Surgical procedures part 2- Additional info

Question 1

Describe malrotation and midgut volvulus.

Answer 1

results from abnormal migration or incomplete rotation of the intestines from the yolk sac back into the abdomen
intestines twisted around the superior mesenteric artery may produce kinking or compression of the vascular supply
may result in atretic segments, comprised perfusion, and intestinal ischemia

Question 2

Describe the meaning of volvulus

Answer 2

bowel strangulation and shock

Question 3

Describe the presentation of malrotation and midgut volvulus.

Answer 3

1/3rd of cases present within the first week of life with bilious vomiting, distended abdomen, & hemodynamic instability- may present with hypotension, hypovolemia, and electrolyte abnormalities
blood stools are an ominous sign
rapidly compromised blood supply
a true surgical emergency due to risk necrosis

Question 4

Describe surgery for the intestinal malrotation with midgut volvulus.

Answer 4

reduces volvulus and relieves obstruction by dividing the fixation bands between the cecum and the duodenum or jejunum and widening the base of the mesentery
children with less than 30 to 40 cm of small bowel generally develop short-gut syndrome and ultimately require TPN

Question 5

Describe Ladd’s procedure

Answer 5

performed to alleviate intestinal malrotation
involves counterclockwise detorsion of the bowel, surgical division of Ladd’s bands, widening of the small intestine’s mesentery, performing an appendectomy, and reorientation of the small bowel on the right and the cecum and colon on the left

Question 6

Describe anesthetic concerns for the patient with midgut volvulus.

Answer 6

risk for aspiration–> RSI
avoid N2O
septic shock- IV access/a-line, often an opioid based anesthetic and paralysis with ketamine as the induction agent of choice
Hypovolemic- fluid, blood and electrolyte replacement, blood products should be available, Hct may be falsely increased secondary to marked intravascular volume depletion

Question 7

Describe omphalocele and gastroschisis.

Answer 7

external herniation of abdominal contents through an anterior abdominal wall defect

Question 8

Describe the presentation of omphalocele and gastroschisis

Answer 8

may present with impaired blood supply to herniated organs, intestinal obstruction, and major intravascular fluid deficits

Question 9

How is omphalocele and gastroschisis diagnosed

Answer 9

US confirms presence of lesions at nuchal scan at 10 to 13 weeks gestation
large defects are an indication for C-section

Question 10

Describe omphalocele.

Answer 10

hernia or rupture at the umbilicus

failure of the gut to migrate from the yolk sac into the abdomen

Question 11

Omphalocele has associated ______ abnormalities.

Answer 11

genetic, cardiac, urologic, and metabolic abnormalities. **

Question 12

In omphalocele, the viscera emerge

Answer 12

from the umbilicus and are covered with a membranous sac*****

Question 13

Describe gastroschisis.

Answer 13

exstrophy of “belly” “viscera” through an abdominal wall gap

results in occlusion in the omphalomesenteric artery during gestation

Question 14

Gastroschisis is ________ with other congenital anomalies.

Answer 14

usually associated

Question 15

In gastroschisis, the herniated viscera are exposed to

Answer 15

air after delivery resulting in worsening inflammation, edema, dilation with abnormal bowel function

Question 16

Although gastroschisis and omphalocele are different in presentation,

Answer 16

they have almost identical anesthetic and medical managements
Maintenance of perfusion and reduction of FLUID LOS from exposed visceral surfaces is important
closure of the abdomen is the goal however is often delayed to avoid exposing the viscera to excessive pressure

Question 17

With gastroschisis and omphalocele, high intra-abdominal pressure may result in

Answer 17

cardiorespiratory failure, renal failure, decreased hepatic function, ischemic bowel, and death
pressures >20 mmHg are poorly tolerated

Question 18

A silo is

Answer 18

temporary housing for the bowel
sutured to the defect and over the next several days, the silo is reduced to allow accommodation of gastric contents into abdominal wall via gravity & stretching

Question 19

Anesthetic considerations for gastroschisis and omphalocele include

Answer 19

assess for associated anomalies
increased IAP- gastric tube inserted to decompress stomach
severe electrolyte disturbances- monitor blood glucose
rehydrate (gastroschisis lose more fluid than omphaloceles)- availability of blood products, plan for IV access
-prevent hypothermia
aspiration risk necessitating RSI, avoid nitrous oxide
-risk for infection

Question 20

Describe the postoperative considerations for the patient with gastroschisis and omphalocele

Answer 20

assess ability to extubate
-continue gastric suction until bowel function recovers
continue IV fluids and glucose
may require IV alimentation (weeks to months)
often remain intubated with IV sedation, paralytics, and opioids until clinical status stabilizes

Question 21

Criteria for aborting primary closure in gastroschisis and omphalocele includes:

Answer 21

intragastric pressure >20 mmHg
intravesical pressure >20 mmHg
end-tidal CO2 50 mmHg or higher*
max ventilatory pressure of 35 cmH2O or greater

Question 22

Esophageal atresia and tracheoesophageal fistula are often associated with

Answer 22

VATER or VACTERL 
V-vertebral abnormalities
A- imperforated anus
C- congenital heart disease
T-tracheo
E- esophageal fistula
R-renal abnormalities 
L-limb abnormalities

Question 23

Tracheoesophageal fistula occurs because of

Answer 23

incomplete separation of the trachea and esophagus that begins during the 4th-5th week of gestation

Question 24

Survival of infants with TEF and no other congenital abnormalities is

Answer 24

> 95%

Question 25

Risks associated with TEF include:

Answer 25

pneumonia, poor nutrition, gastric distension which impairs ventilation

Question 26

Esophageal atresia with or without TEF is normally diagnosed immediately after

Answer 26

birth when the newborn has excessive secretions, coughing, and choking after first feeding
-additional indicators: recurrent pneumonias, OG cannot be passed into the stomach

Question 27

Treatment for TEF includes

Answer 27

surgical repair with ligation of fistula and anastomosis of esophagus

Question 28

Describe surgery for TEF.

Answer 28

surgery is urgent, but not emergent
+/- gastrostomy placement
ligation of the fistula
anastomoses of esophagus atretic segments
left lateral decubitus position and right thoracotomy

Question 29

Describe the discussion involving clinical presentation of TEF in the preop period.

Answer 29

inability to feed, chest x-ray, prenatal US with polyhydramnios

Question 30

Describe associated anatomic anomalies of the patient with TEF.

Answer 30

prematurity, cardiac defects/echo, vacterl, cleft

Question 31

Describe assessment of the pulmonary system for patients with TEF.

Answer 31

aspiration, PNA, diaphragmatic expansion

Question 32

Describe medical management of the patient with TEF.

Answer 32

NPO, NG tube, gastric tube, IV fluids, TPN, corrected acidosis, ABG, CBC, electrolytes, T&C, glucose

Question 33

Describe the positioning and monitoring for TEF patients.

Answer 33

left lateral position- right thoracotomy
standard monitors
a-line q1 hour ABGs (lung retraction may compromise accurate ETCO2)
left-sided precordial to assess tube migration
minimal blood loss- however proximity of surgical site to major vessels and organs (T&C), Hct goal> 30%
glucose infusion and monitoring

Question 34

Describe airway management for TEF.

Answer 34

RSI
challenging airway- consider fiberoptic and awake intubation- minimizes gastric distension & allows precise placement of ETT cuff
-inhalation induction-avoiding positive pressure ventilation- maintain spontaneous ventilation
-confirm ETT placement**
-crucial to place ETT between fistula and carina*** (distal to fistula, right main-stem and slowly withdrawal until BBSE)

Question 35

The presence of bowel gas suggests

Answer 35

TEF, on occasion abdominal distension is severe enough to cause atelectasis and impede ventilation

Question 36

Describe maintenance of anesthesia for TEF.

Answer 36

combination inhalation and opiates
avoid nitrous oxide (decreases fraction of inspired O2 and contributes to bowel distension)
muscle relaxation
large surgical surface area- at risk for hypothermia
surgical traction may compromise lung, great vessels, trachea, heart & vagus nerve

Question 37

A common pitfall during TEF is

Answer 37

adequate tissue oxygenation

Question 38

If a patient experiences arterial hypoxia during TEF

Answer 38

the surgeon may need to release traction and alveolar recruitment maneuvers performed

Question 39

Precipitous O2 desaturation can occur during TEF for a variety of reasons:

Answer 39

atelectasis and secretions preoperative= shunting of pulmonary blood flow
retraction on lung tissue, bleeding, tracheal, and bronchial compression
ETT malposition

Question 40

Adequate tissue oxygenation for TEF patients invovles

Answer 40

monitoring ABGs & frequent suctioning and ventilator setting changes

Question 41

Early complications of TEF includes

Answer 41

anastomosis leaks and strictures
GERD
feeding aversions
esophageal dysmotility

Question 42

Long-term complications of TEF icludes

Answer 42

strictures
pulmonary disease
tracheomalacia

Question 43

Early extubation for TEF is desirable because

Answer 43

it prevents prolonged pressure of the ETT on the suture line

• may extubate if adequate spontaneous respirations
• respiratory depression in the neonate can be due to hypothermia, hypoglycemia, or anemia

Question 44

The following may complicate recovery for TEF postop patients.

Answer 44

recurrent laryngeal injury, overlook additional fistulas, and recurrent fistulas

Question 45

Patients with TEF may remain intubated

Answer 45

although it can cause excessive pressure on new anastomosis, reintubation can also be traumatic

• position ETT 1 cm away from fistula repair
• suction catheter marked with distance for insertion to stay above suture line

Question 46

Conditions requiring emergency surgery in neonates may be accompanied by

Answer 46

concurrent medical problems*****

Question 47

_______ of an average neonate is 5-8 mL/kg/min.

Answer 47

Oxygen consumption*****
rapid decreases in arterial O2 content after brief periods of ventilatory compromise must be balanced coupled with risk of ROP and lung tissue toxicity from hyperoxia

Question 48

_______ is a large concern for any neonatal case

Answer 48

postoperative apnea monitoring*****

Question 49

Temperature regulation requires

Answer 49

warming the room temperature***** and active warming

Question 50

_______ has an increased affinity for oxygen and can reduce oxygen release of Hgb to the tissues

Answer 50

Fetal Hgb

Question 51

______ results in increased Co2 production and the respiratory rate must be increased to facilitate CO2 elimination

Answer 51

high metabolic rate***

-expired O2 may be diluted with exhaled gas and dead space