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SNRAObPedGer > Prematurity > Flashcards

Prematurity Flashcards

1
Q

Anesthetics have both________and _________ properties.

_________protect against __________Ischemic injury

A

Anesthetics have both neuroprotective and neurotoxic properties
• Volatiles protect against hypoxic-ischemic injury
• Better than IV agents
c/surgeries c/ risk of brain ischemia
• VP shunt, cardiac, vein embolization

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2
Q

Anesthesia DOES

A

PRE CONDITIONING in heart and brain

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3
Q

• Studies showed prolonged exposure of commonly used anesthetics in primates and rats →

A

neuroapoptosis

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4
Q

• Human premies might have more risk of

A

anesthetic neurotoxicity

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5
Q

• However, neurodegeneration and apoptosis is part of

A

normal developmental phenomenon

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6
Q

When anesthesia is combined with surgery, more

A

neuroapoptosis occurs than with either alone

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7
Q

• Anesthetic neuro-degeneration depends on

A

age, brain region, and duration

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8
Q
  • Inhalational anesthetics

* MAC of isoflurane in micropremie (

A

32 weeks PCA; 20% less than term neonates

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9
Q

• All ages experienced a @ 1 MAC of iso

A

20-30% decrease in SBP (SVR goes down, myocardial suppression)

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10
Q

Premies might have more risk of cardiac depression

•

A

Neonatal heart depends on iCa2+ for contractractility

Inhalational anesthetics block calcium channels

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11
Q

Only FDA approved for induction

A

SEVOFLURANE

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12
Q

NO inhalation with bad lung condition s

A

DESFLURANE

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13
Q
  • Intravenous agents
  • Preterm infant might be inherently amnestic by virtue of age
  • Fentanyl =
A

hemodynamic stability, no amnesia or areflexia

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14
Q

Conditions to PRODUCE ANESTHESIA

A

Sedation, amnesia, analgesia, AREFLEXIA

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15
Q

Clearance in premies remained constant up to_______

A

120 minutes = ↓clearance

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16
Q
  • Elimination ½ life in premies =

* ↑

A

6-32 hours (2-3 hr in children/adults)

Vd of fentanyl

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17
Q

Hepatic in PREMIES

A

• Might be due to immature CYP 450 3A4 and ↓hepatic function

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18
Q

PREMIES have

A 
ABNORMAL PHARMACOKINETICS
May go apneic, BRADYCARDIA
Slow to recover
RESPIRATORY DEPRESSIOn 
MORE RISK OF POST OP APNEA
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19
Q
  • Intravenous agents
  • Morphine
  • Elimination half-life in micropremie =
  • Reduced elimination of__________
  • More _________effects when compared c/ fentanyl
A

6-16hrs (2-4 in adults)
morphine-6-glucuronide
hemodynamic

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20
Q

Remifentanil
• Elimination half-life =_________
•____________
• Premies have normal-high levels of_____________

A

3-4 min in all pts
Independent of duration
nonspecific esterase activity

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21
Q

REMIFENTANYL

A

NO PAIN RELIEF AFTERWARDS

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22
Q

CAUTION with Fentanyl products

A

CHEST WALL RIGIDITY

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23
Q 
Ketamine
•\_\_\_\_\_\_\_,\_\_\_\_\_\_\_,\_\_\_\_\_\_
• Minimal\_\_\_\_\_\_\_\_\_\_\_\_
• Can\_\_\_\_\_\_\_\_\_ →
• Always\_\_\_\_\_\_\_ unless brief painful procedure
A

Analgesia, amnesia, unconsciousness
↓CV function (stimulates)
↓ventilation/airway reflexes; airway obstruction, apnea, aspiration
use ETT

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24
Q

• Caution c/ blousing (1-3mg/kg IV) =

A

protracted hypotension +↓CO in otherwise stable infants → hypoxia

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25
Q

• Possibilities of Propofol

A

systemic vasodilation, acute pulmonary HTN with reversion to persistent fetal circulation

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26
Q

• Recovery delayed in micropremies

A

(↓ fat/muscle for redistribution, ↓ clearance)

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27
Q
  • Intravenous agents
  • Midazolam
  • ______clearance in micropremie
  • Further prolonged________
  • _______________
  • Hypotension even greater if administered
A

↓
with ↓ liver function
Systemic hypotension, ↓ ventilation, impaired airway reflexes in premies
c/ fentanyl

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28
Q
  • Regional anesthesia

* None of the complications listed above!

A

↑risk of infection, injury, bleeding
↑local doses per kg required in infants (↑Vd in CSF, ↑surface area of spinal cord/nerve roots, ↑CO/BF to spinal cord = faster distribution, uptake, and elimination = ↓ DOA

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29
Q

Preparation for a Neonatal Emergency

A
  • Is it an “urgent” emergency?
  • Normally have time to medically optimize
  • Warm the patient
  • ↑OR temp 80°F to 85°F (normally 60-65°F)
  • Radiant warming units
  • Forced air heating pads
  • Humidify FGF (or rebreathe)
30
Q

Preparation for a Neonatal Emergency: Monitors

A

• EKG, chest/esophageal stethoscope, BP, temperature probe, pulse oximeter, ETCO2 and agent analyzer

31
Q

Preparation for a Neonatal Emergency: Oxygen saturation

A

Normally limit use of O2 to keep SpO2 between 83-95% to ↓ oxidative stress
• Anesthesia and surgery adversely affect oxygenation → we use it!
• In event of PDA still present, take sats at right hand and left hand/foot to assess extra-pulmonary shunting of DeO2 blood via PDA

32
Q
  • Circuit adds __________ → ETCO2 underestimates _______
  • Large VD when neonates use ___________
  • Usually have _________
  • Might need to _____ ________ during parts of surgery
  • Esp with old ventilators
  • Consider asking NICU to send one
  • Umbilical venous catheter =________
  • Umbilical arterial catheter = _________
  • Umbilical catheters can only be used up to______Days
A
  • Circuit adds dead space volume (VD) → ETCO2 underestimates PaCO2
  • Large VD when neonates use very small TV
  • Usually have bad lungs
  • Might need to ventilate manually during parts of surgery
  • Esp c/old ventilators
  • Consider asking NICU to send one
  • Umbilical venous catheter = central line
  • Umbilical arterial catheter = A-line
  • Umbilical catheters can only be used up to 7-10 days
33
Q

Equipment to always have on hand

A

Suction catheters, various face masks, oral airways, pediatric breathing circuits, laryngoscopes, numerous small ETT, IVF warmer, body warmers, LR, D10W, NS, 5%
albumin

34
Q

• Emergency drugs:

A

atropine, epi (1:10,000),
dopamine, calcium, bicarbonate,
isoproterenol

35
Q 
• Medication administration
• Only draw up \_\_\_\_\_\_\_\_\_\_\_\_
• Tuberculin needle needed \_\_\_\_\_\_\_\_\_ (e.g. 5
mcg fentanyl)
• If diluting, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Always administer\_\_\_\_\_\_\_\_\_always
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Keep empty labeled syringes until the end of case
A

• Only draw up what you intend to give
• Tuberculin needle needed for small doses (e.g. 5
mcg fentanyl)
• If diluting, verify concentration c/ someone
• Always administer in port closest to pt, always
flush line after administering
• Keep empty labeled syringes until the end of case

36
Q
  • Fluid maintenance
  • Fluid overload can open _______________
  • NO _____________
  • Continue whatever they were getting in ______because it Contains ______and _________
  • Do NOT stop _____or _________ why?
  • If no fluids are going, use ________or _____
A
  • Fluid overload can open a DA and cause CHF
  • NO AIR BUBBLES
  • Continue whatever they were getting in NICU
  • Contains glucose and calcium
  • Do NOT stop TPN or dextrose
  • Maybe slightly ↓rate to ward off hyperglycemia
  • If no fluids are going, use LR or plasmalyte
37
Q

**CHOANAL ATRESIA is
Developmental failure of ______ _____________
• Associated with ____________
• CHARGE syndrome

  • Treacher-Collins
  • Pfeiffer
  • VATER
  • _____________________
A

Developmental failure of nasal cavity to communicate c/
nasopharynx
• Associated c/ other congenital anomalies
• CHARGE syndrome
• (Coloboma,Heart disease, Atresia
choanae, Retarded growth, Genital anomalies, Ear
anomalies)
• Treacher-Collins
• Pfeiffer
• VATER
• (Vertebral defects, Anal
atresia, Tracheoesophageal fistula c/ Esophageal
atresia, and Radial and renal anomalies

38
Q 
*****CHOANAL ATRESIA Only a surgical emergency if\_\_\_\_\_\_\_\_\_\_\_
• Presents c/in\_\_\_\_\_\_\_\_\_
• Resp distress, \_\_\_\_\_\_\_\_\_cyanosis
• High risk for airway obstruction
• Oral airway early
A

bilateral stenosis present
5 days of life
(associated c/feeding; relieved by crying)

39
Q

**TEF is
Error in _______________ around______week gestation
• VACTERL association
__________________
• Diagnosis: ____________________
MOST SEEN IS ______________
Early postnatal s/s: excessive salivation,
choking/coughing/regurgitation at first feed → cyanosis and/or respiratory distress, distended abdomen (stomach filling c/ air every time the baby cries) → may compress the lung and ↓ resp

A

Error in separation of trachea from floor of the foregut around 4th-5 th wk gestation
• VACTERL association
• (Vertebral anomalies, imperforate Anus, Congenital heart
disease,Tracheoesophageal fistula, Renal abnormalities, LIMB ABNORMALITIES*)
• Diagnosis: polyhydramnios (cant swallow)
Early postnatal s/s: excessive salivation,
choking/coughing/regurgitation at first feed → cyanosis and/or
respiratory distress, distended abdomen (stomach filling c/ air every
time the baby cries) → may compress the lung and ↓ resp

40
Q

MOst common TEF

A

TYPE C

41
Q

Most common type TEF

A

(Gross classification C, type IIIB in Vogt) consists

of blind proximal esophageal pouch (atresia) c/ a distal TEF just above the carina • (80%–90% of cases)

42
Q 
TEF
• NOT a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• IV access, correct anemia, F/E imbalances, type and crossmatch, *****look for o\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*****, place \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Surgical repair
• Traditional =\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Thorascopic repair gaining popularity
• OLV no longer required
A

• NOT a surgical emergency
• IV access, correct anemia, F/E imbalances, type and crossmatch, look for
other congenital anomalies, place gastrostomy tube
• Surgical repair
• Traditional = open thoracotomy c/manual lung retraction
• Thorascopic repair gaining popularity
• OLV no longer required

43
Q

With TEF

A

Can’t feed through ESOPHAGUS

44
Q

TEF Anesthesia Considerations

A
  • Anesthesia considerations
  • Option 1: keep baby spont. vent.
  • Inhalation induction
  • Avoiding positive pressure ventilation ↓ amount of gas entering stomach

Option 2: gentle mask ventilation c/low peak pressure ventilation
• ↓ amount of gas entering stomach
• Tip of ETT must be placed above carina but distal to fistula
• Right mainstem tube on purpose, then slowly c/draw until you have first bilateral breath sound
• Fiberoptic scope
• Pain: epidural catheter threaded from caudal to thoracic space

45
Q 
Congenital Diaphragmatic Hernia
(CDH)
✤ Failure of \_\_\_\_\_\_
• Inhibits normal\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ of bronchi/alveoli
•\_\_\_\_\_\_\_\_\_\_PVR/ Pulmonary HTN
✤ Etiology \_\_\_\_\_\_\_\_\_
✤ Diaphragm formation at \_\_\_\_\_\_\_\_\_\_ Separates the chest and abdomen
• Hernia forms around \_\_\_\_\_\_\_\_
✤ Hernia: Intestine penetrates the hole in the diaphragm
and enters the chest
✤ Not a surgical emergency
• Optimize medically first
A 
✤ Failure of closure of pleural + peritoneal canal → herniation of abd contents into thorax
• Inhibits normal lung growth
• ↓# of bronchi/alveoli
• ↑PVR + primary pulmonary HTN
✤ Etiology unknown
✤ Diaphragm formation at 5 - 10 wks gestation
• Separates the chest and abdomen
• Hernia forms around 8 wks
✤ Hernia: Intestine penetrates the hole in the diaphragm
and enters the chest
✤ Not a surgical emergency
• Optimize medically first
46
Q

Congenital Diaphragmatic Hernia

CDH

A

Left side closes last
• 90% CDH occur at foramen of Bockdalek
• Largest degree of pulm hypoplasia
• Associated c/ congenital heart defects,
chromosomal abnormalities, GU/GI malformations
• ↑PVR → R-to-L shunt via PFO and DA
• Hypoxemia
• Respiratory distress, tachycardia, tachypnea, and
cyanosis observed shortly after delivery
• At birth: ↓ breath sounds, bowel sounds in
thorax, resp insuff, barrel chest, scaphoid abd

47
Q 
Anesthesia considerations of CONGENTIAL DIAPHRAGMATIC HERNIA
Anesthesia considerations:
• Gentle mechanical ventilation to avoid
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Frequent, small \_\_\_\_\_\_\_\_\_\_\_\_
• Permissive hypercapnia \_\_\_\_\_\_\_\_\_\_\_
• Avoid \_\_\_\_\_\_\_\_
• \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Avoid introducing \_\_\_\_\_\_\_\_\_\_\_\_
• Insert \_\_\_\_\_\_\_\_
• Avoid\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Avoid \_\_\_\_\_\_\_\_\_\_\_
A
  • Gentle mechanical ventilation to avoid pneumothorax/barotrauma/volutrauma
  • Frequent, small TV breaths c/limited peak inspiratory pressures (< 20 cm H2O)
  • Permissive hypercapnia 60-65 mm Hg
  • Avoid ↑PVR
  • Hypoxemia, acidosis, hypothermia, hypercarbia
  • Avoid introducing air to GI tract
  • Insert NGT before induction
  • Avoid CPAP and prolonged mask vent
  • Avoid N2O
48
Q

CDH surgical

A

• Open surgical transabdominal approach vs
thoracoscopy
• If abd too small to accommodate additional
bowels → intense ↓pulm compliance,
desaturation, hypercapnia
• OLV not always necessary anymore
• CO2 insufflation to collapse lung

49
Q 
CHD Temporary fetoscopic tracheal
plugging 
Performed \_\_\_\_\_\_weeks of gestation
• Prevents outflow of\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Retained fluid helps enlarge lungs, accelerates growth,
reduces mass effect of herniated bowels
A

• Temporary fetoscopic tracheal
plugging • Performed 25 -28 weeks gestation
• Prevents outflow of surfactant -rich fetal fluid

50
Q

GI PATHOLOGY

NOT a surgical emergency UNLESS

A

• All considered full stomachs
• Suction gastric contents first, then RSI
• Avoid N2O d/t intestinal distention
NOT a surgical emergency unless compromised organ blood flow*
• Correct underlying medical issues and achieve euvolemia
• Prone to:
• ↓BP
• Metabolic abnormalities (↑K+)
• Anemia
• Thrombocytopenia

51
Q

Hypertrophic Pyloric Stenosis

What kind of Vomiting?

How long does it take for metabolic derangements to be fixed?
Signs of proper optimization

A

• 1/500 live births
• Usually presents 2-8 weeks of age c/:
• Nonbilious projectile vomiting
→ ↓K+ ↓Cl- metabolic alkalosis–>Severe cases progress to metabolic acidosis

NOT a life threatening emergency
Fixing metabolic derangements and fluid
status takes 24-48hrs

Signs of proper medical optimization:
UOP of 1-2 mL/kg/hr or more
Na+ > 130 mEq/L
K+ > 3.0 mEq/L
Cl- > 85 mEq/
52
Q

Hypertrophic is______Vomiting

A

NON-BILIOIUS

53
Q

Treatment of HPS

A

pyloromyotomy
• Anesthesia considerations:
• Modified RSI
• Maybe inhalation induction
• Muscle relaxation not always necessary in every case
• Opioids typically not needed
• Local combined c/ acetaminophen or an NSAID normally enough

54
Q 
Duodenal Atresia •
Duodenal Atresia it is a \_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_ associated c/ other congenital
anomalies (OBSTRUCTION after bile duct) 
• Presentation: 
\_\_\_\_\_\_\_\_vomiting beginning \_\_\_\_\_\_\_\_\_\_→\_\_\_\_\_\_\_\_\_\_\_\_
NOT a surgical emergency, medically
optimize first
• Abdominal XR show \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
A

Congenital absence or complete closure of a portion of the lumen of duodenum
50 -70% associated c/ other congenital anomalies
Presentation: • Bilious vomiting beginning 24 -48hrs
after birth →dehydration + F/E imbalance
• NOT a surgical emergency, medically optimize first
• Abdominal XR show “double bubble” sign • Air trapped in stomach and proximal duodenum

55
Q

INGUINAL HERNIA
IT is a Protrusion of _____________
• Typically occurs within _____________
_____________ →***true surgical emergency
• Elective should receive _______ • Caudal, spinal, ilioinguinal block, TAP block

A

Protrusion of abdominal cavity and gonadal structures through the inguinal canal • Failure of process vaginalis to close
• Typically occurs c/in 6 mo of life and more
prevalent in males
• Incarcerated or strangulated hernia →true
surgical emergency
• Elective should receive regional • Caudal, spinal, ilioinguinal block, TAP block

56
Q

Necrotizing Enterocolitis (NEC)
It is a multifactorial ____________
_____mortality rate
Potential etiologies:

Associated with

A

Multifactorial disease that can lead to bowel necrosis
• Leading cause of neonatal mortality
• 10-50% mortality rate
• Potential etiologies:
• Unbalanced inflammatory responses of bowel mucosa, alterations in normal intestinal flora by antibiotics and feeds, and lack of a fully developed intestinal mucosal barrier → breakdown of intestinal wall and bowel necrosis

Associated c/:
• Prematurity, low systemic cardiac output, hypoxia, PDA, infection, red blood cell transfusion, and enteral feedings (especially formula-fed neonates)

57
Q

Leading cause of NEONATAL MORTALITY

A

NECROTIZING ENTEROCOLITIS

58
Q

Early signs of NEC

A

• Early Signs • Temp instability, poor feeding c/ residual
volumes or vomiting, lethargy, apnea,
bradycardia, mild abdominal distention, and
bloody stools

59
Q

Late signs of NEC

A

• Late signs • Tachycardia, poor perfusion/hypotension,

metabolic acidosis, thrombocytopenia, abdominal tenderness, and peritonitis

60
Q

• Abd XR of NEC shows

A

ileus c/ thickened bowel walls and dilated
loops, later gas in the intestinal wall and in
hepatobiliary tract or portal venous system

61
Q

***PROMPT SURGICAL INTERVENTIO of NEC, if you find

A

**• Finding free air in abd cavity = prompt surgical

intervention

62
Q
  • Fast preop prep of NEC
  • Predisposed to ________________
  • Septic and volume depleted c/ ______________as the result of massive third-space losses
  • Enormous need for ____________ just to maintain intravascular volume (up to 1 blood volume of more) because of third spacing
  • Hypokalemia c/ renal failure common
  • Commonly need plt and FFP transfusion
  • CVP for inotropic support (dopamine, epi)
A

Predisposed to hypovolemia, CV and resp failure, capillary leak syndrome, DIC, and hypoglycemia
• Septic and volume depleted c/ very large fluid requirements as the result of massive third-space losses
• Enormous need for 5% albumin just to maintain intravascular volume (up to 1 blood volume of more) because of third spacing
• Hypokalemia c/ renal failure common
• Commonly need plt and FFP transfusion
• CVP for inotropic support (dopamine, epi)

63
Q

OMPHACELE

A

Failure of gut to migrate from yolk sac into
abd during gestation
• 1/5000 births
• Commonly have other issues:
• associated genetic, cardiac, urologic, metabolic abnormalities, visceromegaly, macroglossia, hypoglycemia, polycythemia
• Bowel looks and functions normally

64
Q

Gastroschisis

A

• Results from occlusion of the omphalomesenteric artery during gestation
• 1/2000 births
• Usually not associated c/congenital anomalies
• Due to exposure, present c/inflammation, edema, and dilated,
foreshortened, functionally abnormal bowel
• Keep covered c/ saline-soaked dressings
• Extreme evaporative volume loss and hypothermia –> More than omphalocele

65
Q

Anesthesia Considerations for GASTRO and OMP

A

Volume replacement • Prevention hypothermia • Monitor intra-abdominal pressure (IAP) • > 20 mm Hg after surgery → abd ischemia, urgent reoperation → ↓ organ perfusion and ventilatory reserve, including perfusion of the intestines, kidney, and liver •
Altered metabolism/eliminatio n/prolongation of meds

66
Q

Malrotation and Midgut Volvulus

A

Etiology:
• Abnormal migration or incomplete rotation of intestines from yolk sac back into abdomen
• 1/500 births
• 30-60% have other congenial anomalies

Presentation:
• Bilious emesis, tender and distended abdomen, increasing abdominal girth, hypotension, hypovolemia, and electrolyte abnormalities
• True neonatal surgical emergency
• Do NOT delay surgery to correct
F/E imbalances
67
Q

Hirschsprung Disease

A

• Absence of parasympathetic ganglion
cells in large intestine • Nonperistaltic segment, tonically
contracted anorectal sphincter, and delayed passage of meconium • Functional obstruction

• Symptoms: bilious vomiting, abd distention
• Compromised blood supply
→perforation
• Enteric bacteria invasion of bowel
wall to bloodstream → toxic megacolon
• 60% have other associated anomalies • Require massive volume replacement and vasopressor support

68
Q

Ligation of Patent Ductus Arteriosus

A

• Controversial procedure due to conflicting
evidence • 1/3 develop severe cardiovascular instability • Increased risk of chronic lung disease, ROP,
and neurosensory impairment after ligation
• Medical management: cyclooxygenase inhibitor,
such as indomethacin or ibuprofen • Indomethacin in premies may cause: thrombocytopenia, renal failure,
hyponatremia, and intestinal perforation
• Ibuprofen works just as well s/complications • Paracetamol being used c/ equal effectiveness

69
Q

Ligation of Patent Ductus Arteriosus surgica

A

• Surgical correction: Left thoracotomy c/ manual
retraction of lung
• Hard to distinguish PDA from aorta
• Monitoring BP and pulsox on right arm
(preductal) and oximetry on the foot
(postductal) will assist surgeon to ID
correct vessel to be ligated
• Temporary clamp placed on perceived PDA
• If aorta is clamped → loss of post ductal oximetry
• If PA is clamped → ↓in both oximeters and ↓ETCO2
• Successful PDA ligation → ↑MAP (↑DBP) + NO changes in pulse oximeters

70
Q

Ligation of Patent Ductus: Transcatheter occlusion of PDA

MOST COMMON complications are

A
  • Coils or occlude device
  • Similar efficacy to traditional surgery
  • Can be done in NICU c/ echo guidance
  • More rapid recovery of resp function

• Most common complications

  • ->Femoral artery thrombosis
  • -> Left pulmonary artery stenosis
  • -> Aortic coarctation
71
Q

COMPARE OMPHACELE and GASTROCHISIS

A

Know

SNRAObPedGer (25 decks)

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