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AS - N935 Advanced Patho II > Pediatrics II > Flashcards

Pediatrics II Flashcards

1
Q

Premature Infant

Anesthetic Considerations

A

Already intubated ICU transport
Uncuffed/cuffed ETTs
Difficult intubation - subglottic stenosis
Difficult ventilation - poor compliance; avoid barotrauma & excessive oxygen
Position change → check ETT
NSAIDs contraindicated
Consider IV caffeine to prevent apneas

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2
Q

Why are NSAIDs contraindicated in premature infants?

A

Immature renal system
Premature PDA closure

Avoid IV Ketorolac until 6mos-1yo

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3
Q

What effect do inhalational anesthetics have on premature infants?

A

More susceptible to the cardio-depressant effects

Neonatal heart dependent on plasma Ca2+

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4
Q

Neonate MAC

A

Sevo 3.2% (2)
Iso 1.6% (1.2)
Des 9.2% (6)

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5
Q

Infant MAC

A

Sevo 3.2% (2)
Iso 1.8% (1.2)
Des 10% (6)

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6
Q

Child MAC

A

Sevo 2.5% (2)
Iso 1.4% (1.2)
Des 8.2% (6)

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7
Q

Fentanyl

A

↑Vd
↓elimination 1/2 life
Premature infants 6-32hrs
Children & adults 2-3hrs

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8
Q

Propofol

A

Protracted hypotension & ↓CO
↓dosages
Infusions rarely used long-term

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9
Q

Midazolam

A

↓clearance especially w/ impaired liver function

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10
Q

Dexmedetomidine

A

Propofol pre-treatment to alleviate neuronal cytotoxicity

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11
Q

HbF

A

Fetal hemoglobin
Main O2 transport protein in fetus during development in-utero & persists until 6mos
↑oxygen binding affinity
LEFT SHIFT
Carries 20-50% more oxygen than maternal Hgb

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12
Q

Physiologic Anemia

A

Transition HbF → HbA
Full-term infants 10-11g/dL
↓erythropoiesis & shorter RBC lifespan

Premature infants 7-9g/dL
Consider transfusion when Hct <30%

3mos Hgb level stabilizes to 11-12g/dL until 2yo

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13
Q

PDA

A

L → R shunt
Excessive pulmonary blood flow
CHF & respiratory failure

R → L shunt
Pulmonary HTN → cyanosis

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14
Q

PDA Ligation

A 
Medical:
- Admin COX inhibitor
- Indomethacin (Indocin) or Ibuprofen
Surgical:
- L thoracotomy w/ lung retraction
- Clip or transcatheter closure "plug"
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15
Q

PDA Ligation

Preop

A

Assess arterial pressure ↓diastolic (widened pulse pressure), HR, arterial blood gas, ventilator setting, FiO2
PRBCs on hold
Antibiotics - endocarditis risk

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16
Q

PDA Ligation

Intraop

A

Blood pressure monitoring on R arm (reflects cerebral perfusion & pre-ductal)
Pox pre & post-ductal
ETCO2 monitoring
Minimal ETT leak (lung retraction ↑ventilator inspiratory pressures & FiO2)
Opioids, amnesia, & muscle relaxation
Intercostal nerve block placed by surgeon at surgery completion

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17
Q

PDA Ligation

Complications

A

Inadvertent aorta or pulmonary artery ligation or laceration
Aorta clamp → Pox loss signal LE
Pulmonary artery clamp ↓oxygen saturation & ETCO2

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18
Q

NEC

A

Necrotizing enterocolitis
Low birth weight infants mortality up to 50%
85% cases infants < 1,500g birth weight
Morbidity associated w/ short bowel syndrome, sepsis, & adhesions

Intestinal mucosal injury 2° to bowel ischemia & ulceration

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19
Q

NEC S/S

A

Early signs - abdominal distension, bloody diarrhea, temperature instability, & lethargy
Metabolic & hematologic abnormalities - hyperkalemia, hyponatremia, metabolic acidosis, hypo/hyperglycemia, coagulopathy, DIC, anemia
Often already intubated d/t abdominal distension w/ OG/NG tube suctioning & hemodynamic instability

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20
Q

NEC Treatment

A

1° NICU medical management
Peritoneal drainage often performed at bedside
Bowel perforation & free air present in abdominal cavity → urgent/emergent surgery
Exploratory laparotomy w/ necrotic bowel resection
Risk life-threatening sepsis after perforation d/t bacteria entering bloodstream

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21
Q

NEC

Anesthetic Considerations

A

Aspiration risk → RSI or awake intubation
Inhalational agents poorly tolerated
- Consider narcotic technique w/ muscle relaxation to maintain hemodynamic stability
Avoid nitrous oxide
PIV x2
A-line or UAC
Fluid & blood loss
- Admin PRBCs (10-15mL/kg), FFP (10-15mL/kg), platelets
Correct electrolytes
Monitor glucose

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22
Q

Allowable Blood Loss

A

[EBV x (starting Hct - allowable Hct)] / starting Hct
25%

Relatively small amount blood loss → severe hypovolemia

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23
Q

NEC

Preop

A

Optimize hemodynamic & coagulation status
Check blood product availability
ETT & catheter placement
Adequate IV access
Know acceptable hemodynamic parameters (HR, BP, SpO2, FiO2)

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24
Q

NEC

Intraop

A 
Standard monitoring
Arterial catheter
Maintain hemodynamic stability
Vasoactive support (Dopamine or Epi gtt)
Opioids or low-dose inhalation anesthetic agent w/ neuromuscular paralysis
Check glucose levels & electrolytes
Fluid resuscitation
PRBC, FFP, cryo
Temperature homeostasis - forced air warmer
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25
Q

NEC

Postop

A

Mechanical ventilation
Sedation
Analgesia

26
Q

Inguinal Hernia

A

1/3 pre-term infants

1% full-term neonates

27
Q

Inguinal Hernia

Complications

A 
Incarcerated bowel
Intestinal obstruction
Gonadal infarction
Infection
Hematoma
Recurrent hernias
28
Q

Inguinal Hernia Repair

A

General or regional anesthesia
Small defect consider LMA
Large defects requiring muscle relaxation → ETT
Ilioinguinal, iliohypogastric, or caudal/epidural blocks

29
Q

ROP Treatment

A

Cryotherapy - freezing probe to avascular retina, requires general anesthesia, 32-42wks corrected
Laser photocoagulation - moderate ROP 10-30min every few weeks
Scleral bucking surgery or vitrectomy - severe ROP w/ retinal detachment > 6mos-1yo
- Requires general

30
Q

CDH

A

Congenital diaphragmatic hernia
Anatomic defects permit abdominal contents to intrude into thoracic cavity
Asymptomatic → life-threatening
Early - abdominal mass inhibits normal cardiopulmonary growth; severe lung hypoplasia associated w/ morbidity & mortality; negatively correlates w/ gestational age at time hernia occurred
Late - occurs near or even after delivery, mature well-developed lungs, minimal problems w/ ventilation

31
Q

When does the diaphragm formation complete in utero?

A

Week 7-10

32
Q

Most common CDH type

A

Bochdalek hernia 95%
More likely to have concurrent birth defects & chromosomal abnormalities
L sided lesions 7x more frequent

33
Q

CDH S/S

A

Hypoxia
Scaphoid abdomen
Bowel sounds in thorax

34
Q

CDH Complications

A

Abdominal viscera present in thoracic cavity itself not life-threatening rather the compression effects on developing pulmonary structures obstruct smooth transition from fetal to neonatal circulatory pattern

  • Hypoplastic lungs
  • Intrapulmonary shunting & inadequate gas exchange
  • ↓total cross-sectional area results in pulmonary arteriole HTN
35
Q

CDH

Anesthetic Considerations

A

Initial management - airway control & optimize oxygenation/ventilation
Avoid mask ventilation to limit gastric insufflation
Place NG tube to decompress stomach
Supine or lateral dependent on defect location
Pre & post-ductal monitoring R → L shunt or pulmonary HTN
- PIV x2 and/or CVC
- A-line or UAC
- Serial ABGs
- EBL 5-10mL/kg
- PRBCs available
Limit inhalational agent, paralysis, & narcotics
Avoid nitrous oxide
Prevent excessive oxygenation
Sedation important to limit catecholamine response

36
Q

CDH

Surgical Approaches

A

Recurrent defects - minimally invasive approach through abdomen
Primary closure vs. synthetic path
Delay closure until cardiorespiratory & medically stabilization
Before, during, or after ECMO
Transiently worsens pulmonary HTN → persistent fetal circulation (PDA open & shunts blood R → L bypassing lungs)
Outcomes 1° dependent on underlying pulmonary hyperplasia & HTN
Stabilize cardiorespiratory status during transition from intrauterine to extrauterine before surgical repair
- 48hrs to 4-6 days old
- Stabilize in NICU before OR

37
Q

Inhaled Nitric Oxide

A

Pulmonary vasodilator (avoids systemic hypotension)
Refractory pulmonary HTN treatment ↓ R → L shunt & improve oxygenation
Short acting

38
Q

VV ECMO

A

Temporary measure allows lungs to rest & mature while providing appropriate gas exchange through membrane oxygenators
Venovenous
Double lumen resides in IJ vein

39
Q

VA ECMO

A

Temporary measure allows lungs to rest & mature while providing appropriate gas exchange through membrane oxygenators
Venoarterial
Two catheters - IJ vein & carotid artery

40
Q

ECMO Contraindications

A

IVH

Obtain HUS 1st

41
Q

How should CRNAs approach & treat severe cardiovascular compromise in CDH?

A

Volume & inotropic support

Dopamine

42
Q

Malrotation

A

Intestines twist around superior mesenteric artery → kink & compress vascular supply
Atretic segments, compromised perfusion, & intestinal ischemia

43
Q

Volvulus

A

Bowl strangulation & shock

44
Q

Malrotation & Midgut Volvulus

Presentation

A 
Bilious emesis
Abdominal distension
Hemodynamic instability
Hypotension
Hypovolemia
Electrolyte abnormalities
Bloody stools

Surgical emergency - necrosis risk

45
Q

Omphalocele

A

Hernia or rupture at the umbilicus
Failure gut to migrate from yolk sac into the abdomen
Associated genetic, cardiac, urologic, & metabolic abnormalities
Viscera emerge from umbilicus & covered w/ membranous sac

46
Q

Gastroschisis

A

Herniated viscera exposed to air after delivery
Risk inflammation, edema, & dilation /w abnormal bowel function
Not usually associated w/ other congenital abnormalities

47
Q

Omphalocele & Gastroschisis

Medical Management

A

Maintain perfusion & prevent fluid loss
Goal = abdominal closure (often delayed to avoid exposing the viscera to excessive pressure)
↑intra-abdominal pressure → cardiorespiratory failure, renal failure, ↓hepatic function, ischemic bowel, & death
Pressures >20mmHg poorly tolerated

48
Q

Omphalocele & Gastroschisis

Postop

A

Assess ability to extubate
Continue gastric suction
IV nutrition TPN weeks → months
Often remain intubated w/ IV sedation, paralytics, & opioids

49
Q

Criteria to Abort 1° Closure

A

Intra-gastric pressure >20mmHg
Intra-vesical pressure >20mmHg
ETCO2 >50mmHg
PIP (ventilatory pressures) >35cmH2O

50
Q

VACTERL

A 
Vertebral abnormalities
Imperforated anus
Congenital heart disease
Tracheo-
Esophageal fistula
Renal abnormalities
Limb abnormalities
51
Q

Esophageal Atresia

A

Esophagus does not connect to stomach

52
Q

Tracheoesophageal Fistula

S/S

A

TEF
Normally diagnosed immediately after birth
Excessive secretions, coughing, & choking after 1st feeding

Additional indicators - recurrent pneumonias & unable to pass OG

53
Q

TEF Associated Risks

A

Pneumonia, poor nutrition, gastric distension → impaired ventilation

54
Q

TEF Types

A 
Esophageal atresia w/ distal TEF 
Isolated esophageal atresia 8%
Isolated TEF 4%
Esophageal atresia w/ proximal TEF 1%
Esophageal atresia w/ double TEF 1%
55
Q

Most common TEF type _____

A

Esophageal atresia w/ distal TEF 87%

Type C/IIIB

56
Q

TEF

Anesthetic Considerations

A 
Consider "awake" fiberoptic intubation
Avoid +pressure ventilation
RSI induction
Place ETT b/w fistula & carina
Avoid nitrous oxide
Surgical traction effect on lung, vasculature, trachea, heart, & Vagus nerve
57
Q

What does precipitous O2 desaturation in TEF repair indicate?

A

Atelectasis & secretions → pulmonary blood flow shunt
Lung tissue retraction
Tracheal & bronchial compression
Bleeding
ETT malposition (utilize L sided precordial to assess tube migration)
Arterial hypoxia → surgeon release traction & perform alveolar recruitment maneuvers

58
Q

TEF Complications

A 
Anastomosis leaks & strictures
GERD
Feeding aversions
Esophageal dysmotility
Strictures
Pulmonary disease
Tracheomalacia
59
Q

Average neonate oxygen consumption

A

5-8mL/kg/min

Adult 2-3mL/kg/min

60
Q

What causes an increased CO2 production in neonates?

How do they compensate for this change?

A

↑metabolic rate ↑CO2 production

↑respiratory rate to facilitate CO2 elimination

61
Q

Fetal Hgb has an _____ oxygen affinity

A

INCREASED

↓oxygen Hgb release → tissues

62
Q

What postop complication needs to be closely monitored for in neonates?

A

APNEA

AS - N935 Advanced Patho II (20 decks)

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