Pediatrics slide 59-78

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  1. Most common metabolic problem in newborns?
  2. what is hypoglycemia?
    • Inadequate
    • glycogen stores and deficient gluconeogenesis are important factors.

    • Incidence
    • of symptomatic hypoglycemia is highest in SGA infants.

    Onset is 4 hours to 1 week after birth.
  3. what are the s/s of hypoglycemia?
    • nS/S
    • irritability, Apnea, cyanotic spells, seizures, hypotonia,
    • lethargy.

    • nSerum
    • glucose rarely < 25-45 mg/dl.  No
    • absolute established level.

    • nCNS
    • s/s seen at < 20 mg/dl in PI; < 30 in term infants (for first 72 hours).
  4. Anesthesia
    considerations:  hypoglycemia
    • nUse
    • glucose containing solutions to correct LBG

    • nD5
    • 0.2NS solution. 4ml/kg/hour.  Caution
    • with resultant hyperglycemia in stressed infants. 

    • nFluid
    • deficits and third space losses corrected with non glucose containing fluids.

    • nSerum
    • glucose in excess of 125 mg/dl can result in osmotic diuresis and dehydration.
  5. Hypocalcemia:
    • High risk for LBW infants, and premature infants, infants of insulin dependent
    • diabetic mothers, and asphyxia during delivery.

    • Late hypocalcemia usually due to ingestion of cow’s milk, maternal hypercalcemia,
    • and DiGeorge syndrome.
  6. Late hypocalcemia usually due to?
  7. ingestion of cow’s
    • milk, maternal hypercalcemia,
    • and DiGeorge
    • syndrome.
  8. most common cause of neonatal seizures
  9. s/s, dx and tx for hypocalcemia?
    • S/S
    • most common cause of neonatal seizures. 
    • Also causes irritability, éskeletal
    • muscle twitching, tremors, and hypotension.

    • nDx’d
    • by serum Ca
    • < 8mg/dL  in term infants and< 7mg/dL in
    • preterm neonates or serum ionized Ca of < 4.4

    • Treat
    • immediately with IV calcium (gluconate or chloride)

    • Most
    • commonly treated with100 mg/ml of ca gluconate with 9mg of elemental calcium.

    Must replete using cardiac monitor with atropine available.
  10. Pyloric
    • § Palpable “olive” in
    • RUQ

    §Hypertrophy of esophageal sphincter

    §1 in 500 births

    • § s/s – projectile vomiting, met. Alkalosis
    • progressing to met. acidosis, hypokalemia, hypovolemia, hypochloremia, hyponatremia

    § Pyloromyotomy
  11. Anesthesia Management of pyloric stenosis
    §Correct metabolic and fluid imbalance

    §NGT to suction prior to induction

    §Awake intubation and IV induction

    §Use normal saline with K+

    §Extubate fully awake
  12. Tracheal Esophageal Fistula
    which type is most common, describe it
    • §Type C – combination of upper esophagus
    • that ends in a blind pouch and a lower esophagus that connects to the trachea

    • §Type C is most common (90%) as breathing
    • causes gastric distention and feeding leads to choking and asp. Pneumonia

    §Often exists with congenital anomalies
  13. VATER syndrome
    • §VATER syndrome (vertebral defects, anal
    • atresia, tracheo-esophageal
    • fistula, radial dysplasia)
  14. Anesthetic Considerations for tracheal esophageal fistula
    • §Frequent suctioning for copious
    • secretions

    • §Patients are often dehydrated and
    • malnourished

    • §Avoid positive pressure ventilation and
    • require awake intubation

    positive pressure ventilation will increase gastric distension

    • §Keep spontaneously breathing with minimal
    • assist until fistula is ligated (100% O2)

    §Most important part of induction is placement of ET between fistula and carina, ETT higher than that the stomach is distended
  15. types of tracheal esophageal fistula?
    Image Upload 1
  16. Congenital Diaphragmatic Hernia:
    • §Gut can herniate into the thorax during
    • fetal development.

    • §Incidence of CDH is 1 in 5,000 live
    • births

    • §Left sided herniation is most common type
    • (90%)

    • §Hallmarks include hypoxia, a scaphoid
    • abdomen, evidence of bowel in the thorax

    • §Pulmonary hypoplasia and malrotation of
    • intestines are almost always present

    • §Often accompanied by PHTN; and is
    • associated with 40 – 50% mortality
  17. what is the most common congenital diaphragmatic hernia?
    §Left sided herniation is most common type(90%)
  18. what are the S/s of a congenital diaphragmatic hernia?
    §Hallmarks include hypoxia, a scaphoid abdomen, evidence of bowel in the thorax

    §Pulmonary hypoplasia and malrotation ofintestines are almost always present

    §Often accompanied by PH; and isassociated with 40 – 50% mortality
  19. Anesthetic Considerations of congenital diaphragmatic hernia
    • §NGT placed to alleviate gastric
    • distention/avoid high ventilation pressures

    • §Awake intubation often without muscle
    • relaxants

    • §Inspiratory pressures should be less than
    • 30 cm H2O

    • §Sudden fall in lung compliance, blood
    • pressure or oxygenation may signal a contralateral pneumothorax

    • §Caution with expansion of ipsilateral
    • lung following surgical decompression
  20. what usually causes problems for the patients with congenital diaphragmatic hernia?
    pulm hypoplasia is the reduction of alveoli and bronchioles in the pulm circuit

    cardio pulm compromise is due to pulm hypoplasia and hypotension rather than the mass effect of herniated viscera

    anesthesics maintained with volatiles and opioids use muscle relaxants as tolerated

    post op prognosis parallels the extent  of pulm hypoplagia and the presence of other congenital defects
  21. Downs syndrome
    • Trisomy
    • 21 Down Syndrome:

    • §Most common congenital pattern of human
    • malformation caused by additional chromosome 21

    • §Characteristics: Short neck, irregular
    • dentition, mental retardation, hypotonia
    • and large tongue, unstable atlanto-occipital joint

    • §Associated abnormalities: CDH (40% of
    • patients, Endocardial
    • cushion defects and VSD), subglottic stenosis, tracheal esophageal fistula,
    • chronic pulmonary infections, and seizures

    §Often premature and SGA
  22. downs syndrome anesthetic considerations
    Anesthetic Considerations:

    §Often difficult airways, especially during infancy

    §Typically use smaller ETTs

    §Respiratory complications (stridor and apnea) are common

    §Neck flexion may result in A/O dislocation

    §Caution with air in IV due to possibility of right to left shunts

    used to be prone to reps infections
  23. Pierre Robin Sequence
    • Occurs
    • in 1/8500 births

    • Autosomal
    • recessive

    • Mandibular
    • hypoplasia, micrognathia, cleft palate, retraction of
    • inferior dental arch, glossptosis

    • Severe
    • respiratory and feeding difficulties

    • Associated with OSA, otitis
    • media, hearing loss, speech defect, ocular anomalies, cardiac defects,
    • musculoskeletal (syndactyly, club feet), CNS delay, GU
    • defects)
  24. Treacher
    Collins Syndrome
    Mandibulofacial dysotosis

    Occurs in 1/10 000 births

    • Cheek
    • bone and jaw bone underdeveloped

    • External
    • ear anomalies, drooping lower eyelid, unilateral absent thumb

    • Respiratory
    • difficulties

    • Underdeveloped
    • jaw causes tongue to be positioned further back in throat (smaller airway)

    • Associated
    • with OSA, hearing loss, dry eyes

    • Anticipate
    • difficult intubation

    • Awake
    • extubation.
  25. Beckwith-Wiedemann
    • Occurs
    • in 1/13000-15000 births

    • 50%
    • born prematurly.

    • Autosomal
    • dominant

    Macroglossia, Exomphalos, Gigantism

    • Associated
    • with mental retardation, organomegaly, abdominal wall defect, pre- and
    • postnatal overgrowth, neonatal hypoglycemia, earlobe pits, Wilms tumor, omphalocele.

    • Manage
    • Polycythemia and hypoglycemia.
  26. Klippel-Feil syndrome
    • Feature
    • include:

    • nShort
    • neck

    • nRestricted
    • mobility of c-spine

    • nLow
    • hairline


    • Occurs
    • during early weeks of fetal development.

    • Fusion
    • of C2-C3 most common.

    • 3
    • Types:

    •   Type I- massive fusion of many cervical and
    • thoracic segments.

      Type II- Fusion at one or two interspaces.

    •   Type III- Includes both cervical and thoracic
    • or lumbar segments.


    • Awake
    • fiberoptic
    • intubation.

    • Unstable
    • upper cervical spine (A-C junction).

    • Limited
    • neck mobility.

    • Prone
    • to neurologic damage.

    • May
    • involve other anomalies: VSD, craniofacial anomalies, Limb deficiencies.
  27. Tetralogy
    of Fallot:
    • 1.Right
    • ventricular outflow obstruction


    • 3.Over-riding
    • Aorta

    • 4.Right
    • ventricular hypertrophy (25% have pulmonary stenosis)

    • Neonate
    • deteriorate when PDA starts to close. 
    • Prostaglandin may be used to keep PDA open.
  28. Anesthetic
    Management: tetrology of fallot
    • §Keep SVR up, maintain intravascular
    • volume, beta blockade to decrease HR

    • §R>L shunting may slow induction of
    • inhalation of agents

    • §Avoid acidosis, increases in PVR and
    • excessive airway pressures

    • §Consider Ketamine and narcotic
    • anesthetics
  29. tetrology of fallot-  what controls the flow patterns
    • 1 - pulmonary stenosis (a form of right
    • ventricular outflow tract obstruction)
    • 2 - right ventricular hypertrophy
    • 3 - overriding aorta
    • 4 - ventricular septal defect

    •   The degree of pulmonary stenosis controls the flow patterns.  The shaded blue arrows show blue blood mixing with red blood. The broken white arrows indicate diminished blood
    • flow through the pulmonary artery.
  30. what is the most severe form of tetrology?
    pulm atresia- no blood flow from the right ventricle to pulmonary artery and lungs

    prostaglandin needs to be given to keep the PDA open.  need to maintain some blood flow to the lungs
  31. Acute Epiglottitis
    §Characterized by Supra-Glottic Edema

    • §Causes difficulty swallowing progressing
    • to complete airway obstruction; may
    • proceed to airway emergency.  Intubate.

    • §Bacterial infection associated with fever
    • (Haemophilus
    • influenza) lasts 2 – 4 days; Tx-ampicillin

    • §Usually child 2 – 8 years, but now also
    • in adults due to H flu vaccine
  32. acute epiglottitis sx and tx
    • §Drooling, difficulty swallowing,
    • lethargy, tachypnea, cyanosis, acidosis, dehydration; best sitting forward

    • §Intubate in OR if possible or ER in
    • emergency

    §No paralysis, may need emergency trach

    • §Half to 2x smaller ETT tube with cuff
    • leak < 20 cm H2O

    • §Intubated for 48 – 62 hours, extubate
    • when leak demonstrated
  33. Croup (Laryngotracheobronchitis)
    • §Characterized by sub-glottic
    • edema developing slowly over time in children with URI

    §Rarely requires intubation

    • §Barking cough, stridor, rhinorrhea (less
    • obstruction than epiglottitis)

    • §Usually viral infection with low grade
    • fever in children 3 months to 3 years

    • §Treatment is racemic epi,
    • nebs, humidified air/O2

    §Watch for rebound edema
  34. Obstructive
    Sleep Apnea
    • Prolonged (or complete intermittent) upper
    • airway obstruction disrupting ventilation during sleep.
  35. Kids at risk for OSA
    • craniofacial
    • abnormalities

       neuromuscular disorders


    • adenotonsillar
    • hypertrophy
  36. Apnea index
    measurement of severity of OSA

    • mild 1-5
    • moderate 5-10
    • severe more than 10

    kids with cardiac disfunction or for pulmonale needing ICU and ventilation are at increased periop risk

    children that live long distances form adequate health care may not be amenable to ambulatory surgery
  37. Kids at risk for postoperative complications:
    (1) age younger than 3 years;

      (2) abnormal coagulation values;

      (3) evidence of OSA;

      (4) systemic disorders (metabolic diseases)

    •   (5) presence of craniofacial or other airway
    • abnormalities;

      (6) peritonsillar abscess

       (7) Social and logistical challenges
  38. anesthesia considerations for OSA
    • Anesthesia
    • considerations:

    Higher sensitivity to the respiratory depressant effects of narcotics.

    •   Upregulated Mu receptors due to minor
    • hypoxic events, and response to carbon dioxide.

    Narrowed upper airway

    Propensity to upper airway collapse.
  39. OSA preop and intra op considerations
    Preoperative assessment:

    History and exam. Consult for severe cases.

      Optimal preop condition.

      23 hour admit or ICU postoperatively.

    • Intro
    • management

      Non narcotic meds ( toradol, Acetaminophen PR)

    •   Short
    • acting narcotics

    •   Regional
    • or local anesthesia for post op pain.

    •   Dexamethasone
    • (0.0625 mg/kg - 0.15 mg/kg)

  40. Adenotonsillar hypertrophy

    History of URIs and ear infections.

    Use of medications: antihistamines, antibiotics.

    Physical examination : mouth breathing,  audible respirations, nasal speech, chest retractions, facial features.

    History of symptoms of OSA (snoring, irregular breathing patterns.)

    Speech difficulties and evidence of hearing impairment.

    History of swallowing difficulties.

    History of previous surgeries and hospitalizations resulting from URIs.
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Pediatrics slide 59-78
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