Pediatric General Surgery Part 2 Flashcards
How many types of Tracheoesophageal Fistulas (TEF) are there?
- 5 Types
- A, B, C, D, and E
Which Tracheoesophageal Fistula (TEF) is the most common?
- Type C (80-85%)
- Distal esophageal pouch and a proximal tracheoesophageal fistula
Where are Tracheoesophageal Fistulas (TEF) usually located?
1-2 rings above the carina
When does Tracheoesophageal Fistula (TEF) occur during gestation?
4th to 5th week of gestation d/t error in separation of trachea from floor of foregut
What is Tracheoesophageal Fistulas (TEF) often associated with?
- VACTERL
What does VACTERL stand for?
Acronym for a spectrum of congenital anomalies:
Vertebral anomalies
Imperforated Anus
Congenital heart disease
TracheoEsophageal fistula
Renal anomalies
Limb anomalies
How is Tracheoesophageal Fistulas (TEF) prenatally diagnosed?
- Polyhydramnios (↑amniotic fluid)
- Small/absent gastric bubble
- Blind ending upper pouch in the fetal neck.
What are postnatal S/S of Tracheoesophageal Fistulas (TEF)?
- Excessive salivation
- Choking
- Coughing
- Regurgitation at first feeding → Cyanosis/ distress
- Distended abdomen from baby crying
- Inability to pass NGT
What are the three C’s of Tracheoesophageal Fistulas (TEF)?
- Choking
- Coughing
- Cyanosis
Tracheoesophageal Fistulas (TEF) is confirmed with the inability to pass NGT into the stomach more than how many centimeters?
7 cm
Other ways to confirm diagnosis include dilated proximal esophagus with air in conjunction with air in the distal stomach on Xray, CT or direct visualization via bronchoscopy/endoscopy
What does the yellow circle indicate?
What does the red arrow indicate?
What is the suspected diagnosis?
- Yellow Circle: Feeding tube coiled in the esophageal pouch
- Red Arrow: Large volume of gas in the abdomen.
- Dx: Tracheoesophageal fistula with esophageal atresia
For pre-surgical goals of TEF, the proximal pouch should be secured and placed to ________ suction.
Continuous
Why should mask ventilation be avoided in TEF patients about to undergo surgery?
Mask ventilation can exacerbate gastric distention
What position is used for a thoracoscopic TEF procedure?
Left lateral decubitus position for a right thoracotomy approach to avoid the aortic arch
Why is the fistula ligated first in a TEF procedure?
Prevent further air entrapment in the stomach
Primary “End to End” anastomosis of the esophagus follows the ligation
ETT placement for TEF procedures
- The tip of the ETT is placed above the carina but distal to the fistula
- This is achieved by purposeful right main stem intubation and w/d ETT while auscultating the left chest until breath sounds are first heard bilateral
Anesthetic Considerations for TEF
- Keep the infant spontaneously breathing.
- IV induction w/ muscle relaxants.
- Gentle mask ventilation with low peak pressure
- Frequent ETT suctioning
- After surgical correction ventilation with increased I:E time to re-expand alveoli
- Leave pt intubated, transfer to NICU
- Maintain head in neutral position
- An epidural catheter from the caudal space or an intrapleural catheter can be left in place for post-op analgesia
Is pyloric stenosis more common in firstborn males or females?
More common in firstborn males (4:1)
When and how is pyloric stenosis diagnosed?
- Usually dx b/w 2-8 weeks of age with non-bilious projectile vomiting
- Immediate post-prandial vomiting
- Hungry in b/w feedings
Define pyloric stenosis
- Hypertrophy and hyperplasia of the muscular layer of the pylorus
- Causes a gastric outlet obstruction
Treatment of pyloric stenosis
- Supportive treatment (treat lytes imbalance)
- Pyloromyotomy (laparoscopically)
What kind of acid-base imbalance does pyloric stenosis cause?
Hypochloremic hypokalemic metabolic alkalosis
How is the hypertrophied pylorus muscle often presented?
Olive-shaped mass in RUQ
What IV fluids are administered to infants with pyloric stenosis
Dextrose IVF
When will infants with pyloric stenosis be considered ready for surgery?
Skin:
UOP:
Na+:
K+ :
Cl- :
Skin: Good skin turgor
UOP: adequate 1-2 mL/kg/hr
Na+: >130 mEq/L
K+ : >3 mEq/L
Cl- : >85 mEq/L
What is the hallmark US sign for pyloric stenosis?
- Target or Donut Sign
If a pyloromyotomy is done openly, the approach will be a _______ incision
periumbilical incision
Pyloric Stenosis Anesthesia Management
- RSI secondary to gastric outlet obstruction
- Towels, it will be messy
- Large red rubber catheter to suction out gastric content
- Preoxygenate with 100% oxygen
- Suction (turned RIGHT, CENTER, LEFT)
Pyloric Stenosis Anesthesia Meds
Lidocaine:
Atropine:
Propofol:
Sux:
Tylenol:
Narcs:
- Lidocaine: 1-2mg/kg
- Atropine: 0.02mg/kg
- Propofol: 2-4mg/kg
- Sux: 2mg/kg
- Tylenol: 30-40mg/kg (given as rectal suppository)
- No Narcs!
Why are narcotics typically not needed for pyloromyotomy?
- Quick surgery
- Minimal pain with laparoscopic approach
- Local anesthetic administered at incision site
For pyloric stenosis patients, pre-op alkalosis will lead to post-op ________
- Apnea
Pyloric Stenosis in PACU considerations
- Awake extubation
- Post-op respiratory depression is common
- Apnea monitor for the first 24 hours postoperatively
- Monitor for hypoglycemia
- Morphine can be used in PACU in small doses (0.02-0.03mg/kg) after extubation
Differentiate between a gastroschisis and an omphalocele.
- Gastroschisis: Bowels out, no sac
- Omphalocele: Bowels out w/ sac
How does Gastroschisis occur?
- Results of occlusion of omphalomesenteric artery during gestation
- Not associated with other congenital abnormalities
Describe bowel function status in Gastroschisis
Functionally abnormal dilated and foreshortened bowel because they are exposed to amniotic fluid in utero and air after delivery which results in inflammation and edema
How does Omphalocele occur?
D/t failure of the gut to migrate from the yolk sac into the abdomen during gestation
What congenital abnormalities are associated with Omphalocele?
- Genetic
- Cardiac
- Urologic
- Metabolic
Describe bowel function status in Omphalocele.
The bowel is morphological and usually functions normally
Gastroschisis vs Omphalocele
Cause:
Location of defect:
Associated:
Another way to remember the difference between Omphalocele and Gastroschisis
Aim for both Omphalocele and Gastroschisis is to maintain perfusion to the viscera and reduce _______
Fluid loss
For both Omphalocele and Gastroschisis, what should be used to cover mucosal surfaces?
Sterile saline-soaked dressing
What is the purpose of using plastic wrap over the herniated viscera?
- ↓ Evaporative Loss
- Prevent heat loss and hypothermia
- More pronounced in gastroschisis
For both Omphalocele and Gastroschisis procedures, an intragastric tube can measure pressure that exceeds ____mmHg after primary closure which can cause abdominal ischemia and can result in a surgical emergency
20 mmHg
How do Omphalocele and Gastroschisis procedures decrease venous return?
- Bowel can become edematous and renal congestion can result in decreased urine output, lower extremity congestion, and cyanosis from impeded venous return
- Have BP and Pulse ox on both upper and lower extremities to monitor discrepancies
How do Omphalocele and Gastroschisis procedures affect diaphragm and pulmonary function?
Decreased diaphragm function bilateral lower lobe atelectasis and respiratory failure
Anesthetic management for Omphalocele and Gastroschisis (long list)
- Warm the room (80F)
- Aspirate the in situ gastric tube
- Preoxygenate with 100% oxygen
- RSI with cricoid
- No nitrous (can worsen edema)
- Narcotics and muscle relaxation for surgical repair
- IVF (Dextrose)
- Monitor Peak Airway Pressure and maintain < 25mmHg during primary closure
- Watch for hypotension (increased intrabdominal pressure can decrease venous return)
- Post-operative intubation and controlled ventilation
