ITE Peds 2

Question 1

Pt with Tetralogy of fallot becomes hypoxic and cyanotic during inhalational induction. What is the likely cause and treatment?

Answer 1

Tet spell

• d/t R to L shunting
• d/t increased and worsening PVR and blood is shunted through VSD

Phenylephrine

• increase SVR -> increases pulmonary blood flow -> decreases R to L shunt -> improves end organ perfusion pressures
• Reflex bradycardia reduces hypercontractility and limits RVOT

Question 2

4 cardiac lesions of TOF

Answer 2

1. VSD
2. Overriding aorta (aorta sits on top of VSD)
3. Infundibular pulmonic stenosis
4. RVH -> RVOT

Question 3

Isoproterenol is a ______. and causes cardiac muscle _____, and vascular smooth muscle ______

Answer 3

nonselective beta-agonist

• cardiac m contraction
• sm relaxation

*worsens TET spell

Question 4

Milrinone is a ______. Causes cardiac muscle _____ and vascular smooth muscle ____

Answer 4

phosphodiesterase type 3 inhibitor

• cardiac m contraction
• sm relaxation and decreases SVR.

*worsens TET spell

Question 5

Goals of anesthetic management of TOF (3)

Answer 5

1. maintaining SVR
2. reducing HR and contractility
3. ensuring adequate oxygenation and normocarbia

Question 6

Management of post op obstructions in pts following cleft palate and lip repairs

Answer 6

positional changes
- proning

Avoid nasal or oral airways - damage the surgical repair

Question 7

Which pain medication is NOT recommended for children following T&A?

Answer 7

Codeine

• shown to inc pain post op
• FDA black box warning in children following T&A if they are rapid metabolizers

Question 8

Codeine is and inactive medication that becomes ____ after CYP __ metabolism. It has a wide polymorphism in metabolic pathway (some metabolize it rapidly, and others do not metabolize it at all)

Answer 8

morphine

CYP 2D6

Question 9

Why are pain control response more predictable with morphine and oxycodone vs codeine?

Answer 9

Morphine and oxy are active and do not require metabolism for activation

Codeine is inactive and requires CYP2D6 metabolism

Question 10

Why is pulmonary edema a possible complication of post-tonsillectomy procedures?

Answer 10

Airway obstruction is relieved by tonsillectomy ->
increase negative inspiratory pressure ->
Increases pulmonary venous return and blood volume

Question 11

Cardiomyopathy from repeated transfusions is most likely found in pts d/t ____ and _____

Answer 11

iron overload and hemosiderosis

Question 12

Thalassemias are a variety of hemolytic anemia disorders in which the ratio of ____ to ____ units is unequal.

Answer 12

alpha to beta globin units

Question 13

A pt with longstanding ostium primum defect (ASD) presents with dyspnea, SOB at baseline, and dec exercise tolerance indicates that the pt has _____, and is at risk for arrhhythmias.

Answer 13

pulmonary HTN

Question 14

Permissive hypercapnia is not ideal for pts with pulmonary HTN bc it ______

Answer 14

increases pulmonary vascular resistance and worsens pulm HTN

Question 15

Benzodiazepines act (Centrally/Peripherally) to potentiate GABA, which activates chloride channels and hyperpolarize the membranes, thus having muscle-relaxing properties

Answer 15

centrally

Question 16

GABA is an (excitatory/inhibitory) neurotransmitter that controls the state of chloride ion channels

Answer 16

inhibitory

Question 17

Infants have a more (cephalad/caudad) larynx than adults at C __ level

Answer 17

cephalad, C3,4

as the infant grows, the neck lengthens and moves caudal C5,6

Question 18

How do the vocal cords differ in infants vs adults?

Answer 18

Adults
- perpendicular vocal cords to trachea

Infants

• angled vocal cords
• anterior insertion is lower than posterior insertion

Question 19

Why is nitrous oxide contraindicated in pts with air filled cavities like emphysema?

Answer 19

Nitrous oxide is poorly dissolved in blood and will ppt out into air filled cavities and expand the cavity

Question 20

Induction of anesthesia for pts with congenital emphysema includes _______ and ______

Answer 20

spontaneous ventilation

minimal peak inspiratory pressure

*Avoid nitrous oxide

Question 21

Myelination of nerve fibers in the pediatric population is (accelerated/delayed) compared to adults, which leads to faster onset time and shortened duration.

Answer 21

delayed

- easier intraneural penetration of LA

Question 22

(higher/lower) cognitive function in children leads to increased preoperative anxiety

Answer 22

higher

Question 23

Pts with myelomeningocele often have associated ____ defects.
Neuraxial anesthesia is contraindicated d/t potential _____ and _____.

Answer 23

arnold-chiari malformation 80%

herniation of cerebellar tonsils and hydrocephalus

Question 24

Neural tube defects include (3), in order of worsening severity

Answer 24

1. spina bifida occulta
2. meningocele
3. myelomeningocele

Question 25

NTD occurs during the ___ week of embryonic development, during neural tube pore closure, prevention with _____ supplementation is important.

Answer 25

3rd - before most women realize they are pregnant Folate

Question 26

Hypothermia in neonates and infants if left uncorrected, can result in ______, from nonshivering thermogenesis and metabolism of brown fat.

Answer 26

metabolic acidosis

Question 27

How does metabolic acidosis arise in infants after prolonged hypothermia?

Answer 27

Skin and core temp difference -> Hypothalamus stimulates release of norepi -> Norepi binds receptors on brown fat cells -> Activates breakdown of fatty acids -> Consumes oxygen and glucose -> Promotes ketone production -> metabolic acidosis

Question 28

Examples of Active humidifiers

Answer 28

Nebulizers | Vaporizers

Question 29

Maximum allowable blood loss equation

Answer 29

EBV x (pt starting Hct - min acceptable hct) / Pt's starting Hct

Question 30

What is the minimum acceptable hct lvl in children?

Answer 30

20%

Question 31

Neonatal myasthenia gravis usually resolves w/in ___ weeks, after maternal antibodies (anti-AChR) that were transferred across the placenta are metabolized

Answer 31

2-4 weeks

Question 32

Neonatal myasthenia gravis (decreased muscle tone, feeding/respiratory difficulties) occurs in __% of babies born to mother with myasthenia gravis

Answer 32

20%

Question 33

Treatment of neonatal myasthenia gravis

Answer 33

Same as adult MG | - anticholinesterases or acetylcholinesterase inhibitors

Question 34

Pts with myasthenia gravis response to succinylcholine and nondepolarizing NMB agents

Answer 34

resistance to succinylcholine sensitivity to nondepolarizing NMB agents

Question 35

Marfan syndrome can have (obstructive/restrictive) pulmonary defects

Answer 35

both obstructive - pneumothorax - emphysema restrictive - pes excavatum: restrictive lung disease - kyphoscoliosis

Question 36

Hydralazine is an arteriolar (vasodilator/vasoconstrictor) and can cause significant reflex tachycardia

Answer 36

vasodilator

Question 37

Nitric oxide, epoprostenol, and sildenafil have all been shown to (increase/reduce) pulmonary HTN in children

Answer 37

reduce

Question 38

Sildenafil is a _____, and can help with pulmonary vasodilation cause by endogenous nitric oxide

Answer 38

PDE5 inhibitor

Question 39

Pt with TOF becomes hypotensive after induction, how does applying pressure to abdomen help combat decreased systemic vascular resistance?

Answer 39

During induction, the pt has worsening R to L shunt. Applying pressure increases preload and increases afterload and improves shunt conditions *shoulda induced with ketamine, not propofol

Question 40

Nitrous oxide causes an (increase/decrease) in pulmonary vascular resistance. In pts with VSD, this causes a _ to _ shunt

Answer 40

increase R to L

Question 41

What does VACTERL stand for?

Answer 41

congenital anomalies ``` Vertebral defects Anal atresia Tracheoesophageal fistula with Esophageal atresia Radial dysplasia Limb abnormalities ```

Question 42

Most common type of tracheoesophageal fistula

Answer 42

type IIIb - upper esophagus ends in blind pouch - lower esophagus connects to trachea

Question 43

Down syndrome abnormalities of concern to anesthesiologists (6)

Answer 43

1. short neck 2. atlantooccipital instability 3. irregular dentition 4. mental retardation 5. hypotonia 6. large tongue 7. 40% congenital heart disease

Question 44

Down syndrome abnormalities of concern to anesthesiologists (6)

Answer 44

1. short neck 2. atlantooccipital instability 3. irregular dentition 4. mental retardation 5. hypotonia 6. large tongue