Pediatrics Flashcards
What are the traits of Epiglottis?
Organism: bacterial (H. Influenza, streptococci, pneumococci, staphylococci)
Age: 2-6 years
Onset: < 24 hours
Region affected: Supraglottic features (epiglottis, vallecula, arytenoids)
Neck X-RAY: thumb sign
Clinical presentation: fever, tripod position and the 4 Ds ~
> drooling
> Dyspnea
> dysphonia
> dysphasia
Treatment: oxygen and urgent airway tx
> tracheal intubation
> tracheostomy
> abx
> induction with SPONTANEOUS RR
> CPAP 10-15 to prevent airway collapse
>ENT SURGEON MUST BE PRESENT
What are some traits with laryngotracheobronchitis (croup!)
Organism: viral (influenza, parainfluenza, resp syncytial virus)
Age: < 2
Onset: 24-72 hrs
Region affected: laryngeal structures BELOW vocal cords
X-RAY: steeple sign
Clinical presentation:
> low grade fever
> barking cough
> vocal hoarseness
> inspiratory stidor
> retractions
Treatment:
> oxygen
> racemic epi
> corticosteroids
> humidification
> fluids
> INTUBATION RARELY NEEDED
What is postintubation croup?
Post-intubation laryngeal edema 😆~ complication of endotracheal intubation
> more common in small children
most common cause is using an ETT that is too large
other causes: rigid bronch, multiple intubation attempts
Usually presents 30-60 mins following extubation
What are the risk factors for post-intubation laryngeal edema?
Age < 4
ETT too large
ETT cuff volume too high
Multiple intubation attempts
Prolonged intubation
Coughing
Head or neck surgery
Trisomy 21
Upper resp tract infection
How do you prevent post intubation tracheal edema?
Maintain air leak < 25 cm H20
What is the preferred tx for post-intubation laryngeal edema?
Racemic epi
What is the volume of racemic epi and volume of NS for a child weighing 0-25 kg?
Racemic epi: 0.25 mL
NS: 2.5
What is the volume of racemic epi and volume of NS for a child weighing 20-40 kg?
Racemic epi: 0.5 mL
NS: 2.5 mL
What is the volume of racemic epi and volume of NS for a child weighing > 40 kg?
Racemic epi: 0.75 mL
NS: 2.5 mL
How long should a patient with post intubation laryngeal edema (post racemic epi) be monitored?
Min of 4 hours
What is the least to most stimulating airways?
Face mask > LMA»_space;»> ETT
What are reasons to allow surgery BUT proceed with caution?
Clear rhinorrhea (runny nose)
No fever
Active
Appears happy
Clear lungs
Older child
What are reasons to CANCEL a peds surgery? (Think URI)
Purulent nasal discharge
Fever >38 / 100.4
Lethargic
Persistent cough
Poor appetite
Wheezing/rales
Child < 1 or previous preemie
How long do most clinicians wait following a resp infection of a child before proceeding?
2-4 weeks AFTER onset of symptoms
How much does use of an ETT increase the risk of bronchospasm?
10-fold!!!
What dose of decadron will reduce the risk of post-intubation croup?
0.25-0.5 mg/kg
What is the best inhaled anesthetic to reduce post-intubation croup?
Sevo. Less pungent
What is the classic triad of foreign body aspiration?
Wheezing, couch, decreased breath sounds on affected side
Which side do children most commonly aspirate on?
Right.
How does a supraglottic aspiration present?
Stridor
How does a subglottic aspiration present?
Wheezing
What is the GOLD standard to retrieve a foreign body?
Rigid Bronch
What is the best anesthetic for a child with an aspirated foreign body?
Sevo induction with spontaneous resps
> spontaneous resps should be used THROUGHOUT procedure ~ maintains laminae flow and reduces changes of distal movement of the foreign body
avoid positive pressure (push object further)
anesthesia circuit can be connected to rigid bronch ~ easy delivery of oxygen and volatile agent
may need to add TIVA d/t dilution (like a reg bronch) ~ best maintenance technique
avoid patient coughing or bucking (also moves object further)
What are the conditions with a large tongue?
Remember “Big Tongue”
B: beckwith syndrome
T: trisomy 21
What are the conditions of a small/underdeveloped mandible?
“Please Get That Chin”
Pierre
Goldenhar
Treacher Collins
Cri du Chat
Cervical Spine Anomaly?
“Kids Try Gold”
Klippel-feil
Trisomy 21
Goldenhar
What is Pierre Robin?
Small/underdeveloped mandible (micrognathia mandibular hypoplasia)
Tongue that falls backward
Cleft palate
***these neonates usually require intubation
What is treacher collins?
Small mouth
Small underdeveloped mandible
Ocular and auricular anomalies
***Chonanal atresia ~ you won’t be able to pass a suction catheter part the point of the atresia
What are some traits of Down syndrome?
Small mouth
Large tongue
Atlantoaxial instability
Small subglottic diameter (subglottic stenosis)
What are some traits about klippel-feil?
Congenital fusion of cervical vertebrae
Neck rigidity
What is goldenhar?
Small underdeveloped mandible
Cervical spine abnormality
What is beckwith syndrome?
Large tongue
What is cri du chat?
Small underdeveloped mandible
Laryngomalacia
Stridor (probs r/t to ^)
What are some airway considerations for cleft lip/palate?
Airway obstruction
Difficult laryngoscopy
Difficult mask
Aspiration
What can reduce venous drainage and cause tongue enforcement during cleft lip/palate surgery?
Dingman-Dott mouth retractor
***increase risk of post-extubation airway obstruction
What are some considerations for cleft lip/palate?
Failure to thrive (unable to generate enough negative pressure required for sucking)
When is cleft lip repaired?
1 month of age
When is cleft palate repair performed?
12 months of age
What % of Down syndrome patients have a cardiac dx?
50%
What is the most common cardiac dx associate with Down syndrome? What is the second
Atrioventricular septal defect ~ 1st!!!
VSD ~ 2nd
What is the most common chromosomal disorder?
Down syndrome (trisomy 21)
Results from the addition of a 3rd copy of chromosome 21
Why should a Down syndrome patient have a peds operative cervical spine X-ray before anesthesia?
Risk of atlantoaxial instability
> C1 and C2 subluxation ~ avoid neck FLEXION
How does subglottic stenosis affect the anesthetic management for a Down syndrome patient?
Increased risk of death post-intubation croup
Smaller ETT!!!
What is common during inhalation induction with a Down syndrome child?
Bradycardia!!
Tx is anticholinergic!
What is CHARGE?
C: coloboma (a hole in one of the eye structures)
H: heart defects
A: atresia of the nasal passage
R: restriction of growth and develop.
G: genitourinary problems
E: ear anomalies
A pirate names COLOmbus who was in CHARGE of a small RESTRICTED (growth)ship, was sailing the seas. One day a seagull attacked his GENITALS….no one on board HEARD (due to ear anomalies) him scream. This gave his HEART (anomalies) a fright. Thank goodness he had NASAL ATRESIA because he couldn’t smell his poopy pants.
What is Catch 22?
CATCH 22
C: cardiac defects
A: abnormal face
T: thymic hypoplasia
C: cleft palates
H: hypocalcemia
22: 22q11.2gene deletion
On day a chef named CARD B (cardiac anomalies) made the biggest CATCH of her life. She cause a ABNORMAL (face)looking fish, but thought it would be delish with a little THYME (thematic hypoplasia)! She served it on the Crystal Plates (cleft palate). But she forgot the glasses of MILK (hypocalcemia). Fortunately all 22 guests, including kind DiGeorge (also called DiGeorge) loved it!!!
What type of electrolyte imbalance is common in DiGeorge syndrome?
Hypocalcemia!!’
What is the child with DiGeorge at risk for if the thymus is absent?!
Infection!!!
Tx consists of thymus transplant or mature T cell infusion
What type of transfusion product is best for DiGeorge?
Leukocyte-depleted irradiated blood
What is the most common coagulation disorder in patients undergoing adenotonsillectomy?
Von Willebrand Dx
What is the MOST common indication for adenotonsillectomy?
Upper airway obstruction and sleep disordered breathing.
What is the other indication for adenotonsillectomy?
Chronic and/or recurrent infections (tonsillitis, pharyngotonsillitis, otitis media, etc…)
What is the most common cause of OSA in kids?
Adenotonsillar hypertrophy
children with OSA undergoing adenotonsillectoy…
Have longer emergence
Should receive lower opioid dose
Higher incidence of airway obstruction
**should be admitted for 23 hours ops
SHOULD NOT RECEIVE CODEINE FOR POST-OP PAIN
What electroly disorder are patients who receive DDAVP at risk for?
Hyponatremia (it’s like ADH)
What should you ensure is removed prior to extubation with a adenotonsillectomy?
Throat pack!!!
Also suction well
Post-tonsillectomy is considered what?
Surgical emergency!
When does primary bleeding following a tonsillectomy occur?
First 24 hours
(75% or post-tonsillectomies bleed within first 6 hours)
When does secondary bleeding following a tonsillectomy occur?
5-10 days after tonsillectomy.
(Following scar -eschar- covering contacts ~ secondary bleeding)
Why are patients with post-tonsillectomies nauseous?
They may have swallowed a lot of blood.
They should be RSI!!! (Surgeon needs to be present prior to induction)
How does ongoing bleeding following post-tonsillectomy affect volume status/CO?
Reduces volume
Reduces CO
Reduce BP (> 20% loss is suggestive when dizziness and orthostatic hypotension are present) ~ need ongoing resuscitation.
How should you oxygenate an active post-tonsil bleed?
Left lateral with head down
What is defined at geriatric/elderly?
65 years and older
What is the most significant risk factor for developing by cancer?
Getting old!
What is one MET (metabolic equivalent) equal to?!
3.5 mL/O2/min
For every 1 MET a patient can achieve, mortality decreases by what?
11%
What are examples of 1 MET?
Self care activities
Working at a computer
Walking two blocks slowly
What are examples of 4 METS?
Climbing a flight of stairs
Walking up a hill
Light housework
Raking leaving
Gardening
What are examples of 10 METS or more?
Strenuous sports (running, swimming. Basketball)
How is frailty defined?
Decreased reserve coupled with reduced resistance to stress.
Patients that are frail are more likely to suffer poor outcomes with perioperative stressors
