Pediatric Ortho. Surgery Flashcards
What are anesthetic issues with pediatric orthopedic surgery?
- airway
- positioning
- blood loss/fluid therapy
- temp. Conservation
- post-op pain
What causes congenital dislocation of the hip?
Prolonged displacement of fetal femoral head fro the acetabulum, resulting in posterior dislocation during hip flexion
—> ranges from joint laxicity to irreducible displacement
What is the treatment for congenital dislocation of the hip?
Pa lick harness, fluro. Guided closed reduction and spica casting
What are anesthetic considerations for congenital hip dislocation?
- 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
What is congenital club foot?
Structural deformity- shortened medial tendons of lower leg, shortened Achilles’ tendon—> foot pointed downward and rotated inward
What is the treatment for club foot?
- manipulation and casting
- surgical correction and casting at 3-6 months
What is the anesthetic management for club foot?
- 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
What is osteogenesis imperfecta (OI)?
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
How does OI present?
- bowing of long bones and kyphoscoliosis
- otosclerosis and deafness
- hypermetabolic-not MH
- platelet abnormalities and decreased factor VIII in 30%
Anesthetic management for OI.
- 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)
What is cerebral palsy (CP)?
Static encephalopathy, or any non-progressive central motor deficit related to hypoxia or anoxic cerebral damage in prenatal period
What is CP caused by?
Prematurity, birth trauma, hypoglycemia, intrauterine and neonatal infections, congenital vascular malformations
How does CP present clinically?
- 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
Anesthetic management for CP?
- 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
What are common drug interactions seen with patients who have CP?
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
What are anesthetic considerations with pediatric fractures?
- RSI/ETT indicted in pts coming from ED for urgent/emergent care
- analgesia: IV or caudal
- have blood products available
- temp conservation
What is myelodysplagia?
- 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
What is seen in meningocele?
- intact neural function
- spinal cord is tethered by sacral nerve roots
- unrepaired will lead to ortho and uro symptoms
What is seen in myelomeningocele?
- varying degrees of sensory and motor deficits
- upper urinary tract dilation
- spasticity and scoliosis
Anesthetic management for myelodysplagia?
- 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
What is scoliosis and how does it manifest?
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
What are physiologic derangements seen with scoliosis?
- 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
What is included in the pre-op eval for a scoliosis pt?
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
Anesthetic management for scoliosis?
- 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)
