Pediatric Anesthesia Flashcards
Otorhinolaryngology
Head & neck
OHN/ENT
Tonsillectomy & Adenoidectomy
T&A
Chronic lymphoid tissue inflammation & hypertrophy in the pharynx
Surgical intervention to relieve the obstruction & remove the infection focus
3rd most common surgical procedure
Common Tonsillitis Causes
Streptococcus Viral agents (adenovirus, influenza, Ebstein-Barr, parainfluenza, enteroviruses)
Tonsillitis S/S
Inflammation & swelling → respiratory obstruction
What’s currently the most common indication for T&As in America?
OSA 80% → chronic airway obstruction, CO2 retention, cor pulmonale, FTT, & speech abnormalities
Infection 20%
Considerations to admit T&A postop:
< 3yo Abnormal bleeding tendencies Significant OSA Airway abnormalities Other systemic diseases Excessive distance from hospital
Tonsillectomy Recommendations
Dexamethasone 0.5mg/kg IV NO periop Abx Adequate pain management - Avoid Codeine - Ketorolac?
T&A Intraop Considerations
Standard induction
- Oral RAE cuffed ETT (consider reinforced)
- LMA
- Secure midline
Rotate HOB 45-90°
Mouth gag (requires stimulating jaw thrust)
- Adequate anesthesia
- Re-evaluate airway to ensure correct placement
- Throat pack in/out
Muscle relaxants okay
Relatively quick operation
T&A Analgesic Management + Dosages
Fentanyl 1-2mcg/kg Tylenol 10-15mg/kg IV Dexamethasone 0.5-1mg/kg Ondansetron 0.1mg/kg Dexmedetomidine 0.1-0.5mcg/kg Ketorolac or Ibuprofen
Tonsillectomy Methods
Cold Steel
Stainless steel scissors & scalpels
Toothed forceps & herd’s dissector/retractor used to dissect the tonsil tissue from its capsule
↑pain & hemorrhage risk
Tonsillectomy Methods
Electro-Dissection
Mono-polar or bipolar whole tonsil dissection
Cautery up to 300-400°C to induce hemostasis
Lateral thermal damage ↑postop pain & discomfort
Kinetic energy heats the intracellular & extracellular fluids & ruptures localized tissue cells
Tonsillectomy Methods
Microdebrider
Soft tissue shaver
90-95% tonsillar tissue removed (risk to return)
Natural biological dressing left in place over the pharyngeal muscles, preventing injury, inflammation, & infection
↓blood loss & pain
Tonsillectomy Methods
Coblation
Cold ablation
Energy used in plasma field to break the molecular bonds to excise or dissolve soft tissue at 40-70°C
Maintains surrounding tissue integrity
Provides dissection, cautery, suction, & hemostasis
Quick, precise, & smooth procedure
Tonsillectomy Methods
Radio Frequency
Cost-effective, easy to use, & time-saving alternative to laser
Mono polar radio frequency transferred via inserting probe into the tonsil tissue in 3-4 settings
Produces tonsil tissue scarring → reduces size
Tonsillectomy Methods
Laser
CO2 & KTP lasers
↓bleeding, pain, & discomfort
↑postop pain & 2° hemorrhage (bleeding after the scab formed or > 24hrs postop)
T&A Emergence
Laryngospasm, aspiration, & airway reactivity risk
OG to empty the stomach
Awake (able to protect airway) vs. deep extubation
Soft suction & prevent coughing
Recovery position - lateral w/ head down (allows blood to brain away from vocal cords)
What S/S present in children w/ restless?
Airway compromise or hypoxia
Careful opioid administration
Post-Tonsillectomy Bleeding
S/S include abdominal pain (especially w/ PONV prophylaxis)
1° hemorrhage w/in 24hrs
2° hemorrhage > 24hrs (5-10 days)
Ensure adequate IV access x2
Vigorous resuscitation to treat hypovolemia
Hemodynamic instability on induction
Labs: Hgb/Hct, type & cross, coags
RSI Propofol or Ketamine + Succinylcholine 2mg/kg IV
OG to empty stomach (blood)
Bilateral Myringotomy & Tympanostomy
BMT
Chronic otitis media common in young children → hearing loss & cholesteatoma formation
Myringotomy - creates an opening in the tympanic membrane to allow fluid to drain
Tympanostomy - ventilation tube placement w/ lumen to alleviate pressure from the middle ear & serves as stent to allow continual drainage until the tube are naturally extruded in 6mos-1yr
BMT Anesthetic Considerations
Often patients present w/ URI (reason they’re getting the surgery)
Short operation
Consider rectal Tylenol > PO Midazolam (outlasts the procedure)
Mask-only case
Place IV only when another procedure being done
Discontinue Sevo when turn to 2nd side
Myelodysplasia
Most common CNS defect that occurs during the 1st month gestation
Spina bifida - failure the neural tube to close resulting in the spinal cord & meninges herniating through a defect
Meningocele - contains ONLY meninges
Myelomeningocele - contains meninges & neural elements
Hydrocephalus often present & paralysis below the lesion
URGENT repair required w/in 24-48hrs d/t infection risk or worsening cord function
Myelodysplasia Risk Factors
Folate deficiency
Chromosomal abnormalities
Where does myelodysplasia most commonly occur (the region)?
Lumbosacral region
Myelodysplasia Repair
Anesthetic Considerations
Preop - Assess lesion level & deficit - Systems review & r/o additional congenital anomalies - Labs: CBC & type + screen Intraop - Routine monitors - Avoid muscle relaxation when MEPs - Supine or lateral for induction - Prone to perform surgery - Inhalational or IV induction - Blood loss dependent on defect size - Prone to hypothermia - Latex free OR Postop - Goal to extubate - Apnea monitoring
Hydrocephalus
Excess CSF builds-up w/in the fluid-containing ventricles
Hydro meaning water & cephalus meaning head
Hydrocephalus Causes
Congenital defect (Arnold-Chiari aqueduct stenosis) Acquired disease - trauma, infection, or tumor
Ventriculoscopy
Fiberoptic scope inserted via cranial burr holes to visualize lateral, 3rd, & occasional 4th ventricle
Shunts also able to be positioned under U/S guidance
Ventriculo-Peritoneal Shunt
VP shunt
Lateral ventricle → peritoneum
*Most common
Allows room for growth
Ventriculo-Atrial Shunt
VA shunt
Lateral ventricle → R atrium
Endoscopic 3rd Ventriculostomy
ETV
Burr hole created in the 3rd ventricle floor allowing CSF to flow directly into the basal cisterns
CSF Shunt Creation
Anesthetic Considerations
Preop - Assess baseline neuro status & ICP - Avoid premeds when ↑ICP - Assess vomiting history & dehydration - Review previous anesthesia records (repeat shunt revisions) - PIV x1-2 Induction - Standard monitoring - Fentanyl, Propofol, & Rocuronium - Isoflurane or Sevoflurane - GETA - Protect & pad the eyes - Cefazolin 30mg/kg IV
VP Shunt
Anesthetic Considerations
Maintenance - Avoid hyperventilation - Maintain paralysis or bolus Propofol when tunneling - VA shunts caution air embolism or PPV when vein open Emergence - Reverse paralytic - Antiemetics - Extubate - Neuro assessment
Humerus Fracture
Types
Proximal - break in upper part near shoulder
Mid-shaft - break in the middle
Distal - break occurs near the elbow (usually more complex elbow injury involving loose bone fragments)
Supracondyle Humerus Fractures
Most common elbow fracture in children
Result from falling w/ an outstretched hand & extended elbow
Complications include compartment syndrome, nerve palsies, & late deformities
Humerus Fracture
Anesthetic Considerations
Supine w/ HOB rotated 90° GETA Assess NPO status & RSI indications Pinning 30-60min Open reduction 30-90min Emergence timing based on cast or splint placed after closing
Scoliosis
Sideway spine curvature
Idiopathic - no definite cause, most common form (> 70%), 1° affects adolescent girls
Neuromuscular - caused by conditions w/ muscle weakness (CP, MD, SCI) or spasticity & associated w/ ↑blood loss
Scoliosis
Cobb Angle
Degree lateral curvature → impairs respiratory function
> 45°
Restrictive lung disease
↓TLC & VC
Posterior Spine Fusion
Instrumentation
Prevent curve progression & correct curvature
Metal implants attached to the spine then connected to 1-2 rods
Anterior (one-lung ventilation) vs. posterior approach
Prone positioning
6 hours
Significant blood loss risk - hypotensive technique, maintain BP w/in 20% baseline, admin TXA, cell save, autologous blood & hemodilution
Posterior Spine Fusion
Preop
Labs: CBC, coags, BMP, HCG
Type & cross
PRBCs 2 units available & cell saver
Posterior Spine Fusion
Intraop
Prone position w/ superman arms Bair hugger Nerve monitoring Bilateral soft bite blocks A-line & PIV x2 Cell saver, fluid warmer, & blood tubing Standard induction BIS & cerebral oxygen OG tube Multiple fluids & syringe channels
Posterior Spine Fusion
Evoked Potential Monitoring
Avoid volatile inhalational agents & N2O Dexmedetomidine & opioids are compatible Ketamine enhances amplitude Propofol ↑latency ↓EPs amplitude Continue monitoring 15-20min after surgical closure started
Posterior Spine Fusion
Postop
Dependent facial edema Plan to extubate when possible CXR when patient supine on inpatient bed Admit 3-6 days step-down or ICU Neuromuscular scoliosis patients potentially more sensitive & require postop ventilation 2° muscle weakness
Posterior Spine Fusion
Complications
Spinal cord ischemia Massive blood loss Embolism Accidental extubation Corneal abrasion Visual loss Neurological sequel w/ SSEP or MEPs loss
Hypertrophic Pyloric Stenosis
Pylorus thickening or swelling (muscle b/w the stomach & intestines) that causes severe & forceful vomiting in the first few months life
Pylorus enlargement → narrowing (stenosis) of the opening from the stomach to the intestines ჻ blocks stomach contents from moving into the intestine
Hypertrophic Pyloric Stenosis
Clinical Presentation
Palpable obstruction lesion (olive-shaped)
Usually diagnosed b/w 2-12 weeks old
Post-prandial projectile emesis, palpable pylorus, visible peristaltic waves
Surgical correction = pyloromyotomy
Semi-elective surgery (urgent, but requires medical management 1st to correct dehydration & electrolyte imbalance)
Pyloric Stenosis
Persistent vomiting depletes Na+, K+, Cl¯, & H+ ions causing hyperchloremic metabolic alkalosis
- Kidneys attempt to compensate via sodium bicarbonate excretion
- Hyponatremia/dehydration worsen & kidneys attempt to conserve Na+
Avoid LR (lactate metabolized to bicarbonate)
Pyloric Stenosis
Anesthetic Considerations
IV to replace intravascular volume
Suction stomach w/ OG prior to induction
Twist/roll/tilt to remove all stomach contents
RSI w/ cricoid pressure
HIGH aspiration risk
Pre-oxygenate → Propofol & Succinylcholine or Rocuronium
Cuffed ETT
Quick procedure
Extubate awake - limit Fentanyl & Dexmedetomidine
Nissen Fundoplication
General abdominal procedure for children w/ gastric reflux that fail medical management
Laparoscopic minimally invasive procedure to restore LES (valve b/w the esophagus & stomach) function
Surgeon wraps the stomach around the esophagus
Nissen Fundoplication
Anesthetic Considerations
GETA
Laparoscopic - insufflation, VAE, vagal response
Minimal blood loss, fluid shifts, & pain
Esophageal bougie to ensure no leaks after anastomosis
Circumcision
Foreskin removal
Most common procedure
Foreskin opened, adhesion removed, & foreskin separated from the glans
Cut foreskin then cauterize & suture the skin edges
Circumcision
Anesthetic Considerations
Indications include phimosis, recurrent balanitis, or parental preference
Local, regional, or GA (adults)
≈ 1 hour
Most common complication = bleeding
Hypospadius
Malposition of the urethra meatus
Urethral opening not located at the penis tip
Underneath the penis tip more common than near the penis base
Hypospadius
Anesthetic Considerations
1-4+ hours
General LMA or ETT
Regional controversial
Cleft Lip & Palate
Repaired in stages - Lip 10-12 weeks - Palate 12-18mos - Alveolar bone graft - Pharyngoplasty 5-15yrs Difficulty feeding → malnutrition Impaired speech development Congenital heart defects
Cleft Lip & Palate
Anesthetic Considerations
Standard induction
Potential difficult airway
Oral RAE w/ flexible connector
Mouth gag - reassess breath sounds once positioned
No air bubbles
Local anesthetic + Epi to reduce blood loss & provide analgesia
Protect eyes
Airway & tongue edema
Awake extubation once protective airway reflexes intact
