Pediatric Anesthesia

Pediatric Anesthesia Indian Medical PG Question 1: Which of the following is the induction anesthesia of choice in the pediatric age group?

• A. A. Sevoflurane (Correct Answer)
• B. B. Desflurane
• C. C. Halothane
• D. D. Isoflurane

Pediatric Anesthesia Explanation: ***A. Sevoflurane*** - **Sevoflurane** is an inhalation anesthetic widely preferred for **pediatric induction** due to its rapid onset and non-pungent odor, which makes it well-tolerated by children. - Its low blood-gas partition coefficient allows for swift changes in anesthetic depth and rapid emergence. *B. Desflurane* - **Desflurane** has a **pungent odor** and is known to cause airway irritation, making it unsuitable for inhalational induction in children. - Its rapid onset and offset are beneficial, but its irritant properties limit its use for induction, especially in younger patients. *C. Halothane* - **Halothane** was previously used for pediatric induction but has largely been replaced due to its association with **hepatotoxicity** and cardiac arrhythmias. - It also has a slower onset and offset compared to newer agents like sevoflurane. *D. Isoflurane* - **Isoflurane** has a **pungent odor** and can cause airway irritation, making it less suitable for inhalational induction in children compared to sevoflurane. - While effective for maintenance, its irritant properties make for a less smooth and potentially distressing induction experience for pediatric patients.

Pediatric Anesthesia Indian Medical PG Question 2: The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:

• A. Oxygen saturation
• B. Torso
• C. Verbal response (Correct Answer)
• D. Cry

Pediatric Anesthesia Explanation: ***Verbal response*** - The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) is designed for children **under one year of age**, who are typically pre-verbal. - While verbal complaints are not assessed, a child's **verbal response** (e.g., moaning, crying, or not making sounds at all) in relation to pain is a component of the scale, contributing to the interpretation of their comfort level. *Oxygen saturation* - **Physiological parameters** like oxygen saturation are typically not part of behavioral pain scales like CHEOPS, which focus on observable behaviors. - While low oxygen saturation can indicate distress, it is not a direct measure of pain for this scale. *Torso* - The CHEOPS scale assesses **pain-related behaviors** of extremities (e.g., legs, arms) and facial expressions, but does not specifically include observations of the "torso" as a separate category. - Behaviors like stiffening or arching of the torso might be implicitly considered under overall body tension, but it’s not a distinct domain. *Cry* - The **quality and intensity of crying** is a primary behavioral indicator of pain in pre-verbal infants and is a significant component of many pediatric pain scales, including CHEOPS. - A child's cry, along with other behaviors, helps differentiate between various levels of discomfort or pain.

Pediatric Anesthesia Indian Medical PG Question 3: Child with aspiration risk needs emergency surgery. Best induction sequence is:

• A. Preoxygenation-ketamine-succinylcholine
• B. Sevoflurane-propofol-succinylcholine
• C. Midazolam-propofol-rocuronium
• D. Preoxygenation-propofol-succinylcholine (Correct Answer)

Pediatric Anesthesia Explanation: ***Preoxygenation-propofol-succinylcholine*** - This sequence describes a **rapid sequence intubation (RSI)**, which is the preferred method for patients at high risk of aspiration, including children needing emergency surgery with an unknown fasting status. - **Preoxygenation** provides an oxygen reserve during the apneic period, **propofol** offers rapid induction with good hemodynamic stability, and **succinylcholine** provides fast-onset, short-acting neuromuscular blockade, crucial for preventing aspiration. *Preoxygenation-ketamine-succinylcholine* - While preoxygenation and succinylcholine are appropriate for RSI, **ketamine** may not be the optimal choice for a child with aspiration risk due to its potential to increase secretions and maintain laryngeal reflexes, which could complicate intubation. - Ketamine can also cause **emergence delirium** in some children, making it less favorable for a smooth anesthetic course compared to propofol. *Sevoflurane-propofol-succinylcholine* - **Sevoflurane** is an inhaled anesthetic often used for mask induction in children due to its non-pungent odor and rapid onset. However, it is generally **not suitable for RSI** in patients with aspiration risk as it has a slower induction time compared to intravenous agents and can cause coughing or laryngospasm. - Using both sevoflurane and propofol for induction in an RSI scenario is redundant and prolongs the induction phase, increasing aspiration risk. *Midazolam-propofol-rocuronium* - **Midazolam** is a benzodiazepine used for anxiolysis and sedation but has a **slower onset** and longer duration of action compared to propofol for rapid induction. - **Rocuronium** is a non-depolarizing neuromuscular blocker with a slower onset of action than succinylcholine, making it less ideal for RSI where immediate paralysis for intubation is critical to prevent aspiration.

Pediatric Anesthesia Indian Medical PG Question 4: Shivering observed in the early part of the postoperative period is due to

• A. Hypothermia (Correct Answer)
• B. Pain
• C. Emergence delirium
• D. Drug withdrawal

Pediatric Anesthesia Explanation: **Hypothermia** - Shivering is a primary physiological response to **hypothermia**, an attempt by the body to generate **heat** by increasing muscle activity. - Patients often experience a drop in core body temperature during surgery due to factors like cold operating rooms, exposed body cavities, and anesthetic effects. *Pain* - While pain can cause discomfort and muscle tension, it typically does not manifest as generalized **shivering** in the early postoperative period. - Pain is usually managed with analgesics, and shivering is more indicative of a **thermoregulatory disturbance**. *Emergence delirium* - Emergence delirium is characterized by disorientation, agitation, and non-purposeful movements, but not primarily by **shivering**. - This condition is often related to the residual effects of anesthetic agents or anxiety upon waking. *Drug withdrawal* - Drug withdrawal can cause tremors and agitation, but it is less likely to present as **shivering** in the immediate postoperative period in a patient without a known history of substance dependence. - Withdrawal symptoms typically manifest hours to days after the cessation of the drug, depending on its half-life.

Pediatric Anesthesia Indian Medical PG Question 5: Incorrect statement regarding the management of frostbite:

• A. Antibiotics and analgesics not used (Correct Answer)
• B. Amputation in severe cases
• C. Rewarming is done
• D. The area is dried and cleaned

Pediatric Anesthesia Explanation: ***Antibiotics and analgesics not used*** - This statement is incorrect as **antibiotics are used** in the management of frostbite for prophylaxis against infection, especially in severe cases or open wounds. - **Analgesics are also crucial** to manage the significant pain associated with frostbite and the rewarming process [1]. *Amputation in severe cases* - **Amputation** is a necessary intervention for severe, irreversible tissue damage and necrosis caused by frostbite, typically reserved as a last resort [1]. - This decision is usually made after sufficient time has passed to demarcate viable from non-viable tissue, often several weeks post-injury [1]. *Rewarming is done* - **Rapid rewarming** of the affected area in a warm water bath (37-39°C) is the most critical initial treatment for frostbite to minimize tissue damage. - This process is painful and should be done only when there is no risk of refreezing. *The area is dried and cleaned* - After rewarming, the affected area should be **gently dried** to prevent further skin breakdown and the development of maceration. - **Cleaning the wound** helps prevent infection and maintains a sterile environment for healing.

Pediatric Anesthesia Indian Medical PG Question 6: The most appropriate treatment for hypothermia during anesthesia is

• A. Treated with warm saline (Correct Answer)
• B. Mechanism of heat loss is conduction
• C. Occurs in all types of Anaesthesia
• D. Is beneficial to patients

Pediatric Anesthesia Explanation: ***Treated with warm saline*** - **Warm intravenous fluids**, particularly saline, are a primary and effective method for rewarming hypothermic patients during surgery. - This helps to directly transfer heat into the patient's core circulation and raise body temperature. *Mechanism of heat loss is conduction* - While **conduction** (heat loss to colder surfaces) is one mechanism of heat loss during anesthesia, **radiation** (heat loss to the environment) and **convection** (heat loss to moving air currents or blood) are often more significant. - Evaporation (from open surgical sites) also contributes substantially to heat loss. *Occurs in all types of Anaesthesia* - Hypothermia is a common complication of **general anesthesia** due to impaired thermoregulation, but it is less common or sometimes deliberately avoided in certain regional anesthesia techniques unless the patient is already cold. - The degree and likelihood of hypothermia vary depending on the type and duration of anesthesia, ambient temperature, and patient factors. *Is beneficial to patients* - **Hypothermia** is generally **detrimental** to most surgical patients, leading to complications like increased bleeding, impaired drug metabolism, prolonged recovery, and increased risk of wound infection. - Therapeutic hypothermia is only medically induced for specific conditions (e.g., post-cardiac arrest) and is not a general benefit during anesthesia.

Pediatric Anesthesia Indian Medical PG Question 7: In human beings, the least useful physiological response to low environmental temperature is:

• A. Shivering
• B. Vasoconstriction
• C. Release of thyroxine
• D. Piloerection (Correct Answer)

Pediatric Anesthesia Explanation: ***Piloerection*** - **Piloerection**, or 'goosebumps,' is a vestigial reflex in humans, meaning it has lost most of its original function. - While it causes hair to stand on end, which would trap an insulating layer of air in furry animals, humans lack sufficient body hair for this to be an **effective heat retention mechanism**. *Shivering* - **Shivering** involves involuntary muscle contractions that generate heat through increased metabolic activity. - This is a highly effective and significant physiological response for **acute heat production** in response to cold. *Vasoconstriction* - **Vasoconstriction** of peripheral blood vessels reduces blood flow to the skin, thereby decreasing heat loss to the environment through conduction, convection, and radiation. - This is a crucial mechanism for **conserving core body heat** in cold conditions. *Release of thyroxine* - The **release of thyroxine** (thyroid hormone) increases the body's basal metabolic rate over a longer term, leading to increased heat production. - This is an important **adaptive response to prolonged cold exposure**, rather than an immediate one.

Pediatric Anesthesia Indian Medical PG Question 8: A soldier from Siachen came in emergency. How will you rule out hypothermia?

• A. Measure temperature via nasal route
• B. Measure temperature via oral route
• C. Measure temperature via tympanic route
• D. Measure temperature via rectal route (Correct Answer)

Pediatric Anesthesia Explanation: ***Measure temperature via rectal route*** - A **rectal temperature** is the most reliable and accurate core body temperature measurement, crucial for diagnosing and monitoring **hypothermia** [1]. - It is less affected by external environmental factors compared to other sites, making it ideal in emergency situations like those involving a soldier from **Siachen**. *Measure temperature via nasal route* - The nasal route is **not a standard or reliable method** for measuring core body temperature, and its accuracy in diagnosing hypothermia is questionable. - This method is more prone to environmental influence and provides readings that **do not reflect the core temperature** accurately. *Measure temperature via oral route* - **Oral temperature measurements** are often inaccurate in hypothermic patients due to factors like mouth breathing, the presence of cold fluids, or the patient's inability to cooperate. - In a severe cold environment like Siachen, the oral cavity can be significantly cooled, leading to **falsely low readings** that do not reflect core body temperature. *Measure temperature via tympanic route* - Tympanic (ear) temperature measurements can be unreliable in hypothermia due to issues with **probe placement**, ear canal cerumen, and the influence of ambient air temperature on the sensor. - While it attempts to measure core temperature, its accuracy is **inferior to rectal temperature**, especially in severely hypothermic individuals.

Pediatric Anesthesia Indian Medical PG Question 9: The recommended ambient temperature for NICU is

• A. 20-22° C
• B. 22-26° C (Correct Answer)
• C. 26-30° C
• D. 30-35° C

Pediatric Anesthesia Explanation: ***22-26° C*** - Maintaining an ambient temperature of **22-26°C** in the NICU is crucial for preventing **cold stress** in neonates. - This temperature range helps to maintain the baby's **core body temperature**, reducing metabolic demands and ensuring optimal thermal regulation. *20-22° C* - While this might be a comfortable room temperature for adults, it is generally **too cold** for newborns in the NICU. - Temperatures below the recommended range can lead to significant **cold stress**, increasing oxygen consumption and metabolic rate in vulnerable infants. *26-30° C* - This temperature range is generally **too warm** for a NICU environment. - Excessive warmth can lead to **hyperthermia** and sweating, which increases fluid loss and can be detrimental to a neonate's health. *30-35°C* - This temperature is **dangerously high** for neonates in the NICU. - Such high temperatures would significantly increase the risk of **hyperthermia, dehydration**, and other severe complications, compromising the infant's well-being.

Pediatric Anesthesia Indian Medical PG Question 10: Which of the following is most cardio depressant

• A. Sevoflurane
• B. Halothane (Correct Answer)
• C. Isoflurane
• D. Desflurane

Pediatric Anesthesia Explanation: ***Halothane*** - **Halothane** is known for causing significant **myocardial depression** by directly reducing myocardial contractility and stroke volume. - It also **sensitizes the myocardium to catecholamines**, increasing the risk of arrhythmias. *Sevoflurane* - **Sevoflurane** causes less **myocardial depression** and is often preferred in patients with compromised cardiac function. - Its effects on heart rate and blood pressure are generally moderate compared to halothane. *Isoflurane* - **Isoflurane** can cause **systemic vasodilation** and a dose-dependent decrease in blood pressure but is generally less cardio-depressant than halothane. - It maintains **cardiac output** better than halothane, sometimes increasing heart rate to compensate for vasodilation. *Desflurane* - **Desflurane** typically causes a **lesser degree of myocardial depression** and tends to preserve cardiac output. - It can, however, lead to transient increases in heart rate and blood pressure upon rapid increases in concentration due to **sympathetic stimulation**.

Pediatric Anesthesia Flashcard 1 of 3

Question: Criteria for terminating the procedure, for electrolyte containing media is when there is deficit of _____mL for younger patients

Answer: 2500

Pediatric Anesthesia Flashcard 2 of 3

Question: A _____mm endotracheal tube and laryngoscopy blade of size _____ are used to intubate a preterm infant

Answer: 3; 0

Pediatric Anesthesia Flashcard 3 of 3

Question: Inhalational induction with _____ ventilation is avoided in kids with tracheo-esophageal fistula

Answer: bag and mask