Neonatal Anesthesia Flashcards
Idiopathic Hypertrophic Pyloric Stenosis general info
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
Assessing urine output in neonates
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)
Pyloric Stenosis Medical Management
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.
Pre-Op for pyloric stenosis
IV access
Adequate preop hydration
Replacement of Electrolytes
Pyloric Stenosis Anesthesia Management
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
Pyloric Stenosis Post-Op Management
Extubate
Observe for Apnea
observe for Hypoglycemia and temperature issues
hallmark labs of pyloric stenosis
hypokalemic
hypochloremic
metabolic alkalosis
in later stage, baby will have compensatory hypoventilation
Congenital Diaphragmatic Hernia
BILATERAL Lung Hypoplasia
- Hernia Side Greater
Pulmonary Hypertension
LEFT more common
- Foramen of Bochdalek
Signs and Symptoms of Congenital Diaphragmatic Hernia
CXR,U/S, Physical exam
Scaphoid abdomen
Barrel-shaped, large chest
Respiratory distress – Cyanosis
Pneumothorax (unaffected side) pre-op
Malrotation of intestines - 100%
Why is it so important to correct electrolyte status in a pyloric stenosis patient BEFORE surgery not during?
if they stay alkalotic, they will have an impaired drive to breathe and will be apneic in PACU
Prognosis of Congenital Diaphragmatic Hernia
50% Mortality
Related to degree of:
Pulmonary hypoplasia
Pulmonary hypertension
+/- Cardiac Defects (25%) (left ventricular hypoplasia)
Also:
Prematurity
Birth Weight
+/- Pneumothorax
Associated syndromes and anomalies with Congenital Diaphragmatic Hernia
Associated Syndromes
Carnelia de Lange
Fryns Pallister-Killian
Chromosomal Deletions
Associated Anomalies
Spinal dysraphism
Craniofacial abnormalities
Extremity abnormalities
If you give less than the minimum dose of atropine or you give it too slowly, what can happen?
bradycardia
Pre-Operative for Congenital Diaphragmatic Hernia
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)
Anesthesia Management for Congenital Diaphragmatic Hernia
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
(general info) esophageal malformations
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
What is the most common type of Esophageal Malformation?
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
pre-ductal and post-ductal O2 sats for congenital diaphragmatic hernia
right hand and left foot
if the difference starts to get larger, that’s a good indication that the shunt is increasing
Pre-Op Considerations for Esophageal Malformations
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
Vactrel vs. VATER?
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
Induction for esophageal malformations
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
If the patient with esophageal malformation desaturates, what is the trouble shooting?
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
Post Op Management for esophageal malformations
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
Wall Defects
Omphalocele
Gastroschisis
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
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)
Ventral Wall Defects: urgent vs. emergent
Urgent not Emergent
Medical unless imminent threat of:
Bowel ischemia
Obstruction
Sepsis
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
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
Post-Op Management for ventral wall defects
Ventilation/ARDS risk
Fluids/Nutrition
Renal Failure
Glucose Monitoring
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)
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
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
As necrotizing enterocolitis worsens, what are the stages known as?
Bell’s stages
necrotizing enterocolitis prognosis
Prognosis: 10-50% Mortality
Complications: Sepsis, intestinal strictures (leading to obstruction), short bowel syndrome, wound infections
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
