Peds

Question 1

S/s of TEF in newborn?

Answer 1

• maternal polyhydramnios (baby can’t swallow amniotic fluid)
• copious oral secretions
• inability to pass OGT into stomach
• progressive gastric distention w/PPV

Question 2

Steps to take w/newborn who shows signs of having a TEF?

Answer 2

• stop PPV to avoid further gastric distention –> impaired ventilation –> dec venous return –> dec preload
• if baby seems unstable, call for surgeon to possibly perform emergent Gtube
• in the meantime, attempt to intubate past the fistula (ideally before carina though)
• place pt in head up position to minimize regurgation into lungs
• intermittent/continuous suctioning of upper esophageal pouch
• keep neonate NPO
• xray to confirm dx (coiling of OGT in blind pouch)

Question 3

What are a few things to think about when trying to ventilate newborn with TEF and Gtube already in place?

Answer 3

• vent the Gtube whenever you need! Don’t want too much gastric distention
• consider intubating past the fistula (hopefully before the carina if able)
• consider passing a Fogarty catheter retrograde through the gastroctomy to occlude the tracheal orifice of the fistula

Question 4

Types of TEF and which is most common?

Answer 4

• See pictures for all 5 types
• type C is most common - esophageal atresia w/blind upper pouch and lower segment tracheal fistula (80-90% of cases)

Question 5

Prematurity problems, specifically those that may complicate periop care? (11 total)

Answer 5

**I would try to think about these by going head to toe
- resp distress syndrome (dec compliance)
- persistent pulm HTN of the newborn (PPHN)
- apneic spells
- BPD (bronchopulm dysplasia)
- nec enterocolitis
- retinopathy of prematurity
- IVH
- dec renal fxn, impaired glu regulation, immature hepatic fxn, susceptibility to hypothermia

Question 6

Congenital abnormalities associated with TEF?

Answer 6

VACTERL
- vertebral defects
- anal atresia
- cardiac (coarc, ASD/VSD, TOF)
- tracheo-esophageal fistula
- renal (hydronephrosis)
- limbs

Question 7

How can a precordial stethoscope be utilized as a “monitor” intraop?

Answer 7

For example, during a TEF repair:
- 1 over the L axilla of baby to help monitor ventilation and HR while aiding in the detection of surgical obstruction of mainstem bronchus and intentional/accidental R mainstem intubation
- Another over stomach in order to detect ventilation through fistula

Question 8

When asked about what monitoring you’d use for a TEF case, what can you say about the pulse ox?

Answer 8

“I’d pay special attention to the pulse oximetry due to the importance of the correct positioning of the ETT”…think about this for various cases where you’d like to emphasize 1-2 of the monitors

Question 9

How do you place an art line in a neonate?

Answer 9

• umbilical artery, or
• one of the femoral arteries

Question 10

How would you induce and intubate neonate with TEF for repair if he already has a g-tube or if he didn’t?

Answer 10

If g tube present:
- ensure proper monitoring and access (always forget to say this!)
- place in head up position (minimize regurg of gastric secretions)
- suction proximal esophageal segment
- suction g-tube
- topically anesthetize airway to minimize symp stimulation associated with laryngoscopy (could lead to IVH in premie)
- give atropine (ablate bagal response to laryngoscopy)
- perform RSI
- advance ETT into R mainstem bronchus –> slowly w/d until able to hear ventilation in L axilla
- verify that I could provide adequate PPV thru ETT w/o causing excessive bubbling from submerged end of the G tube
- if not, could 1) reposition ETT or 2) pass Fogarty catheter retrograde thru G-tube to occlude fistula

If g-tube not present:
- need to do awake b/c too high risk for gastric distention with PPV (gastric rupture, HD instability, impaired ventilation)
- NEED to provide adequate analgesia d/t risk for IVH if big symp response
- if neonate stable enough, could provide minimal sedation too

Question 11

Several options for securing airway of neonate w/TEF and EA

Answer 11

• awake intubation
• inhalation induction w/o NMB: inc risk of aspiration
• inhalation induction w/NMB: easier intubation, dec risk of IVH, still some risk of aspiration vs RSI bc slower + use pf PPV
• IV induction: fastest and easiest intubation, though use of NMB = use of PPV so inc aspiration risk, and possibly higher risk of IVH d/t unclear plane of anesthesia d/t rapid nature

Question 12

Pros of cuffed vs uncuffed ETT

Answer 12

• Cuffed: dec risk of aspiration, dec need for repeated laryngoscopy to place appropriately sized ETT, dec subglottic pressure, more reliable delivery of high airway pressures, dec OR pollution
• Uncuffed: can use bigger overall ETT w/larger internal diameter –> less airway resistance, possibly dec risk of post-extubation croup? But data has actually shown that there’s no difference

Question 13

Definition of hypothermia? Normal limits for a neonate? Why are they prone to hypothermia?

Answer 13

< 35*C = hypothermia in adult
36.5-37.5 = normal for neonate

They’re prone to hypothermia d/t thin skin, large BSA: mass ratio, low subQ fat, inefficient mech of heat production (brown fat metabolism)

Question 14

Extubation criteria for (all?) neonates?

Answer 14

• CP status stable
• awake
• complete reversal of NMB
• couch/gag reflex was intact
• spontaneous TVs of 5-7cc/kg on CPAP
• PIP < 30
• O2 requirements < 40% w/PEEP 3-5

Question 15

Risk factors for retinopathy of prematurity (aka retrolental fibroplasia)?

Answer 15

• age < 44 wks post-conception!!! So shouldn’t use 100% FiO2 even in a full term neonate that is <1mo (minimal risk after vascularization of retina)
• excessive inspired [O2] - hyperoxia, or maybe even just fluctuations in O2 sat
• multiple blood transfusions
• parenteral nutrition
• hypoxia
• hypercapnia and hypocapnia
• congenital heart disease, IVH
• <1500g (low birth weight)
• lots of others

Question 16

Normal Hct of healthy full term neonate?

Answer 16

~55%, appears reasonable to maintain at least 35% during big surgery
- also remember that fetHb shifts curve to the L, and comprises 75% at birth. So less able to deliver o2 to tissues

Question 17

Barking cough w/insp stridor after surgery. Ddx? Tx for the main one?

Answer 17

• post-intubation croup, most likely. Tx: neb recemic epi and IV decadron
• develops 2/2 glottic or tracheal edema formation
• epiglottitis, laryngotracheobronchitis, laryngeal foreign body are other ddxs

Question 18

What are some options for management of postop pain in neonate s/p big surgery (like TEF)?

Answer 18

• lumbar/caudal epidural w/bupi and fent
• tylenol q4h, IV fent q1hr PRN

Question 19

Spina bifida occulta vs cystica?

Answer 19

Occulta: incomplete/abnormal midline structures but NO herniation of meninges/neural elements (5-35% of population, usually singular vertebrae, but can be multiple and have skin changes/hair tuft, tethered cord, neuro deficits, scoliosis)

Cystica: failed fusion of neural arch w/herniation of meninges (meningocele) or meninges + neural elements (myelomeningocele)

Question 20

Omphalocele vs gastroschesis mechanism? Other things to think about for each?

Answer 20

• O: gut fails to return to abd cavity during gestation. Membrane protects from infx and fluid losses. Nlly functioning bowel. Congenital associations like diaphragmatic hernia, trisomy 21, cardiac stuff, exstrophy of the bladder. Beckwith-Wiedemann
• G: occlusion of omphalomesenteric artery –> abd wall defect and subsequent herniation of abd contents. Inflammed and fxnally abnl bowel
• O: can protect exposed bowel by covering w/sterile, saline soaked dressings, then place lower half of infant in sterile, clean plastic bag filled w/warm saline

Question 21

Parts of Beckwith Wiedemann syndrome?

Answer 21

• macrosomia, macroglossia (diff intubation possible)
• omphalocele/umb hernia
• neonatal hypoglycemia
• polycythemia

Question 22

What is the Cobb angle?

Answer 22

• used to measure severity of scoliosis
• lines drawn on radiographs of spine
• > 10 = abnl, surgery rec for 40-50*, pulm dysfxn 60-65, pulm HTN past that

Question 23

Why can you get SOB w/kyphoscoliosis?

Answer 23

• chest wall deformity –> impaired pulm development + restrictive lung disease + inc WOB, V/Q mismatch –> hypoxia + hypoxic pulm constriction can –> pulm HTN and RV failure

Question 24

Why can you have SOB from DMD?

Answer 24

• abnl production of dystrophin can lead to:
  1) CM, vent dysrhythmias, MR
  2) dec pulm reserves, ineffective cough and retained pulm secretions, recurrent PNA
  3) chronic aspiration 2/2 impaired laryngeal reflexes
  4) nocturnal O2 desat and sleep apnea

Question 25

DMD and sux - what's the deal?

Answer 25

- no association between DMD and MH, however: - DO have risk of hyperK and muscle rigidity --> rhabdo, myoglobinuria, arrythmias, cardiac arrest

Question 26

What is considered an actual fever?

Answer 26

38.5 C = 101.3 F

Question 27

Reasonable strategy for completing elective surgery for child w/resp illness?

Answer 27

Sufficient time to dec airway reactivity would risk child getting another illness. So, 1) delay sx for 4-6 weeks if severe sxs (fever > 38.5, productive cough, mucopurulent secretions, malaise, pulm involvement like wheezing 2) for 2-4 weeks if mild sxs (sneezing, nasal congestion, dry cough) + need ETT + other risk fx (asthma, second hand smoke, etc) 3) proceed if mild sxs that don't meet above criteria

Question 28

Does an ETT or LMA carry inc risk for bronchospasm and desaturation events?

Answer 28

ETT! So if have a kid with pulm infx, favor using an LMA to dec periop resp complications

Question 29

Premed possibilities for strabismus surgery for an asthmatic?

Answer 29

- atropine/glyco to dec airway hyperresponsiveness and dec brady events (oculocardiac reflex) - versed - zofran, decadron, fluid bolus (highly emetic procedure) - toradol - bronchodilator

Question 30

Would you use sux in 7yo undergoing strabismus sx?

Answer 30

- no, could interfere w/forced duction test that occurs ~20mins after - also could have undx muscular dystrophy (should be hesitant with this in pts <8yo, especially males)

Question 31

A few orofacial abnormalities a/w/ adenotonsillar hyperplasia?

Answer 31

- high arching palate - retrognathic mandible - dental abnormalities

Question 32

Why is it good to know if airway obstruction was the indication for tonsillectomy?

Answer 32

Results of a sleep study is helpful in IDing any inc risk of rapid desaturation and difficult airway management

Question 32

If pt has vague hx of prolonged bleeding after whatever, what do you do?

Answer 32

- order coag profile (if nl PT w/high PTT: c/f vWD, Hemo A&B&C, lupus, or on low dose heparin) - ask about family hx, easy bleeding and bruising otherwise, prolonged bleeding after minor injuries

Question 33

Factor VIII replacement postop guidelines?

Answer 33

- yes, continued for up to 2 weeks - half life of factor VIII can be as short as 6 hrs in kids

Question 34

What happens when newborn has pulm HTN? (e.g. 2/2 congenital diaphragmatic hernia, for example)

Answer 34

- pulm HTN --> blood doesn't want to flow into the pulm circuit (usually this is the least resistant way after birth) and instead shunts from L --> R through PFO and PDA --> increasingly hypoxic, hypercarbic, acidotic --> these all further exacerbate pulm HTN --> vicious cycle

Question 35

A-a gradient scale for predicting survival of neonates w/congenital diaphragmatic hernia (CDH)?

Answer 35

> 500: poor prognosis (non-survival) 400-500: uncertain < 400: predicts survival

Question 36

Initial management/stabilization of baby born with CDH?

Answer 36

- delay surgery until pulm HTN is no longer causing shunting - avoid PPV d/t distention of intrathoracic viscera + aggressive suctioning - suppl O2 - intubate (RSI or awake, both ok) - OGT/NGT for decompression - vent settings to resolve hypoxia, hypercarbia, acidosis while avoided high airway pressures (pTX on opposite side) - sedation w/opioids and BDZs (dec cat release) - muscle relaxant to dec O2 consumption - correct hypothermia - ABG, CXR, TTE (cardiac defects, RH dysfxn, pulm HTN) - possibly give pulm vasodilators (PGE1, iNO), exogenous surfactant, jet ventilation - if everything else insufficient, consider ligation of PDA to dec shunting (though could lead to RHF) or ECMO

Question 37

How to get immediate IV access in neonate (emergency)

Answer 37

- umbilical or femoral veins - can attempt UE peripheral - to cannulate umbilical vein: sterilize and drape, caudal traction of stump (for vein) or cephalad (for artery). Insert soft catheter filled w/hep that is long enough to reach jxn of IVC and RA. CXR, then secure

Question 38

Complications of umbilical vein catheterization?

Answer 38

- infx, sepsis, hemorrhage, thrombosis of portal/mesenteric veins - portal cirrhosis, liver abscess - endocarditis, cardiac tamponade

Question 39

In what type of situation would you consider where you place an art line for peds? How about two pulse oximeters?

Answer 39

- R radial more accurately reflects oxygenation provided to the brain if still has PDA - Two pulse oximeters can ID an increase in intracardiac shunting across PDA during the case (if pt developed more pulm HTN, etc)

Question 40

If pulse ox on R hand and one of feet are significantly different in neonate, what two things to consider?

Answer 40

- coarctation of aorta - significant R --> L shunt through PDA (can happen if significant dec in systemic vasc R because then that becomes the easier path)

Question 41

Ways to dec PVR?

Answer 41

- inducing resp alkalosis w/hyperventilation (this is opposite of what CO2 normally does, which is dilate) - tx any metabolic acidosis w/bicarb - ensure normothermia and adequate anesthesia to minimize cat secretions

Question 42

Would you expand a neonate's hypoplastic lung (like in CDH) w/+ pressure?

Answer 42

- NO! - the pressures required to expand it is very risky for contralateral side of PTX, which would be disastrous

Question 43

What can postop ventilation do in terms of pulm HTN?

Answer 43

- dec O2 requirements - helps prevent and tx hypoxemia, hypercarbia, acidosis

Question 44

Explain normal fetal circulation (with the 3 conduits)

Answer 44

- ductus arteriosis - ductus venosus - foramen ovale - see this youtube video! "fetal circulation" lisa mccabe by openpediatrics

Question 45

Predisposing factors to PDA?

Answer 45

- prematurity (their ductus is comprised of poorly contractile muscular layer, which is less responsive to increasing O2 levels and other endogenous mediators). Usually, increased arterial oxygenation is one of the primary stimulants for the ductus to close - RDS - hypoxia - acidosis - excessive fluid therapy

Question 46

What is RDS?

Answer 46

- after delivery of premature infants - 2/2 insufficient surfactant production (which usually occurs if born <35wga) - causes widespread atelectasis --> intrapulm shunting --> hypoxemia and metabolic acidosis - tachypnea, tachycardia, nasal flaring, intercostal, subcostal retractions, b/l rales, cyanosis, CXR w/ ground glass infiltrates - survival greatly improved w/steroids given to mother and neonatal exogenous surfactant admin

Question 47

What is one non-sedative premed to consider for peds? Pros/cons

Answer 47

- Atropine - Pros: dec secretions, minimize vagal response to laryngoscopy/surgical manipulation, prevent brady 2/2 sux and/or volatiles - Cons: modern volatiles not associated with much bradycardia + timing w/induction often difficult, can usually just have it available PRN

Question 48

Potential complications in surgery for premature infant?

Answer 48

- hypothermia, hypoglycemia - retinopathy of prematurity - IVH - postop apnea

Question 49

Optimal PaO2 or O2 sat to avoid ROP in premie?

Answer 49

PaO2 of 50-80 SpO2 of 87-94%

Question 50

How to monitor blood loss and replacement in neonate?

Answer 50

- entire blood volume is ~100cc/kg (so can be about 100cc total), so important to be precise - weigh all laps, sponges, etc - replace 3:1 crystalloid, or colloid/pRBCs PRN - for sick premie with dec cardiac reserve, would prefer to maintain Hct > 40%. In other neonates, threshold much lower (20-25%)

Question 51

How do infants maintain heat?

Answer 51

- non-shivering thermogenesis - hypothermia-induced release of NE initiates metabolism of brown adipose tissue --> inc O2 consumption --> heat prod - inefficient process already, then even worse for premies and sick infants who are deficient in these brown fat stores. So super important for them!!

Question 52

Ddx for causes of seizures in neonate?

Answer 52

- hypoglycemia, hypoCa, hypoMg - benign seizures - mother with TORCH - sepsis - ICH (likely in premie!)

Question 53

Induction for foreign body aspiration?

Answer 53

- give reglan (recent eating) - give glyco (secretions and reflex brady) - monitors, emergency airway equipment - inhaled w/sevo (avoid PPV d/t distal migration. This puts at higher risk of aspiration though, so have to weigh risk/benefits of RSI vs inhalational) - ensure adequate depth of anesth (avoid coughing, laryngo/bronchospasm) - IV acess - ENTs to DL and insert bronchoscope - hook up circuit to bronchoscope

Question 54

Complications possible w/foreign body aspiration?

Answer 54

- chemical pneumonitis (certain nuts, veggies highly irritating to bronchial tree) but if removed w/in 24 hrs, complication rate very low. If left for longer though: - bronchial stenosis - bronchiectasis - PNA, lung abscess, tissue erosion/perforation - penumomediastinum/PTX

Question 55

Steps to take in neonatal resusc (meconium, APGAR 3):

Answer 55

- clear airway - warm, dry, stimulate - if HR still <100, start PPV - pulse ox on RUE (preductal - target increases from 60 to 90% after 10 mins of birth), consider EKG - If HR < 60 after 30s of PPV: intubate, chest compressions, get IV access through umbilical or IO - If HR < 60 after another 60s: epi, IVF if hypovol, eval for PTX/hypoglycemia (give glu)/MG toxicity (give Ca)/narcosis (don't give narcan, just support) from maternal IV pain meds

Question 56

Why might newborn's resp effort be weak s/p mom in PEA?

Answer 56

- low perfusion P during resuscitation - if mom had preE, also impaired uteroplacental perfusion --> neonatal depression - TTN (transient tachypnea of newborn) - hypoglycemia (if mom diabetic) - Mg - meconium - undx congenital anomaly (choanal atresia/stenosis, laryngeal/subglottic webs, pierre robin, Beckwith-Wied

Question 57

What are a few findings c/w/ child abuse?

Answer 57

- bruises/burns in the shapes of objects - bruises/fractures of different ages - signs of neglect (poor hygiene/height/weight <5%ile) - retinal hemorrhages - delay in seeking medical care - handicapped kids more likely - should write detailed note of findings and report to appropriate authorities

Question 58

Which conditions can produce cyanosis in first year of life?

Answer 58

Any that results in R to L cardiac shunting (5): 1- TOF 2- transposition of great vessels 3- truncus arteriosus 4- tricuspid atresia 5- total anomalous pulmonary venous return

Question 59

What is osteogenesis imperfecta? Presentation?

Answer 59

- conn tissue disorder (abnl synth of type I collagen affects bones, ligaments, dentition, sclera) - sxs: blue sclera, fxs from minimal trauma, kyphoscoliosis, bowing of femurs/tibias, hearing loss, coagulopathy (pltl dysfxn), CV issues, craniocervical instbility, macroglossia - should think about all of the anesthetic considerations for OI (mostly fx associated issues): BP cuff cycling, vert art injury if doing neuroaxial technique bc bones so soft, avoid cricoid pressure, don't use sux (fasciculation induced fxs, wheelchair bound hyperK), don't do IO if at all possible (central line instead)

Question 60

How would you eval and resuscitate infant w/pyloric stenosis?

Answer 60

- H&P: vol/freq of vomiting, UOP, diarrhea, weight change, last feeding time, mental status - CBC, lytes, ABG - skin turgor, sunken fontanelles, mucous membranes, BP, pulse - give NS (avoid LR since lactate converts to bicarb) until UOP is established, then supplement w/K. If hypoglycemic, consider glu containing IVF

Question 61

What to do prior to performing awake intubation for baby?

Answer 61

- depends on situation, but likely give atropine d/t pain and discomfort associated w/it --> induce bradycardia (neonates have an inc in parasymp tone) + mild sedation, then could empty stomach w/NGT

Question 62

Why would a neonate who had pyloric stenosis myotomy be at inc risk for postop apnea?

Answer 62

- postconceptional age of <50wks (need to monitor for 12-24 hrs) - resideual effects of GA - preop alkalosis could inc risk for apnea - any narcotic admin

Question 63

RIsk factors for postextubation croup?

Answer 63

- oversized ETT - repeated/traumatic intubation attempts - UTI - previous hx of croup - head and neck procedures - intraop changes in head positions - surgery duration >1 hr - pt age 1-4yo

Question 64

How do you resuscitate neonate irt FiO2 administration?

Answer 64

- there's a target range for preductal O2 sat after birth from 1-10min (60% --> 95%) - preductal means that you place the pulse ox on RUE! Provides better assessment of CNS oxygenation - if 35w and older, start with 21% FiO2. If <35w, start w/21-30%, titrate upward from there until attain target SpO2

Question 65

What's your threshold before intubating neonate during resus?

Answer 65

- if bag/masking was ineffective - chest compressions required - prolonged mech ventilation anticipated - ETT drug admin needed - other special pt factors