Pediatric Flashcards
- Correct statement regarding neonatal physiology is
A. Neonates have a greater volume of distribution for water-soluble drugs
B. Total body water is higher in adults
C. Dose of propofol (mg/kg) is lower in neonates than in adults
D. Neonates have a higher body fat content than adults
A
○ Total body water in a term neonate is 75% of the total body weight, as compared to 60% in adult males and 55% in adult females.
○ Water-soluble drugs will have an increased volume of distribution because of increased body water.
○ Propofol dose (mg/kg) will be higher in neonates and infants than adults.
- A 4-year-old child weighing 16 kg is scheduled for hernia repair under general anesthesia. Assuming he was NPO for 8 hours, his total fluid deficit will be about _____ (mL):
A. 380
B. 420
C. 460
D. 500
- B. Maintenance fluid requirements to replace fluid deficits accounting for a period of fasting can be calculated by the following formula.
○ 4:2:1 rule
Thus using above formula, total fluid deficit would be 40 + (6 × 2) = 52 mL/h. Accounting for 8 hours of fasting, total fluid deficit will be 52 × 8 = 416 mL.
- The total dose of midazolam thatmay be given orally as premedication is
A. 0.2 mg/kg, maximum 10 mg
B. 0.2 mg/kg, maximum 20 mg
C. 0.5 mg/kg, maximum 15 mg
D. 0.5 mg/kg, maximum 20 mg
D.
○ Preoperatively, midazolam is the most common medication given for sedation and anxiety.
○ Midazolam can be given orally in a dose of 0.25 to 0.5 mg/kg (maximum dose of 20 mg) in children.
○ Sedative premedication is generally omitted for neonates, infants, and sick children.
○ Oral ketamine (4–6 mg/kg) can also be used as premedication.
○ For uncooperative children, intramuscular midazolam (0.1–0.15 mg/kg, maximum of 10 mg) and ketamine (0.02 mg/kg) can be used.
- A newborn baby of 37 weeks of gestation has a heart rate of 90 bpm, is crying, is pink with blue extremities, and shows some flexion. Her Apgar score would be
A. 6
B. 7
C. 8
D. 9
B. Apgar scores recorded at 1 minute and 5 minutes after birth remains a valuable method for assessment of the well-being of a neonate.
Apgar score in this case would be 1 + 2 + 1 + 2 + 1 = 7.
A newborn baby of 37 weeks of gestation has a heart rate of 90 bpm, is crying, is pink with blue extremities, and shows some flexion. Her Apgar score would be A. 7
5. After initial evaluation of the baby described above, the next step in managing her would be
A. Provide positive-pressure ventilation
B. Chest compressions
C. Warming blanket
D. Cardiology consult
- A.
○ Indications of positive-pressure ventilation in a newborn include apnea, gasping respirations, persistent central cyanosis with 100% oxygen, and heartrate less than 100 bpm. Assisted ventilation by bag and mask should be at a rate of 30 to 60 bpm with 100% oxygen. If after 30 seconds the heart rate is less than 80 bpm, chest compressions should be started and the neonate should be intubated (Fig 18-2).
- All of the following drugs can be given through endotracheal tube, except
A. Epinephrine
B. Lidocaine
C. Surfactant
D. Calcium
- D. Lidocaine, epinephrine, atropine, and vasopressin can be delivered down a catheter whose tip extends beyond the endotracheal tube. The dose of drugs through endotracheal tube is 2 to 2.5 times the intravenous dose. Surfactant can be given through endotracheal tube in children with severe bronchopulmonary dysplasia.
- The disease or syndrome with known association with malignant hyperthermia is
A. Huntington chorea
B. Fabry disease
C. King Denborough syndrome (KDS)
D. Burns
- C.
Musculoskeletal diseases associated with a relatively high incidence of malignant hyperthermia include Duchenne muscular dystrophy, myotonia, and KDS.
○ KDS is seen primarily in young boys who exhibit short stature, mental retardation, cryptorchidism, kyphoscoliosis, pectus deformity, slanted eyes, low-set ears, webbed neck, and winged scapulae.
- An 8-year-old child is brought to the emergency room with testicular torsion. The parents tell you he ate a sandwich 6 hours ago. Surgeon wants to operate immediately. Your response should be
A. Take him to the OR, deem it
emergent, rapid-sequence intubation
B. Wait for 2 more hours, deem it urgent, rapid-sequence intubation
C. He is adequately fasting, elective, intubation
D. Wait for 2 hours, elective, intubation
- A. A male presenting with sudden onset of acute scrotal pain in the absence of trauma should be suspected to have testicular torsion.
○ Testicular torsion requires immediate investigation and possible surgery to preserve potentially viable testis.
○ Surgery should be performed within 6 hours of onset of pain to save the testicle.
○ The salvage rate decreases to 50% if surgery is delayed between 6 and 12 hours.
○ Children with suspected torsion of testis are assumed to have a full stomach and should have a rapid-sequence endotracheal intubation.
○ The surgery is emergent and the patient needs to be taken to the OR.
- Which of the following statements about pediatric airway is true?
A. More caudal position of larynx as compared to adult
B. More acute angulation of epiglottis
C. Glottic opening is the narrowest part of airway
D. Longer trachea as compared to adults
- B.
○ Neonates and infants have a larger head and tongue, an anterior and cephalad epiglottis and larynx, and a short trachea and neck.
○ The larynx is at a vertebral level of C4 versus C6 in adults.
○ The narrowest portion of larynx in children is at thelevel of cricoid cartilage as compared to glottic opening in adults.
○ An adult’s epiglottis is flat and broad, and its axis is parallel to that of trachea, whereas an infant’s epiglottis is typically narrower, omega-shaped, and angled away from the axis of trachea.
- A 10-week-old baby, who was born prematurely at 30 weeks of gestation, undergoes circumcision uneventfully under general anesthesia. After the baby recovers from anesthetics in postanesthesia care unit, he can/should be
A. Admitted and monitored for 24 hours
B. Discharged home with parents
C. Discharged home if parents live within a 30-minute radius
D. Admitted to the ICU
- A.
○ Premature infants who are less-than-50-weeks postconceptional age at the time of surgery are prone to postoperative apneic episodes for up to 24 hours.
○ Besides prematurity, other risk factors for postanesthetic apnea include hematocrit <30% (anemia), hypothermia, and neurological abnormalities.
○ Thus, elective or outpatient procedures should be deferred until the preterm infant reaches the age of at least 50 weeks’ postconception.
○ These patients should be monitored for 12 to 24 hours postoperatively with pulse oximetry.
- Hypertrophic pyloric stenosis is associated with
A. Metabolic acidosis
B. Metabolic alkalosis
C. Hyperkalemia
D. Hyperchloremia
- B.
○ Hypertrophic pyloric stenosis causes stasis of gastric contents and thus leads to persistent vomiting.
○ This can lead to depletion of sodium, potassium, chloride, and hydrogen ions, causing a hypochloremic metabolic alkalosis.
○ Patients are first medically stabilized (correction of volume-deficit and metabolic alkalosis), and then a pyloromyotomy is performed.
○ Hydration should be done with a sodium chloride solution supplemented with potassium (avoidance of ringer lactate as it is metabolized to bicarbonate).
- A child with which of the following diseases/syndromes should be evaluated for heart disease?
A. Omphalocele
B. Gastroschisis
C. Hypertrophic pyloric stenosis
D. Tracheobronchitis
- A.
○ Both gastroschisis and omphalocele are congenital disorders characterized by defects in the abdominal wall.
○ Omphaloceles have a hernia sac, and are often associated with other congenital anomalies (trisomy 21, 13, 18, diaphragmatic hernia, cardiac and bladder anomalies, Beckwith Wideman syndrome, pentalogy of catrell).
○ Gastroschisis, on the other hand, does not have a hernia sac, and is often an isolated finding.
○ The latter is a more serious condition, as the absence of a hernial sac can lead to dehydration, hypothermia, and infection.
- The earliest and the most pathognomic feature of malignant hyperthermia (MH) is
A. Increased temperature
B. Increased end-tidal CO 2
C. Increased heart rate
D. Increased respiratory rate
- B.
○ MH is a rare but potentially fatal hypermetabolic disorder triggered by exposure to volatile inhalational anesthetics or succinylcholine.
○ The incidence of MH is 1:15,000 in pediatric population and 1:50,000 in adults.
○ Signs of MH include masseter muscle rigidity, tachycardia, tachypnea, hypercarbia (increased CO 2 production—earliest sign), and hyperthermia (late sign).
○ Hypertension and arrhythmias may be seen (sympathetic overactivity).
○ Generalized muscle rigidity is not consistently present, and presence of dark-colored urine indicates myoglobinuria.
- The most common type of tracheoesophageal fistula (TEF) is
- C.
○ Among the different types of TEF, the most common is the type IIIB.
○ This is where the upper esophagus ends in a blind pouch and a lower esophagus that connects to the trachea. ○ At birth, TEF is suspected by failure to pass a catheter into the stomach and visualization of the catheter coiled in the blind upper esophageal pouch.
○ Typically, breathing leads to gastric distension and feeding leads to choking and cyanosis.
○ TEF patients are, therefore, prone to pulmonary aspiration.
○ Coexistence of cardiac congenital anomalies is common.
○ TEF patients may have associated vertebral defects, anal atresia, and radial dysplasia, known as the VATER syndrome. ○ Addition of cardiac and limb anomalies is called the VACTERL variant.
- Down syndrome is associated with all of the following, except
A. Large tongue
B. Atlantooccipital instability
C. Hyperthyroidism
D. Increased incidence of seizures
- C.
○ Down syndrome or trisomy 21 is one of the most common congenital syndromes in pediatric population.
○ Anesthetic considerations in these patients include presence of short neck and large tongue (possible difficult airway), irregular dentition, mental retardation, hypotonia, congenital heart disease in 30% to 40% of patients (particularly endocardial cushion defects and ventricular septal defect), subglottic stenosis, tracheoesophageal fistula, chronic pulmonary infections, seizures, duodenal stenosis, and delayed gastric emptying.
- The first sign of intrathecal injection following the placement of caudal epidural with 0.25% bupivacaine in a 1-year-old child would be
A. Hypotension
B. Bradycardia
C. Falling oxygen saturation
D. Tachycardia
- C.
○ Unlike older children and adults, subarachnoid and epidural blockade in infants and small children is characterized by hemodynamic stability, even when the level of block reaches upper dermatomes.
○ Young children rely more on the diaphragm for maintaining tidal volumes; thus, apnea may be the first sign of total spinal in infants and small children.
- A 2-year-old child weighing 13 kg is scheduled for inguinal hernia repair. The calculated dose of 0.25% bupivacaine for a caudal epidural would be approximately ______ (mL):
A. 13
B. 7
C. 10
D. 20
- B.
○ Armitage formula can be used for calculation of caudal bupivacaine in a child with appropriate weight for his age.
• 0.5 mL/kg for a lumbosacral block
• 1 mL/kg for a thoracolumbar block
• 1.25 mL/kg for a midthoracic block 0.25% **Bupivacaine up to a maximum of 20 mL
- All the following are physiologic changes that occur at birth, except
A. Closure of foramen ovale
B. Closure of ductus arteriosus
C. Decreased right-ventricular afterload
D. Decreased left-ventricular afterload
- D.
○ Fetal circulation is associated with increased pulmonary vascular resistance, decreased pulmonary blood flow, decreased systemic vascular resistance, and right to left blood flow through patent ductus arteriosus and foramen ovale.
○ At birth, the onset of spontaneous ventilation and elimination of placental circulation decreases pulmonary vascular resistance and increases pulmonary blood flow.
○ Simultaneously, systemic vascular resistance increases, left-atrial pressure increases, foramen ovale closes functionally, and right-to-left shunting ceases.
○ When anatomic closure is achieved and the cardiac anatomy is normal, shunting through ductus arteriosus ceases.
- Neonates lose heat by all the following mechanisms in theoperating room, except
A. Conduction to cold surfaces
B. Exposure to cold operating room
C. Dry airway gases
D. Metabolism of brown fat
- D.
○ Neonates are susceptible to increased heat losses due to thin skin, low fat content, and a higher relative body surface area.
○ Cold operating room, wound exposure, unwarned intravenous fluid administration, dry anesthetic gases, and the direct effect of anesthetic agents on temperature regulation can further accelerate heat loss.
○ Hypothermia is associated with delayed awakening from anesthesia, cardiac irritability, respiratory depression, increased pulmonary vascular resistance, altered drug responses, delayed wound healing, and coagulation and platelet dysfunction.
○ Metabolism of brown fat is responsible for heat production in infants.