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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
Q

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:

A

4-9

9

congenital diaphragmatic hernia

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26
Q

What is this?

A

congenital diaphragmatic hernia

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27
Q

What are general locations of congenital diaphragmatic hernia?

A

Foramen of Bochdalek , posterolateral (80%)

Esophageal hiatus (20%)

Foramen of Morgagni, anterior (2%)

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28
Q

Label:

A
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29
Q

What is the occurrence of Left:Right congenital diaphragmatic hernia?

A

5:1

30
Q

Congenital diaphragmatic compression of abdominal contents in chest causes _____ arrest at ___-___ weeks.

A

bronchial

11-13

31
Q

What pulmonary issues does congenital diaphragmatic hernia cause? (4)

A

50% reduction in alveoli
Mediastinal shift
Hypoplastic pulmonary artery
Pulmonary HTN

32
Q

What is generally the cause of death in congenital diaphragmatic hernia? (3)

A

Progressive hypoxemia
Respiratory failure
Pulmonary HTN

33
Q

What are anomalies associated with congenital diaphragmatic hernia? (4)

A

GI: (40-60%)

CNS: (28%)

CHD (20%)

GU

34
Q

Is congenital diaphragmatic hernia a surgical emergency?

A

No since surgery does not cure lung hypoplasia.

35
Q

How do you preoperatively manage a congenital diaphragmatic hernia infant? (5)

A
  • ECMO to allow lungs to grow before surgery
  • Must be able to oxygenate/ventilate
  • Correct acidosis
  • Treat pulmonary HTN
  • Gastric decompression
36
Q

How do you proceed to surgery with congenital diaphragmatic hernia? (5)

A
  • 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
Q

What are monitors for congenital diaphragmatic hernia? (4)

A

Art line
Pre and postductal pulse ox
Urinary catheter
Precordial on opposite side of defect

38
Q

How is induction performed on a congenital diaphragmatic hernia neonate?

What are ventilation settings? (2)

A

Awake intubation

If ventilated, intermittent mandatory ventilation (IMV) 60/min

Pin < 30 cm H2O

Note: May need pressure-limited vent.

39
Q

For congenital diaphragmatic hernias, what is goal for:

paO2
paCO2
pH

A

paO2 > 80

paCO2: 25 - 30

pH >7.5

40
Q

What is anesthetic management for congenital diaphragmatic hernia? (2)

A

Fentanyl 10 - 25 mcg/kg

Muscle relaxation

41
Q

What are fluids and rates needed for congenital diaphragmatic hernia ? (3)

A

D5

NS 1/4 (4-6 cc/kg/hr)

Albumen 5% (5-10 cc/kg)

42
Q

NS, LR, albumen, RBCs can be given in ________.

A

umbilical art line

43
Q

What is the postoperative plan for congenital diaphragmatic hernia? (4)

A

KEEP INTUBATED!

Vent requirements determined by abdominal pressures.

Minimize suctioning

Provide nutrition

44
Q

What are the intra-op complications of congenital diaphragmatic hernia? (4)

A

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
Q

The risk of mortality from congenital diaphragmatic hernia is highest, ___% due to: (3)

A

90

Respiratory distress in first hour of life
Associated CHD
< 35 weeks gestation

46
Q

80% mortality from congenital diaphragmatic hernia is due to __________.

A

contralateral pneumothorax

47
Q

50% mortality from congenital diaphragmatic hernia is due to ________.

A

Respiratory distress in first 6 hours.

48
Q

30 - 40% mortality of congenital diaphragmatic hernia is due to ______.

A

ECMO

49
Q

10% of mortality from congenital diaphragmatic hernia is due to ________.

A

Respiratory distress after 6 hours

50
Q

What are the indications for ECMO? (5)

A

reversible respiratory failure

Meconium aspiration
Congenital diaphragmatic hernia
Drowning
Infection
Asthma

51
Q

What are the criteria for ECMO consideration? (4)

A

> 34 week gestation
> 2 kg
Reversible lung disease
80% predicted mortality

52
Q

What criteria excludes consideration for ECMO? (2)

A

> grade II intraventricular hemorrhage

life threatening anomalies

53
Q

What are morbidity risks of ECMO? (3)

A

Sepsis

Bleeding

CNS hemorrhage

54
Q

What neonates are at highest risk for mortality on ECMO? (2)

A

30-40% for congenital diaphragmatic hernia

12% for neonatal ECMO

55
Q

What is an abnormal fusion of the neural groove in the first month of gestation leaving some portion of brain or cord exposed?

A

myelodysplasia

56
Q

What predisposes myelodysplasias?

A

inheritance

57
Q

What is the location of myelodysplasias?

A

75% lumbosacral

58
Q

What’s this?

A

myelodysplasia

59
Q

What’s this?

A

meningomyelocele

60
Q

What is the rate of mortality associated with myelodysplasia?

What is morbidity due to?

A

17%

Infection due to exposed CNS

Note: Delayed closure worsens motor function.

61
Q

Greater than 10% of myelodysplasias have _____ or other anomalies that are immediately life threatening.

A

intracranial

62
Q

What are preop assessments that need to be made for myelodysplasias? (5)

A

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
Q

What are anesthetic concerns in myelodysplasia neonate? (5)

A
  • Awake intubation for encephaloceles
  • Inhalational or IV
  • Muscle relaxant of choice
  • Maintenance with volatile/N2O/O2
  • Extubate sooner rather than later
64
Q

What is this?

A

cystic hygroma

65
Q

What is depicted?

A

cystic hygroma

66
Q

What anatomic structures may cystic hygromas affect? (7)

A

Tongue
Great vessels
Brachial plexus
Facial
Vagus
Phrenic
Hypoglossal nerves

67
Q

What morbidity is associated with cystic hygroma? (3)

A

AW
Bleeding
Infection

68
Q

Cystic hygromas are relatively common. True or false?

Cystic hyromas may adhere to great vessels. True or false?

What labs are needed?

A

True for both.

Hct, glucose, calcium, type/cross

69
Q

What monitors are needed for cystic hygroma? (2)

A

Art line

IV access in LOWER extremeties since upper vessels may be unreliable.

Note: Also important as always to have a warm room.

70
Q

What is the induction strategy for a cystic hygroma? (3)

A

Volatile

Atropine before laryngoscopy

Maintain spontaneous ventilation even during induction!

71
Q

What is the postop plan for a cystic hygroma?

A

Keep intubated because usually staged surgery.

72
Q

What are post-op risks for cystic hygromas? (4)

A

Risk for RLN injury
Bleeding
Subglottic edema
Upper AW edema

AP Summer Final (7 decks)

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