Fluid Management in Pediatric Anesthesia — MCQs
Amount of ORS to be given in the first 4 hours to a child with some dehydration is
What is the calculated fluid requirement for treating dehydration and maintenance over a 4-hour period in a 14 kg, 14-month-old child with a 4-day history of loose stools, decreased urine output, delayed skin pinch, sunken eyes, and dry mucosa?
A 50 year old male is posted for elective laparoscopic cholecystectomy. No history of comorbidities. His surgery is scheduled at 2 PM on the day of surgery. Which of the following is against the ASA guidelines for preoperative fasting
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?
Which of the following is the induction anesthesia of choice in the pediatric age group?
A 6-year-old child is scheduled for tonsillectomy. Which inhalational agent is most suitable for induction?
A 5 year old boy suffering from Duchenne muscular dystrophy has to undergo tendon lengthening procedure. The most appropriate anaesthetic would be –
What is the maintenance fluid requirement in a 6 kg child ?
A patient in shock comes to you in the trauma ward. You examine him and decide not to give him vasoconstrictors. Which type of shock is your patient having?
A 12 kg child with diarrhoea and some dehydration: based on WHO guidelines, how much fluid should be replaced in the first 4 hours?
Fluid Management in Pediatric Anesthesia Indian Medical PG Practice Questions and MCQs
Question 1: Amount of ORS to be given in the first 4 hours to a child with some dehydration is
- A. 75 ml/kg body wt. (Correct Answer)
- B. 50 ml/kg body wt.
- C. 100 ml/kg body wt.
- D. 200 ml/kg body wt.
Explanation: ***75 ml/kg body wt.*** - For a child with **some dehydration**, the World Health Organization (WHO) and UNICEF recommend administering **75 mL/kg body weight** of ORS over the first 4 hours as part of Plan B. - This volume is calculated to replenish lost fluids and electrolytes, addressing the estimated fluid deficit in **some dehydration**. *50 ml/kg body wt.* - A dose of **50 mL/kg** is generally insufficient for effective rehydration in a child presenting with **some dehydration**. - This amount might be used in milder cases or for maintenance, but not for initial rehydration in the **first 4 hours** with signs of dehydration. *100 ml/kg body wt.* - Administering **100 mL/kg** body weight is typically used for **severe dehydration** (Plan C) when given as **intravenous fluids**. - For **some dehydration** treated with ORS, the recommended dose is 75 mL/kg, not 100 mL/kg. This higher amount could lead to fluid overload if given orally in the first 4 hours. *200 ml/kg body wt.* - A dose of **200 mL/kg** body weight is excessive and potentially dangerous for a child with **some dehydration**. - Such a large volume could lead to **fluid overload**, electrolyte imbalances, and other complications, especially in young children.
Question 2: What is the calculated fluid requirement for treating dehydration and maintenance over a 4-hour period in a 14 kg, 14-month-old child with a 4-day history of loose stools, decreased urine output, delayed skin pinch, sunken eyes, and dry mucosa?
- A. 1050 ml (Correct Answer)
- B. 700 ml
- C. 1200 ml
- D. 2000 ml
Explanation: ***1050 ml*** - This calculation includes **dehydration correction** (70-75 ml/kg for severe dehydration over 4 hours: 14 kg × 75 ml/kg = 1050 ml) and **maintenance fluid** (14 kg requires 50 ml/hour by Holiday-Segar: 50 ml/hr × 4 hours = 200 ml), but in **severe dehydration**, the initial rapid rehydration phase prioritizes deficit correction. - The child exhibits signs of **severe dehydration** (decreased urine output, delayed skin pinch, sunken eyes, dry mucosa), indicating 7-10% fluid loss requiring **Plan C (IV rehydration)** per WHO/IAP guidelines. - **Standard protocol:** 100 ml/kg total over 6 hours (30 ml/kg in first 1 hour, then 70 ml/kg over next 5 hours). For a 4-hour calculation, approximately 75 ml/kg (1050 ml) addresses the urgent deficit while allowing gradual correction. *1200 ml* - This represents the full calculated amount including both **deficit replacement** and **maintenance fluid** (1050 ml + 200 ml ≈ 1250 ml). - While mathematically close, administering this volume over only 4 hours might be **too rapid** for a severely dehydrated child, increasing risk of complications. - The question specifically asks for 4-hour management, where **deficit correction takes priority** over full maintenance addition. *700 ml* - This volume represents only **50 ml/kg**, which is significantly **insufficient** for severe dehydration (requires 100 ml/kg total). - Would be appropriate for **moderate dehydration** (5-7% deficit) but inadequate for this child's clinical presentation. - Administering only 700 ml would lead to **persistent dehydration** and worsening clinical status. *2000 ml* - This amount (143 ml/kg) would result in **gross overhydration**, potentially causing life-threatening complications like **pulmonary edema**, **cerebral edema**, or **heart failure**. - Exceeds the standard 100 ml/kg deficit by nearly 50%, with excessive volume administered too rapidly. - Represents dangerous **fluid overload** for a 14 kg child with severe dehydration.
Question 3: A 50 year old male is posted for elective laparoscopic cholecystectomy. No history of comorbidities. His surgery is scheduled at 2 PM on the day of surgery. Which of the following is against the ASA guidelines for preoperative fasting
- A. Water at 12:00 PM
- B. Black coffee at 5:30 AM
- C. Pancakes at 10:00 AM (Correct Answer)
- D. A non-clear liquid (e.g., orange juice) at 7:30 AM
Explanation: **Pancakes at 10:00 AM** - According to ASA guidelines, the fasting period for solid food is typically **6-8 hours** before surgery. Eating pancakes, which are solid food, at 10:00 AM for a 2:00 PM surgery (4-hour interval) violates this guideline. - This short fasting period for solids increases the risk of **pulmonary aspiration** during induction of anesthesia. *Water at 12:00 PM* - Water is considered a clear liquid, and ASA guidelines typically allow clear liquids until **2 hours** before surgery. Drinking water at 12:00 PM for a 2:00 PM surgery is within these guidelines. - Rapid gastric emptying of clear liquids minimizes the risk of aspiration. *Black coffee at 5:30 AM* - Black coffee is considered a clear liquid, and it is consumed well within the **2-hour** fasting window for clear liquids before a 2:00 PM surgery. - The absence of milk or cream ensures it is treated as a clear liquid, which empties quickly from the stomach. *A non-clear liquid (e.g., orange juice) at 7:30 AM* - Non-clear liquids, such as orange juice, are treated similarly to light meals and generally require a fasting period of **6 hours** before surgery. Drinking orange juice at 7:30 AM for a 2:00 PM surgery (6.5-hour interval) is compliant with these guidelines. - The protein and pulp in non-clear liquids delay gastric emptying compared to clear liquids.
Question 4: 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 5: 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 6: 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 7: 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.
Question 8: What is the maintenance fluid requirement in a 6 kg child ?
- A. 240 ml/day
- B. 600 ml/day (Correct Answer)
- C. 300 ml/day
- D. 1200 ml/day
Explanation: **600 ml/day** - The **Holliday-Segar formula** is used to calculate maintenance fluid requirements. For the first 10 kg of body weight, the requirement is 100 ml/kg/day. - For a 6 kg child, the calculation is 6 kg * 100 ml/kg/day = **600 ml/day**. *240 ml/day* - This value is significantly **lower** than the recommended maintenance fluid for a 6 kg child, which would lead to **dehydration**. - It does not align with the standard Holliday-Segar formula for this weight. *300 ml/day* - This amount is **insufficient** for a 6 kg child's daily maintenance fluid needs and would risk **hypovolemia**. - It represents roughly half of the calculated requirement based on standard pediatric guidelines. *1200 ml/day* - This volume is significantly **higher** than the maintenance fluid requirement for a 6 kg child and could lead to **fluid overload** and hyponatremia. - This calculation might be appropriate for a much heavier child or in situations of increased fluid loss.
Question 9: A patient in shock comes to you in the trauma ward. You examine him and decide not to give him vasoconstrictors. Which type of shock is your patient having?
- A. Cardiogenic shock
- B. Distributive shock (Correct Answer)
- C. Neurogenic shock
- D. Hemorrhagic shock
Explanation: ***Distributive shock*** - Distributive shock, particularly **septic shock**, often presents with **peripheral vasodilation** and a low systemic vascular resistance. - Administering additional **vasoconstrictors** in this context could worsen tissue perfusion if not carefully titrated, as the primary issue is maldistribution of blood flow rather than inadequate vascular tone alone. *Cardiogenic shock* - In **cardiogenic shock**, there is **myocardial dysfunction** leading to decreased cardiac output. - **Vasoconstrictors** may be used cautiously to maintain systemic perfusion pressure and improve coronary perfusion, although inotropes are often prioritized. *Neurogenic shock* - **Neurogenic shock** is a form of distributive shock caused by the **loss of sympathetic tone** due to spinal cord injury, leading to widespread vasodilation [1]. - **Vasoconstrictors** are a primary treatment in neurogenic shock to restore vascular tone and increase blood pressure [1]. *Hemorrhagic shock* - **Hemorrhagic shock** results from **significant blood loss**, leading to decreased circulating volume and reduced cardiac output. - The immediate priority is **fluid resuscitation** and **stopping the bleeding**, but vasoconstrictors are not typically the primary treatment and can worsen perfusion in some vascular beds [1].
Question 10: A 12 kg child with diarrhoea and some dehydration: based on WHO guidelines, how much fluid should be replaced in the first 4 hours?
- A. 0-400 ml
- B. 400-800 ml
- C. 800-1200 ml (Correct Answer)
- D. 1200-1600 ml
Explanation: ***800-1200 ml*** - For a child weighing **12 kg** with **some dehydration** due to diarrhea, WHO Plan B recommends **75 mL/kg** over 4 hours. - Therefore, 12 kg × 75 mL/kg = **900 mL**, which falls within this range. - This range allows for slight variations in clinical practice while staying close to the WHO standard guideline. *0-400 ml* - This range is significantly **too low** for a 12 kg child with some dehydration, as it would not adequately address the fluid deficit. - Inadequate fluid replacement can lead to worsening dehydration and its associated complications, such as **persistent signs of dehydration or progression to severe dehydration**. *400-800 ml* - While higher than the lowest option, **400-800 mL** is still generally insufficient for a 12 kg child needing rehydration over 4 hours per WHO Plan B. - This amount would only partially correct the fluid deficit, potentially delaying recovery and necessitating further interventions. *1200-1600 ml* - This range is **excessive** for WHO Plan B rehydration in a 12 kg child over 4 hours, potentially leading to **fluid overload**. - While adequate rehydration is crucial, administering significantly more than 75 mL/kg can increase the risk of complications, especially in children with underlying cardiac or renal conditions.
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