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My Peds > Pediatric Ortho. Surgery > Flashcards

Pediatric Ortho. Surgery Flashcards

1
Q

What are anesthetic issues with pediatric orthopedic surgery?

A
  • airway
  • positioning
  • blood loss/fluid therapy
  • temp. Conservation
  • post-op pain
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2
Q

What causes congenital dislocation of the hip?

A

Prolonged displacement of fetal femoral head fro the acetabulum, resulting in posterior dislocation during hip flexion
—> ranges from joint laxicity to irreducible displacement

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3
Q

What is the treatment for congenital dislocation of the hip?

A

Pa lick harness, fluro. Guided closed reduction and spica casting

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4
Q

What are anesthetic considerations for congenital hip dislocation?

A
  • short procedure, not painful
  • IA, maintained via mask, LMA or ETT
    • greatest concern is loss of airway
  • pt is lifted from OR table to spica cast frame, then back to OR table (pt barely on table- scary)
  • mask/LMA—> keep deep (stage 3) so that manipulation doesn’t cause laryngospasm
  • LMA/ETT—> secure well- don’t want it dislodged with position changes
  • DISCONNECT circuit during position changes
    • DC N2O prior to circuit disconnect
  • continuously monitor breath sounds
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5
Q

What is congenital club foot?

A

Structural deformity- shortened medial tendons of lower leg, shortened Achilles’ tendon—> foot pointed downward and rotated inward

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6
Q

What is the treatment for club foot?

A
  • manipulation and casting

- surgical correction and casting at 3-6 months

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7
Q

What is the anesthetic management for club foot?

A
  • GA and regional
  • IA and then one shot caudal with bupivicaine 0.25%, 1mL/kg
  • analgesia for 4-6 hours
  • use glucose IV soln for longer procedures
  • can use IV opioids (fentanyl or morphine) instead of caudal
    Other considerations:
  • tourniquets are used
  • stabilize ETT, continuously monitor breath sounds
  • pad/position upper extremities
  • intra op glucose monitoring
  • temp conservation
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8
Q

What is osteogenesis imperfecta (OI)?

A

A defect of collagen production- resulting in abnormal bones, ligaments, teeth and sclera

  • pts suffer fractures after innocuous contact or trauma
  • wide range of severity
  • fibroblasts don’t work well
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9
Q

How does OI present?

A
  • bowing of long bones and kyphoscoliosis
  • otosclerosis and deafness
  • hypermetabolic-not MH
  • platelet abnormalities and decreased factor VIII in 30%
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10
Q

Anesthetic management for OI.

A
  • gentle manipulation of C spine is vital *
  • muscle relaxants only after adequate mask ventilation
  • airway cartilage and teeth easily damaged
  • difficult airway—> fiber optic intubation
  • meticulous attention to padding and positioning of extremities
  • avoid aggressive heat conservation measures and anti-muscarinic a (hypermetabolic)
    • Succinylcholine induced fasiculations can cause fractures (so can tourniquets)
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11
Q

What is cerebral palsy (CP)?

A

Static encephalopathy, or any non-progressive central motor deficit related to hypoxia or anoxic cerebral damage in prenatal period

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12
Q

What is CP caused by?

A

Prematurity, birth trauma, hypoglycemia, intrauterine and neonatal infections, congenital vascular malformations

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13
Q

How does CP present clinically?

A
  • mental retardation, seizures, abnormalities of vision, speech, hearing, behavior and cognition
  • skeletal muscle spasticity and contractures
  • impaired laryngeal and pharyngeal reflexes, GERD, aspiration
  • poor dental hygiene
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14
Q

Anesthetic management for CP?

A
  • all techniques and agents have been used safely
  • mod-severe CP—> intubate to prevent aspiration
  • succ does not increase K+ any more than usual
  • caudal decreases IA and post op pain
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15
Q

What are common drug interactions seen with patients who have CP?

A

Seizure disorder:
- phenobarbital—> CYP 450 INDUCER
- ok to take phenobarbital, phenytoin and carbazapime up to and the day of surgery
Spasticity:
- dantrolene: direct action skeletal muscle relaxant
- inhibits Ca++ release from SR
- baclofen: skeletal muscle relaxant
- inhibits excitatory neurotransmitters

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16
Q

What are anesthetic considerations with pediatric fractures?

A
  • RSI/ETT indicted in pts coming from ED for urgent/emergent care
  • analgesia: IV or caudal
  • have blood products available
  • temp conservation
17
Q

What is myelodysplagia?

A
  • congenital failure of middle or caudal end of neural tube to close, resulting in:
  • spina bifida: missing vertebrae
  • meningocele: bulging spinal fluid through area of missing vertebra
  • myelomeningocele: bulging of spinal fluid and spinal cord
18
Q

What is seen in meningocele?

A
  • intact neural function
  • spinal cord is tethered by sacral nerve roots
  • unrepaired will lead to ortho and uro symptoms
19
Q

What is seen in myelomeningocele?

A
  • varying degrees of sensory and motor deficits
  • upper urinary tract dilation
  • spasticity and scoliosis
20
Q

Anesthetic management for myelodysplagia?

A
  • surgical repair on 1st day of life
    • lack of skin covering —> prone to infections/sepsis
  • position lateral decubitus or supine with towel rolls to avoid pressure to sac
  • neurometric monitoring - avoid NMBs initially
  • pre-op volume assessment: potential for hypovolemia d/t seepage of fluid from sac
  • aggressive temp conservation
  • blood loss not extensive
21
Q

What is scoliosis and how does it manifest?

A

Lateral and rotational deformity of thoracolumbar spine

  • head not centered over body
  • one shoulder higher- shoulder blade higher and more prominent
  • spine obviously curved
  • 1 hip more prominent
  • unequal gaps between arms and trunk
22
Q

What are physiologic derangements seen with scoliosis?

A
  • decreased lung volumes
  • decreased chest wall compliance
  • V/Q mismatch—> chronic hypoxemia
  • increased PVR, pulm HTN—> RV failure

Thoracic curvature 40–> surgical intervention
>65 associated with restrictive lung disease

23
Q

What is included in the pre-op eval for a scoliosis pt?

A 
thorough H and P
- exercise tolerance
- respiratory symptoms
- CV symptoms 
- co-existing diseases
Tests—> CXR, EKG, echo, PFTs
Labs—> ABG, H/H, PT/PTT, platelets, lytes
24
Q

Anesthetic management for scoliosis?

A
  • routine: EKG, SPO2, NIMP, ETCO2, core temp, breath sounds, PNS
  • invasive: arterial BP, CVP, foley (usually no CVP unless child is complex)
  • SSEPs-dorsal column function
  • multiple large bore IVs (14-16g)
25
Q

What is important regarding positioning of a scoliosis pt?

A

Prone:

  • lung compression, increased intra-abd pressure, compression of IVC, epidural vein engorgment, increased bleeding, decreased venous return/CO
  • pt transfer- disconnect circuit and all monitors
  • support head and extremities and pad all pressure points
  • Q 15 min checks to eyes, nose, ears
  • use sufentanyl
26
Q

Anesthetic management in scoliosis?

A
  • blood loss often exceeds 25mL/kg
    • H/H Q 1 hour
    • aggressive temp conservation
    • use autologous, donor, or cell saver blood
  • consider medical causes of bleeding after 1 volume of blood loss
  • do not start case unless blood is in the room
  • i stat in room
  • using TXA has dramatically changed the amount of blood transfused

My Peds (6 decks)

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