it diagnosed?

Answer 17

• Esophagus doesnt form correctly and communicates with the trachea causing aspiration peumonitis
  
  • esophagus ends in a blind pouch
• suspect this with polyhydramnios
• diagnosed by inability to pass a suction catheter into the stomach
• Suspect other anomolies (VATER, VACTERL)
• GET ECHO before anesthesia

Question 18

What are the different types of TEFs?

(pic)

Answer 18

Question 19

Airway management with esophageal atresia

Answer 19

• anticipate pt to have aspiration pna- may require g-but before esophageal surgery
• Airway management:
  
  • hold feedings
  • place soft suction in the esophagus to drain saliva
  • position prone in a head-up position
  • plan for awake intubation with sedation
  • intentionally right mainstem then back out to BBS
    
    • ideally you want end of ETT bast fistula but above bifurcation

Question 20

How do you want to ventilate a pt with esophageal atresia?

How might you manage post-op pain?

Answer 20

• spontaneous assisted ventilation is best to avoid stomach over distention until the fistula is ligated or g-tube is placed
• watch preductal and post ductal SpO2
• Consider left precordial stethescope under left axilla to continuously monitor for r mainstem intubation
• May require post-op ventilation
• post op pain may be managed with caudal catheter

Question 21

What is an omphalocele?

Gastroschesis?

What complications can occur?

Answer 21

• They are major defects in the closure of the abdominal wall that result in exposure of viscera
• omphalocele is covered by peritoneium
  
  • comon to have cardiac abnormalities as well
• gastorschesis is not covered by peritoneum
• Complications:
  
  • severe dehydration
  • massive fluid loss
  • heat loss
  • complex surgical closure (staged)
• Get echo before anesthesia
• anticipate post-op ventilation

Question 22

Omphalocele/gastroschisis repair anesthetic considerations

Answer 22

• Early repair reduces the potential for infection and compromis of bowel function, minimizes fluid and heat loss
• must optimize fluid and electrolyte balance before surgery
• obtain good IV access
• anticipate need for TPN postop
• expect invasive monitoring if cardiac defect is present
• expect to need lots of muscle relaxant to close the defect
• anticipate hypotension secondary to tension on liver or caval compression
• increased abdominal pressure after closure impairs ventilation
• risk of abdominal compartment syndrome

Question 23

Omphalocele is associated with what syndrome?

Answer 23

• Beckwith-Wiedemann syndrome
  
  • profound hypoglycemia
  • hyperviscosity syndrome
  • congenital heart disease
  • visceromegaly

Question 24

What is different between omphalocele and gastroschisis?

(table)

Answer 24

Question 25

What is Hirschsprung?

symptoms?

What happens if not treated?

surgical repair?

Answer 25

• Hirschsprungs is the absence of parasympathetic ganglion cells in the large intestine. A segment of colon has no paristalsis, delays passage of meconium
  
  • functional obstruction at level of affected segment
• Sx consistent with bowel obstruction: bilious vomiting and abdominal distention
• Can lead to toxic megacolon- this will requie volume replacement and vasopressor support
• Surgical repairs vary:
  
  • anorectal myomectomy
  • mucosal resections
  • diverting colostomies
  • transanal pull-throughs