UCI Anesthesiology 4U Didactic Session 9.23.20 Outline: 1. Review of Systems 2. Anesthetic Management Essentials 3. Pre-Term (PT) Neonatal Emergencies 4. Full-Term (FT) Neonatal Emergencies 5. Pediatric Issues Intended Audience: - CA-2 and CA-3 level resident trainees for specialty rotations - Pediatric Anesthesiology Fellows - All trainee levels in preparation for the Advanced Exam.

1. 4U Didactics
September 23, 2020
Aalap Shah, MD
Assistant Clinical Professor of Anesthesiology
University of California, Irvine
aalaps@hs.uci.edu
Anesthesia for the Young
Anesthesiology & Perioperative Care

2. Resources
- Miller’s Anesthesia
- Chapters 82, 83, 84
- A Practice of Anesthesia for Infants & Children –
Charles Cote
- UPMC Presentation – Dr. James Cain
- Stanford (pedsanesthesia.Stanford.edu)
- Essentials of Pediatric Anesthesia – Alan David
Kearne
- Big Blue – Dr. Neils Jensen
- The World Wide Web
- OpenAnesthesia Keywords

3. Open Anesthesia Keywords
Airway: Pediatric vs Adult Infant preop fasting: Breast milk Peds circuit, work of breathing
Beta-thalassemia: Newborn Intubation in Pierre Robin syndrome Peds sleep apnea risk factors
Caudal anesthesia Meningomyelocele: Arnold-Chiari assoc Persistent fetal circulation: Causes
Caudal anesthesia - Infant dose Midazolam: Peds oral dosage Pharmacodynamics of vecuronium in infants
CDH: Ventilation strategy Myelomeningocele - Assoc anomalies PONV - Prevention in children
Chronic pain: Methadone vs morphine Neonatal apnea hypoxemia physiol PONV after pediatric surgery
Congenital emphysema: Mgmt Neonatal bradycardia: treatment Post-tonsillectomy complications
Dantrolene mechanism Neonatal hypoxia: physiology Postoperative apnea: post conceptual age
Delayed emergence: differential diagnosis Neonatal nasal CPAP: mechanism Preoperative anxiolysis in children
Epiglottitis Neonatal vs. adult cardiac physiology Prostaglandin for congenital heart: Dx
Epiglottitis: Airway management Neonate: duration of post-anesthesia monitoring Pyloric stenosis - Electrolytes
Epiglottitis: anesthetic management Newborns: Dehydration assessment Pyloric stenosis: Fluid therapy
Epiglottitis: diagnosis O2 desaturation causes: Neonate Pyloric stenosis: metabolic abnormality
Epiglottitis: inhalation induction Parental presence: Indications Respiratory distress syndrome: effects (peds)
Ex-premature: Pulmonary Cx Parental presence: Induction Sevo uptake: Infant vs. adult
Fetal Hb: Oxygen transport Patent ductus arteriosis: Diagnosis Spinal anesthesia: Premie indications
Fluid replacement in peds Pediatric airway management Spinal block: Infant vs. adult
Gastroschisis & Abd closure - pulm Pediatric circuit: Dead space TE fistula: ETT positioning
Gastroschisis: Abd closure pulm eff Pediatric postop reg analg TEF: Other abnormalitiesx
Hypothermia: Infant vs. toddler Pediatric warming techniques Tracheoesophageal fistula - Assoc anom
Hypovolemia signs: Pediatrics Pediatric: Preoperative anxiety Work of breathing: Neonate vs. adult
Ilioinguinal block - Complications Peds - Foreign body aspiration

4. Age Definitions
 Neonates: 0-30 days old
 Infants: 1 month to 1 year
 Children: older than 1 year
 Post-Conceptual Age (PCA):
• Actual age – Pre-maturity (# weeks)
• Used up until age 2 yo

5. Learning Objectives
I. Review of Systems
II. Anesthetic Management Essentials
III. Pre-Term (PT) Neonatal Emergencies
IV. Full-Term (FT) Neonatal Emergencies
V. Pediatric Issues

6. Review Of Systems

7. Neuro
  Skull rigidity (fontanelles)
  Cortical neurons (2 x 10^9)
• Originate at 22 weeks, maximum at 29 weeks
• Thalamacortical connections (until 5 yrs of life)
• Sleep-wake at 32 weeks
• PNS mature at 37 weeks
  Myelination
 Reaches adult size at 40 kg / 11-12y
  BBB integrity

8. Neuro
Spinal Cord & Dura

9. Neuro
Neonatal Reflexes

10.   Pain threshold
•  Nerve endings / cm2 of skin
•  Dorsal horn receptor fields, decrease at 42 weeks
•  Dorsal horn receptor NMDA concentration
• Immature inhibitory pathways
 GABA depolarizes based on intracellular Cl-
  Hypersensitive until 2-6 months
•  Increased stress response to pain (cortisol, glucagon,
GH, aldosterone, O2 consumption/SpO2/PaO2
•  Autoregulation
•  Sensitivity to respiratory depressant effect of opioids
Neuro

11. Neuro
MAC
 (0 months  9-12 months)  1.5x adult
 (prematurity, 12 months +), ~linear
 Exception: sevoflurane
 NMJ maturity /  sensitivity
 Shorter onset time offset by  Vd
o #1 utilizer of glucose

12. Respiratory
Anatomical - Upper Airway
  Head
•  Occiput
•  Face and lower jaw
  Neck length
•  Trachea length (~5 cm in newborns)
•  Cords-to-carina length (2 cm)
• Short trachea directed downwards and posteriorly
• Right main bronchus less angled than left

13. Respiratory
Anatomical - Upper Airway
 Nostrils / nasal passages
 Tongue size, length
 Adenoids
 Loose teeth or awkward dentition
 Floppy OR stiff horseshoe (U)-shaped epiglottis

14. Respiratory
 Larynx
 Anterior & Cephalad
 C3 preemie, C3-4 neonate, C5-6 in adult
 Narrowest
 Cricoid (neonate – age 10)
 Edema
 La Poiseuille’s law
 Vocal cords (puberty)
 Larynx has a gradually
tapering shape

15. Respiratory
Anatomical - Lower Airway
 Alveoli increased starting 32 weeks GA, increased over 18
months, continues for 10 years
•  Chest wall compliance
 Stiffens ( compliance) thereafter
  Lung compliance,  Compliance thereafter
 Soft chest wall
 Horizontal ribs
 Circular chest
  Diaphragm endurance
  Type 1 muscle fibers

16. Respiratory
Physiological Differences
 Obligate nose breathers until 3-5 months
 Abdominal > thoracic breathing
• NO CHANGE (per / kg)
 TLC (90 ml/kg) Dead space (2 ml/kg)
 Vt (7-9 ml/kg) VC (90 ml/kg)
 FRC
•  RR
• Controlled expiration (laryngeal braking)
• Tonic activity of ventilatory muscles
• PEEP helps during controlled ventilation

17. Respiratory
  INCREASE
 FA/FI due to
  RR   MV
  Tissue/blood partition coefficients
  CO (opposite of adults due to VRG)
 Closing volumes
  DECREASE
 Blood: gas coefficient
  Solubility
 FRC buffering capacity
  Time to desaturation
 Hypoxic respiratory drive
 Hypercapnic respiratory drive
Physiological Differences

18. Cardiovascular
  Muscle fiber
  Myocyte glycogen
 No change CO
•  Contractile elements    SV
•  HR (dependent)
•  Vagal tone / Avoid bradycardia
 Vagal stimulation with laryngoscopy
 Hypoxemia
•  Sympathetic tone
•  Baroreceptor tone and response

19.   BP, MAP
  RR
  Incidence of hypoxemia-induced dysrhythmias
(bradycardia)
 Vessel-rich group as a % of CO
  PR, QRS intervals during infancy
 T-wave inverted in V1-V4 until adolescence
Cardiovascular

20. Hematologic
 Hct: Preterm > Neonate > Infant
• HbF breakdown,  erythropoisis,  plasma volume
• Erythropoesis shifts from liver to BM at 24wk GA
• HbF: Leftward shift on oxyhemoglobin dissociation curve
 P50 (19 mmHg vs 26 mmHg)
 Granulopoiesis occurs in BM
•  Platelets over the few days but then return  to normal levels
after the 1st week of life

21. Temperature Regulation
  Body surface area : volume
•  radiant heat loss)
 Thin skin
•  Subcutaneous body fat
•  Shivering thresholds (i.e. occurs at lower temperatures)
in children
 Neonates do NOT shiver
•  norepinephrine  brown adipose tissue
metabolism
• Found scapulae, mediastinum, kidneys, adrenal
glands
 Thermoregulatory center not well developed

22. Hepatic / Metabolism
  Homeostatic metabolism
•  O2 consumption (7-8 ml/kg/min FT vs
3-4 ml/kg/min Adult ; ~ 2x of adults)
•  Glucose consumption (6-7 mg/kg/min PT vs
4-5 FT vs 3 mg/kg/min Adult)
  Drug metabolism until 3 months
•  Hepatic size/blood flow : body weight ( with age)
•  CyP450 (adult at 1 mo) (Enzyme systems not induced)
•  Oncotic proteins (e.g. albumin)  Protein binding

23. Hepatic / Metabolism
  bilirubin load
  Hepatic cell uptake & conjugation
 reaches adult levels at 6 months.
  Pseudocholinesterase activity until 6 months
  Phase II block after succinylcholine
  Hepatic glycogen (FT 30 mg/dl vs infant 40 mg/dl)
•  Gluconeogenesis (primary in muscles)
•  Glycogenesis / g liver mass
  Blood glucose d/rt use
•  With maternal DM (insulin Ab)
• Utilizer: Brain > Heart, ~ adult use at 40kg
  Fetal calcium stores (until 3mo)

24. Renal
  Volume of distribution (water-soluble drugs)
  Diluting ability
  Creatinine clearance
  GFR (67% reduction)
• Reaches adult values by 1-2 years of age
• Tubular function by 7th month
• More decreased by hypoxia, hypothermia, and CHF

25.   Urine concentrating ability (6 months)
•  Glucose excretion
•  FeNa
 Responsible for 10% loss of body weight over first 7-19 days
• Followed by  Sodium excretion
  H+ excretion
•  Morphine metabolite excretion
•  HCO3- resorption threshold
  TBW (70-75%) , ECF
•  TBW with age
• 1 mo: 75%, 1 yr: 70%, 10 yrs: 65%
Renal

26. Anesthetic Management

27. GI
  pH on DOL 1  normal on DOL 2+
 Delayed gastric emptying
 Delayed absorption
  GERD
• Coordination of swallowing with respiration occurs at 4-5 months

28. Face Masks & Circuits

29. Mapleson Circuits
Adult, SV
Adult + Pediatric, CV
Pediatric, SV
FGF
 Spont: 2 -3x /
minute ventilation
 PPV: 220 ml/kg
(up to 20 kg)

30. Pre-Operative
Assessment

31. Pediatric Pain Assessment
2 mo – 7 yo
3 yo +
8 yo +
FLACC
Wong-Baker
Scale
NRS

32. NPO Time
- Bottled milk, formula,
feeds = SOLIDS
- Clear liquids 2 hours
before surgery:
- NO CHANGE in
Gastric volume
& PH

33. Estimating Weight /Height
 Weight
 Always have all medications calculated out
for patients < 20 kg
 Estimating weight
 2 x (age + 4)
 (2 x age) + 8 or 9
Breslow Tape (ED)

34. Monitors
Anchor to arm to prevent hyperextension
Pre-ductal vs . Post-ductal considerations

35. Monitors
Pediatric
Vital Signs (VS)

36. Venous Air Embolism
(In order of sensitivity)
1. TEE
2. Doppler (left or right parasternal, between 2nd and 3rd
rib, mill wheel murmur)
3. ETN2, ETCO2 and/or PA pressure
4. Cardiac output
and/or CVP
5. Blood pressure,
EKG (RV Strain
pattern, ST
depression),
stethoscope
(least sensitive)

37. Preventing Heat Loss

38. Table Setup

39. Developmental Milestones

40. Developmental Milestones

41. Developmental Milestones

42. Perioperative Fluid Replacement
 1st 0-10 kg → 4 cc/kg/hr
 2nd 10-20 kg → 2 cc/kg/hr
 20 kg → 1 cc/kg/hr Calculate preoperative deficit
• Replace 50% first hour
• Replace 25% second hour
• Replace 25% third hour
 Minor surgery → additional 2 cc/kg/hr
 Major surgery → up to additional 10 cc/kg/hr
 Transfusion threshold: Hgb 9-10 ( O2 consumption)

43. Estimated Allowable Blood Loss
(EBL)
• Blood volume
• Premies → 95 ml/kg
• Term neonates → 90 ml/kg
• Up to 1 year → 80 ml/kg
• > 1 year old → 70 ml/kg
• EABL → wt kg x est blood vol x (starting Hct- allowable
Hct) / ave Hct

44. Airway Management
• Water volume
• Laryngoscopy
• Blades
• – Straight most common
• Miller Phillips Wis-Hipple
• Curved available
• Fiberoptic
• Bullard Glide

45. ETT Tube Sizing
ETT tube size
 < 2 yrs:
 2.5 – 3 (premature)
 3 – 3.5 (neonate – 6 month)
 3.5 – 4.0 (6 month – 1 year)
 4.0 – 5.0 (1 – 2 year)
 > 2 yrs:
 (Age / 4)
o +4 (cuffed)
o +4.5 (uncuffed)
ETT tube length
 Neonates: 7 – 9cm
 Other
 Height (cm) / 10
 Weight (kg) / 12
 (Age / 2) + 12

46. Laryngoscopy
 Neonate to 3 months: Miller 0
 3 months to 18 months: Miller 1
 18 month- 3 years: Miller 1.5, Mac 1,
Wisc 1.5
 3-5 years: Miller 1.5, Mac 2, Wisc 1.5
 >5 years: Miller 2, Mac 2-3
Straight blade necessary for neonates and young infants, can
be used as a Mac blade

47. LMA Sizing
iGel

48. Medication Management
Higher doses needed for younger rather than older children
 Hepatic blood flow
 Decreased filtration until 3-4 months
 Decreased CYP450 activity
 Increased Vd
 Decreased pseudocholinesterase activity

49. Airway Management Table

50. Medication Management

51. Medication Management
ç

52. Medication Management

53. Medication Management

54. Medication Management

55. Emergency Medications

56. Perioperative Analgesia

57. Intraosseous (IO)
- IO kit or bone marrow bx
needle
- 1-2 cm below tibial tuberosity
- Insert with screwing motion
until lack of resistance
- Aspirate marrow to confirm
placement
- Secure needle Volume
replacement Labs
- Drug administration

58. Intravenous (IV) Placement
IV “leashes” with stopcockDe-airing filters

59. Invasive monitoring
• Require expertise and caution
• CVL most often IJ or femoral
• A-line most often right radial
artery
– Preductal - Mirrors carotid &
retinal
UA/UV may be
considered

60. Pre-Term
Neonatal Emergencies

61. Incidences of Disorders &
Syndromes
Disorder Incidence Disorder Incidence Disorder Incidence
PPH 1:20 TEF 1:3000 Biliary atresia 1:12500
Cryptoorchidism 1:50 OWR 1:3000 BWS 1:13700
Laryngeal papillomatosis 1:400 DMD 1:3000 Williams 1:20000
Pyloric stenosis 1:500
Congenital
Hypothyroid 1:4000 CCAM 1:30000
Intestinal malrotation 1:500 CDH 1:4000 SCT 1:40000
CP 1:5000
Duplication
cysts 1:4500 Prune belly syndrome 1:40000
T21 / Downs 1:800 TTTS 1:5000 KFS 1:42000
Myelomeningocele 1:1000 Graves 1:5000 TCS 1:50000
Amniotic Band 1:1200 T18/Edwards 1:5000 Sirenomelia 1:100,000
CF 1:2000 DiGeorge 1:5000 Hurlers 1:100,000
CMT 1:2500 Omphalocele 1:6000 Conjoined twins 1:100,000
Turner's 1:2500 PRS 1:8500 Crouzon 1:600,000
PDA 1:2500 CHARGE 1:12500 Apert 1:700,000

62. Neonatal Apnea
 Anemia
 Sepsis
 Intracranial bleeding
 PDA
 Following GA
 Hypoglycemia, hypothermia, hypoxia
No elective procedures until 46 weeks GA, 56-60
weeks PCA (institution-specific)
 Prematurity (GA and PCA) Anemia
 Apnea at home Weight at birth

63. Others
 Retinopathy of prematurity
• Hypoxia & hypercarbia
 Maintain PaO2 50-80 mmHg
 Low birth weight
 Kernicterus
• Hypoxia, acidosis, hypothermia,
hypoalbuminemia

64. Intraventricular Hemorrhage
 Intraventricular hemorrhage
• Hypoxia & hypercarbia
• Hypernatremia
• Fluctuation of arterial and venous pressures
• Low Hct
• Rapid administration of hypertonic fluids

65. Bronchopulmonary Dysplasia
 Bronchopulmonary dysplasia
• Supplemental oxygen after the age of 6 months
• CXR—> cystic emphysema, fibrosis, hyperinflation; alveolar duct
dilation
• Prematurity, pressure ventilation, genetics, inflammation, infection,
oxygen radicals
• Permissive hypercapnia
 PDA with pulmonary overcirculation
• PGE2 keep it open
• Starts closing at 12 hours, completely closes at 4 days, ductus
arteriosis at 3 weeks

66. Necrotizing Enterocolitis
 Pre-mature babies, low birth weight, lack of enteral
nutrition
 Not seen in fetus
 Pneumatosis intestinal (terminal ileum, cecum,
ascending colon)
 Sudden increase in CRP / Abdominal wall distension/
erythema—> severe inflammatory condition
 Thrombocytopenia, coagulopathy, metabolic acidosis
 LLD AXR to show free air
 1/3 need surgery

67. Full-Term (FT)
Neonatal Emergencies

68. Neonatal
Resuscitation

69. Omphalocele & Gastroschisis
Omphalocele
• Base of umbilicus
• Hernia sac
• Other assoc defects
- Trisomy 21
- BWS
- Cardiac (20%)
- Diaphragmatic hernia
- Bladder malformation
Gastroschisis
• Lateral to umbilicus
• No hernia sac
• Intrauterine disruption of the
omphalomesenteric artery
• Not associated with other
defects
• Increased risk of infection

70. Omphalocele & Gastroschisis
 Induce RSI / awake
• Treat acidosis when pH < 7.0
• Don’t extubate (unless staged
bedside silo placement in ICU)
• Decompress stomach
 Muscle relaxant to assist
reduction
 Criteria for closure
• Intragastric or intravesical pressure
< 20
• PIP < 35
• EtCO2 < 50

71. CDH
 Gut herniates into chest
• Left (most common ~ 90%) or right posterolateral
foramen of Bochdalek
• Anterior foramen of Morgagni
 Hallmarks
• Hypoxia
• Scaphoid abdomen
• Bowel sounds in chest
 Respiratory support
 ECMO

72. CDH
 NG tube
 Avoid high PPV
 Intubate
 PIP < 30
 Avoid aggressive
lung re-expansion
 Consider PTX if
sudden change in
compliance

73. CDH
 Cardiac defects 25%, pulmonary hypoplasia +
PHTN ~ 100%
 Scoliosis association
 PTX, avoid N2O
 Severe acidosis, dehydration
• Place IV in upper extremity (increased
abdominal pressure can compress IVC)
• IV fluids = D5 ½ NS
 Permissive hypercapnia, fluid resuscitation, watch
PIP, muscle relaxation

74. Malrotation & Volvulus
 Developmental abnormality
 Spontaneous rotation of midgut around
mesentary (SMA)
 Presentation
• Acute or chronic obstruction
• Bilious vomiting
• Abdominal distention and tenderness
• Metabolic acidosis

75.  True surgical emergency
 Compromised intestinal blood supply
 1/3 occur in 1st
week of life
 Bloody diarrhea → bowel infarction
Malrotation & Volvulus

76. Malrotation & Volvulus
 Obstruction present without obvious volvulus
• Stabilize coexisting conditions
• Insert NG
• Broad spectrum abx
• Fluid and electrolyte management
 To OR ASAP
 Cautious induction and anesthesia if unable to be preoperatively
stabilized

77. Malrotation & Volvulus
 Usually hypovolemic and academic
• Aggressive fluid management
• Consider bicarb
 Full stomach precautions
• RSI → ketamine?
• Awake intubation
 Opioid based anesthetic
 Post op intubation common
• Significant bowel edema → Silo

78. FT Neonatal Emergencies
 Choanal atresia
• Cannot pass a 3.5 Fr catheter through nares
• Cyclical crying
 Hypoxia  crying and open mouth relieves
obstruction  relief/close mouth  hypoxia
 Rule out: neck mass, vascular anomaly, RDS, PE,
PTX
 Vomiting in infants
• Non-bilious: GER, Pyloric Stenosis
• Bilious: Duodenal obstruction, atresia, malrotation,
Meckel’s diverticulum (rule of 2’s)

79. Pyloric Stenosis
 4-6 weeks old
 M > F
 Persistent vomiting
 Metabolic disarray
• Hypochloremic hypokalemic hypokalemic
• Vomiting depletes hydrogen ions
• Kidney compensates by excreting NaHCO3 Hyponatremia and
dehydration worsen
• Kidney conserves sodium at expense of
• hydrogen → paradoxic aciduria
• Correct metabolic issues prior to surgery
o 12-72 hrs to correct electrolyte deficiencies
 Na > 130, K > 3, UOP 1-2 cc/kg/hr
 Balanced salt solution, add K+ when good UOP

80. Pyloric Stenosis
 Empty stomach
• Supine, lateral and prone
 RSI
• Propofol or thiopental + NMB or remi
 Awake intubation
 Laparoscopic vs open
 Post op
• Increased risk for respiratory depression
 Persistent metabolic or CSF alkalosis

81. Sacrococcygeal
Teratomas
 Hensen’s node
• High-output cardiac failure,
pre-term delivery
• Procedure:
 EXIT vs. fetoscopic
 Middle sacral artery,
other II
branches
 Coccyx must be removed
 Injury to bowel, bladder,
and presacral nerve
plexus

82. Myelomeningocele
 Failure of full closure of “embryonic ridge”
 Folate deficiency
 Intubate supine with cushion, OR lateral
 Associations with AC malformation, latex allergy
• Consider if apnea, HTN
 Extracellcular fluid loss  IV fluids – balanced salt

83. Pediatric Issues - Anesthesia

84. Pediatric Pre-Operative URI
 Pre-operative URI
• Infectious vs. allergic vs vasomotor?
• Viral infection within 2 weeks increased risk of post-GA RAEs
 Wheezing – 10x
 Laryngospasm – 0-5x
 Breath holding
 Hypoxemia
 Atelectasis
 PACU stay
 Poor prognosticators
• ETT – 10x
• Purulent (green) secretions + wet cough – 5x
• Smoking at home

85. Pediatric Pre-
Operative URI

86. Pediatric Pre-Operative Anxiety
 Personality: Children who are shy,
inhibited, introverted are at Increased risk
 Age > 7 years
 Children who have anxious
parents
 Prior upsetting hospital
experience
 Only children (children without
siblings)
 Children who did not attend
pre-school

87. Why treat it?
 Delay anesthetic induction and recovery
 ~ 10 % of children can have behavior problems up
to 1 year after surgery
Pediatric Pre-Operative Anxiety

88. Malignant Hyperthermia (MH)
 Acute hypermetabolic state in muscle tissue
 Triggering agents
• Volatile agents
• Succinyl Choline
 Incidence
• 1:15,000 peds
• 1:40,000 adults
 MH may occur at any point during anesthesia or emergence
 Recrudescence despite treatment

89. MH
 Family history
• Muscle bx → caffeine
contracture test
• – +/- Ryanodine
receptor abnormality
 High flow O2 flush circuit x 20
min
 Nontriggering
 TIVA, Nitrous
Increased risk of MH
 Duchenne's muscular dsytrophy
 Central core disease
 Osteogenesis
imperfecta
 King Denborough syndrome

90. MH
Specific
 Rapid rise in EtCO2 early sign
 Rapid increase in temp late
sign
 Muscle rigidity +/
 Rhabdomyolosis
• Increase CK
 Myoglobinuria
Nonspecific
 Tachycardia
 Tachypnea
 Acidemia
• Metabolic
• Respiratory
 Hyperkalemia
 Dysrhythmias
Classic Signs

91. MH
 Discontinue triggering agents
Hyperventilate with 100% FiO2
 NaHCO3 1-2 mEq/kg IV
 Dantrolene 2.5 mg/kg IV
 Cool patient
 Support as indicated → intropes, dysrhythmias
 Monitor labs
 Consider invasive monitoring
 1 800-MH-HYPER
Treatment

92. Laryngospasm
 Stimulation of superior laryngeal nerve
 involuntary spasm
 Immediate post-extubation
 Poor depth of anesthesia, secretions, tobacco
exposure, infancy, +/- URI
 Tx: Positive pressure, succinylcholine

93. Post-Intubation Croup
 Cricoid > tracheal > glottic edema
 Barking cough, inspiratory + expiratory stridor
 “Steeple” sign
 ~ 3 hours post-extubation

94. Post-Extubation Stridor
 Glottic > cricoid edema  dexamethasone
 Large ETT  decreased by 0.5mm
 Repeated intubation  consider LMA
 Prolonged surgery  check manometry
 ENT procedures
 Excessive tube manipulation

95. Epiglottitis
 2yo – 6yo
 Hib, GAS
 “Thumb print” sign
 Fever, Sore throat, dysphagia, drooling, inspiratory
stridor, leaning forward/tripod, NO COUGH/rhinnorhea
 Prep: DL, bronchoscope, ENT on standby, ASA
monitors applied
 Induction: Inhalational, CPAP 10-15 cm H2O, no
muscle relaxants, + atropine
 Intubation: ETT 1-2mm smaller, chest compressions to
visualize glottis,keep ETT in place until swelling
subsides
 Abx therapy (i.e. ampicillin)

96. Foreign body Aspiration/Ingestion
 Acute onset
 Toxic: Nuts, lithium
batteries
 Supraglottic/glottic
 Stridor
 Subglottic
 Wheezing
 Esophageal
 IV induction/RSl
 Age < 6 and battery 15mm or larger
 +magnet
 GI sx
 >4 days without passing it
Ingestion
o Location of FB
 Bronchus: either, but initiate
PPV is dislodged in trachea
with resultant complete
obstruction during removal
 Trachea: spontaneous
ventilation
 Above vocal cords: RSI

97. Pediatric Issues - Other
 Natural upper airway obstruction
 Pharyngeal dilator muscle collapse + genioglossus
 Periodic breathing (5-10s)
 93% PT / 78% of FT
 Normal
 Propofol infusion syndrome
-  in neonates > pediatrics > adults
- 90 mcg/kg/min x > 8hrs

98. Cleft Palate Associations
 PRS
 DiGeorge
 Klippel-Feil
 Turners
 Apert
 Treacher Collin
 Goldenhaar

99. Pierre Robin Sequence
 Mandibular hypoplasia  posterior/downward
retraction  OBSTRUCTION
 Abnormalities
• Micrognathia Glossoptosis
• Airway obstruction +/- cleft palate
 Associations
• Stickler Treacher Collins
• FAS 22q11 / VCF
 25-50% surgical
• Lip/tongue adhesion
• MDO
• Trach/PEG

100. Trisomy 21
 Macroglossia, Tonsillar & adenoid
hypertrophy, OSA
 Short neck, AO instability (9%), Small trachea
 CHD (50%)
 (endocardial cushion defects/AV canal >
ASD > VSD, TOF)
 PHTN
 Developmental delay, hypotonia

101. VATER / VACTERL
o Gastrostomy,
o fistula ligation,
o esophageal anastomosis