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AP Summer > Pediatrics - Surgical Emergencies > Flashcards

Pediatrics - Surgical Emergencies Flashcards

1
Q

What is the increased O2 consumption for a neonate?

A

7 mL/kg/min

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2
Q

What are the diaphragmatic and chest wall differences in the ped population?

A
    • Lung tissue less compliant

- - Chest wall more compliant

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3
Q

What is significant about fetal hemoglobin?

A

It binds O2 more tightly than adult hemoglobin

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4
Q

What does CO in peds depend on?

A

HR (SV is constant)

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5
Q

Which autonomic nervous system is more developed in the neonate?

A

Parasympathetic, which means they are more prone to bradycardia, etc.

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6
Q

At birth, how does neonatal GFR compare to that of adults?

A

25%

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7
Q

At what age does regular kidney function occur?

A

6 months

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8
Q

What ability do neonates gain at 32 weeks gestational age?

A

Sodium retaining ability

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9
Q

What is TBW?
What % water are premies?
Term Baby?
Adult?

A

Total Body Water
Premies: 75-85% water
Term Baby: 70%
Adult: 60%

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10
Q

How do renal and hepatic function in neonates compare to that of adults?
Why is this important in anesthesia?

A
    • Decreased renal function and blood flow, decreased liver blood flow, decreased enzymes, decreased protein binding
    • All important to drug metabolism–drugs will last longer in neonates
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11
Q

How do blood vessels aka IV access compare to that of adults?

A

Small, fragile vessels –> more difficult IV access (if very desperate, go to intraosseus method)

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12
Q

What are the two defects in the abdominal wall that allow a portion of the intestinal viscera to remain outside the abdominal cavity?

A

Omphalocele and Gastroschisis

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13
Q

What management considerations relate to Omphalocele and Gastroschisis? (3)

A
  1. Impaired blood supply to visceral organs
  2. Bowel obstruction
  3. Extreme fluid shifts/deficits
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14
Q

What are the characteristics of omphalocele?

A

Definition: failure of gut to migrate into abdomen during gestation
1 in 6000 births
Male:female = 2:1
30% mortality

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15
Q

Where is the defect of an omphalocele?

A

At the base of the umbilicus

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16
Q

Which has the larger defect?

A

Omphalocele

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17
Q

Which defect is associated with congenital abnormalities and prematurity? Omphalocele or gastroschisis?

A

– Omphalocele assoc with congenital abnormalities, such as cardiac, genetic, metabolic, and urologic abnormalities

– Gastroschisis is more assoc with prematurity

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18
Q

True or False: Pts with omphalocele usually have normal bowel function.

A

True

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19
Q

Describe the bowels of the omphalocele.

A

Covered by sac and protected amniotic fluid in utero, looks more like a balloon

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20
Q

What are the characteristics of gastroschisis?

A

Develops as a result of occlusion of the omphalomesenteric artery during gestation
Incidence 1:15k (rare)
Male:female = 1:1
15% mortality

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21
Q

True or false: gastroschisis is associated with other congenital abnormalities.

A

False (omphalocele is assoc with other congenital abnormalities)

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22
Q

Where is the defect in gastroschisis?

A

To the right of the umbilicus

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23
Q

Describe the bowels of gastroschisis patients.

A
    • Edematous and inflamed with a “peel”
    • Dilated, foreshortened, and functionally abnormal
    • Usually very red and angry-looking
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24
Q

Why does the bowel of gastroschisis patients look the way it does?

A

Tissue reaction from exposure to amniotic fluid

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25
Q

What are the anesthetic considerations for Omphalocele or gastroschisis?

A

Pts are volume depleted and will have heat and fluid loss from large exposed surface SO:

  1. Keep warm
  2. Replenish fluids
  3. Good IV access in upper extremities
  4. Get labs to watch out for hypoglycemia and calcemia bc of possible renal dysfunction
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26
Q

What is the greatest cause of pulmonary dysfunction in omphalocele and gastroschisis patients?

A

RDS assoc with prematurity

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27
Q

What is important to monitor intraop for Omphalocele or gastroschisis correction procedures?

A
  1. Intra-abdominal pressures
  2. Clear drape over legs to monitor low extremity perfusion
  3. Possible CVP in case compression of large vessels that would result in dec venous return
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28
Q

What are the induction/intubation preferences for Omphalocele or gastroschisis procedures?

A
    • Awake intubation if hypovolemic

- - RSI if normovolemic

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29
Q

At what pressure should the ETT leak be for Omphalocele or gastroschisis patients?

A

30-40 cm H2O

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30
Q

What is the intraop mgt of Omphalocele or gastroschisis procedures?

A
  1. Warm OR to 80 degrees F
  2. Decompress stomach
  3. Keep sats bw 94-97 for term baby and 90-94 for premie
  4. Hematocrit > 30%
  5. Use fluids D10 1/4 NS at 10-15 cc/kg/hr (free water to help kidneys, dextrose for hypoglycemia)
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31
Q

What is the difference bw primary and secondary closures of Omphalocele or gastroschisis?

A

Primary: entire bowels put back into abdomen
Secondary: bowels stay exposed and require staged closures that have cinching of silo with definitive closure at 7-10 days

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32
Q

If primary closure has taken place for Omphalocele or gastroschisis, what are postop concerns?

A
    • Pt with no lung disease may be extubated

- - If lung disease present, maintain PPV until intra-abdominal pressures decreases and keep PEEP to improve FRC

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33
Q

What complications can occur from Omphalocele or gastroschisis procedures?

A
    • Most occur when too aggressive when trying to put too much bowel back into abdominal cavity
      1) Respiratory failure
      2) Bowel ischemia
      3) Hypothermia
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34
Q

What is the failure of embryonic neuroganglion cells to migrate to Auerbach and Meissner plexuses of the colon and will present as a bowel obstruction?

A

Hirschprung’s Disease

Congenital aganglionic megacolon

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35
Q

What is the most common cause of neonatal GI obstruction?

A

Hirschprung’s Disease

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36
Q

What are the characteristics of Hirschprung’s Disease?

A

– Usually confined to rectosigmoid (anus to proximal)
– Only 10% of cases involve entire colon
1: 5000 births
Male: female = 4:1
Is associated with congenital defects

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37
Q

What are the ganglion cells of Hirschprung’s Disease needed for?

A

They are needed to allow relaxation of the internal sphincter to pass a bowel movement

    • These babies do not make a bowel movement within first 24 hours of life (emergency)
    • Some get not diagnosed and do not come in until adolescents (not an emergency)
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38
Q

What are the 2 diagnoses of Hirschprung’s Disease?

A
    • Barium enema

- - Rectal biopsy

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39
Q

What is the surgical treatment of Hirschprung’s Disease?

A
    • Leveling colostomy in which biopsies are taken and sent to pathology to determine at which level ganglia are present
    • Can then reconnect portion of colon that has ganglion cells to the rectum
    • Can be a very long procedure waiting on pathology
40
Q

What is the definitive repair for Hirschprung’s Disease and when can this take place?

A
    • Abdominoperineal resection with colon pull through

- - When child reaches 10 kg

41
Q

Which disease presents as polyhydramnios (excessive amniotic fluid), excessive oral secretions, and cyanosis with feedings?

A

Tracheoesophageal Fistula

42
Q

What are the characteristics of Tracheoesophageal Fistula?

A

1:3000 live births
Male = female ratio
Mortality: 1-15% depending on prematurity
Associated abnormalities : VACTERL
– Gas noted distally to fistula on x-rays

43
Q

What is most common type of TEF? (apparently a favorite board question)

A

Esophageal atresia with distal fistula

90% of cases

44
Q

What is EA?

A

Esophageal atresia

the esophagus has not formed fully

45
Q

How do you discover a TEF ?

A

– Noted by failure to pass OG tube

46
Q

What is difference in EA and TEF?

A
    • Pure EA has no gas distal to esophagus and only occurs in 7% of cases
    • Pure EA managed with gastrostomy and later anastomosis
47
Q

EA with air in stomach = ______

No air in bowel, ____ alone

A

TEF

EA

48
Q

The most common TEF has what two distinct features?

A
    • Blind esophageal “floating” pouch

- - Fistula off distal trachea to stomach

49
Q

What are most common associated anomalies associated with Tracheoesophageal Fistula?

A

1) Prematurity
2) Cardiac
3) Muscoloskeletal

50
Q

What does VACTERL stand for?

A
    • Vertebral
    • Anal
    • Congenital heart disease
    • TEF
    • EA
    • Renal or radius abnormalities
    • Limb abnormalities
51
Q

What are induction considerations for Tracheoesophageal Fistula?

A
    • Head up to minimize aspiration
    • NG in esophagus to continuous suction
    • Warm room
    • Good IV access
    • Type and cross blood with blood in room
52
Q

What kind of induction should be performed in Tracheoesophageal Fistula patients?

A
    • Awake if unstable

- - RSI if stable

53
Q

Where should the ETT be positioned in TEF?

A

Above carina but below fistula (can be very very difficult to do)

54
Q

What are intraop considerations for TEF?

A
    • Lower ventilatory pressures
    • A line
    • Lateral decubitius with incision opposite side as aortic arch
55
Q

What are postop risks/considerations for TEF?

A
    • Extubation preferable
    • Humidified O2
    • Highest risk is URI / LRI 75%
    • Aspiration develops abnormal swallowing and GERD
    • Can develop atelectasis/tracheomalcia
56
Q

What are the long term complications of TEF?

A
    • Increased bronchial reactivity 18 years after repair
    • By 2nd-3rd decade 90% asympotomatic or have mild dysphagia
    • Abnormal esophageal motility
57
Q

What is necrotizing enterocolitits (NEC)?

A
    • Ischemia condition of GI tract of multifactorial etiology (etiology unknown)
    • Basically inflammatory and ischemia areas in GI tract
58
Q

What are characteristics of necrotizing enterocolitits?

A

Incidence : 5-8% of NICU admissions
>90% are premies < 1500 Gm
Mortality 25%

59
Q

What are risk factors for NEC?

A
    • Onset of gastric feedings / hypertonic feedings
    • Gut hypoperfusion
    • Hypoxemia
    • Bacterial colonization
60
Q

What are most common signs of NEC?

A
    • Abdominal distention/discoloration
    • Bloody stools
    • Temperature instability
    • Vomiting or DIC
61
Q

How does NEC present?

A

– Distended, tender abdomen in child that appears septic

– Requires intubation, fluids, supportive care, antibiotics

62
Q

What is treatment plan for NEC?

A
    • Conservative early
    • As soon as pt shows signs of getting worse, surgical treatment is performed
    • Gastric decompression
    • Surgical (as soon as you see free air on film, take to surgery bc this indicates a perforated bowel)
63
Q

Preop considerations for NEC?

A
  1. Urgent fluid/blood resuscitation 150 cc/kg (start in NICU)
  2. May require inotropes (CHF due to sepsis/acidosis)
  3. Careful bicarbonate administration to correct acidosis
    - HCO3 deficit = BD x weight x 0.3
    - Give half of calc deficit SLOWLY in preop
  4. IVH risk due to aggressive fluid resuscitation, lack of autoregulation, wide swings in BP
  5. RBCs, platelets, FFP, cryo available
64
Q

Intraop considerations for NEC?

A
  1. Good IV access
  2. Standard monitor, A-line, urinary catheter +/- CVP
  3. Warm OR
  4. EBL 10-100 cc/kg, maintain Hct > 30%
  5. Anes: ketamine/O2/air/opioid/m. relaxation
  6. Keep sat 94-95%
65
Q

Postop considerations for NEC?

A
  1. PPV
  2. Continue opioids & max m. relaxation (will remain intubated)
  3. Transport w/ extra volume, AW equipment, emergency drugs, & full monitors
66
Q

What is a congenital diaphragmatic hernia?

A

At 4-9 wks gestation, the pleuroperitoneal membrane separates the chest and abdominal cavities. This hernia results in incomplete closure of the membrane. Bowels move into chest cavity, impacting lung development.

67
Q

How is CDH diagnosed?

A

Possibly by prenatal ultrasound, or diagnosed at birth by presence of scaphoid or sunken abdomen with respiratory failure

68
Q

What issue is most associated with CDH?

A

Pulmonary hypoplasia (due to impingement of bowel on lungs)

69
Q

What is the most prevalent location for CDH?

A

Foramen of Bochdalek (posterolateral)

Left:right 5:1

70
Q

What are the consequences of the compression of abdominal contents into the chest in CDH? (5)

A
  1. 50% reduction in alveoli
  2. Mediastinal shift
  3. Hypoplastic pulmonary artery
  4. Pulmonary HTN
  5. Bronchial arrest at 11-13 wks
71
Q

What are the 3 causes of death associated with CDH?

A
  1. Progressive hypoxemia
  2. Respiratory failure
  3. Pulmonary HTN
72
Q

What is the most commonly associated anomaly in CDH?

A

GI 40-60% (100% have malrotation which presents with bowel obstruction symptoms)

73
Q

Is CDH a surgical emergency?

A

No (surgery does not cure lung hypoplasia)

74
Q

What must you do prep before surgery can take place for CDH pts?

A
  1. Stabilize medically or with ECMO
    • must be able to oxygenate/ventilate
  2. Correct acidosis
  3. Treat pulmonary HTN
  4. IV access
  5. Gastric decompression
75
Q

After weaning from ECMO, what does the surgical repair of CDH consist of?

A
    • Abdominal incision for bowel and diaphragm repair

- - May have to construct an artificial akinetic diaphragm

76
Q

What is the intraop mgt of CDH?

A
    • Opioid heavy
    • Low PIP pressures
    • Poss need for pressure-limiting ventilator
    • Consider awake intubation
77
Q

What is the postop mgt of CDH?

A
    • Minimize suctioning to prevent any damage to bowels

- - Maintain PPV and respiratory alkalosis

78
Q

What are CDH complications?

A
  1. Contralateral PTX (do not attempt to expand lungs when mask ventilation)
  2. Hypothermia
  3. Metabolic acidosis
  4. Persistent pulmonary HTN with right to left shunting
79
Q

What is the prognosis for CDH?

A

If <35 wks gestation, mortality is 90% (bc of respiratory distress in first hour of life)

80
Q

What is the bridge used for CDH until definitive repair?

A

ECMO

81
Q

What is ECMO?

A

Extracorporeal Membrane Oxygenation, acts as a lung machine

82
Q

What is the one definitive indication for ECMO?

A
    • MUST be REVERSIBLE respiratory failure/lung disease
    • Must be >34 wks gestation
    • Must be >2 kg
83
Q

What excludes a patient from receiving ECMO?

A

> Grade II intraventricular hemorrhage

Or other life-threatening anomalies

84
Q

What is the mortality for CDH?

A

30-40%

12% for all neonatal ECMO

85
Q

What are the two myelodysplasias that occur bc of abnormal fusions of neural grooves that leave some portion of brain or cord exposed?

A

Meningomyelocele and Encephalocele

86
Q

Which is the more common myelodysplasia?

A

Meningomyelocele
Occurs 3:1000
(Encephalocele only occurs 0.3:1000)

87
Q

What is the most common site for myelodysplasias?

A

lumbosacral (75%)

88
Q

What is the risks of myelodysplasias and what is subsequent mortality?

A
    • Infection/death due to exposed CNS elements
    • Delayed closure worsens motor function later in life
    • Mortality 17.6% so correct abnormality AS SOON AS BABY IS BORN
89
Q

What are preop considerations of myelodysplasias?

A
  1. Warm room
  2. Position to protect neural plaque (no pressure on defect so cannot lie on back)
  3. Plan AW mgt (intubation may be difficult, poss prone)
90
Q

What is the anes mgt of myelodysplasias?

A
  1. Position important
  2. Awake intubation safest
  3. Extubate awake asap in lateral position (want to make sure no neurological deficits)
91
Q

What is a large, multi-septated cystic lesion that is the result of large lymphatic malformations?

A

cystic hygroma

92
Q

What structures could cystic hygroma affect?

A
    • 10-15% extend to the mediastinum

- - Great vessels, tongue, brachial plexus, vagus, phrenic, facial, and hypoglossal nerves

93
Q

What is morbidity of cystic hygroma associated with?

A

AW compromise, infection, or bleeding

94
Q

What are preop considerations for cystic hygroma?

A
    • Potential for AW compromise, prepare for difficult intubation
    • Have blood in room & be prepared for large amts of blood loss
    • Get labs, crit, glu, calcium, etc.
95
Q

What are induction and intraop considerations for cystic hygroma?

A
    • Warm room
    • Maintain SV
    • A-line
    • IV access in LOWER extremities
    • Can do inhalational induction
    • IV atropine before DL
96
Q

What are postop considerations for cystic hygroma and what should you watch out for?

A
    • Keep intubated and transport to ICU
    • Watch out for RLN injury, subglottic/upper AW edema, and bleeding
    • May be brought back to OR for extubation

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