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Neonates

OB, Peds, etc.

QuestionAnswer
the five most frequent major surgical procedures performed in the first week of life? CDH, omphalocele and gastroschisis, tracheoesophageal fistula (TEF), intestinal obstruction, and meningomyelocele.
Which of the five most freq. major surgical procedures are obvious at birth? CDH, omphalocele and gastroschisis, and meningomyelocele
this condition is seen in weeks 5-10 of fetal life abdominal contents extruded into extraembronic coelom and does not return at week 10 oomphalocele
what is oomphalocele covered with? amnion
where is the umbilical cord located in a oomphalocele apex of the sac
T or F oomphalocele is associated with a high risk of associated congential anomalies? True
CHD is associated with what % of oomphalocele 25%
what is Beckwith-Wiedemann syndrome consist of? omphalocele, mental retardation, hypoglycemia, large tongue, congenital heart disease
when does the gut returnto the abdominal cavity 10th week
what does the amnion do? protects the abdominal contents from infection and the loss of extracellular fluid
T or F gastroschisis develops later in fetal life? True
T or F there is a high incidence of associated congenital anomalies with gastroschisis but not with omphalocele False; vice versa
this develops after abdominal content returned gastrochisis
how does gastrochisis develop? interruption of the omphalomesenteric artery, which results in ischemia and atrophy of the various layers of the abdominal wall at the base of the umbilical cord. the gut herniates through this tissue defect.
where is the umbilical cord located in gastrochisis one side of the intestinal contents
you have a high risk for what in gastrochisis infection; no protective covering
how can you dx oomphalocele and gastrochisis alpha-fetoprotein (ATF), ultrasound
what causes high levels of ATF? inadequate closure of the abdominal wall and neural tube.
high levels of ATF means? concerns of abdominal wall defect or nerual tube defect in the fetus
which is more urgent gastrochisis or omphalocele gastrochisis
preop: respiratroy failure is associated with____ omphalocele
preop: gastroschisis is associated with infection
during gastrochisis and omphalocele surgery it is important to have ___ ____ ____ when gut is returning to the abd. lower extrem. pulse ox; to make sure on occlusion of the fem. art. is not being occluded.
preop: it is important to ___ gastrochisis to prevent infection bagging
preop care search for assoc. anomalies, ABC's, fluids and electrolytes, CVP, A/L, ventilation, muscle relax, no nitrous,
ways to protect the bowel, minimize fluid and temp. loss with gastroschisis bagging
a difficult airway can be anticipated in pts with beckwith-Wiedemann syndrome
fluid vol administration often is balance with salt solution
nitrous oxide should not be used b/c? it increases the gas in the intestines
if primary closure is impossible what is incorporated? silo
muscle relaxant are required during closure of the abd? it is necessary to allow closure of the abd.
post-op: the increased abdominal pressure can have affect the kidneys by? reducing the circulation to the kidney resulting in release of renin.
what can the HTN be associated with during increased abd. pressure during closure renin release from decrease circulation to the kidneys
postop concerns after closure? lower extrem. edema and HTN
diaphragm forms b/n 5 to 10 weeks
the gut is herniated or extruded to the extraembryonic coelom during ninth or tenth week
how does the congenital diaphragmatic hernia develop in the 9th or 10th week the developing gut returns to the peritoneal cavity, if there is a delay or incomplete closure of the diaphragm, or it the gut returns early, a diaphragmatic hernia develops
what is not known for sure about the diaphragm why defects or holes occur in the diahragm
CDH occurs in how many live births and still births? 1 in 4000 1 in 2000 still
what is the mortality of CDH 40-50%
90% of CDH is ___-side left
what portion of the diaphragm closes later left (foramen of bochdalek)
what is the right-sided foramen called? foramen of morgagni
what can develop during CDH that puts the neonate at more risk pulm. hypoplasia, hyper-reactive pulm. vasulature, LV hypoplasia
how do you dx CDH ultrasound
the occurence of symptoms of the clinical presentaion of CDH depends on the degree of herniation and interference with pulm. fx.
what are the initial clinial findings with CDH scaphoid abd. (sunken in abd) decreased breathe sounds(L), and resp. failure
excessive airway pressures with CDH can cause a high risk for pneumo., barotrauma
appears week 2-4 of later, nonbilous vomitting pyloric stenosis
untreated pyloric stenosis leads to hypokalemic, hyponatremic, hypochloremic, metabolic alkalosis, 33-36% with hyperkalemia later:respiatory acidosis
how is pyloric stenosis dx H&P, palpable "olive" or mass, u/s, xray
what is a medical emergency pyloric stenosis
why is atrophine given prior to rapid sequence of an neonate to produce some kind of sympathetic response since theirs isn't developed
conventional ventilation with permissive hypercapnia60-65 favored with CDH
preop diaphragmatic hernia avoid hypothermia, acidosis which can precipitate pulm. HTN, nitrous, muscle relaxants, diff. abd. closure
patho of CDH cardiac development may be impaired, LV hypoplasia with attenuated muscle mass and cavity size
newborn first 24 hrs
crista dividends a structure that divides right atrium
how does the foramen ovale remain open RAP>LAP
the Pulm. vascular bed has a high vascular resistance b/c the alveoli are relatively closed and filled with fluid and bld vessels compressed
decreased PAO2 and decreased pH increase PVR
the ductus artenosus represents a low-resist. syst. b/c it is dilated 2ndary to a low PAO2
the transition of the alveoli from fluid-filled to air-filled results in low compression of the pulm. alveolar capillaries with a decreased in PVR over first several hours
how long does it take PVR to decrease 2-3 days
decrease PVR is accompanied by constriction of the ductus arteriosus 2ndary to oxygentation=increase in pulm. bld flow and an increase in L atrial pressure so foramen ovale functionally closes
when are DA and FO permanently closed lst several mnths
with ventilation the first 5-10min what ocurs? normal ventilatory vol. develop and normal TV
initial negative intrathoracic pressure generated 40-60 cm H2O
when is FRC near normal and bld gases stablized by 10 to 20 min. of life
placenta oxygenates> inferior vena cava, R atrium, foramen ovale,L atrium, LV, ascending aorta
bld returns upper body> R side by SVC directed by crista dividends, RV, PA, 90% ductus arteriosus, descending aorta, and 10% PA, pulm. vascualr bed for growth of lungs and surfactant production
what cause the DA to open/close decrease pO2, decrease pH, prostaglandins(placenta) close:increasepO2, pH, no prostaglandings
95% of babies have closed DA in __, and permanent in ___ 48-72 hrs, 2-3wks
PPH presistent pulm HTN
elevated PVR to the pt what venous bld is diverted to some degree through fetal channels PPH
what can cause DA and FO to remain open PPH
systemic aterial hypoxemia PPH
primary causes: unknown 2ndary causes: PPH meconium aspirat., sepsis, PNA, Resp. distress, CDH
what can be a sign of interuterine fetal hypoxia meconium aspiration
what are the classification of PPH 1. PPHN with pulm. parenchymal disease, 2.PPHN with radioraphical normal lung, 3. PPHN with lung hypoplasia
what is the goal of PPH txment PAO2 50-70 cmH2O PACO2 40-60 cmH2O
this is inhaled, selective pulm. vasodilation for txment for PPH nitric oxide
ECMO extracorporeal membrane oxygentation
risk of ECMO bleeding, clot, stroke, infect, eq. fail, labor time, expensive
functional, physiologially closed, permanent anatomic closure: 12hrs, 2nd day, first 2 months
s/s of PDA poor feeding, poor wt.gain, tachycardia, dyspnea, CHF
PDA is what kind of shunt L to R, inceases pulm. bld flow=CHF
risk factor for PDA endocarditis
PDA txment indomethacin, ligation,
what is ductal depend. congential heart disease needs PDA to survive 1)lesion with restricted pulm. bld flow(pulm. atresia or stenosis, tricuspid atresia) 2)mitral atresia, aortic atresia, preductal coarctation, interrupted aortic arch
txment for ductal depend. CHD needs prostag. to keep PDA open
PFO in what % of adults 20-30
umbilical arterty and umbilical ligaments turn into umbilicalligaments and superior vesicular artery to bladder
what are the newborn anatomial airway diffences lg tougue, high glottis, narrow cricoid ring, slanting vocal cords, lg occiput
what type of breathers are neonatal obligate nose
most common cause of airway obstur tongue
narrowest portion for neonates cricoid ring
what age does the narrowest portion change <10
neonatal pulm. syst. differs by high O2 consumption, high closing volumes, high ratio of MV to FRC, pliable ribs
O2 consumption adults 3ml/kg/min for infant 7-9ml/kg/min
lung volumes at with alveoli close, resulting in the shunting of bld by a closed alveolus high closing volumes
high closing volumes of the neonate's lung are w/in the range of normal tidal volumes
neonate have increased O2 consumption, what helps increased alveolar ventilation
neonates have a high ration minute volume to FRC
neonatal ratio of MV to FRC 5:1
5:1 ratio results with anesthesia rapid induction and emergence from inhalational anesthesia
neonate has a higher % of body wt as vessel rich groups
FRC in infants? 27-30 ml/kg
neonates FRC 23ml/kg
type 1 muscle slow twitch, high oxidation for sustained muscle activity
diaphargm has type 1 till 8 mnths
fast twitch muscle decreased oxidative, immed. but short activity
intercostal muscle achieve maturity by 2 mnths
neonates has more CO than adults compared to body wt. b/c increased O2 consumption
poor contractility results in relatively fixed SV
what makes the heart stiffer and less contractile than adults rich mitchondria and ER
neonates has decrease SVR 2ndary to pristine vessels
MAP 35-40
babies have a fully developed parasympath. prone to bradycardia
myocardial stimulation produces limited increase in CO or contractility 2dary to undeveloped sympathetics
what is the major cause of bradycardia hypoxia
in the sniffing position the head is ___ and the neck is ___ flexed;extended
place roll under shoulders for ages <2 years of age
place roll under neck what ages 6-11
infant airway differs in five ways larynx ↑ in the neck: preemieC3, term C3-4, adult C4-5 2)lg tongue 3)epiglot. short, stubby, angled away from tracheal axis 4)infant v/c have a ↓ attachment ant. than post. vs adults 5)narrowest part of the infant n young ped airway cricoid cartilage
Sodde's law of anesthesia the laryngoscope light stays on until the blade is down the pt's throat
how long is the average NB trachea from vocal cords to carina neonate 5cm adult 8-13cm
beyond 2 years formula for internal distance age + 16/4
distance of insertion age + 12/2
cuff tracheal tube low press, high vol cuff generaly indicated for children 8-10yrs or older
ETT tube size formulas premature 1-2-3-4 kg 7-8-9-10cm
down's syndrome macroglosdsia, cervical spine stability, congenital subglottic stenosis, atlantoaxial subluxation20%, congenital heart disease(AV canal defects
micrognathia may be the most common cause of a difficult airway in infancy
mandible develops from the first branchial arch micrognathia
micrognathia abnormalities hemifacial microsomia, bilateral 1st arch synd., treacher collins synd., pierre robin synd.
preauricular skin tags or abnormally developed external ears, may be used as a marker for a potentially difficult intubation with micrognathia
natural hx of most of these airway problems is they improve with age and growth
T or F the tongue is easily displace during direct laryngoscopy T
management tips of micrognathia laryngoscope is inserted on the extreme R side of the oral cavity (retromolar)
bilateral 1st arch syndrome a very rare disease charact. by complete absence of the mandible and other structures derived from the 1st branchial arch.
underdeveloped cheek and jaw, down slanting eyes, ear deformitites, treacher collins syndrome
goldenhar's synd. rare congenital do of hemicariofacial and vertebral defects related to the abnormal development of the 1st and 2nd branchial arches
these infants not only have a difficult managed airway, congenital heart disease, pulm. and renal defects goldenhar's syndrome
goldenhar's syndrome:difficult tracheal intub. may be due to a combination of retrognathia, micrognathia, mandibular hypoplasia, palatal defects and vertebral anomalies
myocardiacl stimulation of a neonate produces a increases in CO and contractility false;neonates lack sympath.
what contributes to formation of amniotic fluid fetal urine
whar are the 4 major reasons for low RBF and GFR low syst. arterial press., increased reanl vascualur resistance, decreased permeability of the glomerular cap., small size and # of glomeruli
meonate concentrates and produces unrine within 3-4 days
in 1 mnth kidneys mature to 70%
why considered obligate Na losers tubular con't to reabsorb Na
neonate unrine Na 20-25meq/L
80% of fetal Hgb is HgbF increased affinity for O2;
newborn Hgb levels falls for the first 6-8wks NB fluid should contain Na
4-2-1 Rule (0-10kg)=4ml/kg/hr (11-20kg)=2ml/kg/hr (>20kg)=add 1ml/kg/hr
maintenance Na for infants is 3 to 5 meq/kg/day
how to calculate replace NPO hourly maintenance X hours NPO (1/2 1st hr) (1/4 2nd hr) (1/4 3rd hr)
problems with temp regulation lg SA, small mass to generate heart, poor insulation, inability to shiver
what is the major source of heat production in cold stressed neonates catecholamine stimulation, nonshibering, thermogenesis by brown fat
brown fat forms in 26-30 wks gestation
brown fat produces heat by fatty aci metabolism
name 5 ways to treat heat loss radiant heat lamps, warming blankets, hats-wrapping limbs, warm-humidified gas, warmed IV fluids
increased bulirubin load comes from poor hepatic conjugation
increased bilirubin comes from 75% from rbc destruction/UDP-glucuronyl/transferance reaches normal at age 3
what makes bilirubin water soluble for excretion UDP-glucuronyl transferance
what is the COPD for neonates bronchopulm. dysplasia
neonate unrine Na 20-25meq/L
80% of fetal Hgb is HgbF increased affinity for O2;
newborn Hgb levels falls for the first 6-8wks NB fluid should contain Na
4-2-1 Rule (0-10kg)=4ml/kg/hr (11-20kg)=2ml/kg/hr (>20kg)=add 1ml/kg/hr
maintenance Na for infants is 3 to 5 meq/kg/day
how to calculate replace NPO hourly maintenance X hours NPO (1/2 1st hr) (1/4 2nd hr) (1/4 3rd hr)
problems with temp regulation lg SA, small mass to generate heart, poor insulation, inability to shiver
what is the major source of heat production in cold stressed neonates catecholamine stimulation, nonshibering, thermogenesis by brown fat
brown fat forms in 26-30 wks gestation
brown fat produces heat by fatty aci metabolism
name 5 ways to treat heat loss radiant heat lamps, warming blankets, hats-wrapping limbs, warm-humidified gas, warmed IV fluids
increased bulirubin load comes from poor hepatic conjugation
increased bilirubin comes from 75% from rbc destruction/UDP-glucuronyl/transferance reaches normal at age 3
what makes bilirubin water soluble for excretion UDP-glucuronyl transferance
what is the COPD for neonates bronchopulm. dysplasia
txment for BPD O2, bronchodilators, diuretics,ventilation
txment for NEC IV hydration, ax, D/C feeds, surgical exploration, resection of damaged bowel
intraventricular hemorrhage occurs more in 500-750gm or 1000-1500gm infants 500-750gm (60-70%) (10-20%)
what type of infant is at risk for postop apnea and bradycardia ex-preemies <60wks PCA full term at risk 44-46 wks tx with anticholinergic
Created by: melbacs