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Mar: Sem 6 - Principles B > Pediatric General Surgery Part 1 > Flashcards

Pediatric General Surgery Part 1 Flashcards

1
Q

The _______ and ________ are very compliant in children and are prone to collapse.

A
  • Trachea
  • Bronchi
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2
Q

In pediatric airways, resistance is inversely related to airway radius to the ________ power.

A
  • 5th
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3
Q

Where will there be the greatest resistance in infants?

A
  • Small airways
  • Bronchi

This is d/t the relatively small diameter of airway and greater compliance of the trachea and bronchi

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4
Q

What is airway obstruction during anesthesia usually caused by?

A

Loss of muscle tone in pharyngeal and laryngeal structure

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5
Q

Where will airway obstruction be most pronounced at?

A

Hypopharynx at the level of the epiglottis

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6
Q

Laryngospasm is a result from an _________ effort, which longitudinally separates the vocal folds from the vestibular folds.

A

Inspiratory

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7
Q

What muscles do not contract during a laryngospasm?

A
  • Instrinsic Muscle
  • Extrinsic Muscle
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8
Q

Two common causes of laryngospasms

A
  • Stimulation during light anesthesia
  • Secretion
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9
Q

Name the breathing technique that involves forcefully exhaling air while keeping your airway closed.

A

The Valsalva Maneuver

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10
Q

What is the hallmark sign of a mild laryngospasm?

A

High-pitch inspiratory stridor d/t cords being partially open

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11
Q

What are the treatments for laryngospasm?

A
  • 100 FiO2
  • Stop stimulation
  • Call for help
  • Sniffing position/ Jaw thrust
  • IVP of Propofol
  • Deepen anesthetic gas
  • Positive Pressure
  • Sux/Atropine (persistent laryngospasm)
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12
Q

Risk factors of intraoperative bronchospasm

A
  • Loss of muscle tone during induction increases WOB
  • Asthma
  • Smoking
  • URI
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13
Q

Signs and Symptoms of Intraoperative Bronchospasm

A
  • Polyphonic and prolonged expiratory wheeze
  • Increase respiratory effort
  • Increase peak airway pressures
  • Slow up slope of ETCO2 waveform (shark-fin)
  • Increase ETCO2
  • Decrease SpO2
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14
Q

Describe the capnograph of a bronchospasm.

A

Slow upslope of ETCO2 waveform (shark-fin)

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15
Q

Which induction drugs are excellent bronchodilators?

A
  • Ketamine
  • Propofol
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16
Q

Which VA can increase airway resistance in children and should be avoided?

A

Desflurane

17
Q

List intraoperative treatment for bronchospasm.

A
  • Removing Stimulus
  • Deepen anesthesia (IV meds first)
  • Inhaled β-agonist
  • ↑ FiO2
  • Decrease PEEP and adjust I:E ratio to minimize air trapping
  • IV steroids/ epinephrine
18
Q

How is I:E ratio adjusted to minimize air trapping?

A

The expiratory time is increased to minimize air trapping.

19
Q

What is the dose of epinephrine to treat intraoperative bronchospasm?

A

0.05-0.5 mcg/kg every minute

20
Q

What phase of breathing does laryngospasm primarily affect?

What phase of breathing does bronchospasm primarily affect?

A
  • Laryngospasm affects the inspiratory phase
  • Bronchospasm affects the expiratory phase
21
Q

What sound is associated with laryngospasm?

What sound is associated with bronchospasm?

A
  • Laryngospasm: Stridor (high-pitch)
  • Bronchospasm: Wheeze, Croup
22
Q

Physical presentation of laryngospasm vs bronchospasm.

A
  • Laryngospasm: Retraction of intercostal at the suprasternal notch (tracheal tug)
  • Bronchospasm: Increase use of accessory muscles of inspiration (↑ WOB)
23
Q

What are the changes associated with expiration with laryngospasm compared with bronchospasm?

A
  • Laryngospasm: No change in expiration
  • Bronchospasm: Prolonged expiration
24
Q

Differentiate the onset of cyanosis of laryngospasm vs bronchospasm.

A
  • Laryngospasm: Cyanosis has fast onset
  • Bronchospasm: Cyanosis has slow onset
25
Q

What is Post-Extubation Croup?

A
  • Inflammation/ Edema r/t compression of tracheal mucosa
  • The reduction in the luminal diameter and increase in airway resistance
26
Q

Post-extubation croup can occur in up to ___% of children.

A

1%

27
Q

List the risk factors of post-extubation croup.

A
  • Larger ETT than airway (no leak > 25 cm H2O)
  • Change in position during surgery
  • Repeated intubation attempts/ traumatic intubations
  • Pediatrics b/w ages 1-4 yrs (subglottic airway narrowest in children)
  • Surgery length > 1 hour
  • Previous hx of croup
28
Q

Treatment for Croup in pediatrics

A
  • Nebulized Epinephrine (Racemic Epi)
  • Steroids (Dexamethasone/Decadron): 0.5 mg/kg
29
Q

Describe how a micro-cuff ETT is used to mitigate the risk of croup in pediatric patients.

A
  • Micro-cuff ETT is high volume, low pressure
  • Cuff with an elliptical balloon placed more distally
  • No Murphy’s Eye and able to provide uniform surface contact
30
Q

What is the cause of Congenital Diaphragmatic Hernias (CDH)

A
  • Caused by failure of complete closure of pleural and peritoneal canals
  • Results in herniation of abdominal organs in the thorax
31
Q

How does Congenital Diaphragmatic Hernias (CDH) affect the pulmonary system?

A
  • Inhibits lung growth (division of airways, pulmonary vasculature, decrease bronchi/alveoli)
  • Decrease SA for gas exchange, leading to increased PVR and pulmonary HTN.
  • The ipsilateral lung is usually affected
32
Q

Most common type of Congenital Diaphragmatic Hernias (CDH)

A
  • Postlateral Foramen of Bochdalek (90%)
  • Left side
  • Associated with the greatest amount of hypoplasia
33
Q

Infants born with Congenital Diaphragmatic Hernias (CDH) are more likely to have what other birth defects?

A
  • Congenital Heart Disease (20-40%)
  • Chromosomal Abnormalities (5-15%)
  • GU/GI malformations
34
Q

Diagnosis and Findings of Congenital Diaphragmatic Hernias (CDH)

A
  • Most diagnoses are made prenatally vis US
  • Findings: Polyhydramnios, intrathoracic gastric bubble, mediastinal shift from herniation site
  • Antenatal diagnosis via abdominal CXR showing intestinal loops, abdominal organs in thorax, ipsilateral lung compression
35
Q

Signs and Symptoms of Congenital Diaphragmatic Hernias (CDH).

A
  • Respiratory distress
  • Tachycardia
  • Tachypnea
  • Cyanosis (R → L shunting contributes to severe hypoxemia)
  • Concave abdomen
  • Barrel Chest
  • Absent breath sounds on the affected site
36
Q

Congenital Diaphragmatic Hernias (CDH) Treatment

A
  • Focus on stabilizing and optimizing patient before considering surgery
  • Improve pulmonary HTN and ↓ PVR
  • High-frequency oscillatory ventilation (small frequent Vt, limit Peak Pressure, and avoid CPAP).
  • Vasodilator to ↑ Oxygenation (inhaled NO)
  • Prostaglandin E1 to maintain PDA and reduce RV afterload
  • Severe Cases of hypoplasia and pulmonary HTN: ECMO (PaO2 < 50 mmHg w/ FiO2 of 100%)
37
Q

For patients with Congenital Diaphragmatic Hernias (CDH), what is the major cause of morbidity and mortality undergoing surgical repair w/o ECMO?

A
  • Pulmonary HTN
38
Q

Congenital Diaphragmatic Hernias (CDH) Anesthesia Management

A
  • Avoid volutrauma with control ventilation
  • Avoid increase PVR (hypoxemia, acidosis, hypothermia, hypercarbia)
  • Decrease PVR (hyperventilation, narcotics to blunt sympathetic discharge)
  • NGT should be passed before induction to decrease air entering the stomach
  • Avoid N2O
  • Paralysis
  • Fentanyl induction (50 mcg/kg), Roc 1.2 mg/kg or Nimbex 2mg/kg, Sevo as tolerated
  • Patient will go to the ICU intubated

Mar: Sem 6 - Principles B (14 decks)

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