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
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
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
4
Q
Epiglottitis Vs Laryngotracheobronchitis
(table)
A
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
- Symptoms: harsh noise/stridor on expiration caused by airway collapse
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
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
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%)
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
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
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
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
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
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)
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
25
Q
Table of physical exam findings in down syndrome pts
HEENT
CV
ENDO
IMMUNE/ONC
MS
A
30
Q
Table to remember which syndromes have these traits:
Large tongue
small/underdeveloped mandible
cervical spine anomaly
A
