Emergence Delirium in Children — MCQs
Which of the following is the induction anesthesia of choice in the pediatric age group?
The inhalational agent of choice in children is
All are features of emergence delirium with ketamine anesthesia except:-
A child presents with complaints of bed wetting. What is the first line of treatment?
All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
A patient with mitral stenosis is having surgery tomorrow. There is some liver compromise. Which of the following inhalational agents is preferred?
All the following cause malignant hyperpyrexia except?
Which volatile anesthetic agent is MOST commonly recognized for its clinically significant tocolytic effects in obstetric anesthesia?
Which of the following anesthetic induction agents should be avoided in a 4-year-old boy with temporal lobe epilepsy?
Which of the following is a difference between a pediatric airway and an adult airway?
Emergence Delirium in Children Indian Medical PG Practice Questions and MCQs
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
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.
Question 2: The inhalational agent of choice in children is
- A. Methoxyflurane
- B. Desflurane
- C. Sevoflurane (Correct Answer)
- D. Isoflurane
Explanation: ***Sevoflurane*** - Sevoflurane is the **inhalational agent of choice for children** due to its pleasant odor and rapid **onset and offset of action**. - Its low pungency makes it suitable for **mask inductions** in pediatric patients, minimizing airway irritation. *Methoxyflurane* - Methoxyflurane is an older inhalational agent that is **nephrotoxic** and is not used in modern anesthetic practice. - Its slow onset and offset, coupled with its toxicity, make it an unsuitable choice for any patient population, especially children. *Desflurane* - Desflurane has a very **pungent odor** and is highly irritant to the airway, making it unsuitable for mask induction in children. - It often causes **coughing, breath-holding, and laryngospasm** during induction, which is poorly tolerated by pediatric patients. *Isoflurane* - While Isoflurane can be used in children, its **strong, pungent odor** often causes airway irritation and makes mask induction difficult. - It is also associated with a **slower onset and offset** compared to sevoflurane, making it less ideal for rapid anesthetic control in children.
Question 3: All are features of emergence delirium with ketamine anesthesia except:-
- A. No hallucination
- B. Auditory, proprioceptive and confusional illusions
- C. Cortical blindness (Correct Answer)
- D. Visual illusions
Explanation: **Cortical blindness** - **Cortical blindness** is a rare neurological condition resulting from damage to the **visual cortex** in the brain, leading to an inability to process visual information. It is not typically associated with ketamine emergence delirium. - While ketamine can cause visual disturbances, true cortical blindness is not a characteristic feature of **emergence delirium**. *Auditory, proprioceptive and confusional illusions* - Ketamine emergence delirium is well-known for causing various **illusions**, including auditory, proprioceptive, and confusional experiences, due to its dissociative effects on the central nervous system. - Patients may experience distorted perceptions of sound, body position, and their surroundings during recovery from anesthesia. *No hallucination* - This statement is incorrect because **hallucinations** are a common feature of ketamine emergence delirium, particularly vivid and sometimes disturbing visual or auditory hallucinations. - Ketamine's mechanism, involving NMDA receptor antagonism, can lead to these profound perceptual alterations. *Visual illusions* - **Visual illusions** are a very common symptom of ketamine emergence delirium, where patients may perceive objects or their environment in a distorted or unreal way. - These illusions contribute to the disorientation and agitation experienced during recovery from ketamine anesthesia.
Question 4: A child presents with complaints of bed wetting. What is the first line of treatment?
- A. Bed alarm technique (Correct Answer)
- B. Motivational therapy
- C. Oxybutynin
- D. Desmopressin
Explanation: ***Bed alarm technique*** - The **bed alarm technique** is considered the most effective first-line treatment for **nocturnal enuresis** in children. - It works through **classical conditioning**, training the child to wake up in response to bladder fullness. *Motivational therapy* - **Motivational therapy** can be a useful adjunct to other treatments, but it is not typically the sole **first-line therapy** due to varying effectiveness. - It focuses on building the child's confidence and encouraging dryness but does not directly address the physiological aspects of bedwetting. *Oxybutynin* - **Oxybutynin** is an anticholinergic medication that can reduce bladder contractions and increase bladder capacity. - It is usually reserved for cases where **bedwetting alarms** and **desmopressin** have been ineffective, or when there is an identifiable **overactive bladder component**. *Desmopressin* - **Desmopressin** is an antidiuretic hormone analogue that reduces urine production during the night. - While effective, it is often considered a **second-line treatment** after behavioral interventions like the bed alarm, or when rapid but temporary improvement is desired.
Question 5: 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 6: A patient with mitral stenosis is having surgery tomorrow. There is some liver compromise. Which of the following inhalational agents is preferred?
- A. Enflurane
- B. Xenon
- C. Sevoflurane (Correct Answer)
- D. Halothane
Explanation: ***Sevoflurane*** - **Sevoflurane** is preferred due to its **minimal hepatic metabolism** and rapid elimination, making it a safer option in patients with **liver compromise**. - It maintains **cardiovascular stability**, which is beneficial in mitral stenosis and avoids the arrhythmogenic potential seen with other agents. *Enflurane* - **Enflurane** is extensively metabolized in the liver, leading to the production of inorganic fluoride ions, which can cause **renal toxicity**. - It can also induce a decrease in **hepatic blood flow**, exacerbating existing liver compromise. *Xenon* - While **Xenon** has excellent cardiovascular stability and minimal metabolism, its **high cost** and **limited availability** make it an impractical choice for routine use. - Its anesthetic potency is relatively low, requiring **higher concentrations** for surgical anesthesia. *Halothane* - **Halothane** is associated with a significant risk of **halothane-induced hepatitis** due to its extensive hepatic metabolism and the production of toxic metabolites. - It can also cause **cardiac depression** and **arrhythmias**, which are undesirable in patients with mitral stenosis.
Question 7: All the following cause malignant hyperpyrexia except?
- A. Methoxyflurane
- B. N20 (Correct Answer)
- C. Isoflurane
- D. Halothane
Explanation: ***N2O*** - **Nitrous oxide (N2O)**, or laughing gas, is an inhaled anesthetic that does not trigger **malignant hyperthermia (MH)**. - It is often used as a carrier gas or adjunct during anesthesia, even in patients susceptible to MH, as it does not affect **ryanodine receptors**. *Methoxyflurane* - **Methoxyflurane** is a volatile inhaled anesthetic known to trigger **malignant hyperthermia (MH)** in susceptible individuals. - It causes an uncontrolled release of **calcium** from the sarcoplasmic reticulum in muscle cells, leading to severe hypermetabolism. *Isoflurane* - **Isoflurane** is a commonly used volatile inhaled anesthetic that can induce **malignant hyperthermia (MH)** in genetically predisposed individuals. - Like other volatile agents, it activates **ryanodine receptors** in skeletal muscle, leading to excessive muscle contraction and heat production. *Halothane* - **Halothane** is a potent volatile inhaled anesthetic historically associated with a high incidence of triggering **malignant hyperthermia (MH)**. - Its use has largely been replaced by newer agents due to concerns about MH and **hepatotoxicity**.
Question 8: Which volatile anesthetic agent is MOST commonly recognized for its clinically significant tocolytic effects in obstetric anesthesia?
- A. Isoflurane (Correct Answer)
- B. Sevoflurane
- C. Nitrous oxide
- D. Desflurane
Explanation: ***Isoflurane*** - **Isoflurane** is well-known for its potent dose-dependent uterine relaxation (tocolytic) properties, which can be clinically useful during obstetric procedures requiring uterine quiescence, such as manual placenta removal or fetal manipulation. - This effect is due to its ability to decrease the frequency and intensity of uterine contractions by relaxing myometrial smooth muscle. *Sevoflurane* - While sevoflurane does possess uterine relaxant properties, its tocolytic effect is generally considered less potent compared to isoflurane at equipotent doses. - It is frequently favored for maintenance of anesthesia in obstetrics due to its rapid onset and offset, but its uterine relaxation is often less pronounced than that of isoflurane. *Desflurane* - Desflurane also causes dose-dependent uterine relaxation, but its tocolytic effects are not typically considered as significant or as commonly utilized for specific uterine relaxation needs as isoflurane. - Its rapid pharmacokinetics make it suitable for obstetric anesthesia, but its uterine effects are generally in line with other volatile agents, with isoflurane having a more pronounced reputation for tocolysis. *Nitrous oxide* - **Nitrous oxide** has minimal to no direct significant uterine relaxant (tocolytic) effects, making it a common choice for analgesia during labor in sub-anesthetic concentrations. - It does not cause the widespread smooth muscle relaxation observed with potent volatile agents, hence is not used for obstetric scenarios requiring uterine quiescence.
Question 9: Which of the following anesthetic induction agents should be avoided in a 4-year-old boy with temporal lobe epilepsy?
- A. Thiopental
- B. Halothane
- C. Ketamine (Correct Answer)
- D. All of the above
Explanation: **Explanation:** The correct answer is **Ketamine**. **1. Why Ketamine is avoided:** Ketamine is a phencyclidine derivative that acts as an NMDA receptor antagonist. While it provides excellent analgesia and dissociation, it is known to stimulate the central nervous system. In patients with a history of epilepsy, Ketamine can lower the seizure threshold and induce **epileptiform activity** on an EEG. Specifically, it can trigger seizure foci in the cortical and subcortical areas, making it contraindicated (or used with extreme caution) in patients with poorly controlled epilepsy or temporal lobe lesions. **2. Analysis of Incorrect Options:** * **Thiopental:** This is a barbiturate and is actually considered an **anticonvulsant**. It is often used to terminate status epilepticus. It increases the seizure threshold and is safe (even protective) for patients with epilepsy. * **Halothane:** While potent inhalational agents can occasionally show EEG changes at very high concentrations, Halothane does not have significant pro-convulsant properties. It is generally safe for induction in epileptic children, though Sevoflurane is more commonly used in modern practice. **3. NEET-PG High-Yield Pearls:** * **Pro-convulsant Agents:** Ketamine, Methohexital (often used to *induce* seizures during ECT), and Etomidate (can activate seizure foci). * **Meperidine (Pethidine):** Its metabolite, **normeperidine**, is a potent CNS stimulant and can cause seizures, especially in renal failure. * **Sevoflurane Paradox:** At high concentrations (>2 MAC) and with hypocapnia, Sevoflurane can show epileptiform patterns on EEG, but it is clinically used safely in most pediatric cases. * **Drug of Choice for Status Epilepticus (Anesthesia):** Thiopental or Propofol.
Question 10: Which of the following is a difference between a pediatric airway and an adult airway?
- A. Large tongue (Correct Answer)
- B. Short epiglottis
- C. Narrowest part is the glottis
- D. Larynx is in a lower position
Explanation: **Explanation:** The pediatric airway is not merely a smaller version of the adult airway; it possesses distinct anatomical differences that have significant implications for airway management. **1. Why "Large Tongue" is Correct:** In infants and young children, the **tongue is relatively large** in proportion to the oral cavity. This makes the pediatric airway more prone to obstruction (especially when the child is supine or anesthetized) and can obscure the view of the larynx during direct laryngoscopy. **2. Analysis of Incorrect Options:** * **Short epiglottis:** In children, the epiglottis is actually **long, stiff, and U-shaped (or omega-shaped)**. It often flops posteriorly, necessitating the use of a straight laryngoscope blade (like a Miller blade) to lift it directly. * **Narrowest part is the glottis:** In adults, the narrowest point is the glottis (vocal cords). In children (traditionally under age 8), the narrowest part is the **subglottic region at the level of the cricoid cartilage**. This is why uncuffed tubes were historically preferred to prevent subglottic edema (croup). * **Larynx is in a lower position:** The pediatric larynx is positioned **higher and more anteriorly** (at the level of C3–C4) compared to the adult larynx (at C4–C5). **High-Yield Clinical Pearls for NEET-PG:** * **Occiput:** Infants have a large occiput, which causes neck flexion when supine. A shoulder roll (rather than a head ring) is often needed to achieve the "sniffing position." * **Laryngoscope Blade:** A **straight blade** is preferred in infants to pick up the long, floppy epiglottis. * **Breathing:** Infants are **obligate nasal breathers** up to 3–6 months of age; nasal obstruction can cause significant respiratory distress.
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