Paeds

Question 1

Syndromes:

Apert

Answer 1

AD

cardiac / renal
“C’s”

premature closure of cranial sutures
midface hypoplasia

choanal atresia
cleft palate
C5/6 fusion

syndactyly

II due to megalocephaly/hypoplasia of white matter/corpsum collosum agenesis

Key
1. OSA 50% –> UAW –> routine maneouver

craig sims

craniosynostosis - usual surgery

Question 2

Syndomes:

Beckwith-Wiedemann

Answer 2

Macroglossia
Visceromegaly - big heart etc
* Hypoglycaemia
Omphalocoele

Key
1. Glucose when fasting

Question 3

Syndromes:

CHARGE

Answer 3

Colobama of eye
Heart defects
choAnal atresia
R - develop delay
G - GU abnor
E - ear abnor

Key
1. Cardiac defect
2. Poor resp reserve

Question 4

Syndrome:

DiGeorge

Answer 4

1:4000 microdeletion 22q11.2 chromosome deletion

~ cardiac disease

Key
1. Micrognathia
2. Cleft palate
3.

Question 5

Syndrome

Cri-du-Chat

Answer 5

C - C
Cat cry / cardiac defect

Severe II
Hypotonia

Key
1. Micrognathia
2. Abn larynx
3. Cardiac defect

Question 6

Syndrome

Prader-Willi

Answer 6

Chr 15

PWC OOHH - cardiac/obesity/OSA/hypot/hypog

Hypotonia
Hypogonad
II
erratic
short
MO***

Key
1. OSA
2. Cardiac
3. Difficult PIVC
4. Difficult to fast

Question 7

Syndrome

Treacher Collins Syndrome

Answer 7

1st 2nd branchial arches

AB C - b arches collins

Key
1. Very diff airway
2. Abnom funnel shape larynx
3. LMA effective
4. AW more diff with age - mandible does not grow

• ## require trache

Question 8

Conditions associated with airway problems

Answer 8

Pierre Robin
Treacher Collins
Goldenhar

Micrognathia
Retrognathia

goldenhar - Congenital heart disease - asymmetry treacher collins

PRS - cleft palate, tongue immobile due to small mandible
AW mx - nasopharyngeal (suture - tricky if cleft palate), jaw thrust, LMA, prone/lateral (displace tongue)

Question 9

Syndrome

Down’s

Answer 9

Commonest - 1.6/1000

3/3/3/3

CNS
Impaired development
Atlantoaxial instability
Epilepsy

CVS
Congential cardiac defects - AVSD/TOF
Eisenmenger’s syndrome
*Bradycardia (autonomic dys)

Resp
Recurrent RTI –> O2 + PT
hypoventilation

Endo
Obesity
Hypothyroidism
GORD

Ex:
Large tongue
crowding mid facial feactures
narrow palate
micrognathia
short/broad neck

CVS/resp EX + IX
Hypotonia

Key:
1. Difficult BMV
2. Bradycardia —> consider pre-induction atropine + early attach ECG + 6% sevo/dial back sooner
3. Difficult PIVC
4. Avoid a2 agonist maybe - bradycardia (2microg/kg) - but faster
5. If intubate - CMAC

Question 10

Pyloric stenosis

PAEDIATRICS – GI/Gen - Pyloromyotomy

[16A08] A six-week-old term baby weighing 4.0 kg requires pyloromyotomy for pyloric stenosis.

How would you assess the baby’s hydration status? (50%)

Detail and justify your resuscitation regimen. (50%)

Answer 10

1:350
80% male
4-6 weeks of age

hypochloraemic
alkalosis
dehydrate

never urgent –> resus

PERIOP:
- risk of asp due to GOO
- NGT
- RSI+cric if NG loss >2mL/kg/h

rectus sheath block if laparoscopic
remove NGT end of surg
Extubate awake

Risk of apnoea (worsened by alkalosis)

Resus and replace NG loss with NS 0.9%

a) Hydration status
5/10/15% body weight loss
5% - skin turg/CRT
10% (shock) - fontanelle/cool skin/oliguria
15% - ALOC/sbp down

b) Resus
- replace/resus - 10mL/kg
- maintain - 4/2/1
- ongoing loss - add K+
- K+ = 3mmol/kg/24h OR add 20mmol to 1L (20mmol/L KCl)

c) ongoing loss PRN

Think
1. NGT
2. Add K
3. Cl > 95, HCO3 <300, K>3.5
4. UO 1-2ml/kg/hr

Shock - give resus fluid stat
Dehydr - loss given over 24-48h

SSU + SAQ

Question 11

Emergency drug doses

• Sux (IV/IM)
• Atropine
• Adrenaline (anaphylaxis/arrest)
• Adenosine
• Amiodarone

Shock
Cardioversion

Fasting

Answer 11

sux IM 4mg/kg
sux IV 1.5-2mg/kg

atropine 20microg/kg

adrenaline
1. anaphylaxis 10microg/kg
2. arrest 10/kg
3.*reduce to 1microg/kg in LAST

+ IM
150microg = <6yo
300 microg = 6-12yo
500 microg = 12yo+
q5min PRN lateral thigh

adenosine
100–>200–>300microg/kg

amiodarone
5mg/kg

Shock
arrest 4J/kg
other 1–>2–> 4Jg

1hr = CF
4hr = BM
6hr = Everything else - FM

https://www.anzca.edu.au/safety-advocacy/standards-of-practice/perioperative-anaphylaxis-management-guidel

Question 12

Pros and cons of T piece

Answer 12

Pros:
1. Low resistance
2. valveless
3. lightweight
4. expiratory limb > Vt - prevent emtrainment of room air during SV
5. assess Vt
6. PEEP/CPAP by occluding bag
7. potential of assisted/controlled ventilation
8. Lung compliance
9.

Cons:
1. Up to 20kg, inefficient beyond
2. Scavenging is limited
3. FGF min 3L for most
4. FGF dependent of RR - high RR = high FGF

Question 13

CMT

Answer 13

prejx

muscle atrophy - spinal/limb —> kypho

Key
1. RLD
2. Neuropathic pain
3. Avoid sux
4. inc sens to NDMB

cvs/resp/drugs/triggers

Question 14

Friedreich’s

Answer 14

AR

Skeletal muscle weakness

Key
1. Risk of RF
2. cardiac involvement
3. avoid sux - debility —> hyperK
4. inc sens to NMDB

Question 15

Duchenne

Beckers

Answer 15

X-linked recessive
- lack of dystrophin (duchenne)
- partial lack (beckers)

Prox muscle wasting

CVS/RESP failure

Can be normal at birth, weakness before 8, WC by adolescence

Key:
1. DCM - negative inotropes…
2. RLD
3. risk of AIR (anaes induced rhabdo) - HALOGENATED
- absent

Question 16

Myotonic dystrophy

Answer 16

Type 1: DMPK gene - birth
Type 2: CNBP - mild

CNS: bulbar —> aspiration

Key:
- Aspiration —>

Lung protective strategies
F: fluid mx
I: Intubate
P: pain
P: PT - pre/post
V: ventilation strategy

• avoid sux - generalised contractures from fasciculations

-

Question 17

Myotonia congenita

Answer 17

AD chr 17
muscle hypertrophy

• resp - asspiration

Question 18

Hyperkalamic periodic paralysis

Question 19

Hypokalaemic periodic paralysis

Question 20

Metabolic myopathies

Question 21

Mitochondrial myopathies

Answer 21

loss of ATP product

Question 22

Hurler’s

Answer 22

Muccopolysacchrides
Deposits - airway, muscle, skin, cardiac

Difficult intubate
LMA effective
Consider PICU if intubated

Question 23

Syndrome

Williams

Answer 23

Sudden death
Supravalvular AS - tertiary only if elective

Question 24

Marfans

Answer 24

DCM
Arrhythmmias AOurtic root dialtion

Question 25

VATERYL
VACTERL

Answer 25

Tracheosohageal fistula
Renal - drug

Question 26

Turners

Answer 26

Coartation aorta
Small jaw
renal

Question 27

Noonan

Answer 27

PS
HOCM
Diff intub

Question 28

Achondroplasia

Answer 28

OSA
Difficult PIVC
Premed

Question 29

Osteogenesis

Answer 29

Gentle

Question 30

Stickler’s

Answer 30

Boney
SUFE

Question 31

Septic child

Answer 31

Recognition:
1. Proven infection +
2 of
a) <36.5 or >38.5
b) tachy
c) altered ms
d) prolonged cap refill (>2s)
e) immunocompromise
f) hypotension

Warm shock:
vasodilation
bounding peripheral pulse
wide pp

Immediate:
1) ABC
2) fluid bolus
3) DEFG - 2mL/kg 10% gluc
4) adren 0.1-0.5 microg/kg/min
5) abx: cefotaxime 50 microg/kg/min

Question 32

Inhaled FB

Answer 32

Bronch
Acute AW obstruction
CXR - hyperinflation

Induction:
- 100% O2 with sevo
- topical to VC
- drying agent
– glyco 5microg/kg IV
– atro 10microg/kg IV

FM or LMA

Upper AW - maintain SV
lower AW - ippv + relaxant

Post op:
- DEX if traumatic

PRN:
1. physio
2. bronchodilator
3. abx

Question 33

Gestation

Answer 33

Term: 37+
Preterm: 32-37, 28-32
Ex-prem: 22-28

Question 34

Caudal block

Answer 34

Achieve:
Surgical anaesthesia for BELOW the umbilicus

sacral epidural space

sacral canal
1. terminal dural sac
2. cauda equina
3. filum terminale
4. venous plexus
5. epidural fat

Caudal space:
Define: position/palp/punc
Pos: left lat
Palp: triange - PSISx2 and sacral cornu - sacral hiatus between 2 cornu

Location: S4 - sacral hiatus

Access:

Question 35

PAEDIATRICS – CVS – Praecordial murmur

[16B15] A 2yo boy scheduled for hypospadias repair is found to have a praecordial murmur. Justify decision to proceed. (also 11A09, 08A11)

Answer 35

(74.3%) The borderline candidate should demonstrate they can differentiate b/w a benign and pathological murmur and comment on
potential cardiac sequelae. Inappropriate cardiology review or investigations without consideration of a benign murmur may be marked down.

Benign vs pathological

70% infant has murmur - most are innocent

Innocent murmur
- Still’s
- pulm flow
- venous hum (flow in systemic great veins)
continuous, disappear when supine

HX (likely pathological)
1. Age - ** < 12mo **
2. chromosome abn
3. Cardiac -
4. Resp - cough, wheeze,
5. FTT
6. Recurrent infection

EX (pathological)
1. Loud/harsh murmur
2. Timing - pansystolic/diastolic vs early/ejection systolic

IX
*ECG

Referral when
1. <1yo
2. Features of path murmur

7s of innocent murmur
Short
sweet small soft systolic small single

Question 36

Univentricular circulation
Aims

Answer 36

Preserve HPV
Pathophys: Inc PVR —> inc PAP —> blood shunt via PDA to aorta

1. Forward flow - SVR maintain/minimuse
2. Min PVR
3. Max CO
   - inotropy
   - ensure left side goes to right side
   - run dilute adrenaline
4. Fluids +++ (resuscitate) —> more fluid
5. Spont vent - less PVR, short I time
6. Positioning - foot > RA (lower limb ~ 20-30% circulation)

Obtain IV access + IAL +/- CVL (avoid neck and upper arm —> FEMORAL)
10-20mL/kg fluid prior induction

Question 37

PAEDIATRICS - Autism

[21B11] A 14yo with severe autism is rescheduled for dental surgery. The operation was previously abandoned due to their poor cooperation with the team.

Justify your perioperative management plan.

Answer 37

Key
1. Recent exp
2. Anticipating
3. Priorities
4. Plan pre/intra/post

Anticipate CCPP
1. Comm
2. Coop
3. Postop del
4. Pain mx

Priorities
- ID from last exp
- Calm
- Low stim
- safe d/c

Pre
Min waiting time

Intra
- streamline
- premed
- OT

Postop
- post op distress ?cause
- FLACC score
- Hyration

Question 38

PAEDIATRICS – CNS/Neuro – Craniotomy/MH

[20A01] You are asked to anaesthetise a two-year-old child for an eight-hour craniotomy. The child is susceptible to developing malignant hyperthermia.

a. Outline your strategies for obtaining intravenous access in this child.(50%)

b. Discuss the issues of using a total intravenous anaesthetic technique in this situation.(50%)

Answer 38

a) PIVC strategy in VA CI pt
1. Environ
- parent present
- calm and quiet room
- distraction
2. Improve visibility
- Warming
- Prox tourni
3. Pharm
- EMLA
- Coolant
- N2O
- Premed - IN dexmed
4. Tech
- illum
- USS

b) TIVA techniqie
Paeds difference:
1) Larger Vd vs adult
2) Faster V2 to V1 (redis)

• Paedfusor - 1-16yo, 5-61kg
• Kataria - 3-16yo, 15+kg
• Eleveld model captures patients from age 5 days to 85 years old and with weights between 2.5 kg and 106 kg.

Manual
1. McFarlan - based on Kataria (3-11yo)
- ind - 2.5mg/kg
- 15/13/11/10 mg/kg/hr - dec q15
- aim Cp 3 mcg/mL
2. Steur <3yo

pEEG - useful adjunct 2yo+

*Risk of
- accum/delayed emergence
- bac contam
- metabolic phenomena (unlikely in this case)

Usual TIVA consideration
- IV access
- disconnect/failure
- Waste
- Cost

TCI Anesthesia- New and More Universal Models BD June 2022

Question 39

PAEDIATRICS – CNS/Neuro – Cerebral palsy 1

[19A04] A 9-year-old girl with cerebral palsy is scheduled to undergo bilateral femoral varus de-rotation osteotomy and adductor lengthening.

Outline the challenges of providing effective postoperative analgesia for her surgery and

discuss the analgesia options available.

Answer 39

Ax = challenge
1. Self report
- VAS
- Numeric

2. Visual
   - FLACC

Analgesic option
1. Multimodal
2. Pharm
- Simples
- PO opioids
- NCA
- Adjuncts - ket/clon
3. Regional
- Caudal
- Femoral

Question 40

PAEDIATRICS – CNS/Neuro – Cerebral palsy 2

[13B10] A 7-year-old nonverbal girl with severe spastic cerebral palsy is scheduled for cystoscopy.

a. Describe the important features of cerebral palsy relevant to planning anaesthesia for this procedure. (70%)

b. What are the advantages and disadvantages of inhalational induction in this child? (30%)

Answer 40

CP:
Spectrum of motor/sensory II of variying severity
CNS/GIT/MSS/Resp/Drug issues

CNS
- epilepsy 50%
- II

GIT:
- bulbar palsy
- poor feeding

MSK
- thin skin

Drugs

Question 41

PAEDIATRICS – CNS/Neuro – Emergence delirium

[10A09]

a) Describe the factors that influence emergence delirium in children. (50%)

b) How would you manage emergence delirium in a 3 year old child having had myringotomy tubes inserted under general anaesthesia? (50%)

Answer 41

ED
- Disso state - irritable, uncompromising, uncooperative, incoherent, inconsolably crying, moaning, kicking, thrashing

RF
Anaes
1. Short acting INH

Surg
1. Around H&N - ENT/ophthal

Pt
1. 2-5yo

B) Mx
- Prevention
1. PPF (1 mg/kg), ketamine, a2ago, fent

• Pharm
• PPF (1 mg/kg), dexmed (0.3mcg/kg), clonidine (1mcg/kg)

Question 42

PAEDIATRICS – AW/Resp - adenosonsillectomy

[15B06] A three year old child requires an adenotonsillectomy for obstructive sleep apnoea. Outline and justify your peri-operative management plan.

Answer 42

Pre/Intra/post

Pre
** assess severity **
OSA
- UAO during sleep, restless, apnoea, enuresis
-** IX ** PSG –>
AHI > 1 v s 5 in adult
AHI > 10 = severe

Intraop
- sed premed BAD cuz post op apnoea
- IV ind if severe OSA
- Gas + ETT + throat pack + gag
- Shared AW !!!
- Dex
- suction, awake lateral extub,

Post op
R - hyrdation
A - simples, short acting opioids post op apnoea
Ward - Daycase vs O/N
- Admit if severe OSA, comorb, < 3yo

ER 68.3%
1. Assess severity of OSA
2. shared AW, AW plan, premed bad
3. post op mon and care
4. Analgesia

Question 43

PAEDIATRICS – AW/Resp – stridor

[12A09] A 3-year-old presents to the emergency department with a recent onset of stridor.

a. List the differential diagnoses (30%)

b. How do you differentiate between the potential causes of this stridor? (70%)

Answer 43

Stridor = inspiration, extrathoracic obs ~ laryngomalacia

ExLarry

Exp stridor = intrathoracic ~ tracheomalacia

inTRAcheo

RF
1. small children
2. recent URTI
3. oversized ETT

a)
DDx
Supra/glottic/sub

80% stridor = croup = 0.5-3yo = 2’ parainfluenza

b) Differentiate
Hx
- neonate = congen ; toddles = croup ; school = peritonsillar abscess
- onset: Acute = itis
- subacte = croup
- chronic = subglottic stenosis

Ex
Body position
Vitals - febrile, hypotensive - sepsis
Stridor timing

Ix
CXR - FB radiolucent - but hyperdynamic inflation

Question 44

PAEDIATRICS – AW/Resp - URTI

[11B08] A child with active upper respiratory tract infection presents for general anaesthesia.

a. Outline the factors that increase the rate of adverse respiratory events during anaesthesia. (50%)

b. How can you reduce the risk of an adverse event occurring? (50%)

Answer 44

PRAE - periop resp AE

Pt/Anaes/Surg

Pt
1. Whheze
2. URTI 2/52
3. Asthma
4. Passive smoking

Anaes
1. ETT
2. LMA
3. Exp anaes
4. Inh

Surg
1. AW
2. NT

b)
Risk reduc
1. Dec sec
Mech - suction, physio
Pharm - glyco, salbutamol, nasal spray,
2. AW choice
3. Monitor

COLDS - current/onset/lung dx/AW device/surgery

Question 45

PAEDIATRICS – AW/Resp – croup

[05B01]

a) What are the indications for tracheal intubation in a 3 year old who presents with croup?

b) Describe your technique for intubation.

Answer 45

Croup = viral laryngotracheitis
Laryngo = (hoarse voice)
Trach/bronch = cough
Cause:
1. Paraflu 1/2
2. Rhino
3. Flu A/B
4. Adeno
5. RSV

Prodromal + seal bark

DDx: epiglottitis, bacterial tracheitis, angioedema, FB and RP abscess

Question 46

How common is VSD?

Answer 46

30%

Question 47

How common is VSD?

Answer 47

30%

Question 48

Tet spell mx

Answer 48

Def: period of hypercyanosis

Pathophys: Inc O2 demand

Treat: Max VR, maintain SVR

Hospital: O2, fluid, SVR, beta blocker, opioid (pharm vs non pharm), max PBF
*phenyl/metaraminol

Mechanical:

Question 49

TOF

Answer 49

1. VSD
2. Overriding of aorta - aorta lies over VSD
3. RVOTO - OT start at leaving the RV —> 4. RVH