Paediatrics Flashcards
Airway Foreign Body (FB)
Considerations
Goals
Conflicts
Optimization
Complications
Airway Foreign Body (FB)
Considerations
Emergency, full stomach/aspiration risk
Pediatric patient considerations
Potential for airway obstruction & respiratory complications:
Ball-valve effect & barotrauma
Bronchospasm, laryngospasm
Edema
Post obstructive pneumonia/sepsis
Rigid or flexible bronchoscopy, esophagoscopy:
Shared airway
Immobility required
Ventilatory strategies, spontaneously-breathing method preferred
Goals
Maintain spontaneous ventilation (avoid hyperinflation/barotrauma, FB dislodgement/airway obstruction)
Provide adequate analgesia for rigid bronchoscopy (avoid coughing/airway trauma)
Effective teamwork with ENT throughout
Prevent airway complications
Conflicts
Uncooperative patient vs. spontaneous ventilation
Deep anesthesia vs. spontaneous ventilation
Shared airway vs. ventilation/oxygenation/deep anesthesia
Optimization
Establish IV
ENT STAT, call for OR & second anesthesiologist or anesthesia assistant
Hold child in position of comfort if upper airway FB or with affected lung down if lower airway FB
Bronchodilators
Humidified O2, heliox
Aspiration prophylaxis (can delay case for 8 hrs if child stable)
Dexamethasone to reduce swelling
Glycopyrrolate to dry secretions
Spontaneously breathing induction methods:
Total IV anesthesia:
Titrate to RR 12-16 or 50% of baseline before stimulation of the child
Inhalational with sevoflurane
Once anesthesized, perform staged stimulation/laryngoscopy & topicalization with lidocaine
Staged approach example steps:
Jaw thrust
Insert oral airway
Do direct laryngoscpy & spray with lidocaine
Complications
Bronchospasm
Laryngospasm on awakening
Inadequate ventilation
Pneumothorax, BPF (ball valve)
Unable to ventilate, hypoxemia
Complete airway obstruction:
Push FB into a mainstem bronchus
Hypertension, tachycardia, tachyarrhythmias
Pulmonary hemorrage
Post obstructive pneumonia
Bronchopulmonary Dysplasia (BPD)
Background
Considerations
Optimisations/Management
Bronchopulmonary Dysplasia (BPD)
Background
BPD is a clinical diagnosis defined as O2 dependence at 36 weeks’ postconceptual age or O2 requirement (to maintain PaO2 > 50 mm Hg) beyond 28 days of life in infants with birth weights of less than 1500 g
Most significant symptoms in 1st year of life, many with mild disease become asymptomatic but reactive airways may remain
Considerations
Pulmonary dysfunction:
Hypoxemia & hypercarbia
Hyperinflation & bullae
Reactive airways disease
Associated pulmonary hypertension, RV dysfunction & risk of perioperative pulmonary hypertension crisis/RV failure
Post-op disposition & pain management:
Maximize ventilatory function to decrease complications
Regional, neuraxial & adjuncts whenever possible
Former premature infant with possible previous intubation
Airway: subglottic stenosis, tracheomalacia/bronchomalacia
CNS: seizures, hydrocephalus, cerebral palsy
Cardiovascular: PDA, cardiomyopathies
GI: GERD, malnutrition, swallowing problems (risk of aspiration)
Management of medications:
Diuretics
Stress dose steroid if on chronic steroids
Optimization/ Management
Treat & optimize any acute respiratory decompensation
Regional if possible
If GA:
Deep anaesthesia
Ventilatory settings as asthma (longer expiratory time, slow-normal RR)
Consider LMA to avoid tracheal stimulation
Avoid ↑ PVR:
Avoid hypoxia, hypercapnia (although mild hypercapnia is ok given they have obstructive pattern), acidosis, sympathetic surges, ↑ airway pressures, hypothermia
Cerebral Palsy (CP)
Background
Considerations
Cerebral Palsy (CP)
Background
A disorder of movement & posture due to a static encephalopathy
Huge spectrum of presentation: almost asymptomatic to completely dependent
Caused by a cerebral insult in the immature brain that occurred prenatally, perinatally, or during infancy
The motor deficit may manifest as:
Hypotonia
Spasticity
Extrapyramidal features such as choreoathetoid/dystonic movements or ataxia
Considerations
↓ C-spine mobility & possible difficult intubation
Aspiration risk (GERD/↓lower esophageal sphincter tone)
Pulmonary:
Recurrent aspiration & pulmonary impairment
Scoliosis & ↑ bleeding risk during scoliosis surgery
Rule out pulmonary HTN/RV failure
CNS:
Developmental delay/lack of cooperation
Seizure d/o
Hydrocephalus
Altered response to anesthetics:
↓ MAC of volatiles & longer emergence
↑ resistance to muscle relaxants
Volatiles & succinylcholine NOT contraindicated
Difficult IV access, monitoring, & positioning due to contractures
Ex-premature conditions
↑ risk of hypothermia
CHARGE Syndrome
Background
Considerations
CHARGE Syndrome
Background
A genetic syndrome with the CHD7 gene on chromosome 8 most implicated. Acronym stands for:
C: Coloboma
H: Heart Defects. Most common are tetralogy of Fallot (33%), VSD (ventricular septal defect), AV (atriventricular) canal defect, and aortic arch anomalies.
A: Atresia choanae
R: Retarded growth & development
G: Genital hypoplasia
E: Ear anomalies/deafness
Considerations
Pediatric patient considerations
Difficult airway management & aspiration risk:
Micrognathia may make endotracheal intubation difficult
Patients may have Choanal atresia & laryngomalacia
Severe GERD & aspiration risk
Swallowing & feeding problems
Congenital heart disease considerations
Most common are Tetralogy of Fallot (33%), VSD (ventricular septal defect), AV (atriventricular) canal defect, and aortic arch anomalies
Cleft Lip & Palate
Considerations
Goals
Cleft Lip & Palate
Considerations
Potential difficult airway (especially bag mask ventilation):
Careful airway plan required
Ensure direct laryngoscope does not enter cleft!
Swallowing dysfunction:
Lung soiling, restrictive lung disease
Malnutrition
Associated craniofacial disorders/congenital diseases:
Pierre-Robin
Cogenital heart disease in 20%
Post-op airway complications:
Laryngospasm
Edema/obstruction (surgery makes airway management more difficult)
Goals
Assess airway for bag mask ventilation, laryngoscopy, & establish sequential airway plan
Evaluate for congenital heart disease & other congenital abnormalities
Safe post-op airway management
Congenital Diaphragmatic Hernia
Background
Considerations
Resuscitation
Congenital Diaphragmatic Hernia
Background
Diaphragmatic hernia with intestinal contents in chest
90% left sided
Lung will be underdeveloped & newborn could have persistent pulmonary hypertension
Delayed surgery is preferred to stabilize prior to closure
Conventional ventilation with permissive hypercapnia is now favoured
Other therapies:
Surfactant
High-frequency oscillatory ventilation, in addition to nitric oxide
Considerations
Emergency situation
Critically ill neonate
Hypoplastic lungs:
Respiratory insufficiency (hypoxemia, hypercarbia, acidosis)
Permissive hypercarbia may be required
Consider HVO or ECMO
Pulmonary hypertension:
Potential for RV failure/↓ cardiac output
Consider inhaled nitric oxide
Transitional circulation:
Potential for R→L & L→R shunting
PDA
Delayed surgical repair, resuscitation is first priority
NICU required
Resuscitation
Call NICU
Indication for immediate intubation (no bag mask ventilation)
NG to decompress stomach
ABG, chest x-ray, echocardiogram
Umblical artery/vein lines
Lung protective ventilation strategy:
Target SaO2 > 85% & permissive hypercapnia (PaCO2 <65 mmHg, pH >7.25)
PCV or PSV PIP < 25 cmH2O
Inspiratory time 0.35 s
PEEP 3-5 mmHg
RR < 65
Consider HVO, iNO or ECMO
Pulmonary hypertension:
Consider inhaled nitric oxide
Inotropes
Fluid: target MAP 45-50 mmHg
Sedation: opioids & benzodiazepines, thoracic epidural
Avoid NMB
Craniofacial Dysostosis (Alperts, Crouzons, Pfeiffers)
Background
Considerations
Craniofacial Dysostosis (Alperts, Crouzons, Pfeiffers)
Background
Alpert syndrome:
Difficult bag mask ventilation (high arched palate, choanal atresia)
Difficult airway: cervical spine fusion, tracheal stenosis
↑ ICP
Congenital heart disease (10%) & other malformations
Developmental delay
Syndactyly
Crouzons:
Difficult bag mask ventilation & intubation. Patients may be significantly obstructed requiring early tracheostomy
Mild developmental delay
No visceral or extremity invovement
Potential for ↑ ICP
Considerations
Pediatric patient
Difficult airway: BMV, intubation:
Midface hypoplasia
Airway obstruction (OSA)
CNS:
May have ↑ ICP
Visual loss, developmental delay
For skull surgery:
Long surgery (blood loss, hypothermia, positioning injuries)
Venous air embolism
Discharge to PICU
Croup/Laryngotracheobronchitis
Considerations
Treatment
Croup/Laryngotracheobronchitis
Considerations
Pediatric patient considerations
Possible airway difficulty & complications:
Consider double set-up, rigid bronchoscope, spontaneously breathing patient
Obstruction, laryngospasm
Respiratory fatigue/failure
Super infection with bacterial trachietis possible
Dehydration, need for volume replacement
PICU & extubation plan
Treatment
Nebulized epinephrine 0.5 ml/kg of 1:1000 to max 5 ml q15-20 min
Dexamethasone 0.6 mg/kg PO or 0.15-0.3 mg/kg IV
Budesonide 2 mg via neb (2 ml)
Humidified O2
Heliox
Approach to intubation:
Perform in OR with difficult airway cart & ENT +/- rigid bronchoscopy
Use small endotracheal tube, cuffed & stylet
Down Syndrome
Considerations
Goals
Conflicts
Down Syndrome
Considerations
Potential for atlanto-axial (AAI) or atlanto-occipital instability & neurologic injury with neck manipulation
Potential for difficult bag mask ventilation (but not usually intubation):
Large tongue,↑ oropharyngeal soft tissue, small mouth, subglottic stenosis, high arched palate
Tonsillar & adenoid hypertrophy
Possible obstructive sleep apnea:
Pulmonary hypertension/RV dysfunction
Sensitive to sedatives/hypnotics
Developmental delay/cooperation problems
Associated congenital heart disease (up to ½):
Cushion defect (AVSD) = #1
VSD, ASD, TOF
Pulmonary hypertension
Other medical issues:
Obesity
Accelerated coronary disease & valvulopathy (MVP, AI)
Hypothyroidism
GI: duodenal atresia or stenosis, TEF, Hirschsprungs, celiac disease
Heme: polycythemia, leukemia, immune deficiency
Joint laxity (careful with positioning)
Early Alzheimer’s dementia
Goals
Rule out & manage AAI: neurologic exam/history & flexion-extension views of c-spine
Airway adjuncts such as a video laryngoscope
Skin topicalization for IV start
Sedation (midazolam may be paradoxical)
Arrange post-op monitoring
Overnight oximetry useful
Conflicts
Unstable C-spine vs uncooperative patient with developmental delay:
Consider IM/PO sedation to facilitate IV placement
Ketamine 5 mg/kg IM, 7 mg/kg PO
Midazolam 0.5 mg/kg PO (max dose 20 mg)
Inhalational induction may be problematic in an adult with DS due to obesity, OSA, uncooperative nature
Duchenne Muscular Dystrophy
Background
Considerations
Conflicts
Duchenne Muscular Dystrophy
Background
X-linked recessive degenerative disease of skeletal & smooth muscle that usually first manifests in males of 2-5 years of age
Becker muscle dystrophy is essentially a milder form of Duchenne
Considerations
Possible difficult airway if macroglossia
Aspiration risk: bulbar weakness, ↓ gastric motility
Succinylcholine/volatile anesthetics contraindicated due to rhabdomyolysis/hyperkalemia risk, use total IV anesthesia
Pulmonary:
Possible obstructive sleep apnea:
Sensitivity to sedatives/hypnotics
Pulmonary hypertension/RV failure
Restrictive lung disease from scoliosis & respiratory muscle weakness
Risk of perioperative respiratory failure
Impaired cough reflex (atelectasis, recurrent aspirations)
Cardiovascular:
Dilated cardiomyopathy:
Tall R waves in precordial leads, ↑ R:S, deep Q in I, aVL, V5-6
Mitral regurgitation common (due to papillary muscle involvement from LV dilation)
Conduction defects & arrhythmias common (atrial, SVT, AV nodal)
CNS: mild cognitive impairment is common
Medications: ACE inhibitors, beta-blockers, steroids (may need stress dose)
Conflicts
RSI vs. succinylcholine
Prolonged postoperative ventilation
Advanced directive discussions
Epiglottitis
Considerations
Management
Epiglottitis
Considerations
Impending airway obstruction:
Difficult bag mask ventilation & intubation
Do not upset child or manipulate airway
Emergency: risk of aspiration, ↓ time to optimize
Sepsis & need for early goal-directed therapy
Pediatric patient considerations
Post-op disposition: PICU & plan for extubation once process resolved
Management
Call for ENT (“double set up”) & maintain spontaneous ventilation
Use smaller endotracheal tubes (1-3mm smaller)
OR set up with second anesthetist or anesthesia assiant & difficult airway cart, rigid bronchoscopy & tracheostomy set
Skin topicalization for IV start
Obtain CBC & blood cultures
Fluid bolus 20 ml/kg, repeat prn
Aspiration prophylaxis ranitidine 0.5 mg/kg & maxeran 0.1 mg/kg
Glycopyrrolate 10 mcg/kg to dry secretions
Small styletted ETT (cuffed preferable)
Spontaneouly-breathing induction with sevoflurane or propofol/remifentanil if IV, then intubate
IV antibiotics, fluids, PICU post-op:
Antibiotics: cloxacillin, cetriaxone, ampicillin, clindamycin +/- vancomycin
Extubation plan: ensure there is a leak & swelling has resolved. Then extubate in the OR & be prepared for re-intubation
Don’t use steroids empirically but consider if extubation has proven difficult after several days of antibiotic therapy
Fontan Physiology
Background
Key Considerations
Goals
Pregnancy Considerations
Laparoscopy & Fontan
Fontan Physiology
Background
Fontan is a palliative procedure for patients with functional univentricular physiology
Selection criteria for performance of Fontan are: adequately sized pulmonary arteries; low PVR; good LV function & the presence of sinus rhythm
The driving force for blood flow through the pulmonary circulation is the difference between central venous pressure (CVP) & atrial pressure:
There is NOT active pumping of blood through the lungs
Cardiac output is essentially completely dependent on pulmonary blood flow
Hypovolemia is tolerated very poorly
Preoperative preparation:
Review information from patient’s cardiologist; changes in patient’s exercise tolerance, level of cardiac impairment, details of the patient’s physiology, anatomy, & any residual & sequelae of previous surgeries
Minimize NPO interval, maintain intravascular volume (↓ preload results in ↓ pulmonary blood flow & cardiac output)
Key Considerations
Congenital heart disease patient with altered cardiac anatomy & potentially other congenital anomalies
Hemodymanic & ventilatory goals of Fontan circulation (see below)
High risk cardiac patient
Consider surgery at tertiary cardiac centre
Consultation with cardiology
Perioperative TEE invaluable
Single ventricle pathophysiology
Venous congestion: protein losing enteropathy, CKD, hepatic failure, FTT
Arrhythmias, embolic stroke, anticoagulation
LV dysfunction
Hypoxemia & hyperviscosity
Medication management (possible beta blockers, ACEI, anticoagulants, diuretics)
Consideration of bacterial endocarditis prophylaxis if applicable
Possible ↑ risk of bleeding
Postoperative monitoring in HAU/ICU
Goals
Hemodynamic goals:
Preload: keep full, avoid dehydration
Rate & rhythm: strict normal sinus rhythm
Contractility: maintain
Afterload: maintain
Pulmonary vascular resistance: keep low
Avoid hypercarbia, hypoxemia, acidosis, stress, pain, high intrathoracic pressures
Fluid management:
Guided by CVP or TEE (TEE very useful)
Vascular capacitance is ↑ in the Fontan patient; more fluid may be required than anticipated based on the formula commonly used to calculate fluid requirement
Ventilatory strategy:
Spontaneous ventilation is best as it enhances venous return & pulmonary blood flow
For PPV:
Limit peak inspiratory pressure (<20 cmH2O), use low respiratory rates (<20 bpm), short inspiratory times, avoid excessive positive end-expiratory pressure, moderately elevated tidal volumes (10–15 mL/kg), ensure adequate intravascular volume
Postoperative concerns:
Maintaining volume status, acid-base balance, & cardiac output are essential in the postoperative period; ensure adequate hydration & aggressively manage low cardiac output with intravenous hydration & inotropes
Adequate analgesia improves pulmonary mechanics & oxygenation; enhanced vigilance is required to avoid the effects of hypercapnia secondary to opioids
Treat postoperative nausea & vomiting to permit adequate hydration, prevent dehydration & electrolyte loss, & allow the patient to resume their medication regimen
Pregnancy Considerations
Case reports exist
Titrated epidural is probably the safest technique as it does not worsen PVR; caution with reduction in preload so ensure well-hydrated; reduction in afterload is probably desirable
Labor is NOT contraindicated but needs to occur in a cardiac centre with invasive monitoring (arterial line) & with assisted 2nd stage
If cesarean section: best to use epidural technique
If GA required, use strategies mentioned above
Laparoscopy & Fontan
Case reports exist
Detailed discussion with surgeon ahead of time
Minimize insufflation pressures or do staged insufflation & see effects
Avoid high intrathoracic pressures, reduced preload, & hypercarbia
If cannot tolerate, may need an open technique
Former Premature Infant
Considerations
Former Premature Infant
Considerations
Current post conceptual age & apnea risk
Congenital anomalies or syndromes
Complications of prematurity:
Airway: tracheal stenosis & malacia, subglottic stenosis, aspiration risk from GERD
Pulmonary: bronchopulmonary dysplasia, reactive airways, bullae, O2 dependency
Cardiovascular: cardiomyopathy, persistent pulmonary hypertension of the newborn (PPHN)
CNS: intraventricular hemorrhage, intracranial hemorrhage, cerebral palsy, hydrocephalus, seizure disorders
Others:
Retinopathy of prematurity
GERD/swallowing difficulties
Kidney disease
Genetic Syndromes: General Approach
Considerations
Genetic Syndromes: General Approach
Considerations
Potentially difficult airway
Many patients with genetic syndromes abnormal airway findings
Special attention is needed for syndromes with mandibular hypoplasia (e.g. Pierre Robin, Treacher Collins, Goldenhar) as well as patients with cleft lip/palate
Careful airway physical exam & review of previous anesthetics is warranted
Congenital cardiac defects
Syndromes associated with cardiac defects include: VACTERL, CHARGE, trisomy 13, 18, and 21, and velocardiofacial syndromes
Imperative to conduct thorough physical exam, review Echocardiogram, & understand cardiac anatomy/pathophysiology
Neuro-Cognitive abnormalities
Potentially anxious & uncooperative patient
Possible cognitive deficits & increased sensitivity to effects of anesthetics
Positioning & vascular access issues
In presence of limb abnormalities, positioning & vascular access may be difficult
Orthopedic abnormalities
Scoliosis, hip dysplasia, & limb contractures are common in this patient population
Goldenhar Syndrome
Background
Considerations
Goldenhar Syndrome
Background
Also called oculo‐auriculo‐vertebral syndrome or hemifacial microsomia
Developmental disorder of the first & second branchial arches
Most frequently unilateral
Characterized by:
Malformations/hypoplasia of the external & middle ear often with sensorineural hearing loss
Mandibular hypoplasia
Congenital heart disease in about a third of patients, most commonly septal & conotruncal defects (e.g. Tetralogy of Fallot)
Eye abnormalities (e.g. microphthalmus & epibulbar dermoids)
Vertebral anomalies including cervical spine malformations & scoliosis
Developmental delay & autism spectrum disorder in some patients
Considerations
Pediatric patient considerations
Potentially very difficult airway
Airway is difficult due to mandibular hypoplasia & inadequate space for direct laryngoscopy
Airway plan essential with multiple adjuncts, have ENT/surgical option on stand-by, plan on spontaneously breathing sleep technique (titrated TIVA vs IH). Fiberoptic or video‐assisted laryngoscopy are almost always required.
Congenital heart disease in about a third of patients
Most commonly septal & conotruncal defects (e.g. Tetralogy of Fallot)
OSA more common in this patient population
Tracheoesophageal Fistula
Background
Considerations
Management
Tracheoesophageal Fistula
Background
May be diagnosed antenatally on prenatal U/S
Presents as excessive oral secretions, with coughing & cyanosis during feeds
Unable to pass NG into stomach
Usually repaired w/in 24 hours of birth to minimize risk and complications of aspiration
Types: I-III (see picture below)
Considerations
Aspiration risk
Risk of dehydration/acidosis
GI distension can compromise ventilation
May require urgent gastrostomy decompression
Intraop surgical retraction can compress airways, major vessels, & heart
Associated conditions
VACTERL
Cardiac anomalies: preop echo required
Prematurity
Management
Decompress blind upper pouch with NG to suction
Raise head to reduce risk of aspiration
Advance ETT into right mainstem; slowly withdraw until bilateral breath sounds heard
Goal: tip of ETT between carina & fistula
Spontaneous ventilation is preferred
Low airway pressures if PPV required
Avoid N2O (gastric distension)
