CHAPTER 43 | Pediatric Anesthesia

Question 1

For patients under 7 years old without a difficult airway who have undergone a volatile based anesthetic, which of the following features have been significantly
associated with AWAKE tracheal extubation success:

A. conjugate gaze
B. tidal volume 4ml/kg
C. withdraws to pain upon suctioning the oropharyngeal airway
D. presence of gag reflex

Answer 1

A. conjugate gaze

An awake extubation is performed when the patient has return of protective airway reflexes. Various criteria are used to determine readiness for awake extubation. Depending on age and developmental status, following commands may not be attainable in the pediatric population. For patients under 7 years old without a difficult airway who have undergone a volatile-based anesthetic, the following five features have been significantly associated with tracheal extubation success:

1. conjugate gaze
2. facial grimace
3. eye opening
4. purposeful movement, and
5. tidal volume greater than 5 mL/kg160

Question 2

Which of the following factors is highly associated with an UNSUCCESSFUL extubation:

A. URTI within 48 hours of the procedure
B. Premedication with midazolam in patients over one month old
C. End-tidal carbon dioxide (ETCO2) greater than 55 mmHg
D. Conjugate gaze

Answer 2

C. End-tidal carbon dioxide (ETCO2) greater than 55 mmHg

Factors associated with an unsuccessful
extubation include:

1. URI within 7 days of the procedure
2. premedication with midazolam in patients over one year old, and
3. end-tidal carbon dioxide (ETCO2) greater than 55 mmHg

Question 3

TRUE or FALSE

Successful tracheal extubation does not have a universal definition but may be defined as:

Lack of oxygen desaturation below 92% or desaturation below 92% for <30 seconds

Patient requiring CPAP with 100% oxygen for <30 seconds.

Answer 3

TRUE

Successful tracheal extubation does not have a universal definition but
may be defined as:

1. lack of oxygen desaturation below 92% or desaturation below 92% for
   <30 seconds and
2. patient requiring CPAP with 100% oxygen for <30 seconds.

Barash | 9th edit
Pediatric Anesthesia

Question 4

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

Answer 4

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.

Question 5

Conventionally, post-extubation stridor typically manifests WITHIN 30 minutes after tracheal extubation. Which of the following is NOT a RISK FACTOR in developing post-extubation stridor?

A. use of a larger endotracheal tube
compared to that recommended for the patient’s size

B. prolonged tracheal intubation

C. history of multiple intubations or multiple intubation attempts

D. uncuffed endotracheal tubes are highly protective against airway complications

Answer 5

D. uncuffed endotracheal tubes are highly protective against airway complications

Post-extubation stridor typically manifests within 30 minutes after tracheal
extubation. Risk factors include:

(1) use of a larger endotracheal tube
compared to that recommended for the patient’s size

(2) prolonged tracheal
intubation

(3) history of multiple intubations or multiple intubation attempts

Question 6

A 7 year old male, ASA II patient underwent tonsillectomy. 1 hour post-operatively, He suddenly developed hypoxia, course breath sounds, and pink frothy sputum. What is your primary consideration of his current post-operative status?

A. Negative pressure pulmonary edema

B. Post-operative stridor

C. Anaphylaxis

D. Post-operative apnea

Answer 6

A. Negative pressure pulmonary edema

Negative pressure pulmonary edema (NPPE) is noncardiogenic pulmonary
edema that develops following severe acute upper airway obstruction.

The incidence is reported as 0.05% to 0.1% for all anesthetics.

Risk factors include male gender, younger age, prolonged procedure time, active smoking, and endotracheal intubation.

Question 7

Which of the following is NOT a risk factor in developing NEGATIVE PRESSURE EDEMA?

A. Female

B. Younger age

C. prolonged procedure time

D. Active smoking

E. endotracheal intubation

Answer 7

A. Female

Risk factors include:

male gender
younger age
prolonged procedure time
active smoking
endotracheal intubation

Question 8

TRUE or FALSE

Negative pressure pulmonary edema (NPPE) is noncardiogenic pulmonary
edema

Answer 8

TRUE

IT IS NOT A CARDIOGENIC PULMONARY EDEMA

Question 9

TRUE or FALSE

Muscular teenagers who are able to
generate large intrathoracic negative pressure should be considered high
risk in developing negative pressure edema

Answer 9

TRUE

Muscular built > High-risk to develop NEGATIVE PRESSURE PULMONARY EDEMA

Question 10

During an inguinal hernia repair, a newborn infant will have a larger fluid requirement (in milliliters per kilogram) than an adult because of relatively greater

(A) insensible water loss
(B) lean body mass
(C) metabolic rate
(D) sodium loss
(E) third space losses

Answer 10

C. Metabolic rate

Question 11

The capnographic tracing is from a 2-month-old infant anesthetized using a pediatric circle system and mask at a fresh gas flow of 4 L/min. The sampling port is in the elbow connector. The tracing in the picture indicates:

(A) adequate alveolar ventilation
(B) exhausted soda lime
(C) expired halothane concentrations representative of alveolar concentrations
(D) mixing of inspired and expired gases
(E) the need to change to a Mapleson D circuit

Answer 11

D. mixing of inspired and expired gases

Question 12

Compared with normal adults, which of the following characteristics of neonates best explains the more rapid inhalation induction in neonates?

(A) Greater cardiac index
(B) Greater metabolic rate
(C) Greater perfusion of vessel-rich tissues
(D) Greater ratio of alveolar ventilation to functional residual capacity
(E) Less lean body mass

Answer 12

(D) Greater ratio of alveolar ventilation to functional residual capacity

Because the FRC in the newborn is comparable to that of the older child or adult, but the minute ventilation is much higher, the ratio of minute ventilation to FRC is two to three times higher in the newborn.

The clinical significance of this ratio is twofold. First, anesthetic induction with a
volatile anesthetic agent should be faster, as should emergence.

Second, the decrease in FRC relative to minute ventilation and oxygen consumption
means that there is less “oxygen reserve” in the FRC compared to that of older children and adults. There will be a more rapid drop in arterial oxygen levels in the newborn in the presence of apnea or hypoventilation

Question 13

Which of the following respiratory physiology is CORRECT among INFANT patients in comparison to adult?

A. Frequency of breath in infant patient is 20-30 cpm

B. TV of 7ml/kg

C. Alveolar ventilation ratio of 80 ml/kg/min

D. Oxygen consumption of 3-5 ml/kg/min

Answer 13

B. TV of 7ml/kg

Question 14

A 2600-g neonate is to undergo surgical repair of a small gastroschisis. The infant is preoxygenated with 100% oxygen. Arterial hemoglobin desaturation is noted during laryngoscopy after a rapid-sequence induction. Which of the following is the most likely cause?

(A) High fetal hemoglobin concentration
(B) High ratio of oxygen consumption to functional residual capacity
(C) Low functional residual capacity in milliliters per kilogram
(D) Poor thoracic compliance
(E) Patent ductus arteriosus

Answer 14

(B) High ratio of oxygen consumption to functional residual capacity

Question 14

A 2-year-old child has cardiac arrest during an inguinal herniorrhaphy under general anesthesia administered during a Jackson-Rees system. The graph shows end-tidal PCO2 monitored from the tip of the endotracheal tube during cardiopulmonary resuscitation; minute ventilation is unchanged. Which of the following is the most likely cause of the change beginning at the arrow?

(A) Decreased fresh gas flow
(B) Inadequate chest compression
(C) Increased dead space
(D) Restoration of cardiac output
(E) Sampling artifact

Answer 14

(D) Restoration of cardiac output

Question 15

The portion of the infant airway with the smallest cross-sectional area occurs at the level of the:

(A) cricoid cartilage
(B) false vocal cords
(C) thoracic inlet
(D) tonsillar pillars
(E) true vocal cords

Answer 15

(A) cricoid cartilage

In adults, the narrowest aspect of the upper airway is at the vocal cords, but in the neonate there is further narrowing ending at the level of the cricoid ring, the first complete cartilaginous ring.

Although studies have challenged the funnel shape in infants and children, there has been no study further clarifying this relationship in neonates

Question 16

In the premature infant, the GLOTTIS is at the level of which cervical vertebrae:

A. C3
B. C4
C. C6
D. C5

Answer 16

A. C3

Cervical level and GLOTTIS

3 = Preterm
4 = Fullterm
5-6 = Adult

Question 17

A full-term infant is expected to have the glottis at which cervical level:

A. C3
B. C4
C. C6
D. C7

Answer 17

B. C4

Cervical level and GLOTTIS

3 = Preterm
4 = Fullterm
5-6 = Adult

Question 18

The combination of a large tongue and a relatively cephalad glottis in INFANT means that on laryngoscopic examination:

A. It is more difficult to establish a direct line of vision between the mouth and the larynx

B. There is relatively less tissue in a
smaller distance

C. The infant’s larynx appears to be posterior and cephalad

D. the tip of the epiglottis lies at C3 and its close apposition with the soft palate allows the newborn to simultaneously suckle and breathe

Answer 18

A. It is more difficult to establish a direct line of vision between the mouth and the larynx

Question 19

The principal rationale for the use of warmed humidified inspired anesthetic gases in children is to:

(A) decrease postoperative respiratory complications
(B) decrease postoperative shivering
(C) preserve ciliary function
(D) prevent dehydration
(E) prevent evaporative heat loss

Answer 19

(E) prevent evaporative heat loss

Question 20

Which of the following is the primary physiologic response in a neonate exposed to a hypothermic environment?

(A) Hyperventilation
(B) Increased 2,3-DPG concentration in erythrocytes
(C) Metabolism of brown fat
(D) Shivering
(E) Vasoconstriction

Answer 20

(C) Metabolism of brown fat

Question 21

Compared with adults, caudal anesthesia in children is associated with

(A) higher risk for subarachnoid puncture
(B) more severe hypotension
(C) more rapid onset of sensory block
(D) smaller volume of anesthetic per kilogram of body weight
(E) toxic effects at lower serum levels of bupivacaine

Answer 21

(A) higher risk for subarachnoid puncture

Question 22

Each of the following structures may participate in causing acute bradycardia during strabismus surgery EXCEPT the

(A) globe
(B) rectus muscles
(C) optic nerve
(D) trigeminal nerve
(E) vagus nerve

Answer 22

(C) optic nerve

Question 23

A 35-kg child requires mechanical ventilation with pure oxygen at a tidal volume of 350 ml and a rate of 20/min during a severe asthma attack. The most likely cause of severe hypotension after initiating mechanical ventilation is

(A) hypoxic circulatory depression
(B) inadequate expiratory time
(C) increased pulmonary vascular resistance
(D) respiratory alkalosis
(E) tension pneumothorax

Answer 23

(B) inadequate expiratory time

Question 24

Which of the following is the most likely effect of intramuscular ketamine used for induction of anesthesia in a 2-year-old child undergoing elective surgery?

(A) Bronchoconstriction
(B) Decreased heart rate
(C) Decreased intracranial pressure
(D) Increased salivation
(E) Respiratory depression

Answer 24

(D) Increased salivation

Question 25

In pediatric patient, Perioperative respiratory adverse events
(PRAEs) includes the following EXCEPT:

A. bronchospasm
B. laryngospasm
C. severe persistent coughing
D. Oxygen desaturation and stridor
E. Negative pressure pulmonary edema

Answer 25

E. Negative pressure pulmonary edema

Perioperative respiratory adverse events
(PRAEs) include:

bronchospasm
oxygen desaturations
laryngospasm
severe persistent coughing
stridor
airway obstruction
apnea

BOLSSAA

The patients at highest risk include
neonates, those with a current or recent upper respiratory infection, and those with chronic lung disease.

Question 26

Pierre Robin sequence clinical features include the following EXCEPT:

A. micrognathia
B. airway distress in the first 24 to 48 hours after birth
C. Glossoptosis
D. improvement of the condition as age increases
E. macrognathia

Answer 26

E. macrognathia

Pierre Robin sequence:

micrognathia
airway distress in the first 24 to 48 hours after birth
Glossoptosis
improve with age, although in severe cases Surgical airway may be needed.

Question 27

Which of the following is NOT a clinical feature of Treacher Collins syndrome?

A. Hypoplasia of the zygomatic complex, cheekbones, jaw, palate and mouth,

B. Downward slanting palpebral fissures

C. Easier to manage surgically as age advances

D. It present with difficulty in bot mask ventilation and tracheal intubation

Answer 27

C. Easier to manage surgically as age advances

Treacher Collins syndrome:

(hypoplasia of the zygomatic complex, cheekbones, jaw, palate and mouth,
with downward slanting palpebral fissures) become progressively more difficult to manage with age

• both difficulties in mask ventilation and tracheal intubation.

Question 28

TRUE

The cricoid ring is the only complete
ring of cartilage in the airway and functionally forms the narrowest point.

Answer 28

TRUE

Question 29

The rate at which inhaled anesthetics are washed into the body and become
clinically effective is determined by three factors. WHICH OF THE FOLLOWING IS NOT A FACTOR that reflect drug delivery to the lungs :

A. Inspired concentration
B. Alveolar ventilation
C. FRC
D. Tidal Volume

Answer 29

D. Tidal Volume

The rate at which inhaled anesthetics are washed into the body and become
clinically effective is determined by three factors that reflect drug delivery to
the lungs:

Inspired concentration
Alveolar ventilation
FRC

Question 30

Which is INACCURATE in terms of airway management of the pediatric patient?

A. For laryngoscopy, the child is often positioned flat on the table with the
head stabilized with a gel ring to prevent lateral movement

B. LMAs complications in pediatric patients include sore throat, gastric insufflation, aspiration, large airway leak, laryngospasm, and bronchospasm

C. In neonates, ETT may become dislodged or endobronchial with movement of as little as 1 cm

D. The depth of nasal tubes is typically 20% to 30% more than an oral tube

E. Uncuffed tubes are frequently used in less than 1 year old because of its propensity to high volume and high pressure thereby exerting less pressure on the trachea

Answer 30

E. Uncuffed tubes are frequently used in less than 1 year old because of its propensity to high volume and high pressure thereby exerting less pressure on the trachea

Question 31

According to BARASH, the most appropriate ET tube for a premature infant weighing <1,500g is:

A. 2.5 UNCUFFED

B. 3.0 UNCUFFED

C. 3.5 UNCUFFED

D. 3.0 CUFFED

Answer 31

A. 2.5 UNCUFFED

Question 32

Why we don’t commonly use MAINSTREAM CAPNOGRAPHY in newborn or infant?

Answer 32

It can INCREASE DEAD SPACE

• Mainstream capnography is rarely used in pediatric anesthesia, particularly in infants and neonates, because it increases dead
  space, must be fitted at the endotracheal tube/elbow, and is heavy—which can lead to kinking or obstructing of the endotracheal tube.

Sidestream capnography provides accurate data, even in neonates who have small tidal volumes.

Question 33

Ideally, the CORE body temperature is monitored among pediatric patients because they have a very dramatic thermoregulation changes intraoperatively. Core temperature is ideally monitored at:

A. Mid-esophagus

B. Distal-esophagus

C. Rectal

D. Nasopharynx

E. Tympanic membrane

Answer 33

A. Mid-esophagus

Monitoring at the mid-esophagus
is ideal, though rectal or nasopharyngeal temperature probes may also be
used.

If monitoring core temperature is not feasible due to patient anatomy or
competition with the surgical site, alternative monitors may be used.

Accurate monitoring of temperature is critical for early detection of MH, fever, and hypothermia. Hypothermia delays
emergence from inhalational anesthesia, decreases the rate of metabolism of
many medications, and increases risk of surgical site infections

Question 34

Intraoperatively, which measures DO NOT CONTRIBUTE in the reduction of Heat loss among pediatric patients?

A. wrapping exposed areas of the
anesthetized child with plastic sheets or blankets

B. IV fluid warmers

C. use of high fresh gas flows

D. use of humidity trap in the breathing circuit

Answer 34

C. use of high fresh gas flows

The heater must be placed an appropriate distance from the patient to reduce the
risk of burns.

Heat loss can be reduced by wrapping exposed areas of the anesthetized child with plastic sheets or blankets, IV fluid warmers, use of low fresh gas flows, and a humidity trap in the breathing circuit.

Question 35

Hypothermia can have catastrophic clinical implications intraoperatively. Which of the following is INACCURATE in terms of the effect of Hypothermia?

A. Delays emergence from inhalational anesthesia

B. Decreases the rate of metabolism of
many medications

C. Increases risk of surgical site infections

D. Decreases the coagulation cascades and glycemic-control

Question 36

Evidence-based medicine suggests that maintaining an adequate depth of anesthesia can be achieved using a minimum, end-tidal, age-adjusted, anesthetic MAC of:

A. 0.7

B. 0.5

C. 1.0

D. 1.2

Answer 36

A. 0.7

The incidence is higher in cardiac and open abdomen procedures. Maintaining
adequate depth of anesthesia can be achieved using a minimum, end-tidal,
age-adjusted, anesthetic MAC of 0.7, and/or the use of processed EEG monitoring.

KEYPOINT:

Adequate depth of anesthetic: MINIMUM end-tidal MAC of 0.7

Question 37

TRUE or FALSE

Quantitative twitch monitors can be used in children including neonates.

Answer 37

TRUE

QUANTITATIVE TWITCH MONITORS is the GOLD standard.

Question 38

In the context of EMERGENCY surgical procedure among adult and pediatric patients, What is a FULL STOMACH?

Answer 38

“full stomach” refers to the presence of residual solid or liquid foods in the stomach at induction of anesthesia.

A full stomach is assumed to be
present in children who require emergency surgery and have not waited the
appropriate recommended fasting time, infants with pyloric stenosis, those with gastric dysmotility syndromes including short gut, and those who display evidence of gastroparesis.

Question 39

In a modified RSI, what is minimum pressure if I want to BAG-MASK ventilate a patient?

Answer 39

10 - 20 cm H20

It is still considered a low-pressure (10 to 20 cm H2O) mask ventilation hence it is SAFE.

Question 40

All are ACCURATE when a difficult airway is considered among pediatric patients EXCEPT?

A. Patients under 10 kg are potentially at higher risk

B. Ask for help before you start

C. Use of O2 supplements during and between attempts

D. DO NOT persist with failing techniques

E. Delay FONA (front of neck access) as much as possible as this possess higher incidence of morbidity and mortality

Answer 40

E. Delay FONA (front of neck access) as much as possible as this possess higher incidence of morbidity and mortality

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, and do not delay emergency front of neck access if you cannot
oxygenate.

Question 41

Difficult bag-mask ventilation is expected in all of the following conditions EXCEPT:

A. Down syndrome

B. Beckwith-Wiedemann syndrome

C. Apert Syndrome

D. Crouzon Syndrome

E. ALL OF THE ABOVE are accurate

Answer 41

E. ALL OF THE ABOVE are accurate

The large tongue in Down syndrome and in Beckwith–
Wiedemann syndrome can make mask ventilation difficult, as can the facial anomalies that are seen in Crouzon syndrome and Apert syndrome.

Question 42

Which of the following INACCURATE regarding inhalation anesthetics among pediatric patients?

A. As the fetus matures and reaches term, the MAC increases, peaking in infants beyond 6 months of age

B. The MAC of halothane is 25% less in children who are taking seizure medications

C. Isoflurane is not a good option for Inhalation induction

D. R - L shunts have limited effects on the uptake and distribution of inhalational anesthetics provided the cardiac output is maintained

Answer 42

B. The MAC of halothane is 25% less in children who are taking seizure medications

As the fetus matures and reaches
term, the MAC increases, peaking in infants 1 to 6 months of age, and then decreases steadily thereafter with increasing age

Isoflurane and Desflurane are not good inhalation inducting agents.

Left-to-right shunts have limited
effects on the uptake and distribution of inhalational anesthetics provided the
cardiac output is maintained. However, right-to-left shunts present a more complex clinical situation.

Question 43

Patient A is an 8 year old with ASA II classification for controlled asthma. Local anesthesia was done at the ambulatory clinic with lidocaine and epinephrine. What inhaled agent should be avoided in patient’s who have been immediately exposed with epinephrine?

A. Isoflurane

B. Halothane

C. Xenon

D. Nitrous Oxide

Answer 43

B. Halothane

Halothane is particularly prone to causing bradydysrhythmias
and was often given with an anticholinergic such as atropine.

Halothane is also associated with ventricular dysrhythmias, particularly in the presence of circulating epinephrine.

Question 44

what is the ED50 of Propofol necessary to insert LMA?

A. 3.5mg/kg

B. 2 mg/kg

C. 1.5 mg/kg

D. 5.4 mg/kg

Answer 44

A. 3.5mg/kg

The ED50 and ED90 of propofol necessary to insert a laryngeal
mask airway (LMA) in children is 3.5 and 5.4 mg/kg, respectively.

The dose of propofol necessary to facilitate tracheal intubation in children during sevoflurane anesthesia is 1 to 2 mg/kg.

Question 45

What is the dose of Propofol necessary to facilitate tracheal intubation in children during sevoflurane anesthesia?

A. 1mg/kg with 8 vol% sevoflurane

B. 3 - 5mg/kg

C. 1 - 2 mg/kg

D. 5.4 mg/kg

Answer 45

C. 1 - 2 mg/kg

The ED50 and ED90 of propofol necessary to insert a laryngeal
mask airway (LMA) in children is 3.5 and 5.4 mg/kg, respectively.

The dose of propofol necessary to facilitate tracheal intubation in children during sevoflurane anesthesia is 1 to 2 mg/kg.

Question 46

What is the dose of ketamine if to be given as ORAL premedication?

A. 5 - 6mg/kg

B. 10mg/kg

C. 3 mg/kg

D. It should not be given orally

Answer 46

A. 5 - 6mg/kg

KETAMINE can be given via (oral, nasal, rectal, or intramuscular [IM]), a general anesthetic induction agent (IV or IM), a maintenance agent as an infusion (IV), or as a neuraxial analgesic (caudal/epidural).

Question 47

If given to an UNCOOPERATIVE child via IM route. Ketamine is expected to produce a sedative effect in:

A. 10 minutes after

B. 5 - 10 minutes after

C. 3 - 5 minutes after

D. immediately after

Answer 47

C. 3 - 5 minutes after

For IM use, 2 to 5 mg/kg ketamine sedates an uncooperative child in 3 to 5 minutes with a duration of action of 30 to 40
minutes.

Question 48

TRUE or FALSE

Even with a 1 - 2mg/kg IV dose of KETAMINE during general anesthesia preserve the spontaneous respiration.

Answer 48

TRUE

General anesthesia may be induced with 1 to 2 mg/kg IV, a technique that is useful in children with cyanotic heart disease, septic shock, and conditions in which spontaneous respiration should be preserved, such as the
child with an anterior mediastinal mass.

Question 49

What is the recommended induction dose of ETOMIDATE among pediatric patients?

A. 0.3 mg/kg

B. 0.3 - 0.5 mg/kg

C. 0.1 mg/kg

D. 1mg/kg

Answer 49

A. 0.3 mg/kg

ETO -midately induced!

Question 50

What is IV inducting dose of NEONATE?

A. 4mg/kg

B. 2mg/kg

C. 5mg/kg

Answer 50

A. 4mg/kg

The IV dose of succinylcholine is 3 to 4 mg/kg in neonates and infants, 2 mg/kg in children, and 1 mg/kg in adolescents.

4 mg/kg Neonate
2 mg/kg Children
1 mg/kg Adolescents

Question 51

In healthy children during
sevoflurane anesthesia, what dose of ROCURONIUM can provide a suitable intubating condition in 2 to 3 minutes?

A. 1.2 mg/kg

B. 0.3 - 0.4 mg/kg

C. 1mg/kg

Answer 51

B. 0.3 - 0.4 mg/kg

The ED95 in infants is 0.25 mg/kg and in children is 0.4 mg/kg. In healthy children during sevoflurane anesthesia, 0.3 to 0.4 mg/kg rocuronium provides suitable intubating conditions in 2 to 3 minutes and permits antagonism within 20
minutes.

Question 52

In healthy INFANT, the ED95 of ROCURONIUM is?

A. 0.25 mg/kg

B. 0.4 mg/kg

C. 0.15 mg/kg

Answer 52

A. 0.25 mg/kg

The ED95 in infants is 0.25 mg/kg and in children is 0.4 mg/kg. In healthy children during sevoflurane anesthesia, 0.3 to 0.4 mg/kg rocuronium provides suitable intubating conditions in 2 to 3 minutes and permits antagonism within 20
minutes.

Question 53

The typical dose of NEOSTIGMINE pediatrics is:

A. 0.05 mg/kg

B. 0.5 mg/kg

Answer 53

A. 0.05 mg/kg

Doses can be repeated if full reversal is not achieved, but care
must be taken to avoid exceeding 0.1 mg/kg neostigmine, as acetylcholine associated
weakness may occur.

Question 54

The typical dose of GLYCOPYROLATE when used with neostigmine as a reversal agent among pediatric patient is:

A. 0.01 mg/kg

B. 0.1 mg/kg

Answer 54

A. 0.01 mg/kg

Question 55

TRUE or FALSE

The rocuronium/sugammadex complex is excreted UNCHANGED in the kidney.

Answer 55

TRUE

Question 56

Which of the following OPIOID is preferred among children with due to its long acting ability and absence of active metabolite and therefore cannot accumulate in the renally challenged pediatric patient?

A. Hydromorphone

B. Methadone

C. Remifentanil

D. Meperidine

Answer 56

A. Hydromorphone

Hydromorphone is a long-acting opioid analgesic. This μ-opioid receptor agonist is 5- to 10-fold more potent than morphine. Bolus dosing is 10 to 20 mcg/kg IV. It can also be used in IV infusions and in the epidural space.

Unlike morphine, hydromorphone does not have metabolites that are sedating or that can accumulate in renal failure, so it is the preferred long-acting opioid for children with renal impairment

Question 57

What is the dose of acetaminophen if given via rectal route?

A. 20 mg/kg

B. 15 mg/kg

C. 30 - 40 mg/kg

Answer 57

C. 30 - 40 mg/kg

Acetaminophen has no antiinflammatory properties and is also free of platelet inhibiting properties. Oral doses of 10 to 15 mg/kg or rectal doses of 30 to 40 mg/kg yield adequate blood concentrations.

Absorption after oral administration is rapid (∼10 to 15 minutes) whereas after rectal administration it is slow and
variable (1 to 2 hours). With an elimination half-life of 2 to 4 hours after any route, repeat doses may be administered every 4 to 6 hours, while maintaining the maximum 24-hour dose at less than 90 mg/kg.

Question 58

What is the maximum dose of Ibuprofen in 24 hours?

A. 1200 mg

B. 2400 mg

C. 4000 mg

D. 3000 mg

Answer 58

B. 2400 mg

Ibuprofen is a widely used analgesic, antipyretic, and anti-inflammatory agent in the perioperative period in children.

A dose of 10 to 15 mg/kg oral
(maximum 2,400 mg/24 hours)

Question 59

Midazolam as a premedication agent can be administered in this route EXCEPT:

A. Sublingual
B. intranasal
C. IM
D. Rectal
E. Intraosseus

Answer 59

E. Intraosseus

Question 60

As a premedication agent, Which of the following is correctly paired with respect to the choice of route and dosage of DEXMEDETOMIDINE:

A. Intranasal: 1 to 2 mg/kg

B. Oral: 1 to 2 mg/kg

C. IV: 0.3 mcg/kg/hr as loading dose

D. IM: 1mg/kg

Answer 60

A. Intranasal: 1 to 2 mg/kg

The oral dose, which requires 30 to 60 minutes to provide sedation, is 2 to 4 mcg/kg, with increasing doses being more effective, but with delayed recovery.

The intranasal dose is 1 to 2
mcg/kg with 1 mcg/kg sedating ∼60% of children within 1 hour.

The dose of IV dexmedetomidine may include a loading dose of 1 mcg/kg infused over 10 minutes, followed by an IV infusion of 0.3 to 0.7 mcg/kg/hr.

Question 61

What is the bradycardia dose of ATROPINE in pediatrics?

A. 20mcg/kg

B. 20 mcg IV bolus

C. 5mcg/kg

Answer 61

A. 20mcg/kg

Atropine is used in doses of 20 mcg/kg to treat or to prevent bradycardia due to vagal stimulation, such as during strabismus surgery with traction on the extraocular muscles

Question 62

Which of the following is the recommended dose of Epinephrine in cardiac arrests or symptomatic unstable bradycardia?

A. 0.1 mL/kg of 1:10,000

B. 0.01 ml/kg of 1:1,000

C. 0.5 ml/kg of 1:10,000

Answer 62

A. 0.1 mL/kg of 1:10,000

Pediatric anesthesiologists often have epinephrine available for emergency
use in cardiac arrests or symptomatic unstable bradycardia in a dose of 0.1
mL/kg of 1:10,000 (100 mcg/mL).