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| THE NARROWEST OPENING OF THE INFANT/SMALL CHILD LARYNX IS THE _____ ______ WHICH IS A _____ _____ |
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Definition
| CRICOID CARTILAGE, COMPLETE RING |
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| Children less than 2 years of age should be placed into a _____ head position, with a _____ _____ _____ |
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Definition
| neutral head position, with a towel below the shoulders |
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| In a child greater than 2 years of age, the ________ _______ makes for optimal alignment of the airway just as in the adult, with a towel under ___ ____ |
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| sniffing position, with a towel under the head |
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| The distance from the vocal cords to the carina is ____ in the infant. |
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| The adult has a right bronchus angle of about ___ degrees where the left has an angle of _____ degrees |
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| Anatomical airway differences between kids and adults |
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Definition
Obligate nose breathers
Small nares
Large head/occiput
Small mouth opening and chin
Large tonsils and adenoids
Short neck and trachea
Larynx is more cephalad/superior
Narrowest portion of airway = cricoid cartilage
Cords attach lower anteriorly (on a slant)
Main stem bronchi leave at 55 degree angle |
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| Average depth of ETTs for infants under one year |
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| Newborn = 10cm, 6months-1year = 11-12 cm |
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| Premie under 1000gms ETT size |
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| Premie 1000-2500 gms ETT size |
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| 7cm + 1cm x(each kg above 1 kg) (max 10cm) |
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| Hypertrophic Pyloric Stenosis symptoms |
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| manifests within the 2nd to 6th week of life as nonbilous, projectile vomiting about 30 minutes after feedings |
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| Hypertrophic Pyloric Stenosis feels like... |
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Definition
| an olive shaped mass between the midline and right upper quadrant |
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| Chronic vomiting in HPS causes |
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Definition
| metabolic alkalosis, hypokalemia and hypochloremia |
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| HPS causes paradoxical aciduria because... |
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Definition
| Due to Na loss the kindeys start to conserve Na and spit out hydrogen ions |
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| pyloromyotomy may indicate a ___________emergency, but ____ _ _______ emergency |
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Definition
| MEDICAL, NEVER a surgical |
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| Pyloromyotomy can be dangerous if you don't do what preop? |
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Definition
| Hydration and electrolyte correction, can take 24-48 hours in severe cases |
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| IVF of choice for pyloromyotomy |
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| Preop optimizatoin goals for pyloromyotomy |
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| , the Sodium should be >130mEq; Potassium >3mEq; Chloride>85 mEq; urine output should be 1-2 ml/kg/hr. |
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| Major concern in pyloromyotomy |
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OGT
RSIV or awake intubation |
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| Pyloromyotomy postop major concern |
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| respiratory depression and hypoventilation is an increased risk in this population. The increased risk comes from persistent metabolic alkalosis or CSF alkalosis (central chemoreceptors are bathed in CSF. Alkolotic CSF makes the brain want to decrease respirations whick drives up CO2). |
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| should you use narcotics in pyloromyotomy |
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| wouldnt be a great idea due to resp depression and quick speed of cases |
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decompress stomach with OGT,
Use esophageal dilator,
sometimes OG must come out for dilator |
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| Intussusception feels like and looks like what foods? |
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feels like a distinct “sausage” mass in the abdomen
bloody, maroon stools (look like currant jelly) |
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| Is intussusception an emergecny? |
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Definition
Yes, Intussusception creates a real potential for dead bowel if not relieved in a timely manner, and therefore is an emergency
Do RSIV, watch electrolytes, and fluid status |
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| 20-30% of children with duodenal atresia also have |
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| Meconium ileus occurs in 10-15% of infants with |
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| Duodenal and Ileal Obstruction anesthetic considerations |
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Definition
massive fluid and electrolyte shifts,
OG or NG,
AVOID nitrous!
hemodynamically unstable so Consider TIVA,
RSIV induction,
NDMRs are required for abdominal relaxation and manipulation. |
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| herniation of abdominal contents at the umbilicus, covered by a thin membrane, includes the umbilical cord in the herniation |
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| surgery in 2-3 days of life |
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| _____ _____syndrome is often associated with an omphalocele |
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| Beckwith-Wiedomann symptoms |
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| macroglossi (large tongue), visaromegaly (large organs) and hypoglycemia (due to islet hyperplasia and hyperinsulinism). |
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| gastroschisis (images on the right) is a full thickness abdominal wall defect usually to the right of the normal umbilical cord |
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| True or false: kids with gastrochisis typically have other anomalies |
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| True or false: kids with omphalocele typically have other anomalies |
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| True, they can have GI, cardiovascular, GU and CNS anomolies and beckwith-weidoman syndrome |
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| Anesthetic considerations for gastrochisis and omphalocele |
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1 Maintain body heat and fluid balance!
more an issue for gastroschisis
2 Watch for major fluid shifts with exposed bowel!
3 These kids need to be intubated and paralyzed.
4 continue mechanical ventilation
5 RSIV induction or awake intubation
6 No nitrous!
7 Full paralysis |
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most common form of MD and one of the most severe
Duchenne MD occurs more frequently in males (1:3,300).
abnormality of dystrophine. |
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| Is duchenne MD associated with MH |
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| In duchenne MD what muscle is often effected? |
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| Anesthesia Considerations:Muscular Dystrophy |
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Definition
1 Aspiration risk
2 no succs
3 NDMRs are OK
4 Post operative ventilation
5 use a 5 lead ECG
6 Kyphosis is the most common reason for surgery |
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| Cerebral Palsy occurs from lack of O2 to cerebellum at what time? |
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Definition
| during pregnancy (75%), during childbirth (5%), or after birth up to about age three (15%). |
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-Aspiration risk, full stomach
-positioning challenges
-NO SUCCS
-Unable to shiver, susceptible to hypothermia
-Slow emergence
-high rate of POPCs |
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| Cystic Fibrosis considerations |
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Definition
-fat soluble vitamin deficiencies
-may have meconium ileus as newborns
-many lung issues |
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| CF anesthetic considerations |
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Definition
-Prolonged induction/emergence
-CPT preop is good
-No to aggresive narcotic use
-No nitrous
-Ketamine is bad d/t incresed secretions
-Glyco is controversial
-Intubate DEEP
-Suction during case and before extubation
-Regional is preferred |
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-Airwaydifficult (stiff neck and larynx)
-MAS (macrophage activation syndrome)
-Avoid NSAID triggers for MAS |
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| Turner syndrome characteristics |
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Definition
Short stature
Webbed neck
Small mandible
Coarctation of aorta
Diabetes
Thyroid conditions
Lymphedema |
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| Turner syndrome key points |
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Definition
1) difficult intubation
2) HTN d/t coarctation of aorta (avoid sympathomimetics, ketamine)
3) endocrine involvement, renal, thyroid, diabetes
4) check for any other cardiac anomalies |
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| Klinefelter syndrome characteristics |
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Definition
1. mental disabilities
2. Scoliosis
3. Microcephally
4. Aggressive behavior
5. Congenital heart disease
6. Most frequently – infertility
7. Gynecomastia, which can develop into breast cancer |
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Difficult intubation
Characteristics:
Microcephaly
Micrognathia
Often have CHD
Hypotonia
Laryngomalacia |
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| The most important anesthetic consideration for trisomy 21 |
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| CHD associated with trisomy 21 |
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| VSD, PDA, tetralogy of fallot |
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| What about Volatile anesthetics for trisomy 21? |
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Definition
| You need less volatile anesthetic |
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| What about muscle relaxants for trisomy 21? |
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Definition
| decreased dose, they are sensitive to these drugs |
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Micrognathia, horseshoe cleft, downwardly displaced tongue
Aiwary challenge
never on backs |
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| Crouzon anesthetic considerations |
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Definition
Anesthesia considerations: 1. Difficult intubation
2. Upper airway obstruction
3. Increased ICP
4. Strabismus is associated with MH!
5. Cardiac conditions should be ruled out
6. Careful eye care! |
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| Osteogenesis imperfecta anesthetic implications |
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Definition
Transferring patient to/from OR bed and positioning obviously require EXTREME care!
BP cuff can/will break bones – change settings to inflate as low as possilbe if monitor allows
Teeth are very fragile!
Old and new fractures should be documented
Avoid succs….the associated fasciculations can cause fractures!
Body temperature often elevates with general anesthesia…which is NOT usually associated with MH |
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| Is osteogensis imperfecta associated with MH? |
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Definition
| No, they have a rise in temp with GA but it is not usually associated with MH |
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| Is freeman-sheldon syndrome associated with MH? |
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| Scleroderma anesthetic implications |
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Definition
Anesthetic implications:
Difficult intubation – tightening of skin around mouth, small mouth opening, stiff/rigid larynx and neck. Skin tears easily with rough intubations.
May have pulmonary functions testing to determine degree of pulmonary involvement
Renal and hepatic function may change some of your dosing/drug choices
Vitamin K malabsorption leads to a vitamin K dependent factor deficiency and a tendency to bleed
RSIV induction
Wean and extubate fully awake
If hypertension exists, remember the patient may by hypovolemic preoperatively. Be prepared (as you always should be) to treat both hyper and hypotension. |
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| Mitochondrial disorder considerations |
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Definition
-No IVFs with lactate
-IVF with glucose is good
-minimize NPO time
-Minimize stressors like pain hypo-hyperthermia |
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