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Mar: Sem 6 - Adv. Principles B > Pediatric General Surgery Part 2 > Flashcards

Pediatric General Surgery Part 2 Flashcards

1
Q

How many types of Tracheoesophageal Fistulas (TEF) are there?

A
  • 5 Types
  • A, B, C, D, and E
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2
Q

Which Tracheoesophageal Fistula (TEF) is the most common?

A
  • Type C (80-85%)
  • Distal esophageal pouch and a proximal tracheoesophageal fistula
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3
Q

Where are Tracheoesophageal Fistulas (TEF) usually located?

A

1-2 rings above the carina

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4
Q

When does Tracheoesophageal Fistula (TEF) occur during gestation?

A

4th to 5th week of gestation d/t error in separation of trachea from floor of foregut

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5
Q

What is Tracheoesophageal Fistulas (TEF) often associated with?

A
  • VACTERL
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6
Q

What does VACTERL stand for?

A

Acronym for a spectrum of congenital anomalies:

Vertebral anomalies
Imperforated Anus
Congenital heart disease
TracheoEsophageal fistula
Renal anomalies
Limb anomalies

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7
Q

How is Tracheoesophageal Fistulas (TEF) prenatally diagnosed?

A
  • Polyhydramnios (↑amniotic fluid)
  • Small/absent gastric bubble
  • Blind ending upper pouch in the fetal neck.
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8
Q

What are postnatal S/S of Tracheoesophageal Fistulas (TEF)?

A
  • Excessive salivation
  • Choking
  • Coughing
  • Regurgitation at first feeding → Cyanosis/ distress
  • Distended abdomen from baby crying
  • Inability to pass NGT
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9
Q

What are the three C’s of Tracheoesophageal Fistulas (TEF)?

A
  • Choking
  • Coughing
  • Cyanosis
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10
Q

Tracheoesophageal Fistulas (TEF) is confirmed with the inability to pass NGT into the stomach more than how many centimeters?

A

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

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11
Q

What does the yellow circle indicate?
What does the red arrow indicate?
What is the suspected diagnosis?

A
  • Yellow Circle: Feeding tube coiled in the esophageal pouch
  • Red Arrow: Large volume of gas in the abdomen.
  • Dx: Tracheoesophageal fistula with esophageal atresia
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12
Q

For pre-surgical goals of TEF, the proximal pouch should be secured and placed to ________ suction.

A

Continuous

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13
Q

Why should mask ventilation be avoided in TEF patients about to undergo surgery?

A

Mask ventilation can exacerbate gastric distention

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14
Q

What position is used for a thoracoscopic TEF procedure?

A

Left lateral decubitus position for a right thoracotomy approach to avoid the aortic arch

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15
Q

Why is the fistula ligated first in a TEF procedure?

A

Prevent further air entrapment in the stomach

Primary “End to End” anastomosis of the esophagus follows the ligation

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16
Q

ETT placement for TEF procedures

A
  • 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
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17
Q

Anesthetic Considerations for TEF

A
  • 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
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18
Q

Is pyloric stenosis more common in firstborn males or females?

A

More common in firstborn males (4:1)

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19
Q

When and how is pyloric stenosis diagnosed?

A
  • Usually dx b/w 2-8 weeks of age with non-bilious projectile vomiting
  • Immediate post-prandial vomiting
  • Hungry in b/w feedings
20
Q

Define pyloric stenosis

A
  • Hypertrophy and hyperplasia of the muscular layer of the pylorus
  • Causes a gastric outlet obstruction
21
Q

Treatment of pyloric stenosis

A
  • Supportive treatment (treat lytes imbalance)
  • Pyloromyotomy (laparoscopically)
22
Q

What kind of acid-base imbalance does pyloric stenosis cause?

A

Hypochloremic hypokalemic metabolic alkalosis

23
Q

How is the hypertrophied pylorus muscle often presented?

A

Olive-shaped mass in RUQ

24
Q

What IV fluids are administered to infants with pyloric stenosis

A

Dextrose IVF

25
Q

When will infants with pyloric stenosis be considered ready for surgery?

Skin:
UOP:
Na+:
K+ :
Cl- :

A

Skin: Good skin turgor
UOP: adequate 1-2 mL/kg/hr
Na+: >130 mEq/L
K+ : >3 mEq/L
Cl- : >85 mEq/L

26
Q

What is the hallmark US sign for pyloric stenosis?

A
  • Target or Donut Sign
27
Q

If a pyloromyotomy is done openly, the approach will be a _______ incision

A

periumbilical incision

28
Q

Pyloric Stenosis Anesthesia Management

A
  • 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)
29
Q

Pyloric Stenosis Anesthesia Meds
Lidocaine:
Atropine:
Propofol:
Sux:
Tylenol:
Narcs:

A
  • 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!
30
Q

Why are narcotics typically not needed for pyloromyotomy?

A
  • Quick surgery
  • Minimal pain with laparoscopic approach
  • Local anesthetic administered at incision site
31
Q

For pyloric stenosis patients, pre-op alkalosis will lead to post-op ________

A
  • Apnea
32
Q

Pyloric Stenosis in PACU considerations

A
  • 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
33
Q

Differentiate between a gastroschisis and an omphalocele.

A
  • Gastroschisis: Bowels out, no sac
  • Omphalocele: Bowels out w/ sac
34
Q

How does Gastroschisis occur?

A
  • Results of occlusion of omphalomesenteric artery during gestation
  • Not associated with other congenital abnormalities
35
Q

Describe bowel function status in Gastroschisis

A

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

36
Q

How does Omphalocele occur?

A

D/t failure of the gut to migrate from the yolk sac into the abdomen during gestation

37
Q

What congenital abnormalities are associated with Omphalocele?

A
  • Genetic
  • Cardiac
  • Urologic
  • Metabolic
38
Q

Describe bowel function status in Omphalocele.

A

The bowel is morphological and usually functions normally

39
Q

Gastroschisis vs Omphalocele
Cause:
Location of defect:
Associated:

A
40
Q

Another way to remember the difference between Omphalocele and Gastroschisis

A
41
Q

Aim for both Omphalocele and Gastroschisis is to maintain perfusion to the viscera and reduce _______

A

Fluid loss

42
Q

For both Omphalocele and Gastroschisis, what should be used to cover mucosal surfaces?

A

Sterile saline-soaked dressing

43
Q

What is the purpose of using plastic wrap over the herniated viscera?

A
  • ↓ Evaporative Loss
  • Prevent heat loss and hypothermia
  • More pronounced in gastroschisis
44
Q

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

A

20 mmHg

45
Q

How do Omphalocele and Gastroschisis procedures decrease venous return?

A
  • 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
46
Q

How do Omphalocele and Gastroschisis procedures affect diaphragm and pulmonary function?

A

Decreased diaphragm function bilateral lower lobe atelectasis and respiratory failure

47
Q

Anesthetic management for Omphalocele and Gastroschisis (long list)

A
  • 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

Mar: Sem 6 - Adv. Principles B (14 decks)

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