Term
| What are some common neurological processes/diseases in the pediatric population that require surgery? |
|
Definition
*Congenital hydrocephalus
*Myelomeningocele
*Medulloblastoma
*Arnold Chiari Malformations I&II
*Epilepsy
*Tethered Cord
*Tumors-astrocytoma
*Cerebral palsy
*Chromosomal abnormalities |
|
|
Term
| In the child with neurological problems if there is one anomaly..... |
|
Definition
|
|
Term
|
Definition
*Bradycardia
*HTN
*Irregular respirations (or widening of pulse pressure)
**Hypotension is a LATE sign of increased ICP |
|
|
Term
What kinds of hydrocephalus are there?
What procedure is commonly performed?
And what is the causes of hydrocephalus? |
|
Definition
*Communicating and noncommunicating hydrocephalus
*Ventricular-Peritoneal Shunt
*Causes: aqueductal stenosis, IVH, Arnold Chiari malformation, brain tumors, craniofacial anomalies |
|
|
Term
| What are some early and late signs of increased ICP? |
|
Definition
*Early: headache, irritable
*Late: emesis, seizures, bradycardia, lethargy |
|
|
Term
| What locations other than the peritoneum can a shunt be placed for CSF drainage? |
|
Definition
*Vetricular atrial
*Ventricular gallbladder |
|
|
Term
| What are the two myelodysplasias commonly seen in infants? |
|
Definition
*Menigocele: the meninges protrude through the opening
*Myelomenigocele: Spina bifida, a portion of the cord and membranes are protruding |
|
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Term
| What type of surgeries may be preformed on children with myelodysplasias? When are they typically performed and what complications may arise? |
|
Definition
*May require a VP shunt or have a tethered cord.
*Often repaired during first day of life
*Intubation may be difficult due to positioning
*EBL~10% |
|
|
Term
| What is an arnold-Chiari malformation? |
|
Definition
| *Displacement of the cerebelar vermis thru the foramen magnum, along with elongation of the brainstem. |
|
|
Term
| Why does an arnold chiari malformation occur? |
|
Definition
*Due to abnormal formation of the occiput and vertebral areas that do not allow for enough volume.
*Can be due to adhesions or possibly birth trauma |
|
|
Term
| Which Chiari malformation is usually associated with myelodysplasia and a tethered cord? |
|
Definition
|
|
Term
| What are the S&S of a Chiari Malformation? What are the implications of when the malformation is found? |
|
Definition
*S&S: difficulty swallowing, stridor, recurrent aspiration, depressed gag reflex.
*The earlier the signs and symptoms are picked up the worse the long term results. |
|
|
Term
| 60% of brain tumors in children are in the _________ fossa an peak between ages _______ years old. |
|
Definition
|
|
Term
| Brain tumors in children are often _________ and are detected d/t the mass effect causing _______ & _______. |
|
Definition
*Benign
*increased ICP
*hydrocephalus |
|
|
Term
| What drug may be utilized for posterior fossa tumor surgeries? |
|
Definition
|
|
Term
| What is premature intrauterine fusion of one or more cranial sutures resulting in an abnormal skull shape? |
|
Definition
|
|
Term
| When is craniosynostosis typically detected and what are implications of fixing vs. not fixing the defect? |
|
Definition
*Primarily detected before 3 months old
*Intelligence and ICP are normal but without Treatment
*ICP increases and intelligence decreases |
|
|
Term
| What syndromes are often associated with craniosynostosis? |
|
Definition
*Clover leaf
*Apert's
*Couzon's |
|
|
Term
| What are important points for consideration when managing a case to fix a craniosynostosis? |
|
Definition
*They are large blood loss cases 50-150% of EBV
*Need 2 IV's, a-line, blood, FFP, PLTs, and calcium readily available |
|
|
Term
| What is sagittal synostosis and metopic synostosis? |
|
Definition
*Two types of craniosynostosis.
*Sagittal is "football head" and is easier to fix |
|
|
Term
| What are common pediatric opthomologic procedures? |
|
Definition
| *Tear duct probing, EUA for glaucoma or tumor, strabisumus |
|
|
Term
| What are important considerations for opthomologic cases? |
|
Definition
*Be careful with cautery and mask case- may have to d/t O2 when cautery is on
*Use a RAE ETT
*These patients have a higher chance of N/V postop
*Be aware of strabismus and MH precautions |
|
|
Term
| What reflex can be elicited during opthalmic surgery? |
|
Definition
| *Oculocardiac Reflex (OCR) or Trigeminal-vagal reflex |
|
|
Term
| What can be done to treat the oculocardiac reflex? What can elicitation of this reflex cause? |
|
Definition
*Occurs at an incidence as high as 70-79% during opthalmic surgery
*Caused by traction or pressure
*Prophylaxis is in debate
*Retrobulbar blocks are effective in preventing OCR but they can trigger the effect when being placed
*Most common effect is bradycardia but other ominous signs can be AV block, VT, & bigeminy, this reflex should fatigue itself but if the bradycardia is not transient, you may ask the surgeon to lighten up and or give atropine (10-20mcg/kg IV) or glycopyrrolate (10mcg/kg IV)
**Remember bradycardia can cause hypotension in children |
|
|
Term
| This occurs when elevated O2 tension causes arrest of normal vasculogenesis and fibrous tissue forms. |
|
Definition
*Retinopathy of Prematurity
*There is also failure of retinal vascular development |
|
|
Term
| 70% of infants weighing less than 1000gms have ______. |
|
Definition
*ROP
* Fortunately 80-90% of these infants have spontaneous regression of their retinal changes |
|
|
Term
| What is the treatment for ROP? |
|
Definition
| *Cryotherapy and laser photocoagulation |
|
|
Term
| What type of surgery has a PONV incidence of 40-88%? |
|
Definition
| *Eye surgery, prophylaxis is extremely important |
|
|
Term
| What are common pediatric ENT procedures? |
|
Definition
| *BMT, middle ear surgery (mastoidectomy or tympanoplasty) avoid N2O, choanal atresia, T&A, & laryngeal obstruction |
|
|
Term
| What are important considerations when managing a BMT? |
|
Definition
*No IV necessary, treat with IM, IV or intranasal
*Fentanyl, ketorolac, or tylenol suppository (suppositories for children not walking) |
|
|
Term
| What are common reasons that children get T&As? |
|
Definition
*OSA
*Chronic tonsillitus
*frequent URIs
*obstructive hyperplasia of tonsils
*Peritonsilar abscess |
|
|
Term
| What are important considerations for managing a T&A? |
|
Definition
*May be a difficult induction if recent URI, be aware
*Decadron often given
*Watch blood loss replace 10cc/kg crystalloid
*Safest postop position: Sims
*If <3 years old the patient must stay due to airway size and edema
*Use RAE tube |
|
|
Term
| When will the post op bleeding tonsil most likely occur? |
|
Definition
*75% occur within 6 hours
*25% occur within the first 24 hours
*Can occur as late as 6-7 days |
|
|
Term
| What are the signs and symptoms of a bleeding tonsil? |
|
Definition
*Frequent swallowing
*Increased HR
*Irritability
*Bright red emesis
*Orthostatic hypotension>20-30% loss |
|
|
Term
| Your patient has a bleeding tonsil post-op, what should you do before returning to the OR? |
|
Definition
*Get IV access
*Restore volume
*T&C
*Check Coags
*No premeds |
|
|
Term
| Your patient has a bleeding tonsil and you are heading to the OR, what should you have ready and how should you do the induction? |
|
Definition
*Have 2 of everything ready- 2 blades, 2 OPAs, 2 bite blocks, ect.
*Suction gently before laryngoscopy, no mask induction, use what ever position is most comfortable to you. |
|
|
Term
| What are common causes of stridor that may require the need for a diagnostic laryngoscopy and bronchoscopy? |
|
Definition
*Subglottic stenosis
*Laryngeal atresia/web
*Polyps
*Papillaoma
*Congenital rings
*Masses: cystic hygroma, neurofibroma
*Vascular ring
*Tracheomalacia
*Foreign body |
|
|
Term
| The goal of anesthesia for ENT is to...... |
|
Definition
*Provide a deep plane of anesthesia while maintaining spontaneous ventilation.
*May have post op croup- order racemic epi nebulized
*Review laser airway fire implications... |
|
|
Term
| What are differential diagnosis for epiglottitis? |
|
Definition
*Croup
*foreign body aspiration
*measles
*congenital abnormalities
*allergic reaction
*chicken pox
*mumps
*Epiglottis
* recurrent tonsillitis |
|
|
Term
| What are s/s of epiglottitis? |
|
Definition
*Supraglottic
*usually 3-7yo
*less common now d/t vaccination for H. Flu
*acute bacterial infection
*loss of c/spine curve on x-ray
*sudden onset
*high fever
*marked dysphagia
*drooling
*Tripod stance
*decreased voice
*Intense pain! |
|
|
Term
|
Definition
*Sublottic
*Common in less than 3yo
*AKA- laryngotracheobronchitis
*6mo-3yo
*gradual onset
*Low-grade fever
*low pain
*barking cough
*medical/supportive
*racemic epi helpful
*Steeple church sign on x-ray |
|
|
Term
| Once epiglottitis is diagnosed what should never happen? |
|
Definition
| *A child should NEVER be left unattended because the disease can progress so rapidly that complete upper airway obstruction may ensue within minutes. |
|
|
Term
| What is the treatment for epiglottitis? |
|
Definition
*Transfer the child sitting to the OR, keep the child spontaneously breathing.
*Muscle relaxants are CONTRAINDICATED, secure the airway in the OR.
*Usually they can be extubated within 24-48 hours. |
|
|
Term
| Patients with cleft lip/palate have a higher incidence of.... |
|
Definition
*Syndromes
*Congenital Heart Disease
*Middle Ear Disease
*Fetal hydantoin
*Fetal trimetadion
*Mohr syndrome
*Orofaciaodigital syndrome
*Trisomy 18 and 4P |
|
|
Term
| What airway concerns are there with Cleft Lip/Palate? |
|
Definition
*May be a difficult airway/intubation
*Difficulty in securing tube
*Securing must be to mandible
*may be micrognathic |
|
|
Term
| What are management implications for the pediatric patient undergoing a Cleft lip/palate repair? |
|
Definition
*Keep BP low approx 80mmHg (consider labetolol, esmolol, nipride, or propofol)
*Surgical repair will require awake extubation
*Do not put pressure on the face after extubation
*Postoperative airway obstruction and bleeding are problems |
|
|
Term
| What are the implications for a pediatric patient undergoing a craniofacial reconstruction? |
|
Definition
*Massive blood loss cases 50-150% EBV
*Majority are developmental appropriate
*May be difficult intubation
*Long time consuming repair ranging from 8-14 hours |
|
|
Term
| What are the characteristics of Aperts? |
|
Definition
*Acrocephaloayndactyly
*craniosynsostosis
*Syndactyly of hands
*Difficult intubation
*Possibly increased ICP
*Congenital heart disease |
|
|
Term
| What are the characteristics of Crouzons? |
|
Definition
*Exopthalmos
*Hypertelorism
*craniosynostosis
*hypoplastic mandible |
|
|
Term
| What are the characteristics of Pierre-Robin? |
|
Definition
*Cleft-palatte
*Micrognathia
*Glossoptosis
*Congenital Heart Disease
*Neonate may asphyxiate
*Difficult intubation |
|
|
Term
| What are the characteristics of Treacher-Collins? |
|
Definition
*Mandibulofacial dysotosis
*Microgranthia
*aplastic zygomatic arch
*microstomia
*choanal atresia
*Congenital heart disease
*difficult airway |
|
|
Term
| When are hernia repairs urgent? |
|
Definition
*If it is incarcerated
*They are usually inguinal or umbilical
*Often associated with prematurity
*can be preformed with GETA or SAB |
|
|
Term
| What is associated with 2-20% of patients with tracheoesophageal fistula? |
|
Definition
| *Congenital Heart Disease |
|
|
Term
| What is an indicator of a good prognosis of a patient with a tracheoesophageal fistula? |
|
Definition
| *If the patient is >1800gms |
|
|
Term
| What anomalies are associated with tracheoesophageal fistula? |
|
Definition
*Congenital heart disease (VSD, ASD, AV canal)
*Anorectal
*Genitourinary
*Vertebral
*Skeletal
*VATER syndrome |
|
|
Term
| What is tracheoesophageal fistula and which type is most common? |
|
Definition
*Failure of the trachea and esophagus to separate during division
*Most common type is type C, where the esophagus is a blind pouch and the distal esophagus is attached to the trachea. |
|
|
Term
| What pregnancy complications are associated with tracheoesophageal fistula? |
|
Definition
*Intrauterine polyhydramnios
*Preterm labor |
|
|
Term
| What are signs and symptoms of an infant with tracheoesophageal fistula? |
|
Definition
*Unable to pass suction catheter to stomach
*Drooling
*Cough
*Cyanosis
*Confirmed with x-ray and air in stomach |
|
|
Term
| What should be done preoperatively before fixing a Tracheoesophageal fistula? |
|
Definition
*NPO
*May need G-tube placement
*May need to postpone total repair until >9kg or >1 yo
*Check ECHO d/t possible undiagnosed associated cardiac anomalies |
|
|
Term
| What is included in the anesthetic management for an infant undergoing a tracheoesophageal fistula? |
|
Definition
*Awake intubatoin or intubation after induction
*Proper tube placement may entail right mainstem then pull back just until bilateral breath sounds heard (use a FOB)
*Low PIP
*No N2O!
*Right thoracotomy
*Most often left intubated
*NO post op NG tubes |
|
|
Term
| What defect has parts of the abdomen ending up in the chest resulting form an anatomic lung defect in proportion to the amount of GI tract in the chest? |
|
Definition
*Congenital Diaphragmatic Hernia
*Fewer alveoli can form and there is a decreased lung size and decreased size of the pulmonary arteries |
|
|
Term
| What are the types of congenital diaphragmatic hernia and which is the most common? |
|
Definition
*Posterolateral
-Bochdalek 80% (Left)
-bilateral 0.15
-right 5%
*Anterior
-foramen of Morgagni 2%
-Esophageal 8% |
|
|
Term
| Other associated defects occur 40-57% of the time in patients with congenital diaphragmatic hernia, what are they? |
|
Definition
*ASDA
*SD
*Coarctation
*Tetralogy of Fallot
*Spina Bifida 28%
*Myelo
*hydrocephalus
*Esophageal atresia 20%
*Hypospadias 15% |
|
|
Term
| True or False: Congenital Diaphragmatic Hernias can be detected on antenatal ultrasounds and is 90% accurate. |
|
Definition
|
|
Term
| What are the S&S of Congenital Diaphragmatic Hernia if not detected in utero? |
|
Definition
*Respiratory compromise during the first 24 hours
*Tachypnea
*Pallor
*Cyanosis
*Scaphoid abdomen
*decreased heart sounds
*bowel sounds in chest |
|
|
Term
| What are some NICU implications for managing the patient with a congenital diaphragmatic hernia? |
|
Definition
*Avoid increasing PVR
*Warm Isolette
*Increase PaO2
*Decrease PaCO2
*Alkalosis (Avoid CPAP)
*Sedation and paralysis |
|
|
Term
| What is the number one problem in patients with congenital diaphragmatic hernia? How is this problem treated? |
|
Definition
*Pulmonary Hypertension
*Treatment is: Nitric Oxide, prostaglandins (PGE-1), Tolazoline. Nitroglycerin and nipride.
*ECMO utilized to bridge the vascular reactivity time frame. |
|
|
Term
| What is a common GI anomaly occurring in the first 6 months but usually within the first 6 weeks of life. It is sometimes associated with a cleft palette and reflux? |
|
Definition
|
|
Term
| What are the signs of pyloric stenosis? |
|
Definition
*Projectile vomiting
*Hypochloremic metabolic alkalosis
*Olive shaped mass in epigastrum |
|
|
Term
| What is the surgical treatment for pyloric stenosis? Discuss induction and postoperative concerns. |
|
Definition
*Treatment- Pyloromyotomy. This is NOT a surgical emergency, it is a medical emergency. Manage first and correct all abnormal labs especially chloride >90. Ideally want >100.
*Induction: suction stomach first (May have barium swallow, take NGT out prior to induction), RSI
*Postop apnea is common because of alkalosis |
|
|
Term
|
Definition
*Herniation of intestine into cord
*A defect of the lateral abdominal wall and peritoneal sac. |
|
|
Term
|
Definition
*No sac or membrane
*60% premature
*Low incidence of associated anomalies |
|
|
Term
| What are associated anomalies for a patient with an omphalocele? They occur in up to 2-30%... |
|
Definition
*30% are premature
*Malrotation gut
*Tetralogy of Fallot
*Bladder exstrophy
*Beckwith Wideman syndrome
*Pentalogy of Cantrell
|
|
|
Term
| What are considerations for the anesthetic management of a patient undergoing surgery for an omphalocele/gastrochisis? |
|
Definition
*Normothermia
*Decompress stomach
*Fluid up to 20+ cc/kg/hr
*Infant may not tolerate all of GI contents being returned to abdomen so they may have to create a silo.
*Watch PIP!
*No IV in lower extremities
*No N2O
*Provide good muscle relaxation
*Know principles of neonatal anesthesia |
|
|
Term
|
Definition
*An encapsulated nephroblastoma
*HTN present in 60% of cases
*Will require chemotherapy before or after surgical resection |
|
|
Term
| What is the most common extracranial solid tumor of childhood? |
|
Definition
|
|
Term
| At what age is neuroblastoma often diagnosed? What is often associated with neuroblasotma? |
|
Definition
*22 months of age
*Often associated with metastasis |
|
|
Term
| What are some common congenital urologic malformations in children? |
|
Definition
*Double renal pelvis/ureters
*Posterior ureteral valves
*Ectopic ureter
*Mega ureter
*Ureterocele
*Neurogenic bladder
*exstrophy
*undescended testes
*Hypospadias
*phimosis
*vaginal anomalies |
|
|
Term
| What are common urological cysts and tumors in the pediatric population? |
|
Definition
*Wilms Tumor
*Cystic kidney
*neuroblastoma
*gangiloiteuroma
*adrenogsnital
*Pheochromocytoma
*teratoma
*ovarian tumors |
|
|
Term
| What are common results of urological trauma? |
|
Definition
*Renal rupture
*bladder rupture
*Injury |
|
|
Term
| What are common surgical cases in children that have renal failure? |
|
Definition
*Biopsy
*nephrectomy
*transplantation |
|
|
Term
| What are some common urological cases in the pediatric population? |
|
Definition
*Cystoscopy
*Circumcision
*Hypospadias |
|
|
Term
| What type of anesthesia can be used for hypospadias repair that is an excellent for postop pain control? |
|
Definition
*Caudal block
*Marcaine 0.25% 0.5-1mL/kg with/without Astromorph 50mcg/kg (if astromorph is added to any caudal the infant must remain in the hospital for 23 hours) |
|
|
Term
| What orthopedic problem can be seen in an otherwise normal child or also in a child with a neuropathy such as myelo or spinal muscular atrophy? |
|
Definition
|
|
Term
| What are important considerations for repair of a clubfoot? |
|
Definition
*Repair is traditionally done prone
*Tourniquets often used
*Caudal anesthesia for pain control
*Casting
*Sometimes done without anesthesia |
|
|
Term
| What are some reasons that a pediatric patient may need a spinal fusion? |
|
Definition
*Vertebral/rib anomalies
*Spinal dysraphism
*Trauma to zygote/embryo during early formation
*Classifications can be infantile <3yo, juvenile 3-10yo, adolescent >10yo |
|
|
Term
| What Neuromuscular diseases, syndromes, or trauma are often associated with the need for spinal fusions? |
|
Definition
*Cerebral Palsy
*Polio
*Syringomyella
*Frederichs ataxia
*Fractures
*radiation
*burns
*neurofibromatosis
*Muscular dystrophy
*osteogenesis imperfecta
*mucopolysacchoidosis
*rheumatoid arthritis |
|
|
Term
| What artery is the major supplier of the T4-T7 and the lower 2/3 of the spinal cord? |
|
Definition
|
|
Term
| What is the spinal cord perfusion pressure and what is it influenced by? |
|
Definition
*Spinal cord perfusion pressure: 50-150mmHg
*Arterial oxygen
*carbon dioxide
*pH
*Cord temperature |
|
|
Term
| At what curvature of the spine is respiratory function impaired? |
|
Definition
|
|
Term
| What is the normal curvature of the spine? |
|
Definition
|
|
Term
| At what angle of the spine is surgical intervention usually required? |
|
Definition
*>40 degrees
At >65 degrees- restrictive lung disease
>100 degrees- symptomatic lung disease, dyspnea
>120 degrees- alveolar hypoventilation |
|
|
Term
| Since EBL during a spinal fusion can be massive, what are some techniques that the anesthetist can use to prevent blood loss or decrease its impact? |
|
Definition
*Consider induced hypothermia: in the pediatric patient this is the best accomplished with esmolol or propofol infusions since the cardiac output is heart rate dependent. In the patient with cardiac disease and scoliosis, it is best to utilize nipride.
*Consider Acute Normovolemic Hemodilution in idiopathic scoliosis
*Cell saver
**Post op management- epidural and On-Q pain pump or morphine drip. |
|
|
Term
| What are major associated findings r/t Down Syndrome or Trisomy 21? |
|
Definition
*mental retardation
*Characteristic facial features
*C1-C2 instability
*visual and hearing impairment
*heart defects
*at high risk for thyroid problems and leukemia |
|
|
Term
| What are some assoicated findings with Apert's syndrome? |
|
Definition
*Prematurely fuse cranial sutures
*Dextrorotation
*Pulmonary atresia
*Patent Ductus Arteriosus
*Tracheoesophageal Fistula
*Bicornate Uterus
*Sleep Apnea
*Increased incidence of eye injuries
*Fused fingers
*Various heart defects
*Hydrocephalus
*Ear infections
*Pyloric stenosis
*Polycystic kindeys
*Severe Acne
*Fused toes
*A retruded midface
*Increased ICP |
|
|
Term
| What are some assocaited findings with DeGeorge's Syndrome? |
|
Definition
*No Thymus/parathyroid glands (immunodeficient)
*Aortic arch anomalies
*Recurrent infections
*low calcium |
|
|
Term
| What are some associated findings with Crouzon's Syndrome? |
|
Definition
*Flattened back and top of head
*Protruding lower jaw
*Flattened forehead
*Shallow eye sockets
*Protruding eyeballs
*Hearing loss
*Absence of ear canals
*Deformity of middle ears
*Vertigo and dizziness
*Deformity of limbs
*Beaked like nose
*Overcrowding teeth
*Narrow high arched palate
*Cleft palate
*Curvature of the spine
*Vision problems
*Crossed eyes
*Involuntary movement of eyes
*Facial deformity
*Webbed toes |
|
|
Term
| What are some associated findings with Kippel-Feil syndrome? |
|
Definition
*Torticollis
*Facial asymmetry
*Renal anomalies |
|
|
Term
| What are some associated symptoms with Pierre-Robbin sequence? |
|
Definition
*Micrognathia
*Cleft palate
*glossoptosis
*apnea |
|
|
Term
| What are some associated findings with Treacher-Collins (mandibulfacial dysostosis)? |
|
Definition
*Absent cheekbones
*mandibular hypoplasia
*dysplastic ears
*hearing loss
*macrostomia
*Cleft palate
*colobomas |
|
|
Term
| What are the associated findings with Trisomy 18 (Edward's Syndrome)? |
|
Definition
*Back part of head may be prominant
*Micrognathic
*Cleft lip/palate
*Syndactyly- Clenched fists with the index finger overlapping the 3rd and 4th fingers
*Congenital anomalies of the lung and diaphragm
*Renal malformation (watch renally excreted drugs)
*Clubfeet
*Low arch dermal ridge pattern on fingertips
*Hernias and/or separation of the rectus muscles of the abdominal wall |
|
|
Term
| What are the associated findings of VATAR? |
|
Definition
*VACTERL association is an acronym for:
-Vertebral anomalies
-Anal atresia
-Congenital Cardiac disease
-TracheoEsophageal fistula
-Renal anomalies
-radial dysplasia
-Limb defects |
|
|
