Paediatrics

Question 1

A term neonate is undergoing closure of gastroschisis under general anaesthesia with pressure control ventilation via an endotracheal tube. The estimated blood loss is 10 mL. Fluid therapy has been 4% albumin 40 mL/kg in addition to maintenance 10% dextrose 4 mL/kg/h. During closure of the defect, the oxygen saturation falls to 80%. The most likely cause of the desaturation is:

a) Pulmonary oedema/excessive fluids
b) Reduced Lung compliance
c) Undiagnosed congenital heart disease
4) Return to foetal circulation

Answer 1

b) Reduced Lung compliance

• Closure of abdominal wall post gastroschisis repair leads to significantly increased abdominal compartment pressures and can splint diaphragm. May need staged closure.

Term neonate = ~3.5 kg
40ml/kg = ~140mls in
Normal blood volume 90 x 3.5 = 315ml
10ml blood loss + added environmental losses from exposed bowel
The key is the timing with closure, and to be aware that staged closures are frequently done. Most likely answer is lung complicance, and PCV which would result in a reduction in volumes on closing.

Question 2

REview Duchenne muscular dystrophy is NOT associated with:

a) Increased CK
b) Cardiomyopathy in female carriers
c) decreased Sensitivity to non-depolarising NMBs

Alternative remembered answers:

a) Reisistant to NDNMB
b) Premature death
c) Aspiration
d) Conduction abnomality in females

Answer 2

Increased sensitivity to non depolarisers

Ck -> Anaesthesia induced rhabdo
Cardio- All at-risk females, regardless of their carrier status, should be monitored for development of cardiomyopathy

Question 3

Obstructive sleep apnoea in children is diagnosed with an apnoea-hypopnoea index
(AHI) of at least:

a) >1
b) >5
c) >10

Answer 3

a) >1

0 normal

Mild/mod/severe
1-5
5-10
>10

Question 4

A neonate with a postmenstrual age of 34 weeks (born at 26 weeks) and weighing
2 kg is undergoing retinal laser therapy under general anaesthesia. The oxygen
saturation is 92% on the following ventilator settings: FiO2 0.4; inspiratory pressure
15 cmH2O; PEEP 5 cmH2O; rate 24 breaths per minute. The most appropriate
course of action is to:

a) Increase FiO2 to 100
b) Suction tube
c) Increase PEEP to 7
d) Recruitment breath at 30cmh2o
e) Do nothing

Answer 4

E: Do nothing

Targets for premature babies:
* Volume-targeted or pressure-limited mode targeting tidal volumes of 5 ml kg1
* Ventilatory frequency: 30-60 bpm
* PEEP: 6-8 cmH2O
* Titrate above to maintain normocapnia or mild hypercapnia
* Titrate FIO2 to achieve SpO2 90-95%.

RCH guidelines

Question 5

During resuscitation of a newborn, the heart rate is noted to be 50 beats per minute
despite optimal ventilation and chest compressions. The next step in management
is to give intravenous adrenaline:

a) 0.1-0.3ml/kg 1:1000
b) 0.5-1ml/kg 1:10000
c) 0.1-0.3ml/kg 1:10000
d) 0.1-0.3ml/kg 1:100000

Answer 5

C

Anaphylaxis
Less than 6 - 0.15ml 1:1000
6-12 - 0.3ml 1:1000
Moderate allergy - 0.1ml/kg
Life threatening - 0.2 to 0.5ml/kg
(1mg in 50ml - 20mcg/ml)

Question 6

The minimum age in years for in vitro contracture testing for suspected malignant
hyperthermia is

a) 6
b) 8
c) 10
d) 12

Answer 6

10

All current Australian and New Zealand laboratories follow the guidelines of the European Malignant Hyperthermia Group for In Vitro Contracture Testing.

The EMHG guidelines are summarised as follows:

Age and Weight

The minimum weight limit for Australian and New Zealand laboratories is 30 kg and the minimum age for IVCT is 10 years.
(Emhg actually says min age for muscle biopsy is 4 yrs but lab’s should not test children under 10 yrs without relevant control data)

IVCT details

The biopsy should be performed on the quadriceps muscle (eithervastus medialisorvastuslateralis), using local (avoiding local anaesthetic infiltration of muscle tissue), regional, or trigger-free general anaesthetic techniques.

The muscle samples can be dissected in vivo or removed as a block for dissection in the laboratory within 15 minutes.

The time from biopsy to completion of the tests should not exceed 5 hours.

Muscle specimens should measure 20-25 mm in length and at least four tests should be performed each one using a fresh specimen.

The tests should include a static cumulative caffeine test and a dynamic or static halothane test.

The results should be reported as the threshold concentration, which is the lowest concentration of caffeine or halothane that produces a sustained increase of at least 2 mN (0.2 grams) in baseline force from the lowest force reached.

Question 7

A seven-year-old child is ventilated in the intensive care unit after an isolated closed head injury. Their serum sodium concentration is 142 mmol/L. The most appropriate intravenous maintenance fluid is:

a) 0.45% saline + 5% dextrose
b) 0.9% saline
c) CSL + 5% dextrose
d) CSL
e) 0.3% saline + 3% dextrose

Answer 7

STEPH https://www.rch.org.au/clinicalguide/guideline_index/Head_injury/

isotonic fluids (eg NaCl 0.9% recommended)

https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_fluids/

Glucose 5% should be given in maintenance fluids for children with no other source of glucose

On balance I’d put C.

Then found a remembered MCQ that just had NaCl 0.9% which is probably the right answer.

A kid this age in ICU with severe injury would get ng/og fed

Question 8

A 6-year-old child with a history of asthma is intubated and ventilated for tonsillectomy. During surgery, the SpO2 falls. You increase the FiO2 to 1.0 and hand-ventilate, and note that ventilation is difficult. The next step in the management is to:

a) Deepen anaesthesia
b) Give salbutamol
c) Ask surgeon to release gag

Answer 8

STEPH C

Question 9

A ten-year-old boy (weight 30 kg) has a displaced distal forearm fracture that requires manipulation and application of plaster. The volume of 0.5% lidocaine that should be used for intravenous regional anaesthesia (Bier block) is:

a) 9ml
b) 12ml
c) 15ml
d) 18ml
e) 36ml

Answer 9

REPEAT

0.5% lidocaine = 5mg/ml
Max dose - 3mg/kg
30kg = 90mg max dose for this pt.
90/5=18mls of 0.5% solution
Therefore D.

Question 10

An eight-year-old child with sickle cell disease is scheduled for emergency fixation of a fractured radius. Their preoperative haemoglobin (Hb) is 80 g/L. The most appropriate management is:

a) Proceed with careful haemostasis and check post op Hb
b) Transfuse to Hb >100
c) Blood type and screen
d) Exchange transfusion for HbSS <30%

Answer 10

REPEAT

b) transfuse for Hb >100
Emergency fixation means there is no time for an exchange transfusion

perioperative goals:
- planning and optimisation
- ensuring adequate O2 delivery
- hydration
- analgesia
- performed at a centre with a multidisciplinary sickle cell team

Children presenting for high-risk surgery (for example neurosurgical, cardiothoracic, or complex orthopaedic surgery) or high-risk children (previous stroke, acute CS, or end-organ damage), who were not included in this study, commonly receive an exchange transfusion or top-up transfusion, aiming for a preoperative haemoglobin concentration of 10 g dl−1 and Hb SS <30%. There is less evidence available for the role of transfusion in children with other forms of SCD.

Exchange transfusion vs. top-up transfusion
Exchange Transfusion:
- slowly removing the person’s blood and replacing with fresh donor blood or plasma
- Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body
- in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30%
- Exchange transfusion removes HbS and increases HBA

Top-up transfusion:
- standard transfusion process of giving donor blood
- advantages of simple top-up include:
1. Increase oxygen carrying capacity
2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA)
3. Prevent or reverse complications of vast-occlusion
4. Can be given acutely
- disadvantages include:
1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l)
2. HbS is not removed, only diluted

Question 11

In neonates, an imaginary line joining the most superior points of the iliac crests will cross the spinal interspace of:

a) L3-4
b) L4-5
c) L5-S1
d) S1-S2

Answer 11

c) L5-S1

https://www.nysora.com/pediatric-atlas-of-ultrasound-and-nerve-stimulation-guided-regional-anesthesia/chapter34-spinal-anesthesia-preview/

Question 12

A normal systolic arterial blood pressure in the awake term neonate is approximately:

a) 60
b) 70
c) 85
d) 90

Answer 12

REPEAT

70

Term 1 hr - 70
Term 12 hr - 66
Day 1 asleep - 70
Day 1 awake - 71
Week 2 - 78
Week 4 - 85

https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/blood-pressure-disorders#goto-noninvasive-bp-measuring

Question 13

A 10-year-old child (weight 30 kg) presents to the emergency department in status epilepticus. They have received one dose of 15 mg midazolam buccally prior to arrival to hospital. According to Advanced Paediatric Life Support Australia guidelines the next drug treatment should be intravenous:

a) Ketamine 15mg IV
b) Midazolam 4.5mg IV
c) Propofol RSI and burst suppression
d) Levetiracetam 1.2g IV

Answer 13

REPEAT

b) Midazolam 4.5mg IV

Status epilepticus is defined as:
- Continuous seizure activity for 5 minutes or more without return of consciousness,
- recurrent seizures (2 or more) without an intervening period of neurological recovery

So needs urgent treatment.

APLS (in order)
Midaz dose is 0.15/kg IV/IM or 0.3mg buccal/IN

After first dose, if still seizing, repeat midaz, IV/IO

Levetiracetam of phenytoin
Lev = 40-60mg/kg, phen = 20mg/kg)

RSI

1st line: Midazolam IV/IO/IM –> 0.15mg/kg
2nd line: Midazolam IV/IO/IM –> 0.15mg/kg
3rd line: Keppra 40mg/kg (max 3g)
4th line: Phenytoin 20mg/kg or phenobarbitone
5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone

Question 14

A 5-year-old child with severe life-threatening anaphylaxis and no intravenous access, the recommended initial dose of intramuscular adrenaline is:

a. 100mcg
b. 150mcg
c. 300mcg
d. 500mcg
e. 600mcg

Answer 14

Repeat A

Up to 6 years 150 IM
Over 6 years 300 IM

(ideally 10microg/kg)

Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min

Refractory management:
Additional IV fluid 20-40ml/kg,
Noradrenaline infusion 0.1- 2mcg/kg/min
Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV

Question 15

A four-year-old child weighing 15 kg develops severe laryngospasm during an inhalational induction. Intravenous access is unobtainable. The recommended dose of intramuscular suxamethonium is:

a) 15mg
b) 30mg
c) 60mg

Answer 15

4 x 15 = 60mg

Question 16

NP Self-report of pain in children is usually possible by the age of:

a. 2 yo
b. 4 yo
c. 6 yo
d. 8 yo

Answer 16

REPEAT

A) 4

4 yo = wong baker faces score 3-18.
8 yo = Visual analogue scale.

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/

APMSE 5 also

Question 17

When inadvertent total spinal anaesthesia occurs in an awake neonate, the first sign is most likely to be

Answer 17

MAYANK
? Options

Bronchospasm
Desaturation
Hypotension
Apnea
Bradycardia
Loss of consciousness

Question 18

22.1 A four-year-old boy is in refractory ventricular fibrillation. The recommended dose of amiodarone is

Answer 18

80mg

Age + 4 x 2-> 4 + 4 x 2 =16kg
5 x 16mg =80mg

Question 19

22.2 A four-year-old boy is in refractory ventricular fibrillation. The recommended dose of amiodarone is

a) 40mg
b) 80mg
c) 120mg
d) 160mg

Answer 19

80mg

Age + 4 x 2-> 4 + 4 x 2 =16kg
5 x 16mg =80mg

16kg x 5mg/kg = 80mg

Question 20

22.1 The risk of a perioperative respiratory adverse event in a child is least likely to be increased by

a. Asthma
b. Infection 3 weeks ago
c. History of eczema
d. Passive smoking

Answer 20

History of eczema

APRICOT study

Question 21

21.1 Predictors of successful awake extubation after volatile anaesthesia in infants include

a. 2mL/kg tidal volume,
b. grimacing
c. coughing
d. RR > 20

Answer 21

b. grimacing

conjugate gaze
facial grimace
eye opening
purposeful movement
tidal volume greater than 5 ml/kg

Source: SPANZA 2019 article

Question 22

21.1 Predictors of successful awake extubation after volatile anaesthesia in infants include

a. 2mL/kg tidal volume,
b. grimacing
c. coughing
d. RR > 20

Answer 22

b. grimacing

conjugate gaze
facial grimace
eye opening
purposeful movement
tidal volume greater than 5 ml/kg

Source: SPANZA 2019 article

Question 23

21.1 A baby is brought to the emergency department three days after a term home birth. It has not been feeding well and has had few wet nappies. The child is grey in appearance and femoral pulses are difficult to palpate. You note an enlarged liver and marked tachycardia. Pulse oximetry reveals
saturations of 75% despite oxygen being administered. You suspect a duct-dependent circulation. The best initial management is

a) Intubation and controlled ventilation
b) 20ml/kg crystalloid bolus
c) Alprostadil (PGE1)
d) Stop administration of oxygen

Answer 23

c) Alprostadil (PGE1)

From Paediatric BASIC on CHD:
- Resuscitation of an infant or newborn in shock should follow a standard approach regardless of the aetiology.
- Any patient with a duct dependent lesion either for pulmonary blood flow, or systemic output, will require PGE1. The problem is that whether or not a duct dependent lesion is present is unclear in most cases. If CHD has been diagnosed antenatally, PGE1 should be started.
- The cyanosed neonate presenting with severe cyanosis (O2 <75) and/or in extremis should be started on PGE1; the assumption being that the duct has closed and needs to be reopened.

Question 24

21.1 A neonate born by emergency caesarean section is limp, pale, has a weak grimace and weak cry, and a heart rate of 60 beats per minute. The Apgar Score is

A. 3
B. 4
C. 5
D. 6
E. 7

Answer 24

3

Question 25

22.1 A normal sized six-year-old girl has a haemoglobin of 70 g/L following surgery. The volume of packed red blood cells that you would plan to infuse to raise her haemoglobin to 80 g/L is

a. 80ml
b. 100ml
c. 120ml
d. 180ml
e. 200ml

Answer 25

b. 100ml

Paediatric weight estimation:
Luscombe: Weight (kg) = (age x 3) + 7
RCH: Weight (kg) = (age + 4) x 2

Formula for calculating transfusion volume (mL)
Children <20 kg:
PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor)

Children >20 kg: 1 unit PRBC

Example:
6 + 4 x 2 = 20kg

20kg x 10g/l x 0.5 = 100ml

Question 26

22.1 The most clinically useful indicator of effective ventilation during neonatal resuscitation is an improvement in

a. HR increases
b. Grimace
c. Resp rate

Answer 26

a. HR increases

Question 27

21.1 The advantage of the Mapleson E circuit in paediatric anaesthesia is due to its

A. Can use low gas flows
B. Feel compliance
C. Assess tidal volume
D. Can rapidly change levels of CPAP
E. Low resistance

Answer 27

low resistance

MAPLESON E
- Derived from the Ayre T-piece used in Mapleson D circuit and functions on the same principle as Mapleson D
- The primary difference is in the length of the tubing that is increased to be greater than the patient’s tidal volume
- For spontaneous ventilation, the expiratory limb is open to the atmosphere
- It has no valves so there is no resistance to airflow nor points for possible mechanical failure
- Rebreathing is dependent on the fresh gas flow, patients minute volume and capacity of the expiratory limb
- Its main use is in paediatric patients

Question 28

21.1 A five-year-old child weighing 25 kg is to be strictly nil by mouth overnight following a laparotomy. The most appropriate fluid prescription is

a. 65ml/hr N Saline
b. 45ml/hr N saline
c. 45ml/hr N Saline w 5% dex
d. 65ml/hr .45% saline w 2.5% dex
e. 65ml/hr .45% saline w 5% dex

Answer 28

b. 45ml/hr N saline w 5% dextrose
Nsaline + 5% dextrose is fluid of choice

A guide to paediatric anaesthesia fluid management
-421 rule overestimates fluid resus
-due to stress response from ADH release
-post-op fluid maintenance is 2/3rds calculated due to increased ADH
-never use hypotonic fluids

https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_fluids/

Question 29

The ANZCA guidelines regarding pre-operative oral intake for infants under 6 months of age having an elective procedure under anaesthesia are

a) Breast milk 2 hours before, clear fluids 1 hour before 3mls/kg
b) Breast milk 2 hours before, clear fluids 1 hour before 5mls/kg
c) Breast milk 3 hours before, clear fluids 1 hour before 3mls/kg
d) Breast milk 3 hours before, clear fluids 1 hour before 5mls/kg
e) Breast milk 4 hours before, clear fluids 1 hour before 3mls/kg

Answer 29

c) Breast milk 3 hours before, clear fluids 1 hour before 3mls/kg

PS07 - patient preparation and preanaesthetic consultation appendix 1 2023

Children up to 16 years:

Clear fluids of 3ml/kg up to 1 hour before.

<6 months
Formula 4 hours
Breast 3 hours
Clear 1 hour

> 6 months:
solids and formula wait 6 hours. Breast milk 4 hours.
Clear 1 hour

Question 30

21.2, 22.2 You are involved in the care of a two-year-old child who ingested a button battery within the last 4 hours. You should consider giving

a. milk,
b. sodium bicarbonate
c. Pantoprazole
d. sucralfate

Answer 30

Honey (or sucralfate) - 10 mL every 10 minutes (maximum 6 times) while awaiting surgical retrieval

Source QCH guidelines

Question 31

23.1 A five-year-old child weighing 25 kg is to be strictly nil by mouth overnight following a laparotomy. The most appropriate fluid prescription is

a) 45ml/hr 0.9% NS 2.5% dextrose
b) 65ml/hr 0.9% NS 5% dextrose
c) 45ml/hr 0.45% saline with 2.5% dextrose
d) 65ml/hr 0.45% saline with 5% dextrose
e) 45ml/hr 0.9% NS 5% dextrose

Answer 31

e. 45ml/hr 0.9% NS 5% dextrose

REPEAT
2/3rd standard full maintenance as unwell

Question 32

23.1 Self-report of pain in children is usually possible by the age of

a. 2 yo
b. 4 yo
c. 6 yo
d. 8 yo

Answer 32

b) 4yo

4 yo = wong baker faces score 3-18.
8 yo = Visual analogue scale.

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/

APMSE 5 also

Question 33

22.2 A child with well controlled dysrhythmias has an ASA (American Society of Anesthesiologists) Physical Status classification of at least

a) I
b) II
c) III
d) IV
e) V

Answer 33

B II

ASA II Paediatric examples: Asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations

Question 34

22.2 A five-month-old child is to undergo routine elective morning surgery. Current ANZCA guidelines advise minimum fasting intervals prior to anaesthesia of

A. 4 hours for breast milk, 2 hours clear fluids
B. 4 hours for formula, 1 hour clear fluids
C. 3 hours for breast milk, 1 hour for clear fluids
D. 6 hours for formula, 2 hours clear fluids
E. 8 hours for solids, 4 hours for all fluids

Answer 34

C 3 hours for breast milk, 1 hour for clear fluids

also

B. 4 hours for formula, 1 hour clear fluids

0-6mo 4/3/1
Children > 6mo 6/4/1

Clear fluids 3mL/kg max

Question 35

23.1 Of the following, the drug that is LEAST likely to provide effective analgesia following paediatric tonsillectomy is

A. Inhalational anesthesia
B. Remifentanil at end of case
C. Dexamethasone
D. Intranasal ketamine

or

a. Ketamine
b. Clonidine
c. NSAIDs
d. Paracetamol
e. Dexamethasone

Answer 35

A. Inhalational anesthesia

or

b. Clonidine
Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy.

PROSPECT
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.

Question 36

21.1 The risk of a perioperative respiratory adverse event in a child is least likely to be increased by

A. Asthma
B. infection 3 weeks ago,
C. history of eczema,
D. passive smoking

Answer 36

history of eczema

Question 37

23.1 A newborn baby is pale, limp, grimacing with stimulation, gasping weakly, and has a pulse rate of 90 beats per minute. This corresponds to an Apgar score of

A. 1
B. 2
C. 3
D. 4
E. 5

Answer 37

C. 3

Subject repeat but different stem

Question 38

22.2 Of the following, the congenital condition LEAST commonly associated with obstructive sleep apnoea in children is

Answer 38

Hypoplastic mandible (micrognathia) – difficult intubation
§ Pierre Robin sequence
§ Treacher Collins
§ Hemifacial microsomia (Goldenhar syndrome)

Midface hypoplasia – difficult bag-mask ventilation
§ Apert syndrome
§ Crouzon syndrome
§ Pfeiffer syndrome
§ Saethre-Chotzen syndrome

Macroglossia – difficult bag-mask ventilation AND difficult intubation
§ Hurler’s/Hunter’s syndrome (mucopolysaccharidoses)
§ Beckwith-Wiedemann syndrome
§ Down’s syndrome

https://www.frca.co.uk/Documents/250%20The%20Difficult%20Paediatric%20Ai

Mucopolysaccharidoses, Down syndrome, muscular dystrophies, and other neurologic disorders have been associated with obstructive sleep apnea

Prevalence of OSAS.
Genetic Disorder Prevalence of OSAS
Neuromuscular diseases 69.2%
Prader–Willi syndrome 94.7%
Arnold–Chiari syndrome 80%
Achondroplasia 100%
Crouzon syndrome 100%
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156845/

https://www.frca.co.uk/Documents/250%20The%20Difficult%20Paediatric%20Ai

Question 39

(

21.1 A 10-year-old boy (weight 30 kg) has a displaced distal forearm fracture that requires manipulation and application of plaster. The volume of 0.5% lidocaine (lignocaine) that should be used for intravenous regional anaesthesia (Bier block) is

a. 12 ml
b. 18ml
c. 30 ml
d. 42 ml

Answer 39

b. 18ml

3mg/kg max dose as per RCH guidelines
3mg x 30kg = 90mg
90mg/5mg/ml = 18ml

or

0.6ml/kg of 0.5% Lignocaine
0.6ml x 30kg = 18ml

https://www.rch.org.au/clinicalguide/guideline_index/Bier_block/

Question 40

23.1 In children, severe sleep apnoea is suggested by an apnoea-hypopnoea index
greater than

a. 10
b. 15
c. 20
d. 30
e. 40

Answer 40

a) 10

Question 41

21.1 A four-year-old boy with a history of waddling gait, larger than normal calves and frequent falls receives a spontaneously breathing volatile-based anaesthetic with sevoflurane.

One hour into the case he develops peaked T waves and then the end-tidal CO2 begins to rise. The most appropriate immediate treatment is to

a. Temp probe, and go from there
b. Cool + dantrolene
c. Stop volatile, cool + dantrolene
d. Stop volatile, calcium
e. Stop volatile

Answer 41

d. Stop volatile, calcium

?Duchenne muscular dystrophy?
This patient most likely has Anaesthesia Induced Rhabdomyolysis (AIR) given the peaked Twaves and slow rise in ETCO2

Immediate MH Management:
Stop administering Sevo, flush machine (or new), charcoal filters. Dantrolene.

Question 42

20.2 The ANZCA guidelines regarding pre-operative oral intake for infants under 6 months of age having an elective procedure under anaesthesia are

a) Breast milk 2 hours before, clear fluids 1 hour before to max 3ml/kg
b) Breast milk 2 hours, clear fluids 1 hour before to max 5ml/kg
c) Breast milk 3 hours, clear fluids 1 hour to max 3ml/kg
d) Breast milk 3 hours, clear fluid 1 hour to max 5ml/kg
e) Breast milk 4 hours, clear fluids 1 hour to max 3ml/kg

Answer 42

Repeat

c) Breast milk 3 hours, clear fluids 1 hour to max 3ml/kg

Infants <6 months having elective procedure
* 4 hours for formula
* 3 hours for breast milk
* 1 hour for clear fluids (≤3 ml/kg/hr)

Children > 6 months having elective procedure
* 6 hours for limited solid food or formula
* 4 hours for breast milk
* 1 hour for clear fluids (≤ 3ml/kg/hr)

Question 43

22.1 A two-year-old boy with a history of respiratory tract infection one week previously has just undergone squint surgery. His airway was managed with a size 4.5 mm cuffed endotracheal tube.
The surgery was unremarkable. Twenty minutes after extubation he is awake and appears anxious, with stridor and a visible tracheal tug. His oxygen saturation is 96% on room air. The best initial management of this child is to administer

a) Dexamethasone 0.6mg/kg
b) Adrenaline nebulised 1:1000 - 0.5mL/kg
c) CPAP + T piece
d) Drugs for re-intubation

Answer 43

Nebulised Adrenaline
1mg
0.5ml/kg of 1:1000 Adrenaline nebulised
once adrenaline given consider dose of Steroid dexamethasone or hydrocortisone

Question 44

23.1 An otherwise healthy child with a history of leukaemia four years ago, now in
remission, has an American Society of Anesthesiologists (ASA) classification of at
least

a. 1
b. 2
c. 3
d. 4
e. 5

Answer 44

ASA 2

Question 45

21.1 Consideration for same-day discharge in an ex-premature infant after orchidopexy for undescended testis would be suitable at a minimum postmenstrual age of

a) 46 wks
b) 48 wks
c) 50 wks
d) 52 wks
e) 54 wks

Answer 45

e) 54

ANZCA PS 29:
1. Ex-preterm infants at risk of post-op apnoea should not be considered for same day discharge unless they are medically fit and have reached a PMA of 54 weeks.
2. Term infants should not be considered for same day discharge unless they are medically fit and have reached a PMA of 46 weeks.

SPANZA PS29 BP:
Apnoea significant if:
- lasts more than 15 seconds
- HR <100 (or <30 from baseline)
- SpO2 <90%
Apnoea risks are: PMA, anaemia, chronic lung disease, pre-operative apnoea of prematurity

Most post-op apnoea occur within first 2 hours
In healthy infants, after 12 apnoea free hours, apnoea risk approaches preop levels in health infants
infants should be monitored for 12 apnoea free hours
high risk infants need to be admitted for a longer period of monitoring

Question 46

22.2 Most consistent risk factor for PONV in children (not on report)
a. Use of N2O
b. Patient anxiety
c. Use of short acting opioids
d. Age >3
E.

Answer 46

d. Age >3

Question 47

22.1 Predictors of successful awake extubation after volatile anaesthesia in infants do NOT include

a. Grimace
b. RR >16
c. TV >5ml/kg
d. Conjugate gaze
e. Eye opening

Answer 47

b. RR >16

Question 48

22.1 In the awake term neonate the systolic arterial blood pressure is normally approximately

a. 55mmHg
b. 70mmHg
c. 80mmHg
d. 90mmHg

Answer 48

b. 70mmHg

Question 49

20.1 A 15-year-old boy undergoes a cardiac procedure for congenital heart disease. The intrathoracic device is a(n) (chest X-Ray shown)

a) AV repair
b) PV repair
c) ASD closure device
d) Parachute device
e) Right atrial appendage closure
device

Answer 49

c) ASD closure device
Amplatzer Device

Question 50

22.2 In preschool-aged children having tonsillectomy under general anaesthesia, delirium is more likely with the use of

a) Remifentanil at end of case
b) Dexamethasone
c) IN something? ketamine?
d) Inhalational anaesthetic

Answer 50

D Inhalational anaesthetic

https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/

Question 51

22.2 An eight-year-old-child with sickle cell disease is scheduled for emergency fixation of a fractured radius. Her haemoglobin is 80 g/L. The most appropriate management is

a. Blood type and screen
b. Exchange transfusion for HbSS <30%
c. transfuse for Hb >100
d. careful haemostasis and monitor Hb

Answer 51

c. transfuse for Hb >100
Emergency fixation means there is no time for an exchange transfusion

perioperative goals:
- planning and optimisation
- ensuring adequate O2 delivery
- hydration
- analgesia
- performed at a centre with a multidisciplinary sickle cell team

Children presenting for high-risk surgery (for example neurosurgical, cardiothoracic, or complex orthopaedic surgery) or high-risk children (previous stroke, acute CS, or end-organ damage), who were not included in this study, commonly receive an exchange transfusion or top-up transfusion, aiming for a preoperative haemoglobin concentration of 10 g dl−1 and Hb SS <30%. There is less evidence available for the role of transfusion in children with other forms of SCD.

Exchange transfusion vs. top-up transfusion
Exchange Transfusion:
- slowly removing the person’s blood and replacing with fresh donor blood or plasma
- Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body
- in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30%
- Exchange transfusion removes HbS and increases HBA

Top-up transfusion:
- standard transfusion process of giving donor blood
- advantages of simple top-up include:
1. Increase oxygen carrying capacity
2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA)
3. Prevent or reverse complications of vast-occlusion
4. Can be given acutely
- disadvantages include:
1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l)
2. HbS is not removed, only diluted

Question 52

22.1 In a 5-year-old child with severe life-threatening anaphylaxis and no intravenous access, the recommended initial dose of intramuscular adrenaline is

a. 100mcg
b. 150mcg
c. 300mcg
d. 500mcg
e. 600mcg

Answer 52

150mcg IM

Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min

Refractory management:
Additional IV fluid 20-40ml/kg,
Noradrenaline infusion 0.1- 2mcg/kg/min
Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV

Question 53

22.2 You have diagnosed anaphylaxis in an eight-year-old girl having an appendicectomy. She weighs 20 kg and has refractory bronchospasm despite an adrenaline (epinephrine) infusion running at 15 mcg/min. The recommended initial dose of salbutamol (100 mcg/puff) via metered dose inhaler is

a) 1 puff
b) 3 puffs
c) 6 puffs
d) 10 puffs
e) 12 puffs

Answer 53

12 puffs
6puffs< 6yrs
12 puffs> 6 yrs

Question 54

20.2 The therapy most likely to decrease mortality in neonates with congenital diaphragmatic hernia is

a) Early surgical intervention - within 6 hours
b) HFOV
c) Lung protective ventilation
d) Nitric oxide
e) thoracoscopic vs open approach?

Answer 54

c) Lung protective ventilation

A congenital diaphragmatic hernia (CDH) occurs when a defect in the diaphragm allows abdominal organs to protrude into the thoracic cavity (Fig. 1). It affects approximately 1 in 3600 registered births and is a potentially life-threatening condition, the severity of which is primarily related to the extent of lung hypoplasia and pulmonary hypertension.

Advances in management strategies include protective ventilation, careful timing of surgery, the judicious use of extracorporeal membrane oxygenation (ECMO) and the introduction of both thoracoscopic and fetal intervention, but it remains a challenging condition to treat successfully with overall mortality rates still around 30%

A validated scoring system has been proposed based on various measurements, including:

(i) birth weight <1.5 kg,
(ii) Apgar score at 5 mins <7,
(iii) presence of chromosomal abnormality,
(iv) presence of major cardiac abnormality, and
(v) suprasystemic pulmonary hypertension on echocardiography.

This scoring system enables patients to be stratified into low (<10%), intermediate (∼25%) or high risk (∼50%) mortality groups.
Cardiac defects have been shown to worsen outcome regardless of the severity of the hernia
The presence of a small contralateral lung or a bilateral CDH are also poor prognostic signs.

Ventilation
Historically, aggressive ventilation was used to induce hypocapnia and alkalosis and thereby reduce pulmonary hypertension; however, protective ventilation strategies that avoid further injury to damaged lung tissue have reduced mortality in CDH. The CDH EURO Consortium advocates aiming for the limitation of peak inspiratory pressures to 25 cm H2O with PEEP kept at 3–5 cm H2O and allowing permissive hypercapnia.

High-frequency oscillatory ventilation
High frequency oscillatory ventilation (HFOV) is classically used as a rescue strategy when hypoxia and severe hypercapnia persist despite maximal conventional ventilation. The VICI trial (2016) randomised 171 neonates to conventional ventilation or HFOV as the initial mode of ventilation and found no significant difference in mortality, but those who had conventional ventilation were ventilated for shorter periods, needed less nitric oxide, sildenafil and ECMO, and had lower requirements for inotropic drugs.

Timing of surgery
Historically, CDH repair was treated as a surgical emergency. However, the degree of pulmonary hypoplasia is the major influence on prognosis and emergency surgery therefore confers little benefit. There is much debate but little consensus within the literature regarding the optimal timing of surgery.
Recommendations from the CDH EURO Consortium state that the following physiological parameters should be met before surgery:

(i) mean arterial pressure normal for gestation,
(ii) preductal oxygen saturation consistently 85–95% on FiO2 <0.5,
(iii) lactate below 3 mmol litre−1, and
(iv) urine output more than 1 ml kg−1 h−1 12

These recommendations do, however, acknowledge that repair on ECMO is a viable treatment strategy in the context of appropriate patient selection.

Little evidence Thorascopic approach has improved mortality compared to open approach

BJA Education Article - ​Anaesthetic management of patients with a congenital diaphragmatic hernia
https://www.bjaed.org/article/S2058-5349(18)30013-1/fulltext

Question 55

23.1 During neonatal resuscitation, the pulse oximeter should be placed on the

A. Right hand
B. Left hand
C. Right foot
D. Left foot

Answer 55

R hand

probe should be attached to a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm)
N.B
right foot - post ductal

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.110.971119

Question 56

22.2 You are giving IPPV via a mapleson D (bain) circuit. Minimum FGF to maintain normocapnia is
a) 50ml/kg/min
b) 70ml/kg/min
c) 100ml/kg/min
d) 150ml/kg/min
e) 200ml/kg/min

Answer 56

70-80ml/ kg/ min
Controlled ventilation

https://www.frca.co.uk/article.aspx?articleid=100141
A fresh gas flow of only 70 ml/kg is required to produce normocarbia.

Bain and Spoerel have recommended the following:

2 L/min fresh gas flow in patients <10 kg
3.5 L/min fresh gas flow in patients 10-50 kg
70 ml/kg fresh gas flow in patients >60 kg

The recommended tidal volume is 10 ml/kg and respiratory rate is 12-16 breaths/minute.

Question 57

21.2 When performing a paediatric pain assessment, the five elements assessed to obtain the FLACC score are
a) face, legs, activity, cry, consolability
b) face, legs, arms, cry, consolability
c) function, legs, arms, cry, crossed legs
d) frown, legs, activity, cry, crossed arms

Answer 57

a) face, legs, activity, cry, consolability

Question 58

22.1 Moderate obstructive sleep apnoea in children is diagnosed by an apnoea-hypopnoea index of

a. 5-10
b. 10-15
c. 15-20
d. 20-25
e. 25-30

Answer 58

a. 5-10

Question 59

22.2 A 6-year-old patient (140 cm, 24 kg, BSA 0.97m2) is on hydrocortisone 15 mg/day. Perioperative glucocorticoid supplementation is (considered if)

a.
b. Taking >1week
c. Taking >1 month
d. Taking >2 months
e. Taking >4 months

Answer 59

Taking > 1 month

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14963

Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra-articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency

All children who have known glucocorticoid deficiency (primary or secondary), or who are at risk of glucocorticoid deficiency (on significant exogenous dose of glucocorticoid >10–15 mg.m-2 per day) 38, should receive an i.v. dose of hydrocortisone at induction (2 mg.kg−1 for minor or major surgery under general anaesthesia).

Question 60

21.2 A ten year old child (weight 30 kg) presents to the emergency department in status epilepticus. He has received one dose of 15 mg midazolam buccally prior to his arrival. According to Advanced Paediatric Life Supprt, Australia (APLS) guidelines the next drug treatment should be intravenous

a) Midazolam
b) Propofol
c) Levetiracetam
d) Phenytoin

Answer 60

a) Midazolam 0.15mg/kg

1st line: Midazolam IV/IO/IM –> 0.15mg/kg
2nd line: Midazolam IV/IO/IM –> 0.15mg/kg
3rd line: Keppra 40mg/kg (max 3g)
4th line: Phenytoin 20mg/kg or phenobarbitone
5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone

Question 61

23.1 You are asked to review a 5-year-old child weighing 24 kg in the recovery room for acute pain management after a tonsillectomy performed for obstructive sleep apnoea. The most appropriate analgesic regimen would be

Painstop formulation (codeine 1mg/ml, paracetamol 24mg/ml). (interestingly composition of painstop not included in the released stem but was on the day of the exam)

A Painstop q6h PRN, ibuprofen, tramadol
B Painstop q6h, oxycodone PRN
C Paracetamol 300mg q6h oxycodone
D Paracetamol 300mg QID, ibuprofen 200mg TDS, tramadol 20mg PRN

Answer 61

Poorly remembered options
Definitely do not give Painstop as contains codeine
Opioids should be PRN only

c or d
-go with D - tramadol versus oxycodone re OSA

paracetamol 15mg/kg (360mg) QID
ibuprofen 10mg/kg (240mg) TDS
tramadol 1mg/kg (24mg) QID
oxycodone 0.1-0.2mg/kg (2.4-4.8mg) 4hourly

Codeine should not be used. Deaths. Ultrafast metabolisers –> high levels of morphine.

Nonselective NSAIDs may increase the risk of any bleeding-related outcome after
tonsillectomy in adults (U) (Level I); however, not in paediatric patients

Prospect advice:

The basic analgesic regimen should include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) administered pre-operatively or intra-operatively and continued postoperatively.

A single dose of intravenous (i.v.) dexamethasone is recommended for its analgesic and anti-emetic effects.
Pre-operative gabapentinoids, intra-operative ketamine (only in children) and dexmedetomidine are recommended in patients with contra-indications to the basic analgesic regimen.

Analgesic adjuncts such as intra-operative and postoperative acupuncture and postoperative honey are recommended.

Opioids should be reserved as rescue analgesics in the postoperative period

Question 62

21.1 Severe obstructive sleep apnoea in a 6-year-old child is confirmed if during polysomnography the
apnoea/hypopnea index (AHI) is greater than or equal to

A >5
B >10
C >15
D >20
E >30

Answer 62

> 10

Question 63

23.1 In preschool-aged children having tonsillectomy under general anaesthesia, delirium
is more likely with the use of

a. Inhalational anesthesia
b. Remifentanil at end of case
c. Dexamethasone
d. Intranasal ketamine

Answer 63

a) inhalational anaesthesia

https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/

Question 64

20.1 Sublingual (intralingual) sux 15kg kid what dose:
a) 20mg
b) 40mg
c) 50mg
d) 60mg
e) 15mg
? 30mg as other option

Answer 64

30 (2 mg/kg)

CEACCP Laryngospasm in anaesthesia (2014)
https://academic.oup.com/bjaed/article/14/2/47/271333

Intravenous (IV):
- 0.1-2 mg/kg
- lower doses used to break laryngospasm, but keep patient spont vent

Intramuscular (IM):
- 4 mg/kg (max 200 mg)
- break laryngospasm: 45-60 seconds
- full paralysis: 3-4 minutes

Intralingual (IL):
- 2 mg/kg
- an IM injection into body of tongue
- full relaxation after 75 seconds

Intraosseous (IO):
- 1 mg/kg
- onset 35 seconds

Question 65

22.1 Of the following, the drug that is LEAST likely to provide effective analgesia following paediatric tonsillectomy is

a. Ketamine
b. Clonidine
c. NSAIDs
d. Paracetamol
e. Dexamethasone

Answer 65

b. Clonidine
PROSPECT 2021
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299

Pre-operative and intra-operative interventions that improved postoperative pain were:
- paracetamol;
- non-steroidal anti-inflammatory drugs;
- intravenous dexamethasone;
- ketamine (only assessed in children);
- gabapentinoids;
- dexmedetomidine;
- honey;
- acupuncture.

Inconsistent evidence was found for:
- local anaesthetic infiltration;
- antibiotics;
- magnesium sulphate.
Limited evidence was found for
- clonidine.

The analgesic regimen for tonsillectomy should include:
1. paracetamol;
2. non-steroidal anti-inflammatory drugs; and
3. intravenous dexamethasone,
4. with opioids as rescue analgesics.

Analgesic adjuncts such as:
1. intra-operative and postoperative acupuncture as well as
2. postoperative honey are also recommended.
3. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated

Question 66

22.2 A six-year-old child weighing 20 kg presents to hospital two hours after sustaining a burn to 25% of her body. Appropriate fluid management should include 1000 mL Hartmann’s solution in the next

a. 4 hours
b. 6 hours
c. 8 hours
d. 12 hours
e. 24 hours

Answer 66

B 6 hours

20 x 25 x 4 = 2000 L
(Parklands)

In first 8 hours 50%
1 L in 8 hours FROM TIME OF BURN

So in 6 hours.

Question 67

In the management of anaphylaxis in a 5-year-old with no intravenous or intra-osseous access, the correct dose of intramuscular adrenaline is

A. 20mcg
B. 50mcg
C. 100mcg
D. 150mcg
E. 300mcg

Answer 67

D. 150mcg

Question 68

21.1 The most common cause of mortality in children with diabetic ketoacidosis is

a. Cerebral oedema
b. Septic shock
c. Central pontine myelinolysis

Answer 68

a. Cerebral oedema

Cerebral Oedema

Source: UpToDate

Question 69

23.1 Consideration for same-day discharge in an ex-premature infant after orchidopexy for undescended testis would be suitable at a minimum postmenstrual age of

A. 44 weeks
B. 46 weeks
C. 50 weeks
D. 54 weeks

Answer 69

d. 54

Ex-preterm infants at risk of post-operative apnoea should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 54 weeks.

Term infants should not be considered for same day discharge unless they are
medically fit and have reached a postmenstrual age of 46 weeks.d) 54 weeks

https://www.anzca.edu.au/getattachment/568bad2d-7517-4eea-9c5d-cb7aa1c60

Question 70

21.2 The advantage of the Mapleson E circuit in paediatric anaesthesia is due to its

a) Use with low FGF
b) Ability to assess compliance
c) Ability to assess tidal volume
d) Ability to rapidly change levels of CPAP
e) Low resistance

Answer 70

e) Low resistance

Question 71

22.1 Of the following clinical conditions, difficult intubation is LEAST likely to be associated with

a. Apert syndrome
b. Hurler
c. Pierre Robin
d. Downs Syndrome
e. Treacher collins

Answer 71

d. Downs Syndrome

Question 72

Assuming a blood volume of 70 ml/kg, a massive transfusion in a 20 kg, 5-year-old child is
defined as a three-hour packed red blood cell (PRBC) transfusion volume of

a) 250ml
b) 500ml
c) 700ml
d) 1000ml

Answer 72

700ml
50% of blood volume in 3 hours

S Blaine. BLAE Paediatric massive transfusion

Question 73

A 4 week old full term neonate with an inguinal hernia, who is otherwise healthy, has an ASA (American Society of Anesthesiologists) classification of at least

a) 1
b) 2
c) 3
d) 4

Answer 73

ASA 3