Neonatal Anesthesia Flashcards

1
Q

Idiopathic Hypertrophic Pyloric Stenosis general info

A

Narrowing/Thickening Pyloric Muscle
Etiology: 1:5000 Live Births
Presentation:
Projectile, Non-bilious vomiting
Palpable, Olive-shaped mass RUQ
More Common in:
First Born Males
2-6 weeks of life

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2
Q

Assessing urine output in neonates

A

UOP (diaper changes)
Weight Loss
Skin Turgor
Sunken (Anterior) Fontanel
Sunken Eyeballs
Dry/Pale Mucus Membranes
Salivation/Tearing
Degree of vasoconstriction (IV/A Line Access)
Pulse (Thin/Thready)
Skin Color (Mottled)
Tachypnea
Tachycardia* Hypotension* (these two are non-sensitive signs)

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3
Q

Pyloric Stenosis Medical Management

A

Correct Fluids/Electrolytes BEFORE surgery
A Plasma Cl- <90-100mEq/L = DRY (if less than 85, they’re severely dehydrated)
Want:
Na+ > 130mEq/L
Cl- > 85mEq/L
K+ > 3mEq/L
HCO3 < 30mEq/L

IVF D5-D10 0.45-0.9% Na+Cl- + K+
NO LR Metabolized to HCO3
LR would make alkalosis worse before you make it better which is less than ideal.

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4
Q

Pre-Op for pyloric stenosis

A

IV access
Adequate preop hydration
Replacement of Electrolytes

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5
Q

Pyloric Stenosis Anesthesia Management

A

Intraoperative
Prevention of Aspiration
Suction stomach supine awake, LLD, RLD prior to induction
?Pre-treat with (0.01-0.02)mg/kg Atropine (Min 0.1mg, Max 1mg)
RSI vs Inh–generally no muscle relaxants
Analgesia
LA at surgical site
Paravertebral Nerve Block
Rectus Sheath Block
Acetaminophen
Spinal

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6
Q

Pyloric Stenosis Post-Op Management

A

Extubate
Observe for Apnea
observe for Hypoglycemia and temperature issues

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7
Q

hallmark labs of pyloric stenosis

A

hypokalemic
hypochloremic
metabolic alkalosis

in later stage, baby will have compensatory hypoventilation

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8
Q

Congenital Diaphragmatic Hernia

A

BILATERAL Lung Hypoplasia
- Hernia Side Greater
Pulmonary Hypertension

LEFT more common
- Foramen of Bochdalek

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9
Q

Signs and Symptoms of Congenital Diaphragmatic Hernia

A

CXR,U/S, Physical exam
Scaphoid abdomen
Barrel-shaped, large chest
Respiratory distress – Cyanosis
Pneumothorax (unaffected side) pre-op
Malrotation of intestines - 100%

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10
Q

Why is it so important to correct electrolyte status in a pyloric stenosis patient BEFORE surgery not during?

A

if they stay alkalotic, they will have an impaired drive to breathe and will be apneic in PACU

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11
Q

Prognosis of Congenital Diaphragmatic Hernia

A

50% Mortality
Related to degree of:
Pulmonary hypoplasia
Pulmonary hypertension
+/- Cardiac Defects (25%) (left ventricular hypoplasia)

Also:
Prematurity
Birth Weight
+/- Pneumothorax

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12
Q

Associated syndromes and anomalies with Congenital Diaphragmatic Hernia

A

Associated Syndromes
Carnelia de Lange
Fryns Pallister-Killian
Chromosomal Deletions

Associated Anomalies
Spinal dysraphism
Craniofacial abnormalities
Extremity abnormalities

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13
Q

If you give less than the minimum dose of atropine or you give it too slowly, what can happen?

A

bradycardia

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14
Q

Pre-Operative for Congenital Diaphragmatic Hernia

A

ABG –Acidosis, Hypoxemia, hypercarbia
CBC, BMP (BUN/Cr), Coagulation
Chromosomal Microassay
Electrolytes, Glucose
CXR
Cardiac (25%)/Renal U/S(7%)
ECHO
Cranial MRI/Sonography (for ECMO prep)

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15
Q

Anesthesia Management for Congenital Diaphragmatic Hernia

A

Extracorporeal Membrane Oxygenation (ECMO) available
OGT- decompress and continuous suction
Vasoactive Agents–Dopamine, Milrinone, Dobutamine, Epinephrine
Pulmonary Vasodilator – Nitric Oxide
Opioids
NO Nitrous
Volume (D10)

Intubate/Ventilate
Optimize Ventilation/Oxygenation while minimizing PIP –> (<30cmH20) Barotrauma and Pneumothorax Risk

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16
Q

(general info) esophageal malformations

A

Tracheal-Esophageal Fistulas/Esophageal Atresia

1:4000
30-50% Premature
30% Cardiac Anomalies
87% Blind Upper Pouch
Copious Secretions/drooling (inability to swallow)
3 C’s – Cyanosis, Coughing, Choking with feeding
Polyhydramnios

17
Q

What is the most common type of Esophageal Malformation?

A

Type C/Type 3B Proximal EA (esophagus continuous with the mouth ending in a blind loop superior to the sternal angle) with a distal esophagus arising from the lower trachea or carina. (Most common, 85-90% of cases.) +EA, + TEF

it means you swallow and it just goes nowhere to a blind pouch

18
Q

pre-ductal and post-ductal O2 sats for congenital diaphragmatic hernia

A

right hand and left foot

if the difference starts to get larger, that’s a good indication that the shunt is increasing

19
Q

Pre-Op Considerations for Esophageal Malformations

A

Respiratory
Pneumonia
Lung disorder/hypoplasia (Premature)
Fluid Status, Glucose
Evaluate for other disorders
Access, T&C
Aspiration (abdominal distension)
NPO
Elevate HOB
OG/NGT in proximal pouch-unable to pass into stomach

20
Q

Vactrel vs. VATER?

A

VACTREL stands for vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities.

VATER = same as VACTREL but WITHOUT the cardiac anomalies

21
Q

Induction for esophageal malformations

A

Intubate (awake?, spontaneous respirations, +/- muscle relaxants?, RSI?, Mod RSI?, just wing it?)
Most Practitioners mRSI
Avoid PP breaths
Tip ETT distal to fistula, proximal to carina

he talked about the issue in masking is that majority of the breath goes to the stomach

22
Q

If the patient with esophageal malformation desaturates, what is the trouble shooting?

A

Kinked/Obstructed ETT – Mucus plug, blood
Migration into fistula
Low lung compliance + high fistula compliance
Esophageal intubation?
Small patient -
A spontaneously breathing patient – can still hear BBS

23
Q

Post Op Management for esophageal malformations

A

Intubated to ICU up to 5 days post-op
Esophageal anastomosis under tension
Avoid any BMV for several days (fragility of anastomosis)
Analgesia
Nerve block
Caudal/Epidural

24
Q

Wall Defects

A

Omphalocele
Gastroschisis

25
Omphalocele
Herniation of bowel/liver into base of umbilical cord-Failure of intestines to return to abdomen CENTRAL cord insertion Associated Anomalies -- 40% incidence Need CARDIO Evaluation Beckwith-Wiedemann Syndrome Trisomy 21 Pentalogy of Cantrell
26
Gastroschisis
Paraumbilical defect (right), full-thickness WITHOUT a covering membrane Bowel Fibrosis Sonogram - 2nd trimester Chromosomal Analysis Fetal ECHO Pedi surgeon consult Serial Sono to dx polyhydramnios/Intrauterine Growth Restriction (IUGR)
27
Ventral Wall Defects: urgent vs. emergent
Urgent not Emergent Medical unless imminent threat of: Bowel ischemia Obstruction Sepsis
28
Preoperative Considerations for ventral wall defects
Water Loss Heat Loss Infection Risk Hypoproteinemia – decreased plasma oncotic pressure Metabolic Acidosis GI Obstruction, vomiting, distention Twisting Delayed onset NEC (bloody stools) Prematurity Issues (Apnea, Glucose, ETT size) Volume, O2 Carrying Capacity Gas Exchange Blood products available
29
Intra-Op considerations for ventral wall defects
Warm OR Potential for difficult ventilation Aggressive IVF: 8-16mL/kg/hr +/- 5% Albumin Abdominal compartment syndrome: - Dusky Bowel - Dead Bowel - Dead Baby
30
Post-Op Management for ventral wall defects
Ventilation/ARDS risk Fluids/Nutrition Renal Failure Glucose Monitoring
31
Presentation of Necrotizing Enterocolitis
Abdominal distention Bloody stools/diarrhea – Anemia Apnea, bradycardia, lethargy, shock, bowel retention Bowel Ischemia Thrombocytopenia, Neutropenia (ANC<1500), Met Acidosis (HCO3 < 20)
32
Etiology of Necrotizing Enterocolitis How is diagnosed?
90% of cases premature (low birth weight) infants Cause: ? Bacterial Colonization, Hypoxic Ischemic Injury? Predisposing Conditions: Mucosal Injury, Ischemia Breast milk better than formula/enteral for prevention Abdominal XR-Pneumatosis, free air (if perforated) Abd U/S-Ascites, Loculation/abscess
33
If you suspect Nectrotizing enterocolitis, what is the first step? and so on?
Suspicion: #1 = HOLD enteral feedings OGT (relieve distention of alimentary tract) IV-Fluid, electrolytes, TPN AbxVentilatory/Inotropic support Sx: Ex Lap for perforated/necrotic bowel, resection of dead bowel vs. Peritoneal Drainage under LA
34
As necrotizing enterocolitis worsens, what are the stages known as?
Bell's stages
35
necrotizing enterocolitis prognosis
Prognosis: 10-50% Mortality Complications: Sepsis, intestinal strictures (leading to obstruction), short bowel syndrome, wound infections
36
Necrotizing Enterocolitis Anesthesia Management
IVF - D5-D10 LR ABG – acidosis Ventilation Difficulties Sepsis - Inotropes (dopamine, norepinephrine) , Antibiotics Hypothermia Hyperoxia - Retinopathy of Prematurity Post-Op: they stay intubated and medically managed for a few days