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
Mitochondrial Disease
Background
Considerations
Goals
Mitochondrial Disease
Background
Definition: group of disorders that affect the function of mitochondria (ATP powerhouse of the cell) resulting in a complex multisystem disease of varying severity
disorders can affect any system with any symptom and any mode of inheritance
associated with ↑ lactate
Prevalence = 1: 4000, most manifest by 20 y/o
Common procedures:
muscle biopsies, MRI/CT scans, endo/gastrostomy creations, strabismus sx
Considerations
Potential effects on multiple organ systems:
CVS: cardiomyopathy, conduction abnormalities
Resp: central hypoventilation, respiratory muscle weakness
GU: renal insufficiency
GI: hepatic insufficiency
Endo: DM, hypoparathyroidism
Heme: anemia, thrombocytopenia
Ascertain degree of organ involvement especially cardio-resp:
PFTs, CXR, ABG, ECG, Echo if available
Ensure relevant multi-disciplinary consultants are involved
↑ Risk of metabolic encephalopathy
Altered effects of anesthetic medications:
Propofol: avoid when possible (especially prolonged infusions) due to ↑ risk of PRIS
Succinylcholine: avoid due to ↑ hyperkalemia risk
NDMR: unpredictable response
Goals
Overarching goal: Minimize metabolic stress of surgery
consider trending lactate as marker of metabolic stress
Avoid:
Hypotension, hypoxia, hypoglycemia, hypothermia
Lactate containing solutions (Ringer’s)
Propofol, succinylcholine
Prolong periods of fasting
Good post-operative analgesia plan (regional, multi-modal analgesia when possible)
Mucopolysaccharidosis (Hunters and Hurlers)
Background
Considerations
Goals
Mucopolysaccharidosis (Hunters and Hurlers)
Background
The mucopolysaccharidoses (MPS) are the result of a deficiency of lysosomal enzymes that cleave mucopolysaccharides (glycosaminoglycans)
An accumulation of mucopolysaccharides occurs in the brain, heart, liver, bone, cornea, & tracheobronchial tree. There are seven types & several subtypes of MPS, each with various clinical presentations
Multisystem diseases but airway is the main concern:
difficult intubation 53%
failed intubation 23%
Considerations
Review the patient’s particular type of mucopolysaccharidoses & clinical features
Airway:
Difficult to impossible airway (BMV & DL) that worsens with time:
Macroglossia
Hyperplasia of adenoids, tonsils, pharyngeal tissue
Friable tissues
↓ TMJ
Possible atlantoaxial instability (only for Morquio’s or MPS-IV)
Difficult surgical airway (short neck, retrosternal trachea)
Respiratory:
RLD: recurrent pulmonary infections, pectus excavatum & kyphoscoliosis
OSA, pulmonary hypertension
Possible need for post-operative ventilatory support
Cardiac:
Cardiomyopathy
Diffuse CAD from coronary artery deposition
Valvulopathy: AI, MR
Neuro:
Potential developmental delay, uncooperative
Dural thickening can result in compressive myelopathy
Developmental delay
Hydrocephalus
Others:
Hepatosplenomegaly
Hepatic dysfunction
Periop risk of hypoglycaemia
Metabolic acidosis due to inability to convert lactic acid to glycogen (avoid ringer’s)
Hemorrhagic diathesis due to platelet dysfunction
Goals
Safe establishment of airway:
Consider awake fiberoptic intubation
If uncooperative: spontaneous breathing fiberoptic intubation
Surgical backup for rigid bronchoscopy & tracheostomy immediately available
Avoid/minimize resp-depressants if possible
Perioperative monitoring of of serum glucose, minimization of fasting times when possible
Pre-operative identification & optimization of cardiac system
Necrotizing Enterocolitis
Considerations
Goals/Conflicts
Necrotizing Enterocolitis
Considerations
Premature infant considerations
↑ risk of aspiration:
Bowel obstruction, dilated bowel loops, pneumatosis intestinalis
Associated multisystem derangements:
Hypoxia
Sepsis, hypovolemia
DIC, thrombocytopenia
Metabolic acidosis
Associated conditions:
Birth asphyxia, hypotension, respiratory distress syndrome, patent ductus arteriosus, recurrent apnea, intestinal ischemia, systemic infections
Goals/Conflicts
Optimize multisystem abnormalities of prematurity
Prevent aspiration (consider RSI):
Conflict with sepsis/hypovolemia & hemodynamic stability
Anticipate & optimize fluid, electrolyte, glucose derangements
Ensure good IV access (or central line above the diaphragm)
Ensure continuous temperature monitoring & maintain normothermia
Correction of coagulopathy
Omphalocele and Gastroschisis
Background
Considerations
Management
Omphalocele and Gastroschisis
Background
Both are defects of anterior abdominal wall that permit external herniation of abdominal viscera
Omphalocele: contents are covered by a sac formed by the peritoneal membrane (up to 3/4 of omphalocele cases are associated with other congenital defects including cardiac anomalies & trisomy 21)
Gastroschisis: hernia sac does not cover the herniated abdominal viscera. Therefore, the bowel is exposed to the external environment
Considerations
Neonate considerations
Sequelae of open abdomen:
Aspiration
Hypothermia
Fluid & electrolyte abnormalities
Sepsis
Discussion with surgeon regarding primary versus staged closure
Abdominal compartment syndrome after closure:
Shock/cardiac dysfunction, ↓ venous return
Acute kidney injury
Restrictive lung disease/respiratory failure
↓ splanchnic & liver blood flow (prolonged drug effect)
Congenital heart disease considerations if present with omphalocele
Management
Needs RSI or awake intubation
Needs muscle relaxation for closure
Arterial line likely needed
Potential for fluid shifts + need for ongoing resuscitation
Avoid hypovolemia, coagulopathy, acidosis, hypothermia
Likely back to NICU intubated
Pediatric Anxiety
Background
Considerations
Non-pharmacologic techniques
Pharmacologic techniques
Pediatric Anxiety
Background
Pre-operative anxiety is associated with:
↑ opioid requirements
Emergence delirium
Sleep disturbances
Enuresis
Considerations
Risk factors:
Age < 4 years
Temperament: shy, inhibited, dependent, withdrawn
↓ time for preoperative preparation
Accompanied by anxious parents
Previous negative experience with anesthesia or hospitalization
Multiple previous hospital admissions
Separation anxiety develops at 6-8 months old
Age < 6 months can be soothed by surrogate (i.e. nurse or physician)
Non-pharmacologic techniques should be employed for all children
Pharmacologic techniques can be used in carefully selected children
Consider avoiding pharmacologic techniques children with:
Potential difficult airway
OSA or central sleep apnea
Renal or hepatic impairment
Altered LOC
Increased ICP
Acute systemic illness
URTI
New or unexplained O2 desaturations
Allergies or adverse reaction to proposed medication
If considering pharmacologic techniques:
Ensure patient is in monitored setting
Resuscitation equipment must be available
Transfer to OR on stretcher bed, with portable suction and Ambu bag available, accompanied by nurse or physician
↓ LOC or respiratory depression
protect airway, support ventilation
consider naloxone (if opioid given) and flumazenil (if midazolam given)
Non-pharmacologic techniques to reduce anxiety
Providing adequate pre-hospital information (i.e. books, videos, OR tours)
Play therapy
Distraction (i.e. cartoons, toys, games)
Engaging with anesthetic equipment (i.e. holding the mask, “blowing up the balloon”)
Environmental adjustments (i.e. limiting healthcare staff, choosing music)
Calm parents accompanying to OR
Breathing techniques
Communication aids (info about the child’s needs/routines)
Pharmacologic techniques to reduce anxiety
Benzodiazepines (midazolam)
Oral liquid midazolam (0.25-0.5 mg/kg, maximum 20 mg)
Buccal midazolam (0.3 mg/kg, max 10mg)
Caution: potential for paradoxical reaction, unpleasant taste
Alpha-2 Agonists (Dexmedetomidine, clonidine)
Intranasal / buccal dexmedetomidine (1-4 mcg/kg, maximum 200 mcg)
Oral clonidine (4 mcg/kg, maximum 200mcg)
Caution: caution in patients with Grade 2/3 heart block, hypertension, cardiovascular disease, instability, on digoxin
Ketamine
Oral (3-8 mg/kg + midazolam)
IM (4-5 mg/kg)
IV (1-2 mg/kg)
Caution: ↑ salivation, hallucinations and emergence delirium, PONV
Opioids
Morphine (0.2 mg/kg, max 10mg)
Caution: risk of respiratory depression
Pediatric Patient
Considerations
Pediatric Patient
Considerations
Uncooperative patient
Altered airway anatomy
↑ risk of laryngospasm
Rapid desaturation on induction
↑ vagal tone & potential for bradycardia
Rate-dependent cardiac output
Altered phamacokinetics/dynamics:
↑ MAC
Immature liver & kidney function
↑ total body water
Pierre Robin Syndrome
Considerations
Airway Management
Pierre Robin Syndrome
Considerations
Pediatric patient considerations
Difficult airway due to micrognathia, mandibular hypoplasia, glossoptosis:
Improves with age
Difficult bag mask ventilation & intubation
Obstructive sleep apnea:
Pulmonary hypertension, cor pulmonale
Negative pressure pulmonary edema
May need to be nursed prone
GERD, aspiration pneumonias
Airway Management
If intubation required:
May be impossible: maintain spontaneous ventilation
Inhalational induction vs. titrated TIVA induction followed by asleep fibreoptic intubation
Strongly consider having an ENT surgeon equipped with a rigid bronchoscope on standby
Airway obstruction:
Oral & nasal airways, pull tongue forward, consider suturing to lip, prone position
LMA placement followed by fibreoptic intubation through the LMA
Nasal fiberoptic bronchoscopy
Lightwand
If intubation not required (e.g. myringotomy & tubes):
IV/IH induction followed by LMA placement
Attempt to maintain SV
If airway obstruction occurs, paraglossal laryngoscopy may relieve obstruction & allow oxygenation to resume
Maintain with TIVA
Premature Infant
Considerations
Goals
Premature Infant
Considerations
Altered airway anatomy
Other physiologic derangements of prematurity:
Pulmonary: respiratory distress syndrome, bronchopulmonary dysplasia, rapid desaturaiton, post-op apnea, persistent pulmonary hypertension
Cardiovascular: HR/preload dependant cardiac output, transitional circulation/PDA, bradycadia, congenital heart disease
CNS: intraventricular hemorrhage, seizures, retinopathy of prematurity, apnea
GI: GERD, NEC
Metabolic: Impaired temperature & glucose regulation
Hematology: anemia, thrombocytopenia
Altered pharmacology:
↑ volume of distribution
Opioid sensitivity
↓ clearance, protein binding, metabolism, ↓ MAC
Immature renal & hepatic function
Difficult IV access
Post op apnea monitoring
Goals
Ensure optimization of multisystem derangements including respiratory, cardiovascular, hepatic, renal, hematological
Anticipate fluid, electrolyte, glucose derangements, & optimize preoperatively
Ensure continuous temperature monitoring & maintain normothermia
Pyloric Stenosis
Considerations
Goals
Conflicts
Optimization & management
Pyloric Stenosis
Considerations
Medical but not surgical emergency
Infant considerations
High aspiration risk
Resuscitation of metabolic derangements:
Hypovolemia
Metabolic alkalosis
Hypochloremia
Hyponatremia
Hypokalemia
Post-op dispostion & apnea monitoring
Goals
Correction of volume deficit & acid/base & electrolyte abnormalities prior to pylormyotomy
Prevent aspiration (OG/NG, RSI)
Appropriate post-operative apnea monitoring
Conflicts
Resuscitation vs. surgical timing
RSI vs. hypovolemia
Optimization & management
Restore intravascular volume:
NS 10-20ml/kg IV boluses
Maintenance D5/NS + KCl 20-40 mEq/L
Clinical signs to assess (HR, BP, fontanelles, mucous membranes, skin turgor, urine output, capillary refill)
Correct electrolyte & acid/base disturbances:
Na > 130 mEq/L
K > 3 mmol/L
Cl > 90 mEq/L
HCO3 < 27 mmol/L
Urine output > 1cc/kg/hr
Vital signs normal for age (HR ~150, SBP >/= 60 mmHg)
Empty stomach: OG/NG in supine, lateral x2
RSI or awake intubation, suggested RSI method with cricoid applied:
NG suction in supine/R+L lateral
Atropine 20mcg/kg
Propofol 3mg/kg & succinylcholine 2mg/kg
Post-op analgesia
Avoid narcotics post-op
Preop PR acetaminophen 40 mg/kg
Local anesthetic infilitration (BPV 0.25% 1cc/kg)
Post-op apnea monitoring
Scoliosis
Considerations
Goals/Conflicts
Scoliosis
Considerations
Etiology: idiopathic vs. non-idiopathic:
Associated comorbidities (Marfan’s, NF Scheurmann’s disease, DMD, congenital)
Potential difficult airway secondary to back curvature, neck involvement
Restrictive lung disease:
pHTN with cor pulmonale; postop respiratory failure; prolonged ventilation
Cardiac involvement with idiopathic (MVP), Duchenne muscular dystrophy (CM, coarctation, CHD)
Surgical consideration: worse for kyphoscoliosis
Blood loss; hypothermia; airway edema;
Positioning:
Prone: VAE, positioning injuries, POVL
Lateral: OLV if thoracic approach
Monitoring: wake-up test/SSEP/MEP’s
Post-op pain control: clonidine, gabapentin, ketamine, opioids
Goals/Conflicts
Avoid exacerbations of pHTN (hypoxemia, hypercarbia, acidosis, hypothermia, light anesthesia & pain)
Balance perfusion pressure to spinal cord vs. need for mild hypotension to minimize blood loss:
TXA, cell saver
Manage anesthetic agents to allow adequate monitoring of spinal cord integrity (SSEPs/MEPs)
Vigilance for life threatening complications of VAE or major vascular injury
Optimize for postoperative wean from ventilation:
Dexmedetomidine, ketamine, acetaminophen, morphine infusions
Strabismus Surgery
Background
Considerations
Strabismus Surgery
Background
Affects 3-5% of the population, most patients are ASA 1 & 2
occasional association with syndrome (e.g. Trisomy 21)
Age ranges anywhere from neonate to teenagers (and older if
Surgery requires tightening, lengthening, transposing or shortening the extra-ocular muscles
Considerations
Potential for perioperative anxiety as patients may require multiple procedures
Limited access to head
Avoid succinycholine/ketamine (potential for increased IOP)
Avoid coughing on emergence
Potential for oculocardiac reflex and resultant bradycardia
Risk for sinus arrest
Consider sub-Tenon’s block at the start of surgery to prevent the reflex
Management:
notify surgeon to release traction/pressure on globe
10 mcg/kg glycopyrrolate IV bolus
High risk for PONV
Especially in patients older than 3
Consider:
dual-therapy prophylaxis: ondansetron and dexamethasone
TIVA
Relatively painful procedure:
Patients will need long-acting opioids (hydromorphone/morphine) post-op
Surgeon should perform sub-Tenon’s block at the end of surgery
Multi-modal analgesia with Tylenol and NSAIDs
Potential comorbid conditions:
Craniosynostosis (Apert/Pfeiffer/Crouzon syndromes)
Craniofacial abnormalities (Treacher Collins/Goldenhar syndromes)
Trisomy 21
Edward’s syndrome
Ocular myopathies rarely associated with malignant hyperthermia
Avoid succinycholine
Employ temperature monitoring
Tetralogy of Fallot
Background
Considerations
Anaestehtic Goals/Conflicts
Induction Options for Patient with Unrepaired TOF Undergoing Non-cardiac Surgery
Repaired Tetralogy of Fallot
Tetralogy of Fallot
Background
Congenital heart defect resulting in right to left shunt, characterized by:
Large VSD
Aorta that overrides RV & LV
RVOT obstruction
Right ventricular hypertrophy
Considerations
Complex congenital heart disease with high risk of perioperative cardiac complications
Both fixed & dynamic RVOT obstruction:
Fixed RVOT obstruction: variable R → L shunt & pulmonary blood flow
Dynamic RVOT obstruction (infundibular spasm): ↑ R to L shunting & hypoxia
Associated conditions:
Paradoxical embolus – avoid air bubbles in lines
Thrombophilia 2’ to polycythemia
25% have another congenital abnormality
Tracheoesophageal fistula & trisomy 21
SBE prophylaxis
No AIR in IVs!
Anesthetic Goals/Conflicts
Hemodynamic goals:
Full preload: stiff RV, stent open RVOT
↓ contractility to reduce dynamic RVOT obstruction
Maintain afterload to minimize R → L shunt & promote pulmonary blood flow
Avoid ↑ PVR (hypoxia, acidosis, aggressive PPV/PEEP)
“Tet spell”: sudden hypoxia/acidosis due to infundibular spasm or ↓ systemic vascular resistance (SVR): causes ↑ R → L shunt:
100% O2 +/- gentle PPV
Fluid bolus
Sedation (↓ sympathetic drive): morphine 0.1mg/kg
Knee chest position (↑ SVR & preload)
Phenylephrine 5 mcg/kg, propanolol 0.1-0.3mg/kg (to ↓ infundibular spasm)
Induction Options for Patient with Unrepaired TOF Undergoing Non-cardiac Surgery
Goals are to prevent significant R → L shunt:
Avoid ↑ PVR
Avoid ↓ SVR
Avoid myocardial depression
Keep full preload
Options include:
Sevoflurane induction then place IV then paralyze then ETT
If IV → ketamine IV (2mg/kg), then paralyze, then ETT
Avoid propofol/remifentanil in these kids to prevent reduced SVR/contractility
Repaired Tetralogy of Fallot: Most kids get definitive repair in 1st year of life
The repair:
Patch closure of the ventricular septal defect (VSD), thereby separating the pulmonary & systemic circulation
Enlargement of the RVOT, relieving obstructed pulmonary flow
RVOT enlargement is accomplished by relieving pulmonary stenosis, resecting infundibular & subinfundibular muscle bundles, &, if necessary, by a transannular patch, creating unobstructed flow from the right ventricle (RV) into the pulmonary arteries
Chronic problems after repair that may arise:
Chronic pulmonary regurgitation
Pulmonic stenosis
RV enlargement & dysfunction
Aortic root & valve dilation
Arrhythmias
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)
Tonsillectomy
Considerations
Post-Tonsillectomy Bleed
Criteria for Admission Post-op
Tonsillectomy
Considerations
Indication for surgery: obstructive sleep apnea (OSA), recurrent infections
Potential OSA: difficult bag mask ventilation, pulmonary hypertension/RVF, respiratory depressant sensitivity, post-op monitoring
Shared airway, oral rae ETT
Need for smooth emergence (dexmedetomidine)
Post-op complications: bleeding, negative pressure pulmonary edema, airway obstruction, apnea, PONV, pain
Postoperative disposition (day surgery vs. admission vs. PICU)
Post-Tonsillectomy Bleed
Considerations:
Emergency with limited time to optimize
Full stomach: RSI is essential, ensure gastric decompression at the end
Potential for hypovolemia, ensure aggressive resuscitation
Potentially difficult airway due to blood
Call for help
Have 2 suctions ready
Styletted ETT
Conflicts:
Full stomach vs. hemodynamic instability
Full stomach vs. difficult airway
Volume resuscitate vs. emergency surgery for potential airway obstruction
Criteria for Admission Post-op
Age < 3 years
Severe OSA
Coagulation disorder
Comorbid serious systemic disorders
Child with craniofacial abnormality (e.g. Down Syndrome, Treacher Collins, Goldenhar, Crouzon, Pierre Robin, CHARGE)
Situation not consistent with close observation (social issues, extended travel time)
Treacher Collins Syndrome
Background
Considerations
Treacher Collins Syndrome
Background
TCS is an autosomal dominant disorder of bilateral facial development
Abnormalities can result in airway narrowing & respiratory compromise. Affected patients may require prone positioning or surgery to maintain a patent airway.
Features:
Malar hypoplasia & a cleft in the zygoma
Eyes have an antimongloid slant with colobomas (eyelid notch) along the lateral 1/3 of the lower lid
Lashes are absent from the medial 2/3 of the lower eyelid
Face has a convex profile with a retrusive chin & jaw. Associated with an overbite
External ear abnormalities are common
Considerations
Pediatric patient considerations
Potentially very difficult airway
Airway is difficult due to high arched palate & mandibular hypoplasia
Airway becomes more difficult as patient gets older
Airway plan essential with multiple adjuncts, have ENT/surgical option on stand-by, plan on spontaneously breathing sleep technique (titrated TIVA vs IH)
LMA & video laryngoscope use have been successfully described in these patients
OSA considerations. OSA is a common comorbidity
Association with congenital heart disease (uncommon)
Deafness common
Upper Respiratory Tract Infection
Background
Considerations
Management
Upper Respiratory Tract Infection
Background
Upper respiratory tract infection (URTI) definition is two or more of the following symptoms: rhinorrhoea, sore or scratchy throat, sneezing, nasal congestion, malaise, cough, or fever > 38°C
children under the age of 4 have on average up to 8 URTI per year
Between 25%-45% of children presenting for elective surgery will have a history of a recent URTI
URTI is the most common cause of surgery cancellation in children
Considerations
↑ Risk of perioperative respiratory adverse events (e.g. laryngospasm, bronchospasm, desaturations, breath holding) up to 2 weeks after a URTI
Risk factors that ↑ this risk further: age <2, prematurity, passive smoking, respiratory comorbidities, airway surgery, and use of ETT
Risk and benefit analysis of proceeding with surgery by considering the severity of the URTI and the urgency of the surgery
Management
Determine whether or not to proceed with surgery
Mild URTI (clear runny nose, dry cough):
Proceed with surgery but practice good perioperative pulmonary care
Moderate URTI (green runny nose, mild moist cough):
Need to consider risk/benefit ratio for the patient
Factors in favour of proceeding: team experience, institutional setting, previous cancellations and logistics, non-invasive airway management, extended monitoring possible
Factors in favour to cancel: parental concerns, age <1 year and prematurity, respiratory comorbidity, certain viral illnesses such as RSV, airway surgery, ETT required
Severe URTI (green runny nose, severe moist cough, wheezing, fever, lethargy): post-pone and re-evaluate in 2 weeks
Good preoperative pulmonary care:
Experienced paediatric anesthesia team
Less invasive airway device (e.g. LMA) preferred
Consider pre-treatment with inhaled salbutamol
IV induction is preferred
Avoid desflurane
TIVA or propofol bolus prior to airway removal
IV lidocaine may be helpful to reduce the laryngospam reflex
VACTERL
Background
Considerations
VACTERL
Background
Acronym stands for:
V: vertebral defects (e.g. hemivertebrae, fused or butterfly vertebrae, or extra vertebrae)
A: anal or other intestinal atresia
C: cardiac defects (VSD & tetralogy of Fallot are the most common)
TE: tracheoesophageal fistula (TEF)
R: renal malformations (e.g. horsheshoe kidney, renal agenesis, vesicoureteral reflux, hypospadias, dysplastic kidney, & cryptorchidism
L: limb defects
Not all features are always present, but TEF is accepted as essential for the diagnosis, along with at least one other major defect in one of the five other categories
Most patients are developmentally normal
Considerations
Pediatric patient considerations
Risk of regurgitation & considerations of TEF
Risk of cardiac malformations, especially VSD & TOF
Renal & limb defects
