Surgery Questions - Kenz Flashcards
When should anesthesia be consulted for procedural sedation?
- CPS: Recommendations for Procedural Sedation in Infants, Children and Adolescents
- Anesthesia consultation should be considered for patients who:
- have symptoms of acute illness (ie. upper resp tract infection) or who have active chronic conditions (ie recent asthma exacerbation).
- at higher risk of respiratory complications: bronchospasm/laryngospasm, oxygen desaturations.
infants <6 months (higher risk of adverse events).
- at higher risk of respiratory complications: bronchospasm/laryngospasm, oxygen desaturations.
- have symptoms of acute illness (ie. upper resp tract infection) or who have active chronic conditions (ie recent asthma exacerbation).
- Other patients who should prompt involvement of anesthesia include:
- those with potentially difficult airway (history of difficult intubation/phenotypic features), resp distress (including reduced pulmonary function tests), cardiac disease (including pulmonary hypertension).
- preterm infants -> at risk of post-anesthetic apneas until 60 weeks post-conceptual age (ie 5 months corrected)
- obese patients and those with OSA
What are the requirements for procedural sedation? (specifically, things that the hospital can provide)
- Immediate availability of a clinician with advanced airway skills and competent in resuscitation and stabilization of the critically ill paediatric patient.
- An additional health care provider (HCP) to assist the clinician administering sedation. If the clinician is also performing the procedure and delegating continuous monitoring and directed administration of medications, the assistant must be a highly qualified HCP (e.g., another physician, nurse practitioner, anesthesia assistant, or a nurse with advanced resuscitation skills).
- Continuous physiologic monitoring with pulse oximetry and non-invasive blood pressure measurements. ECG and end-tidal capnography should be available when using intravenous (IV) sedation.
- Immediate availability of emergency equipment and rescue medications.
- Adequate post-sedation monitoring capabilities, including overnight admission if necessary.
HCPs considering procedural sedation must ensure what?
- The paediatric patient is an appropriate candidate (i.e., ASA Class I or II) based on a thorough history and focused physical examination.
- The patient is fasted in accordance with institutional guidelines.
- Consenting decision makers and assenting patients are informed of the indications for, alternatives to, and risks and benefits of, procedural sedation. Informed consent for the sedation itself is required.
- Referral to anesthesia occurs when these criteria cannot be met or an increased level of complexity is predicted.
Clinicians providing procedural sedation should be what?
- Appropriately credentialed and participate in maintenance of skills activities.
- Fully cognizant of the indications, contraindications, and adverse effects of administered medications and experienced with their use.
- Prepared to manage patients at any depth of sedation.
- Competent in resuscitation and stabilization of the critically ill paediatric patient.
Hospitals should develop institutional policies and procedures for procedural sedation that include what?
- Documentation of pre-sedation evaluation, informed consent, vital signs, medications administered, response to sedation, and unanticipated or emergency interventions.
- A checklist of immediately available emergency equipment and rescue medications.
- A process for reporting, monitoring, and reviewing adverse events.
Name 4 risk factors for anesthetic complications for kids with asthma?
- hospital admission within the previous year
- ED visit in the last 6 months
- Previous ICU admission
- previous IV steroids
What are good rules of thumb for kids with asthma and/or URTI symptoms around the time of anesthesia?
- ideally, kids should be free of wheeze for (at least) several days before surgery - even if this necessitates increased controller meds. Active wheeze is an indication to delay elective surgery.
- “Clear rhinorrhea without fever is not associated with increase anesthetic risk”
***Resp illness associated with fever, mucopurulent nasal discharnge, productive cough or lower resp symptoms (crackles/wheeze( are assoicated wit increase airway reactivity and anesthetic complications for up to 6 weeks after! (this is per Nelsons)
What are the ASA classifications?
Name 6 risk factors for apnea post-anesthetic
- Prematurity
- Multiple congenital anomalies
- Hx of apnea/bradycardia
- Chronic lung disease
- Post-conceptual age < 60 weeks at time of surgery
- Anemia
Which children need to be observed after anesthetic for a minimum of 12 hours (age requirements**)?
- Term kiddos < 3 months
- Preterm with postnatal age < 60 weeks
what are the associated risks of a current or recent URTI (WRT anesthesia complications)?
Higher risk for perioperative respiratory adverse events (airway hyperactivity- laryngospasm, bronchospasm, atelectasis, coughing,airway obstruction, hypoxia, stridor and breathholding) if current or recent URTI, most are mild and easily managed.
What is the COLDS score?
Use COLDS score to determine risk → decision is based on balancing the risk is based on local resources and individual experience
“For children who are found during preoperative screening prior to an elective procedure to have or have had a URI, we postpone the procedure until two to four weeks after symptoms subside” - If current and MILD may proceed, if fever or moderate to severe symptoms recommend postpone - CUTOFF SCORE 8
Patients score = 10-12/25
How do you diagnose appendicitis?
Acute appendicitis (not peritonic or septic to suggest perforation) - history + PE features + elevated WBC (>10,000)
Pediatric appendicitis score = 5 (up to 8 if hoping tenderness & anorexia)
Investigations: If the ultrasound study is unable to visualize the appendix, or the appendix is visualized but the findings inconclusive, the next options would include admission for a period of observation and planned reassessment, CT imaging, or diagnostic laparoscopy
How do you treat appendicitis?
An observation strategy seems most useful in patients who present with a brief history of illness (<12 hr) when advanced imaging studies predictably have lower sensitivity and specificity. A child may be observed with intravenous fluids, serial vital signs, and planned re-examinations is another strategy. At the end of a period of observation, typically 12-24 hr, the clinician decides on discharge based on reassuring clinical status, proceeds to diagnostic laparoscopy and appendectomy, or proceeds with advanced imaging evaluation
Score <4 = low risk → discharge no imaging
Score 4-7 = intermediate → observation or imaging
Score >7 = high risk → surgical consultation
What is the Pediatric Appendicitis Score?
What are the risk factors for a perforated appendix?
Highest risk for perforated appendicitis (40-59%) is delayed presentation (>48 hours), higher risk if insidious onset of symptoms (40-50%)
What is the management of a ruptured appie?
Management of a perf’d appie
Management: non-surgical (IV antibiotics (2 days - 7-10 days oral), percutaneous drainage of abscess) successful in >80% of patients. Failure to demonstrate recovery should prompt appendectomy, if recovery consider interval appendectomy in 4-6 weeks if no recurrence of symptoms
what is the most likely cause of a SBO (small bowel obstruction) in kids who have not had prior abdo surgery?
The most likely diagnosis in children who present with signs and symptoms of mechanical small bowel obstruction who have not had prior abdominal surgery is complicated appendicitis
What are complications/presenting features of a perf’d appie?
Complications:
- Patients typically develop signs and symptoms evidencing advanced disease, including worsening and diffuse pain, abdominal distension, and bilious emesis suggestive of developing small bowel obstruction
- The most likely diagnosis in children who present with signs and symptoms of mechanical small bowel obstruction who have not had prior abdominal surgery is complicated appendicitis
What is the most common complication of a perf’d appie?
“Intra-abdominal abscesses are the most common complication after perforated appendicitis and remain a significant problem ranging in incidence from 14 to 18%”
what are bowel adhesions? when do they develop? what are their symptoms?
Bowel Adhesions:
Adhesions are fibrous tissue bands that result from peritoneal injury -> can constrict hollow organs. Major cause of postop small bowel obstruction.
- most remain asymptomatic, but problems can arise any time after the 2nd postop week to a year after surgery.
- symptoms include: abdo pain, constipation, emeses and a history of intraperitoneal surgery.
- Initially bowel sounds are hyperactive and abdo is flat → progress to loss of bowel sounds and abdo distension.
