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Advanced Principles II > Pediatric Disorders and Problems > Flashcards

Pediatric Disorders and Problems Flashcards

1
Q

What are the common Craniofacial anomalies?

A
  • Cleft lip/palate- varying degrees
    • aspiration risk
    • feeding difficulty
    • frequent otitis
  • Mandibular hypoplasia- tongue displaced posteriorly causing obstruction–always a difficult airway!
    • ***very difficult to BMV, always maintain spont vent!
    • Pierre robin- small and posterior mandible, airway obstruction, cleft palate (far left pic)
    • Treacher-Collins- (far right pic)
      • normal mental development, no disability
      • defective ossification of the bone
      • small/absent cheek bones
      • normal size nose
      • eat tabs, receding chin
  • Midface hypoplasia
    • Apert syndrome, Crouzon syndrome (middle pic)
    • BMV difficult d/t location of eyes
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2
Q

What is epiglottitis?

A
  • Epiglottitis- life threatening bacterial infection of the epiglottis, aryepiglottic folds, arytenoids and sometimes uvula
  • Symptoms
    • high fever
    • severe sore throat
    • drooling
    • ill appearing
  • Rapid deterioration may occur;
    • DO NOT aggitate the child!
    • DO NOT manipulate the airway!
    • DO a calm, sitting inhalational induction
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3
Q

What is Croup (Laryngotracheobronchitis)?

A
  • Viral infection of the subglottic structures
  • more gradual onset
  • barky or seal-like cough with hoarse voice and inspiratory stridor
  • Most cases resolve with simple management including humidified air or oxygen
  • Use ETT 1/2 size smaller if require intubation
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4
Q

Epiglottitis Vs Laryngotracheobronchitis

(table)

A
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5
Q

What is Laryngomalacia?

Tracheomalacia?

A
  • Laryngomalacia- immature cartilage of the supraglottic larynx leads to symptoms. Slowly resolves by 12-18 mo.
    • Symptoms: Insp stridor with activity or feeding that resolves when child is calm
    • Most common airway problem in infants and children
  • Tracheomalaci- weakened or “floppy” trachea
    • Symptoms: harsh noise/stridor on expiration caused by airway collapse
      • onset in early neonatal period
      • diagnosed by bronchoscopy
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6
Q

How should an asthmatic pt be treated?

A
  • Optimize the asthmatic pt preoperatively
  • Pre-op review:
    • previous hospitalization?
    • intubated?
    • ER visit?
    • age on onset?
    • treatments? steroids?
  • Assess carefully for wheezing: defer if surgery is elective and pt is wheezing
  • Give pre-op bronchodilators even if not wheezing
  • Avoid intubation if face mask or LMA can be used
  • Consider ketamine
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7
Q

OSA:

Primary cause in Children?

Assessment/risk factors?

A
  • Primary cause in children is large tonsils and adenoids
    • also craniofacial abnormalities, neuromuscular disorders, obesity
  • Aassessment of risk factors:
    • loud snoring
    • witnessed apnea
    • nocturnal enuresis
    • ADHD
    • behavioral problems
    • increased in african american
    • daytime somnolence is NOT a feature in children
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8
Q

OSA:

anesthesia concerns?

A
  • Anesthesia concerns:
    • opioid sensitivity- reduce dose by 1/2!
    • post-op resp complications
    • post-op admission for monitoring
  • Intermittent hypoxia can lead to PHTN and right heart failure
    • ECHO recommended in child with severe OSA
    • Red flags:
      • systemic HTN
      • right ventricular dysfunction (peripheral edema, hepatic enlargement, elevated liver enzymes)
      • frequent, severe desats (<70%)
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9
Q

OSA:

Who needs post-op observation?

Classification (mild, mod, severe)

A
  • Post-op observation
    • <3 yo
    • craniofacial abnormalities
    • parents can’t keep an eye on them
    • live far from hospital
    • obese
  • Classification:
    • mild: 1-5 apneic episodes/hr
    • moderate: 5-10 apneic episodes/hr
    • Severe: >10 apneic episodes/hr
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10
Q

URI:

Why is it a concern?

When can you proceed?

A
  • Most common comorbidity in children presenting for surgery
  • Concern: increased risk for complications (bronchospasm and laryngospasm)
    • Avoid airway manipulation (ETT) if possible. Use LMA or mask
  • Use caution, but may proceed with:
    • clear runny nose
    • no fever
    • playful
    • clear lungs
  • Cancel if:
    • purulent nasal discharge
    • fever
    • lethargy
    • persistent cough
    • wheezing/rales
    • previous premie
    • <1 yo
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11
Q

Tonsillectomy:

indications

preferred airway

risks

A
  • Indicated for recurrent infections and OSA
    • many pts have large tonsils but otherwise normal airways
    • consider they might have OSA
  • Preferred airway: usually ETT, some use LMA (choice is surgeons)
  • Risks:
    • post-op hemmorhage (0.1-0.3%); can be day of surgery or 7-10 days later
    • Active bleeding will make visualization more difficult, full stomach, potential for hypovolemic shock
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12
Q

Myringotomy and Tympanostomy tubes anesthetic procedure

A
  • Usually a short outpatient procedure
  • 5-10 minutes of operating time
  • Technique:
    • usually no premed req unless extremely apprehensive
    • ASA monitors
    • inhalation induction (Sevo, O2, +/- Nitrous)
    • maintenace phase with mask ok
    • IV access usually not necessary
  • Acute otitis media is one of most common diseases in first decade of life
  • Pt may have co-existing tonsillar hypertrophy- usually relieved with positive pressure or OA
  • Pain:
    • rectal/PO tylenol
    • intranasal fentanyl
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13
Q

What is Pectus excavatum?

Carinatum?

A
  • Pectus carinatum- abnormal protrusion of the xiphoid process and sternum
    • predominantely males 4:1
    • can be associated with: scoliosis, marfan, and CHD
  • Pectus excavatum- abnormal depression of the sternum
    • usually medically insignificant
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14
Q

What is Tetralogy of Fallot?

When is it repaired?

A
  • Most common cyanotic CHD
  • Anatomy:
    • RVOT obstruction
    • infundibular narrowing
    • pulmonary stenosis
    • PA hypoplasia
    • pulmonary atresia
    • VSD (large, unrestrictive)
    • Overriding aorta
    • RV hypertrophy
  • Left unrepaired, tet spells can lead to RVH, RV failure and death (50% in first year of life)
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15
Q

What is significant about caring for a pt with a previously repaired CHD?

Key points for anesthetic for a single ventricle pt?

What is williams syndrome?

What should you check before anesthetizing a former cardiac transplant pt?

A
  • Can later develop dysrhythmias (esp if approach was ventriculotomy)
    • repaired single ventricles have high risk for sudden death as a result of pathologic arrhythmias
    • any intraop arrhythmias MUST be reported to cardilogist, may req RF ablation
  • Single ventricles:
    • keep well hydrated
    • avoid PEEP
    • avoid laparoscopic surgery
  • Williams syndrome- aortic stenosis, abnormal coronary arteries, pulmonic stenosis
    • high risk for sudden death with anesthesia
  • Former cardiac transplants- rule out small vessel CAD first
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16
Q

Sickly cell:

Quick review

Complications

A
  • Hgb S allows deoxygenated Hgb to polymerize into rigid insoluble fibers, resulting in sickled erythrocytes
    • these have shortened life span, leading to hemolysis and anemia
  • Complications:
    • anemia
    • stroke
    • acute chest syndrome
    • myonecrosis
    • CHF
    • MI
    • splenic sequestration
    • retinal hemorrhage
    • hematuria
    • ESRD
    • sz
    • wound infection
    • UTI
17
Q

Sickle Cell:

Things to avoid

pre-op

Intra-op

post-op

A
  • Avoid:
    • dehydration
    • stasis
    • hypoxia
    • hypothermia
    • acidemia
    • pain
  • Pre-op: often admitted night before for IV fluids
    • warm
    • well oxygenated
    • hydrated
    • consult hematologist
    • may transfuse to target hgb of 10
  • Intra-op:
    • maintain euvolemia and normothermia
    • avoid tourniquets
  • Post-op
    • Adequate IV hydration
    • early mobilization
    • incentive spirometry
    • supplemental O2
    • consider multi-modal analgesia, many are tolerant to opioids
18
Q

Appendicitis

Risks

considerations

A
  • Most seen in teen years
  • Risks
    • increased perforation if dx delayed >24
    • abscess
    • ileus
    • sepsis
  • Considerations
    • aspiration (considered full stomack; RSI)
      • evacuate stomach with NG/OG
    • active N/V
    • tachycardia d/t pain
    • dehydration
    • sepsis
    • pre-op abx with gram negative coverage
19
Q

What are the three myopathies and what is significant with each?

A
  • Get Pre-op ECHO and EKG!
  • Duchenne muscular dystrophy
    • X-linked
    • lack of dystrophin in skeletal and cardiac muscle
    • progressive cardiomyopathy at adolescence
  • Becker muscular dystrophy
    • milder form of Duchennes seen in 2nd decade of life
  • Emery Dreifuss
    • may have concurrent heart block
20
Q

What is Tumor lysis syndrome?

What is anesthesia often needed for in pediatric pts with cancer?

What should you consider in pts getting treated for cancer?

A
  • Tumor lysis syndrome is a metabolic crisis that often occurs when chemo is started
    • caused by acute lysis of a large number of tumor cells
    • classic triad: hyperuricemia, hyperkalemia, hyperphosphatemia
      • elevated phosphate causes hypocalcemia
    • these pts require good fluid and electrolyte managment
  • Anesthesia needed for:
    • central line placement
    • lumbar punctures
    • bone marrow aspirates
  • Chemo effects:
    • Anthracyclines (doxorubicin, daunorubicin): cardiotoxicity
    • Bleomycin: pulmonary toxicity
21
Q

Mediastinal mass:

causes

Sx

What is concerning about these?

A
  • Causes:
    • lymphoma
    • teratoma
    • thymoma
    • thyroid tissue
  • Symptoms: varies based on size and location
    • stridor
    • SVC syndrome
    • symptoms can progress rapidly esp in non-hodgkins lymphomas
  • Life threatening airway obstructions and CV collapse can occur with induction of GA
  • Pts may be receiving radiation and steroids
22
Q

What are some treatment considerations for pts with a mediastinal mass?

A
  • May go to IR for needle biopsy and local ispreferred if cooperative
  • PRESERVE SPONTANEOUS BREATHING
  • SVC syndrome will need IV in lower extremity
  • Preferred to keep pt in semi sitting position
  • Severe obstruction may require repositioning prone or lateral
  • CV collapse may require cardiopulmonary bypass
    • may have bypass on standby for large mass
23
Q

Downsyndrome:

incidence

Physical exam findings

common surgeries

A
  • 3rd copy of chromosome 21
  • 1:1,000 live births, increased incidence in moms >35 years
  • Physical findings:
    • midface hypoplasia
    • brachycephaly
    • epicanthal folds
    • simian crease
    • downward medial slant of eyes
    • high-arched palate
    • glossoproptosis
    • murmur
  • Surgeries:
    • tympanostomy
    • strabismus (poor eye muscle control)
    • CHD repair
    • duodenal/esophageal atresia
    • marrow aspiration/biopsy
    • cervical spine fusion
24
Q

What are downsyndrome pts at high risk for?

A

Five-fold risk of bradycardia during sevo induction (first 6 minutes) in children with downs

25
Q

Table of physical exam findings in down syndrome pts

HEENT

CV

ENDO

IMMUNE/ONC
MS

26
Q

Anesthesia considerations for down syndrome pts

A
  • Airway:
    • have a variety of devices available to manage obstruction (oral/nasal airways, LMA, glidescope, fiberoptic)
    • avoid neck extension during laryngoscopy (atlanto axial instability
    • smaller ETT may be necessary for narrowed subglottic space
  • Vascular access
    • meticulously avoid IV air d/t possible CHD
  • Anticpate problems:
    • Bradycardia with inhalation induction
    • Resistance to separation from caregiver
27
Q

What is associated with VACTERL syndrome?

A
  • VACTERL
    • vertebral anomalies
    • anal atresia
    • CHD
    • tracheoesophageal fistula
    • esophageal atresia
    • renal and radial dysplasia
    • limb defects
      *
28
Q

What is associated with CHARGE syndrome?

A
  • CHARGE
    • coloboma (a hole in one of the structures of the eye)
    • heart defects
    • choanal atresia
    • retardation of growth and dev
    • genitourinary problems
    • ear abnormalities
29
Q

What is associated with CATCH 22 syndrome?

A
  • CATCH 22
    • cardiac defects
    • abnormal face
    • thymic hypoplasia
    • cleft palate
    • hypocalcemia
30
Q

Table to remember which syndromes have these traits:

Large tongue

small/underdeveloped mandible

cervical spine anomaly

31
Q

Anesthetic considerations for a pt who is susceptible to MH

A
  • A pt with a family history of MH or a + muscle biopsy test
  • First case of the day
  • remove vaporizes from the machine, flush machine per manufacturer guidelines
  • Use trigger-free anesthetic:
    • propofol
    • opioids
    • BZDs
    • NDMB
    • N2O
    • regional
  • Monitor ETCO2, temp
  • Susceptible children can have outpatient procedures as long as trigger-free anesthetic is used
32
Q

Childhood obesity:

definitions

IBW calculation for children

LBW calc

A
  • Definition for obesity in children based on BMI
    • Obesity = BMI > 95th percentile
    • morbid obesity = BMI > 99th percentile
  • IBW calc:
    • <8 yo: 2 x Age (years) + 9
    • >8 yo: 3 x age in years
33
Q

What are the physiological changes seen in obese children?

A
  • Pulm
    • Restrictive pulmonary pattern
    • decreased chest wall compliance
    • decreased FRC and VC
  • CV
    • HTN
    • LVH
    • premature atherosclerosis
  • Insulin resistance

Advanced Principles II (20 decks)

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