Surgery Questions - Mal

Question 1

Risk factors for apnea post general anesthetic.

Answer 1

• 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

Question 2

Children with asthma who are at increased risk for anesthetic complications.

Answer 2

• 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

Question 3

Anesthesia consultation pre-op indications:

Answer 3

• 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

Question 4

What is the pediatric appendicitis score?

Answer 4

• 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

Question 5

What is the most common complication of ruptured appendicitis?

Answer 5

Intra-abdominal abscesses

Question 6

What is the management of ruptured appendicitis?

Answer 6

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.

Question 7

When can adhesions start to cause bowel obstruction?

Answer 7

2 weeks to 1 year after surgery

Question 8

How do bowel adhesions present?

Answer 8

• Abdominal pain
• Constipation
• Emesis
• History of intra-peritoneal surgery
• Hyperactive bowel sounds and flat abdomen progresses to hypoactive bowel sounds and abdominal distension

Question 9

How do you treat symptomatic bowel adhesions causing SBO?

Answer 9

• NG decompression
• IV fluids
• Broad spectrum antibiotics
• non-operative management is contraindicated unless a patient is stable with obvious improvement*

Question 10

What is the Parkland formula?

Answer 10

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

Question 11

How do you classify burns?

Answer 11

• 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

Question 12

What are the indications for hospitalization in a burn patient?

Answer 12

• > 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

Question 13

Describe the management of minor burns

Answer 13

• 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

Question 14

What is diaphragmatic eventration? What conditions is it associated with?

Answer 14

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

Question 15

How do you manage diaphragmatic eventration?

Answer 15

Most are asymptomatic and do not require repair. Large ones may require surgical repair.

Question 16

What is a congenital diaphragmatic hernia (CDH)?

Answer 16

Congenital defect in the diaphragm that allows herniation of abdominal viscera into the thorax leading to pulmonary hypoplasia and pulmonary hypertension.

Question 17

What is Congenital Diaphragmatic Hernia associated with?

Answer 17

• Anomalies of the CNS or CVS system, esophageal atresia and omphalocele
• Syndromes: T21/13/18, Fryns, Brachmann-de-Lange, Pallister-Killian, Turner Syndrome

Question 18

How does congenital diaphragmatic hernia present?

Answer 18

Prenatal US: polyhydramnios, chest mass, mediastinal shift, fetal hydrops

Clinical: Tachypnea, scaphoid abdomen, decreased breath sounds, displacement of cardiac impulse

Question 19

How do you manage congenital diaphragmatic hernia in the delivery room?

Answer 19

ETT (avoid PPV) immediately - gentle ventilation with permissive hypercapnea

Question 20

Describe the presentation, etiology and treatment of epididymitis.

Answer 20

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

Question 21

Describe the differences between gastroschisis and omphalocele.

Answer 21

• 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)

Question 22

What is the differential diagnosis for GI bleed in a neonate?

Answer 22

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)

Question 23

What are the indications for surgical repair of an umbilical hernia?

Answer 23

• If persistent > 4-5 years of age
• if causing symptoms
• strangulated
• progressively larger over 1-2 years

Question 24

Describe the presentation and management of an incarcerated inguinal hernia.

Answer 24

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

Question 25

When should a hydrocele be treated surgically?

Answer 25

If persistent after 12-18 months

Question 26

A 13 month old male presents with vomiting and intermittent abdominal pain causing him to flex his knees to his chest. His mom is very worried that his stool had blood in it tonight. He is not in pain on assessment, but is very lethargic. He has a palpable sausage-shaped mass in his abdomen. What is the diagnosis and what are the options for investigation?

Answer 26

Intussception!

• Abdominal X-ray (first line to rule out perforation)
• Abdominal ultrasound (diagnostics) - target/donut sign
• Air enema with fluoroscopy or contrast enema (diagnostic and therapeutic) - contraindicated if signs of peritonitis, pneumoperitoneum or persistent hypotension –> surgical repair

Question 27

What is the etiology of intussception?

Answer 27

75% of cases are idiopathic 
2-8% of cases have recognizable lead points
- Meckel diverticulum
- intestinal polyp
- neurofibroma
- intestinal duplication cysts
- inverted appendix stump
- leiomyomas
- hamartomas
- ectopic pancreatic tissue
- anastomotic suture line
- enterostomy tube
- posttransplant lymphoproliferative disease
- hemangioma
- malignant conditions such as lymphoma or Kaposi sarcoma
- gastrojejunal and jejunostomy tubes