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Epidemiology – Thyroid Nodule
Nodules common, whereas cancer relatively uncommon
Goal is to minimize “unnecessary” surgery but not miss any cancer
It increases with age.
Higher in women
Estimated 5-15% of nodules are cancerous
Although cancer more common in women, a nodule in a man is more likely to be cancer

Epidemiology – Pregnancy
Pregnancy increases risk
One study: u/s detection nodules –
    9.4% nulliparous women
    25% women previously pregnant
Attributed to increased renal iodide excretion and basal metabolic rate
Rosen: Nodules presenting during pregnancy – 30 patients, 43% were cancer
 HCG may be growth promoter (TSH-like activity)

Epidemiology – Radiation
Appears to be dose-dependent
ERR 7.7 at 100 cGy
Maximum risk approximately 30 years later
Nodule in radiated patient: 35-40% cancer
Data suggest no more aggressive behavior over spontaneously-occurring cancers, but may be larger at presentation
Only unequivocal environmental cause of thyroid cancer

Epidemiology – Children
Nodule more likely to be cancer than adults
10% thyroid cancer age <21
Thyroid ca 1.5-2.0% all pediatric malignancies
More likely to present with neck metastasis
Most common cause thyroid enlargement is chronic lymphocytic thyroiditis

Medullary Thyroid Carcinoma
FMTC, MEN 2A, MEN 2B
RET proto-oncogene (chromosome 10)
Calcium / Pentagastrin stimulation
Prophylactic thyroidectomy recommended age 2-6


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Things to consider:
Normal changes in TBW, ECF
All babies are born with an excess of TBW, mainly ECF, which needs to be removed
Adults are 60% water (20% ECF, 40% ICF)
Term neonates are 75% water (40% ECF, 35% ICF) : lose 5-10 % of weight in first week
Preterm neonates have more water (23 wks: 90%, 60% ECF, 30% ICF): lose 5-15% of weight in first week

Normal changes in Renal Function
Adults can concentrate or dilute urine very well, depending on fluid status
Neonates are not able to concentrate or dilute urine as well as adults - at risk for dehydration or fluid overload
Renal function matures with increasing:
 gestational age
 postnatal age

Insensible water loss (IWL)
Insensible” water loss is water loss that is not obvious: through skin (2/3) or respiratory tract (1/3)
 depends on gestational age (more preterm: more IWL)
 depends on postnatal age (skin thickens with age: older is better --> less IWL)
 also consider losses of other fluids: Stool (diarrhea/ostomy), NG/OG drainage, CSF (ventricular drainage), etc

Assessment of fluid and electrolyte status
Lab evaluation:
Serum electrolytes and plasma osmolarity
Urine output
Urine electrolytes, specific gravity (not very useful if the baby is on diuretics - lasix etc), FENa
Blood urea, serum creatinine (values in the first few days reflect mom’s values, not baby’s)
ABG (low pH and bicarb may indicate poor perfusion)

Fluids and Electrolyte in common neonatal conditions
RDS: Adequate but not too much fluid. Excess leads to hyponatremia, risk of BPD. Too little leads to hypernatremia, dehydration
BPD: Need more calories but fluids are usually restricted: hence the need for “rocket fuel”. If diuretics are used, w/f ‘lyte problems. May need extra calcium.
PDA: Avoid fluid overload. If indocin is used, monitor urine output.
Asphyxia: May have renal injury or SIADH. Restrict fluids initially, avoid potassium. May need fluid challenge if cause of oliguria is not clear.


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Calcium metabolism
99% of total body calcium in the bone .
1% in ICF ,ECF ,& cell membranes .
Calcium weight is 400mg/kg in infant & 950mg/kg in adult .

physiologic functions :
   1.blood coagulation .
      2.muscle contraction .
        3.neuromuscular transmission .
          4.Skeletal growth & mineralization
Ionized Ca is physiologically important .

Serum CA level is determined by net absorption (GI) & excretion (RENAL).
Each components is tightly regulated-hormonally- to keep normal serum level .
Total CA is usually measured & provides satisfactory assessment of ionized form .

Calcium regulation :mainly by 3 common hormones :
    1}Parathyroid hormone
          2}Vitamin D
              3}Calcitonin
Vitamin D
Actions:
1)increase Ca absorption from intestine.
2) increase PO4 absorption from intestine.
3) increase renal reabsorption of Ca &PO4.
4) increase bone resorption from old bone &mineralize new bone{net resorption} .
Overall effect :increase serum Calcium and Phosphate .

PTH hormone
Major hormone in regulation serum Ca .]
Synthesis & secreted from chief cells of parathyroid gland .
Actions :
1)increase bone resorption..increase serum Calcium and Phosphate .
2)increase renal Calcium reabsorption .
3)increase Calcium absorption from intestine indirectly by increase VITD .
4)decrease Phosphate reabsorption from proximal tubules …increase ionized Calcium .
Overall effect :increase serum Calcium & decrease serum Phosphate.

Hypocalcemia
Causes of hypocalcemia
Specific causes in neonates
Early neonatal hypocalcemia:(within 48-72 hour of birth)
Causes:    1- prematurity: poor intake, decrease response to Vit. D, increase calcitoni, decrease albumin.
    2- birth asphyxia: delayed introduction to feed, increase calcitonin, increased endogenous PO4 load, alkali therapy.
    3- infant of diabetic mother: functional parahypothyroidism induced by Mg defficiency has predominant role


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Indications
Pericarditis or pleuritis
Progressive uremic encephalopathy or neuropathy (AMS, asterixis, myoclonus, seizures)
Bleeding diathesis
Fluid overload unresponsive to diuretics
Metabolic disturbances refractory to medical therapy (hyperkalemia, metabolic acidosis, hyper- or hypocalcemia, hyperphosphatemia)
Persistent nausea/vomiting, weight loss, or malnutrition
Toxic overdose of a dialyzable drug

Modalities
Peritoneal dialysis
Intermittent hemodialysis
Hemofiltration
Continuous renal replacement therapy

Decision of modality determined by catabolic rate, hemodynamic stability, and whether primary goal is fluid or solute removal

Hemodialysis Apparatus
Dialyzer (cellulose, substituted cellulose, synthetic noncellulose membranes)
Dialysis solution (dialysate – water must remain free of Al, Cu, chloramine, bacteria, and endotoxin)
Tubing for transport of blood and dialysis solution
Machine to power and mechanically monitor the procedure (includes air monitor, proportioning system, temperature sensor, urea sensor to calculate clearance)

Hemodialysis Access
Acute dialysis catheter (vascular catheter, i.e. Quentin catheter)
Cuffed, tunneled dialysis catheter (Permcath)
Arteriovenous graft(AVG)
Arteriovenous fistula (AVF)

Complications of AVF and AVG
Thrombosis
Infection (10% for AVG, 5% for transposed AVF, 2% for non-transposed AVF)
Seromas
Steal (6% of B-C AVF, 1% of R-C AVF)
Aneurysms and pseudoaneurysms (3% of AVF, 5% of AVG)
Venous hypertension (usually 2/2 central venous stenosis)
Heart failure (Avoid AVFs in pts with severely depressed LVEF)
Local bleeding


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Congenital Diaphragmatic Hernia
Estimated Incidence to be between 1/2000 to 5000 live births
Cause of CDH is unknown
In most cases the defect is established by gestational week 12
Classic left sided CDH features a 2-4 cm posterolateral defect
Herniated contents often include the left lobe of the liver, the spleen, and almost the entire GI tract
Long term compression of the developing fetal lungs results in pulmonary maldevelopment and lung hypoplasia
Alveolar development is also severely affected

Esophageal Atresia and Tracheoesophageal Fistula
EA and TEF are relatively common congenital anomalies
Associated Anomalies:VACTERL: vertebral, anal, cardiac, TE,  renal,  limb

Congenital Intestinal Obstruction
Duodenal Atresia
Most common site of neonatal intestinal obstruction
Association with Trisomy 21

Radiologic studies
Plain radiograph of the abdomen will generally confirm the diagnosis with a finding of the “double bubble sign
Upper GI series or barium enema may be helpful to differentiate from midgut volvulus

Meconium Ileus
Almost always associated with cystic fibrosis
Reported to be the presenting symptom in 15-20% of cases
Complicated meconium ileus
 In utero dilated proximal intestine volvulizes
 Early in gestation may cause one or more atresias
 Late in gestation infants may present with perforation -> meconium peritonitis

Radiologic Studies – Simple Meconium Ileus
Plain radiographs
Varying sized loops of distended bowel
Absence of air fluid levels
Soap bubble appearance particularly in the right lower quadrant

Intestinal Malrotation and Volvulus
Malrotation is when the normal process of rotation is arrested or deviated at various stages
Anomalous fixation may also occur
Dense fibrous bands extending from the cecum and right colon across the duodenum to the retroperitoneum may form – Ladd’s Bands

Hirschsprung’s Disease
Absence of ganglion cells in the distal intestine is the hallmark of the disease
Ganglion cells are absent in the submucosal plexus and intermuscular plexus
Rectosigmoid region in ~80% of cases
Aganglionosis is almost always continuous distally

Diagnosis
Rectal biopsy is the gold standard

Imperforate Anus
Average incidence worldwide is believed to be 1 in 5000 live births
Most common in females – rectovestibular fistula
Most common in males – rectourethral fistula
Imperforate anus without fistula 5% of patients and half of these patients have Down’s syndrome


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Indications for Endoluminal radiofrequency ablation and Endovenous laser therapy
Clinical
C0: No visible or palpable signs of venous disease
C1: telangiectases or reticular veins
C2: varicose veins
C3: edema
C4: skin changes ascribed to venous disease
 a. pigmentation or eczema     
 b. lipodermatosclerosis or atrophie blanche
C5: skin changes as defined previously with healed ulcer
C6: skin changes as defined previously with active ulcer
Etiologic: congenital, primary, secondary or none
Anatomic: superficial, perforator, deep or none
Pathophysiologic: reflux, obstruction, both or none

Endoluminal radiofrequency ablation (RFA) of the great saphenous vein: mechanism
By directing resistive radiofrequency energy through a vein, a narrow
  rim of tissue less than 1mm is heated by an electrode.

- The amount of heating is modulated using both a microprocessor and
  manual movement, resulting in controlled collagen contraction,
  thermocoagulation and absorption of the vein.

Percutaneous access to the greater saphenous vein most commonly at the level of the knee under duplex ultrasound guidance
1) A guidewire is then advanced to the saphenofemoral junction over which the closure catheter is passed
2) catheter prongs are extruded to contact the intimal lining of the vessel wall
3) radiofrequency generator allows the tip of the catheter and the prongs to attain a temperature of 85 degrees C.

Results
1) Vein occlusion at 1 week documented by venous ultrasound success rate of 98%
2) None of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%.
3) At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein,for a success rate of 90%.
4) Side effects were minimal, and no skin burns or thromboses were observed

Endovenous laser therapy (EVLT): mechanism
Thermal reaction after laser exposure is essential.
- Damages endothelial, intimal internal elastic lamina, and to some
  degree the media. Adventitia is rarely affected.
- In vitro studies suggest that energy results in ‘boiling of blood’ and
  and generation of ‘steam bubbles’ that indirectly, homogenously 
  affect the varicose vein.


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Compare/contrast the difference between asthma, emphysema & chronic bronchitis
List 3 anesthetic strategies in caring for this population
Identify 3 pre operative tests  desired for anesthesia screening
Describe intraoperative planning for postoperative recovery in this population

ASTHMA-what is it?
Chronic, inflammatory disease
Reversible obstruction (to a degree)
Increased airway reactivity
Most common chronic illness in children under 17 years
Complex; involves inflammatory cells,mediators, cells&tissues residing in the airway

ASTHMA-early response
Immed bronchospasm on exposure
Symptoms occur in 10-20 min
Resolves in 60-90 min
Antigen binds to IgE “coated” mast cells,bronchospasm .
Reversible with B2 agonist inhalers

ASTHMA-Late Response
Onset 3-5 hrs after exposure
Involves inflammation&inc. airway reactivity
May begin cycles of exacerbation
Chronic inflammation leads to airway remodeling, which limits reversibility degree

CARDIAC ASTHMA
Due to heart failure
Chronic, nonproduct cough-becomes worse when supine(autotransfusion effect)
Bronchospasm occurs b/o congestion of the bronchial mucosa

EMPHYSEMA-what is it?
Loss of lung elasticity, abnormal permanent enlargement of air spaces distal to term bronchioles with distention of alveolar walls &

capillary beds without obvious fibrosis
Alpha1-antitrypsin normally protects lung against destruction caused by inflammatory cells-diminished in this disease

CHRONIC BRONCHITIS or Blue Bloaters
Inflammation of major & small airways.  Edema & hyperplasia of submucous glands with inc. mucous production.  Chronic cough (3 mos) for at least 2 consecutive years in the absence of other diseases


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