Pediatrics

Question 1

Acid-base disturbance and electrolytes in pyloric stenosis?

Answer 1

hyponatremic hypokalemic hypochloremic metabolic alkalosis

Question 2

Management goal in single ventricle physiology like hypoplastic left heart syndrome?

Answer 2

Balanced circulation between pulmonary and systemic sides (Qp:Qs=1)

These patients need higher pulmonary vascular resistance to “squeeze” circulation to systemic side via PDA – this is why they are maintained at lower oxygen saturations because they rely on hypoxic pulmonary vasoconstriction (as well as probably hypercarbic pulmonary vasoconstriction).

Also anything that increases systemic vascular resistance will make things worse because pulmonary “squeeze”through PDA will be ineffective.

Question 3

Associated defects with tetralogy of Fallot?

Answer 3

PROVe:
pulmonary stenosis
RVH
overarching aorta
VSD

Question 4

Goals of anesthetic management in TOF?

Answer 4

maintain SVR & reduce HR and contractility: think same as HOCM
-plus-
normocarbia
adequate oxygenation

Question 5

Drug that keeps the ductus arteriosus open? drug that closes the ductus arteriosus?

Answer 5

Prostaglandin E1 keeps it oPen; in”door”methacin closes the “door”

Question 6

Common side effect of prostaglandin E1 (PGE1)?

Answer 6

APNEA, CNS irritability, hypotension and fevers.

Question 7

Infant diaphragms have a higher percentage of type I or type II muscle fibers?

Answer 7

Type II fast-twitch muscle fibers making them more prone to respiratory fatigue

Question 8

The most common syndromes associated with Pierre Robin sequence?

Answer 8

Stickler

Velocardiofacial

Treacher-Collins

fetal alcohol syndrome

Question 9

Classic triad of congenital diaphragmatic hernias?

Answer 9

dyspnea, cyanosis and dextrocardia

Question 10

Key points to the anesthetic management of newborns with congenital diaphragmatic hernia?

Answer 10

permissive hypercapnia to avoid volutrauma – lung injury can increase inflammatory mediators and lead to pulmonary vasoconstriction (more than the likelihood of mildly increased PaCO2 causing PHTN)

AVOID:

• pulmonary hypertension
• hypothermia
• venous access in LE’s because the inferior vena cava may become compressed after the reduction of the hernia
• nitrous oxide as it can diffuse into the viscera residing within the thoracic field causing further lung compression

Question 11

thumbprint sign is associated with?

Answer 11

acute epiglottitis (as seen on lateral radiograph)

Question 12

Steeple sign is associated with?

Answer 12

Laryngotracheobronchitis (croup) - seen on frontal radiograph - indicates tracheal mucosal edema causing tracheal narrowing

Question 13

Best initial treatment for hypotension in the euvolemic neonate?

Answer 13

Atropine for three reasons:

cardiac output is determined primarily by HR

Cardiac myocytes are relatively insensitive to catecholamines

neonatal myocytes have poor lusitropy and cannot respond with increased stroke volume to increased preload (volume bolus)

Question 14

How does PGE2 affect ductal patency?

Answer 14

Maintains ductal patency in utero

A decrease in PGE2 plus oxygenated blood closes ductus arteriosus after birth

Question 15

neonatal PaO2 5 minutes after birth? 1 hour after birth? and PaO2 in utero?

Answer 15

5 minutes: 35-40 mmHg

1 hour: 60-65 mmHg

in utero: 20 mmHg

Question 16

Risk factors for postop respiratory events following adenotonsillecomy?

Answer 16

age < 2

apnea-hypopnea index greater than 10

BMI greater than 95 percentile

history of craniofascial syndromes (Down’s)

comorbid conditions (mod to severe asthma, congenital heart disease)

Question 17

Risk factors for retinopathy of prematurity?

Answer 17

prematurity

low birth weight

LOW serum IGF-1

hyperoxia

HIGH neonatal glucose

(Thought to be caused by the disorganized growth of retinal blood vessels)

Question 18

When is the risk for post-tonsillectomy hemorrhage the greatest?

Answer 18

75% within first 6 hours

25% within first 24 hours

Question 19

Pathogen usually responsible for epiglottitis?

Answer 19

vaccinated: polymicrobial including staph, strep pyogenes, strep pneumoniae, and NON-typeable haemophilus

non-vaccinated: haemophilus influenza type b (Hib)

Question 20

Klippel-Feil Syndrome and its common associations?

Answer 20

congenital fusion of cervical spine, low hairline, and short neck

difficult intubation

commonly associated with scoliosis, strabismus and scapular defects

Question 21

When does surfactant production begin? by which pneumocytes?

Answer 21

Week 32; type II pneumocytes

Question 22

lecithin and sphingomyelin ratio in early pregnancy?

Answer 22

lecithin does not begin to be secreted by the developing fetal lung until 24-26 weeks

Question 23

lecithin and sphingomyelin ratio at 32 weeks?

Answer 23

approximately equal amounts

Question 24

lecithin and sphingomyelin ratio at lung maturity?

Answer 24

L/S ratio > 2 or more

In diabetic mothers, L/S ratio should be > 3.5

Question 25

When is jaundice considered phsyiologic after birth?

Answer 25

first 12-48 hours

Question 26

When does breast milk jaundice occur after birth?

Answer 26

around day 4-7

Question 27

When is jaundice considered pathologic after birth?

Answer 27

persists beyond 10 days with total bili > 12 and direct bili > 2.

Question 28

Croup management of westley score <2

Answer 28

steroids then home with 24h follow up

Question 29

Croup management of westley score 3-7

Answer 29

humidified air/oxygen

steroids

racemic ep

then observe 3-4 hours

recurrence of symptoms -→ admit and rpt racemic epi

improvement -→ home with 24 hour follow up

Question 30

Croup management of westley score 8-11

Answer 30

humidified air/oxygen

steroids

racemic epi

poor response -→ admit

good response -→ observe 3-4 hours

recurrence of symptoms -→ admit and rpt racemic epi

improvement -→ home with 24 hour follow up

Question 31

Croup management of westley score >12

Answer 31

racemic epi

steroids

intubate

Question 32

highest odds ratio for successful extubation in peds patient aged 0 to 7 years?

Answer 32

in following order:

eye opening

tidal volume > 5 mL/kg

purposeful movement

conjugate gaze

facial grimace

(the more factors present, incrementally improves likelihood of a successful, uneventful awake extubation