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UBP Pearls > Peds > Flashcards

Peds Flashcards

1
Q

S/s of TEF in newborn?

A
  • maternal polyhydramnios (baby can’t swallow amniotic fluid)
  • copious oral secretions
  • inability to pass OGT into stomach
  • progressive gastric distention w/PPV
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2
Q

Steps to take w/newborn who shows signs of having a TEF?

A
  • stop PPV to avoid further gastric distention –> impaired ventilation –> dec venous return –> dec preload
  • if baby seems unstable, call for surgeon to possibly perform emergent Gtube
  • in the meantime, attempt to intubate past the fistula (ideally before carina though)
  • place pt in head up position to minimize regurgation into lungs
  • intermittent/continuous suctioning of upper esophageal pouch
  • keep neonate NPO
  • xray to confirm dx (coiling of OGT in blind pouch)
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3
Q

What are a few things to think about when trying to ventilate newborn with TEF and Gtube already in place?

A
  • vent the Gtube whenever you need! Don’t want too much gastric distention
  • consider intubating past the fistula (hopefully before the carina if able)
  • consider passing a Fogarty catheter retrograde through the gastroctomy to occlude the tracheal orifice of the fistula
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4
Q

Types of TEF and which is most common?

A
  • See pictures for all 5 types
  • type C is most common - esophageal atresia w/blind upper pouch and lower segment tracheal fistula (80-90% of cases)
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5
Q

Prematurity problems, specifically those that may complicate periop care? (11 total)

A

**I would try to think about these by going head to toe
- resp distress syndrome (dec compliance)
- persistent pulm HTN of the newborn (PPHN)
- apneic spells
- BPD (bronchopulm dysplasia)
- nec enterocolitis
- retinopathy of prematurity
- IVH
- dec renal fxn, impaired glu regulation, immature hepatic fxn, susceptibility to hypothermia

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6
Q

Congenital abnormalities associated with TEF?

A

VACTERL
- vertebral defects
- anal atresia
- cardiac (coarc, ASD/VSD, TOF)
- tracheo-esophageal fistula
- renal (hydronephrosis)
- limbs

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7
Q

How can a precordial stethoscope be utilized as a “monitor” intraop?

A

For example, during a TEF repair:
- 1 over the L axilla of baby to help monitor ventilation and HR while aiding in the detection of surgical obstruction of mainstem bronchus and intentional/accidental R mainstem intubation
- Another over stomach in order to detect ventilation through fistula

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8
Q

When asked about what monitoring you’d use for a TEF case, what can you say about the pulse ox?

A

“I’d pay special attention to the pulse oximetry due to the importance of the correct positioning of the ETT”…think about this for various cases where you’d like to emphasize 1-2 of the monitors

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9
Q

How do you place an art line in a neonate?

A
  • umbilical artery, or
  • one of the femoral arteries
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10
Q

How would you induce and intubate neonate with TEF for repair if he already has a g-tube or if he didn’t?

A

If g tube present:
- ensure proper monitoring and access (always forget to say this!)
- place in head up position (minimize regurg of gastric secretions)
- suction proximal esophageal segment
- suction g-tube
- topically anesthetize airway to minimize symp stimulation associated with laryngoscopy (could lead to IVH in premie)
- give atropine (ablate bagal response to laryngoscopy)
- perform RSI
- advance ETT into R mainstem bronchus –> slowly w/d until able to hear ventilation in L axilla
- verify that I could provide adequate PPV thru ETT w/o causing excessive bubbling from submerged end of the G tube
- if not, could 1) reposition ETT or 2) pass Fogarty catheter retrograde thru G-tube to occlude fistula

If g-tube not present:
- need to do awake b/c too high risk for gastric distention with PPV (gastric rupture, HD instability, impaired ventilation)
- NEED to provide adequate analgesia d/t risk for IVH if big symp response
- if neonate stable enough, could provide minimal sedation too

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11
Q

Several options for securing airway of neonate w/TEF and EA

A
  • awake intubation
  • inhalation induction w/o NMB: inc risk of aspiration
  • inhalation induction w/NMB: easier intubation, dec risk of IVH, still some risk of aspiration vs RSI bc slower + use pf PPV
  • IV induction: fastest and easiest intubation, though use of NMB = use of PPV so inc aspiration risk, and possibly higher risk of IVH d/t unclear plane of anesthesia d/t rapid nature
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12
Q

Pros of cuffed vs uncuffed ETT

A
  • Cuffed: dec risk of aspiration, dec need for repeated laryngoscopy to place appropriately sized ETT, dec subglottic pressure, more reliable delivery of high airway pressures, dec OR pollution
  • Uncuffed: can use bigger overall ETT w/larger internal diameter –> less airway resistance, possibly dec risk of post-extubation croup? But data has actually shown that there’s no difference
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13
Q

Definition of hypothermia? Normal limits for a neonate? Why are they prone to hypothermia?

A

< 35*C = hypothermia in adult
36.5-37.5 = normal for neonate

They’re prone to hypothermia d/t thin skin, large BSA: mass ratio, low subQ fat, inefficient mech of heat production (brown fat metabolism)

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14
Q

Extubation criteria for (all?) neonates?

A
  • CP status stable
  • awake
  • complete reversal of NMB
  • couch/gag reflex was intact
  • spontaneous TVs of 5-7cc/kg on CPAP
  • PIP < 30
  • O2 requirements < 40% w/PEEP 3-5
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15
Q

Risk factors for retinopathy of prematurity (aka retrolental fibroplasia)?

A
  • age < 44 wks post-conception!!! So shouldn’t use 100% FiO2 even in a full term neonate that is <1mo (minimal risk after vascularization of retina)
  • excessive inspired [O2] - hyperoxia, or maybe even just fluctuations in O2 sat
  • multiple blood transfusions
  • parenteral nutrition
  • hypoxia
  • hypercapnia and hypocapnia
  • congenital heart disease, IVH
  • <1500g (low birth weight)
  • lots of others
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16
Q

Normal Hct of healthy full term neonate?

A

~55%, appears reasonable to maintain at least 35% during big surgery
- also remember that fetHb shifts curve to the L, and comprises 75% at birth. So less able to deliver o2 to tissues

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17
Q

Barking cough w/insp stridor after surgery. Ddx? Tx for the main one?

A
  • post-intubation croup, most likely. Tx: neb recemic epi and IV decadron
  • develops 2/2 glottic or tracheal edema formation
  • epiglottitis, laryngotracheobronchitis, laryngeal foreign body are other ddxs
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18
Q

What are some options for management of postop pain in neonate s/p big surgery (like TEF)?

A
  • lumbar/caudal epidural w/bupi and fent
  • tylenol q4h, IV fent q1hr PRN
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19
Q

Spina bifida occulta vs cystica?

A

Occulta: incomplete/abnormal midline structures but NO herniation of meninges/neural elements (5-35% of population, usually singular vertebrae, but can be multiple and have skin changes/hair tuft, tethered cord, neuro deficits, scoliosis)

Cystica: failed fusion of neural arch w/herniation of meninges (meningocele) or meninges + neural elements (myelomeningocele)

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20
Q

Omphalocele vs gastroschesis mechanism? Other things to think about for each?

A
  • O: gut fails to return to abd cavity during gestation. Membrane protects from infx and fluid losses. Nlly functioning bowel. Congenital associations like diaphragmatic hernia, trisomy 21, cardiac stuff, exstrophy of the bladder. Beckwith-Wiedemann
  • G: occlusion of omphalomesenteric artery –> abd wall defect and subsequent herniation of abd contents. Inflammed and fxnally abnl bowel
  • O: can protect exposed bowel by covering w/sterile, saline soaked dressings, then place lower half of infant in sterile, clean plastic bag filled w/warm saline
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21
Q

Parts of Beckwith Wiedemann syndrome?

A
  • macrosomia, macroglossia (diff intubation possible)
  • omphalocele/umb hernia
  • neonatal hypoglycemia
  • polycythemia
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22
Q

What is the Cobb angle?

A
  • used to measure severity of scoliosis
  • lines drawn on radiographs of spine
  • > 10 = abnl, surgery rec for 40-50*, pulm dysfxn 60-65, pulm HTN past that
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23
Q

Why can you get SOB w/kyphoscoliosis?

A
  • chest wall deformity –> impaired pulm development + restrictive lung disease + inc WOB, V/Q mismatch –> hypoxia + hypoxic pulm constriction can –> pulm HTN and RV failure
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24
Q

Why can you have SOB from DMD?

A
  • abnl production of dystrophin can lead to:
    1) CM, vent dysrhythmias, MR
    2) dec pulm reserves, ineffective cough and retained pulm secretions, recurrent PNA
    3) chronic aspiration 2/2 impaired laryngeal reflexes
    4) nocturnal O2 desat and sleep apnea
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25
Q

DMD and sux - what’s the deal?

A
  • no association between DMD and MH, however:
  • DO have risk of hyperK and muscle rigidity –> rhabdo, myoglobinuria, arrythmias, cardiac arrest
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26
Q

What is considered an actual fever?

A

38.5 C = 101.3 F

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27
Q

Reasonable strategy for completing elective surgery for child w/resp illness?

A

Sufficient time to dec airway reactivity would risk child getting another illness. So,
1) delay sx for 4-6 weeks if severe sxs (fever > 38.5, productive cough, mucopurulent secretions, malaise, pulm involvement like wheezing
2) for 2-4 weeks if mild sxs (sneezing, nasal congestion, dry cough) + need ETT + other risk fx (asthma, second hand smoke, etc)
3) proceed if mild sxs that don’t meet above criteria

28
Q

Does an ETT or LMA carry inc risk for bronchospasm and desaturation events?

A

ETT! So if have a kid with pulm infx, favor using an LMA to dec periop resp complications

29
Q

Premed possibilities for strabismus surgery for an asthmatic?

A
  • atropine/glyco to dec airway hyperresponsiveness and dec brady events (oculocardiac reflex)
  • versed
  • zofran, decadron, fluid bolus (highly emetic procedure)
  • toradol
  • bronchodilator
30
Q

Would you use sux in 7yo undergoing strabismus sx?

A
  • no, could interfere w/forced duction test that occurs ~20mins after
  • also could have undx muscular dystrophy (should be hesitant with this in pts <8yo, especially males)
31
Q

A few orofacial abnormalities a/w/ adenotonsillar hyperplasia?

A
  • high arching palate
  • retrognathic mandible
  • dental abnormalities
32
Q

Why is it good to know if airway obstruction was the indication for tonsillectomy?

A

Results of a sleep study is helpful in IDing any inc risk of rapid desaturation and difficult airway management

32
Q

If pt has vague hx of prolonged bleeding after whatever, what do you do?

A
  • order coag profile (if nl PT w/high PTT: c/f vWD, Hemo A&B&C, lupus, or on low dose heparin)
  • ask about family hx, easy bleeding and bruising otherwise, prolonged bleeding after minor injuries
33
Q

Factor VIII replacement postop guidelines?

A
  • yes, continued for up to 2 weeks
  • half life of factor VIII can be as short as 6 hrs in kids
34
Q

What happens when newborn has pulm HTN? (e.g. 2/2 congenital diaphragmatic hernia, for example)

A
  • pulm HTN –> blood doesn’t want to flow into the pulm circuit (usually this is the least resistant way after birth) and instead shunts from L –> R through PFO and PDA –> increasingly hypoxic, hypercarbic, acidotic –> these all further exacerbate pulm HTN –> vicious cycle
35
Q

A-a gradient scale for predicting survival of neonates w/congenital diaphragmatic hernia (CDH)?

A

> 500: poor prognosis (non-survival)
400-500: uncertain
< 400: predicts survival

36
Q

Initial management/stabilization of baby born with CDH?

A
  • delay surgery until pulm HTN is no longer causing shunting
  • avoid PPV d/t distention of intrathoracic viscera + aggressive suctioning
  • suppl O2
  • intubate (RSI or awake, both ok)
  • OGT/NGT for decompression
  • vent settings to resolve hypoxia, hypercarbia, acidosis while avoided high airway pressures (pTX on opposite side)
  • sedation w/opioids and BDZs (dec cat release)
  • muscle relaxant to dec O2 consumption
  • correct hypothermia
  • ABG, CXR, TTE (cardiac defects, RH dysfxn, pulm HTN)
  • possibly give pulm vasodilators (PGE1, iNO), exogenous surfactant, jet ventilation
  • if everything else insufficient, consider ligation of PDA to dec shunting (though could lead to RHF) or ECMO
37
Q

How to get immediate IV access in neonate (emergency)

A
  • umbilical or femoral veins
  • can attempt UE peripheral
  • to cannulate umbilical vein: sterilize and drape, caudal traction of stump (for vein) or cephalad (for artery). Insert soft catheter filled w/hep that is long enough to reach jxn of IVC and RA. CXR, then secure
38
Q

Complications of umbilical vein catheterization?

A
  • infx, sepsis, hemorrhage, thrombosis of portal/mesenteric veins
  • portal cirrhosis, liver abscess
  • endocarditis, cardiac tamponade
39
Q

In what type of situation would you consider where you place an art line for peds? How about two pulse oximeters?

A
  • R radial more accurately reflects oxygenation provided to the brain if still has PDA
  • Two pulse oximeters can ID an increase in intracardiac shunting across PDA during the case (if pt developed more pulm HTN, etc)
40
Q

If pulse ox on R hand and one of feet are significantly different in neonate, what two things to consider?

A
  • coarctation of aorta
  • significant R –> L shunt through PDA (can happen if significant dec in systemic vasc R because then that becomes the easier path)
41
Q

Ways to dec PVR?

A
  • inducing resp alkalosis w/hyperventilation (this is opposite of what CO2 normally does, which is dilate)
  • tx any metabolic acidosis w/bicarb
  • ensure normothermia and adequate anesthesia to minimize cat secretions
42
Q

Would you expand a neonate’s hypoplastic lung (like in CDH) w/+ pressure?

A
  • NO!
  • the pressures required to expand it is very risky for contralateral side of PTX, which would be disastrous
43
Q

What can postop ventilation do in terms of pulm HTN?

A
  • dec O2 requirements
  • helps prevent and tx hypoxemia, hypercarbia, acidosis
44
Q

Explain normal fetal circulation (with the 3 conduits)

A
  • ductus arteriosis
  • ductus venosus
  • foramen ovale
  • see this youtube video! “fetal circulation” lisa mccabe by openpediatrics
45
Q

Predisposing factors to PDA?

A
  • prematurity (their ductus is comprised of poorly contractile muscular layer, which is less responsive to increasing O2 levels and other endogenous mediators). Usually, increased arterial oxygenation is one of the primary stimulants for the ductus to close
  • RDS
  • hypoxia
  • acidosis
  • excessive fluid therapy
46
Q

What is RDS?

A
  • after delivery of premature infants
  • 2/2 insufficient surfactant production (which usually occurs if born <35wga)
  • causes widespread atelectasis –> intrapulm shunting –> hypoxemia and metabolic acidosis
  • tachypnea, tachycardia, nasal flaring, intercostal, subcostal retractions, b/l rales, cyanosis, CXR w/ ground glass infiltrates
  • survival greatly improved w/steroids given to mother and neonatal exogenous surfactant admin
47
Q

What is one non-sedative premed to consider for peds? Pros/cons

A
  • Atropine
  • Pros: dec secretions, minimize vagal response to laryngoscopy/surgical manipulation, prevent brady 2/2 sux and/or volatiles
  • Cons: modern volatiles not associated with much bradycardia + timing w/induction often difficult, can usually just have it available PRN
48
Q

Potential complications in surgery for premature infant?

A
  • hypothermia, hypoglycemia
  • retinopathy of prematurity
  • IVH
  • postop apnea
49
Q

Optimal PaO2 or O2 sat to avoid ROP in premie?

A

PaO2 of 50-80
SpO2 of 87-94%

50
Q

How to monitor blood loss and replacement in neonate?

A
  • entire blood volume is ~100cc/kg (so can be about 100cc total), so important to be precise
  • weigh all laps, sponges, etc
  • replace 3:1 crystalloid, or colloid/pRBCs PRN
  • for sick premie with dec cardiac reserve, would prefer to maintain Hct > 40%. In other neonates, threshold much lower (20-25%)
51
Q

How do infants maintain heat?

A
  • non-shivering thermogenesis
  • hypothermia-induced release of NE initiates metabolism of brown adipose tissue –> inc O2 consumption –> heat prod
  • inefficient process already, then even worse for premies and sick infants who are deficient in these brown fat stores. So super important for them!!
52
Q

Ddx for causes of seizures in neonate?

A
  • hypoglycemia, hypoCa, hypoMg
  • benign seizures
  • mother with TORCH
  • sepsis
  • ICH (likely in premie!)
53
Q

Induction for foreign body aspiration?

A
  • give reglan (recent eating)
  • give glyco (secretions and reflex brady)
  • monitors, emergency airway equipment
  • inhaled w/sevo (avoid PPV d/t distal migration. This puts at higher risk of aspiration though, so have to weigh risk/benefits of RSI vs inhalational)
  • ensure adequate depth of anesth (avoid coughing, laryngo/bronchospasm)
  • IV acess
  • ENTs to DL and insert bronchoscope
  • hook up circuit to bronchoscope
54
Q

Complications possible w/foreign body aspiration?

A
  • chemical pneumonitis (certain nuts, veggies highly irritating to bronchial tree) but if removed w/in 24 hrs, complication rate very low. If left for longer though:
  • bronchial stenosis
  • bronchiectasis
  • PNA, lung abscess, tissue erosion/perforation
  • penumomediastinum/PTX
55
Q

Steps to take in neonatal resusc (meconium, APGAR 3):

A
  • clear airway
  • warm, dry, stimulate
  • if HR still <100, start PPV
  • pulse ox on RUE (preductal - target increases from 60 to 90% after 10 mins of birth), consider EKG
  • If HR < 60 after 30s of PPV: intubate, chest compressions, get IV access through umbilical or IO
  • If HR < 60 after another 60s: epi, IVF if hypovol, eval for PTX/hypoglycemia (give glu)/MG toxicity (give Ca)/narcosis (don’t give narcan, just support) from maternal IV pain meds
56
Q

Why might newborn’s resp effort be weak s/p mom in PEA?

A
  • low perfusion P during resuscitation
  • if mom had preE, also impaired uteroplacental perfusion –> neonatal depression
  • TTN (transient tachypnea of newborn)
  • hypoglycemia (if mom diabetic)
  • Mg
  • meconium
  • undx congenital anomaly (choanal atresia/stenosis, laryngeal/subglottic webs, pierre robin, Beckwith-Wied
57
Q

What are a few findings c/w/ child abuse?

A
  • bruises/burns in the shapes of objects
  • bruises/fractures of different ages
  • signs of neglect (poor hygiene/height/weight <5%ile)
  • retinal hemorrhages
  • delay in seeking medical care
  • handicapped kids more likely
  • should write detailed note of findings and report to appropriate authorities
58
Q

Which conditions can produce cyanosis in first year of life?

A

Any that results in R to L cardiac shunting (5):
1- TOF
2- transposition of great vessels
3- truncus arteriosus
4- tricuspid atresia
5- total anomalous pulmonary venous return

59
Q

What is osteogenesis imperfecta? Presentation?

A
  • conn tissue disorder (abnl synth of type I collagen affects bones, ligaments, dentition, sclera)
  • sxs: blue sclera, fxs from minimal trauma, kyphoscoliosis, bowing of femurs/tibias, hearing loss, coagulopathy (pltl dysfxn), CV issues, craniocervical instbility, macroglossia
  • should think about all of the anesthetic considerations for OI (mostly fx associated issues): BP cuff cycling, vert art injury if doing neuroaxial technique bc bones so soft, avoid cricoid pressure, don’t use sux (fasciculation induced fxs, wheelchair bound hyperK), don’t do IO if at all possible (central line instead)
60
Q

How would you eval and resuscitate infant w/pyloric stenosis?

A
  • H&P: vol/freq of vomiting, UOP, diarrhea, weight change, last feeding time, mental status
  • CBC, lytes, ABG
  • skin turgor, sunken fontanelles, mucous membranes, BP, pulse
  • give NS (avoid LR since lactate converts to bicarb) until UOP is established, then supplement w/K. If hypoglycemic, consider glu containing IVF
61
Q

What to do prior to performing awake intubation for baby?

A
  • depends on situation, but likely give atropine d/t pain and discomfort associated w/it –> induce bradycardia (neonates have an inc in parasymp tone) + mild sedation, then could empty stomach w/NGT
62
Q

Why would a neonate who had pyloric stenosis myotomy be at inc risk for postop apnea?

A
  • postconceptional age of <50wks (need to monitor for 12-24 hrs)
  • resideual effects of GA
  • preop alkalosis could inc risk for apnea
  • any narcotic admin
63
Q

RIsk factors for postextubation croup?

A
  • oversized ETT
  • repeated/traumatic intubation attempts
  • UTI
  • previous hx of croup
  • head and neck procedures
  • intraop changes in head positions
  • surgery duration >1 hr
  • pt age 1-4yo
64
Q

How do you resuscitate neonate irt FiO2 administration?

A
  • there’s a target range for preductal O2 sat after birth from 1-10min (60% –> 95%)
  • preductal means that you place the pulse ox on RUE! Provides better assessment of CNS oxygenation
  • if 35w and older, start with 21% FiO2. If <35w, start w/21-30%, titrate upward from there until attain target SpO2
65
Q

What’s your threshold before intubating neonate during resus?

A
  • if bag/masking was ineffective
  • chest compressions required
  • prolonged mech ventilation anticipated
  • ETT drug admin needed
  • other special pt factors

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