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Anesthesia Concepts 4 (Butera) > Neonatal Anesthesia > Flashcards

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
Q

Omphalocele

A

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
Q

Gastroschisis

A

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
Q

Ventral Wall Defects: urgent vs. emergent

A

Urgent not Emergent

Medical unless imminent threat of:
Bowel ischemia
Obstruction
Sepsis

28
Q

Preoperative Considerations for ventral wall defects

A

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
Q

Intra-Op considerations for ventral wall defects

A

Warm OR
Potential for difficult ventilation
Aggressive IVF: 8-16mL/kg/hr +/- 5% Albumin
Abdominal compartment syndrome:
- Dusky Bowel
- Dead Bowel
- Dead Baby

30
Q

Post-Op Management for ventral wall defects

A

Ventilation/ARDS risk
Fluids/Nutrition
Renal Failure
Glucose Monitoring

31
Q

Presentation of Necrotizing Enterocolitis

A

Abdominal distention
Bloody stools/diarrhea – Anemia
Apnea, bradycardia, lethargy, shock, bowel retention
Bowel Ischemia
Thrombocytopenia, Neutropenia (ANC<1500), Met Acidosis (HCO3 < 20)

32
Q

Etiology of Necrotizing Enterocolitis

How is diagnosed?

A

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
Q

If you suspect Nectrotizing enterocolitis, what is the first step? and so on?

A

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
Q

As necrotizing enterocolitis worsens, what are the stages known as?

A

Bell’s stages

35
Q

necrotizing enterocolitis prognosis

A

Prognosis: 10-50% Mortality
Complications: Sepsis, intestinal strictures (leading to obstruction), short bowel syndrome, wound infections

36
Q

Necrotizing Enterocolitis Anesthesia Management

A

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

Anesthesia Concepts 4 (Butera) (15 decks)

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