Lifespan Plastic Surgery In The Pediatric – Flashcards
Unlock all answers in this set
Unlock answersquestion
Pressure equalization (PE) tubes are inserted under general mask anesthesia. PE tubes are inserted through a myringotomy in the TM to treat chronic/recurrent middle ear infections (otitis media) when abx are no longer effective. What can be helpful in this surgery?
answer
N2O is helpful in inhalational induction because of 2nd gas effect. Helps with surgery by pressuring the ear drum which helps the ear drum pop out.
question
PE tubes allows what to occur?
answer
Allows drainage of serous infected material when the normal eustachian tube drainage passage is obstructed. Eustachian tubes can be very narrow/blocked by enlarged adenoids in young children. Eustachian tube connects middle ear to nasopharynx. Adenoids are in the nasopharynx close to opening of eustachian tubes. So it may be performed with or without an adenoidectomy.
question
If you need a drainage tube and an adenoidectomy, you will be required to?
answer
Intubate
question
What is the anesthetic management and considerations for myringotomy?
answer
- Pt may have conductive hearing loss/URI - Oral Midazolam outlasts surgical procedure (only need for chronically sick) - Mask induction (Volatile and N2O) and maintenance of GA - N2O is helpful to surgeon - Usually no PIV required
question
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?
answer
Avoid NMBS due to facial nerve monitoring (specifically NDMB). A branch of the facial nerve passes through the ear canal.
question
*What is the main anesthetic consideration of tympanoplasty surgery?*
answer
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.*
question
A tympanoplasty may need to be done because?
answer
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
question
What frequently occurs following middle/inner ear surgeries?
answer
N/V so need effective antiemesis medication (Decadron/Zofran). Deep extubation/Lidocaine to avoid bucking/coughing on emergence.
question
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?
answer
1. Lacrimal duct probing and chalazion 2. Strabismus surgery and cataracts
question
What is the most common eye surgery?
answer
Correction of strabismus
question
What do you need to ensure in the surgery for strabismus?
answer
Anesthesia must be deep to ensure eyes are immobile/fixed centrally. When light, the eyes usually roll up (stage 2).
question
What is OCR and what can you do when this occurs?
answer
- 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
question
In a rhinoplasty/septoplasty surgery, there is usually a throat pack. You should document?
answer
When it came in/out
question
Closed reduction nasal fracture can be done with?
answer
Propofol and O2 NC or can be done with mask
question
*Neonates are obligate nasal breathers, obstruction must be relieved by use of?*
answer
An oral airway... they don't know how to hold mouth to breath
question
What is choanal atresia?
answer
Membranous or bony occlusion of the posterior nares between the nasal cavity/nasopharynx. If complete (90%), causes respiratory distress immediately after birth.
question
*In choanal atresia, coexisting anomalies must be considered such as?*
answer
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
question
What may be performed in these patients?
answer
- 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
question
What is functional endoscopic sinus surgery (FESS)?
answer
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.
question
What is used liberally for FESS?
answer
Liberal use of vasoconstrictors (because of a lot of vascularity) to shrink edematous mucosa can cause systemic effects (HTN, dysrhythmias)
question
What are some FESS anesthetic considerations?
answer
- 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)
question
Pt with _____ make up a large portion of those having sinus surgery.
answer
CF.... so careful pulmonary monitoring and avoidance of respiratory depression
question
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?
answer
- Younger than 3 - Hx of coagulopathy - Significant OSA - Other significant systemic disease (CHD, neuromuscular/endocrine, chromosomal abnormalities) - Craniofacial/airway abnormalities - Hx of peritonsillar abscess
question
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?
answer
Deep extubation.
question
What are some specific pre-op considerations for tonsillectomy/adenoidectomy?
answer
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
question
What are some intra-op considerations for tonsillectomy/adenoidectomy?
answer
- 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*
question
How should you treat laryngospasms?
answer
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
question
Tonsil bleeds are?
answer
- 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)
question
What are some S&S of tonsil bleeds and *when do they usually occur?*
answer
- S&S: Frequent swallowing, N, vomiting blood, tachcyardia, hypotension - Usually seen 10 days to 2 weeks after original tonsillectomy when eschar falls
question
During endoscopy, what kind of ventilation and induction is preferred?
answer
- 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
question
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?
answer
Jet ventilation.... Allow adequate time for exhalation (which is essential for V/Q, can cause excessive intrathoracic pressure with impedes venous return/CO)
question
What are some anesthetic considerations with foreign body aspiration?
answer
- 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
question
Laryngeal papillomas can cause serious?
answer
Obstruction to ventilation
question
Laryngeal papillomas are resected by laser to seed to wear?
answer
Need to wear special mask because can be aerosolized in the room
question
*Avoid and have what with laryngeal papillomas??*
answer
*- 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
question
During an esophagoscpy, coughing, straining, or moving can result in esophageal perforation so you should?
answer
Anesthetize adequately
question
Severe subglottic stenosis requires?
answer
Tracheotomy followed by a cricoid split (divide the cricoid cartilage/insert a cartilate graft to increase the diameter)
question
During a tracheostomy, after incision of the trachea what happens to ETT?
answer
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.
question
During dental surgery, what are some anesthetic considerations?
answer
- Nasotracheal intubation preferred - Throat pack inserted - Maintain spontaneous ventilation - Some will do dental nerve blocks - If extractions done, extubate awake
question
With mandible facial fractures, what % have brain injury?
answer
69%
question
Lefort 3 fractures develop?
answer
Severe airway obstruction; 40% need trach
question
Nasal intubation is contraindicated in?
answer
In most midface fractures r/t risk of neurologic injury in pt with basilar skull/cribiform plate fracture
question
What are facial hemangiomas associated with?
answer
PHACES SYNDROME: Posterior fossa abnormalities (dandy-walker) Hemangiomas Arterial anomalies (coarctation) Congenital heart diseae (PDA, VSD) Eye abnormalities (cataracts) Sternal defects
question
Pressured equalization tubes are inserted via what kind of anesthesia method?
answer
General mask anesthesia
question
PE tubes are inserted through a myringotomy in the TM to treat?
answer
Chronic/recurrent middle ear infections (otitis media) when antibiotics are no longer effective.
question
Is N2O helpful during insertion of PE tubes?
answer
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.
question
*In mastoidectomy, avoid what medications?*
answer
Avoid NMBS due to facial nerve monitoring (can use ScH)
question
Is N2O helpful during tympanoplasty?
answer
Avoid N2O in this surgery. N2O can dislodge the graft.
question
The need for a tympanoplasty may be due to?
answer
Grafting on a new TM after traumatic rupture, removal of retained PE tubes, or middle ear reconstruction
question
What frequntly occurs following middle/inner ear surgeries?
answer
N/V
question
What kind of extubation is wanted after a tympanoplasty?
answer
Deep extubation/Lidocaine to avoid bucking/coughing on emergence
question
What type of anesthesia is required for eye surgery (except for lacrimal duct probing and chalazion removal)?
answer
GA
question
Strabismus surgery/cataracts with intraocular lens replacement can be performed under GA with flexible LMA. Anesthesia must be deep to ensure?
answer
To ensure eyes are immobile/fixed centrally; when light, the eyes usually roll up
question
What is the 1st intervention for OCR bradycardia?
answer
- Ask surgeon to stop/stop stimulus - Can be readily blocked by giving Atropine .01-.02 mg/kg IV (or Glyco)
question
After a rhinoplasty/septoplasty, placement of _____ before emergence can facilitate extubation since nose breathing is impossible due to nasal packing.
answer
an oral airway
question
*After a rhinoplasty, what type of extubation is done?*
answer
FULLY AWAKE EXTUBATION
question
What is an important documentation with rhinoplasty/septoplasty?
answer
Document in/out of throat back (because can cause obstruction)
question
Closed reduction of nasal fracture can be done with what type of anesthesia management?
answer
Propofol and O2 NC
question
If there is obstruction in choanal atresia neonates, obstruction must be relieved by use of?
answer
Oral airway
question
Transpalatal repar in choanal atresia in FT healthy NB is performed when?
answer
1-2 after birth. Stents are left in for 3-6 months.
question
When is a functional endoscopic sinus surgery performed?
answer
Tx for chronic sinus disease; resection of the diseased tissue/relief of obstruction while preserving normal mucosa to restore normal sinus function
question
FESS liberally uses?
answer
Vasoconstrictors (a lot of vascularity) to shrink edematous mucosa. Can cause systemic effects (HTN, dysrythmias)
question
During FESS, bleeding may be considerable and may require nasal packing to remain in place post op. What kind of extubation is wanted?
answer
Fully awake before extubation
question
Why do you not want to tape eyes during FESS?
answer
Rupture through bony wall of sinuses into the orbit can be readily detected. The eyes will have periorbital ecchymosis, tenseness, and swelling.
question
Patients with _____ make up a large portion of those having sinus surgery.
answer
CF
question
What are some anesthetic considerations prior to a tonsillectomy?
answer
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
question
Where there is a tonsil bleed, what kind of extubation should occur?
answer
Awake extubation
question
Patients with reoperation for bleeding of tonsillectomy/adenoidectomy are going to be in what condition?
answer
Severely anemic/hypovolemic, going to be a full stomach
question
What kind of ventilation is preferred during an endoscopy?
answer
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
question
Endoscopy can be done for diagnosis or treatment of?
answer
Stridor or foreign body removal
question
During an endoscopy, inhaled anesthetics can be administered via a ventilating bronchoscope but not during?
answer
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.
question
What kind of ventilations would you want in a foreign body aspiration? What medication (non-anesthesia) would you considering giving?
answer
- Maintain spontaneous ventilations to prevent distal migration by PPV - Glyco .01 mg/kg to dry secretions and prevent bradycardia from vagal stimulation with endoscopy
question
What post-op medications would you consider giving post-op?
answer
Racemic Epi nebs and Dexamethasone 0.15 mg/kg IV to decrease subglottic edema
question
*What is the current treatment for laryngeal papillomas?*
answer
Laser... need to wear special mask because can aerosolize the room. Return for repeated laryngoscopy/resection when symptoms worsen.
question
What is the sign and symptom for laryngeal papillomas in children 2-4 yrs old?
answer
Hoarseness and dyspnea
question
*What do you avoid during papilloma resection?*
answer
Avoid N2O and FiO2 <30%
question
During an esophagoscopy, you want to anesthetize adequately because?
answer
Coughing, straining, or moving can result in esophageal perforation during the procedure
question
What are some S&S of esophagoscopy?
answer
Tachycardia, F, pneumothorax
question
Severe sublottic stenosis requires?
answer
Tracheotomy followed by a cricoid split
question
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?
answer
Until proper placement/confirmation of tracheostomy is verified by anesthesia provider
question
If dental extractions are done, extubate?
answer
Extubate awake
question
There is a strong association (69%) between mandible fracture and?
answer
Traumatic brain injury
question
Le Fort 3 fractures develop severe airway obstruction. _____ need trach.
answer
40%
question
Malocclusion fractures (e.g. mandible or Le Fort 1) require maxillomandibular fixation (wired jaw). This requires what kind of intubation?
answer
Nasal or retromolar intubation due to wired jaw
question
Midface fractures or panfacial fractures requires what kind of intubation?
answer
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.
question
What is a cystic hygroma?
answer
Congenital mass of head/neck; can be very large and extend into pleural cavity
question
What is thyroglossal duct cyst?
answer
Most common midline mass in children; frequently involves hyoid bone
question
What is the treatment for facial hemangiomas?
answer
Observation, steroid (may need stress dose), YAG laser (no N2O, low FIO2--fire risk)
