Week 11 - ENT, Plastic, Orthopedic, Eye surgery Flashcards
Ear Surgery
- Otitis media, or inflammation of the ___________, is the most prevalent disease of childhood secondary to upper respiratory tract infections (URIs).
- Eustachian tube obstruction results in negative middle ear pressures and can produce a sterile transudative middle ear effusion.
Infants and young children have __________ eustachian tubes than older children, which makes them more susceptible 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 ______________.
- middle ear
- shorter
- bilateral myringotomy with placement of tubes (BMT).
Bilateral Myringotomies and Tubes
Premedication?
Induction
IV?
Maintenance
Post-op analgesia?
- usually versed, not on all patients
- mask induction
- ## no IV
- toradol, nasal fentanyl
Middle Ear and Mastoid
Chronic otitis media may lead to complications which may entail more complex surgeries such as:
- Mastoidectomy
- Middle ear exploration
- Tympanoplasty
Middle Ear Procedures
- __________ preservation (Avoid ________); nerve monitoring
- Control bleeding with the use of _________ solutions; elevate the head to improve venous draining and +/- _____________.
- Take steps to decrease PONV
- Avoid nitrous oxide because N2O 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.
- Facial nerve (NMBs)
- epinephrine-containing; controlled hypotension
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 ________________.
- Surgeon’s use of vasoconstrictors (i.e., epinephrine ____:_________ solution, maximum dose is _______________)
- Emergence:
- chronic sinus disease
- 1:200,000, 10 mcg/kg
- awake extubation
T & A
- The single most important task during the preoperative evaluation of the child for adenotonsillectomy is to distinguish the child with the __________ from the child with isolated obstructive breathing (e.g., primary snoring) and chronic infectious tonsillitis, because the former children are at greater risk for developing severe perioperative respiratory adverse events (PRAEs), possibly including death, after adenotonsillectomy.
OSAS
Indications for T & A
- ______ and ________ in the pharynx, to relieve an airway obstruction or focus of infection.
- Repeated middle ear infections may be improved by ______________.
- ______________ is now the most common indication for T&A.
- Rarely, acute tonsillitis may lead to peritonsillar abscess or quinsy (quinsy = “to strangle”) tonsil.
- Chronic inflammation and hypertrophy of lymphoid tissue
- adenoidectomy
- Obstructive sleep apnea
- 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.
Indications for admission after T&A:
- Generally, age less than ______ years
- Abnormal __________ studies or a history of increased bleeding tendencies
- Evidence of __________.
- Systemic diseases presenting increased perioperative risk (congenital heart disease, endocrine or neuromuscular disease, chromosomal abnormalities, obesity)
- _____________ abnormalities including Down syndrome.
- History of a _____________.
- 3
- coagulation
- obstructive sleep apnea (OSA)
- Craniofacial
- peritonsillar abscess
Tonsillectomy & Adenoidectomy
- ____________ induction
- Supine position, shoulder roll, head extended,
- Tracheal intubation; LMA use is increasing in popularity depending upon the surgeon
- “Field avoidance” (table turned ____ degrees) with the surgeon at head of the table
- EBL varies widely from ___ - ___ ml, so monitor carefully
- Inhalational
- 90
- 10 - 200
Tonsillectomy & Adenoidectomy
- High risk for _________ 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 ETT or accidental extubation when throat pack is manipulated and/or if Dingman retractor is utilized.
- Patients with Down syndrome may need to be evaluated for possible ________________, as the neck is typically extended.
- Blood and secretions should be suctioned from the oropharynx and stomach following the completion of surgery to avoid PONV.
- Verify removal of throat packs.
- Extubating “awake” vs “deep”
- Extubation under deep anesthesia decreases coughing. However, it requires vigilance to avoid airway obstruction and aspiration at emergence and during transport to PACU.
- laryngospasm
- atlantoaxial subluxation
Clinical Presentation of OSA (12)
- 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
Tonsillectomy & Adenoidectomy
- ___________ is common
- Decrease the risk by withholding post-op fluids until the child requests them
- Rehydrate during anesthesia (____-______ LR or NS)
- Administration of dexamethasone and a (5HT3) antagonist.
- PONV
- 20 - 25ml/kg
Tonsillectomy & Adenoidectomy
- Post-operative complications include bleeding leading to hypovolemia and airway obstruction
- There are two vulnerable periods of potential bleeding including up to _________ hours after surgery (although the majority occur within _______ hours) and… the first post-operative week when the scab falls off ____-____ days later.
- 24
- 6
- 5-10
Between 1 - 3 % of patients who experience post-operative bleeding will return to the OR for surgery.
Respiratory obstruction from blood clots = hypoxia
Hypovolemia
Hypoxia + hypovolemia = cardiac arrest
Post tonsillectomy bleeding
- Full stomach
- Dehydration
- OR preparation (cuffed ETT ___________ than usual) AIRWAY, AIRWAY, AIRWAY
- Surgery is typically quick and minimally painful. Plan accordingly.
- EXTUBATE ________.
Tonsillectomy & Adenoidectomy postoperative complications
- 0.5mm smaller
- AWAKE
- Considered a full stomach (potential for aspiration)
- Be cautious when ordering opioids for a restless child as the restlessness may be an indication of hypoxia
- Abdominal pain (stomachache) after T & A are suggestive of swallowing blood from ongoing bleeding
Ludwig’s Angina
- An acute, life threatening cellulitis of the _____and______ spaces
- It spreads ________
- Respiratory obstruction can occur due to fulminant edema of the mouth, tongue, neck and deep cervical fascia.
- sublingual and submandibular
- rapidly
Peritonsillar Abscess
- Occurs in ______ or _______.
- Infection originates in the _______ spreading to the __________ space between the tonsillar capsule and the superior constrictor muscle
- Patients present with: (5)
- older children or young adults
- tonsil; peritonsillar
- Fever,
- Pharyngeal swelling,
- Sore throat,
- Difficulty in swallowing, and
- Trismus that results from spasm of pterygoid muscles (moves jaw from side to side).
Epiglottitis
Croup
Epiglottitis
- Most common in children ___-____ years old but also occurs in infants or adults. It is accompanied by severe systemic illness with _______ AND ________.
- S/S included:
- In addition to the epiglottitis, all the supraglottic structures are swollen and inflamed, creating a potential obstruction.
- 3-7
- pyrexia and leukocytosis
- sore throat,
- dysphagia,
- drooling,
- obstruction.
Epiglottitis is associated with:
- Drooling
- Dysphagia
- Dysphonia
- Dyspnea
- Dehydration
- These children are septic with no cough and rapid onset.
Epiglottitis
- Avoid making child cry as he/she may become acutely obstructed. Parent may be present. No _________________.
- Transfer the child to the OR ASAP. The OR should be prepared for emergency _________ and possible _________ (surgeon present, scrubbed, and ready to intervene if needed).
- Child should remain ______ at all times. Do not examine airway in ED.
- premedication
- bronchoscopy; tracheotomy
- sitting
Epiglottitis
- Remember the patient will most likely have a longer than normal induction time secondary to _______________.
- If a PIV has been established, consider administering lidocaine 1 mg/kg IV to minimize the risk of coughing and laryngospasm.
- Use a _________ than predicted ETT
- smaller tidal volumes
- smaller
Epiglottitis
- Once intubated, place monitors
- Administer ____-____ ml/kg of crystalloid because the patient is most likely dehydrated
- Obtain blood cultures once airway is secured.
- _____________________ is the most common bacteria that causes epiglottitis. Due to HiB vaccine, increase in incidence caused by _________.
- 20 - 30
- Haemophilus influenzae type B (HiB); Strep
Laryngotracheobronchitis LTB or “croup”
- Most commonly caused by a _______ in children < _____ years.
- An obstruction of the airway, below the epiglottis, characterized by a __________.
- Principal symptom is _____________ caused by swelling of the loose tracheal mucosa at the level of the cricoid cartilage.
- Symptoms are worse at _________.
- virus; 3
- barking cough
- inspiratory stridor
- night.
Laryngotracheobronchitis (croup)
- ________ ml of ________% Racemic Epinephrine in 2 - 3 ml of normal saline in nebulizer.
- Be aware of the potential “______________,” requiring monitoring for ______ hours (per facility protocol)
- Suitable pediatric face mask held comfortably around child’s face
- Monitor the child for ______ or _________ requiring intervention
- 0.5; 2.25
- rebound affect; 4
- stridor or a barking cough
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 ______ cm H2O PIP.
* Constant respiratory care because the thick secretions and small ETT will lead to obstruction/blockage.
20
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 croup
Endoscopy Issues
Laryngoscopy, bronchoscopy, esophagoscopy
Existing airway problem – complete airway obstruction
Premedication?
Spontaneous versus controlled-ventilation
- judicious w/ premedication
Foreign Body Aspiration
- Upper airway obstruction varies from a partial obstruction with ______,________,________, _______ and __________ to complete obstruction with _______ and __________compromise
- Considered a “full stomach”
- Potentially a difficult airway
- coughing, wheezing, drooling, stridor, and respiratory distress
- hypoxia and cardiorespiratory
Foreign Body Aspiration
- Dyspnea, Coughing, Wheezing and Decreased air entry on the affected side are indicative of a ________.
- Dyspnea, Coughing, Stridor and Cyanosis are more common with ____________.
- Aphonia is of particular concern as it may indicate a ________________.
- bronchial aspiration
- laryngeal or tracheal foreign body
- total obstruction
Foreign Body Aspiration
- 95% foreign bodies lodge in right mainstem bronchus
- History of choking while eating or playing
- If the FB completely obstructs bronchus, then ______________ from air trapping can be seen on CXR
- A late sign may present as __________.
- distal hyperinflation
- pneumonia
- ___________: air can be inhaled but not exhaled (i.e., ___________)
- __________: air can be exhaled but not inhaled (i.e., ___________)
- ___________: partial obstruction of both inhalation & exhalation
- ____________: total blockage (i.e., ___________)
- Check valve; emphysema
- Ball valve; collapse of the bronchopulmonary segment
- By-pass valve
- Stop valve (airway collapse and consolidation).
Cleft Lip and Cleft Palate
- The most frequent congenital craniofacial malformations – 1 in 700 births in US (_____>______)
- May be isolated, familial, or part of a syndrome – more than ________ syndromes are associated with cleft lip and palate; more with ________.
- Primary cleft lip repair at _____-_____ months of age.
- Primary cleft palate is done around ____-_____ months.
- Males > Females
- 300; palate
- 2- 3
- 6- 10
Cleft Lip and Cleft Palate
Cleft lip closure may be carried out early
“Rule of ten” refers to:
Hb of 10,
At least 10 weeks old,
At least a weight of 10 lbs
Cleft Lip and Cleft Palate
- Early childhood lip & nose revisions
- Palatal revision & alveolar bone grafts around ________ years of age.
- Rhinoplasty & maxillary osteotomy complete repair around _____-______ years of age.
- Some may need _______ to allow normal speech & to prevent nasal regurgitation.
- 10
- 17 - 20
- pharyngoplasty
Anesthetic Issues: Cleft Lip and Cleft Palate
- Induction – inhalational or Intravenous
- Airway issues
- Intubate with _________
- Movement of head
- Epinephrine dose issues
- Pharyngeal packs
Emergence:
- Pharyngeal packs gone? Oral cavity dry?
- Stomach emptied? Nasal airway?
- Extubation only if patient is ** completely awake!**
- Can they maintain own airway without intervention?
- Restrain arms to prevent child from pulling at suture lines
- Pain management
oral RAE
Partial list of syndromes and conditions commonly associated with craniofacial anomalies:
Cleft Lip and Cleft Palate: Postoperative Concerns
- The most common complications are bleeding and swelling (airway obstruction).
- Airway edema (obligate mouth breathers) about 10% experience will experience:______
- Acute airway obstruction from lingual swelling, especially if mouth retractor is in place for more than _____-_____ hours.
- obstructive sleep apnea.
- 2 to 3
- _______________: repair to prevent permanent craniofacial deformity
- May involve multiple surgical services, e.g., ENT, Plastics, Neuro, etc.
- Severe forms associated with:
- Craniosynostosis
Part of genetic syndromes
Elevated ICP
Neurologic deficits
Ophthalmologic problems
Most common type of craniosynostosis (50%)
Premature closure of sagittal suture
Scaphocephaly
(18%) results from unilateral synostosis of a coronal suture, producing a unilateral “tilting” forehead and orbital anomalies
(9%) results from bilateral coronal synostosis and causes a broadened skull and midface hypoplasia
- Neurologic complications
- Apert’s and Crouzon’s syndromes
(9%) is the result of premature closure of the metopic suture, resulting in a triangular shaped head and hypotelorism.
Syndromes associated with cranyosystosis
Upper extremity and hand surgery
__________: another finger (usually the _______ finger) and is turned into a thumb by surgically moving the finger to where a thumb should be.
Pollicization; pointer
Fractures
- Consider NPO status for non planned cases.
- Homeostasis is more complex b/o __________.
- Risk of infection due to prior contamination (during the accident) and hardware implantation
- Deep venous thrombosis and fat embolism incidence is _______ common in children.
- Congenital, genetic and birth disorders (dysmorphic)
- Trauma or accidents
- Osteogenesis imperfecta (OI)
- ORIF vs closed reduction
- smaller blood volume
- not as
- Trauma or accidents
- Osteogenesis imperfecta (OI)
- ORIF vs closed reduction
- is a condition of the hip joint where the head of the femur slips off of the neck.
- Upon detection by clinical exam and x-ray, immediate bed rest , +/- traction, and surgery 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.
Slipped Capital Femoral Epiphysis (SCFE)
Used to treat Developmental Dislocation of the Hip (DDH) (i.e., congenital dislocation)
Pavlik harness or Wheaton Harness
types of 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 _____ 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
- ETT
Scoliosis
- ______ curvature of the spine with rotation of vertebrae within the curve
- Requires an ______ or _______ spinal fusion
- May be _____,_____ or ________.
- Early detection offers the best treatment options (PT, OT, Casting, Bracing, Surgery)
- Lateral
- anterior or posterior
- congenital, idiopathic, or neuromuscular
Scoliosis
- Pre-operative 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 ____ and ________, positioning considerations and the evaluation of motor function in the OR.
surgery consists of:
SSEPs and MEPS
Harrington rods
Distraction (expandable) rods
Pedicle screws with or without rods
Vertical expandable prosthetic titanium ribs (VEPTR)
Retinopathy of Prematurity (ROP): Disease Classification & Progression
Progression of the disease in five stages
* Stage I =
* Stage II =
* Stage III =
* Stage IV =
* Stage V =
Zones I - III determine area of damage.
- Stage I – mildly abnormal blood vessel growth
- Stage II – moderately abnormal blood vessel growth
- Stage III – Severely abnormal blood vessel growth
- Stage IV –partially detached retina
- Stage V – completely detached retina
Eye Operations
- Congenital cataracts: lens opacity present at birth and must be surgically removed. Associated with __________ and other chromosomal conditions.
- Glaucoma: a _______ issue; several anomalies are in association, _______ measurements are taken before intubation.
- maternal rubella
- Congenital; IOP
The most common eye surgery in children
Strabismus sx.
