neonatal emergencies Flashcards
what is the most common type of tracheo esophageal fistula (TEF)?
C (90% of cases. upper esophagus ends in blind pouch and lower esophagus communicates with distal trachea
key diagnostic indicator for TEF?
maternal polyhydraminos (because esophageal atresia prevents fetus from swallowing amniotic fluid)
sx of TEF and confirmation
unable to pass OG
sx: choking, coughing, cyanosis during PO feeding
VACTERL association
Vertebral defects
imperforated Anus
Cardiac anomalies
Tracheoesophageal fustula
Esophageal atresia
Renal Dysplasia
Limb anomalies
approx 20% of neonates with TEF have what? what should you do preop?
cardiac defect: (ASD, VSD, TOF, aortic coarctation)
get a preop echo
anesthetic management of TEF patient
head up and frequent suctioning for gastric management
awake intubation or mask induction with spontaneous inhalation
gastric decompression before induction
place ETT below fistula but above carina (if placed too high, resp gas is delivered to stomach)
right lung compression during surgery is common. right mainstem intubation will cause rapid desaturation
when do type 2 pneumocytes start producing surfactant and when does production peak?
22-26 weeks: start
35-36 weeks: peak
risk factors for respiratory distress syndrome (RDS)
LBW (low birth weight)
low gestational age (GA)
barotrauma from positive pressure ventilation
O2 toxicity
endotracheal intubation
maternal DM
dx of RDS:
soon after birth. neonate is grunting , tachypnea, intercostal and subcostal retractions, nasal flaring
ABG: hypoxemia, hypercarbia, mixed acidosis
tx of RDS:
betamethasone (starts working in 18h, peaks at 48h)
describe L/S ratio and its significance
lecithin (surfactant)/sphingomyelin (surfactant precursor) ratio gives advanced warning about state of fetal lung
L/S >2 suggests adequate lung development
L/S < 2 associated with increased risk of RDS
first line tx for neonates after delivery that have not produced enough surfactant
CPAP (may progress to mechanical ventilation)
anesthetic implications for patient with lack of surfactant
pre ductal SpO2 (RUE) and post ductal SpO2 (LE) should be used. (difference in values suggests pHTN, R to L shunt, return to fetal circulation via PDA
aline- pre ductal artery for ABG’s
what congenital diaphragmatic hernia is MOST likely to occur?
D, most commonly occurs through the foramen of bochdalek (usually on the left side)
the orientation- you are in the stomach looking up, NOT the thorax looking down
when is congenital diaphragmatic hernia (CDH) diagnosed?
at birth. newborn will have RDS and sunken (scaphoid) abdomen
what happens to the lungs r/t CDH
mass effect of abdominal contents impairs lung development, leading to pulmonary hypoplasia.
could include poor pulmonary vascular development, increased pulmonary vascular resistance, impaired airway development, and airway reactivity
respiratory related anesthetic management in a patient with CDH
keep PIP <25-30cmH2O
avoid conditions that increase PVR (hypoxia, acidosis, hypothermia)
OLV may be better d/t pulmonary hypoplasia of other lung
abdominal closure may increase PIP. surgeon may create temporary ventral hernia to increase abdominal volume
pulse ox on lower extremity can warn of increased intra abdominal pressure
explain how right to left shunting affects PVR and how to monitor it
right to left shunting through the ductus arteriosus leads to hypoxemia and cyanosis where PVR further increases
pulse ox on RUE to monitor pre ductal O2 and BP
pre ductal O2 should be >90%
how long is surgery for CDH delayed and why
5-15 days to allow for stabilization of pulmonary, cardiac, and metabolic status
ID each anatomical structure and diaphragmatic abnormality
define gastroschisis
congenital defect where abdominal wall does not develop fully and no membrane covering (sac) to protect the viscera
what is gastroschisis highly associated with?
prematurity
most common congenital abdominal wall defects
omphalocele and gastroschisis
what is omphalocele caused by
failure of gut migration from the yolk sac to the abdomen
