Week 11

Question 1

Pediatrics Week 11

Reading Assignment
Chapter 32 Orthopedic and Spine Surgery
Chapter 33 Otohrinolaryngologic Procedures
Chapter 34 Ophthalmology
Chapter 35 Plastic and Reconstructive Surgery
Ch 33: Otorhinolaryngology (ENT)

Please review the following topics in your textbook:
Myringotomy and insertion of tympanostomy tubes
Mastoidectomy and tympanoplasty
Tonsillectomy and adenoidectomy
Obstructive sleep apnea syndrome
Facial and airway features suggestive of obstructive sleep apnea
Clinical features that predict respiratory compromise
Subglottic stenosis
Epiglottitis

Ch 33: Otorhinolaryngology (ENT)
Common procedures

Myringotomy & tympanoplasty tubes (BMT)
Mastoidectomy & tympanoplasty
Cochlear implantation
Otoplasty
Reduction of nasal fracture
Nasal polypectomy
Sinus surgery
Choanal atresia
Tonsillectomy and adenoidectomy
Laser surgery of the airway
Tracheostomy
Laryngeal stenosis
Subglottic stenosis
Laryngotracheal reconstruction
Acute supraglottitis or epiglottitis

Major Otologic Procedures
*Preoperative sedation
*Communication issues
*PONV
*Anesthesia to minimize bleeding
*Emergence issues such as coughing and bucking

Answer 1

Go Review Outline Topics

Question 2

Ear Surgery

• _______(1), or inflammation of the middle ear, is the most prevalent disease of childhood secondary to upper respiratory tract infections (URIs).
• _______(a) results in negative middle ear pressures and can produce a sterile transudative middle ear effusion.
• Infants and young children have _______(2) eustachian tubes than older children
  
  • makes them more _______(3) to reflux of nasopharyngeal secretions into the middle ear space and the subsequent development of otitis media.
• Eustachian tube dysfunction
• Recurrent URI
• Otitis media that is non-responsive to antibiotics may require _______(4) with placement of tubes (BMT).

Answer 2

Answers:
1. Otitis media
2. shorter
3. susceptible
4. bilateral myringotomy
a. Eustachian tube obstruction

Question 3

Bilateral Myringotomies and Tubes
- Premedication?
- Best to avoid use or limit use, midazolam may delay _______(1)
- Induction
- IV?
- Best to avoid _______(2), but place after induction
- Maintenance
- Post-op analgesia?
- _______(3) is usually sufficient

Middle Ear and Mastoid
- Chronic otitis _______(4) may lead to complications which may entail more complex surgeries.
- _______(5)
- Middle ear exploration
- _______(6)

Answer 3

Answers:
1. emergence
2. IV
3. Tylenol
4. media
5. Mastoidectomy
6. Tympanoplasty

Question 4

Middle Ear Procedures
- Facial nerve preservation (Avoid _______(1)); nerve monitoring
- You can use _______(2); or Rocuronium and Reverse
- Control bleeding with the use of _______(3)-containing solutions; _______(a) the head to improve venous drainage and +/- controlled hypotension
- Take steps to decrease PONV
- Avoid _______(4) oxide because _______(b) diffuses into the middle ear more rapidly than nitrogen can leave and causes an increase in middle ear pressure, which may displace the graft or cause a tympanic membrane rupture.

Nasal Surgery
- Generally associated with a pathophysiology such as:
- Asthmatics
- Cystic fibrosis
- Chronic sinusitis
- Congenital Disorders
- Turbinate reduction

Functional Endoscopic Sinus Surgery (FESS)
- Treatment for chronic sinus disease
- Surgeon’s use of vasoconstrictors (i.e., epinephrine 1:200,000 solution, maximum dose is 10 mg/kg)
- Emergence

Answer 4

Answers:
1. NMBs (Neuromuscular Blockers)
2. Succinylcholine
3. epinephrine
4. nitrous
a. elevate
b. N20

Question 5

T & A

• The single most important task during the preoperative evaluation of the child for adenotonsillectomy is to distinguish the child with the OSAS from the child with isolated obstructive breathing (e.g., primary snoring) and chronic infectious _______(1), because the former children are at greater risk for developing severe perioperative respiratory adverse events (PRAEs), possibly including death, after adenotonsillectomy.

Indications for T & A:
- Chronic inflammation and hypertrophy of lymphoid tissue in the pharynx, to relieve an airway obstruction or focus of infection.
- Repeated middle ear infections may be improved by adenoidectomy.
- _______(2) is now the most common indication for T&A.
- Rarely, acute _______(3) may lead to peritonsillar _______(4) or quinsy (quinsy = “to strangle”) tonsil.

Answer 5

Answers:
1. tonsillitis
2. Obstructive sleep apnea
3. tonsillitis
4. abscess

Question 6

Indications for admission after T&A:

Review figures 33.15 and 33.16
Generally, age less than 3 years
Abnormal coagulation studies or a history of increased bleeding tendencies
Evidence of obstructive sleep apnea (OSA)
Systemic diseases presenting increased perioperative risk (congenital heart disease, endocrine or neuromuscular disease, chromosomal abnormalities, obesity)
Craniofacial abnormalities including Down syndrome.
History of a peritonsillar abscess

Tonsillectomy & Adenoidectomy

• Surgery often performed in ambulatory surgical unit (ASU)
• Special consideration required in selection of suitable children.
• Efficient follow-up service must be provided to deal with unexpected complications.
• MUST have a plan for a re-bleed
  Inhalational induction
• Supine position, shoulder roll, head extended,
• Tracheal intubation; LMA use is increasing in popularity depending upon the surgeon
• “Field avoidance” (table turned 90 degrees) with the surgeon at head of the table
• EBL varies widely from 10 - 200 ml, so monitor carefully
• 200 is Excessive- that is above the norm

Consideration:
- High risk for laryngospasm secondary to upper respiratory infection and/or airway secretions.
- Throat pack may be placed in the posterior of the pharynx to limit blood draining into the stomach.
- Observe for compression of _______(1) or accidental extubation when throat pack is manipulated and/or if ______(a) retractor is utilized.
- Patients with _______(2) syndrome may need to be evaluated for possible atlantoaxial subluxation, as the neck is typically extended.
- Usually less of an issue as they get older

Emergence
- Blood and secretions should be suctioned from the oropharynx and stomach following the completion of surgery to avoid _______(3).
- Verify removal of throat packs.
- Extubating “awake” vs “deep”
- You can do both- consider the pros and cons of each- and know your surgeons!
- Extubation under deep anesthesia decreases coughing. However, it requires vigilance to avoid airway obstruction and aspiration at emergence and during transport to PACU.

Answer 6

Answers:
1. ETT (Endotracheal Tube)
2. Down
3. PONV (Postoperative Nausea and Vomiting)
a. Dingman

Question 7

T&A

Clinical Presentation of OSA

Young age (< 6yr )
Snoring during sleep
Failure to thrive
Recurrent URI
Craniofacial abnormalities
Cardiac arrhythmias
Apnea during sleep
Somnolence when awake
Developmental delay
Obesity
Behavioral problems
Cor Pulmonale

PONV
PONV is common
Associated with failure to thrive
Decrease the risk by withholding post-op fluids until the child requests them
Rehydrate during anesthesia (_______(a) ml/kg LR or NS)
Administration of _______(b).

Complications
- Post-operative complications include _______(1) leading to hypovolemia and airway obstruction
- There are two vulnerable periods of potential bleeding including up to _______(c) hours after surgery (although the majority occur within ________(d) hours) and… the first post-operative week when the scab falls off _______(e) days later.
- Between _______(f) % of patients who experience post-operative bleeding will return to the OR for surgery.
- Respiratory obstruction from blood clots = _______(2)
- Hypovolemia
- Hypoxia + hypovolemia = _______(3)

Post tonsillectomy bleeding
- Full stomach
- Dehydration
- OR preparation (cuffed ETT 0.5mm _______(4) than usual) AIRWAY, AIRWAY, AIRWAY
- Surgery is typically quick and _______(5) painful. Plan accordingly.
- EXTUBATE _______(6)

Tonsillectomy & Adenoidectomy postoperative complications
- Considered a full stomach (potential for aspiration)
- Be cautious when ordering opioids for a restless child; restlessness may be indication of _______(7)
- Abdominal pain (stomachache) after T & A are suggestive of swallowing blood from ongoing bleeding

Answer 7

Answer
a. 20 - 25
b. dexamethasone and a (5HT3) antagonist
c. 24
d. 6
e. 5-10
f. 1 - 3
1. bleeding
2. hypoxia
3. cardiac arrest
4. smaller
5. minimally
6. AWAKE
7. hypoxia

Question 8

Ludwig’s Angina
- An acute, life-threatening _ A. of the sublingual and submandibular spaces
- It spreads rapidly
- Respiratory obstruction can occur due to fulminant edema of the mouth, tongue, neck, and deep cervical fascia.

Peritonsillar Abscess
- Occurs in older children or young adults
- Infection originates in the tonsil spreading to the peritonsillar space between the tonsillar _______(1) and the _______(2) muscle
- Patients present with fever, pharyngeal swelling, sore throat, difficulty in swallowing, and trismus that results from spasm of _______(3) muscles (moves jaw from side to side)

Preop
- Airway assessment
- IV line
- Labs, CT scan
- Antibiotics
- Fluids (dehydration)
- Needle aspiration, I & D or abscess tonsillectomy

Answer 8

Answers:
A.cellulitis
1. capsule
2. superior constrictor
3. pterygoid

Question 9

Epiglottitis
- Most common in children _______(a) years old but also occurs in infants or adults.
- It is accompanied by severe systemic illness with_______(1).
- S/S included sore throat, dysphagia, drooling, obstruction.
- In addition to the epiglottitis, all the _______(2) structures are swollen and inflamed, creating a potential obstruction.
- Review table 33.9 for differential diagnosis of croup and _______(3).

5-6 Ds for Danger!
- _______(b)
- _______(c)
- _______(d)
- _______(e)
- _______(f)
- Draco Malfoy (not a clinical term, likely included for mnemonic humor)
These children will call their Dad on you

• These children are septic with no cough and rapid onset.

Avoid making child cry as he/she may become acutely obstructed. Parent may be present. No premedication.
Transfer the child to the OR ASAP. The OR should be prepared for emergency bronchoscopy and possible tracheotomy (surgeon present, scrubbed, and ready to intervene if needed).
Child should remain _______(g) at all times.
Do not _______(h) airway in ED.

• Remember the patient will most likely have a longer than normal induction time secondary to smaller tidal volumes.
• If a PIV has been established, consider administering lidocaine 1 mg/kg IV to minimize the risk of coughing and laryngospasm.
• Use a smaller than predicted ETT
• Once intubated, place monitors
• Administer _______(i)ml/kg of crystalloid because the patient is most likely dehydrated
• Obtain blood cultures once airway is secured.
• _______(j) is the most common bacteria that causes epiglottitis.
  
  • Due to _______(2) vaccine, increase in incidence caused by Strep.

Answer 9

Answers:
1. pyrexia and leukocytosis
2. supraglottic
3. epiglottitis
a. 3-7
b. Drooling
c. Dysphagia
d. Dysphonia
e. Dyspnea
f. Dehydration
g. sitting
h. examine
i. 20 - 30
j. Haemophilus influenzae type B (HiB)

Question 10

Laryngotracheobronchitis (LTB or “croup”)
- Most commonly caused by a virus in children <3 years.
- An obstruction of the airway, below the epiglottis, characterized by a barking cough
- Principal symptom is _______(1) stridor caused by swelling of the loose tracheal mucosa at the level of the _______(2) cartilage.
- Symptoms are worse at night.
- Remember; Croup is _______(3)

Laryngotracheobronchitis (croup)
- 0.5 ml of 2.25% Racemic Epinephrine in 2 - 3 ml of normal saline in nebulizer.
- Be aware of the potential “rebound affect,” _______(4) (per facility protocol)
- Suitable pediatric face mask held comfortably around child’s face
- Monitor the child for stridor or a barking cough requiring intervention

Answer 10

Answers:
1. inspiratory
2. cricoid
3. subglottic
4. requiring monitoring for 4 hours

Question 11

Nasotracheal intubation
- If you must perform a nasotracheal intubation, remember the following:
- The size of the endotracheal tube must be small enough to provide a leak at about 20 cm H2O _______(1).
- Constant respiratory care because the thick secretions and small ETT will lead to obstruction/blockage.

Tracheostomy
- Tracheostomy may be necessary for certain cases:
- A child who cannot be intubated
- A child who cannot be successfully extubated after standard time
- Most common in infants, < 1 year of age, with a history of congenital subglottic stenosis or a history of repeated _______(2)

Endoscopy Issues: (ie a Child that swallowed a coin)
- Laryngoscopy, bronchoscopy, esophagoscopy
- Existing airway problem – complete airway obstruction
- Premedication?
- Spontaneous versus controlled-ventilation

Answer 11

Answers:
1. PIP (Peak Inspiratory Pressure)
2. croup

Question 12

Foreign Body Aspiration
- Upper airway obstruction varies from a partial obstruction with coughing, wheezing, drooling, stridor, and respiratory distress to complete obstruction with hypoxia and cardiorespiratory compromise
- Considered a “________(a) stomach”
- Potentially a difficult airway

Complications
- Coughing, wheezing, dyspnea and decreased air entry on the affected side are indicative of a bronchial _______(1).
- Dyspnea, _______(2), coughing, and _______(b) are more common with laryngeal or tracheal foreign body.
- _______(3) is of particular concern as it may indicate a total obstruction.

Pathophysiology
- 95% foreign bodies lodge in _______(c) mainstem bronchus
- History of choking while eating or playing
- If the FB completely obstructs bronchus, then distal _______(4) from air trapping can be seen on CXR
- A late sign may present as _______(5)

Four types of obstruction
- _______(d): air can be inhaled but not exhaled (i.e., emphysema)
- _______(e): air can be exhaled but not inhaled (i.e., collapse of the bronchopulmonary segment)
- _______(f): partial obstruction of both inhalation & exhalation
- _______(g): total blockage (i.e., airway collapse and consolidation)

Answer 12

Answers:
1. aspiration
2. stridor
3. Aphonia
4. hyperinflation
5. pneumonia

a. full
b. cyanosis
c. right
d. Check valve
e. Ball valve
f. By-pass valve
g. Stop valve

Question 13

Ch 35: Pediatric Plastic Surgery

Cleft lip and/or palate repair
Craniosynostosis Repair
Trauma
Syndactyly
Orbital hypertelorism
Midface procedures
Orthognathic procedures
Hemifacial microsomia (Treacher Collins syndrome)

Cleft Lip and Cleft Palate
- The most frequent congenital craniofacial malformations – 1 in 700 births in US (Males>females)
- May be isolated, familial, or part of a syndrome – more than 300 syndromes are associated with cleft lip and palate more with palate.
- Primary cleft lip repair at _______(a) months of age.
- Primary cleft palate may be done around _______(b) months.

Cleft lip closure may be carried out early
- “Rule of ten” refers to
- Hb of _______(1).
- At least _______(2) weeks old.
- At least a weight of _______(3) lbs.

Early childhood lip & nose revisions
- Palatal revision & alveolar bone grafts around _______(c) years of age.
- Rhinoplasty & maxillary osteotomy complete repair around _______(d) years of age.
- Some may need _______(e) to allow normal speech & to prevent nasal regurgitation.

Anesthetic Issues
- Induction – inhalational or Intravenous
- Airway issues
- Intubate with oral _______(4)
- Movement of head
- Emphreneic dose issues
- _______(f) packs
- Keeps fluid out of stomach and airway
- Make sure Packs are GONE at the end of surgery

Answer 13

Answers:
1. 10
2. 10
3. 10
4. RAE (Ring-Adair-Elwyn tube)

a. 2-3
b. 6-10
c.10
d. 17 – 20
e. pharyngoplasty
f. Pharyngeal

Question 14

Cleft lip and palatte surgeries

Emergence
- Pharyngeal packs gone? Oral cavity dry?
- Yes remove _______(1)
- Stomach emptied? Nasal airway?
- Yes at the end of procedure ask _______(2)
- Extubation only if patient is completely awake!
- Can they maintain own _______(3) without intervention?

Restrain arms to prevent child from pulling at suture lines
- No-no’s: Straight Arm Velcro _______(4) that prevent arm bending to pull at mouth
Pain management
- Clips to prevent them from touch mouth

Answer 14

Answers:
1. packs
2. surgeon
3. airway
4. jawns

Question 15

Postoperative Concerns-cleft surgery
- The most common complications are _______(a) (airway obstruction).
- Airway edema (obligate _______(1) breathers) about 10% experience will experience obstructive sleep apnea
- Acute airway obstruction from lingual swelling, especially if mouth retractor is in place for more than _______(2).

Craniosynostosis (Relisten!)
- Repair to prevent permanent craniofacial deformity
- May involve multiple surgical services, e.g., ENT, Plastics, Neuro, etc.
- Severe forms
- Part of genetic syndromes
- Elevated ICP
- Neurologic deficits
- Ophthalmologic problems

Scaphocephaly
- Most common type of craniosynostosis (50%)
- Premature closure of _______(3) suture

Answer 15

Answers:
1. mouth
2. 2 to 3 hours
3. sagittal

a. bleeding and swelling

Question 16

Craniosyntosis

_______(a) (18%) results from unilateral synostosis of a _______(1) suture, producing a unilateral “_______(b)” forehead and orbital anomalies
_______(c) (9%) results from _______(d) coronal synostosis and causes a _______(e) skull and midface hypoplasia
- Neurologic complications
- Apert’s and Crouzon’s syndromes
_______(f) (9%) is the result of premature closure of the _______(2) suture, resulting in a triangular shaped head and hypotelorism.

Anesthetic concerns
Comorbidities
Elevated ICP
Craniotomy and large scalp flaps will be associated large blood loss > 1 BV
(maintain hemoglobin > _______(g))
Increased incidence of VAE
Adequate IV access, +/- a-line
Airway management
Surgical duration
Orbit and face manipulation (OCR)
Emergence issues
Postoperative airway problems
Prolonged intubation

Answer 16

Answers:
1. coronal
2. metopic

a. Plagiocephaly
b. tilting
c. Brachycephaly
d. bilateral
e. broadened
f. Trigonocephaly
g. 7.5

Question 17

Upper extremity and hand surgery
*Often performed by Plastic Surgeon or Specialty “Hand” Surgeons

Upper extremity and hand surgery
*_______(1): another finger (usually the pointer finger) and is turned into a thumb by surgically moving the finger to where a thumb should be.

Ch 32: Pediatric Orthopedic Surgery
Fractures
Slipped Capital Femoral Epiphysis
Congenital dislocation of the hip
Spica cast placement
Scoliosis

Fractures
- Consider NPO status for non planned cases.
- Consider Full stomachs
- Ketamine and versed → reduce fracture
- Homeostasis is more complex b/o smaller blood volume.
- Risk of infection due to prior contamination (during the accident) and hardware implantation
- Deep venous thrombosis and fat embolism incidence is _______(2) in children.
- When compared to adults
- Congenital, genetic and birth disorders (dysmorphic)

Causes
- Trauma or accidents
- Osteogenesis imperfecta (OI)
- Brittle bones
- ORIF vs closed reduction
- Closed first then if unable → _______(3)

Answer 17

Answer
1. Pollicization
2. not as common
3. ORIF

Question 18

Length Discrepancy

Slipped Capital Femoral Epiphysis
- SCFE is a condition of the hip joint where the head of the _______(1) slips off of the neck.
- Upon detection by clinical exam and x-ray, immediate bed rest , +/- traction
- _______(2) is required!
- A surgical incision is made and a screw is inserted through the femoral head and the growth plate to prevent any further slip.
- Bone will not grow (if growth plate is affected), may cause asymmetrical abnormalities

Congenital dislocation of the hip
- Usually occurs at birth or soon after
- “_______(3)” means the femoral head is not in the proper place in the socket.
- The goal of treatment is to maintain the proper position to prevent damage to the hip and promote normal joint development.
- If harness, traction, cast and/or braces fail, then surgery is indicated.

Pavlik harness
Used to treat Developmental Dislocation of the Hip (DDH)
(i.e., congenital dislocation)

Wheaton Harness
Used to treat Developmental Dislocation of the Hip (DDH) (i.e., congenital dislocation)

Spica cast placement
Bilateral long leg hip spica cast
One and one-half hip spica cast
Short leg spica cast

Spica cast placement
The patient is moved to a “spica table”. The patient must remain still and an ETT is typically indicated.
Padding is used during the casting process to ensure room for abdominal expansion.
A hole is cut out for elimination.

Post-anesthesia recovery issues
Emergence delirium
Is it pain?
Is the cast too tight? Excess swelling? Should we bi-valve the cast?
PONV
Distraction techniques (parents, fluid, food)
Compartment syndrome

Tourniquets & Pain
Used to minimize EBL and improve visualization of the surgical field.
Complications: muscle, nerve, vascular damage; skin safety; altered temperature regulation
Typically, pressure is set at ______(4) mmHg > SBP for a maximum of ______(5) hours.
After ______(6) minutes or so, evidence of TQ pain is expressed by increased HR and BP
Considerations in Sickle Cell Disease
Appropriate timing of antibiotic administration

Answer 18

1. femur
2. Surgery
3. Dislocation
4. 50
5. 1.5-2
6. 30

Question 19

Scoliosis
Lateral curvature of the spine with rotation of vertebrae within the curve
Requires an anterior or posterior spinal fusion
May be congenital, idiopathic, or neuromuscular
Early detection offers the best treatment options (PT, OT, Casting, Bracing, Surgery)
See Table 32.1 Classification of Scoliosis with Associated Key Anesthetic Risk Factors

TYPES

• Congenital
  
  • Present at birth, caused by failure of the vertebrae to form normally
  • Child may also have _______(1) tract, cardiac or spinal cord problems, which make the anesthetic plan more complex.
• Idiopathic
  
  • Most commonly presents at age greater than _______(2) years of age
  • Cause is unknown
  • Occurs seven times more frequently in _______(3)
  • _______(a) may or may not progress during growth
• Neuromuscular
  
  • Caused by various disorders such as _______(b), cerebral palsy, spina bifida, arthrogryposis, _______(c) and muscular dystrophy
  • Children may have rapid and unpredictable deterioration of the curve
  • Surgery typically results in extensive _______(4)

Answer 19

Answers:
1. urinary
2. 5
3. girls
4. EBL (Estimated Blood Loss)

a. Curves
b. polio
c. neurofibromatosis

Question 20

Scoliosis Management

Preoperative preparation
includes x-rays, EKG, +/- echocardiogram, +/- PFTs,
Labs include CBC, CMP, Coags, PFA and Type & Screen
A pre-surgical anesthesia evaluation is necessary to explain the anesthesia plan to the patient and the parents.
It is necessary to discuss the use of SSEPs and MEPS, positioning considerations and the evaluation of motor function in the OR.

Equipment
Harrington rods
Distraction (expandable) rods
Pedicle screws with or without rods
Vertical expandable prosthetic titanium ribs (VEPTR)

Spinal Cord Monitoring
“_______(1)” test (“Gold Standard”)
Sematosensory Evoked Potentials (SSEPs)
Motor Evoked Potentials (MEPs)
Lower Extremity Motor Function evaluation

A typical anesthetic plan requires
–2 large bore IVs at least
–Arterial line for precise control of BP and sampling
–_______(2) position, two soft bite blocks 2nd to MEPs
–Precise control of neuromuscular blockade
–Maximize SSEP and MEP evaluation
–Consider TIVA
Remi, sufentanyl, propofol
–Ability to quickly wake-up the patient for examination of motor function
–Post-operative pain management
–Minimize blood loss through precise control of MAP (hypotensive anesthesia MAP _______(3) mmHg)
–Positioning
Prone
–Temperature regulation: Lot of Exposed body surface area- keep room very warm until draped
–Be prepared for massive blood loss (colloids, antifibrinolytics, cell saver, PRBC)
–Be prepared for loss of evokes (i.e., Spinal Cord Protocol: increase BP to perfuse cord, increase temperature, ? steroids to decrease inflammation)

Post-Procedure
Once the dressings are on, the patient will be turned supine onto the hospital bed.
At this time, a thorough motor function examination must occur.
If the awake patient passes the motor function examination, the trachea can be extubated.
Otherwise, the patient is returned to the prone position, GA is induced and exploration to identify and correct the problem causing spinal cord ischemia.

Scoliosis: Assessing Motor Function-
Assess the patient in a _______(4) position. Compare the right and left sides.
Ask the patient to separate both legs to test for hip abduction.
Ask the patient to bring the legs back together to test for hip adduction.
Ask the patient to flex and extend the knee. If the patient is able to do this, apply resistance as these movements are repeated.
Test plantar flexion (a.) and dorsiflexion (b.) by having the patient push down against your hand with their foot and then pull up against your hand with their foot.
This Exam is Very Complicated
Confirm we can move all extremities
It’s not always the exact same test, especially with little kids

Answer 20

1. Wake-up
2. Prone
3. 50-65
4. supine
5. sudden aggressive
   a.L4, S1
   b.L5

Question 21

Ch 34: Ophthalmic Surgery

Retinopathy of prematurity
Strabismus
Lacrimal apparatus dysfunction
Cataracts
Glaucoma
Retinoblastoma
Tramatic injury and ruptured globe

Please review the following topics in your textbook:
Oculocardiac reflex
Prophylaxis for postoperative nausea and vomiting Table 34.4 below

TABLE 34.4 Antiemetic Strategies for Prophylaxis and Treatment of Postoperative Nausea and Vomiting

Strategy | Drug and Dose
Butyrophenone (dopamine antagonist) | Droperidol (10–70 µg/kg)
Serotonin (5HT₃ receptor antagonists) | Ondansetron (0.1 mg/kg), Granisetron (10–40 µg/kg), Dolasetron (0.35 mg/kg)
Propofol-based total IV anesthesia | Propofol (100–175 µg/kg per minute)
Local anesthetic Opioid-sparing | Lidocaine local-topical and systemic (1–1.5 mg/kg), Retrobulbar block with bupivacaine

Other pharmacology
Analgesics or anesthetics | Dexamethasone (10–500 µg/kg; maximum, 8 mg)
Other pharmacology | Dimenhydrinate (0.5–1 mg/kg), Metoclopramide (0.15–0.25 mg/kg), Benzodiazepines (e.g., lorazepam, midazolam) (10–100 µg/kg), Avoid nitrous oxide (N₂O), Avoid opioids, Use ketorolac (Toradol) (0.5 mg/kg PO, IV, IM), acetaminophen (30–40 mg/kg PR or 15 mg/kg IV), or diclofenac (1 mg/kg PR), or short-acting opioids (e.g., remifentanil, alfentanil, fentanyl)

Nonpharmacologic adjuvants
IV hydration
Gastric decompression

IV, intravenous; IM, intramuscular; PO, per os (oral); PR, per rectum (suppository).

General Anesthesia for Eye Surgery
- GA is almost always required for this type of surgery due to children’s immaturity and inability to remain still during these delicate procedures.
- During emergence avoid unnecessary sympathetic responses such as increased intraocular pressure from straining, crying, coughing and bucking.

Ophthalmic Medication & Side Effects
- Medications applied to the conjunctiva or injected into the eye have multiple systemic effects.
- Phenylephrine & Epinephrine can cause hypertension and arrhythmias
- Review Table 34.3

Phenylephrine- avoid 10% eye drops contraindicated in children because it can cause cardiac arrest; (may use _______(1))
Scopolamine eye drops can cause excitation, disorientation and possible psychosis.
- Treat adverse side effects with IV _______(2).

Pre-operative
- May give IV _______(3) or glycopyrrolate at induction.
- Avoid pre-operative emotional stress such as crying evoked by (separation) anxiety
- Parents and family are of great assistance in these scenarios.

Anesthetic Considerations
- Children have increased sensitivity to oculocardiac reflex (OCR).
- Monitor HR closely with manipulation of the eyes and extraocular muscles.
- Ocular nerve is connected to the vagus nerve.
- _______(4) (0.01-0.02mg/kg) or glycopyrrolate can be given at induction to block OCR.
- If atropine is contraindicated in a pediatric patient, note that a vagotonic response is more likely to be elicited from a _______(5) pull versus gradually applied traction.

Answer 21

Answers:
1. 2.5%
2. physostigmine
3. atropine
4. Atropine
5. sudden aggressive

Question 22

Ophthalmic Reflexes
- OCR (oculocardiac reflex)
- _______(1) nerve
- _______(2) nerve
- ORR (oculorespiratory reflex)
- _______(3) nerve
- OER (oculoemetic reflex) or oculogastric
- _______(4) nerve

Foreign Body/Trauma
- Atropine causes a slight increase in IOP and is not contraindicated in children with glaucoma
- IV succinylcholine causes a transient increase in IOP.
- An RSI dose of _______(5) is preferred in pediatric patients with penetrating eye trauma.
- Conservative pre-op sedation recommended for “full stomach” patients to prevent further risks of aspiration.

Answer 22

Answers:
1. Trigeminal
2. Vagus
3. Trigeminal
4. Vagus
5. Rocuronium

Question 23

Eye Surgery

Anesthetic Considerations
- Ketamine was originally thought to substantially _______(1) IOP but is now thought to have little effect on IOP. However, Ketamine causes _______(2), which is an undesired side effect during eye surgery.
- If child is undergoing an elective surgery and is not a “full stomach”, an LMA is an option.
- Any increase in IOP during correction of a penetrating eye trauma can cause protrusion of eye contents.
- Be careful with the use of a facemask, which can increase pressure on the eye globe increasing IOP. It also may be difficult to maintain a good seal with face mask ventilation when a child has an eye patch/eye dressing.
- Be careful with O2 leaks from face masks and electrocautery near the eyes secondary to increased risk of surgical fires.
- Avoid _______(3)
- Respirations should be closely monitored.
- If a foreign body presents in the eye trauma, IV _______(4) will be prescribed immediately
- Early IV access is critical.
- IV lidocaine 1 - 1.5 mg/kg followed by propofol minimizes the increase in IOP precipitated by laryngoscopy
- Also, IV lidocaine prior to extubation may blunt the cough reflex and avoid unnecessary increases in IOP.
- Extubate the child fully awake and in the lateral position to facilitate a smoother transition

Post-Op Pain, Nausea & Vomiting
- Acetaminophen suppository post-induction
Tylenol IV now
- Retrobulbar block placed intraoperatively has great benefits postoperatively
- Topical local anesthetics such as tetracaine eye drops administered post-operatively.
- PONV prophylaxis: consider propofol as your primary anesthetic and/or IV ondansetron, IV dexamethasone
TIVA

Retinopathy of Prematurity (ROP)
- Preemies, retinal vessel proliferation and retinal detachment
- <_______(5) kg most likely
- Previously inc FIO2 → now angiogenesis (hypoxia)
Eyes

Answer 23

Answers:
1. increase
2. nystagmus
3. N2O
4. antibiotics
5. 1.5

Question 24

Retinopathy of Prematurity (ROP)

Eyes
- Retinopathy of Prematurity (ROP) is caused by retinal vessel proliferation and retinal detachment.
- It is the leading cause of blindness in preterm neonates, particularly those weighing less than _______(1) grams.
- It was initially believed high FiO2 caused ROP.
- Now it is believed to be a process of _______(2) (stimulated by hypoxia).
- Exposure of the retina of the preterm neonate to tissue oxygen levels in excess of the usual fetal levels interrupts normal vasculogenesis.
- It is theorized that additional oxygen will not cause further damage.
- Risk factors include
- hypoxia,
- hypercarbia or hypocarbia,
- blood transfusions,
- exposure to light,
- recurrent apnea,
- sepsis.
- Monitor the SaO2 at a ______(3) site (_______(4) or right earlobe) and maintain SaO2 (_______(5)%.)
- If high fractions of inspired oxygen are required, such as in a code situation, then do not be afraid to do what is necessary to take care of the patient.

Neonatal Screening
The screening process is recommended to begin at ______(6) weeks of gestation or ______(7) weeks of age, whichever is greater.
Dilation of the pupils is accomplished with ______(8); indirect ophthalmoscopy is completed by an ophthalmologist.
Risk analysis is used to identify neonates that are at higher risk for unfavorable outcomes.

Answer 24

Answers:
1. 1500
2. angiogenesis and vasculogenesis
3. preductal
4. right hand
5. 90% to 95
6. 31
7. 4
8. phenylephrine and Tropicamide

Question 25

Retinopathy

Disease Classification and Progression
- Stage I – ______(a) abnormal blood vessel growth
- Stage II – _______(1) abnormal blood vessel growth
- Stage III – Severely abnormal blood vessel growth
- Stage IV – partially _______(2) retina
- Stage V – completely _______(3) retina

Surgical intervention
- Retinal _______(4) is currently the preferred method of treatment.
- A diode _______(5) is utilized to make small burns in the ______(b) of the retina preventing further growth of abnormal vessels.
- Treatment can be accomplished with deep sedation, or under general anesthesia. Depending on ______(c) of the patient.

Answer 25

Answers:
a. mildly
1. moderately
2. detached
3. detached
4. photocoagulation
5. laser
b. periphery
c. age

Question 26

Retinopa thy of Prematurity

Intraoperative management
- No significant blood loss or surgical stress but case can be long in duration
- Biggest challenges in these patients are due to _______(1) (monitoring, vascular access, hypothermia)
- Limited access to patient during procedure
- Avoid _______(2) due to its potential to expand and increase IOP
- Monitoring of blood _______(3) during long procedures
- Smooth extubation without _______(4) or bring patient back to NICU _______(5)

Postoperative management
- Close monitoring postoperatively
- Higher incidence of postop apnea due to prematurity; remaining _______(6) may be safest approach
- Antibiotic drops are administered post-operatively to reduce risk of infection
- Repeat examination should be completed within 5-7 days
- If regression is noted, re-treatment should occur within 10-14 days

Answer 26

Answers:
1. size and prematurity
2. N2O (Nitrous Oxide)
3. glucose
4. coughing
5. intubated
6. intubated

Question 27

Intraocular Surgery and EUA for Cataracts, Glaucoma and Tumors
- Children undergoing surgery for cataract or glaucoma, treatment of detached retina or examination under anesthesia (EUA) for glaucoma or tumor often require general anesthesia.
- Children do not tolerate sedation and local analgesia for the eye.

Operations
- _______(1) cataracts: lens opacity present at birth and must be surgically removed. Associated with maternal rubella and other chromosomal conditions
- _______(2): a congenital issue; several anomalies are in association, IOP measurements are taken before intubation.

Special Anesthesia Problems
- The oculocardiac reflex (OCR)
- Intraocular pressure may be affected by anesthesia drugs and techniques
- Coughing and straining may elevate the intraocular pressure (induction and emergence from anesthesia should be as quiet and as smooth as possible)

Preoperative Management
- Give adequate sedation to prevent coughing and straining
- Explain to older children that their eye will probably be covered with an eye patch after surgery

Answer 27

Answers:
1. Congenital
2. Glaucoma

Question 28

Congenital Cataracts

Perioperative Management
- Anesthesia induction should be as smooth as possible, by inhalation of Sevoflurane and N2O or intravenously with Propofol.
- Current recommendations do not favor the administration of _______(1).
- For brief EUA procedures, you may use a facemask, but avoid pressure on the globe as it may increase IOP.
- Otherwise, either deepen anesthesia using a single dose of _______(2) (up to 3 – 5 mg/kg IV) or spray the larynx with lidocaine before intubating the trachea or inserting a well-lubricated LMA.
- For prolonged surgeries, a nondepolarizing muscle relaxant may be administered.
- Maintain anesthesia with isoflurane, sevoflurane, or desflurane.
- Allow spontaneous ventilation for brief EUA procedures, otherwise, control ventilation to prevent hypercapnia.
- Alternatively, use a _______(3) infusion to maintain anesthesia because it may be advantageous in reducing postoperative vomiting.
- If sulfur hexafluoride or air is to be injected, discontinue _______(4) early.
- A ______(5) block may help reduce postoperative pain.
- Avoid coughing or straining on emergence
- Suction pharynx, extubate trachea or remove LMA while child is ______(6) anesthetized
- Administration of lidocaine _______(7) mg/kg IV prior to extubation.
- Re-apply facemask, support airway and administer O2 until child awakens

Answer 28

Answers:
1. succinylcholine
2. Propofol
3. Propofol
4. N2O
5. retrobulbar
6. deeply
7. 1 - 1.5

Question 29

• What is it?
• Both Pupils don’t lineup midline
  per ChatGPT: Strabismus, often referred to as “crossed eyes,” is a condition in which the eyes do not properly align with each other when looking at an object. This misalignment can be constant or intermittent and can occur in one or both eyes. It usually results from a lack of coordination between the muscles that move the eyes, which prevents bringing the gaze of each eye to the same point in space and thus disrupts binocular vision.
• The most common eye surgery in children

Special Anesthesia Problems
- Oculocardiac reflex (REWATCH- Per Andrew)
- Severe bradycardia/cardiac arrest can occur due to traction on extraocular muscles
- Powerful in children
- Atropine a.__ mg/kg

• Oculogastric reflex
  - Vomiting after surgery is common
  - Also triggered by b.__
• Post operative pain may be considerable in older children.
• Excessive sedation should be avoided in order to assess adjustable sutures post operatively.
• Consider c.__

Answer 29

a. 0.02
b. pushing fluids” & early ambulation
c. ondansetron and dexamethasone.

Question 30

Strabismus Surgery

Preoperative
- Do not give heavy sedation as the surgeon usually examines the child immediately before surgery.
- Effective premedication:
- Versed (______(a) PO, >6 yr old)
- Clonidine (_______(1) PO); give 60-90 min before surgery
- Consider IV _______(2) on induction.

Perioperative
- Intubate and place an oral _______(3) or regular endotracheal tube depending on surgeon preference.
- Alternatively, with suitable children, a well lubricated LMA may be used
- Maintain anesthesia with either air/O2/isoflurane or sevoflurane
- Perioperative
- Monitor for _______(4); if it occurs, ask surgeon to discontinue traction, and administer IV _______(b) or glycopyrrolate.
- Alternatively, repeated gentle traction on the muscle may fatigue the reflex.

• Postoperative analgesia should be provided
• IV ketorolac decreases postoperative pain and is associated with less PONV
• Tetracaine eye drops and injections of _______(5) or ropivacaine (by the surgeon) can also provide postoperative analgesia

Answer 30

Answers:
1. 4 mcg/kg
2. Atropine
3. RAE
4. bradycardia
5. bupivacaine

a. 0.5-0.75 mg/kg
b. atropine

Question 31

Postoperative strabismus
- Smooth removal of the LMA or ET tube should be considered as coughing or straining on emergence can cause a _______(1) hemorrhage.
- Deep extubation with airway support is common.
- Provide analgesics and adequate hydration.
- There is a high incidence of PONV with _______(2) surgery!

Retinoblastoma
- Rapidly developing cancer of the cells of the _______(3)
- ______(5) is the most common pediatric intraocular tumor
- Prevalence: 1 in _______(4)

Answer 31

Answers:
1. subconjunctival
2. strabismus
3. retina
4. 15k-20k
5. Retinoblastoma

Question 32

Treatment for Retinoblastoma
- ______(1) (Lens-sparing radiation, photoradiation)
- IV ______(2)
- Laser ______(3)
- Cryotherapy
- In advanced cases, ______(4)(removal of the eye) may be needed

Anesthesia for Radiotherapy

Anesthesia Considerations:
- Treatment may require daily, repeated radiotherapy, where patients have to remain absolutely still
Expect a ‘shockingLy ‘ significant increase in propofol requirement over time
- Challenge is to administer short-acting anesthetics and have the child return to normal activity and feeding as soon as possible
- Retching and vomiting provoked by radiation present a potential challenge for proper radiotherapy and anesthesia management
- Many children will have an indwelling venous port or PICC line for the duration of their radiation therapy treatments

Answer 32

1. Radiotherapy
2. chemotherapy
3. photocoagulation
4. enucleation

Question 33

Anesthesia management for lens-sparing radiotherapy:
- Anesthesia time: < _______(1)
- Various techniques may be used
- Inhaled sevoflurane
- IV propofol
- LMA or nasal oxygen with capnometry
- Avoids repeated risk of laryngeal trauma with endotracheal intubation
- Maintain airway with careful positioning or with molded immobilization device.

Anesthesia management for photoradiation therapy:
- Photoradiation uses a _______(2) to mark the tumor for argon laser therapy
- Use of General Anesthesia in darkness
- effects of HpD therapy include skin pigmentation and burns, when exposed to light
- Pulse oximetry is safe and reliable in the presence of HpD
- Consider ↑ risk of PONV (chemotherapy and anesthesia)

Answer 33

Answers:
1. 20 minutes
2. hematoporphyrin derivative (HpD)