Peds Flashcards
Management of foreign body aspiration
Inhalation induction w/ spontaneous ventilation
TIVA
PPV with RSI places patient at risk for distal migration of foreign object –> difficulty with extraction, hyperinflation, PTX
Management of airway edema/stridor
Decadron 0.5-1.5mg/kg Humidifed O2 Racemic epi (alpha-agonist) - monitor for 3 hours Check for cuff leak Rule out obstruction, bronchospasm, residual foreign body
Anti-emetic contraindicated in peds
Phenergan <2 y/o resp depression
Associated anomalies with TEF
VACTERL
- vertebral
- anal
- cardiac
- TEF
- renal
- limb
Management of TEF
suction in blind pouch
elevate HOB
ventilate lungs without ventilating fistula leading to abdominal distention
ETT –> right mainstem –> slowly withdraw to b/l breath sounds to be distal to fistula
Sedated and relaxed until anastomosis heals, also risk of apnea
If unable to ventilate initially, stop
Surgeon perform gastrostomy to decompress —> intubate as above
Complications from TEF repair
anastomotic leaks stricture GERD feeding issues esophageal dysmotility
recurrent aspiration, PNA
reactive airway
Electrolyte abnormality with pyloric stenosis
hypoK
hypoCl
Metabolic alkalosis
How would you rehydrate a patient with pyloric stenosis
NaCl until normal diuresis resumes
1/2 NaCl w/ K, dextrose
Remember to continue dextrose after surgery d/t depleted glycogen stores
LR - lactate —> bicarb worsens alkalosis
Induction of pyloric stenosis patient
OG to decompress stomach as much as possible - supine, lateral, prone positions
Pretreat with atropine 0.02mg/kg
Pre-O2
RSI with cricoid pressure and roc
inc dose of Sux d/t inc Vd (2-3mg/kg)
Pathogenesis and complications of CDH
Atelectasis from abdominal contents compressing developing lung –>
- Pulmonary hypoplasia
- Hypoxia
- Pulmonary HTN –> persistent fetal circulation –> R–L SHUNT through PDA, PFO –> worsening hypoxia, hypercarbia, acidosis and further worsening pulm HTN
What promotes extra-pulmonary R –> L shunt?
#1 is pulmonary HTN Inc PVR inc de-oxy blood through PDA/PFO
Tx for pulmonary HTN
avoid inc PVR (hypoxia, acidosis) avoid stress catecholamines (sedated, paralyzed) avoid 100% O2 Give NO HFOV ECMO
DDX for hypoxia and hypotension in CDH
PTX of contralateral lung (vigorous re-inflation of hypo plastic lung)
Severe pulmonary HTN
Compression of great vessels (difference in pulse Ox)
Blood loss
Dec venous return from IVC compression once contents return to abdomen - surgeon relieve pressure and close abdomen later
PDA concerns
H&P to evaluate current resp, cardio and fluid status
ABG, H&H, lytes, coag and type and cross
IVH - indomethicin (PG inhibitor) contraindicated
Pulm - compliance, pulm HTN
NEC - blood shunted away from systemic to pulmonary
Renal and hepatic function
Electrolytes
Glucose levels
Temp
Dx of PDA
Dx
- bounding pulses
- widened pulse pressure
- CHF, dec breath sounds, rales, S3
- ECHO - inc shunt, Pulm blood flow and dilation of LA
Monitors for PDA
A-line - right upper in case of Left subclavian clamping following torn PDA
Pulse-ox right hand and lower extremities
Post-PDA ligation concerns
Systemic HTN and inc LV afterload
- persistent vasodilator like nitro
- severe LV dysfunction then ionotrope like dopamine
Recurrent laryngeal nerve palsy
Phrenic nerve injury
Chest wall deformities
What are ductal dependent conditions
HLHS
AS
Interrupted aortic arch
Coarctation of aorta
TOF
Tricuspid atresia
Pulmonic stenosis
Transposition
Anomalies in TOF
RV outflow tract obstruction
VSD
Overrising aorta
RVH
Management of Tet spell
Imbalance in right sided heart pressures and dec SVR
Inc SVR by tucking knees to chest +/- Neo
Inc depth of anesthesia with ketamine
Hyperventilating with 100% O2
Fluid bolus
Beta blocker to reduce infundibular spasm
Induction w/ TOF
100% O2
Ketamine, fent, roc
Maintenence w/ fent +/- ketamine +/- N2O <50% to avoid inc PVR, hypoxia
Airway considerations with CHARGE syndrome
Cleft lip
Micrognathia
Laryngomalacia
Subglottic stenosis
Would you get an echo prior to surgery for patient with CHARGE syndrome?
Yes
Cardiac defects, often complex like TOF
C - coloboma of the eye H - heart (TOF, DORV, ASD, VSD, Right aortic arch) A - atresia of choanae R - reatrded growth G - genital anomalies E - ear abnormalities
Difference between Treacher-Collins and Pierre Robin
Both known for micrognathia and difficult airways
Both have cardiac defects
Pierre robin has glossoptosis
Treacher-collins = more congenial defects
Neck prepped, difficult airway, sedate spontaneous fiber optic
Speed of IV induction with TOF
Faster due to right to left shunt
How would you induce patient with pyloric stenosis
Assuming hypoCl, hypoK metabolic alkalosis is fixed
Decompress to stomach lateral, supine prone NG/OG
100%O2
Atropine
RSI prop and roc
Emergent tonsil rebleed, how would you induce?
Full stomach due to blood
If unstable RSI with cricoid, ketamine, roc
Pre-op considerations with Down
Airway - macroglossia, subglottic stenosis
GI - duodenal atresia - full stomach
Cardiac - cardiac defects
Neuro - AA subluxation, maintain neutral
Resp - obstructive disease, snoring, apnea
What is a Cobb angle and when is surgery recommended?
Measure of severity of scolisis
Angle of perpendicular lines from upper cephalad and lower caudad vertebral bodies
> 10 = abnormal
40-50 = surgery
Pulmonary dysfunction = 60-65
Pulm HTN = 70
Concerns with DMD
Macroglossia —> difficult intubation
Diminished laryngeal reflexes
Delayed gastric emptying
Cardiac - loss of myocardial tissue —> dysrhythmia, MVP, cardiomyopathy, RVH and RV failure
Contractures - positioning
HyperK and rhabdo with volatile
Induction
- GI PPx + cricoid
- DI equipment, ketamine preserves reflexes and spont vent if difficult
Considerations with scoliosis surgery? What monitors would you use?
Prone Positioning
- head and neck neutral
- no compression on eyes
- arms <90
- padding joints
- avoid abdominal compression –> venous congestion
- restrictions in ROM of joints
Wake up test - recall, extubation, pain, air embolism with vigorous inhalation
Monitors:
- A-line
- Precordial Doppler
- CVC for venous air embolism
- SSEPs + MEPs (inc sensitivity w false negatives w SSEPs)
Unable to open mouth following sux administration, what is your Ddx?
Masseter muscle rigidity vs. myotonic syndrome vs. MH vs. TMJ
MMR may suggest susceptibility for MH
Cancel case and monitor for 24 hours for myoglobinuria, generalized rigidity, hypermetabolism
Assuming presence of dantrolene could proceed after frank risk benefit discussion or if they returned in 1 week - non-triggering anesthetic. No PPx dantrolene as nausea, vomiting common
Concerns with prematurity
IVH
Retinopathy of prematurity
Respiratory distress syndrome
Persistent pulm HTN
Apneic spells
BPD
NEC
Impaired glucose reg
Hypothermia
Intra-op fluid management with peds patient
4ml/kg/hr dextrose fluid
Replace insensible losses with NS 6-8ml/kg/hr
Ml:ml of EBL and keep HCT >35% (dec risk of NEC, ischemia, better would healing)
Concerns with prematurity
IVH
Retinopathy of prematurity
Respiratory distress syndrome
Persistent pulm HTN
Apneic spells
BPD
NEC
Impaired glucose reg
Hypothermia
Initial treatment in neonate with flaring, dec breath sounds on left, scaphoid abdomen?
Avoid PPV (distends intrathoracic viscera)
Intubate neonate (inhalational)
NG/OG for gastric decompression
Vent settings to correct hypoxia, hypercarbia while avoiding high airway pressures (C/L PTX risk)
Muscle relaxation (reduce O2 consumption)
Sedation (dec catecholamine induced inc in PVR)
Get ABG, CXR, ECHO
FiO2 to use in neonates
O2 to avoid hypoxemia which can lead to acidosis and inc PVR
Avoid high O2 to avoid retrolental fibroplasia (ROP)
SpO2 goal >87-95%
PaO2 50-80mmHg
Cyanotic after induction (75% on foot), but hand 95% cause?
Normal pre-ductal + low post-ductal = significant R–>L shunt through PDA
Tx = 100% O2, ventilation adequate + inc SVR and dec PVR
Markers of stability for pyloric stenosis patient pre-op
Good urine output 1-2ml/kg/hr pH 7.3-7.5 Na >130 K >3 Cl >85
Is inhalation induction in kids slower or faster than adults?
faster d/t higher MV:FRC and inc BF to vessel-rich organs
What are the risk factors for post-op apnea in premature infants?
low gestational AGE (<50 weeks) chronic lung disease hx of apnea/brady spells congenital anomalies sepsis anemia alkalosis narcotic use
How does PDA closure normally occur?
Initiation of ventilation + inc arterial O2 + dec PVR
Hypoxia d/t RD –> no bradykinin to induce closure. Thinner less responsive muscular layer in pre-me
Dec PG following separation from placenta
Factor predisposing to PDA
Prematurity
RDS/hypoxia –> low bradykinin = can’t close PDA
Acidosis
Describe respiratory distress syndrome of the newborn
Occurs in premature infants 2/2 insufficient surfactant production
Tachypnea, tachycardia, retractions, rales, cyanosis
Risk factors for retinopathy of prematurity
Prematurity (esp <32wks until 44 weeks) Low birth weight (<1,500g) mechanical vent RDS hyperoxia/hypoxia acidosis/infection anemia bradycardia
Transfusion threshold for premature infant
Hct 30%
How do you calculate maximum allowable blood loss
Preme 95ml/kg
ABL = [EBV x (Hi-Hf)] / Hi
Desaturation and bradycardia during PDA ligation dissection, what would you do?
100% O2 manually ventilate
Surgical retraction –> hypoxemia, inc shunt and bradycardia
Release traction, assess value status and consider atropine
When do most tonsillectomy re-bleeds occur?
75% in first 6 hours
Remaining majority within 24 hours
Risk factors for emergence delirium?
Pre-op anxiety/underlying temperment Young age (1-5yrs) Post-op pain Use of less soluble volatiles (sevo, des) Prolonged surgical duration
Cannot be reliably prevented
- attempt by reducing pre-op anxiety
- pain control
- recover in quiet , stress free environment
Omphalocele vs. gastroschisis
Omphalocele - at umbilicus, membranous covering, assoc congenital defects (CDH, Trisomy 21, extrophy of bladder, cardiac)
Gastroschisis - lateral to umbilibcus, exposed viscera, abnormal bowel function
How would you prepare neonate for omphalocele repair?
- address resp insufficiency (pre-me, lung hypoplasia)
- cover viscera with sterile soaked gauze, wrap in plastic
- Prevent infection
- Maintain normothermia
- IV access
- Replace fluid loss with LR and 5% albumin, lytes, acid-base
- decompress stomach (aspiration risk)
- delay until baby stabilized and complete assessment for congenital abnormalities can be performed
What is Beckwith-Wiedmann syndrome?
Disorder assoc with omphalocele
- macrosomia
- macroglossia (potential DI)
- hypoglycemia
- polycythemia
What monitors would you use for omphalocele repair?
In addition to standard AS monitors
- a-line d/t potential for significant fluid loss and monitor acid-base balance
- closely monitor airway pressure during reduction of abdominal viscera
- pulse ox lower extremity to monitor lower extremity circulation with inc abdominal pressure, delay closing
Why would a neonate with a PDA have LA enlargement on ECHO?
PDA shunts blood from systemic to pulmonary circulation which when large can increase blood flow 3-4x normal –> overload of pulmonary vasculature and left heart
How would you maintain anesthesia for PDA ligation?
Dec SVR with gas can dec L–R shunt but infants are often sick, hypovolemic so i would prefer to maintain with fentanyl with supplement N2O or ketamine.
How would you extubate following pyloric stenosis repair
awake, lateral
What post-op problems do you anticipate following repair of pyloric stenosis
aspiration
hypothermia
hypoglycemia (inadequate glycogen stores)
apnea
What conditions produce cyanosis in the first year of life?
TOF Transposition (higher post-ductal SpO2) Truncus arteriosus Tricuspid atresia Total anomalous return
How would you induce a patient with epiglottis?
In OR with surgeon and DI equipment
Seated position
Inhalation w/ Sevo = avoid PPV
Cause of inc A-a gradient in CDH
Hypoplastic lung tissue –> intrapulmonary shunt and persistent pulm HTN
Pulm HTN then causes extrapulmonary shunt through PFO and PDA
Is there inc risk of hyperK or MH with CP?
No
High incidence of GERD
Difference between child and adult airway
Narrowest: cricoid (peds) - VC (adult)
Location: C3,4,5 (peds) - C4,5,6 (adult)
Epiglottis : longer, stiffer
VC: anterior angle
Mucosa more vulnerable to trauma
Unable to open mouth following sux administration, what would you do?
Suspect MMR
- attempt to mask
- call for help
- place nasal airway
- attempt nasal intubation
- perform trachestomy
- admit for 24 hour observation
- get MH labs
A baby is born making no respiratory effort, grimaces with stimulation, flaccid muscle tone, acrocyanotic and HR of 80. What is the APGAR score?
3
A - appearance
- normal color = 2
- acrocyanosis = 1
- blue/gray all over = 0
P - pulse
- > 100 = 2
- <100 = 1
- absent = 0
G - grimace
- pulls away, coughs = 2
- grimace with stim = 1
- absent = 0
A - activity
- active, spontaneous movement = 2
- flexion = 1
- flaccid = 0
R - respirations
- normal, good cry = 2
- slow, irregular, weak = 1
- absent = 0
Newborn w/ weak resp effort ddx
Pre-E dec uteroplacental perfusion –> neonatal depression
Transient tachypnea of newborn - retained fetal lung fluid
magnesium toxicity
hypoglycemia
meconium aspiration
undiagnosed congenital anomaly - choanal atresia, subglottic stenosis, Pierre-Robin
Is CDH repair an emergency surgery
No.
Should be medically optimized first
- improving oxygenation to >90%
- correcting acidosis
- reduction R—>L shunt
- inc pulmonary perfusion with lung protective ventilation
Maintenance in CDH
Sevo, fent, vecuronium
Low dose Sevo as its effects dec SVR > dec PVR which could worsen R—>L shunt
Would you use sux in TOF case?
No.
It’s not indicated for routine use in pediatrics
Histamine release would dec SVR and promote right to left shunting
Given the risk of PION in prone spine surgery, would you agree to deliberate hypotension during this case?
I would employ deliberate hypotension because patient has no history of chronic HTN and there is no reliable evidence suggesting an association b/w deliberate hypotension and vision loss.
I would not completely dismiss theoretically risk as this could also place patient at risk for spinal cord or cerebral ischemia
Therefore I would
- optimize end-organ perfusion by ensuring adequate oxygen carrying capacity (avoiding anemia and hypoxia)
- monitoring CVP, urine output, EKG, MEPs and ABGs for acidosis
What technique would you employ to produce deliberate hypotension?
Reduce to no lower than MAP 60 ensuring adequate intravascular volume, Hb of 7-8, and monitor for signs of end-organ dysfunction.
Remi
Na Nitroprusside
Esmolol
Does a positive Babinski sign in a Down patient concern you?
Yes
Strongly suggests neurologic compromise, likely from atlantoaxial subluxation
Reschedule and have neurologist evaluate
How would you induce a child with a retropharyngeal abscess?
Goals are to maintain spontaneous ventilation, avoid loss of airway, disruption of infection leading to aspiration or laryngospasm
Would prefer to have IV before induction to administer emergency medications but if excessive anxiety would proceed without.
Awake fiberoptic first choice, may prove impossible in pediatric patient.
Then inhalation induction and fiberoptic assisted laryngoscopy –> trach
