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AP Summer Final > Neonatal Surg. Emerg. Part II > Flashcards

Neonatal Surg. Emerg. Part II Flashcards

1
Q

What is an ischemic condition of the GI tract of multifactorial etiology?

A

necrotizing enterocolitis

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2
Q

What part of the GI tract does necrotizing enterocolitis primarily involve? (2)

A

Ilieum

Colon

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3
Q

What is the incidence of necrotizing enterocolitis?

A

5 - 8% of NICU admissions

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4
Q

In what neonates is necrotizing enterocolitis common?

Specifically, what population?

A

Preterms < 36 weeks (vast majority)

< 32 weeks, < 1500 grams

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5
Q

What are risk factors for necrotizing enterocolitis? (6)

A
  • Onset of gastric feedings
  • Hypertonic feedings
  • Gut hypoperfusion
  • Hypoxemia
  • Bacterial colonization
  • Perinatal stress

Basically anything that stresses the baby.

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6
Q

What are the signs and symptoms of necrotizing enterocolitis? (6)

A

Abdominal distension/discoloration
Vomiting
Bloody stools
Temperature instability
Shock due to sepsis and 3rd space loss
DIC / thrombocytopenia

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7
Q

How does necrotizing enterocolitis present? (3)

A

Distended, tender abdomen in a child that appears septic

Abdominal erythema

Fixed bowel loops

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8
Q

What is the managment of necrotizing enterocolitis? (5)

A

Intubation
Fluids
ANTIBIOTICS
Supportive care
Radiographs

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9
Q

What is this?

A

necrotizing entercolitis

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10
Q

What is this?

A

necrotizing entercolitis

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11
Q

What is the treatment for necrotizing entercolitis? (6)

A
  • Conservative early on
  • Gastric decompression
  • Antibiotics
  • Replace IV volume
  • Pressors to keep output higher
  • Surgery if bowel is punctured

scar gp

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12
Q

What are cardiovascular issues relating to necrotizing entercolitis? (5)

A

Fluid/blood rescuscitation (150cc/kg)
Rescuscitation starts in NICU
Acidosis/shock
CHF secondary to sepsis
Inotropes

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13
Q

What are metabolic considerations of necrotizing entercolitis? (4)

A

Severe acidosis
Avoid hypoglycemia
Avoid hypocalcemia
Careful bicarb replacement

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14
Q

How do you replace bicarbonate in necrotizing entercolitis infant?

A

bicarb deficit * wt. * 0.3

Give half of calculated deficit slowly.

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15
Q

Who are some of the sickest patients?

A

infants with necrotizing entercolitis

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16
Q

What are neurological concerns with necrotizing entercolitis infants?

A

intraventricular hemmorhage in the brain

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17
Q

What causes intraventricular hemorrhage in necrotizing entercolitis infants? (3)

A

Aggressive fluid resuscitation

Lack of autoregulation

Wide swings in BP

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18
Q

What blood products do you need to have available for necrotizing entercolitis? (4)

A
  • RBCs
  • Platelets
  • FFP
  • Cryo

Note: At increased risk of DIC, coagulopathy.

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19
Q

What monitors/equipment do you need for necrotizing entercolitis surgery? (4)

A

Art line
Foley catheter
Warm OR
Femoral IV access

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20
Q

What is the average fluid requirement for necrotizing entercolitis surgery?

A

150 cc/kg

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21
Q

What is the anesthetic management for necrotizing entercolitis surgery? (5)

A

Ketamine
Opioid
Muscle relaxant
SaO2 ~95%
Hct > 30%

Note: EBL ~10-100cc/kg!

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22
Q

What is post-op care for necrotizing entercolitis? (4)

A

Maintain PPV

Persistent 3rd space loss and increased intra-abdominal pressure

Continue opioids and max. muscle relaxation

Transport with extra volume, AW equipment, drugs, full monitors

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23
Q

Mortality in necrotizing entercolitis is 25% due to: (6)

A

Sepsis
Gangrenous bowel
Respiratory failure
IVH
PDA
Refractory metabolic acidosis

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24
Q

What is the incidence of congenital diaphragmatic hernia in M:F?

A

1 - 2 : 1

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25
At \_\_-\_\_ weeks gestation, the pleuroperitoneal membrane separates the 2 cavities. Incomplete closure of membrane allows bowel to herniate into chest when gut returns from yolk sac to the abdomen at ___ weeks gestation This is known as:
4-9 9 congenital diaphragmatic hernia
26
What is this?
congenital diaphragmatic hernia
27
What are general locations of congenital diaphragmatic hernia?
Foramen of Bochdalek , posterolateral (80%) Esophageal hiatus (20%) Foramen of Morgagni, anterior (2%)
28
Label:
29
What is the occurrence of Left:Right congenital diaphragmatic hernia?
5:1
30
Congenital diaphragmatic compression of abdominal contents in chest causes _____ arrest at \_\_\_-\_\_\_ weeks.
bronchial 11-13
31
What pulmonary issues does congenital diaphragmatic hernia cause? (4)
50% reduction in alveoli Mediastinal shift Hypoplastic pulmonary artery Pulmonary HTN
32
What is generally the cause of death in congenital diaphragmatic hernia? (3)
Progressive hypoxemia Respiratory failure Pulmonary HTN
33
What are anomalies associated with congenital diaphragmatic hernia? (4)
GI: (40-60%) CNS: (28%) CHD (20%) GU
34
Is congenital diaphragmatic hernia a surgical emergency?
No since surgery does not cure lung hypoplasia.
35
How do you preoperatively manage a congenital diaphragmatic hernia infant? (5)
* ECMO to allow lungs to grow before surgery * Must be able to oxygenate/ventilate * Correct acidosis * Treat pulmonary HTN * Gastric decompression
36
How do you proceed to surgery with congenital diaphragmatic hernia? (5)
* Wean from ECMO * Check PT/PTT/platelet/ACT * Abdominal incision * All contents may/may not return to abdomen for primary closure * May construct artificial (akinetic) diaphragm
37
What are monitors for congenital diaphragmatic hernia? (4)
Art line Pre and postductal pulse ox Urinary catheter Precordial on opposite side of defect
38
How is induction performed on a congenital diaphragmatic hernia neonate? What are ventilation settings? (2)
Awake intubation If ventilated, intermittent mandatory ventilation (IMV) 60/min Pin \< 30 cm H2O Note: May need pressure-limited vent.
39
For congenital diaphragmatic hernias, what is goal for: paO2 paCO2 pH
paO2 \> 80 paCO2: 25 - 30 pH \>7.5
40
What is anesthetic management for congenital diaphragmatic hernia? (2)
Fentanyl 10 - 25 mcg/kg Muscle relaxation
41
What are fluids and rates needed for congenital diaphragmatic hernia ? (3)
D5 NS 1/4 (**4-6 cc/kg/hr**) Albumen 5% (**5-10 cc/kg**)
42
NS, LR, albumen, RBCs can be given in \_\_\_\_\_\_\_\_.
umbilical art line
43
What is the postoperative plan for congenital diaphragmatic hernia? (4)
KEEP INTUBATED! Vent requirements determined by abdominal pressures. Minimize suctioning Provide nutrition
44
What are the intra-op complications of congenital diaphragmatic hernia? (4)
**Contralateral pneumothorax-**-do not attempt to expand lungs! Hypothermia Metabolic acidosis Persistent pulmonary HTN with R → L shunting Note: Intracardiac shunting leads to decreased oxygenation.
45
The risk of mortality from congenital diaphragmatic hernia is highest, \_\_\_% due to: (3)
90 ## Footnote Respiratory distress in first hour of life Associated CHD \< 35 weeks gestation
46
80% mortality from congenital diaphragmatic hernia is due to \_\_\_\_\_\_\_\_\_\_.
contralateral pneumothorax
47
50% mortality from congenital diaphragmatic hernia is due to \_\_\_\_\_\_\_\_.
Respiratory distress in first 6 hours.
48
30 - 40% mortality of congenital diaphragmatic hernia is due to \_\_\_\_\_\_.
ECMO
49
10% of mortality from congenital diaphragmatic hernia is due to \_\_\_\_\_\_\_\_.
Respiratory distress after 6 hours
50
What are the indications for ECMO? (5)
reversible respiratory failure ## Footnote Meconium aspiration Congenital diaphragmatic hernia Drowning Infection Asthma
51
What are the criteria for ECMO consideration? (4)
\> 34 week gestation \> 2 kg Reversible lung disease 80% predicted mortality
52
What criteria excludes consideration for ECMO? (2)
\> grade II intraventricular hemorrhage life threatening anomalies
53
What are morbidity risks of ECMO? (3)
Sepsis Bleeding CNS hemorrhage
54
What neonates are at highest risk for mortality on ECMO? (2)
30-40% for congenital diaphragmatic hernia 12% for neonatal ECMO
55
What is an abnormal fusion of the neural groove in the first month of gestation leaving some portion of brain or cord exposed?
myelodysplasia
56
What predisposes myelodysplasias?
inheritance
57
What is the location of myelodysplasias?
75% lumbosacral
58
What's this?
myelodysplasia
59
What's this?
meningomyelocele
60
What is the rate of mortality associated with myelodysplasia? What is morbidity due to?
17% Infection due to exposed CNS Note: Delayed closure worsens motor function.
61
Greater than 10% of myelodysplasias have _____ or other anomalies that are immediately life threatening.
intracranial
62
What are preop assessments that need to be made for myelodysplasias? (5)
Check: * Neurologic deficits * Volume status (3rd space losses) * Position must protect neural plaque! * Plan AW management esp. for encephaloceles! (may need to intubate prone) * WARM ROOM MOST CRITICAL
63
What are anesthetic concerns in myelodysplasia neonate? (5)
* Awake intubation for encephaloceles * Inhalational or IV * Muscle relaxant of choice * Maintenance with volatile/N2O/O2 * Extubate sooner rather than later
64
What is this?
cystic hygroma
65
What is depicted?
cystic hygroma
66
What anatomic structures may cystic hygromas affect? (7)
Tongue Great vessels Brachial plexus Facial Vagus Phrenic Hypoglossal nerves
67
What morbidity is associated with cystic hygroma? (3)
AW Bleeding Infection
68
Cystic hygromas are relatively common. True or false? Cystic hyromas may adhere to great vessels. True or false? What labs are needed?
True for both. Hct, glucose, calcium, type/cross
69
What monitors are needed for cystic hygroma? (2)
Art line IV access in LOWER extremeties since upper vessels may be unreliable. Note: Also important as always to have a warm room.
70
What is the induction strategy for a cystic hygroma? (3)
Volatile Atropine before laryngoscopy Maintain spontaneous ventilation even during induction!
71
What is the postop plan for a cystic hygroma?
Keep intubated because usually staged surgery.
72
What are post-op risks for cystic hygromas? (4)
Risk for RLN injury Bleeding Subglottic edema Upper AW edema

AP Summer Final (7 decks)

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