peds ortho surgery

Question 1

Anesthesia management issues with ortho procedures

Answer 1

airway,
positioning.
blood loss/fluid therapy,
temperature conservation,
post-operative pain

Question 2

Congenital dislocation of the hip cause

Answer 2

prolonged displacement of the fetal femoral head from the acetabulum resulting in posterior dislocation during hip flexion (common in breech deliveries). Severity ranges from joint laxity to irreducible displacement.

Question 3

Treatment for congenital dislocation of the hip

Answer 3

Pavlick harness,

fluroscopy guided closed reduction and spica casting

Question 4

What is the name of the click as femoral head moves in and out of acetabulum

Answer 4

Ortalani

Question 5

anesthetic management for congenital hip dislocation

Answer 5

short procedure, not painful,
inhalation anesthetic maintained via mask, LMA, ETT,
Greatest concern is LOSS OF AIRWAY!!! d/t positioning changes
Pt in air on SPICA casting frame,
Pt need to be deep stage III
Disconnect circuit prior to positioning changes and DC N2O,
Prevent hypothermia

Question 6

What is congenital clubfoot?

Answer 6

structural deformity-shortened medial tendons of the lower leg, shortened Achilles tendon,
Foot pointed downward, rotated inward,

Question 7

Treatment for congenital clubfoot?

Answer 7

manipulation and casting,

surgical correction and casting at 3-6months

Question 8

Anesthetic management for congenital clubfoot

Answer 8

General and Regional
IH and then one shot caudal w/ bupi 0.25% 1mL/kg,
Analgesia for 4-6 hrs, decrease IH requirement,
Fentanyl and Mag sulfate IV opioids instead of spinal (can also use dilaudid) ,
immense post op pain-may need caudal epidural catheter

Question 9

Anesthetic management of congenital clubfoot continued

Answer 9

tourniquets used,
stabilization of ETT, continuous monitoring of breath sounds,
intraop glucose monitoring and use of glucose containing solution,
temp conversation.
Usually 3-6months that have surgery anc can take up to 4 hrs. if bilateral

Question 10

What is osteogenesis imperfecta?

Answer 10

Defect of collagen production resulting in abnormal bones, ligaments, teeth, and slcera.
Patients suffer fractures after innocuous contact or trauma.
(fibroblasts don’t work well)

Question 11

What is a fibroblast?

Answer 11

a type of biological cell that synthesizes the extracellular matrix and collagen, produces the structural framework (stroma) for animal tissues, and plays a critical role in wound healing.

Question 12

osteogensis imperfecta clinical presentation

Answer 12

bowing of long bones and kyphoscoliosis,
otosclerosis and deafness,
hypermetabolic-not MH,
Plt abnormalities and decreased Factor VIII levels in 30%

Question 13

OI anesthetic management

Answer 13

Gentle manipulation of cspine and airways is vital
-Atlantooccipital instability
-cervical and mandibular fractures occur easily
-airway cartilages and teeth easily damaged
Normal airway-routine IH or IV induction and intubation,
Difficult-awake fiberoptic,
Muscle relaxants only after adequate mask ventilation is established.
Analgesia fentanyl 2-5mcg/kg and mso4 0.1mg/kg

Question 14

OI anesthetic management continued

Answer 14

meticulous attention to positioning and padding of extremities,
avoid aggressive heat conservation measures and anti muscarinics,
toruniquets are utilized,
succs induced fasiculations can cause fractures

Question 15

What is cerebral palsy?

Answer 15

static encephalopathy, or any nonprogressive central motor deficit r/t hypoxic or anoxic cerebral damage in the perinatal period

Question 16

Etiology of cerebral palsy

Answer 16

prematurity, birth trauma, hypoglycemia, intrauterine and neonatal infections, congenital vascular malformations

Question 17

CP clinical presentation

Answer 17

associated with mental retardation, seizures disorders, abnormalities of vision, speech, hearing, behavior, and cognition,
skeletal muscle spasticity and contractures,
impairment of laryngeal and pharyngeal reflexes-GERD and aspiration
Poor dental hygiene

Question 18

CP anesthetic management

Answer 18

all techniques and agents have been used safely,
mod-severe CP airway management should involve intubation r/t predisposition to aspiration,
succs does NOT produce an exaggerated K release,
response to NDNMBs is normal,
Tend to have lower MAC than children without.

Question 19

CP drug interactions/implications

Answer 19

Seizure Disorder-
phenobarbital, phenytoin, carbamazepine should be taken up to and including the day of procedure,
phenobarbital is hepatic microsomal enzyme inducer,
Spasticity-
Dantrolene-direct acting skeletal muscle relaxant, inhibits Ca release from sarcoplasmic reticulum,
Baclofen-skeletal muscle relaxant, inhibits excitatory neurotransmitters

Question 20

Common in pediatric population r/t trauma

Answer 20

fractures

Question 21

child sustraining blunt force trauma must be evaluated for?

Answer 21

injury to cspine and other organ systems

Question 22

surgical repair of fractures

Answer 22

urgent/emergent-vascular compromise, large hematoma, hypotension,
Delayed stabilized and admitted

Question 23

most common fracture in children

Answer 23

elbow fx from monkey bar falls

Question 24

anesthetic considerations for fractures

Answer 24

RSI and endotracheal intubation indicated in patients coming from ED for urgent/emergent repair,
analgesia as indicated-IV opioids or caudal,
availability of blood products as needed,
temp conservation,
in acute fx, often blocks are not used to nerve injury is easier to be detected

Question 25

Myelodyplasia

Answer 25

congenital failure of the middle or caudal end of the neural tube to close resulting in: spina bifida, meningocele, myelomeningocele

Question 26

what is spina bifida occulta

Answer 26

is a malformation of one or more vetebrae. It is sometimes called “closed” spina bifida. In most cases, spina bifida occulta causes no problems. Nerves escape between malformation of vertebrae

Question 27

what is meningocele

Answer 27

the meninges is protruding with sac present filled with spinal fluid

Question 28

what is myelomeningocele

Answer 28

the nerves of the spinal cord are present in sac-most severe

Question 29

meningocele clinical presentation

Answer 29

neural function intact,
spinal cord is tethered by sacral nerve roots,
in unrepaired, results in orthopedic and/or urologic symptoms

Question 30

Myelomeningocele clinical presentation

Answer 30

varying degrees of sensory and motor deficits,
dilation of upper urinary tract,
spasticity,
scoliosis,
some have sensory loss in lowers and don’t need as many narcotics

Question 31

myelodysplasia anesthetic management

Answer 31

surgical repair on first day of life,
lack of skin covering defect, prone to infection and sepsis,
avoid pressure on the sac with ETI in lateral decubitus position or supine with pillows,
Avoid NDNMBs initially d/t neurometric monitoring,
potential for hypovolemia d/t seepage of fluid from sac,
aggressive temp,
blood loss not extensive

Question 32

What is scoliosis

Answer 32

Lateral and rotational deformity of the thoracolumbar spine accompanied by deformity of the ribcage,
Etiology - 80% idiopathic and coincide with periods of rapid growth,
Infantile <3yo
Juvenile 3-10yo,
Adolescent >10yo

Question 33

scoliosis physiologic derangements

Answer 33

decreased lung volumes,
decreased chest wall compliance,
V/Q mismatch leading to chronic hypoxemia,
Increased PVR, pulmonary htn leading to RV faiure
Thoracic curvature >25 echo,
>40surgical intervention
>65 restrictive lung disease

Question 34

scoliosis anesthetic monitoring

Answer 34

aline, cvp, foley,
SSEPs-dorsal column function,
multi large bore IVs-16g
MEPs also used and more sensitive

Question 35

scoliosis surgical positioning

Answer 35

prone
-compression of lungs
-increased intra abd. pressure,
compression of IVC,
epidrual vein engorgement, increased bleeding,
Decreased venous return, decreased CO,
Protect eyes

Question 36

Scoliosis management

Answer 36

Narcotic based balanced technique is the best choice,
inspired concentration of IH agent kept at 0.5-1.0 MAC so as not impair SSEPs,
MEP use avoid IH so use prop, remi with bolus versed/ketamine,
May need to wake up test

Question 37

scoliosis blood loss

Answer 37

often exceeds 25mL/kg, (often in first hour of surgery

Question 38

scoliosis managment

Answer 38

TXA,
deliberate hypotension(60-75MAP),(carefeul with eye perfusion)
hourly measurement of H/H,
aggresive temp,
use autologous and directed donor blood and cell saver,

Question 39

what medical causes of bleeding to consider after loss of one blood volume

Answer 39

dilutional thrombocytopenia,
decreased facotrs V and VIII
Banked products will be used.

Question 40

Scoliosis post op management

Answer 40

problems- mech vent, hypovolemia, pain, ileus, SIADH,
Hypotension with flip after being prone,
Extubation dictated by patient pre-op reps status, intra op course, and ability to demonstrate all extubation criteria