Pediatric Anesthesia Week 6 Flash Cards
In which population is Necrotizing Enterocolitis most common in?
Preterm Infants
Morbidity associated with Necrotizing Enterocolitis include…
- Short bowel syndrome
- Sepsis
- Adhesions associated with bowel obstruction
What are some risk factors associated with Necrotizing Enterocolitis?
- Birth asphyxia
- Hypotension
- Respiratory distress syndrome (RDS)
- PDA
- Recurrent apnea
- Intestinal ischemia
- Umbilical vessel cannulation
- Systemic infections
- Early feedings
What is Omphalocele?
- A birth defect where intestines are COVERED with the amnion and is located AT THE BASE of the umbilicus
- Failure of the gut to migrate from the yoke sac into the abdomen during 5TH TO 10TH WEEK OF GESTATION
What is Gastroschisis?
- A birth defect where intestines are NOT COVERED and exposed to hypothermia, infection, and dehydration and is located PERIUMBILICAL
- Develops as a result of OCCLUSION OF THE OMPHALOMESENTERIC ARTERY during 12TH TO 18TH WEEK OF GESTATION
Compare Omphalocele and Gastroschisis with regard to locaton, hernial sac, and associated congenital anomalies
Omphalocele:
- Location is at the base of the umbilicus
- Hernial sac is present
- Associated congenital anomalies are present and include:
- Trisomy 21 (Down's Syndrom)
- Cardiac anomalies
- Diaphragmatic hernia
- Bladder anomalies
Gastroschisis:
- Location is lateral to umbilicus
- Hernial sac is absent
- No known associated congenital anomaliesPerioperative management of Omphalocele and Gastroschisis centers around what 3 preventative measures?
- Hypothermia
- Dehydration
- Infection
In which order, Omphalocele or Gastroschisis, are hypothermia, dehydration, and infection most serious? Why?
More serious in Gastroschisis because the hernial sac is absent
Where is the fistula usually located in a patient with a trachea-esophageal fistula (TEF)?
LOWER SEGMENT of the esophagus, about 90%, where the esophagus inserts just above the carina onto the posterior wall of the trachea
Where is the proper placement of the ETT in a patient with tracheal-esophageal fistula? Describe the procedure for intubating the patient with a TEF?
- The tip of the ETT can be placed just distal to the TEF (in between the fistula and carina)
- Steps for proper placement:
- Insert ETT until mainstem occurs
- Confirm with unilateral breath sounds
- Slowly WITHDRAW until bilateral breathsounds are
present
The key to successful anesthetic management of the neonate with TEF is correct positioning of the ETT. What is the important consideration for intubating the infant with a TEF? What intubaton techniques are appropriate?
- AVOID POSITIVE PRESSURE VENTILATION
- Use 1 of 2 techniques:
- Inhalation induction followed by topical application of
lidocaine and intubate while the patient is
spontaneously breathing - Use an IV or inhalation induction and intubate the
trachea with muscle paralysis.
*The latter technique may lead to distension of the fistula and stomach after onset of positive pressure ventilation
- Inhalation induction followed by topical application of
What is Tracheomalacia (also known as Tracheobronchomalacia)? What patients are at risk for developing Tracheomalacia?
- “Malacia” means abnormal softening of tissue, so softening of the tracheal tissue
- Commonly seen in neonates/infants often in a association with esophageal atresia (TEF) or with extrinsic compression by vascular anomalies or mediastinal masses. May also be associated with hyperthyroidism
What is the anesthetic concern for the patient with Tracheomalacia?
AIRWAY OBSTRUCTION, possibly requiring urgent intubation
What is the etiology of Epiglottitis?
Due to a life-threatening infection by Haemophilus Influenza Type B bacteria
List 9 signs & symptoms of Epiglottitis?
- Upper airway obstruction
- Inspiratory stridor
- Chest retractions
- Tachypnea
- Drooling
- Cyanosis
- Difficulty swallowing
8 Insists on sitting - Restlessness
Children of what age are at highest risk of Epiglottitis?
Children ages 1 to 7 years old, occurs more frequently in children less than 3 years of age.
Where is the optimal location for intubation of a patient with Epiglottitis in the hospital? Why?
- The operating room
- Because total obstruction of the airway could occur at any moment. Attempt to visualize the epiglottis should not be taken unless in the area where emergency tracheostomy can be performed
What is the induction agent of choice and ETT size of choice in a patient with Epiglottitis?
An inhalation induction should be performed, followed by an intubation with ETT 1/2 to 1 size smaller than usual
How long would you expect the ETT to be left in place with a patient with Epiglottitis? What is one sign suggesting the patient is ready for extubation?
- ETT is left in place for 24 to 96 hours
- AIR LEAK usually appears around the ETT as swelling decreases
Where and when should the patient with Epiglottitis be extubated?
Extubation should be performed in the OR only after direct laryngoscopy has confirmed resolution of the swelling of the Epiglottis
How is general anesthesia induced in the child with acute Epiglottitis?
- Parents should be present until airway is secure
- OR should be quiet
- Initiate inhalation induction with 100% O2 and Sevo with patient in SITTING POSITION
- Start IV, give fluids and Atropine
- **DO NOT USE MUSCLE RELAXANTS
- **AVOID TOUCHING THE EPIGLOTTIS (Go in Vallecula)
In what position would you induce a patient with Epiglottitis?
A parent should hold the child in his/her lap and after mask induction the child is placed supine with HEAD SLIGHTLY UP
What is another name for Laryngotracheobronchitis? What is its characteristic?
- Croup
- Barking cough
List 3 treatments for post-intubation laryngeal edema (post-intubation “croup”)?
- Cool, humidified mist, and O2 therapy via face tent
- Aerosolized racemic epinephrine (0.25 to 0.5 ml or 2.25% epinephrine mixed in 3 mL of normal saline)
- Intravenous Dexamethasone (0.25 to 0.5 mg/kg) may prevent edema, but takes up to 4 to 6 hours for onset
What is the usual cause of croup?
The cause is usually VIRAL
Identify 11 factors associated with post-intubation laryngeal edema i.e. “Croup”?
- Age YOUNGER than 4 years old
- Tight-fitting ETT, no audible leak at 15 to 25 cmH2O
- Traumatic or repeated intubation
- Prolonged intubation
- High-pressure, low-volume cuff
- Patient “bucking” or coughing during intubation
- Head repositioning while intubated
- History of infectious or post-intubation croup
- Neck/airway surgery
- Upper respiratory infection
- Trisomy 21 (Down’s Syndrome)
What is the pathogenesis of post-intubation croup? Identify 6 risk factors for post-intubation croup?
- Due to glottic or tracheal edema
1. Early childhood (age 14 years)
2. Repeated intubation attempts
3. Large ETT
4. Prolonged surgery
5. Head & neck procedures
6. Excessive movement of the ETT
What is the appropriate treatement for post-intubation croup?
Inhalation of NEBULIZED RACEMIC EPINEPHRINE (0.25 to 0.5 mL of 2.25% solution in 3 mL of normal saline) and/or IV Dexamethesone (0.25 to 0.5 mg/kg)
What is the most frequent pediatric surgical emergency?
Foreign body aspiration into the airway or esophagus
What is Spina Bifida Occulta?
A Spina Bifida that occurs when skin and soft tissues cover the defect
What is Spina Bifida Aperta?
A Spina Bifida that is used to describe the lesions where the defect communicates with the outside as either a MENINGOCELE or MYELOMENINGOCELE
What causes Myelomeningocele? What is the difference between a Meningocele and Myelomeningocele?
- Caused from failure of the neural tube to close in the fetus during development
- Failure of the caudal end to close results in Spina Bifida
- A sac is present which contains meninges and neural elements
- A Meningocele is a sac containing only meninges
List 7 anomalies often co-existent with Myelomeningocele?
- Club foot
- Hydrocephalus (along with stenosis of the aqueduct of the Sylvius and Arnold-Chiari malformation)
- Dislocation of hips
- Extrophy of bladder (possible incontinence)
- Prolapsed uterus
- Klippel-Feil Syndrome
- Congenital cardiac defects
What are the concerns for anesthetizing the newborn with a Myelomeningocele?
- Patient may not be able to lay supine for intubation due to sac disruption
- A lateral intubation after inhalation induction is usually performed
- An awake lateral decubitus position may be necessary, but doesn’t really happen
- What is Arnold-Chiari malformation? What are 4 symptoms of Arnold-Chiari malformation?
- The malformation consisting of an elongated cerebellar vermis that herniates through the foramen magnum and also compresses the brain stem. No CSF drainage, thus resulting in hydrocephalus
- 4 symptoms include:
- Difficulty swallowing
- Recurrent aspiration
- Stridor
- Possibly apneic episodes
A 7 year-old patient with Spina Bifida comes to the OR for a ventricular-peritoneal shunt. What is the primary concern?
The patient is a high probability of LATEX ALLERGY, which may trigger an anaphylactic episode in the OR
What is the incidence of latex allergies in children with Spina Bifida?
18 to 34% (w/out SB usually 6 to 7%)
Which type of shock is most frequent in the pediatric patient?
Hypovolemic shock
Children may lose as much as _________ of their blood volume without significant cardiovascular changes in the supine position.
1/4
What is the best fluid replacement for the pediatric patient in hypovolemic shock?
Lacated Ringer’s Solution
Children with long-standing obstructive sleep apnea (caused by hypertrophied tonsils, for example) show what anatomic changes in the heart?
Development of pulmonary artery hypertension and RV hypertrophy due to the long-standing hypoxemia and hypercarbia
What is Pick-Wickian Syndrome?
Morbid Obesity, Obstructive Sleep Apnea, Lethargy
List 3 congenital anomalies associated with Prune-Belly Syndrome?
- Cryptochidism (undescended testicle)
- Club foot
- Genitourinary tract abnormalities
*No associated gastrointestinal anomalies
What is Prune-Belly Syndrome?
A lack of abdominal muscles r/t undescended testicles
Name 9 pediatric syndromes
- Pierre Robin Sequence
- Treacher Collins Syndrome
- Goldenhar Syndrome
- Beckwith-Wiedemann Syndrome
- Down Syndrome (Trisomy 21)
- VATER/ VACTERL Syndrome
- Cerebral Palsy
- Fetal Alcohol Syndrome
- Cystic Fibrosis
What is Pierre Robin Sequence? What are the concerns and how should this patient be managed? What intubation technique should be used?
- A combination of a cleft palate, micrognathia, and glossoptosis
- Respiratory obstruction may occur and can lead to Cor Pulmonale
- Maintain airway by placing prone on the frame, may require tongue suture, intubation, or tracheostomy
Describe the suggested tracheal intubation technique for a patient with Treacher Collins Syndrome?
- Topicalization with 1% Lidocaine
- LMA insertion
- Fiberoptic intubation through the LMA
- Also consider fiberoptic tracheal intubation after inhalation induction
What is the most common mandibulofacial dystoses?
Treacher Collins Syndrome
What is Treacher Collins Syndrome? What are its characteristics?
- Most common of the mandibulofacial dystoses, a group of syndromes that freature mandibular hypoplasia (underdeveloped chin)
- 30% have an associated cleft palate, down slanting eyes, notched lower eyelids, underdeveloped or absent cheekbones, LOWER JAW IS OFTEN SMALL and RECEDING, and underdeveloped or malformed ears
Treacher Collins Syndrome is associated with cleft palate, what congenital heart disease is associated with Treacher Collins Syndrome?
- It is frequently accompanied by congenital heart disease, prominantly VSD (the most common congenital heart disease)
** 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?
- 30% have an associated cleft palate
- VSD
- Malar hypoplasia
- Colobomas (notching of the lower eyelids)
- Macrostomia (large mouth)
- Malocclusion
- Small oral cavity
- Treacher Collins Syndrome IS NOT ASSOCIATED with Macroglossia (large tongue) or mental retardation
