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80 Cards in this Set
- Front
- Back
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frequently performed ear surgeries are
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tympanoplasty
mastoidectomy stapedectomy myringotomy with insertion |
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most common pediatric surgical procedure
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ear tube placement (myringotomy with insertion)
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myringotomies are most common in
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young, healthy children - but are sometimes placed in older children, adults, or elderly
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PE tubes stands for
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pressure equalizing
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why are PE tubes placed
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chronic, serous otitis media and recurrent otitis media
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chronic serous otitis manifests as
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fluid in the middle ear
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recurrent otitis media is defined as
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more than 6 episodes of ear infections in a given year
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untreated otitis media can lead to
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permanent hearing loss
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delayed speech development in children or a speech impediment can be caused by
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chronic or recurrent otitis media leading to hearing loss
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children with otitis media will frequently have
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URIs as well
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should children with URI's have surgery that day?
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read article - but seems to be that unless infection is rampant, the risk for hearing loss will outweigh the URI risk and the placement of the tubes will help improve the child's health
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how long is a myringotomy with PE tube placement
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< 10 minutes
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can you use nitrous in myringotomies
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yes - because it takes several minutes to diffuse into the middle ear spaces - by which time the surgeon has placed the tubes which allows the pressure to equalize
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nitrous oxide is how many times more soluble than nitrogen
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34 times
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why might nitrous be a problem in myringotomies for middle ear infections?
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there is no outlet for the pressure build up because the eustachian tubes are blocked
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common anesthetic technique for PE tube placements
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mask the patient
use nitrous shut off gas during 2nd tube placement to facilitate emergence |
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other medications surgeons use in myringotomies
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place antibiotics and steroids in the ears with cotton
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pain management for myringotomies and PE tube placement
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nasal fentanyl (1-2 mcg/kg)
demerol IM (1mg/kg) rectal fentanyl tylenol suppositories (15 ml/kg) |
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if you use nitrous with tympanoplasty, remember to
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shut it off at least 15 minutes before the graft is completely in place
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tympanoplastys use tissue
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from behind the ear to fix the ear drum making the middle ear a closed space again
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why would the ear surgeon hate you if you used nitrous?
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the increasing pressure in the middle ear could tear the newly reconstructed tympanoplasty
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would the ear drum bulge in or out with nitrous use
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either - originally will push out, but as the nitrous dissipates it will sink in due to negative pressure in the middle ear
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how long can negative inner ear pressure last after a tympanoplasty
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up to 6 weeks
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side effects of graft bulging either positively or negatively can lead to
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serous otitis, disarticulation of the stapes, displacement of the graph, and impaired hearing
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most common side effect of middle ear surgery
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PONV
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problem with PONV after tympanoplasty
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can tear the graft
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anesthetic concerns for tympanoplasty
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do not use nitrous or shut it off early
medicate for prevention of PONV |
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prevention of blood loss in tympanoplasty since even a small drop can affect success of surgery
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injecting the ear with epinephrine solution
10 - 15 degree head up position deliberate hypotension with short acting drugs NO NITROUS |
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anesthetic challenges with T&As
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hypertrophic tonsils
infected tonsils - systemic infections obesity - OSA - Pickwickian syndrome - enlarged RV - CHF - V:Q mismatching |
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what about use of opiods and OSA
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people with OSA are very very sensitive to opiods
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anesthetic considerations for T&A
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mask induction vs IV induction
potentially difficult intubation equipment awake intubation? tracheostomy with local? watch the opiods and benzos |
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what type of induction is most common for children having a T&A
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mask induction
place your IV short acting NDMR reverse it at the end |
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intubation for a T&A is usually done with
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an oral RAE or a reinforced ETT
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cuffed ETT are recommended if
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children are >8 years of age
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how much air leak should you allow for non-cuffed ETT
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20 cm H2O
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why leak around ETT in children?
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reduce risk of post op croup and edema
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secure ETT for T&A surgeries where
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midline
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after the patient is intubated for a T&A, the surgeon
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rotates table 45 - 90 degrees
wraps the head places mouth GAG |
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what to remember with mouth GAG placement in T&A surgeries
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placement is VERY stimulating so make sure patient is deep for this placement
it will open the mouth very wide and retract the toungue |
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what to evaluate after GAG placement in T&A surgeries
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is the tube being compressed
is the tube placement intact |
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good anesthesia for T&A will encompass
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adequate anesthetic depth for stimulating procedure
rapid return of protective reflexes good post op analgesia reduced post op bleeding reduced post op nausea |
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what increases PONV
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dehydration
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most serious complication from T&A
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post op tonsilar bleed
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most common reason for readmittance after T&A
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persistant PONV
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PONV after a tonsillectomy is as high as what %
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70%
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problems associated with blood loss in T&A
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blood loss normally minimal but is very difficult to assess if it becomes excessive
no H&H or T&S normally done Blood in the stomach contributes to PONV |
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to prevent PONV after T&A surgery
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decompress stomach with soft catheter after surgery is done
suction oral and nasal pharynx gently may be a good idea to ask surgeon nicely to do these things so you don't accidently disturb their work incorporate antiemetics into the anesthetic plan |
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what is the tonsil position
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after surgery place patient in tonsil position - lateral with head slightly down
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when will surgeons admit patients after T&A
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if the patient has an obstructive pattern disease
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other drugs that might be used during T&A
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antisaligogs (glycopyrrolate)
steroid IV (decadron) |
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what steroid provides best edema coverage
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decadron
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one possible complication of decadron
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may increase bleeding occassionally
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incidence of bleeding tonsil
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0.3 - 0.6 %
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majority of tonsilar bleeds occur within
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first 6 hours (75%)
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second most risky time for tonsilar bleed is within
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24 hours
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a tonsilar bleed can occur up to
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6 days post op
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why 6 days post op
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this is when the scab falls off
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complications of tonsilar bleed
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Nausea and vomiting
unable to assess how much blood was lost |
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anesthetic management of post op tonsilar bleed
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fluid resuscitation (20 - 40 ml/kg)
H&H, T&S or T&C awake intubation or RSIV induction etomidate or ketamine if hemodynamically compromised place OG or NG to empty stomach immediately after induction slight head down position for induction to prevent blood aspirate from entering lungs |
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UPPP stands for
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uvulopharyngopaltoplasty
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UPPP are done for
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severe OSA
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presentation of patients for UPPP
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obesity, redundant pharyngeal tissue, heart involvement
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anesthesia considerations of induction for UPPP
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careful airway exam
awake fiberoptic inductions or tracheostomy RSIV are common short acting drugs preferred |
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most frequent post op complication from UPPP
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swelling and related complications
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drugs commonly used in UPPP
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intraop steroids to reduce swelling
antisaligogs |
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emergence from UPPP
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decompress stomach with soft catheter
gentle suctioning place airway (nasal preferably) protective reflexes, adequate breathing pattern, awake extubation xylocaine 1 - 1.5 mg/kg to reduce coughing and bucking complete reversal of NDMRs post op pain meds vs respiratory effectiveness and ventilation |
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length of stay for UPPP
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frequently admitted overnight for observation and continuous pulse ox
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success rate of UPPP
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50%
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cleft lip and palate deformities involve
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the soft palate, the hard palate, or both
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repair of cleft lip and palate deformities occurs
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in stages with the lip deformity fixed first, then hard palate, then soft palate after 6 months of age
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cleft lip and palate deformities repair are dependent on
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ability of child to feed
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children with cleft lip and palate deformities may also have
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congenital heart anomalies (atrial or ventricular defects)
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why is intubation of a patient with cleft lip and palate deformities difficult
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blade tends to slip into the defect
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how can intubation be improved in cleft lip and palate deformities
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pack the defect with gauze before using your blade
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what ETT is used for cleft lip and palate deformities
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oral RAE and tape it midline
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what else should you check carefully in kids with cleft lip and palate deformities
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air bubbles in the IV line - may have ASD or VSD where bubble could go directly to the brain
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type of anesthesia for cleft lip and palate deformities will be chosen based on
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presence or lack of congenital heart conditions
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what other drugs are determined if you can use in cleft lip and palate deformities repair by whether or not they have a congenital heart anomaly
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antisaligogs and local anesthetics
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additional things to remember for patients with cleft lip and palate deformities
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eye protection for the kids - at least tape and gauze
a suture is placed through the tongue to keep it out of the way gentle suction of copious secretions to prevent laryngospasms hand mittens and arm restraints |
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two things a cleft lip and palate repair may retain for a while after surgery
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the suture through the tongue to keep it from occluding the airway
logans bow |
