Physical Exam Anesthesia Flashcards
Preterm babies have an increased risk of:
Bronchopulmonary dysplasia (chronic breathing difficulties)
Congenital heart disease
Which medications require consult prior to day of surgery? (P GAAI)
Phentermine –> affect heart rate
GLP-1 Analogues (-glitides) → risk of aspiration
Anticoagulants
ACEI/ARBS –> refractory hypertension
Insulin/diabetes → hypoglycemia risk
Most common allergy to medications:
Antibiotics
Muscle relaxants
(does not include LA)
Is there a true allergy to opioids?
NO –> histamine release & GI reaction.
True anaphylaxis presents as
Rash & Breathing difficulty
Egg allergy is cross reactive to
propofol sensitivity
Tobacco use/exposure increases risk of
perio-operative adverse events
NPO guidelines
To eliminate risk of GI aspiration
2: clear liquids, no pulp
4: breast milk
6: formula/cows milk, chewed candies
6: light meals
8: fried, heavy fatty meals, meat, chocolate
PONV is genetic T/F?
TRUE there is a genetic component
What features may lead to problems with masking?
large soft tissues (tongue, T&A)
small mouth
facial deformity
What features may lead to problems with intubation?
Atlantooccipital restriction (Down Syndrome)
TMJ restriction
What is the 3-3-2 rule?
3 fingers Interincisal distance
3 fingers submandibular space
2 fingers thyroid to the floor of the mandible
How to test TMJ mobility?
Upper lip bite test
Class 1 = good, Class 3 = bad
Modified Mallampati:
1: Uvula & Throat
2: Uvula
3: Only base of uvula
4: Only hard palate
Adenoid Hypertrophy stage 3/4
Beware –> OSA & extreme sensitivity to narcotics
Pierre Robin Sequence
micrognathia, glossoptosis –> improves with age
Treacher Collins
small mandible –> improves with age
Mucopolysacchardoses
coarse facies, huge tongue.
–> airway worsens with age
Klippel-Feil
fused cervical vertebrae
Goldenhar Syndrome
hemifacial microsomia & limited TMJ mobility
Beckwidth-Weideman
macrosomia & large tongue
How common are heart murmurs?
72% prevalence
<1% true cardiac pathology
screen via auscultation
What type of murmurs are usually benign?
SYSTOLIC
Asymptomatic
Wheeze indicate
small airway obstruction e.g. asthma, bronchospasm
Fine crackles indicate
fluid in lung (pulmonary edema)
Coarse crackles associated with
pneumonia, bronchiectasis
Decreased breath sounds
airway obstruction, or pneumothorax (one sided)
Infant Vitals
HR: 100-180
BP:
Resp: 30-53
Toddler 1-2
HR: 90-140
BP:
Resp: 20-37
Preschool 3-5
HR: 80-120
BP:
Resp: 20-28
School age 6-9
HR: 75-118
BP:
Resp: 18-25
POCUS =
Point of Care UltraSound
–> check lungs, GI (npo), etc.
Upper Respiratory Infection concerns:
increases risk of Perioperative Respiratory Adverse Events (PRAE) up to 30%
2x likely of laryngospasm
URI Decision making (after resolution of symptoms)!!
URI –> 4 weeks
Hospitalized –> 6 weeks
COVID:
Immunocompromised/Diabetic –> 8 weeks
ICU admission –> 10-12weeks
Cyanotic Congenital Heart Defects
1) Truncus Arteriousus (1 outflow tract)
2) Transposition of the great vessels
3) Tricuspid atresia
4) Tetralogy of Fallot (Pulmonary Stenosis, Right Ventricular Hypertrophy, Overriding Aorta, Ventricular Septal Defect)
5) TAPVR → Total Anomalous Pulmonary Vascular Return
6) + Hypoplastic Left Heart (left side never developed)
Asthma Management
1) Symptoms: B-agonists
2) Disease-modifying: corticosteroids
Avoid precipitating factors
Anesthesia considerations Asthma
Pre-op albuterol
Adequate depth of anesthesia –> go deep
Avoid opioids, succinylcholine (histamine release)
Inhaled agents are generally bronchodilators
OSA screening Questions
1) Snoring?
2) Trouble breathing?
3) Stop breathing?
3+ –> OSA risk high, take PSG study for Gold standard Diagnosis (to find AHI)
Anesthesia considerations OSA
High risk of PRAE
Increased sensitivity to opioids
When is overnight obs advised?
<3yo with OSA
Severe OSA (AHI >10)
+ cardio or Trisomy 21/ comorbities
Cyanotic heart disease is
Right to left shunt (lungs bypassed)
Dental indications SBE?
manipulation of the gingival tissue, manipulation of the periapical region, or perforation of the oral mucosa
SBE not indicated for
injection through noninfected tissue
shedding of deciduous teeth
bleeding from trauma to lips or oral mucosa
SBE dosages review
Amox: 50mg/kg up to 2g
Cephalexin: 50mg/kg up to 2g
Azithromycin: 15mg/kg up to 500mg
Doxycycline: 2.2mg/kg up to 100mg
Seizure considerations for GA
Take morning dose
Anti-epileptic meds –> faster liver metabolism –> higher dose required for GA
Phenytoin (rare) –> gingival hyperplasia
ASD considerations for GA
Hypersensitive and antisocial (like a cat)
Challenges during Induction & recovery
Child life & pre-op midazolam (up to 20mg)
CP considerations for GA
Motor disabilities –> positioning, airway concerns
Cognitive impairement
Delayed gastric emptying –> risk of periop aspiration
Impaired thermoregulation (thin)
Trisomy 21 considerations for GA
Atlanto Occipital (AO) instability → can decapitate
Large tongue, difficult airway & difficult IV
Cardiac problems: ASD, VSD, AV canal
Obesity considerations for GA
1/5 USA children
Difficult airway, difficult positive pressure ventilation, difficult IV
Delayed gastric emptying –> aspiration risk
Post-op PRAE
Obesity Dosing considerations
Varies per med:
Lean body weight (LBW) → opioids (sensitivity), sedatives, neuromuscular blocking agents
Total body weight (TBW) → reversal agents, antibiotics, succinylcholine
Metabolic considerations for GA
blood glucose levels
MH considerations for GA
hyperthermia, heart & renal failure risk
Avoid Halogenated inhalants –fluranes & succinylcholine –> NITROUS OK
Mitochondrial considerations for GA
avoid use of Lactated ringers & propofol
Muscular disorder considerations for GA
avoid neuromuscular blockers
Heme/Onc considerations for GA
CBC, Coagulation, pre-op transfusion
Consult for optimization
