Transcript Pediatric Anesthesia A Brief Review of Major Topics

Pediatric Anesthesia
A Brief Review of Common Disorders
By: Christine Mazza, T4
Diseases with Difficult Airways
• Pierre Robin – micrognathia, glossoptosis, cleft palate
– Nasal airway, tongue suture, LMA
– Pre-op cardiac eval required
• Treacher-Collins – facial and pharyngeal hypoplasia, aplastic
zygomatic arches, micrognathia, choanal atresia
– Narrowing of airway above larynx, LMA useful
– Pre-op cardiac eval required
• Hurler’s – short thick neck, course facies, macroglossia, large tonsils
and adenoids
– Post-op subglottic edema common
– Cardiac eval pre-op
Diseases with Difficult Airways
• Goldenhar Syndrome – unilateral (usually) disruption in formation
of craniofacial structures and vertebral abnormalities
– Difficult airway
– Pre-op eval of heart and c-spine
• TE fistula – part of VATER syndrome
– Awake intubation preferred
– Insert tube deeply and pull back until fistula is occluded but both lungs
are ventilated
• CDH – dyspnea, cyanosis, scaphoid abdomen, BS in chest
– Use minimal pressure ventilation to avoid pneumothorax; if sudden
cyanosis, assume pneumothorax
Review in Pictures
Cardiac Abnormalities
•
Cyanotic Defects (R  L) – defect between arterial and venous circulation with
outflow obstruction on venous side
– Tetralogy of Fallot, truncus arteriosis, transposition of the great vessels
– Pre-op treatment of dz, endocarditis prophylaxis, remove air bubbles from IV tubing
– OXYGEN! Hydration, gentle ventilation
•
Acyanotic Defects (L  R) – single defect between arterial and venous circulation
so that blood flows from high to low pressure
– ASD, VSD, PDA, cushion defects
– Pre-op treatment of dz, endocarditis prophylaxis, remove air bubbles from IV tubing
– PPV, low FiO2 as tolerated
•
PPHN – persistence or return of fetal circulation after birth
– Basically same treatment as Cyanotic defects above
– Increase pulm blood flow, hyperventilate
Genetic/Hematological Diseases
•
Hemophilia A – most common inherited coagulation disorder
– Oral medications, general anesthesia
– Intubation acceptable, but be wary of hemorrhage
•
Sickle Cell
– Pre-op: HYDRATION, transfuse to increase Hct to 30
– Intra-op: HYDRATION, oxygenation, replace blood loss when necessary
•
Porphyria – demyelination, flaccid paralysis, weakness, autonomic dysfunction
– NO barbituates, steroids, etomidate, enflurane, ketamine
– Ok to use opiates, local, N2O, isoflurane, helothane, atropine
– Exaggerated response to muscle relaxants
•
Trisomy 21 – microcephaly, macroglossia, CHD, duodenal atresia, atlanto-axial
instability, congenital subglottic stenosis
– Difficult airway –consider ETT 1 size down
– Decreased MAC, exaggerated response to muscle relaxants
– Pre-op cardiac work up, c-spine films?
Resources
• Bell, C.; Kain, Z. The Pediatric Anesthesia Handbook Mosby-Year Book, Inc,
St. Louis: 1997.
• Infosino, Andrew. “Pediatric Upper Airways and Congenital Anomalies”.
Anesthesiology Clinicals of North America. 20 (2002): 747-766.
• Macksey, Lynn Fitzgerald. Pediatric Anesthetic and Emergency Drug Guide.
Jones and Bartlett Publishers, Ontario Canada: 2009.
• Stoelting, R; Dierdorf, S. Handbook for Anesthesia and Co-Existing Disease.
Churchill Livingstone Publishing, Philadelphia: 2002.
• http://www.theaba.org/Home/anesthesiology_initial_certification