Peds Flashcards
Compared to epiglottitis, which findings are MORE likely to occur with laryngotracheobronchitis? (select 3)
a. Age affected <2 years
b. high fever
c. tripod position
d. steeple sign
e. onset between 24-72 hours
f. more likely to require anesthesia for urgent airway control
A - age affected <2 years
D - Steeple Sign
E - Onset between 24-72 hours
Is epiglottitis viral or bacterial?
Bacterial
What age does epiglottitis affect?
Ages 2-6 years
Epiglottitis has a ____ onset.
rapid
What is the clinical presentation of epiglottitis?
Drooling, dyspnea, dysphonia, dysphagia, and high fever
(the 4 Dās)
What is the treatment for epiglottitis?
O2, urgent airway management, Abx
Who must be present for induction for epiglottitis?
ENT
What is another name for laryngotracheobronchitis?
Croup
Is croup viral or bacterial?
Viral
What age does croup affect?
Ages <2 years
Croup has a ____ onset.
gradual
What are the clinical presentations of croup?
mild fever, inspiratory stridor, barking cough, hoarseness, and retractions (suprasternal, substernal, intercostal)
What is the treatment for croup?
O2, racemic epi, steroids, humidification, fluids
T/F: Intubation is often required for croup.
False - rarely required
Epiglottitis is also called ____.
supraglottitis
What bacteria cause epiglottitis?
H. influenza (less common today)
Group A streptococci
Pneumococci
Staphylococci
What viruses cause croup?
H. parainfluenzae
Respiratory syncytial virus
Influenza type A & B
Although rare, the ______ bacteria can cause croup.
mycoplasma pneumoniae
Epiglottitis onset is _____ hours.
<24 hours
What region and structures are affected in epiglottitis?
Supraglottic - epiglottis, vallecula, arytenoids, aryepiglottic folds
What region and structures are affected in croup?
Laryngeal structures below the vocal cords
The thumb sign occurs with what pediatric disease?
Epiglottitis
A lateral or frontal x-ray is used for epiglottitis?
Lateral
What is the neck x-ray findings for croup?
Subglottic narrowing called a steeple sign (dx w/ frontal x-ray)
What position will kids with epiglottitis be in?
Tripod
Does epiglottitis or croup present with inspiratory stridor?
Croup
When diluted into 2.5 mL of NS, what is the MOST appropriate dose of racemic epi to adminsiter to a 30 kg kids with post-intubation croup?
A. 0.5 mL of a 0.25% solution
B. 0.5 mL of a 2.25% solution
C. 5 mL of a 0.25% solution
D. 5 mL of a 2.25% solution
B - 0.5 mL of a 2.25% solution
While post-intubation laryngeal edema can occur with cuffed or uncuffed ETTs, the key point is to maintain an air leak of _____.
<25 cm H2O
What age is considered a risk factor for post-intubation laryngeal edema?
Age < 4
What is the treatment for post-intubation laryngeal edema?
cool/humidified O2, decadron, racemic epi
Post-intubation laryngeal edema is also called what?
post-intubation croup
What is the most common cause of post-intubation laryngeal edema?
Using an ETT that is too large
Pediatrics, the tracheal mucosa perfusion pressure is ____.
25 cm H2O
How does a patient with post-intubation laryngeal edema present?
Hoarseness, barky cough, stridor
Post-intubation laryngeal edema typically occurs within _____ following extubation.
30-60 minutes
What disorder is a risk factor for post-intubation laryngeal edema?
Trisomy 21
How is racemic epi preferably delivered for post-intubation croup?
by intermittent positive-pressure ventilation, face mask, or nebulization
T/F: Racemic epi is not diluted.
False - it must be diluted into NS
What percentage of racemic epi dose should be used?
2.25% racemic epi
For a kid that weighs 0-20 kg, what is the volume of 2.25% racemic epi solution? What is the volume of normal saline diluent?
0.25 mL ; 2.5 mL
For a kid that weighs 20-40 kg, what is the volume of 2.25% racemic epi solution? What is the volume of normal saline diluent?
0.5 mL; 2.5 mL
For a kid that weighs >40 kg, what is the volume of 2.25% racemic epi solution? What is the volume of normal saline diluent?
0.75 mL; 2.5 mL
What is the Dexamethasone dose for post-intubation laryngeal edema?
0.25 - 0.5 mg/kg IV
How long does the max effect of Dexamethasone take when using for post-intubation laryngeal edema?
4-6 hours
What is Heliox?
A mix of Helium and Oxygen
Heliox improves ____ airflow by reducing _____.
laminar; Reynoldās number
Are antibiotics indicated for post-intubation croup?
No it is not infectious (like laryngotracheobronchitis is)
How long should you observe a patient after racemic epi treatment for post-intubation laryngeal edema is complete?
minimum of 4 hours
What age is postintubation laryngeal edema. most often seen?
Age <4 years
A 5 y/o kid presents for surgery w/ clear rhinorrhea, but she is afebrile and appears active. Rank the following airway techniques form MOST to LEAST favorable to minimize the risk of airway reactivity.
LMA, Facemask, ETT
- Facemask
- LMA
- ETT
When a kid has a recent URI, most clinicians will postpone the procedure for _____ after the onset of symptoms.
2-4 weeks
What are infection-related reasons to cancel a procedure in pediatrics?
- purulent nasal discharge
- temp > 38 C
- lethargy
- persistent cough
- poor appetite
- wheezing and rales that donāt clear w/ cough
If you must use an ETT in a kid that has has a recent URI, what is recommended?
Use a smaller size than normal
Does propofol attenuate or antagonize airway reactivity?
Attenuate
What is the best volatile agent to use in a kid that has a recent URI?
Sevo (b/c it is non-pungent)
T/F: For kids with recent URI, pretreatment w/ an inhaled bronchodilator or Robinul does not provide a clear benefit.
True
Kids with a recent URI are more likely to experience pulmonary complications including ______, ______, _____, ____, _____, and _________.
bronchospasm, laryngospasm, mucous plugging, atelectasis, desaturation events, and post-op hypoxemia
What type of infection is the most common cause of URI?
Viral
In kids with recent URI, mechanical irritation (such as ETT us) increases the risk of bronchospasm _____-fold!
10
A 3 year old kid aspirated a peanut and presents for rigid bronchoscopy. What is the MOST important anesthetic consideration for this patient?
A. inhalation induction
B. observing NPO guidelines
C. positive pressure ventilation
D. Rocuronium
A - inhalation induction
What is the classic triad of foreign body aspiration?
Cough, wheezing, and decreased breath sounds on the affected side (usually right)
Does a supraglottic obstruction cause stridor or wheezing?
Stridor
Does a subglottic obstruction cause stridor or wheezing?
Wheezing
What is the gold standard procedure to retrieve foreign body from the airway in peds?
Rigid bronchoscopy
What type f induction is usually best for foreign body aspiration?
Sevo induction w/ spontaneous ventilation
Why do you avoid PP ventilation in foreign body aspiration?
It can push the foreign body deeper into the bronchial tree
What is the best maintenance technqiue for foreign body apsiration?
TIVA
The foreign body most commonly lodges in the _____ bronchus.
right
What are complications for rigid bronchoscopy for foreign body aspiration in pediatrics?
laryngospasm, bradycardia during scope insertion, post-intubation croup, pneumothorax
T/F: Patients will improve immediately after foreign body removal.
False - may not d/t residual lung inflammation
What are other options besides rigid bronch for foreign body aspiration?
flexible bronch or thoracotomy
What is the most significant concern with foreign body aspiration?
Airway obstruction
_____ ventilation should be used thorough-out the foreign body aspiration procedure. Why?
SV; it maintains laminar airflow, which reduces the risk of distal movement of the foreign body
There is some degree of air leak around the rigid bronch for foreign body aspiration. This leak permits room air entrainment which can dilute the concentration of volatile. How can you compensate for this leak?
Increase the FGF and vaporizer output
Which congenital condition is associated with macroglossia?
A. Glucose-6-dehydrogenase deficiency
B. Klippel-Feil
C. Treacher Collins
D. Trisomy 21
D - trisomy 21
What two congenital conditions are associated with a large tongue?
Beckwith Sydnrome
Trisomy 21
(Big tongue)
What 4 congenital conditions are associated with a small/underdeveloped mandible?
Pierre Robin
Goldenhar
Treacher Collins
Cri du Chat
(Please get that chin)
What 3 congenital conditions are associated with a cervical spine anomaly?
Klippel-Feil
Trisomy 21
Coldenhar
(kids try gold)
What are the anesthetic considerations for cleft lip and palate?
Airway obstruction, difficult DL, difficult mask ventilation, aspiration
The _________ mouth retractor can reduce venous drainage and cause tongue engorgement. This increases the risk of post-extubation airway obstruction.
Dingman-Dott
A neonate with Pierre Robin often requires what?
Intubation
What are the characteristics of Pierre Robin?
Small/underdeveloped mandible (micrognathia or mandibular hypoplasia), tongue that falls back adn down (glossoptosis), and cleft palate
What are the characteristics of treacher collins?
Small mouth, small/underdeveloped mandible, nasal airway is blocked by tissue (chonanal atresia), and ocular & auricular anomalies
What are the characteristics of Trisomy 21?
small mouth, large tongue, atlantoaxial instability, small subglottic diameter (sublottic stenosis)
What is the characteristics of Klippel-Feil?
Congenital fusion of cervical vertebrae ā> neck rigidity
What are the characteristics of Goldenhar?
Small/underdeveloped mandible and cervical spine abnormality
What is the characterisitc associated with Beckwith Sydnrome?
Large tongue
What are the characteristics of Cri du Chat?
Small/underdeveloped mandible, laryngomalacia, stridor
Cleft lip repair is typically performed at _____ age.
@1 month of age
Cleft palate repair is typically performed at _____ age.
@12 months of age
What are 3 conditions associated with Cri Du Chat?
- Small, underdeveloped mandible
- laryngomalacia
- stridor
What are 2 conditions associated with Goldenhar?
- Small mandible
- Cervical spine abnormality
What is the MOST common cardiac anomaly associated with Down Syndrome?
A. Atrioventricular septal defect
B. 1st degree heart block
C. Bicuspid aortic valve
D. single ventricle
A - AV septal defect
What is the most common chromosomal disorder?
Trisomy 21 (Down Syndrome)
Why is the patient with Down Syndrome at an increased risk for difficult ventilation and intubation?
** Small mouth, large tongue, palate is narrow w/ high arch, midface hypoplasia, atlantoaxial instability, subglottic stenosis, OSA *******
Our genetic makeup consists of ____ chromosomal pairs.
23
What causes Down Syndrome?
The addition of a 3rd copy of chromosome 21
T/F: Older mothers are more likely to give birth to a child with Down Syndrome.
True
Down Syndrome:
_____ mouth
Small
Down Syndrome:
_____ tongue
Large
Down Syndrome:
_____ palate
Narrow + high arched
Down Syndrome:
Midface _____
Hypoplasia
For Down Syndrome, the atlantoaxial instability is associated with subluxation at what level?
C1 & C2
Because of atlantoaxial instability, what should be avoided during DL? And what should be done pre-op in Down Syndrome patients?
Neck flexion; Cervical spine X-ray
Down Syndrome:
_____ stenosis
Subglottic
Co-existing _____ disease is common in Down SYndrome.
heart
What is the most common congenital heart disease in Down SYndrome?
AV septal defect (endocardial cushion defect)
What is the second most common congenital heart disease in Down Syndrome?
VSD
For Down Syndrome patients, what is common during induction with Sevo? How do you treat it?
Bradycardia; Treat with anticholingergic
(Carefully increase Sevo concentration during inhalation to avoid profound bradycardia)
Down Syndrome patients have ____ levels of circulating catecholamines
Low
T/F: Down Sydnrome is associated with epilepsy
True
T/F: Down Syndrome is associated with strabismus
True
T/F: Down Syndrome is associated with hypotonia
Ture
T/F: Down Syndrome is associated with hyperflexible joints
True - be careful with positioning
T/F: Down Syndrome is associated with GERD
true
T/F: Down Syndrome is associated with thyroid disease
True
T/F: Down Syndrome is associated with increased incidence of leukemia
True
What 8 factors associated with trisomy 21 increase the risk of airway complications?
- Small mouth
- Large tongue
- Narrow palate
- Midface hypoplasia
- Atlantoaxial instability
- Subglottic stenosis
- OSA
- Chronic pulmonary infection
Match each congenital condition with its MOST likley presentation.
VACTERL association, Catch 22 (DiGeorge) Syndrome, CHARGE association
Renal dysplasia, Choanal atresia, hypocalcemia
VACTERL association - Renal dysplasia
CHARGE association - Choanal atresia
CATCH 22 (DiGeorge) syndrome - hypocalcemia
What does VACTERL association stand for?
V - Vertebral defects
A - Imperforated Anus
C - Cardiac anomalies
T - tracheoesophageal fistula
E - esophageal atresia
R - renal dysplasia
L - limb aanomalies
What does CHARGE association stand for?
C - coloboma
H- heart defects
A - choanal atresia
R - restriction of growth and development
G - genitourinary problems
E - ear anomalies
What does CATCH 22 (DiGeorge) Syndrome stand for?
C - cardiac defects
A - abnormal face
T - thymic hypoplasia
C - cleft palate
H - hypocalcemia
22 - 22a11.2 gene deletion
What is the cause of DiGeorge Syndrome?
22q11.2 gene deletion
VACTERL association, CHARGE association , and CATCH 22 are all associated with _______ defects.
CV
What is coloboma?
A hole in one of the eye structures
What is choanal atresia?
The back of the nasal passage is obstructed
Why does hypocalcemia occur in CATCH 22?
D/t hypoparathyroidism
What electrolyte abnormality is common in DiGeorge syndrome?
Hypocalcemia
What 3 things lower iCa in the blood?
- hyperventilation
- albumin
- citrated blood products
If the______ is absent in kids with DiGeorge syndrome, the kid is at high risk for infection. How is this treated?
thymus; thymus transplant or mature T cell infusion
What type of blood transfusion is best for kids with DiGeorge syndrome?
Transfusion of leukocyte-depleted irradiated blood
What is the MOST common coagulation disorder in kids undergoing adenotonsillectomy?
A. Hemophilia A
B. Heparin-induced thrombocytopenia
C. Sickle cell disease
D. von Willebrand disease
D - von Willebrand disease
What are the 2 most common pediatric surgical procedures?
Tonsillectomy and adenoidectomy
What are indications for tonsillectomy and adenoidectomy?
Nocturnal upper airway obstruction and chronic and/or recurrent infections
What is the most common cuase of OSA in kids?
adenotonsillar hypertrophy
______ is the most common coagulation disorder in patients undergoing adenotonsillectomy.
Von Willebrand disease
Dexamethasone (dose ________) may reduce post-op airway swelling, pain, and PONV in kids undergoing adenotonsillectomy.
1 mg/kg up to 25 mg
There is a risk for _____ with adenotonsillectomy. How do you help to prevent this?
airway fire; maintain low FiO2 and avoid N2O
T/F: N2O supports combustion.
True
You should maintain a low FiO2 at </= ____% for adenotonsillectomy. Why?
40%; risk for airway fire
Kids with OSA undergoing adenotonsillectomy should be admitted to the hospital for ______ and receiving monitoring for airway obstruction.
23 hours
What is a surgical emergency associated with adenotonsillectomy?
Post-tonsillectomy bleeding
What are the key anesthetic risks for post-tonsillectomy bleeding?
Hypovolemia and aspiration
(Perform volume resuscitation and RSI)
What is the most common indication for adenotonsillectomy?
Nocturnal upper airway obstruction and sleep disordered breathing (w/ or w/o OSA)
What chronic and/or recurrent infections are indications for adenotonsillectomy?
tonsillitis, pharyngotonsillitis, streptococcal carriage, otitis media, or rhinosinusitis
Kids with OSA undergoing adenotonsillectomy:
Emergence consideration - _______
Have longer emergence
Kids with OSA undergoing adenotonsillectomy:
Opioid consideration - _______
Should receive lower intra-op opioid dose or non-opioid analgesics (Precedex and Ketamine)
Kids with OSA undergoing adenotonsillectomy:
Post-Op consideration - _______
Have higher incidence of post-op airway obstruction, prolonged O2 requirements, and greater need for airway instrumentation
What medication should kids with OSA undergoing adenotonsillectomy NOT receive? (There is FDA warning about this!)
Codeine (d/t increased risk of death d/t respiratory depression)
How can you assess a kids risk for bleeding?
Ask about easy/frequent bruising, epistaxis, and family hx of bleeding disorders
Patients who recieve DDAVP are at risk for ________ (electrolyte abnormality)
hyponatremia
In patients who receive DDAVP, use isotonic crystalloids at ___ - ____ of the calculated maintenance values.
1/2 ā 2/3
What does the surgeon place during the adenotonsillectomy that must be removed prior to suctioning and extubation?
Throat pack
Why should you suction the airway well during emergence of adenotonsillectomy?
Secretions and blood can increase risk of laryngospasm
What special techniques should you used to suction post-tonsillectomy?
Use a tonsil tip suction and keep it mdiline to stay away from the lateral tonsil fossa
Primary post-tonsillectomy bleeding typically occurs within the first _______ hours.
first 24 hours
Approximately 75% of post-tonsillectomy bleeds occur within the first ___ hours after surgery.
6 hours
Secondary bleeding typically occurs _____ after tonsillectomy. What causes this secondary bleeding?
5-10 days; the scar (eschar) covering the tonsil bed contracts
Dizziness and orthostatic hypotension are suggestive of a ____% loss of circulating volume.
> 20%
How should you pre-oxygenate a patient that is being brought back for post-tonsillectomy bleed?
In the left-lateral and head down position to help drain blood from the airway
What do dizziness and orthostatic hypotension suggest in the kid presenting with a post-tonsillectomy bleed?
> /= 20% loss of circulating volume
(these patients should receive ongoing volume resuscitation before induction)
A child with which condition is MOST likley to develop QT prolongation after receiving blood products?
A. Trisomy 21
B. DiGeorge
C. CHARGE
D. VACTERL
DiGeorge (B/c hypocalcemia is common)
QT prolongation is a sign of symptomatic ________ electrolyte abnormalitiy
hypocalcemia
