Lifespan Plastic Surgery In The Pediatric – Flashcards
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Chronic ear infections can require a mastoidectomy. Cholesteatoma can result and destroy the ear ossicles. Middle ear reconstruction can require revision or replacement of some/all of the ossicles. Avoid what in these patients?
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Avoid NMBS due to facial nerve monitoring (specifically NDMB). A branch of the facial nerve passes through the ear canal.
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*What is the main anesthetic consideration of tympanoplasty surgery?*
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N2O causes expansion of the TM by diffusing into the air-filled space in the middle/inner ear. *N2O can dislodge the graft so avoid N2O in this surgery.*
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A tympanoplasty may need to be done because?
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Grafting on a new TM after traumatic rupture, removal of retained PE tubes (usually fall out spontaneously within months/year after insertion), or middle ear reconstruction
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What frequently occurs following middle/inner ear surgeries?
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N/V so need effective antiemesis medication (Decadron/Zofran). Deep extubation/Lidocaine to avoid bucking/coughing on emergence.
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GA is generally required for eye surgery in children because they cannot tolerate sedation. But what 2 surgeries can be performed with mask anesthesia/LMA? What can be performed under GA with flexible LMA?
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1. Lacrimal duct probing and chalazion 2. Strabismus surgery and cataracts
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What is the most common eye surgery?
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Correction of strabismus
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What do you need to ensure in the surgery for strabismus?
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Anesthesia must be deep to ensure eyes are immobile/fixed centrally. When light, the eyes usually roll up (stage 2).
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What is OCR and what can you do when this occurs?
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- OCR: Bradycardia associated with traction applied to extraocular muscles or compression on the eyeball. Mediated by connections between the trigeminal/vagus nerve of the PNS. Reflex usually subsides when stimulus is stopped. - Consider prophylaxis with Glycopyrrolate IV - 1st intervention is to ask surgeon to stop. Communicate to give you a minute till it's controlled. - Can readily be blocked by giving Atropine (.01-.02 mg/kg IV) if already occuring
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In a rhinoplasty/septoplasty surgery, there is usually a throat pack. You should document?
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When it came in/out
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Closed reduction nasal fracture can be done with?
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Propofol and O2 NC or can be done with mask
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*Neonates are obligate nasal breathers, obstruction must be relieved by use of?*
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An oral airway... they don't know how to hold mouth to breath
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What is choanal atresia?
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Membranous or bony occlusion of the posterior nares between the nasal cavity/nasopharynx. If complete (90%), causes respiratory distress immediately after birth.
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*In choanal atresia, coexisting anomalies must be considered such as?*
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CHARGE SYNDROME: C: Coloboma (eye defect) H: Heart anomalies (TOF, ASD, VSD, PDA, CAVC [complete AV canal defect], DORV [double outlet RV--both the aorta and pulmonary artery arise from the RV]) A: Atresia of choanae R: Retarded growth G: Genital anomalies (hypogonadism) E: Ear anomalies
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What may be performed in these patients?
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- Transpalatal repair is performed 1-2 days in healthy, FT newborn. Stents are left in for 3-6 months. - Transnasal puncture may be performed in preterm infants/associated significant disease
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What is functional endoscopic sinus surgery (FESS)?
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A standard surgical tx for chronic sinus disease. Precise endoscopic resection of diseased tissue/relief of obstruction, while preserving normal mucosa to restore normal sinus function.
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What is used liberally for FESS?
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Liberal use of vasoconstrictors (because of a lot of vascularity) to shrink edematous mucosa can cause systemic effects (HTN, dysrhythmias)
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What are some FESS anesthetic considerations?
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- Bleeding may be considerable and may require nasal packing to remain in place postop - *Have pt fully awake before extubation* - Do not tape eyes. Rupture through bony wall of sinuses into the orbit can be readily detected (periorbital ecchymosis, tenseness, swelling)
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Pt with _____ make up a large portion of those having sinus surgery.
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CF.... so careful pulmonary monitoring and avoidance of respiratory depression
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Adenoids/tonsils are both lymphoid tissues that tend to shrink after puberty. Adenoidal hypertrophy can result which can obstruct the eustachian tube resulting in middle ear disease. Recurrent tonsillitis can result in extreme hypertrophy and tonsils can contact each other (kissing tonsils)==> airway obstruction. Tonsillectomy and adenoidectomy is often performed in an outpatient basis but some patients are not suitable for ambulatory surgery on the tonsils such as?
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- Younger than 3 - Hx of coagulopathy - Significant OSA - Other significant systemic disease (CHD, neuromuscular/endocrine, chromosomal abnormalities) - Craniofacial/airway abnormalities - Hx of peritonsillar abscess
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During tonsillectomy/adenoidecetomy, inhalational induction followed by insertion of oral rae ETT secured to middle of jaw. Retractor inserted by surgeon may kink ETT or endobronchial intubation. Blood loss for adenoidectomy is not as great for tonsillectomy. The patietion should be suctioned MIDLINE of mouth/pharynx prior to extubation (need to do because can aspirate that which is also irritating to stomach and causes N/V). What kind of extubation is common?
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Deep extubation.
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What are some specific pre-op considerations for tonsillectomy/adenoidectomy?
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Optimize asthmatics (use inhalers), delay elective case for fever or productive cough, r/o pre-op NSAID (can cause bleed), give anticholinergic to decrease pharyngeal secretions (and oppose PSNS), acute tonsillitis should not be treated electively
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What are some intra-op considerations for tonsillectomy/adenoidectomy?
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- Mask induction followed by IV access vs IV induction - Lubricate and tape eyes - R mainstem endobronchial intubation is more common in kids - Laryhgoscopy/tracheal intubation may be difficult for extreme infection or hypertrophy - Oral rae ETT low profile. Tape to lip/mandible. *- Document throat pack IN/OUT*
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How should you treat laryngospasms?
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1. Continuous PP 10-15 CM H2O 2. Atropine .01 mg/kg and ScH 1 mg/kg IV or Atropine .02 mg/kg and ScH 4 mg/kg IM
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Tonsil bleeds are?
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- Full stomachs (RSI with cricoid pressure, awake extubation, NGT) - Stomach may contain blood which can be regurgitated during induction - Hypovolemic (tx severe anemia, ensure sufficient fluids)
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What are some S&S of tonsil bleeds and *when do they usually occur?*
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- S&S: Frequent swallowing, N, vomiting blood, tachcyardia, hypotension - Usually seen 10 days to 2 weeks after original tonsillectomy when eschar falls
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During endoscopy, what kind of ventilation and induction is preferred?
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- Spontaneous ventilation because of ability to examine the anatomic structures of the airway. Airway compression/collapse may not be detected during controlled ventilation. The surgeon is an airway expert so can place tube back in. - Inhalation induction
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Oxygenation/inhalational agent can be provided through the side arm of the rigid bronchoscope allowing spontaneous ventilation or if needed, controlled ventilation. Apneic oxygenation (periods of hyperventilation 100% O2 interspersed with brief periods of broncoscopy/laryngoscopy) can maintain acceptable saturations. What else can be used?
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Jet ventilation.... Allow adequate time for exhalation (which is essential for V/Q, can cause excessive intrathoracic pressure with impedes venous return/CO)
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What are some anesthetic considerations with foreign body aspiration?
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- IV induction vs Mask induction followed by IV access - Maintain spontaneous veintilations to prevent distal migration by PPV - Glycopyrollate .01 mg/kgIV to dry secretions and prevent bradycardia from vagal stimulation with endoscopy - Post-op: Racemic Epi nebs, Dexamethasone .15 mg/kg IV to decrease subglottic edema
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Laryngeal papillomas can cause serious?
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Obstruction to ventilation
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Laryngeal papillomas are resected by laser to seed to wear?
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Need to wear special mask because can be aerosolized in the room
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*Avoid and have what with laryngeal papillomas??*
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*- Avoid N2O and FiO2 <30%* - Have water in basin/bottle at hand *- Reinforced laser ETT* - Usually done with a suspended laryngoscopy and jet ventilation with addition of a microscope and laser - IV anesthetic technique with Propofol/Remi infusions
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During an esophagoscpy, coughing, straining, or moving can result in esophageal perforation so you should?
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Anesthetize adequately
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Severe subglottic stenosis requires?
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Tracheotomy followed by a cricoid split (divide the cricoid cartilage/insert a cartilate graft to increase the diameter)
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During a tracheostomy, after incision of the trachea what happens to ETT?
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The ETT is withdrawn just enough to insert the tracheostomy tube. Complete removal of the ETT is not done until proper placement/confirmation of tracheostomy is verified by anesthesia provider. If tracheostomy tube cannot be placed, the ETT can be easily advanced to restore ventilation.
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During dental surgery, what are some anesthetic considerations?
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- Nasotracheal intubation preferred - Throat pack inserted - Maintain spontaneous ventilation - Some will do dental nerve blocks - If extractions done, extubate awake
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With mandible facial fractures, what % have brain injury?
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69%
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Lefort 3 fractures develop?
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Severe airway obstruction; 40% need trach
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Nasal intubation is contraindicated in?
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In most midface fractures r/t risk of neurologic injury in pt with basilar skull/cribiform plate fracture
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What are facial hemangiomas associated with?
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PHACES SYNDROME: Posterior fossa abnormalities (dandy-walker) Hemangiomas Arterial anomalies (coarctation) Congenital heart diseae (PDA, VSD) Eye abnormalities (cataracts) Sternal defects
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Pressured equalization tubes are inserted via what kind of anesthesia method?
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General mask anesthesia
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PE tubes are inserted through a myringotomy in the TM to treat?
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Chronic/recurrent middle ear infections (otitis media) when antibiotics are no longer effective.
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Is N2O helpful during insertion of PE tubes?
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N2O is helpful in inhalational induction because of second gas effect and it helps with surgery by pressurizing the ear drum which helps the ear drum pop out.
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*In mastoidectomy, avoid what medications?*
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Avoid NMBS due to facial nerve monitoring (can use ScH)
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Is N2O helpful during tympanoplasty?
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Avoid N2O in this surgery. N2O can dislodge the graft.
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The need for a tympanoplasty may be due to?
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Grafting on a new TM after traumatic rupture, removal of retained PE tubes, or middle ear reconstruction
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What frequntly occurs following middle/inner ear surgeries?
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N/V
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What kind of extubation is wanted after a tympanoplasty?
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Deep extubation/Lidocaine to avoid bucking/coughing on emergence
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What type of anesthesia is required for eye surgery (except for lacrimal duct probing and chalazion removal)?
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GA
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Strabismus surgery/cataracts with intraocular lens replacement can be performed under GA with flexible LMA. Anesthesia must be deep to ensure?
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To ensure eyes are immobile/fixed centrally; when light, the eyes usually roll up
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What is the 1st intervention for OCR bradycardia?
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- Ask surgeon to stop/stop stimulus - Can be readily blocked by giving Atropine .01-.02 mg/kg IV (or Glyco)
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After a rhinoplasty/septoplasty, placement of _____ before emergence can facilitate extubation since nose breathing is impossible due to nasal packing.
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an oral airway
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*After a rhinoplasty, what type of extubation is done?*
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FULLY AWAKE EXTUBATION
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What is an important documentation with rhinoplasty/septoplasty?
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Document in/out of throat back (because can cause obstruction)
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Closed reduction of nasal fracture can be done with what type of anesthesia management?
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Propofol and O2 NC
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If there is obstruction in choanal atresia neonates, obstruction must be relieved by use of?
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Oral airway
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Transpalatal repar in choanal atresia in FT healthy NB is performed when?
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1-2 after birth. Stents are left in for 3-6 months.
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When is a functional endoscopic sinus surgery performed?
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Tx for chronic sinus disease; resection of the diseased tissue/relief of obstruction while preserving normal mucosa to restore normal sinus function
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FESS liberally uses?
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Vasoconstrictors (a lot of vascularity) to shrink edematous mucosa. Can cause systemic effects (HTN, dysrythmias)
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During FESS, bleeding may be considerable and may require nasal packing to remain in place post op. What kind of extubation is wanted?
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Fully awake before extubation
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Why do you not want to tape eyes during FESS?
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Rupture through bony wall of sinuses into the orbit can be readily detected. The eyes will have periorbital ecchymosis, tenseness, and swelling.
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Patients with _____ make up a large portion of those having sinus surgery.
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CF
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What are some anesthetic considerations prior to a tonsillectomy?
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Delay effective cases for F or cough R/O pre-op NSAID use because of bleeding that can arise Give anti-chilinergic to decrease pharyngeal secretions Optimize asthmatics Acute tonsillitis should not be treated electively
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Where there is a tonsil bleed, what kind of extubation should occur?
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Awake extubation
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Patients with reoperation for bleeding of tonsillectomy/adenoidectomy are going to be in what condition?
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Severely anemic/hypovolemic, going to be a full stomach
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What kind of ventilation is preferred during an endoscopy?
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Inhalation induction with spontaneous ventilation (because able to examine the anatomic structures of the airway, airway compression/collapse may not be detected, surgeon is airway expert)... can be difficult to maintain optimal ventilation because this is a shared airway
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Endoscopy can be done for diagnosis or treatment of?
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Stridor or foreign body removal
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During an endoscopy, inhaled anesthetics can be administered via a ventilating bronchoscope but not during?
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Not during apneic oxygenation or jet ventilation (only spontaneous). Depth of inhalational anesthesia is unreliable. IV anesthetics (Propofol, Remi) are useful as adjucts to increase depth of anesthesia avoiding potential bronchospasm.
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What kind of ventilations would you want in a foreign body aspiration? What medication (non-anesthesia) would you considering giving?
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- Maintain spontaneous ventilations to prevent distal migration by PPV - Glyco .01 mg/kg to dry secretions and prevent bradycardia from vagal stimulation with endoscopy
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What post-op medications would you consider giving post-op?
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Racemic Epi nebs and Dexamethasone 0.15 mg/kg IV to decrease subglottic edema
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*What is the current treatment for laryngeal papillomas?*
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Laser... need to wear special mask because can aerosolize the room. Return for repeated laryngoscopy/resection when symptoms worsen.
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What is the sign and symptom for laryngeal papillomas in children 2-4 yrs old?
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Hoarseness and dyspnea
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*What do you avoid during papilloma resection?*
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Avoid N2O and FiO2 <30%
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During an esophagoscopy, you want to anesthetize adequately because?
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Coughing, straining, or moving can result in esophageal perforation during the procedure
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What are some S&S of esophagoscopy?
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Tachycardia, F, pneumothorax
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Severe sublottic stenosis requires?
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Tracheotomy followed by a cricoid split
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During tracheotomy... after incision of the trachea, the ETT is withdrawn just enough to insert the tracheostomy tube. Complete removal of the ETT is not done until?
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Until proper placement/confirmation of tracheostomy is verified by anesthesia provider
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If dental extractions are done, extubate?
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Extubate awake
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There is a strong association (69%) between mandible fracture and?
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Traumatic brain injury
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Le Fort 3 fractures develop severe airway obstruction. _____ need trach.
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40%
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Malocclusion fractures (e.g. mandible or Le Fort 1) require maxillomandibular fixation (wired jaw). This requires what kind of intubation?
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Nasal or retromolar intubation due to wired jaw
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Midface fractures or panfacial fractures requires what kind of intubation?
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Oral ETT, submandibular/submental ETT, tracheostomy. Nasal intubation is contraindicated for most midface fractures r/t risk of neuro injury in pt with basilar skull/cribiform plate fracture.
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What is a cystic hygroma?
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Congenital mass of head/neck; can be very large and extend into pleural cavity
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What is thyroglossal duct cyst?
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Most common midline mass in children; frequently involves hyoid bone
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What is the treatment for facial hemangiomas?
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Observation, steroid (may need stress dose), YAG laser (no N2O, low FIO2--fire risk)
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