Pediatrics

Question 1

Epiglottis

Organism

Answer 1

Bacterial:

• H. Influenza
• Group A strep
• Pneumococci
• Staphylococci

Question 2

Epiglottis

Age

Answer 2

2-6 yr

Question 3

Epiglottis

Onset

Answer 3

Rapid (<24hrs)

Question 4

Epiglottis

Region affected

Answer 4

Supraglottic structures

Question 5

Epiglottis

Lateral neck Xray

Answer 5

Swollen epiglottis (thumb sign)

Question 6

Epiglottis

Clinical presentation

Answer 6

High fever
Tripod position
4Ds - drooling, dysphonia, dyspnea, dysphagia

Question 7

Epiglottis

Treatment

Answer 7

• O2
• Urgent airway mangement - intubation/trach
• ABX (if bacterial)
• Induction with spontaneous ventilation (CPAP 10-15cm H2O minimizes airway collapse)
• ENT surgeon must be present
• Post-op ICU care

Question 8

Laryngotracheobronchitis (croup)

Organism

Answer 8

Viral

• H. parainfluenza
• RSV
• Influenza A & B

Question 9

Laryngotracheobronchitis (croup)

Age

Answer 9

< 2 yr

Question 10

Laryngotracheobronchitis (croup)

Onset

Answer 10

Gradual (24 - 72 hrs)

Question 11

Laryngotracheobronchitis (croup)

Region affected

Answer 11

Laryngeal structures

Question 12

Laryngotracheobronchitis (croup)

Lateral neck XRAY

Answer 12

Subglottic narrowing (steeple sign)

Question 13

Laryngotracheobronchitis (croup)

Clinical presentation

Answer 13

Mild fever
Inspiratory stridor
Barking cough

Question 14

Laryngotracheobronchitis (croup)

Treatment

Answer 14

O2
Racemic epi
Corticosteroids
Humidification
Fluids
Intubation rarely required

Question 15

Pathophysiology of postintubation laryngeal edema

Answer 15

AKA post intubation croup - complication of endotracheal intubation or rigid bronch

Tracheal mucosa perfusion pressure is 25cm H2O. Using an ETT that is too large or injecting an excessive amount of air into the cuff reduces tracheal perfusion -> edema -> decreases subglottic airway diameter -> increase WOB

Question 16

Presentation of postintubation laryngeal edema

Answer 16

Pt presents with hoarseness, barky cough, and/or stridor

Typically occurs 30-60 min following extubation

Question 17

What are the risk factors for postintubation laryngeal edema?

Answer 17

Risk factors (all rom small airway or airway trauma)

• Age <4
• ETT is too large
• ETT cuff volume too high
• Traumatic or multiple intubation attempts
• Prolonged intubation
• Coughing while intubated
• Head or neck surgery
• Head repositioning during surgery
• Hx of infection or post intubation croup
• Trisomy 21
• URI?

Question 18

Best way to minimize postintubation laryngeal edema

Answer 18

Best treatment is prevention!

Key point is to maintain an air leak < 25 cm H2O. If using cuffed ETT, use manometer intermittently to measure cuff pressure

Question 19

Treatment or postintubation laryngeal edema

Answer 19

Treatment aims at reducing swelling and improving laminar airflow:

• Cool and humidified oxygen
• Nebulized racemic epi 0.5 ml or 2.25% solution in 2.5 ml NACL
• Decadron 0.25-0.5 mg/kg IV (effect in 4-6 hrs)
• Heliox is a helium + oxygen mixture and improves laminar airflow by reducing Reynolds number

NOT infectious so no ABX

Observe pt for 4-6 hours after racemic epi

Question 20

A patient with a respiratory infection presents for a tonsillectomy. Which S/S favor postponing the procedure?

Answer 20

Proceed with caution:

• Runny nose without other symptoms
• Clear nasal drainage
• No Fever
• Active
• Appears happy
• Clear lungs
• Older child

Reasons to CANCEL:

• Purulent nasal drainage
• Fever (>38 or 100.4)
• Lethargic
• Persistent cough
• Poor appetite
• Wheezing & rales that do not clear with cough
• Child <1 or previous premie

Question 21

Hoe can you reduce the risk of airway complications while anesthetizing a child with an upper respiratory infection?

Answer 21

• Avoid mechanical irritation of airway: Facemask > LMA»_space;> ETT
• Mechanical irritation (ETT) increases risk of bronchospasm 10-fold!
• If ETT must be used, use smaller size than normal, at higher risk for post intubation croup
• Dexamethasone 0.25-0.5 mg/kg will reduce risk of post-intubation croup
• Ensure deep plane of anesthesia before instrumenting airway
• Propofol attenuates airway reactivity and may reduce risk of bronchospasm
• Sevo best = non-pungent
• Pretreatment with inhaled bronchodilator or glycolic doe snot provide a clear benefit

Question 22

Describe presentation of child who presents with foreign body aspiration

Answer 22

Classic triad of cough, wheezing, a decreased breath sounds on affected side (usually right)

Airway obstruction significant enough to impair gas exchange can quickly progress to hypoxemia, cyanosis, lathered mental status, cardiac arrest and death

Supraglottic = Stridor (S/S)
Infraglottic = Wheezing

Question 23

What are the complications of rigid bronchoscopy?

Answer 23

Rigid branch is GOLD STANDARD for retrieval of foreign body

Complications:

• Laryngospams
• Bradycardia during scope insertion
• Post-intubation croup
• Pneumothorax

Question 24

Syndrome associates with difficult airway management

Large Tongue

Answer 24

“Big Tongue”

Beckwith syndrome
Trisomy 21

Question 25

Syndrome associates with difficult airway management Small/Underdeveloped mandible

Answer 25

“Please Get That Chin” Pierre Robin Goldenhar Treacher Collins Cri du Chat

Question 26

Syndrome associates with difficult airway management Cervical spine anomaly

Answer 26

"Kids TRY Gold” Klippel-Feil Trisomy 21 Goldenhar

Question 27

Describe the airway in a patient with trisomy 21

Answer 27

At risk for difficult intubation & ventilation - Small mouth - Large tongue - Palate narrow with high arch - Midface hypoplasia - Atlantoaxial instability (C1 & C2 subluxation - avoid neck flexion) - Subglottic stenosis (use smaller ETT) - Obstructive sleep apnea - Chronic pulmonary infection

Question 28

What is CHARGE association?

Answer 28

``` C - Coloboma (hole in eye structure) H - Heart defects A - choanal Atresia R - Retardation of growth & development G - Genitourinary problems E - Ear anomalies ```

Question 29

What is CATCH - 22

Answer 29

AKA DiGeorge syndrome or 22q11.2 gene deletion syndrome C - Cardiac defects A - Abnormal face T - Thymic hypoplasia C - Cleft palate H - Hypocalcemia (d/y hypoparathyroidism) 22 - 22q11.2 gene deletion (cause of syndrome)

Question 30

What are the unique anesthetic considerations for the patient with DiGeorge syndrome?

Answer 30

Hypokalemia is common (remember hyperventilation, albumin, and citrated blood products lower free Ca +2 in the blood) If the thymus is absent, the child is at high risk for infection. Treatment consists of thymus transplant or mature T cell infusion. Transfusion of leukocyte-depleated irradiated blood is best.