Pediatric Anesthesia Quiz #6 Flashcards
What type of procedure is a Myringotomy and Ventilating tube insertion, and what type of anesthetic does it require?
-Myringotomy is the surgical drainage of accumulated fluid in the middle ear. -Ventilating tubes are often placed in the tympanic membrane as stents which allows for continued drainage of the middle ear.
-very brief procedure, requiring GETA with SEVO inhalation induction, mask ventilation with or without oral airway and usually no iv catheter placement -Intranasal Fentanyl 1‐2 mcg/kg -IM Ketorolac 0.5‐1 mg/kg
What condition would require a Adenotonsillectomy?
Chronic or recurrent tonsillitis and obstructive adenotonsillar hyperplasia are the major indications for surgical removal of tonsils and adenoids.
What could be some side effects to having tonsillar hyperplasia?
Tonsillar hyperplasia may lead to chronic airway obstruction, resulting in sleep apnea, carbon dioxide retention, cor pulmonale, failure to thrive,
swallowing disorders, and speech abnormalities.
Children with cardiac valvular disease may be at risk for endocarditis d/t recurrent streptococcal bacteremia
secondary to infected tonsils.
Describe a Adenotonsillectomy.
Surgical techniques for adenotonsillectomy vary and include guillotine and snare technique, cold and hot knife dissection, suction, ultrasound coblation, and unipolar
and bipolar electrocautery techniques.
What are the advantages and risk of using electrocautery intraop.
A major advantage of electrocautery dissection is a reduction in the incidence of intraoperative blood loss as well as post‐op primary and secondary hemorrhage.
A major disadvantage is greater pain and poor oral intake post‐operatively.
Keep FiO2 low – risk of airway fire!!!
What is the mortality rate and the morbidities associated with Adenotonsillectomy?
Mortality associated with adenotonsillectomy is estimated to be 1: 16,000 to 1: 35,000 procedures – wow!
Common morbidities include throat pain, otalgia, poor oral intake, dehydration, obstructive breathing (3y and younger) and post‐op bleeding (> 10y).
Children who are scheduled for T&A have a high incidence of ___ ___ and ___.
- airway reactivity
- laryngospasm
What is the standardized system for evaluation of tonsillar size?
0-sugically removed tonsils 1-tonsils hidden within tonsil pillars 2-tonsils extending to the pillars 3-tonsils are beyond the pillars 4-tonsils extend to midline
Pts classified as +3 or greater, having more than 50% of
the pharyngeal area occupied by hypertrophied tonsils, are at increased risk of developing airway obstruction during anesthetic induction.
Adenotonsillectomy for a child with OSA: What do patients with OSA experience?
-Patients with OSA experience apnea, hypopnea and
flow limitations:
-Apnea –cessation of airflow lasting ≥ 10 seconds
-Hypopnea – a decrease in airflow lasting ≥ 10 seconds
with a 30% O2 reduction in airflow and with at least a
4% O2 desaturation from baseline.
-Flow limitation – narrowing of the upper airway and an
indication of an impeding upper airway closure
OSA is the most common form of sleep‐disordered
breathing (SDB)
A partial or complete collapse of the upper airway
that causes muscles controlling the soft palate and tongue to relax
What is the Apnea Hypopnea Index(AHI) and describe the grading system associated with it.
-The AHI (Apnea Hypopnea Index) is the
summation of the number of obstructive apnea
and hypopnea events
-Apnea‐Hypopnea Index (AHI) is the standard measure of OSA during a sleep‐study.
-Measured as total events per hour of sleep
Check out the differences between AHI of
Adults and Pediatrics!!!
Severity of OSA: Adult AHI Pediatric AHI None 0‐5 0 Mild OSA 6‐20 1‐5 Moderate OSA 21‐40 6‐10 Severe OSA >40 >10
Describe the anesthetic plan for a Adenotonsillectomy in the pediatric patient with OSA.
If OSA‐pt is getting a pre‐med -> observe closely
and monitor with pulse oximetry.
Titrate analgesia (fentanyl ) carefully to the RR –
have pt spontaneously breathing throughout the
procedure!
Remember: Children with severe OSA may
produce an exaggerated resp. depression to
smaller doses of opioids than children without
OSA.
Pts with OSA experience recurrent episodes of
hypoxia and hypercapnia during sleep, which
impairs the arousal mechanism at emergence
from anesthesia.
Describe the extubation and discharge of a pediatric Adenotonsillectomy that has OSA.
Fully awake extubation after T&A of OSA pt!!!
Suction stomach and pharynx, have nasal airway
in place, titrate carefully more analgesia after
extubation.
To prevent PONV, suction stomach, hydrate well,
give IV “airway”‐dose of Dexamethasone 0.5
mg/kg (max. 10 mg) and 0.1 mg/kg of IV
ondansetron (max. 4 mg).
Discharge policy for ambulatory T&A: OSA pts will
stay over night with pulse oximetry/ apnea
monitor
Otherwise healthy, non‐OSA pt will probably stay
6‐8 hrs for observation.
What are the characteristics of a Post-Tonsillecetomy Bleed?
POST‐TONSILLECTOMY BLEEDING IS A SURGICAL
EMERGENCY.
This can be primary (within first 24 hrs after
T&A) or
secondary (5‐10 days after T&A, when the
eschar covering the tonsillar bed retracts).
Primary bleed is more serious, more brisk &
profuse.
Consider the circumstances: you might deal with
anxious parents, an upset surgeon, and a
frightened anemic, hypovolemic child with a
stomach full of blood and potentially no IV
catheter.
What should be the anesthetic plan for a Post-Tonsillectomy Bleed?
Assess the child for dizziness, orthostatic
hypotension and estimated amount of hematemesis.
Place iv catheter, draw lab samples and Type &
Cross and rehydrate pt well before entering the
OR.
Vigorous fluid resuscitation with crystalloids
(repeated boluses of 20ml/kg of balanced salt
solution) and/or colloids to improve CO and
hemodynamic stability before RSI.
RSI with Succinylcholine or Rocuronium, cricoid
pressure, suction catheter and styletted cuffed
ETT, …
After airway is secured, place OGT and suction
stomach – consider large blood clots are often
too large to be suctioned.
Surgeon will find and repair the bleeding vessel
which is generally not very painful.
GIVE IV “AIRWAY”‐DOSE OF DEXAMETHASONE 0.5
MG/KG (MAX. 10 MG) AND 0.1 MG/KG OF IV
ONDANSETRON (MAX. 4 MG).
Awake extubation and close observation
Children with long-standing obstructive sleep apnea(caused by hypertrophied tonsils, for example) show what anatomic changes in the heart?
-In children with long-standing hypoxemia and hypercarbia, pulmonary artery hypertension and RV hypertrophy develop.
What is the average amount of blood lost(in ml/kg) during an tonsillectomy?
- During tonsillectomy, blood loss averages 4 ml/kg and must be carefully monitored.
- In terms of percentage, Gregory states that 5-10% blood volume may be lost during a tonsillectomy
What are the three complications of tonsil and adenoid surgery?
- bleeding
- laryngospasm
- emesis
Should extubation be performed while the patient is awake or asleep after a tonsillectomy? Why?
An awake extubation is preferred by most anesthetist because risk of aspiration is reduced.
What actions are taken if the tonsillectomy patient begins bleeding? What are the major consideration
- Initial attempts to control bleeding may be made using pharyngeal packs and cautery.
- If the patient needs to be taken to the OR, intravascular volume must first be restored, and the patient must be considered to have a full stomach because large quantities of blood can be swallowed.
What is the problem with an Inguinal hernia and when is it considered an emergency?
In an inguinal hernia, a loop of bowel protrudes beyond the internal ring, causing a bulge in the inguinal region or scrotum.
If no bowel ischemia is suspected, elective surgery can
be scheduled.
If strangled bowel is suspected, surgical emergency with full stomach is required.
Regional block (penile block or single shot caudal anesthesia)
What nerves are blocked for repair of an inguinal hernia?
The ilioinguinal and iliohypogastric nerves are blocked for inguinal hernia repair.
What pediatric syndromes are considered difficult airway/intubation?
Pierre Robin Sequence Treacher Collins Syndrome Goldenhar Syndrome Beckwith‐Wiedemann Syndrome Klippel‐Feil Syndrome Apert Syndrome, Pfeiffer Syndrome, Crouzon Syndrome
What are the characteristics of Pierre Robin Syndrome?
-DIFFICULT INTUBATION
-Cleft soft palate ( no cleft lip)—>difficulty with “breath‐suckswallow” pattern, choking and failure to thrive
Micrognathia / retrognathia —>difficult intubation
-Glossoptosis = the tongue being placed further back in the mouth —> partial/complete obstruction of airway and tracheostomy is often required
What is Pierre Robin Syndrome? What are the concerns and how should this patient be managed? What intubation technique should be used?
- Pierre Robin syndrome is a combination of a cleft palate, migrognathia(small lower jaw with receding chin), glossoptosis(downward retraction or displacement of the tongue).
- Respiratory obstruction may occur(the tongue may cause total airway obstruction) and can lead to cor pulmonate; maintain airway by placing prone on the frame; may require tongue suture, intubation, or tracheostomy.
What are the characteristics of Treacher-Collins Syndrome?
-DIFFICULT INTUBATION
-down‐slanting eyes
-notched lower eyelids
-underdevelopment or absence of cheekbones and
the side wall and floor of the eye socket
-lower jaw is often small and receding
-underdeveloped, malformed and/or prominent ears
-Most children with Treacher Collins have normal development and intelligence; however, it is important
that there be early hearing tests & speech interventions.
What types of operations may a patient with Treacher Collins require?
These TCS patients may require extensive bony and soft tissue reconstruction over multiple procedures, including orbital and zygomatic reconstruction before age
10, external ear reconstruction, and mandibular advancement as teenagers when bony growth is
complete.
Describe the suggested tracheal intubation technique for a patient with Treacher Collins syndrome?
- Treacher Collins syndrome is the most common of the mandibulofacial distress, a group of syndromes that feature mandibular hypoplasia.
- In addition, up to 30% of Treacher Collins patients have an associated cleft palate. An awake tracheal intubation(oral or nasal) with aid of a fiberoptic laryngoscope after adequate topical anesthesia is recommended.
- Miller advocates: (1) topicalization with 1% lidocaine, (2) LMA insertion, followed by (3) fiberoptic intubation through the LMA. Also consider fiberoptic tracheal intubation after inhalational induction.
Treacher Collins syndrome is associated with cleft palate, as you know, indicating a difficult airway. What congenital heart disease is associated with Treacher-Collins syndrome?
- Treacher Collins syndrome is frequently accompanied by congenital heart disease, most prominently VSD.
- Concept: ventricular septal defect(VSD) is the most commonly occurring congenital heart disease, therefore VSD is frequently associated with many other congenital anomalies.
In addition to cleft palate and VSD, what other conditions are associated with Treacher-Collins syndrome? Is a macroglossia(large tongue) associated with Treacher Collins syndrome?
- Treacher Collins syndrome is associated with cleft palate(30%), VSD, malaria hypoplasia, colhbomas(notching of the lower eyelids), macrostomia(large mouth), malocclusion, and a small oral cavity.
- Treacher Collins syndrome is not associated with macroglossia(large tongue) or mental retardation.
What are the characteristics and possible causes of Goldenhar Syndrome?
-DIFFICULT INTUBATION
• Unilateral or bilateral underdevelopment of the
mandible, microtia (small ears), reduction in size and
flattening of the maxilla (upper jaw)
• Causes of Goldenhar Syndrome: thought to be a vascular accident in the fetus. This accident causes the blood supply to be cut off and production of blood clots in the area of those tissues which will develop into the
structures of the ear and lower jaw.
Mandibular hypoplasia is associated with what three congenital diseases? Should these patients generally be intubated awake or asleep?
- Patients with Pierre Robin syndrome, Treacher Collins syndrome and Goldenhar syndrome have mandibular hypoplasia and may be difficult to intubate
- These patients are more often intubated after induction of anesthesia with volatile anesthetics.
- While awake intubation can sometimes be accomplished, awake intubation of these patients may produce severe trauma to the upper airway and does not eliminate the risk of pulmonary aspiration.
What are the characteristics of Beckwith-Wiedemann Syndrome?
-DIFFICULT INTUBATION
Macroglossia (relatively improves with growth; may require partial glossectomy) —>Difficult intubation
Chronic airway obstruction may predispose to cor pulmonale
Hypoglycemia from increased insulin secretion
Visceromegaly: Large heart, visceromegaly (nephromegaly, hepatomegaly, splenomegaly,
pancreatomegaly)
Omphalocele, increased incidence of intra‐abdominal tumors
What are the characteristics of Klippel-Feil Syndrome?
-DIFFICULT INTUBATION
Klippel‐Feil syndrome is a bone disorder characterized by the abnormal joining (fusion) of two or more cervical vertebrae, which is present from birth.
Three major features result from this abnormality:
- –>a short neck,
- –>a limited range of motion in the neck,
- –>a low hairline at the back of the head.
Most affected people have one or two of these characteristic features
What three syndromes are associated with Craniosynostois, and what are the major characteristics of these syndromes?
- Apert Syndrome
- Pfeiffer Syndrome
- Crouzon Syndrome
- Major characteristics of syndromic craniosynostosis include:
- –>Skull deformities (premature closing of the cranial sutures
- –>Eyes abnormally far apart
- –>Fusing or webbing of the digits and other abnormalities.
Long‐term, life limiting or life threatening consequences may result from these abnormalities.
What are the clinical characteristics of Pierre-Robin Sequence?
-Micrognathia, cleft palate, glossoptosis(posterior displacement of tongue)
What are the clinical characteristics of Treacher-Collins Syndrome?
-Hypoplasia of maxilla and mandible, variable eye and ear deformities
What are the clinical characteristics of Hemifacial microsomia(i.e. Goldenhar’s)?
-Unilateral/bilateral mandibular hypoplasia, variable microphthalmia, microtia, macrostomia(wide mouth)
What are the clinical characteristics of Beckwith-Wiedemann syndrome?
-Macroglossia, Visceromegaly/organomegaly, omphalocele, hypoglycemia
What are the clinical characteristics of Klippel-Feil syndrome?
-cervical vertebral fusion
What are the clinical characteristics of Apert Syndrome, Pfeiffer Syndrome and Crouzon Syndrome?
-Craniosynostosis
Difficult Pediatric Airway
It is important to recognize circumstances that may cause airway obstruction or difficult laryngoscopy.
Conditions that predispose to airway problems may be due to congenital or neoplastic disorders, inflammation
(___ ___), trauma (___, ___, ___ ___ ___) or metabolic disorders (___).
- rheumatoid arthritis
- fractures, subluxation, neck burn contracture
- mucopolysaccharidosis
What is Mucopolysaccharidosis?
-Mucopolysaccharidosis are a group of metabolic disorders caused by the absence or malfunctioning of lysosomal enzymes needed to break down molecules called glycosaminoglycans(long chains of sugar carbohydrates) in each of our cells that help build bone, cartilage, tendons, corneas, skin and connective
tissue.
Describe the laryngoscopical grading system of Cormack and Lehane:(grades I-IV)
Grade I = visualization of the complete laryngeal
opening
Grade II = visualization of just the posterior area
Grade III = visualization of just the epiglottis
Grade IV = visualization of just the soft palate
What is the preferred technique when dealing with an difficult airway?
-Preferred technique is when the patient is
either awake but sedated or spontanenously
breathing under GETA with adequate
oxygenation while the airway is evaluated.
-Combi of Benzos & Opioids (Versed &
Fentanyl) or Ketamine & Versed & Glyco or
-SEVO and spray VC with Lidocaine (max. 5mg/kg) – KEEP THE PATIENT SPONTANEOUSLY BREATHING!!!
In the event of an unexpected difficult intubation, what is the differences between infants and adults regarding hypoxia?
-Although it is a rare occasion, the practitioner
should be prepared for life‐threatening event.
-Because infants have an increased metabolic rate
and decreased FRC, the time between the loss of
the airway and resultant hypoxemia with
potential secondary neurologic injury is
significantly diminished compared to adults.
-DESATURATION OF 10 KG INFANTS FROM SPO2 90 ‐ 0% WITHIN 4 MINUTES VERSUS 10 MINUTES IN HEALTHY 70KG ADULT.
Describe the process of performing an emergency cricothyrotomy.
-Extend the head in the midline with a rolled towel or folded sheet beneath the shoulders; standing to the left of the child, stabilize trachea with the right
hand
-The cricothyroid membrane is located with the index fingertip of the left hand between the thyroid and cricoid cartilages{This space is so narrow (1 mm) in an infant that only a fingernail can discern it. The trachea is then stabilized between the middle finger and thumb of the left hand while the fingernail of the index finger marks the cricothyroid membrane.}
-A large intravenous catheter (12to 14 gauge) is then inserted through the cricothyroid membrane (C), and air is aspirated.
-The catheter is advanced into the trachea through the
membrane, and the needle is discarded; an intraluminal
position is reconfirmed by attaching a 3‐mL syringe
and aspirating for air.
-An adapter from a 3.0 ETT can be attached to any intravenous catheter. Ventilation is accomplished by attaching to a breathing circuit.
IF YOU DON’T HAVE A 3.0 ETT ADAPTER:
An alternative would be to leave the barrel of the 3‐
mL syringe attached to the intravenous catheter,
insert an 8.0 ETT adapter to the syringe barrel, and
then attach to the breathing circuit.
Describe the characteristics of Trisomy 21/Down Syndrome:
Small mouth, hypoplastic mandible, protruding tongue may be difficult intubation
Mental retardation
50% have cardiac issues: VSD, ASD, Tetrology of Fallot,…
Hypotonia (floppy‐ ”Downs’s dance!”)
Increased risk of bradycardia on induction
Atlanto‐occipital instability –avoid
hyperextension!
Increased risk of post‐intubation stridor
Increased risk of hypothyroidism, acute
leukemias, …
Describe the risk of Atlanta-Occipital Instability in the Down Syndrome patient:
Down syndrome patient needs MRI/CT evaluation of their cervical and temporomandibular anatomy
d/t the unique risk of atlantooccipital instability if neck pain or neurological symptoms exist (e.g.,
abnormal gait, incr. clumsiness, complaints of numbness/
tingling/weakness of an extremities, etc.)
Avoid excessive flexion, rotation, or neck extension during any manipulation of the neck or airway
during mask ventilation or intubation.
HAVE THE RADIOLOGIST/SURGEON HYPEREXTEND HEAD IF IT REQUIRES IT AND DOCUMENT THAT IS WAS PERFORMED BY THE MD.
What is a simian crease?
A simian crease is a single palmar crease as compared to two creases in a normal palm. Simian crease occurs in
about 1 out of 30 normal people, but is also frequently
associated with other conditions such as Down Syndrome, Aarskog syndrome or fetal alcohol syndrome.
What are three major concerns related to anesthetizing the Down’s(trisomy 21) patient?
- Intubation may be difficult owing to the large tongue, short neck, small mouth, and subglottic stenosis(select ETT one size smaller than anticipated)
- Neck flexion during laryngoscopy and intubation may result in atlanto-occipital(cervical spine) dislocation because of congenitally weak ligaments(consider getting cervical-spine films);
- Congenital heart disease is present in 40% of patients(anesthesia compatible with the patient’s congenital heart defects should be delivered).
What are four pathophysiological features associated with Down syndrome, inanition to difficult airway, atlanto-occipital instability and congenital heart defect?
- Pathophysiological features of Down syndrome also include:
- –>Irregular dentition
- –>Mental retardation
- –>Hypotonia
- –>Tracheoesophageal fistula
- –>Chronic pulmonary infections
- –>Seizures
What may be the most important considerations for anesthetizing the Down’s patient?
- Intubation of the trachea is generally not too difficult to accomplish.
- Hence, the most important consideration may be the atlanto-occipital(cervical spine) instability.
What are the 6 anomalies associated with VACTERL(VATER) Syndrome?
V = vertebral anomalies A = anal or intestinal atresia C = cardiac anomalies T E = tracheo‐esophageal fistula R = renal malformations L = limb defects
Babies who have been diagnosed as having VACTERL association usually have at least three or more of these individual anomalies.
The TE fistula is often accepted as essential for the diagnosis.
What are the characteristics of Vertebral anomalies associated with VACTERL Syndrome?
Vertebral anomalies, or defects of the spinal
column, usually consist of small (hypoplastic)
vertebrae or hemivertebra where only one half
of the bone is formed. Risk of scoliosis.
What are the characteristics of Congenital heart disease associated with VACTERL Syndrome?
Congenital heart disease (up to 75 percent)‐
most common heart defects seen with VACTERL
association are VSD, ASD and Tetrology of Fallot
What are the characteristics of Renal/kidney defects associated with VACTERL Syndrome?
Renal / kidney defects (50%) ‐ these defects can
be severe with incomplete formation of one or
both kidneys or urologic abnormalities.
