Advanced | Pediatric Anesthesia Part II Flashcards
There are 2 techniques to surgically repair a TEF (tracheo-esophageal fistula). Supposedly, if endoscopic TEF repair is to be done, which of the following anesthetic management is TRUE?
A. The infant should be kept spontaneously breathing until the fistula is ligated
B. The infant should be kept
controlled breathing until the fistula is ligated
C. TEF is a surgical emergency therefore, surgical repair should be employed within 24-48 hrs in a hemodynamically compromised patient
D. The most common cause of mortality is primarily due to pulmonary complications
A. The infant should be kept spontaneously breathing until the fistula is ligated
- A major aim of anesthesia is to minimize positive-pressure ventilation until an endotracheal tube is placed distal to the fistula and/or the fistula is occluded or ligated. Positive-pressure ventilation may inflate the stomach through the fistula, leading to distention of the stomach and reduction of functional residual capacity of the lungs
Which of the following is ACCURATELY describing the pathophysiology of TEF?
A. Approximately 15% consist of a fistula from the distal trachea
B. The embryologic pathology usually occur between the fourth and fifth weeks of intrauterine life
C. Only 10 percent of affected infant presents with cardiac co-morbidities
D. One of the ante-natal cue is the presence of anhydramnios
B. The embryologic pathology usually occur between the fourth and fifth weeks of intrauterine life
- 85% of cases are fistula from the DISTAL trachea
- 50% of affected infants presents with cardiac anomaly
- Atresia of the esophagus leads to inability of the fetus to swallow amniotic fluid and the subsequent development of polyhydramnios.
Ultrasound may well raise the possibility of a congenital anomaly.
- For that reason, if polyhydramnios is present, attempts should be made to pass a nasogastric tube shortly after delivery.
THREE approaches in the airway management of TEF undergoing Conventional Open TEF Closure:
READ
Reasons for selecting a cuffed endotracheal tube (ETT) over an uncuffed ETT include all of the following EXCEPT
A. Fewer intubations and ETTs are needed
B. Less chance for airway fires
C. Spontaneous breathing is easier
D. Aspiration of gastric contents is less likely
C. Spontaneous breathing is easier
Myelomeningocele results from failure of neural tube closure during the ___ week of gestation.
A. 4th
B. 2nd
C. 10th
D. 26th
A. 4th week
TRUE of myelomeningocele:
A. In contrast to meningocele, myelomeningocele both affects the meninges and neural components
B. Elevated maternal serum AFP
detects only 5% of neural tube defects
C. Amniotic fluid AFP is less reliable compared to maternal level AFP
D. Folic acid supplementation during pregnancy completely abolish the pathology
A. In contrast to meningocele, myelomeningocele both affects the meninges and neural components
- Elevated maternal serum AFP
detects only 5% of neural tube defects - False - 50% to 90% is detected thru maternal AFP
Amniotic fluid AFP is less reliable compared to maternal level AFP - False
* Amniotic fluid AFP is a confirmatory
Folic acid supplementation during pregnancy completely abolish the pathology - False
*Despite folic acid supplementation, about 0.5 - 1% still occurs.
A delay in surgery for 24 to 48 hours for preoperative stabilization and preparation is acceptable in each of the following neonatal conditions EXCEPT
(A) biliary atresia
(B) diaphragmatic hernia
(C) meningomyelocele
(D) pyloric stenosis
(E) tracheoesophageal fistula
(C) meningomyelocele
- The infant with a myelomeningocele is usually operated on within the
first 24 to 48 hours of life, thus reducing the risk for development of ventriculitis or progressive neurologic deficits.
Complications of brainstem dysfunction in myelomeningocele includes stridor, apnea, bradycardia, aspiration pneumonia, sleep-disordered breathing patterns, vocal cord paralysis, lack of coordination, and spasticity.
If the symptoms are not improved by shunting, posterior fossa decompression is necessary.
TRUE or FALSE
Myelomeningocele patient rarely presents with INCREASE ICP. Therefore, inhalation induction is not contraindicated.
TRUE!
TRUE or FALSE
Nitrous oxide is contraindicated in Hydrocephalic patient.
FALSE
A rapid-sequence induction of anesthesia to control the airway and intracranial pressure is preferred. Volatile drugs, nitrous oxide, and opioids are all reasonable choices for maintenance of anesthesia, with no evidence that one technique is
superior.
Noninvasive intracranial pressure measurements in neurologically
normal preterm infants have shown a decrease in intracranial pressure with all drugs, including ketamine, fentanyl, and isoflurane.
Which of the following peri-operative considerations in inguinal hernia before 1 year old is INACCURATE?
A. This patients have history of RDS, history of incarceration,
and congenital heart disease
B. The apneic events associated with the disease are
directly related to both gestational age and post-conceptual age.
C. Apnea-free for at least 12 hours post-operatively is a good indicator to discharge the patient
D. The use of preservative-free caffeine in a single dose of 10 mg/kg can possibly improve apneic events
B. The apneic events associated with the disease are
directly related to both gestational age and post-conceptual age - Inaccurate
- Apneic events are inversely related to gestational age. Meaning, the incidence of apnea is less in small-for-gestational age infants. Additionally, anemia increases the incidence of apneic events. Apneic events at home are associated with a higher incidence in the perioperative period.
A 6 week old infant presents with projective vomiting without fever. You immediately suspected Pyloric stenosis. This patient will MOST likely present with which of the following electrolyte derangement?
A. Hypokalemia, Hyponatremia, Hypochloremia and metabolic alkalosis
B. Hypokalemia, Hypernatremia, Hypochloremia and metabolic acidosis
C. Hypokalemia, Hyponatremia, Hypochloremia and metabolic acidosis
D. Hypokalemia and hypochloremia with compensated metabolic acidosis
A. Hypokalemia, Hyponatremia, Hypochloremia and metabolic alkalosis
Metabolic alkalosis with compensatory respiratory acidosis!
- This is a MEDICAL emergency not a SURGICAL emergency.
The patient should not be operated on until there has been adequate fluid and electrolyte resuscitation. The infant should have normal skin turgor, and the correction of the electrolyte imbalance should produce a sodium level that is
greater than 130 mEq/L, a potassium level that is at least 3 mEq/L, a chloride level that is greater than 85 mEq/L (trending upward), and a urine output of at
least 1 to 2 mL/kg/hr.
Which of the following is NOT a RISK FACTORS for postoperative apnea include
A. Low gestational age
B. Observed apnea at home
C. Anemia
D. Small-for-gestational age infants
D. Small-for-gestational age infants
Risk factors for postoperative apnea include low gestational age, observed
apnea at home, and anemia.
- Small-for-gestational age infants have a
decreased risk.
The exact age at which infants are no longer susceptible to postoperative apnea has yet to be determined. Thus, institutional guidelines vary with regard to required postoperative monitoring guidelines for infants.
In the context of airway management among infant, which will likely develop post-operative croup?
A. cuffed ET tube
B. uncuffed ET tube
Uncuffed ET will likely develop post-operative croup
- Treatment: racemic epinephrine and steroid
Immediately post-op, an infant who underwent elective cleft lip surgery seem to be having a delayed emergence. The surgery was uneventful except there were episodes of hypothermia. Which of the following is LEAST likely a sequelae of hypothermia?
A. Metabolic acidosis
B. Prolonged duration of action of nondepolarizing muscle relaxants
C. Hyperglycemia
D. Impaired coagulation
C. Hyperglycemia
Although hypothermia has some advantages such as protection against cerebral ischemia and hypoxia, other effects are less desirable.
In neonates or infants, the response to hypothermia includes non-shivering thermogenesis
(brown fat metabolism) and shivering (mainly in infants > 3 months).
These increase total body oxygen consumption and produce metabolic acidosis and
often hypoglycemia (not hyperglycemia). Hypothermia also can depress ventilation, decrease metabolism of drugs, prolong the duration of action of nondepolarizing muscle relaxants, produce coagulopathies and platelet dysfunction, and increase wound infections.
Wound healing can be impaired
as a result of impaired immune function, as well as a result of decreased blood supply from vasoconstriction.
Pierre-Robin sequence is characterized by cleft palate, micrognathia and:
A. Craniosynostosis
B. Macroglossia
C. Glossoptosis
D. Microstomia
C. Glossoptosis
Pierre-Robin Syndrome is characterized by micrognathia (small mandible), cleft palate, and glossoptosis (downward displacement/retraction of the tongue.
Suppose you want to give a scopolamine patch to prophylactically address PONV of your patient. What is the onset of action if patch is used?
A. 2 hours
B. 1 hour
C. 30 minutes
D. 15 minutes
Scopolamine patches can be safely used in children over age 10, but must be applied early as the onset of action is 2 to 3 hours
A 6-year-old male is scheduled for an elective inguinal hernia repair, but his mother mentioned that he consumed grape juice at 7 a.m. According to ASA guidelines, at what time would you expect the child to achieve an optimal NPO (nothing by mouth) status?
A. 11 am
B. 9am
C. 8am
D. 1pm
B. 9am
Induction of general anesthesia for an elective operation should be delayed how many hours after breastfeeding?
A. 2 hours
B. 4 hours
C. 6 hours
D. No fasting needed because breast milk is OK
B. 4 hours
Which of the following is ACCURATE when dealing with pediatric patient with a difficult airway?
A. Ask for help before you start
B. Use supplemental oxygen during and between attempts.
C. Use advanced airway techniques for your FIRST attempt.
D. Do not persist with failing techniques
E. All of the above
E. All of the above
CARDINAL RULES in pediatric difficult airway.
Updated guidelines for management of the difficult airway were recently published by the ASA. Key points for pediatric practice include:
Ask for help before you start.
Use supplemental oxygen during and between attempts.
Use advanced airway techniques (e.g., video laryngoscopy) for your FIRST attempt.
Do not persist with failing techniques
Do not persist with failing
providers
Do not delay emergency front of neck access if you cannot
oxygenate
A 10 month old patient is admitted for what seems to be pyloric stenosis. Based on the patient’s hemodynamics, volume depletion is apparent. Which of the following medications should be LEAST likely used for induction of this patient?
A. Thiopental
B. Midazolam
C. Etomidate
D. Atropine
A. Thiopental
Because of the large volume of distribution in neonates, it may be necessary to use large doses of thiopental for induction of anesthesia.
However, because of its reduced clearance, the effect may last longer than anticipated. Thiopental can cause hypotension in neonates who are volume depleted, especially in infants presenting for emergency surgery.
In the context of pediatric cardiac pre-operative preparation, which of the following drugs SHOULD be DISCONTINUED prior to a cardiac surgery?
A. Beta-blocker
B. Ca channel blocker
C. Diuretics
D. Alpha-agonist
C. Diuretics
Plasma level of this ___ primarily increases with resultant brown fat metabolism as a response to hypothermia:
A. Norepinephrine
B. Epinephrine
C. Vasopressin
D. Enkephalins
E. Prostacyclin
A. Norepinephrine
Suppose you will administer a SINGLE dose of BUPIVACAINE via CAUDAL block to an infant, what is the RECOMMENDED dose?
A. 0.25%
B. 0.75%
C. 0.5%
D. 0.1%
A. 0.25%
Single CAUDAL BLOCK dose
Bupivacaine - 0.25% or 0.125%
Ropivacaine - 0.2%
This is the accepatable PaO2 in the premature infant to minimize the risk of retinopathy of prematurity?
A. 50 -70 mmHg
B. 20 - 30 mmHg
C. 10 - 15 mmHg
D. 70 - 90 mmHg
A. 50 -70 mmHg
A Pao2 between 50 and 70 mm Hg or an oxygen saturation between 88% and 93% should be maintained during anesthesia in the premature neonate to minimize the risk of retinopathy of prematurity.
Which of the following medications CANNOT be given to a patient with suspected myotonia?
A. Neostigmine
B. Propofol
C. Meperidine
D. Diazepam
A. Neostigmine
Neostigmine inhibits acetylcholinesterase, thereby increasing acetylcholine at the neuromuscular junction.
This increase in acetylcholine causes increased muscle activation and has been associated with myotonias
