Anesthesia for Common Pediatric Surgeries — MCQs
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 4-month-old child can be given clear fluid until how many hours prior to surgery?
A 6-year-old child is scheduled for tonsillectomy. Which inhalational agent is most suitable for induction?
Child with aspiration risk needs emergency surgery. Best induction sequence is:
Anesthesia of choice for induction in children among the following is:
During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
Which one of the following life-threatening congenital anomalies in the newborn presents with polyhydramnios, aspiration pneumonia, excessive salivation and difficulty in passing a nasogastric tube?
All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
A one-year-old child, preterm, and low birth weight with delayed milestones is posted for elective hernia repair. Which of the following statements is true?
A 5 year old boy suffering from Duchenne muscular dystrophy has to undergo tendon lengthening procedure. The most appropriate anaesthetic would be –
Anesthesia for Common Pediatric Surgeries Indian Medical PG Practice Questions and MCQs
Question 1: 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
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.
Question 2: A 4-month-old child can be given clear fluid until how many hours prior to surgery?
- A. 2 hrs (Correct Answer)
- B. 4 hrs
- C. 3 hrs
- D. 1 hr
Explanation: ***2 hrs*** - Current guidelines from the **American Society of Anesthesiologists (ASA)** recommend a minimum fasting period of **2 hours for clear liquids** in infants and children. - This recommendation balances the risk of **pulmonary aspiration** with the benefit of preventing dehydration and patient discomfort. *4 hrs* - A 4-hour fasting period for clear fluids is longer than typically required for infants and children and may lead to unnecessary dehydration without additional safety benefits. - This duration is more commonly associated with non-human milk formula or solid food. *3 hrs* - While closer to the recommended time, 3 hours for clear fluids in an infant is still slightly longer than the current standard. - It does not offer a significant advantage over the 2-hour guideline and may still contribute to prolonged fasting. *1 hr* - A 1-hour fasting period for clear fluids in an infant is generally considered too short and carries an increased risk of **pulmonary aspiration** during induction of anesthesia. - Insufficient time for gastric emptying could lead to complications if regurgitation occurs.
Question 3: A 6-year-old child is scheduled for tonsillectomy. Which inhalational agent is most suitable for induction?
- A. Isoflurane
- B. Halothane
- C. Sevoflurane (Correct Answer)
- D. Desflurane
Explanation: ***Sevoflurane*** - **Sevoflurane** is preferred for inhalational induction in pediatric patients due to its **low pungency** and rapid onset/offset, making it well-tolerated and less likely to cause coughing or breath-holding. - Its **minimal airway irritancy** facilitates a smooth induction, which is particularly important in children who may be uncooperative or anxious. *Isoflurane* - **Isoflurane** is a **pungent** inhalational agent, making it unsuitable for inhalational induction, especially in children, as it can cause coughing, breath-holding, and laryngospasm. - While it has a good safety profile for maintenance, its irritant properties preclude its use for a smooth mask induction. *Halothane* - **Halothane** was previously a common pediatric anesthetic but is rarely used now due to its association with **hepatotoxicity** (halothane hepatitis) and increased risk of **cardiac arrhythmias**. - Although it has a pleasant odor, its significant side effect profile has led to its replacement by safer agents like sevoflurane. *Desflurane* - **Desflurane** is very **pungent** and highly irritating to the airway, causing coughing, breath-holding, and laryngospasm, making it unsuitable for inhalational induction, especially in pediatric patients. - It also has a **high MAC value**, requiring higher concentrations that can exacerbate airway irritation.
Question 4: 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)
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.
Question 5: Anesthesia of choice for induction in children among the following is:
- A. Isoflurane
- B. Sevoflurane (Correct Answer)
- C. Halothane
- D. Desflurane
Explanation: ***Sevoflurane*** - **Sevoflurane** is the anesthetic of choice for induction in children due to its **low pungency**, which reduces the likelihood of coughing and laryngospasm. - It has a relatively **rapid onset of action** and allows for a smooth, inhalation induction, making it well-tolerated by pediatric patients. *Isoflurane* - **Isoflurane** has a **pungent odor** and is known to cause a higher incidence of airway irritation, coughing, and breath-holding, making it less suitable for mask induction in children. - It also has a **slower onset** compared to sevoflurane, which can prolong the induction process. *Halothane* - **Halothane** was previously used for pediatric induction but is largely uncommonly used today due to its association with **hepatotoxicity** (halothane hepatitis) and cardiac arrhythmias. - While it has a relatively pleasant odor, its significant side effect profile makes it a less desirable option now. *Desflurane* - **Desflurane** is very **pungent** and frequently causes airway irritation, coughing, and laryngospasm, making it unsuitable for mask induction in children. - It also has a **low potency** compared to other volatile anesthetics, requiring higher concentrations that can exacerbate airway complications.
Question 6: During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
- A. Administer oxygen (Correct Answer)
- B. Analgesic injection with Fentanyl
- C. Preanaesthetic medication with atropine and lignocaine
- D. IV anesthetic Diazepam/Ketamine
Explanation: ***Administer oxygen*** - Pre-oxygenation with 100% oxygen is critical before **rapid sequence intubation (RSI)** to maximize **oxygen reserves** and extend the safe apnea time. - This step helps prevent **hypoxemia** during the intubation procedure, especially in children who have lower functional residual capacity. *Analgesic injection with Fentanyl* - While fentanyl is often used in RSI for its **analgesic** and **sedative properties**, it typically follows pre-oxygenation and is administered as part of the **induction phase**, often concurrently with a paralytic. - Administering fentanyl alone without prior oxygenation or other induction agents would not be the immediate next step in a structured RSI protocol. *Preanaesthetic medication with atropine and lignocaine* - **Atropine** may be used in children to prevent **bradycardia** during intubation, particularly in infants, but it's not the immediate next step after initial assessment; pre-oxygenation is more critical. - **Lidocaine** can be used to blunt the sympathetic response to intubation or to suppress cough, but it's not universally required and comes after pre-oxygenation and other induction medications. *IV anesthetic Diazepam/Ketamine* - **Diazepam** and **ketamine** are **induction agents** that cause sedation and loss of consciousness, but they are administered after pre-oxygenation and often just before the paralytic agent. - Administering an induction agent without adequate pre-oxygenation would increase the risk of **hypoxemia** during the subsequent apnea.
Question 7: Which one of the following life-threatening congenital anomalies in the newborn presents with polyhydramnios, aspiration pneumonia, excessive salivation and difficulty in passing a nasogastric tube?
- A. Choanal atresia
- B. Gastroschisis
- C. Diaphragmatic hernia
- D. Tracheo-esophageal fistula (Correct Answer)
Explanation: ***Tracheo-esophageal fistula*** - This condition presents with **polyhydramnios** due to the fetus being unable to swallow amniotic fluid, **excessive salivation** from accumulated secretions in the blind-ending esophageal pouch, and difficulty passing a **nasogastric tube** because of the esophageal obstruction. - **Aspiration pneumonia** is a common complication as saliva and gastric contents can be aspirated into the lungs through the fistula. *Choanal atresia* - Characterized by **blocked nasal passages**, leading to **cyclical cyanosis** relieved by crying, but not typically associated with polyhydramnios or excessive salivation in this manner. - While it can cause respiratory distress, it does not involve esophageal obstruction or directly cause aspiration pneumonia from swallowed fluids. *Gastroschisis* - This is an **abdominal wall defect** where intestines protrude outside the body, unrelated to swallowing difficulties, polyhydramnios caused by inability to swallow, or excessive salivation. - It does not involve difficulty in passing a nasogastric tube or directly cause aspiration pneumonia. *Diaphragmatic hernia* - Involves **abdominal contents herniating into the chest cavity**, leading to **pulmonary hypoplasia** and respiratory distress. - It does not explain polyhydramnios due to impaired swallowing, excessive salivation, or the characteristic inability to pass a nasogastric tube.
Question 8: All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
- A. Halothane
- B. Propofol (Correct Answer)
- C. Nitrous Oxide
- D. Opioids
Explanation: ***Propofol*** - Propofol is known to have **antiemetic properties** and is often used to reduce the incidence of postoperative nausea and vomiting (PONV). - Its mechanism involves modulating **GABA-A receptors** and potentially other pathways that suppress emetic responses. *Halothane* - **Inhalational anesthetics** like halothane are a significant risk factor for PONV, particularly in children and following surgeries like squint repair. - They tend to increase PONV by directly stimulating the **chemoreceptor trigger zone** and altering gut motility. *Opioids* - Opioids, commonly used for postoperative pain control, are a well-known cause of **nausea and vomiting**. - They activate **opioid receptors** in the chemoreceptor trigger zone and the gastrointestinal tract, leading to emesis and delayed gastric emptying. *Nitrous Oxide* - The use of **nitrous oxide** as part of a general anesthetic regimen has been consistently associated with an increased risk of PONV. - It is believed to contribute to PONV by increasing the risk of **bowel distension** and stimulating neurotransmitter release involved in emesis.
Question 9: A one-year-old child, preterm, and low birth weight with delayed milestones is posted for elective hernia repair. Which of the following statements is true?
- A. Wait for complete neurological evaluation (Correct Answer)
- B. Avoidance of regional anesthesia
- C. Avoidance of combination of inhalational and muscle relaxation
- D. Inhalational agents are contraindicated in this scenario.
Explanation: ***Wait for complete neurological evaluation*** - Preterm, low birth weight, and delayed milestones suggest a heightened risk of **neurological complications** and underscore the importance of a thorough pre-operative neurological assessment. - A comprehensive evaluation can identify specific neurological deficits or vulnerabilities, informing anesthesia planning and **post-operative monitoring** to prevent exacerbation or new onset issues. *Inhalational agents are contraindicated in this scenario.* - **Inhalational agents** are not absolutely contraindicated in preterm, low-birth-weight children with delayed milestones, but their use requires careful titration due to potential for **hemodynamic instability** and increased risk of apnea. - The choice of anesthetic technique depends on the child's specific condition and the surgeon's preference, with a focus on **neuroprotective strategies** and minimizing risks. *Avoidance of regional anesthesia* - **Regional anesthesia** can be beneficial in preterm infants for hernia repair by potentially reducing the need for systemic opioids and their associated side effects, as well as lowering the incidence of **post-operative apnea**. - Its use, however, requires careful consideration of the child's coagulation status, cardiovascular stability, and the expertise of the anesthesiologist in performing blocks in this vulnerable population. *Avoidance of combination of inhalational and muscle relaxation* - The combination of **inhalational agents** and **muscle relaxants** is routinely used in pediatric anesthesia for appropriate surgical conditions and is not inherently contraindicated in this population. - Careful titration of both agents is essential to minimize their respective side effects, such as cardiovascular depression from inhalational agents and prolonged muscle weakness from neuromuscular blockers, especially in a child with baseline neurological challenges.
Question 10: A 5 year old boy suffering from Duchenne muscular dystrophy has to undergo tendon lengthening procedure. The most appropriate anaesthetic would be –
- A. Induction with inhalation sevoflurane; maintenance with isoflurane and vecuronium
- B. Total intravenous anesthesia (TIVA) with propofol and remifentanil (Correct Answer)
- C. Induction with intravenous propofol and N2O; TIVA maintenance with propofol
- D. Induction with intravenous thiopentone; maintenance with sevoflurane and non-depolarizing muscle relaxants
Explanation: ***Total intravenous anesthesia (TIVA) with propofol and remifentanil*** - **Duchenne muscular dystrophy (DMD)** patients are highly susceptible to **malignant hyperthermia** and rhabdomyolysis when exposed to volatile anesthetics (e.g., sevoflurane, isoflurane) and succinylcholine. TIVA avoids these triggers. - **Propofol** and **remifentanil** are suitable anesthetic agents for TIVA in DMD patients, providing stable anesthesia without triggering adverse muscle reactions. *Induction with inhalation sevoflurane; maintenance with isoflurane and vecuronium* - **Sevoflurane** and **isoflurane** are volatile anesthetic agents that can trigger **malignant hyperthermia** and severe rhabdomyolysis in patients with DMD due to their muscle pathology. - While vecuronium is a non-depolarizing muscle relaxant that is generally safe in DMD, the use of volatile agents makes this regimen inappropriate. *Induction with intravenous propofol and N2O; TIVA maintenance with propofol* - **Nitrous oxide (N2O)**, while not a direct trigger for malignant hyperthermia itself, is often used in conjunction with volatile anesthetics and does not significantly mitigate the risks associated with them in DMD patients. - Although propofol for induction and TIVA maintenance is appropriate, the inclusion of N2O does not improve safety in the context of DMD, and concerns about potential interactions or masking early signs of complications might arise. *Induction with intravenous thiopentone; maintenance with sevoflurane and non-depolarizing muscle relaxants* - **Thiopentone** (thiopental) is an intravenous anesthetic that is generally safe for induction in DMD patients. - However, **sevoflurane** is a volatile anesthetic that is contraindicated in DMD due to the risk of triggering **malignant hyperthermia** and severe rhabdomyolysis.
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