1. Hany El-zahaby Ain Shams University 2011

2. Case 1 You have been called to anesthetize 6h old, 3.1kg male born at 36W by CS with Gastroschisis for primary closure.

3. What is Gastroschisis?

4. What are the differences between Gastroschisis and Omphalocele?

6. What are the main anesthetic problems: 1- volume status 2- thermal status 3- induction techniques 4- intra-abdominal pressure

7. preoperative assessment & preparation history Apgar Score IV line & IVF NG aspirate UOP antibiotics anomalies

8. examination HR Bp RR Spo2 Temp Capillary refill airway chest heart

9. investigation CBC S. electrolytes renal function coagulation CBG CXR echocardiography

10. premedication monitoring thermal control induction stomach aspiration rapid sequence ventilation muscle relaxation

11. Diagnosing hypovolemia under anesthesia: Is the HR persistently increased (not with surgical stimulation)? Is the BP reduced for age? Does BP vary with IPPV? Are the extremities cold? Is the capillary refill brisk? What about UOP? Core to skin temp. gradient? What is the response to 10-20ml/kg bolus of isotonic crystalloid?

12. after reduction, the surgeon asked you if it is OK to continue closure, the PIP increased from 18 to 27cmH 2 O, how would you answer?

13. high intra-abdominal pressure: - decrease organ perfusion/function, prolonged drug effect - decrease diaphragmatic function & lower lobes atelectasis - decrease venous return - lower extremity venous congestion measurement: intra-gastric or bladder pressures (20mmHg) gut & skin color lung compliance cv stability

14. after closure and removal of towels, moderate mottling of the lower limbs was noticed, how would you manage? fluid boluses vasopressors oxygen

15. postoperative: ventilation (PEEP) sedation/analgesia relaxation TPN complications: cv collapse ileus

16. Silon patch

17. Case 2 7 years old, 14 kg male child with long history of cerebral palsy scheduled for laparoscopic Nissen fundoplication and gastrostomy tube insertion. History of URTI two weeks ago & he is now much better according to the mother. Patient has long standing spastic quadriplegia & underwent multiple orthopedic operations.

19. 2:1000 live birth cranial nerve weakness, bulbar palsy, poor coordination of laryngeal muscles gastro-esophageal reflux resistant to medication & thickened feeds (Feeding video-fluroscopy) recurrent aspiration & decreased pulmonary reserve immobility, dehydration, poor diet, bowel stasis, constipation, fecal impaction. common surgeries: orthopedic, scoliosis, ENT (adeno- tonsillectomy/obstructive sleep apnea)

20. problems: muscle spasms seizures respiratory problems medications laparoscopy

21. preoperative assessment & preparation old files neonatal history previous anesthesia recent chest infection medications

22. examination: HR Bp RR Spo2 temp capillary refill neurological status & posture head & neck chest heart abdomen limbs

24. investigations CBC S. electrolytes renal function liver function coagulation ABG CXR Echocardiography? serum levels of antiepileptics

25. Medications Antiepileptics: Scheduling? IV forms? S. levels? Benzodiazepine- respiratory depression, sedation (0.1mg/kg) Sodium valproate- weight gain, tremors Lamotrigine- rash, tremors, vomiting Carbamazepine- rash, sleep - > 8mg/L Phenobarbitone- (15mg/kg) - > 10mg/L Phenytoin- (15mg/kg) - > 10mg/L Other medications included ranitidine, omeprazole, baclofen & salbutamol

27. Would you reserve an ICU bed? Premedication? antacid-EMLA cream Position? modified Lloyed Davis- avoid force- good padding Induction? Intubation/Ventilation? Maintenance? Pneumo-peritonium Analgesia?

28. Immediately after extubation, laryngeal spasm has occurred with gradual desaturation, what would you do? 10 minutes after arrival to PACU, the patient desaturated down to 88% on oxygen face mask 6l/m, how would you manage?