PEDS surg. procedures 4/16+ Flashcards
peds ENT: bilateral myringotomy tubes (BMT): 1. what type of anesthesia? 2. what is a side effect of gas case? 3. what can be used for pain?
- usually mask GA with no IV
- may have emergence delirium (especially if no narcotic used)
- can use IM fentanyl or torodol also intranasal fentanyl
ENT cases
- what is the dose of fentanyl?
- what is the dose of morphine?
- what is the dose of decadron?
- fentanyl 1-2 mcg/kg
- morphine 0.1 mg/kg
- decadron 0.25-0.5 mg/kg (closer to 0.5 mg/kg)
ENT: T&A-
- what type of induction?
- what type tube?
- narcotics used?
- how long of a case?
- inhalation induction
- RAE tube is usually used (some doctors like a straight tube)
- morphine 0.1 mg/kg or fentanyl 1-2 mcg/kg
- these can be very fast cases
ENT: T&A
maintainance:
1. what can interfere with your ETT airway?
2. how will you manage this patient? keep them breathing or paralyze?
3. what medication will you be giving to these cases in a higher than usual dose?
- mouth gag or shoulder roll can cause displacement or disconnect of ETT
- patient may breathe spontaneously as long as they are deep; no need to paralyze
- high dose decadron (0.25-0.5 mg/kg)
ENT: T&A-
- Emergence (deep or awake)?
- do you use antiemetics?
- most do children deep, though awake is the recommended way
- antiemetics may mask the feeling of nausea from swallowed blood
Peds ENT: T&A-
complications: post obstructive negative pressure pulmonary edema:
- post obstructive negative pressure pulmonary edema: caused by negative intrathoracic pressure, hypoxia and resultant massive sympathetic discharge
- this leads to an increase in venous return to the right heart, increasing pulmonary blood volume and microvascular pressure
- this results in rapid trasudation of fluid and lymph into alveoli
- presentation and treatment same in adults and children
ENT: complications-
Bleeding tonsil:
1. considered what for intubation?
2. what should you have sooooo available?
3. what might the hydration status of this patient be?
4. if you have to re-intubate, how can you see?
- full stomach; RSI intubation
- have suction ready
- severely dehydrated
- sometimes you can’t; follow the bubbles
ENT: Laryngoscopy, bronchoscopy: 1. indications: 2. what are the airway issues? 3. be ready for what...? 4. the MD may want to do an awake...? 5. local anesthesia via what device? 6. words of advice: "stay \_\_\_\_"
ENT:
Laryngoscopy, bronchoscopy:
1. indications: for evaluation of airway obstruction or stridor
2. what are the airway issues? shared airway with physician, table turned 90 degrees.
3. be ready to take over airway.
4. the MD may want to do an awake look
5. local anesthesia via what device? LTA
6. stay organized and know where everything is on your table.
Ear, Nose and Throat
Laryngoscopy, bronchoscopy
1. what is the best way to manage the airway? what else can be used?
2. how would you start the case?
3. what do you do with your breathing circuit?
4. what should you have handy (just in case)
5. what might you hear post extubation? how do you treat it?
Ear, Nose and Throat
Laryngoscopy, bronchoscopy
1. Spontaneously breathing patient is usually desired
may use LMA for flexible bronchoscopy
2. Start as mask GA, titrate in propofol as needed
3. Connect circuit to rigid bronchoscope
Can use jet ventilation if patient is not spontaneously breathing
4. Have multiple size ETT’s available in case, pt. may require smaller size
5. May have post extubation stridor,
Tx with racemic epi and or decadron as needed
Tympanoplasty & Mastoidectomy
- what type induction?
- what dont you want to use for maintainance? what about muscle relaxants? why?
- what will be the table positioning?
- these patients are high risk for what condition? what must you do? what reginem would you give?
- what type of emergence? why?
Tympanoplasty & Mastoidectomy
1. Standard induction
2. Maintenance: No N2O for tympanoplasty
Usually no muscle relaxants for mastoidectomy
Surgeon may monitor facial nerve
3. Table turned 90-180 degrees
4. PONV risk; Aggressive PONV prophylaxis
give dramamine pre op, decadron, and zofran intra-op (save reglan for post op)
5. Emergence= Deep
Avoid straining or coughing that could blow tympanic graft
General Surgery
Hernia Repair
1. What hernias are usually for children?
2. what type of anesthesia plan?
3. If using GA, what can you use?
4. if doing caudal anesthesia, what should be limited?
General Surgery Hernia Repair 1. Usually umbilical or inguinal 2. GA with caudal or SAB 3. If GA, may use LMA, muscle relaxation not usually required 4. Limit narcotic if caudal
General Surgery
Appendectomy
1. what will the patient definately need?
2. appendectomies are considered what? therefore intubation sequence should include…?
3. what do you need for this procedure (“glue”)
4. patient should be extubated in what manner?
General Surgery Appendectomy Preop IV and antibiotics 2. Full stomach; RSI with sux (after versed and 10% zem priming dose). 3. Muscle relaxation required, 4. Awake extubation
General Surgery Broviac/port placement/PICC 1. what pre-op tests? 2. what type of induction? 3. what type of sedation with older children?
General Surgery Broviac/port placement/PICC 1. May need CBC if oncology patient 2. Mask or IV induction 3. May be able to do deep sedation with older children, or use LMA
Pediatric General Surgery Circumcision 1. anesthesia type 2. what type of block is performed? what should you do? 3. what type of local?
Pediatric General Surgery
Circumcision
1. Usually GA with LMA and caudal block.
2. Surgeon may perform penile block if no caudal; Limit narcotic
3. local WITHOUT epi
Frenulectomy:
how quick of a case?
any IV?
how do you give pain meds?
Frenulectomy
Quick mask case,
usually no IV
IM fentanyl
General Surgery Colostomy, bowel resection 1. Induction: 2. what's one of the most important aspects of child surgery? how is this accomplished? 3. what is one of the biggest things that must be monitored in child surgery? what fluid is used for replacement? how many lines will you need? can you free flow your IV? how can you determine EBL
General Surgery
Colostomy, bowel resection
1. Induction
May be inhalation or IV
Fentanyl 1-2 mcg/kg to start (?up to 5 mcg/kg) for case Maintenance
2. Keep patient warm
Bair hugger
Fluid warmer
3. Keep up with fluid and blood losses
Use LR for replacement
Use 2 lines, one for maintenance and one for 3rd space and blood losses
Pumps are helpful in determining fluids delivered, necessary with infants (unless using buretrol)
EBL: May need to weigh sponges (1 gram sponge weight=1cc blood)
ORIF
what anesthetic considerations?
ORIF
Standard
Plastic Surgery Cleft Lip and Palate Surgery 1. what age are these patients usually? 2. induction; what type? 3. d/t nature of surgery, what issues might one run into? 4. how is this issue remidied 5. what type of ETT tube?
Plastic Surgery
Cleft Lip and Palate Surgery
1. Cleft palate repair at 1-5 years, cleft lip as early as 1 week
2. Inhalation induction
3. Cleft palate can be associated with craniofacial defects
4. FOB (fiber optic bronchoscope) if difficult airway suspected
5. RAE tube
Plastic Surgery
Cleft Lip and Palate Surgery: Maintenance
1. how will the table be positioned?
what will you need on your tube?
2. what other items will be needed?
3. will you anesthetize with gas only or will you use MRs?
Plastic Surgery Cleft Lip and Palate Surgery: Maintenance 1. Table turned 90-180 degrees Long circuit 2. Mouth gag and throat pack 3. gas +/- muscle relaxation
Plastic Surgery
Cleft Lip and Palate Surgery: Emergence
1. What do you want for emergence?
2. do you put an oral airway in automatically?
3. what should come out before extubation?
Plastic Surgery
Cleft Lip and Palate Surgery: Emergence
1. Smooth wake up
2. No oral airway, usually no nasal airway
Communicate with surgeon on nasal airway use (sometimes you can use a soft bite block)
If nasal airway, use unaffected nares (Cleft lip repair usually affects one side of nose )
3. Ensure throat pack removed
Opthamology Strabismus Repair 1. induction type: 2. what is a side effect of eye repair? what might be given pre-emptively for this 3. what type tube? 4. what is table position? 5. what medication should not be given to strabismus kid?
Opthamology
Strabismus Repair
1. Standard induction
2. bradycardia d/t stimulation of occulocardiac reflex
May give Atropine or Glycopyrrolate if not given preop
3. tube type:Oral RAE
4. Table turned 90-180 degrees
5. no sux d/t Muscular Dystrophy risk with strabismus
Opthamology Strabismus Repair: Maintenance 1. how is patient maintained? 2. what can cause bradycardia? 3. how does this occur? what are manifestations? 4. what is the treatment?
Opthamology
Strabismus Repair: Maintenance
1. +/- muscle relaxant
2. Oculocardiac reflex
3. Triggered by pressure, pain or traction on ocular structures
Bradycardia, junctional rhythm, ventricular arrythmias, asystole
4. Treatment
Alert surgeon, discontinue stimulus
Ensure adequate depth of anesthesia Atropine for persistent bradycardia Surgeon may infiltrate local
Opthamology
Strabismus Repair: Emergence
1. common post complaint?
2. how do you avert this situation medicinally?
3. what should be done before emergence to prevent PONV?
4. what type of extubation?
Opthamology Strabismus Repair: Emergence 1. PONV common 2. Aggressive PONV prophylaxis: Reglan, ondansetron, decadron 3. Suction stomach while deep 4. deep extubation
Opthamology Nasolacrimal duct probing: 1. indications 2. anesthesia considerations? 3. airway if table is turned? if not?
Opthamology Nasolacrimal duct probing 1. for blocked tearducts 2. Standard anesthetic considerations 3. LMA mask
Oral Surgery: Tooth extraction 1. what may be an issue with this patient? this may cause a challenge with what? 2. what type of airway? what should you always do?
Oral Surgery: Tooth extraction 1. Patients may be mentally disabled Induction may be challenging 2. usually a Nasal RAE tube, ask surgeon first though
Out of Operating Room Procedures:
Where might these take place (5 places)?
Out of Operating Room Procedures 1. Endoscopy EGD Colonoscopy Rectal Biopsy 2. CT Scan 3. MRI 4. EEG 5. Interventional Radiology (PICC line)
Out of Operating Room Procedures: Endoscopy EGD &Colonoscopy 1. what is the best way to manage the patient during this procedure? 2. Induction for: child under 5 y/o: age 5-9: older child: 3. advantages of this technique:
Out of Operating Room Procedures: Endoscopy
EGD &Colonoscopy
1. Let patients breathe spontaneously throughout
2. induction:
Under age 5, usually GA with ETT, Mask induction, once intubated may d/c agent and titrate propofol
age 5-9 may be mask induction, then O2 by nasal cannula or blow-by: d/c agent and titrate propofol
Older patients with IV can usually be done with deep sedation
3. advantages of this technique:
Less nausea and emergence delirium
Quicker discharge
Out of Operating Room Procedur: Endoscopy
Rectal Biopsy
– type of anesthesia:
Out of Operating Room Procedur: Endoscopy
Rectal Biopsy
–Often times no anesthesia is required (If anesthesia is desired by endoscopist, mask GA)
EEG:
–What type of anesthesia?
EEG
–Usually light GA with LMA (propofol sedation)
Out of Operating Room Procedures: CT Scan
– Anesthesia type?
Out of Operating Room Procedures: CT Scan
–GA or sedation, depending on patient (Infants & cooperative patients may be able to go without anesthesia)
Out of Operating Room Procedures: MRI
- anesthesia type (allow for what)?
- remember you are in MRI so… no___ in the MRI?
Out of Operating Room Procedures: MRI
- GA for pediatrics with ETT/ LMA Standard induction without narcotic (Allow spontaneous respirations)
- (No precordial in MRI)
Out of Operating Room Procedures: Recovery-
- what should you bring with you to PACU?
- what other “monitor” should be on the patient during transport?
Out of Operating Room Procedures: Recovery-
- Bring monitors (including pulse ox), mask & O2 to travel long distance to PACU
- Use precordial during transport
