TEST 4 Flashcards
What (6) pediatric syndrome are considered difficult airway algorithm and cricothyrotomy?
Pierre Robin Sequence
Treacher Collins Syndrome
Goldenhar Syndrome
Beckwith-Wedemann Syndrome
Klippel-Feil Syndrome
Apert Syndrome, Pfeiffer Syndrome, Crouzon Syndrome
Visualization of complete laryngeal opening
Grade 1
Visualization of just the posterior area
Grade II
Visualization of just the epiglottis
Grade III
Visualization of just the soft palate
Grade IV
How should you approach a difficult airway?
You should formulate a plan that includes several contingencies for failure or loss of airway.
Who should you have present when dealing with a difficult airway?
Have skilled help available
Have ENT surgeon experienced in performing pediatric bronchoscopy and tracheostomy. ,
What should you have in close proximity when dealing with difficult airway?
Difficult airway cart with flexible fiberoptic bronchoscope in the OR
When dealing with difficult airway clear ____________ about the airway management plan is required.
Clear communication
What is the preferred technique with difficult airway management?
Either awake but sedated or spontaneously breathing under GETA with adequate oxygenation while the airway is evaluated.
What 3 medications combos are utilized with difficult airway management?
Combinations of benzo’s, opiods (Versed and Fentanyl)
Ketamine and Versed and Glyco
OR
Sevo and spray VC with Lidocaine (max 5mg/kg) - keep patient spontaneously breathing
Unexpected difficult intubation; although it is rare occasion, the practitioner should be prepared for _____________ event.
Life threatening
Because infants have increased/decreased FRC, the time between the loss of the airway and resultant hypoxemia with potential secondary neurologic injury is significantly increased/diminished compared to adults.
Decreased FRC
Diminished compared to adults
Desaturation of 10 kg infants from SpO 90-0% within how many minutes?
How many minutes does it take SpO2 to go from 90-0% in a healthy 70kg adult?
4 minutes for 10 kg
10 minutes in healthy 70 kg adult
What is multi handed mask ventilation?
One person uses both hands for tight mask seal, chin lift and jaw thrust while to other is hand- ventilating with increased peak airway pressure
What is an Air- Q LMA?
A tool for use in both nonemergency (can ventilate but cannot intubate) and the emergency pathway (cannot ventilate nor intubate). Maybe used as a conduit for intubation.
What are the special techniques for ventilation 5 different steps?
- Multi handed mask ventilation
- Air Q LMA
- Fiberoptic laryngoscopy, bullards, light wand
- Percutaneous needle cricohyrotomy
- Surgical airway (tracheostomy)
Positioning of child during percutaneous cricothyrotomy?
Extend the head in the middle with rolled towel or folded sheet beneath the shoulders.
Where should you stand when performing a percutaneous cricothyrotomy?
To the left of the child
Hand positioning of the practitioner during percutaneous cricothyrotomy?
Stabilize trachea with right hand
Cricothyroid membrane is located with the index fingertip of the left hand between thyroid and cricoid cartilage. Space v narrow (1mm) in infant only fingernail can discern it.
Trachea then stabilized between middle finger and thumb of L hand while fingernail of the index finger marks the cricothyroid membrane.
What gauge IV catheter is used for percutaneous cricotothyrotomy?
What should happen after inserted?
12-14 g through cricothyroid membrane and air is aspirated.
What is done after air is aspirated?
The catheter is advanced into the trachea though the membrane, and the needle is discarded; an intraluminal position is reconfirmed by attaching a 3mL syringe and aspirate for air.
An adapter from a _______ ETT can be attached to an IV catheter and ventilation is accomplished by ______________________ .
3.0
Attached to a breathing circuit.
What could you do if you don’t have a 3.0 ETT adapter?
An alternative would be to leave the barrel of the 3 mL syringe attached to the IV catheter, insert an 8.0 ETT adapter to the syringe barrel, and then attach to the breathing circuit.
What is trisomy 21
Down syndrome
Characteristics of Down Syndrome children?
Small mouth, hyopolastic mandible, protruding tongue -> may be difficult to intubate
Are Down syndrome considered mentally retarded?
Yes
How many have cardiac issues? And what are they?
50% have cardiac issues: VSD, ASD, Tetrology of Fallot
Down syndrome have hypotonia T/F?
True floppy “Down’s Dance”
Down syndrome children have increased risk of bradycardia on induction? T/F
True
Down syndrome children can tolerate hyperextension of the head. T/F?
False, avoid hyperextension because they have Atlanta- occipital instability
Avoid shoulder roll because it can increase hyperextension
Down syndrome children have decreased risk of post intubation stridor? T/F?
False -> increased risk of post intubation stridor
Down syndrome children have increased/decreased risk of hypothyroidism, acute leukemia?
Increased
Down syndrome patient needs _____/_____ evaluation of their cervical and temporomandibular anatomy d/t the unique risk of _____________ _____________ if neck pain or neurological symptoms exist (e.g. Abnormal gait, increased clumsiness, complaints of numbness/tingling/weakness of an extremities, etc)
CT/MRI
Atlanta occipital instability
What do you want to avoid during any manipulation of the neck or airway during mask ventilation or intubation?
Avoid excessive flexion, rotation, or neck extension.
What is the crease called in the hand of a Down syndrome child?
Simian crease
What is the difference in a simian crease and a normal palm
Simian crease is a single palmar crease compared to two creases in a normal palm.
How often does a simian crease occur in normal people?
1 out of 30 normal people
What 2 conditions does a simian crease usually occur in?
Down syndrome, Aarskog syndrome, or fetal alcohol syndrome
MM
What are three major concerns related to anesthetizing the Down’s (trisomy 21) patient?
Intubation may be difficult owning to the large tongue, short neck, small mouth and subglottic stenosis (select ETT one size smaller than anticipated)
Neck flexion during laryngoscopy and intubation may result in antlanto occipitla (cervical spine) dislocation because of congenitally weak ligaments (consider getting cervical- spine films)
COngenital heart disease is present in 40% of patients (anesthesia compatible with the patients congenital heart defects could be delivered)
What does VACTERL (VATER) Syndrome stand for?
V= vertebral abnormality A= anal or intestinal atresia C= cardiac anomalies T E= tracheo- esophageal fistula R= renal malformations L= limb defects
Babies who have been diagnosed as having VACTERL association usually have how many individual anomalies?
At least three or more
What fistula is accepted as essential for the diagnosis?
TE fistula
What are vertebral anomalies with VACTERL syndrome?
Defects of the spinal column
What do the vertebral anomalies with VACTERL syndrome usually consis of?
Small (hypoplastic) vertebrae or hemivertebra where only have of the bone is formed
What are VACTERL syndrome kids at risk for because their vertebral anomalies?
Risk of scoliosis
What might be difficult to place because the vertebral anomalies associated with VACTERL syndrome?
Difficult to place epidural for TEF repair (thoracotomy)
How prevalent is congenital heart disease with VACTERL syndrome?
Up to 75%
What are the most common heart defects seen with VACTERL?
VSD
ASD
Tetrology of Fallot
How prevalent are renal/kidney defects with VACTERL syndrome?
50%
What are the renal/kidney defects with VACTERL syndrome?
They can be severe with incomplete formation of one or both kidneys or urologic abnormalities
What are the limb defects commonly associated with VACTERL syndrome?
Absent or displaced thumbs, extra digits (polydactyl), fusion of digits (syndactyly) and forearm defects
What is the growth like in VACTERL syndrome?
Small stature, difficulty gaining weight, but normal development and normal intelligence.
What type of disorder is an autosomal recessive disorder (requires the presence of two copies of a gene mutation in order to express observable phenotype?
Cystic Fibrosis (CF)
Cystic Fibrosis causes a disruption of ___________ transport in __________ cells in sweat ducts, airway, pancreatic duct, biliary tree -> elevated sweat chloride concentration (test for diagnosis), viscous mucous production, lung disease, intestinal obstruction, pancreatic insufficiency, biliary cirrhosis.
Electrolyte
Epithelial
What does a normal CFTR do?
Moves chloride ions to the outside of the cell
What does a mutant CFTR channel do?
Does not move chloride ions, causing sticky mucus to build up on the outside of the cell
What does CTFR channel stand for?
Cystic Fibrosis Transmembrane Conductance Regulator
What is the most common problem with cystic fibrosis?
Lung disease; mucus plugging d/t impaired ciliary clearance, chronic infection, inflammation, bronchial hyperactivity, increased airway resistance.
What are the health problems associated with cystic fibrosis?
Sinus problems Nose polyps (growths) Salty sweat Frequent lung infections Enlarged heart Trouble breathing Gallstones Abnormal pancreas function Trouble digesting food Fatty BM's
What are 4 additional problems with CF?
- Malnutrition with increased caloric demand d/t severe lung disease
- DM (pancreatic insufficiency)
- Coagulopathy (hepatic dysfunction)
- End- stage for pulmonary (organ transplantation needed
CF children require what kind of surgeries in their life?
Nasal polypectomy ENT surgery Central line placement Bronchoscopy/ lavage EGD & colonoscopy GI surgeries Cholecystecomy Tx of recurrent pneumothorax Organ transplantation
Anesthesia considerations with CF? (8)
- Anxiolytics (CF patients are emotionally vulnerable)
- Hydrate well
- Give nebulized saline tx before and after surgery
- Circuit humidifier, optimize ventilation with high FiO2
- Expect high airway pressure (be careful with barotrauma/pneumothorax)
- Suction ETT under deep anesthesia
- Complete reversal of neuromuscular blockade (neostigmine and glyco) but avoid glycopyrrolate as antisialagogue
- Reverse isolation to keep our germs away from CF patients
What is cerebral palsy?
A term used to describe a group of chronic conditions affecting body movement and muscle coordination
What causes cerebral palsy?
Damage to one or more specific areas of the brain, usually occurring during fetal development; before, during, or shortly after birth; or during infancy
Characteristics of hemiplegia?
Arm and leg on one side
Arm bent; hand spastic or floppy often of little use
She walks on tip toe or outside of foot on affected side
The other side is completely/almost normal
Characteristics of paraplegia?
Both legs only
Or with slight involvement elsewhere (diplegic)
Upper body usually normal or with very minor signs
Child may develop contracture of ankles and feet
Characteristic of quadriplegic?
Both arms and legs
When he walks, his arms, head, and even his mouth may twist strangely
Children with all 4 limbs affected have such severe brain damage that they may never be able to walk
The knees press together
Legs and feet turned inward
May develop contracture of ankles and feet
Cerebral palsy is caused by problems in the muscles or nerves. T/F?
False -> due to faulty development or damage to motor areas in the brain disrupt the brain’s ability to adequately control movement and posture
CP is a group of disorders that are often accompanied by disturbances of sensations, cognition, communication, perception, behavior and seizure disorder or mental impairment. T/F?
True
Antenatal risk factors for CP?
Prematurity and LBW
Intrauterine infections
Multiple gestation
Pregnancy complications
70-80% CP
Perinatal risk factors for development of CP
Birth asphyxia
Complicated labor and delivery
10% of CP
What are postnatal risk factors for development of cerebral palsy?
Non accidental injury
Head trauma
Meningitis/encephalitis
Cardio- pulmonary arrest
What are protective factors for OB care to help reduce risk of CP?
Management of pre eclampsia- MAG SULFATE
Management of infections- ANTIBIOTICS
Preterm labor- CORTICOSTEROIDS
What are the 5 types of CP?
- Athetoid
- Spastic
- Ataxia
- Rigidity
- Tremors
What is athetoid?
Constant uncontrolled motion of head, limbs, and eyes
What is spastic CP?
Tense, contracted muscles (most common type of CP)
What is ataxic CP?
Poor sense of balance often causing falls and stumbles
What is tremor CP?
Uncontrollable shaking, interfering with coordination
What is rigidity CP?
Tight muscles that resist effort to make them move
MM
At what age is cleft palate usually repaired?
Cleft palate repair is usually undertaken when the infant is 12- 18 months old, but sometimes younger.
What is the syndrome where the cleft soft palate (no cleft lip) which leads with “breath-suck-swallow” pattern, choking and failure to thrive?
Pierre Robin Sequence
What is the main reason why Pierre Robin Sequence is a difficult intubation?
Micrognathia/retronagthia
In Pierre Robin Sequence, what is it called when the tongue is placed back further in the mouth?
Glossoptosis
What can glossoptosis cause?
Partial/complete obstruction of airway
Due to glossoptosis in Pierre Robin Sequence, what is often required?
Tracheostomy
What is the syndrome where the patient has down/slanting eyes, lower jaw is often small and receding (micrognathia/retrognathia)?
Treacher Collins Syndrome
In Treacher Collins Syndrome, what is the underdevelopment or absence of cheekbones and the side wall and floor of the eye socket?
Macrostomia
In Treacher Collins Syndrome, what is underdeveloped, malformed ears called?
Microtia
In Treacher Collins Syndrome, what describes the conditions where normal tissue in or around the eye (iris, retina, choroid, or optic disc) is missing from birth?
Coloboma
What 6 conditions does a patient with Treacher Collins Syndrome have?
Down-slanting “antimongoloid” palpebral fissures
Microtia, malformed ears
Coloboma of the lower lid of the eye
Macrostomia
Micro/retronathia
Cleft Palate
Treacher Collins patients may require ___ __ and __ __ __ over multiple procedures.
Extensive bony and
Soft tissue reconstruction
In Treacher Collins Syndrome, what reconstructions can occur before age 10, and as teenagers?
Before 10: orbital and zygomatic reconstruction
Teenagers: external ear reconstruction and mandibular advancements as when bony growth is complete
Most children with Treacher Collins have normal __ and __; however it is important that there should be early hearing tests and speech interventions
Development and intelligence
What are the (3) characteristics that is associated with Goldenhar Syndrome?
Unilateral or bilateral underdevelopment of the mandible
Microtia (small ears)
Reduction in size and flattening of the maxilla (upper jaw)
What is thought to be the cause of Goldenhar Syndrome?
Thought to be a vascular accident in the fetus
Due to a vascular accident in the fetus in Goldenhaar Syndrome, it causes the blood supply to be cut off and production of __ __ in the areas of those tissues and while develop into the structures of the __ and __ __.
Blood clots
Ear
Lower jaw
What 3 conditions occurs with Beckwith-Wiedemann Syndrome (Visceromegaly)?
Macroglossia
Visceromegaly
Omphalocele
In Beckwith-Wiedemann Syndrome, macroglossia relatively improves with ___; May require partial ___
Growth
Glossectomy
What is a life-threatening clinical syndrome of hyper metabolism involving the skeletal muscle?
Malignant Hyperthermia (MH)
What is the function of the sarcoplasmic reticulum (SR) inside the skeletal muscle and cardiac muscle?
The SR of cardiac muscle and striated skeletal muscle functions as a storage and release area of calcium
What is a structural unit of a myofibrils in a muscle called?
Sarcomere
What is called the “powerhouse” of the cell?
Mitochondrion
Where is Ca 2+ stored?
Sarcoplasmic reticulum
In Malignant Hyperthermia, there is uncontrolled and excessive Ca2+ release in the cardiac muscles. True or False.
FALSE. In the skeletal muscles
Due to an abundance of Ca2+ in the skeletal muscle, what two things can occur in MH?
Skeletal muscle contractions
Induce a drastic and uncontrolled increase in oxidative metabolism in skeletal muscle
In MH, Excessive Calcium acts like “adding coal to a train furnace.” True or False
True
Due to the uncontrolled and excessive calcium release in skeletal muscle, what (3) symptoms can occur with MH? And what can lead it to?
Overwhelms the body’s capacity to supply oxygen -> HYPOXIA
Elevates carbon dioxide -> Increased CO2
Causes excessive heat production (increased TEMP)
Eventually leads to CIRCULATORY ARREST and DEATH if not immediately treated
What are the primary triggers of MH?
Succinylcholine
All volatile anesthetics (SEVO, ISO, DES, ENFL, Halothane)
NO other drugs used in anesthesia today for intravenous or regional anesthesia are triggering agents for MH. True or False
True
(At the cellular level) Persons susceptible to MH, the __ ___ ___ or other genes involved in calcium regulation are altered, resulting in excessive calcium release from the SR in the presence of MH-triggering agents.
Ryanodine receptor gene 1 (RyR1)
In MH, what controls calcium release, causing an excessive Calcium overload in skeletal muscle and results in a massive metabolic reaction?
An abnormal ryanodine receptor
What (6) things occurs when there is an uncontrollable release of intramyoplasmic calcium?
Sustained muscle contracture
Hypermetabolic response
Increased oxygen consumption and CO2 production
Heat production
Muscle cell hypoxia
Eventually death
In almost all cases, the first manifestation of MH occur in the PACU. True or False.
False in the OR.
What are the (3) early signs of MH?
Tachycardia
HTN
Tachypnea
Beside the first (3) signs, what are the next (4) consecutive early signs of MH?
Increased end-tidal CO2 (hypercapnia)
Increased O2 consumption
Increased heat production (body temperature increases at a rate of 1-2 degrees Celsius every five min
Metabolic and respiratory acidosis
What could be (8) LATE SIGNS of MH?
Truncal and.or masseter rigidity
Hyperkalemia
Arrhythmias
Cola-colored urine (myoglobinuria)
Rhabdomyolysis (increased CPK-often exceeds 20,000 units/L in the first 12-24 hrs)
Coagulopathy (DIC)
Multiple organ dysfunction and failure
Eventually Death
What are the INITIAL STEPS to treat MH?
Call for help!!!
Discontinue triggering anesthetic
Hyperventilate with 100% oxygen
Notify your surgeons, anesthesia team, nursing team
Ask for MH cart
How do you TREAT an MH crisis? (8)
Administer dantrolene sodium (Ryanodex) ASAP
Place activated charcoal filters on circuit
Initiate TIVA
Hyperventilate (blow off CO2)
Aggressive IV hydration
Cool patient actively
Place A-line, Foley, central line
Send labs
What is dantrolene sodium?
A ryaondine receptor 1 antagonist; an antidote to MH
What is the mechanism of action of dantrolene sodium?
Blocks the ryanodine receptors, therefore inhibits abnormal calcium release from the SR, leading to muscle relaxation
How many mg of dantrolene in Revonto
How many vials do you need for a 70 kg patients?
Water to reconstitute 1 vial?
Vials required to stock?
Price?
Shelf life?
20 mg
8 vials
60 ml
36
3000
3 years
How many mg of dantrolene in Dantrium?
How many vials do you need for a 70 kg patients?
Water to reconstitute 1 vial?
Vials required to stock?
Price?
Shelf life?
20 mg
8 vials
60 ml
36
$3000
3 years
How many mg of dantrolene in Ryanodex?
How many vials do you need for a 70 kg patients?
Water to reconstitute 1 vial?
Vials required to stock?
Price?
Shelf life?
250 mg
1 vial
5 ml
4
$6900
2 years
What is the drug of choice of MH?
Ryanodex
What is the initial dose of Ryanodex and are you able to repeat as needed?
2.5 mg/kg
YES
What is the maximum cumulative dose of Ryanodex?
10 mg/kg
MHAUS suggests no upper limit treatment doses, what does MHAUS recommend if patient does not respond to 10 mg/kg of Ryanodex?
Consider other etiologies
For a 70 kg patient, what is the loading dose of Ryanodex?
3.5 ml or 175 mg of dantrolene sodium
What (9) medications are in the MH cart? And What may you need to call the pharmacy for?
Ryanodex 250 mg vials x 3
Sterile preservative free water
Sodium bicarb 8.4%
Regular insulin (in refrigerator)
Dextrose
Furosemide
Calcium chloride/Calcium gluconate
Heparin
Lidocaine
What is in the MH card Refrigerator?
Medications:
Regular insulin
Supplies:
Cold IV fluids (NS 1000 ml x 5)
5 ice packs
With macroglossia in Beckwith-Wiedemann Syndrome, chronic airway obstruction may predispose to __ __.
Cor Pulmonale
What is Visceromegaly?
Cardiomegaly
Nephromegaly
Hepatomegaly
Splenomegaly
Pancreatomegaly
With Visceromegaly in Beckwith-Wiedemann Syndrome, ____ occurs due to increased insulin secretion.
Hypoglycemia
With Beckwith-Wiedemann Syndrome, ___ increase the incidence of intra-abdominal tumoral
Omphalocele
What is a bone disorder characterized by the abnormal fusion of two or more cervical vertebrae, which is present from birth?
Klippel-Feil Syndrome
What are the three major features that result in Klippel-Feil Syndrome?
Short neck
Limited ROM in the neck
Low hairline at the back of the head
In Klippel-Feil Syndrome, most affected people have __ or __ of the three characteristics.
One or two
What are the (3) syndromes that encompass craniosynostosis?
Apert Syndrome
Pfeiffer Syndrome
Crouzon Syndrome
What are the (3) major characteristics of Syndromic craniosynostosis include?
Skull deformities (premature closing of the cranial sutures)
Eyes abnormally far apart
Fusing or webbing of the digits and other abnormalities
With craniosynostosis, long term, life-limiting or life threatening consequences may result from these abnormalities. True or False
True
What type of Craniosynostosis if characterized by premature fusion of cranial sutures?
Type I
What kind of symptoms do Type I Craniosynostosis exhibit?
Recessed cheekbones
Various toe and finger abnormalities
Intelligence is affect with Type I Craniosynostosis. True or False
False; not usually affected.
Does Type I Craniosynostosis have a good survival rate?
Yes. Significant
What type of Craniosynostosis is characterizesd with “cloverleaf” shape of the skull?
Type II Craniosynostosis
Why does the “cloverleaf” shape of the skull occur in Type II Craniosynostosis?
Due to extensive fusion of cranial sutures
In Type II Craniosynostosis, the “cloverleaf” skull shape can hamper what (2) things?
Normal brain growth
Mental retardation
What type of Craniosynostosis is occurring where the symptoms are similar to type 2, but “cloverleaf” skull shape is NOT present in thes patients?
Type III Craniosynostosis
What are the (3) clinical characteristics with Pierre-Robin Sequence?
Micrognathia
Cleft palate
Glossoptosis (posterior displacement of tongue)
What are the (2) clinical characteristics of Treacher-Collins Syndrome?
Hypoplasia of maxilla and mandible
Variable eye and ear deformities
What are the (4) clinical characteristics of Hemifacial microsomia (Goldenhar’s)?
Unilateral/bilateral mandibular hypoplasia
Variable microphthalmia
Microtia
Macrostomia (wide mouth)
What are (4) clinical characteristics with Beckwith-Wiedemann Syndrome?
Macroglossia
Visceromegaly/Organomegaly
Omphalocele
Hypoglycemia
What is the surgical drainage of accumulated fluid in the middle ear?
Myringotomy
What kind of tubes are often placed in the tympanic membrane as stents to allow for continued drainage of the middle ear in myringotomy?
Ventilating tubes
Myringotomy is a very slow procedure requiring GETA with SEVO inhalation induction.
FALSE.
Brief procedure, requiring GETA and SEVO inhalation induction,
Mask ventilation w/ or w/o oral airway and
NO IV PLACEMENT
Since myringotomy does NOT require IV catheter placement, how is fentanyl give? Dose?
Intranasal Fentanyl 1-2 mcg/kg
What are the (2) major indications for surgical removal of tonsils and adenoids (Adenotonsillectomy T&A))?
Chronic or recurrent tonsillitis
Obstructive adenotonsillar hyperplasia
Tonsillar hyperplasia may lead to ACUTE/CHRONIC airway obstruction resulting in what (6) things
CHRONIC
Sleep Apnea
CO2 retention
Cor pulmonale
FTT
Swallowing disorders
Speech abnormalies
With T&A, children with ___ __ __ may be at risk for ENDOCARDITIS due to recurrent __ __ secondary to infected tonsils.
Cardiac valvular disease
Steptococcla bacteremia
Surgical techniques of T&A vary and include what (6) techniques?
Guillotine and snare technique
Cold and hot knife dissection
Suction
Ultrasound coblation
Unipolar electrocautery
Bipolar electrocautery
With T&A, what is the major advantage of electrocautery dissection?
Reduction in the incidence of intraop blood loss as well as primary and secondary hemorrhage
What is a major disadvantage in T&A?
Greater pain and poor oral intake post op
Due to risk of airway fire in T&A, make sure you keep what LOW?
FiO2
Mortality associated with T&A is estimated to be 1:___ and 1: ___.
1:16,000 - 1:35, 000
With T&A, what are (6) common morbidities?
Throat pain
Otalgia
Poor oral intake
Dehydration
Obstructive breathing (3 years and younger)
Post-op bleeding (>10 y)
Children who are schedule for T&A have a HIGH incidence of __ and ___.
Airway reactivity
Laryngospasm
Patients classier as Class 3 or greater of Tonsillar Size have more than __ of the pharyngeal occupied by ___ tonsils.
50% of pharyngeal
Hypertrophied tonsils
Children with Class 3 Tonsillar Size are at INCREASED risk of developing ___.
Airway obstruction during Anesthetic induction
What class of tonsillar size are classified as surgically removed tonsils?
0
What class of tonsillar size are classified as tonsils hidden within tonsil pillars?
1
What class of tonsillar size are classified as tonsils extending to the pillars?
2
What class of tonsillar size are classified as tonsils are beyond the pillars?
3
What class of tonsillar size are classified as tonsils extend to midline? “Kissing tonsils”
4
What is the most common form of sleep-disordered breathing?
OSA
What is OSA?
Partial or complete collapse of the UPPER airway that causes muscles controlling the soft palate and tongue to relax
What are some causes of OSA for a child with T&A?
Large tonsils and adenoids make airflow difficult
Patients with OSA experience with what (3) things?
Apnea
Hypoapnea
Flow limitations
What is cessation of airflow lasting > or equal to 10 seconds?
Apnea
What supplies are in the MH cart?
- Activated charcoal filters
- ABG syringes and blood tubes
- IV supplies
- A line and central line supplies
- Triple transducer kit
- Pressure bag
- Salem Sumps
- Esophageal stethoscope
- Bucket for ice
- Bladder irrigation set
- Foley with urine meter
- Sterile drape
- Test strips for urine myoglobin
- Urine collection container
What is the other name for activated charcoal filters?
Vapor clean
In less than 90 seconds, Vapor- clean activated charcoal filters reduce exposure to less than ________ of desflurane, sevoflurane, and isoflurane molecules from reaching the patient
5 ppm
How do you treat malignant hyperthermia? (Cooling measures)
Begin cooling measures, administer iced solutions, ice packs to groin, axilla and neck, nasogastric lavage with iced solution, or more aggressive measures as needed
Initial step for treatment of malignant hyperthermia?
Call for help Discontinue triggering anesthetic Hyperventilate with 100% O2 Notify your surgeons, anesthesia them and nursing team Ask for MH cart
How to treat MH crisis? (7 steps)
- Administer dantrolene sodium ASAP
- Place activated charcoal filters on circuit
- Initiate TIVA
- Hyperventilate
- Aggressive IV hydration
- Cool patient actively
- Place A line, foley and central line
What is supportive therapy for MH?
- Correct acidosis and hyperkalemia
- Send labs
- Monitor for rhabdomyolysis, arrhythmias, acute renal failure
- Prepare to transport to ICU
How to treat acidosis and hyperkalemia?
Correct acidosis:
- hyperventilate
- increase minute volume to lower ETCO2
- sodium bicarb 8.4% (1-2 mEq/kg)
Correct hyperkalemia:
- glucose/insulin: Peds: 0.1 units regular insulin/kg IV and 0.5 g/kg dextrose; Adults: 10 u reg insulin IV and 50 mL 50% dextrose. Check glucose hourly
CaCl2: 10 mg/kg or Ca2+ gluconate 30 mg/kg
- for refractory hyperkalemia, consider albuterol (or other beta agonist), kayexelate, dialysis, or ECMO if patient is in cardiac arrest
What labs should be sent in MH and what should be monitored to monirot for rhabdo, arrhythmias, acute renal failure
ABG (metabolic status includes lactate, glucose, BE, K+)
BMP (basic metabolic panel)
Electrolytes (K+)
CBC
Serum myoglobin/urine myoglobin CPK (creatinine phosphokinase) Coags, D Dimer, fibrinogen
What is rhabdomyolysis?
The rapid breakdown of muscle tissue
Complications can occur when, after the muscle is damaged, the cells release their contents rapidly into the blood–> hyperkalemia –> arrhythmia
Rhabdomyolysis has been known to cause damage to kidneys and DIC
What is the earliest sign of rhabdomylysis
Myoglobinuria/myoglobinemia
What is a myoglobin blood test?
It is a test to detect muscle damage
Myoglobin is filtered from the blood by the kidneys and is released into the urine. Sometimes a urine test is ordered to evaluate myoglobin levels in people who have had extensive damage to their skeletal muscles (rhabdomyolysis).
Urine myoglobin levels reflect the degree of muscle injury and, since myoglobin is toxic to the kidneys, reflect the risk of kidney damage.
What is a CPK test?
Creatine phosphokinase
Serum CPK levels may not rise for several hours, serum CPK concentration may remain elevated for days and should be monitored until it returns to normal
Once rhabdo has been diagnosed, what should you do to to prevent renal failure?
Treat with IV fluids and other supportive care: ie: furosemide, mannitol etc.
How to prevent acute renal failure in rhabdo.(4 things)
- Force diuresis to help prevent acute renal failure
- Ensure urine output of 2.0 mL/kg/hr with mannitol, furosemide, and fluids as needed
- Furosemide 0.5-1 mg/kg once (max 20 mg)
- If CPK or K+ rise, assume myoglobinuria and give bicarbonate infusion of 1 mEq/kg/hr to alkalinize urine
How much ryanodex should you give as supportive management to treat MH?
Continue ryanodex at 1.0 mg/kg every 4-8 hours for 24-48 hours titration to the desired effect (resolution of hyperthermia, acidosis, and myoglobinemia.
What should you avoid while giving ryanodex?
Avoid calcium channel blocking agents with Ryanodex because life threatening hyperkalemia may result.
Cooling for supportive management to treat MH?
Actively cool pt until core body temp is 38 degrees
- iced normal saline 10mL/kg IV every 10 minutes X 30 minutes
- surface cooling ice packs
- –> axillary, groin, neck, head
- –> hypothermia blanket
- iced lavage of stomach via NGT
How long should the child be managed in the ICU after MH and why?
What should you continue to do?
Observe the individual for at least 36 hours because of 25% chance of recrudescence following initial treatment. Obtain blood gases, serum concentration of electrolytes and CPK, blood and urine for myoglobin, and coagulation profile
Check values every 6-12 hours. The earliest sign of rhabdo is myoglobinuria/myoglobinema. Serum CPK levels may not rise for several hours, serum CPK concentration may remain elevated for days and should be monitored until it returns to Normal
MH is genetically inherited in humans in an ___________ ___________ _________; about 1:________ people are thought to carry a ryanodine receptor 1 gene mutation, but it may be present in as many as 1:__________ .
Autosomal dominant pattern
1: 3000
1: 2000
Both a _____________ predisposition and exposure to 1 or more MH triggering agents are assumed to be necessary to evoke an MH crisis during surgery
Genetic
MH susceptibility is a result of a ___________ abnormality (there are multiple mutations); consequently, MH clusters appear in ________ groups.
Genetic
Family
MH varies ______________ depending on the concentration of MH families in a given area.
Geographically
Where are high incidence areas of MH in the United States?
Wisconsin
Nebraska
West Virginia
Michigan
An MH episode may not occur with every exposure to “trigger” agents. T/F?
True
What may clinical manifestation of MH depend on?
Genetic predisposition
Dose of trigger agents
Duration of exposure
Up to 50% of individuals with MH susceptibility have undergone anesthesia eventfully despite use of one of the agents known to trigger MH. True/False
False; uneventfully
A history of uneventful anesthesia with MH- triggering agents does rule out susceptibility to MH. T/F?
False; does not
Clinically the demographic data suggests that the incidence or suspicion of MH was greater in children/adults compared with that in children/adults?
Children
Adults
What is the incidence of MH in anesthetics for children?
1 in 10,000
What is the incidence of MH in anesthetics for adults?
1 in 50,000
According to Li et al. Found in their kids’ inpatient database study that children with MH were 69% ________ and had some form of __________ ________ or __________ .
Male
Muscular dystrophy
Strabismus
What are 9 syndromes that share elements of MH?
- Hyperthyroidism
- Sepsis
- Pheochromocytoma
- Metastatic carcinoid
- Cocaine intoxication
- Heat stroke
- Masseter Spasm
- Neuroleptic malignant syndrome
- Serotonergic toxicity
What is a decrease in airflow lasting > or equal to 10 seconds with a 30% O2 reduction in airflow and with at least 4% desat from baseline?
Hypopnea
What is the narrowing of the upper airway and an indication of an impeding upper airway closure?
Flow limitation
What is the AHI (Apnea Hypopnea Index)?
The summation of the # of obstructive apnea and hypopnea events?
Standard measure of OSA during a sleep study
If the Pediatric AHI is a Score of 0, what does that entail?
No OSA
If the Pediatric AHI is a Score of 1-5, what does that entail?
Mild OSA
If the Pediatric AHI is a Score of 6-10, what does that entail?
Moderate OSA
If the Pediatric AHI is a Score of >10, what does that entail?
Severe OSA
For a child with T&A + OSA getting a pre-med, what should you do?
Observe closely and monitor with pulse ox
Child with T&A and OSA, titrate __ carefully with RR and have the pt ___ breathe throughout the case.
Analgesia (fentanyl)
Spontaneously
Remember: children with SEVERE OSA may have an ___ resp ___ to the SMALLER/LARGER amount of opioids than children without OSA.
Exaggerated respiratory depression
Smaller doses
Pts with OSA experience recurrent episodes of what (2) things during sleep?
Hypoxia
Hypercapnia
Pts with OSA experience episodes of hypoxia and hypercapnia during sleep, which impairs the __ at emergence from anesthesia.
Arousal mechanism
How should you extubate a patient with OSA undergoing T&A?
FULLY AWAKE extubation after T&A of OSA patient?
How should you approach anesthesia from induction to extubation with a patient with T&A with OSA?
What meds and actions would you do?
Suction stomach and pharynx
Nasal airway in place
Start case with Ketamine (0.5 mg/kg) and Fentanyl 0.5 mcg/kg
AWAKE EXTUBATION
Consider Precedex 0.5 mcg/kg
With T&A and OSA, how should you prevent PONV?
Suction stomach
Hydrate well
Give airway dose of Dexamethasone 0.5 mg/kg (max of 10 mg)
And 0.1 mg/kg ondansetron (max 4 mg)
What is the discharge policy for ambulatory T&A with OSA?
Will stay overnight with pulse Oximeter/apnea monitor
What is the discharge policy for T&A patient’s WITHOUT OSA?
Stay 6-8 hrs for observation
Post-tonsilectomy bleeding is a MEDICAL emergency. True or False.
False. SURGICAL
What is primary post-tonsillectomy bleeding?
Within 24 hrs after T&A
What is secondary post tonsillectomy bleeding?
5-10 days aft T&A, when the Eschar is covering the tonsillar beds retracts
Primary or Secondary post-tonsillectomy bleeding is more serious, more brisk and profuse?
Primary
What (6) circumstance you should consider if a child is having post-tonsillectomy bleeding?
Anxious parents
Upset surgeon
Frightened anemic child
Hypovolemic
Stomach full of blood
NO IV catheter
Initially with post-tonsillectomy bleeding, what should you assess the child for?
Dizziness
Orthostatic hypotension
Estimated amount of hematemesis
What (4) things should you before taking the child back in the OR with post-tonsillectomy bleeding?
Place IV
Draw lab samples
Type and Cross
Rehydrate
What are (2) things you can give to a patient with post-tonsillectomy bleeding to improve CO and hemodynamic stability before RSI?
Vigorous fluid resuscitation with Crystalloids (20 ml/kg of balanced salt solution)
Colloids
How should you intubate a patient with post-tonsillectomy bleeding?
RSI with SUX or Roc
Cricoid pressure
Suction fathered
Style, Cuffed ETT
After an airway is secure with post-tonsillectomy, what should you place and do?
Place OGT and suction stomach
***Consider LARGE BLOOD CLOTS are often too large to be suctioned
With post-tonsillectomy bleeding, the surgeon with find and repair the bleeding vessel which is VERY PAINFUL. True or False.
False. NOT painful
What (2) medications should you give for a patient with post-tonsillectomy bleeding?
IV “airway” dose of Dexamethasone (0.5 mg/kg; max of 10)
0.1 mg/kg of IV Ondansetron (max of 4)
How should you extubate a patient with post-tonsillectomy?
AWAKE extubation and Close observation
(MM) Children with long standing OSA (caused by hypertrophied tonsils) show what anatomic changes in the heart
‘
Children with long standing hypoxemia and hypercarbia, pulmonary artery HTN and RV hypertrophy develop.
Is it ok to have nitrous oxide for an electrocautery case?
NO!!!! It is combustible
The use of regional anesthesia techniques in children has increased dramatically in the past two decades T/F?
True
What is the advantage of supplementing GETA with central neuroaxial blocks and/or peripheral nerve blocks?
Pain free awakening and post op analgesia without potentially deleterious side effects such as NV/ altered sensorium associated with opioids
What does regional help in children that have undergone thoracic or upper abdominal surgery?
Improves the pulmonary function
What are amides?
Lidocaine Bupivicaine Ropivicaine Mepivicaine Prilocaine
How are amides metabolized?
By the liver by cytochrome P450 enzymes
What medications are the esters?
Procaine
Tetracaine
2 Chloroprocaine
How are the Esters metabolized?
By plasma cholinesterases
What does the choice of LA depend on?
The desired speed of onset
Duration of action
Potential toxicity
Bupivicaine remains a commonly used amide/ester LA for regional blockade in infants and children. After a single administration how long can analgesia be expected for?
Amide
Can be expected for up to 4 hours (maybe less in small infants)
What is the most commonly used concentration of bupivicaine for peripheral nerve block?
0.25% with reduced concentration of 0.0625% to 0.1% for continuous epidural
Robpivicaine 0.2% has gained more popularity because of the reduced risks of ____________ and ____________ toxicities compared with bupivicaine.
Cardiac and neurologic
What two amides should you watch out for>?
Mepivicaine and Prilocaine
Why should you be careful with Mepivicaine and prilocaine?
Neonates do not metabolize Mepivicaine and hepatic metabolism of prilocaine yields o touluidine which can produce methemoglobinemia, thereby rendering RBC’s less capable of carrying oxygen
The decreased activity of methemoglobin reductase and increased susceptibility of fetal hemoglobin to oxidation make ______________ an unsuitable LA for use of neonates.
What is also one component of EMLA cream?
Prilocaine
Prilocaine
MM
Which local anesthetic is not metabolized in neonates?
Mepivicaine is not metabolized in neonates; this is controversial, but generally accepted
The neonatal enzyme systems are adequately developed to metabolize most rugs, with the possible exception of Mepivicaine
Plasma cholinesterase activity in infants is increased/decreased compared with adults thus the plasma half life of the ester LA may be shortened/prolonged?
Decreased
Prolonged
2,3 Chloroprocaine (1.5% concentration) has been recommended for neonatal regional techniques not including epidural blockade. T/F?
False, Including
Chloroprocaine comes in ____% ___% and ___% which one is the easiest to dilute and how?
1,2, and 3
3 % is easiest to dilute in 1:1 ratio to yield 1.5%
With Local Anesthetics The pharmacokinetics are different in infants and small children compared with older children and adults in what 3 ways.
Absorption of the drug is rapid
The CO and regional tissue blood flow are higher
The epidural space contains less fat tissue to buffer the uptake
Drugs sprayed into the airway are absorbed how?
Rapidly
The volume of distribution of the drug is larger/smaller?
What would this do to the plasma levels of bupivacaine after administration of a standard 2.5mg/kg dose into the epidural space?
Larger
Plasma levels of bupivicaine after administration of a standard 2.5 mg/kg dose into the epidural space are therefore lower in infants than in young children’s and adults
The greater Vd also extends the ____________ ______ _____.
Elimination half life
The extend of protein binding of local anesthetics is less/more; __________ and _____________ levels are low in the neonate.
Less
Albumin and a1 acid glycoprotein
What may further reduce the potential for protein binding?
Bilirubin
When is caution advised when LA are being considered?
In the jaundiced neonate
What should determine the dose of LA?
The child's: Age Physical status Area to be anesthetized Weight according to lean body mass
If a large volume of LA is required for a particular procedure, a ________ concentration should be used?
Diluted
Doses of amides should be decreased by _______ in infants if less than _________ _______ of age.
30%
6 months of age
Injection of LA into very vascular area leads to greater blood concentrations. What is the mnemonic to remember the order of uptake?
ICE Block I= Intercostal C= Caudal E= Epidural Block= Peripheral nerve blocks (brachial, femoral, sciatic, etc)
Greatest order to least order of uptake
Max dose and duration of procaine?
10mg/kg
60-90 minutes
Max dose and duration of 2- chloroprocaine
20mg/kg and 30- 60 minutes
Max dose and duration of Tetracaine?
1.5mg/kg and 180-600 minutes
Max dose and duration of lidocaine?
4.5mg/kg and 90-200 minutes
Max dose and duration of mepivacaine?
7 mg/kg and 120-240 minutes
Max dose and duration of bupivacaine?>
2.5 mg/kg and 180-600 minutes
Max dose and duration of ropivicaine?
2.0 mg/kg and 120- 40 minutes
Duration of action is based on what 4 things?
- Concentration
- Total dose
- Site of administration
4, the child’s age
