Surgery Questions - Mal Flashcards
Risk factors for apnea post general anesthetic.
- Prematurity
- Hx of apnea/bradycardia
- Chronic lung disease
- Post-conceptual age < 60 weeks at time of surgery
- Anemia
- *Observe term kids < 3 months and preterm kids < 60 weeks post GA
Children with asthma who are at increased risk for anesthetic complications.
- Hospital admission within the previous year
- ED visit in the last 6 months
- Previous ICU admission
- Previous IV steroids
- Ideally free of wheeze for at least several days before surgery
Anesthesia consultation pre-op indications:
- have symptoms of an acute illness - delay for 6 weeks post-illness if positive
- active chronic conditions
- difficult airway
- cardiac disease
- respiratory distress
- preterm infants
- obese patients or those with OSA
What is the pediatric appendicitis score?
- Fever > 38 = 1
- Anorexia = 1
- Nausea/vomiting = 1
- Cough/percussion/hopping tenderness = 2
- Right lower quadrant tenderness = 2
- migration of pain = 1
- leukocytosis > 10,000 = 1
- PMN > 7,500 = 1
< 4 = low risk –> discharge without imaging
4-7 = intermediate –> observation or imaging
> 7 = high risk –> surgical consult
What is the most common complication of ruptured appendicitis?
Intra-abdominal abscesses
What is the management of ruptured appendicitis?
IV antibiotics and percutaneous drainage of the abscess. (successful in 80%). Failure to improve -> appendectomy.
Consider interval appendectomy in 4-6 weeks if no return of symptoms.
When can adhesions start to cause bowel obstruction?
2 weeks to 1 year after surgery
How do bowel adhesions present?
- Abdominal pain
- Constipation
- Emesis
- History of intra-peritoneal surgery
- Hyperactive bowel sounds and flat abdomen progresses to hypoactive bowel sounds and abdominal distension
How do you treat symptomatic bowel adhesions causing SBO?
- NG decompression
- IV fluids
- Broad spectrum antibiotics
- non-operative management is contraindicated unless a patient is stable with obvious improvement*
What is the Parkland formula?
4mL/kg x weight (kg) x %TBSA = resus fluid in 24 hours –> 1/2 in 8 hours FROM INJURY and 1/2 in 16 hours
ADD maintenance fluid
How do you classify burns?
- Superficial: epidermis only, painful, red and blanching (not included in TBSA)
- Superficial partial thickness: epidermis and dermis, painful to temperature and air, blisters, may be weeping, red and blanching
- Deep partial thickness: epidermis and dermis, non-painful, blisters can be weeping or dry, non-blanching
- Full thickness: epidermis and full dermis, non-painful, appearance from waxy and taut to charred, non-blanching
What are the indications for hospitalization in a burn patient?
- > 10% BSA in kids, >10-20% BSA in adolescents
- 3rd degree burns (full thickness)
- Electrical burns with high tension wires or lightning
- Chemical burns
- Inhalational injury - regardless of %TBSA
- Social supports
- Suspected abuse
- Burns to: dace, hands, feet, perineum, genitals, major joints
- Pre-existing medical conditions impacting recovery
- Associated injuries
- Pregnancy
Describe the management of minor burns
- Remove all clothing and jewelry
- Pain management (NSAIDS +/- opiates)
- Cool skin (gauze, water, NO ice directly on skin)
- Clean with soap and water, debride ruptured blisters
- Dress with 3 layers: antimicrobial ointment, non adherent dressing, dry gauze (wet gauze predisposes to hypothermia)
- Tetanus
What is diaphragmatic eventration? What conditions is it associated with?
Abnormal elevation of the diaphragm.
Consisting of thinned diaphragmatic muscle that causes elevation of the entire hemidiaphragm or more often the anterior aspect of the hemidiaphragm → causes a paradoxical motion of the affected hemidiaphragm
Associated with pulmonary sequestration, CHD, SMA, T21/18/13
How do you manage diaphragmatic eventration?
Most are asymptomatic and do not require repair. Large ones may require surgical repair.
What is a congenital diaphragmatic hernia (CDH)?
Congenital defect in the diaphragm that allows herniation of abdominal viscera into the thorax leading to pulmonary hypoplasia and pulmonary hypertension.
What is Congenital Diaphragmatic Hernia associated with?
- Anomalies of the CNS or CVS system, esophageal atresia and omphalocele
- Syndromes: T21/13/18, Fryns, Brachmann-de-Lange, Pallister-Killian, Turner Syndrome
How does congenital diaphragmatic hernia present?
Prenatal US: polyhydramnios, chest mass, mediastinal shift, fetal hydrops
Clinical: Tachypnea, scaphoid abdomen, decreased breath sounds, displacement of cardiac impulse
How do you manage congenital diaphragmatic hernia in the delivery room?
ETT (avoid PPV) immediately - gentle ventilation with permissive hypercapnea
Describe the presentation, etiology and treatment of epididymitis.
Def’n: acute bacterial inflammation in the epididymis resulting from an ascending retrograde infection from the urethra through the vas into the epididymis.
Presentation: acute scrotal pain, erythema and swelling. Rare before puberty unless congenital abnormality of the wolffian duct.
Etiology: E. coli (younger), gonococcus or chlamydia (sexually active), mediterranean fever, enterovirus, adenovirus
Treatment: bed rest & antibiotics
Describe the differences between gastroschisis and omphalocele.
- Through umbilicus (O) vs. Lateral to umbilicus (G)
- Covered by thin membrane (O) vs uncovered (G)
- Associated with cardiac defects and Beckwith-Widemann & other congenital anomalies (O) vs. associated with intestinal atresia in 10-20% and malrotation (G)
- Normal bowel function post-repair (O) vs. strictures and dysmotility post-repair (G)
What is the differential diagnosis for GI bleed in a neonate?
Upper GI: - swallowed maternal blood - NG tube placement trauma - Less common: gastritis, ulcer, vit K deficiency, vascular malformation, gastric duplication, congenital coagulation factor deficiency Lower GI Bleed: - swallowed maternal blood - anorectal fissures - FPIAP (mild allergy) - NEC - midgut volvulus - bacterial enteritis - Less common: vascular malformation, hirschsprung enterocolitis, intestinal duplication, coagulopathy (hemorrhagic disease of newborn)
What are the indications for surgical repair of an umbilical hernia?
- If persistent > 4-5 years of age
- if causing symptoms
- strangulated
- progressively larger over 1-2 years
Describe the presentation and management of an incarcerated inguinal hernia.
Presentation:
- Most common in first year of life, greatest risk < 6 months
- Greatest risk factor: prematurity
- Irritability
- SBO: feeding intolerance, abdominal distension, vomiting, failure to pass stool
- Tense, non-fluctuant mass in inguinal region/scrotum/labia - well-defined and non-reducible
- Tender mass with overlying erythema and edema
- Signs of bowel obstruction on X-ray
Management:
- Surgical emergency
*The presence of an inguinal hernia itself is an indication for repair within 1 month of diagnosis as it will not resolve spontaneously and has a high risk of incarceration
